Digital educational technology content production and validity about Japanese bathtub (ofurô) in neonatal unit / Producción y validación de contenido de tecnología educativa digital sobre baño de hidromasaje en unidad neonatal / Produção e validação de conteúdo de tecnologia educacional digital sobre banho de ofurô em unidade neonatal

ABSTRACT Objective: To describe the elaboration and content validity stages of a digital educational technology for nursing professionals about Japanese bathtub (ofurô) in newborns in neonatal care units. Method: A methodological study conducted between August 2019 and July 2021, in a public maternity hospital in Manaus, Amazonas, developed in two stages. In the first, the e-book images, text and editing were produced. In the second, material content validity was carried out, through the opinion of 15 expert judges, nurses and neonatal care experts. In data analysis, the percentage of agreement was applied with agreement score estimation. Items with 80% or more agreement were considered valid. Results: The e-book "Japanese bathtub: manual for nursing professionals" was produced, organized into nine sessions, which describe the technique execution. Content was considered valid by expert judges (general score 90%). Conclusion: The e-book was considered suitable for use in training nursing professionals, with potential for dissemination of knowledge regarding humanization of care for premature babies.

RESUMEN Objetivo: Describir las etapas de elaboración y validación de contenido de una tecnología educativa digital para profesionales de enfermería sobre el baño ofurô en recién nacidos en Unidades de Cuidados Neonatales. Método: Estudio metodológico realizado entre agosto de 2019 y julio de 2021, en una maternidad pública de Manaus, Amazonas, desarrollado en dos etapas. En la primera se produjeron las imágenes, el texto y la edición del e-book. En el segundo, se realizó la validación de contenido del material, a través de la expresión de 15 jueces expertos, enfermeros y experimentados en cuidados neonatales. En el análisis de datos se aplicó el porcentaje de concordancia con estimación del puntaje de concordancia. Se consideraron válidos los ítems con un 80% o más de acuerdo. Resultados: Se elaboró el libro electrónico "Banho de ofurô: manual para profissionais de enfermagem" (Baño de Ofurô: manual para profesionales de enfermería), organizado en nueve sesiones, que describen la ejecución de la técnica. El contenido fue considerado válido por los jueces expertos (puntuación general 90%). Conclusión: El e-book se consideró apto para ser utilizado en la formación de profesionales de enfermería, con potencial para la difusión de conocimientos sobre la humanización del cuidado del recién nacido prematuro.

RESUMO Objetivo: Descrever as etapas de elaboração e validação de conteúdo de uma tecnologia educacional digital para profissionais de enfermagem sobre o banho de ofurô em recém-nascidos em Unidades de Cuidado Neonatal. Método: Estudo metodológico conduzido entre agosto de 2019 e julho de 2021, em uma maternidade pública de Manaus, Amazonas, desenvolvido em duas etapas. Na primeira, foram produzidas as imagens, texto e editoração do e-book. Na segunda, foi conduzida a validação de conteúdo do material, pela manifestação de 15 juízes especialistas, enfermeiros e experientes no cuidado neonatal. Na análise dos dados, aplicou-se a porcentagem de concordância com estimação de escore de concordância. Foram considerados válidos os itens com 80% ou mais de concordância. Resultados: Foi produzido o e-book "Banho de ofurô: manual para profissionais de enfermagem", organizado em nove sessões, que descrevem a execução da técnica. O conteúdo foi considerado válido pelos juízes especialistas (escore geral 90%). Conclusão: O e-book foi considerado adequado para ser utilizado em treinamento de profissionais de enfermagem, com potencial para a difusão do conhecimento quanto à humanização da assistência ao recém-nascido prematuro.

Visualization analysis of master of nursing specialist at home and abroad based on Citespace / 中华医学教育探索杂志

Objective To explore the overall research focus and frontier of master of nursing specialist at home and abroad to provide reference for the development of master of nursing specialist in China.Methods The numbers of literatures from 2006 to 2016 that related to master of nursing specialist are 1 595 in web of science and 249 in China National Knowledge Internet respectively.Knowledge mapping and visual analysis were carried out by CiteSpace.Results In 2006-2016,the numbers of both domestic and foreign relevant literatures were generally on the rise.The international researchers focused on the research of nurse practitioners and primary care,while Chinese ones on curriculum,training pattern,core competencies,etc.The current international frontier was in the field of systems and team,while the Chinese one was in the field of education and training model.Conclusion There is a certain gap between the research of master of nursing specialist at home and abroad.Our country should take our own national conditions as the basis and learn from foreign research focus and frontiers to promote the development of master of nursing specialist.

