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Articles 2851 - 2880 of 6199
Full-Text Articles in Entire DC Network
Effect Of An Educational Intervention On Coronary Artery Disease Knowledge In Men And Women At Risk For Coronary Artery Disease, Rochelle Anderson-Doyley
Effect Of An Educational Intervention On Coronary Artery Disease Knowledge In Men And Women At Risk For Coronary Artery Disease, Rochelle Anderson-Doyley
Doctor of Nursing Practice Projects
Background
Coronary artery disease (CAD) is the leading cause of death in the United States. The management of CAD, a preventable disease, has significant implications for health and wellness outcomes in the United States. Decades of research have examined the role and effectiveness of an educational intervention in promoting the patient's knowledge of and ability to manage risk factors for CAD. This project examined the effectiveness of an educational tool implemented in a primary care setting in improving patients' knowledge about CAD risk factors.
Method
The research design was a non-experimental one-group pre-test and post-test design. After receiving institutional review …
Examining Body Mass Index And Sepsis Mortality At One Year After Sepsis, Jamie D. Robinson
Examining Body Mass Index And Sepsis Mortality At One Year After Sepsis, Jamie D. Robinson
Theses and Dissertations
Introduction: Sepsis is a serious and life-threatening syndrome affecting 1.7 million Americans annually and resulting in approximately 270,000 deaths. An “obesity paradox” where obese individuals have lower sepsis mortality than their non-obese counterparts has been described. The problem is that the longevity of the effect is unknown, and few studies have examined the obesity paradox after 1-2 months post-diagnosis.
Methods: This retrospective cohort study examined clinical, demographic, and biomarker variables thought to affect sepsis mortality at three-time points: 30 days, 180 days, and at one year post-sepsis diagnosis in order to shed light on specific factors that might define …
Improving Low Health Literacy In Poststroke Patients By Educating The Health Care Staff, Marthilde Brzycki
Improving Low Health Literacy In Poststroke Patients By Educating The Health Care Staff, Marthilde Brzycki
Electronic Theses and Dissertations
Abstract
Lack of health literacy in the poststroke patient population is a serious issue; with the addition of the homeless population to that group, the result may be devastating. According to the American Heart Association and American Stroke Association (AHA/ASA, 2016), stroke is considered the primary cause of death and one of the chief reasons for disability in the United States, and nearly75% of strokes occur in those who are 65 years of age or older. Nurse practitioners are vital, providing necessary training and stroke education to the nursing and other health care staff. This DNP project was initiated to …
Blood Flow Improvement Trial: Design And Enrollment Developing Topics, Maiya F. Macalpine, Margo B. Heston, Julian M. Gaitán, Ozioma C. Okonkwo, Barbara B. Bendlin, Kimberlee A. Gretebeck, Randall J. Gretebeck
Blood Flow Improvement Trial: Design And Enrollment Developing Topics, Maiya F. Macalpine, Margo B. Heston, Julian M. Gaitán, Ozioma C. Okonkwo, Barbara B. Bendlin, Kimberlee A. Gretebeck, Randall J. Gretebeck
College of Nursing Faculty Research and Publications
Background
Midlife insulin resistance (IR) has previously been shown to be associated with lower cerebral blood flow (CBF), and is a potentially modifiable risk factor for dementia. The Blood Flow Improvement Trial (BFiT), NCT03117829 , tested a 12 week carbohydrate restricted diet (CRD) and exercise behavioral intervention to reverse IR, and aimed to 1) determine the extent to which improving or normalizing glucose homeostasis improves CBF and cognitive function in individuals with IR, 2) determine whether participants continue to maintain improved or normalized glycemic control for 6 months, and 3) determine changes in the human metabolome as individuals improve or …
I Was Determined To Breastfeed, And I Always Found A Solution: Successful Experiences Of Exclusive Breastfeeding Among Chinese Mothers In Ireland, John Kearney, Qianling Zhou, Haoyue Chen, Katherine Younger, Tanya M. Cassidy
I Was Determined To Breastfeed, And I Always Found A Solution: Successful Experiences Of Exclusive Breastfeeding Among Chinese Mothers In Ireland, John Kearney, Qianling Zhou, Haoyue Chen, Katherine Younger, Tanya M. Cassidy
Articles
Background: The prevalence of exclusive breastfeeding for at least 4 months was previously found to be very low among Chinese immigrants in Ireland, at 5.8% (Zhou et al., Front Public Health 6:351, 2018). This study investigates the successful experiences of Chinese mothers living in Ireland who exclusively breastfeed for between four and 6 months.
