Nursing research
Critical Appraisal of a Quantitative Study Assignment Guideline and Rubric The goals of this assignment are to: 1. Assist students in understanding the basic process of conducting a literature review/critical appraisal. 2. Assist
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students in understanding the beginning process of conducting an evidence-based practice review. 3. Provide students with the beginnings of scientifically based knowledge on a selected procedure/topic related to nursing research. Steps of the process: 1. Select a topic with instructor’s approval. Important because some articles that have been shown to me are not research quantitative nor qualitative research studies that have come from refereed journals. Article can be quantitative or qualitative and preferably from a nursing research journal. (Please submit article to me by end of the day on Monday because I must critique it in order to be able to evaluate your critique.) 2. Appraise the article critically using the guidelines provided in Chapter 12. This is the information provided in the syllabus.. 3. Prepare a presentation to facilitate where a/the group member(s) discuss aspects of the critique. (See guidelines/questions below.) Power point is suggested because it may provide creativity and generate audience interest. Information to include in the report (see examples on pages 433-442) Research Problem and Purpose Why is the problem significant to nursing? • Will the study problem and purpose generate or refine knowledge for nursing practice? Literature Review • How current is the literature review? • Does the literature review provide rationale and direction for the study? • Is a clear, concise summary presented of the current empirical and theoretical knowledge in the area of study? Study Framework • Is the framework/theoretical basis presented with clarity? • If a map or model is presented, is it adequate to explain the phenomenon of concern? • If a proposition from a theory is tested, is the proposition clearly identified and linked to the study hypotheses? Research Objectives, Questions, or Hypotheses • Are the objectives, questions, or hypotheses expressed clearly? • Are the objectives, questions, or hypotheses logically linked to the research purpose and framework? • Are the research objectives, questions, or hypotheses linked to concepts and relationships from the framework? 1 Variables • Do the variables reflect the concepts identified in the framework? • Are the variables clearly defined? • Is the conceptual definition of a variable consistent with the operational definition? Method/Design . What type of research is it? Explain. • How were study subjects selected? • Are any subjects excluded from the study based on age, socioeconomic status, or race, without a sound rationale? • If more than one group is used, do the groups appear equivalent? • Are the rights of human subjects protected? • Is the setting used in the study typical of clinical settings? Measurements What are the instruments that were used to measure variables and if they are scales and questionnaires did the investigator(s) clearly describe them, especially the reliability/validity of the instruments? If data were collected by observation as in qualitative studies are the phenomena to be observed clearly identified and defined? Is interrater and intrarater reliability described? Are the techniques for recording observations described? Interviews Do the interview questions address concerns expressed in the research problem? Are the interview questions relevant for the research purpose and objectives, questions, or hypotheses? Physiological Measures • Are the physiological measures or instruments clearly described? Are the methods for recording data from the physiological measures clearly described? • Data Collection and Analysis • Is the data collection process clearly described? • Is the training of data collectors clearly described and adequate? Are the results presented in an understandable way? Interpretation of Findings • • • Are findings discussed in relation to each objective, question, or hypothesis? Are the findings clinically significant? Do you believe that there are limitations that the investigator(s) did not identify? Evaluation • What do you determine are the major strengths/weaknesses of the study? • To what populations can the findings be generalized? • What questions emerge from the findings, and are these identified by the researcher? • What future research can be envisioned? Can the study be replicated by other researchers? 