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Background: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has long recognized and championed increasing diversity within the surgical workplace. SAGES initiated the Fundamentals of Leadership Development (FLD) Curriculum to address these needs and to provide surgeon leaders with the necessary tools and skills to promote diversity, equity, and inclusion (DEI) in surgical practice. In 2019, the American College of Surgeons issued a request for anti-racism initiatives which lead to the partnering of the two societies. The primary goal of FLD was to create the first surgeon-focused leadership curriculum dedicated to DEI. The rationale/development of this curriculum and its evaluation/feedback methods are detailed in this White Paper. Methods: The FLD curriculum was developed by a multidisciplinary task force that included surgeons, education experts, and diversity consultants. The curriculum development followed the Analysis, Design, Development, Implementation and Evaluation (ADDIE) instructional design model and utilized a problem-based learning approach. Competencies were identified, and specific learning objectives and assessments were developed. The implementation of the curriculum was designed to be completed in short intervals (virtual and in-person). Post-course surveys used the Kirkpatrick's model to evaluate the curriculum and provide valuable feedback. Results: The curriculum consisted of interactive online modules, an online discussion forum, and small group interactive sessions focused in three key areas: (1) increasing pipeline of underrepresented individuals in surgical leadership, (2) healthcare equity, and (3) conflict negotiation. By focusing on positive action items and utilizing a problem-solving approach, the curriculum aimed to provide a framework for surgical leaders to make meaningful changes in their institutions and organizations. Conclusion: The FLD curriculum is a novel leadership curriculum that provided surgeon leaders with the knowledge and tools to improve diversity in three areas: pipeline improvement, healthcare equity, and conflict negotiation. Future directions include using pilot course feedback to enhance curricular effectiveness and delivery. [ABSTRACT FROM AUTHOR]

Introduction: Poor communication is a leading root cause of preventable maternal mortality in the United States. Communication challenges are compounded with the presence of biases, including racism. Hospital administrators and clinicians are often aware that communication is a problem, but understanding where to intervene can be difficult to determine. While clinical leadership routinely reviews incident reports and acts on them to improve care, we hypothesized that reviewing incident reports in a systematic way might reveal thematic patterns, providing targeted opportunities to improve communication in direct interaction with patients and within the healthcare team itself. Methods: We abstracted incident reports from the Women's Health service and linked them with patient charts to join patient's race/ethnicity, birth outcome, and presence of maternal morbidity and mortality to the incident report. We conducted a qualitative content analysis of incident reports using an inductive and deductive approach to categorizing communication challenges. We then described the intersection of different types of communication challenges with patient race/ethnicity and morbidity outcomes. Results: The use of incident reports to conduct research on communication was new for the health system. Conversations with health system‐level stakeholders were important to determine the best way to manage data. We developed a thematic codebook based on prior research in healthcare communication. We found that we needed to add codes that were equity focused, as this was missing from the existing codebook. We also found that clinical and contextual expertise was necessary for conducting the analysis—requiring more resources to conduct coding than initially estimated. We shared our findings back with leadership iteratively during the work. Conclusions: Incident reports represent a promising source of health system data for rapid improvement to transform organizational practice around communication. There are barriers to conducting this work in a rapid manner, however, that require further iteration and innovation. [ABSTRACT FROM AUTHOR]

The integration of artificial intelligence technologies, such as large language models (LLMs), in health care holds potential for improved efficiency and decision support. However, ethical concerns must be addressed before widespread adoption. This article focuses on the ethical principles surrounding the use of Generative Pretrained Transformer-4 and its conversational model, ChatGPT, in healthcare settings. One concern is potential inaccuracies in generated content. LLMs can produce believable yet incorrect information, risking errors in medical records. Opacity of training data exacerbates this, hindering accuracy assessment. To mitigate, LLMs should train on precise, validated medical data sets. Model bias is another critical concern because LLMs may perpetuate biases from their training, leading to medically inaccurate and discriminatory responses. Sampling, programming, and compliance biases contribute necessitating careful consideration to avoid perpetuating harmful stereotypes. Privacy is paramount in health care, using public LLMs raises risks. Strict data-sharing agreements and Health Insurance Portability and Accountability Act (HIPAA)-compliant training protocols are necessary to protect patient privacy. Although artificial intelligence technologies offer promising opportunities in health care, careful consideration of ethical principles is crucial. Addressing concerns of inaccuracy, bias, and privacy will ensure responsible and patient-centered implementation, benefiting both healthcare professionals and patients., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Anthropological reports have long suggested that speaking to young children is very infrequent in certain populations (notably farming ones), which is in line with scattered quantitative studies. A systematic review was undertaken to use available literature in order to estimate the extent of population variation. Database searches, expert lists, and citation searches led to the discovery of 29 reports on the frequency of vocalizations directed to infants aged 24 months or younger, based on systematic observations of spontaneous activity in the infant's natural environment lasting at least 30 min in length. Together, these studies provide evidence on 1314 infants growing up in a range of communities (urban, foraging, farming). For populations located outside of North America, the frequency with which vocalization was directed to urban infants was much higher than that for rural infants (including both foraging and farming, medians = 12.6 vs. 3.6% of observations contained infant-directed vocalization behaviors). We benchmarked this effect against socio-economic status (SES) variation in the United States, which was much smaller. Infants in high SES American homes were spoken to only slightly more frequently than those in low SES homes (medians = 16.4 vs. 15.1% of observations contained infant-directed vocalization behaviors). Although published research represents a biased sample of the world's populations, these results invite further cross-population research to understand the causes and effects of such considerable population group differences., (© 2022 John Wiley & Sons Ltd.)

