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The meaning of touch in care practice
Sot. Sci. Med. Vol. 18. No. 12, pp. 1081-1088. Printed in Great Britain
THE MEANING Department
1984
0277-9536/84 $3.00 + 0.00 Pergamon Press Ltd
OF TOUCH
IN CARE
PRACTICE
JOHN W PRATT and ALLEN MASON of Health Studies, Sheffield City Polytechnic, 36 Collegiate Crescent, Sheffield SIO 2BP, England
Abstract-76
respondents were asked to categorise 28 specified examples of touching within health care. Broad agreement was found across the sample group as a whole, in its application of 8 of the 10 categories
offered by the researchers. The need for alternative or additional categories and the occasional differences between responses of professional groups are discussed.
INTRODUCTION
There has been relatively little research on the significance of touch in health care, especially in relation to the social aspects of such interaction between practitioner and client. Health consultatiqns, often concerned with the client’s bodily functioning, afford many examples of bodily contact. Indeed the implying a practitioner, i.e. health practitioner qualified medical, para medical or nursing professional, is accorded the right of access to the client’s personal space and his body. Yet within the appar ently straightforward delivery of medical and nursing care there exists, in the act of touching, a variety of purposes and communications. There is an extensive literature on the attribution of intentions or motives, in which the contributions made by Heider [l], Jones and Davis [2] and Kelly [3] are seen as significant [4,5]. In this literature it is generally assumed that motives are sought and subsequently attributed by the perceiver of another’s actions in order to explain that person’s behaviour and thus allow the interaction to continue undisrupted. In this way the attribution of ‘caring’ or ‘diagnostic’ to the touching behaviour of a doctor has important consequences for the way the client then responds. Investigations into the implications of touching in practitioner/client interactions have tended to centre around nursing and psychotherapy and have dwelt on the value of physical contact as a means of communicating, establishing rapport or developing verbal behaviour with clients. For example Burnside [6] employed touch as a means of increasing external stimuli to clients with chronic brain syndrome, in order to observe changes in response level or linguistic coherence. McCorkle [7] found that touch facilitated the gaining of rapport between nurses and seriously ill clients, while Aguilera [8] noted increased verbal interaction with bodily contact. Traditionally psychotherapy is seen as a verbal
The following abbreviations are used for the ten categories of intention as listed in Table 3: C = Communication: D = Diagnostic; INCID = Incidental; PCARE = Personal Care; ASS = Assisting; ACC = Accidental: G = Guiding; PG = Pleasure Giving: INSTR = Instrumental; PR = Pleasure Receiving.
process though there are proponents of bodily contact as an alternative or complementary medium to the verbal [9]. Previous research has treated the implications of touching by a practitioner in such general terms as not to question the intended or inferred meaning of the action in any detail [6, lo]. Other researchers record the effects of touching on observable behaviour [7, 1l] again without reference to the thoughts or feelings of either participant. What, therefore, do professionals mean or intend in their actions of touching, or, more realistically, what do they and others judge such intentions to be? In health care there is little or no research to investigate the meaning of touching behaviour as both professional and personal contacts between practitioner and client. The present study is aimed specifically at revealing generalised intentions of practitioners as perceived by various groups of health professionals and a group of lay respondents. It uses examples of common tactile interactions between practitioner and client in a number of different situations, proposing a detailed categorisation of possible intentions, in contrast, for example to that of Watson [12] who indicated only two-instrumental and expressive. METHOD
There were 76 respondents, comprised as shown in Table 1. Lay respondents were mainly colleagues and acquaintances of the researchers, probably having similar educational backgrounds (see Discussion). They were chosen as not being trained or qualified in the professions of health care, nor having special experience or other connection with health care except as ‘normal’ patient or client. The practitioners were either departmental staff, post registration students in health studies, or from local hospitals and centres. Each respondent was asked to complete a questionnaire which it was estimated would take about one hour, though some respondents reported needing longer. The questionnaire consisted of descriptions of 28 care situations, as listed in Table 2, each of which had to be described by the respondent in terms of 10 categories of possible practitioner intention provided by the researchers, or other category as thought appropriate by the respondent (Tables 3 and 4). The
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JOHN W. PRATT and ALLEN MASON Table I. Classification of the 76 respondents Students’ Lay resaondents
8
Practitioners
Nurses 9
*Not of health-related
Teachers”
Housewives
5
3
5 Health visitors 10
by occupation
Lecturers*
Others __~~__~
Occupational therapists 9
Physiotherapists 9
Totals .~~._.
9 Occupational health nurses 9
30
46
Subjects. Table 2. Descriptions of 28 care situations used in the questionnaire Situations
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28.
w’here contact
takes place
In a Rheumatology clinic a patient has complained of pain in the ankle region and the consultant gently probes the area While she is enquiring about the home circumstances, an occupational theraptst holds the band of an elderly patient A psychiatric nurSe puts his hand on a young female patient’s knee as he talks to her On a geriatric ward a nurse (F) combs a patient’s (F) hair A physiotherapist puts a patient through an exercise routine passively prior to doing it with resistance A nurse cuddles a child who is having a plaster cast removed from her leg A physiotherapist and a nurse support a patient who has stumbled and they help her to a chair In an orthopaedic ward, a patient in lower limb traction is having his bed made by two nurses (F) In the gymnasium a physiotherapist (F) acts as a partner for a patient during an exercise session that involves resistance work (M) A student nume leans against a male patient as she is shown a photograph A doctor places both his hands into those of a patient and tells him to grip as hard as he can A patient asks for a drink and a nurse (F) supports his head and gives him a cup of water On a male geriatric ward, a physiotherapist (F) kisses one of the patients on the cheek on the occasion of his birthday An elderly patient is walking down the corridor using a walking aid. A nurse accompanying her puts an arm around the patient’s waist (M) A physiotherapist attempts to reduce the spasticity in a hemiplegic child. She gets on to a treatment mat on the floor with the child Whilst a therapist (M) demonstrates an exercise to a group of patients, his arm comes into contact with the arm of the person nearest to him (F) A blind patient (M) asks the way out and a member of staff (F) takes his forearm and steers him towards the door A patient (M) with the help and advice of an occupational therapist (F), is attempting to put his above-knee prosthesis for the first time A physiotherapist (F) places her hands on a patient’s (M) neck during a relaxation class. and strokes it gently A radiographer (M) helps a patient (M) down from the X-ray table An occupational therapist steadies herself against a patient (M) after having to move out of the way of a trolley After examining a female patient the consultant continues to hold her hand while explaining his findings In Intensive Care, a staff nurse (F) carries out a routine of oral hygiene on a conscious patient (M) In a factory clinic a nurse (F) applies a skin cream to the leg of a patient (M) A nurse (F) bed baths a patient who is unable to wash himself A medical student (M) performs a vaginal examination on a young pregnant woman A sleeping patient (F) is shaken gently by the ward sister (F) as visiting time is about to begin -. 1 . . ,__. A pnySlOttteraplSt (M) COrreCtSa patlent’s (I-‘) posture Table 3. Ten categories of touch as provided on each page of the questionnaire Categories
