Interaction with the patient is part of nursing care: to see, to hear, to touch and to feel by means of an empathy process. Clinical practice unavoidably involves moving in the field of personal relationships, in other words, moving in such situations where the emphatic ability of the clinical staff comes into play. Our body expresses itself by means of sensations, and these are expressed by means of words. Therefore, hearing is very important for health care.1
Patient intimacy and nursing care give rise to a patient-professional interaction. Patients are forced to reveal intimate sensations, thus leading to highly emotional situations. Are the limits of this intimacy really known? Does the nurse establish a therapeutic relationship that leads to care?2
When patients feel physically and emotionally vulnerable, they rely on the nurses.3 This is why nursing care demands for intimacy and privacy conditions that must be guaranteed by the nursing staff.
Intimacy is a concept involving emotional and physical proximity, in other words, a connection that binds us to people sharing their intimacy with us. It is not a freely used term in nursing care; however it is a concept related to care.4,5
Intimacy is of one's one and exclusive, a personal space that should not be invaded by anyone and that everybody offers to freely share with whomever and whenever he/she wills. Like Torralba says: "The patient as an autonomous being has the faculty to decide how he/she wants to manage his/her own intimacy".6
This study aims to analyze the concept of intimacy based on the feelings, to know the nurses' opinion on this theme and to describe which role senses play in the field of intimacy.
Theme's nature is clearly subjective, demanding us a qualitative approximation that allows us to analyze it in a deeper and more comprehensible way. Like Ray says: "because we are human beings, it is possible to understand how a human being is".7
The phenomenological method was chosen among all the qualitative ones because it tries to understand the nature of being and the essence of life experiences.
This investigation is enclosed within the humanistic paradigm (Anna Ramió and Carmen Domínguez call it the nursing paradigm)8 characterized by health assistance, professional compromise, autonomy, justice and respect.
The work and perspective of Watson serve as a concrete reference.9 In this paradigm, initiative and judgment of each nurse professional confer a broad power to create and evolve towards a care management within the strictest humanistic and comprehensive concept, considering a person physically, psychically and spiritually.
This theoretical perspective allows us to analyze participants' experiences related with the study subject. It is looked at how experiences, emotions and situations of the participants are felt, learned, understood or experienced.10
Participants and methods
Some bibliographic research was done with the purpose of knowing existing literature about the theme, thus helping to define the question of our investigation.
Because the concept of intimacy is broad and ambiguous, we let the nursing staff define it according to their experience in the ICU.
The objectives of the study were: analyze the concept of intimacy from the feelings perspective, know and define the role of senses as an important dimension of perceived intimacy and improve clinical assistance by means of ethical practices.
This study was done in the University Hospital Son Dureta (HUSD) in Palma de Mallorca. Study population was nursing professionals (nursing assistants and registered nurses). Seniority of the participants oscillated between 6 months and 32 years, thus covering a broad spectrum of professional experience. We did 10 semi-structured interviews reaching the saturation of data because no further information was obtained.
Inclusion criteria were to search the maximum variability in sex, professional status and years of work experience. Participants had to be full age and had been working at the ICU for at least 6 months.
For this investigation we used the in-depth interview because it allows the interviewee to freely express its experiences and which dimension intimacy has for him.
Interviews were tape-recorded, transcribed and later analyzed by the research group. All were conducted by the same group member. Their duration oscillated between 30 and 60 minutes.
It was asked for voluntary participation, verbal and written consent and permission of the hospital ethics committee. Confidentiality of data was guaranteed during the whole process (collection, analysis and divulgement of results). Original recordings were destroyed once the study was finished.
A content analysis was done and meaning units were established by means of data coding. Each interview was independently codified by all researchers, doing later a brainstorming of coded data. If data were not coincident, each researcher exposed his own reflection process and an agreement was reached through dialogue. One only code list was done. These codes were later grouped into categories according to meaning similarity. Three main categories were defined: intimacy as a concept defined by participants; senses, the influence they have on intimacy perception and also the feelings they can lead to; and empathy as a part of communication nurse-patient and as a therapeutic relationship.
This investigation is limited because data is contextualized to the ICU of the HUSD Palma de Mallorca. Although it was tried to have highly heterogeneous sample, the transfer of this data to other contexts must be done carefully. Despite studies based on a qualitative perspective contribute to knowledge of great social value, they must not be generalized.
The rigor of analysis was guaranteed: tape recording of the interviews, their later transcription and the audition of all research group members were done by the same person, establishing in each of the steps of analysis the consensus among all researchers and contrasting the obtained results with bibliographic sources.
Three categories were drawn from the analysis of the interviews and they are related to different aspects of intimacy: definition and perception of intimacy, senses vs. intimacy and empathy.
Definition and perception of intimacy
Intimacy is an ambiguous concept that is difficult to define and to contextualize. Nursing professionals define intimacy as having an own space to protect the own principles, the right of showing what one wants, being able to mix with other people and protecting the body from foreign invasion. When interviewees were asked to define intimacy, most of them doubted, hesitated or reflected about the meaning and asked.
