**4.2 Reasonable-care model**

Also known as a due-care model, reasonable care builds on and goes a step further than the minimalist model. The technologist must take reasonable precautions and to provide care in practice (especially in the engineering profession). Interestingly, every major philosophical theory of ethics includes such a provision, such as three mentioned previously, i.e. the categorical imperative in duty ethics, the harm principle in utilitarianism, and the veil of ignorance in social contract ethics.

Determining what is reasonable can be quite subjective, so this model applies a mechanism borrowed from the legal profession, i.e. the *reasonable person standard*. Applying this to emerging technologies, the result of the decision to design or use a new technology is measured against the metric of the degree to which the design and use would be seen as ethical or unethical according to a "standard of reasonableness as seen by a normal, prudent nonprofessional"(ASME 2012).

In a highly technical area, this mechanism should be based on a more knowledgeable *and* reasonable person, i.e. a "reasonable engineer standard" or "reasonable scientist standard." If the innovator is an engineer, for example, this affiliation adds a professional onus. Not only should an action be acceptable to the majority of users it should also be acceptable to one's peers in the profession, as well as to scientists and designers outside of engineering, depending on the technology itself.

An action could very well be legal, and even professionally permissible, but may still fall below the ethical threshold if reasonable people consider it to be wrong.

### **4.3 Good works model**

A truly ethical model goes beyond obeying the law or preventing harm. An ethical innovator excels beyond the standards and codes and does the right thing to improve product safety, public health or social welfare. Doing what is "right" is more than simply avoiding what is "wrong." Much as peace is more than the absence of war, research integrity is more than avoiding immoral acts. It requires a proactive and preventive approach. Ethics must be integrated throughout the design life cycle (Vallero and Vesilind 2007). Certainly, the rules are important, but legality and morality are not completely inclusive (See Fig. 6).

The good works model is rooted in the moral development theories such as those expounded by Kohlberg (1981), Piaget (1965), Rest (1986), and Rest et al. (1999), who noted that moral action is a complex process entailing four components: moral sensitivity, judgment, motivation and character. They and others (e.g., Duska and Whelan, 1975) have noted that the age and education level are the two most important factors in determining a person's likelihood of making moral judgments, prioritizing moral values, and following

to predict problems, and is often certainly in the best position to foresee low probability, negative outcomes. In other words, the innovator may see the flaws of existing performance criteria and rules in assuring the safety, health and welfare. Knowing this places the onus on the innovator, since the regulators may not be aware of the potential risks (sometimes in ethical inquiries, the conclusion is that an engineer "knew or should have known" the risks

Also known as a due-care model, reasonable care builds on and goes a step further than the minimalist model. The technologist must take reasonable precautions and to provide care in practice (especially in the engineering profession). Interestingly, every major philosophical theory of ethics includes such a provision, such as three mentioned previously, i.e. the categorical imperative in duty ethics, the harm principle in utilitarianism, and the veil of

Determining what is reasonable can be quite subjective, so this model applies a mechanism borrowed from the legal profession, i.e. the *reasonable person standard*. Applying this to emerging technologies, the result of the decision to design or use a new technology is measured against the metric of the degree to which the design and use would be seen as ethical or unethical according to a "standard of reasonableness as seen by a normal, prudent

In a highly technical area, this mechanism should be based on a more knowledgeable *and* reasonable person, i.e. a "reasonable engineer standard" or "reasonable scientist standard." If the innovator is an engineer, for example, this affiliation adds a professional onus. Not only should an action be acceptable to the majority of users it should also be acceptable to one's peers in the profession, as well as to scientists and designers outside of engineering,

An action could very well be legal, and even professionally permissible, but may still fall

A truly ethical model goes beyond obeying the law or preventing harm. An ethical innovator excels beyond the standards and codes and does the right thing to improve product safety, public health or social welfare. Doing what is "right" is more than simply avoiding what is "wrong." Much as peace is more than the absence of war, research integrity is more than avoiding immoral acts. It requires a proactive and preventive approach. Ethics must be integrated throughout the design life cycle (Vallero and Vesilind 2007). Certainly, the rules are important, but legality and morality are not completely

The good works model is rooted in the moral development theories such as those expounded by Kohlberg (1981), Piaget (1965), Rest (1986), and Rest et al. (1999), who noted that moral action is a complex process entailing four components: moral sensitivity, judgment, motivation and character. They and others (e.g., Duska and Whelan, 1975) have noted that the age and education level are the two most important factors in determining a person's likelihood of making moral judgments, prioritizing moral values, and following

below the ethical threshold if reasonable people consider it to be wrong.

and declared them before the problems occurred).

**4.2 Reasonable-care model**

ignorance in social contract ethics.

nonprofessional"(ASME 2012).

depending on the technology itself.

**4.3 Good works model**

inclusive (See Fig. 6).

Fig. 6. Ethical decisions differ from legal decisions. Legality can be a subset of ethical decisions (A). An example is a biomedical researcher's responsibility to abide by copyright and intellectual property laws. In addition, ethics also includes extra-legal responsibilities, such as maintaining competence in the scientific discipline. Other situations may arise where a certain amount of legal behavior is, in fact, unethical (B). An example is the paying of bribes or gratuities or conducting research without appropriate informed consent of the subjects, which in certain cultures may be legal or even mandated by regulations. On rare occasions, the laws may be completely unethical (C), such as slavery. Some would argue, for example, that current research like embryonic stem cell and blastocyst research, cloning, and animal experimentation falls into this category.

Ethical Decisions in Emergent Science, Engineering and Technologies 41

Fig. 7. Comparison of Kohlberg's moral development stages to technological ethics

organization they represent, but also the broader society and even future generations.

is a challenge for such a results-oriented profession.

Ethical content is not an afterthought, but integrated within the decision making process. That is, the engineering exemplars recognize the broad impacts their decisions may have, and they act in such a way that their actions will be in the best interest of not only themselves and the

Much of the ethics training to date has emphasized pre-conventional thinking; that is, adherence to codes, laws and regulations within the milieu of profitability for the organization. This benefits the technologist and the organization, but is only a step toward full professionalism. Those who teach engineering ethics must stay focused on the engineer's principal client, "the public." One interpretation of the "hold paramount" provision mentioned previously is that it has primacy over all the others. So, anything the professional engineer does cannot violate this canon. No matter how competent, objective, honest, and faithful, the engineer must not jeopardize public safety, health or welfare. This

Technical professionals must navigate through their professional codes. The NSPE code, for instance, reminds its members that "public health and welfare are paramount

(Vallero 2007).

through on moral decisions. Consistent with Aristotle's argument that the way to achieve excellence is though practice, experience is particularly critical regarding moral judgment: A person's ability to make moral judgments tends to grow with maturity in pursuit of further education, generally reaching its final and highest stage of development in early adulthood. This theory of moral development is illustrated in Table 2.

Table 2. Kohlberg's (1981) stages of moral development.

During the two earliest stages of moral development, i.e. the "pre-conventional level," a person is primarily motivated by the desire to seek pleasure and avoid pain. This is similar to the malpractice model. The "conventional level" consists of stages three and four: In stage three, the consequences that actions have for peers and their feelings about these actions; in stage four, considering how the wider community will view the actions and be affected by them. The parallel here is with the reasonable-care model. Only a minority reach the "postconventional" stage, wherein they have an even broader perspective: Their moral decision making is guided by universal moral principles (Kant 1785); that is, by principles which reasonable people would agree should bind the actions of all people who find themselves in similar situations. This stage tracks closely with the good works model.

A normative model can be applied to emerging technologies. The moral need to consider the impact that the use of a technology will have on others forms the basis for the normative model. Pursuing a technological advancement merely with the goal of obeying the law may lead to avoiding punishment for wrongdoing, but it is not usually sufficient for any technological pursuit, let alone one with the uncertainties of emerging technologies. Pursuing a technology with the goal of improving profitability is clearly in line with investors' desires; but presumably customers', suppliers', and employees' desires must also be met at some level. And finally, pursuing an activity with the goal of "doing the right thing," behaving in a way that is morally right and just, can be the highest level of engineering behavior. This normative model of ethical engineering can be illustrated as Fig. 7.

There is a striking similarity between Kohlberg's model of moral development and growth within a technical profession. Avoiding punishment in the moral development model is similar to the need to avoid problems early in one's career. The pre-conventional level and early career experiences have similar driving forces.

The second level focuses on peers and community. The engineer must balance the needs of clients and fellow professionals with those of society at large. Engineering services and products must be of high quality and be profitable, but the focus is shifting away from selfcenteredness and personal well-being toward external goals.

Universal moral principles begin to govern actions at the highest level of moral development. The driving force or motivation is trying to do the right thing on a moral (not legal, financial or even advancement of science) basis. These behaviors set an example, now and in the future.

through on moral decisions. Consistent with Aristotle's argument that the way to achieve excellence is though practice, experience is particularly critical regarding moral judgment: A person's ability to make moral judgments tends to grow with maturity in pursuit of further education, generally reaching its final and highest stage of development in early adulthood.

