The Journal of Continuing Education in Nursing

Original Article 

A Narrative Review of the Description of Training Profiles Used for Emergency Nursing Care Worldwide

Ana Vazquez-Casares, RN, MSN; Javier Vidal, PhD

Abstract

Background:

This study describes the training profiles of emergency care nurses worldwide, which can serve as a guide for training these professionals.

Method:

A narrative review was developed.

Results:

Five training profiles were identified, according to the requirements of undergraduate, postgraduate, complementary training, and previous work experience within the training itineraries of emergency nursing worldwide.

Conclusion:

The most appropriate level of training for emergency nursing is the 1-year postgraduate level (academic or specialty). The description of these profiles can guide the regulatory organizations and professionals regarding the most appropriate training requirements for effective, safe, and adjusted care assistance. [J Contin Educ Nurs. 2019;50(12):543–550.]

Abstract

Background:

This study describes the training profiles of emergency care nurses worldwide, which can serve as a guide for training these professionals.

Method:

A narrative review was developed.

Results:

Five training profiles were identified, according to the requirements of undergraduate, postgraduate, complementary training, and previous work experience within the training itineraries of emergency nursing worldwide.

Conclusion:

The most appropriate level of training for emergency nursing is the 1-year postgraduate level (academic or specialty). The description of these profiles can guide the regulatory organizations and professionals regarding the most appropriate training requirements for effective, safe, and adjusted care assistance. [J Contin Educ Nurs. 2019;50(12):543–550.]

Emergency nursing is dynamic. Working as an emergency nurse requires the integration of a large number of skills and expertise in evaluation, patient management, and complex decision making (Andersson, Jakobsson, Furåker, & Nilsson, 2012), as well as nontechnical and nonmedical skills, such as teamwork, leadership, and communication skills (Cooper & Grant, 2009; Delamaire & Lafortune, 2010; Nilsson & Lindström, 2016), in addition to the will and ability to quickly adapt to any situation (Considine et al., 2012; Nilsson & Lindström, 2016).

The growing demand for emergency nursing care (Andersson et al., 2012; Brysiewicz & Bruce, 2008) innovations and evolutions in science and technology (Arcos-González, Castro-Delgado, & Martín-Reyes, 2014; Hoskins, 2011) and changes in the structure of health models and in the health care and economic policies of nations have generated an increase in the need for more nurses in emergency departments (Griffin & Melby, 2006; Hoskins, 2011) on the five continents. This need is verified in intrahospital and prehospital settings and has precipitated a shift toward emerging roles that require greater competence to meet new professional demands (Delamaire & Lafortune, 2010; McClelland, 2012a).

New roles in nursing, considered as specialist roles (Bell et al., 2014; Brysiewicz & Bruce, 2008; Fitzpatrick, Campo, & Gacki-Smith, 2014; Wihlborg, Edgren, Johansson, & Sivberg, 2014) or advanced nursing care (Christofis, 2001; Considine et al., 2012; Hoskins, 2011; McClelland, 2012a), imply an increased clinical responsibility and professional autonomy, and they entail new professional skills or a higher level of mastery than previously needed (Bell et al., 2014; Fitzpatrick et al., 2014; McClelland, 2012b; Scott & Brysiewicz, 2016), thus going beyond traditional nursing care (Delamaire & Lafortune, 2010; Hoskins, 2011). In addition, they face two fundamental problems: the delimitation and homogenization of training, together with its regulation and registration. There is a direct relationship between the competencies assigned to a professional and his or her academic training and work experience (Christofis, 2001; Wihlborg et al., 2014), so the development of new roles requires the adaptation of training requirements (Andersson et al., 2012; Cooke, 2006; Griffin & Melby, 2006) necessary to ensure competence and high-quality, safe, and holistic care (Aftyka, Rudnicka-Drożak, & Rybojad, 2014; Andersson, Sundström, Nilsson, & Jakobsson Ung, 2014; Delamaire & Lafortune, 2010; Lambrou, Papastavrou, Merkouris, & Middleton, 2015; Nilsson & Lindström, 2016; Pogue, 2007; Scott & Brysiewicz, 2016; Sjölin, Lindström, Hult, Ringsted, & Kurland, 2015; Van Schuppen & Bierens, 2011; Wihlborg et al., 2014).

