Workplace Violence in Healthcare: Effects and Preventive Measures and Strategies

Workplace violence (WPV) in public healthcare organizations has become a notable issue globally, leading to adverse health, safety, and legal consequences [1-3]. From 2015, the Occupational Safety and Health Administration (OSHA) has classified WPV as any instance of physical violence, intimidation, harassment or other disruptive behaviour at work; indeed, healthcare organizations have a higher reported rate of WPN compared to social service providers and industry [4]. This phenomenon can have a range of physical and psychological effects on victims. Roughly half of all workplace assaults in the UK result in physical discomfort for healthcare workers, like chest pressure or headaches, and also lead to emotional effects like anger, shock, fear, depression, anxiety, and sleep disruptions. These bodily and mental responses may result in decreased job contentment, diminished output, and heightened employee turnover. In addition, workplace violence can affect professional careers, as those who have experienced workplace bullying are more likely to report that they want to quit their job. In most cases, workplace violence is perpetrated by the patient's family, friends or visitors, and the patient themselves [5-8].

Although violence against healthcare professionals is common, there is limited research on how organizations handle the psychological impacts of workplace violence against healthcare providers or how they address this issue through strategies [9-12]. At a theoretical level, social learning theory (SLT) was created to study deviant behaviour and emphasizes that human behaviour is acquired and sustained through the interplay of personal factors, environmental influences, and the behaviour’s characteristics. As such, a conceptual framework for scrutinizing WPV is available. According to this framework, any behaviour can be altered when positive or negative consequences occur, and any strategy can be based on learning by cognitive processes (i.e., the ability to manipulate motivation to change behaviour), observational learning, mutual determinism (i.e., the interactions between behaviour and personal or environmental factors), and the dynamics of reciprocal influences between environmental factors [13]. Due to the increase in epidemics, migration flows and financial constraints, social unrest, poor interpersonal relationships, increasing workload, rotating shift work, shortage of staff, heavy work pressure, extreme work stress, it seems that workplace violence will continue to increase in the healthcare organizations. 

Purpose of the study

This article highlights the significance of acknowledging the effects of WPV in public healthcare environments and emphasizes the importance of collaborative efforts to improve the handling and prevention of such violence.

The examination made use of literature concerning workplace violence in public healthcare settings. The research was carried out following the current legal regulations in the European Union that protect employees' health. The methodologies of the publications were validated and qualified based on how well they aligned with the subject matter. The literature review utilized the specified databases and online journals, among others: Scopus, PubMed, Elsevier Direct, Google Scholar, CINAHL, Web of Science, and Embase. Information sources were located by conducting keyword searches in various databases, online repositories, and digital libraries, taking into account factors such as publication date, authorship, and article type. The literature selected included research articles considered essential for investigating the research questions posed in this study.

Effects of workplace violence in public healthcare environments

The negative consequences of WPV are varied (direct or indirect), complex and extend to different levels. To distinguish the effects of violence against healthcare professionals, three levels can be distinguished:

Effects at the individual level, the occurrence of violence seems to lead to decreased morale among professionals and further negative impacts on the health, both physical and mental, of those affected in the workplace, including victims and witnesses, such as: high blood pressure, sleep disturbances, chronic fatigue, shame, anger, depression, loss of appetite, irritability, low self-esteem and self-confidence, lack of concentration, poor decision-making, poor performance, inability to work, absenteeism, loss of appetite, fear, insecurity, isolation, occupational burnout, post-traumatic stress. Furthermore, if bullying or harassment continues for a long time and is severe enough, it can lead to paranoid disorder, suicide or even death [3,14,15].

Several research studies have demonstrated that physicians who experience frequent WPV are less satisfied with their work, are more prone to burnout and even have to quit their jobs and ultimately can lead to a shortage of physicians, particularly in hospitals. WPV causes physicians to feel themselves in an unhealthy environment, which significantly reduces their enthusiasm. Physicians have also reported feeling that patients and their families do not respect or value their work, causing them to doubt their values and professional standing during the provision of healthcare. Furthermore, doctors who experience violence regularly show lower levels of empathy, potentially resulting in a breakdown of trust between physician and patient. They could also opt to ignore and take proactive measures to deal with the conflicts they face, resulting in a diminished motivation in their job. Hence, creating a calm healthcare environment and reducing workplace violence is an effective way to improve job satisfaction, reduce burnout and turnover intentions, and sustain the cohesion of the physicians' team. The nursing field is deemed to be most susceptible to WPV among different healthcare roles because of their close interaction with patients and visitors [16-20].