2 • How do findings inform your practice as a nurse? • When the findings are examined based on previous studies, what is now known and not known about the phenomenon under study? That is, are the findings consistent with those from previous studies? Does the author indicate the implication of the findings for practice? What are the implications of the findings for nursing practice? • 3 NURS 400 – INTRODUCTION TO NURSING RESEARCH Rubric for evaluation of research critique NURS 400 – INTRODUCTION TO NURSING RESEARCH Rubric for evaluation of research critique TITLE OF ARTICLE: CRITERIA Value % % Earned COMMENTS STRUCTURE Evaluation of overall Critique 90% Introduction (10%) Title of article How was article selected Purpose of the study Paper logically arranged to address main points of criteria for critique: (70%) Statement of the problem Hypotheses Theoretical framework Literature review Variables Operational definition(s) Sample Instruments Data collection and analysis Results 4 Summary: (10%) Conclusions/How do findings inform nursing practice? APA 10% Where necessary uses APA format correctly (5%) Uses correct grammar, spelling, punctuation, and capitalization. Article critiqued is from peer reviewed journal (5%) FINAL GRADE 100% 100% 5 Original Research Report Moral Distress Among School Nurses The Journal of School Nursing 1-8 ª The Author(s) 2017 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1059840517704965 journals.sagepub.com/home/jsn Shannon Baker Powell, PhD, RN, CNE1, Martha Keehner Engelke, PhD, RN, CNE, FAAN1, and Melvin S. Swanson, PhD1 Abstract School nurses are well positioned to provide care to a diverse population of school-age children, but their role and work environment can present a variety of moral dilemmas leading to moral distress. The purpose of this study is to identify the moral distress level that exists in school nurses and to describe its relationship to common moral dilemmas and school nurse characteristics. Data were collected through face-to-face attendance at school nurse meetings in North Carolina where 307 school nurses participated in the survey. Moral distress was measured using the moral distress thermometer, and common moral dilemmas were identified using a researcher developed questionnaire. Almost all of the school nurses (97.3%) experienced some degree of moral distress. Each of the common moral dilemmas was positively correlated with moral distress levels. The findings suggest that many of the common moral dilemmas experienced by school nurses are strongly related to moral distress. Keywords quantitative research, moral distress, moral dilemma, school nurse characteristics Background Moral distress is a phenomenon that has been studied primarily in acute care settings, but it has not been studied among nurses working in schools. Jameton (1984) described moral distress as the distress that “arises when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action” (p. 6). Moral distress has further been described as “a form of distress that occurs when one knows the ethically correct thing to do, but is prevented from acting on that perceived obligation” (Hamric, 2012, p. 167). Limited studies exist related to moral distress in nurses or health-care workers outside of the acute care setting. A better understanding of moral distress among school nurses is important for school nurses and their employers but most importantly for the students they serve. School nurses are well positioned to positively impact the health and well-being of children in the United States since children spend such large amounts of time in the school setting (National Association of School Nurses [NASN], 2016). The school nurse is often the only health-care provider in most school settings and thus a likely professional to successfully implement preventative services in school-age children as well as interventions for children with chronic illness. Several recent national reports recognize the importance of school nurses in improving the health and academic success of children and adolescents (American Academy of Pediatrics Council on School Health, 2016; NASN, 2015a; Robert Wood Johnson Foundation, 2010). School nurses are often limited in their ability to provide services due to constraints within their practice settings. The inability of the school nurse to provide the level of care they feel is optimal may lead to the development of moral distress. The phenomenon of moral distress in nurses is found in the literature with reported negative consequences (De Veer, Francke, Struijs, & Willems, 2013; Eizenburg, Desivilya, & Hirschfeld, 2009; Hamric, 2012). Moral distress has been studied most often among acute care nurses (Corley, Elswick, Gorman, & Clor, 2001; Corley, Minick, Elswick, & Jacobs, 2005; Elpern, Covert, & Kleinpell, 2005; Hamric, Borchers, & Epstein, 2012; Hart, 2005; McClendon & Buckner, 2007; Meltzer & Huckabay, 2004; Mobley, Rady, Verheijde, Patel, & Larson, 2007; Rice, Rady, Hamrick, Verheijde, & Pendergast, 2008). Negative consequences found in nurses working in acute care settings includes decreased work satisfaction and increased burnout, intent to leave, and nurse turnover (Corley et al., 2001; De Veer 1 East Carolina University College of Nursing, Greenville, NC, USA Corresponding Author: Shannon Baker Powell, PhD, RN, CNE, East Carolina University College of Nursing, 3185M Health Sciences Bldg., Greenville, NC 27858, USA. Email: bakersh@ecu.edu 2 The Journal of School Nursing XX(X) et al., 2013; Elpern et al., 2005; Hamric et al., 2012; Hart, 2005;; Meltzer & Huckabay, 2004; Pendry, 2007; Trautmann, Epstein, Rovnyak, & Snyder, 2015). Fewer studies discuss findings related to moral distress among nurses in other settings. Eizenburg, Desivilya, and Hirschfeld (2009) included nurses working in community, nursing home, chronic care, and mental health facility settings in addition to nurses working in hospitals in a study of moral distress, while De