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Assignment: Practicum: Planning for the Practicum

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Assignment: Practicum: Planning for the Practicum
The practicum experience provides a significant opportunity to cultivate your professional growth and development. What skills, attributes, or categories of knowledge do you most need or want to nurture? How would improving in these areas enable you to be a more effective leader? And how would that allow you to facilitate the translation of evidence into practice?
This course includes a 216-hour practicum as part of the 1,000 clinical hours that are required for the DNP credential. In your practicum experience for this course, you will examine the change process as it relates to the translation of evidence into practice. In addition, throughout your practicum experience you will pay close attention to the role of leadership in such endeavors and reflect on your own development of leadership competencies.
This week you develop a plan for your practicum.
Note: If you have not already done so, formalize the relationship with your practicum mentor.
To prepare:

  • Review      the information presented in the Learning Resources, and consider what      approach you would use (including specific steps of the process) to plan      for and implement an aggregate-level change that facilitates the      translation of evidence into practice. Begin with the analytical process      required to identify the change that needs to be made.
  • Think      about learning objectives that would guide your practicum hours, as well      as the activities you will undertake to achieve those objectives. Draft      two or three learning objectives that are related to the AACN DNP      Essentials, your practice area specialty competencies, and the focus of      this course—planning for and implementing a sustainable change related to      the translation of evidence into practice, as well as the development of      leadership competencies to facilitate this.
  • Refer      to the Practicum Time Log and Journal document      (see attached file).
  • Develop      a time line for your practicum experience. Note: You will      submit your time log and a journal entry by the end of Weeks 3, 7, and 11.

Note: It is important to formulate a big-picture view of this process. In Weeks 2 and 3, you will work with your practicum mentor to examine a change already underway or previously accomplished, and identify an additional aggregate-level change you would like to propose. You are not required to implement this change, but you do need to select an idea that is feasible, based on evidence, and appropriate for your practicum setting.
By Wednesday 2/27/19 before midnight, write a 3-page essay in APA format with at least 5 scholarly references from the list of required readings below. Include the level one headers as numbered below. 
To complete:
Write a 3-page paper that includes the following:
1) An outline or visual representation indicating how you would guide planning for and implementing change related to the translation of evidence into practice for your practicum setting
2) Three learning objectives for your practicum hours that are aligned to the AACN Essentials, your specialty area competencies, and the focus of this course (i.e., systems-related issues, translation of evidence into practice, intentional change, and leadership) (refer to the attached AACN Essential IV [Nursing Informatics]).
3) Key leadership and other activities you will undertake to fulfill your identified learning objectives
4) A proposed time line for accomplishing your practicum hours (divide 216 hours in 10 weeks to come up with how many hours per weeks in order to makeup the required 216 hours for this semester).
By Wednesday 2/27/19 before midnight
Submit this Assignment.
Required Readings
White, K. M., Dudley-Brown, S., & Terharr, M. F. (2016). Translation of evidence into nursing and health care practice (2nd ed.). New York, NY: Springer.
· Review Chapter 3, “Change Theory and Models: Framework for Translation”
As you review this chapter (assigned in a previous course), consider the foundational information about change. Also, pay attention to the frameworks and processes described, as they will be valuable as you proceed through this course. What insights arise regarding how you might be able to guide the implementation of change?
American Association of Colleges of Nursing (AACN). (2006). The essentials of doctoral education for advanced nursing practice. Retrieved from http://www.aacn.nche.edu/publications/position/DNPEssentials.pdf (see attached file).
Use the information in this report to guide the formulation of goals for your practicum experience.
Bleich, M. R. (2011). IOM report, The Future of Nursing: Leading Change, Advancing Health: milestones and challenges in expanding nursing science. Research in Nursing & Health, 34(3), 169-170. doi:10.1002/nur.20433 (see attached file)
​IOM report, The Future of Nursing: Leading Change, Advancing Health: milestones and challenges in expanding nursing science. Research in Nursing & Health by Bleich, M. R., in Research in Nursing & Health, Vol. 34/Issue 3. Copyright 2011 by John Wiley & Sons – Journals. Reprinted by permission of John Wiley & Sons – Journals via the Copyright Clearance Center.
Pritham, U. P. (2016). Assessing DNP impact using program evaluations to capture healthcare system change. The Nurse Practitioner, (4), 44.
Kotter, J. P. (2007). Leading change: Why transformation efforts fail. Harvard Business Review, 85(1), 96-103. Retrieved from https://cb.hbsp.harvard.edu/cbmp/pl/76758028/76758030/42e82c2469b7f33387aa79dc5736bb1f
In this foundational reading, Dr. John Kotter discusses errors commonly made as organizations undergo change, and he recommends steps leaders can take to help avoid them (see attached file).
Moriber, N. A., Wallace-Kazer, M., Shea, J., Grossman, S., Wheeler, K., & Conelius, J. (2014). Transforming Doctoral Education Through the Clinical Electronic Portfolio. Nurse Educator, 39(5), 221-226. doi:10.1097/NNE.0000000000000053
Murphy, M. P., Staffileno, B. A., & Carlson, E. (2015). Original Article: Collaboration Among DNP- and PhD-Prepared Nurses: Opportunity to Drive Positive Change. Journal of Professional Nursing,31388-394. doi: 10.1016/j.profnurs.2015.03.001
Sherrod, B., & Goda, T. (2016). DNP-Prepared leaders guide healthcare system change. Nursing Management, (9). 13.
Optional Resources
Osters, S., & Tiu, F. S. (n.d.). Writing measurable learning outcomes. Retrieved from http://www.gavilan.edu/research/spd/Writing-Measurable-Learning-Outcomes.pdf (see attached file).

