NURSES’ PROFESSIONAL COMPETENCIES AND THE CARE PRODUCT IN EMERGENCY DEPARTMENTS: A MIXED-METHODS STUDYABSTRACT
Objective: to analyze the relationship between nurses’ professional competencies and the nursing care product.
Method: this is a mixed-methods study with an explanatory sequential design prioritizing the quantitative phase. The study was conducted in an emergency unit of a public hospital in São Paulo, Brazil, and involved 132 nurses in the quantitative phase and 20 in the qualitative phase. The Assessment of the Nursing Care Product and Lilalva Scale instruments were applied. The quantitative analysis included descriptive statistics and a Linear Mixed Model, while the qualitative analysis included thematic content analysis integrated with joint displays.
Results: the care product scores ranged from 21-28 (“good”) to 29-32 (“excellent”), with “good” predominating. Competencies in planning, resources, staffing, educational activities, multidisciplinary work, and meeting needs stood out. In turn, “professional practice” received the highest score on the Lilalva Scale, while “constructive conduct” received the lowest. The “workplace relationships” factor showed a significant effect (p=0.047). The total score was also significant (p=0.016; ES=0.210). The qualitative analysis revealed perceptions about technical preparation, multidisciplinary challenges, and the need for educational strategies, corroborating the quantitative findings. Integrating the results highlighted the interdependence between competencies and quality of care.
Conclusion: the relationship between professional competencies and the care product highlighted the importance of clinical development in optimizing care, pointing to institutional strategies for strengthening nurses’ competencies.
DESCRIPTORS:
Professional performance assessment; Health care process assessment; Professional competence; Emergency nursing; Nursing administration research; Professional practice
RESUMO
Objetivo: analisar a relação entre as competências profissionais dos enfermeiros e o produto do cuidado em enfermagem.
Método: estudo de métodos mistos, com design sequencial explanatório, priorizando a fase quantitativa. Realizado em unidade de urgência e emergência de hospital público de São Paulo com 132 enfermeiros na fase quantitativa e 20, na qualitativa. Foram aplicados os instrumentos Avaliação do Produto do Cuidado em Enfermagem e Escala Lilalva. A análise quantitativa incluiu estatísticas descritivas e Modelo Linear Misto, e a qualitativa, análise temática de conteúdo, integrada por joint displays.
Resultados: as pontuações do produto do cuidado variaram entre 21-28 (“bom”) e 29-32 (“ótimo”), predominando “bom”. Destacaram-se competências em planejamento, recursos, dimensionamento de pessoal, ações educativas, atuação multiprofissional e atendimento das necessidades. Na Escala Lilalva, “prática profissional” obteve maior pontuação, enquanto “conduta construtiva” foi a menor. O fator “relações no trabalho” apresentou efeito significativo (p=0,047). A pontuação total também foi significativa (p=0,016; TE=0,210). Na análise qualitativa, emergiram percepções sobre preparo técnico, desafios multiprofissionais e necessidade de estratégias educativas, corroborando os achados quantitativos. A integração dos resultados evidenciou a interdependência entre competências e qualidade assistencial.
Conclusão: a relação entre competências profissionais e produto do cuidado evidenciou a relevância do desenvolvimento clínico para otimizar a assistência, apontando para estratégias institucionais de fortalecimento das competências dos enfermeiros.
DESCRITORES:
Avaliação de desempenho profissional; Avaliação de processos em cuidados de saúde; Competência profissional; Enfermagem em emergência; Pesquisa em administração de enfermagem; Prática profissional
RESUMEN
Objetivo: analizar la relación entre las competencias profesionales de las enfermeras y el producto de la atención de enfermería.
Método: estudio de métodos mixtos con un diseño secuencial explicativo, priorizando la fase cuantitativa. Realizado en una unidad de urgencias de un hospital público de São Paulo, el estudio involucró a 132 enfermeras en la fase cuantitativa y 20 en la fase cualitativa. Se aplicaron los instrumentos de Evaluación del Producto de Atención de Enfermería y la Escala de Lilalva. El análisis cuantitativo incluyó estadística descriptiva y un Modelo Lineal Mixto, mientras que el análisis cualitativo incluyó análisis de contenido temático, integrado con visualizaciones conjuntas.
