Enhancing Your Work Environment

My comfort work has taken me into the process of institutional recognitions – I am told by folks who are doing it that using a theoretical framework is recommended, makes the process more fun, and causes the whole institution to be on the same page. Therefore,  I recently put all my stuff together in a packet and am taking it on the road. Applications for this packet include applying for Magnet Status, for the AACN Beacon Award, and for the JCAHO Gold Seal of Approval. For example, I went to New Hampshire (NH) in April, 2005 to do a two day workshop (including two formal presentations to staff nurses). The packet that I left with the Magnet committee contains documentation forms (for patient comfort), a section on nurses’ comfort (which is another emphasis of Magnet), competency and post tests, clinical practice guidelines, etc. So…..perhaps your hospital will consider using Comfort Theory as their umbrella for the application process. I would, of course, LOVE to come down and give a workshop.

In NH, I met with the nursing practice council, all the specialty units, staff nurses, and the Magnet committee. They also sponsored a cocktail party in the evening for area nursing faculty…these are just a few suggestions for promoting Comfort Theory in your area. I charge about $1000.00 per day for a workshop, but you can purchase the packet (without the workshop) for $40.00 (plus postage).  

If interested only in the packet at this time, please send a check to me at 165 South Franklin St., Chagrin Falls, OH  44022. I will also need your snail mail address.

The mailed packet will NOT contain the personalized powerpoint presentation(s) that are inherent in the workshop day(s), thus offering  you incentive for me come in person! Of course, you can always change your mind later and arrange for a one or two-day workshop, after examining the packet. Another benefit of a workshop is that I will bring all of the contents of the packet (plus updates) on a CD ROM for you to keep and use for personalizing the documents, with my permission.

This is an exciting time for nursing theory….

The packet contains the following documents (which are copyrighted):

TABLE OF CONTENTS:

Comfort: An Umbrella Term (Introduction)
Nurses’ Comfort (can substitute manager, administrator, patient)
Comfort Theory, abbreviated (2 figures, definitions, propositions)
Clinical Practice Guidelines for Comfort Management
     Post-Test Comfort Management
     Core Competencies for Comfort Management
Comfort Care Plans
Holistic Comfort Enhancement: NIC, NOC, and NANDA (approval pending)
Comfort Rounds
Continuing Education Course: Comfort Theory at www.CEU4U.com
Suggestions for Creating a Comfort Place:
     Brochures
     Mission Statement
     Performance Review Suggestions
     Other Unit-Specific Policies
     Etc.
Documentation of Patient Comfort (clinical practice)
     Total Comfort Lines
     Verbal Comfort Scale
     Visual Comfort Graph
     Comfort Behaviors Checklist (non-verbal or unconscious patients)
     Comfort Daisies (children)
Comfort Interventions
Quality Improvement: Suggestions (not in packet)
     Comfort Units/Patient Satisfaction
     Comfort Studies (conceptual map)
     Comfort Studies (instruments)
     General Comfort Questionnaire (research)
Standards of Care (ASPAN example, separate packet)
Resources and References
     Kolcaba, K. (2003). Comfort Theory and practice: A vision for holistic health care and research. NY: Springer.
     TheComfortLine.com by K. Kolcaba  (All instruments and references available on this website.)
     www.CEU4U.com Comfort Theory: A Holistic guide for practice and research. By K. Kolcaba. Approved for 3 contact hours.

 And many more references!

Comfort: An Umbrella Term
(Introduction)

According to Comfort Theory, Comfort is a term that entails  physical, psychospiritual, sociocultural and environmental contexts of experience for all persons, including patients, providers of care, and administrators. In health care institutions, where providers are intentionally dedicated to meeting comfort needs of patients and each other, a comfort place is created. Such a place is uniquely facilitating for healing, working, and growing.

The application process for Magnet Status is a rigorous one, which is driven by 14 forces of magnetism. The project was developed by the American Nurses Association about 10 years ago to help institutions build better organizational structures. Such organizations would attract and keep the best nurses, which in turn would lead to vastly improved patient outcomes, savings in health care costs, and recognition of excellence. Data show that these goals have been realized in places where Magnet Status has been achieved.

