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Reflecting Art in Nursing Practice

Developing Visual Arts Programs to Transform and Strengthen Practice

Anglin, Carlita MSIS; Halpin-Healy, Carolyn MA; Rosenfeld, Peri PhD, FAAN

Author Information
JONA: The Journal of Nursing Administration: May 2020 - Volume 50 - Issue 5 - p 274-280
doi: 10.1097/NNA.0000000000000883

Abstract

The field of medical humanities has been defined as “an interdisciplinary and multidisciplinary field that explores contexts, experiences, and critical and conceptual issues in medicine and healthcare, while supporting professional identity formation.”1 Humanities-oriented learning experiences refer to educational encounters that employ elements from disciplines not typically associated with science-concentrated curricula. The current field was motivated by desire to prepare physicians, and subsequently other healthcare providers, with the ability to deal with ambiguity, uncertainty, and fundamental complexities of the human experience.2 Key concepts from the humanities such as ethics, literature, history, art, music, and other fields are now part of the educational preparation of a variety of healthcare providers, which has given rise to the term “health humanities.”1,3

Contemporary commitment to person-centered care, which is recognized as a best practice framework of care,4 may also be a source of inspiration for health humanities programs. Self-care modalities, a component of person-centered care,5 encourage individuals to improve their own health and navigate chronic illness though personal agency. Good self-care practices activate both providers and consumers to effect positive health outcomes in their lives, underscoring a shared humanity between provider and patient. These trends may also explain current interest in humanities offerings for healthcare providers in training and practice. Nonetheless, despite growing interest in the connections between humanities thinking and clinical experiences, as well as current interest in self-care, these remain uncommon in nursing education, and rarer still as professional development for nurses in practice.

This article describes the development and implementation of a visual arts humanities program, Reflecting Art in Nursing Practice, for practicing nurses at NYU Langone Health, an academic medical center in New York City. In addition, we will also discuss the lessons learned in promoting and delivering the program in a busy hospital setting and describe the impact on nursing practice as provided through participant feedback.

Literature Review

Over the past decades, there has been growing interest in integrating visual arts, music, poetry, and literature in the preparation and training of healthcare professionals. Proponents argue that meaningful engagement with the visual arts increases provider competencies such as tolerance of ambiguity6; developing empathy or compassion7; improved communication with patients8; increased ability to notice subtle changes linked to clinical risk factors9; enhanced problem solving skills10 and strengthened observation, description, and analytic skills that are foundational skills in nursing assessment.10 Interdisciplinary humanistic experiences among nurses and physicians have been shown to improve interprovider communication, as well.11

An annual report of art museum and healthcare partnerships from The Edith O'Donnell Institute of Art History at The University of Texas at Dallas documents and describes known programs nationwide. The 2018 compendium, Art Museum and Medical School Partnerships Program Descriptions, provides basic information, program features, and instructional characteristics of 120 self-reported programs.12 We aggregated the information contained in the compendium and found that the majority (54%) of current museum-health partnerships are designed exclusively for physicians, medical students, and residents. An additional 20% are characterized as interdisciplinary or interprofessional, and 10% are intended for nonphysician or nonnurse providers (eg, pharmacists). Only 5% (n = 6) are designed specifically for nurses, and only 2 of those focus on practicing nurses, both in New York City academic medical centers and 1 is at this institution.

Osman et al7 examined 62 “arts-based interventions” in healthcare and found a somewhat larger majority (61%) of the programs catered to medicine; 15% were designed for nursing students, and only 2% for practicing nurses. Most typically, these programs reported positive results among participants in “development of empathy or compassion” (30%) and “personal or professional development” (34%). A large majority of these programs (76%) required some sort of active participation among the participants, although only one-third of the programs reported collaboration with an artist/art organization or arts educator. Active engagement of an artist or museum educator, rather than a faculty member, is strongly recommended.7

Institutional Characteristics and Program Elements

NYU Langone Health is an academic medical center located in New York City with a nursing workforce of more than 3000 RNs, of whom more than 90% hold a BSN or higher degree. The institution has a large cadre of 546 advanced practice nurses and holds 4-time Magnet® nursing designation, as well as designations of excellence in several clinical areas.

