Multiprofessional learning: the attitudes of medical, nursing and pharmacy students to shared learning

OBJECTIVES: The belief that the effectiveness of patient care will improve through collaboration and teamwork within and between health care teams is providing a focus internationally for 'shared learning' in health professional education. While it may be hard to overcome structural and organizational obstacles to implementing interprofessional learning, negative student attitudes may be most difficult to change. This study has sought to quantify the attitudes of first-year medical, nursing and pharmacy students' towards interprofessional learning, at course commencement. DESIGN: The Readiness for Interprofessional Learning Scale (RIPLS) (University of Liverpool, Department of Health Care Education), was administered to first-year medical, nursing and pharmacy students at the University of Auckland. Differences between the three groups were analysed. SETTING: The Faculty of Medical and Health Sciences, University of Auckland. RESULTS: The majority of students reported positive attitudes towards shared learning. The benefits of shared learning, including the acquisition of teamworking skills, were seen to be beneficial to patient care and likely to enhance professional working relationships. However professional groups differed: nursing and pharmacy students indicated more strongly that an outcome of learning together would be more effective teamworking. Medical students were the least sure of their professional role, and considered that they required the acquisition of more knowledge and skills than nursing or pharmacy students. CONCLUSION: Developing effective teamworking skills is an appropriate focus for first-year health professional students. The timing of learning about the roles of different professionals is yet to be resolved.     

Learning together: clinical skills teaching for medical and nursing students

OBJECTIVE: To evaluate the feasibility and effectiveness of shared learning of clinical skills for medical and nursing students at the University of Manchester. DESIGN: Medical and nursing students learned clinical skills in either uniprofessional or multiprofessional groups. These groups rotated through skills stations taught by multiprofessional facilitators. The groups stayed together for a series of 3 sessions held at weekly intervals (an induction meeting followed by 2 3-hour teaching sessions). Both quantitative and qualitative methods were used to evaluate the project. CONTEXT: A total of 113 Year 3 students registered on the Medical (n = 41), Bachelor of Nursing (Honours) (n = 43) or the Diploma for Professional Studies in Nursing (n = 29) courses participated in the project which was set in the clinical skills unit of a teaching hospital. RESULTS: Pre- and post self-evaluation of confidence levels for the taught skills revealed a statistically significant increase for all skills. The primary reason students gave for participation in the project was to learn or consolidate skills. An additional inducement for participation was the opportunity to share knowledge and observations between professional groups. Tutors also evaluated the experience favourably, particularly with regard to small group discussions. They indicated that the programme provided an opportunity to standardise clinical skills teaching. CONCLUSION: Collaborative learning opportunities for nursing and medical students are feasible and add value to the learning experience. Data indicate positive outcomes of learning in multiprofessional groups, comprising increased confidence levels, increased understanding of others' professional roles and personal development.     

Continuity in a longitudinal out-patient attachment for Year 3 medical students

Context  Concerns about the quality of medical student learning experiences during traditional clerkships have prompted calls to restructure clinical education around continuity. Many US medical schools have added longitudinal out-patient attachments to enhance student continuity with patients and supervising doctors. However, continuity with patients can be difficult to achieve and little is known about the independent effect of continuity with a supervising doctor and setting. This study describes students' perceptions of the types of continuity experienced in longitudinal attachments and the learning associated with continuity.
Methods  This is a qualitative study using a grounded theory approach. Interviews were conducted with 12 Year 3 medical students about their continuity experiences with patients, supervisors and settings during their attachment. The resulting data were subjected to thematic analysis.
Results  Continuity with supervising doctors provided students with career mentorship and personal support. Student autonomy varied and was most dependent on the supervisor and setting. Students with patient continuity were more likely to report learning about chronic illness and communication skills. Students described the longitudinal attachment as helping them to develop their clinical skills and gain self-confidence within their role as future doctors, and as influencing their career choice.
Conclusions  There is much variation in student experiences of patient continuity during a longitudinal attachment. Continuity with patients, supervisors and settings affects student learning in different ways. Additional dimensions of the experience, such as the nature of the patient–doctor relationship, the pace of work and the patient population, impact learning outcomes and should be considered when continuity experiences are being designed.     

