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Articles 7231 - 7260 of 34141
Full-Text Articles in Nursing
Evaluating A Novel Patient Intake Model For Newly Referred Patients Seeking Cancer Care: An Evidence-Based Practice Project, Roquinna Serna, Stella Fernandez, Morgan Nestingen, Stephen Breazeale
Evaluating A Novel Patient Intake Model For Newly Referred Patients Seeking Cancer Care: An Evidence-Based Practice Project, Roquinna Serna, Stella Fernandez, Morgan Nestingen, Stephen Breazeale
Nursing & Health Sciences Research Journal
Introduction: Cancer survivors must engage in a complex medical system that requires coordinating care, traveling for treatment, obtaining referrals, and scheduling multiple appointments with various teams. Cancer care facilities are implementing oncology navigation programs that help survivors navigate barriers in complex cancer care systems. However, new patients require additional support prior to their first visit. This article aims to describe the development and design of Miami Cancer Institute’s (MCI) Intake NOW program and evaluate its effects on scheduling-related outcomes among individuals seeking to establish cancer care. Methods: We conducted a retrospective data analysis before and after the MCI Intake NOW …
Allied Health Scholars Program: Addressing Workforce Shortage And Talent Pipeline Through Educational Programs, Carolina Perticari, Melissa R. Maguina, Lorell Bergolla, Maria Gauthreaux, Aleister Avila, John Mouw, Alwyn Leiba, Bryan Stewart, Agueda Hernandez, Zuanel Diaz
Allied Health Scholars Program: Addressing Workforce Shortage And Talent Pipeline Through Educational Programs, Carolina Perticari, Melissa R. Maguina, Lorell Bergolla, Maria Gauthreaux, Aleister Avila, John Mouw, Alwyn Leiba, Bryan Stewart, Agueda Hernandez, Zuanel Diaz
Nursing & Health Sciences Research Journal
No abstract provided.
Emergency Department Patient Navigator Post Chest Pain Diagnosis Discharge, Nancy Simoes
Emergency Department Patient Navigator Post Chest Pain Diagnosis Discharge, Nancy Simoes
Seton Hall University Dissertations and Theses (ETDs)
Abstract The most common complaint seen in the Emergency Department, along with abdominal pain, is nonspecific chest pain. Often, these complaints cause prolonged lengths of stay in the ED, followed by hospital admissions and subsequent readmissions for various reasons. When thinking about these various reasons, the question for prevention of readmission comes to mind. What could we do as a department to keep patients from continuously using the Emergency Department as a primary point of care instead of outpatient facilities when necessary? Project Aim: The purpose of this quality improvement project was to initiate the need for a patient navigator …
Exploring Nursing Faculty Perceived Individual And Organizational Readiness To Use Online Simulation As A Teaching Strategy, Luz-Patricia Torres
Exploring Nursing Faculty Perceived Individual And Organizational Readiness To Use Online Simulation As A Teaching Strategy, Luz-Patricia Torres
Seton Hall University Dissertations and Theses (ETDs)
Problem: Academic institutions have employed online simulations in nursing education to meet the needs of the growing nursing student population and demands for distance learning. While some nursing educators have been trained to use simulation learning experiences, few have specific training in applying online simulation as a teaching strategy. With a dearth of evidence in the literature specific to the use of online simulation in nursing education, exploring nursing faculty's perceived individual and organizational readiness to do so is warranted to optimize the use of this innovation.
Purpose: This study explored the nursing faculty's perceived individual and organizational readiness …
Staff Education Project To Decrease Variations In Surgical Optimizations, Shelly Bressoud
Staff Education Project To Decrease Variations In Surgical Optimizations, Shelly Bressoud
Walden Dissertations and Doctoral Studies
No abstract provided.
