Workplace Environment Assessment

JONA
Volume 41, Number 7/8, pp 324-330
Copyright B 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

T H E J O U R N A L O F N U R S I N G A D M I N I S T R A T I O N

Fostering Civility in
Education and Practice
Nurse Leader Perspectives

Cynthia M. Clark, PhD, RN, ANEF

Lynda Olender, MS, RN, ANP, NEA-BC

Cari Cardoni, BSN

Diane Kenski, BSN

Incivility in healthcare can lead to unsafe working
conditions, poor patient care, and increased medical
costs. The authors discuss a study that examined
factors that contribute to adverse working relation-
ships between nursing education and practice, effective
strategies to foster civility, essential skills to be taught
in nursing education, and how education and practice
can work together to foster civility in the profession.

The work of nursing is 4 times more dangerous than
most other occupations,1 and nurses experience work-
related crime at least 2 times more often than any
other healthcare provider.2 Root causes for workplace
violence are multifaceted and include work-related
stress due in part to an increasingly complex patient
population and workload and deteriorating interper-
sonal relationships at the bedside.1 When normalized
or left unaddressed, these uncivil and disruptive be-
haviors may emerge into an incivility spiral,3 depicted
along a continuum from an unintentional act leading
to intentional retaliation, escalating to workplace bul-
lying and even violence.4 Incivility and disruptive be-
haviors have been identified both in the academic5-7

and clinical settings8-10; however, no direct study of
incivility between the 2 environments has been made.

Review of the

Incivility and disruptive behavior in nursing educa-
tion and practice are common,4,9 on the rise,11 and
frequently ignored.12 Two decades ago, Boyer13

noted several challenges facing institutions of higher
education, including academic incivility. Although
incivility in the academic setting is not a new phe-
nomenon, the types and frequency of misbehavior
are increasing and have become a significant prob-
lem in higher education, including nursing educa-
tion. Clark and Springer14,15 explored faculty and
student perceptions of incivility in nursing education
and found negative behaviors to be commonplace
and exhibited by students and faculty alike. The ma-
jority of respondents (71%) perceived incivility as a
moderate to serious problem and reported that stress,
high-stake testing, faculty arrogance, and student en-
titlement contributed to incivility.14 More than half
of the respondents reported experiencing or know-
ing about threatening student encounters between
students or faculty.14

A small but growing body of research suggests
that incivility and disruptive behaviors are particu-
larly commonplace to the new graduate nurse or
nursing student within the clinical setting.10 Paral-
leling incivility in the academic setting, staff nurses
are also vulnerable to bullying, defined as negative
behavior that is systematic in nature and purpose-
fully targeted at the victim over a prolonged time
frame with the intent to do harm.16 These findings
are also supported by a recent Joint Commission
(TJC) survey17 reporting that more than 50% of
nurses are victims of disruptive behaviors including

324 JONA � Vol. 41, No. 7/8 � July/August 2011

Author Affiliations: Professor (Dr Clark) and Research
Assistants (Mss Cardoni and Kenski), School of , Boise
State University, Idaho; Doctoral Candidate (Ms Olender), Seton
Hall University, South Orange, New Jersey, and Executive Con-
sultant and Nurse Researcher (Ms Olender), James J. Peters VA
Medical Center, Bronx, New York.

The authors declare no conflict of interest.
Correspondence: Dr Clark, School of , Boise State Uni-

versity, 1910 University Dr, Boise, ID 83725 ([email protected]).
DOI: 10.1097/NNA.0b013e31822509c4

Copyright @ 201 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.1

incivility and bullying, and more than 90% of nurses
stated witnessing abusive behaviors of others in the
workplace. Likened to the concept of nurses ‘‘eating
their young’’,18 the findings of several studies suggest
that these negative behaviors are a learned process,
transferred through staff nurses to new nurses and
student nurses via interaction within the hierarchi-
cal nature of the profession.10

