CIN: Computers, Informatics, Nursing

& Vol. 33, No. 3, 108–114 & Copyright B 2015 Wolters Kluwer Health, Inc. All rights reserved.

F E A T U R E A R T I C L E

E-simulation Preregistration Nursing Students’ Evaluation of an Online Patient Deterioration Program ROBYN CANT, PhD SUSAN YOUNG, EdD, RN, RM SIMON J. COOPER, PhD, RGN, FHEA JOANNE PORTER, PhD, RN

Technological developments and resource limitations in nursing education have encouraged exploration of e-learning and computer-based education (CBE) programs.1 Common forms to date include teacher-centric, instructivist approaches involving information provision and/or facilitator-moderated online student discussion groups.1–3 Latterly, developments have included e-Simulation programs based on more constructivist principles that promote student engagement and reflectivity.4 In this model, students complete a specialized learning program on a standalone computer or on the Internet.5 These e-Simulation programs have various educational advantages in their approximation of real-world situations where students learn through identifying and resolving Author Affiliations: School of Nursing and Midwifery, Monash University, Berwick, Victoria (Drs Cant and Cooper); and Teaching and Learning, School of Nursing and Midwifery, The University of Queensland, Ipswich, Queensland, Australia (Dr Young); School of Nursing and Midwifery, University of Brighton, United Kingdom (Dr Cooper); Academic School of Nursing and Midwifery Federation University, Churchill, Victoria (Dr Porter), Australia; and the FIRST2 ACT Research Team. Support for the original work was provided by the Australian Learning and Teaching Council Ltd, an initiative of the Australian Government Department of Education, Employment and Workplace Relations. Contribution to authorship: S.J.C. was the principal project investigator with the FIRST2 ACT Research Team collaborators (named in the Acknowledgment). Authors R.P.C. and S.Y. analyzed the data, and R.P.C. and J.P. drafted the report, which was edited by S.J.C. and S.Y. All authors approved the final draft for publication. The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Robyn Cant, PhD, School of Nursing and Midwifery, Monash University, 100 Clyde Rd, Berwick, Victoria 3806, Australia ([email protected]). DOI: 10.1097/CIN.0000000000000133

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This study explores preregistration nursing students’ views of a Web-based simulation program: FIRST2 ACTWeb (Feedback Incorporating Review and Simulation Techniques to Act on Clinical Trends-Web). The multimedia program incorporating three videoed scenarios portrayed by a standardized patient (human actor) aims to improve students’ recognition and management of hospital patient deterioration. Participants were 367 final-year nursing students from three universities who completed an online evaluation survey and 19 students from two universities who attended one of five focus groups. Two researchers conducted a thematic analysis of the transcribed narratives. Three core themes identified were as follows: ‘‘ease of program use,’’ ‘‘experience of e-Simulation,’’ and ‘‘satisfaction with the learning experience.’’ The Web-based clinical learning environment was endorsed as functional, feasible, and easy to use and was reported to have high fidelity and realism. Feedback in both focus groups and surveys showed high satisfaction with the learning experience. Overall, evaluation suggested that the Web-based simulation program successfully integrated elements essential for blended learning. Although Web-based educational applications are resource intensive to develop, positive appraisal of program quality, plus program accessibility and repeatability, appears to provide important educational benefits. Further research is needed to determine the transferability of these learning experiences into real-world practice. KEY WORDS Competency-based education & Education & Nursing & Patient simulation & Program development & Web-based simulation

dilemmas that ‘‘challenge their knowledge, values, and emotions.’’6(p3) E-Simulation has been utilized in a number of fields including business management, the retail industry and in healthcare,4 aiming to expand a learner’s experience of ‘reality’ and, in nursing, to contribute to clinical learning.7–10 For example, students have the opportunity to practice nursing assessments and make clinical decisions with screen-based ‘patients’10–12 in preoperative and postoperative patient care management using screen-based simulations and multiple case stories.8

