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Patient Education and Counseling 89 (2012) 439–446

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Patient Education and Counseling


journal homepage: www.elsevier.com/locate/pateducou

The implementation and evaluation of therapeutic touch in burn patients:


An instructive experience of conducting a scientific study
within a non-academic nursing setting
Martine Busch a,*, Adriaan Visser c,1, Maggie Eybrechts a, Rob van Komen b, Irma Oen b,
Miranda Olff d, Jan Dokter b, Han Boxma b
a
Van Praag Instituut, Utrecht, The Netherlands
b
Burn Center, Maasstad Hospital, Rotterdam, The Netherlands
c
Rotterdam University, Knowledge Center Innovations in Care, Department of Transitions in Health Care, Rotterdam, The Netherlands
d
Academic Medical Center of the University of Amsterdam, Center for Psychological Trauma, Amsterdam, The Netherlands

A R T I C L E I N F O A B S T R A C T

Article history: Objective: Evaluation of therapeutic touch (TT) in the nursing of burn patients; post hoc evaluation of the
Received 24 February 2012 research process in a non-academic nursing setting.
Received in revised form 8 June 2012 Methods: 38 burn patients received either TT or nursing presence. On admission, days 2, 5 and 10 of
Accepted 27 August 2012
hospitalization, data were collected on anxiety for pain, salivary cortisol, and pain medication.
Interviews with nurses were held concerning research in a non-academic setting.
Keywords: Results: Anxiety for pain was more reduced on day 10 in the TT-group. The TT-group was prescribed less
Therapeutic touch
morphine on day 1 and 2. On day 2 cortisol level before dressing changes was higher in the TT-group. The
Nursing presence
Implementation
situational challenges of this study led to inconsistencies in data collection and a high patient attrition
Burns rate, weakening its statistical power.
Anxiety Conclusion: Conducting an effect study within daily nursing practice should not be done with a nursing
Procedural pain staff inexperienced in research. Analysis of the remaining data justifies further research on TT for burn
Itching patients with pain, anxiety for pain, and cortisol levels as outcomes.
Cortisol Practice implications: Administering and evaluating TT during daily care requires nurses experienced
Pain medication both in TT and research, thus leading to less attrition and missing data, increasing the power of future
studies.
ß 2012 Elsevier Ireland Ltd. All rights reserved.

1. Introduction in patients who received TT. The Burn Center wanted to stimulate
nursing staff to participate in research. Therapeutic touch being in
Nurses often play an important role in the introduction and need of more evidence was thus the chosen topic for a practice
development of complementary care. Where conventional care based nursing study.
falls short, nursing staff may look for non-pharmacological
interventions [1]. One of these complementary nursing interven- 1.1. Therapeutic touch for burn patients
tions is the energy based therapeutic touch (TT). It is often aimed at
enhancing relaxation and comfort in patients and as such is Studies indicate that TT may affect anxiety, pain, relaxation, and
included in the internationally accepted Nursing Intervention physiological measures (see Box 1). As pain and anxiety manage-
Classification (NIC). [2] ment are leading issues in the nursing of burn patients, TT may be
Clinical observations by nurses in the Burn Center in Rotterdam, of clinical relevance for this specific group of patients. Pain is not
the Netherlands, showed increased relaxation and reduced anxiety only caused by the injury, but also by the daily traumatic medical
procedures such as wound dressing. In spite of pharmacological
pain treatment, burn patients still report a fairly high level of pain
[3,4]. Turner et al. [5] studied TT in patients with burn injuries. In
* Corresponding author at: Van Praag Instituut, Springweg 7, 3511 VH Utrecht,
The Netherlands. Tel.: +31 30 234 1707.
their single blinded randomized clinical study, 99 patients were
E-mail address: mbusch@vanpraaginstituut.nl (M. Busch). given TT or sham TT for 5 days. The experimental group’s anxiety
1
During the study: Helen Dowling Institute, Utrecht, The Netherlands. rating on the VAS and the pain ratings on the McGill Pain

0738-3991/$ – see front matter ß 2012 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.pec.2012.08.012
440 M. Busch et al. / Patient Education and Counseling 89 (2012) 439–446

