• Gestational diabetes mellitus (GDM) and adverse pregnancy outcome in South Asia: a systematic review

      Mistry, Sabuj Kanti; Das Gupta, Rajat; Alam, Sabiha; Kaur, Kuljeet; Shamim, Abu Ahmed; Puthussery, Shuby; BRAC University, Dhaka; University of New South Wales; University of Dhaka; University of Bedfordshire (Wiley, 2021-07-03)
      Introduction The prevalence of gestational diabetes mellitus (GDM) is increasing in developing countries including the South Asian Nations. The current study aimed to examine the association of GDM with adverse pregnancy outcomes from foetal and maternal perspectives in South Asia. Methods A systematic review was conducted including primary studies published since January 2020 from South Asian countries. Following electronic databases were searched to locate the articles: MEDLINE, EMBASE and EMCARE. Data were extracted using a customized extraction tool and methodological quality of the included studies was assessed using modified Effective Public Health Practice Project (EPHPP) quality assessment tool. Narrative synthesis was performed as statistical pooling was not possible due to the heterogeneous nature of the studies. Results Eight studies were included in the review. Overall, the review found a positive correlation between GDM and adverse foetal outcomes such as macrosomia, neonatal hyperglycaemia, intrauterine growth retardation (IUGR), stillbirths and low birthweight (LBW), but the findings were not conclusive. GDM was also positively associated with preeclampsia but the association between GDM and C-section delivery was not conclusive. Conclusion Policymakers, public health practitioners and researchers in South Asia should take in to account the link between GDM and adverse pregnancy outcomes while designing interventions to promote maternal health in South Asia. Researchers should focus on conducting longitudinal studies in future to clearly understand the epidemiology and pathobiology of this issue.
    • Going beyond blame: reporting NHS medication errors in nursing home residents with diabetes

      Milligan, Frank; Gadsby, Roger; Ghaleb, Maisoon; Ivory, Philip; McKeaveney, Colette; Newton, Kathryn; Smith, Jackie; Randhawa, Gurch; University of Bedfordshire; Warwick Medical School; et al. (Royal College of General Practitioners, 2015-07-01)
      It is widely accepted in literature on patient safety that an open culture — one that seeks to understand the multiple reasons for error — is required to promote incident reporting and maximise learning for system improvement.1 In the attempt to deliver the research described here we encountered a culture of blame. Such a culture leads to low levels of medication error reporting with regard to NHS systems supplying the nursing home setting. This article explores the problem of this low level of reporting being detrimental to future learning on NHS medication errors.2 The study we undertook, ‘Root causes of medication errors in nursing home residents with diabetes: enhancing safety in NHS medicines management’, was funded by the Research for Patient Benefit (RfPB) programme. It focused on residents with diabetes in nursing homes, as defined by the Care Quality Commission (CQC),3 and involved consenting homes in Bedfordshire and Hertfordshire. Nursing homes were selected because medication delivery processes are slightly different from residential care home provision, although the incident reporting systems are similar. The aim of the study was to gather data on NHS errors, and report on and analyse them for learning purposes and solution development. The comments made here relate to the data collection process. The final research findings will be summarised in future publications.
    • Grieving a disrupted biography: an interpretative phenomenological analysis exploring barriers to the use of mindfulness after neurological injury or impairment

      Finlay, K. A.; Hearn, J.H.; Chater, Angel M.; University of Reading; Manchester Metropolitan University; University of Bedfordshire (Biomed Central, 2021-08-24)
      Mindfulness has demonstrated strong utility for enhancing self-management and health outcomes in chronic illness. However, sensation-focused mindfulness techniques may not be appropriate for clinical populations with neurological injury. This study aimed to identify how expert mindfulness teachers with sensory loss/impairment naturalistically adapt and experience mindfulness. We aimed to highlight the rationale for and barriers to mindfulness practice when living with sensory loss. A qualitative, semi-structured interview design was used, analysed via Interpretative Phenomenological Analysis (IPA). Eight (5 females, 3 males) mindfulness teachers with neurological injury were recruited via a national registry of Mindfulness for Health teachers. Interviews (range: 50-93 min) were completed, transcribed verbatim and analysed idiographically for descriptive, linguistic and conceptual themes, before a cross-case analysis was completed. Two superordinate themes were identified: (1) Overcoming a disrupted biography; and (2) Proactive self-management. These themes considered the challenge of reconciling, through grief, a past health status with the present reality of living with sensory loss due to Spinal Cord Injury, Multiple Sclerosis or Functional Neurological Disorder. Mindfulness was experienced as a method by which proactive choices could be made to maintain control and autonomy in health, reducing perceptions of suffering, psychological distress, cognitive reactivity and rumination. Mindfulness was found to support the self-management of health after neurological injury/impairment. Mindfulness meditation presented an initial challenge as trauma and grief processes were (re-)activated during mindfulness sessions. However, mindfulness was found to support the resolution of these grief processes and encourage adaptive approach-based coping and acceptance of health and neurological impairment/injury.
    • “Hard to reach, but not out of reach”: barriers and facilitators to recruiting Black African and Black Caribbean men with prostate cancer and their partners into qualitative research

