The Art of Holding Hands

34 International Journal for Human Caring

Key Words: Physical touch, short-term stay,phenomenological, hermeneutical

Introduction

Facilities for short-term stay occupy animportant position in today’s healthcare set-ting (Clarke & Rosen, 2001; Lynn, 2002;Simpson et al., 2005; Timmins, 2009). Theyinclude a large variety of outpatient clinicsand treatment and emergency units at hospi-tals. Bound by their duty of care (SSN,2003) to protect and do no harm to those intheir care, nurses are expected to control andexcel in various technical and instrumentaltasks routinely performed in these techno-logical, often highly advanced, settings(AAACN, 2007; ESGENA, 2010; JointCommission, 2010). Research findingsagree (Allan, 2002; Mcilfatrick et al., 2006;Murphy, 2001) that nursing in these facili-ties involves a high proportion of technicaland instrumental aspects, while caring as-pects are somewhat less transparent. Theclaim is, though, that nursing in these facili-ties also involves aspects of caring, but weseem to lack knowledge of how caring is ac-

tually expressed in this context.Nursing has generally departed from an

ethical and relational perspective (Nelson &Gordon, 2006). The ideal of nursing hasbeen described as one where the nurse hassufficient time and space to get to know thepatient, so that care may be tailored to theindividual patient’s needs and expectations(Foy & Timmins, 2004; Mcilfatrick et al.,2006; Nyström et al., 2003).

The nursing literature on the relationshipbetween nursing and technology often po-larizes nursing and technology (Barnard,1997; Bevan, 1998; Crocker & Timmons,2009) and argues that “technology usage” ison par with the “culture of caring” (Barnard& Sandelowski, 2000; Bjørk & Kirkevold,2000; Hawthorne & Yorkuvich, 1995).Recent studies (Foy & Timmins, 2004;Mcilfatrick et al., 2006; Nyström et al.,2003) question if it is at all possible to tailornursing to the individual patient’s needs andexpectations in the context of facilities forshort-term stay where technical and instru-mental aspects of treatment take priorityover aspects of caring. The present study

suggests that caring in this context may ex-press itself in ways other than in traditionalnursing contexts and argues that physicaltouch may be one way to exercise aspects ofcaring in nursing.

Methodology

Research Strategy

The approach is phenomenologicalhermeneutical (Gadamer, 2004; Husserl,1992) and its method inspired by practicalethnographic principles (Hammersley &Atkinson, 2007; Sørensen et al., 2011).Fieldwork has been shown to be a particu-larly suitable method in nursing research(Sørensen et al., 2011) in general and forshedding light on nursing in facilities forshort-term stay in particular (Allan, 2001,2002).

The analytical strategic approach was in-ductive; hence, the data did the talking.During the course of the fieldwork, the re-searcher turned to the phenomenon itself,i.e., nursing in facilities for short-term stayand, thus, borrowing patients’ and nurses’experiences and reflections (Hammersley &Atkinson, 2007). By observing what hap-pened, hearing what was said, and askingquestions, the researcher obtained a deeperunderstanding and more insightful descrip-tions of nursing care in this setting.Moreover, the researcher gained insight intothe expectations and needs for nursing carevoiced by the patients.

The Art of Holding Hand: A FieldworkStudy Outlining the Significance ofPhysical Touch in Facilities for Short-TermStayKarin Bundgaard, RNT, MScN, PhD(c) and Erik Elgaard Sørensen, RN, MScN, PhDAarhus University HospitalAalborg University

Karl Brian Nielsen, MScE, PhDAalborg University

Abstract

This paper focuses on the use of physical touch in nursing care in facilities for short-term stay. Extant research (Foy & Timmins, 2004; Mcilfatrick et al., 2006; Nyström etal., 2003) has raised the questions, How can nursing care best be tailored to meet the pa-tient’s overall needs, both physical and emotional? and How to strike an optimum bal-ance between caring and instrumental aspects of nursing? This paper discusses how theexchange of physical touch can be seen as an epitome of caring in nursing care in facili-ties for short-term stay; it is connected to psychological and spiritual aspects.

