Effects of a Multimodal Program Including Simulation on Job Strain Among Nurses Working in Intensive Care Units: A Randomized Clinical Trial
IMPORTANCE: Nurses working in an intensive care unit (ICU) are exposed to occupational stressors that can increase the risk of stress reactions, long-term absenteeism, and turnover. OBJECTIVE: To evaluate the effects of a program including simulation in reducing work-related stress and work-related...
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| Veröffentlicht in: | JAMA : the journal of the American Medical Association 2018-11, Vol.320 (19), p.1988-1997 |
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| creator | El Khamali, Radia Mouaci, Atika Valera, Sabine Cano-Chervel, Marion Pinglis, Camille Sanz, Céline Allal, Amel Attard, Valérie Malardier, Julie Delfino, Magali D’Anna, Fifina Rostini, Pierre Aguilard, Stéphan Berthias, Karine Cresta, Béatrice Iride, Frédéric Reynaud, Valérie Suard, Jérémie Syja, Wlady Vankiersbilck, Cécile Chevalier, Nicole Inthavong, Karen Forel, Jean-Marie Baumstarck, Karine Papazian, Laurent |
| description | IMPORTANCE: Nurses working in an intensive care unit (ICU) are exposed to occupational stressors that can increase the risk of stress reactions, long-term absenteeism, and turnover. OBJECTIVE: To evaluate the effects of a program including simulation in reducing work-related stress and work-related outcomes among ICU nurses. DESIGN, SETTING, AND PARTICIPANTS: Multicenter randomized clinical trial performed at 8 adult ICUs in France from February 8, 2016, through April 29, 2017. A total of 198 ICU nurses were included and followed up for 1 year until April 30, 2018. INTERVENTIONS: The ICU nurses who had at least 6 months of ICU experience were randomized to the intervention group (n = 101) or to the control group (n = 97). The nurses randomized to the intervention group received a 5-day course involving a nursing theory recap and situational role-play using simulated scenarios (based on technical dexterity, clinical approach, decision making, aptitude to teamwork, and task prioritization), which were followed by debriefing sessions on attitude and discussion of practices. MAIN OUTCOMES AND MEASURES: The primary outcome was the prevalence of job strain assessed by combining a psychological demand score greater than 21 (score range, 9 [best] to 36 [worst]) with a decision latitude score less than 72 (score range, 24 [worst] to 96 [best]) using the Job Content Questionnaire and evaluated at 6 months. There were 7 secondary outcomes including absenteeism and turnover. RESULTS: Among 198 ICU nurses who were randomized (95 aged ≤30 years [48%] and 115 women [58%]), 182 (92%) completed the trial for the primary outcome. The trial was stopped for efficacy at the scheduled interim analysis after enrollment of 198 participants. The prevalence of job strain at 6 months was lower in the intervention group than in the control group (13% vs 67%, respectively; between-group difference, 54% [95% CI, 40%-64%]; P |
| doi_str_mv | 10.1001/jama.2018.14284 |
| format | Article |
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OBJECTIVE: To evaluate the effects of a program including simulation in reducing work-related stress and work-related outcomes among ICU nurses. DESIGN, SETTING, AND PARTICIPANTS: Multicenter randomized clinical trial performed at 8 adult ICUs in France from February 8, 2016, through April 29, 2017. A total of 198 ICU nurses were included and followed up for 1 year until April 30, 2018. INTERVENTIONS: The ICU nurses who had at least 6 months of ICU experience were randomized to the intervention group (n = 101) or to the control group (n = 97). The nurses randomized to the intervention group received a 5-day course involving a nursing theory recap and situational role-play using simulated