Wound Care Education Research Articles

Current Wound Care Education in Entry-Level Doctor of Physical Therapy Curricula.

To investigate how wound care instruction is currently delivered within entry-level doctor of physical therapy (DPT) educational curricula. An electronic survey was distributed to 226 DPT programs in the US. The questionnaire contained 27 questions about the characteristics of the wound care instruction as well as the credentials, clinical experience, and teaching experience of the instructors. Descriptive statistics were analyzed for each questionnaire item response. The response rate was 22.1% (n = 50). The majority of respondents reported 10 to 29 contact hours of wound care instruction throughout the curriculum. More than half of the programs reported that their students completed a wound care observation in clinical settings. Forty-four percent of programs stated that their students had the opportunity to participate in a clinical rotation focused solely on wound care. All respondents reported that their wound care instructors were physical therapists. Of those instructors, most were seasoned clinicians, and 46% held a wound care-related certification. Current entry-level DPT curricula provide physical therapy students with adequate contact hours in wound care and the opportunity for clinical experiences. The instructors are seasoned physical therapists, and nearly half of them hold advanced certification in the content area. Further studies are warranted to investigate how physical therapists practice in wound management in various clinical settings.

Spontaneous hemorrhage from varicose veins: A single-center experience

ObjectiveWhereas the commonly described manifestations of venous insufficiency include telangiectasia, varicose veins (VVs), edema, skin changes, and ulcers, we have noted some patients who present with external hemorrhage from lower extremity VVs. Because there are few recent data examining this entity, we herein describe our experience. MethodsDuring 29 months, we had 32 patients present with hemorrhage from lower extremity VVs. There were 15 men and 17 women with a mean age of 60.2 years (range, 38-89 years; standard deviation [SD], ±14.9 years). Interestingly, 16 of these patients presented after coming into contact with warm water; 28 patients, 19 patients, and 1 patient presented with reflux >500 milliseconds in the great, small, and accessory saphenous veins, respectively. Eight patients and six patients had reflux >1 second in the femoral and popliteal veins, respectively. ResultsAll patients were treated with weekly Unna boots. Mean ulcer healing time was 2.12 weeks (range, 1-8 weeks; SD, ± 2.15 weeks). Patients with VV hemorrhage after contact with warm water had a mean healing time of 1.75 weeks, whereas those who bled without such exposure took an average of 3.5 weeks (P = .0426). Twenty patients underwent at least one endovenous thermal ablation procedure, with the average patient in the cohort receiving 2.16 procedures (range, 0-9; SD, ± 2.37). There was no significant difference between laterality, age, or sex between patients who bled after warm water contact and those who bled spontaneously. The ulcers recurred in three of the patients, and Unna boot treatment was reapplied until wounds healed once more. Patients had an average follow up of 7.2 months (range, 26 months; SD, ± 8.9 months), and we noted no recurrent bleeding episodes. ConclusionsSpontaneous hemorrhage of VVs, although relatively under-reported, is not a rare occurrence. Risk factors are unknown; however, half of our patient cohort reported VV hemorrhage during or directly after coming into contact with warm water. Furthermore, these patients demonstrated a significantly shorter wound healing time compared with the rest of the cohort. Basic first aid, wound care, and hemostasis control education should be provided to all patients with VVs. Further investigation surrounding the risk factors associated with VV hemorrhage is warranted.

Status quo of knowledge, attitude and practice about palliative wound care in wound nurses

Objective To investigate the status quo of knowledge, attitude and practice (KAP) about palliative wound care in wound nurses, to analyze its influencing factors and to lay a basis for the development of palliative wound care. Methods Totally 183 wound nurses were selected using convenient sampling from June to August 2018 and investigated with the general information questionnaire and KAP scale for palliative wound care. Univariate analysis and multivariate linear regression analysis were used to analyze the influencing factors to KAP. Results The knowledge score of the wound nurses was (5.75±1.58) , with a pass yield of 59.02%; the attitude score was (26.07±3.22) , and the practice score was (29.20±7.05) . Multivariate linear regression analysis showed that the influencing factor to wound nurses' knowledge about palliative wound care was their length of service dedicated to wound care (P<0.05) ; the influencing factors to their attitude were their length of service dedicated to wound care, role in the wound care team, and whether to attend further education in wound care (P<0.05) ; the influencing factor to their practice was their role in the wound care team (P<0.05) . Conclusions Wound nurses' knowledge about palliative wound care stands at a low level. Their attitude is positive, but their practice is poor. Relevant knowledge and skill training shall be organized and the opportunities to attend various academic meetings and lectures should be provided to improve their clinical wound care. Key words: Questionnaire investigation; Wound nurse; Palliative wound care; Knowledge, attitude and practice; Wound care

