a study of practising nurses’ perceptions and experiences of intimacy within the nurse–patient...

ISSUES AND INNOVATIONS IN NURSING PRACTICE2

A study of practising nurses' perceptions and experiences of intimacy

within the nurse±patient relationship

Angela Williams BN PGCE MSc RGN

Lecturer, School of Health Science, University of Wales Swansea, Swansea, UK

Submitted for publication 7 November 2000

Accepted for publication 9 March 2001

Introduction

Contemporary perspectives in nursing re¯ect a ®rm belief that

the nurse±patient relationship is central to patient health,

well-being and recovery (McMahon & Pearson 1991,

McMahon & Pearson 1998). Such therapeutic effect is

suggested to be intrinsically related to the level of intimacy

between the nurse and patient (Kadner 1994). Therapeutic

intimacy is a phenomenon that has been studied across a

number of disciplines and its existence has been found to be

integral to positive health outcomes during illness (Cohen &

Wills 1985).

From the patient's perspective, the process of hospitaliza-

tion has long been identi®ed as an extremely stress provoking

experience (Franklin 1974, Wilson-Barnett 19795 ). In addi-

tion, the onset of disease, illness, dependency and the effects

of medical interventions and treatments, can have negative

consequences for the physical, psychological, social and

spiritual well-being of the individual (Barnett 1972). Thus,

it would appear that patients might need and bene®t from the

opportunity to develop an intimate relationship with the

nurse. Research offers some tentative support for this concept

by reporting that patients value the opportunity to share their

worries and concerns (Webb & Hope 1995) and recognize

188 Ó 2001 Blackwell Science Ltd

Correspondence:

Angela Williams,

School of Health Science,

University of Wales Swansea,

Singleton Park,

Swansea SA2 8PP,

UK.

E-mail: [email protected]

W IL L I A M SW I L L I A M S A . (2 0 01 )A . ( 20 01 ) Journal of Advanced Nursing 35(2), 188±196

A study of practising nurses' perceptions and experiences of intimacy within

the nurse±patient relationship

Aim. This study investigated the perceptions and experiences of intimacy within the

nurse±patient relationship.

Background.4 Intimacy is an increasingly recognized nursing concept, which is

intrinsically related to the therapeutic potential of nursing. However, the nature of

intimacy as practised in nursing remains largely unexplored. A qualitative design

was used and a purposive sample of 10 nurses was involved. Data were collected by

means of semistructured interviews and diaries.

Findings. Content analysis of the data yielded ®ve categories relating to the nature of

intimacy, involvement, resources, af®nity for the patient and the rejection of

intimacy. This paper focuses on the ®rst of these categories. Intimacy emerged as a

complex concept and included the subcategories of disclosure, levels of disclosure,

sharing personal experiences, patient dependency and vulnerability, instrumental

touch and intimacy and intimacy as an inappropriate term for the nurse±patient

relationship. These ®ndings are discussed in the light of existing theories and

recommendations made for further research to expand and develop the issues

highlighted.

Conclusions. The paper concludes by highlighting the complexity of the concept and

identi®es some of the constraints to intimacy in practice such as insuf®cient

resources, the health care system and role changes.

Keywords: intimacy, disclosure, patient vulnerability, touch, nurse±patient rela-

tionship, the new nursing

and value opportunities for closeness with the nurse (Ersser

1991, 1998).

The development of intimacy within the nurse±patient

relationship is therefore increasingly prescribed and valued,

at least on a theoretical level within the nursing literature

(Pearson 1988, McMahon & Pearson 1991, 1998). These

initiatives are enshrined within the `New Nursing' philosophy

(Salvage 1990).

However, despite evident theoretical enthusiasm and

endorsement of intimacy, there appears to be a lack of

conceptual clarity from a nursing perspective and little

published research investigating intimacy in practice. Both

of these areas are arguably critical to the successful imple-

mentation of the concept in practice. The latter issue is

particularly important in the light of the current political and

economic climate, which favours cost containment and cost

effectiveness. Also, chronic problems of inadequate staf®ng,

skill mix and excessive workloads are well publicised. Such

realities do not lend easily to the nature of relationships

advocated and serve to justify research investigation.

