Scenario Analysis: This scenario presents a professional challenge due to the inherent conflict between a patient’s expressed wishes and the clinician’s assessment of potential harm. The patient, having experienced a previous stroke, is refusing a recommended preventative medication due to perceived side effects and a desire for a “natural” approach. This requires the advanced practice clinician to navigate complex ethical considerations, including patient autonomy, beneficence, and non-maleficence, while adhering to professional standards of care and communication. The clinician must balance respecting the patient’s right to make decisions about their own health with the professional obligation to provide evidence-based care aimed at preventing serious harm. Correct Approach Analysis: The best professional approach involves a comprehensive, empathetic, and collaborative discussion with the patient. This includes actively listening to and validating the patient’s concerns about side effects and their preference for natural remedies. The clinician should then provide clear, understandable information about the specific risks of stroke recurrence without the medication, the evidence supporting the medication’s efficacy, and explore potential strategies to mitigate perceived side effects or integrate complementary approaches alongside the prescribed treatment. This approach upholds patient autonomy by ensuring informed consent and shared decision-making, while fulfilling the duty of beneficence by advocating for the patient’s best medical interests. It aligns with professional guidelines that emphasize patient-centered communication and shared decision-making in all aspects of care, particularly when managing chronic conditions and preventative strategies. Incorrect Approaches Analysis: One incorrect approach would be to dismiss the patient’s concerns and insist on immediate medication adherence without further discussion. This fails to respect patient autonomy and can erode trust, potentially leading to non-compliance and a breakdown in the therapeutic relationship. It also neglects the clinician’s duty to understand and address the patient’s specific fears and preferences. Another incorrect approach would be to unilaterally alter the treatment plan based solely on the patient’s refusal, without a thorough exploration of the underlying reasons or providing adequate information about the consequences. This could be seen as abandoning the patient to potential harm and failing to meet the standard of care for stroke prevention. A third incorrect approach would be to present the information in a highly technical or dismissive manner, making the patient feel unheard or unintelligent. This communication failure would hinder informed consent and shared decision-making, as the patient would not be empowered to make a truly informed choice. Professional Reasoning: Professionals should employ a structured decision-making framework that prioritizes open communication, active listening, and shared decision-making. This involves: 1. Understanding the patient’s perspective: Elicit and validate their concerns, beliefs, and values. 2. Assessing capacity: Ensure the patient has the capacity to make informed decisions. 3. Providing clear, balanced information: Explain the risks, benefits, and alternatives of all treatment options in an understandable way. 4. Exploring options collaboratively: Work with the patient to find a treatment plan that aligns with their values and medical needs. 5. Documenting the process: Record the discussion, the patient’s decision, and the rationale.

Scenario Analysis: This scenario presents a professional challenge related to the interpretation and application of examination policies, specifically concerning blueprint weighting, scoring, and retake procedures. Advanced practice professionals are expected to understand and adhere to the rules governing their certification and ongoing professional development. Misinterpreting these policies can lead to significant personal and professional consequences, including wasted time and resources, delayed career progression, and potential reputational damage. The challenge lies in navigating the nuances of policy language and applying it to individual circumstances, requiring careful judgment and a commitment to understanding the governing framework. Correct Approach Analysis: The best professional practice involves a proactive and thorough review of the official examination handbook and any supplementary policy documents provided by the examination board. This approach ensures a comprehensive understanding of the blueprint weighting, which dictates the relative importance of different subject areas; the scoring methodology, which outlines how performance is evaluated; and the retake policies, which specify the conditions and limitations for re-examination. Adhering to these documented policies is ethically mandated, as it demonstrates a commitment to fair and transparent examination processes. It also aligns with professional integrity by ensuring that decisions regarding examination preparation and retakes are based on established, authoritative guidelines, rather than assumptions or hearsay. Incorrect Approaches Analysis: Relying solely on informal discussions with colleagues or mentors about the examination policies is professionally unacceptable. While colleagues may offer helpful insights, their interpretations may be inaccurate, outdated, or incomplete, leading to a misunderstanding of critical details. This approach risks violating the spirit and letter of the examination rules, potentially resulting in disqualification or other penalties. Assuming that the retake policy is the same as for previous examinations without verifying current regulations is also a significant professional failure. Examination boards frequently update their policies to reflect evolving best practices or to address emerging issues. Failure to consult the most current official documentation means operating under potentially obsolete rules, which can have serious repercussions. Focusing only on the scoring mechanism and neglecting the blueprint weighting and retake policies demonstrates an incomplete understanding of the examination’s overall structure and requirements. While understanding how one is scored is important, it is insufficient for effective preparation or for making informed decisions about retakes. A holistic understanding of all policy components is necessary for professional compliance and success. Professional Reasoning: Professionals facing situations involving examination policies should adopt a systematic decision-making process. This begins with identifying the authoritative source of information – typically an official examination handbook or website. Next, engage in a detailed and careful reading of all relevant sections, paying close attention to definitions, procedures, and stated requirements. If any part of the policy remains unclear, the professional should seek clarification directly from the examination board’s administrative or support staff. Documenting any communications with the board for future reference is also advisable. This methodical approach ensures that all decisions are grounded in accurate information and adhere to established professional standards.

