Assignment: Workplace Environment Assessment
Clearly, diagnosis is a critical aspect of healthcare. However, the ultimate purpose of a diagnosis is the development and application of a series of treatments or protocols. Isolated recognition of a health issue does little to resolve it.
In this module’s Discussion, you applied the Clark Healthy Workplace Inventory to diagnose potential problems with the civility of your organization. In this Portfolio Assignment, you will continue to analyze the results and apply published research to the development of a proposed treatment for any issues uncovered by the assessment.
The Assignment (3-6 pages total):
Part 1: Work Environment Assessment (1-2 pages)
- Review the Work Environment Assessment Template you completed for this Module’s Discussion.
- Describe the results of the Work Environment Assessment you completed on your workplace.
- Identify two things that surprised you about the results and one idea you believed prior to conducting the Assessment that was confirmed.
- Explain what the results of the Assessment suggest about the health and civility of your workplace.
Part 2: Reviewing the Literature (1-2 pages)
- Briefly describe the theory or concept presented in the article(s) you selected.
- Explain how the theory or concept presented in the article(s) relates to the results of your Work Environment Assessment.
- Explain how your organization could apply the theory highlighted in your selected article(s) to improve organizational health and/or create stronger work teams. Be specific and provide examples.
Part 3: Evidence-Based Strategies to Create High-Performance Interprofessional Teams (1–2 pages)
- Recommend at least two strategies, supported in the literature, that can be implemented to address any shortcomings revealed in your Work Environment Assessment.
- Recommend at least two strategies that can be implemented to bolster successful practices revealed in your Work Environment Assessment.
Assignment: Workplace Environment Assessment Clearly, diagnosis is a critical aspect of healthcare. However, the ultimate purpose of a diagnosis is the development and application of a series of treat
Work Environment Assessment Template Work Environment Assessment Template Summary of Results – Clark Healthy Workplace Inventory After filling out the inventory, I received a score of 45, and my conclusions were that my current workplace is not healthy. The obtained results confirmed that I viewed my workplace as uncivil and unhealthy. The tool was great, especially in making me aware of my workplace and understanding potential areas that required positive changes. The core reasons why a poor score was observed were poor communication, especially between the leaders and nurses, and poor conflict resolutions that escalated into workplace divisions. Additionally, the nurses often distrust the leaders since there are no active listening platforms; the leaders usually claim to be very busy; thus, most requests are unresolved. Due to a drastic change in my organization, we are experiencing a nursing deficit which has increased incivility. Identify two things that surprised you about the results. Also, identify one idea you believed before conducting the Assessment that was confirmed. The first thing I learned was before completing the inventory; I used to consider my organization to be average healthy; however, after completion, I realized that it is unhealthy. It is not a good organization, and many changes must be implemented. The second thing is most of my answers were either wholly untrue or somewhat untrue, which clearly shows that we lack essential aspects like communication, especially between nurses to nurses or leadership to nurses. Hoffman & Chunta (2015). What do the results of the Assessment suggest about the health and civility of your workplace? From the inventory, the results (45) show that our organization is both unhealthy and uncivil. The score was low on essential elements like employee satisfaction with the leadership, communication and limpidity. Therefore the suggestions are we require drastic measures to improve and deliver more quality service to our clients. The observed elements are embedded within the organizational culture, which has been negative even before I began working here. Apart from poor communication, negative criticisms or sarcastic comments about coworkers and clients relate to incivility. These negative cultures have often affected our productivity leading to the organization’s failure. Briefly describe the theory or concept presented in the article(s) you selected. Explain how the theory or concept presented in the article(s) relates to the results of your Work Environment Assessment. For this paper, I selected an article by Clark (2015) that introduces numerous measures geared toward promoting a healthy workplace that considers the employees’ personal and professional views. Therefore the workplace improvement inventory is significant in identifying potential areas to improve along with enhancing elements in the organizations that may be ignored if effective measures are not implemented. To address workplace incivility, the author introduced the ‘DESC model’ that is interested in promoting communication. The DESC model would be significant within my