CIN: Computers, Informatics, Nursing & March 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Computer-based e-learning strategies are generally endorsed by students as an alternative to classroom learning.13 The benefits are not limited to knowledge enhancement, as students also favor the flexibility and control regarding the timing and pace of learning.14 In nursing, for example, laboratory-based simulation using a problem-based approach was enhanced by synchronous Web-based learning materials.15 Positive learning outcomes were demonstrated, including improved examination results and higher satisfaction and self-efficacy. Furthermore, case-based critical care scenarios using e-learning have been positively reported and found to be easy to use and realistic.10 In evaluating an e-learning program, both objective and subjective measures are of benefit.16 The key factor to be examined, however, is the overall ‘usability’ of Internetbased programs,17 because for students to engage with a CBE program high-quality visual effects and content relevance are essential.18 Although usability measures vary, key elements include the computer interface experience, the level of preparation required, and satisfaction with the quality of the learning experience. Students are more likely to engage with a clinical e-learning simulation program if it is easy to use and realistic and perceived as a valuable learning experience.13,14 In this article, we aim to explore preregistration nursing students’ views about the clinical e-Simulation program: FIRST2ACTWeb. This program was developed by the authors with the objective of improving students’ recognition and management of patient deterioration. Details of the project protocol are reported elsewhere,19 as are performance outcomes.20,21 The educational intervention is summarized in the following sections.

METHODS This mixed-methods study reported qualitative data in the form of focus groups and quantitative data from postprogram student feedback and an online satisfaction survey.

The E-Simulation program FIRST2ACTWeb The educational package FIRST2ACTWeb (Feedback Incorporating Review and Simulation Techniques to Act on Clinical Trends-Web) (http://first2actweb.com/) was developed based on feedback from face-to-face laboratory simulation trials. The linear multimedia format utilizes three video scenarios, each with 32 assessment and treatment options. The scenarios present common medical conditions (acute myocardial infarction, hypovolemic shock, and chronic obstructive pulmonary disease) and feature a standardized patient (a human actor). The multimedia approach facilitates the participant learning experience, using the following media: visual, text, voice, optional choices, and feedback. Following a slide presentation designed to introduce the key elements of patient management, during the ‘patient intervention,’ students are required to make real-time decisions about nursing management. Each scenario runs for 8 minutes while the student role-plays each step of the nursing role. The scenario is timed, with the on-screen clock counting down to zero, thus creating a sense of urgency. Assessments are collected from the participant’s on-screen actions in order to provide feedback at the end of each scenario in the form of a summary score and generic reaction. Further learning is optional by downloading and studying the course manual. In general, a participant will be engaged with the program for about 1 hour. The sequence is summarized in Table 1.

Recruitment for online Evaluation The e-Simulation program was evaluated by a convenience sample of 367 preregistration students from a population of 483 final-year nursing students at three universities and two vocational colleges. The clinical performance of survey participants has been previously reported.21 Faculty staff who administered the educational units were also invited to complete the online program (Figures 1 and 2).

T a b l e 1 Summary of Participation (the Student Journey) in FIRST2ACTWeb The e-Simulation Package FIRST2ACTWeb Online Procedures Occur in the Following Order 1. 2. 3. 4.

Login and registration with a short demographic survey. Completion of a short pretest multiple choice clinical knowledge questionnaire (MCQ). Introductory verbalized PowerPoint presentation. Complete a series of three interactive videoed simulation exercises, each commencing with ‘handover’ and rated using objective structured clinical examination checklists; 32 patient assessment/treatment options are available for each scenario over a period of 8 min with acute deterioration at the midpoint. Numerical and textual performance feedback is provided at the end of each scenario. 5. Completion of posttest knowledge MCQ (repeated) and correct answers provided by e-mail. 6. Completion of a short evaluation and a satisfaction survey (online). 7. Online ordering of participation certificate of program completion—subsequently delivered by via e-mail. 8. Optional download of First2Act Manual (for further study). Response data are remotely tracked (collected online via a server database) in order to provide participants with feedback To access further details and the program, see first2actweb.com

CIN: Computers, Informatics, Nursing & March 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

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researcher-generated semistructured focus group questions.23 Each analyst attributed nominal codes to narrative segments, which were then grouped in tabular format. Subthemes that were identified were likewise clustered under the main themes. Once each researcher had determined the emergent themes, the findings were shared, and the data underwent further collaborative refinement until consensus was achieved,23 and the final themes were agreed upon. Satisfaction survey data gathered online were downloaded from the Internet and entered into IBM SPSS (IBM, Armonk, NY) for analysis. Ratings were reported using descriptive summary statistics (means, percentages).