Effects at the organism and the health system, loss of job satisfaction and low morale have a negative impact on the organization itself. Examples include conflicts, increased number of accidents and injuries, coordination problems, occurrence or increase in dangerous incidents or errors, dissatisfaction, poor loyalty and commitment, loss of productivity and efficiency, negative impact on the organization's reputation and image. Significantly, more accidents and injuries occur in emergency departments, surgery, and intensive care and psychiatry departments than in other departments [3,21]. 

Effects at the family and society, victims of workplace violence take their problems outside the workplace and their quality of life is negatively affected as a result. Relationships characterized by suspicion, sensitivity to criticism, isolation, hostile behaviour and reduced trust in others are established. In other words, broken relationships and coercive behaviour are observed [3].

Moreover, violent incidents can cause significant damage to the healthcare system by leading to: a) decline in care quality, b) worsening work environment, c) professionals exiting the field, reducing available healthcare services, d) hindering recruitment in health professions, e) perpetuating undesirable social behaviours, g) raising healthcare expenses, h) harming personnel health.

Workplace violence in healthcare – an underreported phenomenon

Underreporting occurs when an aggrieved employee does not report an incident to their employer, the police or other relevant authorities. Many HCWs, including physicians, nurses and paramedics, enter the healthcare field due to a strong feeling of empathy for others. The value of assisting others emotionally cannot be quantified, while healthcare professionals face challenges such as extended and strenuous work shifts. HCWs are at higher risk because they are on the forefront when handling individuals in stressful, unpredictable, and potentially volatile situations. It is difficult for HCWs to realize that they are facing WPV and understand that it is a harmful phenomenon that should condemned. So, one explanation for this lack of reporting is the empathy of staff towards patients whose aggression stems from a medical condition, HCWs often justify that the patient “couldn't control it” [18]. Frequently, HCWs fail to report incidents because they believe that violence from patients is just a natural part of their job and therefore downplay the situation. Additional factors that contribute to underreporting include: a) complexity of an incident, excessive paperwork and lack of trust are factors that connected with reporting system, b) an unsupportive culture, no visible changes after reporting and the absence of reporting guidelines are factors that connected with lack of policy, c)  obstacles like having to finish a report after completing a shift or having limited computer access are factors to occur organizational weaknesses or deficiencies, d) the perception that the incident was not significant enough to report or management's perceived lack of response to non-serious incidents, e) disagreement on what constitutes violence, e.g. including verbal harassment, f) reluctance to report workplace violence by supervisors, g) emotional experiences like feelings of guilt, shame, or fear of reprisals [22,23]. Under these circumstances, healthcare services might be impacted by concerns or dangers of violence in the workplace, as healthcare providers may provide lower quality care if they are afraid of the people they are serving.

Violence phenomenon accreditation tools

Questionnaires, observational checklists, and screening tools for identifying risks are commonly utilized to help identify high-risk patients. Although these interventions show impressive rates of success, they still do not perform well on their own. The basic research tools that have been developed to measure violence are:

• The Work Harassment Scale (WHS) questionnaire developed by Bjorkqvist, Osterman & Hjelt-Back in 1992. It includes 24 questions-statements that participants use to rate their exposure to oppressive and humiliating behaviours from coworkers over the past six months on a five-point scale. The questions/statements concern behaviours such as shouting, isolation, formulating untruths, exercising unjustified criticism are evaluated using a five-point Likert scale. The scale's reliability is quite satisfactory and demonstrates a strong level of internal consistency [24].
• Leymann's (LIPT) questionnaire, is a primary tool for researching the phenomenon of violence in healthcare organizations, includes forty-five questions, divided into five main groups, depending on the effect which have on the individual: 1) effect on freedom of expression and communication, 2) effect on social contacts, 3) effect on professional status and quality of life, 4) effect on personal reputation and 5) effect on physical health. The correlation coefficient r has been calculated at 0.982 while the Cronbach coefficient was found at ?=0.87 [25].
• The NAQ (Negative Act Questionnaire) questionnaire, created by Einarsen and Raknes in 1997, aims to evaluate psychological harassment, recording and measuring the frequency, intensity and prevalence of bullying at work. It consists of 22 structured questions/opinions on a five-point Likert scale referring to potential direct and indirect attacks of psychological harassment experienced by the employee. The sum of the individual responses to the 22 questions gives a total score for the NAQ. A lower score indicates a lower incidence of negative behaviours in the past 6 months. However, it is divided into two main components: a) work-related bullying factor score and b) person and personality-related factor score, the Cronbach reliability coefficient was found in a =0.97. In 2001, Einarsen and Hoel developed a revised version of the NAQ (renamed NAQ-R), consisting of 23 questions, divided into three subscales: a) the first concerns personal bullying (12 questions), b) the second concerns work-related bullying (7 questions), and c) the third concerns physical bullying (3 questions) [26]. 
  

