The novel COVID-19: impacts on nursing professionals’ mental health?

Abstract

Objective:

To understand mental health impacts on nursing professionals in the face of interactions with the novel COVID-19 pandemic.

Methods:

This is a qualitative cut, from the macrosearch “ Estudo VidaMenta/Covid-19 ”, carried out with 719 nursing professionals residing in Brazil. Data collection was performed in a virtual environment using the snowball technique. For methodological analysis, the Discourse of the Collective Subject was used and for theoretical and philosophical interpretation, Symbolic Interactionism elements were used.

Results:

The collective discourse showed that nursing professionals’ mental health was affected by: interactions with the ‘new’ with the elaboration of meanings attributed to the pandemic; interactions with nursing care related to patient care; interactions with work demarcated by professional and institutional relationships.

Conclusion:

The findings confirm that there are impacts on nursing professionals’ mental health in the COVID-19 pandemic context that manifest themselves through the interaction with the ‘new’. In this interaction, they bring the advent of ‘pandemic nursing care’, permeated by specificities that have emerged and presents a possibility of changing the paradigm for nursing training guidelines, in technological advances in teaching and learning and in professional practice.

Keywords
Pandemics; Coronavirus infections; COVID-19; Mental health; Nurses practitioners

Resumo

Objetivo:

Apreender os impactos na saúde mental de profissionais de Enfermagem face às interações com o ‘novo’ da pandemia da Covid-19.

Métodos:

Recorte qualitativo, da macropesquisa “Estudo VidaMenta/Covid-19”, realizado com 719 profissionais de Enfermagem residentes no Brasil. A coleta de dados foi realizada em ambiente virtual com a aplicação da técnica bola de neve . Para a análise metodológica utilizou-se o Discurso do Sujeito Coletivo e para interpretação teórica e filosófica recorreu-se a elementos do Interacionismo Simbólico.

Resultados:

O discurso coletivo evidenciou que a saúde mental de profissionais de Enfermagem foi afetada pelas: interações com o ‘novo’ com elaboração de significados atribuídos à pandemia; interações com o cuidado de Enfermagem relacionadas com os atendimentos aos pacientes; e interações com o trabalho demarcadas pelas relações profissionais e institucionais.

Conclusão:

Os achados confirmam que há impactos na saúde mental de profissionais de Enfermagem no contexto da pandemia Covid-19 que se manifestam a partir da interação com o ‘novo’. Nessa interação trazem o advento de um ‘cuidado de Enfermagem pandêmico’, permeado por especificidades que emergiram e apresenta uma possibilidade de mudança de paradigma para as diretrizes de formação em Enfermagem, nos avanços tecnológicos de ensino-aprendizagem e na prática profissional.

Descritores
Pandemia; Infecções por coronavirus; COVID-19; Saúde mental; Profissionais de Enfermagem

Resumen

Objetivo:

Comprender los impactos en la salud mental de profesionales de enfermería frente a las interacciones cono lo “nuevo” de la pandemia de COVID-19.

Métodos:

Recorte cualitativo, de la macroinvestigación “Estudo VidaMenta/Covid-19”, realizado con 719 profesionales de enfermería residentes en Brasil. La recolección de datos fue realizada en ambiente virtual con la aplicación de la técnica bola de nieve . Para el análisis metodológico se utilizó el Discurso del Sujeto Colectivo, y para la interpretación teórica y filosófica se recurrió a elementos del Interaccionismo Simbólico.

Resultados:

El discurso colectivo evidenció que la salud mental de profesionales de enfermería estuvo afectada por: interacciones con lo “nuevo” con elaboración de significados atribuidos a la pandemia; interacciones con el cuidado de enfermería relacionadas con la atención a pacientes, e interacciones con el trabajo determinadas por las relaciones profesionales e institucionales.

Conclusión:

Los resultados confirman que hay impactos en la salud mental de profesionales de enfermería en el contexto de la pandemia de COVID-19, que se manifiestan a partir de la interacción con lo “nuevo”. Esta interacción trae consigo el advenimiento de un “cuidado de enfermería pandémico”, impregnado de especificidades que surgieron, y presenta una posibilidad de cambio de paradigma de las directrices de formación en enfermería, en los avances tecnológicos de enseñanza-aprendizaje y en la práctica profesional.

