Abstract
Background
Research shows low evidence-based practice (EBP) uptake among palliative care nurses, a global concern because the demand for palliative care services is rising, raising the urgent need to improve healthcare quality. Promoting EBP uptake in palliative care can improve healthcare quality. This systematic review investigated nurses’ barriers to EBP implementation in palliative care.
Methods
PubMed, MEDLINE, CINHAL, and Google Scholar were used to identify seven articles. Articles were included for review if they were published within the past 10 years (English only) and investigated barriers to EBP implementation in palliative care.
Results
Four barriers were identified: (a) time and resource constraints, (b) lack of readiness for organizational change, (c) negative attitudes toward palliative care, and (d) process-specific difficulties.
Conclusion
This systematic review's findings can inform policy changes to improve the uptake of EBP in palliative care.
Keywords: evidence-based practice, EBP, palliative care, barrier, nurses
Introduction
Evidence-based practice (EBP) in nursing refers to no gap between what nurses know and do (Duncombe, 2018). Nurses are trained to rely on scientific evidence to inform practice, but there are concerns that they continue to rely on traditions (Duncombe, 2018). EBP nursing has been linked to better patient outcomes, safety, and healthcare quality (Melnyk et al., 2018). Therefore, nurses jeopardize healthcare quality, patient outcomes, and safety when they lack EBP competencies. This review investigates nurses’ barriers to EBP in palliative care settings.
There is a growing demand for palliative care services worldwide (Riahi & Khajehei, 2019). Therefore, quality concerns, safety, and improved patient outcomes in palliative care must be addressed. Palliative care is very complex because patients at the end of life have many physiological, psychological, spiritual, and social needs that must be addressed simultaneously in the face of complex multimorbidity (Visser et al., 2015). It is challenging to draw evidence from randomized controlled trials (RCTs) that investigate the effectiveness of interventions. Every patient in palliative care is unique. Hence, drawing evidence from RCTs may sometimes be challenging regarding the generalizability of findings from one patient to another. The rationale for conducting this systematic review is elaborated below.
The primary rationale for conducting this systematic review is that little is known comprehensively about the challenges or barriers to EBP in palliative care nurses. Research has shown that nurses have limited access to evidence-based databases in hospice and palliative care settings due to limited knowledge and skills (Klein-Fedyshin, 2015). In community nursing contexts, nurses have negative or improper attitudes toward the usefulness of EBP. Little is known about the various barriers to EBP in palliative care nursing despite empirical evidence that EBP is underutilized. Therefore, it is imperative to systematically and comprehensively explore the various barriers to inform interventions that can improve the quality of care in palliative care settings.
This systematic review aims to identify nurses’ barriers to EBP in palliative care. The following objectives were addressed:
To examine the global demand for palliative care services.
To identify nurses’ barriers to EBP in palliative care.
To explore nurses’ facilitators of EBP in palliative care.
The PEO (P=population; E=exposure; O=outcome) framework was used to construct the research question. The research question was based on the population of palliative care nurses providing supportive care to cancer and noncancer patients. Due to the nature of the research topic, there was no specific intervention of focus. The exposure of interest was the factors that influence palliative care nurses to implement or not implement EBP. The target outcomes were the themes associated with how the exposure factors shape nurses’ palliative care practice. The primary research question was: “What are nurses’ barriers to EBP in palliative care settings?”
There is a rising demand for quality palliative care services (WHO, 2021). In Israel, the growing demand for palliative care needs has prompted the government to introduce palliative care advanced practice nursing to bridge the current care quality gap due to the underutilization of EBP (Collett et al., 2019). Globally, it is estimated that by 2060, more than 48 million people will die yearly from severe health-related diseases requiring palliative care services (Centeno & Arias-Casais, 2019). Research also shows that it has been highly challenging to maintain quality care in palliative settings due to the evolving nature of the practice (Pantilat et al., 2017). This trend has been associated with an inefficient use of palliative care resources and low sustainability of palliative care services (Pantilat et al., 2017). Since EBP has been associated with improved patient outcomes and healthcare quality (Melnyk et al., 2018), it is imperative to investigate nurses’ barriers to EBP in palliative care and generate insights into what can be done to improve the quality of palliative care.
Methods
The systematic review followed the PRISMA 2020 Checklist for systematic reviews and meta-analyses (Page et al., 2021). The checklist has 27 items that reviewers can use to ensure transparent reporting.