organization to promote a positive relationship between the employees, clients and leaders. The DESC model is more interested in understanding potential gaps and failures in the workplace and developing measures to make gradual improvements. It also proposes relevant measures that seek to discipline leaders and workers that do not abide by the improvement policies. The model also ensures there is continuous evaluation of the new policies implemented in organizations to understand the effective and less effective ones. Clark (2015) Explain how your organization could apply the theory highlighted in your selected article(s) to improve organizational health and/or create stronger work teams. Be specific and provide examples. There are numerous ways that our organization would apply the DESC model presented; firstly is understanding the current communication needs. Within our organization, we understand that the management does not listen to employees’ demands; employees crack jokes and criticize each other, which is related to incivility. Therefore before these problems escalate into physical fights and more employees leave the organization, there is a need to evaluate this problem deeply. The DESC model will help the management develop robust measures to ensure everyone abides by the regulations. Additionally, new nurses need to be improved since there is a work overload and burnout due to an underpopulated workforce. The DESC model also advocates for higher interaction between leaders and followers; that is why increased training and conferences will improve the levels of incivility at the workplace. These meetings will promote trust and transparency within the team, which will increase the chances of success. The final method is the management should ensure employees are involved when making new organizational decisions to give their views and make an agreement to prevent bias. Crawford et al. (2019). General Notes/Comments In conclusion, I now feel that our workplace is unhealthy and incivility; it is the role of management to promote communication, collaboration and trust between the working units. The best methods to address workplace incivility include increased nurse training between leadership and nursing management and improved staffing and communication. Additionally, the inventory is a great tool that the nurse leaders could use to understand areas that require improvement and develop compulsory measures for everyone to improve gaps and weaknesses. References Clark, C. M. (2015). Conversations to inspire and promote a more civil workplace. American Nurse Today, 10(11), 18-23. https://www.researchgate.net/profile/Cynthia-Clark-3/publication/302941121_Conversations_to_inspire_and_promote_a_more_civil_workplace_Let’s_end_the_silence_that_surrounds_incivility/links/580b928008ae2cb3a5da6c5e/Conversations-to-inspire-and-promote-a-more-civil-workplace-Lets-end-the-silence-that-surrounds-incivility.pdf Crawford, C. L., Chu, F., Judson, L. H., Cuenca, E., Jadalla, A. A., Tze-Polo, L., … & Garvida Jr, R. (2019). An integrative review of nurse-to-nurse incivility, hostility, and workplace violence: a GPS for nurse leaders. Nursing administration quarterly, 43(2), 138-156. https://journals.lww.com/naqjournal/fulltext/2019/04000/an_integrative_review_of_nurse_to_nurse.7.aspx Hoffman, R. L., & Chunta, K. (2015). Workplace incivility: Promoting zero tolerance in nursing. Journal of radiology nursing, 34(4), 222-227. https://www.sciencedirect.com/science/article/pii/S1546084315001698 © 2018 Laureate Education Inc. 5
Assignment: Workplace Environment Assessment Clearly, diagnosis is a critical aspect of healthcare. However, the ultimate purpose of a diagnosis is the development and application of a series of treat
Combining Cognitive Rehearsal, Simulation, and Evidence-Based Scripting to Address Incivility Cynthia M. Clark, PhD, RN, ANEF, FAAN ABSTRACT Background:Nurses have a professional and ethical obligation to foster civility and healthy work environments to protect patient safety. Evidence-based teaching strategies are neededto prepare nursing students to address acts of incivility that threaten patient safety. Problem:Incivility in health care must be effectively addressed because the delivery of safe patient care may depend on these vital skills. Approach:Cognitive rehearsal (CR) is an evidence-based technique where learners practice addressing workplace incivility in a nonthreatening environment with a skilled facilitator. The author describes the unique combination of CR, simulation, evidence-based scripting, deliberate practice, and debriefing to prepare nursing students to address uncivil encounters. Outcomes:Learners who participated in CR identified benefits using this approach. Conclusions:Combining CR with simulation, evidence-based scripting, repeated dosing through deliberate practice, and skillful debriefing is an effective method to provide nursing students with the skills needed to address incivility, thereby increasing the likelihood of protecting patient safety. Keywords:civility, cognitive rehearsal, debriefing, deliberate practice, incivility, simulation Cite this article as: Clark CM. Combining cognitive rehearsal, simulation, and evidence-based scripting to address incivility.Nurse Educ. 2019;44(2):64–68. doi: 10.1097/NNE.0000000000000563 I ncivility in health care settings can have a detrimental impact on individuals, teams, and organizations. In the patient care environment, uncivil encounters can provoke uncertainty and self-doubt, weaken self-confidence, and compromise critical thinking and clinical judgment skills. If poorly managed, incivility can lead to life-threatening mistakes, preventable complications, harm, or death of a patient. 