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Please answer the questions regarding the article. The article is pasted at the bottom. I have also attached the reference. Reese, C. E., Ruppel, K. J., Matulis, B., & Wendler, M. C. (2018). “I am surprised at the change in me”: What is it like for nurses to be in the process of completing a baccalaureate degree in nursing? The Journal of Continuing Education in Nursing, 49(7), 307-314. https://doi.org/10.3928/00220124-20180613-06 1. Purpose: What experience, situation, or subculture does the researcher seek to understand? 2. Does the researcher want to produce a description of an experience, a social process, or an event, or is the goal to generate a theory? 3. Does the researcher describe a problem or give a problem statement? 4. How was data collected? Discuss the sample selection and provide a definition of the type of sample(s) used. 5. How did the researcher control his or her biases and preconceptions? 6. Does the researcher address internal or external threats to validity? Review text on threats to validity in qualitative research 7. How could qualitative researchers increase the validity of their research? 8. What are the main findings of the study? 9. Is the study published in a source that required a peer review process? How didyou determine this. ? Yes ? No ? Not clear 10. Were the research methods used appropriate to the study purpose? Why/Why not? ? Yes ? No ? Not clear 11. Was the sample selected for interviews appropriate and varied enough to serve the purpose of the study?Support your answer ? Yes ? No ? Not clear 12. Were data collection methods effective in obtaining in-depth data?What does the researcher report ? Yes ? No ? Not clearabout data saturation and themes? 13. Did the data collection methods avoid the possibility of oversight, underrepresentation, or ? Yes ? No ? Not clearoverrepresentation from certain types of sources? 14. Were data collection and analysis intermingled in a dynamic way? ? Yes ? No ? Not clear 15. Is the data presented in ways that provide a vivid portrayal of what was ? Yes ? No ? Not clearexperienced or happened and its context? Support your answer 16. Does the data provided justify generalized statements, themes, ? Yes ? No ? Not clearor theory that the author(s) reported?Support your example with examples. 17. Are the findings credible? ? Yes All ? Yes, Some ? NoExplain and support your answer thoroughly. 18. Clinical Significance: Check the box and provide supporting detail in complete sentences. Are the findings rich and informative? ? Yes ? No ? Not clear 19. Is the perspective provided ? Yes ? Some ? No ? Not clearpotentially useful in providing insight, support, or guidance for the degree completion student? 20. Are the findings significant? Explain ? Yes All ? Yes, Some ? No 21. What did you learn about the Qualitative research process? Article pasted below: “I Am Surprised at the Change in Me”: WhatIs It Like for Nurses to Be in the Process ofCompleting a Baccalaureate Degree in Nursing?Cynthia E. Reese, PhD, RN, CNE; Kelly J. Ruppel, PhD, RN, CNE; Brittany Matulis, BSN, RN; and M. Cecilia Wendler, RN, PhD, NE-BCThe Institute of Medicine (2010) The Future of Nurs- ing report included the recommendation to have 80% of practicing nurses attain a minimum of a baccalaureate degree in nursing (BSN) by the year 2020. Evidence supports better patient outcomes when care is provided by nurses with BSNs; for each 10% increase in BSN-prepared nurses, hospitals can expect a concomitant reduction of 5% to 7% in mortality and failure to rescue (Aiken, Clarke, Cheung, Sloane, & Silber, 2003; Aiken etal., 2014). Therefore, health care organizations are striv- ing to align their workforce with the IOM’s 2020 recom- mendations and are urging their nurses with an associate degree (ADN) or RN with a diploma to return to school and complete their BSN.At the time of the IOM report (2010), approximately 50% of American nurses were educated at or above the BSN level. With an estimated 3.1 million RNs in the workforce, this meant that 930,000 nurses with the ADN or RN diploma would need to either be replaced by BSN- prepared nurses or return to school for a BSN. With such a large number of ADNs and RNs with diploma need- ing the BSN, questions arose as to how to facilitate BSN completion. Nursing schools have expanded their capaci- ties (Beurhaus, Auerbach, & Staiger, 2014), and regional data indicate that local schools have capacity at present to handle this potential influx (C. Wendler, personal com- munication, December 3, 2016) so availability of pro- grams is not a problem. Research demonstrates there are many barriers, as well as facilitators, for practicing nursesDr. Reese is Clinical Associate Professor and Director, University of Illinois at Chicago, Springfield Campus, Ms. Matulis is Staff Nurse, and Dr. Wendler is Former Director of Nursing Research and Academic Part- nerships, Memorial Medical Center, Springfield, Illinois; Dr. Ruppel is As- sistant Professor, Bellarmine University, Louisville, Kentucky.The authors received no monetary support for this project. In-kind support was received from the University of Illinois College of Nursing, Springfield Campus, for transcription of the