Practice Nurses Research Articles

A philosophical exploration of rural health and nursing based on an undergraduate United States-Australian collaboration through the lens of 'positionality'.

Growing nursing workforce maldistributions impede rural healthcare access globally. In-depth exploration of underlying philosophical ideas about rural health in nursing curricular could support recruitment and retention of nurses who are well positioned to support and advocated for health care and services relevant to their communities. Through a lens of positionality, the purpose of this paper is to explore rural health and nursing within the United States and Australia from the perspective of undergraduate students. Recognizing that both countries have 'first world' health services, issues of access to services associated with systemic and structural biases were significant features identified by participants. Their perceptions were supported by discussion with attendees of the 26th International Nursing Philosophy Conference from several countries, during a presentation titled 'What is different about rural health nursing: A philosophical exploration.'This international consistency suggests that systemic and structural biases are global phenomena. While exposure to rural health and rural nursing may be beneficial for recruitment, preparing nurses for rural practice requires more than educating students to complete clinical tasks. Uncovering collaboration, advocacy and policy development opportunities for nurses in rural communities could move the dial from recruiting rural nurses to fulfill immediate needs to retention of well-educated and highly skilled nurses. Building a stronger philosophical base for rural healthcare inclusive of all people, honouring their distinguishing characteristics such as age, gender, ethnicity, is long overdue. Positionality can inform how nurses across the globe relate to other countries' governments, cultures, norms, values, expectations, etc., which can influence the advancement of the profession and address social inequities among rural populations.

A Global Review of Advanced Practice Nursing in the Emergency Department.

As demands in the way of healthcare delivery increase, nurse practitioners have become essential components in optimizing access to healthcare and improving outcomes around the globe. The authors recognize the vital role nurse practitioners play globally and that education, practice, and credentialing differ significantly across countries. Many countries have a wide variation in educational requirements, resulting in a lack of adequate advanced practice nursing training and regulation of practice. Additionally, many countries are experiencing increased demands in the form of emergency services, with long waiting times and severe crowding in emergency departments. Worldwide, many programs are being developed to educate advanced practice nurses on improving emergency medical care, but developing such programs is a complex process This article aims to discuss the scope of practice and roles of advanced practice nurses globally. We will also attempt to clarify and improve these global standards and discuss competencies in this role.

Knowledge, attitude, and practice toward hyperuricemia among healthcare workers in Shandong, China.

Hyperuricemia is a relatively common condition, with a prevalence of over 20% among the general population. Also, most patients initially present no symptoms. This study aimed to investigate the knowledge, attitude, and practice (KAP) toward hyperuricemia among healthcare workers in Shandong, China. Healthcare workers were recruited in this cross-sectional study conducted in Shandong in December 2022. A self-designed questionnaire was used to collect demographic information and KAP data. A total of 372 questionnaires were distributed, and 216 (58.06%) valid questionnaires were collected from 131 physicians, 80 nurses, and five other healthcare workers. The participants had a mean score of 10.76 ± 2.53 (possible range: 0-14, 76.9%) and 31.94 ± 2.58 (possible range: 0-40, 79.9%) in knowledge and attitude, respectively. The physicians' and nurses' practice scores were 47.57 ± 5.34 (possible range: 0-55, 86.5%) and 30.06 ± 4.11 (possible range: 0-35, 85.9%), respectively. The attitude scores were independently associated with proactive practice in both physicians (P < 0.001) and nurses (P = 0.046). This study found that healthcare workers in Shandong had adequate knowledge, positive attitudes, and proactive practices towards hyperuricemia. However, there is room for improvement in the attitudes of both physicians and nurses to achieve better practice.

An animated education program to reduce anxiety, vascular complications, and flat time among children undergoing cardiac catheterization: A randomized control trial, study protocol

