Bullying, incivility, and intention to leave the job among novice nurses: A multicenter cross-sectional study

Article Type : Original/Research Papers

Authors

1 Student Research Committee, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran

2 Department of Nursing, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran

3 Department of Biostatistics, Road Trauma Research Center, School of Health, Guilan University of Medical Sciences, Rasht, Iran

Abstract

One of the major challenges in the world healthcare system is the bullying, incivility, and intention to leave the job among novice nurses. The study focused on bullying, incivility, and intention to leave the job and the relationship and factors associated with them among novice nurses. In a cross-sectional study, novice nurses working in 26 educational and treatment hospitals in northern Iran were enrolled. Data were collected via census sampling from March to April 2018 using a four-part questionnaire including demographic and work-related characteristic information form, workplace incivility scale, workplace bullying scale (EAPA-T), and intention to leave the job scale. A total of 600 out of 653 novice nurses were included in the study (response rate=91.8%). There were significant positive correlations between intention to leave the job score and scores of bullying (r=0.312, P<0.001) and incivility (r=0.304, P<0.001). There was also positive correlation between bullying and incivility scores (r=0.731, P<0.001). Multiple linear regression analyzes showed that having more than one year of experience (b=0.160, P=0.046), lack of interest in nursing (b=0.489, P<0.001), insufficient salary (b=0.281, P<0.001), high bullying score (b=0.237, P=0.002) and high incivility score (b=0.127, P=0.032) were significantly related to high intention to leave the nursing profession. Nursing managers and policymakers need to eliminate factors associated with intention to leave the job such as bullying and incivility through educational measures. Also, increasing interest in the nursing profession and the salary of novice nurses, in general, can reduce their intention to leave the job.

 

Keywords

1 Introduction

Hospitals face a lack of human resources today, especially in the field of nursing [1-11]. In Canada, a shortage of 60,000 nurses is projected by 2022 [12], and in the USA a shortage of 1,000,000 nurses is projected by 2030 [13]. In Iran, the projected shortage is 200,000 nurses [14]. Also, the cost of replacing experienced staff with novice graduated nurses is high, financially and organizationally [15]. On the other hand, inadequate nurses in the health care system increase the mortality rate and treatment complications of patients as well as reduces the safety of nurses [2]. However, one of the reasons for the shortage of nurses is the leaving of jobs by nurses, especially novice nurses [16]. Intention to leave a job is one's perception of leaving a job, although the person might have stayed in their occupational position [17]. Previous evidence showed that the intention to leave a job in nurses has increased [2, 18]. The results of studies in Italy and Iran showed that intention to leave a job in nurses was 33.1% and 23.7%, respectively [19, 20]. Also, a longitudinal study in Sweden showed that intention to leave a job increases over time [21]. Previous studies have shown that intention to leave the job is higher among novice nurses [16, 22]. Intention to leave the job among novice nurses in the USA and New Zealand were 61-33% and 30%, respectively [12]. Reasons for leaving the job include high workload, exhaustion [23, 24], inadequate working conditions, physical and occupational stress [22], and no job satisfaction [16]. One of the reasons to leave the job among nurses is mistreatment [25, 26]. The workload and high stress in caring situations may cause nurses to mistreat other colleagues [27]. Workplace mistreatment is described as non-professional behavior, which includes various types of bullying, incivility, abuse, aggression, conflict, mobbing, and social undermining [28]. Incivility is defined as an abnormal behavior that inadvertently or deliberately harasses others and conflicts with norms of mutual respect at the workplace [29]. The experience of incivility from the colleagues is destructive and leads to a sense of isolation and rejection. Incivility at the workplace by colleagues or managers could influence the individual's feelings and attitudes towards the organization [30]. Bullying is a behavior to frighten and subjugate another party and achieve tangible and intangible benefits in two-way communication using verbal or nonverbal power [13, 25]. The experience of bullying and incivility by novice nurses in the workplace negatively affects their work and health [13]. In Taiwan, 21.3% of nurses had experienced bullying in the past 6 months [31]. In a qualitative study, nurses complained of aggressive behaviors and bullying from their colleagues [12]. Results of some studies in Iran showed that incivility scores in the nurses are low [32, 33], but it was higher than the scores in studies from other countries [13, 29].

