Nurses' self-efficiency levels in safe blood and blood component transfusion: The case of Turkey.

OBJECTIVE: The study aimed to determine nurses' self-efficacy levels for safe transfusion of blood and blood components. METHOD: The design of this study is descriptive and cross-sectional. Before starting the study, ethics committee approval and institution approval was obtained. The participants were informed about the purpose of the study, and their written consent was obtained. The research was conducted between the dates 01 March 2022 and 01 May 2022, a private hospital in Turkey. The study sample consisted of 482 nurses. Data were collected using descriptive characteristics form and the Safe Blood and Blood Products Transfusion Self-Efficacy Scale (SBT-SES). RESULTS: The total SBT-SES scores of the nurses were high (202.7 ± 50.1), and the behavioral sub-factor self-efficacy scores were moderate (48.2 ± 19.5). When the SBT-SES scores were analyzed based on demographic characteristics, it was found that those who had received previous safe blood transfusion training scored higher than those who had not, and women scored higher than men (p < 0.05). In addition, no relationship was found between age, working time, number of weekly blood transfusions, and self-efficacy levels. DISCUSSION: As a result, nurses' self-efficacy levels towards blood transfusion are high. However, the behavioral sub-factor self-efficacy level is not sufficient. CONCLUSION: Based on these results, in order to increase the behavioral self-efficacy levels of nurses, our recommendations are as follows: investigating appropriate training methods, considering the sex factor when choosing training methods and techniques, investigating the barriers to safe transfusion behaviors, and measuring self-efficacy levels at regular intervals.

Perceptions of Nurses Regarding Opioid Administration: A cross-sectional study.

BACKGROUND: Opioids are important drugs used in pain management due to their strong analgesic effects. However, there is limited research on nurses' perceptions of administering opioids. PURPOSE: This study aims to determine nurses' perceptions of administering opioids. DESIGN: This study used a descriptive cross-sectional design. SETTINGS: A university hospital located in the south of Turkey. METHODS: A self-reporting survey was provided to a convenience sample of 190 nurses. The data were collected with the "Introductory Information Form," and the "Nurses' Perceptions on Opioid Medications Administration Questionnaire." Descriptive statistics were applied for data analysis. RESULTS: The mean age of the nurses was 33.11 ± 7.82 and 86.3% were female. The majority of the nurses did not receive any training on opioid administration other than their undergraduate education. Among the nursing staff, 90.0% expressed the importance of having trust in the prescribing doctor for their comfort in administering opioids. Of the nurses, 30% were undecided about "Nurses associate opioids with drug abuse." and 78.9% disagreed with the statement "Nurses often associate giving opioids with helping patients to die." CONCLUSIONS: The results of this study provided further insight into nurses' perceptions of administering opioids that potentially contribute to pain management. Nurses had information needs and some prejudices regarding opioid administration. Also, relying on the prescribing doctor was important, and problems with prescribing were an obstacle to pain control. CLINICAL IMPLICATIONS: Determining the knowledge and needs of nurses regarding opioid administration and providing in-service training on this subject would positively affect their approach to opioids.

The Effect of Pain Management Education on Nurses' Pain Knowledge and Attitudes.

BACKGROUND: Pain is a nursing diagnosis. As such, it should be evaluated and recorded regularly. Nurses should possess a high level of pain management knowledge and a positive attitude toward pain, as these are the most important factors affecting pain control and management in children. AIM: To evaluate the effect of the pain management training provided to pediatric nurses on their pain knowledge and attitudes. METHODS: The study, conducted as a pretest-posttest experiment with a control group, was carried out from January-March 2019 with 61 nurses in the institutions of the Ministry of Health in Turkey. The content of the pain management for children education consisted of the definition of pain, pain theories, factors affecting pain, pain in children, the effects of pain on children, pain symptoms in children, perception of pain according to the developmental levels of children, false beliefs, and facts about pain, pain assessment, and factors preventing pain control in children. Data were obtained using the Personal Information Form, the Pediatric Pain Information form, and an Attitude Scale. Data were analyzed using descriptive statistics, a chi-square test, a t test, and validity and reliability analyses. All ethical principles were adhered to. RESULTS: No significant difference was found between the nurses' pain knowledge and attitudes on the pretest scores in the experimental and control groups, while the mean posttest scores of the nurses in the experimental group increased significantly (p < .001). As for the pain and knowledge sub-dimensions of nurses in the experimental and control groups, no significant difference was found between the pretest scores for care, pain physiology, painless medication methods, pain relief with medication, pain psychology, and sociology. The mean posttest scores in all subdimensions increased significantly in favor of nurses in the experimental group (p < .001). CONCLUSIONS: Mean posttest scores of pain knowledge and attitude and subdimensions of the nurses in the experimental group increased significantly, indicating that nurses' knowledge deficiencies in the realm of strong pediatric pain management can be overcome by education, and that their attitudes can be improved.