Research reported here aims to contribute to an under-

standing of intimacy through identifying and exploring

the concept from the perspective of practising nurses and

the factors that they perceive to in¯uence it. This paper is the

second of a two-part paper, the former of which presents a

literature review on the concept of intimacy in nursing

(Williams 2001).

Study aims

The overall purpose of this study is to explore practising

nurses' perceptions and experiences of intimacy within the

nurse±patient relationship. The study utilizes a qualitative

approach to investigate the following speci®c areas:

· What do practising nurses understand by the term intimacy

within the nurse±patient relationship?

· How do nurses describe relationships that involve inti-

macy?

· What factors in¯uence the level of intimacy in a positive

and negative way?

· What are nurses' personal feelings about intimacy within

the nurse±patient relationship?

Method

In recognition of the purpose of the study and the apparent

lack of published research on intimacy an exploratory,

descriptive design was chosen. Semi-structured interviews

(Morse & Field 1996) were used in this study as the primary

method of data collection. Interviews were based on ®ve

open-ended exploratory questions, which emerged from an

analysis of the current literature and related to meanings of

the term intimacy, examples of intimacy, factors that

promote and inhibit intimacy and personal feelings about

intimacy as a feature of the nurse±patient relationship.

Interviews allow for depth and richness of responses by

allowing respondents to expand upon and illustrate their

answers (Morse & Field 1996).

Diaries were used as a secondary supportive data collection

technique. Respondents were requested to record and

describe examples of intimacy and their related thoughts

and feelings over a period of one week. The decision to use

diaries was in¯uenced by the phenomenological nature of the

research question and the exploratory approach to the

subject. It was anticipated that the diaries would provide

access to everyday experiences of intimacy in practice and

would serve to support and validate the interview data.

Sample selection

The participants in this study were 10 registered, practising

nurses who were undertaking postregistration courses for

example, in palliative care and research and critical thinking,

within a nursing faculty of a large university. This therefore

constituted purposive sampling, as the researcher consciously

targeted speci®c respondents. The respondents were conveni-

ently placed within the college to allow the researcher easy

access. This proved to be important in relation to time

constraints and the anticipated dif®culty in accessing nurses

in a variety of clinical settings.

The researcher arranged to meet groups of students whilst

they were undertaking periods of study in college and

explained the purpose of the study and the process of data

collection planned. The students were requested to consider

participating in the study and to provide written consent

within 3 days.

The sample included four males and six females employed

in a variety of largely acute clinical settings. The amount of

post registration experience held by the participants varied

from a few years to at least 15 years. It was therefore

anticipated that all respondents would have suf®cient experi-

ences on which to draw.

Data collection

The interviews were tape recorded with the respondent's

consent and lasted between 30 to 45 minutes. The interviews

produced rich, descriptive insights into the nurses' percep-

tions and experiences of intimacy and were willingly and

enthusiastically related by the respondents.

Issues and innovations in nursing practice2 Nurses' perceptions and experiences of intimacy

Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 35(2), 188±196 189

Following completion of the interview each respondent

was given a diary and a set of guidelines requesting the

recording and description of incidents involving intimacy. All

respondents were given a large stamped addressed envelope

and were requested to send the diary to the researcher on

completion. Unfortunately, however, only ®ve diaries were

returned despite the researcher's attempts to remind respond-

ents. This provided a source of disappointment and frustra-

tion for the researcher, which could not have been

anticipated.

However, diaries received provided further descriptive

examples of intimacy, which have served to validate the

interview data. The diaries were generally well completed

although differences in the level of description were evident.

This may have been related to time and perhaps individual

commitment from the respondent.

Validity and reliability

Traditionally, qualitative research has been criticised for lack

of attention to the validity and reliability of the ®ndings

(Bryman 1992). However, ways of increasing rigour have

been recently emphasized (Lincoln & Guba 1985, Silverman

1993). Within this study reliability has been addressed

through the achievement of intercoder reliability and consis-

tency and the development of an `audit trail' (Morse & Field

1996). Validity of the ®ndings was achieved through a

nondirective interviewing style, which aimed at avoiding the

imposition of preconceived ideas and expectations on

the respondents' answers. Validation was also achieved by

the process of triangulation where, in this study two methods

of data collection were used (Bryman 1992, Silverman 1993).

