Clinical Teaching Faculty Research Articles

Validation of a Clinical Teaching Competency Framework for Physical Therapists: A Mixed-Methods Approach.

A competency framework for clinical teaching in physical therapy was established in a recent study. Validation of competency frameworks requires multiple steps, including consideration of end-user perceptions of value and utility. The purpose of this study was to further validate the clinical teaching competency framework by gathering input specifically from clinical education faculty. This study used an explanatory sequential mixed methods approach to seek input from clinical instructors (CI) and site coordinators of clinical education (SCCE) from diverse practice areas and geographic regions. A survey invited participation from active clinical education faculty, and survey respondents were invited to participate in a focus group. Two focus groups were held via Zoom. Survey responses from those holding roles of CI (59.3%), SCCE (11.3%), and CI/SCCE (29.4%) indicated support for the competency framework, including perceived value to their role (93.1%) and enhancement of quality of clinical education (94.1%). Concern regarding ease of utilization of the framework was indicated by 24% of respondents. There were no statistically significant differences in responses based on role or credentials. The focus groups resulted in an overarching theme of Collective Impact, with 4 subthemes: Assessment, CI development, Implementation, and Guidelines. Clinical education faculty perceive value and utility in the Clinical Teaching Competency Framework. Implementation of the framework into practice should be collaborative and consistent across academic and clinical education programs. This study moves the profession one step closer to use of a competency framework specifically targeted at clinical teaching in physical therapy. Clinical education faculty will be primary users of a competency framework and buy-in from this user group is key to implementation. Continued efforts to validate this framework contribute to addressing the need for CI development and support in delivering excellence in clinical education.

An Exploration of Support for Clinical Education Partners.

Effective academic-clinical partnerships require a greater understanding of how academic programs can best support clinical education (CE) faculty. This study aimed to determine resources and support that clinical partners need. As the number of physical therapist (PT) programs, cohort sizes, and CE weeks have risen, so has demand for CE sites. Conversely, staffing reductions, increased administrative duties, and rising productivity expectations have decreased the time available for clinical instruction. To promote a successful CE experience, there must be a renewed understanding of CE faculty needs. Clinical education faculty affiliated with any of the 8 contributing programs from the Ohio-Kentucky Consortium participated in survey research (n = 24) and subsequent interview (n = 4) and focus group (n = 6) research. Constructivist grounded theory design was used to explore the needs of CE faculty. Academic and clinical partners developed the initial survey and used survey results to establish interview questions. The investigators iteratively assessed data saturation and clarity of results of coded survey, interview, and focus group data to determine whether the study's aims of identifying CE faculty needs had been met. The aggregated results yielded 5 main themes of Director of Clinical Education support for CE faculty needs: student readiness for CE experience; effective academic-clinical partner communication; collaborative management of exceptional students; judicious standardization of CE processes; and provision of CE faculty development resources. Clinical education faculty have noted challenges that affect their ability to mentor students. They want academic programs to be more collaborative and proactive with communication, resources, and support. Future research should address aids and barriers to proactive communication, resource provision, and academic-clinical partner collaboration.

A Novel, Combined Student and Preceptor Professional Development Session for Optimizing Feedback: Protocol for a Multimethod, Multisite, and Multiyear Intervention.

BackgroundProviding feedback to medical learners is a critical educational activity. Despite the recognition of its importance, most research has focused on training preceptors to give feedback, which neglects the role of learners in receiving feedback. Delivering a combined professional development session for both preceptors and students may facilitate more effective feedback communication and improve both the quality and quantity of feedback.ObjectiveThe objective of our research project is to examine the impact of a relational feedback intervention on both preceptors and students during a longitudinal integrated clerkship.MethodsStudents and preceptors will attend a 2.5-hour combined professional development session, wherein they will be provided with educational tools for giving and receiving feedback within a coaching relationship and practice feedback giving and receiving skills together. Before the combined professional development session, students will be asked to participate in a 1-hour preparation session that will provide an orientation on their role in receiving feedback and their participation in the combined professional development session. Students and preceptors will be asked to complete a precombined professional development session survey and an immediate postcombined professional development session survey. Preceptors will be asked to complete a follow-up assessment survey, and students will be asked to participate in a follow-up, student-only focus group. Anonymized clinical faculty teaching evaluations and longitudinal integrated clerkship program evaluations will also be used to assess the impact of the intervention.ResultsAs of March 1, 2022, a total of 66 preceptors and 29 students have completed the baseline and follow-up measures. Data collection is expected to conclude in December 2023.ConclusionsOur study is designed to contribute to the literature on the feedback process between preceptors and students within a clinical setting. Including both the preceptors and the students in the same session will improve on the work that has already been conducted in this area, as the students and preceptors can further develop their relationships and coconstruct feedback conversations. We will use social learning theory to interpret the results of our study, which will help us explain the results and potentially make the work generalizable to other fields.International Registered Report Identifier (IRRID)DERR1-10.2196/32829

