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Articles 1 - 30 of 103
Full-Text Articles in Medicine and Health Sciences
Influence Of Sense Of Coherence, Spirituality, Social Support And Health Perception On Breast Cancer Screening Motivation And Behaviors In African American Women, Regina Conway-Phillips, Linda W. Janusek
Influence Of Sense Of Coherence, Spirituality, Social Support And Health Perception On Breast Cancer Screening Motivation And Behaviors In African American Women, Regina Conway-Phillips, Linda W. Janusek
Regina Conway-Phillips
Despite formidable barriers, some African American women (AAW) engage in breast cancer screening (BCS) behaviors. Understanding individual characteristics that allow AAW to overcome barriers to BCS is critical to reduce breast cancer mortality among AAW. A salutogenic model of health was used to evaluate the influence of sense of coherence, social support, spirituality and health perception on BCS motivation and behaviors in AAW, and to determine differences in these factors in AAW who participate in free BCS programs compared to AAW who do not. Findings revealed that greater levels of spirituality were significantly associated with greater motivation to practice BCS. …
Measuring Nurse Caring Behaviors In The Acute Hospitalized Geriatric Patient, Susan A. Goncalves
Measuring Nurse Caring Behaviors In The Acute Hospitalized Geriatric Patient, Susan A. Goncalves
Susan A. Goncalves
The number of older adults in the United States is increasing substantially with the highest impact of the baby boomers phenomenon turning 65 in the year 2011, and the number projected to keep growing until the year 2030. The rapid growth of older adults inherently requires expert physicians and nurses to care for this population. The art of simple basic communication between the nurse and patient is essential to nursing.
Successful Aging In The United States And China : A Theoretical Basis To Guide Nursing Research, Practice, And Policy., Valerie Lander Mccarthy, Hong Ji, Jiying Ling
Successful Aging In The United States And China : A Theoretical Basis To Guide Nursing Research, Practice, And Policy., Valerie Lander Mccarthy, Hong Ji, Jiying Ling
Valerie L. McCarthy
Successful aging is an idea gaining increasing attention given the exponential growth in the older adult population. Criteria and definitions within multiple disciplines vary greatly in Western literature, with no consensus on its meaning. Moreover, sociocultural, economic and political differences between the Western view of successful aging and its use in China – with the world’s largest older adult population – add to the confusion. Similarities and differences in the meaning of successful aging in the United States and China are examined and the potential for a common definition that is useful to nursing in both countries is explored. Using …
Health Care Reform: Current Updates And Future Initiatives For Ambulatory Care Nursing, Beth Ann Swan, Phd, Crnp, Faan, Sheila Haas, Phd, Np, Faan
Health Care Reform: Current Updates And Future Initiatives For Ambulatory Care Nursing, Beth Ann Swan, Phd, Crnp, Faan, Sheila Haas, Phd, Np, Faan
Sheila A. Haas, PhD, NP, FAAN
Executive Summary: While the signing of the Patient Protection and Affordable Care Act was a historical event marking the beginning of health care reform in the United States, it signaled the start of a golden age for ambulatory care nursing. Ambulatory care RNs are well-positioned to fully participate in health care reform initiatives. RNs are well-positioned to lead, facilitate, and/or participate in all patient care medical homes' and accountable care organizations'quality and safety initiatives through enhanced use of major ambulatory care RN role dimensions such as advocacy, telehealth, patient education, care coordination and transitional care, and community outreach. RNs are …
The Association Between Hospital Obstetrical Volume And Maternal Postpartum Complications, Kathy Kyser, Xin Lu, Donna Santillan, Mark Santillan, Stephen Hunter, Alison Cahill, Peter Cram
