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An Exploratory Study of Relaxation Response
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Mary Miller Sies

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AN EXPLORATORY STUDY OF RELAXATION RESPONSE
IN NURSES WHO UTILIZE THERAPEUTIC TOUCH

BY

Mary Miller Sies

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1994

ABSTRACT

AN EXPLORATORY STUDY OF RELAXATION RESPONSE
IN NURSES WHO UTILIZE THERAPEUTIC TOUCH

BY

Mary Miller Sies

The Therapeutic Touch (TT) is an advanced nursing
intervention used to balance a client's energy field and
potentiate a healing pattern which elicits a relaxation
response. It is the purpose of this study to explore the
existence of a relaxation response in the practitioner
utilizing TT. Experienced practitioners of TT, as
determined by a SETTS score of >97, who had practiced TT for
at least a year and were actively practicing nursing (n=8)
measured their peripheral skin temperature while performing
TT. Fifty percent of the practitioners demonstrated a
relaxation response. A Chi-square analysis of relaxation
response and time of TT intervention revealed residuals of +
or - 2.5, Pearson's Chi-square at 7.3 and a small observed
significance level of 0.0007. A one-way analysis of
variance of relaxation response to time of TT intervention
showed a significant difference between groups (F=9,
p=.0240). These findings demonstrated that a TT
intervention of greater than 15 minutes has a significant
effect on relaxation response in the practitioner.
Implications for research and nursing practice are

presented.

Copyright by

MARY MILLER SIES
1994

To my husband Richard,
Whose support and patience
have helped me expand my horizons
and fly.

iv

ACKNOWLEDGMENTS

This research would not have been possible without the
patience and assistance of many people. I am especially
grateful to Gwen Wyatt, RN, PhD, and Rachel Schiffman, RN,
PhD, for their guidance and expertise on the topic and in
the research process, respectively, and for serving as
co-chairpersons for this thesis. I would also like to thank
the thesis committee members, Brigid Warren, RN, MSN, and
Joan Predko, RN, PhD, for their expertise and support.

I would like to extend a warm thank you and hug to the
life that surrounds me (human, animal, plant, and mineral)

that has supported and nurtured me through this catharsis.

TABLE OF CONTENTS

List of Tables ....................................... viii
List of Figures ....................................... ix
Introduction ....................................... 1
Statement of the Problem .............................. 3
Purpose and Research Question .................... 4
Conceptual Definition ................................. 5
Relaxation Response .............................. 5
Therapeutic Touch ................................ 8
Theoretical Framework ................................. 10
Proposed Model for the Study ..................... 12
Assumptions of the Model ......................... 14
Review of the Literature .............................. 14
Methods ............................................... 22
Study Design ..................................... 23
Sample ........................................... 23
Operational Definitions .......................... 24
Therapeutic Touch ........................... 24
Relaxation Response ......................... 25
Instruments ...................................... 26

Data Collection Procedures ....................... 28

Data Analysis .................................... 29
Protection of Human Subjects ..................... 30

vi

Assumptions of the Study .........................

Limitations ......................................

Results .....

Discussion..

Implications .....................................

Summary ..........................................

APPENDIX A.

APPENDIX B.

APPENDIX C.

REFERENCES

COVER LETTER AND CONSENT FORM TO STUDY

PARTICIPANTS ...........................

SUBJECTIVE EXPERIENCE OF THERAPEUTIC
TOUCH SURVEY (SETTS) ...................

DEMOGRAPHIC DATA SHEET .................

INSTRUCTIONS FOR PERFORMING THERAPEUTIC
TOUCH INTERVENTION .....................

RECORD SHEET ...........................

UCRIHS APPROVAL LETTER .................

vii

30

30

31

36

38

41

43

44

47

49

50

51

52

Table
Table

Table

Table

LIST OF TABLES

Summary of Demographic Data .................
Summary of TT Experience ....................

Summary of Intervention Data ................

One-way Analysis of Variance of Relaxation
Response to Mean Time of TT .................

viii

33

33

35

35

Figure 1.

LIST OF FIGURES

A Model for the Study ......................

ix

ll

Introduction

As the art, science, and philosophy of nursing evolves,
those within the profession are challenged to move forward
into new frontiers. This challenge is strikingly present as
the health care system in the United States is in the midsts
of dramatic change and restructuring. This challenge has
the potential of accelerating the evolution of nursing into
primary care in which the advanced practice nurse (APN) is
the initial, first—line, health provider for the client. By
following Nursing's Agenda for Health Care reform (American
Nurses' Association, 1992), the APN will be more vulnerable
to job stress because of increased primary responsibility
for client care and emphasis on fostering change in the
client.

The demands of primary care practice may be accompanied
by all the stressors long experienced by physicians and
particularly female physicians in primary care. APNs will
need to develop strategies that decrease stress and allow
continued high-level functioning. Nurses in advanced
practice have historically used a variety of psychosocial
interventions to assist the client, such as relaxation
training, humor, counseling, assertiveness training,
cognitive reappraisal, music therapy, and therapeutic touch,

to mention a few. Most of the psychosocial interventions

are taught to the client by the APN based on her/his
knowledge, time, and energy. Therapeutic touch (TT), on the
other hand, is performed by the practitioner (APN) on the
client. TT has a documented relaxation response in clients
(Krieger, Peper, & Ancoli, 1979; Fedoruk, 1984; Kramer,
1990; Samarel, 1992; Heidt, 1990, 1991) and is an
intervention the APN may use in her/his practice that may
prove to have a relaxing effect on the practitioner as well
as the client (Krieger et al., 1979; Heidt, 1990). TT is
unique in that it may elicit a relaxation response in the
APN who is treating a client and potentially decrease stress
in the APN. This may be due, at least in part, to the
meditative state intrinsic to performing TT. This differs
from other stress reducing modalities that the APN may
utilize for her/himself, because TT can be integrated into a
busy practice. The APN does not have to take time out to
initiate a stress reducing strategy for her/himself separate
from the professional work environment.

The literature on physician stress and coping
strategies is abundant. Bowman & Allen (1990) identify three
major sources of unique stress for women physicians as being
minority status/prejudice, lack of role models/mentors/
sponsors, and role strain. Gross (1992) studied the gender
differences in physician stress and identified stressors
specific to gender. Since the majority of APNs in primary
care are presently women, this study is significant for APNs

to identify stress reducers specific to gender.

The stressors most frequently reported by the
respondents in the Gross (1992) study were the pressure of
time demands, doctor-patient relationships, the
responsibility inherent in the role, the conflict between
career and family obligations, the inability to cure, and
the threat of malpractice. Female physicians were more
likely to be concerned about the responsibility inherent in
the physician's role, whereas male physicians were most
distressed by relationships with patients, the inability to
cure, and the threat of malpractice. Since APNs in primary
care will be practicing in a similar environment, they can
expect to experience similar stressors as both male and
female physicians. It is therefore important for APNs to
develop strategies that minimize stressors in practice. One
way is to promote interventions that elicit a relaxation
response to decrease physiological effects of stress on the
health professional. This thesis explored TT as one
advanced nursing intervention that may be utilized by the
APN as a strategy to reduce the practitioner's stress by
eliciting a relaxation response during a typical day of

practice.

Statement of the Problem
The APN role is in its infancy and there is testing,
role ambiguity, role intensity, role uncertainty and,
therefore, stress in this new position. While there is

abundant research that addresses stress and the female

physician (Bowman & Allen, 1990; Manderino & Brown, 1992;
Gross, 1992), none looks at the APN in primary care. The
role stressors experienced by APNs may lead to role strain
depending on intervening conditions, such as amount of role
pressure, self-esteem, role mastery, and cultural factors
(Ward, 1986). This role strain may then manifest in the APN
with attributes of fatigue, exhaustion, depression,
cognitive strain, insecurity, tension, and indecision (Ward,
1986). It is important for the APN to intervene early to
positively address role stress before it advances to role
strain. By avoiding role strain, the APN will be able to
continue to interact therapeutically with clients.

