Background: Registered nurses in the emergency department are exposed to a high workload, and the work environment is stressful. Frequent reports of burnout in the health care profession are a fact, and nurses are a particularly vulnerable group. Aim: The aim of this study was to investigate registered nurses’ experiences of work-related stress in the emergency department. Method: A literature review including 13 quantitative and qualitative studies was conducted. The databases CINAHL and Pubmed were used to find relevant research for this study’s intended purpose. The authors read all the studies multiple times to gain understanding and to find connections between the results. Results: The findings in this study revealed three main themes: the feeling of inadequacy, not having control and, finally, the deterioration of their health. The nurses conveyed that they were not capable of performing optimal care due to a lack of recourses paired with a high workload. The feeling of endangering the patients' safety because of the nurses' stress was recurring. The nurses described multiple coping mechanisms to handle stressful situations at emergency departments, but none that really worked. Conclusion: The nurses in the emergency department feel that work-related stress has a negative impact on their mental and physical health. Feelings such as powerlessness, guilt towards the patients and shame were common. Most nurses described that they were not satisfied with the quality of the care they provided. All nurses expressed the need for more resources to manage stress and to provide appropriate patient-safe care.

Bakgrund   Huvuduppdraget för akutmottagningar är att ta emot och stabilisera patienter som är i behov av omedelbart medicinskt omhändertagande. Patienter förväntar sig en snabb process med korta genomströmningstider och ställer allt högre krav på hälso- och sjukvården och att den ska vara tillgänglig när behovet för vård uppstår (Region Stockholm, 2013). De utmaningar som finns på akutmottagningar såsom väntetider, resursbrister och kontinuitet resulterar i att patientens förväntningar ej stämmer överens med verkligheten som råder på en akutmottagning. För att vårdpersonalen ska kunna bemöta patienter på ett så bra sätt som möjligt är det därför av vikt att beskriva vilka faktorer som påverkar patienters upplevelse av besök på akutmottagning. Syfte Syfte var att undersöka patienters upplevelse av besök på akutmottagning. Metod  För att svara på syftet användes en icke-systematisk litteraturöversikt baserad på 19 vetenskapliga artiklar publicerade 2012-2022. Sökningarna utfördes i databaserna PubMed och CINAHL, samt genomfördes manuella sökningar. Artiklarna kvalitetsgranskades och innehållet analyserades för att sammanställas i fyra huvudkategorier: upplevelse av vårdbehov, att vara patient, mötet med vårdpersonalen och upplevelse av väntan och prioriteringssystem.  Resultat Utifrån huvudkategorierna skapades sex subkategorier, där patienters upplevelse av besök på akutmottagning beskrivs. Patienters anledning till att uppsöka akutmottagning, patientens upplevelse att få uppmärksamhet och bli respekterad, patientens förtroende för vårdpersonalen, bristande kommunikation och information, patientens upplevelse av delaktighet, långa väntetider och känslan av att bli bortglömd. Slutsats Resultatet visade på både positiva och negativa upplevelser, men majoriteten var negativa. Ur ett patientperspektiv visade resultatet på att kommunikation och information viktiga parametrar. Genom att informera patienten vid triageringen och förbereda inför väntetiden bidrar det patientens upplevelse av bemötande ökar och bidrar även till ökad tillfredsställelse. Resultatet påvisade även att patienternas upplevelse förbättrades när vårdpersonalen lyssnade aktivt, gjorde patienterna delaktiga i vården och visade respekt för patienternas integritet. Upplevelsen kan därmed förbättras genom att vårdpersonalen använder sig av relativt enkla insatser för att öka patienternas tillfredsställelse av besök på akutmottagningen. / Background The primary designated responsibility for emergency departments (ED) is to receive and stabilize patients who are in need of immediate medical care. The expectation of the patient is a fast process with short throughput times and they place ever higher demands on healthcare and that it should be available when the need for care arises. The typical challenges that exist in ED, such as waiting times, lack of resources and continuity, often result in the expectation of the patient not being in line with the prevailing reality in an ED. In order for the care staff to be able to treat patients in the best possible way, it is therefore important to describe the factors that affect the experience of patient visits to the ED. Aim The purpose was to investigate the experience of patient visits to the emergency department. Method To answer the purpose, a non-systematic literature review based on 19 scientific articles published in 2012-2022 was used. The searches were performed in the PubMed and CINAHL databases, and manual searches were performed. The articles were quality reviewed and the content was analyzed and compiled into four main categories: experience of care needs, being a patient, meeting with care staff and experience of waiting and prioritization systems. Results Based on the main categories, sex subcategories were created, in which the patient experiences of visits to the emergency department are described. The patient's reason for seeking emergency care, the patient's experience of receiving attention and being respected, the patient's trust in the care staff, lack of communication and information, the patient's experience of participation, long waiting times and the feeling of being forgotten. Conclusions The results showed both positive and negative experiences, but the majority were negative. From a patient perspective, the results showed that communication and information are important parameters. By informing the patient during the triage and preparing for the waiting time, it contributes to the patient experience of the overall treatment and also contributes to increased satisfaction. The results also showed that the patient experience improved when the care staff listened actively, made the patient involved in the care and showed respect for patient integrity. The experience can thus be improved by the care staff using relatively simple measures to increase patient satisfaction with visits to the emergency department.

