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This section was written over a period of years, before my collaboration with Dr. Bice. Please feel free to ask her additional questions, especially regarding her experience with pediatric nursing and research. Dr. K
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Frequently Asked Questions about Research
TYPES:
Relief: the state of a patient who has had a specific need met.
Ease: the state of calm or contentment.
Transcendence: the state in which one rises above one's problems or pain.
CONTEXTS IN WHICH COMFORT IS EXPERIENCED:
Physical: pertaining to bodily sensations and homeostatic mechanisms.
Psychospiritual: pertaining to internal awareness of self, including esteem, concept, sexuality, and meaning in one's life; one's relationship to a higher order or being.
Environmental: pertaining to external surroundings, conditions, and influences.
Sociocultural: pertaining to interpersonal, family
They were combined because indicators of each overlapped and, in some cases, were identical (e.g. meaningfulness, faith, identity, self-esteem). Judith Spross independently combined psychological and spiritual contexts the same way and came up with the same contexts of experience in her work about suffering.
Comfort is a larger umbrella term compared to pain. As stated above, there are three types of comfort: relief, ease, and transcendence. Relief is the absence of specific previous discomforts, a common one being pain which can be of varying intensity. Pain that has a physical origin also is influenced by psychospiritual, sociocultural, and environmental factors.
I define pain as a multidimensional discomfort including sensory, cognitive, and affective components (Melzak & Wall, 1982). It is a specific sensation in the body that “hurts” with a varying degree of intensity (for example, from mild to severe or from 1 to 10). The discomfort of pain is often a significant detractor from comfort. Looking at pain holistically, pain is intensified by loneliness, fear, anxiety, noxious stimuli, anger, etc.
Comfort is a complex concept but, prior to this work, was defined negatively as absence of pain, nausea, and itching. My definition defines comfort as a positive concept and accounts for its many aspects beyond physical comfort. The taxonomic structure enables us to identify comfort needs, design interventions targeted to those needs, and measure the effectiveness of those interventions.
An early assignment in my MSN program (by Dr. Rosemary Ellis) was to diagram my nursing practice. At that time, I was a head nurse on an Alzheimer's unit, and I used the concept of comfort to designate the state I wanted my patients to be when they weren't trying to perform special tasks. At a presentation of my "framework" to a gerontological conference, I was asked if I had done a concept analysis of comfort. I replied, "No, but that's the next step." Actually, I hadn't thought about it before, but realized that it should be my next step, and I had an obligation to do so after committing myself publicly.
Some of my background is on my personal page of my web site and much more is in my book. But I guess the biggest influences on me were:
The death of my father when he was 39, I was 8, my brother (John) was 6 and my mom was only 33.
The courage of my mom to buy a house for the three of us before she had a job, and then her raising of us with the right mixture of trust, encouragement, and hands-off discipline. John and I didn’t need much discipline, as we were good kids. I don’t think we even minded being relatively poor as we were in an ordinary working-class school and neighborhood, where we fit quite well. I had wonderful friends in high school whom I still see often.
My mother was always concerned about what people would say if family “secrets” became public (not that ours were particularly interesting!). Her mother was rather heavy handed in this regard, and my mom has a hard time even now being straight forward. As a result, I try to be very direct in my writing and speaking. But she never put any limitations on my brother or me, as far as what we could achieve, and she was proud when we did well in school. She was supportive of our ideas and accomplishments. But I always missed having a father, still do!
We continued visiting my father’s family every summer (about a 6 hour drive) and I believe I am more like them than my mother’s family. I particularly admired my paternal grandmother who was more intellectual, strong willed, and direct than my maternal grandmother. Because of her, I have a positive view on aging, and went into gerontology.
My choice to be a nurse when I was in high school was made because I like people and science. A local diploma program gave me a full scholarship so I could give my half of my insurance money (from my father’s death) to my brother for a state university. At this time, the most common way to be a nurse was with a diploma from a hospital-based “training” program. We were not exposed to nursing theory, and I don’t think much was available at that time (in the 1960’s) anyway.
I always loved nursing, but also wanted to be a stay at home mom, so I worked part time in a variety of settings while my girls were little. I didn’t go to graduate school until I was in my late 30’s and my children were pretty independent. At that point in my “career” I wanted more responsibility but couldn’t get promoted without a college degree. But I gathered lots of clinical experience in my early years, so I knew what specialties I liked. I was drawn particularly to dementia care, forming the foundations for Comfort Theory, I had to be a nurse-detective because my patients couldn’t verbalize why they were uncomfortable. Our practice was very compassionate, required strong leadership, creativity, and empathy. These were the characteristics of nursing that I valued a lot, rather than technology. (The movie ET aroused in me very negative feelings when he was hooked up to all that equipment. I paid attention because I was about to accept a perioperative nursing position with lots of technological components. I realized that job wasn’t for me, and also began thinking about the importance of comfort in nursing.)
