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EBP: EVIDENCE TO PRACTICE
Evidence Into Practice: Publishingan Evidence-Based Practice Project
Susan Adams, PhD, RN, Michele Farrington, BSN, RN, CPHON,
Laura Cullen, MA, RN, FAAN
THE FINAL AND perhaps most intimidating stepin the evidence-based practice (EBP) process is dis-
semination. Dissemination is critical as it is the
method by which the body of nursing knowledge
expands. An EBP project is not complete until
the information learned and outcomes achieved
are shared in a public forum, both internally and
externally, whether via a poster presentation,
oral presentation, journal article, or a combinationof these methods.1
Multiple benefits result from dissemination of EBP
projects, not only for the nursing staff but also for
former, current, and future patients. Participating
in the dissemination process promotes professional
growth and development as nurses write and speak
about what they have learned and outcomes thathave been achieved. Sharing EBP projects has the
potential to improve patient safety and outcomes
as other health care professionals learn about EBP
changes being implemented in diverse settings
and are stimulated to consider the need to imple-
ment similar changes to impact their own practice.
Little is knownaboutwhat strategieswork for imple-
Susan Adams, PhD, RN, Investigator, Comprehensive Access
and Delivery Research and Evaluation (CADRE) Center, Iowa
City VA Health Care System (152), Iowa City, IA; Michele Far-
rington, BSN, RN, CPHON, Staff Nurse, Department of Nursing
Services and Patient Care, University of Iowa Children’s Hos-
pital, Iowa City, IA; and Laura Cullen, MA, RN, FAAN,
Evidence-Based Practice Coordinator, Department of Nursing
Services and Patient Care, University of Iowa Hospitals and
Clinics, Iowa City, IA.
The views expressed in this article are those of the authors
and do not necessarily reflect the position or policy of the
Department of Veterans Affairs.
Conflict of interest: None to report.
Address correspondence to Susan Adams, Comprehensive
Access and Delivery Research and Evaluation (CADRE) Cen-
ter, Iowa City VA Health Care System (152), 601 Highway 6
West, Iowa City, IA 52246-2208; e-mail address: susan-
� 2012 by American Society of PeriAnesthesia Nurses
1089-9472/$36.00
doi:10.1016/j.jopan.2012.03.004
Journal of PeriAnesthesia Nursing, Vol 27, No 3 (June), 2012: pp 193-202
menting change with various topics in different set-tings and with different practitioners. Access to
information on projects implemented in other insti-
tutionsmayprovidepractitionerswith ideas onhow
best to proceed and what potential land mines to
avoidwhen implementing change in their own insti-
tution or unit(s). And finally, sharing experiences
with other nurses reduces duplication of effort as
health care professionals across sites ask the samequestions and search for evidence to guide their
own clinical decision making. Building on the
work of others when appropriate is especially pru-
dent given the time and resource limitations present
in the current health care environment.
Published journal articles on EBP projects have the
advantage of reaching a larger audience than mostconference presentations and create a permanent
resource for others to access, both nationally and
internationally. However, many clinicians express
anxiety at the overwhelming prospect of prepar-
ing a manuscript for publication. This article pro-
vides a systematic approach to write and publish
an article, and hopefully will encourage first-time
authors to submit an article for publication.
Obtaining Approval
There remains a great deal of confusion among clini-cians regarding related concepts such as conduct
of research, research utilization, EBP, quality im-
provement, quality management, quality assurance,
and performance improvement, just to name a few.2
The lack of clarity regarding what constitutes con-
duct of research and use of research in practice,
and subsequently, what actually needs to be ap-
proved by an organizational oversight committee(commonly referred to as an Institutional Review
Board or IRB),3 can be a stumbling block for clini-
cians. Although clinicians may understand who
might need to approve a project to implement
changes in practice on their unit, they may be less
clear if, when, or by whom, approval should be
193
194 ADAMS, FARRINGTON, AND CULLEN
obtained to submit an article for publication on
the same project. The confusion arises not just
among practicing nurses, but among researchers
and IRBs as well.4-10 According to the US
Department of Health and Human Services (2011),‘‘The intent to publish is an insufficient criterion
for determining whether a quality improvement
activity involves research. Planning to publish an
account of a quality improvement project does not
necessarily mean that the project fits the definition
of research; people seek to publish descriptions of
nonresearch activities for a variety of reasons, if
they believe others may be interested in learningabout those activities.’’11 Be sure to follow organiza-
tional policies regarding review and approval for
publication. The departments’ nursing research or
EBP committee should be able to provide guidance.
