Physiotherapists’ use of touch in inpatientsettings

JOHN ROGER, DANIEL DARFOUR, ANIL DHAM, ORIT HICKMAN, LAURASHAUBACH and KATHERINE SHEPARD College of Allied Health Professions,Temple University, Philadelphia, USA

ABSTRACT Background and Purpose. Although touch is a basic element in the practiceof physiotherapy, no research has been done to establish the type and purpose of practi-tioner touch in clinical settings. The purpose of the present study was to determine howphysiotherapists use touch in inpatient acute and rehabilitation settings. Method. Fifteenphysiotherapists with three or more years’ experience were videotaped treating two tothree patients. The participant physiotherapists reviewed a videotape of themselves anddescribed the types of touch used and their intent behind each touch. Cross-case analysiswas used to determine common themes in the descriptions. Mutually exclusive categoriesof touch were then refined, based on the cases. Results. The most common types of touchused by physiotherapists included assistive touch, touch used to prepare the patient, touchto provide information, caring touch, touch to provide a therapeutic intervention, andtouch used to perceive information. The physiotherapists also used 33 different combina-tions of touch, that is, a single touch used for more than one purpose. Conclusions.Inpatient physiotherapists clearly perform in a ‘high touch’ arena. Clinical experience wasreported as the strongest factor in developing the physiotherapists’ sensitivity to patientneeds and their skill in using specific types of touch. Further research is needed concern-ing the way patients perceive and respond to the presence or absence of these variousforms of practitioner touch.

Key words: physiotherapy, qualitative methods, touch

INTRODUCTION

I usually use touch to mainly assist a patientwith physical activity, give a level of security,to greet a patient, to do manual techniques ...(Dawn)

I think that how much you touch some-body really depends on the person and theirneeds. I don’t really think there is a rule forit. (Maria)

Touch has been described as the foundationof all human senses (Vortherms, 1991).During development, humans use touch toexplore the environment and to acquire asense of the world. Through life experience,adults learn to interpret touch differently invaried situations. With aging, the need fortouch increases as other senses deteriorate,

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making touch an integral part of the humanexperience from birth to death.

Touch is also an integral and necessarypart of the physiotherapy profession.Instances of touch occur when physiothera-pists steady patients during gait or assistpatients with therapeutic exercise. Touch isused as a method of gathering informationin the form of palpation. Touch is also usedto convey a comforting or caring messageto a patient. Most patients understand thatthere is a need for touch and consent to itsuse during therapy sessions. Patients mayassume that physiotherapists are well edu-cated in the use of touch. However, littleresearch on touch has been conducted in thearea of physiotherapy; thus, scarceresources are available to teach physiother-apy students about touch. The small amountof research that has been conducted ontouch is found predominantly in the nursingprofession and can not be generalized accu-rately to physiotherapy.

Literature review

In the last 20 years, researchers from pro-fessions that use their hands on patients,such as medicine, occupational therapy andchiropractice, have begun to examine theuse of touch (Krauss, 1987; Stewart et al.,1999; Bowers, 2000). In the nursing profes-sion, where the preponderance of researchexists, studies have focused on the effect,responses to and factors which influencepatients’ perceptions of touch in nursing(Tommasini, 1990; McCann and McKenna,1993; Moore and Gilbert, 1995; Routasalo,1999). This research could only be com-pleted once working definitions of the typesof touch used in nursing were created.

In order to study the use and effect oftouch, it is first imperative to describe thetypes of touch that occur in physiotherapypractice. Although touch in physiotherapy

has not been described extensively, severalstudies in the nursing field have attemptedto categorize the use of touch (Routasalo,1999). For example, Pratt and Mason(1984) discuss 10 types of touch: commu-nicative, diagnostic, incidental, personalcare, assisting, accidental, guiding, plea-sure-giving, instrumental and pleasure-receiving. Four major types of touch used innursing were described in a study byVotherms (1991): affectional, functional,protective and non-physical. However,many of these definitions were producedusing observational or self-reported data.

A major limitation of conducting obser-vational research is the possibility ofmisinterpretation by the observer. In an arti-cle describing the use of touch by nurses,Schoenhofer (1989) indicated that manydifferent types of touch might be occurringduring a single instance of clinician–patientcontact. Therefore, it is imperative to exam-ine clinicians’ motivations and intentionsmore directly. Schoenhofer (1989, p. 153)states ‘Phenomenology seems to offermethods appropriate to further inquiry intothe nurse’s perception of a client’s need foraffectional touch’.

