ORIGINAL RESEARCH

THE EFFECTS OF HEALING TOUCH ON PAIN, NAUSEA, AND ANXIETY FOLLOWING BARIATRIC SURGERY: A PILOT STUDY Joel G. Anderson, PhD, CHTP1# Liliana Suchicital, BSN, RN4, CBN, HBB-PA2 Maria Lang, RN, HBB-PA2 Azra Kukic, RN, MSN, CBN, ACM2 Lucrezia Mangione, MA, LGPC, CMT, CHTP/I3 Diane Swengros, MSN, RN-BC, HBB-PA4 Jennifer Fabian, BSN, RN3, CCRN5 and Mary Ann Friesen, PhD, RN, CPHQ, HBB-PA4

Context: Given the growth in the number of bariatric surgeries, it is important for healthcare practitioners to maximize symptom management for these patients, including the option of complementary therapies such as Healing Touch. Objective: A quasi-experimental study was conducted to determine the feasibility of a Healing Touch intervention for reducing pain, nausea, and anxiety in patients undergoing laparoscopic bariatric surgery. Design: Following surgery, a nurse administered the Healing Touch intervention once daily. Study participants reported levels of pain, nausea, and anxiety immediately before and after the Healing Touch intervention using separate numeric rating scales.

INTRODUCTION Obesity has become an epidemic worldwide, with an estimated 1.5 billion adults overweight (BMI Z 25) and 500 million adults obese (BMI Z 30) in 2008.1 In the U.S., the prevalence of obesity is estimated at 34% of the population.1 The rise in the incidence of obesity is closely related to increased prevalence of comorbidities, including type 2 diabetes, hyperlipidemia, hypertension, heart disease, and sleep apnea, which contribute to a decrease in life expectancy of 10 or more years.2 Until the development of a less invasive, successful, long-term intervention to counter the effects of obesity, bariatric surgery (including gastric bypass, gastric sleeve, and gastric banding) will continue to be used, potentially at increased rates. Indeed, the annual number of bariatric surgeries performed in the U.S. has increased to approximately 200,000 in the last decade.3 Post-operative pain control continues to be managed ineffectively after surgical procedures4,5 and can have 1 Center for the Study of Complementary and Alternative Therapies, School of Nursing, University of Virginia, P.O. Box 800782, Charlottesville, VA 22908-0782 2 Inova Fair Oaks Hospital, Fairfax, VI 3 Handcrafted Health, LLC, Silver Spring, MD 4 Inova Health System, Falls Church, VI 5 Inova Loudoun Hospital, Leesburg, VI

# Corresponding author. e-mail: [email protected]

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& 2015 Elsevier Inc. All rights reserved. ISSN 1550-8307/$36.00

Results: Significant decreases in pain, nausea, and anxiety were observed immediately following the intervention on post-operative days one and two, and in pain and anxiety on post-operative day three compared with pre-intervention levels. These findings indicate that the Healing Touch intervention is feasible and acceptable to patients undergoing bariatric surgery, and significantly improved pain, nausea, and anxiety in these patients. Key words: Healing Touch, pain, surgery, nausea, nurse (Explore 2015; 11:208-216 & 2015 Elsevier Inc. All rights reserved.)

deleterious effects on patient recovery and satisfaction.6 Abdominal pain is one of the most common symptoms experienced by patients following bariatric surgery. Strategies to reduce opioid use in this patient population are highly desirable.7,8 There is a high prevalence of obstructive sleep apnea among these patients, and the use of opioids to manage post-operative pain can lead to complications related to the development of adverse respiratory events.9,10 Additionally, opioid use is inversely related to the quality of recovery from surgery,11 and there is a relationship between opioid-sparing strategies and better patient outcomes.12,13 Pain management is recognized as a quality measure for optimal care by the Joint Commission,14 which emphasizes alternatives to pharmacological interventions in the management of patient comfort, pain control, and healthrelated quality of life (HQoL).15 Therefore, patients may require more than prescription medication for pain relief or comfort. Obesity is associated with mood disorders and anxiety disorders16 and is correlated with a significant increase in lifetime diagnoses of major depression and panic disorders.16 Obese subjects seeking treatment have been shown to have more psychopathologies, including anxiety and depression, than normal-weight controls.16 Moreover, those persons seeking medical treatment of obesity, including bariatric surgery, have higher rates of anxiety disorders than those seeking behavioral-based treatments for weight loss.17 Although the results are equivocal, most studies point to a decrease in weight-loss outcomes following surgery in

