NAUSEA RELIEF AND PURPOSEFUL TOUCH: DECREASING

DISTRESS BY ALTERING THE PERCEPTUAL FIELD

A DISSERTATION

SUB:MITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS

FOR THE DEGREE OF DOCTOR OF PIIlLOSOPHY

IN THE GRADUATE SCHOOL OF THE

TEXAS WOMAN'S UNIVERSITY

COLLEGE OF NURSING

BY

LINDA S. DUNE, M.S.

DENTON, TEXAS

MAY2002

TEXAS WOMAN'S UNIVERSITY

DENTON, TEXAS

December 13, 2001

To the Dean of Graduate Studies and Research

I am submitting herewith a dissertation written by Linda S. Dune entitled "Nausea Relief and Purposeful Touch: Decreasing Distress by Altering the Perceptual Field." I have examined this dissertation for form and content and recommend that it be accepted in partial fulfillment of the requirements for the degree of Doctor of Philosophy, with a major in nursing.

We have read this dissertation and recommend its acceptance

Dean of Graduate Studies and Research

Copyright © Linda S. Dune, 2002 All rights reserved

ACKNOWLEDGMENTS

My sincere appreciation is offered to the members ofmy committee, Drs. Jeanette

Kernicki, Ann Young, and Joan Killen, for their support and guidance. Deep

appreciation is extended _to:

The patients and staff of the emergency center where this study was conducted.

Dr. Mary Watson for her statistical counseling.

, Rosa Lee Bachtel for her expert editorial skills.

IV

NAUSEA RELIEF AND PURPOSEFUL TOUCH: DECREASING

DISTRESS BY ALTERING THE PERCEPTUAL FIELD

LINDA S. DUNE, M.S.

MAY 2002

ABSTRACT

This study explored nausea levels after purposeful touch (PT) in patients who

presented to an emergency center (EC). PT is a commonly used nursing intervention that

can provide comfort in times of distress. Patient responses to distress were decreased by

the sensation of touch applied to a sensory pathway that communicates within the same

neuronal pool. PT decreased nausea by altering the perceptual field through stimulating

somatosensory peripheral areas that alter one or more of the nausea pathways. An

experimental two-group before-after design was used to determine the effects of PT or no

PT on the level of nausea of EC patients. The experimental group received PT while the

control group did not. The study sample included 140 patients randomly assigned to

either group based on order of presentation to the EC. The instruments used for data

collection included a Demographic Data Tool and a 100-mm visual analog nausea scale

(VANS). The patients in the experimental group received a 5-second bimanual touch to

the dominant hand and shoulder of the patient. The study groups were compared based

V

on demographics and findings. Frequencies and percentages were performed on the

variables of age, gender, ethnic origin, reason for EC visit, reactions to nausea, and history

of nausea. The analysis of covariance (ANCOVA) was used to analyze pretouch as the

covariate and experimental/control group data as recorded by each participant on the

VANS. Mean nausea intensity score among EC patients receiving PT to alter their

perceptual field was found to be significantly lower than the mean nausea intensity score

among the EC patients not receiving PT to alter their perceptual field (ANCOV A,

F= 27.22, df= 1, 139,p < 0.0005). These data supported the use of PT as an effective

nursing intervention to decrease nausea in EC patients with the common complaints of

gastrointestinal distress, pain, and headache.

VI

TABLE OF CONTENTS

ACKNOWLEDGI\ffiNTS... ... ...... ............ ... ... ... ... ... ...... ...... ... ... ... ... .... lV

ABSTRACT................................................................................... V

LIST OF TABLES ............... -........................................................ :... lX

LIST OF FIGURES.......................................................................... X

CHAPTER

1. Introduction .............................................................................................. . Problem of Study ................................................................................. . Rationale of Study ............................................................................... . Theoretical Framework ........................................................................ . Assumptions ........................................................................................ . Hypothesis ........................................................................................... . Definition of Terms .............................................................................. .

1 2 2

15 18 18 19

Limitations....................................................................................... . . . . . 20 Summary.............................................................................................. 21

2. Review of Literature................................................................................. . . 22 Nausea as a Focal Stimulus.................................................................... 23 Touch as a Focal Stimulus..................................................................... 34 Touch as a Nursing Intervention........................................................ . . . . 40 Stimuli Alteration for Nausea Relief....................................................... 45 Summary.............................................................................................. 58

3. Procedure for Collection and Treatment of Data.......................................... 60 Setting................................................................................................... 61 Population and Sample........................................................................... 61 Protection of Human Subjects................................................................ 63 Instruments ...................................... ·................................................. . . . . . 64 Data Collection.................................................................................. . . . . 69 Pilot Study............................................................................................. 71 Treatment of Data ........................................... ;.................................. . . . . 7 4 Summary............................................................................................ ... 75

vu

CHAPTER

4. Analysis ofData.......................................................................................... 76 Description of Sample........................................................................... 77 Findings............................................................................................. . . . 84 Summary of Findings............................................................................ 88

5. Summary of the Study................................................................................ 89 Summary............................................................................................. 89 Discussion of Findings....................................................................... . . . 92 Conclusions....................................................................................... . . . 98

Implications...................................................................................... . . . . 99

Recommendations for Further Study.................................................. . . . 99

REFERENCES...................................................................................................... 102

APPENDIX

A. AGENCY APPROVALS ............................................................................ 116 B. INFO�D CONSENT ............................................................................ 119

C. DEMOGRAPIDC DATA TOOL ................................................................ 123 D. VISUAL ANALOG NAUSEA SCALE...................................................... 125

vm

LIST OF TABLES

Table

1. Nursing Interventions to Decrease Physiological Effects of Nausea... . . . .. . . . . 6

2. Studies Reporting Significant Outcomes of Therapeutic TouchInterventions........................................................................................ ... .... 56

3. Descriptive Statistics for VANS by Age and Treatment Group...................... 78

4. Descriptive Statistics for VANS by Gender, Ethnic Originand Treatment Group.................................................... ... ... ... ... ... ... ... ... 80

5. Frequencies and Percentages of Primary Reason for EC Visit . . . . . . . . . . . . . . . . . . . . 81

6. Frequencies and Percentages of Symptoms with Nauseaby Treatment Group...................................................... . . . . . . . . . . . . . . . . . . . . . . . . 83

7. Bivariate Frequency Distribution of 140 VANS ScoresPretouch and Posttouch............................................................... . . . . . . . . . . . . . 86

8. Means and Mean Differences for VANS Scoresfor the Total Group ............................................................................ ...... 87

9. Analysis of Covariance for Mean Nausea Intensity Scores.......................... 87

lX

LIST OF FIGURES

Figure

1. Scatterplot Pre and Posttouch VANS by Group ............ ·...................... . . . . . . 85

X

CHAPTER!

INTRODUCTION

The basic and often used nursing actions ameliorating the effect of nausea are

sporadic in the current literature. Based on estimates from the National Health Interview

Survey in 1996, there were at least three episodes of nausea that contributed to at least

seven and one-half restricted activity days per 100 persons per year (Adams, Hindershot,

& Morano, 1999). Patients consider nausea to be so distressful that they will avoid

medications and treatments for life threatening diseases to avoid the sensation (Pervan,

1993).

The patient becomes vulnerable to the nausea stimuli through the perceptive

pathways of smell, sight, taste, or hearing. Nausea also can occur as a result of internal

stimuli caused by neurological dysfunctions, gastrointestinal inflammation, or chemical

poisonous substances. Nurses can use the focal stimulus of touch to interfere with one or

more of the nausea pathways in order to decrease the intensity of the distress.

Touch remains a fundamental nursing intervention that has been researched for

overall improvement in the patient's condition (Waddell, 1979). Nurses often touch the

patient to comfort or relieve patient distress (Barnard & Brazelton, 1990; Triplett &

Arneson, 1979). Nurses intervene on the patient's behalf by blocking or removing noxious

stimuli or stressors from the perceptual field (Ujhely, 1979). Physicians often administer

I

medications that block the nausea impulse in the central nervous system or use multiple

medications to alleviate the nausea distress. Side effects and medication interactions

increase proportionally to compounded medication use (Al-Sadi, Newman, & Julious,

1997). A single medication or one nursing intervention will not consistently alleviate the

distress of nausea. If nursing interventions and medications are used together, the distress

can be decreased beyond just the single medication effect (Arakawa, 1997).

Problem of Study

Nursing interventions combined with medication has ihe potential of decreasing

nausea. This study was conducted to answer the question: Will purposeful touch (PT)

applied to specific nerve pathways decrease nausea levels in patients who present to an

emergency center (EC) with nausea as a primary or secondary complaint?

Rationale for Study

Even though nausea research has been conducted and reported in the literature,

there are few reported studies on touch interventions for the distress of nausea.

Interviews conducted by the investigator revealed that nurses used different interventions

based on previous personal experiences rather than documented research. C. R. King

(200 I) identified that practical interventions need to be developed to relieve nausea and

vomiting immediately to avoid interference with the patient's daily activities and quality of

life. According to Quinn, Brown, Wallace, and Asbury (1994), postoperative nausea

remained as the most negative aspect of having surgery. Tobias ( 1993) reported that

2

patients preferred to be in pain rather than have nausea as a side effect of pain

medications. In addition to the nausea itself, patients reported multiple physiological and

psychosocial effects (Muth, Stem, Thayer, & Koch, 1996). Even though nausea and

vomiting effect the physical, psychological, social and spiritual well-being domains of

quality of life (Grant, 1997), there were no documented studies on the nursing intervention

of touch to relieve nausea for the EC patient.

Physiological Effects

Nausea is an overwhelming, unpleasant sensation in the back of the throat that may

precede vomiting (Hawthorn, 1995). Since nausea does not always result in vomiting, the

two concepts should not be used interchangeably (Rhodes, McDaniel, & Johnson, 1995).

The physical effects of nausea are well documented in nursing textbooks and research

(lgnatavicius, Workman, & Mishler, 1999; Muth et al., 1996). Responses to nausea

include changes in nutritional and functional status, fluid and electrolyte imbalances,

fatigue, and self-care deficits. Patients experiencing nausea report weakness often severe

enough to discourage any physical movement. Nausea is a syndrome of all-consuming

physical symptoms including: sweating, pallor, salivation, gastric stasis, drowsiness,

diarrhea, or hypotension (Muth et al., 1996� Rhodes et al., 1995). Arakawa (1997)

reported that the physical syndrome of nausea increases with activity of the autonomic

nervous system and visceral efferent nerves.

3

The sensation of nausea can be a response to stimulation of intestinal, meningeal,

gastric, and other receptors which can include direct chemical stimulation of the nausea

center, afferent integrated pathways, and the cerebral cortex (Edwards, 1996; Mannix,

1999). Nausea is believed to be a reaction to a complex physiology of stimulation of

receptors by the neurotransmitters dopamine, serotonin, 5-hydroxytryptamine ( 5-HT),

histamine, and somatostatin. These neurotransmitters are released from multiple sites

which include, but are not exclusively located in, the gastrointestinal tract, central nervous

system, cardiac muscle, bladder, and uterus (Hawtho� 1995; Hogan & Grant, 1993; C.

R. King, 200 I; Mannix, 1999). Since there are multiple numbers of neurotransmitters and

receptors, the nausea syndrome can be initiated by many physiological etiologies including

Addison's disease, anesthetic agents, anoxia, ascites, autonomic nervous system failure,

bruxism, cancer, cerebral infection, chemotherapy, congestive heart failure, constipation,

diabetic gastroparesis, diabetic ketoacidosis, diarrhea, disgusting sights, foul smells,

gastritis, gastroesophageal reflux, gastrointestinal irritation, hepatitis, hypercalcemia,

increased intracranial pressure, infection, intestinal obstruction, labyrinthitis, medications,

mesenteric ischemia, myocardial infarction, opiate analgesics, overindulgence, pain,

pancreatitis, peptic ulcer, pregnancy, premenstrual syndrome, pyloric stenosis, radiation,

Rey's syndrome, side effects of medications, surgical procedures, travel, toxins, tumor

lysis syndrome, and uremia (Bianchi, Grelot, Miller, & King, 1992; Hawthorne, 1995;

Mannix, 1999). Edwards ( 1996) summarized these etiologies according to the physiologic

4

input pathways of the cerebral cortex, chemoreceptor trigger zone (CTZ), sympathetic

visceral afferents, vagal visceral afferents, and vestibulocerebellar afferents.

The nausea syndrome stimulates the release of neurotransmitters that communicate

with the detectors in cranial nerves and visceral afferent nerve fibers. The nerves carry the

resulting impulses directly to the CTZ in the area postrema (AP) (Jablonski, 1993) or by

way of the nucleus tractus solarius (NTS) and the reticular formation to the AP (Hartman,

1992). Other detectors are located in the labyrinth of inner ear and higher brain centers.

The CTZ can detect substances in the circulating blood and cerebrospinal fluid since it is

located at the floor of the fourth ventricle and is not restricted by the blood-brain barrier

(Guyton & Hall, 1996). Once the nerve impulses are interpreted by the vomiting center,

messages are sent via the efferent pathways and sympathetic nervous system to the

respiratory, cardiovascular, and gastrointestinal systems to prepare the body for vomiting.

These sensations, created by the efferent pathways, result in some of the symptoms that

accompany nausea (Hogan & Grant, 1997).

Nursing interventions to relieve the physical effects of nausea have been used to

halt the initial response or the resultant sensations of nausea (Table 1 ). Other interventions

reported as anecdotally helpful include preparing cold food to avoid the odor of cooked

food and use of ice orally or placed on the abdomen or forehead. In this study, touch was

explored as an additional nursing intervention for nausea that can create or inhibit impulses

communicating to the central nervous system by way of the autonomic nervous system

and the peripheral nervous system (Lederman, 1997; Tovar & Cassmeyer, 1989).

5

Table I

Nursing Interventions to Decrease Physiological Effects of Nausea

Intervention Researcher Date

cold clear liquids sipped slowly Hogan (1983)

cool cloth to the forehead Hinojosa (1992)

position change Hinojosa (1992)

colorless food Menashian, Flam, Douglas-Pazton, (1992) &Raymond

nothing by mouth Wenrich (1994)

dietary counseling Diiorio, V anLier, & Maneuffel (1994)

assessment Rhodes, McDaniel, & Johnson (1995)

self-care modalities Rhodes, McDaniel, & Johnson (1995)

pain medication Paech, Pavy, Kristensen, & (1997) Wojnar-Horton

oral care Bowsher (1997)

peppermint oil Tate (1997)

therapeutic touch Giasson & Bouchard (1998)

educational programs Coslow & Eddy (1998)

ginger root Visalyapputra, Petchpaisit, (1998) Somcharoen, & Choavaratana

oxygen Greif, Laciny, Rapf, Hickie, & (1999) Sessler

6

Table 1 (Continued)

Intervention Researcher Date

protein meals J ednak et al. (1999)

intravenous fluid intake Bennett, McDonald, Lieblic� & (1999) Piecuch

acupressure (bands) Harmon, Gardiner, Harrison, & (1999) Kelly

alcohol vapor (isopropyl) Wang, Hofstadter, & Kain (1999)

acupressure (finger) Dibble, Chapman, Mack, & Shih (2000)

According to Selye (1976), a sensory stimulus can be communicated through

several branches of nerves and can create diverse reactions throughout the nervous

system. A researcher then could logically postulate that when a nurse uses PT on several

somatosensory peripheral areas which stimulate or inhibit one or more of the nausea

pathways, the sensation of nausea might be decreased. Nerve stimuli can also converge

from multiple sources to excite a single neuron which would insure conduction of stimuli

to the central nervous system (Guyton & Hall, 1996). Touch to a sensory pathway as a

focal stimulus could alter the patient's perceptual field or modify neurotransmitter action

to decrease the distress from nausea.

The dynamic perceptual field of the open system has to do with how a person

interacts and reacts within the adaptive system (Roy, 1984). I. M. King (1981) pointed

7

out that human beings are open systems who interact with the environment. Nurses can

treat the distress of nausea by altering the perceptual field of the patient through

introducing stimuli via the senses that act as input into the central nervous system, after

which the patient can adapt to nausea (Roy & Andrews, 1999).

Touch as a Physiological Nursing Intervention

Purposeful touch (PT) was defined by Snyder and Nojima ( 1998) as intentional

physical contact by the nurse for the intent of helping. A wide range of touch

interventions was identified in the literature, such as: (a) caring, (b) protective,

(c) affective, (d) connecting, (e) working, (f) orienting, (g) therapeutic, (h) relaxation,

(i) healing, and G) social (Bottorff, 1992; Estabrooks, 1989; Meehan, 1998; Silva, 1992;

Wardell & Mentgen, 1999). The nursing intervention of PT differs in intent from other

types of touch since it is planned as a therapeutic intervention based upon scientific

rationale for a specific patient complaint. PT differs from therapeutic touch because it

utilizes tactile stimulation rather than the manipulation of energy fields. Estabrooks

defined PT as a physical, working kind of touch used during emergent or crisis situations.

Since patients identify nausea as an overwhelming distress, an emergent type of nursing

intervention would be appropriate.

PT is an intentional, planned nursing intervention that can be used for helping the

patient. According to Weiss ( 1986), there are four qualities of touch to be considered

when applying the external independent environmental stimuli: (a) intensity, (b) action,

8

( c) location, and ( d) duration of touch. Moderate intensity was identified as optimal since

too light a pressure would be minimally perceived and not even create a response and

strong pressure could cause distortions in neural conduction. In addition, the technique of

using stroking, rubbing, holding, or squeezing on a cutaneous area was identified as

meaningful by Weiss. The duration of touch was identified as important because the

length of the contact provided time for the patient to integrate the stimulus. Finally,

location was identified as a consideration, since the degree of enervation depends upon the

amount of somatosensory stimulation that results from the touch (Lamb, Ingram, Johnson,

& Pitman, 1980; Weiss, 1986). According to Guyton and Hall ( 1996), the sensory system

provides input to the central nervous system through mechanoreceptors that are sensitive

to touch, pressure, warmth, cold, and pain sensations. The transmissions of the touch

sensations adapt rapidly. These sensations continue as long as the stimuli are present and

may last minutes or hours beyond the initial stimulus.

