Nursing Practice in Comfort Theory - Term Paper Example

? Katharine Kolcaba and Comfort Theory 26 July Nursing Practice in Comfort Theory Focus of Nursing Nurses attend to providing standards of care that are mandated by the government and their profession. Kolcaba (2003) believed that nurses and health care providers should focus and can provide “Comfort Care” (p.19). The emphasis is on responding to different comfort needs of diverse kinds of patients. Nurses should be attuned to the patients' unexpressed, such as through observing “body language,” and expressed health problems and attempt to provide the highest level of comfort possible (Kolcaba, 2003, p.3). Purpose of Nursing “Holistic nursing care” sees comfort as a significant need throughout a person's lifetime (Malinowski & Stamler, 2002, p.599). Some of the indicators of quality and holistic nursing care are nursing outcomes that impact “holistic comfort” and patient satisfaction (Malinowski & Stamler, 2002, p.601). Kolcaba and Kolcaba (1991) lamented about the lack of richness and complexity of nursing as a science, because of the absence of further conceptualization of critical care terms: “... meanings of the term [comfort] are not specified” (p. 1301). Boundaries of Nursing Nursing has “comfort” as one of its fundamental theme, value, and outcome, which differentiates it from other health-related professions that focus on other technical values (Siefert, 2002, p.16). Nursing is related to disciplines of anthropology and psychology. Nursing is associated with anthropology, because both require careful observations and documentations of observed settings (Kolcaba, 2003, p.23). Nursing is also related to psychology, where comfort is a physical, mental, and emotional state: “a state of ease and quiet enjoyment, [no] worry” (Kolcaba & Dimarco, 2005, p.188), as well as “satisfaction” and “relief” (Tutton & Seers, 2003, p.690). Nursing plays a large role in interdisciplinary practice, as it concentrates on “comfort measures” (Kolcaba & Kolcaba, 1991, p.1304), while other disciplines concentrate on “hard” concepts of care, such as laboratory tests and analysis. The Comfort Theory has wide applications, such as those empirically tested already, like on women with breast cancer and receiving radiation therapy, as well as people with urinary problems or mental problems, or are at their end-of-life stages (Kolcaba & Dimarco, 2005, p.188). Description of Nursing Situations The one nursed has physical, psychospiritual, sociocultural, and environmental comfort needs (Kolcaba & Dimarco, 2005, p.188). Nurses should be knowledgeable and skilled in their profession (i.e. knowledgeable in communication strategies), sensitive and emphatic to patients who are asking for help and complain about discomfort, and have practical knowledge about medicines (Epstein, 2010, p.577; Stajduhar, Thorne, McGuinness, & Kim-Sing, 2010, pp.2040-2041) and other important non-pharmacological interventions (i.e. massage, as studied by Harris & Richards, 2010) . Quality interactions between nurses and the nurse can be described as resulting to patient satisfaction, because the patients feel relieved in how their comfort needs are met, and they are also satisfied with their relations and interactions with their nurses (Zaccardi, Wilson, & Mokrzycki, 2010, p.138). Context of the Development of Comfort Theory Katharine Kolcaba and Her Comfort Theory Kolcaba (1991) developed the Comfort Theory, because during her course of study, she believed that “comfort” is not yet fully analyzed as a nursing concept (p.1301). In addition, there is a need for a mid-range theory that has rich concepts and real applications to nursing practice (Kolcaba & Dimarco, 2005, p.188). She also asserted that the nursing profession would benefit from clearer conceptual terms that can be operationalized and measured more accurately. In 1965, Kolcaba obtained her nursing diploma from St. Luke's Hospital School of Nursing in Cleveland (Kolcaba, 2003, p.2). She practiced full and part-time nursing jobs in medical surgical nursing and long-term care (Kolcaba, 2003, p.2). She specialized in gerontology at the Frances Payne Bolton School of Nursing (Kolcaba, 2003, p.2). She pursued her doctorate degree, while serving as one of the faculty of The University of Akron (UA) College of Nursing (Kolcaba, 2003, p.2). For the next ten years, she worked on her Theory of Comfort, which started from her “framework of care for gerontological nursing” (Kolcaba, 2003, p.4). Kolcaba (1994, 2001, 2003) defined comfort as “the immediate state of being strengthened through having the human needs for relief, ease, and transcendence” in four basic realms of experiences, “physical, psychospiritual, sociocultural, and environmental” (qtd. in Kolcaba & Dimarco, 2005, p.188). Kolcaba (2003) asserted that comfort is a nursing-specific outcome, because it supports nursing practice standards and impacts patient perceptions of care satisfaction. In 1926, Harmer underlined the value of giving “environmental comfort” and he stressed that relief of pain and discomfort as critical to the nursing practice (Kolcaba & Kolcaba, 1991, p.1303). One of the nursing models that inspired Kolcaba is Benner's discussion of the “Helping Role” of nurses, where the role entails transforming care meanings, including being brave enough to be with the patient and providing for his/her comfort needs (Kolcaba, 