One of the most dangerous and prevalent birth disorders is congenital heart defects (CHD). Children diagnosed with CHD may need many operations or medical treatments throughout their lives, including cardiac catheterization (CC). Children undergoing CC experience elevated levels of anxiety. Elevated levels of anxiety among children undergoing CC can be harmful to children physiologically, psychologically, and behaviorally. Additionally, vascular complications such as bleeding and hematoma represented the majority of complications among children undergoing CC. To achieve positive management outcomes, nurses must use an effective method to prepare children for CC. This study present the protocol for developing and implementing an animated education program (AEP) about CC on anxiety, vascular complications, and flat time among children undergoing CC for the first time. A Parallel Randomized Control Trial (RCT) design will be utilized to test the study hypotheses. It is an experimental design where participants are assigned randomly to either receive an intervention or not, and the outcome of interest is then evaluated after the intervention to assess its impact. The trial had been registered as Clinical Trails.gov PRS (Protocol Registration and Result system) Identifier: Protocol ID 101271-6 and clinical trials.gov ID (NCT06483087) under the brief title: Effect of Animated Education on Anxiety and Vascular Complications (VAEda) ClinicalTrials.gov Protocol Registration and Results System (PRS). A random sample of 98 children scheduled for a CC, whose ages range from 6 to 12 years old, will be recruited from a military hospital for medical and surgical heart disease in Jordan, with 49 children in the intervention group and 45 children in the control group. Children in the control group will receive routine care. However, children in the experimental group will receive an AEP, an 8-minute carton animated video that illustrates pediatric CC. The animated cartoon video was developed in Arabic using age-appropriate information. The study’s intervention is intended to give adequate information to children to prepare them for the events occurring before, during, and after the CC procedure, it will be presented to the intervention group 24 hours before the procedure. Outcome measures include anxiety levels that will be assessed 2 hours before children undergo CC. Bleeding and hematoma at the CC site will be assessed 2 hours postsheath removal, and flat time will be assessed by recording the hours that the child stays in a flat position postsheath removal. This exploratory experiment is a necessary first step in investigating important components of a full-scale clinical study. This study presents a novel technique designed for children undergoing CC to lower their anxiety, vascular complications, and flat time. The results of the current study provide evidence-based data that can improve nursing practice and research in pediatric cardiac nursing. Create a policy that emphasizes the critical role that nurses play in delivering high-quality health education through the use of AEP.

‘’It’s like I am always on a leash’’: A multi-stakeholder qualitative analysis of the time toxicity of cancer care.

209 Background: As the oncology community increasingly acknowledges the time burdens of cancer care, there is a critical need for foundational work to understand the sources, populations impacted, and consequences of time toxicity. We sought to evaluate these through qualitative interviews. Methods: We conducted semi-structured interviews with adults with advanced stage gastrointestinal cancer, informal care partners, and clinicians at an NCI-designated cancer center in MN, USA from Feb-Oct 2023. We explored aspects of cancer care that took up time and were perceived as burdensome, identified those most impacted, and the consequences. We recorded and transcribed interviews, and conducted inductive thematic analysis. Results: We interviewed 47 participants [16 patients (8 &lt;60 years; 12 women), 15 care partners (10 &lt;60 years; 9 women), and 16 clinicians (including advanced practice providers, nurses, physicians, schedulers, and social workers; 11 women)]. We identified 22 subthemes that we grouped into 5 themes (Table). Conclusions: This multi-stakeholder qualitative analysis provides a deeper understanding of time toxicity. These data will help the oncology community to map, measure, and ultimately address time toxicity. Theme Subthemes Illustrative quotes Source: Healthcare outside the home Travel, parking, and, waiting time, planned appointments, unplanned care, hospitalizations and facility-based care '’My wife and I made over 100 drives in two years, over an hour and a half in each direction.’’ (Patient) Source: Often invisible tasks performed at home Logistic and administrative tasks, learning about the disease and treatment, medical management, time spent managing symptoms and on recovery, home-based care ‘’A large burden was like the insurance paperwork.’’ (Care partner)‘’And that has happened before where I've just spent the whole day at home waiting for home care.’’ (Patient) Populations impacted: Care partners alongside patients Care partners are equally affected, taking over social responsibilities/ tasks of daily living ‘’Anything that takes time for me, is almost an equal burden on her. If not more sometimes.’’ (Patient) Consequences Care becomes all-consuming, short visits turn into ‘’all-day’’ affairs, missing important life events/work, emotional distress, demoralization, financial burdens ‘’ It’s like I am always on a leash. I really don't have any control.’’ (Patient)‘’Even for a 30-minute infusion, you'll be there, like half a day or a whole day.’’ (Patient) Positive interactions and hope for change Not all time spent is perceived as burdensome, clinicians are hopeful of decreasing time burdens, clinicians recognize their own time burdens as a barrier to addressing patients’ ‘’Patients having to walk through this incredibly long, circuitous way to check in, do labs as ritual—we are disdainful of a patient's time. We should demand change.’’ (Clinician)

Research Trends of Specialty Nurse Training from 2003 to 2023: A Bibliometric Analysis via CiteSpace.

