A review of communication with intubated patients and those with tracheostomies within an intensive care environment

/nttnrn~e Care Nuning (1991) 7, 17%186 0 Longman Group UK L.td 1991

A review of communication with intubated patients and those with tracheostomies within an intensive care environment John W. Albarran

A major aspect of nursing care within intensive care environments is communication. If nursing communication with patients is to be both effective and therapeutic nurses need to understand the principles of communication and identify the purposes of nurse-patient interactions. The main purpose of this article is to review and examine normal communication channels and the actual and potential barriers to communication between nurses and patients who are intubated or have tracheostomies. The assessment of these patients’ needs for communication, planning, implemention and evaluation of nursing to meet them are discussed, and also implications for the future.

dynamic

INTRODUCTION Human beings communicate with each other as an integral part of daily life, usually without much thought or recognition of the complexity of the process. But nurses need to consider it more deliberately

in order to avoid or overcome

some of the factors which impede Communication conveying

between

messages

nels to a recipient. message clarify

and

understood

through The

provides

or indicate (Argyle,

process

and cyclical in ‘nature

(Shuld-

ham, 1984).

it.

two people involves one or more chan-

recipient feedback

decodes in order

that the message 1983).

Thus

tion, whether verbal or nonverbal,

the to

has been

communicais an on-going

Verbal

communication

may convey different

(Argyle,

skill with language

and 1983).

Speech relies on varying kinds of utterance, as tone or loudness

such

of voice, and also involves and vocabulary.

language

people solve problems,

standing

about facts, and means

(Shuldham, 1984). Nonverbal communication

By the use of

have an underto apply logic

is much more ver-

satile and has 4 main functions: Nonverbal nant

signals

are much

in transmitting

more

emotions,

bally

between

language; Nonverbal

(Requests for offprints to JAI

speech,

Manuscript

channels;

cues

allowing

people can

of’

support

feedback

domi-

attitudes

and beliefs; Messages may easily be conveyed

John W. Albarran SRN, DN,ENB, 100/124, Charge Nurse, Intensive Care Unit, Southmead Hospital, Bristol BSlO 5NB accepted 23 May 1991

can be complex

meanings

nonverdifferent

or replace

through

other 179

4. Nonverbal

channels

can convey

which may be difficult (Argyle, There

1983). including

between individuals,

gesture,

or posture, proximity

or mode of dress. However

is the most widely used and can in others (Argyle,

1983; Hewitt,

is also an expression

communication, concern

conveying

interest and a caring (Blondis

communication reassurance,

social inter-

and advice and counselling

Macleod

Clarke,

1981).

siders that the purpose ill patients

Ashworth

and

social

Bradley

for

them

integrity.

structural, the

depends

on

of the message as

of the relationship

(Ash-

(1982)

have stated that

should be patient-centred, while that caring is demonstrated by

planned

interactions

to all aspects of care (Ashworth, In assessing

implementing

1980;

Watson, planning,

and evaluating care through

com-

nurses focus on the uniqueness

patients

increasing

and is crucial

patients’ needs,

each person as an individual; and

maintain

However

interaction

and Edinberg

munication,

lo injury,

1981;

into

greater

(Ashworth,

of

this brings nurses contact

the nurses’ awareness

communication

Zori, 1984).

various channels

or para(Ash-

or treatment

At this stage patients

for communication.

of the

Howeve~

other patients in ICLJs may be recuperating the

process

assistance,

01

to move, see or hear clearly or

of being

weaned

off

or in

ventilatory

and able to use some communication

channels. Critically

ill patients

often

have multi-organ

tubes and wires which are attached equipment

such as cardiac Although

life

these

interaction

1980;

as well as for effective Bradley

&

also may

contribute impairing

his sensory

Jackson,

the

(Clifford,

people

their

through

perception

usual

as well as

(Blondis

&

nurses as the most

in this setting,

who under-

feelings,

provided reassurance always being there; and nurses’ expla-

nations were comforting 1985; Ashworth, could

ventilated they

of

1985;

in a patient’s

Yet patients have perceived

who

level

1982).

difficulty

recall

the

reported

could

not

Although

1976;

Asbury,

experience

of

being

that they were worried

talk

(Asbury,

in conveying

1980; Uprichard

(Adler,

1980). However many patients

1985),

or

that had

their wishes (Ashworth,

et al. 1987).

