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Abstract

Purpose

Communities in Canada have created targeted hospice palliative care strategies such as facility-based hospices for the homeless (H4H) to promote equitable access to care. To ensure the sustainability of H4H programs, there is a need to prevent and mitigate burnout and enhance workplace wellbeing. The objectives for this study were to, (1) develop a better understanding of H4H staff and volunteers’ experiences of stress and wellbeing; and (2) explore opportunities for additional resources to support workplace wellbeing.

Methods

We developed and administered an anonymous 26-item survey to 104 providers including both staff (eg, nurses, administrators) and volunteers at a facility-based H4H in Ontario. The survey gathered open and closed-ended data on sociodemographic information, compassion satisfaction, and H4H stories of workplace experiences.

Findings

The response rate was 56% (n = 58). Most respondents had high compassion satisfaction. However, multiple factors causing stress at work across the socio-ecological model were discussed. Requests for additional resources to foster workplace wellbeing included educational, process-related, spiritual/psychological, and social supports. Respondents storied that positive workplace wellbeing includes being able to provide quality care, and having supportive relationships, personal fulfillment, and a respectful culture within the workplace.

Conclusion

Provider participants were satisfied with their ability to be effective carers, yet chronic multi-level work-related stressors can erode a sense of meaning in H4H work. A multi-faceted evidence-based approach to supporting workplace wellbeing is needed in H4H settings. Research has shown that mindfulness could be an effective strategy, as it can decrease burnout and promote coping, team connection, and anti-oppressive care.

Keywords

hospice for the homeless provider wellbeing hospice volunteers compassion satisfaction burnout stress workplace culture mindfulness in healthcare

Introduction

Several communities in Canada have created targeted hospice palliative care strategies, such as facility-based specialized hospices for the homeless (H4H), to promote equitable access to care for the 235 000 people experiencing homelessness in any given year.^1-5 H4H organizations provide services within home-like facilities where clients receive palliative care often for the last 30 days of their life. This differs from other specialized hospice services that deliver care in the community. H4H organizations aim to improve quality of life by attending to symptoms of illness and psychosocial suffering⁶ and use trauma-informed and anti-oppression approaches to care.⁵

Sustaining and growing equitable access to H4H care hinges on staff and volunteers having work conditions that support their wellbeing and protects their capacity to deliver care.^7,8 However, multiple compounding work-related stressors are thought to put providers working at the intersection of death and homelessness at high risk for burnout.⁹ Burnout results from “extreme occupational stress” (9, p. 1365) and presents as as emotional exhaustion, cynicism, and/or feeling inefficient in job-related roles.^7,10 It is estimated that the prevalence of burnout in palliative care nurses is between 24%-39%^9,11 and largely associated with factors¹⁰ such as heavy workloads; workplace harassment; tense relationships with colleagues; and contact with death.^7,10,12To account for the H4H context of caring for structurally vulnerable people, we also examined literature on burnout in homeless shelter workers, which has a similar estimated prevalence of 30%-40%¹³ due to exposure to violent deaths, vicarious trauma, and witnessing the realities of structural oppression.^4,13

Furthermore, experiences of burnout are often stratified across diverse identities. Men are more likely than women to exhibit cynicism.^11,14 Women tend to have higher levels of exhaustion than men.^14,15 Additionally, younger people are at a higher risk for cynicism,^11,16 and non-white individuals and members of 2SLGBTQ + communities are more likely to experience exhaustion and feelings of job inefficiency than white and heterosexual individuals.¹⁴ When left unaddressed, burnout often leads to poorer provider wellbeing, compromised care, provider attrition, and decreased organizational and system capacity.^8,9,17,18

A factor that protects against burnout and supports providers’ wellbeing at work and at home is compassion satisfaction (ie, the feeling that one is an effective carer).^8,19,20 Wellbeing is a multidimensional concept that utilizes a holistic understanding of the relationship between physical, mental, social and spiritual functioning that results in a sense of flourishing. However, this strengths-based conceptualization has received little attention in burnout literature to date.²¹ It is known that compassion satisfaction is positively correlated with job satisfaction and employee retention and negatively correlated with burnout.¹⁰ Compassion satisfaction is often increased by leaning on support systems and resources, effective coping strategies (eg, self-compassion), displaying compassion, and seeing the positive impact of one’s work.^8,19,20

At this time, little is known about the experience of burnout, compassion satisfaction, or wellbeing in H4H settings, or the factors shaping these phenomena. To sustain H4H programs and enhance workplace wellbeing, there is a need to better understand provider experiences in this context.