This study focused on how adopted adults who have reunited with at least one birth family member experienced identity shifts related to their original birth certificates (OBCs). Framed by the Communication Theory of Identity (CTI), 50 adopted adults discussed their experiences related to their OBCs and how their identities are connected to this symbol through three of the layers of CTI, the personal, enacted, and relational layers. Participants discussed the presence of an ambiguous and unsolvable identity that interpenetrated with their other identity layers. Findings extend CTI to include an additional layer for adoptees – phantom identity – which can explain the life adoptees would have lived had they not been adopted. This identity was salient for participants as it manifested in ways such as expressing frustration with obstacles in gaining access to their OBC and refocusing their professional life to support other adopted adults. Moreover, findings offer implications for the examination into current adoption record practices in the United States, additional state mutual consent registries, and increased access to adoption-competent counselors for adoptees. [ABSTRACT FROM AUTHOR]

The process of development, manufacturing, registration, distribution, and postmarketing support of drug and biologic products includes the need for clear, active, and ongoing communication between the sponsor/applicant and the Food and Drug Administration (FDA). Such communication occurs in written and spoken form, involving multiple media (including letters, secure e-mail, fax, face-to-face meetings, and teleconferences). Personnel in PhRMA member companies and FDA recognize the importance and challenges of communication. FDA's attention to a number of key principles of communication is illustrated in the guidance document Good Review Management Principles and Practices for PDUFA Products. this white paper, members of PhRMA's Best Practices Working Group have summarized key information on communication from the guidance document, proposed expectations for communications to facilitate a shared understanding between FDA and applicant about a communication strategy during review of a New Drug Application (NDA) or Biologics License Application (BLA), and drafted some basic principles for companies to adopt to help foster constructive, professional, and efficient communication with FDA on Prescription Drug User Fee Act (PDUFA) products. Dialogue with FDA and other stakeholders about these principles and proposals is suggested as the logical next step in discussion of best practices for communication. [ABSTRACT FROM AUTHOR]

An introduction to articles in the issue is presented on topics including description of a free neurorehabilitation clinic staffed by volunteers to fill the gap for people with physical, cognitive, and communication disorders, concussion recovery as a dichotomous state, and how and why we do what we do in clinical practice.

An introduction to articles in the issue is presented on topics including description of a free neuro-rehabilitation clinic staffed by volunteers to fill the gap for people with physical, cognitive, and communication disorders, concussion recovery as a dichotomous state, and how and why we do what we do in clinical practice.

Under Medicare's Value-Based Purchasing Program, scores derived from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey are used in the determination of incentive payments and financial penalties for healthcare organizations. Organizations, therefore, invest in approaches to improve the likelihood of positive patient responses. Evidence suggests that nurse communication as measured by HCAHPS influences overall patient satisfaction, yet little is known regarding what patients believe constitutes effective communication with nurses. In this qualitative descriptive study, we conducted phone interviews with 49 recently hospitalized patients to better understand patients' perceptions of their communication with nurses. Our findings indicate that patients perceived their communication with nurses to unfold via nurses' behaviors. Namely, nurses' engagement with patients, anticipation of patients' needs, responsiveness to patients' concerns, and teaching practices positively influence patient satisfaction with communication with nurses. These behaviors resonated most strongly with patients during particularly memorable moments of uncertainty and vulnerability over the course of a hospital stay. These findings suggest that focusing on the development of nurses' behaviors, ensuring processes are in place to support positive behaviors and creating organizational environments that position nurses to consistently apply these behaviors, can improve patients' perceptions of their communication with nurses. These findings also provide a foundation for further research focused on developing and testing specific behavioral interventions and their effect on communication perception., (© 2020 Wiley Periodicals LLC.)

Overview: In 2012, the Institute of Medicine Roundtable on Health Literacy established 10 attributes of a health literate health care organization that, if instated, would improve health information and empower patients to make more informed health decisions. Few studies have assessed how well organizations meet these attributes., Purpose: This study sought to describe the extent to which health care systems in North Texas were adopting policies and practices that address the 10 attributes of a health literate health care organization. More specifically, we sought to describe key organizational leaders' and clinicians' perceptions in this regard., Study Design and Methods: This was a mixed-methods study, conducted with a convenience sample of 74 key informants from 13 hospitals across five health care systems. Informants provided demographic data, and their perceptions of the extent to which their hospital met the 10 attributes were measured via the Health Literate Health Care Organization 10-item questionnaire (HLHO-10) and semistructured interviews., Results: Mean scores for HLHO-10 items ranged from 3.74 to 5.39, with 7 as a maximum score. Qualitative data provided richer content, elaborating on the survey results. Workforce training in health literacy, patient inclusion in health information development and evaluation, and communication about health care costs were rated the lowest and were described as issues of concern., Conclusion: Study findings indicated limited leadership and little systemic promotion of efforts to ensure health literate health care organizations, although individual health literacy champions sometimes stepped up with creative initiatives.

The American College of Surgeons Committee on Trauma requires physician-to-physician communication prior to interhospital transfer. This requirement can be difficult to achieve in high-volume trauma centers. This pilot project utilizes trauma advanced practice providers (APPs) as the primary communicator, in lieu of the trauma surgeon, prior to interhospital transfer. The hypothesis suggests that APPs can provide safe recommendations and accurately triage patients for the highest level trauma alert. From January to April 2018, a total of 1,145 patients were transferred to a Level I or Level II trauma center. All interhospital trauma transfers were dispatched through a designated transfer center APP (TCAPP). Descriptive statistics were used to describe the frequency of core TCAPP recommendations, including reversal agents for anticoagulants, antibiotics for open fractures, direct admission criteria, administration of blood products, and triaging to the highest level of trauma activation. TCAPP triage accuracy was analyzed and reported as percentages. Percentages are compared between independent groups using a chi-square test. Prior to implementation of the TCAPP role, provider-to-provider communication occurred in less than 1% of interhospital transfers; TCAPP-to-provider communication occurred 92% of the time (p < .001). During the study period, the TCAPP made 398 care-related recommendations. Three (<1%) TCAPP recommendations were deemed inappropriate. The TCAPP (89.7%) and physician (89.9%) triage accuracy was not significantly different (p = .43). Interhospital transfer communication and recommendations can be performed safely and accurately by a trauma trained APP.

