Resident Work Research Articles

Factors and conditions of successful professional adaptation of residents

BACKGROUND: Residency is the main stage in the training of highly qualified medical personnel. Requirements for the level of training and professional values of future doctors are increasing, approaches to training and assessment technologies are changing, which imposes additional responsibility on all participants in the educational process: teachers, mentors and residents.
 AIM: To identify the factors and conditions that affect the professional adaptation of residents in the first months of training.
 MATERIAL AND METHODS: The study involved 369 residents studying at Kazan State Medical University, Kazan (Volga region) Federal University, Kazan State Medical Academy, aged 22 to 36 years. Residents were subdivided into groups according to the following criteria: specialty, place of previous training, basis of training (by general competition, target, commercial), gender, age, clinical base of residency. An original questionnaire developed by the authors containing 27 questions was used. Questions of the questionnaire concerned various aspects of the adaptation of residents. Filling the questionnaire was anonymous and was carried out using Internet survey technology via Yandex Forms. Statistical analysis and visualization of the obtained data were performed using the StatTech v. 3.0.9. Categorical data were described with absolute values and percentages. Comparison of percentages in the analysis of multifield contingency tables was performed using Pearson's χ2 test.
 RESULTS: Satisfaction with training was considered as one of the indicators of successful adaptation of residents. Based on the results of the 1st and 2nd months of residency training, 48.2% of respondents showed satisfaction with their training. There were no significant differences in the degree of satisfaction among residents of various specialties (p=0.424). Statistically significant differences (method used — Pearson's χ2) were established by the presence of a mentor/curator, as well as cases of disrespectful attitude on the part of the medical staff of the clinical base where they were trained, patients and their relatives, and the administration of the institution (p 0.05). The dependence of the process of residents’ adaptation on the chosen specialty, place of previous training, the basis of training (by general competition, target, commercial), gender, age, clinical base of residency was not found.
 CONCLUSION: The conditions for successful adaptation of residents are the presence of a mentor from a medical organization, the accuracy of the instructions received, the frequency of meetings with a teacher/curator, the attention of the head of the department to the work and study of residents, and the motivation for learning from the residents themselves.

Customised knowledge-sharing platform to foster resident quality improvement activities, tracking and scholarship

IntroductionMeeting accreditation requirements to train resident physicians in quality improvement (QI) may require more than education. Barriers to resident QI engagement underscore the need to demonstrate the impact and value...

Strategi Pengembangan Usaha Mikro Kecil Dan Menengah (UMKM) Untuk Meningkatkan Perekonomian Masyarakat Dihuntap Pombewe Kabupaten Sigi

Pombewe Huntap is a relocation place for residents affected by disasters in Sigi Regency, Central Sulawesi, especially for residents from Oloboju, Jono Oge, Loru, and Pombewe Villages. The majority of Pombewe Huntap residents work in the agriculture, livestock and Micro, Small and Medium Enterprises (MSMEs) sectors. MSMEs have a vital role in national economic growth, but their development in Pombewe Huntap still faces obstacles. The purpose of this research is to find the best way to develop MSMEs to improve the economy of the Pombewe Huntap community in Sigi Regency. The results showed that Pombewe Huntap MSMEs face major problems related to capital, marketing, and production. This study suggests the village government to improve existing programs to support MSMEs, including training, financial assistance, and provision of equipment, as well as consistent evaluation of results.

The current landscape of emergency medicine resident scheduling.

The Accreditation Council for Graduate Medical Education (ACGME) and Residency Review Committee oversee resident physician work hours with additional specifics for U.S. emergency medicine (EM) residency programs. While there are maximum work hours, the regulatory bodies do not describe minimum work hours to achieve competency, leading to variable scheduling practices. This study aimed to understand the current landscape of U.S. EM residency scheduling given the expansion of programs, evolution of policies, and increased emphasis on wellness. We conducted a cross-sectional study to assess current strategies of U.S. EM residency scheduling. The RedCap survey was sent to all ACGME-accredited EM residency programs across the United States via individualized emails between January 10, 2023, and March 15, 2023. Data were combined using Microsoft Excel. A total of 138 of 278 (50%) programs responded to the survey. A total of 73.2% of programs were using thirteen 28-day blocks with the remainder using twelve 1-month blocks or reported "other" block scheduling. The number of blocks in the ED increases with each postgraduate year (PGY). For PGY-1 through PGY-3, the most commonly used shift duration was 9 h. The mean total shifts per ED block and hours worked per ED block are as follows: 19 shifts and 185.1 h (PGY-1), 18.2 shifts and 173.9 h (PGY-2), 17.3 shifts and 163.6 h (PGY-3), and 14.8 shifts and 157.2 h (PGY-4). Programs provide a median for 4 weeks of vacation per year of residency. Given the expansion of U.S. EM residency programs, we reevaluated the landscape of resident scheduling. We described scheduling patterns related to night shifts, vacations, requested time off, conference coverage, charting time, and circadian rhythms. Programs should utilize these data as a starting point for setting a clinical experience for their residents.

