Review Article
How to cite this article: Bernardino SP, Bernardino CP. Clinical governance through audit in promoting
quality in clinical practice: scoping review. Pensar Enf [Internet]. 2025 Feb; 29(1): e00341. Available from:
https://doi.org/10.71861/pensarenf.v29i1.341
Pensar Enfermagem / v.29 n.01 / february 2025
DOI: 10.71861/pensarenf.v29i1.341 /e00341
Clinical governance through audit in promoting
quality in clinical practice: scoping review
Abstract
Introduction
Clinical auditing is one of the main pillars of clinical governance, crucial for safe healthcare.
It is a key tool for continuous improvement in terms of clinical practices and results,
making it possible to verify the application of strategies and procedures aimed at increasing
patient safety.
Objective
To map the knowledge and identify the effects, through a literature review, of clinical
governance through the auditing process in promoting quality in clinical practice.
Methods
Literature review, namely scoping review, according to the methodology of the Joanna
Briggs Institute, and PRISMA 2020 Checklist guidelines, registered on the OSF (Open
Science Framework) platform. The studies were identified by a search carried out on 31
January 2024 in the PUBMED, EBSCO (MEDLINE Complete, Cochrane Library Plus
and CINAHL Plus With Full Text), SCOPUS, Web of Science and RCAAP (Repositório
Científico de Acesso Aberto de Portugal) grey literature databases using descriptors and
free terms in Portuguese, English, Spanish and French, from 1998 onwards. Two
independent reviewers carried out the study's relevance analysis with data extraction and
synthesis between March and May 2024.
Results
Initially, seventy articles were obtained, but fourteen were subsequently eliminated because
they were duplicates. A total of fifty-six articles were analysed. Thirty-seven articles were
excluded for not meeting the inclusion criteria and seven for not having access to the full
article. Nineteen articles were analysed in full. In the end, nine articles were included in the
review article, with three articles excluded due to eligibility. The effects of clinical
governance in promoting quality in clinical practice through the audit process identified
were access to quality care, guaranteeing user safety, collective responsibility, as well as
accountability. In turn, the main shortcomings identified were the absence of an ingrained
culture, lack of training for auditors, along with breaks in the audit cycle.
Conclusion
Clinical auditing is an asset in the clinical governance process, so its systematic practice
promotes increased clinical effectiveness, risk management, professional development, as
well as transparency in terms of publicising the results obtained, ensuring standards of
professional practice and promoting continuous improvement in the quality of services. It
plays a crucial role in ensuring adherence to legal regulations and standards, minimising
legal and financial risks and promoting clinical management based on responsibility and
transparency. This is vital for maintaining the trust of users, as well as the credibility of
institutions in the eyes of regulatory bodies and society as a whole, ensuring that healthcare
practices are always in line with legal and ethical requirements.
Keywords
Clinical audit; clinical governance; promotion, quality; clinical practice.
Sofia Pinto Bernardino1
orcid.org/0000-0002-9612-7182
Carla Pinto Bernardino2
orcid.org/0009-0000-0132-2990
1 Master. Unidade Local de Saúde de Trás-os-montes e
Alto Douro, Portugal.
2 Master. Unidade Local de Saúde do Oeste, Portugal.
Correspondence author
Sofia Pinto Bernardino
E-mail: spbernardino@chtmad.min-saude
Received: Aug 14 2024
Accepted: Feb 7 2025
Bernardino, S.
