Nursing Theories

theory
a set of interrelated concepts that give a systematic view of a phenomenon
why are theories needed
theories are needed to guide and support a profession, practice, education, and research (to better patient care)
purpose of theories
developing, describing, understanding, explaining, and predicting
what are theories grounded in
the values and beliefs (philosophies) underpinning a particular paradigm or worldview
what does theory do
theory guides research and research validates and modifies theory
what does theory enhance
theory enhances professional accountability when used in practice
how is knowledge gathered
through scientific inquiry or research, which is guided by theory
–provide a framework for new knowledge and validate old knowledge
concept
words that describe objects, properties, or events
what are concepts
–labels for phenomena
–the basic components of a theory
what do concepts represent
some aspect of reality
what do concepts describe
the mental images of phenomena
three types of concepts
–empirical
–inferential
–abstract
empirical concepts
easily understood (temperature)
inferential concepts
indirectly observable (blood pressure)
abstract concept
non observable (pain)
proposition
–statements that link concepts
–statement of the relationship between two or more variables
–statements that explain the relationship between variables
assumptions
statements of facts or beliefs that people accept as the underlying theoretical foundations
–assumptions are derived from scientific theory or practice
philosophy
a statement of beliefs and values
philosophies are…
statements about what people assume to be true in relation to the phenomena of interest to a discipline and what they believe regarding the development of knowledge about the phenomena
metaparadigm
the metaparadigm of any discipline is made up of global concepts that identify the phenomena of interest to a discipline and global propositions that state the relationships among these phenomena
the broadest concensus within a discipline
metaparadigm
the metaparadigm of nursing
environment
health
nursing
person
what does the metaparadigm provide
–general parameters of a discipline and the parameters for a field of study
–a unique perspective of the concepts that help to distinguish nursing from other disciplines
models
representations of the interaction among and between the concepts showing patterns
conceptual models
a set of abstract and general concepts and the propositions that integrate those concepts into a meaningful configuration
–cannot be tested empirically
grand theory
are broad in scope, but are less abstract than conceptual models
–cannot be tested empirically
middle range theory
are narrower in scope than grand theories
–are made up of concepts and propositions that are empirically measurable
hypothesis
statement of the relationship between two or more concepts
–states the relationship in a form to be tested
science
a community of individuals engaged in similar and related activities of inquiry (Gale)
what are the goals of science
prediction, control, explanation, and understanding
nursing science represents…
understanding of human biology and behavior in health and illness, including the processes by which changes in health status are brought about and the principles and laws governing life states and processes
nursing science is the base of…
knowledge underlying human behavior and social interaction, under normal and stressful conditions, throughout the lifespan
primary use of theory
the primary use of theory is to guide research
–can enhance practice
what does research do
research validates and modified theory
nursing theory
provides boundaries for nurses conducting research
why is research performed
research is done to explore SIGNIFICANT issues in the field
why use theory
by doing research supported by theory there is development for the expansion of nursing knowledge
–justifying our profession
philosophy
investigation and causes of laws underlying reality; inquiry into the nature of things based on logical reasoning rather than empirical (objective) methods
–what is really going on
research
formal, systematic process of gathering data from the real world to gain solutions and interpret new ideas, facts, or assumptions
metaparadigm of any discipline
is made up of global concepts that identify the phenomena of interest to a discipline and global propositions that state the relationships among these phenomens
–it identifies the phenomena of interest
historicism
–perceived view
–holistic problems that cannot be measured
–“richer data”
–qualitative
–more unique to nursing

metatheory and grand theory

empiricism
–received view
–a set of ideas not to be challenged (written in stone)
–true statements/facts are only those based on experience
–objective type of information
–quantitative
–data focused

middle range theory and empiricism

empirical indicators
are directly connected to theories by means of the operation definition for each middle range theory concept
–have other things that need to be defined
origin of theories
induction and deduction
induction:
–reasoning that moves from specific to general
–research–>theory
deduction
–reasoning that moves from general to specific
–theory–research
profession
–characterized by prolonged education that takes place in a college or university
–autonomous in decision making
–accountable for your own actions
theory development is a means of establishing what..
