The Association of periOperative Registered Nurses (AORN) approached the Nursing Informatics Rese... more The Association of periOperative Registered Nurses (AORN) approached the Nursing Informatics Research Team (NIRT) with a request to collaborate and conduct a competency assessment for their organization. An online tool was developed to determine current technology in perioperative settings. This presentation shares the process used to conduct research that led to a method for assessing perioperative nurses' competencies skills in their practice as well as identified gaps in curricula that faculty could address. Both successes and areas for improvement are detailed. The outcome of the process demonstrated a need to understand what skills are being assessed as AORN did not know what technology existed or how existing equipment was being used.
Aims and objectives. To report the informatics competencies of students in selected undergraduate... more Aims and objectives. To report the informatics competencies of students in selected undergraduate and graduate nursing programmes, to examine whether informatics competencies differed between the different programmes and to suggest competency-based applications that will strengthen informatics courses and informatics-related content throughout the curricula. Background. Nursing students in undergraduate and graduate nursing programmes have different educational backgrounds and different practice experience. Thus, their informatics preparation is apt to be varied, and nursing curricula must reflect this variation while advancing students towards informatics proficiency. However, studies on informatics competency assessment in these nursing students are scarce. Design. A descriptive survey design. Methods. Data were collected from 289 nursing students using a 30-item Self-Assessment of Nursing Informatics Competencies Scale via an email sent to students using a LISTSERV mailing list. The email embedded link to the Internet survey package, SurveyMonkey, which included the Self-Assessment of Nursing Informatics Competencies Scale and demographic questions along with an online consent form. Results. Students in both programmes were competent in three subscale areas: basic computer knowledge and skills, clinical informatics attitude, and wireless device skills. Graduate students reported slightly higher mean competency scores than did undergraduate students in three subscales: clinical informatics role, clinical informatics attitude and wireless device skills. Conclusions. Findings indicate specific topics for nurse educators to consider when designing informatics curricula. The comparison of undergraduate and graduate students indicates similarities in informatics competencies in terms of areas where students were competent and small mean score differences. Further studies are suggested to examine whether there are differences in informatics competencies between undergraduate and graduate students. Relevance to clinical practice. These results assist nurse educators in determining specific areas of informatics content that need greater focus and inclusion in the design of better nursing educational programmes. Examples of integrating competencies into existing curriculum or informatics courses are suggested.
ursing informatics is an exciting nursing specialtydit affects learning environments, meaningful ... more ursing informatics is an exciting nursing specialtydit affects learning environments, meaningful use, interprofessional collaboration, patient care settings, strategic planning, patient satisfaction, and, ultimately, patient outcomes. Simply put, nursing informatics is the practice of using nursing science and technology to enhance the pathway that data take to become knowledge to improve patient care. Furthermore, nursing informatics "is the synthesis of nursing science, information science, computer science, and cognitive science for the purpose of managing and enhancing health care data, information, knowledge, and wisdom to improve patient care and the nursing profession." 1(p90) According to Hebda and Czar, it is "broadly defined as the use of information and computer technology to support all aspects of nursing practice, including direct delivery of care, administration, education, and research. The definition of nursing informatics is evolving as advances occur in nursing practice and technology." 2(p6) Nursing informatics is important to all nursing specialty areas. It is important for nurses to understand the relevance of nursing informatics to their practice. In clinical practice, for example, nursing informatics can be used to track patient outcomes, find data trends, and assess workload and interventions. It also can help develop technologies, such as apps, to help health care workers virtually monitor and stay in touch with patients,
Competencies (HITCOMP) tool is an interactive instrument to assess global health information tech... more Competencies (HITCOMP) tool is an interactive instrument to assess global health information technology (HIT) skills. It originated from efforts to increase the supply of healthcare workers equipped with the knowledge and skills needed to foster optimal use of HIT. 1 The HITCOMP competencies are grouped by the following five domains: (1) direct patient care, (2) administration, (3) engineering/information systems/ information and computer technology, (4) research/biomedicine, and (5) informatics. The TIGER-based Assessment of Nursing Informatics Competencies (TANIC) and Nursing Informatics Competency Assessment of Level 3 and Level 4 (NICA L3/L4) tools were designed by researchers in the US exclusively for the self-assessment of nursing informatics (NI) competencies. When the Chamberlain Nursing Informatics Research Team (NIRT), developers of TANIC and NICA L3/L4, learned of the HITCOMP tool, they were eager to learn more about it and determine how it compared with their work, in relation to its identification of informatics competencies, and whether it might be adopted in lieu of or in addition to the TANIC and NICA L3/L4 instruments. This article provides an overview of the development of the HITCOMP, a comparison of the HITCOMP informatics competencies in relationship to competencies identified in the TANIC and NICA L3/L4 tools and the ANA 2015 Nursing Informatics: Scope and Standards of Practice from a US NI perspective, and suggestions for future development.