TT practitioner directs the patient’s energy field using the hands as


Box 1. Effects of TT interventions an instrument.
Because various authors recommend no restriction on the
Several studies have shown a significant decrease in anxiety in length of TT treatment [5,13,14], the duration of the intervention
TT intervention groups [25–28]. A number of studies show was set between 5 and 15 min. The 14 nurses (36% of total nursing
findings supporting the clinical observation that TT significant- staff) who administered TT, had completed a 3 months TT-training
ly decreases perceived pain [22,29,30]. Several studies have
in the Krieger–Kunz method and had a minimum of 2 years TT-
reported physiological outcomes (heart rate, blood pressure,
skin temperature, and respiratory rate) showing significant practice at the outset of the study.
effects [31] or trends toward relaxation [32], while others found NP is a nursing intervention which aims to achieve outcomes
patients to remain physiologically stable [33]. like satisfaction with nursing care, comfort, growth and enhanced
When compared to control groups, for instance placebo or healing [15]. The nurse places her-/himself in an available, caring
other interventions, the findings are less conclusive. Research- and open manner at the disposal of the patient [16], and immerses
ers found significantly lower anxiety in patients receiving TT her-/himself in the patient’s situation in a fashion which is
than in control groups (placebo or other interventions) meaningful to the patient [15]. All nurses were instructed in NP
[22,26,34], while other studies found no significant differences prior to the study.
in anxiety between experimental and control groups [31,35].
The study was approved by the Centrale Commissie Mensge-
Some studies found no significant differences in pain scores
bonden Onderzoek (CCMO) of the Netherlands, a National Medical
between TT and control groups [30,34], while others found
positive trends [36]. Meehan [13] showed that TT did not Ethical Committee.
significantly decrease postoperative pain compared to a pla-
cebo control group, but noted that patients in the TT-group 2.2. Participants
required significantly less analgesic medication and waited
significantly longer before requesting analgesics, suggesting Participants in this study were hospitalized patients at the
that TT decreased patients’ need for analgesics. Although Rotterdam Burn Center, a small independent ward of 20 beds and
more indications of subjective relaxation have been reported 42 nurses at the Medical Center Rijnmond-Zuid (since then
[26,28,33,37], authors not always report significant differences renamed as Maasstad Hospital). Inclusion criteria were that the
in objective relaxation scores between TT-groups and placebo
patient was responsive and comprehended Dutch, and that the
control groups [30]. Results are also inconclusive regarding
endocrine functions (cortisol, nitric oxide). Lafreniere et al., in expected number of days of hospitalization would be 10 days or
a study of biochemical and mood indicators in women, found a more. The patient had to be older than 18 years of age to be able to
significant decrease in levels of nitric oxide, but no significant fill out the questionnaires. Participating children had to be older
effects for cortisol or catecholamines [28]. The lack of stan- than 3 years and were only included for the measurement of
dardization across the conditions in this study leaves uncer- cortisol. Exclusion criteria were the presence of psychiatric
tainty about these findings being the effect of TT. Other disorders, developmental disabilities and a history of endocrine
authors reported no significant changes in cortisol [22]. or neurological health problems, as evidenced by the medical files.
Eligible subjects were asked to participate after being given
information about the study. Written consent was obtained from
Questionnaire [6] decreased significantly. There was no difference
all patients who agreed to participate and, in the case of children,
in medication intake. Turner et al. concluded that the effectiveness
from their parents.
of the pain medication alters when combined with TT.
Aside from pain, severe pruritus, while using antihistamines or
2.3. Randomization
other standard measures of controlling itching, is not uncommon
[7,8]. Burn patients also face anxiety and depression [9].
Patients were studied during the first 10 days of hospitalization.
Prior to intervention, patients were classified in six groups:
1.2. Aim of the study
children (3–18 years) or adults (>18 years), with 3 categories each
for the percentage of total burned surface area: (0–10%, 11–25%
The purpose of this study initially was to evaluate the clinical
and >25% TBSA). The first recruited patient in one of these
use of therapeutic touch by nurses with the aim of reducing
categories was randomly assigned to one of the two intervention
anxiety, pain, cortisol level and pain medication in burn patients.
groups: TT or NP. The next patient categorized in the same group
Critics of complementary and alternative medicine (CAM) have
was included in the other intervention group, and the following
claimed that any effects of CAM are merely due to an increased
patient again categorized randomly, and so forth.
attention for the patient [10]. We therefore decided to compare TT
to nursing presence (NP), which can be regarded as an intervention
2.4. Evaluation of TT
of increased attention for the patient. Complementary care being
relatively new to the Dutch nursing profession, this would be the
To evaluate the effects of TT anxiety, pain and cortisol were
first study on TT ever in the Netherlands. It was also one of the first
measured. In order to establish a baseline, measurements were
nursing research projects in the Rotterdam Burn Center.
taken on days 1 and 2 after admission. Further measurements were
taken on days 5 and 10 of hospitalization.
2. Methods Pain anxiety: The Burn Specific Pain Anxiety Scale (BSPAS) was
used [17] for measuring the experienced anxiety at two moments:
2.1. The interventions before and after dressing changes. Five items were rated on a visual
analog scale from 0 (‘not at all’) to 10 (‘worst imaginable’). The
Patients daily received either therapeutic touch (TT) or nursing patients were asked to complete the BSPAS and for those who were
presence (NP) for 10 consecutive days after being given medication unable to write the nurse marked the answers. This instrument
and before dressing changes. Both interventions were applied in was developed and validated specifically for burn patients by Taal
accordance with NIC-protocols. [2] et al. [4]
TT is based on the assumption that health is reflected in and Pain: The Visual Analog Thermometer (VAT) – an adapted
affected by changes in an alleged human energy field [11,12]. The version of the VAS [18] – was used to measure the experienced
M. Busch et al. / Patient Education and Counseling 89 (2012) 439–446 441