Medical residency in Portugal: a cross-sectional study on the working conditions.

The current European crisis in human resources in health has opened the debate about working conditions and fair wages. This is the case with Resident doctors, which have faced challenges throughout Europe. In Portugal, they account for about a third of the doctors in the Portuguese National Health Service. No studies to date objectively demonstrate the working conditions and responsibilities undertaken. This study aims to quantify the residents' workload and working conditions. Observational, retrospective cross-sectional study which involved a survey on the clinical and training activity of Portuguese residents, actively working in September 2020. The survey was distributed through e-mail to residents' representatives and directly to those affiliated with the Independent Union of Portuguese Doctors. The descriptive analysis assessed current workload, and logistic regression models analyzed associations with geographical location and residency seniority. There were a total of 2,012 participants (19.6% of invited residents). Of the residents giving consultations, 85.3% do so with full autonomy. In the emergency department, 32.1% of the residents work 24 h shifts and 25.1% work shifts without a specialist doctor present. Regarding medical training, 40.8% invest over EUR 1,500 annually. Autonomy in consultations was associated with being a Family Medicine resident (OR 4.219, p < 0.001), being a senior resident (OR 5.143, p < 0.001), and working in the Center (OR 1.685, p = 0.009) and South regions (OR 2.172, p < 0.001). Seniority was also associated with investing over EUR 1,500 in training annually (OR 1.235, p = 0.021). Residents work far more than the contracted 40 h week, often on an unpaid basis. They present a high degree of autonomy in their practice, make a very significant personal and financial investment in medical training, with almost no time dedicated to studying during working hours. There is a need to provide better working conditions for health professionals, including residents, for the sake of the sustainability of health systems across Europe.

Management of the Electronic Health Record Inbox: Results From a National Survey of Internal Medicine Program Directors.

Background Internal medicine (IM) resident physicians spend a considerable amount of time managing their inbox as part of their longitudinal continuity clinic experience. There are no standardized guidelines for how programs should train, monitor, or supervise residents in this type of patient care. Objective To understand how IM residency programs educate, monitor, and supervise resident electronic health record (EHR) inbox management as part of their longitudinal continuity clinic and determine whether patient safety events have occurred due to EHR inbox-related patient care decisions made by unsupervised resident physicians. Methods In August 2021, 439 program directors at accredited US IM residency programs who were members of the Association of Program Directors in Internal Medicine (APDIM) were asked 12 questions developed by the study authors and APDIM survey committee members regarding resident EHR inbox management as part of the annual APDIM survey. Results Two hundred and sixty-seven (61%) PDs responded. The majority (224 of 267, 84%) of programs provided guidelines for expected message response times; less than half (115, 43%) monitored timeliness metrics. Only half (135; 51%) of programs required faculty supervision of inbox messages for all residents; 28% (76) did not require supervision for any residents. Twenty-one percent of PDs (56) reported awareness of a patient safety event occurring due to an unsupervised resident inbox-related patient care decision. Conclusions Substantial variability exists in how IM residency programs train, monitor, supervise, and provide coverage for resident inbox work. Program directors are aware of patient safety events resulting from unsupervised resident inbox management.

