This study assessed the effectiveness of care plan automation through Web and mobile applications among nursing students. Many undergraduate nursing programs lack access to electronic medical records for educational purposes. Our work aimed to transform nursing care plans into easily accessible, auditable, and storable electronic forms using a developed automation system. Conducted at a nursing school, the descriptive study involved 169 nursing students practicing pediatric health and nursing courses. Data were collected using a questionnaire with 15 statements to measure the effectiveness of care plan automation. The mean age of participants was 21.69 ± 2.29, with a mean grade point average of 3.18 ± 0.58, and 77.5% were female. The highest-rated statement was that automation allowed students to keep and review care plans (mean, 4.34 ± 1.13), whereas the lowest was that it increased interest in care plans (mean, 3.91 ± 1.37). Students also found automation more satisfying (mean, 4.14 ± 1.23). Overall, the study found that nursing students rated care plan automation positively, indicating increased motivation and benefits and decreased challenges. Implementing this system in clinical practice may enhance students' education, efficiency, and motivation in care planning.

This study aimed to identify the care needs of individuals with chronic liver disease, develop a standardised nursing care plan (SNCP) based on international nursing terminologies, and evaluate its effectiveness, quality, and satisfaction. A participatory action research design comprising three phases was used. In Phase 1 (December 2017), qualitative data from eight patients identified care needs and disease experiences. In Phase 2, feedback from 18 nurses guided the development of a SNCP, incorporating international nursing terminologies, which was then validated. In Phase 3 (October-December 2023), the plan's effectiveness, quality, and satisfaction were evaluated through implementation with 10 inpatients and 18 nurses. Qualitative analysis revealed two themes: disease-related symptoms and daily living challenges. Most nurses in phase 2 were familiar with the nursing process and NANDA terminology. The SNCP included 22 NANDA diagnoses, NOC outcomes, and NIC interventions, achieving 95%-100% validity. In Phase 3, a statistically significant improvement was observed in nurses' total care plan scores from pretest (5.44 ± 2.81) to posttest (16.50 ± 4.98). Additionally, patient files documented with the care plan SNCP showed a statistically significant quality improvement compared to those using traditional care plans. Nurses reported high satisfaction, citing ease of use, improved patient follow-up, support for evidence-based practice, enhanced care quality, and focus on individual patient needs. The SNCP based on international nursing terminologies was evaluated as valid in terms of scope, effective in identifying care problems compared to traditional care plans, better quality in terms of documentation, and satisfactory for nurses using it in patients with chronic liver disease. In this direction, it is recommended that the standard nursing care plan based on international nursing terminologies for chronic liver patients be widespread, and the care outcomes be evaluated with further studies.

Think–pair–share as an active learning strategy for prioritizing nursing care plans

Introduction: Learning in the community presents different challenges than learning in a clinical setting. However, studies on student nurses' experience in the community have not been discussed comprehensively. This study aimed to explored nursing students’ experiences in a community setting using the five stages of the nursing process Method: This study used a qualitative design with the Photovoice approach. A total of 14 students were involved in the study. Data was collected by taking photos and small group discussions for the narrative photo with the SHOWED approach. Photos and narration are the primary data and are analyzed thematically. Result: A total of approximately eighteen photos have been included. At the assessment phase, the student requires an adaptation process and strategic anticipation, as the practice was conducted directly in the participants’ community. Formulating nursing diagnosis is done through teamwork and group discussion with an approach based on evidence and theory, and asking for guidance from the lecturer as a facilitator for learning. The development of nursing intervention was done with active participation from society, presenting the intervention plan to the community, community meetings, and ensuring the legality of the plan's activities. Implementation in the nursing community is implemented collaboratively between students and the community following the agreed-upon plan. Evaluating nursing practice is done with collaborative reflection of students, discussion together, and related plans, actions, and carrying on independently in public. Conclusion: This study finds that community-based nursing practice requires student adaptation, strategic planning, and evidence-based teamwork. Keywords: Clinical nursing education, community health nursing, photovoice, nursing students, nursing care plan