2003, p.26). Benner also explored eight nursing competencies that evolved in helping patients obtain peace and hope, as part of their care needs (Kolcaba, 2003, p.26). The Theory of Comfort is related to theories of holism and psychology (Kolcaba, 2003, pp.60-67). Holism refers to viewing the human body as a product of people's mental, emotional, and spiritual dimensions (Kolcaba, 2003, p.60). Kolcaba also sees comfort as a “whole-person response” (2003, p.60). Comfort Theory is, in addition, connected to the psychological study of human needs, including their basic need for comfort (Kolcaba, 2003, p.64). Kolcaba's (1991) work defines comfort as “the state of having met basic human needs for ease, relief, and transcendence” (p. 240). It is connected to the theory of human care, which Watson (1988) asserted to be “metaphysical,” and ascends to “a higher level of abstraction and a higher sense of personhood, which incorporates the concept of soul and transcendence” (p.49 qtd. in Malinowski & Stamler, 2002, p.602). As a nursing student, one of the major external influences on Kolcaba's Theory of Comfort is Dr. Rosemary Ellis' class on “Introduction to Nursing Theory,” where their class was given an assignment on diagramming nursing practice, including the relationships among these concepts (Kolcaba, 2003, pp.2-3). Her job as a head nurse in an Alzheimer's unit also made her more interested in the “facilitative environment” critical to providing comfort in gerontological nursing settings (Kolcaba, 2003, p.4). Her husband, who is a philosopher, also helped her deepen the conceptual foundations of her Comfort Theory. Authoritative Sources for Development, Evaluation, and Use of Comfort Theory Several personalities have become authorities on the development and evaluation of comfort theory, because they also studied comfort as a concept, either conceptually or empirically, or both. One of the nursing authorities who has spoken on the concept or theory of comfort is Florence Nightingale. In 1859, she argued that comfort is a “desirable outcome” for nursing care (Kolcaba & Kolcaba, 1991, p.1301). Nightingale served as one of the seminal theorists on nursing, where she defined nursing in personal, spiritual, and moral terms (Sitzman & Eichelberger, 2011, p.28). Joan Hamilton also studied “comfort” from the perspective of patients through an interview research design (Kolcaba, 2003, p.31). She provided five “comfort themes,” namely: 1) “physical comfort” that encompasses more than textbook treatments of pain, for instance, but also includes simple actions of patients, who can go back to bed, 2) “furniture and personal belongings” that can be changed to increase comfort levels, 3) “self-esteem” that can fit into Kolcaba's notion of psychospiritual comfort, 4) “staff attitudes and approaches,” and 5) the three kinds of comfort, “relief, ease, and transcendence” (Kolcaba, 2003, pp.31-32). Some of the major sources that further elucidate the theory are articles from Journal of Clinical Nursing, Pediatric Nursing, Journal of Advanced Nursing, Nursing Forum, Urologic Nursing, and Nursing Ethics. Kolcaba also has articles of her own on her theory and a book, Comfort Theory and Practice published in 2003. The book on Understanding the Work of Nurse Theorists: A Creative Beginning also discusses several theorists that directly and indirectly help analyze, develop, and evaluate the Comfort Theory. Nursing societies that support and share the Comfort Theory are pediatric, oncology, gerontological, and other clinical nursing organizations that believe that comfort is a viable and critical nursing outcome. An example is the American Nurses Association (ANA) that provide individualized and holistic care to their patients, which include comfort measures (Kolcaba & Dimarco, 2005, p.187). Service and academic programs that are considered as authoritative sources for practicing and teaching the theory are programs on: labor and delivery, peri- and intra-operative care, critical care, burn units, gynecological practice, nursing care of persons with mental or hearing disabilities, emergency air transport, and newborn nurseries. Perianesthesia nurses have developed clinical practice guidelines and advanced care competencies. (Kolcaba & Dimarco, 2005, p.188). Overall Significance of Comfort Theory Kolcaba's Comfort Theory has witnessed increasing significance in individual practice, although it is not yet fully embedded in nursing education and requires further analysis and testing in nursing literature. Some of the exemplars of the theory’s use that structure and guide individual practice are when nurses use the “three senses of comfort” in identifying and responding to comfort needs: “relief, ease, and transcendence,” particularly Kolcaba's taxonomic structure (Kolcaba & Dimarco, 2005, p.188). “Relief” refers to mitigating or relieving discomfort; “ease” pertains to the lack of certain discomforts, and “transcendence” means “rising above” discomforts that cannot be relieved or eased (Kolcaba & Dimarco, 2005, p.188). The Comfort Theory has also been used to guide programs of nursing education, though not in general, where it is sometimes included in the discussion of nursing theories. Malinowski and Stamler (2002) suggested the addition of comfort theories to the course on nursing theories (p.604). Tutton and Seers (2003) studied the literature on “comfort” and concluded that it