Not much is known about the impact that various nursing
interventions, such as relaxation training, cognitive
reappraisal, humor, counseling, assertiveness training and
TT, have on the APN. It is possible that one or more of
these interventions may have a positive, stress reducing
effect on the APN. This study explored one of these
interventions, TT, and specifically, if it elicited a
relaxation response and thus assisted in reducing stress in

the practitioner.

WW

APNs need to develop practical nursing interventions
that promote wellness and decrease stress for themselves as
practitioners. By maintaining a state of wellness, the APN

may be less prone to errors, have increased satisfaction,

and be able to maintain more positive client interactions.
Therefore, a study focusing on a stress reducing
intervention that can be utilized by APNs should provide
APNs with a means of coping with stressors of everyday
practice.

The purpose of this study was to examine an advanced
nursing intervention, TT, as a potential stress reducing
modality for the APN. The specific research question was:
Does the administration of TT to a client elicit a
relaxation response in the practitioner?

Since there has been little research done on what
effect the practice of TT has on the practitioner, this
study was of an exploratory, descriptive design. At this
level, the study design provided an exploration of a single
concept--relaxation response--while describing the
characteristics of a specific, single population: APNs who
are administering TT. Because of the exploratory nature of
this research, no inferences can be drawn from the data. It
is hoped that the data will lead to suggestions of

hypotheses for future studies.

Conceptual Definitions
Relaxation_Resp_Qnse
Relaxation response is the antithesis of the stress
response as is the parasympathetic response to the
sympathetic response. By initiating a relaxation response,

one then decreases the stress response. Benson (1975, 1993)

describes the state of relaxation as an innate physiological
response that, once initiated, evokes specific physiological
changes. These changes include a decrease in oxygen
consumption, serum lactate, pulse, respiration, blood
pressure, skeletal muscle tone, and a relaxation of smooth
muscles in vessel walls (vasodilatation). This
vasodilatation is the basis for measuring distal skin
temperature to gage relaxation. It is assumed that
vasodilatation will lead to increased skin temperature.

Fischer-Williams, Nigil and Sovine (1986) describe the
physiological basis of thermal feedback (monitoring of
temperature changes on the skin) as being linked to the
sympathetic branch of the autonomic nervous system (ANS) and
exercising significant control over distal skin temperature
through electrochemical changes stimulated by norepinephrine
and other neurotransmitters. Sympathetic activation leads
to contraction of smooth muscles surrounding the peripheral
blood vessels (vasoconstriction) which in turn results in
lowered skin temperature as peripheral blood flow decreases.
Conversely, parasympathetic activation causes relaxation of
the smooth muscles in the vessel wall (vasodilatation) and
increased distal skin temperature. Smith, Airey, and
Salmond (1990) identify the prime reason for the
effectiveness of relaxation in stress reduction is that it
alters the ANS activity.

Specific psychological changes were also identified

to occur during relaxation. These changes include a

decrease in anxiety and an increase in a sense of well—being
(Benson, 1993). Benson (1993) and Pelletier (1993) both
postulate that the physiological and psychological aspects
of relaxation are not parallel phenomena but are
interrelated. Likewise, Gelhorn and Kiely (1972) describe
the reticular activating system as the communication
mechanism between the cortical and subcortical areas of the
brain. Since the cerebral cortex controls psychological
activity and the subcortex controls physiological activity,
it is logical to conclude that the two aspects of relaxation
influence each other. Psychological relaxation can induce
the physiological changes of relaxation, and physiological
relaxation can promote the psychological changes of
relaxation. The mental and physical aspects of relaxation
are not two separate spheres but are intimately related
(Herman, 1985).

Relaxation response is viewed by Kunz and Peper
(1985) as a healing pattern in which the energy field
expands and creates a primary mechanism for energy flow to
be re-established or replenished. Therefore, for the
purpose of this study, the relaxation response is defined as
an integrated hypothalamic response which results in
decreased sympathetic nervous system activity and some
increase in parasympathetic activity (Benson & Rosner, 1974)
and a repatterning of existing energy fields that allows for

a flow of energy. For this study, relaxation response was

demonstrated by a physiological response (increased distal

skin temperature) in the practitioner administering TT.

Therapeuticmch

Therapeutic Touch is an advanced nursing intervention
that was derived from the work of Krieger (1973). TT was
later described by Krieger and colleagues (1979) as an act
of healing or helping in which "there appears to be a
transfer of energy from the healer (nurse) that helps the
patient to repattern his/her energy level to a state
comparable to that of the healer (nurse)" (p.660). Meehan
(1990) viewed TT as facilitating energy field repatterning.
This repatterning "occurs in the human-environmental energy
field patterning as the nurse assumes a meditative state of
awareness, recognizes his/her own unitary nature and
integrality with the environmental field, and focuses
his/her intent to help the patient" (p.6). More recently,
Quinn and Strelkauskas (1993) have postulated that the TT
practitioner, "knowingly participating in the mutual
human/environment process by shifting consciousness into a
state that may be thought of as a healing meditation,
facilitates repatterning of the recipient's energy field
through a process of resonance, rather than energy exchange
or transfer" (p.14).

The framework of TT is based on a Rogerian
conceptualization of the universe as an open system composed

of a progressive dynamic series of wholes that are in

constant, evolving interaction with each other and lead to
an ever-increasing order and complexity (Keller, 1984). In
this open system, each whole is a subsystem and a reflection
in miniature of the one system. It consists of an abstract
conceptualization of subtle states of matter/energy having
primacy over gross physical states. At its core is the
concept of a life energy which is coextensive with the
universe and in constant interaction and exchange with
environmental energy fields (Rogers, 1990).

The concept of life energy is indispensable to TT as a
healing phenomenon (Weber, 1981). Keller (1984) states

that:

Due to the openness and complete connection
between the universe and all its subsystems, life
energy can be channeled, sent and received, not
only in its multitude of obvious physical forms,
but in its pure essence as well. It is the fluid,
versatile currency of life (p. 93).

Quinn and Strelkauskas (1993) postulate that life energy is
not exchanged between the practitioner and recipient of TT,
but that the repatterning of the recipient's energy field
occurs through a process of resonance with the practitioner.
For the purpose of this study, TT is defined as a

nursing intervention in which the practitioner intentionally
repatterns/opens the energy field of the client by means of
a healing meditation to allow for a flow and replenishing of
energy through a process of resonance (Quinn & Strelkauskas,

1993). According to Kunz and Peper (1985), this elicits a

10

relaxation response in the client and practitioner. Since
TT is conceptualized in a world of open systems in constant
interaction, the practitioner should be affected by the TT
interaction with a client as well as the client being

affected by the practitioner.

Theoretical Framework

The majority of nursing research on TT utilizes Rogers'
(1970, 1980, 1990) theory on the science of unitary human
beings as a conceptual basis for understanding the
phenomenon of TT. The concepts of energy fields, openness,
and pattern are at the heart of Rogers' abstract system.

Rogers (1990) perceives a universe made up of open
systems of energy fields that are integral with each other
and in constant, evolving interaction. Energy fields are
"the fundamental units of the living and the non-living"
(Rogers, 1990, p.7). Field is a unifying concept between
humans and their environments. Energy signifies the
dynamics created by the human and environmental fields
(Lutjens, 1991). According to Rogers (1990), it is the
mutual, simultaneous interaction of these two energy fields
through which healing occurs; a change in pattern takes
place (See Figure 1). Pattern is an abstraction that cannot
be seen; however, manifestation of a pattern can be
observed. Patterns represent expressions of unique
relationships of individuals and their environment. They

display themselves as nonrepeating rhythms in behavior, such

11

OPEN UNIVERSE

Environment
|_—_—| |__——|
| |_______\_| I
APN CLIENT
| performing TT I Resonance causes energyl receiving TT |
resonating field repatterning resonating
| relaxation | in both directions | relaxation |

response response

I l<—_—__| |

Figure 1. A model for the study.

The relationship of the APN and client as Unitary
Human Beings in the Universal Environment and how
an intervention such as TT resonates between the

two and causes dynamic energy field repatterning.