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Setting and Participants

The fieldwork was performed at a hightechnology endoscopic out-patient clinicduring 2008 and 2009. Data were collectedusing participant observations, includingparticipant reports and interviews. Fieldnotes were recorded both during and afterfield observations and interviews. The inter-views were recorded.

Field observations were performed over12 weeks and lasted approximately 4 hoursper day. During these hours one researcherstayed in the endoscopic clinic, trailed anurse in her work, talked to patients in theresting and waiting area, and talked to othernurses in the clinic (Hammersley &Atkinson, 2007). The patients arrived at theendoscopic out-patient clinic from theirhomes, underwent gastroscopy, and then re-turned to their homes. Their stay at theclinic lasted between 21⁄4 and 21⁄2 hours.

The patient interviews were carried outprior to gastroscopy. Patients undergoinggastroscopy at pre-fixed times on randomlyselected days were contacted and asked ifthey would participate in an interview. Theresearcher was in contact with 10 patients,nine accepted and one declined. One of thenine never came for the gastroscopy or theinterview. Thus, eight patient interviewswere performed. Informed consent was ob-tained.

The interviewees were both male and fe-male, over the age of 18, and fluent inDanish. The age distribution among patientsranged from 25 to 91 years. This was con-sidered a strength since young and elderlymay have different expectations (Gadamer,2004). Both patients having gastroscopy forthe first time and patients who had regas-troscopy participated in the study under theassumption that they could have differentnursing expectations and requirements(Gadamer, 2004; Murphy, 2001).

The nurses participating in the nurse in-terviews were working in the endoscopicclinic. They were randomly selected andparticipation was voluntarily. The nurse in-terviews were carried out after the re-

searcher had trailed an individual nurse for1 day. Four nurse interviews were per-formed.

Participant observations and interviewswere interrelated, thus the interviews con-tributed with knowledge on what to focuson in the participant observations and thesemi-structured interview guide was devel-oped based on participant observations. Thenumber of participant observations and in-terviews was not decided in advance. Theaim was data saturation, i.e., when whatwas heard, seen, and experienced seemed torepeat itself.

Ethical Considerations

The study was conducted in conformitywith the ethical guidelines for nursing re-search in the Nordic countries (SNN, 2003).The ethical considerations applied to bothuniversally human values and professionalopinion of what constitutes proper behaviorand attitudes in relation to employees and inrelation to sick and vulnerable persons.

Data Analysis

According to Hammersley and Atkinson(2007), a set recipe for fieldwork does notexist, but they offer guidelines that may aidthe researcher performing research. Thefirst step of analysis in these guidelines is aconceptual development that includes athorough reading of the text (empiricism);identification of patterns, concepts, and cat-egories; and processing of categories cen-tral to the analysis. The second step is thecreation of a typology where, for example, apattern of unlike strategies used by the play-ers to help them face a certain problem isdescribed. Finally, the third step is theorydevelopment and testing.

In this study, the process of analysis un-folded as a dynamic process that involved aconstant movement back and forth betweenthe above steps. Research may involve allsteps, but to describe and understand nurs-ing care in facilities for short-term stay,most attention was paid to the first step of

conceptual development. The researcher performed the interviews,

undertook participant observation, and per-formed the transcriptional work. Field noteswere made for each observed patient coursein the endoscopic clinic; in the followingthese notes are referred to as “Report,”which is followed by a number. The inter-views are referred to as “Patient” or“Nurse” followed by a number.

A central category emerged from theanalysis: The art of holding hand. This cate-gory will be unfolded in the following nar-rative.

The Art of Holding Hand

To ease the reader’s understanding, thefollowing text will describe the patient ashe/him and the nurse as she/her, eventhough this is in no way meant as a gendergeneralization.