According to Schoenhofer (1989), intensive care nurses touch the hand and

shoulder of their patients most often. The investigator has made similar observations in

which nurses used the same type of touch to calm patients in crisis, to support patients

during painful procedures, and/or to soothe patients in pain or with nausea. Based on

these observations, PT to the shoulder and handshake position was chosen as the

somatosensory areas for the purposes of this study. The areas of the touch were to the

patient's shoulder between the midclavicle and the lateral surface of the neck and the

handshake position. According to Holmes (2001 ), the touch to the shoulder area would

9

stimulate sensory neurons of the transverse cervical nerve and the supraclavicular nerves

of the superficial cervical plexus. The handshake position would stimulate the superficial

branch of the radial, the proper palmar digital branches and the palmar branches of the

· median, and the superficial and dorsal branches of the ulnar nerves of the brachia! plexus

(Holmes, 2001). The use of this bimanual touch could decrease nausea since afferent

nerve areas inclusive of dermatomes from cervical spine nerves three, four, six, seven, and

eight are stimulated simultaneously in order to alter the patient's perceptual field. The

resulting stimuli are communicated through multiple tracts to the thalamus and cerebral

cortex (Guyton & Hall, 1996). The touch could conceivably alter the focal stimulus of

nausea.

Psychological Effects

Roy ( 1984) identified nausea as an unpleasant sensation reported as a feeling of

sickness that can be stimulated by several intrinsic and extrinsic factors. Nausea can be

described as an overwhelming distress with pre learned anticipatory responses based on

previous focal stimuli. The person experiencing nausea generally reports feelings of

helplessness, overwhelming distress, and an increased need for nursing interventions to

relieve the nausea (Golberg, 1998). Other reported occurrences of nausea were attributed

to stressful situations or conversations, memories of nausea, phobias, or mental images of

chemotherapy (Redd, Dadds, Futterman, Taylor, & Bovbjerg, 1993). Anxiety is one of

the most documented psychological responses that contribute to nausea and vomiting.

------- -- ----

10

F essele ( 1996) identified that anxiety can be related to multiple factors of fear of

treatment, pain, or anticipatory expectations.

In addition to the stimuli that cause nausea, patients described experiences with

nausea as signifying suffering, demoralizing, and demeaning (Mannix, 1999). Patients

often apologize and seem embarrassed when experiencing nausea and vomiting (Renouf,

1998). These patients express concerns about causing a mess or creating offensive odors.

Concerns about the symptoms and their possible meaning were identified as anxiety

producing enough to exacerbate distress (Lenz, Pugh, Milligan, Gift, & Suppe, 1997).

According to Roy ( 1984 ), the person has innate ways of adapting to the environment and

uses both the cognator and regulator subsystems to adapt to stimuli. The person has the

ability to respond to nausea through a process of forming perceptions and using

information processing, learning, judgment, and emotion to adapt to the stimulus (Roy &

Andrews, 1999).

Nurses can treat the distress of nausea by altering the perceptual field of the patient

through introducing stimuli via the senses that act as input into the central nervous system,

after which the patient can adapt to nausea (Roy & Andrews, 1999). Behavioral

interventions identified in the literature for psychological causes or responses to nausea

are effective because they produce relaxation, distraction, feelings of control, have no side

effects, and can be used by the patient without the therapist being present (C.R. King,

2001). Some of the interventions identified were self-hypnosis, altered states of

consciousness, progressive muscle relaxation, biofeedback, imagery, distraction,

11

desensitization, and music therapy. O'Brien, Relyea, and Lidstone (1997) described

interventions such as deep breathing, resting, silence, soft music and quiet conversation to

be beneficial to decreasing nausea caused by visual or auditory stimuli. Hogan ( 1983)

suggested that empowering the patient by allowing for previous interventions that have

been successful during times of illness in the past would decrease anxiety and thus help

manage nausea. Hawthorn ( 1995) suggested the following nursing interventions for

psychological effects of nausea: (a) take time to explain treatment, (b) reassure that

vomiting is not inevitable but be realistic about it occurring, ( c) inform the patient that

anti emetics will be available, ( d) use vocabulary familiar to the patient, ( e) remove any

exacerbating factors" (p. 136). PT could be employed to provide comfort in times of

distress along with other nursing interventions that introduce stimuli into the cognator

subsystem to be processed so that the patient's adaptive responses to nausea can be

produced.

Social Effects

The social effects of nausea extend beyond just costly outcomes or lost school or

lost work days to include a direct influence upon activities of daily living and social

interactions. Nausea experienced by anyone within a group detracts from the types and

meaning of interactions. Family and friends may continue to eat but report a lack of

enjoyment of the meal (O'Brian & Naber, 1992). Nausea adds complexity to already

severe illnesses. Fifty percent of patients with myocardial infarction complained of nausea

12

(Ahmad, 1978; Ingram, Fulton, Protal, & Aber, 1980). Nausea is costly because of the

influence upon the ability of a person to work or attend school during times of illness.

Rhodes (1990) reported that among the symptoms of viral respiratory infections, nausea

and vomiting are the most common causes of employee absenteeism. Patients reported

weakness and alterations in activities of daily living and a resultant inability to work when

nausea is a concern (Engstrom, Hernandez, Haywood, & Lilenbaum, 1999). Even though

nurses can decrease nausea, it remains a distress associated with multiple diseases and the

most common complication of anesthesia despite antiemetic medications and

nonpharmacologic treatments such as acupressure (Ferrara-Love, Sekeres, & Bircher,

1996). Carroll, Miederhoff, and Cox ( 1994) reported that postoperative nausea and

vomiting costs averaged as much as $1,040 per patient with the cost for additional

supplies of at least $16 per patient. Patients who experience the distress of nausea will

spend more time in an EC, use more supplies, and require more medications than the

patients who do not have nausea (Carroll et al., 1994). If more time is required to treat

patients in the EC, other presenting patients may have to wait for care in the triage area.

According to Marley ( 1996), concerns of optimal facility usage and the inability to

provide timely care for all patients arose when there was an increased amount of care

needed for the patients with nausea in the outpatient setting. Patients who require an

increased level of care related to nausea contribute to a backup in services, and additional

holding areas may be required to allow for control of medication side effects and needed

monitoring after conventional therapies for nausea. More staff would be needed to

13

J - ---�- --��

operate the additional beds, and thus other patients may receive decreased time with health

care professionals. Individual patients who stayed longer in EC because of nausea

treatment delayed care that other patients required because of the lack of available beds

during busy times. Patients waiting for services may become more ill and require more

time to reverse symptoms which might decrease the patient satisfaction with care.

Carroll et al. (1994) reported nausea extended the length of post anesthesia time

by an average of 24 minutes. A waiting time of 24 minutes in an EC could translate into

significant loss of revenue and decreased patient satisfaction. In today's health care

environment, the cost of health care signifies an enormous concern to patients and nurses,

and relieving nausea could decrease these costs and, as a result, the concern.

Implementation of nursing interventions for nausea can provide cost-effective care with

clinically useful patient outcomes. Many of the nonpharmacologic techniques help

decrease nausea and improve the patient's quality oflife without an increase in cost. By

using PT, the nurse can support the patient until nausea medication can be administered

and augment the nausea medication effects so that a lower dose might be needed. A

lowered dose could decrease the amount of time that the EC patient spends in recovering

from the sedation side effects for many antinausea medications. PT can be implemented as

a part of nursing care without additional care time. In addition, this study of PT and

nausea relief contributed to the number of individualized interventions possible for the

patient with nausea and added to the body of nursing knowledge.

14

Theoretical Framework

A theory base is an important component of nursing research. The theoretical

basis of this study was Roy's adaptation model (Roy, 1984; Roy & Andrews, 1999).

Nausea, one of the signs and symptoms of disturbed gastrointestinal function, often occurs

with stressors to the human system in general. Since nausea can be a symptom resulting

from stress or a stressful event that often accompanies illness, groups of reactions must be

considered when assisting the patient to adapt to nausea as a pattern of response to

stressors.

The response of the person to nausea as a stressor can result from physical or

psychological stimuli from multiple pathways that can influence adaptation. Nurses can,

according to Roy and Andrews ( 1999), "promote adaptation in situations of health and

illness and enhance the interaction of human systems with the environment" (p. 55).

Human beings are adaptive systems which are more than just individual parts that function

as a whole. Human beings interact with the environment by use of internal and external

stimuli. Stimuli that catch the patient's attention and energies are called focal stimuli.

These focal stimuli can enter into the human adaptive system as input along with

contextual and residual stimuli. Stimuli and internal input result in the adaptation level.

The adaptation level remains in constant flux of change because human beings and the

environments tend to readjust constantly.

Compensatory processes may be triggered to assist with adaptation (Roy &

Andrews, 1999). The nerve impulses influence the functioning of neurotransmitters and

15

many other organ systems including the gastrointestinal tract. The endocrine glands

attempt to defend against stressors by producing adaptive hormones that cause local and

systemic changes to combat the organic effect of stress. Adaptation, as a group of

inhibitory and activating reactions to stress, integrates into a pattern of responses and not

just a single reaction (Selye, 1976). The regulator and cognator processes identified by

Roy ( 1984) can work together or as separate systems to assist with the adaptation of the

human being as part of the pattern of response. Both processes have input, internal

systems, and output. The regulator subsystem includes inputs of chemical, neural, and

endocrine stimuli that result in automatic channeling and an automatic, unconscious

response. The cognator subsystem consists of internal systems that enable the patient to

use perceptual and information processing, learning, judgment, and emotion that result in

problem solving and decision making with the output as relief from anxiety. The

autonomic processes or reflexes that may follow as a result of the body's response to

stimuli are considered outputs from the regulator subsystem (Roy & Roberts, 1981).

Nurses identify adaptation to nausea by assessing the patient's behavior during

autonomic body responses of diaphoresis, skin pallor, hypersalivation, and hypotension

(Cole, l 996� Muth et al., 1996) or by the patient's verbal complaints of nausea. In

addition, behaviors identified by Roy and Andrews (1999), such as eating patterns, sense

of taste, sense of smell, food allergies, pain, and altered ingestion, would need to be

assessed. Focal, contextual, and residual stimuli such as the structural integrity of the

digestive tract, functions of digestion, conditions of eating, or cues for eating are assessed

16

in order to identify the factors that influence the patient's digestive processes. The

sensation of nausea enters into the regulator subsystem as either internal or external

stimuli (Roy & Andrews, 1999). Nausea stimulates the system processes by way of

neural, chemical, or endocrine stimulation of the gastrointestinal tract, peripheral nerves,

cerebral cortex, cerebrospinal fluid, and the chemoreceptor trigger zone ( CTZ) ( Arakawa,

1997).

Once the stimuli and behavioral responses are identified, then barriers to

adaptation can be considered and goals established. A decision then must be made

regarding how to best assist the human system toward adaptation and which nausea

pathway can be influenced by direct intervention. As indicated by Roy and Andrews

(1999), nursing interventions promote adaptation by "altering, increasing, decreasing,

removing or maintaining" stimuli (p. 86).

According to Roy and Andrews (1999), nurses promote adaptation by altering

focal stimuli. Since the NTS is the primary relay of messages between the AP and the

respiratory, circulatory, and gastrointestinal tract, it could be deduced that a change in

external stimuli could change the focal stimulus of nausea and promote adaptation.

Nurses can use PT to change or eliminate the focal stimulus of nausea by decreasing the

associated autonomic behaviors and thus increasing the patient's ability to cope with

nausea (Roy & Andrews, 1999). As a result of this study, another focal stimulus, PT, that

enhances adaptive responses as described within the Roy adaptation model, was

supported.

17

Assumptions

This study was based on assumptions from the conceptual framework derived from

Roy's (1984; Roy & Andrews, 1999) adaptation model:

1. Human beings are adaptive systems that are more than just parts, but components

that function as whole systems (Roy & Andrews, 1999).

2. Human beings interact with the environment by use of internal and external stimuli

that enter through regulator and cognator subsystems (Roy & Andrews, 1999).

3. Nurses identify adaptive processes of illness by assessing behavior, patients'

complaints, and the focal, contextual, and residual stimuli (Roy & Andrews, 1999).

4. Nursing interventions promote adaptation by altering, removing, or decreasing

stimuli t�at can enter through the regulator subsystem (Roy & Andrews, 1999).

Hypothesis

It has been proposed that purposeful touch serves as an effective nursing

intervention to decrease the intensity of the sensation of nausea for individuals who

present to an EC treatment area with a primary or secondary complaint of nausea. The

hypothesis for this study can be stated as:

The mean nausea intensity score among emergency center patients receiving

purposeful touch to alter their perceptual field will be significantly lower than the

mean nausea intensity score among the emergency center patients not receiving

purposeful touch to alter their perceptual field.

18

Definition of Terms

For the purpose of this study, the following terms were conceptually and

operationally defined:

1. Nausea: Conceptually, nausea was defined as the feeling of distress and loss of

control of bodily functions in anticipation of vomiting (Rhodes & Watson, 1987).

Nausea was operationally measured on a 0-100 millimeter visual analog nausea

scale (VANS) with 0 being none and the 1 OD-millimeter mark described as the

worst nausea ever felt.

2. Patient: Patient was conceptually defined as a human system functioning as a

whole, who, as the focus of nursing activities, can adapt to environmental changes

(Roy & Andrews, 1999). Operationally, patient included any adult male or female

more than 18 years of age presenting to the emergency room or emergency center

complaining of nausea without history of chemotherapy, radiation therapy, or

current abdominal pathology. The patients were able to self-report nausea and

mark the degree of nausea on the VANS with their dominant hand.

3. Purposeful touch (PT): Conceptually, PT was defined as an intentional physical

- contact by a nurse intended to activate nerve impulses that can change the focal

stimulus of nausea and influence adaptation. The physical contact was the stimulus

of the nurse's hands on the patient's anterior shoulder to stimulate sensory neurons

of the transverse cervical nerve and the supraclavicular nerves of the superficial

cervical plexus and in a handshake position to stimulate the superficial branch of

19

the radial, the proper palmar digital branches and the palmar branches of the

median, and the superficial and dorsal branches df the ulnar nerves of the brachial

plexus prior to receiving other nursing or medical interventions for nausea

(Holmes, 2001 ). The operational definition of PT was an intentional physical

contact exemplified as a bimanual touch performed by a nurse, which lasted 5

seconds (Schoenhofer, 1989; Weiss, 1979) and was moderate in pressure so there

was a shallow skin indentation with no resultant change in the patient's skin color

during the time of contact (Weiss, 1986).

Limitations

The study was limited by the following:

1. Severely nauseated patients may be unable to assess or respond to the visual

analog scale for nausea.

2. Patients with a history of previous episodes of nausea or vomiting are at an

increased risk of developing nausea from sights, smells, sounds, or taste because of

a well-developed reflex arc or conditioned reflex (C.R. King, 1997; White &

Shafer, 1988).

3. Generalizability may be limited to patients of emergency rooms o,r emergency

centers.

20

Summary

The purpose of this study was to explore differences in nausea pre and post

nursing interventions between a control group (no nursing intervention) and a test group

(PT). The theoretical framework for this study, based on Roy's adaptation model,

supported PT as a method to change the sensation of nausea and the resultant distress of

the symptom. Nurses use PT to reduce anxiety, support patients during painful times, and

soothe stressful situations (Schoenhofer, 1989). Therefore, the question explored in this

study was: Will purposeful touch (PT) applied to specific nerve pathways decrease nausea

levels in patients who present to an emergency center (EC) with nausea as a primary or

secondary complaint? Assumptions were presented, the hypothesis was stated, concepts

were defined, and the limitations of this study were identified.

21

LtREWMlfl ■

CHAPTER2

REVIEW OF LITERATURE

The use of touch as a comfort measure has been described in nursing, sociology,

and psychology literature. Nurses use touch to support patients during difficult

treatments or distress (Morse, 1983; Weiss, 1986). The planned nursing intervention of

purposeful touch (PT) as a sensory stimulus, based on a scientific rationale for action,

helps relieve patient distress. Bottorff (1992) described a similar type of touch as being

provided not only for comfort but also for "calming, soothing, quieting, reassuring, or

encouraging" (p. 55). PT was not the typical physical nurse-patient contact occurring

with routine nursing procedures, but it was a nursing intervention based on the intentional

stimulation of sensory receptors of touch.

Nausea presents as a common but unique symptom for everyone (Hawthorn,

1995). "Nausea is a conscious awareness of the need to vomit" (Cole, 1996, p. 792).

Many researchers have explored vomiting but have failed to explore the distress of

nausea (Jenns, 1994). Many nursing interventions exist for relief of nausea; however,

few researchers have reported touch nursing interventions for_ nausea. The distress of

nausea has been trivialized in the past (Jablonski, 1993).

This study was designed to investigate the symptom of nausea after PT and

determine the effectiveness of PT as an intervention between a control group (no PT) and

22

""" -

a test group (PT). The related literature was reviewed and was categorized into the

following topics: (a) nausea as a focal stimulus, (b) stimuli alteration for nausea relief, (c)

touch as a focal stimulus, and ( d) touch as a nursing intervention.

Nausea as a Focal Stimulus

Almost everyone experiences nausea sometime during life. Nausea has been a

concern for people since the earliest times of human history. Hippocrates (400 B.C.E.)

described the sequencing of appetite symptoms as indicators of poor or good health.

Most of the early documented history described vomiting but omitted nausea as a form of

distress. Nausea during the Roman times was believed to result from indigestion after

eating exceptionally large meals. Roman authors also documented the occurrence of

nausea maris [sic] or seasickness (Bianchi & Grelot, 1992).

Nau sea and vomiting continued to be researched and described throughout

history, but nausea was included with vomiting rather than as a separate symptom

(Rhodes, 1990, 1997; Rhodes, McDaniel, & Johnson, 1995). Patients began making

decisions on health care based on quality of life and comfort level post chemotherapy and

would withdraw from curative treatments because of distress from nausea and vomiting

(Rhodes & Watson, 1987). Medications were developed for nausea and vomiting, but

nausea remained an overwhelming distress experienced by patients that was difficult to

measure and to research. Since nausea symptoms have a subjective nature, a valid animal

model has not been found to test medications for complaints of nausea (Fox, 1992). The

lack of specific nausea medications then increased the importance of nonpharmacologic

23

----·· ·- ·---�-- ----·- - · -· ·

interventions (C. R. King, 1997). According to Grant (1997), nurses were essential in

relieving the side effects of chemotherapy and contributing to the resultant enhanced

quality of life. Although nausea has been documented throughout history and occurs in

almost every lifetime, there continues to be little research that supports nursing

interventions for the distress of nausea.

