Safeguarding Professional Intimate Care and Touch in Nursing Education: Humanistic Care in a Technological Era

Abstract

Facilitating intimate care and touch in the digital age advocates for quality humanistic care that is culturally, socially and religiously acceptable. The chapter attempts to create awareness of professional intimate care and touch on nursing education and practice to incorporate technology into humanistic care. The Participatory Action Research (PAR) process was used to allow for active participation in intimate care and touch activities to create new knowledge into humanistic intimate care practice. Symbolic interactionism’s theoretical framework complemented the understanding of attitudes, motives, behaviors, and how individuals interpret experiences and events. Naïve sketches collected initial data to establish their diversity and understanding of intimate care. After that, facilitated diversity in intimate care and touch discussion sessions were conducted, humanistic intimate care and touch simulation sessions, drawing from intimate care and touch experiences, and post-interviews were conducted to narrate the drawing. These activities created a visual and multimodal experience for nursing students. Knowing one’s socio-cultural beliefs and learning others’ identities creates a sense of belonging and acceptance. When nursing students understand who they are (as individuals, collectively), it makes it easier to acknowledge the diverse patients requiring intimate care and touch. Thus, nursing students’ preparedness in intimate care and touch is critical to allow them to practice in a safe space before being exposed to clinical placement.

1. Introduction

Nursing is an inherently human experience done for humans by humans. Nursing care basic activities require nurses to see and touch patients’ bodies to promote healing and comfort. Caring in nursing involves human relationships between persons focused on knowing each other’s uniqueness and sharing individual experiences to affirm each other’s humanness in the world [1]. Through caring, a human person is valued, therefore, humanism in care is a necessity and global priority to improve quality of life [2]. Great emphasis is placed on nursing values to develop humanism and humanize the care provided. This means that nursing should be humanized to value and respect human life [3]. Therefore, caring rests on humanistic values that translate into attitudes and behaviors geared to protecting, enhancing or preserving the human dignity of patients [4]. Humanistic nursing care is further described as an interaction between nurses and patients/families as a response to the caring situation and is characterized by empathy, respect for human dignity, autonomy of patients and holistic care [5]. The authors [5] make a humanistic care distinctive shift from a task-oriented care model to a person-centered or relationship-centered model.

Nursing practice demonstrates technical skills performed following a standardized plan of care derived from the nursing process [1]. Every basic nursing procedure requires physical touch. The symbol of touch and being touched means different things to different people. It creates interpersonal relationships that can contribute to the student’s failure or success. Intimacy is revealed as a site of connecting through which a sense of belonging is created [6]. A nurse and patient meet in a social space where human recognitions are established [7] to co-create a relationship between a nurse and patient, coordinated for the mutual purpose of knowing each other [1]. Intimate care is classified as closeness at a physical, psychological, and spiritual level. It is the care provided by the nurses that requires physical closeness or bodily contact and touch, thus invading the physical space and privacy of a patient [8]. Intimate care touch is task-oriented to areas of the patient’s body that might produce feelings of discomfort, anxiety and fear or might be misinterpreted as having a sexual purpose [9]. Intimate care and touch are a significant element in the healthcare profession that defines the nursing profession as it requires a nurse to provide comprehensive physical, mental and emotional care. It transforms a very private, personal activity into a social process which impacts the providers and recipients of intimate care and touch [10].

Intimate care and touch may be threatened by the advancements in health technologies, where nurses rely on data technology produces, rather than incorporating it into quality nursing care. Technology is used in care, and interactions happen in diverse places, either private or social spaces. Technologies are conceptualized as embedded in relations with other tools, practices, groups, professionals, and patients [11]. Vast advancements in electronics, computing, and medicine have generated space for new dimensions of interactions between technology and the human body [12]. Technology at the clinical bedside has the power to become the point that nurses use to inform, direct, evaluate understand their nursing care [7]. Technological knowing is a way of understanding persons using technologies of health and human care and provides nurses with another way of knowing persons [1].