Consistency was noted between perceptions of intimacy

expressed during the interviews and examples of intimacy

described within the diaries, which served to enhance the

validity of the ®ndings.

Ethical considerations

The participants in this study have been protected in several

ways. The researcher presented a detailed proposal to the

appropriate Departmental Ethics Committee within the

university, for review and approval. It was not anticipated

that participants would experience harm as a consequence of

involvement in the research.

Potential participants were given verbal and written infor-

mation regarding the nature of the study, the data collection

methods and procedure, and details of how the data were

to be used, and signed their consent. They were assured

both verbally and in written form that their decision to

participate or not and the information given would have

no detrimental effects on them as students in the university.

They were verbally informed of their right to participate in

the study and that they could withdraw their consent at

any time.

Assurances of con®dentiality were given to the partici-

pants, who were requested to provide only their name, a

contact number and an indication of the type of clinical

setting in which they worked. The tapes, transcripts and

completed diaries were carefully stored in the researcher's

study at home.

Data analysis

Content analysis was used to analyse the text from the

interview transcripts and the diaries. This process requires the

organization of data into broad topic areas or categories,

which are then, coded (Morse & Field 1996). Some

researchers also advocate the counting or quanti®cation of

responses (Silverman 1993). Concerns to quantify are based

on positivist approaches, which have been rejected by many

social scientists (Cicourel 1964, Silverman 1972). Given the

nature of this study a quantitative approach was not adopted.

However, the researcher did take some note of the frequency

of responses, in interpreting the data, as an indicator of the

dominance of certain perspectives.

The process of data analysis began with the researcher

listening carefully to each tape-recorded interview in order to

familiarize herself with the data. This was followed by the

process of transcribing, whereby the interview content was

transformed into written text. Transcripts were read several

times by the researcher, again to acquire familiarity with the

data and the views expressed. The researcher became

increasingly aware of persistent themes and recurrent issues

raised within the interviews and was able to identify some

broad categorizations. The researcher then coded relevant

pieces of text indicating the appropriate category. Coding

was undertaken in a systematic way with major categories

dealt with individually until saturation was achieved. Less

signi®cant issues were also highlighted and utilized to

communicate the concept and the variety of related experi-

ences. The diary material was similarly subjected to content

analysis and was coded within the previously identi®ed

categories.

Findings

Analysis of the data yielded three major categories and two

minor categories. The major categories included the nature

of intimacy, involvement and resources, and the minor

A. Williams

190 Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 35(2), 188±196

categories related to an af®nity for the patient and the

rejection of intimacy. For the purposes of this paper the

®ndings relating to the nature of intimacy will be presented

and discussed.

The nature of intimacy

The nature of intimacy emerged as a complex concept with a

variety of interpretations and dimensions. Sub-categories

related to:

· disclosure;

· levels of disclosure;

· sharing personal experiences;

· patient dependency and vulnerability; and

· instrumental touch and intimacy. A minor, though inter-

esting subcategory related to the perceived inappropriateness

of the term intimacy in the nurse±patient relationship.

Disclosure

Analysis of the data revealed that a signi®cant perception of

intimacy related to the disclosure of personal information

between the nurse and patient. It involved the development

of a rapport, through which personal and sometimes

private information was shared. Both the nurse and patient

made disclosures. Descriptions of this aspect of intimacy

included:

Nurse C: I perceive it to be the sharing of information between

the health visitor and the client. The sort of information that

they share with me that they would not share with anybody

else.

Nurse J: You deal with patients who undergo investigations and tests

and they are bound to be worried¼perhaps they won't have said

anything to anybody else on how they are feeling¼but they will

con®de in the nurse.

Nurse H: It's just like perhaps if you're maybe just talking and the

patient discloses something to you.