The European Commission has implemented health and safety regulations for workers. Council Framework Directive 89/391 specifically addresses the enforcement of measures aimed at enhancing safety and health, including workplace violence prevention. Article 5 mandates that: "The employer is obliged to ensure the safety and health of employees in all aspects of work" and in article 6 it is stated that the employer "assesses the risks that cannot be avoided", while article 9 specifies that: "the employer must have at his disposal an assessment of the safety and health risks existing at work, including those concerning groups of workers exposed to particular risks". Prevention measures and work and production methods should be incorporated throughout the organization and across all levels of operations [27]. In the last decade, there has been an increase in violence prevention strategies advised for healthcare by government agencies and experts on violence. The suggestions can be grouped into preventive measures for patient or companion violence and preventive measures for partner violence, with some similarities between them. A strong commitment from healthcare management is needed for any prevention program, along with a clear written occupational safety program/policy that is communicated to all staff. Additional measures for prevention should shift attention towards the physical environment (e.g., removing potential weapons, ensuring good lighting, installing security cameras, alarm buttons, etc.), strengthening administrative protocols, and offering employees increased training and educational options. Job stress factors, such as high workloads or ineffective communication among colleagues, can lead to higher chances of abuse towards patients and partners, indicating a need for job restructuring to alleviate stress. The majority of suggestions highlight the importance of having a monitoring system that evaluates the quantity, variety, and seriousness of violence and injuries in a company, which can also be utilized to gauge the success of prevention measures.

To address violence in Health Care Institutions, the World Health Organization recommends an overall plan that will take into account both the special characteristics of each unit and will also introduce interventions at the national level with policies to prevent violence, strengthen custody and measures that will attempt to deal with the causes that give rise to these phenomena. An important factor is the information and training of the staff as well as the psychological and legal support of the staff who have been attacked in the workplace. What is needed to deal with violence in Health Care Institutions is the awareness of citizens, better organization of health services and the establishment of stricter penalties for perpetrators. As ways of managing incidents of violence, cited having an adequate number of security staff, the observance of access rules to the hospital premises, the attempt to appease with condescension and exclusively verbal management, calling in the help of a specialist and coordinator, informing administrative hierarchy, clinic on-call, on-call manager of the Hospital Service as well as the Authorities and the written notification of the incident to the administration. Many governments and international organizations have explored methods to enhance the management of violence in healthcare facilities through laws, regulations, and administrative directives. One example is the passing of the Workplace Violence Prevention for Health Care and Social Services Act in the U.S.A to address violence against employees. A recent report stressed the significance of having a comprehensive OHS framework to address WPV, according to the International Labour Organisation. Furthermore, Shao (2023) have recommended incorporating certain HRM strategies like security protocols and anti-violence training to assist HCWs [4-6, 28-32].

Measures to address workplace violence in healthcare facilities

Despite extensive research on WPV, there is a scarcity of recommendations on how to effectively address it. Efforts should be directed towards promoting a safe work environment for employees and preventing incidents of WPV. It is crucial to have adaptable approaches for dealing with situations involving increased aggression and risk of violence and harm. Research indicates that a combination of strategies is necessary to address workplace violence towards workers. All measures devised to combat violence within healthcare institutions must be implemented at three distinct levels: 1) the personal level, 2) the health organization level and 3) the level of society (Figure 1).

Figure 1: Levels of measures against violence in Healthcare Organizations.

