Touch and visualisation to facilitate a therapeutic relationship in an intensive care unit - a personal experience

Louise Green

This paper describes how the nature of touch was explored and utilised in nursing practice to promote a therapeutic relationship between nurse and client in an intensive care setting.

It explains how this, and other complementary therapies such as visualisation and relaxation techniques, were used to facilitate a counselling situation, and also to effect the resolution of acute anxiety as an alternative to the traditional allopathic approach.

THE SETTING

David was a 17-year-old boy suffering from a rare form of muscular dystrophy which caused his body and limbs to become grossly deformed and his respiratory function severely impaired. Despite these handicaps he had managed to live a very full life. With the support of his parents and two siblings he had been able to attend a normal school rather than one which catered only for dis- abled people. On leaving school at 16 he had gained employment in an office as a computer operator, where he appeared to be very popular with his peers. From an early age David’s parents had encouraged an independent lifestyle and had supported him in his quest for a ‘normal’ life. His social life was hectic. He became adopted as hon- orary coach to a local sports team and through this acquired a wide circle of friends. All those

Louise Grem RGN, DipPSN, ENB 100, ENB 998, Sister ITU, Victoria Hospital, Blackpool, UK

(Requests for offprints to LG)

Manuscript accepted 19 November 1993

who knew David testified to his outgoing person- ality, courage, and above all his struggle for inde- pendence.

David had been admitted to a medical ward suf- fering from a chest infection. When this proved slow to resolve and septicaemia resulted, he required artificial ventilation and was transferred to the Intensive Care Unit (KU). Although his general condition improved slowly with treat- ment, his respiratory function failed to improve and the consultant physician felt that his illness had probably reached its end stage. Weaning from the ventilator was considered unrealistic and yet David was fully conscious and totally miserable due to his immobility and the devastating change in his lifestyle. The physician suggested that a tra- cheostomy might at least prolong his life, allowing him to remain ventilated either in hospital or in a special unit for the young disabled. It seemed unlikely that home ventilation was a viable option in this case. It was decided to discuss the possibili- ty of tracheostomy with David’s parents.

David’s parents were extremely supportive of him. Despite the vast amount of resources he had

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required from them over the past 17 years, his two siblings, one older and one younger, did not appear to bear any resentment and were totally devoted to his well-being.

I attempted to discover how much knowledge the family possessed about his illness. David’s mother perturbed me by saying that although they were aware of his disability and the fact that it would never improve, they understood that the disease process was self-limiting and that David would not deteriorate further. This, of course, was not the case. She also maintained that David had had no serious respiratory problems in the past and therefore the entire family was shocked to discover that his respiratory function had deterio rated to the point where he was no longer capable of spontaneous breathing. When tracheostomy was suggested David’s parents felt unable to sub ject him to the procedure, and yet felt equally unable to refuse the procedure - knowing that this refusal might result in David’s early death. It was suggested to them that as David was used to making decisions for himself perhaps he should be allowed to take this one also. His mother felt that this would be a solution, but was concerned that David might not realise how seriously ill he was. I explained that it is quite common for patients, even children, to have a deeper under- standing of their situation than anyone suspects, and that it was possible that David had already addressed the question of whether or not he was going to survive. When asked to approach David about his wishes regarding tracheostomy, I agreed to do this when a suitable opportunity occurred, and began to seek the best way of counselling David regarding his wishes and expectations. The extreme anxiety and distress he was already dis playing prompted my decision to employ some complementary practices to try to promote a ther- apeutic relationship which would facilitate David coming to terms with his situation, and being able

intensive care as a patient (McKegney, 1966; Kleck, 1984; Campbell, 1986)) and yet the lack of effective treatments for these symptoms has led to nurses’ disillusion with conventional methods (Smith, 1990). This has promoted a rising interest in holistic therapies which, though untraditional, address the health of each person as a whole, including physical, mental and spiritual well- being - a holistic approach. Although it is neces- sary for a nurse to receive extensive training in complementary therapies before using them in a clinical area there seems to be a common factor in many of these treatments - TOUCH. Massage, shiatsu, reflexology, acupressure, therapeutic touch and aromatherapy are all therapies based on this sense. They involve the transmission of various tactile messages via the haptic system and may be seen as a treatment or a form of communi- cation. It seems that touch can be a useful clinical tool for a nurse who has not yet undergone spe- cialised training in alternative therapies.

Physical touch is a powerful means of commu- nicating almost any emotion, from acceptance and support to anger and frustration. Schoenhofer (1989) stated that:

Human touch is recognised as a valuable way to communicate caring in nursing situations.