interviews, and the staff of the Memorial Center for Learning and Education provided meeting space and office supplies.The authors have disclosed no potential conflicts of interest, financial or otherwise.Address correspondence to Cynthia E. Reese, PhD, RN, CNE, Clinical Associate Professor and Director, University of Illinois at Chicago, Spring- field Campus, One University Plaza, SAB 23, SpringReceived: August 11, 2017; Accepted: March 6, 2018 doi:10.3928/00220124-20180613-06The Journal of Continuing Education in Nursing · Vol 49, No 7, 2018307returning to school (Anbari, 2015; Bickett, 2014; Duffy, 2014). However, little is known about what it is like for RNs experiencing a return to school. The purpose of this study was to identify what it is like to be actively engaged in completing an RN-to-BSN program for experienced nurses returning to school.LITERATURE REVIEWThe literature reveals that returning to school for BSN completion is challenging for most students, resulting in a significant investment of personal time and financial resources. There is some evidence about the influence on professionalism when RNs complete a BSN (Osterman, As- selin, & Cullen, 2009). Sarver, Cichra, and Kline (2015) found that RNs enrolled in RN-to-BSN programs because they were seeking to expand knowledge, enhance job op- portunities, and attain personal satisfaction; this was fur- ther supported by Graf (2006). Lillibridge and Fox (2005) found this as well, calling it “having an edge” (p. 15) for career advancement. Researchers (Romp et al., 2014; Sarver et al., 2015) also reported that making the decision to re- turn to school was easier for RNs if tuition reimbursement, short programs, and flexible work schedules were available.Common barriers to enrolling in a RN-to-BSN pro- gram included a lack of time, family responsibilities, and limited finances, including lack of direct financial reward (McEwen, Pullis, White, & Krawtz, 2013; Romp et al., 2014; Sarver et al., 2015). McEwen et al. (2013) noted that it may take 8 to 10 years to recoup educational costs. However, this financial loss may be offset by the fact that RNs are seeking BSN completion much earlier in their careers than in the past, allowing the recoup to also occur earlier (McEwen et al., 2013). Therefore, specific struc- tures designed to support RNs returning to school for an RN-to-BSN program are facilitating enrollment, such as tuition reimbursement, online learning, and shortened programs (McEwen et al., 2013).Although research about the experience of returning to school for RNs exists, no research describes the experiences of RNs in the middle of completing an RN-to-BSN. The purpose of this study was to address this gap by understand- ing the experiences of currently enrolled students as they moved through an RN-to-BSN program, while still work- ing and (in most cases) providing family care. By under- standing the experiences of the enrolled student, organiza- tions and educational institutions can initiate interventions that ensure continued student success, as well as increase faculty understanding of the stresses and rewards involved.METHODConsistent with the research question and qualitative methodology, naturalistic inquiry processes (Lincoln &Guba, 1985) were used for the recruitment of potential participants, data gathering and management, and data analysis.Theoretical UnderpinningsAppreciative inquiry (Cooperrider, Whitney, & Stav- ros, 2008) provided the theoretical underpinnings of the study. In appreciative inquiry, researchers ask what works well to do more of that. Appreciative inquiry, a qualitative descriptive research approach, is the research methodology most often used by the discipline of or- ganization development and provided a strong structure for the study.SampleQualitative study sampling procedures are purposive (Munhall, 2012); individuals experiencing the phenom- enon of interest are included. Nurses with an ADN or an RN diploma who were older than 18 years and who could read and write English were recruited from a midwestern region of the United States via e-mail and a flyer. Nurs- es needed to be currently enrolled in their RN-to-BSN programs to participate. Participants enrolled in online, traditional/seated, blended, or accelerated RN-to-BSN programs were eligible. Participants needed to have com- pleted their first course in their program but not yet begun their final course.Sample sizes are typically 8 to 20 for qualitative research studies (Munhall, 2012); however, data saturation deter- mines the final number of participants (Munhall, 2012). Data saturation occurs when no new ideas or themes are identified, and interviews reveal no new data. In the cur- rent study, data saturation occurred with a total of 16 par- ticipants.Recruitment of ParticipantsPurposive sampling was initiated primarily from a pool of RNs employed at a Magnet®-designated mid- western hospital and affiliated health system, employ- ing more than 1,000 RNs. Within a 100-mile radius of the facility where the study took place, there are nine traditional private, not-for-profit, and public universi- ties with seated, online, or blended programs for BSN completion. These local programs have fluid enrollments in BSN completion programs between 