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Nilsson, A., Edvardsson, D. & Rushton, C. (2019). Nurses’ descriptions of person‐centred care for older people in an acute medical ward—On the individual, team and organisational levels’. Journal of Clinical Nursing, 28(7–8), 1251-1259
Open this publication in new window or tab >>Nurses’ descriptions of person‐centred care for older people in an acute medical ward—On the individual, team and organisational levels’
2019 (English)In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 28, no 7–8, p. 1251-1259Article in journal (Refereed) Published
Abstract [en]

AIM AND OBJECTIVES: To describe nurses' experiences of providing person-centred care for older people on an acute medical ward.

BACKGROUND: There is evidence that person-centred care for older people contributes to a higher quality care and increased satisfaction with care. However, there is a shortness of studies providing concrete examples of what facilitates nurses providing person-centred care for older people in acute care.

DESIGN: An interview study with qualitative content analysis. COREQ guidelines have been applied.

METHOD: Fourteen registered nurses and enrolled nurses from an acute care ward participated in semi structured research interviews. The interviews were conducted during 2016 and interpreted using qualitative content analyses.

RESULTS: Person-centred care was described at different levels in care; at the individual nurse level, person-centred care was described as involving person-centred assessing, relating and spacing which involved personalising assessments, relationships as well as the physical environment. At the team level, person-centred care was described in terms of person-centred goal setting, team responsibilities and team support, and involved having shared and personalised goals, different team responsibilities and a climate of support and collaboration. At the organisational level, person-centred care was described in terms of having person-centred routines, workloads and staff roles that all contributed to put the person at the core of the organisation and build routines to support this.

CONCLUSIONS: The current study emphasises that, rather than confining person-centred care to specific moments or relationships, a systematic, multilevel organisational approach seems needed to enable nurses as individuals and teams to provide person-centred care consistently and continuously to older people in acute care settings.

RELEVANCE TO CLINICAL PRACTICE: The results of this study should inspire nurses and managers to expedite implementation of person-centred care for older care recipients hospitalised in acute care wards. Examples of person-centred care are presented herein at clearly identified sites, namely, the "individual," "team" and "organisational levels."

Place, publisher, year, edition, pages
John Wiley & Sons, 2019
Keywords
aged, care, emergency nursing, organisation, patient-centred care, person, team, ward
National Category
Nursing
Identifiers
urn:nbn:se:umu:diva-155365 (URN)10.1111/jocn.14738 (DOI)000460767400021 ()30552784 (PubMedID)2-s2.0-85059650873 (Scopus ID)
Available from: 2019-01-14 Created: 2019-01-14 Last updated: 2019-04-04Bibliographically approved
Nilsson, A., Rasmussen, B. H. & Edvardsson, D. (2016). A threat to our integrity: meanings of providing nursing care for older patients with cognitive impairment in acute care settings. Scandinavian Journal of Caring Sciences, 30(1), 48-56
Open this publication in new window or tab >>A threat to our integrity: meanings of providing nursing care for older patients with cognitive impairment in acute care settings
2016 (English)In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 30, no 1, p. 48-56Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Older people with cognitive impairment represent a large group of patients in acute care settings. Research show that these acute care environments can be unsafe and even unfriendly for frail older patients. Research and clinical experience show that being a nurse in acute/specialised medical facilities means to work in a high-speed, technologically complex and demanding environment. When caring for older patients with cognitive impairment, nurses' workload and responsibilities have been shown to increase. This is largely dependent on how easily it is to connect with and help patients understand what to do, and what is best for them.

AIM: This study aimed to illuminate meanings of caring for older patients with cognitive impairment in acute care settings as experienced by nursing staff.

METHOD: A purposeful sample of thirteen nurses experienced in caring for older people with cognitive impairment in acute care settings participated in the study. Narrative interviews were conducted during autumn 2012 and interpreted using a phenomenological hermeneutic method.

FINDINGS: Caring for older, acutely ill cognitively impaired patients was found to be very complex. The meanings of caring for these older patients seemed to change depending on the nurses' perceptions of the patients and the gap between what they could do (real) and wanted to do (ideal) in providing care for them. The greater this gap was felt to be and the more care was perceived as meaningless, the more serious was the threat to nurses' personal-professional integrity which could be at risk, compromised or harmed.