Care Bundle Approach to Minimizing Infection Rates after Neurosurgical Implants for Neuromodulation: A Single-Surgeon Experience

Implant-related infections carry a high morbidity. Infectious rates for neuromodulation implants range from 1% to 9% for deep brain stimulation (DBS), 0%to 10% for spinal cord stimulation (SCS) systems, and 3% to 15% for intrathecal (IT) pump systems. Meanwhile, studies of care bundles report infection rate reduction to 1.0% for SCS and 0.3% for cardiac implants. Herein, we evaluate the effectiveness of an infection prevention bundle (IPB) in minimizing infections after surgeries for neuromodulation implants. An IPB focused on preoperative checklists, screening questionnaires, methicillin-resistant and methicillin-sensitive Staphylococcus aureus decolonization, weight-based antibiotic prophylaxis, strict draping and surgical techniques, and wound care education was implemented in our functional neurosurgery division in April 2015. We retrospectively reviewed all surgeries for implantation or replacement of SCS, DBS, and IT pump system components from March 2013 to October 2017. The patients were divided into pre-IPB and post-IPB groups. All procedures were performed by a single surgeon. Each surgical site was considered a unique surgical case. Infection rates were calculated for pre-IPB and post-IPBgroups. A total of 688 patients underwent 1161 unique surgical procedures (222 DBS electrodes, 419 IPG, 203 SCS, 317 IT pumps) during the study period. There were 546 pre-IPB and 615 post-IPB surgical procedures. The pre-IPB infection rates were 0%, 1.3%, and 8.7% for SCS, DBS, and IT pumps, respectively. The post-IPB infection rates were 0%, 0.3%, and 1.8% for SCS, DBS, and IT pumps, respectively. Implementation of a standardized IPB approach reduced the number of infections for all neuromodulation implants studied. This approach can be adopted within any specialty to potentially decrease the incidence of implant-related infections.

Computer-Assisted Wound Assessment and Care Education Program in Registered Nurses

Computer-Assisted Wound Assessment and Care Education Program in Registered Nurses

Computer-Assisted Wound Assessment and Care Education Program in Registered Nurses: Use of an Interactive Online Program by 418 Registered Nurses.

The purpose of this descriptive study was to evaluate use of a previously validated, online, interactive wound assessment and wound care clinical pathway in a group of RNs. Specific aims were to (a) evaluate the proportions of correct, partially correct, and incorrect algorithmic decisions and dressing selections, (b) compare response rates between nurses who are and who are not wound care certified, and (c) evaluate its ease of use, educational value, and applicability in clinical practice. Descriptive study. Participants were recruited using convenience and snowball sampling methods. Four hundred eighteen nurses completed all 15 assessments; nearly half held a bachelors' degree in nursing (189, 45%), more than two-thirds worked in an inpatient acute care settings (277, 68%), and 293 (70%) were not certified in wound care. After providing written informed consent and completing the participant demographics form, participants assessed 15 photographs of wounds with accompanying moisture descriptions and completed an algorithm and dressing selection for each. All responses were anonymously collected by the program. Existing, retrospective, program data were also downloaded and data from nurses who completed all assessments were extracted and analyzed. Descriptive statistics were used to analyze all variables. Selection outcomes and survey responses between nurses who were and who were not wound care certified were compared using a 2-sample Student t test assuming unequal variances. Individual responses for the first 6 wounds were compared to the last 6 wounds using a paired t test. The mean (M) proportions of fully or partially correct (operationally defined as safe but not fully correct) algorithm and dressing choice were 81% (SE: 0.88, 95% confidence level: 1.73) and 78.1% (SE: 0.70, 95% confidence level: 1.39), respectively. Wound care-certified nurses had higher mean algorithm scores than those who were not certified (M: 89.2%, SE: 1.27 vs M: 77.8%, SE: 1.10, P < .001). Most incorrect/partially correct choices were attributable to incorrect necrotic tissue assessment (n = 845, 58%). The difference between fully correct first 6 and last 6 algorithm choices was statistically significant (M: 310, SE: 0.02 vs M: 337, SE: 9.32, P = .04). On a Likert scale of 1 (not at all) to 5 (very), average scores for ease of program and algorithm use, educational value, and usefulness for clinicians ranged from M: 4.14, SE: 0.08 to M: 4.22, SE: 0.08. Results suggest that the algorithm is valid and has potential educational value. Initial evaluation also suggests that program refinements are needed. Evaluation of participant responses indicated potential problems with the definitions used for necrotic tissue or assessment knowledge deficits. Results also substantiate the importance of instructional design and testing online education programs. More research is needed to uncover potential gaps in nurses' wound care knowledge that may hamper evidence-based practices adoption and the need to develop effective, evidence-based education-delivery techniques.