10 and 1,000 stu- dents (C. Wendler, personal communication, December 3, 2016). Further, local nurses have access to countless online programs of all types. RNs were accepted into the study regardless of their choice of program as long as inclusion criteria were met.The research university’s institutional review board (IRB) approved the study under expedited rules, and308Copyright © SLACK IncorporatedQuestionTABLE 1 SEMISTRUCTURED INTERVIEW GUIDE1. Could you please tell me a little bit about your program?2. Thinking back, how did you come to make the decision to go back for your baccalaureate degree in nursing (BSN) at this time in your life?3. How did you come to choose the program that you are enrolled in?4. Can you describe for me some of the things you most like about your BSN completion program?5. Can you describe for me some of the things you most dislike about your BSN completion program?6. If you are employed: In what ways did your employer make it easy to go back to school? In what ways did your employer make it dif- ficult to go back to school?7. So far, how have you benefitted from going back to school? Are there any long-term benefits to you having your BSN? 8. In what ways have your family members benefitted from you going back to school?9. What adjustments in your life do you find you are making to accommodate the demands of school?10. What barriers have you encountered (work, home, other) in going back to school?11. What has facilitated your return to school (work, home, other)?12. On a scale of 0 to 10, with 0 being not at all satisfied and 10 being the most satisfied I can be, how satisfied are you with your BSN completion program?13. On a scale of 0 to 10, with 0 being not at all satisfied and 10 being the most satisfied I can be, how satisfied are you with your own growth and development so far in your BSN program?14. What would you like to tell us about what it is like to go back for your BSN that we have forgotten to ask you?recruitment began via e-mail and through regional dis- tribution of a recruitment flyer. The e-mail was sent to nurses in the Midwest at an acute care hospital, students from RN-to-BSN programs, and program directors at additional RN-to-BSN programs to recruit students via online course management platforms. E-mail lists were generated in several ways. First, all nurses at an acute care hospital in the Midwest were sent a recruitment flyer with information about the study. If they were interested and met the criteria for inclusion, prospective participants were asked to e-mail the nurse scientist (M.C.W.). If they did not meet inclusion criteria, nurses were asked to for- ward the recruitment e-mail to anyone they may know who was currently completing an RN-to-BSN program. The researchers also generated a list of e-mails by contact- ing program directors of regional RN-to-BSN programs, asking them to post the recruitment flyer on their course management platform. Recipients of the e-mail were also invited to forward the e-mail to any friends or acquain- tances who met the inclusion criteria, using a snowball recruitment technique to obtain a purposive sample (Munhall, 2012). If a potential participant had questions or indicated interest in the study, they were directed to call or e-mail a member of the research team. If requested by the potential participant, the interview appointment was made. The interview was completed at a time and place ofconvenience to the participant and was also available over the telephone if preferred.Data CollectionBecause of the nature of the study and its minimal risk, the investigators received a waiver of written consent from the IRB. Instead, verbal consent was used to con- firm agreement to participate and to allow audio-digital recording of the interview. The participants’ right to de- cline to answer a question or to withdraw at any time was discussed prior to the outset of the study.To provide full attention and engage in active listening during the interview, the interview was digitally record- ed. Notable moments experienced during data reduction were captured in field notes. To support confidentiality, each participant chose a pseudonym and all records were stripped of any identifying data; research data were kept in a secure computer file. No record of the participants’ names was kept, in accordance with the requirements of the IRB. In fidelity with the qualitative approach chosen for the study, a semistructured interview guide facilitated the organization of the interview (Table 1). A brief de- mographic survey was also used to learn more about the sample.The interviews were completed by a PhD-prepared nurse scientist (M.C.W.) with expertise in qualitative re-The Journal of Continuing Education in Nursing · Vol 49, No 7, 2018309VariableAgeYears as an RN Gender Ethnicity/race Marital status Parental statusNumber of classes completedDataaM = 39.63 years (range = 24-60)M = 9.25 years (range, , 1 to 24)12 women, 4 men1 non-Caucasian, 15 Caucasian75% married, 25% unmarried68.75% were parents, 31.25% were notM = 5 (range = 1-14)TABLE 2 DEMOGRAPHIC INFORMATIONa To protect confidentiality, only minimal demographic data were requested.search methodology and execution. All interviews took place at a private location