Many experts, professional organizations, landmark reports, and nurse executives have called for ... more Many experts, professional organizations, landmark reports, and nurse executives have called for a nursing workforce that demonstrates informatics competencies. However, surprisingly, gaps in the integration of informatics into nursing curriculum and development of informatics competencies among nurses remain. To obtain a clearer picture of the current status of the integration of informatics content into baccalaureate and graduate nursing education, the authors discuss their assessment of a 2012 published list of the top online schools of nursing in the United States.
Simulation in healthcare : journal of the Society for Simulation in Healthcare, Dec 1, 2013
ABSTRACT Introduction/Background: This presentation explores the Results of a pilot program, depl... more ABSTRACT Introduction/Background: This presentation explores the Results of a pilot program, deployed from June - August 2013, which examines the benefits of both Game Based Learning and Interdisciplinary Collaboration among computer information sciences (CIS) students and graduate and undergraduate nursing students within a virtual environment called Second Life. Methods: "The use of simulations and games have been increasingly recognized as an effective way to engage learners across cultures".1 Game Based Learning (GBL) refers to the combination of educational materials and game mechanics to facilitate engaging learning experiences. GBL has proven to be an effective learning tool and beneficial in cognitive development in ways that foster soft skills among students. These skills include collaboration, communication, problem-solving, and critical thinking.3 This presentation explores the Results of a pilot program, deployed from June - August 2013, which utilized both GBL and Interdisciplinary Collaboration. This program provided an opportunity for computer information science (CIS) students to collaborate with nursing students in the virtual world, Second Life. The program provides CIS students with actual project development skills including benchmark and deadline goals and client feedback related to their programming efforts. Graduate level nursing students enrolled in the nursing informatics track experience management of project implementation regarding advancements in healthcare technology, such as radio frequency identification (RFID) in a simulation world that are not always available to undergraduate students in actual clinical environments. In the pilot program, a small group of CIS students came together to build an educational Radio Frequency Identification (RFID) simulation for undergraduate nursing students under the subject matter expertise of a graduate nursing student. The implementation of Radio Frequency Identification (RFID) for the process of Positive Patient Identification (PPID) is an ideal application of HIT as a means to improve patient care and outcome. RFID is a wireless technology that presents as a solution for process automation.3 RFID uses a reading device to capture data from an intelligent label or tag without the need for any physical connection; the data is sent over radio waves as its name suggests.3 The data can be transmitted from the data tag, via tag reader, to a central computer or server for interpretation and processing.3 Preparing nursing students in the proper use of RFID for PPID at the bedside is crucial. The simulation of PPID with RFID within the Second Life virtual environment provides nursing students the experience to use this technology in a safe, interactive and innovative manner. In the simulation built by CIS students, undergraduate nursing students get to walk through the medication administration process using PPID and RFID at the virtual patient bedside. The simulation prepares clinical students to practice proper use of advanced technology in patient care. Faculty will discuss how this program benefited the CIS, graduate and undergraduate students. Faculty will discuss how the topic of patient safety focusing Radio Frequency Identification (RFID) scanner technology and medication administration was selected and how the development process unfolded. In addition, course faculty will discuss pre and post test survey Results supporting learner interest and acceptance supporting this project. And finally, faculty will discuss the successful integration of the simulation into the nursing curriculum to teach undergraduate nursing students how to use RFID technology to support safe medication administration. Results: Conclusion: To conclude, the use of simulations provides oppurtunities for CIS students to learn and develop their skills while providing clinical students, such as nursing students, with a safe and effective way to initiate and master their clinical skills. Patient outcome will improve with the bettering of student teaching. References: 1. Blasi, L. & Alfonso, B. (2006). Increasing the transfer of simulation technology from R&D into school settings: An approach to evaluation from overarching vision to individual artifact in education. Simulation & Gaming, 37, 245 - 267. 2. Giorgio, A. (2012). An rfid based device for innovating the patients management. International Journal of Bioinformatics Research, 4(1), 254-257. 3. Johnson, L., Adams, S., and Cummins, M. (2012).NMC horizon report: 2012 K-12 edition. Austin, Texas: The New Media Consortium. Retrieved on June 2nd, 2013 from: http://www.nmc.org/publications/2012-horizon-report-k12. Disclosures: None.
