Touch, Massage & Nursing
In the nineteenth century Per Hendrick Ling, a Swedish doctor, developed his own system of massage after visiting China, this ‘Swedish Massage’ becoming popular among physicians as a form of treatment. At the Radcliffe Infirmary, in Oxford, ‘rubber nurses’ were trained to massage stiff joints and fractured limbs (Barclay 1994). Archives at University College and Middlesex Schools of Nursing show that nurses were being trained in massage in the early twentieth century. During both World Wars massage was used by nurses in the rehabilitation of wounded men. The increased use of technology in medical and nursing care has been a major factor in the decline in the use of massage by nurses and physiotherapists. So massage is not ‘new’ to nursing but although it is gaining in popularity, its use within contemporary nursing should not be taken for granted. Massage requires specialised knowledge and skills and the rationale for its use must be clearly defined.
This article will look at some of the reasons why nurses feel comfortable about including massage in their repertoire of therapeutic skills, exploring practice that runs from purposeful nurturing touch to a specific therapeutic intervention requiring complex knowledge and skills. The literature will be reviewed in order to develop some understanding of the concept of touch within nursing.
Touch and nursing
The use of touch is an inherent component of the provision of nursing care (Lawler 1991). A number of studies have explored touch within nursing practice from different perspectives and have emphasised the complex nature of a very powerful means of communication that is an aspect of caring central to nursing practice (Weiss 1979: Simms 1988: Bottorff 1993).
Touch has been identified as the earliest sense to develop in humans, providing a fundamental means of interacting with the environment and others (Montague 1986). Tactile stimulation is necessary for physical survival and has biological significance in the nurturing and healthy behavioural development of the individual (Bowlby 1984). Touch and touching are complex phenomena and may be acts of great significance or may be taken for granted. Touch can enhance verbal communications and facilitate social interaction including information giving and the expression of feelings (Sims 1988). Unlike verbal communication, the message conveyed through touch cannot be easily changed or corrected (Argyle 1975) so there is potential for misinterpretation. Pratt & Mason (1981) suggest that touch is used by the majority of people in a ritual form to indicate the relationship existing between one person and another and requires some kind of contract between the people concerned.
Nurses have the permission of society to seemingly violate norms because touching others intimately is a component of the physical contact between nurse and patient which is an integral, unavoidable aspect of day-to-day care (Estabrooks & Morse 1992). This ‘nursing touch’ has been assigned to a variety of categories in the literature. Routasalo (1996) describes two different types of touching – necessary and non-necessary. This typology can then be sub-divided to uncover the complexities of a key nursing skill. ‘Necessary touch’ can cover procedural (Barnett 1972), instrumental (Watson 1975) and task touch (Estabrooks & Morse 1992). These can also be grouped under the heading of functional touch (Vickers 1996). ‘Non-necessary touch’ touch is defined as ‘spontaneous physical contact between nurse and patient’ by Routasalo (1996) and can include expressive (Watson 1975), comforting (Morse et al 1994), reassuring (Teasdale 1995) and caring touch (Seaman 1982). These can be grouped under the heading of affective touch (Vickers 1996).
Traditionally, nursing has tended to focus on the ‘instrumental’ acts of touching (Sims 1986) such as helping a patient to eat or take medication. Such practices are often easily observed and measured thus providing security, the nurse can be seen to be busy. Many ways of identifying nursing workloads, and indeed the nature of nursing, have tended to assume that these types of activities are all that nursing is about. It is a reductionist approach that predicts that nurses help people to get better by caring for them and doing to them, many actions, usually of a manual technical nature associated with a disease diagnosis (Wright 1995). There is a move in nursing away from these tenets and a shift towards the softer and difficult to define expressive things that make up nursing practice.
Touch is a useful therapeutic tool in nursing.
The amount of physical contact exercised in a society is governed by sets of fairly well-defined behavioural norms which provide for the individual’s role and for the situation they are in (Pratt & Mason 1981). Jourard (1966) identified that the incidence of touching within Western society declines from childhood but Montagu (1986) found that the need for touch did not diminish with age. However, Day (1973) noted that whilst younger patients saw the use of touch as a positive aspect of nursing care, older patients thought that touch should only be used for specific conditions such as pain, depression and loneliness. It has been suggested that the frequency of the need for touch which was common in childhood can recur in situations of incapacity and sickness (Barnett 1972). This may mean that the need for touch in illness might outweigh notions of proper behaviour. In the care context touch is primarily used as a form of communication (Barnett 1972) but can also be used within physical care, to ‘reawaken’ and maintain the older person’s perceptual and sensory abilities (Burnside 1973). In a study by McCann & McKenna (1993) the perceptions of comfort and being touched by nurses appeared to be linked to the part of the body touched and the gender of the nurse initiating that touch. Day (1973) also noted that patients would need to know ‘their’ nurse before the touch would provide the support and comfort that they required. Davidhizar & Giger (1997) whilst acknowledging the important role that touch can play in the nurse patient relationship, also point out that the value of touch is not appreciated by all health professionals or considered appropriate or desirable by some patients. Touch and lack of touch are intriguing and complex entities because the meaning of touch varies from one person to another and from one situation to another.
