
==== Front
Crit Care Explor
Crit Care Explor
CC9
Critical Care Explorations
2639-8028
Lippincott Williams & Wilkins Hagerstown, MD

39250800
CCE-D-24-00121
00004
10.1097/CCE.0000000000001157
3
Qualitative and Mixed Methods Study
Healthcare Provider Experiences With Unvaccinated COVID-19 Patients: A Qualitative Study
Griffin Candice MD 12
Lee Christie MSc, MD Christie.Lee@sinaihealth.ca
13
Shin Phil MSc, MD Phil.Shin@nygh.on.ca
14
Helmers Andrew MHSc, MD andrew.helmers@sickkids.ca
15
Kalocsai Csilla MPhil, PhD csilla.kalocsai@sunnybrook.ca
2
Karim Allia 6
Piquette Dominique MSc, MD, PhD Dominique.Piquette@sunnybrook.ca
12
1 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
2 Department of Critical Care, Sunnybrook Health Sciences, Toronto, ON, Canada.
3 Department of Critical Care, Mount Sinai Health System, Toronto, ON, Canada.
4 Department of Critical Care, North York General Hospital, Toronto, ON, Canada.
5 Department of Critical Care, The Hospital for Sick Children, Toronto, ON, Canada.
6 Reserca, Toronto, ON, Canada.
For information regarding this article, E-mail: candice.griffin@medportal.ca
09 9 2024
9 2024
6 9 e1157Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

IMPORTANCE:

In the setting of an active pandemic the impact of public vaccine hesitancy on healthcare workers has not yet been explored. There is currently a paucity of literature that examines how patient resistance to disease prevention in general impacts practitioners.

OBJECTIVES:

The COVID-19 pandemic created unprecedented healthcare challenges with impacts on healthcare workers’ wellbeing. Vaccine hesitancy added complexity to providing care for unvaccinated patients. Our study qualitatively explored experiences of healthcare providers caring for unvaccinated patients with severe COVID-19 infection in the intensive care setting.

DESIGN:

We used interview-based constructivist grounded theory methodology to explore experiences of healthcare providers with critically ill unvaccinated COVID-19 patients.

SETTING AND PARTICIPANTS:

Healthcare providers who cared for unvaccinated patients with severe COVID-19 respiratory failure following availability of severe acute respiratory syndrome coronavirus 2 vaccines were recruited from seven ICUs located within two large academic centers and one community-based hospital. We interviewed 24 participants, consisting of eight attending physicians, seven registered nurses, six critical care fellows, one respiratory therapist, one physiotherapist, and one social worker between March 2022 and September 2022 (approximately 1.5 yr after the availability of COVID-19 vaccines in Canada).

ANALYSIS:

Interviews were recorded, transcribed, de-identified, and coded to identify emerging themes. The final data was analyzed to generate the thematic framework. Reflexivity was employed to reflect upon and discuss individual pre-conceptions and opinions that may impact collection and interpretation of the data.

RESULTS:

Healthcare providers maintained dedication toward professionalism during provision of care, at the cost of suffering emotional turmoil from the pandemic and COVID-19 vaccine hesitancy. Evolving sources of stress associated with vaccine hesitancy included ongoing high volumes of critically ill patients, resource shortages, and visitation restrictions, which contributed to perceived emotional distress, empathy loss, and professional dissatisfaction. As a result, there were profound personal and professional consequences for healthcare professionals, with perceived impacts on patient care.

CONCLUSIONS:

Our study highlights struggles of healthcare providers in fulfilling professional duties while navigating emotional stressors unique to vaccine hesitancy. System-based interventions should be explored to help providers navigate biases and moral distress, and to foster resilience for the next major healthcare system strain.

COVID-19 pandemic
emotional dissonance
healthcare burnout
moral distress
unvaccinated COVID-19 patients
vaccine hesitancy
Physicians' Services Incorporated Foundation 10.13039/501100000241 2022-2609 Candice GriffinRoyal College of Physicians and Surgeons of Canada 10.13039/100014735 RC/AMS CanMEDS Research Grant Candice GriffinOPEN-ACCESSTRUE
SDCT
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pmcKEY POINTS

Question: This study qualitatively explored experiences of healthcare providers in providing care to unvaccinated patients during the COVID-19 pandemic.

