Nurses' Perceived Effects of Visitor Restrictions in Hospital Maternity Units.

PURPOSE: To explore how perinatal nurses perceive the effects of visitor restrictions on patient care within a hospital setting. STUDY DESIGN AND METHODS: We distributed a cross-sectional survey online to perinatal nurses in May of 2022. Characteristics of respondents were analyzed using descriptive statistics. Responses to an open-ended question were analyzed via conventional content analysis. RESULTS: Among our sample of 101 nurses, we identified seven codes representing positive effects and seven codes representing negative effects. The most frequently reported positive effects were ability to provide person-centered care ( n = 36, 35.6%) and less patient stress and more rest ( n = 29, 28.7%). The most frequently reported negative effects were limited patient support ( n = 22, 21.8%) and emotional distress to the patient ( n = 15, 14.9%). Fourteen percent ( n = 14) of respondents cited both positive and negative effects. CLINICAL IMPLICATIONS: Nurses perceived that visitor restrictions resulted in both positive and negative patient experiences. Balancing clinical needs and safety considerations with emotional needs of the childbearing individual requires careful consideration by maternity care clinicians and health care systems. Subsequent research is needed to determine optimal visitation policies during intrapartum and postpartum with consideration to hospital context and patient preferences for optimal care.

Perform hand hygiene and the doors will open - the effectiveness of new system implementation on paediatric intensive care unit visitors' handwashing compliance.

Hand hygiene (HH) performance on entering intensive care units (ICUs) is commonly accepted but often inadequately performed. We developed a simple, inexpensive module that connects touchless dispensers of alcohol sanitiser (TDAS) to the automatic doors of a paediatric ICU, and assessed the impact of this intervention on HH compliance of hospital staff and visitors. A prospective observational study was conducted over a 3-week period prior to the intervention, followed by a 4-week period post intervention. HH performance was monitored by a research assistant whose office location enabled direct and video-assisted observation of the ICU entrance. A total of 609 entries to the ICU was recorded. Overall HH performance was 46.9% (92/196) before and 98.5% (406/413) after the intervention. Our findings suggest that HH performance on entering an ICU can be improved via a mechanism that makes operation of an automatic door dependent on use of a TDAS system, and thus contribute to infection control.

Family-centered care with visitor limitations.

ABSTRACT: Communication and support for patients and family members can be challenging, especially when in-person visitation is limited or eliminated entirely. This article discusses how healthcare teams can promote family-centered care during periods of limited visitation.

Parental access to hospitalised children during infectious disease pandemics such as COVID-19.

The COVID-19 pandemic has resulted in many hospitals severely limiting or denying parents access to their hospitalised children. This article provides guidance for hospital managers, healthcare staff, district-level managers and provincial managers on parental access to hospitalised children during a pandemic such as COVID-19. It: (i) summarises legal and ethical issues around parental visitation rights; (ii) highlights four guiding principles; (iii) provides 10 practical recommendations to facilitate safe parental access to hospitalised children; (iv) highlights additional considerations if the mother is COVID-19-positive; and (v) provides considerations for fathers. In summary, it is a child's right to have access to his or her parents during hospitalisation, and parents should have access to their hospitalised children; during an infectious disease pandemic such as COVID-19, there is a responsibility to ensure that parental visitation is implemented in a reasonable and safe manner. Separation should only occur in exceptional circumstances, e.g. if adequate in-hospital facilities do not exist to jointly accommodate the parent/caregiver and the newborn/infant/child. Both parents should be allowed access to hospitalised children, under strict infection prevention and control (IPC) measures and with implementation of non-pharmaceutical interventions (NPIs), including handwashing/sanitisation, face masks and physical distancing. Newborns/infants and their parents/caregivers have a reasonably high likelihood of having similar COVID-19 status, and should be managed as a dyad rather than as individuals. Every hospital should provide lodger/boarder facilities for mothers who are COVID-19-positive, COVID-19-negative or persons under investigation (PUI), separately, with stringent IPC measures and NPIs. If facilities are limited, breastfeeding mothers should be prioritised, in the following order: (i) COVID-19-negative; (ii) COVID-19 PUI; and (iii) COVID-19-positive. Breastfeeding, or breastmilk feeding, should be promoted, supported and protected, and skin-to-skin care of newborns with the mother/caregiver (with IPC measures) should be discussed and practised as far as possible. Surgical masks should be provided to all parents/caregivers and replaced daily throughout the hospital stay. Parents should be referred to social services and local community resources to ensure that multidisciplinary support is provided. Hospitals should develop individual-level policies and share these with staff and parents. Additionally, hospitals should ideally track the effect of parental visitation rights on hospital-based COVID-19 outbreaks, the mental health of hospitalised children, and their rate of recovery.

