DiversityNursing Blog

By Neal St. Anthony

Registered nurse Rachele Simmons walked away from a $100,000 career two years ago.

She still isn’t generating enough cash to pay herself a salary from the St. Paul business she started in 2011. But if passion and commitment matter, Simmons already is wealthy from her mission to train and place more minorities in health care jobs.

And as business continues to grow at fledgling Foundations Health Career Academy, Simmons should generate positive cash flow by the end of this year.

“Rachele is phenomenal,” said Tom Thompson, administrator at St. Paul’s Galtier Health Center. “She’s positive and she knows what she is doing. We’ve hired some of her graduates and never had any problem. Her people are very good. And we have a diverse clientele in our facility. So we need staff who speak different languages and who are from different backgrounds and races.”

Simmons is the founder, teacher, marketer and chief bottle washer at Foundations Health, a state-certified private school that has graduated 160 students through its four-week, certified nursing assistant/home health aide program. For many graduates, the course offers a first step into the growing health care industry into jobs that can pay as much as $20 per hour plus benefits.

Simmons, 44, has been a hospital nurse and last worked as a manager at Walgreens, training managers and others to use retail-medical equipment. And she always worked a shift or two a week as a hospital nurse to build a rainy-day fund.

Over the years, Simmons got used to being the only black nurse on the floor or in managerial meetings at Walgreens.

She also knew that health care is a growth area, particularly lower-cost primary care that can be delivered relatively inexpensively outside the hospital and help keep patients in their homes.

She also thought she could be an inspiration to young people of color.

“I just wanted to give something back,” said Simmons, who decided, as her sons reached adulthood, she could handle some business risk. “I had been involved in nursing for 25 years. I was always the nurse called to see the ‘diverse’ patients, often black. It meant so much to them.

“This is what I was called to do. Maybe we can start something that … will get more people of color in nursing, in science, in medicine. We need more black nurses and Hmong nurses and more diversity in health facilities.” She’s even had a couple of white medical students take the class because they wanted to learn the grass roots and work in diverse clinics.

Foundations Health, housed in the Hmong Professional Building a mile west of the State Capitol on University Avenue, is a first business step for Simmons.

Simmons is no stranger to drive and hard work. Divorced when her sons were toddlers, Simmons said her ex-husband never paid child support, forcing her for a short time onto public assistance. The St. Paul Highland Park High School graduate completed two-year nursing school in St. Paul and worked days while completing her registered-nurse degree at Minneapolis Community and Technical College, often bringing her boys to play in the commons while she attended class.

“She was a successful nurse and thrifty with her money,” said Isabel Chanslor, a business trainer with nonprofit Neighborhood Development Center, which for 20 years has provided training to several thousand would-be urban entrepreneurs, including Simmons. “She did not want to take a loan.’’

Last month, NDC recognized Simmons for her commitment to community as a finalist in the organization’s annual entrepreneurial awards.

“She’s a gutsy lady,’’ Chanslor said. “She’s high energy, sharp, rides her little motor scooter everywhere. She has a good business plan and she’s a really good instructor and very focused and dedicated, according to her students.”

Simmons has invested $50,000 in space and equipment. She uses word-of-mouth and social media to attract students. The 80-hour course costs about $950.

“My students are mostly young, single, with kids, without kids, battered, not battered, on welfare, not on welfare … most of them are working poor,” Simmons said. “If they want to work hard and truly better their life, we’ll take them.”

Na Yang graduated from Foundations Health in 2011, but can’t work as a nursing assistant because of an injury. So, she joined the office as a part-time office manager.

Simmons said Yang works more hours than she’s paid because of her commitment to the cause and the need to stay on top of the paperwork.

“You couldn’t find a better instructor,” Yang said of Simmons.

“She’s knowledgeable and passionate. She couldn’t do this without her passion.”

Source: Star Tribune

The American Nurses Association (ANA) this week applauded the introduction of federal legislation that empowers registered nurses (RNs) to drive staffing decisions in hospitals and, consequently, protect patients and improve the quality of care. The Registered Nurse Safe Staffing Act of 2013 (H.R. 1821), crafted with input from ANA, has sponsors from both political parties who co-chair the House Nursing Caucus—Reps. David Joyce (R-OH) and Lois Capps (D-CA), a nurse.

