Characterizing nursing time with patients using computer vision.

BACKGROUND: Compared to other providers, nurses spend more time with patients, but the exact quantity and nature of those interactions remain largely unknown. The purpose of this study was to characterize the interactions of nurses at the bedside using continuous surveillance over a year long period. METHODS: Nurses' time and activity at the bedside were characterized using a device that integrates the use of obfuscated computer vision in combination with a Bluetooth beacon on the nurses' identification badge to track nurses' activities at the bedside. The surveillance device (AUGi) was installed over 37 patient beds in two medical/surgical units in a major urban hospital. Forty-nine nurse users were tracked using the beacon. Data were collected 4/15/19-3/15/20. Statistics were performed to describe nurses' time and activity at the bedside. RESULTS: A total of n = 408,588 interactions were analyzed over 670 shifts, with >1.5 times more interactions during day shifts (n = 247,273) compared to night shifts (n = 161,315); the mean interaction time was 3.34 s longer during nights than days (p < 0.0001). Each nurse had an average of 7.86 (standard deviation [SD] = 10.13) interactions per bed each shift and a mean total interaction time per bed of 9.39 min (SD = 14.16). On average, nurses covered 7.43 beds (SD = 4.03) per shift (day: mean = 7.80 beds/nurse/shift, SD = 3.87; night: mean = 7.07/nurse/shift, SD = 4.17). The mean time per hourly rounding (HR) was 69.5 s (SD = 98.07) and 50.1 s (SD = 56.58) for bedside shift report. DISCUSSION: As far as we are aware, this is the first study to provide continuous surveillance of nurse activities at the bedside over a year long period, 24 h/day, 7 days/week. We detected that nurses spend less than 1 min giving report at the bedside, and this is only completed 20.7% of the time. Additionally, hourly rounding was completed only 52.9% of the time and nurses spent only 9 min total with each patient per shift. Further study is needed to detect whether there is an optimal timing or duration of interactions to improve patient outcomes. CLINICAL RELEVANCE: Nursing time with the patient has been shown to improve patient outcomes but precise information about how much time nurses spend with patients has been heretofore unknown. By understanding minute-by-minute activities at the bedside over a full year, we provide a full picture of nursing activity; this can be used in the future to determine how these activities affect patient outcomes.

Assessing the Potential of Technology to Describe Resident and Staff Interactions in Assisted Living Facilities.

PURPOSE: Falls are a significant financial burden and health hazard for residents in assisted living facilities (ALFs). However, limited capacity to observe residents has hindered understanding of resident-staff interactions within rooms. The current study aimed to describe nurse-resident interactions using data from a remote technology combining computer vision and staff location tracking. METHOD: Eighty-three staff working at an urban ALF with 215 residents were trained at the initiation of the study. Remote surveillance devices were installed in 32 residences and staff and resident interactions were tracked over 170 days. RESULTS: Staff visited residents an average of 20.7 times per day for short durations (mean = 1.08 minutes). Urgent alert response times averaged 3.0 minutes, with faster response times through the mobile application (mean = 2.7 minutes) compared to in-person (mean = 3.3 minutes) response. CONCLUSION: By better understanding staff activity patterns in ALFs, this study has the potential to improve fall prevention and care for residents in ALFs. [Journal of Gerontological Nursing, 50(7), 7-11.].

Experiences of women with physical disabilities accessing prenatal care in low- and middle-income countries.

INTRODUCTION: Women with physical disabilities experience barriers to accessing patient-centered and accommodative care during the prenatal and childbirth periods. While there is a growing body of work in high-income countries to address these needs, there is little research detailing specific challenges in low- and middle-income countries (LMICs) where a woman's' burden- and need-is greatest. METHODS: We conducted an integrative review to synthesize the experiences of women with physical disabilities accessing prenatal care and childbirth services in LMICs. Five databases were searched for systematic reviews, retrospective cohort studies, cross-sectional studies, narrative literature reviews, as well as other evidence types. We used Ediom's EvidenceEngine™, a machine-assisted search engine that uses artificial intelligence to conduct this search using pertinent keywords to identify original research published between January 2009 - September 2018. These results were augmented by hand searching of reference lists. Forty articles were identified using this method and 11 retained after duplicates were removed and inclusion and exclusion criteria applied. RESULTS: Four types of experiences are described in these 11 studies: (1) limited physical and material resources; (2) health care worker knowledge, attitudes, and skills; (3) pregnant people's knowledge; and (4) public stigma and ignorance. DISCUSSION: People with physical disabilities face specific challenges during pregnancy and childbirth. Importantly, these findings offer targets for enhanced clinical training for nurses, midwives, traditional birth attendants and public health workers, as well as opportunities for the improved delivery of prenatal care and childbirth services to these vulnerable women.

