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Upskilling of the Healthcare Workforce: A Pertinent National Healthcare
Issue Affecting Healthcare Organizations in the United States
Upskilling of the Healthcare Workforce: A Pertinent National Healthcare Issue Affecting
Healthcare Organizations in the United StatesUpskilling of the Healthcare Workforce: A
Pertinent National Healthcare Issue Affecting Healthcare Organizations in the United
StatesPermalink: https:// /upskilling-of-th…he-united-states/Upskilling of the Healthcare
Workforce: A Pertinent National Healthcare Issue Affecting Healthcare Organizations in the
United States[Student name][College/ Institution]There are many national healthcare
stressors or issues affecting and impacting healthcare organizations all over the United
States. All of them require addressing, although some are more urgent than others. The
healthcare issue chosen in this case and one of the most significant stressors at the moment
is the issue of upskilling of healthcare professionals. In this context, these would be the
nurses working within the healthcare organization. According to Ross (2019), upskilling is
the process of retraining employees so that they can acquire new skills for them to continue
practicing in their field with ease. Upskilling of the Healthcare Workforce: A Pertinent
National Healthcare Issue Affecting Healthcare Organizations in the United States. Recent
developments (particularly technological) within and around healthcare have necessitated
the requirement that workers such as nurses possess skillsets that are upgraded. As a
matter of fact, upskilling was identified as one of the six important healthcare issues in 2019
by PwC Health Research Institute (Ross, 2019). Currently, whole healthcare workforces are
threatened with redundancy by technologies such as artificial intelligence (AI) if they do not
upskill. This includes nurses, who have traditionally not been involved with technology in
the course of delivering nursing care (Teague, 2019). Upskilling of the Healthcare
Workforce: A Pertinent National Healthcare Issue Affecting Healthcare Organizations in the
United StatesORDER HERE FOR ORIGINAL, PLAGIARISM-FREE PAPERSThe impact to my
healthcare organization of upskilling as a healthcare issue is immense. This is because
emerging healthcare technologies are becoming more and more mandatory in diagnostics,
therapeutics, and nursing care. Nurses are therefore finding themselves short of skills to
deliver quality patient care. This makes the organization set aside resources to retrain and
upgrade the skills of its nurses so that they can cope with the emerging technological
changes. This, however, is an inevitably resource-intensive undertaking fir the organization.
In my organization, for instance, the policy makers have already had to set aside funds for
training of the nurses and other healthcare staff on the use of the recently introduced EHR.
Upskilling of the Healthcare Workforce: A Pertinent National Healthcare Issue Affecting
Healthcare Organizations in the United States Already, upskilling is happening in the
healthcare sector with the now standard requirement for electronic health records or EHR.
That said, the hallmark of upskilling in healthcare is predicted to be artificial intelligence-
assisted telehealth interventions (Teague, 2019).Some of the Areas of ConcernHealthcare
organizations must invest in the abilities of their workforce if they are to have a competitive
advantage over their peers. Not doing so will of course render the organization unable to
compete effectively in an ever-changing healthcare marketplace. Upskilling of the
Healthcare Workforce: A Pertinent National Healthcare Issue Affecting Healthcare
Organizations in the United States. For instance, AI is more and more used in healthcare at
the moment. What this means is that rising sophistication of emerging medical technologies
is driving the need for upskilled health workers (Ross, 2019). The advent of digital
therapeutics is the other area of concern. This is the treatment of disease using healthcare
technologies to complement or replace traditional methods in disease management. The
reality is that the clinical validation of these digital therapeutics products and connected
medical devices is already being done by the Food and Drug Administration or FDA (Siwicki,
2019). This is an indicator of the urgency with which upskilling of healthcare staff like
nurses should be treated.Two Articles on the Upskilling of Healthcare Workers as a
Healthcare Issue of Concern Rimmer (2018) has posited that doctors have to undergo
additional training in order to be successful at using emerging healthcare technologies. This
particular article addresses doctors as the healthcare workers of concern, but it has been
chosen because the very same situation is true for the nurses. This article talks of a report
that states that training is needed by doctors in areas such as artificial intelligence
algorithms, genomics, and digital literacy. As mentioned above, that is the same treatment
that nurse practitioners should also receive. The article goes ahead to stress that training is
a must for healthcare staff in order to cope with emerging healthcare technologies.Fralic
(2013) on her part observes that the American healthcare system is undergoing change that
is radical and monumental. She states, correctly, that with change there is need to re-
strategise and re-organize to deliver quality healthcare. To do this, upskilling is a must to
keep up with healthcare technologies. In other organizations in the healthcare sector, the
same situation portends. They, too, are adopting the same approach of retraining to upskill
nurses, doctors, and other health workers so that they can cope with the recent
technological changes and continue to offer quality and safe patient care.Strategies to
Address the Organizational Impact of UpskillingSince the reality of upskilling in healthcare
organizations is inevitable, it is essential to develop strategies that aim at addressing the
organizational impact of this issue. Three strategies are especially helpful. First, the
organization needs to introduce new technologies gradually to allow for adaptation and
training. Second, upskilling should be made a policy initiative that features in the
organization’s goals. Third and last, upskilling should be properly budgeted for like any
other expense if it is to succeed (Fralic, 2013; Rimmer, 2018; Teague, 2019). Under no
circumstances should upskilling be considered as an afterthought. These strategies impact
my organization positively in that they are geared towards giving the organization a
competitive advantage. On the negative side, however, budgeting means that this strategy
will consume resources that the organization must set aside.ReferencesFralic, M.F. (2013).