Video recordings of clinician–patientinteractions have been used successfully tolimit bias that may be inherent in reportsgenerated from memory alone (Bottorff,1993). Investigating nurses’ use of touchand their intentions via videotape analysisof nurse–patient interactions, Bottorff(1993) described f ive types of touch.Nurses indicated the use of the followingtypes of touch in their interviews: comfort-ing, connecting, working, orienting, andsocial touches. The use of video segmentsin the study by Bottorff (1993) providedcues for participants during discussion ofspecific incidents of touch and often stimu-lated comments on their perceptions duringthe touching act.

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Estabrooks (1989) developed a concep-tual framework for the acquisition of atouching style by intensive care nurses. Thetypes of touch were defined as caring, pro-tective and task-oriented. Estabrooks andMorse (1992) used this information as afoundation for a further study that examinedacquisition of a touching style. These authorsfound that touching style was affected byfamily and cultural background, personalexperience with touch and education. Cueingwas also found to be an important aspect inunderstanding how to use touch. Estabrooksand Morse (1992, p. 454) stated ‘Cues repre-sent information that nurses use to make adecision and range from subjective feeling toobjective physical signs’.

Foundation for conceptual framework

Using the Estabrooks and Morse (1992)conceptual framework as a basis for theirstudy, Helm et al. (1997) investigated theprocess by which physiotherapists acquire atouching style. The respondents discussed

four types of touch: therapeutic interven-tion, assistive, perceiving/providinginformation and caring touch. Respondentsin the study also reported that withincreased experience there was a perceivedincrease in their ability to read patients’verbal and non-verbal responses to touch.The conceptual framework revised by Helmet al. (1997) was then used as the initialconceptual framework for the present study(Figure 1). The purpose of the present studywas to determine how physiotherapists usetouch during clinical practice in inpatientacute and rehabilitation settings.

METHOD

Sample

A purposive sample of 15 experiencedphysiotherapists from inpatient acute careand rehabilitation settings in south-easternPennsylvania participated in the presentstudy. Clinical experience for the partici-pants ranged from 3.5 years to 21 years(mean 9.4 years; standard deviation (SD)

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FIGURE 1: Model portraying physiotherapists’ acquisition of a touching style and types of touch used in phys-iotherapy practice. (Reprinted with permission from the Journal of Physical Therapy Education, Vol. 11, No. 1, Spring 1997.)

PERCEIVE & PROVIDE INFORMATION

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6.1 years). Table 1 displays the completephysiotherapist demographics. For the pur-pose of the present study, an experiencedphysiotherapist was defined as an individ-ual who had practised for at least threeyears as a licensed physiotherapist. In addi-tion, physiotherapists in the present studyhad at least two months’ experience in theirpresent practice setting to ensure that theywere familiar and comfortable with thetreatment environment. Inpatient facilitieswere used since it was assumed that ahigher amount of touch might be used withpatients in these facilities compared to out-patient facilities. Institutional ReviewBoard approval was obtained for the presentstudy and all the physiotherapists and

patients who were videotaped or inter-viewed signed consent forms.

Research design and instrumentation

The present study used a naturalistic casestudy design with a cross-case analysis.Each of the five investigators in the studycollected interview and videotape data onthree physiotherapists working with two tothree patients in their clinical setting. Afterthe treatment session, the physiotherapistswere asked to watch the videotape andreport on the types of touch they wereusing. Touch definition guidelines, pro-vided by the investigators, were used toprovide a common language to facilitate

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TABLE 1: Demographics of physiotherapists interviewed

Age Gender Experience Experience Continuing education Ethnicity High touch/(years) in current courses related low touch

setting (years) to touch family

43 Female 21 4 None Not indicated Low touch43 Female 21 15 None Irish, Mexican Low touch41 Female 19 14 None Not indicated Low touch34 Female 10 5 None American Low touch37 Female 9 2 Motor learning Caucasian High touch34 Female 9 2 Mary Massery ‘if you Caucasian, High touch

can’t breathe, you can’t African–American,exercise’ Greek, Hispanic,

Russian, Japanese

33 Female 9 3 None Irish, Scottish No touch38 Female 8 8 None Italian High touch37 Female 7 7 None Italian American Low touch30 Male 7 6 None Italian, Filipino, Low touch

Japanese, NativeAmerican

28 Female 7 3 Manual therapy/muscle Caucasian Low touchenergy, NDT inservces

32 Female 5 5 Manual therapy Asian–American Low touchinservices

28 Female 4 2 Amputee courses Irish, Italian Low touch28 Male 4 4 None Caucasian Low touch28 Female 4 2 None Caucasian High touch

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dialogue (Table 2). In addition, the physio-therapists were engaged in asemi-structured dialogue that consisted ofsix open-ended questions concerning thetheir use of touch (Table 3). Data from theinterviews were then used to produce indi-vidual case reports describing eachphysiotherapist’s use of touch. From thesedata, the original touch definition guide-lines were modif ied and new categoriesemerged, reflecting the physiotherapists’actual use of touch.