The emphasis on research evaluation has brought scrutiny to the role of self‐citations in the scholarly communication process. While author self‐citations have been studied at length, little is known on national‐level self‐references (SRs). This paper analyses the citation context of national SRs, using the full‐text of 184,859 papers published in PLOS journals. It investigates the differences between national SRs and nonself‐references (NSRs) in terms of their in‐text mention, presence in enumerations, and location features. For all countries, national SRs exhibit a higher level of engagement than NSRs. NSRs are more often found in enumerative citances than SRs, which suggests that researchers pay more attention to domestic than foreign studies. There are more mentions of national research in the methods section, which provides evidence that methodologies developed in a nation are more likely to be used by other researchers from the same nation. Publications from the United States are cited at a higher rate in each of the sections, indicating that the country still maintains a dominant position in science. On the whole, this paper contributes to a better understanding of the role of national SRs in the scholarly communication system, and how it varies across countries and over time. [ABSTRACT FROM AUTHOR]

Lists the top-ranking doctorate-granting institutions in communication studies in the United States. Combination of the National Communication Association and International Communication Association awards from 1994 to 1998; Use of the rankings to assess the programs of particular doctoral institutions.

We show that an information nudge increased the rate of American citizenship applications among low-income immigrants eligible for a federal fee waiver. Approximately half of the 9 million naturalization-eligible immigrants qualify for a federal programme that waives the cost of the citizenship application for low-income individuals. However, take-up of this fee waiver programme remains low 1-3 . Here we use a randomized field experiment to test the effectiveness of a low-cost intervention (a 'nudge') that informed low-income immigrants about their eligibility for the fee waiver. We find that the information nudge increased the rate of citizenship applications by about 8.6 percentage points from 24.5% in the control group to 33.1% in the treatment group (ordinary least squares regression with robust standard errors (d.f. = 933); P = 0.015; 95% confidence interval ranged from 1.7 to 15.4 percentage points). We found no evidence that the nudge was less effective for poorer or less educated immigrants. These findings contribute to the literature that addresses the incomplete take-up of public benefits by low-income populations 4-10 and suggest that lack of information is an important obstacle to citizenship among low-income immigrants who demonstrate an interest in naturalization.

EU-US data transfers for health research remain a particularly thorny issue in view of the stringent rules of the EU General Data Protection Regulation (GDPR) and the challenges related to US mass surveillance programs, particularly the manner in which US law enforcement and national security agencies can access personal data originating from the EU. Since the entry into force of the GDPR, evidence of impeded collaborations is increasing, particularly in the case of sharing data with US public institutions. The adoption of a new EU-US adequacy decision in July 2023 does not hold the promise for a long-lasting solution due to the risks of being challenged and invalidated – yet again – at the Court of Justice of the EU. As the research community is calling for answers, the new proposal for a European Health Data Space regulation may hold a key to solving some of the existing issues. In this paper, we critically discuss the current rules and outline a possible way forward for transfers between public bodies. [ABSTRACT FROM AUTHOR]

In response to the pervasive challenges posed by online health misinformation, our objective was to develop a training program aimed at enhancing the skills and confidence of healthcare workers in recognizing and effectively responding to misinformation, with a particular focus on vaccinations. This article discusses the design of a training program aimed at equipping healthcare workers with the skills to combat health misinformation, offering theoretical foundations for integrating evidence-based strategies into problem-based learning to help learners retain and apply information, and also shares examples and insights gained from its application across diverse learner groups. The training curriculum integrates evidence-based misinformation intervention strategies, learner engagement strategies and draws from authentic scenarios across diverse cultural contexts. The trainings were administered from January through July 2023 to 287 participants across eight countries (Cameroon, Guyana, India, Kenya, Mozambique, Nigeria, Philippines, and the United States) in English, French, Spanish, and Portuguese. Throughout the implementation of the training, a key emphasis was placed on a learner-driven approach that fostered real-world application. Participants engaged in role-playing exercises and problem-solving sessions, enabling them to practice their newfound skills in a controlled setting. Our findings contribute to the literature of participatory, problem-based learning for healthcare professionals and vaccine communication and misinformation response, and can serve as a resource for practitioners implementing similar trainings., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

This paper explores patterns of communication during the COVID-19 pandemic in four countries with right-wing populist governments during that period, Brazil, Poland, Serbia and the United States, based on interviews with key actors involved in that process. We look at a number of characteristics normally associated with populist rule and political culture likely to affect pandemic communication, including polarization, cultural populism hostile to expertise, personalized rule and machismo, the performance of crisis, and illiberalism. We find that many of these characteristics can be seen in patterns of pandemic communication across the four countries, but also find significant differences in the response of populist leaders between the U.S. and Brazil, on one hand, and Poland and Serbia on the other. Differences can be linked to different varieties of populism in the four countries and specifically their commitment to libertarian or more statist approaches, which also inform disparate public health policies, as well as to different levels of entrenchment of populists in positions of power. We conclude by discussing the politicization of public health and the lessons of the COVID pandemic for emergency risk communication in the era of populism., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objectives: To identify perceived differences in the key domains of patient-provider communications between sexual and gender minority (SGM) and non-SGM patients., Methods: We reviewed data from the Health Information National Trends Survey (HINTS) to assess patient perspectives on different domains of patient-provider communications in the ideological framework by Epstein and Street (2007) [1]. Between SGM-identified (N = 491) and cisgender, heterosexual respondents (N = 7426), we assessed the proportions of responses to survey questions about the six domains of patient-provider communications and calculated odds ratios (OR) with 95 % confidence intervals (CI) (N = 7917)., Results: Overall, compared to cisgender, heterosexual individuals, fewer SGM individuals reported always experiencing optimal patient-provider communications across all domains, most notably in areas of emotional support (OR=0.70, 95 % CI: (0.51, 0.97)), patient self-management (OR=0.73, 95 % CI: (0.54, 0.99)), and managing uncertainty (OR=0.68, 95 % CI: (0.49, 0.94))., Conclusion: Further research on detailed SGM patient perceptions of their relationships with healthcare providers is needed to understand why such differences in communication exist and provide practical recommendations to improve care delivery., Practice Implications: SGM patients perceive their current provider communications to be suboptimal, so we must improve emotional management training in future provider-based SGM competency trainings and encourage patient self-management during individual provider encounters., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Goals of care conversations explore seriously ill patients' values to guide medical decision making and often inform decisions about life sustaining treatments. Ideally, conversations occur before a health crisis between patients and clinicians in the outpatient setting. In the United States Veterans Affairs (VA) healthcare system, most conversations still occur in the inpatient setting. Strategies are needed to improve implementation of outpatient, primary care goals of care conversations., Methods: We plan a cluster randomized (clinician-level) sequential, multiple assignment randomized trial to evaluate the effectiveness of patient implementation strategies on the outcome of goals of care conversation documentation when delivered in combination with clinician implementation strategies. Across three VA healthcare system sites, we will enroll primary care clinicians with low rates of goals of care conversations and their patients with serious medical illness in the top 10th percentile of risk of hospitalization or death. We will compare the effectiveness of sequences of implementation strategies and explore how patient and site factors modify implementation strategy effects. Finally, we will conduct a mixed-methods evaluation to understand implementation strategy success or failure. The design includes two key innovations: (1) strategies that target both clinicians and patients and (2) sequential strategies with increased intensity for non-responders., Conclusion: This study aims to determine the effect of different sequences and combinations of implementation strategies on primary care documentation of goals of care conversations. Study partners, including the VA National Center for Ethics in Health Care and Office of Primary Care, can consider policies based on study findings., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier Inc.)