Higher Depression of Patients with Alzheimer's Disease During than Before the Lockdown.

We assessed depression in 72 patients with Alzheimer's disease (AD) who live in retirement homes during the COVID-19-related lockdown. We invited caregivers of 72 patients with AD who live in retirement homes to rate depression in the patients both before and during the lockdown. Analysis demonstrated increased depression in the patients during the lockdown. We attribute this increased depression to the restrictive measures on activities, visits, and physical contact between patients with AD and family members during the lockdown.

Coronavirus Disease 2019 Policy Restricting Family Presence May Have Delayed End-of-Life Decisions for Critically Ill Patients.

OBJECTIVES: To determine if a restrictive visitor policy inadvertently lengthened the decision-making process for dying inpatients without coronavirus disease 2019. DESIGN: Regression discontinuity and time-to-event analysis. SETTING: Two large academic hospitals in a unified health system. PATIENTS OR SUBJECTS: Adult decedents who received greater than or equal to 1 day of ICU care during their terminal admission over a 12-month period. INTERVENTIONS: Implementation of a visit restriction policy. MEASUREMENTS AND MAIN RESULTS: We identified 940 adult decedents without coronavirus disease 2019 during the study period. For these patients, ICU length of stay was 0.8 days longer following policy implementation, although this effect was not statistically significant (95% CI, -2.3 to 3.8; p = 0.63). After excluding patients admitted before the policy but who died after implementation, we observed that ICU length of stay was 2.9 days longer post-policy (95% CI, 0.27-5.6; p = 0.03). A time-to-event analysis revealed that admission after policy implementation was associated with a significantly longer time to first do not resuscitate/do not intubate/comfort care order (adjusted hazard ratio, 2.2; 95% CI, 1.6-3.1; p < 0.0001). CONCLUSIONS: Policies restricting family presence may lead to longer ICU stays and delay decisions to limit treatment prior to death. Further policy evaluation and programs enabling access to family-centered care and palliative care during the ongoing coronavirus disease 2019 pandemic are imperative.

Mechanism of a Flexible ICU Visiting Policy for Anxiety Symptoms Among Family Members in Brazil: A Path Mediation Analysis in a Cluster-Randomized Clinical Trial.

OBJECTIVES: To investigate whether the effect of a flexible ICU visiting policy that includes flexible visitation plus visitor education on anxiety symptoms of family members is mediated by satisfaction and involvement in patient care. DESIGN: We embedded a multivariable path mediation analysis within a cluster-randomized crossover trial as a secondary analysis of The ICU Visits Study (ClinicalTrials.gov number: NCT02932358). SETTING: Thirty-six medical-surgical ICUs in Brazil. PATIENTS: Closest relatives of adult ICU patients. INTERVENTIONS: Flexible visitation (12 hr/d) supported by family education or usual restricted visitation (median, 1.5 hr/d). MEASUREMENTS AND MAIN RESULTS: Overall, 863 family members were assessed (mean age, 44.7 yr; women, 70.1%). Compared with the restricted visitation (n = 436), flexible visitation (n = 427) resulted in better mean anxiety scores (6.1 vs 7.8; mean difference, -1.78 [95% CI, -2.31 to -1.22]), as well as higher standardized scores of satisfaction (67% [95% CI, 55-79]) and involvement in patient care (77% [95% CI, 64-89]). The mediated effect of flexible visitation on mean anxiety scores through each incremental sd of satisfaction and involvement in patient care were -0.47 (95% CI, -0.68 to -0.24) and 0.29 (95% CI, 0.04-0.54), respectively. Upon exploratory analyses, emotional support, helping the ICU staff to understand patient needs, helping the patient to interpret ICU staff instructions, and patient reorientation were the domains of involvement in patient care associated with increased anxiety. CONCLUSIONS: A flexible ICU visiting policy reduces anxiety symptoms among family members and appears to work by increasing satisfaction. However, increased participation in some activities of patient care as a result of flexible visitation was associated with higher severity of anxiety symptoms.

