Chapter 23 The patient as person
Learning outcomes
Introduction
This chapter outlines interpersonal skills related to mental health nursing. It is based on a perspective that values the strengths and skills of both the mental health nurse and the person who is the client, while recognising that both can have vulnerabilities (Hem & Heggen 2003). The chapter is divided into three sections. It begins with an overview of the communication skills that underpin the therapeutic nurse–client relationship and nurses’ interactions with families and carers. These are the underlying skills that the mental health nurse needs when working with clients in special situations. Issues related to nurse vulnerabilities are discussed in this section, particularly in relation to use of self. A strengths approach to working with families and carers is also outlined. The second section of the chapter discusses risk. In this section the management of clients at risk of self-harm, suicide, aggression and violence is addressed. Special attention is given to risk assessment. Tools to aid assessment, and subsequent nursing interventions, are included. Section three introduces the ethico-legal issues of client choice and consent, which are important when planning and implementing nursing skills.
Communicating with clients and families
Arguably, mental health nurses use ‘self’ as their most essential therapeutic tool, and the nurse–client relationship is one of the most vital clinical components of nursing practice (Fourie et al 2005; Lauder et al 2002; Stein-Parbury 2005). ‘Self’ in this context relates to self-awareness and the need for the mental health nurse to understand and be aware of their own subjective and experiential world while using specialist skills. This use of self includes professional detachment, self-awareness, and understanding of personal emotions, beliefs and values (see Ch 1). This personal understanding is used to facilitate the therapeutic relationship, where the outcome is a focus on the needs of clients and their families (Fontaine 2003; Horsfall, Stuhlmiller & Champ 2000). The therapeutic relationship is a balance between the personal self, offering human closeness, and professional distance (Hem & Heggen 2003; Welch 2005). What does this mean for nurses practising in this specialty? It challenges nurses to review who they are in ways that may not be as rigorously required in other nursing specialties. In addition, there is an increased emphasis on interpersonal communication skills. It is understandable that some undergraduate and novice nurses have difficulty with the notion that communication is a ‘skill’ and that these skills require theory, understanding, practice and personal reflection. One of the activities we all engage in throughout our lives is communication—we communicate with others individually, in groups, via the telephone, via electronic means, in writing, and in a variety of social, informal and formal situations. It could therefore be claimed that this amount of understanding, practice and personal involvement would mean that we already have expertise in communication. Although this argument seems reasonable, there are many indicators to suggest that we are not always good at communicating.
Critical thinking challenge 23.1
Take a minute to think about communication situations that you find difficult.
Therapeutic relationships
A cornerstone skill for initiation, development and maintenance of a therapeutic relationship between nurse and client is interpersonal communication (Cameron, Kapur & Campbell 2005; Lauder et al 2002; Stickley & Freshwater 2006). Further, there is increasing evidence that supports a positive link between the efficacy of a therapeutic relationship and improved outcomes for clients with mental illness (Howgego et al 2003). A therapeutic relationship is an enabling relationship that supports the needs of the client. The nurse is entrusted to understand the client, to enable the client to understand their own needs and therefore become empowered in their life (Lauder et al 2002; McAllister et al 2004). Mutually agreed goals for nursing practice are enhanced by the therapeutic relationship. A therapeutic relationship is based on rapport—establishing a connection with the person and developing trust—and is distinct from interviewing, counselling and education (McAllister et al 2004). Therapeutic relationship differs from other interactions in its structure, purpose and intent. The value of the relationship is exhibited by improvement in the client’s wellbeing and capacity to take control of their life (Lauder et al 2002; Borg & Kristiansen 2004). Therapeutic relationships also differ from social relationships and intimate relationships (Horsfall et al 2000). While establishing and engaging in a therapeutic relationship, the mental health nurse focuses his or her skills on the client and judiciously uses self-disclosure. In addition, contemporary mental health services are now focusing more on the context in which the client exists, and there is a developing emphasis on providing family-focused care, as opposed to the traditional focus on the individual client. Therefore the principles of therapeutic rapport also need to be extended to include families and carers of people with mental illness.