Veer, Francke, Struijs, and Willems (2013) studied moral distress in a sample of nurses working in nursing homes, homes for the elderly, home care, and acute care hospitals. In this study, moral distress was associated with decreased job satisfaction (De Veer et al., 2013). Moral distress may be applicable to school nurses because they are one of the few nursing specialties in which the primary focus of the work setting is not on health but education. Furthermore, they are usually the only health professional in a school, and moral distress may arise from conflicts between their organizational and professional obligations. These relationships, however, have not been examined in previous studies. Purpose The purpose of this study was to examine moral distress among school nurses. A second purpose was to describe the relationship between moral distress, common moral dilemmas, school nurse characteristics, and job-related characteristics. The following research questions were examined in this study: 1. What is the level of moral distress in school nurses as measured by the moral distress thermometer (MDT)? 2. What is the relationship between moral dilemmas experienced by school nurses and moral distress? 3. Does the level of moral distress and the type of moral dilemmas experienced by school nurses differ by demographic and work characteristics? Method Design This study used a descriptive, correlational quantitative design to examine the level of moral distress among school nurses and the relationship between moral distress and moral dilemmas experienced by school nurses. The study was approved as an exempt study from the East Carolina University and Medical Center Institutional Review Board (IRB) prior to data collection. Responses were not linked in any way to those participating in an effort to protect privacy and also increase accurate responses to the survey. Participants who completed the entire survey were given the option to enter into a drawing for a US$50 visa gift card. There were a total of four gift cards distributed. The name of participants that entered the drawing was not linked to their responses as a separate slip of paper was provided and collected. As an exempt study, participants were provided an information sheet approved by the IRB explaining the study. Population and Setting This study utilized a convenience sample of practicing school nurses in North Carolina during the school year of 2015–2016. Inclusion criteria required that participants be currently practicing as a school nurse. School nurses serving in an administrative position or lead role were eligible to participate if they currently had a school assignment in their workload. Those only working in administrative positions were not eligible. Data were collected face-to-face in an effort to have an increased number of respondents. Face-to-face surveys were administered through attendance at school nurse meetings in North Carolina. School nurse meetings for this sample included a total of eight meetings, four regional school nurse meetings and four individual school district nurse meetings. The principal investigator (PI) contacted five School Nurse Association of North Carolina regional presidents via e-mail to request an invitation to attend the respective regional meetings to administer the survey. All five of the regional presidents contacted extended an invitation to the PI to attend meetings and ask for volunteers to take the survey. Each of the five regions had representation in the study. The PI attended three of the regional meetings where a scripted introduction was given to the participants seeking volunteers to participate in the survey and surveys were administered. The other two regional meetings were scheduled for the same dates as other regional meetings attended by the PI. To allow for participants from these two regions, a regional school nurse president from one region volunteered to administer the survey at the respective meeting. Training for the survey administrator was provided by the PI via phone, while a script and surveys were provided for administration. The other region was sampled through PI attendance at two of the largest school district meetings within the region to allow representation from the last region. In addition to the regional meetings, lead nurses for six large school districts in North Carolina were contacted via e-mail or phone to request an invitation to one of their school district-wide nurse meetings. Four of the school districts extended an invitation. The same scripted introduction was given to these participants seeking volunteers to take the survey and the survey was administered by the PI. Measures The MDT (Wocial & Weaver, 2013) was used to measure moral distress. In addition, the researcher developed individual items to measure school nurse moral dilemmas that included 14 questions. Additional questions in the survey included 14 questions related to demographic and employment variables. Powell et al. Instruments used to measure moral distress have most commonly been used with nurses and other health-care workers in acute care settings and were evaluated for use in this study. An attempt to adapt a current instrument, the revised Moral Distress Scale (MDS-R; Hamric et