Review Article

The Nurses’ Perception of Expressive Touch: An Integrative Review

Introduction

The concept of touch in nursing is not new. Touch, in its many facets, has been found in nursing literature for decades.^1-8 In following therapeutic or healing touch literature, an explosion occurred in the late 1970s to mid-80s with studies implementing hands-on massage therapy. Since then touch, with its benefits for patients and cultural nuances, has been present in nursing literature.^9-12

Watson provided one of the first attempts at defining touch in nursing by identifying and comparing two main types of touch: instrumental and expressive. Instrumental touch was described as touch used during direct nursing care (e.g., procedures) while expressive touch was described as unrequired spontaneous touch normally aimed at communicating compassion.⁸ Expressive touch has been viewed as an integral part of being human.^13,14 Expressive touch has been shown to have multiple benefits for patients and nurses; most of the benefits are centered around communication of compassion and improvements in nurse-patient rapport.^15-20

Since Watson’s binary definition of touch in nursing, there have been surprisingly few attempts to clearly differentiate types of touch used by nurses during patient care.⁸ Current literature focusing on touch often provides no definition, and the use of terms and meanings across the literature has been inconsistent,³ adding to the ambiguity of the term. In this review of literature, only ten articles discussed types of touch, which offers very little conceptual consensus. For this integrative review, expressive touch is defined using Watson’s definition of unrequired and spontaneous touch aimed at communicating compassion.⁸ In the few cases where a definition was provided, Watson’s definition has been the most consistently used.^21-24 Currently only one review on the perceptions of various medical professionals regarding touch in healthcare exists.¹⁶ Yet, no reviews exist specific to the nurses’ perception of expressive touch. Therefore, this integrative review aims to provide a greater understanding of nurses’ perceptions of expressive touch.

Materials and Methods

Copper’s integrative review process was used to review and analyze the evidence on nurses’ perceptions of expressive touch. The systematic process uses the following steps: problem formation, data collection/literature search, data evaluation, data analysis, and interpretation of results.²⁵ Peplau’s theory of interpersonal relations provided the theoretical framework.²⁶

Peplau’s theory, a middle-range nursing theory that explores the use of touch as a form of communication in nurse-patient relationships, was used to assist in this step.²⁶ According to Peplau’s theory, communication in any form can take on different meanings for both the communicator and the receiver. While expressive touch has been identified as a basic human need with extreme importance to the human experience, expressive touch has also been identified as the most misunderstood form of touch.^3,14 Though reviews of literature involving the patient perception of touch do exist, no reviews nurse perceptions of expressive touch were found.¹⁶ Since the review by Singh et al, no further evidence of nurse perceptions of expressive touch are found within the literature. The theory of interpersonal relations also emphasizes the importance of nurse self-awareness of perceptions.²⁶ Perceptions of nurses undoubtedly impact patient care and nurse-patient communication.^22,24,26,27 Therefore, exploring nurse perceptions specifically related to expressive touch is suggested. The aim of this integrative review is to provide a clearer understanding of nurses’ perceptions of using expressive touch during patient care.

The second step in Cooper’s systematic process of integrative reviews is data collection/literature searching.²⁵ A search of the literature for articles on the nurses’ perception of expressive touch was conducted using the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Academic Search Premier, and Complimentary Index databases. The search phrase expressive touch OR caring touch OR compassionate touch AND nurse/nurses/nursing AND perception OR perspective was used. Included articles that were written in English; data-based, qualitative, quantitative, mixed-methods, and reviews; published in peer-reviewed journals from 2000 through the year 2022; and focused on nurses’ perceptions of expressive touch. Sources without an explicit definition of expressive touch were included; however, further investigation was undertaken to understand the type of touch described was indeed expressive touch. For instance, a source might not have used Watson’s definition of expressive touch but may have described the nurse holding a patient’s hand to provide comfort. This is a form of expressive touch and thus was included in this integrative review.

The third and fourth steps in Cooper’s systematic process are data evaluation and analysis.²⁵ Articles were reviewed for rigor using the Mixed-Methods Appraisal Tool (MMAT), an objective measure of methodological quality,²⁸ to identify threats to validity in quantitative, qualitative, and mixed-method studies. A table was developed to further appraise review articles. This table used criteria for threats to validity that have been identified in the literature (Table 1).^29,30 None of the screened sources were excluded after quality appraisal.

*If 4 or more “Y”s, exclude the source.

Each article retained for full review was initially read in its entirety and information was organized into a matrix with columns for author(s) and year of publication, the study design, journal, demographic information, population and sample, findings, and limitations. Secondary reading of each study was used to both clarify the type of touch being used and identify nurses’ perceptions of expressive touch. After all relevant data were extracted and placed in the matrix for evaluation, analysis was undertaken.