Background. Happiness and achievement motivation are two important concepts in students’ lives. T... more Background. Happiness and achievement motivation are two important concepts in students’ lives. Therefore, this study was aimed at investigating the association between happiness and achievement motivation in undergraduate nursing students and examining their relationship with students’ demographic characteristics. Method. A descriptive correlational study was undertaken; 255 undergraduate nursing students enrolled in one nursing school in an urban area of Iran during the academic year 2017-2018 were included in the study using census method sampling. The demographic data questionnaire, Oxford Happiness Questionnaire (OHQ), and Hermans Achievement Motivation Questionnaire (HAMQ) were used for data collection. Data were analyzed using univariate analysis and multivariate linear regression analysis. Results. The total mean (SD) of happiness and achievement motivation scores were 40.73 (11.20) and 82.61 (7.50), respectively. There was a direct significant correlation between happiness ...
Based on feedback from the pilot, the task force recommended implementation of the revised gradin... more Based on feedback from the pilot, the task force recommended implementation of the revised grading rubric for the threaded discussions. The recommendation was approved by the faculty and the curriculum committee and implemented in the September 2016 session for all courses in the MSN program.
Background/Objective: The aim of this research was to develop a reliable, valid instrument for se... more Background/Objective: The aim of this research was to develop a reliable, valid instrument for self-assessment of perceived nursing informatics (NI) competencies. This article describes the development and validity assessment of the instrument. Informatics competencies are deemed a necessity in today's technologically-rich healthcare delivery system. Work to identify essential informatics skills commenced shortly after the introduction of information technology into healthcare. In subsequent years, professional organizations and individual experts have established NI competencies needed at various levels of nursing practice, from entry level through advanced practice. The Technology Informatics Guiding Educational Reform (TIGER) Initiative represents one such effort. The TIGER Initiative emerged in 2006 as a grassroots effort dedicated to the preparation of a clinical workforce capable of using information technology and informatics to improve the delivery of healthcare. TIGER quickly organized into several different collaborative groups, including one that identified a set of recommended informatics competencies for nurses in 2009. The TIGER effort listed NI competencies in three areas: basic computer skills, information literacy, and clinical information management but did not operationalize these competencies into an instrument that could be used for assessment purposes. Methods: Three rounds of reviews were conducted. In the first review, the researchers examined TIGER competencies, removing duplicative terms and combining items with similar content. The second and third rounds of reviews were each done by two separate sets of three experts in nursing informatics. During the second round, the list from round one was examined for items to retain or add. Resulting items were reworded to reflect measurable behaviors and then subjected to a third round of reviews to establish content validity, using the content validity index (CVI) methodology. Results: CVIs demonstrated moderate validity for the instrument, and items not deemed relevant to the objective of the instrument were deleted, reducing the number of the items on the instrument. The instrument was piloted by posting the invitation on the online discussion forum of a nursing informatics organization. An additional invitation was extended to a group completing a weekend-long NI course. There were 184 respondents. Most respondents ranked themselves as expert on the majority of items, although a lesser degree of confidence was seen with items related to information literacy Conclusions: TIGER competencies provided a useful foundation for the creation of a feasible online instrument for self-assessment of levels of competency. Fewer respondents identified themselves as expert in information literacy www.sciedu.ca/jnep
Many experts, professional organizations, landmark reports, and nurse executives have called for ... more Many experts, professional organizations, landmark reports, and nurse executives have called for a nursing workforce that demonstrates informatics competencies. However, surprisingly, gaps in the integration of informatics into nursing curriculum and development of informatics competencies among nurses remain. To obtain a clearer picture of the current status of the integration of informatics content into baccalaureate and graduate nursing education, the authors discuss their assessment of a 2012 published list of the top online schools of nursing in the United States.
