INTRODUCTION:

With the decrease in the birth rate, improvement in living standards and prolonged life expectancy), the older population is increasing all over the world. It is estimated that the total population ratio of the population over the age of 65 in Turkey will increase to 12.1% in 2030 and to 20.6% in 2050.^1,2,3

With the advanced age, older people become less productive, experience decline in mental functions, delay to respond to new situations, weakening of the short-term memory and need others’ help to maintain activities of daily living, which cause them to experience loneliness and anxiety.

In Turkey, due to transition from the patriarchal family structure to the nuclear family structure, and socioeconomic conditions of big cities in recent years, families have had difficulty in older care and thus the number of older adults living in nursing homes has increased.^1,4 The comfort level of older people decreases due to both the deterioration in functionality caused by the anxiety they experience and the fact that they have to live in a different environment outside their own homes.⁵ Providing comfort is the main objective of therapeutic nursing practices and primary nursing functions. Comfort, an important need throughout life, is an inseparable part of nursing care.⁶

In her comfort theory, Kolcaba defines comfort as “an expected outcome which has a complex structure within the physical, psychospiritual, social and environmental cohesion which provides assistance and relief for an individual to meet his/her needs and to overcome problems”.^7,8 Older people have comfort needs in physical, socio-cultural, environmental and psychospiritual comfort areas.⁶ Practices such as giving oral care to older people, allowing them to have family and friend visitors, facilitating visits paid to them and massage practice are among the nursing interventions that meet comfort needs of older people.⁶

It is known that massage is well known has a long history which can be traced back to ancient Egypt, China, and India and is the oldest and most widely used complementary method in the field of health care.⁹ Massage enables patients to express their feelings easily, enhances the interaction between nurses and patients, and enables the nurse to provide an effective care.^10,11 Massage is stated to help blood and lymph flow, to decrease heart rate and blood pressure, to increase mental and psychological peace and to decrease anxiety by increasing mental well-being, psychospiritual comfort.¹² Back massage is the gentle movement of the skin so that the hands slide over the skin and do not move the deep muscles. Back massage is stated that has physiological and psychological effects massage to reduced muscle tone and anxiety and has very beneficial effects in patient relaxation.¹³ Hand massage reported to be a reliable and easy to apply method is of relaxing effect in reducing anxiety.¹⁰ The extent of hand massage is limited, but it can be administered more easily and comfortably than the whole body massage because hands are in a more easily accessible area, and it is also preferred due to its pain-reducing comfort-enhancing effect.⁶

In the literature there are several studies whose results demonstrate the relaxing and calming effects of back and hand massage.^6,11,14,15 Back and hand massage application is a non-invasive nursing intervention which can be easily learned and applied by nurses.⁶ While back massage requires persons giving and receiving massage (nurses and older persons in this case) to change position, hand massage does not require position change, and can be easily applied by older persons themselves without worrying about their privacy. In the present study, the duration of hand massage and back massage applications were the same, which raised the question of whether there is any difference between hand massage and back massage in terms of their effects on comfort and anxiety. Our search for studies conducted to compare the effectiveness of hand and back massage on older people living in nursing homes demonstrated a gap in the literature. Therefore, to fill in this gap, the present study was conducted. The purpose of the present study was to investigate the effect of back massage and hand massage applications on comfort and anxiety of older people living in nursing homes.

MATERIAL AND METHODS:

The population of this single-blind randomized controlled experimental study with a pretest - posttest control group comprised seniors living in two different nursing homes in Izmir, a province in western Turkey. The study included 65- 89-year-old people who were able to speak and communicate in Turkish, were not diagnosed with dementia, major depression and neurological disease, were living in the nursing home for at least three weeks⁶, did not develop ecchymoses or hematoma in the hand, did not have hand or nail deformities, thrombus or phlebitis, severe obstructive respiratory tract disease, any scar tissue, chronic inflammatory skin diseases such as dermatitis, abscess on the back and had intact skin.^16,17 Since the type of the intervention to be performed in older people is of importance for the reliability of the study, the older people to be included in the present study were assigned to Back Massage (BM), Hand Massage (HM) and Control (C) groups using the stratified simple randomization method by taking their gender and age into consideration.