"Nurse staffing has a direct impact on patient safety," said ANA president Karen Daley, PhD, RN, FAAN.  "We know that when there are appropriate nurse staffing levels, patient outcomes improve. Determining the appropriate number and mix of nursing staff is critical to the delivery of quality patient care. Federal legislation is necessary to increase protections for patients and ensure fair working conditions for nurses."

Research has shown that higher staffing levels by experienced RNs are linked to lower rates of patient falls, infections, medication errors, and even death, ANA reported. And when unanticipated events happen in a hospital resulting in patient death, injury, or permanent loss of function, inadequate nurse staffing often is cited as a contributing factor.

The bill would require hospitals to establish committees that would create unit-by-unit nurse staffing plans based on multiple factors, such as the number of patients on the unit, severity of the patients’ conditions, experience and skill level of the RNs, availability of support staff, and technological resources.

The safe staffing bill also would require hospitals that participate in Medicare to publicly report nurse staffing plans for each unit. It would place limits on the practice of "floating" nurses by ensuring that RNs are not forced to work on units if they lack the education and experience in that specialty. It also would hold hospitals accountable for safe nurse staffing by requiring the development of procedures for receiving and investigating complaints; allowing imposition of civil monetary penalties for knowing violations; and providing whistle-blower protections for those who file a complaint about staffing.

ANA backed a similar staffing bill in the last Congress. This version includes requirements that a hospital’s staffing committee be comprised of at least 55 percent direct care nurses or their representatives, and that the staffing plans must establish adjustable minimum nurse-to-patient ratios.

Additionally, ANA has advocated for safe staffing conditions for the nation’s RNs through the development and updating of ANA’s Principles for Nurse Staffing, and implementation of a national nursing quality database program that correlates staffing to patient outcomes. 

To date, seven states have passed nurse safe staffing legislation that closely resembles ANA’s recommended approach to ensure safe staffing, utilizing a hospital-wide staffing committee in which direct care nurses have a voice in creating the appropriate staffing levels. Those states are Connecticut, Illinois, Nevada, Ohio, Oregon, Texas, and Washington.

Source: EndoNurse

BY ELIZABETH HANINK, RN, BSN, PHN

How do you approach continuing education? Do you seek out courses that will truly enhance your skills as a practitioner? Or do you simply look around a week before the renewal deadline and pick an online course you think you can complete in a short amount of time? Is price a deciding factor for you — getting the most hours for the lowest cost or only considering courses offered for free at the most convenient facility?  

We have all probably fallen into several of the above practices at one time or another. While California’s requirement of 30 CEUs per year can hardly be considered onerous, somehow continuing education falls to the bottom of our lists of priorities. Also, some courses are very expensive. Often, a single day at a seminar that offers 7.5 contact hours will run over $200. With the increase in license fees — now $140 — it is quite possible to spend a hefty chunk of money just keeping your license current. Nonetheless, there is real value in many of the courses offered, and we owe it to ourselves to make the most of our continuing education.  ➲

Research the Providers
Because the Board of Registered Nursing certifies course providers, not individual courses, the key is to look for a good provider, either one you know from past experience or one that comes recommended.
Courses generally need to be related to either direct or indirect client or patient care, like patient education strategies, cultural and ethnic diversity or skills courses like stoma care. Indirect patient care may include courses in nursing administration, quality assurance and nurse retention, as well as instructor courses for CPR, BLS or ALS.

Multiple Formats
You can find good courses in any of several formats:

Online:  There are wonderful online companies that offer excellent material and the advantages of time flexibility and low cost. California is very generous in allowing all 30 required hours to be completed online; not all states are as accommodating. Almost every online course offers the option of a hardcopy text if you want it,  and buying one for a few extra dollars is a good, inexpensive way to build up a reference library.  Many online courses also offer the option of retaking the final test several times over a lengthy period (although I have never come across a continuing education test that was even remotely difficult). Several courses also offer a webinar component that allows for greater participation. Virtually all professional organizations offer online courses to their members.

All-day sessions: Usually taught by an expert in a particular field, these classes do not offer as much flexibility or as low a cost as online courses, but can be much more rewarding. Many all-day courses are very hands-on, with tons of take-home material and opportunities to ask the instructor questions — a luxury rarely afforded by online courses. Many all-day sessions target nurses in a particular practice area and presume a certain amount of basic knowledge of the subject matter. (All continuing education courses require that the information provided be above and beyond that required for licensure.)

