Introduction
Kolcaba’s Comfort Theory, which is a middle range theory, is a holistic theory based on patients’ needs (Kristen, & Swanson, 1991). It is a theory on comfort management or palliative care where seriously ill patients and families are given specialized healthcare for them to have improved quality of life (that is, by reducing or eliminating the patients’ pain, anxiety, etc.). Comfort management is a core part of Kolcaba’s theory especially in nursing practice that seeks to ease discomfort, relieve pain, alleviate symptoms and assuage stress in patients with chronic diseases such as cancer. In comfort management, comfort or palliative care may be the only available health option for patients when the disease has progressed and there is no viable cure. As such, just as in Kolcaba’s theory on comfort management, comfort is applied in improving the quality of life of patients by a team of healthcare specialists and professionals (such as nurses) who work together to deliver alleviative care to patients. Many chronic conditions require extensive comfort to reduce suffering experienced due to various symptoms (e.g., pain, difficult breathing, and fatigue). Of these symptoms, pain is the most serious and a pain control is a top priority in comfort management. Thus, the objective of this paper is to review Kolcaba’s Comfort Theory and related theories concerning pain control in comfort management, that is, in the context of the nursing meta-paradigm of health. Further, the paper develops evidence-based guidelines to address pain in palliative care using perspectives from various theorists.
Personal Nursing Meta-paradigm
In nursing theory and practice, part of a nurse’s reflective experiences include an understanding and application of the meta-paradigms or the general concepts that define nursing in the context of comfort management among terminally ill patients. These meta-paradigms include concepts such as person or client, environment, health, and nursing that are central to nursing meta-paradigm (Swanson, 1991).
First, the person refers to the client receiving nursing care, which includes families, groups, or communities who are affected by the care that is provided to the patient. The clients for cancer pain management are the cancer patients, but nurses deliver care as an integral element of nursing that is provided to all patients to promote optimum recovery. Further, considering that each individual carries their own unique sentiment and may have similar disease attributes, each patient should be treated as an individual and not as the disease. Based on Benner’s theory (Altmann, 2007; Benner & Wrubel, 1989), human beings should be viewed as open energy field with unique life experiences and their needs should be tailored to individual needs and not from a generic care plan. For instance, as an Eating Disorder Nurse Specialist in my present organization, after a patient refuses two oral foods, normal protocol calls for Nasal Gastric tube placement, which may involve using two or four point restraint for noncompliance. However, there are occasions that a customized protocol must be implemented. For example, I had a Patient A, who refused two oral foods but after seeking a doctor’s order for both the nasal gastric tube placement and a restraint order; I was unable to pursue the procedure because Patient A would have been physically more compromised due to her physically frail body. Thus her care plan was customized to meet the patient’s needs by giving her oral supplements as tolerated.
Second, the environment refers to the internal and external surroundings of the client where there social experiences occur depending on people’s geographical area, cultural and religious values, society, and expectations. The expectations of cancer patients on comfort or palliative care are relief from symptoms such as pain in order to improve the quality of life and reduce suffering. To promote optimal wellness, an individual’s environment should not be neglected. For instance, one of the biggest concerns in the hospital is Nosocomial infection, while a nurse’s role is to care for the patient; we must also ensure proper hand-washing protocol and cleaning of equipment are observed to prevent the spread of gems. Oftentimes, it is easy to focus on caring for the patient at the expensive neglect of the environment, such as, not observing hand-washing protocol before and after patient care.
Third, health is a patient’s dynamical view of wellness. Illnesses result from loss of functions and negative lived experiences that lower a person’s perception of health. Cancer patients who suffer from pain have reduced quality of life; thus, the need for comfort. As a nurse, I work with patients that are financially secure, living in their beautiful American dream homes. However due to their mental illness, they are unable to forge ahead and enjoy every aspect of life. Nevertheless, patients’ overall wellness should always be taken into consideration.
Fourth, the goal of nursing is to deliver quality health services to patients. Nursing practice can leverage the environment to improve patient wellbeing. For instance, nurses provide culturally acceptable interventions to provide comfort or alleviate pain among cancer patients, offer societal support to improve emotional wellbeing, use of religious values to enhance the life experiences of cancer patients, and other comfort or palliative care techniques. Nurses act autonomously or in interdisciplinary teams and use evidence to deliver acceptable health services. Nurses plan the palliative care or comforts offered to cancer patient and implement the pain (comfort) management interventions. Thus, nursing and caring are so intertwined, which is the core of my practice. Although, medicinal treatment alone may achieve healing — frail patients, and those suffering from chronic diseases require physical assistance and nursing care. They should not be left to personally care for themselves but rather it is critical to utilize nursing and caring practice for optimal recovery. Caring is primary, because caring sets up the possibility of “giving help and receiving help” (Benner & Wrubel, 1989, p.4).
