Skip to content

Posts from the ‘Featured Articles’ Category

Words Matter: Sex and Gender


The current featured article in ANS is titled “Words Matter: Sex and Gender as Unique Variables in Research” authored by John R. Blakeman, MSN, RN, PCCN-K, who completed his PhD degree earlier this year! Download this article at no cost while it is featured – it is accredited for Continuing Education and you can access the CE test on the ANS website to receive credit! Here is a message from Dr. Blakeman about this work:

The impetus for this paper can be traced back to a conversation I had with several of my friends about two and a half years ago, when I was still a PhD student.  We were all sitting around a campfire and discussing a wide array of topics.  At one point during the conversation, a friend of mine noted that she was excited to be attending a “gender reveal party” for one of her friends the following weekend.  At that point, another friend asked, “I wonder why they call them ‘gender’ reveal parties and not ‘sex’ reveal parties, since we find out the baby’s sex and not their gender?”  And that is when the conversation became very interesting  What followed was confusion and division among the group.  

Some of us had a solid understanding of the differences between sex and gender – the idea that biologic sex is really about the 23rd chromosome’s configuration and that gender is socially constructed and variable from society to society.  However, others viewed and used the terms sex and gender interchangeably.  We debated the necessity of these two terms and the importance of distinguishing them.  A few of my friends even admitted that they preferred to use the term gender because it seemed less offensive than the word sex.

Of course, this discussion with my friends led me to develop this paper.  After I left the celebration that night, I began to think about the nursing literature.  How do nurses use the terms sex and gender?  Do we use these terms correctly?  Do we even give these two terms a second thought when designing a study?  As I read several journal articles, I realized that many authors had used the terms sex and gender synonymously and that there was not great clarity in the nursing literature.  As a result, I decided to write a paper that would specifically highlight this issue.

Indeed, measuring and operationalizing sex and gender can present a number of challenges as noted in the manuscript.  There are sometimes more questions than answers, and I certainly do not purport to have all of the answers.  However, I hope that this paper stimulates thought and critical reflection among nurse scientists.  This paper is meant to serve as an initial stimulus for discussion and action.  I hope that we, as nurse scientists, can continue to refine our thinking on this issue and do our best to incorporate these two variables precisely in the research and theoretical work that we conduct. 

 

Visual Elicitation in Applied Qualitative Health Research


The first featured article for the newly published ANS Vol 43:3 is titled “Visual Elicitation: Methods for Enhancing the Quality and Depth of Interview Data in Applied Qualitative Health Research” authored by Elizabeth R. Orr, MSc; Marilyn Ballantyne, PhD; Andrea Gonzalez, PhD and Susan M. Jack, PhD. We invite you to access this article at no charge while it is featured! Here is a message from Elizabeth Orr about this work!

Elizabeth Orr

Reaching the stage of data collection or generation is often a momentous occasion in the life of a research project. It follows long hours of planning and revising study protocols, completing ethical review and the frequently arduous task of participant recruitment. So how do you ensure this stage of research is meaningful and productive? What factors threaten to derail this stage of your project and what strategies can be adopted to mitigate this risk? These were the driving questions behind my exploration of arts-based research methods and the decision to incorporate visual elicitation strategies into my study exploring the transition home from NICU for adolescent mothers.

Using my PhD project – the NICU-to-Home Transitions study – as a study example, this article focuses on the operational or ‘how to’ aspects of incorporating visual elicitation tools or tasks within a semi-structured qualitative interview for the purpose of generating rich qualitative data. The considerations for planning and execution described in this article represent the deliberations that guided my adoption of these methods; however because they are presented as general strategies they can be applied broadly across study populations and contexts – particularly when factors such as power differentials or developmental processes threaten achieving the depth or detail required for the selected study design.

Generating rich, in-depth data and thus saving valuable time and resources was the impetus for exploring innovative approaches to qualitative interviews and the incorporation visual elicitation into my study protocol. However, the reason I will consider such activities in future studies – in addition to their contribution to rich and detailed interview data – is the value and meaning such tasks can have for the research participant (this was neither anticipated nor planned for). When a parent-participant asked me to keep their drawings so they could continue adding to them beyond the interview encounter I realized the methods I had carefully chosen – albeit for a different purpose – were meaningful for the participants in a way that would not be possible through semi-structured interviewing alone. It is my hope that with the clear guidance given in this article for the use of visual elicitation in qualitative data generation, that others will explore, adopt and experience the possibilities these methods hold.