Methodology

Research Objectives

Study objectives were to: (1) develop an understanding of H4H staff and volunteers’ experiences of stress and wellbeing; and (2) explore opportunities for additional resources to support workplace wellbeing. Research questions to meet these objectives included:

1. To what extent are H4H staff and volunteers experiencing compassion satisfaction;

2. How do H4H staff and volunteers experience work-related stressors;

3. In what ways can resources support their workplace wellbeing; and

4. How do H4H staff and volunteers envision workplace wellbeing?

Study Design

We developed a cross-sectional, multi-method survey informed by a pragmatic paradigm that incorporated both post-positivist and interpretive knowledge.²² The Sex- and Gender-based Analysis (SGBA+) framework²³ and socio-ecological model²⁴ guided our exploration of factors that are thought to influence burnout such as racism, sexism, and workplace harassment (see Image 1).^{4,7,11,12,14,15}

Figure 1.

Image 1: Socio-Ecological Model With SGBA + Factors

Sampling and Recruitment

The site for this study was a facility-based H4H in Ontario, Canada located in an urban environment with 16 beds and 104 providers, half of which were volunteers. In this hospice, there are several managers and coordinators, several supportive care providers, and one physician, with the largest proportion of staff being nurses and personal support workers (PSWs). There is an approximate provider-to-patient ratio on days and nights of 3:16 with one registered nurse, one registered practical nurse and one PSW. Data on the age, race, and gender of providers was unavailable.

H4H leadership provided the email contacts of current staff and volunteers to support sharing of the voluntary survey participation opportunity. Our research team emailed potential survey respondents a recruitment letter containing a study summary, consent information, and a link to the secure online survey that included radio button consent. Up to two follow-up reminder messages were sent. Participants were offered a $10 CAD gift card for completing the survey.

Data Collection

The online survey, hosted via Qualtrics, contained 26 items (see Supplemental File (1)) and took approximately 20 minutes to complete. Anonymous responses were collected over 2 weeks in May 2024. Duplicate detection, bot detection, and preventing indexing were used. The survey included: (1) closed-ended questions collecting sociodemographic information; (2) self-rating via the compassion satisfaction (CS) subscale from the Professional Quality of Life scale (PROQOL-5)²⁵; and (3) open-ended questions on H4H workplace experiences with one dichotomous question about accessing resources.

The PROQOL-5 CS subscale is a 10-item measure that uses a 5-point frequency scale (1 = never to 5 = very often) to determine the degree to which individuals feel satisfied in being able to do their work well. Items are added for a total score^25,26 with a ‘high CS’ cut-off ≥42, ‘moderate CS’ cut-off ≥23, and ‘low CS’ cut-off ≤22. The CS subscale is publicly available and is a valid and reliable tool for use in hospice palliative care settings; the burnout and secondary trauma subscales from PROQOL were excluded due to concerns with their validity and reliability.^27,28

Open-ended questions were informed by narrative inquiry and asked people to reflect on their H4H experiences.²⁹ Respondents were invited to engage in metaphoric reflection and storytelling.^29,30 This included asking respondents to create a metaphor that represents their experience of work-related stressors.³⁰

Data Analysis

Survey responses were analyzed both descriptively and interpretively while considering levels of the socio-ecological model. Quantitative data were analyzed using descriptive statistics (eg, frequency, mean, standard deviation, t-tests) in SPSS. As is common practice in the use of the CS frequency scale, data were treated as continuous variables.^10,20 There was no missing CS subscale data. Open-ended questions were analyzed by looking for narrative threads (ie, patterns) within and across responses.³¹ Lead researcher (CC) treated the respondents’ metaphors, metaphor stories, and descriptions of work-related stress as a whole; grouping similar threads together across and between responses. Data about requested resources and stories of wellbeing were analyzed by creating common threads across responses. Thread groupings and names of threads were refined iteratively through discussion with the research team until they felt credible and resonant.³² While not initially planned, differences between staff and volunteers become apparent in the qualitative threads; sub-group analysis was then applied to survey data.³³

Results

A total of 58 surveys (response rate = 56%) were received with 50 respondents providing responses to the open-ended questions.

