Hands off or on when it comes to patient care?

Offering simple comfort can be thwarted

For as long as humans have been taking care of other humans who are sick or hurt, the rendering of solace and physical comfort has been the core from which all other types of aid have grown. But a nurse and ethicist in California says that ignoring the value of giving of solace and comfort amounts to turning away from the prime reason for the practice of medicine.

Rapid advances in technology, cultural differences between nurses and patients, and the current nursing shortage have all contributed to a hands-off approach by some nurses, says Patricia Benner, RN, PhD, professor in the department of social and behavioral sciences and department of physiological nursing at the University of California at San Francisco. "One colleague felt like it didn’t occur to nurses to reach out, physically, to patients, and to offer comfort other than medication, and I think that’s a real deterioration of the practice," says Benner. "It’s a loss of self and ethos of the practice."

Benner disagrees with the opinion that nurses are not being taught in school the value of being there for patients, or presencing (being present and available to the patient) oneself, and offering comfort. But she agrees that cultural differences and concerns about the possibility of unwelcome touch possibly offending the patient or family members have led some nurses to not engage in hands-on comforting.

The basis of all nursing

Offering comfort of the human type, and not just medications and technology, is what nursing has always been about, says Benner, a belief echoed by American Hospital Association president Dick Davidson. "There will always be personal contact and caring," Davidson says. "We will always have hands touching patients. Everything we do is about human need. That’s the constant over time."

Nursing and medical students are still being taught the arts of gentle touch and hands-on comfort measures, such as simply being present in a reassuring manner, says Benner, who works as a consultant in the development and enhancement of delivery of nursing care. "However, there are threats to this central nursing practice, it is invisible, it is rarely charted, and it is never mentioned in a nursing care plan."

This leaves nurses to decide individually, patient by patient, what role comfort and presencing will play.

It all depends on the patient

Just how much physical comfort a nurse should impart on a patient — if at all — is a largely going to depend on the patient. "It always — always — has to be lodged in the relationship," says Benner. "Just as you can’t suggest that you’ll do it for all patients, it would also be very wrong to say you won’t do it at all. And of course, if a patient does not want comforting, it would be wrong to force it," she adds.

Cultural diversity plays a role as well; some cultures have deeply ingrained attitudes toward physical touching. "You have multiculturalism on the side of both nurses and patients, and both groups are diverse [in their ethnicities]," Benner says. "And the language of presencing and comforting practices are deeply cultural. And there are even status barriers that might prevent a nurse from offering solace, or prevent the patient from accepting it."

Benner says that for medical staff to know how to give a patient the comfort and solace he or she needs, and to the degree that he or she needs it, the clinician must first get to know that patient to determine what his or her needs and preferences are.

Staffing can have an impact on what kind of care can be rendered. If manpower is short, so is the time a nurse or physician can spend with individual patients. "If you are short-handed, there isn’t going to be lots of time for sitting with a patient, listening, just presencing," Benner points out. "But with adequate staffing, there’s no reason comfort and caring can’t be part of the delivery of care."

Veterinarians as role models?

Delivery of comfort is taught in medical and nursing schools, Benner says, and is an integral part of the ethos of the practice. "You really couldn’t have good judgment or trust without good relational care, at least in some specialties."

One specialty, in particular, gets it right when it comes to giving patients individualized, hands-on, comforting care. "I’ve always felt it was very sad that veterinarians give much more individualized care to their patients than we who take care of humans," says Benner. Without that human element — the willingness to sit and hold a patient’s hand, to listen, to massage cramping legs or bed-weary backs — "we have nothing but a technical enterprise of delivering goods and services to patients," she adds.

When someone is ill, Benner notes, that person needs more than just the best drugs and most advanced treatment available. "They need more than justice and rights — they need comfort and goods."

Simply being there for a patient, even without offering anything in the way of real care, is more and more difficult as hospitals continue to struggle with staffing. But it’s a care delivery method that patients really shouldn’t have to do without, Benner says.

"Presencing yourself when someone is in distress — not abandoning them — is a very important comfort strategy," she says. "This is especially true when someone is trying to get his own equilibrium back, regulate his breathing, get his heart rate back in tow. Just having someone with them can be a real source of comfort."


For more information about providing physical comfort to patients, contact:

Patricia E. Benner, RN, PhD, FAAN, Professor, Thelma Shobe Endowed Chair in Ethics and Spirituality; and Chair, Department of Social and Behavioral Sciences; Joint Appointment, Department of Physiological Nursing, University of California at San Francisco. Telephone: (415) 476-4313. E-mail: benpat@itsa.ucsf.edu.