Purposeful Rounding For Fall Reduction, Deborah Grant Rn
Purposeful Rounding For Fall Reduction, Deborah Grant Rn
Master's Projects and Capstones
Objective. The quality improvement project aimed to study the effects of purposeful rounding on falls in a long-term care unit. The focus was on CNAs who provided care for 6 residents each, with a current census of 36 residents in the long-term care setting. Problem. Many of the residents are at risk for falls due to immobility, medication, and environmental hazards (Centers for Disease Control and Prevention, 2022). Context. Research has found that the key reasons residents call for staff include needing to use the bathroom, to address pain, to address positioning, and to address IV pumps and alarms (Studer …
Project: Mhealth Applications For Educating Community Nurses, Nkemdilim Stacy Egbo
Project: Mhealth Applications For Educating Community Nurses, Nkemdilim Stacy Egbo
Electronic Theses and Dissertations
Hypertension is a chronic health condition linked to high morbidity and mortality rates in America and around the world. Hypertension care in developing and underdeveloped countries requires quick intervention. The proliferation of smart technologies and mobile health applications offer some leverage for the alternative management of hypertension, but evidence related to effectiveness in Nigeria are limited. The purpose of the study was to assess the impact of m-Health apps on hypertension self-management through nurses’ education in Southern region of Nigeria, as well as their self-confidence or efficacy using the Hypertension Evaluation of Lifestyle Management assessment. A quasi-experimental pretest-posttest design was …
Evaluation Of Cardiovascular Risk Compliance For Primary Prevention: A Quality Improvement Project, Rachelle S. Campbell
Evaluation Of Cardiovascular Risk Compliance For Primary Prevention: A Quality Improvement Project, Rachelle S. Campbell
Electronic Theses and Dissertations
The American College of Cardiology and American Heart Association clinical practice guidelines recommend a cardiovascular risk assessment every 4–6 years in ages 40–75 to prevent cardiovascular disease. This DNP project aimed to improve awareness, compliance with cardiac risk assessments, and stratification of high and low-risk patients. This quality improvement project utilized the Johns Hopkins nursing evidence-based model to create the inquiry question and foundational plan for implementing the clinical practice guideline, calculating the cardiac risk score, and creating a clinical workflow process. A retrospective chart audit was guided by the Plan-Do-Study-Act (PDSA) method to collect pre- and postintervention data on …
Transformational Leadership Training For Leaders, Kristie M. Gilliland
Transformational Leadership Training For Leaders, Kristie M. Gilliland
Electronic Theses and Dissertations
The purpose of the study was to evaluate the impact of transformational leadership training on improving a leader’s skills and knowledge in performing daily operations and interacting with frontline staff, decreasing attrition. Ineffective leadership contributes to staff dissatisfaction, poor performance, and attrition. The literature supports transformational leadership is effective in leading teams of nurses and contributes to staff autonomy, staff satisfaction, decreased attrition, and improved patient outcomes. A quasi-experimental research study was completed on a leadership team in a managed care organization. Fourteen leaders with anywhere from 1 to more than 6 years of leadership experience were evaluated. Lewin’s change …
A Case Study Of The Political Determinant Of Health On The Public Health Crisis Of Malaria In Nigeria, Bisola M. Olumegbon
A Case Study Of The Political Determinant Of Health On The Public Health Crisis Of Malaria In Nigeria, Bisola M. Olumegbon
Electronic Theses and Dissertations
Abstract
Globally, there were about 229 million cases of malaria in 2022. The sub-Saharan African region accounted for 92% of the reported cases and 94% of deaths. Nigeria had the highest number of malaria cases and deaths, representing 27% of global cases. This scholarly project was a case study guided by the political determinants of health. Triangulation of data using thematic analysis was used to identify the political determinants of malaria in Nigeria and to understand how the concept of interaction contributes to the persistence of the disease. The analysis involved a deductive and inductive approach based on the literature …
The Relationship Between Job Challenge And Leadership Aspiration From The Perspective Of The Entry Level Nurse Leader, Rose M. Johnson
The Relationship Between Job Challenge And Leadership Aspiration From The Perspective Of The Entry Level Nurse Leader, Rose M. Johnson
Electronic Theses and Dissertations
While the nurse leader plays an important and integral role in the success of healthcare organizations, the nurse leader pipeline has experienced a troubling and downward trajectory for several years. The lack of leadership aspiration among direct care nurses has been noted as one of several reasons for the downward trajectory. In addition, researchers identified the lack of understanding of perspectives of the various nurse leader roles and the lack of understanding of the effectiveness of experiential learning in the nurse leader role as potential contributions to the problem. The purpose of this quantitative, correlational research was to examine the …
Promoting Patient Mobility To Decrease Hospital Length Of Stay, Saira Kinuthia
Promoting Patient Mobility To Decrease Hospital Length Of Stay, Saira Kinuthia
Student Scholarly Projects
Practice Problem: Promoting patient mobility may reduce hospital-acquired complications and length of stay (LOS). Evidence-based studies have established that there is a correlation between immobility and an increased length of stay in the hospital. How can nurse-driven mobility interventions effectively increase patient mobility and reduce the risk of complications and length of hospital stay?