Yadal [12] indicates that as intimate technologies develop, it is important for healthcare practitioners to know how they will shape lived experiences and cultural issues and normative views to be addressed regarding the body. Even McCarthy [7] warns that technology may serve to further distance nurses from patients both proximally and emotionally, questioning the therapeutic nurse-patient relationship in healthcare environments. Thus, constant examination of how technology is created and used needs to be interpreted by the users and recipient of care [11]. Technologies used in nursing must increase proficient human caring, by providing opportunities to further the knowing of the person [1]. If technology is blindly accepted, it will serve to categorize and marginalize patients’ illness experiences, especially if nurses practice without critically examining the overwhelming presence and impact of technology on knowledge development and nurses’ interaction with patients.

This chapter illustrates the value of intimate care and touch in nursing education. It aims to safeguard the human element made visible through interaction and touch in caring for the body. It is important to conscientize the nursing fraternity to their pledge to service of humanity, which is realized through acknowledgement of human diversity, knowing a patient as a person, and respecting the touched body. There is no scientific dispute on the value of technology in advancing nursing science. However, moral and ethical decisions must be made when technology is used, and therapeutic nurse-patient relationships should be promoted. The future of the nursing profession lies in the nursing students’ humanistic care competency and support.

2. Theoretical framework

Symbolic interactionism was used as a theoretical framework to direct the study. Symbolic interactionism is a theoretical perspective that addresses how society is generated and maintained through face-to-face, repeated, meaningful interactions among individuals [13]. The basic notion is that human action and interactions are understandable only through exchanging meaningful communication or symbols [14]. It takes a small-scale view of society by studying the interaction between individuals and through this approach, social order and changes in society are explained [14]. Therefore, individuals use language and significant symbols to communicate with others. The source of data is human interaction that focuses on individual perspectives through character, signs of facial expression, body language, gestures, and human behavior [15].

Several authors [13, 14, 16] describe the four tenets of symbolic interactionism: (i) individuals act based on the meanings objects have for them, (ii) interaction occurs within a particular social and cultural context in which physical and social objects and situations must be defined based on individuals meanings, (iii) meanings merge from interactions with other individuals and with society, and (iv) meanings are continuously created and recreated during interaction with others. Therefore, the communities are distinguished not only by a collectively shared symbolic knowledge but also by cultural activities in which they stage and perform such knowledge in rituals in which the particular social system is expressed, projected, and reproduced [17].

Symbolic interactionism is for understanding the relationship between individuals and society to empower nurse practitioners to provide holistic intimate care to diverse patients. The human body has various meanings attached to it; therefore, nursing students must understand these meanings to provide acceptable intimate care and touch to all patients. Symbolic interactionism was incorporated with the Model for facilitating the teaching of intimate care [8] that was implemented in this phase. The model posits four steps to the facilitation of intimate care which are summarized in Table 1 and were used in Participatory Action Research that directed the study.

Intimate care facilitation steps	Descriptions
Step 1: intimate care conflict	This step reflects the diversity of nursing students and patients when intimate care procedures are delegated. Lack of intimate care knowledge and experiences of caring for the body of the other person.
Step 2: Facilitation of Intimate care	In this step, nurse educators are empowered to facilitate intimate care. Reflecting on the current curriculum and creating intimate care realities for nursing students. Creating a safe space for the nursing students to experience touching a real human being using humanistic intimate care simulations using silicone masks.
Step 3: Intimate care support	Preparing nursing students for intimate care and touch, giving them tools to know when and how to touch. Strengthening intimate care support during clinical placement anticipating alleviating intimate care conflict.
Step 4: Therapeutic nurse-patient relationship	Intimate care knowledge and support, and debriefing sessions create a safe space for nursing students to experience intimate care realities. They will be able to establish a professional intimate care therapeutic relationship based on trust, respect, and dignity. Advocating for the provision of intimate care without fear of being stereotyped and the caring touch being misinterpreted.

Table 1.

Summary of the intimate care facilitation steps [8].

2.1 Research design

In this chapter, qualitative Participatory Action Research (PAR) was used to understand the intimate care and touch experiences of nursing students. A participatory approach is a qualitative methodology that values genuine and meaningful participation and direct engagement of local priorities and perspectives [5]. The PAR emphasizes the production of knowledge and empowerment, it seeks to transform social realities so that the lives of people are improved [18]. It affirms that experience can be a basis for knowing and that experiential learning can lead to a legitimate form of learning that influences practice [19]. The PAR cyclic process and goals discussed in Ref. [20] were followed and discussed below.