The Association Between Hospital Obstetrical Volume And Maternal Postpartum Complications, Kathy Kyser, Xin Lu, Donna Santillan, Mark Santillan, Stephen Hunter, Alison Cahill, Peter Cram
Stephen K. Hunter
OBJECTIVE: The purpose of this study was to examine the relationship between delivery volume and maternal complications. STUDY DESIGN: We used administrative data to identify women who had been admitted for childbirth in 2006. Hospitals were stratified into deciles that were based on delivery volume. We compared composite complication rates across deciles. RESULTS: We evaluated 1,683,754 childbirths in 1045 hospitals. Decile 1 and 2 hospitals had significantly higher rates of composite complications than decile 10 (11.8% and 10.1% vs 8.5%, respectively; P < .0001). Decile 9 and 10 hospitals had modestly higher composite complications as compared with decile 6 (8.8% and …
Friends Of Nursing: A Community Of Caring To Promote Excellence In Nursing Practice, Education, And Research, Kim S. Hitchings Msn, Rn, Nea-Bc, Terry Capuano Rn, Svp, Clinical Services, Mary Ellen Herzog Med, Cfre, Cgms
Friends Of Nursing: A Community Of Caring To Promote Excellence In Nursing Practice, Education, And Research, Kim S. Hitchings Msn, Rn, Nea-Bc, Terry Capuano Rn, Svp, Clinical Services, Mary Ellen Herzog Med, Cfre, Cgms
Terry A Capuano MBA, MSN, RN, FACHE, NE-BC
More than 25 years ago, the name "Friends of Nursing" was adopted by an academic, community Magnet(®) hospital to signify a model for community support of nursing. From inception, the intent was to recruit philanthropic dollars to promote recognition of and excellence in nursing practice, education, and research. Although philanthropy in health care settings is common, what is unique about this program is the long-standing, dedicated conceptual framework for nursing philanthropy and the very significant number of philanthropic dollars from literally thousands of donors to support a diverse range of activities to affect and advance the professional excellence of nurses …
A Mandatory Single Blastocyst Transfer Policy With Educational Campaign In A United States Ivf Program Reduces Multiple Gestation Rates Without Sacrificing Pregnancy Rates, Ginny Ryan, Amy Sparks, C. Sipe, Craig Syrop, A. Dokras, Bradley Van Voorhis
A Mandatory Single Blastocyst Transfer Policy With Educational Campaign In A United States Ivf Program Reduces Multiple Gestation Rates Without Sacrificing Pregnancy Rates, Ginny Ryan, Amy Sparks, C. Sipe, Craig Syrop, A. Dokras, Bradley Van Voorhis
Amy E.T. Sparks
OBJECTIVE: To reduce the twin rate in our IVF program. DESIGN: A prospective educational study of infertile couples; a retrospective review of IVF outcomes before vs. after mandatory single embryo transfer (mSBT) policy change. SETTING: University-based infertility center. PATIENT(S): One hundred ten of 120 consecutive new infertile couples completed the educational study. Outcomes of all embryo transfers (n = 693) performed 17 months before and 17 months after mSBT were evaluated. INTERVENTION(S): A 1-page educational summary of comparative risks of twins vs. singletons to maternal and child health. MAIN OUTCOME MEASURE(S): Knowledge of twin risks and desired number of embryos …
A Mandatory Single Blastocyst Transfer Policy With Educational Campaign In A United States Ivf Program Reduces Multiple Gestation Rates Without Sacrificing Pregnancy Rates, Ginny Ryan, Amy Sparks, C. Sipe, Craig Syrop, A. Dokras, Bradley Van Voorhis
A Mandatory Single Blastocyst Transfer Policy With Educational Campaign In A United States Ivf Program Reduces Multiple Gestation Rates Without Sacrificing Pregnancy Rates, Ginny Ryan, Amy Sparks, C. Sipe, Craig Syrop, A. Dokras, Bradley Van Voorhis
Bradley J Van Voorhis