Background: Stillbirth is a devastating event for families as well as hospital staff. Hospital practices around internal and external staff communication, debriefing, and training are unknown. Methods: We systematically sampled U.S. hospitals that provide obstetrical care. Staff knowledgeable of bereavement care on labor and delivery were invited to participate in an anonymous survey linked to hospital descriptors. We evaluated stillbirth communication, debriefing, and training for staff. Results: We received 289 usable surveys from 429 eligible staff (67% response). Most (94%) noted hospitals' marked rooms housing bereaved families, but only a third (37%) reported a marker on the paper or electronic medical record. Half of the hospitals had no standard debriefings post-loss, and 38% reported no perinatal loss training for labor and delivery nurses. Conclusions: Hospitals have significant variations and gaps in staff communication, support, and training, which are key aspects of respectful stillbirth care.

Introduction: Site visits (SVs) are a common component of clinical education. The purpose of this paper was to explore clinicians' perspectives regarding SVs, including methods of communication used and their effectiveness, purposes of SVs, and the level of interaction between the stakeholders., Review of the Literature: Several communication methods are used to conduct SVs, with varying levels of "richness" and effectiveness. Previous studies have explored the perceptions of physical therapist (PT) students and Directors of Clinical Education regarding communication methods used during SVs, as well as reporting the purposes, effectiveness, and logistics., Subjects: Clinicians, including clinical instructors (CIs) and Site Coordinators of Clinical Education, from across the United States, representing various geographical locations and settings were invited to participate., Methods: An electronic survey was distributed to participants using information from 2 PT education programs and the Physical Therapist Clinical Performance Instrument database., Results: A total of 273 responses were included in the analysis. Clinicians ranked in-person visits as their first choice of communication for future SVs (n = 157, 59.9%) and indicated that in-person communication was "very effective" (n = 143, 52.4%) when compared with videoconferencing (n = 55, 20.1%) and telephone (n = 49, 17.9%). Clinicians ranked verifying the competency level of the student and verifying site resources during the SV as "extremely important" or "important" (n = 257, 94.2% and n = 250, 91.5%, respectively). Answering CI's questions and providing support to the CI were also identified as "extremely important" or "important" (n = 262, 96% and n = 244, 89.4%, respectively). Analysis of open-ended responses revealed 5 themes: Communication is important, flexibility allows best fit for a situation, on-site visits offer a more complete picture, real-time dialog is preferred, and email can lead to misinterpretation., Discussion and Conclusion: Communication is a key component of the clinical-academic relationship. Although clinicians prefer in-person communication, flexibility is necessary when planning and conducting SVs. Future research recommendations include gathering student and clinician perceptions regarding faculty involvement in SVs, as well as gathering faculty perspectives regarding their participation in SVs. In addition, the impact of the pandemic on the future of SVs warrants further exploration., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Academy of Physical Therapy Education, APTA.)

Examines the common scholarly characterizations of the U.S. penny press during the 1830s and 1840s. Provision of a myth of origins of the contemporary press; Inaccuracies and misleading elements in penny press methodology; Relationships among objectivity, market forces and freedom of the press.

Objective: COVID-19 vaccination is critical for reducing serious illness and hospitalizations, yet many remain hesitant. We conducted a survey of frontline physicians to identify patient concerns and physician strategies to address COVID-19 vaccine-hesitancy., Methods: A national random sample of physicians in frontline specialties selected from a comprehensive list of practicing physicians in the U.S. were emailed a survey in August 2021. Multiple choice and open-ended questions inquired about patient concerns related to the COVID-19 vaccines and strategies used by physicians to counter vaccine misinformation and encourage vaccine-hesitant patients. Weighting was applied to achieve representativeness and reduce non-response bias. Network analysis examined co-occurring patient concerns. Open-ended responses on communication strategies were coded via thematic analysis. Multi-variable logistic regression examined associations between physician and pandemic characteristics with patient concerns and use of communication strategies., Results: 531 physicians responded: primary care (241); emergency medicine (142); critical care (84); hospitalists (34); and infectious disease (30). Weighted response balance statistics showed excellent balance between respondents and nonrespondents. On average, physicians reported four patient vaccine concerns. Safety, side effects, vaccine misinformation, and mistrust in government were most common, and often co-occurring. 297 physicians described communication strategies: 180 (61 %) provided vaccine education and 94 (32 %) created a safe space for vaccine discussion. Narrative responses from physicians provided compelling examples of both successes and communication challenges arising from misinformation. Compared with emergency medicine, critical care (OR 2.45, 95 % CI 1.14, 5.24), infectious disease (OR 2.45, 95 % CI 1.00, 6.02), and primary care physicians (OR 1.66, 95 % CI 1.02, 2.70) were more likely to provide communication strategies., Conclusions: Many physicians engage with vaccine hesitant patients using a variety of strategies. Dissemination of effective system and physician-level communication interventions could enhance physician success., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

The US National Weather Service (NWS) and emergency managers (EMs) around the country are tasked with communicating severe weather information to the public. Frequent interaction between professionals and residents is essential to building effective partnerships. This paper investigates these interactions and also explores the perspectives of NWS forecasters, EMs, and rural residents related to the efficacy of warning communication, message understanding, preferred platforms, and engagement in protective actions. Data for this study were collected through three original survey instruments that were directed to NWS forecasters and EMs across the country, and residents in four rural communities. Findings reveal that residents generally understand warning messages and generally feel tornado risk communication is effective in their communities. However, residents do not appear to have a plan of action formulated prior to a warning and are, therefore, making, rather than implementing, a plan when warning is issued. This study gives rural residents a voice in the warning communication process and a chance for forecasters and EMs to gain valuable information as they better plan to serve these communities.