Social Capital


Our latest featured article is titled “Social Capital: A Concept Analysis” authored by Kristi K. Westphaln, PhD, RN, CPNP-PC; Eileen K. Fry-Bowers, PhD, JD, RN, CPNP, FAAN; and Jane M. Georges, PhD, RN. I join the authors to invite you to download this article while it is featured, and return here to share your comments. This is a message from Dr. Westphain giving background about this work:

Kristi Westphaln

Social capital is broadly defined as the resources obtained via social membership and engagement. I first encountered it in the “life lab” during a health care mission in Tachloban City in the Philippines, where I helped care for survivors of Hurricane Yolanda. This was my first experience with international disaster relief and I wasn’t sure what to expect in terms of how the people were coping with such devastating losses. I became friends with a young woman who shared her story of how three tsunami waves unexpectedly swept her out of her home. She told me that the tsunami scene from “The Impossible” was authentic. And, how she was the only person in her family to survive. Another young man recalled how he had to cling to a pole for 4 hours to prevent being washed away by the storm; he vividly remembered bodies floating by as he held on for his life. Almost everyone I met had lost homes, beloved family members, and/or friends to the storm. Despite this, people didn’t want to solely talk about the trauma they experienced. Many of their narratives were centered within the context of how their community came together to take care of each other. They found homes for the homeless, cleaned the debris, attended church, and found ways to make each other laugh. It seemed to extend beyond resilience or coping.

This concept analysis emerged from a desire to better understand how membership and interactions within social networks foster individual and collective capacity. Some of the shared themes across the literature on social capital from multiple disciplines include a socioecological perspective (most frequently at the community level), an asset-based philosophy, structural and functional dimensions, and benefits/rewards for membership and participation within social networks. Given that nurses frequently interact on the front lines of patient care while also navigating the complex connections among individuals, families, and the health care system; this manuscript focuses on the definition and uses of social capital within the discipline of nursing.

The operational definition derived from this analysis was consistent with definitions used within the literature from multiple other disciplines. Dissimilar to the literature from other disciplines, the most common themes at the intersection of social capital and nursing were the nursing workforce and workplace (hospital settings) rather than involving patient- or community-oriented applications. I’m optimistic for further investigation on how nursing and social capital contribute to optimizing public health. Relational aspects of health are often difficult to articulate and measure, however they represent important foundations for growth, development, and sustainability from individual people to entire populations.

Mutuality in Caregiving


ANS is currently featuring the article titled “Family Caregiver-Receiver Mutuality: A Concept Analysis” authored by Brennan P. Streck, MSN, RN, CNE; Diane Wind Wardell, PhD, RN, WHNP-BC and Geri LoBiondo Wood, PhD, RN, FAAN. We invite you to download this article at no cost while it is featured, and share your comments here! Brennan Streck shared this background information about this work for ANS blog readers!

This concept analysis came to be after I dove into the literature on caregiver-patient (often called caregiver-receiver, as in this paper) dyads. I am an oncology/stem cell transplant nurse by training. Anecdotally, my nursing and medical colleagues noticed that our patients with positive reflections of their caregivers and those who seem to have stable, fruitful relationships tended to have better outcomes. This phenomenon is well documented in the literature; many studies have found that social support is an integral part of healing. Thus, caregiver research has become more popular over the last decade or so. Caregivers are being considered for their potential role in patient outcomes now more than ever. Studies are evaluating whether some characteristics (either those that make up the caregiver or patient as individuals, or those which are dyadic in nature) are associated with better health outcomes.

At the top of the list of characteristics that may prove important is the obvious: the dyadic relationship. As nurses, we often witness the nuances of our patients’ personal lives. We sometimes notice when patients seem to have strong support systems while others do not, and when some patients and their caregivers have healthy/bonded relationships while others’ are tumultuous. In the ideal case scenario, a sick patient would recruit a caregiver to help them get through an illness. The relationship between patient and caregiver should benefit both people; it should be mutualistic. When it isn’t mutualistic, the relationship suffers, which can ultimately affect the health of both involved individuals. There is a term that describes the mutualistic relationship between patients and caregivers. I came across this term a few times while researching the phenomenon of the patient-caregiver relationship. That term was mutuality.