of touch
Communicative
To convey an idea or a feeling to the patient (often of a carmg attitude) Examples: patting lightly to indicate approval; placing hand on the patient’s Shoulder to express concern Diagnostic
To obtain information about the condition or function of the patient Examples: taking a pulse: feeling for swollen glands Incidental
The touch is an integral part of, but secondary or incidental to the practitioner’s Examples: bandaging; undressing the patient Personal
therapeutic action
care
Carrying out actions on the patient’s body that he would normally do for himself Examples: giving a bed pan; washing a patient’s hair Assisting
When the practitioner acts as an extension of the patient to enable him to obtain some phystcal movement Examples: helping patient up from a chair; assisting in or out of bath Accidental
Contact is not intentional Examples: bumping into another person; standing unavoidably
close as in a crowded lift
Guiding
To indicate a desired movement or to achieve an awareness of some static or dynamic body function Examphs: creating awareness of the affected side in a stroke patient; indicating direction to a blind person Pleasure
giving
To give pleasure to the patient Examples: playfully touching a baby or child; touching a patient’s hair lnstrumentnl
To use a degree of pressure on the patient’s body directly causing anatomical of mechanisms to produce observable changes in function Pleasure
or physiological change: usually involving the activation
receiving
To receive pleasure from touching a patient Examples: deliberately standing so that contact with the patient’s body is achieved: (agam) touching a patient’s hair Other
Please specify any other categortes you can think of that are not wholly included in one or more of the above Take each CARE SITUATION in turn and assess the extent to which each category, in your judgement, applies to the given description. Use the 5-point to do this. remembering that I is used when the category does nut apply, and 5 when it very much applies
The meaning
of
touch in care practice
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Table 4. Scale description and example given on page two of the questionnaire The scale to be used for relating the CATEGORIES
of touch to the given CARE SITUATION
is:
I = Not at all L
4 5 = Very much using the intermediate values, 2, 3, 4 as appropriate For example; “A staff nurse (F) swabs a patient’s skin and gives him an injection” might be assessed:
(F) = Female (M) = Male
Communicative Diagnostic Incidental Personal care Assisting Accidental Guiding Pleasure giving Instrumental Pleasure receiving (Other)
3 2 5
I 1 1 I I 1
if one though that rhe rouching in this act was partly communicative, though you may well decide to assess this example differently
28 care situations were generated by the researchers after discussions with colleagues in the department of Health Studies. Criteria for selection and wording of statements included the need for a diversity of care situations each representing in some degree at least one of the response categories, a non-overlapping of health care contexts, but the inclusion of all main professional practices, including medicine, nursing and para-medicine. The questionnaire was first circulated as a pilot to 8 colleagues and subsequently modified. Several minor changes were made so as to word situations less ambiguously. One more important change was to use two categories ‘pleasure giving’ and ‘pleasure receiving’ instead of the original single category of ‘erotic’, which had caused some confusion, first because it was not clear for whom the contact was ‘erotic’ and second because some respondents doubted the validity (or at least face validity) of such a term on the questionnaire. The selection of these situations therefore, is based on the assumption that respondents would attribute at least one predominant intention from those seen as implicit in the contacts by the researchers themselves. RESULTS
Table 5 shows the response of the sample group as a whole to each of the 28 specified situations. Only the median responses of 2 or greater are included in the table since in the questionnaire the digit 1 was used to signify no intention in any particular category of touch. The care situations are arranged under the categories of intention and, within these categories, by item order according to the questionnaire. The categories of intention thus subsume situations chosen by the researchers supposedly as prime examples of each category. For example. situations 2, 6, 27 (reading horizontally) were selected because the kind of touching described in each was presumed primarily to be communicative. The researchers’ hypothesised scores for each situation are given in brackets.
diagnostic,
and incidental,
It will be seen that there is a broad similarity between the judgements of the researchers’ and those of the sample group, notably as to the primary intentions of the imaginary practitioner in each care situations and on the widespread perception of the practitioners’ intention to communicate by means of touch. Thus most, but not all the situations seem to elicit a fairly high degree of certainty in the perception of the practitioners’ intentions, indicated by a median score of 5 (‘very much’). Jones and Davis [2] use the term ‘correspondence’ to indicate the certainty with which such attributions of intention are made and propose factors which affect the degree of correspondence; these we will discuss later. It is also noticeable that the respondent group used four or more categories to describe intentions in the majority of the situations, when less might have been expected with such brief descriptions. For example INCID was used to qualify 15 of the 28 situations. The professions observed are generally speaking predominantly female and therefore it has not been possible nor realistic to analyse sex differences within the professional groups. For example there are small numbers of male Health Visitors in the U.K. and in Physiotherapy the proportion of males is only approx. 10%. In the professional groups of the present sample the proportion of males is approx. 15% and in the lay groups 27%. However we have focused on professional rather than gender differences although we recognise the possibility of the latter having some effect. A more detailed examination of the use of and support for each category of practitioner intention is now given. The general picture of the judgements of all respondents is qualified where appropriate by reference to observed differences in the ways in which particular professional groups perceived the intention of touching. These differences have been tested by comparing each group with the remainder of the sample using the Median Test [13]. Only if an observed difference reaches a level of significance
Situation
PR
PG
G
ACC
INCID
numbers
subsumed
(3) 3
3
under categories
2
of intention
2
4
3
12
(3) 2
(4) 5
(5) 5
3
(4) 3
23
2
(5) 5
4
(2) 2
7
2
(5) 5
3
(2) 3
2
(4) 3
(5) 4
(3) 4
14
ASS
2
(5) 5
2
(2) 2
20
and 10 categories
hypotheses.
(3) 3
2
(5) 5
3
(4) 3
25
by 28 situations PCARE
to researchers
(5) 5
(3) 3
(3) 3
according
3
4
2
3
18
ASS
2
2
2
8
3
(5) 5
2
26 (3)
(5) 5
II
(5) 5
I
(3) 2
4
5
27
(5) 4
INCID
and lay respondents
P. CARE
___~
6
(5) 5
2
(5) 5
D
(5) 3
~
C
scores of 76 health practitioners
(5) 3
D
C
Categories of intention
Table 5. Median
(5) 5
I6
21
(5) 5
ACC 5
(5) 5
3
5
2
3
(3) 3
of intention
2
(5) 5
4
2
(4) 4
17
G
(5) 4
3
3
(2) 3
28
in touching
(5) 3
2
3
IO
PC
(5) 5
(4) 5
I3
(researchers,
9
.
