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Full-Text Articles in Other Nursing

Attention-Deficit/Hyperactivity Disorder And Teachers, Samantha Ann Tierney, Samantha Ann Tierney Dec 2023

Attention-Deficit/Hyperactivity Disorder And Teachers, Samantha Ann Tierney, Samantha Ann Tierney

Honors College Theses

Attention-Deficit/Hyperactivity Disorder (ADHD) is a common disorder, estimated to affect 5% of all children and adolescents. The current rate of diagnosis is steadily increasing. This increase in the number of students with ADHD affects educators, who have a large role in the success of students with ADHD. Despite this, many teachers are not prepared to deal with the extra challenges that come with teaching students with ADHD. Teachers may not be properly taught how to deal with children who have ADHD in their classrooms or the role they have in these children’s lives. The purpose of this study is to …


The Benefits Of Using Patient Transfer Devices In The Emergency Department, Abby Lawhorn, Mikaylen Dearmond Mar 2023

The Benefits Of Using Patient Transfer Devices In The Emergency Department, Abby Lawhorn, Mikaylen Dearmond

Scholars Week

The Emergency Department (ED) is known as one of the most fast-paced environments in which nurses work. Because of the nature of their responsibilities and daily tasks, ED nurses are at high risk of injury. One of those tasks that occur multiple times throughout the day is patient transfers. The Emergency Department staff is constantly moving patients in and out of the unit. Most often, patients seen in the ED are weak, in pain, elderly, or unable to transfer from vehicles, ambulance, stretchers, or wheelchairs independently or without minimal assistance. Our research focuses on the benefits of using assistive devices …


The Relationship Between Increased Wages And Nurse Satisfaction And Intent To Stay, Jean Andres Mar 2023

The Relationship Between Increased Wages And Nurse Satisfaction And Intent To Stay, Jean Andres

College of Health Sciences Posters

The Relationship between Increase in Wages and Nurse Satisfaction and Intent to Stay

Abstract

The recent COVID-19 pandemic contributed to a negative climate in healthcare and increased the workforce demands of nurses leading to decreased satisfaction and an unprecedented staffing crisis. Further compounding the problem, staffing agencies have offered fiscally lucrative contracts that enticed experienced nurses to leave permanent staff positions for external contract agency nursing.

Research Questions for this study are as follows:

  • RQ1: What is the relationship between increased wages and nurse satisfaction?
  • RQ2: What is the relationship between increased wages and intent to stay?
  • RQ3: What is …


Exploring Novel Intradialytic Techniques To Identify & Ameliorate Of Hemodialysis-Induced Myocardial Ischemic Injury, Jarrin D. Penny Feb 2023

Exploring Novel Intradialytic Techniques To Identify & Ameliorate Of Hemodialysis-Induced Myocardial Ischemic Injury, Jarrin D. Penny

Electronic Thesis and Dissertation Repository

Patients with chronic kidney disease requiring hemodialysis to sustain life have extremely high rates of cardiovascular morbidity/mortality. This is both a consequence of the disease process and treatment. Hemodialysis induces systemic circulatory stress is largely due to the extracorporeal circuit and volume removal. The stress induced by intermitted hemodialysis is repetitive with cumulative cardiovascular effect and is the principal driver of heart failure and sudden death in this vulnerable population. The insults imposed by hemodialysis result in left ventricular regional wall motion abnormalities and lead to myocardial stunning with permanent damage to the vasculature and myocardium. Currently, the adversity caused …


Practicum Structures And Nursing Student Retention/Achievement Rates In A United Kingdom University: A Quantitative Analysis, Phil M. Coleman Feb 2023

Practicum Structures And Nursing Student Retention/Achievement Rates In A United Kingdom University: A Quantitative Analysis, Phil M. Coleman

Quality Advancement in Nursing Education - Avancées en formation infirmière

This study sought to examine whether the consistent application of a specific placement design to student practice learning experiences within two pre-registration nursing degree programmes offered by a university in the United Kingdom (UK) affected retention and achievement levels. The quantitative analysis involved a sample of 460 employer-sponsored undergraduates, all of whom worked as non-registrant carers, within two cohorts of a part-time adult (physical) or mental health nursing degree programme, both of four years duration, offered by a large academic institution with a presence in all four UK nations. Cross-tabulation and multinomial logistic regression analyses found no statistically significant relationship …


