CLINICAL FEATURE KEYWORDS Leadership theory / Facilitation / Anaesthetic nurse specialist / Clinical supervision Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication August 2013.

Anaesthetic nurse specialist role: leading and facilitation in clinical practice by E Fynes, DSE Martin, L Hoy and A Cousley Correspondence address: Daphne SE Martin, Lecturer (Education)/Pathway Leader Specialist Practice in Anaesthetic Nursing, School of Nursing and Midwifery, Queen’s University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL. Email: [email protected]

Leadership and its effectiveness is becoming more prevalent within the nursing profession with anaesthetic nurse specialists showing their ability to lead, inspire and motivate others to work towards a shared vision in the rapidly changing peri-anaesthesia environment. Anaesthetic nurse specialists must therefore be aware of their personal leadership skills and continually develop these within clinical practice. They are also well placed regarding the facilitation of learning. Within the current culture of healthcare there are many issues which aid and prevent the provision of quality care to patients that also have a direct impact on the professionals within the organisation. The perioperative environment incorporates multi-professional roles in the collaborative provision of individualised patient care. Changes in post registration nurse education in the early 1990s resulted in the creation and development of a specialist anaesthetic nursing course within Northern Ireland, facilitating education and training of anaesthetic nurse specialists (Martin & McCartney 1997). The anaesthetic nurse specialist (ANS) role inputs directly into the multidisciplinary decision making process, bringing the uniqueness of nursing to the planning and delivery of high quality patient care.

Background Early developmental definitions by Miller (1995) envisaged the specialist nurse as a clinical expert, resource/consultant, educator, change agent, researcher and advocate. Martin and McCartney (1997) built upon this definition viewing the anaesthetic nurse specialist (ANS) role as autonomous yet complementary to that of the anaesthetist working in collaboration with other professionals, patients and families. They enthused that the coordination of a person centred approach

to care would bring the uniqueness of nursing into the peri-anaesthesia environment. Oakley (2006) supported these early definitions identifying four key areas of practice for the ANS, namely: n Clinical expert n Specialist n Advocate and n Educator The Nursing and Midwifery Council (2001) guidelines for specialist practice outline that the specialist practitioner must exercise: higher levels of judgment, discretion and decision making in clinical care. The NMC (2001, p4) further stipulate that specialist practitioners will demonstrate higher levels of clinical decision making and so enable the monitoring and improving of standards of care through: n supervision of practice n clinical audit n development of practice through research n teaching and the support of professional colleagues n the provision of skilled, professional leadership.

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The NMC (2001) competencies for specialist practitioners are embedded in current educational programmes for those wishing to record their specialist qualification on the NMC register. This reinforces the need for specialist practitioners to be educators, experts, advocates and leaders in their own specialist field. In this article current leadership styles will be discussed in terms of the impact they have on the anaesthetic nurse specialist’s role in clinical practice. Additionally, the role of the ANS in the facilitation of learning within the peri-anaesthesia environment will be explored using a clinical supervision framework.

The role of the ANS and leadership Nursing leadership in the 21st century is fraught with difficulty due to dynamic changes in healthcare policy and the way in which healthcare is delivered (Sellgren et al 2006, Duygulu & Kublay 2010). Cummings et al (2010) purport that it is a concept that has been discussed and explored for many decades with an abundance of leadership theories, however, there is still a lack of consensus on a firm definition (Welford 2002, Cummings et al 2010).