To analyze research trends, frontiers, and hot topics in specialty nurse training over the past 20 years, and provide a reference for researchers to understand the current research landscape in this field. Studies from the core collection of Web of Science were used. Furthermore, CiteSpace 6.3 R3 was utilized to analyze information on country, institution, authors, keywords and burst words. A total of 296 articles were included in the analysis. The United States had the highest number of articles, and there was limited cooperation between authors and institutions. The research hotspots in this field included "clinical education models for specialist nurses", "APN role training", and "interprofessional education". The future research trend is to explore the effective integration of training models suitable for different regions and cultural backgrounds and cross-professional education models. It is suggested that researchers pay attention to the innovation and development of specialized nursing clinical practice under different cultural backgrounds, and strengthen international exchanges and cooperation.

Seamless Transition: Strategies for Effective New Nurse Orientation and Practice Integration

Seamless Transition: Strategies for Effective New Nurse Orientation and Practice Integration

Getting a colonoscopy at The Valley Hospital.

71 Background: Colorectal cancer (CRC) is the 3rd most common cancer in the U.S., yet it is preventable with evidence-based strategies such as early screening. The Valley Hospital (TVH) located in Bergen County NJ, is recognized for its high insured payer mix and median household income. According to the 2016 TVH Community Health Needs Assessment, only 71.4% of patients in TVH service area have had a CRC screening. The American Cancer Society National Colorectal Cancer Roundtable (NCCRT) campaigned to reach CRC screening rates of 80% and higher in communities across the nation. The Fast Track Screening Colonoscopy Program (FTSCP) at TVH was created to streamline the process of obtaining a screening colonoscopy and reach the NCCRT’s goal. Through the FTSCP, patients can omit the initial consultation with a gastroenterologist or colorectal surgeon. Patients are instead screened via a telephone call by a Physician Assistant (PA) or Advanced Practice Nurse (APN). The FTSCP is cost effective for patients as it potentially eliminates the initial consultation copayment and/or coinsurance. Methods: The purpose of the FTSCP is to achieve the NCCRT’s 80% goal of CRC screenings in TVH service area. An interdisciplinary team of gastroenterologists, colorectal surgeons, oncologists, anesthesiologists, and administration collaborated to create the FTSCP. A screening questionnaire was developed using the Lincoln Hospital in NYC’s existing criteria for patients who are eligible for a direct endoscopy referral. The questionnaire criteria ensures patients are safe to eliminate the initial consultation. A PA or APN determines the patients’ eligibility for the FTSCP over a screening telephone call. To qualify, patients cannot have significant medical comorbidities or exhibit signs or symptoms of CRC. If deemed eligible, the PA or APN sends a bowel preparation prescription to the patient’s pharmacy, reviews the instructions with them, and meets with them on the day of the procedure at TVH to perform a pre-procedural physical exam. To promote awareness and education of the FTSCP, multiple ongoing outreach events are held in the community. Patients also learn about the FTSCP through primary and specialty care referrals. Results: Since the inception of FTSCP in 2018, over 1300 patients have been screened for CRC. Additionally, adenocarcinomas, carcinoid tumors and tubular adenomas with high grade dysplasia have been detected. 394 tubular adenomas (30%) were identified and removed. In 2018, 59 patients were screened. The number of patients increased by 500% to 296 in 2023. The 2022 TVH Community Health Needs Assessment showed an increase to 79.6% of patients in TVH service area who have undergone CRC screening. Conclusions: The FTSCP at TVH is maximizing patient’s access to the prevention and timely screening for CRC. Additionally, TVH’s relocation from Ridgewood, NJ to Paramus, NJ offers further opportunities to educate a new community on CRC prevention.

EP.15B.02 Real-World Data from Advanced Practice Nurse Care in Lung Cancer in a Private Clinic in Brazil

EP.15B.02 Real-World Data from Advanced Practice Nurse Care in Lung Cancer in a Private Clinic in Brazil

A Global Review of Advanced Practice Nursing in the Emergency Department.