Incivility and disruptive behaviors may also be
normalized or perpetuated by organizational cul-
ture,12,18 particularly during times of restructuring
or downsizing. This is suggested to be secondary to
unclear roles and expectations, professional and per-
sonal value differences, personal vulnerabilities, and
power struggles common within organizations dur-
ing periods of change.18 Other consequences of inci-
vility include heightened stress levels, physiological
and psychological distress,5 job dissatisfaction,10,19

decreased performance,20 and turnover intention.21

Bartholomew18 noted that uncivil behaviors may
contribute to the exodus of new graduates leaving
their first job within 6 months. If disruptive behav-
iors are tolerated, nurses may leave the profession
altogether.21 Disruptive and bullying behaviors have
been identified as a root cause of more than 3,500
sentinel events over a 10-year time frame22 and con-
tribute to an annual estimate of 98,000 to 100,000

patients dying secondary to medical errors in hos-
pitals.23,24 Collectively, these findings led TJC17 to
intervene and release a sentinel event alert calling
for zero tolerance of intimidating and bullying
behaviors.

Conceptual Framework

Clark5 developed a conceptual model to illustrate
how heightened levels of nursing faculty and student
stress, combined with attitudes of student entitle-
ment and faculty superiority, work overload, and a
lack of knowledge and skills, contribute to incivility
in nursing education. This conceptual model has
been adapted to reflect the stressors that contribute
to incivility in both nursing education and practice
(Figure 1). Factors that contribute to stress in nurs-
ing practice are similar to the stressors experienced
in nursing education including work overload, un-
clear roles and expectations, organizational condi-
tions, and a lack of knowledge and skills. Moreover,
in both practice and academia, stress is mitigated by
leaders who role model professionalism and utilize
effective communication skills.25 The importance of
modeling effective communication and related edu-
cation to address incivility cannot be underestimated,
can reduce its incidence and effects,26 and can assist
in fostering cultures of civility.6

Figure 1. Conceptual model for fostering civility in nursing education (adapted for nursing practice).

JONA � Vol. 41, No. 7/8 � July/August 2011 325

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Nurse Leaders’ Survey

Mindful of the need to enhance the culture of civility
both in the academic and clinical settings, a descrip-
tive qualitative study was conducted. The purpose of
the study was to gather practice-based nursing lead-
ers’ perceptions about factors that contribute to an
adverse working relationship between nursing ed-
ucation and practice, the most effective strategies
needed to foster civility, the skills needed to be taught
in nursing education, and how nursing education and
practice can work together to foster civility in the
nursing workplace.

Procedure and Analysis

The survey was developed by the author (C.M.C.)
and included 4 open-ended questions designed to
garner nurse leaders’ perceptions on ways to foster
civility in nursing education and practice. The ques-
tions were constructed based on a comprehensive
review of the literature on incivility and numerous
empirical studies. Two other researchers reviewed
the survey for content validity and logical construc-
tion. Institutional approval to conduct the study was
obtained. The surveys were administered to nurse
leaders attending a statewide nursing conference
using a paper method for gathering narrative, hand-
written responses. Once the study was clearly ex-
plained, the respondents provided consent and
voluntarily completed the survey. Aside from indi-
cating their employment position, no demographic
information was gathered about the participants.
The survey contained 4 questions:

1. What factors contribute to an adverse
working relationship between nursing edu-
cation and practice?

2. What are the most effective strategies for
fostering civility in the practice setting?

3. What essential skills need to be taught in nurs-
ing education to prepare students to foster ci-
vility in the practice setting?

4. How can nursing education and practice
work together to foster civility in the prac-
tice setting?

The sample consisted of 174 nurse leaders: 68
(39.1%) nurse executives and 106 (60.9%) nurse
managers who were attending a statewide conference
held in a large western state. The respondents were
recruited by the researcher (C.M.C.), who explained
the purpose of the study during the keynote address.
The surveys were collected and prepared for analysis.

Textual content analysis was used to manually
analyze the respondents’ narrative responses. Key
words or phrases were quantified by the researchers;

inferences were made about their meanings and cat-
egorized into themes. Two members of the research
team reviewed the nurse leaders’ comments indepen-
dently to quantify the recurring responses and orga-
nize them into themes. Then, 2 other research members
reviewed the comments. Areas of theme agreement
and disagreement were discussed, and verbatim com-
ments were reviewed until all researchers were con-
fident that the analysis was a valid representation of
the comments.

