Acute Care Nurses Research Articles

Planning for Success: A Multidisciplinary Approach to Complex Discharges in Pediatric Blood and Marrow Transplant

Topic Significance & Study Purpose/Background/Rationale The discharge process for the pediatric bone marrow transplant patients is very complex. It is overwhelming for both the patient and their caregiver as they struggle to learn about infections, precautions, medication administration, dietary restrictions, social isolation, and when and whom to call in the event of a fever or other medical emergency. Although patients look forward to leaving the hospital after a tenuous inpatient stay, the care remains very multifaceted and informational needs are high at the time of discharge. We have developed a pathway that eases the stressors of discharge for families and helps the team provide individualized support specific to their needs. As a team we can anticipate those needs and ensure a successful transition to home. Methods, Intervention, & Analysis Preparation starts early with education provided prior to admission and is reinforced repetitively during their inpatient stay. The multidisciplinary team who collaborate with discharge planning include providers, pharmacists, social workers, case managers, nurses, and nutritionists. The role of each team member is explained and they are present at a discharge meeting that is scheduled with the family upon the patient showing first signs of engraftment and clinical stability. Those members are then expected to follow-up as needed with each patient prior to discharge. A discharge roadmap and checklist is used and may be modified based on additional needs of individual patients. Key elements of the discharge pathway reviewed at the discharge meeting include: clinical eligibility for discharge completed by the provider, medication review completed by BMT Pharmacist and Case Manager, transition to home completed by Acute Care Nurse Coordinator, and ensuring appropriate resources are utilized while identifying potential barriers completed by the BMT Social Worker. Findings & Interpretation This pathway has streamlined the discharge process by decreasing medication errors and improving medication compliance, establishing effective communication among the team and to patients and their caregivers, setting clear expectations for patients in the outpatient setting. Discussion & Implications This pathway can help other Pediatric Blood and Marrow Transplant Centers in reorganizing the discharge process to improve quality of care and outcomes.

Acute Care Nurses' Experiences of Basic Palliative Care.

As the population of chronically ill, older adults increases, there is a growing need for palliative care. The Institute of Medicine recommends that health care providers have a basic competency in palliative care. However, the definition of basic palliative care in practice and providers' understanding of basic palliative care lack clarity. The purpose of this study was to describe nurses' perceptions of basic palliative care in the acute care setting. This was accomplished by conducting focus group and individual interviews. The major themes of helping families navigate chronic illness and empowering families and subthemes of being present, giving options, and advocating emerged from the analysis. Through education and role modeling, nurses helped families navigate illness and end-of-life experiences. Study findings describe acute care nurses' perceptions of basic palliative care and may help to identify the educational needs of nurses in order to provide basic palliative care for patients and their families in acute care settings.

Nurse Continuity at Discharge and Return to Hospital.

Promoting continuity of nurse assignment during discharge care has the potential to increase patient readiness for discharge-which has been associated with fewer readmissions and emergency department visits. The few studies that examined nurse continuity during acute care hospitalizations did not focus on discharge or postdischarge outcomes. The aim of this research was to examine the association of continuity in nurse assignment to patients prior to hospital discharge with return to hospital (readmission and emergency department or observation visits), including exploration of the mediating pathway through patient readiness for discharge and moderating effects of unit environment and unit nurse characteristics. In a sample of 18,203 adult, medical-surgical patients from 31 Magnet hospitals, a correlational path analysis design was used in a secondary analysis to evaluate the effect of nurse continuity on readmissions and emergency department or observation visits within 30 days after hospital discharge. The mediating pathway through discharge readiness measured by patient self-report and nurse assessments was also assessed. Moderating effects of unit environment and nursing characteristics were examined across quartiles of unit environment (nurse staffing hours per patient day) and unit nurse characteristics (education and experience). Analyses were adjusted for patient characteristics, unit fixed effects, and clustering at the unit level. Continuous nurse assignment on the last 2 days of hospitalization was observed in 6,441 (35.4%) patient discharges and was associated with a 0.85 absolute percentage point reduction (7.8% relative reduction) in readmissions. There was no significant association with emergency department or observation visits. Sensitivity analysis revealed a stronger effect in patients with higher Elixhauser Comorbidity Indexes. Readiness for discharge was not a mediator of the effect of continuity on return to hospital. Unit characteristics were not associated with nurse continuity. No moderation effect was evident for unit environment and nurse characteristics. Continuity of nurse assignment on the last 2 days of hospitalization can reduce readmissions. Staffing for continuity may benefit patients and healthcare systems, with greater benefits for high-comorbidity patients. Nurse continuity prior to hospital discharge should be a priority consideration in assigning acute care nurses to augment readmission reduction efforts.