The scientific literature identifies several roles in emergency nursing care and provides evidence that there is no consensus regarding their nomenclature nor in the attribution of competencies or even in their regulation, leaving such decisions to policy makers in each country (Delamaire & Lafortune, 2010; Hoskins, 2011). Therefore, nurses working in urgent care settings have different competencies, as well as different educational backgrounds, clinical experiences, and levels of autonomy according to each individual country. Thus, it is possible to find professionals in two countries who have the same job title but different accreditations, levels of training, and work experience. Moreover, it is not unlikely to find similar training profiles but different job titles in two different countries.

The starting point is the designation registered nurse (RN), which indicates that an individual has met the minimum training requirements of the nursing degree (Fitzpatrick et al., 2014; Henrik & Kerstin, 2009; Hudson & Marshall, 2008; Lambrou et al., 2015; Wong & Lau, 2008).

With additional training requirements, we find other designations. These requirements can be a postgraduate program, a specialization program, a complementary training program, the accreditation of work experience in the critical care area, or a combination of these.

Advanced practice nurses may hold the following titles: emergency nurse practitioner, advanced nurse practitioner, or clinical nurse specialist (Aftyka et al., 2014; Brysiewicz & Bruce, 2008; Christofis, 2001; Fitzpatrick et al., 2014; Hoskins, 2011; Hudson & Marshall, 2008; Scott & Brysiewicz, 2016). In general, these workers conduct their professional duties in the intrahospital setting (Considine et al., 2012; Delamaire & Lafortune, 2010; Hoskins, 2011; McClelland, 2012a, 2012b), although there is some reference to their participation in prehospital teams (Aftyka et al., 2014; Wong & Lau, 2008). In some countries, the nursing specialist in prehospital urgent care is given the designation of prehospital emergency nurse, and accreditation for this specialty is regulated by each country (Andersson et al., 2014; Cooper & Grant, 2009; Sjölin et al., 2015; Wihlborg et al., 2014). This role does not exist in all countries, and in the countries that do offer this accreditation the training requirements for specialization programs may differ.

In the region of Oceania, the clinical initiatives nurse (Cashin et al., 2007; Considine et al., 2012; Hudson & Marshall, 2008) must have work experience in an emergency care setting (Christofis, 2001; Considine et al., 2012) and has a level of autonomy lower than that of advanced practice nurses (Cashin et al., 2007) but higher than that of RNs.

Finally, the designation emergency care practitioner refers to professional nurses responsible for providing emergency nursing care based on the Anglo-Saxon model (Cooke, 2006; Cooper, O'Carroll, Jenkin, & Badger, 2008; Mason, Coleman, O'Keeffe, Ratcliffe, & Nicholl, 2006). These professionals combine advanced nursing and paramedical skills (Hoskins, 2011; Mason et al., 2006). The requirement to access training as an ECP is a degree in nursing or the completion of a program designed to train paramedics (Cooke 2006; Cooper & Grant, 2009; Mason et al., 2006). ECPs are fundamentally prehospital professionals, but they are also present in intrahospital settings (Cooper & Grant, 2009) and in primary care emergencies (Cooke, 2006).

The research related to these emergent profiles of emergency nurses has been directed toward their description based on the analysis of the assumed competencies (Andersson et al., 2012; Andersson et al., 2014; Cashin et al., 2007; Considine et al., 2012; Fitzpatrick et al., 2014; Henrik & Kerstin, 2009; McClelland, 2012b; Sjölin et al., 2015; Van Schuppen & Bierens, 2011; Wihlborg et al., 2014) and the benefits of their implementation (Cooke, 2006; Cooper & Grant, 2009; McClelland, 2012a; Miller Wilson, 2011). However, these studies are limited either by the description or comparison of some of the roles or by the description of the emerging roles in a delimited and specific territory.

No research has provided a specific description of the training of intrahospital and prehospital emergency care nurses focusing only on training requirements regardless of these professionals' designation; therefore, this is the main contribution of the current study.

Based on the available evidence, the aim of this work is to identify, group, and describe the training profiles of nurses who perform duties in emergency care in the five continents according exclusively to the accredited training requirements, and to identify the most frequent training profile in the world, which can be proposed as the most appropriate to follow. In addition, this study presents the different profiles existing in each of the countries analyzed and compares possible differences in nursing training for prehospital and intrahospital care.

