Barriers of Nursing Students about Touching: In General Life and Clinical Settings

Abstract

Background: Although touching have a vital role in the nursing-patient relationship, there have been some opportunities and obstacles in some culture. Aim: To identify the touching-related barriers of nursing students at clinical setting and general life. Method: This cross-sectional exploratory study was carried out with nursing students (n=94) studying at a state university in the east of Turkey. The research data were collected between April 24 and 28, 2017 and evaluated using the mean, number, percentiles. Results: Of the students, 41.1% had concerns about patients' responses, 15.4% was not comfortable about touching someone of the opposite gender, and 7.3%, 4.1% and 2.3% of them had difficulty in touching due to obstacles caused by their lifestyles, religious beliefs and cultural values, respectively. Young women (15.5%), young men (15.5%), psychiatric patients (14.9%) and forensic patients (9.3%) were the primary groups that students had difficulty in touching. Providing care for individuals with infectious diseases (20.6%), providing perineal care (16.2%), inserting/providing care for catheters (15.3%), providing care for dirty areas (13.1%) were the types of care that the students had difficulty in touching most. Conclusion: It has been observed that some religion, gender and other cultural codes of students constituted barriers about touching, in general life and professional setting.

Headnote

Abstract

Background: Although touching have a vital role in the nursing-patient relationship, there have been some opportunities and obstacles in some culture.

Aim: To identify the touching-related barriers of nursing students at clinical setting and general life.

Method: This cross-sectional exploratory study was carried out with nursing students (n=94) studying at a state university in the east of Turkey. The research data were collected between April 24 and 28, 2017 and evaluated using the mean, number, percentiles.

Results: Of the students, 41.1% had concerns about patients' responses, 15.4% was not comfortable about touching someone of the opposite gender, and 7.3%, 4.1% and 2.3% of them had difficulty in touching due to obstacles caused by their lifestyles, religious beliefs and cultural values, respectively. Young women (15.5%), young men (15.5%), psychiatric patients (14.9%) and forensic patients (9.3%) were the primary groups that students had difficulty in touching. Providing care for individuals with infectious diseases (20.6%), providing perineal care (16.2%), inserting/providing care for catheters (15.3%), providing care for dirty areas (13.1%) were the types of care that the students had difficulty in touching most.

Conclusion: It has been observed that some religion, gender and other cultural codes of students constituted barriers about touching, in general life and professional setting.

Keywords: Care, culture, nursing, patient, student, touching.

Introduction

Touching has been identified as a successful form of nonverbal communication and interaction for all age groups that meets holistic needs of body, mind, and soul. Touching another person's skin provides sensory stimulation, communication, relaxing, security, warmth, confidence and ego integrity (Hertenstein et al. 2009). Physical contact, which is promoted by touching, provokes neural, glandular, muscular and mental alterations and contributes to the recovery in all age groups. Therefore, touching plays a vital role in human life from antenatal period to the end of life. Historically, and today, a significant portion of nursing care requires nurses directly touch patients (Green 2013); Hence, touching is of importance in terms of the professional roles. For this reason, health professionals should know how to use touch for healing strategy and emotional comfort. Especially with the increasing use of technology in the field of health, touching becomes even more important for patients and nurses, given that the emotional gap between people and machines can be filled by nurses.

There are different classifications about touching in the literature. However, in the nursing-patient relationship, touching is classified into three types in general: instrumental touch, expressive touch, therapeutic touch. In some other studies, classifications such as systematic touch, emphatic touch, positive effect touch, and task related touch can also be seen. Instrumental touch is identified as having purposeful physical contact in order to complete nursing intervention. Expressive touch is identified as warm, friendly physical contact and is not solely for performing a task (Morris et al. 2014). This touch is often applied to the shoulder, arm, or hand to express feelings of comfort or reassurance. Therapeutic touch is thought to promote healing through restoring harmony in a person's energy fields (Caroll 2005). However, applying a therapeutic touch requires special training.