Acute Care Nurses' Arrhythmia Knowledge: Defining Competency.

Most methods of evaluating arrhythmia knowledge acquisition are internally developed by nursing professional development practitioners and are institution specific. This approach has resulted in assessing nurses' minimal qualifications for rhythm recognition as defined by the facility but does not result in describing basic, intermediate, and advanced competency levels for practice. This quantitative study with a convenience sample of 85 acute care nurses refined an instrument to assess varying levels of arrhythmia recognition competency for acute care nurses. The final instrument, called the Cardiac Arrhythmia Recognition Tool (CART), consisted of 33 items divided into basic, intermediate, and advanced subscales, with an overall Cronbach's alpha of .84. This study significantly contributes to defining arrhythmia competency in nurses caring for electrocardiographically monitored patients. [J Contin Educ Nurs. 2020;51(1):39-45.].

Diabetes self-management support by acute care nurses and associated factors

Diabetes self-management support by acute care nurses and associated factors

Considering “the more” of patients suffering from alcohol use disorders. An illustration of acute nursing care from a lifeworld-led perspective

ABSTRACT Purpose The purpose of this study is to illustrate a theoretical value framework for humanisation of healthcare, a lifeworld-led care that has the potential to support nurses in acute medical units in addressing and meeting both challenges and care needs expressed by patients suffering from alcohol use disorders. Providing care to these patients means working with a very divergent and complex group of patients. When hospitalised in an acute medical unit, nurses are often these patients' first encounter, which gives a unique opportunity to initiate and establish a successful care alliance. Method The present study is a qualitative study based on an amplified secondary analysis of 25 pre-conducted interviews. Following a hermeneutic approach, the analysis was structured in accordance with the conceptual value framework for humanisation of care, drawing on the recognition of the patients' lifeworld as an aspect of importance. Findings The study showed that while there were examples of humanising care guided by the patients’ lifeworld present, there were also situations of care that were dehumanising. Conclusion: When letting the patients’ perspective of well-being be the centre of care, the patients’ experience of meaningfulness and sincerity within the provided care was nurtured, and they felt more humanly met.

Blended learning in undergraduate nursing education – A scoping review

ObjectivesTo provide a comprehensive scoping review of the existing literature regarding the use of blended learning in undergraduate nursing education. To align the varied educational terms and definitions with the broad definition of blended learning. DesignScoping review following established methodology. Data sourcesIn consultation with library services, the academic literature was searched. Electronic databases searched included ERIC (OVID), Medline (OVID), PubMed, Nursing and Allied Health, and CINAHL Plus. Review methodsA total of 189 potentially relevant nursing research articles published between the years of 2009 and 2019. Three reviewers independently reviewed the articles, leaving 37 relevant primary articles in the nursing field to be included in the scoping review. ResultsNursing content delivered using blended learning approaches were organized into 8 themes. Themes include Professional Nursing Skills; Mental Health Nursing; Bioscience; Pharmacology, Specialty Populations; Nursing Assessment; Acute Care Nursing; and the Art of Nursing. A variety of blended learning approaches are being utilized in Undergraduate nursing education, the majority of which are happening in the classroom. ConclusionThis scoping review presents explicit the degrees to which blended learning is referred to in the nursing education literature and expanded the definition of blended learning to encompass the terminology associated with distributed, decentralized, hybrid, and flexible learning. There is a wide, varied, and expanding number of blended learning approaches currently being utilized in nursing education to teach a wide range of nursing content and skills. An expanded scoping review focused on blended learning in psychiatric nursing, licenced practical nursing, nurse practitioners, and all graduate level nursing education programs is recommended as is additional research into the use of blended learning in the lab or clinical setting.

A Professional Nursing Acute Care Practice Curriculum.