Symptom management in Chinese adults with end stage renal disease (ESRD).

BACKGROUND: With over $50 billion spent annually in the United Sates (U.S.) on patients with chronic kidney diseases, and an incidence of end-stage renal disease (ESRD) in Asian Americans that is 1.5 times higher than in Caucasians, there is a compelling need to improve symptom management strategies for this population. AIMS: 1) To identify common, bothersome symptoms and both Eastern and Western symptom-management strategies in older Chinese-American ESRD patients. 2) To validate the effectiveness of these symptom-management strategies through literature review and an expert panel. METHODS: 1) Older Chinese-Americans were surveyed to assess common ESRD symptoms and management strategies. 2) An umbrella review of patients' symptom-management strategies was conducted, and findings were confirmed by experts. RESULTS: 1) Thirty Chinese-American ESRD patients with an average age of 80 (SD = 13.08) reported strategies to manage fatigue, pain, sleep disturbance, dyspnea, anxiety, nausea and vomiting, constipation, and pruritus. 2) A total of 55 studies were included in the umbrella review. Evidence of varying quality and confirmation by experts supported the effectiveness of 33 symptom-management strategies used by Chinese-American ESRD patients. CONCLUSION: Further study is needed to understand why Chinese-American patients, on average, reported fewer symptoms compared with the general population but scored lower on quality of life measures; to validate reported amelioration strategies; to explore strategy effectiveness; and to uncover additional symptoms and strategies among older Chinese-Americans living with ESRD.

A Study Looking at a Lower Cost Option for Cultural Competence Education.

To meet the growing demands in the US healthcare system caused by multiculturalism and the expansion of health inequities, due diligence must be given to testing the efficacy of tools used in teaching nurses to provide culturally competent care. This project assessed the utility of a free US government-developed training module. The team found an improved trend in nurse-patient communication scores and improved willingness to ask for help with cultural issues for the intervention unit. The use of no-cost, publicly available resources may be a cost-effective option for training materials.

Exploring Practices of Bedside Shift Report and Hourly Rounding. Is There an Impact on Patient Falls?

OBJECTIVE: To describe the relationship of inpatient falls to bedside shift report (BSR) and hourly rounding (HR). BACKGROUND: Falls are a major healthcare concern. Although measures such as BSR and HR are reported to reduce falls, studies are often based on self-reported data related to nurse compliance with protocols for HR and bedside report. METHODS: Observational data were collected on nursing tasks, including BSR and HR. RESULTS: Nine thousand six hundred ninety-three observations were recorded on 11 units at 4 hospitals over 281 shifts. Falls were associated with shift and day of the week but not BSR, HR, or the frequency of encounters with the patient. The regression model included frequency with patient, shift, day of week, and HR. CONCLUSIONS: Increased nurse frequency with patient may signal increased fall risks. Bedside shift report and HR may require robust and sustained interventions to provide lasting effects.

Evaluation of the joint nurse scientist role across academia and practice.

BACKGROUND: Mapped with the guiding principles of academic-practice partnerships (APPs) outlined by the American Association of Colleges of Nursing and the American Organization for Nursing Leadership, a joint nurse scientist role between a nursing school and acute care facility at a large academic health center was developed and characterized by a PhD-prepared nurse appointed in a research role across organizations. To date, eight faculty are now appointed across the School and four health systems. PURPOSE: Describe outcomes, facilitators and vulnerabilities of the joint nurse scientist role. METHODS: Review of administrative records. DISCUSSION: Outcomes include the 1) conduct and dissemination of joint research, 2) translation of evidence into practice, 3) development of educational programs for health system nurses, 4) scholarly activities among health system nurses, and 5) improved visibility and valuation of the PhD-prepared nurse. Role facilitators include those previously reported for APPs, the joint nurse scientists' ability to broker opportunities across settings, and the evolving nature of the role. Role vulnerabilities pertain to the negotiation of workload, promotion, and institutional priorities. CONCLUSION: The joint nurse scientist role fosters shared scholarly successes across academia and service.

