The use of an escape room-based learning strategy to enhance pharmacology knowledge among nursing students
- Open Access
- 31.12.2025
- Research
Erschienen in:
Abstract
Background
Medication administration, which requires a high level of attention and knowledge in terms of patient safety, is a fundamental nursing skill [1, 2]. It is stated that one of the most important causes of medication errors, which threaten patient safety and can result in death in some cases, is insufficient pharmacology knowledge [3]. Therefore, it is crucial for students to learn basic pharmacological concepts in order to administer medication safely [4]. Research findings show that the theoretical knowledge gained by nursing students in pharmacology courses reduces the likelihood of medication errors in clinical practice and supports safe medication administration [5]. In a study conducted with nursing students, medication administration skills were taught through simulation based on the ‘six rights’ criteria. Following the simulation, a significant increase was observed in the students’ compliance rates with criteria such as ‘right medication,’ ‘right dose,’ and ‘right time’ [6]. In this context, it is recommended that pharmacology education be supported by practical and active teaching methods in addition to theoretical knowledge for effective learning [6, 7]. Accordingly, it is recommended that active teaching methods be incorporated into nursing education to support effective learning. Among these active methods, gamification can make the teaching-learning process more engaging and help boost student motivation. Within the scope of gamification, several strategies are suggested to increase student participation in lessons [8, 9].
One of these strategies that has recently gained popularity in nursing education is educational escape rooms, known for capturing students’ attention, increasing their motivation, and encouraging enjoyable learning [10‐12]. Escape rooms are live-action, team-based games in which players uncover clues, solve puzzles, and complete tasks to achieve a specific goal within a limited time frame [13, 14]. MacKenzie et al. (2024) found that an escape room focused on cardiovascular pharmacology helped students learn the topic effectively. Similarly, Plakogiannis et al. (2020) reported that escape rooms designed around heart failure pharmacology, medicinal chemistry, and pharmacotherapy contributed positively to students’ learning and fostered positive attitudes toward the game. Eukel et al. (2017) reported that pharmacy students’ knowledge of diabetes management improved after participating in an educational escape room and that they provided positive feedback. Another study by Hermanns et al. (2018) conducted with nursing students taking a pharmacology course found that the escape room improved students’ knowledge of cardiovascular medications.
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The inherently complex nature of pharmacology, high medication error rates, and the expanding scope of medication administration by nurses in particular highlight the urgent need to improve pharmacology education in nursing degree programmes [15]. Furthermore, it has been reported that teaching pharmacology poses challenges in creating innovative and engaging learning experiences. In this context, the escape room game offers a new approach to imparting pharmacology knowledge beyond traditional lecture-based teaching methods [4]. Numerous studies indicate that nursing curricula lack the necessary knowledge base to effectively administer medication and that nurses and nursing students do not possess sufficient pharmacology knowledge [1, 2, 16‐18]. Furthermore, it has been noted that nursing students often struggle to learn the names and effects of medications, calculate medication doses, and understand medication administration techniques. In this context, it is crucial for students to learn basic pharmacological concepts in order to provide safe and effective care [4]. These findings necessitate the application of innovative teaching concepts instead of traditional pharmacology course methodologies [16].
Although several studies have explored the use of escape rooms in pharmacology education [19‐21], there remains a limited number of studies focusing specifically on pharmacological knowledge in nursing education [4, 22]. In this regard, our study utilized an educational escape room, which has gained popularity in recent years, to enhance knowledge of autonomic nervous system pharmacology, which is critically important for patient safety in relation to high-risk medications.
Methods
This study was conducted to evaluate the effect of an educational escape room on nursing students’ knowledge of autonomic nervous system pharmacology and their game experiences. To this end, the study addressed the following research questions:
1.
Is there a significant difference between the ANSPKT pre-test and post-test scores of the nursing students who participated in the escape room?
2.
What are the gaming experiences of the nursing students who participated in the escape room?