El papel de la enfermera practicante en los Estados Unidos de América dentro de los modelos de atención de transición y coordinación de la atención / The Nurse Practitioner Role in United States of America within Transitional Care and Care Coordination Models

Objetivo: Examinar las variaciones en los modelos de atención de transición y coordinación de atención de enfermeras practicantes (NP) que se han puesto en funcionamiento dentro de poblaciones objetivo que han reducido fiscalmente los costos de atención médica en los EE. UU. Se discutirá un contexto de aplicación futura de la globalización de estos modelos emergentes. Antecedentes La atención médica de EE. UU. Es complicada y la necesidad de coordinación de la atención entre sistemas y proveedores es esencial para mantener la calidad de la atención. Los NP están en una posición ideal para actuar como líderes y clínicos, tanto dentro como fuera de la organización de atención médica, para brindar atención centrada en el paciente y modelos de coordinación de atención en las poblaciones de insuficiencia cardíaca, geriatría, cuidados paliativos y salud mental. Evaluación De la evidencia de investigación disponible, varios Las estructuras y los mecanismos de apoyo se identifican como facilitadores para que los PN desempeñen su papel de liderazgo en la atención de transición y los modelos de coordinación de la atención. y la prestación de servicios de coordinación de atención en todos los niveles de atención. El liderazgo de enfermería puede promover que las NP tengan potencial para liderar reformas de la atención médica en diversas poblaciones. Conclusión Las organizaciones nacionales y mundiales de atención médica deben incluir la creación de apalancamiento para las NP para brindar modelos de atención de transición y coordinación de atención como una prioridad en su plan estratégico de atención médica y tomar medidas para promover el nivel de liderazgo de las NP en la atención innovadora centrada en el paciente.

AimTo examine the variations in nurse practitioner (NP) transitional care and care coordination models which have been operationalized within targeted populations that have fiscally reduced healthcare costs in the USA. A context of future globalization application of these emerging models will be discussed.Background The USA healthcare is complicated and the need for care coordination across systems and providers is essential to maintain quality of care. NPs are ideally positioned to act as leaders and clinicians both within and beyond the health care organization to deliver patient centric transitional care and care coordination models in the heart failure, geriatrics, palliative care and mental health populations.Evaluation From the available research evidence, several support structures and mechanisms are identified as enablers for NPs to enact their leadership role in transitional care and care coordination models.ImplicationsNurses have a vital role influencing the organization's strategic plan and prioritizing leadership capacity building to advocate that the NP role can be expanded to transitional care and care coordination service delivery across levels of care. Nursing leadership can promote that NPs have potential in leading health care reforms in diverse populations.Conclusion National and global health care organizations need to include building leverage for NPs to deliver transitional care and care coordination models as a priority in their healthcare strategic plan and take action to promote the level of NPs leadership in innovative patient centric care.

The feasibility and practice of Nurse Practitioner in China / 中华护理杂志

With the development of China's economy and aging of the population,patient's demands for nursing are increasingly high,thus it is very important to cultivate high-end and practical nursing personnel.This paper analyzes the necessity and feasibility of the development of Nurse Practitioner in China,and explores the qualifications and management of Nurse Practitioner,the job content of Nurse Practitioner,and the training of Nurse Practitioner.

Research of gerontological nurse practitioner training curriculum / 中华医学教育探索杂志

Objective To explore the theory of curriculum contents for gerontological nurse practitioner training which is suitable for the situation of our country. Method Delphi technique was used in this research to build content indicators of gerontological nurse practitioner training curricu-lum, and calculate the variation coefficient. Results The theory training curriculum includes founda-tions of gerontological nursing, geriatric syndrome, facilitating physiological balance and general gero-tological care modules and 41 core indexs. Every coefficient of variation is less than 20 percent [(4.35±0.71), (4.63±0.57), (4.55±0.57), (4.67±0.55)]. The mean values of the importance (4.54± 0.622) and general characteristics are more than four. Conclusion The content setting of the geron-tological nurse practitioner training theory course not only highlights the training characteristics of the geriatric care, but also has comprehensive and systematic content, reflects humanistic care spirit and pays attention to developing nurses’clinical practice ability. Therefore, it is worthy of reference and promotion.