theory development is a meas of establishing nursing as a profession
why do nurses need to know theories
nurses need to know about theories to defend nursing as a profession for practice and legislative issues
professions need practice based on what…
-theory
–practice offers ideas for research, through research theory can be developed, proved, or disproved
practice cannot be based on what in order to be a profession…
to be a profession, your practice cannot be based on intuition, habits, or tuition
what do nursing theories lead to
nursing theories lead to propositions (links between concepts)
what can propositions be developed into
hypotheses
how do you test hypotheses
thorough research
research and theory
the more research behind a theory, the more useful that theory is in practice
systems theory
systems theory is concerned with changes due to interactions among all the variables in a situation
what does systems theory provide
systems theory provides a way to understand the many influences on the whole person plus the impact of change on any part of the whole
–divides situations into parts
a change in one system
effects the entire “body of systems”
why is systems theory useful
systems theory is useful in nursing to understand, predict, and control possible effects of nursing care on the client system
what does systems theory explain
systems theory explains the breaking of whole things into the parts and the working together of the parts into a whole system
history of systems theory
systems theory was developed in the 1950s by Ludwig von Bertaianffy [psychology]
–it is a universal theory that can be applied to many fields of study
concepts of systems theory
–system
–boundary
–subsystem
–suprasystem
system
a whole with interrelated parts, in which the parts have functions and the system as a totality has a function
boundary
real or imaginary line that differentiates one system from another or one system from its environment
subsystem
–small part of each system
–each subsystem belongs to a higher system
–the subsystems of a system are constantly interacting and changing (ex. the organ systems of the body)
suprasystem
incorporates other system
examples of system, subsystem, and suprasystem
although a system (human) may be divided into smaller subsystems (GI, cardiac), each system belongs to a suprasystem (community)
fundamental components of a system
matter, energy, and communication
types of systems
open and closed
closed system
–does not exchange energy, matter, or information with its environment
–it receives no input from the environment and gives no output to the environment
–in reality, no closed systems exist because they could not survive

(best example would be a chemical reaction in a closed test tube but even that is not a closed system)

open system
–energy, matter, and information move into and out of the system constantly through the boundary
–in a constant state of change
–all living things are open systems since survival depends on a continuous exchange of energy
Interactions in open systems
open systems have interactions and these interactions depends on the quality and quantity of input, output, and feedback
input
information, matter, or energy that enters the system
throughput
transformation and organization of the input by the system so the input can be used by the system; modifies the input
–what the system does with what it is given
output
energy, matter, or information given out by the system as a result of its processes
–what is given in return
feedback
when output of a system is returned to the original system as input; enables the system to regulate itself
–analyzing output; usually then manipulate the input
example of feedback loop
some patients cannot breathe:
–input: ventilator, intubated
–throughput: gas exchange (respirator); the client has to do this
–output: improvement in oxygenation (increase in blood gases)
how do open systems survive
to survive, open systems must maintain dynamic equilibrium through constant stimuli entering the environment
homeostasis
a balanced state (dynamic equilibrium)
what does systems theory guide
systems theory guides the nursing process to assess all relationships among variables
focus of systems theory
on understanding the interaction among the various parts of the system rather than describing the function of the parts themselves
basis for nursing’s holistic view of the client
interaction/interrelationships
relationship of systems theory to nursing process
Input: Assessment and Diagnosis (Planning)
Throughput: Intervention
Output: Patient’s response
Feedback: Evaluation
health care systems
totality of services offered by all health disciplines
healthcare
two services (episodic care and distributive care)
episodic care
refers to the curative and restorative aspects of health care or secondary or tertiary care; may also be referred to as “illness” or “rescue” care
–what the U.S. has
distributive care
also known as primary care; refers to health maintenance and disease prevention
–a lot cheaper to keep you healthy than to rescue you
primary care
focuses on health maintenance, health promotion, and prevention of illness
–exercise, good nutrition, not smoking, titers, and immunizations
secondary care
treatment toward cure of an illness; focuses on preventing complications of a disease
–going to the doctor and getting antibiotics to treat all illness
tertiary care
is rehabilitative services, long term care, hospice
healthcare in the U.S.
mainly focuses on episodic care which is much more expensive than primary or distributive care
influencing factors of health care
–demographic factors
–epidemiological factors
–economic facts
demographic factors
most significant influence is increased population of Americans older than 65
–2/3 of daily census in acute care hospitals are patients over 65
–3/4 of all home health visits are patients over 65
–“baby boomers” were born between 1946-1964, large generation of individuals who are getting older
——best generation (b/c of education) at taking care of themselves
–frail elderly-oer 85; more time consuming with everything
epidemiological factors
–with an increase in elderly, will have more acute care hospitalizations; also look for multisystem failure (more issues)
—-will also increase need for home health and long term care
–infant mortality
–HIV+/AIDS positive individuals (~10.8 million living in U.S.)