scenarios (based on technical dexterity, clinical approach, decision making, aptitude to teamwork, and task prioritization), which were followed by debriefing sessions on attitude and discussion of practices. MAIN OUTCOMES AND MEASURES: The primary outcome was the prevalence of job strain assessed by combining a psychological demand score greater than 21 (score range, 9 [best] to 36 [worst]) with a decision latitude score less than 72 (score range, 24 [worst] to 96 [best]) using the Job Content Questionnaire and evaluated at 6 months. There were 7 secondary outcomes including absenteeism and turnover. RESULTS: Among 198 ICU nurses who were randomized (95 aged ≤30 years [48%] and 115 women [58%]), 182 (92%) completed the trial for the primary outcome. The trial was stopped for efficacy at the scheduled interim analysis after enrollment of 198 participants. The prevalence of job strain at 6 months was lower in the intervention group than in the control group (13% vs 67%, respectively; between-group difference, 54% [95% CI, 40%-64%]; P < .001). Absenteeism during the 6-month follow-up period was 1% in the intervention group compared with 8% in the control group (between-group difference, 7% [95% CI, 1%-15%]; P = .03). Four nurses (4%) from the intervention group left the ICU during the 6-month follow-up period compared with 12 nurses (12%) from the control group (between-group difference, 8% [95% CI, 0%-17%]; P = .04). CONCLUSIONS AND RELEVANCE: Among ICU nurses, an intervention that included education, role-play, and debriefing resulted in a lower prevalence of job strain at 6 months compared with nurses who did not undergo this program. Further research is needed to understand which components of the program may have contributed to this result and to evaluate whether this program is cost-effective. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02672072</description><identifier>ISSN: 0098-7484</identifier><identifier>ISSN: 1538-3598</identifier><identifier>EISSN: 1538-3598</identifier><identifier>DOI: 10.1001/jama.2018.14284</identifier><identifier>PMID: 30357264</identifier><language>eng</language><publisher>United States: American Medical Association</publisher><subject>Absenteeism ; Adult ; Caring for the Critically Ill Patient ; Clinical decision making ; Clinical trials ; Decision making ; Employee turnover ; Female ; France ; Hospitals ; Humans ; Intensive care ; Intensive Care Units ; Intervention ; Male ; Medical personnel ; Nurses ; Nursing ; Nursing Staff, Hospital - education ; Nursing Staff, Hospital - psychology ; Occupational health ; Occupational stress ; Occupational Stress - epidemiology ; Occupational Stress - prevention & control ; Online First ; Original Investigation ; Personnel Turnover - statistics & numerical data ; Role Playing ; Simulation ; Simulation Training ; Staff Development ; Strain</subject><ispartof>JAMA : the journal of the American Medical Association, 2018-11, Vol.320 (19), p.1988-1997</ispartof><rights>Copyright American Medical Association Nov 20, 2018</rights><rights>Copyright 2018 American Medical Association. All Rights Reserved.</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><cites>FETCH-LOGICAL-a353t-af1305131be80f8e1e5d68af09fa3b4c42dec23f6252b168fc854d7e92c4521e3</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://jamanetwork.com/journals/jama/articlepdf/10.1001/jama.2018.14284$$EPDF$$P50$$Gama$$H</linktopdf><linktohtml>$$Uhttps://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2018.14284$$EHTML$$P50$$Gama$$H</linktohtml><link.rule.ids>64,230,314,776,780,881,3327,27901,27902,76231,76234</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/30357264$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>El