Implementing a Chronic Wound Care Workshop for Internal Medicine Residents.

To determine the feasibility of a piloted wound care curriculum within a busy internal medicine (IM) curriculum. This prospective pilot study was conducted with 89 IM residents at an academic teaching hospital. The residents were provided a 90-minute workshop in chronic wound care. They anonymously completed a clinical vignette to target practice behavior prior to the workshop. The workshop was mixture of didactic and hands-on practice of sharp debridement and wound dressing selection. Three months later, the residents completed the same clinical vignette along with questions on changes and barriers to change in their practice. Change in behavior of chronic wound care management, measurements of barriers to change in participant continuity clinics. Of the participants, 57 residents (64%) and 25 residents (28%) completed a pre- and postvignette, respectively. Ten (40%) of the postvignette respondents stated that they had made changes in their care. Barriers to change included having a supervising attending physician who is not comfortable with wound care, a lack of wound care resources available in clinic, and a lack of confidence even after the session. It is feasible to insert a chronic wound care education into a busy IM curriculum. Future efforts will be aimed at assessing the wound care needs/resources of the IM outpatient clinics, addressing the comfort of the supervising attending physicians and residents with wound care, and focusing the curriculum on high-yield interventions.

Can a smartphone app help manage wounds in primary care?

Although wound care guidelines are available for primary care providers, barriers to assessment and treatment remain. This article examines current evidence supporting wound management, wound guidelines, and provider comfort with wound management in primary care and discusses the need for improved training, education, and the development of a simplified approach to wound management in primary care. This review of evidence examines knowledge of wound care, wound curriculum, and the current availability of guidelines for health care providers at the frontlines. Few primary care curriculums and institutions require wound care education. Access to guidelines, pathways, and educational resources is limited, which negatively effects primary care provider's knowledge and comfort level in treating wounds in current clinical practice. Educating the general practitioner on evidence-based wound management and providing adequate resources remain a priority. Increasing awareness of available electronic wound care applications (apps) can improve a timely wound care assessment, diagnosis, and initiation of treatment.

How Is Wound Care and Integumentary Education Being Taught in Professional-Level Physical Therapy Programs?