Kolcaba’s Comfort Theory
Health and medical care specialists and professionals, such as nurses, offer quality comfort management to improve patients’ health outcome, quality of life, satisfaction and experience. They promote patients’ comfort through appropriate care where concern, empathy, or compassion is shared to them (in this case, among patients who have serious illness such as cancer) (Swanson, 1991). As such, it is through caring that nursing derives its uniqueness and contributes significantly to healthcare (Altmann, 2007; Benner & Wrunbel, 1989). Such attributes formed the core reason why I pursue nursing as a career because it afforded to me the opportunity to share my compassion towards people, families, and communities.
Katharine Kolcaba’s Theory of Comfort “provides a foundational and holistic approach to comfort management” that is critical in meeting the needs of seriously ill patients (Wilson & Kolcaba, 2004, p. 164). Initiallly, Kolcaba (2003) assumed that patients have holistic responses to sophisticated stimuli, comfort is a wanted holistic outcome, and people try to attain their comfort needs or have their comfort needs satisfied. Nurses evaluate the comfort needs of patients and implement different interventions to satisfy the needs. Moreover, meeting the comfort needs strengthens the patient and improves health outcome (Wilson & Kolcaba, 2004).
Further, Kolcaba (2003) believed that patients experience comfort in different forms including relief, ease, and transcendence within the different comfort context (e.g., physical, environmental, sociocultural and psycho-spiritual contentment. First, patients can experience comfort by getting relief. For instance, patients in pain receive relief comfort by taking pain medications (Wilson & Kolcaba, 2004). Second, patients experience comfort in the sense of ease if their anxieties are eliminated. In this case, nurses address issues causing anxiety. Ease describes comfort in a state of contentment. Third, in transcendence, patients are able to overcome their challenges. Similarly, she identified diverse contexts in which comfort consists of physical, environmental, sociocultural and psycho-spiritual contentment (Kolcaba, 2003). Concisely, patients experience comfort when their comfort needs are met. Hence, the comfort theory, as applied in patient care, transformed care offered to patients.
Despite the universality of Comfort theory (that is, given that is is simple enough and easily understood to guide practice), it is limited in scope and has a lower level of abstraction as it is a middle range theory (Katharine, 2006; Kristen & Swanson, 1991)). Middle range theories are not wider in scope like grand nursing theories. Middle range theories provide an effective link between grand nursing theory and nursing practice. Middle range theories describe propositions and nursing concepts at a lower level of abstraction and are useful in nursing practice. Middle range theories have less concepts and relationships. The theories are developed from different sources and can be tested. Comfort theory can be considered a middle range theory as Kolcaba has clearly defined the concepts and their relationship. The concepts can be generalized and measured by developing measurement tools. Comfort theory has been applied in different areas including peri-operative, hospice, end of life care and pediatric care. As such, since it was developed by Kolcaba in the 1990s, its effectiveness has already been chronicled in various peer reviewed journals hitherto (Kolcaba, 2010).
Other than Kolcaba’s Comfort Theory, Patricia Benner also ranks caring as the most pivotal aspects of all the nursing. Benner and Wrubel (1989), like Nodding, propose that caring is central to assessing and intervening on behalf of another. They emphasized on client centered approach and the importance of clients utilizing coping skills. Similarly, Alliwood and Tomey (2010) also focuses on person as the drive of nursing practice. Furthermore, Olga Jarrin (2012) concurred with Florence Nightingale’s statement that nature alone heals and that the role of nursing is to put the patient in the best environment. While environment is an important aspect of patient care, reflecting back to my previous example of prevention of nosocomial infection, there has been more emphasis on treating patient as a whole, not as an entity.
Clinical Issue
This paper evaluates pain control in palliative care with a focus on cancer patients. The author selected pain control among cancer patients because it is a common problem in nursing practice. Pain is a major cause of hospital visits since it causes discomfort and disrupts everyday activities. Deandrea et al. (2008) assert that while cancer pain is a common complaint among cancer patients, the pain is often undertreated. Under-treating cancer pain can result from misdiagnosis of pain or lack of effective evidence-based pain control guidelines. Under-treating cancer pain represents missed nursing care and results in suffering and lower quality of life among patients. Uncontrolled pain can create a sense of helplessness and anxiety-causing depression in cancer patients. Practice nurse can improve the quality of care offered to cancer patients by developing and implementing pain management guidelines. Cancer patients experience pain either from the disease pathology or from curative interventions such as radiation therapy, chemotherapy, and surgery. The pain can range from mild to severe and can be constant or intermittent. Therefore, effective cancer-pain management guidelines should differentiate different levels of pain in order to provide patient-centric nursing services rather than adopting a one-size-fits-all intervention.
Evidence-Based Guideline
Cancer pain is a cause of suffering for cancer patients and comfort management or pain alleviation should be the priority in the strategies adopted for palliative care (Brawley, Smith & Kirch, 2009). Pain assessment using comfort management is the first step in the management of cancer pain considering that assessing comfort as a holistic patient outcome is valuable for measuring the effectiveness of various comforting strategies (Kolcaba & Dimarco, 2005). The application of Kolcaba’s Comfort Theory (that is, concerning the various comfort forms, contexts and related concepts) are adopted as useful pain assessment tool for a comprehensive measures of pain intensity, frequency of pain, distribution of pain, breakthrough pain, pain precipitating factors, and the history of use of analgesics. During pain assessment, nurses should combine the questions with direct observation in order to have a comprehensive assessment.
