Journal of Nursing Education

Major Article 

Impact of Interprofessional Simulation on Nursing Students' Attitudes Toward Teamwork and Collaboration

Linda Krueger, EdD, RN; Kim Ernstmeyer, MSN, RN, APN-BC, CHSE; Ellen Kirking, PhD, RN

Abstract

Background:

The purpose of this study was to examine the influence of a multipatient, interprofessional simulation session on nursing students' attitudes toward nurse–physician collaboration using the Jefferson Scale of Attitudes Toward Physician–Nurse Collaboration.

Method:

Final-semester nursing students, along with medical resident and students from other health programs, participated in a simulation exercise that included a period of prebriefing, simulation, and debriefing. Participants completed pre- and postsimulation surveys to assess the impact on collaboration.

Results:

In total, 268 nursing students completed the survey. Participants had a more positive attitude toward nurse–physician collaboration following the simulation event, compared with prior to it. Significant differences between male and female nursing students were found on mean postsimulation scores and for three of the four subscales of the tool.

Conclusion:

Interprofessional simulation may be an effective way to enhance collaborative relationships, which ultimately may influence patient safety and quality of care. [J Nurs Educ. 2017;56(6):321–327.]

Abstract

Background:

The purpose of this study was to examine the influence of a multipatient, interprofessional simulation session on nursing students' attitudes toward nurse–physician collaboration using the Jefferson Scale of Attitudes Toward Physician–Nurse Collaboration.

Method:

Final-semester nursing students, along with medical resident and students from other health programs, participated in a simulation exercise that included a period of prebriefing, simulation, and debriefing. Participants completed pre- and postsimulation surveys to assess the impact on collaboration.

Results:

In total, 268 nursing students completed the survey. Participants had a more positive attitude toward nurse–physician collaboration following the simulation event, compared with prior to it. Significant differences between male and female nursing students were found on mean postsimulation scores and for three of the four subscales of the tool.

Conclusion:

Interprofessional simulation may be an effective way to enhance collaborative relationships, which ultimately may influence patient safety and quality of care. [J Nurs Educ. 2017;56(6):321–327.]

A national focus on transforming health care education is occurring in response to concerns about the impact of human error on morbidity and mortality rates. This transformation includes the importance of teamwork training and improved communication. In 2001, the Institute of Medicine (IOM) stated that developing effective teams and redesigned systems is critical to achieving care that is patient centered, safer, timelier, and more effective, efficient, and equitable. In 2010, the World Health Organization (WHO) promoted the use of interprofessional education (IPE) to improve teamwork and patient outcomes. IPE was defined as, “When students from two or more professions learn about, from, and with each other to enable effective collaboration and improve health outcomes” (WHO, 2010, p. 7). IPE was viewed as a necessary step in preparing a “collaborative practice-ready health workforce that is better prepared to respond to local health needs” (WHO, 2010, p. 7). More recently, the Quality and Safety Education for Nurses (QSEN) project used the IOM core team competencies to further define quality and safety education in nursing using the domains of knowledge, skills, and attitudes (QSEN, 2014). The QSEN teamwork and collaboration competency was defined as “function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care” (QSEN, 2014, p. 3).

The purpose of this study was to examine the influence of IPE using a multipatient simulation exercise to assess nursing students' attitudes toward nurse–physician teamwork and collaboration. Qualitative results based on student comments and quantitative results are reported.

Literature Review

Human patient simulation (HPS) has been shown to be an effective and safe learning activity for nursing students, medical students, and other health care programs. Effective communication and collaboration among health care team members can be improved via simulation (Birkhoff & Donner, 2010; Booth & McMullen-Fix, 2012; Dillon, Noble, & Kaplan, 2009; Garbee et al., 2013; Messmer, 2008; Reising, Carr, Shea, & King, 2011; Strachan, Graham, Hormis, & Hilton, 2011). A recent study conducted for the National Council of State Boards of Nursing found no significant difference in nursing graduates' outcomes regarding licensure examination pass rate or employer satisfaction when up to 50% of the clinical experiences were delivered via simulation (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014). Nursing students who participated in the 50% simulation group showed greater levels of self-confidence, compared with their nursing student counterparts.