12

as sleep and waking and perceptions of time and motion.
Patterns are continually changing as energy fields remain in
constant interaction in a universe of open systems. TT is
viewed as facilitating energy field repatterning.
Simultaneous, mutual interaction of energy fields is a
key concept to the action of TT. It is through this
interaction that the practitioner of TT attempts to
repattern the client's energy so that it is in a more
balanced or healthful pattern. The healing pattern, in
turn, creates a primary mechanism for energy flow to be
re-established or replenished and yields a relaxation
response (Kunz & Peper, 1985). Since the practitioner must
create a healing pattern and energy flow in TT by assuming a
meditative state of awareness and since energy fields are in
simultaneous, mutual interaction, then the energy flow
should yield a relaxation response in the practitioner as
that pattern resonates between client and practitioner (See

Figure 1).

W
The building blocks of Rogers (1990) theory of Unitary

Human Beings, openness, energy fields and pattern, explain
the phenomena of TT and how a relaxation response may occur
in the practitioner who is administering TT. The
interrelationship of the Unitary Human Being and the
environment are depicted in Figure 1. The Unitary Human

Being and the environment are integral with one another and

13

constantly exchanging energy and repatterning in an open
universe. The openness of the universe is depicted by
broken lines. Any energy field that comes in contact with
another will cause a change in pattern in both fields. The
type and degree of change depends on the type of contact.
The practitioner of TT has a positive intent to help a
client by repatterning the client's energy field into a
healing pattern which yields a relaxation response (Kunz &
Peper, 1985). Since there is a mutual exchange or resonance
of energy between practitioner and client, the practitioner
should experience a relaxation response when doing TT,
irrespective of what occurs with the client's energy field.
The practitioner, in sending the healing pattern out, will
have some of that same healing pattern reflected back on
her/him because of the integral relationship of energy
fields and by the process of resonance (Quinn &
Strelkauskas, 1993). This multidirectional resonance of
energy is depicted by the two-way arrow in Figure 1.

Rogers (1990) states the human and environmental fields are
a continuous and mutual process in which two fields are open
systems integral with one another. The practitioner in
interacting with the client becomes part of the client's
environmental field, as does the client part of the
practitioner's environmental field as illustrated by the
broken lines and two-way arrow in Figure 1. Information
from this study could provide the groundwork for future

experimental research related to the effects of TT on the

14

practitioner who is administering TT and if TT is an
effective strategy for stress reduction in the practitioner

in a primary care practice.

WW

1. The practitioner and client are Unitary Human Beings,
irreducible energy fields in open, integral
relationship with the universe in a constantly changing
pattern.

2. The health care environment and its interventions are
irreducible energy fields identified by patterns and
are constantly changing in integral relationship with
Unitary Human Beings.

3. There is a mutual exchange or resonance of energy
between the TT practitioner and the client.

4. Stress is the antithesis of the relaxation response.

5. Relaxation response is created by a healing pattern
which allows for a replenishing or repatterning of

energy flow.

Review of the Literature
Most of the empirical research on TT has been directed
towards effects on the client. Particularly, research has
focused on anxiety reduction, pain reduction, and relaxation
response in the client. Only three research studies have
been done on what effect TT has on the practitioner. Quinn

and Strelkauskas (1993) in a pilot study looked at

15

psychoimmunologic effects of TT on practitioners and
recently bereaved recipients. Two TT practitioners and four
recently bereaved individuals who received TT treatments
were the subjects. Psychological profiles were obtained on
both recipients and practitioners using the State-Trait
Anxiety Inventory and the Affect Balance Scale and the
Effectiveness of Therapeutic Touch Scale. Examination of
data for state and trait anxiety scores for practitioners
and clients did not reveal any obvious relationships between
scores of recipients of TT and scores of practitioners.
There was an average decrease in state anxiety following
treatment of TT, of 29% in recipients, while practitioner's
scores were at or close to no change. The researcher did
not establish reliability or validity for the affect and
effectiveness scales, so results obtained with these scales
need further investigation.

A comparison of actual time elapsed during a TT
treatment and practitioner and recipient estimation of time
elapsed during TT treatment was performed. This comparison
was made to evaluate if the shift in consciousness that is
assumed to occur during TT is reflected in an individual's
perception of time. The comparison raised questions about
the degree of consciousness shift and the perceived
effectiveness of the TT treatment by the client and what
level of consciousness shift (time perception) is needed by
the practitioner in order to enter a healing state of

consciousness. Time perception was found to be parallel in

16

the client and the practitioner. Both perceived time
shifting in the same direction--either shorter or longer
than actual intervention time.

A profile of immune functions was developed for each
practitioner and recipient and was drawn before and after
the TT intervention. Findings were displayed as a
percentage of change. While there was no conclusive
interpretation of the data, Quinn and Strelkauskas (1993)
stated the data indicated that the TT treatment had an
impact on lymphocyte subset composition and improved the
helping function of the immune system.

It is difficult to draw any conclusions or
relationships with such a small sample size (two
practitioners and four clients) as was employed in the Quinn
and Strelkauskas study. Percentages are misleading.
Larger, more controlled studies need to be done so that
correlations between variables can be made. The Quinn and
Strelkauskas (1993) pilot study does, however, provide
direction for further research.

Heidt (1990) conducted a qualitative analysis of
nurses' and patients' experiences of TT using a constant
comparative method. A sample of fourteen persons, seven
nurses who had studied TT as taught by Krieger and who had
practiced TT for a minimum of three years and seven clients
who were chosen by the nurses, participated in the study.
All clients had previous TT treatments. One TT treatment

was observed followed by a 90—minute, tape-recorded,

17

interview with the nurse and a 50-minute interview with the
client. Broad descriptive questions formed the basis of the
interviews. The data were coded using key words and
phrases. It was noted that clients and practitioners had
remarkably parallel experiences. The investigator therefore
combined the categories of experience for both practitioners
and clients to indicate their complementary nature.
"Opening" was defined as the core variable linking the
experiences of the practitioners and clients in the process
of giving and receiving TT. "Opening" was defined by Heidt
(1990) as "(a) the experience of allowing oneself to focus
intent on getting the universal life energy moving again;
(b) assessing the quality of its flow; and (c) participating
in a healing relationship that unblocks engages and enlivens
its movement" (p. 182). The primary outcome for the
practitioners as a result of the energy exchange with
clients during TT was a continuous opening and/or deepening
of their consciousness. The experiences of the clients
during treatment paralleled those of the nurses. This
definition of opening creates a relaxation response as
defined by Kunz and Peper (1985); a healing pattern is
established in which energy flow is re-established or
replenished. These findings parallel Rogers' theory that
patterns are continually changing as energy fields remain in
constant interaction in an universe of open systems; one
energy field affects another. The study (Heidt, 1990) is

limited because of the small sample size which decreases the

18

generalizability of the data. It is, however, the basis for
further research.

In 1979, Krieger, in collaboration with Peper and
Ancoli, undertook a study which sought to identify
physiological response of both the client and the
practitioner of TT during a TT treatment. Three clients
from the Pain and Stress Control Outpatient Department of a
California hospital received TT from Krieger (the
practitioner). No significant changes were found on any of
the three clients when they were monitored using
physiological measures from electroencephalogram (EEG),
electromyogram (EMG), galvanic skin response, peripheral
skin temperature, and heart rate. However, because of the
high abundance of large-amplitude alpha activity found on
the EEG in both the eyes-open and eyes-closed states, the
clients were considered to be in a relaxed state. Alpha
activity is usually associated with a closed-eyes state
without visual orientation. Also, each client reported
attaining a relaxed state during TT.

The practitioner, Krieger, was attached to EEG, EMG,
and electro-oculogram (EOG) while doing TT as well as while
she was not doing TT. In all experimental conditions,
Krieger's recordings showed an unusual amount of fast beta
EEG activity that indicated a state of deep concentration.
There was no reported evidence of a relaxed state in the

practitioner.

19

The study is limited in that the sample size was very
small (three clients and one practitioner). In addition,
one of the investigators was a subject and had a biased
interest in the outcome of the study. Different measures of
physiological response were used on the clients and on the
practitioner without explanation. Bullough and Bullough
(1993), in a critical review of TT research, state that this
study was found to be methodologically flawed by Clark and
Clark (1984) because different measures of response to
treatment were used on the clients and the practitioner.

