Covid-19: Clinical strategies and medication safety in critical care

By Rhona Sloss, Specialist Pharmacist Critical Care and Reena Mehta, Pharmacy Team Leader Critical Care, King’s College Hospital NHS Foundation Trust

Rhona Sloss (left) and Reena Mehta (right)

As part of the King’s Critical Care Team, we have had to respond quickly to a rapidly changing Covid-19 situation, after receiving our first patient on Friday 6th of March.

Over the last three weeks, we have been faced with new challenges on an hourly basis, as we prepare to increase our critical care bed capacity by 380% across two sites. While this brings several operational and logistical challenges, it is also important to prioritise appropriate clinical strategies and medication safety considerations to ensure patient safety is not compromised.

With a variety of consultants from different specialities caring for patients, as well as junior doctors with no prior critical care experience, some consistency in our clinical approach is required. Based on the recognisable pattern of how Covid-positive patients present, we have created an “admission prescribing order set” to ensure key drugs are prescribed quickly and accurately. We have focused on streamlining sedation strategies by devising a flow sheet to guide the choice of appropriate agents, giving options of alternatives if supply of first line drugs becomes difficult. To help with prescribing and administration, all areas have implemented a pre-printed infusion prescription chart. These interventions are necessary in order to ensure patients can be managed safely.

The increasing demand and workload placed on our critical care nurses over the past three weeks has also been evident. As nurse-to-patient ratios increase, it is important as pharmacists to consider reviewing the various medicines management policies and seek opportunities to make safe changes which can help during this period. This may include single nurse checking of injectables (with some exceptions) and reviewing storage of medicines at the bedside where POD lockers may not be available.

Considering strategies to reduce the burden on nurses of continually drawing up multiple infusions is also vital. Ideas we have considered include giving medications as intermittent boluses instead of infusions, using more concentrated solutions and looking at options to source pre-filled syringes, including exploring an in-house CIVAS service.

As pressure on us all undoubtedly increases in the coming weeks, the crucial role of clinical pharmacists will be more vital than ever. As we continue to learn on a daily basis and deal with new challenges, the value of communicating with each other, both locally and nationally, has never been more important.

Critical care pharmacy during the COVID-19 pandemic

Sinéad O’Halloran, Consultant Pharmacist Critical Care

by Sinéad O’Halloran, Consultant Pharmacist Critical Care, Lewisham & Greenwich NHS Trust

The first critical care COVID 19 patient arrived on our ward on 7th March. By Monday 23rd March we had more than double the usual number of ventilated patients at both of our hospitals. There seems to be a clearly recognisable pattern, patients in their 50s and 60s with single organ failure, presenting with a history of fever, and flu like symptoms. Patients are acutely hypoxaemic, and many required proning. On critical care, side rooms and negative pressure rooms quickly became full and ventilated patients were then cohorted in open ward areas. All staff entering COVID areas require varying degrees of PPE and this has been also been an area of challenge. 

Read more Critical care pharmacy during the COVID-19 pandemic

Social media – let’s make it a force for good.

Social media use is always under scrutiny.

Whether it’s the amount of screen time children should have or whether vloggers should be encouraging gambling, the public’s mood seems to be in favour of more regulation, accountability and transparency.

We are fast approaching the 2020 RPS elections! We want everyone to enjoy the experience of being part of the elections, whether as a candidate or as voter, so we will do our best to encourage friendly and professional discussion.

We’ll be encouraging members standing for election to campaign via social media, online forums and blogs. We know this is a great way to reach and engage with voters. If you’re standing for election this year, we will send you specific guidance to help.

The best advice I’ve ever received about testing whether something is suitable to be shared on social media or not is: “If you wouldn’t say it in the ‘real world’, don’t say it in the ‘digital world’.

We love a robust but polite debate. Read more Social media – let’s make it a force for good.

How to get the most out of a mentoring relationship

By Helen Middleton, MSc (Education), FFRPS, FPharmS

Mentoring can provide opportunities for both mentors and mentees to progress. Read on to find out how to make this relationship work…

Mentoring will have a different meaning for different individuals. For some it will mean a relationship where the mentor guides the mentee on specific topics; for others it will relate to a wider, less directive relationship.

Match expectations

If there is a mismatch of the expectations of the mentor with those of the mentee, the mentoring relationship could be destined for failure. Therefore, it is important to discuss expectations at the outset of any mentoring relationship.

