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REVIEW01-01-2018
Patient safety and infection control: bases for curricular integration
Revista Brasileira de Enfermagem. 2018;71(3):1170-1177
Abstract
REVIEWPatient safety and infection control: bases for curricular integration
Revista Brasileira de Enfermagem. 2018;71(3):1170-1177
DOI 10.1590/0034-7167-2017-0314
Views0See moreABSTRACT
Objective:
To analyze curricular integration between teaching of patient safety and good infection prevention and control practices.
Method:
Integrative review, designed to answer the question: “How does curricular integration of content about ‘patient safety teaching’ and content about ‘infection prevention and control practices’ occur in undergraduate courses in the health field?”. The following databases were searched for primary studies: CINAHL, LILACS, ScienceDirect, Web of Science, Scopus, Europe PMC and MEDLINE.
Results:
The final sample consisted of 13 studies. After content analysis, primary studies were grouped into two subject categories: “Innovative teaching practices” and “Curricular evaluation.
Conclusion:
Patient safety related to infection prevention and control practices is present in the curriculum of health undergraduate courses, but is not coordinated with other themes, is taught sporadically, and focuses mainly on hand hygiene.
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REVIEW01-01-2018
Dry Eye Syndrome in Intensive Care Units: a concept analysis
Revista Brasileira de Enfermagem. 2018;71(3):1162-1169
Abstract
REVIEWDry Eye Syndrome in Intensive Care Units: a concept analysis
Revista Brasileira de Enfermagem. 2018;71(3):1162-1169
DOI 10.1590/0034-7167-2016-0582
Views0See moreABSTRACT
Purpose:
To analyse the concept of Dry Eye Syndrome in patients admitted to Intensive Care Units (ICU).
Method:
This is a concept analysis, according to Walker’s and Avant’s method, conducted using an integrative review, through search in the database. Science Direct, Scopus, Cinahl, Pubmed, Lilacs, Cochrane and Web of Science. The following keywords were used: “Keratoconjuntivite Sicca”, “Risk Factors”, “Dry eye Syndromes” and “Intensive Care Units”. After selection, 85 articles have been kept.
Results:
Antecedents found: age, lagophthalmos, environmental factors, use of medications, systemic diseases, mechanical ventilation and eye surgeries. Attributes: Tear Break-up Time < 10 s, Schirmer’s test I < 10 mm, Schirmer’s test II < 5 mm and signs and symptoms. Consequents: eye damage and discomfort; unstable vision. The Model Case and the Contrary Case were used to illustrate it.
Conclusion:
The research provided clarification of the concept and consequent understanding of the Dry Eye Syndrome, which is preventable especially in ICU.
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REVIEW01-01-2018
Institutional violence during the parturition process in Brazil: integrative review
Revista Brasileira de Enfermagem. 2018;71(3):1152-1161
Abstract
REVIEWInstitutional violence during the parturition process in Brazil: integrative review
Revista Brasileira de Enfermagem. 2018;71(3):1152-1161
DOI 10.1590/0034-7167-2017-0238
Views0See moreABSTRACT
Objective:
To identify the types of institutional violence of childbirth reported by the woman, the birth companion and health professionals.
Method:
Integrative review that analyzed 33 articles in the LILACS, BDENF, INDEXPSI, regional SciELO, Scopus, Web Of Science and PubMed databases.
Results:
Women were the main violence rapporteur, with predominance of the psychological type. Precarious infrastructure and the imposition of professional decisions were identified by the companion as violence. For health professionals, performing procedures without consent does not characterize violence, but guarantees childbirth security.
Final considerations:
The most common types of violence in Brazilian maternity hospitals are psychological, physical and structural. Most of the time, violence is reported by women, although professionals also perceive and admit its perpetuation.
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Education practices: research-action with nurses of Family Health Strategy
Revista Brasileira de Enfermagem. 2018;71(3):1144-1151
Abstract
Education practices: research-action with nurses of Family Health Strategy
Revista Brasileira de Enfermagem. 2018;71(3):1144-1151
DOI 10.1590/0034-7167-2017-0284
Views0ABSTRACT
Objective:
to identify the factors that determine the implementation of educational practices of health promotion and to construct proposals to implement the educational actions of the nurses of the Family Health Units (FHU).