Almost every action that humans make associal beings demands some kind of manualskills. From the initial handshake when wel-coming somebody until the final handshakewhen saying good-by, there is much physi-cal contact between the patient and thenurse in the facilities for short-term stay.However, the extent of the physical contactis determined by the individual’s prefer-ences and the situation in which this contactis established. For example, Nurse 1 ex-pressed that she was very physical by natureand, indeed, she was observed to be so. Sheexperienced that most patients needed andwished that their hands be held. The few pa-tients who did not wish this were easilyidentified and the nursing was adjusted ac-cordingly. Nurse 2 stood out from the othernurses by expressing how she intentionallylimited physical touch. When observed, shewas clearly more reserved in her use oftouch than most nurses. She argued that toomuch touching could be perceived as a pos-sessive behavior instead of as a way ofbuilding confidence or showing presence.Instead, like the other nurses, she aimed toclarify if the patient wished to have a handto hold before the gastroscopy started. The



nurses agreed that both the patient’s age andgender were considered when using physi-cal touch. The experience was that elderlypatients and females needed it most.

The exchange of touch can be exempli-fied by how the nurse touched the patient’sarm, shoulder, or leg during the initial con-versation; how the nurse made a drawing onthe patient’s body to illustrate her words ortouched his throat to explain where he mayfeel the most discomfort during the gas-troscopy; how the nurse took the patient’shand when explaining the procedure for ap-plying an intravenous access; how the nurseheld the patient’s hand while providing anintravenous access; or how the patient againreached out and held onto the nurse’s handor arm. During the gastroscopy, physicaltouch was reflected in how the nurse sup-ported the patient with one hand resting onhis cheek, with a hand resting lightly on hishand, or with her hand resting very close tohis hand or how she placed the other handon his shoulder or on his upper back andsometimes even when positioned behind thepatient, she had one arm around him.

Physical touch seemed to hold differentmeanings. These will be explained underthe headings: Building Confidence,Readiness to Help, Keeping a BalanceBetween Comforting and Restraining, and,finally, The Technically Skilled Hand.

Building Confidence

The importance of confidence in the rela-tionship between the patient and the nursewas evident in the interviews and in the par-ticipant observations. One way of buildingthis confidence was experienced to be theuse of physical touch.

For the patient, physical touch involvedaspects of safety and protection, “Yes, thiscontact makes me feel safe, I feel that some-one is present.” (Patient 2)

Touch added to the patient’s confidenceand trust in the nurse. Moreover, touch orsometimes lack of touch revealed thenurse’s presence. A lack of presence was as-

sociated with feelings such as discomfortand insecurity, “Their touch reveals if theyare present or not. I very soon can detect ifthey are actually here for me in this situa-tion.” (Patient 4)

“The patient is wheeled into the examina-tion room by the physician. Meanwhile, thenurse is racing around busy at cleaning andpreparing the room for this next patient. Fora few minutes the patient is watching thenurse with confusion before asking, ‘Am Iin the right room?’” (Report 33)

Furthermore, during the gastroscopy,touch was experienced as comforting and asa response to the patient’s active reflexmechanisms. It noticeably eased the pa-tient’s discomfort during the gastroscopyprocedure, “The nurses are very caring andI find it very positive when I’m being of-fered a hand to hold onto, because I squirma bit when my body’s reflex mechanismsare activated.” (Patient 7)

Physical touch was employed both inten-tionally and instinctively by the nurses.Thus, time and again the nurses touched thepatient during the initial conversation withthe patient during the gastroscopy, or duringtheir interaction after the gastroscopy. In theinitial contact between the patient and thenurse, the nurses considered physical touchto be an instrument employed in getting toknow the patient. Touch served to commu-nicate information about the patient’s con-dition in the sense that it informed the nurseabout the patient’s reaction whether one ofanxiousness, shakiness, feverishness, or, al-ternatively, calmness and relaxation.“Sometimes, if they are anxious, I feel it intheir handshakes. Their handshake makesme think, ‘Ok, this patient needs a littleextra information and reassurance,’ whileothers waltzed in here and clearly signal,‘Save your breath and let’s get on with it.’”(Nurse 3)

During the patient’s stay in the examina-tion room, touch was deliberately employedas an instrument of reassurance to make thepatient feel safe and secure. “The hand on

the patient’s shoulder is meant to give a lit-tle reassurance and to tell the patient, ‘Youcan’t see me, but I’ll be right here behindyou and I’ll look after you.’You veryquickly feel if it’s someone who wants tohold hands or not.” (Nurse 4)