The Association of periOperative Registered Nurses (AORN) approached the Nursing Informatics Rese... more The Association of periOperative Registered Nurses (AORN) approached the Nursing Informatics Research Team (NIRT) with a request to collaborate and conduct a competency assessment for their organization. An online tool was developed to determine current technology in perioperative settings. This presentation shares the process used to conduct research that led to a method for assessing perioperative nurses' competencies skills in their practice as well as identified gaps in curricula that faculty could address. Both successes and areas for improvement are detailed. The outcome of the process demonstrated a need to understand what skills are being assessed as AORN did not know what technology existed or how existing equipment was being used.
Aims and objectives. To report the informatics competencies of students in selected undergraduate... more Aims and objectives. To report the informatics competencies of students in selected undergraduate and graduate nursing programmes, to examine whether informatics competencies differed between the different programmes and to suggest competency-based applications that will strengthen informatics courses and informatics-related content throughout the curricula. Background. Nursing students in undergraduate and graduate nursing programmes have different educational backgrounds and different practice experience. Thus, their informatics preparation is apt to be varied, and nursing curricula must reflect this variation while advancing students towards informatics proficiency. However, studies on informatics competency assessment in these nursing students are scarce. Design. A descriptive survey design. Methods. Data were collected from 289 nursing students using a 30-item Self-Assessment of Nursing Informatics Competencies Scale via an email sent to students using a LISTSERV mailing list. The email embedded link to the Internet survey package, SurveyMonkey, which included the Self-Assessment of Nursing Informatics Competencies Scale and demographic questions along with an online consent form. Results. Students in both programmes were competent in three subscale areas: basic computer knowledge and skills, clinical informatics attitude, and wireless device skills. Graduate students reported slightly higher mean competency scores than did undergraduate students in three subscales: clinical informatics role, clinical informatics attitude and wireless device skills. Conclusions. Findings indicate specific topics for nurse educators to consider when designing informatics curricula. The comparison of undergraduate and graduate students indicates similarities in informatics competencies in terms of areas where students were competent and small mean score differences. Further studies are suggested to examine whether there are differences in informatics competencies between undergraduate and graduate students. Relevance to clinical practice. These results assist nurse educators in determining specific areas of informatics content that need greater focus and inclusion in the design of better nursing educational programmes. Examples of integrating competencies into existing curriculum or informatics courses are suggested.
ursing informatics is an exciting nursing specialtydit affects learning environments, meaningful ... more ursing informatics is an exciting nursing specialtydit affects learning environments, meaningful use, interprofessional collaboration, patient care settings, strategic planning, patient satisfaction, and, ultimately, patient outcomes. Simply put, nursing informatics is the practice of using nursing science and technology to enhance the pathway that data take to become knowledge to improve patient care. Furthermore, nursing informatics "is the synthesis of nursing science, information science, computer science, and cognitive science for the purpose of managing and enhancing health care data, information, knowledge, and wisdom to improve patient care and the nursing profession." 1(p90) According to Hebda and Czar, it is "broadly defined as the use of information and computer technology to support all aspects of nursing practice, including direct delivery of care, administration, education, and research. The definition of nursing informatics is evolving as advances occur in nursing practice and technology." 2(p6) Nursing informatics is important to all nursing specialty areas. It is important for nurses to understand the relevance of nursing informatics to their practice. In clinical practice, for example, nursing informatics can be used to track patient outcomes, find data trends, and assess workload and interventions. It also can help develop technologies, such as apps, to help health care workers virtually monitor and stay in touch with patients,
Competencies (HITCOMP) tool is an interactive instrument to assess global health information tech... more Competencies (HITCOMP) tool is an interactive instrument to assess global health information technology (HIT) skills. It originated from efforts to increase the supply of healthcare workers equipped with the knowledge and skills needed to foster optimal use of HIT. 1 The HITCOMP competencies are grouped by the following five domains: (1) direct patient care, (2) administration, (3) engineering/information systems/ information and computer technology, (4) research/biomedicine, and (5) informatics. The TIGER-based Assessment of Nursing Informatics Competencies (TANIC) and Nursing Informatics Competency Assessment of Level 3 and Level 4 (NICA L3/L4) tools were designed by researchers in the US exclusively for the self-assessment of nursing informatics (NI) competencies. When the Chamberlain Nursing Informatics Research Team (NIRT), developers of TANIC and NICA L3/L4, learned of the HITCOMP tool, they were eager to learn more about it and determine how it compared with their work, in relation to its identification of informatics competencies, and whether it might be adopted in lieu of or in addition to the TANIC and NICA L3/L4 instruments. This article provides an overview of the development of the HITCOMP, a comparison of the HITCOMP informatics competencies in relationship to competencies identified in the TANIC and NICA L3/L4 tools and the ANA 2015 Nursing Informatics: Scope and Standards of Practice from a US NI perspective, and suggestions for future development.