4
3
2
(3) 3
(3) 2
(5) 2
2 (5) 2
2
2
(2) 4
4
(4) 4
3
2
19 (4) 3
I5
24
(5)
2
2
4
(3) 2
3
(4) 2
(3) 5
PR
(3) 3
(4) 5
22
scores in brackets)
(3) 4
INSTR
hypothesised
The meaning of touch in care practice
P < 0.05 (the probability of it being due to a random effect being less than 1 in 20) is it reported below. Communicative (C)--Situation Nos 2, 6 and 27 Table 5 shows that respondents gave strong support to C as the main intension in each of these three situations. In 2 and 6 PG and PR are also used, situation 6 (nurse cuddles a child) eliciting as much support for PG as for C. This situation evoked some proposals for additional categories. Two of these might reasonably be subsumed under the communicative category (‘reassurance’ and ‘comforting’) while three others (‘aiding treatment’, ‘security’ and ‘restraint’) have a sense of physically controlling the patient. This intention is not included among the researchers’ categories (see Discussion). Respondents consider that C is intended in almost all of the other situations. In these there is exact agreement with the researchers’ values in 5 instances and a difference of one in 12 other instances. In four cases respondents inferred a communicative action where the researchers did not. In one case (No. 26, the vaginal examination) the researchers’ hypothesized intent (C = 3) was not confirmed except by the physiotherapists (C = 2, P < 0.01). There are differences in the strengths of these judgements, however, especially in 3, 13 and 22 where respondents gave C ( = 5) as the primary intention in contrast with researchers’ PG or PR. These reversals will be discussed later. Diagnostic (D)---Situations Nos 1, 11 and 26 In these situations there is almost the maximum possible support for D, only a few responses (13/278) being less than the maximum of 5. The situations are seen also as C, INCID and INSTR to a minor extent. Situations 5, 9 and 15 also attracted support for the D category though not as the practitioner’s primary intention. Physiotherapists, in comparison with the rest of the sample group, generally elevated the importance of diagnostic touch. For example physiotherapist respondents judged situations 9 (median value =4, P < 0.01) and 15 (med. =4, P < 0.001) primarily as D and situations 14 (med = 3, P < O.OOl),23 (med. = 2, P < 0.05) and 28 (med. = 3, P < 0.05) as having some function of D. Incidental (INCID FSituation Nos 8 and 18 This category, described in the questionnaire as “the touch (which) is an integral part of but secondgry or incidental to the practitioner’s therapeutic action” was intended to identify touch which is deliberate, unvoidable but disregarded by the practitioner, as for example in bandaging or undressing the patient. In this the classification shares with ACCIDENTAL the property that other categories of intention are logically excluded if it is used to describe contact at any single point in the encounter. Respondents saw neither situation as solely, mainly or even primarily as INCID, though it received (along with other categories. PCARE, C and ASS) substantial support in both cases. These situations, therefore were more widely categorised and more evenly valued. As can be seen from the table, 13 other situations have a median value >2 for INCID.
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Personal care (PCARE)--Situation 25
Nos 4, 12, 23 and
This category comprises practitioners’ intentions in touching a patient’s body to achieve things that the patient would normally be able to do for himself. In each situation the hypothesised values, both primary and subsidiary were well supported as Table 5 shows. Respondents’ reference beyond this was mainly to INCID and ASS. In other situations PCARE was used on 5 occasions by the group as a whole, while Nurses saw this in situation 6 (med. = 3, P < 0.001) where others did not. Assisting (ASS)-Situation
Nos 7, 14 and 20
Again there was general agreement with the researchers’ primary and secondary values with only minor and limited use of other categories to describe these situations. ASS was by the sample group for 10 other situations; only 2 of these 10 were similarly qualified by the researchers. Accidental (ACC)--Situations Nos 16 and 21 In the two fairly obvious examples of accidental touch there was exact agreement with the researchers’ values. As proposed earlier this category logically excludes other intentions. Nevertheless individual respondents occasionally conceived these instances as intentioned even to the point of attributing diagnostic and instrumental purposes! Guiding (C)-Situation Nos 5, 17 and 28 Responses to these situations in the G and C categories closely followed those predicted by the researchers, though in each case a number of other categories were used. Prominent among these were INCID and ASS perhaps reflecting a relatedness of the three categories. Guding is also observed by the respondent group in other instances, particularly in association with the situations primarily exemplifying ASS and INSTR (7, 14, 20; 9, 15, 19, 24.) Occupational health nurses (situation 12, med. = 4, P < 0.05; situation 27, med. = 3, P < 0.05) and physiotherapists (situation 12, med. = 3, P < 0.05 and other situations close to this level of significance) infer more guiding than other groups in some situations. Pleasure giving (PG)-Situation Nos 10 and 13 This category was well supported in these two situations although some ambivalence is shown about the intention of the female nurse who leans against a male patient. PG, PR and C all have a median value of 3 here, whilst ACC also scores 2. Indeed about half of the respondents gave scores of 2 or more both to PG and ACC. PG was also used to describe 14 other situations, only 7 of which were similarly rated by the researchers. Instrumental (INSTR)-Situation Nos 9, 15, 19 and 24 This category was conceived by the researchers as implying the intention to cause anatomical or physiological change by means of touch or some variation of touch, particularly where it is used in a directly
JOHNW. PRATTand ALLEN MASON
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therapeutic way. Such a notion was apparently either not established or at least employed extensively by the respondent group. Other categories (C, INCID, G, PG) were used with equal or greater emphasis in describing these four situations and every category excepting ACC was used at some point or other. INSTR was also used to describe situations 1, 5, 11 and 28. In two of these (situation 5, med. = 2, P < 0.01; situation 11, med. = 3, P < 0.05) the lay response was significantly different from the remainder of the group. Pleasure receiving (PR)-Situation
Nos 3 and 22
Again these situations were not well supported as intended PR, probably for different reasons than the moderate use of the previous category (see Discussion). Respondents saw these situations primarily as examples of C and to a lesser extent as PG, here agreeing with the researchers, as they did in employing no further categories. PR was further used in four other situations, as compared to only once by the researchers. In situation 3 the low overall response was in spite of the lay groups med. value of 3 for PR (P < 0 15). Nurses seem reluctant to attribute PR to the practitioner. In situations 6 (P < O.Ol), 13 (P < 0.05) and 22 (P < 0.02-the same significance for occupational health nurses in this situation) the nurses’ median responses are significantly lower than the rest of the sample. DISCUSSION This study attempted to reveal the intentions of health practitioners in touching their patients as perceived by a sample containing both positions. It assumed that the 10 categories previously established by the researchers were the main if not the only terms needed to qualify the practitioners’ intentions in a wide variety of health care situations chosen to represent the different contexts in which instances of touching generally occur. Table 5 shows that in 7 out of 10 categories of touching respondents’ median scores were equal to 5 (‘very much’). In other words the majority perceived the situations as revealing clear intentions on the practitioner’s part in these 7 categories. Jones and Davis [2] attempt to explain the certainty with which intentions are attributed to others by means of four factors two of which are concerned with the presence of the observer in the action itself and these therefore will not apply here. However the factors of noncommon effects and social desirability offer some explanation of the above results. The non-common e8kct.s idea is that the fewer possible alternative intentions which might be attributed as leading to a particular action, the more certain is the observer about the attribution he actually makes. In the health care situations described in Table 2 almost all are instances of some kind of helping action and this is inferred and judged as such in attributing the practitioner’s primary intention. Carrying out an oral hygiene routine or combing a patient’s hair are not obviously amenable to attributions other than personal care. Jones and Davis regard behaviour perceived as socially desirable as less likely to be attributed to
