Open Journal of Nursing, 2013, 3, 437-444 OJN
http://dx.doi.org/10.4236/ojn.2013.36059 Published Online October 2013 (http://www.scirp.org/journal/ojn/)
Perceptions and barriers that influence the ability to
provide appropriate incontinence care in nursing
home residents: Statements from nursing staff
Liv Heidi Skotnes1,2*, Ove Hellzen2,3, Esther Kuhry4
1Department of Me d icine, Division of Geriatrics, Nord-Trøndelag Hea lt hTrust, Namsos, Norway
2Nord-Trøndelag University College, Namsos, Norway
3Department of He a lth Sciences, Mid-Sweden University, Østersund, Sweden
4Department of Surgery, St. Olavs Hospital, Trondheim, Norway
Received 21 July 2013; revised 22 August 2013; accepted 19 September 2013
Copyright © 2013 Liv Heidi Skotnes et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Urinary incontinence is a common medical condition
among nursing home residents. Urinary incontinence
in older people has a multifactorial etiology and is
therefore more difficult to assess and treat than uri-
nary incontinence in younger people. Previous re-
search has shown that incontinence care in nursing
home residents often is inadequate and little systema-
tized. The aim of this study was to identify percep-
tions and barriers that influence the ability of the
nursing staff to provide appropriate incontinence care.
This was a qualitative study using focus-group meth-
odology. Data were collected from three focus-group
interviews with 15 members of the nursing staff from
six different units in a nursing home. The focus-group
interviews were recorded on tape, transcribed verba-
tim and analyzed according to qualitative content
analysis. Three topics and eight categories were iden-
tified. The first topic, Perceptions and barriers associ-
ated with residents, consisted of one category: “phy-
sical and cognitive problems”. The second topic, Per-
ceptions and barriers associated with nursing staff,
consisted of three categories: “lack of knowledge”,
“attitudes and beliefs” and “lack of accessibility”.
The third topic, Perceptions and barriers associated
with organizational culture, consisted of four cate-
gories: “rigid routines”, “lack of resource”, “lack of
documentation” and “lack of leadership”. The find-
ings from this study show that there are many barri-
ers that might influence the possibilities of nursing
staff to provide appropriate incontinence care to re-
sidents in nursing homes. However, it can neverthe-
less seem like opinions and the attitude of nursing
staff, together with a lack of knowledge about UI, are
the most important barriers to provide appropriate
Keywords: C o ntent Analysis; Focus Groups;
Incontinence Care; Nursing Homes; Urinary
Urinary incontinence (UI) is one of the most common
medical conditions among nursing home residents. Be-
tween 45% and 70% of residents in nursing homes have
UI and the prevalence increases progressively with age
. UI is associated with significant morbidity and uti-
lization of health care resources . Furthermore, UI has
a significant impact on resident’ psychosocial well-being
and quality of life . UI among nursing home residents
has a multifactorial etiology, involving neurologic dis-
orders, urologic and gynecologic conditions, behavioral
and psychological factors, and functional impairment.
These conditions may have an effect on bladder control
and cause urinary frequency, urgency, urge incontinence
or problems with bladder emptying. Nursing home re-
sidents are getting older and therefore, on average, re-
quire more assistance with daily activities, including go-
ing to the toilet . Cerebral changes can cause psycho-
logical, behavioral and environmental problems and con-
tribute to the inability to use the toilet or to ask for
assistance . Although UI has a multifactorial etiology
in the older population, research has shown that many of
the contributors to UI are reversible with appropriate
intervention. Studies have reported that up to 70% of the
*Corresponding a uthor.
