The Association between the Mental Health Nurse-to-Registered Nurse Ratio and Patient Outcomes in Psychiatric Inpatient Wards: A Systematic Review
Abstract
:1. Introduction
1.1. Nursing Skill Mix in Medical and Surgical Wards
1.2. Nursing Skill Mix and Patient Outcomes in Mental Health Settings
1.3. Why Is Admission to Hospital a Good Research Outcome?
1.4. Nursing Skill Mix on Mental Health Wards
1.5. Aims
1.6. Review Question
2. Materials and Methods
2.1. Search Strategy
2.2. Eligibility Criteria
- Observational and experimental studies.
- Conducted in an acute-inpatient psychiatric unit.
- The manuscript was written in English.
- Involving patients aged 18 years or over.
- Reported registered mental health-to-registered nurse ratio as the measure of skill mix.
- Readmission to psychiatric inpatient care or referral to a mental health crisis team was a reported outcome.
3. Results
Excluded Studies
4. Discussion
Review Limitations
5. Conclusions
Author Contributions
Funding
Conflicts of Interest
References
- Blegen, M.A.; Vaughn, T.E.; Goode, C.J. Nurse experience and education: Effect on quality of care. J. Nurs. Adm. 2001, 31, 33–39. [Google Scholar] [CrossRef] [PubMed]
- Aiken, L.H.; Clarke, S.P.; Cheung, R.B.; Sloane, D.M.; Silber, J.H. Educational levels of hospital nurses and surgical patient mortality. JAMA 2003, 290, 1617–1623. [Google Scholar] [CrossRef] [PubMed]
- Sasichay-Akkadechanunt, T.; Scalzi, C.C.; Jawad, A.F. The relationship between nurse staffing and patient outcomes. J. Nurs. Adm. 2003, 33, 478–485. [Google Scholar] [CrossRef] [PubMed]
- Estabrooks, C.A.; Midodzi, W.K.; Cummings, G.G.; Ricker, K.L.; Giovannetti, P. The Impact of Hospital Nursing Characteristics on 30-Day Mortality. Nurs. Res. 2005, 54, 74–84. [Google Scholar] [CrossRef] [PubMed]
- Kutney-Lee, A.; Aiken, L.H. Effect of nurse staffing and education on the outcomes of surgical patients with comorbid serious mental illness. Psychiatr. Serv. 2008, 59, 1466–1469. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Sales, A.; Sharp, N.; Li, Y.-F.; Lowy, E.; Greiner, G.; Liu, C.-F.; Alt-White, A.; Rick, C.; Sochalski, J.; Mitchell, P.H.; et al. The association between nursing factors and patient mortality in the Veterans Health Administration: The view from the nursing unit level. Med. Care 2008, 46, 938–945. [Google Scholar] [CrossRef]
- Van den Heede, K.; Lesaffre, E.; Diya, L.; Vleugels, A.; Clarke, S.P.; Aiken, L.H.; Sermeus, W. The relationship between inpatient cardiac surgery mortality and nurse numbers and educational level: Analysis of administrative data. Int. J. Nurs. Stud. 2009, 46, 796–803. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Lucero, R.J.; Lake, E.T.; Aiken, L.H. Nursing care quality and adverse events in US hospitals. J. Clin. Nurs. 2010, 19, 2185–2195. [Google Scholar] [CrossRef] [Green Version]
- Sermeus, W.; Aiken, L.H.; Van den Heede, K.; Rafferty, A.M.; Griffiths, P.; Moreno-Casbas, M.T.; Busse, R.; Lindqvist, R.; Scott, A.P.; Bruyneel, L.; et al. Nurse forecasting in Europe (RN4CAST): Rationale, design and methodology. BMC Nurs. 2011, 10, 6. [Google Scholar] [CrossRef] [Green Version]
- Aiken, L.H.; Cimiotti, J.P.; Sloane, D.M.; Smith, H.L.; Flynn, L.; Neff, D.F. Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. J. Nurs. Adm. 2012, 42 (Suppl. 10), S10–S16. [Google Scholar] [CrossRef] [Green Version]