Before the study, a seven-member panelof physiotherapists reviewed the interviewquestions. The members of the panel had arange from five to 28 years’ clinical prac-tice across a wide variety of settings and all

were knowledgeable in the practice of qual-itative research. Following the review,substantive content and editorial changeswere made to the interview questions. Apilot study was conducted, consisting of amock treatment session that was video-taped, to determine the technical aspects ofrecording patient–physiotherapist interac-tions. An interview was then conductedwith the pilot physiotherapist to test theefficacy of the revised interview questionsand to provide interview practice for theresearchers. After the pilot study, possiblecategories of touch were determined usingthe conceptual framework of Helm et al.(1997), data from the pilot study and theclinical experience of the researchers. These

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TABLE 2: Guidelines for identifying types of touch

Type of touch Guidelines

Therapeutic intervention (TI) Task-oriented touch, such as manipulation or massage

Assistive touch (AI) Touch used to physically aid a patient, for example, in a specific movementsuch as active-assisted range of motion exercises, guarding techniques ortransfers

Perceiving information (PER) Touch used to gain information about the patient’s diagnoses, symptoms,etc. An example is the use of palpation techniques during an evaluation andtreatment

Providing information (PRO) Touch used to convey a message to the patients, such as showing a patienthow to perform an exercise correctly

Caring touch (CAR) Touch used to comfort, encourage and show a caring attitude; touch used toconvey emotion or support. A pat on the back for encouragement and hold-ing a patient’s hand are two examples

Building rapport (RAP) Touch used to build a relationship with a patient. An example is a hand-shake.

Security (SEC) Touch used to produce a feeling of safety or reassurance for a patientwhether or not it is physically needed

Preparation (PREP) Non-therapeutic form of touch that is used to prepare a patient for treatment.Examples include draping, donning and doffing slippers and fastening apatient’s gown

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possible categories of touch formed thetouch definition guidelines displayed inTable 2.

Procedure

Physiotherapy directors from 15 acute careand rehabilitation facilities that met the cri-teria for the study were contacted bytelephone. Physiotherapists from six facili-ties agreed to participate in the study.Demographic information was collected forall physiotherapists and patients. Patientstreated during the videotaped session werechosen by the physiotherapists and wererequired to be adults who were not undergo-ing an initial evaluation. This exclusioncriteria was used since it was assumed thatmost patients would not have met theirphysiotherapist before an initial evaluationand that touch during an initial evaluationmight differ from touch used during subse-quent evaluation and treatment sessions.The mean number of treatments patientsreceived before the videotaped treatmentsession was 11.3 (SD 9.3) and the mostcommon diagnoses were acquired neurolog-ical disorders of the central nervous systemand orthopaedic surgical procedures. Table4 contains patient information, including

age, gender, diagnosis and number of treat-ments received.

Each investigator collected data fromthe three physiotherapists by videotaping atreatment session of approximately 30minutes with each physiotherapist, using aVHS video recorder. The treatment tookplace in an active clinical setting with thephysiotherapists treating two to threepatients simultaneously. The videotapingwas conducted in a way that kept interfer-ence with the treatment session to aminimum, allowing the physiotherapist totreat in as natural an environment as possi-ble. The videotape was then used as amemory prompt for the physiotherapistduring the audiotaped interview (Jensen etal., 1999). Before viewing the videotape,the physiotherapists were given the cate-gories of touch to use as a guide fordiscussing the types of touch they wereusing. Use of these categories establisheda common vocabulary and focused thephysiotherapists on the intent behind eachtype of touch. The physiotherapists weretold that the categories were merely guide-lines and would be modified based on theirresponses. Whilst viewing the videotape,the physiotherapists were asked to identifyeach instance of touch and comment on

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TABLE 3: Interview questions

Interview questions

Before viewing the videotape:Tell me about your use of touch during a treatment session.

Whilst viewing the videotape:What kind of touch are you using here with this patient?Why are you using this particular type of touch?

After viewing the videotape:How do you know what kinds of touch a patient needs?How has your use of touch changed since you started working as a physiotherapist?What would you tell a physiotherapy student about the use of touch with patients?Is there anything else you would like to tell me about your use of touch in patient care?

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the reasons for using each one. In addition,the investigators also asked the physiother-apists the interview questions listed inTable 3 above.

