A call to action for public health nurses during the COVID-19 pandemic

Understanding the mental health and intention to leave of the public health workforce in Canada during the COVID-19 pandemic: A cross-sectional study

BACKGROUND

There is limited evidence about the mental health and intention to leave of the public health workforce in Canada during the COVID-19 pandemic. The objectives of this study were to determine the prevalence of burnout, symptoms of anxiety and depression, and intention to leave among the Canadian public health workforce, and associations with individual and workplace factors.

METHODS

A cross-sectional study was conducted using data collected by a Canada-wide survey from November 2022 to January 2023, where participants reported sociodemographic and workplace factors. Mental health outcomes were measured using validated tools including the Oldenburg Burnout Inventory, the 7-item Generalized Anxiety Disorder scale, and the 2-item Patient Health Questionnaire to measure symptoms of depression. Participants were asked to report if they intended to leave their position in public health. Logistic regression was used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) for the associations between explanatory variables such as sociodemographic, workplace factors, and outcomes of mental health, and intention to leave public health.

RESULTS

Among the 671 participants, the prevalence of burnout, and symptoms of depression and anxiety in the two weeks prior were 64%, 26%, and 22% respectively. 33% of participants reported they were intending to leave their public health position in the coming year. Across all outcomes, sociodemographic factors were largely not associated with mental health and intention to leave. However, an exception to this was that those with 16-20 years of work experience had higher odds of burnout (aOR = 2.16; 95% CI = 1.12-4.18) compared to those with ≤ 5 years of work experience. Many workplace factors were associated with mental health outcomes and intention to leave public health. Those who felt bullied, threatened, or harassed because of work had increased odds of depressive symptoms (aOR = 1.85; 95% CI = 1.28-2.68), burnout (aOR = 1.61; 95% CI = 1.16-2.23), and intention to leave (aOR = 1.64; 95% CI = 1.13-2.37).

CONCLUSIONS

During the COVID-19 pandemic, some of the public health workforce experienced negative impacts on their mental health. 33% of the sample indicated an intention to leave their role, which has the potential to exacerbate pre-existing challenges in workforce retention. Study findings create an impetus for policy and practice changes to mitigate risks to mental health and attrition to create safe and healthy working environments for public health workers during public health crises.

The competence of nurses caring for COVID-19 patients regarding disaster management: Structural equation modeling of knowledge, attitude, and performance

Background

The outbreak of COVID-19 as a global disaster has required nurses, as front-line providers of safe and quality care to patients with this disease, for proper disaster management to have a high level of competence, which demands an acceptable level of knowledge, attitude, and performance. Therefore, this study was conducted to model the relationship between knowledge, attitude, and performance with the competence of nurses caring for patients with COVID-19 regarding disaster management.

Methods

This descriptive-correlational study was conducted on 291 hospital nurses using the structural equation modeling approach in three provinces of Iran, including Kerman, Hormozgan, and Fars, from June to December 2021. Data were collected through a researcher-made questionnaire that provided information on demographics, knowledge, attitude, performance, and competence regarding disaster management. Data analysis, which included descriptive and inferential statistics, was performed using SPSS and AMOS software. Moreover, the structural equation modeling method was based on the covariance to examine the proposed model of the relationship between knowledge, attitude, and performance with nurses' competence.

Results

The study revealed that the nurses had average knowledge, acceptable attitudes, high performance, and acceptable competence scores. A positive and significant relationship was found between knowledge, attitude, and performance with nurses' competencies (P < 00.05). Furthermore, the coefficient of determination of nurses' competence in the modified structural model indicates that exogenous variables, namely knowledge, attitude, and performance, could predict 36 % of the changes in nurses' competence. Finally, the path coefficient of the effect of knowledge, attitude, and performance on nurses' competence was higher than 1.96.

Conclusions

According to the study, although the knowledge, attitude, performance, and competence of nurses caring for patients with COVID-19 were at an acceptable level, there were obstacles to improving their competence. Hence, identifying and prioritizing educational needs and learning preferences based on their cultural backgrounds are also emphasized.

Public Health Nurses' Proficiencies and Training Needs in an Emergency Response: A Cross-Sectional Observational Study

OBJECTIVE

To address gaps in understanding the public health nursing workforce regarding competencies recognized as critical during an emergency response.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional observational study using data with information on local health department staff- and organizational-level characteristics collected from across the United States in 2021. We used logistic regression to estimate the association between 2 binary nurse-specific predictors-(1) whether the staff person was a nurse and (2) whether the staff worked in a local health department that was "nurse-led" (directed by a nurse)-and reported proficiencies important to the COVID-19 response. Models controlled for relevant local health department and community characteristics.

RESULTS

In the sample, 19% were nurses and 37% were at nurse-led health departments. Nurse versus nonnurse staff had higher odds of reporting proficiencies in skills related to Justice, Equity, Diversity, and Inclusion and in the skill "identifying/applying evidence-based approaches to address public health issues." However, nurses, compared with their nonnurse peers, had higher odds of reporting training needs in domains related to community engagement, policy engagement, and cross-sectoral collaboration. Conversely, staff at nurse-led health departments, compared with non-nurse-led staff, had higher odds of reporting proficiencies in many of these same areas, including "collaborating across the public health system" and "influencing policies external to the organization that affect community health." There were no areas in which nurse-led staff had lower odds of reporting proficiencies or higher odds of identifying training needs.

CONCLUSIONS

Findings from this study highlight areas of strength for public health nurses, particularly strengths related to diversity, equity, and inclusion, as well as areas where more training is needed. Such findings can help guide future public health nurse workforce development as well as underscore the value of public health nursing leadership and staff at local health departments for supporting community health.

Association between obtaining injury prevention information and maternal and child health services during COVID-19

BACKGROUND

Coronavirus disease 2019 disrupted the delivery of public maternal and child health services to caregivers of preschool children, leading to decreased opportunities for injury prevention education. We aim to 1) explore the timing, content, and methods of providing injury prevention information desired by pregnant women and mothers and 2) identify mothers who experienced difficulty in obtaining injury prevention information owing to reduced maternal and child health services.

METHODS

From March 24 to 29, 2022, we conducted a population-based cross-sectional study and web-based survey. Of the registered monitors of the internet research company Rakuten Insight, 675 mothers raising their first child aged 0-2 during the COVID-19 period (February 2020 to March 2022) were included in the analysis.