–ETOH/drug abuse
–accidents
–changes in economy, lost wages, loss of healthcare coverage
–homelessness
epidemiological factors (environmental factors)
–pollution
–“greenhouse” effect
–UV radiation
–toxic and nuclear waste
–lead problems
economic factors
–U.S. spends $1.2 billion on health care every day and costs continue to rise (b/c hospitals have to absorb costs and operate in the red occasionally)
–healthcare costs have increased 400% in the last 30 years
–public hospitals serve populations without adequate reimbursement; unfortunately those with inadequate reimbursement tend to be more complex, more vulnerable, and limited access to care
methods used for health care reimbursement
–prospective payment
–third party payer system (private insurance)
–managed care
–government reimbursement
prospective payment
–used by medicare in which a predetermined, fixed amount is paid to a health care provider (doctor, hospital) for a certain illness/procedure
–DRGs or diagnostic related groups are utilized for in hospital services
—-this predetermined amount is what the hospital receives for care of a medicare patient decided by the patients DRG; the hospital receives only that predetermined amount regardless of what costs the patient actually incurs
–fluctuatations in a DRG patient related to: complications, earlier discharge, or increase in acuity of a patient
third party payer system (private insurance)
–Fee for service: most common reimbursement model; 3rd party payer actually pays the bills but enrollee has some responsibility that vary from one policy to another
—-can be deductible or copayment & anual limits
–employee pays part and employer pays a larger portion
—-fees/policies vary from one employer to another
–currently no requirement that every employer in the U.S. provides health care coverage
–preexisting conditions
deductible
part of the bill the patient must pay before the insurer will pay for the services
–have to pay for so much then it will kick in
–some things are exempt
copayment
a fixed amount patient may be required to pay for service
–doctor’s visit/ED visit/prescriptions
annual limits
maximum, predetermined amount that the insured will have to pay; once that maximum amount is reached, the insured does not have to pay anymore
–many policies include co-pays and deductibles in this amount
pre-existing coditions
–a medical condition that you (the proposed insured) developed before applying for a particular health insurance policy
–this condition could affect the person’s coverage
–what is considered pre-existing varies from one policy to another
—-usually something that will go away (treatable types of cancer)
managed care
–HMO’s (Health Maintenance Organizations) and PPO’s (Preferred Provider Organizations)
–gained popularity in the 80s
–a third party payer system with more control over the delivery services such as: identifying type of provider can be seen, may even identify specific individuals who can be seen, number of physician visits in a time frame, number of days a person can stay in the hospital, and types of medications that can be prescribed
–also monitor providers (doctors, hospitals, etc.) to ensure they are sticking to guidelines regarding treatments, labs, etc
—-if providers don’t meet criteria set forth by HMO/PPO, they may be denied payment
government reimbursement for healthcare
–must apply for medicare or medicaid; not automatically given to the uninsured
–started in 1965 under the Social Security Act
–in addition to Medicare and Medicaid, the government also provides care to military, VA, federal employee’s health benefit program and state insurance programs for state employees
medicare
–federal health insurance for people age 65 & older
–everyone gets part A for hospitalization
–can elect to buy part B which covers doctor’s visits, labs but have to pay a premium for it
–can also elect to buy part D which covers drugs
medicaid
–designed to provide care to certain categories of low income people including, but not limited to: children, aged, blind, disabled, and people eligible to receive federal income maintenance payments
–covers most services excluding psychiatric or behavioral health inpatient
–can also cover those medically needy (those who have too much money to qualify for medicaid but require care that would exhaust their resources)
uninsured and under-insured
–in 2010, 53 million people, ~18% of U.S. population, were uninsured
—-problems stem when these individuals do seek care because it is usually for an acute illness, not prevention (acute illnesses are far more expensive than preventative care)
principles of economics (supply and demand)
–an economic model based on price, utility, and quantity in a market
–in a competitive market, price will function to equalize the quantity demanded by the consumers and the quantity supplied by the producers resulting in economic equilibrium of price and quantity
–an increase in the quantity produced will typically result in reduction of price and vice versa
Health
“freedom from pain or disease”, “optimum capability”, “structurally and functionally whole”
WHO definition of health
a state of complete well-being, physical, social, and mental, and not merely the absence of disease of infirmity
how does nursing view health/illness
nursing tends to view health/illness as a continuum, more medical model to see health as being dichotomous to illness
disease
–indication of a physiological dysfunction or pathological reaction
–more of a medical term meaning a process of alteration in the body that can result in decreased capacities or shortened live span
–label of disease gives objectivity to the complaints
disease objective
to classify with signs and symptoms
illness
–subjective feeling of being unhealthy that may or may not relate to a disease
–a person may feel ill in absence of disease; unable to diagnose cause of pain, etc.