"I get to spend time with my patients": nursing home physicians discuss their role

OBJECTIVES: The purpose of this study was to learn about the role of the nursing home physician, and to begin to identify and articulate key concepts related to the role. DESIGN: A qualitative exploratory methodology was selected. Two medical students interviewed nursing home physicians in person, using open-ended questions. SETTING: The data reflect the nursing home setting. PARTICIPANTS: Twelve physicians who practice full-time or part-time in a nursing home setting were interviewed. Six physicians were fellowship trained and seven were affiliated with an academic medical center. Eight physicians were from an urban area, and four were from a rural area in a Midwestern state. MEASUREMENT: Qualitative data were grouped and coded to develop conceptual categories. RESULTS: Physicians were categorized as "pursuers, inheritors, or practice builders," based on their path to coming to care for nursing home residents. The medical directors among the physicians reported that their role was heavily dependent upon the desires of the nursing home administrator. Students were encouraged to visit many nursing homes to learn about the different ways in which the medical director role can be played out. Physicians reported positive aspects of their role including relationships with residents, families,staff; interesting and meaningful patient care; and autonomy. Less desirable aspects included: staff turnover, difficult expectations, and administrative issues. Although physicians indicated that social and indeed professional stigma are troublesome to people who work in nursing homes, they assured the medical student interviewer that caring for nursing home residents was gratifying and meaningful work. CONCLUSION: The need for physicians to care for the growing number of nursing home residents will continue for decades. Learning more about how physicians come to care for nursing home residents can be used to develop better ways to recruit, train, and retain physicians. Information about what nursing home physicians value about their role can be used to structure more desirable roles.     

Trainee health care professionals'' knowledge of the health risks associated with obesity

BACKGROUND: Trainee nurses, doctors and dietitians will direct the future of obesity treatment and prevention. To do so effectively, they must have sufficient knowledge regarding the health risks associated with obesity and feel that part of their professional role is to counsel obese patients regarding these risks. METHODS: An online survey collected data on professional roles, training needs and the Obesity Risk Knowledge-10 (ORK-10) scale from 38 dietetic, 88 nursing (Diploma), 74 nursing (Masters) and 389 medical students. RESULTS: Final-year dietetic students demonstrated higher ORK-10 scale scores than final-year nursing (Dip), nursing (MSc) and medical students (P < 0.001). The majority of students agreed that part of their profession's role was to counsel obese patients about the health risks associated with obesity. Dietetic students were more satisfied with the teaching they had received than each of the other student groups (P < 0.05). CONCLUSION: Future health care professionals recognize their responsibility to communicate health risk information to obese patients. Dietetic students have a sound knowledge base to support them in this. Educators of trainee nurses and doctors may like to respond to their students' lower levels of knowledge and desire for more training.     

Medical students’ professional identity development in an early nursing attachment

Medical Education 2010: 44 : 674–682 Objectives The importance of early clinical experience for medical training is well documented. However, to our knowledge there are no studies that assess the influence of very early nursing attachments on the professional development and identity construction of medical students. Working as an assistant nurse while training to be a doctor may offer valuable learning experiences, but may also present the student with difficulties with respect to identity and identification issues. The aim of the present study was to describe first‐year medical students’ perceptions of nurses, doctors and their own future roles as doctors before and after a nursing attachment. Methods A questionnaire containing open questions concerning students’ perceptions of nurses, doctors and their own future roles as doctors was administered to all Year 1 medical students (n = 347) before and directly after a 4‐week nursing attachment in hospitals and nursing homes. We carried out two confirmatory focus group interviews. We analysed the data using qualitative and quantitative content analyses. Results The questionnaire was completed by 316 students (response rate 91%). Before starting the attachment students regarded nurses as empathic, communicative and responsible. After the attachment students reported nurses had more competencies and responsibilities than they had expected. Students’ views of doctors were ambivalent. Before and after the attachment, doctors were seen as interested and reliable, but also as arrogant, detached and insensible. However, students maintained positive views of their own future roles as doctors. Students’ perceptions were influenced by age, gender and place of attachment. Conclusions An early nursing attachment engenders more respect for the nursing profession. The ambivalent view of doctors needs to be explored further in relation to students’ professional development. It would seem relevant to attune supervision to the age and gender differences revealed in this study.     