L. H. Skotnes et al. / Open Journal of Nursing 3 (2013) 437-444
older population suffering from UI can be cured or ame-
liorated with lifestyle adjustments and behavioral thera-
pies [6-8]. UI among frail nursing homes residents is
often more complex to assess and to treat than UI in
younger people. It is therefore important that the nursing
staff performs a careful assessment of incontinent resi-
dents in order to be able to give appropriate care. The
complexity of UI in frail nursing home residents has
been described as a challenge for nursing staff. Several
studies have reported that incontinence care is incom-
plete and little person-centered [9-11]. Incontinence care
is a very sensitive matter, and it is important to preserve
a resident’s privacy and dignity during such care. In a
qualitative study, six elderly women with UI in long-
term care were interviewed about their experiences of
living with UI in long-term care. The women told that
they lacked decision-making and choices about their per-
sonal UI care. Further, they described how loss of control
of bodily functions, loss of dignity and loss of inde-
pendence influence their quality of life and self-esteem
. Resnick and colleagues performed a qualitative
study in a nursing home. They found that the attitude of
nursing staff was a major contributor to UI. Lack of
knowledge about UI and negative attitude towards effec-
tiveness of UI treatment among nursing staff, together
with adhering to toileting schedules or ignoring requests
for toileting, were mentioned by directors of nursing
homes as reasons for inadequate UI care . Conti-
nence assessment by nursing staff has traditionally fo-
cussed on selecting the appropriate absorbent pads,
rather than on treatment of incontinence [14,15]. Several
countries have developed evidence-based guidelines for
the prevention and treatment of UI [16-18]. Despite an
increased focus on UI among residents in nursing ho mes,
researchers still report problems with the implementation
of appropriate incontinence care . The nursing staff
plays a primary role in incontinence care. Ho wever, little
research has been performed on nursing staff’s ex-
perience with incontinence care.
To identify perceptions and barriers that influence the
ability of the nursing staff to provide appropriate incon-
2. DESIGN AND METHOD
This article is based on a qualitative study that uses
purposive sampling and a focus group methodology. The
idea behind a nursing focus group is that the group pro-
cess will help the participants to express their expe-
riences in a way that would be more difficult in a one-to-
one interview situation . According to Kitzinger,
focus groups are particularly useful to study attitud es and
experiences, and to study how knowledge and ideas de-
velop and op erate within a cultural context .
2.1. Participants and Setting
The study was carried out at six different units in one
Norwegian nursing home. Eighteen nurses were invited
to participate, including six Charge nurses (CN), six
Registered nurses (RN) and six Certified Nursing Assis-
tants (CNA). All nurses and nursing assistants gave in-
formed consent prior to their participation to the study.
The median work experience was respectively 12 years
for CN, 9 years for RN and 23 years for CAN (Table 1).
RN and CNA were chosen according to the time
schedule; meaning that only nurses that were at work
during the days of the interviews were asked. Of those
who agreed to participate, a random sample was chosen.
Three participants that had agreed to participate did not
show up for the interviews; two were unable to come for
medical reasons and one had forgotten the appointment.
In all, 15 nurses participated; 14 females and one male.
The nurses were divided in three groups according to
their profession. Each group consisted of 5 participants.
According to Kitzinger, and Polit et al., the ideal group
size for focus interviews is four to eight participants
[21,22]. We choose to form groups according to pro-
fession based on the assumption that the participants
would feel more comfortable and free to express their
experience within their own professional group. None of
the nurses in the respective groups worked together in
the same unit. Participation was based on informed
consent. Permission to perform the study was granted by
the Local Ethics Committee at Mid-Sweden University.
2.2. Focus-Group Interviews
Data from focus group interviews was collected during
March and April 2010. Two moderators were present.
The first moderator led the interviews, encouraged open
conversation and tried to involve all participants. The
second moderator took notes, observed reactions of the
participants, and provided an oral summary halfway and
at the end of the focus group interv iews. The participants
were invited to add or correct the summaries. Once
confirmation was obtained, these summaries became part
of the data analysis. A focus group guide was developed
Table 1. Characteristics of the interviewed nurses.
Qualification GenderNumber Years of experience
M 1 6
Charge nurses F 4 12, 12, 14, 30
Registered nursesF 5 1, 9, 9, 13, 3 2
assistants F 5 6, 22, 23, 34, 37
Copyright © 2013 SciRes. OPEN ACCESS
L. H. Skotnes et al. / Open Journal of Nursing 3 (2013) 437-444 439
based on the overall research question. Nurses were
asked to reflect on their practice concerning continence
care and to discuss what knowledge they thought was
necessary to handle residents’ different bladder disorders.