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patients with higher levels of anxiety.18 Still, most studies point to a decrease in overall weight lost following the surgery in those with anxiety disorders or higher levels of anxiety.16 Given the life-changing nature of bariatric surgery and the prevalence of anxiety disorders among this patient population, patients undergoing this surgical procedure can exhibit high levels of anxiety during the perioperative experience. Post-operative nausea and vomiting remain primary factors related to dissatisfaction with the perioperative experience in patients undergoing laparoscopic bariatric surgery.19 Pharmacological advances in treatment of post-operative nausea and vomiting have met with limited success.20 Onethird to one-fifth of this patient population continue to have significant post-operative nausea and vomiting despite prophylactic treatment using frontline anti-emetics.21 Postoperative nausea and vomiting are associated with significant perioperative morbidity in terms of dehydration, electrolyte imbalance, hypertension, and potential aspiration. Current available interventions for post-operative nausea lack universal effectiveness.22 Although these pharmacological treatments may decrease the incidence of vomiting, these treatments have little to no effects on patients' ratings of nausea.20 Given these findings, holistic and integrative care can offer other aspects of symptom management for these patients that may be neglected by conventional treatment. One such integrative modality that holds promise for improving outcomes in this patient population is Healing Touch. Healing Touch (HT) arose in the nursing field and is described as a patient-centered modality in which the practitioner and recipient participate jointly in the healing process.23,24 Biofield therapies, such as HT, are categorized as mind–body therapies and involve the direction of healing energy through the practitioner's hands to facilitate general health and well-being by modifying the patient's energy field.25,26 These biofield modalities are most demonstrable when used to treat symptoms affecting patient-centered outcomes encompassing HQoL. To date, most published research on the use of biofield therapies, including HT, in clinical settings and studies has been among cancer, pain, and palliative care patients.27 While several studies have demonstrated the effectiveness of energy-based healing modalities in reducing generalized pain,27–35 most of these studies focused on the benefits and effectiveness of Therapeutic Touch rather than HT, and none have focused on symptom management in patients undergoing bariatric surgery. Recent reviews and metaanalyses have found many biofield studies, including HT, to be promising enough to warrant further research,36 including a recent Cochrane review that found biofield therapies to be effective for managing pain.37 Given the potential effectiveness in improving HQoL, these modalities represent an untapped resource for improving patient-centered outcomes, complementing conventional care models.38–40 While HT studies have examined some clinical endpoints in the inpatient setting,41–44 no study to date has examined the impact of nurses' delivery of HT in the acute care setting on pain and other patientcentered outcomes in persons undergoing bariatric surgery.

Healing Touch in Bariatric Surgery

Thus, the aim of the proposed study was to determine the effectiveness of a HT intervention for reducing length of stay, use of pain and nausea medications, hospital complications (coded complication, infections, extended LOS, and additional surgery), pain, stress, anxiety, and nausea in patients undergoing laparoscopic bariatric surgery (gastric bypass/Roux-en-Y or gastric sleeve), using a quasiexperimental study design. METHODS Study Sample Participants in the Healing Touch intervention group were recruited from a mid-Atlantic, mid-sized hospital during preoperative bariatric surgery education classes. A total of 46 participants were recruited for the study (Figure 1). For the Healing Touch intervention group, 21 patients age Z 18 years scheduled for laparoscopic bariatric surgery were enrolled. For the control comparison group, 25 patients who underwent surgery during the three months prior to the intervention period were identified and matched by age, sex, BMI, and type of surgery to participants in the intervention group. Data concerning the outcomes outlined below were obtained from the electronic medical record for both groups. Inclusion criteria were (1) scheduled for laparoscopic bariatric surgery (gastric bypass/Roux-en-Y or gastric sleeve), (2) the ability to ensure informed consent and completion of assessments, and (3) the ability to speak and understand English. Exclusion criteria included (1) prior regular use of Healing Touch (4one session/month) within three months of enrolling in the study and (2) concurrent Healing Touch or other mind–body/biofield therapy outside of the study protocol. All participants provided informed consent, and all study procedures were approved by the health system Institutional Review Board. Recruitment Patients scheduled for laparoscopic bariatric surgery (gastric bypass/Roux-en-Y or gastric sleeve) were introduced to and informed of the study by a member of the study team during pre-operative patient education sessions. An overview of the study was presented, as well as the pros and cons of study participation. Once screened for eligibility, a member of the study team provided informed consent during these patient education sessions and collected baseline data as outlined below. Healing Touch Intervention Following surgery and admission to the surgical unit, a nurse on the unit trained in Healing Touch and familiar with the study protocol delivered the Healing Touch intervention. The Healing Touch intervention used was modified from the Magnetic Clearing technique learned during the first level of Healing Touch training. Magnetic Clearing is a full-body technique used to clear the entire biofield, reducing nausea and pain.45 The intervention was designed for ease of use in the inpatient setting and took approximately seven minutes to complete. During each 24-h period of a participant's inpatient stay, a nurse on the unit trained in Healing Touch and familiar with the study protocol delivered the Healing Touch intervention. Immediately before and immediately following the Healing Touch