Upskilling for new-era healthcare: Lessons from high impact readings. Nurse Leader,
11(4). http://dx.doi.org/10.1016/j.mnl.2013.05.008Rimmer, A. (2018). Upskill doctors to
make the most of new medical technologies, report says. BMJ, 361(k2861). Doi:
10.1136/bmj.k2861 Upskilling of the Healthcare WorkforceRoss, J.R. (2019). Upskilling
could be an ideal treatment for healthcare’s employment woes. Retrieved 4 March 2020
from https://www.cardiovascularbusiness.com/topics/healthcare-economics/upskilling-
could-be-ideal-rx-healthcares-employment-woesSiwicki, B. (2019). Here are 6 major issues
facing healthcare in 2019, according to PwC. Healthcare ITNews. Retrieved 4 March 2020
from https://www.healthcareitnews.com/news/here-are-6-major-issues-facing-
healthcare-2019-according-pwcTeague, T. (2019). Will healthcare employees need to be
upskilled or reskilled as technology advances? Retrieved 4 March 2020
from https://www.whatisbluesky.com/blog/will-healthcare-employees-need-to-be-
upskilled-or-reskilled-as-technology-advances Upskilling of the Healthcare Workforce: A
Pertinent National Healthcare Issue Affecting Healthcare Organizations in the United
States[Student name][College/ Institution] Upskilling of the Healthcare Workforce: A
Pertinent National Healthcare Issue Affecting Healthcare Organizations in the United
StatesThere are many national healthcare stressors or issues affecting and impacting
healthcare organizations all over the United States. All of them require addressing, although
some are more urgent than others. The healthcare issue chosen in this case and one of the
most significant stressors at the moment is the issue of upskilling of healthcare
professionals. In this context, these would be the nurses working within the healthcare
organization. According to Ross (2019), upskilling is the process of retraining employees so
that they can acquire new skills for them to continue practicing in their field with ease.
Recent developments (particularly technological) within and around healthcare have
necessitated the requirement that workers such as nurses possess skillsets that are
upgraded. As a matter of fact, upskilling was identified as one of the six important
healthcare issues in 2019 by PwC Health Research Institute (Ross, 2019). Currently, whole
healthcare workforces are threatened with redundancy by technologies such as artificial
intelligence (AI) if they do not upskill. This includes nurses, who have traditionally not been
involved with technology in the course of delivering nursing care (Teague, 2019). Upskilling
of the Healthcare Workforce: A Pertinent National Healthcare Issue Affecting Healthcare
Organizations in the United StatesThe impact to my healthcare organization of upskilling as
a healthcare issue is immense. This is because emerging healthcare technologies are
becoming more and more mandatory in diagnostics, therapeutics, and nursing care. Nurses
are therefore finding themselves short of skills to deliver quality patient care. This makes
the organization set aside resources to retrain and upgrade the skills of its nurses so that
they can cope with the emerging technological changes. This, however, is an inevitably
resource-intensive undertaking fir the organization. In my organization, for instance, the
policy makers have already had to set aside funds for training of the nurses and other
healthcare staff on the use of the recently introduced EHR. Upskilling of the Healthcare
Workforce: A Pertinent National Healthcare Issue Affecting Healthcare Organizations in the
United States. Already, upskilling is happening in the healthcare sector with the now
standard requirement for electronic health records or EHR Upskilling of the Healthcare
Workforce: A Pertinent National Healthcare Issue Affecting Healthcare Organizations in the
United States. That said, the hallmark of upskilling in healthcare is predicted to be artificial
intelligence-assisted telehealth interventions (Teague, 2019).Some of the Areas of
ConcernHealthcare organizations must invest in the abilities of their workforce if they are
to have a competitive advantage over their peers. Not doing so will of course render the
organization unable to compete effectively in an ever-changing healthcare marketplace. For
instance, AI is more and more used in healthcare at the moment. What this means is that
rising sophistication of emerging medical technologies is driving the need for upskilled
health workers (Ross, 2019). The advent of digital therapeutics is the other area of concern.