al., 2012), was made. Personal communication with the author (A. B. Hamric, personal communication, December 17, 2015) who is considered a leader in research related to moral distress in acute care settings was initiated and suggested using Wocial and Weaver’s (2013) instrument, MDT. A second researcher (M. M. Eizenberg, personal communication, December 18, 2015) with studies in moral distress was contacted regarding the moral distress questionnaire (MDQ) for clinical nurses (Eizenberg et al., 2009). Permission to use the MDQ instrument was received; however, the scale was found to be inappropriate for use with school nurses. The MDT is less situation specific and was found to be more applicable with school nurses. The author of the MDT (L. D. Wocial, personal communication, January 6, 2016) was contacted and gave permission for its use in this study. The MDT is an individual item, 11-point scale that ranges from 0 to 10 (Wocial & Weaver, 2013). The scale includes words to help identify varying degrees of moral distress and ranges from “none” to “worst possible.” The thermometer includes a definition of moral distress and instructions for respondents to reflect on their practice and identify their level of moral distress by circling a number on the thermometer. The MDT has been tested with other moral distress measures and found to be a valid instrument to test moral distress (Wocial & Weaver, 2013). Benefits of the MDT include its convenient measurement using only one question and being less situation specific compared to other moral distress measures specific to nurses working in acute care. The original MDT asked respondents to reflect on their practice over the past 2 weeks and indicate their level of moral distress on the thermometer. Due to the variability of school nurse workloads over the school year, the MDT instructions for this survey asked school nurse participants to reflect on their practice over the past month and indicate their level of moral distress on the thermometer. An author of the MDT was contacted via e-mail regarding the desire to change instructions from past 2 weeks to 1 month and agreed that this was an acceptable alteration (L. D. Wocial, personal communication, February 22, 2016). The school nurse moral dilemma items were developed following a review of the literature and discussion with other authors of instruments related to moral distress. In addition, the dilemmas that were chosen were informed by a previous qualitative study with school nurses completed by the author (Powell, Engelke, & Neil, 2017). The format of the questionnaire was based on principles of constructing closedended questions described by Dillman, Smyth, and Christian (2009). After development of the moral dilemma items, the survey was reviewed by school nurse volunteers and experienced researchers in instrument development. Several 3 significant revisions were made based on feedback. There were a total of 14 moral dilemma items that were presented in a Likert-type scale with five response options from strongly agree to strongly disagree. The total instrument was printed on two pages with an introductory paragraph and included 29 items and could be completed in 5–10 min. After the PI or designee read the scripted introduction, the school nurses completed the survey and returned it when finished. The script included brief information about the purpose of the study, IRB approval, and general information to facilitate survey completion including instructions for those with multiple schools to complete the survey based on their overall experience as a school nurse as well as specific attention given to the thermometer question instructing participants to circle number. The thermometer information was added to the script after a large percentage of surveys were missing a response to the MDT during the first administration of the survey. Data Analysis Data were entered in to the Statistical Package for the Social Sciences (Version 23). Descriptive statistics were used to analyze the characteristics of the sample and the participants’ responses to the moral dilemma items. School nurses that agreed or strongly agreed that a statement was a moral dilemma in their practice were categorized as agreed. To examine if the dilemmas might vary based on the level of moral distress, the sample was divided into those nurses who had high and low moral distress. Scores on the MDT greater than 4 were defined as “high” levels of moral distress, while scores less than 4 were defined as “low” levels of moral distress. The number 4 was chosen for the division because of its description, “uncomfortable.” To investigate if there was a statistically significant association between the common moral dilemma questionnaire and moral distress levels, a correlation was computed. Because each of the variables was normally distributed and the assumption of linearity was not markedly violated, Pearson correlations were calculated. Correlations greater than .5 were considered large, .3–.49 were medium, and less than .3 were considered small. t Test and one-way analysis of variance were computed to compare the effects of selected school nurse characteristics on moral distress levels. The strength of the relationships involving t test and one-way