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Articles 601 - 630 of 5875
Full-Text Articles in Medicine and Health Sciences
Depression Screening In Veterans And Active-Duty Service Members With Chronic Pain, Lynelle Marie Endsley
Depression Screening In Veterans And Active-Duty Service Members With Chronic Pain, Lynelle Marie Endsley
Walden Dissertations and Doctoral Studies
This Doctor of Nursing Practice project addressed the absence of evidence-based depression screening among military members and veterans with chronic pain. Contrary to national guidelines, no standardized depression screening process was in place. This gap in practice was attributed to inadequate staff knowledge and understanding in using such tools. The purpose of this project was to evaluate whether staff education on the Patient Health Questionnaire-9 (PHQ-9) improved knowledge and confidence, in evaluating for and identifying depression in a high-risk population. The practice-focused question asked: Will staff education on the importance and consistent use PHQ-9 increase knowledge and confidence in depression …
Development Of An Evidence-Based Educational Intervention To Advance Nurse Knowledge In Comprehensive Care Of Patients With Congestive Heart Failure, Jessica Smith
Walden Dissertations and Doctoral Studies
The Doctor of Nursing Practice (DNP) project was a staff education intervention to increase nursing staff knowledge. Congestive heart failure (CHF) remains one of the leading causes of hospitalizations and has the highest readmission rates within 30 days of a previous admission. Consistent evidence reveals improving nursing knowledge reduces complications, improves self-management support, lowers readmission rates in this particular patient population. The DNP project was developed as a staff education intervention and focused on 30 nurses working on a telemetry unit in an acute care hospital. The project question was whether an educational intervention would increase general nursing knowledge caring …
Structured Follow-Up After Outpatient Visits: A Clinical Practice Guideline, Jeanette Serrano
Structured Follow-Up After Outpatient Visits: A Clinical Practice Guideline, Jeanette Serrano
Walden Dissertations and Doctoral Studies
I conducted this Doctor of Nursing Practice (DNP) project to develop an evidence-based clinical practice guideline (CPG) to reduce missed follow-up appointments and improve care continuity in a family medicine outpatient clinic. Missed follow-ups, especially common in underserved populations, compromise safety, delay treatment, and increase costs. The purpose of this doctoral project was to develop and appraise a CPG that integrates evidence-based strategies to improve follow-up procedures, reduce missed appointments, and enhance patient safety and care continuity in an outpatient setting. This project addressed the practice-focused question: Will a CPG around structured follow-up for patient visits in an outpatient clinic …
Executive Summary: Staff Education Project Staff Education To Close A Knowledge Gap Regarding Restraints, Aaron Ross Ledbetter
Executive Summary: Staff Education Project Staff Education To Close A Knowledge Gap Regarding Restraints, Aaron Ross Ledbetter
Walden Dissertations and Doctoral Studies
The purpose of this Executive Summary is to address a gap in knowledge that I attempted to close regarding restraint utilization. Restraints, both physical and chemical, have been prevalent over the past ten years and with their increased utilization during the pandemic which has continued post-pandemic. Nursing as a culture has become more reliant on restraints as it allows more time for nurses to provide care elsewhere. Both physical and psychological complications have been recognized during the utilization of physical restraints. Their prominence, although helpful with time constraints for nurses, have shown to negatively impact the patients who they are …
Staff Education To Improve Medicare Lung Cancer Screening And Processes, Ashley Mccammon
Staff Education To Improve Medicare Lung Cancer Screening And Processes, Ashley Mccammon
Walden Dissertations and Doctoral Studies
The doctoral project was a staff education initiative to address underutilization of low-dose computed tomography (LDCT) lung cancer screening among Medicare-eligible patients at the project site. Lung cancer is the leading cause of cancer death, and LDCT screening reduces mortality by up to 20%. Internal data from the project site revealed that only 20.13% of eligible patients completed screening, underscoring the need for structured staff education to improve knowledge and support early detection. The practice focused question asked: Will a staff education on Medicare LDCT screening and processes increase staff knowledge towards the ultimate goal of increasing LDCT screening rates? …
Development Of An Evidence-Based Clinical Practice Guideline For Discharging Patients With Substance Use Disorder (Sud) From Outpatient Treatment To Community Care, Emmanuel Onyeani
