Journal of Gerontological Nursing

Feature Article 

Bullying in Senior Living Facilities: Perspectives of Long-Term Care Staff

Felicia J. Andresen, MA; Jeffrey A. Buchanan, PhD

Abstract

Resident-to-resident bullying has attracted attention in the media, but little empirical literature exists related to the topic of senior bullying. The aim of the current study was to better understand resident-to-resident bullying from the perspective of staff who work with older adults. Forty-five long-term care staff members were interviewed regarding their observations of bullying. Results indicate that most staff members have observed bullying. Verbal bullying was the most observed type of bullying, but social bullying was also prevalent. Victims and perpetrators were reported to commonly have cognitive and physical disabilities. More than one half of participants had not received formal training and only 21% reported their facility had a formal policy to address bullying. The implications of these results support the need for detailed policies and training programs for staff to effectively intervene when bullying occurs. [Journal of Gerontological Nursing, 43(7), 34–41.]

Abstract

Resident-to-resident bullying has attracted attention in the media, but little empirical literature exists related to the topic of senior bullying. The aim of the current study was to better understand resident-to-resident bullying from the perspective of staff who work with older adults. Forty-five long-term care staff members were interviewed regarding their observations of bullying. Results indicate that most staff members have observed bullying. Verbal bullying was the most observed type of bullying, but social bullying was also prevalent. Victims and perpetrators were reported to commonly have cognitive and physical disabilities. More than one half of participants had not received formal training and only 21% reported their facility had a formal policy to address bullying. The implications of these results support the need for detailed policies and training programs for staff to effectively intervene when bullying occurs. [Journal of Gerontological Nursing, 43(7), 34–41.]

The word “bullying” typically evokes images of children on playgrounds or in the hallways of schools, yet bullying occurs in many different contexts where individuals spend long amounts of time with each other in environments with limited resources. For example, although it is well documented that bullying occurs in schools, it is also common in the workplace and prisons (Centers for Disease Control and Prevention, 2011; Ireland & Ireland, 2008; Sansone & Sansone, 2015). One population rarely associated with bullying is older adults. However, recent publications in the media brought the phenomenon of senior bullying (hereafter referred to as “bullying”) to light (Mapes, 2011; Span, 2011; Weiner, 2015).

Few empirical studies on this topic confirm that these anecdotal reports in the media represent a larger problem. Rosen, Pillemer, and Lachs (2008) found that 10% of older adults in assisted living facilities had experienced verbal or physical aggression perpetrated by another resident in the past 2 weeks. Similarly, Trompetter, Scholte, and Westerhof (2010) determined that 19% of older adults in assisted living facilities experience relational aggression. Wood (2007) found that approximately one half of cognitively intact nursing home residents reported some experience with being bullied. Finally, the most comprehensive analysis of the prevalence of resident-to-resident mistreatment estimated that the 1-month prevalence in nursing homes was 20.2% (Lachs et al., 2016).

Bullying is typically defined as a type of aggressive behavior that is repeated over time and involves an inequity of power (Einarsen & Skogstad, 1996). Although bullying can take various forms, Bonifas (2014) classifies bullying into three types: (a) physical, (b) verbal, and (c) social. Some examples of physical bullying include hitting, pushing, and taking or breaking the personal belongings of another individual. Verbal bullying can include teasing, name calling, and threatening to cause harm. Social bullying includes deliberate acts, such as excluding others on purpose, spreading rumors, and embarrassing someone in public. Because the term “bullying” is generally associated with children and adolescents, alternative terms exist to describe phenomenon similar to bullying in the older adult population, including: relational aggression (Crick & Grotpeter, 1995), resident-to-resident relational aggression (Bonifas, 2015; Cardinal, 2015; Wood, 2007), social aggression (Cardinal, 2015), resident-to-resident elder mistreatment (Rosen et al., 2008), resident-to-resident aggression (Pillemer et al., 2012), and resident-to-resident elder bullying (Cardinal, 2015). These alternative terms may be more acceptable to older adults who typically reject the word “bullying” because of its connotations with childhood (Trompetter et al., 2010). However, the current study focused on the construct of bullying to gain a better understanding of all possible forms of mistreatment and because it is a term that is easily understood by most individuals.