The sample size was determined by power analysis. According to the results of the power analysis performed with the IBM Sample Power program, the power of the research was found to be 97.7% using the 95% confidence interval and the p= 0.05 significance level.

In our study, access was provided to 255 elderly people. 210 elderly people were not included in the study due to different reasons. As a result of the study sample consisted of 45 older people between October 15, 2015 and May 1, 2016 and met the sample selection criteria. They were assigned to BM (n = 15), HM (n = 15) and Control (n = 15) groups (Figure 1).

Instruments:

Personal Information Form (PIF): The form prepared by the researchers based on similar studies that evaluated individuals living in nursing homes and the pertinent literature has 5 items questioning the participants’ age, gender, marital status, educational status and length of stay in the nursing home.

General Comfort Questionnaire (GCQ): The questionnaire was developed by Kolcaba (1992) based on the taxonomic structure including three levels and four dimensions which constitute the theoretical components of comfort.⁷ The items with a disorderly response pattern are rated on a 4- or 6-point likert scale.¹⁸ In the present study, the Cronbach’s alpha of the GCQ was 0.87.

State-Trait Anxiety Inventory (STAI): The inventory is used to determine how an individual feel at a particular time and under certain circumstances. The scale was developed by Spielberger et al. (1970).¹⁹ The validity and reliability studies of the Turkish version of the STAI were conducted by Öner and Le Compte (1998).²⁰ Internal consistency and test homogeneity for the STAI were .83 with .87 respectively. In the present study, the Cronbach’s alpha of the STAI was 0.86.

Vital Signs Follow-up Form (VSFF): It was prepared by the researcher to record such vital signs of the participants as blood pressure, heart rate and respiratory rate before and after treatment.

Application of Back massage and Hand massage:

Our review of the pertinent literature demonstrated that Cınar, Eser and Khorshid (2009) and Chen et al. (2013) followed up older people in their studies for 3 days to investigate the effect of massage on them.^11,15 Therefore, the older people who participated in the present study were followed up for 3 days too.

The participants in the back massage group and hand massage were administered the PIF, GCQ, STAI, VSFF after randomization and GCQ, STAI, VSFF after the 10-minute BM application and HM application on the 1^st day. On the 2^nd and 3^rd days, they were first administered the VSFF and then GCQ, STAI, VSFF after the 10-minute minute BM application and HM application.

The participants in the control group were administered the PIF, GCQ, STAI, VSFF twice at a 10-minute interval on the 1^st day. On the 2^nd and 3^rd days, they were first administered the VSFF and then GCQ, STAI, VSFF at a 10-minute interval. Except for filling out data collection forms and measuring vital signs, no intervention was applied to the older adults in the control group.

BM and HM was applied by the researcher 1 hour before or 2 hours after the meal as stated in the literature. The participants in all the groups were followed between the aforementioned hours.¹⁵ The literature review revealed that studies investigating the effect of HM on relaxation and comfort implemented 5- or 10-minute massage programs.^6,11,21 In the present study, a 10-minute hand massage program consisting of classical massage techniques including petrissage, friction and kneading and not requiring any special tools are developed by Kolcaba et al. (2006) was applied.⁶ In the back massage application, a 10-minute BM program that aims relaxation and enjoy for older people in rest home and hospital consists of effleurage and tapotman are developed by Ersser et al. (1998) was applied.¹⁶ BM was performed in the participants’ own room and bed in the prone position or side-lying position with the back of the participant facing the massage therapist. Only the part of the body to be massaged was uncovered. HM was performed in the participants’ own room or in a common area in a comfortable position using baby oil.

