The Art of Holding Hand: A Fieldwork Study Outlining the Significance of Physical Touch in Facilities for Short-Term Stay

Karin Bundgaard, RNT, MScN, PhD(c) and Erik Elgaard Srensen, RN, MScN, PhD
Aarhus University Hospital Aalborg University

Karl Brian Nielsen, MScE, PhD

Aalborg University
Abstract This paper focuses on the use of physical touch in nursing care in facilities for shortterm stay. Extant research (Foy & Timmins, 2004; Mcilfatrick et al., 2006; Nystrm et al., 2003) has raised the questions, How can nursing care best be tailored to meet the patients overall needs, both physical and emotional? and How to strike an optimum balance between caring and instrumental aspects of nursing? This paper discusses how the exchange of physical touch can be seen as an epitome of caring in nursing care in facilities for short-term stay; it is connected to psychological and spiritual aspects. Key Words: Physical touch, short-term stay, phenomenological, hermeneutical Introduction Facilities for short-term stay occupy an important position in todays healthcare setting (Clarke & Rosen, 2001; Lynn, 2002; Simpson et al., 2005; Timmins, 2009). They include a large variety of outpatient clinics and treatment and emergency units at hospitals. Bound by their duty of care (SSN, 2003) to protect and do no harm to those in their care, nurses are expected to control and excel in various technical and instrumental tasks routinely performed in these technological, often highly advanced, settings (AAACN, 2007; ESGENA, 2010; Joint Commission, 2010). Research findings agree (Allan, 2002; Mcilfatrick et al., 2006; Murphy, 2001) that nursing in these facilities involves a high proportion of technical and instrumental aspects, while caring aspects are somewhat less transparent. The claim is, though, that nursing in these facilities also involves aspects of caring, but we seem to lack knowledge of how caring is actually expressed in this context. Nursing has generally departed from an ethical and relational perspective (Nelson & Gordon, 2006). The ideal of nursing has been described as one where the nurse has sufficient time and space to get to know the patient, so that care may be tailored to the individual patients needs and expectations (Foy & Timmins, 2004; Mcilfatrick et al., 2006; Nystrm et al., 2003). The nursing literature on the relationship between nursing and technology often polarizes nursing and technology (Barnard, 1997; Bevan, 1998; Crocker & Timmons, 2009) and argues that technology usage is on par with the culture of caring (Barnard & Sandelowski, 2000; Bjrk & Kirkevold, 2000; Hawthorne & Yorkuvich, 1995). Recent studies (Foy & Timmins, 2004; Mcilfatrick et al., 2006; Nystrm et al., 2003) question if it is at all possible to tailor nursing to the individual patients needs and expectations in the context of facilities for short-term stay where technical and instrumental aspects of treatment take priority over aspects of caring. The present study

suggests that caring in this context may express itself in ways other than in traditional nursing contexts and argues that physical touch may be one way to exercise aspects of caring in nursing. Methodology Research Strategy The approach is phenomenological hermeneutical (Gadamer, 2004; Husserl, 1992) and its method inspired by practical ethnographic principles (Hammersley & Atkinson, 2007; Srensen et al., 2011). Fieldwork has been shown to be a particularly suitable method in nursing research (Srensen et al., 2011) in general and for shedding light on nursing in facilities for short-term stay in particular (Allan, 2001, 2002). The analytical strategic approach was inductive; hence, the data did the talking. During the course of the fieldwork, the researcher turned to the phenomenon itself, i.e., nursing in facilities for short-term stay and, thus, borrowing patients and nurses experiences and reflections (Hammersley & Atkinson, 2007). By observing what happened, hearing what was said, and asking questions, the researcher obtained a deeper understanding and more insightful descriptions of nursing care in this setting. Moreover, the researcher gained insight into the expectations and needs for nursing care voiced by the patients.