- Blegen, M.A.; Goode, C.J.; Park, S.H.; Vaughn, T.; Spetz, J. Baccalaureate education in nursing and patient outcomes. J. Nurs. Adm. 2013, 43, 89–94. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Kutney-Lee, A.; Sloane, D.M.; Aiken, L.H. An increase in the number of nurses with baccalaureate degrees is linked to lower rates of postsurgery mortality. Health Aff. 2013, 32, 579–586. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- McHugh, M.D.; Kelly, L.A.; Smith, H.L.; Wu, E.S.; Vanak, J.M.; Aiken, L.H. Lower mortality in magnet hospitals. Med. Care 2013, 51, 382–388. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Kelly, D.M.; Kutney-Lee, A.; McHugh, M.D.; Sloane, D.M.; Aiken, L.H. Impact of Critical Care Nursing on 30-Day Mortality of Mechanically Ventilated Older Adults. Crit. Care Med. 2014, 42, 1089–1095. [Google Scholar] [CrossRef] [PubMed]
- Yakusheva, O.; Lindrooth, R.; Weiss, M. Economic evaluation of the 80% baccalaureate nurse workforce recommendation: A patient-level analysis. Med. Care 2014, 52, 864–869. [Google Scholar] [CrossRef] [PubMed]
- Aiken, L.H.; Sloane, D.M.; Bruyneel, L.; Van den Heede, K.; Griffiths, P.; Busse, R.; Diomidous, M.; Kinnunen, J.; Kózka, M.; Lesaffre, E.; et al. Nurse staffing and education and hospital mortality in nine European countries: A retrospective observational study. Lancet 2014, 383, 1824–1830. [Google Scholar] [CrossRef]
- Ma, C.; McHugh, M.D.; Aiken, L.H. Organization of Hospital Nursing and 30-Day Readmissions in Medicare Patients Undergoing Surgery. Med. Care 2015, 53, 65–70. [Google Scholar] [CrossRef] [Green Version]
- Cho, E.; Sloane, D.M.; Kim, E.-Y.; Kim, S.; Choi, M.; Yoo, I.Y.; Lee, H.S.; Aiken, L.H. Effects of nurse staffing, work environments, and education on patient mortality: An observational study. Int. J. Nurs. Stud. 2015, 52, 535–542. [Google Scholar] [CrossRef] [Green Version]
- Gkantaras, I.; Mahfoud, Z.R.; Foreman, B.; Thompson, D.R.; Cannaby, A.-M.; Deshpande, D.H.; Watson, R.; Topping, A.; Gray, R. The effect of Nurse GraduaTeness on patient mortality: A cross sectional survey (the NuGaT study). J. Adv. Nurs. 2016, 72, 3034–3044. [Google Scholar] [CrossRef]
- Aiken, L.H.; Sloane, D.; Griffiths, P.; Rafferty, A.M.; Bruyneel, L.; McHugh, M.; Maier, C.B.; Moreno-Casbas, M.T.; Ball, J.E.; Ausserhofer, D.; et al. Nursing skill mix in European hospitals: Cross-sectional study of the association with mortality, patient ratings, and quality of care. BMJ Qual. Saf. 2016, 26, 559–568. [Google Scholar] [CrossRef] [Green Version]
- Ball, J.E.; Bruyneel, L.; Aiken, L.H.; Sermeus, W.; Sloane, D.M.; Rafferty, A.M.; Lindqvist, R.; Tishelman, C.; Griffiths, P. RN4Cast Consortium Post-operative mortality, missed care and nurse staffing in nine countries: A cross-sectional study. Int. J. Nurs. Stud. 2018, 78, 10–15. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Scott, W.R.; Forrest, W.H., Jr.; Brown, B.W., Jr. Hospital structure and postoperative mortality and morbidity. In Organizational Research in Hospitals; Shortell, S.M., Brown, M., Eds.; Blue Cross Association: Chicago, IL, USA, 1976; pp. 72–89. [Google Scholar]
- Hall, L.M.; Doran, D.; Pink, G.H. Nurse staffing models, nursing hours, and patient safety outcomes. J. Nurs. Adm. 2004, 34, 41–45. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Crowe, M.; Carlyle, D. Deconstructing risk assessment and management in mental health nursing. J. Adv. Nurs. 2003, 43, 19–27. [Google Scholar] [CrossRef]
