Nursing Work Life Research

Unreported workplace violence in nursing A. Kvas1


& J. Seljak2 PhD

1 Chair of Nursing Division, Nursing Department, Faculty of Health Sciences, 2 Independent Researcher, Faculty of Administration, University of Ljubljana, Ljubljana, Slovenia

KVAS A. & SELJAK J. (2014) Unreported workplace violence in nursing. International Nursing Review 61, 344–351 Background: Workplace violence occurs on a frequent basis in nursing. Most violent acts remain unreported. Consequently, we do not know the actual frequency of the occurrence of workplace violence. This requires research of nurses’ actions following workplace violence and identification of reasons why most victims do not report violent acts in the appropriate manner. Aim: To explore violence in nursing as experienced by nurses in Slovenia. Methods: A survey was carried out with a representative sample of nurses in Slovenia. The questionnaire Workplace Violence in Nursing was submitted to 3756 nurses, with 692 completing the questionnaire. Results: A total of 61.6% of the nurses surveyed had been exposed to violence in the past year. Most victims were exposed to psychological (60.1%) and economic violence (28.9%). Victims reported acts of violence in formal written form in a range from 6.5% (psychological violence) to 10.9% (physical violence). The largest share of victims who did not report violence and did not speak to anyone about it were victims of sexual violence (17.9%). The main reason for not reporting the violence was the belief that reporting it would not change anything, followed by the fear of losing one’s job. Conclusions: Only a small share of the respondents reported violence in written form, the main reason being the victims’ belief that reporting it would not change anything. This represents a severe criticism of the system for preventing workplace violence for it reveals the failure of response by leadership structures in healthcare organizations. Implications for Nursing and Health Policy: Professional associations and the education system must prepare nurses for the prevention of violence and appropriate actions in the event of violent acts. Healthcare organizations must ensure the necessary conditions for enabling and encouraging appropriate actions following violent acts according to relevant protocols. Keywords: Harassment, Nurses, Nursing Care, Psychological Violence, Sexual Violence, Slovenia, Staff Development, Workforce Organization, Workplace Violence

Background Health care is a field in which workplace violence (WPV) is strongly prevalent (ICN 2009; ILO 2009). Accurate data about WPV do not exist because the majority of violent acts remain Correspondence address: Janko Seljak, Faculty of Administration, Gosarjeva Ulica 5, University of Ljubljana, Ljubljana 1000, Slovenia; Tel: +38641-99-84-99; Fax: +38615-80-55-21; E-mail: [email protected]

Funding: This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Conflict of Interest: No conflict of interest has been declared by the authors.

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unreported. In order to reduce WPV, we first need to establish its prevalence and, based on the data on the scope, type and degree of violence, adopt appropriate measures for its prevention and reduction. Assessments based on surveys show that only 10–25% of victims of WPV submit formal reports (Farrell & Shafiei 2012; Natan et al. 2011). The low rate of reporting violent acts is a consequence of several factors that influence an individual’s decision of whether to report violence or not (Esmaeilpour et al. 2011; Pinar & Ucmak 2011). The first step in preventing violence is to acknowledge the existence of WPV and ensure appropriate reporting of acts of


