Analyzing innovative policies and practices for palliative care in Portugal: a qualitative study.

BACKGROUND: Countries with formal policies for palliative care, and advanced and integrated practices in this field, such as Portugal, face challenges in achieving excellence in care, particularly in home-based assistance. Issues include care coordination among providers, confusion regarding the roles of each health care professional in the network, and a lack of monitoring and evaluation of actions. Our objective was to analyze the implementation of palliative care in primary health care in Portugal. METHODS: We conducted a qualitative, descriptive, and exploratory study in Portugal involving health care professionals with experience in palliative care. The data were collected through semistructured interviews and focus groups between March and October 2023. Eighteen health care professionals participated. We used the Alceste software for lexicographic analysis. The research was authorized by an Ethics Committee. RESULTS: Four classes were identified; classes 1 and 2, comprising 77% of the corpus, addressed the study objectives. Participants highlighted inequitable access, strategic development plans with unattainable short-term goals; and low literacy. They emphasized the importance of legislation, professional training initiatives for generalist palliative care at home, and early referral. Home-based challenges included professionals' lack of exclusive dedication, absence of 24/7 coverage, and unavailability of capable family caregivers. The networks' response to hospital admissions and patient transitions from hospital to home, with access to the specialized team, was also inadequate. CONCLUSIONS: Health care professionals aim to increase patients' time spent at home, reduce emergency department visits, and minimize hospitalizations by leveraging the resources of the national palliative care network. In addition to investments to sustain network implementation and legally guaranteed palliative care rights, the country must focus on measurable indicators for evaluating and monitoring actions, providing better guidance in the short, medium, and long term.

Improved professional competencies and leadership in PhD-prepared nurses and doctoral students after participating in the cross-national and web-based Nurse-Lead program.

BACKGROUND: Doctor of Philosophy (PhD)-prepared nurses are expected to exercise leadership in their various roles. Therefore, European nurse scholars developed a cross-national web-based Nursing Leadership and Mentoring Educational (Nurse-Lead) program. PURPOSE: To evaluate changes in leadership practices, professional and research competencies as well as career development of PhD-prepared nurses and doctoral nursing students after participation in the Nurse-Lead program. METHODS: A pre-post-test evaluation was conducted. Surveys addressed leadership, professional and research competencies, and career development. Quantitative data were analyzed with descriptive statistics and paired sample t-tests. Content analysis was used for qualitative data. DISCUSSION: The 30 participants showed significant improvements in all leadership practices, professional competencies, and most research competencies. Participants reported increased confidence in decision-making, taking on new responsibilities, and becoming more visible within research teams. CONCLUSION: Web-based, international leadership and mentoring programs are promising tools for the leadership and professional development of PhD-prepared nurses and doctoral nursing students.

Translation, Cultural Adaptation, and Psychometric Validation of the European Portuguese Version of the Iceland-Expressive Family Functioning Questionnaire (ICE-EFFQ).

A family's experience of mental illness can change the family's functioning. In clinical contexts, valid and reliable instruments that assess family functioning, therapeutic changes, and the effects of family nursing interventions are needed. This study focuses on the linguistic and cultural adaptation of the Iceland-Expressive Family Functioning Questionnaire (ICE-EFFQ) to European Portuguese and examines the psychometric properties of this instrument. A non-random sample of 121 Portuguese depressed patients and their relatives completed the questionnaire. Principal components analysis extracted 4 factors, explaining 55.58% of the total variance. Confirmatory factor analysis revealed acceptable adjustment quality indices. Cronbach's alpha coefficient was adequate for the global scale α = .86 and for the 4 subscales: communication α = .79, expression of emotions α = .68, problem-solving α = .71, and cooperation α = .61. The Portuguese version of ICE-EFFQ is a sensitive, valid, and reliable instrument for use with Portuguese families with adult members with depression and can be valuable in assessing these families' expressive functioning, before and after intervention.

Learning from the covid-19 outbreaks in long-term care facilities: a systematic review.