Introduction: The integumentary system is 1 of the 4 core systems along with musculoskeletal, neuromuscular, and cardiopulmonary systems that frame the curricular content for professional-level physical therapy programs. The purpose of this study was to investigate how the integumentary system curriculum is taught as 1 of the 4 core systems in professional-level physical therapy programs in the United States. A survey was sent to accredited and developing physical therapy programs within the United States to get a baseline on the following categories: (1) How is the integumentary content taught and delivered inclusive of contact hours? (2) Who teaches the content (full-time faculty, adjunct faculty, or guest lecturers, etc)? (3) What is the background, training, and expertise of the instructors? (4) Is the content part of a stand-alone course or bundled/threaded in other content areas? Subjects: A total of 232 professional (entry-level) physical therapy education programs at accredited or developing status by Commission on Accreditation in Physical Therapy Education were identified to complete the survey. An e-mail invitation requesting voluntary (and anonymous) survey participation was sent to all the programs in 2016. The survey was open to respondents for 2 months at a time with frequent e-mail reminders for participation. A total of 92 (40%) physical therapy education programs responded fully to the survey. Among these, 83 were accredited by Commission on Accreditation in Physical Therapy Education and 9 were developing programs on probationary status. Methods: A 41-question Internet survey to measure certain criteria related to wound management and integumentary education was developed to be answered by educators for this content. The categories included (1) institution demographics, (2) member demographic for person that is primary instructor for such material, (3) primary faculty member education/training related to wound care, and (4) primary faculty member clinical practice background. Question types that were formulated consisted of multiple choice, ranking, short answer, and comments. Results: Analysis of the survey led to several themes and disparities among programs. These included the duration of total time dedicated to didactic and laboratory hours. Student competency with integumentary and wound management was tested through written examination (69.9%) and practical examination (6.6%). Respondents reported that the most beneficial way to increase students' knowledge was clinical observations/affiliations (83%) and by increasing laboratory hours (28.4%). However, 95.8% of those who reported increasing the number of instructional hours reported a lack of time to be able to include further hours in the curriculum and that finding clinical wound/integumentary areas for observation is very challenging. Faculty qualifications were ongoing clinical practice (59.8%), continuing education without certification (49.4%), continuing education, and clinical practice leading to a certified wound specialist certification (50.6%). Discussion and Conclusions: This study provides data showing inconsistency regarding integumentary and wound management curricula in professional-level physical therapy programs compared with other core content areas in the United States. Furthermore, the study identified the core faculty demographics and challenges encountered to deliver this content. More physical therapy specialists with integumentary expertise are needed, as well as a need for more integumentary and wound management residencies.

Assessing knowledge of wound care among cardiothoracic nurses.

to explore cardiothoracic nurses' knowledge and self-reported competence of wound care following cardiac surgery and to ascertain if there were any differences in knowledge between nurses working in public and private hospitals. cardiothoracic nurses are the main providers of wound care for patients post cardiac surgery, however, there is a lack of research about their knowledge of wound care. a descriptive, quantitative design was used in the form of a cross-sectional, self-reported questionnaire. the questionnaire was developed to ascertain nurses' knowledge of cardiac wound management. Census sampling was used and the questionnaire was distributed to 503 nurses in 6 hospitals in the Republic of Ireland. Total knowledge scores were calculated and data analysed using descriptive and inferential statistics. the response rate was 31.2% (n=158). The main knowledge deficits identified were wound healing, the signs and symptoms of surgical site infection and cardiac-specific wound care. Some nurses reported using inappropriate products for cleansing wounds and variable time for initial postoperative dressing removal. the combination of low total knowledge scores and requests for further training and education suggest the need for ongoing wound care education. Audit of the use of wound cleansing products, support bras and wound assessment charts is recommended.

Wound Care Education for Undergraduate Nursing Students

Wound care is a dominant focus in nursing education and it encompasses theoretical underpinnings and practice of wound care related healing modalities. There are gaps in wound care education literature such as inconsistency between theory and lab teachings and constraints within the time allotment for practice. Such gaps impact the Bachelor of Science in nursing (BScN) students’ learning, their critical thinking, and wound care knowledge application. This article will explore wound care education for nursing students and its related gaps with a focus on a recent study that was conducted in Western Canada to further highlight their existence and impacts to create positive change. In this study, 126 BScN students and 44 nursing faculty members participated in three online surveys and two focus groups. The data collected was analyzed and led to identifying strategies to alleviate the existing educational gaps, which consequently will strengthen the BScN students’ decision making skills and wound care knowledge application. In addition, identifying such gaps will increase the wound care education curriculum developers’ awareness of their existence to provide more consistent, updated, and comprehensive wound care education; thus, supporting the BScN students learning.

Graduating student nurses' and student podiatrists' wound care competence - An integrative literature review.

The objective of this literature review is to describe graduating student nurses' and student podiatrists' wound care competence. This integrative literature review has been conducted with a systematic search process. Original studies were analysed by qualitative content analysis with the following stages: open coding, creating categories and abstraction. The literature search was conducted on May 2016 and reconducted on October 2016 using the Medline/Pubmed, CINAHL, Cochrane Library, Web of Science, Scopus and National Medic databases and 12 original studies were found. All the studies addressed graduating student nurses' wound care competence. According to original studies, graduating student nurses' wound care competence was inadequate. However, the students showed a positive attitude towards wound care. Subthemes of this literature review were: 1) Wound care knowledge, 2) Attitudes towards wound care, 3) Wound care preparedness and 4) Wound care education which created the main theme Graduating nurses' wound care competence. No studies were found about graduating student podiatrists' wound care competence. Graduating student nurses' wound care knowledge was deficient. Wound care education seemed to have a positive relation to students' wound care competence. The findings indicate that more information about graduating student nurses', and especially graduating podiatrists', wound care competence is needed.

