International Journal of Nursing Practice 2002; 8: 8–15

INTRODUCTIONThis paper will explore the research and literature sur-rounding nurses’ understanding and perceptions of theterms care and caring. Some of the studies reviewedexplored both nurse and patient perceptions. These willbe included in this section as it is extremely valuable tocompare wherever possible the two groups’ perceptionsof care.

Few people would argue that caring is an integral partof the nature of nursing. Leininger stated that ‘caring’ isthe ‘essence’ of what nursing is.1 Many people wouldagree with this view and would argue that to try to ‘nurse’without care is not, in fact, nursing. Scott points out thathealth-care practitioners have a strong socially recognizedrole and, as such, are legitimately required to care for

patients without question.2 This is generally supported by the nurses code of conduct United Kingdom CentralCouncil.3

In order to clarify the care debate further, it is essen-tial to explore the way that nurses interpret and perceivetheir diverse roles as caregivers. A majority of articles and papers on the subject of care and caring begin with a lengthy and eloquent description of how caring is thecentral and unifying domain for the body of knowledgeand practice of nursing. Jenson defined care as being a stateor mode of being that resists command and instruction.4

As stated earlier, care is a difficult entity to explain ordefine. It is a prime example of emotion, thought andaction coming together to provide comfort, both physicaland emotional, for another individual. Smerke considersthat one important aspect of caring is associated with amoral stance, pointing out that care is the moral ideal ofnursing.5 Caring is considered by many as the primary taskof nursing.6 Indeed, it is argued by some commentators asbeing ‘the fundamental human imperative that must beobeyed by all of humanity’.7 It is a shame that all humansdo not follow this imperative universally. Caring has a

✠ R E S E A R C H P A P E R ✠

Nurses’ perceptions of care and caring

Chris Bassett RN, BA(Hons)Lecturer in acute and critical care nursing, University of Sheffield, Sheffield, United Kingdom

Accepted for publication April 2001

Bassett C. International Journal of Nursing Practice 2002; 8: 8–15Nurses’ perceptions of care and caring

Care and caring have been identified as inherently difficult concepts to define, but many authors believe that care is thecentral and unifying core of nursing. It is vital that nurses understand what care is, with the current issues about mea-suring and justifying exactly what they do for patients in order to be clear about what good care is. If nurses are to con-stantly improve the care they give, they need to be clearer about how to care for patients. Nurses need to make sure thatthey are giving the patients what they want and not what the nurses want.This review of the literature explores nurses’perceptions of care and compares it with what patients want in terms of care. It also highlights some important and inter-esting differences between what patients and nurses perceive as good care.

Key words: care, caring, nurse and patient perceptions, quantitative and qualitative approaches.

Correspondence: Chris Bassett, School of Nursing and Midwifery, Uni-

versity of Sheffield,Winter Street, Sheffield S3 7ND, United Kingdom.

Email: c.c.bassett@sheffield.ac.uk

Nurses’ perceptions of care and caring 9

physical manifestation in addition to having a psychologi-cal, spiritual and social existence. Perhaps the lay person’sview or perception of the nurse is most often that of phys-ical carer, undertaking or assisting in a patient’s activitiesof daily living or even helping the patient through thedying process. Some nurses, in the author’s experience,are also of the view that caring physically is primarily whatnursing is.They would describe this as ‘real nursing’. It isa standing joke in some areas of the profession that psy-chiatric nurses are not real nurses because they do notactually do anything. This is obviously not true. Jamesstated that it was the provision of physical care that definedthe nurse’s caring role.8Without doubt, nursing has alwayshad a strong physical tradition.This is still the case becausenursing, and particularly general nursing, requires theacquisition and use of considerable physical ability andpractical skills to help the patient.

WHAT DO NURSES REALLY THINKCARING IS?