It is always recommended that before implementing
a practice change, the project director go to the
nursing committee that oversees EBP projects in
the organization. When publishing, this is anothertime to seek the counsel of this committee. EBP is
a form of quality improvement and is usually not
considered to be human subjects research.12 The
US Department of Health and Human Services,
Office for Human Research Protection, states that
if the purpose is to improve quality of patient care
andpatient or provider data are collected for clinical
or administrative purposes, it is not research.12
Wanting to publish an EBP project does not change
the requirements for IRB. However, some organiza-
tionsmaywantEBPprojects tohave adetermination
of human subjects research from the IRB prior to
publication. The nursing EBP committee and clini-
cal chair of the IRB can be helpful, as organizations
have differing policies.
If the EBP project director needs to seek determina-
tion of human subjects research by the IRB, follow
these tips. It is important to use correct terminology
to assist the committee in understanding the intent
and scope of the project. Remember, EBP projects
are not studies. Projects involve patients, not sub-
jects, and the intent is to align care for the specified
patient population with current best evidence toimprove patient outcomes. It can be helpful to use
quality improvement terms (eg, project director,
purpose, evaluation plan, etc.) and avoid using re-
search terminology (eg, study, sample, subjects,
and investigators). Plan ahead and limit evaluation
to essential data only and avoid collecting patient
identifiers or sensitive data when possible. The
goal of improving quality care and maintaining
confidentiality supports timely deidentification of
data after pre- and postgroup data analysis.
All organizations are different, and this precludesgiving specific instructions on this aspect of the
writing process. Approval, if needed, can be
obtained after implementation in most cases. The
approval process, although it may seem intimidat-
ing, should not discourage clinicians from sharing
the results of their projects, any more than it
should discourage clinicians from implementing
projects to improve patient outcomes. Seek assis-tance from a nursing leader who has been through
the process. Remember to keep copies of all meet-
ing minutes and recommendations from any com-
mittee or board that reviews the project for later
reference and contact information.
Before Writing Begins
Writing a manuscript for consideration in a profes-
sional journal can seem overwhelming when it has
not been done before, no matter what the educa-
tional and practice level of the nurse. However,
writing about a practice change does not have tobe done by just one person. Consider working
with the team who implemented and worked on
the practice change.
Ifmore than one personwill write themanuscript, it
is important to have a discussion regarding author-
ship at thebeginning to clarifywhowill be identified
as authors on the article and the order in which thenames will appear. This will help solidify account-
ability for writing, meeting deadlines, completing
the revisionprocess, andmost importantly, identifies
whowill be taking leadership of thewritingprocess.
And, if somemembers of the teamareunable tocom-
mit to writing the article or the team is too large,
thesemembersmay still be included in the acknowl-
edgment section available through most journals.
To organize the work, the author(s) must decide
on the major sections to be included. Working
on a draft of one section at a time makes the pro-
cess seem much more manageable. Authors can
work together on each section or individuals can
be assigned a section to complete and then the
overall style and content of the entire article canbe reviewed and revised by the lead author to en-
sure a congruent format. To decide on the sections
EVIDENCE-BASED PRACTICE PROJECT REPORTS 195
and format, it is helpful to take a close look at sev-
eral recent issues of the journal to which you
would like to submit the manuscript.
To select a journal, first reflect on who would bemost interested in hearing about your project
(eg, general practice nurses, specialty nurses, ad-
ministration, or physicians) and then consider
the journal audience or readership of a variety of
journals. This will ensure that the information
you will be sharing meets the needs of the audi-
ence whowill be reading the journal and increases
your chances of the manuscript being accepted forpublication. Having a journal in mind when begin-
ning the writing process also determines the
writing style required, which will eliminate refor-
matting work later in the process. The author
guidelines should then be obtained and followed
closely when dividing the work and writing.