The following questions can be asked by both the mentor and mentee to help decide whether or not they are a suitable match:

  • How would you define mentoring?
  • What do you want to get out of this mentoring process?
  • What do you expect from me?

It is unlikely that the expectations of each party will be identical, so some compromises may be necessary to find common ground. However, if the expectations of each party are quite different then it may be better for the mentee to look for an alternative mentor via the Royal Pharmaceutical Society mentoring platform.

Mentor versus manager?

Some managers think they can mentor individuals at the same time as managing them. This is not recommended because it can be difficult for a manager to balance his or her different roles.

A mentor should focus on:

  • Supporting long-term development for the mentee’s current and future roles
  • Helping the mentee reflect on his or her practice
  • Helping the mentee identify development opportunities and learning needs
  • Setting goals to learn, develop and progress
  • Helping the mentee to monitor his or her own development

In contrast, a manager will tend to focus on: completing tasks and meeting immediate deadlines; assessing performance against standards and carrying out appraisals; enabling the worker to deliver and perform; setting objectives and checking on progress; and monitoring performance to ensure quality.

In addition, managers can be tempted to be directive and give their own answers to the mentee’s problems. It can also be uncomfortable for an individual to discuss their weaknesses and issues in a full and open manner with their manager, particularly if the issues are contentious.

Supportive, not instructive

To be an effective mentor, it is not necessary to be especially senior within an organisation or to have specialist knowledge of the mentee’s area of practice. The mentor should be an enthusiastic “people developer” who facilitates problem solving and action planning.

Mentors need to stand back, be objective and non-judgemental, and be able to put themselves in the mentee’s position. Rather than acting as an expert, mentors take on a supportive role: encouraging mentees to find their own expertise. A mentor can be thought of as a catalyst that stimulates self-directed change, with a belief in the mentee’s ability to solve his or her own problems.

This piece is abridged from an article by Helen Middleton, MSc, MRPharmS, first published in Clinical Pharmacist (2011;3:345).

Sign up on www.rpharms.com/mentoring 

RPS mentoring platform facilitates easy and appropriate matching of mentor to mentee. 

Why visible leadership matters

During LGBTQ+ history month, two deputy chief pharmacists tell us what visible leadership means to them

Rajiv Pandya, Deputy Chief Pharmacist Dudley & Walsall MH Trust

For me, leadership is about being able to be authentic and to allow my personality to be intrinsic to my leadership style. As a professional, feeling able to show the whole of my identity hasn’t always been easy and I have often struggled in terms of whether to be open about being a gay man in the workplace.  I’ve worked in a whole plethora of teams within the NHS and I found that how comfortable I felt about being open about my sexuality differed significantly depending on the organisation I worked in.

One of my most significant negative interactions was when working as a pharmacist visiting a GP surgery to support with their medicines optimisation work streams.

I remember the homophobic conversations in the room which made me feel uncomfortable and I remember almost feeling that I had recoiled into a shell of who I truly was. I remember feeling physically uncomfortable, which impacted on my interactions with the staff and my focus to carry out the task at hand.

On the other hand, the culture within my current organisation is very different. A culture of openness and equality and diversity is high up on the trust’s agenda.

I feel I am able to be my authentic self, which I believe brings richness to my leadership and helps me to establish meaningful professional relationships based on trust and mutual understanding.  Ultimately, I feel I work more effectively in my role which benefits my team and leads to better patient care. I feel empowered within my organisation and I have also taken on the role as chair of the trust’s LGBTQ+ committee, which comes at an exciting time as we begin to prepare our plans for Birmingham Pride.

I am likely to be one of many LGBTQ+ people who have had these experiences and this is why I believe visible diversity and inclusion within leadership is so important. We need more visible LGBTQ+ role models to ensure our workforce feels empowered and enabled to shine as their authentic selves as it will lead to increased confidence, motivation and ultimately positively impact the quality of care we provide to our patients.




Sam Malton, Deputy Chief Pharmacist, University Hospitals Derby & Burton

I work in a teaching hospital. I am also gay. I also have type 1 diabetes. I’ve also struggled with my mental health. Sounds a lot? Perhaps, but there’s not much I can do to change any of it. Instead I accept the challenges and do not allow them to hold me back.