This is the treatment of disease using healthcare technologies to complement or replace
traditional methods in disease management. The reality is that the clinical validation of
these digital therapeutics products and connected medical devices is already being done by
the Food and Drug Administration or FDA (Siwicki, 2019). This is an indicator of the
urgency with which upskilling of healthcare staff like nurses should be treated.Two Articles
on the Upskilling of Healthcare Workers as a Healthcare Issue of Concern Rimmer
(2018) has posited that doctors have to undergo additional training in order to be
successful at using emerging healthcare technologies. This particular article addresses
doctors as the healthcare workers of concern, but it has been chosen because the very same
situation is true for the nurses. This article talks of a report that states that training is
needed by doctors in areas such as artificial intelligence algorithms, genomics, and digital
literacy. As mentioned above, that is the same treatment that nurse practitioners should
also receive. The article goes ahead to stress that training is a must for healthcare staff in
order to cope with emerging healthcare technologies.Fralic (2013) on her part observes
that the American healthcare system is undergoing change that is radical and monumental.
She states, correctly, that with change there is need to re-strategise and re-organize to
deliver quality healthcare. To do this, upskilling is a must to keep up with healthcare
technologies. In other organizations in the healthcare sector, the same situation portends.
They, too, are adopting the same approach of retraining to upskill nurses, doctors, and other
health workers so that they can cope with the recent technological changes and continue to
offer quality and safe patient care.Strategies to Address the Organizational Impact of
UpskillingSince the reality of upskilling in healthcare organizations is inevitable, it is
essential to develop strategies that aim at addressing the organizational impact of this issue.
Three strategies are especially helpful. First, the organization needs to introduce new
technologies gradually to allow for adaptation and training. Second, upskilling should be
made a policy initiative that features in the organization’s goals. Third and last, upskilling
should be properly budgeted for like any other expense if it is to succeed (Fralic, 2013;
Rimmer, 2018; Teague, 2019). Under no circumstances should upskilling be considered as
an afterthought. These strategies impact my organization positively in that they are geared
towards giving the organization a competitive advantage. On the negative side, however,
budgeting means that this strategy will consume resources that the organization must set
aside.ReferencesFralic, M.F. (2013). Upskilling for new-era healthcare: Lessons from high
impact readings. Nurse Leader,
11(4). http://dx.doi.org/10.1016/j.mnl.2013.05.008Rimmer, A. (2018). Upskill doctors to
make the most of new medical technologies, report says. BMJ, 361(k2861). Doi:
10.1136/bmj.k2861Ross, J.R. (2019). Upskilling could be an ideal treatment for healthcare’s
employment woes. Retrieved 4 March 2020
from https://www.cardiovascularbusiness.com/topics/healthcare-economics/upskilling-
could-be-ideal-rx-healthcares-employment-woesSiwicki, B. (2019). Here are 6 major issues
facing healthcare in 2019, according to PwC. Healthcare ITNews. Retrieved 4 March 2020
from https://www.healthcareitnews.com/news/here-are-6-major-issues-facing-
healthcare-2019-according-pwcTeague, T. (2019). Will healthcare employees need to be
upskilled or reskilled as technology advances? Retrieved 4 March 2020
from https://www.whatisbluesky.com/blog/will-healthcare-employees-need-to-be-
upskilled-or-reskilled-as-technology-advances s Upskilling of the Healthcare Workforce: A
Pertinent National Healthcare Issue Affecting Healthcare Organizations in the United States

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Upskilling Healthcare Workers for New Tech

  • 1. Upskilling of the Healthcare Workforce: A Pertinent National Healthcare Issue Affecting Healthcare Organizations in the United States Upskilling of the Healthcare Workforce: A Pertinent National Healthcare Issue Affecting Healthcare Organizations in the United StatesUpskilling of the Healthcare Workforce: A Pertinent National Healthcare Issue Affecting Healthcare Organizations in the United StatesPermalink: https:// /upskilling-of-th…he-united-states/Upskilling of the Healthcare Workforce: A Pertinent National Healthcare Issue Affecting Healthcare Organizations in the United States[Student name][College/ Institution]There are many national healthcare stressors or issues affecting and impacting healthcare organizations all over the United States. All of them require addressing, although