Pre-Conventional Level 1. punishment-obedience orientation

Conventional Level 3. "good boy"-"nice girl" orientation

During the two earliest stages of moral development, i.e. the "pre-conventional level," a person is primarily motivated by the desire to seek pleasure and avoid pain. This is similar to the malpractice model. The "conventional level" consists of stages three and four: In stage three, the consequences that actions have for peers and their feelings about these actions; in stage four, considering how the wider community will view the actions and be affected by them. The parallel here is with the reasonable-care model. Only a minority reach the "postconventional" stage, wherein they have an even broader perspective: Their moral decision making is guided by universal moral principles (Kant 1785); that is, by principles which reasonable people would agree should bind the actions of all people who find themselves in

A normative model can be applied to emerging technologies. The moral need to consider the impact that the use of a technology will have on others forms the basis for the normative model. Pursuing a technological advancement merely with the goal of obeying the law may lead to avoiding punishment for wrongdoing, but it is not usually sufficient for any technological pursuit, let alone one with the uncertainties of emerging technologies. Pursuing a technology with the goal of improving profitability is clearly in line with investors' desires; but presumably customers', suppliers', and employees' desires must also be met at some level. And finally, pursuing an activity with the goal of "doing the right thing," behaving in a way that is morally right and just, can be the highest level of engineering behavior. This normative

There is a striking similarity between Kohlberg's model of moral development and growth within a technical profession. Avoiding punishment in the moral development model is similar to the need to avoid problems early in one's career. The pre-conventional level and

The second level focuses on peers and community. The engineer must balance the needs of clients and fellow professionals with those of society at large. Engineering services and products must be of high quality and be profitable, but the focus is shifting away from self-

Universal moral principles begin to govern actions at the highest level of moral development. The driving force or motivation is trying to do the right thing on a moral (not legal, financial or even advancement of science) basis. These behaviors set an example, now

Post-Conventional Level 5. social contract orientation

similar situations. This stage tracks closely with the good works model.

2. personal reward orientation

6. universal ethical principle orientation

4. law and order orientation

This theory of moral development is illustrated in Table 2.

Table 2. Kohlberg's (1981) stages of moral development.

model of ethical engineering can be illustrated as Fig. 7.

early career experiences have similar driving forces.

and in the future.

centeredness and personal well-being toward external goals.

Fig. 7. Comparison of Kohlberg's moral development stages to technological ethics (Vallero 2007).

Ethical content is not an afterthought, but integrated within the decision making process. That is, the engineering exemplars recognize the broad impacts their decisions may have, and they act in such a way that their actions will be in the best interest of not only themselves and the organization they represent, but also the broader society and even future generations.

Much of the ethics training to date has emphasized pre-conventional thinking; that is, adherence to codes, laws and regulations within the milieu of profitability for the organization. This benefits the technologist and the organization, but is only a step toward full professionalism. Those who teach engineering ethics must stay focused on the engineer's principal client, "the public." One interpretation of the "hold paramount" provision mentioned previously is that it has primacy over all the others. So, anything the professional engineer does cannot violate this canon. No matter how competent, objective, honest, and faithful, the engineer must not jeopardize public safety, health or welfare. This is a challenge for such a results-oriented profession.

Technical professionals must navigate through their professional codes. The NSPE code, for instance, reminds its members that "public health and welfare are paramount

Ethical Decisions in Emergent Science, Engineering and Technologies 43

 NG = (goodness of each consequence) x (importance) x (likelihood) (3) These analyses sometimes use ordinal scales, such as 0 through 3, where 0 is nonexistence (e.g. zero likelihood or zero importance) and 1, 2 and 3 are low, medium and high, respectively. Thus, there may be many small consequences that are near zero in importance and, since NG is a product, the overall net goodness of the decision is driven almost entirely by one or a few important and likely consequences. There are two cautions in using this approach. First, although it appears to be quantitative, the approach is very subjective. Second, as we have seen many times in cases involving health and safety, even a very

The tool can be modified from a purely ethical decision making tool to a risk management tool by incorporating the net goodness into a decision tree. For example, Fig. 8 shows a hypothetical decision on whether to use a GMO (Vallero 2010). The decision is based on the likelihood of various beneficial and adverse outcomes, with ranked importance to three receptors: the environment; public health; and food production. The analysis is qualitative, but can help to identify important factors, as well as potential downstream impacts and artifacts of an immediate decision. The difficulty will be to arrive at probabilities to fill the "likelihood" column. Sometimes these are published, but often will have to be derived from focus groups and expert elicitation. Often, likelihood is presented as an ordinal scale (e.g.

> Non-target effects Biodiversity effects

**Second Order Outcome**

> Pest resistance Crop damage

Direct poisoning\* Indirect contamination (e.g.

Cross-resistant bacteria

Transgenic food problems

track-in)

Fig. 8. Decision tree and net goodness analysis of a decision to insert *Bacillus thuringiensis*  genetic material into crops near an ecosystem. Data are hypothetical. Vallero 2010).

\*This has its own decision tree according to vulnerability index, i.e. percentile exposure (high to no exposure) and sensitive

**1 = Best; 5 = Worst**

**NA 5**

**NA**

Environment

**Likelihood** 0.810

0.005

0.001

0.010 0.020

0.002

0.030

0.020 0.002

0.100

**Importance** Public Health

**1 1 1**

**5 2 3 5 3 2**

**3 2 4 3 3 5**

**3 5 4 3 5 4**

**5 5 5 3 3 5**

Food Production

unlikely but negative consequence is unacceptable.

high, medium, or low – or 1, 2, or 3).

Efficacious with no human health impacts, but with ecological impacts

Efficacious with agricultural effects

Efficacious with human health impacts, but without ecological impacts

Nonefficacious

subpopulations (children, elderly, asthmatic, etc.)

Efficacious with no impacts

**First Order Outcome**

Spores and crystalline insecticidal proteins

considerations." Public safety and health considerations affect the design process directly. Almost every design now requires at least some attention to sustainability and environmental impacts. For example, recent changes in drug delivery have been required, such as moving away from the use of greenhouse gas propellants like chlorofluorocarbons (CFCs) and instead using pressure differential systems (such as physical pumps) to deliver medicines. This may seem like a small thing or even a nuisance to those who have to use them, but it reflects an appreciation for the importance of incremental effects. One inhaler does little to affect the ozone layer or threaten the global climate, but millions of inhalers can produce enough halogenated and other compounds that the threat must be considered in designing medical devices.

Technologists must consider how sustainable the technology will be over its useful lifetime. This requires thinking about the life cycle, not only during use, but when the use is complete. Such programs as "design for recycling" (DFR) and "design for disassembly" (DFD) allow the engineer to consider the consequences of various design options in space and time. They also help designers to pilot new systems and to consider scale effects when ramping up to full production of devices. However, if such a change inordinately affects a vulnerable population, this must be weighted properly in the decision. For example, if asthmatics are placed at additional risk due to a less efficacious delivery system, albeit more environmentally acceptable, it is likely not the best alternative. That is, the risk tradeoff between biomedical and environmental values leans more heavily toward the biomedical value (treating asthma effectively).

This illustrates that like virtually everything else in engineering, best serving the public is a matter of optimization. The variables that we choose to give large weights will often drive the design. The technologist must continue to advance the state-of-the science in high priority areas. Any possible adverse effects must also be recognized. These should be incorporated and properly weighted when we optimize benefits. We must weigh these benefits against possible hazards and societal costs.


*Right Game, Wrong Place? A Case Study: Using a Gamified AR Application in a Heritage… DOI: http://dx.doi.org/10.5772/intechopen.107535*

During this time there was a significant backlash against this conception of gamification, fermented most notably by Ian Bogost [3] who offered the term 'exploitationware' as a better description. It was argued that it reduces games to the '*incidental properties of their medium, points and leaderboards'* [3] and seeks to parcel up these mechanics into productivity products, which are devoid of the '*playful experiences meant to produce gratification*'. This position was supported by Thibault [9] who viewed gamification as certainly problematic and potentially dystopian, and Dragona [15], who positioned gamification as a mechanism *to 'enable exploitation and control'.* Koster went on to state that gamification misses the point of what a game should be, using '*the trappings of games (reward structures, points, etc.) to make people engage more with product offerings'* ([13], p. 50). Layering these trapping '*on top of systems that lack the rich interpretability of a good game. A reward structure alone does not a game make'* [13]*.* Nicholson [16] characterises this as a difference between meaningful and (BLAP) gamification with BLAP standing for badges, levels and leaderboards, achievements and points. Implicit in this debate are the opposing ideas of what elements within a game actually create the positive experiences that motivate and engage. On the one hand, this is positioned as the mechanics; the achievement of a certain level, or the accrual of points within the system in and of itself [12]. On the other, it is the more expansive notion of the contextually specific experience of engaging with a complex system in which playful moments are attained to produce gratifications [3].