Massage and nursing
Massage has been described as an extension of purposeful touch which may enable nurses to use touch to its full potential (Tutton 1991). Massage is generally defined as a systematic form of touch using certain manipulations of the soft tissues of the body by the hand for therapeutic purposes such as the relief of pain and promotion of comfort (Sims 1988: Tutton 1991). In this sense massage is seen as comprising specific strokes or techniques. For example ‘effleurage’ is a longitudinal stroke, where the hands are placed flat on the area to be massaged, usually the back, and moved slowly in a gliding motion with light to moderate pressure. Another stroke or technique is ‘petrissage’ which involves deeper pressure applied by the fingers and thumb, often in a circular movement. These strokes or techniques are part of the conventional understanding of what ‘massage’ might mean in the context of nursing care. The therapeutic intervention used in the methodology of the studies by Sims (1986), Fraser & Ross Kerr (1993) and Tutton (1987) was a back massage that included the strokes described above. The therapeutic benefits identified were the relief of anxiety, and tension, promotion of relaxation, improved nurse/patient communication and the increased well-being of the patient. A significant problem in relation to the integration of massage into clinical nursing practice is that generally the literature does not make explicit the variety of techniques that might constitute the term ‘massage’ (Vickers 1996). Massage is often used in the literature in such a loose way as to suggest that there is a single, standardised technique that would form the therapeutic intervention. Some of the literature from journals selected for this article whilst specifying the part of the body massaged and giving an indication of the duration of the massage, did not go into great detail as to what techniques were used. Other variables that might indicate the necessity for a range of skills and knowledge are the part of the body massaged and the duration of the massage. Some examples of the potential range go from the 5 minute back massage described by Fraser & Ross Kerr (1993), through a neck and shoulder massage lasting 10 minutes by Farrow (1990), 30 minutes for a back massage by Corner et al (1995), a massage taking an hour on body parts to be negotiated described by Bredin (1995), to a full-body massage that could take an hour or more, used in the study by Wilkinson (1995). The length of time the massage takes may be in direct relation to the level of knowledge and skills required but we do not know this from the literature.
Another issue is that in general the studies do not explore in depth the nature of the relationship between the nurse and the patient although in some cases this was part of the rationale for using massage. If a nurse used this as her prime reason, would the knowledge and skills be different for example, from using massage to relieve pain?
Why is massage being used in nursing?
What do nurses mean when they say that they use massage in their practice? Why use massage? Are they using massage to address nursing problems? If so what nursing problems are they addressing? Two sources have been used to explore the rationale of nurses who have introduced massage into their clinical practice. The first source is an analysis of a survey that looked at the use of complementary therapies by nurses and the second source is a selection of literature that was analysed in order to find areas of comparison in the understanding of the therapeutic potential for the use of massage in nursing.
In 1992 a questionnaire was sent to cover the nine Units in a district health authority and a representation of the clinical areas within them to ascertain the extent to which essential oils and massage were being used within nursing practice. When the question about the use of massage was analysed some of the reasons for using it included: as an aid to sleep; to help relaxation; to promote comfort; to improve movement in the care of patients with osteo-arthritis and to enhance communication between nurse and patient.
From the replies three broad categories were identified in relation to the:
• therapeutic potential of massage in promoting relaxationIt was demonstrated that a high proportion of the nurses surveyed could be quite particular in terms of how they were using massage in their clinical practice. Specific nursing problems together with the promotion of relaxation were the main categories of rationale to be put forward for the use of massage.
• therapeutic potential of massage for a specific nursing problem
• enhancement of nursing care by using massage.
Promoting relaxation taken in a general sense, was the main motivation for nurses using massage. Relaxation is also one of the most widely discussed benefits of massage in the general literature (Vickers 1996). If ‘relaxation’ is classified as a nursing problem then the majority of the respondents were integrating massage into their clinical practice in response to a specific patient/client need. Only a small proportion of the respondents articulated the general concept of enhancing patient care but this may have been a catch all way of answering the questionnaire quickly. The analysis showed that where nurses were using massage in their clinical practice it was for a wide spectrum of nursing problems and in a broad range of specialised clinical areas. The analysis highlighted some reasons why massage might be used as a therapeutic intervention but it did not indicate exactly what the ‘massage’ being used entailed in terms of its physical technicality or the complexity of the context of care. Nevertheless the results of the survey do give an indication of the reasons for using massage as a nursing intervention.
A review of 17 references from the literature were analysed to identify the reasons given for the use of massage within clinical practice. When the responses from the survey and the references in the literature were compared within the three categories, there were points of commonality in the rationale of the nurses in the survey and the rationale reported in the literature.
The analysis of the survey and literature indicates that there are patient-centred concerns and problems within nursing practice such as reducing anxiety and stress and the relief of pain, which might be legitimately addressed by using massage as a therapeutic intervention. Promoting relaxation was clearly the single most common justification for using massage in both the survey and the literature. In two studies, Tutton (1987) and Fraser & Ross Kerr (1993), it was demonstrated that back massage could be an effective, non-invasive technique to incorporate into nursing practice for promoting relaxation and improving communication. In particular, Fraser & Ross Kerr highlighted the dehumanising effects of a health care system where technological advance and cure are dominant, that has serious and profound implications for the person who is chronically ill and that the effects of human touch and interaction are important factors in caring. They saw massage as a valuable nursing technique.
There is a scenario in a book called The Value of Nursing published by the Royal College of Nursing (1992) in which a nurse describes how she calmed a patient with Huntingdon’s Chorea by ‘rubbing the back of his neck and stroking his hair at the base of his skull’. The nurse had seen the patient’s wife do this and ‘It seemed a natural and comfortable thing to do’. It is apparent that there is a continuum of activities and skills relating to touch and massage when used in nursing care and these would dictate the type and level of training needed. Massage is valued by many nurses but in order that the therapeutic potential can be realised more research is needed. For the true integration of massage into nursing practice the rationale for its use must be explicit and evidence-based.
A significant issue is that massage is a personal therapy in every sense of the word, and therefore must be used with care, discretion and discipline (Mason 1988).
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