- Pangman, V.C.; Sloan, J.; Guse, L. An examination of psychometric properties of the Mini-Mental State Examination and the Standardized Mini-Mental State Examination: Implications for clinical practice. Appl. Nurs. Res. ANR 2000, 13, 209–213. [Google Scholar] [CrossRef] [PubMed]
- Uppendahl, J.R.; Alozkan-Sever, C.; Cuijpers, P.; de Vries, R.; Sijbrandij, M. Psychological and Psychosocial Interventions for PTSD, Depression and Anxiety Among Children and Adolescents in Low- and Middle-Income Countries: A Meta-Analysis. Front. Psychiatry 2020, 10, 933. [Google Scholar] [CrossRef] [Green Version]
- Leach, M.J.; Jones, M.; Bressington, D.; Jones, A.; Nolan, F.; Muyambi, K.; Gillam, M.; Gray, R. The association between community mental health nursing and hospital admissions for people with serious mental illness: A systematic review. Syst. Rev. 2020, 9, 1–8. [Google Scholar] [CrossRef] [Green Version]
- Staggs, V.S. Nurse staffing, RN mix, and assault rates on psychiatric units. Res. Nurs. Health 2012, 36, 26–37. [Google Scholar] [CrossRef]
- Bowers, L.; Allan, T.; Simpson, A.; Nijman, H.; Warren, J. Adverse incidents, patient flow and nursing workforce variables on acute psychiatric wards: The Tompkins Acute Ward Study. Int. J. Soc. Psychiatry 2007, 53, 75–84. [Google Scholar] [CrossRef] [Green Version]
- Melvin, M.; Hall, P.; Bienek, E. Redesigning acute mental health services: An audit into the quality of inpatient care before and after service redesign in Grampian. J. Psychiatr. Ment. Health Nurs. 2005, 12, 733–738. [Google Scholar] [CrossRef]
- Chou, K.R.; Lu, R.B.; Mao, W.C. Factors relevant to patient assaultive behavior and assault in acute inpatient psychiatric units in Taiwan. Arch. Psychiatr. Nurs. 2002, 16, 187–195. [Google Scholar] [CrossRef]
- Jansen, G.; Dassen, T.; Moorer, P. The Perception of Aggression. Scand. J. Caring Sci. 1997, 11, 51–55. [Google Scholar] [CrossRef] [PubMed]
- Morris, D.W.; Ghose, S.; Williams, E.; Brown, K.; Khan, F. Evaluating psychiatric readmissions in the emergency department of a large public hospital. Neuropsychiatr. Dis. Treat. 2018, 14, 671–679. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Howes, O.D.; Vergunst, F.; Gee, S.; McGuire, P.; Kapur, S.; Taylor, D. Adherence to treatment guidelines in clinical practice: Study of antipsychotic treatment prior to clozapine initiation. Br. J. Psychiatry 2012, 201, 481–485. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Nielsen, J.; Dahm, M.; Lublin, H.; Taylor, D.M. Psychiatrists’ attitude towards and knowledge of clozapine treatment. J. Psychopharmacol. 2009, 24, 965–971. [Google Scholar] [CrossRef] [PubMed]
- Kelly, G.R.; Scott, J.E. Medication compliance and health education among outpatients with chronic mental disorders. Med. Care 1990, 28, 1181–1197. [Google Scholar] [CrossRef] [PubMed]
- Bowie, C.R.; Depp, C.A.; McGrath, J.; Wolyniec, P.; Mausbach, B.T.; Thornquist, M.H.; Luke, J.; Patterson, T.L.; Harvey, P.D.; Pulver, A.E. Prediction of real-world functional disability in chronic mental disorders: A comparison of schizophrenia and bipolar disorder. Am. J. Psychiatry 2010, 167, 1116–1124. [Google Scholar] [CrossRef] [Green Version]
- Schennach, R.; Obermeier, M.; Meyer, S.; Jäger, M.; Schmauss, M.; Laux, G.; Pfeiffer, H.; Naber, D.; Schmidt, L.G.; Gaebel, W.; et al. Predictors of relapse in the year after hospital discharge among patients with schizophrenia. Psychiatr. Serv. 2012, 63, 87–90. [Google Scholar] [CrossRef]