Walden Dissertations and Doctoral Studies
This Doctor of Nursing Practice (DNP) project addressed a gap in practice in an outpatient treatment center for discharging patients with substance use disorder (SUD), addressing the need for follow-up care and relapse prevention due to the widespread impact of SUD. Clinical practice guidelines (CPG) help healthcare professionals make informed decisions for specific clinical situations. The guiding question asked whether an expert panel would evaluate and validate a CPG developed from current, evidence-based literature and recommendations with 70% agreement using the AGREE II tool. The CPG focused on continuity of care, access to resources, and relapse prevention strategies. Seven expert …
Google Search Trends And Their Correlation With Covid-19 Cases And Vaccination Rates In Austria, Stefanie Wendell
Google Search Trends And Their Correlation With Covid-19 Cases And Vaccination Rates In Austria, Stefanie Wendell
Walden Dissertations and Doctoral Studies
Timely digital surveillance is essential because clinical reporting often lags. This quantitative, longitudinal correlational study tested whether weekly Google searches in Austria signal changes in COVID-19 cases and vaccination uptake, and short-term case-vaccination dynamics, guided by Rogers’ Diffusion of Innovations Theory. Weekly Google Trends indices (0-100) and nationally reported surveillance totals (weekly counts of new cases and vaccine doses) were aggregated; cases: N = 175 weeks (Feb 2020–Jun 2023); vaccinations: N = 132 weeks (Dec 2020–Jun 2023). Time series correlations and lagged growth models showed that symptom-related searches consistently rose 1 week before reported cases (Δlog cases_t on Δlog searches_{t−1}: …
Enhancing Home Health Nursing Knowledge Through Targeted Education On Polypharmacy Risk Awareness In Older Adults, Chinyeaka Linda Ogbonna
Enhancing Home Health Nursing Knowledge Through Targeted Education On Polypharmacy Risk Awareness In Older Adults, Chinyeaka Linda Ogbonna
Walden Dissertations and Doctoral Studies
This Doctor of Nursing Practice (DNP) staff education initiative addressed the problem of polypharmacy, a common issue in home health care that increases the risk of drug interactions, side effects, and hospitalizations. Nurses and aides often provide daily care but may not recognize high-risk medications or warning symptoms. Addressing this gap was vital to nursing practice because staff are on the front line of patient monitoring and safety. The practice-focused question asked whether structured education for home health staff would improve knowledge of polypharmacy risks by 20%, increase recognition of high-risk medications by 75%, and result in at least 75% …
Enhancing Diabetes Self-Management Education And Support Knowledge And Awareness Among Nurses, Tamba Sam-Manimoi
Enhancing Diabetes Self-Management Education And Support Knowledge And Awareness Among Nurses, Tamba Sam-Manimoi
Walden Dissertations and Doctoral Studies
Diabetes mellitus (DM) affects 12% of the United States population at an annual cost of $412.9 billion. In the local clinic, 20% of the patient population has a diagnosis of DM. Despite the importance of diabetes self-management education and support (DSMES) in managing DM, patients are often not educated on this important strategy. Leadership identified that patients were reporting a lack of knowledge regarding DSMES practices and that the nurses lacked the necessary knowledge and awareness to educate patients in DSMES. Thus, the purpose of this DNP project was to determine if an educational intervention focused on DM and DSMES …
Exploring Public Health Nurses’ Perceptions Of Syringe Services Programs In Southern Rural Areas, Joel Lowery
Exploring Public Health Nurses’ Perceptions Of Syringe Services Programs In Southern Rural Areas, Joel Lowery
Walden Dissertations and Doctoral Studies
Public health nurses are potentially key stakeholders in syringe services program (SSP) implementation in rural areas, where they can act as liaisons between public health, private healthcare, and the community. However, little research reflects an in-depth understanding of how public health nurses perceive SSPs in rural areas. The purpose of this qualitative study was to explore the perceptions of syringe services programs held by public health nurses practicing in rural areas with no existing SSPs in southern states and ascertain their potential roles in facilitating harm reduction for people who inject drugs. This study was guided by a conceptual framework …
Enhancing Medication Adherence In Primary Care Settings Through Staff Education, Sabita Bhusal
Enhancing Medication Adherence In Primary Care Settings Through Staff Education, Sabita Bhusal
Walden Dissertations and Doctoral Studies