In this review of nausea as a focal stimulus, the distress and complaints of

different patient groups were explored. Multiple causes for nausea and bodily responses

were identified in the literature. Studies were conducted to detect etiologies and

responses among groups of patient with nausea resulting from therapeutic procedures or

treatments. Many articles have been written about the causes of nausea and vomiting.

However, few studies have been concentrated on nausea as an isolated event.

NI edications and Anesthetic Agents

Nausea was a common postoperative complaint often related to medications,

fasting, anesthetic agents, or length of the operative procedure. Bellville, Bross, and

Howland ( 1960) documented factors contributing to postoperative nausea in a large

metropolitan hospital in New York City. They tested the efficiency of commonly used

medications for nausea and collected other demographic data to establish contributing

factors. Data were collected from 3,794 patients regarding medical history, previous

treatment, anesthesia, operation, and recovery room course. The researchers found that

nausea and vomiting were significantly higher among women, after mask administered

anesthesia gases, among patient groups who become hypotensive during surgery, with

24

I

.

I

I

longer anesthesia times, with abdominal surgeries, and with obese patients. Multiple

etiologies for nausea continued to be identified as medication therapies were tested.

Other researchers found that the same factors identified by earlier studies as

contributing factors to developing nausea continued even with the development of new

antiemetic medications and anesthetic agents. M. Cohen, Duncan, DeBoer, and Tweed

( 1994) reported that nausea and vomiting continued at a rate of 20% to 3 0% for the

postoperative patient. The descriptive data collected in four large hospitals in the Eastern

United States and Canada included 15,992 patients who were interviewed within 72

hours postoperative. A visual analog scale was used to allow patients to detect severity

of nausea. Analysis of data was based on crude relative odds and adjusted relative odds

of each risk factor established. Multiple logistic regressions were used to control for

variables such as the role of gender and type of surgical procedure or the type of patients

treated in different hospital sites. The factors that contributed to postoperative nausea

included: (a) being of a younger age, (b) being of the female gender, (c) being intubated

for anesthesia, ( d) having a decreased physical status, ( e) having no preoperative medical

conditions, (f) experiencing a longer anesthesia time, (g) having an elective operation,

(h) receiving opioids intra operative, and (i) being a nonsmoker. Postoperative nausea

continued to be a problem for patients and had not diminished over the years (M. Cohen

et al., 1994).

Patients with middle ear., gynecologic, cardiothoracic, and abdominal surgeries

reported nausea more often than other patients (Cetindag, Boley, Magee, & Hazelrigg,

25

longer anesthesia times, with abdominal surgeries, and with obese patients. Multiple

etiologies for nausea continued to be identified as medication therapies were tested.

Other researchers found that the same factors identified by earlier studies as

contributing factors to developing nausea continued even with the development of new

antiemetic medications and anesthetic agents. M. Cohen., Duncan., DeBoer

., and Tweed

( 1994) reported that nausea and vomiting continued at a rate of 20% to 3 0% for the

postoperative patient. The descriptive data collected in four large hospitals in the Eastern

United States and Canada included 15.,992 patients who were interviewed within 72

hours postoperative. A visual analog scale was used to allow patients to detect severity

of nausea. Analysis of data was based on crude relative odds and adjusted relative odds

of each risk factor established. Multiple logistic regressions were used to control for

variables such as the role of gender and type of surgical procedure or the type of patients

treated in different hospital sites. The factors that contributed to postoperative nausea

included: (a) being of a younger age., (b) being of the female gender, (c) being intubated

for anesthesia, (d) having a decreased physical status, (e) having no preoperative medical

conditions, (f) experiencing a longer anesthesia time, (g) having an elective operation,

(h) receiving opioids intra operative, and (i) being a nonsmoker. Postoperative nausea

continued to be a problem for patients and had not diminished over the years (M. Cohen

et al., 1994).

Patients with middle ear., gynecologic

., cardiothoracic, and abdominal surgeries

reported nausea more often than other patients (Cetindag, Boley, Magee, & Hazelrigg,

25

1999; Grapp, Savage, & Hall, 1996; Honkavaara & Pyykko, 1998). Quinn, Brown,

Wallace, and Asbury (1994) identified common patterns of nausea in their descriptive

study based on nominal data collected from 3,850 postoperative patients. The sample

included patients between the ages of 11 and 91 years, with a total of 1,365 male and

1,879 female participants. Over two-thirds (37%) of the 3,244 patients who received a

general anesthetic and one-fifth (20%) of the 606 patients who received a local anesthetic

reported nausea. Chi-square, Mann-Whitney, or the Kruskal-Wallis tests were used for

analysis of data. However, the results of the statistical tests were not specified but some

percentages and noted median scores were reported. Complaints of nausea were

significantly higher among women (72.2%, p < 0.0001) and the younger age group

( median = 4 7 years., inter quartile range = 3 2 years, p < 0.0001 ). A significant difference

was found between nausea and level of pain (with general anesthesia, M = 4.3 pain level,

with local anesthesia, M = 3. O pain level), placement on a gynecology postoperative unit

(with general, 52%, and with local anesthesia, 50%), anxiety (with general, 40.9%, and

with local anesthesia, none). Twenty percent of all patients reported nausea

postoperatively, with increased numbers within the groups of patients with gynecological,

cardiothoracic, and general surgery. The researchers concluded that nausea was a

multifaceted problem that would require multiple strategies to treat successfully. Thus,

the researchers suggested a multiple medication approach to prevention of postoperative

nausea and vomiting. Postoperative nausea continued to be a problem in at least 23% of

all patients receiving general anesthetics (Quinn et al., 1994 ).

26

Contributing Factors of Age and Gender

Age and gender were identified as significant factors to consider when assessing

nausea as a primary complaint. Rub, Andrews, and Whitehead ( 1992) recruited 596

participants from various social groups, government offices, banks, schools, family

planning clinics, and day care centers for the elderly from a European city. Of the

respondents, 54% reported at least one episode of nausea in the past 12 months. Data

were analyzed with the chi-square test. No significant relationship was found between

nausea and gender. The researchers, in this non experimental descriptive study,

discovered a significant decrease in nausea with increasing age (X2 = 114.1, p < 0.0001 ).

Postmenopausal women were less likely to experience nausea (n = 175, X2 = 74.89,

p < 0.0001) than menstruating women. In healthy populations, nausea was more severe

in the 18-30 year old group than in the 31-60 or in the > 60 year old groups. Age was a

contributing factor in complaints of nausea as a primary complaint and could be a factor

for patients' responses to medications (Rub et al., 1992).

According to Dodd, Onishi, Dibble, and Larson ( 1996), age could be a factor in

outpatient chemotherapy nausea. The researchers conducted a 4-month study including

127 participants from 18 different outpatient settings. The study used a nonexperimental

design to establish differences in nausea between lesser than 64- and greater than

65-year-old patient groups. The Rhodes Index of Nausea and Vomiting Form 2 and a

behavior checklist developed by the researchers were used to determine distress from

nausea and vomiting and self-care measures that patients used to decrease the symptoms.

27

The average age of the younger group was 47.5 years (n = 40), while the older group

mean was 70.4 years (n = 6). Although the older group experienced less nausea and

vomiting than the younger group at 24 hours after the first cycle of chemotherapy, a two­

way ANOVA revealed no significant differences between groups (F = 0.92, with the p

expressed as nonsignificant). Both groups reported doing the same interventions for

nausea. The only significant finding in this study was that the older group used

distraction-type behaviors more often than the younger group based on chi-square

analysis (X2 = 7.14, p = < 0.004). The researchers suggested that more precise

instruments are needed to establish outcomes of interventions and larger groups of

participants in future studies. According to the researchers, further research needs to be

done to determine effectiveness of nursing interventions for the symptoms of nausea and

vomiting in the chemotherapy patient (Dodd et al., 1996).

Anoxia

As pointed out by Ingram, Fulton, Protal, and Aber (1980), myocardial ischemia

can cause nausea and vomiting by stimulating left

ventricular receptors that result in

gastric relaxation. In a descriptive study, Grapp and associates ( 1996) documented

gastrointestinal symptoms in a group of 122 adult patients post cardiac surgery. The

researchers used the Gastrointestinal Symptom Frequency, Symptom Distress Scale and

The Center for Epidemiologic Studies Depression Scale to collect data post intensive care

and at 2 weeks and 6 weeks after discharge. The post discharge data collection was

completed by telephone interview. Nausea was a concern in the postoperative group.

28

One-third (34%) of the subjects reported nausea during the hospitalization, while only

10% continued to report nausea 6 weeks after being discharged. Based on a logistic

regression analysis, subjects who had higher depression scores reported significantly

higher nausea levels while in the hospital (n = 33, odds ratio = 0.264, p < 0.01), and 2

weeks after discharge (n = 18, odds ratio = 3.917, p < 0.05). Reported nausea was

significantly higher among patients receiving antiarrhythmic medications while in the

hospital (n = 33, odds ratio = 0.264,p < 0.01). There was no relationship found between

blood pressure, mixed venous oxygen saturation, and subject age in this study. The

researchers suggested that nurses should be aware of this potential distress and provide

more detailed nutritional instructions for home care after any cardiac surgery (Grapp et

al., 1996).

Psychological Factors

Mental images of treatment increased or created the sensation of nausea among

patients thinking about chemotherapy. Redd, Dadds, Futterman, Taylor, and Bovbjerg

( 1993) explored the possibility of mental images of chemotherapy as causes of nausea.

Ten women with histories of post chemotherapy nausea were observed and videotaped

during imagery scenarios introduced by a psychologist. This experimental study was

designed to explore three scenarios described as: ( a) a walk in a pastoral setting, (b) a non

cancer medical treatment, and ( c) chemotherapy. Participants were interviewed in an

outpatient setting separate from the chemotherapy center. The dependent variables were

nausea, anxiety, and vivid imagery ranked on a 0-100 scale. The independent variables

29

were thoughts of medical treatment and chemotherapy. The results of this study

suggested that the cause of nausea among potential chemotherapy patients could be

associated with mental images of chemotherapy and expectations of the patients. The

researchers suggested that future research should be focused on the conditioned response

of post chemotherapy patients. Redd et al. also suggested nausea research could be done

to develop interventions for cessation for the conditioned response.

Depressed and anxious patients have been identified with complaints of

gastrointestinal distress including complaints of nausea (Langeluddecke, Goulston, &

Tennent, 1990; Talley, Fung, Gilligan, McNeil, & Piper, 1986). Handa and associates

(1999) collected data in Japan from 71 patients complaining of functional dyspepsia.

Patients who complained of epigastric pain (group one) nausea, vomiting, and heartburn

(group two) were evaluated for underlying physical or psychiatric etiologies for their

distress. A control group was assigned from 20 healthy volunteers. All subjects received

esophageal manometry, provocative tests for chest pain, and a State-Trait Anxiety

Inventory assessment. The Mann-Whitney U, chi-square, and Kruskal-W allis tests were

used to compare age, gender, duration of illness, manometry, provocative tests, and the

anxiety inventory results. Results were reported as means, medians, and probability.

There was a probability of 0.0508, based on the chi-square test with Yates' correction

that depression (n = 39, 48.7%) and anxiety (n = 8, 20.5%) can influence the symptoms

. of nausea, vomiting, and heartburn. Randa et al. added that cultural differences must be

considered before this research could be generalized to other patient groups.

30

Pregnancy

Whitehead, Andrews, and Chamberlain (1992) identified that nausea, vomiting�

and taste aversions are common symptoms of pregnancy as early as 4 weeks past the last

menses. The researchers reported that at least 85% of the 1,000 surveyed women, who

were attending an antenatal clinic in a European city, experienced nausea. Several

etiologies for nausea were explored. A chi-square statistic was used to analyze the data

collected from a detailed questionnaire. The results of data· analysis were reported as

totals, percentages, and probabilities only. The groups with nausea as a significant

reported symptom were women: (a) with pre menstrual tension (11 = 283., X2 not reported,

p < 0.005), (b) who developed food cravings (45%, X2 not reported,p < 0.05), and

(c) with planned pregnancies (63%, X2 not reported,p < 0.05). Nausea in pregnancy,

according to the researchers, was not explained by hormones or other circulating factors

but could be caused by complex neuronal circuitry that develops with pregnancy

(Whitehead e� al., 1992).

The complex hormonal and physiological interactions that occur with pregnancy

also may contribute to nausea and vomiting of pregnancy. van Lier, Manteuffel, Diiorio,

and Stalcup ( 1993) investigated the relationship between the nausea and fatigue of

pregnancy. The researchers identified their study as a descriptive correlational design

that included 51 pregnant women 20-41 years of age who visited a nurse-midwifery

clinic in a large southeastern city. The two instruments used were the Pearson-Byars

fatigue-feeling checklist and researcher-developed nausea scale rating nausea and distress

31

from nausea on a Likert scale. The dependent variable was fatigue, and the independent

variable was nausea. The researchers used a t test to compare mean level of reported

fatigue with reported nausea. van Lier et al. reported that women with nausea are no

more likely to complain about fatigue (t = 0.92, p = 0.363) than those without nausea.

Fatigue scores increased with increasing nausea severity scores (t = -1.96, p = 0.055), but

the differences were not significant. Women with severe nausea complained of greater

fatigue based on a Spearman's rank correlation coefficient (rho = 0.46,p = 0.001). The

researchers recommended that helping the gravid women to schedule their day to include

sufficient rest periods might decrease nausea (van Lier et al., 1993).

Many variables may contribute to nausea and vomiting of pregnancy other than

complex physiological interactions and fatigue. O'Brien and Zhou ( 1995) used the

Rhodes Inventory of Nausea and Vomiting (INV) and the 16 Personality Factor (16PF)

questionnaire to establish relationships between symptoms of nausea and vomiting

(dependent variable) and maternal age, occupation, parity, cigarette smoking, infant

gender, and the personality trait ofindependence (independent variables). The 126

pregnant women were observed from their 'first antenatal visit until the postpartum visit

to obstetric and nurse-midwife practices in the Midwestern United States. Demographics

and The Rhodes INV were completed during the first visit at less than 16 weeks of

gestation. The participants completed the 16 Personality Factor questionnaire between 24

and 29 weeks gestation. Based on multiple regression analysis, nausea significantly

correlated with age of gravid women, work outside the home, parity, and independence

32

(F= 4.73,p < 0.01). The inadequate sample size may have contributed to the inability of

the researchers to predict the presence and severity of nausea and vomiting. Further

studies were planned to explore the maternal response to interacting hormones (O'Brien

& Zhou, 1995).

In summary, this review identified the ages, genders, groups, and diagnoses most

affected by nausea. As previously reported, younger age groups between the ages of 18

through 3 0 experience nausea more often than older adult age groups greater than 3 1,

although all age groups used the same interventions for nausea and received similar

medications. A greater risk for developing nausea was identified among pre menopausal

female patients. Surgery also was identified as a cause influencing the development of

nausea. Types of surgery, events in preparation for surgery, and events occurring during

operative procedures were identified as risk factors for developing postoperative nausea.

According to the researchers, nausea was associated with preoperative medications,

preoperative fasting, types of anesthetic agents, length of the operative procedure

( anesthesia time), types of operative procedure, having an elective procedure, being

intubated for general anesthesia, hypotension during the operative procedure, having no

preoperative medical conditions, receiving opioids during surgery, being a nonsmoker,

level of pain, anxiety, and obesity. Nausea most often occurs with middle ear,

gynecologic, cardiothoracic, and abdominal surgical procedures. Nausea also was

associated with mental images of chemotherapy, radiation therapy, and patient

expectation of treatment outcomes. As documented in this review of literature,

33

depression, anxiety, myocardial ischemia, and antiarrhythmic medications also contribute

to nausea. The complex hormonal, neuronal, and physiological interactions that occur

with pregnancy also can contribute to nausea. Women most likely to have nausea and

vomiting were summarized as having the following risk factors: (a) pre menstrual

tension, (b) food cravings, ( c) planned pregnancies, ( d) fatigue, ( e) age of less than 3 5

years, (f) occupations requiring exposure to odors, (g) nulliparity, (h) nonmoving, and

(i) male gender embryos. As demonstrated in this research review, nausea was a

multifaceted problem that requires larger sample sizes, more precise instruments for

assessing, further research to develop nursing interventions, and outcome analyses to

validate patient responses to the multiple interventions needed for nausea relief

Touch as a Focal Stimulus

According to Barnett ( 1972), touch has been used since the beginning of

humankind and was used in nursing from the very beginnings of professional practice.

Barnett described touch as integral to nursing interventions and essential for

communication. McCorkle and Hollenbach (1990) recognized touch as an act of

communication and not as a therapeutic event. However, touch was identified by

S. Cohen (1987) as one of the earliest healing techniques documented in history. The

Egyptians used techniques of touch for medical purposes as early as 1553 B.C. The

ancient Greeks also used touch to cure illness. Around 400 B.C., Greek internists used

their palms and fingers to heal various illnesses (S. Cohen, 1987).

34

1:WTI ""

Touch was a universal healing method in the early church and was found in at

least nine chapters of the Holy Bible (1611). According to the New Testament, Jesus ·

Christ used the power of touch to heal illnesses: "And whenJesus was come into Peter's

house, he saw his wife's mother laid, and sick of a fever. And he touched her hand, and

the fever left her: and she arose, and ministered unto them" (Matthew 8:14-15).

However, little evidence of ancient touch for healing specific ailments has survived since

the early church (Grad, 1965; Ruckman, 1980). Montagu (1986) described touch as a

basic behavioral need essential for normal growth and development that contributes to the

overall efficient functioning of the nervous and immunological systems. Several research

projects followed since then establishing the influence of touch as a focal stimulus.

McCorkle (1974) researched the effects of touch on 60 seriously ill hospitalized

medical surgical patients between the ages of 20 and 64. This experimental study

consisted of a control group and an experimental group of equal numbers based on an

alternate assignment of participants. The participants were selected based on age,

sensory intactness, chance of recovery, orientation to surroundings, freedom from oxygen

masks, and freedom of one arm from intravenous or other treatments that would restrict

touch of the wrist. The dependent variable was identified as positive acceptance

responses, and the independent variable was touching and verbal stimuli. The Interaction

Behavior Worksheet was used by the researcher to focus on the patient's nonverbal

behaviors to initiate the interaction, and the Intrusa-Gram Worksheet was used to classify

35

the nonverbal behavior observed into either facial expressions, body movements, eye

contact, and general response of the patient.

