What is Parish Nursing?

Senior Seminar 1
Prevention of Congestive Heart Failure Readmission
Marie Marthe Areus
New Jersey City University

Abstract
In the roots of many faith communities are concern for justice, mercy, and the need for spiritual and physical healing. Parish nurse practice has developed in response to unique needs and priorities of the members of faith communities. The appeal for caring, the healing of diseases, and acknowledging periods of illness and wellness are universal. Throughout a major portion of twentieth century, religion played an important role in the lives of many in this country. The implementation of a Parish Nurse program at First French Speaking Baptist Church will provide a necessary cost free resource to empower parishioners by focusing on health promotion and disease prevention. The Unites States health care system is changing, in response to the increased emphasis on economic efficiency. Therefore, Parish nursing do not duplicate community services, but instead collaborate with others to meet unattended needs and enhance health care delivery services to their faith community members. Parish Nurses incorporate a holistic approach towards health by caring for the mind, body and spirit of each individual and acknowledging the connection between faith and health. Primary prevention programs to the Church community, prepare, protect, prevent and empower the members with necessary educations towards building a healthy lifestyle and disease prevention and health promotion.

Proposal for First French Speaking Baptist Church Community Nursing Program
Establishing a Parish Nurse Program
What is Parish Nursing?
There is an old saying, “Don’t go where the path leads, go where there is no path and leave a trail.” Many Parish nurses testify to the truth of this saying as they share many stories of beginning a parish nurse program in their own congregation. The developmental process of such a ministry is unique to each nurse and congregations. Parish nursing is a unique specialized practice of professional nursing that focuses on the promotion of health within the context of the values, beliefs and practices of a faith community, such as a church, synagogue, or mosque, and its mission and ministry to its members (families and individuals), and the community it serves(American Nurses Association [ANA], 1998). The parish nurse philosophy interrogates the wellness model between the body, mind and spirit.
The spiritual dimension is central to the practice of parish nursing. Nursing embodies the physical, psychological, social, and spiritual dimensions of clients into professional practice. These services include: monitoring community health status; mobilizing community partnerships to identify and solve health problems; developing policies and plans that support individual and community health efforts Reference (Chase-Ziolek, 1999). Nursing is a science as well as a profession that is meant to ease suffering, to offer comfort, and most of all to look after the patient’s well-being.
Nursing is a vital key in preventing and assisting in a community’s health care. In the past few decades, a primary focus of nurses has been to coordinate care and to link health care providers, groups, and community resources as the client tries to understand diverse health plans. Nurses are aware of the necessity of collaborative practices and the formation of partnerships to care for groups and individuals throughout the age span. Nurses recognize the need for health promotion and disease prevention at all levels. Furthermore, nurses realized that information and guidance must be available via media, and in residential neighborhoods, faith communities. Parish nurses share these and other important nursing functions as they serve populations through faith communities.
Nursing includes a range of specialties and definitions that varies from country to country. Nursing also includes several other fields of medicine, including the prevention of diseases, caring for, and monitoring as well as advising individual on how to get involved in their personal care in promoting their health. Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all setting, as well as promotion of a safe environment, research, participation in shaping health policy, and education are essential key in nursing role. Nurses uses clinical judgment to protect, promote and optimized health, to prevent illness and injury, alleviate suffering and advocate in health care of individuals, families, communities and population.
Florence Nightingale, possibly the most influential figure in modern nursing, defines nursing (1960) as: “The act of utilizing the environment of the patient to assist him in his recovery”. As such a powerful role model inspire me to discover the love for community nursing, the implementation of a parish nurse program will be a good asset for the church and the community of Asbury Park. The mission is to serve as a Good Samaritan and as a servant to those in need. As Christian and nurses, we are called to help one another as Jesus Christ teaches us from his healing mission through various spiritual and healthcare ministries.
Community Identified Health Needs
During a few interviews with various members of the Asbury Park community and at First French Speaking Baptist Church’s Pastor, where I am an active member, revealed many similarities in responses regarding availability and accessibility of health care in a certain population, these interviews also reflected in the diagnoses of knowledge deficit in regard of their health. One interview was with one of the Asbury Park influential citizen, a physician with an established practice in the community for over 15 years, has witnessed countless health disparities among the Asbury Park Population. Lack of insurance within the minority population was evident in the clients he sees in his practice, of which 40% are African American and Hispanics. Most of the individuals had chronic illnesses experienced by most of the population. Among these illnesses are diabetes, hypertension and Congestive Heart Failure (with a steady increase in cardiovascular risk behaviors when compared to other races.