some strong disposition of the individual actor. Since most of the instances of touching described here were probably seen by respondents as socially desirable it would appear that relatively strong attributions about the meaning of the touching actions would not be due to this factor. In other cases (INCID, INSTR), practitioners’ intentions were perceived as less strong. These will be examined individually in order to consider the extent to which they may have further use. The INCID category received moderate support in what were intended to be prime examples of this type of touching (8, 18) although respondents made extensive use of it elsewhere. There are several possible explanations for this, none mutually exclusive of others. First, that there is a contradiction inherent’in the researchers’ idea that it is logically possible to make INCID a primary intention of the practitioner. The definition given in the questionnaire refers to the touch that is ‘secondary or incidental to the practitioner’s therapeutic action’ and as mentioned earlier it was assumed that the use of this category would logically exclude the use of other categories, at least for that, presumably brief, touching action. However most respondents did not use INCID as an exclusive category; therefore, when they perceive an action such as moving the patient during bedmaking primarily as, say, PC, it would be inconsistknt, with the above definition in mind, to rate INCID as higher than this. Second, in situations where touching might be labelled INCID the practitioner’s personal motivation or involvement in the action is likely to be perceived as minimal. Therefore firm attributions about his intentions would be more difficult to make. The touching action does not reflect a particular intention which is accounted for by a personal motive or disposition [2]. A third explanation for this moderate use of the INCID category may lie in the time span implied in the descriptions of the given situations. Many of these situations may be crudely placed into two classesbrief contacts of a few seconds (e.g. situations 3, 12, 13 and 16), or extended contacts involving a variety of movements or some kind of routine (e.g. situations 5, 8, 9 and 18). Obviously in situations of the latter type the intention of the practitioner may be thought to vary over the period of the specified activity. In this respect a respondent has to make a collective judgement about the overall quality or qualities of the interaction. In such instances it is less surprising, perhaps appropriate that equal or greater emphasis is given to caring aspects of the touching, as in cases 8 and 18 where respondents have emphasised ASS and PCARE. In future studies it is clearly important to define the instances more precisely-perhaps by means of photographs or videotape. When this is done the INCID category may become more readily applicable. Four situations were provided as examples of INSTR touching; in the results these received little or no support. It is not felt that this category should be abandoned, however as there still substantial reasons for persevering with its use. First there is clearly a great deal of touching in the
The meaning of touch in care practice practice of health care that can properly only be subsumed under such a title as this. Manipulation of muscles and joints including the reduction of dislocations and the repositioning of fractured bones are obvious examples, although most surgical procedures will involve touching. At the other end of the medical spectrum some practitioners are healing by the ‘laying’ on of hands’ a process for which there is increasing evidence of beneficial physiological change [ 141. The present study has clearly failed to identify this as a category of primary intention in the touching action. There are two possible explanations for the failure. One is that in defining the categories in the questionnaire the researchers omitted to give an example of this kind of intention. This oversight could well have resulted both in a vaguer idea of what was meant by INSTR (as compared to the other categories) and a lesser emphasis on the importance of the category. In addition, the definition, given in fairly precise technical terms may not have conveyed, especially to lay respondents, the implication of immediate beneficial change or medical improvement. Thus it is proposed that many respondents may have been unsure about the meaning of INSTR. Beyond this it appears in retrospect that the situations offered under INSTR were probably ambiguous or misleading to some degree. Situations 9 and 15 were, like those discussed earlier, extended in time and requiring some professional knowledge to appreciate the extent and nature of the touching that would normally occur. In situation 15, for example, the lay response was significantly lower than that of the rest of the sample (P < 0.01). Again, in situation 19 the physiotherapists were significantly more appreciative of the INSTR intention in this action (P < O.Ol), while the sample as a whole saw the gentle stroking of the patient’s neck mainly as PG. Finally in explanation of the limited use of INSTR it was unfortunate that three of the four examples used were in the context of physiotherapy. This, too, may have resulted in many of the 67 nonphysiotherapist respondents having less understanding of and interest in the situations there described. The PR category is also worth individual attention since neither of the situations designated by the researchers as PR were seen by the sample as this. The weak responses obtained may have due to the slightly ambiguous situations. Notwithstanding the existence of PR intentions however, actual behaviour of this sort is outside the expectntions of both parties involved in health care transactions. Perhaps mainly because it ought not to happen it is seen not to happen. Further, because intention is usually associated with conscious behaviour no account can be given of the extent to which unconscious wishes are pursued in the contact effected in health care. Possibly, even when such contact is consciously made, neither practitioner nor lay participant would tend to admit or accept that such intentions exist within the relationship. Such behaviour is normally outside a professional code of conduct and would therefore impede the progress of most forms of health care. There are, therefore. strong social pressures against PR behaviour and these are probably reflected in the
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responses to the questionnaire. It is clear that only a minority of respondents (4 in situation 3, I in situation 22) gave the professional’s action as PR rating higher than other categories. Comprehensiveness
of categories
Within the given situations the category names and definitions were apparently comprehensive enough meet respondents’ needs in completing the questionnaire. There was one exception to this already described under the results section (C). Respondents found the need to include a category implying restraint or control. This is a useful addition to the list and obviously appropriate to certain health care situations. Respondents used the ‘other’ category relatively infrequently. Where they did it was usually to convey some more precise version of C (e.g. concern or reassurance). Communication by means of touch could imply a greater diversity of meanings than a study of this kind is capable of differentiating. For this reason the general category of C was used. A further study might consider the following possibilities as examples of information conveyed to patients by means of touch: concern or lack of concern confidence competence consideration caring attitude empathy understanding authority status (see e.g. Henley [15]) assurance reassurance attention offered attention required orientation to outer world anger love. For a discussion of these and other uses see Pratt and Mason [14]. The conclusions drawn from this study of meanings in situations involving touch are to be qualified by the nature of the respondent sample. Obviously the health care practitioners all have the benefit of some form of further or higher education. However, most, if not all of the lay respondents had similar backgrounds (e.g. teacher, lecturer student, engineer). Moreover it is unlikely that potential respondents of low educational attainment or perhaps those from the Registrar General’s Social Class I would be able to complete the questionnaire satisfactorily. Supposing that this were possible-for example by means of individual interviews-it could well be that such a lay response (unlike that of the present sample) was significantly different from that generally of practitioners. There is increasing evidence (as, for example in the recent Black Report [16]) to suggest a gulf between the lower social classes and the uptake of and benefit from health care provision. Attribution of motives to others is, as indicated in the introduction, the subject of now extensive psychological theory. The present study supports the notion
JOHN
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PRATT
that people can and do ascribe motives (or in this case intentions) to others, even without observing the actual physical action. A wide variety of motives was attributed, overall, on the basis of 28 brief descriptions of instances of touching behaviour. The fact that on the whole both groups of practitioners and the group of lay respondents saw broadly similar sets of intention within the touching situation, would seem to imply a commonly accepted purpose or purposes for actors in these situations. Of course the situations described were relatively unambiguous in their content, and therefore not susceptible of many alternative inferences. However there was, in the group’s response to an individual situation, often a wider variety of interpretation among the secondary intentions. Though these differences might seem as potentially disruptive, respondents when in similar situations themselves may well not consider them to be significant enough to disrupt the smooth flow of the practitioner/client interaction. In conclusion it may be said that the proposed categorises of intention, with the qualifications and additions already discussed are valid and may be used to describe modifications most with minor practitioner/client interactions. REFERENCES 1. Heider F. The Psychology of Interpersonal Relations.
Wiley, New York, 1958. 2. Jones E. E. and Davis K. E. From acts to dispositions: the attribution process in person perception. In Ad-
and ALLEN MASON vances in Experimental Psychology (Edited by Berkowitz
L.), Vol. 2. Academic Press, New York. 1965. 3. Kelley H. H. Attribution theory in social psychology. In Nebraska Symposium on Motivation (Edited bv Levine D.), Vol. 15. University of Wisconsin‘Press. W&onsin. 1967. 4. Ashworth P. Social Interaction and Consciousness. Wiley, New York, 1979. 5. Antaki C. (Ed.) The Psychology of Ordinar>, Expltrnations of Social Behaviour. Academic Press. New York. 1981. Bumside L. M. Touching is. Am. J. ‘Vurs. 73, 2060-2063,
1973.