Students' learning experiences from interprofessional collaboration on a training ward in municipal care

One way to offer students pursuing health and social care programmes realistic experiences of teamwork is interprofessional training wards where students from different educational programmes learn teamwork by working together. In the present study, a training ward in municipal care for older people was evaluated. Students from occupational therapy, nursing and social work programmes worked together on the ward for 3 weeks to learn with, from and about each other. The aim of the study was to compare students' attitudes towards practice on a training ward before and after and to evaluate goal fulfilment after 3 weeks' interprofessional education on a training ward. An attitude questionnaire was distributed to all students before and after their time on the ward, supplemented with a retrospective goal-fulfilment questionnaire afterwards. The results show that the collaborative, social experience the training ward offers was appreciated by the students and in most respects, met the learning goals set up for the course. The most important learning experience was working together in a real-life setting. However, there are some issues to take into consideration when planning and developing training wards. The setting needs to be realistic and relevant in relation to future roles for all of the student groups involved. The value and purpose of engaging together in basic patient care needs to be the subject of further investigation. When it comes to fostering competent team-workers, training wards seem to be one way forward. But to fully understand the challenges and difficulties involved in planning these wards, the learning achieved must be understood in the context of the setting as a whole, in all its aspects.     

Expectations and opinions of pregnant women about medical students being involved in care at the time of delivery

Information was collected from pregnant women about their knowledge of and previous experience with medical students; their opinions towards medical students being involved at the time of delivery and the socio-economic and religious influences on these. The format of the study was a self-administered questionnaire survey. The setting was a teaching hospital in the UK. In total, 118 pregnant women aged between 15 and 46 years, with a gestational age of 18–42 weeks were surveyed. Factors which significantly influenced acceptance of medical students were found to be previous number of children ( P  = <0·001) and religious beliefs of the pregnant women ( P  = 0·002). Only 51·4% of antenatal women knew that a `medical student' is a doctor in training and most assumed that the role of the student at the time of delivery required very few clinical skills. Only 13·6% knew that medical students could deliver a baby under supervision. Of the 118 subjects, 95·4% thought that student participation at the time of delivery was a worthwhile learning experience; however, only 74·6% were actually willing for a student to be involved. In conclusion, pregnant women appear to have made their decisions about medical student participation by balancing personal needs with a sense of responsibility to help in the education of others. The results suggest that patients need more information about medical students, including an explanation of the term `medical student' and an outline of the role they play during the intrapartum period.     

Learning in a clinical education programme in primary care: the Maastricht Adoption Programme

INTRODUCTION: At Maastricht University, the integration of knowledge, skills and attitudes in preclinical medical education is promoted by an 'Adoption Programme', where students carry out assignments in a general practice setting. The assignments are explained and discussed in practical medical coaching groups. The aim of this study was to examine the relationships between the elements that affect learning in the programme. METHOD: Data from the evaluation questionnaires of 188 medical students were used to test a causal model of learning in the programme. A distinction was made between 'action' and 'reflection on action'. We examined the relationships between perceived instructiveness (the programme's value as a learning experience) and the following variables: comprehensibility; feasibility and execution of the assignments; time spent on the assignments, and the direct and indirect influences of the hosting general practitioner (GP) and the practical medical coaching group. RESULTS: Performing the assignments had little effect on perceived instructiveness. Coaching by the hosting GP influenced the execution of assignments mainly by its effect on feasibility. Coaching by the GP and in the practical medical coaching groups barely affected perceived instructiveness. DISCUSSION AND CONCLUSION: The model gives insight into the contribution of aspects of the Adoption Programme to student learning. The results are probably negatively influenced by the insufficient priority given to the Adoption Programme in the practical medical coaching groups and by inadequate instruction given to the GPs for the purposes of their coaching role. More careful planning of patient-related assignments is recommended. Reflection on assignments and feedback on procedures are needed to lift practical experience onto a higher educational level.     

‘Can you take a student this morning?’ Maximising effective teaching by practice nurses

Objectives  Little is known about the contribution nurses make to medical student learning. This study set out to explore the nature of practice nurse teaching during the general practice clerkship and to investigate ways in which the teacher and learner (the practice nurse and the medical student) can be best supported to maximise learning.
Methods  Mixed focus groups were conducted with general practitioner educational supervisors and practice nurses. Further focus groups were conducted with students on completion of clerkships.
Results  There is wide variation in the delivery, organisation and expectations of practice nurse teaching. Although there is some evidence of a passive learning experience, the learning dynamic and the student−nurse relationship are regarded highly.
Conclusions  Time spent with practice nurses is an important part of the clerkship in general practice. The nature of the practice nurse–medical student relationship differs from that of the educational supervisor–medical student relationship and can be built upon to maximise learning during the clerkship. The experience for the practice nurse, medical student and supervisor can be enhanced through formal preparation for delivering teaching.     