Caring for multiple complex patients simultaneously is 1 of the biggest challenges for clinical nurses (CNs) in acute care. We utilized the results of research to develop a 6-hour Professional Nursing Practice Curriculum (PNPC) specifically for CNs who are professionally and legally responsible for providing holistic care to an assigned group of patients on inpatient clinical units in acute care hospitals. The curriculum can be used by faculty to prepare senior nursing students for their 1st professional practice role in an acute care setting. Components of the PNPC will be beneficial for nurse leaders in an assessment of their educational practices for transitioning newly licensed RNs to practice and addressing professional development needs of CNs.

Knowledge and experiences with augmentative and alternative communication by paediatric nurses: a pilot study

Purpose The current mixed methods research study was designed to describe the experience and opinions of paediatric acute care nurses at a single paediatric medical centre regarding augmentative and alternative communication (AAC). This research serves as the beginning of a line of research to determine needs that can be met through later education and training on AAC with paediatric acute care nurses. Methods Mixed methods were used to gather survey and interview data from nurses at a single paediatric hospital to investigate their knowledge of AAC, perceived relevance of AAC for their patient populations, and preferences for training programmes. Results Quantitative survey and qualitative interview data indicated a need for AAC education for these paediatric nurses. Nurses demonstrated limited knowledge and experience with AAC but communicated both a desire and perceived need to know more to effectively care for their patients. Conclusion Nurses reported limited AAC knowledge but expressed a desire for support to use AAC with their patients. AAC education and cross-sector collaboration with healthcare workers such as speech-language pathologists (SLPs) and acute care paediatric nurses are indicated to support effective communication when interacting with patients with complex communication needs (CCN). Implications for rehabilitation Improved background knowledge to develop and implement future nurse education on AAC. Foundation for cross-sector collaboration (e.g., nurses and SLPs) on AAC implementation in paediatric acute care settings

What do caregivers value and is there agreement in perception of met needs between nurses and caregivers?

There is an increasing reliance on informal caregivers to continue the care of patients after discharge. This is a huge responsibility for caregivers and some may feel unprepared for the role. Without adequate support and understanding regarding their needs, patient care may be impeded. This study aimed to identify the needs valued by caregivers and if there was agreement between acute care nurses and caregivers in the perception of whether caregiver needs were being met. We conducted face-to-face interviews with 100 pairs of acute care nurses and caregivers. Participants were recruited from inpatient wards through convenience sampling. Questionnaires included demographic data of nurses and caregivers, patients' activities of daily living, and perception of caregiver needs being met in six domains of care. Independent t-test was used to compare mean values in each domain, and intraclass correlation coefficient was used to compare agreement in perception. Caregivers valued reassurance the most. Three domains of care needs showed significant differences in perception of caregiver needs being met:reassurance (p = 0.002), honesty and timeliness (p = 0.008), and kindness and genuine care (p = 0.026). There was poor agreement in all six domains of caregiver needs being met between nurses and caregivers. Although caregivers valued reassurance the most, there was poor agreement between acute care nurses and caregivers in the perception of caregiver needs being met. Hence, more attention should be paid to the caregiver's needs. Further studies can examine reasons for unmet caregiver needs and interventions to improve support for them.

Choosing Wisely in Critical Care: A National Survey of Critical Care Nurses.

To promote the use of appropriate testing, and decrease unnecessary treatments, the ABIM Foundation established the Choosing Wisely campaign in 2012. Initially targeting physicians, the campaign has evolved to encourage all providers to promote high-value care; however, information related to critical care nursing is limited. To assess nurses' reports of the use of Choosing Wisely recommendations in critical care settings. Responses from nurses were examined as part of a critical care survey of members of 4 societies in order to assess awareness and use of the Choosing Wisely recommendations. Of the 1651 acute and critical care nurses who were members of the American Association of Critical-Care Nurses and responded to the survey, 632 (38.3%) reported being familiar with the Choosing Wisely campaign. Of these respondents, 200 identified as advanced practice nurses. A total of 620 reported implementing the 5 Critical Care Society Collaborative recommendations, including reducing diagnostic testing (n = 311 [50.2%]), reducing the number of red blood cell transfusions (n = 530 [85.5%]), not using parenteral nutrition in adequately nourished patients (n = 293 [47.3%]), not using deep sedation in patients receiving mechanical ventilation (n = 499 [80.5%]), and offering comfort care for patients at high risk for death (n = 416 [67.1%]). Staff education, specific protocols, electronic medical record alerts, and order sets all raised nurses' awareness of the recommendations. Acute and critical care nurses are directly involved with measures to reduce unnecessary testing and treatments. Greater awareness and championing of the Choosing Wisely recommendations by acute and critical care nurses can help to promote high-value care for acute and critically ill patients.