Using a Delphi Survey to Develop Clinical Nursing Research Priorities Among Nursing Management.

OBJECTIVE: The aim of this study was to identify clinical nursing research priorities among nurse managers (NMs). BACKGROUND: Determining research priorities is the 1st step toward building a solid evidence base for clinical practice. NMs are well poised to identify research priorities, and yet, a literature review revealed a dearth of research priorities as determined by clinical NMs. METHODS: Using a Delphi survey, 38 NMs were queried at a large, urban hospital regarding critical priorities for nursing research. RESULTS: Critical priorities for clinical nursing research included nursing workforce/nursing workflow and communication (categorized as critical by 68% and 53% of NMs, respectively). Other important priorities focused on falls/patient safety/hospital-acquired infections, patient/family satisfaction, emergency preparedness, patient outcomes, and collaboration/interdisciplinary research. CONCLUSIONS: Because NMs are positioned to direct clinical research agendas, the results provide a critical guide for policy development surrounding nursing research. Directing research toward these identified topics will help build a solid evidence base for nurses and ultimately improve patient outcomes.

Linking to Improve Nursing Care and Knowledge: Evaluation of an Initiative to Provide Research Support to Clinical Nurses.

OBJECTIVES: The aim of this study is to describe and evaluate the impact of the Linking to Improve Nursing Care and Knowledge (LINK) project on increasing nurse-led clinical research. BACKGROUND: Nurse-generated research is the cornerstone of evidence-based practice and continues to be a marker of nursing excellence. However, the dearth of PhD-prepared nurses creates a challenge for creating an environment to promote clinical nursing research. We evaluated the LINK project, an academic-clinical partnership, to assess its impact and feasibility, for fostering nurse-led clinical research. METHODS: The LINK project created a formal command and control structure bringing together existing academic resources, including a PhD-prepared nurse researcher, a biostatistician, and a development of a formal research consultation request process. Measures tracked over a 12-month period included average response time, request volume, client satisfaction, institutional review board (IRB)-submitted protocols, and work products. RESULTS: All measures exceeded expectations with an average 1-day request response time, 35 requests, 98% client satisfaction, a 367% increase in nurse-led IRB approved protocols from the previous 12-month period, and 2 publications in peer-reviewed journals. CONCLUSIONS: The process and outcome measures indicate that the LINK project is feasible, sustainable, and reproducible. We were able to meet and, in many cases, exceed measurement goals. In addition, implementation science literature indicates that the most valid measure of a successful project rollout is user satisfaction and usefulness. The LINK project received consistently positive feedback.

Promoting nursing research globally: the writing to improve nursing science (WINS) program.

AIM: To test the feasibility of a remote writing programme, Writing to Improve Nursing Science (WINS), for nursing scholars in low- and middle-income countries and assess its impact on scholarly writing and dissemination. BACKGROUND: The ability to write and publish scholarly manuscripts is critical for successful nursing research careers. Yet, there is a lack of resources to appropriately mentor nurse scholars in this area. This is especially true for low- and middle-income countries with fewer resources and a dearth of doctorally prepared nursing faculty. INTRODUCTION: We adapted an existing university-based writing class to mentor 10 nurse scientists through the writing and publication process utilizing three components: online didactic training, remote one-to-one mentorship and an in-person peer-reviewed writing workshop. METHODS: Ten nurse faculty from 10 countries selected via competitive application developed manuscripts with remote mentorship and online training for 6 months. Then, an in-person workshop was held to conduct peer reviews of manuscripts. Mentorship continued for an additional year until the manuscript was either published or the participant no longer wished to pursue publication. RESULTS: All participants prepared a manuscript and were trained in manuscript writing, editing, and the peer review and submission process. To date, four manuscripts have been published. DISCUSSION: The Writing to Improve Nursing Science Program is a feasible model to increase publications among nursing faculty or students globally and allow the sharing of resources across countries. CONCLUSION AND IMPLICATIONS FOR NURSING POLICY: Innovative solutions for sharing of intellectual resources, such as this program may contribute to improving the evidence base globally. Nursing research policies should include a mentorship component to increase publications to improve nursing practice and related patient outcomes.

