Facilitators and barriers to guide implementation strategy design for a blunt chest injury care bundle: A multisite mixed-method survey

Ms Sarah Kourouche1, Dr Belinda Munroe1,2, Associate Professor Tom Buckley1, Dr Connie Van1, Professor Kate Curtis1,2

1University Of Sydney, Susan Wakil School of Nursing and Midwifery, Camperdown, Australia, 2Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital,  Wollongong, Australia

Background: To address the evidence-practice gap, implementing evidence needs planning and strategy that addresses the complexity of multidisciplinary emergency department systems by identifying and addressing facilitators and barriers to change.

Aim: To identify the facilitators and barriers to the implementation of a blunt chest injury care bundle and identify implementation strategies informed by the behaviour change wheel (BCW).

Methods: An electronic survey based on the theoretical domains framework (TDF) was used to identify barriers and facilitators to the future activation of or response to a blunt chest injury care bundle was distributed to 441 staff from 12 departments across two hospitals.

Quantitative data were analysed using descriptive statistics. Qualitative data were analysed using inductive content analysis.  Quantitative and qualitative results were then integrated by mapping to the TDF. When a positively geared item had a mean greater or equal to four on a 5-point scale, then it was considered as a facilitator.

The facilitators and barriers were then evaluated using the BCW to extract specific intervention functions, policies, behaviour change techniques and intervention strategies. Each phase was assessed against the APEASE criteria.

Results: 198 staff (45%) completed the survey. Eight facilitators and seven barriers were identified. The factors facilitating implementation were: understanding patient care; patient assessment skills; blunt chest injury management skills, professional role identity, belief of consequences, provision of training, social supports and the protocol design. The barriers were the not understanding the term ‘care bundle’, lacking regional analgesia skills, not remembering to use protocol, belief of consequences, emotions, equipment and protocol access. Seven intervention functions were selected to address target behaviours: modelling, training, education, incentivisation, environmental restructuring, enablement, and persuasion.

Conclusions: Targeted implementation strategies can be developed using theoretical frameworks to consider facilitators and barriers to behaviour change and guide implementation strategy.


Biography:

Sarah has worked in the emergency department and as a trauma case manager for over 10 years at St George Hospital in Sydney. She is currently working towards a PhD through the University of Sydney investigating the implementation of a care bundle for patients with blunt chest injury. She also teaches at the Sydney Nursing School, teaching undergraduate nursing students.

Freddy’s Finger: A case study of traumatic amputation and healing by secondary intention instead of termination

Ms Michelle Cruse1

1Southern NSW Local Health District, Pambula District Hospital, Australia

How often do we see and treat a patient in the ED and then wonder what happened to them, or what the final outcome was? So often we just don’t know, patients get swallowed up in the black hole of the wards, or inter-hospital transfer, and are lost to us in the daily rush of a new set of ED presentations. By knowing the various ways an injury can be managed allows us as ED nurses to provide information to our patients or to further explain/interpret treatment options if they are given a choice by Specialist services.

This Case Study presentation follows Freddy, a RH dominant chef who had the poor form to drop his boat on his L middle finger when trying to put it onto the tow ball, thus causing a traumatic fingertip amputation. Management was offered in one of two ways, 1. Termination with flap at the DIPJ, or 2. Heal by secondary intention following surgical washout and distal phalanx trimming. The presentation (with all its glorious pictures!) demonstrates the outcome of choice no 2 – the longer healing time option but the one that ultimately ensured less deformity, and gave a better aesthetic outcome. Freddy returned to the Assessment and Treatment Centre for regular dressings which provided an excellent opportunity to track progress, problem solve dressing and other issues to allow Freddy to continue to work. Freddy has given permission for this Case Study to be presented today.


Biography:

Michelle has an extensive nursing background including orthopaedics, burns, education and finally settling in emergency. Michelle has been an emergency Nurse Practitioner for the last 9 years, first in Adelaide metropolitan, then remote small hospital in the WA Kimberley region, and now in southern NSW.  Nurses making a positive difference – to their patient and families, and to each other – is central to Michelle’s personal nursing philosophy. Michelle is a long-standing CENA member holding committee positions in including SA Branch President, National Board Member and is a current CENA Fellow.

