TIP OF THE MONTH: December 2014 / January 2015 
Making Sense Out of Touch; Maintaining the Patient Connection In Our EMR World
Second-Place Article, 2014 Paper of the Year Competition

by Elizabeth Meyers, OTC, CST/SFAC

Consider a time when you were touched and the experience made an important impact on you. Was it a positive or a negative impact? Either way, you learned that touch:
1. Doesn’t necessarily mean physical.
2. Can make an immediate impression.
3. Can have a lifelong impact!

Now consider the patients that you care for on a daily basis. How can you as a health care provider offer a positive encounter with patients in the short amount of time spent during a busy clinic? Touch can change “clinical” into “cared about”.

The obvious thought when you hear touch is physical touch. Touch is the first of the five senses that we acquire.

Skin

Skin is our largest organ. It is a tactile system. Skin has a memory, and it protects the body. Skin can be considered an exposed portion of the nervous system. As a sensory system, the skin is the most important organ system of the body. Skin likes to be touched.

Touch

Touch affects both the person being touched and the person providing the touch. Touch is essential to our species.

Touch reduces stress and lowers blood pressure, decreases depression, improves our immune system and releases oxytocin, which is also referred to as the cuddle hormone. Touch is a potent and powerful form of communication, holding great potential to use or misuse, heal or harm, and can convey intimacy or dominance.

Touch is one of the most essential elements to human development. It is a profound method of communication, a critical component of the health and growth of infants, and a powerful healing force. Ample research has demonstrated that tactile stimulation is extremely important for development and maintenance of physiologic and psychological regulation in infants, children and adults. Touch has been an essential part of ancient healing practices. Touch has roots in Shamanic and religious practices, and is reported to have been an integral part of health care practices and medicine since their emergence from the realms of religion and magic.

Touch strengthens relationships, encourages trust and increases cooperation. During times of intense grief or fear and in ecstatic

moments of joy or love, only the language of touch can fully express what we feel. Touch is the best way to comfort, give solace and heal. We have an innate ability to decode emotion via touch alone.

Touch has a high degree of cultural relativity. Be cognisant of the cultural differences when it comes to touch, as same-sex and opposite-sex touch can have different implications.

It is also important to realize that to some, physical touch can be uncomfortable. These perceptions of touch may have developed from past experience, psychosocial, psychiatric or cultural beliefs. While most people are comfortable with appropriate touch, given or received, there are those that for multiple reasons may find physical touch offensive, threatening or uncomfortable. For this reason, keen observation and understanding of a patient’s history is key. Physical touch should be preceded with understanding, intention, observation and respectful compassion. If ever in doubt ASK! Care should be taken to consider what is appropriate for the situation, stroke vs. squeeze, quality of touch, duration, intensity, and where to touch. Shoulders to hands are considered safe zones.

Types of Physical Touch

Conversational Marker: This form of touch, which takes place during a conversation, is intended to make or highlight a point or to get ones attention. It often manifests as a light touch on the arm, hand, back or shoulder. Accentuated touch or physical punctuation can also take place at times of silence or stillness, often with the purpose of accentuating presence and conveying attention.

Consolation Touch: Holding of the hands or shoulders or providing a comforting hug usually constitutes this kind of supportive or soothing touch. It is most often done in response to grief, sorrow, distress, anguish, agony, sadness or upset. This is one of the most important forms of touch and likely enhances a therapeutic alliance.

Reassuring Touch: This form of touch is geared to encourage and reassure clients and usually involves a pat on the back or shoulders.

Playful Touch: This form of touch may involve physical or verbal play with a child.

Grounding or Reorienting Touch: This form of touch is intended to help reduce anxiety or dissociation. It usually involves helping one to be aware of his or her physical body. Helping the patient touch their own body can assist in reorienting them to a physical change due to injury or illness.

Task-Oriented Touch: This involves touch that is merely auxiliary to the task at hand, such as offering a hand to help someone stand up or bracing an arm around a client’s shoulders to keep them from falling.

Instructional or Modeling Touch: This form of touch is usually part of instructions or modeling regarding how to care for a body part for therapy, dressings or application of appliances.

Celebratory or Congratulatory Touch: This form of complimentary or approval touch can be manifested in a high-five, a pat on the back, or a congratulatory hug with a patient who has achieved a goal or is making satisfactory progress toward a goal.

Referential Touch: This form of touch can be used to reference or bring certain body parts into attention for clinical education.

Clinical (Task-Oriented) Touch

Procedures that are considered simple or benign to you as a health care provider may be the “straw that breaks the camel’s back” to the patient! Consider the patient, who has suffered severe trauma or has a long-term illness and may have met multiple health care providers, gone through invasive testing, multiple medications, treatments, surgical procedures, life changes, financial issues, job loss and emotional distress. As a technician you might see their visit as minor appointment, but the patient might view the visit differently. It is possible the patient cannot bear any more pain, discomfort, loss of control or loss of dignity.

As a compassionate care provider you must realize no patient is the same and consider the patient’s psychological state. They have lost all control of what is happening to their body and their lives; understand there is more to the patient than their medical issues. Their body may not look, feel or behave like their own any longer. This is the point when touch becomes very important.