Larson surveyed 57 cancer patients to assess their per-ceptions of caring behaviours.9 She used a caring assess-ment instrument (CARE-Q) consisting of 50 nursingbehaviour items to rank caring in nursing.9 The patientsconsistently ranked the highest caring behaviours as thosebehaviours that showed that the nurse had competent andknowledgeable technical skills and abilities. Following thisstudy, Larson used the same tool to measure oncologynurses’ perceptions of what they thought would make thepatients feel cared for.10 Conversely, the nurse samplerevealed that it was the expressive humanistic behavioursthat ranked highest, such as listening, comforting andexpressing sensitivity. Dyson carried out a study aimed ateliciting nurse conceptualizations of caring attitudes.11 Todo this, she utilized the repertory grid technique. Thismethod of inquiry examines the research participant’sindividual perceptions of incidents, events and people.This method can provide both quantitative and qualitativedata. The participants, nine in total, were all hospitalnurses. It was concluded that caring is a combination ofwhat the nurse does and what the nurse is. Significantthemes emerged from this research, including ‘considera-tion and sensitivity’, ‘honesty and sincerity’, the ‘generalapproach’ and ‘giving of oneself’. All of the above charac-teristics underline the importance of the humanistic andpsychosocial aspects of care within the caring process.The nurses were given two grids to complete, one relat-ing to caring attitudes and the other to caring behaviours.

Dyson’s findings revealed that the concept of caring as per-ceived by the nurses who participated involves a combi-nation of what the nurse does and what the nurse is likeas a person. Regarding the second point (what the nurseis like as a person), strong themes emerged that includedconsideration and sensitivity, giving of one’s self, and thenurse’s general approach. Regarding the former (what the nurse does), work style was considered to be a key component. Important themes such as having time for patients, appearing unhurried and being in controlemerged.

EXCELLENCE IN NURSINGCoulon et al.12 carried out research to explore themeaning of what ‘excellence in nursing’ means to nursesthemselves. They sent open-ended questionnaires to stu-dents in their first year of study and to registered nurses(RNs) who had previously graduated from hospital-basednurse education programmes. There were 156 respon-dents in total. Responses revealed that at all times, thepatient was at the centre of the nurses’ concern. Thisconcern was grounded in professional practice, deliveredboth competently and humanistically in the form of holis-tic care for the patient and their family. Examples of thiscare provided by respondents suggested that professional-ism was an all-encompassing trait; however, not all of therespondents could define the term professionalism. Fourthemes emerged from the study: (i) professionalism; (ii)holistic care; (iii) practice; and (iv) humanism.

Professionalism, the respondents felt, underpinned allaspects of nursing-care delivery. It implied that quality andhigh standards were expected. Several of the nursesreferred to professionalism overtly by suggesting that it isa tacit expectation regarding excellent nursing care.

Holistic care means that by adopting a certain approachto patients that studied the psychological, social, emo-tional and spiritual needs of the patient, the nurse couldprovide an individualized package of care to the patient.This was seen as important by all nurses but its impor-tance increased with the level of experience that therespondent had.

The theme of practice encompassed scientific princi-ples that were translated to the implementation of com-petent and exceptional nursing care. They believed thatexpert implementation of skills was integral to excel-lence. Many respondents, particularly the postgraduateRNs believed that excellence in nursing care involved theawareness and implementation of the latest and best evi-

10 C. Bassett

dence of knowledge and skills. The first-year undergrad-uates attached most importance to personal traits in the delivery of excellent nursing care. The other moreexperienced respondents deemed this less important.Managerial and organizational skills were also consideredas being important to excellent nursing care.

Humanism was highlighted as being an important partof nursing practice. It was a nurse’s ‘personal qualities’that often made a significant contribution to nursing care.Subcategories were identified as being: (i) the enablingqualities of the nurse; (ii) nurse–patient relationships; (iii)intuitive knowledge; and (iv) nurse–staff relationships.

The enabling skills of the nurse comprised dedication,cheerfulness, tact, commitment and confidence in theirknowledge, sincerity, humility, empathy, subtlety andcompassion.Another important quality was seen as caringfor patients without bias or prejudice.

The nurse–patient relationship, according to therespondents, was seen as essential in achieving excellencein nursing care.

The more experienced nurses only referred to intuitiveknowledge. This was consistent with the fact that theunqualified nurse never overtly acknowledged the abilityto understand the unspoken needs of patients. The moresenior nurses also highlighted the importance of enablingand encouraging the patient to gain more independence,suggesting that the nurse–patient relationship develops asnurses gain confidence through experience.

Respondents acknowledged nurse–staff relationships asimportant. For nursing care to be considered excellent, ithad to be followed through by all members of the nursingteam.

HOW DO NURSES CARE FOR THEIR PATIENTS?