According to the literature review, the effectiveness of the above-mentioned types of touching has been shown in some studies. In a study by Belgrave (2009), the effects of expressive touch accompanied by music on the elderly have been shown, and the study by Tabatabaee et al. (2016) shows the effect of the therapeutic touch in patients with cancer.Touching, which is important from a professional point of view, is also a cultural action in terms of practitioners. Cultural norms about touching to another person vary significantly from one culture to another (Nowak 2005). Especially in some cultures, it is more difficult for men to physically touch another person, while in some cultures it is difficult to touch old people and some others it is difficult to touch someone of the opposite gender (Evans 2002). For example, in some religious groups, touching someone of the opposite gender regarded as failure in ritual ablution. Therefore, the content and purpose of the touching action is affected by the value systems of the patients as well as by the value systems of the nurses.

Although the touch therapy, which entered nursing agenda in the 1970s, is very important in terms of professions such as health and nursing, it has not been addressed much (Keegan, 2003). Some of the previous studies have focused on the investigation of cultural competence of nursing students from different populations (Cruz et al. 2016; Cruz et al. 2017; Karatay et al. 2016; Kleiman 2006). However, it is seen in the literature that the opportunities and obstacles about touching patients have not been studied sufficiently especially in tradational societies. Some other studies (Eser et al. 2017; Karatay et al. 2016; Ayaz et al. 2010) show that nurses in Turkey cannot apply other types of touching adequately, except for compulsory touching patients.

The purpose of this study is to reveal the knowledge, attitudes and behaviors of the nursing students about touching patients. The results obtained are aimed at identifying the touching-related barriers felt by nurses who are prepared for their professional roles as well as expanding the curriculum in line with the results.

Research Questions

1. What are the attitudes of the student nurses about touching others in their general life?

2. What are the factors that prevent students from touching patients?

3. What are the groups and situations that the students have difficulty in touching?

4. What are the attitudes of student nurses about touching patients?

Method

Design: This is a cross-sectional, exploratory type study.

Sampling and setting: This research was conducted with sophomore, junior and senior nursing students at the Nursing Department of a School of Health in a state university located in the eastern part of Turkey. Professional practices begin in the second semester in the Nursing Department, where 8 semesters of education is carried out. However, in the second semester, the students present in the clinical setting only for observation purposes. Since the freshman students had not adequate professional experience about touching, this group was excluded from the sample. In this regard, the study population consisted of 106 students. No sample selection was performed, and all the sophomore, junior and senior students were included in the sample. However, it was able to reach 94 out of 106 students (88.7% of the population) at the dates of the study.

The average age of the students included in the study was 21.91±1.43, 51.1% was female, 31.9% was sophomore, 37.4% was junior and 30.7% was senior student. The families of the majority of the students were living in the southeast (75.5%) and east (22.2%) of Turkey. Of the students, 44.7% stated that they belongs to Shafii faith group, which is a sub-branch of Islam, 26.6% belongs to Hanefi faith group, which is another sub-branch of Islam, and 10.6% belongs to Alevi faith group.

Data collection instruments: The questionnaire titled " Attitudes and Practices of the Nursing Students about Touching", developed by the researchers in line with the literature was used for data collection. The first 10 items of the questionnaire aimed to assess the sociodemographic characteristics of the students and the remaining 12 items addressed the knowledge, attitudes and behaviors of the students in their general and professional lives. The attitudes of students about touching patients were evaluated on the basis of the statements given in the questionnaire.

Data collection: The research data were collected during main vocational courses, which students are the most concerned about, between April 24 and 28, 2017. Before the questionnaire was applied, the students were informed about the purpose and usage of the data collection instrument, and asked to complete the questionnaires in a proper manner. Students were not asked to fill out questionnaires with specific information, such as names and school numbers, so that they could feel more comfortable. The data were collected by questionnaire and it took about 10 minutes to complete each questionnaire.

