# Nursing

Nursing is a health care profession that "integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence". Nurses practice in many specialties with varying levels of certification and responsibility. Nurses comprise the largest component of most healthcare environments. There are shortages of qualified nurses in many countries.
Nurses develop a plan of care, working collaboratively with physicians, therapists, patients, patients' families, and other team members that focuses on treating illness to improve quality of life.
In the United Kingdom and the United States, clinical nurse specialists and nurse practitioners diagnose health problems and prescribe medications and other therapies, depending on regulations that vary by state. Nurses may help coordinate care performed by other providers or act independently as nursing professionals. In addition to providing care and support, nurses educate the public and promote health and wellness.
In the U.S., nurse practitioners are nurses with a graduate degree in advanced practice nursing, and are permitted to prescribe medications. They practice independently in a variety of settings in more than half of the United States. In the postwar period, nurse education has diversified, awarding advanced and specialized credentials, and many traditional regulations and roles are changing.

## History
### Premodern

Nursing historians face challenges of determining whether care provided to the sick or injured in antiquity is called nursing care. In the fifth century BC, for example, the Hippocratic Collection in places described skilled care and observation of patients by male "attendants," who may have provided care now provided by nurses. Around 600 BC in India, it is recorded in Sushruta Samhita, Book 3, Chapter V about the role of the nurse as "the different parts or members of the body as mentioned before including the skin, cannot be correctly described by one who is not well versed in anatomy. Hence, anyone desirous of acquiring a thorough knowledge of anatomy should prepare a dead body and carefully, observe, by dissecting it, and examining its different parts."
In the Middle Ages, members of religious orders such as nuns and monks often provided nursing-like care. Examples exist in Christian, Islamic, Buddhist, and other traditions. The biblical figure of Phoebe is described in many sources as "the first visiting nurse". These traditions were influential in the development of the ethos of modern nursing. Its religious roots remain in evidence in many countries. One example in the United Kingdom is the use of the historical title "sister" to refer to a senior nurse.
During the Reformation, Protestant reformers shut down monasteries and convents, allowing a few hundred municipal hospices to remain in operation in northern Europe. Nuns who had been serving as nurses were given pensions or told to marry and stay home. Nursing care went to the inexperienced as traditional caretakers, rooted in the Roman Catholic Church, were removed from their positions. The nursing profession in Europe was extinguished for approximately 200 years.

### 19th century

During the Crimean War, Grand Duchess Elena Pavlovna called for women to join the Order of Exaltation of the Cross (Krestodvizhenskaya Obshchina) for a year of service in military hospitals. The first section of twenty-eight "sisters", headed by Aleksandra Petrovna Stakhovich, the Directress of the Order, reached Crimea early in November 1854.
Florence Nightingale laid the foundations of professional nursing after the Crimean War, in light of a comprehensive statistical study she made of sanitation in India, leading her to emphasize the importance of sanitation. "After 10 years of sanitary reform, in 1873, Nightingale reported that mortality among the soldiers in India had declined from 69 to 18 per 1,000".$^{:107}$
Nightingale believed that nursing was a social freedom and mission for women. She believed that any educated woman could help improve the care of the ill. Her Notes on Nursing (1859) was a popular call to action. The Nightingale model of nursing education led to one of the first schools of nursing to be connected to a hospital and medical school. It spread widely in Europe and North America after 1870.
Nightingale included five factors that helped nurses in her time who worked amidst poor sanitation and little education. These factors included fresh air, clean water, a working drainage system, cleanliness, and good light. Nightingale believed that a clean working environment was important in caring for patients. In the 19th century, this theory was ideal for helping patients, providing a guide for nurses to alter the environment around patients for the betterment of their health.
Nightingale's recommendations built upon the successes of Jamaican "doctresses" such as Mary Seacole, who like Nightingale, served in the Crimean War. Seacole practised hygiene and the use of herbs in healing wounded soldiers and those suffering from diseases in the 19th century in the Crimea, Central America, and Jamaica. Her predecessors had great success as healers in the Colony of Jamaica in the 18th century, and they included Seacole's mother (Mrs. Grant), Sarah Adams, Cubah Cornwallis, and Grace Donne, the mistress and doctress to Jamaica's wealthiest planter, Simon Taylor.
Other important nurses in the development of the profession include:
* Agnes Hunt from Shropshire was the first orthopedic nurse and was pivotal in the emergence of the orthopedic hospital, the Robert Jones & Agnes Hunt Hospital in Oswestry, Shropshire.
* Valérie de Gasparin opened, with her husband Agénor de Gasparin, the world's first nursing school: La Source, in Lausanne, Switzerland.
* Agnes Jones established a nurse training regime at Brownlow Hill infirmary, Liverpool, in 1865.
* Linda Richards established nursing schools in the United States and Japan, and was officially the first professionally trained nurse in the US, graduating in 1873 from the New England Hospital for Women and Children in Boston.
* Clarissa Harlowe "Clara" Barton was a pioneer American teacher, patent clerk, nurse, and humanitarian, and the founder of the American Red Cross.
* Saint Marianne Cope was a Sister of St. Francis who opened and operated some of the first general hospitals in the United States, instituting cleanliness standards that influenced the development of America's hospital system.
Red Cross chapters, which began appearing after the establishment of the International Committee of the Red Cross in 1863, offered employment and professionalization opportunities for nurses (despite Nightingale's initial objections). Catholic orders such as Little Sisters of the Poor, Sisters of Mercy, Sisters of St. Mary, St. Francis Health Services, Inc. and Sisters of Charity built hospitals and provided nursing services during this period. The modern deaconess movement began in Germany in 1836. Within a half century, over 5,000 deaconesses had surfaced in Europe.
Formal use of nurses in the military began in the latter half of the nineteenth century. Nurses saw active duty in the First Boer War, the Egyptian Campaign (1882), and the Sudan Campaign (1883).

