Sunday, March 27, 2011

A Nursing Study on Touch - And What We Might Learn

When I’ve reflected on what it means to be “research-informed,” I have observed that we need to read research in the journals of other professions.  With that in mind, last week I did a bit of bouncing through journals to see what I could find of interest.  Because I believe clergy function more like nurses than like physicians, in this case I went looking in nursing journals.  And I found several articles that I found interesting.

One of those was titled “How Should I Touch You?: A Qualitative Study of Attitudes on Intimate Touch in Nursing Care.”  (AJN, March 2011: Vol. 111, No. 3, pp. 24-31) Now, I will admit that I was intrigued by the title before I read the subtitle.  Chaplains are almost never involved in “intimate care” as specified by the authors (although I can’t say never: patients have asked chaplains to stay through care when they would normally have excused themselves), much less in “intimate touch.”  However, there are still themes that I think are worth noting for any physical touch during care, even when it’s not “intimate care.”

For the study, the researchers gathered three focus groups, for a total of 24 participants (12 male and 12 female). Potential participants who were nurses or who had been nurses or nursing students were excluded.  Participants were gathered from ROTC students from a Catholic university; parishioners from a Catholic parish; and from a Protestant congregation (the congregations where the researchers worship).  Discussions were guided through a series of questions:

What do you think about, or how does it make you feel when you think about, a nurse having to touch you in private areas of your body in order to take care of you?

If a nurse had to help you take a bath, what things might a nurse do that would make you anxious?

Let’s say you are confined to bed.  After using a bedpan, you realize you accidentally soiled your pajamas and bedsheets, and the nurse has to clean you up.  What things can the nurse do to help you maintain your dignity?

Let’s pretend you have been in a terrible accident and have to have other people do everything for you.  John is your nurse today, and he has dome to do your personal hygiene.  What should John do to show you that he is professional and respectful?

How should John touch you?

Does anyone have a different thought about this?

Is there anything else we should teach nursing students about touch?

The facilitator or recorder will summarize key points and comments from the discussion to validate accuracy and provide an opportunity for clarification.

As in any focus group, these questions provided context and framework, and generated other questions and comments.  Each group lasted 60 to 90 minutes, and was both taped and transcribed.

From the groups, recordings, and notes, the researchers identified four themes.  First, “Participants in each focus group said communication was of the utmost importance before intimate touch could take place…. Also, participants said that communication should convey professionalism and respect.”  They wanted some sense of rapport, and not a clinical distance, and even “welcomed some self-disclosure from nurses….”

A second theme was the desire of participants for choice.  “Participants said they wanted to be involved in deciding whether intimate touch was necessary and whether there were alternatives.”

A third theme was that gender was an issue to be addressed: participants would want to be asked.  Having been a patient who had received care from a nurse of the opposite sex could make a difference in the concern if the experience had been professional and supportive; but not always.  In addition, having a chaperone addressed one issue and raised another.  Participants felt they would want rapport with and involvement by the chaperone in addition to the caregiver.

Finally, the manner in which the nurse approached and touched the patient were also important.  Participants expressed a desire that the nurse appear confident and professional.  The nurse should respect the patient’s privacy as much as possible, including closing doors whenever possible, and not just curtains.  Finally, the nurses touch should also be confident and professional, neither lingering nor rapid and rough.

For the chaplain, presence for, much less participation in, intimate care will be far and away the exception.  At the same time, our interactions are emotionally intimate, and we can apply these same principles in some sense.   Even though between short hospital stays and the priority of treatments and other activities our time with patients may feel quite limited, it is still important for us to communicate clearly our interest in the patient as person, and our role and reason for visiting.  There is power in asking the patient’s permission, not only to touch, but also to be present.  The comments about the chaperone may apply, too, in educational settings where a student may shadow an experienced chaplain, or a supervisor may accompany a student on a visit.  Both persons present should engage the patient, while being clear between themselves who is responsible for care.

It is also important for chaplains to take seriously issues not only of gender but also of other expressions of diversity in encountering patients.  While we as professionals are called to provide care across the boundaries of our differences, our patients are not required to accept it.  While we may chafe if we’re rejected over issues of gender, race, creed, etc, we are still called to respect the individuality of the patient as best we can. At least, by accepting the patient’s refusal with good grace, we allow the patient to exercise some control.

At the same time, we, too, are called to be sensitive about how we touch, both physically and metaphorically.  Even to take a hand or to touch a shoulder for prayer requires the patient’s consent.  We might accept it implicitly if the patient reaches for the chaplain; but we do well to confirm consent in all circumstances.  By the same token, we need the patient’s consent for intimacy regarding the patient’s history and feelings.  There is a point to bringing a limited agenda to the chaplain’s approach to the patient; and the short-term focused psychotherapy appears to demonstrate benefits that we can parallel.  However, the patient in the bed is not the client on the couch, present largely at his or her own request.  It is important that we present ourselves professionally and confidently.  It is also important that we appreciate the patient’s sense of timing.  We are called to approach the patient clearly (and so not be “too slow”), while also accepting the patient’s sense of readiness (and so not be “too fast or too rough”).  There are times and settings where direct confrontation is appropriate, but they are relatively specific.  In general, a sense of the patient’s readiness and timing is an appropriate part of spiritual assessment.

I expect many of my readers will respond to all this with, “Yes; and?”  It seems to me that this is information we know, information we have intuited from our own experiences and our concern and respect for each patient’s individual dignity.  However, the authors of the study were surprised to find that this topic had never been studied and published.  While there is value to our inferences, it is important to test them.  The researchers have studied the topic, and so questioned the inferences among nurses.  We can benefit from their work as well, by respecting what they learn in the process for their own profession, and by considering what we might also learn in the process.

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