COVID-19 pandemic has resulted in an unprecedented global healthcare crisis (1). The management of critically ill patients during the pandemic is being one of the greatest challenges faced by healthcare professionals (HCPs) and healthcare systems (2). Throughout 2020, globally, frontline HCPs in ICUs have been working under extreme pressure and have suffered from several occupational and domestic stressors (3). The limited evidence available on the management of the disease, requiring repeated modifications in recommendations and protocols (4–6), along with the scarcity of resources such as personal protective equipment, intensive care beds, commonly used drugs, and ventilators (7,8), puts significant stress on HCPs (9,10). This psychologic burden has been likewise increased by the fear to get infected and to infect their loved ones, and by the inability to allow family presence at the bedside leading to an inadequate human interaction. Despite current ethical recommendations regarding resource allocation and decision-making process (11–13), during the COVID-19 pandemic, HCPs in ICUs may be at particularly high risk of moral distress (MD) (14–16).
MD arises when HCPs feel powerlessness to provide care according to their core moral values (17–19). MD can be challenging for HCPs as they believe they are doing something ethically wrong, but they lack the ability to change the situation due to institutional and/or external constraints (18–21). Previous studies showed that levels of MD may be influenced by several factors, including personal characteristics, ICU and hospital conditions, and external factors (18,22,23). Although this phenomenon was initially studied in nursing (19), it is now known to be a serious problem for other HCPs (18,20,24). MD is a common experience for HCPs (22), reported by over 80% of nurses (25) and over 50% of physicians (26). MD also threatens healthcare systems, since it compromises care both at a personal (as a root cause of burnout and employee attrition) and at a system (decreased quality of care) level (22). In recent studies, MD has been associated with intention to leave a position, between 7% and 35% of HCPs left a job due to MD (22,27,28). The cost of replacing high-qualified ICU HCPs is greater than the cost of retaining them, and it has been estimated that the cost of hiring and training an ICU nurse is $64,000, plus $145,000 to hire replacement staff to work during the training period (29).
To develop effective interventions to prevent and mitigate the untoward consequences of MD, valid and reliable measurement instruments are needed (30). The Measure of Moral Distress for Healthcare Professionals (MMD-HP; Supplement Digital Content 1, https://links.lww.com/CCM/G928) is the latest validated tool to assess MD (31). It captures the five key components of MD: 1) complicity in wrongdoing, 2) lack of voice, 3) wrongdoing associated with professional (not personal) values, 4) repeated experiences, and 5) three levels of root causes (patient, unit, and system). We have recently adapted and validated the Spanish version of the MMD-HP (MMD-HP-SPA) (32). The MMD-HP-SPA proved to be a valid and reliable instrument to measure MD among Spanish ICU HCPs (27).
Spain was hit by COVID-19 pandemic in early March 2020 (2). It is unknown how this situation has impacted on MD among HCPs working in ICU. Thus, with the hypothesis that COVID-19 pandemic has increased their MD levels, the aims of this study were to measure MD levels in Spanish ICU HCPs during the second wave of the pandemic and to compare these levels with those before the COVID-19 surge.
MATERIALS AND METHODS
We conducted a cross-sectional study in all Spanish ICUs. The study population included ICU nurses and physicians directly involved in critically ill patient care. We developed a 50-item questionnaire that included work-related and sociodemographic characteristics, and the MMD-HP-SPA (32) to assess MD. Data were collected during two separated periods: prepandemic (October-December 2019) and during the COVID-19 second wave (September-November 2020). The questionnaire was electronically distributed via the Spanish Society of Intensive and Critical Care Medicine and Coronary Units, the Spanish Society of Intensive Care Nursing and Coronary Units, and the Spanish Society of Paediatric Intensive Care mailing lists, followed by two reminders in each study period. Participation was on a voluntary anonymous basis without any financial reward. Approximately 10–15 minutes were required to complete the questionnaire. Information on the study was included in a cover letter accompanying each survey; informed consent was assumed by return of completed survey. The study was conducted in accordance with the amended Declaration of Helsinki. The Research Ethics Committee of Santiago-Lugo approved the study (ref. CEIm-G 2020/236).