1-6 Therefore, innovative and evidence-b as ed t ea ch ing strategies are needed to prepare nursing students to foster healthy work environments and address acts of incivility that threaten teamwork and patient safety. The American Nurses Association (ANA)Code of Ethics for Nurses 7clearly emphasizes nurses’ moral and ethical obligation to ensure patient safety by fostering healthy work environments and cultures of civility. Cognitive rehearsal (CR) is an evidence-based technique whereby individualsworkwithacoachorfacilitatortopractice addressing stressful situations in a nonthreatening environ- ment. 8,9 Being well prepared, speaking with confidence, and using respectful expressions to address incivility can empower nursing students and nurses to speak up and ad- dress uncivil behaviors. Using evidence-based approachesto structure responses using a deliberate practice model provides an effective communication tool to protect patient safety and enhance teamwork within health care organiza- tions. The author describes how the combination of CR, simulation, evidence-based scripting, deliberate practice, and debriefing can be used to address workplace incivility. Cognitive Rehearsal Cognitive rehearsal is a technique used in behavioral science whereby individuals work with a skilled facilitator to dis- cuss and rehearse effective ways to address a particular problem or social situation. 8It is designed to decrease anx- iety, heighten confidence, and improve impulse control by practicing effective ways to address potentially stressful sit- uations. 9The use of CR has been reported to be an effective strategy to address incivility in practice and educational set- tings. 8,10-14 Using a planned, rehearsed response helps to create an opportunity to communicate expectations for ap- propriate behaviors and future interactions. 15 Put simply, CR is a behavioral strategy used to prepare an individual for a potentially stressful situation by repeatedly rehearsing the situation to strengthen the probability of a favorable outcome. Using CR as a strategy to prepare for what might be considered a stressful encounter includes preparing for the encounter by rehearsing specific phrases that might be used during the meeting, being coached by someone skilled at effective communication, and rehearsing the encounter using deliberate practice, followed by a debriefing session. This series of activities is likely to lead to a more successful Author Affiliation:Strategic Nursing Advisor, ATI Nursing Education, Boise, Idaho. The author declares no conflicts of interest. Correspondence:Dr Clark, 279 E Danskin Dr, Boise, ID 83716 (cindy. [email protected]). Accepted for publication: April 21, 2018 Published ahead of print: July 13, 2018 DOI: 10.1097/NNE.0000000000000563 Nurse Educator 64 Nurse EducatorVo l . 4 4No. 2, pp. 64–68 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. www.nurseeducatoronline.com outcome because the individual has thoughtfully prepared for the encounter. Although the use of CR can take various forms, the author describes the technique as consisting of 5 essential elements including (1) prebriefing and preparatory learn- ing, (2) identifying and describing uncivil scenarios for simulation, (3) using evidence-based approaches to role- play and rehearse responses, (4) using deliberate practice to repeat the simulated scenarios, and (5) debriefing sim- ulated scenarios of uncivil encounters. Prebriefing and Preparatory Learning Prebriefing and preparatory learning include readings fo- cused on the relationship between incivility, staying silent when uncivil encounters occur, and the subsequent po- tential impact on patient safety. Examples include a series of articles highlighting how staying silent and failing to advocate for patient safety can lead to errors and poor patient outcomes. 4-6 These studies also describe how education, role- play, practice, and“scripting”can improve communica- tion and conflict negotiation skills, which leads to improved patient outcomes. Another preparatory reading includes the ANA posi- tion paper on incivility, bullying, and workplace violence, 11 which articulates individual and shared roles and respon- sibilities of nurses and employers to create and sustain a culture of respect across the health care continuum. Accord- ing to the ANA, 11all nurses in all settings are responsible for creating a culture of respect and implementing evidence- based best practices to prevent and mitigate incivility and bullying and to foster a healthy and safe work environment for all members of the health care team, health care con- sumers, families, and communities. Other suggestions for preparatory readings include select articles from nursing practice and academe such as the ANACode of Ethics for Nurses 7and excerpts from Clark, 16 or students may conduct a review of the relevant