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Introduction
Communication is an inseparable part of human relations, through which we can transform our reality1. When appropriate, it favors the effectiveness, quality, humanization of care1-3, trust in the relationship and assistance in the treatment of patients4.
Communication occurs in two ways: Verbal, through words, spoken, written or sound messages, and nonverbal, mostly unconsciously transmitted and demonstrated through touch, look, body language, gestures, facial expressions, which reveal feelings and intentions5-6.
Nonverbal communication refers to every message sent not through words7, and its skills correspond to 60-90 % of interpersonal communication, besides increasing patient satisfaction and treatment adherence8.
Touch is an effective and inevitable part of the practices of most health professionals9 and can be of the following type: Instrumental, when physical contact only exists during technical procedures and for the provision of care; expressive or affective, which is usually spontaneous and applied in a more humane manner, unrelated to a specific activity; expressive-instrumental, when a technical procedure is accompanied by the affective touch1. There is also the therapeutic touch, considered a holistic imposition of hands, not routinely used by health professionals and, therefore, with no focus in this study10.
Touch stimulates communication, demonstrates affection, acceptance, support, security, empathy and closeness to the patient. In this context of human interaction, expressive touch is a positive stimulus that promotes bonding and trust11, facilitates quality relationships and can provide closer relationship12, and lead to physical well-being13.
Poor use or inappropriate use of touch may distance patient and professional14, which can be a result of the professional’s lack of knowledge or fear of being misunderstood15, self-knowledge problems and internal balance or an environment with low security and support to carry it out16-17.
Therefore, the use of touch requires professional knowledge and skills regarding nonverbal communication to make their care a moment focused on the human aspect18. Such knowledge evolves with training and experience19, and there must also be affective competence 20.
Inherently, the physical therapist has a close relationship with the patient’s body, also communicating through touch11. Despite this proximity, physical therapy has its origin linked to the Cartesian and biomedical model21, besides a technical training restricted to physical aspects and resources, which does not consider the human point of view in understanding the individual’s emotional and social needs22. This perspective is reflected in the knowledge gap identified in the search for studies on nonverbal communication, especially regarding touch, in the performance of the physical therapist.
In this sense, the research problem was limited in the little use of expressive touch, which seems to portray the lack of knowledge of the values added to it, and the lack of preparation in this professional’s training, originated from our health model.
Thus, this study aimed to know the types of touch most used and to understand the meanings of touching for the physical therapists who work in a hospital environment, from the perspective of their feelings, attitudes and behaviors during care.
Material and Method
This is an exploratory study with a qualitative approach23, which used the case study24 as a research strategy, and Minayo’s content analysis25 as a data analysis technique.
The case study is the strategy of choice to investigate a contemporary phenomenon in its real-life context, especially when the boundaries between the phenomenon and the context are not clearly defined24. It is a naturalistic and flexible investigation that, through the use of many sources of evidence and information, aims to describe intensively and profoundly one or more cases that, in the health area, can be represented by the patient, the health professional, the patient-therapist dyad, by the therapeutic process, among others26.
The study was conducted in a large hospital in Brazil, a provider of highly complex services, and was previously approved by the Research Ethics Committee, under the Certificate of Presentation for Ethical Appreciation No. 45938215.6.0000.5404. The participation in the study was subjected to the signing of the Informed Consent Form (ICF), which clarified to the participants the objectives and procedures of the study, guaranteed anonymity in the exposure of research findings, ensured that no harm of any origin was foreseen considering the participation in the study, and cited, as the sole foreseen benefit, the contribution to the expansion of scientific knowledge on the study subject.
The study population consisted of 18 physical therapists who made up the physical therapy team of a Brazilian hospital. The study sample was intentionally composed, determined by the following inclusion criteria: Being a physical therapist hired for a minimum of six months. Exclusion criteria were defined as a researcher involved in the research process. All invited professionals agreed to participate in the study, and the final sample was represented by 16 physical therapists; two team professionals who were also authors of this study were not included in the sample.
The sample closure occurred due to exhaustion, that is, data collection occurred with all participants who were part of the researcher’s universe27.