of convenience to the partici- pants; all chose the nurse scientist’s private office. Each interview was completed uninterrupted, within 17 to 34 minutes.Data AnalysisOnce the interviews were completed, they were tran- scribed verbatim by a professional secretary. Each tran- scription was then compared to the original interview recording to ensure accuracy. Demographic information was examined using descriptive statistics. For the inter- view data, qualitative data were reduced using naturalistic inquiry approaches by engaging in a step-wise approach (Wendler et al., 2017) to gain an understanding (Lincoln & Guba, 1985) of the experience of returning to school for an RN-to-BSN program.After the transcripts were reviewed and accuracy veri- fied, data reduction began with coding. The team con- sisted of three novice researchers who were trained on the structure of, and processes involved in, coding qualitative data by an experienced nurse researcher. To develop skills, a single transcript was coded by all researchers individual- ly, who then came together to compare results. Codes were negotiated between and among researchers until consensus was reached, while preserving the participants’ own words for as long as possible. Once more than 95% agreement on the first data reduction was met, the standard case data were further reduced, allowing isolation of categories. The remaining transcripts were then divided among co-investi- gators. Each researcher completed assigned data reduction for the remainder of their assigned transcripts, while the experienced researcher completed data reduction on all cases; this upheld credibility of the results. Meetings be-tween and among researchers ensured accuracy of coding across the data set. This process continued until all data were reduced. This assured confirmability, dependability, and credibility of results (Wendler et al., 2017). After all coding was complete, the team came together and worked toward categorization of the codes, preserving the voice of the participants at every step. Once categories were agreed upon, themes and a meta-theme emerged (Lincoln & Guba, 1985), in fidelity with the inductive processes in- herent in qualitative research approaches. All documents and decisions were recorded to maintain an intact audit trail (Munhall, 2012).RESULTSA total of 16 RNs volunteered for and completed the study before data saturation occurred. In the study, the average age was about 40 years, with 12 women and four men participating. Most were Caucasian; 75% were mar- ried and approximately two thirds were parents. The mean number of classes completed at the time of the interview was five (range = 1 to 14). Table 2 displays a summary of demographic information.During qualitative analysis this process, a total of 173 distinct codes emerged from the data. In a final work ses- sion involving all researchers, these codes were further re- duced to 10 categories (Table 3); only a minimal number of codes fit into more than one category. Otherwise, all codes fit within one of the 10 categories identified. The categories that emerged were well supported by the data.Categories and their supportive documentation in- clude the following:”I Am Very…Surprised at the Change in Me.”A version of this description was offered by most partic- ipants, sometimes multiple times. For example, “School… gives me confidence” was noted by four participants. Six others noted the RN-to-BSN program “opened my eyes.” The “BSN makes a difference in your practice” was noted by seven, whereas “BSN makes you a better nurse” was identified by eight. One nurse in the intensive care unit noted, “I was very…surprised…shocked at the change in me,” to offer the quote for the category listed:I am actually shocked [at the change in me]. I just feel better about my job now. I think that prior to this…I [could] be satisfied if I worked hard all day long, but now when I’m able to communicate with other people and realize that they really need to hear things, that is where my personal satisfac- tion comes in…. As before, it was just, very ‘I’m just in here to do my job’ and I walk out. I wasn’t very open to stuff and now that I am, I feel like relationships are getting better. I feel like I communicate better, not only with my patients but mainly more with the families. I’ve always been fairlyquiet and to myself, and keep busy tasking and tasking…. Now, I’ve stepped back a little bit and taken some time to really talk to families, and I feel…more confidence…. Now I think my confidence level has increased in just the short time already, in being able to talk to people.”Satisfaction Diminishes When There Are Glitches.”Ten mentioned that problems within the program reduced their satisfaction with their program. Two par- ticipants asserted that “advising [was] insufficient”; five others noted that faculty were slow in returning grades, a dissatisfaction for many students. Three other students complained that the program did not have the rigor they expected or desired.School Is “Totally Do-able.”Of note was the surprise students expressed in finding it possible to complete coursework and still work full-time and have time for family life. Six of the 16 students (from various types of programs) specifically