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Figure 1. Flow diagram of study participants.

intervention, participants reported their present levels of pain, anxiety, and nausea using three numeric rating scales (NRS). Control Group Data from matched controls were obtained from the electronic medical record. The control group was matched by age, sex, BMI, and surgical procedure to participants in the Healing Touch intervention group. Only outcomes obtained from the electronic medical record were collected for the control group. Outcomes Demographics and medications. Information concerning age, partner status, education, ethnicity, and race was collected at the time of recruitment during the patient education sessions for the intervention group or abstracted from the electronic medical record for the control group. Treatment expectancy. The treatment expectancy questionnaire consisted of five items that participants rated (0–10 scale) indicating how logical the treatment is, how confident

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they are about the treatment being successful, how confident they would be in recommending the treatment, and the degree of improvement expected. Completion of the five treatment expectancy items occurred during the patient education session. Additional open-ended questions regarding treatment expectancy were completed by participants following the intervention and before discharge. These descriptive data were summarized to give additional clarity related to feasibility of the intervention.

Mindfulness. The Tellegen Absorption Scale is a validated means of quantifying the personality characteristic absorption, or increased mindfulness, which is associated with increased usage of complementary and alternative medicine (CAM) modalities delivered by a practitioner,46 and may be indicative of the effect of a “healing presence.” Empirically, it is predicted that high absorbers will perceive a greater healing presence than low absorbers and thus may exhibit greater effects in response to practitioner-delivered CAM therapies such as Healing Touch.46 This scale was completed during the

Healing Touch in Bariatric Surgery

Table 1. Sample Characteristics Characteristic Age BMI Sex Female Male Race Caucasian African American Asian Unknown Marital/partner status Married/ partnered Divorced/ separated Single Years of education Mindfulness

Healing Touch (n ¼ 21) 39.43 ⫾ 10.33 42.82 ⫾ 5.49

Historical Matched Control (n ¼ 25) 38.80 ⫾ 13.66 46.20 ⫾ 7.19

18 (85.7%) 3 (14.3%)

22 (88%) 3 (12%)

16 (76.2%) 3 (14.3%)

15 (60%) 5 (20%)

1 (4.75%) 1 (4.75%)

1 (4%) 4 (16%)

Pvalue .708 .110 .913

.899

– 11 (52.4%)

–

2 (9.5%)

–

7 (38.1%)

–

16.25 ⫾ 1.83

–

19.0 ⫾ 6.59

–

patient education session by participants in the intervention group to examine the relationship between mindfulness and the effects of the intervention on pain, nausea, and anxiety. Pain, nausea, and anxiety were measured using individual Numeric Rating Scales (NRS), which ranged from 0 to 10. The NRS takes less than 1 min to complete and is a simple, yet sensitive, measure. Pain, anxiety, and nausea levels were assessed pre- and post-intervention. Additionally, pain levels were documented using the NRS throughout the participants' inpatient stay as a part of usual care. These pain ratings and the use of pain medications following the Healing Touch intervention were used as a comparison to the matched controls. Hospital anxiety and depression scale (HADS). Levels of anxiety and depression were assessed using the HADS, developed by Zigmond and Snaith,47 which is a widely used reliable measure of anxiety and depression48 that has been used in the bariatric surgery population.49–52 The 14item instrument measures anxiety and depression on two intermingled subscales.48 The HADS was administered at baseline and discharge. Patient-centered outcomes, including total length of stay (LOS; days), use of pain medications, and hospital complications (coded complication, infections, extended LOS) potentially associated with bariatric surgery53 were obtained from the electronic medical record. These outcomes were documented daily and used as a comparison to the matched controls.

