Touch: knowledge and considerations for nursing practice

The COVID-19 pandemic has brought about many behavioural changes, including social distancing. Older people have been disproportionately affected, because Public Health England (2021) and other public health bodies advised that they should take particular care regarding potential contact with SARS-CoV-2 vectors and withdraw from previous day-to-day activities, such as shopping and attending community and faith activities. The social isolation and consequent loneliness, together with fear, were an emotional feature of COVID-19 (Brooke and Jackson, 2020). In a small telephone interview study (Brooke and Clark, 2020) 19 older people living in England and the Republic of Ireland described how they adapted their lives in light of the public health advice and, while they had had good lives, they still valued aspects of life that made their lives worth living.

These behavioural changes have heightened awareness of how we think about touch when we can no longer get close to or hug non-household relatives and friends. Durkin et al (2021a) argued that: ‘Touch is fundamental to the human experience’ (p4), and its limitation or elimination results in touch hunger and emotional suffering. Yet, there is remarkably little research on the topic of touch, despite its importance within non-verbal communication as a means of conveying support, reassurance, care and compassion, both within nursing practice and daily life. Touch is a key component of delivering nursing physical care and can convey empathy and compassion, while also creating a bond with a patient (Durkin et al, 2021b). The Francis report (Mid-Staffordshire NHS Foundation Trust public inquiry, 2013) noted a deficiency of such intentional caring practice and the lack of compassion shown by nurses.

This article attempts to summarise the state of knowledge around touch. It is acknowledged that there are negative forms of touch that are associated with anger and conflict, such as slapping and hitting, but these negative forms of touch are not the focus of this article. Additionally, it is not suggested that touch can substitute for other forms of non-verbal communication, such as eye contact and facial expression, within nursing practice, which, like touch, have been altered during the pandemic by the wearing of personal protective equipment (PPE).

The skin is the sense organ of touch, and its nerve endings constantly pick up data about pressure, vibration, pain and temperature, which can be interpreted as pleasure or discomfort. It is thought that foetuses in utero experience touch before other senses, which partially explains why infants like to be swaddled and appear to be calmer when they are held close to a caregiver's skin (‘kangaroo care’). This tactile sense mediates an infant's first contact with its environment and is crucial to early development (Cascio et al, 2019). Touching others and being touched are elements of social interactions and social relationships across the lifespan and are said to be particularly important during bonding and intimate communication.

Evidence relating to touch

There is evidence that social touch between people can reduce stress and have a calming effect in adults, with a reduction of psychobiological stress responses due to neuro-physiological and endocrine processes after touch (Eckstein et al, 2020). Eckstein et al (2020) argued that touch is a social signal of safety that the recipient interprets as indicating that things are alright, thereby inhibiting stress and fear responses through one of two neural mechanisms: inhibition of the amygdala fear response via the posterior insula or activation of the reward system for facilitating approach behaviour, that is, the rewarding effects of safety signals inhibit the normal aversive system. Studies have found that touch activates the low-threshold unmyelinated peripheral afferent fibres (C tactile (CT) fibres), which respond preferentially to gentle, slow, caress-like stroking at skin temperature, and the sensation is perceived as pleasant, with 3 cm/s stroking on the forearm being rated as more pleasurable and resulting in greater heart rate deceleration in comparison with all other stimuli (Pawling et al, 2017). The CT fibres conduct data at one-fifth the speed to the insular cortex (which has homeostatic functions, including taste and environmental regulation) in contrast with the fast nerve fibre response when the skin is pricked or poked, sending data to the somatosensory cortex (McGlone et al, 2014). McGlone et al (2014) found that slow CT fibres have the function of promoting social bonding through gentle stroking of the skin.

