Career Paths of GeriatricNurse PractitionersEmployed in Nursing Homes

DAVID M. RADOSEVICH, MSPH, RNCROBERT L. KANE, MDJUDITH GARRARD, PhDCAROL L. SKAY, BASUSAN McDERMOTT, MPH, RNCLOYD KEPFERLE, MEdJOAN BUCHANAN, PhDSHARON ARNOLD, MPH

Mr. Radosevich is a doctoral candidate in the Division ofEpidemiology, School of Public Health, University of Minne-sota. Dr. Kane is Dean and Professor, and Dr. Garrard isAssociate Professor, in the university's School of Public Health.Ms. Skay is a doctoral candidate in the university's College ofEducation. Ms. McDermott is Research Scientist, CambridgeResearch Center of the American Institutes for Research,Watertown, MA. Mr. Kepferle is Executive Director, MountainStates Health Corporation, Boise, ID. Dr. Buchanan is in theSystems Science Department, and Ms. Arnold is ResearchFellow, the Rand Corporation, Santa Monica, CA.

Tearsheet requests to David M. Radosevich, MSPH, RNC,Box 197 Mayo Hospital, School of Public Health, University ofMinnesota, Minneapolis, MN 55455.

Synopsis....................................

The career paths of geriatric nurse practitioners(GNPs) trained with support from the W. K. Kel-

logg Foundation through the Mountain StatesHealth Corporation (MSHC) were studied. Underthis program, GNPs were recruited from sponsor-ing nursing homes and returned to GNP positionsin the sponsoring facilities following training.Training was carried out under a continuing educa-tion model offered through six university-basedschools of nursing.

Questionnaires were sent to the 111 GNPstrained. Of the 102 respondents, 97 provided com-plete information about past and present educa-tion, work experience, and job functions. TheGNPs were women with a median age of 45 years,and they were employed in rural settings in thewestern United States. More than 45 percent of thenurses had at least a baccalaureate degree at thetime of GNP training.

The GNPs remained employed in long-term carepositions that implemented the practitioner role.The median length of GNP employment in theirfirst jobs after training was more than 4.5 years.The resignation rate from this first position was1.66 resignations for each 10 years of GNP em-ployment. Job changes were likely to be attributedto organizational changes with subsequent positionsshifting toward a diversification of the GNP role.The study demonstrates the success of the MSHCprogram in introducing and retaining GNPs innursing homes.

C ARE FOR THE ELDERLY will create demands forhealth care personnel in the coming decades. Arecent report has estimated increased demands fornursing personnel providing health care for theelderly in nursing homes and in community andpublic health settings (1). These projections aremade because of a declining pool of applicants fornursing programs and fewer men and womenchoosing nursing as a career (2).

There is a special need for registered nurseswhose specialized practice is in the area of geriat-rics. There are currently about 750 geriatric nursespecialists in the United States compared with aprojected need for 25,000 geriatric nurse specialistsin the year 2020 (3).

Geriatric Nurse Practitioner

The geriatric nurse practitioner (GNP) is onesuch nurse specialist employed in long-term care.While the role of nurse practitioner originatedaround 1965, the GNP has emerged only in thepast decade. Within long-term care settings, theGNP functions as a primary health care provider,performing medical management as well as a broadrange of activities which include consultation refer-ral, assessment diagnosis, therapy, and preventivehealth care (4,5).The preparation of GNPs has been conducted

under two distinct models: continuing educationand graduate education. Previous works have de-

January-February 190, Vol. 105, No. 1 65

scribed each of these educational models in somedetail (6,7). Continuing education programs havebeen instrumental in preparing nurses for employ-ment with underserved populations, for example,the elderly and rural populations (7). GNPs trainedthrough continuing education programs have beenmore involved in direct patient care management(8). Academic preparation through graduate pro-grams has prepared the GNP for faculty positionsand clinical research positions, as well as forclinical practice.