Survey respondents (n = 58) reflected the distribution of roles in the H4H organization. Table 1 displays respondent sociodemographic characteristics. There was diversity in age and race. Two-fifths had less than 1 year of experience (n = 22, 38%). There was low representation from men (n = 13, 22%), gender diverse people (less than n = 5), and people identifying as 2SLGBTQ+ (less than n = 5).

Table 1.

Summary of Respondent Socio-Demographic Characteristics

Individual-level variables	Total sample		H4H staff		H4H volunteers
Individual-level variables	n	Percent	n	Percent	n	Percent
H4H role
Nurse	12	21%	12	21%	-	-
Personal support workers	8	14%	8	14%	-	-
Other clinicians	^a	^a	^a	^a	-	-
Volunteer	30	52%	-	-	30	52%
Management and coordinators	^a	^a	^a	^a	-	-
Years of experience
Less than 1 year	22	38%	10	35%	12	41%
1 year	17	29%	12	41%	5	17%
Over 2 years	19	33%	7	24%	12	41%
Age
24 or younger	10	17%	2	7%	8	28%
25-34	18	31%	13	45%	5	17%
35-44	7	12%	5	17%	^a	^a
45-54	8	14%	5	17%	^a	^a
55 or older	15	26%	^a	^a	11	38%
Gender
Woman	44	76%	23	79%	21	72%
Man	13	22%	5	17%	8	28%
Other	^a	^a	^a	^a	0	0%
Prefer not to answer	0	0%	0	0%	0	0%
2SLGBTQ + identity
Yes	^a	^a	^a	^a	^a	^a
No	54	93%	26	90%	28	97%
Prefer not to answer	0	0%	0	0%	0	0%
Visible minority
Yes	21	36%	8	28%	13	45%
No	32	55%	19	66%	13	45%
Prefer not to answer	5	9%	^a	^a	^a	^a

^aPrimary suppression of cell sizes <5; other clinicians include but are not limited to spiritual care, art therapy, and medicine.

Compassion Satisfaction

H4H providers (n = 58) had an average PROQOL-5 compassion satisfaction (CS) subscale score of 45.1 (SD 5.0). No statistically significant differences were noted between staff and volunteer responses (P = .535). Volunteers on average scored 44.3 (SD 4.9), while staff scored 45.8 (SD 5.1). The majority of respondents (74%) scored above the ‘high compassion satisfaction’ cutoff (PROQOL-5 CS subscale >42). No respondents scored within the ‘low compassion satisfaction’ cutoff (PROQOL-5 CS subscale ≤22).

Metaphors of Stress at Work

Fifty respondents answered open-ended questions. When asked to create a metaphor to represent their overall personal experience of stress related to H4H work, some respondents wrote that they preferred not to answer (n = 12). However, most created a metaphor (n = 38). Through our analysis, metaphors were grouped by work-related stressors according to the socio-ecological model (n = 17), coping strategies (n = 6), and workplace wellbeing (n = 15), and narrative patterns and composite stories were created (see Table 2).

Table 2.

Metaphors and Composite Stories of Work-Related Stress, Coping, and Wellbeing in an H4H