Comparison of Job Performance, Job Satisfaction and Job Stress of Child Health Nurse Practitioners by Roles in the Work Place

PURPOSE: Child Health nurse practitioners (CHNPs) in Korea have important roles in disease management and health promotion for children and adolescents. Yet, practices of CHNPs licensed and employed in hospitals have not been adequately identified. Thus, in this study the scope of practice by CHNPs and job satisfaction and stress were investigated and compared according to the CHNPs' position in the working place. METHODS: A descriptive cross-sectional survey design was used. All 53 licensed CHNPs participated in the mail survey which included a 71-item questionnaire on job performance and job satisfaction and a job contents questionnaire. Descriptive statistics, chi2 test, independent t-test and Mann-Whitney U test were used to compare CHNPs employed as nurse practitioner (NP) and CHNPs employed as staff nurses. RESULTS: Compared to CHNPs employed as staff nurses, CHNPs employed as NPs more frequently provided education, environment management, coordination and research in their practice areas. No significant difference was found in job satisfaction between the two groups except for the administration and income subdomains. Only the physical exertion subdomain in job stress was stressful to CHNP employed as staff nurse. Conclusions: Job performance of CHNPs in Korea needs to be revised to include more practical practice in education, coordination, and research related areas. CONCLUSIONS: Job performance of CHNPs in Korea needs to be revised to include more practical practice in education, coordination, and research related areas.

Comparison of Job Tasks and Task Elements of Korean Nurse Anesthetists by Type of Medical Institution: Hospital, General Hospital and Higher General Hospital / 간호행정학회지

PURPOSE: This study was done to identify job tasks and task elements of Korean nurse anesthetists according to type of medical institution. METHODS: A job task scale which consisted of 9 job tasks and 40 task elements was developed. Data were collected from December, 2009 to February, 2010 from 182 nurse anesthetists who were working in medical institutions (response rate: 75.8%). RESULTS: Forty-eight percent of nurse anesthetists were independent from anesthesiologists in anesthetic practice. Preanesthetic nursing assessment was much more frequent in small hospitals than in general hospitals (p<.05), and anesthetic nursing intervention, administering the anesthetics, monitoring the patient's status during anesthesia, and provision of safety and compliance with anesthetic ethics were much more frequent in general hospitals than medical centers (p<.001). There were no differences among the medical institutions for job tasks in post-anesthetic nursing interventions (p=.229), administering anesthetics (p=.354) and monitoring patients' status during anesthesia (p=.099), providing safe anesthetic environment (p=.896), and management of ancillary personnel/equipment (p=.617). CONCLUSION: Results indicate that nurse anesthetists contribute significantly to anesthetic practice in small hospitals and general hospitals. Therefore, it recommended that nursing leaders make efforts to enact legal nurse anesthetist-related policies for safe and high quality anesthetic nursing care.

Liderazgo personal e interpersonal en los cordinadores y profesionales en enfermeria que laboran en las ips de 3er. nivel de atencion de Cartagena / Personal and interpersonal leadership in the nursing coordinators and professionals who work in the ips of 3rd. level of care in Cartagena