Findings: In spite of navigating added layers of emotional stress associated with vaccine hesitancy, such as communication conflicts, personal cognitive biases, and perceived waning public support, healthcare providers strove to fulfill their professional duty toward patients. Many described experiencing heightened levels of burnout, emotional distress, and professional dissonance during the COVID-19 pandemic.

Meaning: Perceived negative impacts of vaccine hesitancy during the COVID-19 pandemic highlight the need for not only individual resilience strategies, but healthcare system and societal accountability toward preserving healthcare provider wellbeing.

The COVID-19 pandemic brought unprecedented challenges in healthcare. Healthcare providers overcame immense obstacles caused by resource constraints, staffing shortages, threats to their personal safety, limited family presence at bedside, and overwhelming grief and trauma of witnessing unusually high volumes of patients suffering (1–3). The pandemic impacted healthcare workers’ wellbeing, leaving many with burnout and moral distress (1–34). Burnout is characterized by emotional exhaustion, reduced efficacy and professional dissatisfaction, and moral distress is the conflict between actions healthcare practitioners believe they are ethically and morally bound to perform and barriers that stand in the way (1, 2, 4–7).

Pre-pandemic approximately 50% of physicians experienced moral distress and burnout, with the highest levels in critical care medicine, palliative care, and emergency medicine (8). According to a cross-sectional study by Burns et al (8), 54.6% of critical care physicians experienced burnout during the pandemic, while a systematic review by Gualano et al (9) reported pandemic-related burnout rates as high as 58% among critical care and emergency department providers. A systematic review by Papazian et al (10) further found that burnout rates rose significantly higher in ICU nurses from 37% to 61% during the pandemic. Burnout and moral distress are associated with negative patient outcomes, poorer quality of care, and system-wide strain secondary to workforce attrition (5, 6, 11).

Many hoped that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines would end the pandemic (12, 13). Public vaccine hesitancy, defined as the delay or refusal to obtain a vaccine when one is available, came to the forefront after the development and availability of the SARS-CoV-2 vaccine (14, 15), highlighting the tension between individual right to autonomy (right to choose to be vaccinated) and the importance of protecting the health of the greater public (16). This created an added layer of complexity for healthcare providers who continued to provide high quality care for unvaccinated patients (14, 15, 17). Public vaccine hesitancy manifested in misinformation on social media channels, public protests outside of hospitals, and even personal threats toward healthcare workers (14, 15, 18), and the impacts of vaccine hesitancy on healthcare workers had not yet been fully explored. Our study qualitatively explored the experiences of healthcare providers with COVID-19 vaccine-hesitant patients admitted with severe COVID-19 infection in the ICU setting.

METHODS

Research Team and Reflexivity

The research team consisted of seven individuals, five women and two men. There were three adult intensivists, one pediatric intensivist, an anthropologist, a critical care fellow, and a research assistant. Two members of the team held masters degrees in bioethics, and all had expertise or prior experience in qualitative research methodology. Five investigators had provided care for unvaccinated COVID-19 ICU patients before and during the interview period. Interviews were conducted by the author (C.G.), a critical care fellow, who had provided care for unvaccinated COVID-19 patients during her residency. Participants were informed of the study objectives, as well as the occupation of the interviewer before the start of the interview. Some of the participants had previously worked directly with the interviewer. Reflexivity was employed throughout the interviews and analyses to reflect upon and openly discuss any individual pre-conceptions and opinions that may impact the collection and interpretation of the data based upon the researchers’ own previous professional and personal experiences.

We maintained rigor through multiple strategies: 1) purposive and snowball sampling of participants involved in the care of critically ill vaccine-hesitant COVID-19 patients; 2) in-depth semi-structured interviews that provided detailed accounts of participants’ experiences; 3) an iterative data collection and analysis process with modifications of the interview guides and data codes to further explore promising, emerging concepts through theoretical sampling; and 4) data collection until thematic saturation was achieved, meaning that each theme and relationships between themes could be described with enough depth of understanding based on the data available.

