Editorial: Is technology responsible for nurses losing touch?

At best, technology supports and improves human life; at its worst, it alienates, isolates, distorts and destroys. John Naisbitt, author of High Tech, High Touch (Naisbitt et al. 1999) Touch by the laying – on of hands is an apparently simple but actually profoundly complex act. The therapeutic, comforting effects of touch have for centuries contributed to improving or maintaining health. Early studies showed us that therapeutic touch raised haemoglobin levels and more recent studies have shown that when people connect and especially when they touch each other, oxytocin (the feel good hormone) is released (Krieger 1975, Macdonald & Macdonald 2010, Pinker 2015). As Florence Nightingale in the mid-1880s guided the teaching of massage as part of nurses’ qualification at St Thomas Hospital, London, touch has been central to the work of a nurse (Krieger 1975). We are nurses with many years of experience in settings where we have – too many times to count – eased some pain with a holding of a hand or a back rub or a massage, shared some grief or loss with a connection made by holding a hand, provided some much needed and absent tactile connection for an older person who has no opportunities anymore for tactile sensory experiences, encouraged a patient to squeeze our fingers to distract from a painful procedure, or simply just sat with someone and held their hand when there was nothing to be said or done to make a situation better. We have seen the value of touch. Touch in nursing is often associated with tasks in delivering physical care or clinical procedures, but we know it is much more than that. It provides a deep connection with our patients and can improve the patient experience (Wright et al. 2006, Parker et al. 2007, Bensing et al. 2013, Deledda et al. 2013, Stein-Parbury 2014). When used appropriately, touch is one of the most therapeutic nonverbal means of communicating and it is invaluable in enhancing the nurse–patient relationship (Arnold & Boggs 2003). Person-centred care, the foundational basis of nursing, is characterised by care that is holistic, individualised, respectful and empowering. It is the environment in which this care takes place that has the greatest impact on patient health and well-being outcomes (Morgan & Yoder 2012). Social contact is described by Timson as ‘a biological drive that online activity can't quite satisfy’ (Timson 2014). Therapeutic touch is a core component of interpersonal communication. Touch is a reassuring action that helps to convey messages irrespective of oral communication interaction. Four decades ago, touch was identified as the ‘imprimatur of nursing’ and in our experience, it continues to be so (Krieger 1975). Increasingly, there is a move to integrate technology into the nursing environment. Reis and others (2013) have suggested that technology has generated many opportunities to enhance communication in healthcare through web-based communication training for healthcare professionals, access to healthcare providers irrespective of geographical boundaries and social media networks for patient and caregiver support (Reis et al. 2013). An example of this would be connecting young people recovering in hospital with their ‘social network’, through provision of a tablet device, WiFi and access to their Facebook friends. There is evidence that this interpersonal social support improves well-being and aids physical recovery (Nabi et al. 2013). Current and emerging health technologies can, however, present a barrier to the creation of ‘relationship’ between clinician and patient which is essential for care that is compassionate and centred for the patient's needs (Weiner & Biondich 2006). Subtle patient cues and personal responses to them such as face-to-face verbal communication or human touch embody what patients and healthcare providers perceive as caring. It is the interpersonal connection which determines much of the satisfaction for the healthcare role. Loss of relationship or distancing from the patients poses the risk for compassion fatigue and burnout in care providers (Bush 2009). Developments in technology have increased rapidly over the last two decades, but good health care practice remains firmly rooted in person-centred care. Studies indicate, however, that nurses tend to concentrate more on the clinical psychomotor skills and technical aspects of their work at the expense of addressing patients’ psychological and emotional needs (Baker & Melby 1996, Dean et al. 2015). We propose that the increasing use of a variety of technological supports for nursing work may be at the expense of offering a comforting touch to our patients. Technology is transforming nursing. Do not get us wrong, we are proponents of the use of technology in nursing. Technology is highly useful and can improve patient outcomes, business processes and clinical decision–making, but nurses must pay careful attention to how they best augment and integrate technology into practice without risking the interpersonal relationship at the heart of our work. There are a number of examples where the increasing use of technology in nursing may be of concern. Disruptiveness is the hallmark of technology. It is an inescapable aspect of daily life. Technology encourages us to multitask. This is disruptive and distracting to the unique and essential nursing interaction. An example of this is device alarms. Whilst alarms on devices have provided nurses with alert for attention, whether this is a ventilator, infusion pump or cardiac monitor, false alarms have desensitised nurses and have led to poor patient outcomes and adverse events (Sendelbach 2012). Within some contemporary health settings, nurses are failing to manually palpate patients’ radial pulses, and instead opting to apply an oxygen saturation probe to a finger. Not only does this impact the overall quality of the cardiovascular assessment (such as assessment of the strength, rate and rhythm of the pulse), but is worrying in terms of a lack of touch. Globally, nurses are transitioning to use computers to access prescriptions, administer medications and document in the clinical setting. Frequently, these computers are known as computers on wheels. These machines more often than not are attached to a large wheel trolley, presenting a physical barrier with patients when providing care or consultation. Such physical barriers of nurses working in front of monitors and on mobile computers may impact the quality of an interpersonal relationship. This may be a distraction to the nurse, a priori of developing a therapeutic relationship with the patient. This may be similar for nurses who sit behind desktop computers as there may be reduced time spent actively observing and interacting with patients. Nurses are increasingly encouraged to use smartphones in practice. Nurses may use tablet devices for patients to complete questionnaires. This is in substitution, or augmented as a component of a nurse interview. The nursing interview is an important contributor to developing rapport with a patient, and it often sets the scene for the relationship which follows. Computerised questionnaires may well save costs as it is less time-consuming for nurses, but how does this impact quality of care and patient outcomes? Patients are freer to focus on the relationship with their healthcare provider if they are not limited to prestructured questionnaires. Personal attention, warmth and empathy can develop when a nurse sits down with a patient to conduct an interview (Bensing et al. 2013). Furthermore, clinics are now providing patients with a tablet device to help them understand surgical procedures, learn about their care plan and explore all the care pathways and understand recovery or illness trajectory. Whilst this appears exciting to be enhancing patient knowledge using on screen narrated animations, we need to be cautious in terms of how patients receive this educational intervention. Finally, shared decision-making is a paradigm shift in nursing and a process of arriving at a clinical decision through nurse and patient partnership. This involves bidirectional conversation, consensus building and agreement on a pathway of care including the patient and nurse. Shared decision-making may incorporate a technological component with a device to support patients with risk and benefit information through an electronic decision aide. However, this may potentially mean less interpersonal interaction with a nurse over an electronic device that may present a risk of cognitive dissonance. Human touch is and always will be the imprimatur of nursing. The technological revolution in nursing is inevitable. In embedding technology in nursing practice, it is imperative that we consider how this impacts nurse–patient relationships. We must not lose touch.