Preparedness,knowledge,and perception of nursing students about climate change and its impact on human health in India

Higher education plays an important role in all aspects of sustainability.Infusing climate change and sustainability into the curriculum is important to prepare future health-care professionals for climate change and sustainability actions to build resilient health systems.In this study,we evaluated the preparedness,knowledge,and perception regarding climate change and its impact on human health among Indian nursing students.A quantitative descriptive survey was conducted among 644 undergraduate nursing students studying in three institutes in the southern,northern,and western parts of India.We used a structured online questionnaire with established validity and reliability to collect data.The data were analyzed using Statistical Package for the Social Sciences version 26 software.The results showed that more than half of the students reported experiencing excessive increase(362;56.2%)and decrease(374;58.1%)in temperature in recent years.Though more than three quarters of the students(494;76.7%)accepted the general truth that climate change is mainly caused by human activities,only less than half of the students(309;48.0%)perceived the impact of climate change to be high.Three quarters of the students(483;75.0%)had a high level of knowledge regarding climate change.The students who had a high level of knowledge about climate change exerted a high perceived impact of climate change(χ^(2)=75.47;P<0.01).More than half of the students(50.9%)felt that they needed information about climate change to be included in the nursing curriculum,and only one sixth of the students(16.1%)were highly confident about engaging in climate change-related conversation with patients.Most of the students who participated in the study had basic knowledge about climate change and its impact on human health.However,there is an observed gap between knowledge and their preparedness and confidence to engage in climate change actions.Hence,we propose to strengthen the nursing curriculum by integrating various curricular and co-curricular activities related to climate change,so that future nurses are empowered to become climate change advocates.

Exploring Critical Thinking Dispositions among Fourth Year BSc Nursing Students of Various Colleges of Nursing, Pakistan

Background: Critical Thinking (CT) dispositions in nursing are prominent predictors of competence in delivering high-quality care, and of professionalism, in newly graduated nurses. CT skills, in isolation of CT dispositions, do not guarantee success in the workplace, because Critical Thinking Dispositions (CTD) are important elements of intellectual reasoning that simulate a person towards using the CT skills. Therefore, nursing educational programs should promote lifelong learning rather than focusing on transferring the content of nursing knowledge only. And for this purpose, quality education is the key. Education should focus on teaching from diverse perspectives, incorporating various teaching learning strategies that are congruent with the modern era. Purpose: The purpose of this study is to explore critical thinking dispositions among final year Baccalaureate Nursing students of various military colleges of nursing, in Pakistan. Methodology: A descriptive qualitative exploratory study design was used to investigate the CTD of BSc final year nursing students. The study population included twelve willing nursing students, from six military colleges across the country. Demographic information and consent was taken from the participants of the study. In-depth interviews, through a semi structured interview guide, and probes were used to obtain data related to personal experiences of CTD amongst the nursing students. Results: Data analysis showed two broad themes: 1) Perceptions of CT, and 2) Experiences of CT dispositions. In theme one, the emerging category was: Clarity of CT;whereas in theme two, the categories that emerged were: a) Truth Seeking, b) Open Mindedness, c) Inquisitiveness, and d) Self Organization. Conclusion: The findings of the study revealed positive dispositions towards truth seeking, open mindedness, and self-organization, whereas disposition towards inquisitiveness was weak. Self-confidence and maturity also emerged as positive factors that the students possessed. This study recommends that faculty and learners should extend their concept of CTD, and emphasizes its application in daily routine. Additionally, faculty should modify their instructional strategies and focus on the cultivation of dispositions of inquisitiveness, curiosity, and allow questioning by students in the class.

Student-Related Factors that Affect Effective Clinical Learner Support among Nursing Students in the Middle-Level Colleges in Nairobi County, Kenya