RESULTS

Over half of the mothers wanted injury prevention information throughout their pregnancy. They preferred receiving information through traditional face-to-face services provided by local governments, such as antenatal classes or checkups. However, 34.1% of mothers said they did not obtain the information they needed; this was particularly true of unemployed mothers, had children aged 0-1, and had children with illnesses requiring hospital visits.

CONCLUSIONS

Mothers who could not obtain injury prevention information were originally disadvantaged mothers concerning access to information. The decrease in maternal and child health services may have widened this information gap. These findings can inform recommendations for caregivers, particularly those susceptible to information gaps during emergencies, and offer insights into future injury prevention education strategies.

The use of Community/Public Health Nursing Competencies during the COVID-19 pandemic

OBJECTIVES

(1) Ascertain the use of the Quad Council Competencies for Community/Public Health Nursing (QCC-C/PHN) Competencies by community/public health nurses (C/PHNs) during the COVID-19 pandemic; (2) Inform from a systems-level the need to sustain the C/PHN workforce; (3) Assess the C/PHN infrastructure for response capacity.

DESIGN

Cross-sectional. Statewide email distribution lists were used for dissemination.

SAMPLE

Convenience sample (n = 169) obtained using emailed Qualtrics link with the eligibility criteria of self-identification as a C/PHN who works in the state of Missouri.

MEASUREMENTS

Demographic questions included employment sector, nursing education level, years of nursing, and C/PHN experience. Two Likert-type questions and one optional open-text question were created for the eight domains.

RESULTS

One hundred sixty-nine participants' data were analyzed. One hundred fifty-four were employed in a local public health agency. Total 63.2% held a bachelor's degree in nursing or higher. The average number of years of nurse experience was 20.84, and C/PHN experience was 9.84. The domain of Communication Skills scored highest and Cultural Competency was the lowest. Three themes emerged from the open-ended questions including vulnerabilities of the public health system.

CONCLUSION

Understanding the experiences of C/PHNs in Missouri related to the utilization of QCC-C/PHN competencies informs efforts to strengthen public health infrastructure and target resources to equip Missouri's C/PHNs.

Wald's leadership: Public health nurses' response to the 1918 influenza pandemic

COVID-19 pandemic brings to light similarities to the 1918 influenza pandemic, one of the deadliest outbreaks in United States history. The work of the Henry Street Visiting Nurse Service also referred to the public health nurses for that time, was a critical part of the New York City response. This case study examined Lillian Wald's leadership in directing the public health nursing response in New York City during the second wave of the influenza pandemic, from September through December of 1918. A historical social framework was used. Primary sources included the Lillian Wald Papers in the Rare Book and Manuscript Library, Columbia University in New York, Wald's (1934) Windows on Henry Street, medical, public health and nursing documents, journals, and newspaper articles published during the early 20th century. Secondary source material include works by historians Sarah Abrams, Arlene Keeling, Karen Buhler-Wilkerson, Sandra Lewenson, John Barry, and Alfred Crosby. Key findings included developing a community wide strategic plan, using data driven decisions, implementing visiting nursing services, teaching in the home, and maintaining a diverse workforce. Lessons learned can guide leadership in emergency planning, system change, infection control and disease prevention, all familiar practices of public health nursing.

Characteristics of Public Health Registered Nurses and Advanced Practice Registered Nurses: Lessons Learned From the 2018 National Sample Survey of Registered Nurses

OBJECTIVES

Little research has compared the demographic and practice characteristics of registered nurses (RNs) who work in public health (PH RNs) with other RNs and advanced practice registered nurses (APRNs) who work in public health (PH APRNs) with other APRNs. We examined differences in characteristics between PH RNs and other RNs and between PH APRNs and other APRNs.

METHODS

Using the 2018 National Sample Survey of Registered Nurses (N = 43 960), we examined demographic and practice characteristics, training needs, job satisfaction, and wages of PH RNs compared with other RNs and PH APRNs compared with other APRNs. We used independent sample t tests to determine significant differences between PH RNs and other RNs and between PH APRNs and other APRNs.

RESULTS

On average, PH RNs and PH APRNs earned significantly less than other RNs ($7082 difference) and APRNs ($16 362 difference) (both P < .001). However, their job satisfaction was comparable. PH RNs and PH APRNs were also significantly more likely than other RNs and APRNs to report the need for more training in social determinants of health (20 [P < .001] and 9 [P = .04] percentage points higher, respectively), working in medically underserved communities (25 and 23 percentage points higher, respectively [P < .001 for both]), population-based health (23 and 20 percentage points higher, respectively [P < .001 for both]), and mental health (13 and 8 percentage points higher, respectively [P < .001 for both]).

CONCLUSIONS

Efforts that expand public health infrastructure and workforce development must consider the value of a diverse public health nursing workforce to protect community health. Future studies should include more detailed analyses of PH RNs and PH APRNs and their roles.

Community Health Nursing During the COVID-19 Pandemic in Korea: Consequences, Challenges, and Directions

PURPOSE

To explore the consequences, challenges, and future directions based on community health nurses' experiences during COVID-19.

DESIGN

Qualitative study. Four focus group interviews were conducted with 27 community health nurses.

FINDINGS

Three major themes emerged: 1) Coordination of roles and duties, 2) Identifying deterioration of patients' health and increasing demand for visits, and 3) Changing service delivery strategies: a testing ground for new services.

CONCLUSIONS

Community health nurses were essential public healthcare providers during the pandemic. The findings are informative for nurses and policy makers who can develop and suggest different services in the post-COVID era.

Out of Chaos Leaders Emerged

COVID-19 had a major influence on nursing with the pandemic resulting in changes in the work environment while experiencing physical and emotional challenges such as moral distress, fear for self and family and dealing with the unknown. However, during this period, nurses demonstrated extraordinary resilience, crafted innovations in clinical practice, communication and support, providing leadership in the health service and in the nursing profession.