aware of the importance

of com-

munication for intubated patients nurses have been found to provide less communication when

nursing process, but this can pose problems the care of ventilated patients.

with critically ill patients is challeng-

staff

to a breakdown

apparently

Communication problems of KU patients and nurses

restrict

ability to receive and convey messages

stood

or pulse

1986). The sum total of these devices can

dealing with sedated,

in

monitors

used to sustain and main-

as well as with nursing Pearce,

to medical

between a patient and his/her family,

Edinberg, 1982; Macleod Clarke, 1988). Communication is entwined in all stages of the

Interacting

often sedated

disease,

open their eyes, and are thus deprived

important

purposefully 1986).

worth,

tain

1980).

communication others suggest

units (ICUsj,

at some time. They may be

to a ventilator,

due

8c

(Bridge

of communication

the value and meaningfulness well as the strength

lysed

oximeters.

con-

is to help

success of nurse-patient

worth,

attached

of

(1985)

their identity as well as psychological, personal

serves to

discussion

feelings,

critically

&

care

failure, so their bodies are invaded by an array of

meet several patient needs including information,

of time to

of nonverbal

for his or her well-being

Jackson, 1982). In nursing practice action,

in intensi1.e

may be unable

ofoneself

198 1 a, 198 1 b). A nurse’s commitment a patient

com-

physical

and presentation

appearance

facial expression

of nonverbal

gaze,

contact, bodily movements

cause reactions

ing for- nurses

because many of these patients are intubated have a tracheostomy

are many aspects

munication,

through

messages

to put into words

patients

in

ICUs, being

paralysed, the

degree

governed

or unconscious of

interaction

by the

patients’

responsiveness (Ashworth, 1980; Noble, 1979). When nurses do communicate with patients the message content is often ‘procedural’ or ‘functional’, associated with physical care (Ashworth, 1980; Gott. 1982). ‘l‘ouch

can provide

sensory

stimulation

and

181

INTENSIVECARENURSING help

a patient

world around and stress 1986).

to perceive

and

him thereby

(Blondis

structure

reducing

& Jackson,

the

his anxiety

1982;

Pearce,

Many of the nurses in Ashworth’s

claimed

that they would use touch

concern,

reassurance

and support,

of them were observed

study

to express

but very few

in purposeful

and sensi-

tive touch. Intensive

care nurses are familiar with alterna-

tracheostomised

patients

(Ashworth,

1984).

These

alphabet tracing

letters

However

1980;

include

boards,

or be under pressure display

Instead

the

herself with charts

to keep them up-to-date

to medical

staff

(Blondis

to

& Jackson,

1982), and in these circumstances

the nurse may

or

lip-reading,

symbol

find these methods

may be frustrating

and

is often

hand.

time-con-

illegible

and lip-

or unsatisfactory

1984).

Patients,

including

nurses as patients, support these findings (Clark, 1985; Smith,

1985). Curiously

Ashworth

(1980)

reported

that on the whole nurses relied on sign

language

and lip-reading

as the main methods of

communication. It appears touch

and

needs

and

other

their intentions

communication.

of prolonged

ment.

nurses recognise for

the

communication,

methods

to reassure

The

competes

stress,

Equally

common

(Belitz, This

overall

aspects

outcome

consideration

1983; Clifford,

situation

or becomes

and

Mackereth,

perienced

nurses (Mackereth, according

1987).

during

or when care is undertaken

include,

a

dehumanised

to recur

Physical and psychological

concern

is that the patient

1985;

is likely

as a

in these

of the equip-

shortages

staff

by inex-

1987). conditioned

to Borsig

and

causes

Steinacker

( 1982), stressors such as sensory overload which may precipitate in

behavioural

patients

with

psychiatric

illness.

emotional

stability

meaningful

bear little resemblance

technical

for the nurse’s attention

secondary

larly

that although

of

result

with the more

& Carrezosa,

on the palm of a nurse’s

1980,

of any nonverbal

areas, a nurse may show an overriding

reading

(Ashworth,

for intubated

and writing either on paper or

nurses

patients,

to a ventilator.

nurse present may preoccupy

Cronin

the writing

using

and also attached

communication heavily bandaged

who are alert and can

suming,

purposes

needs when s/he is disfigured,

have her back to the patient, and so be unaware

tive methods of communication move

difficult to assess an individual’s

reactions,

a history

As cognitive can

interactions

particu-

of

previous

alertness

be disrupted, (Chew,

al, 1978; Fisher & Moxham,

and

so will

1986; Adams et

1984).

to their practice.

