Katherine Kolcaba’s Comfort Theory fits best with my philosophy of nursing and my current work environment. As a hospice nurse comfort is the top priority. The goal of hospice care is to provide comfort and dignity at the end of life. The technical term for comfort for health care is the immediate state of being strengthened by having the needs for relief, ease, and transcendence addressed in the four context of holistic human experience: physical, psychospiritual, sociocultural, and environment.
The change goal would be to implement Kolcaba’s taxonomic structure of comfort as a way for the hospice unit staff to measure comfort. Katherine Kolcaba’s Comfort Theory Kolcaba was born as Katherine Arnold on December 8th, in Cleveland, Ohio. She received her diploma in nursing from St. Luke’s Hospital School of Nursing in 1965. She graduated from the Frances Payne Bolton School of Nursing, Case Western Reserve University in 1987.
She graduated with a PhD in nursing and received a certificate of authority clinical nursing specialist in 1997. She specialized in Gerontology, End of Life and Long Term Care Interventions, Comfort Studies, Instrument Development, Nursing Theory, and Nursing Research. She is currently and associate professor of nursing at the University of Akron College of Nursing. She published Comfort Theory and Practice: a Vision for Holistic Health Care and Research (Nursing Theories, 2011).
Description Comfort Theory is a middle range theory for health practice, education, and research. Comfort is viewed as an outcome of care that can promote or facilitate health-seeking behaviors. Increasing comfort can result in having negative tensions reduced and positive tensions engaged. Kolcaba (as cited in McEwin & Wills, 2011) defined comfort within nursing practice as “the satisfaction of the basic human needs for relief, ease, or transcendence arising from health care situations that are stressful” (p. 34). Purpose According to Kolcaba, (2010) “the overall purpose of Comfort Theory, was to highlight the importance of comforting patients in this high tech world. It is what they want and need from us. ” Origin. To describe the origin or development of Comfort Theory, Kolcaba conducted a concept analysis of comfort that examined literature from several disciplines including nursing, medicine, psychology, psychiatry, ergonomics, and English.
First, three types of comfort (relief, ease, transcendence) and four contexts of holistic human experience in differing aspects of therapeutic contexts were introduced. A taxonomic structure was developed to guide for assessment, measurement, and evaluation of patient comfort (Nursing Theories, 2011). Major concepts. Major concepts described in the Theory of Comfort include comfort, comfort care, comfort measures, comfort needs, health-seeking behaviors, institutional integrity, and intervening variables (Kolcaba, 2010). Propositions.
Kolcaba (as cited in McEwin & Wills, 2011) defines eight propositions that link the defined concepts: * Nurses and members of the health care team identify comfort needs of patients and family members * Nurses design and coordinate interventions to address comfort needs * Intervening variables are considered when designing interventions * When interventions are delivered in a caring manner and are effective, the outcome of enhanced comfort is attained * Patients, nurses and other health care team members agree on desirable and realistic health-seeking behaviors * If enhanced comfort is achieved, patients, family members and/or nurses are more likely to engage in health-seeking behaviors; these further enhance comfort
* When patients and family members are given comfort care and engage in health-seeking behaviors, they are more satisfied with health care and have better health-related outcomes * When patients, families, and nurses are satisfied with health care in an institution, public acknowledgement about that institution’s contributions to health care will help the institution remain viable and flourish. Evidence-based practice or policy improvements may be guided by these propositions and the theoretical framework (P. 234). Population According to the National Hospice and Palliative Care Organization, (NHPCO, 2012) in 2011, an estimated 1. 65 million patients received services from hospice and an estimated 44. 6% of all deaths in the United States were patients under hospice care. In 2001, an estimated 36. 6% of cancer patients accessed three of more days of hospice care.
The median length of service in 2011 was 19. 1 days. 56. 4% of hospice patients were female and 43. 6% were male. 83. % of hospice patients were 65 years of age or older, and more than one-third of all hospice patients were 85 years of age or older. 82. 8% of hospice patients were white/Caucasian. Patients of minority (non-Caucasian) race accounted for more than one fifth of hospice patients. Today cancer diagnoses account for less than half of all hospice admissions (37. 7%). Currently less than 25% of U. S. deaths are now caused by cancer, with the majority of death due to other terminal diseases. The top four non-cancer primary diagnoses for patients admitted to hospice in 2011 were debility, dementia, heart disease, and lung disease (NHPCO, 2012).
Level of care There are four general levels of hospice care: routine home care, continuous home care, general inpatient care, and inpatient respite care. The facility where I currently work is a unit for general inpatient care. General inpatient care is care received in an inpatient facility for pain control or acute or complex symptom management which cannot be managed in other settings. In 2011, 2. 2% of hospice patients received general inpatient care. The percentage of hospice patients receiving care in a hospice inpatient facility increased from 21. 9% in 2010 to 26. 1% in 2011 (NHPCO, 2012). The main reason for a general inpatient admission is for comfort care that cannot be achieved at home or in another setting.
Nursing Role My current role at the hospice unit is one of a staff nurse. I work three, twelve hour shifts on the dayshift. My responsibilities include the day to day care of the patients that I am assigned. I provide the patients with comfort care and symptom management based on the physicians orders. I do have certain standing orders that can be put in place without making a call to the physician and using my nursing judgment alone. I report directly to the unit manager on my unit. Power I feel that I have informal power at my facility. I have been there the longest of all the nurses, including the manager. I am the person that all the nurses turn to when there is a question regarding policy and procedure.