Wound care evidence, knowledge and education amongst nurses: a semi-systematic literature review.

The aims of this study were to determine the knowledge and skills of nurses involved in wound care, to provide a critical overview of the current evidence base underpinning wound care and to determine the extent of utilisation of existing evidence by nurses involved in the management of wounds in practice. A semi-systematic review of the literature was undertaken on Cinahl, Medline Science Direct and Cochrane using the search terms: wound, tissue viability, education, nurse, with limitations set for dates between 2009 and 2017 and English language. Shortfalls were found in the evidence base underpinning wound care and in links between evidence and practice, prevalence of ritualistic practice and in structured education at pre- and post-registration levels. The evidence underpinning wound care practice should be further developed, including the conduction of independent studies and research of qualitative design to obtain rich data on both patient and clinician experiences of all aspects of wound management. More structured wound care education programmes, both at pre-registration/undergraduate and professional development levels, should be established.

Using reusable learning objects (RLOs) in wound care education: Undergraduate student nurse's evaluation of their learning gain

BackgroundBoth nationally and internationally concerns have been expressed over the adequacy of preparation of undergraduate nurses for the clinical skill of wound care. This project describes the educational evaluation of a series of Reusable Learning Objects (RLOs) as a blended learning approach to facilitate undergraduate nursing students learning of wound care for competence development. Constructivism Learning Theory and Cognitive Theory of Multimedia Learning informed the design of the RLOs, promoting active learner approaches. Clinically based case studies and visual data from two large university teaching hospitals provided the authentic learning materials required. Interactive exercises and formative feedback were incorporated into the educational resource. MethodsEvaluation of student perceived learning gains in terms of knowledge, ability and attitudes were measured using a quantitative pre and posttest Wound Care Competency Outcomes Questionnaire. The RLO CETL Questionnaire was used to identify perceived learning enablers. Statistical and deductive thematic analyses inform the findings. ResultsStudents (n=192) reported that their ability to meet the competency outcomes for wound care had increased significantly after engaging with the RLOs. Students rated the RLOs highly across all categories of perceived usefulness, impact, access and integration. ConclusionThese findings provide evidence that the use of RLOs for both knowledge-based and performance-based learning is effective. RLOs when designed using clinically real case scenarios reflect the true complexities of wound care and offer innovative interventions in nursing curricula.

Innovation in digital learning: Perineal wound care education

Innovation in digital learning: Perineal wound care education

Educating Nurses in the United States about Pressure Injuries.

To provide information about the current state of educating nurses about wound care and pressure injuries with recommendations for the future. This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. After participating in this educational activity, the participant should be better able to:1. Discuss the importance of pressure injury education and wound care for nurses and identify the current state of nursing education on the subject. 2. Identify strategies that can be used to put improved wound care and pressure injury education into practice. Wound care nursing requires knowledge and skill to operationalize clinical guidelines. Recent surveys and studies have revealed gaps in nurses' knowledge of wound care and pressure injuries and their desire for more education, both in their undergraduate programs and throughout their careers. Data from baccalaureate programs in the United States can pinpoint areas for improvement in nursing curriculum content. Lifelong learning about wound care and pressure injuries starts with undergraduate nursing education but continues through the novice-to-expert Benner categories that are facilitated by continuing professional development. This article introduces a pressure injury competency skills checklist and educational strategies based on Adult Learning principles to support knowledge acquisition (in school) and translation (into clinical settings). The responsibility for lifelong learning is part of every nurse's professional practice.

Preventing Complications of Pediatric Tracheostomy Through Standardized Wound Care and Parent Education.