Method:
research-action in which individual interviews and focus group were conducted, with 17 nurses from 12 FHU in the city of Cruzeiro do Sul, Acre state, Brazil. The results were organized by the thematic analysis method.
Results:
the thematic units emerged from the analysis: dichotomy between knowledge and doing in the production of care and health; the nurse’s qualification for educational practices; and conditions favorable to health education practices.
Conclusion:
the thematic analysis showed that the educational practice is hampered by the high demand for care in the unit, lack of physical structure and professional qualification for health education. In the action phase, nurses and local managers agreed on actions to improve the quality of educational practices.
Keywords:Collective HealthCommunity Health NursingFamily HealthHealth EducationPublic Health NursingSee more -
Qualification of the family caregiver to the application of the Educational Technology in Health
Revista Brasileira de Enfermagem. 2018;71(3):1135-1143
Abstract
Qualification of the family caregiver to the application of the Educational Technology in Health
Revista Brasileira de Enfermagem. 2018;71(3):1135-1143
DOI 10.1590/0034-7167-2017-0163
Views0See moreABSTRACT
Objective:
To evaluate the changes in the participation of the family caregiver in the treatment of the hypertensive person with the application of the Educational Technology in Health (ETH).
Method:
Participant research carried out in a Primary Health Care Unit with 11 family caregivers (FC). The ETH was elaborated based on health education and applied in ten meetings between June and August 2016. We organized the results into categories.
Results:
FCs experienced learning experiences through the exchange of information, socialization of experiences, and linkage establishments. The FCs were encouraged to share their doubts and experiences, so that, supported by listening to the professional, they felt welcomed and determined to fulfill their role with hypertensive relatives.
Final considerations:
The changes that have taken place have been highlighted in the learning of FCs and their commitment to family and self-care, as well as to the conviction that the family environment is indicated to make these changes effective.
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Discursive archaeology: constituting knowledge of militant nurses in trade associations
Revista Brasileira de Enfermagem. 2018;71(3):1128-1134
Abstract
Discursive archaeology: constituting knowledge of militant nurses in trade associations
Revista Brasileira de Enfermagem. 2018;71(3):1128-1134
DOI 10.1590/0034-7167-2017-0277
Views0See moreABSTRACT
Objective:
To analyze the constituting knowledge of militant nurses in trade associations.
Method:
Historical research, based on the oral history method, with a qualitative approach carried out with 11 nurses who are/were militants for professional issues since the 1980s in the state of Bahia. The data collected through semi-structured interviews were organized in the software n-vivo 10 and analyzed based on dialectical hermeneutics.
Results:
We identified pedagogical, administrative, public health, sociological, and trade union background knowledge as constituent of militant individuals.
Final considerations:
The constituting knowledge of militant nurses are inscribed in the Social Sciences, distanced from biomedical knowledge and power, pointing at ways for structuring nursing curricula. We identified the Brazilian Association of Nursing as a space for political formation.
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Coordination of health care with the community in the clinical management of tuberculosis
Revista Brasileira de Enfermagem. 2018;71(3):1122-1127
Abstract
Coordination of health care with the community in the clinical management of tuberculosis
Revista Brasileira de Enfermagem. 2018;71(3):1122-1127
DOI 10.1590/0034-7167-2017-0255
Views0See moreABSTRACT
Objective:
determine the coordination of Primary Health Care with community resources in the clinical management of tuberculosis.
Method:
descriptive study, of quantitative approach, with participation of one hundred health professionals. Part of a questionnaire was used in evaluating local institutional capacity for the model of chronic conditions care, adapted for tuberculosis care.
Results:
the coordination between health units, individuals with tuberculosis, and community organizations; the partnerships between institutions and local health councils/committees showed limited capacity. On the other hand, the component for the participation of the Community Health Agent presented more favorable capacity.
Conclusion:
the municipality has unfavorable capacity for coordination of health units and the community. It is reinforced the need to promote these coordinations in search of symptomatic cases in the communities, in the directly observed treatment, and in promoting the association between different social actors.