Simulation in undergraduate medical education: bridging the gap between theory and practice

OBJECTIVE: To evaluate the use of simulation-based teaching in the medical undergraduate curriculum in the context of management of medical emergencies, using a medium fidelity simulator. DESIGN: Small groups of medical students attended a simulation workshop on management of medical emergencies. The workshop was evaluated in a post-course questionnaire. SUBJECTS: All Year 4 medical students allocated to the resuscitation rotation during the first half of 2002. MAIN OUTCOME MEASURES: Student perceptions of learning outcomes, the value of the simulation in the undergraduate curriculum and their self-assessed improved mastery of workshop material. RESULTS: A total of 33 students attended the workshop and all completed questionnaires. Students rated the workshop highly and found it a valuable learning experience. In all, 21 (64%) students identified teamwork skills as key learning points; 11 (33%) felt they had learnt how to approach a problem better, particularly in terms of using a systematic approach, and 12 (36%) felt they had learnt how to apply their theoretical knowledge in a clinical setting better. All 33 students were positive about the use of simulation in their training; 14 students wrote that simulation should be used more or should be mandatory in training; 5 students commented positively on the realism of the learning experience and a further 5 said they valued the opportunity to learn new skills in a safe environment. CONCLUSION: This study demonstrates that medical students value simulation-based learning highly. In particular, they value the opportunity to apply their theoretical knowledge in a safe and realistic setting, to develop teamwork skills and to develop a systematic approach to a problem. A medium fidelity simulator is a valuable educational tool in medical undergraduate education.     

Stigma and attitudes towards antenatal depression and antidepressant use during pregnancy in healthcare students

Depression in pregnancy or antenatal depression (AD) occurs in approximately one in five women, with potentially deleterious effects to the mother and fetus. People are encouraged to get treatment for depression; however, pregnant women can experience stigma when they reach out for help with depression. Research indicates that healthcare professionals hold stigma against patients who experience mental health conditions, including depression. The public, as well as healthcare professionals may have negative attitudes towards antidepressant use during pregnancy, despite evidence that many antidepressants are relatively safe for use in pregnancy. The objective of this project was to determine what knowledge and opinions healthcare students may hold towards antenatal depression and its treatment, and whether further knowledge and experience lessened the stigma. Medical, pharmacy, and nursing students (n = 309) were given a scenario regarding a woman with AD based on Corrigan’s Attribution Questionnaire and asked seven questions based on the scenario that assessed their level of stigma and questions related to treatment. Each student group demonstrated some stigma towards the woman and all groups lacked knowledge regarding treatment of AD. Overall, the nursing students were the most stigmatizing of the three groups. The study demonstrates that healthcare students hold stigma towards people with mental health problems, including pregnant depressed women. It points to a need to increase education about antenatal depression and its treatment.     

Early clinical experience: do students learn what we expect?

Medical Education 2011: 45 : 731–740 Context Early clinical experience is thought to contribute to the professional development of medical students, but little is known about the kind of learning processes that actually take place. Learning in practice is highly informal and may be difficult to direct by predefined learning outcomes. Learning in medical practice includes a socialisation process in which some learning outcomes may be valued, but others neglected or discouraged. Objectives This study describes students’ learning goals (prior to a Year 1 nursing attachment) and learning outcomes (after the attachment) in relation to institutional educational goals, and evaluates associations between learning outcomes, student characteristics and place of attachment. Methods A questionnaire containing open‐ended questions about learning goals and learning outcomes was administered to all Year 1 medical students (n = 347) before and directly after a 4‐week nursing attachment in either a hospital or a nursing home. Two confirmatory focus group interviews were conducted and data were analysed using qualitative and quantitative content analyses. Results Students’ learning goals corresponded with educational goals with a main emphasis on communication and empathy. Other learning goals included gaining insight into the organisation of health care and learning to deal with emotions. Self‐reported learning outcomes were the same, but students additionally mentioned reflection on professional behaviour and their own future development. Women and younger students mentioned communication and empathy more often than men and older students. Individual learning goals, with the exception of communicating and empathising with patients, did not predict learning outcomes. Conclusions Students’ learning goals closely match educational goals, which are adequately met in early nursing attachments in both hospitals and nursing homes. Learning to deal with emotions was under‐represented as a learning goal and learning outcome, which may indicate that emotional aspects of medical students’ professional development are neglected in the first year of medical education.     

