1. 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

2. 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.

3. 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

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

5. 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

6. 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

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

8. 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)

9. 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

10. 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

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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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)

18. 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

19. 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?)

20. 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?

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

22. 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;

23. 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;

24. 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;

25. 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

26. 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

27. “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

28. 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.

29. The Whole is Greater than the Sum of Its Parts:

30. 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)

31. 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)

32. 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

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

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

35. Quick Comfort References
1. with link to my
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),

36. Thank you for your attention and commitment.
Questions?

37. 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