      Bamidele, Olufikayo; McGarvey, Helen E.; Lagan, Briege M.; Chinegwundoh, Frank; Ali, Nasreen; McCaughan, Ellis; Ulster University; Barts Health NHS Trust; City University of London; University of Bedfordshire (Blackwell Publishing Ltd, 2018-12-12)
      Access and recruitment barriers may have contributed to the underrepresentation of Black African/Caribbean men and their partners in current psychosocial research related to prostate cancer survivors. Whilst some studies have explored recruitment barriers and facilitators from participants’ perspectives, little is known from researchers' point of view. This paper aimed to address this gap in the literature. Recruitment strategies included the following: cancer support groups, researchers’ networks, media advertisement, religious organisations, National Health Service hospitals and snowball sampling. Thirty-six eligible participants (men = 25, partners = 11) were recruited into the study. Recruitment barriers comprised of gate-keeping and advertisement issues and the stigma associated with prostate cancer disclosure. Facilitators which aided recruitment included collaborating with National Health Service hospitals, snowball sampling, flexible data collection, building rapport with participants to gain their trust and researcher's attributes. Findings highlight that “hard to reach” Black African/Caribbean populations may be more accessible if researchers adopt flexible but strategic and culturally sensitive recruitment approaches. Such approaches should consider perceptions of stigma associated with prostate cancer within these communities and the influence gatekeepers can have in controlling access to potential participants. Increased engagement with healthcare professionals and gatekeepers could facilitate better access to Black African/Caribbean populations so that their voices can be heard and their specific needs addressed within the healthcare agenda.
    • HCAs acquire work experience in a simulated hospital with manikins at the University of Bedfordshire

      Kpodo, Charles; Kemp, Anthony; Adams, Louise; Burden, Barbara (Mark Allen Healthcare, 2015-07-07)
      Healthcare Assistants (HCAs) are important members of the care team. This article looks at how experience in a simulated hospital can enhance their skills. This is achieved in a safe environment where the only consequence of a mistake is learning. The simulated hospital at the University of Bedfordshire is an immersive and fully authentic learning experience. It encapsulates a range of clinical areas that allows HCAs and others to work shifts caring for a range of interactive patients. Through focusing on the First Step Competence Checklist developed by the RCN, the simulated hospital allows HCAs to develop their confidence and competence in their caring skills, while also becoming familiar with the totality of the healthcare environment.
    • Health behaviour change considerations for weight loss and type 2 diabetes: nutrition, physical activity and sedentary behaviour

      Chater, Angel M.; Smith, Lindsey Rachel; Ferrandino, Louise; Wyld, Kevin; Bailey, Daniel Paul (John Wiley and Sons Ltd, 2020-11-30)
      Good nutrition, regular physical activity and low levels of sedentary behaviour are important in the prevention, management and treatment of obesity and type 2 diabetes mellitus (T2DM). Self-management requires individuals to have the capability to enact, opportunity to enable and motivation to perform relevant health behaviours. These behaviours, and the bio-psycho-social drivers of them, should be considered when working in the area of T2DM.
    • Health care providers’ perspectives of disrespect and abuse in maternity care facilities in Nigeria: a qualitative study

