527356

research-article2014
WJNXXX10.1177/0193945914527356Western Journal of Nursing ResearchPedrazza et al.

Article
Western Journal of Nursing Research
1­–18
Nurses’ Comfort with © The Author(s) 2014
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DOI: 10.1177/0193945914527356
Well-Being wjn.sagepub.com

Monica Pedrazza1, Stefania Minuzzo1, Sabrina

Berlanda2, and Elena Trifiletti1

Abstract
Touch is an essential part of caregiving and has been proved to be
useful to reduce pain. Nevertheless, little attention has been paid to
nurses’ perceptions of touch. The aim of this article was to examine the
relationship between nurses’ feelings of comfort with touch and their
well-being at work. A sample of 241 nurses attending a pain management
training course completed a questionnaire, including the following
measures: Comfort with Touch (CT) scale (task-oriented contact, touch
promoting physical comfort, touch providing emotional containment),
Maslach Burnout Inventory (MBI; emotional exhaustion, cynicism), and
Job Satisfaction. Results of structural equation models showed that touch
providing emotional containment was the main predictor of emotional
exhaustion. Emotional exhaustion, in turn, was positively related to
cynicism and negatively related to job satisfaction. In addition, the direct
path from touch providing emotional containment to cynicism was
significant. Practical implications of the findings are discussed.

Keywords
comfort with touch, physical touch, pain, burnout, job satisfaction

1University of Verona, Italy

2University of Trento, Italy

Corresponding Author:
Monica Pedrazza, Associate Professor, Department of Philosophy, Education, and Psychology,
University of Verona, via San Francesco 22, Verona, 37129, Italy.
Email: [email protected]

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2 Western Journal of Nursing Research 

Physical contact with the patient is an intrinsic part of the nursing profession
(Chang, 2001; Routasalo, 1999). To provide appropriate assistance, nurses
have recourse to various forms of contact that differ in their nature and degree
of intimacy depending on whether their purpose is to carry out tasks (e.g.,
taking vital signs), provide physical comfort (e.g., massaging), or provide
emotional containment (e.g., hugging patients; Pedrazza, Minuzzo, Trifiletti,
& Berlanda, 2014). The ability of the professional to reassure the patient
through touch is particularly important when the patient is suffering from
serious pathologies, is in pain, is worried, afraid or anxious, or is physically
and emotionally fragile and vulnerable (Bonacini & Marzi, 2005). This study
shows how feeling comfortable in giving support to patients through touch
may be associated with greater job satisfaction and reduced burnout (emo-
tional exhaustion and cynicism).

Physical Touch in Caring

One form of contact is cutaneous stimulation, for example, superficial mas-
sage of the back, hands, feet, or face. Cutaneous stimulation has been shown
to be useful in reducing pain because it activates the large-diameter fibers that
transmit tactile information, which in turn antagonize the small-diameter
fibers that transmit the pain stimulus (Melzack, 1996). Cutaneous stimulation
also stimulates the production of endorphins, relaxes the muscles, sedates the
patient, and acts as a distracting stimulus. Evidence-based guidelines high-
light the effectiveness of cutaneous stimulation in relieving pain associated
with muscle tension or spasms (Grade C, Level IV; National Guideline
Clearinghouse). Many studies have confirmed that cutaneous stimulation is
useful in reducing pain and anxiety and inducing relaxation in oncology
patients (Jane et al., 2011). Hand massage, on its own or together with sooth-
ing music, has been shown to reduce restless and aggressive behavior in
demented subjects (Fu, Moyle, & Cooke, 2013; Remington, 2002), and to
reduce pain and lower the heart rate and blood pressure in patients in an
emergency department (Kubsch, Neveau, & Vandertie, 2001). Superficial
hand and foot massage is also an effective, inexpensive, risk-free, flexible,
and easily applied strategy for managing postoperative pain (Han & Lee,
2012; H. L. Wang & Keck, 2004).
In general, touch is an essential part of caregiving and an excellent way of
communicating attention, sympathy, closeness, reassurance, and presence
(see Routasalo, 1999). This approach is particularly recommended for suffer-
ing patients, the frail and solitary elderly, the terminally ill, and the dying. It
may be a way of taking charge of the patient to reduce psychological suffer-
ing, feelings of loneliness, difficulty in communicating, and the fear and