My brother died of cancer when he was 41, and during his illness I gained more experience with comforting actions of nurses, and how to articulate what they did. Because of that experience and its timing, my dissertation is about women with breast cancer, not dementia or gerontology. And I have done a lot of work with end of life comfort.
My spirituality, which my mother fostered and role-modeled for me, has also had a strong influence.
This is not a broad or grand theory. The working part of the theory, the last FULL line of the conceptual framework (Diagram 2) matches up to the description of the theory on page one (it diagrams the relationships between the concepts). Also, the theory can be easily operationalized for appropriate settings. When each concept is operationalized, you have a practice level theory.
Nursing: the intentional assessment of comfort needs, design of comfort measures to address those needs, and re-assessment of patients,' families, or community comfort after implementation of comfort measures, compared to a previous baseline.
Patient: an individual, family, or community in need of health care.
Environment: exterior influences (physical room or home, policies, institutional, etc.) which can be manipulated to enhance comfort.
Health: optimum function of a patient/family/community facilitated by attention to comfort needs.
I borrowed the ideas about Relief, Ease, and Transcendence as stated above. Later, I "borrowed" the contexts of experience from the literature review about holism. I put these ideas together in a unique way. Later, I borrowed the framework for the First and Second parts of Comfort Theory from Henry Murray. But I hung nursing concepts on his abstract framework in a unique way. The idea of institutional outcomes was unique and was added through a process Tomen and Alligood call retroduction.
Comfort has been described in Canadian, Hispanic, and Australian cultures. In addition, I have inquiries from Iran, Turkey, Thailand, China, South America, Norway, etc. So, I think COMFORT is a universal concept. The first step to testing comfort theory in other cultures would be to translate the instrument into a different language. I am looking for volunteers!
Recent developments with CT include recently expanding the definition of institutional integrity to include health care organizations at local, regional, state, and national levels. In addition to hospital systems, the definition of “institutions” includes Public Health agencies, Medicare and Medicaid programs, Home Care agencies, Nursing Home consortiums, etc. Examples of variables related to this expanded definition of InI include patient satisfaction (HCHAPS), cost savings, improved access, decreased morbidity rates, decreased hospitalizations and readmissions, improved health-related outcomes, efficiency of services and billing, and positive cost-benefit ratios.
Also, it has been proposed that Comfort Theory is interdisciplinary and not limited to nurses (March & McCormack (2009). I wholeheartedly endorse this idea, acknowledging that CT originated in nursing but is appropriate for all disciplines involved in healthcare.
These are the main points I would like you to remember about the concepts of comfort and caring:
1. Comfort is a patient outcome. Caring is about how nurses do their work.
2. The effects of caring are difficult to measure; the effects of comfort interventions (including caring) are measurable.
3. Comfort (as I use it) is a noun (outcome or product), caring is an adjective - it describes a process.
4. Comfort Theory is testable - I have built my career on testing it. Is Swanson's theory testable? What kind of design for each?
5. There is one taxonomy of comfort, and 12 aspects (cells of the grid). They are inter-related - always - because this is a holistic theory.
First, my professors at CWRU were always ahead of their time and they gave us students so much moxie for presenting and publishing our work. If you read my book, you will see just how fortunate I was to have the right courses and professors at critical junctures during graduate school.
Also, my husband has always been a huge supporter and brain stormer about Comfort Theory.
Health care in the 1990’s was becoming increasingly high tech, as were the work and home environments. The concept of comfort became very important as an antidote to high tech, and as I was beginning to publish my work about comfort, the lay media was also picking up on the importance of comfort. It felt like the American culture was exhibiting evidence of collective consciousness. What surprised me in my early research about comfort in nursing, was how little attention comfort received in nursing textbooks.
The overall purpose of CT was to highlight the importance of comforting our patients in this high-tech world. It is what they want and need from us. The biggest change was to add the concept of Institutional Integrity so that administrators would also value the important comforting actions of nurses.
If nurses care about the comfort and well-being of persons in their community, they will want them to be able to stay healthy and/or return to health. Therefore, a national health care policy which provides basic care for all should be a priority. Many of our demonstration projects for nurse-run clinics and telephone triage, for example, are being scrapped because states do not have enough money to fund them. Yet those governors are not campaigning for a national health policy (nor are many nurses, I might add). The ANA, however, does have a fairly strong lobby in DC and they supported the Patient Affordability Act. Few nurses have joined in that effort....