–just because there is no label or disease does not diminish how a person feels
sickness
–more relates to ones status
–once a person is defined as sick, various dependent behaviors are tolerated
—-without the label, or confirmation, behaviors may not tolerated
–usually associated with disease or illness
–once you get the diagnosis, it justifies the complaints
3 models of health
1. clinical model
2. health promotion model
3. health belief model
clinical model
people seen in physiological systems with interrelated functions
health promotion model
–focuses on attempts to maximize health
–Pender (1982,1996) has developed a model of health promotion; this model focuses on individual characteristics and experiences, emphasizing that each person is unique; 10 aspects of health promotion
Pender’s 10 aspects of health promotion
1. prior related behavior is a good predictor of future behavior
2. personal factors
3. behavior specific cognition and affect
4. perceived benefits of action
5. perceived self efficacy
6. activity related affect
7. interpersonal influences
8. situational influences
9. commitment to a plan of action
10. immediate competing demands and preferences
health belief model
–model developed to predict if a person would follow medical recommendations and to gain an understanding of patient motivation
–Hochbaum (1958)
Hochbaum’s health belief model
Factors that are examined:
–perceived severity
–perceived susceptibility
–perceived benefits
–perceived barriers
–cues that stimulate action toward behavior
continuum of care
–means matching an individual’s ongoing needs with appropriate medical, psychological, health, and/or social care services
–occurs within one organization or across multiple organizations (understands what everyone else is doing)
goal of continuum of care
decrease fragmented care and costs
The continuum of care includes…
–health promotion
–disease/illness prevention
–ambulatory care
–acute care
–tertiary care
–home health
–long term care
–hospice and palliative care
3 areas to focus on to provide continuity of care
1. informational continuity: getting health information from one provider to the next; includes medical information, patient preferences, health history information
2. management continuity: each provider is aware of what the other is doing/prescribing/recommending
3. relational continuity: the need of patients to build relationships with providers, particularly a primary care provider or a case manager
–nurses act as case managers, coordinating care and treatments for patients
case manager
an individual/source who has a relationship with the patient and has access to current and past medical information
role theory
attempts to explain the interactions between individuals in organizations by focusing on the roles they play
role behavior
is influenced by role expectations for appropriate behavior in that position and changes in role behavior occur through an process of role sending and role receiving
role theory
a group of concepts, based on sociocultural and anthropological investigations, which pertain to the way people are influenced in their behaviors by the variety of social positions they hole and the expectations that accompany those positions
–sometimes sociocultural ideas are not always what happens
roles
a set of patterned behaviors unique to a given position and may reflect personal, social, and occupational domains
positions
denotes status or a place within a specified context, such as a health care organization
–an organizational chart is used to illustrate the placement of positions within an organization
role strain
frustration from feeling indadequate or unsuited to a role
role conflict
arises from opposing or incompatible expectations
roles in healthcare
–registered nurse
–physician
–medical student
–intern
–resident
–fellow
–attending
–occupational therapist
–physical therapist
–respiratory therapist
–registred dietician
–social worker
–pharmacist
–licensed practical nurse
–nurse practitioner
–case managers
registered nurse
–nurses are responsible for the protection, promotion, and optimization of health and abilities, prevention of illness, and injury, alleviation of suffering through the diagnosis, and treatment of human response and advocacy in the care of individuals, families, communities, and populations
–nurses are the backbone of any acute care healthcare setting
physician
medical degree with specialty such as surgery, pediatrics, OB, etc.