Analisis Kontribusi PT Intidaya Agrolestari (Inagro) terhadap Lapangan Pekerjaan Penduduk Sekitar sebagai Mekanisme Pertumbuhan Ekonomi dalam Pencapaian Sustainable Development Goals

This study aims to analyze the contribution of PT Intidaya Agrowisata (INAGRO) to employment opportunities for residents around PT Intidaya Agroconservali as a mechanism for economic growth in Bogor Regency in achieving the Sustainable Development Goals. This research was conducted by interviewing six workers at INAGRO. The data used includes previous research, current data from relevant sources, books, and various reports related to the topic studied. The interpretive-phenomenological method is the data analysis used in this research. The results of the research state that PT Intidaya Agrowisata (INAGRO) contributes effectively to creating employment opportunities for the villagers around INAGRO which can be useful as a mechanism for economic growth in achieving the Sustainable Development Goals. INAGRO provides productive work opportunities for village communities. Every village from the 4 sub-districts around INAGRO, is invited to work at INAGRO in accordance with INAGRO's needs, INAGRO can contribute as a mechanism for economic growth in achieving the Sustainable Development Goals (Goal 8), that INAGRO with its context as a tourist spot and place of work for residents is supported by opportunities very productive work.

Freedom Dreaming: An Abolitionist Teacher Residency

Schools are sites of unfreedom. As such we engage in freedom dreaming and co-constituting of non-negotiables of an abolitionist teacher residency (ATR). This conceptual article asks: what non-negotiables are necessary when centering abolition in residency work? Our dream guides illustrate the need to draw on radical imaginations, freedom dreaming, abolitionism, and abolitionist education to dismantle caustic systems. An ATR must: (a) attune to their geo-socio-historical and political situatedness, (b) be democratic/participatory in nature, (c) commit to an onto-epistemological orientation rooted in critical theories and abolition, and (d) emphasize learning as liberation. We invite others into this “abolitionist turn” within residencies.

Public opinion of resident physician work hours in 2022

ObjectiveThe purpose of this study was to characterize public awareness and opinion regarding resident physician work hours in the United States. MethodsWe conducted a nationally representative cross-sectional survey among adults in the United States. Demographic quota-based sampling was conducted by Qualtrics to match 2020 United States Census estimates of age, sex, race, and ethnicity. Descriptive statistics are presented. Hypothesis testing was conducted to identify characteristics associated with agreement with current resident physician work-hour policies. Results4763 adults in the United States participated in the study. 97.1% of the public believes that resident physicians should not work 24-hour shifts and 95.6% believe the current 80 hours resident work week is too long. 66.4% of the participants reported that the maximum shift duration should be 12 consecutive hours or fewer, including 22.9% who recommended a maximum shift length of 8 hours. Similarly, 66.4% reported that maximum weekly work hours should be 59 or fewer, including 24.9% who recommended a maximum of 40 weekly work hours. ConclusionsNearly all US adults disagree with current work-hour policies for resident physicians. Public opinion supports limiting shifts to no more than 12 consecutive hours and weekly work to no more than 60 hours, which is in sharp contrast to current regulations that permit of 28 hours shifts and 80 hours of work per week.

Systematic Review of the Impact of Physician Work Schedules on Patient Safety with Meta-Analyses of Mortality Risk.

Resident physician work hour limits continue to be controversial. Numerous trials have come to conflicting conclusions about the impact on patient safety of eliminating extended duration work shifts. We conducted meta-analyses to evaluate the impact of work hour policies and work schedules on patient safety. After identifying 8,362 potentially relevant studies and reviewing 688 full-text articles, 132 studies were retained and graded on quality of evidence. Of these, 68 studies provided enough information for consideration in meta-analyses. We found that patient safety improved following implementation of the Accreditation Council for Graduate Medical Education's 2003 and 2011 resident physicians work hour guidelines. Limiting all resident physicians to 80-hour work weeks and 28-hour shifts in 2003 was associated with an 11% reduction in mortality (p < 0.001). Limited shift durations and shorter work weeks were also associated with improved patient safety in clinical trials and observational studies not specifically tied to policy changes. Given the preponderance of evidence showing that patient and physician safety is negatively affected by long work hours, efforts to improve physician schedules should be prioritized. Policies that enable extended-duration shifts and long work weeks should be reexamined. Further research should expand beyond resident physicians to additional study populations, including attending physicians and other health care workers.

