Baccalaureate minority nursing students perceived barriers and facilitators to clinical education practices: an integrative review.
AIM This integrative review synthesized baccalaureate minority nursing students' perceptions of their clinical experiences.
BACKGROUND The diversity of the nursing workforce does not mirror the United States population. Attrition rates of minority nursing students remain higher than rates for White students. Literature examining facilitators and barriers to minority student success predominantly focuses on academic factors, excluding those relevant to clinical education.
METHOD An integrative review using literature from nursing and education.
FINDINGS Three common perceived barriers were identified: discrimination from faculty, peers, nursing staff, and patients; bias in faculty grading practices; and isolation.
CONCLUSION Although little is known about the relationship between clinical failures and overall attrition, this review provides evidence that minority students encounter significant barriers in clinical education. To increase the diversity of the nursing workforce, faculty must address these issues and make modifications to ensure an equal opportunity at a quality education for all students.
KEY WORDS Minority Nursing Student--Diversity--Nursing Education--Clinical Nursing
The diversity of the current nursing workforce does not mirror that of the United States population (Melillo, Dowling, Abdallah, Findeisen, & Knight, 2013). Minority nurses are underrepresented, comprising only 16.8 percent of the nursing population, whereas the total US population is 22.3 percent minority (US Census Bureau, 2013; US Department of Health and Human Services, 2010). A recent census report projected that, by 2043, racial and ethnic minorities will make up over half of the population (America.gov, 2010).
A culturally diverse nursing workforce is necessary to meet the health care needs of this increasingly diverse population. Improvements in nursing workforce diversity and cultural competence education for health care providers are among the most potentially effective interventions needed to reverse the numerous differences found in the quality of health care provided to racial and ethnic minorities (Pacquaio, 2007). National organizations, including the National League for Nursing (NLN), the American Association of Colleges of Nursing (AACN), the Institute of Medicine (IOM), and the American Nurses Association (ANA), agree that increasing the racial and ethnic diversity of students in nursing programs is a high priority (AACN, 2009; American Nurses Association, 2011; Institute of Medicine, 2011; Loftin, Newman, Dumas, Gilden, & Bond, 2012; NLN, 2010). Therefore, it is important to identify and address both facilitators and perceived barriers to the success of minority nursing students in all aspects of their nursing education.
Barriers to successful completion of a nursing program for minority nursing students include financial and work issues (Amaro, Abriam-Yago, & Yoder, 2006), inadequate academic preparation and study skills (Amaro et al., 2006), lack of support from family, role models, or mentoring (Amaro et al., 2006; Taxis, 2006; Villarruel, Canales, & Torres, 2001), and experiences with discrimination and isolation in the clinical setting (Sedgwick, Oosterbroek, & Ponomar, 2014). These barriers have contributed to a disparity in the nursing profession and resulted in attrition rates as high as 85 percent in minority student populations (Gardner, 2005; Giddens, 2008; Taxis, 2006).
Efforts to admit, retain, and graduate minority nursing students have resulted in increases in the number of minority students graduating from BSN programs overall, from 24.6 percent in 2009 to 28.4 percent in 2013 (AACN, 2009-2013). Despite these efforts, attrition rates continue to be a concern as the number of Black and Hispanic nursing students graduating from BSN programs continues to fluctuate (AACN, 2009-2013; Coleman, 2008; Jeffreys, 2012; Taxis, 2006). Although the number of minority nursing students enrolled in both associate degree (ADN) and BSN programs have only slightly decreased, from 29 percent in 2009 to 28 percent in 2014, there have been significant decreases in Black and Hispanic student enrollment in ADN programs. Hispanic student enrollment in ADN programs has fluctuated, from 7.6 percent in 2009 to 6 percent in 2012, with Black student enrollment decreasing from 13.9 percent in 2009 to 9 percent in 2012 (NLN, 2009-2013).
The literature is replete with studies identifying facilitators and barriers to successful completion of nursing programs by minority students; however, these studies and interventions focus on academic factors in the classroom and fail to incorporate clinical education experiences. This lack of attention to clinical education is significant, as nursing students report clinical experiences to be the most influential factor in the development of their nursing skills, knowledge, and transition into the professional nurse role (Chun-Heung & French, 1997; Sedgwick et al., 2014).