Another interview was with a community health nurse who serves in the Hispanic population. This nurse is experienced, travelling through Hispanic countries and has familiarity with different cultures. This nurses’ anxiety toward the need for improvement of good health and her strive to create a better social and physical environment for this population was evident in her speech. Most of the client sees are from low-income families that lack health insurance. The elder population seeks medical attention when their symptoms are unmanageable by home remedies. Diabetes, Chronic Obstructive Pulmonary Disease, Hypertension and heart disease are among the chronic illnesses that the factors of health disparities has serves and creates barriers, in achieving good health. This community will definitely benefit from a parish nurse program.
Mission and Goals
The Parish Nursing Ministry project will be implemented at first French Speaking Baptist Church, under the philosophy, norms and regulations of the Church. The Parish Nursing focus is on teaching the church members 60 years and older, and the Asbury Park Community of the importance of complying with their prescribed medication treatment, the program will focus at helping the members make educated lifestyle choices and changes that will promote health and prevent complication. The Parish Nursing reflects the compassionate healing love of Jesus by promoting wellness and preventive health within our Christian community, also by providing the congregation with a reliable resource of primary health care and health-related services, the mission is to build the kingdom of God by serving those in need.
The main goal of the Parish teaching program is to provide the members with the knowledge to be able to make self-directed behavioral changes to improve their overall health and manage their diseases. Learning will be breaking down into small pieces, repetition, inspire, nobody left out, gradually add more, make it fun, achievable steps, Goal to work towards, incentives and celebrate achievements. The Parish Nursing will empower parishioners to reach optimal health by serving as health educators, advocates and resources within our faith community.
How Will Parish Nursing be Supported?
The parish nurses ministry is supported by The Pastor‘s and the church leaders, the pastor provides explanation about the role of a parish nurse as part of a health ministry. There are about 8 registered nurses involved in this program, they will provide teaching and health screening to the members of the church and anyone in the community who comes for help. Minor costs would include:
Locked file cabinet (3 drawers)
Folders and note books
Pens and pencils, white plastic table cloth (disposable)
Blood pressure cuff,
Blood sugar strips (the glucometers are free of charge)
Needle shop disposal
Thermometers and 2 weight scales
Alcohol swab, gauze and gloves
Continental breakfast included with (each health screening meeting)
By including the above mentioned interventions when practicing within the community, parish nurses are promoting healthy lifestyles and encouraging preventative health care both of which are a main focus of Healthy People 2020.
“Healthy People” is a national health agenda developed by the United States Department of Health and Human Services. The revised program was released in December of 2010 and is titled Health People 2020 (Healthy People, 2012). Healthy People 2020, include ten year national objectives for improving the health care of Americans by focusing on prevention and health promotion. One of the goals of this program is to promote quality of life, healthy development and healthy behaviors across all life spans (Healthy People, 2012). To help accomplish this goal parish nurses incorporate a holistic view of each individual by caring for the all aspects of a person’s health, spiritual, emotional and physical within the parish community.
Project Implementation
This Project will: Implement a Parish Nursing Program, at First French Speaking Baptist Church in Asbury Park.
Assess the health needs within the community
Discuss health issues within the Asbury Park Community
Provide holistic care to parishioners by including all aspects of nursing care in daily practice,
spiritual, physical and social.
Promote wellness through educational offerings on health promotion and disease prevention.
Promote empowerment of parishioners living with chronic disease, focusing on quality of life and coping enhancement.
Recruitment of volunteer registered nurses, a total of eight Registered Nurses recruited at First French Speaking Baptist Church for the Parish Program.
The project will consist of a Parish Nurse Program at First French Speaking Baptist Church. This Parish is located at 412 Asbury Avenue Asbury Park New Jersey. The registered nurses involved in this project will be assign the duty to provide educational programs which was developed based on the needs of the faith community and consistent with the religious beliefs of the domination. An assessment will be completed by using a survey and personal interviews through the Church community upon implementation of the program to explore the health needs of the parish community. Prevention and minimization of illness will be the focus of this program. Meeting for the program will take place at the church’s lower level. Approval
obtained from the Pastor to implement the project. A total of 6 workshops running for 1 hour each will be facilitated. Information for the public regarding services and upcoming health topics can be shared through the Sunday News Announcement and “Good News Radio Station” which belongs to the church.