Practicum Journal Entry Week 1-3, 4-7 and 8-11
Name
University
Class
Date

Clinical Time Log and Journal
Student Name:
E-mail Address:

Practicum Placement Agency’s Name:

Preceptor’s Name:
Preceptor’s Telephone:
Preceptor’s E-mail Address:
Time Log
Note: Add rows as needed.
Total: Weeks 1-3:
Total Weeks 4-7:
Total: Weeks 8-11
Total Practicum Hours Completed for Course

WK Date Time  
# of hour
Learner Objective *Bloom’s Taxonomy Course Objective
(Walden)
AACN Essential** Projected Goal Activities Completed Status of completion
 One  11/29/18  8-4  8  I plan to demonstrate the understanding of facts and ideas about the use of information technology in enhancing the patient quality of care by interpreting, exemplifying, classifying, summarizing, inferring, comparing and explaining main concepts  Demonstrate the achievement of learning objectives related to the AACN Essentials for Doctoral Education and specialty competencies for the practicum experience  IV  To gain the ability and expertise needed to partake in, support research and knowledge development in nursing informatics, to better the efficiency of the practice of nursing, as well as its policies and programs.  I attended a meeting with my preceptor regarding updating care plans for the labor and delivery unit. Also, a conference on old policies that are still showing in the hospital new electronic health system epic: “They don’t want nurses to see the old policies so that they don’t refer to the old policies.”  Starting
Two  12/05/18  8-4  8  To be able to examine and break information about information technology use in healthcare into parts by identifying motives, causes, and relationships as well as making inferences and finding evidence to support generalization with the mentorship of my preceptor  Design a program that is aligned to a specific problem and target population about a health-promotion and disease-prevention issue of national significance  IV  To gain the ability and expertise needed to partake in, support research and knowledge development in nursing informatics, to better the efficiency of the practice of nursing, as well as its policies and programs.  My preceptor and I attended a meeting with Karen about the specimen collection. Karen audit the specimen collection data and the nursing informatics sends it out. The hospital had to switch from Mobilab specimen collection to the epic. Unfortunately, the epic system is limited, and nurses now have to revert to two nurses sign off for specimens as labels no longer print at the patient bedside  Ongoing
 Three  12/13/18  8-4  8   I plan to demonstrate the understanding of facts and ideas about the use of information technology to better the quality of patient care by interpreting, exemplifying, classifying, summarizing, inferring, comparing and explaining main concepts  Demonstrate the achievement of learning objectives related to the AACN Essentials for Doctoral Education and specialty competencies for the practicum experience  Essential IV  To gain the ability and expertise needed to partake in, support research and knowledge development in nursing informatics, to better the efficiency of the practice of nursing, as well as its policies and programs.  My preceptor and I attended a meeting with IV therapy regarding how they document PICC insertion. The staff is having issues with that as the flow sheet is not built in properly. IV therapy expressed their concerns about the fact that the Picc line insertion flowsheet was not allowing them to document patient consent to Picc which is a must. The different areas where the PICC line could be inserted as well as whether the Picc is single, double or triple lumen were also discussed.  Midway
 Four  12/20/18  8-4  8  To be able to examine and break information about information technology use in healthcare into parts by identifying motives, causes, and relationships as well as making inferences and finding evidence to support generalization with the mentorship of my preceptor.  Design a program that is aligned to a specific problem and target population in relation to a health-promotion and disease-prevention issue of national significance  Essential IV To gain the ability and expertise needed to partake in, support research and knowledge development in nursing informatics, to better the efficiency of the practice of nursing, as well as its policies and programs.  I attended a Quality Council meeting with my preceptor in the morning, thereafter we attended a Practice Council meeting. In the afternoon we attended a policy protocol guidelines meeting as well as a meeting to discuss all the problems that were brought up by the mock Joint Commission survey arrival next year (2019).  Ongoing
 Five  12/27/18  8-4  8  To demonstrate the understanding of facts and ideas about the use of information technology to better the quality of patient care by interpreting, exemplifying, classifying, summarizing, inferring, comparing and explaining main concepts Analyze the appropriateness of planning and evaluation theories and models for application to a program design