      Orpin, Joy; Puthussery, Shuby; Burden, Barbara; University of Bedfordshire (Springer, 2019-10-31)
      Objectives To explore healthcare providers’ perspectives of disrespect and abuse in maternity care and the impact on women’s health and well-being. Methods Qualitative interpretive approach using in-depth semi-structured interviews with sixteen healthcare providers in two public health facilities in Nigeria. Interviews were audio-recorded, transcribed, and analysed thematically. Results Healthcare providers’ accounts revealed awareness of what respectful maternity care encompassed in accordance with the existing guidelines. They considered disrespectful and abusive practices perpetrated or witnessed as violation of human rights, while highlighting women’s expectations of care as the basis for subjectivity of experiences. They perceived some practices as well-intended to ensure safety of mother and baby. Views reflected underlying gender-related notions and societal perceptions of women being considered weaker than men. There was recognition about adverse effects of disrespect and abuse including its impact on women, babies, and providers’ job satisfaction. Conclusions Healthcare providers need training on how to incorporate elements of respectful maternity care into practice including skills for rapport building and counselling. Women and family members should be educated about right to respectful care empowering them to report disrespectful practices.
    • Health impact assessment in Nigeria: an initiative whose time has come

      Chilaka, Marcus A.; Ndioho, Ibiangake; ; University of Bedfordshire; University of Salford (PAGEpress, 2020-03-19)
      Health Impact Assessment (HIA) is increasingly applied in many developed countries as a tool for advancing healthy public policy. This research was carried out to obtain a HIA situation report for Nigeria and to assess ways of enhancing the use of HIA to promote healthy public policy. Semi structured questionnaires were administered both online and by hand to health and nonhealth professionals in Nigeria. Inferential statistics was used in the analysis of the 510 responses that were received. Only 29% of the respondents had ever heard about HIA; similarly, only 19.3% of those who were aware of HIA had received any form of HIA training. However, 93.2% of respondents were convinced that HIA would be beneficial to the Nigerian health system. Using the approach of SWOT Analysis to discuss the findings, this research concludes that the time has now come, and the right conditions are in place, for the integration of Health Impact Assessment into public policy in Nigeria. Raising awareness and political commitment are the two major strategies to help drive this agenda forward.
    • “Health Party” intervention on genetic testing for ethnic minority women: study protocol

      Kabeya, Valencia; Puthussery, Shuby; Furmanski, Anna L. (Oxford University Press, 2019-11-20)
      Background Culturally appropriate interventions are needed to improve the uptake of genetic counselling and testing among ethnically diverse communities. This study aims to assess the feasibility and preliminary effectiveness of a “Health Party” intervention to increase awareness, knowledge and uptake of genetic testing for breast and ovarian cancer among ethnic minority women in the UK. Methods The “Health Party” intervention will include an educational session in a party setting. Participants will be taught by professionals about genetic testing and how to access genetic testing services in the UK National Health Service. We will recruit a sample of 60 women aged 18 years and over from key ethnic minority groups in the UK (Black African, Black Caribbean, Indian, Pakistani, Bangladeshi) and will conduct four community based sessions, each with about 15 participants. The outcomes will primarily relate to recruitment and attrition rates, data collection, study resources and intervention delivery. A quantitative pre-post evaluation with measurements before, shortly after, and at 6 months following the intervention will be conducted to assess the preliminary effectiveness on awareness, knowledge and uptake of genetic testing. We will use three way mixed analysis of variance (MANOVA) to analyse changes pre- and post- intervention. The fidelity of the intervention including facilitation strategies, quality of delivery and participant response will be assessed. Conclusions Findings will establish the feasibility of the intervention and will provide insights into its effectiveness to increase the awareness, knowledge and uptake of genetic testing for breast and ovarian cancer among women from ethnic minority groups in the UK. Impact: Depending on its feasibility and effectiveness, the intervention can be used to help women from ethnic minority groups to make informed choices about genetic testing and improve early diagnosis and treatment of breast and ovarian cancer. Key messages “Health Party” may be a feasible intervention for ethnic minority women in the UK. “Health Party” intervention may increase awareness, knowledge and uptake of services.
    • A healthy contribution

      Johnston, Marie; Weinman, John; Chater, Angel M. (British Psychological Society, 2011-12-31)
      The Health Psychology Section of the British Psychological Society was inaugurated in December 1986. This special feature celebrates progress during those 25 years. An introduction by the founding chair, a founding committee member, and a current committee member is followed by a series of selections from some of the top figures in the field, as they choose a significant contribution to the discipline and the health of the nation.
    • Hilbert-Huang transformation: application to postural stability analysis