This Doctor of Nursing Practice project was an evidence-based staff education initiative addressing medication nonadherence in hypertension, a critical issue that contributes to poor health outcomes, uncontrolled blood pressure, preventable hospitalizations, and increased healthcare costs. The identified gap in practice was defined by limited staff knowledge, lack of structured training, and inconsistent application of evidence-based adherence counseling strategies. The practice-focused question was: In a primary care clinic, will an evidence-based staff education program on medication adherence increase staff knowledge? A structured training intervention was implemented and then evaluated for its effectiveness. Descriptive statistics and a paired t test comparing pre- …
Perspectives Of Nursing Faculty On The Barriers, Opportunities, And Teaching Strategies For Developing Peer Feedback Skills Among Entry-Level Nursing Students, Anna Kornienko
Walden Dissertations and Doctoral Studies
Peer feedback benefits nursing education and practice by fostering collegial relationships and promoting the quality of care, yet students often lack training to engage effectively. While existing research has examined student perspectives, the experiences and strategies employed by nursing faculty remain underexplored. The purpose of this qualitative study, guided by the student feedback literacy framework, was to explore the perspectives of nursing faculty on the barriers, opportunities, and strategies for developing peer feedback skills among undergraduate nursing students. Seventeen Canadian nursing faculty participated in semi-structured virtual interviews. Analysis revealed five themes that aligned with the study’s three foci: strategies (a) …
Staff Education To Enhance Therapeutic Communication In Community Clinic Settings, Marian Allen
Staff Education To Enhance Therapeutic Communication In Community Clinic Settings, Marian Allen
Walden Dissertations and Doctoral Studies
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Cancer Screening Disparities Among Women With Disabilities In The United States, Kathleen Young
Cancer Screening Disparities Among Women With Disabilities In The United States, Kathleen Young
Walden Dissertations and Doctoral Studies
Breast and cervical cancer screening reduces mortality; however, women with disabilities and mental health challenges experience persistent disparities in access to preventive services. The purpose of this quantitative study was to examine the relationships between self-reported serious difficulty hearing, serious difficulty seeing, and frequent mental distress with breast (mammogram) and cervical (Pap test) cancer screening use among women in the United States (mammogram model, n = 844; Pap model n = 774), using the 2023 Behavioral Risk Factor Surveillance System dataset. The social-ecological model provided the framework. Two logistic regression models were conducted, adjusting for age, race/ethnicity, education, income, marital …
Central Line-Associated Bloodstream Infection Prevention Staff Education For Medical- Surgical Nurses, Grace Ann Abustan Porciuncula
Central Line-Associated Bloodstream Infection Prevention Staff Education For Medical- Surgical Nurses, Grace Ann Abustan Porciuncula
Walden Dissertations and Doctoral Studies
Background: CLABSIs remain a significant cause of morbidity, mortality, and increased healthcare costs, particularly in hospitalized patients requiring long-term vascular access. Despite established guidelines, inconsistent adherence to central line dressing change protocols persists within the DNP project organization, often due to insufficient staff knowledge and variability in practice. This practice gap increases the risk of catheter site contamination and leads to preventable CLABSI events, creating a clear need for intervention. Method: A designed educational program that integrated interactive lectures, case studies, and simulation-based activities. A pre- and post-intervention assessment to measure changes in participants’ knowledge and self-reported confidence in applying …
Psychoeducation For Community Support Workers To Decrease No Call And No-Show Rates In An Outpatient Mental Health Facility, Promise Lum Ngongwashi
Psychoeducation For Community Support Workers To Decrease No Call And No-Show Rates In An Outpatient Mental Health Facility, Promise Lum Ngongwashi
Walden Dissertations and Doctoral Studies
Missed appointments remain a critical issue in health care, as they contribute to poorer patient health outcomes, treatment discontinuity, and increased system costs. Improving staff knowledge in this area is essential for ensuring timely, equitable, and effective patient care. This doctoral project was a staff education initiative designed to enhance community support workers (CSWs’) knowledge of methods for encouraging patient adherence to clinic appointments through psychoeducational training. The practice problem addressed was the inconsistency in staff use of evidence-based strategies to motivate and support patients in maintaining clinic attendance. The practice-focused question guiding the project was: Does psychoeducation improve CSWs’ …
Hiv/Aids Among Young People In South Sudan: Assessing Misconceptions About Transmission, Healthcare Access, And Cultural/Religious Factors, John Valent Abore