Method

The method used was a narrative review with a subsequent content analysis.

Literature Sources

A search of the literature for potentially eligible articles was conducted in the following databases: Web of Science® Core Collection, MEDLINE®, SciELO, and ScienceDirect®. The same search strategy was designed and used in all the databases consulted using the following key words: emergency, nursing, practitioners, and out of hospital.

Inclusion and Exclusion Criteria

Publications in English and Spanish indexed between January 1, 2000, and May 1, 2017, were included in the process of article selection. The main objective of the articles selected was to describe one or several of the emergent roles of emergency care nursing. Articles that focused on describing nursing competencies in a pathology or specific emergency therapy were excluded.

Search Outcome

In the main collection of Web of Science, 68 articles were selected; 118 articles from MEDLINE were selected; and 141 from ScienceDirect were selected. The search conducted for the SciELO database did not return any articles with the specified criteria. Four additional records obtained from repositories were included. The titles and abstracts were evaluated to determine whether they fit the inclusion criteria. After screening the abstracts, 57 articles were selected for further review. Those articles that seemed to meet the selection criteria were read in their entirety and evaluated for inclusion in the current study. Disagreements were resolved by consensus among the authors. Each article selected included at least one use of the term emergency nursing in any of its nomenclatures.

Selection Process

Through a previously designed extraction template, the following data were obtained: role title, country, degree, postgraduate training and duration (number of years), complementary training, work experience and duration (number of years), and scope of performance (intrahospital or prehospital environment).

We assigned the name “record” to each appearance of the term emergency nursing in the analyzed documents, in any of its nomenclatures, but consistently attributed to a specific competency required to provide urgent care.

Postgraduate training refers to regulated training (master, expert, or specialty) received after completing a degree in nursing. Nonregulated training is called complementary training, which is certified by organizations such as professional associations, scientific societies, or departments of continuing training connected to health care centers. Previous work experience is used for those activities accredited in units of critical care services.

Data Analysis

For the adjustment and operation of the data, the following categories were used as nominal dichotomous variables (0 = absence; 1 = presence): degree training, postgraduate training, complementary training, work experience, and prehospital activity area. The categories postgraduate duration and duration of previous work experience were used as scale variables. The training profiles (TPs) have been obtained by combining the variables.

The quantitative analysis was performed using SPSS® (version 24.0) with cross tables for the identification and description of the profiles. The analysis of the differences between the training profiles of the prehospital and intrahospital emergency care nurses was conducted using a chi-square test with a level of significance of p < .05.

Results

After the complete reading of the 57 articles selected, 30 were included in this review. A total of 1,054 records (mentions of emergency nursing) were identified among 26 countries in the five continents.

Description of Training Profiles

The analysis of the variables of undergraduate training, postgraduate training, complementary training, and previous work experience for each record in crossed tables allows us to identify five training profiles worldwide: TP1, TP2, TP3, TP4, and TP5 (Table 1).

Identification of Training Profiles and Frequencies of the Variables that Constitute Each Profile

Table 1:

Identification of Training Profiles and Frequencies of the Variables that Constitute Each Profile

The most basic profile regarding competencies in emergency nursing is TP1. The only training requirement for this profile is a degree in nursing. According to the records, it is a rare profile in emergency care (1.9%).

Training profile 5 (TP5) is a profile comprising two requirements: the degree in nursing and the accreditation of work experience in critical care areas, although it does not specify the minimum time required for previous work experience (Table 2). This profile does not require postgraduate or complementary training. TP5 is the least frequent profile (1.8%) within emergency nursing.

Postgraduate Training and Work Experience Duration

Table 2:

Postgraduate Training and Work Experience Duration

TP3 profile is composed of additional qualifications and training complements. There are two possible itineraries to accredit additional training complements— through the accreditation of complementary training in emergencies, or through that of previous work experience in critical care. Unlike the previous profile (TP5), most records do specify the duration of accredited work experience, where the most frequent requirement regarding previous work experience is a period of 2 to 3 years (44.4%), followed by 1 to 2 years (40.3%). TP3 appears with a frequency of 20.5% over the total number of records found.