CONCLUSION: The comprehensive understanding indicates that being a nurse and having to care for older patients in acute care settings means providing nursing care in an environment that does not support possibilities to protect and develop nurses' personal-professional integrity.

Place, publisher, year, edition, pages
John Wiley & Sons, 2016
Keywords
acute care, cognitive impairment, integrity, meaning, nursing, older people, personal–professional, phenomenological hermeneutical
National Category
Nursing
Identifiers
urn:nbn:se:umu:diva-103676 (URN)10.1111/scs.12220 (DOI)000371477400005 ()25919338 (PubMedID)
Note

Article first published online 2015

Available from: 2015-05-27 Created: 2015-05-27 Last updated: 2018-06-07Bibliographically approved
Rushton, C., Nilsson, A. & Edvardsson, D. (2016). Reconciling concepts of time and person-centred care of the older person with cognitive impairment in the acute care setting. Nursing Philosophy, 17(4), 282-289
Open this publication in new window or tab >>Reconciling concepts of time and person-centred care of the older person with cognitive impairment in the acute care setting
2016 (English)In: Nursing Philosophy, ISSN 1466-7681, E-ISSN 1466-769X, Vol. 17, no 4, p. 282-289Article in journal (Refereed) Published
Abstract [en]

The aim of this analysis was to examine the concept of time to rejuvenate and extend existing narratives of time within the nursing literature. In particular, we hope to promote a new trajectory in nursing research and practice which focuses on time and person-centred care, specifically of older people with cognitive impairment hospitalized in the acute care setting. We consider the explanatory power of concepts such as clock time, process time, fast care, slow care and time debt for elucidating the relationship between 'good care' and 'time use'. We conclude by offering two additional concepts of time, plurotemporality and person-centred time (PCT) which we propose will help advance of nursing knowledge and practice. Nurse clinicians and researchers can use these alternative concepts of time to explore and describe different temporal structures that honour the patient's values and preferences using experiential, observation-based nursing research approaches.

Place, publisher, year, edition, pages
Wiley-Blackwell, 2016
Keywords
Time, cognitive impairment, acute care, person-centred care, person-centred time
National Category
Nursing
Identifiers
urn:nbn:se:umu:diva-126861 (URN)10.1111/nup.12132 (DOI)000388316600005 ()27659589 (PubMedID)
Available from: 2016-10-18 Created: 2016-10-18 Last updated: 2018-06-09Bibliographically approved
Nilsson, A. (2014). Acute hospital admission can be disruptive for people with cognitive impairment, and professionals need the skills and resilience to meet their needs. Evidence-Based Nursing, 18(3), 92
Open this publication in new window or tab >>Acute hospital admission can be disruptive for people with cognitive impairment, and professionals need the skills and resilience to meet their needs
2014 (English)In: Evidence-Based Nursing, ISSN 1367-6539, E-ISSN 1468-9618, Vol. 18, no 3, p. 92-Article in journal (Other academic) Published
Place, publisher, year, edition, pages
BMJ Publishing Group Ltd, 2014
Keywords
cognitive impairment, older peopel, acute care
National Category
Nursing
Research subject
Caring Sciences
Identifiers
urn:nbn:se:umu:diva-96721 (URN)10.1136/eb-2014-101955 (DOI)
Note

Commentary on: Clissett P, Porock D, Harwood HR, et al. The responses of healthcare professionals to the admission of people with cognitive impairment to acute hospital settings: an observational and interview study. J Clin Nurs 2014;23:1820–9.

