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2. nursing

Applying Comfort Theory to Your
Patient(s) or Research Population
Dr. Kathy Kolcaba
Associate Professor, Emeritus,
The University of Akron (OH);
Adjunct Faculty Ursuline College: &
Consultant, The Comfort Line
• Many people have asked me how to
apply Comfort Theory (CT) to their
specific patient(s) or research population.
This slide presentation should help
facilitate this process.
2
Learning Objectives:
Upon completion of this presentation,
each participant will be able to:
• discuss comfort as a value-added, holistic patient outcome of
nursing care.
• apply the definition of holistic comfort to the
Ambulatory Care setting.
• describe how the conceptual framework of comfort
can be used.
• discuss exemplars of Comfort Theory
3
A. What does “comfort” mean?:
• Eight definitions in most modern dictionaries
• Oxford English Dictionary
(origins of English words)
4
A. What does “comfort” mean?:
• Different perspectives based on disciplinary roles in
comforting patients and families:
– **Nursing, medicine, pharmacy, social work, psychology,
theology, ergonomics, psychiatry
• Textbooks, articles, historical & contemporary
– Patient comfort was more holistic and important in early
writings; requires more skill in later writings
5
Comfort as an Umbrella Term,
a Whole Person Term
• “Relief” – unmet comfort needs
• “Ease” – contentment;
attention to risk factors
• “Transcendence” – motivation,
confidence, hope; nurses never
give up: help patient/family cope
when full relief is not possible
• Juxtaposed with contexts of
holistic experience:
– Physical (medical & nursing),
psychospiritual, sociocultural,
environmental
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Relief
Physical
Psychospiritual
Sociocultural
Environmental
pain
anxiety
Ease
Transcendence
Holistic Nature of Comfort:
• Green:
– Ease
– Relief
– Transcendence
• Red/yellow/purple:
– Physical
– Psychospiritual
– Sociocultural
– Environmental
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The Strengthening aspect of comfort:
Confortare: to strengthen greatly
(increased comfort is the immediate
goal of nursing care)
 When patients are strengthened
they do better with specific goals
(Goals are subsequent outcomes,
mutually set with patient/family)
 When patients meet these goals,
the institution does better
– (eg. patient satisfaction,
stay out of hospital)
8
Increased comfort is an outcome that
your patients want…….
• Grid and/or origami is a visual for practice:
– Especially: physical, psychospiritual, sociocultural,
environmental
• Components are interrelated
• The whole is greater than the sum of its parts
• Many tools that are easily accessible for planning
research, quality initiatives, environmental issues
9
Comfort is a value-added outcome rather than a
negative, scary one!
• Perspective that highlights all of the skills nurses bring to a
situation, not just on hazards to prevent.
• When you address specific needs for comfort, including pain
& anxiety, you increase positive subsequent outcomes such as
wellness and self-confidence, patient satisfaction, cost.
• Currently, most nursing outcomes studied by nurses are
negative.
– Bedsores, falls, med errors, nosocomial infections, failure
to “rescue.”
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Definition of Holistic Comfort:
The immediate state of being strengthened by having needs
for relief, ease, and transcendence addressed physically,
psychospiritually, socioculturally, & environmentally.
• Comes directly from my research.
• State specific (comfort right now!)
• The outcome of comfort is patient and family centered,
because comfort is a basic human desire & need.
– Historically, a traditional mission of Nursing.
– What most experienced nurses do intuitively.
• Novice to Expert by P. Benner
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B. A True Story about Comfort:
• 74 year old client in own home with 70 year
old wife (Mr. & Mrs. Green).
Recently, Mr. Green has had:
– weight loss, with increased appetite,
diminished vision
• Mrs. Green very anxious
– physical exam with wife present
– Dx: New onset Type II diabetes
• Assessment using grid
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Total
Comfort
Relief
Ease
Physical
Hyperglycemia
Normal BS
Hunger, weight loss
Optimal weight
Diminished vision
Skin healed
Transcendence
(maintenance)
Wants to be best
possible diabetic
patient with excellent
BS control
Pain managed
without narcotics?)