This debate is essential to an exploration of the efficacy of Temple Newsam Augmented Reality (TNAR), in that the project aimed to create a gamified system that is enjoyable in its own right; to simultaneously educate and entertain. The participants, far from being paid to engage with a task that could be gamified to increase their productivity, had paid to visit the space in which the game was situated. As such it is incumbent on the gamified system itself to evoke pleasure in those engaging with it. To achieve this, an understanding of which characteristics within the gamified system deliver these positive experiences is required. Is it the mechanical or the experiential or a more complicated and context-specific combination of the two as suggested by, for example Tulloch [5]. According to Koster [17], gaming is fundamentally about fun, and that fun, when elicited by playing games, is complex, individual and related to learning and mastery, exploration and rich interpretations.

Bilda [18] aligned positive experience to the notion of 'meaningful play', which is achieved by designing *'experiences that have meaning and are meaningful' (p.34),* with this meaning emerging from *'the interaction between players and the system of game, as well as from the context in which the game is played*'*.* Two notions are contained in this quote: the first relates to context and will be returned later. The second is the notion of enjoyment, which is at once entirely obvious and often overlooked. The reason players play games is because they are fun. This is the underlying premise of gamification, that it can make a rote or uninteresting task enjoyable or engaging. The perceived enjoyment of the participant is positively related to their continuance intention [19]. Salen and Zimmerman point to the writing of Caillios [20] as proving a model to understand this, offering characteristics of play and pleasure through which positive experience can be understood, designed for and measured. This provides a potential way forward that bypasses the rhetoric of the above debate and looks at the fundamentals of play, *'the task is to find how this potential can be translated to actuality'* [21]. To do this, a wider exploration of the history and theory of game playing and the pleasure it offers is needed, this being the focus of the next section.


**7. Acknowledgment**

28 Recent Advances in Arthroplasty

catabolic damages could directly influence on the very high preoperative serum TGF-β1 level. The cytokines familiar with the growth factors group are major factors responsible for the metabolic processes of chondrocytes, consequently for their homeostasis (Shin-Han et al. 2009). TGF-β have role in recruiting immune cells to site of injury and facilitates wound healing by influence for connective tissue remodeling relates with fibroblast proliferation and the synthesis of a number of extracellular matrix proteins (Cutroneo, 2007). Data on dynamic changes of postoperative serum concentration of tested cytokines showed not significant differences (p>0.05). Indeed, the postoperative results of cytokines concentration (IL-6 and TGF-β) revealed the insignificant changes in both groups of patient, regardless the disease severity. The one of possibly explanation for this finding is the significant impairment of inflammatory response due to autoimmune disease. In contrast, many reports have demonstrated the dynamics of the IL-6 increase after surgery in groups of patients with normal immune system (Minetto et al., 2006; Demura et al., 2006;

The CRP levels significantly increased after surgery. The peak level occurred at 36 hour. The changes were similar for both groups. CRP is most important factor involved in inflammatory response and may reflect the surgical magnitude. Its concentration is normally less than 10 mg/L. In this study, the elevated levels of CRP before surgery could be evidence of confirm the chronic inflammatory state. The concentration of CRP revealed

Regional anaesthesia decreases the neuroendocrine response but does not influence on the inflammatory response (Moor et al., 1994; Naito et al., 1992; Høgevold et al., 2000). Both, the regional and general anaesthesia does not significantly influence on the postoperative immunosuppression decrease [Kawasaki et al., 2007). As the matter of fact, the postoperative changes demonstrated in this study may reflect the modulation of immune

The tourniquet time seemed not to have an influence on the serum cytokines level dynamic changes. The average tourniquet time was 86.6 in group 1 and in group 2 was 95.3 minutes. The tourniquet time longer than 105 minutes was found as statistically significant according

Data on the dynamic changes of postoperative serum concentration of tested cytokines revealed the impairment response of the immune system to surgical stress, regardless of the

Together, the evidence presented above suggests that it may be possible to identify patients likely to develop a more intensive problems with wound healing and postoperative complications. In conclusion the abnormal immune system with chronic inflammatory

The future experiments has to be enlarged on the other immunological response factors evaluations including endothelial dysfunction factors. The chronic inflammatory response influence on the wound healing process has to be evaluate in details. Thus, the major role of the growth factors while fibroblastic proliferation reactions as the key pathogenic factor

process due to autoimmune disease can attenuate the cytokines response to surgery.

response to stress surgery due to the chronic inflammatory response.

Cruickshank et al., 1990).

no significant differences between groups.

to the results of previous study (Tak et al., 2000).

during rheumatoid arthritis has to be initially evaluated.

**6. Conclusion and future research**

intensity of disease activity.

The immunological and laboratory tests have been done in the Department of Immunopathology and the Diagnostic Laboratory of the Institute of Rheumatology. Author is extremely grateful to Professor Ewa Kontny for her consultations on the immunological problems.


**3. Soy, estrogen, and breast cancer**

Breast cancer is one of the most common cancers diagnosed in women in the United States, and is the second leading cause of death after lung cancer in women [33]. Breast cancer is strongly linked to ovarian hormones and estrogen levels [34]. Factors like high endogenous estrogen levels and hormone therapy have been implicated in increasing breast cancer risk [35]. Indeed, 2/3 of breast cancer cases are estrogen receptor (ER) positive [36].

Because soy isoflavones closely resemble estrogen, many health practitioners warn against soy consumption in women, women with breast cancer, and postmenopausal women for fear that soy will behave like an estrogen molecule. In our opinion, this idea is misconceived, as soy isoflavones would likely compete with endogenous estrogen for binding receptor sites in the breast, thereby reducing estrogen-stimulated growth and proliferation in the breast tissue, and may reduce endogenous estrogen concentrations [37]. Indeed, it has been shown that soy isoflavones may act as an estrogen antagonist in estrogen rich environments, and an estrogen agonist in low estrogen environments [38]; there is also evidence that the bioavailability of soy isoflavones may be inversely related to estrogen levels [39].

Epidemiological studies have shown that soy isoflavones do exert a protective effect on breast cancer risk, indicating a 16% risk reduction per 10 mg of daily isoflavone consumed [40]. A Dutch study [41] found that high levels of plasma genistein were associated with up to a 32% decreased risk of breast cancer. A 2009 study [42] that investigated soy food intake and breast cancer survival found that soy food consumption was associated with a marked decreased risk of both mortality and recurrence of breast cancer.

A 1997 study [43] found that genistein is a potent estrogen agonist and exhibited cell growth-inhibitory actions in breast cancer cells *in vitro*. A more recent study [44] also found that genistein works to inhibit topoisomerase II activity, thus resulting in the inhibition of breast cancer growth. Davis et al. [45] investigated the radioprotective effects of genistein by injecting female mice with the isoflavone 24 h prior to receiving a toxic dose of radiation, and found that genistein treated mice expressed fewer DNA damage responsive and cell cycle checkpoint genes than untreated mice. Magee et al. [46] investigated the effect of coumestrol, glycitein, daidzein, and the metabolites equol and O-desmethylangolensin on MDA-MB-231 cells, finding that each inhibited invasion by approximately 30% at the lowest dose, while genistein and coumestrol exerted the most potent inhibitory effects on invasion at the highest dose.

 There was a subset of tumors with upregulated FGFR2 expression, which is a marker of poor prognosis in breast cancer patients, and overall soy intake did not significantly change cell proliferation and apoptosis indices compared with the placebo group. While this initially sounds discouraging, the article points out that the clinical ramifications of this minor upregulation have yet to be determined.

Another common concern about soy supplementation in post-menopausal women, specifically, is that it causes lymphocytopenia, which is the condition of having low levels of lymphocytes in the blood. Some of these concerns stem from a multicenter study [48] published in 2001 where postmenopausal women supplemented 600 mg of ipriflavone, a synthetic isoflavone, for 3 years. Out of 234 women, 13.2% developed subclinical lymphocytopenia (<0.5 × 103 /mm3 ). Another 2 year study [49] found that 3% of their participants also developed abnormal

**29**

**5. Soy, leptin, and OA**

*Evidence for the Effectiveness of Soy in Aging and Improving Quality of Life*

lymphocyte numbers. Another study by Ben-Hurt et al. [50] found that postmenopausal women also had higher monocyte levels, indicating that menopause

A rat study [51] by our lab refutes these results. Our study not only found that ovariectomy increased lymphocyte, monocyte, eosinophil, and basophil differential counts, but that soy isoflavones retuned leukocyte counts to pre-surgery levels. To test the truth of this in human populations, our lab also investigated the extent to which 1 year of 25 g soy protein containing 60 mg isoflavones supplementation alters lymphocyte counts in postmenopausal women [52]. This study indicated no effect on total and differential white blood cell counts in postmenopausal women, which may be due to the fact that the estimated isoflavone content of the soy protein

Because leukocyte counts tend to go up with menopause, it is not necessarily a bad side effect for pharmaceutical doses of soy to bring down white blood cell counts. Additionally, the supplementation of soy protein did not have a significant impact on leukocyte levels, indicating that soy supplementation is generally safe for