El presente trabajo de investigación se enmarca dentro de un tipo de estudio descriptivo, con abordaje cuantitativo el cual tuvo como objetivo identificar las características del liderazgo personal e interpersonal en los coordinadores y profesionales en enfermería que laboran en las IPS de 3er nivel de atención en la ciudad de Cartagena, durante el segundo semestre del año 2009 y el año 2010. Se describieron las variables: liderazgo personal, cuyas dimensiones de estudio fueron control del ego, equilibrio, desapego y responsabilidad, y las variables de liderazgo interpersonal que midieron el trabajo en equipo y las destrezas gerenciales. Los Coordinadores y profesionales en enfermería, constituyeron la población para determinar las características del liderazgo personal e interpersonal. Se trabajó con la totalidad de los sujetos (21 coordinadores y 117 profesionales en enfermería) que aceptaron participar voluntariamente en el estudio y que cumplieron con los criterios de inclusión expuestos en el presente trabajo. En el estudio se utilizó la escala de Evaluación de Liderazgo Personal e Interpersonal, propuesta por David Fischman, contando con la autorización del autor obtenida el 07 de Octubre de 2009. Previo a su aplicación, se realizó una prueba de validez facial y dos pruebas pilotos, que permitieron analizar y verificar la compresión de cada pregunta, su contenido, formulación, claridad y la coherencia que debía existir entre el objetivo planteado, la formulación del problema, el marco teórico y el contenido del instrumento. Para dar un puntaje a cada una de las dimensiones estudiadas se siguieron las instrucciones del Sistema de calificación propuesto por Fischman, cuyos puntajes fueron clasificados en las categorías de muy bajo, bajo, moderados, altos y muy altos. La técnica estadística utilizada para el análisis de los datos fue la MannWhitney U. El estudio mostró las principales debilidades y fortalezas de cada una de las dimensiones de las variables de liderazgo personal e interpersonal. Las debilidades observadas en las características del liderazgo personal de los Coordinadores de enfermería se hallaron en el manejo del control de ego, en el equilibrio, afrontamiento productivo y las debilidades más significativa se encontraron en la poca habilidad para hacerse responsables por su crecimiento personal, aceptar desafíos y fomentar hábitos como la disciplina, de perseverancia y de compromiso hacia metas que permitan su crecimiento profesional. En los profesionales en enfermería la principal debilidad se relacionó con la característica de responsabilidad, que al igual que los coordinadores que dificulta el crecimiento personal y profesional de los individuos. Cabe resaltar que las fortalezas más significativas en estos profesionales en enfermería se evidenciaron en las dimensiones del liderazgo personal, en donde se resalta el control del ego y el manejo del equilibrio orgánico, espiritual y mental. Los Coordinadores de enfermería demostraron sus fortalezas en las características del liderazgo interpersonal, se observo mayor habilidad para tener metas claras y asignar prioridades en el equipo de trabajo. Las debilidades y fortalezas de cada una de las dimensiones del liderazgo personal e interpersonal reflejan el aporte que hace cada persona a la organización, al equipo de trabajo y a su crecimiento personal.

The present work of investigation places inside a type of descriptive study, with quantitative boarding which had as aim identify the characteristics of the personal and interpersonal leadership in the coordinators and professionals in infirmary that they work in the IPS of 3er level of attention in the city of Cartagena, during the second semester of the year 2009 and the first semester of 2010. Variables were described: personal leadership, the dimensions of ego-control study were, balance, detachment and accountability, leadership and interpersonal variables that measured the teamwork and management skills. Coordinators and nurse practitioners were the population to determine the characteristics of personal and interpersonal leadership. We worked with all the subjects (21 coordinators and 117 nurse practitioners) who agreed participate voluntarily in the study who met the inclusion criteria set out in this work. The study used the Global Assessment of Personal and Interpersonal Leadership, given by David Fischman, with the permission of the author obtained on October 7, 2009. Prior to implementation, there was a face validity test and two test pilots, who helped analyze and verify the compression of each question, its content, wording, clarity and coherence that should exist between the stated objective, the formulation of the problem, the theoretical framework and the content of the instrument. To give a score to each of the dimensions studied followed the instructions of the grading system proposed by Fischman, whose scores were classified into the categories of very low, low, moderate, high and very high. The statistical technique used to analyze data was the Mann-Whitney U. The study showed the main strengths and weaknesses of each of the dimensions of the variables of personal and interpersonal leadership. The weaknesses in the personal leadership characteristics of nurse coordinators were found in the management of self control, balance, coping productive and the most significant weakness was in the little ability to take responsibility for their personal growth, acceptance challenges and develop healthy habits such as discipline, perseverance and commitment to targets to their professional growth. NP in the main weakness was related to the characteristic of responsibility, as coordinators difficult personal and professional growth of individuals. It should be noted that the most significant strengths in these NPs were found in the dimensions of personal leadership, which highlights the ego's control and management of organic balance, spiritual and mental. Nursing Coordinators demonstrated strengths in interpersonal leadership characteristics, we observed a greater ability to have clear goals and prioritize the team. The weaknesses and strengths of each of the dimensions of personal and interpersonal leadership reflect the contribution each person makes to the organization, team work and personal growth.