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violence (Taylor & Rew 2010). Research shows a common belief that WPV is part of the job in nursing (Roche et al. 2010) and that nurses accept it as a routine occupational hazard (Howerton Child & Mentes 2010). Such beliefs are strong obstacles in the development of appropriate strategies for preventing violence and ensuring a safe working environment (Pich et al. 2010). International Labour Organization (2003) defines WPV as ‘incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health’. WPV appears in many different forms, which are exhibited in a wide range of contexts (Haan 2009). Even the perception of the type and degree of violence varies among individuals and influences the reporting of acts of violence (Neuman 2012). WPV is most frequently categorized according to the type of damage the victim experiences, that is, physical, psychological, economic or sexual violence (or sexual harassment) (International Labour Office 2003; Pinar & Ucmak 2011; Spector et al. 2013). Psychological violence can be defined as violence that causes psychological damage to the victim and it is often accompanied and/or followed by other types of violence (Dillon 2012). Physical violence aimed at another person’s body is less prevalent. Physical violence can be defined as intentional behaviour that harms another person physically (Pai & Lee 2011). Sexual violence can either be physical or verbal. Sexual violence (or sexual harassment) is any unwanted, unreciprocated or unwelcome behaviour of a sexual nature that is offensive to the person involved and that causes that person to feel threatened, humiliated or embarrassed (Pai & Lee 2011; Spector et al. 2013). The intention of economic violence is to cause economic harm to the victim through material harm or damage to his property. It has often been researched with respect to violence in the family, but has always been present in the workplace as well (MacDonald 2012). Estimates of the prevalence of WPV in health care are usually based on self-assessments of respondents (Pinar & Ucmak 2011; Farrell & Shafiei 2012). An individual’s assessment of the form and degree of violence depends on many factors, due to which different individuals perceive the same events differently (Neuman 2012). Another obstacle in the comparison of the results of different research of WPV is the fact that there are no consistent definitions or criteria for measuring WPV (Wu et al. 2012). Because a formal report is submitted by only a small share of victims of violence, the number of registered acts of WPV is much lower than the actual number (ILO 2009). This calls for measures to ensure a higher share of reported acts of

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violence in order to reduce the divergence between estimated and registered acts of violence. WPV can have many negative consequences. Its negative effects are reflected in the efficiency of an organization: decreased commitment to the profession and organization, lower quality of teamwork, increased absenteeism and lower quality of health care (Camerino et al. 2008; Esmaeilpour et al. 2011). However, the greatest negative effects of WPV are felt by the victim. It affects the victim’s health, satisfaction with work and life, confidence, and causes emotional exhaustion and burnout (Budin et al. 2013; Waschgler et al. 2013). Victims feel depression, anxiety and work-related stress (Aytaç & Dursun 2012; Rodwell & Demir 2012). Therefore, it is very important that each individual be informed in advance how to react in the event of violence. Clearly, the only appropriate reaction is a written report according to the protocol (to one’s leader or another designated person) (ZZBN 2013). However, only a small percentage of victims submit written reports (Farrell et al. 2006; Natan et al. 2011). The first goal of this research was to establish which groups of nurses in Slovenia are most frequently exposed to violence and to compare these results with the results of other research. There are certain groups within the nursing profession that are exposed to violence more often than the others. The risk factor for violence are: gender (man), nursing experience or age (younger nurses), education (lower education), leadership position, and type of hospital (emergency wards) (Albashtawy 2013; Camerino et al. 2008; Pai & Lee 2011). Identification of these groups is necessary in order to establish where violence occurs most frequently and where action is necessary. The second goal of the research was to determine what actions were taken by the victims following an act of violence and why some of the victims took no action. The third goal was to establish how the situation regarding WPV could be improved according to the victims.

Methods Sample and data collection

The basis for forming the sample of the research entitled ‘Workplace Violence in Nursing’ was the National Register of qualified nurses and midwives in Slovenia. As of 1 July 2010, there were 18 624 registered nurses recorded in the National Register. The sample was designed on the basis of a three-level stratified sampling (gender, job experience, leadership position). At the first level, the nurses were classified into two strata according to gender. At the second level within each main stratum, nurses were stratified according to age (40 years and under, 41 years and over) into two second-level strata. At the third level within


A. Kvas & J. Seljak

each second-level stratum, nurses were stratified according to education (secondary school, higher education) into third-level strata. After stratification, 3756 nurses were randomly selected for the sample. The research was carried out from November 2010 to February 2011. The survey questionnaire was sent to 3756 nurses, of which 692 responded (18.2% response rate). The sample was representative of the overall nurse population in terms of age and education, with the difference between the sample structure and the structure of the population not statistically significant (Seljak & Kvas 2012). Because of a low response rate from the male nurses (10.5%), the gender aspect of the structure of the sample was poor.

situation with respect to WPV were formed as multiple-choice questions. Following an analysis of the respondents’ responses, their answers were coded into categories. Based on content, the answers were organized into four to six contextually unified categories. The questionnaires were pre-tested and modified for face and content validity by a panel of experts. Data analysis

The SPSS 19.0 statistics software (IBM Corporation 2010) was used for the statistical analysis of the data. The differences between various groups of nurses were determined using chisquare test and t-tests. The significance level of α = 0.05 was used for all statistical tests. The responses to the multiple-choice questions were assessed using the crosstabs analysis.