Metaphor topic	Narrative pattern	Metaphors	Composite story
Societal stressors	Social inequity	Like a drop in a bucket	There are many people we are unable to help, and I wish we could serve/help more
Societal stressors	Social inequity	Look for the beauty and wisdom within this cloud, as it too, shall pass
Organizational stressors	Feeling unvalued (note: volunteers only)	Like a capable and willing person with hands that are often tied and a voice that is not heard	My thoughts and opinions no longer seem to matter. My sense of co-ownership is all but gone. I do not know if my services are wanted or not
	Feeling unvalued (note: volunteers only)	Your call is important to us. Please try again later
	Not able to help as much as desired due to policies (note: volunteers only)	Like a rope that pulls you in another direction when you intend on walking the other way	There is so much more I can offer with my skills and compassion but there are restrictions to what I can do in my role. Even though I have a lot of experience. I want my time and special role to be honored
		Not being able to do more-
		A full tool belt with locks on many of the tools so they can’t be used
	Organizational expectations that feel impossible to meet	A background extra in a film	Sometimes it feels there is a perception that I’m not doing enough or efficient enough and this makes me feel insecure and lowers my mood. Navigating role expectations keeps me in the background
	Organizational expectations that feel impossible to meet	A stick person, with wiry hair, alone in the office, and a coffee (black), with raised eyebrows surrounded by complaints, paper, chaos, and deadlines
Interpersonal stressors	Conflict around values	Rope in a game of tug o war	Competing priorities and approaches can lead to conflict deeply rooted in values about how this work should be done. When treated in a hurtful unpleasant way, it becomes challenging to motivate myself.
Interpersonal stressors	Conflict around values	I leave at the end of the day, tomorrow will be a new day
Personal stressors	A feeling that one could do better	in the bardos…	Hospice is a place of in between. I know the death of clients is inevitable. I sometimes wonder if I’m doing my best. I can’t always help people in meaningful ways. I feel uncertain in knowing how best to prepare
		One thought among many
		A large dark cloud that slowly creeps in above while I move frantically arranging things on the earth plane with minimal to no effect to the cloud rolling in
		Wanting to reach out but at times it feels like I am stuck behind a glass window
	Competing priorities disrupt presence (note: volunteers only)	A wildflower poking through a crack in the sidewalk	I bring joy, even if fleeting, to others but outside responsibilities can interfere with showing up and how present I can be
		A tardy workaholic
Coping in the workplace	Coping by compartmentalizing	A notebook that I close when I head home for the day. (Note: n = 2)	There are work stressors and challenges, but I compartmentalize it and avoid dwelling on it so that I can be in the best possible mindset when I provide care
	Coping by prioritizing care	A rollercoaster	When work is stressful (eg, too many tasks, something is going wrong), I keep fulfilling my role. Stress at work comes and goes, I stay calm and focused – I can’t let it change what I do or how I show up
	Coping by prioritizing care	Just keep swimming
	Coping by taking breaks (note: volunteer only)	Sunshine on a cloudy day!	This work has an emotional impact, and I’ve learned to take breaks to rejuvenate so I can continue to provide comfort for the patients
Workplace wellbeing	Wellbeing from making a difference	A “heart of gold”	Tasks of the role can be stressful but I make a difference in the lives of people with critical illnesses. I bring warmth, kindness, joy, and happiest on the hardest, saddest of days. It can feel beautiful. It is meaningful
		Sunshine on a cloudy day! (Note: n = 7)
		Kindness in an unkind world
		A gentle breeze and blanket of comfort
		Canoeing on a mildly turbulent but beautiful lake
	Wellbeing from learning and growing	A ray of sunshine	Every challenge at work and every patient I meet offers an opportunity to learn. Each day is an opportunity to help others and grow. This makes me feel strong
		You raise me up to more than I can be
		One Day at a Time!!
		Being stressed is like falling: being nervous but willing to push

Resources to Support Workplace Wellbeing

When asked if they accessed any formal or informal resources to support workplace wellbeing, 30 respondents answered “no”, explaining that they were “not interested” or “unaware of resources”. However, of these 30 respondents, five respondents (2 staff; 3 volunteers) said that they drew on personal resources (eg, exercise, prayer, meditation, music). Of the remaining respondents, four (3 staff; 1 volunteer) said they use formal resources (eg, virtual meditation sessions, spiritual counselling). Twelve respondents (6 staff; 6 volunteers) said they use informal resources (eg, peer support) and one preferred not to answer.

When asked which resources they would like to see more of in the workplace, 11 said “not applicable” or “prefer not to answer”, and 12 said that they were unsure or had no comment. A small group was satisfied with current resources (n = 7) (3 staff; 4 volunteers). Some (n = 20) made requests for additional resources (see Table 3) including 12 who did not use formal or informal resources at work.

Table 3.

Requested Resources to Support Workplace Wellbeing

Type of resource	Requested activities
Educational (n = 7) (4 volunteers; 3 staff)	Regular professional development to build team connections, training in mental health and addictions
Process-related (n = 7) (5 volunteers; 2 staff)	Formal team debriefs, clear roles (eg, time to help clients), regular volunteer meetings with coordinator, changes to onboarding for volunteers, meaningful consultations with leadership
Spiritual/Psychological (n = 6) (1 volunteer; 6 staff)	Meditation (eg, compassion training), mental health resources (eg, counselling, coping strategies)
Social (n = 6) (1 volunteer; 5 staff)	Fun activities that build staff connections, opportunities to connect with all team members

Conceptualizing H4H Workplace Wellbeing

To get a sense of what experiencing positive workplace wellbeing means to H4H providers, we asked them to describe a ‘day in the life’ of an H4H provider who is experiencing positive workplace wellbeing. While there were similarities in these stories (n = 34), the threads that constitute workplace wellbeing appear to be shaped by different role expectations (see Table 4).