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Study design and participants
This quasi-experimental study employed a single-group pretest-posttest design. The research population consisted of 40 s-year nursing students enrolled in the “Pharmacology for Nurses” course at a university in the eastern Mediterranean region of Turkey. The inclusion criteria for participation were that students were enrolled in the course for the first time and agreed to participate in the study voluntarily. Students who already had a degree in a health-related field (high school, associate’s degree, or bachelor’s degree) or who had difficulty understanding or speaking Turkish were excluded from the study. In total, eight students who did not attend the theoretical session or did not complete the forms were excluded from the study, resulting in a study sample of 32 participants who met all inclusion criteria. Furthermore, since the population size was accessible, no sampling was performed in the study; a census sampling method was used.
Data collection and instruments
Data were collected using three instruments: the Descriptive Characteristics Questionnaire (DCQ), the Autonomic Nervous System Pharmacology Knowledge Test (ANSPKT), and the Gameful Experience Scale (GAMEX). The DCQ and ANSPKT were developed by the researchers based on the course content and aligned with educational objectives drawn from the literature [8, 23‐25]. The DCQ consisted of four items aimed at capturing sociodemographic characteristics such as age and gender.
The ANSPKT comprised 20 multiple-choice questions, each with five options, designed to assess students’ knowledge of autonomic nervous system pharmacology. The test covered four main domains: five questions on sympathetic nervous system drugs, five on parasympathetic nervous system drugs, five on the effects of the autonomic nervous system on the body, and five on neurotransmitters and receptors. Test scores ranged from 0 to 20, with higher scores indicating greater knowledge. The test was evaluated by 40 s-year nursing students, and item analysis was conducted to calculate item difficulty and discrimination indices. The test yielded a moderate difficulty index of 0.65 and a KR-20 reliability coefficient of 0.76, indicating good internal consistency. To ensure content validity, expert opinions were obtained from four nursing faculty members, one faculty member specialising in educational measurement and evaluation, and one expert in Turkish language and literature education. The Content Validity Index (CVI) for the entire test was calculated as 0.959, indicating that the items were sufficiently valid.
The GAMEX, originally developed by Eppmann et al. (2018), was used to assess students’ experiences with the escape room game [26]. A study conducted by Çömez İkican et al. (2024) confirmed its Turkish validity and reliability among nursing students [27]. The scale consists of 27 items across five subdimensions: enjoyment (items 1–6), absorption (items 7–12), creative thinking and emotional activation (items 13–17, 19, 20), absence of negative effects (items 18, 21–23), and dominance (items 24–27). The scale uses a 5-point Likert system, ranging from 1 (never) to 5 (always), with items 18, 21, 22, and 23 reverse-coded. The original Cronbach’s alpha for the scale was 0.89, while the current study found a value of 0.88, indicating high reliability.
Preparing the escape room
The escape room scenario and associated activities were designed by the researchers using guidance from the existing literature [23‐25, 28, 29]. The scenario was themed “Reach the antivenom and save the patient’s life.” Based on this theme, the game’s objectives and student learning outcomes were defined (Table 1). These outcomes were structured in alignment with Bloom’s Taxonomy, encompassing both the knowledge and cognitive process dimensions. Bloom’s original taxonomy, developed in 1956, was updated by Anderson and Krathwohl in 2001 [30]. The escape room contained four locked boxes—three small and one large—each secured with a numeric code. Throughout the game, students were expected to unlock these boxes by solving puzzles and completing tasks to access the antivenom. Success in these tasks required students to draw on knowledge and skills related to the autonomic nervous system pharmacology that had been taught in a prior lesson. Four primary activities were included: “Open-Ended Question " task addressing the effects of the autonomic nervous system on the body; “Matching Activity” related to neurotransmitters and receptors; “Question Card Activity” focusing on parasympathetic nervous system drugs; and “Crossword Puzzle Activity” on sympathetic nervous system drugs. The patient scenario and all activities were reviewed for content validity by four nursing faculty members, who provided feedback and approval. Experts evaluated each activity using a four-point Likert scale (1: Not suitable, 2: Somewhat suitable, requires improvement, 3: Quite suitable, requires minor improvement, 4: Very suitable). In addition, experts provided their recommendations in the last row. Based on the responses from the experts, it was determined that the KGI value of the activities was 0.950 and that they could be used.
