TeamSTEPPS Teamwork Perceptions Questionnaire Research Articles

Cross-Cultural Validation of the TeamSTEPPS Teamwork Perceptions Questionnaire-Spanish in Colombia.

Teamwork influences health care quality and patient safety. Yet, validated instruments for assessing teamwork in Colombia are lacking. The purpose of this study was to validate the Spanish version of the TeamSTEPPS-Teamwork Perceptions Questionnaire (T-TPQ-S) for the Colombian health care context. The T-TPQ-S underwent translation, cultural adaptation, and comprehensive psychometric testing, including reliability and confirmatory factor analyses and item difficulty and discrimination analyses. The T-TPQ-S demonstrated high internal consistency and excellent fit to the theoretical model. Item discrimination was within expected ranges, with response thresholds displaying an ascending order. The tool better differentiated subjects with low and high teamwork perceptions. The T-TPQ-S is an effective, reliable, and valid instrument for assessing teamwork perception among Colombian health care workers.

Influence of Mutual Support on Burnout among Intensive Care Unit Healthcare Professionals.

IntroductionBurnout among healthcare professionals in intensive care units (ICUs) is a serious issue that leads to early retirement and medication errors. Their gender, lower years of experience, and lower education have been reported as risk factors. Simultaneously, mutual support—commonly referred to as “back-up behavior,” in which staff members support each other—is critical for team performance. However, little is known about the influence of mutual support among ICU healthcare professionals on burnout. The U.S. Agency for Healthcare Research and Quality refers to mutual support as the involvement of team members in: assisting one another, providing and receiving feedback, and exerting assertive and advocacy behaviors when patient safety is threatened.ObjectiveThis study aimed to verify the hypothesis that lower mutual support among ICU healthcare professionals is associated with increased probability of burnout.MethodsA web-based survey was conducted from March 4 to 20, 2021. All ICU healthcare professionals in Japan were included. An invitation was sent via the mailing list of the Japanese Society of Intensive Care Medicine and asked to mail to local communities and social network services. We measured burnout severity using the Maslach Burnout-Human Services Survey and mutual support using the TeamSTEPPS Teamwork Perceptions Questionnaire, as well as occupational background. The cutoff value for burnout was predefined and conducted logistic regression.ResultsWe received 335 responses, all of which were analyzed. The majority of respondents were nurses (58.5%), followed by physicians (18.5%) and clinical engineers (10.1%). The burnout group scored significantly lower on mutual support than the non-burnout group. After adjusting for covariates in a logistic regression, low mutual support was an independent factor predicting a high probability of burnout.ConclusionsThis study suggests that it is important to focus on mutual support among ICU healthcare professionals to reduce the frequency of burnout.

Perceptions of Teamwork in Schools of Nursing.

Characteristics of high-performing teams include shared purpose, clear vision, strong leadership, and the ability to use conflict management when needed. While many individuals who teach in schools of nursing come from the clinical setting where teamwork is normative, that same expectation of teamwork may not be present for the faculty as a whole. This study assessed perceptions of teamwork among faculty members in schools of nursing in 4 states in the Midwestern region of the United States. Perception of teamwork, related to communication, leadership, team structure, situation monitoring, and mutual support, was examined using a modified TeamSTEPPS Teamwork Perceptions Questionnaire. Perceptions of teamwork were highest for team structure and leadership, whereas communication, situation monitoring, and mutual support were lower. In addition, teamwork dimension scores were higher for those who previously participated in teamwork training. There are opportunities to improve teamwork in all domains. Teamwork skills are transferrable to different roles and across various situations; therefore once learned and fostered, these can impact the individual as well as improve the organizational climate.