Social conditioned This

BARRIERS TO COMMUNICATE

refers

to factors

hospitalisation A number

of authors

the problems ventilated

have attempted

of communication

to address

experienced

by

patients with nursing staff. Borsig and

Steinacker

(1982) have identified

which act as barriers group of patients.

5 main spheres

to communication

These

are discussed

because

Steinacker,

1982;

the awkwardness

with

unconscious

there is no feedback

to admission,

technical

admission

jargon.

sudden

awareness

of one’s inability to interreact

to stress and anxiety Carrizosa,

1984).

with this

pounded

below.

explanations

(Asbury,

This

if nurses

to an 1985;

situation

fail

equipment

can add Cronin

&

can be com-

to provide

or introductions

For

ICI-1 and

adequate

about personnel,

or procedures.

Unless

information is structured, in simple terms, the technical medical language may upset the patient or may be misunderstood and add to the

Physical and psychological conditioned causes Communicating

related

and

instance,

environment,

difficult

causes

patients

is

(Borsig

&

patient’s distress (Smith, 1987). A similar situation arises when

Ashworth,

1980) and there is

differences

of talking

to someone

the main

about

whom little is known except for the medical condition (Ashworth, 1985). Similarly it may be

exist. Ethnic population

groups

language

different

of an area

receive fragmented care because tion needs have not been identified

from

are likely

to

communicasatisfactorily

(Watson,

1986): and in a study

Gabriels

(1971)

in

the

as a result

an(l

States

non-

sufl’errtl

patients English-speaking emotional disturbances and others

by lIanilowic/

Linifrcl more

of poor

Illore

isolation

than

staff-patient

inter-

actions. Separation visiting

from

times

1982) and

family

(Belitz, for fear deprives

patients

reassurance

(Pearce,

social

nurses

isolation

wear

may

protective

1987). For example distorts

speech

facial expression. bute

and

(Clifford,

touch

reduces

feelings

can

lead

interventions

may

are

or

aspects

and

instability

In

order

to maintain

ventilation and

patient

patients’

various

notics to induce ation

drugs

sleep,

sedatives drugs

reasons,

reducing

the

particular

but

pancuronium cation alphabet

or

(Carnevale However touch touch

Furthermore,

nurses’ as one within

intact

during

for stimulation along

communidrugs

can use of 1987).

curarisation, must

to express

of

so care focus

on

sympathy

with speech.

For example

Wilson

input

which

states

and

group

ot. patients

1979));

is more

common

become

in

lead

by a catastrophic suffers

patients

reaction

in which

aspects

are

(Adams

et

and part

al,

by careful

activities,

meaningful of

1978;

effective Belitz,

1984; Mackellaig,

the

and deluthat these planning

reality

the level

and

is usually

hallucinations

avoidable

listening

delirium time

This

et al, 1978). It is argued

active

the

may mani-

in

reactions

well as controlling

for

responses:

sions (Adams

night

that

sensory

to confusional

impairment

person.

person

and

bored

stimulation.

(197 1) reported

stressors

followed

day

been

investigated.

affected

are

style of

(Noble,

disorientation

lastly

nurses’

disturbing

in 1C;U reduced

in turn

by

most

sensory

psychological

characterised

bleeps,

and has

who

memory

of these

and

or and

of

orientation, interactions

of noise.

as

All these

communication 1983;

Fisher

8c

1987).

causes

These may contribute stimulation the patient Borsig general

which

of social or

Moxham,

Environmental

this setting

due to lack

place,

out that the sense

needs and

patients’

to alarms,

of’ the

monotony,

2 main

care

quality

conversations

patients

As a result

the

and autocratic

in long-stay

fest

the

field;

doctors’

some

as

patients both

nursing

due

and

(the loudness

In

inappropriate

Mackinnon,

points

of

such

concurrent

boards 1983;

communication

and concern,

expense

such

making

al,

the

perception.