Following a literature review and input from an expert group within the Non-Violence in Health Care Task Force of the Nurses and Midwives Association of Slovenian (ZZBN 2013), we developed a questionnaire Workplace Violence in Nursing. For the purposes of our research, violence was defined in its broadest sense to include all forms of aggressive or abusive behaviour that may cause physical, economical or psychological harm or discomfort to its victim (ILO 2009). Short examples and definitions of each type of violence were also provided as part of the scale: • Physical violence is the use of physical force or a serious threat thereof with the potential of harming another person or threatening their life, such as aggressive gestures, pushing, slapping, punching, kicking, or injury with an object or a threat thereof. • Psychological violence involves acts threatening or harming a person’s psyche, such as bullying, pressuring, manipulation, social isolation, threats, offensive gestures, defamation, silence, ignoring and emotional extortion. Psychological violence also includes verbal abuse, such as: ridicule, mocking, taunting, disrespect, insults, yelling and name-calling. • Economic violence involves refusal to pay overtime, unreasonably expanding the scope of work, performing the work and tasks of co-workers, violations of the work code and workers’ rights, material harm caused by superiors and damage to personal property. • Sexual violence involves any form of unwanted sexual advances in verbal, non-verbal or physical form that injures a person’s dignity, such as unnecessary touching, fondling, sexual innuendo, sending email with sexual content, suggestive remarks and comments, sexually insinuating comments or gestures, sexist jokes, forced sexual intercourse, attempted rape or rape. The questions regarding nurses’ actions following violent acts, their reasons for inaction and proposals for improving the

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Ethical considerations

The research was approved by the Honorary Court of Arbitration of the Nurses and Midwives Association of Slovenia. The survey was anonymous so we did not need to obtain separate written consents. Participants were assured that there was no risk in participating in the research and that their responses would be treated confidentially.

Results Out of the 692 surveyed nurses, 426 (61.6%) had been exposed to at least one form of violence in the past year. The analysis of differences among various groups of nurses (Supporting Information) showed that nurses exposed to violence were significantly younger than those who did not experience violence (t = −2.09; P < 0.05). Those with higher education were more often exposed to violence than those with secondary school education (χ2 = 5.88; P < 0.05). There were also relatively large differences depending on the type of institution (χ2 = 13.62; P < 0.05). The differences between male and female nurses were not statistically significant (χ2 = 3.19; P = 0.07) (Supporting Information Tables S1–S4). The most common form of violence was psychological violence. Out of 426 victims of violence, 416 (60.1% of all respondents) stated psychological violence as being one of the forms of violence they were exposed to. Out of 692 respondents, 101 (14.6%) experienced physical violence, 200 (28.9%) economic violence and 79 (11.4%) sexual violence. Only one form of violence was experienced by 25.3% of the respondents, while 36.3% experienced two or more forms. Table 1 shows the actions taken by victims according to the type of violence. Each victim was able to choose several actions. The most common action following all types of violence was discussing it with a co-worker or colleague, followed by discussion with a superior. Only a small share of the respondents

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Table 1 Nurses’ actions following violence (as a response to violence) and reasons why victims did not report acts of violence Type of violence number (% of responses)

Actions following violence* Number of responses (total) Formal written report Oral report/discussion with a superior Notified the professional association, union Discussed it with co-worker/colleague Did nothing/discussed it with nobody Reasons why victims did not report acts of violence† Number of responses (only victims who did not act) (total) Because nothing would change or due to a previous negative experience Fear of losing one’s job Fear of the person initiating violence Belief that the victim caused the violence Other





220 (100.0) 24 (10.9) 70 (31.8) 18 (8.2) 87 (39.5) 21 (9.5)

