Reclaiming What Has Been Lost in Nursing:
The Evidence Base for Comfort Care
Patricia O’Malley PhD, RN, CNS, CCRN(e)
26th Annual
Spring Conference 2015
Columbus Chapter Oncology Nursing Society
Kaleidoscope of Oncology Care
March 27, 2015
Objectives
1. Describe the evidence base for comfort care.
2. Reflect on how nursing interventions for
comfort can be easily integrated into
practice.
The End of the Industrial Age
Third Age of
Man
Birth of the Information Age
What is coming….
Ethics Fog
Technology Extends Life & Death
Aging Society
Reduced Resources
Nursing Shortage
Birth & Death of Cultures
The Workload
Dissatisfaction!
• Pain scores remain high despite increasing doses of
medications
• Increasingly complex medical care with increasing
loss & disenfranchised grief
• Expectations of relief of pain & grief & suffering
• Nurse distress when the medications “fail”
• Disappointed patients & nurses
Where Did Comfort Go?
Science & Art of Nursing
“Historically, comfort has been a quintessential aspect of nursing
practice. Currently, it is questionable whether or not comfort
remains an integral facet of nursing care. The increasing trend
to focus on the technological and institutional aspects of
patient care rather than the individual's response to illness
and subsequent treatment is heard again and again from the
growing vocal consumer movement.”
Cameron B. The Nature of Comfort to Hospitalized Medical Surgical
Patients. Journal of Advanced Nursing. 1993; 18: 424-436.
Who Has Time to Comfort?
Comfort is not a function of time!
What is Comfort?
Simplicity
Comfort may be a blanket or breeze,
Some ointment here to soothe my knees,
A listening ear to hear my woes;
A pair of footies to warm my toes.
A PRN medication to ease my pain,
Someone to reassure me once again,
A call from my doctor, or even a friend,
A rabbi or priest as my life nears the end.
Comfort is whatever I perceive it to be
A necessary thing defined only by me.
SD Lawrence 1993
• Fulfillment in nursing is not a function of
technical and professional competency.
• Fulfillment in nursing realized in the moral
sense within a personal relationship first. This
is what keeps nurses in nursing.
• Nurse Caring is the provision of comfort within
a relationship
“Comfort is a strengthening process. Patients who lack
comfort are weakened individuals. While consolation
and soothing are important aspects of comfort,
strengthening is necessary for healing.”
Comfort Needs Relationship
A Dynamic Process
Cameron B. The Nature of Comfort to Hospitalized Medical Surgical Patients.
Journal of Advanced Nursing. 1993; 18: 424-436.
» Bishop and Scudder 1990
Compassionate Detachment
• Compassionate detachment asks that we feel deeply for
another person, understand the extent (as much as we can) of
their pain without immersing ourselves in it or assuming
responsibility to solve it or make it better.
• Compassionately paying attention to someone’s distress is
more constructive that trying to fix it.
• Only with compassionate detachment can we comfort
effectively
Sue Patton Thoele 1997
Caring-Comfort
• Nurse CARING is providing COMFORT
– Affective
– Relational
– Concrete Interventions
• Morse J. 1992. Comfort: The Refocusing of Nursing
Care. Clinical Nursing Research 1:91-106
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Patient Views of Comfort
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Patient Descriptions of Comfort
The nurse was a friend to me
Tried to make me comfortable
Talked to me as a real person
Was on my side the whole time
Acknowledged my pain
– Jenny J & Logan J. Caring & Comfort Metaphors Used by Patients in
Critical Care. Image. 1996;28(4):349-352.
Patient Defined Elements of Comfort
Patient View
Walker A. The Expert Nurse Comforter. Perceptions of Medical/Surgical Patients.
International Journal of Nursing Practice. 1996;2:40-44
Physical Care
Intellectual – Knowing & Understanding
Sitting- not standing !
Empathy
Expert calmness- in charge!