Review Article
Introduction
Health systems are organisations built by society to respond
to the health needs of people and populations. It is
imperative that health systems, regardless of their source of
funding, are sustainable, provide quality care and develop
in line with their users' expectations. When said health
systems are public and free of charge, this need becomes
even more pertinent, otherwise they risk extinction. 8 The
occurrence of safety incidents during the provision of
health care is a reality of modern health systems. The
implementation of policies and strategies to reduce these
incidents, a proportion of which are preventable, is
recognised internationally and nationally as leading to
health gains and is now an unequivocal commitment to
health.20 Promoting user safety requires a coordinated and
persistent effort by all stakeholders and a systemic,
continuous approach that promotes safety and a culture of
safety, based on a non-punitive approach and continuous
improvement.20
According to the Manual of Policies and Strategies for
Quality in Health Care21 drawn up by the World Health
Organisation, when establishing a national quality policy, it
is paramount to spell out the definition of quality that will
underpin the national approach, to ensure a common
understanding and a language that is acceptable to the
country's local context. In Portugal, as early as 2012, quality
in health was defined in the National Health Plan (PNS)
2012-20162, by Saturno et al. as the provision of accessible
and equitable health care, with an optimal professional level,
which takes into account the available resources and
achieves citizen adherence and satisfaction. It implies the
adequacy of healthcare to the needs and expectations of the
citizen and the best possible performance. The degree of
quality in health can be conditioned by multiple factors: i)
extraordinary social, political, environmental, scientific and
technological developments; ii) uncertainty and
unpredictability of occurrences such as epidemics and
disasters, climate change and terrorism; iii) characteristics of
the health system; iv) determinants of the demand for care
(ageing, chronic illness, more information, expectations and
demands, among others) and the capacity to respond
(human resources, growing specialisation, multidisciplinary
and intersectoral work, among others); v) new concepts of
health outcomes and quality of life.2 More recently, the
development of the 2030 National Health Plan (PNS)1 was
based on three key assumptions: i) the social value of health
as a major objective in people's lives; ii) the central role of
health as a "starting point" and "end point" for achieving the
2030 Sustainable Development Goals; iii) population-based
strategic health planning as a methodological tool with its
various components and stages.1
The perspectives for promoting quality in healthcare involve
cycles of continuous quality improvement through the
systematic identification of problems and opportunities with
the aim of solving or improving them, establishing desirable
and realistic standards, identifying and acting on critical
points, planning and implementing changes,
monitoring and evaluating.2 The processes should be
multidisciplinary, non-punitive and at the initiative of
the professionals and associated with professional
development plans. They should involve strategies such
as monitoring, benchmarking, as well as external
evaluation, including accreditation processes and the
identification of good practices, among others.3 These
can take place at the level of the professional, the team,
the service, the institution and the supervisory body. All
hierarchical levels within the organisation must be duly
evaluated, valued and held accountable for decisions,
whether they are health professionals, managers or
politicians. They should spell out objectives, indicators
and targets; organisational and delivery models (which
allow for comparability and the identification of good
practices) and structure, process and outcome
standards.4
In the context of the new models of healthcare
organisation, clinical governance is the process by
which healthcare organisations are responsible for
continuously improving the quality of their services and
ensuring high standards of care, creating an
environment that encourages excellence in clinical care.
The term governance was imported from the
commercial world, which defined Corporate
Governance as a system by which companies protected
shareholders' investments and minimised the risks of
fraud and malpractice. In 1998, Clinical Governance
was introduced for the first time in the National Health
Service's health white paper in the UK, reflecting a
strategy to modernise and improve the quality of the
health system.5
In the present article, for conceptual clarification, the
word governance and governorship have the same
meaning. However, the word governorship has a
broader meaning (power, policies, charisma, legislation)
and the concept of governance has a narrower but
more transparent meaning, as it describes the processes
of implementing defined policies.6
Since 2001, Portugal has been trying to improve health
by making accountability mechanisms explicit, and
from 2003 onwards, particular importance has been
given to processes aimed at increasing transparency in
the work of the different health units and professionals
in the National Health Service (SNS). In this way,
clinical governance was one of the strategies adopted
by the new organisational structures of the Health
Centres (formerly Health Centre Groupings) to
improve and maintain the quality of their care.7
The key principles of excellence in clinical governance
include: i) orientation towards results; ii) orientation
towards the user; iii) leadership and coherence of
objectives; iv) management of processes and activities;
v) development and involvement of employees; vi)
Pensar Enfermagem / v.29 n.01 / february 2025
DOI: 10.71861/pensarenf.v29i1.341 /e00341
Review Article
learning, innovation and continuous improvement; vii)
development of partnerships and viii) social responsibility.8
Based on said fundamental principles of excellence,
according to Vitor Ramos6, clinical governance should be
based on three essential pillars:
- the focus on the person and the person's well-being, the
primary gaze of clinical governance is on users, the
community, population subgroups with special care needs,
and only then on the organisation and its processes.
