WEBVTT 00:00:00.220 --> 00:00:06.670 position:50% align:middle - [Hostess] The research of Kristina Thomas Dreifuerst is at the forefront of disciplinary efforts to develop, 00:00:06.670 --> 00:00:14.190 position:50% align:middle use, and test innovative teaching methods to improve students' clinical reasoning skills and investigate how 00:00:14.190 --> 00:00:20.860 position:50% align:middle educators can best be prepared to use evidence-based methods to enhance teaching and learning. 00:00:20.860 --> 00:00:26.890 position:50% align:middle Her work has been recognized for leading initiatives to transform nursing education and 00:00:26.890 --> 00:00:29.080 position:50% align:middle influence changes internationally. 00:00:35.600 --> 00:00:39.905 position:50% align:middle - [Dr. Dreifuerst] Hi, I'm Dr. Kristina Thomas Dreifuerst from Marquette University 00:00:39.905 --> 00:00:41.711 position:50% align:middle in Milwaukee, Wisconsin. 00:00:41.711 --> 00:00:47.640 position:50% align:middle On behalf of my colleagues Dr. Angela McNelis, from George Washington University, 00:00:47.640 --> 00:00:55.470 position:50% align:middle and Dr. Darrell Spurlock, from Widener University, we are pleased to present our study, 00:00:55.470 --> 00:01:02.000 position:50% align:middle the national study of clinical education in family nurse practitioner programs, and, specifically today, 00:01:02.000 --> 00:01:08.600 position:50% align:middle the types, frequency, depth of direct care, experiences of family nurse practitioner students 00:01:08.600 --> 00:01:11.100 position:50% align:middle in the United States. 00:01:11.100 --> 00:01:16.360 position:50% align:middle We gratefully acknowledge the National Council of State Boards of Nursing for their support of this work 00:01:16.360 --> 00:01:24.070 position:50% align:middle through a CRE grant, project number R100010. 00:01:24.070 --> 00:01:28.790 position:50% align:middle Family nurse practitioners care for patients across the lifespan. 00:01:28.790 --> 00:01:35.650 position:50% align:middle And rigorous educational preparation is necessary, which includes diverse clinical experiences to ensure 00:01:35.650 --> 00:01:40.031 position:50% align:middle competent safe practice in our graduates. 00:01:40.340 --> 00:01:45.230 position:50% align:middle During these clinical experiences, learning outcomes are presumed to be met, 00:01:45.230 --> 00:01:50.720 position:50% align:middle yet data-driven research, reporting what actually happens has not been reported 00:01:50.720 --> 00:01:53.084 position:50% align:middle beyond individual program data. 00:01:55.830 --> 00:02:03.920 position:50% align:middle For that reason, our study proposed to describe the types, frequency, and depth of direct patient care 00:02:03.920 --> 00:02:09.036 position:50% align:middle experiences of family nurse practitioner students in the United States. 00:02:13.100 --> 00:02:20.120 position:50% align:middle This is important research because students in FNP programs are expected to develop autonomy in their 00:02:20.120 --> 00:02:24.040 position:50% align:middle practice throughout their educational experiences. 00:02:24.040 --> 00:02:30.470 position:50% align:middle This autonomy includes the management of patients with previously-diagnosed and undiagnosed conditions. 00:02:30.470 --> 00:02:36.728 position:50% align:middle And these experiences should occur during their clinical practicums. 00:02:38.220 --> 00:02:41.690 position:50% align:middle Nurse practitioners, including family nurse practitioners, 00:02:41.690 --> 00:02:47.940 position:50% align:middle must demonstrate competencies in caring for complex patients across all age groups. 00:02:47.940 --> 00:02:55.006 position:50% align:middle And these patients have a variety of healthcare conditions and they live and work in diverse settings. 00:02:57.000 --> 00:02:59.680 position:50% align:middle Nurse practitioners, including family nurse practitioners, 00:02:59.680 --> 00:03:05.990 position:50% align:middle must also demonstrate competencies in caring for complex patients across all age groups throughout the 00:03:05.990 --> 00:03:12.000 position:50% align:middle continuum with a variety of health conditions and, again, in diverse settings. 00:03:12.100 --> 00:03:20.481 position:50% align:middle These age groups include the birth to death continuum, and this is a wide range of expectation. 00:03:21.800 --> 00:03:28.760 position:50% align:middle Traditionally, FNP students work one on one with a preceptor to achieve these competencies 00:03:28.760 --> 00:03:35.820 position:50% align:middle throughout their minimum 500 clinical practicum hours that are required for national board certification. 