The Survey Questionnaire
We collected basic demographic and occupational information regarding age, gender, marital status, offspring, educational level, profession, years of experience in the ICU, hospital bed size, and type of ICU. In addition, we registered some specific variables to depict the COVID-19 experience such as type of working area, type of ICU room, weekly working hours, and work absence due to coronavirus infection or due to psychologic stress, anxiety, and/or depression.
The MMD-HP-SPA (Supplement Digital Content 2, https://links.lww.com/CCM/G929) was selected because it reliably quantifies the level of MD among HCPs (32). It has already been used in a large sample of HCPs in the critical care setting (27). The MMD-HP-SPA is a 27-item questionnaire that measures MD in specific situations. The MMD-HP-SPA scoring method is detailed in Supplement Digital Content 3 (https://links.lww.com/CCM/G930). As recently published, during the questionnaire validation process, an exploratory factor analysis revealed a four-factor structure of the MMD-HP-SPA (27,32). Factor 1 was composed of mainly patient-level root causes, and factor 2 represented clinical root causes at the system level. Factors 3 and 4 were primarily team-level root causes, but a differentiation was noted between these two factors. Root causes in factor 3 appear to relate to witnessing unethical behaviors and breakdowns in the team’s interactions with patients and families. Factor 4 root causes involved situations in which a team member’s integrity could be jeopardized within a team, such as feeling unsafe or bullied or fearing retribution for speaking up (27).
Statistical Analysis
First, a descriptive analysis was performed. Categorical variables were expressed with frequencies and percentages. Continuous variables were expressed with mean and sd, or median and interquartile range (IQR), depending on their adjustment to a normal distribution (Kolmogorov-Smirnov test with Lilliefors correction). Comparisons between groups were analyzed using chi-square test, Mann-Whitney U test, or Kruskal-Wallis test in case of variables with more than two factors. Analysis was performed using the R statistical software (version 3.5.2; R Foundation for Statistical Computing, Vienna, Austria), and for all analyses, a p value of less than 0.05 was statistically significant.
RESULTS
Overall, 2,180 questionnaires were responded. During the first data collection period (prepandemic period), 1,065 HCPs completed the questionnaire: 608 nurses (57.1%) and 457 physicians (42.9%). In the second period (pandemic period), 1,115 HCPs completed the questionnaire: 652 nurses (58.5%) and 463 physicians (41.5%). Characteristics of the participants are presented in Table 1. When comparing the pandemic period with the prepandemic results, participants were significantly younger, mostly working on temporary contracts, and with less experience working in ICU. In addition, during the pandemic period, HCPs mostly worked in mixed ICUs with a greater bed capacity (Table 1).
TABLE 1. -
Characteristics of Participants
| Characteristics |
October-December 2019, n = 1,065 (%) |
September-November 2020, n = 1,115 (%) |
p
|
| Female |
809 (76.0) |
833 (74.7) |
0.497 |
| Age (yr)a |
| ≤ 35 |
311 (29.2) |
415 (37.2) |
< 0.001 |
| 35–50 |
516 (48.4) |
490 (43.9) |
| > 50 |
238 (22.4) |
210 (18.8) |
| Marital statusa |
| Single |
420 (39.4) |
481 (43.1) |
0.117 |
| Married/cohabiting |
577 (54.2) |
578 (51.8) |
| Separate/divorced/widow |
68 (6.4) |
56 (5.1) |
| Offspring |
| Yes |
598 (56.2) |
523 (46.9) |
< 0.001 |
| No |
467 (43.8) |
592 (53.1) |
| Position |
| Nurse |
608 (57.1) |
652 (58.5) |
0.512 |
| Physician |
457 (42.9) |
473 (41.5) |
| Appointment |
| Permanent worker |
570 (53.5) |
513 (46.0) |
< 0.001 |
| Casual worker |
495 (46.5) |
602 (54.0) |
| Years of experience in the ICUa |
| ≤ 10 |
451 (42.3) |
553 (49.6) |
0.014 |
| 11—20 |
354 (33.2) |
310 (27.8) |
| > 20 |
260 (24.5) |
252 (22.6) |
| Hospital bed sizea |
| < 200 |
105 (9.9) |
121 (10.8) |
0.213 |
| 200–500 |
349 (32.8) |
396 (35.5) |
| > 500 |
611 (57.3) |
598 (53.7) |
| ICU typea |
| Mixed |
629 (59.1) |
821 (73.6) |
< 0.001 |
| Medical |
74 (6.9) |
101 (9.0) |
| Surgical |
69 (6.5) |
42 (3.7) |
| Cardiac/coronary |
51 (4.8) |
42 (3.7) |
| Neuroscience/trauma |
45 (4.2) |
45 (4.0) |
| Pediatric |
197 (18.5) |
64 (5.7) |
| Number of ICU bedsa |
| 1–10 |
299 (28.1) |
243 (21.8) |
< 0.001 |
| 11–20 |
475 (44.6) |
475 (42.6) |
| > 20 |
291 (27.3) |
397 (35.6) |
| Teaching unit |
864 (81.1) |
902 (80.9) |
0.891 |
Data are expressed as the number (%). p values calculated by Mann-Whitney U test. Statistically significant difference between groups: p < 0.05.