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Pedrazza et al. 3

anxiety of death (Bonacini & Marzi, 2005). Kübler-Ross (2008) claimed that
gentle hand pressure is the most effective form of communication with dying
patients. The positive effects of touch in caring are, therefore, well-estab-
lished. However, little attention has been paid to how physical touch is per-
ceived by patients and nurses (but see Hollinger-Smith & Buschmann, 1993).
Some attention has been paid to the influence of gender on perceptions of
touch in caring. Research has shown that although male patients perceive
touch from female nurses more positively than do female patients, female
nurses consider female patients more receptive to touch and feel more com-
fortable touching female than male patients (Lane, 1989). As to men nurses,
the stereotype of men as sexual aggressor may generate a sense of vulnerabil-
ity and a need for caution in the use of touch (Evans, 2002).
More in general, touching the patient’s body may be associated with nega-
tive feelings. Picco, Santoro, and Garrino (2010), using data from in-depth
interviews with 14 nurses, found an ambivalent attitude toward taking care of
the patient’s body. They showed that although the body is regarded as a privi-
leged element of nursing care, it is also perceived as a source of uneasiness
and negative feelings. Physical touch requires great involvement on the part
of nurses, because it implies physical, cognitive, and emotional proximity to
the patient. Moreover, nurses may expect patients to refuse or react nega-
tively to touch, as touching the patient’s body implies entering his or her
privacy (Picco et al., 2010).Touching the patient may be therefore associated
with different levels of comfort among nurses. Because touch is an integral
part of the nurse–patient relationship (Hollinger-Smith & Buschmann, 1993;
Routasalo, 1999) and is fundamental in the provision of nursing care (Chang,
2001), it is important to understand how nurses experience touch and how
their feelings about touch relate to workplace well-being. If positive feelings
of ease during contact are likely to be associated with well-being (e.g., greater
job satisfaction, reduced burnout), a lack of comfort in touch may result in
negative organizational outcomes and, consequently, in lower quality of care.
The literature on physical touch generally distinguishes between two
forms of touch: necessary and non-necessary (Routasalo, 1999). Task-
oriented or necessary touch is intended for carrying out a task or procedure
(e.g., taking vital signs); non-necessary touch, in contrast, is spontaneous and
affective (e.g., reassuring a patient by holding his or her hand), and is not
necessary for accomplishing a task. These two forms of contact obviously
imply different degrees of cognitive and affective proximity to the patient.
Based on previous literature on physical touch, Pedrazza et al. (2013) devel-
oped and validated the Comfort With Touch (CT) scale. The scale is articu-
lated into five subscales: Task-Oriented Contact, Personal Care, Physical
Comfort, Reassurance and Emotional Containment. The concept of

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4 Western Journal of Nursing Research 

emotional containment refers to the ability to receive, process, and respond

with understanding to the emotional reactions of another person (Douglas,
2007). Three subscales of the CT scale were selected for the present study—
Task-Oriented Contact, Physical Comfort and Emotional Containment—
which correspond to low, medium and high levels of cognitive and affective
proximity to the patient. This study aims to verify the effects of comfort with
touch on two measures of workplace well-being—burnout and job satisfac-
tion—which appear to be associated with a wide range of individual and
organizational outcomes.
Burnout is a reaction to prolonged exposure to interpersonal and environ-
mental stressors on the job (Maslach, Schaufeli, & Leiter, 2001). Three
dimensions have been generally distinguished: exhaustion, cynicism, and
reduced personal efficacy. However, Schaufeli and Bakker (2004) argued that
personal efficacy can be considered a dimension of work engagement rather
than burnout. Moreover, researchers have found consistent results for emo-
tional exhaustion and cynicism but not for personal efficacy (Laschinger,
Finegan, & Wilk, 2011). Therefore, recent studies have adopted a two-factor
conceptualization of burnout. The present study focuses on emotional exhaus-
tion and cynicism as outcomes of (dis)comfort with physical touch. Emotional
exhaustion, generally regarded as the core of burnout, is a state of physical
and emotional depletion that manifests itself both in physical fatigue and a
feeling of being “burned out” by one’s job. Sustained emotional exhaustion
generally results in cynicism (Leiter & Maslach, 2004), namely, detachment
from the job. Burnout in nursing has been widely investigated. Negative
work conditions, such as nursing shortage, work overload, lack of job auton-
omy, and leader–member exchange, appear to be major determinants of burn-
out (Laschinger et al., 2011; Moustaka & Constantinidis, 2010). Although
previous research on burnout has primarily focused on environmental factors,
individual difference variables are also likely to play a role in the develop-
ment of burnout (Maslach et al., 2001). In a meta-analysis, Alarcon,
Eschleman, and Bowling (2009) found that self-core evaluations, agreeable-
ness, consciousness, extraversion, optimism, hardiness, and proactive per-
sonality were negatively related to both emotional exhaustion and cynicism
(for the relationship between self-core evaluations and burnout in nursing,
see Laschinger et al., 2011). Positive affectivity yielded a negative associa-
tion with the two burnout dimensions, whereas negative affectivity showed a
positive relationship. Given the costs of burnout for both people and organi-
zations, it is important to further explore its possible antecedents. The current
study investigates, for the first time, how nurses’ feelings of comfort with
physical touch relate to emotional exhaustion and cynicism.
Job satisfaction is the affective orientation that an individual has about his
or her work (Price, 2001). Satisfaction at work appears to be a key predictor of