The emphasis on self-disclosure is re¯ected in much of the

intimacy literature and is considered to be a key element

(Timmerman 1991, Kadner 1994, Reis 1995, Savage 1995).

Intimate relationships that involve self-disclosure have been

indicated as signi®cant during traumatic life events and

illness (Medalie & Goldbourt 1976, Brown 1986) and have

served to focus attention on the nurse±patient relationship

(Kadner 1994).

The self-disclosure was reported to occur also between the

nurse and the patient's relatives, sometimes associated with

experiences of death and dying and with its acceptance.

Nurse F: She just outpoured all her worries and concerns about her

young, immediate family, the fact that her dad had always been

independent and in control and it was dif®cult for her to imagine that

he was going to leave her.

Nurse I: Being available for patients and their relatives usually in

times of great sadness, when people are dying or being told bad

news you avail yourself to them to talk and share their fears and

concerns.

This proved to be a signi®cant ®nding which appears to

receive little attention in the intimacy literature, and high-

lights that the provision of nursing often extends beyond the

patient or client, and encompasses the care of emotionally

distraught and anxious relatives.

The reciprocal disclosures evident here appear to contrast

with some perceptions of intimacy as unilateral, that is from

patient to nurse (Timmerman 1991, Kadner 1994), although

Meutzel (1988)6 , did refer to intimacy as a `joint unmasking'

(p. 111). However, a crucial issue may be the actual nature of

information disclosed. Although both nurses and patients in

this study made some disclosures, the nature of information

shared differed, as discussed below.

Levels of disclosure

There appeared to be different levels of disclosure, extending

from the exchange of super®cial information to the sharing of

deeply held private secrets. On one level there appeared to be

evidence of a developing relationship, a developing famili-

arity between the nurse and patient. There was an exchange

of rather super®cial information on general issues such as the

family, the weather, perhaps wider topical issues and the

patient seeking information about the nurse as a person.

Nurse I: They may want to talk about you as a person¼what is going

on in you're life, are you married, what is your husband doing¼and

to a certain degree they want to discuss their lives¼they are trying to

make that bond.

Nurse G: I class intimacy as developing a bond between yourself and

the patients¼talking about the family, do they have any children and

just about the weather, just talking about anything really.

The perception that this conversational exchange of rather

super®cial information was seen as intimacy proved to be

an interesting ®nding. May (1991, p. 555) identi®ed this

phenomenon as `primary involvement'. Interaction was

characterized by reciprocity and the mutual exchange of

information between the nurse and patient.

Whilst this may represent a beginning level of intimacy,

there were indications that such interaction could lead to



patient disclosures on a deeper, more personal level. The

implication here was that intimacy is of a developmental

nature which involves an assessment of the nurse and the

development of trust, prior to deeper disclosure. The patient

appears to be assessing the nurse as a person and determining

whether to trust him or her.

Nurse I: I think they look at nurses and I think they make up their

mind, oh yes I can trust her, no I can't trust her.

Morse (1991) highlighted the importance of trust in the nurse

as a precursor to the development of the nurse±patient

relationship. Her ®ndings suggest that vulnerable and depend-

ent patients in particular assess the nurse as a person and as a

nurse before deciding to trust and relax in the nurse's care.

There appear to be strong similarities between this assess-

ment process and the experiences of nurses in this research

study. As in Morse's study this research revealed that the

patient, through super®cial conversation, strategically invites

the nurse to self disclose and, on the basis of responses to

questioning, determines whether the nurse is a `good person'

and a `good nurse' (Morse 1991, p. 460). Actual questions

posed by patients also revealed strong resemblance between

the two studies. Such questions aim to investigate both the

social and professional dimensions of the nurse's character.

Nurse D: She asked me if I had children and just started talking

about¼how many hours do you work, how long have you worked

here, how long have you been nursing.

There were indications that the process of getting to know the

nurse was perceived by nurses to facilitate trust and deeper

disclosure.

Nurse I: They know what type of person you are, when they get to

know you they can trust you, you are someone they have got a

rapport with.

Nurse D: Perhaps because I was forward with answering a lot of her

questions in that way, she felt she could go on a bit further and ask

me more and sort of involve her life, the things that have happened in

her life.