At this time, there is no recognized standard formatfor presenting EBP projects for publication, and
many of the details will depend on the nature of
the project and the requirements of the specific
journal towhich you are submitting. It is not recom-
mended that EBP projects submitted for either
conference presentations or journal submission
be forced into a research format. For example, con-
ference submission guidelines for poster or oralpresentationsmay call for EBPprojects to be submit-
ted,but thenuse research terminologysuchas study,
subjects, and investigator in their suggestedheaders.
Even author guidelines and author reviewer guide-
lines may use research terminology, confusing nov-
ice and experienced authors and reviewers alike.
Research section headings canbematched to appro-
priate EBP section headings (Table 1). It is better touse the appropriate format and explain your choice
in a cover letter if necessary than to inaccurately de-
scribe the components of the project.
Table 1. Evidence-Based PracticeVersus Research Headings
EBP Headings Research Headings
Title/author/institution Title/author/institution
Purpose/rationale Research question or aim
Synthesis of evidence Background
Practice change Sample
Implementation Methods
Evaluation Results
Implications for practice Implications for practice
How to Start Writing
Some of the basic steps essential for manuscript
preparation include: keeping track of project work
electronically while the EBP project is being done,
arranging your schedule to create blocks of writing
time, having a designated place to work and think,
and beginning with an outline to help organize
your thoughts. Ifyouhavealreadywrittenasummary
of your project for other purposes, use it as a startingpoint for the article. This will jump start the writing
process and will help avoid having a blank sheet of
paper, which can be very discouraging.
It is helpful to ask a peer (or coauthor) to read the
manuscript early in the process to provide com-
ments and suggestions to keep your writing clear
and focused. It may also be to your advantage tohave a colleague who is unfamiliar with the project
read the article for clarity. This colleague will be
able to identify areas that are not clear far more eas-
ily than someone who is familiar with the project.
The following section highlights the main headings
that should be used for manuscript preparation
when reporting an EBP project. The Appendix con-tains sample directions from various journals and in-
cludes recommended articles that illustrate how to
write the specific manuscript section. It is
important to remember that many of the articles
have sections that are not in the recommended style,
for example, some use research terminology or do
not have the suggested headings. Unfortunately,
this is because there has been no standard formatfor reporting EBP work over the last several years.
We suggest accessing at least one article from each
section to get ideas on how to structure your own
manuscript, using the example to structure only
that piece of your manuscript. For example, in the
Appendix, we recommend reviewing an article by
Stebral & Steelman13 to see a well-written
description of a project that began with a problem-focused trigger.
Title
Deciding on a title for your article is an important
step. The title should be concise but it needs to pro-
vide enough information regarding the content to
be captured when an electronic search is donefor EBP work. Readers should get an idea of what
the article is about at a first and fast glance. It is
196 ADAMS, FARRINGTON, AND CULLEN
helpful if the title includes words that indicate the
patient population, the project focus (or topic), the
specialty, if applicable, and indication that it is an
EBP project. Use simple and straightforward lan-
guage. Examples of well-constructed titles include:
� Assessment of Oral Mucositis in Adult and Pe-
diatric Oncology Patients: An Evidence-Based
Approach14
� Double Gloving for Surgical Procedures: AnEBP Project13
� Implementation of an Evidence-Based Feed-
ing Protocol and Aspiration Risk Reduction
Algorithm15
� Listening to Bowel Sounds: An EBP Project16
Abstract
Almost all journals require that authors provide an
abstract. The abstract is important because it may
be the only part of the article people will see and
read. Readers often make a decision on whetheror not to acquire and read a full article based on
the information contained in the abstract. Depend-
ing on the journal you choose for submission, you
may be required to use a structured or an unstruc-
tured format for the article abstract. A structured
format would include specific headings that are
required or recommended; however, as men-
tioned earlier, it is important to be aware that head-ings typically used for research articles may not be
appropriate for an EBP project. Project informa-
tion should not be reported under inappropriate
subject headings just to meet the criteria listed in
the author guidelines. A cover letter may accom-
pany the manuscript when it is submitted for pub-
lication regarding why different subject headings
were used based on the desire to publish an EBPproject rather than a research study. Or, a query let-
ter or e-mail may be sent to the editor of the journal
you are considering before writing begins to see if
they will accept manuscripts that are not research
focused.