PICOT: The PICOT question that guided this project was: For veteran patients in the Progressive Care unit (PCU) of a medical center (P), will using the Johns Hopkins Highest Level of Mobility tool (JH-HLM) (I) compared to not using a mobility tool (C) decrease hospital length …
Facility-Based Audit System With Integrated Community Engagement To Improve Maternal And Perinatal Health Outcomes In Rural Pakistan: Protocol For A Mixed Methods Implementation Study, Zahid Memon, Wardah Ahmed, Shah Muhammad, Sajid Bashir Soofi, Shanti Chohan, Arjumand Rizvi, Paul Barach, Zulfiqar Ahmed Bhutta
Facility-Based Audit System With Integrated Community Engagement To Improve Maternal And Perinatal Health Outcomes In Rural Pakistan: Protocol For A Mixed Methods Implementation Study, Zahid Memon, Wardah Ahmed, Shah Muhammad, Sajid Bashir Soofi, Shanti Chohan, Arjumand Rizvi, Paul Barach, Zulfiqar Ahmed Bhutta
Centre of Excellence in Women and Child Health
Background: Maternal and newborn mortality in Pakistan remains as a major public health challenge. Pakistan faces significant infrastructure challenges and inadequate access to quality health care, exacerbated by sociocultural factors. Facility-based audit systems coupled with community engagement are key elements in achieving improved health system performance. We describe an implementation approach adapted from the World Health Organization audit cycle in real-world settings, with a plan to scale-up through mixed methods evaluation plan.
Objective: This study aims to implement a locally acceptable and relevant audit system and evaluate its feasibility within the rural health system of Pakistan for scale-up.
Methods: The …
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 …
Sleep Quality And Stress Levels Among Nurses: A Single Center Study, Siti Zuhaidah Shahadan, Mohamad Firdaus Mohamad Ismail, Khalidah Nadhirah Kamaruzaman
Sleep Quality And Stress Levels Among Nurses: A Single Center Study, Siti Zuhaidah Shahadan, Mohamad Firdaus Mohamad Ismail, Khalidah Nadhirah Kamaruzaman
Jurnal Keperawatan Indonesia
The issue of nurses' sleep quality, which has a significant impact on their mental health, has not received enough attention. Nurses’ stress and mental health can affect patient care, so poor sleep quality in nurses can lead to stress and patient harm. Thus, this study examines the relationship between sleep quality and stress in nurses at a university hospital in Kuantan, Malaysia. This cross-sectional study used convenience sampling. A total of 101 nurses in the hospital were recruited to complete a series of questionnaires, including the Pittsburgh sleep quality index (PSQI) and the depression anxiety stress scale 21 (DASS21). SPSS …
Smoking Among Adolescents And Associated Factors In Rural Areas, Hanida Hani Mohd Mokhtar, Nurul Farhana Abdul Ghani, Siti Nur Illiani Jaafar, Aini Ahmad, Fitri Arofiati
Smoking Among Adolescents And Associated Factors In Rural Areas, Hanida Hani Mohd Mokhtar, Nurul Farhana Abdul Ghani, Siti Nur Illiani Jaafar, Aini Ahmad, Fitri Arofiati
Jurnal Keperawatan Indonesia
Smoking among adolescents is the major health-related issues in Malaysia. However, information concerning recent smoking rates and how they correlate among adolescents in rural areas is still limited. This study aimed to determine the percentage of adolescent smokers among high school students, examine their level of nicotine dependence, and study the association between sociodemographic data and smoking status. A cross-sectional study was conducted at one of the high schools located in the rural area of Bandar Tun Abdul Razak, Pahang, Malaysia. A convenience sampling method was used to select the participants, as only Form 2 students were available during the …
The Relationship Of Self-Care Behaviours And Online Learning Engagement Among Nursing Students During The Covid-19 Pandemic, Mazlinda Musa, Rohani Mamat, Hamidah Hassan, Sitti Fatimah Sa'at, Syed Syarizman Abd Rahim, Abdul Rahman Ramdzan, Octovia Abdullah, Vellerina Ally Paidius, Mariana Muitaba, Ashley Melissa George