aKruskal-Wallis test.
Moral Distress During COVID-19 Pandemic
Global MD levels were higher during the COVID-19 pandemic. We observed that MD levels in nurses significantly increased between prepandemic and pandemic periods (61.0 [IQR, 35.0–133.0] vs 74.0 [IQR, 41.0–143.0]; p = 0.019). Among physicians, the increase in the levels of MD was not significant (Fig. 1). In both periods, MMD-HP-SPA scores were higher in physicians than in nurses. Although during the prepandemic period, MD levels were significantly higher in physicians than in nurses; those differences disappeared in the pandemic period (Supplemental Table 1, Supplemental Digital Content 4, https://links.lww.com/CCM/G931).
;)
Figure 1.: Differences in participants’ moral distress levels between both periods of study (October-December 2019 vs September-November 2020). A, All participants. B, Nurses. C, Physicians. MMD-HP-SPA = Spanish version of the Measure of Moral Distress for Healthcare Professionals.
During COVID-19 pandemic, single HCPs, younger than 35 years old, with offspring, working on temporary contracts, and with less experience working in ICU, reported significantly higher levels of MD (Supplemental Table 2, Supplement Digital Content 3, https://links.lww.com/CCM/G930). MD levels in HCPs with less than or equal to 10 years of experience working in the ICU significantly increased between the prepandemic and the pandemic period (Supplemental Fig. 1 and Supplemental Table 3, Supplement Digital Content 4, https://links.lww.com/CCM/G931). Table 2 shows specific work-related characteristics of participants during COVID-19 pandemic. HCPs working in hospital areas converted into ICU or in units with double or multiple occupancy rooms reported higher levels of MD. HCPs who were off work for psychologic stress, anxiety, and/or depression also reported higher levels of MD (Table 2).
TABLE 2. -
Work-Related Characteristics of Participants During
Coronavirus Disease 2019 Pandemic and
Moral Distress Levels
| Characteristics |
Participants, n = 1,115 (%) |
Spanish Version of the Measure of Moral Distress for Healthcare Professionals |
| Median (Interquartile Range) |
Min-Max |
Skew (se) |
Kurtosis (se) |
| Working area |
| ICU |
944 (84.7) |
75.0 (39.0–137.0)a |
0–384 |
1.071 (0.080) |
0.705 (0.159) |
| Hospital areas converted into ICU |
171 (15.3) |
85.0 (48.0–158.5)a |
5–392 |
1.082 (0.186) |
0.864 (0.369) |
| Type of ICU roomd |
| Multiple occupancy room |
421 (37.8) |
88.0 (47.0–150.0)b |
0–392 |
1.050 (0.119) |
0.774 (0.237) |
| Double-occupancy room |
68 (6.1) |
87.5 (40.0–126.2)b |
7–322 |
1.047 (0.291) |
0.622 (0.574) |
| Single-occupancy room |
626 (56.1) |
71.0 (36.0–135.0)b |
2–356 |
1.109 (0.098) |
0.784 (0.195) |
| Weekly working hoursd |
| < 30 |
43 (3.9) |
81.0 (36.0–145.5) |
4–262 |
0.519 (0.361) |
–0.867 (0.709) |
| 30–50 |
731 (65.5) |
73.0 (40.0–137.5) |
0–392 |
1.176 (0.090) |
1.073 (0.181) |
| > 50 |
341 (30.6) |
85.0 (40.0–144.0) |
4–384 |
0.956 (0.132) |
0.420 (0.263) |
| Work absence due to coronavirus disease 2019 infection |
| Yes |
128 (11.5) |
70.5 (37.7–119.0) |
5–392 |
1.561 (0.214) |
2.687 (0.425) |
| No |
987 (88.5) |
78.0 (41.0–143.0) |
0–388 |
1.030 (0.078) |
0.612 (0.156) |
| Work absence due to psychologic stress, anxiety, and/or depression |
| Yes |
27 (2.4) |
108.0 (66.0–139.0)a |
18–344 |
1.294 (0.448) |
1.568 (0.872) |
| No |
1,088 (97.6) |
76.0 (40.0–141.0)a |
0–392 |
1.079 (0.074) |
0.763 (0.148) |
Data are expressed as the number (%) or median (interquartile range). p values calculated by Mann-Whitney U test.