Predictors of Healthcare Workers' Compassionate Care Amid the COVID-19 Pandemic: A Cross-Sectional Study from Patients' Perspective in Kelantan, Malaysia

Background: Compassionate care served by healthcare workers (HCWs) has been recognized as one of the most critical aspects of high-quality care. Unfortunately, there is still an unmet need for the assessment of compassionate care from the patient’s perspective. During the COVID-19 pandemic, many new rules were enacted to tackle the raging pandemic, which raised concerns about its effect on compassionate care. Methods: A cross-sectional study involving 315 patients from three public hospitals was conducted during the conditional movement control order (CMCO). A self-administered Malay version of the Relational Aspect of Care Questionnaire (RAC-QM) was used to assess compassionate care. Multiple linear regression was used to determine the predictors. Results: More than 90% of the patients were Malays, Muslims, and fell under the B40 household income category. Companions were present for 51.7% of the patients, but 75.2% had no visitors. All hospitals received scores of more than 90%. Occupation (student, p = 0.032), dependency level (total dependent, p < 0.001), and household income level (M40, p = 0.027) were the statistically significant predictors for compassionate care. Conclusions: The current study revealed that compassionate care to patients was not compromised during the pandemic. Patients with disabilities or financial constraints are more likely to experience less compassionate care, while students are generally more satisfied. This study may provide clues for hospital administrators and policymakers regarding the vulnerable group of patients. It also provides opportunities for future research to study the perspective of HCWs.

Public health nurses' perceptions and experiences of emergency preparedness, responsiveness, and burnout during the COVID-19 pandemic

OBJECTIVE(S)

To describe PHNs' perceptions and experiences of the COVID-19 pandemic, including training, response activities, and work-related challenges.

DESIGN

This was a qualitative study using interpretive description for analysis.

SAMPLE

PHN participants who worked in public health departments in Wisconsin were recruited using purposive sampling. A total of 15 PHNs participated in the study, including both general and supervisor-level PHNs.

MEASUREMENTS

Data were collected via semi-structured interviews from March to May 2021. Interview questions focused on PHNs' perceptions, experiences, response activities, and burnout in relation to the current pandemic as well as perceptions and experiences of emergency preparedness and response in general.

RESULTS

Five themes emerged in the study. These were: (1) experiences and observations of the COVID-19 pandemic, (2) organizational changes and their impacts, (3) public health emergency preparedness and response, (4) public health emergency response activities, and (5) role strain and burnout.

CONCLUSIONS

Findings presented here have important implications for PHN training and support in emergency preparedness and response. A wide array of strategies focused on developing and supporting the PHN workforce in response to the public health crisis this area need to be implemented at the organizational, community, and policy levels.

The roles of community health nurses for older adults during the COVID-19 pandemic in Northeastern Thailand: A qualitative study

Objective

Community health nurses play an important role in primary health care service, especially during the spread of COVID-19. This study aimed to describe the work and activities of community health nurses focusing on the care of older adults during the COVID-19 pandemic in Northeastern Thailand.

Method

This was a qualitative research study. The methods, including observation, in-depth interview, secondary data, and focus group discussion, were employed to obtain data from 46 key informants. The process started from February to August 2022 in northeastern Thailand. Data were analyzed using content analysis.

Results

The results of this study were organized into 3 main themes focusing on 1) Community health nurses' role for older adults during the COVID-19 pandemic, which consists of 12 sub-themes; 2) Barriers of community health nurses in caring for older adults during the pandemic consisted of 2 sub-themes; and 3) Factors contributing to the success of community health nurses in managing health and providing care for older adults during the pandemic consisted of 4 sub-themes.

Conclusions

The findings showed that community health nurses had played important roles, such as educating and advocating health, providing care, promoting and empowering people in the community toward health, and giving emotional and nutritional support to older adults during the COVID-19 pandemic. This study can be used as a guideline for policymakers and health-related agencies to develop healthcare strategies and to optimize the management of community health nurses in caring for older adults during the pandemic. COVID-19 is a major public health challenge; therefore, understanding the roles and activities of community health nurses helps improve primary care cluster development, strengthens healthcare services in community, and for everyone in the community to be ready for possible challenge of future global pandemics.

Sally Lucas Jean, R.N. (1878-1971): Her historical legacy and lessons for contemporary public health nursing education

Sally Lucas Jean, RN (1878-1971) pioneered health education in the United States and globally. At the time of her death in 1971, aged 93, her legacy included serving on boards of leading American health associations, spearheading public health projects worldwide and transforming thinking on contemporary public health education. Sally Lucas Jean's influence continues today, from her input on educational children's television programs, policies on child health and her involvement in developing the early foundations of health communication. In this historical reflection, we examine her role in defining health education and communication, alongside influencing and applying strategies to improve public health nursing.

Comprehensive initial evaluation of an innovative yearlong population health internship for undergraduates

BACKGROUND

The innovative Population Health Internship (PHI) addresses the evolving need for baccalaureate-prepared nurses to achieve population health competency. A comprehensive evaluation of the inaugural year of the PHI was conducted using the Centers for Disease Control and Prevention (CDC) Framework for Program Evaluation in Public Health and the Context, Input, Process, Product (CIPP) curricular evaluation model. Students and community agency partners-both key stakeholders-contributed to the evaluation.

METHODS AND RESULTS

Quantitative data were used to address functional and outcome areas of the PHI for purposes of PHI logistics, student learning gains, and program impact and sustainability. Qualitative data were used to provide insights into challenges in instituting curricular change, complexity in student-agency communications, importance of student preparedness/attitude, issues of role confusion, misperceptions about the population health nursing role, student learning, and impacts on partner agencies and their populations.

IMPLICATIONS

Educational implications include the importance of assessing both learning gains and student buy-in, the need for a long-term evaluation approach to accommodate for challenges related to radical curriculum change, and the importance of strong stakeholder support to facilitate mutually beneficial relationships and a positive learning experience.

Public Health Workforce Gaps, Impacts, and Improvement Strategies from COVID-19

The public health workforce has been instrumental in protecting residents against population health threats. The COVID-19 pandemic has highlighted the importance of the public health workforce and exposed gaps in the workforce. Public health practitioners nationwide are still coming to understand these gaps, impacts, and lessons learned from the pandemic. This study aimed to explore Minnesota's local public health practitioners' perceptions of public health workforce gaps, the impacts of these workforce gaps, and the lessons learned in light of the COVID-19 pandemic. We conducted seven concurrent focus groups with members of the Local Public Health Association of Minnesota (LPHA; n = 55) using a semi-structured focus group guide and a survey of the local agencies (n = 70/72 respondents, 97% response rate). Focus group recordings were transcribed verbatim and analyzed using deductive and inductive coding (in vivo coding, descriptive coding), followed by thematic analysis. The quantitative data were analyzed using descriptive analyses and were integrated with the qualitative data. Participants indicated experiencing many workforce gaps, workforce gaps impacts, and described improvement strategies. Overall, many of the workforce gaps and impacts resulting from COVID-19 discussed by practitioners in Minnesota are observed in other areas across the nation, making the findings relevant to public health workforce nationally.