Impact Of The Covid-19 Pandemic On Nursing Students’ Clinical Learning Experiences In British Columbia: The Student Perspective, Krista Sferrazza, Maura Macphee, Farinaz Havaei, Suzanne Hetzel Campbell Feb 2023

Impact Of The Covid-19 Pandemic On Nursing Students’ Clinical Learning Experiences In British Columbia: The Student Perspective, Krista Sferrazza, Maura Macphee, Farinaz Havaei, Suzanne Hetzel Campbell

Quality Advancement in Nursing Education - Avancées en formation infirmière

The clinical learning environment is where nursing students gain knowledge, practice skills and become socialized into the nursing profession. Traditionally, in Canada, the clinical learning environment takes place hospital and community settings. The COVID-19 pandemic required quick thinking by nursing faculty to replace on-site clinical hours. Given the quick change-over, there was minimal consideration given to nursing students' perspectives in the planning stages. This study aimed to investigate nursing students' experience in the clinical learning environment before and during the COVID-19 pandemic. The perceived quality of students' learning experiences was assessed using the Clinical Learning Environment, Supervision and Nurse Teacher …


University Competency-Based Courses For Internationally Educated Nurses (Iens) In Ontario: A Pilot Education Pathway To Registered Nurse (Rn) Licensure, Elaine E. Santa Mina Dr, Ayesha Bhatti, Patricia Bradley, Elizabeth Manafo, Alice Ormiston, Linda Patrick, Kirsten Woodend Feb 2023

University Competency-Based Courses For Internationally Educated Nurses (Iens) In Ontario: A Pilot Education Pathway To Registered Nurse (Rn) Licensure, Elaine E. Santa Mina Dr, Ayesha Bhatti, Patricia Bradley, Elizabeth Manafo, Alice Ormiston, Linda Patrick, Kirsten Woodend

Quality Advancement in Nursing Education - Avancées en formation infirmière

In 2014, a team of nurse educators and champions of internationally educated nurses (IENs) in Ontario, Canada, came together to address the issue of supporting IEN transition to practice as one route to help address nursing shortages. Courses were developed with funding from the Government of Ontario, and policy and coordination support from the Council of Ontario Universities, to pilot an educational bridging pathway for IENs. The faculty team across four Ontario universities used a consortium approach to coalesce province-wide expertise in IEN education. What began as a selection of targeted, competency-based courses has since evolved into a full Competency-Bridging …


Building Resilience In Graduate Nurses Through Online Virtual Simulation, Robert Harmon Feb 2023

Building Resilience In Graduate Nurses Through Online Virtual Simulation, Robert Harmon

Electronic Theses and Dissertations

Resilience has become a popular topic in nursing research. Nurses experience enormous stress throughout their training process that extends into their first employment as they transition into practice. Simulation training is a standard for training nurses and for continuing professional education within academia. Most simulation training for nurses is focused on building critical thinking skills. While critical thinking is an essential quality equipping nurses to meet professional demands, resilience is a crucial quality to overcome the stress of both training and practice. Resilience is believed to play an essential role in the retention of new graduate nurses and preventing burnout …


Female Ex-Offenders Transitioning Into Society, Stacey L. Forte Feb 2023

Female Ex-Offenders Transitioning Into Society, Stacey L. Forte

Electronic Theses and Dissertations

The purpose of this qualitative study was to examine female ex-offenders’ perceptions of their lived experience(s) while transitioning into society after incarceration. This study examined risk factors that female ex-offenders faced while transitioning into society asking the question, “What are the lived experiences of female ex-offenders who utilized transitional housing for reentry with regard to their perception of the benefits of certain services/offerings and staff support?” Nine participants were part of the study ranging from 25–64 years of age, with the majority being between the ages of 25 and 55 years old, residing originally in five different states. Sixty percent …


Using Doctoral Education And Research-Based Learning To Advance The Nurse Leader, Kara R. De La Fosse Jan 2023

Using Doctoral Education And Research-Based Learning To Advance The Nurse Leader, Kara R. De La Fosse

The Journal of Advancing Education Practice

Nurse leaders perform in highly autonomous positions in two dimensions; academia, and the clinical setting with the awesome responsibility to serve and protect others. To guide nursing practice, research-based skills are crucial to ensure leadership decisions are founded in evidence-based practice. Random controlled studies are gold-standard in healthcare compared to correlation or descriptive studies and employ a systematic review to strengthen findings (Schmidt & Brown, 2021). Research skills are prominent in numerous components of the leadership scope to perform at a stellar level.