Reflective Log
As a Registered Nurse, I have been practicing nursing for about 12 years; I did not have any formal community health content, during the first nine years of my career, I practiced in the hospital. However, during my nursing journey I develop a passion in practicing parish nurses where I can provides intentional spiritual care to a faith community, First French Speaking Baptist Church in Asbury Park. My mission has been to provide the members of First French Speaking Baptist Church with health information, referrals, support and spiritual intervention.
When thinking about who I was going to educate and what community, there are multiples communities that I could go to, because most of them could benefit to such program, but I have decided to initiate my education in the Asbury Park Community at the First French Speaking Baptist Church where the area of concerns will be on health promotion and illness prevention which will in turn mirrors changes in health care delivery. The Congregation has approximately 600 African American members, one third of the church members are 60 years and older and the majority of those members does not speaks English in particular the older members. They are time when a church member is admitted to the hospital not only I have the duty to be their nurse but also to translate from English to creole as well, so that the church member can have a full understanding of their treatment options while receiving care.
As health care costs and chronic illnesses increase, society ages, and health care moves to the community, a Parish Nursing program will fit perfectly at First French Speaking Baptist Church in Asbury Park community.

Literature Review
Heart Failure Overview
Congestive heart failure (CHF) is a serious problem responsible for one of the highest rates of hospitalization in the United States for any medical condition. Despite advances in medical treatment, the prognosis for patients with chronic heart failure is still poor. Important clinical parameters, such as left ventricular ejection fraction and peak oxygen consumption, have been found to be predictive for the course of chronic heart failure. Coronary artery disease is the most common cause of heart failure and is the number one cause of heart failure in women with predominately systolic dysfunction (Michell, 2005).
Heart failure is a condition in which the heart cannot pump enough blood to the rest of the body. It is often a long-term, chronic condition, but it can sometimes develop suddenly. It can be caused by many different heart problems. The condition may affect only the right side or only the left side of the heart. As the heart’s pumping becomes less effective, blood may back up in other areas of the body; fluid may build up in the lungs, liver, gastrointestinal tract, and the arms and legs. This is called congestive heart failure (Perry & Potter, 1997).
This is a problem that is predominantly noted in the Asbury Park community during the windshield survey. One of the specific places visited, was an Adult Day Care Center located in Asbury Park, where 80% of the seniors were taking some medications prescribed by their physician for heart disease. Besides that, as per a rapid observation, some of the participant’s lower extremities were noted as swollen, with fluid buildup in their ankles and feet. These signs suggest a clear indication that this population needs to be in constant awareness of their health conditions in order to maintain their health and prevent admission and readmission to the hospital. Based on the New Jersey Spotlight News issues, an insight for New Jersey Medicare will soon begin penalizing hospitals for readmitting patients within 30 days of their discharge. As have worked over the past few years to get a grip on this issue, hospitals have come to realize that it takes an entire community to reduce readmission. It is very important to not only prevent readmission but also to provide necessary education with regard to CHF in the communities. This way, complications can be detected and treated early. The vulnerability of readmission heightens in seniors due to other underlying conditions such as: Myocardial infarction, hypertension, diabetes, obesity, high cholesterol levels, damaged valves, smoking, chemotherapy or radiation (Oliff, 2012).
Heart failure is a progressive disease that does not have a cure but has treatment options to help manage the symptoms. The different treatment options can be categorized as lifestyle changes, medical management using pharmaceuticals, and surgical procedures with and without implantable devices. Lifestyle changes such as dietary modification and elimination of smoking can slow the progression. Heart failure will not go away, but it can be managed. Understanding the causes and treatment of heart failure will help the individual affected to carry on with their normal activities. When patients follow the treatment guidelines and report any changes in their physical conditions to their physicians, it may create a major impact on their quality of life. Heart failure symptoms range from mild to severe. Signs and symptoms may include dry, hacking cough, sudden weight gain, shortness of breath at rest or when active, swelling or edema in the ankles, feet, legs or abdomen, less frequent urination, extreme fatigue, loss of appetite, nausea and trouble concentrating (Johns Hopkins Medicine, n.d.).
