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cjcsoon2bnp

cjcsoon2bnp

ED NP and Clinical Instructor
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  1. I am new to prescribing as an NP and I can't tell you how helpful all of the local pharmacists have been when I have had to call in scripts. I work in an ED and we have to call in antibiotic prescriptions for positive culture results if someone didn't get a script upon discharge from the ED. Not to mention they are wicked helpful when it comes to answering all sorts of random, crazy questions from us newbies. !Chris
  2. cjcsoon2bnp

    When to delegate to CNAs?

    I seriously hope that this is a joke. When I was an ER nurse I had no problem delegating tasks to CNAs and I certainly wasn't a pushover but I also learned that asking for help and showing a little humility from the get-go made a lot fewer conflicts and very seldom did I have to tell a CNA to stop goofing off to help me. The same could not be said for some of my RN coworkers who "delegated" everything possible to the CNAs but couldn't be bothered to help another nurse out when a critical situation came up. Delegation needs to be used for delivering the best care and using the team in its most efficient capacity. Another user said it best, delegation shouldn't be done only out of convenience. Example, the other day I was in the ED doing my re-assessment of a patient (I was the NP caring for the patient) and I knew I needed a temp. recheck before discharging the patient. I saw a thermometer sitting right outside of the room and it only made sense for me to grab it and take the temp. I walked by the patient's nurse and asked if they didn't mind entering the temp. into the EMR flowsheet for me (because only CNAs and RNs can do that) and the nurse was appreciative that I had done the temp. recheck. By your logic I should have walked past the thermometer, found the nurse and delegated him/her to recheck the patients temp. and then notify me of what it was. Would that be appropriate delegation? Technically, sure it is. Is that within their scope of practice as the RN? Absolutely. Isn't it easier for me as the provider to delegate this task and then go about my business? Probably, but sometimes it's about being a good team player and showing that everyone can help out with no task being beneath anyone. Do I run around doing this sort of thing all the time? Obviously no because it's not efficient. But when I do, people remember it and try to go the extra mile to help me in return. Just a thought... !Chris
  3. cjcsoon2bnp

    Multiple CNA's refusing assigned task

    I don't work in LTC but I have a deep respect for those who possess the skills and disposition suited for that setting because I do not. My experience in LTC is limited to what I saw in nursing school and briefly as a CNA before I worked in a hospital setting. I think that what your talking about is appropriate delegation and good time management and that is exactly what we should be doing. I want to be clear that I have no issue with nurses delegating tasks to CNAs and working as a part of the team. The issue I have is there are certain nurses who NEVER have time to help clean/toilet their patients or get their own vital signs and always need to have the aide do it for them. I know nurses who flat out say "I didn't go to school to spend my life wiping *** all day". When I was a staff nurse and I saw this happen I would see that these nurses tried to justify this by saying how far behind they were with charting or doing XYZ task but then they would go back to doing something not related to work (surfing the web, using cell phone, chatting at the desk) while other people were running around busy. I'm a big fan of the "if it's too busy for one person to sit, then no one should sit" rule. Obviously some nursing tasks like charting, taking orders, and making appointments require sitting but many times the "I'm so behind on charting" excuse is used and it's a cop out. The point about this post is knowing what your job is and being a good team member. If you put yourself out there and go the extra mile to be a good team member then it's easier to get other people to do the same for you, even if it means you have to remind them sometimes. For me when the OP said she had to involve the manager for this matter it shoots up a red flag that this is part of a bigger issue. The CNA(s) involves need to be spoke to about their role, professionalism and job responsibilities. As the nurse manager I would speak to the nurse to determine why she felt this needed management level interventions. It seems like it was escalated quickly and makes me wonder how she interacts with the CNAs on a regular basis if they are refusing to help her. !Chris
  4. cjcsoon2bnp