Visitor Guidelines in US Children's Hospitals During COVID-19.

OBJECTIVES: To examine visitor guidelines among children's hospitals in the United States in response to the coronavirus 2019 (COVID-19) pandemic. METHODS: A retrospective assessment of visitor guidelines in 239 children's hospitals in the United States. RESULTS: In this study, we present an analysis of 239 children's hospital visitor guidelines posted to hospitals' Web sites during 1 week in June 2020. Of the 239 hospitals, only 28 did not have posted guidelines for review. The guidelines were analyzed and grouped by how the guidelines were updated in response to COVID-19. Parental visitation was restricted to 1 parent in 116 of the posted guidelines (49%). There were no obvious similarities among guidelines associated with their geographical (eg, state or local) location. As of February 2021, 33 of 55 (60%) randomly selected hospitals had not changed their visitor policy since our initial review. CONCLUSIONS: The COVID-19 pandemic triggered changes in publicly reported visitor guidelines across the majority of children's hospitals. With our findings, we suggest wide variation in policies and practices in how guidelines were updated. More work is needed to understand how to optimize public safety and preserve family-centered care and parental authority in times of crisis.

Hand(y) hygiene insights: Applying three theoretical models to investigate hospital patients' and visitors' hand hygiene behavior.

BACKGROUND: Improving hand hygiene in hospitals is the most efficient method to prevent healthcare-associated infections. The hand hygiene behavior of hospital patients and visitors is not well-researched, although they pose a risk for the transmission of pathogens. Therefore, the present study had three aims: (1) Finding a suitable theoretical model to explain patients' and visitors' hand hygiene practice; (2) Identifying important predictors for their hand hygiene behavior; and (3) Comparing the essential determinants of hand hygiene behavior between healthcare professionals from the literature to our non-professional sample. METHODS: In total N = 1,605 patients and visitors were surveyed on their hand hygiene practice in hospitals. The employed questionnaires were based on three theoretical models: a) the Theory of Planned Behavior (TPB); b) the Health Action Process Approach (HAPA); and c) the Theoretical Domains Framework (TDF). Structural equation modeling was used to analyze the data. To compare our results to the determinants of healthcare workers' hand hygiene behavior, we searched for studies that used one of the three theoretical models. RESULTS: Among patients, 52% of the variance in the hand hygiene behavior was accounted for by the TDF domains, 44% by a modified HAPA model, and 40% by the TPB factors. Among visitors, these figures were 59%, 37%, and 55%, respectively. Two clusters of variables surfaced as being essential determinants of behavior: self-regulatory processes and social influence processes. The critical determinants for healthcare professionals' hand hygiene reported in the literature were similar to the findings from our non-professional sample. CONCLUSIONS: The TDF was identified as the most suitable model to explain patients' and visitors' hand hygiene practices. Patients and visitors should be included in existing behavior change intervention strategies. Newly planned interventions should focus on targeting self-regulatory and social influence processes to improve effectiveness.

Motivations for Family Members' Visits to Nursing Home Residents With Dementia in Taiwan: A Qualitative Study.

PURPOSE: The purpose of this study was to explore what motivates family members to visit a relative with dementia who has been transferred to a nursing home in Taiwan. DESIGN AND METHODS: Data were collected for this qualitative descriptive study using audiotaped, semi-structured, in-depth, face-to-face interviews. A total of 20 family members of elderly nursing home residents participated in the study. Nursing home residents were from four nursing homes in Taiwan and had been diagnosed with probable or possible dementia by a psychiatrist or neurologist. Transcribed audiotaped interviews were analyzed using thematic analysis. FINDINGS: Most family members were the children of the residents (n =17, 85%). The theme describing the core motivation for family members' visits to nursing home residents was "to maintain the unforgotten family affection." This motivation comprised four relevant categories: hoping to slow degeneration, providing a congruous environment, honoring filial and karmic duty, and ensuring the quality of care. CONCLUSIONS: Motivations for Taiwanese family members' visits to nursing home residents with dementia were similar to those in Western cultures. However, "hoping to slow degeneration" and "providing a congruous environment" were unique categories. CLINICAL RELEVANCE: Nurses and policymakers could use these findings to design interventions that might increase holistic care for both family members and nursing home residents with dementia. Providing programming focused on family members' unique priorities could address swallowing difficulties, management of dementia symptoms, nutritional needs, and selection of residents' roommates. These programs could improve the quality of family members' visits as well as the quality of staff-family relationships.