### 20th century

In the 19th and early 20th century, nursing was considered a woman's profession, just as doctoring was a profession for men. With increasing expectations of workplace equality during the late 20th century, nursing became an officially gender-neutral profession, though in practice the percentage of male nurses remained well below that of female physicians in the 21st century.
Hospital-based training became standard in the US in the early 1900s, with an emphasis on practical experience. The Nightingale-style school began to disappear. Hospitals and physicians saw women in nursing as a source of free/inexpensive labor. Exploitation of nurses was not uncommon by employers, physicians, and education providers.
Many nurses saw active duty in the First World War, but the profession transformed again during the Second World War. British nurses of the Army Nursing Service were part of every overseas campaign. More nurses volunteered for service in the US Army and Navy than any other occupation. The Nazis had their own Brown Nurses, numbering 40,000. Two dozen German Red Cross nurses were awarded the Iron Cross for heroism under fire.
The development of undergraduate and post-graduate nursing degrees came after the war. Nursing research and a desire for association and organization led to the formation of professional organizations and academic journals. Nursing became recognized as a distinct academic discipline, initially tasked to define the theoretical basis for practice.

#### Shortages

Nurses are perceived to be in short supply around the world, particularly in South East Asia and Africa. A global survey by McKinsey & Company in 2022 found that between 28% and 38% of nurse respondents in the United States, the United Kingdom, Singapore, Japan, and France said they were likely to leave their role in direct patient care in the next year. The top five factors which they said would make them stay were:
* Safe working environment
* Work-life balance
* Caring and trusting team-mates
* Meaningful work
* Flexible work schedule
Pay ranked eighth on the list. A 2023 American survey found that around 30% were considering leaving patient care.

## Definition

According to the traditional interpretation physicians are concerned with curing or treating medical conditions, while nurses focus on care. In healthcare settings this line is often blurred, complicating the task of distinguishing the professions. Although nursing practice varies both through its various specialties and countries, nursing organizations offer the following definitions:
   Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well, and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles.
   The use of clinical judgment in the provision of care to enable people to improve, maintain, or recover health, to cope with health problems, and to achieve the best possible quality of life, whatever their disease or disability, until death.
   Nursing is the protection, promotion, and optimization of health and abilities; prevention of illness and injury; alleviation of suffering through the diagnosis and treatment of human responses; and advocacy in health care for individuals, families, communities, and populations.
   The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge.