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ERRATUM01-13-2024
ERRATUM
Revista Brasileira de Enfermagem. 2024;77(6):e2024n6e08
Abstract
ERRATUMERRATUM
Revista Brasileira de Enfermagem. 2024;77(6):e2024n6e08
DOI 10.1590/0034-7167.20247706e08
Views0In the article “Brazilian nursing specific situation, middle and micro-range theories: a bibliometric study”, with DOI number: , published in Revista Brasileira de Enfermagem, 2024;77(4):e20230520, Chart 1:Where it read:[…]See more -
ERRATUM01-13-2024
ERRATA
Revista Brasileira de Enfermagem. 2024;77(6):e2024n6e07
Abstract
ERRATUMERRATA
Revista Brasileira de Enfermagem. 2024;77(6):e2024n6e07
DOI 10.1590/0034-7167.20247706e06pt
Views0No artigo “Crenças e atitudes de pais ou responsáveis legais sobre a vacinação infantil: revisão de escopo”, com número DOI: , publicado no periódico Revista Brasileira de Enfermagem, 2024;77(4):e20240126, página 5:Onde se lia:[…]See more -
ORIGINAL ARTICLE01-13-2024
Indicators associated with severity and mortality in hospitalized people with HIV: A retrospective cohort
Revista Brasileira de Enfermagem. 2024;77(6):e20240204
Abstract
ORIGINAL ARTICLEIndicators associated with severity and mortality in hospitalized people with HIV: A retrospective cohort
Revista Brasileira de Enfermagem. 2024;77(6):e20240204
DOI 10.1590/0034-7167-2024-0204
Views0See moreABSTRACT
Objectives:
to compare the sociodemographic and clinical severity indicators of hospitalized people with HIV in relation to clinical outcomes and urgent hospital admission.
Methods:
a retrospective cohort study was conducted with 102 medical records of HIV-infected individuals hospitalized in a hospital in southern Brazil. In addition to descriptive analysis, Fisher’s exact test, Pearson’s Chi-square, and logistic regression were used.
Results:
the data showed a significant direct effect on severity indicators in the following variables: male sex (p=0.013), skin color (p=0.023), level of education (p=0.000), urgent admissions (p=0.000), late diagnosis (p=0.001), diabetes mellitus (p=0.001), hypertension (p=0.004), kidney disease (p=0.002), high viral load (p=0.006), CD4+ count below 200 (p=0.005), fever (p=0.016), weight loss (p=0.013), co-infection with hepatitis C (p=0.004), and mortality (p=0.007).
Conclusions:
three sociodemographic and thirteen clinical markers were identified as being associated with the risk of clinical deterioration in hospitalized people with HIV.
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ORIGINAL ARTICLE01-13-2024
Nurses’ perspectives on the use of telemonitoring in the management of people with diabetes and hypertension
Revista Brasileira de Enfermagem. 2024;77(6):e20230481
Abstract
ORIGINAL ARTICLENurses’ perspectives on the use of telemonitoring in the management of people with diabetes and hypertension
Revista Brasileira de Enfermagem. 2024;77(6):e20230481
DOI 10.1590/0034-7167-2023-0481
Views1See moreABSTRACT
Objectives:
to understand the perspective of nurses on the use of telemonitoring in the management of people with type 2 diabetes mellitus and arterial hypertension in primary care.
Methods:
this qualitative research involved sixteen nurses from eight municipalities in Paraná. Data were collected between November 2022 and January 2023 through inperson or remote interviews, which were audio-recorded and subjected to content analysis.
Results:
according to the nurses, telemonitoring enhances users’ knowledge about these conditions, communication and connection with the team, and productivity. However, the lack of electronic resources and equipment, high staff turnover, low user adherence, and the limited availability of professional time present significant challenges.
Final Considerations:
the effective implementation and operation of telemonitoring in the management of people with diabetes and hypertension involve both potential benefits and barriers. It is essential to have the availability of human and technological resources, managerial support, and the commitment of professionals and users.
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ORIGINAL ARTICLE01-13-2024
Knowledge, Attitudes, and Practices of nurses regarding blood culture collection
Revista Brasileira de Enfermagem. 2024;77(6):e20230424
Abstract
ORIGINAL ARTICLEKnowledge, Attitudes, and Practices of nurses regarding blood culture collection
Revista Brasileira de Enfermagem. 2024;77(6):e20230424
DOI 10.1590/0034-7167-2023-0424
Views0ABSTRACT
Objectives:
to investigate the knowledge, attitudes, and practices of nurses regarding blood culture collection.
Methods:
a cross-sectional study was conducted in five Brazilian public hospitals with 112 nurses. Data were collected using an adapted questionnaire and analyzed through descriptive and inferential statistics.