Multidisciplinary Initiative to Increase Guideline-concordant Antibiotic Prescription at Discharge for Hospitalized Children with Uncomplicated Community-acquired Pneumonia

Background: Clinical practice guidelines recommend using narrow-spectrum antibiotics to treat uncomplicated pneumonia in children. This quality improvement (QI) project aimed to evaluate if QI methods could improve guideline-concordant antibiotic prescribing at hospital discharge for children with uncomplicated pneumonia. Methods: For this single-center QI project, we implemented QI interventions in serial plan-do-study-act cycles, focusing on the key drivers targeting general pediatric inpatient resident teams. Interventions included: (1)Small bimonthly group didactic sessions, (2)Visual job aids posted in resident work areas, and (3) A noon conference session. Balancing measures included postdischarge emergency room visits, readmission and adverse drug reactions. Results: To establish a baseline rate, we conducted a chart review of 112 children diagnosed with uncomplicated community-acquired pneumonia during hospitalization from July 2017 through January 2019. The average monthly percentage of children discharged with guideline-concordant antibiotics was 67%. The intervention period was from February 2019 through February 2020, with 118 children meeting the criteria after a review of 262 charts. After our interventions, the average monthly percentage of children discharged with guideline-concordant antibiotics increased to 87%, with the increase persisting for at least 12 months. There were no significant differences in balancing measures pre- and post-interventions. Conclusions: Our QI initiative sustained increased rates of uncomplicated community-acquired pneumonia guideline-concordant antibiotic prescribing at discharge over 12 months without an increase in balancing measures. The enduring changes in prescribing behavior suggest a lasting impact of our interventions.

BURNOUT AND COVID-19 FEAR OF RESIDENTS WORKING AT A UNIVERSITY HOSPITAL

Sağlık çalışanlarının tükenmişlik sorunu, pandemide zorlaşan çalışma koşulları ve COVID-19 korkusu ile daha da artmıştır. COVID-19 sürecinde en önde görev alan tıpta uzmanlık öğrencileri, en çok etkilenen gruplardan biridir. Bu çalışmada, bir üniversite hastanesindeki uzmanlık öğrencilerinin tükenmişlik ve COVID-19 korkusu değerlendirilerek ilişkili etmenleri saptamak amaçlanmıştır. Araştırma kesitsel tipte olup Eylül-Kasım 2021’de Ankara Üniversitesi Tıp Fakültesi’nde çalışan tıpta uzmanlık öğrencilerinde yürütülmüştür. Örnekleme seçilen 400 kişiden 324’ü araştırmaya katılmış, veriler tanımlayıcı bilgilerin yanısıra Türkçe uyarlaması yapılmış olan Maslach Tükenmişlik Ölçeği (MTÖ) ve Koronavirüs Korkusu Ölçeği (KKÖ) kullanılarak çevrim içi toplanmıştır. MTÖ’de duygusal tükenme (DT) ve duyarsızlaşma (D) puanlarının yüksek, kişisel başarı (KB) puanının düşük olması yüksek tükenmişlikle ilişkilidir. KKÖ’de puan arttıkça COVID-19 korkusu artışını göstermektedir. Verilerin analizinde SPSS 26 programı kullanılmış, tekli analizlerde anlamlı saptanan değişkenler için çoklu lineer regresyon analizi uygulanmıştır. Araştırmaya katılanların yaş ortalaması 28,03±2,48 yıl olup %59’u kadındı. DT puanı 19,20±7,88, D puanı 8,00±4,11, KB puanı 18,48±4,78; KKÖ puanı 15,72±5,06 idi. Yoğun çalışma koşulları, şiddet, baskı, psikolojik destek ihtiyacı, yetersiz maaş gibi faktörlerin yanı sıra yüksek COVID-19 korkusu da tükenmişliğin çeşitli alt boyutlarını anlamlı ölçüde etkilemiştir. COVID-19 korkusu ise ileri yaşta, kadınlarda, evde 65 yaş üstü bireyle yaşayanlarda, uyku düzeni bozulanlarda, ailesinden ayrılanlarda ve pandemide görev almayanlarda daha yüksek bulunmuştur. İlişkili faktörlere dayanarak iş yükünün ve stresin azaltılması, çalışma sürelerinin kısıtlanması, olanakların iyileştirilmesi ve sağlıkta şiddetin çözümlenmesi önerilmiştir.

Determining the efficacy of disinfectants at nucleic acid degradation.