Fun classes: Some courses promise entertainment, as well as education. Trips to resorts and cruises come to mind, offering sun, scenery, shows and good food — and learning, to boot. Who wouldn’t like that? This is, of course, the most costly option you can choose, but it might be a good way to combine work with pleasure.

Staying Close to Home
Your employer can be a very good source for a wide variety of continuing education programs. These courses are often free to employees and inexpensive for others. Sometimes sponsored by medical equipment vendors or drug companies, many classes of this type are short-term and highly specific. Very often, supervisors are quite accommodating about scheduling if the class is offered in-house — especially if the class is directly related to the care you give. Cross-disciplinary offerings are frequent in hospital settings, and as long as the class is Category I, you can even take courses directed at the medical staff. 

Nurses often make the mistake of thinking that if an instructor is local, he or she has nothing useful to say. But you might be surprised at the credentials of some of your fellow employees. Both day-long and short lunch-hour seminars can be a boon to your professional development and easy ways to rack up the CE hours.

BRN Requirements
As you look for courses to take, don’t forget these essential BRN requirements:

• You cannot take courses designed for nonprofessionals or that focus primarily on self-improvement, like weight reduction or yoga (although some stress-management courses are allowed).

• Providers cannot allow for partial credit, although it is acceptable to break up multiple-day seminars into separate offerings, each with separate CE hours. Staying for only half the day will not cut it.

• If you take a course in California, it must have a California BRN provider number. If taken out of state, courses offered by the American Nurses Credentialing Center are acceptable, as are out-of-state courses offered by providers approved in another state — as long as the course are taken outside of California.

Exceptions to the Rule
The board also excuses certain licensees from needing to accrue CEUs:

•  Advanced degree candidates: If you are in the process of obtaining a higher degree, you can count some of your academic courses toward your CE requirement using the following equation: one semester unit equals 15 CEUs, one quarter unit equals 10 CEUs. 

• Hardship or disability: You may also be excused from some or all of your continuing education requirement if you can prove a personal hardship, such as a physical disability last more than a year, or if you are solely responsible for a totally disabled family member for more than a year.

•  Practicing outside California: If you are employed by a federal agency or in military service and are practicing outside of California, you can maintain your license without CEUs (although those organizations usually have their own requirements).

Other Considerations
Not working right now, but want to maintain an active license? You will need the CEUs, just like everyone else. But you can also choose inactive status; if you go on inactive status and then resume active status within eight years, you will only need 30 contact hours in total to be reinstated.

Don’t forget: It is not enough to take the course and earn the hours. You must retain proof of completion for at least four years, just in case you are one of the randomly selected ­­­­­­nurses whose CEUs the BRN decides to audit and verify.

Whatever your individual circumstances, don’t waste this opportunity for career growth. Choose your courses wisely and try to avoid having to select your CE hours based on expediency. This is the only post-licensure education some nurses will receive. Get as much as you can.   

Resources: 
The California Board of Registered Nursing website

By Georgann Yara

Clad in pajamas and a Diamondbacks cap, the “patient” lay still in the bed as Banner Health registered nurse Stacey Fuller looked on and answered questions from an inquisitive mother worried about her son’s asthma attack.

Fuller determined her “patient” displayed good vital signs — even without a heart, brain and other functioning organs.

A recent nursing school graduate, Fuller was interacting with one of 80 high-tech mannequins at the Banner Simulation Medical Center in Mesa, where some 1,500 registered nurses train a few days annually.

The mannequins give nurses the chance to practice their skills in a real-time setting before working at one of Banner’s medical centers because they simulate breathing, bleeding, giving birth and even speaking.

“At first, it’s odd having these pretend conversations. But you get used to it and you get to practice conversations that you would actually have with patients and their parents,” said Fuller, whose specialty is pediatrics. “I like to talk to people and explain things, so I think it’s a lot of fun.”

The 55,000-square-foot facility is among the largest in the world and gives new hires an opportunity to work out the kinks and adjust to any policies and procedures specific to Banner. The Mesa location is one of Banner’s two simulation centers in the Valley. The other is in central Phoenix.

The center has many of the same departments found in an actual hospital, such as an intensive-care unit, operating room, emergency department and pediatrics.