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Setting and Participants The fieldwork was performed at a high technology endoscopic out-patient clinic during 2008 and 2009. Data were collected using participant observations, including participant reports and interviews. Field notes were recorded both during and after field observations and interviews. The interviews were recorded. Field observations were performed over 12 weeks and lasted approximately 4 hours per day. During these hours one researcher stayed in the endoscopic clinic, trailed a nurse in her work, talked to patients in the resting and waiting area, and talked to other nurses in the clinic (Hammersley & Atkinson, 2007). The patients arrived at the endoscopic out-patient clinic from their homes, underwent gastroscopy, and then returned to their homes. Their stay at the clinic lasted between 214 and 212 hours. The patient interviews were carried out prior to gastroscopy. Patients undergoing gastroscopy at pre-fixed times on randomly selected days were contacted and asked if they would participate in an interview. The researcher was in contact with 10 patients, nine accepted and one declined. One of the nine never came for the gastroscopy or the interview. Thus, eight patient interviews were performed. Informed consent was obtained. The interviewees were both male and female, over the age of 18, and fluent in Danish. The age distribution among patients ranged from 25 to 91 years. This was considered a strength since young and elderly may have different expectations (Gadamer, 2004). Both patients having gastroscopy for the first time and patients who had regastroscopy participated in the study under the assumption that they could have different nursing expectations and requirements (Gadamer, 2004; Murphy, 2001). The nurses participating in the nurse interviews were working in the endoscopic clinic. They were randomly selected and participation was voluntarily. The nurse interviews were carried out after the re-

searcher had trailed an individual nurse for 1 day. Four nurse interviews were performed. Participant observations and interviews were interrelated, thus the interviews contributed with knowledge on what to focus on in the participant observations and the semi-structured interview guide was developed based on participant observations. The number of participant observations and interviews was not decided in advance. The aim was data saturation, i.e., when what was heard, seen, and experienced seemed to repeat itself. Ethical Considerations The study was conducted in conformity with the ethical guidelines for nursing research in the Nordic countries (SNN, 2003). The ethical considerations applied to both universally human values and professional opinion of what constitutes proper behavior and attitudes in relation to employees and in relation to sick and vulnerable persons. Data Analysis According to Hammersley and Atkinson (2007), a set recipe for fieldwork does not exist, but they offer guidelines that may aid the researcher performing research. The first step of analysis in these guidelines is a conceptual development that includes a thorough reading of the text (empiricism); identification of patterns, concepts, and categories; and processing of categories central to the analysis. The second step is the creation of a typology where, for example, a pattern of unlike strategies used by the players to help them face a certain problem is described. Finally, the third step is theory development and testing. In this study, the process of analysis unfolded as a dynamic process that involved a constant movement back and forth between the above steps. Research may involve all steps, but to describe and understand nursing care in facilities for short-term stay, most attention was paid to the first step of

conceptual development. The researcher performed the interviews, undertook participant observation, and performed the transcriptional work. Field notes were made for each observed patient course in the endoscopic clinic; in the following these notes are referred to as Report, which is followed by a number. The interviews are referred to as Patient or Nurse followed by a number. A central category emerged from the analysis: The art of holding hand. This category will be unfolded in the following narrative. The Art of Holding Hand To ease the readers understanding, the following text will describe the patient as he/him and the nurse as she/her, even though this is in no way meant as a gender generalization. Almost every action that humans make as social beings demands some kind of manual skills. From the initial handshake when welcoming somebody until the final handshake when saying good-by, there is much physical contact between the patient and the nurse in the facilities for short-term stay. However, the extent of the physical contact is determined by the individuals preferences and the situation in which this contact is established. For example, Nurse 1 expressed that she was very physical by nature and, indeed, she was observed to be so. She experienced that most patients needed and wished that their hands be held. The few patients who did not wish this were easily identified and the nursing was adjusted accordingly. Nurse 2 stood out from the other nurses by expressing how she intentionally limited physical touch. When observed, she was clearly more reserved in her use of touch than most nurses. She argued that too much touching could be perceived as a possessive behavior instead of as a way of building confidence or showing presence. Instead, like the other nurses, she aimed to clarify if the patient wished to have a hand to hold before the gastroscopy started. The