Aims: To elicit experiences of patients, family caregivers, and healthcare professionals in intermediate care units (IMCUs) in an academic medical centre in Baltimore, MD related to the challenges and intricacies of multimorbidity management to inform development of a multimorbidity symptom management toolkit. Design: Experience‐based co‐design. Methods: Between July and October 2021, patients aged 55 years and older with multimorbidity admitted to IMCUs at an academic medical centre in Baltimore, Maryland, USA were recruited and interviewed in person. Interdisciplinary healthcare professionals working in the IMCU were interviewed virtually. Participants were asked questions about their role in recognizing and treating symptoms, factors affecting the quality of life, symptom burden and trajectory over time, and strategies that have and have not worked for managing symptoms. An inductive thematic analysis approach was used for analysis. Results: Twenty‐three interviews were conducted: 9 patients, 2 family caregivers, and 12 healthcare professionals. Patients' mean age was 67.5 (±6.5) years, over half (n = 5) were Black or Hispanic, and the average number of comorbidities was 3.67. Five major themes that affect symptom management emerged: (1) the patient–provider relationship; (2) open and honest communication; (3) accessibility of resources during hospitalization and at discharge; (4) caregiver support, training, and education; and (5) care coordination and follow‐up care. Conclusion: Patients, caregivers, and healthcare professionals often have similar goals but different priorities for multimorbidity management. It is imperative to identify shared priorities and target holistic interventions that consider patient and caregiver experiences to improve outcomes. Implications for the Profession and/or Patient Care and Impact: This paper addresses the paucity of research related to the shared experience of disease trajectory and symptom management for people living with multimorbidity. We found that patients, caregivers, and healthcare professionals often have similar goals but different care and communication priorities. Understanding differing priorities will help better design interventions to support symptom management so people with multimorbidity can have the best possible quality of life. Reporting Method: We have adhered to the Consolidated Criteria for Reporting Qualitative Studies (COREQ) guidelines in our reporting. Patient or Public Contribution: This study has been designed and implemented with patient and public involvement throughout the process, including community advisory board engagement in the project proposal phase and interview guide development, and member checking in the data collection and analysis phases. The method we chose, experience‐based co‐design, emphasizes the importance of engaging members of a community to act as experts in their own life challenges. In the coming phases of the study, the public will be involved in developing and testing a new intervention, informed by these qualitative interviews and co‐design events, to support symptom management for people with multimorbidity. [ABSTRACT FROM AUTHOR]

The article offers information on the Inaugural Discussion Paper on Patient-Clinician Communication from the Institute of Medicine (IOM) which highlights issues of strategic importance to progress in health and health care.

Via analysis of online survey data of 262 people aged 18 to 70 in the United States who have been involved in a long-distance romantic relationship (LDR) since 2005, we investigate how paper, audio, visual, and digital communication formats may be used and viewed as differentially meaningful. While in most intimate relationships, digital formats such as e-mail, messaging, and texts are frequently used, LDR couples are more likely to use and find most meaningful video chat and audio platforms compared with paper or digital formats. The reason for each platform’s meaningfulness varies according to survey respondents’ subjective understandings. Audio and visual formats are seen as meaningful because they offer intimacy, paper formats offer thoughtfulness, and digital formats offer ease as well as thoughtfulness. This research contributes to understanding the subjectively constructed meaning of ever-changing communication platforms, as well as definitions of shared sociomental spaces, for couples who are geographically separated. [ABSTRACT FROM AUTHOR]

Background: Impaired discourse production is commonly reported for individuals with traumatic brain injury (TBI). Discourse deficits can negatively impact community integration, return to employment and quality of life. COVID‐19 restrictions have reduced in‐person assessment services for people with communication impairments. Advances in telehealth may help speech and language therapists (SLTs) to assess monologic discourse more systematically and improve access to services for patients who may find it difficult to attend in‐person. Aims: To examine the feasibility of telehealth administration of narrative and procedural discourse tasks with individuals with TBI and matched controls. Methods & Procedures: A total of 20 individuals with TBI and 20 healthy controls, aged 18–55 years, were directly recruited from the UK and indirectly recruited from the US. For participants with TBI, time post‐injury was at least 3 months with no diagnosis of aphasia. Control participants were matched for sex and as closely as possible for age. Feasibility of measures was based upon the time to administer both narrative tasks, the report of any technological problems, and participant feed. Discourse samples were transcribed verbatim and analysed using story grammar analysis (for narrative discourse) and identification of propositions (for procedural discourse). Interrater reliability was calculated using percentage agreement for 50% of the data. Non‐parametric analyses were used to analyse the performance of the two groups. Outcomes & Results: Narrative and procedural discourse samples were collected via telehealth in approximately 10 min with no reported technical difficulties or complaints from any participants. For narrative discourse performance, there were significant differences for the TBI and control groups for measures of complete episodes (p < 0.001) and missing episodes (p = 0.005). No significant group differences were noted for any of the procedural discourse measures. Conclusions & Implications: Results support the feasibility of collecting discourse samples via telehealth. Although the participants' discourse performance distinguished the TBI and control groups on the narrative task, no differences between the groups were noted for the procedural task. The narrative discourse task may have been more difficult than the procedural task, or video cue support reduced the cognitive load of the procedural task. This finding suggests the use of more complex procedural tasks without video cue support may be needed. WHAT THIS PAPER ADDS: What is already known on this subject: Although little research has explored the feasibility of administering discourse assessments for individuals with TBI via telehealth, some studies have found that discourse interventions can be feasibly administered via telehealth. It is also well established that individuals with TBI struggle with the supra‐structural and macro‐linguistic elements of discourse production. Both procedural and narrative discourse tasks have been found to differentiate individuals with TBI from healthy controls. What this paper adds to existing knowledge: Few studies have investigated the feasibility of, and procedures for, administering discourse tasks via telehealth. Additionally, the inclusion of multiple types of discourse tasks to parse cognitive–communication abilities is lacking in the current literature. Findings from this study support that narrative and procedural discourse can be feasibly sampled via telehealth and that international collaboration for research on this topic can facilitate such studies. Individuals with TBI performed more poorly on three measures of narrative discourse. No differences between groups were identified for the procedural task. What are the potential or actual clinical implications of this work?: Telehealth assessment for discourse provides flexibility for both the individual with TBI and the speech–language therapist and does not compromise the quality of data collected. The administration of discourse tasks and collection of data was not time‐consuming and was well accepted by the study participants. Additionally, international research collaboration not only expands potential participation in research but increases the opportunity to recruit and study more diverse groups. [ABSTRACT FROM AUTHOR]