McCorkle R. Effects of touch on senously ill patients. Nurs. Res. 23, 125-132. 1974. Aguilera D. C. Relationship between physical contact and verbal interaction between nurses-and patients. .I. Psvchiat. Nurs. Jan.-Feb.. 6-21. 1967. 9. Burton A. B. and Heller L. G. The touching of the body. Psychoanal. Rev. 51, 122-134, 1964. 10. Mintz E. E. Touch and the psychoanalytic tradition. Psychoanal. Rev. 56, 365-316,
1969.
11. Preston T. When words fail. Am. J. Nurs. 73, 2064-2066, 1973. 12. Watson W. H. The meaning of touch: geriatric nursing. J. Commun. 25, 104-112, 1975. 13. Siegel S. Nonparametric Statistics for the Behavioural Sciences. McGraw-Hill, New York, 1956. 14. Pratt J. W. and Mason A. The Caring Touch. Heyden. New York, 1981. 15. Henley N. M. The politics of touch. In Radical Psychology (Edited by Brown P.). Colophon Press, New York. 1973. 16. Working group on inequalities in health, report (Chairman Sir Douglas Black). DHSS, England, 1980.
THE MEANING Department
1984
0277-9536/84 $3.00 + 0.00 Pergamon Press Ltd
OF TOUCH
IN CARE
PRACTICE
JOHN W PRATT and ALLEN MASON of Health Studies, Sheffield City Polytechnic, 36 Collegiate Crescent, Sheffield SIO 2BP, England
Abstract-76
respondents were asked to categorise 28 specified examples of touching within health care. Broad agreement was found across the sample group as a whole, in its application of 8 of the 10 categories
offered by the researchers. The need for alternative or additional categories and the occasional differences between responses of professional groups are discussed.
INTRODUCTION
There has been relatively little research on the significance of touch in health care, especially in relation to the social aspects of such interaction between practitioner and client. Health consultatiqns, often concerned with the client’s bodily functioning, afford many examples of bodily contact. Indeed the implying a practitioner, i.e. health practitioner qualified medical, para medical or nursing professional, is accorded the right of access to the client’s personal space and his body. Yet within the appar ently straightforward delivery of medical and nursing care there exists, in the act of touching, a variety of purposes and communications. There is an extensive literature on the attribution of intentions or motives, in which the contributions made by Heider [l], Jones and Davis [2] and Kelly [3] are seen as significant [4,5]. In this literature it is generally assumed that motives are sought and subsequently attributed by the perceiver of another’s actions in order to explain that person’s behaviour and thus allow the interaction to continue undisrupted. In this way the attribution of ‘caring’ or ‘diagnostic’ to the touching behaviour of a doctor has important consequences for the way the client then responds. Investigations into the implications of touching in practitioner/client interactions have tended to centre around nursing and psychotherapy and have dwelt on the value of physical contact as a means of communicating, establishing rapport or developing verbal behaviour with clients. For example Burnside [6] employed touch as a means of increasing external stimuli to clients with chronic brain syndrome, in order to observe changes in response level or linguistic coherence. McCorkle [7] found that touch facilitated the gaining of rapport between nurses and seriously ill clients, while Aguilera [8] noted increased verbal interaction with bodily contact. Traditionally psychotherapy is seen as a verbal
The following abbreviations are used for the ten categories of intention as listed in Table 3: C = Communication: D = Diagnostic; INCID = Incidental; PCARE = Personal Care; ASS = Assisting; ACC = Accidental: G = Guiding; PG = Pleasure Giving: INSTR = Instrumental; PR = Pleasure Receiving.
process though there are proponents of bodily contact as an alternative or complementary medium to the verbal [9]. Previous research has treated the implications of touching by a practitioner in such general terms as not to question the intended or inferred meaning of the action in any detail [6, lo]. Other researchers record the effects of touching on observable behaviour [7, 1l] again without reference to the thoughts or feelings of either participant. What, therefore, do professionals mean or intend in their actions of touching, or, more realistically, what do they and others judge such intentions to be? In health care there is little or no research to investigate the meaning of touching behaviour as both professional and personal contacts between practitioner and client. The present study is aimed specifically at revealing generalised intentions of practitioners as perceived by various groups of health professionals and a group of lay respondents. It uses examples of common tactile interactions between practitioner and client in a number of different situations, proposing a detailed categorisation of possible intentions, in contrast, for example to that of Watson [12] who indicated only two-instrumental and expressive. METHOD
There were 76 respondents, comprised as shown in Table 1. Lay respondents were mainly colleagues and acquaintances of the researchers, probably having similar educational backgrounds (see Discussion). They were chosen as not being trained or qualified in the professions of health care, nor having special experience or other connection with health care except as ‘normal’ patient or client. The practitioners were either departmental staff, post registration students in health studies, or from local hospitals and centres. Each respondent was asked to complete a questionnaire which it was estimated would take about one hour, though some respondents reported needing longer. The questionnaire consisted of descriptions of 28 care situations, as listed in Table 2, each of which had to be described by the respondent in terms of 10 categories of possible practitioner intention provided by the researchers, or other category as thought appropriate by the respondent (Tables 3 and 4). The
1081
JOHN W. PRATT and ALLEN MASON Table I. Classification of the 76 respondents Students’ Lay resaondents
8
Practitioners
Nurses 9
*Not of health-related
Teachers”
Housewives
5
3
5 Health visitors 10
by occupation
Lecturers*
Others __~~__~
Occupational therapists 9
Physiotherapists 9
Totals .~~._.
9 Occupational health nurses 9
30
46
Subjects. Table 2. Descriptions of 28 care situations used in the questionnaire Situations
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28.