"Intimacy... it is an space where your principles are protected and no other person has to get in there."
When they were asked about their own intimacy during the working day, they do not consider having intimacy in the workplace and say:
"At work I don't think about my own intimacy, I go working and I share my time with other people, other groups and I don't think, isn't it?"
Otherwise some others thought to have intimacy:
"To tell you the truth, I have never thought if we have intimacy. That intimacy, I think I have it as a professional, but I don't know how to explain it."
The interviewees perceive professional and personal intimacy in a different manner. Personal intimacy is that one outside the workplace and it is perceived from the feelings perspective. Professional intimacy is understood as that one developed with the patient, in other words, the process by which we get nearer to a person for dealing with health problems. This perception of intimacy from the professional point of view causes feelings of vulnerability, shame and discomfort linked to body exposure. Nakedness of the patients leaves them in inferiority. Nevertheless, some professionals can feel uncomfortable due to this situation, because patient's shame is projected on nursing staff.
"Well, you are there and the patient is stark naked or lies there just covered with a sheet the whole day. This means that all are a bit embarrassed, sometimes even you are."
It is telling to note that all participants perceive a lack of respect towards patient's intimacy. When they were asked "Do you think that nursing staff respects intimacy?", they answered:
"No, it is not respected, we forget, often we don't even realize. For example, you go into the ICU talking about patients' things without thinking that the others can hear you."
Senses have emerged as an important dimension; they allow us to interact with the environment. To sense is the faculty of receiving stimuli from the outside and the inside by means of sense organs. Senses the interviewees linked to intimacy were: vision, hearing and touch. Nurse professionals manage intimacy, express sensations and experiences related to their professional activity through theses senses.
Vision is understood as the faculty of seeing, perceiving, observing and examining, being therefore witnesses of an action or an event. Nevertheless, this faculty can sometimes act as an invader of intimacy. When asked for defining intimacy some interviewees said:
"For me intimacy means not to be seen, I suppose that, like me, most people don't like it to be seen naked."
Others explain their experiences with the patients:
"The glance disturbs them most. You see them trying to cover themselves with their hands, above all when they are being washed, they cover themselves with the piece of sheet with give them and as much as they can."
We could also observe that the glance can be used as an auto protective method against the own shame of the professionals.
"At the beginning, when I started working, and if I got nervous I told to myself: don't look, don't look, but I couldn't avoid it."
We should not forget the importance of the non verbal language, most of the ICU patients have difficulties to speak, but with the eyes they can communicate and detect situations that can assault their intimacy:
"Above all I would want to be treated with respect, and respect includes the gestures we make with our hands and our face. We often are not aware of that and are doing non verbal communication, isn't it? In fact, with such gestures we express all."
Participants described the figure of the potential observer, in other words, a fortuitous spectator in the hospital that invades other ones' intimacy. There are several potential observers: the hospital staff, the own patients and the family.
The staff is 24 hours beside the patient, but in a hostile environment like a hospital it can be considered an invader of intimacy:
"There are moments the ICU is plenty full of people, because we're so many professionals, more than in other departments. Obviously, it is a university hospital and there have to be as much persons as they are, but this leads to a decreased intimacy, or to an absolute lack of it."
Patients inspect the environment that surrounds them and they realize their situation, the activities that are done in the ICU and the situation of other patients. This is how the nursing staff notices it:
"If patients are conscious they see it all and you don't think about putting a screen, so they see what is happening in the ICU and the other naked patient. They see each other."
Families also act as potential observers during the visit. They care more about the environment, the machines, than about the patient. They observe other patients' characteristics, similarities and differences to the hospitalized familiar. They search for answers in the professionals present in the ICU. Sometimes these glances result uncomfortable or defiant for other patients as well as for some professionals. They say:
"When familiars come into the ICU, they care more about the patient in the bed beside than about the own familiar. They look at the machines and the cables, and it seems they are trying to compare who is worst."
Hearing is the sense by which sounds are perceived. Hearing is more than listening; it is one of the most frequently used senses in the process of communication. In the ICU, there are few moments of calm. Monitoring of the patients is done by means of audible signals, so that there is always an acoustic contamination. Professionals think that don't letting the patient enough rest is a way of intimacy invasion. Neither the loudness nor the intonation is controlled, the night sleep is not respected and there are whispers that can assault their intimacy.
"You often don't realize it and get into a routine. For example, you enter speaking into the ICU or you talk about anything or talk too loud and you often don't think if the patient is sleeping or so. I don't know, I think we could be more careful."
Confidentiality is another aspect of intimacy, that one referring to information. Hospitalized persons have the right that everything about their progress or treatment will be safeguarded and not revealed without their permission. Some professionals plead for not transmitting confidences to someone else, thus avoiding gossips and preserving the patient's intimacy.
"When they are conscious and they tell you something, we neither have to comment anything they told us nor anything about their health conditions while they're still hospitalized (well, it should be forever)."
During visits, family members can also feel that their intimacy is being invaded. The space in the ICU is limited and proximity between them is unavoidable. This factor can affect the expression of feelings, either because they feel ashamed or for fear of being heard.