Psychospiritual
Anxiety, Anger, Why us?
Sociocultural-
Need to understand diet, blood
sugar, sequelae
How will we manage?
Financial distress, body image
challenged
Anxiety of wife, need for
reassurance, rituals
Environmental
Transportation difficult; wait
room crowded & cluttered; wait
for appt. prolonged,
Adherence,
confidence, faith
Engages in exercise &
HSBs; motivated to
learn & grow
Understands
regimen & diet;
social service
helping w
paperwork; uses
phone to connect;
self esteem healthy
Social support system
inspires and gives
material and emotional
aid naturally &
consistently; nurse as
trusted source of
advice and
interventions
Quality of office
furniture,
decorating patient
friendly
Wait time minimal
Vouchers for Bus/taxi
or van transport ;
peaceful view or
hopeful posters
13
Ritual of the Physical Assessment
• Patients & families have
expectations about
thoroughness
• Quick to notice when
“rituals” of personal
examination,
interpretation, and
explanation are
incomplete
14
• The worth of “words of
comfort” which entail:
– Knowledge & skills
– Individualized attention
• Essential for
transformation to trust
– for other positive
outcomes
Comfort Care Plan (ala nsg process):
• Diabetic teaching, diet,
other signs to look for
• Comfort with blood sugar monitoring
• Discharge plan with follow-up and
home support:
–
–
–
–
Frequent appointments at first
Transportation plan
Telephone checks
Multidisciplinary home visits
• Everyone talking the same language
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Evaluation: Patient/Family HSBs
• Blood sugar well controlled
• Hunger and weight normalized
• Less support needed for home care
– Appts 1-2 X year
– Transportation plan works
– Less frequent telephone checks or
call-in questions
– Multidisciplinary visits PRN only
• Comfort Care Plan working!
Measure comfort with care plan
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C. Nursing Conceptual Framework:
Ambulatory Care
A good CF specifies concepts about your setting: ambulatory care nursing
Health
Care
Needs
• Timing pressure
• Control of care by
patient and family
• Learning to use
electronic
resources
• Privacy
• Continuity of care
Te
• Learning
+
Nursing
Interventions
• Per protocol or
individualized
• Advocacy
• Rapid
assessment
• Teaching
+
Increased
holistic
Comfort
Intervening
Variables
• Availability of
standardized
protocols
• Monitoring
equipment/
• Make
nursing
comfort
strategies
visible!
• Communication
methods
• Colllaboration
• Case mgt.
• Care expectations
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© Kolcaba (2007)
Health
Seeking
Behaviors
Institutional
Integrity
• Patient
satisfaction
Internal
Behaviors
External
Behaviors
• Cost
containment
• Decreased
admissions
How do you know your patients
are comfortable?
• Ask them!
“How would you rate your total comfort from 0 to 10?
– What is keeping you from being more comfortable?
– Documentation similar to pain scales
• more holistic
• more reflective of all that you do
• Research: Compare comfort scores before and after nursing
interventions
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Comfort is documentable in all patient
populations…
• HealthConnect®
– If you didn’t input it,
you didn’t do it
– Results of most comforting
interventions and processes
can be documented
(evidence: did your
interventions increase
comfort?)
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Whose comfort?
• Your patients and their families
– Comfort Zone strengthens them for the tasks
ahead!
• Your staff and you
• Your managers
– Is your work place a Comfort Zone?