Delphi Survey of Clinical Nursing and Midwifery Research Priorities in the Eastern Mediterranean Region.

PURPOSE: As the shortage of nurses and midwives is expected to worsen in the Eastern Mediterranean region concomitantly with a growing focus on achievement of universal health coverage, nurses and midwives are expected to fill major gaps in health care. Hence, the need for a solid evidence base for nursing practice and a clear direction for clinical nursing research are paramount. Therefore, a Delphi survey was conducted to determine clinical (research focused on patient outcomes) nursing and midwifery priorities for research within this region. DESIGN: A Delphi survey, using iterative rounds of an online survey of regional clinical nursing and midwifery research experts, was conducted between January and April 2016. METHODS: Consensus was determined by percentage agreement on level of priority for topics as determined by participants. Additionally, results were compared between countries within the region by income and mortality levels using Kendall's tau. FINDINGS: Critical research topics were focused on public/community/primary care as well as emergency preparedness for disasters, and these priorities are well aligned with gaps in the literature for this region. There were statistically significant differences between priority level and country mortality group for geriatrics, self-management of disease, and sexually transmitted infections. CONCLUSIONS: Critical research priorities should focus on population-based health topics. Between-country differences should be analyzed further. A clinical research database for the region may help improve research access for nurses and midwives. CLINICAL RELEVANCE: Practicing nurses and midwives lack extensive evidence (including culturally relevant evidence) on which to practice. Increasing research in areas identified in this survey may improve patient outcomes and quality of care regionally.

Clinical Nursing and Midwifery Research Priorities in Eastern and Southern African Countries: Results From a Delphi Survey.

BACKGROUND: Because of the profound shortage of nurse and midwifery researchers in many African countries, identification of clinical nursing and midwifery research is of highest priority for the region to improve health outcomes. OBJECTIVES: The aim of this study was to gain consensus from experts on the priorities of clinical nursing and midwifery research in southern and eastern African countries. METHOD: A Delphi survey was conducted among experts in the region. Criteria for "expert" included (a) a professional nurse, (b) a bachelor's degree or higher in nursing, (c) published research, (d) affiliated with a school of nursing with at least a master's level nursing program, and/or (e) identified by the African core collaborators as an expert in the region. A list of candidates was identified through searches of published and gray literature and then vetted by core collaborators in Kenya, Malawi, and South Africa. Core collaborators held leadership roles in a nursing school and a doctoral degree in nursing, had conducted and published nursing research, and resided in an included country. RESULTS: Two rounds of the Delphi survey were required to reach consensus. In total, 40 participants completed both rounds, and at least one participant from each country completed both rounds; 73% and 85% response rates were achieved for each round, respectively. Critical clinical research priorities were infectious disease/infection control and midwifery/maternal health topics. These included subtopics such as HIV/AIDS, tuberculosis, maternal health and mortality, infant mortality, and obstetrical emergencies. Many other topics were ranked as important including patient outcomes, noncommunicable diseases, and rural health. DISCUSSION: Areas identified as research priorities were consistent with gaps identified in current literature. As evidenced by previous research, there is a lack of clinical nursing and midwifery research in these areas as well as nurses and midwives trained to conduct research; these priorities will help direct resources to the most essential research needs.

Consent to specimen storage and continuing studies by race and ethnicity: a large dataset analysis using the 2011-2012 National Health and Nutrition Examination Survey.

PURPOSE: To determine if significant differences exist in consent rates for biospecimen storage and continuing studies between non-Hispanic Whites and minority ethnic groups in the National Health and Nutrition Examination Survey (NHANES). METHODS: Using logistic regression, we analyzed 2011-2012 NHANES data to determine whether race/ethnicity, age, gender, and education level influence consent to specimen storage or future testing. RESULTS: Compared to non-Hispanic Whites, some minorities were less willing to donate a specimen for storage and continuing studies, including other Hispanics (non-Mexican) (OR 0.236, 95% CI: 0.079, 0.706), non-Hispanic Asians (OR 0.212, 95% CI: 0.074, 0.602), and other/multiracial ethnic groups (OR 0.189, 95% CI: 0.037, 0.957). Within race and ethnic groups, those aged 20-39 years (OR 2.215, 95% CI: 1.006-4.879) and 40-59 years (OR 9.375, 95% CI: 2.163-40.637) are more willing than those over 60 years to provide consent. CONCLUSION: Lower consent rates by other Hispanics, non-Hispanic Asians, and other/multiracial individuals in this study represent the first published comparison of consent rates among these groups to our knowledge. To best meet the health care needs of this segment of the population and to aid in designing future genetic studies, reassessment of ethnic minority groups concerning these issues is important.