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nurses agreed that both the patients age and gender were considered when using physical touch. The experience was that elderly patients and females needed it most. The exchange of touch can be exemplified by how the nurse touched the patients arm, shoulder, or leg during the initial conversation; how the nurse made a drawing on the patients body to illustrate her words or touched his throat to explain where he may feel the most discomfort during the gastroscopy; how the nurse took the patients hand when explaining the procedure for applying an intravenous access; how the nurse held the patients hand while providing an intravenous access; or how the patient again reached out and held onto the nurses hand or arm. During the gastroscopy, physical touch was reflected in how the nurse supported the patient with one hand resting on his cheek, with a hand resting lightly on his hand, or with her hand resting very close to his hand or how she placed the other hand on his shoulder or on his upper back and sometimes even when positioned behind the patient, she had one arm around him. Physical touch seemed to hold different meanings. These will be explained under the headings: Building Confidence, Readiness to Help, Keeping a Balance Between Comforting and Restraining, and, finally, The Technically Skilled Hand. Building Confidence The importance of confidence in the relationship between the patient and the nurse was evident in the interviews and in the participant observations. One way of building this confidence was experienced to be the use of physical touch. For the patient, physical touch involved aspects of safety and protection, Yes, this contact makes me feel safe, I feel that someone is present. (Patient 2) Touch added to the patients confidence and trust in the nurse. Moreover, touch or sometimes lack of touch revealed the nurses presence. A lack of presence was as-

sociated with feelings such as discomfort and insecurity, Their touch reveals if they are present or not. I very soon can detect if they are actually here for me in this situation. (Patient 4) The patient is wheeled into the examination room by the physician. Meanwhile, the nurse is racing around busy at cleaning and preparing the room for this next patient. For a few minutes the patient is watching the nurse with confusion before asking, Am I in the right room? (Report 33) Furthermore, during the gastroscopy, touch was experienced as comforting and as a response to the patients active reflex mechanisms. It noticeably eased the patients discomfort during the gastroscopy procedure, The nurses are very caring and I find it very positive when Im being offered a hand to hold onto, because I squirm a bit when my bodys reflex mechanisms are activated. (Patient 7) Physical touch was employed both intentionally and instinctively by the nurses. Thus, time and again the nurses touched the patient during the initial conversation with the patient during the gastroscopy, or during their interaction after the gastroscopy. In the initial contact between the patient and the nurse, the nurses considered physical touch to be an instrument employed in getting to know the patient. Touch served to communicate information about the patients condition in the sense that it informed the nurse about the patients reaction whether one of anxiousness, shakiness, feverishness, or, alternatively, calmness and relaxation. Sometimes, if they are anxious, I feel it in their handshakes. Their handshake makes me think, Ok, this patient needs a little extra information and reassurance, while others waltzed in here and clearly signal, Save your breath and lets get on with it. (Nurse 3) During the patients stay in the examination room, touch was deliberately employed as an instrument of reassurance to make the patient feel safe and secure. The hand on

the patients shoulder is meant to give a little reassurance and to tell the patient, You cant see me, but Ill be right here behind you and Ill look after you. You very quickly feel if its someone who wants to hold hands or not. (Nurse 4) During the gastroscopy, the physical contact between the patient and the nurse was interrupted time and again. For example, when the nurse used the computer, assisted the physician, answered the telephone, or answered queries from other staff members. If the physician required assistance the nurse left her position by the patients head or by his back and walked to the left side of the gurney and positioned herself next to the physician. Thus, the nurse prepared the patient beforehand of her different functions during the gastroscopy and the resulting lack of physical presence. Also, beforehand, she reassured the patient that she would return as soon as possible. Patient, I like to hold on to your hand during the gastroscopy. Nurse, Ok, I may need to let go while taking the tissue samples but Ill be back. (Report 7) I always prepare them for where Ill be during the gastroscopy and that I may have to temporarily let go of them, but I try to reassure them that Ill be back and always keep an eye on them. (Nurse 4) Readiness to Help According to the patients, the purpose of nursing in the Endoscopic Unit was for the patient to be helped trough the gastroscopy in the best and most safe way possible, and to have a usable result at the end of the procedure. Physical touch, for example, the nurses hand on his shoulder or the nurses hand to hold, was considered by the patient as a necessity for him to manage the gastroscopy. Thus, physical touch symbolized the nurses willingness to take care of the patient and her readiness to help if necessary. The nurse was very sweet and we had a really good talk before the gastroscopy. She

