Impact of Covid-19 on lung cancer and Mesothelioma specialist nurses: A survey of experiences and perceptions

Impact of Covid-19 on lung cancer and Mesothelioma specialist nurses: A survey of experiences and perceptions

The covid-19 global pandemic has impacted on nurses who have rapidly adapted to new ways of working, and experienced negative impacts due to over-stretched services. Two surveys captured the experiences of lung cancer and mesothelioma specialist nurses in the United Kingdom (UK) in 2020, but the impact of later stages of the pandemic was unknown. This study aimed to explore the impact of covid-19 on lung Cancer and mesothelioma nurses since January 2021, the second wave of the pandemic.

An online cross-sectional survey with both open and closed questions explored the impact of covid-19 on ways of working and workload, quality of care, and health and wellbeing. The survey was open to UK based lung cancer and mesothelioma advanced or specialist nurses.

85 nurses responded to the survey. The majority were Clinical Nurse Specialists, based in England. Respondents reported changes in ways of working due to redeployment, staff shortages, and home working. Widespread adoption of virtual working practices led to concerns of negative impacts. Perceived excessive workload impacted on care with two-thirds of the sample (57, 67%) reporting they had been unable to provide the same quality of care to patients. Impacts on nurses’ health and wellbeing were reported with two-thirds of the sample (56, 66%) reporting a deterioration in emotional wellbeing and mental health. Coping mechanisms employed included online team support to share experiences and increased uptake of exercise; however, impacts on lifestyle and access to coping mechanisms varied.

Nurses have stepped up to the challenges of the pandemic with teamwork and innovation, but pressure arising from the pandemic and high workloads led to negative impacts on wellbeing. The authors have provided recommendations to improve patient care and support the wellbeing of nurses, which will be key to a resilient workforce living with covid-19. Whilst this study focussed on lung cancer and mesothelioma specialists, the findings have wider implications for other cancer specialties.

What impact has Covid-19 had on cancer services? We look at changes in activity in cancer services during the Covid-19 pandemic, Nuffield Trust Blog.

Experiences of nurses caring for respiratory patients during the first wave of the COVID-19 pandemic: an online survey study.

COVID-19 and the multidisciplinary care of patients with lung cancer: an evidence-based review and commentary.

Experiences of nurses caring for respiratory patients during the first wave of the COVID-19 pandemic: an online survey study.

NHS cancer programme: quarterly report overview Q4 2020/2021: january to March 2021 and Q1 2021/2022: april to june 2021. Available at.

In March 2020 a global coronavirus (Covid-19) pandemic was declared by the World Health Organisation () placing healthcare systems under great pressure. Whilst UK health services aimed to maintain cancer treatments during the pandemic () there was widespread disruption. It is estimated that 40,000 fewer patients than expected started cancer treatment in the UK in 2020 (), and 50,000 fewer people were diagnosed with cancer (). By 2021 this backlog led to increased urgent cancer referrals; growing waiting lists for diagnostic tests; delays in cancer treatments (; Nicola J. ); and limited access to clinical trials (; Nicola J. ). New planning guidance was initiated in March 2021 to enable cancer services to recover from the impact of Covid-19 ().

Covid-19 matters. A review of the impact of covid-19 on the lung cancer pathway and opportunities for innovation emerging from the health system response to the pandemic.

Covid-19 matters. A review of the impact of covid-19 on the lung cancer pathway and opportunities for innovation emerging from the health system response to the pandemic.

Promoting early diagnosis and recovering from the COVID-19 pandemic in lung cancer through public awareness campaigns: learning from patient and public insight work.

Covid-19 matters. A review of the impact of covid-19 on the lung cancer pathway and opportunities for innovation emerging from the health system response to the pandemic.

Promoting early diagnosis and recovering from the COVID-19 pandemic in lung cancer through public awareness campaigns: learning from patient and public insight work.

NHS cancer programme: quarterly report overview Q4 2020/2021: january to March 2021 and Q1 2021/2022: april to june 2021. Available at.

Patients living with undiagnosed lung cancers experienced disproportionate impacts due to factors including the similarity of presenting symptoms with those of covid-19, and patients missed out on timely diagnosis (). Delayed presentation and reduced access to treatments led to increased mortality from lung cancer (). Initiatives to address this included restoring targeted lung health checks, and a public health campaign to raise awareness of symptoms and prompt help seeking ().