- Rieke, K.; McGeary, C.; Schmid, K.K.; Watanabe-Galloway, S. Risk Factors for Inpatient Psychiatric Readmission: Are There Gender Differences? Community Ment. Health J. 2015, 52, 675–682. [Google Scholar] [CrossRef]
- Lopez, N.; Sethi, F. The ‘revolving door’: A study of factors involved in readmissions to a women’s psychiatric intensive care unit. J. Psychiatr. Intensive Care 2017, 13, 3–9. [Google Scholar] [CrossRef]
- Rumball-Smith, J.; Hider, P. The validity of readmission rate as a marker of the quality of hospital care, and a recommendation for its definition. N. Z. Med. J. 2009, 122, 63–70. [Google Scholar]
- Barnett, R.; Lauer, G. Urban deprivation and public hospital admissions in Christchurch, New Zealand, 1990-1997. Health Soc. Care Community 2003, 11, 299–313. [Google Scholar] [CrossRef] [PubMed]
- Kilkenny, M.; Dewey, H.M.; Sundararajan, V.; Andrew, N.E.; Lannin, N.A.; Anderson, C.; Donnan, G.; Cadilhac, D.A. Readmissions after stroke: Linked data from the Australian Stroke Clinical Registry and hospital databases. Med. J. Aust. 2015, 203, 102–106. [Google Scholar] [CrossRef] [PubMed]
- Askren-Gonzalez, A.; Frater, J. Case management programs for hospital readmission prevention. Prof. Case Manag. 2012, 17, 219–226. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Gerson, L.D.; Rose, L.E. Needs of persons with serious mental illness following discharge from inpatient treatment: Patient and family views. Arch. Psychiatr. Nurs. 2012, 26, 261–271. [Google Scholar] [CrossRef] [PubMed]
- Ascher-Svanum, H.; Zhu, B.; Faries, D.E.; Salkever, D.; Slade, E.P.; Peng, X.; Conley, R.R. The cost of relapse and the predictors of relapse in the treatment of schizophrenia. BMC Psychiatry 2010, 10, 2. [Google Scholar] [CrossRef] [Green Version]
- World Health Organization. WHO Europe Occupational Health Nursing Curriculum, WHO European Strategy for Continuing Education for Nurses and Midwives 2003; WHO: Copenhagen, Denmark, 2003. [Google Scholar]
- Blythe, J.; White, J. Role of the mental health nurse towards physical health care in serious mental illness: An integrative review of 10 years of UK Literature. Int. J. Ment. Health Nurs. 2012, 21, 193–201. [Google Scholar] [CrossRef]
- Gray, R.; Brown, E. What does mental health nursing contribute to improving the physical health of service users with severe mental illness? A thematic analysis. Int. J. Ment. Health Nurs. 2016, 26, 32–40. [Google Scholar] [CrossRef] [Green Version]
- Moyo, N.; Jones, M.; Gilbert, S.; Romero, L.; Gray, R. The association between mental health nurse to registered nurse ratio and patient outcomes in psychiatric inpatient wards: Protocol for a systematic review. J. Psychiatr. Ment. Health Nurs. 2020. [Google Scholar] [CrossRef]
- Moher, D.; Shamseer, L.; Clarke, M.; Ghersi, D.; Liberati, A.; Petticrew, M.; Shekelle, P.; Stewart, L.A. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst. Rev. 2015, 4, 1. [Google Scholar] [CrossRef] [Green Version]
- Abdelkader, M.; Macmillan, J.F. The effect of a nurses’ industrial action on psychiatric hospital admissions. Soc. Psychiatry Psychiatr. Epidemiol. 1990, 25, 154–158. [Google Scholar] [CrossRef]