Emergency department (ED) overcrowding is a global concern. To help mitigate this issue, this thesis studies impediments to efficient patient flow in the ED caused by suboptimal worker behaviors and patient routing policies. I focus on three issues: (i) admission batching, (ii) hallway placement and (iii) under-triage behavior, and empirically demonstrate their impact on patient flow and quality of care. These studies are summarized as follows. Admissions batching: We study the behavior of admitting patients back-to-back (i.e., batching) by ED physicians. Using data from a large hospital, we show that the probability of batching admissions is increasing in the hour of an ED physician’s shift, and that batched patients experience a longer delay from hospital admission to receiving an inpatient bed. We further show that this effect is partially due to the increase in the coefficient of variation of inpatient bed-requests caused by batching. However, we also find that batching admissions is associated with a higher shift-level productivity. An important implication of our work is that workers may induce delays in downstream stages, caused by practices that increase their productivity. Hallway utilization: A common practice in busy EDs is to admit patients from the waiting area to hallway beds as the regular beds fill up. Using data from a large ED, we first perform a causal analysis to quantify the impact of hallway placement on wait times and quality of care – as defined by disposition time, room-to-departure (R2D) time and likelihood of adverse outcomes. We find that patients admitted to the hallway experience a significantly lower door-to-doctor time at the cost of longer disposition and R2D times. Hallway patients are also substantially more likely to experience an adverse outcome. Next, using a counterfactual analysis we show that a pooling policy, where hallway beds are used only if all regular beds are full, significantly reduces wait times, albeit at the cost of a slightly higher hallway utilization. Also, too little or too much wait tolerance for rooming patients may result in under- or over-utilization of the hallway space, both of which are detrimental to overall ED length of stay (LOS) and wait times. Under-triage behavior: Triaging ED patients upon arrival to the ED and assessing their urgency for treatment is crucial for timely service to all patients. Despite the standard patient classification algorithm by which all nurses are trained, we hypothesize, and show, that the ED’s workload impacts the perceived patient urgency, and subsequently, patient severity scores. We first use a predictive model to predict a patient’s true triage level using information collected at triage and define under-triage, accordingly. We find that under-triage is decreasing up to a certain point of workload but increasing after (U-shape). We also quantify the impact of under-triage on disposition time, room-to-departure time and risk of readmission. Collectively, this thesis demonstrates how patient-flow may be improved without the need to increase explicit physical capacity in the ED (e.g., beds). It offers practical solutions to managers and contributes to the operations management literature.