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helped me throughout the gastroscopy, both by holding my hand and when she professionally placed the needle in my hand. (Report 36) I know it may sound a bit silly, but I need to know that someone is watching over me, I may need a hand to hold, so that I feel their presence and know that they will take care of me. (Patient 8) Patients also experienced the nurse as being distant, either because she was busy doing paperwork and answering inquiries or because she was not present physically in the examination room. In these situations, most patients were actually found to make excuses for the nurses lack of presence. You know that they are busy and you dont want to take up to much of their time. (Patient 3) I know they have much to do, I see patients that need her more than me and the nurses do try their best. (Patient 6) Physical touch was repeatedly employed by the nurses. I feel closer to the patient when I use physical touch and I experience how the patient reaches out for my hand when I touch him. Like a reassurance that Im still here. (Nurse 3) The nurses described that past experience had taught them that most patients wish some kind of physical closeness when undergoing gastroscopy. Thus, touch was used to reassure the patients that the nurse was still present and ready to help, even when out of sight. A crucial and helpful thing for the patients is to relax, itll ease their discomfort. With my hand on the patient, I can feel if he is tense, this aids me in foreseeing how hell react. (Nurse 1) I often place my hand on the patients cheek next to his mouth because I found that this may calm him down. The other hand, I rest on his shoulder. (Nurse 3) The nurses reported that it could be difficult to keep this physical contact with the patient while assisting the physician. Positioned on the left side of the gurney next to the physician, the nurse repeatedly reached across the physicians arms and the endoscope to touch the patients hand or

arm. Furthermore, whenever necessary, she aided the patient by pushing his cheek further down into the pillow in order for him to get rid of his excess saliva. The nurses attention was on both the patient and the tasks she was performing. Yet, emphasis was placed on the latter. Standing over there [on the left side of the gurney] when Im busy taking the biopsies, for example, I do have an eye on the patient, but still there is an instrumental procedure to be performed. (Nurse 3) When there was no option for physical contact between the nurse and patient, other forms of contact, such as eye contact, were used. Almost every action taken was accompanied by a vocal explanation of what was going on and why it was necessary. When Im unable to communicate through physical contact, I communicate through eye contact. (Nurse 4) Keeping a Balance Between Comforting and Restraining Patients described the gastroscopy as a constant battle with their own defense mechanisms. It takes all my will-power and a hand from the nurse not to pull it [the endoscope].(Patient 3) For most patients, the desire for medication was primary, but the option of having a hand to hold during gastroscopy was described as helping them manage the situation. [After the gastroscopy] Patient, Was I very troublesome? Nurse, No, not at all. Patient, It was very uncomfortable, but it helped squeezing your hand. (Report 25) The nurses also described how they recognized that patients battle their defense mechanisms during gastroscopy. To help patients overcome their worst discomfort during gastroscopy, the nurses employed different techniques. For example, one nurse touched the patients nose, told him to take deep breath and to wiggle his toes. Another nurse told the patient to hold on to his own thighs. Some nurses took hold of the patients hand from the start, while others chose to take the patients hand when he