Minority students continue to encounter significant barriers in the clinical component of their education programs (Ackerman-Barger, 2010). Because there is sparse literature addressing issues concerning nursing student clinical failure (McGregor, 2007), it is unclear if a relationship exists between attrition rates and the perceived clinical barriers reported by minority nursing students. The purpose of this integrative review is to identify how undergraduate minority nursing students' perceptions, including facilitators and barriers, of their clinical education experiences is reported in the published literature.
Jeffreys' Nontraditional Undergraduate Retention and Success (NURS) model guided this review. This ecological model provides a discipline-specific framework that addresses the multidimensional factors affecting retention of nursing students in order to identify at-risk students, develop prescriptive strategies for success, guide Innovations in educational research, and evaluate intervention effectiveness (Jeffreys, 2012). The model posits that the retention and overall success of nontraditional nursing students is based on the interaction of student characteristics, including race and ethnicity, with academic factors, professional integration factors, environmental factors, outside surrounding factors, and psychological factors.
Academic factors in the NURS model include personal study skills, study hours, attendance, class schedule, and general academic services (Jeffreys, 2012). Environmental factors are presumed more important for nontraditional nursing students than academic factors and include those factors external to the academic process such as financial status, family emotional support, living arrangements, and transportation. Outside surrounding factors are those factors existing outside the academic setting such as the health care system and nursing professional issues. Finally, professional integration factors include those factors that enhance students' interaction with the social system of the college environment such as memberships in professional organizations, encouragement by friends, peer mentoring, and enrichment programs.
Nontraditional in the Jeffreys (2012) model refers to a nursing student who is enrolled in an entry-level undergraduate nursing program and who meets one or more of the following criteria: a) 25 years or older, b) commuter, c) enrolled part-time, d) male, e) member of an ethnic and/or racial minority, f) speaks English as a second (other) language, g) has dependent children, h) has a general equivalency diploma, and I) is required to take remedial classes. This integrative review focuses on nontraditional students who are members of an ethnic and/or racial minority. The facilitators and barriers reported in this review were organized using concepts of the NURS model.
This integrative review follows the five steps as identified by Whlttemore and Knafl (2005). These steps include problem identification, literature search, data evaluation and analysis, and presentation. Using a two-step strategy, a literature search was conducted to find relevant and related studies published between 1985 and 2015. Consultation with a reference librarian aided in the refinement of search terms in the databases.
In the first step of the search, the key words minority, diversity, education clinical, nursing, and baccalaureate were used in various combinations with the Boolean "and" in the Academic Search Complete, Cumulative Index to Nursing and Allied Health Literature, Educational Resources Information Center, Education Full Text (H.W. Wilson), Ovid/MEDLINE, Scopus, and PubMed databases to ascertain articles relevant to the concept of interest. In the second step of the search, the reference lists of all articles meeting inclusion criteria were searched for additional manuscripts. This strategy initially yielded 634 articles.
For Inclusion in this review, peer-reviewed articles were required to report on a sample of minority nursing students who were currently enrolled in or previously graduated from an ADN or BSN degree nursing program. Studies that focused on all other types of nursing programs were excluded from this study. Articles were excluded if published prior to 1985; a review of the literature revealed that there had been no studies dealing directly or indirectly with minority students' feelings about their education experiences prior to this year. Articles were also excluded if they reported on studies conducted outside the United States and Canada.
Titles and abstracts were reviewed for relevance, eliminating many articles from the review. In total, 14 articles met the selection criteria and were included in this review.
Of the 14 studies included in this review, 10 are qualitative, 1 is a mixed-methods study, and 3 are descriptive. The majority are at least 10 years old; 2 are less than five years old. Minority students represented in the review include Blacks, Hispanics, Asian/Pacific Islander, Portuguese, Filipino, First Nation/Aboriginal, American Indian, and other. Four studies were conducted with samples composed of a combination of White and minority students (Anfinson, 1999; Evans, 2008; Mahat, 1998; Sedgwick et al., 2014).
The subheadings in this section consist of the factors that influence retention of nontraditional nursing students according to the NURS model. The reviewed studies are presented in Table 1 and rated using the Melnyk and Fineout-Overholt (2011) system for determining hierarchy of evidence.