Study Design

We used an interview-based constructivist grounded theory (19) framework to explore experiences of healthcare providers with critically ill, unvaccinated COVID-19 patients who were vaccine-hesitant at the time of admission. Participants were asked about experiences with patients who had not received doses of any available vaccines. Our study is reported according to the Consolidated Criteria for Reporting Qualitative Research (Table S3, http://links.lww.com/CCX/B402) (20). We employed a combination of purposive and convenience sampling of healthcare professionals from the ICUs of two academic centers and one large community hospital, all situated in a major urban center. Hospital A has six ICUs of four to 22 beds (total of 78), which expanded to 95 beds during the pandemic; hospital B contains a 16-bed ICU, which expanded to 24 beds; and hospital C has a 21-bed combined medical/surgical ICU and coronary care ICU that expanded to 26 beds. Interviews were conducted during this expansion. Recruitment via posters and email invitation continued until thematic saturation was reached. Research Ethics Board approval was obtained from each institution (Table S1, http://links.lww.com/CCX/B402). This study was conducted in accordance with the ethical standards of the responsible committee on human experimentation (institutional or regional) and with the Helsinki Declaration of 1975.

Data Collection and Analysis

Interviews were conducted from March 2022 to September 2022 over video conferencing (to maintain social distancing), audio recorded without field notes, de-identified, and transcribed verbatim. There were no nonparticipants present during the interviews. The semi-structured interview guide (Table S2, http://links.lww.com/CCX/B402) was developed by the research team (C.G., C.L., P.S., A.H., C.K., D.P.), informed by qualitative studies on moral distress (21, 22), and pilot tested before recruitment. Modification of the interview guide occurred after initial analysis of themes following the seventh interview, in which questions were added to navigate visitation policies, communication or conflicts with families of patients, and experiencing vaccine hesitancy outside of the clinical setting. A second modification was performed after the fifteenth interview following a second analysis, in which questions exploring the main lessons learned as a provider were included.

RESULTS

We interviewed 24 participants: eight attending physicians, seven registered nurses, six critical care fellows, one respiratory therapist, one physiotherapist, and one social worker. A summary of demographics can be viewed in Table 1. No participants dropped out or refused to participate. The mean length of the interviews was 47 minutes (sd = 9.4 min).

TABLE 1. Participant Demographics

Demographic	n = 24, n (%)	
Profession		
 Attending physician	8 (33)	
 Registered nurse	7 (29)	
 Resident physician/fellow	6 (25)	
 Respiratory therapist	1 (4)	
 Physiotherapist	1 (4)	
 Social worker	1 (4)	
Age, yr		
 > 35	15 (63)	
 30–34	7 (29)	
 25–29	2 (8)	
Sex		
 Female	16 (67)	
 Male	8 (33)	
Hospital		
 Hospital A	16 (67)	
 Hospital B	7 (29)	
 Hospital C	1 (4)	
Duration working in ICU, yr		
 > 10	6 (25)	
 5–10	6 (25)	
 1–5	12 (50)	
Number of COVID-19 patients cared for		
 > 10 patients	17 (71)	
 6–10 patients	4 (17)	
 2–5 patients	3 (13)	

Common themes included: experiencing high volumes of critically ill COVID-19 patients with potentially preventable illness, the emotional response to caring for critically ill unvaccinated COVID-19 patients, conflicts with patients and families pertaining to COVID-19 vaccine hesitancy, the role of social media and medical misinformation on COVID-19 vaccine hesitancy, challenges and coping strategies to maintain the therapeutic relationship, and the impact of navigating vaccine hesitancy.

Experiencing High Volumes of Critically Ill COVID-19 Patients With Potentially Preventable Illness

Early stressors of the pandemic, including personal protective equipment (PPE) shortages, high volumes of critically ill patients, uncertainty regarding the trajectory of the pandemic, fear of contracting the disease, and potentially exposing their own families, were perceived by respondents as contributors to an elevated level of baseline burnout among staff.

[I am] so frustrated, to be honest with you, because we feel that we are risking our own health and well-being when it comes to caring for them [unvaccinated patients]. And, of course, we have a high risk of also taking it at home and giving it to our family. [P02]

However, before the availability of COVID-19 vaccines, despite experiencing exhaustion, burnout, and moral distress, there were high levels of empathy and camaraderie among staff, and strong public support for the sacrifice and risks providers were taking to care for COVID-19 patients.