781 (100.0) 51 (6.5) 209 (26.8) 77 (9.9) 347 (44.4) 97 (12.4)

405 (100.0) 33 (8.1) 107 (26.4) 44 (10.9) 168 (41.5) 53 (13.1)

173 (100.0) 15 (8.7) 42 (24.3) 15 (8.7) 70 (40.5) 31 (17.9)

54 (100.0) 42 (77.8) 7 (13.0) 4 (7.4) 1 (1.9) 0 (0)

218 (100.0) 142 (65.1) 43 (19.7) 24 (11) 1 (0.5) 8 (3.7)

121 (100.0) 63 (52.1) 35 (28.9) 15 (12.4) 2 (1.7) 6 (5)

60 (100.0) 31 (51.7) 15 (25.0) 9 (15) 1 (1.7) 4 (6.7)

*Respondents were able to choose more than one type of violence and more than one action following an act of violence. †Respondents were able to choose more than one reason for not reporting acts of violence.

Table 2 Proposals of WPV victims for the successful prevention and elimination of workplace violence* Proposals of WPV victims*

Action of the victim following WPV number (% of responses)

Number of responses (total) Training in communication skills and conflict resolution Improved awareness of the issue of violence, bullying, sexual harassment, etc. Improvements within the organization: procedures for reporting violence, naming a representative for resolving issues of violence, etc. Improvements implemented by external stakeholders: help provided by the union and NGOs, helpline, etc.

Report, discussion with one’s superior or friends

Did nothing/discussed it with nobody


923 (100.0) 243 (26.3) 155 (16.8) 244 (26.4)

357 (100.0) 115 (32.2) 67 (18.8) 81 (22.7)

1280 (100.0) 357 (27.9) 223 (17.4) 325 (25.4)

281 (30.4)

94 (26.3)

375 (29.3)

*Respondents were able to choose more than one proposal. NGO, non-government organization; WPV, workplace violence.

reported violence in written form (6.5–10.9%). Most of the victims of violence who did not act (51.7–77.8%) believe that reporting violence would not change anything or have had negative experiences with reporting procedures in the past. The final question of the research asked the victims of WPV about the areas they believe would need to be changed

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to more successfully prevent WPV (Table 2). The first two groups involved education and training about violence and greater knowledge about the issue of violence. More than half of the victims who had not discussed their experiences of violence believe that the activities in the first two groups would have a significant impact on resolving the issue of violence.


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Discussion Prevalence of violence and differences between groups of nurses

Our survey of nurses showed that 416 (60.1%) of the respondents had been exposed to psychological violence. Other research also shows psychological violence to be the most prevalent type of violence against nurses (Natan et al. 2011; Spector et al. 2013). The second most frequent form of violence was economic violence, which was listed by 200 (28.9%) respondents. Because of their position in the organization, the most common sources of economic WPV are leaders on all levels of leadership. This characteristic results in economic violence being difficult to manage inside the organization by the individual worker. Trade unions in some countries offer legal aid to their members. They usually have a large number of union representatives in all healthcare organizations and are also very supportive in preventing economic WPV (MacDonald 2012; Richards 2003). A total of 101 (14.6%) respondents were exposed to physical violence. This result corresponds with the results of other research (8.5–19.7%) of physical violence against nurses (Pai & Lee 2011, Aytaç et al. 2011). On the other hand, Spector et al. (2013) reported that 36.4% of nurses were exposed to physical violence. A total of 79 (11.4%) respondents had been exposed to sexual violence. Sexual violence (harassment) is another category in which results differ considerably, ranging from 12.9% (Pai & Lee 2011) to 25% (Spector et al. 2013). Our research showed that differences between male and female nurses were not statistically significant. The gender role in violence exposure is not clear (Howerton Child & Mentes 2010), but WPV was more frequently reported by male nurses in comparison with female nurses (Camerino et al. 2008; Wu et al. 2012). Younger nurses were more exposed to violence than older ones. This is also confirmed by other research (Budin et al. 2013; Farrell et al. 2006; Pai & Lee 2011). The highest rates of violence occurred in emergency wards (73.3% of all respondents working in emergency wards). Emergency wards have also been found to have the highest risk of exposure to violence according to other research (Albashtawy 2013; Taylor & Rew 2010; Wu et al. 2012). On the other hand, our research showed that nurses with college or university education were more exposed to WPV than the others. This does not correspond with some of the other research where a lower education was found to be a risk factor for violence (Pai & Lee 2011). Other research conducted in Slovenia (Domanjko & Pahor 2010) showed that a range of negative attitudes towards graduate nurses exist among nurses with secondary school education and that mistrust exists within the nursing profession. Younger higher education graduates are entering working environments that have a negative attitude

