The aim of this study was to explore patients’ subjective experience and perspectives on pain and other factors of importance after an early nursing intervention consisting of “caring touch” (tactile massage and healing touch) for patients subjected to a motor vehicle accident with minor or no physical injuries.
Study design and setting
The study was conducted as a single-arm longitudinal observational study, combining qualitative and quantitative perspectives, i.e. a mixed-methods design. The rationale for combining quantitative and qualitative methods was to provide a comprehensive exploration of the research question . The study was conducted at the emergency care department of a large university hospital in Stockholm County, Sweden.
A recruitment of potential study patients was made up from a list of incoming patients, inclusion criteria were; 18 years and above, literate in Swedish and cognitively intact, arriving at the emergency department following an MVA, and who upon medical examinations were given an injury severity score (ISS) between 0–3 and subsequently discharged straight home. ISS is a 0–8 point scale rating injury severity, where a rating of 0 indicates no physical injury, 1–3 represents minor physical injuries; and 8 corresponds to a life-threatening injury .
Patients were invited to participate based on a convenience sampling procedure. Initially, the sample of participants was estimated in relation to the possibility of having a control group receiving conventional care only. However, due to logistical barriers in the clinical setting it was not possible to include a proper control group. The patients were informed about the study by mail during the week after the MVA, and those interested in participating in the caring touch intervention were asked to contact the author (FA) by phone or mail and subsequently completed a written informed consent form during the first encounter with the therapist.
Intervention with caring touch
In this study we explore patients experience of a caring touch and not the treatment per se. Touch can be very private and intimate, and for this reason the patients could choose between tactile massage, which requires direct contact with the patient’s skin using a vegetable oil, or healing touch, which can be performed without direct contact with the patient’s skin. In this way, patients who were ambivalent about having their skin touched directly could choose the fully-clothed option. All of the participants choose to receive tactile massage in the beginning of the treatment period and ten percent of the participants later decided to try the treatment with healing touch. The caring touch was provided by nursing staff in a special treatment room with soft lighting and music, with the patient lying on a massage table. The tactile massage was performed by three assistant nurses certified in tactile massage with the same qualifications. Healing touch was given by a nurse certified at level four (of five) in Healing Touch. These two particular touch therapies were selected due to the fact that they were already being provided at the emergency department. The caring touch was adjusted to suit each patient and lasted for 20–60 min (mean = 45 min), once a week, for a maximum of eight treatment sessions altogether. The tactile massage, i.e. a soft tissue massage, was intended to stimulate touch receptors in the superficial layers of the skin and underlying tissues, without applying direct pressure or stretching to the muscles . The massage can be described as slow, gentle, structured, circulating movements with the palm of the therapist’s hand, during which natural oil, or oil with the fragrance of lavender, was applied, sometimes to the whole body. The patient was embedded in towels and blankets, with only the body part undergoing treatment being uncovered.
The healing touch was based on an established procedure, during which the therapist applied a light pressure to the feet, ankles, knees, hips, stomach, heart area, arms, throat, forehead and scalp  with the benefit that the patient could be fully dressed during the healing touch, as the nurse used her/his hand in different positions on the patient’s body.
Data collection and analysis
Data was collected from September 2012 through May 2014 with a hold-up during June to August, and during Christmas, due to the therapists’ vacation. The questionnaires were administrated at inclusion and at follow-up by mail after 6 months. VAS pain ratings were measured before and after each treatment. Individual interviews were conducted after 3 months.
The first author (FA) conducted the interviews in a closed meeting room at the hospital, 3 months after the patient’s first hospital visit. The time span was set to allow the patients to conclude their treatments with caring touch. The interviews, which lasted up to 60 min, were conducted in Swedish, digitally recorded and transcribed verbatim by the first author. An open-ended question was used to initiate the interviews: “Please tell me what you experienced when you had your motor vehicle accident” with an additional question, “Please tell me what you experienced when you received the caring touch”. During the interviews, there were continuous follow-up questions like “could you please explain further” and “could you give me an example”. During the interview, questions like “do I understand you right when you said…” were asked for clarification.