A human factors intervention in a hospital - evaluating the outcome of a TeamSTEPPS program in a surgical ward

BackgroundPatient safety in hospitals is being jeopardized, since too many patients experience adverse events. Most of these adverse events arise from human factors, such as inefficient teamwork and communication failures, and the incidence of adverse events is greatest in the surgical area. Previous research has shown the effect of team training on patient safety culture and on different areas of teamwork. Limited research has investigated teamwork in surgical wards. The aim of this study was to evaluate the professional and organizational outcomes of a team training intervention among healthcare professionals in a surgical ward after 6 and 12 months. Systems Engineering Initiative for Patient Safety 2.0 was used as a conceptual framework for the study.MethodsThis study had a pre-post design with measurements at baseline and after 6 and 12 months of intervention. The intervention was conducted in a urology and gastrointestinal surgery ward in Norway, and the study site was selected based on convenience and the leaders’ willingness to participate in the project. Survey data from healthcare professionals were used to evaluate the intervention. The organizational outcomes were measured by the unit-based sections of the Hospital Survey of Patient Safety Culture Questionnaire, and professional outcomes were measured by the TeamSTEPPS Teamwork Perceptions Questionnaire and the Collaboration and Satisfaction about Care Decisions in Teams Questionnaire. A paired t-test, a Wilcoxon signed-rank test, a generalized linear mixed model and linear regression analysis were used to analyze the data.ResultsAfter 6 months, improvements were found in organizational outcomes in two patient safety dimensions. After 12 months, improvements were found in both organizational and professional outcomes, and these improvements occurred in three patient safety culture dimensions and in three teamwork dimensions. Furthermore, the results showed that one of the significant improved teamwork dimensions “Mutual Support” was associated with the Patient Safety Grade, after 12 months of intervention.ConclusionThese results demonstrate that the team training program had effect after 12 months of intervention. Future studies with larger sample sizes and stronger study designs are necessary to examine the causal effect of a team training intervention in this context.Trial registration numberISRCTN13997367 (retrospectively registered).

Translation, reliability and validity of Japanese version the TeamSTEPPS® teamwork perceptions questionnaire.

AimThis study aimed to translate the TeamSTEPPS® Teamwork Perceptions Questionnaire (T‐TPQ) into Japanese and assess its validity and reliability.DesignTranslation of the T‐TPQ and a cross‐sectional survey.MethodsFollowing a forward and back translation of the questionnaire, content validity was assessed by an expert panel using item‐level content validity index. Construct validity was assessed by a confirmatory factor analysis. Further, intraclass correlation coefficient was estimated by test–retest methods.ResultsA total of 587 healthcare professionals responded to the translated T‐TPQ. The item‐level content validity index ranged between 0.8 and 1.0, indicating an acceptable content validity. The multiple fit indices showed an acceptable fitting model. Fifty‐one healthcare professionals participated in the test–retest method. Intraclass correlation coefficients for all dimensions ranged from 0.838 to 0.957, indicating acceptable test–retest reliability. Our findings suggest that the Japanese version of the T‐TPQ has acceptable validity and reliability.

Long-term effects of teamwork training on communication and teamwork climate in ambulatory reproductive health care.

We previously reported an association between team training in the ambulatory setting and improvements in team climate at 6 and 12 months, but it is unknown whether improvements persist at 2years. From 2014 to 2015, we enrolled 20 organizations, each operating a varying number of health centers, into a teamwork training initiative. We evaluated teamwork outcomes at baseline and 2years using a communication behaviors assessment, the TeamSTEPPS® Teamwork Perceptions Questionnaire (T-TPQ), and the Patients' Insights and Views of Teamwork (PIVOT) survey. At 2years, use of TeamSTEPPS® tools and strategies remained increased compared to baseline at many health centers; results ranged from 32% of centers reporting increased use of pauses to identify the patient to 91% reporting increased use of standardized language. Staff T-TPQ responses indicated that TeamSTEPPS® implementation was associated with improved perceptions of teamwork in approximately half (49%) of statements at 2years. Significant improvements occurred in over half of PIVOT survey statements, and patient satisfaction was significantly greater at 2years compared to baseline. Patient and staff views of teamwork were significantly improved 2years after TeamSTEPPS® implementation in ambulatory reproductive health care centers, demonstrating positive long-term effects of teamwork training.

The Swedish Version of the TeamSTEPPS® Teamwork Perceptions Questionnaire (T-TPQ): A Validation Study.