Yet a well-known study by Ashworth (1980) showed that nurses tended to use lip-reading and sign language as a method of communication with their patients rather than touch. Blondis & Jackson (1982) also found that intensive care nurses tend to be preoccupied with the technology sur- rounding the patient, and with record keeping, rather than improving nonverbal communication channels.

Touch has been defined as:

an intentional physical contact between two or more individuals (Watson, 1986).

to make appropriate choices regarding his treat- Various attempts have been made to categorise ment. types of touch. Watson (1986) described

‘Instrumental touch’ as that involving tasks such as dressing a wound, and ‘Expressive touch’ as

RATIONALE that pertaining to a spontaneous demonstration of affection. Schoenhofer (1989) uses three cate-

Much has been written about the deleterious gories: ‘Instrumental touch’ - again, a deliberate physical and psychological effects of experiencing means of facilitating a task, ‘Therapeutic touch’,

INTENSIVEANDCRITICALCARENURSING 53

described by Krieger (1975) as: ‘The simple plac- ing of hands for about IO-15 minutes on or close to the body of an ill person by someone who intends to help or heal the person’, and ‘Affectional touch’. The latter is defined by Shoenhofer as: ‘Tactile communication from one person to another that has, as its primary purpose, the transmission and receipt of signals of recogni- tion, acceptance, protection and caring concern’.

Carl Rogers (1951) claimed that for a human being to function on an interpersonal level he must be shown ‘unconditional positive regard and warmth’. This philosophy has been the basis for several counselling strategies (Egan, 1986), and it seemed that affectional touch might prove useful in facilitating a successful counselling ses- sion with David. However, Schoenhofer (1989), warns that although the intensive care setting may offer situations ideal for the utilisation of affec- tional touch, there is the potential for harmful effects to occur and it was necessary to explore this area before using the concept as part of David’s treatment.

Feltham (1991) describes how, contrary to other cultures, Europeans generally dislike close physical contact, and may regard unsolicited touch as an invasion of their personal space. If David reacted in this way, my intervention caused him even greater distress rather than promoting a therapeutic relationship. Although unable to talk due to the endotracheal tube he was able to com- municate very well by other means including sign language, a writing pad, and the use of electronic gadgets. His deformities made it impossible for him to sit in a chair whilst requiring ventilation, and the enforced bedrest resulted in stiffness of his joints. His mother regularly massaged his back and joints which he seemed to enjoy, so it appeared that David was not averse to some forms of physical contact. He was also able to communi- cate his willingness for me to use touch as a therapy.

Massage is a technique involving:

systematic form of touch using certain manipu- lations of the soft tissues of the body to promote comfort and healing (Feltham, 1991).

Without formal training in this technique it was not possible for me to employ it as a treatment.

Ersser (1990) underlines the importance of ade- quate training in complementary therapies, and warns that nurses using these methods without adequate preparation risk compromising their accountability regarding the part of the Code of Professional Conduct (UKCC 1984) which declares that the nurse should:

always act in such a way as to promote and safe- guard the well-being and interest of patients.

However, it seemed reasonable to assume that the use of affectional touch in the form of back and joint-rubbing would be likely to produce simi- lar effects of relaxation and stress reduction to those provided by formal massage methods.

Studies by Joachim (1983) and Breakey (1982) suggest that massage is contraindicated if the patient has skin lesions, fractures, severe arthritic pain or thromboses. David did not suffer from any of these conditions, and although he was con- fined to bed and therefore at risk of developing an embolus, my attention could be restricted to his back and joints, rather than his leg muscles where rubbing might precipitate the mobilisation of any clot in the leg veins. Research by Tyler, Winslow & Clark et al (1990) suggested that a one- minute back rub caused physiological stimula- tion, and indicated that this may prove deleteri- ous to the condition of critically-ill patients already experiencing reduced oxygen uptake or cardiovascular instability. David’s septicaemia had, by this stage, resolved and he was not appar- ently suffering from either of these conditions, therefore it was considered that they could be dis- regarded as contraindications to the use of touch therapy in this case. In addition, other studies such as Sims (1986) suggest that although an ini- tial drop in SvO, and increase in heart rate may occur on the instigation of back-rubbing, after 10 minutes duration these effects resolved and physi- ological relaxation occurred. Hill (1993) suggests that these transient adverse effects may be due to pain when the patient is repositioned in order to receive the treatment, or to a momentary increase in stress due to the consequent movement of inva- sive lines, tubes or other equipment. Sims’ research (1986) showed that massage had benefi- cial psychological effects on cancer patients, who displayed increased stamina and relaxation fol-

54 INTENSIVE AND CRITICAL CARE NURSING

lowing a back massage of at least 10 minutes dura- tion. It seemed reasonable to assume that these effects may be replicated in patients suffering from other disease processes also.

