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Articles 61 - 90 of 405
Full-Text Articles in Nursing
Improving Bipolar Diagnosis With The Rapid Mood Screener, Leslie Richard
Improving Bipolar Diagnosis With The Rapid Mood Screener, Leslie Richard
Cohort XII
Background: Bipolar disorder is a chronic, debilitating mental illness that affects individuals globally. It is characterized by significant challenges in diagnosis, often leading to delays in receiving appropriate treatment. This condition can mirror the symptoms of unipolar depression, leading to frequent misdiagnoses and hindering timely intervention that could improve functional outcomes and quality of life.
Aims/Methods: This project aims to enhance the accuracy of bipolar disorder diagnoses in clinical settings, specifically bipolar disorder type 1 (BPT1), at the earliest possible stage of the illness. By doing so, it seeks to improve symptom management, reduce the duration of episodes, and enhance …
Nurse Suicide: Examining Depression And Anxiety In Critical Care Settings, Arianna Bernardine Barata
Nurse Suicide: Examining Depression And Anxiety In Critical Care Settings, Arianna Bernardine Barata
Nursing | Student Research Posters
Nurses play a critical role in healthcare, yet the demanding work environment often exposes them to stressors, leading to the development of depression and anxiety. According to the National Library of Medicine (NLM) (2021), 50.8% of nurses have stress, 74% have anxiety, 70.8% have depression, and 79.1% have at least one of them. Burnout, understaffing, COVID fatigue, alarm fatigue, patient ratios, and disrupted sleep patterns are some of the stressors nurses contend with in every shift. While some nurses may cope and overcome these challenges, many face more severe issues, such as suicide. Nurse suicide is an issue that has …
Educational Campaign: Using Exercise To Prevent Postpartum Depression, Ruth Platt
Educational Campaign: Using Exercise To Prevent Postpartum Depression, Ruth Platt
MSN Capstone Projects
Postpartum depression is one of the most common medical ailments surrounding childbirth. It affects up to 20% of postpartum women and has detrimental effects not only on the mother but her infant and family as well (Navas et al., 2021). Currently, the medical community takes a reactive approach to postpartum depression by screening and treating cases of postpartum depression as they occur. An evidence-based search of peer-reviewed articles found that exercise in the perinatal period had a positive effect on maternal mental health and decreased postpartum depression scores. This is especially true for women who have a history of depression …
Brain Matters: Cognitive-Behavioral Therapy And Antidepressants For Post-Stroke Depression, Lindsey Anne Smith
Brain Matters: Cognitive-Behavioral Therapy And Antidepressants For Post-Stroke Depression, Lindsey Anne Smith
MSN Capstone Projects
Stroke is the leading cause of death and disability in the United States, and approximately one-third of these patients will develop post-stroke depression, which is associated with higher rates of morbidity and mortality (American Stroke Association, 2022). Even though post-stroke depression is prevalent, it often goes undertreated. The combination of antidepressants and cognitive-behavioral therapy has shown to be an effective method of treating post-stroke depression. There are cognitive-behavioral exercises that nurses can implement, such as group therapy, acceptance therapy, and cognitive retraining, a method of coaching the patient to replace negative thoughts with positive ones (Byun et al., 2021). With …
Evaluating The Efficacy Of Universal Depression Screenings In The High School Setting, Telisha Anthony Msn, Fnp-Bc, Jennifer Thorsen Bsn, Rn, Jackie Sharp Dnp, Pmhnp-Bc, Sharon Little Dnp, Fnp-Bc
Evaluating The Efficacy Of Universal Depression Screenings In The High School Setting, Telisha Anthony Msn, Fnp-Bc, Jennifer Thorsen Bsn, Rn, Jackie Sharp Dnp, Pmhnp-Bc, Sharon Little Dnp, Fnp-Bc
Doctor of Nursing Practice Projects
Purpose/Background
Depression in adolescents is rising each year. Early detection of depression has been shown to result in better health outcomes and success in school. This scoping review aims to evaluate the implementation of universal depression screenings in the high school setting and how this detection of depression and initiation of treatment.