2.1.1 Phase 1: collaboration

The researcher created relationships and ownership with the Nursing Education Institution (NEI) and nursing students who were part of the project. Entry into the research setting and initiating a mutual relationship is critical to establishing and nurturing the willingness to participate in the initiatives [21]. The researcher spent time in the NEI before the commencement of the project to establish trust and understand the intimate care practices in the NEI. Two nurse educators assisted with understanding the culture of the institution and the implemented curriculum. Meetings were held with the students during break times and after lectures to avoid disrupting teaching and learning. Informal discussions on the meaning of the body and cultural attributes were conducted. The process of the study was discussed with nursing students who were interested in participating in the study and were invited to complete a short survey with their names and contact details. All nursing students voluntarily signed informed consent before engaging in the research activities.

Twelve (n = 12) nursing students registered for a three-year Diploma in Nursing (Regulation 171) voluntarily participated in the activities of the project. They were in their second year of training. Ten (n = 10) females and two (male) nursing students with age range from 22 to 31 years. South Africa is a diverse country, with multiple cultural communities and in this objective, the participants were from five South African cultural groups which enhanced the diverse group and multiple voices on understanding intimate care and touch. Table 2 displays the summary of the participants’ characteristics.

Characteristics	Frequency (n)
Gender:
Female	10 (83.3%)
Male	2 (16.7%)
Age:
20-24	7 (58.3%)
25-29	3 (25%)
30-31	2 (16.7%)
Cultural backgrounds:
Afrikaans	1 (8.3%)
Swati	4 (33.3%)
Tsonga	2 (16.7%)
Tshwana	2 (16.7%)
Zulu	3 (25%)

Table 2.

Summary of the participants’ characteristics (n = 12).

2.1.2 Phase 2: incorporation of local knowledge

The knowledge of intimate care and touch was explored and analyzed to provide necessary support in the facilitation of intimate care and touch. The participation methods were built on the specific research site care, through understanding the context of the collaboration group. At the onset, four questions were asked to establish a diverse understanding of caring for the human body and they were based on step 1 of the Intimate Care Facilitation Model (see Table 1):

Q1: Discuss your beliefs on caring for the human body.

Q2: What is your understanding of intimate care and touch in nursing care?

Q3: Mention nursing procedures that you consider as intimate care.

Q4: Describe your experience when providing intimate care and touch.

The participants were given open-ended written questions to complete their answers. Narrative data analysis and coding for visual data were used to interpret the findings.

Narrative data is analyzed for the story they have to tell was conducted to understand the story of the touched body in nursing care. The large data patterns and meanings were organized into narrative segments and categories. Finally, the factors that shaped the participant’s lives were identified. An analytic abstraction that highlights (a) the processes in an individual’s life, (b) the different theories that relate to the participant’s life experiences, and (c) the unique and general features of life. The author and an independent coder analyzed data individually and compared the findings. The presented findings were the final themes agreed upon by the two data analysts.

For drawing the participants used “Sketchbook” Application and Deco M Pen Tablet which they connected to their cellphones and were able to draw. Five Deco M Pen were used, and they were shared among the participants. After drawing, they could share the drawing with the researcher via Bluetooth and email. Visual data was analyzed using coding as described by Creswell [22] as follows:

1. Code the image by tagging areas of the image and assigning code labels.

2. Compile all the codes for the images on a separate sheet.

3. Review the codes to eliminate redundancy and overlap, reducing the codes to potential themes.

4. Grouping codes into themes that represent a common idea.

5. Assign the codes/themes to three themes: expected themes, surprising themes and unusual themes. This step helps to ensure the qualitative findings represent diverse perspectives.

6. Writing the narrative for each of them accompanied by the visual data.

In the visual data analysis, a member check was done when the researcher conducted short interviews to allow the participants to confirm that the themes attached to their drawings represented their experiences.

2.1.2.1 Theme 1: nursing education transforming lives

The visual data in this theme presents the participants’ reactions to being accepted into a nursing training programme. It brought joy and hope to individuals who could not afford registration to higher education institutions. Receiving a call from a Nursing Education Institution regarding the positive outcome was a joyful occasion. Figure 1 presents the expressions of being accepted in the nursing training programme.

Figure 1.