OBJECTIVE: To reduce the twin rate in our IVF program. DESIGN: A prospective educational study of infertile couples; a retrospective review of IVF outcomes before vs. after mandatory single embryo transfer (mSBT) policy change. SETTING: University-based infertility center. PATIENT(S): One hundred ten of 120 consecutive new infertile couples completed the educational study. Outcomes of all embryo transfers (n = 693) performed 17 months before and 17 months after mSBT were evaluated. INTERVENTION(S): A 1-page educational summary of comparative risks of twins vs. singletons to maternal and child health. MAIN OUTCOME MEASURE(S): Knowledge of twin risks and desired number of embryos …
Outcomes From Assisted Reproductive Technology, Bradley Van Voorhis
Outcomes From Assisted Reproductive Technology, Bradley Van Voorhis
Bradley J Van Voorhis
The use of assisted reproductive technology (ART) for treating the infertile couple is increasing in the United States. The purpose of this paper is to review the short-term outcomes after ART. Pregnancy rates after ART have shown nearly continuous improvement in the years since its inception. A number of factors affect the pregnancy rate, with the most important being a woman's age. Certain clinical diagnoses are associated with a poorer outcome from ART, including the presence of hydrosalpinges, uterine leiomyomata that distort the endometrial cavity, and decreased ovarian reserve. Multiple gestations are the major complication after ART. New laboratory techniques, …
A Mandatory Single Blastocyst Transfer Policy With Educational Campaign In A United States Ivf Program Reduces Multiple Gestation Rates Without Sacrificing Pregnancy Rates, Ginny Ryan, Amy Sparks, C. Sipe, Craig Syrop, A. Dokras, Bradley Van Voorhis
A Mandatory Single Blastocyst Transfer Policy With Educational Campaign In A United States Ivf Program Reduces Multiple Gestation Rates Without Sacrificing Pregnancy Rates, Ginny Ryan, Amy Sparks, C. Sipe, Craig Syrop, A. Dokras, Bradley Van Voorhis
Ginny L. Ryan
OBJECTIVE: To reduce the twin rate in our IVF program. DESIGN: A prospective educational study of infertile couples; a retrospective review of IVF outcomes before vs. after mandatory single embryo transfer (mSBT) policy change. SETTING: University-based infertility center. PATIENT(S): One hundred ten of 120 consecutive new infertile couples completed the educational study. Outcomes of all embryo transfers (n = 693) performed 17 months before and 17 months after mSBT were evaluated. INTERVENTION(S): A 1-page educational summary of comparative risks of twins vs. singletons to maternal and child health. MAIN OUTCOME MEASURE(S): Knowledge of twin risks and desired number of embryos …
Embryo Transfer Practices In The United States: A Survey Of Clinics Registered With The Society For Assisted Reproductive Technology, E. Jungheim, Ginny Ryan, E. Levens, A. Cunningham, G. Macones, K. Carson, A. Beltsos, R. Odem
Embryo Transfer Practices In The United States: A Survey Of Clinics Registered With The Society For Assisted Reproductive Technology, E. Jungheim, Ginny Ryan, E. Levens, A. Cunningham, G. Macones, K. Carson, A. Beltsos, R. Odem
Ginny L. Ryan
OBJECTIVE: To gain a better understanding of factors influencing clinicians' embryo transfer practices. DESIGN: Cross-sectional survey. SETTING: Web-based survey conducted in December 2008 of individuals practicing IVF in centers registered with the Society for Assisted Reproductive Technology (SART). PATIENT(S): None. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Prevalence of clinicians reporting following embryo transfer guidelines recommended by the American Society for Reproductive Medicine (ASRM), prevalence among these clinicians to deviate from ASRM guidelines in commonly encountered clinical scenarios, and practice patterns related to single embryo transfer. RESULT(S): Six percent of respondents reported following their own, independent guidelines for the number of embryos …
The Pharmaceutical Industry: Friend Or Foe?, Jennifer Niebyl
The Pharmaceutical Industry: Friend Or Foe?, Jennifer Niebyl
Jennifer R Niebyl
No abstract provided.