The Relationship Of Self-Care Behaviours And Online Learning Engagement Among Nursing Students During The Covid-19 Pandemic, Mazlinda Musa, Rohani Mamat, Hamidah Hassan, Sitti Fatimah Sa'at, Syed Syarizman Abd Rahim, Abdul Rahman Ramdzan, Octovia Abdullah, Vellerina Ally Paidius, Mariana Muitaba, Ashley Melissa George
Jurnal Keperawatan Indonesia
The COVID-19 pandemic and the sudden switch from conventional to virtual classes allegedly raised students' risk of mental health illnesses, adversely influencing their academic engagement and learning outcomes. Nursing students in Malaysia, especially those enrolled in universities in Sabah, have traditionally been accustomed to a conventional face- to-face teaching and learning approach. Due to the COVID-19 pandemic, e-learning or online classes have become one of the learning methods for university nursing students in Sabah, either while they are on campus or at home, to obtain access for educational purposes. The purpose of this study was to assess the relationship between …
Willingness Of Graduate Nursing Students To Provide Care For Covid-19 Patients, Andrea Beatrice Josef, Hannah Grace Pascual, Antonette Mei Surigao, Jemina E. Fuentebella, Kathyrine Calong Calong, Gil P. Soriano, Carrisa Juliana Balaria, Ryan Michael F. Oducado
Willingness Of Graduate Nursing Students To Provide Care For Covid-19 Patients, Andrea Beatrice Josef, Hannah Grace Pascual, Antonette Mei Surigao, Jemina E. Fuentebella, Kathyrine Calong Calong, Gil P. Soriano, Carrisa Juliana Balaria, Ryan Michael F. Oducado
Jurnal Keperawatan Indonesia
Nurses play a key role in management and care services to maintain patient safety; however, with the emergence of COVID-19, the number of nurses still continues to decline. Due to the on-going problem that even novice nurses may see as a major challenge, this study aims to identify whether nursing graduates are willing to participate in the care of COVID- 19 patients. The study is cross-sectional where a total of 146 conveniently chosen nursing graduates currently enrolled in Nursing Review Centers in the Philippines preparing to take the Nurse Licensure Examination. The data were collected using Google forms from August …
Full Practice Authority: Policy Review And Recommendation For Regional Nurse Practitioner Practice In The Southeastern Region Of The United States, Tambra Ratledge
Full Practice Authority: Policy Review And Recommendation For Regional Nurse Practitioner Practice In The Southeastern Region Of The United States, Tambra Ratledge
Student Scholarly Projects
This policy analysis examines the limited practice authority for advanced practice registered nurses (APRN) in the Southeastern United States, focusing on Tennessee while drawing comparisons to Georgia and Alabama. The PICO question that guided this policy analysis is: For advanced practice registered nurses within the southeast region of the United States (P), how does the development of a comprehensive policy recommendation for full practice authority (I), compared to existing reduced or restricted practice authority in the southeast region of the United States (C) affect access to care as endorsed by literature (O)? The literature suggests that despite being equipped with …
Reducing The No Show Rates For Mental Health Appointments Among Young Adults, Johnnie Carrico
Reducing The No Show Rates For Mental Health Appointments Among Young Adults, Johnnie Carrico
Student Scholarly Projects
Practice Problem: Missed patient appointments have become an increasingly significant issue for healthcare organizations, private practices, and clinics. No show appointments can negatively impact the operational functions of these organizations including lost revenue. The clinical practice site’s pre-intervention no-show rate for young adult mental health appointments was 21%. The high percentage of missed mental health visits has resulted in both lost revenue for the clinic and disruptions in patient care.