The Reflecting Art in Nursing Practice workshop series was developed by a health sciences librarian and health services researcher from NYU Langone Health's Center for Innovations in the Advancement of Care (CIAC) in collaboration with The Metropolitan Museum of Art's (The Met) Head of Access Services and a member of their teaching staff. Through the workshops, participating nurses: 1) practiced skills to enhance their interactions with patients, family caregivers, and colleagues; 2) had respite from patient care demands through this professional development; 3) engaged with art to support different ways of thinking and making connections13; and 4) cultivated new understandings of their complex workplace. In short, this novel workshop series underscores the institutional commitment to invest in nursing professional development and to develop innovative partnerships.

The museum educators designed a series of four 1-hour sessions on themes relevant for bedside nurses: observation, description, communication, empathy, and art as a resource for self-care. A museum educator instructor led the workshop in the hospital's library classroom furnished with a large, front-room computer display with 4 oblong tables, each equipped with computer monitors for viewing images of works of art and small group exercises. Each session began with a brief meditation exercise to allow participants to refocus their attention. Images of art were chosen to appeal to the senses, spark curiosity, and stimulate discussion. Art from a broad range of historical periods and cultures in a wide range of media including painting, drawing, sculpture, ceramics, photography, and architecture was examined. Works from Europe, Asia, Africa, and the Americas were shown to participants to present familiar pieces alongside the unfamiliar so that participants were exposed to widely varied knowledge and experience of art as a means of developing a greater awareness of art as a vehicle for understanding the human condition.

Participants were required to have 2 years' experience at the institution and compatible scheduling. Continuing education credit was available for those who attended 3 of the 4 sessions; 65% met this requirement and received credit. Participants also received guest passes to the museum. Recruitment was done through word of mouth and by email. Because of room configuration and the benefits of small group interactions, each cohort was limited to 20 participants. Three cohorts were held in the summer and fall 2017 and spring 2018, with a total of 51 participants.

The Met has a long history of bringing art and its therapeutic potential to different populations. Rebecca McGinnis,14,15 Senior Managing Educator of Accessibility, had written extensively on the educational of the museum for people with disabilities and lent her expertise to development of our program. The museum educator provided structured facilitation using a constructivist approach to aesthetic experience rooted in collective looking and dialogic exchange.16 Looking, and therefore seeing, was reinforced through large group discussion and small group exercises developed at The Met and by educators at Harvard's Project Zero.13,17 Nurses engaged and reacted to the artworks by drawing, writing, speaking, and listening. Themes such as perception, empathy, individual perspective, and ambiguity were supplemented with selected short readings including stories, artist quotes, poetry, and excerpts from longer works of fiction. Taken together, these activities were designed to help nurses identify connections between the visual arts and clinical practice, to develop personal awareness, and to apply new strategies to clinical practice and self-care, particularly with regard to the practitioner's own reflective capacity.

In 1 session, participants were presented with the image of a work of late 18th- to early 19th-century African sculpture popularly known as The Dogon Couple (formally known as Seated Couple) (see Supplemental Digital Content 1, http://links.lww.com/JONA/A753, which shows a wooden sculpture of a seated couple, one with an arm around the other) and asked to select and sketch several small areas of the piece. During the session, participants looked closely, recording details and considered the spatial relationships within the form. Class discussion revealed that initial assumptions about gendered anatomy and gender roles, for example, were reassessed after closer looking. In follow-up responses, nurses wrote:

I feel I was able to appreciate the attention to detail of the figure by attempting to draw it. There was a bond between the two, which I noticed when I drew one figure with their arm around the other.

Focusing in enough to draw the figure really made me notice how many tiny details there are in art… that are easy to glance over…. It made me think about my patients—it is easy to just see them in a 1-sided way, of think of them only in the snapshot of the patient, but in reality I know I provide better, more compassionate care when I consciously remind myself they too have live just as full as mine.

Evaluating the Program

From the onset, we recognized the need to gather participant feedback for program improvement purposes and to examine the extent to which participants integrated the workshop experiences in their clinical practices. To evaluate the program and activate participant reflection, we sent carefully crafted electronic surveys with open-ended questions designed to elicit narrative feedback after each session. All items were open-ended, allowing participants to express themselves in their own words. This approach produced a rich and diverse trove of information. Participants from all 3 cohorts received identical questions and were asked to describe their thoughts about the workshop and to note anything they found interesting or different in their thinking following the workshop; 63% of the participants gave feedback, which resulted in 275 unique textual responses to the survey questions.