Empirical literature with other populations has documented the adverse effects that bullying can have on victims, such as depression, anxiety, poor self-esteem, self-harm, and suicide (Hawker & Boulton, 2000; Rigby, 2003). The few studies that have examined psychological consequences of bullying specifically in older adults have produced similar findings. For example, in a study with 156 cognitively intact nursing home residents, Wood (2007) found that individuals who experienced bullying also experienced significantly higher rates of adverse psychological consequences (e.g., anxiety, depression, social dysfunction). In addition, Trompetter et al. (2010) found that experiencing relational aggression (i.e., non-physical forms of aggression) was associated with greater depression, anxiety, social loneliness, and lower life satisfaction in a sample of older adults living in assisted living facilities.

Purpose

Although much has been written about bullying in newspaper articles and blogs, much of what is known is based on clinical experience, anecdotes, and extrapolation of knowledge from research with other populations. Little empirical work has been dedicated to bullying as it occurs in senior living communities, and existing literature has primarily focused on understanding the prevalence and/or consequences of bullying (Lachs et al., 2016; Trompetter et al., 2010). Therefore, the immediate goal of the current study was to better understand bullying and add to the small existing literature.

One unique aspect of the current study was that data were gathered from the perspective of staff working in senior living facilities (SLFs). Staff served as participants because they have the opportunity to observe many resident-to-resident interactions, so it was believed that they would have access to a larger sample of bullying as it occurs throughout a facility. Another reason staff served as participants is that they are in a unique position to intervene when bullying occurs. Although some research suggests that staff frequently observe bullying (Castle, 2012), little is known about how individual staff members and institutions as a whole address bullying when it occurs. Therefore, data were collected regarding typical responses to bullying, availability of staff training, and facility policies regarding bullying. It was hoped that this study would add to the existing literature about what bullying and its victims and perpetrators look like, as well as clarify whether more widespread education, training, and policy on this issue are needed.

Method

Participants

A total of 45 individuals participated in the current study. Participants held many different jobs within facilities (e.g., nurse, nursing assistant, administrator, activity staff, maintenance staff, dietary aide). The mean age of participants was 42.89 years (SD = 14.23 years). The sample was 75.5% female and 24.5% male. Regarding ethnicity, 75.5% of the sample identified as Caucasian, 15.5% as African American, 2.2% as Asian, and 2.2% as Czechoslovakian individuals; 4.6% of the sample were of unknown ethnicity. Participants reported having worked in a senior care facility for an average of 10.47 years (SD = 9.91 years), with 77.7% employed full-time and 22.2% part-time. Participants reported working on a variety of units, including assisted living (42.2%), memory care (35.5%), skilled nursing (33.3%), and independent living (6.6%).

Settings

Participants were recruited from five facilities in Minnesota. Three facilities were for-profit organizations that provided a range of services, such as independent living, assisted living, memory care, and skilled nursing services. One facility was a public housing apartment complex for low-income older adults. The last facility was a government-funded health care facility that provides assisted living, memory care, and skilled nursing for military Veterans.

Procedures and Instruments

Participants were recruited by announcements made at facility staff meetings and obtaining contact information from interested individuals. Individuals interested in participating were later contacted to arrange a time to complete data collection. Prior to starting data collection, informed consent was obtained after receiving approval from the Institutional Review Board at Minnesota State University–Mankato.

Data collection first involved having participants complete a demographic form that asked for their gender, age, ethnicity, length of time in their profession, official job title, full- or part-time employment status, and primary unit/floor on which they worked. Participants were then provided with a detailed definition of bullying to ensure they had an understanding of what bullying entailed. Interviews comprised five sections with a variety of questions regarding the characteristics of bullying, victims, and perpetrators; training and education; typical responses to bullying; and institutional policy with regard to bullying. Facility administrators were given a shorter interview that did not include questions about typical responses to bullying as it was expected that administrators would have less direct contact with residents on a daily basis.

Interviews were semi-structured with a combination of closed- and open-ended questions. Although participants were asked a set of standard questions, interviewers were provided prompts (e.g., “Can you give me some examples of what you mean?”) as a means for encouraging participants to expand on and clarify answers. Participants were also encouraged to share examples and opinions, and deviate from the topic of a given question provided that responses were related to resident-to-resident altercations. This data collection strategy allowed for accumulation of quantitative and qualitative data. Interviews lasted approximately 15 to 20 minutes. Interviews were audiorecorded using Audacity®. Recordings were professionally transcribed and all identifying information was removed from transcripts.