PurposeThe delivery of effective and safe healthcare to patients is highly dependent on careful collaboration between healthcare professionals. Although teamwork is an important component for patient safety, effective teamwork is not always carried out in hospital wards, leading to negative consequences for the patients. Teamwork measurements can be used to evaluate and provide feedback to healthcare professionals to support team performance and to identify areas for improvement. The TeamSTEPPS® Teamwork Perceptions Questionnaire (T-TPQ) evaluates Team Structure and four core competences of teamwork (Leadership, Situation Monitoring, Mutual Support, and Communication) among healthcare professionals in various healthcare settings. The questionnaire was judged to be relevant in a Swedish healthcare context and was translated into Swedish. This study aimed to test the reliability and construct validity of the Swedish version of the T-TPQ.MethodsA total of 450 (of 1176) frontline healthcare professionals working at four hospitals responded to the questionnaire. A confirmatory factor analysis was carried out to test the factor structure. Cronbach’s alpha was used to measure internal consistency.ResultsThe hypothesized five-factor model of the five dimensions showed acceptable goodness-of-fit indexes. Cronbach’s alpha coefficient for the total T-TPQ was 0.94, and the Cronbach’s alpha coefficients for the dimensions ranged from 0.79 to 0.92. The intercorrelation coefficients ranged from 0.27 to 0.74.ConclusionThe Swedish version of the T-TPQ showed acceptable reliability and validity for measuring healthcare professionals’ individual perceptions of teamwork at the group level. Due to the low response rate, further studies are required to test the validity of the Swedish T-TPQ.

The Greek versions of the TeamSTEPPS teamwork perceptions questionnaire and Minnesota satisfaction questionnaire \u201cshort form\u201d

BackgroundTeamwork and job satisfaction are important among the multidisciplinary team who care patients with chronic illnesses such as heart failure (HF) patients. TeamSTEPPS teamwork perceptions questionnaire (T-TPQ) and Minnesota Satisfaction Questionnaire “short form” (MSQ-short) are both self-report questionnaires which examine multiple dimensions of perceptions of teamwork and job satisfaction within healthcare settings, respectively. The aim of the study was to examine the psychometric properties of the Greek versions of the TeamSTEPPS Teamwork perceptions questionnaire (Gr-T-TPQ) and Minnesota Satisfaction Questionnaire “short form” (Gr-MSQ-short).MethodsA methodological study was contacted in order to assess the construct validity and reliability of the Gr-T-TPQ and Gr-MSQ-short. For that reason, 292 questionnaires were administrated to Greek-Cypriot health care professionals (HCPs). Confirmatory factor analysis (CFA) was conducted for the data collected with the GrT-TPQ and Exploratory factor analysis (EFA) and CFA were also conducted for the data collected with the GrMSQ-short questionnaire. Cronbach’s a was calculated as well.ResultsCFA of the data collected with Gr-T-TPQ confirmed the initial scale structure with excellent fit indices (× 2 (df) 1124.75 (550), p < 0.0001, AGFI = 0.986, TLI = 0.994, CFI = 0.994, RMSEA = 0.06, 90%, C.I.[0.055–0.065]). Furthermore, all dimensions were found to be correlated (r = 0.65 to r = 0.88) and internal consistency was found adequate (Cronbach’s α = 0.96). Subscales also, demonstrated high internal consistency (α = 0.87–0.95). CFA for the data collected with Gr-MSQ-short, did not confirm the initial scale’s dimensions. In EFA items 1, 5, 6, 12 and 18 were eliminated from the analysis due to low communalities and multiple components loading. The oblimin rotation with two factors was explaining 58% of the variance. These two factors identified were Supervisor/Autonomy and Task Enrichment.ConclusionsIn general, the Gr-T-TPQ and Gr-MSQ-short are construct-valid instruments for measuring perceptions of teamwork and job satisfaction in Greek speaking HCPs’ population.

The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a patient safety demonstration project