Several studies described the benefits of GNPs tonursing home residents. In an early study, thefunctional outcome measures for nursing homeresidents were significantly greater for servicesfrom teams that included a nurse practitioner thanfor those residents receiving only physicians' ser-vices (9). This same study showed savings thatoffset the costs of providing combined care. In astudy of the Urban Medical Group in Boston,similar savings were observed as a result of im-proved care (10). A recent study of the academicnursing home-an integrated program of care,research, and education as found in the SepulvedaVeterans Administration Nursing Home CareUnit-demonstrated that care provided by GNPs,working with an interdisciplinary team, signifi-cantly reduced transfers to acute care hospitals andimproved resident's functional status and satisfac-tion (11).The benefits of the GNP in providing long-term

care services, along with projections for increaseddemands for nurse specialists in geriatrics, evincethe need for the preparation and retention ofGNPs. This paper describes the career patterns ofnurses trained through continuing education for theGNP role in nursing homes and explores patternsof retention in long-term care.

Retention of GNPs in Long-Term Care

No- previous studies have explored the questionof retention of GNPs in long-term care and thefactors that predict retention. The few studies thatassessed the retention of personnel in long-termcare have limited their investigations to non-professional staff and nursing personnel excludingGNPs. An early study of the effects of nursinghome conditions on job retention among nursingpersonnel concluded that differences in personnelbenefits accounted for the differential retentionbetween nursing personnel in proprietary and non-proprietary homes (12). Cotler and Kane (13)looked at issues attracting nurses to work in

nursing homes and factors associated with jobchange. A high level of satisfaction was foundamong nurses employed in skilled nursing facilities(SNF) compared with nurses employed in othersettings. The nurses employed in SNFs were nomore likely to report an intention to quit their jobsthan hospital nurses.The most recent assessment of personnel reten-

tion is limited to all licensed nursing personnelemployed in long-term care (3). The NationalNursing Home Survey (NNHS) included a samplesurvey of 2,672 nurses employed in nursing homesin the 48 contiguous States. Forty-five factorsimportant to job retention were analyzed throughthe Nursing Staff Questionnaire. Among the fac-tors analyzed, the benefits provided by the nursinghome and salary-related factors were judged asmost critical to retention. Consistent with an earlierstudy (12), retention was highest among nursesemployed in nonprofit (government owned) facil-ities, but no specific findings are presented forgeriatric nurse specialists of GNPs.

Project Description

GNP training under Mountain States Health Cor-poration. Between 1976 and 1986, with fundingfrom the W. K. Kellogg Foundation, MountainStates Health Corporation (MSHC) in Boise, ID,recruited nurses employed by nursing homes fortraining as GNPs and continued employment intheir sponsoring long-term care institutions (14).As a condition for acceptance into the GNP

training program, each nurse was required to havea sponsoring facility; generally, this facility was thenurse's place of employment. Most of the sponsor-ing long-term care facilities were located in thewestern States. Following training, the sponsoringfacility agreed to hire the trainee for a minimum of18 months as a GNP. Finally, the nurse must havehad a designated physician preceptor.The recruited nurses were trained under a con-

tinuing education model. Enloe's (15) basic curricu-lum model for the training of the GNPs differenti-ates two phases of training: a didactic phase and apreceptor phase. The didactic phase, which wasconducted at the school of nursing, lasted 4 monthsand provided the skills needed to deliver primaryhealth care to nursing home residents. Learningduring this phase built upon the nurses' previousexperiences and the current level of knowledge theybrought into the program. The latter half of thedidactic phase provided the theoretical frameworkfor development of the GNP role.

66 PublI ..".atb Reports

The preceptor phase, the final 8 months oftraining, permitted the synthesis of theoreticalknowledge and the integration of nursing andmedical care. The trainees worked in their sponsor-ing nursing homes developing the GNP role. Atleast a half day a week was spent in direct contactwith the clinical preceptor, while the nurse practi-tioner managed a case load of the physician'spatients. The nursing faculty maintained regularcontact with students during this phase.

Background. The work history survey reported inthis paper is one component of a larger project toevaluate the use of GNPs in nursing homes (16).The implementation of the GNP role in nursinghomes has been described elsewhere (17). Thisstudy includes the subsample of GNPs from thecomplete evaluation and extends the sample to in-clude all those trained under the Kellogg-fundedauspices.

This paper details the work history and careerpaths of 97 GNPs trained with the aid of MSHC,including 29 of the 30 GNPs in the larger evalua-tion of the effect of GNPs on nursing home care.The retention of GNPs in long-term care is ad-dressed by these questions:

* What characterizes the recruited nurses at entryto the GNP programs?* How long do GNPs remain employed in long-term care?* What factors are associated with continued em-ployment in long-term care?* What factors are associated with implementationof the GNP role in a long-term care setting?