BACKGROUND: The COVID-19 pandemic has devastatingly affected Long-Term Care Facilities (LTCF), exposing aging people, staff members, and visitors. The world has learned through the pandemic and lessons can be taken to adopt effective measures to deal with COVID-19 outbreaks in LTCF. We aimed to systematically review the available evidence on the effect of measures to minimize the risk of transmission of COVID-19 in LTCs during outbreaks since 2021. METHODS: The search method was guided by the preferred reporting items for systematic reviews (PRISMA) and the reporting guideline synthesis without meta-analysis (SWiM) in systematic reviews. The search was performed in April 2023. Observational and interventional studies from the databases of PubMed, Web of Science, Scopus, Cochrane Systematic Reviews, CINAHL, and Academic Search were systematically reviewed. We included studies conducted in the LTCF with outbreaks that quantitatively assess the effect of non-pharmacological measures on cases of COVID-19. Two review authors independently reviewed titles for inclusion, extracted data, and undertook the risk of bias according to pre-specified criteria. The quality of studies was analyzed using the Joanna Briggs Institute Critical Appraisal. RESULTS: Thirteen studies were included, with 8442 LTCF experiencing COVID-19 outbreaks and 598 thousand participants (residents and staff members). Prevention and control of COVID-19 infection interventions were grouped into three themes: strategic, tactical, and operational measures. The strategic measures reveal the importance of COVID-19 prevention and control as LTCF structural characteristics, namely the LTCF size, new admissions, infection control surveillance, and architectural structure. At the tactical level, the lack of personal and long staff shifts is related to COVID-19's spread. Operational measures with a favorable effect on preventing COVID-19 transmission are sufficient. Personal protective equipment stock, correct mask use, signaling, social distancing, and resident cohorting. CONCLUSIONS: Operational, tactical, and strategic approaches may have a favorable effect on preventing the spread of COVID-19 in LTCFs experiencing outbreaks. Given the heterogeneous nature of the measures, performing a meta-analysis was not possible. Future research should use more robust study designs to explore similar infection control measures in LTCFs during endemic situations with comparable outbreaks. TRIAL REGISTRATION: The protocol of this systematic review was registered in PROSPERO (CRD42020214566).

The effectiveness of nursing interventions in adherence to self-care for preventing venous ulcer recurrence: A systematic literature review.

Venous ulcers affect up to 3% of the global population, with a high impact on economies and quality of life. This is exacerbated by its recurrence rates, which reach 70% at 12 months after healing. The perpetuation of these cycles of healing and recurrence is not interrupted or even attenuated by the self-care activities recommended and directed toward their prevention. In this context, we sought to identify the effectiveness of interventions that promote adherence to self-care to prevent venous ulcer recurrence. In August 2022, we conducted a literature search via EBSCO in the following databases: CINAHL Complete, MEDLINE Complete, Cochrane Database of Systematic Reviews, Scopus, and Web of Science. The inclusion criteria were researched in the form of randomised controlled trials or systematic literature reviews, and 99 studies were identified. During the different times of selection, four studies met the defined inclusion criteria and were included. As the main conclusions, the emphasis goes to the importance of the use of compression and the greater effectiveness of higher compression classes for the prevention of recurrence. Different educational methodologies seem to be important to increase knowledge about prevention, specifically regarding the aetiology of recurrence and the implementation of prevention measures.

Clinical learning environment and graduating nursing students' competence: A multi-country cross-sectional study.

The purpose of this study was to explore nursing students' perceptions of their final clinical learning environment and its association with their self-assessed competence, satisfaction with nursing education, and turnover intentions at graduation in six European countries. A multi-country comparative cross-sectional study was conducted with nursing students (n = 1746) from the Czech Republic, Finland, Italy, Portugal, Slovakia, and Spain using the Nurse Competence Scale and the Clinical Learning Environment and Supervision scale. Nursing students' overall perceptions of their final clinical learning environment and supervision were positive in all the countries studied. The correlation between the students' perceptions of their final clinical learning environment and competence was statistically significant and positive. Satisfaction with the nursing program and clinical practicum and no consideration of career change were related to positive perceptions of the final clinical learning environment. Highlighting the importance of the supervisory relationship and pedagogical atmosphere, nursing students' positive perceptions of the final clinical learning environment and supervision contribute to a better level of self-assessed competence and satisfaction with the nursing program and clinical practicum, leading to lower turnover intentions.

"Falls prevention among older people and care providers: protocol for an integrative review".