Underrepresented Ethnic Minority Nursing Students' Perceptions of Factors That Enhanced or Hindered Their Self-Efficacy.

Self-efficacy is the perceived confidence of students in their ability to learn new skills and knowledge. This study examined underrepresented ethnic minority students' perceptions of the factors that enhanced/hindered their self-efficacy in a bachelor of science in nursing program. Qualitative analysis revealed three themes: 1) doing it, 2) connecting with clinical faculty, and 3) dealing with multiple stressors. Students described clinical faculty's teaching strategies that enhanced their nursing self-efficacy as they managed multiple stressors in their lives.

Brief online implicit bias education increases bias awareness among clinical teaching faculty

ABSTRACT Problem and Purpose Healthcare provider implicit bias influences the learning environment and patient care. Bias awareness is one of the key elements to be included in implicit bias education. Research on education enhancing bias awareness is limited. Bias awareness can motivate behavior change. The objective was to evaluate whether exposure to a brief online course, Implicit Bias in the Clinical and Learning Environment, increased bias awareness. Materials and Methods The course included the history of racism in medicine, social determinants of health, implicit bias in healthcare, and strategies to reduce the impact of implicit bias in clinical care and teaching. A sample of U.S. academic family, internal, and emergency medicine providers were recruited into the study from August to December 2019. Measures of provider implicit and explicit bias, personal and practice characteristics, and pre–post-bias awareness measures were collected. Results Of 111 participants, 78 (70%) were female, 81 (73%) were White, and 63 (57%) were MDs. Providers held moderate implicit pro-White bias on the Race IAT (Cohen’s d = 0.68) and strong implicit stereotypes associating males rather than females with ‘career’ on the Gender-Career IAT (Cohen’s d = 1.15). Overall, providers held no explicit race bias (Cohen’s d = 0.05). Providers reported moderate explicit male-career (Cohen’s d = 0.68) and strong female-family stereotype (Cohen’s d = 0.83). A statistically significant increase in bias awareness was found after exposure to the course (p = 0.03). Provider implicit and explicit biases and personal and practice characteristics were not associated with an increase in bias awareness. Conclusions Implicit bias education is effective to increase providers’ bias awareness regardless of strength of their implicit and explicit biases and personal and practice characteristics. Increasing bias awareness is one step of many toward creating a positive learning environment and a system of more equitable healthcare.

Third year medical students impersonalize and hedge when providing negative upward feedback to clinical faculty

Medical students provide clinical teaching faculty with feedback on their skills as educators through anonymous surveys at the end of their clerkship rotation. Because faculty are in a position of power, students are hesitant to provide candid feedback. Our objective was to determine if medical students were willing to provide negative upward feedback to clinical faculty and describe how they conveyed their feedback. A qualitative analysis of third year medical students’ open-ended comments from evaluations of six clerkships was performed using politeness theory as a conceptual framework. Students were asked to describe how the clerkship enhanced their learning and how it could be improved. Midway through the academic year, instructions to provide full names of faculty/residents was added. Overall, there were significantly more comments on what worked well than suggestions for improvement regarding faculty/residents. Instructing students to name-names increased the rate of naming from 35% to 75% for what worked well and from 13% to 39% for suggestions for improvement. Hedging language was included in 61% of suggestions for improvement, but only 2% of what worked well. Students described the variability of their experience, used passive language and qualified negative experiences with positive ones. Medical students may use linguistic strategies, such as impersonalizing and hedging, to mitigate the impact of negative upward feedback. Working towards a culture that supports upward feedback would allow students to feel more comfortable providing candid comments about their experience.

Incentives for clinical teachers: On why their complex influences should lead us to proceed with caution.