Methods

Through the fall of 1986, 111 GNPs had beentrained with support from the W. K. Kellogg Foun-dation through the MSHC project. A work historyquestionnaire was mailed to each of the nurses onthe roster. The questionnaire was composed of anearly equal number of open- and closed-endeditems. Information was elicited about the GNP'spast and present education and work experience.Of the 111 GNPs, 102 (response rate 93 percent)returned completed questionnaires in the self-addressed stamped envelope that was provided.

Results

Characteristics at entry. The MSHC GNPs werewomen with a median age of 45 years-a range of

29-65 years. The following table shows the age dis-tribution in 10-year intervals:

Age group at entry

25-34 years .............35-44 years .............45-54 years .............55 years and older .......

Total .............

Number of GNPs17293917

102

Percent

16.728.438.217.7

100.0

The respondents were likely to have entered theGNP training programs at least 5 years after theirbasic RN preparation. This first level of prepara-tion is referred to as their basic-entry educationand defines the fundamental level of educationqualifying the graduate for licensure as a registerednurse.The MSHC GNPs received their training through

one of six university-based programs. All but eightof the nurses were trained within the four nursepractitioner programs in the western United States.

InstitutionUniversity of Arizona .........University of California-San Francisco ...............

University of Colorado ........Cornell University ............State University of New York ..University of Washington......

Total ..................

Number ofGNPs trained

24

16342620

Percent23.5

15.733.32.05.919.6

102 100.0

The largest group received their training throughthe University of Colorado. The two universityprograms located in the eastern United States wereamong the first GNP programs to be establishednationally; consequently, graduates from these pro-grams were among the first group of nurses trainedthrough the MSHC program.The basic-entry preparation of the nurses imme-

diately before RN licensure was nonbaccalaureate.This earlier training occurred in hospital-baseddiploma programs and associate of arts degreeprograms. Nearly half of the respondents reportedpreparation at a diploma level before RN licensure.However, the educational level at the time of GNPtraining showed a trend toward increased profes-sional credentialing. By entrance to GNP training,slightly more than 45 percent of the nurses had atleast a baccalaureate degree (fig. 1).

Certification for advanced practice in nursing isoffered through the American Nurses' Association(ANA). To earn national certification as a GNP,the nurse must have graduated from an approvedtraining program that prepares her for advanced

January-February 1990, Vol. 106, No. 1 67

Figure 1. Educational credential at entry into the nursingprofession and before GNP training of nurses in the Mountain

States Health Corporation project

NOTE: GNP = geriatric nurse practitioner.

Figure 2. Survival curve for percentage of GNPs remaining in firstposition after training

practice and passed a written certifying examina-tion. Sixty-one percent of the nurses were certifiedthrough ANA as geriatric nurse practitioners at thetime the questionnaire was completed.

Employment career. Although 100 of the 102nurses (98 percent) were employed at the time thequestionnaire was mailed, only 95 began employ-ment within their sponsors' facility following grad-uation. Among the GNPs who did not begin workin the sponsoring facility immediately upon gradua-tion, two returned to teaching positions that they

had held before GNP training. For the remainingnurses, no reason was given for not assuming aGNP position in the sponsoring facility.Of the 102 GNPs, 97 returned completed ques-

tionnaires providing information on personal back-ground and employment history. The careers ofthese 97 GNPs are studied using two approaches.The first involved a longitudinal view of theemployment duration of the GNPs. Adjustmentswere made for differences in the months each GNPwas eligible for employment. The analysis focusedon the proportion of eligible GNPs still employedafter varying durations of time.The second strategy took a series of cross-

sectional views of GNPs' employment followingtraining. Here the analysis looked at the proportionof eligible nurses.employed at yearly intervals aftergraduation from GNP training. The specific analy-sis for both the cross-sectional and longitudinalapproaches are discussed subsequently.

Length of employment in long-term care. Becauserecent graduates of GNP training programs neces-sarily have short GNP employment histories,whereas early graduates of GNP programs have ac-crued as many as 10 years of GNP employment,comparisons adjust for differences in employmenteligibility among the GNPs.The 97 nurses experienced a total of 56 job

changes during their GNP careers. When theycompleted the questionnaire, 58 GNPs reportedcontinued employment in the position they hadtaken immediately following training. Of the re-maining 39 nurses, 26 reported a single positionchange following GNP training; 10 nurses reportedtwo changes; 2 reported three changes; and 1reported four changes.