Data Analysis

For closed-ended questions, data analysis involved tabulating frequency counts of responses. For open-ended questions, data analysis first involved having the primary researcher (F.J.A.) identify common themes among the responses based on the review of a small (n = 5), random sample of interview responses. This type of coding system helped standardize the data analysis process. When a response matched one of the identified themes, the specific response was recorded. For example, when participants were asked, “In your observations, are there other common characteristics of persons who engage in bullying?”, responses were categorized into the following themes: Perpetrators Typically Have/Do Not Have a Physical Disability, Perpetrators Typically Have/Do Not Have a Cognitive Impairment, and Perpetrators Have Certain Personality Traits that Make Them More Likely to Bully. If a response encompassed more than one theme, each identified theme within the response was coded.

To ensure responses were coded in an objective and consistent manner, interobserver agreement data were collected. A coding system that included detailed descriptions of the coding themes and a list of possible responses indicative of each theme were provided to a research assistant not directly involved in the study. Interobserver agreement was calculated using a random sample of 20% (n = 9) of interviews. Reliability between coders was determined by comparing the two coders' data sheets and recording how often each response theme was recorded by each. If both coders recorded a response theme, it was counted as an agreement. However, if one coder identified a response as matching a possible theme and the other coder did not, it was counted as a disagreement. Reliability was determined by dividing the total number of agreements by the total number of agreements plus disagreements and then multiplying by 100. The mean reliability coefficient was 98%, indicating that the coding system was used consistently across both coders.

Results

Characteristics of Bullying

The first interview question asked whether participants had observed bullying and to provide examples of bullying they had observed. All but one participant (98%) reported having observed bullying. When examining the reported examples of bullying, three general themes emerged that corresponded to the three types of bullying (i.e., verbal, physical, and social). The percentage of interviews in which each theme was conveyed were: 78% verbal, 33% physical, and 19% social (percentages do not total 100% because some responses included examples of multiple types of bullying). Participants were then directly asked about which of the three types of bullying was most common. The prevalence of each form of bullying was: 95% verbal, 24% social, and 5% physical (several participants reported multiple types of bullying as being prevalent). One participant commented, “I have seen residents intentionally exclude people from their table in the dining room. I've seen residents gossiping about each other, name calling…” Another participant added, “I see both the social and the verbal quite frequently. I've never witnessed any physical bullying, but the embarrassing someone in public and the teasing and name calling are very prominent.”

Additional questions were asked to learn more about the nature of bullying in facilities. For example, when participants estimated how many residents they have observed engage in bullying at their current facility, the most common response was five (range = 0 to 50). Participants were also presented with a rating scale to provide an estimate of the frequency of bullying: one to two times per year (3%), three to four times per year (5%), approximately once per month (11%), approximately twice per month (13%), approximately once per week (21%), multiple times per week (24%), approximately once per day (8%), and multiple times per day (16%). When asked about settings in which bullying occurred most frequently, the most common responses were the dining room (n = 30) and other common areas (n = 23).

Characteristics of Perpetrators and Victims

Characteristics of Perpetrators. Participants indicated that perpetrators were more likely to be male (42%) rather than female (18%), although 39% of participants stated that perpetrators had an equal likelihood of being male or female. The most common form of bullying among male perpetrators was verbal (46%), followed by physical (23%) and social (0%). Conversely, female perpetrators were reported to most likely engage in social bullying (42%), followed by verbal (31%) and physical (8%).

When asked about common characteristics of perpetrators, responses fell into a number of categories: 47% of respondents indicated that perpetrators were likely to be cognitively impaired, whereas 9% indicated that perpetrators were likely to be cognitively intact. In addition, 26% of respondents reported that perpetrators were likely to have physical disabilities, whereas only 6% were described as being physically able. Finally, 38% of responses included descriptions of various personality traits (e.g., entitled, controlling, attention seeking) that were common to perpetrators, with one participant noting, “They just kind of feel like they're entitled to more and feel like…they're higher up and, you know, can look down on certain people.”