Rittman et al., using phenomenology as a researchmethod, asked oncology nurses what skills they used incaring for their patients.13 Data consisted of narrativeswritten by six nurses, all with at least 5 years of oncologynursing experience. They were asked to write about anexperience that taught them something about what itmeans to care for a dying patient.Themes were taken fromthe narratives and were interpreted in the following ways.Knowing the patient and the stage of illness was seen asthe key that nurses must gain knowledge of the patient,and that with experience comes the ability to understandthe trajectory of the disease. A ‘special’ bond might ormight not occur between the nurse and patient. The

achievement of a close bond was identified as being ableto provide strength for both the patient and nurse.However, even without the close bond, ‘good’ nursingcare was still given. A mark of expertise in oncology carewas considered as being able to accompany the patient and their family throughout the course of the illnessleading to death. Nurses described the decision to becomeinvolved with patients and eluded to the way that thiscould enhance the nursing care that could be given to thepatient. However, they also stated that it could be damag-ing to the nurse, especially if they had had a painful or dif-ficult experience with a similar patient in the past. Thismight indicate that proximity in relationships can be aconscious use of a nursing skill. Some of the nurses par-ticularly valued the quality of physical care of the dyingpatient and saw it as the first step to providing emotionalcare. Caring for the physical body provided nurses with a way of knowing the patient that they would not havewithout the intimacy of seeing, touching and caring forthe body. As patients allow nurses into the most privateparts of their physical being, they trust and open them-selves to sharing their thoughts and fears. It was seen byrespondents that easing the struggle is achieved throughexpertise in providing physical and emotional care in aseamless process.

Nurses spoke of the need to preserving hope whenpatients were entering the final stages of life. Whereverpossible, they tried to get the patient home to make themost of the time they had left. Nurses approached caringfor terminally ill patients as opportunities to participatein a life completing itself rather than only seeing the lossof life.

Nurses can attend to aspects of care that ease the strug-gle and promote a peaceful death. It was considered asimportant to help family members become involved withthe care of the patient, and to know when and how to talkto the patient’s family to encourage them to stay with thepatient while they die. One nurse described the skill ofproviding physical care ‘smoothly, not as separate steps,not a time for physical care and a time for talking’.

The cornerstone for oncology nursing was consideredas being the provision of privacy while dying. Nursesdescribed how they went to great lengths to accomplishthis goal. Although privacy issues are often culturallydefined, oncology nurses valued the provision of privacyhighly as an important caring action.

Research has been carried out about nurses caring inthe field of gynaecology. McQueen used a qualitative

Nurses’ perceptions of care and caring 11

approach to explore the verbalized experiences of 12nurses relating to the care they provided for theirpatients.14 Following analysis of the data, the following situations were identified as being of relevance to care.1. Direct patient care. The relationship between nurse andpatient was seen as particularly import because the natureof this type of nursing is often of an intimate and privatenature. Following on from this, nurses felt that it wasessential to be especially supportive, dexterous, gentleand sensitive in their approach. Nurses also believed thatunderstanding and empathy were also demonstrated intheir concern with the patients’ lives beyond the hospital,such as preparations for hospital, concerns about ongoingmanagement of the home, and feelings of separation fromthe family during their hospital stay. Some informantsstated that the fact that they were women helped themempathize with the patients.2. Caring for patients having a pregnancy terminated. Theresearch found that despite having their own views aboutabortion, nurses all felt that it was to meet the needs of all patients. Nurse also showed a clear appreciation of the mental turmoil that can accompany a termination ofpregnancy.3. Caring for patients having a miscarriage and/or problems

with fertility. Nurses exhibited the ability to show empathyand were well aware of the importance of sharing in thewomen’s sorrow and in being there for the patient.4. Caring for terminally ill patients.The nurses reported thebelief that the intellectual and emotional work involved incaring for dying patients is often not openly recognized assignificant caring work compared with physical care.Thismight especially be the case in the areas outside oncologyand hospice specializations.5. Caring for patients who are emotionally upset.Although thisarea of care was often difficult to cope with and nursesfound it hard to know what to say, they still believed thatit was important to show compassion and empathy.6. Caring for patients behind a façade. Sometimes whilepatients were waiting for important test results, nursesand doctors often knew the results but the patients didnot. Patients would ask the nurses but the nurses are notable to disclose the information before the doctor speaksto the patient. These kinds of situations impacted uponhonesty and trust in nurses’ caring interactions withpatients.7. Caring for relatives. Nurses deal regularly with relatives,the nurses believed that it was important to support,comfort and empathize with them as well as the patients.