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Meindl (1995) takes a simplistic view that most authors embrace, that in order for leadership to occur, there must be followers. A more comprehensive conceptualisation is outlined by Shaw (2007) and is seen to embrace a number of elements which view leadership as a process. Even though there is disparity amongst theorists regarding the definition, the importance of effective leadership is clear. Grossman (2007) outlines that as undergraduates much emphasis is placed on the development of clinical skills but not on leadership development. Curtis et al (2011) found that leadership abilities are inadequate following primary degrees and recommend that additional training is paramount to ensure that effective skills are developed. In post-registration education programmes, such as those leading to recordable qualifications with the NMC, for example, specialist practice in anaesthetic nursing, practitioners are challenged to critically appraise their leadership capabilities within the context of the anaesthetic environment and the delivery of person-centred nursing care. The phenomenon of leadership has been recognised for many years but was not scientifically studied until the early 1930s (Howieson & Thiagarajah 2011). Historically, effective leaders were seen as those who demonstrated high levels of achievement and possessed certain characteristics and traits that were perceived as innate (Marquis & Huston 2000, Duygulu & Kublay 2010). This theory, known as the Great Man/Trait theory, dominated until the 1950s (Murphy 2005). One of the main criticisms of this theory is that leaders could not be seen to develop through experience or acquire skill through training (Murphy 2005), however, Feldman and Greenberg (2005) argue that leadership is a skill which may be enhanced through education and experience.

Leadership styles The study of leadership identified styles which belonged to either of two groups. The first focuses on task orientation such as laissez faire, management by exception and transactional leadership. The second

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style focuses on followers and leader relationships, such as transformational leadership (Sellgren et al 2006, Cowden et al 2011). Traditionally, nursing leadership has mirrored the hierarchical nature of the health service by embracing the autocratic style (Paterson et al 2010), and this was no less true of the peri-anaesthesia environment. Carney (2006) and Murphy (2005) stipulate that, in a contemporary health service, leadership must embrace innovation and be visionary in order to motivate others to deal effectively with challenging situations. Even in dated work by McDaniel (1997) the consensus prevailed that, in the era of dynamic change within the health service, traditional approaches could not suffice. This has been further reinforced by numerous policies which emphasise that effective, multifaceted leadership is a key element in the dynamic healthcare system to ensure fair and optimum, quality care (DH 2008, 2009). The Association of Anaesthetists of Great Britain and Ireland in their publication The Anaesthesia Team (AAGBI 2010) supports teamwork, leadership and collaboration which all feature in determining the quality of patient care. Bass (1985 archive work) introduced a leadership model that is the most widely used and recognised within today’s leadership forum. The model comprises two leadership styles: transactional and transformational (Stordeur et al 2001). These two approaches are seen to offer greater dimensions to leadership.

n Thirdly, contingent reward management. This sees the reward of followers when goals are completed or achieved. Transactional leadership in times of stress and urgency can prove effective and beneficial as prompt solutions and clear direction can be offered (Murphy 2005). However, the effectiveness of transactional leadership is questionable if used as the mode of choice, as it has the potential to provoke stress amongst followers (Stordeur et al 2001).

Transformational leadership In contrast, transformational leadership is conducted by a very different approach, being concerned with more than just compliance and reward (Curtis & O’Connell 2011). Transformational leaders are seen to motivate their followers to achieve greater performance through introducing and promoting innovative thinking, empowerment and the use of highly developed communication skills. The motivational nature of a transformational leader instils a shared vision, accountability and responsibility in followers to strive towards achieving shared goals and objectives. Effective leadership styles within nursing per se and within anaesthetic nursing in particular have become an important issue because of the huge influence they have within the healthcare setting in relation to staff, quality patient care and the working environment (Curtis & O’Connell 2011).

Background studies In a study conducted by Malloy and Penprase (2010) to examine the relationship between leadership style and the psychosocial work environment, results clearly demonstrated that transformational leadership positively correlated with a more positive, conducive work environment. It was also seen to increase job satisfaction, commitment and motivation by building trust and demonstrating integrity, and by inspiring, encouraging and coaching others.

Transaction leadership Transactional leadership (Murphy 2005) concentrates on the exchange between leader and follower and is comprised of three main components: n Firstly, active management by exception, where the leader closely monitors the performance of the followers, and intervenes before any adverse events occur. n Secondly, passive management by exception, where criticism is the only feedback given following non-favourable performance or incidents.