Fathers' Visitation of Very Low Birth Weight Infants in the Neonatal Intensive Care Unit during the First Week of Life.

OBJECTIVE: The perceived fragility of extremely preterm neonates may deter paternal visitation early during the neonatal intensive care unit (NICU) stay. We retrospectively analyzed the correlation between paternal visitation of very low birth weight (VLBW) infants in our NICU and sociodemographic characteristics. STUDY DESIGN: We identified inborn VLBW infants admitted to our NICU from 2017 to 2018. The rate of visit days in the first week of life was analyzed using Spearman's correlation and Poisson's regression. RESULTS: The analysis included 292 infants (median gestational age [GA]: 29 weeks), with fathers present on a median of 3 days of the first week of life. GA was not correlated with visitation (rho = -0.04). On multivariable regression, fathers visited less frequently if they did not live with the mother or if the mother lived 25 to 75 km from the hospital versus < 25 km. CONCLUSION: Fathers' visitation in our NICU was constrained by socioeconomic factors rather than VLBW infants' characteristics.

Impact of visitor restriction rules on the postoperative experience of COVID-19 negative patients undergoing surgery.

BACKGROUND: Many hospitals have implemented visitor restriction policies in response to the coronavirus disease 2019 pandemic. Because caregivers serve an important role in postoperative recovery, the purpose of this study was to evaluate the impact of visitor restrictions on the postoperative experience of coronavirus disease 2019-negative patients undergoing surgery. METHODS: Patients who underwent surgery immediately before or after the implementation of a visitor restriction policy were enrolled. Patients were surveyed on their inpatient experience and preparedness for discharge using items adapted from validated questionnaires. RESULTS: Among 128 eligible patients, 117 agreed to participate (91.4% response rate): 58 (49.6%) in the Visitor Cohort and 59 (50.4%) in the No-Visitor Cohort. Mean age was 57.5 years (standard deviation 13.9) and 66 (56.4%) were female. Among all patients, 47.8% underwent oncologic surgery, 31.6% transplant, and 20.5% general or other. Patients in the No-Visitor Cohort were less likely to report complete satisfaction with the hospital experience (80.7% vs 66.0%, P = .044), timely receipt of medications (84.5% vs 69.0%, P = .048), and assistance getting out of bed (70.7% vs 51.7%, P = .036). No-Visitor Cohort patients were less likely to feel that their discharge preferences were adequately considered (79.3% vs 54.2%, P = .004). Qualitative analysis of patient responses highlighted the consistent psychosocial support provided by visitors after surgery (84.5%), and patients in the No-Visitor Cohort reported social isolation due to lack of psychosocial support (50.8%). CONCLUSION: The implementation of hospital visitor restriction policies may adversely impact the postoperative experience of coronavirus disease 2019-negative patients undergoing surgery. These findings highlight the urgent need for novel patient-centered strategies to improve the postoperative experience of patients during ongoing or future disruptions to routine hospital practice.

Impact of restrictions on parental presence in neonatal intensive care units related to coronavirus disease 2019.

OBJECTIVES: To determine the relationship between the emergence of COVID-19 and neonatal intensive care unit (NICU) family presence as well as how NICU design affects these changes. STUDY DESIGN: A cross-sectional survey from April 21 to 30, 2020. We queried sites regarding NICU demographics, NICU restrictions on parental presence, and changes in ancillary staff availability. RESULTS: Globally, 277 facilities responded to the survey. NICU policies preserving 24/7 parental presence decreased (83-53%, p < 0.001) and of preserving full parental participation in rounds fell (71-32%, p < 0.001). Single-family room design NICUs best preserved 24/7 parental presence after the emergence of COVID-19 (single-family room 65%, hybrid-design 57%, open bay design 45%, p = 0.018). In all, 120 (43%) NICUs reported reductions in therapy services, lactation medicine, and/or social work support. CONCLUSIONS: Hospital restrictions have significantly limited parental presence for NICU admitted infants, although single-family room design may attenuate this effect.

The experience of transportation to visit a nursing home resident: A case study.

