practical application of comfort theory in the perianesthesia setting

CONTINUING EDUCATION

Practical Application of Comfort Theory in thePerianesthesia Setting

Linda Wilson, PhD, RN, CPAN, CAPA, BCKatharine Kolcaba, PhD, RN, BC

Comfort management is a priority for patients in all settings. Comforttheory provides a foundational and holistic approach to comfortmanagement. This article reviews comfort theory and presents theapplication of comfort theory in the perianesthesia setting.

© 2004 by American Society of PeriAnesthesia Nurses.

Objectives—Based on the content of the following article, the reader will be able to (1) definecomfort; (2) identify comfort interventions; and (3) discuss the importance of a goal for enhancedcomfort in patients.

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HOLISTIC COMFORT IS a desirable outcomeof nursing care in the perianesthesia setting.Moreover, it is an umbrella term under whichthe discomforts that patients experience as aresult of surgery or procedures can be placed.These discomforts are many and include pain,nausea, anxiety, and hypothermia. This articleprovides an overview of current comfort theoryand a framework for addressing the comfortneeds of patients in the perianesthesia setting. A

Linda Wilson, PhD, RN, CPAN, CAPA, BC, is an AssistantProfessor in the College of Nursing and Health Professions atDrexel University in Philadelphia, PA and is a Past Presidentof ASPAN; and Katharine Kolcaba, PhD, RN, BC, is an Asso-ciate Professor in the College of Nursing at the University ofAkron, Akron, OH. She is the author of Comfort Theory andPractice.1

Address correspondence to Linda Wilson, Drexel UniversityCollege of Nursing and Health Professions, 1505 Race Street,7th Floor, Mail Stop 501, Philadelphia, PA 19102; e-mailaddress: [email protected].

© 2004 by American Society of PeriAnesthesia Nurses.1089-9472/04/1903-0006$30.00/0

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seful tool for identifying and addressing pa-ients’ comfort needs is described, and an ex-mple of its application in the perianesthesiaetting is included.

omfort Theory

omfort theory1-3 as it relates to nursing is bestnderstood when divided and described in 3arts. Part 1 states that nurses assess the holisticphysical, psychospiritual, sociocultural, and en-ironmental) comfort needs of patients in allettings. Furthermore, nurses implement a vari-ty of interventions to meet those needs andeasure or assess patients’ comfort levels be-

ore and after those interventions. This part ofomfort theory also describes positive and neg-tive intervening patient variables over whichhe nurse has little control, but that have con-iderable impact on the success of comfort in-erventions. Examples of these variables are theatient’s financial situation, cognitive status, ex-

1-3
ent of social support, and prognosis.
Journal of PeriAnesthesia Nursing, Vol 19, No 3 (June), 2004: pp 164-173

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PRACTICAL APPLICATION OF COMFORT THEORY 165

Part 2 of comfort theory states that enhancedcomfort strengthens patients to consciously orsubconsciously engage in behaviors that movethem toward a state of well-being.4 These be-haviors are called health-seeking behaviors andprovide rationale for implementing comfort in-terventions. For patients in the perianesthesiasetting, health-seeking behaviors might includedecreased blood loss, no complications, in-creased healing, increased mobility, and theability to take oral fluids.1-3

Health-seeking behaviors are related to what iscalled institutional integrity in part 3 of comforttheory. Institutional integrity is defined as thequality or state of health care organizations interms of being complete, sound, upright, pro-fessional, and ethical providers of health care.1-3

It is measured by many indicators, includingcost of care; length of stay; staff turnover rate;and patient, nurse, and staff satisfaction.

Patients Define Comfort

In her seminal work of 1989, Hamilton5 identi-fied 5 themes that 30 elderly hospitalized pa-tients used to describe their experience of com-fort. The first theme was the disease process, orphysical comfort. According to those inter-viewed, physical comfort entailed both an em-phasis on treatment of overt discomforts, suchas pain, as well as meeting less obvious needs,such as being able to go back to bed whenrequested, sitting correctly in furniture, andhaving regular elimination.5

The second comfort theme was self-esteem,which encompassed both psychological andspiritual comfort.5 Moreover, those intervieweddid not differentiate between psychological andspiritual comfort, because persons can be spir-itual without a religious affiliation and viceversa. The third comfort theme, positioning,encompassed the physical and environmentalaspects of comfort.5 Positioning was an impor-tant part of overall comfort for these patients.
These findings demonstrated that the environ- (
ent played a major role in the patient’s per-eption of comfort. This is good news forurses, because often they can easily manipu-

ate the environment to enhance patient com-ort and function. For example, perianesthesiaurses can prevent or treat shivering by offeringatients a variety of warming interventions, in-luding patient-regulated warming devices,hich may both warm and increase patients’

ense of control.