medical student
still attending medical school; limited patient care and conflict
intern
–recent medical school graduate; sometimes referred to as a first year resident
–able to see patients, write orders under the direction of a fellow
resident
after successfully completing medical school, future physicians must undergo at least a three year residency which is hands on training
fellow
–a fellow is a a physician who is participating in a fellowship, or additional education after the completion of residency training
attending
–physician who has completed fellowship in a specialty and serves over the specialty area in a teaching hospital
–the head doctor in a specialty group
occupational therapist
–provides rehabilitation services to patients who may have had strokes or serious accidents
–focus on ADLS (activities of daily living)
physical therapist
provide musculoskeletal care to patients, such as learning to walk again, use of assistive device, and teaching exercise programs to strengthen the patient
respiratory therapist
–provide respiratory care to paitents
–CPT (chest physiotherapy), ventilator assistance, oxygen assistance, and breathing treatments
–usually responds to emergency situations in the acute care setting as well
registered dietician
works with patients to resolve dietary and nutritional needs
social worker
assist families with reimbursement, discharge concerns, housing, transportation, and other social services
pharmacist
maybe in centralized department or assigned to several different units
licensed practical nurse
–LPNs are supervised by RNs
–care LPNs can provide is determined by individual state practice acts
–it is important that an RN know what an LPN can and cannot do for delegation reasons
nurse practitioner
–RN with a doctorate (masters) degree in a clinical specialty area–FNP, PNP, NNP,
–can provide some services independently of MDs such as prescriptions, treatments, and procedures
–may work in acute care or clinics
case managers
–may be nurses or social workers who work directly with patients and families to assess needs, direct patient to care when needed, and monitor progress
–helps patient to navigate the healthcare system
advocate role
–advocates acts for a supporting cause or on the behalf o a patient, family, or group who may not be able to act on their own (infants, elderly, mental health)
–advocates speak for something important and it is an IMPORTANT role for the nurse
nursing agenda for the future
–leadership and planning
–delivery systems
–legislation
–professional nursing culture
–recruitment and retention
–economic value
–work environment
–public relations/communications
–education
–diversity
leadership and planning
–need to have unified and systematic planning focused on the future of nursing
–also need this at the bedside to work with patients and families to achieve goals
delivery systems
–need more involvement in health care systems
–need more influence by working with healthcare policy to affect care at the bedside, competencies, qualifications
–many types of delivery systems exist (ex. hospital, ambulatory care, community, parish nursing, school, occupational, hospice, take care clinics)
legislation
–how do nurses shape public policy? when nurses was to influence policy they can, why?
—-volume; there are a lot of nurses and they have a lot of power
–issue facing nurses now is universal health coverage because it will affect nurses and nursing care
–other policies that nurses have impacted: staffing ratios, mandatory overtime, and regulation of advanced practice issues
professional nursing culture
–develop professional culture of responsibility and accountability
–speciality nursing groups
encourage education–continuing and formal
–support your colleagues
–magnet hospitals-recognizes excellence in nursing care (only hire nurses with a BSN)
recruitment and retention
Finding and keeping nurses
–aging workforce
–sign on bonuses
–nurse internships- long three month orientation
–RN refresher courses
–nursing shortage- 2020
–externship- summer before junior and senior year; able to work one on one with a nurse
economic value
Salaries and benefits vary
–some areas have unions to get better salaries, benefits, more say in decision making
–what about third party payer reimbursement for nurses
work environment
Need certain things for a health environment, including:
–safety, communication, positive work relationships, work design/spaces, infrastructures to support staff, interdisciplinary team (collaboration)
public relations/communication
Need to be vigilant about the positive image of nursing
Johnson and Johnson campaign
education
–important–some talk about different levels on entering practice
–need continuing education to maintain license and also continuing education to advocate the profession
diversity
to represent the individuals, must serve
–need more: cultures, men
principles of learning
–learning is an active, continuous process manifested by growth and changes in behavior
–learning styles and rates vary from one individual to another
–learning is dependent upon the readiness, the emotional state, the abilities, and the potential of the learner
–learning is influenced by life experiences of the individual
learning theories
–behaviorism
–humanism
–cognitivism
behaviorism
learning needs to be based on a learner’s behavior not a teacher’s definition of behavior (Skinner–Behavior modification [stimulus-response])
humanism