8. Caring for the nurse. Nurses believed that it was impor-tant to care for other team members.The support of col-leagues in addition to cooperative teamwork supportednurses in providing emotional and physical care in theirwork.

Overall, the nurses, in describing their work in detail,highlighted the importance of interpersonal and human-istic care for the patient in the workplace.

Critical care nurses were included in a phenomenolog-ical study by Bush and Barr, which involved 15 nursesbeing asked to describe their lived experiences of caring.15

Caring in the critical care area was revealed to be

. . . a multidimensional, complex process involving assessing, and in

priority, addressing patients and families unique needs with the goal

of improving the patients’ condition, and acknowledging nurses’

living out of caring ways in their own lives.

Four categories were drawn from the research.1. Nurses’ feelings. This category involved sensitivity,empathy, loving, general concern, and genuine interest.2. Nurse’s knowledge and competence. Included in this cate-gory were knowledge of the patient, setting priorities forthe patient, knowledge of the family, technical compe-tence, interpersonal competence, expressive competenceand listening competence.3. Nurse’s actions. These involved giving physical care,communicating (speaking and listening), touching, sup-porting, teaching, mediating, advocating, making deci-sions and taking responsibility for actions.4. Patient and family outcomes, and nursing rewards. Theseoccurred when patients moved to another stage of recov-ery and went to different nursing units. The nurse couldsee relief in the patient’s eyes, the patient became happy,and the patient and family were satisfied.

When considering the effects of high technologicalinput in the role of the critical care nurse, it was consid-ered an important part of caring for the patient. For the15 nurses involved in the exploration of the caring activ-ities in their daily work, caring was seen as a series ofprocesses consisting of an affective process, a cognitiveprocess, an action process, and an outcome process.

COMPARING VIEWS ABOUT CARESmith and Sullivan used a caring assessment Instrument(CARE-Q) to explore the perceptions of nurses andpatients in a long-term-care home setting.16 The twogroups, 14 patients and 15 nurses, were given identical

12 C. Bassett

lists of care behaviours and were asked to rank them inorder of importance.

Nurses perceived the item ‘listens to the patient’ as the most important caring behaviour. Their 10 highest-ranking behaviours included seven expressive behaviours(expressing trust, acceptance of feelings, faith, reflecting,comforting and providing cheer) and three instrumentalbehaviours (e.g physical care, treatment and informing).

Patients ranked the item ‘puts the patient first nomatter what happens’ highest. Of the 10 highest rankedbehaviours, five were instrumental and five expressive.Two of the valued instrumental behaviours involved ‘pro-viding honest information to the patient’ and ‘treatments’.Although patients did not rank ‘listens to the patient’ ashighly as nurses, they still ranked it in the top 10. Patientsincluded ‘is cheerful’ among their 10 highest whereasnurses ranked it 29th. Generally, nurses and patients werein wide agreement about the importance of caring behav-iours; however, comparisons can be context dependent.For example, patients in this study were all long-termpatients, and therefore, it might be that they and theirnurses develop a closer rapport than patients and nursesachieve in more transient settings.

Larsson et al., using a CARE-Q approach, comparedcancer patients’ and staff perceptions (179 patients and 62nurses) of caring behaviours.17 The results demonstratedthat patients perceived the dimension ‘anticipates’ as themost important whereas nurses perceived ‘comforts’ tobe the most important (Table 1).

This study did show some interesting differencesbetween staff and patient perceptions of caring dimen-sions. Again, it might be that differing contexts of care can alter perceptions between groups. the findings of this study were similar overall to the findings of otherstudies.18

COMPARING PSYCHIATRIC ANDGENERAL NURSES’ PERCEPTIONS

OF CAREGeneral nurses and psychiatric nurses generally have very different patterns and contexts in the workplace.Greenhalgh et al. carried out a study exploring thesebehaviours relating to the issue of care.19 The study alsoinvestigated the effects that age, gender and qualificationshave on caring behaviours.The researchers used a CARE-Q tool with a convenience sample of 118 Finnish nursesof all grades and experience in a general and psychiatrichospital. The findings of the study are summarized in Table 1. Comparison of the subscale revealed similaritiesas well as differences in the two types of nurses (Table 2).Subscale monitors was ranked highest by the group aged31–50 years. Of nurses under 30 years, only 12% did notagree that they monitored their patients. In contrast, 27%of nurses over 51 years did not agree that they monitoredtheir patients. This study raises many issues betweengeneral and psychiatric nurses. It also stimulates questionsabout research methods, their appropriateness, and issueof conduct.These will be discussed at a later stage.