The care of heart failure is complex and costly to the health care industry. In the United States, it is estimated that over 5.7 million Americans are diagnosed with heart failure with an annual cost to the health care industry of over $33 billion. Insurers’ annual cost of heart failure is estimated at more than $8000 per person per year (Smidt, Balandin, Sigafoos, & Reed, 2009). It is the primary cause of more than 55,000 deaths annually. It contributes to more than 280,000 deaths each year. Approximately half of individuals with heart failure die within five years of diagnosis (Centers for Disease Control and Prevention, 2013).
Therefore, patients benefit from a collaborative health care team that assists with symptom management. The team may consist of the patient’s primary physician, cardiologist, or Nurse Practitioner, physical and occupational therapists, dietitian, mental health professional, pharmacist, and case manager. Patients who understand the subtle signs and symptoms preceding heart failure exacerbation can better communicate with their health care professionals to manage their disease and decrease hospital readmissions.
Comorbidity is directly related to prevalence of heart failure. Diseases such as obesity, hypertension, diabetes, coronary artery disease, substance abuse, and congenital heart disease increase an individual’s risk for developing heart failure. Patients that minimize or manage risk factors by following a healthy diet, managing weight, and following the advice of health care providers reduce the risks. Hypertension is an important risk factor for cardiovascular morbidity and mortality. Hypertension is associated with the development of congestive heart failure by way of left ventricular hypertrophy, with left ventricular dilatation and through myocardial ischemia and left ventricular damage. Reports on the natural history of untreated hypertension indicate that at least 50% of affected subjects develop congestive heart failure (Himmelmann, 1999). The education of patients with or without risk factors is an important role in nursing (National Institutes of Health, 2012).
Despite a growing knowledge base about how to reduce readmissions, heart failure readmission is a concern for organizations because of its relationship with reimbursement reduction. Nearly 50% of heart failure patients are readmitted within six months of discharge. One fifth of Medicare beneficiaries are readmitted within 30 days. This increases costs for organizations and patients, placing an increased burden on the health care industry. An estimated 17 billion dollar cost is associated with unplanned readmissions related to heart failure. This statistic not only suggests the need for change, but also needs to be viewed as the driving force for change to occur (Dunlap & Upper, 2012).
The goal to prevent CHF readmission should be to create awareness through educational programs that focus on behavioral changes in the CHF populations. Also, the integration of nurses and other healthcare providers can reduce congestive heart failure readmission. As a result, the Affordable Care Act is putting systems into place to bundle payments and improve performance. This is forcing organizations to reinvent programs and establish better care for patients, reduce readmissions, cut costs, and improve quality of life for patients (Kim & Hae-Ra, 2013).
Disease management programs are being developed to optimize health care and control costs related to chronic diseases. These interdisciplinary programs emphasize patient education and self-management using evidence-based practice. The goal of these programs is to provide patient support as the patient moves through the gamut of care. Nurses involved in these programs identify patients within the organization, provide education during hospitalization, and ensure that the patient is optimized prior to discharge. Once the patient is discharged, the nurse must provide follow-up by phone to determine patient self-management, compliance with the discharge plan, answer questions, and maintain the link between the patient and provider. Disease management programs in general are nurse driven. They are changing the role of nursing in patient care and redefining health care (DeFelice, Masucci, McLoughlin, Salvatore, Shane, & Wong, 2010).
Telemonitoring programs are being developed by some organizations to manage patients. They use technology to improve communication with patients, collect physiologic data from the patient, and determine patient health status. Patient data is transmitted to the health care team at determined intervals and patients are managed with the goal of avoiding readmission, increasing compliance, and optimizing health (Kim & Hae-Ra, 2013).
In a pilot study conducted by Dobrzanska (2006), indicated that patients readmitted from home versus other sources and patients discharged to home versus other sources had a significantly shorter stay on readmission. The main study showed other significant findings. Patients who lived in care? were readmitted sooner than those who lived at home. Those discharged to home vs. other sources, and agreeing to increased social service provision, had long stays on readmission. A shorter length of stay on index admission up to 72 hours was associated with increased likelihood of earlier readmission. In this study, a framework of factors was identified and could be used to target resources to meet patients’ needs. It is possible that the process of targeting resources to ‘at-risk’ patients might enable services to be delivered in a more cost-efficient and cost-effective way. Overall, the literature concludes that the main cause of readmissions most commonly involves a relapse of an existing illness and that often this relapse may be unavoidable.