In an experiment involving a stressful task, Grewen et al (2003) demonstrated that cohabiting couples who watched a 5-minute romantic video while holding hands followed by a 20-second hug had a lower reactivity in terms of blood pressure and heart rate to a stressful event. Other studies have reported effects upon plasma oxytocin (OT), norepinephrine (NE), cortisol, blood pressure and heart rate (Grewen et al, 2005; Light et al, 2005). However, touching another person is a diverse behaviour, because people touch one another in many ways, for many reasons and in many contexts. Touch may be considered affectionate if it is intended to demonstrate love or fondness, and it may demonstrate care and appreciation with or without affection. The type of touch that one perceives, in addition to situational, personal, relational and cultural factors, might moderate the interpretation of touch to influence the relational-cognitive path.

There are also cultural norms regarding touch. There are high-contact cultures, such as those in Mediterranean and South American countries, where people touch frequently, including non-close others as part of greeting and, in those circumstances, may not indicate the touch provider's level of regard, because the touch is culturally prescribed. Conversely, in low-contact cultures, such as northern European and northeast Asian countries, where people engage in less interpersonal touch with non-close others, touch may indicate the touch provider's regard for the touch recipient. There are also situational variations, for example, there is more touching in such places such as airports where people greet others physically with handshakes, kisses and hugs.

Jakubiak and Feeney's (2017) research review sets out the evidence regarding touch and its promotion of relational (relationship satisfaction, commitment), psychological (reductions in anxiety, positive mood) and physical (lower blood pressure, fewer somatic symptoms) wellbeing in adults by buffering stress and independent of stress. Additionally, touch receipt has been shown to facilitate recovery after a stressor, which might include a medical procedure. Indeed, simple gestures such as a brief squeeze of the arm or tap on the shoulder can convey an emotional message and affect how someone feels and acts (Eckstein et al, 2020). Murphy et al (2018) conducted a 14-day study about interpersonal conflicts, hug receipt and affect and found that hugs buffer against the deleterious changes in affect associated with experiencing interpersonal conflict, a potential source of stress, confirming the benefits of social touch on mood.

Even in the digital age, touch remains important when shopping, with haptic data obtained through touch providing important information about texture, hardness, temperature and weight for the evaluation of a product (Peck and Childers, 2003). The individual need for haptic data varies considerably, and the provision of sufficient haptic information for those who prefer to touch a product prior to purchase is one of the challenges for online retailers. It seems that the need for touch data has international validity, but there is a moderating effect of gender and sense of touch on consumer intentions, with females rather than males self-reporting the negative effects of no-touch opportunities in two carefully designed marketing studies testing the Need for Touch scale (Vieira, 2012).

The Touch Test

The Wellcome Collection, in collaboration with BBC Radio 4, commissioned an online questionnaire study (The Touch Test) led by Professor Michael Banissy of Goldsmiths, University of London, which collected data from a self-selecting sample of almost 40 000 people across 112 different countries between 21 January and 30 March 2020 (BBC, 2020; Wellcome Collection, 2020). This online study is one of the largest on contemporary attitudes towards touch and experiences of touch undertaken just before and briefly overlapping with the beginning of the first lockdown associated with the COVID-19 pandemic in the UK.

Although most people (72%) reported positive attitudes on the measurement scale about being touched, over a quarter (27%) of the participants reported negative feelings and, therefore, it cannot be assumed that everyone likes being touched. The study examined a number of factors, such as age, gender and geographical location, and their relationship with attitudes towards touch and found that personality had the strongest association with attitudes towards touch; people who reported that they liked touch tended to score higher on extraversion, openness to new experiences and agreeableness, especially if the touch involved non-family members. An individual's relationship style also had a strong association, with those preferring to be independent in their relationships and who found getting emotionally close to people difficult reporting less positive feelings about touch. Just over half (54%) of the sample reported that they had too little touch in their lives, with only 3% reporting that they had too much touch in their lives. Two words-‘comforting’ and ‘warm’-were among the three most common words used by people in every region of the world to describe touch, with the word ‘love’ also being reported frequently.