To investigate the effect of massage on physiological symptoms of anxiety in the participants in the BM, HM and control groups, their blood pressure, heart rate and respiratory rate were assessed. The systolic and diastolic blood pressure values of the participants in the three groups were measured using a calibrated sphygmomanometer. Their heart and respiratory rates were measured by the researcher. In order to ensure that BM and HM were administered in a valid and reliable manner, BM an HM were performed by the researcher who was an expert on massage.

Data Analysis:

The SPSS 21.0 for Windows was used to analyze the data obtained from the study. In the analysis of data, while the differences between the days were assessed with the Repeated Measures Analysis of Variance and Kruskal Wallis test, the differences between the pre- and post-massage mean comfort and anxiety scores, mean values for vital signs of the participants in the BM, HM and Control groups were assessed with the Paired -sample t test and Wilcoxon test, and the differences between the mean values obtained on different days by the groups were examined with the Bonferroni test and Least Significant Difference (LSD) test. The results of the study were evaluated at the 95% confidence interval and a significance level of p < .05.

Ethical Considerations:

Before the study was conducted, written permission was obtained from the Ethics Committee of the Faculty of Nursing (Decision number: 114) and the nursing home where the study was to be carried out. To determine who met the inclusion criteria, the verbal informed consent was obtained from all the older people living in the nursing home. Of them, those who agreed to participate in the study gave their written informed consent as well.

RESULTS:

Of the older people who participated in the study, 53.3% (n = 24) were female and 91.1% (n = 41) were literate. While 33.3% (n = 15) of them lived in the nursing home for 1-3 years, 28.9% (n = 13) 7 lived 4-6 years and 37.8% (n = 17) lived 7 or more years.

While there was a significant difference between the pre- and post-intervention mean scores obtained from the GCQ by the participants in the BM and HM groups, there was no significant difference in the control group (t1 = -8.15, p = .00; t2 = -9.26, p= .00; t3=1.00, p= .33) (Table 1).

Table 1. Distribution of the Mean Scores obtained from the overall GCQ by the participants in the BM, HM and Control Groups before and after the Intervention on the First Day

Day	GCQ means
	BM		HM		Control
	Pre Mean±SD	Post Mean±SD	Pre Mean±SD	Post Mean±SD	Pre Mean±SD	Post Mean±SD
First day	2.70±0.11	2.92±0.09	2.86±0.11	3.01±0.12	2.71±0.12	2.71±0.11
	t= -8.15, p= .00*		t= -9.26, p= .00*		t=1.00, p= .33

Note: Abbreviations: GCQ, General Comfort Questionnaire; BM, Back Massage; HM, Hand Massage, SD, Standard deviation. Statistically significant values (p ≤ .05) are shown in bold. *p< .01 within- group differences.

There was a significant difference between the groups in terms of the post-intervention mean scores for the overall GCQ obtained on the first, second and third days (F1 = 26.86, p = 0.00; F2 = 56.93, p = .00; F3 = 103.05, p = .00) (Table 2).

Table 2. Distribution of the Mean Scores Obtained from the Overall GCQ by the Participants in the BM, HM and Control Groups after the Intervention by Days

GCQ means
Days	BM Mean± SD	HM Mean± SD	Control Mean± SD	F	p
First day	2.92± 0.09	3.01± 0.12	2.71± 0.11	26.86	.00*
Second day	3.11 ± 0.10	3.07 ± 0.11	2.70 ± 0.12	56.93	.00*
Third day	3.27 ± 0.10	3.17 ± 0.11	2.70 ± 0.12	103.05	.00*

Note: Abbreviations: GCQ, General Comfort Questionnaire; BM, Back Massage; HM, Hand Massage; SD, Standard deviation. Statistically significant values (p ≤ .05) are shown in bold. *p< .01 within- group differences.