some are more urgent than others. The healthcare issue chosen in this case and one of the most significant stressors at the moment is the issue of upskilling of healthcare professionals. In this context, these would be the nurses working within the healthcare organization. According to Ross (2019), upskilling is the process of retraining employees so that they can acquire new skills for them to continue practicing in their field with ease. Upskilling of the Healthcare Workforce: A Pertinent National Healthcare Issue Affecting Healthcare Organizations in the United States. Recent developments (particularly technological) within and around healthcare have necessitated the requirement that workers such as nurses possess skillsets that are upgraded. As a matter of fact, upskilling was identified as one of the six important healthcare issues in 2019 by PwC Health Research Institute (Ross, 2019). Currently, whole healthcare workforces are threatened with redundancy by technologies such as artificial intelligence (AI) if they do not upskill. This includes nurses, who have traditionally not been involved with technology in the course of delivering nursing care (Teague, 2019). Upskilling of the Healthcare Workforce: A Pertinent National Healthcare Issue Affecting Healthcare Organizations in the United StatesORDER HERE FOR ORIGINAL, PLAGIARISM-FREE PAPERSThe impact to my healthcare organization of upskilling as a healthcare issue is immense. This is because emerging healthcare technologies are becoming more and more mandatory in diagnostics, therapeutics, and nursing care. Nurses are therefore finding themselves short of skills to deliver quality patient care. This makes the organization set aside resources to retrain and upgrade the skills of its nurses so that they can cope with the emerging technological changes. This, however, is an inevitably resource-intensive undertaking fir the organization. In my organization, for instance, the policy makers have already had to set aside funds for training of the nurses and other healthcare staff on the use of the recently introduced EHR.
  • 2. Upskilling of the Healthcare Workforce: A Pertinent National Healthcare Issue Affecting Healthcare Organizations in the United States Already, upskilling is happening in the healthcare sector with the now standard requirement for electronic health records or EHR. That said, the hallmark of upskilling in healthcare is predicted to be artificial intelligence- assisted telehealth interventions (Teague, 2019).Some of the Areas of ConcernHealthcare organizations must invest in the abilities of their workforce if they are to have a competitive advantage over their peers. Not doing so will of course render the organization unable to compete effectively in an ever-changing healthcare marketplace. Upskilling of the Healthcare Workforce: A Pertinent National Healthcare Issue Affecting Healthcare Organizations in the United States. For instance, AI is more and more used in healthcare at the moment. What this means is that rising sophistication of emerging medical technologies is driving the need for upskilled health workers (Ross, 2019). The advent of digital therapeutics is the other area of concern. This is the treatment of disease using healthcare technologies to complement or replace traditional methods in disease management. The reality is that the clinical validation of these digital therapeutics products and connected medical devices is already being done by the Food and Drug Administration or FDA (Siwicki, 2019). This is an indicator of the urgency with which upskilling of healthcare staff like nurses should be treated.Two Articles on the Upskilling of Healthcare Workers as a Healthcare Issue of Concern Rimmer (2018) has posited that doctors have to undergo additional training in order to be successful at using emerging healthcare technologies. This particular article addresses doctors as the healthcare workers of concern, but it has been chosen because the very same situation is true for the nurses. This article talks of a report that states that training is needed by doctors in areas such as artificial intelligence algorithms, genomics, and digital literacy. As mentioned above, that is the same treatment that nurse practitioners should also receive. The article goes ahead to stress that training is a must for healthcare staff in order to cope with emerging healthcare technologies.Fralic (2013) on her part observes that the American healthcare system is undergoing change that is radical and monumental. She states, correctly, that with change there is need to re- strategise and re-organize to deliver quality healthcare. To do this, upskilling is a must to keep up with healthcare technologies. In other organizations in the healthcare sector, the same situation portends. They, too, are adopting