Promoting Health by Promoting Comfort
by Elise I. Gropper, RN, PhD, CS
While comfort is a concept frequently addressed in the nursing literature,few have adequately addressed this concept as a central patient
objective. At present, our literature focuses more on comfort as a nursing action than on comfort
as an individualized patient goal. Comfort may be more likely to be the driving force for patients
obtaining healthcare services than health itself. This patient need, coupled with nursing interventions to assist them in identifying and implementing constructive ways of promoting their own comfort needs, will help to achieve an
Elise I. Gropper, RN,PhD, CS, is Associate Executive Director of Nursing, Elmhurst Hospital Center, Elmhurst, NY.
c
omfort is a concept frequently discussed in the nursing literature. It is most commonly associated with the alleviation of pain (Cooke, 1986; Eland, 1988; Engelking, 1988; Fleming, Scanlon, & DAgostino, 1987; Frazier & Kohl, 1984; Webster, Lyon, & MacDonald, 1986). It is a term used often in the cancer and in obstetrical literature. The traditional goal of nursing has always been to provide comfort, thereby relieving pain and distress, and restoring the health of the patient. Although the term comfort is seen in many aspects of nursing care, few have adequately defined comfort as a concept (Hamilton, 1989; Kolcaba, 1991;Morse, 1983). An etymological examination of the word reveals comfort as being derived from the Latin conforfare,meaning "to strengthen." Its root, fort (the Latin fortis), means "strong" (Klein, 1966; Onions, 1966).According to the Oxford English Dictionary (1978), the word comfort is defined as, "A state of physical and material well-being,
optimal state of health. Figure 1.The Multidimensional Character of Individual Comfort Goals ...-....- - ...-..
i Physical ':
Nursing Forum Volume 27, No.2, April-June1992
5
Promoting Health by Promoting Comfort
with freedom from pain and trouble, and satisfaction of bodily needs; mental or spiritual delight or enjoyment; contentment.”The act of comforting is provided by rendering encouragement, support, guidance, and help. It is a term that has multidimensional meanings. Comfort can be seen from a physical, psychological, social, spiritual, and environmental perspective (Hamilton, 1989; Morse, 1983).These dimensions are integrated uniquely in each individual. Their components are irreducible; they cannot be isolated from one another, as shown in Figure 1. Morse (1983) examined comfort from an ethnoscientific research approach. The domain of comforting was shown to have two main segregates, described as touching and talking. Later in the analysis a third minor segregate, listening, evolved. Listening was used for very stressed individuals. Four subsegregates, combinations of the two major segregates, were further delineated. They were: touching / hugging; touching / little talking; talking / little touching; and talking (Morse, 1983).How and why certain types of comforting were administered depended upon the cause and the severity of the problem, the rolerelations between the comforter and the comfortee, and the type of comforting perceived by the comforter to be required (Morse, 1983). Kolcaba (1991)identified a taxonomic structure for the concept of comfort. She described three technical senses of comfort: Ease, a state of calm or contentment Relief, the experience of a patient who has had a specrfic need met, and Transcendence, the state in which one rises above problems or pain Kolcaba (1991) further analyzed four contexts in which patients experience comfort. These include: Physical comfort, pertaining to bodily sensations Social comfort, pertaining to interpersonal, family and societal relationships Psychospiritual comfort, pertaining to the internal awareness of self, including self-esteem, 6
meaning in one‘s life, and one’s relationship to a higher order or being, and Environmental comfort, pertaining to the external background of human experience, encompassing light, noise, ambience,color, and temperature Comfort is a multidimensional tern, seen across the life span. The act of comforting involves a dynamic relationship between the comfortee and the comforter, as well as a thorough understanding of the individual comfort needs of the person. ~
~
Verbal-tactile interventions were successful within a five-minute period. Comfort as a Nursing Action
Comfort is most frequently identified as an action carried out by the nurse (Eland, 1988; Frazier & Kohl, 1984; Moseley, 1985; Nishioka, 1989; Sohl, 1987; Stockdale & Hutzenbiler, 1986; Triplett & Arneson, 1979). The nurse not only provides physical “comfort measures,” but psychosocial and spiritual support as well. There is substantial diversity in the literature addressing these comfort measures. Nurses are required to have a thorough knowledge of pain management and medication titration to alleviate and prevent pain in their patients (Frazier & Kohl, 1984).The continuous assessment, patient care planning, and patient teaching surrounding pain control are primary mponsibilities of the nurse. By alleviating or controlling pain, the nurse makes the individualcomfortable (Eland, 1988). To comfort may be described as an effort to minimitt e psychobiological distress (Moseley, 1985).The provision of comfort to the terminally ill patient is seen through a holistic perspective. Moseley identified the nursing diagnosis, ”alterations in comfort,” when planning care for the terminally ill patient. A holistic, individualized plan of care should include: pain control, involving both pharmaceutical and nonpharmaceutical interventions; Nursing F o m Volume 27, No. 2, April-June1992