Hill’s review of the effects of massage in critical- ly-ill patients (1993) also revealed specific bene- fits. Some studies have revealed deep relaxation, improved lymphatic drainage, increased muscle flexibility, reduced blood pressure and heart rate and a correction of any preexistent imbalance within the parasympathetic nervous system (Joachim, 1983; Ashton, 1984). David had a tachy- cardia of 130-140 and displayed other classic signs of anxiety, which I hoped affectional touch would resolve without the need for drug therapy.

Considering all the aforementioned literature I decided to use affectional touch as a therapy for David, both to induce relaxation and promote sleep, and also to facilitate a counselling relation- ship designed to help him to make informed deci- sions regarding his treatment.

IMPLEMENTATION

David constantly asked when he would be able to be rid of his ventilator and go home. As the days passed he became more morose and withdrawn. He slept only for short periods and had frequent episodes of acute anxiety which proved difficult to resolve. His personality change was affecting his whole family, and he no longer displayed his char- acteristic sense of humour when friends visited. Medication such as temazepam to promote sleep and amitryptiline to reverse depression appeared ineffective and it seemed that other strategies were necessary to restore David’s quality of life, however short the duration.

Shortly after discussing the possibility of tra- cheostomy with David’s parents I decided to try to build on the rapport that had been established with him and endeavour to promote a therapeutic relationship. As I approached his bed he again began to communicate questions about his condi- tion and I drew the curtains around the bed to provide some privacy, thinking that this might be an opportunity to discuss treatment options; and that he might need encouragement to shed his

inhibitions and reveal his needs and fears. I asked if he would like me to rub his back and joints as his mother did in order to help him to relax and feel more comfortable. He nodded his agree- ment. His heart rate was 130-140 beats per minute (bpm) in sinus tachycardia and his systolic blood pressure 140-150 mmHg. After some time having his back rubbed with use of affectional touch technique, David had a heart rate of around 100 b.p.m. and his systolic blood pressure was 120-130 mmHg, which seemed to mean that he was relaxing. He continued to ask questions by writing them on a pad. Moving to the other side of the bed in order to make eye contact with David, an important factor in a counselling situation (Egan, 1986)) I began to rub his joints. (Although foot massage is advocated by many nurses and appears a beneficial therapy, David found this unpleasant.) He asked: ‘Am I getting better?’

Whilst continuing the therapy I made eye con- tact with him and replied: ‘Do you feel that you are?‘, thus giving him the opportunity to discuss his feelings and anxieties. In response, he shook his head violently. Sitting close to the bed, and after telling him that I understood how fiustrat- ing it must be to be bedridden and reliant when he was used to being very independent, I explained that I had plenty of time and was pre- pared to stay and talk about anything he wished to discuss. David asked me what was going to happen to him and wrote: ‘I know my breathing isn’t get- ting any better.’

Without contradicting this I gently suggested that a tracheostomy was a possibility, and at the very least it would be more comfortable than the orotracheal tube. Stressing that both his parents and the staff were eager for him to have the opportumty to make his own decision about the procedure, I continued the touch therapy in silence. After some time he wrote: ‘Am I going to die?’

I held his hand and was careful to meet his gaze before saying that I hoped not, but would not make any promises which could not be kept; going on to reassure him that I would always be com- pletely truthful with him and would be available whenever he indicated that he needed to ‘talk’. David seemed to accept this, and after a few min- utes began to relax again. I hoped that, despite a

INTENSIVE AND CRITICAL CARE NURSING 55

sense of inadequacy, I had remained truthful without removing his hope.

Although affectional touch seemed to promote relaxation David was still unable to sleep. I there- fore explored the idea of using visualisation in conjunction with affectional touch to promote sleep, and replace temazepam. Benner and Wrubel (1989), advocate this method as a way of promoting relaxation and as a coping strategy when dealing with feelings of anger. Their phe- nomenological approach to patient care seemed compatible with my desire to provide holistic care for David. Visualisation, or guided imagery as it is also known, involves the patient visualising him- self in a different situation or setting. It is often used as an alternative therapy in cancer care where patients are taught to visualise their healthy cells destroying the malignant ones. It is also used widely as therapy for chronic pain. Passant (1991) and McCaffery (1990) highlighted the advantages of using this type of distraction therapy in con- junction with relaxation techniques and anala- gesics in the treatment of protracted pain. Although David was not in acute pain, it seemed that this combination of treatment might prove beneficial. Passant (1990) states that by using visu- alisation techniques: ‘I teach patients that the mind can move anywhere even though the body may be immobile’.

This concept seemed likely to be acceptable to David who was experiencing severe anxiety about his immobility and his future.