Nucleic acids, particularly antibiotic resistance genes, are commonly found on surfaces within healthcare environments, with levels not reducing following cleaning. Within the UK, there are no regulations for testing disinfectants against nucleic acids. A series of commonplace in vitro methods were used to determine disinfectant-induced physical and functional damage to various nucleic acids; RNA (10 μg), genomic DNA (2 μg), and plasmids (1 μg). Using these methods, the optimal residence time (10 minutes) and working concentration (10%) were determined for a new disinfectant. Furthermore, comparison of disinfectants with different active ingredients including lactic acid (LA), sodium hydroxide (NaOH), chloroxylenol (PCMX), and quaternary ammonium compounds (QACs), were compared to controls. All disinfectants showed greater degradation by gel electrophoresis of genomic DNA and RNA than of purified plasmids. Functional analysis using quantitative polymerase chain reaction (qPCR) and polymerase chain reaction (PCR) demonstrated that no disinfectant tested (apart from control) could damage DNA to the level where PCR amplification was not possible, and only the NaOH reagent could achieve this for RNA. The set of methods described herein provides a platform for future standardization and potential regulation regarding monitoring cleaning solutions for their activity against nucleic acids.

Work Patterns and Intensity of Chinese Surgical Residents- A Multicenter Time-and-Motion Study

This study aimed to record and analyze surgical resident trainee time allocation among junior doctors in China in order to understand the training environment and optimize realistic training and patient care objectives. Multicenter observational time and motion study. Multicenter, carried out in 5 tier 3 public hospitals in 5 provinces across China. Surgical resident trainees at various stages of training were eligible to enter the study, total n = 44. Registered nurses were eligible to be observers, n = 4 from each hospital. An expert team comprising 4 chief surgeons and 10 surgical residents participated in establishing the clinical activity list. Participants were observed during working hours (08.00-17.00) for 10 consecutive working days and time spent on different activities were recorded. Work patterns between hospitals were often dissimilar. Most time was spent on direct patient care (34.1%; 95% CI, 28.0%-40.1%) followed by indirect patient care (24.4%; 95% CI, 15.5%-33.2%), scholarly activity (21.1%; 95% CI, 13.7%-28.5%) and other (20.4%; 95% CI, 14.1%-26.8%). Subcategory analysis showed that the amount of time spent each day performing certain tasks was 137 minutes for operating theatre tasks, 103 minutes for medical record-keeping, 25 minutes for direct patient contact, 20 minutes being taught, 12 minutes teaching others, 12 minutes hand-over time, and 0 minutes of outpatient clinic attendance. Inter-observer reliability of 96.5% was obtained prior to recordings. Chinese surgical resident work patterns fall within the range found in other international studies albeit with some exceptions. The training environment appears broadly suitable for competence-based surgical training in China. Inadequate outpatient activity has led to changes in trainee work rosters and trainer requirements. Both strengths and deficiencies were confirmed and addressed. Further audit is required.

Prevalence of post-traumatic stress disorder among residents of Shanghai standardized training programs during the COVID-19 outbreak: a cross-sectional study.

The COVID-19 pandemic may have increased the prevalence of psychiatric disorders, such as anxiety, depressive disorders, and post-traumatic stress disorder (PTSD), among healthcare workers. This study aims to investigate the prevalence of PTSD and its risk factors among residents in the standardized residency training programs (SRTPs) in Shanghai during the COVID-19 outbreak. An online cross-sectional survey was conducted between December 17, 2021, and January 7, 2022, among SRPT residents from 15 hospitals in Shanghai, China. Questionnaires comprising general information, medical-related traumatic event experiences, the PTSD Checklist (PCL-5), and the perceived social support scale (PSSS) were distributed to the participants using the online Questionnaire Star electronic system. We included 835 valid responses for the analysis. In total, 654 residents (78.3%) had experienced at least one traumatic event, and 278 residents (33.3%) were found to have PTSD symptoms. The age 26-30 years old, female sex, and increased resident working hours were identified as the risk factors for PTSD (p < 0.05), and perceived social support had a significant negative association with PTSD (p < 0.05). During the COVID-19 pandemic, there was a high prevalence of PTSD among SRTPs residents in Shanghai. The age 26-30 years old, female sex, and increased resident working hours were identified as risk factors for PTSD, while perceived social support was identified as a protective factor against PTSD. The present findings can be applied in STRPs management and provide useful information for designing special interventions and protocols for SRTPs residents.

The effects of resident work hours on well-being, performance, and education: A review from a Japanese perspective.