I’ve had a varied and interesting career to date and leadership has been at the heart of it. I’ve watched leaders and their styles over the years and this has helped to develop my own leadership.  Interacting with leaders of other professions, with whom I work closely has also taught me a lot.

I can honestly say that being gay has never affected my career. My sexuality has always been accepted, from being a student, up to the present day. I was worried at university about the demographic of my peers being different to mine, but I was lucky to have a large and diverse friendship group. I’ve watched gay leaders in pharmacy with respect and really feel that sexuality has been a non-issue in my career.

In 2016 I was diagnosed with type 1 diabetes out of the blue. This led to a very difficult episode of anxiety and depression, having lived with anxiety all of my life. I felt like my career was over and could not imagine ever leaving the comfort of my role at the time. I knew that I wanted to be a leader and develop further – but could not see how I could ever do that.

Thanks to support from various leaders, I was able to get back to normal over a few months. I began to develop my leadership again and thanks to visible and honest leaders who showed interest in me, I took the next step in my career.

In all this I learned a valuable lesson that leaders are not perfect. They are human and have the same individual challenges as everyone else. I was surprised to learn how many leaders struggle with anxiety. It’s taught me that with the right mind set anything is possible. As a leader I can be confident and anxious at the same time. I can do my job and not worry about hypos, so long as I have sweets in my pocket. I can openly talk about my male fiancé and not be judged. I feel privileged to be in this position and to have had the same chances as everyone else.

Find out more about our work on Inclusion and Diversity

My experience at the RPS Mock Exam Event

by Alya Jassim, Pre-registration trainee 2020

The first day of the event started with an introduction to the course, outlining the important changes that we needed to be aware of, such as the updated de-regulation of medicines. The lecturer, Nadia Bukhari, was great at explaining information and giving lots of little hints and tips along the way. The pre-registration manual evidences were again put to light to ensure the topics were fully covered. We then moved on to calculations. There were quick-fire questions to get us warmed up and I liked how the calculations were categorised into 12 categories highlighting the possible questions that the exam could potentially ask, with slight variations. It made things much simpler. A reflection after each set of questions was particularly useful, as we had the opportunity to think about where we may have gone wrong in the calculation.

There were a few ice breaker sessions which opened conversations with other pre-registration trainees and proved great for networking opportunities. After the break, there was a very thorough clinical session about high risk drugs. The key points were again highlighted, and the speaker did a great job at challenging us to think at a deeper level, which gave me a very clear indication about how in-depth my revision needed to be.

After lunch we had another clinical session, however this was slightly more interactive, with a case study of a patient that had several commodities and risk factors. This was particularly useful as it allowed me to look at a case with a more holistic approach rather than look at one aspect. It gave us the opportunity to speak to other pre-registration trainees and discuss our answers. This was a very enjoyable session.

We then moved on to OTC treatments, another interactive session that I enjoyed. There were lots of example questions that could be asked in the assessment, which I used as guidance about what I should be looking out for when studying OTC medicines.

Day Two was the big day where the assessment took place. The assessment started after a very informative law and ethics lecture. The lecturer, Atif Shamim, gave lots of examples that really resonated and were very applicable to real life. I found it very helpful how the references to the MEP were highlighted on each slide.

Paper 1 was the hour-long calculations paper and then after lunch, we sat the second paper, which was the clinical paper. The feedback session was helpful, as I got to see where I was going wrong and what gaps I needed to address in my revision.

Overall, the experience I had at the event was extremely insightful. The information was well organised, the lecturers were very helpful and I found them greatly inspiring. I highly recommend the event for all pre-registration trainees, an absolute must!

If you’d like to find out more about the RPS Pre-Reg events taking place across the country, take a look at: https://www.rpharms.com/events/pre-registration-mock-exam-and-revision-course

Women in Science

By Dr Amira Guirguis

My entry into Science and Research was a long one as I initially trained and worked as an accountant. After becoming a mother, I decided that I wanted to help people from a healthcare perspective and I undertook the daunting task of training to be a Pharmacist in the UK. I say daunting because I was an Arabic/French speaker but I loved science. Becoming a Pharmacist – it was the best move I ever made! 

Working within community and hospital pharmacies taught me that building a rapport with patients can be magical and can significantly enhance overall patient outcomes.