Develop an evaluation plan that is aligned to a program plan

 Essential IV  To gain the ability and expertise needed to partake in, support research and knowledge development in nursing informatics, to better the efficiency of the practice of nursing, as well as its policies and programs.  I attended several meetings with my preceptor. We also had a meeting in which we troubleshoot some of the issues’ nurses are having with associating a primary problem or diagnosis to the patients individualized care plan. In the afternoon we attended another meeting to discuss all important Epic electronic health record system complaint tickets that were sent out to the nursing informatics department.  Ongoing
 Six  1/3/2019  8-4  8  To solve the different problems in new situations that may arise at my practicum site by applying acquired knowledge, facts, techniques and rules in a different way with the support of my preceptor (r/t NURS 8400 Course Learning Outcome 4)  Explain the significance between the selection and application of appropriate financial strategies and the quality of program outcomes

Demonstrate the achievement of learning objectives related to the AACN Essentials for Doctoral Education and specialty competencies for the practicum experience

  Essential IV  To gain the ability and expertise needed to partake in, support research and knowledge development in nursing informatics, to better the efficiency of the practice of nursing, as well as its policies and programs.  I attended several meetings with my preceptor. Some of the highlights of the day were about the Quality Council Meeting which is held every month. In this month meeting we discuss B16, the hospital orthopedic floor which is rated number one in the area against JHH and UMMC.
We also attended a nursing quality outcome meeting which discuss the hospital patient fall, pressure ulcers and CAUTI for the month of December. The professional practice model for the hospital was also updated and discussed
 Ongoing
Seven 1/10/2019 8-4 8 To be able to examine and break information about information technology use in healthcare into parts by identifying motives, causes, and relationships as well as making inferences and finding evidence to support generalization with the mentorship of my preceptor Design a program that is aligned to a specific problem and target population in relation to a health-promotion and disease-prevention issue of national significance

Analyze the appropriateness of planning and evaluation theories and models for application to a program design

Develop an evaluation plan that is aligned to a program plan

Propose strategies for involving stakeholders in developing a program’s goals and objectives

Create an approved DNP Project Proposal

 Essential IV To gain the ability and expertise needed to partake in, support research and knowledge development in nursing informatics, to better the efficiency of the practice of nursing, as well as its policies and programs. I participated in different meetings with my preceptor. We discuss and troubleshoot the issues that the nurses are having on the mother-baby unit regarding the breast milk donor documentation taking too much (at least 20 minutes) before the nurses can feed the babies and it is impeding workflow for the nurses since they each have at least 3 babies to feed. The nurses end up having to create workarounds. Ongoing
Eight
1/17/2019 8-4 8 To be able to examine and break information about information technology use in healthcare into parts by identifying motives, causes, and relationships as well as making inferences and finding evidence to support generalization with the mentorship of my preceptor Design a program that is aligned to a specific problem and target population in relation to a health-promotion and disease-prevention issue of national significance

Propose strategies for involving stakeholders in developing a program’s goals and objectives