They were also asked to explain which measures and
treatment residents with these problems received. One of
the main aims was to identify factors that might in-
fluence the ability of the nursing staff to perform appro-
priate incontinence care. In addition, the participants
were asked how they made sure that the residents re-
ceived appropriate incontinence care. Members of the
nursing staff participated in the focus groups d uring their
regular work hours and at the nursing home facility. The
interviews lasted between 70 and 90 minutes and were
tape-recorded and transcribed verbatim by the first au-
thor (LHS). The transcriptions were analyzed and inter-
preted using qualitative content analysis.
2.3. Content Analysis
Content analysis has been defined as “the process of
identifying and categorizing th e primary patterns in data”
. According to Patton , Baxter  and Krippen-
dorff  content analysis is appropriate for analyzing
text from interviews. Interpretive content analysis in this
study has been carried out in the following way: the
interviews were read thoroughly several times in orde r to
get an overall picture of the contexts. Topics identified
were used to organize the content in a meaningful way.
Meaning units created by one or more sentences related
to the different topics, were identified and condensed to
shorter formulations. Subcategories were formulated for
subsequent abstraction into categories (Table 2). Finally,
an interpretation of the whole was made . The first
author (LHS) analyzed the text. After that, the analysis
was evaluated by a second (OH) and a third author (EK)
in order to address the question of trustworthiness and
discuss possible interpretations until consensus was
In each of the three groups, nurses expressed that there
were barriers that influenced the ability to provide ap-
propriate incontinence care. These barriers were associ-
ated with three specific topics i.e., residents, nursing staff
and organizational culture. The focus interviews revealed
differences in involvement with incontinence care amon g
groups. The CN were rarely involved in the management
of UI. Some of the RN explained that a high workload
made them prioritize other tasks in the units. They
thought the high workload was an important barrier to
provide good UI care. The CNA were the ones who were
most often responsible for incontinence care in practice.
Despite the fact that they revealed a lack of knowledge
on how to improve UI, they showed great interest for the
residents’ problems. All of them had worked within
nursing homes for sev eral years and had obtained a lo t of
experience with incontinence care. They were able to
refer to many examples from clinical practice and were
often focused on pads; particular pads-shifts, but also
type of pads. Below, the perceptions and barriers and
their corresponding categories are described.
3.1. Perceptions and Barriers Associated with
Physical and cognitive problems. The RN described the
residents’ physical and cognitive problems as an impor-
tant barrier preventing appropriate incontinence care.
Most of the residents in nursing homes have several dis-
eases and use different types of medication that can
affect the bladder function. A number of residents were
not mobile and were dependent on lifts to get out of their
beds and wheelchairs to reach the toilet. These toilet
visits were often demanding, in the sense that it took a
lot of time and effort from the staff. The result was often
that residents couldn’t visit the toilet as often as they
wanted. Instead of toilet visits, residents wore absorbent
pads. Many of the residents were cognitively impaired.
This could create problems with finding the toilet and
expressing the need to come to the toilet. Some residents
could get angry, refusing both toilet visits and pad
changes. Nurses expressed sympathy with the problems
of the residents.
“It must be frustrating, not kno wing where the toilet is
and not being be able to ask for help. Some of the
residents react with anger when they cannot find the
toilet. We have experienced residents urinating in the
garbage can or in other appropriate places. But luckily
we know our residents well. It is often a pattern; they get
uneasy and show it by walking up and down the cor-
The CNA described anger and aggression as being a
big problem for some of the cognitively impaired resi-
dents. They had to develop creative methods to persuade
the residents to visit the toilet. Some needed a lot of time
before they would go. As a result, pads were often an
3.2. Perceptions and Barriers Associated with
Lack of knowledge. Most of the nurses had worked in a
nursing home for many years. However, few had up-
graded their basic knowledge on UI after graduation. All
groups agreed that their basic knowledge on UI was
insufficient. A RN put it like this:
“If we knew something about the causes, we would be
able to do something about it. Maybe nurses would then
Copyright © 2013 SciRes. OPEN ACCESS
L. H. Skotnes et al. / Open Journal of Nursing 3 (2013) 437-444
Copyright © 2013 SciRes.
Table 2. Analysis of content, some examples.
Meaning units Condensed meaning units Sub-categories Main-categories
If we knew something about causes a nd t reat ment
strategy; we can do something with the pro ble m.
Nursing staff wanted more accurate procedures
and guidelines to manage UI.