Of the 14 studies in this review, five identified academic factors from the NURS model as perceived barriers to clinical education practices that may affect retention of minority nursing students (Anfinson, 1996; Evans, 2008; Jordan, 1996; Langston-Moss, 1997; Tucker-Alien, 1991). Two studies (Langston-Moss, 1997; Tucker-Alien, 1991) described Black students' feelings that both clinical assignments and grading were generally unfair in comparison to assignments and grading for their White peers. Hispanic and Asian/Pacific Islander students in these studies viewed the grading practices of clinical faculty as being much fairer than the grading practices of faculty in classroom settings.
In contrast, 18 White students in the Evans (2008) study were asked how school was going, and only one student identified fear of failure in the clinical setting. Evans, Jordan (1996), and Langston-Moss (1997) described the students' clinical experiences and practices In the assessment lab as being void of culturally appropriate practice, with textbook material focused only on White patients. Black students in the Jordan study further expressed concern that the exclusion of culturally appropriate nursing care was a systems issue and was overall unfair to all nursing students, as they would be unprepared as RNs to care for diverse patient populations. Anfinson (1999) described the students' perceptions of clinical faculty's negative assumptions regarding their level of competence in the clinical setting and how this may alter the students' learning experience and academic outcomes.
Outside Surrounding Factors
Two studies in this review identified outside factors that exist as perceived barriers for undergraduate students. Langston-Moss (1997) and Amaro et al. (2006) concluded that minority students experience discrimination from nursing directors, staff, and patients in their clinical education practices. Students told of encounters in which they experienced offensive comments from nursing directors and patients regarding their English as a second language.
Professional integration Factors
Minority students in 11 studies perceived professional integration factors as barriers to clinical education practices. These studies identified negative interactions between minority students and clinical faculty, peers, and nurses to whom they were assigned during clinical rotations. In contrast, Villarruel et al. (2001) identified no perceived barriers to clinical education practices of Hispanic students. Villarruel et al. (2001) and Tucker-Alien (1991) identified experiences promoting professional integration with Hispanic students. Students reported that their clinical experiences in Hispanic communities were beneficial. Patients and clinical faculty valued their bilingual skills, and experiences were organized to ensure success.
Four studies in this review identified interactions with peers in the clinical setting as barriers for Black and Asian/Pacific Islander students. Students reported being the last chosen by their peers in the laboratory, which created a sense of being other (Aiken, Cervero, & Johnson-Bailey, 2001; Dapremont, 2011; France, Fields, & Garth, 2004; Sedgwick et al., 2014). Hispanic students in the study by Evans (2008) reported that being the only Hispanic students in the lab led to repeated absences.
Some Black, Hispanic, and American Indian students perceived that covert racism and racial profiling were present and relayed by both faculty and peers (Aiken et al., 2001; Evans, 2008; Langston-Moss, 1997). These students provided specific encounters of racially offensive comments from both White students and faculty in the clinical area. Langston-Moss (1997), Mills-Wisneski (2005), and Anfinson (1999) reported that the absence of minority faculty in the clinical setting was a perceived barrier fa minority nursing students.
Two studies (Gapper, 2006; Sedgwick et al., 2014) reported students' feeling that nurses in the clinical setting did not share their professional and personal values. These differences impacted their behavior and communication.
One study (Mahat, 1998) identified no significant correlations between stressors (e.g., initial experiences, interpersonal relationships, heavy workload, feelings of helplessness) and the ability to perform roles among Filipino and Hispanic students. However, it identified positive correlations between interpersonal relationships and seeking social support coping strategies from Black and White students. The small sample size (15 African American students) precluded meaningful analysis.
No studies in this review collected individual-level measures to identify minority nursing students' satisfaction with the clinical component of their educational experience. In addition, no study focused on both academic and nonacademic outcomes in minority nursing students. The NURS model posits that psychological outcomes such as satisfaction mediate performance and persistence outcomes (Jeffreys, 2012). No studies focused on facilitators to minority student success in clinical education practices. Only four studies focused on the clinical experiences of diverse groups of nursing students (Anfinson, 1999; Evans, 2008; Mahat, 1998; Sedgwick et al., 2014).