reached out for the endoscope. The nurses described this holding hand as a balancing act between keeping the patient comfortable and restraining him by holding on too tightly. The concern for the patient hurting himself as a result of him pulling the endoscope was voiced, for example, as follows: I know that when the endoscope passes his pharynx, he might reach out and grab the endoscope because of his defense mechanisms. I then take his hand and tell him to hold on to me instead. If I hold onto his hand from the beginning, I might have to hold on too tight to avoid him from grabbing the endoscope and this might feel more like a violation. (Nurse 1) The Technically Skilled Hand For the patients, technical skill was associated with the nurses touch. If this skill was performed safely and properly, the patients quickly developed trust in the nurse. If the skill performed revealed any insecurity or confusion, it made the patient feel disbelief and insecurity. In comparison to what I experienced the last time, today the nurse was very skilled. I felt that she knew what she was doing. (Report 43) When placing an intravenous access in the patients hand, Damn, youre good! (Report 15) and You were extremely skilled in doing that. (Report 2) The nurses stressed the importance of being technically skilled. They experienced that if they showed confidence in their technical skills, this was reflected in the patient becoming relaxed and trustworthy. I find it extremely important to be skilled in handling the technical, instrumental part of nursing. When Im confident and rest in my instrumental nursing, I see the patient relax and put his trust in me. (Report 45) and I often fell the patients eyes follow my every move when handling, for example, the biopsy forceps. One day I had to try out three retrievers before finding one that worked. This made the patient insecure and worried. (Nurse 3)

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Discussion The purpose of this study was to describe and discuss how the exchange of physical touch, i.e., the art of holding hand, could be seen as an epitome of caring in nursing care in facilities for short-term stay. The results will be discussed under four headings: Building Confidence, Readiness to Help, Keeping a Balance Between Comforting and Restraining, and, The Technically Skilled Hand. Research argues that the building of a patient-nurse relationship of confidence is of central importance for the quality of nursing care (Costa, 2001; Foy & Timmins, 2004; Murphy, 2001; Mcilfatrick et al., 2006). According to Foy and Timmins (2004), good communication is the core element in building this relationship. Murphy (2001) considered the ability to listen to be a very important element in building this relationship. He also highlighted the subject of the human touch as a way of creating trust in the relationship. High technology radiological contexts, though, often call for the need to work at a distance from the patient, which often makes it impossible to enhance contact through physical contact. Mcilfatrick et al. (2006) considered the nurses ability to be there to be a key component in building a relationship with the patient. Being there relates to emotional aspects of caring, but it is argued also to incorporate practical aspects of caring. In the oncological day hospital this includes the administration of chemotherapy, but also being with the patient in a very practical sense, for example, by deploying physical touch. Thus, good communication, the ability to listen, and to be there are all instruments employed in building a patient-nurse relationship of confidence. The subject of physical touch has only been briefly touched upon in previous research. The present study presents evidence that physical touch may be used as an instrument for building or enhancing a patient-nurse relationship of confidence within context of facilities for short-term stay.

The research of Karlsson et al. (2010) referred to the subject of physical touch in nursing care and divided carers into two categories: present carers and absent carers. The former, it is claimed, have love in their hands in the sense that they have an inner ability to adapt and to use their hands as tools to mediate caritative caring. The latter, it is argued, have insensitive hands in the sense that there is distance between the body and the person, because the nurse performs only a task or a duty and her hands do not mediate caring. In relation to the present study, present carers in the endoscopic clinic were those nurses who understood how to evoke and demonstrate feelings of confidence, safety, protection, comfort, repose, and presence for the patient. Absent carers were those nurses who evoked and demonstrated the opposite feelings, such as discomfort and insecurity, and showed a lack of presence. Martinsen (2002, 2005) referred to the essence and importance of physical touch in her philosophical caring theory. She described how nursing applies knowledge in both slow and quick ways. The slow ways represent experience-based knowledge displayed through the use of senses; the quick ways represent technology-based knowledge, which is displayed through practical and instrumental skills. The importance of awarding time to letting the slow ways have time on equal footing with the quick ways is stressed by Martinsen (2002, 2005). The present study revealed how the quick ways assumed an important role in nursing care in the endoscopic clinic when, for example, the nurses prepared the endoscope, supplied the intravenous access, and assisted the physician. Particularly important, though, is recognizing that the slow ways were present at all times. The slow ways were interpreted to take the form of the nurse using her eyes and ears and the use of physical touch. For example, the nurses told of how a mere handshake could reveal much information about a patients condition and state of mind. Thus, the senses evoked by this physical touch were an important instrument in