pain. The VAT measures pre-procedural pain, procedural pain, intervention groups were standardized by dividing them by the
post-procedural pain and itching. mean standard deviation in the groups.
Cortisol: Saliva cortisol was collected as the physiological
indicator for stress, measured 7 times per day on the 4 3. Results
measurement days: upon awakening, 30 min after awakening,
right before dressing changes before intervention (pre-procedur- 3.1. Evaluation of data collection
al), right after dressing changes (post-procedural), 10 and 20 min
after dressing changes and in the evening. The study was practice based in that it was performed during
Pain medication: Usage of morphine, tramal, paracetamol and daily routine care by nurses who were inexperienced in research.
diclofenac was retrieved from the patients’ charts afterwards. Together with practical hindrances such as a 6 months closure of
the study site due to a bacterial infection and a broken freezer for
2.5. Evaluation of the study process cortisol samples, this resulted in a high number of incomplete data
sets. For the BSPAS-items the mean missing data per measuring
Post hoc semi-structured interviews with 6 randomly selected day ranged from 19% on day 1 to 51% on day 10; for the VAT it was
participating nurses were held in order to acquire more insight in comparable, ranging from 10% on day 1 to 50% on day 10. For the
the factors, which had affected the study process. The interviews saliva specimen it was even more difficult to include these
consisted of open questions. measurements in the daily nursing practice. Only four out of seven
Main focus of the interviews was the nurses’ experience with cortisol measurements were included in the final analysis, with
the limiting factors experienced in administering TT in daily care missing data ranging from 57% on the first day to 77% on the last
and in the collection and delivery of data. Each interview lasted for day.
1 h, was recorded and transcribed afterwards. Of the 43 patients that were enrolled initially, 4 were excluded
Ajzen’s ‘theory of planned behavior’ was used as the framework at an early stage due to diabetes (1), too frightened or
for structuring the interviews [19]. This theory addresses attitude emotionally disturbed children (2), and not understanding the
and subjective norms with regard to behavior, as well as self- Dutch language (1). Of the remaining 39 patients 17 received TT
efficacy. Ajzen’s theory was expanded with an evaluation of the and 22 received NP (Fig. 1); 20 subsequently dropped out in later
external context of behavior. All replies given were categorized and stages, mostly because of either early discharge or the impossibili-
analyzed according to these four factors. ty to collect sufficient data.

2.6. Evaluation analysis 3.2. Background characteristics

For the statistical evaluation of the group differences on The mean age of the included patients was 37.1 (ranging from 9
anxiety, pain and cortisol, the non-parametric Mann–Whitney U to 77 years-old) with 14 patients being male and 3 females. The
test was applied. ANOVA repeated measures were used with the mean total burned surface area was 9.4% (ranging from 1 to 21),
dependent variables as repeated measures, with age, TBSA, and the mean hospital stay was 22.8 days (ranging from 2 to 137
number of surgical procedures, days of hospitalization and gender days with a median of 19.0). In total 19 patients completed the 10
as covariates. For the analysis, all differences between the days of treatment. No significant differences were found for TBSA,

43 subjects
assigned

excluded (4)

initially randomized (39)

TT (17) NP (22)
discontinued
discontinued for other
for other reasons (4)*
reasons (3)*
discharged (5) discharged (5)
research too much
of burden (1)
research too much
of burden (2)
finally (8 ) finally (11)

1 2 1 2
complete measurements VAT-pain** (7 , 4 ) complete measurements VAT-pain** (10 , 6 )
complete measurements VAT-itch** (5 , 52)
1 1 2
complete measurements VAT-itch** (5 , 4 )
1 2 1 2
complete measurements BSPAS** (7 ,1 ) complete measurements BSPAS** (9 ,4 )
complete measurements cortisol (0) complete measurements cortisol (2)

Fig. 1. Participation and atrition of sample participants. TT, therapeutic touch; NP, nursing presence. *Other reasons: nurses stopped collecting data; data lost or missing data.
**Children excluded. 1Complete mean scores. 2Complete item scores.
442 M. Busch et al. / Patient Education and Counseling 89 (2012) 439–446

Table 1
Demographic characteristics.