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towards their education. Such relationships can lead to violent acts which the younger nurses perceive more sensitive than the older ones. Actions following violent acts

Actions taken by nurses exposed to WPV can be divided into five groups. The first group comprises actions that can be assessed as appropriate. Formal written reporting (to leaders or other designated officers) was most often used by victims of physical violence (10.9%), while the share of reported violence was lowest among victims of psychological violence (6.5%). Psychological violence often precedes other more severe acts of violence, therefore victims of milder acts of violence should be encouraged to report it. In other research, the share of formally reported violence was higher than in Slovenia, ranging from 15.4% (Farrell et al. 2006) to 26.6% (Natan et al. 2011) of all victims. Our research shows that a relatively high share of victims of violence discussed the event with their leaders (second group). This group represents 31.8% of victims of physical violence, but only 24.3% victims of sexual violence. Leaders are supposed to take appropriate action and report violence to their superiors, but whether or not they do so is left to their judgement (Dillon 2012). The third group comprises victims who reported violent acts to their professional association or union. Nurses exposed to WPV should attempt to solve the problem by discussing it with their leader, manager or human resources department in the organization. If they cannot, they should talk to their professional association or trade union representative. This action was most frequently taken by victims of economic violence (10.9%). The Nurses and Midwives Association of Slovenia and Union of Nurses help its members to take appropriate action following an act of violence. They have formulated action protocols for events of violence, and provide a helpline that victims can call to discuss their experiences of violence and possible actions with an expert (ZZBN 2013). The fourth group comprises nurses who discussed the acts of violence with co-workers or colleagues. This action was most frequently taken by victims of psychological violence (44.4%) and least frequently by victims of physical violence (39.5%). Other research (Farrell & Shafiei 2012; Farrell et al. 2006) also shows that discussing the event with colleagues or friends is the most common action taken following WPV. The fifth group comprises victims who have not reported acts of violence or discussed them with anyone. This is the most concerning group for their silence gives perpetrators of violence a clear signal that violence is tolerated (Taylor & Rew 2010). This was the reaction of 17.9% of the victims of sexual violence and 9.5% of the victims of physical violence. Victims of sexual

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violence are often stigmatized and prefer to remain silent about their experiences (McDonald 2012). Reasons for not reporting violence

Reasons for not taking action differed by the type of violence. A total of 77.8% of the victims who did not take any action following physical violence believed that reporting the event would not change anything; the share of victims of economic or sexual violence with the same belief was 52.0%. However, the share of victims of economic violence who did not act due to fear of losing their jobs was significantly higher. Such a high percentage of respondents believing that reporting would not change anything is doubtlessly a consequence of the prevalent belief that violence is an occupational hazard in nursing. However, research also shows that persons to whom nurses report acts of violence often do not report these events to their superiors (Dillon 2012). This makes the victims feel apathy and gives them a sense that their reports will not be investigated appropriately (Esmaeilpour et al. 2011; Pinar & Ucmak 2011). The second group of reasons is related to fear. A total of 25.0% of the victims of sexual violence and 28.9% of the victims of economic violence stated the fear of losing their jobs to be the reason for not reporting an act of violence. This reason is clearly not directly related to the source of violence (aggressor), but to the environment (organization) and the sense of job security (Pinar & Ucmak 2011). Other research also shows that in addition to the character of the aggressor, the environment in which the violence occurs is also an important factor (Appelbaum et al. 2012). Establishing a violence-free environment begins with the organization’s top management, but must involve all employees (Whitmore 2011). In the short term, the top management of organizations needs to establish a system of high organizational responsiveness to WPV (Dillon 2012). Victims’ proposals for improving the situation