Table 4.

Conceptualizing H4H Workplace Wellbeing

	Quality care	Supportive relationships	Personal fulfillment	Respectful culture
Staff workplace wellbeing	Providing quality care (eg, goal-based care)	Engaging in effective team collaboration (eg, clear reports, supportive)	Feeling a sense of accomplishment (eg, proud of the work)	Fostering a respectful workplace culture (eg, team rapport, no gossip)
Volunteers’ workplace wellbeing	Engaging in helpful care tasks (eg, cooking, sitting vigil)	Connecting with residents (eg, sitting with, watching tv with)	Being changed from experience (eg, learning from interactions)	Collaborating with a respectful team (eg, being appreciated)

Discussion

Summary of Findings

Most respondents had high CS and, notably, two-fifths had started H4H work within the last year. Respondents’ storied metaphors span the socio-ecological model, depicting seven factors causing them stress. Volunteers shared unique stressors (eg, feeling undervalued) which may require specific support. While most respondents indicated they do not access resources to support workplace wellbeing, requests for additional resources were made. Respondents conceptualized workplace wellbeing as involving quality care, supportive relationships, personal fulfillment, and respectful culture.

Key Interpretations

Responses on the PROQOL-5 CS subscale were positively skewed and indicated high CS in this population. In other research, hospice care workers in the USA had lower mean CS scores of 40.5²⁰ and 41.07.¹⁰ Previous research demonstrates that CS scores are positively correlated with mindful meditation, self-reflection, play, and rest.^10,20 Some survey respondents reported using meditation, prayer, exercise, music, and spiritual counselling to support their workplace wellbeing. This offers a potential explanation. However, the highly skewed data may also indicate a ceiling effect or a social desirability bias. Future research can examine other scales that measure protective factors against burnout.

The metaphors of work-related stress are similar to other hospice research that attributes provider burnout to organizational factors, such as high workload and prolonged work hours^10,34; interpersonal factors such as disagreement with colleagues over treatment plans; and individual factors such as feeling ineffective in treating patients’ symptoms.³⁴ Likewise, other hospice volunteers also experience stress from not feeling appreciated, conflict with colleagues, and feeling limited by role restrictions.^35,36 Unique to this group of H4H providers, societal inequity was identified as a factor causing stress, which reflects the complex H4H context. While not reflected in hospice literature, our findings share similarities with research on social workers’ and shelter providers’ burnout which is shaped by societal inequities such as reduced resources and clients’ oppression.^13,37 Societal inequities will need to be considered within solutions to mitigate burnout in future work.

Two-fifths of respondents started providing H4H care within the last year. CS is positively correlated with job satisfaction and employee retention¹⁰ and negatively correlated with burnout.¹⁰ Having a workforce that is new to the work and feels effective in their abilities offers an opportunity to develop innovative ways to sustain this feeling of effectiveness. However, over half of the survey respondents said that they do not access any formal or informal resources to support workplace wellbeing. Of the respondents who do, about equal numbers of volunteers and staff use informal resources (eg, peer support) with more staff than volunteers accessing formal resources (eg, virtual meditation sessions, spiritual counselling), which may be related to more time spent at the hospice. To address low engagement with resources yet a desire by many for more, future work could plan for ways to integrate tailored resources into the work flow to increase access and uptake.³⁸ Knowing that burnout develops over time, supporting orienting H4H providers may be especially crucial. This echoes the respondents’ suggestions for enhancing orientation, role clarity, training, and volunteering processes.

Potential indicators that may help sustain workforce capacity are found in respondents’ conceptualization of workplace wellbeing. Most of the concepts align with psychological health and safety in the workplace.³⁹ Both staff and volunteers discussed wellbeing as tied to providing quality care, personal fulfillment, and a respectful culture. Having supportive relationships was also important; staff focused on supporting colleagues, whereas volunteers focused on supporting clients. Other research has found that the wellbeing of hospice providers is linked to the intrinsic emotional rewards of the work^10,36 and having a sense of accomplishment.^5,36 Integrating and enhancing these aspects of wellbeing into future strategies will be important.