Almost two-thirds (63%) of the sample reported that they disliked being touched by a stranger, and, when asked where it was okay for a stranger to touch them, the only place was the hand. Nearly four-fifths (79%) of the sample liked being touched by a friend, and there were different preferences where it was acceptable to be touched compared with a stranger, and it is likely these preferences varied by the closeness of the relationship.

Most (>60%) women and men reported that touch had a positive effect on their sleep, with a stroke or a hug being the most popular form of touch. The sample was divided as to whether there has been a change in the amount people touch each other over time, with one-third of the sample reporting that there had been a reduction, while half of the sample reported that there had been no change. Those who reported a lack of opportunity to touch cited the issue of consent, followed by a lack of social interaction. Interestingly, those in the sample who reported that they liked interpersonal touch also tended to have higher levels of wellbeing and lower levels of loneliness, which confirms empirical findings regarding the association between consensual touch and psychological and physical wellbeing (Jakubiak and Feeney, 2017; Eckstein et al, 2020).

There is increasing interest in intelligent robots within everyday life and in healthcare as service machines, as exemplified by robotic surgical devices. However, robots may also be able to interact with humans in a way that supports psychological and physical wellbeing and partly compensates for the lack of touch, especially when there is a shortage of care staff to give social touch to older people living alone who may be lonely (Eckstein et al, 2020), much in the same way that a pet provides companionship (While, 2017). This raises the question of whether the beneficial effects of touch depend on the social source of the tactile stimulation (Eckstein et al, 2020). In the Touch Test sample, while many reported that they would use a massage chair to replace a human massage, 46% reported that they were definitely not very interested in a device to allow them to shake hands remotely (BBC, 2020; Wellcome Collection, 2020).

Therapeutic touch

Despite the popularity of complementary therapies and non-pharmacological interventions to promote recovery and wellbeing, there is remarkably limited evidence regarding the benefit of therapeutic touch within nursing practice. This, in part, reflects the difficulty of both running a trial with a touch intervention in nursing practice and the challenge of gaining funding for such studies.

An early review by Peters (1999) held on the Database of Abstracts of Reviews of Effects (DARE), which included nine studies reported between 1986 and 1996, suggested that therapeutic touch may have a medium effect. However, the review methods do not meet standards of rigour, and the study data should not have been pooled, due to the heterogeneity of the included studies. Another early review by O'Mathúna (2000) reported a range of problems with both the varied studies of therapeutic touch and the published reviews, but concluded that this review revealed ‘the importance of spending time with patients and addressing personal needs’ (p284).

More recently, Robinson et al (2007) reported in a Cochrane review that they could find no randomised or quasi-randomised controlled trials of therapeutic touch for anxiety disorders. Hansen et al's (2006) review of a range of massage and touch therapies on conditions associated with dementia, which included two randomised controlled trials meeting their minimal methodological criteria, concluded that there was a very limited amount of reliable evidence in favour of massage and touch interventions for problems associated with dementia, but more research was needed. The two included studies comprised a hand massage intervention and a touch and a verbal encouragement intervention for normal nutritional intake.

Furlan et al's (2015) Cochrane review included 25 trials of massage therapy for adults with nonspecific lower back pain. They concluded that massage was not an effective treatment when compared with inactive controls (waiting list, no treatment or sham) or active controls (which included manipulation, mobilisation, transcutaneous electrical nerve stimulation, acupuncture, exercises or self-care education). They noted that the trials were compromised by bias, because it was difficult to standardise the massage performance, and there was likely to be measurement bias, because it was difficult to blind the participants.