Joyful expressions of being admitted to nursing education training.

The joy of being accepted in Nursing Education marks liberation and defiance of poverty for many nursing students. Access to higher education in South Africa is a long-standing challenge. Many young people complete basic education and cannot enroll for further education.

2.1.2.2 Theme 2: sacredness of the human body

The participants narrated their reflections on how African cultures influence the meaning of the body, including the power issues created by patriarchal gender roles. Two sub-themes were identified: respect for the body and boundaries in accessing the body.

2.1.2.2.1 Sub-theme 2.1: respect for the body

The body is multifaceted, which calls one to respect the physical and spiritual presence of the human person.

“[…], the human body must be respected by not being touched or doing anything on it. It must not be exposed unnecessarily” (MP7/24)

“A human body is a very precious and sensitive gift from God […] which need to be treated with respect, taking into consideration their feelings and asking for permission for any activity” (FP1-22)

2.1.2.2.2 Sub-theme 2.2: cultural boundaries in accessing the body

Culture is the totality of the way of life evolved by people in their attempts to meet the challenge of living in their environment, which gives order and meaning to their social, political, and economic status that distinguishes them from others [23]. In African culture, each person has a role and children are not allowed to see and touch the body of the elders. Childhood is not limited to age but to the generational position in the family. The participants acknowledged the importance of knowing what is expected of a child from the body of an adult.

“A child is not supposed to see an adult body naked […]” (FP3/25)

“It is believed that it is not moral to see the naked body of an elderly person, especially their private parts” (FP7-31)

“[…] for me as my young age I am not allowed to see and touch the body of an elderly person” (FP6-24)

As African people, various moral and societal values are meant to regulate interpersonal relationships and the community. In African cultures, respect and honor for elders is important [24]. Gender boundaries also contribute to the care of the body. African cultures ascribe to patriarchal ideologies with defined gender roles. Cross-gender care is frowned upon and may limit quality care.

“A male is not supposed to see his mother or women naked, and females are not supposed to male or their father even when in need of their help. An elderly person of the same gender is requested to assist, at times a person is delegated to assist an elderly family member with physical needs” (FP7-31)

“[…] only old women are allowed to care for the sick person because they are no longer sexually active, and they can handle the human body respectfully” (FP11-26)

Interestingly, even though the participants were from various cultural communities, their understanding of the human body was of the communitarian outlook. Affirming the African notion of personhood that the reality of the communal world takes precedence over the reality of the individual. Even though there are many diverse African cultures, there are many commonalities in value systems, beliefs and systems which reflect the African communitarian worldview [25]. Kpanake [26] confirms that a person does not exist in isolation, therefore, each life and growing up in some specific social and cultural setting influences individual behavior, thoughts and the way of being in the world with others.

2.1.2.3 Theme 3: importance of intimate care in nursing

The nursing students understood that intimate care and touch are part of basic nursing care. It forms part of the daily routine of caring for the physical aspect of the human person.

2.1.2.3.1 Sub-theme 3.1: physical care requiring touch

“Intimate care is coming close to private parts or the whole human body, which makes one uncomfortable, especially during bathing, sometimes very uncomfortable […]” (FP9-22)

“Therapeutic touch you give to patients when caring for them, depending on the gender and age, even the body parts that are touched […]. Well we do it to promote good health and comfort” (FP1-22)

“[…] healing touch for care to another person, when you touch the patient, you need to do it gently and make the patient comfortable and safe” (FP8-30)

The participants’ definition of intimate care is coming near the body and touching the body for care. This understanding is congruent with [27] who define intimate physical touch as involving inspection of and possible physical contact with those parts of the body whose exposure can cause embarrassment to either the patient or the nurse. O’Lynn [9] expanded on this definition by emphasizing that intimate touch is task-oriented to areas of the patient’s body such as genitalia, buttocks, perineum, inner thighs, lower abdomen and breasts that may produce in patients or caregivers, feelings of discomfort, anxiety and fear.