Measures for prevention of violence - primary intervention

Any measures that organizations develop must first have as their primary goal the prevention or deterrence of violence. The actions that can be included in the prevention level include the following:

• • Training and education programs for providers, supervisors, managers and security personnel are necessary to acquaint employees with workplace violence policies and procedures, resources, security contacts, etc. An effective conflict recognition and conflict resolution skills training program, can assist HCWs in how to properly recognize behavioural warning signs of violence in individuals, verbal and non-verbal disengagement skills that can reduce hostility and the potential for violence, methods for restraining violent patients, and self-defense skills that allow staff to be protected without harming the patient. The importance of early intervention and supervision/coaching are skills which considered essential. Across literature, education has proven invaluable, reducing incidence as well as severity. Behavioural coaching can assist healthcare personnel with recognizing and regulating their emotions during stressful instances. Also, integrating virtual reality technology into the healthcare system has ushered in a new era of innovation, offering a unique and effective tool to combat healthcare violence [4,33-35]
  • Security in workplace environment, it is considered that a safe and suitable working environment is a basic condition for reducing violence, this is achieved by developing security measures, such as: reception desks, restricting patient entrances, eliminating potential weapons like sharp and blunt objects (e.g. oxygen tanks, ashtrays, vases), adequate lighting, installation of video surveillance systems, special visitor identification card, coded access for employees, emergency exits, rapid access to police, etc. Recognizing patients who are likely to display aggression by looking for signs such as past violent incidents or observing their behaviour in healthcare settings (e.g. being highly aroused or making threats). A procedure needs to be created to handle these patients. Furthermore, the installation of a discreet panic alarm system can leverage infrared technology to transmit the precise location of the badge holder, enabling the response team to promptly dispatch assistance to the scene [36-40].
  • Comfortable environmental conditions, by creating better waiting conditions, such as: (ventilation, air conditioning, etc.), provision of better seats, information on the progress of appointments, the examination or delays, the decoration, etc. Factors contributing to violence in healthcare include crowded locations, extended wait times, rigid visiting schedules, poor communication, language barriers, and patient and family dissatisfaction. More and more hospitals are forming interdisciplinary teams of experts to promptly address situations with patients and visitors. These groups need to have the capability to recognize and solve security issues, react to violent incidents, carry out violence risk evaluations, and offer prevention suggestions to agency leadership. Previous researches have shown that a work plan which associated with high workload demands, low staff-to-patient ratios and intense time pressure that can contribute to prolonged patient waits or patient perceptions of substandard care that can set the stage for patient frustration and potential aggression. Due to these factors, adding more employees to work schedules or cutting back on freelancer hours can mitigate a potential security risk [36, 41-44].
  • Development of anti-violence policy and a pervasive safety culture, a written occupational policy that must be clearly communicated to all staff. It should provide a definition of workplace violence, clearly state a zero-tolerance stance on workplace violence and management's commitment to worker safety and health, encourage early reporting of violence, ensure that employees who report violence will not face retaliation. A strong commitment by healthcare management to the prevention of workplace violence, this includes allocating adequate resources to safety, risk assessment and monitoring, training workers and management in violence prevention and care of worker victims. Additionally, creating a culture of safety within organizations is also crucial to addressing horizontal violence and bullying in the healthcare workplace. Notably, it is critical for organizations to establish interventions, such as manager training, team building exercises, and clear reporting systems, organizations can enhance allyship, communication, empowerment, and trust among healthcare staff, thus creating a safer work environment for patients and staff alike [36,44].
  • Legislation or regulations, fail usually to clearly specify the meaning of violence, harassment, or bullying. In certain nations, laws regarding harassment or bullying focus on recurring harmful behaviours and the adverse impact on the victim's health. Furthermore, most of these incidents are seldom thoroughly investigated and even less often result in the perpetrators being held accountable through legal actions by authorities, leaving the victim to handle the situation on their own as if it were a personal matter. Nevertheless, the lack of consequences for wrongdoers will not aid in preventing Workplace Violence (WPV) towards Healthcare Workers (HCWs); harsher sanctions must be enforced on those accused of intentionally harming HCWs or disrupting hospital operations.
  • Collective bargaining agreements are crucial for establishing and overseeing commitments to address violence and harassment between workers of different genders, age, experience, education in the workplace. In healthcare facilities, females and consequently nurses, have consistently reported lower levels of engagement and satisfaction compared to other groups of HCWs in the past in relation with security, wages and promotions [36, 44-46].
  • Create a greater sense of community, it appears that training did not have a significant impact on reducing coworker rudeness; building a stronger community within a workplace is important for all employees to work well together and feel secure in their roles. Work environments that successfully foster a feeling of community among employees typically experience higher levels of trust, respect, empathy, engagement, and collaboration among all departments [44,45,47-49]. Additionally, there is a requirement to form a multi-disciplinary team across various organizations to tackle violence. This team should be capable of identifying and resolving security concerns, managing violent situations, conducting risk evaluations, and providing prevention recommendations to agency officials. The group needs to include workers from senior management, security, human resources, legal, and employee representatives [50].