ccording to Hamilton, the fourth comfortheme, approach and attitudes of staff, was de-endent on the nursing staff.5 For example,mpathetic and reliable nurses contributed toomfort, whereas inaccessible nurses and thoseho lacked caring attributes detracted from

omfort. In addition, patients wanted choicesnd to be allowed to do things themselves, evenf it took longer. Hamilton’s fifth comfort theme,ospital life, encompassed physical, social, psy-hospiritual, and environmental aspects of com-ort.5 Patients described comfort in terms of itsomplexity and importance to their well-being.heir hospital life had an overall impact on their

otal comfort experience.

uring Hamilton’s study, the patients who werenterviewed agreed that the 5 themes werequally central to comfort.5 They also describedndividual preferences for the ways nursesould contribute to comfort such as personalecognition and respect, working with a posi-ive attitude, and attention to their individualeeds. Hamilton concluded that comfort is mul-idimensional and means different things to dif-erent people, emphasizing the importance ofndividualizing attention to patients’ needs.5

urses Define Comfort

convenience sample of 220 nurses who at-ended the 2001 ASPAN national conferenceere surveyed to better understand their per-

eptions of pain and comfort.6 The study sam-le consisted of perianesthesia nurses from dif-

erent settings including Pre-Admission Testing
PAT), PREP/Holding, Remote Anesthesia, and

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WILSON AND KOLCABA166

all phases of the PACU. Findings showed thatduring the preoperative phase, nurses identifiedpatients’ desired outcome levels of pain andcomfort at frequencies of 21% and 20%, respec-tively. These findings validated the importanceof further education on pain and comfort forperianesthesia nurses.

In a survey conducted in 2003, nurses attendingannual conferences for ASPAN and the Associ-ation of PeriOperative Registered Nurses(AORN) were asked about their perceptions ofpatient comfort (unpublished data). A total of722 nurses completed the survey, which asked,“What are the top 3 comfort concerns of pa-tients?” Warmth was cited most often (33.3%)as the top comfort concern, followed by painmanagement (18.3%), position (12.2%), and allothers (36.2%). Those who participated in thesurvey were also asked how often cold is acomfort issue for their patients. The majority(71%) responded that cold is often a comfortissue, 25% reported sometimes, and just 4%responded that cold is rarely a comfort issue.These results underscored the need for aggres-sive warming interventions not simply in theclinical context of maintaining normothermia,but also as a means of increasing overall patientcomfort in the perianesthesia setting.

Interviews of 27 critical care nurses were con-ducted to provide further insight into nurses’perceptions of patient comfort. In this unpub-lished data, the nurses described trusting theirown intuition and the family’s intuition about aloved one’s comfort. In addition, they assessedvital signs, gestures, and grimaces to determinethe presence of pain.

Theoretical Framework for Practice

Kolcaba provides a definition of comfort thatappreciates the holistic nature of human be-ings—that individuals have mental, spiritual,and emotional lives, which are intimately con-nected with their physical bodies.1,7,8 Kolcaba
defines comfort as the immediate state of being o
trengthened by having the human needs forelief, ease, and transcendence (types of com-ort) addressed physically, psychospiritually, so-ioculturally, and environmentally (contexts inhich comfort is experienced).1,9 This defini-

ion emphasizes that although nurses may note able to fully meet all of their patients’ needsor comfort, they can continue to address themn a proactive fashion throughout the contin-um of care.

olcaba identifies 3 types of comfort. The firstype, relief, is the state of having a specificiscomfort relieved.1,9 In the perianesthesia set-ing, some of the common discomforts tohich this relates are pain, nausea, cold, or

nxiety. The second type of comfort is ease andefers to a state of contentment for the pa-ient.1,9 This can refer to comfort needs arisingrom a patient’s previous experience with aarticular need or by virtue of the patient’siagnosis or prognosis. For example, patientsith uncertainty regarding their diagnosis mayeed emotional support to achieve comfort inhis area. Nurses can prevent or minimize theseeeds, often without patients realizing that theyre doing so, thus keeping patients in a state ofase. The third type of comfort is transcen-ence, which encompasses the need for inspi-ation, strengthening, and motivation.1,9 Nursesften focus on meeting the needs of transcen-ence when they are unable to fully meet thether types of comfort needs for their patients.or example, they may assist patients in the usef distraction and relaxation breathing whenausea persists despite treatment with anti-metics.

able 1 provides a description of Kolcaba’s 3ypes of comfort in the 4 contexts in whichatients experience them: physical, psychos-iritual, environment, and sociocultural.1,9 The2-cell grid in Table 2 provides a useful tool forategorizing comfort needs in ways that willllow nurses to individualize treatment plans forheir patients. Each cell represents an attribute
f comfort. It is important to note that the cells

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are not mutually exclusive; they are “fluid,” andthere is considerable overlap in the attributes ofcomfort. In other words, most discomforts thatpatients experience in the perianesthesia set-ting, such as pain, hypothermia, and nausea,may have physiological, psychological, environ-mental, and sociocultural components.