Khamali, Radia</creatorcontrib><creatorcontrib>Mouaci, Atika</creatorcontrib><creatorcontrib>Valera, Sabine</creatorcontrib><creatorcontrib>Cano-Chervel, Marion</creatorcontrib><creatorcontrib>Pinglis, Camille</creatorcontrib><creatorcontrib>Sanz, Céline</creatorcontrib><creatorcontrib>Allal, Amel</creatorcontrib><creatorcontrib>Attard, Valérie</creatorcontrib><creatorcontrib>Malardier, Julie</creatorcontrib><creatorcontrib>Delfino, Magali</creatorcontrib><creatorcontrib>D’Anna, Fifina</creatorcontrib><creatorcontrib>Rostini, Pierre</creatorcontrib><creatorcontrib>Aguilard, Stéphan</creatorcontrib><creatorcontrib>Berthias, Karine</creatorcontrib><creatorcontrib>Cresta, Béatrice</creatorcontrib><creatorcontrib>Iride, Frédéric</creatorcontrib><creatorcontrib>Reynaud, Valérie</creatorcontrib><creatorcontrib>Suard, Jérémie</creatorcontrib><creatorcontrib>Syja, Wlady</creatorcontrib><creatorcontrib>Vankiersbilck, Cécile</creatorcontrib><creatorcontrib>Chevalier, Nicole</creatorcontrib><creatorcontrib>Inthavong, Karen</creatorcontrib><creatorcontrib>Forel, Jean-Marie</creatorcontrib><creatorcontrib>Baumstarck, Karine</creatorcontrib><creatorcontrib>Papazian, Laurent</creatorcontrib><creatorcontrib>SISTRESSREA Study Group</creatorcontrib><creatorcontrib>for the SISTRESSREA Study Group</creatorcontrib><title>Effects of a Multimodal Program Including Simulation on Job Strain Among Nurses Working in Intensive Care Units: A Randomized Clinical Trial</title><title>JAMA : the journal of the American Medical Association</title><addtitle>JAMA</addtitle><description>IMPORTANCE: Nurses working in an intensive care unit (ICU) are exposed to occupational stressors that can increase the risk of stress reactions, long-term absenteeism, and turnover. OBJECTIVE: To evaluate the effects of a program including simulation in reducing work-related stress and work-related outcomes among ICU nurses. DESIGN, SETTING, AND PARTICIPANTS: Multicenter randomized clinical trial performed at 8 adult ICUs in France from February 8, 2016, through April 29, 2017. A total of 198 ICU nurses were included and followed up for 1 year until April 30, 2018. INTERVENTIONS: The ICU nurses who had at least 6 months of ICU experience were randomized to the intervention group (n = 101) or to the control group (n = 97). The nurses randomized to the intervention group received a 5-day course involving a nursing theory recap and situational role-play using simulated scenarios (based on technical dexterity, clinical approach, decision making, aptitude to teamwork, and task prioritization), which were followed by debriefing sessions on attitude and discussion of practices. MAIN OUTCOMES AND MEASURES: The primary outcome was the prevalence of job strain assessed by combining a psychological demand score greater than 21 (score range, 9 [best] to 36 [worst]) with a decision latitude score less than 72 (score range, 24 [worst] to 96 [best]) using the Job Content Questionnaire and evaluated at 6 months. There were 7 secondary outcomes including absenteeism and turnover. RESULTS: Among 198 ICU nurses who were randomized (95 aged ≤30 years [48%] and 115 women [58%]), 182 (92%) completed the trial for the primary outcome. The trial was stopped for efficacy at the scheduled interim analysis after enrollment of 198 participants. The prevalence of job strain at 6 months was lower in the intervention group than in the control group (13% vs 67%, respectively; between-group difference, 54% [95% CI, 40%-64%]; P < .001). Absenteeism during the 6-month follow-up period was 1% in the intervention group compared with 8% in the control group (between-group difference, 7% [95% CI, 1%-15%]; P = .03). Four nurses (4%) from the intervention group left the ICU during the 6-month follow-up period compared with 12 nurses (12%) from the control group (between-group difference, 8% [95% CI, 0%-17%]; P = .04). CONCLUSIONS AND RELEVANCE: Among ICU nurses, an intervention that included education, role-play, and debriefing resulted in a lower prevalence of job strain at 6 months compared with nurses who did not undergo this program. Further research is needed to understand which components of the program may have contributed to this result and to evaluate whether this program is cost-effective. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02672072</description><subject>Absenteeism</subject><subject>Adult</subject><subject>Caring for the Critically Ill Patient</subject><subject>Clinical decision making</subject><subject>Clinical trials</subject><subject>Decision making</subject><subject>Employee turnover</subject><subject>Female</subject><subject>France</subject><subject>Hospitals</subject><subject>Humans</subject><subject>Intensive care</subject><subject>Intensive Care Units</subject><subject>Intervention</subject><subject>Male</subject><subject>Medical personnel</subject><subject>Nurses</subject><subject>Nursing</subject><subject>Nursing Staff, Hospital - education</subject><subject>Nursing Staff, Hospital - psychology</subject><subject>Occupational health</subject><subject>Occupational stress</subject><subject>Occupational Stress - epidemiology</subject><subject>Occupational Stress - prevention & control</subject><subject>Online First</subject><subject>Original Investigation</subject><subject>Personnel Turnover - statistics & numerical data</subject><subject>Role Playing</subject><subject>Simulation</subject><subject>Simulation Training</subject><subject>Staff Development</subject><subject>Strain</subject><issn>0098-7484</issn><issn>1538-3598</issn><issn>1538-3598</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2018</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNpdkV1rFDEUhoModq1eC15IwBtvZpvPmYwXhWVpdaV-YFu8DJlMsmbNJDWZKdTf4I8247ZFDYHAOc95T15eAJ5jtMQI4aOdGtSSICyWmBHBHoAF5lRUlLfiIVgg1IqqYYIdgCc571A5mDaPwQFFlDekZgvw68Rao8cMo4UKfpj86IbYKw8_p7hNaoCboP3Uu7CF526YvBpdDLDc97GD52NSLsDVEEv745SyyfBrTN9nutQ3YTQhu2sD1yoZeBncmN_AFfyiQh8H99P0cO1dcLqsu0hO-afgkVU-m2e37yG4PD25WL-rzj693axXZ5WinI6VspgijinujEBWGGx4XwtlUWsV7ZhmpDeaUFsTTjpcC6sFZ31jWqIZJ9jQQ3C8172ausH02oRixMur5AaVbmRUTv7bCe6b3MZrWRMmcE2LwOtbgRR_TCaPcnBZG-9VMHHKkuCyuuVEzOir_9BdnFIo9grFS1Bti9pCHe0pnWLOydj7z2Ak56TlnLSck5Z_ki4TL__2cM_fRVuAF3tgHrzrkgajpmnob2m3rqk</recordid><startdate>20181120</startdate><enddate>20181120</enddate><creator>El Khamali, Radia</creator><creator>Mouaci, Atika</creator><creator>Valera, Sabine</creator><creator>Cano-Chervel, Marion</creator><creator>Pinglis, Camille</creator><creator>Sanz, Céline</creator><creator>Allal, Amel</creator><creator>Attard, Valérie</creator><creator>Malardier, Julie</creator><creator>Delfino, Magali</creator><creator>D’Anna, Fifina</creator><creator>Rostini, Pierre</creator><creator>Aguilard, Stéphan</creator><creator>Berthias, Karine</creator><creator>Cresta, Béatrice</creator><creator>Iride, Frédéric</creator><creator>Reynaud, Valérie</creator><creator>Suard, Jérémie</creator><creator>Syja, Wlady</creator><creator>Vankiersbilck, Cécile</creator><creator>Chevalier, Nicole</creator><creator>Inthavong, Karen</creator><creator>Forel, Jean-Marie</creator><creator>Baumstarck, Karine</creator><creator>Papazian, Laurent</creator><general>American Medical Association</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7QL</scope><scope>7QP</scope><scope>7TK</scope><scope>7TS</scope><scope>7U7</scope><scope>7U9</scope><scope>8FD</scope><scope>C1K</scope><scope>FR3</scope><scope>H94</scope><scope>K9.