Available from: 2014-11-27 Created: 2014-11-27 Last updated: 2018-06-07Bibliographically approved
Nilsson, A. (2014). Att vårda äldre personer med kognitiv svikt i sjukhusmiljöer. Svensk Geriatrik (3), 36-40
Open this publication in new window or tab >>Att vårda äldre personer med kognitiv svikt i sjukhusmiljöer
2014 (Swedish)In: Svensk Geriatrik, ISSN 2001-2047, no 3, p. 36-40Article in journal (Other academic) Published
Place, publisher, year, edition, pages
Bjuv: Svensk geriatrisk förening, 2014
Keywords
äldre, kognitiv svikt, personcentrerad vård, akutsjukvård
National Category
Nursing
Research subject
Caring Sciences
Identifiers
urn:nbn:se:umu:diva-96706 (URN)
Available from: 2014-11-27 Created: 2014-11-27 Last updated: 2018-06-07Bibliographically approved
Nilsson, A. (2013). Att vårda äldre personer med kognitiv svikt i sjukhusmiljöer: attityder, processer, innebörder. (Doctoral dissertation). Umeå: Umeå universitet
Open this publication in new window or tab >>Att vårda äldre personer med kognitiv svikt i sjukhusmiljöer: attityder, processer, innebörder
2013 (Swedish)Doctoral thesis, comprehensive summary (Other academic)
Abstract [sv]

Inledning: Äldre personer med kognitiv svikt, exempelvis i form av demenssjukdom, delirium eller depression, är en vanligt förekommande population inom svensk sjukhusvård. Dessa äldre kan ha särskilda behov till följd av en försämrad kognition, men litteraturen tyder på att akutsjukhusens miljö, organisation och vårdprocesser inte alltid stödjer tillgodoseendet av dessa behov.

Syfte: Det övergripande syftet med avhandlingen var att belysa vården av äldre personer med kognitiv svikt i sjukhusmiljöer.

Metoder: Avhandlingen består av fyra delstudie. I studie I tillämpades en tvärsnittsdesign för att utforska personalens attityder till äldre patienter med kognitiv svikt, personalens tillfredsställelse med vården och arbetet samt upplevelsen av personcentrerat vårdklimat (n=391). I studie II användes en Grounded theory design för att undersöka hinder för personcentrerad vård för äldre personer med kognitiv svikt på en akutmedicinsk vårdavdelning. I studie III tillämpades en tvärsnittsdesign för att utforska de psykometriska egenskaperna i den svenska versionen av ”The Person-centred care of Older People with cognitive impairment in Acute Care scale” (POPAC) i ett urval av sjukhuspersonal (n=293). I studie IV användes en fenomenologisk hermeneutisk design för att belysa innebörder av att vårda äldre patienter med kognitiv svikt på akuta sjukvårdavdelningar utifrån vårdpersonals (n=13) berättelser.

Resultat: Studie I visade att deltagande personal skattade en neutral attityd till äldre patienter med kognitiv svikt i spektret mellan negativa och positiva attityder, samt att faktorer som att vara yngre, undersköterska och att uppleva vården av de äldre som betungande, hade samband med mer negativa attityder. Resultaten visade också att vårdpersonal upplevde att äldre patienters kognition sällan utvärderades under vårdtiden, samt att man sällan baserade vården på evidensbaserade riktlinjer för vård av äldre med kognitiv svikt. Studie II belyste att ett organisatoriskt fokus på medicinska behov, åtgärder och rutiner bidrog till att personal hamnade steget efter i relation till att synliggöra och möta dessa äldre personers multidimensionella behov, och att detta kunde medföra tecken på vårdlidande för de äldre, utanförskap för närstående och frustration för personal. Studie III stödde en fortsatt användning av POPAC-skalan för skattningar av upplevd förekomst av personcentrerade vårdprocesser för äldre patienter med kognitiv svikt, men att ytterligare studier rekommenderades framförallt av skalans olika dimensioner. Studie IV belyste att ju större avstånd som upplevs mellan vad vårdpersonalen kan göra (verklig vård) och vad de vill göra (ideal vård) för äldre patienter med kognitiv svikt i akuta vårdmiljöer, desto meningslösare upplevs vården, och desto större blir hotet mot personalens personlig-professionella integritet. Den tolkade helheten visar på att vårda äldre patienter med kognitiv svikt inom akutsjukvård betyder att försöka ge omvårdnad i miljöer som inte stödjer vårdpersonalens personlig-professionella integritet