the same approach of retraining to upskill nurses, doctors, and other health workers so that they can cope with the recent technological changes and continue to offer quality and safe patient care.Strategies to Address the Organizational Impact of UpskillingSince the reality of upskilling in healthcare organizations is inevitable, it is essential to develop strategies that aim at addressing the organizational impact of this issue. Three strategies are especially helpful. First, the organization needs to introduce new technologies gradually to allow for adaptation and training. Second, upskilling should be made a policy initiative that features in the organization’s goals. Third and last, upskilling should be properly budgeted for like any other expense if it is to succeed (Fralic, 2013; Rimmer, 2018; Teague, 2019). Under no circumstances should upskilling be considered as an afterthought. These strategies impact my organization positively in that they are geared towards giving the organization a competitive advantage. On the negative side, however, budgeting means that this strategy
  • 3. will consume resources that the organization must set aside.ReferencesFralic, M.F. (2013). Upskilling for new-era healthcare: Lessons from high impact readings. Nurse Leader, 11(4). http://dx.doi.org/10.1016/j.mnl.2013.05.008Rimmer, A. (2018). Upskill doctors to make the most of new medical technologies, report says. BMJ, 361(k2861). Doi: 10.1136/bmj.k2861 Upskilling of the Healthcare WorkforceRoss, J.R. (2019). Upskilling could be an ideal treatment for healthcare’s employment woes. Retrieved 4 March 2020 from https://www.cardiovascularbusiness.com/topics/healthcare-economics/upskilling- could-be-ideal-rx-healthcares-employment-woesSiwicki, B. (2019). Here are 6 major issues facing healthcare in 2019, according to PwC. Healthcare ITNews. Retrieved 4 March 2020 from https://www.healthcareitnews.com/news/here-are-6-major-issues-facing- healthcare-2019-according-pwcTeague, T. (2019). Will healthcare employees need to be upskilled or reskilled as technology advances? Retrieved 4 March 2020 from https://www.whatisbluesky.com/blog/will-healthcare-employees-need-to-be- upskilled-or-reskilled-as-technology-advances Upskilling of the Healthcare Workforce: A Pertinent National Healthcare Issue Affecting Healthcare Organizations in the United States[Student name][College/ Institution] Upskilling of the Healthcare Workforce: A Pertinent National Healthcare Issue Affecting Healthcare Organizations in the United StatesThere are many national healthcare stressors or issues affecting and impacting healthcare organizations all over the United States. All of them require addressing, although some are more urgent than others. The healthcare issue chosen in this case and one of the most significant stressors at the moment is the issue of upskilling of healthcare professionals. In this context, these would be the nurses working within the healthcare organization. According to Ross (2019), upskilling is the process of retraining employees so that they can acquire new skills for them to continue practicing in their field with ease. Recent developments (particularly technological) within and around healthcare have necessitated the requirement that workers such as nurses possess skillsets that are upgraded. As a matter of fact, upskilling was identified as one of the six important healthcare issues in 2019 by PwC Health Research Institute (Ross, 2019). Currently, whole healthcare workforces are threatened with redundancy by technologies such as artificial intelligence (AI) if they do not upskill. This includes nurses, who have traditionally not been involved with technology in the course of delivering nursing care (Teague, 2019). Upskilling of the Healthcare Workforce: A Pertinent National Healthcare Issue Affecting Healthcare Organizations in the United StatesThe impact to my healthcare organization of upskilling as a healthcare issue is immense. This is because emerging healthcare technologies are becoming more and more mandatory in diagnostics, therapeutics, and nursing care. Nurses are therefore finding themselves short of skills to deliver quality patient care. This makes the organization set aside resources to retrain and upgrade the skills of its nurses so that they can cope with the emerging technological changes. This, however, is an inevitably resource-intensive undertaking fir the organization. In my organization, for instance, the policy makers have already had to set aside funds for training of the nurses and other healthcare staff on the use of the recently introduced EHR. Upskilling of the Healthcare Workforce: A Pertinent National Healthcare Issue Affecting Healthcare Organizations in the United States. Already, upskilling is happening in the healthcare sector with the now