Healing Touch in Bariatric Surgery

Statistical Analyses Data were analyzed using SPSS version 21. Descriptive statistics were calculated for demographic and baseline outcome variables. Demographic differences between treatment groups were tested using independent t-tests or Mann–Whitney U tests, as appropriate, for continuous variables and chi-square tests for categorical variables. Differences in pre- and post-intervention levels of pain, nausea, and anxiety in the Healing Touch group were assessed using the Wilcoxon signed-rank test. Pearson's and Spearman's correlations, as appropriate, were used to determine relationships between levels of mindfulness and post-operative pain, nausea, and anxiety. Differences in average daily pain ratings between the Healing Touch and control groups were analyzed using separate ANCOVA models. Medication use was accounted for using the method proposed by Sloane et al.54 in which a continuous variable for analgesic load was calculated for each measurement time point. The level of significance for all analyses was set at P o .05.

RESULTS The sample consisted mostly of Caucasian women with a mean age of 39.44 ⫾ 12.12 years and average BMI of 44.83 ⫾ 6.69. Additional demographic characteristics of the study sample are reported in Table 1. Of the 46 individuals preparing to undergo bariatric surgery who attended the patient information sessions, 23 (50%) were enrolled. Of the remaining 23 individuals, one did not meet the inclusion criteria and 22 declined to participate. Individuals in the Healing Touch group had clinically (4 20% reduction) and statistically significant differences in postintervention pain (P ¼ .001), nausea (P ¼ .003), and anxiety (P o .001) on post-operative day one and day two (pain, P ¼ .001; nausea, P ¼ .016; anxiety, P ¼ .001), and for pain (P ¼ .034) and anxiety (P ¼ .041) on post-operative day three (Figure 2). Differences in post-intervention nausea on postoperative day three were clinically significant but not statistically significant (P ¼ .066). Reductions in symptom scores following the Healing Touch intervention using the numeric rating scales ranged from two to eight points. Additionally, participants in the Healing Touch group demonstrated significant decreases in pre-intervention anxiety and nausea on days two and three compared with the previous day (P o .05). There was no significant difference in post-operative average daily pain ratings (Table 2) or LOS (Healing Touch 1.95 ⫾ 0.848, control 1.64 ⫾ 0.638; P ¼ .241) between those in the Healing Touch group and historical controls. While not statistically significant, those in the Healing Touch group had lower mean analgesic ratings post-operatively compared with historical controls (data not shown). Degree of mindfulness was inversely related to postintervention anxiety on post-operative day one in the Healing Touch group (r ¼ 0.483; P ¼ .031). No other significant correlations were observed between post-intervention levels of pain, nausea, and anxiety and degree of mindfulness. In the Healing Touch group, post-intervention pain was significantly correlated with post-intervention nausea (r ¼ 0.611;

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Figure 2. Pre- and post-intervention symptom levels in the Healing Touch group. Mean pre-intervention (gray) and post-intervention (white) pain (A), anxiety (B), and nausea (C) scores using separate numeric rating scales are presented. Error bars represent the standard deviation. *Post-intervention scores significantly different (P o .05) than the corresponding pre-intervention scores. †P o .10.

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Healing Touch in Bariatric Surgery

Table 2. Average Post-oPerative Daily Pain Ratings Abstracted From the Medical Record Healing Touch Historical Matched Post-Operative Day (n ¼ 21) Control (n ¼ 25) P-value Day 1 3.76 ⫾ 1.50 4.15 ⫾ 1.45 .380 Day 2 3.91 ⫾ 1.13 3.65 ⫾ 1.59 .563 Day 3 3.30 ⫾ 1.53 2.96 ⫾ 1.82 .655