RESULTS

FIGURE 1. FIRST2ACTWeb: ‘‘Let’s see how the patient is feeling’’—showing ‘click’ options to view observations and vital signs, and so on. The clock shows the start: 7.55 minutes of the 8-minute scenario. Reproduced with permission of the FIRST2ACT Research team.21

Focus Group Recruitment University students (n = 330) and faculty staff with experience of the program were invited to participate in a focus group, with the aim of gaining in-depth information about the impact and conduct of the program. Mixed student and faculty staff groups were planned to prompt discussion across user groups. Four focus groups were conducted at one university and two at another (in total, at five campuses). Interviews were completed between April and June 2013, over more than 30 to 70 minutes’ duration, each with all participants providing written consent. Ethics committee approval had previously been gained from each university for the study including the evaluation component.

Participants were 330 final-year nursing degree students, of whom 90% were female, and the median age was 21 years. Of these, 19 attended a focus group as described in the following section.

Focus Groups Nineteen students and nine faculty staff who recently completed the FIRST2ACTWeb e-Simulation program participated in one of five focus groups. Four groups comprised both students and staff, and one group comprised only students. In order to focus on students’ responses to e-learning, the views of participating staff were excluded from this report. Three main themes were identified from the students’ discussion: ‘ease of program use,’ ‘experience of e-Simulation,’ and ‘satisfaction with the learning experience.’ (Table 2). Each theme is addressed below. EASE OF PROGRAM USE Provided they had followed instructions, most students found few problems in accessing the program via the

Conduct of Focus Groups Focus groups were conducted by any of three trained researchers with the aid of a topic guide. The discussion was centered around online access issues and technological function, the clinical relevance, and participants’ reaction to the experience, together with likes and dislikes, and how the program might be improved. Discussions were audio recorded and subsequently fully transcribed by an independent provider.

Analysis Focus group transcriptions were analyzed by two trained researchers who independently coded a proportion of the narratives. When possible, student and faculty comments were differentiated for comparative analysis. Content analysis was used to characterize responses to the specific 110

FIGURE 2. FIRST2ACTWeb: a nursing student listens to voiceover and views patient history as 1 option for nursing assessment.

CIN: Computers, Informatics, Nursing & March 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

many cases, they could suspend reality while playing the nursing role.

T a b l e 2 Key Themes and Related Subthemes Identified From Focus Groups Main Theme Ease of program use

Experience of clinical e-Simulation

Satisfaction with the learning experience

Subtheme Access Navigation Overall usability/quality Realistic Stressful Frustrating It’s good to practice Relevant to students’ needs Appropriate for level of skill Scores and feedback were helpful Approving of the program

Internet and in streaming of the interactive videos to their home or university-based personal computer. They logged in and found the introductory information to be well paced and the multiple choice questionnaire relevant. There was much discussion about the best way to learn how to navigate the e-Simulations and to understand action options, including the available treatments and potential backtracking. A number of participants suggested there should be a first nonrated sample scenario to orient them to site navigation and technical aspects. ‘‘Iit would have been good to have a dry run just to get all the clicking, and looking at the various parts of screenI what was available.’’ (Female, FG 1)

Some criticized the verbal ‘patient handover,’ saying there could be more details given about the hospital context and the patient’s history. By the third scenario, participants felt able to better navigate the system and were focused on achieving an increase in their performance score. Others welcomed use of the e-Simulation program and the degree of difficulty and as a practical substitute for challenging real-life clinical experiences. ‘‘You were forced to think about what you were going to do. But then, you also had that other thing underneath—that you knew he wasn’t going to die. ISo, I mean, it was a really good, practice kind of thing.’’ (Female, FG 6)