w’here contact
takes place
In a Rheumatology clinic a patient has complained of pain in the ankle region and the consultant gently probes the area While she is enquiring about the home circumstances, an occupational theraptst holds the band of an elderly patient A psychiatric nurSe puts his hand on a young female patient’s knee as he talks to her On a geriatric ward a nurse (F) combs a patient’s (F) hair A physiotherapist puts a patient through an exercise routine passively prior to doing it with resistance A nurse cuddles a child who is having a plaster cast removed from her leg A physiotherapist and a nurse support a patient who has stumbled and they help her to a chair In an orthopaedic ward, a patient in lower limb traction is having his bed made by two nurses (F) In the gymnasium a physiotherapist (F) acts as a partner for a patient during an exercise session that involves resistance work (M) A student nume leans against a male patient as she is shown a photograph A doctor places both his hands into those of a patient and tells him to grip as hard as he can A patient asks for a drink and a nurse (F) supports his head and gives him a cup of water On a male geriatric ward, a physiotherapist (F) kisses one of the patients on the cheek on the occasion of his birthday An elderly patient is walking down the corridor using a walking aid. A nurse accompanying her puts an arm around the patient’s waist (M) A physiotherapist attempts to reduce the spasticity in a hemiplegic child. She gets on to a treatment mat on the floor with the child Whilst a therapist (M) demonstrates an exercise to a group of patients, his arm comes into contact with the arm of the person nearest to him (F) A blind patient (M) asks the way out and a member of staff (F) takes his forearm and steers him towards the door A patient (M) with the help and advice of an occupational therapist (F), is attempting to put his above-knee prosthesis for the first time A physiotherapist (F) places her hands on a patient’s (M) neck during a relaxation class. and strokes it gently A radiographer (M) helps a patient (M) down from the X-ray table An occupational therapist steadies herself against a patient (M) after having to move out of the way of a trolley After examining a female patient the consultant continues to hold her hand while explaining his findings In Intensive Care, a staff nurse (F) carries out a routine of oral hygiene on a conscious patient (M) In a factory clinic a nurse (F) applies a skin cream to the leg of a patient (M) A nurse (F) bed baths a patient who is unable to wash himself A medical student (M) performs a vaginal examination on a young pregnant woman A sleeping patient (F) is shaken gently by the ward sister (F) as visiting time is about to begin -. 1 . . ,__. A pnySlOttteraplSt (M) COrreCtSa patlent’s (I-‘) posture Table 3. Ten categories of touch as provided on each page of the questionnaire Categories
of touch
Communicative
To convey an idea or a feeling to the patient (often of a carmg attitude) Examples: patting lightly to indicate approval; placing hand on the patient’s Shoulder to express concern Diagnostic
To obtain information about the condition or function of the patient Examples: taking a pulse: feeling for swollen glands Incidental
The touch is an integral part of, but secondary or incidental to the practitioner’s Examples: bandaging; undressing the patient Personal
therapeutic action
care
Carrying out actions on the patient’s body that he would normally do for himself Examples: giving a bed pan; washing a patient’s hair Assisting
When the practitioner acts as an extension of the patient to enable him to obtain some phystcal movement Examples: helping patient up from a chair; assisting in or out of bath Accidental
Contact is not intentional Examples: bumping into another person; standing unavoidably
close as in a crowded lift
Guiding
To indicate a desired movement or to achieve an awareness of some static or dynamic body function Examphs: creating awareness of the affected side in a stroke patient; indicating direction to a blind person Pleasure
giving
To give pleasure to the patient Examples: playfully touching a baby or child; touching a patient’s hair lnstrumentnl
To use a degree of pressure on the patient’s body directly causing anatomical of mechanisms to produce observable changes in function Pleasure
or physiological change: usually involving the activation
receiving
To receive pleasure from touching a patient Examples: deliberately standing so that contact with the patient’s body is achieved: (agam) touching a patient’s hair Other
Please specify any other categortes you can think of that are not wholly included in one or more of the above Take each CARE SITUATION in turn and assess the extent to which each category, in your judgement, applies to the given description. Use the 5-point to do this. remembering that I is used when the category does nut apply, and 5 when it very much applies
The meaning
of
touch in care practice
1083
Table 4. Scale description and example given on page two of the questionnaire The scale to be used for relating the CATEGORIES
of touch to the given CARE SITUATION
is:
I = Not at all L
4 5 = Very much using the intermediate values, 2, 3, 4 as appropriate For example; “A staff nurse (F) swabs a patient’s skin and gives him an injection” might be assessed:
(F) = Female (M) = Male
Communicative Diagnostic Incidental Personal care Assisting Accidental Guiding Pleasure giving Instrumental Pleasure receiving (Other)
3 2 5
I 1 1 I I 1
if one though that rhe rouching in this act was partly communicative, though you may well decide to assess this example differently
28 care situations were generated by the researchers after discussions with colleagues in the department of Health Studies. Criteria for selection and wording of statements included the need for a diversity of care situations each representing in some degree at least one of the response categories, a non-overlapping of health care contexts, but the inclusion of all main professional practices, including medicine, nursing and para-medicine. The questionnaire was first circulated as a pilot to 8 colleagues and subsequently modified. Several minor changes were made so as to word situations less ambiguously. One more important change was to use two categories ‘pleasure giving’ and ‘pleasure receiving’ instead of the original single category of ‘erotic’, which had caused some confusion, first because it was not clear for whom the contact was ‘erotic’ and second because some respondents doubted the validity (or at least face validity) of such a term on the questionnaire. The selection of these situations therefore, is based on the assumption that respondents would attribute at least one predominant intention from those seen as implicit in the contacts by the researchers themselves. RESULTS
Table 5 shows the response of the sample group as a whole to each of the 28 specified situations. Only the median responses of 2 or greater are included in the table since in the questionnaire the digit 1 was used to signify no intention in any particular category of touch. The care situations are arranged under the categories of intention and, within these categories, by item order according to the questionnaire. The categories of intention thus subsume situations chosen by the researchers supposedly as prime examples of each category. For example. situations 2, 6, 27 (reading horizontally) were selected because the kind of touching described in each was presumed primarily to be communicative. The researchers’ hypothesised scores for each situation are given in brackets.
diagnostic,
and incidental,
It will be seen that there is a broad similarity between the judgements of the researchers’ and those of the sample group, notably as to the primary intentions of the imaginary practitioner in each care situations and on the widespread perception of the practitioners’ intention to communicate by means of touch. Thus most, but not all the situations seem to elicit a fairly high degree of certainty in the perception of the practitioners’ intentions, indicated by a median score of 5 (‘very much’). Jones and Davis [2] use the term ‘correspondence’ to indicate the certainty with which such attributions of intention are made and propose factors which affect the degree of correspondence; these we will discuss later. It is also noticeable that the respondent group used four or more categories to describe intentions in the majority of the situations, when less might have been expected with such brief descriptions. For example INCID was used to qualify 15 of the 28 situations. The professions observed are generally speaking predominantly female and therefore it has not been possible nor realistic to analyse sex differences within the professional groups. For example there are small numbers of male Health Visitors in the U.K. and in Physiotherapy the proportion of males is only approx. 10%. In the professional groups of the present sample the proportion of males is approx. 15% and in the lay groups 27%. However we have focused on professional rather than gender differences although we recognise the possibility of the latter having some effect. A more detailed examination of the use of and support for each category of practitioner intention is now given. The general picture of the judgements of all respondents is qualified where appropriate by reference to observed differences in the ways in which particular professional groups perceived the intention of touching. These differences have been tested by comparing each group with the remainder of the sample using the Median Test [13]. Only if an observed difference reaches a level of significance
Situation
PR
PG
G
ACC
INCID
numbers
subsumed
(3) 3
3
under categories
2
of intention
2
4
3
12
(3) 2
(4) 5
(5) 5
3
(4) 3
23
2
(5) 5
4
(2) 2
7
2
(5) 5
3
(2) 3
2
(4) 3
(5) 4
(3) 4
14
ASS
2
(5) 5
2
(2) 2
20
and 10 categories
hypotheses.
(3) 3
2
(5) 5
3
(4) 3
25
by 28 situations PCARE
to researchers
(5) 5
(3) 3
(3) 3
according
3
4
2
3
18
ASS
2
2
2
8
3
(5) 5
2
26 (3)
(5) 5
II
(5) 5
I
(3) 2
4
5
27
(5) 4
INCID
and lay respondents
P. CARE
___~
6
(5) 5
2
(5) 5
D
(5) 3
~
C
scores of 76 health practitioners
(5) 3
D
C
Categories of intention
Table 5. Median
(5) 5
I6
21
(5) 5
ACC 5
(5) 5
3
5
2
3
(3) 3
of intention
2
(5) 5
4
2
(4) 4
17
G
(5) 4
3
3
(2) 3
28
in touching
(5) 3
2
3
IO
PC
(5) 5
(4) 5
I3
(researchers,
9
.