BackgroundConducting post-fall huddles is considered an integral component of a fall-risk-reduction program. However, there is no evidence linking post-fall huddles to patient outcomes or perceptions of teamwork and safety culture. The purpose of this study is to determine associations between conducting post-fall huddles and repeat fall rates and between post-fall huddle participation and perceptions of teamwork and safety culture.MethodsDuring a two-year demonstration project, we developed a system for 16 small rural hospitals to report, benchmark, and learn from fall events, and we trained them to conduct post-fall huddles. To calculate a hospital’s repeat fall rate, we divided the total number of falls reported by the hospital by the number of unique medical record numbers associated with each fall. We used Spearman correlations with exact P values to determine the association between the proportion of falls followed by a huddle and the repeat fall rate. At study end, we used the TeamSTEPPS® Teamwork Perceptions Questionnaire (T-TPQ) to assess perceptions of teamwork support for fall-risk reduction and the Hospital Survey on Patient Safety Culture (HSOPS) to assess perceptions of safety culture. We added an item to the T-TPQ for respondents to indicate the number of post-fall huddles in which they had participated. We used a binary logistic regression with a logit link to examine the effect of participation in post-fall huddles on respondent-level percent positive T-TPQ and HSOPS scores. We accounted for clustering of respondents within hospitals with random effects using the GLIMMIX procedure in SAS/STAT.ResultRepeat fall rates were negatively associated with the proportion of falls followed by a huddle. As compared to hospital staff who did not participate in huddles, those who participated in huddles had more positive perceptions of four domains of safety culture and how team structure, team leadership, and situation monitoring supported fall-risk reduction.ConclusionsPost-fall huddles may reduce the risk of repeat falls. Staff who participate in post-fall huddles are likely to have positive perceptions of teamwork support for fall-risk reduction and safety culture because huddles are a team-based approach to reporting, adapting, and learning.

An examination of the factor structure of TeamSTEPPS measures in school mental health teams.

Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS™) is a tested strategy for improving communication and climate in hospitals. It is a promising but untested tool among school-based mental health teams. We examined the psychometric properties of the TeamSTEPPS Teamwork Perceptions Questionnaire (T-TPQ) and Teamwork Attitudes Questionnaire (T-TAQ) among 167 school mental health team members. Team members worked for one of five agencies in 33 K-8 urban public schools. Exploratory factor analyses and descriptive data are presented. For both the T-TPQ and T-TAQ, a unitary factor structure best fit the data for this sample. The T-TPQ and T-TAQ were not significantly correlated with one another and total scores did not significantly differ by staff role. Agencies differed in T-TAQ results, and one agency had lower T-TAQ total scores relative to other agencies. Results suggest that the factor structures are different among school mental health teams than among other healthcare providers.

Impact of teamwork improvement training on communication and teamwork climate in ambulatory reproductive health care.

While team training is associated with improved hospital-based team climate, less is known about effects in the ambulatory setting. In 2014 and 2015, we enrolled 20 organizations, each operating various health centers, into this ongoing study. Evaluation tools include a communication behaviors assessment (CBA) and Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS® ) Teamwork Perceptions Questionnaire (T-TPQ), which staff completes at baseline, 6 months, and 1year, and the Patients' Insights and Views of Teamwork (PIVOT) survey, which patients complete at baseline and 1year. We also assessed patient satisfaction. We analyzed T-TPQs paired at the individual level and CBAs and PIVOTs paired at the health center level. We also conducted key informant interviews with the first cohort. CBAs showed that TeamSTEPPS tools and strategies were utilized, with 50% or more of centers reporting increases in all behaviors at 1year; key informant interviews confirmed this. T-TPQ findings indicated that TeamSTEPPS implementation was associated with improved staff perceptions of teamwork at 6 months; lesser improvements were seen at 1year. The PIVOT survey demonstrated significant improvements in select patient ratings of teamwork. Patient satisfaction improved at 1year. TeamSTEPPS has positive effects in the ambulatory reproductive health care environment. Improvements persisted at 1year.

Enhancing teamwork using a creativity-focussed learning intervention for undergraduate nursing students - A pilot study.

A cohort of year two students (n = 181) was exposed to a transformational and experiential learning intervention in the form of team-led poster development workshops to enhance competence and interpersonal skills for working in teams. The aims of this study were to test the suitability of an amended TeamSTEPPS teamwork perceptions questionnaire (T-TPQ) for measuring the impact of the intervention on students' perceptions of team working, and to ascertain students' views about the experience. This was a two phase pilot study. Phase 1 was a repeated measures design to test the T-TPQ for evaluating the impact of the experiential intervention, and Phase 2 was a survey of students' views and opinions. Descriptive and statistical analysis of the data were performed. Our findings suggest that age and part-time employment mediate towards more positive teamwork perceptions. Teamwork perceptions increased from week 3 to week 9 of the experiential intervention, and students viewed the experience positively. This was the first time that the T-TPQ was tested for suitability for measuring the impact of an experiential learning intervention among nursing students. Despite limitations, our study indicates that the amended T-TPQ is sensitive to changes in teamwork perceptions in repeated measures design studies among nursing students.