Qualitative study of UK health professionals' experiences of working at the point of care during the COVID-19 pandemic.

The mental health impact of the covid-19 pandemic on healthcare workers, and interventions to help them: a rapid systematic review.

A rapid review of the impact of COVID-19 on the mental health of healthcare workers: implications for supporting psychological well-being.

A growing body of literature captures the impact of the pandemic on nurses working across a range of specialities. Nurses have been at the forefront of healthcare: caring for patients, organising or adapting to new workplace practices (). This required rapid adoption of new ways of working to protect patients within the care settings, and new virtual ways of working/innovations (). Nurses were adaptable, undertaking multiple roles to support patients and families (). Negative mental health effects arose from fears about Covid-19 (), workplace stress (), and witnessing negative impacts on patients (). Nurses experienced moral distress due to difficult clinical and ethical decisions ().

Effects of the COVID-19 pandemic on people with mesothelioma and their carers.

Lung cancer and mesothelioma nurses' experiences of the pandemic were explored in two surveys in 2020. The first, undertaken by Lung Cancer Nursing UK () reported staff redeployments and absences due to Covid-19 resulting in stress, increased workloads, and concerns about maintaining service safety and/or performance. Most consultations were undertaken virtually, and fears were raised about negative patient impacts. Fewer new patients were seen than before the pandemic, and higher proportions via emergency routes. The second () surveyed 20 Mesothelioma UK Clinical Nurse Specialists (CNSs). Key issues were the negative impact on patients' prognosis and barriers in monitoring disease progression. Whilst virtual appointments were perceived as beneficial, some CNSs found the lack of face-to-face contact challenging and upsetting. CNSs witnessed the emotional impact of the pandemic on patients' wellbeing, but the impact on nurses’ wellbeing was not explored.

In 2021 LCNUK, in collaboration with the Mesothelioma UK Research Centre (MURC) and the charity Mesothelioma UK (MUK) undertook a new survey to follow-up on their earlier studies.

The aim of the study was to explore the impact of covid-19 on lung Cancer and mesothelioma specialist nurses since January 2021.

Effects of the COVID-19 pandemic on people with mesothelioma and their carers.

A survey was devised in collaboration with a project team with academic and nursing representatives from MURC, LCNUK, and MUK. It consisted of 28 quantitative and 11 open qualitative questions with attention focussed on exploring issues not investigated by the earlier surveys. Three domains explored the impact of Covid-19 on: (1) ways of working and workload, (2) quality of care, and (3) health and wellbeing (). These domains were selected on the basis of published evidence to explore both issues highlighted by the earlier LCNUK and mesothelioma () surveys and key issues known to the project team to be impacting on nurses and not covered by the previous surveys, such as, health and wellbeing. This ensured that the content of the survey was meaningful and thorough. The project team are leading experts in the field and utilised this expertise and past experience of developing covid surveys to ensure that the survey was valid. This was in addition to the feedback from two CNSs who piloted the survey and minor changes were made based on their feedback.

“A validated tool was included: the measure of moral distress amongst health professionals (MMD-HP, ) this was chosen because of appropriateness and comprehensiveness. For the purposes of this study moral distress is defined as professionals being unable to conduct what they believe to be ethically appropriate actions because of constraints or barriers, with little power to change it ().

The survey asked about care left undone or missed patient care. This was defined as “… any aspect of patient care that is omitted (either in part or completely) or significantly delayed” (, p291).

The online survey was developed using GoogleForms. It was launched on 27/09/21 and closed on 3/12/21. The inclusion criteria required respondents to be aged 18 years and above and working in the UK in an advanced or specialist nursing role in lung cancer or mesothelioma. LCNUK and MUK e-mailed the survey link and accompanying information sheet to nurses who were either members of LCNUK or funded by MUK. The survey was publicised via social media with the aim of broadening participation. A target sample size of 70 respondents was set, based on pragmatic consideration of previous survey responses and number of nurses in relevant roles. Email and social media remainders prompted participation.

Ethical approval was gained from a University Research Ethics Committee. Informed consent was presumed if someone completed the survey, with respondents asked to read the information sheet prior to participation.

Participants were directed to support services at the end of the survey if completing the questions caused distress.

