Category Archives: Nursing

Your Tool Touches Me

It is little known that René Laënnec, the Parisian physician who invented the stethoscope at the Necker Hospital in 1816, found it distasteful to place his ear to the patient’s chest.  The distastefulness of “direct auscultation” was compounded by its impracticality in the hospital where, he observed, “it was scarcely to be suggested for most women patients, in some of whom the size of the breasts also posed a physical obstacle.”[1]  The stethoscope, which permitted “mediate auscultation,” not only amplified heart and lung sounds in diagnostically transformative ways; it enabled Laënnec to avoid repugnant  ear to chest contact.

Many women patients of Laënnec’s time and place did not see it that way.  Accustomed to the warmly human pressure of ear on chest, they were uncomfortable when an elongated wooden cylinder was interposed between the two.  By the closing decades of the nineteenth century, of course, the situation was inverted:  The stethoscope, in its modern binaural guise, had become so integral to physical examination that patients  hardly viewed it as a tool at all.  It had become emblematic of hands-on doctoring and, as such, a sensory extender of the doctor.  Even now, the stethoscope virtually stands in for the doctor, especially the generalist or the cardiologist, so that a retiring physician will announce that he is, or will be characterized by others as, hanging up his stethoscope.[2]

It’s easy to argue for the “oneness” of the physician and his or her instruments when it’s a matter of simple tools that amplify sensory endowment  (stethoscopes), provide a hands-on bodily “reading” (of temperature or blood pressure), or elicit a tendon reflex (e.g., the reflex hammer).  And the argument can be extended without much difficulty to the more invasive, high-tech “scopes” used by medical specialists to see what is invisible to the naked eye.  Instruments become so wedded to one or another specialty that it is hard to think of our providers without them.  What is an ophthalmologist without her ophthalmoscope?  An ENT without his nasal speculum?  A gynecologist without her vaginal speculum?  An internist without his blood pressure meter?  Such hand-held devices are diagnostic enablers, and as such they are, or at least ought to be, our friends.

In “Caring Technology” I  suggested that even large-scale technology administered by technicians, and therefore outside the physician’s literal grasp, can be linked in meaningful ways to the physician’s person.  A caring explanation of the need for this or that study, informed by a relational bond, can humanize even the most forbidding high-tech machinery.  To be sure, medical machinery, whatever the discomfort and/or bodily bombardment it entails, is often discomfiting.  But it need be alienating only when we come to it in an alienated state, when it is not an instrument of physicianly engagement but a dehumanized object – a piece of technology.

Critical care nurses, whose work is both technology-laden and technology-driven, have had much to say on the relationship of technology to nursing identity and nursing care.  This literature includes provocative contributions that look at where nurses stand in a hospital hierarchy that comprises staff physicians, residents, students, administrators, patients, and patients’ families.

For some CCU nurses, the use of technology and the acquisition of technological competence segue into issues of power and autonomy and they, in turn, are linked to issues of gender, medical domination, and “ownership” of the technology.[3]  A less feminist sensibility informs interview research that yields unsurprising empirical findings, viz.,  that comfort with technology and the ability to incorporate it into a caring, “touching” disposition hinge on the technological mastery associated with nursing experience.  Student and novice nurses, for example, find the machinery of the CCU anxiety-inducing, even overwhelming.  They resent the casual manner in which physicians relegate to them complex technological tasks, such as weaning patients from respirators, without appreciating the long list of  nursing duties to which such tasks are appended.[4]  Withal, beginners approach the use of technology in task-specific ways and have great difficulty “caring with technology.”[5]   Theirs is not a caring technology but a technology that causes stress and jeopardizes fragile professional identities.