Based on participants' responses, we extracted initial ideas that informed the development of a manual coding framework. Subsequent reviews of the survey data by the research team of the health sciences librarian and senior health services researcher yielded further clarity and reduction of thematic clusters and consistent descriptions. After developing a series of 23 preliminary thematic concepts, we agreed the concepts clustered around 3 key overarching domains. The health sciences librarian and a senior member of the CIAC staff independently met routinely to review the responses to develop the themes and find consensus on areas of disagreement regarding coding, grouping, and analyzing the responses.

We sought feedback to assess strengths and deficiencies in the educational programming, as well as for the instructor to adapt dynamically to participant reactions. Our intention was to revise and improve the course; it was not intended for generalizable research purposes. This approach therefore fell within the definition of a quality improvement project and did not meet the requirements for review at our institutional review board.

Emerging Themes

Participant feedback provided insight and confirmed findings from other studies on art and nursing care. Participants repeatedly stated that the sessions helped in: 1) improving observation and description skills; 2) developing empathy or compassion; and 3) enhancing personal or professional development. Moreover, there was widespread approval of having an experienced museum educator lead the course, rather than a faculty member as described elsewhere.7

The following major themes were consistently found throughout each of the 3 cohorts: 1) seeing; 2) attunement; and 3) thinking shifts. Each of these themes is presented below with selected quotes that illustrate how the participants described their experience in their own words. All quotes are verbatim from participants.

Seeing as Enhanced Observation

Many participants noted changes in their perceptions and behaviors around observation, the focus of the 1st week's workshop. Participants consistently expressed surprise that, through the guided exercises of viewing the same artwork image, they recognized that everyone sees different things and notices different details. Participants noted that through extended looking their observation changed, and they saw more details and interacted differently with images; they saw more details after longer periods of uninterrupted observation.

It still fascinates me how we all see something different when looking at the same thing.

The more I looked at the picture, the more I noticed the individual details, and I saw more details than on the 1st look.

In a typical exercise, participants worked in small groups and spent several minutes viewing an image before reporting their observations to the entire group. Related to the theme of seeing, participants described collective observation, looking together as a group, yielding a more comprehensive and detailed visual assessment.

The images influenced my observation skills and made me think maybe I need to work more on my assessment and observation skills—like assessing the details of the [patient's] environment.

I did realize that I “looked” more closely when I was asked to draw.

Participants consistently described their increased ability to notice relationships between individual details and an overall image. This observation extended to describing connections of individual parts to whole in both work processes and interpersonal encounters.

We should focus on a small area in order to take every detail, but at the end, we should come back because every patient is more than the addition (sum) of every small detail.

Attunement

Attunement, bringing into harmony or being aware or responsive, was another major theme. The workshop and corresponding exercises allowed participants to make emotional connections and to reflect on how they relate to others both personally and professionally. Through directed close looking, participants became more attuned to and attentive to body language and physical cues. Many of the selected works of art elicited feelings of emotional connection, as did the group exercises. During class, participants described curiosity about the figures depicted in the museum images and empathy for people living in past times, such as the seated woman in Van Gogh's La Berceuse (see Supplemental Digital Content 2, http://links.lww.com/JONA/A754, which shows a painted portrait of a seated woman dressed in green in front of a floral background) or the 16th-century agrarian workers depicted in Bruegel's The Harvesters (see Supplemental Digital Content 3, http://links.lww.com/JONA/A755, which shows a landscape painting of a golden wheat field with peasants working and relaxing in the field).

I was drawn in even more to the workers' task at hand, their body positions and clothing, and the comfort/inner peace they seemed to embody even if their work day in the field was very long.

Patients and caregivers, in my opinion, almost always communicate through gestures, facial expression, and body language. On my service, it is often quite clear if the surgeons are happy or not before a word is spoken. With my patients and their parents often you can tell how they feel simply by looking at them.

[The drawing exercise] made me think about my patients—it is easy to just see them in a 1-sided way, or think of them only in the snapshot of the patient, but in reality, I know I provide better, more compassionate care when I consciously remind myself they too have lives just as full as mine.

