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Affective nursing touch
Affective NursingTouch It can often allay confusion and increase communication, and it always conveys caring. LENNIE SEAMAN Touch is a universal component of practice that is fundamental to the art of nursing. As Weiss contends, the tactile interaction between nurses and patients is important to analyze and appreciate because nurses in their professional role touch patients throughout their lives(l ). We use our touch in both task and nontask-related practice. Touch that is not related to tasks has been termed affective touch by Burnside (2). She maintains that all too frequently nurses view touch as related only to tasks, thus conveying the message " I have to touch you." But if a nurse touches a patient when no task is involved, she is saying clearly, " I don't have to touch you, but 1 want to." Burnside contends that such touching is a powerful therapeutic intervention(3). " It seems logical to assume that the need to be touched continues throughout life and m a y even be intensified by the sensory and personal losses that occur with a g i n g . I have observed that my colleagues in nursing homes frequently employ affective touch, particularly with confused or agitated patients. When asked why, the nurses said that they acted intuitively or that over years of practice they had Lennie Seaman, RN, MSN, is a clinical specialist in geropsychiatry at Marlboro State Hospital, N.J. Previously she had been a charge nurse and inservice instructor at Tower Lodge Skilled Nursing Facility, Wall, N.J.
162Geriatric Nursing May/June 1982
developed a sense of when and how to use affective touch to calm, reassure, or gain the attention of elderly residents. W h a t they have learned is valuable. It needs to be communicated so that the rest of us can eliminate our trial and error method of finding effective nursing interventions for our elderly patients. Huss suggests that the elderly have a greater need for meaningful touch, due to a decrease in visual, hearing, and functional capacities, which limits experiential capacity, and that lack of meaningful touch makes their isolation even more profound(4). The failure of old people to replace lost friends and loved ones leaves them with fewer people to provide touch, Wolanin has said frequently. She states that " T o u c h has a therapeutic value that can be attributed to the placebo effect, which is now solidly based in phys-
"Take My Hand" I was walking down the corridor in the nursing home about seven thirty one morning when ! heard two nurses talking about their concern for one of our patients, Mr. Rosner. I offered to help. We stepped into the room he shared with two other men and ! saw that Mr. Rosner's breathing was deep and labored. A nurse turned the oxygen up higher. W e raised Mr. Rosner to a sitting position and supported him with pillows. Then ! was asked to stay with him. Feeling a little confused, ! held out my hand to him, saying softly, "Take m y hand.? H i s grip was very strong and I had the feeling that he was afraid, i spoke his name again and there was a response, a faint murmur.
iological principles as an arouser of the body's own endorphins, or natural pain relievers'(5). W h y Is T o u c h I m p o r t a n t ?
M o n t a g u contends that, next to the brain, the skin is the most important organ system, and that touch, the sense most closely associated with the skin, is the parent of all other senses, the sense that becomes differentiated into all the others(6). The fetus responds to touch a t about eight weeks of gestation. The fetal skin is stimulated constantly by the amniotic fluid and during labor by the contractions of the uterus. Frank stresses that tactile stimulation during early infancy is extremely important to normal development(7). Because touch is one of the first senses to become functional, the infant uses it as the primary form of communication. As auditory, visual, and kinesthetic sys'TII stay here with you," I said. "Please try to relax." He/vas trembling badly, so I pulled the blanket up and around him, asking if he was warm enough. "Yes," he said, and turned on his right side. He looked more comfortable now. While he was still holding my right hand, with his face resting against my left hand, I s a w s o m e t h i n g sticky on his eyelid. ! told him ! was going to get a warm cloth. 1 hurried back and as I cleansed his eyelids, he smiled up at me and reached for my hand. His breathing was becoming heavy again. ! said soothingly, "i am not going to leave you alone. Just try to breathe a little slower . . . now, take a deep breath and let it out slowly," Again, I tucked the covers around him.