needs greater “clarity” and should be used in relation to “therapy or caring” (p.695). Some nursing organizations are influenced already to include comfort outcomes and measures in their goals. The Department of Health, Education and Welfare (DHEW) (1974) provided the methods for quality health care, which included standards of “quality” care that nurses should also meet (qtd. in Kolcaba & Kolcaba, 1991, p.1304). These standards include maximizing comfort as one of the goals of quality care. The NANDA or North American Nursing Diagnosis Association, now called NANDA International, used comfort to diagnose patient needs (Siefert, 2002, p.18). The American Nurses Association (ANA) provided positions statements during the early 1990s, which stressed that the primary objective of nurses for dying patients is to improve their comfort levels (Siefert, 2002, p.18). Published nursing scholarship reflect the significance of the theory through conceptual and literature review papers and some empirical studies. Zaccardi, Wilson, and Mokrzycki (2010) applied comfort as a patient outcome in their article “The Effect of Pelvic Floor Re-Education on Comfort in Women having Surgery for Stress Urinary Incontinence.” Malinowski and Stamler (2002) studied comfort as a nursing concept. They proposed the need for more studies that use the qualitative approach that would be more suitable, “as it includes naturalistic and phenomenological methods that contribute to an experiential outlook” (p.604). Tutton and Seers (2003) also reviewed the literature on “comfort” and findings showed that definitions of comfort are becoming clearer and more relevant to nursing literature, but these descriptions tend to differ, depending on how authors see nursing as a profession. They also stressed that comfort and nursing, in relation to therapy and caring, is “complex” and they underscored the need for greater empirical and conceptual research (p.770). Kolcaba's Theory of Comfort has influenced the community of scholars by opening discourse and research on a deceptively simple nursing term of “comfort” (Kolcaba, 2003, p.9). When Kolcaba and her husband presented the theory to Sigma Theta Tau (STT), the latter commented that everyone knows what “comfort” means, so turning it into a theory only complicates it (Kolcaba, 2003, p.9). Ray Kolcaba reasoned that if nursing has to progress as a science, it must “define” its “central terms,” so that practitioners and researchers can understand each other and pursue further research (Kolcaba, 2003, p.9). Hence, the ultimate impact of Kolcaba's Theory of Comfort is to launch greater discussion and studies on what “comfort” means to the nursing profession and how it can be applied to divers caring settings using conceptual and empirical research. Nursing Situation The nursing situation that will be analyzed using Comfort Theory is a 59-year old male Stage 4 lung cancer patient, Ramon. He also has hypertension and diabetes. He is a Mexican American and a devout Catholic. He is a businessman, with three grown children, who are all working. Two of his children are working outside the country. His eldest daughter works as a researcher and stays at their home. She has a two-year old girl, the first and only grand daughter in their family, and whom Ramon loves dearly. Ramon receives home care from his family members and goes to the hospital for his chemotherapy sessions. His main caregiver is his wife, who has hypertension. Ramon often complains of lack of appetite, stomach pains, vomiting, and numbness in his legs. He barely walks and stays in bed almost all the time. He dislikes walking and other physical activities, because he says it makes him feel too tired and stressed. He prefers watching TV and movies. Kolcaba's taxonomy of comfort needs will be applied on Ramon's case. See Table 1 for Ramon's comfort needs. This table shows the three types of comfort that can alleviate Ramon's pain and suffering: relief, ease, and transcendence. It also shows the four contexts where comfort and discomfort can occur. The physical discomforts of Ramon that need relief are stomach pain and nausea. His vomiting and lack of appetite should also be eased. He also needs to transcend his pain through mental and spiritual strengthening of his tolerance to pain and helping him feel more physical energy, such as through meditation and praying. The psychospiritual discomforts of Ramon are anxiety and restlessness. His doubts about the chemotherapy sessions should also be eased. He can transcend his psychospiritual discomforts by receiving spiritual guidance from priests and additional emotional and professional support from his health care staff. Ramon also feels environmental discomforts from noise, light, and cold temperature. He needs privacy and recreation too, especially when he does not have or enjoy physical exercise. To transcend these problems, he needs privacy and environmental comforts (i.e. watching his favorite movies and listening to music he loves). He also needs constant access to his grand daughter, who can uplift his spirit and give him hope . His sociocultural discomforts are the absence of his two children and he feels abandonment from other relatives, whom he feels should be there to help take care of him, especially since he sent them all to college. He requires support from his relatives and friends and nurses need additional information on this