Determining the priorities for change in paediatric trauma care delivery in NSW, Australia

Professor Kate Curtis1,2,3,4, Ms Belinda Kennedy1, Professor Andrew  Holland1,5, Associate Professor Rebecca Mitchell6, Dr Gary Tall7, Dr Holly Smith8, Dr Soundappan SV Soundappan1,5, Mr Allan Loudfoot7, Dr Brian Burns7, Associate Professor  Michael Dinh9,10

1The University Of Sydney, Camperdown, Australia, 2Illawarra Shoalhaven Local Health District, , Australia, 3The George Institute for Global Health, Sydney, Australia, 4Illawarra Health and Medical Research Institute, Wollongong, Australia, 5The Children’s Hospital at Westmead, Australia, 6Australian Institute of Health Innovation, Maquarie University, , Australia, 7NSW Ambulance, Rozelle, Australia, 8Northern Sydney Local Health District, Australia, 9NSW Institute of Trauma and Injury Management, Chatswood, Australia, 10Sydney Local Health District, Australia

Background: In Australia, injury remains the leading cause of death and disability for children and there is known variability in the quality of care delivered to injured children.  In 2018 an expert peer-review of 535 major paediatric trauma cases in New South Wales was undertaken using a validated clinical, system and human factors peer-review tool. This multidisciplinary review identified contributing factors to clinical incidents in trauma care resulting in 26 recommendations for change.  This study prioritises these recommendations for implementation with the aim of improving health service delivery to severely injured children.

Methods: A modified-Delphi study was conducted between October 2018 and February 2019. Two rounds of an online survey to rank the suitability and importance of each of the 26 recommendations was conducted. Final decisions on the priorities for change in the paediatric trauma system was determined by a consensus of ≥80% for importance and/or suitability.

A range of key stakeholders from across NSW including clinicians and health service administrators, consumers and government representatives participated.

Results: One hundred and one participants completed Round 1, and 60 participants completed Round 2 of the modified-Delphi. In Round 1, 13 recommendations reached ≥80% and in round 2, 11 recommendations reached ≥80%. Those ranked highest focussed on pre-hospital airway management, streamlining retrieval and transfer processes, improving hospital nursing ratios and radiology reporting.

Conclusion: The prioritisation and implementation of these recommendations, alongside a uniform State-wide trauma case review process with consistent criteria, performance indicators, monitoring and reporting would facilitate improvement in health service delivery to children sustaining severe injury.


Biography:

Professor Kate Curtis has been an Emergency Nurse since 1994 and is Clinical Nurse Consultant for Emergency at Illawarra Shoalhaven Local Health District. Kate is Professor of Emergency and Trauma Nursing at the University of Sydney and an honorary professorial fellow at the George Institute for Global Health. Kate’s translational research program focuses on improving the way we deliver care to patients and their families, and has attracted more than $4 million funding. Kate is the world’s most published author in the field of Trauma and Emergency Nursing and has mentored more than 40 clinicians in research projects.

Emergency care to the Sound of Music

Ms Margaret Murphy1

1Westmead Hopsital, Westmead, Australia

Background:

There has been a recent, substantial change in the pattern and severity of drug related harms associated with music festivals in NSW. Following urgent risk assessment, Health Response Teams (HRT), which included emergency nurses, were deployed to NSW music festivals with high risk features, to support event organisers to deliver safer events. This paper provides insight from emergency nurses into the scope of practice for HRT providing care in the music festival setting.

Method

The planning and intervention strategies designed to provide onsite specialist critical care at music festivals are described. This involved the incorporation of existing event management guidelines and principles of disaster management with information from events where a number of festival goers died, or presented with serious drug related illness. Consideration of the site environment through to team skill mix, patterns of serious drug-related toxicity and guidelines on expert onsite resuscitation practices are discussed.

Results

There were over 70 music festivals in NSW between September 2018 and May 2019. There were 5 deaths in 4 months. 29 patrons required intensive medical management at the festival site before transport, including sedation, rapid sequence intubation and aggressive cooling in cases of drug-related hyperthermia. There were 25 drug related intensive care admissions. MDMA toxicity was responsible for the severity of these clinical profiles.