Many experts, professional organizations, landmark reports, and nurse executives have called for ... more Many experts, professional organizations, landmark reports, and nurse executives have called for a nursing workforce that demonstrates informatics competencies. However, surprisingly, gaps in the integration of informatics into nursing curriculum and development of informatics competencies among nurses remain. To obtain a clearer picture of the current status of the integration of informatics content into baccalaureate and graduate nursing education, the authors discuss their assessment of a 2012 published list of the top online schools of nursing in the United States.
Simulation in healthcare : journal of the Society for Simulation in Healthcare, Dec 1, 2013
ABSTRACT Introduction/Background: This presentation explores the Results of a pilot program, depl... more ABSTRACT Introduction/Background: This presentation explores the Results of a pilot program, deployed from June - August 2013, which examines the benefits of both Game Based Learning and Interdisciplinary Collaboration among computer information sciences (CIS) students and graduate and undergraduate nursing students within a virtual environment called Second Life. Methods: "The use of simulations and games have been increasingly recognized as an effective way to engage learners across cultures".1 Game Based Learning (GBL) refers to the combination of educational materials and game mechanics to facilitate engaging learning experiences. GBL has proven to be an effective learning tool and beneficial in cognitive development in ways that foster soft skills among students. These skills include collaboration, communication, problem-solving, and critical thinking.3 This presentation explores the Results of a pilot program, deployed from June - August 2013, which utilized both GBL and Interdisciplinary Collaboration. This program provided an opportunity for computer information science (CIS) students to collaborate with nursing students in the virtual world, Second Life. The program provides CIS students with actual project development skills including benchmark and deadline goals and client feedback related to their programming efforts. Graduate level nursing students enrolled in the nursing informatics track experience management of project implementation regarding advancements in healthcare technology, such as radio frequency identification (RFID) in a simulation world that are not always available to undergraduate students in actual clinical environments. In the pilot program, a small group of CIS students came together to build an educational Radio Frequency Identification (RFID) simulation for undergraduate nursing students under the subject matter expertise of a graduate nursing student. The implementation of Radio Frequency Identification (RFID) for the process of Positive Patient Identification (PPID) is an ideal application of HIT as a means to improve patient care and outcome. RFID is a wireless technology that presents as a solution for process automation.3 RFID uses a reading device to capture data from an intelligent label or tag without the need for any physical connection; the data is sent over radio waves as its name suggests.3 The data can be transmitted from the data tag, via tag reader, to a central computer or server for interpretation and processing.3 Preparing nursing students in the proper use of RFID for PPID at the bedside is crucial. The simulation of PPID with RFID within the Second Life virtual environment provides nursing students the experience to use this technology in a safe, interactive and innovative manner. In the simulation built by CIS students, undergraduate nursing students get to walk through the medication administration process using PPID and RFID at the virtual patient bedside. The simulation prepares clinical students to practice proper use of advanced technology in patient care. Faculty will discuss how this program benefited the CIS, graduate and undergraduate students. Faculty will discuss how the topic of patient safety focusing Radio Frequency Identification (RFID) scanner technology and medication administration was selected and how the development process unfolded. In addition, course faculty will discuss pre and post test survey Results supporting learner interest and acceptance supporting this project. And finally, faculty will discuss the successful integration of the simulation into the nursing curriculum to teach undergraduate nursing students how to use RFID technology to support safe medication administration. Results: Conclusion: To conclude, the use of simulations provides oppurtunities for CIS students to learn and develop their skills while providing clinical students, such as nursing students, with a safe and effective way to initiate and master their clinical skills. Patient outcome will improve with the bettering of student teaching. References: 1. Blasi, L. & Alfonso, B. (2006). Increasing the transfer of simulation technology from R&D into school settings: An approach to evaluation from overarching vision to individual artifact in education. Simulation & Gaming, 37, 245 - 267. 2. Giorgio, A. (2012). An rfid based device for innovating the patients management. International Journal of Bioinformatics Research, 4(1), 254-257. 3. Johnson, L., Adams, S., and Cummins, M. (2012).NMC horizon report: 2012 K-12 edition. Austin, Texas: The New Media Consortium. Retrieved on June 2nd, 2013 from: http://www.nmc.org/publications/2012-horizon-report-k12. Disclosures: None.