The exploration into Magnet Status which your institution has undertaken promises a brighter future for patients, nurses, managers, administrators, and health care in general. Let us reframe the process from meeting Magnet criteria TO creating a comfort place for all.

This packet was assembled to help answer the basic question, “Where and how do we start?” These materials are generated from Comfort Theory and should provide many ideas upon which you can build a unified, holistic, comfortable, and healthy place for a most rewarding work life.

Good luck!                                                                       

Sincerely,

Comfort Theory: A unifying framework to enhance the practice environment. (2006) JONA, 36 (11), 538-544.Katharine Kolcaba, PhD, RN, C, Colette Tilton, APRN, MSN, CNAA, BC, Carol Drouin, MS, RN  PDF Format

Authors’ Affiliations: Associate Professor (Dr. Kolcaba), The University of Akron College of Nursing, Akron, OH; Vice President Patient Care Services (Ms. Tilton), Southern New Hampshire Medical Center, Nashua, NH; Carol Drouin MS, RN clinical staff, Southern New Hampshire Medical Center, Nashua NH.

Abstract

The application of theory to practice is multifaceted. It requires a nursing theory that is compatible with an institution’s values and mission; easily understood and simple enough to guide practice.  Comfort Theory (CT) was chosen because of its universality. This article describes how Kolcaba’s Comfort Theory was utilized by a not-for-profit New England hospital to provide a coherent and consistent pattern for enhancing care, promoting professional practice, and addressing the forces of Magnetism when applying for Magnet Status.

The following comes from a presentation I did at this hospital; it is my definition of nurses' comfort:

Definition of Nurses’ Comfort: Totality of embeddedness in an organization based on physical, psychospiritual, socio-cultural-political and environmental attributes of an institution or agency,

Type of comfort:

Relief – the state of having a specific comfort need met

Ease – the state of calm or contentment

Transcendence – the state in which one can rise above problems or challenges
 

Context in which comfort occurs: 

Physical – pertaining to policies and facilities which promote good health habits & quality of life, periods of rest, fair & flexible scheduling, control over resources and patient care decisions, good ergonomics and spatial arrangements, generous benefits & pension plan

Psychospiritual – pertaining to internal awareness of self, including esteem, concept, values, meaning in one’s work, positive reinforcement, trust, empowerment, creativity, role clarity, support for learning & advancement

Environmental (Organizational) – pleasing work temperature, light, sound, odor, color, furniture, landscape, etc., distinct & strong nursing dept., flat organizational structure, decrease in non-nursing work, extent of team work and mutual understanding

Socio-cultural-political – pertaining to ease of relationships with peers, managers, administrators, and other members of the health system, openness with which new ideas are heard and advanced, good fit with organization, inter-departmental cooperation, work load adjusted for precepting new nurses & students.

Clinical Practice Guidelines

Comfort Management Protocol
(an example)

ASPAN Pain and Comfort Clinical Guideline©

Assessment

1. Vital signs including pain and comfort goals (e.g., 0 to 10 scale)
2. Medical history (e.g., neurologic status, cardiac and respiratory instability, allergy to medication, food and objects, use of herbs, motion sickness, sickle cell, fibromyalgia, use of caffeine/substance abuse, fear, and anxiety)
3. Pain history (e.g., preexisting pain, acute, chronic, pain level, pattern, quality, type of source, intensity, location, duration/ time, course, pain effect, and effects on personal life)
4. Pain behaviors/expressions or history (e.g., grimacing, frowning, crying, restlessness, tension, and discomfort behaviors [e.g., shivering, nausea, and vomiting]. Note that physical appearance may not necessarily indicate pain/ discomfort or its absence.)
5. Analgesic history (type [i.e., opioid, non-opioid, and adjuvant analgesics], dose, frequency, effectiveness, adverse effects, other medications that may influence choice of analgesics [e.g., anticoagulant, antihypertensive, muscle relaxants])
6. Patient's preferences (e.g., for pain relief/comfort measures, expectations, concerns, aggravating and alleviating factors, and clarification of misconceptions)
7. Pain/comfort acceptable levels (e.g., patient and family [as indicated] agree to plan of treatment/interventions postoperatively)
8. Comfort history (i.e., physiological, sociocultural, psychospiritual, and environmental [e.g., spiritual beliefs/symbols, warming measures, music, comfort objects, privacy, positioning, factors related to nausea/vomiting])
9. Educational needs (i.e., consider age or level of education, cognitive and language appropriateness, and barriers to learning)
10. Cultural language preference, identification of personal beliefs, and resulting restrictions
11. Pertinent laboratory results (e.g., prolonged prothrombin time [PT], partial thromboplastin time [PTT], and abnormal international normalized ratio [INR] and platelet count to determine risk for epidural hematoma in patients with epidural catheter)