Dedicated Vascular Access Team Benchmark Study, Rachel Davis Dec 2022

Dedicated Vascular Access Team Benchmark Study, Rachel Davis

MSN Capstone Projects

Hospitals see a rise in the critically ill population. These patients present with multiple comorbidities resulting in frequent emergency department trips. Unfortunately, with each visit, these patients require a vascular access device. Over time their veins will no longer be easily accessible. Patients with veins that are no longer visible, palpable, or require special techniques to obtain access are considered to be difficult intravenous access (DIVA) patients. They will likely experience multiple attempts with each admission to the hospital, resulting in physical and emotional pain, not to mention being costly. The purpose of this paper is to compare the advantages …


An Enhanced Enrollment Process To Impact Appointment Compliance In The Hf-Optimize Clinic, Carolyn Coons, Teri Diederich, Kyana Holder Dec 2022

An Enhanced Enrollment Process To Impact Appointment Compliance In The Hf-Optimize Clinic, Carolyn Coons, Teri Diederich, Kyana Holder

Doctor of Nursing Practice Projects: College of Nursing

Background The HF-Optimize clinic showed improved utilization of guideline-directed medical therapy (GDMT) along with improved clinical outcomes from 2018 to 2020. Appointment compliance was poor with only 44% of patients completing all HF-Optimize visits. Missed appointments led to worse health outcomes, fragmented care, and provider inefficiencies. Interventions to improve appointment compliance are vital to improving heart failure outcomes. Objective The purpose of this quality improvement project is to evaluate the impact that an enhanced enrollment process has on appointment compliance in a culturally diverse, adult population referred to the HF-Optimize clinic at Nebraska Medicine. Methods This prospective quality improvement project …


Increasing Colorectal Cancer Screening Rates In The Psychiatric Inpatient Unit, Diane R. Ventura Dec 2022

Increasing Colorectal Cancer Screening Rates In The Psychiatric Inpatient Unit, Diane R. Ventura

Master's Projects and Capstones

Increasing Colorectal Cancer Screening Rates in the Psychiatric Inpatient Unit

Abstract

Problem: Colorectal cancer is one of the leading cancer deaths in the United States. The Psychiatric Inpatient Unit has a colorectal cancer screening compliance rate of 40% compared to the statewide average of 80%.

Context: The Psychiatric Inpatient Unit is a 58-bed inpatient intermediate care facility mental health program in Northern California. Upon review of the EMR, most PIU nurses give verbal instructions and patient education on colorectal cancer screenings when due. Still, no printed handout was provided to the patients upon review of the EMR.

Intervention: Review of …


The Effect Of Standardized Patient Education On 30-Day Hospital Readmissions For Heart Failure Patients In The Outpatient Setting, Lurie Dimalanta Dec 2022

The Effect Of Standardized Patient Education On 30-Day Hospital Readmissions For Heart Failure Patients In The Outpatient Setting, Lurie Dimalanta

Master's Projects and Capstones

Problem: Heart failure (HF) is the second leading condition of hospital readmissions. Evidence shows that patient education on self-care and disease management can help reduce and prevent 30-day hospital readmissions. Registered nurse case managers (RN CMs) can help improve patients' ability to self-manage their condition and prevent 30-day hospital readmissions by applying a standard approach to patient education.

Context: The Integrated Care Management (ICM) is an outpatient department that provides post-discharge patient calls. The ICM RN CMs utilized various HF patient education tools for patient teaching. The organization’s HF task force developed health-literate patient resources to be used …


Delirium And Staff Injury, John Olague Jr Dec 2022

Delirium And Staff Injury, John Olague Jr

Master's Projects and Capstones

Abstract

Problem: From April 2021 to January 2022 there were 17 cases of reported patient aggression and staff injury due to patients in the hyperactive state of delirium. In a stroke/tele unit, diagnosis of delirium was delayed due to subjective assessment from the confusion assessment method (CAM) tool. This delay allowed patients to reach the hyperactive state of delirium which poses a threat to patient and staff safety. An objective form of assessment for delirium was needed on this stroke/tele unit.