When greeting a patient enter the room without equipment in tow, explain your intentions, get a sense of the situation; take the time to understand the patient’s history, not just the task at hand. Offer choices to the patient by asking a series of potential questions, for example:
• Where should we start?
• Have you been through this procedure before?
• How did it work for you?
• Is there anything (reasonable) that will help you through this?
• Would you like us to do this together?

Involve the patient in his or her own care. Offer something as simple as a sucker, at any age if not diabetic, sugar does help! Touch is more than physical, it is caring!

When my daughter was young she had her fair share of bouts with strep throat. She would gag and panic when getting a throat culture, which resulted in many attempts to swab a viable culture. I gave her the choice: to be strong and handle it herself, or I could embrace her limbs in mine and hold her head still so they could swab her throat only one time and be done. Her choice was the embrace. It worked like a charm for every experience when she was given the opportunity to make a choice.

I have some patients participate in their care by assisting in removal of their sutures/staples, pins, removal of casts/splints, and dressing changes. I always listen to and allow ideas from patients who have had repeated procedures, and I have learned important lessons from these patients. By allowing the patient to gain some control by participating in their own care, you are touching the part of them that understands you care about them as a whole and communicating they matter to you! This concept applies to all tasks with a patient. Greet patients with no equipment in tow, explain what you propose to do, carry out questions and answers, and then proceed appropriately with the information gathered while connecting with the patient.

If the patient’s family members are present it is important to engage them as well. You will notice the wave of trust, comfort and relaxation go through the family members in the room and ultimately calm the patient or vice versa. At this point, you will visually experience the impact you have had on the patient and family. It is also important to offer the patient and family options as to who should be in attendance during sensitive procedures.

Non-Physical Touch

The face is an extremely developed tool of expression and is a great way to touch others by conveying empathy, concern, understanding or an invitation to communicate you are listening with patience. “Many a man would rather you heard their story than granted their request,” Phillip Stanhope.

Another form of non-physical touch is gestures, offering something to ease the situation and make the patient more comfortable and cared. A gesture could be offering a blanket, putting the patient in more comfortable positioning, getting the patient a drink or snack, calling a family member to sit with them, or simply checking in with them periodically. Getting to know your patient will give you clues on how to best meet their needs physically and emotionally.

The following tips are to help the patient feel cared for. Many of these tips I have learned from patients, family members and friends who have been patients, and from being a patient myself.
• Cool hands are soothing when touching an area of injury.
• When speaking to a patient in bed, raise their head and sit when talking with them. This is a respectful gesture and will diminish the perception of dominance.
• Spend time with the patient, have patience when answering questions, offer answers to questions they didn’t even know to ask, and make the information understandable.
• Repeat complicated information and make sure they have a second or even third set of ears to process everything. Ask the patient if they understand, consider having them repeat what they’ve heard.
• Offer something familiar –music is very therapeutic.
• Pleasing aromas, certain essential oils can make procedures more tolerable.
• Offer suckers, especially if they are having a vasovagal experience. You can possibly prevent a patient from passing out, suckers or juice offer immediate relief.
• Remember that patient’s illnesses and injuries can become a family disease. The family might also need comfort and care.
• If a patient is unresponsive, be sure to address and speak to the patient as if they are responsive, telling them what you are going to do. Ask the family to tell you about the patient’s life outside of medical situations.
• Ask your patient about their life outside of medical situation.
• Clean patients between cast/splint changes or dressing changes, etc. (touch them with dignity).
• Listen and touch with facial expression and body language that convey patience.
• Do not hurry; we have a short period of time to connect with patients if we want to make a difference in their experience.
• Look the patient in the eye and touch on the shoulder.
• When possible, let the patient remain fully dressed when meeting their physician. Leave appropriate attire in the room for them to change into after the initial meeting. This is respectful and also eliminates a perception of dominance.
• Pay attention to body language and proceed appropriately.
• You cannot fully help the patient if you don’t know their history.
• Use a playful touch with children; for very young children you must first gain the trust of their parents.
• When appropriate touch with humor and lightness.
• Encourage touch, cuddling, and intimacy from family members.
• Encourage couples to resume relationships when safe, give them permission to be creative.
• Encourage family members to not get in rut of caregiver – call in favors or give favors.
• Offer distractions and guidance.

Touch with More of Yourself

Without really understanding the patient, as a person, we are never going to be able to help them as much as we are able.

“It is more important to know what sort of Person has a disease than to know what sort of a disease a Person has!” – Hippocrates

About The Author:
Beth Meyers, OTC, CST/SFAC has worked in orthopaedics for 23 years. From the Twin Cities, Beth has held employment in multiple settings including: private practices, one-on-one with orthopaedic surgeons, and in hospitals. She is a first assist in surgery and handles clinical duties. Beth has a wealth of experience, ranging from pediatrics to trauma. She trained with Dr. Ponseti and assisted in implementing his technique in the Twin Cities.

Beth is currently employed at HCMC (Hennepin County Medical Center), a level-one trauma center and public teaching hospital in downtown Minneapolis.