Create an approved DNP Project Proposal

Essential IV To gain the ability and expertise needed to partake in, support research and knowledge development in nursing informatics, to better the efficiency of the practice of nursing, as well as its policies and programs. I first met up with my preceptor for a couple of hours to discuss and prepare for the various meetings of the day as well as preparing the agenda related to the Nursing Informatics department that we will present at these meetings. We attended and participated in a super-user clinical documentation meeting. In the afternoon we also participated in the planning of a Substance Use Screening and Brief Interventions meeting for the Labor and Delivery/Postpartum units. Completed
Nine 1/24/2019 8-12 4 I plan to demonstrate the understanding of facts and ideas about the use of information technology in enhancing the patient quality of care by interpreting, exemplifying, classifying, summarizing, inferring, comparing and explaining main concepts Design a program that is aligned to a specific problem and target population in relation to a health-promotion and disease-prevention issue of national significance

Analyze the appropriateness of planning and evaluation theories and models for application to a program design

Develop an evaluation plan that is aligned to a program plan

Demonstrate the achievement of learning objectives related to the AACN Essentials for Doctoral Education and specialty competencies for the practicum experience

Create an approved DNP Project Proposal

Essential IV To gain the ability and expertise needed to partake in, support research and knowledge development in nursing informatics, to better the efficiency of the practice of nursing, as well as its policies and programs. I participated in patients’ chart audits with my preceptor to track the inpatient nurses that are not correlating a standardized care plan to the patients’ diagnosis or primary problem(s) upon admission. Completed
Ten 1/29/2019 8-12 4 To be able to examine and break information about information technology use in healthcare into parts by identifying motives, causes, and relationships as well as making inferences and finding evidence to support generalization with the mentorship of my preceptor Design a program that is aligned to a specific problem and target population in relation to a health-promotion and disease-prevention issue of national significance

Analyze the appropriateness of planning and evaluation theories and models for application to a program design

Develop an evaluation plan that is aligned to a program plan

Demonstrate the achievement of learning objectives related to the AACN Essentials for Doctoral Education and specialty competencies for the practicum experience

Create an approved DNP Project Proposal

Essential IV To gain the ability and expertise needed to partake in, support research and knowledge development in nursing informatics, to better the efficiency of the practice of nursing, as well as its policies and programs. My preceptor and I continued to audit the patients’ chart to track down nurses who are not adding a standardized care plan to the patients’ diagnoses or primary problem(s). We also discussed the best approach to remedy the situation by building an educational tool for the nurses in order to hold them accountable for not doing it. Completed

Practicum Journal Entry Week 1-3
Description of the Observed Activities
In my first week at the Mercy Medical Center, there are various activities that I observed. For instance, I spent a better part of my time watching and participating in the process of updating care plans for the labor delivery unit. The administration of the Mercy Medical Center focused its attention on familiarizing nurses with its new policies and procedures.
Consequently, meetings were held to discuss the phasing out of old policies that are still being observed in the Epic. The agenda of the meeting was to advise nurses to avoid referencing old policies. After that, I met Karen, a nursing professional to discuss specimen collection. During this period, Karen audited the specimen collection information and instructed the nursing informatics to send it out. This session familiarized me with how nurses coordinate their tasks to generate positive patient outcomes. For an organization that is increasingly embracing information technology to support quality of care, concerns were also raised about switching from the Mobilab specimen collections system to the Epic. There were complaints that the Epic EHR system is still limited. Therefore, nurses have to revert to two nurses’ signoff for the specimens as labels no longer print at the patient bedside. Other meetings were held to explore care plan issues that were not built correctly in the Epic EHR.
Analysis of the Problems/ Issues
Mercy Medical Center is currently facing the challenge of slow implementation of its epic Electronic Health Record (EHR) system. The hospital recently transitioned from Meditech EHR system to Epic. The transition was not successfully implemented; as a result, many issues have arisen from the poor implementation of Epic as well as the Mobilab specimen collection that is marred by numerous inefficiencies. Nurses have also not yet familiarized themselves with the new EHR environment. Therefore, there is the slow pace of adoption of the system, thereby reducing operational efficiencies and quality of patient care (Tavana, 2014). EHRs are information systems that generate significant impacts on the usual clinical and administrative workflows, affecting users and the administrative systems. While significant planning may be undertaken before they are fully implemented, many challenges before the go-live and during the weeks and months after the initial date of full operation may be observed. Some of the issues that pose potential difficulties to nurses and other user groups include failure to train and familiarize nurses with the Epic EHRs, vendor challenges, and the general resistance by some nurses to the change process because they are not used to the new system. Furthermore, departmental coordination becomes a challenge when one department uses EHRs while others still operate on a pen-and-paper information system.
How the Real-World Mirrors Program-Related Evidence, Concepts, and Theories
In light of the rapid proliferation of evidence-based practices, there has been increased call for the identification of the core underlying mechanisms that are common to the many different evidence-based practices in the real world. With the growth and development of large databases, the utilization of EHRs, and sophisticated statistical techniques, the process of examining practices in the real world and comparing the effectiveness of interventions is often enhanced (McDaniel, 2009). Nurses and clinicians may face challenges associated with situations that lack definitive information regarding a course of action. I was exposed to information methodologies that can help inform practice decisions by evaluating outcomes in the real world. Patients may not be the same.
Given the above, the application of intervention may have multiple variations. Thus, the focus should be on external validity. It responds to the issue of whether similar outcomes can be attained on a broader population, in different contexts, with different clinicians, and most likely with limited resources.