Interventions

1. Identify patient, validate physician's order and procedure (i.e., correct name of drug, dose, amount, route, and time, and validate type of surgery and correct surgical site as applicable)
2. Discuss pain and comfort assessment (i.e., presence, location, quality, intensity, age, language, condition, and cognitively appropriate pain rating scale [e.g., 0 to 10 numerical scale or FACES scale] and comfort scale. Assessment method must be the same for consistency.)
3. Discuss with patient and family (as indicated) information about reporting pain intensity using numerical or FACES rating scales and available pain relief and comfort measures (include discussion of patient's preference for pain and comfort measures; implement comfort measures)(i.e., physiological, sociocultural, spiritual, environmental support as indicated by patient)
4. Discuss and dispel misconceptions about pain and pain management
5. Encourage patient to take a preventive approach to pain and discomfort by asking for relief measures before pain and discomfort are severe or out of control
6. Educate purpose of intravenous or epidural patient-controlled analgesia (PCA) as indicated; educate about use of nonpharmacologic methods (e.g., cold therapy, relaxation breathing, music)
7. Discuss potential outcomes of pain and discomfort treatment approaches
8. Establish pain relief/comfort goals with the patient (e.g., a pain rating of less than 4 [scale of 1 to 10] to make it easy to cough, deep breathe, and turn); premedicate patients for sedation, pain relief, comfort (e.g., non-opioid, opioid, antiemetics as ordered; consider needs of chronic pain patients)
9. Arrange interpreter throughout the continuum of care as indicated
10. Utilize interventions for sensory-impaired patients (e.g., device to amplify sound, sign language, and interpreters)
11. Report abnormal findings including laboratory values (prolonged PT/PTT and abnormal INR and platelet count among epidural patients)
12. Arrange for parents to be present for children

Expected Outcomes

1. Patient states understanding of care plan and priority of individualized needs
2. Patient states understanding of pain intensity scale, comfort scale, and pain relief/comfort goals
3. Patient establishes realistic and achievable pain relief/comfort goals (e.g., a pain rating of less than 4 [scale 0 to 10] to make it easier to cough, deep breathe, and turn upon discharge)
4. Patient states understanding or demonstrates correct use of PCA equipment as indicated
5. Patient verbalizes understanding of importance of using other nonpharmacologic methods of alleviating pain and discomfort (e.g., cold therapy, relaxation breathing, music)