    Multiple CNA's refusing assigned task

    I think that CNAs/techs have a role in the delivery of healthcare as do nurses (RNs/LPNs), advanced practice providers (MD/DO/NP/PA) and all of the other disciplines (pharmacy, social work, case management, psychology, physical therapy, occupational therapy etc.) and sometimes we have roles that will overlap between the disciplines. I will respectfully disagree that the problem with nursing is that we have an overlap in duties and I am glad that ADLs are not the exclusive responsiblities of CNAs. When I see nurses in the ED running up and down the hall calling for a CNA to help toilet a patient or attend to some other ADL because they are "too busy" or have "too many other tasks to do" I find it frustrating. That is not to say that as an RN I didn't ask CNAs for assistance or delegate tasks to them but I believe that as the RN it was part of my role to oversee that the ADL related tasks where completed (either by the CNA, myself or together as a team) and some of that is related to time management. If I as an NP can stop what I'm doing to help to boost a patient in the bed or walk them to the bathroom then I think it shouldn't be beneath the LPN/RN to do the same. Before I get a ton of frustrated/angry responses please hear me out... 1. I know that the majority of nurses don't believe that they are above doing these tasks but we all can think of a few people who fit the bill. 2. I also know that there are CNAs/techs out there who either don't enjoy their jobs, don't have the best work ethic or would rather rather do tasks that are in the scope of the nurse. However, I don't think that the majority of CNAs/techs are like that (at least that has been my personal experience). 3. I have been an RN for 7 years now and I found that when I took a few extra minutes to help my patients with these tasks myself and recruit the CNAs to work with me to get the tasks done (versus putting them all on the CNA) then it resulted in a better working relationship and better patient care. I also noted that the more I offered to help the CNAs/techs with the ADL-type tasks in the delivery of care to our patients then the less I would actually have to do it. On more than one occasion, I would go to get the supplies to put my patient on a bedpan only to see that one of the CNAs/techs ran into the room to do it for me just because I didn't always hunt them down and ask them to do that kind of stuff. 4. Over the years I have oriented new nurses and noticed that some nurses really connect well with support staff and integrate as part of a team while others really struggle to develop this skill. There are multiple factors that impact this but sometimes a bit of humility and a few well-timed gestures can really make a huge difference. !Chris
  5. cjcsoon2bnp

    Length of Orientation for New NP

    Hello everyone, I'm looking to get some feedback from NPs who work in acute care settings (ED, Urgent Care, Hospitalist, ICU etc.) regarding the length of orientation that their faculty/practice group provides for brand new/new graduate NPs. I realize that their are some post-graduate residencies for NPs that are 12 months in duration and include both clinical and didatic components but the majority of new providers are not trained in that method yet. I am working with my employer to strengthen our existing training program for new advanced practice providers (NP/PA) in our emergency department and it would be helpful to see what other programs are doing. In addition to reaching out to other hospitals in the area, I am hoping to get some feedback from the AllNurses community. What I am looking to know specifically is the following: 1. What Department/Care Area do you work in? 2. What is the average length of orientation for a newly graduated NP/PA provider? Is there a minimum amount of time (shifts/hours)? Or is there a set amount of time for everyone? 3. How is it structured? What portion of time is one-on-one with a dedicated preceptor? When does the new provider come off of orientation and become formally "on the schedule" or as "a part of the complement"? 4. Do new providers have to report off any/some/all of their cases to the preceptor or attending physician? If so, for how long? Thank you again, !Chris
  6. With all due respect, your response comes across as dismissive and is exactly the reason why I wrote this article in the first place !Chris
  7. cjcsoon2bnp

    Fairness

    Back when I was a nurse manager my unit had self-scheduling and while I loved the idea of staff being able to have real influence over own schedules I found that for every schedule period I would often have to "fix" the schedule so that the unit would be appropriately staffed/balanced on all days. Many times what happens with self-scheduling is that each person will fill out a schedule that meets their personal needs (and that is completely understandable) but they usually don't look at the other staff members working the same shift and make adjustments to meet the units needs. With self-scheduling I found that many people assumed that just because they wrote their schedule the way that they wanted it then I as the nurse manager was obligated to keep it no matter what. I would tell my staff that they were all adults who were capable of talking with each other and creating a schedule that works for the majority of people and I would not change it as long as the unit was appropriately staffed every day for every shift (granted that we didn't have vacations or leave of absences). With that being said, every single month I would have a few days where the schedule wasn't balanced (2 nurses on Monday, 5 nurses on Tuesday, 0 nurses on Wednesday etc.) and every single person would say "But I have XYZ commitment and I can't work this day!". I would then be forced to adjust schedules to ensure that the unit was safely staffed and I did my best to make sure I did it in a way that was fair to everyone and I would encourage staff to make switches among themselves if they could strike a deal that was mutually beneficial and did not result in OT. I went back to being a staff nurse for many reasons (management was an exhausting, mind-numbing and thankless job) and where I work now does not do self-scheduling. You can make a request and they will do their best to honor it but it is very clear that the first priority is to safely staff the unit. !Chris
  8. cjcsoon2bnp

    Many nurses do not chart?