During the gastroscopy, the physical con-tact between the patient and the nurse wasinterrupted time and again. For example,when the nurse used the computer, assistedthe physician, answered the telephone, oranswered queries from other staff members.If the physician required assistance thenurse left her position by the patient’s heador by his back and walked to the left side ofthe gurney and positioned herself next tothe physician. Thus, the nurse prepared thepatient beforehand of her different functionsduring the gastroscopy and the resultinglack of physical presence. Also, beforehand,she reassured the patient that she would re-turn as soon as possible. Patient, “I like tohold on to your hand during the gas-troscopy.” Nurse, “Ok, I may need to let gowhile taking the tissue samples but I’ll beback.” (Report 7)

“I always prepare them for where I’ll beduring the gastroscopy and that I may haveto temporarily let go of them, but I try to re-assure them that I’ll be back and alwayskeep an eye on them.” (Nurse 4)

Readiness to Help

According to the patients, the purpose ofnursing in the Endoscopic Unit was for thepatient to be helped trough the gastroscopyin the best and most safe way possible, andto have a usable result at the end of the pro-cedure. Physical touch, for example, thenurse’s hand on his shoulder or the nurse’shand to hold, was considered by the patientas a necessity for him to manage the gas-troscopy. Thus, physical touch symbolizedthe nurse’s willingness to take care of thepatient and her readiness to help if neces-sary.

“The nurse was very sweet and we had areally good talk before the gastroscopy. She


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helped me throughout the gastroscopy, bothby holding my hand and when she profes-sionally placed the needle in my hand.”(Report 36)

“I know it may sound a bit silly, but Ineed to know that someone is watchingover me, I may need a hand to hold, so that Ifeel their presence and know that they willtake care of me.” (Patient 8)

Patients also experienced the nurse asbeing distant, either because she was busydoing paperwork and answering inquiries orbecause she was not present physically inthe examination room. In these situations,most patients were actually found to makeexcuses for the nurse’s lack of presence.“You know that they are busy and you don’twant to take up to much of their time.”(Patient 3) “I know they have much to do, Isee patients that need her more than me andthe nurses do try their best.” (Patient 6)

Physical touch was repeatedly employedby the nurses. “I feel closer to the patientwhen I use physical touch and I experiencehow the patient reaches out for my handwhen I touch him. Like a reassurance thatI’m still here.” (Nurse 3)

The nurses described that past experiencehad taught them that most patients wishsome kind of physical closeness when un-dergoing gastroscopy. Thus, touch was usedto reassure the patients that the nurse wasstill present and ready to help, even whenout of sight. “A crucial and helpful thing forthe patients is to relax, it’ll ease their dis-comfort. With my hand on the patient, I canfeel if he is tense, this aids me in foreseeinghow he’ll react.” (Nurse 1) I often place myhand on the patient’s cheek next to hismouth because I found that this may calmhim down. The other hand, I rest on hisshoulder. (Nurse 3)

The nurses reported that it could be diffi-cult to keep this physical contact with thepatient while assisting the physician.Positioned on the left side of the gurneynext to the physician, the nurse repeatedlyreached across the physician’s arms and theendoscope to touch the patient’s hand or

arm. Furthermore, whenever necessary, sheaided the patient by pushing his cheek fur-ther down into the pillow in order for him toget rid of his excess saliva. The nurse’s at-tention was on both the patient and the tasksshe was performing. Yet, emphasis wasplaced on the latter. “Standing over there[on the left side of the gurney] when I’mbusy taking the biopsies, for example, I dohave an eye on the patient, but still there isan instrumental procedure to be per-formed.” (Nurse 3)

When there was no option for physicalcontact between the nurse and patient, otherforms of contact, such as eye contact, wereused. Almost every action taken was ac-companied by a vocal explanation of whatwas going on and why it was necessary.“When I’m unable to communicate throughphysical contact, I communicate througheye contact.” (Nurse 4)