In the BM and HM groups, there was a significant difference between the difference means of overall GCQ scores obtained on the first day and those obtained on the second and third days (p = .00) and between those obtained on the second day and those obtained on the third day (p= .00). In the control group, there were no significant differences (p> .05) (Table 3).

In the BM, HM and Control groups, there was a significant difference between the pre- and post-massage mean STAI scores on the first day (t1= 27.90, p= .00; t2= 12.58, p= .00; t3=2.10, p= .05) (Table 4).

Table 4. Distribution of the Mean Scores obtained from the overall STAI by the participants in the BM, HM and Control Groups before and after the Intervention on the First Day

Day	STAI means
	BM		HM		Control
	Pre Mean±SD	Post Mean±SD	Pre Mean±SD	Post Mean±SD	Pre Mean±SD	Post Mean±SD
First day	46.86±2.89	27.26±1.33	41.33±5.32	26.20±2.36	47.73±5.54	47.33±5.71
	t= 27.90, p= .00*		t= 12.58, p= .00*		t=2.10, p= .05**

Note: Abbreviations: STAI, State-Trait Anxiety Inventory; BM, Back Massage; HM, Hand Massage; SD, Standard deviation. Statistically significant values (p ≤ .05) are shown in bold. *p< .01 **p≤ .05 within-group differences.

There was a significant difference between the groups in terms of the post-intervention mean scores for the overall STAI obtained on the first, second and third days (F1=159.26, p= .00; F2=256.96, p= .00; F3=247.38, p= .00) (Table 5).

Table 5. Distribution of the Post-Intervention Mean Scores Obtained from the Overall STAI by the Participants in the BM, HM and Control Groups by Days

	STAI means
Days	BM Mean± SD	HM Mean± SD	Control Mean± SD	F	p
First day	27.26± 1.33	26.20± 2.36	47.33± 5.71	159.26	.00*
Second day	24.60± 1.40	24.46± 1.50	45.93± 4.74	256.96	.00*
Third day	21.93± 1.57	23.00± 1.06	44.86± 5.18	247.38	.00*

Note: Abbreviations: STAI, State-Trait Anxiety Inventory; BM, Back Massage; HM, Hand Massage; SD, Standard deviation. Statistically significant values (p ≤ .05) are shown in bold. *p<.01

In all the groups, there was a significant difference between the difference means of STAI scores obtained on the first day and those obtained on the second and third days, and between those obtained on the second day and those obtained on the third day (p≤ .05) (Table 6).

When the vital signs of the older adults are evaluated, in the BM and HM groups, there was a significant difference between the pre- and post-massage mean systolic blood pressures on the first, second and third days (p< .05). In the control group, there were no significant differences (p> .05). In the BM and HM groups, there was a significant difference between the pre- and post-massage mean diastolic blood pressures on the first, second and third days (p< .05). In the control group, there was a significant difference between the pre- and post-massage mean diastolic blood pressures on the first and second days (p< .05), there were no significant differences on the third day (p> .05). In the BM and HM groups, there was a significant difference between the pre- and post-massage mean heart rates on the first, second and third days (p< .05). In the control group, there were no significant differences (p> .05). In the BM group, there was a significant difference between the pre- and post-massage mean respiratory rates on the first and third days (p< .05), there was no a significant difference on the second day (p> .05). In the BM and control groups, there were no significant differences (p> .05).