Improving Teamwork and Communication through the Use of TeamSTEPPS

Effective teamwork and communication are critical components for quality and patient safety. Investing in the nursing leadership team strengthens the collaboration between all health care professionals. TeamSTEPPS is an evidence based program that has been shown to improve the quality and safety by fostering effective teamwork and communication skills. In this quality improvement project, TeamSTEPPS 2.0 training was used to improve leadership skills among nurses in leadership roles on a mid-sized medical surgical unit. Nursing leadership was evaluated using the TeamSTEPPS Learning Benchmarks Quiz, the TeamSTEPPS Teamwork Perceptions Questionnaire (T-TPQ), and the TeamSTEPPS Observation Tool. The results revealed an improvement in teamwork and communication among the staff and nursing leadership over a ten-week period.

Clinician Perceptions of Teamwork in the Emergency Department: Does Nurse and Medical Provider Workspace Placement Make a Difference?

This study was intended to determine whether positioning emergency department (ED) physicians, physician assistants, and nurse practitioners at the same workstations as registered nurses (RNs) improved communication and teamwork. Historically in this organization, providers and staff had separate physical locations (workstations). Construction of a new ED provided the opportunity to redesign the physical layout and to study whether a new design improved the perception of communication and teamwork among medical providers. A prospective, self-administered presurvey-postsurvey using the TeamSTEPPS Teamwork Perceptions Questionnaire (TPQ) was completed at 2 medical centers with the same staff premove and postmove but different ED designs. The presurvey was conducted while the staff were at the older facility with a more linear floor design and separated nurse and physician stations. The postsurvey was conducted 3 months after employees and physicians were relocated to a new hospital with a pod design and communal workstations in the ED. Forty-six staff members completed both the presurvey and the postsurvey. There was a statistically significant improvement in the total TPQ scores (P = .0009) and 4 of the 5 components of the TPQ: team structure (P = .0283), situation monitoring (P = .0006), mutual support (P < .0001), and communication (P < .0001). There was no change in the leadership component (P = .4519). Adopting a more communal physical layout was associated with improved overall TPQ scores and most of the TPQ components. The lack of change in the leadership component was explained by the lack of change in leadership structure. The physical placement of medical providers and RNs in an ED is important and can increase the perception of communication and teamwork and thereby improve patient outcomes.

Teamwork and Perceptions of Palliative Care Quality

Palliative care practice guidelines recommend experts collaborate on interdisciplinary teams to ensure high-quality care. However, there is limited knowledge of how various palliative care teamwork structures and processes influence care quality. This study describes palliative care team structures (eg, certification, setting) and processes (eg, leadership, communication) and examines their influence on perceptions of palliative care quality. A cross-sectional design addresses the research aims. Providers completed an online survey from May 2013 to May 2014 that included demographic and organizational questions, and the TeamSTEPPS Teamwork Perceptions Questionnaire. Of the 460 participants with outcome data, 81.1% were registered nurses; 89.9% were female. Most participants reported care quality as excellent in their settings (50.4%). Excellent quality was associated with male gender (P = .032), formal team membership (P = .001), hospice/palliative care unit employment (P < .000), non–acute care settings (P = .040), less education (P = .016), and collaborating with more disciplines (P = .003). All TeamSTEPPS scales were associated with excellent quality of care (P < .000). In the logistic model, team structure (odds ratio [OR], 1.132; confidence interval [CI], 1.047-1.225; P = .002), communication (OR, 1.095; CI, 1.014-1.182; P = .021), and collaboration with more disciplines (OR, 1.138; CI, 1.030-1.253; P = .011) were associated with excellent care quality. Interprofessional education and enhanced organizational structures to encourage collaboration may improve palliative care quality.

Creating a sustainable, interprofessional-team training program: initial results.

