Abstract
Background:
For the past 2 months the number of COVID-19 cases in Lebanon has been on the rise, while frontline nurses after the Beirut Blast of August 4th have been practicing through limited resources and a challenging context.
Aim:
This paper aims at exploring the psychological experiences of Lebanese frontline nurses serving at ground zero hospital during the current COVID-19 outbreak.
Setting:
This study was carried out in three main ground-zero hospitals in Beirut which are receiving COVID-19 cases.
Method:
This study have employed a phenomenological exploratory qualitative research design, where virtual interviews were conducted with 18 frontline nurses during the second week of January 2021.
Results:
Thematic analysis of the data expressed by the frontline nurses working in the approached ground-zero hospitals gave rise to five themes, namely ‘helplessness and impending doom’, ‘increased mortality rates and depressive mood’, ‘fear of death and obsessive thinking’, ‘flashbacks, panic, and incompetence’, and ‘public recklessness, governmental responsibility, and anger‘.
Conclusion:
The frontline nurses working at ground zero hospitals in Beirut are facing significant psychological challenges that should be mediated by the government and health policymakers in order to safeguard the quality of care and avoid higher mortality rates.
Introduction
For the past year, Lebanon has been going through highly challenging crises. Since October 2019, a political tide has taken its toll, where a civilian revolution has risen in response to a deepening economic turmoil paralleled with governmental instability (Bizri et al., 2020). After that, the COVID-19 pandemic intensified the Lebanese debacle, where it paralyzed the national economy even more, leading to a worsening in the population’s lived reality. Upon the rise of the pandemic, the country was put under total lockdown and the healthcare workers, mainly nurses were put on the frontlines to fight the outbreak in a flailing healthcare system that is operating in the light of a severe lack of equipment, funds, and consequently deficiency of staff, where high numbers have fled the country to pursue better living conditions abroad (Khoury et al., 2020).
Despite this gloomy picture, the Lebanese frontline nurses served their duties just like all the nurses around the globe. Such nursing diligence have been prevalent in prior findings which have demonstrated that nurses would neglect their own priorities to voluntarily engage in fighting emerging pandemics, unexpected natural calamities and infectious outbreaks and make compassionate sacrifices out of moral and ethical obligation (Catton, 2020). The nursing staff operating at the forefront, such as in emergency rooms, intensive care units, infection control departments and other units treating COVID-19-afflicted patients, had to work extra shifts at some point during the epidemic of COVID-19. The COVID-19 nursing team were not only faced by the long arduous working hours but also by associated psychological and physical constraints. For instance, donning a complete set of protective gear resulted in a decrease in hydration, skipping meals, ventilation and vision some difficulty, facial ulcerations, and back problems which rendered the frontline nurses experiencing a higher degree of work stress, intensified burnout, and physical exhaustion (Zhang et al., 2020). On the psychological level, various mental disruptions have been reported such as clinically relevant depression, post-traumatic stress disorders, panic attacks, sleep cycle disruptions, and prolonged anxiety. Such psychological afflictions have also been reported during previous pandemics, and they are expected not only to pose a detriment on the health and wellbeing of the frontline nurses themselves but rather on the quality of practice and services they are rendering as well as on patient safety measures (An et al., 2020; Nie et al., 2020). On the other hand, the lack of medical resources during the outbreak also raised the incidence of COVID-19 spread among frontline nursing personnel (Chen et al., 2020). Being at the frontline meant that nurses are in contact with COVID-19 positive cases from admission till discharge which putting the nursing workface face-to-face with not only contacting the infection but even death. As the propagation qualities of this virus keeps proving its efficiency, higher numbers of frontline nurses have been reported to be contracting the virus and therefore depleting the healthcare team from important human resources to fight the rising intensity of the pandemic (Belingheri et al., 2020).