Examining nurses' death anxiety and attitudes toward caring for dying patients: a cross-sectional study in Turkey.

Death anxiety may reduce the interaction between nurses and patients, causing nurses to focus more on the physical care needs of patients and ignore their psychosocial and spiritual needs. This study was conducted to examine nurses' death anxiety and attitudes toward caring for dying patients. The data were collected using an information form, the Thorson-Powell Death Anxiety Scale (TPDAS), and the Frommelt Attitudes Toward the Care of the Dying Scale (FATCOD). The mean TPDAS and FATCOD scores were 46.71 (14.48) and 104.97 (13.55), respectively, and it was determined that they had moderate death anxiety and positive attitudes towards the care of dying patients. Those working in intensive care and internal medicine clinics had more positive attitudes toward caring for dying patients compared with those working in surgical clinics. Those who reported having a strong faith had lower death anxiety.

Investigation of Health Professionals' Intention to Use Telemedicine in Turkey.

Introduction: The aim of this study is to determine the usage intention levels by health professionals of telemedicine applications whose legal infrastructure is recently completed by the Ministry of Health in Turkey and whose use is desired to be expanded. Methods: In addition to the questions posed to determine the demographic characteristics of the health professional, their relationship with technology, and their level of knowledge about the word telemedicine; survey data, which included statements to determine factors such as telemedicine use intentions, perceived usefulness, perceived ease, and attitude, were analyzed. Results: Survey questions were answered by 337 health professionals. It has been determined that 83.4% of health professionals have a medium and high level of relationship with technology, 26.4% have never heard of telemedicine, and the rest have various interactions with medicine. According to the results of the research, it is clearly stated that the intention of health professionals to use telemedicine applications is shaped by factors such as perceived usefulness, perceived ease, and attitude. Conclusion: It has been clearly determined that the intention of health professionals to use telemedicine applications is shaped by factors such as perceived usefulness, perceived ease, and attitude. In parallel with this information, it is seen that the possibility of affecting the intentions of using telemedicine by managing the perceptions of health professionals is possible within the obtained results.

"Working in the emergency department is not a job; it's like a war" A narrative inquiry and interpretive phenomenology of the violence experienced by emergency nurses in Turkey.

AIMS: This study aims to reveal the violent experiences of nurses working in the emergency department and the meanings they attribute to them. METHODS: This research was conducted as narrative inquiry and interpretive phenomenology and recruited 15 nurses. Interviews with nurses actively working in the emergency department and who had been exposed to violence by patients or their relatives were conducted with a semi-structured interview form. The consolidated criteria for reporting qualitative research (COREQ) checklist was used. RESULTS: In the study, three themes were determined (1) Unpredictable event, (2) Interminable effects of violence, and (3) Like a bottomless pit. With seven sub-themes. CONCLUSIONS: This study underlined that violence applied to nurses by patients or relatives of patients in the emergency department is an unexpected situation that causes negative emotions. Violence affects all aspects of life and limits communication with the patient. Coping with a violent situation is challenging for nurses, and they demand support from the management.

Turkish nurses' psychological resilience and burnout levels during the COVID-19 pandemic: A correlational study.