Measures after the occurrence of violence in healthcare facilities

Secondary and tertiary interventions involve providing support to professionals impacted by violence and caring for those affected to help lessen the harmful effects of violence through treatment, rehabilitation, and prevention of future victimization.

Secondary intervention

After the violent act has taken place, it is crucial to offer assistance to the individual who has been victimized. Thus, the goal should be to reduce the negative impacts of the incident and address the sense of guilt that may follow an act of violence, as well as deter the victim from reporting the incident. It is imperative to immediately encourage staff support efforts and psychoeducational meetings featuring experts. The subsequent steps should be taken:

Promptly provide medical care to the victim, along with a report detailing the incident and injuries sustained, including photographs if available.

Consulting, qualified staff or an external counsellor provide advises and support to address the psychological effects of violence, with peer support groups as an added resource. It is necessary to offer access to individuals who are able to assist in the resolution of conflicts, these individuals should be chosen from various departments, in order for a person in need of support to have a neutral resource within the organization. Contacts must receive thorough training for the project and be encouraged to offer suggestions for improvements or solutions when necessary. Additionally, having a neutral expert advisor, potentially from an external source, with psychological and legal knowledge is crucial for contacts dealing with difficult and lengthy cases [50,51].

Process Management, is crucial for effectively dealing with conflicts in the organization. It is essential to continuously monitor, report, and investigate violent incidents in order to uncover the root causes of violence and identify ways to enhance prevention measures through incident reports. Executives can monitor trends of violence and assess the success of violence prevention measures through continuous surveillance [50,52].

Investigation of complaints, assistance should be provided to the employee, particularly in instances of harm. Additionally, it is essential to notify the victims that their situation was examined by the proper authorities. Healthcare workers who have been victims of WPV struggle to stand up for their rights due to ongoing emotions of shock, anger, and frustration. If the employee chooses to make a claim because of the injury, a person in power needs to be prepared to provide the required assistance and support to the employee [52,53].

Mediation, is one way to resolve disputes, however it does not always ensure that the incident will not happen again in the future [54,55].

Resolving cases in courts, is typically the course of action taken by employees when they are injured and decide to seek compensation through a claim. In these instances, evidence is gathered and compiled into a thorough file documenting the occurrence of violence.

Tertiary intervention

Tertiary intervention involves providing long-term support for individuals who have experienced a violent event, such as offering rehabilitation or social services to help reduce emotional trauma for the victim.

Social support, prior research has shown that social support can lessen the negative effects of violence on the mental and professional functioning of healthcare workers experiencing workplace violence, such as increased anxiety, work-related stress, and unhappiness. Even though researchers have different interpretations, they agree that social support involves connecting external resources with personal relationships. There are two categories in which social support can be categorized. A group includes physical, visible, or practical assistance, like solid material help, social ties, and involvement in personal connections (such as relatives, buddies, and coworkers). The second kind is personal and experiential emotional support, where people feel appreciated, assisted, and understood in society, and is closely linked to their own emotions. The connection between hazardous work environments and decreased dedication at work was found to be stronger for workers lacking support from colleagues. Additionally, there was a discovered low level of emotional commitment in the workplace and a high level of turnover intention linked to psychological violence in the workplace [51,56].

Compensation, must be provided to providers, as physical WPV can occur suddenly and result in immediate severe injuries and damages, leading to high recovery expenses [57].

Organizational Agreements and Protocols, for establishing safe zones or safely transporting patients outside hospital or emergency entrances. Additionally, recommendations for delivering home healthcare in hazardous circumstances, guaranteeing prompt staff responses and assistance in emergencies, and employing strategies to lessen patient wait times and offer timely updates to patients in the waiting area. In many research studies, patient dissatisfaction with the healthcare system is often attributed to waits for appointments [3,58,59].