Perinatal Management Of Women With Immune Thrombocytopenic Purpura: Survey Of United States Perinatologists, D. Peleg, Stephen Hunter
Perinatal Management Of Women With Immune Thrombocytopenic Purpura: Survey Of United States Perinatologists, D. Peleg, Stephen Hunter
Stephen K. Hunter
OBJECTIVE: The aim of the study was to determine how perinatologists in the United States manage the care of women with immune thrombocytopenic purpura with respect to mode of delivery. Study Design: US members of the Society of Perinatal Obstetricians were surveyed with a 4-question questionnaire. Two mailings were sent. Questions 1 and 2 asked for a response regarding the perinatal management of delivery for women with chronic immune thrombocytopenic purpura and new-onset disease. The options were cordocentesis or fetal scalp blood sampling and cesarean delivery if the platelet count was <50,000 cells/microL, cesarean delivery if the maternal platelet count …
Group B Streptococci Causing Neonatal Bloodstream Infection: Antimicrobial Susceptibility And Serotyping Results From Sentry Centers In The Western Hemisphere, J. Andrews, D. Diekema, Stephen Hunter, P. Rhomberg, M. Pfaller, R. Jones, G. Doern
Group B Streptococci Causing Neonatal Bloodstream Infection: Antimicrobial Susceptibility And Serotyping Results From Sentry Centers In The Western Hemisphere, J. Andrews, D. Diekema, Stephen Hunter, P. Rhomberg, M. Pfaller, R. Jones, G. Doern
Stephen K. Hunter
OBJECTIVE: Group B streptococcal infection is a common cause of neonatal sepsis. Surveillance of antimicrobial susceptibility and serotype frequencies of invasive group B streptococci is important to ensure the effectiveness of therapeutic regimens and to guide vaccine development. STUDY DESIGN: Prospective surveillance of neonatal bloodstream infection was performed at all Western Hemisphere sites participating in the SENTRY Program. From January 1997 through December 1999, a total of 122 isolates of bloodstream infections with group B streptococci were collected and sent to the University of Iowa for antimicrobial susceptibility testing and serotyping. RESULTS: No isolates were resistant to penicillin. More than …
The Sensitivity And Specificity Of A Simple Test To Distinguish Between Urge And Stress Urinary Incontinence, J. S. Brown, Catherine Bradley, L. L. Subak, H. E. Richter, S. R. Kraus, L. Brubaker, F. Lin, E. Vittinghoff, D. Grady
The Sensitivity And Specificity Of A Simple Test To Distinguish Between Urge And Stress Urinary Incontinence, J. S. Brown, Catherine Bradley, L. L. Subak, H. E. Richter, S. R. Kraus, L. Brubaker, F. Lin, E. Vittinghoff, D. Grady
Catherine S. Bradley
BACKGROUND: Urinary incontinence is common in women. Because treatments differ, urge incontinence should be distinguished from stress incontinence. To make this distinction, current guidelines recommend an extensive evaluation that is too time-consuming for primary care practice. OBJECTIVE: To test the accuracy of a simple questionnaire to categorize type of urinary incontinence in women. DESIGN: Multicenter, prospective study of the accuracy of the 3 Incontinence Questions (3IQ) compared with an extended evaluation to distinguish between urge incontinence and stress incontinence. SETTING: 5 academic medical centers in the United States. PARTICIPANTS: 301 women enrolled from April to December 2004 who were older …
A Comparison Of Hospice In The Us And Uk: Implications For Policy And Practice, Ruth Remington, G Wakim
A Comparison Of Hospice In The Us And Uk: Implications For Policy And Practice, Ruth Remington, G Wakim
Ruth Remington
The modern hospice movement in the United States was modeled on the specialized care for dying individuals that was championed by Dame Cicely Saunders, a social worker, nurse, and physician, in London in the 1960s. A collaboration between Saunders and Florence Wald, then at Yale University, led to the establishment of the first hospice in the United States in 1974. Despite similar foundations, the provision of hospice care differs in the United States and the United Kingdom with regard to financing and access. This article reviews these similarities and differences and discusses implications for U.S. hospice policy.
Analysis United Kingdom And United States Healthcare, Joyce K. Kutin
Analysis United Kingdom And United States Healthcare, Joyce K. Kutin
Joyce K Kutin RN, MSN, MOL
United Kingdom and the United States are two dissimilar health systems each having uniquely differing focuses, where the primary differences are a parliamentary verses a republic government application toward the socioeconomic requirements of the populace. The United Kingdom’s National Health Service interprets health care as a public service rather than the commodity. The United States healthcare system is riddled with disparities regarding quality, access and cost. The socioeconomic poor and or homeless are less likely to utilize the healthcare system when compared to others who are more fortunate. Health care systems are facing the same challenges around the world with …
The Independent Nurse Role In Community Care Gerontological Nursing, Deborah Schoenfelder, Janet Specht, Meridean Maas
The Independent Nurse Role In Community Care Gerontological Nursing, Deborah Schoenfelder, Janet Specht, Meridean Maas
Deborah P. Schoenfelder
No abstract provided.