AIMS: To investigate the relationship between the psychological resilience and burnout of nurses caring for COVID-19 patients and to determine the factors that affect their psychological resilience and burnout. BACKGROUND: In pandemic diseases such as COVID-19, nurses experience burnout due to long working hours, decreased quality of life and anxiety/fear about their own/families' health. Psychological resilience helps to control burnout in nurses and prevent the development of a global nurse shortage. DESIGN: This was a descriptive, correlational study. METHODS: The sample of this study included 201 nurses in a Training and Research Hospital. The study used the Brief Resilience Scale and the Burnout Measure Short Version. Data were collected between 4 May and 1 June 2020. Statistical analysis was made with Pearson/Spearman, independent sample t test, one-way analysis of variance (ANOVA) test. RESULTS: Nurses reported moderate burnout and psychological resilience, with a negative and highly significant correlation between psychological resilience and burnout levels. CONCLUSIONS: In order to increase the quality of patient care/treatment, nurse managers need to reduce nurses' burnout and increase their psychological resilience. Nurses are recommended to adopt a healthy lifestyle, organize training programmes and implement psychological resilience interventions to prevent sleep disorders. Giving nurses the tools to understand what they need to manage within their locus of control will allow them to find a new sense of resilience, preventing potential burnout.

Experiences and psychosocial challenges of volunteer nurses in Turkey devastating earthquake zones: Lessons to be learnt for prevention of health system problems in disasters: A qualitative study.

OBJECTIVE: This research aimed to investigate the experiences and psychosocial challenges encountered by volunteer nurses who provided care in the zones affected by the devastating earthquake that struck Turkey in 2023. METHODS: This qualitative study involved semistructured, in-depth interviews with 15 volunteer nurses who were actively working in earthquake-affected regions. The study was conducted between June 2023 and July 2023. Participants were selected from diverse provinces (Hatay, Gaziantep, Adiyaman, Kahramanmaras, and Malatya) affected by the earthquake, ensuring maximum variability. Individual online interviews were conducted using Google Meet, with data collection continuing until saturation was achieved. The study adhered to the COREQ checklist for reporting qualitative research. RESULTS: Three main themes and eight subthemes were developed: (1) Management and Coordination (failure to meet basic needs, bureaucracy, duty, and authority issues, problems with supplies and equipment); (2) Professional Experiences (working conditions, education, perspective on the profession); and Psychosocial Problems and (3) Coping Methods (psychological problems, methods of coping with problems). CONCLUSIONS: The study showed that volunteer nurses encountered management and organizational obstacles, were profoundly impacted by the disaster's psychosocial aspects, and often struggled with inadequacies in handling psychological challenges. Despite these challenges, the nurses reported a sense of competence in delivering care services. The insights derived from this study hold valuable lessons for future disaster response strategies. For this reason, it is recommended to plan the necessary training and initiatives to professionally strengthen the field of disaster nursing.

Is green behaviors of health professionals related to green practices in the workplace? Multicenter study in Turkey.

In this study, it is aimed to examine the relationship between green behaviors of health professionals and green practices in the workplace. The study sample consisted of 174 health professionals from 34 Family Healthcare Centers (FHCs) in Turkey. Number, percent, mean, standard deviation, student's test, Mann - Whitney U test, One Way Anova test, Kruskal-Wallis H test, linear regression analysis were used for statistical analysis. Energy-saving (ß: 0.197; 95%CI: 0.040;0.266) and waste reduction practices (ß: 0.174; 95%CI: 0.019;0.256) in the workplace were positive associated with environmental sensitivity. Waste reduction practices (ß: 0.228; 95%CI: 0.093;0.478) in the workplace were positive associated with environmental participation. Recycling bins (ß: 0.181; 95%CI :0.084;0.799) and using solar energy (ß: 0.198; 95%CI: 0.030; 0.785) in the workplace were positive associated with technological sensitivity. Health professionals who work in workplaces with energy-saving, waste reduction practices, recycling bins and using solar energy more likely to display green behaviors.

Medical device-related pressure injuries prevention practices of intensive care unit nurses: A cross-sectional study in Turkey.