During my career, I encountered patients chewing Khat claiming that it provides them with alertness and enhance their libido. I encountered patients who self-medicated with cannabis for pain relief. I was formally asked by coroners to comment on why death of a patient who has taken novel psychoactive substances, the so called “legal highs”, could not be prevented.

This failure prompted me to think that despite being an expert in medicines, my knowledge of these new emerging drugs and herbal supplements sold over the internet was limited. So I undertook a PhD in Pharmacy and began my career in Academia at the University of Hertfordshire and now as MPharm Programme Director at the new Pharmacy degree in Swansea which is now being provisionally accredited.

Through my research, I have taken the initiative to a new concept, providing insight among pharmacists and other healthcare professionals in the dynamic area of substance misuse and Novel Psychoactive Substances (NPS). My research focussed on how to identify these drugs to inform clinical decision-making and prevent pre-mature deaths.

I believe I represent the many women who try to balance the Research/Teaching careers as well as being a single mother. I do get a buzz from publishing my research from my group and international collaborations, even more so, when you can see your research shaping policy not only in the UK but other countries such as Australia!

I would like to feel that I can be a role model for many women in academia and one which many women can relate to, and in that perspective, I am also a mentor at Swansea University and RPS, mentoring 3 undergraduate students and 3 pre-registration pharmacists so that they can learn from my experiences in pharmacy.   

As I write this blog, I am preparing for a visit to the Middle East where I will be talking to school children about pharmacy and the varied career opportunities for pharmacists – I am really excited to be given this opportunity as I feel many children would choose pharmacy if they had the opportunity to meet pharmacists earlier on in their educational journey.

I think my enthusiasm for pharmacy is infectious as my daughter has become a fully qualified pharmacist and works in hospital pharmacy – may be it is in our genes, but for me it took a little longer to express itself!

A Reflection On The RPS Pre-Registration January 2020 Mock Exam Event

Pardis Amin-Eshghi

Your Pre-Reg year is a tough one, no question: finally putting all of your hard-earned knowledge to work in the real world. And you still have your Pre-Reg exams to pass at the end of it!

Fortunately, the RPS offers events across the country to ensure you get into practice with a minimum of sleepless nights!

These interactive sessions look at real-life examples to help you pass your exams and be ready for practice. They’re an invaluable opportunity to identify your strengths and weaknesses, highlighting key areas to focus your revision on.

At every event you’ll hear from experienced tutors with top tips, both for exams and challenging practice situations. You’ll also get to know fellow Pre-Reg pharmacists, as well as recruiters looking for their next generation of top pharmacists. We spoke to RPS member Pardis Amin-Eshghi, who told us all about her experience of the two-day event in London.

“I heard about the upcoming RPS event from my tutor, swiftly booked my place and then attended a weekend of intense, focused learning on how to pass my pre-registration exam in order to become a qualified pharmacist.

When it comes down to how to prepare, neither the tutors nor the GPhC recommend making your revision an exercise on how much one can memorise from the resource materials (and there is a lot to memorise). It’s more about how well one can apply that knowledge to the everyday scenarios found in practice, whether it be in hospital or community pharmacy.

The Pre-Reg event is split into two days.  Day 1 revolves around clinical lectures, case studies, calculations, and (my personal favourite) OTC. During the sessions, it was great to have the opportunity to bounce off ideas and then network with the other pre-reg’s. In addition to this, the calculation section (hosted by Simon Harris) involved going through all 12 types of pharmaceutical calculation questions listed in the framework – all in a succinct, step-by-step manner.

Being a big clinical buff, one of the highlights of the event was a clinical lecture hosted by Nadia Bukhari (who’s also the series managing editor of ‘Pharmacy Registration Assessment Questions’, a series that has been a staple in my exam practice). I was enthralled by the way the subject matter was taught, with the key take-home message being that this exam is checking our depth in knowledge. When tackling a scenario, ask yourself, e.g. “Why should a patient be on this medication?”, “Why does this medication cause this side effect?”, “What is the result of this interaction?”, “What other medications should this patient be on?” etc.

Day 2 commenced with an interactive session on Law & Ethics, with the main event being the mock paper (done under strict exam conditions, reflective of the actual day), with the questions representative of the style of questions provided by the GPhC. Once both papers were complete, they went through the answers and the rationale behind them. In the end, we got to take the paper/ resource packs home to go over again, along with our booklet of the slides used throughout the event. Overall, I found these events to be pivotal for the learning and development of any pre-reg that’s on the final hurdle to qualify as a day 1 pharmacist.”