This is further supported by a comprehensive and systematic review conducted by Cummings et al (2010) who detailed that 22 of the 24 studies reviewed reported that increased job satisfaction

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CLINICAL FEATURE

There are occasions, depending on the clinical expertise of the team available, where a more transformational approach may be adopted

was associated with relational styles of leadership, mainly transformational. However, Malloy & Penprase (2010) found that the sole use of transformational skills may not be enough to ensure effectiveness unless combined with some components of transactional leadership itself e.g. rewarding achievements and monitoring mistakes. However, it is recognised that there are a number of limitations which affect the applicability and generalisability of Malloy and Penprase’s (2010) study, such as the limited sample size, low response rate and the use of self-reporting which may have resulted in production of a socially desirable response (Polit et al 2001). A more dated study by Stordeur et al (2001) examined the effect of transactional and transformational leadership on levels of emotional stress and exhaustion. This had a much larger sample size of 625 and results from this study, agree with the findings of Malloy and Penprase’s (2010) study. Stordeur et al (2001) purports that transformational leadership, embracing components of transactional leadership (contingent reward) were very closely linked, reducing levels of emotional exhaustion and stress. The authors warned that the transactional approach should not be replaced by transformational leadership but should be used to enhance and complement it. A further finding of this study was the increased level of stress and pressure amongst nurses who felt that their manager led solely through dimensions of transactional leadership, such as active management by exception (Stordeur et al 2001).

Defining the ANS role in leadership The ability to lead effectively is imperative in inspiring and motivating others to achieve set goals or work towards a shared vision, particularly in the current climate of rapid change in the peri-anaesthesia environment. Anaesthetic nurse specialists must therefore be aware of their personal leadership skills and continually develop these within clinical practice (NMC 2001, Sellgren at al 2006). A comparative study by Sellgren et al (2006) focusing on leadership styles used by senior nurses saw a contrast in opinions from those nurses who felt that

their personal styles were more relational i.e. transformational, whereas the opinions of colleagues were that their approach consisted of transactional components. This confirms that the imagined self is sometimes different from the perception of others.

support. As professionals, the facilitation of others is a prerequisite for all nurses through peer development (NMC 2008) and through encompassing the increased knowledge and skills of the anaesthetic nurse specialist role as an educator (NMC 2001, Oakley 2006).

The anaesthetic nurse specialist uses a combination of leadership styles. The key areas of specialist, expert, educator, advocate (NMC 2001) are useful to demonstrate how the ANS adapts within the challenging dynamic of the perioperative point of care delivery. For example, in emergency situations a transactional leadership style may be adopted (Curtis et al 2011) where clear and direct instructions are paramount from a specialist clinical expert (Martin & McCartney 1997, Oakley 2006). Debriefing sessions that follow the response to emergencies allows the ANS to act as an educator and also as patient and colleague advocate (Oakley 2006, WHO 2008).

The appropriate facilitation of learning was further reinforced by the Department of Health (2001) who outlined that the identification of, and opportunity to address learning needs is one of the key elements of nursing leadership (Paterson et al 2010). There are numerous methods available such as mentorship, preceptorship and action learning sets, however, the model that is most commonly used in today’s healthcare arena is that of clinical supervision. This is a mechanism used to enhance practitioners’ knowledge and skill, and to benefit patient care (Milne & James 2002).

There are occasions, depending on the clinical expertise of the team available, where a more transformational approach may be adopted. For example, when the team is comprised of junior staff and management students requiring achievement of learning outcomes, the ANS supports professional development in others by encouraging leadership skill development. Casida & Parker (2010) support this view as they found that junior leaders were more comfortable using a transactional leadership style whilst more experienced leaders were flexible in their approach and more adaptable in the use of their skills in a way appropriate to the situation. In addition to the effective use of transformational leadership, facilitation of learning is also significant in the promotion of autonomy, accountability and optimum patient care.

Clinical supervision was initially introduced as a supportive mechanism for nurses (DH 1993) but more recently it is recognised as a means of providing access to lifelong learning, reflective practice and feedback (Cleary et al 2010). It has been shown to have numerous benefits for both staff and patients in the form of job and patient satisfaction, increased confidence and improved staff knowledge (Edwards et al 2006), resulting in optimum communication between professionals and high quality delivery of patient care (Jones 2006).

Clinical supervision

Facilitation of learning

A study by Koivu et al (2011) examining the reasons for involvement in clinical supervision found that reasons varied between specialities. Nurses working in medical wards viewed clinical supervision as a means of stress management, whereas nurses working on surgical wards regarded it as a supportive means for personal and professional development which is in keeping with our mental health colleagues.