Conclusion

Drug toxicity has been a major driver of drug related harm at NSW music festivals. In this setting, toxicity can progress rapidly with potential for multi-organs failure and death. Early recognition and management of complications by expert HRTs are key to preventing morbidity and mortality. Effective patient management is dependent on front line emergency staff providing appropriate care at the appropriate time, and this may involve exploring and expanding into new horizons.


Biography:

Margaret is employed as a clinical nurse consultant at Westmead Hospital, Sydney.  She has an extensive clinical background in emergency nursing. Prior to working in emergency Margaret has had experience in Intensive Care, Mental Health, Education and Change Management. She has also worked as a principal project officer at the NSW Ministry of Health. She holds executive and advisory positions with NSW Emergency Care institute and Westmead Hospital Clinical Board. She has consulted on emergency care in Nepal, Malaysia, Sri Lanka and Bangkok. She has been recognised by peers with awards that include Westmead Hospital Nurse of the Year. She has a strong commitment to translational emergency care research and is currently completing her PhD.

The night I left my wife for Trevor: You can take the nurse out of Emergency but you can’t take Emergency out of the nurse

Mr Gavin O’Brien1

1Top End Health Service, Darwin, Australia

Originally a psychiatric trained nurse Gavin saw the development and implementation of PECC units into  realms of the ED, worked in Adult and adolescent acute psychiatric wards , and also did a stint in Intesive Care Psych. Then he  saw the Dark side and joined Emergency Nursing. Having worked for 8 years in NSW Health and Top End Health Services  across all clinical areas of ED Gavin developed a passion for trauma and disaster. In his current position Gavin has found he needs to pinch himself every morning to realise that he is not dreaming. He has recently joined the education Team at the National Critical Care & Trauma Response Centre (NCCTRC) which he holds the portfolio of MIMMS and HMIMMS. He co ordinates courses across the Top End and is part of a Regional Engagement Program supported by the Department of Foreign Affairs which engages countries around the Pacific and South East Asia to develop infrastructure around disaster management.

He has also gone back to uni for the 4th time.

Cyclone Trevor was declared a State of Emergency by the Territory Government as the large storm cell was to make landfall as a Category 4 Sever Tropical Cyclone approximately 100km South East of Macarthur River. A combination of severity and the threat of the storm alongside its complications associated with remoteness led the Chief Ministers decision to evacuate the affected areas. To paint a picture one has to appreciate the geo and demographical factors that come into play. The NT covers nearly 1.35 million Km² accounting for the 3rd largest block of land in the country and 11th largest country subdivision in the world with a population of only 246 700. Not only was it the largest evacuation pre cyclone but the second largest evacuation in the countries history secondary to Cyclone Tracy with over two thousand people evacuated from Groote Eylandt, Borroloola, and surrounds to evacuation centres in Katherine and Darwin.

What is ones role in the eye of the storm?

The following presentation will deliver a summary of events through the eyes of Emergency Nurse deployed as a response to a State of Emergency. To be taken out of the comforts and familiarity of the Emergency Department (even though some days it can be somewhat a resemblance of a cyclone) challenges the thought process of what do I need as a clinician to work safely and effectively outside of my comfort zone. The author will highlight some of the key principles and concepts of disaster preparedness and management and the role of health and how it aligns itself with multiple agencies.


Biography:

Gavin has a varied and colourful nursing background.He was steered to the health care profession by his mum (also a nurse with 40 ish years experience) who said he can get a job, study…or get out!!! So he studied.

How Emergency Nurses in Indonesia sustain themselves and provide effective care?

Mrs Gilny Rantung1,2, Associate Professor Virginia  Plummer1, Professor Debra Griffiths1, Associate Professor Cheryle Moss1

1School of Nursing and Midwifery Monash University, Frankston, Australia, 2Faculty of Nursing, Indonesia Adventist University, Bandung, Indonesia

Background: Emergency nurses in Indonesia play a pivotal role in emergency care. However, the stressful nature of the emergency department can cause nurses to experience burnout, demotivation, and intention to leave, which will impact on the effectiveness of emergency care they provide. It remains unknown, nationally or internationally, how emergency nurses sustain themselves personally and professionally while providing effective care.

Aim: This study explored the actions and processes that emergency nurses use to sustain themselves.