TP2 comprises a nursing degree, specific postgraduate training in emergency care, and previous work experience. It does not require additional training. It is the most demanding profile in terms of training requirements because it combines the accreditation of three of the four variables in 73.1% of the records. The duration of the most frequently specified postgraduate (51%) is 1 year, compared with 43% reporting to be longer than 1 year and up to 2 years. In all cases, the accredited work experience must be equal to or greater than 3 years. This profile is present in 10.9% of the records.

Finally, TP4 is the most frequent, corresponding to the training profile described in 64.9% of the records obtained. It combines undergraduate training and specific postgraduate training in emergency care, complemented with complementary training in 12.2% of the cases and with work experience in 11.6% of the records. The majority of the postgraduate degrees are up to 1 year (24.9%), followed by those with a duration greater than 1 year and up to 2 years (7.8%). The rest of the records do not specify the duration of the postgraduate training. The duration of work experience is divided into three categories: (a) 12.6% certify a work experience less than or equal to 1 year; (b) 70.8% between 2 and 3 years; and (c) 16.6% require more than 3 years of work experience.

Distribution of Training Profiles

The distribution of the training profiles in the five continents considered is shown in Table 3.

Distribution of the Training Profiles for the Five Continents Considered in the Current Study

Table 3:

Distribution of the Training Profiles for the Five Continents Considered in the Current Study

The analysis of the profiles by continent allows the identification of differences in the frequency of the variables that make up the TPs among the five continents, as well as among the countries studied for each continent.

In Africa, there are three training profiles: TP2, TP3, and TP4. The frequency of the mentioned profiles corresponds to 40.6%, 28%, and 31.4%, respectively. In this continent, 222 records were obtained from Ghana, Uganda, and South Africa individually, as well as from the sub-Saharan Africa region as a whole. The only variation with respect to other continents is detected in TP3, in which the percentage of records of the variables of work experience and complementary training are doubled compared with other continents. There is homogeneity in those profiles that accredit postgraduate training, and such qualifications are specified as postgraduates in a specialty format, mostly with a duration of 2 years. No differences were found in the profiles among the countries composing this continent.

The highest number of records (428 records, 40.6% of the total) was obtained in the European continent. Records were obtained from 10 countries in Europe: Cyprus (n = 9), Spain (n = 100), Finland (n = 24), the Netherlands (n = 33), Italy (n = 12), Poland (n = 17), Portugal (n = 26), Sweden (n = 124), Turkey (n = 3), and the United Kingdom (n = 80). Four training profiles coexist: TP1, TP2, TP3, and TP4. No differences were found between Europe and the other continents as far as TP1 and TP3 are concerned. TP2 is different from the other continents in the previous work experience variable, with an increased percentage of 50% of the records requiring previous work experience, except for Spain and the Netherlands, which are the only European countries where previous work experience was not recorded.

With regard to TP4, the training requirements composing this TP are found in most European countries. The main variations in this profile are found on the post-graduate training variable in the Netherlands, Portugal, and Turkey, where 52 records (16.6%) were obtained in which postgraduate training is not registered, and in the complementary training variable, which does not complement postgraduate training in eight of the 10 countries analyzed (Cyprus, Spain, Finland, Italy, Poland, Portugal, Sweden, United Kingdom).

In Oceania, four training profiles were identified: TP2, TP3, TP4, and TP5, divided into 138 records (13.09%). From these 138 records, 105 correspond to Australia and 33 to New Zealand. They present only variations in relation to other continents in TP3, in the variable of complementary training, which has only one record instead of 33%, and in TP4, in the variable of previous work experience, which in Oceania appears in 50% of the records.

The American continent accounts for a total of 168 records (15.93% of the total), distributed among the United States and Canada (105 records), South America (54), and Central America (9 records). In this continent, four training profiles (TP1, TP3, TP4, and TP5) were also identified, although records for TP3 were only obtained in the Caribbean. The single variation in relation to the other four continents studied was detected in TP3, in which the criterion of complementary training was found to prevail over that of previous work experience.

Finally, in Asia, 101 records were obtained, distributed among China, Nepal, Thailand, and Saudi Arabia. In this continent, only TP3 and TP4 were recorded, with TP4 being the most frequent profile with frequencies of 84.2%. The only variations compared with the other four continents were detected in TP3 in China, which presents an increase in records of complementary training and work experience of 33% to 50%, and in TP4 in Saudi Arabia, in which only one single case was found not to comprise postgraduate training.