Data analysis

A case report was produced for each of the15 physiotherapists using the data from the

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TABLE 4: Demographic data for patients treated in inpatient settings

Number of Number oftreatments for treatments by

current episode physiotherapistAge Gender Diagnosis interviewed

59 Male TBI secondary to MVA with left hemiparesis 68 718 Female TBI 32 257 Male C5 tetraplegia 25 2579 Female Fractured right acetabulum; fractured right SI joint 21 1378 Male Quadruple bypass 20 2056 Male Central cord syndrome 16 1673 Female S/P ORIF right proximal humerus secondary to 14 6

non-union fracture23 Male T12 paraplegia 14 1083 Male Bilateral TKR 12 1283 Female Left BKA 12 1065 Male Vent dependent respiratory failure 10 1083 Male S/P MVA (restrained driver) with CHI, left sternal 10 8

and right rib fracture, and pneumothorax47 Male S/P TBI secondary to possible MVA 10 660 Female Cauda equina syndrome; s/p knee spacer 8 282 Female Right hip ORIF secondary to fracture 8 841 Female TBI 7 775 Male Bilateral TKR 7 766 Male S/P heart transplant 6 681 Female CVA with bilateral lower extremity hemiparesis 6 674 Male Left hip contusion 6 471 Male Left hemiparesis secondary to right frontal CHI; 6 3

prostate CA79 Female Seizure disorder; respiratory failure 5 171 Female Hemiarthroplasty secondary to left hip fracture 4 268 Male Lung CA with brain metastasis 4 372 Female S/P ORIF left hip 3 377 Male S/P external fixation secondary to left tibial fracture 3 369 Male Acute dyspnea; rapid a-fib 3 374 Male CVA with left hemiparesis 3 373 Male S/P left total hip replacement 2 283 Male Right CVA 2 183 Female CHF; pneumonia; COPD exacerbation 2 2

TBI = total body irradiation; MVA = motor vehicle accident; SI = sacroiliac; S/P ORIF = suspected rightiliac fossa; TKR = total knee replacement; BKA = below knee amputation; CVA = cardiovascular accident;CA = cancer; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disorder.

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videotaped treatment session, transcriptionsfrom the audiotaped interview, the identifiedcategories of touch and demographic datafrom the physiotherapists and the patients.The structured case reports were used to syn-thesize the data and to give the investigatorsa common template from which to conductthe cross-case analysis (Yin, 1994). Eachinvestigator coded the interview transcriptsaccording to the categories of touchdescribed previously as well as new cate-gories that emerged from the data. Thiscoding scheme was continually reviewed andrevised by the investigators, based upon par-ticipants’ responses until independent andmutually exclusive categories of touchemerged. Each case report was then sentback to the corresponding physiotherapists toserve as a member check so the descriptionsand interpretations made in the cases couldbe checked for accuracy. By use of cross-case analysis, common patterns and themeswere noted across the individual cases andare presented in the ‘Results’ below.

Standards of verification

Qualitative (naturalistic) research is foundedon principles that differ from experimental(positivistic) research concerning the issuesof reliability and validity. Terms such as‘truth value’, ‘consistency’ and ‘transfer-ability’ are used to describe more accuratelyinternal validity, reliability and externalvalidity in qualitative research (Lincoln andGuba, 1985; Marrian, 1988; Patton, 1990).Several strategies were implemented to pro-mote truth value, consistency andtransferability in the present study:

• Triangulation: data were triangulated bycollecting information from multiplesources via multiple investigators and byusing multiple methods. Five investiga-tors collected data at six different sites

across 15 physiotherapists, and inter-view and videotape data were used toconfirm the findings.

• Member check: the physiotherapistsreceived the case report describing themand were asked to assure the truth valueand accuracy of the informationreported.

• Peer examination: emerging data werereviewed and discussed among theresearchers throughout the collectionprocess.

• Low inference data: original quotescomprise much of the data presented,allowing for ‘rich, thick description’(Merriam, 1988, p. 177). Thus, theresearchers made their interpretationfrom data for which there was substan-tial evidence.

• Cross-case analysis: f indings werebased on similar themes identif iedacross a number of cases, that is, on apreponderance of evidence.