No real conclusions may be drawn from the study, but it does
raise questions for further research. Such as: Is it the
meditative state that is intrinsic to TT which most affects
the practitioner? Does the energy transfer that occurs in
TT have any effect on the practitioner? If the client
demonstrates a relaxation response, will the practitioner
mirror that response? Is the practitioner's response to
administering TT independent of the client's response to TT?
This investigator looked at the practitioner's response to
administering TT independent of the client's response to TT.

All three of these studies have the limitation of a
small sample size in common. They all attempt to
empirically define the phenomenon of TT, but from different
vantage points. It would be more helpful to the research
base of TT to expand on these studies by duplicating
procedures with samples of sufficient size to have enough

power to test hypotheses.

20

Findings of controlled, clinical efficacy studies of TT
and relaxation response are mixed. Randolph (1980) tested
the physiological responses of female college students to a
stressful stimulus while being treated with TT and found no
significant differences between the treatment group and the
control group on each of the physiological variables.
Collins (1983) also reported no significant differences
between experimental and control groups on all physiological
measures of relaxation response. Fedoruk (1984) and Kramer
(1990) used physiological measures of relaxation response,
such as pulse, peripheral skin temperature, galvanic skin
response, and transcutaneous oxygen blood gas pressure to
evaluate relaxation response after TT in premature neonates
and children between two weeks and two years, respectively.
Both researchers reported significant differences on arousal
or time to calm children between control and experimental
groups reflective of relaxation response in the TT
experimental group as opposed to the control group. Heidt
(1991) and Samarel (1992) performed qualitative studies that
narratively described relaxation response in clients after a
TT intervention.

The finding of the research literature on TT and
relaxation response is mixed, at best. The question of
sufficient power to draw any conclusions statistically is a
problem in all the studies. Also, even though Fedoruk

(1984) reported significant differences between groups,

21

there were methodological inadequacies that could have
skewed the results.

The increase or decrease of anxiety closely parallels
the presence or absence of the relaxation response. Several
research studies have been conducted that look at the
clinical efficacy of TT in relationship to anxiety. Heidt
(1980, 1981) reported that TT significantly decreased
situationally induced anxiety in hospitalized patients.
Quinn (1982, 1984) also reported that TT significantly
decreased anxiety in a similar patient population. However,
Quinn (1989) was not able to duplicate this finding in a
replication study. Parks (1985) did not find a significant
decrease in anxiety in hospitalized patients treated by TT.
Three studies of the efficacy of TT as an analgesic are
reported (Keller & Bzdek, 1986; Meehan 1985, 1990). Keller
and Bzdek (1986) found that TT could be effective in
significantly reducing tension headache pain. Meehan (1990)
found that TT, given in conjunction with narcotic analgesic
medication, could reduce the need for further analgesic
medication in post-operative patients. Meehan's (1990)
study built upon an earlier, controlled study (Meehan, 1985)
with some modification. The findings were replicated.

These studies (Heidt, 1980, 1981; Quinn, 1982, 1984,
1989; Keller & Bzdek, 1986; Meehan, 1985, 1990) demonstrate
an increasing sophistication in research methodology.

Sample sizes are much larger, ranging from 60 to 159, and

researchers are meeting the parameters of a true

22

experimental design. However, it would increase the
reliability of the research findings if more studies were
double blind. Nonetheless, the studies in general lead
towards an opinion that TT decreased anxiety in hospitalized
patients and reduced the need for analgesic medication.

In summary, much of the research on relaxation
response, anxiety, and pain in relation to TT has been
either flawed methodologically and/or of small sample size.
Also, research effort has concentrated on hospitalized
clients or the client, not the practitioner. Those studies
that have been conducted on hospitalized patients have been
strong, and the majority have shown significant results.
Only three studies have been done on the effect of TT on the
practitioner and all three used small samples. It is
important to begin filling in the gaps in the research on TT
between effect on client and effect on practitioner. The
purpose of this study was to begin addressing this need by

examining the effect TT has on the practitioner.

Methods
This section presents the study design, sample,
operational definitions, instruments, data collection
procedures, data analysis, protection of human subjects,

assumptions and limitations.

23

Winn

This study was considered to be of an exploratory,
descriptive design. Since there are only three previous
studies on the effect of TT on the practitioner and only two
of those relate to TT and relaxation response in the
practitioner, the concept of relaxation response in the
practitioner of TT needs further exploration and

description.

Sample

There were 103 cover/consent letters (see Appendix A)
sent to all known registered nurses (RNs) who attended TT
workshops sponsored by a large midwestern university in the
past five years (1989-1993). The study targeted APNs, which
included RNs with advanced certification, but also included
RNs who were not APNs. In order to be included in the
study, participants needed to be RNs who were actively
practicing nursing, had been practicing TT for at least one
year, utilized TT at least six times a year, and obtained a
score of 97 or better on the Subjective Experience of
Therapeutic Touch Survey (SETTS) questionnaire. Forty-one
persons responded for a response rate of 40 percent. Of
those who responded, 18 persons (44%) did not wish to
participate. Of the remaining 23 respondents, 4 (10%) did
not qualify for the study because they were not RNs and 19
(46%) indicated consent and willingness to participate in

the study.

24

Study packets were therefore sent to the 19 respondents
who appeared to qualify. Eleven of the 19 respondents
returned completed study packets. Three of the eleven
respondents were dropped from the study because one had a
SETTS score below 97, one had practiced TT less than a year,
and it was unclear if one was a RN. Therefore, eight
subjects comprised the sample for the study. All subjects
were practicing registered nurses who utilized Krieger's
method of TT, were willing to complete the required
instruments, and were willing to perform TT twice using the
required measures. Four (50%) of the subjects were APNs and
four (50%) were RNs. The subjects had practiced TT at least
one year, a minimum of six times a year, and obtained a
score of 97 or better on the SETTS questionnaire. These
subjects were considered to be experienced practitioners of

TT for this study.

Iheraneuticjmch
The operationalization of TT was explained to the
practitioners as defined in Quinn and Strelkauskas (1993):
1. Quietly center yourself by shifting your awareness from
an external to an internal focus, become calm and make
the intent to assist the client therapeutically.
2. Assess the client's energy field from head to toe by
holding one's hands 4 to 6 inches from the skin's

surface and slowly moving the hands around and through

25

the entire energy field of the client while attuning to
the condition of the client by becoming aware of
sensory cues in your hands.

3. Redirect, with the hands, areas of accumulated
tension/energy in the client's body.

4. Focus attention on the specific flow of energy to the
client using the hands as focal points.

The ability of the practitioner to do TT was assessed using

an established instrument, SETTS, a tool that differentiates

experienced TT practitioners from inexperienced TT

practitioners.

Relaxatienjesnnnse

Relaxation response was operationalized using change in
peripheral body temperature as a measure of relaxation. The
mean temperature change of two TT interventions for each
subject was utilized to evaluate relaxation response. This
was done to strengthen the validity or reliability of the
findings. An increase in peripheral digital body
temperature by 4°F if the temperature started before 90°F or
an increase in peripheral digital body temperature of at
least 1—2°F if the starting temperature was at 90°F or above
was indicative of a relaxation response (Fischer-Williams et

al., 1986).

26

W

Three data sources were used in this study.

Demographig_data_sheet: The first was a demographic
data sheet developed by the investigator. The questions
elicited information about age, sex, ethnicity, level of
education, number of years practicing as a registered nurse,
certification, if an APN, major area of work, number of
years practicing TT, and frequency of TT practice.

W: The
second data source was SETTS, which served to categorize
practitioners of TT into experienced and inexperienced TT
practitioner groups. Krieger, the originator of TT,
(Winstead-Fry, 1983) developed this tool with the intent to
measure the extent to which an individual is performing TT.
Krieger, with an expert in meditation, formulated 70
statements that she believed described the TT experience for
the person performing TT. These statements became the items
in the SETTS tool (see Appendix B).