A small Australian study (eight patients and four nurses) (Durkin et al, 2021b) conducted across a range of purposively selected clinical settings in an acute hospital during 2018/19 reported how compassion was conveyed and received through touch. The patients received compassion through touch, which provided a feeling of safety and comfort and also formed an ‘authentic’ connection with the nurse. The nurses reported using both deliberate and incidental (integrated into a care activity) touch to express compassion, but were mindful of the meanings of touch, so it was used appropriately and was respectful of patient preferences. In the absence of larger studies, these findings confirm the non-nursing research data, which consistently indicate that consensual touch has both psychological and physical benefits, from which community nursing clients can benefit, especially if they have limited social touch in their everyday lives or if they are lonely. Boxes 1 and 2 summarise the potential forms of touch within nursing practice and key considerations prior to touching a client.

Box 1.Potential forms of touch within nursing practice

Box 2.Key considerations related to touch

Nursing practice and the COVID-19 pandemic

The nature of nursing practice, especially contact care, has been significantly impacted by the COVID-19 pandemic, with an emphasis on social distancing and minimal contact, even when protected with full PPE. A qualitative literature review of nurses' experiences of caring for COVID-19 patients included nine studies, six of which were conducted in China, and focused wholly on nursing in hospitals (Joo and Lui, 2021). Reflecting the emerging knowledge of SARS-CoV-2, many nurses reported limited information on which to base their practice, although others reported too much information, making it difficult to keep abreast of all the information. The pandemic resulted in unpredictable and challenging nursing practice, especially because there was a lack of practice guidelines with limited preparation and reorientation to the new context of care. The perception of insufficient support was widespread and included lack of PPE, as well as staff shortages and inadequate resource management. Nurses also reported concern for their families and their families' safety in case they transmitted the virus to those in their homes. As has been reported elsewhere, across the studies, nurses reported psychological stress, anxiety, fear, emotional exhaustion and even depression. It is difficult to extrapolate these findings from studies of hospital nurses to nurses working in the community in the UK, but it is highly likely that community nurses have also experienced pressures, with increased workloads alongside isolated working with the constant risk of the presence of SARS-CoV-2 in households in their caseloads and heightened cross-infection concerns.

McCarthy et al (2021) noted how the COVID-19 pandemic has impacted the communication between nurses and their patients, with the presence of PPE and, in particular, face masks, presenting barriers to effective therapeutic engagement. They proposed a communication model ‘TARGEET’ (T: tune in, A: approach and introduce, G: ground self, E: engage and respond, end encounter, T: tune out), drawing on empirical literature as practical guidance within the constraints of COVID-19. The COVID-19 pandemic has created additional challenges to incorporating touch within nursing practice, with the emphasis on minimal contact, even when protected with full PPE. Indeed, normal infection control measures often require the wearing of plastic gloves, which diminish the quality of the experience for the touch recipient and may also have the subliminal message that the individual is ‘dirty’ and/or ‘untouchable’.

Conclusion

The COVID-19 pandemic has brought about behavioural changes and has interrupted normal communication, including the use of touch, in many settings. Touch is an important experience within people's lives, and the COVID-19 pandemic has given it a new resonance in the wake of social distancing and other restrictions. High-quality non-verbal communication is a key component of community nursing practice, and the appropriate use of touch within clinical practice has the potential to augment the client's experience and convey compassion, but care is needed to respect the nuanced and varied preferences across different individuals. When normal times return, community nurses should consider how they can incorporate appropriate touch within their nursing interventions to maximise its benefits for their clients, being mindful that the wearing of plastic gloves may reduce the pleasurable experience.

KEY POINTS

• Touch is an important form of non-verbal communication within nursing practice, with psychological and physical benefits
• Touch preferences vary across individuals and need to be carefully considered even in the nursing context
• Touch conveys support, reassurance, care and compassion
• The COVID-19 pandemic has had an impact on various social aspects of life, and people have not been able to benefit from the therapeutic effects of touch
• The wearing of personal protective equipment reduces the pleasure induced by touch

CPD REFLECTIVE QUESTIONS

• What factors inhibit the use of touch within nursing practice?
• How might nurses increase their use of appropriate touch within their nursing practice?
• Plan a teaching session for a student regarding the benefits of touch within nursing practice