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Pedrazza et al. 5

nurses’ turnover and intentions to leave (Blegen, 1993; Irvine & Evans, 1995;
Lu, Barriball, Zhang, & While, 2012; Sourdif, 2004; L. T. H. Wang,
Ellenbecker, & Liu, 2012) and is therefore important to understand its sources.
Researchers have outlined a number of environmental and personality factors
associated with job satisfaction. In a systematic review, Lu et al. (2012) found
that organizational environment and working conditions (e.g., structural
empowerment and leader–member exchange; Laschinger et al., 2011), role
conflict and ambiguity, and organizational and professional commitment were
main predictors of nurses’ job satisfaction. Moreover, Laschinger et al. (2011)
found that both emotional exhaustion and cynicism were negatively related to
nurses’ satisfaction at work. As to personal dispositional factors, Judge, Heller,
and Mount (2002) reported significant correlations between job satisfaction
and the Big Five traits of extraversion, neuroticism, agreeableness, and con-
sciousness (for similar results, see Zhai, Willis, O’Shea, Zhai, & Yang, 2013).
Self-core evaluations (Judge & Bono, 2001; Srivastava, Locke, Judge, &
Adams, 2010), positive and negative affectivity, and affective disposition
(Connolly & Viswesvaran, 2000) are also related to satisfaction at work. The
present study examines for the first time the relationship between job satisfac-
tion and comfort with touch among nurses.
The purposes of the present study are (a) to examine whether nurses report
similar levels of (dis)comfort in relation to the three dimensions of touch (task-
oriented contact, touch promoting physical comfort, and touch aimed at emo-
tional containment); (b) to examine the associations between the three dimensions
of touch, emotional exhaustion, cynicism, and job satisfaction; (c) to test the
influence of touch on emotional exhaustion, cynicism, and job satisfaction.

Method
Design, Sample, and Procedure
The study was approved by the ethics committee of the researchers’ institu-
tion. A cross-sectional survey design was adopted. A questionnaire was
administered to a convenience sample of 400 registered nurses, working in
the departments of medicine, surgery, intensive care, oncology, and geriatrics
in several hospitals in Northeast Italy. Data were collected during 2010.
Participants were contacted during a 2-day pain management training course
held by one of the authors. They were given the questionnaire at the end of
the first day and asked to return it on the following day. Informed consent was
obtained from each participant. The final sample included 241 nurses (241 of
400; 60.25% return rate). The mean age was 41.14 years (SD = 7.65, range =
24-60). Females comprised 85.9% of the sample (207 of 241). The mean
length of service was 17.37 years (SD = 8.07, range = 1-35).

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6 Western Journal of Nursing Research 

Instrument
The survey contained the following measures.

CT scale. Nurses’ feelings of ease with touch were measured with eight items
(Pedrazza et al., 2014). Each item describes a specific form of contact with
the patient. Nurses are asked to indicate to what extent they feel at ease at
performing each contact behavior. Responses are given on a 7-point scale,
ranging from 1 (not at all) to 7 (very much). The measure is articulated into
three subscales. Two items measure task-oriented contact (e.g., “Touching
the patient to take his or her pulse”); three items measure touch aimed at
promoting physical comfort (e.g., “Massaging the patient’s hands to reduce
pain”); three items measure touch aimed at emotional containment (e.g.,
“Letting the patient cry in my arms”). Pedrazza et al. (2014) confirmed the
construct validity of the three-factor scale using exploratory factor analysis
(EFA). Cronbach’s alpha reliabilities in their study ranged between.91 (task-
oriented contact) and .96 (emotional containment). For the present study,
Cronbach’s alphas were .78 (task-oriented contact), .83 (promotion of physi-
cal comfort), and .87 (emotional containment).