Descriptores
Pandemias; Infecciones por coronavirus; COVID-19; Salud mental; Enfermeras practicantes

Introduction

The COVID-19 pandemic is considered the biggest public health emergency faced by the international community in decades.^(1,2)The rapid and high dissemination of SARS-CoV-2 changed the population’s daily life and affected health work, with expressiveness for nursing, causing psychosocial repercussions.^(3,4)

The COVID-19 pandemic was damaging to the death of 98 nursing professionals until May 8, 2020. To date, there were more than 3 thousand professionals infected by SARS-CoV-2, which, added to the suspected cases, exceed the mark of 11 thousand notifications reported to the Brazilian Federal Council of Nursing (COFEN) and with a large number of absences from work. From the data issued by COFEN, the number of nursing professionals who died in Brazil surpassed countries such as Spain, Italy and the United States.^(5,6)

As they are the largest contingent of the health workforce and are on the “front line” of assistance to COVID-19, nursing professionals were highlighted, migrating from a status of devaluation to that of hero. However, the mental illness of these professionals is recognized, with increased anxiety, fear and pain in the face of living with the death of patients and colleagues in the work environment, aggravated by the high risk of exposure to infection, transmission of the virus to family members, precarious working conditions, reduced social protection, job insecurity and lack of knowledge to deal with the ‘new’ and ‘unpredictable’.^(7–9)

Through the social interaction process present in the advent and extension of COVID-19, nursing professionals are experiencing significant impacts on mental health. Commitments have already been observed in the workforce, reflecting on the potential years lost, psychic disorder, post-traumatic stress.^(10,11)In view of this worrying scenario, attention and surveillance must be enhanced by public agents, government officials and managers, in order to guarantee protection for life and health and establish effective actions to face the deleterious effects on mental health in this category.⁽¹¹⁾

Given this, the guiding question of this study was: how do nursing professionals interact with the novel COVID-19 pandemic and what are the impacts on mental health arising from this interaction? Thus, the study aims to understand the impacts on nursing professionals’ mental health in the face of interactions with the novel COVID-19 pandemic.

Methods

This is a qualitative approach, a macrosearch “ Saúde mental de profissionais de enfermagem do Brazil - Estudo VidaMental/Covid-19 ”, carried out with 719 nursing professionals residing in Brazil. The research was carried out in a virtual environment, using a Google Forms form, previously elaborated and validated by seven researchers with expertise in the area and a professional linked to the customer service with COVID-19. The questionnaire was composed of 41 closed questions about sociodemographic/occupational/health characterization and an open-ended question about feelings in the COVID-19 pandemic context, which was used for analysis in this article: Tell us about your experiences and feelings throughout the COVID-19 pandemic context.

Data collection took place between April and June 2020, using the snowball sampling technique, which made it possible to perform consecutive recruitment of participants for the study, to reach the initial samples and the subsequent sample waves. For recruitment, it made use of publicity on Facebook, Instagram, Twitter, WhatsApp and emails. Previously to analysis, the questions were checked for duplicity and incompleteness. Of the total seized, five were discarded for the reasons mentioned above. As it is data obtained from digital tools, participant identification was preserved. Thus, no personal data that generated individual exposure was requested. Moreover, security criteria and virtual data protection were introduced, based on the use of codes, folder zipping and manipulation on devices protected by passwords.

The sample was intentional and five steps were adopted: registration of raw data, immersion in data, allocation of themes with the saturation grid construction, in which the main elements of the speech were listed and the recurrence of information as saturation criteria was observed theoretical, due to the high number of responses from the matrix research. Therefore, we use line-by-line reading, search for data co-occurrence, convergence, complementarity and theoretical density.⁽¹²⁾It is known that data theoretical saturation occurred from the collection of responses collected in June 2020. Regarding the sample selection, nursing professionals, residing in Brazil, experiencing the COVID-19 pandemic were included. Professionals traveling internationally and/or in transit between Brazil and other countries during the data collection period were excluded. Thus, with regard to theoretical saturation, it was used when analyzing the findings revealed after processing with IRaMuTeQ^®, a collaborative resource for systematizing the data that identified frequency of words, a process that was guided by the Discourse of the Collective Subject (DCS) method.