Pediatric tracheostomy is commonly performed for upper airway obstruction and prolonged mechanical ventilation. Children undergoing tracheostomy typically have multiple chronic medical problems that place them at high risk for readmission and additional complications. To determine whether the institution of a postoperative protocol for parent education and wound care with a nurse trained in tracheostomy care decreases the rate of readmission and other complications. A case series and medical record review was conducted of children 18 years and younger who underwent tracheostomy at a tertiary pediatric medical center between January 1, 2009, and December 31, 2014. A postoperative tracheostomy care and education protocol. Overall 30-day readmission rate, 30-day tracheostomy-related readmission rate, tracheostomy wound complications, and additional factors that may have affected readmission rates and wound complications (age at the time of tracheostomy, discharge location, indication for tracheostomy). A total of 191 children (118 boys and 73 girls) were included; of these, 112 participated in the education protocol and 79 children did not. Following institution of the education protocol, there was no decrease in the overall readmission rate (26.8% before the protocol vs 26.6% after the protocol; difference, 0.2%; 95% CI, -12.5% to 13.0%) or in the tracheostomy-related readmission rate (10.1% before the protocol vs 7.1% after the protocol; difference, 3.0%; 95% CI, -5.0% to 11.0%). Overall, 68.6% of readmissions were associated with medical comorbidities (95% CI, 55.9% to 81.3%). There was a significant decrease in tracheostomy-related wound complications after institution of the protocol (31.6% to 17.9%; difference, 13.7%; 95% CI, 1.6% to 26.0%). Multiple logistic regression analysis showed that children who were discharged home were significantly more likely to be readmitted for a tracheostomy-related complication than were patients discharged to an advanced care facility (odds ratio, 14.47; 95% CI, 3.08 to 67.92). Tracheostomy care requires expertise for all caregivers and is challenging for people without specialized training. Specialized nursing and education protocols are associated with decreased complications of tracheostomy wounds. Children who are discharged directly to home are at higher risk for readmission compared with children discharged to advanced care facilities. Further development of caregiver education protocols is necessary to continue to reduce readmissions and tracheostomy-related complications.

Second Annual Meeting of the International Society of Pediatric Wound Care.

The overarching goals of the International Society of Pediatric Wound Care (ISPeW) are to (1) set global standards for the assessment and treatment of pediatric wounds of varying etiologies; (2) provide a forum for international interprofessional collaboration among healthcare professionals, researchers, educators, and industry leaders dedicated to the care of pediatric wounds; (3) promote and support clinical research focused on the prevention, assessment, and treatment of pediatric wounds; (4) collaborate with wound care organizations worldwide on pediatric wound care issues; and (5) provide evidence-based pediatric wound care education to healthcare professionals, parents, and lay caregivers. This edition of Advances in Wound Care includes some of the work that was presented at the 2014 ISPeW meeting in Rome. The first article by Dr. Romanelli, is an in-depth description of the progression of skin physiology throughout its maturational stages and clinical implication. A cutting edge article by Dr. Timothy King then follows, with regard to scar prevention in postnatal tissues. This is followed by a comprehensive look at debridement techniques in pediatric trauma by Dr. Ankush Gosain. Next, is a cautionary article by Dr. Luca Spazzapan that examines the prevalence of diabetic foot ulcers in children and the potential for an epidemic. The last article in this series is from the keynote speaker, Dr. Amit Geffen, who eloquently examines the use of biomaterials to offload and prevent pediatric pressure ulcers.

Surgical treatment of low rectal cancers with APER and IGAP flap.

This article describes current treatments for individuals with a low rectal cancer. It examines the rationale for surgical treatment involving abdominoperineal excision of the anus and rectum (APER) and outlines how surgery for rectal cancer has evolved over recent years. Surgical advances mean the use of regional flaps is advocated to overcome the common problem of impaired perineal wound healing and the principles of this surgery are summarised. Postoperative nursing considerations relating to the inferior gluteal artery perforator (IGAP) flap will be discussed, as well as the importance of scrupulous wound care and patient education. The implications of this form of surgery on a patient's recovery and discharge planning are also explored.

Do midwives see caesarean section wound care education as a need?

With the current caesarean section (CS) rate at 25% for England, delivering postnatal wound care is a common element of the midwife's role. Anecdotal evidence suggested CS wound care education was a need within the Trust's midwifery service. A questionnaire was used to investigate midwives' views and the need for education in relation to CS wound care. The results confirm midwives do see wound care education as a need. For the first time, information is available on the topics midwives feel should be the focus of such education and useful methods of delivering it. This information can be used to develop a wound care education package to address midwives' learning needs in this area.