Methods: Participants were recruited from the sample of the Ireland Chinese Mother Survey. Qualitative in-depth interviews were conducted with fourteen participants in their homes or public places.
Results: A content analysis revealed that various factors contributed to a successful experience of exclusive breastfeeding among the group …
Reducing Pressure Ulcers In Emergency Department Boarding Patients, Youa Yang
Reducing Pressure Ulcers In Emergency Department Boarding Patients, Youa Yang
Nursing and Health Professions Faculty Research and Publications
CRMC is a level one trauma and teaching hospital in Fresno, California. CRMC’s emergency department (ED) is licensed for 84 beds. When hall beds are added this ED can go up to 110 beds. CRMC sees over 9,000 patients a month. Due to an increase in hospital census and length of stay, this ED has a daily average of 30 inpatients boarding. In December of 2018, this ED had one hospital acquired pressure ulcers (HAPU). Barriers to preventing HAPU’s in the ED are rooms that are not big enough to accommodate hospital beds, inexperienced new nurses who are unaware of …
Nyc Is A Hotspot For Bedsores Among The Elderly And Immobile, Kara J. Brown
Nyc Is A Hotspot For Bedsores Among The Elderly And Immobile, Kara J. Brown
Capstones
New York City is a hotspot for bedsores in nursing homes, according to data provided by the federal government. The Big Apple is home to nine of the 10 nursing homes in the state with the highest rates of long-stay, high-risk patients suffering from bedsores. Nationwide, those 10 nursing homes are among the worst in the nation—the top 2%—for their high bedsore rates, the data shows. Residents considered high risk are, according to Medicare, those who are impaired in bed mobility or transfer, who are comatose, or who suffer from malnutrition.
More than one out of every four residents at …
Benson’S Relaxation Response: Psychological And Physiological Responses Among Patients With Copd, Crista Reaves
Benson’S Relaxation Response: Psychological And Physiological Responses Among Patients With Copd, Crista Reaves
UNLV Theses, Dissertations, Professional Papers, and Capstones
Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States. In patients with COPD, distress is significantly prevalent and can have adverse psychological and physiological effects. Considering the increased rate of COPD, a mind-body intervention focusing on the reduction of both psychological and physiological responses such as anxiety, elevated blood pressure (BP), heart rate (HR), dyspnea, and respiratory rate must be integrated into the patient’s plan of care. The relaxation response (RR) is a term coined by Dr. Herbert Benson in the 1970s describing the body’s ability to counter the fight-or-flight response to decrease …
Infection Control: The Nurse's Responsibility, Marisa Francis
Infection Control: The Nurse's Responsibility, Marisa Francis
UNLV Theses, Dissertations, Professional Papers, and Capstones
Over the last century and a half, infection control measures implemented by nursing staff have continued to evolve, resulting in improved patient outcomes. While this progress is impressive, a decline in rates of hospital acquired infections (HAIs) seems to have slowed, with only a 0.5% decrease in the last seventeen years. Unfortunately, nurses are rarely provided educational support on infection control practices beyond undergraduate and new employee trainings. Meanwhile, the Centers for Disease Control (CDC) is frequently updating their infection control practice recommendations.