For data collection, field observation was first performed in the participant modality, in which the researcher’s role in the investigated situation may vary from full participation to complete distancing28. Considering that the main researcher was also the institution’s physical therapist team coordinator and that her presence could cause intimidation in the professionals’ practice, another institution’s physical therapist who participated in the same research group made the observations.
Since the observer must know the specific purposes of the study so that the observation guarantees a more complete analysis of the problem23, a script for reflective and descriptive annotations based on the study model was used for field observation. Triviños28, and a script for the analysis of touch in tachetic and proxemic perspectives, as suggested by Maria Júlia Paes1, which allowed us to identify if the performed touch was expressive or instrumental.
The observations were made from August 2015 to November 2016, at random, without prior notice and respecting the activity of each physical therapist. A total of 19 observations were made, with an average duration of five hours each, with a variation of 4.47 hours. One subject required three observations and another two observations, both for confirmation of the data, and this need was due to the high demand of the sector, resulting in quick answers.
After each observation, the collaborator would meet with the main researcher to describe what was noticed during the visits: How and when the physical therapists touched their patients, the way they communicated with them, the affectivity, their attitudes and behaviors, all duly recorded in the area directed to free reflective annotations of the observation script. Participating observations were named by the letter “O”, followed by the observation number.
Semi-structured interviews were conducted by the lead author of the study and collected immediately after the completion of the field observations in order to avoid influences on the participants’ behavior during the observations. For its accomplishment, an interview script was elaborated based on the model proposed by Turato29.
The 16 interviews were recorded in audio and performed in the participant’s own work, in a reserved place according to their availability. The interviews lasted a maximum of 23 minutes and a minimum of 16 minutes, with participants’ perceived difficulty in talking about the topic. They did not have access to the transcript of the interviews to confirm the data. The interviews were later transcribed and named by the letter “E”, followed by the number corresponding to the order that they were performed.
The data obtained from the participant observations and semi-structured interviews were analyzed through Minayo’s thematic content analysis25, which proposes three stages: In the first, called “pre-analysis”, the floating reading is performed, the constitution of the corpus, the formulation and reformulation of hypotheses and objectives; text cut in record units, context units, cuts, categorization, coding modality and more general theoretical concepts. In the second stage, the material is explored and the researcher, considering the data, proposes inferences, performs interpretations and seeks the formation of theoretical or empirical categories that will specify the themes. In the third stage, the author suggests the treatment of the results obtained and their interpretation25-30.
To support the process of analysis and the creation of inferences, two main works were used as theoretical reference: Comunicação tem remédio, by Maria Júlia Paes da Silva 1, and Tocar: o significado humano da pele, by Asley Montagu 31.
Regarding methodological strictness, in order to ensure the study’s credibility, different data collection techniques (observation and interview) were carried out with the use of instruments built according to the literature, peer-reviewed and tested in a pilot data collection. In order to guarantee its reliability, the empirical material from the data collection was analyzed by peers, including the researcher, the study advisor and the research group, and based on the references already mentioned. The study site, the inclusion and exclusion criteria of participants, as well as the data collection process and analysis were detailed to ensure the transferability and reliability of the study 32.
No feedback was given to participants at the end of the study.
Results
The age range of physical therapists ranged from 25 to 39 years old, and only one participant was male. As proposed by Minayo 28-29, from the data analysis, four main thematic categories emerged, described following.
Instrumental touch as a fundamental resource of hospital physical therapy care
The first emerging category of material analysis revealed that touch is the fundamental work instrument for a physical therapist, a requirement of the practice itself and, as a consequence, instrumental touch is predominant during their care in the hospital environment.
Through the script of tachetic and proxemic analysis, it was found that the touch was frequent during the physical therapist’s assistance, which corroborated the close physical proximity between professional and patient. Despite this physical proximity, affection was rarely evidenced through the expressive type touch, which is the one performed to understand the subjectivities implicit in the relationship.
Expressive touch: Its low presence does not mean absence of affection
Despite the rare presence of expressive touch, clear manifestations of affection were found, with visible signs of care through verbal and nonverbal communication. Even during the instrumental touch, attitudes and gestures of affection, bonding and humanization were observed in most professionals.