</scope><scope>M7N</scope><scope>NAPCQ</scope><scope>P64</scope><scope>RC3</scope><scope>7X8</scope><scope>5PM</scope></search><sort><creationdate>20181120</creationdate><title>Effects of a Multimodal Program Including Simulation on Job Strain Among Nurses Working in Intensive Care Units: A Randomized Clinical Trial</title><author>El Khamali, Radia ; Mouaci, Atika ; Valera, Sabine ; Cano-Chervel, Marion ; Pinglis, Camille ; Sanz, Céline ; Allal, Amel ; Attard, Valérie ; Malardier, Julie ; Delfino, Magali ; D’Anna, Fifina ; Rostini, Pierre ; Aguilard, Stéphan ; Berthias, Karine ; Cresta, Béatrice ; Iride, Frédéric ; Reynaud, Valérie ; Suard, Jérémie ; Syja, Wlady ; Vankiersbilck, Cécile ; Chevalier, Nicole ; Inthavong, Karen ; Forel, Jean-Marie ; Baumstarck, Karine ; Papazian, Laurent</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-a353t-af1305131be80f8e1e5d68af09fa3b4c42dec23f6252b168fc854d7e92c4521e3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2018</creationdate><topic>Absenteeism</topic><topic>Adult</topic><topic>Caring for the Critically Ill Patient</topic><topic>Clinical decision making</topic><topic>Clinical trials</topic><topic>Decision making</topic><topic>Employee turnover</topic><topic>Female</topic><topic>France</topic><topic>Hospitals</topic><topic>Humans</topic><topic>Intensive care</topic><topic>Intensive Care Units</topic><topic>Intervention</topic><topic>Male</topic><topic>Medical personnel</topic><topic>Nurses</topic><topic>Nursing</topic><topic>Nursing Staff, Hospital - 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Academic</collection><collection>PubMed Central (Full Participant titles)</collection><jtitle>JAMA : the journal of the American Medical Association</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>El Khamali, Radia</au><au>Mouaci, Atika</au><au>Valera, Sabine</au><au>Cano-Chervel, Marion</au><au>Pinglis, Camille</au><au>Sanz, Céline</au><au>Allal, Amel</au><au>Attard, Valérie</au><au>Malardier, Julie</au><au>Delfino, Magali</au><au>D’Anna, Fifina</au><au>Rostini, Pierre</au><au>Aguilard, Stéphan</au><au>Berthias, Karine</au><au>Cresta, Béatrice</au><au>Iride, Frédéric</au><au>Reynaud, Valérie</au><au>Suard, Jérémie</au><au>Syja, Wlady</au><au>Vankiersbilck, Cécile</au><au>Chevalier, Nicole</au><au>Inthavong, Karen</au><au>Forel, Jean-Marie</au><au>Baumstarck, Karine</au><au>Papazian, Laurent</au><aucorp>SISTRESSREA Study Group</aucorp><aucorp>for the SISTRESSREA Study Group</aucorp><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Effects of a Multimodal Program Including Simulation on Job Strain Among Nurses Working in Intensive Care Units: A Randomized Clinical Trial</atitle><jtitle>JAMA : the journal of the American Medical Association</jtitle><addtitle>JAMA</addtitle><date>2018-11-20</date><risdate>2018</risdate><volume>320</volume><issue>19</issue><spage>1988</spage><epage>1997</epage><pages>1988-1997</pages><issn>0098-7484</issn><issn>1538-3598</issn><eissn>1538-3598</eissn><abstract>IMPORTANCE: Nurses working in an intensive care unit (ICU) are exposed to occupational stressors that can increase the risk of stress reactions, long-term absenteeism, and turnover. OBJECTIVE: To evaluate the effects of a program including simulation in reducing work-related stress and work-related outcomes among ICU nurses. DESIGN, SETTING, AND PARTICIPANTS: Multicenter randomized clinical trial performed at 8 adult ICUs in France from February 8, 2016, through April 29, 2017. A total of 198 ICU nurses were included and followed up for 1 year until April 30, 2018. INTERVENTIONS: The ICU nurses who had at least 6 months of ICU experience were randomized to the intervention group (n = 101) or to the control group (n = 97). The nurses randomized to the intervention group received a 5-day course involving a nursing theory recap and situational role-play using simulated scenarios (based on technical dexterity, clinical approach, decision making, aptitude to teamwork, and task prioritization), which were followed by debriefing sessions on attitude and discussion of practices. MAIN OUTCOMES AND MEASURES: The primary outcome was the prevalence of job strain assessed by