RESULTS

Responses to interview questions

All the physiotherapists stated that priorclinical experience gave them increasedknowledge of which patients need whattype of touch and when that touch wasappropriate. In addition, prior experiencealso provided them with confidence abouttheir use of touch in clinical practice:

I’m comfortable in my skills as a therapistand my ability to get these people better. So,in that sense, I think that my caring touch hasincreased. I think some of my assistive touchhas probably decreased as I’ve gotten morecomfortable with certain situations. (Thad)

One of the physiotherapists admittedthat, as a new graduate, she had hesitated totouch patients:

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Now I’ve been working with this populationfor a long time, and I know that I’m a goodtherapist and I can do well for them. I thinkthat makes it easier to become more friendlyand establish rapport with them. Just with con-fidence, I think there is more touch. (Diane)

All the physiotherapists stated that theiruse of touch varied according to patients’needs. In terms of knowing which kinds oftouch to use on whom, and for what pur-pose, the majority of the physiotherapistsstated that they knew by observing thepatient:

You know, their posture, how they are sittingin the chair, what they are saying to you, howthey are saying it. Sometimes you’ll knowfrom the diagnosis; it’ll give you a little bit ofa clue that way. Sometimes you’ll know fromtheir background, their ethnicity. You cansometimes get hints or ideas before youapproach someone about what they may ormay not appreciate in terms of touch. (Susan)

Although a few of the physiotherapistsdescribed their touch as ‘intuitive’, eachcould support this intuition by citing specificphysical, emotional or cognitive cues thatthey used to assess patients’ need for touch.

All the physiotherapists described theuse of touch for assisting, guiding and per-forming specif ic therapeutic tasks. Inaddition, the physiotherapists stated theyused touch to demonstrate caring and toprovide security to patients:

I think I use it, obviously for safety first of allfor transfers and while walking. And then Ithink a lot of times I use it to make thepatients feel a little more comfortable. A lotof times they are scared and may not under-stand what we are trying to do and just tohelp them feel a little more secure with whatthey are doing here. (Sara)

Only one physiotherapist reported usinglittle touch:

I actually think I’m a little tactile defensive.(Katie)

Despite her sparse use of touch, thisphysiotherapist stated that touch was animportant part of physiotherapy interven-tion.

Single intent use of touch

Assistive touch

‘Assistive touch’ was classified by the phys-iotherapists as touch used to physically aida patient. Examples of this type of touchinclude guiding a specific movement, suchas active assistive range of motion, guard-ing during ambulation, assisting a patientduring transfers and positioning.

The physiotherapists in the present studydemonstrated the ability to tailor their useof touch to meet patient needs. For exam-ple, physiotherapists described changing theamount of assistance given to patients inorder to allow them to complete as much ofthe activity as they could:

I am using assistive touch to range the upperextremity, to assist him through the entirerange of motion, not just part of it. (Margaret)

Providing information

Touch to provide information was used forcommunication between physiotherapistsand patients. This form of touch was usedduring activities, such as exercise instruc-tion and transfer training:

I was trying to provide information because Ididn’t want him to be holding on; it was like atactile cue. (Marcie)

Physiotherapists also used this type oftouch to get the attention of their patients orto ensure that they had positioned them-selves correctly:

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I sort of tapped him on the arm, a touch thatwas out of the ordinary, to say, ‘Now look atme a second.’ (Thad)

Caring touch

Caring touch was classif ied as contactintended to comfort and encourage or toshow empathy and support to a patient.Physiotherapists stated that they used thistype of touch in the form of a pat or tap onthe patient’s shoulder, arm or back. Caringtouch usually occurred during or after anexercise or therapeutic task:

I guess it’s more of a caring touch. This indi-vidual had lung cancer which spread to hisbrain ... I think he was facing some prettytraumatic things. In this case, I think heneeded a lot of explanation, a lot of TLC, so itwas probably more of a caring touch,because it was more of a ‘you’re doing good’kind of tap. (Thad)

One physiotherapist referred to caringtouch as a way to relax and calm a patient,but emphasized the need to treat eachpatient individually with regard to touch:

I would use that kind of touch [caring] tocalm someone down if they were a little agi-tated, but sometimes it works in reverse and itagitates them more so you have to play it byear and take your verbal and visual cues fromthe patient. (Sarah)

Therapeutic intervention

Therapeutic intervention was classified astask-oriented touch used to perform adirect, manual treatment, such as massageor joint mobilization. Other therapeuticintervention activities identif ied by thephysiotherapists included positioning, useof thermal agents, muscle facilitation tech-niques and stretching:

This is a situation where I’m putting hisshoulders in end range and using PNF tech-

niques as well as rubbing his arm, tappinghis arm, which are all facilitation techniquesto wake up the muscle. (Thad)

Perceiving information

Perceiving information was defined by thephysiotherapists as touch used to gain infor-mation about patients’ diagnoses orsymptoms. Activities that were described asperceiving information included taking vitalsigns and performing palpation or manualmuscle tests:

I’m feeling to see if he has winging or if he iscontracting where he needs to contract,because he is not fully innervated in all of hisscapular muscles. (Diane)

This type of touch was also used duringguarding to assess patients’ need for addi-tional support:

I would say, perceiving information, because Iam in a position where I am behind her and ifshe slips forward I am in a place where I cancatch her and it gives me an idea if she iscoming off balance, especially, since a lot oftherapists use their vision. I use touch. (Donna)

Preparation

Touch used for preparation of the patientwas classified as a non-therapeutic form oftouch that was used to get patients ready fortherapy. Activities identified as ‘prepara-tion’ by the physiotherapists in the presentstudy included donning a pair of slippers ordraping the patient. Preparation was usedrepeatedly throughout the treatment sessionto allow for the session to begin or continuewith minimal delay. This form of touch wasfrequently paired with other forms of touch,such as assistive touch and security:

... helping a patient put his gown on beforewe do the transfer to make sure he wasdraped appropriately. (Pete)

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Security

Touch used for the purposes of security wasdefined by the physiotherapists as a form oftouch used to provide a feeling of safety orreassurance for patients, regardless ofwhether or not it was physically needed.One purpose of security was to allow thephysiotherapist to render some sense ofsafety to themselves and the patients theywere treating. This version of security wasoften performed simultaneously with assis-tive touch and took place during transfers,ambulation and guarding techniques:

It is security for both of us, I think, in terms ofme feeling safe with him. I like to have theinitial contact to ground myself as well ashim. He knows I’m there, I know I’m there.(Thad)

Another purpose of security touch wasto provide a source of reassurance for thepatient. This form of touch was most oftenused with patients who presented with somedegree of anxiety or nervousness:

For her, I think I do security touches becauseshe is very anxious. She consistently needsencouragement. (Maria)

Building rapport

Building rapport was classified as touchused to establish an interpersonal relation-ship between the physiotherapist and thepatient. It was observed as a gentle touch onvarious body parts. Building rapport alsoprovided the physiotherapists with someinformation about how comfortable thepatients were with touch to determine theamount of touch that would fit the patient’sneeds:

I tried to get a feel for his emotional state thatday. If I got the impression he was going to

step back, it wouldn’t bother me, but I woulduse a different approach and it certainly givesme an indication if the patient is not feelingup to par or if they aren’t in a generousmood. I would give them more space and finda way to let them know that I understand andthat today you need space. (Donna)

Another example given by the physio-therapists for building rapport was toestablish an initial relationship withpatients. This type of activity was observedas a soft, gentle type of contact withpatients and it was usually used withpatients that the physiotherapists had notseen many times before:

We already have a rapport, but it’s easier forme to sit and hang out with him and talk tohim than it is to lay him down and walk away.(Diane)

Multiple intent use of touch

In addition to the use of single forms oftouch, the physiotherapists in the presentstudy indicated that frequently there weremultiple intents behind a single instance oftouch (Figure 2). The physiotherapists inthe present study identif ied 33 types oftouch with multiple intent, combining twoor more of the single intent categoriesdescribed previously. Only those multipleintent categories that were identified by fiveor more of the physiotherapists and thatoccurred more than 10 times are discussedhere.

Assistive touch and providing information

Assistive touch was combined with provid-ing information during activities such asinstructing patients in specific movementswhilst providing physical assistance:

I think I was trying to get him to reach thebrake on the side that he is weak on and

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reach across. Probably some assistive touchthere and maybe some providing informationas well. I am trying to show him how to do it;not that it is an exercise, but an activity toprovide information to reach across to hisother side. (Sara)

The physiotherapists were also observedproviding tactile cues to their patients inorder to communicate with them whilst pro-viding them with assistance by aiding themphysically. In some instances, when onehand was providing cues, the other handwas guarding or assisting patients in per-forming tasks:

That is going to be assistive, trying to gethim to go through the motion as best he can.Some of that is going to be providing input to... so that he knows the direction to go so thatI can measure. (Susan)

Assistive touch and security

Activities that were described as assistivetouch and security usually involved a gen-

eral type of intervention the physiothera-pists called ‘guarding’. The physiotherapistswho used this combination described thetouch as physical assistance coupled withreassurance for the patient:

She would not move without me physicallyholding on to her. I knew she didn’t need me.I just wanted to get her started, get her going,show her that, with a sense of security, shecan do this. (Sarah)

... mostly assistive, but some security as well.I think a lot of people are afraid you aregoing to drop their leg, because it’s thesurgery leg. (Susan)

Assistive touch and caring touch

Assistive touch combined with caring touchconsisted of touches that occurred simulta-neously:

Some of that is comforting too ... I knew tohave my hand in a position for her to feelmore comfortable. (Susan)

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AT

PREP

PRO

CAR

TI

PER

AT/PRO

SEC

AT/SEC

AT/PREP

RAP

AT/CAR

Typ

es o

f tou

ch

0 50 100 150 200 250 300Number of occurrences

FIGURE 2: Occurrence of each type of touch used by physiotherapists in inpatient settings.