- the involvement of everyone, at all levels;
- outcome orientation, which is understood as health gains,
aims to develop a culture of evaluating processes and, above
all, clinical and health outcomes at all levels.8 Nigel Starey,
director of the Centre for Primary Care at the University of
Derby, has defined 6 constituent elements of clinical
governance: education and training, clinical audit, risk
management, openness (transparency), clinical
effectiveness, research and development.6
In view of the above, clinical audit is one of the key pillars
of clinical governance, crucial for safe healthcare. It is a
fundamental tool for continuous improvement in terms of
clinical practices and results, making it possible to verify the
application of strategies and procedures aimed at increasing
patient safety. Through a structured process of reviewing
procedures, clinical guidelines, as well as clinical practices in
comparison with previously established standards, it makes
it possible to identify and correct faults through the
implementation of improvement actions. According to the
Conceptual Framework of the International Classification
on Patient Safety, as can be seen in figure 1, clinical audit
can be defined as a cycle of activities that involves measuring
care by comparing it with a standard (process or outcome),
ideally leading to the development of interventions aimed at
continuous quality improvement.9
The main aim of the present study, a review article, was to
identify the effects of clinical governance on promoting
quality in clinical practice through the audit process and to
map knowledge through a literature review. To this end, the
following research question was formulated, based on the
PCC mnemonic (population, concept and context), with
different geographical realities as the population; the
concept being the effects of the pillars of clinical governance
on promoting quality in clinical practice; in a hospital
context: What are the effects of clinical governance on
promoting quality in clinical practice through the audit
process?
Methods
The research protocol was drawn up according to the
methodological procedures of the Joanna Briggs Institute
(JBI), in which the objectives, inclusion criteria (described in
table 1) and methods to be used were clarified, and
registered on the OSF (Open Science Framework)
platform
(https://doi.org/10.17605/OSF.IO/XFCUZ).
Reporting Items for Systematic Reviews and Meta-
Analyses).
Table 1. Methodological procedures
Inclusion criteria
Primary or secondary, qualitative or
quantitative studies on clinical governance in
the promotion of quality in clinical practice,
published from 1998 to the present year.
Exclusion criteria
Studies that included pillars of clinical
governance other than audit.
A systematic review of the scientific literature was
carried out, through a scoping review, on the effects of
clinical governance on promoting quality in clinical
practice through the audit process, following the
Joanna Briggs Institute methodology10 and the
guidelines established by the PRISMA model (The
studies were identified by a search carried out on 31
January 2024 in the PUBMED databases, EBSCO
(MEDLINE Complete, Cochrane Library Plus and
CINAHL Plus With Full Text), SCOPUS, Web of
Science and grey literature RCAAP (Repositório
Científico de Acesso Aberto de Portugal) using
descriptors and free terms in Portuguese, English,
Spanish and French, from 1998 to the present year, an
extended period of time, taking into account the date
of origin of the concept of clinical governance, as
described in Table 2. The second stage consisted of
grouping all the studies found in Mendeley Desktop®
and removing any duplicates. Taking into account the
inclusion/exclusion criteria defined, the studies were
screened by carefully reading their titles and abstracts
by two independent reviewers. Potentially relevant
studies were imported and passed on to the full text
reading phase, also carried out by two independent
reviewers, and the inclusion/exclusion criteria were
complied with. As this is a scoping review, the aim of
which is to map knowledge on the subject, the critical
evaluation of sources was waived.
The third stage consisted of consulting the list of
bibliographical references of the selected studies after
reading the full text in order to find inaccessible articles
relevant to answering the research questions. Two
independent reviewers analysed the relevance of the
study with data extraction and synthesis between
March and May 2024, using a table previously
developed by the reviewers. Eleven disagreements
arose and were resolved by consensus between the
parties. Seven studies were identified with no free full
version available, and the journals of publication were
Bernardino, S.
Review Article
contacted to request the studies, but as of the date of
publication there had been no response.
Table 2. Research strategy
Database
PubMed
EBSCO
SCOPUS
Web of
Science
RCAAP
MEDLINE
complete
COCHRANE
Library Plus
CINAHL Plus
with full Text
Search results
#1 - 758
#2 - 299
#3 - 45
#1 - 41
#2 - 12
#3 - 11
#1 - 24
#2 - 20
#3 - 18
#1 - 465
#2 - 124
#3 - 55
#1 - 12
#2 - 9
#3 - 6
#1 - 13
#2 - 10
#3 - 3
#1 - 3
#2 - 2
#3 - 2
Search terms
#1 - Clinical Governance
#2 - Audit Clinical
#3 - #1 AND #2
Filters
Text in English, French, Portuguese and Spanish
Date
Research carried out on 31 January 2024
Results
After searching the aforementioned databases, seventy
articles were initially obtained, fourteen of which were
subsequently eliminated because they were duplicates. A
total of fifty-six articles were analysed, thirty-seven of which
were excluded for not meeting the inclusion criteria and
seven for not having access to the full article. As a result,
nineteen articles were analysed in full.
