Reflection of Kolcaba’s Comfort Theory By: Michelle Heim

Objectives Importance of Comfort to Nursing Profession Kolcaba’s Theory of Comfort Empowerment of Patients and Families Health, Safety, and Transcendence at the End-of-Life (EOL) Planning, Implementation, and Evaluation of Comfort Care Reflection: Elaborate, Analyze, and Revise

Importance of Comfort for Nursing in EOL American Nurses Association (ANA): comfort is a main goal in nursing care of dying patients Richeson & Huch (1988): comfort is nursing’s unique contribution Morse (1992): ultimate purpose of nursing is to promote comfort Kolcaba (1994): nurses facilitate the outcome of comfort in relation to health-seeking behaviors or a peaceful death The ANA’s position statement on promotion of comfort in dying patients states that the main goal in nursing care of dying patients should be maximizing comfort as is consistent with the desires of the patient Richeson & Huch: claim that comfort is nursing’s unique contribution to health care Morse: stated that the ultimate purpose of nursing is to promote comfort Kolcaba: The nurse facilitates the outcome of comfort BECAUSE theoretically it is related to internal/external health-seeking behaviors (palliative) or a peaceful death at the EOL

Introduction to Kolcaba: A Theory of Comfort Defining comfort for nursing: -satisfaction of basic human needs in stressful health care situations Types of comfort: -relief -ease -transcendence Context in which comfort occurs: -Physical -Psychospiritual -environmental -sociocultural “Comfort is defined for nursing as the satisfaction (actively, passively or co-operatively) of the basic human needs for relief, ease, or transcendence arising from health care situations that are stressful” (Kolcaba, K. Y., 1994, p. 1178). There are two dimensions which Kolcaba’s Comfort Theory looks at. The first dimension of comfort looks at three types of comfort: relief, ease, and transcendence. The patient experiences relief when a certain human need is met. Relief is necessary in order to return to former function or to experience a peaceful death. Ease is a state of calm of contentment, which is necessary for the patient to be effective in health-seeking behaviors. Lastly, transcendence occurs when the patient becomes resilient and can rise above problems of pain, even in a state of illness or at the EOL. the second dimension addresses the individual in a holistic manner which is comprised of four parts: physical, psychospiritual, environmental, and sociocultural. The physical dimension pertains to bodily sensations such as pleasure and pain, the psychospiritual dimension pertains to internal awareness such as self-esteem, sexuality, and relationship to a higher power or being, the environmental dimension pertains to one’s surroundings such as light, noise, and temperature, and lastly the sociocultural dimension pertains to interpersonal, family, and cultural relationships. By using and filling out a grid like the one pictured here with all 12 dimensions, the nurse can make sure that the patient and family needs are identified and ultimately met.

Empowerment of Patients and Families Peaceful Death/Good Death Patient and Family involvement Accepting mortality A peaceful and good death is a major part of empowering both patients and families. According to Kolcaba, a peaceful death results in “a family [that] is empowered to work through and assist in their loved one’s death, and a patient who is allowed and encouraged to meet death with peace, dignity, and comfort” (Kolcaba, &Fisher, 1996, p.76). Kolcaba defines a good death as being “meaningful for all, a death that ends well for [the] patient, health care workers, and family” (Kolcaba, &Fisher, 1996, p.75). Comfort care is seen as the best way to empower patients and families to achieve both a peaceful and good death through viewing the patient in a holistic, thoughtful, and goal directed approach to end-of-life. Another empowering quality of comfort care is that both the patient and the family members are involved in care decisions and identifying appropriate comfort interventions. Interventions which are put into place in order to comfort the patient are individualized to meet their specific needs. By allowing the patient and family members to take part in identifying personalized comfort measures, the family and patient become strengthened during the dying process, which ultimately facilitates a peaceful and good death (as previously mentioned). Lastly, comfort care allows patients and families to be in control of their dying process rather than a helpless bystander or victim of chance. Rather than focusing on abstract concepts which are out of the patient and families control such as when the patient will die, comfort care allows the patient and family members to focus on tangible goals such as making the patient as comfortable as possible and providing them with a peaceful and good death.

Health, Safety, and Transcendence at the EOL -Health-seeking Behaviors -Holistic Approach Safety -Defining QSEN Competency for Patient-centered care -Health care, family, and patient as a team Transcendence -Potential for extraordinary performance as an end -Comfort Peaceful/Good Death It is possible to engage patients and family members, who sometimes act as surrogates if the patient is unable to make health care decisions for themselves, in the areas of health, safety, and transcendence through the use of comfort care. When looking at the health of the patient, it is important that the focus is shifted from postponing death to enriching life. Because the focus of comfort care is on strengthening the patient and giving him/her the most peaceful death possible, the patient or surrogate focuses on what behaviors or changes will increase the patients quality of life. These changes are called health-seeking behaviors. According to Kolcaba (1993) there is a “reciprocal relationship [which] exists between health-seeking behaviors and comfort because health-seeking behaviors also can enhance comfort” (p. 1180). Another aspect of comfort care which fosters health is that it is a holistic approach to patient comfort. In other words, comfort care takes into account the patients mental, physical, spiritual, and environmental health when addressing the patient’s comfort. When looking at comfort care from a safety perspective it is important to look at the QSEN Competency for Patient-centered Care. According to QSEN, safety means “minimizing risk of harm to patients and providers through both system effectiveness and individual performance” (Cronenwett, Sherwood, Barnsteiner, Disch, Johnson, Mitchell, Sullivan, Warren (2007). By involving the patient, the family members, and the health care team in establishing appropriate interventions and realistic expected outcomes, which are constantly being evaluated and modified, safety is established through collaboration and teamwork. As the concerns of all parties involved are addressed safe practice is established. Lastly, patients and surrogates can establish transcendence at the end-of-life through active partnership. As a refresher, transcendence is the potential for the patient to experience extraordinary performance as an end. For the patient, extraordinary performance means that they are able to experience a peaceful and good death at the end of their journey. And as was mentioned earlier, comfort and peaceful/good death have a reciprocal relationship, meaning one causes the other.