Home health care programs offer success in the stabilization of patients and symptom management in patients with heart failure. Nursing visits along with the implementation of services provide patients and families with assistance with managing the home, activities of daily living, and health. Patients are offered a variety of services that optimize living with chronic disease. Nursing home care visits assess patients, provide continuing education and reinforcement with patients and families, and communicate patient’s needs with health care providers (Riggs, Madigan, & Fortinsky, 2011). These programs offer a holistic approach by providing nursing presence in the home. This builds a trusting relationship with the patient and improves outcomes, reduces readmissions, and provides support to families (Anderson, 2007).
The home health nurse must understand Congestive Heart Failure (CHF) to be able to instruct his or her patient on preventing a CHF crisis. The home health nurse must understand that CHF is the most common heart problem in the US in the aging population (Perry & Potter, 1997). The nurse must be able to verbalize/teach what causes CHF, signs and symptoms, when to contact the physician, and related pharmacology. The nurse must be able to comprehend when CHF occurs, when the heart is unable to effectively pump blood throughout the body, secondary to the heart failing as a pump.
According to Mourad & Redelmeier (2006), “Clinician teachers are indispensable to faculties of medicine as they contribute to patient care and medical teaching. The medical profession would have little future without such investments.” The nurse must be able to educate his or her patient on the causes of CHF including heart failure as a result of damage to the heart. The signs and symptoms of CHF must be easily recalled. The nurse must understand the common signs of CHF such as shortness of breath at rest or with activities, a dry hacking cough, and edema to the lower extremities, a slight increase in weight, less frequent urination, and an increase in generalized weakness and fatigue.
Nursing is a vital key in assisting and preventing readmissions in the elderly diagnosed with congestive heart failure, and the Nursing Philosophy of Caring is crucial in this population. The main outcome of a nursing treatment or goal is to prevent readmissions. A nurse simply caring and showing compassion to those patients can educate them on healthy habits. Jean Watson’s Philosophy of Nursing was based on caring instead of curing. She felt that caring would prevail over curing and that caring was not learned but felt. Congestive heart failure and the art of caring directly correlate; those patients cannot be cured, but, in fact, need compassion and caring.
Due to the Medicare reimbursement reduction rate, the home health nurse is given the task of being well educated on CHF and understanding the importance of reducing and preventing the CHF patient from returning to the hospital as a result of uncontrolled CHF. With the increased cost of readmissions, the home health nurse must streamline education for the CHF patients in the community to reduce this cost. This includes medication compliance, following the prescribed low sodium diet, checking daily weights and reporting a weight gain of two or more pounds, and frequent follow up with their physician. It is also important that the home health nurse must understand how CHF is treated including diuretics, vasodilators, Angiotensin Converting Enzyme inhibitors, beta blockers, and anti-lipids, and how each medication affects the body and must educate about signs and symptoms for the patient to report.
These findings confirm that compliance with medication is crucial in reducing the risk of hospital readmission. This important information needs to be conveyed to patients in discharge teaching because the high cost of prescription drugs can create a financial burden for patients and decrease patients’ compliance with their medication regimen. The findings further concluded that referrals to appropriate assistance programs should be a component of discharge planning and home health care.
Most of the workforce today is currently in one of three age groups: those born between 1947 and 1964, also called the baby boomers; those born between 1965 and 1980, referred to by some as the generation ‘X’; those born between 1981 and 1995, sometimes called netgen or generation ‘Y’ (Reeves, 2006). The home health nurses being educated will likely be from one of these three generations. Some research has shown that the baby boomer generation does better with, or prefers, the method of discussion, while the generation ‘X’ group wants a fast-paced technique.
The netgen group does well with fun, interactive, and engaging teaching methods (Reeves, 2006). Armed with this knowledge, the home health nurses will serve their audience well to include in their presentation a variety of instructional techniques that may consist of a brief lecture, discussion, interactive lecture, audiovisual media inclusion, such as the DVD, and case study scenarios. These methods will also motivate the learners by using several senses, reviewing the information through case studies, which actively involves the learner, and making the experience a pleasant one. This information can be carried over to the teaching that is done in the community for the congestive heart failure (CHF) client, as the disease is most prominent in those over 60 years of age (Johns Hopkins Medicine, n.d.).