getting to know the patient. The nurses also expressed how their hand on a patients shoulder could quickly reveal if he was tense. Again, this is interpreted as an example of the nurses ability to activate their slow ways of obtaining knowledge. Research confirmed that patients wish to receive nursing care in which the nurse is present, aware, and ready to take care of them whenever necessary (Allen, 2002; Mcilfatrick et al., 2006; Nystrm, 2003). In the present study, physical touch was interpreted to be an instrument showing the nurses presence and readiness to help. Brenchley and Robinsons (2001) research on the subject of outpatient nurses argued that the nurse often personalizes the patients first meeting in the out-patient hospital and that her adopted role is experienced to be a very important instrument in gaining the individual patients trust and confidence. These aspects are considered to ease the patients visit at the out-patient clinic. It is further argued that being is as important as doing. Brenchley and Robinsons (2001) research, thereby, seemed to underscore that emphasis is placed on the emotional aspects of nursing and to outline a possible gap between being and the doing. The question that needs to be asked is whether being and doing could be interpreted to enhance each other rather than as being perceived as each others counterpoints. For example, in the sense that doing will only be experienced to be well-performed if the nurse also knows how to incorporate some kind of being. In research on physical caring by Gardner and Wheeler (1987), patients defined physical comfort and efficiency while assisting with a procedure as instances of caring. In Allans (2002) research among patients in a fertility clinic, physical comfort is found to vary from being there to giving a caring pat or talking a patient through a procedure. We suggest that physical touch and the opportunity to hold onto the nurses hand in the endoscopic clinic represents a form of physical attendance that offers the patient reassurance of the nurses ability to be present and her readiness to help. Physical

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touch, thereby, mediates an emotional awareness and the nurses recognition of what the patient has to go through in order for him to manage the gastroscopy. The act also becomes recognition of the patient and his experience of gastroscopy as a very stressful and daunting situation. The nurses hand on the patient is therefore a way of relating to the patient. According to Nden (1999) the prerequisites for practicing nursing as an art are: (a) Having an understanding of human values, (b) Developing the use of ones self, (c) Being sensitive, (d) Having the ability to see well, (e) Having knowledge of human integrity and suffering, and (f) Having the ability to seize opportunities. When the patient expressed feelings of security, confident, satisfaction, and gratitude, the use of physical touch may be interpreted as a result of a nursing care practiced as an art. Though, when the patient was left with feelings of insecurity and distrust, nursing care never became an art. The patients emotional response to the care delivered in those situations where the nurse was unable or maybe even unwilling to employ physical touch was either a feeling of rejection and insecurity or a feeling of reassurance that hinged on the nurses message given before the procedure that she would be there for him if needed. The present study seems to show that the patients reaction reflected the level of confidence already established in the patient-nurse relationship. Thus, if confidence was high, the patient would feel reassured; if not, the patient would feel anxious. Future research should be conducted to further explore this issue. As professionals, nurses are bound by a duty of care (SSN, 2003) to protect and do no harm to those in their care. This set of principles underpins a nurses own moral obligation to provide optimum treatment. The professional code of conduct further stipulates a need to gain consent prior to care delivery, while respecting the patients choice and rights to decline the proposed

treatment. Nurses in the endoscopic clinic constantly seemed to be facing the challenge of balancing between their duties of care by ensuring that the procedures were carried out in a safe manner and the need to restrain the patient against his wishes. Physical touch may be interpreted as an instrument employed to keep this balance. The question of balancing between restraining and respecting the patients autonomy in geriatric nursing has been discussed by Yamamoto and Aso (2009) in their research on the ethical dilemma of restraining older people with dementia and by Kontio et al. (2010) in their research on the ethical alternatives to seclusion and restraint in psychiatric nursing. The question is also addressed in pediatric nursing by Hull and Clarke (2010) who discussed the issue of restraining children for clinical procedures. In their research on pediatric nursing, Lambrenos and McArthur (2003) introduced the concept of clinical holding, which they defined as, positioning a child so that a medical procedure can be carried out in a safe and controlled manner (p. 31). The matter of balancing between restraining and respecting the patients autonomy has not yet been discussed in nursing care in somatic facilities for short-term stay. The clinical holding, as described in pediatric nursing, is interpreted to be somewhat similar to what was practiced in the endoscopic clinic. The offer of holding onto the nurses hand can be interpreted as an extra precaution to protect the patient. Thus, most patients recognized that if they reached out and pulled the endoscope during the gastroscopy, they would most certainly inflict harm upon themselves. The nurses choice to leave her hand resting close to the patients hand during the gastroscopy could be interpreted as a way of foreseeing the patients reaction to the gastroscopy. If he was to reach out for the endoscope, she had the ability to take his hand. The nurses choice of asking the patient prior to the gastroscopy, if he would like a hand to hold onto during the gastroscopy enabled her to