analysis of variance was assessed with Z2, where a value of .01 is a small effect, .06 is a moderate effect, and .14 is a large effect. Statistical significance was assessed with p values less than or equal to .05. Results The sample consisted of 307 school nurses representing 619 public schools from North Carolina. After review of the surveys, 43 were missing the MDT and were excluded from analysis leaving a total of 264 surveys included in the analysis. Response rates for the school district meetings were 4 90–100%, while the regional meetings were more difficult to assess. Many of the regional meetings included a continuing education component where some of the attendees were not eligible to take the survey limiting complete accuracy of the response rates based on the number of attendees; however, large percentages of surveys were returned at regional school nurse meetings. The majority were female (98.9%) and Caucasian (87.5%). Most of the school nurses held a bachelor’s degree or higher (86.0%) and were certified as a school nurse (64.4%). The majority of the school nurses were employed by the local school system (59.1%) and were assigned to more than one school (68.4%) with greater than 900 students in their assignment (58.0%). Of the 264 school nurses who responded to the MDT (M ¼ 4 .69), 131 (49.6%) reported their level of moral distress as uncomfortable or higher. The characteristics of the sample are described in Table 1. The percentage of school nurse responses related to the moral dilemmas is shown in Table 2. While the dilemmas were different between those with high and low distress, there were some dilemmas that were consistently rated high across all groups. The common dilemmas were “students with chronic illness do not receive needed care,” “unable to provide case management due to workload,” and “unable to achieve goals for students due to family issues.” The least common dilemma across the groups was “no private space.” Each of the moral dilemmas was significantly correlated with moral distress as shown in Table 3. The strongest positive correlations with moral distress were dilemmas “unable to provide care due to lack of time,” “not enough time to provide care to students with chronic illness,” and “unable to provide care due to workload.” Moral distress levels were positively correlated with each of the moral dilemmas with medium to large size correlations according to Cohen (1988) with the exception of small correlations for items “unable to achieve goals due to family situation” and “do not have private space to work with students.” The next analysis examined the relationship among the demographic characteristics, work characteristics, and moral distress. These results are summarized in Table 4. The only characteristic that had a statistically significant relationship with moral distress was the number of students in the school nurse caseload. Nurses with 900 or more students had higher moral distress (M ¼ 5.21) and 59.4% of them reported a high level of moral distress. In comparison, only 36.5% of school nurses with less than 900 students reported high levels of moral distress and the mean level of distress was lower (M ¼ 3.99). The effect size (Z2) for this difference is .06, which is a moderate effect size. Finally, a t test to examine whether there were differences in the moral dilemmas experienced by school nurses based on caseload is summarized in Table 5. School nurses with larger caseloads were more likely to experience moral dilemmas on all of the items except for the availability of resources and family issues (Items 11 and 13) when The Journal of School Nursing XX(X) Table 1. Characteristics of Study Participants. Characteristic n Percentage Age (years) Less than 40 63 23.9 40–50 85 32.2 Greater than 50 115 43.6 Missing 1 0.4 Gender Female 261 98.9 Male 3 1.1 Race/ethnicity Caucasian 231 87.5 African American 28 10.6 Hispanic/Latino 1 0.4 Other 4 1.5 Highest level of education Associate Degree in Nursing 17 6.4 Bachelor of Science in Nursing/Bachelor’s 227 86.0 degree nonnursing Master of Science in Nursing/Master’s 17 6.4 degree nonnursing Missing 3 1.1 National certification in school nursing Yes 170 64.4 No 94 35.6 Years of experience in school nursing Less than 5 years 89 33.7 5–10 Years 74 28.0 Greater than 10 years 101 38.3 Type of employer Local school system 156 59.1 Public health department 83 31.4 Hospital agency 23 8.7 Missing 2 0.8 Number of schools in assignment 1 86 31.3 2 105 41.7 3 or more 72 26.7 Missing 1 0.3 Number of students in assignment Less than 900 104 40.5 Greater than 900 155 58.0 Missing 5 1.6 Percentage of students economically disadvantaged Less than 40% 66 23.8 40–80% 150 58.6 Greater than 80% 48 17.6 Administration of medications School nurse administers majority of 89 33.6 medications Delegated to school personnel 173 65.5 Missing 2 0.8 Moral distress level per moral distress thermometer categories Greater than distressing to worst possible 66 25.0 (>6–10) Greater than uncomfortable to distressing (>4–6) 65 24.6 Greater than mild to uncomfortable (>2–4) 58 22.0 Less than or equal to mild (0–2) 75 28.4 Moral distress level per moral distress 4.69 2.43 thermometer (M/SD) Note. N ¼ 264. SD ¼ standard deviation. Powell et al. 5 Table 