Context: Through a microsystem assessment and strengths, weaknesses, opportunities, and threats (SWOT) analysis, stakeholders in this performance improvement plan …


Standardizing Handoff Report In A Medsurg Telemetry Floor, Brandon Tyler Thompson Dec 2022

Standardizing Handoff Report In A Medsurg Telemetry Floor, Brandon Tyler Thompson

Master's Projects and Capstones

Problem: Hospital A’s 9th floor telemetry units lacked a standardized method of handoff and required investigation. Current practices were evaluated, and an intervention was designed based on weak communication areas. Context: Using a 5 P’s assessment the key stakeholders included unit nurses, the nursing director, nurse educators, and unit nurse managers, and the patients were medsurg telemetry patients. The process included handoff in care and the pattern evaluated was methods of reporting with the purpose of providing high quality evidence-based patient centered care. A SWOT analysis revealed strong teamwork, interdisciplinary collaboration, and proficiency in health record technologies as strengths …


Decreasing Hospital Acquired Pneumonia In Adult Patients By Patient Care Technicians: Education With A Focus On Oral Care And Tooth Brushing, Amanda Nicole Lee Dec 2022

Decreasing Hospital Acquired Pneumonia In Adult Patients By Patient Care Technicians: Education With A Focus On Oral Care And Tooth Brushing, Amanda Nicole Lee

Master's Projects and Capstones

Hospital acquired pneumonia’s (HAPs) are unfortunate and preventable events quality improvement efforts should focus on. At a Northern California Hospital, there was an unmet HAP rate goal of 2.3 (20 out of 8795 patients) against a target goal of 2. This increase in HAP rates, both non-ventilated and ventilated was a call to action to reduce HAP to the target goal. The quality improvement project specifically aimed to reduce HAP rates on medical-surgical units through an ultra-brief refresher on the hospital validated and endorsed ROUTE bundle. The education focused on oral care completed by the patient care technicians (PCT’s). The …


Improving Safe Handling And Administration Of Usp<800> Hazardous Drugs Within The Medical-Surgical Unit, Pavlo Karaputa Dec 2022

Improving Safe Handling And Administration Of Usp<800> Hazardous Drugs Within The Medical-Surgical Unit, Pavlo Karaputa

Master's Projects and Capstones

Nurses comprise the largest proportion of healthcare providers who make contact with Hazardous Drugs (HDs) during multiple types of clinical activities and have a risk of exposure. Hazardous drugs (HDs) are a class of pharmaceuticals that pose serious health risks to individuals who handle them, including organ toxicity, reproductive and developmental defects, infertility, miscarriage, genetic toxicity, cancer, and even death. This project was implemented in a hospital system within Northern California, on two units that serve medical-surgical, oncology, geriatric, and transplant patients. The Medical Surgical microsystem at this hospital comprises a small group of professionals such as registered nurses (RNs), …


Reducing Hospital-Acquired Pneumonia By Educating Patient Care Technicians On Route Bundle Care Measures, Munroop K. Thiara Dec 2022

Reducing Hospital-Acquired Pneumonia By Educating Patient Care Technicians On Route Bundle Care Measures, Munroop K. Thiara

Master's Projects and Capstones

Hospital-acquired pneumonia (HAP) is an infection of the lungs that can lead to severe and sometimes fatal outcomes. HAP can be prevented by oral care interventions, but without proper patient care, treatment can be very expensive. Evidence-proven HAP preventative measures such as the ROUTE bundle and increased patient mobility can significantly lower the risk of pneumonia as well as prevent additional hospital costs. Hospital X is a private nonprofit health care organization in the urban suburbs of a large Northern California city with a current HAP rate of 2.3 and with targeted goals of 2.0. By creating a project that …


Impact Of Pcts In The Prevention Of Hap Through A Route Bundle With An Emphasis On Oral Care And Positioning The Patient Out Of Bed And In A Chair, Melissa Ray Dec 2022

Impact Of Pcts In The Prevention Of Hap Through A Route Bundle With An Emphasis On Oral Care And Positioning The Patient Out Of Bed And In A Chair, Melissa Ray

Master's Projects and Capstones

Background: Hospital Acquired Pneumonia (HAP) is a leading cause of most hospital-acquired infections among surgery patients who are hospitalized and bed-bound for more than 48hrs. The occurrence of HAP is associated with increased hospital stays and cost of care. However, its occurrence can be reduced by oral care. In this regard, this project aimed to decrease the incidence of HAP on the 3rd, 4th, 6th, and 7th floors on the Medical Surgical and ICU units of the Northern California Hospital.