Slutsatser: En rimlig konklusion av dessa resultat är att det i sjukhusmiljöer där äldre patienter ofta vårdas kan finnas anledning att diskutera och ytterligare studera hur attityder, synsätt på och målsättningar för vården och dess innehåll, åtgärder och interventioner kan främja eller motverka en god omvårdnad för de äldre med kognitiv svikt. Det kan också finnas anledning att se över hur personalen kan stödjas i att ge person-centrerad vård till de äldre, exempelvis genom riktlinjer för vård av äldre personer med kognitiv svikt, standardiserade skattningar av kognition, samt implementering av vårdprocesser som stödjer en personcentrerad vård för dessa patienter. Det kan också finnas behov av att ytterligare kritiskt granska hur organisatoriska och miljömässiga faktorer på avdelningar stödjer eller motverkar en personcentrerad vård för äldre patienter med kognitiv svikt. Därtill kan det finnas behov av att skapa ytterligare förutsättningar för vårdpersonalen att bevara och utveckla sin personlig-professionella integritet genom att utveckla miljöer som ger möjligheter för dem att ge en god omvårdnad till dessa äldre.

Abstract [en]

Introduction: Older people with cognitive impairment such as dementia, delirium or depression, are commonly cared for in acute hospital wards. These older people may have specific needs associated with a cognitive impairment. However, literature indicates that the milieu, organisation and care processes in acute care not always support in meeting these needs.

Aim: The overall aim of the thesis was to illuminate care of older people with cognitive impairment in hospital environments.

Methods: The thesis consists of four studies. Study I used a cross-sectional design to explore staff attitudes toward older people with cognitive impairment, staff satisfaction with care and work and perceived person-centeredness of the ward (n=391). Study II used a Grounded theory design to explore barriers to person-centred care for older people with cognitive impairment at an acute medical ward. Study III used a cross-sectional design to explore the psychometric properties of the Swedish version person-centred care for older people with cognitive impairment scale (POPAC) in a sample of acute hospital staff (n=293). Study IV used a phenomenological hermeneutic design to explore the meanings of caring for older people with cognitive impairment in acute hospital wards as narrated by nursing staff (n=13).

Results: Study I showed that participating staff estimated a neutral attitude to older people with cognitive impairment in the spectrum between negative and positive attitudes, and that factors such as being younger, a nurse assistant and experiencing the care of older people with cognitive impairment as burdensome, were associated with more negative attitudes. The results also showed that healthcare professionals felt that older patients' cognitive ability was rarely evaluated during hospitalisation, and that care were rarely based on evidence-based guidelines for care of older people with cognitive impairment. Study II illuminated that an organizational focus on medical needs, interventions and routines contributed to staff falling behind in relation to meeting these older patients' multidimensional needs, and that this could lead to signs of suffering for older patients, feelings of being excluded for relatives, and a frustration for staff. Study III supported a continued use of the POPAC scale for ratings of perceived prevalence of person-centred care processes for older people with cognitive impairment, but further studies was recommended to explore scale dimensionality. Study IV illuminated that the greater a gap that is experienced between what nurses can do (real) and what they want to do (ideal) in caring for older patients with cognitive impairment in acute care settings, the more meaningless care is experienced and the greater a threat is experienced to the nurses personal-professional integrity. The comprehensive understanding indicated that caring for older people with cognitive impairment in acute care settings means to provide nursing care in an environment that does not support the nurses’ possibilities to protect and develop their personal-professional integrity.

Conclusions: A reasonable conclusion from these studies is that there may be reasons to further discuss and study how attitudes, perspectives, and goals for care, together with the content, procedures and interventions that can support or obstruct good nursing care for older people with cognitive impairment in hospital settings. There may also be reasons to explore how staff can be supported to provide person-centred care to these older patients, for example through guidelines for care of older people with cognitive impairment, standardised assessments of cognitive ability, and implementation of care processes that supports person-centred care. In addition, to further critically examine how organisational and environmental factors in hospital wards can support or obstruct person-centred care for older patients seems needed. There may also be a need to further develop conditions that can support nursing staff to maintain and develop their personal-professional integrity, by developing environments that provides further possibilities to provide good care for these older patients.