combining a psychological demand score greater than 21 (score range, 9 [best] to 36 [worst]) with a decision latitude score less than 72 (score range, 24 [worst] to 96 [best]) using the Job Content Questionnaire and evaluated at 6 months. There were 7 secondary outcomes including absenteeism and turnover. RESULTS: Among 198 ICU nurses who were randomized (95 aged ≤30 years [48%] and 115 women [58%]), 182 (92%) completed the trial for the primary outcome. The trial was stopped for efficacy at the scheduled interim analysis after enrollment of 198 participants. The prevalence of job strain at 6 months was lower in the intervention group than in the control group (13% vs 67%, respectively; between-group difference, 54% [95% CI, 40%-64%]; P < .001). Absenteeism during the 6-month follow-up period was 1% in the intervention group compared with 8% in the control group (between-group difference, 7% [95% CI, 1%-15%]; P = .03). Four nurses (4%) from the intervention group left the ICU during the 6-month follow-up period compared with 12 nurses (12%) from the control group (between-group difference, 8% [95% CI, 0%-17%]; P = .04). CONCLUSIONS AND RELEVANCE: Among ICU nurses, an intervention that included education, role-play, and debriefing resulted in a lower prevalence of job strain at 6 months compared with nurses who did not undergo this program. Further research is needed to understand which components of the program may have contributed to this result and to evaluate whether this program is cost-effective. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02672072</abstract><cop>United States</cop><pub>American Medical Association</pub><pmid>30357264</pmid><doi>10.1001/jama.2018.14284</doi><tpages>10</tpages><oa>free_for_read</oa></addata></record> |
| fulltext | fulltext |
| identifier | ISSN: 0098-7484 |
| ispartof | JAMA : the journal of the American Medical Association, 2018-11, Vol.320 (19), p.1988-1997 |
| issn | 0098-7484 1538-3598 1538-3598 |
| language | eng |
| recordid | cdi_pubmedcentral_primary_oai_pubmedcentral_nih_gov_6248163 |
| source | MEDLINE; American Medical Association Journals |
| subjects | Absenteeism Adult Caring for the Critically Ill Patient Clinical decision making Clinical trials Decision making Employee turnover Female France Hospitals Humans Intensive care Intensive Care Units Intervention Male Medical personnel Nurses Nursing Nursing Staff, Hospital - education Nursing Staff, Hospital - psychology Occupational health Occupational stress Occupational Stress - epidemiology Occupational Stress - prevention & control Online First Original Investigation Personnel Turnover - statistics & numerical data Role Playing Simulation Simulation Training Staff Development Strain |
| title | Effects of a Multimodal Program Including Simulation on Job Strain Among Nurses Working in Intensive Care Units: A Randomized Clinical Trial |
| url | https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-02-08T12%3A56%3A05IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-proquest_pubme&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Effects%20of%20a%20Multimodal%20Program%20Including%20Simulation%20on%20Job%20Strain%20Among%20Nurses%20Working%20in%20Intensive%20Care%20Units:%20A%20Randomized%20Clinical%20Trial&rft.jtitle=JAMA%20:%20the%20journal%20of%20the%20American%20Medical%20Association&rft.au=El%20Khamali,%20Radia&rft.aucorp=SISTRESSREA%20Study%20Group&rft.date=2018-11-20&rft.volume=320&rft.issue=19&rft.spage=1988&rft.epage=1997&rft.pages=1988-1997&rft.issn=0098-7484&rft.eissn=1538-3598&rft_id=info:doi/10.1001/jama.2018.14284&rft_dat=%3Cproquest_pubme%3E2125295283%3C/proquest_pubme%3E%3Curl%3E%3C/url%3E&disable_directlink=true&sfx.directlink=off&sfx.report_link=0&rft_id=info:oai/&rft_pqid=2153599909&rft_id=info:pmid/30357264&rft_ama_id=2710777&rfr_iscdi=true |