It was very quiet now. His roommates seemed to understand, to be
I
terns mature, the tactile system is gradually superseded, and eventually verbal communication is achieved. Initial tactile experiences assist in the development of internal homeostasis, without which awareness of the external world could not exist. With internal homeostasis, there is a shift from tactile dependence to symbolic c o m m u n i cation through language. Conditioning is the earliest form of learning, based on a stimulusresponse association, according to Preston(8). The infant explores the world through touch. T h e child cannot solve problems but learns by the repetition of actions reinforced by "reward and punishment. M a n y of the early conditioned responses are learned at nonverbal level and seem to persist in advanced age even in the presence of brain d a m ager Ruesch points out that due to the conditioning nature of early learning, nonverbal language takes on particular importance with confused patients in situations where words fail completely(9). Consequently, nonverbal communication, such as touch, m a y be successful when neural pathology prevents comprehension of verbal c o m m u n i cation.
•wlng deep respect in their quiet
!y.
His lips looked dry, parched. 1 ~ned his bedside cabinet drawer to ',k for cream and, for once, there s a tube of ointment. I applied a itll amount to his lips. His eyes had sed, but his grip was still strong on 'hand. !'he supervisor and another nurse ne into the room. As they turned :k the covers to take his pulse and od pressure, 1 noticed how mottled flesh had become. Quietly we eed Mr. Rosner to a private room, itioned him, and straightened the ers, trying to make him as cornable as possible. ,lone with him, again, it was absoly still except for his breathing !a cough now and then. His eyes e open now, staring at something 9 my left shoulder9 He still held hand but I found m y s e l f breathing
The human need to touch, as well as to be touched, persists throughout life. Here, Ada Oakerson. 100 last August, reaches out in affection to staff member Melinda Thornburg.
To date, nursing research has focused primarily on task-related touch. T h e effects of touch on selfappraisal and interactional appraisal a m o n g p e r m a n e n t l y institutionalized older adults have been examined. C opstead c o m p a r e d the responses of 22 patients receiving touch from the nurse in connection with taking medications with 11 who did not receive touch(10). T h e researcher documented a statistically significant positive correlation between frequency of touch and subsequent positive self-appraisal. This result suggests that nurses can use task-related touch
with him. And then he stopped breathing and his grip slipped away. l called out for the head nurse, who c a m e within seconds. "He stopped breathing," I told her. But just then he took another breath.
My eyes filled with tears and for a few seconds I wanted to leave the room, but I just couldn't. All the nurses in white were in the room now. The head nurse put the stethoscope to his chest. She shook her head. I said to myself, "Breathe, breathe! " .but there was no sound. The time of death was 8:30 A.M. It
had been only a little while---or perhaps a long hour--to m y patient. But
effectively to foster positive self regard. Barnett surveyed the use of touch by 900 health care providers with 540 patients in a general hospital. She reported that the 66- to 100year-old group was touched least frequently. Barnett further reported that decreased self-esteem, fear of death, anxiety, altered body image, sense of isolation, dependency, sense of rejection, depersonalization, and regression increased the need for touch(11). M c C o r k l e ' s 1974 study on the effect of touch or nontouch on 60 seriously ill patients in a general hospital d e m o n s t r a t e d that the nurse can establish rapport with a seriously ill patient in a relatively short time through the use of touch(12). O f the 30 patients touched by the nurse (the experimental group), 28 responded positively to the nursepatient interaction; 21 of the control group, who were not touched, responded positively. Analysis of the data suggested that although patients m a y not be a w a r e of the nurse's touch, they m a y be more a w a r e of the nurses' concern, caring, and interest when touch is employed.
he did know someone was with him,
I m p l i c a t i o n s for P r a c t i c e
just to hold his hand. I am thankful
T h e literature suggests that touch is beneficial, conveys a message of acceptance and caring, and encourages nurse-patient rapport and patient well-being. It is, however, essential to consider individu-
that in those last m o m e n t s I could be
a little comfort to him.--Beatrice L. Hurtt, certified nurse's aide, Centerville Nursing and Convalescent Home, Inc., Mass.