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Assistive touch and preparation

The combination of assistive touch andpreparation was observed when the physio-therapists placed patients in an optimalposition to perform a task and then aidedthem with that task. This combination wasidentif ied mainly during transfers andambulation, which are both activities thatrequire multiple shifts in body position:

I’m doing assistive, but there’s some preparingtoo, so that she can take a step and then I’mcoming back to assistive for her to do moreweightbearing. (Susan)

DISCUSSION

Upon analysis of the results, a revised con-ceptual framework was created whichreflected the way physiotherapists use touchin clinical practice. This revised framework

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FIGURE 3: Revised conceptual framework: physiotherapists’ use of touch in inpatient settings.

Assistive

Preparation

Providing information

Caring

Therapeutic intervention

Perceiving information

Assistive/providing information

Security

Assistive/security

Assistive/preparation

Building rapport

Assistive/caring

Adapt touch to meetpatient’s needs

Acquisition of a touching style

ClinicalexperienceEducationFamily

Culture

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differed in four ways from the initial frame-work (Figure 3).

First, the role of clinical experience inthe acquisition of a touching style wasenlarged to reflect its role compared to thatof education and family/culture. Second,an additional link was made betweenacquisition of a touching style and theforms of touch used in physiotherapy prac-tice. This link represents the finding thatphysiotherapists believe that they adapttheir use of touch to meet patients’ needs.The third change was the rank order of thetypes of touch used by physiotherapists ininpatient acute and rehabilitation settings.Lastly, the types of touch include fourforms used with multiple intent. The useof touch with multiple intent has been sug-gested by Schoenhofer (1989); however,no prior study had described its use inclinical practice.

The role of clinical experience in touch

The physiotherapists in the present studyreported that prior experience providedthem with more knowledge about touchthan formal education or family and cul-ture. This knowledge was used to determinewhich patients needed which types of touchand when it was most appropriate to usethat type of touch. A common belief pre-sented by the physiotherapists in the presentstudy was that there was little informationgained by them during their physiotherapyeducation concerning the use of touch withpatients. Additionally, five of the 15 physio-therapists in the present study reportedhaving taken a continuing education coursethat enhanced their awareness of the use oftouch with patients. The role of family andculture and their influence on touch was notreported to be a strong factor affectingphysiotherapists’ use of touch.

In the initial conceptual framework cre-ated by Helm et al. (1997), the three factors

in acquiring a touching style (family/cul-ture, education and clinical experience)were reported to have an equal influenceover the acquisition of a touching style.Conversely, the physiotherapists in the pre-sent study rarely stated that family orculture influenced their use of touch, andonly four of the 15 physiotherapists in thestudy reported that they came from a ‘hightouch’ family. This information disputes thebelief that physiotherapists are tactile-ori-ented people who come from backgroundswhere touch is commonplace.

Adapting touch to patient needs

The second major modification to the theo-retical framework is the link betweenacquisition of touching style and actual useof touch. We found that the physiotherapistsuse of touch was determined by the needsof their patients. This theme was affirmedby all the physiotherapists in the presentstudy, and is similar to the study byEstabrooks (1989) that states that cueingwas an important factor in enhancingnurses’ use of touch. This finding also sup-ports the statement of Helm et al. (1997),that with increased experience, physiothera-pists perceived an increase in their ability toread patients’ verbal and non-verbalresponses to touch.

Actual use of touch differs from reporteduse of touch

The third modification to the theoreticalframework illustrates a discrepancybetween the types of touch actually prac-tised by physiotherapists in inpatientsettings and the reported use of touch byphysiotherapists in the study by Helm et al.(1997). The physiotherapists in the presentstudy used eight types of single intent touchrather than four (compare figures 1 and 3).

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The physiotherapists in the present studyused touch during patient care primarily fortask-oriented purposes. This finding con-trasts with the study by Helm et al. (1997)in which physiotherapists reported thatcaring touch was used most frequently.