Results

The final step in Cooper’s process is the interpretation of results.²⁵ The initial search returned 283 articles and after duplicates were removed, 265 sources were retained for title and abstract review. One hundred ninety-one articles were excluded because they were not about expressive touch. Of the remaining 74 articles, 52 did not meet inclusion criteria () leaving 22 articles for full text review.

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Figure 1. Flow chart of literature search from identification of articles to final inclusions

Of the 22 articles retained, most were from the discipline of nursing (n=20), and the remaining two described the medical field’s use of touch while still providing insight into nurses’ perceptions of expressive touch. Thirteen sources were from non-categorized nursing journals, three were from psychology, three were from public health journals, two were from education journals, and one was published in a perinatal specialty nursing journal. Most of the sources were from Italy (n=4), followed by the United States (U.S.) (n=3), Ireland (n=3), Turkey (n=2), Canada (n=2) and one publication each from Germany, Australia, Japan, China, Sweden, New Zealand, Korea, and England. The sources ranged in years from 2001-2022. Methods used in the 22 articles varied with nine being qualitative, followed by reviews of literature (n=7), quantitative (n=5), and tool validation/psychometrics (n=1). Additionally, it should be noted that of the 22 articles reviewed, only eight used a theoretical framework and 14 did not use any theoretical framework. None of the eight articles that used a theoretical framework, used the same theoretical framework.

Authors reported touch as a finding. In some cases, authors did not differentiate between types of touch found in nursing, but rather combined all touch types and simply used the term touch. In this review, the examples, author commentary, and participant quotes were used to differentiate types of touch. In general, quantitative studies were aimed at identifying barriers to touch, quantifying nurse comfort with touch, or correlating nurse comfort with touch to variables such as gender or job satisfaction. For this review, five main topics regarding nurse perceptions of expressive touch were identified and supported within this grouping of literature: Comfort with expressive touch and job satisfaction; expressive touch as an essential part of nursing practice; expressive touch as a form of compassion and/or communication; the impact of expressive touch on the humanization of patients in the nurses’ perception; and nurse discomfort with expressive touch. Major findings are all included articles are summarized in Table 2.

Comfort with Touch and Job Satisfaction

The first topic was the correlation between nurses’ comfort with expressive touch and job satisfaction. In Pedrazza et al³⁴ cross-sectional survey (n=241), the Nurses’ Comfort with Touch Scale was used to examine three dimensions of touch: task-oriented (instrumental touch), touch promoting physical comfort (touch used to comfort, which may include expressive touch, but also includes other types of touch such as massage), and touch aimed at emotional containment (expressive touch in response to a patient’s emotional reaction. i.e., holding the hand of a crying patient). Findings indicated that the nurses’ workplace well-being was positively correlated to nurse comfort with any type of touch and nurses lacking comfort with touch were at higher risk for burnout and had lower job satisfaction.³⁴ Additionally, nurses’ emotional exhaustion was negatively related to comfort with all types of touch. Emotional containment touch, the only dimension of touch in the study made up entirely of expressive touch, was the only type of touch able to predict emotional exhaustion and cynicism. This implies that expressive touch has the strongest correlation to nurse workplace well-being.³⁴ It should be noted that this study’s sample was comprised mostly of female nurses with an average length of service of over 17 years and ethnicity data is not reported.

In a similar article, Pedrazza et al³⁷ again used the Nurses’ Comfort with Touch Scale in a cross-sectional study to examine the three dimensions of touch again about the nurses’ attachment style and nurse worry. Worry was found to be negatively correlated to comfort with instrumental touch and touch promoting physical comfort. The results of this study suggested that nurses who were most comfortable with touch may tend to have less pervasive worry and in turn have higher job satisfaction in comparison to nurses who are uncomfortable with touch. Of interest, this study’s sample was approximately 80% female.

Lastly, a cross-sectional survey study aimed at identifying Chinese nurse midwives’ comfort with touch used the same “Nurses’ Comfort with Touch Scale” to examine nurse comfort with touch in relation to perceived professional benefit (the cognitive identification of job benefits and advancement) and burnout.¹⁸ Nurse comfort with touch was positively related to the nurses’ perceived professional benefit and positive nurse-patient rapport while being negatively correlated to burnout Qin et al. These findings indicated a positive relationship between nurse job satisfaction and nurses’ comfort with touch, like the Pedrazza et al³⁴ and Pedrazza et al³⁷ studies. Accordingly, this study shared some of the same limitations: the sample was 100% female and the sample was limited to Chinese nurse midwives rendering the results less generalizable.