This scenario is professionally challenging because it requires a nuanced understanding of the eligibility criteria for advanced practice examinations, balancing the desire for professional development with the need to meet established standards. Misinterpreting these criteria can lead to wasted effort, financial loss, and potential reputational damage for both the individual and the certifying body. Careful judgment is required to ensure that only suitably qualified individuals are admitted to the examination, thereby upholding the integrity and credibility of the certification. The best approach involves a thorough review of the official examination handbook and any supplementary guidance documents provided by the certifying body. This approach is correct because it directly addresses the source of truth for eligibility requirements. Adhering to these documented standards ensures that all applicants are assessed against the same objective criteria, promoting fairness and transparency. This aligns with ethical principles of impartiality and accountability in professional certification. Specifically, the purpose of the Elite Stroke Prevention Medicine Advanced Practice Examination is to recognize individuals who have demonstrated a high level of knowledge and skill in stroke prevention, and eligibility criteria are designed to ensure that candidates possess the foundational experience and education necessary to benefit from and succeed in such an advanced assessment. An incorrect approach would be to rely solely on informal discussions or anecdotal evidence from colleagues regarding eligibility. This is professionally unacceptable because informal sources are often incomplete, outdated, or misinterpreted, leading to a misunderstanding of the precise requirements. This can result in an applicant being deemed ineligible at a later stage, causing significant disappointment and wasted resources. Furthermore, it bypasses the established channels for obtaining accurate information, undermining the principle of due diligence. Another incorrect approach is to assume that meeting general professional experience requirements in neurology or cardiology automatically qualifies an individual. While relevant, these general requirements may not encompass the specific, specialized experience or advanced training mandated for an “Elite Stroke Prevention Medicine” designation. The examination’s purpose is to assess specialized expertise, not just broad clinical experience. Failing to recognize this specificity is a failure to understand the advanced nature and targeted focus of the examination. A further incorrect approach is to focus only on the perceived difficulty or prestige of the examination when determining eligibility, rather than the stated criteria. Eligibility is determined by meeting predefined standards, not by an individual’s subjective assessment of their own readiness or the examination’s standing. This approach is flawed as it prioritizes personal ambition over objective qualification, potentially leading to applications from individuals who lack the necessary prerequisites, thereby devaluing the certification for those who have met the requirements. Professionals should employ a decision-making framework that begins with clearly identifying the specific examination and its governing body. Next, they must locate and meticulously review all official documentation related to eligibility, including purpose statements, prerequisite qualifications (education, experience, licensure), and any specific training or competency requirements. If any ambiguity remains after reviewing the official documentation, the next step should be to contact the examination administrators directly for clarification. This systematic and evidence-based approach ensures that decisions regarding eligibility are informed, accurate, and defensible.