The number of items are coded into four categories:
Physical experiences (items 1-24), emotional experiences
(items 35-42), mental experiences (items 43-54), and altered
states of consciousness (items 55-68). There are two
practice items. One practice item describes a mental
experience and one item describes an emotional experience.

A five-point Likert scale is used to reflect the frequency
with which the experience described in the item occurs to

the respondent while engaged in the process of TT, varying

27

from not at all (0) to all the time (4). All items in the
tool are positively phrased except number 55. This item was
reversed for analysis. The term healee is used in SETTS to
refer to the client. For continuity in this study, the term
healee was changed to client. SETTS has a reported
Cronbach's alpha of .97 and the ability to distinguish
between experienced and inexperienced practitioners of TT
(Ferguson, 1986). The highest possible score on SETTS is
272. Ferguson (1986) describes a minimum score of 97 on
SETTS as indicative of an experienced TT practitioner. For
the purpose of this study, a score on SETTS of 97 or above
was indicative of an experienced TT practitioner as
confirmed by Meehan (1989). A score below 97 was
indicative of an inexperienced practitioner of TT.
Ihermemeeer: The thermometer was a small, portable,
electronic unit produced by Human Measurement Systems that
has a reliability of plus or minus 1°F (Human Measurement
Systems' specifications). The thermometer was specifically
designed to measure peripheral skin temperature. The unit
has a range of 0°F to 160°F, can be calibrated and updates
the temperature every one second. A small probe,-3-l/4
inches high by 1-3/4 inches wide was attached to the tip of
the finger with tape and a 20-inch cord extends from the
probe to the electronic measurement device which displays a
digital readout. The investigator calibrated the
thermometers for accuracy by comparing the thermometer

readings of all thermometers at the same ambient room

28

temperature. Ten readings per instrument at one-minute
intervals were recorded to determine variability among
instruments and establish the error of estimate at a 0.99
confidence interval. The standard error of estimate was
within a confidence interval of .44 to .86 at the 99%
confidence level before intervention. A repeat test, after
intervention, on six returned thermometers (two thermometers
were missing) was found to have a standard error of estimate
within a confidence interval of .05 to .45 at the 99%
confidence level . The mean variation of the thermometers
was therefore within the acceptable variation of plus or

minus one degree Fahrenheit.

W5

A cover/consent letter was sent to 103 potential
participants from a mailing list supplied by the College of
Nursing Outreach Office of a large midwestern university. A
stamped, return envelope into which the subject placed
her/his signed consent was enclosed. The letter indicated
two of the three criteria for experienced practitioners.
The SETTS criteria was not mentioned at this time.. Those
who felt that they met the criteria signed and returned the
consent form. The consent indicated interest in
participation in the study and included the name and address
of the potential subject (See Appendix A). Included in the
packet were the data instruments (demographic data sheet,

SETTS and an intervention data sheet), instructions for

29

completion, a biofeedback thermometer (See Appendix B) and
an addressed, stamped return envelope. Subjects were
instructed to complete all questionnaires and two TT
interventions with data collection and SETTS questionnaire
in a two—week time frame. Completed questionnaires, results
of the data collection, and the biofeedback thermometer were

mailed back to the investigator in the supplied envelope.

mm

Data were summarized in several ways. Initially, SETTS
scores were calculated to determine if subjects met the
criteria for inclusion in the study by obtaining a score of
97. The demographic data were then compiled, and
frequencies and percentages were calculated. The degree of
change in digital temperature before and after TT
intervention was calculated for two TT interventions and the
means determined. Means, ranges, and standard deviations
were calculated on room temperature, skin temperature before
TT intervention, skin temperature after TT intervention,
skin temperature change, and time taken for TT intervention.
The frequency and percent of subjects meeting criteria
(peripheral skin temperature increase of one degree
Fahrenheit if baseline 90°F or greater or peripheral skin
temperature increase of 4°F if baseline less than 90°F) and
those not meeting the criteria for relaxation response were
tabulated. Two groups were thus formed. One-way analysis

of variance between skin temperature change and time of TT

30

intervention was done. Chi-square was computed to determine

differences in proportion between the two groups.

E . E H 3 1.
The study was approved by the University Committee on
Research Involving Human Subjects (See Appendix C). The
explanation of the research project provided in the cover
letter informed each participant of the purpose, benefits,
risks, and right to participation as well as non—
participation without risk (see Appendix A). Confidentiality
of each subject was assured by placing a two-digit numerical
code on the tools, starting with 01, after they were
returned. The name of the subject did not appear anywhere

on the returned materials.

WW

1. Subjects were able to follow the detailed procedure and
answer the questionnaires supplied.

2. The thermometer was able to measure a 1°F change in
skin temperature.

3. The subjects were experiencing some level of stress

prior to doing TT.

I' 'l .
The study was limited in that it used a small
convenience sample of eight practitioners who self-selected.

This decreased the generalizability of the findings. Also,

31

chronic disease process, medications, nicotine product use,
alcohol use, present infection in the practitioner, callous
on fingertip, and meditative practices are variables for

which there were no controls in this study.

Results
The purpose of this section is to present the study
findings through: (1) description of the sample and (2)
description of the study findings.

The sample, as illustrated in Tables 1 and 2,
consisted of Caucasian females who had worked six or more
years as RNs with 75% of them working in an institutional or
agency setting. One participant was a family nurse
practitioner working in a collaborative practice and one
participant practiced in an ambulatory care pain management
clinic. Two participants were family clinical nurse
specialists, one working in collaborative practice and the
other working in a hospital. Three participants had
advanced certification: one family nurse practitioner
(FCNS), one certified transcultural nurse (PhD in Nursing),
and one certified geriatric nurse (BSN). Therefore, four
subjects were APNs, one in primary care and three practicing
in institutional settings, and four were RNs.

Mean SETTS scores for those meeting and not meeting
criteria for relaxation response were 167 (range 123 to 230)

and 153.5 (range 139 to 184), respectively. All subjects

32

obtained SETTS scores well above the score of 97.
Therefore, no one was marginally experienced in TT.

Each of the eight study participants completed two TT
interventions using the outlined procedure (See appendix A).
The skin temperature change of the participant before and
after the two TT interventions was calculated and averaged
to yield an average skin temperature change in the TT
practitioner. Four of the eight participants (50%) met the
relaxation response criteria demonstrating an increase in
peripheral skin temperature of at least 1°F if skin
temperature started at 90°F or of 4°F if skin temperature
started below 90°F (range 1.6 to 20.1) after the TT
intervention. The other four participants (50%) did not
meet the criteria for relaxation response demonstrating a
peripheral skin temperature change of -3.2 to +0.8. Room
temperature ranged from 68°F to 73.6°F (see Table 3 for
description of the sample). There was no significant
proportional difference in the number of participants who
met the relaxation response criteria and those who did not
meet the criteria (X2(1, N=8)=0, p>.05), with a mean of
69.8°F (n=16; SD=1.5). The time taken for the TT
intervention was a mean of 11.9 minutes (n=16; SD=6.2) with
a range between 5 and 26 minutes. One participant had a
very large average skin temperature change of +19.75 with an
average intervention time of 23 minutes (see Table 3).

There was no significant observed relationship between

the variables of SETTS and level of practice (APN or RN) to

33

Table 1. Summary of Demographic Data

 

 

 

 

 

Category Frequency Valid Percent
Age
30-39 years 2 28.6
40—49 years 3 42.9
50-59 years 2 28.6
Missing data 1 00.0
Total 8 100.0
Years working as a RN
6—15 years 2 25.0
16-25 years 4 50.0
25 or more years 2 25.0
Total 8 100.0
Work Area
Med/Surg or ICU 2 25.0
Parent/child/women health 2 25.0
Public health/education/hospice 2 25.0
Independent/collaborative practice 1 12.5
Other (pain clinic; write in) 1 12.5
Total 8 100.0
Education
Associate Degree 2 25.0
BSN 2 25.0
BS other than nursing 1 12.5
MSN 2 25.0
PhD in nursing 1 12.5
Total 8 100.0
Table 2. Summary of TT Experience
Category Frequency Valid Percent
Years Practiced TT
1-3 years 5 62.5
4-6 years 3 37.5
Total 8 100.0
How Often Utilize TT
6 times a year 1 12.5
Once a month 2 25.0
Once a week or more 5 62.5
Total 8 100.0

 

34

relaxation response (See Table 3). APNs did not have higher
SETTS scores than RNs or vice versa. Nor were high SETTS
scores predictive of a demonstrated relaxation response.
Review of the data in Table 3 suggested a relationship
between time and relaxation response. Among those who did
not meet relaxation response criteria (n=4), the mean time

for the TT intervention was 8.6 minutes (SD 1.2, range 5 to

12 minutes). For those who did meet relaxation response
criteria (n=4), the mean time for the TT intervention was
15.3 minutes (SD 2.5, range 5 to 26 minutes). A one-way

analysis of variance of relaxation response between the two
groups on mean time of TT intervention indicated a
significant time of TT intervention effect, (F(l, 8)=9,
p<.05). Therefore, those subjects who demonstrated a
relaxation response demonstrated a significantly longer TT
intervention time (See Table 4).