Characteristics of Victims. It was reported that victims were more likely to be male (42%) rather than female (16%), although 42% of participants stated that victims had an equal likelihood of being male or female. Participants were also asked about common characteristics of victims. First, 60% of respondents stated that victims were likely to be cognitively impaired; none reported that victims were likely to be cognitively intact. Second, 50% of respondents indicated that victims were likely to have some kind of physical disability; none reported that victims were likely to be physically able. Finally, 60% of respondents stated that victims were likely to exhibit various personality traits such as being shy, quiet, submissive, and dependent. One participant explained, “They are more dependent; they really don't talk that much or they are slow at talking. If the individual has a memory impairment…they are more likely targets.”

Training and Education

Regarding training, 58% of participants reported not receiving formal training about bullying, whereas 37% reportedly received training and 5% reported being unsure if they had received training. Sixty-seven percent of administrators indicated that no formal training related to bullying was in place. For participants who did not receive formal training, 76% reported that bullying had been informally addressed in other contexts (e.g., conversations with coworkers about potential solutions) and 96% believed more training was necessary.

Participants who had received formal training were asked a series of follow-up questions regarding the most common mode of training, level of satisfaction with the training, and most common intervention strategies used. The most common mode of staff training involved viewing informational videos (57%), attending classes (57%), and participating in discussions on the topic (50%). Most participants (93%) believed this training was adequate. The most commonly reported intervention strategies were redirection (62%), separation (62%), and de-escalation (23%). One participant commented on redirection:

I guess just trying to redirect the residents when a resident is having a behavior…you're trained in that kind of sense to redirect them. So it's kind of the same with bullying to say, “Let's go for a walk, or talk to me about it.” It's a get-it-off-your-chest kind of thing.

Responses to Bullying

Most participants (87%) reported that staff typically intervene in bullying situations. Participants were also asked which of six response choices best described intervention strategies: intervene while the event is happening by talking to the perpetrator (41%), intervene while the event is happening by talking to the victim (27%), intervene after the event by talking with a supervisor or administrator (14%), intervene after the event by talking to the perpetrator (9%), and intervene after the event by talking to the victim (9%).

In addition, 59% of participants reported that other residents intervene in bullying situations. Participants were given six intervention options to describe various intervention strategies: intervene while the event is happening by talking to the perpetrator (38%), intervene while the event is happening by talking to the victim (24%), intervene after the event by talking with a staff member (22%), intervene after the event by talking to the perpetrator (8%), and intervene after the event by talking to the victim (8%). One participant noted that intervening in bullying situations may involve “[sticking] up for the victim or they might just be saying to the bully to shut up and get out of here.”

Institutional Policy

When participants were asked if their facility has a formal policy describing how to address bullying, 58% were unsure, 21% said yes, and 21% said no. For participants who stated their facility had a policy for bullying, 60% reported that the policy specified how staff should intervene if bullying is observed, whereas 30% were unsure and 10% reported no interventions were specified. When asked what staff are required to do if bullying is observed, common responses included: “report incidents to supervisors or administrators,” “talk to the perpetrator,” and “talk to the victim.” In addition, 64% of participants found institutional policies helpful, whereas 14% found them unhelpful and 21% were unsure if they were helpful.

When specifically examining the responses of facility administrators, 33% indicated their facility had a policy regarding bullying, 50% said no policy existed, and 17% were unsure. When administrators endorsed having a formal policy, they reported their policies had the following characteristics: a statement that bullying will not be tolerated, a requirement that behavioral interventions be applied, medications should be evaluated, and the possibility of eviction if the safety of others has been compromised. Lastly, 67% of administrators indicated there were possible consequences for bullying, such as warnings or possible eviction.

Of participants who claimed the facility did not have a bullying policy, 83% believed one would be necessary or helpful. One participant commented on how formal policies are gray areas in terms of reporting and intervention: “For bullying? We don't have [a reporting procedure]. We have an incident behavior report. We have not used that for bullying. We've used that more for sexually inappropriate behaviors of residents.” Another participant added:

I would assume if it was verbal or physical I know we have to [intervene]. But the social part, I'm not sure…what [staff] do. And I don't step in every single time I see it because it literally happens every day.