There was a consensus about the ease of use of the program in that technical aspects worked as planned. Participants reported they were able to complete the full ‘educational journey’ (Table 1), including receiving feedback and downloading the manual and certificate of completion. Thus, the online program was found feasible and functional. EXPERIENCE OF CLINICAL E-SIMULATION Participants commented on the high degree of realism in video simulations portrayed by standardized patients. In

‘‘I’d just come off my emergency placement, I knew how to deal with chest painI I was impressed with the acting. I was just, like, oh! This is really real.’’ (Female, FG 8)

Participants liked the reality of high fidelity simulation with the standardized patient. ‘‘It was more real than I’d done with a mannequin thus far.’’ (Female, FG 5)

The realism was powerful for many, with a genuine sense of urgency conveyed by the patient who continued to cry out in pain. ‘‘It felt real. And I did get that sense of panic feeling, as well, because the clock was counting down, and then, he was moaningI’’ (Female, FG 6)

While many believed the scenario was true to life, a number also commented that as the scenario progressed it seemed less realistic because the patient appeared ‘‘too well’’ or not pale enough. Students felt stressed because the patient did not appear to respond to nursing actions by showing an improvement in vital signs or a reduction in pain. Some became anxious that the interventions were not working or that no assistance arrived when they asked for help via the emergency button. Some were panicked regarding choice of action buttons: ‘‘I[thinking] ‘where’s that?’ You know what I mean? I clicking on all of them because you’re under pressure.’’ (Female, FG 7)

Some felt that the taking of observations was too slow and felt frustrated because they could not progress nursing actions while waiting for vital signs to be recorded and interventions completed (such as taking an electrocardiogram). That no tasks could be completed concurrently was seen as frustrating; however, the perceived urgency of the situation appeared to override their systematic collection of information with which to make reasoned decisions. While participants felt a strong pull toward providing assistance to the patient, the presence of the on-screen timer counting down the minutes was for some a source of distress. ‘‘If I couldn’t see the clock I probably wouldn’t have been so stressed. Seeing the clock and going ‘I’ve got 30 seconds left’ [was stressful]I’’ (Female, FG 1)

There were suggestions that the timed scenario added to the sense of realism, however. ‘‘I was freaked out, I had no idea what was coming, so I was just like: ‘oh God, I only get one chance at this. I have to be quick and methodical and I have to know everything and how it works’I’’ (Female, FG 8)

Others thought the time-clock assisted their performance. ‘‘[the clock] was an essential feature of this thing because it was putting me on the spot.’’ (Female, FG 1)

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The narratives suggested that participants started to anticipate and prioritize as they progressed through the scenarios and that they became engrossed in the moment. Accordingly, there appeared to be a fine balance to be maintained between actors role playing a clinical situation (the ‘unreal’) versus a student‘s perception of ‘‘the real,’’ viewing a real-life episode of a patient in distress. Some suggestions were made to further improve replication of a real-life situation (eg, to leave the blood pressure cuff on the patient after the first recording was taken). However, participants thought that e-Simulation offered a good opportunity to learn and to practice their clinical skills, and no overtly negative views were apparent. SATISFACTION WITH THE LEARNING EXPERIENCE Although there were clearly limitations to the interactivity of the online e-Simulations, participants were positive about the learning experience. ‘‘I’m just so happy to do these scenarios, to get the [practice]. I felt like after I’d done three, I was like: great, give me 10 more.’’ (Female, FG 1)

Participants reported they learned how to care for a deteriorating patient and that the scenarios were appropriate for their skill level. The feedback (given as scenario ratings and a generic performance report) was highly valued, with a student saying she can ‘‘learn the most from feedback’’ and several others reporting that their performance scores improved between scenarios. Although individualized performance feedback would be preferred, generic reports were seen as acceptable, scenario ratings as helpful, and the certificate of completion of value. Verbal feedback from the standardized patient (a thank-you at the end) was seen as important by participants as it reassured them no harm had been done to the patient. ‘‘[I] felt so much more confident about what I knew and what I didn’t know. And that I actually knew stuff was really goodI. It gives you that reassurance.’’ (Female, FG 1)

Participants appreciated practicing in a simulated environment that was safe for the patient and also safe for the student because their privacy was protected. They knew that they were not being observed and that they could not ‘‘kill’’ the patient; voicing relief that ‘‘he didn’t die.’’ ‘‘I feel more confident now to be at least some sort of help in a real situation.’’ (Female, FG 5)