Experienced CCU nurses, on the other hand, achieve a technological competence that lets them pull the machinery to them; they use it as a window of opportunity for being with their patients.[6]   Following Christine Little, we can give the transformation from novice to expert a phenomenological gloss and say that as technological inexperience gives way to technological mastery, technological skills become “ready-to-hand” (Heidegger) and “a natural extension of practice.”[7]

Well and good.  We want critical care nurses comfortable with the machinery of critical care – with cardiac and vital signs monitors, respirators, catheters, and infusion pumps – so that implementing technological interventions and monitoring the monitors do not blot out the nurse’s “presence”  in the patient’s care.   But all this is from the perspective of the nurse and her role in the hospital.  What, one wonders, does the patient make of all this technology?

Humanizing technology means identifying with it in ways that are not only responsive to the patient’s fears but also conducive to a shared appreciation of its role in treatment.  It is easier for patients to feel humanly touched by technology, that is, if their doctors and nurses appropriate it and represent it as an extender of care.  Perhaps some doctors and nurses do so as a matter of course, but one searches the literature in vain for examples of nurse-patient or doctor-patient interactions that humanize technology through dialogue.  And such dialogue, however perfunctory in nature, may greatly matter.

Consider the seriously ill patient whose nurse interacts with him without consideration of the technology-saturated environment in which care is given.  Now consider the seriously ill patient whose nurse incorporates the machinery into his or her caregiving identity, as in “This monitor [or this line or this pump] is a terrific thing for you and for me.  It lets me take better care of you.”  Such reassurance, which can be elaborated in any number of patient-centered ways, is not trivial; it may turn an anxious patient around, psychologically speaking.  And it is all the more important when, owing to the gravity of the patient’s condition, the nurse must spend more time assessing data and tending to machinery than caring for the patient.  Here especially the patient needs to be reminded that the nurse’s responsibility for machinery expands his or her role as the patient’s guardian.[8]

The touch of the physician’s sensory extenders, if literally uncomfortable, may still be comforting.  For it is the physician’s own ears that hear us through the stethoscope and whose own eyes gaze on us through the ophthalmoscope, the laryngoscope, the esophagoscope, the colposcope.  It is easier to appreciate tools as beneficent extenders of care in the safe confines of one’s own doctor’s office, where instrumental touching is fortified by the relational bond that grows out of continuing care.  In the hospital, absent such relational grounding, there is  more room for dissonance and hence more need for shared values and empathy.  A nurse who lets the cardiac monitor pull her away from patient care will not do well with a frightened patient who needs personal caring.  A parturient who welcomes the technology of the labor room will connect better with a labor nurse who values the electronic fetal monitor (and the reassuring visualization it provides the soon-to-be mother) than a nurse who is unhappy with its employment in low-risk births and prefers a return to intermittent auscultation.

In the best of circumstances, tools elicit an intersubjective convergence grounded in an expectation of objectively superior care.  It helps to keep the “objective care” part in mind, to remember that technology was not devised to frighten us, encumber us, or cause us pain,  but to help doctors and nurses evaluate us, keep us stable and comfortable, and enable treatments that will make us better, or at least leave us better off than our technology-free forebears.

My retinologist reclines the examination chair all the way back and begins prepping my left eye for its second intravitreal  injection of Eylea, one of the newest drugs used to treat macular disease.  I am grateful for all the technology that has brought me to this point:  the retinal camera, the slit lamp, the optical coherence tomography machine.  I am especially grateful for the development of fluorescein angiography, which allows my doctor to pinpoint with great precision the lesion in need of treatment.  And of course I am grateful to my retinologist, who brings all this technology to bear with a human touch, calmly reassuring me through every step of evaluation and treatment.

I experienced almost immediate improvement after the first such injection a month earlier and am eager to proceed with the treatment.  So I am relatively relaxed as he douses my eye with antiseptic and anesthetic washes in preparation for the needle.  Then, at the point of injection, he asks me to look up at the face of his assistant, a young woman with a lovely smile.  “My pleasure,” I quip, slipping into gendered mode.  “I love to look at pretty faces.”   I am barely aware of the momentary pressure of the needle that punctures my eyeball and releases this wonderfully effective new drug into the back of my eye.  It is not the needle that administers treatment but my trusted and caring physician.  “Great technique,” I remark.  “I barely felt it.”  To which his young assistant, still standing above me, smiles and adds,  “I think I had something to do with it.”  And indeed she had.


