Contributor: Mónica Santos (Portugal)

Katharine Kolcaba conceptualised comfort from the perspective of the person and the caregiver. She talks about comfort interventions/strategies in which she tells us that each intervention must have a variable to respond to the discomfort. The theory addresses three dimensions of comfort, but to promote comfort, it is not necessary to intervene in all three dimensions, but rather in the variable in which there is a deficit. She states that the behaviours that make a person ill are internal behaviours (intrinsic) and external behaviours (extrinsic). An environment with good spiritual support has protective factors in the dimension of spirituality, so it will probably be necessary to intervene in the physical comfort. Kolcaba explains that the dimensions of comfort are prioritised and can influence institutional practices and policies. Kolcaba, in this work, has scales to assess comfort and which may be applied in different realities. Whenever instruments exist, they should be used.

Caring for the end-of-life patient and his/her family is a real challenge for nurses. In situations of incurable, advanced and progressive disease, nurses should make efforts to integrate the terminally ill patient’s family into the health care team, considering that “they are both care providers and care receivers” (Neto, 2006, pg.22). Caregivers of end-of-life patients often experience high levels of suffering due to psychological factors, social restrictions and anticipated grief, the closer they are to the patient (Salmon et al., 2005).

I decided to write about this topic of the importance of the comfort of careers of palliative care patients in the community, which throughout my professional life has concerned me and for which I think most health professionals are still not sufficiently aware. This concern arises because as a health professional, I think that we are often more focused on the interventions that promote patient comfort (which I consider to be extremely important), but we neglect the comfort of the caregivers, who are the support and pillar of the care provided to these patients, and who, if they are not well, will not be able to meet the patient’s needs.

In addition, all the interventions provided to the caregivers at the level of comfort are, in my opinion, essential for the minimization of suffering, being necessary to identify, as we do for the patient, the basic human needs affected and implement individualized care plans considering the individual situation of each caregiver. The family should be cared for with as much commitment and dedication as the patient.

What I find is that these caregivers often do not have the necessary support from the health teams, since there are insufficient support/monitoring responses for these families. There are also few health teams with specific training in palliative care, which often means that the patient ends up dying in hospital, even though neither the family nor the patient wants this to happen. We cannot at any time fail to also address the comfort needs of caregivers when providing care to patients in palliative care. It is undoubtedly necessary to strengthen the implementation/maintenance of health policies that allow for the strengthening of responses to families at home.

This concern of mine is not unfounded as, according to scientific evidence, the issues of comfort of careers of patients at the end of life are fundamental. Caring for the terminally ill and witnessing the whole end-of-life process requires the family caregiver to face complex situations that they are not always prepared for.

Thus, Kolcaba’s Comfort Theory defines in the metaparadigm that patients can be considered as individuals, families, institutions, or communities in need of health care. Comfort represents much more than simply the absence of pain, and is itself a complex, useful and an excellent indicator of the provision of quality health care (Kolcaba, 2003).

According to Kolcaba (1991; 1994), who considers comfort as a state resulting from nursing interventions, developed a taxonomic structure that allows operationalizing this concept – a concept which has been considered as a characteristic of the profession. The construction of Kolcaba’s Theory of Comfort (2001; 2003) began in 1987 and was the result of the application of several types of logical reasoning (induction, deduction and abduction) to fill in the gaps felt and experienced in practice.
Comfort is an immediate desirable outcome of nursing care, according to Comfort Theory.

Throughout the centuries, the assessment of comfort in someone caring for someone else was limited to the subjectivity and intuition of the caregiver and was based on the satisfaction of comfort needs at the time of assessment. According to Kolcaba (2003) most nurses want their patients and families to feel better and think intuitively about pain control and anxiety relief. A more holistic approach is to think of Comfort as an umbrella term and a positive outcome of nursing care. Therefore, the outcome of comfort includes pain and anxiety control. Holistic comfort is defined as the immediate experience of being empowered by having needs for relief, ease and transcendence met in four contexts of experience (physical, psychosocial, social and environmental) (Kolcaba, 2010).

Comfort should be one of our intervention priorities to respond to the person’s objectives, not forgetting the family’s needs. Caring for the end-of-life patient is much more than just caring for the patient, it is also caring for his/her family, which is a real challenge for nurses. In situations of incurable, advanced and progressive disease, the nurse should join efforts to integrate the family of the terminally ill patient into the healthcare team. In the study developed by Novak et al. in 2001 on the comfort of the relatives of the end-of-life patient, the family members of palliative patients have comfort needs at various levels, in addition to the concern with the comfort of their loved one. These include the need for information, encouragement, positive reinforcement, rest, socialization and adequate nutrition.