Articles were searched on Google Scholar, PubMed, MEDLINE, and CINHAL. Google Scholar indexes scholarly materials from various online journals, whereas PubMed is a publicly available database that indexes journal articles in various healthcare sciences. MEDLINE AND CINHAL are also renowned for indexing nursing journal articles. Regular keywords were combined with MeSH terms to ensure more relevant articles were displayed in search results. Table 1 summarizes the list of regular keywords and MeSH terms used in this search strategy.
Table 1.
Regular Keywords and MeSH Terms.
| Regular keywords | MeSH terms |
|---|---|
| Evidence-based practice | Evidence-based practice; evidence-based healthcare management; evidence-based health care management; evidence-based healthcare; evidence-based health care; evidence-based healthcare |
| Palliative care | Palliative care; palliative treatments; palliative therapy; palliative supportive care |
| Barriers; challenges; problems; difficulties; issues | Not applicable |
| Nurses | Nurses; nursing personnel; registered nurses; registered nurse |
Boolean connectors were used to combine keywords and search terms. The search strategy for PubMed and the limits and filters used is summarized in Table 2. As shown in the table, before applying any limits, the search string on PubMed yielded 396,865 search hits, which dropped to 360,359 after applying the English-language filter. The search hits dropped to 332,379 after applying the peer-reviewed limit. Eventually, after filtering only nursing journals, the search hits dropped to 7,104—these are the hits screened one by one to identify relevant titles. The relevant titles identified at this stage were 405, then subjected to abstract and full-text screening, as elaborated on later.
Table 2.
PubMed Search Strategy Summary (Same Approach Applied to All Other Databases).
| Database | Search string (machine-generated) | Search hits before limits | Search hits after limits | |
|---|---|---|---|---|
| PubMed | (((((((((((((((((evidence-based practice) OR (evidence-based healthcare management)) OR (evidence-based health care management)) OR (evidence-based healthcare)) OR (evidence-based health care)) AND (palliative care)) OR (palliative treatments)) OR (palliative therapy)) OR (palliative supportive care)) AND (barriers)) OR (challenges)) OR (problems)) OR (difficulties)) OR (issues)) AND (nurses)) OR (nursing personnel)) OR (registered nurses)) OR (registered nurse) | 396,865 | English language | 360,359 |
| Peer-reviewed | 332,379 | |||
| Country: Global | 332,379 | |||
| Publication Year: 2012–2022 (10 years) | 119,348 | |||
| Nursing journals | 7,104 | |||
Articles were selected for review if they were published in English, peer-reviewed, and about nurses’ barriers to EBP in palliative care settings. Only primary studies were selected for review. Hence, secondary research, such as systematic reviews, scoping reviews, and other literature reviews, were excluded because this systematic review is secondary research; it is pointless to use secondary studies in another secondary study. Governmental publications, organizational reports, and student dissertations/theses were included if they met methodological quality standards. Table 3 presents the inclusion and exclusion criteria used.
Table 3.
Inclusion and Exclusion Criteria.
| Inclusion | Exclusion |
|---|---|
| Publication date: 2012–2022 to ensure up-to-date information was retrieved even if no systematic review had been conducted. | Long-term care/nursing homes/homecare without end-of-life care |
| Language: English only to avoid translation errors and associated costs. | Systematic reviews, meta-analyses, scoping reviews, literature reviews, integrative reviews, etc. Secondary studies were excluded because they do not contain primary information to inform the topic of interest. Secondary studies also contain interpreted information, which may be subject to error. However, grey literature, including government publications, organizational reports, and student theses and dissertations, were considered for inclusion to address publication bias likely to emerge by utilizing journal articles only. |
| Population: Palliative Care Nurses because they have lived experiences of how they apply evidence-based practice (EBP) in palliative care and the challenges they experience in implementing EBP. | |
| Country: Global because of the limited number of studies that have been conducted on this topic in specific countries. | |
| Age group: Registered nurses of any age group to limit the number of filters that may prevent retrieving relevant articles from databases. | |
| Setting: Palliative care because knowledge gaps were identified in the barriers to EBP implementation among palliative care nurses. | |
| Research design: Qualitative, quantitative, and mixed methods to ensure that relevant articles that do not use a qualitative methodology are captured in the search. | |
| Type: Peer-reviewed to ensure only relevant and credible information was utilized. | |
| Subject: Nurses’ barriers to EBP |
Additionally, a thematic analysis approach proposed by Braun and Clarke (2006) was used to identify and collate codes concerning nurses’ barriers to EBP in palliative care. After assessing the methodological quality of the studies, the next step entailed reading them one more to gain familiarity with their data. Second, initial codes were generated from the results and discussion sections of the articles. Codes were assigned based on how the authors implied barriers to EBP in palliative care. Third, closely related codes were combined to form a more abstract theme, which means that when the narrative around each code is combined with another, they provide a bigger picture of the whole issue. Finally, the themes were reviewed, named, and then defined appropriately. The reviewing process entailed cross-checking the codes assigned to each theme to ensure they were relevant enough; in the process, some thematic codes were dropped and replaced with others. The themes were defined based on the larger picture generated after combining various thematic codes. Two independent reviewers performed the thematic analysis. They compared themes in their findings. In case of disagreement, a discussion was held to resolve the misunderstanding. If the disagreement persisted, a third independent reviewer was invited to provide an opinion, which helped settle the dissimilarity.