balance her own moral obligation to provide optimum treatment against her respect for the patients choices and rights. It seemed very important for the nurses to justify their choice of holding policy, which implies that they constantly battled to keep this balance between holding hand and restraining the patient. In the past decades, research has debated the use of technology in nursing (Barnard & Sandelowski, 2000; Hawthorne & Yorkuvich, 1995). This debate has often presented the emotional and relational aspects of nursing care as a paradigm of care opposed to the technological and instrumental aspects of nursing care. In the present study, the technological and instrumental aspects of nursing care are exhibited by the nurses use of her free hand to perform technical skills. In their research on technology and human nursing, Barnard and Sandelowski (2000) stated that technology is not necessarily opposed to humanizing care, but is often, specifically and deliberately, enrolled in the service of that care. The claim is that the power any technology exerts derives from how it acts out in any given situation and from its meaningfulness. In Nystrms (2003) research on nursing care in a Swedish emergency department, practical skills were described to be highly valued, whereas what is described as the caring attitude is not considered a part of a professional nursing competence. Mcilfatrick (2006) described the work of the nurses in the day hospital giving chemotherapy to be very task oriented and to be rooted in the nurses fundamental concern for the patients welfare and the need to maintain balance between providing emotional support and performing multiple tasks. However, this balance is found to be very difficult to maintain. In the endoscopic clinic, the task orientation in nursing was very obvious as were the nurses constant strive to maintain the balance between these multiple technical tasks and the caring aspect of nursing. The

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nurses found their technical skill performance to be extremely important, but at the same time they seemed aware that this focus on technology inevitably meant less focus on the patient. The tasks performed were experienced to include more than a display of technical skills performed by the hand, since most work of the hand was accompanied by a vocal explanation and some type of physical touch. Furthermore, eye contact and vocal explanations were used as valid replacements for physical touch when physical contact with the patient was restricted. Thus, use of the physical touch alone or in combination with the vocal explanation and eye contact can be interpreted as ways of keeping the balance between the caring and the technical aspect of nursing. We argue that how the patient experiences and responds to the task performed by the nurse depends on the focus of her nursing. When the nurse was able to keep focus on the patient instead of on the task performed, the nursing was experienced as present and caring. If focus was on the task performed, the nursing was occasionally experienced as distant and impersonal. Conclusion This study concludes that physical touch in facilities for short-term stay may be interpreted as evidence of the caring aspects (i.e., ethical, emotional, relational) in nursing care. The art of holding hand in this context was found to display dimensions of confidence building, readiness to help, keeping balancing between comforting and restraining, and the technically skilled hand. In line with good communication, the ability to listen, and the ability to be there, physical touch was shown to an important instrument employed in building a patientnurse relationship of confidence in the facilities for short-term stay. The study suggests that the physical touch and the opportunity to hold onto the nurses hand in the endoscopic clinic represented a form of physical attendance that offered the patient reassurance of the nurses ability to be present and her readi-