The purpose of this project was to observe the current rate of infection control compliance by nurses, …
Increasing Utilization Of Motivational Interviewing To Promote Pediatric Oral Health, Ulyses Reamico
Increasing Utilization Of Motivational Interviewing To Promote Pediatric Oral Health, Ulyses Reamico
Doctor of Nursing Practice (DNP) Projects
Prevalence of early childhood caries (ECC) remains high even in developed countries such as the United States. An interprofessional education (IPE) project between University of San Francisco (USF) School of Nursing and Health Professions and the University of the Pacific (UoP), Arthur A. Dugoni School of Dentistry was initiated four years ago to enhance nurse practitioner (NP) and dental students’ pediatric oral-systemic health assessment and health promotion communication skills. Since then, USF NP students received pediatric oral health assessment training and spent clinical rotations at UoP to provide pediatric oral care alongside dental students. This doctor of nursing (DNP) project …
A Quality Improvement Project To Implement Shared Medical Appointments For The Management Of Type 2 Diabetes In Latino Patients, Denisse Maldonado
A Quality Improvement Project To Implement Shared Medical Appointments For The Management Of Type 2 Diabetes In Latino Patients, Denisse Maldonado
Doctor of Nursing Practice (DNP) Projects
Problem: Santa Rosa Community Health (SRCH) is one of the largest federally qualified health centers in Northern California, providing health care to more than 30,000 patients. More than half of the patients receiving care at the SRCH Lombardi site are Latino patients. Patients self-identify as Latino or other ethnicity on the initial health center registration form. SRCH serves 964 patients with diabetes. Due to limited access to appointments and resources, seeing a healthcare provider regularly can be difficult, posing a barrier to diabetes management. Patients with diabetes would greatly benefit from regular appointments with their primary care provider and resource …
Dnp Project: Development Of A Nurse-Led Pop-Up Clinic Model In San Diego, Jennifer King
Dnp Project: Development Of A Nurse-Led Pop-Up Clinic Model In San Diego, Jennifer King
Doctor of Nursing Practice (DNP) Projects
Baccalaureate nursing programs across California (CA) are required by the state board of nursing to provide theory of public health and applied clinical learning to meet the requirements of the state’s public health nurse (PHN) certification. Students in Bachelor of Science in Nursing (BSN) programs are expected to enter the workforce prepared to address population health needs that synthesize community-based assessment and understand epidemiologic approaches to strategize interventions in diverse populations at the local, state and national levels. To adequately prepare nurses for true population health practice, clinical experiences need to be in appropriate settings where they can apply theory …
Implementing The Fast Track Improvement Bundle: A Total Joint Replacement Quality Improvement Project, Kathleen Cho, Grace Ryu, Laura Palmer, Crystal Eng, Shannon Danneman
Implementing The Fast Track Improvement Bundle: A Total Joint Replacement Quality Improvement Project, Kathleen Cho, Grace Ryu, Laura Palmer, Crystal Eng, Shannon Danneman
Master's Projects and Capstones
The Fast Track program is a patient-centered and evidence-based intervention for post-surgical patients. It is widely used in many hospitals today because it has proven to promote early recovery, reduce postoperative complications, and decrease both length of stay and medical costs. Within a non-profit, Magnet community based hospital, the Fast Track program was implemented in April 2019. Currently, the success rate of the program is at 74%, which has warranted the initiation of a Quality Improvement (QI) project.
This project began with a microsystem assessment, root cause analysis (RCA), and strengths, weaknesses, opportunities, threats (SWOT) analysis. Four main barriers were …
Standardization Of Postoperative Care Guidelines For Pediatric Cleft Palate Patients, Julie Barragan, Macy Andrada, Mercedes Greenberg, Tatiana Grib, Samantha Gerber, Amanda Dailor
Standardization Of Postoperative Care Guidelines For Pediatric Cleft Palate Patients, Julie Barragan, Macy Andrada, Mercedes Greenberg, Tatiana Grib, Samantha Gerber, Amanda Dailor
Master's Projects and Capstones
At a large, community-based pediatric hospital in Southern California, a quality improvement project commenced with a goal to improve patient outcomes by decreasing length of stay and pain levels, while increasing toleration of feeds. Implementing a standardized guideline would ensure safe practice across the continuum and allow providers to use a systematic tool for postoperative care, including nursing care interventions and medications. The Root-Cause-Analysis tool was used to assess the microsystem and determine the contributing factors to the identified problem. A SWOT analysis was then performed, followed by a plan to collect data from all pediatric cleft palate procedures performed …
Standardization Of Postoperative Care Guidelines For Pediatric Cleft Palate Patients, Tatyana Grib, Macy Therese G. Andrada, Julie C. Barragan, Amanda K. Dailor, Samantha T. Gerber, Mercedes S. Greenberg