Results
After applying the above search strategy, the identified articles were screened using the inclusion and exclusion criteria. There were no automation tools used in the study selection process. Instead, the process was done by two independent reviewers. Each record was screened by the reviewers independently. For example, when applying the inclusion and exclusion criteria, the independent reviewers made independent decisions, which were compared for further processing. In case of disagreement between the two, a third reviewer was invited to perform another independent review of the record or report where disagreement emerged. The majority side of the review outcome was considered.
No automation tools were used in the data collection process. Instead, two independent reviewers were involved in the data extraction process. The process entailed coding information on the articles that answered the research question using ATLAS.ti. The data coded on ATLAS.ti was then downloaded to Excel for data analysis. The two independent reviewers collated their findings and discussed for purposes of agreement on areas of disagreement. If disagreement persisted even after a discussion, a third independent reviewer was invited to provide an opinion to settle the disagreement.
Initially, 21 citations were identified on PubMed, 29 on CINHAL, 50 on MEDLINE, and 89 citations on Google Scholar after title screening. Thirty-three items were eliminated because they were duplicates—reporting the same research findings in different article versions or between the four databases. Eventually, abstracts of 159 articles were screened by two independent reviewers. They agreed that 89 records be excluded because they did not meet all the inclusion criteria, mostly preprints; they did not meet the peer-review criterion. The remaining 70 articles were sought for full-text removal, eight of which were unavailable on free and subscription modes. The full texts of the remaining 62 articles were screened using the inclusion and exclusion criteria by the two independent reviewers, whereby 20 articles were excluded because they were published in non-English languages, and 32 of them were irrelevant because they did not provide the required setting, or the focus of the articles could not imply nurses’ barriers to EBP practice in palliative care. Therefore, the two independent reviewers agreed to exclude 50 articles at this stage. In the remaining 12 articles, the independent reviewers only agreed that six were eligible for inclusion in this systematic review. There was disagreement on the remaining six articles, and upon discussion, four articles were further excluded for quality reasons. The remaining two articles were reviewed by the third independent reviewer, whereby eventually, one was excluded based on the majority consideration of the decision outcome (poor quality methodology). Hence, seven articles were finally included in this systematic review. Of these seven articles, two were identified and retrieved from PubMed, three from Google Scholar, one from MEDLINE, and one from CINHAL. Figure 1 presents a summary (PRISMA flowchart) of the search process.
Figure 1.
PRISMA flowchart showing how the seven articles were selected.