Resultados: las puntuaciones del producto de la atención oscilaron entre 21-28 (bueno) y 29-32 (excelente), con predominio de la puntuación “buena”. Destacaron las competencias en planificación, recursos, dotación de personal, actividades educativas, trabajo multidisciplinario y atención a necesidades. En la Escala de Lilalva, la “práctica profesional” obtuvo la puntuación más alta, mientras que la “conducta constructiva” obtuvo la más baja. El factor “relaciones laborales” mostró un efecto significativo (p=0,047). La puntuación total también fue significativa (p=0,016; ES=0,210). El análisis cualitativo reveló percepciones sobre la preparación técnica, los desafíos multidisciplinarios y la necesidad de estrategias educativas, lo que corrobora los hallazgos cuantitativos. La integración de los resultados destacó la interdependencia entre las competencias y la calidad de la atención.
Conclusión: la relación entre las competencias profesionales y el resultado de la atención destacó la importancia del desarrollo clínico para optimizar la atención, lo que sugiere estrategias institucionales para fortalecer las competencias de las enfermeras.
DESCRIPTORES:
Evaluación del desempeño profesional; Evaluación del proceso de atención; Competencia profesional; Enfermería de urgencias; Investigación en administración de enfermería; Práctica profesional
INTRODUCTION
The Brazilian healthcare system is increasingly overburdened, even with strategies adopted at all levels of governance to ensure equitable care focused on the population’s health and disease processes, and decentralized actions to achieve resolution1. In this context, the emergency care network meets a significant demand from the population accessing these services, serving as the gateway to the Unified Health System (Sistema Único de Saúde - SUS). Each facility seeks to resolve health problems presented by its demand based on its specific characteristics, which is largely spontaneous. However, such efficient resolution is not always possible due to overcrowding2.
Emergency care units are complex environments for nurses’ management and care practices3, requiring competencies, knowledge, skills, and attitudes to provide effective care4. Professional competencies have gained prominence in recent decades, becoming a central theme in business management discussions which seek to diversify the concept to meet the expectations of a globalized world3.
Care planning for nurses working in emergency and urgent care units requires developing previously defined competencies based on a matrix which scales5 the required managerial and care profile. It requires implementing care processes that prioritize effective actions based on rapid clinical reasoning to resolve acute problems presented by patients, starting from the risk classification (RC)6.
Emergency and urgent care units require specific competencies from nurses, including adequate team size and leadership and decision-making skills7. Care management is often faced with unforeseen situations and depends on a well-coordinated team, which ensures prioritization of emergencies and effective care. Therefore, care organization is also fundamental to the quality of care provided8.
In this sense, nurses are part of the multidisciplinary team, constantly seeking collaboration to ensure efficient patient care through coordinated, discussed, and implemented actions aimed at resolving the health problem9. Efficient care will impact the entire team through this interaction, contributing to a better assessment of healthcare quality and consequently patient safety. In this context, the viability of care products guided by nurses’ competencies in emergency care directly impacts the health outcomes and processes presented.
Care delivery is the result of planned care actions based on technical knowledge, ensuring care continuity10. Nurses, as care managers, have the autonomy to implement strategies based on their technical and scientific knowledge11. Studies demonstrate the relationship between nurses’ competencies and emergency care, especially in team size, monitoring and transfer of care, and meeting care needs12.
Thus, the research question of this study is: How do nurses’ professional competencies influence the quality of nursing care? It is worth noting that this question advances existing knowledge by investigating the interdependence between nurses’ technical and emotional competencies, not only emphasizing the impact of these competencies on the care quality, but also exploring strategies for their continuous improvement. In turn, this study was conducted to analyze the relationship between nurses’ competencies and the nursing care product to answer this question.
METHOD
Study design
This is a cross-sectional, mixed-methods study with an explanatory sequential design13. The quantitative data carried the greatest weight, from which qualitative data were obtained. It is noteworthy that this design introduces a qualitative element to explain the initial quantitative results14. The results were integrated and discussed to identify connections between them. A descriptive-analytical cross-sectional study was then conducted to obtain the quantitative results, designed based on Strengthening the Reporting of Observational Studies in Epidemiology. The qualitative phase was characterized as an exploratory-descriptive study, designed according to the Solidified Criteria for Reporting Qualitative Research. Finally, the Mixed Methods Appraisal Tool was used to analyze methodological rigor to obtain data relevant to the mixed method15-16.