EMOTIONAL LABOUR‘The emotional labour of caring’ is a concept that wasdefined by Hochschild to mean the undefined, unex-plained component of the work mainly carried out bywomen.20 This concept is important in several ways as itadds to the general theories of caring. It is applicable tonursing care, which is mainly carried out by women, andit provides a great deal of extra insight into not just whatcaring behaviours might be but what they might mean tothe nurse, and how they might affect the nurse. Staden

Table 1 Comparison between patient and staff care rankings

Dimension and patient ranking Staff ranking

1 Anticipates 2

2 Explains and facilitates 6

3 Comforts 1

4 Monitors and follows through 4

5 Trusting relationship 5

6 Accessible 3

Table 2 Comparison between general and psychiatric nurse care

rankings

Subscale dimension General nurse Psychiatric

ranking nurse ranking

Monitors and follows through 2 1

Explains and facilitates 4 2

Comforts 1 3

Trusts 4 3

Accessible 3 5

Anticipates 6 6

Nurses’ perceptions of care and caring 13

explores this concept with three nurses using a phenom-enological approach.21 Through interview analysis, thedata were coded into themes, which were clustered intocategories.1. Private and public spheres. The women were all consid-ered as ‘emotional labourers’. They all used skills andemotional techniques acquired at home and in their work-based caring. It was recognized in the analysis that emo-tional labour was as demanding as physical labour, and thatsuccess was dependent on the successful handling of eachsituation.2. Appearing to be caring. There was a feeling that it wasessential that nurses appear to be caring both to thepatient and to the general public. Being genuine and open,and self-disclosure was considered important to theprocess of caring. However, too much caring might leadto the patient being too dependent on the nurse.The waythat the nurse expressed herself was adjusted to fit in withthe patient’s mood. Nurses might need to alter theiroutward appearances for the sake of the patients.3. Nurses are human too. One of the nurses stated that rel-atives were sometimes surprised when nurses becameattached to patients or cried when patients deteriorate ordie. It was considered important and positive by thenurses that nurses are viewed as being ‘human’ and subjectto emotions.4. Giving of yourself. It was expressed by one of the res-pondents that it was a good thing to show emotions topatients so that they might identify hidden emotionswithin themselves. One interesting finding was that oneof the nurses who worked in psychiatry felt that it couldbe helpful to patients for nurses to work through their‘own problems’ as it is a way of helping heal others.5. Value and visibility. All of the respondents in this studygreatly enjoyed their work and valued the caring input itinvolved. They alluded to skills that they brought fromtheir home lives.These were described as ‘basically femaleskills’, ‘organizational skills’, ‘how to manipulate or influ-ence others, even their emotions to get what you want (or win)’.6. Coping. There was a general belief that emotional workis hard work. One respondent saw nurses as being a‘never-ending storage bag, taking on others’ emotions’.Caring was sometimes seen to come from colleagueswhen things were too difficult to be easily dealt with bythe nurses.

This report is of real importance in informing the the-oretical debate about how nurses provide care, not just for

the patients but also for each other. Nursing was seen bythe respondents as being a highly satisfying and rewardingjob, but it was made clear in the study that the nursingrole is characterized by extreme emotional demands.Thisseems to be a requirement for providing high-quality carein all health-care situations.