There are several possible explanationsfor the preponderance of task-orientedforms of touch, such as assistive touch andpreparation, found in the present study.First, the data were from inpatient settings,which have patient populations that presentwith more medical issues and a lower levelof function compared with patients seen inoutpatient settings. Therefore, patientsrequire more assistive activities. In addition,with imposed time demands and simultane-ous treatment of multiple patients, it iscommonplace for physiotherapists to targetfunctional activities, such as transfers andambulation, that require the use of assistivetouch. Another possible explanation for thediscrepancy between actual use of touchfound in the present study and the reporteduse of touch found in the study by Helm etal. (1997) may stem from the fact that phys-iotherapists reported their use of touchwithout being observed during treatment.Touch, such as preparation and assistivetouch, may occur automatically for physio-therapists when treating patients. Incontrast, giving a patient a prolonged ‘paton the back’ or other form of caring touchmay be a more salient experience for phys-iotherapists. Thus, more memorable formsof touch may stand out in physiotherapists’minds rather than the automatic forms oftouch. Lastly, the data on touch are boundto the patient population seen by the physio-therapists in the present study. This point isperhaps best reflected in the followingstatement:

Generally, it [touch] depends on the type ofpatient I am working with. If it’s a strokepatient, because we are in the stroke gym, it

might be a little different than a pulmonarypatient because stroke patients typically needmore guarding, more tactile cues to get themuscles working which I didn’t have to dotoday at all. (Marcie)

Difficulties conducting research in naturalistic settings

A major difficulty in conducting the presentstudy involved the procurement of siteswilling to participate in research involvingthe videotaping of physiotherapists’ use oftouch with patients. Six of 15 facilities con-tacted agreed to participate, most with somedegree of hesitation. The current crisis inhealthcare and patients’ rights issues appar-ently played a role in the hospitals’reluctance to participate in the study.Although some physiotherapists were eagerto participate in the study, the institutionalreview board committees felt that videotap-ing might jeopardize patient privacy. Onehospital strongly suggested that the wordtouch be removed and replaced with thera-peutic interaction on all paperwork in orderto conduct research at that facility. Otherfacilities viewed our research as counter-productive because physiotherapists had tomake time for the study. Thus, it seems thata major reason for the lack of clinicalresearch on touch may be due to perceivedpatient privacy issues and time concernsthat limit investigator access.

Recommendations and implications forphysiotherapists

The data gathered in the present studyunderscore the fact that physiotherapistspractise in a ‘high touch’ arena. Under-standing the types of touch used withpatients can enhance physiotherapists’ abil-ity to use touch effectively with theirpatients. Physiotherapists should be awarethat every instance of touch is significant to

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patients’ needs. From an educational per-spective, the present study suggests thatdidactic education does not adequatelyexplore the use of touch in physiotherapy. Itis felt that greater emphasis on touch, aswell as the observational skills necessary toassess patients’ need for touch, maystrengthen entry-level physiotherapists’abilities with the hands-on aspect of ourprofession. Lastly, the present study sug-gests that longer clinical experience forstudents may be of benefit. This assertion isbased on data that show that clinical experi-ence is the strongest factor influencingappropriate use of touch with patients. Stu-dents may also benefit from discussionswith clinical instructors regarding theirexperience with touch.

Limitations of the study

When interpreting these results, a few limi-tations must be considered. We wereconcerned that the use of the touch guide-lines, as a priori categories, may havebiased the study participants. To limit thisbias, these categories were used as guidesrather than choices and were continuallymodified, as inherent to the research design.Also, the sample may not reflect that ofphysiotherapists and patients in similar set-tings nationwide, owing to the location ofselected facilities in the metropolitanPhiladelphia area. Another limitation of thepresent study was that data were confinedto physiotherapists treating only two tothree patients each, and the types of touchused may be patient-specific. Additionally,the time duration of each instance of touchwas not measured.

Suggestions for future research

It is suggested that future researchers incor-porate a larger sample size within and

across different clinical settings. In addi-tion, measuring the duration of eachepisode of touch may yield different data onthe time spent using various forms of touch.For instance, several quick instances ofpreparation touch may not be as significantas one prolonged instance of caring touchbetween a physiotherapist and a patient.Future research should also investigate howexperience plays a role in the way physio-therapists use touch, and what kinds ofexperience are needed for a physiotherapistto use touch effectively. Lastly, with theknowledge gained about the types of touchused by physiotherapists, we must moveforward to determine the effect and effec-tiveness of these various types.

CONCLUSION

Eight forms of touch with single intent wereused by physiotherapists. Physiotherapistsalso used touch with multiple intent, that is,combining two or more forms of touch withsingle intent. Physiotherapists relied pre-dominantly on prior clinical experience andobservation of patients when developingand adapting their repertoire of touch tomeet the needs of their patients.

ACKNOWLEDGMENTS

The authors gratefully acknowledge the co-operation,time and reflections given by the participating phys-iotherapists. They are also indebted to the patients,who shared time and allowed their treatment sessionsto be videotaped.

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Address correspondence to: John Roger MPT,Department of Physical Therapy, College of AlliedHealth Professions, 3307 North Broad Street (602-00), Philadelphia 19140, Pennsylvania, USA.

Submitted May 2000; accepted February 2002.

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