Amid all of this, little did the Lebanese people nor did the nurses working at the frontlines expect to be bombarded by even worse conditions. A tremendous explosion hit the port of Beirut on the 4th of August 2020, detonating approximately 3000 tons of ammonium nitrate, killing around 300 victims, injuring around 6000, and rendering 300,000 civilians homeless. In the night of the blast immense numbers of wounded people flooded emergency departments throughout the city which put the frontline nurses in an unprecedented situation, where they had to maintain infection control measures to contain COVID-19 while treating thousands of people viscously wounded by the blast (Abouzeid et al., 2020). The explosion destroyed at least four hospitals in ground zero that have been serving as essential healthcare facilities responding to the COVID-19 pandemic and welcoming hundreds of patients on the daily. This blast have not only deprived the Lebanese population from their loved ones, but also deprived the Lebanese healthcare system from immense infrastructure, wounded and killed nursing and medical staff in service, as well as wasted immense load of medical resources that were supposed to help in responding to the pandemic (Abdallah et al., 2020; El Sayed, 2020).
For the past 2 months, the number of COVID-19 positive cases have been escalating quickly, where Lebanon has been experiencing a notable outbreak with an estimate of 5000 daily cases being recorded and higher number of frontline nurses are being afflicted (El Deeb & Jalloul, 2020). Currently the hospitals in ground zero and the frontline nurses serving in these facilities are working in maximum capacity and treating COVID-19 patients in waiting rooms, hangars and tents outside emergency departments. In order for these nurses to be able to serve at the frontlines, their physical and mental health should be top priority. However, their health and wellbeing and mainly their psychological perceptions have been neglected. Thus, this paper aims at exploring the psychological experiences of Lebanese frontline nurses serving in ground zero hospital during the current COVID-19 outbreak. Such data would help health raise awareness regarding the reality of the nursing workforce in Lebanon and urge policy makers in the country and the region to take proper action.
Methods
Research design
This study have employed a phenomenological exploratory qualitative research design in order to get an in depth understanding of the psychological experiences lived by the Lebanese frontline nurses serving at ground zero hospitals. The methodology that has been implemented in this research design is one in line with Colaizzi’s phenomenological approach which is focused on the respondents’ experiences and observations to explain the phenomena at hand, thus finding common characteristics across the study population rather than individual one (Shosha, 2012). A constructivist epistemology is adopted in conducting this research as the experiences of the participants would be explored keeping in mind that they are contextual, personal and mediated by they perceive the world around them and how they respond to the phenomena (Schmitt, 2017).
Study subjects
The frontline nurses have been recruited through a purposive sampling technique, where 18 nurses from three main ground zero hospitals have been recruited. The nurses have been contacted through phone and been asked to participate in the study. Upon that official invitation by email have been sent to acquire their written consent. The nurses who met the inclusion criteria were Lebanese registered nurses working on the frontlines of the COVID-19 pandemic particularly in the COVID-19 units, intensive care units, and COVID-19 emergency departments at ground zero hospitals. Ground zero hospitals were specified to be the ones within a 6 mile radius from the point of explosion. The inclusion criteria also specified that the nurses eligible to participate would be ones who have been working at their respective hospitals for at least 1 year and were reported to be on duty during the night of August 4th, 2020.
Interviews
Virtual interviews through video conferencing applications have been carried out until data saturation was reached. The interviews were carried out virtually as a lockdown has been enforced in Lebanon since the 7th of January 2021 in response to the most recent viral outbreak which impeded face-to-face interview, in addition to the hectic schedules these nurses are serving and the need for applying social distancing measures. The interviews were carried out as per the convenience of the participating nurses, where the researchers agreed with the participants on a suitable timing in order to be able to obtain reliable verbatim of the lived experiences. Both researchers have taken turns in conducting the interviews in an attempt to avoid the occurrence of a moderator dominance. Various questions have been asked during the interview namely, ‘How do you describe you experience as a frontline nurse serving at a ground zero hospital?’, and ‘What are the sources of stress that you are facing in your work?’. ‘How do you describe your emotional and psychological profile during this phase?’, ‘How do you evaluate your practice in the current situation?’.
Data analysis
The nurses participating in the study were clearly informed that the interviews will be screen recorded to be used during the analysis of the data. The verbatim of the frontline nurses was transcribed into the English language and was treated using an inductive thematic content analysis. The analysis consisted of recounting the participants’ direct quotations, open text labeling and category development, and thus establishing the emergent themes (Corwin & Clemens, 2020). The evaluation was carried out individually by each investigator, and after that the researchers met and critiqued the outcomes until they achieved consensus on the emerging trends, ensuring through the whole process that their personal opinions on the subject were not included. In order to obtain a deep and accurate interpretation of the narratives, the verbatim was recounted several times and then the quotes were allocated in articulate and constructive terms that illustrates the proper significance of the expressed information by the participants and after that those words were clustered, reorganized and collated into qualitative themes, which were carefully analyzed by the researchers.