Interestingly, OA is often seen in postmenopausal women, and is three times more likely to be a problem for postmenopausal women rather than men [53]. Cartilage is an estrogen sensitive tissue, which may, in part, explain the gender disparity. Because postmenopausal women experience a severe drop in the production of estrogen, it stands to reason that estrogen may be protective against the development of OA. Some studies [54–56] have found an association between hysterectomy and OA, while others [57, 58] have found no association. A study by Gao et al. [59] found that estradiol (E2) deficiency as well as changes in estrogen metabolites are involved in the pathogenesis of OA. Increased cartilage and bone turnover has been found in multiple animal models of menopause [60], but contrary to a general belief that lack of estrogen in women is the cause of OA, Tsai and colleagues [61] have suggested that excessive level of synovial fluid estrogen is responsible for the development of OA in both men and women. Indeed, some studies have found that the direct administration of estrogen to the knee joint has increased OA instance and progression [62, 63]. Intraarticular estradiol injection to ovariectomized rabbits both upregulated ER and ultimately caused further cartilage degeneration [64]. Soy isoflavones are often referred to as phytoestrogens, and may be helpful in relieving some symptoms of OA, and possibly prevent its progression. The conformational binding of soy isoflavones is similar to that of a SERM, which have been shown to be effective estrogen agonists or antagonists [65]. Genistein is the most potent of the isoflavones, and can therefore hypothetically produce positive effects on cartilage by blocking the action of estrogen. In addition to the possibility of modulating ERs, soy isoflavones may be able to increase IGF-1 production and decrease inflammation while also acting as an antioxidant. IGF-1 is thought to slow cartilage degradation [66]. Because soy isoflavones may serve as a natural modulator of IGF-1 production, it

is probable that consumption of soy would benefit people suffering from OA.

Leptin is of particular interest in the pathology of OA, as the severity of OA is associated with both weight and BMI [67, 68], and leptin is generally elevated in

*DOI: http://dx.doi.org/10.5772/intechopen.85664*

definitively alters hematological parameters.

was lower than the pharmacological dose at 60 mg.

healthy postmenopausal populations.

**4. Soy, estrogen, and OA**

*Evidence for the Effectiveness of Soy in Aging and Improving Quality of Life DOI: http://dx.doi.org/10.5772/intechopen.85664*

lymphocyte numbers. Another study by Ben-Hurt et al. [50] found that postmenopausal women also had higher monocyte levels, indicating that menopause definitively alters hematological parameters.

A rat study [51] by our lab refutes these results. Our study not only found that ovariectomy increased lymphocyte, monocyte, eosinophil, and basophil differential counts, but that soy isoflavones retuned leukocyte counts to pre-surgery levels. To test the truth of this in human populations, our lab also investigated the extent to which 1 year of 25 g soy protein containing 60 mg isoflavones supplementation alters lymphocyte counts in postmenopausal women [52]. This study indicated no effect on total and differential white blood cell counts in postmenopausal women, which may be due to the fact that the estimated isoflavone content of the soy protein was lower than the pharmacological dose at 60 mg.

Because leukocyte counts tend to go up with menopause, it is not necessarily a bad side effect for pharmaceutical doses of soy to bring down white blood cell counts. Additionally, the supplementation of soy protein did not have a significant impact on leukocyte levels, indicating that soy supplementation is generally safe for healthy postmenopausal populations.

## **4. Soy, estrogen, and OA**

Interestingly, OA is often seen in postmenopausal women, and is three times more likely to be a problem for postmenopausal women rather than men [53]. Cartilage is an estrogen sensitive tissue, which may, in part, explain the gender disparity. Because postmenopausal women experience a severe drop in the production of estrogen, it stands to reason that estrogen may be protective against the development of OA. Some studies [54–56] have found an association between hysterectomy and OA, while others [57, 58] have found no association. A study by Gao et al. [59] found that estradiol (E2) deficiency as well as changes in estrogen metabolites are involved in the pathogenesis of OA. Increased cartilage and bone turnover has been found in multiple animal models of menopause [60], but contrary to a general belief that lack of estrogen in women is the cause of OA, Tsai and colleagues [61] have suggested that excessive level of synovial fluid estrogen is responsible for the development of OA in both men and women. Indeed, some studies have found that the direct administration of estrogen to the knee joint has increased OA instance and progression [62, 63]. Intraarticular estradiol injection to ovariectomized rabbits both upregulated ER and ultimately caused further cartilage degeneration [64].

Soy isoflavones are often referred to as phytoestrogens, and may be helpful in relieving some symptoms of OA, and possibly prevent its progression. The conformational binding of soy isoflavones is similar to that of a SERM, which have been shown to be effective estrogen agonists or antagonists [65]. Genistein is the most potent of the isoflavones, and can therefore hypothetically produce positive effects on cartilage by blocking the action of estrogen. In addition to the possibility of modulating ERs, soy isoflavones may be able to increase IGF-1 production and decrease inflammation while also acting as an antioxidant. IGF-1 is thought to slow cartilage degradation [66]. Because soy isoflavones may serve as a natural modulator of IGF-1 production, it is probable that consumption of soy would benefit people suffering from OA.


**Laser Shock Processing and Related Phenomena**

Editors

**Jos ´e Luis Oca ˜na Janez Grum**

MDPI • Basel • Beijing • Wuhan • Barcelona • Belgrade • Manchester • Tokyo • Cluj • Tianjin

*Editors* Jose Luis Oca ´ na˜ Polytechnical University of Madrid Spain

Janez Grum University of Ljubljana Slovenia

*Editorial Office* MDPI St. Alban-Anlage 66 4052 Basel, Switzerland

This is a reprint of articles from the Special Issue published online in the open access journal *Metals* (ISSN 2075-4701) (available at: https://www.mdpi.com/journal/metals/special issues/LSP technology).

For citation purposes, cite each article independently as indicated on the article page online and as indicated below:

LastName, A.A.; LastName, B.B.; LastName, C.C. Article Title. *Journal Name* **Year**, *Article Number*, Page Range.

**ISBN 978-3-03936-798-6 (Hbk) ISBN 978-3-03936-799-3 (PDF)**

c 2020 by the authors. Articles in this book are Open Access and distributed under the Creative Commons Attribution (CC BY) license, which allows users to download, copy and build upon published articles, as long as the author and publisher are properly credited, which ensures maximum dissemination and a wider impact of our publications.

The book as a whole is distributed by MDPI under the terms and conditions of the Creative Commons license CC BY-NC-ND.


**Assessment of Workplace Safety Climate among Healthcare Workers during the COVID-19 Pandemic in Low and Middle Income Countries: A Case Study of Nigeria**

**Haruna Musa Moda 1,\* , Fabian M. Dama 2 , Christopher Nwadike 3 , Basim S. Alatni 4 , Solomon O. Adewoye 5 , Henry Sawyerr 6 , Pauline J. S. Doka 7 and Mela Danjin 7**

**Abstract:** The COVID-19 pandemic has presented several organizations with the opportunity to review their operational strategies, as well as the existing safety climate within their establishments. The healthcare sector is not an exception, especially those in Low and Middle Income Countries (LMICs), where most safety systems are not robust when compared with developed countries. The study aim is to assess the occupational safety climate among healthcare workers (HCWs) in LMICs using Nigeria as a case study. A cross-sectional study was adopted to measure safety climate perception among professionals working in healthcare establishment during the COVID-19 pandemic using a validated Nordic Safety Climate Questionnaire (NOSACQ-50). At the end of the survey period, 83% (433) of the responses were adjudged to have met the threshold criteria and were used to inform the study outcome. Worker safety commitment within the healthcare facilities (*M* = 3.01, *SD* = 0.42) was statistically significantly higher than management safety priority, commitment, and competence (*M* = 2.91, *SD* = 0.46), *t*(130.52), *p* < 0.001. A significant effect of the management role was found in regards to management safety priority, commitment, and competence (*F*(1, 406) = 3.99, *p* = 0.046, η 2 = 0.010). On the contrary, the managerial position does not have a significant effect on worker safety commitment (*F*(1, 417) = 0.59, *p* = 0.440, η 2 = 0.001). The outcome from the study showed that, where there is active promotion of a positive safety climate in healthcare sectors in LMICs, employees are more likely to engage in positive safety behaviour. To help address the identified gaps, there is the need for more effort to be made towards promoting an effective and positive safety climate across the establishment, including management and healthcare worker commitments.