The developmental nature of intimacy is supported by earlier

research ®ndings and wider literature which suggests that self

disclosure progresses from super®cial to intimate subjects,

with individuals' deepening familiarity (Jourard 1971,

Altman & Taylor 1973). This highlights the need for trust

and familiarity as prerequisites to disclosure and has impli-

cations for time and resources.

Much of the disclosure appeared to occur on a more

personal level, where there was a sharing of anxieties, fears

and concerns. The disclosure focused completely on the

patient/client and the discussion of their illness and the

implications of this for their dependants and their future.

Nurse G: Patient's concerns with regard to their health, any prob-

lems that they have outside, things that they are worrying about

at home, their husband, their pet, their house, whatever they wish

to con®de in you.

Nurse F: Understanding of the condition, prognosis, treatment, going

home how they are going to manage, how other family commitments

are affected.

This pragmatic interpretation of intimacy is referred to in the

nursing literature (Kadner 1994). A less signi®cant, though

interesting level of disclosure related to deeply personal

information. Information shared was highly intimate and

would not be shared with others. A suitable person would be

carefully chosen with whom to share, what appeared to be

deeply held secrets often relating to the patients' private life.

Nurse C: Some of the information that is being given is quite mind

blowing and I know that they haven't shared that information with

anyone else¼the clients have had this knowledge, this secret almost

for some time, but never come across the right person to share it with.

Nurse A: When you are talking to people about problems¼it's

almost like a confessional, like a priest parishioner sort of scenario,

where people are talking to you about all sorts of things from sex to

how they feel about people.

The focus on the exchange of such apparently highly intimate

information is not explicitly acknowledged in the nursing

literature as a dimension of intimacy. Although, Kadner

(1994), suggests intimacy involves the `exchange of shared

meaningful information' (p. 218), there are no speci®c

indications that the nature of this information can vary. This

may be a consequence of the relative infancy of intimacy as a

nursing concept and the apparent lack of research attention

aimed at specifying and clarifying its nature.

The above levels of intimacy re¯ect an interpretation of

intimacy as a psychological and emotional closeness,

achieved through verbal interaction and disclosure between

the nurse and patient.

Sharing personal experiences

Another important aspect of intimacy related to sharing and

involvement in signi®cant life events and experiences of the

patient. This was made explicit in the examples and descrip-

tions of intimacy. There was evidence of a physical dimen-

sion, of being physically present and of actual bodily contact,

and an emotional closeness. Some incidents related to

experiences of death and dying.

A. Williams


Nurse A: I could hear and sense that he wasn't breathing anymore

and I looked down and he was dead¼and she looked at me and I

looked at her and I could see her eyes sort of ®ll up, this to me is like

intimacy.

Nurse G: He wanted to hold my hand but I felt as if I was there with

him emotionally, I was there with him as he died and it was my hand

he held.

There appeared to be evidence of empathy, caring and

compassion for the patient and emotional involvement from

the nurse. The use of touch and physical presence may signify

the expression of emotional closeness.

Nurse F: Just to place a hand on the arm which I hope tells more, that

I understand, that I appreciate your situation, I'm here for you.

Nurse G: I kept reassuring him that he would be okay. I held his hand

and used a cold wipe to wipe his face¼I felt that I wanted to help this

gentleman.

These perceptions and accounts of intimacy suggest a

concurrent physical and emotional presence by the nurse

when the patient is facing death, dying and suffering.

Savage (1995), similarly found closeness frequently

described by nurses as a con¯ation of physical and nonphys-

ical elements. She felt that this re¯ected the nature of nursing,

which is often experienced holistically.

There were indications also that the nurses involved in

these incidents felt themselves to be in a privileged position to

be sharing in such crucial events.

Nurse G: I don't think you can get more intimate than that really

with a patient to have the privilege of holding somebody's hand when

they are dying.

This highlights the issue of reciprocity and provides some

tentative indications of the rewards and satisfaction associ-

ated with close involvement.