A Global Review of Advanced Practice Nursing in the Emergency Department.

Implementation and missions of an advanced practice nurse in Ehpad and USLD

The number of advanced practice nurses (APNs) is constantly growing, and this means that they are being deployed in settings other than hospitals or private practice. Long-term care units and residential establishments for dependent elderly people are among the places where these professionals are being deployed. Their main missions are to improve patient and resident follow-up and care, develop therapeutic education and promote best practices. Here's an example of APN implementation in a residential establishment for dependent elderly people. This is a recent activity, which should evolve in the future.

Advanced Practice Providers in Cellular Therapy: Survey Results from the ASTCT APP Special Interest Group Exploring Clinical Roles, Compensation, and Job Satisfaction

BackgroundAdvanced practice providers (APPs), which include physician assistants/associates and advanced practice nurses, are critical members of the transplant and cellular therapy (TCT) care team. Despite broad utilization in transplant centers, there is little published literature on the clinical roles and responsibilities, staffing models, compensation structure, and job satisfaction of TCT APPs. This study represents the results of a national survey administered by the APP Special Interest Group to better characterize the TCT APP workforce. ObjectiveTo characterize the TCT APP workforce by investigating clinical roles and responsibilities, compensation and institutional support, and job satisfaction. MethodsA 25-item web-based survey addressing four domains (transplant center data, APP roles and responsibilities, compensation and institutional support, and job satisfaction). Surveys were sent to participants through a chain-referral sampling method. Data were analyzed using descriptive statistics and multinomial logistic regression. ResultsA total of 198 responses were analyzed, representing 64 transplant centers of varying size from 29 states. APPs report working in inpatient and outpatient settings and performing a broad array of TCT-associated procedures including bone marrow biopsy (78%), lumbar puncture (43.2%), intrathecal chemotherapy (47.0%), and cellular infusions (45.9%). Median salary of respondents was $110,000-$119,000 and was significantly associated with geographic location of transplant center and years of experience. A minority of respondents reported no funding (4.2%) or time (9.8%) supporting continuing education. A majority of APPs (55.1%) do not feel they are appropriately paid. A majority (54.3%) did not feel that their center supported a good work-life balance. Nearly 35.4% of respondents did not feel valued in their role. ConclusionsThis survey represents the first to characterize the TCT APP workforce in the United States. APPs are highly integrated into the TCT care team and can serve as means to improve patient access to TCT therapies given a worsening physician shortage. However, the lack of satisfaction with compensation and work-life balance could represent barriers to recruitment and retention of TCT APPs and warrant future studies to better characterize.

Support for Nursing Home Caregivers During the COVID-19 Pandemic: A Review.

To review support systems for nursing home caregivers (NHCGs) that were implemented during the first year of the coronavirus disease 2019 (COVID-19) pandemic. Database searches in PubMed, ScienceDirect, and CINAHL resulted in five publications. Studies differed in design, interventions, and outcomes. An urgent eye movement desensitization and reprocessing protocol was feasible and effective among nurses in services highly mobilized during the acute phase of the pandemic. The "self-help plus" psychological intervention was not associated with significant reductions in anxiety or posttraumatic symptoms but prompted exploration of non-specific factors influencing its effectiveness. The Extension for Community Healthcare Outcomes in Long-Term Care of the Elderly virtual program increased confidence among NHCGs. Self-compassion training was associated with positive changes for certified nursing assistants. Weekly debriefing sessions implemented at one hospital highlighted pathogenic and salutogenic factors. The COVID-19 pandemic had a marked psychosocial impact on NHCGs and necessitated targeted interventions. Despite their limitations, these promising studies provided insights into potential support avenues. Policy considerations should stress the pivotal role of advanced practice nurses in shaping supportive work environments. Future research should focus on robust assessments of the efficacy of psychosocial interventions for NHCGs facing ongoing challenges posed by the pandemic, and even recurrent viral epidemics. [Journal of Gerontological Nursing, 50(10), 24-33.].