Methods
From August 2022 to November 2023, we used the Medline, PubMed, Elsevier, Google Scholar, and PsycINFO databases, using specific keywords related to depression in adolescents. Of the 38 articles found, 10 were chosen after extensive article critique. The publication dates ranged from 2014-2023, were full-text, and from …
Implementing Universal Adult Depression Screening In A Rural Maine Free Medical Clinic, Karen Hussion
Implementing Universal Adult Depression Screening In A Rural Maine Free Medical Clinic, Karen Hussion
Doctor of Nursing Practice Scholarly Projects
Abstract
BACKGROUND: Depression in adults is a leading cause of disability, morbidity and mortality worldwide with an estimated prevalence of 20% in the US population. Despite estimates that one out of every five Americans suffers from depression, less than 50% of adult primary care patients with depression are identified, and less than 5% of all adult primary care patients are screened. To increase early detection and management of depression, the United States Protective Service Task Force (USPSTF) recommends routine depression screening for adults older than 18 years in primary care settings.
LOCAL PROBLEM: This project site was a rural, free, …
Comparisons Of Using Alcohol, Coping Strategies, Anxiety, And Depression Between Usa And Taiwanese College Students, Pi-Ming Yeh Associate Professor, Cheng-Huei Chiao Professor, Jennchang Liou Professor
Comparisons Of Using Alcohol, Coping Strategies, Anxiety, And Depression Between Usa And Taiwanese College Students, Pi-Ming Yeh Associate Professor, Cheng-Huei Chiao Professor, Jennchang Liou Professor
Epsilon Sigma at-Large Research Conference
Purpose: In this study, we compared United States (US) and Taiwanese college students’ using alcohol, coping strategies, anxiety, and depression.
Research Questions:
1. What were the differences in demographic characteristics, using alcohol, coping strategies, anxiety, and depression between US and Taiwanese college students?
2. What were the relationships between US and Taiwanese college students’ using alcohol, coping strategies, anxiety, and depression?
3. How much of US and Taiwanese college students’ anxiety and depression were predicted by their use of alcohol, coping strategies?
Methods: Four hundred and one US and 180 Taiwanese college students were recruited in this study. This was …
Implementation Of Provider-Made Follow-Up Appointments For Depression In Primary Care, Rebecca Vaughn
Implementation Of Provider-Made Follow-Up Appointments For Depression In Primary Care, Rebecca Vaughn
Epsilon Sigma at-Large Research Conference
Implementation of provider-made follow-up appointments for depression in primary care
Rebecca Vaughn
College of Nursing, East Tennessee State University; Whitson Hester School of Nursing, Tennessee Technological University
Author Note
Rebecca Vaughn https://orcid.org/0009-0007-0731-3316 College of Nursing, East Tennessee State University
There are no conflicts of interest to disclose.
Corresponding concerning this manuscript should be addressed to Rebecca Vaughn
108 Reed Mill Lane Monroe TN 38573
Abstract
Depression is a common condition diagnosed and managed in primary care.
Follow-up is inconsistent and low in these settings, creating a gap in care that
impacts management, adherence to treatment, and patient outcomes. The …
Improving Depression Screening In Primary Care, Grace Wilson, Annmarie O'Connor
Improving Depression Screening In Primary Care, Grace Wilson, Annmarie O'Connor
Doctor of Nursing Practice Projects
Depression remains an increasingly prevalent and underdiagnosed disorder affecting approximately 21 million adults in the United States with only 66% seeking treatment (NIMH, 2022). Untreated depression can lead to worsening mental and physical health which negatively impacts a person’s quality of life. The implementation of routine depression screening in primary care is recommended by the US Preventive Services Task Force (USPSTF) to improve early detection leading to improved outcomes (USPSTF, 2023). Despite increased depression prevalence and USPSTF recommendation, there remained an absence of routine depression screening in a primary care practice in Midwest Illinois which led to the development of …
The Association Of Hiv-Related Stigma And Psychosocial Factors And Hiv Treatment Outcomes Among People Living With Hiv In The Volta Region Of Ghana: A Mixed-Methods Study, Jerry John Nutor, Akua O. Gyamerah, Henry Ofori Duah, David Ayangba Asakitogum, Rachel G.A. Thompson, Robert Kaba Alhassan, Alison Hamilton
The Association Of Hiv-Related Stigma And Psychosocial Factors And Hiv Treatment Outcomes Among People Living With Hiv In The Volta Region Of Ghana: A Mixed-Methods Study, Jerry John Nutor, Akua O. Gyamerah, Henry Ofori Duah, David Ayangba Asakitogum, Rachel G.A. Thompson, Robert Kaba Alhassan, Alison Hamilton
College of Nursing Faculty Research and Publications