Methods: This qualitative study utilised constructivist grounded theory methodology informed primarily by Charmaz (2014). To strengthened the research strategy, Clarke’s et al. (2018) situational analysis was adopted as a method to support Charmaz’s grounded theory processes. A total of 30 participants were involved in the study: 15 emergency nurses were recruited from two selected emergency departments in West Java province, and another 15 emergency nurses were recruited from 10 other provinces in Indonesia. Data were generated by contextual observations, multiple interviews, and individual observations.

Results: Through an iterative and simultaneous analysis process, five interconnected categories were constructed: ‘withdrawing self from distressing situation’, ‘maintaining a degree of professional attachment without much investment’, ‘reacting to the driving force’, ‘developing and strengthening oneself’, and ‘endeavouring to sustain and be effective’. These categories showed a dynamic process of how emergency nurses sustain themselves and provide effective care in the context of Indonesia.

Conclusion: The findings of the study provide significant information for future national and international emergency nursing workforce development strategies, as well as recruitment and retention strategies in the emergency department.


Biography:

Gilny Rantung is a PhD Candidate in the School of Nursing and Midwifery, Monash University. She is also a nursing lecturer in Indonesia and awardee of LPDP scholarship.

Everyone’s a Winner: A design better than we’ve ever done before

Mrs Nerys Brackman1,2

1Queensland Health, Caboolture, Australia, 2The University of Queensland, School of Nursing, Midwifery and Social Work , St Lucia, Australia

Background

The current project has used best practice guidelines, data analysis and site visits to develop planning for an interim extension and a complete new build of a Metropolitan Emergency Department.

Aim

To create an Emergency Department design that focused on improving time to treatment by optimising design and supporting flow whilst continuing to foster the unique staff culture and team dynamics.

Methods

Presentation data was collected from 2015-2017, American analytic firm – Huddy Health Care Solutions was hired by MNHHS as an ED design Consultant to deliver operational and design insights to the hospital design, project and infrastructure team.  Following the collection of analytics and prior to a joint workshop at Caboolture Hospital with Queensland Health architects, three members of the ED Management Team visited five US Emergency facilities recommended by Huddy for their unique design and/or flow. To evaluate each facility and capture design ideas we developed an evaluation tool and used real time video reflective ethnography.

Results

In collaboration with Huddy, architects engaged by Qld Health, ED clinicians, Caboolture project team and Metro North Infrastructure a unique design and patient flow model was delivered.  The design and model of care incorporates a Pivot/Intake model to quickly stream patients to their correct area, decrease frustrating waits and safely manage the largest cohort of ATS 3 patients who have historically waited in an undifferentiated state with the greatest risk of deterioration outside of a clinical space.  Our design has standardised all clinical spaces to allow for greater flexibility based on departmental demand.

Conclusion

Caboolture Hospital Emergency Department is the first ED in Australia to have used the innovation and experience of Jon Huddy. This has allowed us to develop a design which meets our brief of maintaining staff culture, improving flow; and outcomes for our community.


Biography:

My nursing career spans over 25 years within the public sector and I have worked in a variety of clinical settings. I have over 17 years’ front-line experience as an Emergency Department nurse at all clinical levels, often in very challenging clinical and social surroundings, and I fully understand the Emergency Department environment and the pressures that staff face.  My current role is as the Nursing Director of Caboolture Emergency Department, Woodford Correctional Facility and Kilcoy Hospital.   My passions lie in clinical innovation in the developing workplace, team work, integrity and improving patient outcomes.

Decentralising the nurses Station, The mobile nurses Station

Mrs Jane Congdon1,2

1Qld Health, Caboolture, Australia, 2University of the Sunshine Coast, School of Nursing, Midwifery and Paramedicine, Caboolture, AUSTRALIA

Background

The current project examines the mobile nurses’ station impact on workloads for nurses in a metropolitan hospital.  The premise is that if nurses have access to tools to perform their job within proximity to patients they are providing care for, they will spend less time away from patients.

Aim

The broad aim is to evaluate the effectiveness of a mobile nurses’ station in improving patient direct care time and patient flow through the ED.

Methods

Data collection includes a Nurses’ activity follow / time in motion study.  There were three data sets collected from the activity follow pre and post implementation and include the activity follow, step count, and interruption count. The survey was adapted from the productive ward toolkit, containing both quantitative and qualitative data, pre- and post-implementation ANOVA will be used to compare the means of the pre and post paired survey quantitative responses, a P value of greater than 0.005 will indicate statistical significance.