Scenario Analysis: This scenario presents a common challenge in advanced practice medicine: balancing established evidence-based guidelines with individual patient variability and the complexities of chronic disease management. The challenge lies in synthesizing current research, patient-specific factors, and the practicalities of implementation to achieve optimal stroke prevention outcomes. Professionals must navigate potential conflicts between guideline recommendations and patient preferences or comorbidities, requiring nuanced clinical judgment. Correct Approach Analysis: The best approach involves a comprehensive, individualized assessment that integrates current evidence-based guidelines with a thorough understanding of the patient’s unique clinical profile, risk factors, and preferences. This includes a detailed review of their medical history, current medications, lifestyle, and any contraindications or potential interactions. The decision-making process should then involve a shared discussion with the patient, explaining the rationale behind recommended interventions, potential benefits, risks, and alternatives, empowering them to participate actively in their care plan. This aligns with ethical principles of patient autonomy and beneficence, and regulatory frameworks that emphasize personalized medicine and patient-centered care. Incorrect Approaches Analysis: One incorrect approach would be to rigidly adhere to a single guideline without considering the patient’s specific circumstances. This fails to acknowledge that guidelines are general recommendations and may not be universally applicable. It can lead to suboptimal treatment, potential adverse events, or patient non-adherence if the recommended strategy is not suitable for their individual needs or preferences. This approach neglects the ethical imperative to tailor care to the individual and can be seen as a failure to exercise professional judgment. Another incorrect approach would be to prioritize patient preference over all established evidence, even when that preference carries significant, avoidable risks. While patient autonomy is crucial, it must be balanced with the professional’s duty to inform and guide patients towards the safest and most effective treatments based on scientific evidence. Ignoring strong evidence in favor of a less effective or riskier option, without robust justification, can lead to harm and is ethically problematic. A further incorrect approach would be to rely solely on anecdotal experience or the practices of colleagues without consulting current, high-quality evidence. While experience is valuable, it should be informed by and integrated with the latest research. Relying on outdated or unverified practices can result in the use of ineffective or even harmful interventions, failing to meet the professional standard of care and potentially violating regulatory expectations for evidence-based practice. Professional Reasoning: Professionals should employ a systematic decision-making framework that begins with a thorough patient assessment. This includes identifying all relevant risk factors and comorbidities. Next, they should consult current, evidence-based guidelines and literature pertinent to stroke prevention. The core of the decision-making process involves synthesizing this information with the patient’s individual characteristics, values, and preferences. This leads to the development of a shared, individualized care plan that is clearly communicated to the patient, with ongoing monitoring and adjustment as needed.

The risk matrix shows a patient presenting with multiple comorbidities and a history of non-adherence to preventative therapies, posing a complex ethical and professional challenge. The core of this challenge lies in balancing the clinician’s duty of care and the patient’s autonomy, particularly when the patient’s decision-making capacity might be influenced by their health literacy or past negative experiences with the healthcare system. Ensuring informed consent in such a scenario requires more than a simple explanation of risks and benefits; it necessitates a thorough assessment of the patient’s understanding and a commitment to shared decision-making. The best approach involves a comprehensive, patient-centered strategy that prioritizes understanding and shared decision-making. This entails dedicating sufficient time to explain the rationale for stroke prevention, the specific benefits and risks of recommended interventions tailored to the patient’s individual profile, and exploring potential barriers to adherence. Crucially, this approach involves actively soliciting the patient’s values, preferences, and concerns, and collaboratively developing a treatment plan that aligns with these factors. This aligns with the ethical principles of beneficence (acting in the patient’s best interest), non-maleficence (avoiding harm), and respect for autonomy. It also reflects best practice in health systems science by acknowledging the patient as a partner in their care and recognizing the importance of addressing systemic factors that may impede adherence. An approach that focuses solely on presenting the medical evidence without adequately exploring the patient’s understanding or addressing their concerns is ethically deficient. This fails to uphold the principle of autonomy, as true informed consent cannot be given if the patient does not comprehend the information or if their values are not considered. It also risks undermining the therapeutic relationship, potentially leading to further non-adherence. Another unacceptable approach would be to proceed with a treatment plan based on the assumption that the patient will comply, despite past non-adherence, without a renewed discussion about the rationale and potential challenges. This disregards the patient’s history and fails to proactively address potential obstacles, thereby potentially leading to suboptimal outcomes and violating the principle of beneficence. Finally, an approach that dismisses the patient’s concerns or past experiences as irrelevant to current decision-making is professionally unsound. This demonstrates a lack of empathy and respect for the patient’s lived experience, which can significantly impact their willingness to engage with healthcare. It fails to acknowledge the holistic nature of patient care and the importance of building trust. Professionals should employ a decision-making framework that begins with a thorough assessment of the patient’s capacity and understanding. This should be followed by clear, jargon-free communication of medical information, tailored to the patient’s literacy level. Active listening and empathetic inquiry are essential to uncover the patient’s values, preferences, and any barriers to care. The subsequent treatment plan should be developed collaboratively, ensuring the patient feels heard and empowered in their healthcare journey. This iterative process of communication, assessment, and shared decision-making is fundamental to ethical and effective medical practice.