Statistically significant difference between groups:
a0.01 < p < 0.05
b0.001 < p < 0.01
cKruskal-Wallis test.
Situations reported as causing the highest MD among HCPs during COVID-19 pandemic were ranked for each provider group (Table 3). Among all participants, “to be required to care for more patients than one can safely care for” was the most highly ranked issue. In particular, the situation that caused the highest MD for physicians was “to experience compromised patient care due to lack of resources/equipment/bed capacity,” whereas among nurses, it was the “concern about patients’ suffering due to a lack of provider continuity.” A comparison was made for the most morally distressing root causes per profession during the pandemic and the prepandemic period. In the prepandemic period, nurses reported higher scores on patient-level root causes than physicians, whereas physicians exhibited higher scores on system-level root causes than nurses. During COVID-19 pandemic, both groups reported higher MD scores on system-level root causes (Supplemental Fig. 2, Supplement Digital Content 4, https://links.lww.com/CCM/G931).
TABLE 3. -
Most Common Sources of
Moral Distress Reported by ICU
Healthcare Professionals During
Coronavirus Disease 2019 Pandemic
| Situation |
All |
Nurses |
Physicians |
| MMD-HP-SPA, mean (sd) |
Rank (Changea) |
MMD-HP-SPA, mean (sd) |
Rank (Changea) |
MMD-HP-SPA, mean (sd) |
Rank (Changea) |
| Be required to care for more patients than I can safely care for |
6.52 (5.18) |
1 (+1) |
6.27 (5.21) |
2 (=) |
6.87 (5.12) |
2 (+1) |
| Watch patient care suffer because of a lack of provider continuity |
6.45 (5.10) |
2 (–1) |
6.39 (5.18) |
1 (+2) |
6.52 (4.99) |
3 (–2) |
| Experience compromised patient care due to lack of resources/equipment/bed capacity |
6.45 (5.21) |
3 (+1) |
6.12 (5.09) |
3 (+3) |
6.91 (5.35) |
1 (+1) |
| Experience lack of administrative action or support for a problem that is compromising patient care |
5.54 (5.22) |
4 (+3) |
4.92 (5.01) |
6 (+4) |
6.41 (5.39) |
4 (+1) |
| Be required to work with other healthcare team members who are not as competent as patient care requires |
5.23 (4.78) |
5 (+5) |
5.85 (4.89) |
4 (+4) |
4.36 (4.49) |
7 (+4) |
| Continue to provide aggressive treatment for a person who is most likely to die regardless of this treatment when no one will make a decision to withdraw it |
5.15 (4.35) |
6 (–3) |
5.65 (4.43) |
5 (–4) |
4.44 (4.14) |
6 (=) |
| Feel pressured to order or carry out orders for what I consider to be unnecessary or inappropriate tests and treatments |
4.32 (4.06) |
7 (–1) |
4.62 (4.10) |
9 (–5) |
3.90 (3.96) |
8 (+2) |
| Witness low quality of patient care due to poor team communication |
4.32 (4.12) |
8 (+1) |
4.64 (4.28) |
8 (–1) |
3.87 (3.85) |
9 (=) |
| Be unable to provide optimal care due to pressures from administrators or insurers to reduce costs |
4.30 (4.86) |
9 (+6) |
4.83 (5.04) |
7 (+6) |
3.56 (4.51) |
11 (+7) |
| Have excessive documentation requirements that compromise patient care |
4.26 (4.60) |
10 (–2) |
3.50 (4.13) |
13 (–1) |
5.33 (5.00) |
5 (–1) |
MMD-HP-SPA = Spanish version of the Measure of Moral Distress for Healthcare Professionals.
aChange in ranking position between October and December 2019 and September and November 2020.
