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ORIGINAL ARTICLE07-31-2023
Primary Health Care assessment in the COVID-19 pandemic from physicians’ and nurses’ perspective
Revista Brasileira de Enfermagem. 2023;76:e20220475
Abstract
ORIGINAL ARTICLEPrimary Health Care assessment in the COVID-19 pandemic from physicians’ and nurses’ perspective
Revista Brasileira de Enfermagem. 2023;76:e20220475
DOI 10.1590/0034-7167-2022-0475
Views0ABSTRACT
Objectives:
to assess the operationalization of Primary Health Care in the COVID-19 pandemic, according to Primary Care Assessment Tool: PCATool-Brasil attributes, from physicians’ and nurses’ perspective.
Methods:
a cross-sectional study, carried out with 99 physicians and nurses from Basic Health Units in a state in northeastern Brazil, with the aid of the adapted instrument PCATool-Brasil.
Results:
Essential Score was classified as high performance (6.6) and General Score as low performance (6.5). First Contact Access, Care Integration, and Community Guidance scores were <6.6. The best performances were attributed to the Longitudinality, Comprehensiveness and Family Guidance services (scores>6.6).
Conclusions:
the attributes of Primary Health Care, in general, showed values above or close to the cut-off point in the assessment. These data can support strategies for local and national managers to strengthen Primary Health Care in the COVID-19 pandemic and future public health emergencies.
Keywords:COVID-19Health Care Evaluation MechanismsHealth PersonnelHealth Services ResearchPrimary Health CareSee more -
ORIGINAL ARTICLE07-10-2023
Correlation between symptoms of depression, attitude, and self-care in elderly with type 2 diabetes
Revista Brasileira de Enfermagem. 2023;76(3):e20220741
Abstract
ORIGINAL ARTICLECorrelation between symptoms of depression, attitude, and self-care in elderly with type 2 diabetes
Revista Brasileira de Enfermagem. 2023;76(3):e20220741
DOI 10.1590/0034-7167-2022-0741
Views0See moreABSTRACT
Objectives:
to correlate depressive symptoms, attitude, and self-care of elderly people with type 2 diabetes.
Methods:
study developed with 144 elderly people with diabetes; carried out in Family Health Units. A semi-structured instrument was used to obtain data on the sociodemographic profile; the Geriatric Depression Scale (15 items), the Questionário de Atitudes Psicológicas do Diabetes [Psychological Attitudes of Diabetes Questionnaire], and the Diabetes Self-Care Activities Questionnaire (DSCA) were also used.
Results:
it was identified that 24.3% of the participants presented depressive symptoms, and 93.8% presented negative attitudes of coping. A greater adherence to self-care activities related to the practice of medication was observed. In the correlation between the scales, a negative and inversely proportional correspondence was noted between depressive symptomatology and physical activity (p=0.010) and foot care (p=0.006), likewise between attitude and foot care (p=0.009).
Conclusions:
self-care in elderly people with diabetes mellitus is influenced by depressive symptoms and negative coping attitudes.
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ORIGINAL ARTICLE07-10-2023
Metodologia Lean Seis Sigma para melhoria do processo de alta em uma unidade de terapia intensiva
Revista Brasileira de Enfermagem. 2023;76(3):e20220538
Abstract
ORIGINAL ARTICLEMetodologia Lean Seis Sigma para melhoria do processo de alta em uma unidade de terapia intensiva
Revista Brasileira de Enfermagem. 2023;76(3):e20220538
DOI 10.1590/0034-7167-2022-0538
Views0RESUMEN
Objetivos:
describir el proceso de implementación de Lean Six Sigma para mejorar el proceso de alta en una unidad de cuidados intensivos brasileña.
Métodos:
estudio prospectivo siguiendo el método de desarrollo de proyectos denominado DMAIC (Define-Measure-Analyze-Improve-Control). Este método consta de cinco fases, a saber: definición del proyecto, medición del punto de partida y recolección de datos, análisis de resultados, mejora en los procesos y control estadístico.
Resultados:
la aplicación de la metodología Lean Six Sigma fue efectiva para mejorar el proceso de alta de la unidad de cuidados intensivos a la unidad de hospitalización. Esta mejora representó una reducción en el tiempo promedio de alta de 189 a 75 minutos, totalizando una mejora del 61%.