00:03:38.340 --> 00:03:45.020 position:50% align:middle For the purposes of this study and to test the question, "What are the frequencies, types, 00:03:45.020 --> 00:03:51.110 position:50% align:middle and depth of these patient care experiences that FNP students experience?" 00:03:51.110 --> 00:03:58.660 position:50% align:middle we used a cross-sectional observational complex sample survey design and we collected data from students 00:03:58.660 --> 00:04:05.633 position:50% align:middle enrolled in or affiliated with accredited FNP programs across the country. 00:04:08.910 --> 00:04:16.610 position:50% align:middle To do this, we used a 33-item investigator-developed, inventory-type survey. 00:04:16.610 --> 00:04:20.080 position:50% align:middle This survey contained four sections. 00:04:20.080 --> 00:04:26.560 position:50% align:middle The first section was a demographic and professional information section and included questions 00:04:26.560 --> 00:04:31.620 position:50% align:middle regarding age, years of experience in nursing, clinical area of practice, 00:04:31.620 --> 00:04:37.530 position:50% align:middle and geographical information about the program they were enrolled in and where they did their 00:04:37.530 --> 00:04:40.247 position:50% align:middle clinical practicum experiences. 00:04:41.580 --> 00:04:47.340 position:50% align:middle The second section included information about the educational program they were enrolled in, 00:04:47.340 --> 00:04:55.230 position:50% align:middle including the program type, the delivery method, for instance, was it online, hybrid, or face to face, 00:04:55.230 --> 00:04:58.240 position:50% align:middle or some combination thereof. 00:04:58.240 --> 00:05:02.930 position:50% align:middle And we also asked for information about their clinical experiences. 00:05:02.930 --> 00:05:08.759 position:50% align:middle These were the precepted clinical experiences traditionally seen in these kinds of programs. 00:05:10.140 --> 00:05:17.170 position:50% align:middle The third section of the survey addressed the four domains of nurse practitioner practice. 00:05:17.170 --> 00:05:22.250 position:50% align:middle These are the domains that nurse practitioner students, particularly FNP students, 00:05:22.250 --> 00:05:29.685 position:50% align:middle are likely to participate in, assessment, diagnosis, treatment, and evaluation. 00:05:31.390 --> 00:05:39.900 position:50% align:middle And finally, the survey included 84 specific tasks across these 4 domains of assessment, diagnosis, 00:05:39.900 --> 00:05:49.368 position:50% align:middle treatment, and evaluation in each of the populations pediatric, adult, and gerontological. 00:05:52.400 --> 00:05:59.126 position:50% align:middle The participants in our study are well representative of FNP students in the United States, 00:05:59.126 --> 00:06:05.130 position:50% align:middle 3,946 students completed the survey in its entirety. 00:06:05.130 --> 00:06:15.060 position:50% align:middle And consistent with national trends, 79% reported that they were female, and 21% reported that they were male. 00:06:15.060 --> 00:06:22.760 position:50% align:middle Our participants are also representative of the age we see in FNP students and nurse practitioner students 00:06:22.760 --> 00:06:25.570 position:50% align:middle in general in the United States today. 00:06:25.570 --> 00:06:30.230 position:50% align:middle Seventy two percent of the participants in the study reported that they were in the 25 00:06:30.230 --> 00:06:33.531 position:50% align:middle to 34-year-old age group. 00:06:35.300 --> 00:06:42.190 position:50% align:middle The participants in this study also represent FNP programs across the regions of the United States 00:06:42.190 --> 00:06:50.940 position:50% align:middle proportional to the way the programs are available in the various urban and rural areas of this country. 00:06:50.940 --> 00:06:55.910 position:50% align:middle For instance, 50% of our participants came from the large middle sections, 00:06:55.910 --> 00:07:04.620 position:50% align:middle north and south of the country where there are larger FNP programs, as reported in the national data set. 00:07:04.620 --> 00:07:10.040 position:50% align:middle Thirty two percent of the participants in our study came from the eastern sections of the country, 00:07:10.040 --> 00:07:15.810 position:50% align:middle both the north and the south part of the east, where there are many many programs but they are smaller 00:07:15.810 --> 00:07:18.100 position:50% align:middle in class sizes. 