Generative artificial intelligence (AI) offers new opportunities for individualized education, yet its effectiveness may vary across learners. This study examined whether ChatGPT improves nursing students’ performance in creating care plans and whether intelligence and language proficiency moderate this potential effect. A total of 221 nursing students completed two care plan tasks in randomized order—one with ChatGPT-4 support and one without. Expert raters, blind to condition, evaluated care plan quality, and students’ intelligence and language proficiency were assessed using standardized measures. Latent change score modeling revealed that ChatGPT-assisted care plans were rated significantly higher in quality than unassisted ones (d = 0.85). Intelligence moderated this benefit, such that students with higher intelligence showed greater improvement in creating nursing care plans through the use of ChatGPT. In contrast, language proficiency predicted overall task performance, but did not moderate ChatGPT-related benefits. These findings indicate that while ChatGPT can substantially enhance nursing students’ performance in complex, domain-specific writing tasks, it may also risk reinforcing existing achievement differences associated with intelligence. Implications for the equitable integration of generative AI in education are discussed.

Introduction: Families are a fundamental context for health, influencing care needs, decisionmaking, and health outcomes across the life course. In nursing, the family may be approached as context and/or as a unit of care; however, the conceptualization and operationalization of family nursing care planning remains inconsistent across clinical settings. Existing evidence suggests variability in how nurses assess families, formulate diagnoses, establish goals, implement interventions, and evaluate outcomes.Objectives: To outline the methodological approach for an umbrella review designed to map and synthesize evidence from systematic reviews and meta-analyses on nursing assessments, diagnoses, goals, interventions, and outcomes in family nursing, across all levels of family focus and healthcare contexts.Methodology: Following the Joanna Briggs Institute methodology for umbrella reviews, the searches will be conducted in MedLine Ultimate, CINAHL Ultimate, MedicLatina (via EBSCOhost), Scopus, and grey literature. Eligible sources will include systematic reviews and meta-analyses published in English, Portuguese, or Spanish between 2014 and 2025. The protocol adheres to PRISMA-P guidelines, and is registered in the Open Science Framework. Findings will be organized narratively and summarized in “Summary of Evidence” tables.Conclusions: The review will synthesize how family care planning is conceptualized and implemented in nursing practice, identifying shared elements, inconsistencies, and research gaps. It shall enhance understanding of family nursing care across contexts, reinforcing its theoretical and empirical foundations.

Delving into the critical role of nursing care plans in Australian aged care, the introduction of electronic systems in these facilities aimed to elevate the standard of documentation. While standardized nursing terminologies, designed to promote communication and professional growth in nursing, aren't obligatory in aged care settings, there's a clear imperative to explore the language employed by nurses in their care plans. Additionally, investigating the influence of electronic systems on documentation quality in residential aged care stands as a significant area of inquiry. This study sought to delineate documentation practices within Australian residential aged care homes, conducting a thorough audit across seven facilities. The review encompassed 111 paper-based and 194 electronically managed nursing care plans, strategically selected for comprehensive assessment. The results underscored the efficacy and practicality of employing decision support mechanisms to capture patient preferences and integrating them into nursing care plans. This integration was found to significantly augment the quality of nursing care and subsequently improve patient outcomes. These encompass the selection processes for cutting fluids, electroplating systems, forging conditions, arc welding procedures, industrial robots, milling conditions, material machinability, and electro-discharge micro-machining parameters. The research emphasizes the WASPAS method's proficiency in precisely ranking alternatives across all these decision-making scenarios. Furthermore, the study delves into examining how the parameter λ (lambda) influences the ranking performance of the WASPAS method

Background: Crohn's disease has a pattern of recurrent remissions and flare-ups which makes patients experience psychological complications; however, few studies have been conducted to identify intra-personal factors associated with health-related quality of life in individuals with Crohn's disease. This study aimed to explore how disease activity, coping, and post-traumatic growth were associated with health-related quality of life in patients with Crohn's disease. Methods: A cross-sectional study was conducted using self-reported questionnaires. Of the 227 adult patients recruited from a Crohn's disease online support group in Korea, 219 were included in the final analysis. Measurements included the Harvey-Bradshaw Simple Index, the Korean version of the Short Inflammatory Bowel Disease Questionnaire, the Korean version of the Coping and Adaptation Processing Scale Short-Form, and the Korean version of the Post-traumatic Growth Inventory. Data were analyzed using descriptive statistics, independent t-tests, one-way ANOVA, Pearson's correlation, and multiple linear regression. Results: The mean score of health-related quality of life was 4.10 out of 7 points, and the subdomain of emotional health showed the lowest score. Most participants were classified as having mild disease activity. The multiple regression analysis revealed that disease activity was significantly associated with health-related quality of life, which accounted for 31.2% of the total variance. Coping and PTG were not significantly associated with health-related quality of life. Conclusions: Disease activity was a significant factor associated with the health-related quality of life of Crohn's disease patients. It is important to control the disease activity level in Crohn's disease patients through self-management strategies. Maintaining a low stage of disease activity can be a crucial component of nursing care plans for enhancing health-related quality of life in individuals with Crohn's disease.