I decided to perform a concept analysis on mutuality because it is, for lack of a better explanation, a rather “flowery” concept. Many people may not truly know what it means, because it is a rather altruistic term that lives in a metaphysical space. However, if mutuality could be clearly and succinctly defined, then the odds of inclusion in future studies would be improved, and we (the research community) would reap the benefits of understanding how mutuality impacts dyadic relationships.

I’m passionate about its inclusion in future research because I think it may be an important concept for dyadic frameworks, and despite having a psychometric scale already developed to measure it, it had never been properly defined. Thus, I performed a wide concept analysis by sifting through interdisciplinary literature, categorizing definitions and attributes, and ultimately arriving at an empirically-supported definition. In doing so, I hoped I could highlight mutuality as a concept for inclusion in caregiver-receiver studies.

Patient and Informal Caregiver Participation in Research (PAICPAIR) Part 1


The current featured ANS article is titled “Patient and Informal Caregiver Participation in Research (PAICPAIR) Part 1” The authors are PhD. candidate Katrine Staats, Professor Ellen Karine Grov, Professor Bettina Husebø, and Postdoctoral fellow Oscar Tranvåg. In this inventive article, the authors presents a framework for Patient and Informal Caregiver Participation In Research (PAICPAIR) — creating a stronger foundation for democracy, equality and research quality by promoting the active participation of vulnerable people with incurable life-threatening illness, as co-researchers. You can access this open access article anytime at no cost; we welcome your comments and responses!

Establishing research collaboration with vulnerable human beings implies ethical challenges and considerations. We do however believe it is unethically not to include patients and their informal caregivers as co-researchers solely based on vulnerability. Little attention is paid to how vulnerable people, living with incurable life-threatening illness, and their informal caregiver, actively can participate as co-researchers.

In this work, we present the first paper of two presenting the PAICPAIR framework for Patient and Informal Caregiver Participation in Research. The framework is founded on learnings from research collaboration with a patient and two informal caregivers experiencing incurable, life-threatening illness − participating as our co-researchers in the ‘Dying with dignity-project’. We describe and discuss crucial aspects of the first part of this research collaboration; how we constituted and developed a formal research collaboration, and how we supported and empowered the co-researchers during the initial stages while developing study aim, research questions, interview guides and letters of information.

From the early stages of the research process we have implemented a thorough collaboration with patients and informal caregivers – as partners of our research team. We acknowledge them as experts of the subject under investigation, making their contributions and unique competence of great value to all phases of the research process. These patient and informal caregivers,representing a large group of people experiencing incurable life-threatening illness, are seated in the projects’ advisory board as well as the steering group. Regularly scheduled planning sessions, plus systematic follow-up phone calls, helps ensure that the project receives adequate consideration from our co-researchers in all phases of the the research project. A strong working relationship of professional researchers and patient and informal caregiver co-researchers, has been a vital foundation throughout the PAICPAIR process thus far. And in this series of research actions a continous awareness of their potential vulnerability is highlighted while placing us as a team at the center of our methodolgical approach.

Learning experiences from the second and conclusive part of the PAICPAIR process will be published in a later article (PAICPAIR framework part 2) − a description and critical discussion of the PAICPAIR process of data analysis, formulating and developing a plan for disseminating of study results – and how we as a research team implement it into practice.

About the Authors

Katrine Staats

Katrine Staats is MSc, oncology nurse, PhD candidate, Centre for Elderly and Nursing Home Medicine, Department of Global Public Health and Primary Care, University of Bergen, Norway.

 

 

Ellen Karine Grov

Ellen Karine Grov is Professor, Institute of Nursing and Health Promotion, Oslo Metropolitan University, Norway.

 

 

 

 

Bettina Husebø

 

is Professor, Centre for Elderly and Nursing Home Medicine, Department of Global Public Health and Primary Care, University of Bergen, Norway.

 

 

 

Oscar Tranvåg

Oscar Tranvåg is Postdoctoral fellow, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway, and; Norwegian National Advisory Unit on Women’s Health, Oslo University Hospital, Rikshospitalet, Norway.