The holistic, interrelated, and individualized na-ture of comfort needs is better understoodwhen nurses mentally place their patients’needs within the cells on the grid. This ap-proach makes it easier for nurses to identify andimplement comfort interventions targeted tomeet those needs. Table 2 provides an exampleof a hypothetical patient and how the grid can

Table 1. Types and Context of Comfort

Type of comfortRelief: having a particular comfort need

met.Ease: being calm or content.Transcendence: a feeling that one can

rise above problems or pain.

Context in which comfort occursPhysical: involving bodily sensations

and homeostasis.Psychospiritual: items such as self

esteem, self concept, sexuality,meaning in life, and spirituality,which contribute to internalawareness.

Environmental: includes temperature,light, sound, odor, color, furniture,landscape, and other factors in thebackground of the human experience.

Sociocultural: involving interpersonal,family, and societal relationshipssuch as finances, teaching, health carepersonnel, etc. May also refer tofamily traditions, rituals, andreligious practices.

Data from Kolcaba and Fisher.12

be used to tailor the treatment plan. c

able 2 demonstrates that a wide variety ofomfort needs of patients in perianesthesia set-ings can be placed somewhere on the grid,ncluding individualized needs for spiritual guid-nce, emotional support and reassurance, envi-onmental adjustments, and physical needs.lso note that essential to comfort is the main-

enance of homeostatic mechanisms such asxygenation, circulation, fluid and electrolytealance, normothermia, digestion, mobility, andlimination. Many of the patient’s homeostaticeeds can be gleaned from a review of theatient’s history and current medical problems.key point to remember is that all of these

omfort needs interact and produce more dis-omfort together than can be accounted for byonsidering each comfort need separately.

omfort Detractors andontributors

fter assessment of comfort needs, nurses ad-ress the sources of discomfort (Table 1).1

urses can implement a number of inter-entions that will contribute to comfort byinimizing or negating the detractors of

omfort. Several interventions can be deliv-red simultaneously in a seamless interac-ion with patients and can influence theatient’s overall perception of comfort. Forxample, pain is a major detractor fromhysical comfort. Patients often describewaiting for pain medication” (a contribut-ng detractor) as a significant pain intensifi-r.1 Nurses can intervene to minimize thisetractor by promptly administering analge-ics. Other detractors are homeostatic im-alance, poor positioning, breathing diffi-ulties, itching, feeling too hot or too cold,ausea, and discomfort from invasive tubesr lines.

nxiety related to surgery and the aftermath ofare is a major detractor from psychospiritualomfort. Other detractors in this context are
onfusing, incomplete, or negative information;

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questionable or threatening diagnoses; fear; andthe prospect of a change in routine or healthstatus. Detractors from sociocultural comfortinclude isolation from family, disregard for cul-tural traditions, uncaring or anxious nursingbehaviors, fragmented care, lack of nursing carewhen desired, poor social support, and limitedresources for ongoing care at home after dis-charge.

Factors in the environment that detract frompatients’ comfort are cold, noise, chaos, endlessbright lights, bad odors, lack of privacy, anduncomfortable stretchers, chairs, and beds. Un-met safety needs can detract from comfort andinclude a lack of properly functioning equip-ment, security problems, security hazards,inaccurate care, poor aseptic/sterile techniqueresulting in nosocomial infections, and medica-tion or treatment errors. Freeing patients fromrestraints and restrictive devices such as intra-venous lines, invasive monitors, and sensors assoon as possible is a goal to which nurses canstrive to achieve by obtaining orders for inter-mittent saline locks, noninvasive monitors, andintermittent, rather than continuous, monitor-ing when appropriate.