Other researchers have found simulation to be effective for learning to deliver bad news to families (Youngblood, Zinkan, Tofil, & White, 2012), improving confidence during crisis situations (Strachan et al., 2011), and learning the roles of other health care providers (Dillon et al., 2009; Reising et al., 2011; vanSoeren et al., 2011). Messmer (2008) found that involvement in multidisciplinary simulation increased nurse–physician collaboration, feelings of collegiality, and cohesiveness. Dillon et al. (2009) reported that as a result of multidisciplinary simulation, medical students developed a newfound appreciation for the value of nurses, and nursing students discovered they are not subservient to physicians but, rather, important equal players in the health care team. Collegial relationships among nurses and physicians influence the work environment and positively affect patient outcomes (Manojlovich, Antonakos, & Ronis, 2009; Manojlovich & DeCicco, 2007).

Theoretical Framework

Experiential learning theory (Kolb, 1984) provides a framework for understanding why students demonstrate effective learning from HPS experiences. Based on Kolb's framework, HPS sessions allow the learner to experience meaningful learning by progressing through concrete experiences, reflective observation, abstract conceptualization, and active experiment. Discussion and reflection during debriefing promotes the integration of new knowledge and teamwork skills into real clinical practice.

Crisis resource management (CRM) is a teamwork and communication strategy that has been used for decades in conjunction with simulation to teach effective teamwork and communication skills to health care professionals and students (Gaba, Howard, Fish, Smith, & Sowb, 2001; Garbee et al., 2013). CRM training focuses on exercising leadership and followership, calling for help early, communicating effectively, distributing the workload, and mobilizing all available resources for optimum management. These elements were embedded in the learning activity described in this study.

Study Purpose

The purpose of this study was to determine whether a difference exists in nursing students' attitudes toward nurse–physician collaboration prior to an IPE event, compared with following such an event. Second, the study examined whether a difference exists in nursing students' attitudes toward (a) shared educational and collaborative relationships, (b) caring as opposed to curing, (c) nurse's autonomy, and (d) physician's authority prior to an IPE simulation event, compared with following such an event.

The session incorporated the use of CRM teamwork principles and the SBAR (Situation-Background-Assessment-Recommendation) communication tool among interprofessional health care team members. SBAR is a communication technique promoted by the Institute for Healthcare Improvement as a framework for critical conversations among interdisciplinary health care members. The qualitative component of the study examined nursing students' and medical residents' comments regarding teamwork and collaboration following the simulation exercise.

Method

Interprofessional Simulation Experience

A core team of nursing and respiratory therapy faculty at a midwestern U.S. technical college developed a simulation curriculum to provide high-fidelity interprofessional simulation experiences for students from various health programs and medical residents to work together while caring for four simulated patients simultaneously. Health care programs included nursing, respiratory therapy, paramedic, radiography technician, pharmacy technician, and medical residents. Simulated patients were designed to follow a basic 3-hour time line of events in which some of the simulated patients had deteriorating conditions that required early recognition and interdisciplinary collaboration, whereas others were stable. All sessions incorporated at least one code blue situation, during which the simulated patient died.

The multidisciplinary, multipatient HPS sessions consisted of four components: a presession online community, a prebriefing session, a simulation session, and a debriefing session. Each component is further described below.

Presession Online Community. A presession online learning community was created for students to participate in the week prior to the HPS session. The discussion area asked students to introduce themselves, explain their health care roles and scopes of practice, and explore CRM teamwork principles.

Prebriefing Session. Prebriefing occurred immediately before the HPS session in which interprofessional students met face to face. HPS expectations, roles and responsibilities, and CRM principles were reviewed. Students listened to a taped shift report from a previous night shift nurse giving SBAR reports about each patient. Nursing students were assigned either in pairs to be the primary nurse for each of the four patients or to the role of charge nurse, resource nurse, or infection control nurse. The charge nurse helped organize work flow; the resource nurse assisted in performing skill procedures; and the infection control nurse tracked hand washing and other safety issues across disciplines for each patient. Existing patients had a paper chart that students could review prior to and during the HPS session and included obtaining history and a physical examination, orders, and a medication administration record. For new admissions, students obtained all of their patient information from a SBAR report from the transporting paramedic, which further emphasized the importance of good handoff reports.

