‘On the Edge of a Whirlpool’ Living With a Fear of Needle Procedures Shona Matthews A thesis submitted in partial fulfilment for the degree of Master of Health Sciences, Unitec New Zealand 2011 Abstract This study explores the lived experience of needle phobia through individual interviews with five participants. The understanding and experience of three medical imaging nurses carrying out procedures on patients with needle phobia is also explored to provide clinical context and comparison. The study is guided by the values of phenomenology and in particular the body philosopher Merleau-Ponty. It will also draw on the research of nurse scholars Patricia Benner and Irena Madjar who have focused on the body and embodiment in nursing practice. Interpretation of the data is informed by the work of Anthony Giddens. The study unravelled a fear notable for its personal idiosyncrasies, and variable origins. It is an obscure fear that is experienced as intensely physical and embodied but is not primarily about pain. A needle piercing the skin violates the integrity of the skin surface, even the sense of self and at worst threatens to overwhelm, likened by one participant to being on the edge of a whirlpool. Living with the fear involves managing a wayward body, with particular capacities for action, but plagued by uncertainty at how it will respond when faced with a needle procedure. It is an irrational fear that impacts upon life choices and ‘pierces the protective cocoon’; the main emotional support that allows us to cope with life, arousing a sense of shame that something so simple cannot be mastered and threatening the usual competent face the person presents to the world. In contrast, the nurses saw needle phobia as an emotional reaction related to pain; they felt empathy and concern for their patient but also personal anxiety when faced with a distressed or fearful patient. Narratives revealed the challenge and dichotomy of their caring, learning and instrumental role. This was particularly acute for the novice practitioner. Caring and coping with their own reactions was closely intertwined with getting the job done. Ethical dilemmas arose. Mutual vulnerability was demonstrated with the nurse’s sense of competence also threatened when the procedure failed. The study revealed significant implications for clinical practice both in regard to caring for people with needle phobia and in teaching and mentoring nurses. A partnership approach to care emerged as the most appropriate way to meet the varying subjective needs of people with needle phobia, while allowing nurses to combine both their pathic and instrumental touch. i Acknowledgements Firstly I would like to thank my participants with needle phobia who have shared their experiences of living with a fear of needle procedures. The very nature of the fear means it is not generally thought or talked about so their willingness to participate was particularly poignant and without their contribution the research would not have been possible. A special thank you to the nurse participants, acknowledging their potential vulnerability and the courage involved in reflecting on and talking to a colleague about clearly distressing interactions, so we might all learn from them. I would also like to thank my brother-in-law Richard Matthews, for his reflections on his own experience of needle phobia. Like many of the extended family, I was unaware of Richard’s fear and his struggles to self-inject insulin. His reflections were particularly helpful in formulating the research questions and his comments peppered throughout the thesis often filled gaps in understanding. My sincere thanks to my principal supervisor, and mentor Dr Elizabeth Niven. I have cherished your wisdom, enthusiasm and friendship throughout my post graduate studies. Thank you for allowing me space to explore research options and finally settle on a project that was both important to me and clinically significant. You were always there to inspire and suggest further reading material and your emails and our meetings helped maintain my motivation and the reflective process. Thanks also to my associate supervisor Jillian Phillips for offering such an enthusiastic clinical focus. The staff in the radiology department at Green Lane Clinical Centre have been a wonderful support throughout the research and writing process. Particular thanks to my nursing colleague Jakob Janse who has filled all the gaps while my mind was elsewhere, and to our team leader Kathryn Bush for her continued interest and encouragement. Finally I would like to thank my husband Graham and family for their love, support and encouragement. Special thanks to my daughter Dr Brya Matthews for proof reading, comment and technical support and to my daughter Megan for her word processing expertise. ii Table of Contents Abstract ................................................................................................................................................. i Acknowledgements .............................................................................................................................. ii Glossary .............................................................................................................................................. vii Chapter 1 – Introduction ...................................................................................................................... 1 Part A – Setting the Scene ................................................................................................................ 1 Origins of the Study ...................................................................................................................... 2 The Terminology .......................................................................................................................... 3 Part B – Defining Needle Phobia ...................................................................................................... 5 The Neurophysiology of Needle Phobia ...................................................................................... 6 Aetiology of Needle Phobia ....................................................................................................... 10 Prevalence .................................................................................................................................. 11 Significance ................................................................................................................................ 12 Part C – The Philosophical Basis of the Study ................................................................................ 14 The Embodied Self ..................................................................................................................... 