Influencing factors of fatigue among public health nurses during the COVID-19 pandemic: A cross-sectional study

OBJECTIVE

This study investigated the effects of occupational stress, anxiety, depression, and sleep disturbance on the level of fatigue among public health nurses (PHNs).

DESIGN

The study had a cross-sectional, correlational survey design.

MEASURES

A total of 198 PHNs were enrolled from 30 public healthcare centers/offices. Data were collected between May and July 2021 using a structured questionnaire to investigate the general characteristics, occupational stress, anxiety, depression, sleep disturbance, and fatigue of the participants. Descriptive statistics and multiple regressions were used to determine fatigue and its influencing factors among PHNs.

RESULTS

The participants showed high fatigue and occupational stress levels due to a lack of rewards. The percentage of participants with mild-to-severe anxiety and mild-to-severe depression, and those who identified themselves as poor sleepers were 44.9%, 50.5%, and 70.2%, respectively. High levels of sleep disturbance (β = .23, p < .001), occupational stress (β = .21, p < .001), anxiety (β = .20, p = .016), depression (β = .17, p = .043), being younger (β = -.15, p = .004), and being a regular worker (β = .13, p = .017) were influencing factors of fatigue.

CONCLUSIONS

Individual efforts and organizational interventions to enhance sleep quality are needed to relieve fatigue among PHNs. Further, organizational support can be considerate of young nurses and regular workers, and alleviate their occupational stress. Moreover, anxiety and depression should be managed efficiently to reduce fatigue.

A scoping review of strategies to support public health recovery in the transition to a "new normal" in the age of COVID-19

Background

During the COVID-19 pandemic, the public health workforce has experienced re-deployment from core functions such as health promotion, disease prevention, and health protection, to preventing and tracking the spread of COVID-19. With continued pandemic deployment coupled with the exacerbation of existing health disparities due to the pandemic, public health systems need to re-start the delivery of core public health programming alongside COVID-19 activities. The purpose of this scoping review was to identify strategies that support the re-integration of core public health programming alongside ongoing pandemic or emergency response.

Methods

The Joanna Briggs Institute methodology for scoping reviews was used to guide this study. A comprehensive search was conducted using: a) online databases, b) grey literature, c) content experts to identify additional references, and d) searching reference lists of pertinent studies. All references were screened by two team members. References were included that met the following criteria: a) involved public health organizations (local, regional, national, and international); b) provided descriptions of strategies to support adaptation or delivery of routine public health measures alongside disaster response; and c) quantitative, qualitative, or descriptive designs. No restrictions were placed on language, publication status, publication date, or outcomes. Data on study characteristics, intervention/strategy, and key findings were independently extracted by two team members. Emergent themes were established through independent inductive analysis by two team members.

Results

Of 44,087 records identified, 17 studies were included in the review. Study designs of included studies varied: descriptive (n = 8); qualitative (n = 4); mixed-methods (n = 2); cross-sectional (n = 1); case report (n = 1); single-group pretest/post-test design (n = 1). Included studies were from North America (n = 10), Africa (n = 4), and Asia (n = 3) and addressed various public health disasters including natural disasters (n = 9), infectious disease epidemics (n = 5), armed conflict (n = 2) and hazardous material disasters (n = 1). Five emergent themes were identified on strategies to support the re-integration of core public health services: a) community engagement, b) community assessment, c) collaborative partnerships and coordination, d) workforce capacity development and allocation, and e) funding/resource enhancement.

Conclusion

Emergent themes from this study can be used by public health organizations as a beginning understanding of strategies that can support the re-introduction of essential public health services and programs in COVID-19 recovery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13663-2.

A Community-Based Participatory Intervention in the United States Using Data to Shift the Community Narrative From Deficits to Strengths

With Minneapolis, Minnesota, partners, we developed a community-based participatory intervention using a mobile health application to provide actionable data to communities. More than 550 participants completed the survey. Key messages included strengths in our homes, neighborhoods, and faith communities. Key challenges were related to substance use and sleeping. We jointly conducted virtual community meetings such as webinars, Facebook Live shows, and online newsletters to begin to shift the community narrative from deficits to whole-person health, including strengths. (Am J Public Health. 2022;112(S3):S275-S278. https://doi.org/10.2105/AJPH.2022.306852).

Enumeration of Public Health Nurses in the United States: Limits of Current Standards

Recent national initiatives in nursing and public health have emphasized the need for a robust public health nursing (PHN) workforce. In this article, we analyze the extent to which recent national enumeration surveys base their counts of this workforce on the definitions, scope, and standards for practice and practice competencies of the PHN nursing specialty. By and large, enumeration surveys continue to rely on practice setting to define the PHN workforce, which is an insufficient approach for meeting the goals of major nursing and public health initiatives. We make recommendations for the development of new standards for PHN enumeration to strengthen the broader public health infrastructure and evaluate PHN contributions to population-level outcomes. (Am J Public Health. 2022;112(S3):S292-S297. https://doi.org/10.2105/AJPH.2022.306782).

Exploring the context, role and impact of public health nursing during COVID-19: A multiple case study protocol

AIM

The purpose of this study is to: (a) describe public health nursing roles over the course of the COVID-19 pandemic in Ontario, Canada; (b) describe the contextual factors that influence public health nursing role implementation; and (c) describe nurses' perceived impact of their roles on client outcomes and professional/personal nursing practice.

DESIGN

Descriptive multiple case study.

METHODS

Recruitment of public health nurses (PHNs), working in direct service or administrative leadership positions, in an Ontario public health unit will be conducted through purposive and snowball sampling. Nursing roles will be compared and contrasted across three cases differentiated by geographic setting: urban, urban-rural, northern. In each geographic case, a priori estimates of sample size will include 10 PHNs providing direct care and at least five nurses in an administrative leadership role; with an overall estimated study sample size of 45 individuals. Demographic data will be collected using an online anonymous survey. Individual semi-structured interviews with PHNs, and focus groups with nursing administrators will be conducted via telephone and audio-recorded. Individual interviews and focus groups will be transcribed verbatim. Reflexive thematic analysis will be used to generate emergent themes in each case and cross-case synthesis will be used to compare and contrast patterns across geographic cases.