Findings

Analyses of the narrative responses from the partici-
pants were organized into themes, ranked in order
of the number of responses, and described according
to each research question. The first research ques-
tion asked nurse leaders to identify factors that con-
tribute to an adverse working relationship between
nursing education and practice. Both groups identi-
fied a noticeable gap between nurses in education
and practice (Table 1). Nurse executives reported
nurse educators failing to keep pace with practice
changes, lacking familiarity with practice regulations
and standards, being slow to respond with curricular
changes, and a lack of shared goals between nurses in
education and practice. Nurse managers reported
similar findings, but suggested that a limited number
of nursing faculty, a highly stressed work environ-
ment, and lack of adequate resources also contributed
to adverse working relationships. These reported defi-
cits resulted in the perception that students were not
being adequately prepared for practice.

The second research question asked the respon-
dents to identify the most effective strategies for fos-
tering civility in the practice setting. Nurse executives
identified 4 major themes, and nurse managers iden-
tified 7 themes, listed in Table 2. Strategies that ren-
dered less than 10 responses are not listed in the table.
For nurse executives, these themes included holding
self and others accountable for acceptable behaviors,
addressing incivility in nursing education programs,
implementing stress reduction strategies, making ci-
vility a requirement for hiring, and conducting in-
stitutional assessments to measure incivility. Nurse
managers’ responses to this question were similar to
those of nurse executives. Notable differences between
the 2 groups were nurse executives’ recommendations
for civility teaching starting at the education level,
civility as a requirement for hiring, and ongoing ci-
vility assessment. Nurse managers’ responses differing
from executives were establishing a healthy work en-
vironment, ongoing practice-preparedness education,
and reinforcing positive behavior.

326 JONA � Vol. 41, No. 7/8 � July/August 2011

Copyright @ 201 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.1

The third research question asked the respon-
dents to identify essential skills that need to be taught
in nursing education programs to prepare students to
foster civility in the practice setting (Table 3).

Nurse executives identified 4 major themes, and
nurse managers identified 8 themes. Strategies that
rendered less than 10 responses are not listed in the
table. For nurse executives, these themes included re-
flective practice and critical thinking, respect for di-
versity, and stress reduction strategies. Nurse mangers
had similar responses for essential skills and also sug-
gested critical-thinking skill sets (time management,
decision-making, and problem-solving skills), organi-
zational culture of civility, and civility education.

The final research question asked nurse leaders
for strategies about how nursing education and prac-
tice can work together to foster civility in the prac-
tice setting (Table 4). Both groups identified 5 major

themes. Once again, strategies that rendered less than
10 responses are not listed in the table. For nurse
executives, these themes included making civility a
requirement for hiring, teaching conflict resolution
and managing difficult situations, implementing stress
reduction strategies, and conducting institutional as-
sessments to measure incivility. Teaching civility was
identified only by nurse executives, and themes iden-
tified only by nurse managers were mentorship, pro-
fessionalism, and reinforcing and rewarding civility.
Nurse managers also suggested focusing on patient
care and safety and implementing stress reduction
strategies (G10 responses).

At both the organizational level and unit levels,
nurse leaders in practice noted the importance of
having a shared vision of civility and underscored the
importance of adopting and implementing codes of
conduct and effective policies and procedures. Both

Table 2. Strategiesa for Fostering Civility in the Practice Setting

Nurse Executives (n = 64 of 68 [94.11%])b Nurse Managers (n = 95 of 106 [85.62%])b

1. Conducting joint meetings to develop a shared
vision and a culture of civility (49)

1. Conducting joint meetings to develop a shared vision and
a culture of civility (38)

2. Establish codes of conduct with and policies
with clearly expected behaviors (40)

2. Establish codes of conduct and policies with clearly
expected behaviors (32)

3. Provide ongoing education (conflict resolution,
problem solving, respectful communication) (23)

3. Establish a healthy practice environment, emphasizing
workplace civility (32)

4. Positive role modeling by all members of the
healthcare team (20)

4. Positive role modeling by all members of the
healthcare team (30)

5. Provide ongoing education (conflict resolution, problem solving,
respectful communication) with a focus on practice preparedness (20)

6. Hold self and others accountable for acceptable behaviors (19)
7. Reinforce positive behavior (11)

aStrategies identified by less than 10 respondents are not included; please see text.
bThe number in parentheses following the strategies indicates the number of times the strategy was identified. The number exceeds the number
of respondents because of suggestions of multiple strategies.