Boldface entries indicate those scores are the highest for each group.
Intention to Leave a Position Due to Moral Distress
Significantly, more HCPs reported that they had considered leaving a position or were currently considering leaving a position due to MD during COVID-19 pandemic compared with the prepandemic period (Supplemental Fig. 3, Supplement Digital Content 4, https://links.lww.com/CCM/G931). Figure 2 shows that MMD-HP-SPA scores were significantly higher for those HCPs that had considered leaving their position or were currently considering leaving a position due to MD in both periods. Among those HCPs with that intention, MMD-HP-SPA scores were higher during the pandemic period than the prepandemic period (Supplemental Tables 4 and 5, Supplement Digital Content 4, https://links.lww.com/CCM/G931). Similar results were seen for physicians and nurses independently (Supplemental Figs. 4–7, Supplement Digital Content 4, https://links.lww.com/CCM/G931).
Figure 2.: Participants’ moral distress levels and their intention to leave a position. A, Past intention to leave a position due to moral distress between October and December 2019. B, Current intention to leave a position due to moral distress between October and December 2019. C, Past intention to leave a position due to moral distress between September and November 2020. D, Current intention to leave a position due to moral distress between September and November 2020. CL = Consider leaving a position, L = Left a position, MMD-HP-SPA = Spanish version of the Measure of Moral Distress for Healthcare Professionals, NCL = not consider leaving a position.
DISCUSSION
The COVID-19 global crisis has left frontline HCPs in ICUs with their backs against the wall since they were exposed to several stressors (3). The fear to get infected and to infect their loved ones, national lockdown policies, constant bad news in the media (33), and the absence of family members at the bedside, among others, have resulted in an overburdening of ICU HCPs (34,35).
This is the first national, cross-sectional study focused on MD in ICU HCPs comparing prepandemic and pandemic periods. Our findings confirm that MD levels have increased among Spanish ICU HCPs during COVID-19 pandemic, particularly among ICU nurses, when compared with the immediate prepandemic situation. Although, before COVID-19, Spanish intensivists reported significantly higher levels of MD than ICU nurses (27), we have observed that these differences have decreased during the pandemic period. Although in most studies (all conducted before the pandemic) nurses reported higher MD levels than physicians (18,22,23,31), our results are consistent with the most recently published data where both groups of HCPs had similar MD levels (36,37).
It has been established that MD have negative consequences for HCPs, teams, and healthcare systems (24,38,39). MD negatively impacts on physical and emotional well-being of HCPs affecting their ability to assume expected job responsibilities and decreasing the amount of time spent with patients and their families (40). As a result, patient satisfaction, outcomes, and mortality rates are worsened (41). Thus, this increase in MD levels during COVID-19 pandemic may ultimately lead to a deterioration of quality-of-care and patient safety (35).
Our data point out a change in the profile of HCPs and the working conditions in ICUs during COVID-19 surge that could have influenced on increased MD levels. Due to the scarcity of medical, structural, and human resources, HCPs and institutions had to allocate those resources fairly (7–10). Under these circumstances, younger and less experienced HCPs, sometimes even with a little or no qualification to deliver quality intensive care, were called to work in Spanish ICUs during the pandemic. In this study, such HCPs reported higher levels of MD than older and more experienced HCPs. Furthermore, the lack of ICU bed capacity led critical care departments to open additional ICU beds in other hospital areas that used to lack the most adequate characteristics for full intensive care. In line with previous studies (39), our results have shown that working in unfamiliar working environments proved to be a source of MD. In addition, participants reported that the structural organization of the ICUs also influenced in the MD they experienced.
The MMD-HP-SPA measures MD at three different levels of root causes (patient, unit, and system) (27,31,32). Item-level analysis of MD root causes allows for a more accurate study into the situations that are morally distressing for ICU HCPs. Our findings underscore that system-level root causes became more morally distressing during the pandemic period. Six system-level root causes were ranked in the top 10. Particularly, caring for too many patients was the situation in which HCPs experienced MD the most. In line with a recent Dutch study conducted among ICU HCPs (37), other two situations became substantially more morally distressing in the pandemic period: compromised patient care due to scarcity of resources and having to work with colleagues believed not to be competent enough. Due to the high volume of patients and the scarcity of resources, patient-to-professional ratios and the need for less-qualified colleagues to deliver intensive care were greatly increased (7,35,42). These conditions have contributed to a constant dilemma between safe working conditions and high quality-of-care during COVID-19 pandemic (35).