When using DCS as a basis, we identified the Key Expressions and Central Ideas of a collective representation.⁽¹³⁾Thus, the use of DCS made it possible to recognize the analytical categories through the method premises. Furthermore, the analyzed data were interpreted by the fundamentals of Symbolic Interactionism (SI),⁽¹⁴⁾which has as a paradigm people and their insertion and interaction with/in the social world. From localizing Central Ideas, we sought to seize the anchorages, which were interpreted in the light of SI, from its essential premises.

Categorization is represented in the infographic made using the Coggle^®tool. For categorization, line-by-line reading, apprehension of co-occurrences, convergences and complementarities were taken as a basis, which were guided by the DCS method.

The COREQ criteria⁽¹⁵⁾were adopted and the study met all national and international standards of ethics in research involving human beings.

Results

Nursing professionals, nurses and nursing technicians who worked in direct assistance (65.6%), with an average professional training time of 14 years and residents in the five regions of Brazil participated in the study. Most were women (87.1%), 626, and were aged between 25 and 45 years old, married, 292, (40.6%) and white race/self-reported color, 343 (47.7%).

The collective discourse showed that nursing professionals’ mental health was affected by interactions with the ‘new’, arising from the COVID-19 pandemic. The collective representation of speeches elaborated of the meanings attributed by participants to terms/words were: pandemic, coronavirus, COVID-19, exposure, suspect, patients, care, professionals, institutions, sectors, doing and work process, not restricted only to the pandemic itself, but everything that comes from the historical process of their interactions in daily work, presented in speeches-syntheses that are anchored in their respective central ideas.

According to Figure 1 , the work of nursing professionals is central to their reports and articulates with the requirements and needs for the exercise of patient care, as well as exposing the interfaces of “how” professional action takes place in the context of deficiencies and not protection of the pandemic situation.

Figure 1
Similitude tree with the words most evoked by nursing professionals

The structure of the categorization of the findings expressed in the synthesis speeches and their Central Ideas are shown in Figure 2 .

Figure 2
Structuring the analytical categories of the Discourse of the Collective Subject of the investigated phenomenon

Speeches-synthesis 01: Interaction with the ‘new’

The interaction with the pandemic and COVID-19 context emerged in the collective discourse and demonstrated the specific character of nursing performance in Brazil, not experienced in this century. In this interaction, when advancing knowledge about the virus and the new disease, nursing professionals found the complexity of virulence and experienced the difficulty of dealing with the ‘new’, which triggered negative feelings:

“[…] unfortunately, we are dealing with a unique situation, with a new virus and, as a health professional on the “front line”, I am apprehensive, scared and desperate in the face of new events related to COVID-19. The virus is devastating, I feel insecure, vulnerable and small to face COVID-19. Even looking for knowledge about the disease, the contagion and the care to be performed at work, I feel powerless.” (DCS).

The meanings were constituted in social interactions with peers in the professional environment and are anchored in the fear of ‘exposure’, due to job insecurity, the lack of training to deal with the unprecedented and, fear of the continuing profession devaluation:

“[…] I am exposed to many hours of work with patients with COVID-19. There is a lack of job security and training. I feel unprepared, we don’t know how to care for patients with COVID-19 and whether the protective measures are being carried out properly. The pandemic emerged in the year of nursing valorization, but we are suffering without knowing if we will be forgotten again when everything is over.” (DCS).

The pandemic led to the adoption of new attitudes and behavioral changes both for the protection of professionals themselves and their family as well as measures of economic containment:

“[…] I had to isolate myself at home, in a separate room and have to adopt more stringent hygiene care before and after work. I also started to take safety measures to be able to continue working. I sought to help the neediest people, save on water consumption, avoid wasting food and organize finances.” (DCS).

In the interaction between the nursing professional and the ‘suspect’ of contamination by COVID-19, whether patient or professional, the symbolic imagery of the pandemic was constructed, which is permeated by contradictions between fear of contact and satisfaction in providing care. The novelty of the context experienced by the category generates a multiplicity of sensations that reveal the “unspoken”, expressed in metaphors to name what they do not know or do not know how to describe:

“[…] nursing will be the “soul” of care in this new situation, it has also left me at the bottom of the well, making me feel like a “robot” and “trash”. Assisting suspected and confirmed COVID-19 patients generates several sensations. On the one hand, I feel grateful to be working, to contribute professionally. On the other hand, I feel apprehension, frustration, impotence and anger at living with the uncertainty of not knowing who is a suspect for the coronavirus, be it patients, co-workers and even myself.” (DCS).

