Concept analysis is an important factor within theory development, because it allows for critical thinking to be applied to a theory. This allows for increased clarity of the theory, so that purposes of the theory can be clarified, data sources can be chosen, examined and integrated, and the theory can be examined to ensure its adequacy (Kramer, 1993). By analyzing concepts, researchers are able to clarify problems and to challenge commonly held beliefs that are thought to be common sense. Challenging accepted beliefs or obvious conclusions can allow for new angles to be studied, and allows for “vague terminology, ambiguous definitions, and inconsistent theories” to be clarified (Buosso, Poles, and Monteiro de Cruz, 2014). The nursing concept selected is comfort. The nursing theory that this was obtained from is Kolcaba’s Theory of Comfort. In this paper, the nursing concept is defined and explained, a literature review is performed, attributes, antecedents, consequences and empirical references are done on the concept. Additionally, a model case and two alternative cases are presented, followed by the conclusion of the concept analysis.
Definition/Explanation of Comfort
The concept of comfort is one that has been explored thoroughly by theorists and researchers, but in regards to nursing, there has been no consensus on the definition of comfort. “Various definitions have included comfort as an outcome of nursing, a function of nursing, a basic human need, and a process” (Malinowski and Stamler, 2002). For the purpose of this concept analysis, the dictionary definition of the word “comfort” will be used: “(1) A state of physical ease and freedom from pain or constraint; (2) the easing or alleviation of a person’s feelings of grief or distress” (Oxford Dictionary, 2017). This definition is upheld in Kolcaba’s Theory of Comfort.
Kolcaba’s theory looks at the concept of comfort as being one that spans past just physical comfort, and moves to offer holistic comfort through three different forms, and across four different contexts. According to Kolcaba, the three forms are: Relief, ease, and transcendence. The three forms are defined as follows: When a patient experiences relief, a specific comfort need has been met. When a patient experiences ease, they enter into a state of calm, or as Kolcaba explains, a state of contentment. When a patient experiences transcendence, they have reached a state where they are able to move past the pain and rise above it (Kolcaba, 2003). These three forms can exist in one of four different contexts: The physical, pscyhospiritual, environmental, and sociocultural (Kolcaba, 2003).
Findings across the literature review show that comfort levels increase when the patient’s comfort is addressed across all four contexts, rather than just the physical context. In a study conducted by Parks and Kolcaba (2005), the physical comfort of patient warmth was studied in psychiatric hospitalization. While the study admits to limitations due to the sample size, there was no significant level of improved comfort found when a group of patients were given warmed blankets, compared to the control group who did not receive warmed blankets (Parks and Kolcaba, 2005). A study conducted by Coelho, Parola, Escobar-Bravo and Apostolo (2016) used a phelomenological descriptive study to assess what it was that made patients experience comfort. The findings of the study showed revealed that patients “experience comfort through humanized care, differentiated environment, symptomatic control, hope and relationships” (Coelho et al, 2016). These findings shed light on the potential reasons behind Parks and Kolcaba’s 2005 study, where increased physical comfort in the form of a warmed blanket would show no significant increases in the feeling of comfort. By only addressing one aspect of comfort, which does not address or solve a significant discomfort, increased comfort is not attained in patients.
According to Kolkaba and DiMarco (2005), “Comfort is a positive outcome that theoretically empowers children and their families to engage in health seeking behaviors” (Kolcaba and DiMarco, 2005, p.193). The study in 2005 found something interesting, however, which expanded the Theory of Comfort further. In the cases where patients were able to make recoveries, comfort across the three forms and four contexts pushed both the children and families to adopt health seeking behaviors (Kolcaba and DiMarco, 2005). In cases where recovery was not possible, enhancing the comfort of the children and families within clinical settings was found to be “altruistic, practical and satisfying for recipients and nurses” (Kolcaba and DiMarco, 2005, p. 193).
The study by Boudiab and Kolcaba (2015) agreed with the findings of Kolcaba and DiMarco (2005). The study found that a context care checklist helped to ensure that patients were routinely asked about their comfort across all four contexts on a regular basis. Veteran-centered care on the individual level was found to be enhanced when nurses and providers integrated strong communication strategies into the process. The study found that the concept of comfort “is a value-added indicator because it represents what families want and need during their health care experiences” (Boudiab and Kolcaba, 2015, p. 277). When applied to the veteran population, comfort was found to help both the veterans and their families to adjust to civilian life and create what Boudiab and Kolcaba describe as, “a new normal” (Boudiab and Kolcaba, 2005).
In order to understand what provides comfort, understanding what detracts from the concept of comfort is needed. A qualitative study conducted by Egger-Rainer, Trinka, Hofler and Dieplinger (2017) looked to discover what epilepsy patients in the Epilepsy Monitoring Unit (EMU) perceived as discomfort in the hospital setting. Patients reported that boredom, bed rest, and anticipating potential seizures all detracted from their levels of comfort. On the other hand, comfort was increased when the patient had hope of seizure control, supportive staff and family members present, and when they had clear information given to them about necessary restrictive conditions (Egger-Rainer et al, 2017). This study enhances the information found in Kolcaba and DiMarco’s 2005 study, in which clear communication plays an essential role. Egger-Rainer et al’s study reflects the importance of clear communication not just with other nurses and practitioners, but also with the patients.