Since most of the GNPs' job experiences oc-curred in the first and second positions followingGNP training, resignation rates were computed onthe basis of resignations from their first position,that is, employment with their sponsoring facility.The resignation rates from the first position follow-ing GNP training were computed using standardlife table techniques.

After computing the months employed duringthe first position, each GNP was classified as eithercontinuing employment in the first GNP positionor as resigning from the first GNP position. Theresignation rate is expressed as the number ofresignations from the first position for each monthemployed. The 39 resignations across 2,818 totalmonths employed in the first position yields a rateof 0.014 resignations for each month employed in

W8 Public Health Reports

the first position. This rate can be expressed asbetween one and two resignations for each 10 yearsof employment in the first position following GNPtraining.A survival curve representing job retention in the

first GNP position was constructed using theKaplan-Meier method (18). The curve shows theproportion of eligible GNPs still employed after somany months of employment (fig. 2). Based on thiscurve, the median length of employment for thefirst position was slightly more than 4.5 years, wellbeyond the 18 months of continued employmentagreed to at recruitment by the sponsoring facility.

Continuation of employment in long-term care.The total months of potential employment wascomputed from GNP graduation through the sur-vey date. The resultant number of months was usedas the denominator in the calculation of the pro-portion of months employed. The numerator wasthe total months of reported employment afterGNP training. As a whole, the nurses were em-ployed for 95.5 percent of the eligible months.

Using reported place of employment and com-ments regarding the job title and job duties, GNPemployment was judged as either in long-term careor outside long-term care. For this analysis, nodifferentiation has been made between long-termcare in the community and in an institution. Allbut six of the GNPs were classified as employed inlong-term care, although not all were in nursinghomes.

Across the 97 GNPs, 91.4 percent of the employ-ment months were within long-term care. For thefirst 2 years after GNP training, 91.7 percent of themonths of GNP employment were in a long-termcare setting. For the intervals of 2 to 4 years andmore than 4 years after GNP training, the percentof months employed in long-term care was 90.2percent and 91.7 percent, respectively. Continuedemployment in long-term care settings remained astrong probability for the GNPs who left their firstjob after training.

Cross-sectional trends in employment. At each an-niversary month following the completion of train-ing, GNP employment status was evaluated. Thispermitted a cross-sectional picture of the GNPs ona year-to-year basis. At the end of each year, thefollowing questions were asked:

* Had the GNP completed training and become el-igible for employment?* Was the GNP employed?

Figure 3. Employment status of GNPs training through MountainStates Health Corporation at each year following training

* If the GNP was employed, was the employmentin a long-term care setting?* If the employment was in long-term care, wasthere evidence that she functioned as a GNP?

The proportion of eligible GNPs by employmentstatus at each year following training is shown infigure 3. Among the GNPs eligible for employ-ment, the proportion employed remained relativelyconstant and exceeded 92 percent throughout theyears analyzed. Less than 10 percent of the GNPsreported employment outside of long-term care, forexample, in nursing education and as clinical nursespecialists in a hospital. Finally, among the GNPsemployed in long-term care, a high proportionreported being actively employed in the geriatricnurse practitioner role.

Reasons for leaving first GNP position. The 39who resigned from their first GNP position wereasked the reason for leaving. Their responses wereclassified into five broad categories, and the resultsare summarized in table 1. Organizational changesrefer to changes within the employing institutionthat resulted in a dissolution of the GNP role. Thetransfer of nursing home ownership frequently ledto this dissolution. Seeking promotions or betterpositions included responses such as increases insalary or taking positions with administrative-supervisory responsibilities, or "improved job op-portunities." The category personal and family rea-sons for resignations was often characterized by aspouse's career relocation. In the category coded as"other," returning to school was the most fre-quently mentioned reason.