Empathy
Empathy is not sympathy. Sympathy is about pity, compassion, commiseration and condolence, and while there are social situations where the offering of sympathy may be culturally and socially relevant, still it is not empathy. Nor is sympathy appropriate for the therapeutic relationship. Five conceptualisations of empathy have been proposed: empathy as a human trait, a professional state, a communication process, caring and a special relationship (Kunyk & Olson 2001). Empathy as a communication process and a professional state can offer us a clear understanding of what we mean by ‘empathy’ and a theoretical basis for our understanding (seeCh 1).
Empathy is about observing, listening, understanding and attending. It is ‘being’ with the person physically, cognitively and emotionally, and understanding their story, thoughts, feelings, beliefs and emotions. It is an ability to understand the person as fully as we can, and from their subjectively expressed view. It means not making judgments and not giving advice, but genuinely striving to understand the client’s subjective experience and communicating this understanding to the person. Here empathy is conceptualised as both a communication process and a professional process (Kunyk & Olson 2001).
Empathy involves perceptiveness, listening to meaning, listening to feelings, and listening in context, attending, responding appropriately and maintaining presence with the client (Boggs 2007). In this sense, empathy is linked to the therapeutic use of self. The mental health nurse is able to actively listen to both the cognitive content of the client’s story and the subjective meaning this has for the client. Nurses need to be honest about their own experiences and subjective responses, so they are able to clearly hear, respect and understand the experience of the client. This means that the client’s experience is acknowledged (Collins & Cutcliffe 2003). Empathy is one of the important building blocks of a constructive therapeutic alliance between nurse and client.
Earlier research suggested that rather than the five conceptualisations of empathy listed above, there are two types of empathy (Alligood 1992, cited in Evans et al 1998). The first is basic empathy. This is our trait capacity to understand and feel for others. This personal characteristic is shaped by our family, social environment and culture, and is contextually and culturally expressed. The second type of empathy is trained empathy (Evans et al 1998). Trained empathy is a professional skill that is taught, learnt and developed. Trained empathy enables the nurse to create a trusting relationship in which the client feels able to discuss their feelings and thoughts, thus facilitating the nurse’s understanding of the client, the client’s responses and health needs (Reynolds & Scott 2000). These two types of empathy are reflected in the five conceptualisations and can be aligned with ‘empathy as a human trait’ and ‘empathy as a professional state’ (Kunyk & Olson 2001, p 319).
Two personal characteristics of the nurse that contribute to the skill of empathy are the capacity for immediacy and the ability to be open-minded. The skill of immediacy refers to the capacity of the mental health nurse to respond to the client and their feelings in the ‘here and now’ with warmth and genuineness (Kneisl, Wilson & Trigoboff 2004; Reynolds & Scott 2000). It is a combination of both an appropriate physical presence and the clinical use of communication skills, such as those discussed in this book. Open-minded people tend to have a dynamic or fluid (rather than static) world-view. Open-mindedness conveys the nurse’s attitude of acceptance and capacity to ‘take the person as they are’.
Active listening
Active listening requires attention, genuineness and an ability to ‘hear’ what the client has to say and validate the meaning of the client’s perceptions. This does not mean that the nurse overtly or inadvertently agrees, or disagrees, with delusions or hallucinations; rather, the client’s perception and experience are heard and acknowledged. The skilful use of active listening requires practice and reflection on the part of the mental health nurse and contributes to the capacity of the nurse to maintain presence with the client. As discussed in Chapter 1, the examined ‘self’ affects the ‘micro’ skills that are valuable in the therapeutic relationship.
Listening to clients is improved by being available, in the here and now, in the best environment for communication—in a therapeutic space with reduced distractions and noise (Stickley & Freshwater 2006). The ideal may not always be possible, but consideration of the safety and privacy of the environment demonstrates good communication skills on behalf of the nurse. Often when we first start working with people in the mental health context, we are overly worried about what we will say next rather than what the client is saying. A good way to increase your skills and be more effective is to concentrate on what the client is saying and become an effective and active listener.
Mental health nurses’ communication skills are a combination and purposeful extension of a number of personal and professional communication strategies (Rydon 2005). While the skills discussed here are not exhaustive, they offer some explanation and description of communication strategies, including: closed and open-ended questions; reflective listening; paraphrasing; summarising; body language; touch; transference and counter-transference.