Speeches-synthesis 02: Interaction with nursing care

The interaction of nursing professionals with patients in providing care is permeated by feelings of fear towards those who are sick/suffering; for ignorance of the disease, which causes refusal to assist and excessive emotionality; for fear of forgetting protection and security procedures and techniques; for not being instrumentalized for care; for fear of being on the “front line” of patient care:

“[…] the direct relationship of being on the “front line” terrifies me and generates fear for the “new” and for not knowing what may happen in the near future. Many co-workers were hysterical, some even refused to see COVID-19 patients. I work in direct assistance to patients, but I am afraid every day, afraid of forgetting the rules and protocols for care, afraid of becoming ill and of contaminating someone, such as family members, and the fear of not doing my job.” (DCS).

In this symbolic interactional field, the relationship between providing care to patients with COVID-19 and feelings of distress before the possibility of changing from being a professional to patients, given the risk of contamination, death and convalescence of co-workers, reveals situations of emotional and physical overload of these professionals who provide care in a pandemic context that deprive them of fulfilling their basic needs:

“[…] service involves a professional activity with high contact and exposure, and many colleagues needed to leave work for being with COVID-19. Others even died, which creates physical and emotional apprehension and exhaustion. I care about caring for patients with COVID-19, I dedicate myself intensely, I try to do the best, but there are times that I fear becoming ill and becoming patient. I can hardly ever stop to drink water and use the toilet. I spend many hours with PPE, without having an adequate place to bathe after the shift, attire and unattire and still deal with work overload. I have little confidence in improvements to the nursing profession.” (DCS).

The interaction of nursing professionals with the population when providing care with/in the pandemic was permeated by the recognition and notoriety of the professional category in care production. However, the reports also point out situations of violence, discrimination, stigma and disrespect for social isolation by the population, which hinder professional practice:

“[…] patient care is compromised because I have been experiencing moments of anguish. I suffer aggressions, I witness the lack of empathy of many patients and family members, who do not recognize the challenge faced. Living with violence has been closer/more frequent with the pandemic. People react negatively to working with COVID-19. I am thrilled with the recognition, but saddened by discrimination, lack of love, compassion and the non-fulfillment of social isolation, which makes nursing work even more difficult.” (DCS).

In the interactions of nursing professionals with the patient when providing care during the pandemic context, there is satisfaction and a sense of accomplishment, in addition to the adoption of new ways of working:

“[…] there is also the feeling of pleasure, of accomplishment, in being able to provide assistance to patients who need and count on me so much. Now I also work with the call center, which is new, but I’m having contact.” (DCS).

Speeches-synthesis 03: Interaction with daily work

When the adverse situations generated by the pandemic start to influence nursing professionals’ work, especially in the context of the category’s relationship with health institutions and work sectors, related to organizational interference and irresponsibility that do not guarantee professional security to provide quality care, feelings of dissatisfaction emerge due to the lack of emotional/psychosocial support/embracement:

“[…] even the transformation brought about by the pandemic had to deal with the lack of a mask, how to act on the “front line” with these conditions? There is a lack of management at work, because in addition to assisting, I still have to train employees who have never worked in assistance and this overloads me and affects the quality of care. Irresponsibility to deal with the high number of cases of the disease, and lack of psychological support.” (DCS).

The relationship with the work sectors is permeated by unexpected changes in jobs for the performance of different and new assignments, swift reappropriation of new knowledge, which transformed the work routines, prioritizing other demands arising from COVID-19:

“[…] I had to take care of critically ill patients who needed to be admitted to the Intensive Care Unit, even without having been trained and never having worked in that sector. Training was quick and superficial and many newly hired people were summoned to work. I need to deal with the challenges of teamwork, with the arrival of countless patients with COVID-19, creating gaps in care. I had to prioritize the care of patients in critical situations. There were transformations in work routines, service schedules and social distance.” (DCS).