DISCUSSION

Expected findings will provide an in-depth analysis of the rapidly evolving roles and functions of PHNs throughout the COVID-19 pandemic and their impact on individuals, families and communities. As well, findings will provide a new understanding about the contextual barriers and facilitators of PHN role implementation in their working environments.

IMPACT

Study findings can support decision-making in relation to funding, resource allocation and supportive work structures and processes at a public health system and/or individual public health organization level.

The Roles of Community Health Nurses' in Covid-19 Management in Indonesia: A Qualitative Study

Background

The majority of Covid-19 cases occur at the community level requiring health services to be available at the primary health care level, which also includes Community Health Nursing (CHN) services. It is important to understand various perspectives of the parties involved, effective solutions, and strategies used by nurses in managing Covid-19 in order to be able to provide these services. The purpose of this study was to explore the community health nurses' (CHNs) roles in the Covid-19 management in Indonesia.

Methods

A qualitative method was used to explore the perspective from nurses and health cadres as participants. Data were collected through in-depth phone interviews with 11 participants from December 2020 to February 2021 in Bandung. Data were analyzed manually using thematic analysis.

Results

Five themes were extracted in this study, namely providing comprehensive services by CHNs; utilizing technology to bridge the information needs; implementing family nursing care; spreading the wings of health cadres by CHNs; and collaborating as the heart of Covid-19 prevention and management.

Conclusion

CHNs should employ health education, empowerment strategies, group processes, and advocacy in adapting to the Covid-19 pandemic situation. The five themes identified in this study can be used by policy makers to develop strategies in optimizing the CHN in Covid-19 pandemic management and the possible challenges of future global pandemics.

The effect of COVID-19 pandemic on lifestyle-related behaviours in Turkey: A web-based cross-sectional study

Background

The COVID‐19 pandemic and restrictions imposed to eradicate it have affected healthy lifestyle‐related behaviours.

Aim

The aim of this study was to determine the effect of COVID‐19 on lifestyle‐related behaviours.

Methods

This cross‐sectional web‐based survey research was performed with a convenience sample of 1020 adults residing in Turkey. Data were collected with self‐report data collection tools on 8–28 April 2021: a sociodemographic characteristics form and the impact of COVID‐19 on lifestyle‐related behaviours questionnaire.

Results

Eating behaviours, physical activity and sleep patterns of the participants were negatively affected during COVID‐19 pandemic (p < 0.001). More than half of the participants experienced weight gain during the pandemic. Also, stress levels and smoking increased (p < 0.01). The participants reported having changes in their lifestyles most frequently due to the fear of COVID‐19 infection, stress, decreased motivation, closure of the facilities for social and sports activities and increased food prices. Predictors of lifestyle‐related behaviours were found to be education (β = .189), income (β = −.101), residing in a village (β = .113) and the presence of a chronic disease (β = .075) (p < 0.001).

Conclusions

During the pandemic, COVID‐19‐related restrictions should be applied whilst taking account of both social distancing measures and maintenance of healthy lifestyle‐related behaviours. Nurses should offer counselling for maintenance of healthy lifestyle‐related behaviours.

What is already known about this topic?

Studies performed at the beginning and during the course of COVID‐19 pandemic in different countries have shown that lifestyle‐related behaviours are negatively affected.

Few studies have used a valid and reliable tool to determine the effect of COVID‐19 on lifestyle‐related behaviours.

The effect of COVID‐19 on lifestyle‐related behaviours has not been examined from a nursing perspective.

What this paper adds?

In the present study, which was performed at a time when night curfews and weekend shutdowns were imposed in Turkey, lifestyles of the participants were found to be negatively affected.

More than half of the participants gained weight and had increased stress and smoking and a decreased sleep quality.

The negative effect on lifestyle‐related behaviours was more severe in participants with low education and income levels, living in a village and suffering from a chronic disease.

The implications of this paper:

Restrictions introduced during the pandemic should both take account of social distancing measures and allow healthy lifestyle‐related behaviours.

Nurses playing a role in first line health care services should offer education and counselling for maintenance of healthy lifestyle‐related behaviours by utilizing information and communication technology (e.g., video calls).

Perceptions of COVID-19 Mitigation Strategies between Rural and Non-Rural Adults in the US: How Public Health Nurses Can Fill the Gap

The purpose of this study was to capture the perceptions of COVID-19 mitigations' efficacy of rural and non-rural participants, using the health belief model (HBM), as well as to describe where public health nursing may be able to fill behavior gaps in rural communities. Rural and non-rural participants completed electronic surveys. Surveys collected demographic information and perceptions of various mitigation strategies' effectiveness. Rurality was significantly associated with perceptions of the effectiveness of public health mitigation strategies including wearing facemasks, limiting time indoors, avoiding gatherings, non-essential business closure, and staying home. Our findings suggest people in rural areas perceive mitigations to be effective. Other researchers have consistently shown rural residents are least likely to partake in the same mitigations. Rural public health nurses on the front line serve as the key to closing the aforementioned gap. Understanding where their community's perceptions lie is pivotal in creating educational programs to continue mitigation efforts as we embark on the second year of this pandemic.

Impact of COVID-19 on public health nursing student learning outcomes

BACKGROUND

The COVID-19 pandemic has highlighted the importance of a strong, effective public health nursing workforce while also requiring public health nursing faculty to adapt teaching strategies as courses transitioned online. It is essential to understand how the pandemic-enforced transition from face-to-face to remote learning impacts student outcomes. The purpose of this paper is to compare student learning outcomes in a pre-licensure public health nursing course before, during, and after the transition to remote learning.

METHODS

Descriptive statistics were computed for assignments, exams, and final course grades for three terms (Fall 2019, Spring 2020 and Fall 2020).

RESULTS

Analysis showed statistically significant differences between terms for assignments and exams but not the final course grade. However, these differences were driven by small standard deviations rather than differences between mean scores demonstrating that there was actual little difference in student learning outcomes across terms.

CONCLUSIONS

Authors suggest strategies to support consistent academic outcomes and future research needed understand student learning outcomes during the pandemic; ultimately building the public health nursing workforce necessary to address the current and future public health crises.