Recently, the simulation program received accreditation from the Society for Simulation in Healthcare in five areas of expertise, becoming one of three organizations in the world to achieve this status. Last year, the program was accredited by the American College of Surgeons.

Being placed in real scenarios has given Fuller a better idea of her strengths, like patient interaction, and areas she needs to work on, like time management.

“I’m practicing getting the timing down,” Fuller said. “What I like is that Banner hones their nurses’ education and is supportive of that. Other places don’t do that.”

As Fuller made her rounds, registered nurse and simulation specialist Vickie Hawkins sat in a control room in the pediatrics department. Here, she can watch nurses interact with patients and evaluate their performance. Nurses have the opportunity to see themselves at work by viewing the videos.

Hawkins also plays multiple roles, depending on the scenario. With Fuller’s asthma patient, she was the voice of the mother. In other situations she can play the patient or physician.

The simulation center gives new graduates the chance to function independently — a luxury that they typically don’t get to experience in training, Hawkins said. It also gives veteran nurses new to Banner exposure to situations that they may not have experienced despite their years in the field.

“We allow them to make decisions and mistakes because, unfortunately, mistakes are how we learn,” said Hawkins, who has worked at the center since it opened in 2009.

However, nurses aren’t the only ones gaining knowledge. Simulation director Karen Josey described a scenario that simulated post-labor hemorrhaging. It required taking a mannequin to Banner Gateway Medical Center in Gilbert and putting everyone involved, including representatives from the local blood bank, through the paces.

A few days later, doctors at Gateway repeated that scenario. But this time, it was for real.

“Everyone knew exactly what they had to do and they could do it quickly because they had just gone through it,” Josey said.

The training center is a far cry from when Josey, as a registered nurse in training years ago, practiced inserting IV’s by using oranges.

“We immerse them in a clinical environment so they get that complexity,” Josey said. “It’s about how realistic we can make it.”

Source: AZ Central

BY LYNDA LAMPERT

You’re the kind of person who’s in the right place at the right time.

No, I mean it.

Look at yourself. You’re a nurse when it’s a great time to be a nurse. Plus, you’re obviously thinking about your future (You’re reading this article, right?). You want to know where you need to be in 2013 in order to make the most money –– and be in the most demand.

I’ve pulled together the numbers to help you plan your next steps (and determine where your competition lies). These stats from the Bureau of Labor Statistics (BLS) may surprise you with some interesting projections.

Where the Jobs Are

If you love med-surg, get ready for some good news. According to the BLS, nurses can expect to find a variety of employment opportunities in privately owned, general medical surgical hospitals. This includes physician’s offices, local medical surgical hospitals, home health care agencies and nursing care homes. Job seeking nurses may also want to consider government agencies, nursing education and administrative roles in hospitals and insurance companies.

Salary Forecast

Although it may not seem like it sometimes, nursing is among the higher paid professions. In May 2010, the average annual median salary for nurses was $64,690 per year (the top 10 percent earned more than $95,130). So how will your salary stack up in the near distant future?

Nurses in private medical surgical hospitals can expect to earn $66,650 per year. Those who work in doctor’s offices, local medical surgical hospitals and home health agencies can all expect a salary just above $60,000.

Where the Competion Will Be

Although anecdotal evidence in the nursing community doesn’t necessarily point to a nursing shortage, statistics show that growth for the nursing profession is expected to increase exponentially by the year 2020. In fact, growth is projected to increase by 26 percent, while all other professions are only expected to grow by 14 percent.

That isn’t to say that some venues aren’t more competitive than others. Hospital nursing is a good place to find a job due to the relatively high turnover of nurses and the progressive aging of retirement-eligible nurses. The competition is expected to be much higher for positions in doctor’s offices and outpatient care centers as well due to the family-friendly shifts and relatively lower patient care demands.

Should You Beef Up Your Credentials?

The demand for nurses with at least a BSN is expected to rise in the US. Additionally, all advanced practice registered nurses, such as certified registered nurse practitioners, nurse midwives and nurse anesthetists are expected to be in higher demand. If you’re looking for the hot jobs in this profession, you would do well to advance your education as far as possible.

References:

Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2012-13 Edition, Registered Nurses.