00:07:18.100 --> 00:07:24.230 position:50% align:middle And 18% of the participants in our study came from the rural western regions, 00:07:24.230 --> 00:07:29.840 position:50% align:middle both north and south areas of the country, where there are fewer programs and they also have 00:07:29.840 --> 00:07:31.933 position:50% align:middle smaller class sizes. 00:07:35.640 --> 00:07:42.140 position:50% align:middle Our findings were very interesting, and our findings were broken up using the frequency 00:07:42.140 --> 00:07:46.680 position:50% align:middle of clinical task by domain and population. 00:07:46.680 --> 00:07:51.410 position:50% align:middle And what we found is when we looked at those four areas, 00:07:51.410 --> 00:08:00.080 position:50% align:middle assessment and we looked at treatment and we looked at care of patients across adults, geriatric, 00:08:00.080 --> 00:08:08.700 position:50% align:middle and pediatric populations, we found that there was quite a range between students 00:08:08.700 --> 00:08:16.450 position:50% align:middle who had never done many activities to students who had done activities greater than 10 times. 00:08:16.450 --> 00:08:23.820 position:50% align:middle There were no students who did all of the expected activities greater than 10 times and there were no 00:08:23.820 --> 00:08:28.856 position:50% align:middle students who never did any of the required activities. 00:08:29.830 --> 00:08:32.360 position:50% align:middle The data was not a bell curve, however. 00:08:32.360 --> 00:08:41.800 position:50% align:middle We did not see that most students had done most activities in either 3 to 6 or 7 to 10 times. 00:08:41.800 --> 00:08:49.750 position:50% align:middle In fact, what we found is that, while students had many opportunities to do activities 00:08:49.750 --> 00:08:57.720 position:50% align:middle associated with the care of adults, they had infrequent opportunities to demonstrate or 00:08:57.720 --> 00:09:04.250 position:50% align:middle even participate in the required competencies associated with the care of pediatric 00:09:04.250 --> 00:09:07.237 position:50% align:middle and geriatric populations. 00:09:09.380 --> 00:09:17.440 position:50% align:middle So, in our sample of 3,946 students, across those populations, adult, geriatric, 00:09:17.440 --> 00:09:26.260 position:50% align:middle and pediatric, the most common task that students reported never experiencing in their clinical rotations 00:09:26.260 --> 00:09:32.080 position:50% align:middle were performing a mental health assessment, ordering diagnostic tests, 00:09:32.080 --> 00:09:39.860 position:50% align:middle performing primary care procedures, or evaluating treatment and educational outcomes 00:09:39.860 --> 00:09:46.391 position:50% align:middle related to chronic pain in adult, geriatric, and pediatric populations. 00:09:47.690 --> 00:09:52.940 position:50% align:middle So, this is pretty important data for us, as a discipline, and for us as we think about the 00:09:52.940 --> 00:09:59.740 position:50% align:middle preparation that our students are getting in their role as an FNP. 00:09:59.740 --> 00:10:06.340 position:50% align:middle Because, although significant numbers of students reported never experiencing some clinical tasks in each 00:10:06.340 --> 00:10:15.420 position:50% align:middle domain and others reported doing some tests more than 10 times, these tests were all deemed to be important 00:10:15.420 --> 00:10:19.390 position:50% align:middle and to be a criteria upon which programs are measured. 00:10:19.390 --> 00:10:27.829 position:50% align:middle So, having any students that had not experienced some of these items is concernful. 00:10:29.220 --> 00:10:32.130 position:50% align:middle Now, our data does have some limitations. 00:10:32.130 --> 00:10:38.980 position:50% align:middle We relied on students' recall of their clinical experiences, although we did allow them to look if they 00:10:38.980 --> 00:10:45.840 position:50% align:middle had a recording system such, as Typhon, some of them did use that data to inform how they 00:10:45.840 --> 00:10:47.760 position:50% align:middle answered the survey. 00:10:47.760 --> 00:10:54.120 position:50% align:middle But we, potentially, have biased data, based on responses, also because there is 00:10:54.120 --> 00:10:59.040 position:50% align:middle self-selection involved in the respondents to survey solicitation. 00:10:59.040 --> 00:11:02.600 position:50% align:middle We did our recruitment in several different manners. 00:11:02.600 --> 00:11:07.910 position:50% align:middle We recruited through program administrators and directors, we did direct recruitment, 00:11:07.910 --> 00:11:10.370 position:50% align:middle and we did social media recruitment. 