Time of TT intervention was therefore divided into two
groups: (1) TT intervention of 15 minutes or greater; and
(2) TT intervention less than 15 minutes. Study alpha was
set at .05. A Chi-square analysis of relaxation response
and time of TT intervention revealed significant
proportional differences between the groups with the
relaxation group having the larger intervention time,
(X2(1,N=8)=7.3, p<.05). Of the subjects whose mean TT
intervention time was 15 minutes or greater (n=4), all
demonstrated a relaxation response. Of those subjects whose

mean TT intervention time was less than 15 minutes (n=4), 73

35

Table 3. Summary of Intervention Data

 

 

 

ID# MRT MSTBTT SD MSTATT SD MSTC SD MT SD SETTS APN

or RN
01 72.5 91.2 7.1 97.5 0.5 +6.3 6.6 5.5 0.7 123 *APN
02 68.6 71.8 2.1 70.3 2.1 -1.5 0.1 8 0.0 149 RN
03 69.8 95.7 0.8 95.7 1.3 0.0 0.5 11 1.4 184 RN
05 71.0 73.6 5.2 93.3 5.7 +19.7 0.5 23 4.2 230 *RN
06 69.3 91.4 0.3 93.7 0.1 +2.3 0.2 17.5 4.9 175 *APN
07 68.5 92.0 0.1 92.8 0.2 +0.8 0.1 6.5 2.1 142 APN
10 70.2 82.4 15.1 80.2 13.6 -2.2 1.4 9 1.4 139 APN
11 69.0 93.5 1.4 96.7 1.5 +3.2 0.1 15 0.0 140 *RN
Note:

MRT=Mean room temperature

MSTBTT=Mean skin temperature before TT

SD=Standard deviation

MSTATT=Mean skin temperature after TT

MSTC=Mean skin temperature change

MT=Mean time of intervention (in minutes)

SETTS=Subjective Experience of TT Survey score

APN or RN=Advanced practice nurse or registered nurse.

* Demonstrated a relaxation response by definition of the study.

Table 4. One-way Analysis of Variance of Relaxation
Response to Mean Time of TT Intervention

 

Relaxation Response by Mean Time of TT Intervention

 

Source D.F. Sum of Mean F Ratio F Prob.
Squares Squares
Between Groups 1 1.2000 1.2000 9.000. .024
Within Groups 6 .8000 .1333

Total 7 2.0000

 

36

percent demonstrated no relaxation response and 27 percent
demonstrated a relaxation response. Therefore, it is highly
likely that relaxation response is related to time of TT

intervention.

Discussion

The current research was an effort to explore the
effect of TT on the APN, relative to relaxation response.

In this study, half of the subjects met the criteria for
relaxation response. This may be due to variables for which
there were no controls. One subject who did not show a
relaxation response reported that she had just had a baby
and that she had noted that her hands were cooler than
usual. Other variables might be chronic disease condition,
medications, nicotine use, alcohol use, present infection in
the practitioner, callous on fingertip to which probe was
attached, distractions during TT intervention, stress level
of the practitioner, and meditative practices. Also, the
ability to correctly use the thermometers provided by the
study and if the thermometer hindered the TT treatment or
distracted the practitioner were variables for which there
were no controls.

These results support an inconclusive trend that has
been illustrated in previous research (Quinn & Strelkauskas,
1993; Heidt, 1990; Krieger et al.; 1979) concerning TT and
its effect on the practitioner. Quinn & Strelkauskas'

(1993) study showed scores at or close to zero change in

37

state and trait anxiety scores for practitioners before and
after TT intervention. However, this study suggested a
positive influence of TT on practitioner immune system and
raised questions about time of TT intervention, its
relationship to an altered state of consciousness, and its
effect on the resonance of a healing pattern (relaxation
response) between the practitioner and client. Heidt's
(1990) study described a qualitative outcome for all the TT
practitioners of a continuous opening and/or deepening of
consciousness which, as defined by Kunz and Peper (1985),
creates a relaxation response. While the Krieger et al.
(1979) study reported no evidence of a relaxed state in the
practitioner, it appears that the effect of TT on the
practitioner is hard to quantify and lends itself better to
qualitative description. The quantifiable data related to
TT and the practitioner has been collected on sample sizes
too small from which to draw conclusions. It can only raise
questions for further research.

As with previous research, the sample size of this
study had insufficient power to make statistical inferences.
The intent of the researcher was to obtain 30 study
participants. However, only eleven persons completed the
data collection, and three of those persons did not meet the
criteria for the study. This may have been due to the fact
that data was collected over the winter holiday seasons
(November-December). Also, there may have been a

significant difference in those who did not participate in

38

the study. Their ability, confidence, and experience with
TT and time and place in which to perform TT may have caused
them to self-select not to participate in the study.
Subsequently, the study is limited to describing the data
without drawing any inferences or being able to show trends.
Four of the subjects were APNs and four were RNs. As stated
earlier, there was no significant proportional difference in
APNs or RNs who demonstrated relaxation response. The study
does act as a pilot, but leaves the research question
unanswered. Instead, it raises questions about the
relationship of time of TT intervention and relaxation
response. It also emphasizes the importance of method and
sample size. .

Because of the results and limitations, this study
neither supported or refuted Rogers' theory of Unitary Human
Being. In terms of this study, it is still open to question
if a healing energy resonates from the practitioner to the
client and back to the practitioner in a never-ending
repatterning and flow of energy as the practitioner includes
the client in her/his environment. Also, the question of
whether this resonation of healing energy can be
demonstrated by the defined relaxation response remains

unanswered.

I J' I'
It is important that APNs utilize some strategy to

assist in maintaining balance and energy in a busy practice

39

setting. If TT does elicit a relaxation response in the
practitioner, as suggested by this descriptive study, then
this unique nursing intervention has the potential to
decrease stress in a primary care practice and help the
practitioner remain more focused and efficient. However, if
time is the major variable for eliciting a relaxation
response in the practitioner (mean 15.3 minutes), TT may be
impractical to use spontaneously in a busy primary care
setting because of time, caseload, and financial
constraints. Therefore, it may be better to schedule an
appointment specifically for the purpose of a TT
intervention and code the visit relative to a reimbursable
procedure, such as pain management or hypertension
management. For example, the practitioner may set aside a
four hour time block once a week specifically for performing
TT along with other alternative nursing interventions.
Another option is for the APN to utilized the simple act of
centering, intrinsic to TT when coming into contact with all
clients; this intervention has the potential for relaxing
the APN and the client. This effect has been suggested by
Heidt (1990). It may be that one need not perform an entire
TT intervention in order to elicit a relaxation response if
the APN uses centering with each client contact. Further
research may want to pursue this possibility.

The APN can integrate TT into the larger plan of care
for the client and evaluate how TT can be utilized to

empower the client and the family. This may be through

40

individual treatments or teaching the client and/or family
how to perform TT. This type of empowerment has the
potential for a positive effect on all concerned--the
practitioner, client and family.