Background The emergency department is intended for people with acute illness or injuries. In the acute phase and in urgent situations, the focus of the healthcare staff is not always on attendance and respectful treatment or care. Instead, quick handling and strict schedules are prioritized. As a result, communication and information fail and the patients' basic needs are overlooked. Consequently, the healthcare staff might be perceived as indifferent and rude. This uncaring encounter leaves the patients feeling vulnerable, abandoned and disrespected. The absence of communication and respectful treatment may have adverse effects on the patients' well-being. Aim The aim of this study was to describe patients' experiences of treatment in emergency departments. Method A literary study was made using 9 articles with a qualitative approach. Results Two themes were identified: the patients' experiences of being noticed in emergency departments and the patients' experiences of the meaning of communication in emergency departments. The themes had two subthemes each: not to be seen, to feel confirmed, lack of information and the importance of communication in health care. Conclusion The absence of caring encounters and lack of information contributes to negative experiences in the emergency departments and is the cause of great suffering in patients. / Denna studie hade som syfte att undersöka patienters upplevelser av bemötande när de sökte vård på akutmottagningar. Resultatet visade att patienter hade svårigheter i att tala om varför de sökte vård, då personalen upplevdes som ifrågasättande och nonchalanta. Patienterna kände sig bortglömda i väntrummet då det var långa väntetider samt att de inte informerades tillräckligt. Detta resulterade i att känslor av otrygghet, rädsla och oro belystes. De patienter som däremot informerades, uppmärksammades av personalen samt där personalen bjöd in patienten till delaktighet i sitt vårdbesök, upplevde ett gott bemötande. Denna studie visar att patienter upplevde brister i bemötandet på akutmottagningar och att personcentrerad vård värderades högt av patienterna för att känna en trygghet till vården. Att inte bli respektfullt bemött resulterar i ett onödigt lidande för patienten. Vården som bedrivs på akutmottagningen är inriktad på allvarliga skador och åkommor, där personalen har som ansvar att bedöma, sortera och prioritera så att de allvarligaste skadorna hanteras först. En del av sjuksköterskan ansvar på akutmottagningen är att uppmärksamma patientens psykosociala behov, likaledes är hennes ansvar att prioritera patienters fysiska behov. Studiens resultat påvisade att patienter upplevde brister kring dessa ansvarsområden. Patienter som sökte vård på akutmottagningen upplevde ångest och oro då de saknade kunskap om sitt förändrade hälsotillstånd och var beroende av kontinuerlig information. För att ge patienten en positiv upplevelse av sitt besök så kan personcentrerad vård vara en ingång. Personcentrerad vård innebär en kärnkompetens för sjuksköterskor och belyser vikten av att tillsammans med patienten bilda en relation och ett partnerskap för att patienten ska kunna uppleva delaktighet i sin egen vård. Genom delaktighet kan patienten på ett bättre sätt hantera och begripa sin situation. Den metod som använts är en litteraturstudie. Kvalitativ forskning har granskats för att skapa en överblick av tidigare forskningsresultat kring detta ämne. Studiens syfte var att undersöka patienters upplevelser och därför valdes kvalitativ forskning, då denna forskningsmetod rekommenderas för granskningar av upplevelser.

Bakgrund: Patienter med ett aggressivt beteende mot sjuksköterskor på akutmottagningen har ökat de senaste åren. Att känna sig hotad av aggressiva patienters verbala eller fysiska beteende kan påverka sjuksköterskans hälsa. Utifrån patienters bakgrund och behov behöver sjuksköterskan ta ställning till hur patienten ska bemötas för att minska risken för uppkomst eller eskalering av ett aggressivt beteende hos patienten. Syfte: Syftet var att beskriva sjuksköterskors erfarenheter av möten med aggressiva patienter på akutmottagningar. Metod: Studien genomfördes som en allmän litteraturstudie och resultatet togs fram genom en innehållsanalys av åtta vetenskapliga artiklar. Resultat: Resultatet presenteras i kategorierna sjuksköterskors erfarenheter av utlösande faktorer som ökar risken för aggressivitet, kommunikation mellan sjuksköterskor och patienter, sjuksköterskors upplevelser av möten med aggressiva patienter, brist på debriefing och utbildning samt utbrändhet och känslor. Resultatet belyser olika faktorer som gör att aggressivitet eskalerar på akutmottagning. Det uppmärksammas att behovet av debriefing och utbildning behövs för att hantera aggressiva situationer. Sjuksköterskor kan uppleva aggressivitet som hotande och kan därmed försämra deras hälsa. Konklusion: Resurser som fler sjuksköterskor, mer utbildning i hur man kommunicerar och interagerar med aggressiva patienter och fler tillfällen av debriefing behövs för att sjuksköterskor ska kunna omvandla en farlig situation till en trygg arbetsplats. / Background: Patients with aggressive behavior towards nurses at the emergency department have increased in recent years. Feeling threatened by the verbal or physical behaviour of aggressive patients can affect the nurse's health. Based on patients' background and needs, the nurse needs to decide how the patient should be treated in order to reduce the risk of the patient developing or escalating aggressive behaviour. Aim: The purpose was to describe the nurse´s experiences in meetings with aggressive patients in emergency rooms. Method: The study was conducted as a general literature study and the result was obtained through a content analysis of eight scientific articles. Results: The results are presented in the categories of nurse´s experiences of triggering factors that increase the risk of aggression, communication between nurses and patients, nurse´s experiences of meetings with aggressive patients, lack of debriefing and training and burnout and feelings of abandonment. The result highlights various factors that make aggressiveness escalate in the emergency department. The need for debriefing and training is needed to deal with aggressive situations. Nurses may experience aggressiveness as threatening and can thus impair their health. Conclusion: Resources like more nurses, more training in how to communicate and interact with aggressive patients and more opportunities for debriefing are needed for nurses to transform a dangerous situation into a safe workplace.