      Amoud, Hassan; Snoussi, Hichem; Hewson, David; Duchêne, Jacques (IEEE, 2007-10-22)
      The aim objective of this paper is the analysis of the Centre Of Pressure (COP) time series by the means of the Hilbert Huang Transformation (HHT). The HHT consists of extracting the Intrinsic Mode Functions (IMFs) from an Empirical Mode Decomposition (EMD), and then applying the Hilbert Transformation on the IMFs. The trace of the HHT in the complex plane has a circular form, with each IMF having its own rotation frequency. The area of the circle represents a possible indicator of the postural stability status of the subjects. Experimental results show the effectiveness of the area of this circle in order to identify the post-vibratory effects on standing posture in healthy adult subjects.
    • The HOTSHOT taxonomy and a signature pedagogy framework for operating department practice: the juxtaposition to the academic apartheid surrounding higher order thinking

      Beckwith, Philip (SAGE, 2019-01-02)
      Bloom’s insistence on using verbs and Anderson and Karthwohl’s juxtaposition with nouns creates an academic apartheid, where there is only black and white with no grey when addressing the parts of speech used to define Higher Order Thinking. This paper embraces the grey and by draining the conceptual swamp surrounding traditional perceptions of Higher Order Thinking, creates fertile new ground which in turn feeds emergent notions, and allows pioneering characterisation of Higher Order Thinking to propagate.
    • How can health systems be strengthened to control and prevent an Ebola outbreak? a narrative review

      Regmi, Krishna; Gilbert, Ruth; Thunhurst, Colin (Taylor & Francis, 2015-11-24)
      The emergence and re-emergence of infectious diseases are now more than ever considered threats to public health systems. There have been over 20 outbreaks of Ebola in the past 40 years. Only recently, the World Health Organization has declared a public health emergency of international concern (PHEIC) in West Africa, with a projected estimate of 1.2 million deaths expected in the next 6 months. Ebola virus is a highly virulent pathogen, often fatal in humans and non-human primates. Ebola is now a great priority for global health security and often becomes fatal if left untreated. This study employed a narrative review. Three major databases MEDLINE, EMBASE, and Global Health were searched using both ‘text-words’ and ‘thesaurus terms’. Evidence shows that low- and middle-income countries (LMICs) are not coping well with the current challenges of Ebola, not only because they have poor and fragile systems but also because there are poor infectious disease surveillance and response systems in place. The identification of potential cases is problematic, particularly in the aspects of contact tracing, infection control, and prevention, prior to the diagnosis of the case. This review therefore aims to examine whether LMICs’ health systems would be able to control and manage Ebola in future and identifies two key elements of health systems strengthening that are needed to ensure the robustness of the health system to respond effectively.
    • How the integration of telehealth and coordinated care approaches impact health care service organization structure and ethos: mixed methods study

      Davidson, Rosemary; Barrett, David Ian; Rixon, Lorna; Newman, Stanton; ; ACT Program; University of Bedfordshire; University of Hull; City University of London (JMIR Publications, 2020-10-09)
      Coordinated care and telehealth services have the potential to deliver quality care to chronically ill patients. They can both reduce the economic burden of chronic care and maximize the delivery of clinical services. Such services require new behaviors, routines, and ways of working to improve health outcomes, administrative efficiency, cost-effectiveness, and user (patient and health professional) experience. The aim of this study was to assess how health care organization setup influences the perceptions and experience of service managers and frontline staff during the development and deployment of integrated care with and without telehealth. As part of a multinational project exploring the use of coordinated care and telehealth, questionnaires were sent to service managers and frontline practitioners. These questionnaires gathered quantitative and qualitative data related to organizational issues in the implementation of coordinated care and telehealth. Three analytical stages were followed: (1) preliminary analysis for a direct comparison of the responses of service managers and frontline staff to a range of organizational issues, (2) secondary analysis to establish statistically significant relationships between baseline and follow-up questionnaires, and (3) thematic analysis of free-text responses of service managers and frontline staff. Both frontline practitioners and managers highlighted that training, tailored to the needs of different professional groups and staff grades, was a crucial element in the successful implementation of new services. Frontline staff were markedly less positive than managers in their views regarding the responsiveness of their organization and the pace of change. The data provide evidence that the setup of health care services is positively associated with outcomes in several areas, particularly tailored staff training, rewards for good service, staff satisfaction, and patient involvement.
    • How young, disadvantaged fathers are affected by socioeconomic and relational barriers: a UK-based qualitative study