Conclusiones:
este artículo demuestra la efectividad de la aplicación de la metodología Lean Six Sigma para mejorar el flujo de descarga en una unidad crítica, lo que resulta en la reducción de tiempo y desperdicio.
Keywords:Administração em SaúdeFluxo de TrabalhoGestão da QualidadeMelhoria de QualidadeUnidades de Terapia IntensivaSee more -
REVIEW07-10-2023
Lean Six Sigma methodology to improve the discharge process in a Brazilian intensive care unit
Revista Brasileira de Enfermagem. 2023;76(3):e20220538
Abstract
REVIEWLean Six Sigma methodology to improve the discharge process in a Brazilian intensive care unit
Revista Brasileira de Enfermagem. 2023;76(3):e20220538
DOI 10.1590/0034-7167-2022-0538
Views0ABSTRACT
Objectives:
to describe the Lean Six Sigma implementation process to improve the discharge process in a Brazilian health institution’s ICU.
Methods:
prospective study following the Define-Measure-Analyse-Improve-Control project development method. This method consists of five phases, namely: project definition, measurement of the starting point and data collection, analysis of results, improvement in processes, and statistical control.
Results:
applying Lean Six Sigma methodology following the Define-Measure-Analyse-Improve-Control in the discharge process from the intensive care unit to the inpatient unit was effective in improving processes. This improvement represented a reduction in the mean patient transfer time to the inpatient unit from 189 minutes to 75 minutes, representing a 61% improvement in discharge time.
Conclusions:
this article demonstrates the effectiveness of applying Lean Six Sigma methodology to improve the discharge flow in a critical unit, resulting in time and waste reduction.
Keywords:Health Services AdministrationIntensive Care UnitsPatient DischargeTotal Quality ManagementWorkflowSee more -
ORIGINAL ARTICLE07-10-2023
Primary care in supplementary health: assessment of costs in the care of older adult patients with heart diseases
Revista Brasileira de Enfermagem. 2023;76(3):e20220486
Abstract
ORIGINAL ARTICLEPrimary care in supplementary health: assessment of costs in the care of older adult patients with heart diseases
Revista Brasileira de Enfermagem. 2023;76(3):e20220486
DOI 10.1590/0034-7167-2022-0486
Views0ABSTRACT
Objectives:
to identify whether implementing a supplementary Primary Health Care (PHC) system makes it possible to reduce care costs for older adults with heart diseases.
Methods:
a retrospective cohort of 223 patients with heart disease aged ≥ 60 years. Data were obtained from medical records and cost databases, assessed for a period of one year before and after PHC implementation. The results were expressed as mean absolute frequencies for number of hospitalizations and as average annual expenses expressed in dollars (US$) in relation to cost data.
Results:
there was a reduction in hospitalization expenses after implementing supplementary PHC (p=0.01) and a decrease in the frequency of hospitalizations for the entire sample (p=0.006). There was a reduction in the frequency of consultations at the Emergency Room among frail older adults (p=0.011).
Conclusions:
there was a reduction in hospitalization costs and frequency of visits to the Emergency Room after supplementary PHC.
Keywords:AgedCardiovascular DiseasesCosts and Cost AnalysisLearning Health SystemPrimary Health CareSee more -
ORIGINAL ARTICLE07-10-2023
Occurrence and preventability of adverse events in hospitals: a retrospective study
Revista Brasileira de Enfermagem. 2023;76(3):e20220025
Abstract
ORIGINAL ARTICLEOccurrence and preventability of adverse events in hospitals: a retrospective study
Revista Brasileira de Enfermagem. 2023;76(3):e20220025
DOI 10.1590/0034-7167-2022-0025
Views0See moreABSTRACT
Objectives:
to analyze the incidence of preventable adverse events related to health care in adult patients admitted to public hospitals in Brazil.
Methods:
observational, analytical, retrospective study based on medical records review.
Results:
medical records from 370 patients were evaluated, 58 of whom had at least one adverse event. The incidence of adverse events corresponded to 15.7%. Adverse events were predominantly related to healthcare-related infection (47.1%) and procedures (24.5%). Regarding the adverse event severity, 13.7% were considered mild, 51.0% moderate, and 35.3% severe. 99% of adverse events were classified as preventable. Patients admitted to the emergency room had a 3.73 times higher risk for adverse events.