If you’d like to take some of the pain out of your Pre-Reg and boost your chances of passing, there are RPS Pre-Reg events across the country – find out more at :https://www.rpharms.com/events/pre-registration-mock-exam-and-revision-courses

Mentoring is not just about asking an expert

By Helen Middleton, MSc (Education), FFRPS, FPharmS

Mentoring provides opportunities for pharmacists to obtain guidance and support at any time in their career. Those who are new to the profession, changing sector of practice, dealing with difficult work situations or developing a career plan often enlist the help of a mentor.

Mentoring is traditionally defined as “a relationship in which a more experienced or knowledgeable person helps a less experienced or knowledgeable person”. However, there are other definitions of mentoring which describe the mentor’s role to facilitate reflection and learning in relation to the mentee’s agenda rather than acting as an expert or adviser

A mentor supports and encourages another to manage their own development in order that they may maximise their potential, develop their skills, improve their performance and become the professional they want to be”.  Eric Parslow, The Oxford School of Coaching and Mentoring

By taking this approach I do not need to be more experienced that my mentee. It is also not necessary for me to be specialised in his or her area of practice. This approach opens the door for mentees to learn with a wider range of mentors; for example, I have been successfully mentored by a dietitian and even by the director of an art gallery!

Anyone can be a mentor provided they have good communication skills, are able to use a variety of different questioning techniques, are willing to listen and put the mentee’s needs first and view the time spent with their mentee as a valued investment. I hope that this will empower pharmacists who don’t consider themselves as ‘experts’ to sign up to be a Mentor on the Royal Pharmaceutical Society mentoring platform and contribute to the development of other pharmacists.

The four stages of mentoring are:

Getting together involves finding a suitable mentor. The Royal Pharmaceutical Society mentoring platform launched to members in October 2019 facilitates easy and appropriate matching of mentor to mentee. When you join the platform as a Mentor – you create an online profile which describes your experience and what you can offer as a Mentor. Mentees create an online profile which describes what support they are looking for. Then the mentee searches for a Mentor who matches their needs, e.g. the mentee might want to change sector of practice and look for short term mentoring from someone who already works in that sector including CV building and interview practice. Or they might be looking for a longer term mentoring relationship to develop leadership or research skills. The mentoring platform provides a list of potential Mentors and the mentee can view potential Mentors’ profiles, decide on a preferred Mentor/s and send a request for mentoring via the platform.

The first meeting between a Mentor and mentee is a way for you both to check the compatibility of the relationship. You should discuss your preferred mentoring and learning styles with each other, to make sure that you understand how the relationship might work. I ask the mentee two key questions: “How would you define mentoring?” and “What do you want and expect from a mentor?” Mentoring is likely to be ineffective if the mentee is seeking advice and guidance (a directive approach) but the mentor intends to empower the mentee to find their own solutions through questioning and reflection (a non-directive approach). In these situations, it is better for the mentee to search for an alternative Mentor using the RPS mentoring platform. 

All too often mentoring relationships miss the vital step of getting to know each other before launching straight into discussing difficult work situations or developing a career plan. Taking time to get to know the “whole person” (rather than his or her professional persona only) at the start of the mentoring relationship is necessary to establish rapport and trust, otherwise mentees can feel uncomfortable disclosing information. In my opinion, the first and second stages of mentoring are the most important in determining the success of a mentoring relationship. Get these initial aspects right and you will be well on the way to fulfilling the next step: learning together. I believe shared learning within the mentoring relationship brings many benefits for the mentor as well as the mentee.

The final stage is saying goodbye, since all good things must come to an end. My motto is: “Mentoring is like Red Bull — it gives you wings!” One of the hardest things for mentors to do is to let go and let their mentees fly. I always like to end by looking back over the mentoring relationship together and celebrating success.

Join the RPS mentoring platform today and find your perfect match
It’s easy to sign up and the mentoring platform facilitates easy and appropriate matching of mentor to mentee. 

You need to decide what you would like a Mentor to support you with. You can then select a Mentor based on their profile of skills, experience and interests.