expressed that school was “do-able.” Online programs worked well for the six students enrolled in those type of program, and the remaining 10 students who were in a blended accelerated program thought that worked well for them.”I Want to Do Well [in School].”This was important to three participants. Sometimes doing well required commitment, motivation, and flex- ibility (said two participants), whereas three others said they had to work to prepare for the rigors of school by “getting my head wrapped…around school [again].”Time ManagementTime management was critically important to 14 of the 16 participants. Four noted that school was a “juggling act” with multiple projects, whereas five discussed the crit- ical importance of maintaining life-work-school balance.Making Adjustments in Activities to Accommodate SchoolEleven discussed at length the importance of making adjustments in activities to accommodate school. Four- teen of 16 participants said flatly, “I have less time with [my family],” but six noted that this was a short-term sac- rifice “to reach a goal.”Support From Other Students, Former Students, and CoworkersSupport from other students, former students, and co- workers was an unexpected bonus for many participants. Three participants noted that “having coworkers in theprogram with me [helped].” Seven noted that the influ- ence and support of prior students in the same program was helpful, even in sharing resources such as textbooks.”Family Has Benefitted From My Return to School.”This was mentioned by nine participants. Five of the women discussed the importance of role modeling a re- turn to school for their children. Four noted that their family members were proud of them. Participants also rec- ognized that completing the BSN meant more money or career advancement (mentioned by 14 of 16 participants); for one, this was seen as a benefit for the family.Barriers to Returning to SchoolBarriers to returning to school included the fact that family members reportedly were not always support- ive (noted by three participants). “Returning to school [was] overwhelming [if out of school for a while]” and was a significant barrier for five participants, especially students needing to adjust to changing technology (six participants). Four simply stated that barriers included unexpected hardships or pregnancies as a “life happened” event, keeping them from returning to school before now.Supportive EmployerAll these experiences were made easier and richer by the impact of having a supportive employer noted 13 partici- pants. Data supporting this large category included:l “Financial support made it easy/is important” (12 par-ticipants).l Employer works with your schedule (10 participants). l There is synergy between work and school (seven par-ticipants).TABLE 3QUALITATIVE CODES EMERGING FROM THE DATA”I am very…surprised at the change in me” (also emerged as the overarching theme of the study)”Satisfaction diminished when there are glitches” School is “totally do-able””I want to do well [in school]”Time managementMaking adjustments in activities to accommodate school Support from other students, former students, and coworkers Family has benefitted from my return to schoolBarriers to returning to schoolSupportive employerThe Journal of Continuing Education in Nursing · Vol 49, No 7, 2018311l My employer “prefers the BSN” (three participants); even this: “Returning to school [to complete the BSN] recently…[is] being pushed” (eight participants).l Academic advising (available at work) “made it easy” to overcome barriers and return to school (three partici- pants).Together, the research team identified the dominanttheme of personal growth and development, a process which surprised the participants. An exact quote from the data illuminated this well: “I am very…surprised…at the change in me” (one participant) became the overarching theme of the study and allowed inclusion of all 10 major categories discussed.Participants returned to school for a variety of reasons; some were intrinsic, such as wanting to be a better nurse, and some were more career-oriented, motivated by aging. “I don’t think I can continue bedside nursing as I age,” was a reported issue for five participants.Participants urged others to be proactive on one’s own behalf; they insisted on meeting with advisors to prevent redoing work. They urged nurses to find out what the employer can do to assist in the return to school, and to know that family and friends will see less of you, but “it is worth it in the end” (one participant) for one’s career, for patients, and for oneself. They also commented, “School is completely do-able!” (two participants); “You do have time, even if you think you don’t” (one participant); and, finally, “[By] looking at the big picture, you know [return- ing to school to complete the BSN] is worthwhile” (one participant).DISCUSSIONNurses know and understand that there is a renewed national effort for them to return to school and complete their BSNs. When RNs return to school, they need to make many complex social, familial, and work decisions besides simply choosing a program to attend. For some, this is a daunting task, and nurses appreciate receiving spe- cific guidance in choosing a program