Student perceptions about the characteristics of an effective discussion during the reporting phase in problem-based learning

To explore student perceptions of factors contributing to the effectiveness of discussions in the reporting phase of the problem-based learning (PBL) process, where students report and synthesise the results of self-study. Forty-eight Year 1 and 2 medical students participated in 6 focus group interviews about the characteristics of effective group discussions and possible improvements. The data were analysed qualitatively in several stages. The analysis yielded 4 main characteristics of effective discussions: asking for, giving and receiving explanations; integrating and applying knowledge; discussing differences with regard to learning content, and guiding and monitoring the content and the group process of the discussion. Integrating and applying knowledge included structuring, relating and summarising information and providing examples from practice. Discussing different opinions included discussing a variety of literature resources and disagreements. The main learning effects mentioned by the students were retention, understanding, integration and application of knowledge. Students have clear ideas about what promotes effective discussions during the reporting phase. Their PBL experience has provided them with some insights that are in line with theory and research on collaborative learning. Future research should examine differences between student and tutor perceptions of the quality of discussions. Introductions to PBL for students and tutors should include training in asking open but focused questions, supporting explanations with arguments and dealing with conflicts about learning content. Tutors should be trained in giving effective and personal feedback. Collaborative creation of external knowledge representations (i.e. concept maps) should be advocated, as should variety of literature resources.     

Marginalisation of dental students in a shared medical and dental education programme

Objectives  Internationally, there are a number of universities at which medical and dental education programmes share common elements. There are no studies about the experiences of medical and dental students enrolled in different programmes who share significant amounts of learning and teaching.
Methods  Semi-structured interviews and focus groups were conducted with 36 students and staff in a learning programme shared between separate medical and dental faculties. They were transcribed and an iterative process of interpretation and analysis within the theoretical framework of the contact hypothesis and social identity theory was used to group data into themes and sub-themes.
Results  Dental students felt 'marginalised' and felt they were treated as 'second-class citizens' by medical students and medical staff in the shared aspects of their programmes. Contextual factors such as the geographical location of the two schools, a medical : dental student ratio of almost 3 : 1, along with organisational factors such as curriculum overload, propagated negative attitudes towards and professional stereotyping of the dental students. Lack of understanding by medical students and faculty of dental professional roles contributed further.
Conclusions  Recommendations for reducing the marginalisation of dental students in this setting include improving communication between faculties and facilitating experiential contact. This might be achieved through initiating a common orientation session, stronger social networks and integrated learning activities, such as interprofessional problem-based learning and shared clinical experiences.     

Interprofessional training in the context of clinical practice: goals and students' perceptions on clinical education wards

AIMS: This paper describes the context of interprofessional training on clinical education wards (CEWs) and reports students' perceptions of this type of interprofessional and professional training. CONTEXT: A 2-week interprofessional clinical course was designed for medical students in their surgical eighth term, and nursing, occupational therapy and physiotherapy students, all in their sixth term. Clinical tutors were responsible for the patients and also supervised the students. The goals for the students included: to provide the patients with good medical care, nursing and rehabilitation; to develop their own professional roles; to enhance their level of understanding of the other professions; to stress the importance of good communication for teamwork and for patient care; to enhance understanding of the role of the patient, and to become more aware of ethical aspects of health care. MATERIAL AND METHODS: A questionnaire developed by teachers from the 4 educational departments was used. A total of 962 students responded (78%). RESULTS: The CEWs provided the students with good clinical practice in terms of training in their own professions as well in learning more about the other professions. The importance of good communication for teamwork and for patient care was recognised. The quality of supervision and students' perception of their own professional roles were important factors regarding satisfaction with the CEW course. CONCLUSIONS: The CEW course seemed to provide the students with an opportunity to develop their own professional roles and their functions as team members.     