Trustworthiness and credibility
In an effort to enhance the trustworthiness of the study and eliminate the emergence of any biases, the authors have undertaken different protocols in accordance with prior research in the field of qualitative methodology (Anney, 2014). Coherently designed interview frameworks were employed by both researchers and the exact same questions were asked, and they ensured that the emergent topics were extensively explored and that there were no missed points regarding any aspects of the results. Many quotes were used to express the findings of the analysis, which brought a true voice to the study participants. In turn, specialists were contacted in the field of qualitative analysis, where a control protocol to double-check the findings was employed. The evaluation was separately carried out and, in conjunction to peer-checking, the investigators have used member-checking to guarantee validity and reliability, where after finalizing the themes, they were redirected to the participants for verification (Speziale et al., 2011). In addition, in order to guarantee that the findings are generalizable, independent member-checking was also utilized where nurses with the same features as those who actually participated in the research were asked to consider the consistency between the emerging trends and their own experiences.
Ethical considerations
Institutional Review Board approval was obtained (IRB number: ECO-R-56). All the nurses have sent written informed consent through email upon the invitation email they received. The researchers clarified to all the participants that their contribution is totally voluntary and opting out from the research has no adverse consequences. The nurses were also informed that their contribution is anonymous and that any data to be published would be unidentified.
Results
Characteristics of the respondents
The sample of this study comprised of 18 frontline nurses working at three different ground-zero hospitals in Beirut, Lebanon, where 10 (55.5%) of them were females and 8 (44.5%) were males. The mean age of the nurses who took part was 24.6 years, where 7 (38.9%) worked in emergency departments, 6 (33.3%) worked in COVID-19 units and 5 (27.8%) worked in intensive care units.
Phenomenology
Thematic analysis of the data expressed by the frontline nurses working in the approached ground-zero hospitals gave rise to five themes, namely ‘helplessness and impending doom’, ‘increased mortality rates and depressive mood’, ‘fear of death and obsessive thinking’, ‘flashbacks, panic, and incompetence’, and ‘public recklessness, governmental responsibility, and anger’.
Helplessness and impending doom
During the most recent outbreak of the coronavirus in Lebanon, the participating frontline nurses have expressed an intense of feeling of helplessness due to their inability to control the rising numbers and to provide dignified treatment to all citizens especially that they work at institutions that have primarily been affected by the massive explosion at Beirut port. For instance one nurse said, ‘It is heart wrenching to see people suffer all the time and you can’t do anything about it. . .not enough beds. . .not enough equipment. . .it feels like you are chained and watching your loved ones die in front of you. . .’ (N12). Another nurse also proclaimed, ‘. . .the people are suffering. . .our people. . .and we can only help them by minimum requirements. . .our hospitals are full. . .our hospitals lack a lot of needed equipment and staff. . . we are doing our best, but it is not enough. . .it is not enough. . .and no one can help. . .the whole country is deep in a huge crisis and all we can do is pray. . .’ (N3). Similar account was shared by another fellow nurse, ‘the numbers keep rising and we only have limited resources. . .our beds are all occupied and after the explosion we lost a a significant amount of beds and equipment so we are doing what we can, but on the other hand the numbers are skyrocketing and people keep coming and we turn them down or treat them in the waiting room until they have found a transfer. . .it is hopeless. . .’ (N8). The nurses also indicated that in the midst of this crises they are experiencing a haunting feeling of doom as if the whole world is ending. For instance, one of the nurses said, ‘. . .with everything that has been happening in Lebanon for the past year, and mainly with the rise of cases during the past month, we were the most affected, each crisis adds pressure on us. . .our profession and our personal lives. . . it feels like everything is ending. . .we are not living anymore. . . we lost a lot of people and it feels like we are going to die any minute now. . .’ (N17). Another nurse shared a similar experience, ‘. . .it all has been too much. . .I. don’t know for how long we will persevere. . . all I know that I feel like it is all going to get even worse. . . the very high number of cases. . .worse and worse economic situation and security wise were very unstable. . .I don’t know where we are heading but it’s not going to be a very nice situation. . .’ (N10).