Homesafe: Supportive Assistance For Elderly Individuals Through A Nurse-Managed Plan, Deborah Schoenfelder, Meridean Maas, Janet Specht
Homesafe: Supportive Assistance For Elderly Individuals Through A Nurse-Managed Plan, Deborah Schoenfelder, Meridean Maas, Janet Specht
Deborah P. Schoenfelder
A lack of quality, cost-effective alternatives to nursing home care for community-dwelling older adults exists. The evidence suggests that case management provides quality care in a cost-efficient manner to help older adults remain at home safely and as independently as possible. This article describes HomeSafe, a nurse-managed membership plan that assists older individuals to enhance their health and quality of life, and to age in place in their homes and communities. HomeSafe serves as an innovative model of care and a teaching site for undergraduate and graduate nursing students and nursing faculty at The University of Iowa.
Economics And The Education Of Nurse Anesthetists: Part 1, Cormac O'Sullivan, E. Thompson
Economics And The Education Of Nurse Anesthetists: Part 1, Cormac O'Sullivan, E. Thompson
Cormac T. O'Sullivan
No abstract provided.
Economics And The Education Of Nurse Anesthetists: Part 2, Cormac O'Sullivan, E. Thompson
Economics And The Education Of Nurse Anesthetists: Part 2, Cormac O'Sullivan, E. Thompson
Cormac T. O'Sullivan
Economic assumptions and other factors affecting the economics of nurse anesthesia education are presented in Part 2 of this 2-part column. In Part 1, published in the October 2004 issue of the AANA Journal, general economic principles and healthcare economic principles in particular were described, explained, and related to the current US healthcare system.
Evidence-Based Management Assessment Of Return On Investment From Anesthesia Information Management Systems, Cormac O'Sullivan, F. Dexter, D. Lubarsky, M. Vigoda
Evidence-Based Management Assessment Of Return On Investment From Anesthesia Information Management Systems, Cormac O'Sullivan, F. Dexter, D. Lubarsky, M. Vigoda
Cormac T. O'Sullivan
A systematic and comprehensive review of the scientific literature revealed 4 evidence-based methods that contribute to a positive return on investment from anesthesia information management systems (AIMS): reducing anesthetic-related drug costs, improving staff scheduling and reducing staffing costs, increasing anesthesia billing and capture of anesthesia-related charges, and increased hospital reimbursement through improved hospital coding. There were common features to these interventions. Whereas an AIMS may be the ideal choice to achieve these cost reductions and revenue increases, alternative existing systems may be satisfactory for the studied applications (i.e., the incremental advantage to the AIMS may be less than predicted from …
Innovativeness In Nursing: A Phenomenological And Constructivist Study, Maria Joseph
Innovativeness In Nursing: A Phenomenological And Constructivist Study, Maria Joseph
Maria (Lindell) Joseph
Hospital administration and the medical field have maintained the status quo of nursing practice, in which nurses have adopted bureaucratic structures where conformity and regimentation are maintained to ensure large-scale efficiency. The lack of control to act on nursing knowledge and expert judgment is linked to work conditions of oppression, lack of autonomy, dissatisfaction, concomitant patient mortality, and morbidity. A climate of innovativeness is one strategy to reverse the negative impact caused by hospital administration and the medical field. The purpose of this phenomenological study was to explore the behavioral characteristics of lived experiences and knowledge of innovativeness among nurses …
An Examination Of The Sustainable Adoption Of Whole-Person Care (Wpc), Maria Joseph, D. Laughon, Richard Bogue
An Examination Of The Sustainable Adoption Of Whole-Person Care (Wpc), Maria Joseph, D. Laughon, Richard Bogue
Maria (Lindell) Joseph
AIM: This study illustrates how King's theory of goal attainment was used to focus an examination of whole-person care (WPC) and to extend the range of knowledge needed for WPC and nursing practice. BACKGROUND: Leadership implemented a faith-based innovation using continuing education for patient care that incorporates body-mind-spirit and eight principles called CREATION. Three questions arose: (1) Is there an evidence-based framework to determine whether the philosophy supports the discipline of nursing? (2) How extensive is the adoption and application of WPC? (3) Does the model make a difference in the context of nurse-patient interactions and outcomes in support of …
Work Environment Characteristics Of High-Quality Home Health Agencies, S. Tullai-Mcguinness, J. Riggs, Amany Farag