[1] Quoted in J. Duffin, To See with a Better Eye: A Life of R. T. H. Laennec (Princeton: Princeton University Press, 1998), p. 122.

[2] Here are a few recent examples:  O. Samuel, “On hanging up my stethoscope,” BMJ, 312:1426, 1996; “Dr. Van Ausdal hangs up his stethoscope,” YSNews.com, September 26, 2013 (http://ysnews.com/news/2013/09/dr-van-ausdal-hangs-up-his-stethoscope);  “At 90, Gardena doctor is hanging up his stethoscope,” The Daily Breeze, October, 29, 2013 (http://www.dailybreeze.com/general-news/20131029/at-90-gardena-doctor-is-hanging-up-his-stethoscope);  “Well-known doctor hangs up his stethoscope,” Bay Post, February 8, 2014 (http://www.batemansbaypost.com.au/story/1849567/well-known-doctor-hangs-up-his-stethoscope)

[3] See, for example, A. Barnard, “A critical review of the belief that technology is a neutral object and nurses are its master,” J. Advanced Nurs., 26:126-131, 1997; J. Fairman & P. D’Antonio, “Virtual power: gendering the nurse-technology relationship,” Nurs. Inq., 6:178-186, 1999; & B. J. Hoerst & J. Fairman, “Social and professional influences of the technology of electronic fetal monitoring on obstetrical nursing,” Western J. Nurs. Res., 22:475-491, 2000, at pp. 481-82.

[4] C. Crocker & S. Timmons, “The role of technology in critical care nursing,” J. Advanced Nurs., 65:52-61, 2008.

[5] M. McGrath, “The challenges of caring in a technological environment:  critical care nurses’ experiences,” J. Clin. Nurs., 17:1096-1104, 2008.

[6] A. Bernardo, “Technology and true presence in nursing,” Holistic Nurs. Prac., 12:40-49, 1998;  R. C. Locsin,  Technological Competency As Caring in Nursing: A Model For Practice (Indianapolis: Centre Nursing Press, 2005);  McGrath, “The challenges of caring,” op. cit.

[7] C. V. Little, “Technological competence as a fundamental structure of learning in critical care nursing: a phenomenological study,” J. Clin. Nurs., 9:391-399, 2000, at pp. 398, 396.

[8] See E. A. McConnell, “The impact of machines on the work of critical care nurses,” Crit. Care Nurs. Q., 12:45-52, 1990, at p. 51; D. Pelletier , et al., “The impact of the technological care environment on the nursing role, Int. J. Tech. Assess. Health Care, 12:35     8-366, 1996.C

Copyright © 2014 by Paul E. Stepansky.  All rights reserved.

You Touch Me

Etymologically, the word “touch” (from the old French touchier) is a semantic cornucopia.  In English, of course, common usage embraces dual meanings. We make tactile contact, and we receive emotional contact.  The latter meaning is usually passively rendered, in the manner of receiving a gift:  we are the beneficiary of someone else’s emotional offering; we are “touched” by a person’s words, gestures, or deeds.  The duality extends to the realm of healthcare:  as patients, we are touched physically by our physicians (or other providers) but, if we are fortunate, we are also touched emotionally by their kindness, concern, empathy, even love.  Here the two kinds of touching are complementary.  We are examined (and often experience a measure of  contact comfort through the touch)  and then comforted by the physician’s sympathetic words; we are touched by the human contact that follows from physical touch.