Sign up on www.rpharms.com/mentoring 

Parental leave and returning to work

by Elen Jones, Director for RPS Wales, and Robbie Turner, RPS Director of Pharmacy and Member Experience

Elen Jones

Elen: Swapping the baby wipes, nappies and the bottles for policies, business plans and strategic meetings.

Maternity leave is over. In a blink of an eye, my baby boy is babbling away and walking round the furniture. He’s nine months, I just about feel like I’m getting to grips with being a mum of two and all of a sudden, it’s time to go back to work.

It’s been amazing to spend so much time with the boys; watching the little one develop and being able to take my eldest to school every day as he starts nursery has been brilliant. On the flip side, it’s often felt chaotic. The demands of two children are something else!

Three weeks into maternity leave I attended an interview and was fortunate enough to get a new role as Director of RPS Wales. 

It’s such a privilege to be returning to work and starting this role. I definitely had huge anxiety during the days leading up to my return. How will we cope with getting the boys to nursery and all be out the door by 8am? How will I catch up on the last 9 months? RPS think I’m the right person for the job, but what will members and my team really think? Impostor syndrome was creeping in! I did check out the RPS Return to Practice guide which helped allay some of my worries. I’ve been back in work for two weeks, and I miss my boys very much. Fortunately, my youngest has settled into nursery quite well (better than his big brother did!)

If I’m really honest, I’m actually feeling more like me again. I’m back to feeling more in control, enthused by the work and by my colleagues.  I’m full of ideas, getting out there and speaking to like-minded pharmacists. I’ve caught up with lots of our members already, everyone’s been so kind and supportive.

The sleepless nights unfortunately don’t stop when you return to work, but I don’t mind them as much now, time with the boys has become more precious. I so look forward to getting back from work to their big smiles and hugs.

So, a big thank you to all my colleagues and our amazing members for all the support and your patience while I’ve been away! I look forward to working with you all to make sure RPS and pharmacy continue to go from strength to strength.

Robbie Turner

Robbie: This year I’m going to get an extra three months off work. And, I’ve been surprisingly anxious about it.

Not that pre-holiday anxious when you’re trying to work out exactly how much ludicrously expensive sun cream to pack so you don’t need to bring any back with you. No, it’s a feeling that’s hard to describe but I bet there are millions or people (mainly women) who have experienced it even more deeply than me.

My partner Ben and I are soon (everything crossed) going to adopt two children. We’ve been aiming to make this a reality for over a year now. A big thank you to work friends and colleagues who have given me support and advice over the last year. Your words of encouragement have been hugely helpful. But, nobody warned me about this bit – preparing for paternity leave.

I know we’re lucky at RPS to have a good paternity leave entitlement. As part of our work on inclusion and diversity we identified that our gender pay gap was too high and introducing paternity pay was one of the tools we put in place to start to be a better employer for both men and women. Check out this article “Men’s parental leave is key to women’s progression

I’d like to think that I’ve always been supportive of women (and I think it has always been women who’ve taken any form of parental leave in my teams) when they announce the news that they are pregnant. I’ve cried a few times, but that’s always been with excitement rather than thinking about covering their maternity leave! I know this isn’t the experience of lots of women and that’s one of the reasons why I’m committed to taking my full paternity allowance. What I’ve never considered is what could be going through an expectant mother’s mind when they’re thinking about taking parental leave. And I now have a small insight into both their perceptions AND the realities..

I work with a great team who are brilliant at their jobs.  Even then, I’m worried about the added pressure me going off for three months will put on them.  BUT, when I really reflect, my main worry is the complete opposite. It’s that I will get found out as a bit of a fraud. That everyone will cope just fine without me or (arghhhhh) that it will be even better when I’m not here interfering and distracting people. Will I still have a job at the end of it all? How much will the world of pharmacy have moved on – will I be able to catch back up?

So, if I’m feeling like this – a (fairly confident), white man, in a senior role, only going on paternity leave for three months – then what must it be like for others who don’t have the same privilege of gender, colour, or seniority facing up to a year away from the work place?

Now, when women (and increasingly, men) tell me their great news about their pregnancy or adoption I’ll be just as excited but I’ll also understand how stressful planning for parental leave can be. Wish me luck!

Are you returning to practice? Check out our Return to Practice guide which is packed full of practical advice and tips to help you return to the workplace with confidence.