This scenario is professionally challenging because it requires balancing a patient’s expressed wishes with the clinician’s professional judgment regarding the optimal stroke prevention strategy, especially when the patient’s understanding of the risks and benefits might be incomplete or influenced by external factors. The clinician must navigate potential conflicts between patient autonomy and the duty of beneficence, ensuring that the patient’s decision is truly informed and aligned with their best medical interests. Careful judgment is required to assess the patient’s capacity, the validity of their concerns, and the potential consequences of deviating from evidence-based guidelines. The best approach involves a comprehensive shared decision-making process that prioritizes patient education and addresses their specific concerns. This includes thoroughly explaining the rationale for the recommended stroke prevention strategy, detailing its efficacy and potential side effects, and actively listening to and validating the patient’s anxieties. The clinician should then explore the patient’s reasons for preferring an alternative, assess their understanding of the risks associated with that preference, and collaboratively develop a plan that respects their autonomy while mitigating risks. This aligns with ethical principles of informed consent and patient-centered care, ensuring the patient’s decision is based on a clear understanding of all available information and options. An approach that dismisses the patient’s concerns and insists on the clinician’s preferred treatment without adequate exploration of the patient’s reasoning fails to uphold the principle of patient autonomy. This can lead to a breakdown in trust and a patient who feels unheard or coerced, potentially resulting in non-adherence to treatment. Another incorrect approach involves immediately agreeing to the patient’s less evidence-based preference without a thorough assessment of their understanding or the potential risks. This abdication of professional responsibility can lead to suboptimal patient outcomes and may not fully meet the clinician’s duty of care to recommend the most effective preventative measures. Furthermore, an approach that focuses solely on the patient’s stated preference without exploring the underlying reasons or providing sufficient information about alternative options is insufficient. True shared decision-making requires a dialogue where both parties contribute to the final plan, ensuring that the patient’s values are considered alongside medical evidence. Professionals should employ a structured decision-making framework that begins with assessing patient capacity, followed by a thorough exploration of the patient’s values, preferences, and concerns. This should be followed by presenting evidence-based treatment options, including their risks and benefits, in a clear and understandable manner. The clinician should then engage in a collaborative discussion to reach a mutually agreeable plan, ensuring the patient feels empowered and informed in their healthcare choices.

This scenario is professionally challenging due to the inherent complexity of integrating advanced biomedical science findings with direct patient care decisions, particularly when those findings suggest a novel or less established preventative strategy. The need for rigorous evidence-based practice, patient autonomy, and adherence to evolving clinical guidelines creates a delicate balance. Careful judgment is required to ensure patient safety, efficacy of treatment, and responsible adoption of new medical knowledge. The best professional approach involves a thorough review of the latest peer-reviewed literature and current clinical guidelines from reputable professional bodies. This approach is correct because it prioritizes evidence-based medicine, which is a cornerstone of ethical and effective medical practice. It ensures that any proposed intervention, even one suggested by foundational biomedical science, has been scrutinized for safety and efficacy through established scientific and clinical validation processes. Adhering to guidelines from organizations like the National Institute for Health and Care Excellence (NICE) in the UK, or equivalent bodies in other jurisdictions, provides a framework for decision-making that balances innovation with patient well-being and resource allocation. This systematic evaluation respects the principles of beneficence and non-maleficence by ensuring interventions are likely to benefit the patient and minimize harm. An incorrect approach would be to immediately implement a novel preventative strategy based solely on promising foundational biomedical research without awaiting further clinical validation or guideline updates. This fails to adhere to the principle of evidence-based practice, potentially exposing the patient to unproven risks or ineffective treatments. It bypasses the crucial step of rigorous clinical trials and expert consensus building that informs established guidelines. Another incorrect approach is to dismiss the foundational biomedical findings entirely without any consideration or further investigation. This demonstrates a lack of intellectual curiosity and a failure to stay abreast of scientific advancements, potentially depriving patients of future beneficial treatments. It can be seen as a failure of beneficence, as it may prevent the adoption of a potentially life-saving or life-improving intervention. A further incorrect approach would be to present the foundational biomedical findings to the patient as definitive proof of a new preventative strategy, without contextualizing them within the current evidence base or acknowledging the lack of established clinical guidelines. This undermines patient autonomy by providing incomplete or potentially misleading information, hindering their ability to make truly informed decisions. It also fails to uphold the professional responsibility to provide accurate and balanced medical advice. The professional reasoning framework for similar situations should involve a continuous learning process, critically appraising new scientific information, and understanding its place within the existing clinical evidence and guidelines. When faced with novel findings, professionals should engage in a process of literature review, consultation with peers and specialists, and consideration of the potential benefits and harms to the patient, always prioritizing established evidence and patient safety.