al preferences. Not every person is comfortable with touch. The very elderly, for instance, grew up in an era when the touch and even sight of certain body areas by another person were taboo. Burnside points out that "nonaffectionate persons may be threatened by affectionate persons"(2). She suggests that a simple handshake may be the most appropriate form of touch with new patients. Further, much can be learned from grasping a person's hand, such as warmth, clamminess, perspiration, arthritis, p a l s y , and very thin hands. Does the person cling or want to release his hand immediately? The answer may provide clues about the elderly person's degree of dependence and need for touch(2). Burnside cautions that one should never pat the head of an elderly person seated in a wheelchair. This gesture, frequently used in dealing with small children, can be seen as patronizing. She also calls attention to the physical barriers in the institutional setting that tend to decrease sensory input. Geriatric chairs and wheelchairs make it diffucult to touch the elderly person. Beds with side rails tend to wall off elderly patients from physical contact with others(2). Unless repeated contact through touch is made with regressed patients, they will continue to withdraw(8). And if there is an inability to speak, the isolation is even more profound. Because nonverbal communication appears to be retained in the confused person after more complex behaviors no longer exist, nurses can endeavor to maintain contact with the confused, regressed patient through f r e q u e n t affective touch. I recall an elderly nursing home resident, Ms. Eggley, who had been confused for many years but relatively content through her companionship with another resident. Arm in arm, the two women walked the corridors, chatting happily. Following her friend's death, Ms. Eggley's condition became so deteriorated that her speech was
164 Geriatric Nursing May/June 1982
garbled and she could no longer walk, or toilet or feed herself. At night she frequently screamed and shook the bed rails violently. Bathing, positioning, and speaking to her did little to calm her. Various sedatives were prescribed, but without success. Her agitation continued for nearly an hour after the medicine was given, and the next day she would have a drug hangover and do little but sleep. One night I gently released her hand from the side rail she was shaking. Holding her hand firmly, I stroked her arm with my other hand. The screaming stopped within minutes and her tense muscles relaxed. Soon she was sleeping. By using touch, Burnside increased appropriate verbal communication and eye contact in a small. group of elderly patients with chronic brain syndrome, using touch as the primary intervention(13). She shook each patient's hand at the beginning and end of each group meeting. Frequently she placed her hand on the person's shoulder when speaking to him. Findings regarding the use of affective touch suggest that it should be included in the patient care plan. Nurses need to communicate the responses of patients to their touch during nursing rounds or report. If a nurse finds that her touch calmed a disoriented person during the night hours, giving this information to nursing colleagues will encourage them to continue the intervention. Touch--affective or task related----could well be more relaxing than a sedative or tranquilizer. During extensive work with dying patients, Kiibler-Ross documented that a most meaningful nurse-patient communication was gentle pressure of the hand during moments of silence. She also observed that as the dying person accepts his terminal illness, communication becomes increasingly nonverbal(l 4). I clearly recollect caring for an elderly woman who was in coma and quite near death. After completing her physical care, I held her hand for a few moments. To my
surprise, she gave my hand a short but very firm squeeze. Not long afterward she died. Previously, I had never realized that a person so near death and seemingly out of contact with the environment could respond to the touch of another. Since that time, I have made affective touch part of my care for all who are unconscious or near death. The selective use of affective touch to enter the personal space of the elderly person in a gentle and reassuring manner is therapeutic. If we neglect or avoid touching elderly patients, we may imply that the patient is untouchable, thus reinforcing feelings low self-worth and society's pejorative view of aging. Used with care and sensitivity, affective nursing touch may be especially therapeutic for the institutionalized aged person. It can convey acceptance and empathy, increase communication w i t h , or calm, the confused or agitated patient, and help to halt the cycle of confused rambling speech. References I. Weiss, S.J. The language of touch. IVur$.Res. 28:76, Mar.-Apr. 1979 2. Burnside, I. M., ed. Nursing and the Aged. 2nd ed. New York, McGraw-Hill Book Co., 1981, p. 51 I. 3. . Nursing and the Aged. New York, McGraw Hill Book Co., 1976, pp. 160161. 4. Huss, A. J. 1976 Eleanor Clarke Slagle Lecture: touch with care or caring touch? Am.J.Occup.Ther. 31: l l -Ig, Jan. 1977. 5. Wolanin," M. O. The older adult and drug therapy. Part I. Geriatr.Nurs. 2:410, Nov.* Dec. 1981. 6. Montagu, A. Touching: The Human Significance o f the Skin. New york, Columbia University Press, 1971, p. I, 2. 7. Frank, L. K. Tactile communication. Genet.PsyclloLMonogr. 56:229. 231, Nov. 1937. 8. Preston, T. Caring for the aged: when words fail. Am.J.Nurs. 73:2065, Dec. 1973. 9. Ruesch, Jurgen, and Kees. Weldon, Nonverbal Communication. Berkeley, University of California Press, 1956, pp. 189-190. 10. Copstead, L. E. Effects of touch on selfappraisal and interaction appraisal for permanently institutionalized older adults. J.Gerontol.Nur$. 6:747-752, Dec. 1980. I I. McCorkle, R. Effect of touch on seriously ill patients. Nurs.Res. 23:129-130, Mar.-Apr. 1974. 12. Barnett, K. A survey of the current utilization of touch by health team personnel with hospitalized patients, lnt.J.Nurs.Stud. 9:207, Nov. 1972. 13. Kiibler-Ross, Elisabeth. On Death and Dying. New York, Macmillan Co., 1975, p. 100.