00:11:10.370 --> 00:11:17.170 position:50% align:middle And so, we're aware that the people who chose to participate in the study may be different and may have 00:11:17.170 --> 00:11:25.560 position:50% align:middle had different experiences than those who chose not to participate or who were unaware of the study. 00:11:25.560 --> 00:11:31.030 position:50% align:middle And we're aware that we, potentially, admitted recently-accredited schools and, therefore, 00:11:31.030 --> 00:11:36.160 position:50% align:middle respondents because they were not yet included on published lists. 00:11:36.160 --> 00:11:44.130 position:50% align:middle And so, this might have narrowed our sample inadvertently, so...but we feel that, overall, 00:11:44.130 --> 00:11:52.464 position:50% align:middle our demographics reveal that our representation is very strong and our response rate quite good. 00:11:56.340 --> 00:12:05.180 position:50% align:middle So, in conclusion, what we discovered is that for many students the clinical experiences in their FNP programs 00:12:05.180 --> 00:12:12.060 position:50% align:middle did not provide the patient encounters reflecting the tasks that were deemed as essential, 00:12:12.060 --> 00:12:17.390 position:50% align:middle outlined in the ANCC FNP Role Delineation study and used for the development of the 00:12:17.390 --> 00:12:19.833 position:50% align:middle National Certification Examination. 00:12:21.620 --> 00:12:28.280 position:50% align:middle And because of this, as demand continues to grow for primary care providers 00:12:28.280 --> 00:12:37.030 position:50% align:middle and FNP needs to continue to grow in both urban and rural areas, our graduates need to possess the skills 00:12:37.030 --> 00:12:46.640 position:50% align:middle and knowledge to practice autonomously and to assess, diagnose, evaluate, and treat across the human age 00:12:46.640 --> 00:12:53.360 position:50% align:middle range of pediatric through geriatric in accordance with their scope of practice. 00:12:53.360 --> 00:12:58.270 position:50% align:middle And we are accountable to ensure that they're ready to do that. 00:12:58.270 --> 00:13:05.200 position:50% align:middle The gaps and inconsistencies in this requisite learning experiences for students require a critical 00:13:05.200 --> 00:13:11.740 position:50% align:middle conversation among leaders in academe, regulation, and certification. 00:13:11.740 --> 00:13:17.550 position:50% align:middle And we believe that working collaboratively, these three groups, leaders in academe, 00:13:17.550 --> 00:13:25.460 position:50% align:middle leaders in regulation, and leaders in certification must re-examine competency expectations. 00:13:25.460 --> 00:13:33.680 position:50% align:middle And they must really consider the availability of clinical learning environments today and in the future 00:13:33.680 --> 00:13:40.960 position:50% align:middle and consider what preparation for advanced practice looks like, and should look like, and the quality 00:13:40.960 --> 00:13:47.930 position:50% align:middle indicators that we need to be sure that we are all meeting to ensure development of qualified nurse 00:13:47.930 --> 00:13:56.100 position:50% align:middle practitioners who will then provide safe, high-quality care across the lifespan. 00:13:56.100 --> 00:14:06.150 position:50% align:middle And finally, if our data holds true, then we have to ask ourselves some other questions. 00:14:06.150 --> 00:14:13.450 position:50% align:middle For instance, if traditional clinical precepted rotations are not providing the opportunities for NP 00:14:13.450 --> 00:14:21.580 position:50% align:middle student experiences that we expect and they are not having an opportunity to participate in or experience 00:14:21.580 --> 00:14:29.980 position:50% align:middle the expected tasks and develop competency in these areas, perhaps it's time that alternative 00:14:29.980 --> 00:14:37.790 position:50% align:middle experiential approaches, such as simulation, be explored and developed further as a concurrent way 00:14:37.790 --> 00:14:40.750 position:50% align:middle to meet clinical requirements. 00:14:40.750 --> 00:14:46.110 position:50% align:middle We know that our interdisciplinary colleagues in other health care professions 00:14:46.110 --> 00:14:49.770 position:50% align:middle have moved in this direction for this reason. 00:14:49.770 --> 00:14:57.970 position:50% align:middle And it will take collaboration between academe, regulation, and certification leaders to push 00:14:57.970 --> 00:14:59.390 position:50% align:middle this agenda forward. 