You know, the pots and pans were banging at 7 o’clock for a few months at the beginning and it was sort of nice. [P13]

Many subsequently hoped that broad public vaccine uptake would end the pandemic and help ease their elevated levels of distress.

I think everybody was thinking just tough it out a little longer, once the vaccine’s out, we’ll be home free, everything will go back to normal. [P16]

Following the public availability of COVID-19 vaccines, vaccinated patients became largely protected against severe, life-threatening infections, but ICUs saw an increasing proportion of unvaccinated patients admitted with respiratory failure due to vaccine hesitancy. Healthcare providers’ main sources of stress evolved as they attended to increasing volumes of critically ill patients with potentially preventable illness, driven often by social media misinformation pertaining to vaccination and unfounded treatments.

We were getting to the point where there were just too many patients and there was no end in sight, it was one wave after the other and it felt like we had a solution, but people weren’t willing to take the solution. [P15]

The Emotional Response to Caring for Critically Ill Unvaccinated COVID-19 Patients

Many experienced emotions ranging from anger, frustration, sadness, guilt, and helplessness during the provision of care of unvaccinated patients. Participants perceived these patients as direct contributors to the prolongation of the pandemic and as being partially responsible for the strain on an already overburdened healthcare system. Practitioners commonly expressed transient anger and frustration when initially caring for COVID-19 patients, both toward the patient and certain family members, especially if they served as barriers to the patient becoming vaccinated.

I think for me it was a lot of anger in the beginning…there was something that could have been done to prevent this, and it was so hard for all of us. We were working so short, we didn’t have proper PPE, we didn’t have the supports in place that we needed to take care of these patients, and why couldn’t they just do something to help prevent it? [P17]

However, these emotions rapidly faded and/or turned into guilt, sadness, and hopelessness when their patients became sicker, distressed, or required invasive life support.

I was sad because clearly the patient does not understand the benefit that the vaccine could have had, in his case, given all his comorbidities. He couldn’t benefit from it. And it’s sad to see him asking for help to breathe, when he could have prevented it, to a certain level. [P03]

Conflicts With Patients and Families Pertaining to COVID-19 Vaccine Hesitancy

Many healthcare providers experienced conflicts with patients and families regarding the medical management of COVID-19 illness and the validity of unfounded treatments. The anticipation of difficult conversations and/or tensions with this patient population and their families before interacting with them was an additional source of stress for participants.

I also remember interactions with families going through tons of lists of drugs of experimental therapies, and stuff that they wanted us to apply to their family member. When it came down to the fact that they just weren’t vaccinated, and they were being desperate and trying to work around it.. and it’s rather been awful. [P09]

Institutional visitation policies were another source of conflict between providers and families. Practitioners expressed distress over visitation policies they were responsible for enforcing and yet had little agency in developing, particularly when infection control policies and PPE were more robust but visitation policies remained restrictive for unvaccinated families in certain institutions.

I felt like a monster [for enforcing the visitation policies]…patients were punished because they couldn’t see their family and they suffered terrible deaths despite all of the medical things that we boast about. It was really traumatizing. [P05]

The Role of Social Media and Medical Misinformation on COVID-19 Vaccine Hesitancy

Most respondents were frustrated or defeated at the role of social media misinformation in feeding vaccine hesitancy.

…the intoxication of all this fake information that’s out there that’s really damaging to these [patients]. And I think that sometimes gets overwhelming, and [I] feel defeated. [P09]

Anti-vaccine rhetoric became more prevalent on social media and through public protests in the late stages following distribution and availability of COVID-19 vaccines and healthcare providers began to experience a tired discontentment due to feelings of underappreciation.

I was just too baffled to be angry. People have hailed us as the angels of the pandemic. And now they’re demonstrating in front of our door, yelling at us? [P16]

Many felt targeted by public protests against masking and vaccine mandates and experienced public aggression from anti-vaccine advocates over social media simply because of their profession.