I believe that nursing practice must be fully described and then honored for the important comforting work that we do. To do this, nurses must document in the patient record the nature of patients’ comfort needs and how those needs were addressed. Additionally, patients’ rating of their comfort from 0 to 10 with 10 being the highest comfort possible in the health care situation. If patients are unable to rate their own comfort, and Comfort Behaviors Checklist is available on my web site (along with lots of other comfort questionnaires and the children’s Comfort Daisies.
I believe that nursing science is about patient/family comfort primarily, and secondarily about nurses’ comfort. Nurses’comfort is related to retention and continuity of care and can be addressed and measured effectively by nurses in management. Further, patient/family comfort is a direct and value-added indicator of quality rather than an indicator or POOR quality, such as skin breakdown or med errors.
Lastly, I believe that theoretical nursing is easier and more efficient than nursing without a theory, because a theory provides a pattern for care by which all elements of nursing can be organized. It is towards these values that all my work has been directed.
them to be able to stay healthy and/or return to health. Therefore, a national health care policy which provides basic care for all should be a priority. Many of our demonstration projects for nurse-run clinics and telephone triage, for example, are being scrapped because states do not have enough money to fund them. Yet those governors are not campaigning for a national health policy (nor are many nurses, I might add). The ANA, however, does have a fairly strong lobby in DC and they supported the Patient Affordability Act. Few nurses have joined in that effort....
I believe that nursing practice must be fully described and then honored for the important comforting work that we do. To do this, nurses must document in the patient record the nature of patients’ comfort needs and how those needs were addressed. Additionally, patients’ rating of their comfort from 0 to 10 with 10 being the highest comfort possible in the health care situation. If patients are unable to rate their own comfort, and Comfort Behaviors Checklist is available on my web site (along with lots of other comfort questionnaires and the children’s Comfort Daisies.
I believe that nursing science is about patient/family comfort primarily, and secondarily about nurses’ comfort. Nurses’comfort is related to retention and continuity of care and can be addressed and measured effectively by nurses in management. Further, patient/family comfort is a direct and value-added.
Well I guess my ultimate goals would be for patient comfort to be documented in every hospital and home care situation, as pain is documented right now. I want nurses to realize how important their non-technical comforting interventions are, and how important it is to try to connect to patients. I would like nursing theory, in general, to be more widely applied in hospitals and nursing education programs.
Benefits: patients will have a better hospital experience and will credit nurses for that improved experience.
Limitations: you tell me the indicator of quality rather than an indicator or POOR quality, such as skin breakdown or med errors.
Lastly, I believe that theoretical nursing is easier and more efficient than nursing without a theory, because a theory provides a pattern for care by which all elements of nursing can be organized. It is towards these values that all my work has been directed.
Health care in the 1990’s was becoming increasingly high tech, as were the work and home environments. The concept of comfort became very important as an antidote to high tech, and as I was beginning to publish my work about comfort, the lay media was also picking up on the importance of comfort. It felt like the American culture was exhibiting evidence of collective consciousness. What surprised me in my early research about comfort in nursing, was how little attention comfort received in nursing textbooks.
I would like to see more publications about the relationship of nurses’ comfort to institutional outcomes such as cost-benefit analysis of increased staffing and theory-based nursing.
I would like to see comfort, as a patient outcome, be utilized in more electronic data bases.
I would like to see more theories applied in undergraduate clinical experiences, so that new graduates have an idea of which theory best suits them and their patient population. Right now, only graduate students are exposed to the benefits of theory in nursing.
My ultimate goals would be for patient comfort to be documented in every hospital and home care situation, as pain is documented right now. I want nurses to realize how important their non-technical comforting interventions are, and how important it is to try to connect to patients. I would like nursing theory, in general, to be more widely applied in hospitals and nursing education programs. Benefits: patients will have a better hospital experience, and will credit nurses for that improved experience.
When we do our “jobs,” we intuitively think about the needs of our patients. Thinking in terms of comfort needs gives us a quick pattern for assessment, intervention, and documentation. A pattern makes our work easier and more satisfying to give and receive – especially when it facilitates our thinking holistically and efficiently.
Also, as nurses, it is important not only to be aware of what makes our patients more comfortable, but of what makes US more comfortable. In the workplace, we need to advocate for better working environments. For our patients, we need to advocate for services that will make them more comfortable. And in our homes, we need to allow ourselves the time to be “comfortable,” to return to our comfort zones often in order to become rejuvenated and energized (some folks call this “margins” – allowing time for us).
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