Table 1
Escape room scenario, purpose, objectives, and game flow
Main Game Theme: “Reach the antivenom and save the patient’s life.” Case Scenario: At approximately 8:00 a.m., Mr Ahmet was bitten on the pulp (tip) of the second finger of his left hand by a snake while collecting eggs from his garden. He described the snake as a viper. In his initial response, the patient reported that he made incisions on his finger to induce bleeding. He then presented to the emergency department of the nearest healthcare facility. Aged 72, the patient has a medical history of diabetes and hypertension. Although his general condition was moderately impaired, he was conscious and oriented. Vital signs–Blood pressure: 170/85 mmHg, Pulse: 94 beats/min, Respiratory rate: 16 breaths/min, Body temperature: 36.0 °C-- Ecchymosis, oedema, and tenderness were observed intermittently along the left upper extremity up to the elbow. Given the presence of nausea and vomiting, neurotoxicity affecting the central nervous system was suspected.The patient was being monitored and treated in the emergency department of a private clinic. After wound cleansing and tetanus prophylaxis, the following treatments were initiated sequentially: - Adrenaline 0.01 mg/1 ml, once daily subcutaneously (SC) - Oxygen 2 L/min via the nasal route - ∗Antivenom: 1 ampoule + 1 ampoule (administered via IV infusion in 100 cc saline over 30 min) Purpose: To assess the patient presenting to the emergency department due to a snake bite and to administer emergency nursing interventions to reach the antivenom. Goal: To enable students to unlock the boxes containing the antivenom sequentially by using their autonomic nervous system pharmacology knowledge and completing the related activities. | ||
Learning activities: | Learning objectives: | The facilitator’s role: |
- The first task begins with reading patient data and performing the treatments (e.g., adrenaline, oxygen) requested by the physician. - Discovers the three-digit code on the treatment cart. - The group answers the “Open-Ended Question. | - Explains the effects of autonomic nervous system drugs on the body. | - The facilitator gives the group permission and guides them to open first box. |
Box I: “Crossword Puzzle Activity” - The group completes the puzzle and reaches the keyword. - They reach the password for the second box inside the box. | - Analyses the sympathetic nervous system drugs. | - The facilitator gives the group permission and guides them to open second box. - If there are group members who are not actively participating, it alerts them with a whistle sound. - For each hint request or incorrect answer from the group, it adds a + 1 min penalty to the completion time. |
Box II: “Question Card Activity” - The group completes the activity and reaches the password for the third box. | - Analyses parasympathetic nervous system drugs. | - The facilitator gives the group permission and guides them to open third box. - If there are group members who are not actively participating, it alerts them with a whistle sound. - For each hint request or incorrect answer from the group, it adds a + 1 min penalty to the completion time. |
Box III: “Matching Activity” - The group completes the activity and reaches the password for the fourth box. | - Lists the functions of the autonomic nervous system, neurotransmitters, and receptors. | - The facilitator gives the group permission and guides them to open fourth box. - If there are group members who are not actively participating, it alerts them with a whistle sound. - For each hint request or incorrect answer from the group, it adds a + 1 min penalty to the completion time. |
Box IV: The group receives the message, “Congratulations, you have reached the antivenom.” - The group delivers the antivenom inside the syringe to the facilitator. | - Stops the timer and records the group’s completion time on the whiteboard. | |
The nursing skills laboratory was adapted to function as the escape room environment. Game rules were defined, and one researcher was appointed as the facilitator responsible for providing hints and managing the game. Materials such as locked boxes, number-coded locks, stopwatches, whiteboards, whistles, and relevant medical items (e.g., oxygen masks, syringes, ampoules) were acquired. The patient room setup included a hospital bed, a mannequin, a bedside unit, a bedside table with a nurse’s chart, and activity materials. Locked boxes, a whiteboard, and a medication trolley were placed in appropriate locations within the laboratory setting.
The pre-test of the escape room game was conducted by researchers with 12 volunteer third-year students who had successfully passed the Pharmacology Course for Nurses, in order to ensure control of the game flow and make the necessary adjustments. One of the researchers took on the role of facilitator. The students participating in the pre-test were divided into groups of four to play the game. The average time spent by the groups in the game was determined to be 37 min. At the end of the pre-implementation, several structural adjustments were made to the activities in the game, and the game rules prepared by the researchers were finalised.