    I haven't been a Med/Surg nurse in a while because I'm in the ED now and the charting requirements are completely different but my previous nurse manager regarded me as a pretty thorough in the documentation department and I didn't have to stay late in a shift to document very often. Here is what I used to chart on my patients during a given shift: Initial Physical Assessment (Head-to-Toe) - Done at the beginning of the shift and completed using the template provided so if something was WNL (meeting each of the form criteria) then I would check that box and I would elaborate more on the systems that were directly affected by patient's problem (e.g. COPD Exacerbation - Cardio, Resp., Appendectomy - GI, Wound etc.). I don't repeat a physical assessment unless something changes during my shift. In this template we had sections for Fall Risk, VTE/DVT Prophylaxis, Braden Scale etc. Progress Note - Our hospital's policy was that if you worked an 8 hour shift then you only needed one physical assessment note for your patient but if you worked 12 hours then they needed some form of progress note or reassessment after 8 hours. I made a generic note that briefly described that the patient's condition that I was continuing care of the patient and the patient's physical assessment remained was unchanged from my previous note unless otherwise noted. If at any point the patient had a physical change (e.g. New onset of chest pain or abdominal pain with vomiting) then I would open up the physical assessment template for that specific system (cardio-respiratory, GI etc.) and check the findings along with write a comment of the interventions. If it was a complicated situation or had a lot of interventions I would write a progress note instead and put the physical assessment findings in that instead. I would only write a progress note if it was indicated, if I worked 8 hours and the shift was unremarkable then I wouldn't write it. Medications/EMAR - I would chart in our EMAR by scanning the meds. I don't re-write them elsewhere, if I need to say a patient refused or something special then I can add it as a comment in the EMAR for the medication in question. Care Plan - Our facility required us to write on the patient's care plan each shift. I found many nurses didn't do this because they found it to be redundant and a waste of time (I personally did not find it very "value add" documentation myself but I just wanted to follow the rules). I tended to be brief in the care plan and use the template provided to make it faster. Physician Communication or Critical Lab Value - There was a section in the chart for each of these and it was pretty I&O - If I emptied a urinal or admin. IVF then I would add what I needed to at the end of my shift based on a list I made. This was a shared task with the CNA so sometimes it was just me verifying/double checking that it had been completed. V/S - Similar to I&O this was a shared task with the CNA, I would write them if I took them myself but if I didn't then I would simply review it to make sure nothing was abnormal or need to be rechecked. That was my list of required documentation, I did not write a generic progress note that summed up the entire shift because I found it repetitive of the other documentation and it was not mandatory on our unit. When I was writing on the patient's care plan I would tend to include a few brief statements that could be described as a form of shift summary and gave a similar feel to the traditional end of shift progress note. I realize that physicians, case management and everyone else on the team enjoyed having the narrative progress notes that summarized the entire shift because it was easier to find the information (and I honestly liked reading them as well). However, with all of the additional requirements in documentation added to nurses over the years I don't have the time to do something if it is (a) not required per my hospital's policy and (b) if I have already included the same data elsewhere in the medical record (even if it requires a few more steps to find each piece). If our manager had reinstated the end of the shift progress notes or I hadn't chart something elsewhere in the record then I would happy to create a generic progress note. Lastly, here were a few other tips I found helpful. Using the WNL feature of the physical assessment form/template - I say this with caution because you need to make sure your template/form/checklist has a clear definition what WNL is for each category and you need to read through it carefully before you check it. Don't be the nurse that checks WNL under the peripheral vascular or musculoskeletal sections for a patient who is a bilateral below the knee amputee, you will look incompetent, lazy or inattentive. If you don't have a template/form within the chart that clearly defines WNL for something I would suggest you use that phrase carefully because you may need to be able to define the parameters of "normal" in your charting if you were ever to be audited.. Don't repeat the same thing 100X - I see a lot of nurses re-writing the V/S or meds. given in 100 different places on the chart and I don't understand why. If you are writing a progress/event note for a situation that required repeat V/S and med. administration you can write [see Vital Sign Flowsheet] [see EMAR] and that is appropriate. Give yourself time - This means give yourself time to learn what data is the most relevant and to refine your note taking ability. This also means to try to coordinate your shifts to give yourself plenty of time to write if you're someone who takes a long time to write. I agree with the other user who said many times the people staying late are the nurses who either write too much, talk too much, or struggle to plan out their time in the most efficient manner. I hope this helps! !Chris
  9. cjcsoon2bnp