Important t o know causes and
treatment. Procedures and guideline s
Lack of knowledge
Nursing staff is busy with other tasks in unit or
having more than one resident to go to to ile t a t
same time. Nurses referred to situations where
they were busy with bathing, dres sing, feeding.
Busy with other tasks when resident
needs assistance to go to toilet.
More than one resident
Lack of accessibility
Nursing staff paid littl e a t t e n t i o n to improve or
prevent UI in residents. A common belief am on g
them was that UI is a completely normal
consequence of aging and that treatment had little
or no effect.
UI is a normal consequence of aging.
Little attention to improve and
prevent UI. Treatment had little or no
Treatment Attitudes and beliefs
understand why some residents need more time on the
toilet then others”.
The RN and CNA expressed a lack of knowledge with
regard to assessment and management of UI. They
wanted more accurate procedures and guidance in this
area. Evidence-based clinical practice guidelines to ma-
nage UI in older people were unknown among all groups.
Some of them, at the same time, expressed a lack of con-
fidence in the treatment and doubted whether or not it
would improve the continence status for the residents’
Attitudes and beliefs. The interviews revealed that
nurses paid little attention to improve or prevent UI in
residents. A common belief among them was that UI is a
completely normal consequence of aging and that treat-
ment had little or no effect. Most of the nurses expressed
that urinary incontinence after all is common.
“There are so many that have it, and so we think that’s
the way it is. We don’t reflect upon it. We react first and
foremost when problems occurs”.
With problems she meant urinary retention and urinary
Lack of accessibility. The CNA believed that lack of
personnel and need to prioritize other tasks meant that
the resident didn’t get the help they needed to reach the
toilet in time. They thought this was an important factor
in the residents’ incontinence problems. Nurses also
referred to situations where they were busy with bathing,
dressing, feeding or exchange of reports during shifts.
“We have to prioritize. We think it is more important
that they eat well than that they visit the toilet in time.
We always have too few resources. It is not so impo rtant
compared to other things, such as food, drinks and
3.3. Perceptions and Barriers Associated with
Rigid routines. At admission to the nursing home, the
resident’s continence status was documented in the me-
dical record by the physician. Further assessment was
rarely carried out. Nurses said they assumed that the re-
sidents who were incontinent when they moved to a
nursing home were previously assessed.
“No, incontinence is not discussed with a doctor when
they come in with this diagnosis. We discuss it when the
situation changes or there are problems, or when they
become incontinent after they have moved here. But
there are not many in this nursing home that were not
incontinent when they moved in”.
It was very rare that residents were sent to a specialist
for assessment of their incontinence problems. The few
times this did happen, it was mostly to exclude physical
causes in the residents that asked for frequent visits to
the toilet. In residents who were not able to get to the
toilet on their own or ask for help, it was common that
toilet visits were initiated by the nursing staff and the
routines in the nursing home. The nurses toileted resi-
dents when they woke up in the morning, before and
after meals and at bedtime. Usually residents visited the
toilet three to four times daily. Help with nightly visits
was rare. Prompted voiding or other behavioral programs
were unknown for all nurses. Interventions in residents
with UI were mainly focused on type of incontinence
products used. Every unit had their own nurse who had
the responsibility to ensure that the resid ents got the right
type of absorbent pad and the right size related to the
leakage volume. This nurse also made sure that pads
were available. This “pads co ntact” was one of the nurses
working regularly. The contact was allowed to attend
yearly seminars arranged by different vendors. Several of
the nurses admitted that incontinence care rarely was
“It is not always our own choice, but we do not have
enough nurses, so it is easier to follo w the rou tines in the
unit. However, we have experienced that if we take resi-
dents who are incontinent to the toilet more frequently,
they have actually remained dry longer”.
L. H. Skotnes et al. / Open Journal of Nursing 3 (2013) 437-444 441
Lack of resources. The lack of time and number of
nurses were mentioned as important cause for inadequate
“Sometimes the workload is so high that we cannot
provide the best care. It can happen that a resident needs
two nurses to be able to come to the toilet. When th ere is
only one nurse available at that moment, this can be a
problem. It can also happen that we are inside a room
and they cannot find us”.