as well as verbal

Mackinnon

remains

to meet

at the

sensory

restricts

picture et

relax-

the and

of sleep;

lack of windows

may be given for

or atracurium

blurring,

Hyp-

paralyse

relaxants

channels. visual

to

use of muscle

use of most nonverbal cause

often

during

be used. producing

ventilation

patients’

the

comfort

may

curare-like

and facilitate

altruistic

causes

when

voices;

4. sensory

Chemically conditioned

and the visual

lights

aspects

the

limits

interrupt

described

1985).

in which

overload

bright

into

equipment,

which

deprivation

3. sensory

may contri-

to emotional

position

investigations

by

of helplessness

nursing

of stresso1‘6,

to the intrusion

of invasive

nursed

consistency

communication

patients‘

ollt

lo 3 li~rnis

related

to move

2. sleep

(Mackellaig, and

I0 c’arry

lead

bodies

often

ability

when

muffles

order

nanielv:

and

increased

clothing

All ofthese

to patients’

isolation

of

the use ofmasks

and

in

the supine

1986). On occas-

be

environnienl

patients’

the patient

Furtherniorc~

~n;~rii~)~~l~~tio~i of‘ the

1. restraint,

restricted

caring ferling.

;I \v;trm.

constant

to approach

of upsetting

emotional

the

8c Steinacker,

reluctance

equipment ions

to

1983; Borsig

the families’

the bedside

due

crearin
to the quality of sensory receives whilst in an ICU.

and Steinacker (1982) observe that in ICUs are like laboratories, rather than

Organic and therapeutic causes These include conditions which have a physiological basis for which intubation or tracheostomy and artificial ventilation are par’ of the

INTENSIVE

treatment; for example respiratory failure status asthmaticus or muscle paralysis. The

issues raised

by Borsig

in

(1982) in relation to these 5 main aspects contribute vastly to understanding

of the problems

of

communication

intubated patients. with However they are concerned with actual practice

and do not include

other

such as the educational working in intensive Ashworth

contributory

background

factors of nurses

care.

(1985)

patient’s ability to see, hear, touch, write, understand, or use facial expressions

and Steinacker

(Borsig

patient’s

physical,

strengths

and deficits must also be assessed when

organising The

Bridge

and

Speight

from

munication knowledge

deficient

preparation

in relation

tion skills and that understanding According

factor

or knowledge

hence

have

of- interpersonal

communication

a low priority

in

skills

in education.

have

The

evidence

taining

to indicate

that

when choosing some

endotracheal

tubes,

prior

interpersonal

skills

patients’ communication

to

and

meet

such

needs.

for

respiratory

PLANNING

AND PROVIDING

CARE

communication

is not only neces-

or

and data

and methods

for

and giving information.

In

are able to visit ICU

and ventilation

cardiac

surgery

patients

function

are

brought

et al,

to 1CU if

needs monitoring,

is imminent.

including

afterwards,

(Stovsky

is at risk,

At this stage nurses

should assess and agree nonverbal used,

Nurse-patient

by hypnotics

patients

to admission

or intubation

func-

of such aspects may be crucial

instances

other

occurs.

and perceptual

the provision

stimulation

1988),

an

as a result of trauma

for example

example,

even

1985); in doing

experience

cognitive

may be altered

sensory

with

patient (Ashworth,

patient’s

tioning

nurses must have broad theoretical and practical knowledge of the problems of patients with

social and occupa-

may help the nurse in main-

so a more humanising The

com-

(Blondis

et al, 1987). Equally,

communication

unresponsive

treatment,

order

1985).

be obtained

the appropriate

of the patient’s

may

as well as empathy

must

for the individual

1982; Uprichard

from assessment

so far seems

in

identifies

channels

This

still be true in some places.

details

The

intellectual

or his/her family or friends.

tional background

of communication.

to these writers nurse teachers

and

received

have

to communica-

this is a crucial

the problems

lacked resources skills

programmes

1982).

and

the plan of care (Ashworth,

the patient,

&Jackson,

post-basic

emotional

The patient’s profile will help to ensure that the

taken

and

Steinacker,

biographical

(198 1) argue that even nurses who have underbasic

&

such as smiling~or

blinking

nurse concerned

and

183

CARE NIIRSIKG

signals to be

cues for yes and no, and for

drawing attention

of the nurse, or picture boards

sary in itself to meet patients’ needs for human

(Parker,

interaction;

assessment

allows a nurse to plan specific com-

munication

strategies

it is also an essential

provision

of other

emphasised

that

care.