Keeping a Balance Between Comfortingand Restraining

Patients described the gastroscopy as aconstant battle with their own defensemechanisms. “It takes all my will-powerand a hand from the nurse not to pull it [theendoscope].”(Patient 3)

For most patients, the desire for medica-tion was primary, but the option of having ahand to hold during gastroscopy was de-scribed as helping them manage the situa-tion. [After the gastroscopy] Patient, “Was Ivery troublesome?” Nurse, “No, not at all.”Patient, “It was very uncomfortable, but ithelped squeezing your hand.” (Report 25)

The nurses also described how they rec-ognized that patients battle their defensemechanisms during gastroscopy. To helppatients overcome their worst discomfortduring gastroscopy, the nurses employeddifferent techniques. For example, onenurse touched the patient’s nose, told him totake deep breath and to wiggle his toes.Another nurse told the patient to hold on tohis own thighs. Some nurses took hold ofthe patient’s hand from the start, while oth-ers chose to take the patient’s hand when he

reached out for the endoscope. The nursesdescribed this holding hand as a balancingact between keeping the patient comfortableand restraining him by holding on tootightly. The concern for the patient hurtinghimself as a result of him pulling the endo-scope was voiced, for example, as follows:

I know that when the endoscope passeshis pharynx, he might reach out and grabthe endoscope because of his defense mech-anisms. I then take his hand and tell him tohold on to me instead. If I hold onto hishand from the beginning, I might have tohold on too tight to avoid him from grab-bing the endoscope and this might feel morelike a violation. (Nurse 1)

The Technically Skilled Hand

For the patients, technical skill was asso-ciated with the nurse’s touch. If this skillwas performed safely and properly, the pa-tients quickly developed trust in the nurse.If the skill performed revealed any insecu-rity or confusion, it made the patient feeldisbelief and insecurity. “In comparison towhat I experienced the last time, today thenurse was very skilled. I felt that she knewwhat she was doing.” (Report 43)

When placing an intravenous access inthe patient’s hand, “Damn, you’re good!”(Report 15) and “You were extremelyskilled in doing that.” (Report 2)

The nurses stressed the importance ofbeing technically skilled. They experiencedthat if they showed confidence in their tech-nical skills, this was reflected in the patientbecoming relaxed and trustworthy. “I find itextremely important to be skilled in han-dling the technical, instrumental part ofnursing. When I’m confident and rest in myinstrumental nursing, I see the patient relaxand put his trust in me.” (Report 45) and “Ioften fell the patient’s eyes follow my everymove when handling, for example, thebiopsy forceps. One day I had to try outthree retrievers before finding one thatworked. This made the patient insecure andworried.” (Nurse 3)



Discussion

The purpose of this study was to describeand discuss how the exchange of physicaltouch, i.e., the art of holding hand, could beseen as an epitome of caring in nursing carein facilities for short-term stay. The resultswill be discussed under four headings:Building Confidence, Readiness to Help,Keeping a Balance Between Comfortingand Restraining, and, The TechnicallySkilled Hand.

Research argues that the building of a pa-tient-nurse relationship of confidence is ofcentral importance for the quality of nursingcare (Costa, 2001; Foy & Timmins, 2004;Murphy, 2001; Mcilfatrick et al., 2006).According to Foy and Timmins (2004),good communication is the core element inbuilding this relationship. Murphy (2001)considered the ability to listen to be a veryimportant element in building this relation-ship. He also highlighted the subject of thehuman touch as a way of creating trust inthe relationship. High technology radiologi-cal contexts, though, often call for the needto work at a distance from the patient,which often makes it impossible to enhancecontact through physical contact.Mcilfatrick et al. (2006) considered thenurse’s ability to “be there” to be a keycomponent in building a relationship withthe patient. Being there relates to emotionalaspects of caring, but it is argued also to in-corporate practical aspects of caring. In theoncological day hospital this includes theadministration of chemotherapy, but alsobeing with the patient in a very practicalsense, for example, by deploying physicaltouch. Thus, good communication, the abil-ity to listen, and to be there are all instru-ments employed in building a patient-nurserelationship of confidence.