the prevention of fatigue, depression, and anxiety; the prevention of alterations in bodily functions related to defecation and urination; easement of labored breathing patterns; promotion of proper body alignment; and provision for personal needs. Children are emotionally comforted in ways similar to adults. Psychological support is often provided by verbal and tactile exchanges. Sparshott (1989) identified procedures for comforting an infant. These procedures included cuddling, ConsoIation by voice, and stroking. Triplett and Ameson (1979) observed distressed children’s responses to verbal and tactile comfort measures. Verbal interventions were more successful for children over one year of age, whereas tactile interventions were more successful for infants. However, all comforting measures should include both verbal and tactile components, because a calming voice and warm touch help to alleviate distress. Verbal-tactile interventions were found to be successful within a five-minute period from the time of initiation. This time period does not appear unreasonable in a nurse’s busy schedule. When nurses use such interventions, children are better able to use their energy for recovery rather than for expressing displeasure. Providing comfort to a grieving family is another important nursing role. This comfort may be provided by offering both psychological and spiritual support. Meaningful, honest, and ongoing communication is imperative to this process (Stockdale & Hutzenbiler, 1986). Personalizing communication, by knowing the names and familial relationship of family members, promotes a sense of comfort. Explaining surprising behavior and expectations related to physical appearance and use of equipment helps to decrease anxiety. Again, the use of both verbal and tactile interventions are comforting. Family members need this caring approach as much as patients do. Spiritual comfort provides hope, and hope is a necessary component of the healing process. People have various ways in which they express themselves spirituallythrough rituals, prayers, Bible readings, and other expressions of faith. Spiritual imagery can also help soothe physical and emotional pain. Spiritual imagery Nursing Farum Volume 27,No. 2, April-June1992
can be performed by an individual in any setting. Essentially, people envision themselves as directly interacting with a higher being or power. Spiritually, this higher being or power can be anyone who is comforting to the individual (Ferszt & Taylor, 1988). The nursing adion of comforting is definitely a multidimensional endeavor. The individual needs of the patient and family must be assessed and responded to on a continuous basis. Needs change, since patients and families alternate rhythms, life situations, and interpersonal relationships. Comfort as a Patient Goal
The desire to find comfort is a basic human need. Individuals are constantly attempting homeostasis of this need. Comfort is a personalized experience, meaning different things to different people. This experience also varies with the person’s alternating rhythms.
Health for many is defined as physical and emotional comfort. ~
~~
~
While comfort is frequently seen as a nursing action, or nursing objective, comfort should also be considered a primary patient objective. Many of the behaviors s e n in individuals as they strive for comfort are benign and beneficial, such as maintaining close family relationships and friendships, being involved in hobbies and exercise p r e grams, and maintaining a physically healthy existence. Some behaviors can prove detrimental to health. These behaviors include drug and alcohol abuse, sexualpromiscuity,obesity, self-inflicted injuries, poor social relationships, and failure to resolve personal conflict and issues. Few may have ever considered behaviors such as alce hol and drug abuse, attempts at suicide, or other violent behaviors as a way of attempting to comfort oneself. However, it is often because of feelings of discomfort that individuals would involve themselves in these practices. 7
Promoting Health by Promoting Comfort
Psychological instances of comfort are less welldocumented than physical incidences. Most of the literature addresses comfort as a relief from pain (Eland, 1988). Many of the nursing measures identified have a physical, pain- relieving basis. While comfort has been addressed in some nursing theories, (Roy & Roberts, 1981;Orlando, 1961; Watson, 1979) the central patient objective documented in nursing thee ries is health. This concept is defined biopsychosocially and has multidimensional components. Yet, when exploring reasons why consumers seek healthcare services, researchers have found that services are sought to relieve distress.For instance, discomfort or pain is the most likely reason for a healthcare visit of the indigent (Brecht, 1990).If nursing is truly committed to assisting all individuals in promoting their best possible health status, then nurses must examine what health means through their patients’ eyes. Health for many is defined as physical and emotional comfort. The nurse should be expected to teach patients constructive ways of comforting themselves, which in turn will promote health. Figure 2 depicts this process.