Emotional Labor and Burnout of Public Health Nurses during the COVID-19 Pandemic: Mediating Effects of Perceived Health Status and Perceived Organizational Support

The purpose of this study was to identify the mediating effects of perceived health status (PHS) and perceived organizational support (POS) in the association between emotional labor and burnout in public health nurses (PHNs). The participants were 207 PHNs convenience sampled from 30 public health centers and offices in Jeju, Korea. Data regarding emotional labor, PHS, POS, and burnout were collected between February and March 2021 using a structured questionnaire. Collected data were analyzed by Pearson’s correlation coefficient and multiple regression analysis. Burnout of PHNs was positively correlated with emotional labor (r = 0.64, p < 0.001) and negatively correlated with PHS (r = −0.51, p < 0.001) and POS (r = −0.51, p < 0.001). In the association between emotional labor and burnout, PHS (B = −1.36, p < 0.001) and POS (B = −0.42, p = 0.001) had a partial mediating effect. Reduction of burnout among PHNs requires not only effective management of emotional labor but also personal and organizational efforts to improve PHS and POS.

The first line of prevention: A public health nursing advocacy video

Public health nurses (PHNs) serve as the first line of prevention in public health and safety threats such as the COVID-19 pandemic. Although PHNs provide vital services to protect communities and populations' health, a pervasive lack of knowledge exists regarding the PHN role among policymakers and the general public. Advocacy for investment in the public health nursing workforce remains a priority as staffing and financial constraints have created sizeable barriers for PHNs during the COVID-19 response. Creating an advocacy video with personal stories from PHNs emerges as a powerful and cost-effective strategy to increase the visibility of PHNs. For this project, interviews with PHNs from COVID-19 hot spots were used to create a 3-min advocacy video. PHNs featured in this video discussed the implications of rerouting resources to combat COVID-19 for the populations they serve. The authors disseminated the video through popular social media venues, public health and nursing organizations and nurse influencers to reach nursing students, faculty, and the public. Over an 8-week period, the video received 2732 views on social media with an average view duration of 2 min. This article includes strategies to maximize the impact of an advocacy video when shared with relevant stakeholders.

"No Man Is an Island": Perspectives of CHamorus in Guam on COVID-19

OBJECTIVES

Guam is a United States territory situated in the western Pacific Ocean with a multiethnic population numbering approximately 168,000. The CHamorus, who are the Indigenous people of Guam, make up 37%. In this study, we sought to explore CHamorus' perspectives on and experiences of COVID-19.

DESIGN

Interviews were conducted with 10 CHamoru adults in June-July 2020 via telephone for a larger study on understanding how the collective history of the CHamoru people is perceived relative to contemporary health beliefs and practices. This study is a secondary data analysis of questions that focused on COVID-19. We used thematic analysis techniques to analyze the data.

RESULTS

Three themes were identified: self and other, or "no man is an island"; trust in government; and focusing on the positives. A cross-cutting theme was commitment to the common welfare of the community through interconnectedness and inafa'maolek (doing good for others).

CONCLUSION

Results indicated that CHamorus recognized a balance between community and individual, the need to protect the vulnerable while also considering personal choice, and the implications of enforced social distancing on community and economic stability.

Alternative capstone nursing experience to scale up testing and case investigation

BACKGROUND

Surges related to the SARS-COV2 virus in the United States have underscored the critical importance of large-scale testing, case investigation and contact tracing. Baccalaureate nursing students have the potential to serve as surge capacity workforce in mitigation measures during this public health emergency.

METHODS

Over the course of eight weeks (September-December 2020) baccalaureate senior capstone nursing students served as case investigators for a local health department (LHD) on Long Island, New York and surveillance pooled saliva testers for their college to ensure compliance with a state-wide COVID-19 testing mandate. To determine student perceptions working in these concurrent novel academic-partnerships during the COVID-19 pandemic, a descriptive survey of open-ended interview questions was completed by student participants (n = 10).

RESULTS

Analysis of aggregate responses revealed common themes across the data set linking student learning and appreciation of the "eye-opening" experience to a sense of purpose, the value of communication, education and teamwork-all within the structure of public health nursing.

CONCLUSIONS

Baccalaureate nursing students can effectively serve as an untapped workforce within an academic partnership to support surveillance testing and case investigation during the COVID-19 pandemic and future public health crises. This partnership had the added benefit of exposing nursing students to the critical nature of public health nursing during this historic time in our nation.

Protecting persons experiencing homelessness through a global pandemic

In response to the challenges imposed by the COVID-19 global pandemic, the leadership of a large homeless service and residential recovery organization transformed its organizational practices in accordance with best available evidence for prevention and containment of the SARS-CoV-2 virus. The coordinated organizational response was based on the CDC's "whole community" framework for addressing the threat of COVID-19 among persons experiencing homelessness and included strategies for preparation and containment of the virus and identification of exposures and disease outbreaks. Organizational practice changes were also instituted to mitigate spread. New protocols and procedures addressed admission intake processes, testing and monitoring, and guidelines for managing staff, vendors, and volunteers. Finally, an on-site vaccination clinic was organized through the establishment of a four-pronged coalition. The program outreached to staff, residents, and essential volunteers. Following implementation of this coordinated organizational response, confirmed SARS CoV-2 cases in the facility declined to zero. Through this experience, the leadership became more adept at improving its digital fitness and pivoting when circumstances dictated a shift in policy and practice. In every major initiative or policy change aimed at addressing the spread of the virus, community partnerships were key to effective implementation of COVID-19 prevention and containment strategies.

Public Health Nursing and Community Health Worker Teams: A Community-Based Preventive Services Clinic Exemplar

Since 2009, a community-based, collaborative exemplar in Richmond, Virginia, involving 8 satellite clinics of the state health department, has been implemented within public housing units to focus on prevention and access to care. These satellite centers, known a resource center (RCs), are staffed by public health nurses, community health workers, and nurse practitioners working in complementary roles. The RCs have provided education to 2609 clients on family planning, safe sex practices, safe car seat use, and screening for sexually transmitted infections and have made 9591 patient referrals to health, social, and community services.

Attitudes towards social distancing in response to COVID-19

OBJECTIVES

COVID-19 has highlighted differences in our engagement in health prevention behaviors. The Health Belief Model (HBM), personality traits (conscientiousness, extraversion, and neuroticism), and sociodemographic variables were used to evaluate social distancing during the first month of a state-mandated Stay At Home (SAH) order.