Research on gender differences in learning are varied and tend to focus on girls and boys in the elementary stages of education. For the adult learner, there is some information that has found that females more so than males may prefer a single mode of information, whereas male students prefer a multimodal type of instruction. The single mode preferred by the females was found to be toward kinesthetic learning, which uses the senses (Wehrwein, Lujan, & DiCarlo, 2007). This can certainly be accomplished via the case study simulation type of learning technique. For the teaching that will be done in the community, it is important to remember that CHF is a disease that does not discriminate between males or females. It is best to have a variety of learning tools to present in order to be sure the client has a full understanding of how they or their loved ones and caregivers may help to manage this disease. Knowledge of their comprehension level and readiness to learn will be of utmost importance in determining how they will be taught.
The adult learning theory of Malcolm Knowles is a method of educating adults in a problem-based format. Adult learning theory places emphasis on the method of learning between the teacher and the learner. The home health nurse must focus on creating change as he or she presents educational material to his or her patient. The home health nurse must accept the fact that his or her skills, behavioral responses, and beliefs must be centered on the individual patient. The home health nurse must understand that his or her knowledge of CHF must increase to be effective and the nurse must be aware of the adult learning principles and adult learning style (Oliff, 2012).
Real life examples will be presented to the home health nurse to ensure he or she understands the importance of teaching the home health patient. This information will be presented in the form of CHF case studies. One targeted case study will be “Heart failure case disease management program: a pilot study of home telemonitoring versus usual care” from Oxford University, (year?) wherein each student will be allowed the opportunity to present information from their experiences with educating the home health patient with CHF.
Many teaching strategies will be used including videos on how the home health visit should be presented. When teaching the patient with CHF, written materials will be provided, and verbal instructions including lecture will be presented, as well as visual teaching aids. The nurse must understand the importance of a daily weight log and copies of a basic weight log will be used for demonstration. A variety of teaching strategies will be used to ensure the entire audience is captured. The educational information will be delivered to the home health nurse using patient specific information. The information will be structured around the CHF patient using multiple teaching strategies.
Formative evaluation involves evaluating student outcomes and curriculum during the education process, while summative evaluation is performed at the end of the administration of knowledge. Both types of evaluation are important for the educator to assess and fine tune curriculum offered, but also to support staff who provide additional assistance or education where needed. The Kirkpatrick Model is a tool that can be utilized to accomplish both formative and summative evaluation (Smidt, Balandin, Sigafoos, & Reed, 2009). This model has four levels of evaluation, including reaction, learning, behavior, and results. Reaction, learning, and behavior all coincide with formative evaluation.
Reaction can be compared to a post-education survey, and does not typically evaluate the program but gives the educator an idea as to what the learner thought of the program. Learning evaluation, the second level, is compared to role playing and or written or skills exercise administered post education; role playing and the written teaching pamphlets can be used for learning evaluation. Behavior evaluation is accomplished by evaluating staff performance in the field and staff documentation. Results are measured by just that; results indicating how the agency is meeting yearly goals, decreasing readmissions, and receiving outcomes based reimbursement.
In conclusion, congestive heart failure is a global problem and continues to remain a public health concern in particular among those aged 65 and over. It is a concern that needs to constantly be addressed. This vulnerable population needs to be provided with proper CHF education, family support and access to healthcare. It is very important for nurses working in home health to understand and learn how to teach patients about early warning signs associated with congestive heart failure. Home health nurses should be cognizant of signs and symptoms, treatments, and patient teachings to patients with CHF to achieve the best outcomes.
Nurses must also be aware that without efficient patient teaching and patient understanding of the seriousness of the chronic condition post-hospitalization, hospital re-admission can occur. Adequate nurse teaching strategies and resources to promote effective teachings to patients with congestive heart failure will enhance patient compliance, well-being and independence. It is imperative that home health nurses are informed on how to teach and manage congestive heart failure. The long-term goals and results would include a positive outcome for the patient and cost containment for the health care agency. These are the positive ways healthcare providers, including nurses, can educate those patients.

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