PICOT: The PICOT question that guided this project was: In young adults 18-25 years with mental health appointments (P) how does patient preferred appointment reminders (I) compared to …
Effects Of Chlorhexidine Products On Nosocomial Infections: A Benchmark Study, Sarah Withers
Effects Of Chlorhexidine Products On Nosocomial Infections: A Benchmark Study, Sarah Withers
MSN Capstone Projects
Healthcare associated infections (HAI) are more than a burden as they can result in subsequent complications, prolonged patient stays in the hospital, as well as additional antibiotic treatment. The evidence-based change project will focus on ensuring that patients with any form of a central line who are admitted to the intensive care unit (ICU), receive a bath using chlorhexidine gluconate (CHG) products once daily as well as the use of antimicrobial intravenous (IV) caps.
Untrained Bystanders Administering Drone-Delivered Naloxone: An Exploratory Study, Nicole Adams, Nan Kong, Renran Tian, Christelle Altidor, Shen Chang
Untrained Bystanders Administering Drone-Delivered Naloxone: An Exploratory Study, Nicole Adams, Nan Kong, Renran Tian, Christelle Altidor, Shen Chang
Purdue University Libraries Open Access Publishing Fund
Introduction:
Opioid overdose deaths continue to climb in the United States. Administering naloxone to an overdose victim can save their life, but rapid access to naloxone remains a barrier. Delivering naloxone to a bystander using a drone has potential to increase naloxone availability but there are still many uncertainties about this mode of delivery. Can an untrained bystander to an opioid overdose successfully administer drone delivered naloxone after viewing video instructions on the drone and how long does it take?
Methods:
This mixed-methods observational study, conducted in a controlled outdoor environment, simulated an opioid overdose using a mannequin (overdose victim) …
The Impact Of Boxing Exercise On The Quality Of Life In People Living With Parkinson's Disease, Jen Baker
The Impact Of Boxing Exercise On The Quality Of Life In People Living With Parkinson's Disease, Jen Baker
Master of Science in Nursing Final Projects
This integrative review aimed to explore the effects of boxing exercises on the quality of life (QOL) of people with Parkinson’s Disease (PwP). Boxing exercise programs are popular in the Parkinson’s Disease (PD) community. Decreasing motor symptoms tends to be a primary focus in exercise and PwP. However, non-motor symptoms are a side effect of PD that varies amongst individuals and can impact QOL. Understanding the effects of boxing, especially on non-motor QOL, can support practitioners when prescribing specific exercise modalities for PwP. An integrative review with the search of PUBMED, CINAHL, and MEDLINE was performed, and the methodology of …
Improving Access To Care For Specialty Pediatric Orthopedic Patients: Maximizing Telehealth To Achieve Outcomes, Tammy Keesey
Improving Access To Care For Specialty Pediatric Orthopedic Patients: Maximizing Telehealth To Achieve Outcomes, Tammy Keesey
Student Scholarly Projects
Practice Problem: The lack of resources such as transportation, insurance, and finances can negatively impact a patient’s access to much-needed specialty care. Providing education, assessing telehealth literacy, and creating a specific process for identifying appropriate telehealth visits can improve pediatric specialty access to care.