Background: Student nurses’ clinical learning is a key requirement in the profession. However, the students often face many challenges in clinical sites that put a negative perception on their professional growth. Clinical learner support is the most challenging part because of several guidelines, policies, and requirements that must be followed during the training. To enhance effective clinical learner support, training needs to be designed to support problem-based learning, trainees’ characteristics should portray positivity, and team-based coaching should focus on skills and results attainment. Objectives: The broad objective of the study sought to establish determinants of effective learner support for nursing students in middle-level colleges. The specific objectives were: To assess student-related factors, identify primary training institutions, other related placement site-related factors, and establish the students’ perceptions of the existing clinical learner support systems. Methodology: A descriptive design was utilized. Qualitative and quantitative data collection methods were utilized. A Simple random method was used to sample 394 respondents from a total population of 3368 nursing students across 12 training institutions. The data was coded and analyzed using Excel and SPSS Version 28. The study findings are presented using tables, pie charts, bar graphs and histograms. The data was first presented in the form of descriptive in terms of percentages. The chi-square test of independence was then calculated at a p-value of Conclusions: The learners achieved effective clinical learner support where n = 302 out of 380, with 75% indicating effective learner support. It is recommended that qualitative and more quantitative studies should be carried out on postgraduate and other healthcare cadres to compare the results. Further study needs to be carried out on the students’ attitude towards learner support.

Research on the Ideological and Political Work of Nursing Students in the New Era under the Strategy of Healthy China

Nursing students have uniqueness within the general university student population as they are among the primary practitioners of the “Healthy China Strategy 2030” and guardians of people’s health. Innovating and strengthening ideological and political education for nursing students, enhancing their skills in serving the people, is a significant political task for medical universities. Against the backdrop of the “Healthy China Strategy,” how to effectively improve nursing students’ professional competencies, integrate life education, medical humanities education, and general ideological and political education, and utilize life education to construct a more suitable ideological and political education system for nursing students, in order to better establish correct worldviews, values, and professional outlooks, are urgent practical issues that need to be addressed in ideological and political education in medical universities. This article takes life education as an entry point and focuses on integrating it with the internalization and unification of ideological and political education courses, aiming to explore the possibilities and new pathways for integrating life education into the ideological and political education of nursing students in the new era.

Preceptors'experiences in guiding nursing students to use research findings and to implement evidence-based practice

Objective:Evidence-based practices(EBPs)have been taught to students by identifying the best evidence/evidence from research results.However,the experiences of Indonesian nurse preceptors in helping students implement research findings have not been explored thoroughly.This study aimed to explore Indonesian nurse preceptors in guiding nursing students to use research findings.Methods:This study used interpretive phenomenology analysis that involves 9 nurse preceptors from hospitals in West Kalimantan,Indonesia.Semi-structured in-depth interviews were recorded and then transcribed verbatim.Results:Three themes were generated during the analysis:“types of student supervision,”“issues during supervision,”and“the need for research literacy and supervision.”Conclusions:Nurse preceptors need support to supervise the nursing students to use research findings.In addition to upgrading nursing skills,nurse preceptors must receive training in research and its utilization.Developing an appropriate strategy to assist students in using research findings will enhance the promotion of evidence-based nursing practices on a daily basis.

Attitudes of nursing students about palliative care:an analysis of influencing factors

Background:As the population continues to age and the number of people suffering from incurable diseases,such as malignant tumors and Alzheimer’s disease,increases,the need for quality end-of-life care is becoming more and more prominent.Nursing students,as a reserved talent in the nursing field,have an attitude towards palliative care that will directly affect the quality of care for future terminal patients.Methods:This descriptive and cross-sectional survey was conducted from November 2020 to January 2021.A stratified sampling method randomly selected 1168 undergraduate and postgraduate nursing students as respondents.Students’attitudes were measured using a revised palliative care attitude questionnaire.Results:The palliative care attitude score was 7.233±1.812 with a score of 72.3%and a median score of 7.50 with a range of 0-10.63.10%of the nursing students had an attitude score of 7 or more and only 2.40%of the nursing students had a negative attitude towards palliative care.The results showed that gender,grade level,health status,and attitudes toward the nursing profession affected nursing students’attitudes toward palliative care(P<0.05).Conclusion:Currently,Chinese nursing students have better attitudes towards palliative care,but are less likely to want to pursue a career in palliative care in the future.Medical schools can take into account their actual gradual opening of palliative care courses,using a variety of teaching methods to stimulate the interest of nursing students to learn and improve their willingness to palliative care services.