Increased mortality rates and depressive mood
The second theme that was prevalent throughout the interviews with the nurses revolved around the notion that their work has been lately focused on dealing with death, which have led to the dominance of a depressive mood. For instance one of the nurses have declared, ‘for the past year. . . with COVID-19, the blast, and now the immense outbreak, all that we have been doing is discharging people to the morgue. . .putting people in bags. . .nothing else has meaning with the recurrent deaths. . .’ (N5). Another nurse also said, ‘we are not breathing. . . we are not living. . . we are just dying, out families, friends, our patients, and then who knows else. . . first the blast and now this huge outbreak. . . the numbers are high for such a small country like ours. . . every day you hear that someone you know has died. . .and every other shift one of your patients die. . . it’s like life has no meaning anymore other than mourning your loved ones and your patients. . .it is intense’ (N14). Moreover, a similar account was shared, ‘. . .it is everywhere around us. . . I lost my brother to the explosion and now I have lost my grandmother and uncle to the pandemic. . .our colleagues are losing their families too. . .we are losing young people to the pandemic. . .in their twenties and thirties. . .we are here fighting the outbreak and mourning at the same time. . .it is just absurd what we are going through. . .you try to find meaning in everything that you are going through but it is quite hard. . . you stop enjoying anything hardly and you feel guilty for smiling sometimes. . .’ (N4).
Fear of death and obsessive thinking
The nurses have reported a growing pattern of fear and overthinking regarding losing a patient, the quality of care they are rendering, and the nursing acts that they are carrying out in treating COVID-19 patients, especially after all the efforts that they have exerted in saving lives upon the blast. For instance one of the nurses said, ‘. . .I am afraid all the time that my patient would die. . .I triple check everything I do. . .with all the deaths that I have seen since the night of the blast, I would do anything to keep my patients and loved ones alive. . .I don’t want to be doing acts that would not help my patient so I tend to overthink about every small detail of care’ (N16). Another nurse also proclaimed, ‘. . .it haunts you. . .the thought that something bad is going to happen any minute and you feel guilty for it that you are the reason that this patient could not pull through. . .you can’t control the thought it is quite intrusive so you start compulsively repeating your actions to make sure that you have done all that you can. . .’ (N1). Similarly, a nurse also shared, ‘. . .working in our place has been very stressful. . .recently it has been only about expecting the worse. . . I’m always fearful that another catastrophe like the blast would happen especially with the surrounding atmosphere that there is still something dangerous at the port and might blow up again. . .that’s on one hand. . .on the other hand you feel responsible about the worsening of the patients that have been agonizing due to the extreme spread of COVID-19 this past month. . . you feel like you are doing something wrong all the time and at any moment the patient is going to die. . .it is there in your stomach all the time’ (N18).
Public recklessness, governmental responsibility, and anger
Another theme that was highlighted by the frontline nurses working at ground zero hospitals is that the absurdity of the national reality has provoked a constant feeling of anger, especially that they feel that after all that they have been through, now they are fighting all alone. For instance one of the nurses exclaimed, ‘. . .it is maddening how everyone is being careless and mindless. . .the people are still acting as if nothing is wrong with the pandemic and the country and they just want to go to cafes and the government has been only taking impulsive decision that is only making things worse not only for us but also for the people. . . no one is helping. . . no one’ (N7). Another nurse also said, ‘ I am easily provoked these days especially with the everything that we are going through. . .it is like everything you do for the public good gets shut down. . . gets antagonized by irresponsibility. . . I mean I am not even seeing my family so that we can get through this and on the other hand out efforts go to waste’. (N13). A consistent testimonial was also expressed, ‘. . . sometimes we get treated as if we don’t know what we are doing and talking about, we have raised the voice regarding social constraints during the holidays but no one listened and look where we are now. . . we are conflicted between the economy and our health. . . I don’t know what to think or say anymore. . .sometimes the decisions taken are stupid. . .just stupid. . .it makes you angry all the time as if you are working for nothing’ (N2).