Facilitation of learning within the healthcare setting has been described by the RCN (2002) as a learning opportunity that provides support in an organised and considered manner. The skills in facilitation were highlighted by Howeston-Jones (2003) as the empowerment of others through listening, challenging, negotiation, and

One of the influencing factors found regarding involvement in clinical supervision was the organisational culture of the different wards. Although the sample was representative of a large teaching hospital in Finland, care must be taken when applying and generalising the findings to

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Anaesthetic nurse specialist role: leading and facilitation in clinical practice Continued

other countries. The study identified that organisational culture varies between wards even within the same hospital, it is then indicative of the differences that may exist between countries and nursing cultures. In contrast to these findings, Cummins (2008) warns that the organisation must be vigilant to ensure that, when providing high quality clinical supervision, it is not being used solely to benefit the career and development of the participants but also to inform clinical praxis. The reasons for participation in clinical supervision are significant; however, it is equally important to recognise that there are also barriers existing in the effective implementation of this concept. An audit of clinical supervision by Barriball et al (2004) found that, although the majority of respondents in the study found that some form of regular clinical supervision occurred, it was not conducted in a wellorganised manner. Increased workloads, time constraints and staff shortages were identified as the main reasons for cancellation of meetings or taking an ad hoc approach to clinical supervision. Clouder & Sellars (2004) are supportive of this finding, outlining that in recent years the approach to clinical supervision has been disjointed and sporadic, or seen as a luxury due to lack of available time (Gray 2001). Furthermore, not all who take part in clinical supervision feel that it is of benefit, but rather the process has been misunderstood as a means of monitoring poor performance (Cheater & Hale 2001, Koivu et al 2011). Clouder and Sellars (2004) provided recommendations outlining how the difficulty of time constraints may be overcome by allowing protected time and developing group sessions as opposed to individual one to one sessions. Barriball et al (2004) indicated that only a small percentage of the respondents in their study (18%) felt that group sessions were feasible; it was difficult enough to find a suitable time for a one to one session and respondents saw a group session as too difficult to arrange. Furthermore, respondents alluded to the difficulties of trust and confidentiality as major issues within a group, particularly when working in one department. Walsh et al (2003) highlighted the importance of confidentiality, respect and 100

participants’ feelings of security as crucial aspects of facilitation between those in the clinical supervision relationship, as well as trust and support. Spence et al (2002) however outlined that the building of effective relationships does not always occur due to the allocation of supervisors, resulting in personality clashes and the inability to find common ground between professionals. This does not provide an environment conducive to learning, however Gilbert (2001) outlined that exercising autonomy through the choice of supervisor may prove to develop a more fruitful relationship.

The anaesthetic nurse specialist’s perspective within organisational culture is that of professionalism, quality, cost effective health care delivered in an environment where much consideration is placed on patient safety reduced mortality and staff development. However, it is also apparent that unrealistic expectations prevail where the drive for increased patient throughput can be at the expense of patient safety (Carney 2004). Hence it is important that the autonomous practitioner must strive to maintain and improve quality through advocacy for both patient and colleagues alike.

Teasdale et al (2001) detailed that, through the use of effective clinical supervision, participants would experience reduced levels of stress and enhanced feelings of wellbeing. Jones (2006) in contrast described how, if conducted inappropriately or by a facilitator with poor facilitation skills, clinical supervision can be a catalyst for anxiety. The author recommended further research into how the personalities of nurses and the culture of nursing may influence the experience of clinical supervision (Jones 2006).

The anaesthetic nurse specialist’s role in clinical supervision

The literature suggests that an awareness of organisational culture is crucial to enable both effective leadership and learning via facilitation, using one of the many available methods e.g. clinical supervision. A study by Carney (2011) to examine organisational culture found that the concept was somewhat more complicated than initially perceived, and several influences were identified. Two of the themes highlighted within the study included cost effective care and professionalism. In today’s healthcare economy the drive for efficiency and patient throughput is important to senior management and does shape organisational culture, with professionalism a key influence on that culture (Carney 2011). Therefore, as eluded to by McNicholl et al (2008) the professional development of staff knowledge and skills would suggest a need for effective facilitation of learning through mechanisms such as clinical supervision to support the creation of a more positive organisational culture. The use of effective leadership skills and appropriate methods of facilitation can therefore result in positive outcomes (Shobbrook & Fenton 2002, Ritter 2011).