Conclusions:
this study’s results indicate a high incidence of avoidable adverse events and highlight the need for interventions in care practice.
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RESEARCH01-01-2016
Nurses’ managerial knowledge in the hospital setting
Revista Brasileira de Enfermagem. 2016;69(4):676-683
Abstract
RESEARCHNurses’ managerial knowledge in the hospital setting
Revista Brasileira de Enfermagem. 2016;69(4):676-683
DOI 10.1590/0034-7167.2016690409i
Views0See moreABSTRACT
Objective:
to analyze nurses’ managerial skills in the hospital setting, their perception of their own education and the relevance of training for their professional practice.
Method:
qualitative study based on the dialectical hermeneutics framework. Thirty-two nurses from three hospitals in the Brazilian state of Minas Gerais contributed to the study by taking part in six focus groups. Records were transcribed and three categories emerged from content analysis.
Results:
results evidenced the following managerial skills: supervision, leadership, decision making, planning and organization, as well as the relevance of education centers for their improvement and the continuing development of the nurses’ managerial skills.
Conclusion:
the authors believe this investigation will contribute for the improvement of nurses’ necessary managerial skills and also to identify gaps in this area of their education.
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RESEARCH01-01-2016
Analysis of obstetric care provided by the Mobile Emergency Care Service
Revista Brasileira de Enfermagem. 2016;69(4):669-675
Abstract
RESEARCHAnalysis of obstetric care provided by the Mobile Emergency Care Service
Revista Brasileira de Enfermagem. 2016;69(4):669-675
DOI 10.1590/0034-7167.2016690408i
Views1ABSTRACT
Objective:
analyze the pertinence of calls made by obstetric users of the Mobile Emergency Care Service (SAMU 192) of Botucatu-SP.
Method:
retrospective and analytical research. All records of prehospital obstetric care delivered by the SAMU 192 in 2012 were analyzed. To be considered responsive, calls should lead to referral to a reference obstetric hospital or be classified with the colors red, orange and yellow, according to risk criteria defined by the Ministry of Health.
Results:
considering the two outcomes evaluated: referral to a reference hospital and risk criteria defined by the Ministry of Health, 6.7% and 75.6% of the calls were not pertinent, respectively. There was no matching between outcomes, neither variation between primiparas and multiparas as regards the call pertinence.
Conclusion:
this study ratifies the need for implementing a risk classification protocol in obstetrics, and support managers in the organization, qualification and effective implementation of the Rede Cegonha.
Keywords:Emergence Medical ServicesEmergency NursingObstetric NursingPregnant WomenPrehospital ServicesSee more -
RESEARCH01-01-2016
Experiences with severe maternal morbidity: a qualitative study on the perception of women
Revista Brasileira de Enfermagem. 2016;69(4):662-668
Abstract
RESEARCHExperiences with severe maternal morbidity: a qualitative study on the perception of women
Revista Brasileira de Enfermagem. 2016;69(4):662-668
DOI 10.1590/0034-7167.2016690407i
Views0See moreABSTRACT
Objective:
to know and analyze the experiences of women who developed an episode of Severe Maternal Morbidity.
Method:
this is a qualitative study, in which we interviewed 16 women admitted to a tertiary level hospital, as a result of this morbid state. We used content analysis in data processing.
Results:
two categories were identified: “Understanding maternal morbidity as a negative presence” and “Moving ahead: on constant alert”. The interviewees mentioned negative aspects, such as treatment difficulties and hospitalization, feelings of fear, concern for the fetus, frustration with the idealized pregnancy, trauma; and positive aspects, such as learning and the expression of the divine will in the experience of illness.
Conclusion:
effective care during the prenatal period, delivery and postpartum period should provide adequate support for the prevention and assistance in Severe Maternal Morbidity.
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RESEARCH01-01-2016
Dialogue: network that intertwines the pedagogical relationship into the practical-reflective teaching
Revista Brasileira de Enfermagem. 2016;69(4):654-661
Abstract
RESEARCHDialogue: network that intertwines the pedagogical relationship into the practical-reflective teaching
Revista Brasileira de Enfermagem. 2016;69(4):654-661
DOI 10.1590/0034-7167.2016690406i
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Objective:
to understand how dialogue occurs in the pedagogical relation in the practical reflective teaching in an undergraduate program in nursing.