By JESUS CHAVEZ Special to the Herald

Article from U.S. News

By DAVID BORNSTEIN

In 2010, 5.9 million children were reported as abused or neglected in the United States. If you were a policy maker and you knew of a program that could cut this figure in half, what would you do? What if you could reduce the number of babies or toddlers hospitalized for accidents or poisonings by more than half? Or provide a 5 to 7 point I.Q. boost to children born to the most vulnerable mothers?

Well, there is a way. These and other striking results have been documented in studies of a program called the Nurse-Family Partnership, or NFP, which arranges for registered nurses to make regular home visits to first-time low-income or vulnerable mothers, starting early in their pregnancies and continuing until their child is 2.

We tend to think of social change as more of an art than a science. “What’s unique about Nurse-Family Partnership is that the program was studied in what’s considered the strongest study design, and it showed sizable, sustained effects on important life outcomes which were replicated across different populations,” explained Jon Baron, president of the Coalition for Evidence-Based Policy, a nonpartisan group. “This is very unusual. There are probably only about ten programs across all areas of social policy that currently meet that standard.”

What that means, notes Baron, is that if policy makers replicate the program faithfully they can be confident that it will change people’s lives in meaningful ways — improving child and maternal health, promoting positive parenting, children’s school readiness and families’ economic self-sufficiency, and reducing juvenile delinquency and crime.

NFP is not a new idea — it’s almost 40 years old — but after decades of study the program, which has assisted 151,000 families, has the potential for broader impact, thanks to the Affordable Care Act’s Maternal, Infant, and Early Childhood Home Visiting Program, which provides $1.5 billion for states to expand such programs.

Done well, it could be among the best money the government spends. Investments in early childhood development produce big payoffs for society. (A 2005 RAND study estimated that NFP provided $5.70 in benefits to society for every dollar spent.) But there’s an important concern: home visiting programs are not all effective. When carefully studied, only a few have been shown to reduce the physical abuse and neglect of children. Among the programs that meet the government’s standard for funding, there are large variations in evidence of impact (pdf). Policy makers and proponents of home visiting would do well to pay attention to the specific elements in the Nurse-Family Partnership’s model that account for its success.

NFP was founded by David Olds, who directs the Prevention Research Center for Family and Child Health at the University of Colorado Health Sciences Center. Early in his career, Olds worked in a day care center in Baltimore because he believed that quality preschool attention would help disadvantaged children succeed in life. What he began to see was that, for some kids, it was already too late to make big gains. If children had been abused or neglected or exposed to domestic violence, or if their mothers had abused drugs, alcohol or tobacco while pregnant, their brains could have been damaged in ways that limited the children’s abilities to control impulses, sustain attention or develop language.

Olds developed NFP in the early 1970s. He conducted his first large study in 1977, in Elmira, N.Y., a semi-rural, mostly white, community with one of the highest poverty rates in the state. The program produced strong results. Follow-up studies would reveal that, by age 19, the youths whose mothers received visits from nurses two decades earlier, were 58 percent less likely to have been convicted of a crime. In the 1980s and 1990s, Olds spread the work to Memphis and Denver and subjected the program to more randomized study with populations of urban blacks and Hispanics. The results continued to be impressive. In 1996, NFP began wider replication; the model is now being implemented by health and social service providers in 40 states.

As Olds published his results, the idea gained momentum, but the imitations did not remain faithful to NFP’s approach. “People adopted all kinds of home visiting models and used our evidence to make claims,” he recalled. In the early 1990s, for example, the federal government, inspired in part by NFP, began a $240 million program to train paraprofessionals, rather than nurses, to make home visits to low-income families with young children. NFP also experimented in Denver, using paraprofessionals (trained from the communities they served) in place of nurses for a subset of families.

In both cases, paraprofessionals didn’t get the same results. When it came to improving children’s health and development, maternal health, and mothers’ life success, the nurses were far more effective. In the federal program, paraprofessionals produced no effects on children’s health or development or their parents’ economic self-sufficiency.

What’s special about nurses? For one thing, trust. In public opinion polls, nurses are consistently rated as the most honest and ethical professionals by a large margin. But there were other reasons nurses were effective. Pregnant women are concerned about their bodies and their babies. Is the baby developing well? What can I do for my back pain? What should I be eating? What birthing options are available? Those are questions mothers wanted to ask nurses, which was why they were motivated to keep up the visits, especially mothers who were pregnant for the first time.