Self-Efficacy Among Nursing Students Using Flipped and Traditional Teaching Modalities

Objective:To measure the self-efficacy of nursing students taught using both flipped and traditional classroom modalities.Method:A quantitative research design was employed.The control group was taught using the traditional classroom model,while the experimental group utilized the flipped classroom model.The study population consisted of undergraduate nursing majors at Shandong University of Traditional Chinese Medicine.Two out of twelve classes were selected through random sampling.Results:The study presents an analysis of the t-test results using SPSS,which shows a significant difference when the calculated P-value falls between 0.00 and 0.05.The P-value obtained was 0.00,indicating a statistically significant difference.Conclusion:The teaching model,whether flipped or traditional,has an impact on nursing students’self-efficacy.Students in the flipped classroom exhibited higher self-efficacy in mastering the curriculum.

Correlation between critical thinking and emotional intelligence:a national crosssectional study on operating room nursing students in Iran

Objective:According to the World Federation of Medical Education,critical thinking should be part of the training of medical and paramedical students.Professionals can improve the quality of care of patients after surgery by having or acquiring this skill in health care.Also,Emotional intelligence is introduced as an impor tant and effective factor on the professional performance and mental health of healthcare professionals.Thus,the present study was designed and implemented to determine the relationship between emotional intelligence and critical thinking among operating room nursing students of medical sciences universities in Iran.Methods:This cross-sectional study was done on 420 operating room students in 10 top medical sciences universities of Iran in 2022.The sampling method in this research was multistage sampling.The data collection instruments included demographic characteristics,Rickett's critical thinking,and Bradberry-Greaves'emotional intelligence questionnaires.After receiving the ethics code,data collection was done for 2 months.For data analysis,descriptive and inferential analyses including independent t-tests,analysis of variance,and Pearson correlation were used.The collected data were analyzed by SPSS 18(IBM Corporation,Armonk,New York,United States).P-value<0.05 was considered significant.Results:The mean age of the students participating in this study was 23.02±3.70 years,with women constituting 67.4%of them.The results of data analysis indicated that the mean total score of critical thinking and emotional intelligence was 124.10±37.52 and 114.12±43.63,respectively.A direct significant correlation between critical thinking and emotional intelligence(r=0.459,P-value<0.001)and a significant relationship between gender and emotional intelligence(P-value=0.028)were found.Conclusions:Based on the present study results,educational managers in the Ministry of Health are suggested to consider suitable educational programs for improving critical thinking and emotional intelligence to enhance the quality of care provided by students in operating rooms.

Analysis of adversity quotient of nursing students in Macao:A crosssection and correlation study

Objectives: To investigate the adversity quotient (AQ) of Macao undergraduate nursing students and analyse its influencing factors.Methods:A cross-section design was used,and a convenience sample of nursing students(n=158 valid)was selected from a tertiary institute in Macao.In addition to demographic questions,the Chinese versions of the Adversity Quotient Scale,the Emotional Intelligence(EI)Scale,the Simplified Coping Style Questionnaire and the Parenting Styles Scale were used to assess the students'characteristics.Results:The average AQ score of the students was 116.72±11.39.AQ scores were negatively correlated with coping-negative,and maternal style(excessive interference,excessive protection)(r=-0.332,P<0.001;r=-0.167,P=0.036).Coping-negative entered the regression equation(F=19.154,P<0.001).The female nursing students had higher scores in ownership dimension of AQ than their male counterparts(31.98±3.26 vs.29.21±3.08,t=-4.442,P<0.001).Conclusions:The average AQ scores of Macao undergraduate nursing students were moderate.The female nursing students are more likely to attribute the cause of adversity to themselves,and specific psychosocial and cultural issues may be at play.There is a necessity for Macao nursing students to improve their ability to overcome setbacks.Special attention should be paid to the cultivation of students'positive coping styles.

Comparison of Clinical Thinking Ability in Nursing Students of Different Grades

Objective： This study investigated and compared the clinical thinking ability of undergraduate nursing students of different grades, and searched for influencing factors of clinical thinking ability of nursing undergraduate students. Methods： The convenience sampling method was used to select the Subject of the study. In total, 180 third-year, fourth-year, and fifth-year nursing undergraduate students were enrolled in this study. A self-designed scale of clinical thinking ability was used to collect the data. SPSS17.0 was used to analyze the data. Results： The average scores of clinical thinking ability of undergraduate nursing students were 68.14±9.13. In addition, 71.1% of the students have a higher level of clinical thinking ability, and only 7.2% of the students have the best level. The ANOVA test showed that the fourth-year students had the highest scores（72.96±8.64）, and the third-year students had the lowest scores（62.35±8.09）, which indicated a significant difference in the scores of the three groups（ F= 26. 79, P〈0.05）. Multiple linear regression analysis indicated that the frequency of academic activities and the frequency of department rounds were significantly correlated to clinical thinking ability（P〈0.05）. Conclusion： We must pay attention to the changes and influencing factors of clinical thinking ability of nursing undergraduate students. Thus, traditional teaching methods need to evolve and be revised to host the capacity of clinical practice most effectively and, eventually, promote the development of clinical thinking ability of nursing undergraduate students.