Such actions of care by touching were demonstrated by permission requests that preceded the care, concern to explain the technique, make the patient comfortable, besides the proximity and calm tone of voice during verbal communication. Thus, the touch has been shown to favor the proximity and the actions of care and affection of this professional.
In this context, when touching the patient, even if instrumentally, the professional used the look, gestures, empathic postures, facial expressions, always followed by a smile, attention and care with the pressure exerted during the touch. Physical therapists also paid attention to the patient’s comfort signals through the positioning performed, the pain signals manifested by the resistance to the exercise or the withdrawal reflex of the painful stimuli, through displeasure expressions and also through the expressions before the vital signs observed in the patients’ monitors or before the breathing pattern, through mechanical ventilators.
Physical therapist feelings related to touch
Although expressive touch was rare during the observations, feelings of affection, bonding and energy exchange during touching were reported, in contrast to the visualized behaviors. Physical therapists who perceived touch as affection related it with sensitivity, feeling and perception:
“I often touch like that… with love. Touch their head, their face.” [E6]
“[...] because he [the patient] can’t express himself, so I think it gives you a ... need for greater care, greater attention”. [E9]
The balance between positive and negative affects becomes a challenge for health professionals, as the hospital environment causes them to experience moments of healing, hope, well-being and, on the other hand, there are periods of suffering, pain and death.
Affection was confirmed to occur when there is a bond with the patient, which seemed to be more evident in patients with pain, elderly, long-term babies, unable to express themselves or when they are seriously ill:
“[...] There are patients that we get much more involved, especially if they have serious illness... then we always touch them more carefully”. [E7]
“[...] because he [the patient] can’t express himself, so I think we end up feeling a ... need for greater care, greater attention”. [E9]
Physical therapists who perceive touch as a bond promoter also associate it with closeness, contact, intimacy, and trust:
“So, touch is a way to approach this patient and to think of the patient as a human being and not just as a patient who needs rehabilitation.” [E4]
Subjects who described touch as energy exchange reported that they also want to convey positive feelings to patients to aid their recovery. Confirming this belief, they express positive or negative feelings after touching depressed patients:
“I think touch is a transmission of energy. It’s something I get. It’s a donation, right? ” [E15]
Difficulty talking about touch means there is a deficiency in training
The difficulty in discussing expressive touch was inferred as a deficiency in the training of the physical therapist. In the speeches, an embarrassment is noticed when commenting on something that seemed to be unknown, which can be apprehended by the many moments of silence and reflection on what to say. Some reported surprise and shame that they had never realized the importance of emotional touch, and most acknowledged the difficulty in approaching the topic because they feel unprepared since their academic education. They attributed such difficulty because the main learning focus was technicist. This can be proven through the many speeches of physical therapist professionals:
“[...] I think it should be in the curriculum because it makes a great [emphasis on pronunciation] difference.” [E4]
“[...] in undergraduate course [the subject is treated] very little, we didn’t talk about it that much”. [E10]
Currently, the curricular organization is based on techniques, procedures, care methods and clinical-therapeutic approach and very little is taught about human practices, capable of providing an approximation between physical therapy and patients’ needs.
Discussion
In health, the act of touching is a means of relating and communicating, used by various professions to express care 33. In physical therapy, in particular, touch underlies the actions of this professional, as it allows the therapist to approach the patient’s body in a deep and legitimate way, going beyond simple skin-to-skin contact, which differentiates this profession 15.
Physical therapists allow themselves to approach the patient’s body due to the dialogue promoted by touch and movement, which is vital in this practice, and, through their skills, they explore the body’s capacity, its limits and possibilities. This is because the professional directly participates in the therapy, which makes them experience it, allows them to collect data and to understand them in their many meanings 15.
Considering that the instrumental touch is very frequent in the physical therapist’s assistance and that the simple act of touching favors the physical, affective and cognitive proximity with the patient 11, this professional has a privileged position for humanized care; however, he/she needs knowledge to perform such skills.
Among the types of touch, expressive touch stands out for facilitating the development of quality relationships, being used in the closest relationships to show support and acceptance, which promotes individual comfort 9. For the recipient, the other’s touch can be soothing, relieve pain and minimize negative emotions 12, so that its use by health professionals can bring numerous benefits and provide a better relationship with the patient.