Care Professional Programs and contracts led by psychologists, doctors, and psychiatric nurses are essential in mitigating the detrimental effects of WPV, which encompasses post-traumatic stress disorder, anxiety, depression, and other concerns. The most common problems faced by those impacted are related to mental health. Typically, victims of workplace violence and bullying require several months of therapy to tackle their psychological issues. Furthermore, further studies suggest that cognitive therapy can reduce the impact of anxiety, depression, and trauma on healthcare workers who are subjected to workplace violence and bullying. Psychiatric nurses provide cognitive therapy through teaching skills to address workplace violence and bullying issues [52,57].

Providing remedial opportunities, as psychological distress plays a key role in the reintegration process of workplace violence victims, taking time off work will enable them to receive appropriate professional assistance for their individual needs. An alternative work environment must be an option the victim should have [60].

Considering the above, the combination of different offenders, forms of violence, and care environments presents a challenge for developing interventions for violence, suggesting that a one-size-fits-all strategy may not work or be viable. A multifaceted approach (Table 1) is required to combat WPV, as the common culprits (patients, their relatives/visitors, and coworkers) are varied.   

Violence in the workplace against healthcare workers during the Covid-19 outbreak

Worryingly, the latest data show even bigger increases in aggression and WPV in various healthcare environments amid the Covid-19 crisis. HCWs were on the frontlines battling the disease, facing risks such as increased workload, reduced sleep, isolation and quarantine, and less socializing. Thus, insufficient personnel and equipment, increased risk of morbidity and mortality associated with the disease increases the likelihood of burnout, exhaustion, bulling, threatening behaviour and physical assault. Emergency departments have experienced a disproportionate rise in violent incidents, with up to twice as many occurrences compared to before the pandemic.

Frequent violent incidents have been consistently linked to a reduction in the level of care provided to patients and a decrease in the well-being of healthcare workers. Nurses and physicians, who are both involved in direct patient care and on the front line, faced the highest rates of WPV, compared to other professions. Unfortunately, although WPV is common and has a significant impact, research shows that many organizational interventions do not lead to lasting improvements [61-65]. In Greece, many cases of violence against healthcare providers go undocumented and unreported as they are not reported to official authorities or competent agencies. The victim internalizes social attitudes and expectations, worrying about potential judgement and stigma if the situation becomes known to others. In some instances, professionals encounter violence or aggression so often that they become accustomed to it and view it as a normal aspect of their job. Approximately two-thirds of HCWs are believed to have encountered workplace violence, research literature from Greece has shown that nurses being more susceptible to WPV compared to physicians. Law 3850/2010 has been aligned with European Directive 89/391, which mandates that companies are responsible for ensuring the health and safety of their workers. Also, in 2021, Law 4808/2021 ratified the International Labour Organization's (Convention 190) on eliminating workplace violence and harassment, leading to the regulation of similar circumstances. Currently, Greece is part of a cluster of nations that have introduced haphazard strategies to address WPV and bullying. Which are still in the initial phases of development and application. However, the increase in migration flows, incidents of juvenile violence, domestic violence and gypsy attacks indicate that measures should be intensified [66-69].

The global issue of addressing workplace violence in healthcare facilities requires investments in resources and implementing prevention campaigns and programs to enhance occupational health and safety. The outcomes of workplace violence (WPV) can result in lower productivity and quality of medical care, ultimately harming health equity for the population. The true scope of violence among healthcare professionals is uncertain because many are afraid to report it, while some other view it as a normal part of their job. Controlling the factors that cause physical, psychological, and sexual assaults, along with verbal violence, is essential to eliminate the acceptance of violence in healthcare environments. Combat measures against violence should be developed at multiple levels (individual, organization, society) and aligned with global organizations' guidelines for implementing anti-violence policies and measures. In Greece it appears urgent to update the legal system, and healthcare workers need to be educated on available options to prevent violence and promote de-escalation. Continued research on violence in healthcare settings will contribute to creating advancements.

The authors declare no conflict of interest.

Each author declares that he or she has no commercial associations (e.g., consultancies, stock ownership, equity interest, patent/licensing arrangement etc.) that might pose a conflict of interest in connection with the submitted article.

None

All authors were involved in all steps for preparation of this article, including final proofreading and gave final approval of the version to be published.

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