The data were checked to ensure that the inclusion criteria were met, and one record was deleted.

The quantitative data was analysed using descriptive statistics. Moral distress scores were calculated, and inferential statistics (Mann-Whitney and Kruskal-Wallis) used to explore differences in levels of reported moral distress within respondents, e.g., comparing levels of moral distress in nurses reporting that they had to leave care left undone, with nurses who did not. This analysis was undertaken to explore different experiences which might impact on moral distress. SPSS software and excel were used to undertake the analysis.

Open questions were analysed using the six-step approach to qualitative thematic analysis outlined by . Initial coding was undertaken by SH and checked by CG and AG, and theme development was undertaken collaboratively. The final themes were discussed with the wider project team. Nvivo software was used to manage qualitative data analysis.

The “Strengthening the Reporting of Observational Studies in Epidemiology” (STROBE) checklist was used as the reporting guideline.

There were 85 responses to the survey and participant demographics are presented in . Most respondents were female (n = 80, 94%), white/white British (n = 82, 96%), working in England (n = 78, 92%), in roles held for between one and ten years (n = 50, 59%). A range of job roles were represented, most commonly CNSs (n = 74, 87%).

Since January 2021, has your work changed in the following ways?.

The survey explored changes in ways of working since January 2021 (). 63 (74%) of respondents reported changes, and of these 44 (70%) reporting an increase in working from home; 25 (40%) being redeployed to cover COVID-19 wards or services, or other services; and 18 (29%) volunteering to work in inpatient services in an ad-hoc way or supporting COVID-19 services.

The qualitative data highlighted the impacts of stretched services. Nurses reported working longer hours to compensate for staff absences with negative impacts for patients due to thin and disjointed services, and also for nurses due to workload and the knowledge that quality of care was impacted:

The move to virtual working was a significant change, with 83 (98%) of respondents reporting new ways of virtual working not used prior to the pandemic (). Respondents indicated whether they perceived a positive or negative impact on quality of care in comparison to face-to-face provision and/or prior to the pandemic. The work activities with the highest percentage of positive impacts reported were Telephone or Video Health Needs Assessment (60%), and Video consultation (54%). Activities with the highest percentage of negative impacts were virtual support groups for families (43%), and telephone clinics (40%). Overall there was a higher percentage of positive responses to virtual working practices (60%) as opposed to negative (39%).

The shift to virtual clinical practice required a rapid adoption. The qualitative data highlighted concerns with some nurses reporting that patients lacked internet access, and were reliant on telephone communication. Whilst respondents perceived that there were benefits in terms of convenience and in some cases patient preference, a strong concern was expressed about deficits arising from the loss of face-to-face interactions.

Face-to-face communication was perceived as “superior” in terms of the quality of interactions enabling the building of rapport/relationships, conversational flow and discussion, and insights from visual cues. Virtual patient assessment was perceived as particularly challenging, with concerns about the quality of assessment. Respondents highlighted barriers in assessing symptoms, and holistic needs:

Respondents sought to compensate for the deficits by new practices such as increasing the number of calls to check on patient welfare, and taking more time and care to explore issues. The potential for increased workload was highlighted with reports of repeated conversations.

In some circumstances virtual communication was considered inappropriate, such as, when breaking bad news or discussing a diagnosis. There was also a need to consider individual patient preference regarding virtual care.

Virtual working impacted upon job satisfaction. Nurses missed face-to-face interaction with patients and perceived that they had lost an important aspect of nursing in the provision of empathetic support.

The pandemic provided an opportunity to review current practices and for nurse-led innovation to reduce negative impacts of COVID-19 on patients. There were examples of new nurse-led clinics, greater collaborative working, and new ways of working to increase efficiency and reduce patient burden. One example of this was the implementation of a new community nursing service for lung cancer and mesothelioma patients. The following quotation illustrates this innovative approach:

A high proportion of respondents reported that their patients had received a delayed diagnosis (86%) and were subject to disruptions in primary care services (90%) (). Qualitative data gave insights into the impact on patient care, with patients attending at a later stage of disease progression, requiring more complex care, and with greater support needs for both patients and their families:

Experiences of virtual working – ways of working used since January 2021 (not used before the pandemic). T ick all that apply.

Impact on workload and care delivery. Compared to before the pandemic, workload changes since January 2021.