Experimental (TT-group) Control (NP group)


a b
Initially Finally Initiallya Finallyb

Mean age 36.0 34.75 37.9 36.6


Group size 17 8 22 11
Children 2 1 2 1
TBSA 1 11 5 14 6
TBSA 2 5 2 7 5
TBSA 3 0 0 0 0
TBSA unknown 1 1 0 0
%TBSA 9.4 9 9.4 10.6
Male 14 5 12 5
Female 3 3 10 6
Hospitalization days 20.75 19.1 24.47 25.7
a
Initially randomized.
b
After attrition.

days of hospitalization or number of surgical procedures. There Pain medication (morphine, tramal, paracetamol and diclofenac)
was a significant under representation of female patients in the TT- was retrieved post hoc for each subject from the patient’s chart. On
group (male 82.4% and female 17.6%; Table 1). measurement days 1 and 2 significantly more patients in the NP-
group received morphine than in the TT-group (Table 3).
3.3. Differences between intervention groups Furthermore, more morphine was prescribed on day 1 to the
patients in the NP-group than in the TT-group (Table 4). Taking all
Anxiety: No statistically significant differences were found pain medication (morphine, tramal, paracetamol and diclofenac)
between the intervention groups for mean anxiety scores. on all measurement days together in a sum score, no significant
Compared on item level a statistically significant effect was found differences were found.
in the TT-group vs. the NP-group on day 10 with regard to post-
procedural anxiety for pain 19.0 vs. 38.7 for NP (p  0.05).
However, after Bonferroni correction this difference turned out 3.4. Within group changes
to be not statistically significant.
Pain and itching: No significant differences were found between ANOVA repeated measures showed that the mean anxiety
the intervention groups. scores resulted in a non-significant between group effect
Cortisol: On day 2 of treatment the TT-group showed a [f(1,8) = 0.247; p = 0,634]. The mean anxiety scores of the patients
statistically significant higher cortisol level compared with the in the TT-group in this analysis decrease, while the scores of the
NP-group before dressing change (Table 2). patients in the NP-group slightly increase (Fig. 2).

Table 2
Analysis of differences cortisol mean scores per measurement date.

Cortisol TT NP p valuea Effect size

Mean (SD) n Mean (SD) n

Day 1
Pre proc 10.8 (6.6) 5 10.1 (8.1) 6 0.715 0.095
Post proc 1 5.4 (3.0) 10 8.2 (6.7) 10 0.520 0.577
Post proc 2 4.1 (1.8) 8 6.1 (4.7) 9 0.596 0.615
Night 4.9 (3.4) 9 6.7 (4.7) 9 0.490 0.444

Day 2
Pre proc 12.2 (5.1) 6 5.8 (4.7) 8 0.014* 1.306
Post proc 1 10.0 (5.7) 8 7.7 (7.6) 8 0.344 0.345
Post proc 2 7.3 (7.7) 8 7.8 (9.3) 8 0.916 0.059
Night 4.1 (3.7) 7 6.2 (5.3) 10 0.500 0.467

Day 5
Pre proc 8.1 (3.8) 6 6.1 (3.2) 5 0.273 0.571
Post proc 1 6.7 (5.7) 6 6.0 (3.8) 5 0.714 0.147
Post proc 2 6.0 (4.2) 5 4.5 (4.7) 7 0.222 0.337
Night 3.3 (1.6) 4 5.7 (7.5) 6 0.83 0.527

Day 10
Pre proc 8.9 (1.8) 4 10.6 (2.7) 5 0.327 0.756
Post proc 1 3.0 (1.9) 3 7.3 (5.5) 7 0.210 1.162
Post proc 2 1.8 (6.2) 4 6.2 (5.1) 6 0.302 0.779
Night 1.8 (1.6) 4 1.7 (1.6) 3 0.720 0.062

TT, therapeutic touch; NP, nursing presence; and SD, standard deviation.
Pre proc – (first or second) pre procedural measurement.
Post proc – (first or second) post procedural measurement.
Night – last measurement.
a
Mann–Whitney U test.
*
p < 0.05.
M. Busch et al. / Patient Education and Counseling 89 (2012) 439–446 443

Table 3
Analysis of differences in number of patients receiving pain medication.