Hiv/Aids Among Young People In South Sudan: Assessing Misconceptions About Transmission, Healthcare Access, And Cultural/Religious Factors, John Valent Abore
Walden Dissertations and Doctoral Studies
The HIV/AIDS epidemic continues to be a significant public health challenge among young people in South Sudan (SSD). Despite global efforts to curb the spread of HIV, misconceptions about HIV transmission, barriers to access to healthcare services, and cultural/religious factors that affect the epidemic persist in South Sudan, and it is not obvious how these factors interact to impact outcomes. This quantitative cross-sectional study investigated whether there is a relationship between misconceptions about HIV transmission and HIV/AIDS status and whether access to healthcare and cultural/religious factors mediate this relationship among young people (aged 18–35) in SSD. A secondary data analysis …
A Clinical Practice Guideline For Managing Gastrointestinal Toxicities Related To Glp-1ra And Gip/Glp-1ra Medications, Lindsay Williamson
A Clinical Practice Guideline For Managing Gastrointestinal Toxicities Related To Glp-1ra And Gip/Glp-1ra Medications, Lindsay Williamson
Walden Dissertations and Doctoral Studies
The project is a Clinical Practice Guideline (CPG) for managing Gastrointestinal (GI) toxicities related to Glucagon-like Peptide-Receptor Agonist 1 (GLP-1RA) and Glucose-dependent insulinotropic polypeptide/Glucagon-like peptide-1Receptor Agonist (GIP/GLP-1RA) medications. Many patients are seeking weight loss with these agents, which cause GI toxicities that lead prescribers to have patients remain at lower doses that are sub-therapeutic or discontinue therapy. Advanced Practice Registered Nurses (APRNs) are prescribing these therapies for patients and lack an evidence-based CPG for properly managing the most common GI toxicities. APRNs can successfully monitor and manage GI symptoms to promote tolerability and treatment adherence. The project question focuses on …
Nurse Residency Program: Improving Staff Awareness Through Education, Cynthia Kay Butterman
Nurse Residency Program: Improving Staff Awareness Through Education, Cynthia Kay Butterman
Walden Dissertations and Doctoral Studies
Across the health care continuum, organizations face persistent nursing shortages and the challenge of integrating novice nurses into clinical practice, often with limited skills and underdeveloped critical thinking abilities. Nurse residency programs have been integrated by many facilities to provide support for new novice nurses in transitioning from academia to the professional nursing role. This quantitative, quasi-experimental research project was conducted at a community-based hospital with an existing 8- to 10-week nurse residency program that had very limited stakeholder involvement. The purpose of the project was to create an educational training module for key stakeholders to strengthen awareness of why …
Subjective Excessive Daytime Sleepiness And Frailty Progression In Veterans Over 50 With Insomnia, Mona Amirmazaheri
Subjective Excessive Daytime Sleepiness And Frailty Progression In Veterans Over 50 With Insomnia, Mona Amirmazaheri
Walden Dissertations and Doctoral Studies
Frailty is common in aging veterans and linked to adverse outcomes. This retrospective cohort study of 6,824 veterans with insomnia examined whether excessive daytime sleepiness, sleep treatments, and PTSD affected frailty progression over four years. Frailty was measured using a validated index, with models adjusted for demographics and comorbidities, including chronic coronary insufficiency. Manuscript 1 showed that a higher Epworth Sleepiness Scale (ESS) score (range 0-24) was independently associated with a higher frailty index (FI) (p < .001). A clinical threshold of ≥11 indicated EDS and greater odds of frailty worsening compared to scores <11 (adjusted odds ratio (aOR) = 1.16, 95% CI [1.02, 1.32], p = .021). There was no significant interaction between ESS and time, suggesting that sEDS reflects persistently elevated frailty levels rather than accelerated decline. Manuscript 2 showed that nonpharmacologic sleep interventions were protective, while pharmacotherapy was associated with increased frailty risk. Cognitive behavioral therapy for insomnia was associated with lower odds of frailty worsening (aOR = 0.31, 95% CI [0.19, 0.53], p < .001), and continuous positive airway pressure therapy also reduced risk (aOR = 0.55, 95% CI [0.39, 0.76], p < .001). In contrast, sleep medications were associated with increased odds of frailty progression (aOR = 1.16, 95% CI [1.02, 1.32], p = .021). Manuscript 3 showed that PTSD was not associated with baseline frailty levels but showed a significant time interaction (B = 0.001, p = .008), indicating modest acceleration of frailty progression among affected veterans. Findings support positive social change through early sEDS screening and trauma-informed, nonpharmacologic sleep care to reduce frailty in veterans.