The nurses realized that the help the resident got was
deficient and not individually adjusted. They thought
individually adjusted help could be provided if there
were more resources available. The CN, on the other
hand, meant that hiring of unskilled nursing staff for
shorter periods was the main problem. New faces meant
more people that didn’t know the routines, the rules
and/or the residents. The CNA were frustrated because of
re- strictions imposed by the management on how often
they should change pads and what type of pads they
should apply to residents. They thought these decisions
had an impact on the residents’ comfort and quality of
Lack of documentation. None of the units had proce-
dures for residents with different bladder disorders, nei-
ther for preventing, examination or treatment. Some of
the units had care plans, but most were outdated and not
very detailed. Documentation of residents’ incontinence
problems was rare and the care plans were seldom app-
lied in daily routine.
Lack of leadership. The CN had only a small role in
the management of UI. They said that they trusted nur-
sing staff to take care of residents’ incontinence pro-
blems in a sufficient way. On the other hand, both RN
and CNA expressed the need for seminars to refresh their
knowledge about UI. They also wanted more focus on
this area from the management. They expressed that they
wanted more time for reflection and debates about
incontinence problems in the un its. Th e CN had a week ly
meeting with the nursing staff in which different pro-
blems were discussed, but bladder disorders were seldom
a topic at these meetings.
This study identified perceptions and barriers that influ-
ence the ability of nursing staff to provide appropriate
incontinence care in nursing home. These barriers were
associated with three specific topics, i.e. residents, nurs-
ing staff and organization culture. In the topics, the fol-
lowing categories were highlighted: physical and cogni-
tive problems, lack of knowledge, attitudes and beliefs,
lack of accessibility, rigid routines, lack of resources,
lack of documentation and weak leadership.
Impaired mobility and cognitive impairmen t hav e been
consistently identified as risk factors for UI in the elderly
population [1,26,27]. Our study reported that toilet visits
often were demanding, in the sense that it took a lot of
time and required a lot of resources. Jirovec (1991)
found that training and competency in transfer tech-
niques may improve nursing staff’s capacity to imple-
ment a toileting regime . Although cognitive im-
pairment is a risk factor for developing UI, research has
shown that not all patients with d ementia are in continen t.
It usually emerges at the stage of moderate dementia .
Previous studies have shown that cognitive impairment
should not exclude nursing home residents from inconti-
nence assessment and treatment, especially behavioral
therapies . Prompted voiding has been shown to be
effective in cognitively impaired nursing home residents
. Timed voiding has been described to be appropriate
for residents who cannot independently toilet themselves
In accordance with the current study, several studies
have reported that incontinence care is inadequate and
that the nursing staff has a lack of knowledge about UI
[9,10,31]. Evidence-based clinical practice guidelines for
UI in older people were unknown among all groups in
our stud y. Thes e guidelin es address th e major ev aluative,
diagnostic, treatment, and management issues of UI
[16-18,32]. The nurses expressed that UI got little atten-
tion compared with other tasks, and they looked at the UI
is a normal part of ageing and nothing can be done to
prevent or treat it. A number of studies have shown that
nurses’ attitudes and values determine how they think,
interact and behave towards older people [33,34]. Nega-
tive attitudes can lead to ageism which is a process of
stereotyping and discriminating against someone because
they are ageing or aged [35 ]. According to Henderson et
al., treatment options with regard to UI depend on atti-
tudes and beliefs among the nursing staff . Wyman,
outlines that educational and attitudinal barriers, in addi-
tion to organizational, financial and professional barriers,
are important for implementation of evidence based in-
continence care .
According to Smith, the organizational culture has a
major impact on continence care . Organizational
culture is described as a pattern of shared values, know-
ledge and assessments that people within an organization
learn as a group, pass on to new members, and which in-
fluence their social interactions . Eide et al. de-
scribe the culture as “something that sits in the walls”, a
pattern of action. The culture can consist of ritual b ehav-
ior, common rules and beliefs about what works well,
and therefore, be regarded as true. Attitudes are taken fo r
granted and they will reig n. If habits, beliefs an d practice
patterns have been repeated over a long time, it will be
difficult to develop other ways to solve problems .
The incontinence care in the current study was char-
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L. H. Skotnes et al. / Open Journal of Nursing 3 (2013) 437-444
acterized by routines toileting and changing of pads.
Campbell and colleagues found that the sociocultural
environment of nursing homes fosters routine care,
which tends to impede nursing staff behavior change .