Data collection setting
The study was conducted in the emergency unit of a secondary public hospital with tertiary care in the Southwest region of São Paulo, Brazil. It is a referral center for the Emergency Network, high-risk pregnancies, pediatrics, and mental health, and primarily serves SUS patients. The hospital offers outpatient, inpatient, and emergency services, prioritizing immediate and uninterrupted care, with diagnostic and therapeutic support.
The service is managed by the São Paulo Department of Health, operates on a voluntary basis and has a structure consisting of a critical care unit, an emergency and shock room, emergency care, suturing, medication, a pediatric emergency room, backup units, and psychiatric observation.
Population
The sample for this study consisted of clinical nurses working in the emergency department.
Selection criteria
Nurses participated in the quantitative phase after explaining the objectives and proposals of the study. Professionals with 90 days or more of experience in the service were considered eligible for the study. It should be noted that the qualitative phase consisted of nurses who participated in the quantitative phase.
Sample definition
A total of 132 of the 140 eligible nurses participated in the study, resulting in a response rate of 94.3 %. This sample ensured data representativeness and validity, ensuring the robustness of the study. Next, 20 nurses were randomly selected in the qualitative phase, from among those who responded to the quantitative phase, applying the data saturation criterion. Random selection was performed by a simple draw, ensuring equal opportunities among participants.
Instruments used for data collection
The Assessment of Nursing Care Product (APROCENF) scale17, validated in emergency units12, was used for quantitative analysis. The scale has eight domains, each with four items: 1) care planning; 2) care resources; 3) staffing; 4) educational activities and development; 5) monitoring and transfer of care; 6) multidisciplinary interaction; 7) patient/family care; and 8) meeting care needs. Nurses evaluated the items at the end of their shift, classifying them as “poor” (8-12 points), “fair” (13-20 points), “good” (21-28 points), and “excellent” (29-32 points).
The second quantitative instrument was the Lilalva Scale for Measuring Clinical Competencies in Emergency Nursing18. This is a soft-hard technology that measures the presence and level of clinical competence considering self- and peer assessment. The scale has seven dimensions: professional practice; workplace relationships; positive challenge; targeted action; constructive conduct; professional excellence; and adaptation to change. It includes eight core competencies, 32 associated competencies, and 78 behavioral items/actions, allowing for a comprehensive assessment of nurses’ clinical competence in the emergency department.
The qualitative phase used a sociodemographic questionnaire (age, gender, time since graduation, experience in the department, academic qualifications, and work shift) and a semi-structured questionnaire with two questions developed by the authors. The questions explored nurses’ perceptions of the relationships evidenced or not in the quantitative analysis, seeking to identify areas for improvement in competency development and care delivery. Participants were informed of the need for continued study and participated in individual interviews lasting 10 to 20 minutes at a previously agreed-upon location to answer the following questions: 1) How do you interpret the relationship between your professional competencies and the care provided to patients in emergency situations? 2) In your opinion, how can nurses’ professional competencies be improved in the emergency department to optimize nursing care? This study analyzed the potential gap in the competencies required for nurses in emergency departments and the delivery of nursing care.
Data collection
Quantitative data collection took place between September and October 2024, with nurses responding to the APROCENF17 and the Lilalva Scale18. The APROCENF17 was completed at the end of 10 shifts, reflecting the delivery of care. The qualitative phase took place in person between November and December, at agreed times. Nurses who agreed to participate received an envelope containing the Care Characterization Form and the APROCENF17, to be completed at the end of 10 shifts and returned within 25 days. After this stage, they received the Lilalva Scale18, with five days to return it. Interviews in the qualitative phase were conducted individually, recorded on MP3, and transcribed for analysis. Only the researchers had access to the data, which were discarded after transcription.
Data processing and analysis
The data were analyzed using descriptive statistics, with frequency and correlation tables for the variables. IBM SPSS 22 software was used with the support of a statistician. The statistical significance level was set at 5 % (p ≤ 0.05). Qualitative data were transcribed, organized into tables, and analyzed by content theme using an inductive approach. The correlation between APROCENF and the Lilalva Scale was analyzed using a Mixed Linear Model (MLM), considering individuals as a random effect and the Lilalva Scale factors as fixed effects. Multicollinearity was assessed (mean VIF = 1.183; maximum = 1.307; minimum tolerance = 0.765) with no violations. Significance was tested using the Kenward-Roger method, and F values were converted to correlation coefficients (r) to interpret the magnitude of the association. The estimation followed the restricted maximum likelihood method with unstructured covariance. Data integration was performed using joint displays, connecting quantitative and qualitative approaches19,20.