Bakgrund: Litteraturgenomgången visar att samhället genomsyras av heteronormativitet. Kunskapsbrister finns i utbildningarna inom sjukvården och i den kliniska verksamheten om möten med HBTQ- personer. En kunskapslucka kan identifieras om hur möten skapas mellan sjuksköterskor och HBTQ- personer på en akutmottagning. Syfte: Studiens syfte var att beskriva hur legitimerade sjuksköterskor på en akutmottagning möter HBTQ- personer. Metod: Deskriptiv empirisk studie med kvalitativ ansats, interaktiva samtalsintervjuer med sex legitimerade sjuksköterskor genomfördes och analyserades med modifierad innehållsanalys, editing analysis style. Resultat: Ur analysen utkristalliserades fyra kategorier: spirande genuserfarenhet, en krävande men öppen arbetsmiljö, tvetydig relation och god och värdig vård. Slutsats: Analysfynden från interaktiva samtalsintervjuer med sex legitimerade sjuksköterskor på en akutmottagning förklarades med begrepp ur queerteorin. Trots att den spirande genuserfarenheten hämmas av den förhärskande heteronormativiteten och kunskapsbristen om kön, genus och sexualitet bidrar till tvetydigheten hos sjuksköterskorna på akutmottagningen, skapas det, även under rådande förutsättningar, möten inom vilka HBTQ- personer ges en god och värdig vård. / Background: The literature review shows that society is permeated by heteronormativity. Knowledge gaps in education programs in health care and in clinical practice concerning encounters with LGBTQ people. A knowledge gap can be identified on how encounters are created between nurses and LGBTQ people in an emergency department. Aim: The aim of this study was to describe how registered nurses in a hospital emergency department encounter LGBTQ- people. Method: Descriptive empirical study with qualitative approach, interactive conversation interviews with six registered nurses was conducted and analyzed with modified content analysis, editing analysis style. Results: From the analysis emerged four categories: emerging gender experience, a demanding but open work environment, the ambivalent pair and good and dignified care. Conclusion: The findings from interactive conversation interviews with six registered nurses in an emergency department were explained with concepts of queer theory. Despite the emerging gender experience is hampered by the dominant heteronormativity and lack of knowledge concerning sex, gender and sexuality contributes to the ambiguity of the nurses in the emergency department, even under present conditions, encounters are created with LGBTQ people, in which they are given a good and dignified care.