 

Weight Stigma in Pregnancy


Rachel Dieterich

The current ANS featured article is titled “Weight Stigma Related to
Pregnancy: A Concept Analysis
” by Rachel Dieterich, MSN, RN; Jill Demirci, PhD, RN, IBCLC and Cynthia Danford, PhD, RN, PNP-BC, CPNP-PC. While this is featured, we invite you to download it at no cost, and share your comments here. Here is a message that Ms. Dietrich has shared for our readers:

As a first year nursing PhD student at the University of Pittsburgh, I found myself knee-deep in the literature, investigating any and everything I could related to maternal body weight and breastfeeding outcomes, and how these two were related. I learned about the physiological relationship, such as the association between excess maternal adipose tissue and delayed lactogenesis II. As I delved more into this topic, I discovered that women with pre-pregnancy overweight or obesity have very poor breastfeeding outcomes compared to women without overweight or obesity. I had a feeling that these breastfeeding disparities may be attributed to more than just hormones and physiology.

Through my time sifting through the literature, I found numerous qualitative research studies detailing a wide range of psychosocial breastfeeding barriers experienced by women with higher body weight, including feeling uncomfortable and embarrassed breastfeeding around others or in public. I was in a rabbit hole – as they say. I then found several other qualitative studies interviewing obese women about their experiences interacting with their obstetric providers. The consensus was this: women with pre-pregnancy overweight or obesity often feel stigmatized, vulnerable, and judged when interacting with their obstetric healthcare professionals based her weight. In fact, one study found that midwives admitted to making negative judgments about a pregnant patient’s character or intelligence if she was obese. I was on to something. Has anyone examined this concept of weight stigma in relation to pregnancy before?

In my second semester of my PhD program, I took a course that challenged us to develop a concept analysis paper for our phenomenon of interest, the topic we would most likely conduct our dissertation research about. For me, the choice was easy. I chose to write a concept analysis on weight stigma related to pregnancy. I found that there was no definition or investigation into this concept and I felt the need to fill this gap to bring awareness to this ugly and unfortunate reality that some pregnant women are currently facing. It is my hope that through this article, nurses and other healthcare professionals will become more aware of the existence and consequences of weight stigma in the obstetric setting.

Currently, I am conducting my dissertation study, “The Relationship between Perinatal Weight Stigma and Breastfeeding Outcomes.” The development and publication of this concept analysis manuscript has been pivotal in the operationalization and development of my dissertation study data collection measures. In my future work, I aim to investigate how maternal race and ethnicity may influence the relationship between weight stigma and breastfeeding outcomes.

Beyond Resilience to Human Flourishing


The ANS article we are currently featuring is titled “Beyond Resilience: A Concept Analysis of Human Flourishing in Adolescents and Young Adults With Cancer” authored by Eunji Cho, MSN, RN and Sharron L. Docherty, PhD, PNP, FAAN. While the article is featured you can download and read it at no cost, and we invite you to return here to share your comments and questions. This is the message that Ms. Cho sent about this work:

This paper is a part of my doctoral dissertation about human flourishing in adolescents and young adults (AYAs) with cancer, exploring positive growth and the maximum potential of young cancer survivors who were diagnosed with cancer during adolescence. Being diagnosed with cancer during adolescence is a life-challenging experience. AYAs with cancer confront the unique developmental tasks of their age groups while dealing with a range of challenges related to cancer and its treatment. Despite the unexpected, challenging impact of cancer, a unique cohort of AYAs with cancer has shown exceptionally positive growth across the turbulent period of cancer treatment and entry into survivorship. This small group of AYAs shows the ability to move beyond the period of distress and suffering to emerge and live a high-quality life. They find meaning in their cancer experience, perceive the world positively, and use adversity as an opportunity to improve relationships with others and to aid others in suffering. Understanding these positive outliers may inform how healthcare professionals can provide adequate, age-appropriate care for this vulnerable population that is so full of potential.