4
3
2
(3) 3
(3) 2
(5) 2
2 (5) 2
2
2
(2) 4
4
(4) 4
3
2
19 (4) 3
I5
24
(5)
2
2
4
(3) 2
3
(4) 2
(3) 5
PR
(3) 3
(4) 5
22
scores in brackets)
(3) 4
INSTR
hypothesised
The meaning of touch in care practice
P < 0.05 (the probability of it being due to a random effect being less than 1 in 20) is it reported below. Communicative (C)--Situation Nos 2, 6 and 27 Table 5 shows that respondents gave strong support to C as the main intension in each of these three situations. In 2 and 6 PG and PR are also used, situation 6 (nurse cuddles a child) eliciting as much support for PG as for C. This situation evoked some proposals for additional categories. Two of these might reasonably be subsumed under the communicative category (‘reassurance’ and ‘comforting’) while three others (‘aiding treatment’, ‘security’ and ‘restraint’) have a sense of physically controlling the patient. This intention is not included among the researchers’ categories (see Discussion). Respondents consider that C is intended in almost all of the other situations. In these there is exact agreement with the researchers’ values in 5 instances and a difference of one in 12 other instances. In four cases respondents inferred a communicative action where the researchers did not. In one case (No. 26, the vaginal examination) the researchers’ hypothesized intent (C = 3) was not confirmed except by the physiotherapists (C = 2, P < 0.01). There are differences in the strengths of these judgements, however, especially in 3, 13 and 22 where respondents gave C ( = 5) as the primary intention in contrast with researchers’ PG or PR. These reversals will be discussed later. Diagnostic (D)---Situations Nos 1, 11 and 26 In these situations there is almost the maximum possible support for D, only a few responses (13/278) being less than the maximum of 5. The situations are seen also as C, INCID and INSTR to a minor extent. Situations 5, 9 and 15 also attracted support for the D category though not as the practitioner’s primary intention. Physiotherapists, in comparison with the rest of the sample group, generally elevated the importance of diagnostic touch. For example physiotherapist respondents judged situations 9 (median value =4, P < 0.01) and 15 (med. =4, P < 0.001) primarily as D and situations 14 (med = 3, P < O.OOl),23 (med. = 2, P < 0.05) and 28 (med. = 3, P < 0.05) as having some function of D. Incidental (INCID FSituation Nos 8 and 18 This category, described in the questionnaire as “the touch (which) is an integral part of but secondgry or incidental to the practitioner’s therapeutic action” was intended to identify touch which is deliberate, unvoidable but disregarded by the practitioner, as for example in bandaging or undressing the patient. In this the classification shares with ACCIDENTAL the property that other categories of intention are logically excluded if it is used to describe contact at any single point in the encounter. Respondents saw neither situation as solely, mainly or even primarily as INCID, though it received (along with other categories. PCARE, C and ASS) substantial support in both cases. These situations, therefore were more widely categorised and more evenly valued. As can be seen from the table, 13 other situations have a median value >2 for INCID.
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Personal care (PCARE)--Situation 25
Nos 4, 12, 23 and
This category comprises practitioners’ intentions in touching a patient’s body to achieve things that the patient would normally be able to do for himself. In each situation the hypothesised values, both primary and subsidiary were well supported as Table 5 shows. Respondents’ reference beyond this was mainly to INCID and ASS. In other situations PCARE was used on 5 occasions by the group as a whole, while Nurses saw this in situation 6 (med. = 3, P < 0.001) where others did not. Assisting (ASS)-Situation
Nos 7, 14 and 20
Again there was general agreement with the researchers’ primary and secondary values with only minor and limited use of other categories to describe these situations. ASS was by the sample group for 10 other situations; only 2 of these 10 were similarly qualified by the researchers. Accidental (ACC)--Situations Nos 16 and 21 In the two fairly obvious examples of accidental touch there was exact agreement with the researchers’ values. As proposed earlier this category logically excludes other intentions. Nevertheless individual respondents occasionally conceived these instances as intentioned even to the point of attributing diagnostic and instrumental purposes! Guiding (C)-Situation Nos 5, 17 and 28 Responses to these situations in the G and C categories closely followed those predicted by the researchers, though in each case a number of other categories were used. Prominent among these were INCID and ASS perhaps reflecting a relatedness of the three categories. Guding is also observed by the respondent group in other instances, particularly in association with the situations primarily exemplifying ASS and INSTR (7, 14, 20; 9, 15, 19, 24.) Occupational health nurses (situation 12, med. = 4, P < 0.05; situation 27, med. = 3, P < 0.05) and physiotherapists (situation 12, med. = 3, P < 0.05 and other situations close to this level of significance) infer more guiding than other groups in some situations. Pleasure giving (PG)-Situation Nos 10 and 13 This category was well supported in these two situations although some ambivalence is shown about the intention of the female nurse who leans against a male patient. PG, PR and C all have a median value of 3 here, whilst ACC also scores 2. Indeed about half of the respondents gave scores of 2 or more both to PG and ACC. PG was also used to describe 14 other situations, only 7 of which were similarly rated by the researchers. Instrumental (INSTR)-Situation Nos 9, 15, 19 and 24 This category was conceived by the researchers as implying the intention to cause anatomical or physiological change by means of touch or some variation of touch, particularly where it is used in a directly
JOHNW. PRATTand ALLEN MASON
1086
therapeutic way. Such a notion was apparently either not established or at least employed extensively by the respondent group. Other categories (C, INCID, G, PG) were used with equal or greater emphasis in describing these four situations and every category excepting ACC was used at some point or other. INSTR was also used to describe situations 1, 5, 11 and 28. In two of these (situation 5, med. = 2, P < 0.01; situation 11, med. = 3, P < 0.05) the lay response was significantly different from the remainder of the group. Pleasure receiving (PR)-Situation
Nos 3 and 22
Again these situations were not well supported as intended PR, probably for different reasons than the moderate use of the previous category (see Discussion). Respondents saw these situations primarily as examples of C and to a lesser extent as PG, here agreeing with the researchers, as they did in employing no further categories. PR was further used in four other situations, as compared to only once by the researchers. In situation 3 the low overall response was in spite of the lay groups med. value of 3 for PR (P < 0 15). Nurses seem reluctant to attribute PR to the practitioner. In situations 6 (P < O.Ol), 13 (P < 0.05) and 22 (P < 0.02-the same significance for occupational health nurses in this situation) the nurses’ median responses are significantly lower than the rest of the sample. DISCUSSION This study attempted to reveal the intentions of health practitioners in touching their patients as perceived by a sample containing both positions. It assumed that the 10 categories previously established by the researchers were the main if not the only terms needed to qualify the practitioners’ intentions in a wide variety of health care situations chosen to represent the different contexts in which instances of touching generally occur. Table 5 shows that in 7 out of 10 categories of touching respondents’ median scores were equal to 5 (‘very much’). In other words the majority perceived the situations as revealing clear intentions on the practitioner’s part in these 7 categories. Jones and Davis [2] attempt to explain the certainty with which intentions are attributed to others by means of four factors two of which are concerned with the presence of the observer in the action itself and these therefore will not apply here. However the factors of noncommon effects and social desirability offer some explanation of the above results. The non-common e8kct.s idea is that the fewer possible alternative intentions which might be attributed as leading to a particular action, the more certain is the observer about the attribution he actually makes. In the health care situations described in Table 2 almost all are instances of some kind of helping action and this is inferred and judged as such in attributing the practitioner’s primary intention. Carrying out an oral hygiene routine or combing a patient’s hair are not obviously amenable to attributions other than personal care. Jones and Davis regard behaviour perceived as socially desirable as less likely to be attributed to