Data integration
Integration of the quantitative and qualitative stages followed a sequential explanatory design, in which the results of the APROCENF and Lilalva Scale guided the development of the semi-structured interview script. This connection process allowed for a deeper and more contextualized analysis of the statistical findings, seeking a more comprehensive understanding of the relationship between nurses’ competencies and the outcome of emergency care.
Integration occurred in three stages: (1) connection, when quantitative data supported the formulation of qualitative questions; (2) comparison, using joint displays, which organized quantitative results, corresponding qualitative evidence, and meta-inferences side by side; and (3) integrated interpretation, in which convergences (when qualitative findings reinforced quantitative ones), complementarities (when they added new dimensions to the phenomenon), and divergences (when they brought distinct perspectives) were explored. Presentation of the results included integration tables (joint displays) to ensure transparency and rigor, highlighting how the different data sets related and contributed to a more comprehensive understanding of the study object.
Ethical aspects
After clarifying the research objectives and potential risks, such as privacy violations, emotional distress, and data leaks, the professionals consented by signing the Informed Consent Form. The study followed ethical guidelines and was authorized by the Federal University of São Paulo (UNIFESP) and the hospital where the study was conducted. The project was submitted to the Research Ethics Committees of UNIFESP and the hospital via the Brasil platform.
RESULTS
The study included the participation of 132 nurses out of a total of 140 professionals working in the unit, 73 (55.3 %) of whom were female. The majority were single (n=72; 54.5 %) and worked day shifts (n=67; 50.8 %) or night shifts (n=64; 48.5 %), with shifts from 7 am to 7 pm (n=67; 50.8 %) or 7 pm to 7 am (n=65; 49.2 %). More than half (n=68; 51.5 %) worked in an institution other than the research site. Training ranged from 2008 to 2022, with the highest concentration between 2015 and 2017 (n=61; 46.2 %). Lato sensu specialization was reported by 99 (75 %) participants. In addition to the quantitative phase, 20 nurses participated in the qualitative phase of the study.
The APROCENF evaluation indicated that most responses were concentrated in the “good” category, with scores ranging from 21 to 28, and to a lesser extent in the “excellent” category, with scores between 29 and 32. The results demonstrate a favorable perception of nurses regarding their competencies in the eight domains evaluated: nursing care planning; resources needed to provide care; staffing; educational activities and staff development; monitoring and transfer of care; interaction and multidisciplinary work; patient and/or family care; and meeting care needs.
The predominant scores across the evaluations were 3 and 4, suggesting that professionals recognize their performance as adequate for the demands of emergency care. The low frequency of responses in the lower categories (scores 1 and 2) reinforces that although there are opportunities for improvement, nurses consider themselves qualified to provide care. The sample’s characterization based on responses to the Lilalva Scale reveals that most nurses rated their clinical competencies highly, predominantly at levels 4 (very competent) and 5 (extremely competent). The assessment covered seven dimensions: professional practice; workplace relationships; positive challenge; targeted action; constructive conduct; professional excellence; and adaptation to change.
The results indicate that participants demonstrate a high level of professional competence, with a consistent distribution of high scores across all dimensions analyzed. Some questions presented variability in responses, reflecting possible individual or contextual differences in clinical practice. However, the predominance of positive evaluations reinforces the perception of qualified performance aligned with care requirements.
Table 1 presents the characterization of the groups based on scores on the Lilalva Scale and the APROCENF. On the Lilalva Scale, the average total score was 331.35 (SD = 5.46), with a higher score in the professional practice dimension (F1) and a lower score in the constructive conduct dimension (F5), suggesting greater mastery of technical skills and less emphasis on behavioral aspects. On the APROCENF scale, the average scores (A1-A10) ranged from 26.06 to 26.95, with medians ranging from 24 to 26 points, indicating stability in perceptions throughout the evaluated moments.