## Professional nursing

The practice of nursing is based upon a social contract that delineates professional rights and responsibilities as well as accountability mechanisms. In almost all countries, nursing practice is defined and governed by law, and entrance to the profession is regulated at the national or state level.
The nursing community worldwide aims for professional nurses to ensure quality care, while maintaining their credentials, code of ethics, standards, and competencies, and continuing their education. Multiple educational paths lead to becoming a professional nurse; these vary by jurisdiction; all involve extensive study of nursing theory and practice as well as training in clinical skills.
Nurses provide care based on the individual's physical, emotional, psychological, intellectual, social, and spiritual needs. The profession combines physical science, social science, nursing theory, and technology.
Nurses typically hold one or more formal credentials. Roles and responsibilities follow the level of education. For example, in the United States, Licensed Practical Nurses (LPN) have less education than Registered Nurses (RN) and accordingly, a narrower scope of practice.

### Diversity

Nursing is a female-dominated profession in many countries; according to the WHO's 2020 State of the World's Nursing, approximately 90% of the nursing workforce is female. For instance, the male-to-female ratio of nurses is approximately 1:19 in Canada and the United States. This ratio is matched in many other countries. Notable exceptions include Francophone Africa, which includes the countries of Benin, Burkina Faso, Cameroon, Chad, Congo, Côte d'Ivoire, the Democratic Republic of Congo, Djibouti, Guinea, Gabon, Mali, Mauritania, Niger, Rwanda, Senegal, and Togo, which all have more male than female nurses. In Europe, in countries such as Spain, Portugal, Czech Republic and Italy, over 20% of nurses are male. In the United Kingdom, 11% of nurses and midwives registered with the Nursing and Midwifery Council (NMC) are male. The number of male nurses in the United States doubled between 1980 and 2000. On average, male nurses in the US receive more pay than female nurses.

## Theory and process

Nursing practice is the actual provision of nursing care. In providing care, nurses implement a nursing care plan defined using the nursing process. This is based around a specific nursing theory that is selected based on the care setting and the population served. In providing nursing care, the nurse uses both nursing theory and best practice derived from nursing research. Many nursing theories are in use. Like other disciplines, the profession has developed multiple theories derived reflecting varying philosophical beliefs and paradigms or worldviews.
In general terms, the nursing process is the method used to assess and diagnose needs, plan outcomes and interventions, implement interventions, and evaluate outcomes. The nursing process as defined by the American Nurses Association comprises five steps: 1) evaluate, 2) implement, 3) plan, 4) diagnose, and 5) assess.

## Healthcare staffing platforms

Digital health platforms connect nurses and nurse assistants with job openings in healthcare facilities such as skilled nursing homes, home health agencies, and hospitals. Platforms offer an app to facilitate communication and allow nurses to find work opportunities based on their preferences. Healthcare partners and facilities benefit from access to qualified nurses. In 2017, the UK's National Health Service began trialing such a platform.
Platforms such as United States–based ConnectRN, Nomad Health, Gale Healthcare solutions or Lantum add resources, career development tools, and networking opportunities.

## Nursing as a science

Florence Nightingale's seminal epidemiological study examining mortality among British soldiers during the Crimean War was published in 1858. With the exception of her works, nursing practice remained an oral tradition until the mid-20th century. The inaugural issue of Nursing Research, the first scientific journal specialized in nursing, came in in 1952. During the 1960s, interest in attaining PhDs increased among nurses in the US, but nursing remained a fledgling area of research, with few journals until the 1970s. Nursing research is increasingly presented as a valid discipline, although lacking a prevailing definition. The question is further complicated by the numerous interpretations of nursing's defining essence.

### Evidence-based practice

During the 1980s there was an increased focus on research utilization (RU). Nursing research took an interest in clinical issues and US nursing schools began teaching research methods to facilitate interpretation and integration of scientific findings in routine practice. Several RU initiatives were active during the late 20th century, but the RU movement was superseded by evidence-based practice in the 1990s. Evidence-based practice (EBP) is about using research, but unlike RU it allows for the integration of research findings with clinical expertise and patient preferences. The EBP movement had originated in the field of medicine with Archie Cochrane publishing Effectiveness and Efficiency in 1972, leading up to the founding of the Cochrane Collaboration in 1993. The emerging area of evidence-based medicine also applies to nursing. Common barriers to the study and integration of research findings into clinical decision making include: a lack of opportunity, inexperience, and the rapid pace of evidence accumulation.