Attitude of nursing students towards Internet-based nursing services for the aged

Objective To investigate the attitude,willingness,and motivation of third-year undergraduate nursing students from a university of Chinese medicine toward Internet-based nursing services for the aged(IBNSA),providing a reference for its development and related nursing education.Methods This study was conducted from March to April 2019.Using a self-designed questionnaire,this cross-sectional study comprised 508 third-year undergraduate nursing students from a university of Chinese medicine.The questionnaire was divided into two parts.The first part contained the general information of nursing students.The second part investigated nursing students’attitudes,willingness,and motivation towards IBNSA(a total of seven questions).Results Of the 508 nursing students,314(61.81%)expressed support for the IBNSA,44(8.66%)expressed disapproval.Regarding career choice,279(54.92%)were willing to choose IBNSA,51(10.04%)were unwilling.The top three motivations for choosing IBNSA as a nursing student career were increased income,high autonomy and flexibility,and good job prospects.On the contrary,the top three reasons not to choose this option were safety concerns,lack of time and energy,and unwillingness to undertake elderly care.Experience with community activities or a part-time job,experience with elderly care,willing to choose the nursing profession,willing to engage in nursing care after graduation,and willing to engage in nursing for elderly patients after graduation were significantly associated with the motivation of nursing students to participate in IBNSA(P<0.05).Conclusion The majority of nursing students have a positive attitude towards IBNSA and are willing to choose it as their future career.Nurses’and patients’safety guarantees and salary distribution were critical factors influencing their choice.Nursing schools should pay attention to the concerns of nursing students,constantly improve the management system of IBNSA,strengthen safety education,and provide professional knowledge and skills to improve the quality of personnel training.

Attitudes of undergraduate nursing students toward Objective Structure Practical Examination: An Exploratory study

Background: Objective Structured Practical Examination (OSPE) is a method of assessment of clinical competence.The examination is conducted at multiple stations.Besides practical and problem-solving skills,theoretical knowledge is also tested.OSPE can be traced back more than 40 years.OSPE has been included more than two decades,as a part of assessment in the College of Nursing,All India Institute of Medical Sciences (AIIMS),New Delhi.Objectives: This study was carried out to determine nursing students' attitudes towards OSPE as an assessment tool.Participants: The responses of all the 252 Undergraduate nursing students studying at the College of Nursing,AIIMS were obtained for this study (77 from B.Sc.(H) Nursing first year,61 from the second year,69 from the third year and 45 from the fourth year).Methods: The students attitudes towards OSPE were assessed by using a validated questionnaire containing 28 item statements on Likert's 5-point scale (LS) and 11 bipolar adjectives on Osgood's 7-point Semantic'Differential Scale (OSDS).Result: Most of the students approved of OSPE and felt that it was fair,useful,good,effective,exciting,interesting,practical,skill oriented but also taxing.The study also revealed that amongst the second years' students there was a strong correlation between Overall Rank in the Class and Assessment of OSPE.Conclusion: The study supports the introduction of OSPE as one of the methods of assessment of B.Sc.(Hons.) Nursing students.

Discrepancy between the Image Held by Nursing Students of Themselves as Employed Nurses during the Pre-Employment Period and the Post-Employment Reality Faced by Novice Nurses