Predicting patient acuity according to their main problem.

AimTo assess the ability of the patient main problem to predict acuity in adults admitted to hospital wards and step‐down units.BackgroundAcuity refers to the categorization of patients based on their required nursing intensity. The relationship between acuity and nurses' clinical judgment on the patient problems, including their prioritization, is an underexplored issue.MethodCross‐sectional, multi‐centre study in a sample of 200,000 adults. Multivariate analysis of main problems potentially associated with acuity levels higher than acute was performed. Distribution of patients and outcome differences among acuity clusters were evaluated.ResultsThe main problems identified are strongly associated with patient acuity. The model exhibits remarkable ability to predict acuity (AUC, 0.814; 95% CI, 0.81–0.816). Most patients (64.8%) match higher than acute categories. Significant differences in terms of mortality, hospital readmission and other outcomes are observed (p < .005).ConclusionThe patient main problem predicts acuity. Most inpatients require more intensive than acute nursing care and their outcomes are adversely affected.Implications for nursing managementProspective measurement of acuity, considering nurses' clinical judgments on the patient main problem, is feasible and may contribute to support nurse management workforce planning and staffing decision‐making, and to optimize patients, nurses and organizational outcomes.

Moral distress in acute psychiatric nursing: Multifaceted dilemmas and demands.

In this article, the sources and features of moral distress as experienced by acute psychiatric care nurses are explored. A qualitative design with 16 individual in-depth interviews was chosen. Braun and Clarke's six analytic phases were used. Approval was obtained from the Norwegian Social Science Data Services. Participation was confidential and voluntary. Based on findings, a somewhat wider definition of moral distress is introduced where nurses experiencing being morally constrained, facing moral dilemmas or moral doubt are included. Coercive administration of medicines, coercion that might be avoided and resistance to the use of coercion are all morally stressful situations. Insufficient resources, mentally poorer patients and quicker discharges lead to superficial treatment. Few staff on evening shifts/weekends make nurses worry when follow-up of the most ill patients, often suicidal, in need of seclusion or with heightened risk of violence, must be done by untrained personnel. Provision of good care when exposed to violence is morally challenging. Feelings of inadequacy, being squeezed between ideals and clinical reality, and failing the patients create moral distress. Moral distress causes bad conscience and feelings of guilt, frustration, anger, sadness, inadequacy, mental tiredness, emotional numbness and being fragmented. Others feel emotionally 'flat', cold and empty, and develop high blood pressure and problems sleeping. Even so, some nurses find that moral stress hones their ethical awareness. Moral distress in acute psychiatric care may be caused by multiple reasons and cause a variety of reactions. Multifaceted ethical dilemmas, incompatible demands and proximity to patients' suffering make nurses exposed to moral distress. Moral distress may lead to reduced quality care, which again may lead to bad conscience and cause moral distress. It is particularly problematic if moral distress results in nurses distancing and disconnecting themselves from the patients and their inner selves.

The experiences of the agency registered nurse: An integrative literature review.

To examine experienced registered nurses' motivations for choosing agency work, their experiences and perceptions of agency nursing and how they meet their regulatory professional development obligations. Agency registered nurses are employed by healthcare organizations to meet staffing shortfalls and contain costs. Using an integrative review framework, four databases (CINAHL, Medline, Embase and Scopus) were systematically searched between 2000 and 2017: study selection followed the Preferred Reporting Items for Systematic reviews and Meta-analyses. Our search identified 491 sources. From these, two primary qualitative sources were included in this review. Four themes were identified: orientation, allocation of the agency nurse, isolation in clinical practice and lack of education opportunities. Given the limited literature on agency nurses and how to support them, further research is required on this subject. Support for agency nurses is necessary, so they can seamlessly integrate with the healthcare team to provide safe patient care. This review may assist managers to identify strategies to effectively engage and support agency registered nurses in the acute care nursing team. The gaps identified highlight the need for further research to explore agency nurses' motivations, and support needs to inform future strategic workforce planning.