Satisfaction Survey Participants (n = 330) rated the program’s value (on a scale of 1–5) and their satisfaction with the Web-based learning process. The responses (Table 3) include those from all students who attended the focus groups. The e-Simulation education was rated highly, averaging 4.57 of a possible five points. In particular, 95% of participants thought the session ‘relevant’ to their needs, were ‘encouraged to think through a clinical problem,’ and rated the curriculum as ‘appropriate to my level of training.’ For 94%, the program stimulated the student’s interest, and 92% thought the program challenging ‘without being threatening.’ The lowest rated item was: This session as a whole provided effective feedback, as 88% agreed, whereas 13% were uncertain or disagreed. None of the ratings indicated negative views overall. The course satisfaction scale demonstrated a high level of internal consistency (reliability) (Cronbach’s ! = .90).

Substantiation of Results Qualitative inquiry can be liable to investigator bias, and hence we examined the trustworthiness of the focus group findings using methodological triangulation comparing the focus group themes with students’ quantitative survey responses.24 Both sources supported the notion that the program met students’ learning needs. In particular, responses indicated that practice in simulation scenarios helped students

Ta b l e 3 E-Simulation Course Satisfaction Survey: Feedback From 330 Nursing Studentsa

This Session as a Whole Encouraged me to think through a clinical problem Was relevant to my needs Helped me integrate theory into practice Was appropriate to my level of training Stimulated my interest in the topic area Was challenging without being threatening Provided effective feedback Total a

Positive Response: (Rating = 4 or 5), n (%)

Uncertain (Rating = 3), n (%)

Disagreement (Rating =1 or 2), n (%)

Mean Score/SD

314 (95.1)

12 (3.6)

4 (1.2)

4.67 (0.62)

313 (94.9) 312 (94.6) 313 (94.8) 311 (94.3) 302 (91.6) 291 (88.2) 93.4%

12 (3.6) 14 (4.2) 16 (4.8) 17 (5.2) 24 (7.3) 27 (8.2) 5.3%

5 (1.5) 4 (1.2) 1 (0.3) 2 (0.6) 4 (1.2) 12 (4.8) 1.5%

4.62 (0.28) 4.59 (0.65) 4.66 (0.60). 4.62 (0.61) 4.46 (0.68) 4.43 (0.84) 32.0 (3.70)

Ratings: 1 (not at all) to 5 (to a large extent).

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Scale Total

transfer knowledge into practice, although with a level of performance stress that was challenging because of the realism portrayed, yet not at a level that was perceived as too threatening. Investigator triangulation was achieved through results review.25 Two researchers read the focus group transcriptions, independently analyzed the narratives, and corroborated the findings. We found agreement throughout, regarding students’ perceptions of a positive impact of the program on clinical learning.

DISCUSSION E-Simulation is an educational strategy that takes computerbased clinical education to a new level, as it is entirely student-centric with flexibility in timing and the pace of learning. It uses constructivist principles that require a student’s engagement,4 yet it allows reflectivity. Simulation education aligns with recommendations for deep knowledge transfer with known benefits for students through enacting integration of theory into clinical practice.26 We explored the clinical learning environment of the FIRST2ACTWeb online clinical learning program, to find that it was fully endorsed by participants who rated the e-Simulation education highly. In focus groups and in written feedback, participants reported the online program had functioned adequately, allowing access to online videos and optional clinical interactions to complete all steps in the journey (Table 1). Given the complexity of the program software and remote data collection and individual feedback, the evaluation was gratifying. However, we were not able to report the views of students who were unable to complete the program with some earlier anecdotal evidence that there had been video streaming problems until the videos were subsequently compressed. This also meant that some students may not have been able to access and complete the evaluation. Webbased educational programs can succeed or fail based on the perceived ease of use by participants, a major consideration during design.18 While there was consensus about ease of program use and high levels of satisfaction with the learning experience, students did make practical suggestions to enhance any revision of the program or the software. Continued development is important as students are more likely to engage in e-learning if it is easy to use and realistic and is perceived as a valuable learning experience.13,14 While the fidelity achieved in video simulations was high, with a student declaring ‘‘Oh! This is really real,’’ some also voiced limitations to suspension of belief in a simulated setting. The program was designed to encourage a systematic nursing process including data and cue collection, also requiring the processing of results prior to any action.27 In order to create a sense of urgency, many of the interventions took a designated amount of time to simulate clinical practice (with the on-screen clock counting