## Scope of activities

Nurses perform a variety of different tasks. Their activities vary based on their level of training and their specialty. For example, operating room nurses work in surgical settings and perform tasks that other nurses do not. Nurses may receive additional training and certifications to perform a variety of tasks. For example, in the United States, RN first assists (RNFAs) perform basic surgical procedures.

### Assessment

Assessment is an essential nursing skill. Nurses assess patients' physical and mental health. In hospital settings, nurses regularly perform assessments to notice any acute changes in their patients. Nurses also assess a patient's response to medication or other treatments, such as physical activity and blood transfusion. Nurses may also take health histories. Nurses also must assess a patient's understanding of their health status and their medications. Critical thinking is an important skill for nurses to have: in emergency situations, nurses must quickly assess a patient and determine the best course of action.

### Medication

Medication management and administration are common hospital nursing roles, although prescribing authority varies across jurisdictions. In many areas, RNs administer and manage medications prescribed by others. Nurses are responsible for evaluating patients throughout their care – including before and after medication administration – adjustments to medications are often made through a collaborative effort between the prescriber and the nurse. Regardless of the prescriber, nurses are legally responsible for the drugs they administer. Legal implications may accompany an error in a prescription, and the nurse may be expected to note and report the error. In the United States, nurses have the right to refuse to administer medication that they deem to be potentially harmful. Some nurses take additional training that allows them to prescribe medications within their scope of practice.

### Patient education

Effective patient/family education leads to better outcomes. Nurses explain procedure, recovery, and ongoing care, while helping everyone cope with the medical situation.
Many times, nurses are busy, leaving little time to educate patients.
Patients' families needs similar education. Educating both patient and their families increases the chance for a better outcome.
Nurses have to communicate in a way that can be understood by patients. Education techniques encompass conversations, visuals, reading materials, and demonstrations.

### Daily living assistance

Nurses manage and coordinate care to support activities of daily living (ADL) such as hygiene and toileting. This includes assisting in patient mobility, such as moving an activity intolerant patient within a bed. They often delegate such care to nursing assistants.

## Specialties

Nursing is the most diverse of all health care professions. Nurses practice in a wide range of settings, but generally follows the needs of their patients.
The major specialties are:
* communities/public health
* family/individual care
* adult-gerontology
* pediatrics
* obstetrics
* neonatal
* women's health/gender-related
* mental health
* informatics (eHealth)
* acute care
* ambulatory settings (physician offices, urgent care settings, camps, etc.)
* school/college/institutional infirmaries
* military
* cardiac care
* orthopedic care
* palliative care
* perioperative
* oncology
* telenursing
* radiology
* emergency care
Nurses with additional degrees allow for specialization. Nursing professions can be separated into categories by care type, age, gender, certain age group, practice setting, individually or in combination.

## Settings

Nurses practice in a wide range of settings, including hospitals, private homes, schools, and pharmaceutical companies. Nurses work in occupational health settings (also called industrial health settings), free-standing clinics, physician offices, nurse-led clinics, long-term care facilities and camps. They work on cruise ships, military bases, and in combat settings.
Nurses act as advisers and consultants to the health care and insurance industries. Many nurses also work in health advocacy and patient advocacy, helping in clinical and administrative domains. Some are attorneys and others work with attorneys as legal nurse consultants, reviewing patient records to assure that adequate care was provided and testifying in court.
Nurses can work on a temporary basis, which involves doing shifts without a contract in a variety of settings, sometimes known as per diem nursing, agency nursing or travel nursing. Nurses work as researchers in laboratories, universities, and research institutions. Nurses work in informatics, acting as consultants to the creation of computerized charting programs and other software. Nurse authors publish articles and books to provide essential reference materials.