Maintaining social connections in the community can be accomplished through transportation access and opportunities. This includes relationships between family and residents in nursing homes. Previous research supports the relationship between transportation, social support, and visitation of residents in nursing homes (NHs), however no empirical research to date explores this relationship of family member transportation as a means to visit their loved one in this setting. Guided by a case study approach, a sample of 11 (N = 11) family members of residents in nursing homes across North Central Texas were selected to develop an in-depth understanding of transportation access and mobility, as it relates to visitation of residents in nursing facilities. Analyses revealed the following seven themes: Car access, Alternative modes, Flexibility, Travel time, Actual cost, Collateral cost, and Health and Mobility. Findings from this study uncover how cost, both actual cost and collateral cost, are greatly linked to car access, transportation access, and opportunities to visit, as well as the impact each of these features, and emergent themes, related to transportation have on maintained or fractured relationships of family and residents in nursing homes. This article concludes with implications for future research and social work practice.

Smoke-free hospital grounds.

This study investigated whether the implementation of a multicomponent intervention project could improve compliance with the New South Wales (NSW) Health smoke-free healthcare policy. Environmental interventions were implemented on the hospital grounds for a 12-week period. Compliance was measured by a pre- and postintervention observational count of smokers on the hospital grounds. After implementation, there was a significant 73% reduction in people smoking on the hospital grounds, indicating improved compliance with the NSW smoke-free healthcare policy through the use of a non-punitive multicomponent intervention.

Prevalence of Workplace Physical Violence against Health Care Professionals by Patients and Visitors: A Systematic Review and Meta-Analysis.

Workplace physical violence against health care professionals perpetrated by patients and visitors has been a persistent problem worldwide. Prevalence estimates varied vastly across studies and there was a lack of quantitative syntheses of prevalence studies. This review aimed to quantify pooled one-year prevalence estimates at the global and regional levels. A systematic literature search was performed in the databases of PubMed, PsycINFO, Web of Science, and Embase between 1 January 2000 and 8 October 2018. Studies providing information about one-year prevalence of self-reported workplace physical violence against health care professionals perpetrated by patients or visitors were included. Heterogeneity between studies was evaluated using Cochran's chi-squared test (Cochran's Q) and I2 values. Subgroup analysis and meta-regression were used to explore heterogeneity. A total of 65 eligible studies reported one-year prevalence estimates for 61,800 health care professionals from 30 countries. The pooled one-year prevalence of workplace physical violence against health care professionals perpetrated by patients or visitors was 19.33% (95% confidence interval (CI): 16.49%-22.53%) and the overall heterogeneity was high across studies. We noted geographic and staff categories variations for prevalence estimates through subgroup analysis. The meta-regression showed that sample size, type of health care setting, and quality score were significant moderators for heterogeneity. One in five health care professionals experienced workplace physical violence perpetrated by patients or visitors worldwide annually. Practical intervention was needed to ensure safety of health care professionals.

Hand hygiene compliance of patients' family members in India: importance of educating the unofficial 'fourth category' of healthcare personnel.

INTRODUCTION: In India, due to manpower constraints, patients' family members are often actively involved in healthcare activities of their near and dear ones. They have significant contact with the patient at all World Health Organization (WHO) 'five moments for hand hygiene'. This study analysed the impact of decade-long awareness campaigns on the hand hygiene compliance (HHC) by our patients' carers. METHODS: Trained infection control nurses observed the HHC at each of the five moments for patients' attendants in different hospital settings from January 2014 to December 2018. Compliance was calculated as percentage of events divided by total opportunities. FINDINGS: A total of 7302 opportunities were observed with an overall compliance of 46.1% (35.5% in 2014 to 48.2% in 2018, P < 0.0001). Compliance at WHO moments 1, 2, 3, 4, and 5 was 51.0%, 47.4%, 67.6%, 48.8%, and 24.3% respectively. Among family members, mothers of newborns had a much higher HHC (77%) than others (44.5%) (P < 0.0001). Also, the compliance was higher in medical versus surgical wards and in paediatric wards versus adult wards (P < 0.0001 in both). CONCLUSION: This is the first study on family members' HHC in a hospital setting in a low- and middle-income country. The study shows that family members, once trained, exhibit fairly good HHC while caring for their patients, especially mothers of newborns. It is worthwhile empowering and educating patient attendants about the importance and process of hand hygiene as it is likely to result in immense benefit for patients.