Burnout. The Emotional Exhaustion and Cynicism scales of the Maslach

Burnout Inventory (MBI; Maslach & Jackson, 1981) were used in the Italian
version validated by Sirigatti and Stefanile (1993). Six items measured emo-
tional exhaustion (e.g., “I feel burned out from my work”), and five items
measured cynicism (e.g., “I feel I treat some recipients as if they were imper-
sonal objects”). Responses were given on a 7-point scale, ranging from 1
(completely disagree) to 7 (completely agree). Cronbach’s alpha coefficients
for the Italian adaptation are generally higher than .87 for emotional exhaus-
tion and .67 for cynicism (e.g., Martini & Converso, 2012). In this study,
Cronbach’s alphas were .87 (emotional exhaustion) and .72 (cynicism).

Job satisfaction. Job satisfaction was measured with four items (e.g., “I am satis-
fied with my job”), adapted from Dazzi, Voci, Capozza, and Bergamin’s (1998)
scale. The 7-point response scale ranged from 1 (completely disagree) to 7 (com-
pletely agree). Bobbio, Manganelli Rattazzi, and Muraro (2007) demonstrated
the construct validity of the one-factor scale with EFA and reported a Cronbach’s
alpha of .86. The Cronbach’s alpha coefficient for this study was .64.

Data Analysis
Data analysis was performed using SPSS 21.0 and LISREL 8.7 (Jöreskog &
Sörbom, 2004). PRELIS (LISREL 8.7) was used for the imputation of

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Pedrazza et al. 7

Figure 1. Hypothesized model of the effects of comfort with touch on emotional

exhaustion, cynicism, and job satisfaction.

missing data with the Expectation-maximization (EM) algorithm. Only

1.44% of the total responses (80 of 5,543) were missing scores. Following
Schafer and Graham’s (2002) recommendations, maximum likelihood impu-
tation (EM algorithm) was used to estimate values for missing scores.
Maximum likelihood procedures provide more accurate estimates of popula-
tion parameters than list-wise deletion or mean substitution (Schafer &
Graham, 2002). The validity of the CT scale was tested by applying CFA
(LISREL 8.7) to the eight items. Descriptive statistics were obtained with
SPSS 21.0. For each variable, a composite score was computed by averaging
the respective items. To test whether nurses reported similar levels of (dis)
comfort in relation to task-oriented contact, touch promoting physical com-
fort, and touch aimed at emotional containment, a one-way repeated-mea-
sures ANOVA (SPSS 21.0) was applied, using the Bonferroni correction for
multiple comparisons. Pearson correlation (SPSS 21.0) was used to examine
the relationship between the three CT subscales and well-being outcomes
(emotional exhaustion, cynicism, and job satisfaction). Structural equation
modeling (SEM; LISREL 8.7) was applied to test the relationship between
the three CT subscales and well-being outcomes. It was also examined
whether cynicism and job satisfaction are predicted by emotional exhaustion,
as found by previous research (Laschinger et al., 2011). To this aim, a media-
tion model was tested, in which CT subscales predict emotional exhaustion,
which, in turn, predicts cynicism and job satisfaction (see Figure 1). Two
parcels were computed for each of the following constructs: physical comfort
and emotional containment (CT scale), emotional exhaustion, cynicism, and

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8 Western Journal of Nursing Research 

job satisfaction. Parceling is a measurement approach commonly used in

latent-variable analysis techniques (Little, Cunningham, Shahar, & Widaman,
2002). A parcel is an aggregate-level indicator formed by averaging two or
more items. The use of parcels limits measurement error and provides a good
ratio of participants to variables. Moreover, compared with items, aggregate-
level data have some psychometric merits, such as higher reliability and a
lower likelihood of distributional violations. Items also have fewer, larger,
and less equal intervals between scale points than do parcels (Little et al.,
2002). For task-oriented contact, the two respective items were used as indi-
cators. In testing the model, the regression paths from the three CT subscales
to cynicism and job satisfaction (residual direct effects) were estimated. The
goodness of fit of the CFA and the SEM model was evaluated using the chi-
square test, the comparative fit index (CFI), and the standardized root mean
squared residual (SRMR). A model fits the data well when chi-square is non-
significant, CFI is ≥.95, and SRMR is ≤.08 (Hu & Bentler, 1999). Mediation
was tested with the Sobel test. For all analyses, the p value for statistical
significance was .05.