Respondents reported increased workload to meet the changing care needs. Examples included providing more emotional and psychological support (71, 85%), and supporting family carers (68, 81%) (). Qualitative data highlighted increased workloads due to staff absences and attending to unaddressed patient needs due to barriers in accessing primary care services. GP access issues led to increased phone calls, and patients attending clinics with health issues normally dealt with in primary care: .

Respondents described the hard work required, and subsequent exhaustion, to keep services afloat. For some there was anxiety because they had not been able to provide the same level of care as prior to the pandemic. They described their work during the pandemic as “fire-fighting” as opposed to proactive care. However there was pride in keeping services going:

Two-thirds of the sample (57, 67%) reported they had been unable to provide the same quality of care to patients as prior to the pandemic (). The impact on ‘care left undone’ was less pronounced, with 41% (n = 35) of the total sample reporting that they had omitted or delayed aspects of required patient care.

The survey explored the impact of the COVID-19 on nurses’ health and wellbeing since March 2020 (). Two-thirds of the sample reported a deterioration in emotional wellbeing and mental health (56, 66%). Impact on physical health and fitness was less pronounced, with one-third of the sample reporting a deterioration (28, 33%).

Qualitative data highlighted increased levels of stress. The pressure of working long hours and being the face of services receiving high volumes of late-stage presenting patients with a poor prognosis was both physically and emotionally demanding:

Staff redeployed into front-line services faced pressures from working outside their usual scope of practice, worry for colleagues left behind, and some described a lasting emotional legacy:

For respondents that had not been redeployed there was stress from increased workload, and for some worry and uncertainty about the prospect of being redeployed themselves.

A high proportion of the sample reported worry about exposing family members to Covid-19 (70, 83%). Nurses expressed fears of contracting Covid-19 and exposing family, patients, and colleagues to risk:

Moral distress scores in the sample ranged from 0 to 432 (the minimum and maximum achievable scores, with higher scores indicating greater moral distress), with a median of 42 (). Analysis was undertaken to explore associations between moral distress and all the appropriate survey variables. Nurses reporting care left undone had significantly higher moral distress scores (median = 82), compared to those that did not (median = 46) (p = .032). Respondents who had never considered leaving (or had left) a clinical position had significantly lower moral distress scores (median = 23) than nurses who had considered leaving, but did not leave (median = 70) (p = .001).

When asked if they were considering leaving now (at the time of filling out the survey) due to moral distress, most respondents reported that they were not (n = 69, 83%).

Respondents reported a range of positive and negative coping strategies. In the qualitative responses some described comfort eating to cope with stress, whereas others sought to boost their mental health through exercise. The quantitative data reported changes in lifestyle during the pandemic (). Two-thirds of the sample reported no change in alcohol intake (n = 56, 66%), while a quarter reported increased intake (n = 21, 25%). Impacts on healthy eating and exercise were more variable, with over one-third of the sample reporting decreased levels (n = 31, 37%). One-fifth of the sample reported an increase in healthy eating (n = 18, 21%), and approximately one-third reported increased levels of exercise (n = 30, 35%).

Opportunities for respite and coping mechanisms were limited. Some respondents reported not attending the gym due to work pressures, protecting patients, or feeling too exhausted. Others lacked the motivation to socialise, or were unable to because of COVID-19 guidelines:

However working from home created more opportunities for some nurses to build activity into their routine:

Team support was a key coping mechanism with some respondents reporting that this had been instrumental in getting them through the pandemic, with technology used to connect and share experiences:

However this method did not work for all, and some nurses felt unsupported with impacts on retention of staff.

World Health Organization, 2020a Mental health and psychosocial considerations during the Covid-19 outbreak. The survey provided insights into the experiences of lung cancer and mesothelioma nurses during the second wave of Covid-19, and of the legacy of working through the pandemic. This is the first paper to explore experiences of this stage of the pandemic from this nursing perspective. Nurses are at the centre of building a resilient workforce required to restore services and deal with the backlog of undiagnosed cancer. The themes of the survey around virtual working, innovation, patient care, and nurse wellbeing are key to improving patient care and supporting the workforce ().