Table 1. Factors Contributing to an Adverse Working Relationship Between
Education and Practicea

Nurse Executives (n = 67 of 68 [98.53%])b Nurse Managers (n = 101 of 106 [95.28%])b

1. Educators not keeping current with practice
changes (standards and regulations) (39)

1. Limited number of faculty and disconnected
from practice (40)

2. Lack of communication, collaboration, and mutual
curriculum planning between nursing faculty
and staff (16)

2. Highly stressed work environments plagued by rude,
uncivil behaviors among members of the health
care team (32)

3. Lack of preceptor engagement due to stress
and workload (23)

3. Faculty and staff workload and being stretched
too thin (29)

4. Lack of shared vision, mission, and goals
between practice and education (11)

4. Lack of communication, collaboration, and mutual curriculum
planning between nursing faculty and staff (21)

5. Lack of adequate resources (human and financial) (18)

aFactors identified by less than 10 respondents are not included; please see text.
bThe number in parentheses following the factors indicates the number of times the factor was identified. The number exceeds the number of
respondents because of suggestions of multiple factors.

JONA � Vol. 41, No. 7/8 � July/August 2011 327

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nurse executives and managers expressed the need
for effective communication and collaboration, pos-
itive role modeling, and the importance of vigilant
and purposeful hiring with civility in mind.

Discussion

The applicability of Clark and Olender’s (Figure 1)
conceptual model for fostering civility in nursing
academic and clinical practice environments is
supported by the results of this study. Indeed, results
suggest an increased awareness of stressors likely
contributing to a culture of incivility by these nurs-
ing leaders. As depicted in the model, and as Table 2
denotes, the implementation of strategies to reduce
stressors (such as policy and procedure, education,
and self-care initiatives) is a key objective for the
establishment of a culture of civility. A high percent-
age of nursing leaders emphasized the importance of
a collaborative vision and partnership between educa-
tion and practice to meet this goal. This vision could
emerge via joint education and practice meetings

that focus on designing up-to-date and relevant cur-
ricula that reflect current practice standards with em-
phasis on civility education and teamwork. Ideally,
this would result in the development and implemen-
tation of comprehensive, well-defined, nonpunitive
policies and procedures that focus on civility, are
widely disseminated, and have measurable outcomes.
An emphasis on individual accountability at all or-
ganizational levels, as well as organizational adop-
tion of a culture of civility, would be required for
policies to be effective. In addition, leadership mind-
fulness and intentionality toward positive role mod-
eling, professionalism, collaboration, teamwork,
and ethical conduct would be required. Related com-
petencies would be reinforced and practiced through
simulation and role playing, in real time, and in-
clusion of these skills within competency assessment
systems.

Our findings lend support to studies indicating
that stress is a major contributor to incivility1,5,14,15,19;
thus, it is important to integrate self-care and stress
reduction into daily activities. The American Holistic

Table 4. How Education and Practice Can Work Together to Foster Civility
in the Practice Settinga

Nurse Executives (n = 58 of 68 [85.29%])b Nurse Managers (n = 84 of 106 [79.24%])b

1. Improve communication and partnerships between
education and practice (33)

1. Improve communication and partnerships between
education and practice (55)

2. Develop a shared vision for a culture of civility (14) 2. Integrate civility into the nursing curriculum (30)
3. Integrate civility into the nursing curriculum (13) 3. Develop codes of conduct with expected behaviors (23)
4. Foster leadership and positive role modeling (11) 4. Foster leadership, professionalism, positive role

modeling, and mentoring (16)
5. Teach civility and behavioral expectations (11) 5. Reinforce and reward civility (11)

aStrategies identified by less than 10 respondents are not included; please see text.
bThe number in parentheses following the strategies indicates the number of times the strategy was identified. The number exceeds the number
of respondents because of suggestions of multiple strategies.