P ¼ .004) and anxiety (r ¼ 0.528; P ¼ .017) on post-operative day one and post-intervention pain (r ¼ 0.559; P ¼ .013) on post-operative day two. Post-intervention nausea on postoperative day one was correlated with post-intervention nausea on post-operative day two (r ¼ 0.679; P ¼ .001), as was post-intervention anxiety on post-operative day one (r ¼ 0.616; P ¼ .005). Additionally, post-intervention anxiety on post-operative day one was correlated with post-intervention anxiety on post-operative day two (r ¼ 0.605; P ¼ .006). Postintervention anxiety was correlated with post-intervention nausea on post-operative day three (r ¼ 0.692; P ¼ .027). Levels of anxiety and depressed mood using the HADS significantly decreased from recruitment to discharge among those in the Healing Touch group (Figure 3). At discharge, participants in the Healing Touch group were asked about their perceptions of the benefits of Healing Touch over the course of the study. Individuals in the Healing Touch group described feelings of “relaxation” and that the intervention “calmed the pain”, putting participants “at ease,” and becoming “more and more relaxed [with] each session.” The following quote is an exemplar of these effects: My first day post op was very difficult because I was unable to urinate or pass gas to relieve pressure in my abdomen. The Healing Touch treatment finally relaxed me to a point where I could relieve the pressure. I would recommend it to everyone having bariatric surgery. I was skeptical at first but it really made the difference.

patients, particularly those undergoing bariatric surgery. In terms of treatment expectancy, the majority of participants in the Healing Touch group expected or perceived some benefits from the intervention, both at the time of recruitment (76.2%) and discharge (81%).

DISCUSSION The study results reveal that it is feasible to provide Healing Touch in the acute care setting to patients undergoing laparoscopic bariatric surgery. A novel aspect of the current study was the delivery of Healing Touch by nurses during daily care, lending continuity to the intervention during the inpatient stay. To our knowledge, this is the first published study of Healing Touch or any other biofield therapy to use this approach in any patient population. Participants in the Healing Touch group had significant decreases in pain, nausea, and anxiety immediately following the intervention. Additionally, significant correlations were observed between post-operative levels of pain, nausea, and anxiety. Significant reductions in levels of pain using other biofield therapies (Reiki and Therapeutic Touch) in the cancer population have been reported,55,56 and Healing Touch has been shown to decrease pain in patients undergoing chemotherapy.34 A Cochrane review of biofield therapies, including Healing Touch, found these therapies to be efficacious in reducing pain.37 Post-White et al.34 examined the effects of therapeutic massage, Healing Touch, and presence in patients with cancer using a crossover design. A significant decrease in current pain was observed following the Healing Touch intervention (P o 0.001), as well as therapeutic massage. No significant effects on nausea were noted. These previous results contrast with the significant reductions in nausea following Healing Touch observed in the current study. Danhauer et al.28 conducted a prospective cohort trial using a Healing Touch intervention in leukemia patients and observed a trend toward a significant reduction in pain (P ¼ .06). The majority of participants in

Participants described Healing Touch as helping to “relieve nausea some and definitely help[ing] with [levels of] pain.” They described feeling “less anxious, less worried [and] less agitated,” with Healing Touch helping them to “sleep comfortably.” For example, one participant stated: I was able to truly relax and focus on my breathing. I was able to relax so much that I was almost in a sleep state. Afterwards I continued to feel relaxed and the pain wasn't running the show anymore, I was. Another participant described receiving the Healing Touch intervention with the following quote: All of my pain symptoms disappeared for at least 45 min and didn't need as much pain medicine throughout the night. I felt very calm after and was able to relax and sleep a little better in between vital sign checks. I am glad I participated in the study. Overall, Healing Touch was perceived as a positive intervention during the post-operative period in these patients, with some participants recommending Healing Touch to all

Healing Touch in Bariatric Surgery

Figure 3. Hospital Anxiety and Depression Scale scores. Mean baseline (gray) and discharge (white) anxiety and depression scores using the Hospital Anxiety and Depression Scale are presented. n Discharge scores significantly different (P o .05) than the corresponding baseline scores.