Expressive Touch as an Essential Part of Nursing Practice

Three studies indicated that nurses perceived expressive touch as an important and essential part of nursing practice.^27,32,35 In De Luca et al³² qualitative study aimed at exploring nurse’s perceptions of touch in practice, 39 participants (four of which were male) from multiple nursing backgrounds and practice settings were interviewed. Themes of De Luca et al³² study reflected the importance and impact of expressive touch on nurse-patient rapport and nurse self-awareness. Evans³⁵ completed a qualitative study using only male registered nurses (n=8). From this small gender-specific sample, touch was identified as an important, if not central, aspect of nursing practice.³⁵ In Wearn et al review of qualitative literature, expressive touch was found to be an essential part of nursing practice through the connection it creates between the nurse and patient; thereby improving nurse-patient rapport. The positive effects of expressive touch on nurses’ self-awareness and transformation were also identified in Wearn et al review.²⁷

The topic of touch as an essential part of nursing practice was also identified in a descriptive survey study of 430 nursing students (57.9% of which were female) in which student nurse empathy skill scores were positively correlated to the nursing students’ compassionate communication scores.³¹ Nursing student empathy scores predicted compassionate conversations and use of expressive touch. These findings indicated that nursing student empathy, an essential part of nursing practice, and nurses’ use of expressive touch as a form of compassionate communication also may be positively correlated.³¹

Expressive Touch as a Form of Compassion and/or Communication

Ten articles in this review reported that nurses perceived expressive touch as a form of compassionate and/or caring communication. Four articles were reviews of literature aimed at other aspects of nursing that identified expressive touch as a finding.^16,20,21,27 For example, Fleischer et al review of literature included articles related to nurse-patient interaction and communication.²¹ Fleischer et al found that nurses used expressive touch to reassure, comfort, and enhance communication with their patients.²¹ Other reviews of literature that aimed at identifying ways in which nurses expressed compassion also found expressive touch to be perceived by nurses as a form of communicating compassion in their care.^15,16 In a review of literature aimed at identifying the values of nurses in palliative care, expressive touch was one of several actions identified in which nurses connected with their patients in a close and rapport-building way.²⁰ Of all these studies, only Fleischer et al review addressed the use of theory in any way.²¹ Fleischer et al²¹ found in their review of 97 sources the most commonly used theories were Peplau’s theory of interpersonal relations and King’s interacting systems framework. While these reviews were specific to nurse perception, a shared understanding of the use of expressive touch between patients and nurses is needed to understand the impact on nurse-patient rapport.

Three sources in this review included perceptions of touch from both the nurse and the patient.^17,23,40 Gleeson and Timmins included articles on both the patient and nurse perception of both instrumental and expressive touch in the older adult mental health population. Findings indicated that patients perceived the nurses’ touch as a display of affection that caused comfort. Similarly, nurses perceived expressive touch as comforting and calming to patients while also promoting perceived safety.²³

In Durkin et al qualitative study, which included four nurses and eight patients, nurse and patient perceptions were again similar as both viewed expressive touch as a form of compassion.¹⁷ In one example, a nurse tells a story of receiving a phone call from a grateful husband months after his wife had died while in palliative care. The husband wanted to explain an incident that left him feeling that the nurse cared for him.

“…during the wee small hours, probably three or so in the morning, a nurse came into him with a blanket. This nurse, at night, had gone and got one of these blankets and walked into the room –very gently, of course –and just wrapped it around the husband as he sat in the chair.…he wanted -he’s never -he’d never forgotten that occasion where the nurse came in very quietly and just wrapped him up in a blanket and had a brief few words, and it’s how it made him feel. He felt just so cared for…” (p. 6).

It should be noted that all nurse participants in Durkin et al¹⁷ study were female with between ten and twenty years of experience. Participant work setting was quite broad from emergency medicine to rehabilitation.

Karlsson et al qualitative study explored the healthcare provider’s perception of expressive touch specifically in the intensive care unit (ICU).¹⁹ Thirteen healthcare professionals, including six nurses and five nurse assistants, took part in the study. The sample was comprised of mostly females with only two males represented. Participants’ perceptions of expressive touch included being authentic, strengthening rapport, having a calming effect on patients, increasing patient feelings of security, and overall showing care and compassion to the patient.⁹ Wearn et al found similar themes in their qualitative research synthesis regarding touch in practice.²⁷ Of the 20 articles that were included in Wearn et al review, nine reported positive impacts on nurse-patient rapport through touch. Overall, Wearn et al²⁷ found nurses’ perceptions of expressive touch to include themes such as compassion in action and connection with patients. Similar findings were also reported in the qualitative study by Chang,⁴⁰ where 39 individuals were interviewed, including nurses, regarding physical touch in caring. Participants in Chang’s study reported expressive touch as a mediator between the patient and nurse that both conveyed compassion and brought about an emotional bond. Participants also described expressive touch as a means to provide comfort for patients in distress.⁴⁰ In total, of the ten sources included in this topic, only four used theory in some way.^20,21 Additionally, only three of the sources were specific to a nurse work setting.^19,20,23 These work settings were ICU, palliative care, and mental health, leaving a plethora of work settings unstudied.