Method:
qualitative research, case study. Data collection was conducted from May 2013 to September 2014 with eight professors of Nursing, by means of observation and interviews. Data analysis followed the operational proposal constituted by the exploratory stage and the interpretive stage.
Results:
point the dialogue established within the pedagogical relation as a challenge to be faced in practical-reflective teaching, so professor and student build a relationship that foster thought and action in the theoretical context and in the field of practice.
Conclusion:
in establishing a dialogic-reflective tone in the pedagogical relationship, the professor opens paths to new discoveries, enabling the creation of teaching-learning spaces that stimulate autonomy, abilities, and critical and reflective attitudes of students along their education.
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RESEARCH01-01-2016
Nursing care through the perception of hospitalized children
Revista Brasileira de Enfermagem. 2016;69(4):646-653
Abstract
RESEARCHNursing care through the perception of hospitalized children
Revista Brasileira de Enfermagem. 2016;69(4):646-653
DOI 10.1590/0034-7167.2016690405i
Views0See moreABSTRACT
Objective:
to describe the perception of hospitalized children of school age, on nursing care and understand what are, from their perspective, the best ways to address it to when performing such care.
Method:
qualitative, descriptive, exploratory research, with concepts of Vygotsky used as theoretical framework. The data collection occurred through interviews mediated by drawings and was performed with ten school children, with the interview later transcribed and submitted to a thematic analysis.
Results:
showed the importance of playing during hospitalization, of a friendly and caring approach and providing explanations regarding the performed procedures.
Conclusion:
nursing professionals need to consider how the children would like to receive the care being provided, so that their singularities are respected, characterizing nursing actions according to a perspective of the whole human being.
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RESEARCH01-01-2016
Cost of dressings for prevention of sacral pressure ulcers
Revista Brasileira de Enfermagem. 2016;69(4):641-645
Abstract
RESEARCHCost of dressings for prevention of sacral pressure ulcers
Revista Brasileira de Enfermagem. 2016;69(4):641-645
DOI 10.1590/0034-7167.2016690404i
Views0See moreABSTRACT
Objective:
to identify costs of dressings to prevent sacral pressure ulcers in an adult intensive care unit in Paraná, Brazil.
Methods:
secondary analysis study with 25 patients admitted between October 2013 and March 2014, using transparent polyurethane film (n=15) or hydrocolloid dressing (n=10) on the sacral region. The cost of each intervention was based on the unit amount used in each type of dressing, and its purchase price (transparent film = R$15.80, hydrocolloid dressing = R$68.00).
Results:
the mean cost/patient was R$23.17 for use of transparent film and R$190.40 for use of hydrocolloid dressing. The main reason for changing the dressing was detachment.
Conclusion:
the transparent film was the most economically advantageous alternative to prevent sacral pressure ulcers in critical care patients. However, additional studies should be carried out including assessment of the effectiveness of both dressings.
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RESEARCH01-01-2016
Health practices: the view of the black elderly population in a terreiro community
Revista Brasileira de Enfermagem. 2016;69(4):633-640
Abstract
RESEARCHHealth practices: the view of the black elderly population in a terreiro community
Revista Brasileira de Enfermagem. 2016;69(4):633-640
DOI 10.1590/0034-7167.2016690403i
Views1See moreABSTRACT
Objective:
to understand health practices of black, elderly people in a terreiro community (community of followers of traditional African-Brazilian religions).
Method:
qualitative descriptive study under the Black-African paradigm of civilization constituted by the Black-African cultural complex and the structuring elements of the African cosmovision. Semi-structured interviews were carried out from July to September 2013, with six black older people from a terreiro community in Porto Alegre, RS.
Results:
thematic content analysis resulted in the following categories: Ancestry; Belonging: the way to know and practice health; Health knowledge and practices in terreiro communities; and Complementarity: promoting health in the terreiro and traditional medicine and its respective subcategories.
Conclusion:
the study understood the importance of having a knowledge of the practices of African traditions in both the lifestyle and health of the older black population to help with nursing planning and interventions in response to their needs.