Standardization Of Postoperative Care Guidelines For Pediatric Cleft Palate Patients, Tatyana Grib, Macy Therese G. Andrada, Julie C. Barragan, Amanda K. Dailor, Samantha T. Gerber, Mercedes S. Greenberg
Master's Projects and Capstones
At a large, community-based pediatric hospital in Southern California, a quality improvement project commenced with a goal to improve patient outcomes by decreasing length of stay and pain levels, while increasing toleration of feeds. Implementing a standardized guideline would ensure safe practice across the continuum and allow providers to use a systematic tool for postoperative care, including nursing care interventions and medications. The Root-Cause- Analysis tool was used to assess the microsystem and determine the contributing factors to the identified problem. A SWOT analysis was then performed, followed by a plan to collect data from all pediatric cleft palate procedures …
Standardization Of Postoperative Care Guidelines For Pediatric Cleft Palate Patients, Amanda Dailor, Macy Therese G. Andrada, Julie C. Barragan, Samantha T. Gerber, Mercedes S. Greenberg, Tatyana Grib
Standardization Of Postoperative Care Guidelines For Pediatric Cleft Palate Patients, Amanda Dailor, Macy Therese G. Andrada, Julie C. Barragan, Samantha T. Gerber, Mercedes S. Greenberg, Tatyana Grib
Master's Projects and Capstones
At a large, community-based pediatric hospital in Southern California, a quality improvement project commenced with a goal to improve patient outcomes by decreasing length of stay and pain levels, while increasing toleration of feeds. Implementing a standardized guideline would ensure safe practice across the continuum and allow providers to use a systematic tool for postoperative care, including nursing care interventions and medications. The Root-Cause-Analysis tool was used to assess the microsystem and determine the contributing factors to the identified problem. A SWOT analysis was then performed, followed by a plan to collect data from all pediatric cleft palate procedures performed …
The Nurse’S Role In Prognosis-Related Communication In Pediatric Oncology Nursing Practice, Amy Rose Newman, Lauri Linder, Kristin Haglund
The Nurse’S Role In Prognosis-Related Communication In Pediatric Oncology Nursing Practice, Amy Rose Newman, Lauri Linder, Kristin Haglund
College of Nursing Faculty Research and Publications
The experiences of pediatric oncology nurses with prognosis-related communication (PRC) remain largely unknown. The purpose of this article is to report results of focus groups wherein 15 pediatric oncology nurses from three Midwestern pediatric cancer programs provided descriptions of PRC and how they experience PRC within their daily practice. Data from focus groups were analyzed via an interpretive descriptive approach, which resulted in three themes: (1) nurses’ operational definition of PRC, (2) nurses’ roles in PRC, and (3) nurses’ preparation for engagement in PRC. From discussions within the focus groups, nurses recognized that PRC occurs across a continuum. Nurses distinguished …
Patient-Centered Education To Improve Health Outcomes Of Adult Jamaicans With Diabetes, Patricia Anderson
Patient-Centered Education To Improve Health Outcomes Of Adult Jamaicans With Diabetes, Patricia Anderson
DNP Qualifying Manuscripts
There is a 42% prevalence of diabetes among Jamaicans (Ministry of Health, Jamaica Health and Lifestyle Survey, 2018). The survey found that Jamaicans will continue to face challenges of diabetes and its complication as approximately four out of ten Jamaicans are unaware that they have diabetes, and thus delay receiving healthcare.
Limited health literacy is predominant among the diabetic Jamaican population and negatively affects health outcomes (Singh & Aiken, 2017). Jamaicans were found to have poor knowledge of diabetes; in particular, they had difficulty identifying clinical signs of hyper/hypoglycemia, the importance of examining eyes and feet for abnormalities, normal fasting …
Diabetes Prevention, Shelly Johnson, Miles Hassell, Heidi Davis, Caroline Garrett, Joseph Kaempf
Diabetes Prevention, Shelly Johnson, Miles Hassell, Heidi Davis, Caroline Garrett, Joseph Kaempf
Articles, Abstracts, and Reports
Introduction:
Gestational diabetes mellitus (GDM) is one of the most common medical complications of pregnancy. If not treated properly, medicine is recommended = A2GDM. Both are preventable.
Addressing Childhood Obesity In A Rural Community Using Motivational Interviewing, Chituru Uwaoma
Addressing Childhood Obesity In A Rural Community Using Motivational Interviewing, Chituru Uwaoma
Doctor of Nursing Practice (DNP) Projects
Abstract
Purpose: Childhood obesity is a significant health problem associated with increased adult morbidity and mortality. Rural areas like Central Valley California demonstrate disproportionate rates of obesity. Children in rural and underserved populations are at a higher risk of developing obesity. Data suggest that obesity is often under-addressed during routine health care visits. Primary care practitioners are the first point of health care contact and have a unique opportunity to prevent and address obesity through health monitoring and education.
