Is therapeutic touch a valid nursing method?
Therapeutic Touch (TT) is a skill that nurses use in daily practise although little research has been done in this area, thus creating a gap that has made it possible for a novice researcher to explore this topic (Hawley, 2007). TT is considered to be a holistic way of treating clients by consciously directing a process of energy exchange during which the practitioner uses the hands as a focus to facilitate healing. Healing is considered to be of utmost importance in nursing as it aims at improving the quality of life for clients. (Sayre-Adams & Wright, ………). Healing is considered to be core to healthcare, and is part of every healthcare practitioner’s work to some degree whether consciously so or not. The basis of this research is to find out how far mental health nurses can use physical touch with people who experience mental health needs because this is a nursing practise that I have observed in different clinical settings. As a novice researcher I was uncertain if this method can be applied to mental health nursing. TT is of interest to the author and the research has made it possible for the author to gain more knowledge in how this nursing intervention can be used. There are a number of reasons for choosing this topic, one of which is because Gleeson and Higgins (2009) found out that TT is debatable because from reading around this topic the author noted that some scholars dispute the validity of this practice. Macnee & McCabe (2008) state that research seeks to gather information so as to understand or learn something. In doing a research in TT the author aims at obtaining knowledge that will be valuable to the nursing profession and make it a safe and open method for nurses to use without any fears or concerns.
Burns & Grove (2005) state that, nursing studies are conducted by examining subjects in interaction with their environment. They further noted that when research involves people, nothing is completely predictable. The author agrees with preceding statements but also argue that for an intervention to be a valid nursing practice, then more research is needed to confirm its use. I will evaluate the strengths and limitations of using TT in mental health nursing and explain why I chose this topic, the method used, the research strategy used and ethical issues will be explained in detail. Polgar and Thomas (2000) explained that a qualitative approach is the traditional research methodology of nursing is mainly concerned with practical theories. Questionnaires will be carried out with six registered mental health nurses who were randomly selected to participate in the study both male and female. Parahoo (2006) argues that randomised control is seen as a gold standard in research.
Watson (2006) distinguished between two kinds of physical touch: instrumental and expressive. Their findings indicated that physical touch was used in mental health nursing, however, it was only considered to be therapeutic to clients if used judiciously, with effective interpersonal skills. Practitioners using TT should communicate well with their clients and seek consent before touching them. In partaking in TT practitioners must be aware of client needs like cultural background.
Dziopa and Ahern (2010) state that the investigators found that a therapeutic relationship in advanced mental health nursing could be deconstructed to humanistic qualities which are fundamental to the successful use of TT in clients with mental health illness as they are vital aids of recovery. Rober et al (2001) state that a significant issue in this study was male participants concerns that touching female clients would be misinterpreted as a sexual advance, so to protect themselves, male participants used touch in a cautious and minimal manner, and only in a public. Space, where others could view the interaction. This has been the main setback in using TT as a nursing intervention to male mental health nurses in fear of being misinterpreted of being unprofessional.
Therapeutic, touch, mental health nursing.
From the search history the author noted that it is not possible to make any major claims because there is limited published research in this topic.
A search was conducted through the electronic search databases CINAHL, MEDLINE/PUBMED, and PSYCH INFO. The keywords used were therapeutic, touch, and mental health nursing. Boolean operators were used to narrow the results. Research literature between the years 1998-2010 was accessed as this is a phase which marks some of the published research done in TT. The literature review yielded five research studies (appendix 2).
List of articles chosen (see appendix 1 for both papers)
The author has chosen work by Salzmann-Erikson (2005) and another paper by Rosa, Rosa, Sarner & Barrett (1998). I chose these two papers because the article by Salzmann-Erikson (2005) supports TT but the other by Rosa et el (1998) dispute the use of this intervention as in their results reveal. I chose these articles because the authors searched extensively and gathered a lot of valid information TT. The paper by Rosa et al (1998) is explained in more detail and so gives more valuable information on TT. The researchers incorporated ethical issues that were identified and considered for their work. Both researches were qualitative in nature but Rosa et al (1998) also used a bit of quantitative information to stress facts, this helps novice researchers to understand both styles of approach. Parahoo (2006) states that statistical data and research findings can provide valuable back- up for the arguments put forward by the researchers for their studies.