One particular active-listening exercise heightened participants' attunement to their fellow classmates' body language and facial expressions. Participants were grouped in 3's and asked to take turns as speaker, listener, or observer while the speaker described a work of art without interruption. The exercise required that each participant remain in his/her respective role for several minutes.

This exercise will absolutely influence how I listen in the future in my communications with others: I feel I will be less likely to interrupt a speaker and more likely to actively listen without feeling I have to make a comment.

I tend to multitask while I thought I am listening when someone is trying to communicate with me. This week's session highlights my poor management of communication skills as well as it brought to light my perception of how communication should be. It was a self-discovery and self-awareness session.

In addition to attunement with others, another thread emerged that could be characterized as increased attunement with the self, or self-awareness. The theme of self-attunement or self-awareness reflects the workshop's intention to stimulate introspection and suggest opportunities and strategies for using art for self-care. A majority of participants described lingering reflections of the class experience, the discussion, and their impressions afterward later in the week.

Thinking Shifts

The most notable and unexpected theme that emerged from the participants' feedback related to changes in internal thinking. Participants noted that the description exercises challenged and enriched their everyday, clinical-minded vocabulary. Participants noted the benefit of being challenged to describe a work of art with strictly objective, not interpretative, language. Many commented that these exercises made them more self-reflective and self-aware about their clinical observation skills and the tendency to rush to interpretation.

I thought I was a good observer, but maybe not as good as I thought. I realized that I can do it better.

By the end of the last class, I could significantly tell a difference in the way I was observing and describing pieces of art rather than interpreting.

It's [the workshop series] forcing me to be a bit more objective in my observations, not necessarily trying to interpret things, just being more descriptive.

Participants also believed their thinking processes became more nuanced and flexible as a result of the class exercises and discussions. Navigating and accepting ambiguous contexts became a recurring discussion theme participants responded to.

I have noticed a difference in how I am taking in information, both personally and professionally.

My thinking has more possibility.

Others noted a heightened awareness of their need to stop and reflect. Nurses described that workshop participation had a positive effect on their mood, lessened their feelings of workplace stress, and increased feelings of relaxation, focus, and concentration. The workshops also offered opportunities to build relationships and collaborate with coworkers from disparate areas of the hospital enterprise and to become more appreciative of others' connected roles.18

I met a participant in the elevator afterward. We spoke briefly about how much the group relaxes us and that both of us had to tear ourselves away from a busy day but were so glad we did.

Attending the class was engaging and created an opportunity to “pause” during my hectic day. I noticed being more present and focused.

Discussion

Our findings align with prior work on the positive outcomes associated with health humanities programs, such as enhanced provider compassion and improved observation skills. A Joanna Briggs Institute mixed-methods systematic review19 of articles dealing with “arts-based pedagogy” (ABP) found 21 articles using qualitative methods, which were characterized as high methodological quality and which provide evidence of the meaningfulness of ABP for undergraduate nursing students. The 20 studies using quantitative methods, though, were of lower methodological quality and did not produce compelling evidence of enhanced competencies or learning in nursing students. In the final analysis, the authors identify several significant implications of ABP for nursing practice, including: 1) developing skills such as empathy, cultural competence, ability to collaborate, awareness of multiple perspectives, and understanding one's unique personal context; 2) illuminating key aspects of professional practice such as advocating for a client, holism in nursing care, and person-centered care.19,20 Although this systematic review focused on nursing students, we found similar results at our academic medical center.

Workshop participants identified several unanticipated benefits of the program. Most notable, the workshop drew participants from varying clinical and administrative departments, offering a rare opportunity to learn about the complexities of nurse responsibilities across the institution. This cross-fertilization, particularly evident during the exercises, allowed the participants to recognize shared philosophies, as well as to reconcile different perspectives. After weeks of shared class experience, nurses established professional camaraderie. In addition, participants repeatedly remarked on the benefits they gained from respite from a stressful workday and refocusing their attention through the class experience.