Revolutionizing Patient Surveillance in Assisted Living Facilities: Insights from AUGi Technology Implementation.

In the face of escalating non-fatal fall-related expenses and an aging population, innovative solutions in assisted living facilities (ALFs) are imperative. This study evaluates the implementation of a remote-surveillance technology (AUGi) across three diverse ALFs, emphasizing its impact on falls and falls with injury across sites. Utilizing comprehensive data collection, AUGi facilitated an average reduction of 64% in falls (p < 0.01) and falls with injury (p = 0.05), a statistically and clinically significant difference. The technology's success in enhancing nurse surveillance, providing prompt notifications, and reducing falls underscores its potential to transform ALF care dynamics. This pioneering approach not only fosters better staff-patient interactions but also provides a foundation for future advancements in clinical decision support systems, offering hope for mitigating falls in ALFs.

Development of a Symptom Self-Management Guide for Older Chinese Americans Kidney Receiving Replacement Therapy.

Aim: To assess the acceptability of a symptom self-management booklet among older Chinese Americans receiving kidney replacement therapy. Background: In previous work, we identified commonly occurring, bothersome symptoms and strategies used in this population to ameliorate symptoms. We used these data to develop a symptom self-management booklet in English, traditional, and simplified Chinese. Introduction: In the United States, the prevalence of kidney disease is 1.5 times higher in Asians compared to whites. With the many symptoms associated with this disease, self-management of symptoms would be particularly helpful. Methods: Seven older Chinese Americans receiving kidney replacement therapy and their caregivers were interviewed to assess the acceptability of the booklets. We reviewed participant feedback on content, graphics, and design, reading experience, suggestions for improvement, and health information sources using the inductive thematic method. Results: Overall, patients confirmed acceptability of these self-management booklets across all domains. Discussion. This study validated the booklet as a source of health information for older Chinese American patients with kidney disease, which some studies suggest are preferred to electronic materials or methods in this population. Health care providers can use the resultant booklets when caring for these patients to provide culturally sensitive information on self-management of symptoms. Conclusion and Implications for Nursing. These booklets provide a free resource tailored to an underserved population and may help nurses and nurse practitioners provide care with cultural humility. Implications for Health Policy. Embracing community-based participatory research, as was done in this study, can help create culturally appropriate patient education materials that empower patient symptom self-management and promote informative and culturally sensitive conversations between patients, families, and providers.

KIdney aNd blooD prESsure ouTcomes in Childhood Cancer Survivors: Description of Clinical Research Protocol of the KINDEST-CCS Study.

Background: Approximately 30% of childhood cancer survivors (CCSs) will develop chronic kidney disease (CKD) or hypertension 15 to 20 years after treatment ends. The incidence of CKD and hypertension in the 5-year window after cancer therapy is unknown. Moreover, extent of monitoring of CCS with CKD and associated complications in current practice is underexplored. To inform the development of new and existing care guidelines for CCS, the epidemiology and monitoring of CKD and hypertension in the early period following cancer therapy warrants further investigation. Objective: To describe the design and methods of the KIdney aNd blooD prESsure ouTcomes in Childhood Cancer Survivors study, which aims to evaluate the burden of late kidney and blood pressure outcomes in the first ~10 years after cancer therapy, the extent of appropriate screening and complications monitoring for CKD and hypertension, and whether patient, disease/treatment, or system factors are associated with these outcomes. Design: Two distinct, but related studies; a prospective cohort study and a retrospective cohort study. Setting: Five Ontario pediatric oncology centers. Patients: The prospective study will involve 500 CCS at high risk for these late effects due to cancer therapy, and the retrospective study involves 5,000 CCS ≤ 18 years old treated for cancer between January 2008 and December 2020. Measurements: Chronic kidney disease is defined as Estimated glomerular filtration rate <90 mL/min/1.73 m2 or albumin-to-creatinine ratio ≥ 3mg/mmol. Hypertension is defined by 2017 American Academy of Pediatrics guidelines. Methods: Prospective study: we aim to investigate CKD and hypertension prevalence and the extent to which they persist at 3- and 5-year follow-up in CCS after cancer therapy. We will collect detailed biologic and clinical data, calculate CKD and hypertension prevalence, and progression at 3- and 5-years post-therapy. Retrospective study: we aim to investigate CKD and hypertension monitoring using administrative and health record data. We will also investigate the validity of CKD and hypertension administrative definitions in this population and the incidence of CKD and hypertension in the first ~10 years post-cancer therapy. We will investigate whether patient-, disease/treatment-, or system-specific factors modify these associations in both studies. Limitations: Results from the prospective study may not be generalizable to non-high-risk CCS. The retrospective study is susceptible to surveillance bias. Conclusions: Our team and knowledge translation plan is engaging patient partners, researchers, knowledge users, and policy group representatives. Our work will address international priorities to improve CCS health, provide the evidence of new disease burden and practice gaps to improve CCS guidelines, implement and test revised guidelines, plan trials to reduce CKD and hypertension, and improve long-term CCS health.