Due to the importance of this issue, the present study focused on bullying, incivility, and intention to leave the job and the relationship and factors associated with them among novice nurses.

 

2 Methods

2.1 Study design and subjects

In a cross-sectional study, novice nurses working in 26 educational and treatment hospitals in Guilan province, northern Iran were enrolled. Data were collected via census sampling from March to April 2018. Inclusion criteria were including novice nurses with work experience of at least one month and a maximum of 5 years and consent to participate in the present study. Also, nurses working in office positions and outpatient clinics were excluded.

 

2.2 Ethical consideration

Ethical approval was approved by Guilan University of Medical Sciences (IR.GUMS.REC.1395.273). Research objectives were presented to the participants and informed consent was obtained. All the participants were informed that involvement was completely voluntary and assurance of confidentiality was provided.

 

2.3 Questionnaires and data collection

Data were collected using a four-part questionnaire including demographic and work-related characteristic information form, workplace incivility scale, workplace bullying scale (EAPA-T), and intention to leave the job scale. Participants were asked about demographics and work-related characteristics information including age, sex, marital status, level of education, work experience, work shifts, interest in the nursing profession, satisfaction with salary, other sources of income, and unity of the city of work and life.

 

2.3.1 Workplace incivility scale

This tool contains 7 items with 5-point Likert from never (score 1) to most of the time (score 5). The minimum and maximum scores assigned to these items were 1 and 5, respectively. Higher scores indicate higher perceived workplace incivility by the nurses [34].

 

2.3.2 EAPA-T

This tool contains 12 items with 5-point Likert from never (score 1) to most of the time (score 5). EAPA-T evaluates workplace bullying in four dimensions: 1) control and manipulation of the work context, 2) emotional abuse, 3) professional discredit, and 4) role devaluation. The minimum and maximum scores assigned to these items were 1 and 5, respectively. Higher scores indicate higher perceived workplace bullying by the nurses [35].

 

2.3.3 Intention to leave the job scale

This tool contains 4 items with 5-point Likert from strongly disagree (score 1) to strongly agree (score 5). The minimum and maximum scores assigned to these items were 1 and 5, respectively. Higher scores indicate higher intention to leave the job by the nurses [36].

 

2.3.4 Psychometric properties

Content validity of questionnaires was administered by a 14-member panel consisting of Nursing Faculty members, nurses, and Guilan University of Medical Science clinical instructors. These questionnaires were approved with the minimum content validity index and content validity ratio of 0.80 and 0.71, respectively. Cornbrash's alpha and test-retest were used to assess the internal consistency and interclass correlation coefficient of the questionnaires, respectively. Cornbrash's alpha for workplace incivility scale, EAPA-T, and intention to leave the job scale were 0.93, 0.94, and 0.85, respectively. Also, through a pilot study on 20 novice nurses over a two-week period, the correlation coefficients for the workplace incivility scale, EAPA-T, and intention to leave the job scale were 0.85, 0.85, and 0.87, respectively.

 

2.4 Statistical analysis

In the present study, continuous variables were expressed as mean (standard deviation [SD]) and categorical variables as number (percentage). In univariable analysis, the relationships between demographic variables and scores of bullying, incivility, and intention to leave the job were examined by using independent t-test and Pearson correlation coefficient. Moreover, Pearson correlation coefficient was calculated to examine the relationship of intention to leave the job with scores of bullying and incivility. In multivariable analysis, multiple linear regression was applied to investigate the relationship of intention to leave the job with bullying and incivility scores, controlling for demographic variables. The presence of multicollinearity was examined by calculating collinearity diagnostics via tolerance and variance inflation factor (VIF). A tolerance<0.1 and/or VIF > 5 indicates a multicollinearity problem. Statistical analysis was done using SPSS for windows, version 16.0 (SPSS Inc., Chicago, IL, USA) and a P<0.05 was considered statistically significant.

 

3 Results

3.1 Participants

A total of 600 out of 653 novice nurses were included in the study (response rate = 91.8%). The mean age of the nurses was 25.42 (SD=2.49) years. Most of them were female (94.2%), single (58.8%), had a Bachelor of Science in Nursing (BSN) degree (98.2%), had more than one year working experience (67.2%), and had rotating shift work (97.0%). The demographic characteristics of the nurses are outlined in Table 1.