Coffey et al. (2021) conducted a mixed-methods study using a pre–post design. They aimed to explore barriers to EBP in dementia palliative care. Dalberg et al. (2013) conducted qualitative focus groups with pediatric oncology providers to identify barriers and facilitators of integrating an EBP-based model into their routine practice. Kernohan et al. (2018) interviewed palliative care researchers in Ireland to identify barriers to successful knowledge transfer in EBP in palliative care. Nilsen et al. (2018) conducted interviews with nursing home managers to explore barriers to and facilitators of EBP in palliative care in nursing homes. Rankin et al. (2015) conducted qualitative interviews with healthcare professionals to identify barriers to and facilitators of implementing an EBP-based clinical pathway in a palliative care setting. Temkin-Greener et al. (2015) undertook a descriptive quantitative study whereby they asked palliative care clinicians to identify the usefulness of various EBP-based clinical guidelines. Their study was relevant to this systematic review because the participants were also asked to indicate some barriers to implementing the clinical guidelines in their settings. Finally, Melnyk et al. (2014) conducted a quantitative descriptive study whereby seven national EBP leaders developed key EBP competencies for nurses in various clinical settings, including palliative care. They then surveyed 80 EBP mentors in the United States to determine their level of agreement with the EBP competency areas. They also identified nurses’ barriers to EBP implementation in various clinical settings, including palliative care. Table 4 provides a complete description of the various characteristics of the studies, namely, the research design used, sample size, country, data collection, data analysis, findings, quality assessment findings, and critical appraisal (strengths and weaknesses).
Table 4.
Summary of the Characteristics of the Selected Studies.
| Authors (date) | Research design | Sample/population | Data collection | Findings |
|---|---|---|---|---|
| Coffey et al. (2021) | Mixed methods (pre–post study) | 59 nurses were surveyed; three directors of nursing were interviewed | Questionnaires (quantitative part); interviews (qualitative part) | The main barriers identified were (a) time and resource constraints and (b) lack of readiness to change |
| Dalberg et al. (2013) | Qualitative research (phenomenology) | Seven nurse practitioners | Four focus groups | Process-specific difficulties due to team ineffectiveness were the main barrier to evidence-based practice (EBP) in palliative care |
| Kernohan et al. (2018) | Qualitative research (phenomenology) | 15 palliative care researchers (PhD holders) | Qualitative semistructured interviews | Barriers identified: (a) time and resource constraints; (b) negative attitudes toward palliative care |
| Nilsen et al. (2018) | Qualitative research (phenomenology) | Five palliative care nurses | Qualitative semistructured interviews | Three barriers were identified: (a) time and resource constraints; (b) negative attitudes toward palliative care; (c) lack of readiness to change. |
| Rankin et al. (2015) | Qualitative research (phenomenology) | Three nurses | Qualitative semistructured interviews | The main barrier that was identified in their study was time and resource constraints |
| Temkin-Greener et al. (2015) | Quantitative descriptive study | Eleven directors of nursing, nine nurse managers, and three nurse practitioners | A two-item questionnaire using Likert scales | The main barrier identified in their study was time and resource constraints |
| Melnyk et al. (2014) | Qualitative synthesis study | Seven national EBP leaders and 80 EBP mentors | Delphi survey | Barriers identified: time limitations, organizational culture constraints, limited knowledge and skills, lack of access to databases, resistance from nursing staff and colleagues, uncertainty about critically appraising evidence, and lack of critical resources to support EBP. |
Further, the CASP Checklist was used to assess the methodological rigor of the studies (Brice, 2018). The cut-off score of the methodological quality of the selected studies was 65%. As shown in Table 5, all the studies met the cut-off; four qualitative studies scored 88.89% (Coffey et al., 2021; Dalberg et al., 2013; Kernohan et al., 2018; Nilsen et al., 2018; Rankin et al., 2015) and one qualitative study (Melnyk et al., 2014) scored 100%. It is worth mentioning that Coffey et al. (2021) used a mixed-methods approach. Nevertheless, the CASP checklist for qualitative studies was used to assess it because findings from the qualitative part of the study were used in this systematic review. Additionally, CASP does not provide descriptive (quantitative) studies checklist. Instead, the Temkin-Greener et al. (2015) study was assessed using the checklist for cohort studies, on which it scored 91.67% because it scored a “no” on Items 5(a) and 5(b), each carrying 0.5 points. The study scored a “yes” on all other items on the checklist.
Table 5.