Methods: To achieve the aim above, the project utilized methods namely …


Improving Nursing Shift Handoff Reports: A Quality Improvement Project, Nathan Mm Secrest Dec 2022

Improving Nursing Shift Handoff Reports: A Quality Improvement Project, Nathan Mm Secrest

Master's Projects and Capstones

Nursing shift-to-shift handoff report can greatly impact a patient’s quality of care. According to the Joint Commission, “an estimated 80 percent of serious medical errors involve miscommunication between caregivers when patients are transferred or handed-off” (Inadequate handoff communication, 2017). In total, this quality improvement (QI) project worked with three hospital inpatient units on three different floors in an urban California (CA) city. Each unit and even shifts within each unit varied, leading to the conclusion that interventions should be trialed by units with the most buy-in, then adjusted to the unique needs of each unit. For our main intervention we …


Developing Competence And Improving Patient Safety With Documentation Training In The Simulated Environment, Laura Zebreski Dec 2022

Developing Competence And Improving Patient Safety With Documentation Training In The Simulated Environment, Laura Zebreski

DNP Final Reports

With the advent of electronic health records, nursing documentation has declined in quality. Poor documentation exposes patients to safety risks. Nursing documentation is subject to legal standards set by the Texas State Board of Nursing. A DNP scholarly project was designed to create a learning and safety intervention to train student nurses to provide correct documentation before entering clinical settings. The goal of this project was to prepare nursing students to provide quality documentation that fulfills the legal standard to attempt to correct the current deficiencies seen in practice and promote patient safety. For this project, the students took a …


Evidence-Based Selection Of A Fall Risk Assessment Tool: A Program Evaluation Review, Lindsey Adams Dec 2022

Evidence-Based Selection Of A Fall Risk Assessment Tool: A Program Evaluation Review, Lindsey Adams

Student Scholarly Projects

Fall prevention strategies are a consistent topic of discussion for healthcare regarding patient safety, as patient falls are costly to the patient and the organization. This project uses the CDC Framework for Program Evaluation to assess the fall prevention policy of a local hospital system, with particular emphasis on the fall risk assessment tool, Hester Davis. This project also explores the risks and benefits of adopting an alternative fall risk assessment tool, predictive analytics. Predictive analytics uses electronic health record (EHR) data analysis to provide a highly individualized patient fall risk score based on a large variety of patient and …


Reducing Readmission (And Mortality) For Older Patients & Survivors Of Life-Threatening Conditions: A Study Using The Staarr Protocol, Akhenaten Amun Dec 2022

Reducing Readmission (And Mortality) For Older Patients & Survivors Of Life-Threatening Conditions: A Study Using The Staarr Protocol, Akhenaten Amun

Symposium of Student Scholars

Readmission rates for patients admitted for heart failure, pneumonia, chronic obstructive pulmonary disorder, a myocardial infarction, a hip or knee arthroplasty, or coronary artery bypass surgery tend to have high readmission and mortality rates within 30 days of their discharge from a hospital. Starting in October 2012, the Healthcare Reimbursement Reduction Program enforced penalties on Medicare reimbursements for hospitals with readmission rates, for patients with the conditions above, were higher than averages based on facilities with similar characteristics and patient populations. Teach-back and verify (Klingbeil & Gibson, 2018), interdisciplinary teams that engage in patient care and support (Reiter-Palmon et al., …


Botulism Toxin And Its Affects On Spasticity, Paige Nicholas Dec 2022

Botulism Toxin And Its Affects On Spasticity, Paige Nicholas

Symposium of Student Scholars

Abstract

Spasticity is a symptom associated with spinal cord injury patients that is caused from an influx in excitatory and inhibitory signals controlling muscles and reflexes generating a pattern of spasms in a period of time. When not treated properly adverse effects include: contractures, respiratory arrest, pain, paralysis and decrease in efficiency of nursing and therapeutic care. Interventions including medications (i.e. baclofen, dantrolene, gabapentin), physical therapy, surgery and orthotic devices are used to decrease spasticity however show minimal effect, short duration and multiple side effects. These side effects include dizziness, weakness, confusion, headaches, nausea and constipation. Recent research has shown …


Do Automated Reposition And Alert Systems Reduce The Development Of Pressure Ulcer?, Adanech Jones Dec 2022

Do Automated Reposition And Alert Systems Reduce The Development Of Pressure Ulcer?, Adanech Jones

Symposium of Student Scholars

Abstract

Do Automated Reposition and Alert systems reduce the development of Pressure Ulcer?