 

3.2 Correlation among major study variables

As presented in Table 2, there were significant positive correlations between intention to leave the job score and scores of bullying (r=0.312, P<0.001) and incivility (r=0.304, P<0.001). There was also positive correlation between bullying and incivility scores (r=0.731, P<0.001).

 

3.3 Univariable analyses

Table 3 shows the relationships of bullying, incivility and intention to leave the job with demographics variables among novice nurses using univariable analysis.

There was a significant relationship between age and bullying (r=0.083, P=0.043). Compared to females, males obtained higher scores on bullying scores (P=0.004). Nurses with lack of interest in nursing profession, nurses with insufficient salary, and nurses with another source of income obtained higher bullying scores compared to other nurses (P=0.003, P<0.001, and P=0.019, respectively).

Compared to females, males obtained higher scores on incivility scores (P=0.001). Nurses with a Master of Science in Nursing (MSN) degree showed significantly higher score than the nurses with a BSN degree on the incivility scores (P=0.014). Nurses with long years of working experience had high incivility scores (P=0.005). Nurses with lack of interest in nursing profession and nurses with insufficient salary obtained higher incivility scores compared to other nurses (P=0.003 and P<0.001, respectively).

 

Table 1. Demographic characteristics of the novice nurses (n=600).

 

Mean (SD) or n (%)

Age (y)

25.42 (SD=2.49)

Sex

 

     Male

35 (5.8)

     Female

565 (94.2)

Marital status

 

     Single

353 (58.8)

     Married

247 (41.2)

Education

 

     BSN

589 (98.2)

     MSN

11 (1.8)

Working experience

 

     < 1 year

197 (32.8)

     ≥ 1 year

403 (67.2)

Shift Work

 

     Fixed

18 (3.0)

     Rotation

582 (97.0)

Interest in nursing

 

     Yes

488 (81.3)

     No

112 (18.7)

Satisfaction with the salary

 

     Yes

146 (24.3)

     No

454 (75.7)

Another source of income

 

     Yes

53 (8.8)

     No

547 (91.2)

Unity of the city of work and life

 

     Yes

414 (69.0)

     No

186 (31.0)

SD: Standard Deviation; BSN: Bachelor of Science in Nursing; MSN: Master of Science in Nursing.

 

Compared to females, males obtained higher scores on intention scores (P=0.025). Single nurses showed significantly higher score than the married nurses on the intention scores (P=0.015). Nurses with long years of working experience had high intention scores (P=0.049). Nurses with lack of interest in nursing profession and nurses with insufficient salary obtained higher intention scores compared to other nurses (P<0.001 and P<0.001, respectively).

 

3.4 Multivariable analyses

As presented in Table 4, multiple linear regression analyses were performed to examine the variables related to the bullying, incivility and intention to leave the job.

Females (b=-0.441, P<0.001), shift rotation (b= -0.454, P=0.004), lack of interest in nursing (b=0.192, P=0.005), insufficient salary (b=0.270, P<0.001), no other source of income (b= -0.256, P=0.008), and lack of unity of the city of work and life (b= -0.118, P=0.038) were significantly related to high bullying. The model R2 was equal to 0.128, indicating that 12.8% of the variance in bullying score was explained by the demographic variables.

Females (b= -0.392, P=0.010), nurses with an MSN degree (b=0.520, P=0.045), having more than one year of experience (b=0.192, P=0.014), lack of interest in nursing (b=0.241, P=0.007), insufficient salary (b=0.351, P<0.001), and lack of unity of the city of work and life (b= -0.150, P=0.045) were significantly related to high incivility. The model R2 was equal to 0.093, indicating that 9.3% of the variance in incivility score was explained by the demographic variables.

Having more than one year of experience (b=0.160, P=0.046), lack of interest in nursing (b=0.489, P<0.001), insufficient salary (b=0.281, P<0.001), high bullying score (b=0.237, P=0.002) and high incivility score (b=0.127, P=0.032) were significantly related to high intention to leave the nursing profession. The model R2 was equal to 0.194, indicating that 19.4% of the variance in the intention to leave the job score was explained by the demographic variables and bullying and incivility scores. Results showed that multicollinearity was not detected, as none of the independent variables had a high VIF or a small tolerance value (VIF range: 1.04-2.30, tolerance range: 0.43-0.96).