Results

A total of 62 nurses returned completed pre-implementation surveys, and 43 nurses completed the post-implementation survey.

During the activity follows, nurses were tracked for 32 hours in the ED, there was no statistically significant increase in direct care time.  The steps by nursing staff reduced from an average of 864.72 per hour to 548.6 per hour.

Conclusion

The response survey responses data indicated that there was a positive response from staff to the implementation of the mobile nurses’ station.  There was no statistical increase in patient direct care time, however there was a significant reduction in nurses’ superfluous motion activities.  Furthermore, an analysis of the available literature has clearly identified a gap in the research and practice knowledge, there is insufficient data available on the benefits of decentralising the nurses’ station.


Biography:

I completed my Bachelor of Nursing in 2007 at the University of South Australia, I am enrolled in a Master of Health Research at Sunshine Coast University, having submitted a recent application to articulate to a PHD.  I am currently employed as the BPIO at Caboolture Emergency Department and have worked here for the past eleven years.  Diversity in practice is reflected by my employment history, and participation in a variety of projects within the University and Hospital.  My nursing history is patient focused; improving data and performance is centred around improving the situation for the benefit of the patient.

Emergency Nurses’ experience of adult basic and advanced life support workstations as a support strategy for clinical practice in the Emergency Department

Dr Sharyn Ireland1,2, Mr Marc Marquez1, Ms Claire Hatherley1, Ms Nicole Farmer1,2, Ms Bella Luu1,2, Ms Charlotte Stevens1, Dr Eldho Paul3, Professor Biswadev Mitra1,3

1Alfred Hospital, Emergency & Trauma Centre, Melbourne, Australia, 2La Trobe University, School of Nursing & Midwifery, Melbourne, Australia, 3Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University , Melbourne, Australia

BACKGROUND: Basic Life Support (BLS) and/or Advanced Life Support (ALS) knowledge and skills are essential for health professionals working in Emergency Departments (EDs) and across healthcare facilities.

AIMS: To determine the proportion of Registered Nurses (RNs) in the ED who completed a competency assessment in Adult ALS within 6 months of attending a programme to rehearse essential skills for adult BLS and ALS in a safe learning environment; whether RNs who attended found the programme beneficial to increase their knowledge and skills in BLS and/or adult ALS; and whether RNs felt more confident to use the skills and knowledge clinically after attending the programme.

METHODS: Consented participants were invited to complete an on-line evaluation survey of their experience immediately after the programme and at 6-months following the programme.

RESULTS: A total of 143 RNs working in the ED consented to participate in this study. Post-programme surveys were received from 103 RNs; a response rate of 72%. Of these, 62 (60.2%; 95% CI: 50.5-69.1) RNs had completed their annual competency in ALS since completing the programme. The majority of RNs (97.1%) found the programme to be beneficial and 82 (80.4%) reported using the knowledge and skills gained from the programme in their clinical practice.

Immediately after conclusion of the programme, 128 participants returned surveys on their perception of the programme; a response rate of 89.5%. In general, the majority of nurses reported increased knowledge and skills (93.7%), opportunity to practice skills (91.9%) and increased confidence (91.9%) following workstation attendance.

CONCLUSION: Majority of participants successfully completed their annual ALS competency within 6 months of attendance of the workstations. Participants found this programme beneficial and attendance increased ED RN’s knowledge and skills in adult BLS and ALS. RNs report improved confidence to use their knowledge and skills since attending this programme.


Biography:

Marc Marquez is an Associate Nurse Manager at The Alfred Hospital’s Emergency & Trauma Centre, with a background of ten years clinical experience. Marc graduated from Victoria University with a Bachelor of Nursing in 2008. He holds a Master of Nursing (Emergency Care) from La Trobe University and was awarded the 2018 Australasian Emergency Nurse of the Year by the College of Emergency Nursing Australasia (CENA). Marc has recently been involved in a publication entitled “The World Health Organization trauma checklist versus Trauma Team Time-out: A perspective”, which has been published with the Emergency Medicine Australasia in May 2019.  He also serves as a Nursing Officer for the Royal Australian Army Nursing Corps, and has been an active serving member of the Army Reserve for thirteen years. With a strong passion for the development of international healthcare standards, Marc is heavily involved with the Alfred Hospital’s international programs.