AIM: Medical device-related pressure injuries (MDRPIs) are becoming increasingly common across all healthcare services and age groups in terms of both incidence and severity. It is crucial for nurses to be aware that MDRPI is a potential complication of healthcare services. This study aimed to assess the preventive practices of intensive care unit (ICU) nurses in relation to MDRPIs. MATERIALS AND METHODS: This cross-sectional and descriptive study was conducted with 96 nurses between March 10 and April 31, 2021. The "Nurse Information Form" and the "MDRPIs Prevention Practices Questionnaire" form were used for the data collection. RESULTS: The overall practice scores of ICU nurses in preventing MDRPIs were 50.83 ± 12.93. Out of the participants, 57.3% (n = 55) achieved a total practice score of 51 and above out of 68 (considered an acceptable score indicating proficiency in positive practice). The items with the most negative practice levels among nurses were related to statements such as 'I apply hydrocolloid, thin foam, or a silicone-type dressing to prevent MDPRI' (2.86 ± 0.85) and 'I use the normal pressure injury staging when staging the MDRPI' (2.88 ± 0.86). No significant difference was observed between the mean scores of MDRPI prevention practices and the characteristics of ICU nurses, such as education level, years working in the unit, and years of experience in the profession (p > 0.05). Furthermore, a positive correlation was found between age and practice levels in preventing MDRPIs (p < 0.05). CONCLUSION: The study results indicate that the practice levels of ICU nurses in preventing MDRPIs were insufficient. We believe that regular in-service training programs, grounded in clinical practice, are necessary to enhance nurses' awareness and management of MDRPIs.

Management of Pediatric Convulsive Status Epilepticus From the Perspective of Emergency Nurses: A Cross-sectional, Multicenter Study.

INTRODUCTION: Pediatric convulsive status epilepticus is one of the most common neurologic emergencies and should be managed by health care professionals as soon as possible based on current guidelines. This study aimed to determine the nursing approaches and management of pediatric convulsive status epilepticus from the perspective of emergency nurses in Turkey. METHODS: A cross-sectional, multicenter study was conducted with 162 emergency nurses working in emergency departments in 35 different provinces in Turkey. The data were collected via an online form. Descriptive statistical methods were used in data analysis. RESULTS: Most emergency nurses (72.2%) attempted an intravenous access immediately to administer antiseizure medications during the stabilization phase. Approximately half the emergency nurses stated that rectal diazePAM was frequently administered in the initial therapy phase and intravenous diazePAM was administered in the second therapy phase. The emergency nurses had most difficulties attempting intravenous access, determining status epilepticus types, and calming the parents. DISCUSSION: As health care professionals and important members of the health team, emergency nurses have the responsibility to manage pediatric convulsive status epilepticus in the fastest and the most appropriate way based on current practice guidelines in emergency departments. When intravenous access is not available, nonintravenous benzodiazepines should be considered in the first-line treatment of pediatric convulsive status epilepticus, followed by immediate intravenous access.

Inadvertent Hypothermia in the Perspective of Operating Room Nurses: A Phenomenological Qualitative Study.

PURPOSE: The aim of the study was to reveal the awareness and perceptions of operating room nurses concerning inadvertent hypothermia, as well as their experiences and recommendations for its prevention. DESIGN: The study employed a phenomenological qualitative approach. METHODS: This study was conducted with 17 nurses working in the operating room of a university hospital in Konya, Turkey. Data were collected face to face between 15 August and 30 September 2022 using the in-depth individual interview method. The data were subjected to inductive content analysis. Written permission was obtained from the hospital, the ethics committee, and the participants to conduct the study. FINDINGS: The mean age of the nurses was 28.4 years and the majority were female. The nurses were graduates of a four-year health vocational high school, a two-year nursing associate degree program, or a four-year nursing bachelors' degree program. Their operating room experience ranged from 1 to 22 years. All the nurses were aware of inadvertent hypothermia, and all but one encountered hypothermia and applied preventive measures. The data analysis revealed 263 codes, 12 categories, and 4 themes on the awareness and perceptions of operating room nurses about inadvertent hypothermia and their experiences and recommendations for its prevention. CONCLUSIONS: The findings showed that the majority of the participants were aware of inadvertent hypothermia and its risk factors, and frequently encountered inadvertent hypothermia despite implementing preventive measures.

The Speaking Up Climate of Nurses for Patient Safety Concerns and Unprofessional Behaviors: The Effects of Teamwork and Safety Climate.