Stigma and discrimination have been identified as significant barriers to HIV treatment among people living with HIV (PLWH). HIV stigma affects decision to seek HIV testing and early treatment. Evidence shows that HIV stigma undermines antiretroviral therapy (ART) adherence by affecting the psychological process such as adjusting and coping with social support. In Ghana, stigma toward PLWH occurs in many ways including rejection by their communities and family members, ostracism, and refusal to engage in social interactions such as eating, sharing a bed, or shaking hands. Therefore. we examined PLWH’s experiences with different forms of HIV-related stigma and the impact …
The Effects Of Aerobic Exercise To Improve Depression In Overweight Adults, Curtis Lura
The Effects Of Aerobic Exercise To Improve Depression In Overweight Adults, Curtis Lura
Master of Science in Nursing Family Nurse Practitioner
Overweight/obese adults are at an increased risk for both physical and mental comorbidities (CDC, 2019). Depression is a common comorbidity in those that are obese (CDC, 2019) and the standard of care currently to treat depression may increase the risk of physical comorbidities because weight gain is a common side effect of antidepressants (Hall-Flavin, 2018). The aim of this capstone research paper is to present evidence that an aerobic exercise regimen can be a valid treatment option for depression.
Introducing Mental Health Resources To Nurse Practitioner Residents, Tiffanie Bailey
Introducing Mental Health Resources To Nurse Practitioner Residents, Tiffanie Bailey
Doctor of Nursing Practice Projects
This DNP Project identified the increased need for mental health resources after the COVID-19 pandemic. Studies showed the rate of anxiety, depression, and substance use has also been on the rise since the beginning of the pandemic. As the impact of the COVID-19 pandemic began to devastate the country mentally and physically, it became quickly apparent that additional resources to provide support for those suffering from mental illness were essential. This project aimed to introduce a Mental Health First Aid course within the Residency Program at the Center for Family Guidance. Participants were asked to complete a pre-test indicating their …
Community Educational Session On Identifying The Signs Of Depression And Resources Available, Desiree Young
Community Educational Session On Identifying The Signs Of Depression And Resources Available, Desiree Young
Doctor of Nursing Practice Projects
The DNP Project was designed to educate the community on identifying the signs of depression and the community resources available to them. The intent of the project was to improve the community’s knowledge of depression symptoms and the community resources available that offer assistance to those dealing with these symptoms. There is a great need for education on depression signs, as many in various communities suffer from untreated depression, which often leads to negative outcomes. The impact of the project implementation was measured by using pre- and post-survey data evaluating the participants' overall knowledge of the signs of depression, stigma …
Increased Concern Of Suicide Behaviors In The Adolescent Population, Jaime Shareen-Porter Earle
Increased Concern Of Suicide Behaviors In The Adolescent Population, Jaime Shareen-Porter Earle
Doctor of Nursing Practice Projects
This quality improvement project focused on addressing the concern for the increase of depression, anxiety, and self-harm behaviors among adolescents, which can lead to suicidal ideation and attempts. Suicide behaviors have increased among adolescents, and research revealed that suicide is the second leading cause of death in this population. An educational PowerPoint was presented to members of the community on suicide behaviors, how to identify the behaviors, and where to get support and resources in the community. Pre- and post-surveys were used to assess the participants' knowledge and confidence levels before and after project implementation. The surveys contained the same …
Increasing Annual Depression Screening For Adults In A Primary Care Setting, Sandy Zachery, Sheryl Winn, Flor Culpa-Bondal
Increasing Annual Depression Screening For Adults In A Primary Care Setting, Sandy Zachery, Sheryl Winn, Flor Culpa-Bondal
Graduate Research Showcase
Increasing Annual Depression Screening for Adults in a Primary Care Setting
Background:
Depression is a mental illness that's common worldwide, which can cause an individual to function poorly in society and can progress to suicide. Because of several barriers, patients in a primary care environment are not being seen or treated for depression. Even though the U.S. Preventive Services Task Force (USPSTF) recommends that all adults in primary care receive annual depression screening that delivers effective treatment with the correct diagnosis and accurate follow-up, patients are still not being screened for depression.
