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.

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

A. What does “comfort” mean?: Eight definitions in most modern dictionaries Oxford English Dictionary (origins of English words)

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

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 Relief Ease Trans-cendence Physical pain Psycho-spiritual anxiety Socio-cultural Environ-mental Relief: pain, nausea, itching Psychospiritual: anxiety, loss of meaning, mortality/immortality Sociocultural: isolation, role change, financial concerns Environmental: noise, odors, clutter, disruptive routine tasks

Holistic Nature of Comfort: Green: Ease Relief Transcendence Red/yellow/purple: Physical Psychospiritual Sociocultural Environmental

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)

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

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.” Green #11

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

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

Total Comfort Relief Ease (maintenance) Transcendence Physical Hyperglycemia Hunger, weight loss Diminished vision Normal BS Optimal weight Skin healed Pain managed without narcotics?) Wants to be best possible diabetic patient with excellent BS control Psycho-spiritual Anxiety, Anger, Why us? How will we manage? Adherence, confidence, faith Engages in exercise & HSBs; motivated to learn & grow Socio-cultural- Need to understand diet, blood sugar, sequelae Financial distress, body image challenged Anxiety of wife, need for reassurance, rituals 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 Environ-mental Transportation difficult; wait room crowded & cluttered; wait for appt. prolonged, Quality of office furniture, decorating patient friendly Wait time minimal Vouchers for Bus/taxi or van transport ; peaceful view or hopeful posters

Ritual of the Physical Assessment Patients & families have expectations about thoroughness Quick to notice when “rituals” of personal examination, interpretation, and explanation are incomplete 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

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

C. Nursing Conceptual Framework: Ambulatory Care A good CF specifies concepts about your setting: ambulatory care nursing Health Care Needs Increased holistic Comfort Health Seeking Behaviors + Nursing Interventions + Intervening Variables Institutional Integrity Timing pressure Control of care by patient and family Learning to use electronic resources Privacy Continuity of care Learning Care expectations Per protocol or individualized Advocacy Rapid assessment Teaching Colllabora- tion Case mgt. Availability of standardized protocols Monitoring equipment/ Communication methods Make nursing comfort strategies visible! Patient satisfaction Cost containment Decreased admissions Internal Behaviors External Behaviors Point out double arrows Te © Kolcaba (2007)

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

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?)

Whose comfort? Your patients and their families Your staff and you Comfort Zone strengthens them for the tasks ahead! Your staff and you Your managers Is your work place a Comfort Zone?

D. Nurses’ (& staff) Comfort: Definition: Totality of embeddedness in an organization based on physical, psychospiritual, sociocultural, and environmental attributes of an institution or agency

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 self-scheduling;

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;

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;

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

Article, J of Nsg Scholarship (2006) Autonomy Distributive justice Group cohesion Promotional opportunities Supervisory support 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

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.

The Whole is Greater than the Sum of Its Parts:

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)

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)

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

Group level: Comfort studies utilizing the organizing framework for populations: Breast Cancer Incontinence End of Life College Students

Individual Level: Back to Mr. & Mrs. Green A Special Comfort Intervention

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.

Thank you for your attention and commitment. Questions?

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