For nurses, caregiving as touching and being touched has been central to professional identity.  The foundations of nursing as a modern “profession” were laid down on the battlefields of Crimea and the American South during the mid-nineteenth century.  Crimean and Civil War nurses could not “treat” their patients, but they “touched” them literally and figuratively and, in so doing, individualized their suffering.  Their nursing touch was amplified by the caring impulse of mothers:  they listened to soldiers’ stories, sought to keep them warm, and especially sought to nourish them, struggling to pry their food parcels away from corrupt medical officers.  In the process, they formulated a professional ethos that, in privileging patient care over hospital protocol, was anathema to the professionalism associated with male medical authority.[1]

This alternative, comfort-based vision of professionalism is one reason, among others, that nursing literature is more nuanced than medical literature in exploring the phenomenology and dynamic meanings of touch. It has fallen to nursing researchers to isolate and appraise the tactile components of touch (such as duration, location, intensity, and sensation) and also to differentiate between comforting touch and the touch associated with procedures, i.e., procedural touch.[2]  Buttressing the  phenomenological viewpoint of Husserl and Merleau-Ponty with recent neurophysiologic research, Catherine Green has recently argued that nurse-patient interaction, with its “heavily tactile component” promotes an experiential oneness:  it “plunges the nurse into the patient situation in a direct and immediate way.”  To touch, she reminds us, is simultaneously to be touched, so that the nurse’s soothing touch not only promotes deep empathy of the patient’s plight but actually “constitutes” the nurse herself (or himself) in her (or his) very personhood.[3]  Other nurse researchers question the intersubjective convergence presumed by Green’s rendering.  A survey of hospitalized patients, for example, documents that some patients are ambivalent toward the nurse’s touch, since for them it signifies not only care but also control.[4]

After World War II, the rise of sophisticated monitoring equipment in hospitals pulled American nursing away from hands-on, one-on-one bedside nursing.  By the 1960s, hospital nurses, no less than physicians, were “proceduralists” who relied on cardiac and vital function monitors, electronic fetal monitors, and the like for “data” on the patients they “nursed.”  They monitored the monitors and, for educators critical of this turn of events, especially psychiatric nurses, had become little more than monitors themselves.

As the historian Margarete Sandelowski has elaborated, this transformation of hospital nursing had both an upside and a downside.  It elevated the status of nurses by aligning them with postwar scientific medicine in all its burgeoning technological power.  Nurses, the skilled human monitors of the machines, were key players on whom hospitalized patients and their physicians increasingly relied.  In the hospital setting, they became “middle managers,”[5] with command authority of their wards. Those nurses with specialized skills – especially those who worked in the newly established intensive care units (ICUs) – were at the top of the nursing pecking order.  They were the most medical of the nurses, trained to diagnose and treat life-threating conditions as they arose.  As such, they achieved a new collegial status with physicians, the limits of which were all too clear.  Yes, physicians relied on nurses (and often learned from them) in the use of the new machines, but they simultaneously demeaned the “practical knowledge” that nurses acquired in the service of advanced technology – as if educating and reassuring patients about the purpose of the machines; maintaining them (and recommending improvements to manufacturers); and utilizing them without medical supervision was something any minimally intelligent person could do.

A special predicament of nursing concerns the impact of monitoring and proceduralism on a profession whose historical raison d’être was hands-on caring, first on the battlefields and then at the bedside.  Self-evidently, nurses with advanced procedural skills had to relinquish that most traditional of nursing functions: the laying on of hands.  Consider hospital-based nurses who worked full-time as x-ray technicians and microscopists in the early 1900s; who, beginning in the 1930s, monitored  polio patients in their iron lungs; who, in the decades following World War II, performed venipuncture as full-time IV therapists; and who, beginning in the 1960s, diagnosed and treated life-threatening conditions in the machine-driven ICUs.  Obstetrical nurses who, beginning in the late 1960s, relied on electronic fetal monitors to gauge the progress of labor and who, on detecting “nonreassuring” fetal heart rate patterns, initiated oxygen therapy or terminated oxytocin infusions – these “modern” OB nurses were worlds removed from their pre-1940s forebears, who monitored labor with their hands and eyes in the patient’s own home.  Nursing educators grew concerned that, with the growing reliance on electronic metering, nurses were “literally and figuratively ‘losing touch’ with laboring women.”[6]