Purpose:.
This project aims to improve …
The Relationship Between Mild Cognitive Dysfunction And Diabetes Self-Management In Community Dwelling Older Adults, Hossein Hafezi Nia
The Relationship Between Mild Cognitive Dysfunction And Diabetes Self-Management In Community Dwelling Older Adults, Hossein Hafezi Nia
Wayne State University Dissertations
Background. Cognitive dysfunction is an important comorbidity of diabetes, which may reflect brain changes as a consequence of diabetes. Objective The purpose of this study was to examine the association between specific cognitive domains and diabetes self-management behaviors in individuals with diabetes and mild cognitive impairment (MCI). Furthermore, the association between social determinats of health and MCI was investigated. Design A cross-sectional descriptive correlational design was used to address the study aims using data extracted from the 2022 Health and Retirement Study (HRS) and 2016 Harmonized Cognitive Assessment Protocol (HCAP) datasets. Participants Of the total HRS and HCAP participants, 2035 …
Nurse Suicide: Examining Depression And Anxiety In Critical Care Settings, Arianna Bernardine Barata
Nurse Suicide: Examining Depression And Anxiety In Critical Care Settings, Arianna Bernardine Barata
Nursing | Senior Theses
Nurses play a critical role in healthcare, yet the demanding work environment often exposes them to stressors, leading to the development of depression and anxiety. According to the National Library of Medicine (NLM) (2021), 50.8% of nurses have stress, 74% have anxiety, 70.8% have depression, and 79.1% have at least one of them. Burnout, understaffing, COVID fatigue, alarm fatigue, patient ratios, and disrupted sleep patterns are some of the stressors nurses contend with in every shift. While some nurses may cope and overcome these challenges, many face more severe issues, such as suicide. Nurse suicide is an issue that has …
Utilizing A Structured Music Therapy Program For Adolescents With Anxiety And Depression, Amy Haagen
Utilizing A Structured Music Therapy Program For Adolescents With Anxiety And Depression, Amy Haagen
West Chester University Doctoral Projects
Anxiety and depression are two of the most common mental health issues that affect children and adolescents. It has been noted that twenty percent of adolescents will have a depressive episode or be affected by anxiety by the time they are 18 years old. Mental health issues affecting children and adolescents majorly impact all aspects of their lives, most notably academic success, behavior, growth, and development (Porter et al., 2017). Current treatments for mental disorders, including depression and anxiety, include pharmacological and psychotherapeutic treatments. In the adolescent population, there are conflicting opinions on the use of antidepressants due to risks …
Psychosocial Factors Affecting Quality Of Life In Kidney Transplant Recipients, Lawrence Panlilio
Psychosocial Factors Affecting Quality Of Life In Kidney Transplant Recipients, Lawrence Panlilio
Nursing | Student Research Posters
Background: Kidney transplantation is the best solution to save lives for those that have end-stage renal disease. However, psychosocial issues play a huge role in their quality of life after the procedure which can affect these individuals negatively. These issues recipients face include depression and anxiety, a lack of social support, and self management difficulties. Objective: This research consists of investigating psychosocial factors that affect kidney transplant recipients’ quality of life. Evidenced by research, focused assistance with ongoing support in patients is essential after receiving surgery and recovery. A literature review was conducted that consists of research on studies with …
Integrating Behavioral Health Into Family Medicine: Improving Access To Specialty Care Using A Collaborative Care Model, Christina Stephens
Integrating Behavioral Health Into Family Medicine: Improving Access To Specialty Care Using A Collaborative Care Model, Christina Stephens
DNP Scholarly Projects
Primary care, an extensive of family medicine remains a key access point for patients entering the healthcare system. Accessing medical care and specialty psychiatric services is limited in rural communities. Patients often find exhaustive wait times, untimely referrals, and reliance on emergency services for crisis management. The primary care provider is able to help their community improve access to behavioral health care by using a collaborative approach. This quality improvement initiative used the framework produced by the AIMS Center at the University of Washington and adopted for use creating an 8-week intensive program in a family medical practice located in …
Clinical Practice Guideline For The Management Of Depression In Primary Care, Estrella Catherine Villarreal
Clinical Practice Guideline For The Management Of Depression In Primary Care, Estrella Catherine Villarreal
Doctor of Nursing Practice (DNP) Scholarly Projects - Archive
Background: The prevalence of depression poses a significant challenge in primary care, emphasizing the urgent need to address this issue during patient visits. Primary care providers are at the forefront of managing depression, yet they encounter difficulties in screening, diagnosing, assessing, and treating this complex condition. Clinical guidelines serve as valuable tools for primary care providers and practices, offering support in identifying and addressing depression effectively. An evidence-based approach to treating depression in primary care, with a focus on collaborative interventions with behavioral health to enhance depression management for American Indian/Alaskan Native (AI/AN) communities.