After the interaction, the patients were questioned about their perceptions of

comfort and interest that the nurses portrayed. The data from the worksheets and Bales'

Interaction Process were analyzed using the Kolmogorov-Smimov two-sample test. The

researcher reported a significantly greater number of patients measured by facial

expression within the experimental group as responding positively to touch (D = -0. l 7,

p = 0.01). No significant differences were found between the groups when changes in

body movement, eye contact, length of nurses' verbalization, or EKG changes were

· analyzed. The results of this study supported the use of touch to communicate caring to

seriously ill patients. McCorkle (1974) suggested that touch should be considered as one

aspect of communicating and that nurses need to develop other methods of nonverbal

communication and touch to help the seriously ill patients.

Mills, Thomas, Lynch, and Katcher (1976) explored the effect of touch (taking a

pulse) on 62 coronary care patients. A total of 171 pulse palpations was monitored with a

3-minute resting time before and after the intervention. The independent variable was the

use of touch, and the dependent variables were supra ventricular and ventricular cardiac

arrhythmias. A significant increase in cardiac arrhythmias was found in all participants

who were touched based on chi-square statistical analysis (X2 = 5.26, p < 0.01). The

researchers concluded, based on the outcome of this study, that the changes in cardiac

arrhythmia frequency could be associated with autonomic activity resulting from social

36

interactions. These researchers did not explore other neurogenic or psychogenic factors

that could contribute to myocardial irritability. The findings suggested that, despite other

environmental stimuli in critical care settings, touch was a potent enough

neurophysiologic stimulus to cause a change in the patient condition (Mills et al., 1976).

Drescher, Gantt., and Whitehead (1980) also investigated heart rate and response

to touch (talcing a pulse). They explored the effect of touch on four men and four women

participants with an average age of26.4 years. The environment for the study was

controlled, and a closed circuit television camera monitored the action. A polygraph

machine with skin and ear electrodes was used to record the heart rate. Each participant

received the same interventions--door closed, door open before touching; hand on

participants' wrist, door open after touching., and door closed. There was a significant

increase in heart rate (t = 2.68, p < 0.05) when the researchers entered the rooms and a

significant decrease when the researchers touched the wrist for 30 seconds (F= 10.7,

p < 0.001).

Drescher et al. (1980) then replicated the study to discover if the change in heart

rate was from touch alone or could be the result of touch by another person. Heart rates

of a new group composed of five women and three men (average age of25.8) were

compared with the same design with the addition of the action of the subjects taking their

own pulse. The results showed that touch by the researcher decelerated pulse rates

(t = 3.67, p < 0.05) between the subjects and that self-touch slightly accelerated pulse

rates. Touch influenced the pulse rate of both healthy and coronary care patients. This

37

cardiac response was similar to one noted in infants as a potent reaction to touch

(Drescher et al., 1980).

Knable ( 1981) researched hand holding to determine its effect on vital signs and

nonverbal communication gestures made by patients and to describe reasons for use and

situations where the technique might be used. Fifteen critically ill patients were selected

from a sample in a community hospital in the Eastern United States. All patients were

monitored by electrocardiogram, and vital signs were taken by one of 12 female nurses

involved in the patients' care. The researcher described the facial expressions, body

movements, eye contact, and general responses recorded on the Intrusa-Gram Worksheet

used by trained observers. The observer documented three different responses among

participants: positive, neutral, or negative. Nurses chose the times to touch the patients,

and the touch was described as purposeful and nonprocedural in nature. Vital sign

changes were reported from hand holding. The patients responded to 25 touches as

genuinely interested, and 221 out of 3 06 reported touches were evaluated as nonverbally

positive by the observers. The nurses described hand holding for providing emotional

support for patients who were alone or apprehensive (Knable, 1981 ). This research did

not establish statistical significance. However, the researcher suggested that hand

holding should be used as a nursing intervention to enhance nonverbal communications.

Glick ( 1986) postulated there was a relationship between procedural and caring

touch and anxiety experienced by the patient with a myocardial infarction in the

intermediate care unit. The researcher defined procedural touch as "the use of the hands

38

in completing nursing duties and caring touch as non task related, conscious, nonverbal

communication in which one's hands or anns make contact with another person, in the

promotion of that individual's inherent uniqueness" (Glick, 1986, p.63). In the quasi­

experimental study, 40 male and female patients were systematically assigned to study

groups. Anxiety was the dependent variable measured by the State-Trait Anxiety

Inventory. The type of touch was the independent variable. However, the analysis of

data using analysis of variance (ANOVA) revealed no significant difference between

groups (n = 33, experimental group pre touch (PRE) M = 35.31, post touch (POST)

M = 33.93; control group PREM= 34.39 and POST M = 34. 78 with total groups'

ANOV A between F = 0.00, p = 0.9949). Thus, the results did support previous research

regarding touch and scientific rationale suggested by other authors, such as the sensory

influence of the skin and the ability of touch to reduce tension (Glick, 1986). Glick

erroneously assumed levels of anxiety to be high but they were not assessed as such by

the participants. The researcher also underestimated the effect of age and preexisting

coronary artery disease in this study.

Research and early historical writings support touch as a potent stimulus that can

comfort patients in distress. Since early human history to current times, human touch has

been effective but research has not empirically established the significance of touch

therapies. Touch as more than just nonverbal communication can influence cardiac

rhythm, emotions, blood pressure, pulse, and respirations. Nurses change patient

39

behavior by altering, changing, removing, or maintaining stimuli (Roy & Andrews,

1999). The research cited established the fact that touch can be a strong focal stimulus.

Touch as a Nursing Intervention

According to Barnett ( 1972), registered nurses touch twice as often as other health

care personnel. · Durr ( 1971) used a nonexperimental research design to explore reactions

to touch in 13 medical-surgical patients. The six men and seven women included in this

study were able to identify physical contact between themselves and the nurses as

beneficial. These patients reported a feeling of physical support, an increased level of

understanding, and verification of verbal communication based on the physical contact

between the research subjects and the nurses. The researcher suggested that touch and

physical closeness facilitate patient comfort as long as the interactions are therapeutically

relevant. However, actual practices of touch between patients and health professionals

still needed to be identified (Durr, 1971).

Barnett ( 1972) conducted a survey of the frequency of touch to determine the

practice of touch between patients and health team members. The researcher observed

540 patients and 900 health team personnel for a total of 452 touches over a 4-week

observation period in all patient care units. These units were in both a church-supported

and tax-supported facility in a large metropolitan medical center. Patients were touched

significantly more often (F = 4.1849, p < 0.001) in the tax-supported facility by personnel

between the ages of 18 and 32. Other analyses of data were reported as percentages of

touch occurrences. The researcher reported that health personnel's use of touch

40

T -

decreased with age, which refutes the claims of other researchers that touch was equated

with sexual intent and usually avoided unless with friends in the American culture.

Female personnel touched 85% more often than males. Registered nurses touched twice

as often as other personnel. Personnel reporting to be among the White race touched

more often than the other races (73%) .. The patients' extremities were touched 60% more

frequently than other parts of the body. Touch was used more often in the pediatric, labor

and delivery, recovery room, comatose, and intensive care units in both hospitals.

Patients who were listed in good or fair conditions were touched 70% of the time as

opposed to patients in serious or critical condition. Patients between the ages of 26 and

33 (25%), White (66%), and female (53%) were touched more often than the other

groups. The researcher reported data to support and identify factors involved with the

intervention of touch but failed to establish statistical significance between groups other

than differences in frequencies of touch between types of hospitals. Health care workers

did not touch the more affluent patients as often (Barnett, 1972).

Copstead ( 1980) pointed out that touch communicated caring to the elderly adult.

The researcher investigated touch, nurse/patient interaction appraisal, and self-appraisal

scores between the elderly patient and registered nurses. The dependent variables were

the nurse/patient interaction and self-appraisals of the patient. The independent variable

was the use of touch. This study had a control group with no touch and an experimental

group of patients receiving physical body contact with a nurse at any time of the

nurse/patient interaction. A random sample of 3 3 permanent residents of three nursing

41

homes was included in the study. The participants were included in the study if they

were able to feel the nurse's touch, follow directions, respond verbally in English to direct

questions, read and write in English, and had known the medication nurse for at least one

month. Self-appraisal scores were significantly higher in the experimental group

(p = 0.001) based on a Pearson's correlation coefficient (r = .86). Since the interaction

times in the experimental group ranged from 5.40 to 197.69 seconds and 6.24 to 38.78 in

the control group, the researchers postulated that touch lengthens interaction durations.

However, the interactions times could have contributed to the heightened self-appraisal

scores rather than touch alone. Since the use of touch lengthened interactions, the

researcher suggested that more time be allocated for routine nursing procedures so that

touch could be used during nursing procedures, even while administering medications to

the elderly, to enliven the lived experience (Copstead, 1980).

Langland and Panicucci ( 1982) postulated that touch preserved relational aspects

of communication with elderly confused patients. This experimental study used a

selected sample of 32 elderly confused participants who were divided into control and

experimental groups. The researchers were exploring the effect of the independent

variables of touch and verbal request on the dependent variables of attention, relevant

verbal responses, and action responses. A significant increase in attention was found

when touch was used based on analysis by the Wilcoxon rank sum test ( experimental

11 = 16, sum of scores = 315.00; control n = 16.,

sum of scores = 213, andp = 0.05).

However, the other dependent variables were not supported as significant by the data

42

analysis. Although verbal and action responses of the patients were not influenced by

touch in this study, the researchers felt that significance could be established with more

participants and more experiences of touch (Langland & Panicucci, 1982).

In one study, affectional touch was primarily used for transmitting signals of

recognition, acceptance, protection, and caring. Schoenhofer ( 1989) collected data to

establish qualitative and quantitative factors involving affectional touch in critical care

nursing. The researcher used a convenience sample of 30 nurse-patient groups in three

intensive care units in two Midwestern hospitals. Instances, form, qualitative factors,

accompaniments, stimuli, and proximity without touch were the six observed factors.

Patients in this study received affectional touch by nursing personnel an average of2.8

times per hour. Nurses used sustained stationary touch (f = 26) to a hand (f = 29) or

shoulder (f = 23) most often. The researcher identified that the shoulders were the most

common touch location which was reported as the least touched area by Copstead (1980).

The motivation underlying touch and assessment for the need for touch were identified as

essential for further formalization of a nursing theory for touch (Schoenhofer, 1989).

Weaver (1989), in a qualitative pilot study, explored the meaning of touch for

obstetrical nurses. Eleven registered nurses practicing in labor and delivery were

interviewed using a semi-structured interview guide. The sample was composed of

nurses with an average age of 31, with five graduates from baccalaureate programs and

having an average of 4. 5 years of obstetrical experience. The researcher concluded that

touch: (a) was an essential strategy, (b) was potentially a powerful modality, (c) was used

43

by nurses based on experience and sensitivity, ( d) included both giving and receiving,

( e) could be a learned competency, and (f) could be perceived by patients as negative if

withheld. The researcher suggested further study to clarify the use of touch for specific

medical diagnoses and to develop the ability to teach the use of touch. Nurses shared self

with patients by using touch (Weaver, 1989).

Bottorff ( 1992, 1993) pointed out that touch forms an important aspect of nursing

practice. The researcher used qualitative ethology to identify types of touch and

attending types used by nurses. Five types of touch were identified by analysis of video­

taped nurse-patient interactions with eight oncology patients. These touches were similar

to procedural and caring touch as identified by other researchers but offered more

comprehensive descriptors of touch techniques. Comforting, connecting, working,

orienting, and social were identified as types of touch used while nurses attended patients

with cancer. The types of attending (Bottorff, 1992; Bottorff & Morse, 1994) identified

by the researchers supported the premise that the context of touch was critical to

understanding the use of touch. The types of touch and caring methods can be changed

to meet the needs of each patient (Bottorff, 1993).

Based on the previously cited research, touch contributed to feelings of physical

support, increased levels of understanding, and verification of communication between

patients and nurses. Furthermore, touch can be a learned competency and must be

therapeutically relevant to transmit signals of recognition, acceptance, protection, and

caring. In some studies, the patients' extremities were touched most often by female

44

nurses in the pediatric, labor and delivery, recovery room, intensive care, and in not-for­

profit hospital settings. Additionally, some uses of touch identified by the researchers

included: (a) an essential strategy identified by nurses as a way to share self with patients,

(b) a potentially powerful modality, (c) a determinant factor of nurses' experience,

sensitivity, giving, and receiving, (d) a way of lengthening nurse/patient interactions, and

( e) a contributor to heightened self appraisals and increased quality of life. Touch could

be perceived by patients as negative if withheld. In one study conducted within critical

care units, nurses used a stationary touch to a hand or shoulder most often (Schoenhofer,

1989). Another study identified five types of touch: (a) comforting, (b) connecting,

(c) working, (d) orienting, and (e) social (Bottorff, 1992). The researchers also identified

that further research will be needed to explore the influence of the context of touch, types

of touch as caring methods for meeting the needs_ of each patient, actual practices of

touch between patients and health professionals, use of touch to intervene on specific

medical diagnoses, and formulation of a nursing theory for touch.

Stimuli Alteration for Nausea Relief

Even though acupressure (AP) and therapeutic touch (TT) are interventions that

require different techniques than the PT identified in this study, they are reviewed as

interventions to activate stimuli that could relieve nausea. AP is the use of a deep,

constant pressure on exact points along acupuncture meridians which have a relationship

with various physiological functions (Tappan, 1988). According to Krieger (1987), TT

represents a human field phenomenon that uses a human energy transfer from the healer

45

to the ill person via electron transfer resonance to restore the vital flow in the patient's

open system.

Acupressure

Ulett, Han, and Han (1998) identified acupuncture as an umbrella term that

included acupressure (APr Uses for acupuncture include but are not limited to headache,

menstrual cramps, fibromyalgia, low back pain, carpal tunnel syndrome, asthma, and

nausea. Acupuncture is an ancient system of healing developed from the traditional

medicine of China and other Eastern countries over 2,500 years ago. The practice began

with the idea that stimulation of areas of the skin can influence organ functioning. The

skin areas are located on specific locations that are believed to lie on energy channels or

meridians. Acupuncture is the practice of inserting needles in these energy channels to

either stimulate or depress organ actions associated with the skin areas. Acupressure is a

therapy that utilizes the same skin areas and the meridians of acupuncture to identify

points where finger friction and pressure can improve organ function (Ulett et al., 1998).

According to The National Institute of Health (1997), acupuncture can have therapeutic

effects for pain conditions, nausea and vomiting in adult postoperative, chemotherapy

patients, and nausea of pregnancy. A similar statement regarding AP was not included in

The National Institute of Health Consensus Statement (1997).

Researchers have established scientific rationale for the use of AP over the P-6 or

ST-38 points to relieve nausea. The P-6 point was located two thumb-breadths (two cun

[sic]) "above the ventral wrist fold between the tendons of palrnaris longus and flexor

46

carpi radialis" (Tappan, 1988, p.151 ). The ST-36 point was located "one cun lateral and

distal to the tibial tuberosity" (Tappan, 1988, p. 152). AP activates the same points to

relieve nausea as the corresponding acupuncture point. In all of the following reported

research, the dependent variable was nausea and the independent variable was the

technique of finger AP or AP bands.

Dundee, Sourial, Ghaly, and Bell (1988) conducted a prospective study to test the

efficacy of AP in preventing morning sickness of pregnancy. The sample included 350

pregnant outpatients randomly assigned to one of three groups. The patients in the P-6

experimental group were instructed to press the P-6 point for 5 minutes every 4 hours for

four consecutive days. The second group was to press a dummy point near the right

elbow with the same frequencies. The control group was to report emetic symptoms with

the same frequencies. The grading of emetic symptoms was a 5-descriptor Likert scale

which allowed the participants to rank the nausea from none to severe. Only 50% of the

acupressure group, 52% of the dummy group, and 70% of the control group returned

completed data cards. Data were analyzed using chi-square tests. Significant differences

occurred between the experimental, control, and dummy groups. The experimental group

experienced less nausea than the dummy (X2 = 21.9,p < 0.0005) or control group

(X2 = 36.4,p < 0.0005). There was also a significant decrease in the dummy group's

nausea as compared to the control group (X2 = 13.4, p < 0.01). Chi-square analyses were

reported as comparisons between two groups rather than an overall significance with post

hoc investigation. The researchers reported there was a beneficial effe�t of P-6 AP

47

despite the high attrition rate. They asserted that AP was a safe technique that can be

used for morning sickness instead of medications which frequently cannot be used with

the gravid female because of side effects (Dundee et al., 1988).

Postoperative nausea and vomiting can be decreased by AP, as reported by

Dundee et al. (1989). Fifty-one women were selected with similar weights, ages,

anesthesia times, and type of anesthesia. AP bands were used on the dominant arm at the

P-6 AP point and were pushed by the patients for 5 minutes each hour during the time of

the study, as encouraged by the nurses who accompanied the patients during the

postoperative period. Data were collected at 1 hour and 6 hours postoperative as nausea,

vomiting, or no nausea/vomiting. Chi-square analysis indicated a significant difference

between the AP group and the control group within the first hour only (X2 = 31.4,

p < 0.001). Since this AP study was part of a larger study on the effects of acupuncture

on postoperative nausea and vomiting, the control participants were used for analysis in

both the acupuncture and the AP groups.(Dundee et al., 1989).

Dundee and Yang (1990) used AP bands to prolong the antiemetic effects of

acupuncture in 40 patients receiving chemotherapy. The AP bands were applied to the

patients' dominant arms immediately after the pre-chemotherapy acupuncture procedure,

and the patients were instructed to press the stud on the AP band for 5 minutes every 2

hours. Significance was not established in this descriptive study. Percentages of

effectiveness over time were reported as 95% of the patients having beneficial anti emetic

48

effects for 24 hours after acupuncture on a scale of good, moderate, slight, or nil [sic]

benefits from P-6 AP (Dundee & Yang, 1990).

According to Brown, North, Marvel, and Fons (1992), nausea and vomiting may

be a major distress for terminally ill patients. In an attempt to decrease medication use

and resultant side effects, the effectiveness of AP was explored in this six-subject study.