Flashbacks, panic, and incompetence
The final theme that has risen throughout the interviews was quite characteristic to all the participating nurses who have witnessed the Beirut blast on the 4th of August and have worked with the victims of that calamity. The nurses have indicated that through their practice at their respective hospitals they are living and reliving the incident through flashbacks that are inducing panic sometimes, which renders them sometimes feeling incompetent of delivering care and they need care themselves. For instance, one of the nurses said, ‘. . .it is always in memory. . .when you walk through the hallways you start seeing the ceiling falling again and again. . . you expect it to happen again just like the first time. . .my heart starts racing all of sudden as I think distantly. . . I can’t get over that I am alive now’ (N15). Another nurse also shared, ‘. . . I am physically exhausted. . .on top of that I mentally not present sometimes. . . I have to work here in this hospital but I cannot help to always think about that night where I was administering medication to my patient and the window blew. . .I feel unsafe but obliged to serve. . .sometimes I feel that I need care myself and that I am not in the right mindset to care for my patients. . .’ (N11). Similarly another colleague said, ‘I panic every time they close the door of the unit or I hear an ambulance. . .it’s like I am living the experience of that night all over again. . . it is tiring. . . that night we had to care for hundreds of patients, while our hospital was destroyed and we had to deal with the social distancing and infection control measures as we were amid a pandemic. . .it was a mess. . . I always catch myself thinking about what happened and the I get conscious and stop myself’ (N6). Another nurse also highlighted, ‘. . .I think that I am psychologically inept to deal with a health crisis right now but I have to. . . there’s no one else to take care of the patients, not enough staff to get me laid off for a small break I have to do this’ (N9).
Discussion
Lebanon has been facing an impending humanitarian crisis that have been accentuated by the flailing economy, the unstable political climate, and a massive blast that have destroyed the capital along with three main hospitals that have been acting as COVID-19 response centers and flattened piles of medical supplies and vaccines which were the safe net for fighting COVID-19 (Dyer, 2020). Now a sweeping wave of COVID-19 cases that is paralyzing the healthcare system and specifically psychologically challenging the nurses working at the frontlines in Beirut (Devi, 2020). The results of our study showed that in the context of the national crisis, the nurses treating COVID-19 patients at the frontlines have reported immense psychological conflicts. Several other researches have recorded elevated rates of psychological disturbance among nurses throughout pandemics, which supports the results of this research (Amin, 2020; Du et al., 2020). For instance, a thorough analysis and review of evidence have reported the incidence of psychological distress and illnesses among nurses who are serving at the frontlines of the COVID-19 pandemic globally (Pappa et al., 2020). Particularly, the phenomenological findings of our study have indicated that the nurses are mainly experiencing fear, depressive inclination, anger, frustration, and panic attacks. This is consistent with Kim (2018), which have investigated the effects of the MERS pandemic on the healthcare providers serving at the frontlines. The results of this study showed that the nurses’ experienced anxiety, fear, exhaustion, and depressive moods as they rendered treatment for the victims of the pandemic at the time. Nurses suffered fear and depression related to the mortality of COVID-19 victims in this research paper. Loss due to COVID-19 disease can be troubling as the victim assumes a non-determining role in acquiring the infection in many circumstances. Patients can also have due regard to healthy habits in some situations, but they become contaminated because of the indifference of others about health guidelines (Khademi et al., 2020). Various studies support our findings and have indicated that the increased mortality rates can influence the psychology of the nursing workforce, where research have indicated that fear of death is a multifaceted, perceptual, experience that might originate from anxiety experienced by nurses due to recurrent exposure to patient death, and constant delivery of news of death to families (Galehdar et al., 2020). Our findings also showed that the nurses started exhibiting obsessive thoughts relating to the accuracy of nursing care they are rendering, which originates from the high mortality rates among COVID-19 patients despite of the rising efforts. This has been in line with Ergenc et al. (2020) which have studied the prevalence of anxiety, depression, and obsessive compulsive disorder among COVID-19 frontline healthcare workers. The study resulted in the increasing prevalence of obsessive thoughts mainly among nurses who are caring for COVID-19 cases. This finding is also supported by Zareie (2020) who have urged the need for action in preventing the development of obsessive compulsive disorder among healthcare workers fighting at the frontline of the pandemic. In addition, the findings of our study have indicated that the nurses are experiencing a sense of hopelessness due to the inability to reduce the numbers, lack of resources, despite of the increased efforts, fatigue and detachment they are living through. This is consistent with Franza et al. (2020) which have highlighted the prevalence of hopelessness and depression among frontline