Following a concept analysis Lyth (2000) defined clinical supervision as a medium whereby participants could: …share clinical, organisational, developmental and emotional experiences with other professionals in a secure, confidential environment in order to enhance knowledge and skills leading to increased awareness of other concepts including accountability. The anaesthetic nurse specialist is a clinical expert (Oakley 2006) with specialist knowledge and skills, therefore a clinical supervision model incorporating problem solving, knowledge sharing and reflection should be used which will facilitate learning within the peri-anaesthesia area. As an ‘expert’ the ANS has the skills of peri-anaesthetic assessment, planning, implementation and evaluation of care, reviewing and implementing research, promoting the developing a therapeutic environment. He or she is competent in IV cannulation, IV drug administration, advanced life support and tracheal intubation. As a ‘specialist’ (NMC 2001) the ANS can give advice to other professionals regarding patient needs and act as a resource/ consultant for other specialties i.e. ICU and A&E, as well being a change agent when required.

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CLINICAL FEATURE

As leadership is a complex phenomenon, education and knowledge gain are both seen as essential to facilitate learning in the clinical environment

As ‘advocate’ the ANS acts on the patient’s behalf ensuring high quality care is given according to the patient’s wishes and in their best interests. Finally as an ‘educator’ the ANS is in a pivotal position with specialist knowledge and skills to co-ordinate pre, intra and post anaesthetic education with staff induction and education programmes. It is evident that the ANS brings a myriad of specialist knowledge and skills to the clinical supervision situation.

Conclusion

Carney M 2006 Health service management: culture, consensus and the middle manager Cork, Oak Tree Press

Gilbert T 2001 Reflective practice and clinical supervision: meticulous rituals of the confessional Journal of Advanced Nursing 36 (2) 199-205

Carney M 2011 Influence of organisational culture on quality healthcare delivery International Journal of Health Care Quality Assurance 24 (7) 523-39

Gray W 2001 Combining clinical and management supervision Nursing Management 8 (6) 14-22

Casida J, Parker J 2011 Staff nurse perceptions of nurse manager leadership styles and outcomes Journal of Nursing Management 19 478-86 Cheater FM, Hale C 2001 An evaluation of a local clinical supervision scheme for practice nurses Journal of Clinical Nursing 10 119-31 Cleary M, Horsfall J, Happell B 2010 Establishing clinical supervision in acute mental health inpatient units: acknowledging the challenges Issues in Mental Health Nursing 31 525-31

Grossman S 2007 Assisting critical care nurses in acquiring leadership skills Dimensions of Critical Care Nursing 26 (2) 57-65 Howeston-Jones IL 2003 Difficulties in clinical supervision and lifelong learning Nursing Standard 17 (37) 37-41 Howieson B, Thiagarajah T 2011 What is clinical leadership? A journal-based meta-review International Journal of Clinical Leadership 17 (1) 7-18

Following examination of historical and more modern leadership styles it is evident that the use of transformational leadership with the underpinnings of shared accountability, equity and empowerment provides many benefits for staff, patients and the organisation. It is noteworthy that flexibility in leadership is crucial due to the fluid and unpredictable nature of perianaesthesia care which requires critical judgement and competence. The ANS brings in-depth clinical knowledge and expertise into these situations to promote safe clinical outcomes.