Having experienced visualisation as part of a stress management course some time ago, I felt able to teach David how to achieve muscular relaxation, within his own limitation, in an attempt to facilitate visualisation. After some dis- cussion and much activity with pencil and paper we agreed to use the scenario of a warm, deserted sunny beach with a gentle breeze and the sound of waves lapping the sand. I rubbed David’s back and simultaneously described the sounds and sights of this beach in a suitably quiet, monotonous tone. It was gratifying to feel him relax under my touch and to watch the monitor reflect his drop in blood pressure and heart rate. Eventually he slept! I continued to use this combi- nation of therapies for David and attempted to teach it to other members of staff. But despite

assurances that they would try it I sensed a great deal of scepticism in their approach!

The day after I had counselled David about the possibility of tracheostomy he decided to consent to the procedure. Although the operation was uneventful it did not provide any improvement in his respiratory status. It did, however, seem to make communication easier for him, and he appeared more comfortable without the oral endotracheal tube. Throughout the last days of David’s life I continued to use affectional touch and visualisation to calm him when he was anx- ious and to promote a therapeutic relationship whenever he needed to discuss his fears and feel- ings, and hope it also facilitated relationships within the family. As David’s anxiety subsided he was better able to communicate with his parents and siblings and perhaps come to terms in some way with his terminal condition.

CONCLUSION

Touch is a universal means of communication. It is particularly important to intensive care patients whose surroundings may be dominated by imper- sonal technology and disorientating sounds and sights. A study by McCorkle (1974) suggested that critically-ill patients in coronary care units (CCUs) and ICUs responded well to touch thera- py and that they tended to feel better cared for, and developed a more meaningful rapport with their nurses. However, despite these benefits nurses may avoid touching their patients, as Ashworth (1980) revealed, possibly due to the same sense of taboo and protection of personal space that some patients experience when they avoid being touched. Feltham (1990) acknow- ledges this, and suggests that nurse education programmes should incorporate courses to encourage the use of mutually acceptable tactile expression between nurse and patient.

Whilst complementary therapies such as touch are often thought most suitable for the elderly (Barnett, 1972), it would seem that an ICU, with its high ratio of staff to patients, is an ideal setting for the teaching and acceptance of these meth- ods. Nurses who seek more autonomy in their quest for professionalism should also recognise

56 INTENSIVE AND CRITICAL CARE NURSING

the value of these therapies to their practice. For a tion, especially for anxious patients. Autton nurse to practise safely, within the professional (1989) states: scope of practice, it is necessary to develop a wide knowledge-base in this area backed by compre- hensive research. Kankin-Box (1991) explains why this is lacking. She suggests that methods of scientific evaluation of complementary therapies are contradictory to the holistic philosophy underpinning them. Nevertheless, critical research is necessary if these therapies are to be recognised as a credible addition or option to conventional treatments.

Physical touch alone cannot eliminate a patient’s anxiety completely or ensure his being relaxed, yet it can help him cope with his fears and to cooperate.

By exploring and researching complementary therapies nurses may add another dimension to their practice. Whilst formal training is to be recommended, even without it I feel confident that the therapeutic use of touch facilitated and enhanced my interactions with David.

The name of the patient has been changed to protect the identity of his family.

Drug therapy is becoming an ever-increasing burden on the budget of ICUs and a significant amount of the funding is disbursed on opioids and hypnotics, all with side-effects and contraindi- cations. Surely there may be a case for employing touch as a therapy rather than these expensive drugs. Pharmacologic agents have also been implicated in the condition known as intensive care syndrome, where a patient admitted to the unit develops apparently unpredictable psycho- logical disturbance (McKegney, 1986; Kleck, 1984)) but there appears to be no evidence to sug- gest that touch has ever been proposed as a causative factor in this disorder. On the contrary, lack of touch, as a form of sensory deprivation has been suggested as contributory to this form of psy- chosis (McKegney, 1966).

The use of touch in counselling situations, once taboo (Autton, 1989), is now considered by some to enhance the therapeutic relationship between client and counsellor. A study by Pattison (1973) found that clients who were touched during coun- selling tended to reveal their thoughts and feel- ings more than those who were not touched. Autton (1989) is careful to explain that touch in this context must be nonerotic in nature, and he quotes Bacorn & Dixon’s (1984) definition of touch in this context: ‘Physical contact between the hands of the counsellor and the hands, arms, shoulders, legs or upper back of the client’.

These were the areas used during my coun- selling sessions with David. The experience of using these alternative therapies led me to acknowledge limitations of skill in this area but also convinced me that there is value in the prac- tice of therapeutic types of touch and visualisa-

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