2. Percentage Agreement of Responses to Moral Dilemma Items for Participants With High and Low Levels of Moral Distress (MD). Moral Dilemmas 1. Not enough time to provide care to students with chronic illness 2. Pressure from administration 3. Unable to provide care due to workload 4. Unable to provide care due to lack of time 5. Concern students with chronic illness do not receive needed care 6. Unable to address family requests due to lack of time 7. Unable to address staff requests due to lack of time 8. Pressured to not interrupt class to provide needed care 9. Unable to provide preventive care 10. Unable to provide care due to lack of school resources 11. Unable to provide care due to lack of referral services 12. Unable to provide case management due to workload 13. Unable to achieve goals for student due to family situation 14. Don’t have a private space Total High MD Low MD Group (%) (%) (%) 63.7 87.0 40.5 41.3 58.0 55.7 82.4 27.1 33.8 50.6 74.6 27.1 64.1 81.4 47.4 34.5 54.7 15.0 41.1 63.4 18.9 64.4 74.0 54.9 55.9 74.6 37.6 43.0 56.9 29.3 40.5 54.3 27.3 68.3 84.7 51.9 76.9 84.0 69.9 33.3 40.5 26.3 Note. N ¼ 264. Responses to individual items for total group range from 259 to 264, high MD range from 127 to 131, and low MD range from 131 to 133. compared to those with smaller caseloads. The largest differences were found in “having enough time to provide care for students with chronic illness” and “unable to provide care due to workload.” All of the statistically significant differences were found to have large to moderate effects. Discussion This study examined moral distress in school nurses which is an area that had not been previously addressed in the literature. The school nurses in this sample confirmed that moral distress exists in the population of school nurses. The moderate to large correlations between moral distress level and the moral dilemmas offer insight into the source of this distress. Not being able to provide adequate care to students with chronic illness because of time constraints was the largest source of distress. Although moral distress was higher in nurses with larger caseloads, some nurses with smaller caseloads also experienced high levels of moral Table 3. Pearson Correlations of Moral Dilemmas With Moral Distress Levels. Moral Dilemmas 1. Not enough time to provide care to students with chronic illness 2. Pressure from administration 3. Unable to provide care due to workload 4. Unable to provide care due to lack of time 5. Concern students with chronic illness do not receive needed care 6. Unable to address family requests due to lack of time 7. Unable to address staff requests due to lack of time 8. Pressured to not interrupt class to provide needed care 9. Unable to provide preventive care 10. Unable to provide care due to lack of school resources 11. Unable to provide care due to lack of referral services 12. Unable to provide case management due to workload 13. Unable to achieve goals for student due to family situation 14. Don’t have a private space r .58 .39 .58 .60 .41 .51 .50 .32 .44 .42 .36 .49 .27 .23 Note. N ¼ 264. Responses for individual items range from 259 to 264. *All p values less than .001. distress. The moderate to large effect sizes found in the analysis suggest that these differences are important for understanding school nurse practice. The literature suggests that a perceived lack of time to deliver care to patients increases moral distress (Austin, Lemermeyer, Goldberg, Bergum, & Johnson, 2005; De Veer et al., 2013; Eizenburg et al., 2009; Glasberg et al., 2006; Rager Zuzelo, 2007; Redman & Fry, 2000; Sørlie, Kihlgren, & Kihlgren, 2005). Similar to acute care nurses, lack of time to deliver optimal care the school nurse perceived important was associated with increased moral distress in this study. Additionally, this study adds to existing knowledge by exploring common moral dilemmas in school nursing practice as well as school nurse characteristics, of which larger caseloads were found to be related to increased moral distress in school nurses. Limitations and Recommendations for Future Research A limitation of this study is the convenience sample. Recruitment at regional school nurse association meetings may have recruited school nurses who were more engaged in school nursing issues as well as the availability of school nurses with employers that allowed time off from a school day to attend the regional meeting. Therefore, this sample is not necessarily a representative sample of all school nurses. Recruitment at local school district meetings was more likely to include a more representative sample of school nurses in the district, as attendance was mandatory unless there was a pressing issue in a school or personal issue. Another limitation of this study was that the MDT had not previously been used in the population of school nurses. 6 The Journal of School Nursing XX(X) Table 4. Means, Standard Deviations, and t Test or One-Way Analysis of Variance for the Effects of Selected Nurse Characteristics on Moral Distress Levels. MDT Characteristic Education ADN BSN/bachelor’s degree MSN/master’s degree School nurse experience Less than 5 years 5–10 Years Greater than 10 years Number of students
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