Perhaps the most noteworthy finding of this integrative review is that, despite the congruence in perceived barriers to clinical education practices as reported by minority students in nursing programs throughout the US, no high level of evidence or intervention studies exist in this area. The barriers reported add to the barriers to success for minority nursing students identified in an integrative review by Loftin, Newman, Gilden, Bond, and Dumas (2013). Results support the need for nursing programs to adopt a multidimensional approach for the overall success of minority students in clinical education practices by selecting and adapting strategies that best fit the students' needs and resources.
Results of this review highlight the need for the nursing profession to focus its endeavors on the Sullivan Commission's (2004) recommendation to increase the diversity of the nursing workforce by first acknowledging the exclusive Eurocentric culture of nursing education (DeBrew, Lewallen, & Chun, 2014). Efforts must be implemented to change the environment to one that ensures diverse groups of learners are successful in all aspects of their nursing programs.
The evidence presented suggests that bias and discrimination are both an issue at the nursing program level as well as a systemic issue as students in these studies experience bias and discrimination with all groups of people in their clinical education practices. DeBrew and colleagues (DeBrew et al., 2014; DeBrew & Lewallen, 2014) conducted a qualitative study to describe faculty decision-making regarding clinical evaluation; 88 percent of participants were White women. Faculty struggled with whether to pass or fail students who are often viewed as outsiders in nursing education.
Findings from this review confirm that prejudicial and discriminatory practices of clinical faculty have a negative effect on the clinical experiences of minority nursing students. Because nurse faculty in the US are primarily White women, it is imperative that unbiased and culturally competent pedagogical efforts are taken to ensure that race does not play a role in the instruction and evaluation of minority students (AACN, 2011a, 2011b; Hassouneh, 2006; Puzan, 2003). Students who may harbor this suspicion must be disabused of the notion that bias exists from clinical faculty (Anfinson, 1993). The clinical evaluation process requires analysis and restructuring to ensure an objective, inclusive process in which faculty avoid unintentionally holding students to their own cultural norms.
The participants in the reviewed studies most commonly described clinical experiences affecting professional integration and socialization. These findings are alarming because professional integration factors are at the center of the NURS model and are considered the crossroads of a nontraditional nursing student's decision to persist, drop out, or stop out (Jeffreys, 2012). Opportunities for professional socialization in clinical experiences can become facilitators of success and achievement for diverse students (Jeffreys, 2012; Loftin et al., 2012). However, nursing programs have failed to identify best practices or develop enrichment programs for minority students in their clinical education practices.
Multiple nursing remediation programs focus on academic factors, with increased retention the primary intervention outcome. Very few clinical remediation programs exist for nursing students overall, with even fewer programs implementing and evaluating the effectiveness of interventions aimed at facilitating minority student success in the clinical setting (Gallant, McDonald, & Smith Higuchi, 2006; Loftin et al., 2013). The development and testing of enrichment programs focusing on both clinical and emotional support during the key transitional phase from nursing student to professional nurse is vital and will provide minority students safe avenues to be successful in their nursing careers.
The findings from this review have implications for nurse faculty, program administrators, and clinical education practice partners. Commitment to the retention and program success of minority nursing students can significantly reduce, if not eliminate, many of the barriers they face and increase the retention of minority nursing students.
This review includes only students currently enrolled or recently graduated from a nursing program. It is not clear if minority students who are not able to persist through to program completion have similar or additional barriers to success that are not identified by those who are successful in their nursing programs.
To achieve a nursing workforce that is able to meet the health care needs of all patient populations, advances to promote diversity in nursing education must begin with changing its exclusive, traditional culture to one that ensures that all learners are provided an equal opportunity to a quality nursing education. The first step is to address the challenges and issues within nursing education programs that may negatively impact the clinical experiences of minority nursing students. This integrative review provides evidence of the significant barriers minority nursing students encounter in their clinical education experiences that may affect attrition.
Crystal L. Graham, MSN-Ed, RN, CHSE, Is a PhD candidate and simulation lab coordinator/instructor, Francis Marion University Department of Nursing, Florence, South Carolina. Shannon M. Phillips, PhD, RN, CCRN, is assistant professor, Medical University of South Carotina College of Nursing. Susan D. Newman, PhD, RN, CRRN, is associate professor, Medical University of South Carolina College of Nursing. Teresa W. Atz, PhD, RN, CHSE, is assistant professor, Medical University of South Carolina College of Nursing. For information, write to firstname.lastname@example.org.