**Keywords:** safety climate; safety leadership; healthcare; LMICs; Nigeria

#### **1. Introduction**

The COVID-19 pandemic has had a significant impact on existing health and safety systems in different sectors of the economy, to which the healthcare establishment has had its own share of this impact. Professionals within the healthcare sector had to find means of responding to the increasing rate of infection, as well as endure back to back overtime

**Citation:** Moda, H.M.; Dama, F.M.; Nwadike, C.; Alatni, B.S.; Adewoye, S.O.; Sawyerr, H.; Doka, P.J.S.; Danjin, M. Assessment of Workplace Safety Climate among Healthcare Workers during the COVID-19 Pandemic in Low and Middle Income Countries: A Case Study of Nigeria. *Healthcare* **2021**, *9*, 661. https://doi.org/ 10.3390/healthcare9060661

Academic Editors: Alberto Modenese and Fabriziomaria Gobba

Received: 3 May 2021 Accepted: 26 May 2021 Published: 1 June 2021

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

shifts as they dealt with the overwhelming rate of hospitalization due to the pandemic and manage other diseases and chronic conditions, all of which increase physical and mental exhaustion. In Africa and other LMICs, the states of healthcare delivery systems are mostly below the required safety standards owing to their abject state of neglect, deficiency of both human and technical resources, and the almost nonexistence of healthcare management information systems, which predate the emergence of the SARS-CoV-2 pandemic [1–3].

In order to warrant workplace safety performance, healthcare sectors will be required to come up with safety rules and procedures and ensure that they are applied across the organization [4]. The principle is to guarantee both employees and patients their safety, as well as the avoidance of costs associated with accident or injury. While this has been the tradition moving forward, healthcare facilities, especially in LMICs, now need to invest in the implementation of formal safety programs and risk management systems [5].

Developing a culture of safety in healthcare organizations is an important pillar, as it strives to eliminate the factors that contribute toward the management of mental and physical exhaustion, medical errors, patient harm, unsafe conditions, and the enhancement of overall patient safety [6–9]. In addition, an organization's safety culture is an important factor that influences systems safety. Wagner, Schöne, and Rieger [10] advanced seven antecedent variables that help form a good safety climate: structural attributes of the work environment, symbolic social interaction, group and organization leadership, psychological work ownership, organizational commitment, job stress, burnout, and personality. Nieva and Sorra [11] defined safety culture as "shared attitudes, beliefs, values and assumptions that underlie how people perceive and act upon safety issues within their organizations", whereas the term safety climate refers to the shared expression or measurable components of safety culture, such as management behaviors, safety systems, and employee safety perceptions [12]. Even though the precise denotations of safety culture and safety climate are dissimilar, these two expressions have been used interchangeably. Moving forward, the present study focus is around safety climate within healthcare settings in Nigeria.

Traditionally, safety climate has been researched in high-risk industries that include oil and gas, the construction sector, transportation, manufacturing factories, nuclear facilities, etc. [13–17]. However, the complex and unique characteristics of the healthcare organization further call for safety climate research to help improve both patients' and employees' safety. Recently, there has been growing acceptance within the healthcare establishment around the assessment of leading indicators, which are considered important in the promotion of patient safety. These factors include emphasis on production, efficiency, and cost controls, organizational and individual inability to acknowledge fallibility, and professional norms for perfectionism among healthcare providers [11,18,19]. Workplace safety climate assessment provides organization understanding of safety-related perceptions and attitudes of its workforce, and can be applied as a diagnostic tool to help identify areas within the organization that need improvement, providing needed impetus for further assessment while making use of staff input to address identified gaps [11]. As such, the benchmarking of the safety climate within healthcare facilities is now a focus, especially in developed countries that include the United Kingdom, USA, etc. [20,21].

The high increase in the number of healthcare facilities in Nigeria over the last decade has presented the challenge of the maintenance of best practices to guarantee the safety of patients and employees [3,22]. In addition, Nigeria has one of the largest pools of healthcare personnel in Africa [23]. The healthcare sector in the country makes up about one-third of the total workforce, but mostly is concentrated in urban tertiary healthcare services in the southern part of the country. Due to the present state of the healthcare services in most LMICs, healthcare workers (HCWs) perform their duties in an increasingly hazardous work environment and occupational setting [24–26]. Personnel in this workforce are responsible for providing quality healthcare services, even though their work places are increasingly unsafe [27], and they encounter frequent forms of hazards at work that include injuries, direct infections, stress, assault from patients and their relatives, allergies, back pain, and other musculoskeletal injuries [5,28]. The multiplier effects of occupational

injuries and diseases among HCWs include economic loss, physical loss, and psychological disorders, such as stress and depression. These have an overall negative impact on the workers, their families, and the nation at large. Identifying factors relating to occupational hazards among HCWs is essential in formulating occupational health safety policy and a system that will improve productivity and the overall wellbeing of HCWs [29].

Promotion of a positive culture of safety is associated with clinical outcomes [30]; as such, the assessment of the safety climate within healthcare facilities can provide a picture of management commitment, performance, and quality of care that further promotes a positive safety culture within the organization. While there has been a resurgence in research on workplace safety within healthcare, there are limited research works that have focused explicitly on the workplace safety climate and workplace characteristics in Nigeria. The aim of the present study is to assess the occupational safety climate among healthcare workers (HCWs) in LMICs using Nigeria as a case study. The objectives of the study are to compare the impacts that individuals with managerial roles have on the seven indicators of work safety climate in the promotion of an effective safety culture in healthcare sectors; to establish the most significant determinants of the work safety climate; and to make appropriate recommendations for improving the workplace safety climate in the healthcare sector in Nigeria.

#### **2. Materials and Methods**

The present study measured safety climate perception among healthcare workers during the COVID-19 pandemic. The Nordic Safety Climate Questionnaire (NOSACQ-50) was used among randomly selected healthcare workers. The questionnaire consists of 50 statements, which set out to evaluate seven safety climate dimensions.

#### *2.1. Sample Size*

Due to the lack of official data in the public domain, an estimated 14,000 HCWs are working in the study area. To determine the sample size for the study, Fisher's formula [31] for estimating single proportions and an estimation for minimum sample size was applied, and the estimated sample size was 423.

Fisher's formula:

$$n = \frac{Z^2 P(1-P)}{d^2}$$

where:

*n* = sample size;

*Z* = standard deviation for a 95% confidence level (*Z* = 1.96);

*P* = prevalence of the attribute (50.0%);

*d* = acceptable difference (if 5%, *d* = 0.05);

*q* = 1 – *p.*

#### *2.2. Study Population*

At the end of the survey, 433 participants comprised of doctors, nurses, midwives, pharmacists, laboratory scientists, physiotherapist, dietitians, radiographers, community health officers, community health extension workers, environmental health professionals, etc., from five states in the northern part of Nigeria consisting of Adamawa, Gombe, Plateau, Taraba, and the federal capital territory Abuja were considered in the study. The survey was conducted using the Joint Information Systems Committee (JISC) online survey platform, and a link was sent to target healthcare management for distribution among the staff. Similarly, the survey link was sent to social media host administrators for each local professional identified, and, where deemed appropriate by the administrator, it was shared among its group members. All participants agreed to participate in the study by signing an electronic consent form before they were able to progress to the question section. The Gombe State Ministry of Health (MOH/ADM/621/1/294) granted ethics approval for the study.

#### *2.3. Survey Design*

The survey was conducted from October 2020 to March 2021 with different professionals working in healthcare establishments across the northeast and north central region of Nigeria. The NOSACQ-50 questionnaire was adopted to capture the employee's perception of safety climate features that relate to supervisor and management support regarding workplace safety. A translated and validated English version of the questionnaire comprised of 50 items across seven safety climate dimensions to measure the participant's shared safety climate perceptions was adopted. Sections of the questionnaire included: (i) management safety priority, commitment, and competence; (ii) management safety empowerment; (iii) management safety justice (six items); (iv) workers' safety commitment; (v) workers' safety priority and risk non-acceptance; (vi) peer safety communication, learning, and trust in safety ability; and (vii) trust in the efficacy of safety systems. Accordingly, the first three items measured the perception of safety management within the healthcare organization, while the remaining four items were related to employees' safety commitments. Each item was rated using a four-point Likert scale of agreement (from 1 = strongly disagree to 4 = strongly agree) that corresponded to a 1–4 rating scale in case of positively formulated statements or 4–1 for the reversed statements, respectively, and attaining a high scale score was indicative of a positive response. In addition, questions on demographic characteristics were considered in the questionnaire that included age, sex, and whether the respondent held a management position [32].

#### *2.4. Sampling Technique*

A pilot survey was conducted among 20 HCWs to assess the instrument acceptability, validity, and reliability. The response and general comments received were found to have met the need of the study, and, as such, there was no further adjustment made to the initial questionnaire in the main study.

A cross-sectional study design was adopted for the study, and a convenient snowball sampling technique was used to reach out to the target participants. Participants were drawn using deliberate contact and sensitization of the different health professional associations and workplace units. All HCWs voluntarily completed the survey either using an online link shared on the HCW's association internal mails or closed social media platforms or by physical administration of hard copies of the questionnaires.