By symbolically analyzing the interaction of nursing professionals with the sectors and working conditions to which they are submitted with COVID-19, they intensified work problems. The professional category lived with breakdowns, inadequacies, alteration of routines, scarcity of materials, work overload and unhealthy conditions, aspects that triggered insecurity and impacted psychosocial well-being:

“[…] I had to deal with unhealthiness, increased exposure to coronavirus contamination, and increased length of stay at work. These institutional problems are not new, the ‘new’ is the arrival of COVID-19, which has intensified the lack of decent working conditions and not paid attention to professionals. It is a new and difficult scenario. It is humanly impossible for a nursing professional alone to care for twenty patients, without a complete team and with insufficient materials. It afflicts me, it generates impotence, dissatisfaction and there is no financial and social recognition.” (DCS).

Insecurity in the workplace caused by the pandemic brought feelings of anxiety, anguish, decision conflicts, hopelessness, dissatisfaction and constant experience of fear, which are often not valued by peers themselves:

“[…] the work environment has become a place of fear of contamination, which “goes round” and worries at all times. We are at risk, there is no testing. There is anguish, insecurity and fear. I have been experiencing anxiety attacks and depression, but I hide it. This has contributed to a “picture” of fear and panic at work. The negative comments coming from the professionals themselves, shakes, discourages and discourages. When I need to rely on psychological support, I am labeled as crazy, mainly by the coordinators, which makes me feel like “trash”“. (DCS).

Discussion

This study has as a limitation the fact that data collection was conducted virtually, which made it impossible to employ more questions that would guide the deepening of the meanings of the investigated object. However, the relationship established by nursing professionals in the interaction with the novel pandemic was apprehended, the meanings attributed to the new work reality constituted in interactions with patients, COVID-19 and their peers and the evidence of impacts on mental health of this category inserted in a different social world.

The findings reveal the impacts on nursing professionals’ mental health before the interaction with the fear of the novel pandemic. It was clarified that the meanings and social actions are permeated by fear. The challenge in the professional coping with the unknown and the outbreak of anxiogenic and depressive signs were recognized. Interactional phenomena were found that are composing the new pandemic scenario and its influences in the face of professional suffering.

These revelations are corroborated by literature,^(3,4,13,14)greater attention and vigilance should be directed by managers, coordinators, educators in service, psychosocial support teams towards nursing professionals, who are intimately dealing with the new contexts that emerged from the COVID-19 pandemic. When evidencing the interaction with the ‘new’, it was noticed that the meaning that the professionals attributed, even though they seem individual and particular to the self dimension, is occurring through the interrelations and interactions with the previous repertoires and with the new phenomena.⁽¹²⁾Thus, it is important to pay attention to the impacts caused by interactions with new phenomena and causing disruptions to the mental health situation of nursing professionals in the face of doing in the collective work.

When nursing professionals are faced with the novel pandemic, they are driven to move from a common place and interact⁽¹²⁾with the context of COVID-19. In the professional interaction with the ‘new’ nursing care, meanings and senses were transversalized by the ambiguities that mark the position of exercising the profession and being vulnerable, which causes direct and continuous impacts on mental health. Nursing professionals, as social actors, in a given interaction with the ‘new’, express “covert activities” that are present in the “external behavior”, symbolized by phenomena such as “exposure”, “suspect” and “patient”, mobilizing the impacts on professionals’ mental health.⁽¹²⁾

High transmissibility and the urgency to adopt measures that promote the safety of professionals who provide assistance place them in a scenario that integrates greater support of care, translated into greater exposure and high risk of contamination.^(15,16)In this regard, professionals experience feelings of fear, uncertainty and insecurity in the provision of care at high and constant levels. The impacts on nursing professionals’ mental health revealed, in convergence with the premises of SI,⁽¹²⁾seem to be permeated by particularities, and/or that elucidate that they occur restricted to the care work environment. The vigilant look at the particularities existing in the interaction with the novel pandemic context, such as those evidenced in this study, will allow the adoption of collective measures that are effective in protecting nursing professionals’ mental health.