## Occupational hazards

The international nursing shortage is in part due to their work environment. In a recent review of the literature specific to nursing performance, nurses were found to work in generally poor environmental conditions. Some jurisdictions have legislation specifying acceptable nurse-to-patient ratios.
The fast-paced and unpredictable nature of health care places nurses at risk for injuries and illnesses, including high occupational stress. Nurses consistently identify stress as a major work-related concern and have among the highest levels of occupational stress among all professions. This stress is caused by the environment, psychosocial stressors, and the demands of nursing, including mastering new technology, emotional labor, physical labor, shift work, and high workload. This stress puts nurses at risk for short-term and long-term health problems, including sleep disorders, depression, mortality, psychiatric disorders, stress-related illnesses, and overall poor health. Nurses are at risk of developing compassion fatigue and moral distress, which can damage mental health. They have high rates of occupational burnout (40%) and emotional exhaustion (43.2%). Burnout and exhaustion increase the risk for illness, medical error, and suboptimal care provision.

### Patient handling

Healthcare has consistently ranked among the industries with the highest rates of musculoskeletal injuries, largely related to patient handling. Anywhere from 30 to 70% of reported musculoskeletal injuries are related to patient handling. Nurses are routinely tasked with lifting, repositioning, and mobilizing patients. According to the National Institute for Occupational Safety and Health (NIOSH) the single greatest factor in overexertion injuries is the manual lifting, moving and repositioning of patients. These tasks present unique ergonomic hazards that results in a high rate of acute and cumulative musculoskeletal injuries.
The most frequently injured body part is the back, with up to 72% of nurses reporting non-specific low back pain. The US Bureau of Labor Statistics reported that for 2021-2022 the rate of overexertion injuries leading to days away from work for nurses was 45.4 per 10,000 full time employees, while nursing aids came in at 145.5 compared to the average for all industries of 26.1.
Traditionally, nurses are trained in manual patient handling techniques. The body of evidence has demonstrated, however, that such interventions area ineffective.

### Workplace violence

Nurses are at risk for workplace violence and abuse. Violence is typically perpetrated by non-staff (e.g. patients or family), whereas abuse is typically is by hospital personnel. In the US in 2011, 57% of nurses reported that they had been threatened at work; 17% were physically assaulted.
The three types of workplace violence that nurses can experience are: physical violence (hitting, kicking, beating, punching, biting, and using objects); psychological violence (threats or coercion); sexual violence (attempted/completed non-consensual sex act).
Workplace violence can be in another way: interpersonal violence and organizational coercion. Interpersonal violence is committed by workers or patients and their families. Its predominant form is verbal abuse. Organizational coercion may include excessive workloads, mandatory shifts, involuntary placement in another part of the workplace, low salaries, denial of benefits/overtime, poor working environment, and other stressors. These issues affect quality of life. Managers who lack understanding of the severity of these problems and do not support workers increase worker stress.
Many factors contribute to workplace violence. These factors can be divided into environmental, organizational, and individual psychosocial. The environmental factors can include the specific setting (for example the emergency department), long patient wait times, frequent interruptions, uncertainty regarding patients' treatment, and heavy workloads. Organizational factors can include inefficient teamwork, organizational injustice, lack of aggression- and stress-management programs, and distrust between colleagues. Individual psychosocial factors may include nurses being young and inexperienced, previous experiences with violence, and a lack of communication skills. Misunderstandings may also occur due to the communication barrier between nurses and patients. An example of this could be patients' conditions being affected by medications, pain, or anxiety.
Workplace violence has many causes. The most common perpetrators of harassment or bullying of nursing students were registered nurses including preceptors, mentors, and clinical facilitators. However, the main perpetrators of workplace violence against nurses were patients. 80% of serious violent incidents in health care centers were by patients.
Workplace violence has many effects. It has negative emotional and physical impacts on nurses. They feel depersonalized, dehumanized, worn out, and stressed out. Nurses have reported burn-out due to frequent exposure to this violence.

### Interventions

Interventions can mitigate these occupational hazards. They can be individual-focused or organization-focused. Individual-focused interventions include stress management programs, which can be customized to individuals. Stress management programs can reduce anxiety, sleep disorders, and other symptoms of stress. Organizational interventions focus on reducing stressful aspects of the work environment by identifying stress generators and developing solutions to them. Combining organizational and individual interventions is most effective at reducing stress. In some Japanese hospitals, powered exoskeletons are used to reduce physical loads. Lumbar supports (i.e. back belts) have been trialed.