Closed and open-ended questions
Closed and open-ended questions elicit different types of responses from the client, and both are useful in mental health nursing. A closed question is one that elicits a
Table 23.1 Examples of closed and open-ended questions
| Closed | Open-ended |
| Are you feeling good today? | How are you feeling today? |
| Are you still getting side effects from your medication? | How are your medications affecting you now? |
| Do you want to come to group? | What would you like to do today? |
| Does feeling stressed still make you feel like harming yourself? | How does your stress affect you now? |
brief answer, often a single word. Asking many closed questions in a row can seem like an interrogation, but there is value in asking closed questions in order to gather specific information. An open-ended question allows the respondent to answer more fully. Open-ended questions have the advantage of not narrowing down or directing the response, and so the answer can give you information that you may not have expected. This style of questioning also allows the client to tell their subjective experiences, an important communication strategy that enhances the nurse–client therapeutic relationship. Individuals will nevertheless share information at the level they feel comfortable or safe with, so a closed question might elicit a detailed response or an open-ended question might be answered with a single word. Ordinarily, however, these questioning styles are a good guide for communication.
Reflective listening
Reflective listening means literally echoing the client’s communication. The purpose of this skill is to redirect the content or feelings back to the client. Reflective listening can include reflecting the content of the communication or reflecting the client’s feelings (Stickley & Freshwater 2006). Reflection of feelings, however, requires prudent, skilful use and a good therapeutic relationship. Over-use of reflective listening can seem contrived and stilted:
| Client: | I feel really sad about my family. |
| Nurse: | You feel really sad about your family? |
| Client: | I want to go home. |
| Nurse: | You want to go home? |
Paraphrasing
Essentially, paraphrasing is confirming the main points made by the client—either the content of the communication or the feelings—by restating them (Arnold 2007). Restating these main points can be a combination of your own words or the same phrases that the client has used. Paraphrasing is a useful communication skill that is different to, but can overlap with, other skills. Paraphrasing can be used to confirm that you have heard and understood the client’s subjective experience or perception. Any misunderstandings can also be clarified with the use of paraphrasing (Stein-Parbury 2005). It indicates that you have been actively listening to both content and feelings.
| Client: | I’m sorry for the mess I’m in. It’s just that some days I can’t find the energy to tidy up or do anything. |
| Nurse: | I see. You’re feeling distressed about your lack of energy. |
| Client: | If they do that to me one more time I’m just going to have to tell them, that’s all. |
| Nurse: | It sounds like you’re feeling angry about this issue and think it’s time to let people know. |
Summarising
Summarising means putting together the main issues and ensuring that you have understood them from the client’s perspective. The main issues could be focused on the content, perceptions or feelings of the client. This communication strategy can be useful for clarifying what you have shared, or for gaining some new perspectives or insights, or it can be used to conclude your current communication with the client (Arnold 2007).
| Nurse: | So, the important issues for you are finding suitable accommodation, repaying your car loan and getting organised so you can return to your university studies. |
The use of ‘rote’ learnt responses (‘Tell me about that’) or reflective paraphrasing (‘So you say you feel down’) might impede the development of the nurse–client relationship, as the nurse may not convey genuine concern and empathy (Rydon 2005). Clearly there are times when active listening is the best response, and silence or minimal verbal responses enable the client to better express their perceptions and feelings. The point here is that when the emphasis of communication is restricted to ‘rote’ and learned responses, the nurse is unable to express genuine concern and empathy, and this in turn impedes the development of the therapeutic relationship. Skilful therapeutic communication with clients and their families requires practice and self-awareness so that the nurse can use a variety of responses that are congruent with who she or he is as a person.
Body language and touch
Communication, of course, is not only verbal exchanges. Body language is an integral part of how we send and receive messages. Both verbal messages and messages sent via our body language can be misunderstood or misinterpreted. Body language, or non-verbal signals, include all the cues we send with our body: how we stand, our facial expressions, how close to other people we position ourselves, what we wear, how much we move our hands, if we cross our arms and any other physical movement that can be interpreted (or misinterpreted) by the recipient of our communication (Stein-Parbury 2005). There may be times when we communicate one message verbally but give a conflicting message with our body language. Nurses need to consider both the impact of their body language alone (a raised eyebrow or hands on hips) and the congruence between their body language and their verbal communication. Congruence between verbal messages and body language is important.