TT NP p-Valuea

TT-patients receiving medication (n) NP-patients receiving medication (n)

Morphine
Day 1 10 (14) 13 (18) 0.037*
Day 2 6 (13) 11 (16) 0.015*
Day 5 6 (11) 6 (11) 0.502
Day 10 5 (9) 7 (11) 0.149

TT, therapeutic touch; NP, nursing presence.


a
Mann–Whitney U test.
*
p < 0.05.

Table 4
Analysis of differences in amount of prescribed mg pain medication per intervention group.

TT NP p-Valuea sign. Effect size effect


Mean (SD) n Mean (SD) n

Morphine (mg)
Day 1 6.46 (4.37) 14 11.23 (6.75) 13 0.050* 0.860
Day 2 4.27 (4.86) 13 7.58 (3.32) 12 0.077 0.809
Day 5 5.55 (4.86) 10 6.88 (4.58) 8 0.438 0.282
Day 10 5.28 (5.07) 9 7.63 (3.70) 8 0.341 0.536

TT, therapeutic touch; NP, nursing presence; and SD, standard deviation.
a
Mann–Whitney U test.
*
p < 0.05.

The patients receiving TT seem to experience more pain and


anxiety scores itching (Table 5) compared to the patients in the NP-group, though
not significantly so. In Fig. 3, which shows the pain scores during
50 the course of treatment, a declining tendency can be noted in the
TT-group compared to the NP-group. The figure of the itching
scores shows an increase in itching in the TT-group after day 5 of
45
treatment.
The mean salivary cortisol levels per measurement day are
shown in Fig. 4. Intended was an exploration of the whole
mean anxiety scores

40
trajectory of salivary cortisol during the 10 days of treatment, e.g.
for the pre-procedural measurements, but too many cells
remained empty. Furthermore, because of missing data only
35
gender and age were taken as covariates in the analysis of day 10.
For this analysis only data of the category TBSA = 0–10% remained.
30 In Fig. 4 various trends on the measurement dates are shown. The
effect of the interventions on salivary cortisol, as shown in Table 6,
seemed similar for both intervention groups.
25
interventions
3.5. Post hoc interviews
TT (n=6)
NP (n=8)
20 Despite several instruction and intervision sessions, internal
newsletters and other updates on the study, it proved difficult for
1 2 3 4
nurses to obtain sufficient data. In order to understand the limiting
measurement days
factors of the study post hoc interviews were undertaken with 6
Fig. 2. Course of mean anxiety scores during research; TT, therapeutic touch; NP, randomly selected nurses. They were interviewed about their
nursing presence. collection and delivery of research data and about their use of TT.

Table 5
Repeated measures ANOVA of anxiety, pain and itching during 10 days of treatment.

TT NP ANOVA Power

Mean n Mean n F df1 df2 p

Anxiety 27.7 6 33.9 7 0.247 1 8 0.634 0.072


Pain 3.6 6 2.8 9 1.729 1 8 0.225 0.213
Itching 2.0 4 0.8 4 4.304 1 2 0.174 0.230

TT, therapeutic touch; NP, nursing presence; and SD, standard deviation.
*
p < 0.05.
444 M. Busch et al. / Patient Education and Counseling 89 (2012) 439–446

pain scores itching scores


3,0

4,0

2,5

mean itching scores


mean pain scores

3,5
2,0

1,5
3,0

1,0

2,5 interventions interventions


TT (n=6) TT (n=4)
NP (n=9) NP (n=4)
0,5

1 2 3 4 1 2 3 4

measurement days measurement moments

Fig. 3. Course of mean pain and itching scores during research. TT, therapeutic touch; NP, nursing presence.

Fig. 4. Course of mean cortisol levels in mg/L on measurements (1 = pre-procedural, 2 = first post-procedural, 3 = second post-procedural, 4 = night) per measurement day. TT,
therapeutic touch; NP, nursing presence.

Table 7 shows the themes that were addressed, following Ajzen’s nurses. The study design was clear to all nurses, but the
‘theory of planned behavior’. combination of providing daily care and collecting data proved
External context: Performing research activities in the midst of too complex. The limited number of new admissions created a
daily care was experienced as creating a great time strain by most discontinuity in study attention, resulting in forgetting to include
M. Busch et al. / Patient Education and Counseling 89 (2012) 439–446 445

Table 6
Repeated measures ANOVA of cortisol during 10 days of treatment.