some strong disposition of the individual actor. Since most of the instances of touching described here were probably seen by respondents as socially desirable it would appear that relatively strong attributions about the meaning of the touching actions would not be due to this factor. In other cases (INCID, INSTR), practitioners’ intentions were perceived as less strong. These will be examined individually in order to consider the extent to which they may have further use. The INCID category received moderate support in what were intended to be prime examples of this type of touching (8, 18) although respondents made extensive use of it elsewhere. There are several possible explanations for this, none mutually exclusive of others. First, that there is a contradiction inherent’in the researchers’ idea that it is logically possible to make INCID a primary intention of the practitioner. The definition given in the questionnaire refers to the touch that is ‘secondary or incidental to the practitioner’s therapeutic action’ and as mentioned earlier it was assumed that the use of this category would logically exclude the use of other categories, at least for that, presumably brief, touching action. However most respondents did not use INCID as an exclusive category; therefore, when they perceive an action such as moving the patient during bedmaking primarily as, say, PC, it would be inconsistknt, with the above definition in mind, to rate INCID as higher than this. Second, in situations where touching might be labelled INCID the practitioner’s personal motivation or involvement in the action is likely to be perceived as minimal. Therefore firm attributions about his intentions would be more difficult to make. The touching action does not reflect a particular intention which is accounted for by a personal motive or disposition [2]. A third explanation for this moderate use of the INCID category may lie in the time span implied in the descriptions of the given situations. Many of these situations may be crudely placed into two classesbrief contacts of a few seconds (e.g. situations 3, 12, 13 and 16), or extended contacts involving a variety of movements or some kind of routine (e.g. situations 5, 8, 9 and 18). Obviously in situations of the latter type the intention of the practitioner may be thought to vary over the period of the specified activity. In this respect a respondent has to make a collective judgement about the overall quality or qualities of the interaction. In such instances it is less surprising, perhaps appropriate that equal or greater emphasis is given to caring aspects of the touching, as in cases 8 and 18 where respondents have emphasised ASS and PCARE. In future studies it is clearly important to define the instances more precisely-perhaps by means of photographs or videotape. When this is done the INCID category may become more readily applicable. Four situations were provided as examples of INSTR touching; in the results these received little or no support. It is not felt that this category should be abandoned, however as there still substantial reasons for persevering with its use. First there is clearly a great deal of touching in the
The meaning of touch in care practice practice of health care that can properly only be subsumed under such a title as this. Manipulation of muscles and joints including the reduction of dislocations and the repositioning of fractured bones are obvious examples, although most surgical procedures will involve touching. At the other end of the medical spectrum some practitioners are healing by the ‘laying’ on of hands’ a process for which there is increasing evidence of beneficial physiological change [ 141. The present study has clearly failed to identify this as a category of primary intention in the touching action. There are two possible explanations for the failure. One is that in defining the categories in the questionnaire the researchers omitted to give an example of this kind of intention. This oversight could well have resulted both in a vaguer idea of what was meant by INSTR (as compared to the other categories) and a lesser emphasis on the importance of the category. In addition, the definition, given in fairly precise technical terms may not have conveyed, especially to lay respondents, the implication of immediate beneficial change or medical improvement. Thus it is proposed that many respondents may have been unsure about the meaning of INSTR. Beyond this it appears in retrospect that the situations offered under INSTR were probably ambiguous or misleading to some degree. Situations 9 and 15 were, like those discussed earlier, extended in time and requiring some professional knowledge to appreciate the extent and nature of the touching that would normally occur. In situation 15, for example, the lay response was significantly lower than that of the rest of the sample (P < 0.01). Again, in situation 19 the physiotherapists were significantly more appreciative of the INSTR intention in this action (P < O.Ol), while the sample as a whole saw the gentle stroking of the patient’s neck mainly as PG. Finally in explanation of the limited use of INSTR it was unfortunate that three of the four examples used were in the context of physiotherapy. This, too, may have resulted in many of the 67 nonphysiotherapist respondents having less understanding of and interest in the situations there described. The PR category is also worth individual attention since neither of the situations designated by the researchers as PR were seen by the sample as this. The weak responses obtained may have due to the slightly ambiguous situations. Notwithstanding the existence of PR intentions however, actual behaviour of this sort is outside the expectntions of both parties involved in health care transactions. Perhaps mainly because it ought not to happen it is seen not to happen. Further, because intention is usually associated with conscious behaviour no account can be given of the extent to which unconscious wishes are pursued in the contact effected in health care. Possibly, even when such contact is consciously made, neither practitioner nor lay participant would tend to admit or accept that such intentions exist within the relationship. Such behaviour is normally outside a professional code of conduct and would therefore impede the progress of most forms of health care. There are, therefore. strong social pressures against PR behaviour and these are probably reflected in the
1087
responses to the questionnaire. It is clear that only a minority of respondents (4 in situation 3, I in situation 22) gave the professional’s action as PR rating higher than other categories. Comprehensiveness
of categories
Within the given situations the category names and definitions were apparently comprehensive enough meet respondents’ needs in completing the questionnaire. There was one exception to this already described under the results section (C). Respondents found the need to include a category implying restraint or control. This is a useful addition to the list and obviously appropriate to certain health care situations. Respondents used the ‘other’ category relatively infrequently. Where they did it was usually to convey some more precise version of C (e.g. concern or reassurance). Communication by means of touch could imply a greater diversity of meanings than a study of this kind is capable of differentiating. For this reason the general category of C was used. A further study might consider the following possibilities as examples of information conveyed to patients by means of touch: concern or lack of concern confidence competence consideration caring attitude empathy understanding authority status (see e.g. Henley [15]) assurance reassurance attention offered attention required orientation to outer world anger love. For a discussion of these and other uses see Pratt and Mason [14]. The conclusions drawn from this study of meanings in situations involving touch are to be qualified by the nature of the respondent sample. Obviously the health care practitioners all have the benefit of some form of further or higher education. However, most, if not all of the lay respondents had similar backgrounds (e.g. teacher, lecturer student, engineer). Moreover it is unlikely that potential respondents of low educational attainment or perhaps those from the Registrar General’s Social Class I would be able to complete the questionnaire satisfactorily. Supposing that this were possible-for example by means of individual interviews-it could well be that such a lay response (unlike that of the present sample) was significantly different from that generally of practitioners. There is increasing evidence (as, for example in the recent Black Report [16]) to suggest a gulf between the lower social classes and the uptake of and benefit from health care provision. Attribution of motives to others is, as indicated in the introduction, the subject of now extensive psychological theory. The present study supports the notion
JOHN
1088
W.
PRATT
that people can and do ascribe motives (or in this case intentions) to others, even without observing the actual physical action. A wide variety of motives was attributed, overall, on the basis of 28 brief descriptions of instances of touching behaviour. The fact that on the whole both groups of practitioners and the group of lay respondents saw broadly similar sets of intention within the touching situation, would seem to imply a commonly accepted purpose or purposes for actors in these situations. Of course the situations described were relatively unambiguous in their content, and therefore not susceptible of many alternative inferences. However there was, in the group’s response to an individual situation, often a wider variety of interpretation among the secondary intentions. Though these differences might seem as potentially disruptive, respondents when in similar situations themselves may well not consider them to be significant enough to disrupt the smooth flow of the practitioner/client interaction. In conclusion it may be said that the proposed categorises of intention, with the qualifications and additions already discussed are valid and may be used to describe modifications most with minor practitioner/client interactions. REFERENCES 1. Heider F. The Psychology of Interpersonal Relations.
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