14 Hearing and Telling Stories ........................................................................................................ 15 Phenomenology and Hermeneutic Analysis .............................................................................. 15 The Development of Self Identity .............................................................................................. 16 The Research Gap ...................................................................................................................... 17 Chapter 2 Literature Review ......................................................................................................... 19 The Paediatric Setting and Venepuncture ..................................................................................... 19 The Challenge of Researching Needle Phobia ............................................................................... 21 The Role of Fear and Disgust ......................................................................................................... 22 Case Studies ................................................................................................................................... 24 Imaging Studies .............................................................................................................................. 25 Qualitative Research on Needle Phobia ........................................................................................ 25 iii Interpretation of Findings .............................................................................................................. 26 Chapter 3 – Methodology and the Research Process ........................................................................ 29 Phenomenological Enquiry and this Study .................................................................................... 29 Merleau-Ponty and the Concept of Embodiment ..................................................................... 31 Nursing and Phenomenology ..................................................................................................... 33 Use of Narrative and Forceful Metaphor ................................................................................... 35 Achieving Quality ........................................................................................................................... 36 Ethical Considerations ................................................................................................................ 36 Assumptions and Expectations .................................................................................................. 38 Trustworthiness and Authenticity ............................................................................................. 39 The Research Process ..................................................................................................................... 42 Pilot Studies................................................................................................................................ 42 Selection of Participants ............................................................................................................ 42 Selection of Nurse Participants .................................................................................................. 44 The Interviews ............................................................................................................................ 44 Hermeneutic phenomenology; Data analysis and Interpretation ................................................. 47 The Emerging Story .................................................................................................................... 50 Limitations of the Study ............................................................................................................. 50 Chapter 4 – Discussion: The Participant Experience.......................................................................... 52 Introducing the Discussion ............................................................................................................. 52 The Participants ............................................................................................................................. 53 Unravelling the Fear ....................................................................................................................... 53 Personal Idiosyncrasies .............................................................................................................. 53 A Fear Evolves ............................................................................................................................ 55 ‘Violation of Integrity’ ................................................................................................................ 58 Living with the Fear ........................................................................................................................ 61 A Wayward Body ........................................................................................................................ 61 iv ‘Challenge to Integrity’ ............................................................................................................... 64 ‘Capacity for Action’ ................................................................................................................... 66 ‘Piercing the Protective Cocoon’ .................................................................................................... 70 A Sense of Shame ....................................................................................................................... 70 A Threat to Competence ............................................................................................................ 72 Chapter 5 – The Nurse Experience ..................................................................................................... 75 The Clinical Context........................................................................................................................ 75 The Nurse Participants ................................................................................................................... 76 An Etic Perspective ......................................................................................................................... 76 The Personal Challenges ................................................................................................................ 78 Getting the Job Done ..................................................................................................................... 