The interviews were analysed using Systematic Text Condensation (STC), based on Giorgi’s psychological phenomenological analysis . Applying a phenomenological approach, one looks at the objects from the perspective of how they are experienced, while bracketing presuppositions, allowing the essence of the phenomenon to emerge. The procedure consisted of the following steps: 1) An overview of the data was established, reading through all the interview transcripts while trying to bracket preconceptions, the purpose being to get an overall impression – “from chaos to themes”; 2) A systematic review of the interviews was made line by line, identifying and sorting meaning units, in order to elucidate the research question – “from themes to codes”; 3) Meaning units were systematically abstracted and sorted into thematic code groups across individual patients – “from code to meaning”; 4) Data was synthesized from the thematic code groups to descriptions and concepts – “from codes to concepts”. Two authors (FA and MA) independently did a preliminary reading and then discussed the meaning of the text. STC as well as Giorgi’s method implies an analytic reduction with shifts between de-contextualization and re-contextualization of data.
VAS pain ratings and questionnaires
The quantitative outcome was current level of pain measured by VAS, ranging from 0 (no pain) to 100 (worst imaginable pain) . Patients rated their current VAS pain at baseline during the initial visit and before and after each treatment session with caring touch, and then again via a postal follow-up after 6 months. The VAS is a standard instrument for assessing pain that was feasible for the nurses to use in the emergency care setting.
Further exploratory outcomes were sense of coherence (SOC), constructed by Antonovsky on the basis of a salutogenic model. The Sense of Coherence scale was of interest since this instrument capture the patients’ experiences of comprehensibility, manageability, and meaningfulness which we assumed could be linked to patient recovery. SOC, a 13-item rating scale, developed using the subscales of comprehensibility, manageability, and meaningfulness. Total scores of 21–59 indicate low sense of coherence, 60–74 an average sense of coherence, and 75–91 high sense of coherence . Additionally, the Impact of Event Scale (IES-R) has been well used in previous trauma research and was decided as being an appropriate tool to explore to what extent the patients experienced post-traumatic stress disease. IES-R, 22-item scale shows the degree to which the traumatic experience is felt on a consciousness level, and if the person exhibits avoidant behaviour. The IES-R is based on a 4-point frequency scales (i.e., 0 = not at all, 1 = a little bit, 2 = moderately, 3 = quite a bit, and 4 = extremely). An average of the total scale sum of 1.8–2.0 indicates post-traumatic stress disorder. The IES-R seems to be a solid measure of post-traumatic phenomena that can augment related assessment approaches in clinical and research contexts [21, 22]. The European Quality of Life (EQ-5D) instrument was employed to explore patients’ health-related quality of life and self-related health. The EQ-5D instrument was selected because of the short-form and that it has been widely used to measure quality of life among the County Councils of Sweden. EQ-5D is a standardized instrument for measuring health outcome. Respondents classify their health in terms of five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Each dimension has three levels of severity: (1) no problems, (2) moderate problems, and (3) severe problems. From the sum a number of total 243 combinations of health can be created. Each health combination generates an index value from -0.59 to 1.0, where 1.0 indicates full health. Additionally, the EQ-5D has a visual analogue scale for self-rated health with the anchors at zero (worst imaginable health) up to 100 (best imaginable health) .
Data from VAS pain ratings and questionnaires was manually transferred from paper into an electronic database before statistical analysis. Summary characteristics of patients were presented as proportions, mean, median, standard deviation and/or min-max values. Change scores of VAS pain ratings, SOC, IES-R and EQ-5D over time between baseline and follow-up after 6 months were analysed for patients with complete data. Considering rating scales and ordinal types of data, and the relatively small sample sizes, non-parametric statistical analysis, i.e. the Wilcoxon signed-rank test was employed for assessing change scores over time. All p-value calculations were conducted with a 5 % significance level. An additional descriptive analysis was conducted for VAS pain ratings before and after each treatment session with caring touch. Computational software included STATA 13, StataCorp, USA and Microsoft Excel 2011, Microsoft, USA.