TT NP ANOVA Power

Mean n Mean n F df1 df2 p

Day 1 6.35 5 6.73 4 1.137 1 2 0.398 0.101


Day 2 8.18 4 4.95 4 16.660 1 1 0.153 0.251
Day 5 6.85 4 4.45 4 0.029 1 1 0.893 0.051
Day 10 3.75 3 6.73 3 0.613 1 2 0.516 0.078

TT, therapeutic touch; NP, nursing presence; and SD, standard deviation.
*
p < 0.05.

Table 7 power of the study and possibly led to limited effects of TT on the
Interview themes. well-being of patients and pain medication. Analysis of the
Data collection Therapeutic touch
remaining data, however, reflects earlier findings and justifies
further research with the outcomes chosen.
External Time strain Experience of
context providing TT
Complexity Environmental influences 4.1.1. The role of the nurses
Clarity The study provides insights in the feasibility of enrolling nurses
Discontinuity in a research project during ongoing care in a non-academic
Feasibility hospital setting. This study was originally initiated because of
Attitude Toward participating in a study Toward effects of TT positive clinical results, achieved by three TT pioneering nurses at
Toward study practicalities Toward efficiently the Burn Center. Following this experience a group of sixteen
providing TT
colleagues were trained in TT. However, when the study started,
Long term considerations Toward TT as such
two of the TT-pioneers had moved on to other jobs, leaving a group
Subjective Patients Experiences of patients of fourteen nurses who had been trained but, as only became clear
norm Colleagues Experiences of colleagues
in the course of this study, did not practice TT as much as was
Team leaders Motivation by team leaders
expected before the study started. In future studies the importance
Self-efficacy Own capabilities (Lack of) confidence of the involvement of experienced TT nurses and role models
Responsibilities Feedback by patients
should not be underestimated.
Some of the nurses experienced a conflict of interest in caring
patients. This and earlier than expected discharges resulted in for the patient: burn patients suffer severely and need to be
collecting incomplete datasets. comforted. To the nurses TT seemed to be an effective intervention,
Attitude: All nurses expressed their hesitancy to include new but in trying to establish this effect, patients had to be burdened
admissions, especially when patients experienced severe suffering with ‘invasive’ measurements as well. Furthermore, collecting data
and when children were admitted, resulting in missing patients for was time consuming and thus discouraging. Due to practical
inclusion. Many nurses were hesitant to collect saliva samples with problems with scheduling nursing staff, sometimes TT was
included patients, as they experienced those to be ‘too invasive’ omitted because no TT-nurse was on duty or a TT-nurse had to
and too time consuming. This resulted in missing important data. provide NP because no one else was available to do so.
All nurses expressed enthusiasm about participating in the study It should be emphasized that the nurses cannot be held
and contributing to the knowledge base on TT. responsible for being inexperienced in participating in research.
Subjective norm: All included patients were cooperative. Management and researchers overestimated the nurses’ enthusi-
Although the nurses were sometimes hesitant to use the ques- asm and motivation and underestimated the impact on their lack
tionnaires, patients never expressed any misgivings about the of research skills would have on this study. This conforms the
instruments used. Some nurses and team leaders tried to stimulate experiences reported by Hicks [20] and Dykeman and Despotes
colleagues, who gradually lost interest in the study or felt it too much [21] that conducting an RCT within a clinical setting with nurses
of a burden. Team leaders regularly inquired why a patient had not inexperienced in research is very difficult.
been included.
Self-efficacy: On the one hand all nurses felt that they had given 4.1.2. Discussion of the results
their best effort, on the other hand they all acknowledged having Although the results are inconclusive, the limited findings are
missed new admissions, forgetting about measurement days, not supportive of findings in other studies in showing lower scores for
giving it enough attention. Their colleagues had been even post-procedural anxiety for pain in the TT-group on day 10, a
sloppier, had not been interested enough, and had not been as higher pre-procedural cortisol level in the TT-group on day 2, and a
meticulous as they should have. lower use of morphine in the TT-group on days 1 and 2.
Uses of TT: None of the interviewed nurses expressed any doubts The higher cortisol level before dressing changes on day 2 in the
toward therapeutic touch as a possibly effective intervention, but TT-group suggests the experience of more stress. However, one
half of them mentioned circumstances that they experienced as not would expect higher cortisol levels, if patients would report more
conducive for proper TT: a busy ward, colleagues watching, and pain or anxiety. This was not the case: patients’ perception of both
having to give TT to patients who were not theirs. These hindrances pain and anxiety in both groups were comparable on day 2. On the
resulted in sometimes ‘forgetting’ to offer TT. other hand, patients in the TT-group were prescribed significantly
less morphine on days 1 and 2 than patients in the NP-group,
4. Discussion and conclusion suggesting better pain control. Lin and Taylor [22] found that
salivary cortisol levels correlated more strongly with anxiety than
4.1. Discussion with pain. These results support Turner et al.’s [5] findings of TT
increasing pain relief for hospitalized burn patients as an adjunct
The results show that is was difficult to combine daily nursing to pain medication, and point to the relevance of future studies of
care with studying the effects of TT. Limited data weakened the TT in combination with analgesic medication.
446 M. Busch et al. / Patient Education and Counseling 89 (2012) 439–446