Bakgrund. På akutmottagningen är flödet av patienter stort och möten mellan sjuksköterskor och patienter är korta och tidspressade. Det primära för patienter på en akutmottagning är att sjuksköterskan vet vad som ska göras. Omvårdnad kan delas upp i två kategorier: instrumentell omvårdnad och emotionell omvårdnad. För att agera med omvårdnad, måste sjuksköterskan dels ha ett omhändertagande med teknisk kompetens och samtidigt stödja patientens emotionella behov. Syfte. Studiens syfte är att undersöka vad omvårdnad är i ett akut omhändertagande på en akutmottagning. Metod. Sju sjuksköterskor från en akutmottagning inkluderades. Semi-strukturerade intervjuer genomfördes och analyserades med en kvalitativ innehållsanalys. Resultat. Två huvudkategorier framstod ur analysen: vad sjuksköterskorna beskrev som betydelsefullt i det akuta omhändertagandet och förutsättningar på akutmottagningen. Att stabilisera patienten beskrevs som det primära och allt annat omvårdnadsarbete utfördes i mån om tid. Slutsats. Omvårdnad kan sammanfattas i instrumentell och emotionell omvårdnad. Den instrumentella kategorin beskrevs som det primära för att rädda liv och stabilisera vitala funktioner. Sjuksköterskan beskrev även vikten av att bejaka patientens integritet och välbefinnande i det akuta omhändertagandet. Tidsbrist var dock en faktor som försvårade den emotionella omvårdnaden. Sjuksköterskan beskrev inte alltid den instrumentella kategorin som omvårdnad, dock kan omvårdnadsdiagnoser användas för att tydliggöra sjuksköterskans omvårdnadsarbete. Klinisk betydelse. Resultatet kan tillämpas i syfte att tydliggöra omvårdnaden i det akuta omhändertagandet. / Background. There is a high flow of patients in the emergency department and encounters between nurses and patients are short and time pressed. The primary for patients in an emergency department is that the nurse knows what to do. Nursing care and can be divided into two categories: instrumental nursing care and emotional nursing care. To act with nursing care, the nurse must have technical skills, while supporting the patient's emotional needs. Aim. The purpose of this study was to investigate what nursing care is in the emergency care situation at an emergency department. Method. Seven nurses from an emergency department were included. Semi-structured interviews were conducted and analyzed using a qualitative content analysis. Results. Two main categories emerged from the analysis: what the nurses described as important in the acute care setting and the emergency departments conditions. To stabilize the patient was described as the primary focus, and all the other nursing tasks were performed according to time. Conclusions. Nursing care can be summarized in the instrumental and emotional caring. The instrumental category was described as the primary focus in order to save lives and stabilize vital functions. The nurses also described the importance of affirming the patient's privacy and well being in the emergency care setting. However lack of time was considered to be a factor that hindered the execution of adequate emotional care. Some nurses didn´t describe the instrumental category as nursing, however nursing diagnoses can be used to clarify what nursing care is. Relevance to clinical practice. The result can be applied in order to clarify the role of nursing care in the emergency care.

Bakgrund: Syftet med triage på akutmottagningen är att säkerställa att patienter med störst behov av vård får det inom rimlig tid och på ett korrekt sätt. Triageprocessen inleds med att skapa en första kontakt mellan sjuksköterska och patient där kommunikationen är av stor betydelse. Att kunna delge andra människor information och dessutom kunna tolka och läsa av meddelanden är en del av kommunikationen samt att lyssna och ge svar på andra personers uttryck. Även icke-verbal kommunikation är en stor del av det som kommuniceras. Akutmottagningen är en stressig miljö och det finns mycket att lära angående vad som kan förbättra kommunikationen mellan sjuksköterska och patienter. Syfte: Att belysa hinder och befrämjande av kommunikation mellan sjuksköterska och patient vid triage och på akutmottagning. Metod: En allmän litteraturstudie baserad på tio kvalitativa artiklar. Resultat: Två huvudteman med sju underrubriker identifierades. Huvudtemana var: Befrämjande av kommunikation och Hinder för kommunikation. Underrubrikerna var: Verbal kommunikation, Icke-verbal kommunikation, Delaktighet i vård, Icke-delaktighet, Bristande individfokus, Tidsbrist och Informationsbrist. Slutsats: Av resultatet framgår att fler faktorer inom triage och akutsjukvård utgör hinder för kommunikation. Resultatet tyder på att patienterna saknar information om rutinerna på akutmottagningen samtidigt som sjuksköterskorna inte alltid anser sig ha tid för att ge informationen till patienterna. De faktorer som påverkar befrämjandet av kommunikationen stämmer överens med Habermas (1981/1990) teori där kommunikation baseras på öppenhjärtig grund, ärlighet och samförstånd. Klinisk betydelse: En mer patientcentrerad kommunikation och bättre information kan behövas på akutmottagningarna för att patienterna ska få bra vård och för att arbetet ska bli enklare för sjuksköterskorna. / Background: The purpose of triage in the emergency department is to ensure that patients with the greatest need of care receive it within a reasonable time and in a proper manner. The triage process starts by creating an initial contact between nurse and patient, where communication is a vital part. Being able to communicate information to other people and to interpret messages is a part of the communication and also to listen and provide answers to other people's expressions. Non-verbal communication is also a great part of what is communicated. The emergency room is a stressful environment and there is much to learn in what can make communication between nurses and patients better. Aim: To highlight what hinders and promotes communication between nurses and patients in triage and at the emergency department. Method: A general literature study based on ten qualitative articles. Results: Two main themes and seven subthemes were identified. Main themes were: Promoting communication and Obstacles for communication. Subthemes were: Verbal communication, Non-verbal communication, Participation in care, Non-participation, Lack of individual focus, Lack of time and Lack of information. Conclusion: The results of the study show that more factors in triage and emergency care became hindrance of communication. The patients lack information about the routines in the emergency department and the nurses do not have enough time to inform the patients. The factors that affect promotion of communication consist with Habermas (1981/1990) theory where communication is based on open-hearted grounds, honesty and understanding. Clinical implication: A more patient-centered communication and better information may be needed at the emergency departments to secure good care of the patients and thereby facilitate the nurses work.