The Real Picture of the Care Costs Paid to Korean Oncology Advanced Practice Nurses / 종양간호학회지

PURPOSE: The purpose of this study was to examine the actual care costs paid to Korean Oncology Advanced Practice Nurses (KOAPN). METHODS: We collected data using a group discussion and questionnaire identified 115 tasks from job descriptions developed by the Korean Accreditation Board of Nursing. Forty-two KOAPN working at three university hospitals in Seoul were asked to evaluate each task as to type and whether the cost is paid or not. They were also asked to indicate the tasks in urgent need of development of a care cost with high priority. RESULTS: Only five tasks (4.3%) related to treatment and complication related interventions or education were paid, and they were paid only once during the entire treatment period and were not covered by national health insurance. It was approved as a medical fee by health insurance review & assessment service. Furthermore, the names of the authority (doctor) and the actual provider (nurse) of the prescriptions were different for three of those tasks. Most of the suggested tasks needing development of care costs were actions specifically performed by nurses (physical-psychosocial-spiritual assessment, independent nursing interventions). CONCLUSION: KOAPN are currently paid for few tasks. To maximize the utilization of KOAPN, the establishment of a clear rational payment system directly related to their actual activities is needed.

Task Analysis of the Job Description of Rehabilitation Nurse based on DACUM / 재활간호학회지

PURPOSE: The aim of this study was to develop and to analyze the duty and the task of rehabilitation nurse in Korea. METHOD: The definition of rehabilitation nurse and job description was developed based on developing curriculum(DACUM) by panels who have experienced in DACUM analysis and rehabilitation nursing. 228 nurses who were working at rehabilitation centers and rehabilitation unit in general hospitals were participated. The questionnaire included frequency, importance, and difficulty of duties and tasks. The data were collected in March and April 2009, analyzed by descriptive statistics. RESULTS: The job description of rehabilitation nurse in Korea revealed 11 duties, and 61 tasks. On the all 11 duties, the highest duty in frequency and importance was direct nursing care (2.47+/-.31, 2.77+/-.28) and the highest duty in difficulty was self-development (2.39+/-.48). Among the tasks of duties 'direct nursing care' in 'manage medication' (2.87+/-.35) in frequency, the task 'prevent and manage bedsore' (2.91+/-.31) of duty 'direct nursing care' in importance, and 'cope emergency situations' (2.72~.49) of duty direct nursing care in difficulty showed the highest degree. CONCLUSION: The political efforts for the legislation of role and task of rehabilitation nurse were needed.

Role-Identity of Home Care Nurse Practitioners / 간호학회지

INTRODUCTION: It is important to understand the nature of the identity through the live experiences of Home Care Nurse Practitioner(HCNP) because the role identity of a professional is constructed by continuous social interactions, This study aims to understand the construction of the role identity of HCNP. METHOD: Data was collected from 12 hospital based HCNPs. This study involved two focus group discussion sand four in-depth individual interviews. The main question was "what is the role of HCNP?" The debriefing notes and field notes were analyzed using consistent comparative data analysis method. RESULT: First, Home care (HC) is a small clinic. HCNP brings it to home to provide various services. Second, HC is the real nursing and HCNP is the 'genuine' nurse who actualizes the essence of nursing in practice. Third, HC is empowering activity to promote self-care ability of the patients and their caregivers. Forth, HC is like the dish-spinning required high-level mastery and HCNP is an expert who provides the most appropriate services to the patients. CONCLUSION: HCNPs have the role identity as a highly qualified professional who delivers services from hospital to home, actualizes the essence of nursing in practice, empowers the patients and their caregivers to have self-efficacy to recover, and offers the most appropriate nursing care.

Role-Identity of Home Care Nurse Practitioners / 간호학회지

INTRODUCTION: It is important to understand the nature of the identity through the live experiences of Home Care Nurse Practitioner(HCNP) because the role identity of a professional is constructed by continuous social interactions, This study aims to understand the construction of the role identity of HCNP. METHOD: Data was collected from 12 hospital based HCNPs. This study involved two focus group discussion sand four in-depth individual interviews. The main question was "what is the role of HCNP?" The debriefing notes and field notes were analyzed using consistent comparative data analysis method. RESULT: First, Home care (HC) is a small clinic. HCNP brings it to home to provide various services. Second, HC is the real nursing and HCNP is the 'genuine' nurse who actualizes the essence of nursing in practice. Third, HC is empowering activity to promote self-care ability of the patients and their caregivers. Forth, HC is like the dish-spinning required high-level mastery and HCNP is an expert who provides the most appropriate services to the patients. CONCLUSION: HCNPs have the role identity as a highly qualified professional who delivers services from hospital to home, actualizes the essence of nursing in practice, empowers the patients and their caregivers to have self-efficacy to recover, and offers the most appropriate nursing care.