PURPOSE: This study aims to investigate the influence of teamwork and safety climate on nurses' speaking up for patient safety concerns and unprofessional behaviors. DESIGN: This study incorporates a cross-sectional research design. METHODS: The study included 217 surgical nurses employed in a Turkish university hospital. The research data were collected between April and June 2023 using the Teamwork Climate, Safety Climate Survey, Speaking Up Climate for Patient Safety, and Speaking Up Climate for Professionalism instruments. The relationships between these scales were assessed using Pearson correlation analysis. The Turkish validity and reliability of the Speaking Up Climate for Patient Safety and Speaking Up Climate for Professionalism scales were verified. The research model was tested using path analysis. FINDINGS: The mean age of the 217 surgical nurses was 25.88 ± 5.64 years. Teamwork climate showed a positive effect on safety climate and speaking up climate about patient safety concerns and unprofessional behaviors. Safety climate showed a positive association with nurses' speaking up climate about patient safety concerns and unprofessional behaviors. CONCLUSIONS: Teamwork climate and safety climate both positively affect the speaking up climate about patient safety concerns and unprofessional behaviors. Nurse managers who wish to promote a culture of speaking up about patient safety and unprofessional behaviors should prioritize improvements in the teamwork climate and safety climate.

Occupational fatigue, compassion competence and caring behaviours of intensive care nurses: A structural equation modelling approach.

BACKGROUND: No previous study has examined the direct effect of occupational fatigue, inter-shift recovery and compassion competence on caring behaviours, including assurance, knowledge-skill, respect and commitment in intensive care nurses. AIM: We studied the direct effect of participating nurses' occupational fatigue, inter-shift recovery and compassion competence levels on their caring behaviours and the relationship among these variables. STUDY DESIGN: This was a descriptive correlational study. All nurses who were registered members of the Turkish Intensive Care Nurses Association were invited to participate in this online survey. This study was conducted with 315 intensive care nurses using convenience sampling between April and July 2022. The data were collected using the Occupational Fatigue Exhaustion/Recovery Scale, which consists of three subscales: acute fatigue, chronic fatigue and inter-shift recovery; the Compassion Competence Scale, including communication, sensitivity and insight subscales; and the Caring Behaviours Inventory-24. In addition, a structural equation model was established using variables correlating with caring behaviours. Independent variables were occupational fatigue, inter-ship recovery and compassion competence; and the dependent variable was caring behaviours in this hypothesized model. RESULTS: Three hundred and fifteen nurses completed the survey (315/1000) with a response rate of 31.5%. The increase in the inter-shift recovery levels of participants was statistically and positively associated with caring behaviours (95% confidence interval [CI]: 0.001-0.011, ß = .154 [moderate effect size], p < .05). The sub-dimensions of the Compassion Competence Scale, that is, communication (95% CI: 0.110-0.443, ß = .251 [moderate effect size]) and sensitivity (95% CI: 0.084-0.427, ß = .241 [moderate effect size]), were statistically and positively associated with the caring behaviours of participants (p < .05). In addition, independent variables accounted for 35% (large effect size) of the total change in caring behaviours (R2 = 0.350). CONCLUSIONS: This study suggests that the high inter-shift recovery and compassion competence levels of intensive care nurses are positively associated with their caring behaviours. RELEVANCE TO CLINICAL PRACTICE: Nursing managers should consider the direct effect of occupational fatigue, inter-shift recovery and the compassion competence levels of intensive care nurses on their caring behaviours to provide high-quality care.

Ayse Sadiye Güvendiren and Hatice Azra Demirelli: Turkey's first certified female dentists.

Ayse Sadiye Güvendiren and Hatice Azra Demirelli were the first Turkish female dentists. In a country that came out of the First World War and fought for her independence, they laid the foundations of women's presence in the Turkish dental community and took their honorable place in history with their courage, devotion, and determination.

German pathology professor Philipp Schwartz: His enduring life from Frankfurt to Istanbul during the Second World War era: A "forgotten savior".