Table 3. Essential Skillsa Needed to Prepare Students to Foster Civility in the Practice Setting

Nurse Executives (n = 61 of 68 [89.70%])b Nurse Managers (n = 99 of 106 [93.39%])b

1. Conflict resolution, negotiation, assertiveness,
learning to address incivility (43)

1. Effective communication, teamwork,
and collaboration (57)

2. Effective communication, teamwork, and collaboration (31) 2. Conflict resolution, negotiation, assertiveness (38)
3. Professionalism and leadership skills (24) 3. Professionalism and leadership skills (35)
4. Personal accountability and patient safety (22) 4. Time management, organizational skills, and

decision-making and problem-solving skills (17)
5. Creating a healthy work environment and

organizational culture (17)
6. Civility education (13)
7. Patient-focused care and patient safety (11)

aSkills identified by less than 10 respondents are not included; please see text.
bThe number in parentheses following the skills indicates the number of times the skill was identified. The number exceeds the number of
respondents because of suggestions of multiple skills.

328 JONA � Vol. 41, No. 7/8 � July/August 2011

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Nurses Association27 recommends several stress
management techniques including enjoying the com-
pany of family, friends, and other supportive people;
getting regular exercise and adequate sleep; eating
healthy foods; and drinking plenty of water. We also
suggest lunchtime walking programs, change of shift
aerobic classes, meditation, and 5-minute massages.
This may also include implementing caring compe-
tencies such as empathy, collaboration, and conflict
resolution in the work site. Last, Olender-Russo28

suggests creating forums to share success stories and
to communicate evidence-based outcomes such as
staff and patient satisfaction, low turnover rates, and
patient-related adverse events or avoidances both at
the organizational and unit levels to sustain work-
place civility and staff motivation.

Conclusion

Recent reports of the increasing prevalence of in-
civility and related disruptive behaviors within our
nursing academic and clinical settings are alarming,
especially when considering the impact on patient
and staff safety. The old adage, ‘‘it takes a village,’’
rings true when one considers the complexity of the
task of fostering a culture of civility. A comparison
study with academic nurse leaders could illuminate
shared perceptions or alternative ways to foster ci-
vility in nursing education and practice.

The model proposed in this study is newly adapted
to practice and requires further empirical testing. For
example, evidence-based data obtained through in-
stitutional assessments, such as the Organizational
Civility Scale,29 are needed to measure the organiza-
tional culture so that targeted interventions may be
implemented and empirically tested. Case study meth-
ods may be beneficial to showcase best practices.

Researchers also suggest that negative behaviors
in the workplace may be a learned process and likely
exacerbated within stressful academic and clinical set-
tings.12 Conversely, fostering civility in nursing edu-
cation and practice may also be a learned process and,
as such, amenable to positive interventions. Nurse
leaders need to be extremely attentive and supportive
toward the success of the nursing practice and nurs-
ing education partnership for the cocreation and sus-
tainment of a healthy work environment. Indeed, the
promotion of a positive organizational culture has
been shown to be a successful strategy and is asso-
ciated with increased nurse manager engagement in
authentic leadership.25 As healthcare providers, we
all have an ethical responsibility to care for those
who care for others. Specifically, nurse leaders must
create and promote a work environment conducive
to caring. This includes fostering a culture of civility
both within the academy (where nursing learning
begins) and within practice environments (where
learning of nursing continues).

References

1. Gallant-Roman M. Strategies and tools to reduce workplace

violence. AAOHN J. 2008;56(11):449-455.
2. Dunhart DT. National Crime Victimization Survey: Violence

in the Workplace, 1993-1999. Washington, DC: US Depart-
ment of Justice; 2001:1-12. Available at http://bjs.ojp.usdoj.

gov/index.cfm?ty=pbdetail&iid=693. Accessed June 19, 2011.
3. Anderson LM, Pearson CM. Tit for tat? The spiraling effect

of incivility in the workplace. Acad Manage Rev. 1999;24(3):
452-471.

4. Hutton S, Gates D. Workplace incivility and productivity losses
among direct care staff. AAOHN J. 2008;56(4):168-175.

5. Clark CM. The dance of incivility in nursing education as de-

scribed by nursing faculty and students. Adv Nurs Sci. 2008;
31(4):E37-E54.

6. Clark CM. Faculty and student assessment and experience

with incivility in nursing education: a national perspective.