The purpose of this program evaluation was to explore whether incorporating deliberate learning concepts, through the use of simulated patient scenarios to teach interprofessional collaboration skills to a healthcare team on one acute-care hospital unit, would improve the resuscitation response in the first 5 minutes on that unit. This was a pilot program evaluation utilizing a unit-based, clinical nurse specialist in the deployment of an interprofessional educational program involving simulation on an acute medical floor in a large tertiary-care hospital. Eighty-four staff members participated in 17 simulations. The sample included first-year internal-medicine residents, registered nurses, respiratory therapists, and patient care technicians. This was a program evaluation that used the TeamSTEPPS Teamwork Perceptions Questionnaire (T-TPQ) (Classroom slides: TeamSTEPPS essentials; http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/essentials/slessentials.html#s3) during the presimulation/postsimulation sessions to assess the participants' perceptions of teamwork. Expected intervention behaviors were collected through observations of participants in the simulations and compared with the American Heart Association guidelines (Circulation 2010;122:S685-S670, S235-S337). Common perceptions of participants regarding the experience were obtained through open-ended evaluation questions. Fifty-three participants completed the pre- and post-T-TPQ. Mean scores in the leadership category of T-TPQ decreased significantly (P = .003) from the pretest (median, 2.167) to the T-TPQ posttest (median, 2.566). Only 35% of the groups administered a defibrillation during the ventricular fibrillation simulation scenario, and only 1 group delivered this shock within the American Heart Association's recommended time frame of 2 minutes (Circulation 2010;122:S235-S337). A single resuscitation simulation was not enough interventional dosage for staff to improve the resuscitation process. A longitudinal study should be conducted to determine the effectiveness of the program after staff members have repeated the program multiple times. A unit-based quality-improvement simulation training program could help improve the first-5-minute response and resuscitation skills of staff by increasing the frequency of unit-based training overseen by the unit's clinical nurse specialist.

A Team of Experts or an Expert Team: Interdisciplinary Teamwork and Perceptions of Palliative Care Quality (S742)

Objectives Identify potential IDT structures as targets for quality improvement (QI) programs. Identify potential IDT processes (e.g., leadership, communication) as targets for quality improvement (QI) programs. Original Research Background. The collaboration of multiple disciplines is required for optimal care of patients and families facing serious illness. While an interdisciplinary team (IDT) approach is widely recognized as important to the provision of palliative care (PC), less is known about how structures and processes of IDTs are associated with perceptions of PC quality. Research Objectives. This study examines how IDT structures (e.g., personnel, certification status, and organizational characteristics) and processes (e.g., leadership, communication) influence provider perceptions of PC quality. Methods. A cross-sectional survey design addressed the research objectives. PC providers completed an online survey from May 2013 to May 2014 which included demographic and organizational questions, and the subscales of the TeamSTEPPS Teamwork Perceptions Questionnaire (T-TPQ). Results. Of the 372 respondents providing complete data on all variables, 81.4% were RNs and 18.6% were other disciplines. The quality of PC was rated as excellent by 51.3% of respondents (versus 48.7% for all other responses). In bivariate analysis, higher perceptions of PC quality were associated withmembership on a formal IDT (p1⁄40.002), male gender (p1⁄40.030), less than a masters level education (p1⁄40.014), collaboration with more disciplines (p1⁄40.002), employment in non-acute care settings (p1⁄40.040), and all T-TPQ subscales (leadership, mutual support, communication, team structure [p<0.000 respectively]). In the multivariate model, team structure and communication subscales (OR: 1.133, CI: 1.047-1.225, p1⁄40.002; and OR: 1.093, CI: 1.012-1.180, p1⁄40.023 respectively), collaboration with more disciplines (OR: 1.148, CI: 1.040-1.268, p1⁄40.006), employment in non-acute care settings (OR: 1.891, CI: 1.133-3.157, p1⁄40.015), andmale gender (OR: 2.544, CI: 1.073-6.034, p1⁄40.034) were independent predictors of perceptions of excellent PC quality. Conclusions. Perceptions of PC quality may be influenced by both the structures of IDTs as well as the processes associated with IDT functioning. Implications for Research, Policy, or Practice. This research suggests potential targets for quality improvement projects to transform an IDT of experts into an expert team for providing exceptional PC.

Validation of a teamwork perceptions measure to increase patient safety

BackgroundTeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) is a team-training intervention which shows promise in aiding the mitigation of medical errors. This article examines the construct...