162Geriatric Nursing May/June 1982
developed a sense of when and how to use affective touch to calm, reassure, or gain the attention of elderly residents. W h a t they have learned is valuable. It needs to be communicated so that the rest of us can eliminate our trial and error method of finding effective nursing interventions for our elderly patients. Huss suggests that the elderly have a greater need for meaningful touch, due to a decrease in visual, hearing, and functional capacities, which limits experiential capacity, and that lack of meaningful touch makes their isolation even more profound(4). The failure of old people to replace lost friends and loved ones leaves them with fewer people to provide touch, Wolanin has said frequently. She states that " T o u c h has a therapeutic value that can be attributed to the placebo effect, which is now solidly based in phys-
"Take My Hand" I was walking down the corridor in the nursing home about seven thirty one morning when ! heard two nurses talking about their concern for one of our patients, Mr. Rosner. I offered to help. We stepped into the room he shared with two other men and ! saw that Mr. Rosner's breathing was deep and labored. A nurse turned the oxygen up higher. W e raised Mr. Rosner to a sitting position and supported him with pillows. Then ! was asked to stay with him. Feeling a little confused, ! held out my hand to him, saying softly, "Take m y hand.? H i s grip was very strong and I had the feeling that he was afraid, i spoke his name again and there was a response, a faint murmur.
iological principles as an arouser of the body's own endorphins, or natural pain relievers'(5). W h y Is T o u c h I m p o r t a n t ?
M o n t a g u contends that, next to the brain, the skin is the most important organ system, and that touch, the sense most closely associated with the skin, is the parent of all other senses, the sense that becomes differentiated into all the others(6). The fetus responds to touch a t about eight weeks of gestation. The fetal skin is stimulated constantly by the amniotic fluid and during labor by the contractions of the uterus. Frank stresses that tactile stimulation during early infancy is extremely important to normal development(7). Because touch is one of the first senses to become functional, the infant uses it as the primary form of communication. As auditory, visual, and kinesthetic sys'TII stay here with you," I said. "Please try to relax." He/vas trembling badly, so I pulled the blanket up and around him, asking if he was warm enough. "Yes," he said, and turned on his right side. He looked more comfortable now. While he was still holding my right hand, with his face resting against my left hand, I s a w s o m e t h i n g sticky on his eyelid. ! told him ! was going to get a warm cloth. 1 hurried back and as I cleansed his eyelids, he smiled up at me and reached for my hand. His breathing was becoming heavy again. ! said soothingly, "i am not going to leave you alone. Just try to breathe a little slower . . . now, take a deep breath and let it out slowly," Again, I tucked the covers around him.
It was very quiet now. His roommates seemed to understand, to be
I
terns mature, the tactile system is gradually superseded, and eventually verbal communication is achieved. Initial tactile experiences assist in the development of internal homeostasis, without which awareness of the external world could not exist. With internal homeostasis, there is a shift from tactile dependence to symbolic c o m m u n i cation through language. Conditioning is the earliest form of learning, based on a stimulusresponse association, according to Preston(8). The infant explores the world through touch. T h e child cannot solve problems but learns by the repetition of actions reinforced by "reward and punishment. M a n y of the early conditioned responses are learned at nonverbal level and seem to persist in advanced age even in the presence of brain d a m ager Ruesch points out that due to the conditioning nature of early learning, nonverbal language takes on particular importance with confused patients in situations where words fail completely(9). Consequently, nonverbal communication, such as touch, m a y be successful when neural pathology prevents comprehension of verbal c o m m u n i cation.
•wlng deep respect in their quiet
!y.