[Anti-vaccine advocates] would attack me personally for working in the ICU and make claims that I must be paid to say that the vaccine works or that I must be contributing to lying about the current COVID numbers. [P07]

Challenges and Coping Strategies to Maintain the Therapeutic Relationship

Despite navigating complexities and conflicts pertaining to vaccine hesitancy, unanimously participants were dedicated to preserving the therapeutic relationship, which took considerable effort to achieve.

First was frustration, anger, sadness. And on the other hand, of course, after feeling angry I felt guilty. [I reflected on] my own reason why I’m in medicine. Just to help others. [P03]

To do so many compartmentalized their emotions toward patients, preferring to not know the vaccination status to avoid bias, accepting that physicians and patients can disagree, and recognizing their professional limitations in advocating for vaccination in the critical care setting.

I actively do not want to know [vaccination status] because I don’t want any form of bias, conscious or unconscious affecting how I treat my patient. [P10]

Others rationalized patients’ behavior regarding vaccination as a coping mechanism, believing that decisions not to get vaccinated were driven by fear of vaccine safety, lack of appropriate vaccine-related information, and issues with access based on socioeconomic status and race.

We are helping someone that, clearly, does not have enough information about the vaccines. So I feel bad for them. [P03]

Most believed patients received the standard of care, regardless of vaccination status, while others observed differences in communication, time spent in the room, and empathy toward patients.

I do think that there were difficulties with communication with unvaccinated cohorts with families and patients in the ICU. I don’t know if it was due to resentment or due to unconscious bias, but I do think the communication was compromised. [P13]

Furthermore, providers noted that unvaccinated patients expressed fear that they may not receive the same level of care or have the same outcomes as vaccinated counterparts.

She didn’t want to be admitted to the hospital because she didn’t have the vaccine and she was afraid something would happen because of that, like we would or not pay enough attention to her or not bring good care. [P04]

The Impact of Navigating COVID-19 Vaccine Hesitancy

The dedication of healthcare providers toward maintaining professionalism during the provision of care often came at the cost of suffering intense emotional turmoil associated with simultaneously navigating vaccine hesitancy (Fig. 1).

Figure 1. Healthcare providers stated an utmost adherence and dedication to maintaining their professional duties toward patients and preserving the therapeutic relationship; however, this came with immense emotional burden as multiple layers of stress continued to mount post vaccine availability. The layers of emotional stress were brought on by interactions involving patients and families (conflicts around vaccine hesitancy or unfounded COVID-19 treatments), the institutions in which healthcare professionals worked (having to enforce visitation policies), and with the broader society (sensing a shift in appreciation toward healthcare workers during public anti-vaccine protests and with social media rhetoric that at times targeted healthcare practitioners).

[Vaccine hesitancy] was just one other stress during a time that was very dark. We talk about how the medicine is difficult, but it’s the emotional layer of the patient and their family and those interactions that are more difficult things to cope with and contribute to burnout. [P11]

Many participants learned to prioritize personal wellness to address job dissatisfaction, with some leaving critical care medicine or the healthcare profession altogether.

I’ve lost my co-workers in droves: leaving the ICU to go to less patient focused opportunities. I have also started applying to positions that are away from the bedside. I don’t think that I could ever completely leave patient care altogether, but I definitely recognize that I can only do so much for so long and I don’t want to see myself implode. [P07]

You don’t let people get into a situation [where they are] so stressed that they can’t do anything about themselves. I mean the stress really is about a sustained increase in intensity that you can’t avoid and that’s why people left. [P11]

DISCUSSION

Through exploring healthcare provider experiences providing care to vaccine-hesitant patients with severe COVID-19 illness, we found practitioners were dedicated to maintaining professionalism and adhering to their ethical duties but were forced to navigate several layers of growing emotional stress and declining protective factors. External stress was layered in three main relationships and interactions: the provider-patient relationship, the provider-institution relationship, and the provider-societal interactions. Overall, the cumulative and sustained increase in intensity of external stresses was felt to contribute to healthcare worker burnout, attrition, and human resource shortages seen in the late stages of the pandemic.