  • 4. standard requirement for electronic health records or EHR Upskilling of the Healthcare Workforce: A Pertinent National Healthcare Issue Affecting Healthcare Organizations in the United States. That said, the hallmark of upskilling in healthcare is predicted to be artificial intelligence-assisted telehealth interventions (Teague, 2019).Some of the Areas of ConcernHealthcare organizations must invest in the abilities of their workforce if they are to have a competitive advantage over their peers. Not doing so will of course render the organization unable to compete effectively in an ever-changing healthcare marketplace. For instance, AI is more and more used in healthcare at the moment. What this means is that rising sophistication of emerging medical technologies is driving the need for upskilled health workers (Ross, 2019). The advent of digital therapeutics is the other area of concern. This is the treatment of disease using healthcare technologies to complement or replace traditional methods in disease management. The reality is that the clinical validation of these digital therapeutics products and connected medical devices is already being done by the Food and Drug Administration or FDA (Siwicki, 2019). This is an indicator of the urgency with which upskilling of healthcare staff like nurses should be treated.Two Articles on the Upskilling of Healthcare Workers as a Healthcare Issue of Concern Rimmer (2018) has posited that doctors have to undergo additional training in order to be successful at using emerging healthcare technologies. This particular article addresses doctors as the healthcare workers of concern, but it has been chosen because the very same situation is true for the nurses. This article talks of a report that states that training is needed by doctors in areas such as artificial intelligence algorithms, genomics, and digital literacy. As mentioned above, that is the same treatment that nurse practitioners should also receive. The article goes ahead to stress that training is a must for healthcare staff in order to cope with emerging healthcare technologies.Fralic (2013) on her part observes that the American healthcare system is undergoing change that is radical and monumental. She states, correctly, that with change there is need to re-strategise and re-organize to deliver quality healthcare. To do this, upskilling is a must to keep up with healthcare technologies. In other organizations in the healthcare sector, the same situation portends. They, too, are adopting the same approach of retraining to upskill nurses, doctors, and other health workers so that they can cope with the recent technological changes and continue to offer quality and safe patient care.Strategies to Address the Organizational Impact of UpskillingSince the reality of upskilling in healthcare organizations is inevitable, it is essential to develop strategies that aim at addressing the organizational impact of this issue. Three strategies are especially helpful. First, the organization needs to introduce new technologies gradually to allow for adaptation and training. Second, upskilling should be made a policy initiative that features in the organization’s goals. Third and last, upskilling should be properly budgeted for like any other expense if it is to succeed (Fralic, 2013; Rimmer, 2018; Teague, 2019). Under no circumstances should upskilling be considered as an afterthought. These strategies impact my organization positively in that they are geared towards giving the organization a competitive advantage. On the negative side, however, budgeting means that this strategy will consume resources that the organization must set aside.ReferencesFralic, M.F. (2013). Upskilling for new-era healthcare: Lessons from high impact readings. Nurse Leader,
  • 5. 11(4). http://dx.doi.org/10.1016/j.mnl.2013.05.008Rimmer, A. (2018). Upskill doctors to make the most of new medical technologies, report says. BMJ, 361(k2861). Doi: 10.1136/bmj.k2861Ross, J.R. (2019). Upskilling could be an ideal treatment for healthcare’s employment woes. Retrieved 4 March 2020 from https://www.cardiovascularbusiness.com/topics/healthcare-economics/upskilling- could-be-ideal-rx-healthcares-employment-woesSiwicki, B. (2019). Here are 6 major issues facing healthcare in 2019, according to PwC. Healthcare ITNews. Retrieved 4 March 2020 from https://www.healthcareitnews.com/news/here-are-6-major-issues-facing- healthcare-2019-according-pwcTeague, T. (2019). Will healthcare employees need to be upskilled or reskilled as technology advances? Retrieved 4 March 2020 from https://www.whatisbluesky.com/blog/will-healthcare-employees-need-to-be- upskilled-or-reskilled-as-technology-advances s Upskilling of the Healthcare Workforce: A Pertinent National Healthcare Issue Affecting Healthcare Organizations in the United States