The subject of physical touch has onlybeen briefly touched upon in previous re-search. The present study presents evidencethat physical touch may be used as an in-strument for building or enhancing a pa-tient-nurse relationship of confidencewithin context of facilities for short-termstay.

The research of Karlsson et al. (2010) re-ferred to the subject of physical touch innursing care and divided carers into twocategories: present carers and absent carers.The former, it is claimed, have love in theirhands in the sense that they have an innerability to adapt and to use their hands astools to mediate caritative caring. The latter,it is argued, have insensitive hands in thesense that there is distance between thebody and the person, because the nurse per-forms only a task or a duty and her hands donot mediate caring. In relation to the presentstudy, present carers in the endoscopicclinic were those nurses who understoodhow to evoke and demonstrate feelings ofconfidence, safety, protection, comfort, re-pose, and presence for the patient. Absentcarers were those nurses who evoked anddemonstrated the opposite feelings, such asdiscomfort and insecurity, and showed alack of presence.

Martinsen (2002, 2005) referred to theessence and importance of physical touch inher philosophical caring theory. She de-scribed how nursing applies knowledge inboth slow and quick ways. The slow waysrepresent experience-based knowledge dis-played through the use of senses; the quickways represent technology-based knowl-edge, which is displayed through practicaland instrumental skills. The importance ofawarding time to letting the slow ways havetime on equal footing with the quick ways isstressed by Martinsen (2002, 2005). Thepresent study revealed how the quick waysassumed an important role in nursing carein the endoscopic clinic when, for example,the nurses prepared the endoscope, suppliedthe intravenous access, and assisted thephysician. Particularly important, though, isrecognizing that the slow ways were presentat all times. The slow ways were interpretedto take the form of the nurse using her eyesand ears and the use of physical touch. Forexample, the nurses told of how a merehandshake could reveal much informationabout a patient’s condition and state ofmind. Thus, the senses evoked by this phys-ical touch were an important instrument in

getting to know the patient. The nurses alsoexpressed how their hand on a patient’sshoulder could quickly reveal if he wastense. Again, this is interpreted as an exam-ple of the nurse’s ability to activate theirslow ways of obtaining knowledge.

Research confirmed that patient’s wish toreceive nursing care in which the nurse ispresent, aware, and ready to take care ofthem whenever necessary (Allen, 2002;Mcilfatrick et al., 2006; Nyström, 2003). Inthe present study, physical touch was inter-preted to be an instrument showing thenurse’s presence and readiness to help.Brenchley and Robinson’s (2001) researchon the subject of outpatient nurses arguedthat the nurse often personalizes the pa-tient’s first meeting in the out-patient hospi-tal and that her adopted role is experiencedto be a very important instrument in gainingthe individual patient’s trust and confi-dence. These aspects are considered to easethe patient’s visit at the out-patient clinic. Itis further argued that being is as importantas doing. Brenchley and Robinson’s (2001)research, thereby, seemed to underscore thatemphasis is placed on the emotional aspectsof nursing and to outline a possible gap be-tween being and the doing. The questionthat needs to be asked is whether being anddoing could be interpreted to enhance eachother rather than as being perceived as eachother’s counterpoints. For example, in thesense that doing will only be experienced tobe well-performed if the nurse also knowshow to incorporate some kind of being.In research on physical caring by Gardnerand Wheeler (1987), patients defined physi-cal comfort and efficiency while assistingwith a procedure as instances of caring. InAllan’s (2002) research among patients in afertility clinic, physical comfort is found tovary from “being there” to giving a caringpat or talking a patient through a procedure.We suggest that physical touch and the op-portunity to hold onto the nurse’s hand inthe endoscopic clinic represents a form ofphysical attendance that offers the patientreassurance of the nurse’s ability to be pre-sent and her readiness to help. Physical


2011, Vol. 15, No. 3 39

touch, thereby, mediates an emotionalawareness and the nurse’s recognition ofwhat the patient has to go through in orderfor him to manage the gastroscopy. The actalso becomes recognition of the patient andhis experience of gastroscopy as a verystressful and daunting situation. The nurse’shand on the patient is therefore a way of re-lating to the patient.