Using Simulation to Evaluate Clinical Performance and Reasoning in Adult-Geriatric Acute Care Nurse Practitioner Students.

The use of simulation-based learning experiences (SBLE) with nurse practitioner (NP) students is largely unexplored. The purpose of this pilot project was to develop, implement, and evaluate a simulated patient (SP)-SBLE to improve confidence and evaluate clinical performance and reasoning in Adult-Geriatric Acute Care NP (AG-ACNP) students. A mixed-methods design was used to evaluate an SP-SBLE on AG-ACNP student clinical performance and reasoning. Self-confidence scores and themes from reflections indicated that students perceived this as a valuable experience that enhanced learning and confidence. Results supported the use of SP-SBLEs to improve confidence in clinical performance and reasoning with AG-ACNP students. [J Nurs Educ. 2019;58(10):599-603.].

Does Simulation Training for Acute Care Nurses Improve Patient Safety Outcomes: A Systematic Review to Inform Evidence-Based Practice.

Simulation is increasingly used as a training tool for acute care medical-surgical nurses to improve patient safety outcomes. A synthesis of the evidence is needed to describe the characteristics of research studies about acute care nurse simulation trainings and patient safety. An additional purpose is to examine the effects of acute care registered nurse (RN) simulation trainings on patient safety outcomes. Five Internet databases were searched for articles published on any date through October 2018 examining the effect of RN simulation trainings on patient safety outcomes in the adult acute care setting. N=12 articles represented 844 RNs of varying experience levels and 271 interprofessional participants. Nine studies (75%) used high-fidelity scenarios developed locally about high risk but infrequent events. Five studies (42%) incorporated interdisciplinary team members in the scenarios and/or outcome evaluations. Outcome measures were self-reported, direct observation, or clinical indicators. All studies in this review achieved improved patient safety outcomes. It is unknown how outcomes vary for different groups of RNs because of insufficient gender, ethnicity/race, and age reporting. Findings support the design of simulation training research studies for patient safety outcomes and use of simulation training and research in acute care RNs. Additional high-quality research is needed to support this field. Future studies should include descriptors that characterize the sample (i.e., age, gender, education level, type of nursing degree, ethnicity or race, or years of experience); incorporate interdisciplinary teams; evaluate a combination of outcome measure types (i.e., self-report, direct observation, and clinical outcomes) both proximal and distal to the simulation; and that utilize standardized scenarios, validated outcome measure instruments, and standardized debriefing tools.

Nurses’ perceptions of high‐alert medication administration safety: A qualitative descriptive study

The aim of this study was to determine nurses' perceptions of supports and barriers to high-alert medication (HAM) administration safety. A qualitative descriptive design was used. Eighteen acute care nurses were interviewed about HAM administration practices. Registered nurses (RNs) working with acutely ill adults in two hospitals participated in one-on-one interviews from July-September, 2017. Content analysis was conductedfor data analysis. Three themes contributed to HAM administration safety: Organizational Culture of Safety, Collaboration, and RN Competence and Engagement. Error factors included distractions, workload and acuity. Work arounds bypassing bar code scanning and independent double check procedures were common. Findings highlighted the importance of intra- and interprofessional collaboration, nurse engagement and incorporating the patient in HAM safety. Current HAM safety strategies are not consistently used. An organizational culture that supports collaboration, education on safe HAM practices, pragmatic HAM policies and enhanced technology are recommended to prevent HAM errors. Hospitals incorporating these findings could reduce HAM errors. Research on nurse engagement, intra- and interprofessional collaboration and inclusion of patients in HAM safety strategies is needed.

Experiences of the older hospitalised person on nursing pain care: An ethnographic insight.