References
McDaniel, J. G. (Ed.). (2009). Advances in information technology and communication in
health (Vol. 143). New York: Ios Press.
Tavana, M. (Ed.). (2014). Healthcare Informatics and Analytics: Emerging Issues and Trends:
Emerging Issues and Trends. New York: IGI Global.

Practicum Journal Entry Week 4-7

Description of the Observed Activities
There are various activities that I had observed in my experience. For instance, in my first week, I visited a Quality Council meeting with my preceptor, after which I participated in the Practice Council meeting. The fifth week kicked off with by attending several meetings in the entire day. Some of the issues that we discussed in the meeting included the negative findings of the Joint Commission’s recent visit of the Mercy Medical Center towards the end of December 2018. One of the outcomes of the Joint Commission was the fact that nursing professionals are not correlated to patients’ diagnosis or primary diagnosis to the patient individualized care plan. In the sixth week, discussions were aimed at exploring the Epic electronic health record system tickets that were sent out to the nursing informatics unit. The key issues that affected the mother-baby units relating to breast milk donor documentation. There included workflow issues related to feeding babies. Finally, in the seventh week, the Quality Council Meeting was convened. During that session, we found that the orthopedic floor is ranked leading above Johns Hopkins and the University of Maryland Medical Center Unit.
Analysis of the Issues, Problems, or Situations
The main problem that Mercy Medical Center faces is poor design and implementation of their new Epic electronic health record system (EHRs). The mother-baby unit is especially experiencing issues related to slow documentation of the breast milk donor which can take as long as 20 minutes because there was no bundle designed in their Epic EHRs related to donor breast milk, therefore, impeding the workflow for the nurses causing them to create workarounds. The health institution should re-engineer its processes by integrating EHRs in all its units and operations. This medium should be undertaken through a dynamic and iterative process. One of the most important issues about process reengineering is that not all steps in a process should be optimized. Some inefficiency should be designed into the workflow to improve the overall efficiency of the system. The Epic EHRs that has been introduced should be modified to enhance the quality of the outpatient clinical documentation (Skolnik, 2010). As such, all the components and prime quality scores should be remarkably improved. The critical elements that health care professionals should focus their attention on include chief complaints, history of present illness, physical findings, evaluations, and careplans. Since this health institution has poorly implemented its Epic electronic health record, it is still facing the challenge of low-quality scores on core elements. The electronic health records should have checkboxes to make it simpler for doctors and nurses to complete a comprehensive note.
How Real-World might Mirror the program-Related Evidence
The real world mirrors the program-related evidence in many ways. For instance, I have observed that integrating evidence-based real-world information into the care of patients necessitate having the correct information accessible at the right time. This correct time may include diagnostic procedures while providing care at the bedside of the patient or any specific point within a small period (Fowler et al., 2014). Nurses and physicians are often under pressure to attend to more patients within a short period (Silvia, Valerio & Lorenza, 2012). This medium is the precise problem that nurses are facing at Mercy Medical Center’s mother-baby unit, where they have many patients to attend to, but they spend at least 20 minutes with each patient. Nurses who are already experiencing pressure to see more patients in fewer periods would probably not look for information to inform their decisions when the search processes interrupt the flow of their work (Fowler et al., 2014). A mechanism to rectify this issue is to develop a clinical decision support system, which connects appropriate evidence-based data resources that can be retrieved straight from the EHRs (Fowler et al., 2014).