ness to help. Furthermore, the study implies that touch was employed to help the nurses in their constant struggle to keep a balance between holding hand and restraining the patient against his wishes. Finally, the tasks performed by the nurses in the endoscopic clinic were experienced to hold aspects of emotional and relational nursing as an addition to the display of technical skills performed by the hand. The complexity of the art of holding hand was evident when the nurse managed to integrate some kind of being in her doing. Physical touch was deployed not only for instrumental purposes, but also to serve relational aspects of the nurse-patient relationship, i.e., in conformity with the caring aspects of nursing and with the nurses moral and ethical obligation toward the patient. References American Academy of Ambulatory Care Nursing (AAACN) (2007). Ambulatory care nursing administration and practice standards. Retrieved from http://www. aaacn.org/cgi-bin/webobj/aaacnmain. woa/wa/viewsection_?s_ID=#1073743941 Allan, H.T. (2002). Nursing the clinic, being there and hovering: Ways of caring in a British fertility unit. Journal of Advanced Nursing, 38(1), 86-89. Allan, H.T. (2001). A good enough nurse: Supporting patients in a fertility unit. Nursing Inquiry, 8(1), 51-60. Barnard, A. (1997). A critical review of the belief that technology is a neutral object and nurses are its master. Journal of Advanced Nursing, 26, 126-131. Barnard, A., & Sandelowski, M. (2000). Technology and humane nursing care: (Ir)reconcilable or invented difference? Journal of Advanced Nursing, 34, 367375. Bevan, M.T. (1998). Nursing in the dialysis unit: Technological enframing and a declining art or an imperative for caring. Journal of Advanced Nursing, 27, 730736. Bjrk, I.T., & Kirkevold, M. (2000). From

simplicity to complexity: Developing a model for practical skill performance in nursing. Journal of Clinical Nursing, 9, 620-631. Clarke, A., & Rosen, R. (2001). Length of stay. How short should hospital care be? European Journal of Public Health. 11, 166-170. European Society of Gastroenterology and Endoscopy Nurses and Associates (2010). Retrieved from http://www.esgena.org/index.php/publ_guide/guide_es ge_esgena Foy, R., & Timmins, F. (2004). Improving communication in day surgery settings. Nursing Standard, 19(7), 37-42. Gadamer, H.G. (2004). Sandhed og metode. rhus, Denmark: Forlaget Systime. Gardner, K.G., & Wheeler, E.C., (1987). Patients perceptions of support. Western Journal of Nursing Research, 9, 115-131. Hammersley, M., & Atkinson, P. (2007). Feltmetodikk. Grundlaget for feltarbeid og feltforskning. Oslo, Norway: Gyldendal Akademisk Forlag. Hawthorne, D.L., & Yorkuvich, N.J. 1995. Science, technology, caring and the professions: Are they compatible? Journal of Advanced Nursing, 21, 1087-1091. Hull, K., & Clarke, D. (2010). Restraining children for clinical procedures: A review of the issues. British Journal of Nursing, 19, 346-349. Husserl, E. (1992/1950). Cartesianska meditationer. En inledning till fenomenologien [Cartesian meditations. An introduction to phenomenology]. Gothenburg, Sweden: Bokfrlaget Daidalos. Joint Commission (2010). Retrieved from http://www.jcrinc.com/AC-Resources Karlsson, M., Post, I., & Bergbom, I. (2010). Being cared for and not being cared for: A hermeneutical interpretation of an autobiography. International Journal for Human Caring, 14(1), 58-65. Kontio, R., Vlimki, M., Putkonen, H., Kuosmanen, L., Scott, A., & Joffe, G. (2010). Patient restrictions: Are there ethical alternatives to seclusion and re-

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Author Note Karin Bundgaard, RNT, MScN, PhD(c), Department of Gastroenterology, Aarhus University Hospital, Denmark and student at the Faculties of Engineering, Science, and Medicine, Aalborg University, Aalborg, Denmark; Karl Brian Nielsen, MScE, PhD, Professor, Department of Production, Faculties of Engineering, Science, and Medicine, Aalborg University, Aalborg, Denmark; Erik Elgaard Srensen, RN, MScN, PhD, Post Doctorate, Clinical Research Unit, Aalborg Hospital Science and Innovation Center, Aalborg Hospital, Aarhus University Hospital, Aalborg, Denmark. Correspondence concerning this article can be sent via Internet to karinmik@rm.dk The authors would like to thank the Danish Society for Nursing Research for financial support for the language revision of the article.

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