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that study liked Healing Touch “very much,” found Healing Touch “quite a bit” or “very much” helpful, wanted to continue using Healing Touch, and would recommend Healing Touch to others. This feedback is similar to the descriptive comments provided by participants in the present study and aids in providing a rich understanding of the unique perceived effects of Healing Touch that may be missed by standardized patient-reported outcome measures.27,38 For example, in the present study, sleep disturbances were not specifically assessed; however, qualitative feedback from several participants indicated an improvement in sleep following the Healing Touch intervention. Had a mixedmethods approach not been used, these outcomes would have been lost. In terms of other studies involving the use of Healing Touch in surgical patients, a randomized, controlled trial in first-time elective and non-emergent inpatients who had undergone coronary artery bypass graft surgery57 reported a significant decrease in length of stay (120% greater chance of length of stay r six days) and anxiety levels following Healing Touch compared with patients receiving visitation or usual care alone. No differences in the use of pain or anti-emetic medications were observed. Seskevich et al.58 used a randomized, controlled design to examine the effects of four noetic therapies, including Healing Touch, on mood in patients undergoing percutaneous coronary intervention. Noetic therapies are defined as treatments involving no tangible drug or medical device and include biofield therapies.59 Healing Touch significantly decreased feelings of worry and increased feelings of satisfaction compared to standard care alone. A significant decrease in feelings of worry also was reported in the imagery and stress management groups. Compared with levels of anxiety and depressed mood at recruitment, participants in the Healing Touch group had significant reductions in HADS scores at discharge. Given the study design, it is impossible to determine how much of the improvement in anxiety and mood was related to the Healing Touch intervention or to a successful and positive surgical outcome. The concept of healing presence is a tenet of both Healing Touch practice45 and integrative medicine46 and is described as a component of Watson's Theory of Human Caring.60 While healing presence may emanate from the healer, it requires a level of interaction with the patient or client for positive effects on health and well-being to be perceived or observed. The personality trait of absorption may favor a greater capacity of the patient to detect and even respond to a healing presence.46 Possibly genetically determined,61 absorption correlates with CAM use,62 as well as better outcomes from mind–body therapies including meditation, relaxation, and imagery.63 The Tellegen Absorption Scale was included in the present study to examine the relationship between absorption or mindfulness and the effects of Healing Touch. Empirically, it is predicted that those individuals characterized with a higher degree of absorption will perceive healing presence better than low absorbers, thus exhibiting greater effects in response to healing presence. Absorption, or the degree of mindfulness, was inversely related to post-intervention anxiety on postoperative day one in the Healing Touch group, suggesting that those participants who possessed a greater degree of mindful

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focus experienced a decrease in levels of anxiety following Healing Touch than those who did not. This is the first Healing Touch study to explore the influence of absorption or mindfulness on outcomes of the intervention. Limitations of the current study include the small sample size and quasi-experimental design. Additionally, patients with pre-existing depression, anxiety, or psychiatric disorders or patients with chronic pain conditions were not excluded. Historical controls for the current study were abstracted from a period during the roll out of a new electronic medical record system, leading to differences in the number of pain ratings between groups as nurses became familiar with charting in the new system. These differences, along with the lack of equivalent outcome measures for the control group because of the quasi-experimental design, may account for the lack of significant differences between groups and should be addressed in future studies. Finally, there was no control for the presence of the nurse alone in the current study, a factor that has been shown to improve patient outcomes.46 However, the present study has several strengths. To the authors' knowledge, this is the first study to assess a tailored complementary intervention of any kind to improve symptoms in patients undergoing bariatric surgery. Also, the current study is novel in the delivery of Healing Touch by nurses as a part of daily care in the acute care setting. Previous studies examining Healing Touch have relied on volunteer practitioners to provide the study intervention.26,44,64 The current study expands the possibilities of conducting research of Healing Touch interventions by demonstrating the feasibility and acceptability of the delivery of Healing Touch in the acute care setting to examine the impact on patientcentered outcomes. Many studies of complementary therapies suffer from a demographically homogenous sample. The current study sample had representation of several racial and ethnic groups, as well as both men and women. The idea that comforting interventions such as Healing Touch are feasible and efficacious for patients suffering disease- and treatment-related pain challenges today's healthcare system where most therapies are technologically or drug driven. Healing Touch requires no energy expenditure on the part of the patient and has no known side effects or potential pharmacological interactions.28 Given the potential effectiveness in symptom reduction, Healing Touch may represent an untapped resource for improving symptom burden, complementing conventional care.

Acknowledgments

The authors would like to thank the Healing Touch intervention nurses of the surgical unit at the Inova Fair Oaks Hospital for their assistance in conducting the research study, as well as the study participants. The authors also would like to recognize the contributions of Anna Herbst, Karen Gabel Speroni, Betty Ann Duffy, Kerry Brooks, Amir Moazzez, Harpreet Gujral, and Jean Edelman. This study was supported by funding from the Office of Nursing Research at the University of Virginia School of Nursing (JGA) and the Inova Health System Foundation (MAF).

Healing Touch in Bariatric Surgery

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