Need for Future Research and Concept Development Comfort continues to be an important concept within the nursing literature.Yet “comfort” has not been definitively defined, and the concept remains abstract. Comfort must be defined from multiple perspectives and dimensions. It requires investigation from the perspechve of the patient, family, and nurse. A qualitative approach to its definition and further taxonomy development is required. Figure 2. Comfort as a Promoter of Health
i Comfort
A
Nurse dl
I
8
Physical Psychological Social Spiritual Environmental
Patient teaching of constructive interventions
,
Promotion
The multidimensional facets of this concept must be continuouslyassessed. As comfort is a basic human need that is sought by all human beings, comfort must not only be seen as a nursing action, but as an individualized patient goal as well.
References Brecht, M. (1990). Nursing’s role in assuring access to care. Nursing Outlook, 38 (l), 6-7. Cooke, H. (1986).Sleep and comfort during pregnancy. Nursing b n c l ) , 3,352-353. Eland, J. (1988).Pain management and comfort. Journal of Gerontological Nursing, 14 (4),10-15. Engelking, C. (1988). Comfort issues in geriatric oncology. Seminars in Oncology Nursing, 4 (3), 198-207. Ferszt, G., & Taylor, P. (1988).When your patient needs spiritual comfort. Nursing, 18 (4),48-49. Fleming C., Scanlon, C., & JYAgostino, N. (1987).A study of the comfort needs of patients with advanad cancer. Cimcer Nursing, 10,237-243. Frazier, L., & Kohl, E. (1984).To comfort always: Strategies for pain management in terminal cancer. North Carolina Medical \mml, 45,2&2%. Hamilton,J. (1989).Comfort and the hospitalized chronicallyill. Journal of Gerontological Nursing, 15 (41,2843. Klein, E. (1966). A Comprehensive Etymological Dictionary of the English Language. New York Elsevier. Kolcaba, K. (1991). A taxonomic structure for the concept comfort. Image, 23,237-240. Morse, J. (1983).An ethnoscientific analysis of comfort: A preliminaiy investigation.Nursing Papers, 15 (l), 6-20. Moseley, J. (1985). Symposium on compassionate care and the dying experience: Alterations in comfort. Nursing Clinics of North Americtg, 20,427-438. Nishioka, E. (1989). Comfort versus cure. American Journal of Nursing, 89,1125-1126. Onions, C. (Ed.) (1966).The Oxford dictionary of English etymology. New York Oxford University Press. Orlando, 1. (1961). 7% dynamic nurse-patient relationship: Function, process, and principles. New York: G.P. Putnam’s Sons. Oxford English Dictionary. (1978).New York Oxford University Press. Roy, C., & Roberts, S. (1981). Theory construction in nursing: An ad+tion model. Englewood Cliffs, NJ:Prentice Hall. Sohl, R. (1987). How to comfort and guide the family. Nursing, 17 (2), 6344. Sparshott, M. (1989). Minimizing discomfort of sick newborns, part 2. Nursing Times, 85 (42),18-24. Stockdale, L., & Hutzenbiler, T. (1986). How you can comfort a grieving family. Nursing Life, 6 (3), 22-26. Triplett, J., & Ameson, S. (1979).The use of verbal and tactile comfort to alleviate distress in young hospitalized children. Research in Nursing and Health, 2 (l), 17-23. Watson, J. (1979). Nursing the philosophy and science of caring. Boulder, C O Colorado Associated Press. Webster, N., Lyon, G., & MacDonald, R. (1986).Sleep and comfort after caesarean section. Anaesthesia, 41,1143-1145.