Dr Sharyn Ireland is currently a Clinical Nurse Educator at the Emergency and Trauma Centre, Alfred Health. In her role as senior adjunct lecturer for La Trobe University, Sharyn contributes to the education of Emergency Nurses studying at postgraduate level. For the past 20 years, Sharyn has developed and instructed on many programmes involving various levels of simulation. After completing the Harvard Simulation Instructors programme in Boston, United States of America, Sharyn developed an interdisciplinary fully immersive simulation programme to support health professionals locally progress to working in the Resuscitation area of the Emergency and Trauma Centre. In addition, she co-ordinates and co-facilitates a one-day fully immersive programme with a focus on Trauma, delivered multiple times annually.  Her doctorate research investigated hypothermia in trauma. Sharyn has won many awards for her publications in this area and is held in high esteem internationally as she supports researchers in this topic, both nationally and internationally. She is a peer reviewer for multiple journals and is a current instructor at the Centre of Health Innovation teaching 5th year medical students where she has worked for many years.  As part of her Master’s in Education (Monash University), Sharyn’s thesis explored registered nurses’ experience of their annual Advanced Life Support competency. Outside of her professional life, Sharyn enjoys celebrating the lives of her five adult children and particularly loves participating in and contributing to the achievements of her seven grandchildren, often spending time with them on school holidays whilst their parents work.  Sharyn is an avid traveler enjoying snorkeling where ever that may take her. Swimming with whale sharks on the West coast to Manta rays in Bali and recently meeting a moray eel in New Caledonia are just some of her memorable encounters.  Sharyn is looking forward to attending Wagner’s opera Tristan and Isolde in Bayreuth Germany later in 2019.  Sharyn was the recipient of the prestigious Philippa Moore publication prize awarded by the College of Emergency Nurses Australasia in 2011 and more recently in 2018.

Smashing the stigma, it starts with us! A unique and personal presentation addressing how the stigma held by frontline emergency staff impacts not just on our patient’s survivability, but also our own colleague’s wellbeing

Ms Jess Morton1

1Nepean Hospital, Australia

Every 40 seconds, someone, somewhere around the world dies by suicide. Global economic projections have estimated that by 2030, mental illness will cost the world $6 trillion per annum. (World Health Organisation, 2018).

As the burden of disability and the death toll soars, so is the burden on Emergency departments around the world. Emergency frontline staff often feel inadequately trained to assess, manage and care for patients who are experiencing mental distress (Tyerman, 2014).

The manner by which nurses treat the patient and the time to which the clinician gives to obtain their relevant history has a large impact on not only that patients perception of their immediate care, but also their likelihood of continuing their care (Clarke, Dusome and Hughes, 2007). Stigma has been shown to be a significant deterrent to seeking help, especially in crisis situations. Emergency staff can play a significant role in reducing this stigma (Thornicroft, Rose and Kassam, 2007).

Conversely, professional organisations across the world are lamenting at the rising rate of burn out, mental illness and sadly, suicide amongst nurses, paramedics and doctors which are becoming more prevalent (Milner et al., 2016).

This presentation will address on how the stigma held by frontline staff impacts not just on the wider general public and their associated carers, but also on the direct wellbeing of our colleagues and their likelihood of seeking help in a crisis. The consensus of this talk was presented at the 2019 SMACC conference in Sydney in the format of an interview. It brought the theatre to silence and received overwhelming praise and positive feedback.

Utilising a unique perspective that incorporates the presenters previous and very personal experience as a mental health patient, but also now as an Emergency Nurse, this presentation will broaden delegates’ perspective of the mental health patient in the Emergency Department and learn how to recognise and change harmful stigmatising attitudes.


Biography:

Jess Morton has been an Enrolled Nurse for over 13 years.  Having worked across a vast range of specialties and facilities, Jess has found her niche in Emergency Nursing whilst plodding through a Bachelor Of Paramedic Science.  Jess has served in the community engagement portfolio and as co-chair of Student Paramedics Australasia.  Jess writes a blog titled “Textbooks, Tears & Trauma” for the Prehospital Research website and has co-authored various papers for international Paramedicine journals.  She has recently won the “Enrolled Nurse of the Year award” for Nepean hospital for the annual excellence in Nursing awards.

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