Our study examines the unique attributes of those special AYAs with cancer and their maximum favorable growth and development by applying a developing concept, human flourishing. Human flourishing, a life-long process to achieve “uniqueness, dignity, diversity, freedom, happiness, and holistic well-being of the individual” (National League for Nursing, 2014, p. 1), can work as an excellent target for healthcare that addresses the unique needs of this population. However, the concept of human flourishing has received scant attention in the field of pediatric and young adult oncology, and has been applied in a very limited fashion to AYAs with cancer. The primary aim of this study is to conduct an evolutionary concept analysis to describe the history and current usage of human flourishing in various disciplines, and analyze human flourishing and its related concepts in the AYA oncology literature.
We present three antecedents (i.e., the situational conditions that precede the concept); seven attributes (i.e., the critical characteristics of the concept); and three consequences (i.e., the outcomes, conditions, or situations that follow the concept). The figure below  shows a metaphor of an apple tree, describing the characteristics of human flourishing in this population.

In this study, we can describe human flourishing in AYAs with cancer as the highest positive state that AYAs can attain, and also a continuous, life-long, self-driven process and methods for reaching this heightened state. As human flourishing is a process that continues throughout life, the consequences can become antecedents as well as attributes of human flourishing in the ongoing process. The individual characteristics and resources that have been fortified during an AYA’s past encounter triggering events such as cancer diagnosis. The direct and indirect experiences associated with cancer diagnosis and treatment during the unique developmental period create a strong foundation and new opportunities for growth. By achieving positive intrapersonal changes and interacting and engaging with others or with the external environment, a flourishing AYA positively influences others (and even trigger flourishing in others), lives a truly owned life, and achieves ongoing harmonious development with their environment.

National League for Nursing (2014) claimed that nurses can guide individuals’ journey of self-actualization and fulfillment and help them to recover or develop pathways to human flourishing by providing individualized, holistic, culturally tailored, relationship-focused care. It is evident that this concept can be applied as a health care goal for a range of populations with health care challenges, including AYAs with cancer. Our next studies will focus on further exploration of human flourishing in this population and develop various methods to apply this concept to nursing practice, education, and policy.

Living with End-State Renal Disease


The current ANS featured article is titled “Existential Contradictions in
Living With End-Stage Renal Disease: A Qualitative Metasynthesis
” authored by Ingrid Villadsen Kristensen, MScN; Jette Henriksen, PhD, MScN;
Regner Birkelund, PhD, Dr Phil, MScN; Annelise Norlyk, PhD, MScN. Here is a message the Ms. Kristensen sent about this work!

This article presents a study, which is a part of a phd study, that encompasses the entity of investigating the existential experiences of living with end-stage renal disease and undergoing a kidney transplantation with a living donor.

Ingrid Villadsen Kristensen

The title of the phd dissertation is “Living with ambivalence while facing the future: The existential experiences of patients living with end-stage renal disease before and after a kidney transplantation with a living donor”. Besides the qualitative metasynthesis, the phd study includes two empirical studies conducted in the tradition of Ricoeur’s theory of narration and interpretation. The dissertation has been accepted for defense by the Faculty of Health at Aarhus University, Denmark, and defended May 27, 2020.

My supervisors during my phd studies are co-authors in this article: Main supervisor Annelise Norlyk, RN, Associate professor, Study Director, PhD, MScN, Research Unit for Nursing and Health Care, Department of Public Health, Aarhus University; Co-supervisor Regner Birkelund, RN, Professor, PhD, dr. Phil, MScN, Lillebaelt Hospital, Vejle & Institute of Regional Health Research, University of Southern Denmark and Co-supervisor Jette Henriksen, RN, Senior lecturer, PhD, MScN, VIA Nursing, VIA University College.

The qualitative metasynthesis conducted in this article follows parts of ‘Handbook for Synthesizing Qualitative Research’, where qualitative metasynthesis is amplified by two American nursing researchers, Margarete Sandelowski & Julie Barroso. Living with end-stage renal disease is anchored in complexity, and to reach profound knowledge concerning the experiences of living with end-stage renal disease, we conducted this qualitative metasynthesis.

Kidney transplantation is a well-established treatment for end-stage renal disease. Simultaneously, kidney transplantations with a living donor are increasing in number. However, patients experience challenging existential aspects concerning kidney transplantation. Furthermore, some patients have the possibility to undergo transplantation with a living donor, while others may have to wait for a deceased donor for several years. As not all patients living with end-stage renal disease are eligible for a kidney transplantation, some patients will be in need of dialysis. This qualitative metasynthesis following Sandelowski and Barroso’s method, therefore investigates the existential experiences of living with end-stage renal diasease.