79 On Caring and Coping ................................................................................................................ 84 The Ethical Dilemmas ..................................................................................................................... 88 The Ambiguity Between the Pathic and Instrumental Touch .................................................... 89 Learning Verses Caring ............................................................................................................... 91 Weighing Up the Greater Good ................................................................................................. 92 Autonomy and Self Determination versus Paternalism ............................................................ 92 ‘Piercing the Protective Cocoon’ .................................................................................................... 93 A Threat to Competence ............................................................................................................ 94 Chapter 6 – Recommendations ......................................................................................................... 96 The Lived Experience of Needle Phobia ......................................................................................... 96 The Nurses’ Experience of Needle Phobia ..................................................................................... 98 Implications for Clinical Practice: Care of Patients with Needle phobia ..................................... 100 The Practicalities ...................................................................................................................... 102 Implications for Further Research ........................................................................................... 103 Implications for Clinical Practice: Support and Training of Nurses ............................................. 105 Implications for Further Research ........................................................................................... 107 v Drawing the Threads Together .................................................................................................... 109 References........................................................................................................................................ 112 Appendix A: Study documentation .................................................................................................. 116 vi Glossary Aichmophobia: fear of pointed objects. Algophobia: fear of pain. Blenophobia: fear of needles. Bracketing: a term derived from mathematics meaning to set aside or suspend one’s various beliefs. Diaphoresis: sweating. Embodiment: the ways meanings, expectation, styles and habits are expressed and experienced in the body. Emic: Internally evaluated or experiential view (qualitative). Epistemology: concerns how and what people know. Etic: externally evaluated view based on normative standards. Functional Magnetic Resonance Imaging (fMRI): a specialised MRI scan which measures the hemodynamic response (change in blood flow) related to neural activity in the brain or spinal cord of humans. Gnostic: as in (dia)gnostic or to know thoroughly in the sense of ‘seeing through the body’. Integrity of Self: the person’s sense of soundness in the various dimensions of her or his life. Integrity is challenged when something has the potential to disrupt that conceptualisation and there is corresponding uncertainty about the ability to respond adequately. Intravenous (IV) Cannulation: the insertion of a fine plastic tube into a vein for the administration of fluids or medication. Lived experience: the way people encounter situations in terms of their own personal concerns, background meanings, temporality, habitual cultural bodies, emotions and reflective thoughts. vii Mind-body-split: the idea that originated from Descartes that the mind and body are separate and distinct entities. As long as the mind is the only source of meaning and interpretation, the body cannot be understood as a knower but only as a means of bringing information to the mind. Moral agency: capacity for making moral judgement or taking moral action. Ontology: concerns how people are or exist. Pathic: derived from ‘pathos’ meaning ‘suffering’ and also passion and disease or ‘a quality that arouses pity or sorrow. The pathic also refers to the general mood, sensibility and felt sense of being in the world. Phenomenology: a philosophy that focuses on the ‘lifeworld’ or ‘lived experience’ of human beings as revealed through their own descriptions. PICC: A PICC line is, by definition and per its acronym, a peripherally inserted central catheter. It is long, slender, small, flexible tube that is inserted into a peripheral vein, typically in the upper arm, and advanced until the catheter tip terminates in the superior vena cava to obtain intravenous access. Phlebotomy: puncturing a vein with a needle to collect blood for diagnostic tests or to remove blood for treatment purposes. Term used in American literature. Interchangeable with venesection. Reflection: critical examination of the research process or of an event or behaviour. Reflexivity: Examining and uncovering the researcher’s place in the research process. Syncope: fainting or partial or complete loss of consciousness with interruption of awareness of oneself and one’s surroundings. Temporality: the way the person simultaneously lives in the present, is influenced by the past, and is projected into the future. It does not refer to the linear passage of time but to the way the person is anchored in a present that is made meaningful by past experience and the anticipated future. Trypanophobia: fear of injections. viii Vasovagal reflex: a reflex mediated by stimulation of the vagus nerve (parasympathetic nervous system) resulting in a slowing of the heart rate (bradycardia), fall in blood pressure (hypotension) and peripheral vasodilation. May result in vasovagal syncope or fainting as a result of reduced cerebral blood flow or cerebral anoxia Venesection: puncturing a vein with a needle to collect blood for diagnostic tests or to remove blood for treatment purposes. (Latin derivation) Vicarious Needle phobia: a phobic response to the witnessing of someone else having a blood test or needle procedure done. Vulnerability: an experiential quality of life, the foundation of which is the individual’s experience of being unprotected and open to damage in threatening environments (qualitative perspective). Vulnerability: The universally present relative risk of potential or actual harm from external judgments of endangerment, functional capacity, and socially sanctioned need for intervention (quantitative perspective). ix