#### *2.5. Reliability Test*

To measure the reliability for sets of latent variables in each dimension, Cronbach's alpha test was done [33], and the result revealed that all sets of items were closely related, with an acceptable to good alpha score range of 0.703–0.810 among the seven dimensions measured. The management safety priority, commitment, and competence consisted of nine items (α = 0.787), the management safety empowerment subscale consisted of seven items (α = 0.793), safety communication, learning, and trust among co-workers' safety competence consisted of eight items (α = 0.810), and the overall NOSACQ-50 was found to have an excellent α score of 0.932 (Table 1).

#### *2.6. Statistical Analysis*

The statistical data analysis was conducted using SPSS statistics version 25 (IBM, Armonk, NY, USA) after data cleaning.

Descriptive statistics using frequencies and percentages were employed to provide information on the socioeconomic characteristics of the study population. Inferential statistics carried out included a one-tailed Student's t-test to establish statistical differences between the seven NOSACQ-50 components adopted for the study, while associations between dimensions of the safety climate were tested using the Pearson correlation. The mean scores of the safety climate were calculated for all dimensions, where a mean score of more than 3.30 indicated a good level allowing for maintaining and continuing safety developments. Lastly, a one-way ANOVA was conducted to compare the impact that employees had on the promotion of an effective safety climate. Statistical significance was set at <0.05.

**Table 1.** Distribution of the mean and Cronbach's alpha reliability test across the seven dimension using the NOSACQ-50.

#### **3. Results**

At the end of the survey period, 433 (80%) responses were adjudged to have met the study threshold criteria and were used to inform the study outcome. Participants' demographic characteristics are presented in Table 2. From the results, more than half of the participants (53.7%) were male, while 40.7% identified their profession as either nurses or midwives; 45.3% of the sampled group held various managerial positions, such as director, matron, unit head, supervisor, etc. Based on the feedback generated as part of the open-ended comment at the end of the questionnaire survey, 85% of the participants said that they found the questions to be relevant and easy to understand, and had no issue with their layout.

Table 3 shows one sample t-test result conducted to determine if a statistically significant difference existed between the seven NOSACQ-50 dimensions applied in the study. From the analysis, participants' responses on workers' safety commitment within the healthcare facilities (*M* = 3.01, *SD* = 0.42) was statistically significantly higher than management safety priority, commitment, and competence (*M* = 2.91, *SD* = 0.46), *t*(130.52) = *p* < 0.001). In addition, dimension six (*M* = 3, SD = 0.42) was found to be statistically higher than management safety justice (*M* = 32.744, SD = 2.69), *t*(147.02) = *p* < 0.001).

**Table 3.** One-sample test for the seven domains measured.

\* Significant, *p* < 0.001.

To examine the extent to which scores in one dimension were related to other items in the Nordic safety climate questionnaire used, inter-correlation analyses were performed, and the results are presented in Table 4. From the results, all dimensions were statistically significant, and were found to be greater than or equal to *r* (357) = 0.33, *p* < 0.001. The management safety justice dimension was found to have a high, statistically significant correlation to management safety empowerment (*r* (357) = 0.68, *p* < 0.001) among the participants. Employees' trust around the efficacy of existing safety systems measured was weakly correlated to management safety justice (*r* (357) = 0.33, *p* < 0.001).

**Table 4.** Summary of the inter-correlation matrix testing the correlation between the seven safety climate dimensions.

Note: All correlations are significant at *p* < 0.001.

A one-way ANOVA between subjects to compare the impact that employees with a managerial role had in the promotion of an effective safety climate showed a significant effect of a managerial role on the promotion of a safety climate within the healthcare facilities when compared to management safety priority, commitment, and competence (*F*(1, 406) = 3.99, *p* = 0.046, η 2 = 0.010). On the contrary, a management role did not have a significant effect on workers' safety commitment (*F*(1, 417) = 0.59, *p* = 0.440, η 2 = 0.001) (Table 5). In addition, there was no significant effect on the role played by each professional group toward the promotion of a safety climate within their organization. Additionally, a low level of trust in the efficacy of existing safety systems was found among different

participants in different job roles, and presented the need for improvement (*F* = 21.965, *n* = 416).

**Table 5.** Analysis of variance summary for a managerial position measured against the seven dimension considered in the study.

#*df* between groups = 1, \* *p* < 0.05.

#### **4. Discussion**

The main purpose of the present study was to measure the safety climate among professional employees within healthcare facilities in Nigeria. The survey tool adopted (NOSACQ-50) has proven to be useful in achieving the study goal. Furthermore, the outcome from the study demonstrated the need for strengthening the safety climate within healthcare facilities, especially in LMICs. The importance of safety climate enhancement in the LMICS healthcare establishment was further demonstrated as part of the participants' safety commitment response: (1) "We who work here try hard together to achieve a high level of safety"; (2) "We who work here take joint responsibility to ensure that the workplace is always kept tidy"; (3) "We who work here help each other to work safely and management safety priority, commitment, and competence; (1) "Management places safety before production"; and (2) "We who work here have confidence in the management's ability to deal with safety", where a mean score of 2.70 to 2.99 was achieved, demonstrating a fairly low level of safety practices and commitment from management. In general, the outcome shows a significant correlation between these outcomes and poor safety perceptions, low job satisfaction, and a high level of stress among the participants. Hence, there is a need for further improvement.

The relationship between safety outcomes among healthcare professionals and the organizational climate has been earlier researched [34,35]; each study concluded that the promotion of a high-quality work environment is likely to present positive effects on the workplace safety climate and outcomes. In the present study, the role played by employees identified as having a managerial position was found to have a significant effect on management safety empowerment (*F*(1, 415) = 4.03, *p* = 0.045, η 2 = 0.010). To this end, investment in safety empowerment will help enhance the work environment and promote the needed safety climate where an individual will feel supported and enhance their professional service delivery [36]. In addition, employees' trust in the efficacy of existing safety systems was found to have a weak correlation with management safety justice (*r* (357) = 0.33, *p* < 0.001). In line with this finding, for an organization to encourage the adoption of positive safety culture among its employees, there is the need to apply the right occupational safety and health standards, which in turn requires strong political will and good governance across every stakeholder [37].

Earlier studies have demonstrated a safety climate as highly related to safety participation, and, to promote safety climate in any organization, safety communication, safety training, and safety systems should be actively encouraged within the establishment [38–41]. From the present study, there was acknowledgement of the role played by communication, training, and having good safety systems as the means of achieving a safety climate within the healthcare sector; however, safety climate was found to be not actively encouraged across the participating organization, as represented in the participants' responses. Where safety communication and training is neglected, HCWs are likely

to harbor mistrust and dissatisfaction with the management, and will most likely engage in unsafe behavior that might compromise either their patient or their personal safety. General comments among the present study participants reflect on this position: " . . . . . . the management assume we are in the know, considering we are all professionals as such safety training don't often come up until accident happen". This statement further demonstrates the need for managers in healthcare organizations to ensure the promotion of policies that reflect their commitment to employee health and safety, especially in LMICs [39]. While the study did not consider the association between safety climate and staff morale, it is, however, worth highlighting the likely association between safety climate in the healthcare establishment and the brain drain of professionals in LMICs like Nigeria. The reasons cited for a high level of exits from these countries' healthcare systems among professionals include poor safety policies, poor and insecure working conditions, etc., that, in combination, makes work harder to deliver and presents a state of hopelessness among the workforce [42,43].

Previous studies have established a link between safety climate items with occupational accidents, injuries, and illnesses [44–46]. Our study does expand on this finding and emphasizes that safety climate items can impact employees' work ability. Results from questions that measured management effort toward accident prevention include: (1) "Management collects accurate information in accident investigations"; (2) "Fear of sanctions from management discourages employees here from reporting near-miss accidents"; (3) "Management listens carefully to all who have been involved in an accident"; (4) "Management looks for causes, not guilty persons, when an accident occurs"; (5) "Management always blames employees for accidents"; and (6) "Management treats employees involved in an accident fairly"; the mean score range was 2.70 to 2.99. This outcome demonstrates the existence of a fairly low-level safety climate within the participating healthcare facilities, thereby demonstrating the need for further safety culture improvement in order to help reduce the risk of accident and minimize physical and mental impact among the healthcare workers.

#### **5. Strengths and Limitations**

The present study has both strengths and limitations. A key strength is the ability to adapt the validated NOSACQ-50 questionnaire to measure safety climate among healthcare workers in Nigeria, and, to our knowledge, this is the first study that has considered the application of the survey tool among HCWs in the country. In addition, acceptance by the state ministry of health to approve the study is a demonstration of the hospital management board's willingness to look into measures that will help enhance the safety climate within healthcare establishments in the region. Furthermore, the present study provides a platform for further application of the survey instruments across the geographical regions of the country.

This study has some limitations. With the proliferation of private healthcare clinics/hospital across the country, a major limitation associated with the study is that the study has failed to ask specific question to enquire if participant works in either a government or private healthcare establishment, which could have helped to compare the safety climates across these two settings. This is recommended in future research work. In addition, because the study only considered HCWs in limited states within the northern part of the country, the present results are limited in terms of generalizability. It can, however, be applicable to other healthcare establishments across the country. Another limitation of the study is the low response rate among the professionals across the region, which was partly due to the data collection approach using an online questionnaire, to which staff with no access to the link were less likely to engage with the survey. In addition, the low research culture in the healthcare establishment, especially in this region, is another likely reason why staff did not engage with the survey.