NHS England, 2020 Specialty Guides for Patient Management during the Coronavirus Pandemic Clinical Guide for the Management of Remote Consultations and Remote Working in Secondary Care during the Coronavirus Pandemic. LCNUK, 2020 The impact of COVID-19 on lung cancer care: views from lung cancer specialist nurses. Dalby et al., 2021 Cancer patient experience of telephone clinics implemented in light of COVID-19. Taylor et al., 2019 Communication of a mesothelioma diagnosis: developing recommendations to improve the patient experience. Round et al., 2021 COVID-19 and the multidisciplinary care of patients with lung cancer: an evidence-based review and commentary. LCNUK, 2020 The impact of COVID-19 on lung cancer care: views from lung cancer specialist nurses. Watson et al., 2021 Safety and efficacy of telephone clinics during the COVID-19 pandemic in the provision of care for patients with cancer. The move to virtual working has been a key change in practice resulting from Covid-19 (). Whilst its use may not continue to the same extent in the future, virtual practices are now embedded as part of standard healthcare. In common with other studies the survey identified benefits for patients and nurses, with the greater flexibility and convenience of accessing care and providing services from home (). However, there were concerns which provide important learning points around when virtual consultations are appropriate for patients. Respondents perceived face-to-face interactions to be more productive for patient assessments exploring holistic needs. In common with other studies the survey identified occasions when virtual consultations are not appropriate, such as, when breaking bad news (), or where patients prefer face-to-face interactions (). This echoes the LCNUK survey (2020) finding that breaking bad news via telephone/virtually is emotionally difficult for patients and nurses. Further to this, Taylor et al.‘s study (2021) highlighted occasions when patients prefer face-to-face interactions, such as, conversations about disease progression, and end of life.

Brown, 2020 Will Covid-19 affect the delivery of compassionate nursing care?. Cruickshank, 2021 Covid-19: the impact on people affected by cancer, oncology nurses and the wider healthcare community. Taylor et al., 2021 Effects of the COVID-19 pandemic on people with mesothelioma and their carers. Nurses in this study did not wish to lose a fundamental part of their nursing practice in building therapeutic relationships in face-to-face interactions. This resonates with concerns raised about the impact of Covid-19 on compassionate nursing, with nurses distanced from patients () facing cancer and covid-19 (). However the survey showed how nurses adapted their virtual care practices to step-up compassionate support through the provision of additional calls to patients, and by taking time to explore issues. This is evidence that nurses were adapting practices either instinctively or to follow recommendations, such as, the call to increase check-in calls by

Rygg et al., 2021 Oncology nurses' lived experiences of video communication in follow-up care of home-living patients: a phenomenological study in rural Norway. Centre for Ageing Better, 2021 COVID-19 and the digital divide: supporting digital inclusion and skills during the pandemic and beyond. The need to acknowledge the limitations of technology is key to a balanced approach to future hybrid working (Reeves et al. 2021). This is appropriate for addressing the needs of lung cancer and mesothelioma patients who are most frequently diagnosed in old age (). Respondents reported that patients were often limited to telephone communication, and thus do not benefit from video communications allowing nurses to observe patients, and for families to participate (). It is important to ensure that patients without internet access are not disadvantaged ().

Baldwin and George, 2021 Qualitative study of UK health professionals' experiences of working at the point of care during the COVID-19 pandemic. Nymark et al., 2022 Patient safety, quality of care and missed nursing care at a cardiology department during the COVID-19 outbreak. Griffiths et al., 2018 The association between nurse staffing and omissions in nursing care: a systematic review. House of Commons Health and Social Care Committee, 2021 Clearing the backlog caused by the pandemic Ninth Report of Session 2021-22 Report, together with formal minutes relating to the report. Crusz et al., 2021 Providing an acute oncology service during the COVID-19 pandemic. LCNUK, 2020 The impact of COVID-19 on lung cancer care: views from lung cancer specialist nurses. Leary et al., 2014 The work left undone. Understanding the challenge of providing holistic lung cancer nursing care in the UK. This study adds evidence in understanding the impact of covid-19 on nursing during the second wave. Care became focussed around providing support for patients with complex needs and their families. Nurses took on new roles to cover redeployment and staff absences and were at the forefront of innovations to reduce negative impacts on patient care, such as, new nurse-led clinics. This versatility is seen in other studies (). Increased workload was a key theme of the survey with nurses perceiving workload to be excessive. Respondents reported not being able to provide the same quality of care as prior to the pandemic, and of leaving care left undone. This combination of reduced staffing levels, and changes in the patient population in terms of greater numbers and complexity of care needs are factors in reported poorer patient care seen in other studies (e.g. ). Care left undone may be an indicator of inadequate staffing levels () and of an under-resourced NHS stretched to the limits by the pandemic (). Nurses were on the frontline of care and bore the brunt of this pressure. It is imperative that strategies are put in place to reduce pressures and improve the safety of both patients and nurses (), especially as this issue of concern was highlighted both earlier () and prior to the pandemic ().