Data analysis: The data obtained in the study were entered into SPSS, and evaluated using the mean, number, and percentiles. The relationship between touching attitudes of students and gender, religious beliefs and family type was determined using the chi-square significance test. Ethical consideration: Permission was obtained from the School of Health Nursing Department before starting to conduct the study. In addition, before the data collection, verbal consents were obtained from the instructor and students after the necessary explanations were made. Based on the voluntary principle in line with the Declaration of Helsinki, students were not forced to participate in the study.

Results

Meaning of touching in the general lives of the students: Within the scope of the study, the place and meaning of touching were evaluated in the lives of the students in general. According to the findings, the majority of the students (69.9%) stated that they sometimes use touching in communication, and 9.8% stated that he/she never used, and 8.6% was not aware whether he/she touches during a communication. While 38.4% of the students stated that touching is a tool to facilitate communication, 28.0% expressed it as a comforting action, 12.8% stated it's an unnecessary action, and 11.2% said that it was a violation of personal space. While 41.9% and 37.9% of the students indicated that they can easily touch their family members and the people of the same gender respectively, it was observed that it was difficult for them to touch individuals of the opposite gender (17.9%) and people outside their family members (2.3%). Of the students, 28.5% and 5.7% had concerns about misunderstanding when touching people of the opposite gender and the same gender, respectively (Table 1).

Factors that prevent students from touching patients : Within the scope of the study, the factors that prevent students from touching patients, the groups and conditions that students have difficulty in touching were evaluated. In terms of the factor that prevents students from touching the illness, 41.1% of the students had concerns about patients' responses, 15.4% was not comfortable about touching someone of the opposite gender, and 7.3%, 4.1% and 2.3% of them had difficulty in touching due to obstacles caused by their lifestyles, religious beliefs and cultural values, respectively. In addition, 7.2% of the students stated not to not know how to touch their patients. Young women (15.5%), young men (15.5%), psychiatric patients (14.9%) and forensic patients (9.3%) were the primary groups that students had difficulty in touching. On the other hand, providing care for individuals with infectious diseases (20.6%), providing perineal care (16.2%), inserting/providing care for catheters (15.3%), providing care for dirty areas (13.1%) and terminal patients (11.1%) were the types of care that the students had difficulty in touching most (Table 2).

Cultural attitudes about touching: The attitudes of the students about touching patients were evaluated on the basis of the structured statements. According to their statements, 12.8% of the students stated that it was unnecessary to touch patients, 29.8% had difficulty in touching, 14.9% did not believe that touching patients makes communication easier, 28.7% did not believe that touching facilitates healing, whereas 67.1% stated that one can touch patients in compulsory conditions, 23.4% said that the nurses had no obligation to touch patient of the opposite gender, and 65.9% stated that professional touch should be addressed more in the curricula (Table 3).In addition, students were also asked about the types of touch that they have applied until now. The vast majority of students have stated that they use instrumental touch, whereas only few of them using expressive touch in clinics.

Discussion

It is believed that the findings obtained in this study, which is carried out to understand the attitudes and behaviors of nursing students about touching in their general and professional lives, are important despite some limitations. This is because, studies on this issue are scarce, despite the observations regarding the students' barriers and difficulties in touching some patient groups in clinical practice. However, the fact that the data were mostly obtained from Muslim students, especially from those in Shafii faith, reduce the generalizability of the study. Therefore, the findings of this study cannot be generalized beyond this regional setting. Despite the limitation of this last study, it is expected to make contributions to the literature in terms of understanding the conditions that prevent touching patients when providing care. However, the findings were not sufficiently compared with the results of other studies since there were no studies in the literature evaluating the touchingrelated attitudes and behaviors of the health care providers.

According to the results of the study, touching is not a sensory stimulation method that students can easily use in their general life. Particularly with the influence of factors such as religious, cultural and lifestyle habits, it is seen that students have limitations related to touching individuals who are not family members. It is observed that their concerns of misunderstanding increase when touching the individuals of the opposite gender in their everyday life. Similar anxiety can also be reflected in professional life. In a study by Cocksedge et al. (2013), it is stated that all of the physicians are concerned about misunderstanding while using the expressive touch, and that the patients think that this type of touch is necessary in stressful situations.