2.1.2.3.2 Sub-theme 3.2: touch-oriented basic nursing care

“I consider nursing procedures such as bed bath, vaginal examination and insertion of a urinary catheter. For me, any procedure that requires a patient to remove his or her clothes is intimate as it requires a high level of trust” (FP10-23)

“[…] includes bathing the patient and touching sensitive areas of the body during physical examination […]” (FP5-22)

Unfortunately, intimate care procedures are often regarded as simple humble tasks and are thought to be less prestige than procedures requiring technical nursing skills [10]. Yet, physical and emotional encounters with the patient can be exhausting and create feelings of discomfort and fear when sensitive parts of the body are exposed and touched. Intimate care and touch fulfill the basic needs of a human person which are hygiene, elimination, and circulation to promote the dignity of the body.

2.1.2.4 Theme 4: learning nursing care

The visual data presents the participants’ process of care learning journey starting from the lecture room (nursing theory), and skills laboratory where basic nursing care procedures were simulated and using high-tech equipment for simulated care. Thereafter, they had walkabouts in the hospital with their clinical facilitators to orientate them to the real hospital setting. Figure 2 depicts the process of learning nursing care.

Figure 2.

Facilitation of nursing care in nursing education institution.

The simulations in the skills laboratory were basic nursing care procedures such as bed baths and physical examination of the manikins. This is in line with [28] who assert that many nursing students’ experience of intimate care provision occurs during clinical placement, where they are in physical contact with the human body.

2.1.2.5 Theme 5: not ready for the “other”

The participants drew on their experiences of intimate care and touch. From the visual data, one can see the emotions of the nursing students when caring for the body, feelings of embarrassment, fear and cultural taboo of cross-gender and age. Figure 3 displays the visual data and verbatim extracts on intimate care experiences.

Figure 3.

Visual data of intimate care implementation experiences.

The two female participants’ tears are prominent, with many tears in the toilets and students’ residential rooms. These were tears of helplessness and knowing that they would go through the same process the next day. The male participant did not cry, but frustration and helplessness. These feelings are expected during intimate care and touch implementation as cultural boundaries are crossed and interacting with the naked body.

2.1.2.6 Theme 6: left in the dark: met with death

Nursing students have to care for patients who are critically ill, and they experience caring for dying and dying patients. Having to touch or prepare the cold body was not an easy task as it was not something that was a normal practice in African cultural practices. Figure 4 shows the emotions surrounding caring for the lifeless body.

Figure 4.

Visual data of experiences for caring for a demised patient.

Death was an untapped territory, participants felt as if they were surrounded by darkness. Seeing a lifeless body for the first time was a shocking experience. In the drawings, the black, gray and red dots bring to life the pain of losing a patient, fear and trigger previous family member’s losses.

2.1.3 Phase 3: emergent process

In this phase, intimate care activities were created and implemented. After understanding the local knowledge of the body and intimate care in phase 2. The major themes were used to create intimate care activities. Discussing matters of the body was not easy as the body is considered sacred and private in their cultural context. To break down the barrier, two nursing students were paired together and six groups were created. Deliberations on the diverse issues of age, gender, nakedness and touch were discussed. They were supported in finding humor and being appreciative of their cultural values.

After the discussions learning to negotiate physical space and touch content was presented. The main ethical principles were used to assist nursing students in preparing the patient for intimate care and touch. Table 3 provides a guide for intimate care and touch planning.

Ethical principles	Intimate care and touch discussion with the patient
1. Autonomy	Tell me how you are going to touch me
2. Informed consent	Ask permission to touch
3. Beneficence	Benefits of intimate care and touch
4. Non-maleficence	give me preferences before touching respect and dignity of the exposed body
5. Privacy, confidentiality	Physical privacy (screening, avoiding unnecessary exposure of body) Emotional privacy (gender preferences)
6. Justice	Equal treatment for all patients regardless of gender, age or cultural affiliations

Table 3.

Intimate care and touch interaction with the patient.

Participants engaged in intimate care humanistic simulation in a skills laboratory where the cultural discourses on the human body were discussed.

Humanistic care simulations were conducted using silicone masks in the skills laboratory. Based on the findings in phase 2, the nursing students viewed the body as sacred. Seeing and touching the naked body of an elderly person was not an easy task to fulfill. Therefore, the activities focused on African elderly male and female patients. Figure 5 offers visualization into intimate care humanistic simulation.

Figure 5.

Humanistic intimate care simulation for elderly patients.

NB: the two procedures were conducted as the initial stage of establishing intimate care and touch for elderly patients. It offered nursing students an opportunity to apply the ethical principles in Table 3.