Results:
nurses who did not consider themselves capable of collecting blood cultures had a 72% lower chance of performing the collection at the recommended site and an 83% lower chance of using the same needle for blood inoculation into the vials. Nurses working in the emergency department had a 75% lower chance of knowing the international benchmark for blood culture contamination rates, and those with less than 5 years in the position decreased their chance of accuracy in this matter by 79%.
Conclusions:
there are gaps in the knowledge, attitudes, and practices of nurses regarding blood culture collection. Standardization of the technique, periodic education, supervision and guidance of the collection team, and process auditing are recommended coping strategies.
Keywords:Blood CultureBlood Specimen CollectionHealth Knowledge, Attitudes, PracticeNursing CareQuality of Health CareSee more -
ORIGINAL ARTICLE01-13-2024
Evaluation of care for people with HIV in Primary Health Care: construct validation
Revista Brasileira de Enfermagem. 2024;77(6):e20230190
Abstract
ORIGINAL ARTICLEEvaluation of care for people with HIV in Primary Health Care: construct validation
Revista Brasileira de Enfermagem. 2024;77(6):e20230190
DOI 10.1590/0034-7167-2023-0190
Views0ABSTRACT
Objectives:
to verify the construct validation of an instrument for evaluating care for people living with HIV in Primary Health Care.
Methods:
methodological study carried out in 2021 with 260 health professionals in Recife, PE. Validation based on the internal structure was carried out at this stage using exploratory and confirmatory factor analysis, and validity based on item response theory.
Results:
the validation determined the retention of five factors and 63 items. The instrument’s internal consistency and quality of fit was 0.90, the Tukey-Lewis index was 0.915 and the comparative fit index was 0.918 in the confirmatory factor analysis. The indication for the absolute majority of items is adequate fit.
Conclusions:
the instrument has construct validity, making it possible to use it to evaluate the decentralization process and care for People Living with HIV in Primary Health Care.
Keywords:Acquired Immunodeficiency SyndromeComprehensive Health CareHIVPrimary Health CareProgram EvaluationSee more -
ORIGINAL ARTICLE01-10-2024
Inventory of ethical problems in mobile pre-hospital care
Revista Brasileira de Enfermagem. 2024;77:e20230539
Abstract
ORIGINAL ARTICLEInventory of ethical problems in mobile pre-hospital care
Revista Brasileira de Enfermagem. 2024;77:e20230539
DOI 10.1590/0034-7167-2023-0539
Views0See moreABSTRACT
Objective:
to construct and validate the content of an inventory of ethical problems experienced by nurses in mobile pre-hospital care.
Method:
a psychometric approach study, developed with the following stages: (1) instrument construction through a theoretical matrix based on deliberative bioethics, scoping review and online qualitative research; (2) content validity by judges; (3) pre-testing with Mobile Emergency Care Service nurses in various Brazilian states. For content validity analysis, the Content Validity Ratio was calculated (CVR>0.45 for judges and CVR>0.35 for the target population).
Results:
the instrument had 44 items, distributed across four dimensions.
Final considerations:
the constructed instrument presented sources of evidence of content validity, providing good psychometric measurements and constituting a useful tool for nurses’ practice in the pre-hospital setting.
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ORIGINAL ARTICLE12-16-2024
Nursing team’s perceptions about care for pregnant women in a psychiatric unit
Revista Brasileira de Enfermagem. 2024;77(6):e20230186
Abstract
ORIGINAL ARTICLENursing team’s perceptions about care for pregnant women in a psychiatric unit
Revista Brasileira de Enfermagem. 2024;77(6):e20230186
DOI 10.1590/0034-7167-2023-0186
Views0See moreABSTRACT
Objectives:
to understand the nursing team’s perception in relation to the care provided to pregnant women with mental disorders admitted to a psychiatric hospital unit.
Methods:
Convergent Care Research carried out between August and December 2021, through semi-structured interviews with 25 nursing professionals from a Psychiatric Unit from a reference Hospital in Southern Brazil.
Results:
the organized and analyzed data resulted in two thematic categories: Technical, generic and impersonal care; and From impersonality to the singularity of nursing care. Ensuring unique care for pregnant women with mental disorders means giving them a meaning of existence and providing care from a multidimensional and continuous perspective.