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D. Nurses’ (& staff) Comfort:
Definition:
• Totality of embeddedness in
an organization based on
physical, psychospiritual,
sociocultural, and
environmental attributes of
an institution or agency
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Physical Comfort:
Clean, safe environment; attractive, convenient,
and clean lounge; restful breaks; good coffee, tea,
etc; leave on time; continuity of patient care;
adequate staffing; resources allocated consistently
and fairly; control over resources; equipment that
works, is available, is complete; good salary,
benefits, profit sharing, retirement; increased
routine-ization; day care available; noise controlled;
enough room to work; flexible and/or selfscheduling;
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Psychospiritual Comfort:
Job fits with one’s own values; managerial support;
decrease in non-nursing work; opportunities for
advancement; timely feedback on job performance
(positive also!); control over practice; freedom to make
important patient-care decisions; inter-departmental
cooperation; trust in management; sharing of feelings;
empowerment; agreement with organization goals &
culture; creativity encouraged; support for learning,
growth, & development; role clarity; appropriate
authority, responsibility, respect, & recognition; skills and
talents utilized optimally; positive change models;
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Sociocultural Comfort:
Supportive social environment; opportunities to be
part of major decisions; information shared by
administration; strong communication; cultural &
ethnic diversity of patients, families, and staff;
mentorship; nurse-physician collaboration; support
for data collection or research; enough time to
discuss patient-care problems with other nurses;
education provided; teamwork valued; nurse
managers strong leaders and advocates for staff;
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Organizational (Environmental) Comfort:
Distinct and strong nursing department; flat organizational
structure; professional milieu for practice; decreased paperwork
and administrative duties; work-load adjusted for precepting
new nurses & students; visionary leaders; good organizational
fit; respect for professional goals;
“I’m a big believer in making people comfortable in meetings so
they ask questions….The point is, to make them feel good.” (CEO
Adam Bryant, Hain Celestial Group, NYT, 3/20,Bus-2)
– play to strengths
– build confidence
25
Article, J of Nsg Scholarship (2006)
•
•
•
•
Autonomy
Distributive justice
Group cohesion
Promotional
opportunities
• Supervisory support
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• Work variety
• More time in direct
patient care ***
• Low organizational
constraints
• Low work-family
conflict
“Health Seeking Behaviors"
(HSBs) of Staff
• Increased satisfaction of staff members
– If you are comfortable,
patients & families
are more comfortable
– Other related outcomes
(HSBs of staff, patients
and families)
• Better outcomes for your institution
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E. Contributions of Comfort Theory
as part of your nursing model
• Speaks to your comfort as well as to patients’ comfort
• Multidisciplinary, transcultural language
• Targeted to specific needs and outcomes of recipient
• Value-added and direct indicator of quality care (explanatory
power, mediator for subsequent outcomes)
• It’s what patients/families want and hope for during times of
stress, and what you hope for in your workplace.
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The Whole is Greater than the Sum of Its Parts:
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Co-creating a culture of comfort at KP
• Write policies for your department that are
proactive:
– Clinical practice guidelines for comfort
management
– Core competencies for comfort management
– Care plans, assessment, goals based on comfort
needs of patients and nurses
– Comfort studies (patients, families, nurses)
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Pattern & Language for Health Care:
• Concrete and simple pattern for comfort planning, evaluation,
& communication
– What nurses DO; Intuitive, feels good
• “Our job is to provide comfort for our patients and
their families.”
– Also applicable and understandable to other disciplines
(symptom management & pain)
(Photo from USA Today, 1/27/10, 2A)
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F. Exemplars of Comfort Management
 Institutional level:
Benchmarks (Southern New Hampshire MC)
HCHAPS (Mount Sinai, NYC)
Specific Projects
ASPAN Comfort Management Guidelines
CEU4U on-line course
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Group level:
• Comfort studies utilizing the organizing
framework for populations:
– Breast Cancer
– Incontinence
– End of Life
– College Students
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Individual Level:
• Back to
Mr. & Mrs. Green
• A Special
Comfort
Intervention
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Quick Comfort References
1. www.TheComfortLine.com
with link to my e-mail:
all instruments and strategies downloadable
2. Kolcaba, K. (2003). Comfort Theory and Practice.
NY, NY: Springer.
3. Kovner, C., Brewer, C., et al. (2006). Factors
associated with Work Satisfaction of Registered
Nurses. J of Nursing Scholarship, 38(1), 71-79.
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Thank you for your
attention and
commitment.
Questions?
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Envisioning Comfort Theory in
Your Practice and Workplace
Dr. Kathy Kolcaba
Associate Professor, Emeritus,
The University of Akron (OH);
Adjunct Faculty Ursuline College: &
Consultant, The Comfort Line
Thank
You
!