It is assumed that COVID-19 pandemic has jeopardized frontline HCP mental health. Several reports evidenced that the overwhelming situation experienced by ICU HCPs has resulted in an overall surge of new cases of depression and anxiety (34,35,43). In this sense, we have observed that HCPs who were off work due to this psychologic burden reported the highest levels of MD among all participants.
Current shortage of ICU HCPs worldwide, particularly ICU nurses, has been exacerbated during the pandemic (44). MD has been previously associated with the propensity to leave one’s job (27,31,38,45,46). In this study, it is relevant that nearly one-third of ICU HCPs (27.0%) were thinking about leaving their position due to MD. It should be noted that in the pandemic period, the number of HCPs thinking of leaving their job was significantly higher than the prepandemic period (27,31,45). To leave a job when working in ICU is a matter of concern, since HCPs working experience in the ICU is essential to adequately manage both standard and complex critically ill patients. Furthermore, the cost of replacing high-qualified ICU HCPs is greater than the cost of retaining them. Consequently, MD can increase healthcare costs and decrease productivity (29). Our results have shown that the association between MD and the propensity to leave one’s job has been compounded during the COVID-19 pandemic. HCPs considering leaving their job reported higher levels of MD during the pandemic than that in the prepandemic period, particularly ICU physicians (128.0 [54.5–207.0]). Thus, MD may accelerate the staff turnover and may be associated with suboptimal quality of care (20,30,40).
In the context of COVID-19 pandemic, there is a clear need to design and implement strategies to reduce and prevent MD. Once the most morally distressing situations have been assessed, targeting high-risk areas or teams to design specific interventions to different HCPs groups may yield substantial benefits on patient safety and quality-of-care. Different interventions have been proposed to alleviate MD (17,26,30). Since caring for too many patients and the scarcity of resources were two of the most morally distressing situations reported by HCPs, increase the number of high-qualified ICU HCPs through system wide training, and an adequate investment in the material and human resources required would reduce the likelihood of MD. In addition, improving the collaboration between physicians and nurses to aid in continuity of care and building a healthier working culture where HCPs could freely speak out or seek advice could assist in mitigating the prevalence of MD among HCPs. Furthermore, studies are needed to ascertain whether these strategies and interventions may achieve a reduction in MD levels and how is quality of patient care impacted.
Our study has some limitations. First, as an online survey study, we have no information about the exact number of HCPs who received the questionnaire to calculate the response rates across centers or societies, so the findings may be biased and difficult to generalize. However, with more than 1,000 participants in each study period, this is the largest study assessing MD among ICU HCPs to date. Second, a selection bias should be considered. If the most morally distressed HCPs return less surveys, the “healthy worker effect” may have occurred or vice versa. Third, this study did not assess long-term consequences of increases in MD on ICU HCPs and their families, the patients, and the healthcare systems. Fourth, interregional differences of MD levels were not considered. Although we surveyed broadly using the mailing lists of our adult and pediatric critical care national societies, we cannot exclude the potential effect of different pandemic pressures on the regional healthcare. Last, MD among Spanish ICU HCPs during COVID-19 pandemic may differ from that in other countries. Studies assessing MD in relation with the pandemic in other countries are warranted.
CONCLUSIONS
ICU HCPs in Spain have experienced more MD during the COVID-19 pandemic compared with the prepandemic period. Both ICU nurses and physicians reported similar levels of MD in the pandemic period. This increase in MD among ICU HCPs may have negative consequences on quality of patients care. During the pandemic, nurses and physicians reported higher MD on system-level root causes. Strategies like increasing competent staff through systemwide training; investing in more equipment, resources, and supplemental staff; improving the collaboration between physicians and nurses to aid in continuity of care; and building a healthier working culture could assist in mitigating the prevalence of MD among ICU HCPs.
ACKNOWLEDGMENTS
We acknowledge all the critical care nurses and intensivists who has contributed to this study answering the questionnaires. We would also like to thank Dr. Juan Ruiz-Bañobre for his assistance in figure design.
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