Simulation Session. Three-hour simulation sessions included eight to 12 nursing students and one or two students from other disciplines, including respiratory therapy, paramedic, radiography, and pharmacy technicians, and one or two medical residents. The difference in student numbers across disciplines resulted from the difference in sizes of the programs at the institution. Eight to 10 sessions were held consecutively over 1 week, across three semesters for this study. Four different patient scenarios unfolded during the simulation event: some patients were stable, some were unstable, and one patient became a code situation. These patient scenarios changed across semesters so that the students always had a fresh experience. As the patients' conditions evolved, critical thinking, communication, teamwork, and collaboration skills were required by the interprofessional team to provide effective patient care. Although this simulation was lengthier than most published simulation scenarios, the 3-hour simulation mimicked the real world of health care requiring assessment, recognition of early signs of deterioration, prioritization of care, and communication with interdisciplinary team members. The fourth-semester nursing students gathered assessment data and made decisions on prioritizing care for the patient and who needed to be involved in that care. They communicated with the respiratory therapy and paramedic students and updated the medical residents. Medical residents made rounds, were paged to the bedside as needed, and wrote new orders as needed. Paramedic students brought in new admissions and also acted as the rapid response team. Pharmacy technician students assisted in medication reconciliation for the new admissions. Respiratory therapy students administered nebulizers and continuous positive airway pressure, and they assisted with rapid sequence intubation as needed. They were called upon by nurses when a patient's respiratory condition was deteriorating. Radiology technician students obtained portable radiographs as ordered during scenarios, and they emphasized radiation safety among team members through the sessions. Faculty from all disciplines participating were present to answer questions, assist students with problem-solving as needed, and to retrieve laboratory or diagnostic results as requested by the nursing students. Four simulation technicians were in the control room and acted as the voices of the patients, controlled the progression of the simulators' conditions, and assisted in maintaining a controlled, effective learning environment. Volunteers participated as family members of the patients.

Debriefing Session. A debriefing session immediately followed the simulation event and included students, faculty, staff, and volunteers participating in the session. All students were encouraged to share their reactions to the interprofessional experience in a safe environment, reflect on the teamwork and collaboration that occurred while caring for the simulated patients, and suggest ways to optimize their own teamwork and communication in the future. According to Kolb (1984), this reflective observation session focusing on collaboration and teamwork was included to enhance all participants' understanding and appreciation for interdisciplinary collaboration.

Institutional Review Board Approval and Protection of Human Subjects

This study was discussed with all nursing faculty prior to implementation and received approval by the institutional review board of the college. Student participation in the inter-professional simulation experience was a requirement in each program area; however, participation in the actual study was voluntary. During the presession, faculty explained the purpose of the research. Each student or resident was provided a packet of materials for the study. This packet included a consent form, a presimulation survey, and a postsimulation survey.

Instrument

Jefferson Scale of Attitudes Toward Physician–Nurse Collaboration. The Jefferson Scale of Attitudes Toward Physician–Nurse Collaboration was used in this study. The instrument consists of 15 items that were rated by participants on a 4-point Likert-type scale. The 15 items are divided into four factors: shared educational and collaborative relationships; caring as opposed to curing; nurse's autonomy; and physician's authority. A higher overall score (or higher score on each factor) indicates a more positive attitude toward collaborative relationships between nurses and physicians. Permission was obtained to use this tool by one of its developers. Construct and content validity have been determined along with internal reliability (alpha coefficient) at .85 for medical and nursing students (Hojat et al., 1999). Scruggs Garber, Madigan, Click, and Fitzpatrick (2009) reported a Cronbach's alpha of .80 and Ward et al. (2008) determined a reliability coefficient of .77 in a study of associate degree and baccalaureate nursing students. This study determined the reliability coefficient for the presimulation survey (.83) and subscales (subscale 1 = .758; subscale 2 = .627; subscale 3 = .599, and subscale 4 = .583). The postsimulation survey alpha coefficient was .83, with subscales 1 = .816, 2 = .634, 3 = .715, and 4 = .635.

Students completed a demographic section and a commentary section of the survey. These sections were created by faculty specifically for this study. The results of the student commentary are reported in this article. The student comments were obtained with the postsimulation survey.