Place, publisher, year, edition, pages
Umeå: Umeå universitet, 2013. p. 75
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1618
Keywords
acute care, attitudes, care management, cognitive impairment, grounded theory, health professionals, measurements, nursing, older people, perception, personal-professional integrity, person-centred care, phenomenological hermeneutical, akutsjukvård, attityder, fenomenologisk hermeneutik, grounded theory, kognitiv svikt, organisation, omvårdnad, personcentrerad vård, personlig-professionell integritet, skattningar, vårdpersonal, äldre personer
National Category
Nursing
Research subject
Caring Sciences
Identifiers
urn:nbn:se:umu:diva-83174 (URN)978-91-7459-748-6 (ISBN)
Public defence
2013-12-13, Aulan, Vårdvetarhuset, Umeå universitet, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Funder
Swedish Research Council
Note

Centrum för personcentrerad vård vid Göteborgs universitet 

Available from: 2013-11-22 Created: 2013-11-20 Last updated: 2018-06-08Bibliographically approved
Nilsson, A., Rasmussen, B. & Edvardsson, D. (2013). Falling behind: a substantive theory of care for older people with cognitive impairment in acute settings. Journal of Clinical Nursing, 22(11-12), 1682-1691
Open this publication in new window or tab >>Falling behind: a substantive theory of care for older people with cognitive impairment in acute settings
2013 (English)In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 22, no 11-12, p. 1682-1691Article in journal (Refereed) Published
Abstract [en]

AIMS AND OBJECTIVES: To develop a theoretical understanding of the processes hindering person-centred care of older people with cognitive impairment in acute care settings.

BACKGROUND: Although person-centred care with its holistic focus on the biopsychosocial needs of patients is commonly considered the gold standard care for older people with cognitive impairment, the extent to which care is person-centred can increase in acute care settings generally.

DESIGN: Grounded theory inspired by Strauss and Corbin.

METHOD: The study used a grounded theory approach to generate and analyse data from a Swedish sample of acute care staff, patients and family members.

RESULTS: The substantive theory postulates that staff risks 'falling behind' in meeting the needs of older patients with cognitive impairment if working without consensus about the care of these patients, if the organisation is disease-oriented and efficiency-driven, and if the environment is busy and inflexible. This facilitated 'falling behind' in relation to meeting the multifaceted needs of older patients with cognitive impairment and contributed to patient suffering, family exclusion and staff frustration.

CONCLUSIONS: The theory highlights aspects of importance in the provision of person-centred care of older people with cognitive impairment in acute settings and suggests areas to consider in the development of caring environments in which the place, pace and space can meet the needs of the older person.

RELEVANCE TO CLINICAL PRACTICE: The proposed substantive theory can be used to critically examine current ward practices and routines, and the extent to which these support or inhibit high-quality person-centred care for older patients with known or unknown cognitive impairments.

Place, publisher, year, edition, pages
Hoboken: Wiley-Blackwell, 2013
Keywords
Acute care, cognition disorders, culture, frail older, grounded theory, patient-centred, person-centred care
National Category
Nursing
Identifiers
urn:nbn:se:umu:diva-70118 (URN)10.1111/jocn.12177 (DOI)000317614300022 ()23452009 (PubMedID)
Available from: 2013-05-06 Created: 2013-05-06 Last updated: 2018-06-08Bibliographically approved
Nilsson, A., Lindkvist, M., Rasmussen, B. & Edvardsson, D. (2013). Measuring levels of person-centeredness in acute care of older people with cognitive impairment: evaluation of the POPAC scale. BMC Health Services Research, 13, 327
Open this publication in new window or tab >>Measuring levels of person-centeredness in acute care of older people with cognitive impairment: evaluation of the POPAC scale
2013 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 13, p. 327-Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Person-centeredness is increasingly advocated in the literature as a gold-standard, best practice concept in health services for older people. This concept describes care that incorporates individual and multidimensional needs, personal biography, subjectivity and interpersonal relationships. However, acute in-patient hospital services have a long-standing biomedical tradition that may contrast with person-centred care. Since few tools exist that enable measurements of the extent to which acute in-patient hospital services are perceived as being person-centred, this study aimed to translate the English version of the Person-centred care of older people with cognitive impairment in acute care scale (POPAC) to Swedish, and evaluate its psychometric properties in a sample of acute hospital staff.