DISCUSSION:

The review of pertinent studies in the literature shows that massage is performed in intensive care units, different units of hospitals and nursing homes. The results of these studies indicate that massage can be used to increase the comfort of individuals and to reduce their pain caused by many different factors, anxiety, stress, depression and insomnia by reducing muscle tension.^{6,11,14,15, 17, 21- 24}

Comfort, a concept associated with the art of nursing, is a highly complex, person-specific and holistic concept. It is inevitable that the comfort of older people living in a different environment outside their own homes deteriorates. In the present study, while both massage treatments caused an increase in comfort levels of the participants day by day, the difference between the mean scores for the overall GCQ was higher in the BM group. When the review of similar studies in the literature, Chen et al. (2013) found that back massage increased the comfort level of patients with congestive heart failure.¹⁵In Demir and Sarıtas’ s (2020) study conducted to investigate the effect of back massage on vital signs, pain and comfort levels in liver transplant patients, back massage, was found to increase their GCQ scores.²² Consistent with the results of the present study, in their study, Kolcaba et al. (2006) conducted to investigate the effect of hand massage on comfort in older people living in a nursing home found that there was a significant difference between the experimental and control groups in terms of comfort levels and that the comfort level was higher in the experimental group.⁶ In her other study, Kolcaba et al. (2004) found that hand massage increased the comfort of older people living in a nursing home.²¹ These results demonstrate the positive effects of back massage and hand massage on comfort level and are in line with the findings of our study. This situation is thought to be a result of the massage, which relaxes the body and increases comfort by integrating the physical, sociocultural, environmental and psychospiritual dimensions. The use of massage, which is an easy-to-apply, free and harmless method that does not require invasive intervention, is recommended for the nurses working in nursing homes, who meet the inclusion criteria in our study in order to increase the comfort of the older adults. The results showed that back massage and hand massage can be safely applied to increase the comfort of the older adults.

It is stated that anxiety is closely related with the facilities of a nursing home and the satisfaction of the residents of the nursing home with it, and that the sense of belonging and loneliness and lack of social support play a significant role in the development of anxiety.²³ A decrease observed in anxiety levels of the participants both in the experimental group who had BM an HM, and in the control group on the first day is an unexpected finding (Table 4). The greatest decrease in the anxiety score after the intervention on the first day was observed in the BM group. The decrease in the anxiety score in the control group is thought to be an effect of meeting, chatting and spending time with the older adults. In the results of our study, it was determined that the anxiety levels of the elderly in the HM, BM and control groups decreased. However, the effect of BM in reducing anxiety is more. The review of the relevant literature demonstrated that in Cınar et al.’s study (2009) conducted to investigate the effect of back massage on the vital signs and anxiety in older people, back massage was found to reduce their anxiety levels.¹¹ Holland and Pokorny (2001) reported that individuals aged 52-88 years felt less anxious after they were administered slow-stroke back massage for three successive days.¹⁴ Çavdar et al., (2020) investigated the effect of HM before cataract surgery on patients and found that the anxiety scores obtained in the patient's room after the hand massage and postoperative was statistically significantly lower than that of the control group.²⁴ Yücel and Eser (2015) investigated the effect of HM and acupressure on patients undergoing mechanical ventilation and found a statistically significant difference in their perceived anxiety levels.¹⁷ Although this study differs from other aforementioned studies in terms of sample and method, these findings are consistent with the results of the present study. The findings of the studies demonstrate that although different sample groups, back massage and hand massage have an anxiety-reducing effect. One of the most important features that distinguishes the findings of our study from other studies is that the anxiety levels of the older adults in the control group are also decreased. It is thought that spending time with the older adults in the control group while filling out the questionnaires is effective in the development of this situation.

This is the first study to evaluate the efficacy of back massage and hand massage in older adults who live in nursing home. This is a strong aspect of our study. Our findings show that even just chatting with someone reduces anxiety. Therefore, it is thought that directing school children to nursing home visits and chatting with the older adults can be effectively in reducing the anxiety of the older adults. For this reason, schools can be contacted to direct school children to nursing home visits. In this study, we believe that we emphasize the importance of back massage and hand massage for older adults who live in nursing home and that the positive effects of BM and HM on comfort and anxiety and will shed light on the literature.