nurses in fighting the rising numbers of cases during the COVID-19 pandemic. Our results were also in line with a study done in Turkey by Hacimusalar et al. (2020) and have found notable levels of helplessness in dealing with the outbreak. Moreover, our study showed that the nurses reported a frustration from the general attitude toward the pandemic from the public and the ineffective decisions taken by the government which have caused added anger and psychological challenge among the nurses especially with their constant endeavors to help the community. This is in line with Galehdar et al. (2020) which have found that the nurses on the frontlines felt that their efforts are being wasted due to the general carelessness in dealing with the pandemic, thus making their job harder and posing more pressure on the workforce. Finally, the results of our study are pointing toward signs of moral injury among ground zero frontline nurses in Lebanon. Moral injury is a complicated subject to identify (Hodgson & Carey, 2017), but it can be characterized as the product of becoming compelled to do or observe a situation that goes against one’s morality, and result from a struggle to prevent negative consequences. Moral injury is not a psychiatric condition, but it may be a contributing cause, yielding in high levels of stress, depression, or PTSD symptomatology. Moral injury was originally described in military personnel, but analogous circumstances and moral considerations can also exist in health care contexts, so the word has been adopted to reflect on the pain and problems faced by different healthcare professionals operating in challenging conditions (Williamson et al., 2018), which are comparable to circumstances lived by the nurses at ground zero hospitals in Beirut, Lebanon. Moral injury (MI) can make you feel guilty, humiliated, remorseful, or even furious. It’s not to be confused with burnout, which has significant psychological and physical effects. Moral injury, on the other hand, can result in burnout. Such feelings and emotional experiences were demonstrated by the nurses participating in this study which also points toward the signs of the emergence of moral injury. This is consistent with previous researches, which have shown that during the COVID-19 pandemic and especially in circumstances upon which healthcare providers have to work with minimal resources and feel unable and incompetent to provide proper care for suffering patients, signs of moral injury have started to emerge (Greenberg et al., 2020; Williams et al., 2020).
Limitations
The main limitation of this study might have been the inability to carry out the interviews through a face-to-face prolonged interviews, which might have fortified the rigor of the qualitative findings. However, this was essential to avoid the risk of contamination among the researchers and the participants. Thus, the validity of the data was confirmed by multiple protocols adopted by the researchers, while the interviews were carried out virtually.
Conclusion
The COVID-19 frontline nurses working at ground-zero hospitals in Beirut have been dealing with a tremendous load of challenges that have been significantly affecting their psychological well-being. The experiences of the nurses that have been explored in this study have showed that they are facing various sources of distress that are associated with the recurrence of death of patients and loved ones, and inability to control the pandemic due to lack of resources and inaccurate control policies on the national level, which is accentuated by the unstable milieu they are living and practicing in.
Recommendations
In order to effectively fight the pandemic and dodge another national calamity, the frontlines nurses must be the focus of the governmental national economic and health policy. A support network powered by the government and non-governmental organizations must be formed to tend to the needs of the nurses serving at the fore-front especially the ones working with the ground-zero. This network would provide the nurses with readily available psychological counseling services, and tend to their economic and family needs in this very challenging time. A requirement for delivering care and enhancing its consistency is to pay heed to the perspective of nurses throughout the COVID-19 outbreak. Policymakers must reduce the emotional strain of nurses by providing sufficient personal protection supplies, improving mutual cooperation among health professionals, and providing appropriate knowledge and training for optimum quality patient care services during disease outbreaks. Empowering the public to comply with health recommendations and remain at home will decrease the spread of illness and reduce the pressure of nurses and improve their psychological well-being. Running practice sessions on how to deal with the present situation, empowering nurses to respond to the needs of each other, and avoiding the dissemination of bad news amongst health care staff will also strengthen the balance needed by these nurses.
Footnotes
Acknowledgements
The authors would like to acknowledge the efforts and cooperation of the nurses who participated in the study, which enabled the publishing of this paper.
Data availability
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
Disclosure statement
On behalf of both authors, the corresponding author states that there is no conflict of interest.
Ethical considerations
The work described has been carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans; Uniform Requirements for manuscripts submitted to Biomedical journals. Institutional Review Board approval was acquired (IRB number: ECO-R-56).
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