learning that deals with emotional aspects of behavior (Carl Rogers-how do you feel about something)
cognitivism
learning is a complex cognitive activity (Kurt Lewin-very goal directed)
4 factors influencing learning
1. motivation
2. readiness
3. active involvement
4. feedback
motivation
–desire to learn
–person/patient recognizes the need to learn (seen as a good thing)
–motivational strategies nurses may use:
—-explain through examples and models
—-analyzing and dividing complex skills into parts
–motivation is enhanced if:
—-student and teacher trust and respect each other
—-teacher assumes student can learn
—-teacher is sensitive to individual student needs
readiness
–behavior that reflects motivation at a given time
–to determine readiness of a patient, need to:
—-assess where patient is
—-how open is patient to the information
—-what if patient has not learned what they need to know are they are going home (will not be sent home)
active involvement
–practice and demonstration
–learner is more eager and has increased recall of information
feedback
–validates learning
–giving information related to a person’s performance at achieving a specific goal
learning domains
–psychomotor
–cognitive
–affective
psychomotor (learning domain)
deals with physical or motor skills
–observe practice, return demonstration, and feedback
cognitive (learning domain)
acquisition of new knowledge; includes thinking, knowing, and understanding
affective (learning domain)
feelings, emotions, attitudes, and values
relationship of teaching to the nursing process (assessment)
what does the nurse need to know about the client–what does the client already know
relationship of teaching to the nursing process (diagnosis)
centered around learning need
relationship of teaching to the nursing process (planning)
clarify what is to be taught, learned, how it will be evaluated, and what to document
relationship of teaching to the nursing process (implementation)
communicating information about specific objectives to the patient; nurse selects a method of presentation that maximizes the involvement of the client’s senses
relationship of teaching to the nursing process (evaluation)
e and patient determine whether or not objectives have been achieved; evaluation criteria of each behavior should be stated in each objective
relationship of teaching to the nursing process (documentation)
outcome of teaching needs to be recorded; not achievement, reactions, and revisions
change
–the relearning on the part of an individual or group response to newly perceived requirements of a given situation, requiring action, and which results in a change in the structure and/or functioning of social systems
–the process by which alterations occur in the function and structure of society
types of change
–unplanned (haphazard)
–planned (intended)
unplanned change
random and completely unpredictable
planned change
–designed or purposeful attempt to influence individuals, groups, or situations
–planned change is based on rational thinking, assumes that change is a good thing
–deliberate action
–planned change is a complex intervention that requires knowledge, anticipation of consequences, and skillful action by the nurse acting as a change agent
purpose of planned change
to improve the functioning of the system
change agent
a person who initiates the change
–generates and introduces ideas
–develops a climate for planned change by overcoming resistance
–implements and evaluates the change
strategies to implement change
–power-coercive
–empirical rationale
–normative re-educative
power-coercive (change strategy)
–based on the use of power
–it is believed that despite the need for knowledge and for modification of behavior, change will only occur when it is supported by legitimate power
–a basis for political action
–effects change quickly, but change doesn’t last long when it is forced upon people
–use a power to change leads to increased resistance to change
empirical rationale (change strategy)
–assumes person will act rationally
–aims to educate person about available options and assume person will change behavior because he knows that new behavior will be desirable
–may not work alone as a strategy because people do not always act rationally
normative re-educative (change strategy)
–assumes that sociocultural norms are fundamental to a person’s behavior, that actions are guided by norms and values
–aimed at changing beliefs, attitudes, and values
–the re-educative focuses on how much better off the client would be if they would change
–an example would be a famous athlete talking about not using drugs
reasons for resistance to change
–may oppose for a good reason (threatened self interest)
–inaccurate perception of the change or the goal behind the change
–psychological resistant (most changes present some unknown-some there is anxiety); person may see change as loss of autonomy or self-control
–some people have a low tolerance to change
–social factors-more educated individuals adopt to change easier
–cultural factors-change may violate cultural norms
dealing with resistance
–communicate with people opposing change
–clarify misinformation
–supporters of change need to be open to revision and clear about areas that cannot be changed
–explain consequences of resistance to change
–emphasizes the positive aspects
image of nursing
borrow from sciences to take care of the whole patient

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