Nurses had more influence encouraging mothers to delay subsequent pregnancies, Olds explained. They could identify emerging complications more promptly, and they were more successful at getting mothers to stop or reduce smoking, drug or alcohol use. This is vital. Prenatal exposure to neurotoxicants is associated with intellectual and emotional deficits. It can also make babies more irritable, which increases risks of abuse. (A mother who was abused herself is more likely to misinterpret an inconsolable baby’s crying as “bad behavior.”)

“A lot of the young mothers have had some pretty terrible early life experiences,” says Olds. “It’s not uncommon for them to have been abused by partners or never have had support and care from a mother. Their lives haven’t been filled with much success and hope. If you ask them what they want for themselves, it’s not uncommon for them to say, ‘What do you mean?’”

A big part of NFP’s work is helping them answer this question.

Consider the relationship between Rita Erickson and Valerie Carberry. Rita had had a methadone addiction for 12 years and was living from place to place in Lakewood, Colo. She found out she was pregnant; a parole officer told her about NFP. “I’d burned bridges with my family,” Rita told me. “I was running around with the wrong people. I didn’t have anyone I could ask about being pregnant.” In the early months, Valerie had to chase her around town, Rita recalled. “I was worried she might say, ‘This is too much hassle. Come back when you have your act together.’ But she stuck with me.”

Over the next two years, they embarked on a journey together. “I had a zillion questions,” Rita recalled. “I was really nervous at first. I had lived most of my adult life as a drug addict. I didn’t know how to take care of myself.” On visits, they discussed everything: prenatal care, nutrition, exercise, delivery options. After Rita’s daughter, Danika, was born, they focused on things like how to recognize feeding and disengagement cues, remembering to sleep when the baby sleeps, how to manage child care so Rita could go back to school. For Rita, what made the biggest impression was hearing about how a baby’s brain develops — how vital it was to talk and read a lot to Danika, and to use “love and logic” so she develops empathy. Once Valerie explained that when babies are touching their hands, they’re discovering that they have two. “To me that was really amazing,” Rita said.

This month, Rita is graduating from Red Rocks Community College with an associate degree in business administration. She’s going to transfer to Regis University to do a bachelors degree. Her faculty selected her as outstanding graduate based on leadership and academic achievement — and she was asked to lead the graduation procession and give one of the commencement speeches. Danika is thriving, Rita said. Recently, she came home from preschool and announced:  “Mommy, I didn’t have a good day at school today because I made some bad decisions and you wouldn’t be proud of me.” (She had pushed another child on the playground.) As for the NFP, Rita says that it helped her recover from her own bad decisions. When Valerie came along, she needed help badly. “I didn’t care about my life. I didn’t care about anything. I never ever thought I would have ended up where I am today.”

“When a woman becomes pregnant whether she’s 14 or 40, there’s this window of opportunity,” explained Valerie, who has been a nurse for 28 years and hasworked with more than 150 mothers in NFP over the past seven. “They want to do what’s right. They want to change bad behaviors, tobacco, alcohol, using a seat belt, anything. As nurses, we’re able to come in and become part of their lives at that point in time. It’s a golden moment. But you have to be persistent. And you have to be open and nonjudgmental.”

Beyond the match between nurses and first-time moms, there are multiple factors that make NFP work. (NFP has identified 18 key elements for faithful replication.) The dosage has to be right: Nurses may make 50 or 60 visits over two and a half years. The culture is vital: It must be non-judgmental and respectful, focusing on helping mothers define their own goals and take steps towards them. The curriculum should be rigorous, covering dozens of topics — from prenatal care to home safety to emotional preparation to parenting to the mother’s continuing education. Nurses need good training, close supervision and support, and opportunities to reflect with others about difficult cases. And, above all, data tracking makes it possible to understand on a timely basis when things are working and when they are not.

With the government making such a large investment in home visiting, it’s crucial for programs to get the details right. Otherwise, society will end up with a mixed bag of results, and advocates will have a hard time making the case for continued support. That would be a terrible loss. “When a baby realizes that its needs will be responded to and it can positively influence its own world,” says Olds, “that creates on the baby’s part a sense of efficacy — a sense that I matter.” It’s hard to imagine higher stakes.