Many scientists were forced to leave Germany mostly under challenging circumstances as a result of the pressure applied to anti-Nazi German scientists and artists (mostly from the medical field) who were or were not of Jewish origin before World War II. They emigrated primarily to the United States, Switzerland, Turkey and South America. Two eminent pathology professors, namely Prof. Philipp Schwartz (from Frankfurt) and Prof. Sigfried Oberndorfer (from Munich) came to Istanbul University. They regarded Turkey as their second homeland. They were obliged to leave Germany due to mounting pressure. Schwartz settled in his father-in-law's house in Zurich. Schwartz was an organizer. He established the "Emergency Society of German Scholars Abroad" (Notgemeinschaft) to gather German scientists and artists in his situation. During the same period, the founder of modern Turkey, Mustafa Kemal Atatürk wanted to apply reforms at Istanbul University to make it attain a Western structure. He invited Swiss pedagogue Prof. Malche and asked him to prepare a report for this purpose. Malche highlighted the need for Western experts is advised. Contact was made with Schwartz's organization in Switzerland. Numerous scientists specialized in almost all fields of science starting with medicine as well as many artists came to Istanbul University and other public institutions. Schwartz established the Pathology Department at Istanbul University while Prof. Oberndorfer established the Department of Experimental Pathology at the same university. Schwartz enabled pathology to gain a contemporary identity in Turkey. Pathology was mostly focused on autopsy during those years. Schwartz attached importance to the pathology training of medical students. He initiated clinico-pathology classes and encouraged surgeons to take a biopsy for surgical pathology. He produced numerous publications. Schwartz worked in Turkey for 19 years and then moved to the US. Thus, a generation of pathologists following the footsteps of Schwartz was raised in Turkey. Frankfurt University, in which he was obliged to leave, erected a stele in his memory at the entrance of the main hospital building. Schwartz thus became an unforgotten savior.

Change in the geographic distribution of human resources for health in Turkey, 2002-2016.

INTRODUCTION: Turkey, which suffers from both undersupply of physicians, nurses and midwives and imbalanced distribution of healthcare personnel, has been developing and implementing various policies to solve these problems. The Ministry of Health launched the Health Transformation Program in 2003 for effective, efficient and fair provision of healthcare services for all people. This study aimed to take a closer look at the impact of policies implemented to reduce the imbalance of the distribution of human resources for health for the past 15 years in Turkey. METHODS: Data for the distributional imbalance obtained from Ministry of Health registries was analysed by using Lorenz curves and Gini coefficient for the years 2002, 2005, 2008, 2012 and 2016. RESULTS: Geographical imbalances for healthcare professions decreased distinguishably during the 15 years. Gini coefficient was 0.33 for specialist distribution in 2002, and decreased gradually to 0.26 in 2008 and finally 0.21 in 2016. Similarly, Gini coefficients were 0.18, 0.20 and 0.25 for general practitioners, nurses and midwives, respectively, in 2002. In 2012, Gini coefficients for the same professionals were calculated as 0.09, 0.11 and 0.19, respectively. CONCLUSION: The findings indicate that the policies targeting the distribution of healthcare personnel in Turkey have yielded positive results. Yet it is evident that these results are not due to a single action. It is essential to improve existing implementations, identify the instruments and factors that satisfy and motivate healthcare personnel, and continue developing and implementing comprehensive policies.

Perspective of Doctors and Nurses on the Principle of Extended Autonomy in Konya, Turkey.

Despite the support with legislation in Turkey regarding extended autonomy and advance directive, there is no clear provision and sufficient practice on the subject. Turkish doctors and nurses are generally unfamiliar with the conception of extended autonomy or advance directive, which raises dilemmas in terms of life-support choice, and this situation can even affect clinical decision-making processes. This study investigated the awareness level about extended autonomy and advance directive in Turkey and assessed doctors and nurses' attitudes toward patient autonomy. This was a quantitative descriptive study. It was found that the 46.8% of the respondents supported the principle of extended autonomy in health service delivery. However, 53.8% of the respondents had poor knowledge regarding advance directive. Majority (77.9%) of the respondents indicated that the legislative arrangements should be made concerning the principle of extended autonomy and the advance directive, which is its field of application.

New public management, physicians and populism: Turkey's experience with health reforms.

Recent debates on the rise of right-wing or neoliberal populism globally have prompted public health and health systems researchers to explore its implications in the healthcare systems. This case study of Turkey's recent health reform initiative, the Health Transformation Program, aims to contribute to this debate by examining the nexus among populism, professionalism and the contemporary market and managerial reforms, often described as New Public Management (NPM). Building on document analysis and secondary sources, this article introduces a framework to explore whether and how populist agendas grow up in the shadow of NPM policies. We aim to deepen our understanding of the governance settings that might be used in different ways by right-wing populist leaders to advance their agendas. Our research reveals that the NPM reforms in Turkey have opened a 'backdoor' through which right-wing populist agendas were supported and the position of the medical profession as an important stakeholder in the institutional settings was weakened. However, what mattered most in the reform process was not the policies themselves but the ways new managerialist policies were implemented. Our analysis makes blind spots of the NPM reforms and healthcare governance research visible and calls for greater attention to implementation processes.