Background. Happiness and achievement motivation are two important concepts in students’ lives. T... more Background. Happiness and achievement motivation are two important concepts in students’ lives. Therefore, this study was aimed at investigating the association between happiness and achievement motivation in undergraduate nursing students and examining their relationship with students’ demographic characteristics. Method. A descriptive correlational study was undertaken; 255 undergraduate nursing students enrolled in one nursing school in an urban area of Iran during the academic year 2017-2018 were included in the study using census method sampling. The demographic data questionnaire, Oxford Happiness Questionnaire (OHQ), and Hermans Achievement Motivation Questionnaire (HAMQ) were used for data collection. Data were analyzed using univariate analysis and multivariate linear regression analysis. Results. The total mean (SD) of happiness and achievement motivation scores were 40.73 (11.20) and 82.61 (7.50), respectively. There was a direct significant correlation between happiness ...
Based on feedback from the pilot, the task force recommended implementation of the revised gradin... more Based on feedback from the pilot, the task force recommended implementation of the revised grading rubric for the threaded discussions. The recommendation was approved by the faculty and the curriculum committee and implemented in the September 2016 session for all courses in the MSN program.
Background/Objective: The aim of this research was to develop a reliable, valid instrument for se... more Background/Objective: The aim of this research was to develop a reliable, valid instrument for self-assessment of perceived nursing informatics (NI) competencies. This article describes the development and validity assessment of the instrument. Informatics competencies are deemed a necessity in today's technologically-rich healthcare delivery system. Work to identify essential informatics skills commenced shortly after the introduction of information technology into healthcare. In subsequent years, professional organizations and individual experts have established NI competencies needed at various levels of nursing practice, from entry level through advanced practice. The Technology Informatics Guiding Educational Reform (TIGER) Initiative represents one such effort. The TIGER Initiative emerged in 2006 as a grassroots effort dedicated to the preparation of a clinical workforce capable of using information technology and informatics to improve the delivery of healthcare. TIGER quickly organized into several different collaborative groups, including one that identified a set of recommended informatics competencies for nurses in 2009. The TIGER effort listed NI competencies in three areas: basic computer skills, information literacy, and clinical information management but did not operationalize these competencies into an instrument that could be used for assessment purposes. Methods: Three rounds of reviews were conducted. In the first review, the researchers examined TIGER competencies, removing duplicative terms and combining items with similar content. The second and third rounds of reviews were each done by two separate sets of three experts in nursing informatics. During the second round, the list from round one was examined for items to retain or add. Resulting items were reworded to reflect measurable behaviors and then subjected to a third round of reviews to establish content validity, using the content validity index (CVI) methodology. Results: CVIs demonstrated moderate validity for the instrument, and items not deemed relevant to the objective of the instrument were deleted, reducing the number of the items on the instrument. The instrument was piloted by posting the invitation on the online discussion forum of a nursing informatics organization. An additional invitation was extended to a group completing a weekend-long NI course. There were 184 respondents. Most respondents ranked themselves as expert on the majority of items, although a lesser degree of confidence was seen with items related to information literacy Conclusions: TIGER competencies provided a useful foundation for the creation of a feasible online instrument for self-assessment of levels of competency. Fewer respondents identified themselves as expert in information literacy www.sciedu.ca/jnep
Many experts, professional organizations, landmark reports, and nurse executives have called for ... more Many experts, professional organizations, landmark reports, and nurse executives have called for a nursing workforce that demonstrates informatics competencies. However, surprisingly, gaps in the integration of informatics into nursing curriculum and development of informatics competencies among nurses remain. To obtain a clearer picture of the current status of the integration of informatics content into baccalaureate and graduate nursing education, the authors discuss their assessment of a 2012 published list of the top online schools of nursing in the United States.
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