      Donald, Louisa; Davidson, Rosemary; Murphy, Suzanne; Hadley, Alison; Puthussery, Shuby; Randhawa, Gurch; ; University of Bedfordshire (2021-11-05)
      This article is based on the interviews of nine young, socially disadvantaged fathers from the UK. Young fathers are more likely to experience socioeconomic deprivation and disrupted pathways towards parenthood, which affect their participation in socially accepted trajectories of ‘father involvement’. Whilst this has received some attention in research, studies have largely neglected to examine the lived experiences of such fathers directly. The current article aims to address this gap, building upon the limited body of research that exists exploring the impact of socioeconomic and relational barriers on father involvement. In this study, three interrelated themes demonstrate the cyclical nature of generational disadvantage, reduced socioeconomic circumstances and disrupted relationships, providing a different perspective on the decreased levels of involvement exhibited by young fathers in prior research. The findings also enlighten our understanding of how these fathers can be better supported in policy and practice, thereby contributing to current academic debate.
    • Identification of complex health interventions suitable for evaluation: development and validation of the 8-step scoping framework

      Davidson, Rosemary; Randhawa, Gurch; Cash, Stephanie; University of Bedfordshire; Flying Start (JMIR Publications, 2019-03-05)
      Background: There is extensive literature on the methodology of evaluation research and the development and evaluation of complex interventions but little guidance on the formative stages before evaluation and how to work with partner organizations that wish to have their provision evaluated. It is important to be able to identify suitable projects for evaluation from a range of provision and describe the steps required, often with academic institutions working in partnership with external organizations, in order to set up an evaluation. However, research evaluating programs or interventions rarely discusses these stages. Objective: This study aimed to extend work on evaluability assessment and pre-evaluation planning by proposing an 8-Step Scoping Framework to enable the appraisal of multiple programs in order to identify interventions suitable for evaluation. We aimed to add to the literature on evaluability assessment and more recent evaluation guidance by describing the processes involved in working with partner organizations. Methods: This paper documents the steps required to identify multiple complex interventions suitable for process and outcome evaluation. The steps were developed using an iterative approach by working alongside staff in a local government organization, to build an evidence base to demonstrate which interventions improve children’s outcomes. The process of identifying suitable programs for evaluation, thereby establishing the pre-evaluation steps, was tested using all Flying Start provision. Results: The 8-Step Scoping Framework was described using the example of the local government organization Flying Start to illustrate how each step contributes to finding projects suitable for process and outcome evaluation: (1) formulating overarching key questions that encompass all programs offered by an organization, (2) gaining an in-depth understanding of the work and provision of an organization and engaging staff, (3) completing a data template per project/program offered, (4) assessing the robustness/validity of data across all programs, (5) deciding on projects suitable for evaluation and those requiring additional data, (6) negotiating with chosen project leads, both within and outside the organization, (7) developing individual project evaluation protocols, and (8) applying for ethical approval from the university and partner organization. Conclusions: This paper describes the processes involved in identifying suitable projects for evaluation. It adds to the existing literature on the assessment of specific programs suitable for evaluation and guidance for conducting evaluations by establishing the formative steps required to identify suitable programs from a range of provision. This scoping framework particularly relates to academic partners and organizations tasked with delivering evidence-based services designed to meet local needs. The steps identified have been described in the context of early years provision but can be applied to a range of community-based evaluations, or more generally, to cases where an academic partner is working with external stakeholders to identify projects suitable for academic evaluation.
    • Identification of the period of stability in a balance test after stepping up using a simplified cumulative sum