January-February 1990, Vol. 105, No. 1 69

Table 1. Reasons for leaving first employment followinggeriatric nurse practitioner (GNP) training

GNPGNP positons resignations Percent

Organizational change ............. 15 38.5Promotion, better position .......... 7 18.0Personal-family reasons ............ 7 18.0Failed to meet expectations ........ 5 12.8Other ........................... 5 12.8

Total ....................... 39 100.0

Table 2. Percent of time employed in positions classified asfull, partial, and no GNP role implementation, by monthssince completion of geriatric nurse practitioner (GNP) training

Months since GNP trainingGNP roheimplementatIon 0-24 25-48 49 plus Total

Full ........... 53 45 41 49Partial .......... 36 45 52 41None ........... 11 10 7 10

Total ..... 100 (2,009) 100 (814) 100 (680) 100

NOTE: In parenthesis are the number of months employed stratifed on thebasis of months from GNP training. Uncorrected chi-square with 4 degrees offreedom - 54.30; P <.001.

GNP role implementation. For the jobs followingGNP preparation, positions were characterized ac-cording to the level that the GNP role was imple-mented. Using job title and duties as the principalcriteria, positions were classified as full GNP roleimplementation, partial GNP role implementation,and no GNP role implementation.GNP role implementation was defined on the

basis of job title and duties as follows:

* full GNP implementation-GNP with neither su-pervisory nor administrative titles; only GNP dutiesreported;* partial GNP implementation-GNP job titlecombined with either supervisory or administrativejob title; some GNP duties reported along withsupervisory or administrative duties;* no GNP implementation-no GNP job title; noGNP duties reported.

Typical GNP functions were identified in promo-tional material distributed by MSHC as takingadmitting histories and doing physicals, manage-ment of common acute and chronic health prob-lems, family and patient counseling, patient teach-ing, and geriatric inservice. Almost half of theGNP employment months were classified as fullrole implementation. GNP roles were classified as

partial for 41 percent of the GNP employmentmonths. For the remaining 10 percent, no GNProle implementation was identified. As elapsed timesince GNP training increased, role implementationshifted from full to partial implementation (table2).

Factors associated with retention in long-term careand GNP role. Factors associated with (a) the pro-portion of a GNP career spent in long-term careand (b) the proportion of the GNP's career in fullrole implementation were analyzed. The factorsconsidered included age (less than 45 years andmore than or equal to 45 years); entry-level educa-tion (baccalaureate versus nonbaccalaureate); edu-cation level at'entry to the GNP program (baccca-laureate versus nonbaccalaureate); ANA GNPcertification; and share of pre-GNP training spentin long-term care (less than 50 percent and morethan or equal to 50 percent). The only positive as-sociation that was statistically significant was be-tween the proportion of experience in long-termcare before GNP training and the proportion ofGNP career spent in long-term care(chi-square= 16.22, 1 degree of freedom, P-value<.001).

Since the sponsoring facilities had agreed to hirethe GNPs for 18 months following their training,time from GNP training may have acted as apotential bias in associations with retention. Theanalysis was therefore repeated, controlling forlength of time since GNP training (classified as lessthan or equal to 24 months or greater than 25months). Again, the only statistical significanceoccurs between proportion of months of pre-GNPexperience in long-term care and the proportion ofmonths following GNP training employed in long-term care.

Discussion

This study suggests that the continuing educationmodel of GNP training successfully produced acohort of nurses who stayed in nursing homes andlong-term care settings. With career maturation,there was a trend toward increased diversificationof duties accompanying job changes and promo-tions in the facilities employing GNPs. With posi-tion changes, the GNPs were more likely to take onsupervisory or administrative responsibilities whilecontinuing to carry out some GNP functions.

In a study by Kane and coauthors (17), barriersto the implementation of the GNP role for a subsetof these GNPs were identified. Although this study

70 Public Helth Reports

was unable to make similar statements regardingthe barriers to GNP role implementation for theextended sample, our work has suggested thatchanges in nursing home ownership may reduce theretention of GNPs in these facilities. Organiza-tional change was the reason most frequently citedin our study for terminating GNP employment.The retention experience of these GNPs was

much higher than that of general nursing personnelemployed by nursing homes. From the 1984 Na-tional Sample Survey of Registered Nurses, the1-year retention of all RNs employed in nursinghomes was 72.7 percent. The 1-year retentionexperience of MSHC GNPs employed in long-termcare has exceeded 90 percent. A significant propor-tion of the GNPs prepared through MSHC werereintroduced into long-term care settings and re-mained employed there following the promissoryposttraining 18-month employment.