Stability was observed in the means and medians of the scales applied, suggesting consistency in participant perceptions across the assessment periods. Table 2 presents the results of the MLM fixed effects test, analyzing the effect of pressure, frequency, and group on the scores in the different dimensions of the Lilalva Scale. Factor F2 (work relationships) showed a statistically significant effect (p = 0.047), indicating that pressure, frequency, and group influence this dimension of the scale. The other dimensions, such as F1 (professional practice) and F3 (positive challenge), did not show statistical significance (p > 0.05). The overall model (total Lilalva Scale score) also demonstrated a significant effect (p = 0.016), with a small effect (TE = 0.210), suggesting that the combination of the factors analyzed has a slight influence on the total scale scores overall.
Statistically significant results were found for the Lilalva-F2 and Lilalva-total factors, indicating a significant effect of pressure, frequency, and group on care quality. The other factors showed no significant differences, suggesting stability in the other dimensions analyzed. The combined analysis of the Lilalva Scale and APROCENF confirms the relationship between nurses’ competencies and the quality of care in emergencies. Despite some significant effects, they were small, indicating the need for improvements in planning, resource management, and multidisciplinary work. The qualitative data reinforce the importance of clinical and behavioral competencies in care practice. The qualitative analysis followed the thematic technique, involving reading, coding, and grouping into categories, from which the main themes emerged. These themes reflect the participants’ perceptions and experiences, allowing for deeper understanding of the studied phenomenon.
The analysis of the nurses’ statements on the relationship between professional competencies and care in emergencies revealed three categories: technical competencies as a basis for safe care; emotional and interpersonal competencies in critical situations; and the dynamic relationship between competencies and quality of care. Statements like N1’s, which emphasizes clinical assessment, emotional control, and quick decisions as essential, and N5’s, which emphasizes risk identification, leadership, and agility in decision-making to ensure quality and safety, stand out.
In turn, three categories emerged for the question “In your perception, how can nurses’ professional competencies be improved in the emergency room to optimize nursing care?”: C1 - continuing education and technical training; C2 - practical strategies for professional development; and C3 - promoting a culture of learning and innovation. Thus, continuous training, simulations, and protocol updates are highlighted in C1; feedback, case discussions, and mentoring to strengthen skills are emphasized in C2; and the creation of an environment which fosters safety, collective learning, and innovation is highlighted in C3. Integrating these strategies is essential for continuous improvement in the quality of care in emergencies. Chart 1 presents the categories and excerpts from statements related to the central theme.
Emerging categories from qualitative analysis of professional competencies and improvement strategies in emergency care units. São Paulo, SP, Brazil, 2025
Chart 2 integrates quantitative and qualitative data, demonstrating that both the scales (Lilalva and APROCENF) and the nurses’ testimonies indicate the need for continuous skills development. The interdependence between technical and emotional skills is highlighted to ensure safe, high-quality emergency care.
DISCUSSION
The analysis revealed that specific technical and emotional competencies (such as decision-making, emotional control, and resilience) are interdependent and central to the care quality in emergencies, enabling appropriate interventions and minimizing errors. This finding confirms previous studies that emphasize the importance of technical training and the ability to deal with complex situations, which are key characteristics in the emergency environment21. Technical competencies enable appropriate interventions, while emotional competencies, such as control and resilience, are essential to minimize errors22.
Qualitative data showed that emotional competencies, such as resilience and stress management, are as important as technical competencies in the care of critically ill patients. Nurses emphasized quick decision-making and maintaining calm, reinforcing the interdependence between technical and emotional skills, in line with the literature on emotional intelligence and effective communication. The literature also emphasizes the need for emotional training to strengthen resilient healthcare teams22. In this sense, the complementarity between technical and non-technical competencies observed in this study converges with international evidence that communication, coordination, and situational awareness are determinants of performance in emergencies and can be strengthened through interprofessional simulation23.
Most nurses rate themselves as highly competent, especially in terms of “professional excellence” and “constructive conduct”. However, as N4 emphasized, there is a continuous need for updating in light of technological changes and emergency demands. Recent studies in emergency services corroborate these findings, showing that higher patient safety competence levels are associated with better teamwork and psychological safety, constituting elements which may mediate the relationship between self-rated competence and perceived quality of care24.