00:15:00.400 --> 00:15:09.830 position:50% align:middle We recognize that this is one study and that this is one set of participants, but we believe that this data 00:15:09.830 --> 00:15:11.680 position:50% align:middle is a call to action. 00:15:11.680 --> 00:15:20.380 position:50% align:middle And we encourage additional research and additional data collection to ensure that we all understand what 00:15:20.380 --> 00:15:29.600 position:50% align:middle are the expectations of FNP students and how and when are those expectations being met and how and when are 00:15:29.600 --> 00:15:33.980 position:50% align:middle they not being met in current educational environments. 00:15:37.000 --> 00:15:40.710 position:50% align:middle And then we've provided some selected references. 00:15:40.710 --> 00:15:47.007 position:50% align:middle We can be contacted if you would like additional references or additional data. 00:15:48.090 --> 00:15:50.856 position:50% align:middle Thank you so much for your time today. 00:16:10.000 --> 00:16:14.500 position:50% align:middle Hi everyone. Welcome and thank you for attending this session. 00:16:14.500 --> 00:16:20.570 position:50% align:middle I am available now to answer any questions that you might have or comments about the study. 00:16:20.570 --> 00:16:27.835 position:50% align:middle And so, if you'd put any questions or comments into the Q&A section, I will be able to see them there. 00:16:29.040 --> 00:16:32.240 position:50% align:middle And I do see one from Jackie. 00:16:32.240 --> 00:16:40.920 position:50% align:middle And Jackie asks, "Did your study capture whether or not students had to pay for preceptor experiences?" 00:16:40.920 --> 00:16:44.920 position:50% align:middle We did not specifically ask that question. 00:16:44.920 --> 00:16:53.660 position:50% align:middle However, we did ask whether students had to get their own preceptor or whether preceptors were provided 00:16:53.660 --> 00:16:55.590 position:50% align:middle by the program. 00:16:55.590 --> 00:17:02.510 position:50% align:middle And we do have a paper in preparation that looks at the difference, because there was a significant difference 00:17:02.510 --> 00:17:12.200 position:50% align:middle between the experiences students had when they had to get their own preceptor versus when preceptors were 00:17:12.200 --> 00:17:17.025 position:50% align:middle hired and/or contracted by programs directly. 00:17:20.067 --> 00:17:23.940 position:50% align:middle I see another question from Shannon. 00:17:23.940 --> 00:17:29.690 position:50% align:middle Shannon asks, "Another big question is, 'Do we need so many FNPs?' But maybe, 00:17:29.690 --> 00:17:41.076 position:50% align:middle rather than trying to create alternative experiences, we should increase students' entry into...so, the AGPC, 00:17:41.076 --> 00:17:43.950 position:50% align:middle CNP or the peds? 00:17:43.950 --> 00:17:51.270 position:50% align:middle So, maybe the lack of sites is reflected of the healthcare arena, our peds..." 00:17:51.270 --> 00:17:57.850 position:50% align:middle Oh, so, you're asking if other preparation programs have the same challenges. 00:17:57.850 --> 00:18:03.680 position:50% align:middle Our study was solely about FNP education. 00:18:03.680 --> 00:18:11.850 position:50% align:middle And so, we only surveyed students who were in FNP programs, so I don't have data 00:18:11.850 --> 00:18:13.770 position:50% align:middle about the other programs. 00:18:13.770 --> 00:18:20.610 position:50% align:middle However, anecdotally, we know that many of our FNPs do share preceptors. 00:18:20.610 --> 00:18:25.870 position:50% align:middle So, our FNPs often, in programs, will have the same preceptors that, 00:18:25.870 --> 00:18:31.360 position:50% align:middle if the program has pediatric nurse practitioner students or gyro nurse practitioner students, 00:18:31.360 --> 00:18:37.870 position:50% align:middle concurrently, we know that there's a lot of the preceptors doing work with students 00:18:37.870 --> 00:18:39.530 position:50% align:middle in different programs. 00:18:39.530 --> 00:18:42.940 position:50% align:middle But we did not collect that data specifically. 00:18:42.940 --> 00:18:52.350 position:50% align:middle As far as the number of FNPs and whether or not we...we did not collect any data about that, 00:18:52.350 --> 00:18:59.910 position:50% align:middle but certainly there is data in the literature to support the increasing need for primary care providers 00:18:59.910 --> 00:19:06.300 position:50% align:middle and the increasing role that FNPs are serving in that role across the United States, 00:19:06.300 --> 00:19:10.838 position:50% align:middle particularly in rural and urban areas. 