Clouder L, Sellars J 2004 Reflective practice and clinical supervision: an interprofessional perspective Journal of Advanced Nursing 46 (3) 262-9

Jones A 2006 Clinical supervision: what do we know and what we need to know? A review and commentary Journal of Nursing Management 14 577-85

Cowden T, Cummings G, Profetto-McGrath J 2011 Leadership practices and staff nurses’ intent to stay: a systematic review Journal of Nursing Management 19 461-77

Koivu A, Saarinen PI, Hyrkas K 2011 Stress relief or practice development: varied reasons for attending clinical supervision Journal of Nursing Management 19 644-54

Cummins A 2008 Clinical supervision: the way forward? A review of the literature Nurse Education in Practice 9 215-20

Lyth GM 2000 Clinical supervision: a concept analysis Journal of Advanced Nursing 31(3) 722-9

As leadership is a complex phenomenon, education and knowledge gain are both seen as essential to facilitate learning in the clinical environment. Clinical supervision is a forum to facilitate learning once shortfalls have been identified. The ANS is therefore in a pivotal position to bring clinical expertise to the learning situation. The nurturing and development of this role will enhance care provision with the uniqueness that the ANS brings to the perioperative situation.

Curtis E, De Vries J, Sheerin F 2011 Developing leadership in nursing: exploring key factors British Journal of Nursing 20 (5) 306-9

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Nursing and Midwifery Council 2001 Standards for specialist education and practice London, NMC Nursing and Midwifery Council 2008 The NMC code: standards of conduct, performance and ethics for nurses and midwives London, NMC

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Anaesthetic nurse specialist role: leading and facilitation in clinical practice Continued

Oakley M 2006 The anaesthetic nurses’ perception of their role British Journal of Anaesthetic and Recovery Nursing 7 (1-2) 11-14 Paterson K, Henderson A, Trivella A 2010 Educating for leadership: a programme designed to build a responsive health care culture Journal of Nursing Management 18 78-83 Polit DF, Beck CT, Hungler BP 2001 Essentials of nursing research: methods, appraisal and utilisation Philadelphia, Lippincott Williams and Wilkins Royal College of Nursing 2002 Helping students get the best from their practice placements London, RCN Sellgren S, Ekvall G, Tomson G 2006 Leadership styles in nursing management: preferred and perceived Journal of Nursing Management 14 348-55 Shaw S 2007 Nursing leadership Oxford, Blackwell Publishing Shobbrook P, Fenton K 2002 A strategy for improving nurse retention and recruitment levels Professional Nurse 17 (9) 534-6

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About the authors Elizabeth Fynes RN, BSc (Hons), Post Grad. Dip. Specialist Practice in Anaesthetic Nursing Anaesthetic Nurse Specialist, In Patient Theatres, Causeway Hospital, Coleraine, N. Ireland

Teasdale K, Brocklehurst N, Thom N 2001 Clinical supervision and support for nurses: an evaluation study Journal of Advanced Nursing 33 (2) 216-24

Daphne SE Martin RN, RNT, MICHT, DipEdNurs., Dip. Reflex., BSc (Hons), MSc

Walsh K, Nicholson J, Keough C et al 2003 Development of a group model of clinical supervision to meet the needs of a community mental health nursing team International Journal of Nursing Practice 9 33-9

Lecturer (Education)/Pathway Leader Specialist Practice in Anaesthetic Nursing, School of Nursing and Midwifery, Queen’s University Belfast Leontia Hoy RN, RCNT, RNT, PGCE, MSc

Welford C 2002 Matching theory to practice Nursing Management 9 (4) 7-11 World Alliance for Patient Safety 2008 Implementation of the manual surgical safety checklist – Safe Surgery Saves Lives Geneva: WHO

Spence C, Cantrell J, Christie C, Sarnet W 2002 A collaborative approach to the implementation of clinical supervision Journal of Nursing Management 10 (2) 65-74

Lecturer (Education)/Course Director Specialist Practice in Nursing, School of Nursing and Midwifery, Queen’s University Belfast Ann Cousley RN, Dip Health Studies (Commendation) BSc (Hons) Specialist Practice in Anaesthetic Nursing, PGCE Anaesthetic Nurse Specialist, In Patient Theatres Causeway Hospital, Coleraine, N. Ireland

No competing interests declared

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Anaesthetic nurse specialist role: leading and facilitation in clinical practice.

Leadership and its effectiveness is becoming more prevalent within the nursing profession with anaesthetic nurse specialists showing their ability to ...
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