The difference between the expectations of work an individual forms before joining an organization and their perception of work after becoming an organization member is called reality shock and has a significant impact on the reasons why new nurses leave their jobs. To reduce reality shock, it is necessary to clarify the discrepancy between the reality and the image of oneself after employment, which is the source of expectations. However, while there is a large body of literature on reality shock among nurses, no studies have specifically investigated student nurses’ image of post-employment confidence. We conducted semi-structured interviews with eight nursing students who had received job offers and 10 professional nurses up to two years after graduation to clarify the differences between the image that nursing students hold of themselves as employed nurses during the period immediately before employment and the reality that they find after employment. As a result, four core categories (with 25 categories) related to participants’ images of themselves as employed nurses were extracted: life after employment, adaptation to work, adaptation to the workplace, and career foundation-building. Fourteen categories were extracted regarding the reality that nurses found after employment;upon comparing and classifying these categories according to the four core categories, a lack of concreteness in the nursing students’ image of themselves as employed nurses was identified. The results suggest that support measures, both in the basic nursing education program and in clinical hospital practice, to improve the concreteness of the image that nursing students hold of themselves as employed nurses and of nursing work can reduce reality shock and prevent job turnover upon their entry into the workforce.

Real experience among undergraduate nursing students in learning the course of geriatric nursing : a qualitative study

Objective:To understand the real experience of nursing students majoring in geriatric nursing in learning the course of geriatric nursing,so as to provide reference for the design of this course.Methods:The semi-structured int erview was used to interview 27 sophomore nursing students in the department of geriatric nursing in a a Chinese medicine college to understand their experience of learning the course of"Geriatric Nursing",and to apply a seven-step phenomenological analy sis method for data analysis.Results:Refined 8 themes:Lack of cognition of physiological aging;focus on social issues and daily life care;adopting a blended teaching style to stimulate nursing students'interest in learning;understanding the life of the elderly from a professional point of view after class;reverence for life and realisation of life values;little attention is paid to the career of the elderly in China;Geriatric Nursing program expands the scope of employment;and fostering nursing s tudents'willingness to engage with the elderly.Conclusion:The nursing students can understand and experience to the elderly and their lives through learning the course of Geriatric Nursing,but lack the motivation to learn actively.Teachers should guid e nursing students to pre-study before class,enrich the course content,expand their knowledge outside of class,and adopt blended teaching to cultivate their perception of the elderly.

The status of professional identity and professional self-efficacy of nursing students in China and how the medical documentaries affect them: A quasi-randomized controlled trial

Objectives: Professional identity and self-efficacy are important for the education and career develop-ment of students. However, how to improve these factors among Chinese nursing students needs further study. This quasi-randomized control trial was designed to explore the effect of medical documentaries on professional self-efficacy and identity among nursing students in Chinese technical schools. Methods: A total of 277 nursing students were enrolled in this study and divided into an experimental group (n = 135) and a control group (n = 142). The experimental group was invited to watch Chinese medical documentaries, whereas the control group remained on a waiting list. A self-designed general questionnaire, along with professional identity and professional self-efficacy questionnaires, was completed by the nursing students. Results: No significant change in professional self-efficacy was observed (-3.55 ± 14.23, P=0.173) in the experimental group, while professional identity significantly declined (-6.24 ± 12.85, P = 0.002) after the intervention. No significant change was found in the two aspects in the control group. Conclusion: Medical documentaries negatively affect professional identity but do not affect professional self-efficacy. Further researches should be conducted to explore the real reasons.

The experience of transition from nursing students to newly graduated registered nurses in Singapore

Objectives:To investigate the experience of newly graduated registered nurses(NGRNs)in Singapore following their initial 6-12 months of transition from nursing student to registered nurse.Methods:This mixed-methods study consisted of two phases.In the first phase,data were collected via the administration of the online survey to 30 NGRNs.The questionnaire contained 42 items of the fourpoint Likert scale survey.In the second phase,a focus group interview was conducted with 5 NGRNs to gather complementary information regarding the major findings from the first phase.Results:The survey revealed despite most NGRNs(80%)in this study expressed overall satisfied with their transition,the item score was(2.97±0.61)out of 4,the majority(83.3%)also perceived their transition to professional practice being stressful,the item score was(3.07±0.74)out of 4.Three themes emerged from the interview,'personal transition experience','professional transition experience',and'organizational transition experience',which are entwined to construct overall NGRNs'transition experiences.Conclusions:This study reaffirms the theory-practice gap phenomenon.This signifies the need for closer collaboration between educational,healthcare industry and regulatory stakeholders to examine and address factors that influence their transition experience to better support them for workforce readiness.