An abstract in an unstructured format does not have
specific headings that must be included. However,being familiar with headings used in structured
abstracts will enable you to write in a concise and
coherent format. Check the author guidelines for
the target journal for other details, such as word
count, font specifics, and spacing, just to name
a few. Most abstracts do not include citations.
Key Words
Journals may request that the author provide key
words, the exact number needed is journal specific.These are words that would be helpful in locating
your article during a database search. Try to include
themain clinical subject of the article, population of
interest, and indicate that thework is anEBPproject,
just as this same information is reflected in the title of
the article. Some journals require the use of Medical
Subject Headings (MeSH) when choosing key
words. These headings are part of a controlled vo-cabulary that standardizes search terms. Formore in-
formation on using the MeSH terms, visit http://
www.nlm.nih.gov/mesh/meshhome.html.
Body of the Article
If the body of the article is separated into sections ofthe EBP process, it is easier for the reader to follow
the project timeline and progression. The following
sections represent headers that reflect the various
steps in the EBP process.
Purpose/Rationale
In this section, youwillmake thecase forwhy itwas
important that you did this project. A good article
depicting the case for why a project was started af-
ter a problemwas recognizedon theunit is ‘‘Double
Gloving for Surgical Procedures: AnEvidence-BasedPractice Project.’’13 The authors identified the cur-
rent problem: ‘‘Needlestick and sharps injuries are
a serious hazard exposing health care workers to
bloodborne pathogens and deadly viruses’’ (p.
251). The authors then gave an assessment of the
current situation in the clinical practice area, the
operating room, in this case: ‘‘Between September
1, 2004 and August 31, 2005, there were 63 re-ported sharps injuries in the operating room, occur-
ringwhen thepersonwaswearing gloves’’ (p. 253).
Be clear on the purpose of the project. Do not
make the readers search for this, but rather use
the words ‘‘the purpose of this project.’’ This
can be placed before or after the rationale, but it
should be early in the article to give readers a frameof reference as they begin to read the article.
Synthesis of the Evidence
The article should include a synthesis of the evi-
dence indicating that the author(s) performed
EVIDENCE-BASED PRACTICE PROJECT REPORTS 197
a thorough literature search and evaluated the
available evidence before determining what the
practice change would look like. EBP projects usu-
ally evolve over many months, or years in some
cases, so it may be necessary to perform anotherliterature search when you get to the point of pub-
lication to make sure all of the latest evidence is in-
cluded. Citations must be included in this section,
and the format for the citations will be determined
by the author guidelines of the journal.
Practice Change
This section should include a concise description of
what changes were made based on the evidence
available, such as policy development, policy revi-
sions, or protocol development. Tables work well
to highlight the key concepts in this area. Informa-
tion should be clear in this section so that practi-
tioners at another institution could implement the
same practice change. This section should also in-clude a discussion of how and when the practice
change was piloted and a general description of
the unit(s), types of patients, hospital setting, etc.
Implementation Strategies
Information in this section of the manuscript
should include how practitioners on the unit orwithin the institution were made aware of the
practice change(s) and what strategies were used
to facilitate the change.17 For example, were edu-
cation sessions held, and if so, how were they con-
ducted? Were change champions or opinion
leaders used to assist in rolling out the change or
for problem solving? Were reminders, practice
prompts, new documentation, logos, or sloganscreated? Be specific regarding any barriers that
arose, and how they were overcome.
Evaluation
Implementation of all EBP projects needs to include
how theprojectwas evaluated, both before and after
the practice change occurred. Evaluation compo-nents may include staff questionnaires assessing
knowledge, attitudes, and practices18; patient ques-
tionnaires; electronic health record data; core mea-
sures from publicly reported data (eg, Hospital
Consumer Assessment of Healthcare Providers and
Systems scores)19; and measures reported for value-
based purchasing.20,21 Evaluation of an EBP project
does not require an intense statistical analysis of
the data; the impact of the project can be shared
through the use of mean scores and percentages
depending on the type of data gathered for the
project. Use of these simple descriptive statisticscan facilitate interpretation and trending of data22
for integration of the practice change.