In response to escalating rates of obesity, clinical recommendations have been established for primary care providers including the use of patient-centered …
Using Lifestyle Educational Intervention To Decrease Blood Pressure Reading Amongst African American Adults, Catherine Madu
Using Lifestyle Educational Intervention To Decrease Blood Pressure Reading Amongst African American Adults, Catherine Madu
Dissertations
Hypertension or high blood pressure is a global epidemic and a major public health challenge in the United States. Hypertension increases the risk of cardiovascular disease, stroke, and renal failure. The disease disproportionately affects African Americans (AAs) and is a leading cause of morbidity and mortality in this ethnic group. Effective management of hypertension decreases complications from the disease. The purpose of the clinical scholarly project (CSP) was to decrease blood pressure readings amongst AA adults, ages 18 to 65 years old using educational intervention on lifestyle modifications. A convenience sampling of 20 AA (n = 20) adult participants was …
Medication Management In A Primary Care Practice, Melissa Fowler
Medication Management In A Primary Care Practice, Melissa Fowler
Doctor of Nursing Practice
Improving medication management has become the 3rd National Patient Safety Goal. Medication errors cost $42 billion annually. A 5-month quality improvement project was conducted in a primary care clinic located in a south Texas metropolitan city to address medication reconciliation problems. The project improved medication management by implementing 7 tools to decrease preventable medication errors: One Source Medication List, staff knowledge pre- and post-tests, visual signs and staff badges, staff templates, Beers Criteria pocket guide, patient brochure, and a quality improvement tracking form. There were two objectives: 1. Staff would improve medication reconciliation documentation by 50%. 2. For patients 65 …
Implementation Of A Program To Identify And Assess At-Risk Patients For Peripheral Arterial Disease, Brenna Brothers
Implementation Of A Program To Identify And Assess At-Risk Patients For Peripheral Arterial Disease, Brenna Brothers
Doctor of Nursing Practice
Lower extremity peripheral arterial disease is a condition that affects approximately 200 million people worldwide and 8 million women and men in the United States (McDermott, 2015). Although there are modifiable risk factors associated with peripheral arterial disease, it is believed to be under-diagnosed and under-treated in the general population (McDermott, 2015). The progression of asymptomatic peripheral arterial disease to symptomatic peripheral arterial disease can be reduced with the introduction of medications and therapeutic lifestyle modifications (Itoga et al., 2018). The purpose of the project was to identify and assess at-risk clinic patients with typical and atypical symptoms for lower …
Implementing A Community-Based Breastfeeding And Infant Support Tent At University Of Arkansas Athletic Events, Moranda Clark
Implementing A Community-Based Breastfeeding And Infant Support Tent At University Of Arkansas Athletic Events, Moranda Clark
The Eleanor Mann School of Nursing Undergraduate Honors Theses
Breastfeeding is such an important role in a mother and baby’s relationship as it establishes a unique bond while also providing health benefits for both parties involved. Unfortunately, many women are discriminated against for trying to breastfeed in public and with little to no designated breastfeeding areas or sanitary places in such spaces; they are left with very few viable options. During the last year I have been completing an internship surrounding the subject of breastfeeding and have helped to implement a breastfeeding and infant support tent at University of Arkansas athletic events. My work has included extensive research, lactation …
Managing Childhood Obesity In A Primary Care Clinic, Linda Nnajiofor
Managing Childhood Obesity In A Primary Care Clinic, Linda Nnajiofor
Doctor of Nursing Practice
Background: Childhood obesity and overweight have increased health burdens on health care systems, and contribute to chronic diseases such as diabetes, heart disease, asthma, and cancer. Childhood obesity is very complex for healthcare providers to manage in primary care settings.
Purpose: To improve childhood overweight and obesity approach and management in a selected primary care practice (Clinic A) in a large east Texas urban community.