After the sessions, debriefing sessions were conducted in small groups of six. They had to discuss their experiences during intimate care and touch sessions. In each group, the masked patient revealed him/herself and shared the experience of being touched. Also, the nurse providing care had to share the experience of touching the “other”. Figure 6 provides the debriefing moments of post-intimate care and touch discussions and affirmation that they are not alone on the journey.

Figure 6.

Debriefing sessions post intimate care and touch sessions.

Humanistic aspects of caring might be neglected due to time limitations during clinical placement, shortage of competent nursing practitioners, heavy workload, and use of technology. Intimate care simulation using Mask-Ed™ allowed nursing students to authentically experience the shocking factor of caring for a naked elderly woman [28]. This indicates the importance of humanistic simulation in preparing nursing students for affective skills.

2.1.4 Phase 4: linking scientific understanding to social action

The research findings are presented to reflect the participants’ understanding of intimate care and touch in their context. This section discusses the findings from two phases of the activities (phase 2 – incorporation of local knowledge and phase 3 – emergent process).

2.1.4.1 Part 1: discussion of phase 2 – Incorporation of local knowledge

The participants viewed the body as a sacred entity that needs to be respected with its boundaries.

Nursing Education Transforming Lives: South Africa’s democracy draws from its humble begins from apartheid where most black African students were excluded from higher education. After the democratic government election in 1994, the goal of access to higher education was set to achieve equity [29]. Therefore, Section 29 of the Constitution promises the right to quality education for all, expanding access and inclusion in higher education. Nursing education is regulated by the South African Nursing Council and Council of Higher Education. Acceptance to accredited NEI was the first entry to higher education for all the participants.

Learning Nursing Care: The nursing curriculum includes both theory and clinical learning. Clinical competency is the ability to effectively integrate cognitive, affective and psychomotor skills when delivering nursing care [30]. The simulation laboratories should function as a replicate of a real hospital for the nursing students to practice humanistic care. Many NEIs use technology-enhanced simulated learning such as videos to develop psychomotor clinical skills that are critical for patient care and challenging to teach students [31]. Unfortunately, the affective skills are not enhanced during this teaching strategy. As indicated earlier, intimate care requires a nurse to touch the body of the patient, if it is not facilitated in NEI, the student becomes exposed to the human body during clinical placement. A vast literature from humanistic care scholars such as [9, 28, 32, 33] has indicated that intimate care and touch are not facilitated in skills laboratories and nursing students learn it from trial and error and from other students. Since registered nurses are not knowledgeable about the supervision of intimate care, therefore, intimate care empowerment and support during clinical placement are lacking.

Respect for the human body: The body is a medium of culture, it is a social production of the self [34] which needs to be respected. Culture is a complex whole which includes knowledge, belief, art, custom and any other capabilities and habits acquired by an individual as a member of a society [24]. Body image refers to personal constructions and public projections of the human body involving perceptions, physical sensations and innated expected culture of the body [35]. Respect is often linked to the dignity of a person. The Constitution of the Republic of South Africa, Act 108 of 1996, in Section 9 outlines the fundamental human rights of human dignity, the achievement of equality and the advancement of human rights and freedom. Further Section 10 indicates that “everyone has inherent dignity and the dignity to have their dignity respected and protected”. Dignity is about acknowledging the innate value in every individual, especially when they are feeling vulnerable and dependent on others for aspects of their care [36]. The authors [36] emphasize that treating someone with dignity is to treat them as being worthy, in a way that respects them as valued individuals within society.

Cultural boundaries in accessing the body: Gender and gender-defined roles are socially constructed with the opportunity to change and transform. Gender refers to the roles and responsibilities as well as opportunities that stem from the biological fact of being male or female [37]. Tamale [38] gives reasons for the boundaries in the nakedness of elderly women and mothers is symbolic in most African cultures and is considered the ultimate curse. The reason is that through pregnancy, childbirth and nurturing, women are givers of life, by stripping naked in front of men old enough to be her children or grandchildren, a mother is symbolically taking back the life that she has given, pronouncing social death. Unfortunately, in the nursing profession, young nursing students are exposed to the bodies of elderly people which may be a taboo for them as they cross the cultural norms. Therefore, the nursing curriculum should prepare students to be sensitive to patients’ identity, culture, religion, age, gender and sexual orientation [39].