In the end, nine articles were included in the review article,
and three articles were excluded due to eligibility. Figure 2
shows the identification and selection process.
With regard to the type of studies included in this
review article, the majority are literature review articles
(four articles). There were two articles with mixed
methodology, quantitative and qualitative, as well as
two master's dissertations. Only one randomised
controlled study was found. The studies fall within a
timeline between 2013 and 2024. Given that six of the
nine articles were published in the last 5 years, this
demonstrates the recent relevance of the subject under
study. The main results of the nine studies analysed are
summarised in Table 3.
Table 3. Main results of the articles included in the studies
Authors/Year/Country
Title
Main results
E1
Hanskamp-Sebregts,
Zegers, Boeijen, Westert,
Gurp and Wollersheim11
2013
The Netherlands
Effects of auditing patient safety
in hospital care: design of a
mixed-method evaluation
The audit protocol allows hospitals to detect unsafe care early and continuously
improve patient safety.
E2
Martins, C.12
2014
Portugal
Quality management and
healthcare reform: a case study
The analysis of professionals from three different hierarchical levels
(administration, members of the Quality and Patient Safety Commission and care
providers) in the organisation led to the conclusion that there is no deep-rooted
quality culture throughout the hospital. Quality strategies are implemented in a
fragmented way, essentially to comply with legal regulations defined by supra-
organisational bodies.
E3
Gomes et al.13
2015
Brazil
The Polysemy of Clinical
Governance: a literature review
In terms of results, there are seven subjects that summarise the analysis of the
sources: management, quality promotion, clinical monitoring or auditing,
education, responsibility, safety in care, as well as the systemic dimension. There
is a lack of focus on discussions of planning and policies related to clinical
governance.
E4
Viana C.14
2019
Brazil
The role of auditing in hospital
institutions
Auditing in the hospital context, as in any other organisation, is an extremely
important tool because it is by identifying weaknesses, errors and incorrect
procedures that improvement actions can be implemented. It is therefore an
extremely important management tool.
Pensar Enfermagem / v.29 n.01 / february 2025
DOI: 10.71861/pensarenf.v29i1.341 /e00341
Review Article
E5
Salomão and Guimarães 15
2020
Brazil
Prevention and treatment of
pressure injuries in hospital
settings through the application
of clinical governance strategies
The main strategies identified are related to equipment and materials for
prevention, good care practices, education and training, risk assessment, multi-
professional involvement, participation in process management, auditing,
behaviour and culture change, administrative support, nutrition, implementation
of an incontinent programme, selection of staff with an interest in the area,
communication, commitment, monthly control of indicators, as well as their
dissemination, registers, a wound committee, specialised professionals, a survey
of equipment present in the institution and a cost survey. The data showed that
the reduction in the incidence of pressure injuries in hospitals is due to the
association of quality nursing care with a strategic pressure injury management
process.
E6
Willis et al.16
2022
United Kingdom
Interventions to optimise the
results of national clinical audits
to improve the quality of
healthcare
The impacts of national audits can be improved by strengthening all aspects of
feedback loops, especially effective feedback, and by considering how different
ways of strengthening feedback work together. Identified ways to strengthen audit
cycles included making performance data easier to understand and guiding action
planning. Four requirements for effective collaboration were identified:
commitment - recognising capacity and constraints; logistics - enabling data
sharing, audit quality and funding; leadership - involving local stakeholders; and
relationships - reaching an agreement on shared priorities and needs.
E7
Serra, Costa, Henriques,
Godinho and Gouveia.17
2022
Portugal
Nursing audits in healthcare
organisations
Currently, there is still a punitive view of audits carried out in healthcare
organisations. From the financial and organisational areas to the provision of
nursing care, the influences that these evaluative acts entail are transversal and it
is pertinent to identify their contributions to organisations.
E8
Paixão, Pinheiro, Perdigão,
Zangão and Bilro18
2022
Portugal
Clinical audit: literature review
Clinical Auditing is an asset in the Clinical Governance process, and its systematic
practice promotes an increase in clinical effectiveness, risk management,
professional development, as well as transparency in terms of publicising the
results obtained, ensuring standards of professional practice and promoting
continuous improvement in the quality of services.