A Survey of Hospice and Palliative Care Nurses' and Holistic Nurses' Perceptions of Spirituality and Spiritual Care.

The provision of spiritual care is referred to in professional practice guidelines and mandated in nurses' ethical codes. Still, a gap exists regarding essential training in spiritual conversation and assessment, leaving some health care providers feeling uncomfortable when assessing spiritual support needs. The purpose of this study was to assess hospice and palliative nurses' and holistic nurses' perceptions of spirituality and spiritual care. It was assumed that the standards of care for hospice and palliative nurses and holistic nurses stipulate that spiritualty is addressed within the framework of their specialties and provide education for spiritual care, thus making these nurses proficient in providing spiritual care. This exploratory, descriptive study utilized a web-based survey to measure perception of spirituality and spiritual care giving using a modified Spirituality and Spiritual Care Rating Scale. A convenience sample was recruited from members of the Hospice and Palliative Nurses Association and the American Holistic Nurses Association (n = 250). Descriptive statistics summarized data as well as qualitative analysis of written narratives. Content analysis of open-ended survey questions was used to identify themes until saturation. This study found that given adequate resources and education, nurses can be positioned to address the spiritual needs of patients and provide appropriate care. This study adds to an emerging body of evidence suggesting that training in spiritual care should be an important component of the foundational nursing curriculum.

How much time do nurses spend using electronic devices at work?

Results of the Patient Care and Tracking Increasing Electronics in Nurses' Use of Time (PATIENT) study.

Prevalence and Components of Newborn Assessment Policies Related to Sudden Unexpected Postnatal Collapse.

OBJECTIVE: To describe, in a convenience sample, different hospitals' nursing care policies related to normal newborn assessment, to summarize common components of those policies related to sudden unexpected postnatal collapse (SUPC) of the newborn, and to correlate characteristics of the hospitals with the presence or absence of a normal newborn assessment policy. DESIGN: Descriptive evaluative design. SETTING: Hospital representatives were contacted to complete a questionnaire and provide a copy of their policies regarding normal newborn assessment. PARTICIPANTS: Representatives from 39 hospitals that provide maternal/newborn services within the United States completed the questionnaire and/or provided the investigator with a written nursing care policy for normal newborn assessment. INTERVENTION/MEASUREMENTS: Components of the hospitals' normal newborn assessment policies were evaluated according to the framework of recommended components outlined by the American Academy of Pediatrics in Feldman-Winter et al. (2016). RESULTS: The four components most often included in the policies submitted by 26 hospitals were maternal/newborn dyad assessments (n = 25, 96%), sequence of events postpartum (n = 15, 58%), monitoring (n = 9, 35%), and skin-to-skin contact procedures (n = 8, 30%). Differences were noted based on the size of the hospital as defined by the number of births and number of beds and also by the type of unit. CONCLUSION: Few policies in this study aligned with the recommended suggestions from the American Academy of Pediatrics outlined in Feldman-Winter et al. (2016). It is also important to note that these recommended suggestions relate to safe skin-to-skin contact and rooming-in practices, which may in turn affect the incidence of SUPC. There is much work to be done in terms of disseminating evidence and developing and implementing newborn assessment policies related to SUPC.