Boulton et al., 2021 A Multi-Centre Quantitative Assessment of Moral Distress Amongst Intensive Care Unit Professions in the UK. Respondents within our sample experienced some moral distress with a median score of 42. Whilst comparative data is limited, a preprint of a study exploring moral distress within intensive care units found nurses had a median score of 117 (). This is considerably higher than the score from this study, perhaps reflecting both a different context and the enabling influence of an experienced workforce and different working practices.

Colville et al., 2019 A survey of moral distress in staff working in intensive care in the UK. Senek et al., 2020 Determinants of nurse job dissatisfaction - findings from a cross-sectional survey analysis in the UK. Within our sample moral distress was higher in respondents reporting care left undone and in people considering leaving a clinical position (but not doing so). This finding echoes (2019) assertion of the importance of considering the moral impact of work issues when looking at staff wellbeing. Care undone is a determinant of job satisfaction which has implications for retention of staff (). Most respondents within our study reported that they were not considering leaving their posts due to moral distress (83%). Although not a direct comparison, the found that only 30% of respondents were not considering leaving their jobs. This is telling and speaks of a mesothelioma and lung cancer nurse workforce loyal to patients and colleagues during a global emergency. However, this cannot be relied on in the long-term and has implications for job retention.

Paterson et al., 2020 Oncology nursing during a pandemic: critical reflections in the context of COVID-19. De Kock et al., 2021 A rapid review of the impact of COVID-19 on the mental health of healthcare workers: implications for supporting psychological well-being. Roberts et al., 2021 Experiences of nurses caring for respiratory patients during the first wave of the COVID-19 pandemic: an online survey study. Pollock et al., 2020 Interventions to support the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic: a mixed methods systematic review. Covid-19 had a substantial impact on nurses' wellbeing within our sample as they described living with the legacy of nursing through the pandemic, on-going pressures, and the exhaustion of caring for large numbers of very ill patients. In common with other studies, the survey found a deterioration in emotional wellbeing and mental health, combined with a fear of transmitting Covid-19 to family and colleagues (; Nicola J. ). This finding underlines the importance of strategies to support a nursing workforce living with occupational stress. There is a limited evidence base on interventions to support healthcare workers’ resilience and mental health during a pandemic (). What evidence there is suggests that strategies consider organisational, social, personal, and psychological factors. This study gave insights into beneficial sources of support, such as a supportive team who actively communicate, share and reflect on experiences. Our study found that the building blocks of resilience from both work and home settings, with accounts of nurses actively pursuing health through lifestyle options. Hybrid working enabled nurses to build exercise into routines, and this may partly explain the smaller negative impact on physical health in comparison to mental wellbeing.

Roberts et al., 2021 Levels of resilience, anxiety and depression in nurses working in respiratory clinical areas during the COVID pandemic. Garcia et al., 2022 Mindful self-care, self-compassion, and resilience among palliative care providers during the COVID-19 pandemic. Baldwin and George, 2021 Qualitative study of UK health professionals' experiences of working at the point of care during the COVID-19 pandemic. Jackson, 2022 Supporting nurses' recovery during and following the COVID-19 pandemic. Nurses in our study reported experiencing distressing levels of stress and anxiety but there was little evidence of organisational input to address this. Evidence suggests organisational strategies can reduce stress/anxiety and include signposting to sources of support (N. J. ), or interventions promoting mindful self-care (). The psychological impact of the pandemic will require both short and long-term support (). There are barriers to accessing support arising from the nursing ethos of prioritising patient care above nurses’ own needs (), and support needs may go unvoiced. This would suggest a need for initiative-taking mental health support from organisations, to recognise and normalise the need for support. This need for a programme of support to recover and build resilience is recognised by the literature (e.g. ).

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