Planning, Implementation, and Evaluation of Comfort Care Nursing Diagnoses Death Anxiety r/t unresolved issues Powerless-ness r/t the effects of illness and impending death Chronic pain r/t disease process at EOL Death Anxiety -Assess client for fears r/t death -Assist client with life review and reminiscence -Provide social support (personal contact, phone call, therapeutic self) Powerlessness -explore feelings of powerlessness -have the client assist in planning care whenever possible -help the client specify the health goals he/she would like to achieve Chronic Pain -assess the client for pain using a valid and reliable self-report tool -Assess for pain routinely and at frequent intervals -Manage persistent or chronic pain using a multimodal approach (pharmacological and nonpharmacological) Interventions Expected Outcomes Death Anxiety Express feelings associate with dying Seek help in dealing with feelings State concerns about impact of death on others Powerlessness -State feelings of powerlessness and other associated feelings -Differentiate between factors which are controllable and uncontrollable -Participate in planning and implementing care Chronic Pain -Use a self-report pain tool to identify current pain level and establish a Comfort Functional Goal (CFG) -Perform necessary or desired activities with a pain level at or below CFG -Describe nonpharmacological means of relieving pain A very important part of good nursing care when caring for patients is the use of the nursing process. Here I have created a sample care plan which would be appropriate for addressing the needs of a patient who is at the end-of-life. In comfort care, the patient or surrogate, family members, and the health care team (especially the nurse) come together to create interventions which are appropriate for the patient. These same people are also responsible for evaluating these interventions and adjusting them as needed.

L E A R N Reflection -Look back and reflect -Elaborate and describe feelings A -Analyze the experience R For reflecting on Kolcaba’s comfort theory, the acronym LEARN is used. The letter “L” stands for looking back on my experience while completing this presentation. “E” stands for elaboration of feelings while completing this project. I found this assignment relatively easy as far as content goes because I am familiar with comfort care and have had patient’s that were on comfort care. Also, because I have had patients receiving comfort care I did feel confident presenting on the topic of comfort care. One thing that I found surprising about the reading was that in one of my articles it said that there was a review of nursing literature which was conducted and the researchers were only able to identify one article describing the application of a nursing framework to hospice nursing practice, because those nurses were using intuition and multidisciplinary methods rather than a nursing framework. And that lead to the creation of Kolcaba’s framework for holistic comfort, which is based on nursing principles. “A” stands for Analyze the experience. I feel as though comfort care is often times the best option for terminally ill or chronically ill patients because it focuses on positives such as good and peaceful death and quality of life whereas endlessly seeking treatment focuses all the patients energy on refusing to believe they are mortal and taking time that could be spent making amends or enjoying what time they have left worrying and becoming frustrated over things that are out of anyone’s control. An advantage to using nursing theory is that it is evidence-based and it is a way of unifying care and care goals. A possible disadvantage is that sometimes people disagree with theory, regardless of the fact it is evidence based. IF even one member of the interdisciplinary team disagrees with the theory, basing pt. tx on that theory will not be effective because that member will be providing different care for that patient which is a detachment in the patient care process. I personally believe that if nursing theory is used properly with full participation from all members of the interdisciplinary team, that communication will become more successful and that the goals that are being worked towards will become more clear because everyone will know the blueprint for the patients care needs and desires. “R” stands for revision. I have thought long and hard about how I am going to answer this question and I am going to go with my gut. I do not believe that there is another theory that works better than comfort care in this situation. I believe in focusing on the positives in situations and using one’s energy in a productive manner. At the end-of-life, I believe that the most positive and productive way to use one’s energy is to focus on a good and peaceful death. The letter “N” stands for new trial and is a description of how I would improve this process in the future. The best way that I can think to improve Kolcaba’s comfort theory is to create more awareness about it and to educate more people on it. I think that comfort care is an under-used resource patients use at the end-of-life. It is just as important to inform patients on their option to stop treatment as it is to inform them on options for more treatment. The mind-frame of comfort care needs to be changes from “giving up” to “embracing peace”. -Revision N -New trial and improvement

References Cronenwett, L., Sherwood, G., Barnsteiner J., Disch, J., Johnson, J., Mitchell, P., Sullivan, D., Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55(3)122-131. Retrieved from http://qsen.org/about-qsen/terms- and-conditions. Kolcaba, K. (1994). A theory of holistic comfort for nursing. Journal of Advanced Nursing 19, 1178-1184. Retrieved from PubMed. Kolcaba, K. Y., & Fisher, E. M. (1996). A holistic perspective on comfort care as an advanced directive. Critical Care Nursing Quarterly, 18(4), 66-76. Retrieved from PubMed. Ladwig, G. B., & Ackley, B. J. (2011). Guide to Nursing Diagnosis (3rd Edition). Maryland Heights, MO: Mosby Inc. Vendlinski, S., & Kolcaba, K. Y. (1997). Comfort care: a framework for hospice nursing. The American Journal of Hospice & Palliative Care, 14(6), 271-276. Retrieved from PubMed.