According to Näden (1999) the prerequi-sites for practicing nursing as an art are: (a)Having an understanding of human values,(b) Developing the use of one’s self, (c)Being sensitive, (d) Having the ability to“see well,” (e) Having knowledge of humanintegrity and suffering, and (f) Having theability to seize opportunities. When the pa-tient expressed feelings of security, confi-dent, satisfaction, and gratitude, the use ofphysical touch may be interpreted as a re-sult of a nursing care practiced as an art.Though, when the patient was left with feel-ings of insecurity and distrust, nursing carenever became an art.

The patient’s emotional response to thecare delivered in those situations where thenurse was unable or maybe even unwillingto employ physical touch was either a feel-ing of rejection and insecurity or a feelingof reassurance that hinged on the nurse’smessage given before the procedure that shewould be there for him if needed. The pre-sent study seems to show that the patient’sreaction reflected the level of confidence al-ready established in the patient-nurse rela-tionship. Thus, if confidence was high, thepatient would feel reassured; if not, the pa-tient would feel anxious. Future researchshould be conducted to further explore thisissue.

As professionals, nurses are bound by aduty of care (SSN, 2003) to protect and dono harm to those in their care. This set ofprinciples underpins a nurse’s own moralobligation to provide optimum treatment.The professional code of conduct furtherstipulates a need to gain consent prior tocare delivery, while respecting the patient’schoice and rights to decline the proposed

treatment. Nurses in the endoscopic clinicconstantly seemed to be facing the chal-lenge of balancing between their duties ofcare by ensuring that the procedures werecarried out in a safe manner and the need torestrain the patient against his wishes.Physical touch may be interpreted as an in-strument employed to keep this balance.

The question of balancing between re-straining and respecting the patient’s auton-omy in geriatric nursing has been discussedby Yamamoto and Aso (2009) in their re-search on the ethical dilemma of restrainingolder people with dementia and by Kontioet al. (2010) in their research on the ethicalalternatives to seclusion and restraint inpsychiatric nursing. The question is also ad-dressed in pediatric nursing by Hull andClarke (2010) who discussed the issue ofrestraining children for clinical procedures.In their research on pediatric nursing,Lambrenos and McArthur (2003) intro-duced the concept of “clinical holding,”which they defined as, “…positioning achild so that a medical procedure can becarried out in a safe and controlled manner”(p. 31). The matter of balancing between re-straining and respecting the patient’s auton-omy has not yet been discussed in nursingcare in somatic facilities for short-term stay.The clinical holding, as described in pedi-atric nursing, is interpreted to be somewhatsimilar to what was practiced in the endo-scopic clinic. The offer of holding onto thenurse’s hand can be interpreted as an extraprecaution to protect the patient. Thus, mostpatients recognized that if they reached outand pulled the endoscope during the gas-troscopy, they would most certainly inflictharm upon themselves. The nurse’s choiceto leave her hand resting close to the pa-tient’s hand during the gastroscopy could beinterpreted as a way of foreseeing the pa-tient’s reaction to the gastroscopy. If he wasto reach out for the endoscope, she had theability to take his hand. The nurse’s choiceof asking the patient prior to the gas-troscopy, if he would like a hand to holdonto during the gastroscopy enabled her to

balance her own moral obligation to pro-vide optimum treatment against her respectfor the patient’s choices and rights. Itseemed very important for the nurses to jus-tify their choice of holding policy, whichimplies that they constantly battled to keepthis balance between holding hand and re-straining the patient.

In the past decades, research has debatedthe use of technology in nursing (Barnard &Sandelowski, 2000; Hawthorne &Yorkuvich, 1995). This debate has oftenpresented the emotional and relational as-pects of nursing care as a paradigm of careopposed to the technological and instru-mental aspects of nursing care. In the pre-sent study, the technological andinstrumental aspects of nursing care are ex-hibited by the nurse’s use of her free hand toperform technical skills.