Nor did the dilemma for nurses end with the pull of machine-age monitoring away from what nursing educators long construed as “true nursing.”  It pertained equally to the compensatory efforts to restore the personal touch to nursing in the 1970s and 80s.  This is because “true nursing,” as understood by Florence Nightingale and several generations of twentieth-century nursing educators, fell back on gendered touching; to nurse truly and well was to deploy the feminine touch of caring women.  If “losing touch” through technology was the price paid for elevated status in the hospital, then restoring touch brought with it the re-gendering (and hence devaluing) of the nurse’s charge:  she was, when all was said and done, the womanly helpmate of physicians, those masculine (or masculinized) gatekeepers of scientific medicine in all its curative glory.[7]  And yet, in the matter of touching and being touched, gender takes us only so far.  What then of male nurses, who insist on the synergy of masculinity, caring, and touch?[8]  Is their touch ipso facto deficient in some essential ingredient of true nursing?

As soon as we enter the realm of soothing touch, with its attendant psychological meanings, we encounter a number of binaries.  Each pole of a binary is a construct, an example of what the sociologist Max Weber termed an “ideal type.”  The question-promoting, if not questionable, nature of these constructs only increases their heuristic value.  They give us something to think about.  So we have “feminine” and “masculine” touch, as noted above.  But we also have the nurse’s touch and, at the other pole, the physician’s touch.  In the gendered world of many feminist writers, this binary replicates the gender divide, despite the historical and contemporary reality of women physicians and male nurses.

But the binary extends  to women physicians themselves.  In their efforts to gain entry to the world of male American medicine,  female medical pioneers adopted two radically different strategies.  At one pole, we have the touch-comfort-sympathy approach of Elizabeth Blackwell, which assigned women their own  feminized domain of practice (child care, nonsurgical obstetrics and gynecology, womanly counseling on matters of sanitation, hygiene, and prevention).  At the opposite pole we have the research-oriented, scientific approach of Mary Putnam Jacobi and Marie Zakrezewska, which held that  women physicians must be physicians in any and all respects.  Only with state-of-the-art training in the medical science (e.g., bacteriology) and treatments (e.g., ovariotomy) of the day, they held, would women docs achieve what they deserved:  full parity with  medical men.  The binary of female physicians as extenders of women’s “natural sphere” versus female physicians as physicians pure and simple runs through the second half of the nineteenth century.[9]

Within medicine, we can perhaps speak of the generalist touch (analogous to the generalist gaze[10]) that can be juxtaposed with the specialist touch.  Medical technology, especially tools that amplify the physician’s senses –  invite another binary.  There is the pole of direct touch and the pole of touch mediated by instrumentation.  This binary spans the divide between “direct auscultation,” with the physician’s ear on the patient’s chest, and “mediate auscultation,” with the stethoscope linking (and, for some nineteenth-century patients, coming between) the physician’s ear and the patient’s chest).

Broader than any of the foregoing is the binary that pushes beyond the framework of comfort care per se.  Consider it a meta-binary.  At one pole is therapeutic touch (TT), whose premise of a preternatural human energy field subject to disturbance and hands-on (or hands-near) remediation is nothing if not a recrudescence of Anton Mesmer’s “vital magnetism” of the late 18th century, with the TT therapist (usually a nurse) taking the role of Mesmer’s magnétiseur.[11]  At the opposite pole is transgressive touch.  This is the pole of boundary violations typically, though not invariably, associated with touch-free specialties such as psychiatry and psychoanalysis.[12]  Transgressive touch signifies inappropriately intimate, usually sexualized, touch that violates the boundaries of professional caring and results in the patient’s dis-comfort and dis-ease, sometimes to the point of leaving the patient traumatized, i.e., “touched in the head.”  It also signifies the psychological impairment of the therapist, who, in another etymologically just sense of the term, may be “touched,” given his or her gross inability to maintain a professional treatment relationship.