A structured review of acute lymphoblastic leukemia (ALL) in adults was conducted. Current evidence and literature on its epidemiology, classification, therapeutic strategies for its control and treatment, and current nursing care plans based on the Nursing Care Process (NCP) were reviewed. The literature search was performed in primary databases such as PubMed, PMC, and JNCCN, among others, as well as medical guidelines. Sources were prioritized based on their relevance to the study, their content, and their recency. The study addresses the main clinical and psychosocial problems that characterize patients, the usefulness of minimal residual disease monitoring, the information used for decision-making, and the remission rate. Clear action plans were designed and proposed regarding changes that could be implemented in institutional protocols, nursing staff training, and the accurate recording of patient care.

Abstract Introduction Delirium affects 1 in 4 hospitalised older adults, doubling length of stay and increasing mortality sixfold. Yet, over half of cases go undetected. In 2019, delirium screening compliance at Leeds Teaching Hospitals NHS Trust was under 5%. No standardised care plan for delirium prevention or management existed. We aimed to embed a trust-wide, digital, person-centred strategy to detect and manage delirium in patients aged >65 across all departments. Methods Using the IHI model for improvement, we launched a strategy in March 2023: Spot it, Sort it, Stop it. A 4AT assessment was embedded into our electronic record (PPM+), with a score > 0 triggering a mandatory nursing care plan based on the ‘PINCH ME’ framework (Pain, Infection, Nutrition, Constipation, Hydration, Medications/Mobility, Environment). A live run chart tracked 4AT compliance and care plan use by department. Campaigns included ward-based education, short films, podcasts, posters, and governance engagement. A driver diagram describes our multiple targets for improvement and multiple PDSA cycles, Surveys evaluated staff confidence and knowledge. Results 4AT completion rose from 3.6% to 70.4%, with over 1800 patients assessed monthly. Care plan compliance reached 60–90% across departments. Staff confidence in recognising delirium improved from 47% to 88%, and confidence in managing delirium rose from 43% to 86%. Falls reduced from 3.8 to 3.5 per 1000 bed days, and length of stay decreased by 0.5 days. Staff increasingly recognised delirium as a medical emergency, using 4AT scores as a communication tool. Conclusion Our trust-wide strategy significantly improved delirium detection, staff confidence, and care quality for older adults. Sustained cultural and clinical change was supported by education, data visibility, and MDT engagement. Future plans include real-time ward dashboards, revised care plans, and continued rollout through our frailty education programme.

Objective: This study aimed to assess the quality of the nursing care plan developed using ChatGPT-3.5 and Gemini-2.0 Flash for a breast cancer patient. Material and Methods: The research was both descriptive and comparative. The patient's anamnesis in the breast cancer care plan example from Birol's Nursing Process, a significant resource on the nursing process in Turkey, was presented to the artificial intelligence models ChatGPT-3.5 and Gemini-2.0 Flash. The care plan formed by these models was assessed in relation to the breast cancer care plan example presented in Birol's book, Nursing Process, and the nursing diagnoses established by the International North American Nursing Diagnoses Association (NANDA). Results: Upon evaluating the replies of artificial intelligence models about the nursing care process, it was observed that both models encompassed the phases of nursing diagnosis, goal setting, intervention planning, and assessment; however, only ChatGPT-3.5 incorporated the stages of data collecting and execution. In the sample care plan, 7 nursing diagnoses were generated by ChatGPT-3.5, whereas 6 were produced by Gemini-2.0 Flash in a comparable manner. Furthermore, both models handled supplementary diagnoses that were excluded from the example care plan. The diagnoses generated by ChatGPT-3.5 were akin to those found in NANDA, but the diagnoses produced by Gemini-2.0 Flash encompassed distinct diagnoses absent from NANDA. In the context of nursing interventions, ChatGPT-3.5 concentrated on assessing the efficacy of care post-intervention, whereas Gemini-2.0 Flash prioritized patient education and informational processes during all interventions. Conclusion: ChatGPT-3.5 demonstrated superior efficacy compared to Gemini-2.0 Flash in the nursing process. Furthermore, it was established that both AI models are applicable in nursing diagnosis and the formulation of interventions under the supervision of nurses. It is advisable to incorporate AI systems into the nursing education process under the oversight of nursing educators.