Newly graduated and nurse resident competencies: Perceptions of nurse faculty and acute care hospital leaders in the state of Maryland

BackgroundThe many educational pathways to obtain a professional nursing degree create confusion among healthcare leaders about new graduate nurses' (NGNs) competency expectations when entering practice. PurposeThis research sought to identify, among Maryland nursing academic and practice leaders, a standard set of NGN competencies after completing their prelicensure program and nurse residency program (NRP) at 12 months. MethodA mixed-method approach was used, including a survey of 109 outcome statements and faculty and practice leader focus groups. ResultsResults suggested that 90 % of the nursing programs could collectively meet 18 of the 109 outcomes by NGN program completion, with few differences in responses from the varying academic programs. Faculty attributed these low results to the heavy focus on preparing students for the NCLEX examination, overloaded curricula, and competing priorities. Practice leaders perceived NGNs only partially met/did not meet most competencies, viewing many as unrealistic. Findings support requirements for NGNs to complete an NRP and the existence of a practice-education gap. ConclusionsResearch findings can help inform the development of a nationally accepted, competency-based educational framework for students, new-to-practice nurse residents, and professional nurses to help align entry-level nursing practice expectations with those of nursing programs and NRPs.

A Study to Determine Consensus for Nursing Documentation Reduction in Times of Crisis.

Nurses faced numerous challenges during the pandemic, particularly with the increased burden of electronic documentation. Surges in patient volume and visits led to rapid changes in nursing documentation, prompting diverse responses from regulatory and healthcare organizations. Nurses expressed safety concerns and struggled with changes, calling for national standards and regulatory support. Policy relaxations, such as the 1135 Waiver, sparked debate on the future of nursing care plan documentation. Using mixed-methods exploratory design, the study identified modifications of nursing documentation during crises, commonalities in documentation burden reduction for applicability beyond pandemics, and consensus on the definition of "surge." Documentation patterns were assessed from February to November 2022, involving 175 North American nurse leaders and informaticists. Data analysis included descriptive statistics, thematic analysis, and Pearson correlation coefficient. Significant differences were found between rural and urban settings (P = .02), with urban areas showing higher odds of changes to care plans (odds ratio, 4.889; 95% confidence interval, 1.27-18.78). Key findings highlighted the persistence of postcrisis documentation changes and varied definitions of surge criteria based on organizational leadership, policy, and mandates. The study yielded insights for modifying documentation, offering policy recommendations, and emphasizing ongoing collaboration and evidence-based approaches for future nursing practices.

Introduction of Simulation-Based Learning Strategy to Bridge the Theory-Practice Gap in Advanced Concepts in Community Health Nursing Course: Lens from Students' Perspective.

Simulation has proven to be one of the most powerful forms of enactive experience in medical sciences, which enhances the efficacy of both direct and vicarious learning. At the undergraduate level, community health nurses are expected to be inclusively knowledgeable about population-based nursing practices with diverse communities; so, they prepare well to establish partnership skills with stakeholders and make collaborative decisions that promote awareness and understanding of the community's health needs. Problem prioritisation is an essential step of the planning cycle. It is one of the advanced concepts in community health nursing which needs in-depth knowledge and contemplation about the dynamics of the community. This paper highlights the students' perspectives regarding the impeccable effects of simulation pedagogy on students' learning in terms of improving their communication skills and alleviating the fear of dealing with community stakeholders before the actual problem-priority setting exercise for the clinical community project. Key Words: Community health nursing, Simulation-based learning, Problem prioritisation, Stakeholders.

Obstacles and enablers for using telehealth services online in nursing practice: A systematic review

Background: Comprehensive reporting on the barriers and enablers to telehealth adoption in industrialized nations has identified a wide range of significant factors. We aimed to get the important research information on the elements that nurses found most beneficial and hindering when using online telehealth services for nursing practice, we conducted a systematic review study. Method: This systematic review study was conducted in accordance with PRISMA principles. We searched for articles that discussed the aspects of using telehealth services for nursing practicum that nurse practitioners found most helpful and inconvenient. The international electronic databases that were used were Web of Science, Scopus CINAHL, and PubMed. The search was conducted for articles published in the period from 2011 and 2023. Only research that were written in English and published were considered. Results: We considered 7 articles in our systematic review analysis, totaling 3729 participants. Inadequate resources (time, money) were mentioned as barriers relevant to both organizational and patient issues. Negative attitudes, a lack of telehealth experience, and inadequate training and support were considered to be impediments to the use of telehealth (3). According to the findings of the Kleib et al., 2018 study, the following variables affect user competency and proficiency: age; Prerequisites for qualifying include prior knowledge of information technology and a sufficient, early, and continual informatics education. Conclusion: Numerous facilitators and obstracles were identified. In addition to administrative support, health professionals and information technology specialists must come to local agreements when transitioning from traditional face-to-face nursing practice to telehealth utilization.