When medical education programs have difficulties recruiting or retaining clinical teachers, they often introduce incentives to help improve motivation. Previous research, however, has shown incentives can unfortunately have unintended consequences. When and why that is the case in the context of incentivizing clinical teachers remains unclear. The purposes of this study, therefore, were to understand what values and motivations influence teaching decisions; and to delve deeper into how teaching incentives have been perceived. An interpretive description methodology was used to improve understanding of the development and delivery of teaching incentives. A purposeful sampling strategy identified a heterogenous sample of clinical faculty teaching in undergraduate and postgraduate contexts. Sixteen semi-structured interviews were conducted and transcripts were analyzed using an iterative process to develop a thematic structure that accounts for general trends and individual variations. Clinicians articulated interrelated and dynamic personal and environmental factors that had linear, dual-edged and inverted U-shaped impacts on their motivations towards teaching. Barriers were frequently rationalized away, but cumulative barriers often led to teaching attrition. Clinical teachers were motivated when they felt valued and connected to their learners, peers, leadership, and/or the medical education community. While incentives aimed at producing these connections could be perceived as supportive, they could also negatively impact motivation if they were impersonal, inequitable, inefficient, or poorly framed. These findings reinforce the literature suggesting that it is necessary to proceed with caution when labeling any particular factor as a motivator or barrier to teaching. They take us deeper, however, towards understanding how and why clinical teachers' perceptions are unique, dynamic and fluid. Incentive schemes can be beneficial for teacher recruitment and retention, but must be designed with nuance that takes into account what makes clinicians feel valued if the strategy is to do more good than harm.

188 Does Sex Bias Impact Faculty Clinical Teaching Awards?

Recently, the implications of sex bias for female trainees has taken a prominent place in graduate medical education (GME) research and discussions. However, there is a relative lack of research addressing sex bias in how female faculty are evaluated by their trainees. Teaching awards are given at many residency programs to recognize excellence in teaching. These awards not only offer prestige but are an essential component of academic promotions. Research suggests that women are underrepresented in the recipients of many professional medical association awards and in awards given to medical school faculty. Our objective is to determine whether women are underrepresented in teaching awards honorees in a single Emergency Medicine Residency. We assessed whether there is a discrepancy between female and male faculty clinical teaching award honorees and the overall representation of women in the teaching faculty at a single Emergency Medicine (EM) program. The Regions Hospital Emergency Medicine Program is a 3-year EM Program with 9-11 residents per class over the past 10 years.. Two yearly teaching awards are presented to clinical teaching faculty, based on evaluations from EM residents and on nominations from rotating medical students. We collected data on the sex of the recipient of each award and reviewed the female-to-male ratio of recipients between 2009 and 2018 (table 1). During that same time period, the percentage of female clinical teaching faculty averaged 31.9%. We found there is a discrepancy between the proportion of women who received a clinical teaching award based on evaluations by learners when compared with the proportion of women faculty: 23.1% of awards were given to women when compared with a teaching faculty averaging 31.9% women. Also, the discrepancy between the percentage of resident-selected teaching awards given to women and percentage of female faculty (28.6% vs 31.9%) was less than that of student-selected awards (16.7% vs 31.9%). In a single Emergency Medicine Residency Program, there is a discrepancy between the percentage of women EM faculty who receive clinical teaching awards and the overall percentage of female faculty who are eligible for the award, despite whether the award is chosen by EM residents or medical students. Sex bias may play a role in determining teaching award recipients in our department over the past 10 years.

Louisiana State University School of Medicine in New Orleans.

Louisiana State University School of Medicine in New Orleans.

Curriculum Changes and Trends 2010-2020: A Focused National Review Using the AAMC Curriculum Inventory and the LCME Annual Medical School Questionnaire Part II.