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Intervention
The intervention took place between January and February 2025. The DCQ and ANSPKT (pre-test) were administered immediately after teaching students the theoretical lesson on autonomic nervous system pharmacology. Students were then randomly divided into eight groups of four. Prior to entering the game, a 15-minute briefing was conducted in the skills laboratory by the facilitator for each group. During this session, the facilitator explained the rules and objectives of the game. Once all members confirmed their understanding, the group entered the escape room—designed to simulate a clinical environment—and the game began using a stopwatch. The group that reached the antivenom in the shortest time was declared the winner. Immediately after the game, each group participated in a 15-minute debriefing with the facilitator to discuss any knowledge gaps, misunderstandings, and to share their reflections on the game experience. Each group participated once in the escape room game, with a 60-minute time limit. All groups successfully completed the game within the allotted time. The flow of the escape room game is shown in Table 1. In addition, the number of clues each group used in the game and their completion times are presented in Table 2.
Table 2
The duration that the game groups spent in the game and the number of clues
Groups | Duration spent in the game - min/sec | Number of clues received |
|---|---|---|
1. Grup | 33:06 | 3 |
2. Grup | 29:58 | 1 |
3. Grup* | 27:04 | 1 |
4. Grup | 31:00 | 1 |
5. Grup | 39:01 | 3 |
6. Grup | 35:50 | 2 |
7. Grup | 35:09 | 2 |
8. Grup | 36:30 | 2 |
One week after the intervention, all students completed the ANSPKT again, along with the GAMEX, to evaluate their post-intervention knowledge and experience. The intervention steps flow chart is shown in Fig. 1.
Fig. 1
Intervention steps flow diagram
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In this study, a game design has been created to achieve learning objectives prepared according to Bloom’s taxonomy. In this context, the game includes the materials to be used, a series of interconnected tasks and activities, the nature (cognitive or skill-based) and stages of these tasks and activities; the possible outcomes when tasks and activities are performed correctly or incorrectly; the information and tips to be used for the successful completion of activities; and the indicators of the player’s successful completion of the task. In addition, the procedural steps and implementation details for each task and activity in the game have been prepared, along with theoretical knowledge tips that students are expected to know and learn while performing these steps.
Data analysis
Data analysis was conducted using IBM SPSS version 25. Descriptive statistics, including percentages, frequencies, means, and standard deviations, were used to evaluate participants’ characteristics. The Kolmogorov–Smirnov test was applied to test for normality. Since the data were not normally distributed, the Wilcoxon Signed-Rank Test was used to compare pretest and posttest scores. The effect size was calculated using the formula r = Z/√N. Statistical significance was set at p < 0.05.
Ethical considerations
Prior to the implementation of the study, ethical approval was obtained from the Kahramanmaraş Istiklal University Ethics Committee (document date and number: 30.12.2024–2024/15 − 03). In addition, written informed consent was obtained from all students who participated in the study. This study was conducted in compliance with the ethical principles outlined in the Declaration of Helsinki.
Results
The mean age of the students who participated in the study was 20.28 ± 1.97 years. Among these students, 62.5% were female, and 75% reported being satisfied with their choice to study nursing. None of the participants had previously taken part in an escape room game (Table 3).
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Table 3
Students’ descriptive characteristics
Characteristics (n = 32) | (Min.-Max.) | \(\:\stackrel{-}{X}\)±SD | |
|---|---|---|---|
Age (year) | 19–30 | 20.28 ± 1.97 | |
n | % | ||
Age (year) | 19 | 10 | 31.3 |
20 | 14 | 43.8 | |
21 | 5 | 15.6 | |
22 | 2 | 6.3 | |
30 | 1 | 3.1 | |
Gender | Female | 20 | 62.5 |
Male | 12 | 37.5 | |
Satisfaction with being a nursing student | Yes | 24 | 75.0 |
No | 8 | 25.0 | |
Previous participation in the escape room game | No | 32 | 100.0 |
The students’ total posttest score (16.16 ± 4.38) on the Autonomic Nervous System Pharmacology Knowledge Test was found to be statistically significantly higher than the pretest score (10.69 ± 4.24). Furthermore, the subdimensions of the test - including knowledge of drugs affecting the sympathetic system (p = 0.003), drugs affecting the parasympathetic system (p < 0.001), neurotransmitters and receptors of the autonomic nervous system (p < 0.001), and the effects of autonomic nervous system drugs on the body (p < 0.001) – also yielded significantly higher posttest scores compared to pretest scores (p < 0.05; Table 4; Fig. 2).