The researchers used a 4-item abbreviated Rhodes Index of Nausea and Vomiting rating

scale to collect data after the three interventions of an AP wrist band, a placebo wrist

band, and no wrist band. The subjects were not able to complete the study and data were

incomplete. No decrease in nausea was reported by the researchers to justify the use of

AP bands for terminally ill patients (Brown et al., 1992).

. In an experimental study using AP bands for nausea and vomiting in pregnancy,

Stone ( 1993) recruited 31 participants in their first 12 weeks of pregnancy who were

visiting a university-based health care clinic for prenatal care. The experimental group

wore AP bands and the control group wore placebo bands for a total of 7 days for all

participants. Data were analyzed using a t test for independent samples. A significant

difference (t = -2.04, df= 27, and two tailedp = 0.0520) was found between the 17

experimental group scores (M = 0.3232, SD = 1.128) and 14 control group scores

(M = -0.3978, SD = 0.657). The control group bands were found to be more effective

than the experimental AP bands. The small sample size and the lack of ability to do

follow-up on the correct· application of the AP bands during the length of the study were

identified as limitations (Stone, 1993).

49

Phillips and Gill ( 1993) reported that postoperative nausea could be reduced when

AP wristbands were used. Their sample of 80 female patients between the ages of 18 and

81 were admitted for major gynecological surgical procedures. In this experimental

study, groups were randomized into two groups. The experimental group wore AP bands

on both wrists prior to and for 2 days after surgery, while the control group received no

bands. The nausea levels were evaluated using a 0- to 9-point scale and by measuring the

total amount of antiemetic medications given. Data were analyzed with a Student's Ltest

for paired samples. The experimental group required fewer doses of antiemetics (11 = 28,

M = 1. 5, SD not reported, t not reported, p = 0.001) than the control group ( n = 28,

M = 3.5). The I-test scores or standard deviations were not reported in the data analysis

of this study. There was a significant difference between groups regarding severity of

symptoms (p = 0.002). The researchers suggested that, since the AP bands were effective

in this study, the potential savings in postoperative antinausea medications use would

warrant further research in AP band use for postoperative patients (Phillips & Gill, 1993).

AP was identified as a modality to help decrease the nausea and vomiting of

pregnancy in this randomized blind study (Belluomini, Litt, Lee, & Katz, 1994). Ninety

pregnant women less than 12 weeks gestation referred from midwife and physician

practices were randomly assigned to groups testing the effectiveness of AP. The

experimental group (n =30) was taught how to apply AP to the Neiguan point and the

control group (n =30) was taught to apply AP to a placebo point. The participants were

told not to apply AP during the first 3 days so that those days could be used as control.

50

The instrument used was the Rhodes index of nausea and vomiting. A Student's t test

was used for data analysis of differences between group means �th an ANOV A for

repeated measures of data over time. The reported scores for the experimental group

(PRE,M= 12.64, SD= 5.1 and POST,M= 8.69, SD= 5.0)were significantly lower than

the control group scores (PRE, M = 11.47, SD= 4.9 and POST, M = 10.03, SD= 4.6).

The researchers reported that both groups improved significantly over time (F1,ss = 21. 7,

p < 0. 000 I) but that the nausea in the experimental group improved significantly more

(F1,s& = 10.4,p < 0.0021). According to Belluomini et al. (1994), the use of AP was a

safe, low cost, and an easily learned technique that can decrease nausea in pregnancy.

Ho, Hseu, Tsai, and Lee (1996) researched the effect of AP bands on patients

experiencing nausea and vomiting after epidural morphine for post cesarean section pain

relief Participants were randomized into groups for this experimental study. AP bands

were applied to both wrists for participants enrolled in the experimental group (n = 30)

and placebo bands were applied to both wrists for participants in the control group

(n = 30) prior to spinal anesthesia. Data were collected by an independent

anesthesiologist who was not aware of group assignments. The data collected were vital

signs, pain severity, postoperative analgesic requirements, nausea, vomiting, retching,

respiratory rate, length of time wearing the bands, side effects of pruritus, dizziness,

herpes simplex labialis, and nausea and vomiting at 0, 5, 15, 30, 45 minutes, 1, 2, 4, 8,

12, 24, 36, and 48 hours after the epidural morphine. Data were reported as absolute

values or percentages. The incidence of nausea in the experimental group (3 % ) was

51

significantly less than the control group (43%) (p < 0.05) based on analysis with the

Student's t test. The researchers suggested that AP bands can reduce the incidence of

nausea and vomiting after cesarean section pain relief with morphine (Ho et al., 1996).

O'Brien, Relyea, and Taerum (1996) researched the use of AP in the treatment of

nausea during pregnancy. Of the women who completed the protocol (n = 149), 54 had

been assigned to the treatment group, 53 to the placebo group, and 54 to the control

group. AP bands were properly applied in the treatment group, applied over a non­

treatment area for the placebo, and no AP bands were given to the control group.

Participants were given 13 copies of the Rhodes Inventory of Nausea and Vomiting to

record their symptoms every 12 hours at home. A research assistant called each

participant daily to record symptoms and to make sure that the symptoms were

appropriately assessed. Data were analyzed with an ANOV A of difference scores.

Between group differential effects were not discovered in this study (F = 4.64,

M squares = 6.55, df = 24, p = 0.98 for nausea scores). The researchers did not establish

the effectiveness of AP bands. Since the participants completed data collection every 12

hours, this data collection would be influenced by sleep/awake patterns or relief of nausea

while sleeping or in a supine position (O'Brien et al., 1996).

Concerns of the efficacy of anti emetic medications post laparoscopy was a

rationale for the research conducted by Harmon, Gardiner, Harrison, and Kelly (1999).

This randomized, double-blind study included 104 patients, 19 to 43 years old, receiving

standard anesthesia by different anesthetists. The experimental group (n=52) received the

52

AP bands in correct position on the right arm prior to anesthesia and the control group

(n = 52)., received AP bands placed on non AP points. The participants were evaluated in

the recovery room, 2 hours, and 24 hours after the operation for nausea ranks of none,

mild, moderate, or severe. The Student's t test was used to compare groups. Data were

reported as frequencies of nausea/vomiting complaints with the first 24 hours after the

laparoscopy. The experimental group reported 10 complaints of nausea/vomiting

compared with 22 in the control group. There was a significant reduction in nausea for

the experimental group (p = 0.02). The researchers suggested that AP bands can be used

as an effective treatment to decrease postoperative nausea/vomiting in postoperative

laparoscopy patients (Harmon et al., 1999).

Dibble, Chapman, Mack, and Shih (2000) explored the use of finger AP to

decrease nausea in women receiving chemotherapy for breast cancer. The researchers

used the Rhodes Inventory ofNausea, Vomiting, and Retching (INVR), a nausea

intensity scale, and the Chemotherapy Problem Checklist to assess nausea in 17 women

receiving the combination therapy of cyclophosphamide, methotrexate, and fluorouracil

or doxorubicin in an outpatient oncology clinic for treatment of breast cancer. The

participants completed the daily log each evening for 21 days. The experimental group

·· (11 = 8) was taught how to access and hold pressure to the P-6 and ST-36 AP points for

treatment of nausea and how to complete the daily log. The control group was taught

how to complete the daily log. Repeated measures ANOV A were used to analyze the

data. The overall nausea experience measured on the INVR was significantly less for the

53

RlllilElllall TIM91PI w nr

experimental group (F = 10.44, p < 0.01 ). Nausea intensity was less severe for the

experimental group (F= 5.255,p < 0.04). Analysis of the retrospective Chemotherapy

Problem Checklist, however, revealed no significant differences between the

experimental (M= 2.83, SD =1.6) and control (M= 3.00, SD= 0.58) groups of average

nausea symptoms experienced over the previous month of therapy. The researchers

suggested that AP might be useful in decreasing the nausea intensity for women receiving

chemotherapy for breast cancer (Dibble et al., 2000).

AP was explored as a complementary healing modality to decrease the incidence

of postoperative nausea and vomiting in a quasi-experimental study on patients

recovering from anesthesia (Windle, Borromeo, Robles, & Ilacio-Uy, 2001 ). Participants

(n = 157) in this study were divided into five groups. The randomly assigned groups

were: (a) AP bands with AP on both wrists (n = 29), (b) AP bands with acupressure on

one wrist (n = 34), (c) wristbands without AP on both wrists (n = 30), (d) wristband

without AP on one wrist (n = 35), (e) no wristband (n = 29). Analysis of incidence of

nausea based on retrospective chart audit on nurse's documentation and ANCOVA

revealed no significant differences between groups. The researchers suggested that

significant findings might be obtained with a larger sample size and longer patient

exposure to AP bands postoperative (Windle et al., 2001).

Therapeutic Touch

The Rogerian theory that human beings and the environment are energy fields

interacting mutually form the basis for TT (Krieger, 1987). According to Krieger, the

54

?"3

nurse's hands are used to assess imbalances in the energy field and then balance the field

to enable the patient's own healing processes to intervene. Egan (1998) attributed the

patient healing process to be a result of the intentional and specific interaction between

the healer's and patient's energy field to restore order and harmony to the energy pattern

of the patient.

TT has been examined in myriad research studies (Table 2); however, only the

following study that described its effect upon the relief of nausea was found in the

literature. According to Giasson and Bouchard (I 998), non contact TT significantly

increased the scores on the researcher-developed Well-Being Scale of persons with

tenninal cancer. Non contact TT was a process of energy exchange in which the nurse's

hands were used to re-pattern the human energy field. The components of the scale were

the subjective feelings of physical and emotional comfort that included absence of pain,

nausea, depression, and anxiety. The presence of activity, appetite, relaxation, and inner

peace were also assessed. The dependent variables were the subjective feelings of

physical and emotional comfort, and the independent variable was TT. The instrument

was a visual analog type horizontal scale with one line for each item of well-being

identified by the researcher. The reliability and validity were established by correlation

and coefficients prior to use with the study group.

Twenty adults with terminal cancer admitted to a palliative care unit served as

subjects for this experimental time-series research. The participants were randomly

assigned to either the experimental or control group. The experimental group received

55

- - r ••

Table 2

Studies Reporting Significant Outcomes of Therapeutic Touch Interventions

ResearcherNear

Sneed, Olson, Bubolz, & Finch, 2001

Cox & Hayes, 1999

Snyder, Egan, & Burns, 1995

Gagne & Toye, 1994

Meehan, 1998

Simington & Laing, 1993

Olson, Sneed, Bonadonna, Ratliff, & Dias, 1997

Kramer, 1990

Wirth, 1990

Keller & Bzdek, 1986

F edoruk, 1984

Quinn, 1984

Heidt, 1981

Krieger, 1975

Identified Result

Reduced stress, greater parasympathetic dominance

Increased relaxation, sleep in critical care patients

Increased relaxation in persons with dementia

Decreased anxiety in psychiatric subjects

Decreased postoperative pain

Decreased stress in institutionalized older adults

Lowered perceived stress in patients who experienced a natural disaster

Reduced stress in children

Decreased wound size

Decreased pain in tension headache

Reduced behavioral stress in infants

Decreased stress

Decreased stress

Changed hemoglobin levels

56

TT treatments for 15-20 minutes one hour after analgesics. The control group underwent

rest periods for the same amount of time, and the researcher sat next to the participants

and completed mental mathematical problems to prevent any centering or energy

exchanges. No significant differences in groups emerged considering sociodemographics

and analgesic use based on chi-square and t tests. An ANOV A was used for data analysis

and indicated a significant interaction (F=l 1.89,p < 0.001). A significant increase

occurred in the well-being score of the experimental group (M = 1. 70, SD = 1.28) and a

decrease was found in the control group (M= 0.31, SD= 1.12). The experimental well­

being scores increased significantly over time (F= 14.02,p < 0.001), and the control

group scores (F = 1 . 07, no p reported) decreased over time. Data were not reported

regarding nausea-specific results after TT. This study cannot be used to support the use

of TT to decrease nausea (Giasson & Bouchard, 1998).

The reported research on interventions for nausea to activate stimuli that can

relieve nausea included the use of AP bands, AP, and TT. The effectiveness of AP bands

has not been established by research. Riddled by attrition rates, small sample sizes, data

collection instruments lacking established reliability/validity statistics, incidental

inclusion in larger studies, and possible incorrect placement of the AP bands, results of

research on the use of AP bands remained controversial. The use of AP bands was

supported as an effective technique for use with patients who complain of postoperative

nausea and the nausea of pregnancy. No decrease in nausea was reported to justify the

use of AP bands for terminally ill patients. The effects were viewed as successful if some

57

nausea was relieved because the side effects of medications were avoided and a potential

decrease in health care costs would result if AP bands were effective. Further study will

need to be done to establish the effectiveness of the AP bands. The use of finger AP,

however, was found to be a safe, _low cost, and an easily learned technique that decreased

nausea in pregnancy and chemotherapy for breast cancer. The Rhodes INVR was used

for data collection in studies of finger AP. Further studies are indicated to investigate

other patients who would benefit from finger AP. The effectiveness of TT for use with

nausea patients has not been established. TT significantly increased the scores of well­

being for terminal cancer patients but improvement in nausea could not be established.

Summary

This review of the literature explored the relationships between nausea and the

use of nursing touch. Nausea was described as a multifaceted problem resulting from

_ stress or a stressful event that often accompanies illness and also as a focal stimulus that

catches the patient's attention and energy. Future nausea research will require larger

sample sizes, more precise instruments for assessing, and outcome analyses to validate

patient responses to the multiple interventions needed for nausea relief.

Other techniques of use of stimuli to relieve nausea were reviewed. The use of

finger AP was found to be a safe, low cost, and easily learned technique that decreased

nausea in pregnancy and chemotherapy for breast cancer. Further studies are indicated to

investigate other patients who would benefit from finger AP. The effectiveness of TT for

use with nausea patients has not been established.

58

Touch, as a healing technique, has been documented in early human history.

Scientific rationale for touch techniques have been established and used to decrease or

relieve human distress. Registered nurses use touch as a focal stimulus that can enter into

the human adaptive system as input along with contextual and residual stimuli. Touch

was supported as a mode of caring communication but not as an intervention for nausea.

A need for further research was identified to establish a nursing model for development

of touch intervention that is patient-response specific.

59

CHAPTER3

PROCEDURE FOR COLLECTION AND TREATMENT OF DATA

An experimental two-group before and after design was used to determine the

effects of purposeful touch (PT) and no touch on nausea of patients who present in the

emergency center (EC) complaining of nausea as a primary or secondary complaint.

According to Huck and Cormier (1996), this type of design not only enabled the

researcher to investigate a cause and effect relationship but allowed rigor in exploring how

the independent variable affected the dependent variable. The experimental two-group

design with random assignments to groups reduced external variability due to

experimental error or biased treatment effects (Kirk, 1982). Participants in both groups

were asked to evaluate levels of nausea on a 100-millimeter (mm) scale as pretest and

posttest measures. The experimental group received PT, while those in the control group

did not receive PT. The independent variable of this study was PT, and the dependent

variable was nausea. Since the goal of research is efficiently to draw valid conclusions

about the effects of the independent variable, analysis of covariance and randomization

were used in this experimental study as ways to control for extraneous variables (Kirk,

1982).

60

Setting

The study was conducted in an EC of a private not-for-profit hospital. The large

medical center hospital functions as a teaching facility for a medical school in a

metropolitan area of the southeastern United States. The facility reported a total of 1,200

inpatient beds and 31,626 emergency visits in 2000. The hospital is an internationally

known referral center for many medical specialties.

The participants were assessed in the EC triage area (triage) by hospital personnel

and escorted into a treatment area. Staff nurses recruited the participants by asking if the

patients would like to be involved in the research study. The investigator approached the

participants, who had already agreed to be included in the study, in the EC treatment area

that consisted of rooms or cubicles with curtains or doors that allowed for patient privacy.

The patient remained· in this area until after emergent assessment, interventions, and

evaluations were completed and the patient was released from the EC either by admission

to the facility or discharged to home.

Population and Sample

The population of the study included all patients who presented to a large medical

center hospital EC with complaints of nausea. Data were collected from March 25, 2001

through June 3, 2001. The researcher collected data during afternoon and evening hours

on weekend days for 2 months of the study and then on consecutive days until data

collection was completed.

61

The study sample included a total of 140 patients who presented to the EC with

complaints of nausea. A power analysis determined that a sample size of 70 participants

per group was necessary to achieve a power size of .80, with an effect size of .35, and a

level of significance of0.05 (J. Cohen, 1988). The .35 effect size was based on previous

testing of the visual analog scales (Borjeson et al. 1996; Coppola, Yealy, & Leibold,

1996). If a mean nausea score was 10 points greater than the pre touch mean score, it

was considered important with a documented standard deviation of 29. The effect size

was then computed as .3 5.

Each of the two study groups included patients randomly assigned to either the

experimental or control group. Patients who met the following criteria were included in

the study: (a) arrived in the EC complaining of nausea without a history of chemotherapy,

radiation therapy, or current abdominal pathology, (b) were at least 18 years of age at the

time of data collection, ( c) were able to read, write, and speak English, and ( d) were

willing to participate in the study as indicated by signing the informed consent. All

persons meeting the criteria were asked to participate in the study. A random assignment

technique at the beginning of the study was used to assign participants to the experimental

or control group. A table of random numbers was used to select a group of 70 numbers

from a total count of 140. A toss of a coin then was used to assign control or

experimental group status to the selected numbers. The remaining random numbers were ·

assigned to the other group (Waltz, Strickland, & Lenz, 1991). The random assignment

was based on the order of patient presentation to the EC treatment area.

62

Protection of Human Subjects

Permission to conduct the study was obtained from the Human Subjects Review

Committee of Texas Woman's University (Appendix A). Agency permission was granted

for the hospital through The Institutional Review Board for Human Subjects Research for

Affiliated Hospitals (Appendix A). The guidelines for protection of human subjects were

followed. The study subjects were informed that participation was voluntary and that they

could withdraw from the study at any time (Appendix B). The subjects were told that

there would be no benefit to them if they agreed to participate in the study. They were

informed that the investigator was staying on the site to answer questions or concerns they

had. The results of the study, reported in group format only, were available on request to

the group. Subjects were informed that completion of the signed consent and the two

visual analog scales indicated their consent to participate in the study.

The subjects were informed that all information was confidential. Any data

collection forms were coded so that neither the subject's name nor the name of the

institution appeared on any of the forms or results of the study. A code number was

placed on the upper right comer of each instrument at the time of data collection so that

the results of the pretest and posttest data could be matched.