Differences in the Training Profiles of Emergency Nursing in Intrahospital and Prehospital Settings

Statistically significant differences were found regarding the complementary training variables (p = .001) and work experience (p = .001). No significant differences were observed for the postgraduate training variable (p = .948). We can assume that the differences in the training profile for emergency nursing at intrahospital level and at prehospital level are defined by the complementary training received and by the accredited work experience. In the prehospital setting, the requirement for complementary training is more frequently accredited, whereas in intra-hospital care, it is more common to accredit previous work experience in the specific area.

The analysis by continents shows that the training differences between intrahospital and prehospital settings are registered in TP3 and TP4 in the continents of Central and South America, Oceania, and Europe. No differences were found in North America or Asia (Table 4).

Number of Records in the Training Profiles of Prehospital and Intrahospital Emergency Nursing Differences and Continents Where Those Differences Exist

Table 4:

Number of Records in the Training Profiles of Prehospital and Intrahospital Emergency Nursing Differences and Continents Where Those Differences Exist

Discussion

Five training profiles were identified in urgent care nursing worldwide. Common characteristics can be identified for these profiles regardless of their nomenclature. The accreditation of postgraduate training, complementary training, and/or work experience in four of the five training profiles analyzed place the nursing degree in the least legally required training requisite, thus evidencing the need to complement the training curriculum with additional training of a higher and more specific level.

The records obtained allow us to conclude that the training profiles for emergency care nurses worldwide are significantly demanding. We detected records where only a degree and competencies in urgent care are required in Europe and America. The most frequently noted training complement to the degree is an academic postgraduate program or specialty with a minimum duration of 1 year. These requirements correspond to those proposed in TP4, present in the four continents examined both in pre-hospital and intrahospital settings, which is in line with published studies proposing the postgraduate level as appropriate for the acquisition of specific competencies of emergency nursing (Bell et al., 2014; Brysiewicz & Bruce, 2008; Christofis, 2001; Considine et al., 2012; Delamaire & Lafortune, 2010; Wong & Lau, 2008) and training in advanced practice and research (Bell et al., 2014; Scott & Brysiewicz, 2016; Wong & Lau, 2008).

This literature review confirms there are two other ways to meet the needs of additional training: complementary training and work experience. The first is accepted if the contents are directly related to emergency nursing care and include advanced trauma life support (Christofis, 2001; Lambrou et al., 2015; Wong & Lau, 2008), and the second is considered an asset and a useful way to endorse increased specific knowledge and skills (Brysiewicz & Bruce, 2008; Griffin & Melby, 2006; Hudson & Marshall, 2008; McClelland, 2012a; Miller Wilson, 2011; Scott & Brysiewicz, 2016; Wong & Lau, 2008). At the intrahospital level, previous experience in anesthesia and critical care is valued (Christofis, 2001; Lambrou et al., 2015; Wong & Lau, 2008), whereas experience in the field is prioritized at prehospital level, justified by the specificity of the setting and the circumstances inherent to this type of care. The variable of previous work experience is the training requirement with greatest variability among the four continents and the countries analyzed.

Study Limitations

The main limitation of this study is related to the absence of regulations regarding training and registration of accredited professionals in many countries, which has forced this study to comprise the analysis of published scientific documents.

Another limitation is related to the process of data collection and its translation into records. The consideration of every mention of the term emergency nursing in any of its modalities as a record allowed the establishment of a useful unit of analysis but it also enabled a diversion of the weight of the statistical analyses in favor of the most present roles in literature, to the detriment of those less frequently present or of countries with a lower tradition of scientific publication. To compensate for such a limitation, the time filters of the search were extended to 18 years, thus including both novel and older roles, and the search was also specifically focused on each one of the five continents so that all could be represented.

Implications for Continuing Education and Staff Development

We consider that this work fulfills two fundamental roles for the training and performance of emergency nursing:

  • First, the global perspective of training in emergency nursing around the world shows the need to support specific training in the emergency area of a higher educational level than that of undergraduate training and is a point of homogeneity within the training differences detected in each country, for each of the roles detected.
  • Second, we consider that this work can provide some guidance regarding emergency nursing professionals' training needs and the most efficient training for the acquisition and performance of the competencies required. Some guidance may be useful for the professionals themselves, for employers, and especially for the agencies responsible for the accreditation, regulation, and registration of urgent care nursing.