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Table 1: Presentation of Studies Author, Study Purpose Theoretical Framework Date Tucker- Ascertain minority None stated Alien, nursing students' 1991 feelings about educational experiences in large, urban, multiuniversity setting. Jordan, Examine lived Critical 1996 experience of African hermeneutic American students inquiry enrolled in predominantly White BSN programs. Langston- Explore experiences None stated Moss, of Black American 1997 female students in predominantly White ADN/BSN programs. Mahat, Identify junior BSN Theory of 1998 nursing students from cognitive different ethnic appraisal of stress backgrounds perceived stressors/ coping strategies during clinical component of their nursing education. Anfinson, Twofold, to explore None stated 1999 nursing students' perceptions regarding differences in clinical experience that relate to minority-racial status/to suggest processes that facilitate knowledge application in clinical setting. Aiken et Explain factors that Black feminist al., 2001 encouraged/ discouraged the participation of Black women in RN completion programs. Villarruel Identify barriers and None stated et al., bridges to 2001 educational mobility as experienced by Hispanic nurses who advanced from an ADN degree to a BSN degree. France et Explore lived Watson's Theory al., 2004 experience of Black of Human nursing students in Science and predominantly White Human Care university in rural Southeastern community to develop interventions for retention. Mills- Examine African None stated Wisneski, American BSN 2005 students' perceptions of the absence of minority nursing faculty in their program. Amaro et Determine ethnically Grounded theory al., 2006 diverse nursing students' perceptions of educational barrias. Gapper, Explore past and VanManen's 2006 present expaiences lifeworld of first-genaation conceptual immigrant Asian framework American students of human enrolled in an urban beings using four ADN program. existentials Evans, Compare/contrast Theory of Human 2008 perceptions concerning Caring of Watson barriers to success fam and caring Hispanic/Latino and curriculum of American Indian BSN Bevis and Wktson. students with corresponding perceptions from a comparison group of Anglo students. Dapremont, Examine perceptions/ Theoretical Model 2011 experiences of Dropout contributing to the success for Black graduates who attended nursing degree programs with predominantly White students. Sedgwick Identify factors that None stated et al., influence minority 2014 nursing students' sense of belonging during clinical experiences. Author, Study Design Sample Date Tucker- Descriptive using 44 minority nursing Alien, three-part survey students enrolled in 1991 developed by nursing program at researcher: Minority large, Midwest, Student Nurse urban college of Questionnaire. nursing: 20 Black, 11 Hispanic, 13 Asian/Pacific Islander (API). Jordan, Qualitative critical Four African 1996 hermeneutic using American nursing individual interviews students enrolled in junior/senior year in predominantly White BSN program. Langston- Qualitative Nine senior Black Moss, phenomenological female nursing 1997 using individual students: 1 enrolled interviews. in BSN program, 8 in 2-year technical college. Mahat, Descriptive using 107 junior BSN 1998 a demographic students enrolled in questionnaire and college of nursing In Critical Incident Northeast; 60 White, Technique Tool to 15 Black, 14 Filipino, measure perceived 13 Hispanic, 4 other. stressors; 96% content validity established by 2 clinical nurse educators. Anfinson, Qualitative pitot Seven female/1 male 1999 including first-year ADN observation students. Five of clinical students' were White, experience/ 2 Black, and individual informant 1 Hispanic. interviews. Aiken et Qualitative Seven Black women al., 2001 attending RN completion programs. Villarruel Qualitative using Six focus groups with et al., focus groups in six 37 female nurses of 2001 sites (San Jose/ mixed Hispanic San Francisco, CA; ethnicity who were B Paso/San Antonio, bom in US or TX; Springfield, MA; emigrated from Latin New York City) American countries. France et Qualitative Four Black students al., 2004 phenomenological enrolled in a using individual BSN program interviews, field notes, (entire Black student and the research body in the program). assistant's journal. Mills- Descriptive design Convenience sample Wisneski, using the of 66 female/5 male 2005 researcha-designed Black junior BSN 5-point Likert scale students at followed by 9 private/state open-ended universities in North question to explain Atlantic and rating. No data for Southern regions of tool validity/reliabilrty. the United States. Amaro et Qualitative grounded 17 ethnically diverse al., 2006 theory using in-depth recent RN graduates individual interviews from both ADN and BSN degree programs. 