Data Collection

Students who chose to participate in the study signed the consent form and completed the presimulation survey prior to the HPS session. Following the HPS sessions, students completed the postsimulation survey and then participated in the debriefing session. The faculty left the room during the survey administration. A nonfaculty staff member collected the consent forms and maintained these forms in a secure location in her office. A designated member of the research project team collected and maintained the surveys in her office in a secure location. Surveys were reviewed after graduation to alleviate some concerns by students in responding honestly on the survey.

A pilot project occurred in the spring 2014 academic term. The purpose of the pilot project was to identify areas in the survey that were confusing to students and whether the directions for the survey or the explanation of the research were clear. No revisions to the survey or directions were needed. The survey responses in the pilot project were included in the total data analysis. The remainder of the data collection occurred during the week-long simulation sessions in the fall 2014 and spring 2015 academic terms. Surveys were shredded on completion of the study.

Results

In total, participants in the study included 280 nursing students, 33 medical residents, 42 radiography students, 38 respiratory therapy students, and 35 paramedic/emergency medical technician students. Due to the length of the residency program, medical residents may have participated in more than one session and the survey data did not request this information. Only the medical residency and nursing students completed the survey for this study: 268 (96%) of 280 nursing students and 25 (76%) of 33 medical residents. Because other disciplines were not included in the original validation of the survey instrument, the other students who participated completed a different survey to assess the learning experience, and those results are not reported here. The study included significantly more nursing students than any other discipline. The staffing pattern was modeled from an acute care, emergency, or critical care practice arena. Faculty also wanted to ensure the patient scenarios unfolded in a manner such that all disciplines would be used at various points in time to allow for teamwork, time management, and analysis of the situation.

The majority of students were women (n = 240, 77.9%) and Caucasian (n = 258, 83.8%). Although the ages of students ranged from 19 to older than 50 years, the majority were between 19 and 34 years old (n = 221, 71.7%).

Quantitative Results

Data analysis was conducted using SPSS® version 21 software. One-way analysis of variance (ANOVA), t test, and paired t tests were used to examine the data. The level of significance was set at p < .05.

Research Question One

The first research question was: Is there a difference in nursing students' attitudes toward nurse–physician collaboration prior to an IPE simulation event compared with attitudes following such an event? Table 1 provides the analysis of the quantitative data. The data revealed a significant difference between the mean total presimulation and the mean total post-simulation scores (presimulation, 51.11; postsimulation, 52.25; t = −2.957, p = .003). The results indicated that participants had a more positive attitude toward nurse–physician collaboration following the simulation event compared to prior to the event.


Analysis of Quantitative Data

Table 1:

Analysis of Quantitative Data

No significant differences were found based on age between mean total presimulation scores and mean total postsimulation scores, or between any of the factor scores. However, a significant difference was found between male and female students on mean postsimulation scores for the total and for factors 1, 2, and 3 in that the male students' scores did not increase as greatly as those of the female students. Postsimulation scores for male participants increased only in factor 1. Postsimulation scores increased for female participants in all areas except in factor 4. The decrease in scores for postsimulation are unexpected and unexplainable; therefore, further research is necessary to explain the influence of simulation on each of these factors. The decrease did not reach a level of significance. These scores were obtained prior to the debriefing session, which may affect the learning experience overall. Tables 12 provide the statistical data.


Analysis of Statistical Data: Gender

Table 2:

Analysis of Statistical Data: Gender

Research Question Two

The second research question was: Is there a difference in nursing students' attitudes toward (a) shared educational and collaborative relationships, (b) caring as opposed to curing, (c) nurse's autonomy, and (d) physician's authority prior to an IPE simulation event compared with following such an event? The results revealed a significant difference in the mean factor 1 presimulation score versus the postsimulation score (presimulation, 25.01; postsimulation, 25.84; t = −4.174, p = .000), indicating the participants had a more positive attitude toward shared educational and collaborative relationships following the simulation session compared with their attitudes beforehand. A significant difference was found in mean factor 2 presimulation scores versus postsimulation scores (presimulation, 10.29; postsimulation, 10.55; t = −2.655, p = .008), indicating that participants had a more positive attitude toward caring following the simulation, compared with prior to the experience. No significant differences were found in mean factor 3 or factor 4 scores pre- versus postsimulation.