Results
The fit of the model for the three-factor structure of the CT scale (CFA) was
acceptable: χ2(17) = 90.40, p ≅ .00; SRMR = .059; CFI = .96. Although chi-
square was significant, the other two indices satisfied the respective criterion.
Loadings were all significant and higher than .75 (p < .001). The correlation
(phi coefficient) between task-oriented contact and emotional containment
was .50 (95% confidence interval [CI] = [.40, .60]; p < .001). The correlation
between task-oriented contact and physical comfort was .63 (95% CI = [.53,
.73], p < .001). The correlation between physical comfort and emotional con-
tainment was 71 (95% CI = [.67, .75], p < .001). None of the 95% CIs
included 1 (the perfect correlation), thus indicating that the three components
actually reflected three distinct dimensions.
Means and standard deviations for the study variables are reported in
Table 1. To test whether nurses reported different levels of comfort in relation
to the three CT subscales, a one-way repeated-measures ANOVA was applied.
Using the Greenhouse–Geisser correction, we found that the three subscales
differed significantly in the degree of perceived comfort, F(1.843, 442.393)
= 143.35, p < .001, ηp = .37. The highest perception of comfort was reported
2

in relation to task-oriented contact (M = 6.72, SD = 0.72), followed by touch

aimed at physical comfort (M = 5.93, SD = 1.37) and touch aimed at emo-
tional containment (M = 5.35, SD = 1.60). Multiple comparisons with the
Bonferroni correction were all significant, p < .001.

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 Table 1. Descriptive Statistics and Pearson Correlations Between the Study Variables (N = 241).

Measure M SD 1 2 3 4 5 6
1. Task-oriented contact (CT scale) 6.72 0.72 —
2. Physical comfort (CT scale) 5.93 1.37 .61, p < .001 —
3. Emotional containment (CT 5.35 1.60 .47, p < .001 .66, p < .001 —
scale)
4. Emotional exhaustion (burnout) 2.78 1.30 −.13, p = .04 −.28, p < .001 −.29, p < .001 —
5. Cynicism (burnout) 1.95 1.04 −.14, p = .03 −.21, p = .001 −.32, p < .001 .54, p < .001 —
6. Job satisfaction 4.96 1.23 .12, p = .064 .14, p = .03 .19, p = .03 −.54, p < .001 −.34, p < .001 —

Note. CT = Comfort with Touch.

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9
10 Western Journal of Nursing Research 

Table 2. Standardized Measurement Loadings for the Latent Constructs

(N = 241).

Item 1a Item 2 Parcel 1a Parcel 2

1. Task-oriented contact (CT 1.00 .72, p <.001
scale)
2. Physical comfort (CT scale) .98 .87, p < .001
3. Emotional containment (CT .94 .90, p < .001
scale)
4. Emotional exhaustion .88 .91, p < .001
(burnout)
5. Cynicism (burnout) .72 .86, p < .001
6. Job satisfaction .75 .67, p < .001

Note. Completely standardized parameters are reported. CT = Comfort With Touch.

a. Parameter fixed at 1.00.

Pearson correlations between CT subscales and well-being outcomes are

reported in Table 1. The three CT subscales are negatively associated with
both emotional exhaustion and cynicism, whereas they are positively related
to job satisfaction. Furthermore, in line with previous literature, emotional
exhaustion exhibits a positive correlation with cynicism and a negative cor-
relation with job satisfaction.
To test how the three CT subscales relate to well-being outcomes, SEM
was applied. Before testing the mediation model, we checked for multicol-
linearity by computing the Variance Inflation Factor (VIF) for each predictor.
All VIF coefficients were lower than 2.28, indicating that multicollinearity is
not a problem in our model. The hypothesized model showed an acceptable
fit: χ2 = 88.16, p ≅ .00, df = 39; SRMR = .036; CFI = .98. As to the measure-
ment portion of the model, loadings of latent variables were all significant (p
< .001) and higher than 0.66 (Table 2). The results from the structural portion
of the model are shown in Figure 2. Only touch aimed at emotional contain-
ment significantly predicted emotional exhaustion. Although the three dimen-
sions were all negatively associated with emotional exhaustion (see Table 1),
when they all were included in the same regression model, emotional con-
tainment turned out to be the strongest predictor. Emotional exhaustion, in
turn, was positively related to cynicism and negatively related to job satisfac-
tion (see also Table 1). Moreover, the residual direct effect of emotional con-
tainment on cynicism was significant. Therefore, there was a partial mediation
effect for the path emotional containment–emotional exhaustion–cynicism
and a total mediation effect for the path emotional containment–emotional