 

4 Discussion

Based on the findings of the present study, the scores of bullying, incivility, and intention to leave the job among novice nurses were low. There were significant positive correlations between intention to leave the job score and scores of bullying and incivility. There was also positive correlation between bullying and incivility scores. Multiple linear regression analyzes showed that having more than one year of experience, lack of interest in nursing, insufficient salary, high bullying score, and high incivility score were significantly related to high intention to leave the nursing profession.

As the results of the present study showed, the rate of workplace bullying among novice nurses was low. This finding was supported by studies from the USA [37] and Finland [38]. Inconsistent with this finding, studies from Japan [39], Australia [40], and the USA [41] reported high levels of workplace bullying among novice nurses. To justify this difference, although workplace bullying has a clear and consistent definition, but in practice, the perception of bullying is completely personal and depends on the personality of the individual. The rate of bullying varies according to different work conditions, people's backgrounds, different cultures, and the type of perception of bullying [42, 43]. Therefore, due to cultural differences and factors related to workplace bullying, it is suggested that more comparisons be made between different countries in this field.

The level of workplace incivility among novice nurses was low. This finding was supported by a study in Canada [44]. This finding may be due to the special sensitivity of nursing managers and colleagues in dealing with novice nurses. Also, poor communication between novice nurses and experienced nurses or nursing managers can be another reason for the low level of incivility [44]. Inconsistent with this result, a USA study found that 67.5% and 77.6% of nurses experienced incivility from their managers and colleagues, respectively [45]. However, workplace incivility is not only imposed on novice nurses by colleagues and nursing managers. Another study in the USA found that nurses experience high levels of incivility by patients and their families [46]. The discrepancy in the previous findings can be due to differences in the characteristics of the study population, tools and, individual characteristics in nurses, such as cultural differences [44, 46, 47].

Another finding of the present study was the low level of intention to leave the job among novice nurses. This finding could be due to nurses being novices and more motivated to provide nursing services. This finding was inconsistent with the results of a study in the USA which showed that the intention to leave the job among novice nurses is high [48]. The reason for this discrepancy can be the difference in nurses' job motivations in different societies. Also, some predictors of intention to leave the job such as burnout, stress, self-efficacy, and nurses' performance can be effective in intention to leave the job [49].

The present study showed a positive and significant relationship between intention to leave the job and bullying and incivility. This finding was supported by two studies in Canada [25, 50] and South Korea [51]. Incivility was another predictor of intention to leave the job in studies from the USA [52] and China [47]. Also, bullying and incivility in the workplace were the most important predictors of nurses' intention to leave the job. This challenge has been addressed in various communities. In the United States [53] and Europe [54], guidelines for the prevention of workplace bullying and harassment have been developed for health care providers. Also, the World Health Organization provides guidelines for the prevention of workplace violence [55]. One of the measures to better cope with violence and mistreatment in the USA is the formation of rapid response teams [56]. The application of such measures should be following the organizational culture, working conditions, religion and factors related to incivility and intention to leave the job. However, in Iran, according to available information sources, there are no guidelines to better cope with mistreatment against nurses. Therefore, it is necessary to develop such guidelines based on individual and cultural assumptions in Iran. Also, in previous evidence, various interventions have been performed to better cope with bullying and incivility in the workplace. A study in the USA found that educational interventions enhance nurses' communication abilities to better cope with workplace incivility [57]. Also, the results of a systematic review showed that the use of workplace incivility-related education programs and learning communication skills helps nurses to manage workplace incivility [58]. Therefore, such interventions can be used to improve nurses' coping skills against bullying and incivility in the workplace.

 

Table 2. Means, standard deviations, and correlations among study variables (n=600).

 

Bullying

Incivility

Intention to leave the job

Bullying

1

 

 

Incivility

0.731***

1

 

Intention to leave the job

0.312***

0.304***

1

 

 

 

 

Possible Range

1 - 5

1 - 5

1 - 5

Observed Range

1 - 5

1 - 5

1 - 5

Mean (SD)

1.54 (SD=0.68)

1.99 (SD=0.87)

2.58 (SD=0.94)

SD: Standard Deviation

***P<0.001

 

Table 3. Relationship of bullying, incivility, and intention to leave the job with demographic variables among novice nurses.