The links between intimacy and experiences of death and

dying are interesting. The physical presence of another during

death and dying has been emphasized and is considered to be

a therapeutic feature of nursing (Dyck & Benner 1989). This

is an interesting area, which could be further investigated.

Patient dependency and vulnerability

The importance of physical presence emerged as a minor

perception of intimacy, which was associated with the

experience of caring for vulnerable, dependent patients. The

nurse appeared sensitive and responsive to the patient's

situation and recognized the sense of security and reassurance

offered by the nurse's presence.

Nurse G: It was as if she was dependent on me, if I was there, it

seemed that she was happy, if I was there she felt safe. She wanted my

hand all the time, it was as if she saw me as the person who was

helping her.

Nurse J: It is quite intimate with the patient that is under a general

anaesthetic, you are there and that patient is totally vulnerable,

relying on you and your care for that patient.

The value of presence has been compared to attachment

behaviour (Bowlby 1984) which focuses on desired proximity

to another. It is suggested that this phenomenon is important

for individuals experiencing danger, trauma and crisis and

can reduce anxiety and promote security. This appears to

have particular relevance here and may have been more

dominant if the patient's perspective had been sought. Ersser

(1991, 1998), who explored nurses `and patients' views on

the bene®cial effects of nursing care provided support for

this. The presence of the nurse emerged as a key theme which,

incorporated activities such as giving time to patients, being

with the patient and demonstrating an appreciation of the

patient's experience.

Instrumental touch and intimacy

Touch has emerged as a possible dimension of intimacy and

was related to carrying out tasks involving body care.

Nurse I: You can be intimate in a physical manner regarding washing

somebody's hair, giving somebody's hair a comb, making their hair

look nice.

Nurse A: You can be intimate about your needs¼a physical sort of

touch care wise, like washing somebody, bathing somebody, so

you've got that caring aspect of intimacy.

There is evidence here of instrumental (Tutton 1991), or task

related touch, which by necessity involves an `invasion of the

patient's personal private space' (Routasalo & Isola 1996,

p. 165) and entry into the intimate zone (Hall 1966). Given

the frequency of this touch and assertions of cultural

inhibitions about touch (Autton 1989), it is interesting that

this was not considered a more dominant aspect of intimacy.

Intimacy was also linked by some nurses to the touching

and handling of private parts of the body, which was

perceived to be dif®cult and embarrassing. This is evident in

the examples below.

Nurse C: Assisting a male patient to urinate¼caused embarrassment

for the nurse and patient.

Nurse E: Washing someone following incontinence.



Intimate touch is a recognized function of nursing work and

is acknowledged to create dif®culties for nursing practice, in

which the body is fundamental (Lawler 1991, Ching 1993).

This requires negotiation and careful management of poten-

tially embarrassing and dif®cult situations (Lawler 1991).

Although identi®ed by a number of the respondents, this

perception of intimacy was not as dominant as anticipated

which again, given its signi®cance in nursing practice, appears

interesting. This may re¯ect the nurses' acceptance and

familiarity with this aspect of their role. This is re¯ected below.

Nurse D: You do it all the time, it might be a new thing for the

patient, having to be washed and changed¼for the nurse it happens

20 times a shift¼so you become very, oh gosh, I've seen all this

before.

However, the patient may perceive touch differently and

may perhaps be more inclined to consider such an experience

as intimate. Research is necessary to explore the patient's

perception of such aspects of care giving involving touch.

A minor though interesting issue was raised regarding the

relationship between physical intimacy and psychological,

emotional disclosure.

Nurse H: I ®nd you get a lot out of patients in the bathroom, very

often they talk possibly because they don't think they'll be disturbed.

Here, it appears that undertaking intimate physical care

provides an opportunity and the privacy conducive to

personal disclosures. The concept of combined physical and

psychological closeness has been discussed (Wharton &

Pearson 1988, Savage 1995).

Intimacy ± an inappropriate term

for the nurse±patient relationship

It became apparent that a few respondents felt intimacy to be

an inappropriate term to apply to nurse±patient relations. It

was felt to be more applicable to personal, private relation-

ships with partners and family members. Intimate relation-

ships were characterized by closeness and emotional

involvement which, some respondents felt were not evident

in the nurse±patient relationship.