Table 4
Comparison of students’ autonomic nervous system pharmacology knowledge test pre-test and post-test scores
Autonomic nervous system pharmacology knowledge test and its subscales | Pre-test (n = 32) | Post-test (n = 32) | Z | p | Effect size (r) | |||
|---|---|---|---|---|---|---|---|---|
\(\:\stackrel{-}{X}\)±SD | Median (IQR) | \(\:\stackrel{-}{X}\)±SD | Median (IQR) | |||||
Autonomic nervous system drug knowledge test total score | 10.69 ± 4.24 | 10.00 (7.25) | 16.16 ± 4.38 | 17.50 (6.00) | -4.354 | < 0.001 | -0.77 | |
Sympathetic system acting drug knowledge score | 3.16 ± 1.25 | 3.00 (1.75) | 4.09 ± 1.35 | 5.00 (1.00) | -3.001 | 0.003 | -0.53 | |
Parasympathetic system acting drug knowledge score | 2,78 ± 1.34 | 3.00 (2.00) | 4.34 ± 0.87 | 5.00 (1.00) | -4.093 | < 0.001 | -0.72 | |
Autonomic nervous system neurotransmitters and receptors knowledge score | 2.37 ± 1.31 | 2.00 (2.00) | 3.91 ± 1.38 | 5.00 (2.00) | -4.144 | < 0.001 | -0.73 | |
Autonomic nervous system effects of drugs on the body knowledge score | 2.38 ± 1.41 | 2.00 (3.00) | 3.81 ± 1.33 | 4.00 (2.00) | -4.072 | < 0.001 | -0.72 | |
Fig. 2
Students’ autonomic nervous system drug knowledge test pre-test and post-test score averages
The students’ total mean score on the Gameful Experience Scale (GAMEX) was 109.18 ± 16.06. The mean scores for each subdimension were as follows: enjoyment, 27.19 ± 4.68; absorption, 21.25 ± 7.44; creative thinking and emotional activation, 29.56 ± 5.55; absence of negative effects, 15.53 ± 3.88; and dominance, 15.66 ± 2.94 (Table 5).
Table 5
Gameful experience scale score averages of students
Gameful Experience Scale (GAMEX) | Min-Max | \(\:\stackrel{-}{X}\)±SS |
|---|---|---|
Enjoyment | 14.00–30.00 | 27.19 ± 4.68 |
Absorption | 6.00–30.00 | 21.25 ± 7.44 |
Creative thinking and emotional activation | 20.00–35.00 | 29.56 ± 5.55 |
Absence of negative effects | 4.00–20.00 | 15.53 ± 3.88 |
Dominance | 11.00–20.00 | 15.66 ± 2.94 |
Total | 75.00-134.00 | 109.18 ± 16.06 |
Discussion
Escape rooms are an effective method for improving pharmacology knowledge in nursing. This escape room educational intervention, conducted with a limited and small sample group, focused on evaluating students’ knowledge of autonomic nervous system pharmacology and their perception of the game experience. In this study, students recalled their knowledge of autonomic nervous system pharmacology and learned while having fun as they completed a well-designed series of interconnected, enjoyable, and creative tasks and activities through the escape room. Indeed, in the present study, it was observed that students’ total scores and subscale scores on the ANSPKT were significantly higher than their pre-test scores.
The results of the present study are consistent with previous studies conducted in different settings and contexts. Eukel et al. (2017) found statistically significant improvements in the knowledge of 83 pharmacy students in an escape room study on diabetes management and showed that students responded positively to the game experience. Similarly, Plakogiannis et al. (2020) reported that an escape room designed for second-year pharmacy students on heart failure pharmacology, medicinal chemistry, and pharmacotherapy helped improve learning and promoted positive student attitudes toward the game. Unlike our study results, MacKenzie et al. (2024) concluded in their escape room study with pharmacy students that while it provided a valuable learning experience for acquiring pharmacology knowledge related to the management of cardiovascular diseases, it was not effective in increasing knowledge scores on the subject. It was suggested that this may be due to the insufficient number of questions used in the knowledge assessment.