Importance of intimate care in nursing: Nursing students understood intimate care as physical care requiring touch and touch-oriented basic nursing care. In their intimate care facilitation model [8], intimate care involves physical or psychological closeness between a nurse and a patient. During this proximity, the nurse encounters a patient’s body, and the patient must allow a nurse to touch their body. Therefore, during intimate care, the fragile body of the patient is seen and touched. It is in this view that technology should not be a barrier in humanistic care, not diminish the interaction between the nurse and the person in need of care [1].

Not ready for the “Other”: During intimate care provision, the nurses touch the patients. Nurses use their hands to examine patients’ bodies, bathe them and give physical comfort which may trigger feelings of fear and discomfort [40]. Intimate care procedures such as hygiene, elimination and pressure parts care may be considered simple, but have a psychological impact on those providing and receiving such care [10]. Readiness for intimate care is founded on clinical teaching and support.

Left in the dark – met with death: Death shocks everyone, whether young or old. In nursing life and death are often part of daily routine. Death after all healthcare professionals throughout their careers. There is no getting used to it. Nursing students do not feel ready to confront issues regarding death and dying, they are poorly prepared and vulnerable when providing care to dying patients [41]. In the study of [42] nursing students had terrible dreams of death, were shocked by the first death they encountered and were left insecure emotionally and physiologically. Therefore, nursing students should be prepared for death and dying. Debriefing sessions should be conducted with nursing students to assist them in dealing with their experiences of encountering death.

2.1.4.2 Part 2: discussion of phase 2: emergent process

Teaching humanistic care is critical in creating a respectful environment for nursing students and patients. Technology will undoubtedly shape the future nursing profession but should not replace astute knowledge and humanistic nurse-patient interaction [43]. Humanistic care is characterized by empathy, respect for human dignity, patient autonomy, a friendly environment, and holistic care [44]. Humanization is intended to improve the healthcare delivered to the patients and contributes to understanding human beings in their own unique sense of dignity and identity [45]. In Mainey et al. [28] after participating in intimate care facilitating, there was a shift from fear of engaging in intimate touch to completing nursing tasks leading nursing students to experience patient-centered care. To provide intimate care and touch, the nursing student must be prepared to interact with a diverse patient. Importantly, the nurse and patient need to establish a therapeutic relationship based on respect, trust, and dignity [33]. The authors [33] further state the importance of including intimate care in the nursing curriculum as it will empower nursing students to provide intimate care to diverse patients competently, comfortably, and confidently.

3. Conclusions

This chapter presented the PAR grounded in symbolic interactionism theory. The meanings of the body were deliberated with their limitations. The nursing students’ participation assisted in creating contextual intimate care activities linked to ethical principles of autonomy, informed consent, beneficence, non-maleficence, confidentiality, and justice. Even though NEIs in South Africa have moved to online teaching and learning following the COVID-19 trends, the patient’s body still needs a human touch and interactions. Thus, technology should not replace the nurse. Therefore, the facilitation of intimate care and touch is at the centre of humanistic care. Through the findings, the nursing students indicate their competency in executing clinical procedures but fail to prepare themselves and the patients for intimate care and touch encounters. One cannot overemphasize the importance of establishing a nurse-patient relationship that is respectful and dignified during nursing care interactions. When nursing students are well prepared for diversities in patient care, and understand their cultural backgrounds, it is possible to provide intimate care in a collaborative manner, where there are no power struggles. It becomes important for the human body to be treated with respect and dignity for positive clinical outcomes. Unfortunately, intimate care and touch require time and dedication, and with the shortage of nurses, nursing students may continue struggling with humanistic care. Therefore, nurse educators and clinical preceptors should be vigilant and supportive in creating safe spaces for intimate care and touch activities.

Acknowledgments

I am grateful to UNISA for granting me time to focus on the intimate care project and NRF for the grant which made it easy to fulfill the objectives of the study (South African National Research Foundation Thuthuka Grant Reference: TTK210318590345). Thankful to all stakeholders who permitted to conduct the study in their institutions and all participants who dedicated their valuable time.

Conflict of interest

The author declares no conflict of interest.