The Impact of Expressive Touch on the Humanization of Patients in the Nurses’ Perception

Another topic found in this review was the impact of touch on nurses’ perception of patients. Specifically, the ability of touch to humanize patients in the nurses’ perception. Gregg and Magilvy’s³³ qualitative study of 24 Japanese female nurses reported expressive touch, along with listening and simply “being with” the patient, as nursing actions that increased nurse-patient connection. This connection seemed to humanize the patient to the nurse. To demonstrate this, one participant stated

“Don’t you think you feel better when someone touches your hand especially when you are weak? I had a patient who knew he was going to die because of cancer. He always held my hand before I finished my shift. It continued until he lost consciousness. I realized that there was a difference between just saying goodbye and saying goodbye while holding a patient’s hand” (p. 14).

In Wearn et al²⁷ review of qualitative literature, expressive touch was described as an integral part of the nurse-patient connection that humanizes the relationship. The authors propose that touch enables healthcare providers to understand their patients in ways otherwise not possible.²⁷ Wearn et al also stated “The act of touching and being touched cannot be separated from being human” (p. 17). Similarly, in a qualitative study aimed at providing a conceptual structure to physical touch in healthcare, Chang⁴⁰ formulated a working definition for “physical touch in caring” and stated this type of touch was “based on humanism” (p. 822). Chang’s study was set in South Korea and the concept of Ki, specified as the essence of human life in Asian cultures, was thought to be directly related to and impacted by touch. Thus, support for the use of expressive touch as humanizing for both patients and nurses was provided.^27,33,40

Nurse Discomfort with Expressive Touch

Though positive nurse perceptions were found, negative perceptions also exist. The use of touch of any kind by male nurses was discussed as problematic with the ability to be misinterpreted by patients.^22,41 Though male nurses perceived touch as an integral part of their work, fear of misinterpretation in the use of touch was a common topic found within this review. In a study by Pedrazza et al³⁷ nurse comfort was quantified regarding three types of touch, male nurses were found to be less comfortable than females nurses with performing emotional containment touch, which is the use of touch in response to an emotional need, such as holding the hand of a crying patient. Gleeson and Higgin²² found in their qualitative study, on the perception of touch in the psychiatric nurse setting, male nurses avoided touch of any kind, were extremely cautious with the use of touch, and attempted to only use touch in public settings for fear of misinterpretation. This fear of misinterpretation was also found in Whiteside and Butcher’s⁴¹ literature review which emphasized the need for education regarding the appropriate use of touch for male nurses.

While 12 male nurses in a qualitative study reported perceiving touch as a means of expressing care and compassion, they felt unprepared and unsupported in their use of expressive touch.³⁸ Similar results were found in Evan’s³⁵ qualitative study aimed at exploring male nurses’ experiences regarding the use of touch, in which male nurses reported fear of accusation, a heightened sense of vulnerability, and impediment of their ability to complete the caring work they came into the profession to do. In a review of literature completed in 2013, the lack of education about touch was blamed for male nurse’s tendency to seek out low-touch/high-tech or administrative positions within the nursing profession and was labeled as a failure to protect male nurses from potential false accusations.³⁹

Student nurses comprised another group that expressed discomfort with expressive touch. In a recent cross-sectional survey, student nurses were asked about their perceptions of touch.²⁴ Forty-one percent of the students stated they feared the patient’s response to their use of expressive touch. Religion, gender, and culture were all identified as obstacles to the use of expressive touch and most of the student nurses in the study did not perceive expressive touch as important to care.²⁴

In addition to student nurses, practicing nurses have also expressed some discomfort with expressive touch. Pedrazza et al³⁴ study quantified nurse comfort with three dimensions of touch: task-oriented (instrumental touch), touch promoting physical comfort (may include expressive touch, but also includes other types of touch such as massage), and touch aimed at emotional containment (i.e., expressive touch in response to a patient’s emotional reaction such as holding the hand of a crying patient). Emotional containment touch was found to be the type of touch with which nurses reported the least amount of comfort.