As the APN becomes confident in clinical skills and
expertise in TT increases, she/he may be able to integrate
TT with the physical assessment of the client. This would
eliminate the pressures of time, and perhaps both client and
APN may receive the benefits of TT. It would be important
for the APN to measure outcomes related to TT interventions,
such as increased sleep in an anxious client or a decrease
in pain as evidenced by improved ability to perform
activities of daily living in a client with cancer. These
outcomes could be both short and long term. Utilization of
the TT intervention would help substantiate the clinical
efficacy of TT and be an interesting area for further
research.

It is recommended that future research draw upon a
large sample which might be available from groups such as
the Nurse Healers Association and/or the American Holistic
Nurses' Association in an effort to obtain more power. With
a larger pool, the researcher may be able to add the
qualifying criteria that the subject be an APN in primary
care. This would allow a future study to focus more on the
effect of TT on APNs in primary care. Data collection could
be more controlled by collecting the data at one or more

nursing conferences and having subjects in similar

41

environments with impartial, trained data collectors. This
would eliminate some variables, but one would lose the
"clinical setting".

It may also be possible to concurrently measure other
indicators of relaxation response, such as pulse rate and
oxygen saturation, to strengthen evidence of relaxation
response in the practitioner during TT. At the same time,
variables could be controlled so as to strengthen
statistical findings. It would be interesting to assess
time of TT intervention in relation to relaxation response
in a larger population and evaluate if the 15—minute
intervention time remained significant.

Refinement and decreased cost of instrumentation would
be possible by utilizing the DermaTherm perfusion monitors
by Sharn, Inc. These monitors are accurate within one-half
of 1°F and are less cumbersome than the thermometers
utilized in this study. It would be important for one to
research existing technology to evaluate the most

appropriate instrument at the time.

Summary

The purpose of the study was to explore the existence
of a relaxation response in the practitioner of TT while
performing a TT intervention. It was felt that if TT
elicits a relaxation response in the practitioner, it may be
utilized as a stress reducing strategy for the APN. The

study results were critiqued in light of the conceptual

42

framework and current literature on the topic.
Recommendations for nursing practice and future research
were discussed bearing in mind the limitations of the study.
How the findings in this study may contribute to advanced
nursing practice and primary care were described. This
study is a beginning in identifying and defining the
potential of TT. Given the potential for relaxation that TT
offers the practitioner, it behooves further investigation

for the utilization of this advanced nursing intervention in

primary care.

."fl'

 

I

. . 5

___,,,7

APPENDICES

APPENDIX A

COVER LETTER AND CONSENT FORM TO STUDY PARTICIPANTS

43

APPENDIX A

COVER LETTER AND CONSENT FORM TO STUDY PARTICIPANTS

Dear Fellow Practitioner of Therapeutic Touch:

I am a master's student in the College of Nursing at Michigan State University working with
Dr. Gwen Wyatt. The purpose of my master's thesis is to investigate the effect of
Therapeutic Touch (TT) on the practitioner as a result of performing TT.

The sample for this study is made up of registered nurses who are actively practicing
nursing. The sample will consist of experienced practitioners of Krieger's method of TT
who have practiced TT for at least one year with a minimum of six treatments per year.
Completion of the SETTS and demographic questionnaires will take approximately 20
minutes.

In addition, you are also asked to perform TT using the steps described in the packet on a
client of your choice. You are asked to record the room temperature, take a digital skin
temperature on yourself with the thermometer provided just before the TT intervention and
just after the intervention, and record your readings on the data sheet provided. You are to
perform this procedure twice and return the completed research packet and electronic
thermometer within a two week time frame. The completion of your questionnaires
(demographic data sheet and SETTS) do not have to be done concurrent with the TT
interventions. It may be done at any time within the two week time frame.

Your participation in this project is completely voluntary. You may choose not to
participate, you may choose to participate in only certain procedures or answer only certain
questions and may discontinue the study at any time without penalty. Please sign and date
this letter below and return it in the provided envelope, if you are willing to give your
informed consent to participate in this study. Your name will not be used in any report of
this study, only group data will be reported.

Your participation will be most helpful in providing valuable information on the effect TT has
on the practitioner. All individual responses will remain confidential. I will send a final
abstract to any participant who wishes to receive one.

If you have any questions, please call me or write to the address below. I would appreciate
your returning the consent form as soon as possible, so that I can mail you the research
packet.

Thank you for your assistance in this study.

Sincerely, I,
consent to participate in the above study.

 

Mary M. Sies, RN, BSN

2820 Osseo Road

Hillsdale, Ml 49242 Signed
(517) 287-5835 Date

 

 

 

B
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I
D
N
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P
P
A

AN! W... k.
‘. IN 3.1

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44

APPENDIX B

SUBJECTIVE EXPERIENCE OF THERAPEUTIC TOUCH SURVEY (SETTS)

INSTRUCTION: For each of the itmes listed on the following pages, please
blacken, with a number 2 pencil, the appropriate oval on the computer
answer sheet. The responses reflect the frequency with which the
experience described in the item occurs to you while you are engaged in the
normal touching of patients occurring during care. The ovals are labeled A
through E. The meaning of each letter is:

A = not at all
B=once in a while
C = frequently

D = almost always
E = all the time

The following two items are practice items:

hen

PHPWPPNT‘E

11.
12.

Practice 1. I am aware of a part of my own being that is verbally or
intuitively supplying me with knowledge of the healee's illness.

Practice 2. I feel the totality of beingness and openness to the healee
and other people around me.

SURVEY ITEMS
I do TT:
My heart and respiration rates feel slower.
My breathing becomes slower and deeper.
I feel a sensation of heat and/or cold in my hands.
I feel tingling sensations in my hands.
I feel pressure in my hands.
I feel an electric shock sensation in my hands.
I feel energy pulsations in my hands.
I have the feeling that my hands are being spontaneously drawn to a
particular area in the client's field.
I feel heat coming from my hands.
I seem to be able to maintain an uncomfortable posture much longer
than usual.
I seem to stand or kneel straighter than usual.
My body movements become subtle, soft and flowing.

13.

14.
15.
16.
17.
18.

19.
20.
21.
22.
23.
24.
25.
26.

27.
28.
29.
30.
31.
32.
33.
34.
35.

36.

37.
38.

39.

40.
41.

42.

43.

44.

45

I become very sensitive to how I move my body and whether I am in
an awkward or stressful position.

My movements feel slow, steady, smooth and alert.

I feel energy moving through me and out of my hands.

Energy flows more freely in my body.

I get a sense of stillness and balance in my body, mind and emotions.
My body feels in harmony and seems to be an instrument through
which energy flows.

My body feels quiet, calm and relaxed.

I feel energy flowing rhythmically and evenly within my body.

I feel physically balanced, lined up or integrated.

| feel as though my whole body is working in unison.

I have a sense of physical and psychological attunement.

All my senses are heightened and sharpened.

I feel very close to the person I am healing.

I feel impersonal love for the client, regardless of whether I liked the
person before TT or not.

I feel loving and accepting toward myself and the client.

I am more aware of my own emotions.

My own emotions seem to be set aside during the healing process.

I feel a sense of calmness, peace and inner strength.

I feel detached and purposeful.

I feel an increase in sensitivity.

I feel an increase in empathy.

I feel an increase in compassion.

Emotions of love and peace feel like waves of energy going from me to
the client.

I am aware of the emotions of the client as different qualities of
energy.

I feel joy.

I trust that I have understanding at a level other than my conscious
expenence.

I have a sense of the therapeutic touch process being a totally
integrated flowing interaction.

I feel expansiveness.

| see spontaneous mental images that let me know what Is going on in
the client.

I am most aware of the client and less aware of activity going on in
the surrounding environment.

When I focus attention on my hands and my feelings, the external
environment seems to recede.

When I am focusing on the therapeutic touch process, my mind seems
to split into one part that is primarily attending to the healing process
and another part which simply remains in touch with events in the
environment.

45.

46.

47.
48.
49.

50.
51.
52.

53.
54.
55.
56.
57.
58.
59.

60.
61.
62.
63.
64.
65.
66.

67.
68.

46

My mental perception seems clearer during the therapeutic touch
process.

My thought processes seem to spring from intuitional insight rather
than rationality.

l have no thought during the therapeutic touch process.