Each year more than 2.5 million people in the USA develop pressure ulcers, which are painful skin lesions that increase the risk for serious infection in patients. In some cases, pressure ulcers, if left untreated can lead to death. In the USA, hospital acquired pressure injury costs (HAPI) has a possibility to exceed $26.8 billion. About 59% of these costs are disproportionately attributable to a small rate of Stages 3 and 4 full-thickness wounds, which occupy clinician time and resources. PUs occurs when bedridden or wheelchair bound …


Mentoring Infection Preventionists: An Infection Prevention Practice Fellowship Program, Sejal Naik Dec 2022

Mentoring Infection Preventionists: An Infection Prevention Practice Fellowship Program, Sejal Naik

DNP Qualifying Manuscripts

Background: The COVID-19 pandemic created enormous demands on infection preventionists (IPs). It seriously taxed IPs and required hiring new IPs to support these demands. It is highly competitive to hire experienced IPs, and it can take up to two years for new IPs to demonstrate proficiency before pursuing their certification. A gap analysis revealed that current infection prevention (IP) programs did not provide formal training or mentoring.

Methods: The fellowship program will use the Association for Professionals in Infection Control and Epidemiology (APIC) competency model to train and build IP competency. The APIC accelerated training program will provide training to …


Nurse Efficiency & Ultrasound Guided Intravenous Access: Evidence Based Intervention Benchmark, Jacob D. Frost Dec 2022

Nurse Efficiency & Ultrasound Guided Intravenous Access: Evidence Based Intervention Benchmark, Jacob D. Frost

MSN Capstone Projects

Gaining IV access is this first step into accurate, timely diagnosis and interventions of patients. Nurses are typically the first medical professional a patient sees. If the nurse can establish IV access as early as possible this will lead to faster interventions faster diagnostic results and better management for patients and ultimately better patient outcomes. Ultrasound guided IV can increase first attempt success rates leading to decreased painful IV insertions by multiple nurses. This would increase patient satisfactions scores leading to higher re-imbursement.


An Integrative Review: The Experiences Of Stress, Burnout, And Compassion Fatigue By Ambulatory Care Nurses, Rajean Adams Dec 2022

An Integrative Review: The Experiences Of Stress, Burnout, And Compassion Fatigue By Ambulatory Care Nurses, Rajean Adams

MSN in Leadership in Nursing Final Projects

Abstract

Aim: One aim of this integrative review is to highlight workplace issues outpatient (ambulatory care) nurses experience, related to stress, burnout, and compassion fatigue. Another aim is to bring awareness to and discuss recently implemented tools and strategies to help alleviate these manifestations.

Background: Stressors in the outpatient setting date back to the 1970s when psychologist Herbert Freudenberger mentioned the burnout he experienced while in a Free Clinic. In modern-day, half of nurses experiencing workplace burnout, confess to feeling emotional exhaustion. Various studies discuss the challenges nurses endure in the inpatient setting, but only a few focus on ambulatory …


Remote Patient Monitoring: Decrease Rehospitalization For Spinal Cord Injury Patients, Abegail Cabunoc-Garcia Dec 2022

Remote Patient Monitoring: Decrease Rehospitalization For Spinal Cord Injury Patients, Abegail Cabunoc-Garcia

Student Scholarly Projects

Practice Problem: The lengthy distance required to access specialty care, the overall higher cost of SCI/D care, complications associated with SCI, and the potential negative impact of shortened hospital stays are all compelling reasons to use telehealth technologies to deliver specialty services for medical issues.

PICOT: The PICOT question that guided this project was in adult spinal cord injury patients with chronic disease receiving primary care at a spinal cord injury center (P), how does the implementation of a remote patient monitoring home telehealth for SCI patients recently discharged from acute-care setting (I) compared to the usual practice …