    Accusing Hospice

    This is a great story, your message and choice of language created a really solid picture, at least in my mind. I agree with the user who suggested that it must be the family who brings up religion in these situations and I can appreciate that you were able to help them work through this with the use of their religion and beliefs (whether you shared those beliefs or not). I have worked with families of dying patients and when religion comes up I do my best to help support them using their belief symptom even if it is not one that I share. !Chris
  10. cjcsoon2bnp

    Nurse-client Relationship Boundaries

    I'm a clinical nursing instructor and I would tell my student that this is a matter of professional boundaries. I agree that it was a mistake and a momentary lapse in judgement but I understand how a student could have done it with the very beat of intentions. I know that if this was my student I would have a honest but supportive conversation with them so that they understood the error and would not make a similar decision in the future but I would not crucify them for this type of mistake (especially if it was a one time issue versus a pattern of behavior with poor decision-making/professional boundaries). As a student if this kind of situation ever came up again I would use the fact that you are a student to "break it gently" to the patient and just say that you would "get in a lot of trouble if you gave out any personal info or contacted a patient outside of the facility/hospital". If you ever are not sure about this kind of thing then you should also follow up with your instructor before acting so that they can help you. I also agree with the other users that that at this time I would NOT tell anyone at your school about this because you may be subject to some sort of disaplinary action. Just keep this advice in mind and if the patient contacts you via email then I would not respond to it. !Chris
  11. I understand the the idea of supply/demand and the concept that quality programs will produce quality graduates and only quality graduates will get jobs. However, I can't seem to get past my personal experience of seeing recently hired NPs in my faculty being poorly prepared to start in the role that they are hired for (Community ED/ER) and it is creating a preference for hiring PAs instead of NPs because it is felt that the PAs are better prepared. I think that when offices/facilities have a bad experience with a new provider because they feel like they are not well educated or prepared for their role then they tend to be quick to generalize the program where the person graduated and if it becomes a pattern then the entire profession gets blamed. The recent NP hires have come from schools with good/strong reputations, some havinf previous RN experience while others were accelerated/direct entry and they all seem equally unprepared for the role even as a novice practitioner. I will openly acknowledge that this is only my personal experience and does not constitute as concrete evidence for anything. It is merely a single pattern in one facility, in one part of the country. !Chris
  12. As usual I think that BostonFNP is right on target, programs that don't or can't secure sits for their students are sending a message that tuition dollars are valued above the quality of their students education. I am a FNP student who comes in with 5+ years of RN experience (5 part time in psych and 3 part time in ED) and I have decided as much as I like psych that I want to be an ED NP. I also love to teach and plan to obtain my DNP eventually just so that I can teach and help lead an FNP program. I am taking about these issues now because I really would like to be a part of the solution in improving NP education. I think that there are some really good points being made in this discussion and I'm glad we could get it back on track. !Chris
  13. Ivan, I appreciate your feedback and did not create this post solely for the purposes of offending anyone or diminishing any education track. I understand the word "broken" may have come across a little strong, it was primarily for the purpose of drawing attention to the issue but to an extent I think there are some significant (but not insurmountable) problems with the current system that aren't being addressed much to the frustration of many current students (and their preceptors as well as nursing faculty members). If I may offer a bit of background on myself to provide some context to my perspective. I'm a FNP student who works in the ED setting currently and would like to be an ED NP after I graduate at the end of the year. I'm a full time student at the moment and I work part time so I can have time with my wife and new baby as well. I'm currently doing an elective clinical in the ED and some discussion with my fellow students, faculty members and my preceptors helped to inspire me to write this. I'm not trying to discredit NP education at all and I am not disillusioned with it. On the contrary, I think we have come far as a profession and we have even more room to grow which will only help to secure our position in healthcare for years to come. I'm not suggesting that we make NP programs = PA programs because they come from two different models and there are some great things we do now that allows improved access to education for RNs who want to become NPs (part-time and distance programs for example). I'm suggesting that we look across the aisle at other disaplines and see what works for those programs and see if we are able to adapt some of the teaching methods and practice principles to help us be better equipped to serve our patients. !Chris