Body language and the issue of touch have particular significance in the mental health setting. Regard for the client’s perceptions includes understanding the possible impact of ‘touch’ (Rydon 2005). The nurse touching the client may have significance for the client beyond that intended by the nurse. In some circumstances touch may be perceived fearfully, as a threat, or as seduction. It may also be culturally inappropriate. Remaining sensitive to client feedback about the level of eye contact is also important in therapeutic nurse–client communications. Inappropriate eye contact, in particular a fixed gaze or stare, may also be misinterpreted or culturally inappropriate. Touch and eye contact are two important considerations when communicating with clients with mental illness and reinforce the necessity of competently and skilfully understanding the particular health problem and needs of the client.
Influence
We influence other people by what we say, what we do not say, what we focus on (feelings, content, context), our body language and our attitude to the other person’s communication. That is, we have interpersonal and mutual influence. This is particularly so when we are in a professional role caring for clients who have perceptual, emotional, linguistic or cognitive impairment concomitant with their mental illness. Clients will feel more able to trust a nurse who demonstrates that he or she understands the client’s needs and feelings (Borg & Kristiansen 2004; Reynolds & Scott 2000). In addition to the many micro skills that we can learn and practise to improve our communication skills, attitudes and values are important elements of therapeutic communication. Treating clients with respect, dignity, genuineness and honesty are among the characteristics that interweave with trained empathy to enhance the therapeutic relationship and build trust (Rydon 2005; Stickley & Freshwater 2006; Welch 2005). Talking and approaching situations in a calm manner is also an important feature of effective and therapeutic communication in the mental health setting (Cowin et al 2003). These skills require nurses to recognise their own strengths and limitations and seek appropriate resources and/or mentors.
Transference and counter-transference
So far we have looked at the impact of our communications on the client, their perceptions and feelings. What of the impact of the client on our perceptions and feelings? In order to understand the issues of transference and counter-transference, it is important to gain some insights into where these concepts originated. Sigmund Freud (1856–1939) was the founder of the psychoanalytic model and it is from Freud’s work that these concepts emerged (see Ch 8) (Howgego et al 2003). Without detailing his work, it is important to grasp Freud’s notion of the ‘unconscious’. Unlike the way we use this idea in everyday language, the ‘unconscious’ in psychoanalytic terms means that the person is not aware, or not conscious, of the motivation for their thoughts, feelings or actions. This is pivotal to the idea of transference and counter-transference.
The process of transference occurs when a person transfers beliefs, feelings, thoughts or behaviours that occurred in one situation, usually in their past, to a situation that is happening in the present. Traditionally it was meant to refer to the client with unconscious feelings or beliefs about someone in their past, transferring these feelings or beliefs onto the psychoanalyst. Past issues and conflicts experienced by the client are carried into the therapeutic relationship (Cameron et al 2005; Pearson 2001). These can include issues with authority, sibling rivalry, anxiety and dependence. The client brings these unresolved issues from the past into the present one-to-one relationship with the nurse. These feelings in the therapeutic relationship may be triggered by the nurse’s manner, look, position or speech. The transference may be displayed by covert or overt hostility, contempt for the nurse, lack of cooperation, or deference and submissiveness.
The client’s self-awareness is reduced as a result of transference. Helping the client to identify the past issues, deal with the feelings and emotions, and to examine their meaning in the present, is an effective way to support the client to work through the transference. This supportive strategy develops the client’s capacity to make choices. Dealing with transference in an empathic and honest manner, through judicious and skilful reality-based self-disclosure, can effectively disengage the transference (Pearson 2001).
Counter-transference is regarded as the response of the analyst to the client. It also includes the response of the analyst to the client’s transference (Cameron et al 2005). Generally the nursing perspective is that counter-transference is the response of the nurse to the client (whether this is due to unconscious or conscious reasons). One cue that you might be experiencing counter-transference is having strong feelings towards a client—either negative or positive. For instance, the client may have similarities to you in their age, gender, family relationships, life situation or personal issues that generate strong positive feelings for you. Alternatively, you may experience a strong feeling of dislike or avoidance of a particular client related to their behaviours, such as aggressive or self-harming behaviours, or you may feel a lack of understanding of their behaviours and communications due to their mental illness, particularly clients with personality disorders (Deans & Meocevic 2006).