Final Considerations:
nursing care for pregnant women in psychiatric hospitalization requires continuous professional qualification, interactive technologies and support for the nursing process, in addition to promoting singular and multidimensional care.
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ORIGINAL ARTICLE12-16-2024
Bladder ultrasound: evidence of content validity of a checklist for training nurses
Revista Brasileira de Enfermagem. 2024;77(6):e20230183
Abstract
ORIGINAL ARTICLEBladder ultrasound: evidence of content validity of a checklist for training nurses
Revista Brasileira de Enfermagem. 2024;77(6):e20230183
DOI 10.1590/0034-7167-2023-0183
Views0See moreABSTRACT
Objectives:
to develop and analyze evidence of content validity of a checklist for training nurses in measuring bladder volume through ultrasound.
Methods:
a methodological study, consisting of three stages: literature review; instrument item preparation; and analysis of evidence of content validity. The Content Validity Index (CVI) and Gwet’s AC2 were used for content validity analyses.
Results:
the checklist consisted of 23 items. The CVIs for clarity, relevance and dimensionality were 0.99, 0.99 and 0.98 respectively, and the CVIs for Gwet’s AC2 with coefficients for clarity, relevance and dimensionality were 0.89, 0.97 and 0.95, respectively, with p<0.001.
Conclusions:
the checklist developed for training nurses in measuring bladder volume through ultrasound achieved adequate evidence of content validity, and can be used to train nurses in clinical practice and future research.
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ORIGINAL ARTICLE12-16-2024
Childbirth care by health professionals: conflicting practices in obstetrics
Revista Brasileira de Enfermagem. 2024;77(6):e20230129
Abstract
ORIGINAL ARTICLEChildbirth care by health professionals: conflicting practices in obstetrics
Revista Brasileira de Enfermagem. 2024;77(6):e20230129
DOI 10.1590/0034-7167-2023-0129
Views0See moreABSTRACT
Objectives:
to understand the perceptions of women and health professionals regarding childbirth care at a teaching hospital in the western state of Paraná, Brazil.
Methods:
this qualitative study employed Grounded Theory, conducted in an obstetric care service with 38 participants (women and health professionals) through semi-structured interviews.
Results:
limitations in physical infrastructure and management of care, along with the women’s limited knowledge about the childbirth process and the decision-making and guidance of professionals, show conflicting obstetric practices-a discrepancy between good practices and obstetric violence. Training in obstetric nursing and active participation in care, alongside the presence of a companion, were identified as intervening conditions and strategies in the process.
Final Considerations:
childbirth care is characterized by dichotomous practices. While some professionals base their practices on scientific evidence, others rely on teachings and experiences from the time of their training.
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A relação entre gênero, formação educacional e ambiente de aprendizagem com a ansiedade do estudante de enfermagem
Revista Brasileira de Enfermagem. 2024;77(6):e20220615
Abstract
A relação entre gênero, formação educacional e ambiente de aprendizagem com a ansiedade do estudante de enfermagem
Revista Brasileira de Enfermagem. 2024;77(6):e20220615
DOI 10.1590/0034-7167-2022-0615
Views1See moreRESUMEN
Objetivos:
identificar las variables asociadas a la práctica clínica relacionadas con la ansiedad de los estudiantes de enfermería.
Métodos:
se utilizó un diseño descriptivo, cuantitativo, correlacional con las recomendaciones STROBE, EQUATOR. La población fue de 233 estudiantes de enfermería con una muestra de 135 personas. Los datos se recopilaron de marzo a abril de 2022 utilizando instrumentos validados.
Resultados:
la prueba de chi-cuadrado y razón de verosimilitud significativa para género, formación académica y entorno de aprendizaje son superiores a 0.05, por lo que no existe una relación significativa entre las variables y la ansiedad de los estudiantes.
Conclusiones:
los estudiantes necesitan prepararse nuevamente antes de ingresar al campo de la práctica. Investigaciones cualitativas también son necesarias.
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ORIGINAL ARTICLE12-16-2024
The relationship between gender, educational background, and learning environment with nursing student’s anxiety
Revista Brasileira de Enfermagem. 2024;77(6):e20220615
Abstract
ORIGINAL ARTICLEThe relationship between gender, educational background, and learning environment with nursing student’s anxiety
Revista Brasileira de Enfermagem. 2024;77(6):e20220615
DOI 10.1590/0034-7167-2022-0615
Views0See moreABSTRACT
Objectives:
to identify variables associated with nursing students’ anxiety-related clinical practice.