CASP Checklist for Qualitative Studies.
| Dalberg et al. (2013) | Kernohan et al. (218) | Nilsen et al. (2018) | Rankin et al. (215) | Melnyk et al. (2014) | Coffey et al. (2021) | |
|---|---|---|---|---|---|---|
| Item 1 | Yes(1) | Yes(1) | Yes(1) | Yes(1) | Yes(1) | Yes(1) |
| Item 2 | Yes(1) | Yes(1) | Yes(1) | Yes(1) | Yes(1) | Yes(1) |
| Item 3 | Yes(1) | Yes(1) | Yes(1) | Yes(1) | Yes(1) | Yes(1) |
| Item 4 | Yes(1) | Yes(1) | Yes(1) | Yes(1) | Yes(1) | Yes(1) |
| Item 5 | Yes(1) | Yes(1) | Yes(1) | Yes(1) | Yes(1) | Yes(1) |
| Item 6 | Can’t tell(0) | No(0) | No(0) | No(0) | Yes(1) | No(0) |
| Item 7 | Yes(1) | Yes(1) | Yes(1) | Yes(1) | Yes(1) | Yes(1) |
| Item 8 | Yes(1) | Yes(1) | Yes(1) | Yes(1) | Yes(1) | Yes(1) |
| Item 9 | Yes(1) | Yes(1) | Yes(1) | Yes(1) | Yes(1) | Yes(1) |
| Total Score | 88.89% | 88.89% | 88.89% | 88.89% | 100% | 88.89% |
Note. The CASP Checklist for qualitative studies can be found here. The first nine items of the checklist were used. Items that scored a “yes” carried one point, whereas “can’t tell” and “no” scored zero points. The total score was calculated as a percentage total of the nine items.
Discussion
Four barriers were identified from the thematic analysis of the six articles: (a) time and resource constraints, (b) negative attitudes toward palliative care, (c) lack of readiness to change, and (d) process-related difficulties due to inadequate EBP knowledge or education. They are elaborated on below.
Barrier 1: Time and Resource Constraints
Six out of seven studies indicated that time and resource constraints were a significant barrier to nurses’ implementation of EBP in palliative care settings (Coffey et al., 2021; Kernohan et al., 2018; Melnyk et al., 2014; Nilsen et al., 2018; Rankin et al., 2015; Temkin-Greener et al., 2015). Coffey et al. (2021) argued that work-based learning groups could facilitate the uptake of EBP in palliative care. However, they discovered that nurses inconsistently attended to them due to time and resource constraints (Coffey et al., 2021). Their observations are consistent with Kernohan et al. (2018). They also demonstrated that knowledge transfer could improve the uptake of EBP in palliative care, but professionals, especially nurses, indicated a lack of time and resources as the primary barrier. The same sentiments were shared by Nilsen et al. (2018), Rankin et al. (2015), and Temkin-Greener et al. (2015). Earlier, Melnyk et al. (2014) identified that resource and time constraints were among the main challenges nurses face in implementing EBP in palliative care settings. Nurses have limited access to resources that facilitate EBP, which couples with time constraints to worsen the situation. Implementing EBP is time-consuming because nurses must locate internal and external sources of information to make quality improvements in their practice areas (Melnyk et al., 2014). Thus, it can be concluded that time and resources are the most frequent and common barriers to nurses’ EBP implementation in palliative care.
Barrier 2: Negative Attitudes Toward Palliative Care
Two studies demonstrated that palliative care nurses with negative attitudes toward palliative care were likely less motivated to implement EBP (Kernohan et al., 2018; Nilsen et al., 2018). While investigating facilitators of and barriers to scientific knowledge transfer in palliative care settings, Kernohan et al. (2018) implied that professionals who were skeptical about the research value were less likely to implement EBP. Nilsen et al. (2018) also discovered that professionals’ resolve to pursue EBP guidelines amid numerous concurrent changes in work hindered nurses from implementing EBP in palliative care. In other words, palliative care nurses must have positive attitudes toward EBP guidelines to implement them passionately.
Barrier 3: Resistance to Change
Three studies implied that resistance to change is a barrier to nurses’ EBP implementation in palliative care (Coffey et al., 2021; Melnyk et al., 2014; Nilsen et al., 2018). Coffey et al. (2021) demonstrated that palliative care administrators resist the changes by active EBP implementation. The authors quoted one of the participants, who said, “had a background in [palliative care training] already, so I suppose what it did was to give us the confidence to keep on doing what we were doing” (Coffey et al., 2021, p. 5). Coffey et al. (2021) showed resistance to change with attitudinal origins, which is why this barrier can be linked to Barrier 2 above. In contrast, Nilsen et al. (2018) demonstrated a type of resistance to change related to a lack of readiness to implement EBP due to issues such as a lack of EBP competency. Melnyk et al. (2014) indicated that resistance to change was one of the main barriers to EBP implementation among clinical nurses in various settings, including palliative care. They particularly pointed out that resistance to change can emerge from both the nursing personnel and the leadership and management of the facility. Indeed, supportive administrative support has been found to improve nurses’ compliance with EBP implementation in clinical settings.