J Nurs Educ. 2008;47(10):458-465.
7. Luparell S. The effects of student incivility on nursing faculty.

J Nurs Educ. 2007;46(1):15-19.
8. Olender-Russo L. Reversing a bullying culture. RN. 2009;

72(8):26-29.
9. Randle J. Reducing bullying in healthcare organisations.

Nurs Stand. 2007;21(22):49-56.

10. Simons S. Workplace bullying experienced by Massachusetts

registered nurses and the relationship to intention to leave the
organization. Adv Nurs Sci. 2008;31(2):48-59.

11. Lipley N. Bullying at work on increase, Royal College of

survey finds. Nurs Manage. 2006;12(10):5.
12. Lewis MA. Nurse bullying: organizational considerations in the

maintenance and perpetration of health care bullying cultures.

Nurs Manage. 2006;14(1):52-58.
13. Boyer EL. Campus Life: In Search of Community. San Francisco,

CA: The Carnegie Foundation for the Advancement of Teaching;
1990.

14. Clark CM, Springer PJ. Incivility in nursing education: descriptive

study on definitions and prevalence. J Nurs Educ. 2007;46(1):7-14.
15. Clark CM, Springer PJ. Thoughts on incivility: student and

faculty perceptions of uncivil behavior in nursing education.

Nurs Educ Perspect. 2007;28(2):93-97.
16. Hutchinson M, Vickers M, Jackson D, Wilkes L. Workplace

bullying in nursing: towards a more critical organisational

perspective. Nurs Inq. 2006;13(2):118-126.
17. The Joint Commission. Behaviors that undermine a culture of

safety. Sentinel Event Alert. July 9, 2008; issue 40. Available
at http://www.jointcommission.org/assets/1/18/SEA_40.pdf.

Accessed June 19, 2011.

JONA � Vol. 41, No. 7/8 � July/August 2011 329

Copyright @ 201 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.1

18. Bartholomew K. Ending Nurse to Nurse Hostility: Why
Nurses Eat Their Young and Each Other. Marblehead, MA:
HCPro; 2006.

19. Vessey JA, DeMarco RF, Gaffney DA, Budin W. Bullying of

staff registered nurses in the workplace: a preliminary study
for developing personal and organizational strategies for the

transformation of hostile to healthy workplace environments.

J Prof Nurs. 2009;25(5):299-306.
20. Cortina LM, Magley VJ, Williams JH, Langout RD. Incivility

in the workplace: incidence and impact. J Occup Health
Psychol. 2001;6(1):64-80.

21. Duffield C, O’Brien-Pallas L, Aitken L. Nurses who work
outside of nursing. Nurs Health Care Manage Policy. 2004;
47:664-667.

22. Healthgrades, Inc. Healthgrades Seventh Annual Patient

Safety in American Hospitals Study. March 2010. Avail-
able at http://www.healthgrades.com/media/DMS/pdf/

PatientSafetyinAmericanHospitalsStudy2010.pdf. Accessed

June 19, 2011.

23. Institute of Medicine. To Err Is Human: Building a Safer

Health System. Washington, DC: National Academy Press;
2000.

24. Institute for Safe Medication Practices. Results from ISMP

survey on workplace intimidation. Available at http://ismp.org/
Survey/surveyresults/Survey0311.asp. Accessed June 19, 2011.

25. Shirey MR. Authentic leadership, organizational culture, and

healthy work environments. Crit Care Nurs Q. 2009;32(3):
189-198.

26. Griffin M. Teaching cognitive rehearsal as a shield for lateral
violence: an intervention for newly licensed nurses. J Contin
Educ Nurs. 2004;35(6):257-263.

27. American Holistic Nurses Association. Holistic stress manage-
ment for nurses. Available at http://www.ahna.org/Resources/

StressManagement/tabid/1229/Default.aspx. Accessed

June 19, 2011.

28. Olender-Russo L. creating a culture of regard: an antidote
to workplace bullying. Creat Nurs. 2009;15(2):75-81.

29. Clark CM, Landrum RE. Organizational Civility Scale. Avail-

able at http://nursing.boisestate.edu/civility/research-instr.htm.

Accessed June 19, 2011.

330 JONA � Vol. 41, No. 7/8 � July/August 2011

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