Although the majority of students show professional attitudes, considering the meaning and importance of touching in the course of care provision, it is observed that the general attitudes of a significant part of them reflect on to professional lives as well. In particular, gender role patterns is one of the biggest obstacles to touching. For this reason, young women and young men are among the most difficult groups to touch for nursing students. However, stereotypic biases also constitute an obstacle to touch patients. In this direction, forensic patients, individuals with different gender preferences, psychiatric patients, individuals with different beliefs and ethnicities constitute other groups which are difficult to be touched. According to the results obtained, courses on cultural care and importance of care to be provided for different care groups can be added to the nursing curricula. When the situations that students have difficulty in touching were evaluated, infectious diseases such as AIDS, hepatitis, and intimal regions constitute the situations where touch is difficult. Nevertheless, the fact that students have difficulties in touching terminal patients, patients in intensive care and dialysis patients may be due to their unpreparedness to confront death. In the first years of nursing education, students are not sent to critical units to prevent traumas, avoiding them contact with terminal patients. However, nursing students are expected to gain and develop ability to work and cope with these groups when they reach their final year of graduation.

When students' attitudes about touching patients were evaluated, it was observed that some attitudes need to change. In this regard, students should learn how important to touch patients is, as a part of the healing process, and should also learn that they must use expressive and therapeutic touches other than the instrumental touch used in the mandatory conditions (Green 2013). In a study conducted in Turkey, only 26% of the patients stated that the nurses touched themselves during a communication (Eser et al. 2017). In particular, expressive or tactile sensation is necessary for the ever-continuing formation of personality and interpersonal relations (Connor & Howett 2009; Mattens 2009). Therefore, expressive and therapeutic touching skills of students should be improved. In the expressive touch, the parts of the body to be touched, duration, frequency, time and cultural elements of touch should be taught. Undoubtedly, students are also cultural assets and it is understandable that their cultural norms and values reflect on to professional processes at the beginning of their professional education period. However, cultural norms and values should not conflict with professional ethical values. In this direction, nursing students are expected to develop more professional attitudes regarding the patients they provide care during the education process. It might be helpful to improve nursing school curricula by addressing the importance of touch in the nursing profession and help students improve themselves by using the touch effectively during nursing care. In this study, one third of the students reported that curriculum should address touching patients more, suggesting that this requirement was also felt by the students.

Within the concept of modern care, cultural competence emphasizes the flexibility of care and focuses on the needs of patients and their relatives. However, the sensitivities of the caregiver and the reflections of these sensitivities on the care provided have not been studied adequately. In Muslim societies in particular, the problems faced by the health care providers have not been adequately addressed due to cultural norms, including beliefs. To understand the contradictions between professional attitudes and cultural attitudes, there is a need for studies on this field. Health care providers should be aware of situations that are unique to themselves, but restrict their ability to perform their profession during the professionalization process, and should try to avoid these barriers or should turn to different branches of health. It is therefore important to understand and address the cultural barriers of care in providing healthy or sick individuals in the multicultural education process.

Limitations: These findings can only be generalized to students in this study, enrolled in this specific curriculum. The study would have been strengthened by other studies, particularly qualitative studies.

Conclusion: According to findings in the study, it is seen that some of the nursing students have prejudice about some patient groups and conditions, have not attached sufficient importance for touching in their general life and professionalization process due to their unique religious, cultural and gender codes, and have difficulty in providing care to intimal areas.

Implications for nursing education: In line with these results, it is recommended to add interactive lessons in nursing curricula for overcoming touching-related biases in some patient groups as well as improving touching skills in of students.

Acknowledgement: The authors thank to the nursing students who attended the study.

References

References

Ayaz, S., Bilgili, N. & Akin, B. (2010). The Transcultural nursing concept: A study of nursing students in Turkey. International Nursing Review, 57(4), 449-453.