In the context of interaction with daily work, involvement with the ‘new’, with institutions, sectors, with doing and with the work process, the discourse revealed that nursing professionals, the pre-existing degradations in the profession of low valuation and precariousness were strongly impacted by new degradations, which overlap and sometimes mischaracterize their actions, as reinforced in literature.^(5,15,16)Realities that expose them to even more inappropriate working conditions, and take away the guarantee of achieving well-being at work and, consequently, psychological well-being, given that the scientific literature has already pointed out the secondary impacts such as post-traumatic stress disorders.^(3,5)

The symbolic place can be recognized in objects, languages, symbols, as seen in the “sectors”, “work process” phenomena, which are influenced by interpretive processes, in the unfolding of social weaving,⁽¹²⁾such as media communication about the pandemic and the relations with nursing practice. Complaints made by the category that show stressful working conditions and the potentiation of the experienced physical and mental exhaustion stand out.⁽¹⁶⁾

The concreteness of the discursive data evidenced in this study exposed the production of suffering experienced by the professional category of nursing. The meanings attributed by the investigated category explain the deleterious effects on psychosocial well-being and at work and the negative repercussions in different dimensions of life, which needs attention, vigilance, monitoring and the creation of effective strategies that can guarantee the protection of human integrity and the maintenance of professionals’ quality of life and health status/condition.^(10,11)In view of this scenario, an integrative nursing care that considers symbolic dimensions in the social context deserves to be considered.^(17,19)Programs to promote mental health care need to be implemented and strengthened. Screening for and monitoring the mental health problems of nursing professionals needs to be carried out.

Accurately knowing the novel COVID-19 pandemic promotes more possibilities of directions for the conduct of nursing practice as well as the establishment of protective actions in the context of work. Furthermore, it makes it possible to qualitatively guide the instrumentalization of nursing professionals to adopt the most appropriate coping strategies, given their availability, access and possibilities. It is worth mentioning that this study draws attention to the need to support the nursing category and establish strategies to expand professionals’ work.

It is also noteworthy that the findings bring the advent of ‘pandemic nursing care’ permeated by specificities that emerged with the novel COVID-19, presenting a possibility of changing the paradigm for nursing training guidelines, in technological advances teaching-learning and professional practice, in the ethical and legal regulation of nursing. It also includes reorganizing the nursing work process, institutional structuring, the emergence of new clinical investigations, diagnostic formulations and specific lines of research.

The contributions of this study to practice are expressed through proposing advancing scientific nursing knowledge and its direction in the context of mental health that lead to a new look at the possibilities of implementing actions that minimize impacts, guarantee protection, integrity and human dignity and the improvement of working conditions, even more emergency in this scenario.

Conclusion

The collective discourse of nursing professionals showed that there are impacts on mental health caused by the interaction with the novel COVID-19 pandemic and are made up of elements that occurred in the interaction, which also overlap with those already experienced previously, namely: the ‘new’, coronavirus, COVID-19, outbreak of negative feelings, the vulnerabilities in professional practice - weaknesses in instrumentalization/technical execution, risk of contamination, exposure for being on the “front line”, failures in security, approaching death, fear, job insecurity and lack of emotional and psychosocial embracement/support. The findings alert to the need to support the category with regard to psychosocial issues, training, technological advances in teaching-learning and professional practice, ethical/legal regulation, work organization, strategies to expand qualified performance and protected in critical and emergency scenarios such as a pandemic.

Acknowledgments

To the National Council for Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico), Ministry of Science, Technology, Innovations and Communications (Ministério da Ciência, Tecnologia, Inovações e Comunicações), Ministry of Health (Ministério da Saúde do Brasil). Call MCTIC/CNPq/FNDCT/MS/SCTIE/Decit No. 07/2020 – Research to confront COVID-19, its consequences and other severe acute respiratory syndromes, Process No. 4011002020.

• Erratum

  In the article published in Acta Paul Enferm. 2021; 34:eAPE02523, Queiroz AM, Sousa AR, Moreira WC, Nóbrega MP, Santos MB, Barbossa LJ, et al; “The novel COVID-19: impacts on nursing professionals’ mental health?”, the authors requested to publish the following erratum:
  Acknowledgments
  To the National Council for Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico), Ministry of Science, Technology, Innovations and Communications (Ministério da Ciência, Tecnologia, Inovações e Comunicações), Ministry of Health (Ministério da Saúde do Brasil). Call MCTIC/CNPq/FNDCT/MS/SCTIE/Decit No. 07/2020 – Research to confront COVID-19, its consequences and other severe acute respiratory syndromes, Process No. 4011002020.

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Publication Dates

• Publication in this collection
  14 July 2021
• Date of issue
  2021

History

• Received
  09 Sept 2020
• Accepted
  26 Mar 2021