Routines and rituals are ubiquitous across scholarship in family communication yet are overlapping and idiosyncratic concepts, making a clear distinction between them difficult. This paper builds clarification around the concepts by arguing for attending to what we call the routinized and ritualized aspects of family activities. We demonstrate this approach's utility through a qualitative thematic discourse analysis of 697 Twitter posts discussing the COVID-19 pandemic's impact on family food practices in the United States. We identify three themes that convey the broad impacts of lockdown conditions on family food practices: bolstering, disruption, and reimagining. We then analyze each theme's salience within daily meals and holiday meals – two food provisioning sites frequently considered routines and rituals, respectively. Theoretically, this paper forwards a conceptualization of routines and rituals that delineates the symbolic and instrumental elements embedded within each; empirically, it demonstrates the multifaced effects of the pandemic on family food life. [ABSTRACT FROM AUTHOR]

Management can only thrive in the prevalence of communication. Indeed, the present paper is timely. A 2002 survey of 1,104 employees of organizations in the United States showed that, while managers spend 60 to 80 percent of their time on operational communication, only 17 percent said their managers communicated effectively. Thus, every possible constructive measure must be taken to disentangle areas that stand in the way of effective communication within a given business organization. Efforts must be exhausted to create a business environment in which managers and staff pay close attention to the conceptualization and dissemination of communication media and the messages they transmit. Since the desired purpose of transmitting information from sender to receiver is effective communication, the paper will review pertinent literature to ascertain harbors of problems that result in communication problems in management. To this end, the paper intends to examine attitudes of senders that generate poor and/or ineffective communication; investigate media choices that are inappropriate in certain communication instances; consider cultural/gender insensitive implications prevalent in management communication; as well as the importance of placing the receiver at the center when designing information or messages to be transmitted. In addition, the proposed paper intends to analyze management communication mistakes, such as making controversial announcements, lying [sic], ignoring the realities of power, underestimating the intelligence of the receiver or audience, using inappropriate media or channels of communication, and ignoring to admit mistakes. It is a truism that, 60 percent of corporate public relations effort is devoted to internal communication, which is a reflection that good communication is at the heart of every productive workplace. The paper's objective is to produce a document that chronicles not only missteps in management communication, but also to advance ways of creating awareness and to forge management policies that foster good and effective communication in a business environment. [ABSTRACT FROM AUTHOR]

Background: There is a large body of research showing the negative impact of a total laryngectomy on the resultant voice signal across multiple outcomes (e.g., speech intelligibility/acceptability, listener comprehension, voice quality). However, there is limited information on the effects of laryngectomy on broader communication acts, particularly in the area of pragmatics, commonly referred to as the social use of language. Considering that individuals with a laryngectomy (IWL) frequently report reduced quality of life as well as reduced communicative competency, expanding the current research to include pragmatics is warranted. Aim: To explore the pragmatic changes in communication experienced by tracheoesophageal speakers. Methods & Procedures: The current study adapted an existing 17‐item measure to assess verbal, non‐verbal, paralinguistic and receptive communication competence via self‐report. This adapted measure was then distributed to 65 tracheoesophageal speakers (52 males, 13 females, mean age = 63.4 ± 8.5 years). Outcomes & Results: Both negative and positive pragmatic changes to communication were reported by participants secondary to laryngectomy. This included changes in verbal (negative –37.5%, positive –15.15%); non‐verbal (negative –9.54%, positive –35.45%; and paralinguistic acts (negative –29.55%, positive –34.09%). Changes to receptive communication were also noted (negative –14.78%, positive –43.19%). Conclusions & Implications: The overall results suggest that communication changes post‐laryngectomy exist well beyond the paralinguistic areas (e.g., intelligibility, voice quality) and that males and females may approach or respond to changes in communication differently. Results are discussed specific to clinical intervention and the importance of including assessment of pragmatic function post‐laryngectomy. WHat this paper adds: What is already known on this subject: While there is a large body of research on the changes to the speaker and listener following laryngectomy, there is minimal information on how the use of alaryngeal speech affects overall communication, specifically in the area of pragmatics or the social use of language. What this paper adds to existing knowledge: This study used an adapted version of the widely used Pragmatic Protocol to delineate changes in pragmatic components of communication for tracheoesophageal speakers. What are the potential or actual clinical implications of this work?: Clinically, this information can be used by healthcare professionals to educate and prepare IWL on potential changes in the underrecognized area of pragmatics. [ABSTRACT FROM AUTHOR]

Previous studies have identified associations between affectionate communication and blood lipid levels but been limited by small, homogenous samples and failed replication attempts. Moreover, no study has tested the prediction derived from affection exchange theory that stress mediates the association between affectionate behavior and health. Using secondary analyses of data from the Midlife in the United States (MIDUS) Refresher study Biomarker Project, this paper remedies these limitations by testing the prediction that stress mediates the association between kissing and serum levels of triglycerides, high-density lipoproteins, and low-density lipoproteins using a large probability sample of U.S. American adults ( N  = 863). Results indicate significant indirect effects of kissing frequency on triglycerides and high-density lipoproteins for participants who reported kissing seven or more times in the previous month.

This article focuses on the condition of periodical postal rates in the U.S. The cost of delivery is more than the cost of printing or the cost of writing. For a magazine, postage costs are like extra pounds around the waist and hips. This scenario can even endanger the life of a publication. With this reality, it is no surprise that magazine publishers are looking for ways to reduce the load, even if it means adopting a strategy as drastic as giving up a substance they have grown to love. To alleviate this situation, the author decided to suggest budget reduction aids for magazine publishers. And one such aid is electronic delivery of content.