Implications for Practice
Readers want to know what the practice change
means and how it will impact future patients. For
example, will there be financial savings for the in-
stitution; increased patient safety; improved nurse,
patient, or family satisfaction; or ability for the pro-
ject to impact other patient populations? This sec-tion may also include a discussion regarding next
steps, such as continued audits for assessment of
compliance with the practice change. This section
provides the rationale for other practitioners to
consider doing a similar EBP project, as well as
making the case to the journal reviewer on why
it is important for this EBP project to be published.
Conclusion
The end of the article should include a conclusion
section that will tie everything together for the
reader. It is important to again highlight why the
project was initiated and what impact has been
shown to date.
Tables/Figures
Depending on the type of EBP project conducted,
tables and figures may be used within the narrative
portion of the manuscript to highlight some of thekey practice changes, select information from a pol-
icy that was created, an algorithm developed, or
project timeline. Provide information in the format
of a table or figure that you think the readerwill find
helpful when attempting this project in their own
institution or clinical practice area.When preparing
the manuscript, the tables and figures should be
placed on separate pages after the reference sectionor as directed by the author guidelines of the jour-
nal. After the manuscript is accepted for publica-
tion, the article will be laid out by the copy
editors for review by the author before publication,
and at this time, the tables and figureswill be placed
with the corresponding text.
198 ADAMS, FARRINGTON, AND CULLEN
References
Themanuscript is not complete until the references
have been included. All evidence previously pub-lished that is referenced within the narrative (or
text) portion of the articlemust beplaced on the ref-
erence list at the end of the article. It is important to
read the instructions from the target journal toknow
how to format your references. Each journal has its
own preferred method, and there are many online
resources tohelp format references invarious styles.
If you write articles frequently, there are also pro-grams available that format citations automatically,
for example, RefWorks or EndNote. Your institution
may provide secretarial assistance to format or sub-
mit an article. It is very important that your refer-
ences are cited completely and correctly.
Journal reviewers do pay attention to details. Ref-
erence sections that are well done make the man-uscript appear more professional and suggest that
you have paid close attention to detail. Tables and
figures, if not your original work, must be refer-
enced, and permission for their use in your article
must be obtained from the original journal or pub-
lication. The journal to which you are submitting
the article will most likely need some type of con-
firmation that this permission was obtained.
Final Steps
The next step is, of course, submitting the manu-
script to the journal you have chosen. Be very care-ful to have several people proofread the article.
Spelling errors or typographical errors will nega-
tively impact your chances of receiving a good re-
view. You do not want the reviewers distracted
from the content of your article. Follow the direc-
tions for submission carefully, then sit back andwait. The wait can vary, but it is often several
months before you hear anything from the journal.
Most manuscripts, even if accepted, will need
revisions before the final article is published.
Follow the suggested revisions carefully. If you dis-
agree or cannot make a suggested change, politely
let the editor know your reasoning in a cover letterthat accompanies the revised manuscript. Most ed-
itors are open to this if you explain your reasoning.
If your article is rejected, look carefully at the re-
viewer critiques and decide if you can revise
your article tomake it stronger. If so, consider a sec-
ond journal you would like to submit the article to,
revise it, and send it in. Another journal may bea better fit, and your revised article will be stronger
as a result of the comments from the first journal.
By following the steps in this article, you have
a very good chance of seeing your article in print
and having the satisfaction of knowing that other
practitioners and patients will be able to benefit
from your hard work.
Acknowledgment
The authors would like to thank Kim Jordan for her assistance
with the manuscript preparation.
References
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Appendix. Tips and Examples
Manuscript Sections Practical Tips Direction Examples Article Examples
Title � Include patient population, project focus or
topic, specialty (if applicable), and indication
of an EBP project
Bowman et al15 (2005)
Farrington et al14 (2010)
Madsen et al16 (2005)
Stebral and Steelman13 (2006)
Abstract � Clear and concise
� Engage readers so they will obtain the entire
article
� Journal of Nursing Care Quality (unstruc-
tured abstract): ‘‘Include an abstract of 50 to
75 words that stimulates readers’ interest in
the topic and states what they will learn from
reading the article.’’
� Worldviews on Evidence-Based Nursing
(structured abstract): ‘‘Manuscripts should
include a structured abstract of up to 300
words. The following headings could be used
when appropriate: background and/or
rationale; aims; methods; results/findings;
discussion; implication(s) for practice,
research, policy, management, and/or
education (depending on the focus of the
manuscript); and conclusions. Where
manuscripts are theoretical or debate pieces,
a structured abstract should still be used but
headings adapted accordingly.’’