concern. There is also a need to ease language and cultural barriers between him and his health care providers. Table 1: Taxonomic Structure for Ramon's Comfort Needs The strengths of the Comfort Theory are its conceptual foundations and holistic taxonomic structure. As a concept, Kolcaba greatly explored the different meanings of comfort and how these meanings impact the nurses' and patients' perceptions of comfort. Her conceptual analysis helps understand what “comfort” is and how it can be properly defined and operationalized for further studies. Kolcaba's taxonomic structure is also helpful in understanding her theory's practical applications. This structure is considered as holistic, because it encompasses three comfort needs and four comfort environments. This taxonomy helps nurses develop a comprehensive analysis of their patients' comfort needs and what they can do to help the latter alleviate, ease, or transcend their various discomforts. The weaknesses of the Comfort Theory are its need for further empirical testing and connection with existing nursing theories and practices. Siefert (2002) argued for greater operationalization of the concept of care across diverse settings, since “comfort” can differ for different nursing practices. Its concepts should also undergo further applications in different care settings, so that its strengths and limitations can be identified. Once its weaknesses and boundaries are clearer, it can be modified further for practical uses. There is also a need to connect the Theory of Comfort with other nursing theories, so that it can enrich nursing literature further and for it to be fully acknowledged as a nursing theory required for all nursing students. It can be connected to therapy and caring, as well as specific domains of nursing expertise. Utilization of Comfort Theory in My Nursing Practice As a nurse, I can utilize this theory in practice by using Kolcaba's taxonomic structure, when analyzing my patients' comfort needs and goals. I believe that this table provides a comprehensive analysis of my patients' comfort needs. I can also identify what further skills, knowledge, and information I need and this can help me develop a more comprehensive comfort response plan for my patients. For instance, in Ramon's case, I can ask more information from the wife, regarding the relatives who Ramon particularly want to see. Perhaps I can persuade her to contact them and influence them to visit Ramon. This will improve Ramon's moods and feeling of self-worth. I can also apply Kolcaba's Comfort Theory by making “comfort” as one of my caring outcome as a nurse. I will now increasingly aim to maximize comfort levels for all my patients. On a personal level, this theory has compelled me to probe deeper into the overlooked term of “comfort.” Oftentimes, the lack of staff and great number of patients overwhelm nurses and make them focus on providing physical comforts for their patients. They lack the time and energy to analyze and respond to their patients' psychospiritual, sociocultural, and environmental comfort needs. I believe it will be a disservice to patients, if these other comfort needs are neglected. I will take personal measures and be more determined to understand these comfort needs and respond to them using the resources and relations available to me and the patient. “Comfort,” for me, has become a critical nursing term, because it underlies therapeutic relationships and holistic caring. It connects to the essence of “nursing” patients to better health. Comfort measures require nurses to spiritually, culturally, and socially connect with their patients, who also have inner discomforts that must be relieved, eased, and transcended. Thus, responding to comfort needs goes beyond the physical; it promotes human connections that result to humane and holistic nursing. References Epstein, E.G. (2010). Moral obligations of nurses and physicians in neonatal end-of-life care. Nursing Ethics, 17 (5), 577-589. Harris, M. & Richards, K.C. (2010). The physiological and psychological effects of slow-stroke back massage and hand massage on relaxation in older people. Journal of Clinical Nursing, 19 (7/8), 917-926. Kolcaba, K. (2003). Comfort theory and practice. New York: Springer Publishing. Kolcaba, K. & Dimarco, M.A. (2005). Comfort theory and its application to pediatric nursing. Pediatric Nursing, 31 (3), 187-194. Kolcaba, K.Y. & Kolcaba, R.J. (1991). An analysis of the concept of comfort. Journal of Advanced Nursing, 16 (11), 1301-1310. Malinowski, A. & Stamler, L.L. (2002). Comfort: Exploration of the concept in nursing. Journal of Advanced Nursing, 39 (6), 599-606. Siefert, M.L. (2002). Concept analysis of comfort. Nursing Forum, 37 (4), 16-23. Sitzman, K. & Eichelberger, L.W. (2011). Understanding the work of nurse theorists: A creative beginning (2nd ed.). Massachusetts: Jones & Bartlett Publishers. Stajduhar, K.I., Thorne, S.E., McGuinness, L., & Kim-Sing, C. (2010). Patient perceptions of helpful communication in the context of advanced cancer. Journal of Clinical Nursing, 19 (13/14), 2039-2047. Tutton, E. & Seers, K. (2003). An exploration of the concept of comfort. Journal of Clinical Nursing, 12 (5), 689-696. Zaccardi, J.E., Wilson, L., & Mokrzycki, M.L. (2010). The effect of pelvic floor re-education on comfort in women having surgery for stress urinary incontinence. Urologic Nursing, 30 (2), 137-148. Read More