While the Theory of Comfort focuses on providing a framework, a study by Krinsky, Murillo and Johnson (2014) found that a large number of nurses practice not just providing physical comfort, but also meeting comfort levels across all four contexts outlined in the comfort theory (Kinsky et al, 2014). A nurse’s basic instinct is to provide comfort in any way possible. The comfort theory is an advanced version of the basic comfort given by the majority of nurses, but broken down into a framework that can be applied across all hospital and nursing settings. As shown in each of the studies in this literature review, patients levels of comfort are improved when more than just the physical needs are being met. Above all, communication between nurses, practitioners and the patients helps to increase comfort levels, and having a strong framework or check list allows for comfort to be met in all four contexts on a regular basis.
The characteristics of comfort are reflected best in the three forms addressed throughout the literature study. The first attribute is communication, both between nurses/practitioners, as well as with the patient (Kolcaba and DiMarco, 2005; Egger-Rainer et al, 2017). The second attribute is supportive relationships, including nurses, family members, and friends (Kolcaba and DiMarco, 2005; Boudiab and Kolcaba, 2015). The third attribute is hope, which allows for the patient to remain positive and look toward the future (Egger-Rainer et al, 2017).
Antecedent and Consequence
Antecedents of comfort are: Discomfort, pain, distress or suffering. Those who experience any of the four listed antecedents are in need of comfort in one (or more) of the four contexts (Kolcaba, 2003; Kolcaba and DiMarco, 2005; Boudiab and Kolcaba, 2015). Knowing the source of the antecedent, usually from asking the patient and using communication, can help to find the right method of comfort to help relieve, ease, or transcend the pain (Boudaib and Kolcaba, 2015). Consequences of comfort are: Meeting or satisfying needs.
Since comfort varies from one individual to another, and because the concept of comfort is an abstract idea taking place over four different contexts, empirical referents are needed to measure the concept of comfort. The first way to do this is through communication with the patient, and asking the patient to report on their satisfaction with the nurse’s application of comfort across the four contexts. The second way to measure the concept of comfort is measure the patient’s ability to function independently.
A model case is one that meets all attributes, antecedents, consequences, and referents of the concept, as mentioned previously in the concept analysis (Walker and Avant, 2005). The patient is a 23-year-old female in the EMU. She has been admitted for epileptic seizures, and is being monitored by staff. Through conversations with nurses in the EMU, she has admitted to being hopeful of the procedures after receiving thorough information about her condition, as well as what to expect. She also has the support of her family and friends, who visit often. The antecedents she has experienced prior to being admitted to the EMU were distress over potential epileptic episodes that she had no control over. The consequences of being comforted by a knowledgeable and caring staff are that she now feels she has more control over how she responds to her epileptic episodes moving forward. Nurses measure her concept of comfort by asking how her comfort levels are across all four contexts on a regular basis, using a ‘check in’ calendar (Boudiab and Kolcaba, 2005). The more communication, support, and information that the patient receives, the higher her levels of reported comfort, showing improvements across all four contexts.
Patient is a 58 year old male in the VA hospital and shows no response to communication with nursing staff, and has no supportive social relationships to draw on. Patient shows signs of suffering, but not on a physical level. The nurses are at a loss for how to provide comfort, as communication is the key factor in discerning the needs of the other three contexts. Patient is placed in a group setting, in the hopes that communication will improve, and that social relationships will be formed, in order to increase comfort (Boudiab and Kolcaba, 2015). The consequences of this are that he begins to communicate more with select group members, and has begun to show improvements in regards to health-seeking habits. His comfort levels are measured using self-reporting referents, through which he has begun to respond and show continuous improvements in his communication style, and has reported that he is feeling more hopeful and able to take better care of himself.
Patient is a 61-year-old male in hospice. He shows no desire to be comforted by others, and does not complain about his situation or communicate his concerns to the nursing staff or family members. He does not show distress, pain, or suffering, and has not attempted to clarify his discomfort in order for comfort to be given. Nurses often forget to check in with him on his comfort levels, as he has never given a way to measure improvements in his comfort level across the four contexts. While he engages in some conversation, he has no desire to be part of group activities, or ease his own pain.
The concept analysis shows that comfort is an important part of recovering, or preparing for death. In order to understand what each patient needs, communication has to take place. Without this, nurses will be unable to apply more than physical comfort, and the other three contexts will not be met. In order to see improvement and for the patient to engage in health-seeking behaviors, all four contexts need to be met. While most nurses already practice the Theory of Comfort, the theory itself gives a strong framework that can be used across all nursing practices. The analysis of the concept shows that simply working to provide physical relief will not help the patients make speedy and positive recoveries. What was gained from this concept analysis was a deeper understanding of how comfort needs to be focused on the bigger picture. It is not just about fixing the immediate problem that the patient presents for, but about addressing the four contexts in an effort to help promote the patient’s self-care over the long term.
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