00:19:14.110 --> 00:19:16.420 position:50% align:middle So, let's see... 00:19:16.420 --> 00:19:21.790 position:50% align:middle "Was there a difference based on modality, online versus hybrid versus face to face?" 00:19:21.790 --> 00:19:29.610 position:50% align:middle Again, this study is particularly about the clinical experiences, the precepted clinical experiences. 00:19:29.610 --> 00:19:38.590 position:50% align:middle And so, everyone did those precepted clinical experiences in the presence of their preceptor in a 00:19:38.590 --> 00:19:43.634 position:50% align:middle direct clinical environment. That was the data that we collected for this study. 00:19:46.800 --> 00:19:52.030 position:50% align:middle And let's see, Mary asks, "Why are FNPs spending the same clinical precepted 00:19:52.030 --> 00:19:55.960 position:50% align:middle hours in their programs to do across the lifespan? 00:19:55.960 --> 00:20:00.070 position:50% align:middle I find that they're trying to apply for jobs in pediatrics with their credentials. 00:20:00.070 --> 00:20:07.540 position:50% align:middle As a pediatric nurse practitioner, private practice, I'm called upon all the time to do 80 clinical hours 00:20:07.540 --> 00:20:12.960 position:50% align:middle for pediatrics from FNPs, and they come with little or no knowledge or skills 00:20:12.960 --> 00:20:17.310 position:50% align:middle with children, minimal faculty contact with many students. 00:20:17.310 --> 00:20:20.100 position:50% align:middle Did your study look at that?" 00:20:20.100 --> 00:20:32.885 position:50% align:middle So, again, we used the criteria set by both the [inaudible] and the CCNE around the 500 hours that 00:20:32.885 --> 00:20:38.540 position:50% align:middle is required for advanced practice, clinical education. 00:20:38.540 --> 00:20:48.390 position:50% align:middle We did not look at...we gathered the data around programs who had more than the 500 hours, 00:20:48.390 --> 00:20:52.340 position:50% align:middle no one had less because you need 500 hours as a minimum. 00:20:52.340 --> 00:21:01.170 position:50% align:middle But there was nothing statistically significant that stood out about those extra hours and these particular 00:21:01.170 --> 00:21:02.340 position:50% align:middle areas of deficit. 00:21:02.340 --> 00:21:10.735 position:50% align:middle So, we don't have data that was specifically asking that question, nor was it able to be teased out. 00:21:11.850 --> 00:21:20.789 position:50% align:middle So, let me see here...I can see that there are more questions, give me just a moment to refresh this. 00:21:29.070 --> 00:21:37.410 position:50% align:middle So, Catherine asked, "Was there any indication of barriers..." 00:21:37.410 --> 00:21:41.490 position:50% align:middle I'm sorry, I lost it again, just give me...I apologize. 00:21:41.490 --> 00:21:44.466 position:50% align:middle Suddenly, I have lost the questions. 00:22:00.800 --> 00:22:08.020 position:50% align:middle Yeah, we didn't have data that could tease out that level of specificity at this point. 00:22:08.020 --> 00:22:13.770 position:50% align:middle Again, when we designed this study, the purpose and the intention of designing the study 00:22:13.770 --> 00:22:18.060 position:50% align:middle was to address this huge gap in the literature. 00:22:18.060 --> 00:22:25.230 position:50% align:middle We thought that when we went down this pathway that we would find a great deal of literature 00:22:25.230 --> 00:22:31.210 position:50% align:middle around FNP clinical education, around what the preceptor experience was designed 00:22:31.210 --> 00:22:35.970 position:50% align:middle to do, around outcomes from precepted clinical experiences. 00:22:35.970 --> 00:22:39.140 position:50% align:middle And quite frankly, none of that exists in the literature. 00:22:39.140 --> 00:22:46.830 position:50% align:middle So, this was an opportunity to get started by building the literature in this area, 00:22:46.830 --> 00:22:50.400 position:50% align:middle but there is clearly a lot more work to be done. 00:22:59.100 --> 00:23:01.690 position:50% align:middle I have just a tiny bit more time left. 00:23:01.690 --> 00:23:04.154 position:50% align:middle If there's any other questions... 00:23:09.700 --> 00:23:15.880 position:50% align:middle If not, thank you so much for your time and attention and I appreciate all the questions. 00:23:15.880 --> 00:23:22.549 position:50% align:middle And I encourage you, if this is an area of interest, that you consider adding to this body of literature.