DESIGN

A web-based convenience sample of 645 Ohioans was surveyed. Hierarchical linear regression and mediation analysis were used to examine predictors of social distancing attitudes and behaviors and whether health beliefs mediated the relationship between personality and social distancing.

RESULTS

Most respondents agreed with and adhered to social distancing guidelines. HBM constructs were strong predictors of SAH attitudes, while personality accounted for little additional variance. Anxiety was indirectly related to overall social distancing attitudes and behavior through its relationship with health beliefs. However, violations of social distancing were best explained by situational factors (e.g., being an essential worker).

CONCLUSION

The results demonstrate the power of components of the HBM to explain attitudes and behaviors regarding the SAH order beyond any contribution from personality. By examining the role of personality and health beliefs on social distancing attitudes and behaviors, this research will benefit public health nurses and others tasked with communicating and promoting preventative health behavior.

The effect of coronavirus (COVID-19) outbreak on the mental well-being and mental health of individuals

AIM

This study was conducted to examine the effect of COVID-19 pandemic on the mental well-being and mental health of individuals.

DESIGN AND METHOD

This cross-sectional questionnaire study was conducted with 614 individuals over the age of 18.

FINDINGS

Regarding the coronavirus outbreak, it was found that 84.9% of the participants are afraid/anxious. The psychiatric problems of the individuals who fear/worry about coronavirus becoming a pandemic, who stated that staying at home because of the outbreak negatively affect their mental health and that domestic violence cases have increased due to the outbreak were found to be higher (p < 0.05).

PRACTICE IMPLICATION

The coronavirus outbreak causes fear and anxiety in society. This triggers so many psychological symptoms.

Exploring experiences of COVID-19-positive individuals from social media posts

Aims

This study aimed to explore the experience of individuals who claimed to be COVID‐19 positive via their Twitter feeds.

Background

Public social media data are valuable to understanding people's experiences of public health phenomena. To improve care to those with COVID‐19, this study explored themes from Twitter feeds, generated by individuals who self‐identified as COVID‐19 positive.

Design

This study utilized a descriptive design for text analysis for social media data.

Methods

This study analysed social media text retrieved by tweets of individuals in the United States who self‐reported being COVID‐19 positive and posted on Twitter in English between April 2, 2020, and April 24, 2020. In extracting embedded topics from tweets, we applied topic modelling approach based on latent Dirichlet allocation and visualized the results via LDAvis, a related web‐based interactive visualization tool.

Results

Three themes were mined from 721 eligible tweets: (i) recognizing the seriousness of the condition in COVID‐19 pandemic; (ii) having symptoms of being COVID‐19 positive; and (iii) sharing the journey of being COVID‐19 positive.

Conclusion

Leveraging the knowledge and context of study themes, we present experiences that may better reflect patient needs while experiencing COVID‐19. The findings offer more descriptive support for public health nursing and other translational public health efforts during a global pandemic.

What is already known about this topic?

Social media data can be used to predict potential outbreak areas, which has been beneficial to informing decision makers.

Public opinions about the pandemic can be extracted from social media data, which helps understand patients and the public's experiences and potential needs.

In the early stage of the novel COVID‐19 pandemic in the United States, little was known about the experiences and needs of those with COVID‐19.

What this paper adds?

Individuals who claimed to be COVID‐19 positive used the social media platform (e.g., Twitter) as a broader communication strategy to their social networks during the social distancing phase at the early stage of the COVID‐19 pandemic.

Key messages delivered through the social media included warning their family, friends and network take the pandemic seriously, expressing their symptom profiles related to COVID‐19 and sharing their journey of being a COVID‐19 patient.

Although latent Dirichlet allocation may be underutilized in nursing research, valuable information regarding mental health issues can be discovered and amplified from the social media data using this methodology.

The implications of this paper:

Substantial evidence encourages the public health community to engage in more detailed mental health screening of patients with COVID‐19.

By leveraging the knowledge and context of the social media threads (e.g., patient perspective), there is ample opportunity for more focal and descriptive public health interventions to mitigate the stress and uncertainty of a pandemic.

Faculty perspectives on transitioning public health nursing clinical to virtual in response to COVID-19

The COVID‐19 pandemic has highlighted the need for public health nursing as an integral part of a strong public health workforce. However, it has also created challenges in preparing future nurses as much of nursing instruction, including clinical experiences, needed to urgently transition learning to a virtual environment. This paper describes the process faculty experienced during spring 2020 to quickly transition public health nursing clinicals from in‐person to virtual learning in response to COVID‐19. Further, faculty lessons learned are shared and include the importance of creating a supportive team dynamic, embracing innovation, continuing to engage with community partners, and adapting to meet emerging student needs during the evolving pandemic. The process and lessons learned may act as a guide for other nursing programs as we continue to navigate nursing education during this and future pandemics.

A critical gap: Advanced practice nurses focused on the public's health

BACKGROUND

The COVID-19 pandemic has highlighted the need for nurse leaders who "embrace the interconnection" between medicine and public health. The inequitable impact of COVID-19 on people of color demonstrates the importance of applying expertise from nursing practice and public health systems to work with communities and other professions on complex health issues. Yet, despite a clear need for improved population health, educational programs designed to produce Advanced Public Health Nurses, with skills to address complex system changes, have become increasingly scarce.

PURPOSE

We put forward the perspective that the nation needs more advanced practice nurses prepared for leadership roles focused on the health of whole populations, marginalized communities, and the systems and policies that promote their health.

DISCUSSION

We argue that opportunities should be expanded for nurses to attain education for these roles through increased investments in the Doctor of Nursing Practice model to prepare nurses for advanced public health specialty practice.

Care Delivery and Treatment Decision Making: Bioethical and Nursing Considerations During and After the COVID-19 Pandemic

BACKGROUND

The disruption in the supply chain of resources and interruptions in cancer treatments caused by the pandemic presented tremendous challenges to the healthcare system.

OBJECTIVES

This article describes the National Academy of Medicine-defined states of medical and nursing care delivery for which local plans should be drawn and the shifting and evolving systems framework that can guide decisions to optimize the crisis standards of care.

METHODS

A case study is presented to describe the process of shifting the state of medical and nursing care delivery and bioethical nursing considerations during the pandemic and beyond.

FINDINGS

An evolving and shifting systems framework for crises rooted in deontology, principlism, and the ethics of care model provide meaningful guidance for establishing priorities for patient care.