8 were Asian, 4 Latino, 2 Portuguese, 2 African American. Gapper, Qualitative Nine Asian American 2006 phenomenological students in urban single-site method ADN program. using in-depth interviews. Evans, Qualitative using 12 Hispanic/Latino, 2008 semistructured 2 American Indian, interviews 18 Anglo students enrolled at 2 private/2 public colleges and universities in Spokane area. Dapremont, Qualitative using 16 male/2 female 2011 semistructured Black participants in-depth from four different interviews BSN/ADN nursing schools in the midsouthern United States. Sedgwick Mixed methods 461 students et al., using the total with 2014 Belongingness 44 questionnaires Scale Clinical completed by Placement 2 Black students, Experience and 3 Latino, 9 First semi structured Nation/Aboriginal, qualitative 16 Asian, and interviews. 11 other. Seven students volunteered to participate in semi structured interviews following the questionnaire. Author, Findings Date Tucker- Ten Black students felt Alien, faculty were helpful in 1991 clinical area: 10 felt the opposite and that grading practices were unfair. Hispanic and API students viewed grading practices of clinical faculty as more fair than faculty in other areas. Hispanic students felt that lab sessions were organized to ensure minority student success; Black/API students disagreed. Jordan, Students reported 1996 feelings that educational practices never centered on racially diverse patients/void of opportunities to practice culturally appropriate nursing assessments. Blamed writers of the textbooks for lack of culturally competent material. Langston- Students reported Moss, stereotyped thinking by 1997 White peers in clinical setting. Negative comments by White nursing director of the clinical assignment floor. Health assessment tools biased. No Black clinical faculty. Unfair and more difficult clinical assignments/different consequences in clinical area/unfair grading practices. Continued Mahat, No significant correlations 1998 found in stressors/coping strategies of Filipino/ Hispanics. Initial experiences identified as stresslul by White and Black students. Positive correlations found between interpersonal relationships/seeking social support coping strategies of both Black and White students. Negative correlation found between initial experiences/seeking social support among Black students. Anfinson, Two minority/2 1999 nonminority participants perceived no differences in clinical experiences. One minority/3 nonminority perceived differences related to minority-racial status. Minority status of staff nurse may facilitate or Impede the students' communication with individual. Minority students perceived that clinical faculty made negative assumptions regarding their abilities In clinical setting. Aiken et Grouped according to al., 2001 factors that encouraged/ discouraged participation in the program; no factors encouraging participation. Those discouraging included seeing self as other/ covert racism (e.g., treatment compared to White peers)/faculty unwilling to touch Black students when demonstrating techniques in lab. Villarruel No clinical barriers et al., identified. Bridges 2001 included having clinical experiences in Hispanic communities and perceived value of their bilingual language skills by clinical faculty and patients. France et Students reported being al., 2004 the only one in the lab and last to be chosen because peas feel they don't know anything. Feeling like "the other." Mills- Students report that Wisneski, nurses at the clinical 2005 facility who are Black give them a Black perspective on nursing. Amaro et Several participants al., 2006 denied prejudice or discrimination from nursing teachers but perceived prejudice, discrimination, or racism in clinical experiences from staff and clients. Gapper, Cultural differences 2006 impacted behavior and communication in the clinical setting. Evans, Hispanic students 2008 reported not coming to lab as they were only Hispanics in the class. Also reported repeated incidents of discrimination in clinical groups. Faculty racial profiling of students led to inappropriate clinical assignments. Lack of diversity and instruction with diverse patients. Dapremont, Participants expressed 2011 vital need for peer support from other Black students. These relationships were often formed during clinical experiences. Sedgwick All students viewed et al., clinical placements as 2014 possible place to experience sense of belonging. First Nations/ Aboriginal, Asian, Other felt discriminated against. Did not perceive they worked with nurses who shared professional and personal values. Identified that nurses they worked with, clinical instructors, and peer groups have the most influence, positive or negative, on clinical experiences.
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|Author:||Graham, Crystal L.; Phillips, Shannon M.; Newman, Susan D.; Atz, Teresa W.|
|Publication:||Nursing Education Perspectives|
|Date:||May 1, 2016|
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