Qualitative Results

A total of 136 (90%) of 151 respondents agreed to the following statement: I feel my confidence in communicating with other disciplines has increased as a result of participating in the multidisciplinary simulation. The majority of respondents (n = 144, 95%) also agreed that after completing the multidisciplinary scenario, they had a better understanding of effective teams and the various member roles.

Nursing students and medical residents provided 172 comments on the survey. Medical residents wrote 12 comments. Half of these comments focused on the value of nursing's contribution to patient care. One comment representing this theme included:

Nurses spend much more time with the patients than we do, so their judgment about the patient's condition (improved or worsened) is critical.

Another comment was:

…this gave a much better appreciation of all the work that nurses do. Physicians often rely on nursing staff to facilitate orders but nursing staff must problem solve many times on their own.

Finally, one resident commented that the session:

…shows how dependent patient [physicians] can be on information from nurses, especially about the patient's clinical status.

The majority of comments (n = 160) were written by nursing students. The comments were reviewed by three nursing team members after the completion of the project. Common themes were identified. Two main themes emerged: Collaboration and Teamwork, and Positive Learning Experience.

Collaboration and Teamwork

The Collaboration and Teamwork theme was divided into subthemes of influence on quality of care and the role of the nurse in decision making. Forty-three comments addressed the importance and effects of collaboration and teamwork on quality patient care. A typical comment in this theme included:

This simulation shows how much the nurse and physician need to collaborate in order for the patient to receive the best care possible. Communication is [the] key to do this.

Another nursing student wrote:

The collaboration between a nurse and physicians is very important for safe and effective care of the patient. The nurse is the eyes and ears of the patient and it is so important for clear communication with the nurse and physician.… The scenario…really showed how good communication impacted patient care.

Further, a nursing student wrote:

It really drove home the importance of good, collaborative relationships with the entire team. I realized how much the [physician] relies on [nurses] to keep them informed.

Several comments (n = 30) from nursing students demonstrated that the experience expanded their understanding of the role of the nurse in decision making. An example of commentary in this area included:

It showed me how much the physician depends on us to monitor the patient and tell them what is going on with them, especially if their condition is changing. The nurses can suggest things to do based on what is going on with the patient, and the physicians implement what they feel is best.

Another student wrote:

It is very important to communicate and collaborate together. Nurses clarify orders, not just implement them if you don't understand.

Not only did nursing students learn more about their role in patient care and decision making, they also learned about the value of their role, the respect among providers, and the influence of this on patient care. Nine student comments specifically addressed respect among providers, with the following as an example:

I gained an understanding of how well they need to communicate and how much respect there is! Both roles are so knowledgeable and work together to figure out the best plan of care for patient. Communication is key! Assessments, labs, history, [medications], etc. [are] all crucial! I loved seeing the [physician] ask nurses their thoughts and ideas!

Positive Learning Experience

Nursing students overwhelmingly agreed the interprofessional HPS experience was positive and an effective way to learn communication, collaboration, and teamwork, with 85 nursing student comments representative of this theme. An additional nine comments from nursing students indicated they did not receive enough exposure to collaboration in their clinical experiences. A typical response in this theme was:

I felt more a part of a team than I anticipated. I have witnessed nurses in an “assistant” role rather than a collaborative role. This experience also helped to improve my assertiveness and the likelihood of my feeling comfortable enough to be so in practice.

Other students commented on increasing their comfort level with communication:

  • It changed my preconception of physicians. In past clinical experiences I've been intimidated to speak with physicians, but this experience has given me some confidence in my abilities and knowledge that helped me realize health care is a collaborative effort. I enjoyed this HPS experience and learned a lot.
  • It made me feel a lot more comfortable communicating with the physician. I felt like I was needed a lot more knowing that he had questions for me and wanted my input before making orders. I feel more confident after this experience. I also had a lot more respect for how busy the doctors actually are. It seemed as if every [nurse] wanted the [physician] at the same time.
  • Made me feel more comfortable going to the physician about questions I had, changes in patients' conditions, and trusting my own instincts.

Another student commented:

This simulation was a great experience practicing communication with both physicians and others of the health care team. It is vital part of the patient care for the nurse to work well and collaborate with the physician.