Nurse F: Intimacy outside of the nurse±patient relationship always

came across as a close relationship that one would share with a wife,

or thing of a sexual nature or with your family, where you share great

emotional joys and sadness, which you wouldn't tend to do with

other people and that includes within nursing.

Nurse B: I look at intimacy as being something disassociated from the

nursing profession. I've never associated intimacy as being to do with

work¼I associate it with personal¼private relationships.

The perception of intimacy as an inappropriate adjective for

nurse±patient relations was an interesting and surprising

®nding. However, intimacy is a term used in everyday

language with a wide range of interpretations. For example,

intimacy is a euphemism for sex (Barnhart 1969), which

would understandably lead one to consider intimacy to

be an inappropriate term to apply to the nurse±patient

relationship.

Intimacy was also perceived to be associated with closeness

and emotional involvement within personal relationships.

However, these characteristics were considered inappropriate

within a professional relationship. This is another interesting

issue, which re¯ects a perceived need to maintain an

emotional distance between the nurse and patient. Historic-

ally, there appears to be a ®rm basis to this perspective within

nursing (Menzies 1960), which may account for its emer-

gence among a small number of respondents. This ®nding

also draws attention to perhaps valid concerns for the

protection of the emotional self and the signi®cance of the

socialization process in nursing, which may present barriers

to new ideas proposing a more personally involved recon®g-

uration in the nurse±patient relationship.

Discussion

One of the limitations of this research is that it focused only

on nurses' perception and experiences of intimacy. Further

research needs to explore patients' understandings of inti-

macy in being nursed. This may prove useful to compare with

the professional perspective, particularly perhaps in relation

to physical intimacy.

Other recommendations for further research are:

· Similar research is necessary to further explore the

concept of intimacy. This could include a greater number

of nurses and the possible inclusion of student nurses.

Observation could be introduced as an additional method of

data collection. This may enhance understanding of exam-

ples and incidences of intimacy and could also serve to

capture the physical dimensions and expressions of the

concept.

· Nurses' perceptions and experiences of intimacy during

death and dying could prove to be an interesting area for

further study. Although, the importance of physical presence

during death may be recognized, the need for emotional

presence could be explored.

· Finally, research is necessary to address whether patients

need and value the potential for intimacy with nurses. This is

essential if nursing is to provide effective, valued, patient

centred care and crucial to the quest to gain recognition of its

therapeutic potential.

A. Williams


Conclusion

This study has identi®ed and explored the complex concept

of intimacy. A number of signi®cant and interesting perspect-

ives have emerged which re¯ect psychological, emotional and

physical dimensions of the concept. These have been analysed

and discussed and serve to re¯ect the complex nature of

nursing work and the varied opportunities which arise for

closeness between the nurse and patient.

The achievement of intimacy in nursing practice is subject

to a number of constraints and dif®culties. Nursing exists

within a medically orientated health care system that focuses

on the goals of diagnosis, treatment and cure of largely

physical problems as quickly and ef®ciently as possible.

However, this system clearly does not sit well with nursing's

goals to provide holistic, individualized, patient-centred care

within a deep and meaningful nurse±patient relationship.

In addition, the political and economic climate which

favours cost containment and cost effectiveness present

constraints to intimacy through insuf®cient resources to

sustain the close relationships advocated. Support for this

was provided by the ®ndings of this and previous studies

(May 1991, Savage 1995).

Also, constraints to intimacy may relate to role changes

and the attraction of role extension, which involves the

completion of what have been traditionally considered

medical tasks. The attraction may be related to the higher

status accorded to technical skill acquisition and the visible,

cure orientated aspects of health care. However, the conse-

quence of relinquishing fundamental aspects of care may be

that opportunities for intimacy will lost and perhaps more

signi®cantly, patient needs which extend beyond those of a

physical nature may be overlooked by carers who are trained

in the ef®cient completion of tasks. These are issues that

could be the focus of further research.

The study offers some tentative support for the proposed

therapeutic potential of nursing although further research is

essential if this is to be recognized and valued.

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A. Williams


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