literature to identify and summarize scholarly works on civility and incivility in nursing and health care. Identifying and Describing Uncivil Scenarios for Simulation After completing preparatory readings, faculty may engage students in a deepened understanding of the topical mate- rial by using active learning strategies such as narrative pedagogy, storytelling, learning circle discussions, 17-19 and small and large group activities. These teaching strategies may also be used to introduce students to CR and how the technique may be used to address uncivil encounters in the practice setting, especially those that compromise patient care. Common examples of uncivil behaviors that may occur in a health care environment include refusing to help a colleague in need, withholding important infor- mation during a patient handoff, or engaging in gossip and spreading rumors. 8,12,16 Uncivil scenarios for student role-playing may be written by faculty, obtained from ex- perts on the topic of incivility and bullying, 20,21 ordeveloped by students who identify real or potential un- civil encounters that may occur in health care settings. Using Evidence-Based Approaches to Role-Play and Script Responses Once students establish asolid foundation and work- ing knowledge about civility and incivility in nursing education and practice, faculty can introduce students to evidence-based approaches such as“I”messaging 22 and the Caring Feedback Model 23 and to script responses to address uncivil encounters. Because no 1-size-fits-all approach exists for every individual and because each individual has a unique way of expressing themselves, evidence-based approaches offer a structured procedure and a common language for scripting personalized re- sponses rather than being rigidly“scripted.”In other words, students use the approaches to develop scripts crafted in their own words. One evidence-based approach for effective commu- nication is the use of“I”messaging. 22 Helping students learn and practice using“I”messages to address incivil- ity is a beneficial learning activity. Using“I”messages does not guarantee that a conflict will be successfully resolved; however,“I”messages provide a means to ad- dress conflict in a constructive manner and to preserve relationships rather than making them worse. If possible, “You”messages should be avoided because they may sound critical or accusatory and often trigger defensive- ness, retreat, or confrontation. Examples of“I”messages include“I believe you are saying”or“I understand your position to be”when seeking clarification of the encoun- ter. If addressed in an uncivil manner, one might reply,“I provide the best patient care when I’m treated with re- spect.”Responding with an assertive“Ibegyourpar- don?”i n r e sponse to a demeaning or condescending remark can prompt the offender to step back, think about his/her comment, and perhaps reconsider his/her approach. It is also important to describe objective, observable behaviors, as well as the real or potential impact of the behavior, rather than to focus on the individual and personalize the event. Nursing students need ongoing, realistic opportunities to hone communication skills to function effectively as con- fident, assertive team members; however, reinforcing the importance of communication requires more than discussion. It requires simulating, demonstrating, practicing, and re- hearsing these fundamental skills over and over again. 16 Simulations can be used to create uncivil, high-anxiety situ- ations that give students a safe place to make mistakes, practice addressing uncivil encounters, and observe first- hand how a gesture or word choice can influence the out- come of the situation. 16 Participating in simulated scenarios allows students to sharpen their communica- tion skills by listening for understanding, attending to both verbal and nonverbal cues, interpreting interactions, and reflecting on their view of the uncivil encounter. The next section describes how the evidence-based approach Nurse EducatorVo l . 4 4No. 2.www.nurseeducatoronline.com 65 of“I”messaging and other evidence-based approaches may be used to develop scripts to address uncivil situations. Exemplars of Uncivil Encounters in Academic and Practice Environments Several examples of uncivil scenarios with corresponding responses using evidence-based approaches are presented in Tables 1 to 5. A scenario depicting an uncivil situation among nursing students assigned to collaborate on a group project is presented in Table 1, along with a response using an“I”message approach to address the issue. After gaining experience using an“I”messaging ap- proach, students are introduced to other evidence-based approaches. The next scenario and corresponding script uses the Caring Feedback Model 23 as an evidence-based approach to address an uncivil nurse-to-nurse encounter (Table 2). The Caring Feedback Model includes the fol- lowing steps: (1) state your positive intent/purpose; (2) de- scribe the specific behavior you noticed or heard about; (3) explain the consequence for you, your team, the patients, or the organization; (4) offer“apinch”of empathy; and (5) make a suggestion or request. The next scenario is based on the approach suggested by Caspersen, 24which includes the following elements:“When (the triggering event)happened, I felt/believed(feeling/ belief )because my(need/interest)is important to me. Would you be willing to(request a doable)action?”Table 3 illus- trates Caspersen’s approach when responding to an un- civil encounter occurring among coworkers. The next evidence-based approach was developed by the Agency for Healthcare Research and Quality (AHRQ) 25 as part of the TeamSTEPPS approach designedto equip health care workers with the essential skills needed to address uncivil encounters when they happen, thus increasing the likelihood of success in stopping the behavior and protecting patient safety. The next scenario uses the DESC approach—an acronym for (D) describe the situation, (E) express your concerns, (S) suggest other alternatives, and (C) consequences stated (Table 4)—to illustrate an uncivil encounter between a staff nurse and the nurse manager. The next evidence-based approach was also developed by AHRQ 25as part of the TeamSTEPPS approach. CUS is an acronym for Concerned, Uncomfortable, and Safety— an approach designed to script a response to use during an uncivil or conflicted situation, particularly when patient safety is in jeopardy. The scenarios depicted in Table 5 illus- trate 2 different uncivil experiences occurring in the patient care environment and corresponding responses using the CUS approach. These evidence-based approaches provide a helpful structure to script responses to address uncivil en- counters and to ultimately improve patient safety in health care organizations. Using Deliberate Practice to Repeat the Simulated Scenarios Deliberate repetitive practice (DRP) is a process for learning and mastering psychomotor skills by progressing through 3 primary phases: (1) understanding the skill and learning how to perform it accurately, (2) refining the skill until it be- comes more consistent, and (3) practicing the skill until it is automatic and the learner does not need to consciously think about each step. 26 Oermann 27 further noted that, to master skills, students need opportunities to practice them Table 1. Scenario: The Case of Conflicted Classmates Scenario Response Using an“I”Message Approach Alex is a member of a class project where the final grade is based on each student’s ability to contribute equitably to the project’s completion. The stakes are high because individual grades are based on the overall performance of the group and how the group performs as a team. One of the members (Abby) is frequently late for meetings, fails to complete her share of the work, and sends text message to friends when she seems bored with the group work. The deadline is approaching, and several members of the group are concerned that the project will not be completed on time or be of good quality. On behalf of the group, Alex decides to discuss their concerns with Abby.“Abby, I appreciate the opportunity to meet with you to discuss our class project. The project is nearly due, and I’m concerned about the outcome. When the project started, we all agreed to complete our individual parts on time and in a quality way. If you need help completing your part, we need to know so we can problem-solve as a team. I welcome your ideas about ways to meet the deadline and still produce a quality project.” Table 2. Scenario: The Case of the Impatient Nurse Scenario Response Using the Caring Feedback Model Connie is an experienced nurse who has made it abundantly clear that she has little or no patience when it comes to dealing with new or less experienced nurses. Kim is a newly graduated nurse and reaches out to Connie asking for her help with a complex patient situation. Connie responds rudely stating,“Idon’thavetimetodealwithnovices.I’vegot more important things to do.”“Connie, I respect your experience and hope to learn from you. Earlier today, when I asked for help, it didn’t seem to go well. Without your support, I’m concerned that patient care might suffer. I realize you’re busy and have a lot going on. Still, I need to ask some important questions. When can wemeet to discuss them?” 66 Nurse EducatorVo l . 4 4No. 2.www.nurseeducatoronline.com repetitively and to receive ongoing feedback to guide their performance. Without DRP, many skills may decay or be lost altogether. Like psychomotor skill-building, this same process may be applied to addressing uncivil encounters. Learning these new skills takes training, experience, prac- tice, and feedback. Students require more than 1 practice session to become proficient using CR to address incivility. Repeated opportunities to practice these strategies over an extended period are critical so that, if and when uncivil en- counters occur, nurses are more apt to use a practiced and patterned response. Debriefing Simulated Scenarios of Uncivil Encounters Rehearsal of the simulated scenarios and scripted re- sponses should be followed by a comprehensive coachingand debriefing session. Successful debriefing requires creating safe spaces for reflection and exploring effective ways to address future situations. According to AHRQ, 28 debriefing is an important learning strategy to help indi- viduals identify aspects of individual and team perfor- mance that went well and those that did not. Through debriefing, students learn fromdeficiencies to improve their performance. The goal of debriefing is to discuss the actions and thought processes involvedin a particular situation, en- courage reflection on those actions and thought processes, and incorporate improvementinto future performance. 