Boundaries
Finally, one salient feature of a working therapeutic relationship involves respecting the needs of the client while remaining professional, and that includes the setting of boundaries (Horsfall, Cleary & Jordan 1999). The core aim of the therapeutic relationship is to engage in a collaborative relationship with the client with the aim of providing nursing care that is goal-directed, planned and purposeful (see Chs 1 & Ch 2). The nurse’s aim should be to facilitate and engage in activities that help achieve the client’s healthcare goals, not social goals or the nurse’s own needs. Here the issues of professionalism, therapeutic relationship, counter-transference and boundaries intersect. Confusing the highly personal nature of the nurse–client relationship with that of a social relationship may result in difficulties ranging from a negative treatment outcome for the client through to charges of unprofessional, unethical or illegal behaviour. Boundary transgressions can range from inappropriately disclosing personal information (including personal telephone numbers or home address), agreeing to meet with the client on a social level (in any context or manner), exchanging gifts and breaching client confidentiality, through to inappropriate touching, verbal abuse, physical abuse or sexual abuse (Cleary, Jordan & Horsfall 2002). Keeping client information to yourself, or not documenting some of the information that the client discloses, may indicate that boundary issues need to be reflected upon or monitored. It is important for nurses to remain self-reflective around issues of nurse–client boundaries and ethical practice. Some avenues of support for these issues include seeking peer support, engaging in clinical supervision sessions, remaining current with professional groups, being informed about current education developments and fostering an ethical culture in the work environment or organisation.
Issues in working with families and carers
Over the past few decades, deinstitutionalisation has seen the care of people with mental illness shift increasingly from large psychiatric institutions out into the community. This marked change to service provision has led to growing numbers of people with mental illness living with families and carers in the community. As Kinsella, Anderson & Anderson (1996) recognise, by its very nature, mental illness can be understood as a familial experience. Although an individual may have symptoms of mental illness and receive treatment for them, due to the interconnected nature of families this can affect every member of the family.
In recognition of the changing needs of families, more recently there has also been a paradigm shift in service provision so that the focus of care provided to families has moved to a strengths approach rather than the previous deficit approach. From this perspective, there is an openness to recognising the positive attributes of families (Darbyshire & Jackson 2005). This is also in keeping with the idea that rather than seeing families as damaged, they are viewed as challenged (Walsh 1996). This approach acknowledges that it is more constructive to consider the strengths that a family has, and foster further positive growth and development for family members, than to continue focusing only on the difficulties they face (Usher et al 2005). This offers us a framework for communicating and working together with families. It also means that when we assess a client, we continue to recognise the need to assess the context within which they live.
Skills in specific risk situations
Risk assessment and management
The term risk is commonly used in mental health practice and refers to the possibility of a (usually) adverse outcome occurring when a person engages in destructive behaviour. Risks can be seen in mental health settings for both clients and staff. In the broadest sense of the term, behaviours related to risk include the risk of violence or harm to self and/or others, various forms of physical, emotional and sexual abuse, gambling, promiscuity, reckless behaviours such as dangerous driving of a car, non-adherence (to medications and/or treatment recommendations), substance abuse and the failure to achieve one’s potential. Other risks that can affect staff and/or family/carers include the risk of emotional trauma or stress, and/or physical injury (Kelly, Simmons & Gregory 2002).
Risk assessment and management refers to the need to identify and estimate risk so that structured decisions can be made as to how to manage the risk behaviour(s). As the most common forms of risk in psychiatric settings include the risk of violence and harm to self, the following section explores the assessment and management of the person who is aggressive, the prevention of violence, and the assessment and management of the person who is self-harming and/or suicidal.
Managing the client who is aggressive and preventing violence
Managing violent and aggressive behaviour is becoming an increasing responsibility for mental health nurses (Owen et al 1998; Shepherd & Lavender 1999), who are often the target of aggression because of their frequent and direct contact with clients in the inpatient and community settings (Fry et al 2002). While the level of aggression and violence towards mental health nurses is said to be increasing, the extent of the problem is largely underestimated (Fry et al 2002). It is therefore important for the nurse to have sound background knowledge about aggression and its determinants as well as an understanding of the best ways to manage such behaviour should it occur.