Nursing Fonun Volume 27, No. 2,April-June1992
by Elise I. Gropper, RN, PhD, CS
While comfort is a concept frequently addressed in the nursing literature,few have adequately addressed this concept as a central patient
objective. At present, our literature focuses more on comfort as a nursing action than on comfort
as an individualized patient goal. Comfort may be more likely to be the driving force for patients
obtaining healthcare services than health itself. This patient need, coupled with nursing interventions to assist them in identifying and implementing constructive ways of promoting their own comfort needs, will help to achieve an
Elise I. Gropper, RN,PhD, CS, is Associate Executive Director of Nursing, Elmhurst Hospital Center, Elmhurst, NY.
c
omfort is a concept frequently discussed in the nursing literature. It is most commonly associated with the alleviation of pain (Cooke, 1986; Eland, 1988; Engelking, 1988; Fleming, Scanlon, & DAgostino, 1987; Frazier & Kohl, 1984; Webster, Lyon, & MacDonald, 1986). It is a term used often in the cancer and in obstetrical literature. The traditional goal of nursing has always been to provide comfort, thereby relieving pain and distress, and restoring the health of the patient. Although the term comfort is seen in many aspects of nursing care, few have adequately defined comfort as a concept (Hamilton, 1989; Kolcaba, 1991;Morse, 1983). An etymological examination of the word reveals comfort as being derived from the Latin conforfare,meaning "to strengthen." Its root, fort (the Latin fortis), means "strong" (Klein, 1966; Onions, 1966).According to the Oxford English Dictionary (1978), the word comfort is defined as, "A state of physical and material well-being,
optimal state of health. Figure 1.The Multidimensional Character of Individual Comfort Goals ...-....- - ...-..
i Physical ':
Nursing Forum Volume 27, No.2, April-June1992
5
Promoting Health by Promoting Comfort
with freedom from pain and trouble, and satisfaction of bodily needs; mental or spiritual delight or enjoyment; contentment.”The act of comforting is provided by rendering encouragement, support, guidance, and help. It is a term that has multidimensional meanings. Comfort can be seen from a physical, psychological, social, spiritual, and environmental perspective (Hamilton, 1989; Morse, 1983).These dimensions are integrated uniquely in each individual. Their components are irreducible; they cannot be isolated from one another, as shown in Figure 1. Morse (1983) examined comfort from an ethnoscientific research approach. The domain of comforting was shown to have two main segregates, described as touching and talking. Later in the analysis a third minor segregate, listening, evolved. Listening was used for very stressed individuals. Four subsegregates, combinations of the two major segregates, were further delineated. They were: touching / hugging; touching / little talking; talking / little touching; and talking (Morse, 1983).How and why certain types of comforting were administered depended upon the cause and the severity of the problem, the rolerelations between the comforter and the comfortee, and the type of comforting perceived by the comforter to be required (Morse, 1983). Kolcaba (1991)identified a taxonomic structure for the concept of comfort. She described three technical senses of comfort: Ease, a state of calm or contentment Relief, the experience of a patient who has had a specrfic need met, and Transcendence, the state in which one rises above problems or pain Kolcaba (1991) further analyzed four contexts in which patients experience comfort. These include: Physical comfort, pertaining to bodily sensations Social comfort, pertaining to interpersonal, family and societal relationships Psychospiritual comfort, pertaining to the internal awareness of self, including self-esteem, 6
meaning in one‘s life, and one’s relationship to a higher order or being, and Environmental comfort, pertaining to the external background of human experience, encompassing light, noise, ambience,color, and temperature Comfort is a multidimensional tern, seen across the life span. The act of comforting involves a dynamic relationship between the comfortee and the comforter, as well as a thorough understanding of the individual comfort needs of the person. ~
~
Verbal-tactile interventions were successful within a five-minute period. Comfort as a Nursing Action
Comfort is most frequently identified as an action carried out by the nurse (Eland, 1988; Frazier & Kohl, 1984; Moseley, 1985; Nishioka, 1989; Sohl, 1987; Stockdale & Hutzenbiler, 1986; Triplett & Arneson, 1979). The nurse not only provides physical “comfort measures,” but psychosocial and spiritual support as well. There is substantial diversity in the literature addressing these comfort measures. Nurses are required to have a thorough knowledge of pain management and medication titration to alleviate and prevent pain in their patients (Frazier & Kohl, 1984).The continuous assessment, patient care planning, and patient teaching surrounding pain control are primary mponsibilities of the nurse. By alleviating or controlling pain, the nurse makes the individualcomfortable (Eland, 1988). To comfort may be described as an effort to minimitt e psychobiological distress (Moseley, 1985).The provision of comfort to the terminally ill patient is seen through a holistic perspective. Moseley identified the nursing diagnosis, ”alterations in comfort,” when planning care for the terminally ill patient. A holistic, individualized plan of care should include: pain control, involving both pharmaceutical and nonpharmaceutical interventions; Nursing F o m Volume 27, No. 2, April-June1992