  14. I really like the idea of post-graduate residency programs that combine NPs and PAs, I think it brings together the strengths of both disciplines and will advance the combined education. I am lucky to work side by side with quite a few PAs, many of them are great advanced practice providers. You mention the fact that PA education is primarily 24+ month full-time intensive programs which provide a solid didactic and clinical preparation for new providers but by not providing any part-time options you limit the ability for older students, students who have families, or students who need to work full-time from returning to become a PA (and thus why you see most PA students are in their early 20's and people who very recently completed their undergraduate degee). I think that a plus of having part-time NP programs are the ability to have a more diverse student group but they could stand to borrow a bit of the rigor of PA programs (in my opinion). On a side note, one thing that I have found to be more common with PAs is that these programs tend to attract a lot of young, eager and gifted students but when they graduate they have a hard time working with some of the other disciplines in a cooperative and team-oriented way because they have limited work experience in healthcare settings. It seems like PA programs (and MD/DO programs for that matter) are taught that they are the leaders of the healthcare team and they write or give orders, while nurses, technicians and other therapists exist to carry out orders. In my experience, this mindset makes new PAs come across eager to prove themselves which means they may be hesitant to accept differing opinions or suggestions to change patient care from non-physician providers. This is certainly not the case for every PA and it depends largely on the person's personality, confidence level, precious work/life experience and the culture of the healthcare setting where they are employed. I think that as any new provider (DO/MD, NP, PA) gains more experience in their role and working as part of a team then they will develop a more cooperative approach and be more open to suggestions and constructive criticism. I feel that NPs who were experienced RNs are a bit less likely to do this but on the other hand they may have to deal with tensions with RNs who resent the NP role (but that is an entirely different discussion). Its funny that this discussion came up because just last week one of my PA colleagues asked if I would come and teach skills lab at the PA program where he is an adjunct faculty member. He asked me because he believes the students need to learn how to do the hands-on technical skills that nurses know (NG tube/foley cath and IV insertion, basic wound care dressings etc.) and he said that the teaching style he has seen me use with my nursing students would be supportive to new PAs and help them to develop a better respect for nurses. My takeaway point is, I think any program that brings together NPs and PAs and advances their education and professional cooperation is a good thing and that NP and PA education programs could learn a lot from each other. !Chris
  15. NURSE PRACTITIONER HISTORY When Drs. Loretta Ford, RN and Henry Silver, MD developed the first NP certificate program in 1965 it provided experienced registered nurses (RN) with the additional training to work in pediatric primary care settings collaboratively with physicians to manage acute and chronic illness (American Academy of Nurse Practitioners, n.d.). Drs. Ford and Silver believed that majority of the healthcare needs presenting in pediatric primary care settings could safety be overseen by nurses with advanced training in physical assessment, pathophysiology, pharmacology, and disease management. After creating the program at UC, Dr. Ford continued to work to develop the NP role and advocate for its implementation throughout the country. Since the NP role began, education has evolved from certificate to graduate degree programs and now includes acute and primary care specialties serving patients across the lifespan. NPs work in clinics, community settings, hospitals and private offices; some work completely independently while others work collaboratively in multidisciplinary treatment teams. Even with all of the progress achieved in advancing the NP role, debate continues regarding the necessary education and training required for NPs. Some of the biggest points of dispute include minimum number of clinical practice hours, degree for entry to practice, prerequisite RN experience, and necessity of post-graduate residency/fellowship training. In this two-part series I will discuss each of these topics and offer my take on what is broken within the current system and then suggestions on how we can improve it for future practitioners. Please keep in mind that these are my opinions and do not reflect the views of any college/university or professional organization. This is not a critique of any specific education program but rather a general commentary about NP education in the United States with the hope of starting an open and productive dialog between members of this forum. EDUCATION SYSTEM PROBLEMS The first NP programs were designed