References
Fowler, S. A., Yaeger, L. H., Yu, F., Doerhoff, D., Schoening, P., & Kelly, B. (2014). Electronic health record: integrating evidence-based information at the point of clinical decision making. Journal of the Medical Library Association: JMLA102(1), 52. Doi: 10.3163/1536-5050.102.1.010
Skolnik, N. S. (Ed.). (2010). Electronic medical records: A practical guide for primary care. Springer Science & Business Media.
Silvia, B., Valerio, D., & Lorenza, G. (2012). The reflective journal: A tool for enhancing experience-based learning in nursing students in clinical practice. Journal of Nursing Education and Practice3(3), 102. Doi: https://doi.org/10.5430/jnep.v3n3p102

Practicum Journal Entry Week 8-11
The Observed Activities
The activities in week 8 involved a discussion of agendas about informatics in the Nursing informatics department that we were to present in the upcoming meetings. We attended the super-user clinical documentation meeting and took part in planning the Substance Use Screening and Brief Interventions meeting for the Labor/Delivery and Postpartum units. In the ninth week, I took part in auditing the patients’ charts to trace the inpatient nurses who have not been correlating standardized care plans to the patients’ diagnosis or primary problems upon admission. In week 10, I participated in the auditing of patients’ charts to track nurses who do not add standardized care plans to the patients’ diagnoses or primary problems. I also participated in the discussion about the best possible approaches to solve the situation, primarily through building an educational tool for the affected nurses so as they can be sufficiently educated on the matter. Through this approach, nurses who do not comply with the inpatient admission requirements in the affected departments will be held accountable for noncompliance.
Analysis of the Issue
There have been problems in the process of screening for substance use and brief interventions for the Labor and Postpartum units. Different challenges lead to this problem. The main ones include insufficient expertise and skills by some nurses in handling or operating the electronic equipment needed to accomplish this task, a large number of patients in these units, and noncompliance. The issue of poor understanding of the modern equipment that is required to be used for screening may appear simple, but some nurses are not sufficiently knowledgeable when it comes to operating this equipment (Clark, Raffray, Hendricks & Gagnon, 2016).
Consequently, such nurses may prefer to skip this step to avoid embarrassment by exposing their ignorance. This medium indicates that a good number of nurses are not sufficiently educated on standardized patients’ care plan documentation and need to be retrained more on the latest developments of health technology. Lack of enough knowledge on electronic systems such as the clinical decision support and other electronic health record (EHR), and noncompliance are also the main factors that make nurses fail to establish correlations between standardized care plans to patient diagnoses upon admission (Shin, Park & Kim, 2015). This issue calls for retraining and supervision to avoid such problems in the future.
How the Real World might Mirror or Diverge from Program-Related Evidence/Concepts
In clinical practice, the real world can uphold program-related concepts in many ways. These include: working with a patient-centered approach through avoiding cases of noncompliance. Healthcare providers also mirror program-related practice through constant training on the latest technologies that help to improve patient care. The regular training on health information technology ensures that nurses do not ignore crucial medical stages or processes due to insufficient knowledge or incompetence in handling electronic equipment (Clark et al., 2016). Nurses also mirror the program concepts through upholding ethical and moral values in their practice through treating all patients with dignity and respect irrespective of their cultural backgrounds and avoid negligence when handling patients. Nevertheless, there are some cases in which some nurses in some institutions are negligent possibly due to poor management policies, personal prejudices, or lack of sufficient training. Other ways through which nurses divert from what is required is through working without passion and ignoring their duties (Clark et al., 2016).

References
Clark, M., Raffray, M., Hendricks, K., & Gagnon, A. J. (2016). Global and public health core competencies for nursing education: a systematic review of essential competencies. Nurse education today40, 173-180. https://doi.org/10.1016/j.nedt.2016.02.026
Shin, S., Park, J. H., & Kim, J. H. (2015). Effectiveness of patient simulation in nursing education: meta-analysis. Nurse education today35(1), 176-182. https://doi.org/10.1016/j.nedt.2014.09.009

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