Medical school curricula have evolved from 2010 to 2020. Numerous pressures and influences affect medical school curricula, including those from external sources, academic medical institutions, clinical teaching faculty, and undergraduate medical students. Using data from the AAMC Curriculum Inventory and the LCME Annual Medical School Questionnaire Part II, the nature of curriculum change is illuminated. Most medical schools are undertaking curriculum change, both in small cycles of continuous quality improvement and through significant change to curricular structure and content. Four topic areas are explored: cost consciousness, guns and firearms, nutrition, and opioids and addiction medicine. The authors examine how these topic areas are taught and assessed, where in the curriculum they are located, and how much time is dedicated to them in relation to the curriculum as a whole. When examining instructional methods overall, notable findings include (1) the decrease of lecture, although lecture remains the most used instructional method, (2) the increase of collaborative instructional methods, (3) the decrease of laboratory, and (4) the prevalence of clinical instructional methods in academic levels 3 and 4. Regarding assessment methods overall, notable findings include (1) the recent change of the USMLE Step 1 examination to a pass/fail reporting system, (2) a modest increase in narrative assessment, (3) the decline of practical labs, and (4) the predominance of institutionally developed written/computer-based examinations and participation. Among instructional and assessment methods, the most used methods tend to cluster by academic level. It is critical that faculty development evolves alongside curricula. Continued diversity in the use of instructional and assessment methods is necessary to adequately prepare tomorrow's physicians. Future research into the life cycle of a curriculum, as well optional curriculum content, is warranted.

University of Arizona College of Medicine-Tucson.

University of Arizona College of Medicine-Tucson.

McGovern Medical School at The University of Texas Health Science Center at Houston.

McGovern Medical School at The University of Texas Health Science Center at Houston.

Restructuring of an Orthopaedic Surgery Residency Research Rotation Correlates with Increased Academic Productivity in Teaching Faculty.

Introduction:Contribution toward clinical research is paramount to the education of physician trainees and is required by the Accreditation Council for Graduate Medical Education. From 1987 through 2015, our single institution orthopaedic surgery residency research experience included 2 dedicated research rotations. Because few resident projects were pursued to completion, feedback was used to restructure the curriculum, including the appointment of 2 clinical orthopaedic faculty to serve as codirectors, development of a revised curriculum, use of research teams, and a centralized research database. Our group previously displayed increased resident productivity within 2 years after the 2015 implementation. The aim of this study was to investigate the impact of orthopaedic residency curricular changes on scholarly activity of orthopaedic teaching faculty.Methods:The curriculum vitae (CVs) of a single institution's orthopaedic teaching faculty were collected and retrospectively reviewed from 2014 through 2018 to determine academic productivity of clinical faculty. Indicators of academic productivity included peer-reviewed publications (including journal impact factors) and podium or poster presentations.Results:Twenty-three of 27 faculty members responded to our request for CVs. One hundred three CVs were reviewed on 23 faculty. All academic indicators increased over 5 years. Multivariate analysis of variance (MANOVA) using a multivariate repeated measures analysis was completed. A sphericity χ2 test was violated for all measures, precluding us from using unadjusted univariate analysis. Univariate MANOVA with repeated measures displays significance regarding impact factor (f < 0.02, p < 0.05) and journal publications (f < 0.004, p < 0.05). Subsequent multivariate analysis shows similar results regarding impact factor (f < 0.0008), journal publications (0.0005), and poster presentations (f < 0.016).Conclusions:Improved structure of an established resident research rotation combined with enhanced faculty mentorship resulted in a significant increase in academic productivity for clinical teaching faculty of the department of orthopaedic surgery. This increase parallels that seen in orthopaedic resident research productivity; indicating a positive impact on teaching faculty scholarly activity.Level of Evidence:III.

Showing Your Thinking: Using Mind Maps to Understand the Gaps Between Experienced Emergency Physicians and Their Students.

Clinical teaching faculty rely on schemas for diagnosis. When they attempt to teach medical students, there may be a gap in the interpretation because the students do not have the same schemas. The aim of this analysis was to explore expert thinking processes through mind maps, to help determine the gaps between an expert's mind map of their diagnostic thinking and how students interpret this teaching artifact. A novel mind-mapping approach was used to examine how emergency physicians (EPs) explain their clinical reasoning schemas. Nine EPs were shown two different videos of a student interviewing a patient with possible venous thromboembolism. EPs were then asked to explain their diagnostic approach using a mind map, as if they were thinking to a student. Later, another medical student interviewed the EPs to clarify the mind map and revise as needed. A coding framework was generated to determine the discrepancy between the EP-generated mind map and the novice's interpretation. Every mind map (18 mind maps from nine individuals) contained some discrepancy between the expert's mind and novice's interpretation. From the qualitative analysis of the changes between the originally created mind map and the later revision, the authors developed a conceptual framework describing types of amendments that students might expect teachers to make in their mind maps: 1) substantive amendments, such as incomplete mapping; and 2) clarifications, such as the need to explain background for a mind map element. Emergency physician teachers tend to make jumps in reasoning, most commonly including incomplete mapping and maps requiring clarifications. Educating EPs on these processes will allow modification of their teaching modalities to better suit learners.