Belgrave, M. (2009). The effect of expressive and instrumental touch on the behavior states of older adults with late-stage dementia of the Alzheimer's type and on music therapist's perceived rapport. J Music Ther., 46(2), 132-146.

Cruz, J.P., Estacio, J.C., Bagtang, C.E., & Colet, P.C. (2016). Predictors of cultural competence among nursing students in the Philippines: a crosssectional study. Nurse Education Today, 46, 121126.

Cocksedge, S., George, B., Ren-Wıck, S., & ChewGraham, C. A., (2013). Touch in primary care consultations: Qualitative investigation of doctors' and patients' perceptions. British Journal of General Practice, 63(609), 283-290.

Connor, A., & Howett, M. A. (2009). A conceptual model of intentional comfort touch. J Holist Nurs., 27(2), 127-135.

Cruz, J.P., Alquwez, N., Cruz,C.P., FeliclildaReynaldo,R.F.D, Vitorine,L.M., & Islam,S.M.S. (2017). Cultural competence among nursing students in Saudi Arabia: a cross-sectional study. International Nursing Review, 64(2), 215-223.

Evans, J.A. (2002). Cautious caregivers: gender stereotypes and the sexualization of men nurses' touch. Journal of Advancing Nursing, 40(4), 441448.

Eser, İ., Çelik, G.G., & Gürkan, A. (2017). Addressing and touching to patients by nurses and physicians during communication. International Journal of Psychiatry And Psychological Researches, 8, 52-73.

Gioia Schimidt, T.C., & Paes da Silva, M.J. (2013). An approach to touching while providing highquality affective health care to hospitalized elderly patients. Revista da Escola de Enfermagem da USP, 47(2), 420-426.

Green, C. (2013). Philosophic reflections on the meaning of touch in nurse-patient interactions. Nurs Philos., 14(4), 242-253.

Hertenstein, M.J., Holmes, R., & Keltner, D. (2009). The comunication of emotion via touch. Emotion, 9(4),566-573.

Karatay, G., Bowers, B., Karadag, E., & Demir, M.C. (2016). Cultural perceptions and clinical experiences of nursing students in Eastern Turkey. International Nursing Review, 62(4), 547-554.

Keegan, L. (2003). Therapies to reduce stress and anxiety. Crit Care Nurs Clin North Am., 3:321327.

Kleiman, S. (2006). Discovering cultural aspects of nurse-patient relationships. Journal of Cultural Diversity, 13(2), 83-86.

Ozolins, L.L., Hörberg, U., & Dahlberg, K. (2015). Caring touch - patients' experiences in an anthroposophic clinical context. Scandinavian Journal of Caring Sciences, 29(4), 834-842.

Mattens, F. (2009). Perception, body, and the sense of touch: phenomenology and philosophy of mind. Husserl Studies, 2582), 97-120.

Morris, D., Henegar, J., Khanin, S., Oberle, G., & Thacker, S. (2014). Analysis of touch used by occupational therapy practitioners in skilled nursing facilities. Occup Ther Int.,21(3),133-142.

Nowak, T. (2005). Vietnamese. In J. G. Lipson & S. L. Dibble (Eds.), Culture & Clinical Care (pp. 446-460). San Francisco: The Regents, University of California.

Tabatabaee, A., Tafreshi, M.Z., Rassouli, M., Aledavood, S.A., Alavi Majd, H., & Farahmand, S.K. (2016). Effect of therapeutic touch in patients with cancer: A literature review. Med Arch., 70(2),142-147.

Watson, W.H. (1975). The meaning of touch: geriatric nursing. JCommun., 25(3), 104-112.

Zamanzadeh, V.L., Negarandeh, R., Monadi, M., & Azadi, A. (2013). Factors influencing men entering the nursing profession, and understanding the challenges faced by them: Iranian and developed countries' perspectives. Nurs Midwifery Stud., 2(4), 49-56.