26 Simulation debriefing has also been described as a structured and guided reflection process in which students actively appraise their cognitive, affective, and psychomotor performance, giving them an opportunity to assume an ac- tive role during the learning process. 29 Table 3. Scenario: The Case of the Gossiping Coworkers Scenario Response Using the Caspersen Approach You are a nurse working on the telemetry unit. Some of your coworkers engage in negative gossip and spreading rumors. You believe you have been the target of these behaviors, and one day when you approach the break room, you hear your name mentioned in a derogatory and negative way. As you enter, the voices fall silent. This is not the first time this has happened, so you decide to address the situation.“When I approached the break room, I heard my name mentioned. It concerns me because being accepted as a valued member of the team is important to me. In the future, please speak with me directly if you have something to say.” Table 4. Scenario: The Case of the Frustrated Manager Scenario Response Using the DESC Approach Hey Kathy, Nicole called in sick. We’re shorthanded, so you need to stay and cover her shift. You may not like the decision, but we all need to suck it up and deal with it.“Alice, I appreciate the need to cover the unit. However, I’d like to discuss other options since I’m unable to work an additional shift. I’m exhausted, and because I’ve recently covered other shifts, I’m not rested enough to provide safe patient care. Can we discuss other ways to cover the shift?” Table 5. Scenarios and Responses Using the CUS Approach Scenarios Response Using the CUS Approach The case of the uncivil nurse preceptor Chris is a senior level nursing student assigned to Mr Brown, a patient recently diagnosed with diabetes. Although Mr Brown has orders for the laboratory to draw a glucose level, he is not included on the list of patients to have a glucose level drawn. Chris notices the omission and brings it to the attention of his clinical preceptor. She’s clearly annoyed, rolls her eyes, and reprimands him in front of other nurses stating that he is out of line for questioning her. Despite his discomfort, Chris decides to advocate for Mr Brown using the CUS approach.“Nurse Adams, Mr Brown has been diagnosed with diabetes, and I’m Concerned that he isn’t on the list for glucose testing. I’mUncomfortable administering insulin until his lab results are back to be sure he’s receiving aSafe dose.” The case of the hurried handoff “Geez, Katy, where have you been? You’re late as usual. It’s been a really busy shift, and I can’t wait to get out of here. See if you can manage to get this information straight for once. You should know the patient in 402 since you took care of her yesterday. She has a bunch of treatments and medications that need to be done. You need to check her vital signs too—I’ve been way too busy to do them. I’m outta here. If I forgot something, check the chart.”“Terry, I realize being late is not OK, and we can talk about that later. For now, I’mConcerned about Mrs. Jones andUncomfortable rushing through report. For herSafety, please provide a complete report before you go.” Nurse EducatorVo l . 4 4No. 2.www.nurseeducatoronline.com 67 Examples of debriefing questions for uncivil encoun- ters include the following 14: Ask each student participant: What was it like to be part of this experience? Ask observers: What was it like to observe the experience? Ask student participants and observers: How would you describe the experience? What went well, and what would you do again? What did you learn? How might you apply what you have learned in your clinical practice? What might be done differently next time? Learners participating in the CR experience identified sev- eral benefits of this approach including learning to speak up in stressful situations, communicating more effectively, and advocating for safe patient care. Conclusion In health care, the need to effectively address uncivil situa- tions is critical because the delivery of safe patient care depends on these vital skills. Nurses and nursing students must be well equipped to effectively address incivility in a variety of situations to promote teamwork and collab- oration and to protect patient safety. Combining CR with evidence-based scripting within a deliberate practice model and with skilled debriefing is an effective method to provide nurses and nursing students with the essential skills needed to effectively address uncivil encounters when they happen, thereby increasing the likelihood of success in stopping the behavior and protecting patient safety. Role-playing actual scenarios provides nursing students with real-life experi- ences to effectively address incivility. Debriefing sessions help to create safe spaces for reflective practice and explor- ing effective ways to address future situations. Acknowledgment The author acknowledges Dr Suzan Kardong-Edgren for her review. References1. Rosenstein AH, Naylor B. 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