Barrier 4: Process-Related Difficulties
Two studies implied that process-specific difficulties hinder nurses from implementing EBP in palliative care (Dalberg et al., 2013; Melnyk et al., 2014). Dalberg et al. (2013) argued that EBP implementation requires technical competencies that many palliative care nurses may not have. Barrier 4 is closely connected to Barrier 3 because it is also about confidence and competency in implementing EBP. In more explicit terms, Melnyk et al. (2014) indicated that nurses lack the competency to properly implement EBP in palliative care settings for many reasons, among them inadequate EBP knowledge or education and uncertainty about where to look for credible information and to critically appraise the evidence. The findings suggest that EBP is a technical process that requires proper training of nurses.
Implications for Practice
The findings can be used to design effective interventions to improve the uptake of EBP in palliative care nurses. For instance, nursing leaders in palliative care can develop EBP training modules and offer them to nurses. Inefficient EBP knowledge transfer can be addressed by allocating sufficient resources and time to participate in collective learning. Such educational programs can address negative attitudes, resistance to change, and process-related difficulties. This recommendation is particularly pointed at the barriers of inadequate knowledge and education on EBP implementation and uncertainty about where to access information.
Another application derived from the findings is the formulation of interventions to overcome resistance to change from leadership/management and nursing personnel. It may require the intervention of national bodies in addressing resistance to change from management and leadership as it may be difficult to implement at the organizational level. For example, nurse leaders and managers can be invited to workshops to be exposed to educational modules intended to change their improper attitudes toward EBP in palliative care. Nursing personnel's negative attitudes can be addressed under organizational arrangements on the condition that nurse leaders and managers have appropriate attitudes toward EBP in palliative care.
Additionally, there is a need for palliative care clinics to begin including EBP as a key competency for nurses in job descriptions. In this way, nurses will be encouraged to develop EBP skills by attending available training sessions either at the organization or outside. By doing so, nurses joining the workforce will have higher chances of EBP competency, which means they will easily overcome process-related difficulties such as finding credible information using appropriate databases, critically appraising the studies, and properly extrapolating the findings of the previous studies to their clinical settings.
Conclusion
Before providing a summary of this systematic review's findings, it is imperative to declare that it had some limitations. First, all seven studies were conducted in Western countries such as Australia, Sweden, and the United States. Therefore, the findings should be applied to practice cautiously in Eastern countries in Asia and Africa. Second, many of the qualitative studies reviewed suffered from bias because they did not address the relationship between the researcher and the participants. In qualitative research, the researcher plays a crucial role in the research process; thus, their role and relationship with participants must be declared. Finally, only four databases were searched in this systematic review, which implies that relevant studies available in other eligible databases might have been missed.
Few studies have investigated the palliative care nurses’ EBP barriers. Only seven studies were retrieved after searching four databases. To investigate the barriers palliative care nurses face in EBP implementation, more studies must be undertaken. The synthesis of the seven studies endorsed previous studies that the main EBP barriers in palliative care nurses are inadequate knowledge and skills in database search and critical appraisal of studies. Palliative care nurses with negative attitudes toward their profession are also less likely to appreciate the value of EBP. Resistance to change by nursing leadership/management and nursing personnel also presents a major barrier to EBP implementation in palliative care settings. These findings can inform nursing practice, such as designing training modules for nurses to shape their attitudes and promote their EBP competency.
Acknowledgments
Two independent reviewers partially supported this systematic review. I thank them for providing expertise and insights into the data collection and extraction processes. It would not have been possible to validate the reviewed studies without their immense support.
Footnotes
Author Contribution: The author performed the systematic review independently. The author formulated the search strategy and synthesized the identified articles following successful data extraction. The author also prepared this manuscript.
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical Statement: The authors did not directly study human beings or animals. The only ethical issue is plagiarism. The author declares all the work submitted in this manuscript was authored by himself and that all information obtained from external sources is properly cited.
Funding: The author received no financial support for the research, authorship, and/or publication of this article.
ORCID iD: Falah Jamal Dakka https://orcid.org/0000-0002-9348-255X
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