These binaries invite further scrutiny, less on account of the extremes than of the shades of grayness that span each  continuum.  Exploration of touch is a messy business, a hands-on business, a psycho-physical business.  It may yield important insights but perhaps only fitfully, in the manner of – to invoke a meaning that arose in the early nineteenth century – touch and go.


[1] See J. E. Schultz, “The inhospitable hospital: gender and professionalism in civil war medicine,” Signs, 17:363-392, 1992.

[2]  S. J. Weiss, “The language of touch,” Nurs. Res., 28:76-80, 1979; S. J. Weiss, “Psychophysiological effects of caregiver touch on incidence of cardiac dysrhythmia,” Heart and Lung, 15:494-505, 1986; C. A. Estabrooks, “Touch in nursing practice: a historical perspective: 1900-1920,” J. Nursing Hist., 2:33-49, 1987; J. S. Mulaik, et al., “Patients’ perceptions of nurses’ use of touch,” W. J. Nursing Res., 13:306-323, 1991.

[3] C. Green, “Philosophic reflections on the meaning of touch in nurse-patient interactions,” Nurs. Phil., 14:242-253, 2013; quoted at pp. 250-251.

[4] Mulaik, “Patient’s perceptions of nurses’ use of touch,” pp. 317-318.

[5] “Middle managers” is the characterization of the nursing historian Barbara Melosh, in “Doctors, patients, and ‘big nurse’: work and gender in the postwar hospital,” in E. C. Lagemann, ed., Nursing History: New Perspective, New Possibilities (NY: Teachers College Press, 1983), pp. 157-179.  

[6] M. Sandelowski, Devices and Desires:  Gender, Technology, and American Nursing (Chapel Hill: University of North Carolina Press, 2000), p. 166.

[7] On the revalorization of the feminine in nursing in the Nursing Theory Movement of the 70s and 80s, see Sandelowski, Devices and Desires, pp. 131-134.

[8] See R. L. Pullen, et al., “Men, caring, & touch,”  Men in Nursing, 7:14-17, 2009.

[9] The work of Regina Morantz-Sanchez is especially illuminating of this binary and the major protagonists at the two poles.  See R. Morantz, “Feminism, professionalism, and germs: the thought of Mary Putnam Jacobi and Elizabeth Blackwell,” American Quarterly, 34:459-478, 1982, with a slightly revised version of the paper in R. Morantz-Sanchez, Sympathy and Science: Women Physicians in American Medicine (Chapel Hill: University of North Carolina Press, 2000 [1985]), pp. 184-202.

[10] I have written about the “generalist gaze” in P. E. Stepansky, The Last Family Doctor:  Remembering my Father’s Medicine (Montclair, NJ: Keynote Books, 2011), pp. 62-66, and more recently in P. E. Stepansky, “When generalist values meant general practice: family medicine in post-WWII America” (precirculated paper, American Association for the History of Medicine, Atlanta, GA, May 16-19, 2013).

[11] Therapeutic touch was devised and promulgated by the nursing educator Delores Krieger in publications of the 1970s and 80s, e.g., “Therapeutic touch:  the imprimatur of nursing,” Amer. J. Nursing, 75:785-787, 1975; The Therapeutic Touch (NY: Prentice Hall, 1985); and Living the Therapeutic Touch (NY:  Dodd, Mead, 1987).  I share the viewpoint of Therese Meehan, who sees the technique as a risk-free nursing intervention capable of potentiating a powerful placebo effect (T. C. Meehan, “Therapeutic touch as a nursing intervention,” J. Advanced Nursing, 1:117-125, 1998).

[12] For a fairly recent examination of transgressive touch and its ramifications, see G. O. Gabbard & E. P. Lester, Boundary Violations in Psychoanalysis (Arlington, VA: Amer. Psychiatric Pub., 2002). 

Copyright © 2013 by Paul E. Stepansky.  All rights reserved.