Postanesthesia Phase I

Assessment

1. Refer to preoperative phase assessment, interventions, and outcomes data
2. Type of surgery and anesthesia technique, anesthetic agents, reversal agents
3. Analgesics (i.e., non-opioid, opioid, adjuvants given before and during surgery, time and amount at last dose, and regional [e.g., spinal/epidural])
4. Pain and comfort levels on admission and until transfer to receiving unit or discharge to home (Reassess frequently until pain or discomfort is controlled. During sedation procedure, assess continuously.)
5. Assessment parameters
   1. Functional level and ability to relax
   2. Pain: type, location, intensity (i.e., using self-report pain rating scale whenever possible [age, language, condition, and cognitive appropriate tools], quality, frequency [continuous or intermittent], and sedation level; patient’s method of assessment and reporting need to be the same during the postoperative continuum of care for consistency.) Note pain level at rest and during activity.
   3. Self-report of comfort level using numerical scale (0 to 10 scale) or other institutional approved instruments
   4. Physical appearance (e.g., pain/discomfort behaviors [Note: Pain behaviors are highly individual and the absence of any specific behavior (e.g., facial expression, body movement) does not mean the absence of pain.])
   5. Other sources of discomfort (e.g., position, nausea and vomiting, shivering, environment such as noise, noxious smell, anxiety)
   6. Achievement of pain relief/comfort treatment goals
   7. Assess routinely, and before and after interventions. with verbal rating scales or numeric rating scales for cognitively aware patients; assess with Comfort Behaviors Checklist for non-alert patients (all available in instrumentation section)
6. Age, cognitive ability, and cognitive learning methods
7. Status/vital signs
   1. Airway patency, respiratory status, breath sounds, level of consciousness, and pupil size as indicated and other symptoms related to the effects of medications
   2. Blood pressure
   3. Pulse/cardiac monitor rhythm
   4. Oxygen saturation
   5. Motor and sensory functions post– regional anesthesia technique

Interventions

1. Identify patient correctly; validate physician's order; implement correct drug, dose, amount, route, and time; include type of surgery and surgical site as applicable
2. Pharmacologic (medicate as ordered)
   1. Mild to moderate pain—use non-opioids and may consider opioids (e.g., acetaminophen nonsteroidal anti-inflammatory drugs [NSAIDs], cyclooxygenase 2 [Cox-2] inhibitors). All the patient's regular non-opioid prescription medications should be made available unless contraindicated and per institutional approval.
   2. Moderate to severe pain—use multimodal therapy (e.g., combine non-opioid and opioid)
   3. Utilize the 3 analgesic groups appropriately (consider multimodal therapy)
      1. Non-opioids (e.g., acetaminophen, NSAIDs, Cox-2 inhibitors); adjuvants non-opioids (acetaminophen and NSAIDs, such as aspirin, ketorolac, ibuprofen, Cox-2 inhibitors).
      2. Mu-agonist opioids (e.g., morphine, hydromorphone, fentanyl)
      3. Adjuvants
         1. Multipurpose for chronic pain (e.g., anticonvulsants, tricyclic antidepressants, corticosteroids, antianxiety medication)
         2. Multipurpose for moderate to severe acute pain (e.g., local anesthetics, ketamine)
         3. Neuropathic continuous pain— antidepressants, tricyclic antidepressants, oral or local anesthetic
         4. Neuropathic lancinating pain- (stabbing, knifelike pain) anticonvulsant, baclofen
         5. Malignant bone pain—corticosteroids, calcitonin
         6. Post–orthopedic surgery—consider muscle relaxants if patient experiences muscle spasm
3. Initiate and adjust IV and regional infusions (PCA) as indicated and ordered, and based on hemodynamics status (Refer to institutional permissive procedure.)
4. Nonpharmacologic intervention use to complement, not replace, pharmacologic interventions
5. Administer comfort measures as needed
   1. Physiological (e.g., positioning, pillow, heat and cold therapies, sensory aids [e.g., dentures, eye glasses, hearing aids]; use meperidine [Demerol] for shivering, antiemetics, e.g., Reglan, Zofran as ordered)
   2. Sociocultural (e.g., family/caregiver, interpreter visit)
   3. Psychospiritual (e.g., chaplain or cleric of choice, religious objects/symbols)
   4. Environmental (e.g., confidentiality, privacy, reasonably quiet room)
6. Cognitive behavioral (e.g., education/instruction, relaxation, imagery, music, distraction, biofeedback)

Expected Outcomes

1. Patient maintains hemodynamic stability including respiratory/cardiac status and level of consciousness
2. Patient states achievement of pain relief/ comfort treatments goals (e.g., acceptable pain relief with mobility at time of transfer or discharge)
3. Patient states he/she feels safe and secure with the instructions (e.g., use of PCA machine)
4. Patient shows effective use of at least one nonpharmacologic method (i.e., breathing relaxation techniques)
5. Patient shows effective use of PCA as indicated and discusses expected results of regional techniques
6. Patient verbalizes evidence of receding pain level and increased comfort with pharmacologic and nonpharmacologic interventions