 

Bullying

Incivility

Intention to leave the job

Mean (SD) or r

P

Mean (SD) or r

P

Mean (SD) or r

P

Age (y)

0.083

0.043

0.051

0.212

-0.028

0.493

Sex

 

0.004

 

0.001

 

0.025

     Male

2.08 (SD=1.08)

2.48 (SD=1.05)

2.92 (SD=0.87)

     Female

1.51 (SD=0.63)

1.96 (SD=0.85)

2.56 (SD=0.94)

Marital status

 

0.169

 

0.564

 

0.015

     Single

1.57 (SD=0.68)

2.01 (SD=0.85)

2.65 (SD=0.92)

     Married

1.49 (SD=0.66)

1.97 (SD=0.89)

2.47 (SD=0.95)

Education

 

0.174

 

0.014

 

0.269

     BSN

1.53 (SD=0.66)

1.98 (SD=0.86)

2.57 (SD=0.94)

     MSN

2.04 (SD=1.15)

2.62 (SD=1.28)

2.89 (SD=0.96)

Working experience

 

0.106

 

0.005

 

0.049

     < 1 year

1.48 (SD=0.59)

1.85 (SD=0.76)

2.47 (SD=0.87)

     ≥ 1 year

1.57 (SD=0.71)

2.06 (SD=0.91)

2.63 (SD=0.96)

Shift Work

 

0.096

 

0.472

 

0.189

     Fixed

2.00 (SD=1.15)

2.13 (SD=1.18)

2.29 (SD=0.82)

     Rotation

1.52 (SD=0.65)

1.99 (SD=0.86)

2.59 (SD=0.94)

Interest in nursing

 

0.003

 

0.003

 

<0.001

     Yes

1.49 (SD=0.61)

1.93 (SD=0.81)

2.45 (SD=0.87)

     No

1.76 (SD=0.86)

2.25 (SD=1.04)

3.11 (SD=1.03)

Satisfaction with the salary

 

<0.001

 

<0.001

 

<0.001

     Yes

1.31 (SD=0.43)

1.69 (SD=0.65)

2.21 (SD=0.83)

     No

1.61 (SD=0.72)

2.09 (SD=0.91)

2.69 (SD=0.94)

Another source of income

 

0.019

 

0.157

 

0.288

     Yes

1.83 (SD=0.95)

2.19 (SD=1.06)

2.71 (SD=0.95)

     No

1.51 (SD=0.64)

1.97 (SD=0.85)

2.56 (SD=0.93)

Unity of the city of work and life

 

0.461

 

0.326

 

0.116

     Yes

1.55 (SD=0.67)

2.01 (SD=0.89)

2.54 (SD=0.97)

     No

1.51 (SD=0.69)

1.94 (SD=0.83)

2.67 (SD=0.86)

SD: Standard Deviation; BSN: Bachelor of Science in Nursing; MSN: Master of Science in Nursing.    

Note. r: Pearson correlation coefficient.

 

Table 4. Relationship of bullying, incivility and intention to leave the job with demographic variables among novice nurses.

 

Bullying

Incivility

Intention to leave the job

b

SE

P

b

SE

P

b

SE

P

Age (y)

0.009

0.012

0.466

-0.001

0.016

0.946

-0.017

0.016

0.279

Sex (female vs. male)

-0.441

0.116

<0.001

-0.392

0.152

0.010

-0.026

0.156

0.865

Marital status (married vs. single)

-0.091

0.057

0.107

-0.053

0.074

0.471

-0.109

0.076

0.148

Education (MSN vs. BSN)

0.379

0.197

0.055

0.520

0.259

0.045

-0.034

0.264

0.898

Working experience (≥1year vs. <1 year)

0.058

0.060

0.334

0.192

0.078

0.014

0.160

0.080

0.046

Shift work (rotation vs. fixed)

-0.454

0.155

0.004

-0.142

0.204

0.485

0.350

0.209

0.095

Interest in nursing (No vs. Yes)

0.192

0.068

0.005

0.241

0.090

0.007

0.489

0.092

<0.001

Satisfaction with the salary (No vs. Yes)

0.270

0.062

<0.001

0.351

0.081

<0.001

0.281

0.084

<0.001

Another source of income (No vs. Yes)

-0.256

0.096

0.008

-0.165

0.126

0.191

-0.039

0.129

0.763

Unity of the city of work and life (No vs. Yes)

-0.118

0.057

0.038

-0.150

0.075

0.045

0.087

0.076

0.255

Bullying

-

-

-

-

-

-

0.237

0.078

0.002

Incivility

-

-

-

-

-

-

0.127

0.059

0.032

Model characteristics

 

 

 

     R2

12.8%

9.3%

19.4%

     Adjusted R2

11.3%

7.7%

17.8%

     R

0.358

0.304

0.440

SE: Standard Error; BSN: Bachelor of Science in Nursing; MSN: Master of Science in Nursing.    