AIM: To review the evidence about the role of care providers in fall prevention in older adults aged ≥ 65 years, this includes their views, strategies, and approaches on falls prevention and effectiveness of nursing interventions. BACKGROUND: Some fall prevention programmes are successfully implemented and led by nurses and it is acknowledged the vital role they play in developing plans for fall prevention. Nevertheless, there has not been a systematic review of the literature that describes this role and care providers' views on fall's prevention initiatives. DESIGN: A convergent synthesis of qualitative, quantitative, and mixed methods studies. The eligibility criteria will be based on participants, interventions/exposure, comparisons, and outcomes for quantitative studies and on population, the phenomena of interest and the context, for qualitative studies. To extract data and assess study qualities members of the research team will work in pairs according to their expertise. The review will follow the guidelines for integrative reviews and the proposed methods will adhere to the PRISMA statement checklist complemented by the ENTREQ framework. As qualitative synthesis are emergent, all procedures and changes in procedure will be documented. DISCUSSION: The review has a constructivist drive as studies that combine methods ought to be paradigmatic driven. Review questions are broad to allow issues emerge and have purposefully left the design flexible to allow for adjustments as the review progresses. The review seeks to highlight the roles that care providers play in fall prevention and their views on fall's prevention initiatives.

A qualitative study of older adults: The difficulties and needs of returning home after hip fractures.

BACKGROUND: Falls and consequent fractures are an increasing problem among older adults, with low rates of return to previous functional condition and a substantial risk of subsequent falls. This scenario points to the need for an improved response to this population's needs. OBJECTIVE: To define the difficulties and needs felt by older adults with hip fractures when returning home. METHODS: This was a descriptive and exploratory qualitative study. Semi-structured interviews were conducted with hip fracture patients who had been submitted to surgery and who were treated at a hospital in the central region of Portugal. Bardin's content analysis was used to analyze the data. Content analysis was carried out with the support of MAXQDA® Analytic pro 2022 software. RESULTS: The analysis of the results of the 15 interviews yielded three categories related to the difficulties perceived by hip fracture patients on returning home: functional limitations; pain; and emotional management. Regarding the needs felt, the following categories emerged: resources/help with activities of daily living; capacity-building for the return home; and information. CONCLUSIONS: The needs and difficulties of older adults with hip fractures on returning home are multiple and variable. Knowledge of these aspects can significantly enhance the standardized actions of nurses in this area of intervention, contributing to the improvement of continuity of care and ensuring a safe transition.

Safety-promoting interventions for the older person with hip fracture on returning home: A systematic review.

BACKGROUND: Older adults with a prior history of falls that results in hip fractures have difficulties in regaining pre-fracture functional capacity. Scientific evidence has shown benefits of the implementation of multidimensional rehabilitation programs, but this evidence is not systematized with regard to continuity of care after hospital discharge. OBJECTIVE: To identify interventions that promote safety and functional recovery of older adults with hip fractures after hospital discharge. METHOD: A systematic review was carried out according to Cochrane methodology. The research strategy was predefined for the MEDLINE and CINAHL databases. The identified articles were screened according to the eligibility criteria by two independent reviewers. The articles included in the bibliographic sample were evaluated for risk of bias. RESULTS: Of the 10,036 articles found, 10 were included in this systematic review. The safety-promoting interventions identified were: exercise training, occupational therapy/activities of daily living training, transfer and gait training, strengthening exercises, education on assistive device use, fall prevention education, nutritional assessment, environmental modifications/adjustments at home, use of an app, medication, self-care education, and support and counseling. CONCLUSIONS: In eight studies analyzed, exercise training emerged as the most effective intervention for promoting the safety of older adults after hip fractures on returning home. Three studies associated two or more interventions, which focused on exercise training, occupational therapy/training of activities of daily living, and conventional postoperative rehabilitation with transfer and gait training, strengthening exercises, education on assistive device use and discharge planning, aiming to achieve muscle strengthening and safe gait, associated with the performance of activities of daily living.

Person-centred care intervention to promote self-efficacy in patients following a myocardial infarction (P2MIR): a protocol of a qualitative study for cultural adaptation within a Portuguese healthcare context.