Can educational speech intervention improve visitors' hand hygiene compliance?

BACKGROUND: Hand hygiene, a simple and low-cost measure, remains the leading intervention for reducing the burden related to healthcare-associated infections (HAIs). While many interventions have been tested to improve staff hand hygiene compliance, hospital visitors continue to have low compliance rates, which increases the risk of HAIs and resistant organisms' transmission into hospitals and out to the community. AIM: To assess the effectiveness of educational speech intervention (ESI) for increasing hand hygiene compliance rate among hospital visitors. METHODS: This interventional study was conducted from March to June 2019 in an inpatient unit of a large academic hospital. Visitor hand hygiene compliance was observed before and after implementation of ESI. The purpose of providing ESI to the visitors in the intervention phase was to remind them about the importance of hand hygiene and the proper method for cleaning hands. Post-intervention data were collected using the survey questionnaires. Unpaired t-test compared the hand hygiene compliance rate before and after the intervention. FINDINGS: Baseline hand hygiene compliance rate was 9.73% while hand hygiene compliance rate post-intervention increased to 87.06% (P<0.001). Barriers to hand hygiene compliance included occupied hands, improper location of hand hygiene supplies, and past habit of not practising hand hygiene. Visitors preferred to be reminded about hand hygiene by verbal reminder (57%), followed by signage (38%), and wristband notices (5%). CONCLUSION: The ESI substantially increased visitors' hand hygiene compliance rate. Further studies are warranted to assess the sustainability of ESI and address other barriers to visitors' hand hygiene compliance.

Open visiting in adult intensive care units - A structured literature review.

BACKGROUND: Open visitation in adult intensive care units report benefits such as reduced frequency and duration of deliriums, improved patient and family satisfaction, and reduced anxiety and depression of family members. 'Being close' is one of the most basic and important needs of family members of critically ill patients. Open visitation provides an increased opportunity of being at the bedside with the patient, however, it is not universally embraced by adult intensive care units worldwide. AIM: To critically appraise the literature concerning open visitation in adult intensive care units. DESIGN: A structured literature review. METHOD: This review was guided by the methodology by Kable et al. (2012). Sixteen articles are included in the review. RESULTS: Despite the documented benefits, several challenges exist which hinder broad application of open visitation in adult intensive care units. CONCLUSION: This review acknowledged challenges faced in adopting an open visiting policy in adult intensive care units such as negative staff perceptions and attitudes; patient protection; family and cultural consideration, as well as organisational challenges. The lack of a clear and consistent definition of open visitation is problematic, and strategies are urgently needed to support staff to provide holistic patient- and family-centred care.

Impact of patient and visitor hand hygiene interventions at a pediatric hospital: A stepped wedge cluster randomized controlled trial.

BACKGROUND: Patient and visitor hand hygiene has the potential to prevent health care-associated infections, but there are few data on the efficacy of interventions to improve patient/visitor hand hygiene. OBJECTIVE: To determine whether conventional and front-line ownership (FLO) patient/visitor hand hygiene interventions improve patient/visitor and health care worker (HCW) hand hygiene rates. METHODS: A stepped wedge cluster randomized controlled trial was conducted on inpatient units and the emergency department. A conventional intervention included pediatric-focused posters, which also served as reminders for HCWs. This was compared to a FLO intervention aimed at finding "positive deviants," staff who were already taking steps to improve patient/visitor hand hygiene. Patient/visitor and HCW hand hygiene rates were measured covertly by trained medical students. RESULTS: Patient/visitor hand hygiene rates increased from 9.2% at baseline to 13.9% in the post-intervention period. Hand hygiene rates on units randomized to the standard intervention changed from 7.3% to 10.9% (P = .46), but FLO intervention units significantly changed from 14.3% to 25% (P = .03). The baseline HCW hand hygiene rate was 68.2%, which increased to a greater extent in the FLO group (79.1%) than in the standard intervention (73.1%), but the change was not statistically significant for either intervention compared to control (P = .18 and P = .64, respectively). CONCLUSIONS: Hand hygiene interventions in hospitals can improve patient/visitor and HCW hand hygiene rates, and a FLO intervention appears to be more effective than a conventional intervention.