When asked whether the perpetrator's family was notified, 58% of participants reported yes, 27% said unknown, and 15% responded no. When asked whether the victim's family was notified, 45% reported yes, 45% were unsure, and 9% said no. When administrators were asked the same question, 50% indicated that the families of victims were notified and 33% reported that families of perpetrators were notified.

Discussion

The current study aimed to better understand bullying from the perspective of staff who work in SLFs. Several findings confirm existing information on bullying and are consistent with research with other populations. For example, the finding that staff are frequently exposed to bullying was expected given previous literature concerning the frequency of bullying. The finding that males tend to use more direct forms of bullying whereas females use more indirect behaviors is also consistent with existing information (Bonifas & Frankel, 2012). Others have reported that verbal and social bullying, rather than physical, are more common among older adults (Frankel, 2011; Lachs et al., 2016), a finding corroborated by the current study.

Concerning characteristics of victims, the current findings suggest they were commonly described as having cognitive and physical deficits, which is consistent with anecdotal reports, suggesting provocative behavior from those with cognitive impairments may elicit bullying from those who are cognitively intact (Bonifas & Frankel, 2012). The finding that victims were commonly reported to have physical disabilities and certain personality traits (e.g., shy, quiet, submissive) suggests that victims of bullying are often noticeably vulnerable and may be perceived as easier targets.

Most respondents described perpetrators as having cognitive and physical deficits, a finding consistent with existing information that suggests perpetrators may bully to increase self-esteem or reduce feelings of vulnerability (Bonifas & Frankel, 2012). The finding that perpetrators were commonly reported to exhibit traits such as being entitled, controlling, and attention-seeking is also consistent with existing beliefs that perpetrators are trying to gain more control in their life at a time when they feel powerless (Bonifas & Frankel, 2012).

Implications for Practice and Institutional Policy

Several current findings regarding training and policy are worth noting because they have implications for the daily clinical practice of staff in SLFs. Despite the fact that bullying is commonly observed by staff, formal policy or training is rarely in place to help staff navigate these situations. The current research indicates that facilities typically have a policy in place for severe verbal (e.g., threats of harm) and physical bullying, and staff are mandated to report these behaviors. However, there is less guidance for handling less extreme verbal bullying (e.g., insults, name calling) and social bullying that, although less severe in nature, is common and can cause significant psychological harm (Trompetter et al., 2010). In other words, some bullying behaviors are not considered abusive or incidents that must be reported, a sentiment that was summarized by one participant: “There aren't incident reports for bullying—just for disruptive behaviors.”

This ambiguity in determining when social and verbal bullying crosses the line into being a reportable incident has potential implications for staff in terms of when and how to intervene. Although it was reported that most staff members intervene in bullying situations, it is suspected that they do so based on their own moral code rather than formal training or mandated by institutional policy. For example, one participant stated, “It's just common sense of telling the resident that their behavior is unacceptable, or you don't need to talk that way.” Another participant reported, “I told [the perpetrator] that what she was saying right now was not polite or nice.... I pretty much just say the things that I was raised off of.”

The current data suggest that staff would benefit from more explicit guidance about how and when to intervene when bullying occurs. Based on the current results, training and policies must address two issues that pose greater ambiguity for staff. First, policy that addresses more covert and less severe forms of bullying (i.e., social and verbal) is necessary so different staff members respond consistently to these behaviors. Second, policies must specify how bullying should be handled differently when it is perpetrated by cognitively intact individuals, as staff may be less confident and comfortable intervening in these situations due to significant age differences between staff and residents. It has been suggested that staff may fail to report instances of bullying because they do not perceive verbal aggression and social bullying as harmful or abusive behaviors (Ellis et al., 2014). The current study also indicates staff may be unsure of how to intervene when verbal or social bullying occurs.