To present an ethnographic insight into the older hospitalised person (those aged over 65years) perceptions and experiences of pain care provision by nurses in acute care. Pain care provision by nurses remains less than optimal for the older hospitalised person despite numerous evidence-based guidelines. There is a paucity of research providing input from the experiences of the older hospitalised person in relation to their perspectives of pain care provision by nurses in acute care. Pain care research needs more involvement from those older persons with documented diagnoses of dementia, delirium or cognitive impairment, and intellectual disabilities and those in their end stage of palliation. A focused ethnographic study. The consolidated criteria for reporting qualitative research (COREQ) were used to report the findings of this study. A focused ethnographic study was conducted in 8 acute care units within 2 large tertiary referral hospitals on the east coast of Australia. Consisting of semi-structured interviews (n=12) of cognitively intact older persons (11hr). Twenty-three (23) semi-structured interviews with nine (9) RN participants (12hr and 38min). Participant observation period totalled 1,041hr. The older persons' experiences of receiving pain care were based on a formulaic assessment process focusing on intensity of pain and pain management options provided often lacked their input. The older persons often did not perceive their pain care provision as being of benefit to themselves. The nurses lacked insight and understanding on the nature of pain for the older person. Understanding was gained into how the older persons' pain care was hampered due to the lack of appropriate, and meaningful pain care provision and provides insight into why the older hospitalised person continues to experience a less than optimal experience. Older hospitalised persons can gain continuity of pain care when nurses negotiate with them to repattern or restructure their nursing routines for pain care provision. Older people need inclusion into pain care decisions. All vulnerable older persons require nurses to use an evidence-based pain assessment tool.

Inpatient Nurses’ Perception on The Implementation of Acute Care Nursing in The Hasanuddin University Hospital

Introduction: Acute care is a type of time-sensitive care, this is due to an acute condition requiring rapid intervention. Acute conditions that exist in the inpatient unit would require special care in handling. This acute condition can affect many things, one of which is the patient satisfaction. With proper treatment for acute cases, the course will improve patient satisfaction itself. However, to date, acute care has been poorly defined and inadequately supported in most developing health systems. Aims of Study: This research aims to determine nurses’ perception on the implementation of inpatient acute nursing care in the Hasanuddin University Hospital. Method: This research was a qualitative method, data collection using individual interviews against ten participants (inpatient nurses) and validity checks of the data that utilizes something beyond the data. Data analyze used thematic analysis. Result: The results of the research yield four themes. Those four themes are perception of acute conditions, supporting factors in the management of patients with acute conditions, inhibiting factors in the management of patients with acute conditions, and nurses’ hope for acute care. Conclusion: From this research it is known that the incidence of acute conditions in the inpatient unit of Hasanuddin University Hospital less than chronic conditions. To handle acute cases, nurse in the inpatient unit take action early by monitoring vital signs, then immediately gave emergency action if necessary, while collaborating with the doctor. Supporting factors for nurses is the availability of emergency trolly, as well as cooperation among nurses who are good. Whereas the inhibiting factor is the number of nurses who are still lacking and the absence of code blue team. Advice from researchers, to health institutions is expected to be able to form a rapid response team (code blue), so that patients with serious/acute condition can be handled more quickly and efficiently, so that the implementation of nursing, especially nursing acute to run well and the nurse also will not experience in serving patients overwhelmed.

Attitudes towards the dying and death anxiety in acute care nurses - can a workshop make any difference? A mixed-methods evaluation.

In Singapore, the core curriculum for end-of-life (EOL) care used in nurse training courses is limited. Only 45% of nurses indicated familiarity with inpatient palliative care. Nurses who lack skills in palliative care may develop anxiety and negative attitudes towards caring for dying patients. We explored whether a two-day, multimodal EOL care workshop could reduce nurses' death anxiety and improve nurses' skills, knowledge, and attitude towards palliative care. Forty-five nurses participated in the workshop. At baseline before and at six weeks after, a 20-item knowledge-based questionnaire and the Death Attitude Profile-Revised (DAP-R) were administered. Six weeks post-workshop, in-depth interviews were conducted. We employed descriptive statistics, student paired samples t-test and inductive thematic analysis. There was a significant improvement in nurses' knowledge score (p < 0.01) and reduction in their death anxiety score (p < 0.01). Fear of Death (p = 0.025) and Death Avoidance (p = 0.047) sub-scores decreased significantly. However, the remaining domains such as Neutral Acceptance, Approach Acceptance, and Escape Acceptance did not show any significant difference, although Escape Acceptance showed a trend towards a reduced score (p = 0.063). After the workshop, more nurses adopted the Neutral Acceptance stance (76.2%), and none of them fell into the Fear of Death subdomain. Most nurses interviewed reported a positive change in their knowledge, attitudes, and practice even after the workshop. The multimodal palliative care workshop was useful in improving nurses' EOL knowledge and reducing their anxiety towards death. The positive change in nurses' attitudes and practices were noted to be sustained for at least six weeks after the intervention.