Objectives: 1. Increase the percentage of children and adolescents ages 2 to 19 years seen in Clinic A, who received adequate weight management and obesity counseling, to 75%. 2. Increase the number of referrals to …
A Quality Improvement Initiative To Facilitate Provider Adherence To Type Ii Diabetes Mellitus Guidelines, Yazmin Valencia
A Quality Improvement Initiative To Facilitate Provider Adherence To Type Ii Diabetes Mellitus Guidelines, Yazmin Valencia
Doctor of Nursing Practice
Background:A significant number of individuals with type 2 diabetes mellitus do not receive comprehensive diabetes care management to maintain optimal health.
Purpose:This project was designed to facilitate provider adherence to the type 2 diabetes mellitus evidence-based practice standards of care. A primary care practice needs assessment indicated opportunities to improve care management processes which promote adherence to current clinical practice guidelines.
Methods:This 10-week quality improvement project provided the clinical staff and provider with the necessary tools to implement best practices of diabetes care. Objectives assessed throughout project implementation included the design and use of an electronic health …
Kujdesi Infermieror Te Të Sëmurët Me Cirrozë Të Mëlçisë, Hidajete Baftiu
Kujdesi Infermieror Te Të Sëmurët Me Cirrozë Të Mëlçisë, Hidajete Baftiu
Theses and Dissertations
Ciroza e mëlçisë është një sëmundje kronike që karakterizohet nga një nekrozë e përhapur e qelizave hepatike, kolaps dhe fibrozë e stromës retikulare, rigjenerim nodular i qelizave të mbetura dhe insuficiencës hepatike. Nga kjo rrjedhë se gjatë kësaj sëmundjeje zhvillohën katër procese patoanatomike: 1. Nekroza hepatocelulare, 2. Formimi i shiritave fibrozë, 3. Regjenerimi nodular dhe si pasojë e tyre zhvillohet më pas edhe 4. Çrregullimi i qarkullimit në mëlçi.
Karakteristikë kryesore e kësaj sëmundjeje është dëmtimi ireverzibil i parenhimës së mëlçisë, me rrjedhje deri te fibroza e saj dhe formimi i noduseve. Si pasojë e këtyre ndryshimeve, vjen deri të …
Kujdesi Infermieror Tek Të Sëmurët Me Anemi Sideropenike, Zejnepe Zeqiri
Kujdesi Infermieror Tek Të Sëmurët Me Anemi Sideropenike, Zejnepe Zeqiri
Theses and Dissertations
Anemia paraqet uljen e numrave të eritrociteve në qarkullimin e gjakut, ulje e sasisë së gjakut në trup dhe sasi e zvogluar e hemoglobinës në eritrocite, që natyrisht shkon edhe me ulje të hematokritit.
Eritrocitet janë qeliza të gjakut që shërbejnë për transportimin e oksigjenit dhe dioksidit të karbonit në trupin e njeriut.
Anemia nuk është një sëmundje në vetvete por përshkruan një gjendje organizmi, domethënë ekzistenca e asaj sëmundje. Anemia mund të jetë sëmundje shumë e lodhshme dhe e rëndë për pacientin dhe mund të ndikojë seriozisht në jetën e pacientit.
Në punim do të diskutohet klasifikimi i anemive, …
Exploring Perceptions And Attitudes Of Health In Marshallese Adolescents Who Are Overweight In Northwest Arkansas, Lauren Love
Exploring Perceptions And Attitudes Of Health In Marshallese Adolescents Who Are Overweight In Northwest Arkansas, Lauren Love
The Eleanor Mann School of Nursing Undergraduate Honors Theses
Purpose
Childhood obesity is a growing public health problem in the United States. An increasing number of children are becoming overweight or obese and facing the negative health issues from this diagnosis. They might also suffer socially due to their weight because they are more likely to be bullied or picked on. This project explored the perceptions and attitudes of health in Marshallese adolescents that are overweight in Northwest Arkansas. The goal of our project was to investigate themes for commonality amongst adolescents that are overweight about how they perceive their weight and their beliefs towards health and body image. …
Ricketts, Hunter Christian, B. 1997 (Fa 1382), Manuscripts & Folklife Archives
Ricketts, Hunter Christian, B. 1997 (Fa 1382), Manuscripts & Folklife Archives
Folklife Archives Finding Aids
Finding aid only for Folklife Archives Project 1382. Project completed by Hunter Ricketts in fall 2019 regarding Mennonite health practices as part of a WKU folk studies class on Field Methods in Ethnography.