The majority of the victims of WPV believe that violence would be most efficiently reduced through training in communication and conflict resolution skills, and through improved knowledge of the issue of violence. This is a belief shared by 51.0% of the respondents who had not reported WPV or discussed it with anyone. Pinar & Ucmak (2011) also found education and training to be important factors in reducing violence and increasing the rate of reported violence. However, research also shows that education and training are not enough and that other measures are also necessary in order to reduce and prevent violence and encourage reporting (Howerton Child & Mentes 2010). Finally, research shows that prevention of violence requires activities in

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several areas and that focusing research on a single specific area does not lead to the desired results. On the other hand, a larger share of respondents (56.8%) who did report violence or discussed it with someone believe that improvements within organizations (a designated officer for resolving issues of violence, better organization of reporting and preventing violence) and efforts by external stakeholders (activities within professional associations, e.g. establishing a helpline for victims of violence, and help from other organizations – union, non-government organizations) could improve the situation. These are individuals who have already experienced the procedures of reporting violence and see activities in this area as more important than prevention. Limitations

Some limitations in the research should be pointed out. Because a common definition of violence does not exist, comparison of results of the various studies of the prevalence of violence is somewhat difficult. While the definition of physical violence is more or less unified, definitions of other types of violence can vary significantly. Self-assessment is another limiting factor for monitoring violence. Most research is based on self-assessment, which can vary significantly from one individual to another. The last limitation of our research was the low response rate (18.2%), with the lowest response coming from male nurses (10.5%).

Implications for nursing and health policy Healthcare organizations need to improve procedures for formally reporting violence. They need to determine why violence is not reported and encourage the reporting of violent acts. Reporting procedures must be clearly defined, quick and simple. Those employees who did know about the reporting procedures and non-violence policy of organization were more likely to report incidents, thereby creating a safer environment (Dillon 2012). In order to increase the share of reported WPV, victims of violence must be reassured that their reports will be appropriately investigated and that they will be appropriately protected after submitting a report. All employees must be acquainted with the protocol for reporting violence and know who to report it to. Such a person must be appropriately selected and trained. Most victims of WPV believe that reporting violence would not change anything. Supervision should be established to monitor the progression of procedures after an incidence of aggression has occurred and has been reported. Not only the reporting of WPV, but also appropriate organizational


A. Kvas & J. Seljak

response, should play key roles in establishing non-violence organizational environment. Professional associations should provide training programs in accordance with high standards of socially recognized professionalism. Only appropriate training can ensure the formation of a positive work culture in which conflicts are resolved in an appropriate manner. A long-term solution would be to introduce additional courses on non-violence in higher education programmes for nurses. Therefore, higher education programmes must introduce interdisciplinary courses that include communication, interprofessional and interpersonal relationships, and management of violence.

Conclusion The main reasons for not reporting violence are the victims’ belief that reporting it will not change anything and previous negative experience. WPV in nursing is so prevalent that all members of the profession must be acquainted with the types and degrees of violence and learn how to manage it. Violence is not a constituent part of the profession and nurses deserve to work in a safe working environment. To achieve this goal, all members of the nursing profession must, jointly with other stakeholders (doctors, patients, relatives), actively contribute to changes.

Acknowledgement This study was conducted with support from the Nurses and Midwives Association of Slovenia.

Author contributions AK: Study conceptualization, data collection, drafting the manuscript, critical revisions for important intellectual content; supervision, administrative/material support. JS: Data collection, building the databank, data analysis, statistical expertise, critical revisions for important intellectual content, supervision, technical support.

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Supporting information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site: Table S1 Gender and WPV in nursing Table S2 Age and WPV in nursing Table S3 Education and WPV in nursing Table S4 Type of institution and WPV in nursing

Unreported workplace violence in nursing.

Workplace violence occurs on a frequent basis in nursing. Most violent acts remain unreported. Consequently, we do not know the actual frequency of th...
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