INTRODUCTION: Cardiovascular diseases remain a leading cause of death worldwide. Recovery from myocardial infarction is challenging as the causes of symptoms span multiple aspects of health not just physical conditions. Evidence has shown a gap between the waycare is provided in the clinical setting and the person's needs and preferences. The implementation of person-centred care (PCC) interventions can promote recovery from myocardial infarction by allowing a greater understanding of the person's perception and its role on the overall recovering process. This study aims to culturally adapt an evidence-based PCC intervention to enhance self-efficacy in patients after myocardial infarction within a Portuguese healthcare context. METHODS AND ANALYSIS: The Portuguese person-centred care for myocardial infarction recovery (P2MIR) intervention is set to be developed from an evidence-based intervention, rooted in the ethics of PCC. An intervention of PCC for patients with acute coronary syndrome, which has been successfully implemented and evaluated in the Swedish healthcare context will be validated, culturally adapted and harmonised to the Portuguese healthcare context by using qualitative methods. To evaluate its acceptability, appropriateness and feasibility, a sample of stakeholders, consisting of a sample of healthcare professionals and a sample of people who suffered a myocardial infarction, will be recruited from a hospital, including both inpatient and outpatient departments. The stakeholders will be invited to semistructured focus group discussions, aiming to gather their perceptions about the P2MIR intervention, which will be previously presented to them. Data analysis will be conducted using content analysis following a deductive-inductive approach to further inform the intervention adaptation process to its final intervention in a Portuguese healthcare context. ETHICS AND DISSEMINATION: The study has been reviewed and approved by the Health Ethics' Committees of the Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (registry number 20170700050). The results will be disseminated through peer-reviewed journals and conference presentations.

The Effect of Interventions on Preventing Musculoskeletal Injuries Related to Nurses Work: Systematic Review.

BACKGROUND: The 12-month prevalence of musculoskeletal disorders related to work (MDRW) in nurses rests between 71.8% to 84%, so it is urgent to develop preventive intervention programs with the purpose of avoiding negative physical, psychological, socioeconomic, and working aspects. There are several intervention programs aimed at preventing musculoskeletal disorders related to work for nurses, but few have successfully proven results. Despite the evidence pointing to the benefits of multidimensional intervention programs, it is essential to determine which interventions have positive effects on the prevention of this kind of disorder to create an effective intervention plan. AIM: This review intends to identify the different interventions adopted in the prevention of musculoskeletal disorders related to work in nurses and to compare the effectiveness of these interventions, providing the appropriate and scientific basis for building an intervention to prevent musculoskeletal disorders in nurses. METHOD: This Systematic Review was guided by the research question, "What are the effects of musculoskeletal disorders preventive interventions on nursing practice?" and carried out in different databases (MEDLINE, CINAHL, and Cochrane Central Register of Controlled Trials, SCOPUS, and Science Direct). Later, the results were submitted to the eligibility criteria, the appraisal quality of the papers, and the data synthesis was performed. RESULTS: 13 articles were identified for analysis. The interventions implemented to control the risk were: training patient-handling devices; ergonomics education; involving the management chain; handling protocol/algorithms; acquiring ergonomics equipment; and no-manual lifting. CONCLUSIONS: The studies associated two or more interventions, the majority of which (11 studies) were training-handling devices and ergonomics education, therefore emerging as the most effective instruments in the prevention of MDRW. The studies did not associate interventions that cover all risk factors (individual, associated with the nature of the work, organizational, and psychological aspects). This systematic review can help with making recommendations for other studies that should associate organizational measures and prevention policies with physical exercise and other measures aimed at individual and psychosocial risk factors.

The Organization of Home Palliative Cancer Care by Primary Health Care: A Systematic Review Protocol.

Greater longevity and chronic diseases, such as cancer, require (re)organization of care for the sustainability of health systems and better quality of life. Palliative care organized by primary health care has positive outcomes, changing standards of care at the end of life, reducing hospitalizations and health costs and contributing to people's autonomy to stay at home with controlled symptoms. However, in many countries, this is not possible because the provision of palliative cancer care is isolated or generalized, concentrated in the hospital, and without the strategic participation of primary care. In many developed countries, where palliative care is offered in an integrated way, home care has increased the people's chances of receiving dignified care at the end of life. The aim of this review is to evaluate the organization of home palliative cancer care by primary care to improve the use of health resources and the quality of life of such patients. This systematic review protocol follows the Cochrane methodology to provide a narrative synthesis, with the resulting report guided by the Preferred Reporting Items for Systematic Reviews (PRISMA).