Fortunately, staff training programs designed to assist staff in recognizing, reporting, and intervening in resident-to-resident altercations have recently been developed and show promise. Teresi et al. (2013) developed a training program designed to help certified nursing assistants better recognize, document, and intervene during instances of resident-to-resident elder mistreatment (R-REM), a construct similar to bullying. The training program had three components: education about R-REM, suggestions for managing these behaviors, and how to implement best practices. The education component focused on helping staff recognize that R-REM frequently occurs and involves physical altercations that can take a variety of other forms (e.g., verbal and social acts), all of which have serious consequences in terms of resident well-being. Broadening staff perceptions of what constitutes abuse or a reportable incident can help clarify which events need to be documented. A brief, simple documentation form was also introduced as a means for increasing documentation of R-REM, which was seen as critical to identifying patterns of mistreatment and developing appropriate interventions. Finally, specific strategies for intervening in altercations were presented in the form of SEARCH (support, evaluate, act, report, care plan, and help to avoid) (Ellis et al., 2014). Examples of intervention strategies included interrupting the altercation, listening and validating the concerns of all individuals involved (including bystanders), documenting the incident and notifying supervisors, and developing strategies to avoid future incidents (e.g., avoiding crowding in small spaces, separating residents with a history of altercations, having adequate staff in congregate settings).

The staff training program was implemented using didactic presentations, videos that demonstrated responses to R-REM, and opportunities to practice completing the documentation instrument using filmed vignettes. Teresi et al. (2013) found that this training program successfully increased knowledge, recognition, and reporting of R-REM. Overall, the SEARCH approach appears to be a promising method for teaching practical skills that can be transferred to daily practice. In addition, this method provides a more standardized approach to intervention when bullying occurs, increasing the likelihood that responses to bullying are consistent across staff. This consistency may, in the long term, help establish a facility-wide culture that discourages bullying, sets clear expectations for civil behavior, and fosters a sense of security and safety in residents. Further research is needed to determine if staff training programs ultimately lead to reductions in instances of bullying and improved quality of life for residents.

Limitations and Future Research

Although the current results offer some valuable information regarding bullying, several limitations must be acknowledged. First, the sample was relatively small and predominately comprised Caucasian females who worked in the Midwestern region of the United States. Although staff have a unique perspective on bullying, future research should gather similar data from residents to provide a more comprehensive understanding of the nature of bullying in SLFs.

Additional limitations were related to the data collection instrument. The open-ended interview questions relied on the ability of participants to carefully observe, accurately recall, and clearly articulate their experiences. Therefore, participant responses may have been based on a limited sample of instances of bullying that were particularly recent and/or highly memorable as opposed to being based on more common instances of bullying.

It is also possible that the definition of bullying provided at the beginning of the interview may have biased and limited participant responses. For example, the definition included examples of physical and verbal bullying, which may have primed participants to recall these types of events because they are more memorable. It is suspected that participants had difficulty differentiating between intentional acts of bullying and behaviors due to cognitive impairment that are possibly unintentional in nature. For example, one respondent stated, “I think that there is a lot of memory issues in the [perpetrator] that is being that way…. A fair amount of them don't even know that they are doing it.” Approximately one half of participants reported that perpetrators commonly had cognitive impairments. Including “aggression” as part of the definition of bullying may have led participants to describe severe acts of aggression perpetrated by individuals with cognitive impairment that may actually fail to meet the definition of bullying because they may not be intentional and/or repeated.

Future research should limit the definition of bullying to the more specific construct of relational aggression, which comprises social bullying and some forms of non-threatening verbal bullying. These behaviors appear to be relatively common, cause harm to victims, and pose greater ambiguity for staff in terms of intervention. Future studies could require participants to respond to detailed vignettes describing relational aggression to gather information specifically about these less severe, yet harmful forms of bullying that may go unaddressed by staff.

Conclusion

The findings of the current study suggest that resident-to-resident bullying is a prevalent phenomenon. Although staff are aware of bullying among older adults, respondents described little training and few formal policies to help staff address these situations. When policies were in place, they were limited to physically harmful or threatening behaviors and did not address common forms of social and verbal bullying that are ambiguous in terms of whether intervention or reporting should follow. The uncertainty of such intervention practices demonstrates the need for comprehensive training programs and policies that address bullying in SLFs.

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Authors

Ms. Andresen is Doctoral Student in Clinical Psychology, Utah State University, Logan, Utah; and Dr. Buchanan is Professor of Psychology, Minnesota State University–Mankato, Mankato, Minnesota.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Jeffrey A. Buchanan, PhD, Professor of Psychology, Department of Psychology, Minnesota State University–Mankato, 23 Armstrong Hall, Mankato, MN 56001; e-mail: jeffrey.buchanan@mnsu.edu.

Received: July 29, 2016
Accepted: December 01, 2016
Posted Online: February 03, 2017

10.3928/00989134-20170126-01

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