Unstructured example:
Farrington et al23 (2009)
Structured example:
https://www.uihealthcare.org/
otherservices.aspx?id523011
Key words � Include subject of the article, population of
interest, and indicate EBP project
� Pediatrics: ‘‘Authors should provide keywords
on the title page and use Medical Subject
Headings (MeSH) terms as a guide. Visit: http://
www.nlm.nih.gov/mesh/meshhome.html’’
Cullen and Titler24 (2004)
Purpose and rationale � The purpose of this project was to (imple-
ment, improve, reduce, and so on)
� Do not be too broad
Farrington et al23 (2009)
Hyden and Fields25 (2010)
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Synthesis of evidence � Include databases used/key words, number
of references located, number of articles
used, and were there any existing practice
recommendations or guidelines; if not,
summarize the evidence with your own
recommendations/practice changes based
on synthesis of the research
Hanrahan and Lofgren26 (2004)
Madsen et al16 (2005)
Stebral and Steelman13 (2006)
Practice change � Context (eg, type of unit/hospital)
� Stakeholders, team, clinicians, providers,
and so on
� Policy/protocol development/revision
� Piloting the intervention
� Adjustments made as a result of the pilot
Practice change:
Farrington et al23 (2009)
Van Waning et al27 (2005)
Yackel et al28 (2010)
Policy change:
Madsen et al16 (2005)
Piloting:
Stebral and Steelman13 (2006)
Implementation strategies � Education
� Change champions or opinion leaders
� Logos/slogans
� Reminders
� Audit and feedback
� Practice prompts
� Documentation changes
Hyden and Fields25 (2010)
Van Waning et al27 (2005)
Evaluation � Pre- and postimplementation metrics and
results
� Data analysis
� Discussion
Farrington et al23 (2009)
Yackel et al28 (2010)
Implications for practice � What does this project mean for the unit
and/or hospital?
� What are some of the next steps for moving
the project forward or sustaining the project?
Implications for practice:
Madsen et al16 (2005)
Next steps:
Farrington et al23 (2009)
Conclusion � Tie themain points of the article together and
reemphasize why the project was completed
and the impact shown
Bowman et al15 (2005)
(Continued)
EVID
ENCE-BASED
PRACTICE
PROJECT
REPORTS
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Appendix. Continued
Manuscript Sections Practical Tips Direction Examples Article Examples
Tables and figures � The use, format, and placement of tables or
figures will be dictated by the journal to
which you are submitting the article
� American Journal of Nursing (AJN): ‘‘We
.encourage the use of diagrams, tables,
charts, illustrations, and photos.authors
should include these as attachments, as op-
posed to placing them in the body of the text.’’
� Worldviews on Evidence-Based Nursing:
‘‘Tables should be self-explanatory, and the
data they contain must not be duplicated in
the text or figures. Tables and figures should
be embedded in the text of the manuscript.’’
� Journal of Pediatric Oncology Nursing:
‘‘Each table should be typed on a separate
sheet at the end of the manuscript file. The
author should provide table titles on the same
sheet as the table.’’
Bowman et al15 (2005)
References � References begin on a separate page from
the text
� The format of the references and location
(before or after tables or figures) depends
on the specific journal
� If no recommended style of references or
citations is given, the author may choose
� Worldviews on Evidence-based Nursing:
‘‘References within the text should cite the
author’s name followed by the date of
publication, in chronological order.. Where
there are three or more authors, the first
author’s name followed by et al will suffice.but all authors should be cited in the
reference list.’’
� Pediatrics: ‘‘All aspects of the manuscript
(tables, illustrations, and references) should
be prepared according to the International
Committee of Medical Journal Editors re-
quirements. Citations should be numbered in
the order in which they appear in the
text.Reference style should follow that of
the AMA Manual of Style, 10th edition.
Abbreviated journal names should reflect the
style of Index Medicus.’’
Bowman et al15 (2005)
Farrington et al23 (2009)
Madsen et al16 (2005)
Stebral and Steelman13 (2006)
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CULLEN