The key findings of the study show that living with end-stage renal disease challenges patients existentially; as the lives of patients consist of existential contradictions characterized by different types of oscillations. ‘Oscillation’ symbolises moving back and forth without getting anywhere, passing from one condition to another. Hereby, being in a state of oscillation is challenging for patients, and it highlights the existential characteristics of living with end-stage renal disease:

The findings in the qualitative metasynthesis show that technology plays a major part in the lives of patients living with end-stage renal disease. Time is an important issue. Besides, we found that dialysis treatment is an uncertain condition and a long-lasting reminder that life is time-limited. The metasynthesis contributes with new knowledge about how these oscillations are experienced by patients, and illustrates the need to move beyond providing only treatment by prioritizing the existential dimensions experienced by patients.

A New Perspective on Spiritual Care


The latest ANS featured article is titled “A New Perspective on Spiritual
Care: Collaborative Chaplaincy and Nursing Practice
” authored by DorAnne Donesky, PhD, ANP-BC, ACHPN; Emily Sprague, BSN, RN and Denah Joseph, MS, MFT, BCC. In this article the authors explore the domains of religion, spirituality, and culture as commonly conceptualized by chaplains and offer explanations of specialty-level chaplain interventions, primary spiritual interventions provided uniquely by nurses, and interventions that require the cooperation of both professions. Here is a message in which Dr. Donesky describes how this work evolved:

DorAnne Donesky and Denah Joseph

As a nursing professor fascinated by interprofessional education and practice, one day I had the opportunity to shadow palliative care chaplain Denah Joseph as she wen, t about her daily activities. I watched her provide hope and comfort to the patients and loved ones in each room using the language and rituals that were most familiar and reassuring to them. Her therapeutic interventions extended far beyond religious beliefs and addressed existential suffering, relational challenges, cultural misunderstandings, personal legacy and meaning, and psychosocial distress. Recognizing that spirituality is an important part of holistic nursing practice, I asked Denah how she thought we might share her clinical wisdom with the nursing community. In response, she shared with me a document where she listed spiritual interventions she was collecting and testing.

Emily Sprague

Meanwhile, an undergraduate nursing student contacted our graduate nursing school, asking if she might volunteer as a summer research assistant.  Emily Sprague attended a faith-based university and embraced the suggestion that we explore the application of Denah’s knowledge development to nursing practice. Together, Emily and I explored the best way to translate Denah’s knowledge and interventions, developed through the action/reflection methodology common to chaplaincy practice, for practical application to nursing practice.  We were surprised by the conflation of religion and spirituality in the nursing literature, and the recommendation by trusted advisors to focus on ethics rather than spirituality. These experiences reinforced our commitment to explore Denah’s interfaith spirituality interventions from a nursing perspective.

Given the ubiquity of the Religion, Spirituality, and Culture (RSC) model within interfaith chaplaincy practice, we decided to use the RSC model as a theoretical foundation for our paper (see figure in the article). We used exemplar stories based on composite patient experiences to illustrate the spiritual interventions that Denah had developed. Some of the interventions are appropriate for nurses to deliver as “primary spiritual care,” others are only appropriate for chaplains to deliver as “specialty spiritual care,” and we found that some complex spiritual interventions require nurses and chaplains to collaboratively contribute their expertise simultaneously (see table in the article).

The resulting paper has been embraced for interprofessional journal club conversations by nurses and chaplains who want to enhance their collaborative practice. It has been welcomed by chaplains who feel validated in their practice. And it provides a foundation for additional inquiry and interprofessional scholarship within the domains of primary and specialty spiritual care, and the intersection of nursing and chaplaincy collaborative practice.

Nursing in the Anthropocene


At this time of a global pandemic, the currently featured ANS article is especially relevant. In their article titled “We Have Never Been Nurses: Nursing in the Anthropocene, Undoing the Capitalocene,” Jessica Dillard-Wright, MA, MSN, RN, CNM; Jane Hopkins Walsh, MSN, PNP-BC, RN; and Brandon Blaine Brown, MSN, RN-BC, CNL advance a posthuman critique of the discipline and the future shape that is critical for the knowledge in the discipline.  You can download and read the article on the ANS website while it is featured.  The authors have prepared this short video in which they explain their perspective and why it is so important to understanding the experience of this pandemic, to the future of the earth, and to the development of nursing as a discipline.

%d bloggers like this: