Contributor – Sónia Patrícia Rodrigues Bastos
When I started working in intensive care, I quickly realized the complexity of the nursing care provided there. Within this complexity of care, one of the situations that I find highly relevant is the importance of constantly seeking to provide maximum comfort to the patient and the respect and dignity we should have toward them. Because they are so important, it worries me that, for some reason, these care aspects may be neglected.
This concern and uneasiness stem from the fact that I deal with patients connected to numerous life support equipments, who are ventilated, sedated, utterly dependent on our care, and limited in their communication ability. Reflecting on this situation makes me put myself in their place and think about how I would like to receive this care and how I would like to feel comfort in an environment that, at first sight, conveys some fear, anxiety, and coldness, not only for the patients but also, initially, for the healthcare professionals.
Comfort is a dimension or component of dynamic processes, experiences, and concepts such as quality of life, hope, control, decision-making, and reconciliation (Siefert, 2002). Every day in our professional practice, we seek to comfort our patients, directing various interventions that allow its increase. These dimensions of comfort are experienced, according to Katherine Kolcaba’s theory of comfort, in their physical, psychospiritual, environmental, and sociocultural dimensions (Kolcaba,2003).
One of the nursing interventions that I consider essential to providing comfort to the patient is therapeutic communication. This intervention offers a reduction in the feeling of anxiety, often observed in the patient’s facial expression and even in hemodynamic monitoring parameters. Communicating with the patient calmly and informing him about what we will do is a critical practice to transmit security and reduce feelings such as anxiety, fear, and panic caused by the unknown. In the intensive care unit where I work, I notice that orotracheally intubated patients are patients where initially these feelings are very noticeable, mainly anxiety, as they are being subjected to a ventilation device, which is one of the devices that causes the most discomfort in patients. Therefore, it is crucial to clearly explain to the patient the importance/necessity of having the ventilation device. Pharmacological measures such as sedation and analgesia are necessary to ensure better tolerance.
In this type of patient, the importance of respect for privacy is often forgotten due to being a patient who is limited regarding their communication capacity, often sedated and without perception of the outside world. It is always necessary to remember, whether during hygiene care or when the doctor observes the patient, that privacy, respect, and dignity for the patient must exist. For example, as mentioned earlier, the curtains should be permanently closed during the interventions.
The environment surrounding the patient is also of great importance. A noisy environment with inadequate temperature and luminosity promotes discomfort while reducing noise to a minimum, adjusting the temperature to an adequate value, adjusting the lighting, and creating a safe environment encourages and reinforces the state of the comfort of patients who, it should be remembered, are most often wholly dependent on our care.
Control of the pain caused by all the invasive devices carried out through pharmacological and non-pharmacological measures is essential. Non-pharmacological measures such as patient positioning, massage, skin hydration to prevent injuries, hygiene care, and therapeutic touch promote great comfort. In lightly sedated patients that can communicate with us through head nods, sometimes we can promote comfort through music therapy, through which we can quickly observe a great sense of tranquillity in the patients. Thus, we can see that pleasant or familiar sounds help promote the patient’s comfort, as hearing a familiar voice is also a contributing factor.
In an intensive care unit, I often confront terminally ill patients, for whom I consider comfort, dignity, and respect should be prioritized. In these cases, where death is the expected outcome, I often reflect on why there is an insistence on performing highly invasive and painful interventions that no longer benefit the patient instead of providing a dignified, painless, and peaceful death.
Peaceful death is defined as a death where negative symptoms are well managed, conflicts are resolved, and the process is accepted by the patient and their family, allowing the patient to “depart” in silence and with Dignity (Kolcaba, 2003).
Given the above, I consider the promotion of critical thinking among nurses to be of great relevance, as it is fundamental to providing the best care to patients. I understand the importance of the knowledge acquired about nursing theories, given that they offer solid theoretical foundations to demonstrate the importance of holistically seeing the patient and providing quality nursing care.
The theory that served as the base for the addressed content was Katherine Kolcaba’s Comfort Theory. Kolcaba defines comfort as the direct experience of being strengthened, achieved through the three types of comfort she described: relief, ease, and transcendence. The four contexts in which comfort is experienced are physical, psychospiritual, environmental, and sociocultural (Smith, 2020). Throughout the text, I refer to several interventions that allow the patient to experience the three types of comfort described by Kolcaba. These are actions developed to meet the patient’s comfort needs. When achieved, increased comfort status promotes behaviors seeking external or internal health or peaceful death (Smith, 2020).
Peaceful death is a type of health-seeking behavior. Kolcaba tells us that it is defined as a death where conflicts are resolved, symptoms are well managed through interventions that promote comfort, fostering acceptance by the patient and his family, and allowing the patient to die peacefully with the utmost dignity possible (Smith, 2020), which I believe does not happen, as mentioned above, when there is an insistence on highly invasive and painful interventions that no longer benefit the patient, only prolonging his death, which leads me to reflect on the pursuit of respect and dignity.
According to Jacobs, the central phenomenon of nursing is not health or the pursuit of restoring holistic balance and harmony but rather respect for Human Dignity. When we recognize the importance of another person as we recognize our own, and this importance is manifested through the demonstration of care, we enter the moral realm. In this way, the respect shown is the way to express the person’s importance to us (Jacobs, 2001).
In a deontological view of respect, individuals have value since they possess moral autonomy – sets of laws that each person defines for themselves – and as such, they have dignity. When someone takes away another person’s moral autonomy, they are taking away their autonomy to make decisions about their own life, consequently depriving them of their Dignity (Jacobs,2001). In end-of-life situations, the therapeutic outcome aimed for is the pursuit of comfort and well-being, relieving physical, psychological, and spiritual suffering, and where all therapeutic intentions should be centered around the individual needs expressed by the patient and their family (Sapeta e Lopes, 2007).
Jacobs, B. B. (2001). Respect for Human Dignity: A Central Phenomenon to Philosophically Unite Nursing Theory and Practice through Consilience of Knowledge: Advances in Nursing Science, 24(1), 17–35.
Kolcaba, K. (2003). Comfort theory and practice. A vision for holistic health care and research. New York: Springer publishing company.
Sapeta P. Lopes M. (2007) Caring at the end of life: factors that interfere with the process of interaction nurse-patient. Revista Referência II (4), pp. 35-60.
Smith, M. C. (Ed.). (2020). Nursing theories and nursing practice (Fifth edition). F.A. Davis Company.
Siefert, M. (2002). Concept analysis of comfort. Nursing Forum, 37(4), 16-23. https://doi.org/10.1111/j.1744-6198.2002.tb01288.x
About Sónia Patrícia Rodrigues Bastos
I have been a nurse since 2015 and work in an intensive care unit at a university hospital in Lisbon, Portugal. I have been attending the Master’s course in Nursing since September 2022 at the Health Sciences Institute of the Portuguese Catholic University (Lisbon), having written this post in the curricular unit of Nursing Theories under the guidance of Professor Zaida Charepe (Ph.D., Associate Professor).