PICOT: The PICOT question for this project was: In pediatric orthopedic clinic patients (P), what is the impact of the active introduction of telehealth as a clinic visit option (I) versus the current standard passive process of scheduling telehealth visits (C) on the rates of access to care (O) after nine total weeks of …
Promoting Mammography Screenings In African American Women: Media, Church, And Health Providers, Lasonya Little, Debra C. Wallace, K.Jay Poole
Promoting Mammography Screenings In African American Women: Media, Church, And Health Providers, Lasonya Little, Debra C. Wallace, K.Jay Poole
Journal of Health Disparities Research and Practice
Due to the underutilization of screening mammography, African American women (AAW) are more likely to experience negative health outcomes after receiving a late-stage breast cancer diagnosis than White Women (WW). The purpose of this article is to examine the roles of the media, health community and the African American church and pastor and their potential impact in AAW screening decisions. Fifteen AAW, ages 45 and older, were invited to participate in a semi-structured interview. Most women agreed the African American pastor and church as well as the health community, and media are an integral part of their lives. Therefore, specific …
Workplace Violence In Emergency Departments, Education And De-Escalation Training: A Benchmark Study, Summer Block
Workplace Violence In Emergency Departments, Education And De-Escalation Training: A Benchmark Study, Summer Block
MSN Capstone Projects
Most people do not go to work and fear being assaulted or harassed daily. However, for emergency nurses in this county that is exactly what it has come to. Up to 96% of emergency department nurses state they have been verbally abused. This entails name calling, verbal threats, being shouted at and being sworn at. Anywhere from 25% to 60% of these nurses have had to face physical assaults while on the job. (Al-Aadi, 2020; Copeland & Henry, 2017; Grinberg, 2022; Li et al., 2019; McDermid et al., 2019). Physical assaults can include being spit on, slapped, punched, kicked, choked, …
Impact Of A Provider Flagging System On Increasing Ezetimibe Utilization In High-Cardiac Risk Adults, Janessa Creado
Impact Of A Provider Flagging System On Increasing Ezetimibe Utilization In High-Cardiac Risk Adults, Janessa Creado
Student Scholarly Projects
Practice Problem: Cardiovascular disease continues to be the leading cause of mortality globally. Often, healthcare providers fail to follow evidence-based guidelines in their practice.
PICOT: In high cardiac-risk, adult patients with low-density lipoprotein cholesterol (LDL-C) levels greater than 70 milligram/deciliter (mg/dl) despite being on a maximum tolerated dose of statin (P), what was the effect of a provider flagging system to initiate ezetimibe (I) compared to standard care (C) on increasing the utilization of ezetimibe according to the 2018 American Heart Association (AHA) guidelines (O) within 8 weeks (T)?
Evidence: An extensive evidence literature review …
Minimizing No-Show Rate In An Outpatient Wound Care, Kassandra Kern
Minimizing No-Show Rate In An Outpatient Wound Care, Kassandra Kern
MSN Student Capstones
No abstract provided.
Enhancing Athletic Participation: Continuous Glucose Monitoring For Pediatric Type 1 Diabetes Athletes, Danielle Santiago
Enhancing Athletic Participation: Continuous Glucose Monitoring For Pediatric Type 1 Diabetes Athletes, Danielle Santiago
Nursing | Student Research Posters
Background: Type 1 diabetes mellitus (T1DM) is a lifelong autoimmune condition requiring exogenous insulin, daily insulin management, and blood glucose monitoring (Kahanovitz et al., 2018). Diagnosis, often in childhood, brings overwhelming challenges for children and parents. While no cure exists, advances in monitoring and insulin delivery enhance blood sugar control and quality of life (Mayo Clinic, 2023)
Problem Statement: It is suspected that children with T1DM develop a fear of hypoglycemia (FOH) that deters exercise. Cockroft et al. (2023) found that 70% of youth with T1DM do not meet the recommended amount of exercise (Cockcroft et al., 2023). Physical education …
Vaginal Preparation In Cesarean Delivery To Decrease Surgical Site Infections: A Benchmark Study, Angelica Ware
Vaginal Preparation In Cesarean Delivery To Decrease Surgical Site Infections: A Benchmark Study, Angelica Ware
MSN Capstone Projects
This benchmark project intends to decrease the rate of surgical site infections related to cesarean procedures with vaginal preparation through an evidence-based approach. Vaginal preparation is a simple technique that cleanses the vaginal walls by removing microorganisms. The goal of the benchmark project is to promote the implementation of a vaginal preparation policy across any healthcare facility that performs cesarean procedures. Vaginal preparation is intended for scheduled cases, add-on cases, and urgent cases. The benchmark study does not include emergent cesarean deliveries, as vaginal preparation is at the discretion of the physician in those cases.
The topic of surgical site …