This article examines the impact of working-hour restrictions on the well-being, performance, and education of medical residents in Japan. Despite Japan's plan to introduce new regulations for resident working hours by 2024, there is still an ongoing debate regarding their appropriateness. This review provides a comprehensive overview of the current regulations of resident working hours worldwide, with a specific focus on weekly hours. The varying regulations are highlighted, including the 80-hour-per-week regulation in the United States and the 48-h-per-week regulation in the European Union influencing other regions. The article also discusses the effectiveness of working-hour restrictions on residents' mental health, with shorter working hours having potentially greater benefits. However, the impacts on medical safety and resident education are mixed, and further reduction in working hours must be carefully considered to avoid adverse effects. The planned changes to working-hour limits for residents in Japan offer a unique opportunity to gain new evidence on the impact of such regulations, which will be of interest to policymakers and researchers worldwide.

Intermediate Evaluation of the Work of the Simulator Interface Radiumsim Focus Group of Doctors in Practical Preparation for Accreditation in the Section Radiology

The high level of professional training, technical skill and practical skills of the doctor acquired on the simulator of X-ray and magnetic resonance RadiumSim studies increase the quality of medical X-ray diagnostic care. A focus group of radiologists evaluated the uniqueness and effectiveness of the Radius simulator, as well as indicated the wishes and changes in the formation of the interface (including the designer of medical protocols and conclusions of CT studies) on the RadiumSim simulator. The use of the simulator of X-ray and magnetic resonance RadiumSim studies with additions of scenarios of various pathologies is recommended for accreditation of specialists in the field of radiology, as well as for practical training and training in the organization of independent work of students, residents and radiologists.

Do emergency medicine residents have access to healthy food options during work hours?

Relatively little data describe how diet and food choices impact trainee well-being despite evidence that diet impacts both physical and mental health. The objective was to describe food options available to emergency medicine (EM) residents when on duty. A survey utilizing closed-ended, binary, rank-order responses was developed by experts in graduate medical education and wellness; it was piloted, revised, and then electronically distributed to 211 EM residency programs over 2 weeks in 2021. The program director (PD) or associate PD was invited to participate. A total of 114 EM programs participated (54%). The primary teaching site included 43 community hospitals, 23 county hospitals, and 48 university hospitals. Resident access to an onsite hospital cafeteria was most common (97%); other onsite options were vending machines (87%), fresh food fridges (34%), national chains (32%), local restaurants (25%), food trucks (30%), and farmer's markets (11%). More than one-third (38%) reported that onsite options did not include healthy food, 26% reported being dissatisfied with onsite food, and 35% rarely or never purchased food onsite. Most programs (89%) do not have a dedicated "meal break" for residents while on duty. Few residency programs include diet or nutrition classes or counseling. When programs sponsor meals during residency events, nutritional value and dietary considerations were ranked less important than cost of food and convenience. Access to healthy food options is not always available during scheduled resident work hours, and dedicated meal breaks are infrequent. These data should inform institutional initiatives to improve the health and well-being of resident physicians.

A Comparative Study of Two Networked (neoendogenous) Development Approaches: The EU LEADER and China’s Resident Work Team in Poor Villages (RWTIPV)

A Comparative Study of Two Networked (neoendogenous) Development Approaches: The EU LEADER and China’s Resident Work Team in Poor Villages (RWTIPV)

Gonzaga`s house in Caldas Novas, Goiás: past and presente in the tourist city

The purpose of this article is to present the management, activities and business developed at Casarão dos Gonzaga, a memory and cultural heritage place of Itaguaí II, Caldas Novas, Goiás, Brazil, which constitutes an urban space for residents and tourists. Regarding the methodological aspects, the investigation was divided into two phases – documentary research (survey of references) and fieldwork – and, through the last one, reports were obtained from the professional responsible for the management of the object investigated. This work results from an exploratory and analytical study, whose main results synthesize the history of the place, the physical structure, the greeting work of residents and tourists, the products sold, the subjects involved with the place and the management through the responsibility of Caldas Novas City Hall. In this context, the challenge of the current management is the heritage business hours on Saturdays and Sundays, as there are few workers and retention of expenses. It is explicit that objects, architecture and heritage employees promote to the visitors a journey into the past, rich in details and experiences that enable learning and a sense of belonging.