Provider-Patient Interactions: The Stress of Ongoing Threats to Safety

While providing care to vaccine-hesitant patients, healthcare providers were forced to maintain professionalism in the face of experiences that challenged their professional moral compass, threatened their own physical and psychologic safety, and antagonized their professional identity. Patient autonomy is a critical first principle of healthcare (23). During a pandemic, however, the right to refuse vaccination can conflict with the public health Harm Principle (24). Such refusal may also compromise healthcare providers’ physical safety through the threat of exposure to new variants and exacerbating waves of COVID-19 patients encountered in inpatient settings (25, 26). Healthcare provider psychologic safety was compromised through experiencing ongoing burnout, exhaustion, and repeated emotional trauma following the introduction of the SARS-CoV-2 vaccines (27). Impacts to psychologic and physical safety have been found to negatively impact performance outcomes in the clinical setting (28) and are correlated with higher rates of healthcare worker turnover (29).

Provider-Institution Interactions: The Stress of Enforcing Institutional Visitation Policies

Institutional visitation policies perpetuated moral distress when frontline staff were responsible for enforcing policies, despite having little agency in developing or revising them. Healthcare providers received little training on how to navigate and enforce the visitation policies. Performing duties without adequate training has been associated with higher levels of anxiety and depression among practitioners (30). Policies were often felt to be overly discriminatory in the later phases of the pandemic, especially with more robust infection control measures, creating barriers to effective communication with patients and families (31). Discriminatory practices have been found to exacerbate patient and family mistrust in healthcare providers, which may compromise the therapeutic relationship (31). Many felt enforcing visitation policies placed them in direct conflict with their ethical duty to uphold the highest level of care for patients by preventing families from visiting. Conflict in ethical duties is a major driver of professional dissonance and moral distress, especially when providers have limited ability to change or appeal problematic policies (32–34).

Provider-Society Interactions: The Stress of Growing Underappreciation and Public Antagonism

Following the availability of COVID-19 vaccines, healthcare providers perceived a decline in public appreciation and patient/family trust, which was likely exacerbated by social media misinformation (35). Job dissatisfaction has been inversely correlated with professional recognition and appreciation (36–38). Recognition in the workplace has been shown to reduce burnout and worker attrition (39). Healthcare worker professional identity is in part obtained from public perception of their roles and responsibilities, and incongruities of public perception can be associated with professional dissonance (40).

Practical Implications of Vaccine Hesitancy on Healthcare Providers

The layers of emotional stress placed upon healthcare providers by vaccine hesitancy likely contributed to burnout, professional dissatisfaction, and workforce attrition (9, 41–43). The constraints and strains described by healthcare workers during the pandemic illuminated the impacts of social discourse, interactions between colleagues and patients/families, institutional policy development, healthcare communication, and resource availability on exacerbating emotional exhaustion and professional dissonance (3, 44). The need for interventions that protect the therapeutic relationship between providers and patients (17), while empowering personal resiliency is essential to prepare for, adapt to, and thrive during the next major healthcare challenge.

Limitations

While this study was multicentered and multidisciplinary to capture the experiences of all healthcare professionals, there are limitations. All participating centers were located in a major urban center, and results may not be fully generalizable to other geographic areas. Furthermore, most data were obtained from registered nurses and physicians; therefore, other professionals may not be fully represented. Interviews were conducted when visitation policies were less restrictive and numbers of patients with severe COVID-19 respiratory failure were lower, however, participants were asked to reflect on experiences spanning the entire period of time following availability of COVID-19 vaccines. Despite our participants openly sharing their experiences, when asked about ethical duties toward patients, the potential for observer bias exists such that interviewees may have provided what they perceived to be the most professional response. Finally, there may be additional sources of burnout and moral distress not explored in this study that contributed to the overall emotional experience of healthcare providers during the period of time following the distribution and availability of COVID-19 vaccines.

CONCLUSIONS

Our study highlights the struggles of healthcare providers in fulfilling professional duties while navigating emotional stressors unique to vaccine hesitancy. Interventions designed to help prepare providers to navigate biases and moral distress may help to foster resilience for the next major healthcare system strain and should be further explored.

ACKNOWLEDGMENTS

We thank our participants for sharing their stories.

Supplementary Material

This study was generously supported by the physician services incorporated Foundation and Royal College/associated medical services a Royal College of Physicians and Surgeons of Ontario framework for physician competency Research Development Awards.

The authors have disclosed that they do not have any potential conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccejournal).
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