the prevention of fatigue, depression, and anxiety; the prevention of alterations in bodily functions related to defecation and urination; easement of labored breathing patterns; promotion of proper body alignment; and provision for personal needs. Children are emotionally comforted in ways similar to adults. Psychological support is often provided by verbal and tactile exchanges. Sparshott (1989) identified procedures for comforting an infant. These procedures included cuddling, ConsoIation by voice, and stroking. Triplett and Ameson (1979) observed distressed children’s responses to verbal and tactile comfort measures. Verbal interventions were more successful for children over one year of age, whereas tactile interventions were more successful for infants. However, all comforting measures should include both verbal and tactile components, because a calming voice and warm touch help to alleviate distress. Verbal-tactile interventions were found to be successful within a five-minute period from the time of initiation. This time period does not appear unreasonable in a nurse’s busy schedule. When nurses use such interventions, children are better able to use their energy for recovery rather than for expressing displeasure. Providing comfort to a grieving family is another important nursing role. This comfort may be provided by offering both psychological and spiritual support. Meaningful, honest, and ongoing communication is imperative to this process (Stockdale & Hutzenbiler, 1986). Personalizing communication, by knowing the names and familial relationship of family members, promotes a sense of comfort. Explaining surprising behavior and expectations related to physical appearance and use of equipment helps to decrease anxiety. Again, the use of both verbal and tactile interventions are comforting. Family members need this caring approach as much as patients do. Spiritual comfort provides hope, and hope is a necessary component of the healing process. People have various ways in which they express themselves spirituallythrough rituals, prayers, Bible readings, and other expressions of faith. Spiritual imagery can also help soothe physical and emotional pain. Spiritual imagery Nursing Farum Volume 27,No. 2, April-June1992
can be performed by an individual in any setting. Essentially, people envision themselves as directly interacting with a higher being or power. Spiritually, this higher being or power can be anyone who is comforting to the individual (Ferszt & Taylor, 1988). The nursing adion of comforting is definitely a multidimensional endeavor. The individual needs of the patient and family must be assessed and responded to on a continuous basis. Needs change, since patients and families alternate rhythms, life situations, and interpersonal relationships. Comfort as a Patient Goal
The desire to find comfort is a basic human need. Individuals are constantly attempting homeostasis of this need. Comfort is a personalized experience, meaning different things to different people. This experience also varies with the person’s alternating rhythms.
Health for many is defined as physical and emotional comfort. ~
~~
~
While comfort is frequently seen as a nursing action, or nursing objective, comfort should also be considered a primary patient objective. Many of the behaviors s e n in individuals as they strive for comfort are benign and beneficial, such as maintaining close family relationships and friendships, being involved in hobbies and exercise p r e grams, and maintaining a physically healthy existence. Some behaviors can prove detrimental to health. These behaviors include drug and alcohol abuse, sexualpromiscuity,obesity, self-inflicted injuries, poor social relationships, and failure to resolve personal conflict and issues. Few may have ever considered behaviors such as alce hol and drug abuse, attempts at suicide, or other violent behaviors as a way of attempting to comfort oneself. However, it is often because of feelings of discomfort that individuals would involve themselves in these practices. 7
Promoting Health by Promoting Comfort
Psychological instances of comfort are less welldocumented than physical incidences. Most of the literature addresses comfort as a relief from pain (Eland, 1988). Many of the nursing measures identified have a physical, pain- relieving basis. While comfort has been addressed in some nursing theories, (Roy & Roberts, 1981;Orlando, 1961; Watson, 1979) the central patient objective documented in nursing thee ries is health. This concept is defined biopsychosocially and has multidimensional components. Yet, when exploring reasons why consumers seek healthcare services, researchers have found that services are sought to relieve distress.For instance, discomfort or pain is the most likely reason for a healthcare visit of the indigent (Brecht, 1990).If nursing is truly committed to assisting all individuals in promoting their best possible health status, then nurses must examine what health means through their patients’ eyes. Health for many is defined as physical and emotional comfort. The nurse should be expected to teach patients constructive ways of comforting themselves, which in turn will promote health. Figure 2 depicts this process.