Nurses Practices Related to Enteral and Parenteral Nutritional Therapy for Unconscious Patients

Background: Enteral nutrition reduces the mortality rate and prevents the development of pressure sores. Specific complications with parenteral nutrition, particularly in unconscious patients, include line sepsis and fluid and electrolyte imbalance. This is important because parenteral nutrition reduces the duration of unconscious patients' hospital stay. Objectives: 1. Assess Nurses’ practice regarding unconscious patients’ nutrition. 2. Identify the demographical characteristics of studied population. 3. Find out the relations between practices of nurses and their demographical and employment characteristics. Methodology: A descriptive – observational study design is the choice to study a specific phenomenon of interest regarding assessing nurses practices regarding enteral and parenteral nutritional therapy from period between (November 2022- July 2024). Non-probability convenient sample of (125) nurses who work in the intensive care units were selected. This study conducted in the intensive care units which located at three teaching hospitals in Al-Hilla city- Iraq. Results: The data reveals that the majority, 55.2%, fall within the 20-30 year age range. Interestingly, the sex distribution is nearly equal with 52% males and 48% females. The result recorded the major of study sample were poor level of practice regarding enteral and parenteral nutritional therapy for unconscious patients. Conclusion: There is a substantial need for improvement in nursing practices related to ENT, such as nutritional assessment, equipment preparation, and adherence to protocols.

Impact of moral resilience and interprofessional collaboration on nurses' ethical competence.

Home care nurses are central in providing holistic and compassionate care to patients in home-based palliative care. Ethical caring competency is essential for home care to sustain nurses' integrity in the face of moral adversity. Interprofessional collaboration is vital for ensuring ethical decision-making and providing patient-centered care in home-based palliative care settings. This study explored the predictive roles of interprofessional collaboration and moral resilience on ethical caring competency among home care nurses in home-based palliative care. A cross-sectional survey of 400 nurses was conducted from October to December 2023, utilizing standardized scales to measure interprofessional collaboration, moral resilience, and ethical caring competency. A convenience sample of 400 home care nurses was also included in this study. Correlation and linear regression analysis were used to clarify the associative and predictive findings. Ethical approval from the ethics committee, institutional permission, and informed consent from the participants were obtained for data collection. Correlation analysis showed significant positive correlations between the ethical caring competency, interprofessional collaboration, and moral resilience constructs, with coefficients ranging from 0.482 to 0.967. Linear regression revealed that management of collaborative systems and total moral resilience significantly predict ethical caring competency, explaining 14.6% and 36.6% of its variance, respectively. Other variables, such as the effects of collaboration and communication, did not significantly influence ethical caring competency. The study highlights the significant impact of interprofessional collaboration, particularly the management of collaborative systems and moral resilience, on enhancing ethical caring competency among nurses. Enhancing interprofessional collaboration and moral resilience through targeted strategies in nursing practice and education can significantly improve ethical caring competencies. These efforts are essential for delivering high-quality, patient-centered care and for fostering a healthcare environment that respects the ethical principles guiding nursing practice.

Healthcare Needs of Incarcerated Pregnant and Postpartum Women: Implications for Just Nursing Practice

Women remain the primary caregivers for children, making the imprisonment of women and mothers potentially more complicated for families. Women in the prison system often have significant health problems and lack access to care even before incarceration. While women constitute a minority in the prison system, they have gender-specific needs, often related to pregnancy, birth, and the postpartum period. Often, prisons are not equipped to provide appropriate care, and many state policies vary concerning the healthcare needs of incarcerated pregnant and postpartum women. This article offers an overview of current issues in reproductive healthcare for this vulnerable population by providing a brief background on the topic and exploring how nurses can become their advocates. A review of selected literature describes current relevant research, followed by viewpoints from various healthcare organizations. Recommendations include prison programs and services targeted to pregnant and postpartum women, such as birth doulas and prison nurseries, which are known to benefit this population. Nurses can advocate for this unique population by using a trauma-informed framework of care and participating in legislative efforts to support pregnant and postpartum women who are incarcerated.