Telerehabilitation Intervention in Transitional Care for People with COVID-19: Pre-Post Study with a Non-Equivalent Control Group.

SARS-CoV-2 infection and its resulting sequelae have increased the prevalence of people with respiratory symptoms, with impacts on functional capacity, quality of life, anxiety, depression, and mental health. To mitigate this problem, one challenge has been the design and implementation of interventions that simultaneously allow for education, rehabilitation, and monitoring of people with long COVID, at a time when health services were on the verge of rupture due to the volume of people with active COVID and in need of intensive care. Telerehabilitation emerged as a mode for providing rehabilitative care that brought professionals closer to patients and enabled continuity of care. The present study aimed to evaluate the results of a telerehabilitation intervention for people with injuries associated with SARS-CoV-2 infection in hospital-community transitions, considering their degree of dependence in performing activities of daily living, respiratory symptoms, fatigue, gait capacity, muscle strength, and experience with anxiety and depression. A pre-post study with a non-equivalent control group was carried out with a total of 49 participants (intervention group n = 24; control group n = 25). The post-intervention results showed an increase in saturation, a decrease in heart rate, an improvement in the impact of post-COVID functionality, a decrease in fatigue, a decrease in perceived effort, and a decrease in depressive and anxiety symptoms. The telerehabilitation intervention, which combined educational strategies with respiratory and motor rehabilitation, helped improve global functionality and self-care, with clinical and functional impacts.

Falls and Preventive Practices among Institutionalized Older People.

The present study about falls among the older adult population essentially explores bio-physiological factors. In light of the complexity of the factors that cause these accidents, it is important to identify the safety and self-care practices of institutionalized older adults and their relationship with falls in order to introduce prevention measures and personalized cognitive-behavioral strategies. The objective of this study was to: (a) determine the frequency of falls and their recurrence among institutionalized older adults, and (b) to associate the occurrence of falls among institutionalized adults with or without cognitive impairment to communication and safety practices. This was a quantitative, correlational, and longitudinal study with 204 institutionalized older adults living in two long-term care facilities in Portugal. The Scale of Practices and Behaviors for Institutionalized Elderly to Prevent Falls was administered to the sample. The prevalence of falls at a 12-month follow-up was 41.6%, of which 38.3% were recurring episodes. Older adults with cognitive decline showed lower mean scores for safety practices. Further research with larger samples should explore the relationships between communication and safety practices and falls, their recurrence, and fear of new falls.

Ageing and Long-Term Informal Care: The Reality of Two Countries in Europe: Denmark and Portugal.

The knowledge of long-term informal care is particularly interesting for social and health measures related to ageing. This study aims to analyze how Portugal differs from Denmark regarding long-term informal care, specifically referring to personal care received by older people. A cross-sectional study was developed in Portugal and Denmark through the Survey of Health, Ageing and Retirement in Europe (SHARE) in 2015, with a total of 2891 participants. Descriptive statistics and logistic regressions were performed. The findings suggest a significant association for older people from Portugal who receive long-term informal care from non-household caregivers and household caregivers. Moreover, as they age and are from Portugal, their availability to receive long-term informal care from non-household caregivers increases. Furthermore, older people in Portugal are more likely to receive long-term informal care from a household caregiver. It is important to take a closer look at long-term informal care in both countries and think about healthy ageing policies in the current context of the ageing population. This study provides knowledge about disaggregated health data on ageing in the European region, helping to fill research gaps related to older people.

Needs of older persons undergoing cardiac surgery: Exploring the perceptions of nurses, patients waiting for and patients having had surgery.

AIMS: The purpose of this research was to identify the needs of older persons waiting for elective open-heart surgery. DESIGN: A qualitative exploratory design methodology, using Focus Groups. METHODS: A purposive sampling technique was used. Three interviews were conducted with experienced nurses, individuals waiting for open-heart surgery (≥65years) and individuals having had open-heart surgery (≥65years); enrolling up to 17 participants from October 2019 to January 2020. Qualitative data analysis was conducted using the iteractive model and MaxQDA® software, and EQUATOR COREQ guidelines were followed. RESULTS: Three themes were identified from the analysis of all three Focus Groups: (i) Needing health information; (ii) Needing emotional support; and (iii) Needing access to care.

Informal Caregivers' Health Literacy in Lisbon, Portugal: A Profile for Health Promotion Prioritization.