Need for Future Research and Concept Development Comfort continues to be an important concept within the nursing literature.Yet “comfort” has not been definitively defined, and the concept remains abstract. Comfort must be defined from multiple perspectives and dimensions. It requires investigation from the perspechve of the patient, family, and nurse. A qualitative approach to its definition and further taxonomy development is required. Figure 2. Comfort as a Promoter of Health
i Comfort
A
Nurse dl
I
8
Physical Psychological Social Spiritual Environmental
Patient teaching of constructive interventions
,
Promotion
The multidimensional facets of this concept must be continuouslyassessed. As comfort is a basic human need that is sought by all human beings, comfort must not only be seen as a nursing action, but as an individualized patient goal as well.
References Brecht, M. (1990). Nursing’s role in assuring access to care. Nursing Outlook, 38 (l), 6-7. Cooke, H. (1986).Sleep and comfort during pregnancy. Nursing b n c l ) , 3,352-353. Eland, J. (1988).Pain management and comfort. Journal of Gerontological Nursing, 14 (4),10-15. Engelking, C. (1988). Comfort issues in geriatric oncology. Seminars in Oncology Nursing, 4 (3), 198-207. Ferszt, G., & Taylor, P. (1988).When your patient needs spiritual comfort. Nursing, 18 (4),48-49. Fleming C., Scanlon, C., & JYAgostino, N. (1987).A study of the comfort needs of patients with advanad cancer. Cimcer Nursing, 10,237-243. Frazier, L., & Kohl, E. (1984).To comfort always: Strategies for pain management in terminal cancer. North Carolina Medical \mml, 45,2&2%. Hamilton,J. (1989).Comfort and the hospitalized chronicallyill. Journal of Gerontological Nursing, 15 (41,2843. Klein, E. (1966). A Comprehensive Etymological Dictionary of the English Language. New York Elsevier. Kolcaba, K. (1991). A taxonomic structure for the concept comfort. Image, 23,237-240. Morse, J. (1983).An ethnoscientific analysis of comfort: A preliminaiy investigation.Nursing Papers, 15 (l), 6-20. Moseley, J. (1985). Symposium on compassionate care and the dying experience: Alterations in comfort. Nursing Clinics of North Americtg, 20,427-438. Nishioka, E. (1989). Comfort versus cure. American Journal of Nursing, 89,1125-1126. Onions, C. (Ed.) (1966).The Oxford dictionary of English etymology. New York Oxford University Press. Orlando, 1. (1961). 7% dynamic nurse-patient relationship: Function, process, and principles. New York: G.P. Putnam’s Sons. Oxford English Dictionary. (1978).New York Oxford University Press. Roy, C., & Roberts, S. (1981). Theory construction in nursing: An ad+tion model. Englewood Cliffs, NJ:Prentice Hall. Sohl, R. (1987). How to comfort and guide the family. Nursing, 17 (2), 6344. Sparshott, M. (1989). Minimizing discomfort of sick newborns, part 2. Nursing Times, 85 (42),18-24. Stockdale, L., & Hutzenbiler, T. (1986). How you can comfort a grieving family. Nursing Life, 6 (3), 22-26. Triplett, J., & Ameson, S. (1979).The use of verbal and tactile comfort to alleviate distress in young hospitalized children. Research in Nursing and Health, 2 (l), 17-23. Watson, J. (1979). Nursing the philosophy and science of caring. Boulder, C O Colorado Associated Press. Webster, N., Lyon, G., & MacDonald, R. (1986).Sleep and comfort after caesarean section. Anaesthesia, 41,1143-1145.
Nursing Fonun Volume 27, No. 2,April-June1992