Anxiety for pain showed a statistically significant higher [2] McCloskey JC, Bulechek, GM, editors. Nursing interventions classification
(NIC). 3rd ed., St. Louis: Mosby-Year Book; 2000.
reduction on day 10, but this may not be necessarily of clinical [3] Foertsch CE, O’Hara MW, Stoddard FJ, Kealey GP. Treatment-resistant pain
relevance considering the small sample. It is worth mentioning and distress during pediatric burn-dressing changes. J Burn Care Rehabil
however, as Turner et al. [5] reported a significantly greater 1998;19:219–24.
[4] Taal LA, Faber AW, van Loey NEE, Reynders CLL, Hofland HWC. The abbrevi-
reduction in anxiety after multiple treatment. More research is ated burn specific pain anxiety scale: a multicenter study. Burns 1999;25:
required on the effect of TT on pain related anxiety in burn patients 493–7.
instead of only focusing on overall anxiety. [5] Turner JG, Clark AJ, Gauthier DK, Williams M. The effect of therapeutic touch on
pain and anxiety in burn patients. J Adv Nurs 1998;28:10–20.
The TT-group showed a non-significant increased itching on [6] Melzack R. The McGill Pain Questionnaire: major properties and scoring
day 10. Even though itching is a sign of healing [8,23], this might be methods. Pain 1975;1:277–99.
a premature conclusion, as itching is a multi-factorial phenomenon [7] Matherson JD, Clayton J, Muller MJ. The reduction of itch during burn wound
healing. J Burn Care Rehabil 2001;22:76–81.
and not yet well understood. Morphine can stimulate itching and
[8] Demling R, DeSanti L, Nelson RD. Pruritus and burn wounds. Wounds
itching can differ depending on which part of the body is affected. 2002;14(1 Suppl. A):2A–7A.
Also the TBSA or the occurrence of infections may play a role [8,23]. [9] Aaron LA, Patterson DR, Finch CP, Carrougher GJ, Heimbach DM. The utility of a
In future studies these issues and characteristics of the wounds burn specific measure of pain anxiety to prospectievely predict pain and
function: a comparative analysis. Burns 2001;27:329–34.
(depth or location) should also be considered. [10] O’Mathúna DP, Pryjmachuk S, Spencer W, Stanwick M, Matthiesen S. A critical
evaluation of the theory and practice of therapeutic touch. Nurs Philos
4.1.3. Limitations 2002;3:163–76.
[11] Borelli MD, Heidt P. Therapeutic touch, 1st ed., New York: Springer Publication
The study aimed to evaluate the effects of TT in the daily Company; 1981.
nursing of burn patients. No overall significant differences [12] Busch MEH. Cursusboek therapeutic touch. [Therapeutic touch course manu-
between TT and NP have been found. This may have been caused al]. Utrecht: Van Praag Instituut; 1998.
[13] Meehan TC. Therapeutic touch postoperative pain: a Rogerian research study.
by the small sample size that occurred because of the high attrition Nurs Sci Q 1993;6:69–78.
rate and the limited use of TT, thereby making finding any possibly [14] Quinn JF. Future directions for therapeutic touch research. J Holist Nurs
existing differences a lot less probable [24]. These limitations are at 1998;7:19–25.
[15] Godkin J, Healing presence. J Holist Nurs 2001;19:5–21.
the same time important lessons about how to involve nurses in an [16] Doona MED, Chase SK, Haggerty LA. Nursing presence: as real as a milky way
ongoing intervention as well as in the evaluation of it. bar. J Holist Nurs 1999;17:54–70.
[17] Taal LA, Faber WA, Van Loey NNE, Reynders CLL, Hofland HWC. The abbrevi-
ated burn specific pain anxiety scale: a multicenter study. Burns
4.2. Conclusion
1999;25:493–7.
[18] Chroinière M, Amsel R. A visual analogue thermometer for measuring pain
Conducting an effect study within daily nursing practice should intensity. J Pain Symptom Manage 1996;11:299–311.
preferably not to be done with a nursing staff inexperienced in [19] Eagly AH, Chaiken S. The psychology of attitudes. Orlando: Harcourt Brace &