Background: As delays or disorders in early language and communication are the most prevalent symptom in children with disabilities, early screening is crucial to promote prevention, early diagnosis, and intervention. However, to the best of our knowledge, no screening tool is available for the joint assessment of early language and social communication skills in European Portuguese (EP)‐learning children, which is critical for screening, monitoring and enrolment in appropriate early intervention services. Aims: (1) To adapt and validate the EP version of the Communication and Symbolic Behaviour Scales Developmental Profile™ (CSBS DP™) Infant–Toddler Checklist, a parental report for the screening of early language and social communication skills. (2) To conduct a cross‐cultural comparison between the EP adaptation and the original US version. Methods & Procedures: A total of 611 EP‐learning children (ages 6–24 months) were assessed on the CSBS DP Infant–Toddler Checklist. Normative data, psychometric characteristics (i.e., internal consistency and test–retest reliability), and cross‐cultural comparison between the EP and the original version were explored. Outcomes & Results: Internal consistency ranged from good to excellent and the test–retest reliability was excellent. The performance of the EP and US samples matched on almost all scores. However, EP children performed significantly better than their American peers in the Social compositive at 22 months and in the Symbolic composite at 20 months. No further differences were found. Conclusions & Implications: These findings showed that the EP CSBS DP Infant–Toddler Checklist seems to be a reliable screening tool of communicative and symbolic behaviours for EP‐learning children, which can be particularly relevant for decision‐making in clinical practice. WHAT THIS PAPER ADDS: What is already known on the subject: Early communication skills are known to be related to later language outcomes. Thus, screening tools for the early identification of children at risk for language and communication impairments, which may lead to monitoring and early intervention, have the potential to promote better outcomes. However, to the best of our knowledge, no screening tool is available for the assessment of early communication abilities in EP‐learning children. What this paper adds to existing knowledge: This study adapted and validated the EP CSBS DP Infant–Toddler Checklist, the first published parental report checklist for the assessment of early communication skills in EP. It described the psychometric characteristics of the adapted checklist, summarized the newly available normative data for EP‐learning infants and toddlers, and compared the performance of EP‐learning children with the original standardization sample reported for American English. The results demonstrated that this tool is a reliable instrument for the early screening of language, communicative and symbolic behaviours for EP‐learning children between 6 and 24 months of age. What are the potential or actual clinical implications of this work?: Given that early screening is crucial to promote prevention, early diagnosis and intervention, the availability of this tool is particularly relevant for children monitoring and their enrolment in appropriate early intervention services, helping decision‐making in clinical practice, in line with current guidelines regarding early monitoring and intervention to promote and support better outcomes. Thus, the tool and related normative data will be useful for paediatricians, family doctors, primary healthcare providers, developmental psychologists and speech–language therapists, among other professionals in the healthcare and educational fields, concerned with speech, language, and communication development and impairments. [ABSTRACT FROM AUTHOR]

Accessible Summary: What is known on the subject?: International guidelines for trans‐and‐gender‐non‐conforming (TGNC) exists in outpatient settings.Compared to cisgender and heterosexual people, TGNC individuals are at a higher risk of mental health difficulties and have higher rates of inpatient mental health treatment. What does this paper add to existing knowledge?: An international scoping review identifying the lack of guidelines existing for TGNC individuals in inpatient mental health settings. Compared to psychiatrists and psychologists, mental health nursing has the most contact with patients admitted for inpatient psychiatric treatment. The study identifies unaddressed needs in gender affirming policies and outlines preliminary policy recommendations to assist mental health staff in improving TGNC patient quality of care within the United States. What are the implications for practice?: Reforming existing guidelines or creating new guidelines based on the identified themes and gaps to improve the well‐being and treatment outcomes of TGNC individuals in inpatient psychiatric settings within the United States. Introduction: Access to culturally sensitive care is critical for addressing known mental health disparities among trans‐and gender‐non‐conforming (TGNC) individuals. Although there has been a proliferation of TGNC healthcare guidelines from accrediting bodies, policies have failed to address the needs of TGNC patients in inpatient psychiatric settings. Aim: To identify unaddressed needs in policies and policy recommendations for the care of TGNC patients to inform recommendations for change. Method: A scoping review protocol was developed following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses 850 articles were reduced to seven relevant articles with six themes identified via thematic analysis. Results: Six themes were identified: lack of consistency in preferred and pronoun use, lack of communication among providers, lack of training in TGNC healthcare, personal bias, lack of formal policies, and housing segregation by sex rather than gender. Discussion: The creation of new guidelines or bolstering of existing guidelines to specifically address identified themes and gaps may improve the well‐being and treatment outcomes of TGNC individuals in inpatient psychiatric settings. Implications for practice: To provide a foundation for future studies to integrate these identified gaps and inform the future development of comprehensive formal policies that generalize TGNC care in inpatient settings. [ABSTRACT FROM AUTHOR]

Background: The use of electronic intake forms within the electronic health record (EHR) is an emerging method for routinely collecting patient-reported outcomes (PRO). However, few studies have evaluated experiences/perspectives toward electronic forms among outpatients receiving care within Integrative Health and Medicine (IHM) clinics. The study purpose was to understand patients' perspectives of electronic intake and PRO forms in the outpatient IHM setting. Methods: Electronic intake (e.g., treatment expectations, medical history, chief complaints, prior experience with integrative modalities) and PRO forms (i.e., Patient Reported Outcome Measurement Information System [PROMIS]-29, Perceived Stress Scale 4, Oswestry Disability Index) were designed in collaboration with clinic leadership and the Information Technology team. Semi-structured interviews were used to gather perspectives of the functionality and acceptability of the forms among outpatients receiving care at the IHM center. Interviews were coded to describe themes regarding perceptions and suggestions for improvement. Results: Qualitative interviews were completed with 10 participants (median age 51 years, 70% female, 30% Black/African American). Participants considered electronic intake and PRO forms as relevant to their health concerns, valuable for conveying important health information to providers, and easy to navigate. Suggested changes to the intake form included adding relevant open-ended questions, save and print functions, and examples and definitions to prompt responses. Conclusion: Participants felt the electronic format was a feasible and acceptable method of collecting patient information and PROs. Future goals are to implement the revised forms in a common EHR to patients receiving care at multiple IHM clinics across the United States. [ABSTRACT FROM AUTHOR]