Discussion on literature review
The Chief Nursing Officer’s review of mental health nursing (2006) states that research is important in healthcare today as it is part of the evidence-based practice that underpins nursing. With this in mind practitioners in mental health nursing feel challenged to research more on topics involving their practice, some of which are debatable and therefore are open for more researchers to dwell in the topics. Wood & Haber (2006) explained that the author must be clear that the qualitative approach is the best way to answer the research question. Polgar and Thomas (2000) explained that prior to actually carrying out a research study the researcher would implement a literature search and review to justify the need for the research to take place. The author read widely on the topic of TT to find out how different researchers have acknowledged it as a practice that is a vital nursing intervention. However not all research is relevant and so a broader search is needed for the future progress of the intervention. Burnard & Morrison (1994) point out that writing up a literature review is not simply to list all the books and papers that you have read but to do so critically. The ideal principle would be to validate the information gathered putting it to practice.
The author also investigated the extent of evidence available and areas where further research is required (see Appendix 3). Wharton & Pearson (1988) state that the need for touch is core of who we are as human beings. It is believed that touching enhances a sense of understanding between the practitioner and the client. Krieger, Gelder & Kunz (1970) emphasise that a gentle touch brings a flood of warmth and vitality that conveys physical, emotional and psychological support and healing.
*Krieger et al, developed Therapeutic Touch in the early 1970's. The two guiding principles of TT are compassion and intentionality. Krieger et al (1970) found that TT is a scientifically based healing practice in which the human being is viewed as a complex, dynamic whole and healing is seen as the means of restoring integrity of the body, mind, emotion and spirit. However some authors like Rosa et al (1998) do not believe it is scientific approach of nursing and so do not acknowledge it as an intervention that can be used by practitioners. Krieger et al (1970) argue that TT makes the client feel energised and if successfully done, the system directs itself to a healthier pattern. Findings from their research suggest that therapeutic touch may be effective for management of symptoms like restlessness, anxiety and other mental illness. These are some of the symptoms that most of our mental health service users present with. *
Gleeson & Higgins (2009) emphasise that, the interventions are easy to learn to use and can be an alternative to drug treatment for people with behavioural symptoms. For some clients there is a need for other therapies to be used to help their recovery and TT has proved to be one of them. Krieger et al (1970) support TT in that it allows the patient to be treated holistically and believe that the use of TT gives the patient another method of treatment method when others have failed or are ill suited.
In summary, the results of the literature review seem to support that TT is an effective intervention, whether for pain, stress, or anxiety. Autton (1989) points out that the literature suggests that use of TT can aid in recovery of a patient's physiological and psychological homeostasis.
Pollit & Hungler (1999) identified that a research critique is not just a summary of a study; rather it is a careful, critical appraisal of the strengths and limitations of a piece or research. The author will critically analyse the two researches chosen and make a conclusion based on analysing information from the papers. The author will use Polgar & Thomas (2000) guidelines specific to critical evaluation of quantitative research papers. Rosa et al (1998) research will be referred to as article 1 and the other one by Eriksson & Salzmann-Erikson (2005) be article 2. Polgar & Thomas (2008) suggest that before embarking on a research, the investigator must review previous work and publications relevant to the aims of the intended research as this process is essential, both for providing the appropriate background to justify the investigation in existing knowledge. Pollit & Hungler (1999) (see appendix 3) agree that the critique can be divided into sections. The author will follow the way the sections are listed in critiquing the two articles.
Both papers are relevantly titled giving the focus and nature of their studies. Article 1 title is open for discussion and more reading. This shows that the researcher’s findings were not biased to support the use of TT. Article 2 puts it in way that it is easy to judge that their study was in support of TT. Doordan (1998) states that a critique is an evaluation of the strengths and weaknesses of a study.