Work Environment Characteristics Of High-Quality Home Health Agencies, S. Tullai-Mcguinness, J. Riggs, Amany Farag
Amany A. Farag
This concurrent mixed-method study examines the nurse work environment of high-quality Medicare-certified home health agencies. High-quality (n=6) and low-quality (n=6) home health agencies were recruited using agency-level publicly reported patient outcomes. Direct care registered nurses (RNs) from each agency participated in a focus group and completed the Practice Environment Scale of the Nurse Work Index (PES-NWI). No significant differences were found in the PES-NWI results between nurses working in high- and low-quality agencies, though nurses in high-quality agencies scored higher on all subscales. Nurses working in all the high-quality agencies identified themes of adequate staffing, supportive managers, and team work. …
Expanded Adult Day Program As A Transition Option From Hospital To Home, K. Jones, S. Tullai-Mcguinness, M. Dolansky, Amany Farag, M. Krivanek, L. Matthews
Expanded Adult Day Program As A Transition Option From Hospital To Home, K. Jones, S. Tullai-Mcguinness, M. Dolansky, Amany Farag, M. Krivanek, L. Matthews
Amany A. Farag
This article describes a pilot program for provision of postacute care (PAC) in an established adult day program. Demographic, clinical, utilization, and satisfaction data were abstracted retrospectively from program records; postdischarge readmission and emergency department visit data were obtained from the electronic health record. Comparative data were obtained from the health records of patients who were offered but declined the adult day program. Between 2005 and 2008, 78 patients requiring PAC were approached by the RN coordinator; 33 selected the adult day program, and 45 selected alternative destinations. The majority of patients had a neurological diagnosis, most commonly stroke. Participants …
Ndec Guidelines For Development And Evaluation Of Diagnoses, Martha Craft-Rosenberg, Connie Delaney, J. Denehy
Ndec Guidelines For Development And Evaluation Of Diagnoses, Martha Craft-Rosenberg, Connie Delaney, J. Denehy
Martha J. Craft-Rosenberg
No abstract provided.
Contexts For The Study Of The Economic Influence Of Nursing Diagnoses On Patient Outcomes, M. Lavin, K. Avant, Martha Craft-Rosenberg, T. Herdman, K. Gebbie
Contexts For The Study Of The Economic Influence Of Nursing Diagnoses On Patient Outcomes, M. Lavin, K. Avant, Martha Craft-Rosenberg, T. Herdman, K. Gebbie
Martha J. Craft-Rosenberg
PURPOSE: To examine the historical, legal/ organizational, informatics, clinical, economic, and policy contexts underlying economic consequences of nursing diagnoses on patient outcomes. DATA SOURCES: Published literature, online material. DATA SYNTHESIS: Nursing diagnoses influence diagnostic-specific patient outcomes and other outcome variables such as length of hospital stay, morbidity, and mortality. CONCLUSIONS: Examination of the economic ramifications of nursing diagnosis on patient outcomes can be facilitated using standardized language and databases containing nursing-sensitive measures.
Health Care Quality And Outcome Guidelines For Nursing Of Children And Families: Implications For Pediatric Nurse Practitioner Practice, Research, And Policy, C. Betz, J. Cowell, Martha Craft-Rosenberg, M. Krajicek, M. Lobo
Health Care Quality And Outcome Guidelines For Nursing Of Children And Families: Implications For Pediatric Nurse Practitioner Practice, Research, And Policy, C. Betz, J. Cowell, Martha Craft-Rosenberg, M. Krajicek, M. Lobo
Martha J. Craft-Rosenberg
No abstract provided.
The Disclosure Decisions Of Parents Who Conceive Children Using Donor Eggs, S. Hahn, Martha Craft-Rosenberg
The Disclosure Decisions Of Parents Who Conceive Children Using Donor Eggs, S. Hahn, Martha Craft-Rosenberg
Martha J. Craft-Rosenberg
STUDY OBJECTIVE: To identify variables that influence the disclosure decisions of parents who conceive children using donor eggs and to compare such variables among disclosing, nondisclosing, and undecided families. DESIGN: Exploratory, comparative, descriptive. SETTING: A university hospital-assisted reproductive technology program in the Midwest. PARTICIPANTS: Thirty-one couples with children conceived with anonymously donated eggs. METHODS: Audiotaped telephone interviews, measures of social support and family environment, and a demographic survey. MAIN OUTCOME MEASURES: Content analysis of interview transcripts and comparison of recurring themes among groups. RESULTS: The majority of parents intended disclosure. Dominant themes among disclosing parents included the belief that a …