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Pedrazza et al. 11

Figure 2. Regression model of the effects of comfort with touch on cynicism and
job satisfaction through emotional exhaustion (N = 241).
Note. Goodness of fit indices for the model are χ2 = 88.16, p ≅ .00, df = 39; SRMR = .036;
CFI = .98. Only significant parameters (completely standardized) are reported. Curved paths
indicate correlations (phi coefficients) between latent variables. SRMR = standardized root
mean squared residual; CFI = comparative fit index.

exhaustion–job satisfaction. The Sobel test confirmed that both indirect paths
were significant: z = 2.53, p = .012, for cynicism; and z = 2.54, p = .011, for
job satisfaction. Finally, the effects of age, gender, and length of service were
controlled by entering them in the regression model as covariates. The model
showed a good fit: χ2 = 113.33, p ≅ .00, df = 57; SRMR = .033; CFI = .98.
However, no significant effect of the covariates emerged.

Discussion
Although the positive effects of touch in caring are widely recognized, only
a few studies have investigated how nurses perceive physical contact with
patients. Understanding nurses’ perceptions of contact with patients is of pri-
mary importance, as touch plays a pivotal role in the provision of nursing
care (Chang, 2001). The present study assessed nurses’ comfort in relation to
three types of touch: task-oriented touch, touch promoting physical comfort,
and touch aimed at offering emotional containment. Task-oriented contact
elicited the highest level of comfort, followed by touch aimed at promoting
physical comfort and touch providing emotional containment. This result

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12 Western Journal of Nursing Research 

suggests that the three dimensions of touch reflect three different levels of
affective and cognitive proximity to the patient. The highest perception of
comfort during task-oriented contact can be explained in different ways.
First, Italian nurses are extensively trained to touch patients to accomplish
their tasks, but they do not generally receive adequate training on non-neces-
sary forms of touch, such as touch promoting physical comfort or providing
emotional containment. Second, task-oriented touch requires lower emo-
tional and cognitive proximity to the patient and is, therefore, less likely to
provoke feelings of uneasiness. Research has shown that closer proximity of
an approaching experimenter causes higher discomfort (Hayduk, 1981).
Individuals value the physical space around them and feel increasingly
uneasy as their distance from another person diminishes (Hayduk, 1981),
especially if they are not in a close relationship with the person. For this rea-
son, touch aimed at emotional containment was experienced by our sample as
the less comforting type of contact.
To examine how comfort with touch relates to nurses’ burnout and job
satisfaction, SEM was applied. In the hypothesized model, the three dimen-
sions of comfort predicted lower emotional exhaustion, which, in turn, pre-
dicted higher levels of cynicism and lower levels of job satisfaction. Although
all three CT subscales were negatively related to emotional exhaustion (Table
1), when they were all simultaneously entered in the regression model, only
comfort with touch providing emotional containment significantly predicted
emotional exhaustion and cynicism. This stronger effect of the Emotional
Containment subscale on nurses’ well-being suggests that the affective bond
with patients plays an important role in nurses’ workplace well-being. Our
results show that nurses who find it easy to develop a relationship of emo-
tional closeness to the patient are less likely to develop burnout symptoms.
This result seems at odds with recent findings on dehumanization in medical
contexts, which show that humanization of patients is positively associated
with stress and burnout, especially among health care workers with higher
levels of commitment (Trifiletti, Di Bernardo, Falvo, & Capozza, in press) or
higher levels of contact with patients (Vaes & Muratore, 2012). Furthermore,
research has shown that nurses are likely to be emotionally overwhelmed by
routinely caring for patients experiencing trauma, pain, and suffering (Sabo,
2006). However, it is possible that nurses who feel comfortable with provid-
ing emotional containment through touch are better able to manage intimacy
with patients avoiding to be over-involved in their suffering. Moreover, feel-
ing comfortable with emotional closeness probably helps to establish a posi-
tive and rewarding interaction with patients, and this probably acts as a buffer
against stress. This would also help to explain the direct path from comfort
with emotional containment to reduced cynicism (reduced detachment from
the job and from patients).