Authors for article 2 are from health and social care backgrounds as their areas of practice and qualifications are shown. Polit and Hungler (1997) argue that this leads to a less chance of researcher bias as credibility is maintained. Authors for article 1 are from different backgrounds and one of the researchers is a student which can bring the question of credibility and criticism to their work. A novice researcher cannot put equal effort in collecting data and writing out the research as the others. For authors of article 1 to put strong facts would mean that other researchers would have supported and validated the information that the student was collecting.
Article 1 is well structured giving more detailed guiding principles with subheadings to the different stages in their research. They briefly give the context, objective, design, main outcome measures. The authors then give a short introduction and also give background information of their study. They also give a hypothesis of their study which is a strong background of doing a research. Their sections are all well laid out with subheadings and explanations thereafter. Paper 1 even incorporates follow-up test results which are considered to be an important part of ethical issues in research. However article 2 stages were less elaborative but more explorative in nature. The literature analysis in article 1 is well laid out and referenced showing the extensive gathering of data collection. They also used triangulation on data collection to acknowledge the phenomenon of the study (.Pollit & Hungler 1999). However article 2 does not put headings but merged most of the things and so ended with fewer stages clearer and more explained
The procedure of data collection was all explained in detail in article 1 to the extent of using video taping. The research shows that the authors even allowed the use of experiments and recorded all their findings. The method used was quite detailed but some with negative responses from the participants. In the method the authors use an illustrative diagram to clarify facts. In article 2 the method and research procedures are merged. The authors briefly explain how the verbatim interviews of six participants were recorded and transcribed (Rosa et al 1998). Article 1 showed their results, thus using a bit of quantitative information and even show the follow up test results article 1 used statistics and tables to record their findings. Paper 1 uses questionnaires and experimental evidence in their finding and they had sampling of 28 participants while article 2 used verbal and written interviews on a sample of 7 participants. Both papers explained in detail how the participants were chosen. Slade (2002) stipulates that there will be bias as to what gets included or left out.
Both articles incorporated the use of ethical issues in their research showing its importance in research. Their conclusions differ in that they came up with differing findings from their results leading to different implications. Some of their references are the same with paper 2 researches acknowledging the future use TT.
The author has analysed information from both papers and agree with the methods they used in conducting their researches. Both followed ethical guidelines while embarking on their work. Additionally both papers have presented with similar results from their findings though paper 1 showed that their facts were not biased towards the effectiveness of TT as a nursing intervention. Paper 1 had authors from different backgrounds some out of health care which make their work debatable. Also in interpreting their results it is difficult to validate their findings as some of them, especially the experiments were not done in a therapeutic manner. However, the author has noticed that in conducting a research they need not be biased towards one school of thought but be open to different results and endeavour to explore the topic. The researchers agree that TT has proven to reduce some of the symptoms associated with mental health illness. Paper 2 used a small sample in their research but with good results. As such, the papers showed that TT is still a datable issue especially with researchers outside clinical practice. Furthermore, TT has proven to be a familiar practice in form of non medicinal therapy which was recommended for practice from a scientific of view.
Ethical issues in Therapeutic Touch
Ethical issues in research
To consider the ethical issues in research into health and health care
Hawley (2007) identified that ethics is a central part of research mainly concerned with moral behaviour, which can be regarded as good and correct or bad and wrong and they may differ depending on culture/society.
There are ethics committees in different locations that look at proposals for research made by aspiring researchers. They accept the applications and approve them if they are deemed not have irregularities considering their validity and to protect participants from harm. The Research Governance Framework (2001) shows that research governance is aimed at continuous improvement of standards and the reduction of unacceptable variations in research across health and social care.
From history we learnt that some harm was done to people through researchers who were either secretive of their work or used their power with their subjects. Hawley (2007) established that this created a lot of harm to patients like the Nuremberg code and declaration of Helsinki just to mention a few some of which were funded. Behi & Nolan (…..) stipulated that researchers are not to do their work covertly if it is meant to benefit the society/participants. All human beings have a sense of ethics depending on societal, cultural and religious background however they are unique individuals with their own beliefs and values. Sometimes age gender and diagnosis can be added to the list. This is the true presentation of the clientele that we work with in mental health nursing practice. Autton (1989) suggests that therapeutic touch becomes inappropriate when given at a wrong time, in the wrong dose or to the wrong person. Hence Smith (1998) points out, the effectiveness of TT depending on the socialization and experience of the individual client. It is essential that clinicians inform themselves of their clients' cultural context before using the power of touch.