## National variations
### Americas
#### United States

Nursing in the United States is a professional health care occupation. It is the largest such occupation, employing millions of certified professionals. As of 2023, 3,175,390 registered nurses were employed, paid a median income of $86,070.
Nurses are not doctors' assistants and practice nursing in a wide variety of specialties and departments. They may act in that capacity, such as in the emergency department or in trauma care, but more often independently care for their patients or assist other nurses. RNs treat patients, record their medical history, provide emotional support, and provide follow-up care. Nurses also help doctors perform diagnostic tests.

#### Canada

Nurses in Canada practise in a wide variety of settings, with various levels of training and experience. They provide evidence-based care and educate their patients about health and disease.
The role that nurses have played in the development of Canada has been recognized through the designation of seven National Historic Sites of Canada related to nursing. Five nurses' residences (the Ann Baillie Building, Begbie Hall, the Hersey Pavilion, the Pavillon Mailloux and the St. Boniface Hospital Nurses' Residence) were designated in commemoration of the growing professionalism of nursing and of the expanded role of nurses in health care over the course of the 20th century. The La Corne Nursing Station and the Wilberforce Red Cross Outpost were designated, in part, in honour of the role played by nurses in delivering health care to isolated areas.

#### Latin America/Caribbean

Latin American nursing is based on three levels of training: (a) professional/registered, (b) technical, and (c) auxiliary. Nursing education in Latin America and the Caribbean includes the principles and values of universal health and primary health care. These principles are based on critical and complex thinking development, problem-solving, evidence-based clinical decision-making, and lifelong learning.

### Europe
#### European Union

In the European Union, the profession of nurse requires a specific professional qualification. The qualification of nurses responsible for general care in the EU is regulated in Directive 2005/36/EC. The list of regulated nursing professions is held in the regulated professions database.

##### Spain
#### United Kingdom

Nursing in the United Kingdom is the profession of registered nurses and nursing associates in the primary and secondary care of patients. It has evolved from assisting physicians to encompass a variety of professional roles. Over 700,000 registered nurses practice in the UK, working in settings such as hospitals, health centres, nursing homes, hospices, communities, military, prisons, and academia. Most are employed by the National Health Service (NHS).
Nursing is split into four fields: adults, children, mental health, and learning disability. Within these nurses may work within specialties such as medical care or theatres, and may specialise further in areas such as cardiac care. Nurses often work in multi-disciplinary teams, but increasingly work independently, and may work in supporting sectors such as education or research.

### Hong Kong

Nursing is a licensed professional occupation in Hong Kong. The profession is regulated by the Nursing Council of Hong Kong, a statutory body. Nurses in Hong Kong are divided into registered nurses and enrolled nurses, with the former requiring more extensive professional training.

#### Japan
### Pakistan

Nursing is a major component of Pakistan's health-care system. The topic has been the subject of extensive historical studies, is as of 2009 a major issue in the country, and has been the subject of much scholarly discussion amongst academics and practitioners. In 2009, Pakistan’s government stated its intent to improve the country's nursing care.

#### Taiwan

In Taiwan, the Ministry of Health and Welfare regulates nursing. The Taiwan Union of Nurses Association (TUNA) organizes nurses.

### Islam

In Islam, nurses provide healthcare services to patients, families and communities as a manifestation of love for Allah and Muhammad.
Historically, female nurses during the era of slavery in the Muslim world where often slaves, a tradition which continued in Saudi Arabia until the abolition of slavery in Saudi Arabia in 1962, where nursing was considered a dishonorable profession.

#### Israel

Nurses in Israel has responsibilities including hospital care, patient education, wound care, prenatal and other monitoring, midwifery, and well-baby clinics.
Nurses and midwives are regulated by the Israeli Ministry of Health.
Nursing in Israeli Jewish culture traces its origins to Shifra and Puah, two Hebrew midwives depicted in the Book of Exodus helping women in ancient Egypt give birth and keep their infants safe.
Modern-day nursing was established by nurses sent to Mandatory Palestine and later Israel by the Hadassah organization, as well as at a nursing school founded by Henrietta Szold in 1918. The United Kingdom regulated midwifery in Mandatory Palestine, but nurses were not mentioned in the regulation decree.