down in seconds). For example, taking the patient’s blood pressure or inserting an intravenous cannula resulted in a real-time delay before another task could be completed, which frustrated participants who were keen to multitask. This was, and is, a limit to the software but does reinforce the notion that it takes time to do real things. However, the timed scenario added to the sense of realism for some and was a source of stress to others, all of whom had the objective of playing out the nursing role before the clock reached 8 minutes. Participants reported the program was challenging but not threatening. This ambivalence toward levels of stress and/or frustration is not unexpected as a certain level of stress is anticipated when confronted with emergent clinical situations. It is also acknowledged that stress can add to the learner’s motivation to learn despite the difficulties of knowledge development as their anxiety levels increase.28 Effective simulation education purposely engages emotions in order to mirror the real world and to develop skills in urgent situations.6 However, if anxiety levels are increased too highly, some reports suggest that there is an inverted ‘U’ relationship, with performance increasing as anxiety increases—but as the peak is reached, performance rapidly declines.29 In this study, this seems to have been balanced as students reported feeling a sense of relief that they were not under direct observation while completing the program. In summary, e-Simulation programs based on blended learning (as applies to FIRST2ACTWeb) are an important educational strategy in the development of cognitive, emotional, and behavioral capacities in students.6 Students perceived the program as modeling ‘‘real life’’ and recognized the importance of the clinical application of these skills in their future practice. Only simulation can offer clinical decision-making practice or repeated practice to order, which was an element that students appreciated, saying, ‘‘After I’d done three, I was like, ‘great, give me 10 more.’’’ This program evaluation therefore adds to growing evidence in support of the role for simulation in achieving registration and accreditation requirements.30 The study has several limitations. The inability to generalize beyond this study has resulted in recommendations for further research. While mixed student and faculty staff focus groups may have prompted rich discussion, interaction may also have been limited owing to social or studentteacher conventions. The focus groups comprised students who had completed the e-Simulation trial with little or no representation of those who did not complete the program. As with all qualitative studies, analysis of data can introduce a risk of bias through researcher interpretation, and this was addressed by independent analysis using two researchers. Notably, in the online satisfaction survey, we were also not able to record the views of students who commenced the program, yet did not complete it. Although reasons for their exit prior to reaching the questionnaire are unknown, issues such as video streaming may have

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contributed. Nevertheless, we believe that this report has been able to confirm the findings as valid and reliable, informing future developments in the education field.

CONCLUSION The clinical learning environment provided by the FIRST2 ACTWeb online learning package was endorsed by finalyear nursing students who rated the program as functional, feasible, and easy to use. The program, which aimed to improve knowledge of hospital patient deterioration management, was reported to have high fidelity and realism. Feedback in both focus groups and the online survey showed high satisfaction with the learning experience. Overall, evaluation suggested that the Web-based simulation program, using a blended learning model, highlighted those skills essential for successfully identifying and managing a deteriorating patient. While this Web-based educational strategy might be resource intensive to develop, strong acceptance confirms the potential for students to actively seek to repeat the program outside the classroom to rehearse for their future clinical role. Further research is needed to determine the transferability of these learning experiences into realworld practice.

Acknowledgments The authors acknowledge the contribution of other members of the FIRST2ACT project team: Alison Beauchamp, Fiona Bogossian, Tracey Bucknall, Brett DeVries, Ruth Endacott, Helen Forbes, Victoria Kain, Leigh Kinsman, Lisa McKenna, and Nicole Phillips.

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E-simulation: preregistration nursing students' evaluation of an online patient deterioration program.

This study explores preregistration nursing students' views of a Web-based simulation program: FIRST ACTWeb (Feedback Incorporating Review and Simulat...
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