Detractors can be plotted on the comfort grid(Table 2). Note that their placement on the grid

Table 2. Taxonomic Struct

Context Relief

Physical PainNausea

Comfhom

Psychospiritual Anxiety Uncerpro

Environmental Noisy PACU; brightlights; cold

Lack o

Sociocultural Absence of traditions andculturally sensitive care

Familylang

NOTE. Patient is a 45-year-old Hispanic male withsigmoid colon resection.

illustrates the overlap and interrelatedness of l

omfort needs. In other words, most comforteeds can be placed in more than 1 cell, be-ause they have multiple origins. All detractorsrom comfort interact to produce a simulta-eous perception of total comfort, which theatient can rate, using a 0 to 10 visual ratingcale, as being from no comfort (0) to highestossible comfort (10).1

omfort Care Interventions

omfort care entails at least 3 types of comfortnterventions that can be implemented tochieve the goal of enhancing patients’ totalomfort (Table 3). The first are standard com-ort interventions that are designed to maintainomeostasis such as monitoring vital signs and

aboratory results, and responding to changesn patient assessment findings that indicateomeostatic compromise.1 Standard comfort

nterventions also include attention to pain, hy-othermia, administration of appropriate medi-ations, and repositioning. These comfort inter-entions are designed to help the patientaintain or regain physical function and com-

ort and prevent complications.1

he second type of comfort interventions isenerally referred to as “coaching.”1 Coachingelps to relieve anxiety, provide reassurancend information, and instill hope. It involves

f Comfort Needs Applied

Transcendence

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Patient thinking “How can I tolerate painwhen I wake up?”

about Need for spiritual support

acy Need for calm, familiar environmentalelements

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Need for support from family orsignificant other; need for information,consultation

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recovery in a culturally sensitive way. Effective-ness of these interventions depends on theirimplementation at a time when the patient isready to accept new or more positivethoughts.1,10

The last group of comfort interventions is de-scribed as “comfort food for the soul.”1 Patientsdo not expect this type of intervention but areusually very pleased when it is offered. Exam-ples of interventions that provide comfort foodfor the soul are massage, adapting the environ-ment to enhance warmth, music therapy,touch, and hand holding. Like comfort food thatwe eat, these comfort interventions make pa-tients feel strengthened in intangible, personal-ized ways. Comfort food for the soul targets theneed for transcendence through memorableconnections between the nurse and patient orfamily.1 These connections help to fortify pa-tients for the difficult tasks associated with heal-ing, rehabilitation, and return to what they con-sider a “normal” lifestyle.

Holistic comfort interventions can be used totarget many comfort needs at one time. Forexample, providing medications and using non-pharmacologic and integrative interventions

Table 3. Comfort Care Actions/Interventions

Type of Comfort CareIntervention Example

Standard comfortinterventions

Vital signsLab resultsPatient assessmentMedications and treatments

Coaching Emotional supportReassuranceEducationListening

Comfort food for thesoul

Therapeutic touchMusic therapySpending timePersonal connections

(guided imagery, massage, music) can address a t

atient’s needs across the 4 contexts of comfortTable 2). To illustrate this, a patient receivingusic therapy can have the needs for ease,

elief, and transcendence met simultaneously.ase is addressed by the contentment the pa-ient feels while listening to a favorite type ofusic. The music addresses relief by calming

he patient and thereby reducing the discomfortf anxiety. Transcendence is addressed whenhe music allows the patient to think positivelyr spiritually.

herapeutic use of (the nurse’s) self is often theost important comfort intervention for meet-

ng patients’ social and psychospiritual comforteeds.1 For example, assuring patients thatheir nausea can be treated successfully withoth pharmacologic and nonpharmacologicethods may be more effective than simply

dministering an antiemetic without reassur-nce.

s mentioned earlier, there may be times inhich little improvement in comfort is

chieved despite applying the recommenda-ions outlined in this article. Under these cir-umstances, nurses can look at intervening vari-bles to help explain why comfort care is notorking. Variables such as an abusive home

nvironment, lack of financial resources, devas-ating diagnoses, or cognitive impairment mayender ineffective the most appropriate inter-entions and comforting actions. However, theurse should not give up and through repetitivedministration of comfort care can still try toelp patients transcend such difficult circum-tances. It is important to remember that tran-cendence is a type of comfort!

onclusion

he comfort care model presented in this arti-le includes definitions, comforting actions ornterventions, and the goal of enhanced com-ort. It is proactive, energized, intentional, andonged for by patients and families in all set-

3,5,6,11
ings.