Using Electronic Health Record Data to Assess Residents' Clinical Performance in the Workplace: The Good, the Bad, and the Unthinkable.

Novel approaches are required to meet assessment demands and cultivate authentic feedback in competency-based medical education. One potential source of data to help meet these demands is the electronic health record (EHR). However, the literature offers limited guidance regarding how EHR data could be used to support workplace teaching and learning. Furthermore, given its sheer volume and availability, there exists a risk of exploiting the educational potential of EHR data. This qualitative study examined how EHR data might be effectively integrated and used to support meaningful assessments of residents' clinical performance. Following constructivist grounded theory, using both purposive and theoretical sampling, in 2016-2017 the authors conducted individual interviews with 11 clinical teaching faculty and 10 senior residents across 12 postgraduate specialties within the Schulich School of Medicine and Dentistry at Western University. Constant comparative inductive analysis was conducted. Analysis identified key issues related to affordances and challenges of using EHRs to assess resident performance. These include the nature of EHR data; the potential of using EHR data for assessment; and the dangers of using EHR data for assessment. Findings offer considerations for using EHR data to assess resident performance in appropriate and meaningful ways. EHR data have potential to support formative assessment practices and guide feedback discussions with residents, but evaluators must take context into account. The EHR was not designed with the purpose of assessing resident performance; therefore, adoption and use of these data for educational purposes require careful thought, consideration, and care.

Considering the interdependence of clinical performance: implications for assessment and entrustment.

IntroductionOur ability to assess independent trainee performance is a key element of competency‐based medical education (CBME). In workplace‐based clinical settings, however, the performance of a trainee can be deeply entangled with others on the team. This presents a fundamental challenge, given the need to assess and entrust trainees based on the evolution of their independent clinical performance. The purpose of this study, therefore, was to understand what faculty members and senior postgraduate trainees believe constitutes independent performance in a variety of clinical specialty contexts.MethodsFollowing constructivist grounded theory, and using both purposive and theoretical sampling, we conducted individual interviews with 11 clinical teaching faculty members and 10 senior trainees (postgraduate year 4/5) across 12 postgraduate specialties. Constant comparative inductive analysis was conducted. Return of findings was also carried out using one‐to‐one sessions with key informants and public presentations.ResultsAlthough some independent performances were described, participants spoke mostly about the exceptions to and disclaimers about these, elaborating their sense of the interdependence of trainee performances. Our analysis of these interdependence patterns identified multiple configurations of coupling, with the dominant being coupling of trainee and supervisor performance. We consider how the concept of coupling could advance workplace‐based assessment efforts by supporting models that account for the collective dimensions of clinical performance.ConclusionThese findings call into question the assumption of independent performance, and offer an important step toward measuring coupled performance. An understanding of coupling can help both to better distinguish independent and interdependent performances, and to consider revising workplace‐based assessment approaches for CBME.

Promoting Faculty Scholarship: A Clinical Faculty Scholars Program.

The importance of supporting and promoting faculty scholarship in nursing is acknowledged, but the reality of scholarship for faculty engaged in clinical teaching can be challenging. The article describes the development and initial results of the scholarly practice program. Mentorship, time, and limited funding are essentials for the program. After submitting detailed proposals, 15 faculty were chosen to be project leaders in the first 2 years of the program, resulting in 15 presentations, three posters, 19 publications, and a webinar, to date. External continuing funding has been secured by three projects. Additional dissemination efforts are awaiting peer review. The program has successfully increased the level of scholarship among clinical teaching faculty and contributed to the faculty's professional satisfaction. Faculty have increased experience and ability to conduct clinical quality improvement. Experience supports targeted, substantial support for projects, rather than a general average faculty allocation strategy to promote scholarship. [J Nurs Educ. 2018;57(2):121-125.].

Supporting Veterinary Preceptors in a Distributed Model of Education: A Faculty Development Needs Assessment.