Self-Management Experiences Of Heart Failure Patients Who Received Telehealth Services During The Covid-19 Pandemic, Christie Devine
Self-Management Experiences Of Heart Failure Patients Who Received Telehealth Services During The Covid-19 Pandemic, Christie Devine
Walden Dissertations and Doctoral Studies
The COVID-19 pandemic increased the utilization of telehealth in managing chronic conditions such as heart failure. Existing research has primarily focused on patient experiences with specific telehealth platforms or settings, limiting generalizability within the diverse United States healthcare system. The purpose of this qualitative study, guided by the health promotion model, was to describe patient experiences with self-management of heart failure while receiving medical care through any type of telehealth service (e.g., telephone, video calls, remote monitoring) in the United States. Twenty-two participants were interviewed who met the criteria of having a diagnosis of heart failure and using telehealth since …
Staff Education To Improve Knowledge Of Venous Leg Ulcer Prevention, Bini John
Staff Education To Improve Knowledge Of Venous Leg Ulcer Prevention, Bini John
Walden Dissertations and Doctoral Studies
This Doctor of Nursing Practice (DNP) staff education project implemented a standardized program to strengthen knowledge, confidence, and adherence to venous stasis ulcer (VSU) prevention among staff in an outpatient vascular clinic. The practice problem was the lack of standardized staff education, leading to inconsistent patient teaching and recurrent ulceration. VSUs are a significant public health challenge, increasing morbidity, healthcare utilization, and reducing quality of life (He et al., 2024). The practice-focused question for this project was: In frontline medical staff at a vascular outpatient clinic, does a staff education program on a standardized approach to patient education for VSU …
Staff Education On Oral Health To Night Shift Staff, Uzoamaka Mbionwu
Staff Education On Oral Health To Night Shift Staff, Uzoamaka Mbionwu
Walden Dissertations and Doctoral Studies
Hospital-acquired pneumonia (HAP) remains the most common hospital-acquired infection in the United States, with nonventilated adult patients particularly at risk. This doctoral project focused on improving oral care practices among night shift nursing staff on a medical-surgical unit to reduce the risk of HAP. The practice gap identified was the inconsistent and inadequate delivery of oral hygiene during night shifts, primarily due to staff knowledge deficits, time constraints, and a lack of standardized procedures. The project was guided by the Johns Hopkins Evidence-Based Practice model and addressed the following question: In adult patients on a medical-surgical unit, will staff education …
Mold Exposure And Cognitive Health During Menopausal Transitions: A Quantitative Analysis Using Secondary Data, Holly Jeannette Burns
Mold Exposure And Cognitive Health During Menopausal Transitions: A Quantitative Analysis Using Secondary Data, Holly Jeannette Burns
Walden Dissertations and Doctoral Studies
Mold exposure and menopausal transition have been independently linked to cognitive decline, yet their interaction among socioeconomically disadvantaged populations has not been well examined. This quantitative study is an exploration of how menopausal transition influences the relationship between mold exposure and cognitive health outcomes among women aged 40 to 60 living in low-income housing in the United States. Bronfenbrenner’s ecological systems theory was used to guide the cross-sectional design using secondary data from the 2005–2006 National Health and Nutrition Examination Survey (NHANES; N = 149). Weighted logistic regression and Hayes’ PROCESS (Models 2 and 4) were used to test associations …
Sociocultural Factors Influencing Excess Gestational Weight Gain In Pregnant Puerto Rican Women, Sonia O. Roselló Aponte
Sociocultural Factors Influencing Excess Gestational Weight Gain In Pregnant Puerto Rican Women, Sonia O. Roselló Aponte
Walden Dissertations and Doctoral Studies
More than 50% of women experience excessive weight gain during pregnancy or are overweight at the start of pregnancy, increasing their risk of short and long-term maternal and fetal complications. The literature highlights the relationship between sociocultural factors and excessive gestational weight gain (EGWG) and the need to explore these factors in ethnic subgroups. The purpose of this descriptive qualitative study, guided by Nola Pender’s health promotion model, was to explore the sociocultural factors that influence EGWG for pregnant women living in Puerto Rico. Semi-structured interviews were conducted with seven participants recruited from public and private prenatal clinics in Puerto …