and managing steps along the way.Participants in this study encountered work-life and financial challenges, which is mirrored in the nursing lit- erature (Duffy, 2014), yet they felt the effort was worth it. Many reported individual experiences of personal and professional growth, welcoming the opportunity to role model for their children, and enjoying the support of managers, colleagues, families, and friends. Participants saw the return to school as benefitting them, their fami- lies, and, most of all, their patients.Participants disliked unorganized curricula or class work and complained when there were “glitches.” Some were minor, but some were major. Inadequate advisingas RNs navigated university policies and sequencing of courses can cause major setbacks; indeed, one participant persisted despite that she was required to retake English courses that would have transferred into most other pro- grams and a prerequisite was missed, causing an entire year delay. Participants valued rapid return of feedback on written work and found it off-putting when faculty delayed, putting students who work 12-hour shifts in a time-crunch for processing feedback before subsequent as- signments were due. In fact, delayed return of grades by faculty was a major dissatisfaction for participants.Participants provided coaching and encouragement for potential future RN-to-BSN completion students in the study. They recommended that students update technol- ogy skills prior to returning to school. Training can be obtained from community education programs (such as Microsoft® Office classes) either through the employer or community education. Participants urged others to be proactive on one’s own behalf and to insist on meeting with advisors to prevent redoing work. They urged nurses to find out what employers can do to assist in the return to school and to know that they will see less of family and friends but it is worth it in the end for one’s career, for patients, and for oneself.Compared with the literature reviewed to determine the gap and need for the study, findings from this study were similar in the concern of lack of time, time manage- ment, and financial issues. However, students in previous studies cited a lack of financial reward upon completion of the BSN as a barrier (Anabari, 2015; Bickett, 2014; McEwen et al., 2013). Participants in this study did not indicate this was an issue. In fact, participants discussed opportunities for career advancement as an expected result of BSN completion.Compared with the literature reviewed to determine the gap and need for the study, findings from this study were different. The existing literature examined benefits and barriers to RN-to-BSN program completion for stu- dents either before they embarked on an educational pro- gram or after they completed the program. This study’s targeted population was students who were in the midst of the RN-to-BSN program, having completed at least one course and having at least one course yet to complete. From these findings, many students indicated they felt their RN-to-BSN program was “totally do-able” while they were immersed in the program. Findings from this study filled the gap in the literature by providing a better understanding of student experiences and student percep- tions of benefits and barriers to enrollment in a RN-to- BSN program. These findings provide beginning evidence of supportive measures that may be useful to facilitate working nurses during their educational program.312Copyright © SLACK IncorporatedIMPLICATIONSThe results of this study provide a thick, rich descrip- tion of working nurses’ return to school for their BSN, which allows for the transferability of the results to similar settings (Lincoln & Guba, 1985). The findings provide ample evidence that programmatic and managerial/lead- ership support for return to school is essential. Results may be used by nursing managers and leaders to advocate for resources that reduce barriers for returning to school, provide support while in the BSN program, and celebrate and use new skills gained by RNs, thus rewarding them on completion of the BSN.Nursing leaders need to continue to advocate for fi- nancial support for returning to school because financial barriers continue to be important to remove; our partici- pants’ responses supported previous literature (Bickett, 2014; Duffy, 2014). Flexible work schedules, a theme for our participants, improve practicality and help RNs with work-life balance (Anbari, 2015) when they return to school. Leaders need to know that RNs return to school for a variety of reasons; some are intrinsic, such as wanting to be a better nurse, and some are more career-oriented, motivated by aging.Employers need to support students as they progress through their programs, with items such as financial sup- port, flexible scheduling, a work culture supporting BSN education, availability of academic advising at the work- place, and an employer expectation that RNs will obtain their BSN. Faculty should provide a carefully organized curriculum, appropriate and accurate advisement of stu- dents regarding university policies and sequencing of courses, and rapid feedback and grading. De
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