Neither prompted voiding, nor other behavioral interven-
tion programs were used in the units. Several studies
have suggested that person-centered incontinence care
might be able to significantly reduce the rate of UI
among nursing home residents [41,42]. Person-centred
care has been defined as treating people as individuals
and enabling them to make choices about their care .
A holistic assessment is essential to identify resident
needs, which may require specific interventions in order
to ensure that dignity and integrity is maintained and
person-centred care is achieved . Older people with
UI often feel a loss of dignity in care settings because
individual needs can easily be forgotten when it comes to
the practicalities of toileting and incontinence care .
As long as the resident in our study did not ask to
come to a specialist for assessment and treatment for
their UI, they were rarely sent there. Previous studies
have reported that less than 5% of older incontinent peo-
ple have been evaluated by specialist . Furthermore,
only 1% to 2% of women in nursing homes have an offi-
cial diagnosis of UI . According to Minichiello et al.
are health professionals a major source of ageist treat-
ment. Ageism in health care can relate to receiving a
lower standard of service or even to being denied access
to the service .
In this study, unskilled staffs together with high work-
load were identified as important barriers that hav e to be
overcome in order to be able to provide appropriate UI
care. A frequently cited barrier to implementation of toi-
leting programs in nursing homes are the current staff-
to-residents ratios in most facilities [37,46]. According to
Anger et al., more than 50% of females in nursing homes
need assistance to use the toilet . Schnelle et al.,
found that residents who needed assistance with toileting,
reported that they preferred an average of 2.4 toileting
assists per day and that they received an average of 1.7
Good documentation can ensure the continuity and
quality of care that nursing home residents receive. In
addition, documentation is a tool for the transfer of
knowledge between nurses. Difficulties in d efining types
of UI and a lack of validated continence assessment tools
for older people contribute to poor documentation and
treatment plans . The interviews revealed inadequate
documentation in all units. According to Mueller et al.,
Manghall et al. and Saxer et al., documentation regard-
ing incontinence care is often inadequate in nursing homes,
and poor documentation is linked to inadequate know-
ledge [47-49]. McElroy et al. found that poor document-
tation occurred in all areas of health care in nursing
homes. However, many nurses did not see the link be-
tween good care and documentation .
Our findings showed that the CN were rarely involved
in the management of UI and the RN attention was di-
rected to other tasks in the units. In accordance with
other studies, CNA showed the greatest involvement
with regards to incontinence problems . According to
Smith, RN have no peer group, are frequently over-
whelmed by regulations and residents needs, and have a
lack of reinforcement from superiors . In the absence
of RN, CNA have had to take the main responsibility of
incontinence care and have therefore been described as
the most powerful group within nursing homes .
Studies have shown that medical directors did not view
UI as a medical problem and lack of medical directors
input has been a barrier to improve incontinence care
. Wyman identified limited nurse leadership in the
field of incontinence as it is not seen as a priority with
the competing demands on nursing . Wright et al.,
found that leadership, culture and evaluation were weak
and not conductive to person centered continence care
and management in rehabilitation units for older people
. However, active involvement by all members of the
nursing staff, as well as support by managers and admin-
istrators, has been described as a crucial element to im-
prove incontinence care among nursing home residents
Limitations of the Study
This study used purposive sampling and was limited to a
small number of nurses from a single nursing home. This
fact must be taken into account when interpreting the
results. However, the purpose of qualitative research is
not to generalize the results, but to transform and apply
them to similar situations in other new contexts .
Nevertheless, our literature review from a number of
countries inside and outside Europe confirms that these
problems to provide appropriate incontinence care are
known in other countries.
The findings from this study show that there are many
barriers that might influence the possibilities of nursing
staff to provide appropriate incontinence care to residents
in nursing homes. Managers and administrators have a
strategic role and responsibility fo r the way incontinence
care in nursing homes is delivered, since key decisions
will be taken at this level, and have a direct impact on the
care provided. However, it can nevertheless seem like
opinions, beliefs and the attitudes of nursing staff, to-
gether with a lack of knowledge about UI, are the most
important barriers to provide appropriate incontinence
Copyright © 2013 SciRes. OPEN ACCESS
L. H. Skotnes et al. / Open Journal of Nursing 3 (2013) 437-444 443
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