My thought processes seem to slow down.

I have thoughts, but I don't attend to them unless they relate to the
client and the therapeutic touch process.

My thoughts stop and intuitions, images and impressions take over.
I recognize imbalances in the client's field.

I am aware of consciously directing my attention inward in order to
center myself as I start the therapeutic touch process. ; .
My sense of concentration increases. hi
I am more aware of my inner being.

I am not aware of time during the therapeutic touch process.
I feel as if time stops.

I feel as if time slows down.

I feel as if time speeds up. El
Whiles doing therapeutic touch, I feel that all personality patterns of

the client disappear and all I see is her/his inner beauty.

I feel unified with the client.

My body feels like an expanding mass of energy.

I feel as if my body is dissolving away and that I am becoming

boundless.

I experience my body as a continuous flow of energy rather than a set

of distinct parts.

My cognitive processes seem to step into the background and become

secondary to a more intuitive process of knowledge.

Parts of my body not actively involved in the therapeutic touch

process feel heavy or nonexistent. n
l have a feeling of being united with the external environment.
I have a sense of my own wholeness beyond my personality. .1
I am aware of a part of my being that is verbally or intuitively I
supplying me with knowledge of how best to direct energies to the
client's field.

 

47

DEMOGRAPHIC DATA SHEET

Please complete the following information. Circle the responses that

 

 

 

apply to you.
69. Age in years:
A. 20-29 B. 30-39 C. 40-49 D. 50-59 E. 60-69 F. 70 +
70. Sex
A. Female B. Male
71. How many years have you been a registered nurse?
A. Less than 1
B. 1-5
C. 6-15
D. 16-25
E. More than 25
72. Major area of work
A. Hospital or ambulatory setting: Med-surg/ICU
8. Hospital or ambulatory setting: Psych
C. Hospital or ambulatory setting: Parent/chiId/women's health
D. Public Health/Education/Hospice
E. Independent practice/collaborative practice
F. Other. Please describe.
73. Ethnicity
A. Asian
B. Afro-American
C. Caucasian
D. Hispanic
E. Native American
F. Other. Please write in here.
74. Educational level (circle all that apply to you)
A. Associate degree/diploma in nursing
B. Baccalaureate degree in nursing
C. Baccalaureate degree in other than nursing
D. Master's degree in nursing
E. Master's degree in other than nursing
F. Doctorate in nursing
G. Doctorate in other than nursing
75. Were you trained in the Krieger method of therapeutic touch?

A. Yes
8. No

76.

77.

78.

79.

48

About how many years have you been practicing therapeutic touch?
A. Less than 1

B. 1 - 3 years
C. 4 - 6 years
D. 7 - 9 years

E. More than 10 years

On the average, how often do you utilize therapeutic touch?
A. Not at all

8. 3 times a year

C. 6 times a year

D. About once a month

E. About 3 times a month

F. About once a week or more

Are you a clinical nurse specialist (CNS) or advanced practice nurse
(APN)?

A. Yes Please describe.

 

 

B. No

Are you a certified CNS or APN by American Nursing Association or
another organization?

A. Yes Please describe.

 

 

B. No

HP.“

49

Instructions for Performing Therapeutic Touch Intervention

Select a client of your choice.

Record thermometer code number on record sheet.

Measure the ambient room temperature just before the TT treatment by placing the
provided thermometer and probe on a non-metallic surface in the room. Do not
unwind the thermometer probe at this time. Make sure the switch on the left is in
the up position to record degrees Fahrenheit and that the switch on the right is in
the down position to record temperature. Record the digital reading after one
minute in the column headed "room temperature reading before TT".

Once you are ready to begin, unwind the thermometer probe and attach the probe
on the palmar side of the middle finger of your right hand with the probe taped to
the tip of your finger. See diagram 1. Make sure the unit is set on Fahrenheit and
temperature. Wait one minute and record the thermometer reading on the provided
record sheet in the column labeled ”skin temperature reading just before the TT
treatment".

praise out-Iachcd +0 Cmgtr

 

\ l to Id f‘fil l "\‘IIQrMQMQ‘IW

Diagram 1: Application of thermometer

 

Perform TT using the steps provide with the thermometer remaining attached to
your finger. You may take as long as necessary to complete the treatment. Please
record start time and finish time of TT treatment on the record sheet.

Please perform TT in the following way:

a. Quietly center yourself by shifting you awareness from the external to the
internal focus, become calm and make the intent to assist the client
therapeutically;

b. Assess the client's energy field from head to toe by holding one's hands 4
to 6 inches form the skin's surface-and slowly moving the hands around and
through the entire energy field of the client while attuning to the condition
of the client by becoming aware of sensory cues in your hands;

c. Redirect, with the hands, areas of accumulated tension/energy in the client's
field;
d. Focus attention on the specific flow of energy to the client using the hands

as focal points to balance the client's energy field.
Immediately after your TT treatment, record your peripheral skin temperature from
the thermometer attached to your right, middle finger in the column labeled "skin
temperature immediately after the TT treatment".

Within the two week data collection period, please repeat all steps of this procedure. You
do not need to use the same client nor the same physical environment, but you may if you
wish. The two interventions may be performed anytime within the two week time frame.

50

RECORD SHEET

Directions: Please record information asked for treatments one and two

(items 1-8).
Before TT Date Date
Ist TT Treatment 2nd TT Treatment
After TT
5. Skin temperature reading immediately

 

 

after the TT treatment

6. Finish time of TT treatment

 

 

 

 

Anytime

7. Environment in which TT done
A = Hospital
B = Home

 

 

C = Clinic/office

 

 

D = Other (please specify)

 

 

8. Same client for each TT intervention

 

 

Yes

No

 

APPENDIX C

UCRIHS APPROVAL LETTER

 

51

MICHIGAN STATE

 

UNIVE

RSITY

October 13, 1993

TO: Mary M. Sies
2820 Osseo Road
Hillsdale, Michigan 49242

RE: [RE I:

93455

TITLE: AN EXPLORATORY STUDY OF RELAXATION RESPONSE IN NURSES

WHO UTILIZE THERAPEUTIC TOUCH

REVISION REQUESTED: NIA
CATEGORY: 2-C
APPROVAL DATE: October 13. 1993

The University Committee on Resumh Involving Hum Subjects' (UCRIHS) review of this project
is complete. lam pleased to advise that the rights and welfare ofthe human subjects appear to be
adequatelyprotectedandmethodstoobhininformedconsentareappmpfiate. Therefore. the
UCRIHS approved this project including any revision listed above.

 

Renewal: UCRIHS approval is valid for one calendar year, beginning with the approval
date shown above. Investigators planning to continue a project beyond one year
must use the enclosed form to seek updated certification. There is a maximum of
four such expedited renewals possible. Investigators wishing to continue a project
beyond that time need to submit it again for complete review.

Revisions: UCRIHS must review any changes in procedures involving human subjects, prior
toinitiationofthechange. lfthis isdoneat thetime ofrenewal, please usethe
enclosed form. To revise an approved protocol at any other time during the year,
send your written request to the UCRIHS Chair, requesting revised approval and
referencing the project's [RB I and title. Include in your request a description of
the change and any revised instruments. consent forms or advertisements that are
applicable. the year, please outline the proposed revisions in a letter to the
Committee.

Problelttsl

Changes: Should either of the following arise during the course of the work. investigators

GRADUATE must notify UCRIHS promptly: (1) problem (unexpech side effects. complaints,
STUDIES etc) involving human subjects or (2) changes in the research environment or new
WWW.“ information indicating greater risk to the human subjects than existed when the
m IavaMa. protocol was previously reviewed and approved.
the sweets _
(ml lfwe can be of any future help. please do not hesitate to contact us at (517) 355-2180 or FAX (517)
Michigan Stale University 336-] 17 I ,
225 Administration Building
East W” Michigan Sincerely,

48824-1046

517/355-2180
FAX: 517/335-1171

CRIHS Chair

DEW:pjm

   

. it

David E. Wright, Ph.D.

cc: Dr. Gwen Wyatt

WU IS an WWII)".
MW MIMIM

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"Illilllllllllllllllllllllli