Methods: The descriptive analysis was conducted …
Glutamate Optimization As A Treatment For Depression: A Clinical Guideline, Luisa Angeles Collins Villares
Glutamate Optimization As A Treatment For Depression: A Clinical Guideline, Luisa Angeles Collins Villares
Doctor of Nursing Practice (DNP) Scholarly Projects - Archive
Based on the use of drugs to treat hypertension and tuberculosis for depression, the monoamine hypothesis led to the development of antidepressants in 1952. Serotonin was recognized as a deficiency associated with depression in 1967. As a fine-tuning orchestration of neurotransmitters and neuromodulators, the glutamate system became known using Spravato in 2019 and Auvelity in 2022. In this pilot study, mental health experts rated the importance of 24 science-based recommendations to optimize glutamatergic therapy in depression for a proposed guideline on a Likert scale from zero to four. The results were analyzed using a non-parametric predictive modeling method called Chi-Square …
Predictors Of Occupational Distress Of Catholic Priests On The Eastern Seaboard Of The United States, Michael D. Kostick, Xihe Zhu, Justin A. Haegele, Pete Baker
Predictors Of Occupational Distress Of Catholic Priests On The Eastern Seaboard Of The United States, Michael D. Kostick, Xihe Zhu, Justin A. Haegele, Pete Baker
Human Movement Studies & Special Education Faculty Publications
With ever-increasing demands placed upon active priests in the United States, insight into protecting their mental health may help strengthen vocational resilience for individual priests. The purpose of this study was to examine the association of individual variables, workplace characteristics, and physical activity participation with occupational distress levels among Catholic priests. A 22-question survey consisting of a demographic questionnaire, the Clergy Occupational Distress Index, and the International Physical Activity Questionnaire was employed to collect individual variables, workplace characteristics, physical activity participation, and occupational distress levels of Catholic priests from the Eastern seaboard of the United States. Regression analyses showed that …
Depression Screening Tool For Hysterectomy Patients, Dede C. Mihedji
Depression Screening Tool For Hysterectomy Patients, Dede C. Mihedji
Doctor of Nursing Practice (DNP) Projects
Abstract
Background: The prevalence of hysterectomies in the United States ranges from
5.1 to 5.8 per 1000 women (Harnod et al., 2018). A standardized screening tool for assessing
depression preoperatively could mitigate the worsening of postoperative depressive symptoms in patients scheduled for a hysterectomy.
Local Problem: Currently, there is no standard of practice to routinely screen for depression in preoperative patients scheduled for hysterectomy surgeries. However, as with any surgical intervention, there are risks of long-term complications. Studies have identified that a hysterectomy may increase the risk of cardiovascular events, menopause, depression, and other outcomes (Madueke-Laveaux et al., 2022). …
Animal-Assisted Therapy In Mental Illness, Chanae Cypress
Animal-Assisted Therapy In Mental Illness, Chanae Cypress
MSN Capstone Projects
Mental health disorders are a significant global health concern, with a growing need for alternative therapeutic approaches. Animal-assisted therapy has gained recognition for its potential to improve the emotional and psychological well-being of individuals struggling with these disorders.