      Safieddine, Doha; Chkeir, Aly; Herlem, Cyrille; Bera, Delphine; Collart, Michèle; Novella, Jean-Luc; Dramé, Moustapha; Hewson, David; Duchêne, Jacques; University of Technology of Troyes; et al. (Elsevier, 2017-09-19)
      Falls are a major cause of death in older people. One method used to predict falls is analysis of Centre of Pressure (CoP) displacement, which provides a measure of balance quality. The Balance Quality Tester (BQT) is a device based on a commercial bathroom scale that calculates instantaneous values of vertical ground reaction force (Fz) as well as the CoP in both anteroposterior (AP) and mediolateral (ML) directions. The entire testing process needs to take no longer than 12 s to ensure subject compliance, making it vital that calculations related to balance are only calculated for the period when the subject is static. In the present study, a method is presented to detect the stabilization period after a subject has stepped onto the BQT. Four different phases of the test are identified (stepping-on, stabilization, balancing, stepping-off), ensuring that subjects are static when parameters from the balancing phase are calculated. The method, based on a simplified cumulative sum (CUSUM) algorithm, could detect the change between unstable and stable stance. The time taken to stabilize significantly affected the static balance variables of surface area and trajectory velocity, and was also related to Timed-up-and-Go performance. Such a finding suggests that the time to stabilize could be a worthwhile parameter to explore as a potential indicator of balance problems and fall risk in older people.
    • Identifying patterns in signs and symptoms preceding the clinical diagnosis of Alzheimer's disease : retrospective medical record review study and a nested case -control design

      Bature, Fidelia; Pang, Dong; Robinson, Anthea; Polson, Norma; Pappas, Yannis; Guinn, Barbara-Ann (Bentham, 2018-04-04)
      OBJECTIVE: Evidence suggests that individuals with Alzheimer's disease (AD) are often diagnosed in the later stages of their disease with a poor prognosis. This study aimed to identify patterns in signs and symptoms preceding the clinical diagnosis of AD to suggest a predictive model for earlier diagnosis of the disease in the primary care. DESIGN: A retrospective medical record review; nested case control design. PARTICIPANTS: Participants included one hundred and nine patients from three general practice (GP) surgeries in Milton Keynes and Luton Clinical Commissioning groups (CCG) (37 cases with AD and 72 controls without AD). MAIN OUTCOME MEASURE: A retrospective analysis using the logistic regression of the presence of signs and symptoms before the diagnosis of AD was attained. Identification of the timing and sequence of appearance of these presentations as first reported before the clinical diagnosis was measured. RESULT: Episodic memory with an odds ratio of 1.85 was the most frequent presentation, documented in 1.38% of the controls and 75.6% in cases. Auditory disturbance with an odds ratio of 3.03, which has not previously been noted except in the form of auditory hallucination, could have a diagnostic value. CONCLUSION: Auditory disturbance, which occurred mostly in the Caucasian females, could discriminate individuals with AD from those without. The symptom, which presented up to 14.5 (mean time) years prior to clinical diagnosis, was identified in Caucasians and mixed race individuals only.
    • IFITM proteins drive type 2 T helper cell differentiation and exacerbate allergic airway inflammation

      Yánez, Diana C.; Sahni, Hemant; Ross, Susan; Solanki, Anisha; Lau, Ching-In; Papaioannou, Eleftheria; Barbarulo, Alessandro; Powell, Rebecca; Lange, Ulrike C.; Adams, David J.; et al. (Wiley, 2018-10-26)
      T cells differentiated more efficiently to Th1, whereas Th2 differentiation was inhibited. Ifitm-family-deficient mice, but not Ifitm3-deficient mice, were less susceptible than WT to induction of allergic airways disease, with a weaker Th2 response and less severe disease and lower Il4 but higher Ifng expression and IL-27 secretion. Thus, the Ifitm family is important in adaptive immunity, influencing Th1/Th2 polarization, and Th2 immunopathology.
    • Impact of clinical placements on graduates' choice of first staff-nurse post

      Wareing, Mark; Taylor, Renate; Wilson, Aileen; Sharples, Adrienne; University of Bedfordshire (Mark Allen, 2018-09-01)
      The demand for quality clinical placements for pre-registration healthcare students is set to rise as student numbers within medical and non-medical education are to increase at a time when there is a recruitment crisis within nursing. A study was conducted to identify what impact clinical placements have on pre-registration adult nursing students’ choice of clinical speciality as a newly qualified nurse (NQN). Data was collected from students on their final day of a BSc (Hons) programme at two campus sites at an east of England University. Participants regard the desirability of a clinical placement on the basis of the quality of the learning, working and clinical environment and nature of the speciality. The influence of clinical placements on the choice of first destination of NQNs more than doubles within the final year of study. Clinical placements generate vivid experiences which exert a strong influence on the first employment destination decisions of NQNs.