Staff Education On Antibiotic Stewardship For Urgent Care, Darla Michelle Taylor
Staff Education On Antibiotic Stewardship For Urgent Care, Darla Michelle Taylor
Walden Dissertations and Doctoral Studies
This doctoral project focused on a staff education initiative designed to improve antibiotic stewardship among urgent care providers. It evaluated changes in provider knowledge and prescribing intent following an evidence-based educational intervention by asking, “Does staff education on antibiotic stewardship in an urgent care setting enhance knowledge when compared to pre- and post-education assessments?” The purpose was to increase provider knowledge, confidence, and adherence to stewardship principles while influencing prescribing intent. The project consisted of an educational presentation with pre- and post-education surveys. Data was collected using pre- and post-education surveys featuring Likert-scale items that measured provider confidence, knowledge, and …
Mental Health Amongst African American Healthcare Workers And Covid Vaccine Mandates, Christopher Brandlin
Mental Health Amongst African American Healthcare Workers And Covid Vaccine Mandates, Christopher Brandlin
Walden Dissertations and Doctoral Studies
This qualitative case study investigated vaccine hesitancy among African American healthcare workers in Los Angeles County, California in light of employment loss following the State Public Health Officer Order of August 5, 2021. The literature indicated that vaccination policies have impacted the psychological health of healthcare workers, especially those with vaccine doubts. The research problem addressed in this study was that the mental health effects among African American hospital workers who lost employment as a result of vaccine hesitancy was not known. The purpose of this generic qualitative case study was to explain the factors contributing to vaccine hesitancy in …
Staff Education Project To Reduce Falls In Assisted Living Through Improved Caregiver Knowledge, Attitude, And Skill, Crystal Morrow
Staff Education Project To Reduce Falls In Assisted Living Through Improved Caregiver Knowledge, Attitude, And Skill, Crystal Morrow
Walden Dissertations and Doctoral Studies
Wisconsin has the highest death rates from falls in the nation. In a brief, the Wisconsin Aging Advocacy Network indicated that most falls among individuals over 65 occur in residential settings. Further, a significant number of elderly people will fall each year, resulting in hospitalizations or fatalities. The purpose of this project was to provide staff education in one Wisconsin assisted living facility to effectively improve knowledge, attitude, and skill among frontline staff for fall prevention management. A formal Fall Education Day was provided to improve knowledge and shape positive attitudes among staff. A pretest-posttest design was used to measure …
Improving Suicide Risk Detection And Management In Primary Care, Syndie Volcy
Improving Suicide Risk Detection And Management In Primary Care, Syndie Volcy
Walden Dissertations and Doctoral Studies
Suicide remains a critical public health issue in the United States, with rates continuing to rise despite national prevention initiatives. Primary care settings serve as a pivotal point for early detection, yet inconsistent use of standardized screening and safety planning tools contributes to under-recognition of suicide risk. This Doctor of Nursing Practice (DNP) project aimed to enhance the identification and management of suicide risk in primary care by developing and implementing an evidence-based clinical practice guideline (CPG). The project addressed the practice-focused question: Does implementing a standardized suicide prevention guideline using validated tools improve risk detection and management in primary …
Utilizing An Evidence-Based Educational Intervention To Assess Health Care Provider Knowledge And Confidence Of Weight Management Strategies In A Primary Care Setting, Fanny Ngwa Shu
Walden Dissertations and Doctoral Studies
This Doctor of Nursing Practice (DNP) project aimed to address a clinical gap in primary care by enhancing provider and staff knowledge and confidence in delivering weight management counseling. Despite the high prevalence of overweight and obesity, many healthcare providers feel inadequately prepared to initiate weight-related discussions due to factors such as limited training, cultural barriers, and a lack of understanding of social determinants of health (SDOH) that influence patient behaviors. This gap in care can hinder the effective management of chronic conditions like diabetes, hypertension, and cardiovascular disease. The practice-focused question guiding this project was: Can an educational session …