A scholarly concentration program to promote public health nursing for generalist Clinical Nurse Leader students

BACKGROUND

The number of public health nurses has decreased consistently and significantly since the 1920's. The recent COVID-19 pandemic has put a spotlight on the need for more public health nurses in the workforce. The number of novice nurses entering into public health roles is declining, demonstrating a clear need to mentor pre-licensure nursing students into the public health nursing workforce. Scholarly concentration (SC) programs are a method to explore specialty roles through in-depth scholarly activities, outside of core curriculum. However, SC programs have not been described in the nursing literature. The purpose of this paper is to describe the development of a SC program to engage pre-licensure Clinical Nurse Leader (CNL) students in scholarly activities related to public health nursing.

PROGRAM OVERVIEW

This Public Health Nurse Scholars program was developed in 2014 with the goal of developing a cadre of generalist CNL students with experiences in public health nursing scholarly activities. The program aimed to increase awareness of career and scholarship opportunities through mentorship with public health nursing faculty. Students were encouraged to attend and present at professional conferences, participate in active scholarly projects and conduct quality improvement projects from a public health nursing perspective. The program was designed to foster students' public health nursing leadership and presentation skills and enhance their self-directed learning.

RESULTS

To date, 46 pre-licensure nursing students were selected as Public Health Nurse Scholars. Sixty-seven percent (n = 31) have graduated as Public Health Nurse Scholars; 33% (n = 15) are current Public Health Nurse Scholars. Twelve public health nursing faculty have served as mentors. As a result of the program 15 scholars attended and 3 scholars presented respectively at community/public health nursing conferences, and several scholars had related professional development opportunities. A majority of Public Health Nurse Scholars have designed and implemented a capstone quality improvement project with a public health nursing perspective, 15 of which were completed at community-based sites.

CONCLUSIONS

In the face of our current global, public health crisis, there is a clear need to develop a cadre of novice nurses prepared to enter the public health nursing workforce. The Public Health Nurse Scholars program shows promise towards encouraging an interest in public health nursing scholarship. Schools of nursing may consider the implementation of similar SC programs as an approach to mentor pre-licensure nurses in other specialty areas such as gerontological and neonatal nursing.

Does it make a difference? Exploring the value of combining public health and nursing education

BACKGROUND

Within the evolving United States healthcare system, there is a need to strengthen the public health nursing workforce. Historical and more recent trends within nursing education have demonstrated this need. Nurses who obtain a Master of Public Health (MPH) contribute to this workforce's development.

PURPOSE

This study aimed to describe nurses' educational and professional experiences with an MPH and better understand how professionals use this combination in practice.

METHODS

This study utilized a phenomenological, qualitative research method. Researchers interviewed 11 nurses with an MPH via the telephone. The researchers independently coded the interview transcripts and developed a codebook. Qualitative analysis facilitated the emergence of subsequent themes.

RESULTS

Four themes emerged: (1) educational pathway decisions, (2) education experience, (3) role in the workforce, and (4) nursing and public health in practice. Participants worked in a variety of settings, including primary care, academia, and administration. All participants reported utilizing their nursing and public health skills and described the actual integration of these skills in the workplace.

CONCLUSION

These findings suggest that nurses with an MPH value the education and report being better equipped to promote health on both the individual and community levels.

Identifying public concerns and reactions during the COVID-19 pandemic on Twitter: A text-mining analysis

Efforts to control the current coronavirus disease 2019 (COVID-19) pandemic have led to national lockdowns around the world. Reactions to the rapidly evolving outbreak were shared on social media platforms. We conducted a mixed-methods analysis of tweets collected from May 10 to May 24, 2020, using MAXQDA software in conjunction with Twitters search API using the keywords: "COVID-19," "coronavirus pandemic," "Covid19," "face masks," and included terms such as "Queens," "Bronx," "New York." A total of 7, 301 COVID-19-related tweets across the globe were analyzed. We used SAS Text Miner V.15.1 for descriptive text mining to uncover the primary topics in unstructured textual data. Content analysis of tweets revealed six themes: surveillance, prevention, treatments, testing and cure, symptoms and transmission, fear, and financial loss. Our study also demonstrates the feasibility of using Twitter to capture real-time data to assess the public's concerns and public health needs during the COVID-19 pandemic.

Perceived risk of infection and smoking behavior change during COVID-19 in Ohio

Objective

The recent COVID‐19 pandemic may catalyze smoking behavior modification. The purpose of the study was to examine factors associated with reducing smoking exposure during the COVID‐19 outbreak.

Design

Cross‐sectional design using the Health Belief Model to develop an online survey distributed throughout Ohio early during the outbreak.

Sample

810 adults in Ohio (77.9% non‐smokers, 22.1% current smokers).

Measurements

Sociodemographic factors, smoking and behavior changes since the COVID‐19 outbreak, and perceived risk of infection were collected. Logistic regression analyses were conducted to determine factors associated with indoor smoking bans and factors associated with desire to quit smoking since the outbreak.

Results

For the overall sample, the odds of indoor smoking bans were significantly associated with never smoked, college education, single‐family residence, not living with smokers, and perceived importance of avoiding public places. For smokers, the desire to quit smoking since the COVID‐19 outbreak was associated with diabetes and perceived risk of severe infection.

Conclusions

Identified factors inform residential smoking exposure reduction through indoor smoking bans. Having an increased perceived risk of severe infection among smokers may motivate cessation. Public health nurses can provide accurate and accessible resources for smoking cessation during the COVID‐19 pandemic to promote healthy lifestyle modification.

Being a real nurse: A secondary qualitative analysis of how public health nurses rework their work identities

Many Western nations are emphasizing the importance of population health across health care delivery organizations and education systems. Despite significant momentum to integrate population health into nursing practice, a parallel effort to examine how these efforts impact practicing nurses' views of their professional role and work identity has not occurred. This secondary qualitative analysis, employing an abductive approach, explored processes public health nurses use in creating and maintaining their work identity through three organizing themes: narrative self-identity, mandated identity, and identity as struggle. The analysis was based on interview data collected from 30 US public health nurses residing in 17 states. 'Being a real nurse' describes public health nurses' efforts to balance a contradictory work identity where at times they are expected to focus on populations and at other times, on individuals. The identity work revealed through this study should be further explicated and specific strategies developed for stabilizing a work identity for public health nurses, as well as for any nurse charged with a population health role.