In our study, the intra-group comparison of the pre-massage and post-massage vital signs of the older people showed a decrease in their mean systolic and diastolic blood pressures, heart rates and respiration rates. When the review of similar studies in the literature, investigating the effectiveness of back massage, Holland and Pokorny (2001) found, as a result of a 3-day intervention, a significant difference in respiratory rate, pulse rate, systolic and diastolic blood pressures in the study group compared with the control group.¹⁴ Chen et al., (2013) examined physiologic parameters after back massage in patients diagnosed with heart failure and found a significant decrease in heart rate and systolic and diastolic blood pressure levels.¹⁵ Çavdar et al. (2020) examined that hand massage in patients on cataract surgery and founded statistically significantly lower in the intervention group than in the control group in respiration rate and systolic- diastolic blood pressure of the patients.²⁴ Alimohammad et al. (2018) found hand and foot surface stroke massage improve the vital signs of patients with acute coronary syndrome.²⁵Erzincanli and Kasar (2021) stated that hand massage before venipuncture procedure significantly decrease the vital signs of the patients.¹⁰ Along with other results, our findings demonstrate the effectiveness of back massage and hand massage as a nonpharmacologic method to have a positive effect on vital signs among the different goups. It is thought that the positive effect of back massage and hand massage on vital signs is related to the decrease in anxiety, which causes an increase in heart rate, blood pressure, body temperature and respiratory rate, as a result of massage. The results of this study are important in that back massage and hand massage increase the comfort of the older adults, reduce anxiety and, as a result, have a positive effect on vital signs.

CONCLUSIONS:

In conclusion, it was found that back massage and hand massage which nurses can include in nursing care without hesitation because they are reliable and easy-to-apply nonpharmacological nursing interventions would contribute to the reduction of anxiety and enhancement of comfort in older people living in nursing homes. In the results of the study, it was found that anxiety level decreased in the control group. Although both methods were effective in increasing comfort and reducing anxiety, BM was found to be more effective than HM. It is recommended that nurses working in nursing homes should include massage in their routine nursing care of the older people who meet the inclusion criteria as in our study in order to ensure the continuity of the effectiveness of massage.

CONFLICT OF INTEREST:

No conflict of interest.

REFERENCES:

1. Şenol D, Erdem S. The Old Age and the Perception of Nursing Home in Elderly Women: A Qualitative Study. Journal of Social Sciences Kırıkkale University. 2017 7;2: 31-50.

2. UNDESA: World Population Ageing, 2015. http://www.un.org/ en/ development/desa/population/publications/pdf/ageing/WPA2015_Report.pdf. accessed from, 2017.

3. Kurtkapan H. Socıal Reflections of Demographic Transformation For Older People in Turkey. Journal of Social Insurance. 2019 15: 27-46.

4. Khorshıd L, Eser I, Zaybak A, Yapucu U, Arslan G & Çınar Ş: The Evaluatıon of Lonelıness Level of Elderly Indıvıduals Resıdıng in Rest Homes. Turkish Journal of Geriatrics 2004; 7 (1), 45-50.

5. Aslan M, Hocaoğlu Ç. Aging and Psychiatric Problems Associated with Aging Period. Journal of Duzce University Health Sciences Institute. 2017 7; 1:53-62.

6. Kolcaba K, Schirm V, Steiner R. Effects of hand massage on comfort of nursing home residents. Geriatric Nursing. 2006 27;2: 85-91. doi: 10.1016/j.gerinurse.2006.02.006.

7. Kolcaba K: Holistic comfort: Operationalizing the construct as a nurse-sensitive outcome. Advances in Nursing- Science 1992; 15(1), 1-10. Doi: 10.1097/00012272-199209000-00003.

8. Kolcaba K: Comfort theory and practice: a vision for holistic healt care and research. New York: Springer Publish Company, 2003.

9. Ooi SL, Smith L, Pak SC. Evidence-informed massage therapy–an Australian practitioner perspective. Complementary Therapies in Clinical Practice. 2018 31: 325-331.