I am the person that others seek out for advice and unfortunately the person that most nurses vent to. I am always willing to pick up extra shifts without complaining. I continually hear from the other nurses, “you never complain. ” I love what I do! I love providing comfort care for patients in need. Are there days when things get crazy? Are there things I wish I could change? Absolutely, but complaining doesn’t change anything and I feel that being around someone that complains all the time bring others down as well. I always try to stay positive and encourage others. The management team comes to me as well to ask me my opinion about certain changes.
I feel that I could be a positive influence for change, but ultimately the decision would not be mine to make. Any decision has to go through my unit manager and then up the chain of command to the clinical director, and executive director. Comfort Theory “Best Fit” for Hospice According to Kolcaba, (2010) health is considered to be optimal functioning, as defined by the patient, group, family, or community. There are several major assumptions in Comfort Theory. Human beings have holistic responses to complex stimuli. Comfort is a desirable holistic outcome that is germaine to the discipline of nursing, human beings strive to meet, or to have met, their basic comfort needs. It is an active endeavor.
When comfort needs are met, patients are strengthened (Kolcaba, 2010). The mission statement of the company that I work for includes: * Recognize that individuals and families are the true expert in their own care; * Support each other so we can put our patients and families first; * Find creative solutions which add quality to life; * Strive for excellence beyond accepted standards, and; * Increase the community’s awareness of hospice as a part of the continuum of care. I feel that the mission of my company falls in line with the assumptions of Kolcaba’s Comfort Theory. The main goal of hospice care is comfort care. Currently we assess pain using a number scale or a face/FLACC cale depending on if the patient is able to verbally respond.
The majority of our patients are unable to communicate. Pain using a face or FLACC scale can vary from nurse to nurse. The FLACC scale measures pain using face, legs, activity, cry, and consolability. Kolcaba’s taxonomic structure would be an excellent way to measure comfort on a hospice unit such as the one where I work. Development. Katherine Kolcaba developed an interest in the concept of comfort during her practice as the head nurse of a dementia care unit. Her understanding that comfort lead to optimal functioning of the dementia patients, was the beginnings of her comfort theory.
Kolcaba realized the relationship between behaviors such as aggression, fighting with others, refusal to cooperate, or tearing up the environment and a patient’s comfort level. Interventions to reduce these behaviors were called comfort measures (Kolcaba, 2003). Since that time, the theory has been utilized in the fields of hospice (Kolcaba, Dowd, Steiner, & Mitzel, 2004; Vendlinski & Kolcaba, 1997), orthopaedic care of adult patients (Panno, Kolcaba, & Holder, 2000), pediatrics (Kolcaba & DiMarco, 2005), and perianasthesia nursing (Kolcaba & Wilson, 2002). Kolcaba (1994) stated, “the first dimension of the theory of comfort consists of three states of comfort called relief, ease, and transcendence” (p. 1179). Relief is having a specific comfort need meet.
An example would be relief from pain. Ease is the state of calm or comfort (Kolcaba, 1994). Individuals who feel ease are in a relaxed state. Ease can add to an individual’s health seeking behavior. Transcendence is each individual’s ability to rise above one’s pain or trouble (Kolcaba & Kolcaba, 1991). The second dimension of the theory consists of the contexts in which comfort occurs. This is a holistic concept. It can be examined in the physical, psychospiritual, sociocultural, and environmental perspectives. Physical comfort pertains to the body. Musculoskeletal pain, urinary discomfort, gastrointestinal upset would fall into this category.
Psychospiritual comfort pertains to self-esteem, the meaning of one’s life, and one’s connection with a higher power. Sociocultural comfort pertains to family, personal relationships, and one’s cultural background. Environmental comfort pertains to the external surrounding (Kolcaba, 1994). The theory consists of three parts. Part one describes how comfort needs are assessed, appropriate nursing interventions are implemented, and the patient experiences increased comfort. The second part of the theory describes the relationship between comfort and health seeking behaviors. Kolcaba reports that patients whose comfort needs are meet are better able to participate in positive behaviors, which promote health and well-being.
The third part of the theory describes the relationship between client’s health seeking behaviors and the integrity of the institution (Kolcaba, Tilton, & Drouin, 2006). Outcome measures for institutions can be improved when staff utilizes comfort measures. It is desirable that nurses caring for hospice patients are skilled in the art of comfort. Providing physical comfort such as managing pain, positioning an individual with advanced musculoskeletal problems, keeping bowel patterns regular, assisting residents in a toileting program to avoid incontinence, and protection fragile skin are skills used on a daily basis. Nurses in hospice care must address psychospiritual concerns such as depression, the loss of physical functioning, as well as the loss of loved ones and friends.
Most patients in hospice care have been forced by illness and debility to give up their homes and independence. Sociocultural comfort is provided when nurses understand a person’s cultural background. Encouraging family support and understanding a resident’s background and accomplishments assist nurses in developing interventions to support comfort. The environment also plays a part in an individual’s comfort and well-being in the long-term care environment. Providing a home-like, active, and joyful environment filled with children, animals, and treasured items from home are very important. Comfort theory has been utilized as a framework for hospice nursing (Vendlinski & Kolcaba, 1997).
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