In the United States, an annual estimate of 1.36 million traumatic brain injuries present to the emergency department (ED), of which approximately 75% are concussions. Proper and timely treatment of concussion is especially important in pediatrics as children and adolescents under the age of 19 are at a higher risk for sustaining more severe and longer-lasting consequences. However, due to the wide range of symptoms at presentation, or to the potential lack of obvious symptoms, concussion can be especially difficult to diagnose in the ED setting. Neurocognitive tests provide a valuable supplement to the clinical diagnosis of concussion by objectively identifying aberrant brain activity. However, many of these tests are often too lengthy and impractical for use in the ED setting. The Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) is a 20-minute computer test that is considered to be one of the gold-standard neurocognitive tests used to diagnose concussion and track recovery. The King-Devick test (KD) is a 1-2 minute test that uses saccadic eye movements to detect suboptimal brain impairment associated with concussion. To date, there have not been any studies that analyzed the relative usability of the KD and the ImPACT in the pediatric ED (PED). The present prospective pilot study investigates the use of the KD as a neurocognitive tool for concussion assessment in the PED and at a post-ED visit, relative to the ImPACT, the gold standard tool for concussion diagnosis. We hypothesize that the change in performance in the KD will correlate with the change in the ImPACT results. To date, 20 subjects between the ages of 11-18 years old presenting to the PED within 72 hours of sustaining a head injury have completed the study. The mean age of our study population was 13.6 years. The average change in test scores between PED and follow-up were: 7.2 seconds in the KD, 0.03 points in the ImPACT reaction time, 1.8 points in verbal memory, 8.3 points in visual memory, 0.8 points in visual motor speed, and 14.9 points in post-concussion symptom scale. Analysis of the correlation of the change in the KD scores to the change in the ImPACT measures revealed that the change in the KD was significantly correlated with the change in the ImPACT reaction time (p < 0.01), and with the change in the ImPACT verbal memory (p < 0.05) in the subjects that presented with LOC, 80% of whom were male. In conclusion, our findings report that the correlation between the results of the KD and the ImPACT is more pronounced in patients presenting with more severe head trauma, such as those leading to LOC. The usability of the KD as a reliable concussion assessment tool in the PED would require further investigation with a larger sample of participants. / 2017-04-30T00:00:00Z

Behavioral and mental health issues contribute to the needs of many patients presenting to emergency departments, and yet these needs often go unrecognized. Patient processing procedures in emergency departments may not include mechanisms to consistently identify and triage patients whose care is complicated by behavioral illness. The purpose of this project was to plan a program to improve early identification and management of behavioral health patients presenting to the emergency department. The objective of this project was to develop a rapid mental health screening tool and policies guiding use of the tool in the emergency department. A multi-disciplinary team of emergency department providers cooperated in the selection and evaluation of available screening tools. A literature search was done with the inclusion criterion of behavioral screening tools to be used at time of triage, and results were brought to the team for further consideration. The HEADS-ED pediatric screening tool was chosen through the expert opinions of the team members. The team evaluated and approved adaptations to the tool for its use in adults. Policies were developed to guide the future implementation of the screening tool in the emergency department. A plan for process and outcome evaluation was included in the developed program. Process will be evaluated by monitoring provider use of the screening tool, and patient length of stay in the emergency department will serve as the outcome measure. The program may contribute to social change through improved emergency department care of patients with behavioral illnesses.