The requested workplace resources differ slightly by role, with volunteers requesting more process-related support and staff requesting more spiritual/psychological and social support. Overall, the requests align with research on protective measures against burnout. Process-related resources,^10,18,34 team education,³⁴ and supportive relationships^10,34 can mitigate burnout. Spiritual and psychological resources such as meditation can help manage stress,^7,12 are negatively correlated with burnout,²⁰ and are already being accessed for support by some providers indicating some acceptability.

In developing resources to mitigate occupational stress, personal coping strategies and developing supportive relationships have been found to be particularly important.¹⁰ Given the identified stressors, requested resources, and the conceptualizations of wellbeing, mindfulness-based interventions appear promising as a protective measure in the hospice context. Mindfulness-based interventions have been effective for enhancing personal coping, and addressing personal-level factors such as feeling inadequate and juggling multiple priorities in hospice palliative care providers.⁸ There is also evidence to suggest these practices can address organizational factors by strengthening respectful team relationships, and improving team communication in hospice settings.^7,8 Furthermore, critical for this context, mindfulness training has lowered levels of secondary traumatic stress¹⁰ and helped providers develop anti-oppressive practice to target systemic level stressors.⁴⁰ We recommend future work take a multifaceted approach to providing and integrating resources that support wellbeing in the H4H context, which can include mindfulness-based interventions in addition to education, team building, recognition, and other organizational processes.

Strengths and Limitations

Our survey is among the few hospice studies to include volunteers, who are often excluded despite playing a critical role in care delivery.³⁶ Methodologically, eliciting metaphors³¹ within a survey was, to our knowledge, novel. Over half of respondents created a metaphor, indicating that metaphors are a feasible way to engage experts-by-experience within surveys.

This survey was conducted in a single organization, limiting the sample pool and potential for representation of the perspectives of men, gender diverse people, and people who identify as 2SLGBTQ+. Future work will involve multiple H4H organizations to boost diversity and total sample size which would support more complex analytics to explore the impact of intersectionality on CS.

Conclusion

The wellbeing of these H4H providers appears to be tied to their ability to be of service to clients, develop supportive relationships, experience personal fulfillment, and belong to a respectful culture. Chronic multi-level work-related stressors that erode the sense of meaning about why one is engaged in the work they do is linked to burnout.¹⁷ We recommend future work take a multifaceted approach to supporting workplace wellbeing. One approach could include enhancing orientation with a focus on role clarity, training, and volunteering processes. Another approach could implement group-focused interventions, such as recognition of work and mindfulness-based practices to increase personal coping, strengthen team connections, and promote anti-oppressive practices to address systemic stressors. To our knowledge no mindfulness-based interventions have been tailored to the unique H4H context, creating an opportunity for future research in this area.

Supplemental Material

Supplemental Material - Examining Compassion Satisfaction and Work-Related Stress Within a Hospice for the Homeless (H4H) Organization: Results From a Multi-Method Survey

Supplemental Material for Examining Compassion Satisfaction and Work-Related Stress Within a Hospice for the Homeless (H4H) Organization: Results From a Multi-Method Survey by Celina Carter, Mary Anne Olalia, and Justine Giosa in American Journal of Hospice and Palliative Medicine®

Footnotes

Author Note

All authors have read and agreed to the published version of the manuscript.

ORCID iDs

Celina Carter

Mary Anne Olalia

Ethical Considerations

Ethics was approved and obtained through the Research Ethics Board at Southlake Health (SRHC # S-004-2425).

Consent to Participate

Our research team emailed potential survey respondents a recruitment letter containing a study summary, consent information, and a link to the secure online survey that included radio button consent.

Author Contributions

Authors (CC and JG) made substantial contributions to the concept, design, analysis, interpretation, and writing of the work. (MAO) made substantial contributions to the data collection, analysis, and interpretation. All authors critically reviewed the work, approved the final version to be published and agreed to be accountable for all aspects of the work.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by SE Health and the Saint Elizabeth Foundation.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Data will be made available upon reasonable request.*

Supplemental Material

Supplemental material for this article is available online.

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