Participant feedback to the workshop was overwhelmingly positive. Participants have requested to repeat the course, and nonnurses have asked to join the workshops. Despite these successes, we encountered several significant barriers and challenges. Because of conditions on hospital units, it was not always possible for participants to attend every weekly session. Even with prior nurse manager approval to attend the 4 sessions, unplanned patient care needs drove staffing schedules. The workshop location was some distance to patient care units, which we believe resulted in late arrivals and early departures.

Stellar assessments notwithstanding, participant feedback guided us to make the course content more overtly clinically relevant, resulting in changes to selected images and associated class exercises. Over time, the workshops became more closely aligned with clinical practice through intentional exercises and instructor-led discussions directly linked to nursing practice.

The findings of our program evaluation correspond with those described by Rieger et al19 and underscore the need for further research including more in-depth interviews to elicit participant perspectives; research on the ideal dose of ABP; and more studies using experimental or quasi-experimental designs to identify measureable outcomes of visual arts–humanities workshops for practicing nurses. Nonetheless, our Reflecting Art in Nursing Practice program illustrates the benefits of humanities programming for clinical hospital-based nurses.

Implications for Nurse Leaders

Consistent support from the chief nursing officer and other nursing leaders was critical to the success of our Reflecting Art in Nursing Practice program. Aside from the modest financial investment, there were issues of staffing and other resources that impacted the program and the participants. Yet, the program aligned with institutional priorities such as unconscious bias training, patient-centered care, and the goals of a high-reliability organization.

In addition, this workshop reflects a commitment to the Quadruple Aim, which posits that attention to staff resilience and satisfaction are critical to achievement of the Triple Aim. Since introduced in 2008, the Triple Aim, which focuses on enhancing patient experience, improving population health and reducing cost, remains an essential guide for healthcare organizations to optimize their performance.21 More recently, however, serious concerns are being raised about the needs of healthcare professionals who are practicing in increasingly stressful and pressured work environments. Surveys of physicians and nurses have shown increasing levels of burnout and dissatisfaction, which can result in negative patient outcomes.22,23 These serious developments have led to calls to add a 4th dimension to the Triple Aim, which would address the needs of healthcare providers. Thus, this 4th aim advocates workplace practices and activities that promote a sense of well-being and meaning at work. Workplaces that emphasize dignity, civility, respect, and safety have more engaged staff and higher retention.23,24 The Reflecting Art in Nursing Practice workshop's focus on nurse well-being, self-care, and self-reflection clearly aligns with the intentions of the Quadruple Aim.

We presented our findings to members of nursing leadership, and their reactions were noteworthy. Nurse leaders recognized the program's value to nursing practice particularly as it enhanced clinical observation, effective communication, and critical thinking. Offering a creative and innovative environment, drawing on diversity of images and bringing different types of RNs together, was seen as useful approach to teamwork and collective problem-solving. Some leaders suggested that an abbreviated version of the program be integrated into orientation of new staff. Others recommended the workshop as a meaningful part of professional development for future nurse leaders. Although the program has suffered some difficulties with attendance, the commitment from leadership to sustain the program remains.

Limitations

The findings described are limited to the experiences of a large, urban academic medical center. In addition, there is some selective bias because participants self-selected to participate. The fee for the museum educator was less than $1800 and was covered by funding obtained through a philanthropic contribution to the CIAC at NYU Langone Health. With permission from their nurse managers and supervisors, workshop participants took time during lunch or expended time from their professional development/conference hours. We are fortunate to have funding for this unique undertaking, which may be challenging to other organizations. Nonetheless, our experiences and findings suggest that variants of our Reflecting Art in Nursing Practice workshop can be beneficial for RNs in the practice settings.

Conclusions

The Reflecting Art in Nursing Practice workshop series focuses on developing RN skills in observation, description, empathy, and self-care through exploration of pieces from The Met such as painting, sculpture and ceramics. A large majority of the participating RNs attended at least 3 of the 4 sessions, despite staffing and other challenges in the practice setting. Written feedback from participants found that RNs detected profound changes in their self-awareness in multiple areas, and 3 consistent themes emerged: 1) seeing as enhanced observation; 2) attunement; and 3) thinking shifts. Consistent support from the chief nursing officer and nursing leadership was essential to the success of the program.