This has made it important for different professional bodies to have code of ethics to guide professional in knowing how to present themselves in practice and to protect the participants. The nursing and midwifery council code of professional conduct (2008) lays out the code of ethics for their professionals. Ethical issues have therefore informed professionals on the importance of getting acquainted with the code of ethics for their practice and learn to use it professionally. As a novice researcher in nursing practice it was important that I read and get myself accustomed to ethical issues as my practice involve working with people from different backgrounds thus, the ethics will guide researchers/professionals in conducting themselves well. Behi & Nolan (…..) identified that the principles of *beneficence which is about doing good, helping or improving the individual while *non-maleficence about causing no harm were deemed important in any form of research. Ethics has been an important aspect for health care students undertaking in research as we live and work in a multi cultural and multi racial society. This has made it important for different professional bodies to have code of ethics to guide professional in knowing how to present themselves in practice and to protect the participants. The nursing and midwifery council code of professional conduct (2008) lays out the code of ethics for their professionals. As a novice researcher in nursing practice it was important that I read and get myself accustomed to ethical issues as my practice involve working with people from different backgrounds thus, the ethics will guide researchers/professionals in conducting themselves well. Behi & Nolan (…..) identified that the principles of *beneficence which is about doing good, helping or improving the individual while *non-maleficence about causing no harm were deemed important in any form of research. For nursing students and professionals, it has been noted that sometimes doing a research with their subjects might be a difficult endeavour as they act as advocates of their subjects and in researching might need information from them to use in their work. The code of ethics maintains that confidentiality is to be prioritised as it is a vital aspect of research. Client *dignity is to be maintained and their choices be respected. It has been noted that ethics committees have been set up where researchers are to take their work to for validation (Department of Health DoH 1991). Researchers are advised to seek *consent with their participant before embarking on any form of work with them. It is also important to inform that they have a right to withdraw their consent even during the research if they want to. Sometimes *consent can be extended to clients relatives so that they do not question the interventions or interviews that will be done with participants. However it all depends upon participant’s wishes otherwise they might want to withhold the information from relatives. The participants have a right to *privacy which must be maintained throughout the research. However it is important to ask them to be on the safe side. The participants must not be forced to do things they consider ethically or morally wrong. *Confidentiality of participants information should be highly considered as not doing so would be an act of misconduct on the part of the researcher. Sometimes anonymity and secrecy might be needed by the participants and therefore the researcher must uphold them (Behi & Nolan …..). There must be a balance of power between the participant and the researchers and this often been considered an aspect of concern to nursing researches where patients are used as subject and also to vulnerable people like mentally ill. Justice is equally important in research in that whatever researchers do with their subjects should be done fairly.
Behi & Nolan (……..) state that as researchers, it is therefore important that we need this knowledge and understanding to enable us to design and undertake ethically acceptable investigations
Ethical issues in TT
The author chose to do a therapeutic research as according to McHale & Tingle (2007) it is justified as it can be shown that it is treatment for ‘life, health, well being’
MacInnes (1999) stated that sound clinical research should be underpinned by basic ethical principles based on respect for human dignity autonomy and truth. The author will now expand on ethical issues involved in TT. From gathering information on ethics, the author noted that autonomy, beneficence, justice and non-malificence have all proven to be important when carrying out a therapeutic research with a topic like TT.