#### **6. Conclusions**

The outcome from the study showed a weak level of positive safety climate promotion within the healthcare sector based on the participants' responses. The results also revealed that, while employees are likely to engage in positive safety behavior, there is the need for more visible leadership commitment to ensure that the interest among the employees is maintained. In order to achieve this goal, enhancement of safety communication, safety training, and the adoption of safety systems at work will encourage HCWs to comply with laid out safety rules and procedures as opposed to voluntary participation in safety practices, which might sometimes not be in the interest of their patients or the organization in general. The study concludes that there is still a long way to go in promoting an effective and positive safety climate in healthcare systems in LMICs, and all actors are encouraged to play an active role to make this a reality. Several challenges that include a lack of political will, weak policies, and limited monitoring by the relevant regulatory body have slowed the pace at which both government-owned and private healthcare establishments promote a safety climate in these countries. To help address this setback, more effort is required at promoting an effective and positive safety climate across the healthcare establishments, including management and healthcare workers' commitments.

**Author Contributions:** Conceptualization, H.M.M., M.D. and P.J.S.D.; methodology, M.D., H.M.M. and H.S.; software, H.M.M. and M.D.; validation, M.D., C.N. and S.O.A.; formal analysis, M.D. and H.M.M.; investigation, M.D., P.J.S.D., C.N. and F.M.D.; resources, M.D. and P.J.S.D.; data curation, M.D. and F.M.D.; writing—original draft preparation, H.M.M., M.D., F.M.D. and B.S.A.; writing review and editing, M.D., H.S., S.O.A., B.S.A., F.M.D. and H.M.M.; project administration, H.M.M.; ethical approval and informed consent, M.D. and P.J.S.D. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Gombe State Ministry of Health review board (MOH/ADM/621/1/294).

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** The data presented in this study are available on request from the corresponding author.

**Acknowledgments:** The authors wish to acknowledge the cooperation of the various ministries of health and hospital managements who gave approval and permission for their personnel to participate in this survey. In particular, our special appreciation is given to the Gombe State Ministry of Health research and ethics committee for granting ethical approval for this study.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**


*Article* **Novel Single Inverter-Controlled Brushless Wound Field Synchronous Machine Topology**

**Syed Sabir Hussain Bukhari 1,2, Ali Asghar Memon 3, Sadjad Madanzadeh 2, Ghulam Jawad Sirewal 4, Jesús Doval-Gandoy 5 and Jong-Suk Ro 2,6,\***

**Abstract:** This paper proposes a novel brushless excitation topology for a three-phase synchronous machine based on a customary current-controlled voltage source inverter (VSI). The inverter employs a simple hysteresis-controller-based current control scheme that enables it to inject a three-phase armature current to the stator winding which contains a dc offset. This dc offset generates an additional air gap magneto-motive force (MMF). On the rotor side, an additional harmonic winding is mounted to harness the harmonic power from the air gap flux. Since a third harmonic flux is generated in this type of topology, the machine structure is also modified to accommodate the third harmonic rotor winding to have a voltage induced as the rotor rotates at synchronous speed. Specifically, four-pole armature and field winding patterns are used, whereas the harmonic winding is configured for a twelve-pole pattern. A diode rectifier is also mounted on the rotor between the harmonic and field windings. Therefore, the generated voltage on the harmonic winding feeds the current to the field winding for excitation. A 2D-finite element analysis (FEA) in JMAG-Designer was carried out for performance evaluation and verification of the topology. The simulation results are consistent with the proposed theory. The topology could reduce the cost and stator winding volume compared to a conventional brushless machine, with good potential for various applications.

**Keywords:** brushless topology; third harmonic flux; dc offset; wound field synchronous machines


**Preface**

As an excellent biopolymer material, hydrogel has been widely used in drug delivery, tissue engineering, and disease treatment, among other applications. By combining different polymers through physical or chemical changes, the prepared hydrogels can show better performance and be used in various environments.

At present, the exploration of hydrogel in biomedicine seems to be diversified. To adapt to the complex environment in organisms, higher requirements must put forward for hydrogel. Under the premise that hydrogel is biosafe, it must become tougher or more easily degradable according to the purpose of its application, be able to stay in the body for a longer time to exert its effect, or be easily removed. Moreover, certain hydrogels can respond to changes in pH, temperature, biological indicators, or microorganisms in the body. We are interested in the intelligent properties of hydrogels, and the condition in which these properties can be used to facilitate their applications is undoubtedly a question that researchers need to consider carefully.

This reprint consists of 12 papers, of which 2 are editorials and 10 are research papers. We hope to share the experimental and research results in this field and inspire new ideas for the design and applications of hydrogels.

> **Shige Wang** *Editor*


*3.1. Uniform Corrosion*

After 12 days, the salt fog test revealed that here was a difference in the corrosion susceptibility of transverse and longitudinal surfaces (Figure 5). In general, the transversal surfaces were corroded, with the exception of steel #3, the intensity depending on the steel grade and the manufacturing process. Samples #3, #4 and #5 were made of grade 316L, from three different steelmakers (Germany, France, Italy). The longitudinal surfaces showed no signs of corrosion.

**Figure 5.** Uniform corrosion salt fog test, according to ASTM B 117-97. Samples #2-1.4427 So, #3-1.4435/316L, #4-316LUgim and #5-316L Val.

According to Zanotto et al., the test has limitations, it becomes non-discriminating in case of steels with excellent corrosion resistance [51].

In case of steels #8, #10, #6 and #17, the test, carried out under the same experimental conditions, showed no signs of corrosion of the transversal or longitudinal surfaces, similar to sample #3 (Figure 6).

**Figure 6.** Pitting test results of the transverse and longitudinal surfaces for various grades of steel alloys (0.5 M FeCl3 test medium at 50◦ for 2 h).

The results obtained are presented in Table 6. In general, the transverse surfaces were corroded with the exception of steel #3. Examination of steel #3 did not reveal any traces of corrosion either in the cold-worked state.

**Table 6.** Observations after the salt fog test (samples tested in annealed, cold-worked state).

\* T: transverse surface, \*\* L: longitudinal surface, with respect to the rolling direction.


**7. Other purification techniques**

There has been also limited literature reported on the following alternative methods for purification of tocopherols and sterols from SODD. Hence, Nagesha and coworkers (Nagesha, G. *et al.*, 2003) using nonporous denser polymeric membranes to separate tocopherols from SODD by permeation. The separation in a denser membrane is generally based on a solution-diffusion mechanism. The lower polarity of tocopherols compared to that of free fatty acids appears to have facilitated the preferential permeation of tocopherols through the hydrophobic membrane. Selectivity of the membrane for tocopherols improved with esterified SODD, because the presence of FAME decreased the viscosity of the feed and thereby increased convective flow, which in turn improved permeate flux.

Alternatively, Maza and coworkers (Maza, 1992) concentrated tocopherols and sterols by addition of melted deodorizer distillates to a solution of urea and alcohol which separate fatty acids from the mixture.

In addition, Gunawan and coworkers (Gunawan *et al.*, 2008a) proposed a facile procedure to isolate naturally occurring FASEs from SODD without degradation of FASEs. SODD was first subjected to a modified soxhlet extraction (MSE) to enrich FASEs in a non polar lipid fraction (NPLF). Modified silica gel column chromatography (MSE) was then applied to NPLF to collect FASEs in a third fraction with a purity of 79.99 wt% and a recovery of 97.38%. The third fraction was then subjected to a binary solvent (water/acetone = 20/80, v/v) extraction to purify FASEs to a purity of 86.74 wt% with a total recovery of 85.32%.

solvent-to-feed ratio of 35, the phytosterol esters were concentrated in the raffinate up to

Other supercritical fluids have been explored but unsuccessfully for the separation of different pairs of components. An attempt at using similar methodology to (Mendes, 2000) and (Mendes, 2005) but using liquid gas petroleum instead of carbon dioxide did not change the poor concentration factor between the critical pairs of components (Buczenko *et al.*, 2003). Buczenko and coworkers (Buczenko, 2003) performed the saponification of the raw

As discussed above, there are a lot of experimental studies proving the efficiency of the supercritical extraction to concentrate the vitamin E from different raw material or in some cases, from synthetic mixtures representing the deodorizer distillate, but the extraction of sterols using supercritical fluid from the deodorizer distillate was not described in the

On the other hand, due to the low content of squalene in SODD, specific extraction processes of squalene using supercritical fluid from SODD was not described in the literature. Existing studies are models of fractionation of artificial mixtures such as those mentioned above (Chang, 2000). For example, Brunner (Brunner, 1994a) studied the phase equilibrium for recovering α-tocopherol from a mixture of squalene, tocopherol, and campesterol. He concluded that the separation factor for squalene/α-tocopherol varied between a value of 4 at low squalene concentrations (0.5 wt %), to a value of 1 at high squalene concentrations (85 wt %), at pressures ranging from 200 to 300 bar and

Bondioli and coworkers (Bondioli *et al.*, 1993) esterified FFAs into their corresponding glycerides and then applied a supercritical carbon dioxide extraction to produce a squaleneenriched fraction (purity 90.0%, yield 91.1%), but from olive oil deodorizer distillates.