BackgroundEvidence-based practice is essential for delivering safe, high-quality nursing care; however, its implementation remains challenging due to barriers such as limited knowledge, a lack of supportive organizational culture, and insufficient access to relevant knowledge at the point of care. Knowledge management systems (KMSs) have the potential to bridge this gap by integrating evidence into the nursing process through technological support. Despite growing interest, the integration of KMS into daily nursing practice is still underexplored, especially from the perspective of frontline nurses.ObjectiveThe aim of this study was to explore nurses’ perspectives on the requirements for a KMS that supports evidence-based practice at the point of care, with a focus on usability, process integration into the electronic nursing care plan and patient chart, and implementation challenges and benefits.MethodsA qualitative study was conducted in a Swiss hospital using observations, focus groups, and individual interviews with 6 registered nurses, 9 advanced practice nurses, 2 nursing managers, and 1 head physician. Data were analyzed using thematic analysis.ResultsThe analysis revealed four main categories and ten subcategories: (1) content of the KMS, (2) personal and structural factors of knowledge management, (3) technical conditions of the KMS, and (4) implementation of a KMS. Participants emphasized the need for an intuitively structured, process-integrated system that links evidence-based information directly to nursing interventions in the electronic nursing care plan and patient chart. Organizational support, interprofessional collaboration, and clear responsibilities were identified as critical for successful implementation.ConclusionsThere is a clear need for a KMS that is user-friendly, seamlessly integrated into clinical workflows, and supports quick, reliable access to evidence-based knowledge. A KMS could enhance nurses’ access to reliable knowledge, promote evidence-based decision-making, and strengthen professional confidence at the point of care. By embedding evidence directly into the electronic nursing care plan and patient chart, such systems can streamline workflows, reduce time spent searching for information, and support more consistent application of best practices. These capabilities may improve information retrieval and contribute to a safer, more consistent nursing practice.

To evaluate the acceptability and feasibility among nurses of Decubitus Risk Prediction Alerts based on Artificial Intelligence (DRAAI), and to assess the feasibility of the implementation plan. A process evaluation of a pilot implementation study using mixed methods. Acceptability and feasibility of DRAAI among nurses from three general wards in a university hospital was assessed via questionnaire. The tailored implementation plan included thirteen strategies distributed over six domains, such as facilitation, continuous evaluation, and educational sessions. Adaptations, acceptability, and feasibility were recorded in field notes. Fifty-five nurses completed the questionnaire and valued DRAAI's predictions, believing these could contribute to pressure ulcer (PU) prevention. Some initially faced challenges distinguishing between PU risk and PU detection. Most found it feasible to integrate DRAAI into their workflow. Adaptations included adding PU preventive measures to educational sessions and sharing frequently asked questions and answers. Overall, implementation efforts were feasible. DRAAI generated PU risk predictions for 428 unique admitted patients; 128 (30%) patients received at least one at-risk prediction. Regarding fidelity, nearly 80% (101/128) of at-risk predictions were followed by a nursing care plan. Ongoing involvement and clear communication were crucial for successfully integrating AI into nursing workflows. Although some nurses were concerned that DRAAI might miss at-risk patients, they continued to independently identify at-risk patients. Implementation of DRAAI served as a prompt for nurses to focus more on PU prevention. While DRAAI shows promise in improving PU prevention, future research is needed to evaluate its clinical impact. Addressed the challenge of identifying patients at risk for developing pressure ulcers. Demonstrated feasibility and acceptability of implementing AI in clinical practice. Highlighted the need for ongoing support and communication for successful implementation. None. Standard for Reporting Implementation Studies (StaRI).