E9
Alghamdi et al.19
2023
Saudi Arabia
Effects of a team Quality
Improvement method in a
national clinical audit
programme of four clinical
specialties in Ministry of Health
hospitals in Saudi Arabia
The project showcased that well-designed resources and audits carried out using
evidence-based clinical care standards can result in substantial improvements in
clinical practices in Ministry of Health hospitals in Saudi Arabia. The keys to
success were the improvement methodology incorporated into the audit process,
as well as the requirement for hospitals to appoint multi-professional teams to
carry out the audits. All designated hospitals participated in the audits, collecting
and submitting data at two points in time and implementing improvements after
the first data collection. All hospitals made substantial, statistically significant
improvements in clinical practice.
Discussion
In order to facilitate the interpretation of the results
obtained, they were duly analysed according to the effects of
clinical governance on the promotion of quality in clinical
practice through the auditing process.
So the discussion will be based on two broad categories
- Effects does clinical governance have on promoting
quality in clinical practice through the auditing process
One of the effects identified is access to quality care at all
sites, at all times, through: protocols, guidelines, good
practice manuals with systematised information. Evidenced
in E5, clinical governance is a tool systematised into pillars
of actions, applicable to different health contexts and
practices, providing improvements in the clinical quality of
care, through policies and guidelines responsible for
maintaining and monitoring standards of good practice and
results.15 E9 also evidences that well-designed resources and
audits carried out using evidence-based clinical care
standards can result in substantial improvements in
clinical practices in hospitals.19
Another effect showcased by the literature is the
guarantee of safety for users. This is corroborated by
studies E1, stating that the audit protocol allows
hospitals to detect unsafe care early and continuously
improve patient safety11; and E8 reporting that clinical
auditing is an asset in the clinical governance process,
whereby its systematic practice promotes an increase in
clinical effectiveness, risk management and
professional development13.
Providing the highest quality of care is one of the
effects demonstrated in the literature, confirmed by E4
assuming that identifying weaknesses, errors and
incorrect procedures allows improvement actions to be
implemented. 14 As well as E6 stating that the impacts
of national audits can be improved by strengthening all
aspects of feedback loops, especially effective
feedback, and how different ways of reinforcing
feedback work together.16
Bernardino, S.
Review Article
Finally, one of the effects of clinical governance in
promoting quality in clinical practice through the audit
process is the collective responsibility and accountability
demonstrated by E9 when he said that the keys to success
were the improvement methodology incorporated into the
audit process and the requirement for hospitals to appoint
multi-professional teams to carry out the audits.19
- Gaps in clinical governance in promoting quality in
clinical practice through the audit process
As a starting point, it could have been assumed that clinical
auditing in the clinical governance process would only have
positive effects on promoting quality, but the literature
review identified flaws in the implementation of clinical
governance, jeopardising the whole process, namely the lack
of a culture of quality rooted in the institutions. This was
evidenced by E2, who noted that quality strategies had been
implemented, albeit in a fragmented way, essentially to
comply with legal regulations defined by supra-
organisational bodies.12 Another shortcoming is the lack of
training for auditors, reflected in a punitive approach to the
process, as reflected by E7, who pointed out that currently
there is still a punitive view of audits carried out in
healthcare organisations, which can range from the financial
and organisational areas to the provision of nursing care,
and the influences that these evaluative acts entail are
transversal. 17 Also in the study, E3 emphasises that there is
a lack of focus in institutions on discussions about planning
and policies related to clinical governance as a political and
operational strategy and integrated governorship structure,
but only as a response to a tutelary requirement.13
And finally, another gap identified in the literature review
relates to the breakdown in the fulfilment of the steps in the
audit cycle. Highlighting E6, this study concluded that the
impacts of national audits can be improved by strengthening
all aspects of feedback loops, especially effective feedback,
and by considering how different ways of reinforcing
feedback work together.16 E7 also identifies the lack of
dissemination of results, which can demotivate the
organisation's employees in the audit process to promote
quality, diverting the focus from the primary purpose.17
According to the National Plan for Patient Safety 2021-2026
(PNSD 2021-2026), which aims to consolidate and promote
safety in the provision of health care, defining Leadership
and governance as Pillar 2, it states that leaders and
managers must lead the institution to a level where patients,
families and health professionals feel confident and open to
discuss and anticipate the fragilities of the system, as well as
the possibility of undesirable events, families and healthcare
professionals feel confident and open to discuss and
anticipate the weaknesses of the system, together with the
possibility of undesirable events occurring, but also to
respond transparently to the challenges of the complexity
inherent in the provision of healthcare, guaranteeing a
culture centred on safety. 20
In view of the main results obtained, namely the effects
on access to quality care, guaranteeing user safety, as
well as collective responsibility and accountability. It is
considered that clinical auditing, as one of the pillars of
clinical governance, promotes quality in clinical
practice and is part of a strategy to be adopted by health
institutions in pursuit of achieving objectives, such as
meeting the requirements defined by the PNSD 2021-
2026.