Future research in retention of GNPs needs toidentify relevant factors associated with increasedretention among those employed in long-term care.Among the variables unexplored in this study wereinstitutional characteristics of GNP employmentincluding wages and benefits and the accompanyingpersonal and professional attitudes of the GNPs.The available data did not provide detailed infor-mation about the institutional circumstances con-tributing to stability of employment.

Current trends in nursing education suggest thatthe master's degree has emerged as the dominantroute for nurse practitioner education (5). As fewerGNPs are trained through continuing educationprograms, GNP employment and retention in nurs-ing homes may decline. Can nursing homes attractand retain GNPs trained in higher degree pro-grams? Will the supply of masters-prepared GNPswilling to work in nursing homes increase to meetthe projected growth in nursing home demand?These are important policy questions for the fu-ture.Many of the nurses trained through MSHC are

personally and professionally bound to their placeof residence. Following training, most of the GNPswere employed by their sponsoring facility. TheseGNPs have apparently met a significant need in thesponsoring facilities, as well as the needs forspecialized health manpower over the past decade.While the graduate credential is essential to profes-sional nursing practice, the question remains: Willgraduate programs be capable of providing thenecessary pool of nurse specialists required forfuture employment in long-term care in both thisand the next century?

References ..................................

1. U.S. Department of Health and Human Services: Person-nel for health needs of the elderly through year 2020. U.S.Government Printing Office, Washington, DC, 1987.

2. Aiken, L. H., and Mullinix, C. F.: The nurse shortage,myth or reality? N Eng J Med 37i: 641-646, Sept. 3,1987.

3. U.S. Department of Health and Human Services: Analysisof the environment for the recruitment and retention ofregistered nurses in nursing homes. U.S. GovernmentPrinting Office, Washington, DC, 1987.

4. Swart, J. C.: The role of the nurse practitioner. J Long-Term Care Admin 11: 19-22, fall 1983.

5. Ebersole, P.: Geriatric nurse practitioners past and present.Geriatric Nurs 6: 219-222, July/August 1985.

6. Argondizzo, N. T., and Miller, M. A.: Preparation ofnurse practitioners in continuing education programs: theNew York Hospital - Cornell Medical Center experience. InNurses, nurse practitioners: the evolution of primary care,edited by M. D. Mezey and D. 0. McGivern. Little, Brownand Company, Boston, 1986, pp. 51-61.

7. Mezey, M. D.: Issues in graduate education. In Nurses,nurse practitioners: the evolution of primary care, editedby M. D. Mezey and D. 0. McGivern. Little, Brown andCompany, Boston, 1986, pp. 101-119.

8. Ebersole, P.: Geriatric nurse practitioners. Long-TermCare Currents 6: 11-14, July-September 1983.

9. Kane, R. L., et al.: Is good nursing home care feasible?JAMA 235: 516-519, Feb. 2, 1976.

10. Master, R. M., et al.: A continuum of care for the innercity. N Eng J Med 302: 1434-1440, June 26, 1980.

11. Weiland, D., et al.: Organizing an academic nursing home.JAMA 255: 2622-2627, May 16, 1986.

12. Pecharchik, R., and Nelson, B. H.: Employee turnover innursing homes. Am J Nurs 73: 289-290, February 1973.

13. Cotler, M. P., and Kane, R. L.: Registered nurses andnursing home shortages: job conditions and attitudesamong registered nurses. J Long-Term Care Admin16: 13-18, winter 1988.

14. Kepferle, L.: Projects and demonstrations relating tolong-term care. J Long-Term Care Admin 11: 54-57, fall1983.

15. Enloe, C.: Curriculum and training. J Long-Term CareAdmin 11: 5-9, fall 1983.

16. Kane, R. L., et al.: Assessing the effectiveness of geriatricnurse practitioners. In Nursing homes and nursing care:lessons from the teaching nursing homes, edited by M. D.Mezey, J. E. Lynaugh, and M. M. Cartier-. Springer, NY,1989, pp. 37-61.

17. Kane, R. A., et al.: Geriatric nurse practitioners as nursinghome employees: implementing the role. Gerontologist28: 469-477, August 1988.

18. Kaplan, E. L., and Meier, P.: Nonparametric estimationfrom incomplete observations. J Am Stat Assoc 53:457-481, June 1958.

January-February 1990, Vol. 105, No. 1 71