All data were kept in a locked cabinet during the data collection, and only the

investigator had access to the cabinet. The collected information was destroyed on

completion of the study to further insure confidentiality.

63

Instruments

Two instruments were used to collect data in this study. The first instrument was

the Demographic Data Tool (Appendix C). This instrument included the date of data

collection, assigned treatment group code, age, gender, ethnic origin, reason for EC visit,

current reactions to nausea, and history of nausea. The other instrument was the 100-mm

visual analog nausea scale (Appendix D).

Demographic Data Tool

The Demographic Data Tool (DDT) was used to determine attributes of the

sample of the study. Each component of the DDT was substantiated by research,

including the autonomic reactions and the history of nausea, as potential contributors to

individual variations of the threshold to nausea or confounding variables that could

influence the results of the study. The demographic variables of nausea as identified by

other researchers were also explored in this study to identify sample characteristics.

According to previous researchers, younger patients ( < 60) reported higher nausea

scores and reported nausea more often than older patients(> 60) (Dodd, Onishi, Dibble,

& Larson, 1996; Rub, Andrews, & Whitehead, 1992). M. Cohen, Duncan, DeBoer, and

Tweed ( 1994) found that being of a younger age contributed to the incidence of

postoperative nausea. Quinn, Brown, Wallace, and Asbury ( 1994) also reported a

significantly higher incidence of postoperative nausea in the younger age group. In

addition, Rub et al. identified a significant decrease in nausea with increasing age. Age

64

. i

was a contributing factor in complaints of nausea as a primary complaint and could be a

factor for patients' responses to medications. Since Rub et al. recruited from general

populations in Europe, age groupings were replicated so that significant differences could

be identified between ages in the gen�ral population and this EC study sample.

Since gender influences the frequency of nausea and patient responses to touch

(Porter, Redfern, Wilson-Barnett, & LeMay, 1986; Rub et al., 1992), it was included in

data collection to allow for generalization of the results. Mann ( 1998) reported that

emetic symptoms occur three times more often in women than men. Women who receive

chemotherapy and are younger than 50 are more likely to experience nausea and

anticipatory nausea than are women over 50 (Goodman, 1997). To determine if gender

was a factor for EC patients with nausea, gender was recorded on the DDT.

Barnett ( 1972) and Porter et al. (1986) noted cultural differences in response to

touch. Ethnic group information was included on the DDT to allow for analysis of data to

determine if significant differences existed between ethnic groups and if the convenience

sample was representative of the population at large to allow for generalization of the

findings. Since different cultures have different spacial norms (Barnett, 1972), the analysis

of ethnic groups also would allow identification of differing responses among the groups.

According to Hawthorn (1995), the onset and severity of nausea can vary greatly

based on the etiology. Therefore, the reason for the EC visit needed to be determined.

Patients with a history of nausea experience more nausea with chemotherapy, radiation

therapy, or in the postoperative situation (Hinojosa, 1992; Redd, Dadds, Futterman,

65

Taylor, & Bovbjerg, 1993). According to Rhodes (1990), nausea is an expected symptom

of some specific pathophysiologic conditions. Other researchers identified multiple causes

of nausea, such as: after traumatic injuries, with gastrointestinal infections, headaches,

transient ischemic attacks, anoxia as a result of respiratory or cardiovascular disease,

metabolic disorders, burns, overdoses, and alcohol poisoning (Brechenridge, Larry, &

Mazzaferri, 1996; Grapp, Savage, & Hall, 1996; Hawthorn, 1995; Hepburn et al., 1991;

Rhodes, 1990). Patients with these types of conditions commonly present to the EC with

nausea. The influence of the chief complaint of nausea was explored as it related to the

use of PT.

Other sympathetic symptoms of nausea influenced the perceived distress from

nausea (Rhodes, McDaniel, & Johnson, 1995). The descriptors of effects of nausea,

identified on the DDT, were based upon the factors identified by Muth, Stem, Thayer, and

Koch (1996). According to Redd et al. (1993), classical conditioning can contribute to

the development of nausea even if the patient was distant from the associated treatment.

For example, a previous history of motion sickness increased the risk for developing

postoperative nausea and vomiting (Mann, 1998). The history factors to consider, listed

on the DDT, were extrapolated from Thompson (1999) and Hawthorn (1995). Data were

collected to discover if a history of nausea would influence the effect of PT.

66

Visual Analog Nausea Scale (VANS)

The I 00-mm visual analog nausea scale (VANS) used in this study to determine

the effects of touch on the severity of nausea was designed to measure the severity of

nausea, took only a few seconds to complete, and was used in an EC setting where nausea

was situational and nota recurring symptom. According to Contanch (1984), the VANS

is an easy way to quantify the subjective symptoms of patients. The VANS is a vertical

scale measuring exactly 100 mm, with zero at the lowest point and I 00 at the top of the

scale. Markings are located along the scale at 10-mm increments without labels. Zero is

labeled as "none" and I 00 as the "nausea as bad as it can possibly get." The VANS

measured both before and after purposeful touch or no touch on two separate original

sheets of the instrument. Each VANS was printed as an original to avoid the accidental

enlargement of the scale commonly experienced with duplicating machines.

Validity and Reliability

The DDT was designed as an interview instrument to be completed only by the

researcher. The DDT allowed for direct reliable answers since potential responses were

read for them, the researcher retained the ability to interpret the answers, and the

categories limited the potential responses to established variables (Fowler, 1984). The

questions progressed from general to specific with less distressing questions at the

beginning and more specific nausea questions at the end since there is a cognitive

component to nausea and the researcher did not wish to increase the discomfort for the

67

lli RETTT H

patient at the beginning of data collection (Bateson, 1984). Content validity of the DDT

was established by using language to describe nausea from the literature, investigator

observations in the EC, expert review by a three nurse specialists in oncology actively

involved in treatment of nausea, and expert review by two nurse researchers with

experience in instrument development (Waltz et al., 1991). The reliability of the DDT was

established during a pilot study of 20 patients. Since only one researcher was involved in

the intervention, interrater reliability was not required. The amount of time needed to

complete the DDT was established so that the EC staff and participants of the study could

be assured that the patient would not be detained longer than IO minutes.

Construct validity was established by correlation of the visual analog scale with

other scales for the measurement of sensations (Waltz et al., 1991). According to

Borjeson and associates ( 1996), there was a good concordance between the VANS and a

verbal category scale for complaints of nausea among patients receiving chemotherapy.

The researchers also suggested that the VANS. would be best used to detect small but

significant changes in a retest situation after interventions (Borjeson et al., 1996). Gift

( 1989) indicated that concurrent validity of the visual analog scale was established by use

in other studies on sensations of pain, depression, and dyspnea. Gift also reported

discriminate validity for the use of this scale in studies of quality of life and degrees of

airway obstruction.

The reliability of the VANS, according to Gift (1989) and Waltz et al. (1991), was

established in the test-retest method by demonstrating moderate to strong correlations.

68

Higher test-retest reliability coefficients (r = .92) were notedwhen the visual analog scale

was used to retest after 1 to 2 hours of the first test to evaluate a group of cancer

outpatients with nausea (Padilla et al., 1983). Fetting, Grochow, Folstein, Ettinger, and

Colvin (1982) reported a test/retest reliability of .83 on the VANS based on 27 pairs of

scores. Other forms of reliability testing have not been completed on the VANS. Since

literature establishing reliability for the use of the VANS with nausea patients in the EC

was not found, a pilot study was needed to pretest the applicability of the VANS for this

research.

Data Collection

Human subjects approval for the identified facility was obtained. All patients

meeting the study selection criteria were asked to participate in the study after they were

placed in the treatment area where privacy could be provided. A random assignment

· technique at the beginning of the study was used to assign participants to the experimental

or control group. Data collection forms were coded before the study was implemented.

The forms were selected and assigned in order based on the progression of patient

presentation to the EC treatment areas. The DDT and pre coded VANS (pretest and

posttest) were completed on each identified subject.

Each person agreeing to participate was informed that the purpose of the study

was to determine if nurses can decrease uncomfortable feelings of nausea by using touch.

The participants were then asked to read and sign the consent (Appendix B). After

69

obtaining consent, the researcher completed the DDT from information collected in triage

as documented on the patient chart and by interview. The patient was asked to complete

the pretest VANS while in a sitting position.

Patients included in the experimental group received a 5-second, bimanual touch to

the patient's shoulder between the midclavicle and the lateral surface of the neck and a

handshake position. The touch to the shoulder area stimulated sensory neurons of the

transverse cervical nerve and the ·supraclavicular nerves of the superficial cervical plexus.

The handshake position stimulated the superficial branch of the radial, the proper palmar

digital branches and the palmar branches of the median, and the superficial and dorsal

branches of the ulnar nerves of the brachia! plexus. The researcher remained in the

patient's room and stood 4 to 5 feet away from the foot of the patient's stretcher, while

the patient remained silent, napped, talked with their family, EC personnel, or the

researcher. Any conversations that occurred while the researcher was in the patient

examination room between completing the pretest, intervention, and posttest were patient

initiated. The patient was asked to complete the posttest VANS 2 minutes after the touch

in a sitting position. After the posttest VANS was marked, the patients were informed

that their participation was completed, asked if they had any questions, told that if they

had any questions later that the researcher would be in the area until discharge, and shown

the telephone number located on their copy of the consent form for questions after

discharge.

70

For the patients in the control group, the investigator stayed in the patient's room

for 2 minutes and stood 4 to 5 feet away from the foot of the patient's stretcher, while the

patient remain.ed silent, napped, talked with family members, EC personnel, or the

researcher. Any conversations that occurred while the researcher was in the patient

examination room between completing the pretest and posttest were patient initiated. The

patient was asked to complete the posttest VANS 2 minutes after the pretest VANS was

completed in a sitting position. After the posttest VANS was marked, the patients were

informed that the participation was completed, asked if they had questions, told that if

they had any questions later that the researcher would be in the area until discharge, and

shown the telephone number located on their copy of the consent form for questions after

discharge. If any of the participants were not able to complete the study pretest, posttest,

or asked to withdraw from the study, the collected data were not included in the data

analysis.

Pilot Study

Prior to data collection for the research, a pilot study was conducted to refine the

study design and establish reliability of the instruments for the proposed study. The

convenience sample consisted of 20 subjects randomly assigned to an experimental or

control group. Data for the pilot study were collected over one month in the EC

designated for the research.

71

An experimental two-group before and after design was used to determine the

effects of purposeful touch (PT) and no touch on the level of nausea of patients who

present in the emergency center (EC) of a private not-for-profit hospital complaining of

nausea as a primary or secondary complaint. The population of the study included all

patients who presented to EC with complaints of nausea. Data for the pilot study were

collected from March 25, 2001 through April 28, 2001 ·during high traffic times for the

EC. The sample size of20 was determined, based on approximately 15% of the overall

estimated sample size of 140 for the research. The guidelines for protection of human

subjects were followed and human subjects approval for the identified facility was

obtained.

Data collection forms were coded before the researcher approached the

participants. The forms were selected and assigned in order based on the progression of

patient presentation to the EC treatment areas. The DDT and pre coded VANS .(two

forms marked pretest and posttest) were completed on each identified subject. After

obtaining consent, the researcher completed the DDT from information collected in triage

documented on the patient chart and by interview. Patients included in the experimental

group received a 5-second, bimanual touch to the patient's shoulder between the

midclavicle and the lateral surface of the neck and the handshake position. The researcher

remained in the patient room, and stood 4 to 5 feet away from the foot of the patient's

stretcher, while the patient remained silent, napped, talked with their family, EC personnel,

or the researcher. The patient was asked to complete the posttest VANS 2 minutes after

72

PT in a sitting position. For the patients in the control group, the investigator stayed in

the patient's room for 2 minutes and stood 4 to 5 feet away from the foot of the patient's

.stretcher, while the patient remained silent, napped, talked with family members, EC

personnel, or the researcher. The patient was asked to complete the posttest VANS 2

minutes after the pretest VANS was completed in a sitting position.

The instruments for data collection and analysis were the DDT and the I 00-rnm

vertical visual analog nausea scale. The DDT contained the date of data collection,

assigned treatment group code, age, gender, ethnic origin, reason for EC visit, current

reactions to nausea, and history of nausea. Assessment data listed on the DDT were

obtained by the literature review. Content validity of the DDT was established by a

review by three oncology nurse specialists. lnterrater reliability was not established for

this instrument since the instrument was completed by the researcher only. Reliability and

validity for the VANS was established by previous research.

A total of 20 patients were included in the pilot study. Eleven of the patients were

included in the experimental group and 9 were in the control group based upon the

random assignment technique established for the proposed research. The participants

required more indepth information on how to complete the VANS than expected. Many

of the participants wanted to mark the level with an "X'' or a check mark instead of a

horizontal line. Ink pens were not used on the VANS because of the inconsistency of ink

flow for the marks. Newly sharpened pencils were provided for each participant and

discarded after each participant completed the posttouch VANS.

73

An analysis of covariance was used to establish adequacy of the covariate of

pretouch. The pretouch scores demonstrated adequacy as comparison data with a

significance of (F= 43.699,p < 0.0005). Each participant responded to the questions

regarding reactions and history of nausea. However, some of the terms were confusing to

the respondents. For example, the term palpitations was changed to "Any changes in your

heart beat?" during the interview. The pilot allowed for feedback into the script of the

research and led to improved modalities for communication with the study groups prior to

proceeding with the research. An anecdotal finding as a result of this pilot study was that ·

some staff nurses recruited more patients than others. More orientation sessions were

conducted before beginning the research to address concerns about recruiting patients, and

each triage nurs_e and EC physician was reoriented to the study before recruiting began

each shift.

Treatment of Data

To define the characteristics or attributes of the participants of this study,

demographic data were collected. The variables of gender, ethnic origin, reason for EC

visit, current reactions to nausea, and history of nausea were reported as frequencies and

percentages of nominal data. The age of the participants was reported as frequencies,

median, range, and percentages of resulting ordinal data. Once the demographics were

analyzed, the results of the study were applied to the groups identified (Polit & Hungler,

(1995).

74

The analysis of covariance (ANCOVA), an inferential statistical method, was used

to analyze data obtained from the visual analog nausea scale (VANS). According to

Pedhazur and Schmelkin (1991), the ANCOVA is the appropriate analysis for the

pretest/posttest, treatment/control design, where the pretest is treated as a covariate. The

ANCOV A enables a researcher to decrease the experimental error and to remove potential

sources of bias from the experimental effects (Kirk, 1982). The data were ratio level

based on a ruler measurement. The ruler was aligned along the central vertical line with

the zero of the ruler placed at the bottom of the scale designated by zero or no nausea and

the measurement was made at the bottoms of the marks made by the participants on the

VANS (Bums & Grove, 1997). The level of significance was set atp = 0.05.

Summary

An experimental study with a pretest and posttest design with randomization of

groups was conducted to determine the effectiveness of touch on decrease in nausea

scores. There was a total of 140 subjects with 70 participants in each of the two groups.

The independent variable was purposeful touch, and the dependent variable was nausea.

A DDT and visual analog nausea scale (VANS) were used to collect data on nausea.

Descriptive statistics and an ANCOVA were used to analyze the data from this study.

75

CHAPTER4

ANALYSIS OF DATA

The purpose of this experimental study was to determine if purposeful touch (PT)

applied to specific nerve pathways would decrease nausea in patients who present to an

emergency center (EC) with nausea as a primary or secondary complaint. This study with

a pretest and posttest design and random group assignments was conducted to determine

the effectiveness of touch on nausea. There was a total of 140 subjects with 70

participants in each of the two groups. The experimental group received PT (n = 70) and

the control group did not receive PT (n = 70). The independent variable was purposeful

touch, and the dependent variable was nausea. Both study groups were compared based

on demographics and study findings. Frequencies and percentages were performed on the

variables of gender, ethnic origin, reason for EC visit, reactions to nausea, and history of

nausea. Ages were reported as frequencies, median, range and percentages of the sample.

The analysis of covariance (ANCOVA), an inferential statistical method, was used to

analyze pretouch as the covariate, and experimental/control group data were recorded by

each participant on the visual analog nausea scale (VANS).

76

Description of Sample

Analysis of demographic data was completed to allow for comparisons and

generalization of the study results. The data reported was nominal and ordinal, so

statistics are reported as frequencies and percentages. The scores of pretouch and

posttouch associated with each demographic variable are reported as means and standard

deviations. The following data on age, gender, ethnic origin, reason for the EC visit,

symptoms, and history of nausea were described and used to compare the sample

characteristics between the experimental and control groups.

Age

This study sample consisted of 140 patients between the ages of 18 and greater

than 60. Of these patients, 24% were between the ages of 18-30, 50% between the ages

of 31-60, and 25. 7% greater than 60 years of age. The median range age group was

between the ages of 31-60. As shown in Table 3, the experimental group had more

(n = 20) in the greater than 60 age group and the control group had more (n = 20) in the

18-30 age group. The PT pre and post intervention VANS scores are summarized by age

on Table 3. Since there were lower reported pretouch nausea scores in the greater than

60 group, an a posteriori analysis of variance was completed to determine significance

between age groups. There were no significant differences between age in the pretouch or

posttouch groups even with the > 60 age range reporting less nausea prior to the

intervention.

77

Table 3

Descriptive Statistics for ·VANS by Age and Treatment Group

Age Group !!

18-30 Experimental 14Control 20 Total 34

31-60 Experimental 36Control 34 Total 70

>60 Experimental 20 Control 16 Total 36

Pretouch Mean SD Range

62.00 24.48 84 56.00 27.14 90 58.47 25.87 90

66.81 24.36 84 53.79 30.04 96 60.49 27.85 96

57.55 23.62 83 42.06 26.81 86 50.67 25.92 94

Gender and Ethnic Origin

Posttouch Mean SD Range

50.43 30.13 93 58.60 28.01 90 55.24 28.74 100

49.28 28.49 100 55.06 33.56 98 52.09 30.96 100

45.35 25.31 87 47.56 30.77 94 46.33 27.47 94

Forty-two (30%) male and 98 (70%) female subjects were included in this sample.

The experimental group was composed of 22 male and 48 female EC patients based on

random assignment, while a total of 20 male and 50 female patients were included in the

control group. More female's presented with nausea and randomization of groups was

implemented prior to beginning of the study; however, there was a relatively even

distribution of male and female participants (see Table 4). No significant differences in

mean nausea scores were demonstrated between genders in this study. Even though

females presented more often with nausea, both groups reported decreased nausea scores

78

with PT ( male, decrease of mean scores = 15 .13 and female, decrease of mean

scores = .. 14.66).