Scenario Analysis: This scenario is professionally challenging due to the critical nature of stroke prevention, the rapid progression of potential neurological deficits, and the need for precise diagnostic reasoning to guide appropriate imaging selection and interpretation. Misinterpretation or delayed diagnosis can lead to irreversible harm, impacting patient outcomes and potentially leading to litigation. The advanced practice professional must balance clinical suspicion with resource utilization and patient safety, adhering to established diagnostic pathways. Correct Approach Analysis: The best professional practice involves a systematic approach that begins with a thorough clinical assessment to establish the likelihood of stroke and identify specific stroke syndromes. This clinical reasoning then dictates the most appropriate initial imaging modality, prioritizing speed and sensitivity for acute ischemic stroke. Following imaging, a structured interpretation process, often involving multidisciplinary consultation, is essential to confirm the diagnosis, identify the underlying cause, and guide immediate management. This aligns with ethical obligations to provide timely and effective care and regulatory expectations for evidence-based practice and appropriate diagnostic stewardship. Incorrect Approaches Analysis: One incorrect approach involves ordering advanced imaging modalities like MR angiography or CT perfusion as the initial diagnostic step without a clear clinical indication derived from the initial assessment. This bypasses essential clinical reasoning, potentially leading to unnecessary radiation exposure, increased costs, and delays in initiating time-sensitive treatments if the initial findings are not immediately interpretable or if a simpler, faster modality would have sufficed for initial triage. This fails to adhere to principles of diagnostic stewardship and potentially violates the ethical duty to avoid unnecessary harm. Another incorrect approach is to rely solely on imaging findings without integrating them with the patient’s clinical presentation and history. Imaging is a tool to confirm or refute clinical hypotheses, not a standalone diagnostic entity. Interpreting imaging in isolation can lead to misdiagnosis, especially in cases of transient ischemic attack (TIA) or stroke mimics, resulting in inappropriate treatment or a failure to identify the true cause of symptoms. This deviates from best practice in diagnostic reasoning and can lead to suboptimal patient care, violating the ethical duty of competence. A further incorrect approach is to delay interpretation or consultation of imaging results, particularly in suspected acute stroke. The time-sensitive nature of stroke treatment necessitates rapid interpretation and communication of findings to the treating team. Any significant delay, whether due to workflow inefficiencies or lack of immediate access to expert interpretation, can result in missed treatment windows, such as thrombolysis or thrombectomy, leading to significantly worse patient outcomes. This represents a failure to provide timely care and can be considered a breach of professional duty. Professional Reasoning: Professionals should employ a decision-making framework that prioritizes clinical assessment to generate a differential diagnosis and assess stroke risk. This clinical judgment then guides the selection of the most appropriate, often time-sensitive, imaging modality. Following imaging, a structured interpretation process, integrating findings with clinical data and involving multidisciplinary input when necessary, is crucial for accurate diagnosis and timely management. This iterative process ensures that diagnostic efforts are both effective and efficient, prioritizing patient well-being and adherence to best practices.