In their research on technology andhuman nursing, Barnard and Sandelowski(2000) stated that technology is not neces-sarily opposed to humanizing care, but isoften, specifically and deliberately, enrolledin the service of that care. The claim is thatthe power any technology exerts derivesfrom how it acts out in any given situationand from its meaningfulness. In Nyström’s(2003) research on nursing care in aSwedish emergency department, practicalskills were described to be highly valued,whereas what is described as “the caring at-titude” is not considered a part of a profes-sional nursing competence. Mcilfatrick(2006) described the work of the nurses inthe day hospital giving chemotherapy to bevery task oriented and to be rooted in thenurse’s fundamental concern for the pa-tient’s welfare and the need to maintain bal-ance between providing emotional supportand performing multiple tasks. However,this balance is found to be very difficult tomaintain.

In the endoscopic clinic, the task orienta-tion in nursing was very obvious as werethe nurses’ constant strive to maintain thebalance between these multiple technicaltasks and the caring aspect of nursing. The



nurses found their technical skill perfor-mance to be extremely important, but at thesame time they seemed aware that thisfocus on technology inevitably meant lessfocus on the patient. The tasks performedwere experienced to include more than adisplay of technical skills performed by thehand, since most work of the hand was ac-companied by a vocal explanation and sometype of physical touch. Furthermore, eyecontact and vocal explanations were used asvalid replacements for physical touch whenphysical contact with the patient was re-stricted. Thus, use of the physical touchalone or in combination with the vocal ex-planation and eye contact can be interpretedas ways of keeping the balance between thecaring and the technical aspect of nursing.We argue that how the patient experiencesand responds to the task performed by thenurse depends on the focus of her nursing.When the nurse was able to keep focus onthe patient instead of on the task performed,the nursing was experienced as present andcaring. If focus was on the task performed,the nursing was occasionally experienced asdistant and impersonal.

Conclusion

This study concludes that physical touchin facilities for short-term stay may be inter-preted as evidence of the caring aspects(i.e., ethical, emotional, relational) in nurs-ing care. The art of holding hand in thiscontext was found to display dimensions ofconfidence building, readiness to help,keeping balancing between comforting andrestraining, and the technically skilled hand.

In line with good communication, theability to listen, and the ability to be there,physical touch was shown to an importantinstrument employed in building a patient-nurse relationship of confidence in the facil-ities for short-term stay.

The study suggests that the physicaltouch and the opportunity to hold onto thenurse’s hand in the endoscopic clinic repre-sented a form of physical attendance thatoffered the patient reassurance of thenurse’s ability to be present and her readi-

ness to help. Furthermore, the study impliesthat touch was employed to help the nursesin their constant struggle to keep a balancebetween holding hand and restraining thepatient against his wishes. Finally, the tasksperformed by the nurses in the endoscopicclinic were experienced to hold aspects ofemotional and relational nursing as an addi-tion to the display of technical skills per-formed by the hand.

The complexity of the art of holding handwas evident when the nurse managed to in-tegrate some kind of “being” in her “doing.”Physical touch was deployed not only forinstrumental purposes, but also to serve re-lational aspects of the nurse-patient rela-tionship, i.e., in conformity with the caringaspects of nursing and with the nurse’smoral and ethical obligation toward the pa-tient.

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Author Note

Karin Bundgaard, RNT, MScN, PhD(c), Department of Gastroenterology, Aarhus University Hospital, Denmark and student at theFaculties of Engineering, Science, and Medicine, Aalborg University, Aalborg, Denmark; Karl Brian Nielsen, MScE, PhD, Professor,Department of Production, Faculties of Engineering, Science, and Medicine, Aalborg University, Aalborg, Denmark; Erik Elgaard Sørensen,RN, MScN, PhD, Post Doctorate, Clinical Research Unit, Aalborg Hospital Science and Innovation Center, Aalborg Hospital, AarhusUniversity Hospital, Aalborg, Denmark.

Correspondence concerning this article can be sent via Internet to [email protected] authors would like to thank the Danish Society for Nursing Research for financial support for the language revision of the article.

Documents

The Art of Holding Hands