Health literacy (HL) allows people to access, understand and evaluate health information. Informal caregivers' levels of HL may impact long-term care outcomes. 'Informal caregivers' profile in Lisbon county: a health community approach' is a nurse-led research project aiming to assess informal caregivers' health literacy and associated factors in Lisbon county, as well as to foster the development of a local-specific health literacy strategy. A survey to identify a health/social caregiver profile, including questions about HL (HLS-EU-PT), was submitted to a representative sample of carers. Descriptive and bivariate inferential analysis was developed. Informal caregivers' level of HL was mostly sufficient (n = 99, 38%). More than 60% of caregivers have limited HL regarding health promotion. 'Access', 'Appraisal' and 'Use' are the information processing stages with lower mean scores of HL. Carers with low HL levels appear to be older and to have less education, low knowledge of community resources and decreased wellbeing (p < 0.05). A strategy focused on health promotion-related HL through primary care resources can potentially improve caregivers' knowledge, competencies and motivation, as well as health system sustainability. Reported HLS-EU-PT scores deserve special attention. Future work should emphasize the role of HL-associated factors and health outcomes for caregivers and cared-for persons.

Does Reality Overcome the Expected? Survey on Informal Caregivers' Profile: A Nurse-Led Study in Times of COVID-19.

The increasing overload of chronic conditions raises challenges for the health system. Informal caregivers have a major role in ensuring the quality of life of the cared-for person, despite the reported lack of working resources which can lead to unmet needs. This article reports on the first part of a nurse-led research project entitled ''Informal caregiver' profiles in Lisbon county: a health community approach.' We aimed to support decision-making by developing an informal caregiver profile to promote tailored interventions. A survey addressing the dyad was developed and submitted to a convenient, network-based, stratified sample of carers aged 18 years or above. More than thirty community partners supported the identification of caregivers. Data were submitted to univariate descriptive analysis. A profile of the cared-for person and the informal caregiver was uncovered by identifying 639 caregivers, of whom the majority lived with the cared-for person. Only four percent planned the transition to a caregiver role, and no more than 10% had access to support programs. Approximately half of the respondents found that COVID-19 negatively impacted their performance in the caregiver role. Developing a local and tailored strategy with collaboration between healthcare professionals, academics, and community partners is key to ensuring that meaningful support is provided to caregivers.

Telerehabilitation in the Transitional Care of Patients with Sequelae Associated with COVID-19: Perception of Portuguese Nurses.

The COVID-19 pandemic brought many changes and challenges to health professionals, due to a lack of knowledge when dealing with the disease, fear of contagion, and the sequelae that characterize long COVID. To deal with this situation, respiratory rehabilitation programs are recommended in face-to-face and/or telerehabilitation modalities. (1) Background: This study had as its primary aim identifying the aspects/components to be considered in the planning and implementation of telerehabilitation interventions that guarantee transitional care for people with long COVID-19 after hospitalization and as a secondary aim identifying the positive aspects of telerehabilitation. (2) Methods: The method used to answer the research question was a focus group, carried out online with eight nurses specialized in rehabilitation nursing. The answers to the semi-structured interview were subjected to content analysis, and qualitative data analysis software (WebQDA®) was used to organize and analyze the findings. (3) Results: Four categories emerged from the content analysis: coordination between care levels; transitional care telerehabilitation intervention; advantages of telerehabilitation; and opportunities. (4) Conclusions: These findings make an important contribution to the reorganization of transitional care, allowing the identification of central aspects to be considered in the planning and implementation of telerehabilitation programs for people with long COVID.

The perspective of community health nursing in primary health care in Portugal. / A perspectiva da enfermagem comunitária na atenção básica em Portugal.

Portugal, in 2005, initiated to reconfigure its health centers, an action referred to as the reform of primary health care, with the objective to improve accessibility, efficiency, quality and the continuity of care, and increase the satisfaction of the population and the professionals. The health center groups were reorganized and new types of units were created. Also, at the same time, the health care continuity process and the national network for integrated continuous care were developed. The nursing interventions in the care provided to individuals, families, groups and communities, in the current reform, are essential for success. The first reports still indicate a few inefficiencies that the current reform proposed to systematically improve, affecting the quality of good practices, users' well being, and workers' satisfaction.