The subjects included in this study consisted of 68 (48.6%) White, 58 (41.4%)

Black, JO (7.1%) Hispanic, and 4 (2.9%) other or Asian-American participants. The

distribution of those who received PT (experimental group) was 40 (58%) White, 27

(39%) Black, and 3 (4%) Hispanic participants. The control group participants not

receiving PT were composed of 28 (40%) Whites, 31 (44%) Blacks, 7 (10%) Hispanics,

and 4 (2.9%) other or Asian-Americans. PT used in_this study was applied to locations

without negative personal or cultural connotations. Even though different cultures have

different spacial norms (Barnett, 1972), no significant differences in posttouch scores were

noted between the groups (see Table 4).

Reason for EC Visit

The primary reasons for visiting· the EC included the most common complaint. of

79 (56.4%) gastrointestinal symptoms of vomiting, nausea, or pain, 23 (16.4%) headache,

and 13 (9.3%) with cardiac complaints of chest pain or congestive heart failure. These

data were obtained from the patient triage record (see Table 5). Less common reasons

were respir�tory, trauma, cerebrovascular, and other.

Symptoms Experienced with Nausea

The symptoms experienced with this episode of nausea were explored and

re�orded as reported by the participants. Many participants reported more than one

79

Table 4

Descriptive Statistics for VANS by Gender, Ethnic Origin and Treatment Group

Pretouch Posttouch Gender Ethnic Origin Group 11 Mean SD Mean SD

Male White Experimental 15 57.87 25.28 40.73 30.03

Contra] 10 58.80 32.05 60.40 34.58

I Total 25 58.24 27.53 48.60 32.73

Black Experimental 6 64.17 27.31 59.83 27.37

Control 7 49.57 39.76 74.00 35.49

· Total 13 56.31 34.04 67.46 31.56

Hispanic Experimental 1 60.00 0.00 10.00 0.00

Control 3 45.00 36.51 58.33 46.52

Total 4 48.75 30.74 46.25 45.02

Total Experimental 22 59.68 24.73 44.55 30.23

Control 20 53.50 34.03 64.85 35.21

Total 42 56.74 29.32 54.21 33.88

Female White Experimental 25 57.92 22.37 46.88 22.91

Control 18 49.22 29.88 48.00 29.77

Total 43 54.28 25.81 47.35 25.67

Black Experimental 21 74.86 20.96 57.00 29.28

Control 24 55.75 22.97 54.58 27.32

Total 45 65.13 24.05 55.71 27.95

Hispanic Experimental 2 35.00 26.87 19.00 7.07

Control 4 45.00 26.46 46.25 27.33

Total 6 41.67 24.31 37.17 25.62

Other Experimental 0 0.00 0.00 0.00 0.00

Control 4 37.00 34.30 37.25 40.74

Total 4 37.00. 34.30 37.25 40.74

Total Experimental 48 64.81 23.99 50.15 26.49

Control 50 51.04 26.52 50.16 28.83

Total 98 57.79 26.12 50.15 27.57

80

Table 5

Frequencies and Percentages of Primary Reason for EC Visit

Variable Group n % within

Gastrointestinal Experimental 36 45.6 Control 43 54.4 Total 79 100.0

Headache Experimental 13 56.5 Control 10 43.5 Total 23 100.0

Cardiac Experimental 5 38.5 Control 8 61.5 Total 13 100.0

Respiratory Experimental 5 50.5 Control 5 50.5 Total 10 100.0

Other (Genitourinary) Experimental 5 71.4 Control 2 28.6 Total 7 100.0

Cerebrovascular Experimental 5 83.3 Control 1 16.7 Total 6 100.0

Trauma Experimental 0 0.0 Control 1 100.0 Total 1 100.0

Other (Diabetes) Experimental 1 100.0 Control 0 0.0 Total 1 100.0

Note: Categories without responses omitted from table.

81

% of total

25.7 30.7 56.4

9.3 7.1

16.4

3.6 5.7 9.3

3.6 3.6 7.2

7.1 2.9 5.0

3.6 0.7 4.3

0.0 1.4 0.7

1.4 0.0 0.7

additional symptom; therefore, all symptoms were recorded (see Table 6). Most

participants reported accompanying symptoms of weakness, dizziness, flushed feeling,

diaphoresis, anxiety, changes in respirations, palpitations, and pain. The most common

symptom experienced with nausea was the feeling of weakness (n = 70, 50%).

History of Nausea

Data were collected to discover if a previous experience of nausea would negate

the effect of PT. The study participants reported pain (n = 63, 45%), indigestion (n = 56,

40%), and odors (n = 55, 39.3%) to be the most common stimuli that caused nausea in the

past. Other causes of reported nausea were: (a) pregnancy (11 = 50, 35. 7%), (b) general

anesthesia from surgical procedures in the past (n = 39, 27.9%), (c) motion sickness

(n = 35, 25.0%), (d) medications (n = 35, 25.0%), (e) constipation (n = 31, 22.1 %),

(f) repulsive sights (n = 29, 20.7%), (g) with dysphagia (n = 24, 17.1%), and

(h) associated with thoughts of vomiting (n = IO, 7.1%). Six (4%) patients reported no

history of nausea. Although there were no significant differences between groups and

relief of nausea, the patients who reported a history of nausea with pain evidenced the

greatest mean difference in nausea scores (experimental group M = 5.00, control group

M = 4.00). Patients with a history of motion sickness reported the lowest mean difference

in nausea scores ( experimental group M = 0.30, control group M = 0.20).

82

Table 6

Frequencies and Percentages of Symptoms with Nausea by Treatment Group

Variable Group n % within % of total

Weakness Experimental 39 55.7 a

Control 31 44.3 a

Total 70 100.0 50.0

Dizziness Experimental 30 47.6 a

Control 33 52.4 a

Total 63 100.0 45.0

Flushed feeling Experimental 22 59.5 a

Control 15 40.5 a

Total 37 100.0 26.4

Diaphoresis Experimental 19 54.3 a

Control 16 45.7 a

Total 35 100.0 25.0

Anxiety Experimental 20 52.5 a

Control 12 37.5 a

Total 32 100.0 22.9

Changes in respirations Experimental 15 55.6 a

Control 12 44.4 a

Total 27 100.0 19.3

Palpitations Experimental 8 '61.5 a

Control 5 38.5 a

Total 13 100.0 9.3

Other (Pain) Experimental 1 50.0 a

Control 1 50.0 a

Total 2 100.0 1.4

aComputations not completed, participants may have reported more than one symptom.

83

Findings

The hypothesis for this research study was:

The mean nausea intensity score among emergency center patients receiving

purposeful touch to alter their perceptual field will be significantly lower than the

mean nausea intensity score among the emergency center patients not receiving

purposeful touch to alter their perceptual field.

The analysis of covariance(ANCOVA), an inferential statistical method, was used to

analyze pretouch as the covariate and experimentaVcontrol group data recorded on the

visual analog nausea scale (VANS) as the dependent variable.

The level of nausea was assessed on patients pre and post intervention during one

EC visit. The scatter plot in Figure 1 illustrates the distribution.

The mean post intervention scores and standard deviations supported the findings

in that the experimental group mean (48.39) and standard deviation (27.62) were lower

than the control group (M= 54.36 and SD= 31.25) (see Table 7). The experimental

group reported higher pretouch scores than the control group, however. This finding can

be attributed to the increased numbers of patients enrolled in this study with

gastrointestinal complaints of nausea, vomiting, and pain.

The participants in this study also reported some greater differences in scores if

they experienced nausea with pain in the past. Further analysis revealed that the

participants who reported nausea greater than 7 5 on the pretouch scores from the

experimental group were 72% female, between the ages of 31-60 ( 61 % ) who reported

84

.c (.) :::, 0

80 a

60

40

20

* *

*

D *

* *

*

*

* a

C

*

*

* * D

* cl* D Ccfl * *

D W .-1o D*

D

a

C

C

D

C D

D

GROUP

* EXPERIMENTAL

D CONTROL � a. 0

---------...------------------...----.1

20 40 60 80 100

Posttouch

Figure 1. Scatterplot Pre and Posttouch VANS by Group

weakness (61%) with nausea or experienced nausea with pregnancy (44%). The

corresponding control participants who responded with nausea greater than 7 5 on the

pretouch scores were 53% female between the ages of31-60 (47%) who experienced

dizziness ( 4 7%) with nausea. Despite the increase in pretest scores for the experimental

group, a significant decrease in nausea occurred. The results of the data analysis showed

that the mean difference score (see Table 8) among the emergency center patients

85

Table 7

Bivariate Frequency Distribution of 140 VANS Scores Pretouch and Posttouch

X Experimental (f) Control (f) Totals

Pretouch

100-75 20 17 37 74-50 34 25 59 49-25 9 10 19 24-00 7 18 25

Totals 70 70 140

Mean 63.20 51.74 Standard Deviation 24.16 28.63

Posttouch

100-75 12 19 31

74-50 23 22 45

49-25 17 10 27 24-00 18 19 37

Totals 70 70 140

Mean 48.39 54.36

Standard Deviation 27.62 31.25

86

receiving purposeful touch was significantly lower than the mean difference score among

the EC patients not receiving PT (ti< 0.0005). PT significantly reduced the mean nausea

intensity scores among EC patients in this study (R < 0.0005) (see Table 9).

Table 8

Means and Mean Differences for VANS Scores for the Total Group (N = 140)

n

Experimental 70

Control 70

Table 9

Pretouch VANS Mean

63.20

51.74

Posttouch VANS Mean

48.39

54.36

Analysis of Covariance for Mean Nausea Intensity Scores

Source

Corrected Model a

Intercept

Pre touch

Sum of Squares df Mean Square

77479.605 2 38739.803

3.544 1 3.544

76231.577 1 76231.577

Experimental/ control 8700.554 1 8700.554

Error 43791.080 137 319.643

Total 490734.000 140

Corrected Total 121270.686 139

F

121.197

.011

238.490

27.220

., R Squared= .639 (Adjusted R Squared= .634) *p < 0.0005

87

Mean Difference

14.81

-2.62

Significance

.000

.916

.000*

.000*

Summary of Findings

The level of nausea was assessed on patients presenting to the EC complaining of

nausea as eith�r a primary or secondary complaint. The effects of PT were evaluated in

measurements of nausea based on the VANS. Measurements pre and post intervention

were completed on the experimental group receiving PT and the control group not

receiving it. Findings indicated that the mean nausea intensity score among the EC

patients receiving purposeful touch were significantly lower than the mean nausea ·intensity

score among the EC patients not receiving PT. This finding indicated a decrease in nausea

among participants who received PT.

88

CHAPTERS

SUMMARY OF THE STUDY

This study was designed to test the influence of purposeful touch (PT) on nausea

relief in patients who presented with nausea as a primary or secondary complaint in an

emergency center (EC). The Demographic Data Tool was used to determine attributes of

the sample of the study to allow for comparison between these and other research sample

characteristics. A vertical visual analog nausea scale (VANS) was used to measure nausea

between two randomly assigned groups of patients before and after PT or no PT. The

study is summarized, the findings are discussed, conclusions and implications are

summarized, and recommendations for future research are presented.

Summaiy

An experimental two-group before and after design was used to determine the

effects of PT and no touch on the nausea of patients who presented in the EC complaining

of nausea as a primaiy or secondaty complaint. The hypothesis for this study was:

The mean nausea intensity score among emergency center patients receiving

purposeful touch to alter their perceptual field will be significantly lower than the

mean nausea intensity score among the emergency center patients not receiving

purposeful touch to alter their perceptual field.

89

The study sample included a total of 140 patients who presented to the EC with

complaints of nausea. Each of the two study groups included 70 patients randomly

assigned to either the experimental or control group. The random assignment was based

on the order of patient presentation to the EC treatment area. The first 70 numbers

chosen were assigned as control or experimental based on the toss of a coin (heads as

experimental, tails as control). The remaining 70 random numbers were assigned control

or experimental by default. The numbers were then printed on two individualized original

VANS instruments for each participant and coded with the number assigned, pre- or

posttest, and the group designation as A ( control) or B ( experimental). The results of the

randomization were equal numbers in each group without duplicate numbers.

Participants included in the experimental group received a 5-second� bimanual

touch measured on the EC treatment room wall clocks. The touch was applied half way

between the shoulder and neck and a handshake to the dominant hand. Two minutes after

the touch, the patient was asked to complete the posttest visual analog nausea scale

(VANS), an instrument designed to measure the severity of nausea. The investigator

stayed in the room with the patients in the control group and retested them after 2

minutes.

Permission to conduct the study was obtained from the Human Subjects Review

Committee of Texas Woman's University. Agency permission was obtained for the

hospital through The Institutional Review Board for Human Subjects Research for

Affiliated Hospitals. The guidelines for protection of human subjects were followed.

90

The Demographic Data Tool was used to determine attributes of the sample of the

study and to allow for generalization of the study results. Differences in response to

nausea and touch have been documented in previous studies (Barnett, 1972; Porter,

Redfern; Wilson-Barnett, & LeMay, 1986). The variables identified in the research were

replicated for this study to allow for comparisons and explanations of the study results.

Gender, ethnic origin, reason for EC visit; previous history of nausea, and other symptoms

of nausea were reported as nominal level data. Age was reported as ordinal data based

upon differences in nausea and age as identified by Dodd, Onishi, Dibble, and Larson

(1996) and Rub, Andrews, and Whitehead (1992).

The VANS was used to detennine the effects of touch on the severity of nausea.

This.instrument was a vertical scale measuring exactly l00·mm, with Oat the lowest point

and 100 at the top of the scale. Markings were located along the scale at 10-mm

increments without labels. Zero was labeled as "no nausea" and 100 as the "nausea as bad

as itcan possibly be." In this study, the patient was asked to mark nausea levels on the

measured scale both before and after PT or no touch.

After the final mark on the VANS was completed, the researcher remained

available for questions. The participants shared their questions and comments freely. The

following are some of the questions and comments: (a) "My nausea went away while you

were touching me, but r�turned a few seconds after you stopped," (b) "I think you would

have better results if you had me mark the sheet right after the touch," (c) "Could you

teach my family how to do that?", ( d) "Could you teach me how to do that for this nausea

91

or stop the· nausea from coming back at all? It really has taken over my life," ( e) "Can you

touch me again? It's coming back worse than before," (f) "I can't believe that worked.

Are you a healer or something?", (g) "I would rather have had just a shot," (h) a family

member asked, "How can I help her get over this distress?", and (i) another family

member asked, "I am really surprised that worked. Can you teach that to me?". These

results were not predicted nor measured and can only be considered as suggestions or

ideas for future research.

Discussion of Findings

Findings of the study indicated that a 5-second, bimanual touch to the anterior

shoulder and along the median and ulnar nerve pathways to the dominant hand decreased

the mean nausea intensity score among EC patients (Q < 0.0005). The mean post

intervention scores and standard deviations supported the findings in that the experimental

group mean (48.39) and standard deviation (27.62) were lower than the control

(M = 54.36, SD= 31.25) group analysis. The identified pre touch score, used as the

covariate, was a predictor of posttouch with a probability ofp < 0.0005 based on analysis

of covariance. For purposes of comparison, there were no other published research

studies that compared the effect of PT and decreased nausea.

The decrease in nausea in this study was due to the alteration of the perceptual

field of the participant and a resulting decrease in the patient's degree of reaction

associated with the stress response to nausea. Touch researchers of the past attributed the

92

relief of symptoms or changes in vital signs related to touch or hand holding to autonomic

activity resulting from social interactions with a nurse (Drescher, Gantt, & Whitehead,

1980; Mills, Thomas, Lynch, & Katcher, 1976), rather than an actual alteration in the

perceptual field or changes in neural pathways. The findings of this study supported the ·

use of PT to decrease nausea. The experimental group responded to PT despite a higher

nausea pretouch score and somatic complaints that would increase the distracting stimuli

and resist the introduction of additional stimuli. PT seemed to work for these participants

because several nerve pathways were used to provide sufficient focal stimuli to change the

nausea pathway to the central nervous system. These results supported Roy's ( 1984)

adaptation model since the researcher used one focal stimulus (PT) to alter another

(nausea).

According to Pervan ( 1993 ), nausea can be so distressful that patients will refuse

medications and treatments to avoid it. In this study, patients reported other symptoms

that accompanied nausea, such as weakness, dizziness, flushed feeling, diaphoresis,

anxiety, changes in breathing patterns, palpitations, and pain. According to Selye (1976),

stress was a group of symptoms affecting the entire body system, not just any isolated

organ system. The underlying cause of gastrointestinal symptoms or the symptom of

nausea alone can produce stress to .the entire body system. The findings of this study

supported the documented research on nausea as a stressor and its effect on the autonomic

nervous system and the entire body system.

93

According to other researchers (Barnard & Braselton, 1990; Waddell, 1979),

touch remains a fundamental nursing intervention used to comfort or relieve patient

distress. Nerve impulses influenced the functioning of the central nervous system and

adaptation can be defined as a group of inhibitory and activating reactions to stress (Selye,

197 6). This study used PT as a technique to decrease nausea as a stressor and thus

supported Selye's (1976) definition of adaptation as it applies to nausea in this study.

Nurses intervene on the patient's behalf by blocking or removing noxious stimuli or

stressors from the perceptual field (Ujhely, 1979). The patient becomes vulnerable to the

nausea stimuli through the perceptive pathways of smell, sight, taste, or hearing. This

study explored the perceptive pathways that were commonly associated with nausea by

assessing the patient's history of past nausea events to identify the relationship between

the use of PT as a method to alter nausea stimuli. Gastrointestinal pain was reported as

one of the most common stimuli that contributed to nausea by EC patients. The senses

contributed little to the development of nausea with this study sample. However, PT was

effective in decreasing nausea within the experimental group. PT became a part of the

perceptual field of the system apart from the other stimuli that the participants were

receiving. Roy ( 1984) identified the dynamic perceptual field of an open system as how a

person interacts and reacts within the adaptive system. Nurses can treat the distress of

nausea by altering the p�rceptual field of the _patient by introducing stimuli through the

senses that act as input into the central nervous system that will decrease the patient's

stress response to nausea (Roy & Andrews, 1999). This study supported Roy's (1984)

94

adaptation model by further validating that focal stimuli can interfere with other stimuli to

decrease the intensity of a symptom.