- Han, K.T.; Kim, S.J.; Jang, S.I.; Hahm, M.-I.; Kim, S.J.; Lee, S.Y.; Park, E.C. The outcomes of psychiatric inpatients by proportion of experienced psychiatrists and nurse staffing in hospital: New findings on improving the quality of mental health care in South Korea. Psychiatry Res. 2015, 229, 880–886. [Google Scholar] [CrossRef] [PubMed]
- De Lacy, L.; Maddox, P.J. The Influence of Nursing Staff Numbers and Skill Mix on Seclusion and Restraint Use in Public Psychiatric Hospitals. Ph.D. Thesis, George Mason University, Fairfax, VA, USA, 2006. [Google Scholar]
- Bowers, L.; Crowder, M. Nursing staff numbers and their relationship to conflict and containment rates on psychiatric wards—A cross sectional time series poisson regression study. Int. J. Nurs. Stud. 2012, 49, 15–20. [Google Scholar] [CrossRef] [PubMed]
- Bowers, L.; Douzenis, A.; Galeazzi, G.M.; Forghieri, M.; Tsopelas, C.; Simpson, A.; Allan, T. Disruptive and dangerous behaviour by patients on acute psychiatric wards in three European centres. Soc. Psychiatry Psychiatr. Epidemiol. 2005, 40, 822–828. [Google Scholar] [CrossRef] [PubMed]
- Bowers, L.; Brennan, G.; Flood, C.; Lipang, M.; Oladapo, P. Preliminary outcomes of a trial to reduce conflict and containment on acute psychiatric wards: City Nurses. J. Psychiatr. Ment. Health Nurs. 2006, 13, 165–172. [Google Scholar] [CrossRef]
- Lion, J.R.; Synder, W.; Merrill, G.L. Underreporting of assaults on staff in a state hospital. Hosp. Community Psychiatry 1981, 32, 497–498. [Google Scholar] [CrossRef]
- Owen, C.; Tarantello, C.; Jones, M.P.; Tennant, C. Violence and Aggression in Psychiatric Units. Psychiatr. Serv. 1998, 49, 1452–1457. [Google Scholar] [CrossRef]
- Hogarth, K.M.; Beattie, J.; Morphet, J. Nurses’ attitudes towards the reporting of violence in the emergency department. Australas. Emerg. Nurs. J. 2016, 19, 75–81. [Google Scholar] [CrossRef] [Green Version]
- Yaffe, J.; Montgomery, P.; Hopewell, S.; Shepard, L.D. Empty Reviews: A Description and Consideration of Cochrane Systematic Reviews with No Included Studies. PLoS ONE 2012, 7, e36626. [Google Scholar] [CrossRef]
- Lang, A.; Edwards, N.; Fleiszer, A. Empty systematic reviews: Hidden perils and lessons learned. J. Clin. Epidemiol. 2007, 60, 595–597. [Google Scholar] [CrossRef]
- Grant, M.J.; Booth, A. A typology of reviews: An analysis of 14 review types and associated methodologies. Health Inf. Libr. J. 2009, 26, 91–108. [Google Scholar] [CrossRef]
- Malik, N.; Kingdon, D.; Pelton, J.; Mehta, R.; Turkington, D. Effectiveness of brief cognitive-behavioral therapy for schizophrenia delivered by mental health nurses: Relapse and recovery at 24 months. J. Clin. Psychiatry 2009, 70, 201–207. [Google Scholar] [CrossRef] [PubMed]
- Wiltse Nicely, K.L.; Sloane, U.M.; Aiken, L.H. Lower mortality for abdominal aortic aneurysm repair in high-volume hospitals is contingent upon nurse staffing. Health Serv. Res. 2012, 48, 972–991. [Google Scholar] [CrossRef] [PubMed]
- McKenzie, J.E.; Brennan, S.E.; Ryan, R.E.; Thomson, H.J.; Johnston, R.V.; Thomas, J. Chapter 3: Defining the criteria for including studies and how they will be grouped for the synthesis. In Cochrane Handbook for Systematic Reviews of Interventions Version 6.0; Higgins, J.P.T., Thomas, J., Chandler, J., Cumpston, M., Li, T., Page, M.J., Welch, V.A., Eds.; updated July 2019; John Wiley & Sons: Chichester, UK, 2019; Available online: www.training.cochrane.org/handbook (accessed on 12 April 2020).