‘They don’t know much about us’: educational reform impacts on students’ learning in the clinical environment

Placements are an integral component of the medical, nursing, and allied health curriculum. Literature on problem-based learning indicates that curriculum change can impact student experience. However, outside of the nursing literature, there is little research on the impact of education reform on students’ experiences of placements. This paper reports on medical, midwifery and paramedic students’ perception of the impact of education reform they experienced in the clinical setting. A qualitative study using a semi-structured schedule was conducted. Data was collected using focus groups (17), individual interviews (48) and written responses (2) from undergraduate students (103) and graduates (27) from a tertiary institution in Victoria, Australia. Recorded interviews were analysed, coded and categorised into themes. Whilst students indicated they were prepared for the impact of educational reform on their placement experience, they perceived that clinical educators responsible for teaching them were less prepared. Three themes were identified from the data: clinical educator’s lack of familiarity with new curriculum, clinical educator’s negative attitudes to curricular change and looking to the future. Our study advances the understanding of the implications of education reform during the clinical placement of medical, midwifery, and paramedic students. Whilst important lessons can be learned from the medical and nursing literature this study highlights that staff responsible for curriculum change need to action change management process to ensure that the clinical educators are able to deliver the revised program.     

The consequences of authentic early experience for medical students: creation of mētis

Context Authentic early experience (AEE) describes experiences provided to new medical students to undertake ‘human contact’ to enhance learning. Although the concept of AEE is not new, and was commonplace prior to the Flexner Report of 1910, little is known about how or why meaning and knowledge are constructed through early student placements in medical, social and voluntary workplaces. Variance among settings means AEE is a collection of non‐uniform, complex educational interventions which require students to make repeated transitions between different workplaces and their university institution. The purpose of this paper is to develop theory in this context. Methods We report on a study undertaken in a UK medical school using interviews and discussion groups to generate data from students, workplace supervisors and school faculty staff. We used narrative analysis to access knowledge and meaning construction, in combination with analytic tools drawn from thematic and interpretative approaches to phenomena. We sought to refine theoretical understanding through the application of mētis, a socio‐cultural theory novel to the field of medical education. Results Scott’s concept of mētis provides a useful theoretical framework for understanding how AEE works for students in terms of their creation of meaning and how they choose to use it in relation to formally recognised knowledge. Knowledge and meaning, generated as a consequence of AEE, contained dichotomies and paradoxes. Students improvised, in the face of unpredictability and uncertainty, to create a form of mētis that allowed them to handle the perceived competing demands of AEE settings and the medical school. Discussion We demonstrate how meaning making can be conceived of as student mētis arising from social processes in students’ learning interactions. We suggest that the development of collaborative working with students could potentiate positive forms of student mētis, thereby maximising desirable educational consequences. Further work is required to establish effective ways to do this.     

A Comparison of Problem-Based and Conventional Curricula in Nursing Education

The purpose of this study was to compare graduating baccalaureate students in a problem-based curriculum with those in a conventional nursing program with regard to perceived preparation for clinical practice, clinical functioning, knowledge and satisfaction with their education. Prior tograduation, students completed a self-report questionnaire that consisted of five sections and took about 45 minutes to complete. Following graduation, their pass rates on the National Nursing Registration Examination (RN Exam) were also compared. The findings indicated no significant differences in their perceived preparation for nursing practice, although the conventional students scored higher in all areas. There were also no significant differences between the two groups in their perceived clinical functioning, although there was a trend toward higher function in the areas of communication and self-directed learning in the PBL group. There were no statistically significant differences in RN scores. The PBL students scored significantly higher on perceptions of their nursing knowledge, particularly in the areas of individual, family and community health assessment, communication, teaching/learning, and the health care system. The students undertaking the PBL program were more satisfied with their educational experience than their counterparts in the conventional program, indicating higher satisfaction with tutors, level of independence, assessment and program outcomes, but no difference in relation to workload orclarity of expectations This study contributes to our understanding of the relationship between different educational approaches and student outcomes. It suggests that PBL is an effective approach for educating nurses. Furthermore, it indicates that nursing students in the PBL program, like their counterparts in PBL medical programs, report higher levels of satisfaction. Future studies that are longitudinal in design and rely less on self-report measures would contribute further to our understanding of the benefits and limitations of PBL in nursing education. This revised version was published online in June 2006 with corrections to the Cover Date.