Hawley (2007) noted that the principle of autonomy refers to the rights of the patient regarding what is done to him. In doing a research in TT, the researcher must first of all seek consent from the participant as this is in line with code of ethics in nursing. Since the researcher was working with Clients from a mental health background, they are listed under the vulnerable group of participants in that they are sometimes considered not capable of making an informed consent and because sometimes they will be patients where the researcher is working. However McHale & Tingle (2007) disagree with the preceding statement in that while some persons may have some mental impairment, this does not mean that they are totally unable to give consent. Consent should not only be obtained verbally but there should be written one as well The participant must be given relevant information about the intended research and be kept informed through out the process of the research and be made aware that they have a right to withdraw their consent anytime during the making of the research. The participants should not feel pressured to take part in the research. Participant’s confidentiality must be maintained at all times as their information should not be passed inappropriately to others without their knowledge. Sometimes anonymisation can used ….. Participant’s privacy should be during and after conducting the research. The author had a number of clients who volunteered who were willing to participate in therapeutic research after she posted information on the notice boards. However some of them withdrew their consent for different reasons.
(Hawley 2007) explained that the principle of beneficence refers to the duty of the researcher to bring benefit to the patient. This principle was usually associated with future developments in health care however it has been noted that of late, clients participating in research benefit more in that they tend to be given more consideration. This principle works well in TT as the nurse will be spending sometime with the client to evaluate the effect of therapeutic touch as a nursing intervention.
The principle of justice refers to being fair and treating participants equally and they should not be disadvantaged in anyway (Hawley, 2007). TT is meant to benefit the patient because as an intervention that has been used in nursing for some time now it has proved to be an effective way of aiding recovery sometimes even when medicinal model has not excelled.
Behi & Nolan (…….) state that the principle of non-maleficence is about not doing harm to individuals. This principle is meant to protect participants from researcher who will do anything to finish their work regardless of participant’s health. In TT this is where the importance of using ethical committees and to also follow the code of ethics from the nursing profession as guide to the researchers conducts. Sometimes the methods used in drawing up the research might be daunting to participants especially considering that in TT the researcher was working with clients with mental health illnesses. These involved interviews might have been distressing in nature and sometimes considered to be too long which is not a good aspect to use with this group of clients.
Hawley (2007) explained that data is collected from the participants and once its done, their role is complete.The author used interviews and questionnaires with six staff nurses, both male and female who were randomly selected from an inpatient setting. The author used the two methods as the were fairly suited for the research. Cormack (2001) explains that, the term random does not mean haphazard or careless but refers to a precise method of selection where all individuals in a defined population stand an equal chance of being selected for inclusion in the study sample. The author had eight clients who had volunteered and consented to taking part in this research. With the staff nurses three were willing to do interview but the other three preferred doing questioners because of their busy schedule. To the clients, the author asked them to complete questionnaires. Hancock (2002) states that, topics covered should show whether respondents replies were recorded verbatim or whether answers fitted into a set of pre existing codes as is the case with yes/no, fixed choice or multiple choice questions. The author noted that all the data collected was in support of TT. Most of the clients agreed that nurses who used TT made them feel less anxious. Zur (2007) states that the meaning of touch can be only understood within the context of the client, the therapeutic relationship, and the therapeutic setting.
Contents validity in questionnaire and interview sheets will be discussed and agreed upon with the participants. The author will use questionnaires to find out if practising nurses find the use of TT effective in working with clients. *Nurses participating in this exercise will be randomly selected from different wards in hospitals and from community treatment settings.* Male nurses will be interviewed to find out if they might be having concerns of using TT to female clients in fear that it might be misinterpreted for client abuse. Zur (2007) states that the meaning of touch can be only understood within the context of the client, the therapeutic relationship, and the therapeutic setting.
Tarling & Crofts 2002 emphasis that the traditional research process demands that data collection is followed by data analysis, description of findings discussion implications for practice, summary and conclusions. Within the limits of a sample size the aim was achieved of gaining insight into the experience of using TT as a nursing intervention. The author acknowledges that a larger sample might shed more light on the effectiveness of therapeutic touch related to the nature of mental health nursing. Polit & Beck (2006) explained that, researchers want their findings to reflect the truth. Research cannot contribute evidence to guide clinical practice if the findings are inaccurate, biased, or fail to adequately represent the experiences of the target group
NMC - Nursing and Midwifery Council:
Code of Professional Conduct
TT - Therapeutic Touch
SU - Service User
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