Effective faculty development for veterinary preceptors requires knowledge about their learning needs and delivery preferences. Veterinary preceptors at community practice locations in Alberta, Canada, were surveyed to determine their confidence in teaching ability and interest in nine faculty development topics. The study included 101 veterinarians (48.5% female). Of these, 43 (42.6%) practiced veterinary medicine in a rural location and 54 (53.5%) worked in mixed-animal or food-animal practice. Participants reported they were more likely to attend an in-person faculty development event than to participate in an online presentation. The likelihood of attending an in-person event differed with the demographics of the respondent. Teaching clinical reasoning, assessing student performance, engaging and motivating students, and providing constructive feedback were topics in which preceptors had great interest and high confidence. Preceptors were least confident in the areas of student learning styles, balancing clinical workload with teaching, and resolving conflict involving the student. Disparities between preceptors' interest and confidence in faculty development topics exist, in that topics with the lowest confidence scores were not rated as those of greatest interest. While the content and format of clinical teaching faculty development events should be informed by the interests of preceptors, consideration of preceptors' confidence in teaching ability may be warranted when developing a faculty development curriculum.

Teaching the Physical Exam and Psychomotor Skills in the Clinical Setting

Abstract The physical exam is a useful diagnostic tool in clinical care. Teaching physical diagnosis has been shown to improve students' skills. Clinical teaching faculty, however, may experience d...

How Do We Improve Quality in Clinical Education? Examination of Structures, Processes, and Outcomes

BACKGROUND AND PURPOSEThe imperative of clinical education in health professions is development of students' knowledge, skills, and behaviors essential to competence as new professionals. The current state of clinical education in physical therapist (PT) education programs across the United States reflects disparate approaches to meeting this imperative. The relatively few similarities in clinical education curricula are determined by the criteria for accreditation, which state that the curriculum includes content and learning experiences designed to prepare students to achieve educational outcomes required for initial practice.1(p31) The criteria also require clinical education experiences (CEEs) that allow students to manage patients/clients in various practice settings, across the lifespan and continuum of care; to participate in interdisciplinary care; and to engage in other experiences that lead to the achievement of expected student outcomes.1 Being rather broad and nonprescriptive, these criteria allow a wide variety of models for clinical education. The variation may not be advantageous or appropriate given the high stakes for students, cost to all stakeholders, and increasing demand on clinical sites as the number of academic programs and students grows. Data collated by the Commission on Accreditation in Physical Therapy Education (CAPTE) for 2012-2013 show that 45% of students' total education time is spent in CEEs,2 suggesting the importance of its influence on student outcomes and the need to ensure that this vital component of curricula is of the highest quality.This position paper (1) provides a brief overview of the challenges associated with physical therapist clinical education models, (2) briefly compares components of those models to those of other health professions, and (3) recommends steps toward decreasing variation and improving quality.FrameworkDonabedian's3 classic conceptual framework for examining health care quality seems to be appropriate for considering the issue of quality in clinical education. This framework proposes 3 components of quality (see Figure).* Structures. These are the physical and organizational aspects of clinical education settings (eg, types of settings, personnel, and finances supporting clinical education).* Processes. Processes rely on the structures to provide resources and mechanisms for participants to engage in effective educational activities. Processes in clinical education include student supervision, evaluation mechanisms, and administrative procedures.* Outcomes. Students' clinical performance is the most commonly measured outcome of CEEs; however, stakeholder satisfaction, cost of providing CEEs to students, and the benefits to clinical education faculty might also be considered.Before quality of clinical education can be assessed, it needs to be defined. Because perceptions of the quality of clinical education vary based on the myriad values and goals espoused by PT education programs and clinical education sites, it is difficult to define. The Donabedian model assists in framing this definition. For example, the model suggests that students' clinical performance or other measures of outcome, although important, may be limited as measures of quality. The structures and processes of clinical education as components of quality might be equally important based on an assumption, for example, that students' experiences must be appropriate in scope and depth, with suitable expectations for demonstration of competency.There are limitations to examining clinical education quality using this framework. When evaluating processes, judgments must be made about appropriateness, completeness, coordination, and continuity of CEEs. These judgments are based on values and standards that are sometimes implicit and perhaps not thoroughly examined for biases. Measurement of the processes of clinical education may be difficult due to both lack of agreement as to what processes to measure and lack of reliable measurement tools. …