A limitation to note in escape room studies related to pharmacology within our knowledge and in the current study is the absence of a control group to compare student performance. However, the relevant literature and the current study show that escape rooms positively affect knowledge acquisition. This effect can be attributed to the game’s interactive and enjoyable nature, which produces positive learning outcomes, and the student-centered and motivating learning environment it provides [10‐12]. Furthermore, the post-game evaluation session between participants and facilitators is likely to strengthen memory and further develop understanding by answering students’ questions [31].
Although prior studies have primarily focused on pharmacy students, there is a noticeable gap in the literature concerning the evaluation of nursing students’ pharmacological knowledge through escape rooms. Nevertheless, pharmacological competency is essential for nurses, particularly in relation to the safe administration of medications, monitoring therapeutic and adverse effects, and educating patients about medications [2]. Research has consistently shown that nurses often lack sufficient pharmacological knowledge [2, 18]. In one study, Taasen et al. (2024) revealed that nurses lacked adequate pharmacological knowledge regarding high-risk medications such as opioids. In this context, our study provides a unique contribution by offering a novel and effective approach to strengthening the pharmacological knowledge of nursing students, who are future healthcare providers.
The findings also revealed high scores in GAMEX at both the general and sub-dimension levels. Students participating in the game gave high scores in the areas of enjoyment, absorption, creative thinking and emotional activation, absence of negative effects, and dominance. These results are consistent with other escape room studies using the GAMEX scale, and participants reported having a positive gaming experience, emphasizing positive emotions, as in the current study [32‐34]. The positive emotions experienced after the game are considered an important part of the gaming experience because they increase learning and satisfaction among participants [34]. Furthermore, studies have reported that the satisfaction created by escape rooms among students has a positive effect on their learning by increasing their motivation [10, 35]. This is because high motivation, one of the fundamental principles of learning, increases interest and encourages active participation among students, thereby facilitating the learning process [33]. Indeed, in our study, we can say that one of the reasons for the increase in students’ knowledge of the subject after the game is the high motivation and positive emotional effects that the game creates on participants.
All these findings indicate that escape rooms, an innovative learning strategy that challenges traditional teaching methods and encourages and motivates students to learn, can be integrated into the nursing education curriculum.
Limitations of the study
Since this study employed a single-group pretest–posttest design, the absence of a control group should be considered when interpreting and generalizing the findings. Additional limitations include the small sample size drawn from a single institution and the lack of data regarding long-term knowledge retention related to the topic. Therefore, future research is recommended to examine the long-term effects of escape room interventions using larger samples and randomized controlled designs.
Conclusion
This study concluded that nursing students’ pharmacology knowledge improved following the use of the innovative escape room–based teaching strategy and that students reported a positive gaming experience. These findings indicate that escape rooms, by making learning enjoyable and motivating, can enhance active student engagement and reinforce relevant knowledge within a safe learning environment, thereby contributing to positive learning outcomes. Nursing educators can structure escape room activities in pharmacology courses by linking them to theoretical content in the form of realistic case scenarios and puzzles; this supports students’ clinical decision-making and problem-solving skills in realistic contexts. For this integration to be effective, educators must receive pedagogical training in gamification and scenario design, allocate sufficient time for practice and evaluation, and ensure the appropriate physical/resource infrastructure (e.g., materials, digital tools, locks) is in place; additionally, time and planning support should be incorporated into the program curriculum.
Acknowledgements
We would like to thank all study participants for their contributions.
Declarations
Ethics approval and consent to participate
Before starting the study, ethical approval was obtained from Kahramanmaraş Istiklal University Ethics Committee (Ethics approval code: 2024/15 − 03). Participation in the study was voluntary. Accordingly, the students were informed about the study and verbal, and written informed consent was obtained from the students who agreed to participate in the study. Institutional permission was obtained from the institution where the study was conducted. Before starting the study, ClinicalTrials.gov was recorded (NCT07073222, Registration Date: 9 July 2025 https://clinicaltrials.gov/). The principles of the Declaration of Helsinki and publication ethics were followed in our study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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