The efficiency study reveals that a significant number of advanced practice clinicians preparing for the Elite Stroke Prevention Medicine Advanced Practice Examination are struggling to allocate sufficient time for comprehensive review of candidate preparation resources. This scenario is professionally challenging because inadequate preparation can lead to suboptimal patient care outcomes in stroke prevention, directly impacting patient safety and the clinician’s ability to practice competently. Careful judgment is required to balance demanding clinical workloads with the imperative for continuous professional development and examination readiness. The best approach involves a structured, proactive timeline that integrates dedicated study periods into the clinician’s existing schedule, prioritizing core competencies and high-yield topics identified through official examination blueprints and reputable review materials. This proactive strategy ensures that all essential areas are covered systematically, allowing for deeper understanding and retention rather than superficial cramming. This aligns with ethical obligations to maintain professional competence and regulatory expectations for ongoing learning and skill development, ensuring that advanced practice clinicians are well-equipped to provide evidence-based stroke prevention care. An incorrect approach involves deferring preparation until the last few weeks before the examination. This strategy is ethically problematic as it risks superficial learning and increased stress, potentially leading to an incomplete grasp of critical stroke prevention concepts. It fails to meet the professional standard of diligent preparation and could result in a candidate being inadequately prepared to practice safely and effectively. Another incorrect approach is to rely solely on informal study groups without consulting official examination guidelines or structured review resources. While collaboration can be beneficial, an over-reliance on informal methods without a systematic review of the prescribed curriculum can lead to gaps in knowledge and an inaccurate understanding of the examination’s scope and depth. This deviates from the professional responsibility to prepare using validated and comprehensive resources. A further incorrect approach is to focus exclusively on areas of personal interest or perceived strength, neglecting other critical domains outlined in the examination syllabus. This demonstrates a lack of comprehensive preparation and an ethical failure to address all aspects of stroke prevention medicine, potentially leaving the clinician unprepared to manage a broad spectrum of patient needs. Professionals should adopt a decision-making framework that begins with understanding the examination’s scope and requirements. This involves thoroughly reviewing official candidate handbooks and syllabi. Next, they should conduct a self-assessment of their current knowledge and identify areas requiring the most attention. Based on this assessment, a realistic study schedule should be developed, integrating study time into daily or weekly routines, and prioritizing resources that are aligned with the examination’s objectives. Regular self-testing and seeking feedback are crucial components of this process to ensure effective learning and identify any remaining knowledge gaps.

Scenario Analysis: This scenario is professionally challenging because it requires balancing the immediate needs of a specific patient population with broader public health goals and the ethical imperative of health equity. Advanced practice clinicians are often faced with resource limitations and the need to prioritize interventions, making decisions that can have significant downstream impacts on health disparities. Careful judgment is required to ensure that clinical decisions are not only medically sound but also socially responsible and aligned with public health principles. Correct Approach Analysis: The best professional practice involves a comprehensive population health assessment that explicitly considers the social determinants of health and existing health inequities within the defined service area. This approach recognizes that stroke prevention is not solely a medical issue but is deeply influenced by factors such as socioeconomic status, access to care, education, and environmental conditions. By identifying specific disparities and their root causes, interventions can be tailored to address the unique needs of underserved groups, thereby promoting health equity. This aligns with public health ethics which emphasizes the collective good and the reduction of preventable suffering, particularly among vulnerable populations. Regulatory frameworks often mandate consideration of population health needs and equitable access to services. Incorrect Approaches Analysis: One incorrect approach involves focusing solely on the highest-risk individuals identified through traditional clinical risk factors without considering the underlying social determinants that contribute to their elevated risk. This fails to address the systemic issues that create and perpetuate health inequities, potentially exacerbating disparities by providing resources only to those who can navigate the existing healthcare system most effectively. Another incorrect approach is to implement a one-size-fits-all stroke prevention program that does not account for cultural nuances, language barriers, or varying levels of health literacy within the population. This approach overlooks the critical need for culturally competent and accessible interventions, which is a cornerstone of health equity and can lead to poor engagement and suboptimal outcomes for marginalized communities. A further incorrect approach is to prioritize interventions based solely on the perceived ease of implementation or cost-effectiveness without a thorough assessment of their impact on health equity. While resource constraints are a reality, decisions must be guided by an ethical framework that prioritizes the reduction of health disparities, ensuring that interventions do not inadvertently disadvantage already vulnerable groups. Professional Reasoning: Professionals should employ a decision-making framework that begins with a thorough population health assessment, incorporating epidemiological data and an explicit analysis of health equity. This assessment should identify specific disparities, their contributing social determinants, and the needs of diverse subgroups. Following this, interventions should be designed and prioritized based on their potential to reduce these disparities and promote equitable outcomes, considering feasibility, effectiveness, and ethical implications. Continuous monitoring and evaluation of interventions are crucial to ensure they are achieving their intended equity goals and to adapt strategies as needed.