The study highlighted the importance of ongoing academic development, continuing education, and practical training to enhance nurses’ competencies. N2 and N5 emphasized that technical and emotional training programs, such as simulations and continuous feedback, are effective in preparing professionals for emergency situations. These results corroborate previous studies which advocate educational strategies that integrate technical and emotional aspects22. Continuing education programs with simulation, including in-situ modalities and virtual reality, have demonstrated sustainable gains in technical and non-technical competencies and the potential to impact clinical outcomes25. Continuing education is necessary to foster a learning environment and strengthen organizational culture, improving resilience and quality of care, especially in emergency units26.
Quantitative data indicate that nurses’ perception of the care quality is strongly linked to their self-perceived competence, with the majority rating their performance as “good” or “excellent”. However, the analysis also highlights the need for emotional and psychological support for professionals in high-pressure situations, as suggested by N6. This reflects that despite high self-perceived competence, nurses face high levels of stress, which can impair the care quality27. Emotional overload in critical environments is widely discussed in the literature, with negative impacts on decision-making and increased errors. Meta-analyses indicate that nurse burnout is associated with poorer care quality and safety, supporting the need for organizational support and well-being interventions in high-pressure environments28.
The results indicate that nurses’ competencies directly impact the care quality provided. The ability to act effectively in emergencies is linked to the continuous development of technical and emotional skills. Therefore, improving these skills should be a priority in health and education policies, ensuring that nurses are prepared to face the challenges of emergency units29. Competent performance depends on a robust combination of these competencies, which are essential for effective performance in high-pressure environments30.
The findings indicate that simultaneously investing in technical and non-technical competencies improves emergency care delivery. A quarterly continuing education program with in-situ simulation and structured debriefing is proposed to consolidate clinical decision-making, communication, and coordination. In turn, shift briefings/debriefings, interdisciplinary rounds, and systematic use of the Situation, Background, Assessment, Recommendation method should be implemented to strengthen working relationships (F2). Resource allocation and provision should be adjusted at the managerial level, mapped to the APROCENF domains, with shift checklists, implementing psychosocial support and psychological safety (mentoring, focus groups) to mitigate stress and maintain performance. Furthermore, impact should be monitored using indicators such as APROCENF domain averages, the Lilalva Scale (especially F2), incidents/near-misses (near misses which missed the patient), patient/family satisfaction, and turnover using Plan-Do-Study-Act cycles for continuous improvement.
In summary, the results reinforce that the quality of emergency care not only depends on technical competencies, but also on interpersonal and emotional skills. The continuous development of these competencies should be central to educational strategies and health policies. Lastly, it is essential to foster an organizational culture that prioritizes psychological support and ongoing training, ensuring the quality of care and improving nurses’ performance in critical situations.
CONCLUSION
The relationship between professional competencies and the care product highlighted the importance of clinical development in optimizing care, pointing to institutional strategies for strengthening nurses’ competencies. This study contributes to advance knowledge by highlighting the interdependence between nurses’ technical, emotional, and interpersonal competencies and the quality of care in emergencies, reinforcing the centrality of these skills in rapid decision-making and the effective management of critical situations. The results are relevant to hospital managers, nursing professionals, educators, and health policymakers, providing support for strategies for ongoing education, training, and support for collaborative work. Practical applications include developing institutional continuing education programs, specific training, and strengthening an organizational culture focused on patient safety and improving clinical outcomes. Limitations include the cross-sectional nature of the study and the sample restricted to a single hospital setting, which may limit the generalizability of the results. Future studies could explore different care settings and evaluate the impact of educational interventions aimed at improving nurses’ competencies.
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NOTES
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ORIGIN OF THE ARTICLE
This article is the result of the post-doctorate of the Postgraduate Program in Nursing, of the Paulista School of Nursing of the Universidade Federal de São Paulo, in 2025.
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APPROVAL OF ETHICS COMMITTEE IN RESEARCH
Approved by the Research Ethics Committee of the Universidade Federal de São Paulo and the Municipal Hospital of Campo Limpo, opinion no. 6,946,320, Certificate of Presentation for Ethical Assessment 78455924.1.0000.5505.
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TRANSLATED BY
Christopher J. Quinn.
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DATA AVAILABILITY
The data supporting the findings of this study are not publicly available due to ethical concerns and participant confidentiality. Additional information may be provided by the corresponding author upon justified request and ethical review.
Edited by
The data supporting the findings of this study are not publicly available due to ethical concerns and participant confidentiality. Additional information may be provided by the corresponding author upon justified request and ethical review.