There has been also limited literature reported on the following alternative methods for purification of tocopherols and sterols from SODD. Hence, Nagesha and coworkers (Nagesha, G. *et al.*, 2003) using nonporous denser polymeric membranes to separate tocopherols from SODD by permeation. The separation in a denser membrane is generally based on a solution-diffusion mechanism. The lower polarity of tocopherols compared to that of free fatty acids appears to have facilitated the preferential permeation of tocopherols through the hydrophobic membrane. Selectivity of the membrane for tocopherols improved with esterified SODD, because the presence of FAME decreased the viscosity of the feed and

Alternatively, Maza and coworkers (Maza, 1992) concentrated tocopherols and sterols by addition of melted deodorizer distillates to a solution of urea and alcohol which separate

In addition, Gunawan and coworkers (Gunawan *et al.*, 2008a) proposed a facile procedure to isolate naturally occurring FASEs from SODD without degradation of FASEs. SODD was first subjected to a modified soxhlet extraction (MSE) to enrich FASEs in a non polar lipid fraction (NPLF). Modified silica gel column chromatography (MSE) was then applied to NPLF to collect FASEs in a third fraction with a purity of 79.99 wt% and a recovery of 97.38%. The third fraction was then subjected to a binary solvent (water/acetone = 20/80, v/v) extraction to purify FASEs to a purity of 86.74 wt% with a total recovery of 85.32%.

thereby increased convective flow, which in turn improved permeate flux.

material and the extraction of unsaponifiable matter as pre-treatment of VODD.

82.4 wt-% with satisfactory yield (72%).

temperatures ranging from 70 to 100 ºC.

**7. Other purification techniques**

fatty acids from the mixture.

literature.

These methods do not present a significant advance regarding the most frequently utilized methods and probably their application to production scale would be little profitable. However, they can be used to isolate tocopherols and sterols from SODD at laboratory scale or complement other methods at industrial scale.


**Acknowledgements**

*LabVIEW - A Flexible Environment for Modeling and Daily Laboratory Use*

produced graph. The result based on the graph which represented from the PID tuning demonstrate the working of Blynk application to transfer and receive temperature data is acceptable and reliable. Moreover, the alert system was designed to alert when our hardware interface disconnects from the Blynk (**Figure 9**). Thus, IOT interface has made possible with the presence of low-cost module. Additionally, this study will also provide learning experience in creating a framework to digitize an existing process for

This chapter describes data collection and device integration into IOT applications for remote monitoring. Coordination of data transfer and aggregate technique

**76**

monitoring purposes.

*Simulations results on PID tuning.*

**6. Conclusions**

**Figure 11.**

**Figure 10.** *Experimental setup.*

I would like to thank Universiti Teknologi MARA for providing support throughout the research works.


3.2.2. Lower Binder High Mass Loading Electrodes (LBHME)

In this section, the results of the electrochemical characterization of the LBHME-EDLCs are reported. Figure 5a shows the Nyquist plots of the LBHME-EDLC single electrodes and full cell.

**Figure 5.** Electrochemical characterization of LBHME-EDLC (**a**) Nyquist plots of the (black) full cell, (red) positive and (blue) negative electrodes (500 kHz and 100 mHz), (**b**) 2-electrode CVs at different scan rate from 5 mV s–1 to 200 mV s–1, between 0 V and 3.2 V, (**c**) Capacitance of the EDLC evaluated by CV reported as function of the scan rate; and (**d**) selected galvanostatic charge/discharge cycles between 0 V and 3.2 V at different current densities from 0.5 A g–1 to 5 A g–1.

Like for HBLME, the three Nyquist plots share all the same shape. For the physical interpretation of the Nyquist plots, the considerations that have been drawn in the previous section are still valid. The high frequency intercepts with the real axis of the semicircles are 0.8, 0.9 and 1.7 Ohm cm2 for the positive and negative electrodes and full cell, respectively. Noticeably these values are halved with respect to those of the HBLME electrodes and EDLC (cf. Figure 4a). In LBHME formulation, the quantity of binder and conductive carbon are halved compared to the HBLME one. Therefore, the decrease of the high frequency impedance achieved by LBHME can be explained with the decrease of the insulating component of the electrode, i.e., the binder. Comparing the high frequency semicircles in Figures 4a and 5a, it is possible to notice that the LBHME's is wider than HBLME's. Indeed, the LBHME-EDLC semicircle diameter is 1.3 Ohm cm2 while the HBLME's is 0.3 Ohm cm2. This difference is due to the high mass loading of LBHME with respect to HBLME (1.5-fold), that brings about a worse ionic and electronic connection between the carbon particles [10]. The LBHME-EDLC middle frequency line (45◦ slope) span across the same range of resistance with respect to the HBLME-EDLC. The ESR of the LBHME-EDLC was evaluated from the real axis intercept of the low frequency line and resulted in 7.6 Ohm cm2.

Figure 5b reports the CVs of the full LBHME-EDLC cell at different scan rate, between 0 and 3.2 V. From these measurements, voltammetric specific capacitance values have been calculated and are reported as function of the scan rate in Figure 5c. The highest specific capacitance is 14 F g −1 at 5 mV s−1 and decreases to 7 F g−1 at 200 mV s−1. Therefore, from 5 mV s−1 to 200 mV s−1 there is a 50% specific capacitance reduction, that is higher than what observed for HBLME-EDLC (22%). This can be related to a not optimized electronic and ionic connection of the electrodes carbon particles that has been highlighted by the Nyquist plot analysis reported above (Figure 5a).

The LBHME-EDLC galvanostatic charge/discharge profiles at different current are reported in Figure 5d. The coulombic efficiency was 98.3%, 99.6%, 100%, 100% at 0.5, 1, 2, 5 A g−1, respectively. These values are slightly higher than those that have been observed for the HBLME. The ESR was 7.9 Ohm cm2 in agreement with the EIS value. The CEDCL was 6.2, 5.8, 5.3 and 4.2 F g−1 at 0.5, 1, 2 and 5 A g−1. These values are lower than those featured by HBLME-EDLC and this can be explained with the not optimized ionic and electronic connection highlighted by Table 3 that reports the ESR and CEDLC at 0.5 A g−1 of LBHME-EDLC. The EDLC areal capacitance is also reported in the Table 3.


*3.2. Phenols*

Nineteen phenolic compounds were identified in total, including simple phenols, phenolic acids, flavonoids, lignans, and secoiridoids (Table 3). For many of those significant differences between average concentrations in the investigated EVOOs were found, and a few phenols emerged as exclusive markers of particular monovarietal EVOOs. Lastovka EVOO was generally characterized by the highest concentrations of simple phenols (except vanillin) and *p*-coumaric acid. Leccino turned out to be clearly distinguishable from the other monovarietal EVOOs by the highest concentration of vanillin, and the lowest concentrations of *p*-coumaric acid and luteolin. Among lignans, high pinoresinol content was characteristic for Buža EVOO. The secoiridoid profiles differed among the investigated monovarietal EVOOs. The concentration of one of the major oleuropein aglycons and phenols in general in olive oil, dialdehydic form of decarboxymethylelenolic acid linked to hydroxytyrosol, i.e., 3,4-DHPEA-EDA or oleacein, was the highest in Leccino EVOO. Its tyrosol-based analogue, the major aglycon of ligstroside, *p*-HPEA-EDA or oleocanthal, clearly distinguished two groups of EVOO, I. bjelica, Oblica, and Leccino with higher, and Buža, Rosinjola, and Lastovka EVOOs with lower concentrations. The composition of other oleuropein and ligstroside aglycons also turned out to be variety-specific; it is worth mentioning low concentration of oleuropein aglycon I in Oblica and Leccino, low concentration of oleuropein aglycon II in Oblica, and exceptionally higher concentration of oleuropein + ligstroside aglycons in I. bjelica than in other EVOOs.

**Table 3.** Concentrations (mg/kg) of phenols determined by ultra-performance liquid chromatography with diode-array detection (UPLC-DAD) in monovarietal extra virgin olive oils produced from Buža, Istarska bjelica, Rosinjola, Oblica, Lastovka, and Leccino varieties in Croatia.

\* The phenols for which pure standards were not available were quantified semi-quantitatively and their concentrations were expressed as equivalents of phenols with similar chemical structure assuming a response factor = 1. Different superscript lowercase letters in a row represent statistically significant differences between mean values at *p* < 0.05 obtained by one-way ANOVA and least significant difference (LSD) test.