to build upon the practice of experienced nurses but as time has marched on we have seen the emergence of new educational formats including online and accelerated programs. Students can now complete NP programs in online classrooms from anywhere in the world and non-nursing professionals from a variety of backgrounds can join our field through accelerated degree programs. Utilizing new educational tools and alternative paths to entry are important to remaining current but these methods present challenges for maintaining quality standards and the "nurse" identity of nurse practitioner. Studies have found that having previous clinical experience as an RN was not associated with improved academic success or stronger clinical skills as a new NP (El-Banna et al., 2015; Rich, 2005, Rich & Rodriguez, 2002). While I won't debate that non-nursing professionals can effectively complete accelerated programs and become successful NPs, I believe that these NPs miss out on critical socialization aspects of being an RN and are less likely to identify with the "nurse" aspect of being a nurse practitioner. Another issue that comes under frequent discussion is the variation of clinical practicum hours that NP students have to complete depending on their program. The Commission on Collegiate Nursing Education (CCNE) mandates that programs have a minimum of 500 direct patient care hours but offer few other specific guidelines (2016). A review of programs from around the country, the average number of clinical practicum hours range from 500 - 1000 hours when a masters degree or post-graduate certificate is conferred and 750 - 1250 when a doctoral degree is awarded. At first glance, one might assume that the higher clinical hours associated with completing a doctoral program would mean more direct patient care hours but in most circumstances the additional hours are for the completion of a capstone quality improvement or research project. This has come under serious discussion as it has been suggested that the entry degree to practice be changed from the Master of Science in Nursing (MSN) to the Doctor of Nursing Practice (DNP). The idea of raising education requirements and improving scholarship is good in theory but many question the "value add" of the DNP degree for NP when the additional clinical hours required for the degree are not typically related to direct patient care but are instead focused on a quality improvement or research project. The purpose of this article is not to debate the merits of a particular degree but to consider its value specifically as it relates to improving the ability of a NP to provide direct patient care as a clinician. Another major hurdle for many programs is securing appropriate clinical sites and preceptors. Many prospective NP students and healthcare professionals outside of nursing are unaware that in a number of programs it is the responsibility for students to find their own preceptors and clinical sites, which is challenging and results in unnecessary delays for program completion. For the more programs that take the responsibility of matching students with preceptors it can still be difficulty because most nursing programs do not pay experienced practitioners a stipend for having a student work with them and instead rely on volunteering and offers of continuing education credits or course credit at the affiliated college/university. In this writer's opinion, forcing students to find their own preceptors is inappropriate and contributes to a lack of standardization in quality education. Also, by not offering some form of financial compensation or stipend to preceptors it sends the message that the preceptor's time is not valuable and the education of NPs is less valuable than physicians or physician assistants (many PA and medical school programs provide financial compensation to preceptors for their time working with students). In the next segment I will discuss some problems seen with the modern graduate student and then provide a "prescription" for how fix a broken system. My question for the readers is, do you think that any major change is needed to this system at all? Do you feel that most NP programs are successfully producing graduates who are fully ready to assume the NP role in our current healthcare landscape? Or do you think that a majority of the issues are due to problems in education programs, healthcare institutions, and to a degree, the students themselves (e.g. professionalism, behavior, experience, expectations)? REFERENCES American Academy of Nurse Practitioners. (n.d.). Historical timeline. Retrieved from AANP - Historical Timeline Commission on Collegiate Nursing Education. (2016). Frequently asked questions: Clinical practice experiences. Retrieved from American Association of Colleges of Nursing (AACN) > Home El-Banna, M., Briggs, L. A., Leslie, M. S., Athey, E. K., Pericak, A., Falk, N. L., & Greene, J. (2015). Does prior RN clinical experience predict academic success in graduate nurse practitioner programs? Journal of Nursing Education, 54(5), 276-280. doi: 10.3928/01484834-20150417-05 Rich, E. (2005). Does RN experience relate to NP clinical skills?. Nurse Practitioner, 30(12), 53-56. Rich, E., & Rodriguez, L. (2002). A qualitative study of perceptions regarding the non-nurse college graduate nurse practitioner. Journal of the New York State Nurses Association, 33(2), 31-35.
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