Discussion

The results of this study indicated that an interprofessional, multipatient simulation experience had a positive effect on the nursing students' and medical residents' attitudes toward interprofessional collaboration, shared educational experiences, and patient-centered care. Students had an opportunity to experience CRM principles, learn in a safe environment, and reflect on the teamwork and collaboration during the debriefing.

The results of the current study found a gender difference in the outcomes of simulation in that female students reported more positive attitudes toward collaboration, caring, nurse's autonomy, and shared educational experiences compared with male students. Previous research studies have found no statistically significant correlation between caring behaviors or the importance of caring and gender (Khademian & Vizeshfar, 2008; Labrague et al., 2015). Further research is needed to examine the differences between genders in simulation in more depth.

The completion of the postsimulation survey occurred prior to the debriefing session in an attempt to evaluate the effects of the simulation session. The literature supports the debriefing as a means of enhancing the educational experience, and future replication of this study would benefit from a postdebriefing survey to assess the outcome of the entire learning experience.

Effective and timely communication is essential to improving the safety and quality of patient care. Although physicians and nurses often communicate differently, opportunities exist for improving the communication and collaboration (Leonard, Graham, & Bonacum, 2004). The CRM and SBAR principles were used in this study of nursing students' perceptions of nurse–physician collaboration following an interprofessional simulation event. Nursing students' and residents' comments indicated the simulation enhanced their respect for other providers, increased the value they placed on effective communication and collaboration, and boosted their confidence in their communication skills. In addition to building confidence in communicating with providers, confidence in communicating with patients has been identified as an outcome for nursing students during simulation exercises (Bambini, Washburn, & Perkins, 2009).

According to Bambini, Washburn, and Perkins (2009), “clinical simulations that mimic the real world with real obstacles provide a safe environment in which to learn and apply theoretical principles of nursing care” (p. 79). The simulation session in their study was a 3-hour event during which students rotated through various stations. Many other studies reporting on the effects of simulation used short scenarios of 1 hour or less (Booth & McMullen-Fix, 2012; Strachan et al., 2011; Youngblood et al., 2012). The simulation in this study was a 3-hour session, during which the patient condition evolved similarly to what would be seen in the clinical arena, and nursing students were assigned to one patient to care for during the simulation session. This type of simulation was expected to mimic the real world of nursing in an acute care setting. The interprofessional design created opportunities for students to enhance their communication, collaboration, and teamwork skills more so than during their traditional clinical experiences.

The results of this study add to the growing body of literature supporting simulation as an effective teaching method reaching multiple outcomes. Future research could focus on the long-term effects of these experiences on nursing practice and patient outcomes.

References

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Analysis of Quantitative Data

Survey CategoryAll ParticipantsLevel of Significance
Total, presimulation51.11
Total, postsimulation52.25.003*
Factor 1, presimulation25.01
Factor 1, postsimulation25.84.000*
Factor 2, presimulation10.29
Factor 2, postsimulation10.55.008*
Factor 3, presimulation10.99
Factor 3, postsimulation11.16.064
Factor 4, presimulation4.82
Factor 4, postsimulation4.70.073

Analysis of Statistical Data: Gender

Survey CategoryMalesFemalesLevel of Significance
Total, presimulation/postsimulation50.92/50.2551.39/52.92.454/.003*
Factor 1, presimulation/postsimulation24.81/24.8525.15/26.15.323/.005*
Factor 2, presimulation/postsimulation10.32/10.0810.33/10.68.950/.009*
Factor 3, presimulation/postsimulation11.17/10.7211.00/11.30.312/.006*
Factor 4, presimulation/postsimulation4.62/4.604.90/4.79.128/.391
Authors

Dr. Krueger is Dean of Nursing, Bryant & Stratton College, Milwaukee, Ms. Ernstmeyer is Program Director, and Dr. Kirking is Nursing Instructor, Department of Nursing, Chippewa Valley Technical College, Eau Claire, Wisconsin.

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

Address correspondence to Linda Krueger, EdD, RN, Dean of Nursing, Bryant & Stratton College, 10950 W. Potter Road, Wauwatosa, WI 53226; e-mail: lmkrueger@bryantstratton.edu.

Received: June 10, 2016
Accepted: January 19, 2017

10.3928/01484834-20170518-02

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