Ventricular assist device (VAD) nursing is a critical specialty in the management of patients with advanced heart failure and cardiomyopathy. VAD nurses play an essential role in the preoperative preparation, intraoperative coordination, and postoperative care of patients receiving mechanical circulatory support, particularly those awaiting heart transplantation. These devices assist in improving cardiac function, but their use carries risks, such as infection, bleeding, thrombosis, device malfunction, and psychological challenges. Therefore, VAD nurses must possess expertise not only in general nursing care but also in infection prevention, anticoagulation management, patient education, and psychosocial support. As integral members of multidisciplinary teams, VAD nurses are responsible for educating patients on device management, ensuring safety, and promoting quality of life. With technological advancements, the role of VAD nurses has become increasingly significant in preventing complications and maintaining patient stability. In conclusion, VAD nursing is vital for improving patient outcomes and enhancing quality of life. Continued education and interprofessional collaboration are essential for advancing expertise and ensuring high-quality patient care.

Comparative analysis of nursing care plans produced by artificial intelligence models (ChatGPT, Gemini, and DeepSeek) in terms of readability, reliability, and quality

Schizophrenia is a chronic mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions. Clozapine, a second-generation antipsychotic, is commonly prescribed for treatment-resistant schizophrenia. However, its use is frequently associated with side effects, notably hypersalivation. This case report discusses the clinical consequences of clozapine-induced hypersalivation, emphasizing the importance of individualized nursing care planning. The descriptive case report presents the clinical course of a 47-year-old male patient diagnosed with schizophrenia. The patient exhibited symptoms such as anger, suspiciousness, anxiety, and auditory and visual hallucinations, as well as hypersalivation, which was attributed to clozapine therapy. Three nursing diagnoses were identified: (1) impaired swallowing due to pharmacological side effects, (2) risk of aspiration associated with swallowing difficulties, and (3) ineffective coping mechanisms related to anxiety stemming from fear of choking. Relevant nursing interventions were implemented in line with these diagnoses. This case highlights the critical role of psychiatric nurses in recognizing and managing drug-related side effects. It underscores the necessity for a biopsychosocial approach in psychiatric nursing and points to the need for enhanced training regarding the adverse effects of psychotropic medications. schizophrenia, clozapine, hypersalivation, psychiatric nursing care, side effects, case report.

This study aimed to promote cognitive health and emotional well-being in older adults by implementing a culturally adapted Five-Domain Lifestyle Intervention (FDLI) in Taiwan. Building upon the internationally recognised Finnish FINGER model, the FDLI included core components-nutritional guidance, physical activity, cognitive training and cardiometabolic risk management-while integrating nostalgic music as a culturally meaningful fifth domain to enhance emotional engagement. An 8-month quasi-experimental intervention study was conducted among 38 community-dwelling older adults (aged ≥ 65 years) with mild cognitive impairment (MCI) in Southern Taiwan. Participants were non-randomly assigned to either an experimental group (n = 20) or a control group (n = 18) based on residential community. The experimental group received the FDLI intervention; the control group received no intervention. Outcomes were assessed using validated measures of cognition (MoCA), well-being, positive emotion and depression, analysed using linear mixed models. Compared to controls, participants in the intervention group demonstrated significant improvements in global cognitive function, well-being and depressive symptoms over time. Although positive emotion scores did not change significantly, the multi-domain intervention yielded holistic benefits across cognitive and emotional domains. The FDLI effectively improved cognitive and emotional outcomes among Taiwanese older adults with MCI. By incorporating culturally grounded strategies like nostalgic music, this study contributes to international gerontological nursing by demonstrating the feasibility and benefits of nurse-led, context-specific, non-pharmacological interventions in underrepresented regions. Findings have practical implications for nursing care planning and dementia prevention in aging societies. The FDLI model emphasises the practical role of gerontological nurses in implementing community-based interventions that promote healthy ageing. It can be readily adapted for other cultural contexts and applied in low-resource settings. Training programs for health professionals can incorporate FDLI principles to support person-centred care, especially in underserved populations. Policy-makers may consider supporting the integration of lifestyle interventions into community health systems to delay cognitive decline and enhance quality of life. By fostering cognitive health, emotional well-being and social engagement, the FDLI contributes to active ageing and aligns with WHO strategies for age-friendly and sustainable communities (WHO, 2020). Its use of existing community assets also supports ecological approaches to long-term care.