Conclusion

The records obtained enable the highlighting and identification of differences in the training of emergency care nurses. In the European continent, a greater number of profiles of significant training demand and a greater variability in the profiles were found among the countries analyzed, especially with regard to previous work experience requirements and to the many options for complementary training. In Africa, the trend is homogeneity, with postgraduate training profiles in a specialty format; this may respond to the circumstance of an attempt to implement training models for health care professionals from European countries, which are considered more effective. In America and Oceania, where emergency nursing is mainly intrahospital, training requirements have increased with demands of postgraduate training and previous work experience in the area. Asia is committed to postgraduate training profiles for the acquisition of specific skills.

The differences in the training profiles of emergency care nurses in intrahospital and prehospital settings are based on the accreditation of complementary training and work experience, which are oriented toward the specific characteristics of the position. On the other hand, postgraduate training seems to be fundamental in both areas.

In light of the results found in this study regarding several countries, it would appear that the next step in the accreditation of training for specific emergency nursing care positions should be the regulation and registration of these professionals.

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Identification of Training Profiles and Frequencies of the Variables that Constitute Each Profile

Training Profile (TP)Undergraduate TrainingPostgraduate TrainingComplementary TrainingWork ExperienceTotal
TP120 (100%)00020 (1.9%)
TP2115 (100%)108 (93.9%)084 (73.1%)115 (10.9%)
TP3216 (100%)1 (0.5%)58 (26.9%)72 (33.4%)216 (20.5%)
TP4684 (100%)586 (85.6%)83 (12.2%)79 (11.6%)684 (64.9%)
TP519 (100%)0018 (94.7%)19 (1.8%)
Total1,054 (100%)695 (66%)141 (13.4%)253 (24.1%)1,054 (100%)

Postgraduate Training and Work Experience Duration

VariableTP1TP2TP3TP4TP5Total
Postgraduate training (years)
  ≤ 105511460202
  1 to 2046046092
  > 2000000
  Not specified0603930399
  Total010715850693
Work experience (years)
  ≤ 100010010
  1 to 200290029
  2 to 3003256088
  > 3084013097
  Not specified001101829
  Total084727918253

Distribution of the Training Profiles for the Five Continents Considered in the Current Study

ContinentTraining Profile (TP), n (%)Partial n (%)

TP1TP2TP3TP4TP5
Africa090 (40.6%)62 (28%)70 (31.4%)0222 (100%)
Europe14 (3.3%)21 (4.8%)84 (19.4%)314 (72.5%)0433 (100%)
Oceania04 (3.1%)8 (6.2%)99 (76.7%)18 (14%)129 (100%)
Americas6 (3.6%)046 (27.2%)116 (68.6%)1 (0.6%)169 (100%)
Asia0016 (15.8%)85 (84.2%)0101 (100%)
World (total)20 (1.9%)115 (10.9%)216 (20.5%)684 (64.9%)19 (1.8%)1054 (100%)

Number of Records in the Training Profiles of Prehospital and Intrahospital Emergency Nursing Differences and Continents Where Those Differences Exist

Training Profile (TP)ContinentScope of ActionAccreditation of Complementary TrainingAccreditation of Previous Work Experience
TP3EuropeIntrahospital setting6a11a
Prehospital setting00
Central AmericaIntrahospital setting00
Prehospital setting8a0
TP4EuropeIntrahospital setting04
Prehospital setting44a23
OceaniaIntrahospital setting15a
Prehospital setting0a
South AmericaIntrahospital setting02a
Prehospital setting38a0
Authors

Ms. Vazquez-Casares is Nurse, Departamento de Enfermería y Fisioterapia, Facultad de Ciencias de la Salud, and Dr. Vidal is Professor, Departamento de Psicología, Sociología y Filosofía, Universidad de León, León, Spain.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Ana Vazquez-Casares, RN, MSN, Nurse, Departamento de Enfermería y Fisioterapia, Facultad de Ciencias de la Salud, Universidad de León, Campus de Vegazana, 24071 León, Spain; e-mail: ana.vazquez@unileon.es.

Received: March 29, 2019
Accepted: July 17, 2019

10.3928/00220124-20191115-05

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