This Capstone Benchmark proposed project explores the potential positive impact of animal-assisted therapy (AAT) on patients with mental health disorders during inpatient hospitalization. The project outlines a 4-week intervention program involving 45-60 minutes sessions with dogs, which patients receive 2-3 times per week. For this Capstone Benchmark project, the selected PICOT question is: In patients with mental health disorder (P) how does …
A Quality Improvement Project To Screen For Food Insecurity In Adults With Anxiety Or Depression, Kelsie Evelyn Kroll
A Quality Improvement Project To Screen For Food Insecurity In Adults With Anxiety Or Depression, Kelsie Evelyn Kroll
Doctor of Nursing Practice
Background Food insecurity is the limited availability and inconsistent accessibility of healthy foods (Coleman-Jensen et al., 2022a). Food insecurity contributes to mental health problems. Individuals with food insecurity have greater odds of screening positive for depression and anxiety (Wolfson et al., 2021). The Hunger Vital Sign™ screening tool is a 2-questions evidence-based tool used to identify food insecurity (Hager et al., 2010). Purpose. Implement the Hunger Vital Sign™ tool at a non-profit behavior health clinic to identify food insecurity in adults who screened positive for anxiety or depression, offer resources for them to obtain nutritious food, and provide additional information …
Factors Associated With Depressive Symptoms Among Community-Dwelling Older People In East-Coast Malaysia, Siti Suhana Zakaria, Siti Nur Illiani Jaafar, Muhammad Kamil Che Hasan, Nik Noor Kaussar Nik Mohd Hatta, Wan Nor Aliza Wan Abdul Rahman
Factors Associated With Depressive Symptoms Among Community-Dwelling Older People In East-Coast Malaysia, Siti Suhana Zakaria, Siti Nur Illiani Jaafar, Muhammad Kamil Che Hasan, Nik Noor Kaussar Nik Mohd Hatta, Wan Nor Aliza Wan Abdul Rahman
Jurnal Keperawatan Indonesia
Older people are increasing in number globally, and they are likely to have mental health problems, including de- pression. In this population, the risk of having depressive symptoms is very high due to multidimensional factors, but these symptoms are often undertreated. This study aimed to determine the prevalence and associated factors of de- pressive symptoms among community-dwelling older people living on the East Coast of Malaysia. A cross-sectional study was conducted in several areas of the state of Terengganu based on multilayered stratified sampling. A total of 240 participants were randomly selected. Several instruments were employed, such as the Geriatric …
Targeting Loneliness In Older Adults With Weekly Socialization, Tanja Johnson
Targeting Loneliness In Older Adults With Weekly Socialization, Tanja Johnson
Dissertations
Problem: Loneliness related to social isolation among the older adult population has become an increasing health concern with few interventions available for the general population. Loneliness has been directly associated with depression, poorer physical health outcomes, and overall quality of life.
Methods: The purpose of this study is to evaluate loneliness in the older adult population residing in a senior living community in an urban area in Missouri. Weekly one-on-one socialization, ranging from 45-60 minutes, will be implemented over 6 weeks, with pre and post-intervention screening for loneliness with the 28-item Visit-A-Bit (VAB) screening tool. Approval was received by both …
Psychological Distress, Resilience, And The Impact On Quality Of Life In Breast Cancer Survivors With Taxane-Induced Peripheral Neuropathy, Lauren Schwab
USF Tampa Graduate Theses and Dissertations
The purpose of this dissertation study was to longitudinally examine psychological distress (depressive symptoms and anxiety symptoms), resilience, and the impact on quality of life (QOL) in breast cancer survivors (BCS) with taxane-induced peripheral neuropathy (TIPN). The specific aims were 1) to describe psychological distress (depressive and anxiety symptoms) in BCS with TIPN and the impact on QOL using a scoping review; 2) to determine the relationship between psychological distress, QOL, and resilience in BCS with TIPN over time in a 16-week randomized controlled trial (RCT); and 3) to determine if resilience moderates psychological distress and QOL in BCS with …
Social Activity Restriction And Psychological Health Among Caregivers Of Older Adults With And Without Dementia, Elliane Irani, Kylie Meyer, Scott Emory Moore, Kedong Ding
Social Activity Restriction And Psychological Health Among Caregivers Of Older Adults With And Without Dementia, Elliane Irani, Kylie Meyer, Scott Emory Moore, Kedong Ding
Faculty Scholarship
Objectives: We examined associations between social activity restriction and psychological distress and well-being for caregivers of older adults with and without dementia, and if the identified associations are different for the two groups. Methods: Using data from the 2017 National Study of Caregiving, we identified caregivers of older adults with (N = 541) and without (N = 1701) dementia. Linear regression models were estimated, adjusting for caregivers’ age, gender, race, education, relationship to care recipient, and self-rated health. Results: Restriction in visiting friends and family and attending religious services were associated with higher distress in dementia caregivers. Restriction in visiting …