Acknowledgment

The authors are grateful for the support and collaboration of Rebecca McGinnis, Senior Managing Educator of Accessibility at The Met, and the dedicated, friendly help of Christina Vanech and Marie Clapot. The authors thank Robert Levine for publicizing the workshop series and his contributions in developing, editing, and submitting this article.

References

1. Cole TR, Carlin NS, Carson RA. Medical Humanities: An Introduction. New York, NY: Cambridge University Press; 2015.
2. Jones T, Blackie M, Garden R, Wear D. The almost right word: the move from medical to health humanities. Acad Med. 2017;92(7):932–935. doi:.
3. Crawford P, Brown B, Baker C, Tischler V, Abrams B. Health humanities. In: Health Humanities. London: Palgrave Macmillan UK; 2015:1–19. doi:.
4. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
5. Narasimhan M, de Iongh A, Askew I, Simpson PJ. It's time to recognise self care as an integral component of health systems. BMJ. 2019;365:L1403. doi:.
6. Bentwich ME, Gilbey P. More than visual literacy: art and the enhancement of tolerance for ambiguity and empathy. BMC Med Educ. 2017;17(1):200. doi:.
7. Osman M, Eacott B, Willson S. Arts-based interventions in healthcare education. Med Humanit. 2018;44(1):28–33. doi:.
8. Hensel D, Moorman M. Doctorate of nursing practice students' impressions of uses for visual thinking strategies. J Contin Educ Nurs. 2017;48(8):365–368. doi:.
9. Watson F, Rebair A. The art of noticing: essential to nursing practice. Br J Nurs. 2014;23(10):514–517. doi:.
10. Nease BM, Haney TS. Evaluating an art-based intervention to improve practicing nurses' observation, description, and problem identification skills. J Nurses Prof Dev. 2018;34(1):2–7. doi:.
11. Dellasega C, Milone-Nuzzo P, Curci KM, Ballard JO, Kirch DG. The humanities interface of nursing and medicine. J Prof Nurs. 2007;23(3):174–179. doi:.
12. Pitman B. Art Museum and Medical School Partnerships: Program Descriptions. The Edith O’Donnell Institute of Art History. Dallas, TX: The University of Texas; 2019. https://www.utdallas.edu/arthistory/medicine/resources/2019_ART%20AND%20MED%20PROGRAM%20DESCRIPTIONS.pdf.
13. About The Met | The Metropolitan Museum of Art. https://www.metmuseum.org/about-the-met. Published 2019. Accessed August 8, 2019.
14. McGinnis R. The Disabling Society. In: Hooper-Greenhill E, ed. The Educational Role of the Museum. New York, NY: Routledge; 1999.
15. McGinnis R. Enabling education: including people with disabilities in art museum programming. In: Villenueve P, ed. From Periphery to Center: Art Museum Education in the 21st Century. Reston, VA: National Art Education Association; 2008.
16. Burnham R, Kai-Kee E. In: Lucke A, ed. Teaching in the Art Museum: Interpretation as Experience. Los Angeles, CA: Getty Publications; 2011.
17. Homepage | Project Zero. http://www.pz.harvard.edu/. Published 2016. Accessed August 8, 2019.
18. Karpavičiūtė S, Macijauskienė J. The impact of arts activity on nursing staff well-being: an intervention in the workplace. Int J Environ Res Public Health. 2016;13(4):435. doi:.
19. Rieger KL, Chernomas WM, McMillan DE, Morin FL, Demczuk L. Effectiveness and experience of arts-based pedagogy among undergraduate nursing students: a mixed methods systematic review. JBI Database Syst Rev Implement Rep. 2016;14(11):139–239. doi:.
20. Rieger KL, Chernomas WM. Arts-based learning: analysis of the concept for nursing education. Int J Nurs Educ Scholarsh. 2013;10(1). doi:.
21. Berwick DM, Nolan TW, Whittington J. The Triple Aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759–769. doi:.
22. Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573–576. doi:.
23. Bowles JR, Adams JM, Batcheller J, Zimmermann D, Pappas S. The role of the nurse leader in advancing the Quadruple Aim. Nurse Lead. 2018;16(4):244–248. doi:.
24. Sikka R, Morath JM, Leape L. The Quadruple Aim: care, health, cost and meaning in work. BMJ Qual Saf. 2015;24:608–610. doi:.

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