Aggression is an action or behaviour that can range from violent physical acts such as kicks and punches, through to verbal abuse, insults and non-verbal gestures (Garnham 2001). People who are aggressive behave in a way that demonstrates their anger. For example, aggressive people may invade the personal space of others, shout or talk loudly, bang their fists, stomp their feet, shake their hands, stare until others feel uneasy, or stand over people (Distasio 2002). The overall feeling projected is an attempt to dominate. Violence, on the other hand, can be defined as a serious physical attack where the intent is to cause harm to an individual or object (Garnham 2001; Littrell & Littrell 1998).
Aggressive behaviour is multifactorial. It may be caused by internal, external or situational factors. Internal causes, or causes related to the individual, can be the presence of a serious mental illness such as schizophrenia, intoxication, age and gender, with young males being more likely to be involved in aggression and violence (Lanza 1988; Linaker & Busch-Iversen 1995, Pearson et al 1986). A previous history of violence is a strong, perhaps the strongest, predictor of future violence (Blair 1991; Tardiff 1998). External predictors are the environment, such as crowding or limited space, certain hospital shifts, staff gender (with males more likely to be attacked than females), and timing, where ‘hotspots’ such as handover or other busy periods have been identified as likely times for violent episodes to occur (Aquilina 1991; Nijman et al 1999; Turnbull & Patterson 1999; Vanderslott 1998; Whittington & Wykes 1994). There has also been a higher incidence of violence where the treatment setting was perceived by the client as coercive, controlling, threatening or frightening (Quintal 2002). Both internal and external risk factors can be identified as those that are static (that is, not changeable and based on past history, e.g. age and gender) or dynamic (that is, changeable and can be treated, e.g. intoxication) (Ignelzi et al 2007). Clearly, the dynamic factors are those that nurses and other health professionals can intervene with.
Managing a client who has aggressive behaviour can be challenging for any nurse. The main goal in managing aggressive behaviour is the prevention of an escalation into violence towards self, others and the environment. One way to prevent the escalation of aggression into violence is to know the predictors of violence and have the capacity to recognise these in your clients. Observable behaviour and cues that may indicate a person’s potential for violence (see also Box 23.1) can be identified using a framework based on the acronym STAMP. This stands for:
A number of risk assessment tools have been developed and tested. These tools can be useful in clinical practice as they help identify potential risks and offer a link between assessment and management of aggressive incidents (Doyle & Dolan 2002). A useful tool for assessing aggression is the Overt Aggression Scale for the Objective Rating of Verbal and Physical Aggression (Yudofsky et al 1986). This scale measures aggression in four areas: verbal aggression, and physical aggression against self, objects and other people. The modified overt aggression scale measures verbal aggression, physical aggression against property, and/or aggression against self on a five-point ordinal scale.
The ultimate goal of assessment and management of the risk of violence is the effective management and prevention of violence. In addition to thorough assessment, the nurse’s use of respectful and effective communication aimed at managing the risk, protecting self and others and enhancing recovery is vital (Ignelzi et al 2007). The management of aggressive behaviour is a process that may develop according to the level of risk the person poses. If the client is verbally aggressive, the nurse can use verbal techniques for de-escalation. However, if the person does not respond to these techniques, or is already threatening or acting out aggressive behaviour, intervention may need to increase to include physical intervention and/or the use of medication.
When faced with an angry or verbally aggressive client, remain calm and talk softly but clearly. It is important to intervene early in an attempt to de-escalate the situation (Delaney et al 2001). The following strategies are usually helpful in this instance:
Limit-setting is a means by which the client is told what behaviour is acceptable, what is unacceptable and the consequences of behaving in an unacceptable way. It is one way to avoid aggressive incidents. Limits are often placed on behaviours prior to their occurrence. That is, the nurse and client discuss the outcomes if certain behaviour occurs in the future. If this is the case, it is important that such outcomes do occur in the event of the unwanted behaviour. It is therefore imperative that all staff are aware of the plan and that everyone agrees to follow through with the action in the event of the unwanted behaviour. However, remember that some inpatient environments are perceived as coercive and controlling and, because of limited space, may make the client more likely to become violent (Quintal 2002).
An Australian study (Wynaden et al 2002) found that when managing difficult behaviours, nurses used a management hierarchy that had seclusion at the bottom. The hierarchy included things like distraction, the use of outdoor areas to separate clients, encouraging the client to regain control of their behaviour, and communication techniques. They also found that the nurses used intuitive judgments when deciding whether to seclude a client, and would use seclusion if it had been successful in a similar situation in the past.