His lips looked dry, parched. 1 ~ned his bedside cabinet drawer to ',k for cream and, for once, there s a tube of ointment. I applied a itll amount to his lips. His eyes had sed, but his grip was still strong on 'hand. !'he supervisor and another nurse ne into the room. As they turned :k the covers to take his pulse and od pressure, 1 noticed how mottled flesh had become. Quietly we eed Mr. Rosner to a private room, itioned him, and straightened the ers, trying to make him as cornable as possible. ,lone with him, again, it was absoly still except for his breathing !a cough now and then. His eyes e open now, staring at something 9 my left shoulder9 He still held hand but I found m y s e l f breathing
The human need to touch, as well as to be touched, persists throughout life. Here, Ada Oakerson. 100 last August, reaches out in affection to staff member Melinda Thornburg.
To date, nursing research has focused primarily on task-related touch. T h e effects of touch on selfappraisal and interactional appraisal a m o n g p e r m a n e n t l y institutionalized older adults have been examined. C opstead c o m p a r e d the responses of 22 patients receiving touch from the nurse in connection with taking medications with 11 who did not receive touch(10). T h e researcher documented a statistically significant positive correlation between frequency of touch and subsequent positive self-appraisal. This result suggests that nurses can use task-related touch
with him. And then he stopped breathing and his grip slipped away. l called out for the head nurse, who c a m e within seconds. "He stopped breathing," I told her. But just then he took another breath.
My eyes filled with tears and for a few seconds I wanted to leave the room, but I just couldn't. All the nurses in white were in the room now. The head nurse put the stethoscope to his chest. She shook her head. I said to myself, "Breathe, breathe! " .but there was no sound. The time of death was 8:30 A.M. It
had been only a little while---or perhaps a long hour--to m y patient. But
effectively to foster positive self regard. Barnett surveyed the use of touch by 900 health care providers with 540 patients in a general hospital. She reported that the 66- to 100year-old group was touched least frequently. Barnett further reported that decreased self-esteem, fear of death, anxiety, altered body image, sense of isolation, dependency, sense of rejection, depersonalization, and regression increased the need for touch(11). M c C o r k l e ' s 1974 study on the effect of touch or nontouch on 60 seriously ill patients in a general hospital d e m o n s t r a t e d that the nurse can establish rapport with a seriously ill patient in a relatively short time through the use of touch(12). O f the 30 patients touched by the nurse (the experimental group), 28 responded positively to the nursepatient interaction; 21 of the control group, who were not touched, responded positively. Analysis of the data suggested that although patients m a y not be a w a r e of the nurse's touch, they m a y be more a w a r e of the nurses' concern, caring, and interest when touch is employed.
he did know someone was with him,
I m p l i c a t i o n s for P r a c t i c e
just to hold his hand. I am thankful
T h e literature suggests that touch is beneficial, conveys a message of acceptance and caring, and encourages nurse-patient rapport and patient well-being. It is, however, essential to consider individu-
that in those last m o m e n t s I could be
a little comfort to him.--Beatrice L. Hurtt, certified nurse's aide, Centerville Nursing and Convalescent Home, Inc., Mass.