Validation of Stressors in Nursing Students Scale-Chinese Version (SINS-CN) in a Population of Macao Nursing Students

Objective： To validate the Stressors in Nursing Students Scale-Chinese Version（SINS-CN） in a population of Macao nursing students. Methods： A methodological study was designed with 2 phases. In phase 1, a three-expert panel was invited to evaluate the content validity of SINS-CN, and then its test-retest reliability was examined over a 2-week interval. In phase 2,211 undergraduate nursing students were recruited, and 203 valid responses to the questionnaire were obtained. A principal component analysis with varimax rotation was applied to validate the structure of the instrument. Results： The content validity index（CVI） was 0.89. The correlation coefficient of the test-retest reliability was 0.82 for the overall instrument and 0.70-0.88 for the instrument＇s sub-dimensions. Based on the 43 items of the instrument, five components were identified and accounted for 60. 28% of the variance with eigenvalues ranging from 1.32 to 10. 18. The factor loadings were 0.42-0.79. The internal consistency reliability of Cronbach＇s ot was 0.96 for the overall scale and 0.67-0.94 for its sub-dimensions. Conclusion： The study findings indicated that SINS-CN had acceptable psychometric properties in terms of content validity, stability and internal consistency reliability. The principal component analysis generated a 5-component structure with 43 items; this was slightly different from the origi- nai structure but was more applicable to the studied population, which suggests that this instrument has cross-cultural sensitivity.

Correlation between self-differentiation and professional adaptability among undergraduate nursing students in China

Purpose:This study aimed to investigate the current status of self-differentiation and professional adaptability among undergraduate nursing students,to analyze the relationship between these two variables,and to provide recommendations for nursing educators.Methods:A total of 341 nursing undergraduate students at the University of South China were investigated using the Differentiation of Self Inventory and the Professional Adaptability Scale for college students.Results:The mean scores of self-differentiation and professional adaptability were 3.70±0.60 and 2.87±0.37,respectively,and the two variables were positively correlated(P<0.01).Conclusion:The level of self-differentiation of undergraduate nursing studentsaffects their professional adaptability.Nursing educators should consider the characteristics of self-differentiation of undergraduate nursing students in developing measures to improve their professional adaptability.

Influence of Nursing Students Handwashing Knowledge, Beliefs, and Attitudes on Their Handwashing Compliance

Information regarding current status of handwashing knowledge, beliefs, attitudes and compliance with handwashing practice in nursing students in Jordan is limited. This study aims to explore handwashing knowledge, beliefs, attitudes, and self-reported compliance and to examine significant variables predicting compliance with handwashing practice among nursing students. The study used a cross-sectional survey design. Results found a statistically significant relationship between nursing students’ handwashing compliance and their handwashing knowledge, attitudes, and beliefs (r = 0.68, 0.65, 0.58, P β = 0.423, P = 0.000), followed by attitudes (β = 0.322, P = 0.000), and beliefs (β = 0.171, P = 0.027). Specific handwashing training courses integrated in nursing education curriculum are recommended. These courses need to consider nursing students’ handwashing attitudes and beliefs in conjunction with handwashing knowledge.

Investigation on Relationship between Test Anxiety and Academic Performance of Nursing and Midwifery Students in Tabriz and Maragheh—Iran

Background and Aim: Given the dramatic decline in the ability of test due to test anxiety, the goal of this study was to evaluate the relationship between test anxiety and academic performances in students. Materials and Methods: This descriptive-analytical study was performed on 216 Iranian nursing and midwifery students in 2011-2012, utilizing Sarason Anxiety Inventory, demographic checklist and the average mark of students in the period of midterm and final exam. Multinomial logistic regression analyses by reporting odds ratios and their 95% confidence intervals were performed by SPSS17 software to assess the relationship between test anxiety and academic performances. Results: Mild, moderate and sever test anxiety was observed in 30.6, 43.1 and 26.4 percent of students respectively. Test anxiety was significantly related to academic performance (average), major and city. Also, there was 52.9% decrease for odds of having sever anxiety (compared to mild anxiety) with 1 point increase in average (OR = 0.471, 95% CI = (0.298 - 0.745) and p = 0.001). Conclusions: Due to inverse relationship between test anxiety and academic performance, performing preventive programs such as in time treatment of anxiety, empowering the students to deal with anxiety and conducting consulting services for how to studying are very important. Consequently it would be a big step in decreasing the test anxiety and therefore in improving the academic performance.