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ORIGINAL ARTICLE11-22-2024
Safe practices for prevention and management of antineoplastic agent extravasation: development of an educational video
Revista Brasileira de Enfermagem. 2024;77(5):e20240172
Abstract
ORIGINAL ARTICLESafe practices for prevention and management of antineoplastic agent extravasation: development of an educational video
Revista Brasileira de Enfermagem. 2024;77(5):e20240172
DOI 10.1590/0034-7167-2024-0172
Views0ABSTRACT
Objectives:
to develop, validate, and evaluate an educational video on the prevention and management of antineoplastic agent extravasation, aimed at nursing professionals.
Methods:
this methodological study was developed according to Falkembach’s theoretical framework, which outlines five phases in the production of educational video materials: analysis and planning, modeling, implementation, evaluation, and distribution.
Results:
content validation demonstrated agreement above the minimum threshold stipulated. The overall Content Validity Index was 90.8%, and it was 94.2% among the content and technical evaluation judges, respectively. The target audience evaluated the video positively, highlighting the importance of the content, the clarity of the language used, and the understanding of the information pertinent to the topic.
Conclusions:
the video proved to be an appropriate strategy for instructing interventions on the prevention and management of extravasation, with the potential to improve educational practices among nursing professionals.
Keywords:Antineoplastic AgentsEducational TechnologyExtravasation of Diagnostic and Therapeutic MaterialsInstructional Film and VideoNursingSee more -
REVIEW11-22-2024
Telenursing contributions in Primary Health Care in the COVID-19 pandemic context: an integrative review
Revista Brasileira de Enfermagem. 2024;77(5):e20240093
Abstract
REVIEWTelenursing contributions in Primary Health Care in the COVID-19 pandemic context: an integrative review
Revista Brasileira de Enfermagem. 2024;77(5):e20240093
DOI 10.1590/0034-7167-2024-0093
Views1See moreABSTRACT
Objective:
to identify telenursing contributions in Primary Health Care during the COVID-19 pandemic.
Methods:
an integrative literature review, conducted between January and August 2022 in the PubMed, CINAHL, LILACS, BDENF, Scopus, WoS, EMBASE and SciELO databases. A total of 493 studies was found, 62 were read in full, and of these, 16 were selected. For analysis, a dynamic reading of the studies and synthesis of the main results were carried out.
Results:
the main results highlighted telenursing practice as a challenge for professionals and the population. Among the contributions and positive points and aspects that require improvement, practice showed promise when considered in a post-pandemic scenario.
Final considerations:
through telenursing, the population’s access to Primary Health Care was guaranteed in the face of the COVID-19 pandemic. However, a critical look at current technological advances in healthcare is necessary.
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ORIGINAL ARTICLE11-22-2024
Percepções de pessoas com deficiência física sobre acessibilidade e condições sociais: intervenções para enfermagem de reabilitação
Revista Brasileira de Enfermagem. 2024;77(5):e20240005
Abstract
ORIGINAL ARTICLEPercepções de pessoas com deficiência física sobre acessibilidade e condições sociais: intervenções para enfermagem de reabilitação
Revista Brasileira de Enfermagem. 2024;77(5):e20240005
DOI 10.1590/0034-7167-2024-0005
Views0RESUMEN
Objetivos:
analizar las experiencias de personas con discapacidad física adquirida en cuanto a accesibilidad y condiciones sociales; identificar intervenciones de rehabilitación dirigidas por enfermeras para la accesibilidad y condiciones sociales; determinar indicadores sensibles a la enfermería para mejorar la accesibilidad y condiciones sociales.
Métodos:
estudio cualitativo descriptivo-exploratorio utilizó entrevistas semiestructuradas con personas con discapacidad física adquirida mediante muestreo intencionado en bola de nieve para cumplir con todos los objetivos. El análisis de datos siguió los principios del análisis de contenido de Bardin. Los objetivos 2 y 3 se lograron mediante un enfoque teórico reflexivo.
Resultados:
los 27 participantes informaron desafíos de accesibilidad, que impactan las actividades de la vida diaria y las condiciones sociales. Esto influye en la enfermería de rehabilitación, dando lugar a tres campos de intervención: Evaluar la capacidad para realizar actividades diarias y los factores que influyen; Desarrollar e implementar capacitación para la realización de actividades diarias; Promover la movilidad, la accesibilidad y la participación social.
Consideraciones Finales:
a partir de las experiencias de los participantes, identificamos intervenciones de rehabilitación dirigidas por enfermeras para promover la accesibilidad y condiciones sociales.