A Follow-up Study of Methods for Selecting Students for the School of Allied Health Sciences at Yamaguchi University / 医学教育

A follow-up study with multivariate analysis examined the relations of methods for selecting students, performance after admission, and scores on the national examinations for medical technologists and for nurse practitioners. The subjects were 247 students who had entered the division of laboratory medicine at the School of Allied Health Sciences, Yamaguchi University, from 1995 through 2000 and 484 students who had entered the division of nursing during the same period. Scores on examinations at the School of Allied Health Sciences and on national professional examinations did not differ between students who had been admitted on the basis of recommendations from high school principals (including an interview) and students who had been admitted on the basis of an open entrance examination (also including an interview). However, questions remained about the legitimacy of the high school records of students admitted on the basis of recommendations from high school principals but not of students admitted on the basis of an open entrance examination. Furthermore, the relevance of the interview during the open entrance examination for medical technologists and nurses was not recognized. In addition, for medical technology students who had been admitted on the basis of open entrance examinations, we found that scores on the national examination were correlated with the scores on the entrance examination and with their grades at the School of Allied Health Sciences.

Task Analysis of Korean Transplantation Nurse Practitioner / 간호학회지

PURPOSE: This study was designed to create the job description of Korean transplantation nurse practitioner and examine performance frequencies, criticality, and difficulties of task elements. METHOD: The sample consisted of 63 nurses and coordinators who performed duties related to transplantation at medical center in Korea. A survey method was used, and the questionnaire included frequencies, criticality, and difficulties of task elements in job description by the DACUM method. Using SPSS WIN 10.0, descriptive statistics such as frequency distribution, means, and standard deviations were conducted to examine the subject's general characteristics, the frequencies, criticality, and difficulties of task performance. RESULT: The job description of transplantation nurse practitioners revealed 5 duties, 22 tasks, and 85 task elements. On the all five duties, the averages of the performance frequency, criticality, and difficulty were 2.41, 3.38, and 2.78, meaning that the respondents rarely perform the 5 duties, but consider them critical and easy to perform. CONCLUSION: The job description of the transplantation nurse practitioner included duty, task, and task element and definition of job completed. Thus we recommended a data based trial to confirm and validate the information gathered.

A Study on the Projection of Critical Care Advanced Practical Nurses(APNs) / 성인간호학회지

PURPOSE: This descriptive study was conducted to project the number of critical care APNs needed in critical care units in an acute care hospital setting, up to the year 2020. METHOD: Necessary data and information were collected from various funded reports, professional literature, web-sites and personal visits to national and private institutions. The demand of critical care APNs were projected based on two critical care APNs per critical care units. RESULT: The projected number of critical APNs for the critical care units in acute care hospital settings as follows: 1) The total projected number of critical care APNs needed for critical care units were 1,270 in 2001. 2) By the year 2020, total number of projected critical care APNs needed in critical care units will be 1,080-1,700. CONCLUSION: In order to match the supply to the need, the professional organization should direct their efforts toward enacting legislation. Educational systems should identify strategies in initiation of critical care APN programs in masters level as well as standardizing curriculums across the programs.

Role and Effectiveness of Nurse Practitioner in Neurosurgical Field

The purpose of this article is to identify and explain the role and effectiveness of nurse practitioners(NPs) in the field of neurosurgery. The role of nurse practitioner has expanded over the past 15 years in the areas of administration, clinical activities, counseling, and surgical assistance. One primary activity of the NPs in our department is the frequent periodic neurological examination and rapid detection of deteriorating critical patients. They also improve the rapport between the patients and neurosurgery service and cover wevere manpower shortage or resident staffs. The department of neurosurgery in the hospital can maintain adequate coverage for the neurosurgical patients without increasing the number of residents. The author believes that NPs can improve the quality of care and outcome in a cost-effective manner. Concerns with acceptance and the role of neurosurgical NPs are clearly no longer on issue.