Note. b: regression coefficient.

 

The present study showed that higher work experience, lack of interest in nursing, insufficient salary, high bullying, and high incivility were significantly related to high intention to leave the nursing profession. Salary satisfaction causes less workload for nurses. This finding was supported by studies from Taiwan [59] and China [60]. Consistent with the present study, evidence showed that lack of interest in nursing also leads to high intention to leave the nursing profession [61, 62]. The excessive workload of novice nurses can lead to them leaving the profession and the health system will face more serious challenges [63]. Overall, novice nurses need more support and research due to the many challenges they face at the beginning of their careers and patient care.

 

4.1 Limitations

The present study had several limitations. Responding to some of the items were difficult for the novice nurses due to being concerned about their work security. The researchers tried to assure them about the anonymity of their responses, but this conflict might have affected their answers. Also, novice nurses were selected using non-random sampling, which can affect the generalizability of novice Iranian nurses.

 

4.2 Implications for nursing managers and policymakers

In the opposite of the previous hypothesis that most novice nurses included this profession with no personal interest and due to having no other choice. This study showed that most novice nurses selected this profession with interest. The results of a study in Iran also confirmed this finding [64]. Mistreatment is one of these problems that can reduce the quality of nursing care and increase the intention to leave the job among novice nurses. Awareness of workplace mistreatment towards novice nurses can lead to managerial approaches that would improve the working conditions in the workplace for these nurses, and subsequently reduce their intentions to leave the job. Forming informal groups among novice and expert nurses and supervisors with positive social networks could improve the relationship between all the nurses in hospitals. Also, the low salary of nurses was another factor related to the intention to leave the job. Therefore, considering the appropriate income and rewards by the nursing managers could prevent them from leaving the job in the nursing profession.

 

4.3 Recommendations for future research

Due to the shortage of nurses in hospitals, it is recommended that a study be conducted to assess the differences in the rate of workplace mistreatment and its effect on the intention to leave the job among novice and experienced nurses.

 

5 Conclusions

Overall, the scores of bullying, incivility, and intention to leave the job among novice nurses were low. There were significant positive correlations between intention to leave the job score and scores of bullying and incivility. There was also a positive correlation between bullying and incivility scores. Multiple linear regression analyzes showed that having more than one year of experience, lack of interest in nursing, insufficient salary, high bullying score, and high incivility score were significantly related to high intention to leave the nursing profession. Therefore, nursing managers and policymakers need to eliminate factors associated with intention to leave the job such as bullying and incivility through educational measures. Also, increasing interest in the nursing profession and the salary of novice nurses, in general, can reduce their intention to leave the job.

 

Acknowledgements

Not applicable.

 

Authors’ contributions

Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work: AAQ, MC, EKL, FJ; Drafting the work or revising it critically for important intellectual content: AAQ, MC, EKL, FJ; Final approval of the version to be published: AAQ, MC, EKL, FJ; Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: AAQ, MC, EKL, FJ.

 

Funding

Self-funded.

 

Ethics approval and consent to participate

Ethical approval was approved by Guilan University of Medical Sciences (IR.GUMS.REC.1395.273). Research objectives were presented to the participants and informed consent was obtained. All the participants were informed that involvement was completely voluntary and assurance of confidentiality was provided.

 

Competing interests

We do not have potential conflicts of interest with respect to the research, authorship, and publication of this article.

 

Availability of data and materials

The datasets used during the current study are available from the corresponding author on request.

 

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (CC BY-NC 4.0).

© 2023 The Author(s).

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Volume 1, Issue 3
October 2023
Pages 109-117
  • Receive Date: 01 July 2023
  • Revise Date: 21 July 2023
  • Accept Date: 23 July 2023
  • First Publish Date: 01 October 2023
  • Publish Date: 01 October 2023