Search Strategy: | |
---|---|
# | Searches |
1 | exp Hospitals, Psychiatric/ |
2 | exp Mental Disorders/ |
3 | exp Psychiatric Department, Hospital/ |
4 | exp Mental Health/ |
5 | (acute mental unit * or psychiatric inpatient care or psychiatric ward * or mental ward * or mental health unit *).mp. |
6 | (psychiatric service * or mental health care or psychiatric care or mental health care).mp. |
7 | (mental health hospital or psychiatric institution * or mental health institution * or mental health setting * or psychiatric setting * or psychiatric hospital *).mp. |
8 | (mental health inpatient or psych * inpatient * or psych * patient * or mentally ill patient * or mental patient or mental health patient *).mp. |
9 | 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 |
10 | (nurse patient ratio * or nursing staffing ratio * or nursing skill ratio * or nursing skill mix * or hours per patient day or nurse per patient day or full time equivalent or nurs * staff * or nurs * schedul * or task allocation * or delegation).mp. |
11 | (nursing staff numbers or staff mix or staffing levels).mp. |
12 | (educational preparation or education level or nursing care or grade mix or nurs * staff mix * or nursing grade * or care hours per patient *).mp. |
13 | exp Nursing Staff, Hospital/or Nursing/ |
14 | 11 or 12 or 13 |
15 | exp Psychiatric Nursing/ |
16 | (mental health registered nurs * or mental health nurs * or psych * nurs *).mp. |
17 | 15 or 16 |
18 | 9 and 14 and 17 |
19 | limit 18 to English language |
Author | Setting | Design | Exposure | Measure of Exposure | Outcome | Results | Reason for Exclusion |
Han et al., 2015 [53] | South Korea | Observational study | Psychiatrists and nurse staffing | Number of nurses Proportion of experienced psychiatrists | Readmission within 30 days of discharge | The odds of readmission were 5% lower for every 10 extra nurses per hospital. | Wrong exposure |
Abdelkader et al., 1990 [52] | England | Comparison study | Nurses’ industrial action | Six-month period during the industrial action in 1982 | Admission | In 1982, there was a reduction in the total number of admissions by 30% compared to 1981. | Wrong exposure |
Bowers et al., 2012 [55] | England | Time series analysis | Nursing staff numbers | Numbers of nursing staff on duty | Conflict and containment incidents | An increase in qualified nurses working on a ward was associated with a subsequent increase in conflict and containment incidents. | Wrong exposure and outcome |
De Lacy et al., 2006 [54] | United States | Descriptive correlational research | Nursing staff numbers and skill mix | Nursing care staffing Nursing staff numbers Nursing skill mix Full-time equivalents | Seclusion and restraint use | An increased proportion of registered nurses was associated with a decrease in seclusion- and restraint-use measures. | Wrong exposure and outcome |
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Share and Cite
Moyo, N.; Jones, M.; Kushemererwa, D.; Pantha, S.; Gilbert, S.; Romero, L.; Gray, R. The Association between the Mental Health Nurse-to-Registered Nurse Ratio and Patient Outcomes in Psychiatric Inpatient Wards: A Systematic Review. Int. J. Environ. Res. Public Health 2020, 17, 6890. https://doi.org/10.3390/ijerph17186890
Moyo N, Jones M, Kushemererwa D, Pantha S, Gilbert S, Romero L, Gray R. The Association between the Mental Health Nurse-to-Registered Nurse Ratio and Patient Outcomes in Psychiatric Inpatient Wards: A Systematic Review. International Journal of Environmental Research and Public Health. 2020; 17(18):6890. https://doi.org/10.3390/ijerph17186890
Chicago/Turabian StyleMoyo, Nompilo, Martin Jones, Diana Kushemererwa, Sandesh Pantha, Sue Gilbert, Lorena Romero, and Richard Gray. 2020. "The Association between the Mental Health Nurse-to-Registered Nurse Ratio and Patient Outcomes in Psychiatric Inpatient Wards: A Systematic Review" International Journal of Environmental Research and Public Health 17, no. 18: 6890. https://doi.org/10.3390/ijerph17186890