al preferences. Not every person is comfortable with touch. The very elderly, for instance, grew up in an era when the touch and even sight of certain body areas by another person were taboo. Burnside points out that "nonaffectionate persons may be threatened by affectionate persons"(2). She suggests that a simple handshake may be the most appropriate form of touch with new patients. Further, much can be learned from grasping a person's hand, such as warmth, clamminess, perspiration, arthritis, p a l s y , and very thin hands. Does the person cling or want to release his hand immediately? The answer may provide clues about the elderly person's degree of dependence and need for touch(2). Burnside cautions that one should never pat the head of an elderly person seated in a wheelchair. This gesture, frequently used in dealing with small children, can be seen as patronizing. She also calls attention to the physical barriers in the institutional setting that tend to decrease sensory input. Geriatric chairs and wheelchairs make it diffucult to touch the elderly person. Beds with side rails tend to wall off elderly patients from physical contact with others(2). Unless repeated contact through touch is made with regressed patients, they will continue to withdraw(8). And if there is an inability to speak, the isolation is even more profound. Because nonverbal communication appears to be retained in the confused person after more complex behaviors no longer exist, nurses can endeavor to maintain contact with the confused, regressed patient through f r e q u e n t affective touch. I recall an elderly nursing home resident, Ms. Eggley, who had been confused for many years but relatively content through her companionship with another resident. Arm in arm, the two women walked the corridors, chatting happily. Following her friend's death, Ms. Eggley's condition became so deteriorated that her speech was
164 Geriatric Nursing May/June 1982
garbled and she could no longer walk, or toilet or feed herself. At night she frequently screamed and shook the bed rails violently. Bathing, positioning, and speaking to her did little to calm her. Various sedatives were prescribed, but without success. Her agitation continued for nearly an hour after the medicine was given, and the next day she would have a drug hangover and do little but sleep. One night I gently released her hand from the side rail she was shaking. Holding her hand firmly, I stroked her arm with my other hand. The screaming stopped within minutes and her tense muscles relaxed. Soon she was sleeping. By using touch, Burnside increased appropriate verbal communication and eye contact in a small. group of elderly patients with chronic brain syndrome, using touch as the primary intervention(13). She shook each patient's hand at the beginning and end of each group meeting. Frequently she placed her hand on the person's shoulder when speaking to him. Findings regarding the use of affective touch suggest that it should be included in the patient care plan. Nurses need to communicate the responses of patients to their touch during nursing rounds or report. If a nurse finds that her touch calmed a disoriented person during the night hours, giving this information to nursing colleagues will encourage them to continue the intervention. Touch--affective or task related----could well be more relaxing than a sedative or tranquilizer. During extensive work with dying patients, Kiibler-Ross documented that a most meaningful nurse-patient communication was gentle pressure of the hand during moments of silence. She also observed that as the dying person accepts his terminal illness, communication becomes increasingly nonverbal(l 4). I clearly recollect caring for an elderly woman who was in coma and quite near death. After completing her physical care, I held her hand for a few moments. To my
surprise, she gave my hand a short but very firm squeeze. Not long afterward she died. Previously, I had never realized that a person so near death and seemingly out of contact with the environment could respond to the touch of another. Since that time, I have made affective touch part of my care for all who are unconscious or near death. The selective use of affective touch to enter the personal space of the elderly person in a gentle and reassuring manner is therapeutic. If we neglect or avoid touching elderly patients, we may imply that the patient is untouchable, thus reinforcing feelings low self-worth and society's pejorative view of aging. Used with care and sensitivity, affective nursing touch may be especially therapeutic for the institutionalized aged person. It can convey acceptance and empathy, increase communication w i t h , or calm, the confused or agitated patient, and help to halt the cycle of confused rambling speech. References I. Weiss, S.J. The language of touch. IVur$.Res. 28:76, Mar.-Apr. 1979 2. Burnside, I. M., ed. Nursing and the Aged. 2nd ed. New York, McGraw-Hill Book Co., 1981, p. 51 I. 3. . Nursing and the Aged. New York, McGraw Hill Book Co., 1976, pp. 160161. 4. Huss, A. J. 1976 Eleanor Clarke Slagle Lecture: touch with care or caring touch? Am.J.Occup.Ther. 31: l l -Ig, Jan. 1977. 5. Wolanin," M. O. The older adult and drug therapy. Part I. Geriatr.Nurs. 2:410, Nov.* Dec. 1981. 6. Montagu, A. Touching: The Human Significance o f the Skin. New york, Columbia University Press, 1971, p. I, 2. 7. Frank, L. K. Tactile communication. Genet.PsyclloLMonogr. 56:229. 231, Nov. 1937. 8. Preston, T. Caring for the aged: when words fail. Am.J.Nurs. 73:2065, Dec. 1973. 9. Ruesch, Jurgen, and Kees. Weldon, Nonverbal Communication. Berkeley, University of California Press, 1956, pp. 189-190. 10. Copstead, L. E. Effects of touch on selfappraisal and interaction appraisal for permanently institutionalized older adults. J.Gerontol.Nur$. 6:747-752, Dec. 1980. I I. McCorkle, R. Effect of touch on seriously ill patients. Nurs.Res. 23:129-130, Mar.-Apr. 1974. 12. Barnett, K. A survey of the current utilization of touch by health team personnel with hospitalized patients, lnt.J.Nurs.Stud. 9:207, Nov. 1972. 13. Kiibler-Ross, Elisabeth. On Death and Dying. New York, Macmillan Co., 1975, p. 100.