McFarlane

‘unless

they can neither

factor

nurses

(1980)

has

communicate

assess the patient’s

care, plan care effectively,

in the

need

for

carry out nor evaluate

it.’ priority

of ventilated

to

the

needs

for

advice, reassurance,

discussion

provision

contact

In

of human

dealing

establish

with

these

patients

information,

of feelings,

(Ashworth,

needs

the

throughout

events

allowing

affecting

1985;

Parker,

each

1984).

the frequency

1981).

carried

out (Ashworth,

which

the patient’s stay in

the unit. For intubated and tracheostomised patients the assessment should include a focus on the

Skilled

each patient as

each

patient

The

plan of care should

1981),

earlier

and overload identification

that

of planned

1983).

the potential

sleep deprivation,

to be

recognising

periods

sleep (Belitz

As mentioned

personal (Tschudin,

of interventions

also requires

uninterrupted constraint,

to control

his/her well-being

include

will

1984).

to benefit

and

nurse

the first links in a relationship

will be sustained

should

Appel-Hardin,

well as creating a comfortable and therapeutic environment. Planned communication can increase patients’ autonomy,

The assessment give

1984;

risks of.

sensory monotony

can often be averted by svstematic and attention to the sources of

stress.

Acquainting

a patient

with the various

dexterity,

alertness

and giving careful

staff commitment

preparation for investigations and nursing interventions help to minimise his/her level of anxiety

the client (Cronin

(Belitz, 1983). Visitors affect patients, and in the

the

author’s experience

patients’

sounds

about and

in the environment

the effects reassured

they too need to be warned of hypnotics

that

patient’s comfort

these

and analgesics,

are

given

for

and that effects such as drowsi-

ness are only temporary. The

agreed

means

of

communication,

staff (Tschudin,

and used by all

1985; Parker,

1984). Perhaps

a

8c Carrizosa,

for

reality

1984).

orientation, goals

interactions

and assisting

of care should emphasise

personal 1982).

factors

crucial

to reducing

were:

large

clocks

promoting

and

maximising

(Ashworth,

& Edinberg,

information

whether by tactile stimuli or by other cues such as winking, should be documented

need

as well as the

to supporting

The implementation

effective

the

and motivation,

Clark

198 1; Bradley

(1985)

found

sensory

and

calendars,

frequent

about the time, data, place, knowing

staff by their names, and being taken out of the unit

into

the

ventilator.

open

Other

air

while

factors

attached

which promote

note at the head of the bed would be useful in

nal identity include family photographs,

reminding

cards,

all personnel.

of nurses caring development

Limiting

for each patient

of effective

(Parker,

In planning

continuity

nurse

involved

relationship

as this

by sharing

& Edinberg,

abilities,

something

1984).

However

as the

boards

nonphysical

1980). Research munication

this approach

needs

to

and may not

visual capacity

introduction

fail

(Ashworth, suggests

to use of a com-

board which was to be used during

the intubation

period

resulted in greater

electronic

in ICU

after

patient satisfaction

munication. More sophisticated

rely

formation

depends

on the patient’s

to overcome

use of television can also help

deficits in the sensory environment. draw comfort

to see ‘their’ nurse (Smith,

from being able

1985; Uprichard

et al,

shift (Blondis

that nurses inform

& Jackson,

1982;

Parker,

Equally a nurse must state whether morning,

afternoon

or night

the

1984).

she is on the

shift as part of’

orientation. In general

nurses’ nonverbal

is important. recommend

Bradley

and

that in overcoming

communication

the nurse

communication Edinberg

involved

herself to eye level when interacting patient,

smiling,

and listening

nodding

as relevant,

(1982)

the problems

attentively,

of

must lower with her/his observing

and touching

appro-

with com-

empathy and concern. Clearly each nurse must be patient and well-motivated towards commu-

on and

eye con-

veyance of messages. The use of microcomputers can be adapted to an individual patient’s capacity, for example mouth pointers allow printing of messages by tapping large keyboards 1986). But the success of using u ones,

computers

music

priate areas of the patient’s

aids may be used, such as which

favourite

can help to drown the myriad sounds within an

operation

voice devices or microcom-

and devices puters, movements to control

1985). A patient’s

the

(Ashworth,

patient when they are leaving the bedside or the

discussed

usually

of patients

their

is one pos-

by Stovsky et al (1988)

that preoperative

1981; Clark,

get-well

to meet

1987), so it is important

1986). The

boards

(Appel-Hardin,

the patient’s

and interests

geared

to a perso-

with

in common

1982; Quinn,

has limitations

portable

and ack-

will strengthen

use of large communication

acknowledge

concerns

Many patients

of communication

sible solution to some of the problems

match

must

to the patient her own limitations

communication, (Bradley

sysof care

and conversations

ICU, andjudicious

the

in mind the patient’s

nowledge

the

1984).