10. Erzincanli S., Kasar KS. Effect of Hand Massage on Pain, Anxiety, and Vital Signs in Patients Before Venipuncture Procedure: A Randomized Controlled Trial. Pain Management Nursing 2021 22: 356-360.

11. Cınar S, Eser İ, Khorshid L. The Effects of Back Massage on the Vital Signs and Anxiety Level of Elderly Staying in a Rest Home. Hacettepe University Faculty of Health Sciences Nursing Journal. 2009 14-21.

12. Gasibat Q, Suwehli W. Determining the benefits of massage mechanisms: a review of literature. Rehabilitation Sciences. 2017 3: 58-67.

13. Mohammadpourhodki R, Sargolzaei MS, Basirinezhad MH. Evaluating the effect of massage based on slow stroke back massage on the anxiety of candidates for cataract surgery. Romanian Journal of Ophthalmology. 2019 63;2:146.

14. Holland B, Pokorny M. Slow Stroke Back Massage: Its Effect on Patients In rehabilitation Setting. Rehabilitation Nursing. 2001 26;5:182. doi: 10.1002/j.2048-7940.2001.tb01948.x.

15. Chen WL, Liu GJ, Yeh SH, Chiang MC, Fu, MY, Hsieh YK. Effect of back massage intervention on anxiety, comfort, and physiologic responses in patients with congestive heart failure. The Journal of Alternative and Complementary Medicine. 201319;5: 464-470. doi: 10.1089/acm.2011.0873.

16. Ersser SJ, Bentley T, Chappell S, Taylor HR, Wade S, Walsh R et al. Sleep of old people in nursing care settings and the impact of back massage on sleep: a pilot study. Oxford Centre for Health Care Research & Development Oxford Brookes University, Oxford. 1998.

17. Yücel SC, Eser İ. Effects of hand massage and acupressure therapy for mechanically ventilated patients. Journal of Human Science. 2015 12;2: 881-896.

18. Kuğuoğlu S, Karabacak Ü. Turkish Version of the General Comfort Questionaire. İstanbul University Florence Nightingale Journal of Nursing. 2008 16;61: 6-23.

19. Spielberger CD, Gorsuch RL, Lushene RE. Manual for the state trait inventory. Palo Alto, CA: Consulting Psychologists Press. 1970.

20. Oner N, Le Compte A. State-trait anxiety inventory handbook. Bogazici University, Istanbul, Turkey. 1998.

21. Kolcaba K, Dowd T, Steiner R & Mitzel A: Efficacy of Hand Massage for Enhancing the Comfort of Hospice Patients. Journal of Hospice Palliative Nursing 2004; 6, 91-102.

22. Demir B, Saritas S. Effects of massage on vital signs, pain and comfort levels in liver transplant patients. Explore. 2020 16;3:178-184. Doi: 10.1016/j.explore.2019.10.004.

23. Akyıl RÇ, Adıbelli D, Erdem N, Kırağ N, Aktaş B, Karadakovan A. Relationship of the level of loneliness and perceived social support and happiness in elders staying at home and nursing home. Journal of Anatolia Nursing and Health Sciences. 2018 21;1: 33-41.

24. Çavdar AU, Yılmaz E, Baydur H. The effect of hand massage before cataract surgery on patient anxiety and comfort: a randomized controlled study. Journal of PeriAnesthesia Nursing. 2020 35;1: 54-59. doi: 10.1016/j.jopan.2019.06.012.

25. Alimohammad HS, Ghasemi Z, Shahriar S, Morteza S, Arsalan K. Effect of hand and foot surface stroke massage on anxiety and vital signs in patients with acute coronary syndrome: A randomized clinical trial. Complementary Therapies in Clinical Practice. 2018 31: 126-131.

Received on 02.09.2021 Modified on 10.11.2021

Asian J. Nursing Education and Research. 2022; 12(2):173-179.

DOI: 10.52711/2349-2996.2022.00035