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Pedrazza et al. 13

In our model, emotional exhaustion was in turn related to higher levels of

cynicism. This result is in line with burnout theory (Leiter & Maslach, 2004)
and gives support to the notion that cynicism is an outcome of emotional
exhaustion (Laschinger et al., 2011). Our findings also revealed a negative
effect of emotional exhaustion on job satisfaction, which confirms previous
research on the link between job satisfaction and stress/burnout (Lu et al.,
2012).
In sum, our results indicate that nurses’ comfort with physical touch is
associated with greater workplace well-being. On the other side, these find-
ings suggest that a lack of comfort with touch is related to greater burnout and
lower job satisfaction. Job burnout is associated with serious physical and
mental health problems (Shirom, Melamed, Toker, Berliner, & Shapira,
2005), and job satisfaction is regarded as a key predictor of nurses’ turnover
(Lu et al., 2012). Therefore, organizations should attempt to limit the influ-
ence of factors that could cause burnout and reduced satisfaction, on one
hand, and promote those factors that act as buffers against stress and burnout,
on the other. Clearly, this can be done not only by addressing situational vari-
ables but also by recognizing the role of individual perceptions. Feelings of
comfort or discomfort with physical touch are most likely affected by indi-
vidual difference variables, such as attachment styles (Shaver & Mikulincer,
2007); people with insecure attachment systems (anxious or avoidant) should
be more likely to feel discomfort in their interactions with patients, compared
with people with secure attachment. However, professional training and edu-
cation are also likely to play a role in the management of discomfort with
physical touch and in fostering positive feelings of comfort and safety during
contact. Health care institutions could therefore benefit from training inter-
ventions in which nurses can become aware of their feelings during different
types of physical contact with patients and can learn how to cope with emo-
tionally involving forms of touch. Our results showed that touch providing
emotional containment was perceived as the less comforting type of contact
with patients and yet, was the strongest predictor of well-being outcomes. It
is important to note that this form of touch is especially needed by those
patients who are suffering the most (i.e., oncological patients, critical care
patients) and/or are particularly fragile and vulnerable (e.g., the elderly), and
that nurses working with this type of patients are at risk of developing burn-
out and stress (Burgess, Irvine, & Wallymahmed, 2010). Helping nurses to
establish a positive and warm relationship with patients through touch with-
out being overwhelmed by their suffering could be an advantage for both
nurses’ well-being and quality of care.
A limitation of our study is its cross-sectional design that makes it difficult
to draw definitive conclusions about the direction of causality. Future research

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14 Western Journal of Nursing Research 

should test our model by adopting longitudinal or experimental designs. A

second limitation is that we only used self-report measures at a single point
in time. This can be a source of common method variance. According to
Spector (2006), however, the negative effects of common method variance
have been exaggerated and, under some circumstances, self-report measures
may be more accurate than “objective” measures. Concerns about common
method variance in this study are, to some extent, attenuated by the use of
reliable and validated measures. It is worthwhile noting that although the
internal consistency of our measures was generally good (George & Mallery,
2003; Kline, 1999), the reliability of the job satisfaction measure was just
acceptable. Therefore, it would be useful, in future research, to adopt differ-
ent measures of the constructs included in our model, such as supervisors’
evaluations of burnout symptoms and job satisfaction. Another limitation of
the study is that it did not examine the role of gender. Previous research sug-
gests that gender may affect perceptions of touch (Evans, 2002; Lane, 1989).
Male and female nurses may probably express different levels of comfort
with touch, also depending on patient’s gender. This might be especially true
for the more involving forms of touch. Future studies should analyze the role
of gender and of other factors not analyzed in the present study, such as work
settings or individual difference variables. Importantly, the nature of our sam-
ple may also have contributed to our findings. Participants were nurses
attending a pain management course. This may have affected their responses
in some way. Moreover, our results may not generalize to different countries.
Future studies should investigate the hypothesized relationships between the
variables with a different sample. Finally, more research is needed to investi-
gate other possible outcomes of comfort with touch, such as nurses’ perfor-
mance, patient’s complaints, and perceptions of quality care.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publi-
cation of this article.

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