care

discuss the various methods bearing

facilitates

communication

tems as well as maintaining generally

the number

that

deprivation

eyesight,

body to emphasise

nicating with her patients (Tschudin, contribution

1985). The

of relatives and close friends

to the

sensory and emotional stimuli experienced by patients is essential. According to Tschudin (1985) a member of the patient’s family is often the most suitable person to inform him/her of news of a good or distressing nature. But, to avoid effort and frustration for patients the families need to be taught how to use the same nonverbal signals devised by the nurse and

INTENSIVE

patient. Evaluation

ture cited in this review suggests that communiof the effects

of communication

cation

may be difficult when the patient is unresponsive

depends

(Ashworth,

1981).

niques,

physiological

state or restlessness

However,

result of a nurse’s reassuring evidence

of alleviation

alterations

of

apparently

as a

voice or touch, or

of patients’ symptoms

such as pain, which often depends communication

(Hill,

1985),

on effective

may be used

as

indicators. Many

with

of the standard

plans

care and improving

developed

for

communication

for the future

address postbasic

for

example,

1986; Foster,

1987). This is in line with current

concern

with applying

1987;

theoretical

Dunn,

models

of

learning

and

of care. Roper et al’s (1980) activities of

endotracheal research

studies

them. Further

nursing

models

emphasise

interventions

patient relationship skills. Yet these

that

the

success

and uniqueness depends

of

of nurse-

are often

not assessed

when

techniques, Overall beneficial

there are many dimensions

for communication

are intubated,

satisfaction such

practice, who have

is a comparative and the nurses

research

caring

is necessary

to measure

practice,

lack

to

needs of this

new interactive

and to develop the profession’s

con-

theory.

it is clear that interacting

effectively

patients can have therapeutic

outcomes

for

in order

the effectiveness

develop

to scientific nursing

of

between

as it promotes

and

patients’

physical and social well-being as well as maintain-

CONCLUSION reasons

by

valuable,

Through

of the relationships

group of patients,

with intubated

In conclusion,

in improved

be able to assess the communication

tribution

applying these models.

be

aspect of nursing

patients

of nursing

on communication

as proposed

can

for nurses.

there

ventilated

tation

(1984)

of

of teaching

tubes in situ.

Currently

Orem’s

adap-

methods

of

theory

when dealing with patients

life, not only for social needs but for all curative, and supportive interventions. preventative, and Roy’s (1980)

should

at basic and

to the

using videotapes Joshi

tion as an important

agement

self-care

cited the impli-

means nurses in future will regard communicaespecially

(1980)

Practical

resulting

which direct and facilitate nurses’ manas a vital aspect of

and

the development

related

with communication

nursing,

living include communication

of nurses

problems

levels, including

communication.

apparently

(See,

and tech-

are that nursing

the educational

et al’s framework

Dunaway,

complex

and verbal

In the light of the evidence cations

Wallace

1989;

is

as well as the creativity

communication

Bogdanovic,

patients nonverbal

patients when interacting.

within ICUs have been broadly based on Roper (1980).

such

on both

skills and

structuring

185

CARE iK!RSING

to and

with patients

or who have a tracheostomy.

who

ing their

identity

achieving

and measuring

as individual

humans.

such outcomes

But is not

easy and there is much scope for development.

In

nursing such patients the aims must be to ensure that each patient maintains

his/her identity,

a therapeutic,

relationship

meaningful

lished, as well as communication patient with information

organic

and

providing

chemical,

therapeutic

causes, as well as deficient

environof nurses

are major issues in

the development and maintenance patient interactions for intubated patients.

to

conditioned

preparation

in relation to communication,

ventilated

the

that will contribute

emotional stability. The physical, psychosocial, mental,

that

is estab-

More specifically

of nurseand often the litera-

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