The objective of nursing care in palliative care will then be to promote the comfort of patients and their families by relieving pain, reducing anxiety, fostering a peaceful environment, supporting and promoting educational support about the dying process, helping them to find meaning and growth in this experience. Currently, we are working on broader issues regarding the target audience of comfort when caring for people at the end of life. We talk about the comfort of the health professionals themselves and the implication this may have on the improvement of the care provided.

The Comfort Theory suggests that when nurses’ comfort is valued, nurses are more satisfied, more committed to the institution, and able to work harder. These nursing outcomes result in an improvement in the care provided. An extensive literature review conducted by Kolcaba (2003) on what nurses want in their workplaces identifies many factors that can be organized according to the contexts of comfort as explained in the Comfort Theory (physical, psychospiritual, sociocultural and environmental [organizational structure]).

To implement Kolcaba’s institution-wide comfort theory, there will have to be a change in the theoretical framework. Now, Kolcaba’s theory of comfort classes the application of “Interventions of nursing”, thus limiting the implementation of techniques leading to Comfort to a function of specialist nursing care only. A simple change of this term, however, to the term comfort interventions, expands the potential of the application of this theory to any health professional who chooses to adopt this theoretical framework for practice. This adaptation of Kolcaba’s theory is yet to be tested, the potential benefits can only be speculated. One can assume that Kolcaba’s theory of comfort should be adapted to include all healthcare providers and implemented as an institution-wide framework for practice, which would further enhance comfort for patients.

The application of comfort theory across disciplines is likely to result in quality patient outcomes.
Kolcaba’s theoretical framework dictates that if patients’ health seeking behaviors are increased, institutional integrity will result. It can be proposed, then, that if all healthcare professionals within an institution provide care guided by comfort, that institutional integrity would be enhanced even more than if the theory was used to guide nursing alone. Increasing institutional integrity to such an extent that it could potentially assist in recruitment and retention strategies for healthcare staff within the institution.
Furthermore, it can be assumed that structuring a health institution around the concepts of
comfort theory would improve society’s acceptance and appreciation of the institution, as well as increasing the patient satisfaction, due to the positivity.

Sources

Kolcaba, K., Tilton, C., & Drouin, C. (2006). Comfort Theory: a unifying framework to enhance
the practice environment. The Journal of nursing administration,36 (11), 538-544. https://doi.org/10.1097/00005110-200611000-00010

March, A., & McCormack, D. (2009). Nursing theory-directed healthcare: modifying Kolcaba’s
comfort theory as an institution-wide approach. Holistic nursing practice, 23(2), 75–82.
https://doi.org/10.1097/HNP.0b013e3181a1105b

Neto, I. G. (2006). Princípios e filosofia dos cuidados paliativos. In: A. Barbosa & I.G. Neto (Eds),
Manual de Cuidados Paliativos. Lisbon: Núcleo de Cuidados Paliativos, Centro de Bioética, Faculdade
de Medicina de Lisboa. ISBN 978-972-9349-21-8.

Novak, B., Kolcaba, K., Steiner, R., & Dowd, T. (2001). Measuring comfort in caregivers and
patients during late end-of-life care. The American journal of hospice & palliative care, 18(3), 170-180. https://doi.org/10.1177/104990910101800308

Salmon, J. R., Kwak, J., Acquaviva, K. D., Brandt, K., & Egan, K. A.. (2005). Transformative aspects
of caregiving at life’s end. Journal of pain and symptom management, 29(2), 121-129.
https://doi.org/10.1016/j.jpainsymman.2004.12.008

About Mónica Santos
https://orcid.org/0000-0002-6238-8229

I have been a nurse for 14 years and my experience has always been in the area of the elderly, particularly in the context of ERPI (residential structure for the elderly) and UCCI (Integrated Continuous Care Unit). I also collaborate as a guest teacher with the School of Health of the Portuguese Red Cross of Lisbon where I teach various curricular units. This post was made in the curricular unit of nursing theories of the Master Course in Nursing of the Institute of Health Sciences of the Portuguese Catholic University (Lisbon), with the pedagogical supervision of Professor Zaida Charepe (PhD, Associate Professor).