Background: The language of the science curriculum is complex, even in the early grades. To communicate their scientific observations, children must produce complex syntax, particularly complement clauses (e.g., I think it will float; We noticed that it vibrates). Complex syntax is often challenging for children with developmental language disorder (DLD), and thus their learning and communication of science may be compromised. Aims: We asked whether recast therapy delivered in the context of a science curriculum led to gains in complement clause use and scientific content knowledge. To understand the efficacy of recast therapy, we compared changes in science and language knowledge in children who received treatment for complement clauses embedded in a first‐grade science curriculum to two active control conditions (vocabulary + science, phonological awareness + science). Methods & Procedures: This 2‐year single‐site three‐arm parallel randomized controlled trial was conducted in Delaware, USA. Children with DLD, not yet in first grade and with low accuracy on complement clauses, were eligible. Thirty‐three 4–7‐year‐old children participated in the summers of 2018 and 2019 (2020 was cancelled due to COVID‐19). We assigned participants to arms using 1:1:1 pseudo‐random allocation (avoiding placing siblings together). The intervention consisted of 39 small‐group sessions of recast therapy, robust vocabulary instruction or phonological awareness intervention during eight science units over 4 weeks, followed by two science units (1 week) taught without language intervention. Pre‐/post‐measures were collected 3 weeks before and after camp by unmasked assessors. Outcomes & Results: Primary outcome measures were accuracy on a 20‐item probe of complement clause production and performance on ten 10‐item unit tests (eight science + language, two science only). Complete data were available for 31 children (10 grammar, 21 active control); two others were lost to follow‐up. Both groups made similar gains on science unit tests for science + language content (pre versus post, d = 2.9, p < 0.0001; group, p = 0.24). The grammar group performed significantly better at post‐test than the active control group (d = 2.5, p = 0.049) on complement clause probes and marginally better on science‐only unit tests (d = 2.5, p = 0.051). Conclusions & Implications: Children with DLD can benefit from language intervention embedded in curricular content and learn both language and science targets taught simultaneously. Tentative findings suggest that treatment for grammar targets may improve academic outcomes. What this paper adds: What is already known on the subject: We know that recast therapy focused on morphology is effective but very time consuming. Treatment for complex syntax in young children has preliminary efficacy data available. Prior research provides mixed evidence as to children's ability to learn language targets in conjunction with other information. What this study adds: This study provides additional data supporting the efficacy of intensive complex syntax recast therapy for children ages 4–7 with Developmental Language Disorder. It also provides data that children can learn language targets and science curricular content simultaneously. What are the clinical implications of this work?: As SLPs, we have to talk about something to deliver language therapy; we should consider talking about curricular content. Recast therapy focused on syntactic frames is effective with young children. [ABSTRACT FROM AUTHOR]

Against the backdrop of a global pandemic, this study investigates how U.S. higher education leaders have centered their crisis management on values and guiding ethical principles. We conducted 55 in-depth interviews with leaders from 30 U.S. higher education institutions, with most leaders participating in two interviews. We found that crisis plans created prior to the COVID-19 pandemic were inadequate due to the long duration and highly uncertain nature of the crisis. Instead, higher education leaders applied guiding principles on the fly to support their decision-making. If colleges and universities infuse shared values into their future crisis plans, they will not have to develop a moral compass on the fly for the next pandemic. This paper suggests the following somewhat universal shared values: (1) engage in accuracy, transparency, and accountability; (2) foster deliberative dialog; (3) prioritize safety; (4) support justice, fairness, and equity; and (5) engage in an ethic of care. To navigate ethics tensions, leaders need to possess crisis-relevant expertise or ensure that such expertise is present among crisis management team members. Standing up formal ethics committees composed of diverse stakeholders also is instrumental in navigating tensions inherent in crises. The next pandemic is already on the horizon according to experts. Through infusing values into future crisis plans, higher education leaders can be confident that their responses will be grounded in their communities' shared values. [ABSTRACT FROM AUTHOR]

This paper presents qualitative field research conducted at a radiology department in the USA. It examines 'the radiologist at work' and analyses the intersubjective ground for her individual diagnostic intentions and personalized strategies for enacting diagnostically-relevant experiences via imaging technology. The paper incorporates the radiologists' use of 'enactive proofs'—observations and professional memories made explicit through their interaction with medical imaging technology and other practitioners in the field. The observations strongly support the development of enactive phenomenology and provide a critique of representationalism and of the primacy of inference in cognition. The results demonstrate the crucial role of shared intentions, providing insight into expert performance in the form of concrete dealings with imaging technology, habituality, the origin of mistakes, multilayered communication, and discovering new ways for improving professional praxis. The findings have much to offer to philosophy, anthropology and radiological practice. [ABSTRACT FROM AUTHOR]

This paper describes the authors' exploration of an arts-based practice, called imagined dialogue, as a means for engaging in reflective discourse in the current, global context of political polarization. We introduce the practice of imagined dialogue, taking the readers along on our continued learning journey of the implications of this practice for educational contexts. We highlight the connections of imagined dialogue to the theory and practice of transformative learning. This paper suggests that writing and embodying imagined dialogue can prepare people for real dialogue, allowing them to more deeply understand their own positions, as well as to empathize with and respect the positions of others. In addition to introducing the theoretical background and steps to engaging in the imagined dialogue process, we share several examples; including our own experiences using imagined dialogue in personal contexts, and group processing of a dialogue about an issue of national political significance. Using imagined dialogue is a skill that can be learned and strengthened, enabling learners to engage in and model the practice of critical, reflective discourse over time – even in the emotionally charged political sphere. [ABSTRACT FROM AUTHOR]

Schizophrenia is a global concern, and, this paper, describes the caring roles of health professionals who are mothers of adult children with schizophrenia. A thematic analysis of data from a doctoral study identified a blending of expertise into an informed care model. Caring roles included: constant carer; coordinator carer; watchful bystander carer; and life coach carer. Previous research has not explored these dual roles. This paper elucidates their responsive approaches and contributions to mothering and caregiving roles. Informed by a fusion of professional and mothering knowledges, their insights into mental health care have been forged by their experiences and is an untapped resource. [ABSTRACT FROM AUTHOR]