Postanesthesia Phase II/III

Assessment

1. Refer to preoperative phase and Phase I assessments, interventions, and outcomes data
2. Achievement of pain/comfort treatment goals and level of satisfaction with pain relief and comfort management
3. Pain relief/comfort management plan for discharge and patient agreement
4. Educational and resource needs, considering age, language, condition, and cognitive appropriateness

Interventions

1. Identify patient correctly; validate physician's order; implement correct drug, dose, amount, route, and time
2. Pharmacologic interventions (medicate as ordered): non-opioid (e.g., acetaminophen, NSAIDs, Cox- 2 inhibitors), Mu-agonist opioids (e.g., morphine, hydromorphone, fentanyl), and adjuvant analgesics (e.g., local anesthetics).
3. Continue and/or initiate nonpharmacologic measures from Phase I
4. Educate patient and family/caregiver
   1. Pain and comfort measures
   2. Untoward symptoms to observe
   3. Regional or local anesthetic effects dissipating after discharge (e.g., numbness, motor weakness, or inadequate relief) and potential adjustments as applicable
   4. Availability of resource as needed
5. Discuss misconceptions, expectations and implement plan of action satisfactory to patients
6. Address nausea with pharmacologic interventions or other techniques and discuss expectations

Expected Outcomes

1. Patient states acceptable level of pain relief and comfort with movement or activity at time of transfer or discharge to home
2. Patient verbalizes understanding of discharge instruction plans
   1. Specific drug to be taken
   2. Frequency of drug administration
   3. Potential side effects of medication
   4. Potential drug interactions
   5. Specific precaution to follow when taking medication (e.g., physical limitation, dietary restrictions)
   6. Name and telephone number of the physician/resource to notify about pain, problems and other concerns
3. Patient states understanding or shows effective use of nonpharmacologic methods (e.g., cold/heat therapy, relaxation breathing, imagery, music)
4. Patient states achievement of pain/ comfort treatment goals and level of satisfaction with pain relief and comfort management in the perianesthesia experience.

Sample Comfort Contract
(for patients)

When I wake up from surgery, I expect to have a total comfort level of (rating of 0 to 10 with 10 being highest expected comfort).  I expect that my comfort will be higher when I first wake up because of the pain protection I received from anesthesia and other medications I received before and during surgery.

While I am in the recovery room, I expect that my comfort will (circle one)l:

Stay the same                   Decrease                          Increase

If my comfort decreases, the acceptable level of comfort I am willing to go down to is (rating of 0 to 9 with higher scores meaning more comfort).

I would like to keep my comfort level at: (rating of 0 to 10 with 10 being highest expected comfort).      

I would like to keep my level of alertness at (rating of 0 to 10 with 10 being highest expected alertness).

I understand that, in order to remain alert, I may go down to a lower comfort rating.

The types of discomforts that bother me the most are (circle all that apply): nausea, vomiting, lonliness, anxiety about my diagnosis, poor positions, cold, noise, bad odors, pain at my surgical site, other:

Check one: ___ I have no chronic pain.

                    ___ I have chronic pain for the following reasons: (headaches, allergies, arthritis, vertebral disks, muscular or joint pain, stiff neck, eye pain,            

                            fibromyalgia, other______________________________________________________________________

Comfort measures that might help me stay alert and comfortable (without a lot of pain medication) are:  for example, back rub, guided imagery, cervical neck pillow, warm blanket or gown, positioning with pillows, positioning without pillows, soft music, TV, my family present.  (Please describe your own favorite “comfort measures.”

If I am asked to sit up and/or walk, the following pain medication should be given 20 minutes prior:________________________________________________________

I would like my family members to be in attendance as soon as possible:

Yes______    No________

Signature:_______________________________________Date_____________________