Friendly protective surveillance
– Walker A. The Expert Nurse Comforter. Perceptions of
Medical/Surgical Patients. International Journal of Nursing
Practice. 1996;2:40-44
What Patients Say
Comfort Measures
Comfort my diseased body, my disobedient body, my
vulnerable body, my violated body, my resigned body, my
enduring body, my betraying body and my betraying mind.
me
with illness or injury without being
“Teach
how to live
dominated by my body”.
The phenomenology of comfort. Morse J. Bottorff J. & Hutchinson. Journal of
Advanced Nursing 1994; 20: 189-195.
Comfort Interventions
Comforting strategies could be grouped in 4 contexts:
helping patients put experiences into perspective
helping patients maintain control
providing opportunities to function as normally as possible
providing emotional support
Findings indicated that comforting strategies used by cancer
nurses comprise a significant part of nurses work
Bottorff J, Gogag M, Engelberg-Lotzkar A. Comforting: exploring the work of cancer
Nurses Journal of Advanced Nursing 1995;22:1077-1084.
Comfort Care Premises
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Comfort consists of WORDS & ACTIONS
There must be intent to comfort
Comfort goes beyond the treatment
Comfort strengthens patients
Comfort is applied individually
Comfort is contextual
Expert nurses are proud of methods they use to enhance comfort.
The ability to comfort is a sign of an expert nurse
Comfort is enhanced by manipulation of the environment
Comfort care is an interdisciplinary activity
Comfort Interventions
In the context of comforting interactions with cancer
patients, nurses were observed to use gentle humor,
physical comfort measures, emotionally supportive
language, and comforting and connecting touch.
Nurses also provided opportunities for patients to
make choices, be engaged with social exchange,
increased proximity, and provided information.
Bottorff J, Gogag M, Engelberg-Lotzkar A. Comforting: exploring the work of cancer
Nurses Journal of Advanced Nursing 1995;22:1077-1084.
Comfort & Endurance
Maintaining Patient Endurance: The Comfort Work of Trauma Nurses.
Clinical Nursing Research. Morse J. & Morse M. Clin Nurs Res 1998 7:
250. http://cnr.sagepub.com/
Summary
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Comfort Theory
Providing comfort is an art of nursing using science
Comfort is therapeutic use of self
Comfort is based on assessment
Comfort can only be provided in relationship
Comfort care retains nurses
Katherine Kolcaba
http://www.thecomfortline.com/
Comfort Outcomes
• Comfort measures are unexpected
• Comfort measures are valued
• Comfort measures are welcomed because they
are evidence of “nursing care”
• Patients report feeling “valued” & protected
• Nursing care begins and ends with comfort
In the winter of bondage, we melted the snows of apathy; and rivers
of renewal flowed.
In the darkness of despair, we lit a light of hope; which was not
extinguished in the desert of discouragement.
We planted a tree of valor, and it blossomed; and this we left to you as
your inheritance.
Adapted Liam MacUistin 1976
Comfort Care
• Technical: monitoring, managing, preventing,
administering, observing
• Coaching: reassurance, information, listening,
recognition; acknowledgement
• Use of Self: encouragement, setting targets,
therapeutic touch, massage, hand holding,
presence, reminiscence, music, calling in
comfort, spiritual care, protected rest
Ask this question from now on!
After “are you having pain”? Ask:
Are you comfortable?
What can I do to make you
comfortable?
Resources
• Ferrell B & Coyle N. The Nature of Suffering and the Goals of
Nursing. 2008. Cary, NC; Oxford University Press.
• Kolcaba K. Comfort Theory & Practice – A Vision for Holistic
Health Care and Research. 2003. New York; Springer
Publishing.
• Kolcaba K. The Art of Comfort Care. Image. 1995;27(4): 287289.
Comfort in Social Media
• https://www.youtube.com/watch?v=cDDWvj_
q-o8
Patricia O’Malley PhD, RN, CNS, CCRN (e)
[email protected]