Conclusion
Clinical audits are a careful, structured, systematic and
ongoing analysis in which peers investigate whether
the care provided meets the best available "evidence",
whether the procedures carried out are in line with
what is accepted as the best options and practices.
There is an urgent need to distinguish the external
audits (accreditations, certifications) that are so much
in vogue in our reality from audits in which peers, at
the level of services and departments, continually
assess their performance and the results of the teams
they are part of, according to strict quality criteria.
Quality audits by external auditors only make sense in
the context of organisations where internal audits are
a culturally ingrained practice. Clinical auditing makes
it possible to start a cycle by identifying opportunities
for improvement, designing and implementing actions
aimed at correcting or improving the provision of
care, and then auditing again. As such, it can be
described as a succession of stages that develop in a
cycle and in which the succession of several cycles
evolves in a spiral - this is continuous quality
improvement.
Continuous improvement in the quality of clinical and
relational performance will translate into user
satisfaction and health gains. Clinical governance leads
to the recognition that promoting best practice is one
of the main drivers of economic efficiency. It creates
the necessary conditions for continuous quality
improvement, based on a culture of leadership, co-
operation, learning and motivation, process
management, risk management, transparency and
social responsibility. It plays a crucial role in ensuring
adherence to regulations and legal standards,
minimising legal and financial risks and promoting
clinical management based on responsibility and
transparency. This is paramount for maintaining the
trust of users and the credibility of institutions in the
eyes of regulatory bodies and society as a whole,
ensuring that healthcare practices are always in line
with legal and ethical requirements. The effective
implementation of health audit programmes, despite
bringing numerous benefits, faces a number of
significant challenges. One of the main obstacles is
resistance to change on the part of healthcare
Pensar Enfermagem / v.29 n.01 / february 2025
DOI: 10.71861/pensarenf.v29i1.341 /e00341
Review Article
professionals, which can be caused by discomfort with new
procedures or a perceived increase in workload. In
addition, the need to maintain a culture of continuous
updating with best practices and constantly evolving
regulations requires investment of time and resources.
Securing sufficient resources, including funding, personnel,
as well as technology, also stands out as a critical challenge
to carrying out comprehensive and effective audits. 8
As implications for research and nursing practice, we
obtained a snapshot of the evidence on auditing as a pillar
of clinical governance in promoting quality in a hospital
environment. The study could operate as a facilitator and
adjunct to the process of implementing/continuing quality
in organisations, becoming a benchmarking tool and a
manual of good practices for implementing quality in a
sustained way in hospital organisations. In response to the
question "What effects does clinical governance have on
promoting quality in clinical practice through the auditing
process?" we can state that clinical auditing is an asset in
the clinical governance process, so its systematic practice
promotes an increase in clinical effectiveness, risk
management, professional development, as well as
transparency in terms of publicising the results obtained,
ensuring standards of professional practice and promoting
continuous improvement in the quality of services.
As a suggestion for future research, we propose, to analysing
articles in the primary health care, as we found the latter
already had a long way to go in the field of clinical
governance. We also suggest extending the studies to
include private hospitals, as well as using tools such as
benchmarking to analyse the health gains achieved through
clinical governance.
Authorship and Contributions
Bernardino SP: Conception and design of the study; Data
collection; Data analysis and interpretation; Writing the
manuscript; Critical revision of the manuscript; Approval of
the final version of the manuscript and taking responsibility
for it;
Bernardino CP: Conception and design of the study; Data
collection; Data analysis and interpretation; Writing the
manuscript; Critical revision of the manuscript; Approval of
the final version of the manuscript and taking responsibility
for it;
Conflicts of interest and financing
No conflicts of interest have been declared by the authors.
Sources of support / Funding
The study was not funded.
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