Nurses play a key role in the prevention of diseases among the population, including children, in particular due to the need to integrate medical education and practical activities in the field of health care.The aim is to investigate the role of a nurse in assessing the quality of life of adolescents with cardiac pathology.Material and methods. A survey of 67 adolescents (mean age 16.4±2.8 years) and 123 parents of adolescents was conducted using the standardized questionnaire Pediatric Quality of Life Inventory – PedsQLTM 4.0. The quality of life index and the disease severity index were determined. Statistical processing of the results was carried out using the standard statistical computer system “Microsoft Excel”.Results. The difference in the frequency of scales selected by adolescents and parents was insignificant, with the exception of the scales “Restrictions in work” and “Need to quit smoking” (p<0.05). The indicators of the scales were characterized by a large range of values (18.9-87.7 points) and did not significantly differ when interviewing adolescents and their parents. The total scale, which characterizes the overall assessment of the quality of life, was 70.1±12.4 and 64.7±15.4 points, respectively. Parents assessed the quality of life of their children worse. Most patients were concerned about the need to constantly observe the diet (100%) and to be treated for a long time (81%). On average, the index of the selected scales was 4.8 ± 0.4 and the QOL – -3.9 ± 0.5.Conclusions. 1. The quality of life of adolescents with cardiac pathology is low and depends on the subjective perception of the disease. 2. A nurse can independently assess the quality of life of patients. Incorporating a patient's quality of life assessment into the nursing care plan will increase the effectiveness of treatment and reduce the medical burden.

A bstract Background: Electronic nursing care plan (ENCP) applications are integral tools in modern healthcare settings, offering standardized documentation, enhanced communication, and improved patient care. Objective: This review evaluated the development, nursing diagnosis features, and suitability of existing ENCP applications for rural African settings. Materials and Methods: We searched PubMed and Scopus databases for relevant articles published between 1983 and 2025. Out of an initial 315 identified records, six articles met the inclusion criteria and were reviewed. Key features assessed include the design phases, design tools applied, nursing diagnosis features, nursing speciality intended, and the suitability of ENCP applications for rural African nursing settings. Results: Findings indicate that six ENCP applications were available, each with varying features and functions. While the applications offer robust features for care planning and documentation, gaps existed in the comprehensiveness of nursing diagnosis support. One out of the six included studies (16%) consulted the end-user (clinical nurses) before planning the flow diagram (a requirement for a user-centered software development life cycle). Five out of the six included studies (83%) reported ENCP applications with a limited list of nursing diagnosis expressions. The only ENCP application with an extensive nursing diagnosis list had not been tested outside the simulation room, hence causing a knowledge gap. One (16%) of the ENCPs was potentially suitable for Africa as it could function both online and offline. Conclusion: Future developments in ENCP applications should prioritize end-user consultation and an extensive nursing diagnosis list to optimize the use across all nursing specialties and settings. The review protocol was registered on the Open Science Framework (OSF): http://doi.org/10.17605/OSF.IO/CZA7D.

In recent years, the workload of nursing professionals in intensive care units (ICUs) has been described. Identifying associated factors may contribute to improving nursing care planning. To determine predictors associated with nursing workload in ICU settings using a sample of records collected before and during the first peak of the COVID-19 pandemic. This was an analytical cross-sectional study. A total of 97 ICU patient records were included. Descriptive and multivariate analyses were performed using robust linear regression, with the primary outcome being workload measured with the Nursing Activities Score (NAS). The mean age was 57.67 ± 17.78 years, and 68.04% (n=66) were men. Statistically significant differences were observed between the pre-pandemic period and the first peak of the pandemic for variables such as disease category, ICU type, Sequential Organ Failure Assessment (SOFA) score, and number of nurses (p<0.001). A difference in median NAS values was observed, with 60.85 (Q1-Q3: 51.8-68.25) during the pre-pandemic period, compared with 183.40 (Q1-Q3: 149.30-204.40) during the first peak of the pandemic (p=0.001). The workload levels identified in this study are consistent with those reported in similar studies. However, the specific scenario examined has scarcely been described in the existing literature. The pandemic increased the nursing staff's workload threefold. A weak, direct linear correlation was identified between workload and SOFA score. The pandemic year and the presence of cardiopulmonary conditions were identified as workload predictors.