Discussion

While expressive touch has been researched in studies and included in reviews of literature, none of the reviews focused solely on nurses’ perceptions of expressive touch. This integrative review aimed to provide a better understanding of the nurses’ perception of expressive touch. Inconsistencies are found among definitions of touch and surrogate terms for expressive touch are common. These variances made reviewing the literature difficult as the type of touch studied was not always clear without a detailed review, focusing on terminology and meaning. In this review, five main topics related to nurses’ perceptions of expressive touch were identified and discussed: Comfort with touch impact on job satisfaction; expressive touch as an essential part of nursing practice; expressive touch as a form of compassion and/or communication; the impact of expressive touch on the humanization of patients in the nurses’ perception; and nurse discomfort with expressive touch. Overall, both positive and negative nurse perceptions of expressive touch are found within the literature. Positives noted are humanization, nurse-patient rapport, and job satisfaction. The negatives discovered are fear of misinterpretation of actions especially reported by male nurses.

Several opportunities for further study were identified. First, most sources did not utilize any theoretical framework to provide structure for the study (n=14). This was consistent with Fleischer et al²¹ who reported a similar lack of the use of theory in their review. Unlike Fleischer et al²¹ review, 8 different theories were found in total in this review with no commonalities. This differs from Fleisher and colleagues’²¹ review of literature which found Peplau’s theory as one of the most common foundations for expressive touch research. As Peplau’s theory of interpersonal relations is specific to nurse-patient communication and rapport, it may provide the best framework for expressive touch research. The use of a theoretical framework would strengthen further studies involving expressive touch.

The second opportunity for further research involves the nurse perception based on demographic information. Gender was the most explored demographic in nurses’ perception of expressive touch. While two studies in this review included only the male perspective, most studies lacked gender diversity with five studies including 80% or more females. While seven studies reported nurse work settings, including ICU and mental health, most did not. Furthermore, other demographics such as age, education level, and years of experience have yet to be studied in correlation to nurse comfort with expressive touch. Studies that assess nurses’ perception of expressive touch based on experience level may help identify if expressive touch is learned over time from years in the nursing profession versus being an innate part of the nurses’ caring style versus being taught about touch during nursing student education. These types of studies might also help identify those experience levels with the greatest need for education about expressive and other forms of touch.

The third opportunity for further development is the lack of education regarding expressive touch for nurses and other healthcare professionals. Several sources (n=9) in this review indicated the need for education regarding expressive touch in healthcare. Accordingly, while authors have indicated expressive touch as a positive or potentially negative aspect of the nurse-patient relationship, none have suggested a structured educational offering or intervention, either pre- or post-licensure, to establish a foundation for nursing practice.

Conclusion

The purpose of thisintegrative review was to provide a comprehensive understanding of nurses’ perceptions of expressive touch. The main findings indicate nurses perceive expressive touch as an essential part of nursing practice that conveys compassion and aids in the humanization patients. While nurses who are comfortable with expressive touch are more likely to report positive workplace well-being, those nurses uncomfortable with expressive touch have a higher experience of burnout. Research on expressive touch using theory as a framework and focusing on nurse demographics such as experience level are recommended. Future research is needed to help guide education for nurses at all practice levels on the use and integration of expressive touch. Without education to guide nurses in the appropriate use of expressive touch, nurses may fear the risk of misinterpretation or choose to avoid expressive touch entirely.

Acknowledgments

The corresponding author would like to express their gratitude to Theresa Miller MSN, RN, APRN-BC, CCTN and Samantha Collinson MSN, APRN CNM for their peer reviews.

Authors’ Contribution

Conceptualization: Jade Elyse Burgess.

Data curation: Jade Elyse Burgess.

Formal analysis: Jade Elyse Burgess.

Investigation: Jade Elyse Burgess.

Methodology: Jade Elyse Burgess, Sarah E. Patel, Sue Lasiter.

Project administration: Sue Laister, Karen L. Gorton.

Resources: Sue Lasiter, Karen L. Gorton, Sarah E. Patel.

Validation: Sue Lasiter, Sarah E. Patel.

Visualization: Jade Elyse Burgess, Karen L. Gorton, Sue Laister, Sarah E. Patel.

Writing- original draft: Jade Elyse Burgess.

Writing- Review & eduting: Jade Elyse Burgess, Karen L. Gorton, Sue Lasiter, Sarah E. Patel.

COI-statement

The authors declare no conflict of interest in this study.

Data Availability Statement

All data generated or analyzed during this study are included in this published article.

Ethical Approval

None to be declared.

Funding

No financial support was received.

Research Highlights

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