Thus, it is important for the physical therapist to understand the types of touch and to use the expressive touch more often, consciously and intentionally, because it is associated with better interaction and care involvement, which favors integral care, capable of continuously shaping the patient’s health needs.
As professionals become involved with patients, characteristics such as affection, reciprocity, trust, respect and bonding manifest and become more evident 15. The evidence of affection may appear in the different ways of communicating, in getting closer to the other (proxemic), in how to talk to someone (Paralanguage) and during the behavior of the body when a relation is established (Kinesic) 8.
It was found that physical therapists used nonverbal communication to provide greater empathy, bonding and affection during the sessions, but that expressive touch for this purpose was underused. On the other hand, during interviews, professionals reported experiencing feelings of affection when touching patients, which indicates that touch is so close to care that professionals do not realize that, in their automatic attitudes, they use many types of touch. There is no way to separate their techniques from the subjectivity surrounding this relationship.
In this context, it is noteworthy that nonverbal communication was rarely used consciously by professionals, as a way to facilitate communication or show affection of the relationship with the patient, which indicates the lack of knowledge and unpreparedness of these professionals for this type of communication.
In addition to professional training, touching the other, especially when in suffering, requires professional emotional preparation and self-knowledge. Some physical therapists show sensitivity to interpret patients’ messages, especially when it comes to nonverbal communication and feelings 22. However, to learn nonverbal communication is possible and necessary, considering its importance for intersubjective interactions, in addition to promoting quality in health care activities 34.
In health, attention often turns to cognitive and rational aspects, and little emphasis is placed on affect in human, social and environmental relationships. Understanding the importance of affectivity in relationships is justified by the need to contemplate the subject in its entirety, to recognize the psychosocial dimensions of the professional that arise in the person-environment interrelationship and to unveil how these affects imply the development of their performance35.
Affections presented by positive aspects generate motivation and satisfaction among professionals36. And when they arise in relationships and bonds, they contribute to the strengthening of the professional in the search of improvement of his/her work and social commitment37.
The concept of bonding is polysemic and is articulated with the concepts of humanization37. The bond promotes the possibility of the professional to establish therapeutic plans more appropriate to the reality of the patients, which may determine adherence to treatment due to trust and commitment sharing38.
Thus, touching means engaging with one another in a reciprocal energy exchange36. By touching someone, not only their body is touched, a person is touched with all their memory, which is an essential dimension for caring39.
In this study, it is clear that the academic education of these professionals focused on the social and/or ethical and human attention did not include knowledge about the types and ways of touching, which does not fully meet the needs of the patient. In addition, these professionals must adapt to the model of organization and attention to the population.
One of the possibilities to change this scenario is to insert, in the curriculum of Physical Therapy course, teachings about human sciences subjects, besides reflections that favor the interpersonal relationship of the physical therapist with the patient22.
Conclusion
Touch is so embedded in the physical therapist’s universe of activities that it seems to have been limited to one technique and is rarely used as a tool of affection and humanization. This finding is evidenced by the interviews and the attitudes of affection observed during care, but which materialized through words, gestures, proximity, look and concern, but not through expressive touch.
The underuse of expressive touch evidences the lack of preparation in the formation of the physical therapist, characterized by the lack of knowledge about the types and the ways of touching and the lack of stimulus to self-knowledge, a prerequisite for affection and the creation of bonds.
More literature is needed about the human and affective touch in the health area, as opposed to the still predominant mechanistic formation, which reflects an area to be explored and one of the ways to sensitize professionals on the importance and appreciation of the expressive touch, which provides individualized care that addresses the patient’s real needs, better professional-patient relationship and communication, and more humanized health care.
Given the findings of this study, it is recommended to rethink how the act of touching has been taught and used by the physical therapist during the care of hospitalized patients.
As a limitation of the study, it is noticed that the sample studied was only from physical therapists graduated from private universities, which does not allow generalizing the results. Thus, further studies are suggested in populations coming from federal and state institutions. It is also noted that the low use of expressive touch was evidenced in the hospital environment, since this study did not cover other spheres of the professional physical therapist, such as primary and secondary care, so the findings cannot be generalized.