Methods:
this study used a correlational quantitative descriptive design with the STROBE equator instrument. The population is 233 nursing students with a sample of 135. Data were collected from March to April 2022 using validated instruments.
Results:
the Chi-square test and the sig likelihood ratio on the gender, educational background, and learning environment is more than 0.05 so there is no significant relationship between the variables and student anxiety.
Conclusions:
students need to be prepared again before entering the practice field. Qualitative research is needed too.
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ORIGINAL ARTICLE12-13-2024
Educational booklet on labor and delivery: validity study
Revista Brasileira de Enfermagem. 2024;77(5):e20240138
Abstract
ORIGINAL ARTICLEEducational booklet on labor and delivery: validity study
Revista Brasileira de Enfermagem. 2024;77(5):e20240138
DOI 10.1590/0034-7167-2024-0138
Views0See moreABSTRACT
Objectives:
to develop and validate an educational booklet on labor and delivery for pregnant women.
Methods:
this methodological study involved constructing and validating a booklet based on Echer’s framework. We used the Content Validity Index and Cronbach’s alpha for content and face validation, selecting judges according to Fering’s criteria. We then conducted a clinical validation with the target population.
Results:
the booklet, developed based on evidence from an integrative review and validated by judges and the target audience, achieved global Content Validity Index of 0.919 and 0.913, respectively. After clinical validation with 22 pregnant women, it included 28 topics and 48 pages, with illustrations by a graphic designer.
Conclusions:
expert judges and the target audience considered this educational technology valid, deeming it a relevant tool for promoting the health of pregnant women.
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ORIGINAL ARTICLE12-13-2024
Knowledge and attitudes of nursing students regarding the sexuality of older adults: a quasi-experimental study
Revista Brasileira de Enfermagem. 2024;77(5):e20240011
Abstract
ORIGINAL ARTICLEKnowledge and attitudes of nursing students regarding the sexuality of older adults: a quasi-experimental study
Revista Brasileira de Enfermagem. 2024;77(5):e20240011
DOI 10.1590/0034-7167-2024-0011
Views0See moreABSTRACT
Objectives:
to compare the knowledge and attitudes of nursing students regarding sexual behavior and sexually transmitted infections (STIs) in older adults before and after an educational intervention.
Methods:
this quasi-experimental study involved a convenience sample of 45 nursing students from a public university, conducted in three stages: pre-intervention, intervention, and post-intervention. A questionnaire was used to assess sociodemographic characteristics, academic training, and knowledge and attitudes on the topic. The intervention was an educational web conference. Paired t-test and Wilcoxon test were used for data analysis.
Results:
there was a statistically significant difference in the knowledge and attitude scores of nursing students before and after the educational intervention (p < 0.001). A significant increase was observed in the knowledge score (from 9.3 to 12.2) and attitude score (from 108 to 117.2) in the post-intervention phase.
Conclusions:
the knowledge of nursing students regarding the sexuality of older adults increased after the educational intervention, and their attitudes on the subject became more positive.
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ORIGINAL ARTICLE12-13-2024
Stress in nursing workers caring for people with COVID-19
Revista Brasileira de Enfermagem. 2024;77(5):e20230542
Abstract
ORIGINAL ARTICLEStress in nursing workers caring for people with COVID-19
Revista Brasileira de Enfermagem. 2024;77(5):e20230542
DOI 10.1590/0034-7167-2023-0542
Views0See moreABSTRACT
Objectives:
to analyze stress from the perspective of nursing workers caring for people with COVID-19 in a public hospital in the Recôncavo region of Bahia.
Methods:
this is an exploratory qualitative study, conducted through semi-structured interviews. The data were analyzed using word clouds, similarity trees, and content analysis.
Results:
nursing workers were exposed to stress while attending to patients with COVID-19. The reported stressors in the workplace included: work overload, lack of planning, speed in performing tasks, fatigue, lack of participation in decision-making, lack of support from management, technological changes, excessive responsibility without preparation, interpersonal conflicts, and professional undervaluation.
Conclusions:
exposure to these stressors leads to emotional exhaustion and demotivation, which were intensified during the COVID-19 pandemic.
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