In this study, the researcher used PT to alter focal stimuli pathways of patients

complaining of nausea. The sensation of nausea was diminished through the process of

convergence. Convergence can be described as the coming together of nerve signals from

multiple sources to excite a single neuron (Guyton & Hall, 1996), and as a result, touch to

the sensory pathway could alter the sensation of nausea.

Current literature shows little research in support of nursing interventions for the

distress of nausea. However, studies have been conducted to determine etiologies and

responses among groups of patient diagnoses as a result of therapeutic procedures or

treatments (Cetindag, Boley, Magee, & Hazelrigg, 1999; M. Cohen, Duncan, DeBoer, &

Tweed, 1994; Grapp, Savage, & Hall, 1996; Honkavaara & Pyykko, 1998; Quinn, Brown,

Wallace, & Asbury, 1994 ). Many articles have been written about the causes of nausea

and vomiting (Dodd et al., 1996; Redd, Dadds, Futterman, Taylor, & Bovbjerg, 1993;

Rub et al., 1992). However, few studies have been concentrated on nausea as an isolated

event separate of vomiting.

Some techniques, identified in the literature, used perceptual stimuli to decrease

nausea. Acupressure (AP) and therapeutic touch (TT) were interventions that require

different techniques than the PT identified in this study. The techniques were reported to

decrease nausea. AP used deep, constant pressure on exact points along acupuncture

meridians which have a relationship with various physiological functions (Tappan, 1988).

95

Krieger (1987) defined TT as a human field phenomenon that uses a human energy

transfer from the healer to the ill person via electron transfer resonance to restore the vital

flow in the patient's open system. PT was defined as an intentional physical contact by a

nurse intended to activate stimuli that can change the permeability of receptor cells which ·

travel to the central nervous system in order to decrease nausea.

Belluomini, Litt, Lee, and Katz ( 1994) tested the use of AP to decrease nausea.

The researchers reported that nausea decreased over time with AP technique and was a

safe, low cost, and easily learned technique that can decrease nausea in pregnancy.

Dibble, Chapman, Mack, and Shih (2000) used AP to decrease nausea in chemotherapy

patients. They determined that the intervention might be effective in decreasing nausea for

the sample. PT was found to decrease nausea in the experimental group of this study with

the same safety, low cost, and ease of use as the AP research cited but within time

constraints dictated by the acuity of EC patients. Unfortunately, no research was found to

substantiate TT as an effective intervention for nausea.

Other explanations for the decrease in nausea with PT could be that the technique

can be employed to provide comfort in times of distress as a basic component of nursing

communication and sharing of self (Estabrooks, 1989; Lane, 1989; Langland & Panicucci,

1982; Mccorkle, 1974; Weaver, 1989). Touch and physical closeness also facilitate

patient comfort (Durr, 1971 ), communicate caring and enhance the lived experience

(Bottorff, 1992; Bottorff & Morse, 1994; Copstead, 1980). Even though other reasons

for the possible success of PT were not included as factors in this study, all of the above

96

factors co1:1ld not be excluded from overall results. To control for variations in the way in

which different nurses would comfort or share themselves with patients, the researcher

alone completed all the intervention or control communications on each of the 140

participants.

According to this study, PT decreased nausea in a group of EC patients. Claims

have been made that attached even more significance to touch than this study (Barnett,

1972). The analysis of PT data did uphold some of the other researchers' postulates about

PT being: (a) an essential strategy identified by nurses as a way to share self with patients

(Durr, 1971); (b) a potentially powerful modality (Mills et al., 1976), and (c) could be

perceived by patients as negative if withheld (McCorkle, 1974). The techniques and

locations of PT were supported in the early research on touch interventions (Bottorff

(1993). Schoenhofer (1989) reported that nurses used a stationary touch to a hand or

shoulder most often. Types of touch and touch interventions were identified by others

(Bottorff & Morse, 1994), but no research was found that used PT to decrease nausea.

Further research will be needed to explore the influence of the context of touch, types of

touch as caring methods for meeting the needs of patients, actual practices of touch

between patients and health professionals, using touch to intervene on specific medical

diagnoses, and to formulate a nursing theory for touch. This study on PT and nausea

added to nursing knowledge by identifying a specific technique that can be effective to

decrease nausea. This research was just the beginning in the formulation of a nursing

theory for touch to alter the perceptual field for decreasing nausea.

97

Conclusions

In this study, the hypothesis that mean nausea intensity scores, as measured by the

VANS, among EC patients receiving PT to alter their perceptual field was significantly

lower than mean nausea intensity scores among the EC patients not receiving PT was

supported. Bas_ed on these significant findings, it can be postulated that PT to sensory

areas on the hand and shoulder contributed to a decrease in nausea and that bimanual

touch enhances the overall effect of nausea reliefthrough_the process of convergence that

involve stimuli from two sensory pathways. Since nerve impulses influence the

functioning of the central nervous system and adaptation can be defined as a group of

inhibitory and activating reactions to stress, then nurses can foster adaptation by altering

the perceptual field of the patient. PT can be used as an effective, immediate nursing

intervention to decrease nausea in EC patients with the common complaints of

gastrointestinal distress, pain, and headache. This study further validated that PT applied

to nerve pathways when a patient was experiencing distress from the focal stimulus of

nausea may influence the process of adaptation and decrease the effect of nausea as a

stressor. This perceptual interface can converge with one or more of the nausea pathways

in order to decrease the intensity of the symptom as suggested by Guyton and Hall ( 1996).

Nurses can treat the distress of nausea by altering the perceptual field of the patient and

decreasing the patient's degree of reaction to avoid further complications associated with

the stress response (Roy, 1984; Selye, 1976) to nausea.

98

FT -· ■11

Implications

Since nausea is identified as a stressor and adaptation as a way in which nausea

could be decreased, nurses need to assess the patient's behavior and the focal, contextual,

and residual stimuli influencing the individual as a system (Roy & Andrews, 1999). The

patient's behavior and response to nausea include autonomic body reactions of

diaphoresis, skin pallor, hyper salivation, and hypotension (Cole, 1996 ;·Muth, Stern,

Thayer, & Koch, 1996), or by the patient's verbal complaints of nausea. Once the

assessment of nausea and the response to it are completed, nursing interventions to

promote adaptation by "altering, increasing, decreasing, removing or maintaining" stimuli

(Roy & Andrews, 1999, p. 86) can be implemented. The researcher suggests that nurses

can alter stimuli_ by using PT as a nursing intervention with patients who complain of

nausea in the EC. If PT decreases nausea, then nurses in current practice and student

nurses need to be instructed and encouraged to use the technique to decrease nausea. If

nausea can be decreased by nursing interventions, then the cost of additional anti nausea

medications will decrease, the side effects of the medications can be avoided, and EC costs

will decrease since the patients will need less time to recover from the complications of

nausea.

Recommendations for Further Study

Since this research was based on a convenience sample of EC patients, this study

should be replicated using a more diverse sample. Analysis of the data revealed consistent

99

LL rm

mean values and standard deviations among all variables. This sample was composed

primarily of white (58%) female (70%) patients between the ages of3 l-60 (50%) who

complained of gastrointestinal distress, pain, and headaches (79%). Future research might

explore specific gender, age group, or etiology for nausea, for example.

Other nursing interventions should be tested that are specific to causes and history

of nausea to develop scientific rationale for nausea interventions to help patients avoid the

potential summative and anticipatory causes of nausea. As suggested by Redd et al.

( 1993), a cool cloth to the forehead or to the back of the neck, the aroma of an alcohol

swab, chewing on ice chips, sipping cold ginger ale, dry crackers, pickles, lying flat in bed,

administering intravenous fluids, and anticipatory medications to prevent nausea from

occurring, are interventions that may relieve nausea. Further research may be needed to

establish effective nursing interventions for nausea which might include variations in PT.

This study should be replicated to explore the length of time the PT can be

sustained and how long the effects will last. No research has provided adequate

documentation on the amount of time suggested for this type of touch. According to

Guyton and Hall, ( 1996), all sensory receptors adapt after a period of time either over

seconds, minutes, or hours. It would also be of interest to explore if PT can be more

effective when applied as an alternating stimulus that would use the physiologic principle

of temporal summation rather than simple convergence.

Finally, the study should be replicated to determine the effects of PT on other

patient populations commonly suffering from nausea. For example, PT could be beneficial

100

for patients receiving medications, visiting physicians' offices, inpatient and outpatient

settings, and any location where patients request assistance for nausea symptoms. The

results of this study can only be generalized to the EC population tested. This population

was not receiving chemotherapy, radiation therapy, nor had any abdominal pathology.

However, the scores in this study were not significantly different between age groups.

Therefore, PT may be equally important to all ages of adults who are experiencing nausea.

101

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APPENDIX A

AGENCY APPROVALS

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Department Of Pediatrics-Administration Mail Station: /

One Baylor Plaza

Houston, Texas 77030

Office of Research

(713) 798-6970

RE: #H-9564 • NAUSEA RELIEF AND PURPOSEFUL TOUCH: DECREASING DISTRESS

BY AL TEAING THE PERCEPTUAL FIELD

APPROVAL VALID FROM 2/6/01 TO 2/6/02

Dear

The Institutional Review Board for Human Subject Research for : Affiliated Hospitals (BCM IRB) is pleased to inform you that your above referenced research protocol and consent form were approved according to institutional guidelines and provided they receive the unaltered approval of any other institutional committees in which your research is involved.

1. Continued review will be required( ) a. After each subject's exposure( ) b. Quarterly( ) c. Semi-annually(X) d. Annually(X) e. Change in Protocol(X) f. Development of unexpected problems or unusual

complications( ) g. Other

2. Method of Review(X) a. IRB Renewal Form (IRB2) ( ) b. New Protocol( ) c. Interview with principal investigator( ) d. Other

If a consent form is being used for this protocol, only the IRB approved (and stamped) version should be used for obtaining consent from potential stud� subjects.

Sincerely yours

Kathleen J. Motil, M.D., Ph.D., Chair Institutional Review Board for Human Subject Research

& Affiliated Hospitals

KJM:mrt

humanap

117

'\C., '\S 16 77 j,r, .. ,, '\'?, ., ,;,·.-:··

11,.'l- • ,.·.

� 'I'

t HAR 2001

� RELEASED �

c\.�,

"•�=-=-- '-�· �,--· .·•'.

TEXAS WOMAN'S UNIVERSITY DENTON DALLAS HOUSTON

HUMAN SUBJEC� REVIEW COMMITIEE • HOUSTON CENTER

HSRC APPROVAL FORM

Name of lnvestigator(s) Linda S. Dune RN MS

Social Security Number(s) ____ . · . .a.• i __ ·___.....,;._.._ _________________ _

Name of Research Advisor(s) Jeanette Kemicki RN PhD

Address: -�""""1 __ 17 __ 0=3 __ M=ead=o=wtrail=·�Lan=::::.e __________________ _

Stafford Texas 77477-13S2

Dear: -----=L�in:.::da=-=D"'"un:..:ae=--------------------------

Your study entitled: Nausea relief and purposeful touch: Decre.ising distress by altering the perceptual

field

(11,e applicant must complete the top portion of this form)

has been reviewed by the Human Subjects Review Committee - Houston Center and it appears to meet our requirements in regard to protection of the individual's rights.

Please be reminded that both the University and the Department of Health and Human Services regulations typically require that signatures indicating infonned consent be obtained from all hwnan subjects in your study. These arc to be filed with the Human Subjects Review Committee Chairman. Any exc;eption to this requirement is noted below. Fwthcnnore, according to lll-lS regulations. another review by the HSRC is required if your project changes or if it es:tends beyond one year from this date of approval.

Any special provisions pertaining to your study are noted below:

______ The filing of signatures of subjects with the Human Subjects Review Committee is not :tquircd.

______ Other. sec attached sheet.

___ ./ ___ No special provisions apply.

Sincerely,

g J, IH-d>c "7t}J,_µ) .., '��.G�rsch. Ph.D. Chairperson., HSRC • Houston Center

Date

BSRC-H 1999 • 19

118

APPENDIXB

INFORMED CONSENT

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PAGE 1 of3

AND AFFILIATES CONSENT TO PARTICIPATE IN A RESEARCH PROJECT (BPC) (9 9.6-08)

1. TITLE OF PROTOCOL

NAUSEA RELIEF AND PURPOSEFUL TOUCH: DECREASING DISTRESS BY ALTERING THE PERCEPTUAL FIELD

2. BACKGROUNDThere are few reported studies related to nausea and specific nursing actions that relieveit. Patients with nausea experience a feeling of helplessness and distress that may bedecreased with nursing care.

3. PURPOSE OF THE STIJDYThe purpose of this study is to detennine if nurses can decrease uncomfortable feelingsof nausea in patients who are in the emergency center by using touch. The length of thisstudy will be approximately six months.

4. PROCEDURESI understand that:[X] I will be .one of 140 subjects to be asked to participate in this trial.

I also understand that: 1. This study is to find out if a nurse's actions can make nausea (an upset stomach,

queasiness) stop or decrease.2. I will be asked to be available for fifteen (1 5) minutes to finish the study.3. I will only be participating in the study during this hospital emergency center visit.4. The researcher will explain the purpose of touch and feelings that I.might have from

the touch before beginning the study.5. I will be asked about my nausea and will be asked to mark a place on a paper sca1e to

let the researcher know how bad my nausea is.6. The researcher may touch my shoulder and hand for five (5) seconds.7. I will be asked to mark a place on another paper scale to let the researcher know how

bad my nausea is.8. I will receive all treatments as prescribed by the physician. My medica1 care will not

be slowed down because of my part in this study.9. I will be asked several questions about how I feel and any nausea that I have had in

the past.10. I can refuse to answer all or some of the questions.1 1. I may decide to stop the study at any time.

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5. RISKS/DISCOMFORTSI understand that the risks of participation in this study include:

1. Potential embarrassment from loss of privacy.2. Potential uneasiness, or a pressure sensation to the shoulder or hand when I am

touched.3. Potential that I may be identified in the research report.

6. BENEFITS

I have been told that the benefits of participating in this study may be partial or completerelief of nausea. However, I may receive no benefit from participating in this study.

7. ALTERNATIVESThe only al�emative to this study is non-participation.

8. FINANCIAL COSTS TO SUBJECTSThere will be no cost to subjects of this research study.

9. SUBJECT'S RIGHTSI have been informed that there may be unknown risks/discomforts involved, and that Iwill receive any new information discovered during the course of the study, concerningsignificant treatment findings that may affect my willingness to continue to participate.

Every effort will be made to maintain the confidentiality of my study records. The investigator, and agents of Baylor College of Medicine and The Methodist Hospital will be allowed to inspect sections of my medical and research records related to this study. The data from the study may be published; however I will not be identified by name. The confidentiality of the data will be maintained within legal limits.

In the event of injury resulting from this research, Baylor College of Medicine and/or The Methodist Hospital are not able to offer financial compensation nor to absorb the costs of medical treatment However, necessary facilities, emergency treatment and professional services will be available to research subjects,just as they are to the community generally. My signature below acknowledges my voluntary participation in this research project. Such participation does not release the investigator, or institutions from their professional and ethical responsibility to me.

My participation is voluntary and I may refuse to participate or may discontinue my participation AT ANY TIME, without penalty, loss of benefits, or change in my present or future care. The investigator has the right to withdraw me from the study at any time. My withdrawal from the study may be for reasons re1ated solely to me ( e.g. not following study-related directions from the Investigator; a serious adverse event reaction) or because the entire study has been tenninated.

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PAGE3of3

The investigator has answered all of my questions. lfl have additional questions during the course ofthis study about the research or my rights as a research subject, I may address them to the Baylor Affiliates Review Board for Human Subject Research at (713) 798-6970. In the event of a research-related injury or if any other problems arise, I may

contact Linda Dune at (713) 793-1466.

I HA VE READ THE INFORMATION PROVIDED ABOVE (OR HA VE HAD IT READ TO ME) AND HAD MY QUESTIONS ANSWERED TO MY SATISFACTION. I VOLUNTARIL y AGREE TO PARTICIPATE IN nns STUDY. I WILL RECEIVE COPY OF nns CONSENT FORM.

Signature of Research Subject (Including children - when applicable)

Signature of Legal Representative or next of kin (If applicable)

(Relationship - i.e. Father, Mother, etc.)

Signature of Investigator or Designee Obtaining Consent

122

Date

Date

Date

NOT VALID WITHOUT THE INSTITUTIONAL

REVIEW BOARD STAMP OF CERTIFICATION - ······ ·

LID FOR 1 YEAR FROM ABOVE DATE

APPENDIXC

DEMOGRAPIIlC DATA TOOL

123

Demographic Data Tool

Date: -----------

This fonn is to be completed by the researcher only.

Age: I. 18-302. 31-603. greater than 60

Gender: 2.

I. F

M

Reason for Emergency Center visit: 3. GI symptoms/Flu4. Migraine/headache5. Motor vehicle incident6. Respiratory illness7. Congestive heart failure8. Chest pain9. Trauma10. Burn11. Drug reaction/overdose12. ETOH reaction/overdose13. CVAffIA

Treatment/subject code: _____ _

Ethnic Origin: I. White2. Black3. Hispanic4. Other _______ _

14. Other __________ _

Current reaction to nausea: 15. Anxiety16. Weakness17. Dizziness18. Palpitations19. Flushed feeling20. Diaphoresis21. Changes in respirations22. Other __________ _

History of nausea: 23. Motion sickness24. With indigestion, >heartburn=

25. With dysphagia26. With constipation27. Reaction to repulsive sight28. With pregnancy29. Thinking about vomiting30. Odors31. With surgery32. With pain33. While taking medications (list. __ __;,_ _____ __,

34. Other __________ _

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APPENDIXD

VISUAL ANALOG NAUSEA SCALE

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Visual Analog Nausea Scale (VANS)

Date:. _________ _ Treatment/subject code:. _____ _

Directions:

1. Mark the degree of nausea that you feel right now with the pen provided.2. Sit upright when you mark the degree of nausea on the scale.3. Mark the scale anywhere along the vertical line that you want. Notice that the

bottom horizontal line is no nausea at all and the very top line is nausea as bad as it

can possibly get.

Nausea Scale:

AS BAD AS IT CAN POSSIBLY GET -----

NONE

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