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Proactive care seeks to not only minimizenegative aspects of surgery and illness suchas pain, nausea, and anxiety, but to enhancepositive indicators of daily function, such as
comfort, mobility, and healing. Comfort is a s
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ositive outcome that has been linked touccessful engagement in health seekingehaviors1 and is an important indicator toeasure for perianesthesia care and re-

earch.

ces
1. Kolcaba K: Comfort Theory and Practice: A Vision for
Holistic Health Care and Research. New York, Springer Pub-lishing Co, 2003

2. Kolcaba K: Evolution of the mid range theory of comfortfor outcomes research. Nurs Outlook 49:86-92, 2001

3. Kolcaba K, Wilson L: The framework of comfort care forperianesthesia nursing. J Perianesth Nurs 17:102-114, 2002

4. Schlotfeldt R: The need for a conceptual framework, inVerhonic P (ed): Nursing Research. Boston, Little & Brown,1975, pp 3-25

5. Hamilton J: Comfort and the hospitalized chronically ill. JGerontol Nurs 15:28-33, 1989

6. Krenzischek D, Wilson L: An introduction to the ASPANpain and comfort clinical guideline. J Perianesth Nurs 18:228-231, 2003

7. Kolcaba R: The primary holisms in nursing. J Adv Nurs5:290-296, 19978. Kolcaba KY: The art of comfort care. J Nurs Scholarsp

7:287-289, 19959. Kolcaba KY: A taxonomic structure for the concept of

omfort. J Nurs Scholars 23:237-240, 199110. Benner P: From Novice to Expert. Upper Saddle River,

rentice Hall, 198411. Puntillo K, Stannard D, Miaskowski C, et al: Use of a pain

ssessment and intervention notation (P.A.I.N.) tool in criticalare nursing practice: Nurses’ evaluations. Heart Lung 31:303-14, 200212. Kolcaba KY, Fisher EM: A holistic perspective on com-

ort care as an advance directive. Crit Care Nurs Q 18:66-76,996


Practical Application of Comfort Theory in the Perianesthesia Setting

1.0 Contact Hour

Directions: The multiple-choice examination below is designed to test your understanding of thePractical Application of Comfort Theory in the Perianesthesia Setting according to the objectiveslisted. To earn contact hours from the American Society of PeriAnesthesia Nurses (ASPAN) Continu-ing Education Provider Program: (1) read the article; (2) complete the posttest by indicating theanswers in the test grid provided; (3) tear out the page (or photocopy) and submit postmarked beforeJune 30, 2006, with check payable to ASPAN (ASPAN member, $12.00 per test; nonmember, $14.00per test); and return to ASPAN, 10 Melrose Ave, Suite 110, Cherry Hill, NJ 08003-3696. Notificationof contact hours awarded will be sent to you in 4 to 6 weeks.

Posttest Questions

1. Comfort is most accurately defined asa. pain relief.b. relief of discomfort.c. having human needs for relief, ease, and transcendence addressed.d. satisfaction.

2. The contexts in which comfort can occur area. environmental and physical.b. psychospiritual.c. sociocultural.d. all of the above.

3. Cold detracts from the desired patient state of comfort and must be addressed toachieve the goal of patient comfort.a. Trueb. False

4. Which of the following are pain intensifiers?a. anxietyb. nauseac. poor positioningd. all of the above

5. Which of the following is a physical detractor from comfort?a. shiveringb. fearc. lonelinessd. disregard for cultural traditions

6. Which of the following is an environmental detractor from comfort?a. fearb. anxietyc. noised. hunger

7. Which of the following is a psychospiritual detractor from comfort?a. bright lightsb. anxietyc. visitors
d. dry mouth


8. Which of the following is a sociocultural detractor from comfort?a. isolation from familyb. anxietyc. nausead. shivering

9. Possible priorities for future perianesthesia research includea. comfort outcomes.b. comfort interventions.c. patient/nurse knowledge of comfort.d. all of the above.

10. Current research shows that all patients have adequate pain and comfort management.a. Trueb. False


ANSWERSSystem W010606. Please circle the correct answer1. a. 2. a. 3. a. 4. a. 5. a.

b. b. b. b. b.c. c. c. c.d. d. d. d.

6. a. 7. a. 8. a. 9. a. 10. a.b. b. b. b. b.c. c. c. c.d. d. d. d.

Please Print

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EVALUATION: Practical Application of Comfort Theory in the Perianesthesia Setting

(SD, strongly disagree; D, disagree; ?, uncertain; A, agree; SA, strongly agree) SD D ? A SA

1. To what degree did the content meet the objectives? 1 2 3 4 5a. Objective #1 was met. 1 2 3 4 5b. Objective #2 was met. 1 2 3 4 5c. Objective #3 was met. 1 2 3 4 5

2. The program content was pertinent, comprehensive, and useful to me. 1 2 3 4 53. The program content was relevant to my nursing practice. 1 2 3 4 54. Self-study/home study was an appropriate format for the content. 1 2 3 4 55. Identify the amount of time required to read the article and take the test.

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practical application of comfort theory in the perianesthesia setting

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