"Members of different families are really close to each other. They are hearing other ones' conversations. There is no intimacy, everybody hears everything."
Touching is the sense by which we feel pressure exerted on the skin or mucosa. It is another one of the senses involved in communication. We feel how we are being touched, gently or roughly. It is one way of communication that nursing staff is always using. Touching is personal and it is a fast and direct way of communication. This is why it can be considered as invasive. Professionals think they are always attacking patient's intimacy while they are covering their basic needs or they are washing them. Touching means to get in contact with a part of the body. Depending on the way of touching, one can send messages of tenderness or on the contrary of lack of attention; and we cannot forget that it is an important aspect of non verbal language.
"During washing and other kind of things, for example when they have to relieve themselves, you are in closer contact with the patients. You are washing them and touching them. I think that the way you touch and catch them, and use the sponge has an influence on them."
Empathy is understood as a feeling of affective involvement of one individual in a foreign matter; to put yourself in someone's place. During care they emerge relationships and behaviors between professional and patient. This established communication, verbal or non verbal, is considered as an important tool to interact with the patient. If the patient feels comfortable and safe, he shows part of his intimacy to the professional. He shows feelings that help him getting rid of his anxiety and reinforcing the therapeutic relationship.
"For me, when I put myself in the patient's place, it is really important. I would feel discomforting in some situations I see every day. I don't know, maybe sometimes the nursing staff doesn't pay as much attention as it should to treatment of intimacy."
Intimacy is felt as a complex concept that is difficult to define for nursing staff. The studies of Williams11 and Dowling12 also show this ambiguity and complexity of meaning. It stands out the difference the interviewees made between personal and professional intimacy. They do not consider their own intimacy at work. In this point we coincide with Williams, who states that the perception of intimacy is an inappropriate adjective for the relationship nurse-patient, although it is used daily. The expression of own feelings at work is pushed into the background; one is no more a person but a professional. Intimacy means an involvement of reciprocal behaviors between nurse and patient.13
Senses have emerged as an important dimension of intimacy. They are a fundamental part of communication during care. Both vision and hearing are the most used senses in that process. Vision can act as an invader of intimacy; as Torralba said "there is no doubt that we want preserve specific regions of our body against foreign glances". The interdisciplinary team can become a potential observer. Some studies (like Pupulim14) state that it is necessary to understand how professionals feel and act because in an ICU they are "elements" that also invade intimacy. Results show that there are more potential observers in the ICU and that they can go unnoticed: the own patients and their families. Carmen Ferrer says: "intimacy relationships require participants and do not admit observers". Most of the interviewed professionals declared feeling a lack of respect towards patient's intimacy. Lourdes Rubio says that respect for human nature, for intimacy and for treating persons as such is an important value for the humanization of care in the ICU.15 C. Ferrer and Pupulim also perceive a change towards respect for intimacy.
Hearing is another sense used by the nursing staff. As Bohórquez says: "hearing is important for care". Hearing the patient is a value that is part of professional's way of acting. Therefore, an ethical behavior is required for a good assistance and respect for intimacy. It is telling that one of the participants considered the night rest as a part of patient's intimacy. As cited in an article of Guevara, noises can cause anxiety and make the night rest difficult.17 These considerations make us notice how important it is to respect the patient's environment in moments of 'assistance calm'. According to Jaramillo "the patient requires physical attention, but we all need communicative attention, being heard". Of the same tenor, Torralba says that intimacy is not reduce to put a screen when patients have to relieve themselves, but with the 'art' of asking and listening.
Confidentiality is part of intimacy. Nursing staff refer respect for confidentiality. In this aspect we coincide with C. Ferrer and M. Iraburu.18 Torralba says that it is the concept of interdisciplinary team that demands rigor and conscience from the professionals when talking about the patients.
Touching emerges as a dimension of intimacy related to the corporal care (hygiene, defecation, feeding and cure. Interviewees refer that touching is a way of directly invading patient's intimacy. According to Jaramillo, with the touch one sends out signals of affection and complicity that influence patient's intimacy.
Empathy is part of the therapeutic process between professional and patient. It is the hearth of moral. The possibility of knowing the patient's condition is a requirement for good nursing assistance. Having sensibility humanizes care practices. The therapeutic relationship established with the patient is of use for assistance. Nevertheless, many authors think that projection of professional's intimacy on the patient can be an error because the patient may not share the same idea of intimacy.
Nursing professionals are human beings and therefore they feel. These perceptions lead to vulnerability feelings that are reflected during care.
The care of intimacy demands integrating the senses of vision, touch and hearing as fundamental part of non verbal communication to reach excellence in professional assistance.
The care of patients has to guarantee intimacy and privacy of hospitalized persons in the ICU. It is necessary that professionals are conscious of patient's intimacy. This intimacy must be handled with sensibility and respect.
1. Bohórquez GF, Jaramillo
EL. El diálogo como encuentro: Aproximaciones a la relación profesional
de la salud-paciente. Index Enferm. 2005 Nov:14(50): 38-42. Disponible en: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1132- [Consultado el 18.12.2007].