Barr and Bush explored the views of 15 nurses in anIntensive Care Unit (ICU).21 The researchers asked thenurses about their experiences of caring. Nurses describedfactors that enhanced or reduced care in the ICU setting.Four major factors were identified as being crucial tocaring in the ICU.1. Support. Support from colleagues was seen as essentialto enable and support the respondent’s work.There weremany positive comments relating to care that was carriedout well or difficult situations that were dealt with in anefficient manner. Caring shown by colleagues was seen assupportive in motivating the nurse to further caringactions.2. Role modelling. Twelve of the 15 nurses spoke of theimportance of a role model in exhibiting caring behaviourto nurses in ICU settings. Role models were seen to havea good attitude to their patients by being kind, empathicand thoughtful towards patients and families. They werebelieved to empower care in others.3. Patient–family interactions. Strong feelings of caringwere expressed in statements about the need for expandedvisiting hours. Nurses encouraging families to becomeinvolved with their loved ones’ care was believed to be astrong indicator of caring behaviour.4. Economic/bureaucratic factors. Economic and cost-containing measures were viewed negatively in the caringsituation. Although they were acknowledged as neces-sary factors, they were believed to be the cause of staffshortages, which diminish the level of care. Anger, stress,hopelessness, frustration and burnout were also describedas reducing care in the ICU.

Walsh and Dolan used the caring dimensions inventory(CDI) to assess views on caring of 156 nurses in accidentand emergency (A & E) areas.22 They then compared A &E nurses with general nurses to explore differences incaring attitudes. The top six caring dimension categoriesof the A & E nurse are outlined in Table 3. In short, A &E nurses viewed the relative priorities of caring in a similarway to general nurses. However, they did not regard theimportance of getting to know the patient as a person veryhighly. This was also true with ‘sitting with the patient’;however, the nature of A & E units might explain this.

14 C. Bassett

Again, nurse caring can be seen as a context-dependentperception that will differ from ward to ward and spe-ciality to speciality.

Yam and Rossiter surveyed 10 RNs in Hong Kong toexplore their perceptions of caring using content analysisof transcribed interviews.23 Three categories emergedfrom the data1. Trying one’s best to meet clients’ needs. This involvesmeeting the biological, psychological and spiritual needsof patient and their families. The importance of tailoringcare to the individual’s needs following a health assess-ment was emphasized.2. Demonstrating effective communication. By achievingeffective interpersonal skills, better care could be achi-eved. Caring was the awareness of values, communicat-ing, sensitivity, and the ability to enhance patients’self-concepts.3. Providing a safe environment. This was considered veryimportant because it supported care in a situation wherenurses can provide safe support for patients. In addition,senior nurses acting as positive role models was seen tobe important in enhancing the caring ethos of the team.

CONCLUSIONThe findings of this review reveal some highly importantinsights into the way that nurses perceive care in additionto some insight into what they perceive their role is com-pared to the what the caring process might be for thepatient. The study enforces that nurses value most highlythe interpersonal aspects of the caring relationship. Pa-tients also value these humanistic aspects of care, butperhaps not to the same levels that nurses seem to. In fact,some of the studies cited show a significant divergence ofperceptions between patients and nurses. As stated previ-ously, the most highly valued aspect of care for the nurseis creating a strong relationship with the patient whereas

the patient values a high level of competency and skills inthe nurse. In reality, the patient is unlikely to say that theyare not concerned with the relationship between them andthe nurse. They would clearly want both aspects of care as even the most skilled and competent nurse could notdeliver care properly without the ability to comfort andcreate strong bonds with patients and their families.Perceptions of care and caring are very context depend-ent. Those patients who are acutely ill are perhaps morefocused upon tasks and effective treatments. If they are in pain, they want the nurse to provide the right medica-tion in the right dose at the right time. The patient whois terminally ill or in long-term care might not be soworried about the physical tasks but might want a closeand meaningful relationship so that they can feel free toshare their fears, hopes and expectations with a trustedpartner in care. Indeed, the acutely ill patient who is insevere pain will perhaps require and value a very differ-ent set of caring attributes from their nurses when theircondition has stabilized. This emphasizes the challenge ofnursing to be sensitive to the dynamic and rapidly chang-ing needs of all patients.

Research into care is possible using quantitativemethodology. Qualitative studies also provide a richsource of individual detail into what care is. More researchis needed into this important area of study and both typesof research are required in order to understand moreabout this vital aspect of nursing.

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Table 3 Top six caring dimension strategies of the Accident and Emergency nurse

Dimension Accident and emergency nurses General nurses

Explaining a clinical procedure 1st 8Providing privacy for a patient Equal 1st 2Being honest with a patient 3 6Listening to a patient 4 1Giving reassurance about a clinical practice 5 3Making a nursing record about a patient 6 21

Nurses’ perceptions of care and caring 15

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