Keywords:Acessibilidade ArquitetónicaCondições SociaisEnfermagem em ReabilitaçãoObjetivos de Desenvolvimento SustentávelPessoas com DeficiênciaSee more -
ORIGINAL ARTICLE11-22-2024
Rondas a beira leito no ambiente hospitalar na perspectiva de equipes multiprofissionais de saúde
Revista Brasileira de Enfermagem. 2024;77(5):e20230493
Abstract
ORIGINAL ARTICLERondas a beira leito no ambiente hospitalar na perspectiva de equipes multiprofissionais de saúde
Revista Brasileira de Enfermagem. 2024;77(5):e20230493
DOI 10.1590/0034-7167-2023-0493
Views0RESUMEN
Objetivo:
Analizar la configuración de las relaciones de poder entre el equipo multiprofesional en el proceso de rondas de cabecera en el hospital.
Método:
Investigación cualitativa con datos analizados a través del análisis del discurso, basado en el marco teórico de Michel Foucault. De septiembre a diciembre de 2022, realizamos entrevistas y observaciones de campo con el equipo multiprofesional de un hospital de Belo Horizonte, Minas Gerais, Brasil, así como entrevistas cualitativas semiestructuradas con 37 profesionales.
Resultados:
Los participantes señalaron que las experiencias de los profesionales involucrados en las rondas de cabecera dependen de cómo el médico conduce el proceso, y el proceso centrado en el médico dificulta la participación de otros profesionales del equipo.
Consideraciones finales:
La forma en que los hospitales organizan las rondas de cabecera no promueve la articulación del conocimiento de sus profesionales. Además, dificulta la circulación del poder y perjudica el trabajo interdisciplinario en un proceso que mantiene al médico como actor principal de las decisiones clínicas.
Keywords:Conhecimentos, Atitudes e Prática em SaúdeEquipe de Assistência MultidisciplinarHospitaisPrática ProfissionalRelações InterprofissionaisSee more -
ORIGINAL ARTICLE11-22-2024
Bedside rounds in the hospital environment from the perspective of multiprofessional health teams
Revista Brasileira de Enfermagem. 2024;77(5):e20230493
Abstract
ORIGINAL ARTICLEBedside rounds in the hospital environment from the perspective of multiprofessional health teams
Revista Brasileira de Enfermagem. 2024;77(5):e20230493
DOI 10.1590/0034-7167-2023-0493
Views0ABSTRACT
Objective:
To analyze the configuration of power relations among the multiprofessional team in the bedside round process in the hospital.
Methods:
Qualitative research with data analyzed through discourse analysis, based on Michel Foucault’s theoretical framework. From September to December 2022, we conducted interviews and field observations with the multiprofessional team at a hospital in Belo Horizonte, Minas Gerais, Brazil, as well as qualitative, semi-structured interviews with 37 professionals.
Results:
The participants pointed out that the experiences of the professionals involved in bedside rounds depend on how the physician conducts the process, and the physician-centered process makes it difficult for other professionals in the team to participate.
Final considerations:
The way hospitals organize bedside rounds does not promote knowledge articulation for their professionals. It hinders the circulation of power and harms interdisciplinary work in a process that maintains the physician as the main actor in clinical decisions.
Keywords:Health Knowledge, Attitudes, PracticeHospitalsInterprofessional RelationsPatient Care TeamProfessional PracticeSee more -
REVIEW11-22-2024
Transition to family parenting in the face of the first child: a scoping review
Revista Brasileira de Enfermagem. 2024;77(5):e20230487
Abstract
REVIEWTransition to family parenting in the face of the first child: a scoping review
Revista Brasileira de Enfermagem. 2024;77(5):e20230487
DOI 10.1590/0034-7167-2023-0487
Views1See moreABSTRACT
Objectives:
to identify and summarize the elements that characterize the family transition process in relation to the first child.
Methods:
a scoping review was carried out based on JBI methodology, in six databases, following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews checklist.
Results:
ten articles were included with factors characterizing the transition, such as hindering/facilitating conditions that influence the process, important support structures in adaptation and strategies/responses used in the transition process.
Final Considerations:
elements characterizing the transition process in relation to the first child were identified. However, no theoretical explanation for this was identified. Further research should be carried out to obtain a deeper understanding of this process.
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