Company; 1993.
research. If this is inevitable or even desirable, e.g. from a training [20] Hicks C. The dilemma of incorporating research into clinical practice. Br J Nurs
perspective, more attention should be paid to the preparation of 1997;6:511–5.
the participating nurses as well as more intensive supervision by [21] Dykeman M, Despotes J. The unexpected challenges of clinical research, or
what they do not tell you in school. J Assoc Nurses AIDS Care 1999;10:98–101.
an experienced researcher. Analysis of the remaining data justifies [22] Lin Y, Taylor AG. Effects of therapeutic touch in reducing pain and anxiety in an
further research on TT for burn patients, with pain, anxiety for pain, elderly population. Integr Med 1998;1:155–62.
and cortisol levels as outcomes. [23] Brand-van Tilburg RF, Baljon RM, Klasen HJ, van der Sijde KC, de Vries DHJ.
Brandwondenzorg: een multidisciplinaire benadering. [Care for burn patients:
a multidisciplinary approach]. Maarssen: Elsevier Gezondheidszorg; 2000.
4.3. Practice implications [24] Kazdin AE. Research design in clinical psychology., 4th ed., Boston: Allyn &
Bacon; 2003.
Administering and evaluating TT during daily care require [25] Quinn JF. Therapeutic touch as energy exchange: testing the theory. Adv Nurs
Sci 1984;6:42–9.
nurses experienced both in TT and research or better preparation [26] Heidt PR. Helping patients to rest: clinical studies in therapeutic touch. Holist
and supervision of the participating nurses; this should lead to less Nurs Pract 1981;5:57–66.
attrition and missing data, increasing the power of future studies. [27] Gagne D, Toye RC. The effects of therapeutic touch and relaxation therapy in
reducing anxiety. Arch Psychiatr Nurs 1994;8:184–9.
[28] Lafreniere KD, Mutus B, Cameron S, Tannous M, Giannotti M, Abu-Zahra H,
Role of the funding source et al. Effects of therapeutic touch on biochemical and mood indicators in
women. J Altern Complement Med 1999;4:367–70.
[29] Denison B. Touch the pain away: new research on therapeutic touch and
None.
persons with fibromyalgia syndrome. Holist Nurs Pract 2004;18:142–51.
[30] Blankfield RP, Sulzmann C, Goetz Fradley L, Artim Tapolyai A, Zyzanski SJ.
Conflict of interest Therapeutic touch in the treatment of carpal tunnel syndrome. J Am Board Fam
Pract 2001;14:335–42.
[31] Quinn JF. Therapeutic touch as energy exchange: replication extension. Nurs
None. Sci Q 1989;2:79–87.
[32] Olson M, Sneed N, Bonadonna R, Ratliff J, Dias J. Therapeutic touch and post-
Acknowledgements hurricane Hugo stress. J Holist Nurs 1992;10:120–36.
[33] Cox C, Hayes J. Physiologic and psychodynamic responses to the administra-
tion of therapeutic touch in critical care. Intensive Crit Care Nurs
The authors wish to thank nurses and patients for participating 1999;15:363–8.
in this study, and Stichting Achmea Slachtoffer en Samenleving, [34] Samarel N, Fawcett J, Davis MM, Ryan FM. Effects of dialogue and therapeutic
Stichting De Zaaier and Het Johan Borgman Fonds for their touch on preoperative and postoperative experiences of breast cancer surgery:
an exploratory study. Oncol Nurs Forum 1998;25:1369–76.
financial support. [35] Hale EH. A study of the relationship between therapeutic touch and the
anxiety levels of hospitalized adults. Dissertation Abstracts International
References 1982;47 (University Microfilms no. 8618897).
[36] Philcox P, Rawlins L, Rodgers L. Therapeutic touch and its effects on phantom
[1] Busch M, Huisman A, Hupkens S, Visser A, editors. Inleiding complementaire limb and stump pain. Coop Connect 2003;24(1):10–1.
zorg. [Introduction to complementary care]. Maarssen: Elsevier Gezondheids- [37] Kramer NA. Comparison of therapeutic touch and casual touch in stress
zorg; 2006. reduction of hospitalized children. Pediatr Nurs 1990;16:483–5.

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