METHODS: The 15-item POPAC was translated, back-translated and culturally adjusted, and distributed to a cross-sectional sample of Swedish acute care staff (n = 293). Item performance was evaluated through assessment of item means, internal consistency by Cronbach's alpha on total and on subscale levels; temporal stability was assessed through Pearson's product correlation and intra-class correlation between test and retest scores. Confirmatory factor analysis was used to explore model fit.

RESULTS: The results indicate that the Swedish version POPAC provides a tentatively construct-valid and reliable contribution to measuring the extent to which acute in-patient hospital services have processes and procedures that can facilitate person-centred care of older patients with cognitive impairment. However, some questions remain regarding the dimensionality of POPAC.

CONCLUSIONS: POPAC provides a valuable contribution to the quest of improving acute care for older patients with cognitive impairment by enabling measures and subsequent accumulation of internationally comparable data for research and practice development purposes. POPAC can be used to highlight strengths and areas for improvements in care practice for older patients, and to illuminate aspects that risk being overlooked in busy acute hospital settings.

Keywords
Person-centred care, nursing, older people, cognitive impairment, scale, measurement, intervention
National Category
Nursing
Identifiers
urn:nbn:se:umu:diva-81054 (URN)10.1186/1472-6963-13-327 (DOI)000323384800001 ()23958295 (PubMedID)
Available from: 2013-10-01 Created: 2013-10-01 Last updated: 2018-06-08Bibliographically approved
Edvardsson, D., Nilsson, A., Fetherstonhaugh, D., Nay, R. & Crowe, S. (2013). The person-centred care of older people with cognitive impairmentin acute care scale (POPAC). Journal of Nursing Management, 21(1), 79-86
Open this publication in new window or tab >>The person-centred care of older people with cognitive impairmentin acute care scale (POPAC)
Show others...
2013 (English)In: Journal of Nursing Management, ISSN 0966-0429, E-ISSN 1365-2834, Vol. 21, no 1, p. 79-86Article in journal (Refereed) Published
Abstract [en]

Aim: To construct and evaluate psychometric properties of the person-centred care of older people with cognitive impairment in acute care settings (POPAC) scale.

Background: Older people with cognitive impairment are admitted frequently to acute care, with needs not always met through standard practice. Best practice models have been suggested, but few assessment scales exist.

Methods: Psychometric evaluation using statistical estimates of validity and reliability based on an Australian sample of acute care nursing staff (n = 212).

Results: The final 15-item questionnaire consists of three subscales, using cognitive assessments and care interventions, using evidence and cognitive expertise and individualizing care. Estimates of validity and reliability were highly satisfactory.

Conclusion: The POPAC scale makes a valuable contribution by providing valid and reliable measures of the extent to which acute nursing staff report using best practice care processes to identify and consider cognitive impairment and to employ nursing interventions to meet the needs associated with old age and cognitive impairment.

Implications for nursing management: The POPAC scale is short, easy to administer and not time consuming to complete, but still provides clinically relevant information. It can be used as a conceptual fundament in developing best practice nursing care in the acute clinical setting, as well as for nursing research.

Keywords
Dementia, evidence-based practice, hospitals, nurses practice patterns, psychometrics
National Category
Nursing
Identifiers
urn:nbn:se:umu:diva-60533 (URN)10.1111/j.1365-2834.2012.01422.x (DOI)000313989600008 ()23339497 (PubMedID)
Available from: 2012-10-16 Created: 2012-10-16 Last updated: 2018-06-08Bibliographically approved
Nilsson, A., Rasmussen, B. H. & Edvardsson, D. (2012). Becoming a step behind: acute care of older patients with cognitive impairment. The Gerontologist, 52(S1), 282-282
Open this publication in new window or tab >>Becoming a step behind: acute care of older patients with cognitive impairment
2012 (English)In: The Gerontologist, ISSN 0016-9013, E-ISSN 1758-5341, Vol. 52, no S1, p. 282-282Article in journal, Meeting abstract (Other academic) Published
National Category
Nursing
Identifiers
urn:nbn:se:umu:diva-65933 (URN)000312888202459 ()
Available from: 2013-03-19 Created: 2013-02-13 Last updated: 2018-06-08Bibliographically approved
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0002-9358-3182

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