In line with Kolcaba’s theory, the American Pain Society recommends the use of the World Health Organization’s ladder for cancer pain as an inexpensive and effective strategy for the management of cancer pain (Gordon et al., 2005). Patients with mild and intermittent pain should be administered non-opioid-based pain suppressors, such as aspirin, paracetamol, ibuprofen and acetaminophen. Patients with persistent mild pain should use mild opioids, such as codeine; while those with severe pain should use stronger opioids such as morphine. Careceni et al. (2012) support the use of opioid analgesics in the treatment of cancer pain because opioids are effective and have mild side effects on cancer patients.
In addition to the pharmacological interventions, there are other interventions that practice nurses can use to administer comfort management strategies to palliate cancer patients. Hormone therapies, such as anti-androgen therapy for prostate cancer and anti-oestrogen drugs in breast cancer patients, are effective in controlling metastatic pain and improving the patients’ quality of life (Portenoy, 2011). Additionally, alternative therapies including acupuncture, physiotherapy, herbal medicines, psychotherapy, homeotherapy, and massage are effective in controlling pain in cancer patients to mitigate the impact of pain in cancer patients.
Implications for Practice
Kolcaba’s Comfort Theory meets the criteria set forth by Chinn and Kramer’s criteria for evaluating and analyzing a nursing theory. There criteria are clarity, generality, simplicity and empirical precision (Katharine, 2006; Peterson & Bredow, 2009). As it is used in the pain management of cancer patients, that is, since the comfort is the goal of nursing, Kolcaba’s theory is simple and can be understood by health professionals (Katharine, 2006; Novak, Kolcaba, Steiner, & Dowd, 2001; Peterson & Bredow, 2009). Further, the comfort theory has been tested using empirical data since Kolcaba has developed instruments for testing the theory (Peterson & Bredow, 2009). Questionnaires were used in gathering data to measure a patient’s comfort. Data collected were analyzed in determining the patient’s comfort. Kolcaba also developed a multiple questionnaire to measure a patient’s comfort. The questionnaire aids nurses visualize comfort in a holistic way. The questionnaire has three forms of comfort and four contexts (Kolcaba, 2003). The questionnaire ensures the comfort needs are assessed and nurses can compare score before and after implementing the intervention.
Kolcaba was able to clearly defined the nursing concepts and shown the relationship between different concepts. Kolcaba stated how the diverse forms of comfort including relief, ease, and transcendence can be achieved. In relief, nurses give patients pain medications to relieve pain and ensure they are comfortable. Also, they implement interventions to eliminate problems causing anxiety and enable patients overcome their challenges. Kolcaba believes comfort is holistic and thus the three types of comfort. She differentiates comfort from anxiety, pain and other kinds of physical discomforts. She views comfort positively and believes comfort does not entail total deficiency of discomfort (Kolcaba, 2003). Kolcaba believes pain hinders patients from being comfortable.
Furthermore, Kolcaba defined patients as families, communities and individuals who need healthcare (2003). The environment refers to aspects of the family, community, patient and institution that nurses can modify to improve comfort. Health is the optimal functioning of the client as stated by the client, family and community. Nursing refers to the process of assessing the comfort needs of a patient, developing and implementing suitable care plans. Nursing also entails assessing the patient’s comfort after implementing the care plan (Kolcaba, 2003). Other concepts defined are health seeking behavior, institutional integrity, health care needs and best policies. Health seeking behaviors refers to a patient’s actions which lead to improved health. The different types of comfort can occur in the four contexts, namely: physical, environmental, sociocultural and psychospiritual (Kolcaba, 2003; Krinsky, Murillo, & Johnson, 2014).
In applying Kolcaba’s Comfort Theory in healthcare practice, health professionals can easily comprehend the relationship between the comfort management concepts. Because of the theory’s simplicity, it is applied to patient care. Comfort care is considered intuitive as individuals are familiar with their comfort. Thus, the comfort theory states why and the need to be satisfied and how it should be offered. Additionally, the comfort theory can be generalized. The theory has been studied and researched in different patient settings including pediatric, hospice, end of life and advanced directives. The theory is useful in transforming care offered to patients in different patient settings. The comfort theory offers a clear framework that nurses can utilize to meet patient needs. Nurses determine patient needs within the four contexts and implement interventions to satisfy the needs (Kolcaba, 2003). They evaluate nursing interventions to determine whether they are successful or not and make suitable changes. Therefore, nurses have found the theory useful in meeting the diverse comfort needs of patients.
Conclusion
Comfort management is an important part of the comfort management or palliative care offered to cancer patients. When delivering quality palliative care, nurses must integrate all nursing meta-paradigms such as human being, health, environment, learning, and nursing practice to deliver acceptable services and to include the family in care delivery. Practice nurses offering comfort management or palliative care to manage cancer pains should base interventions on efficacy, safety, and acceptability to the patient. Current evidence supports the continued use of opioid-based analgesics in the management of cancer pain. There are other interventions, including hormone therapy, surgery, physical therapy, and acupuncture, that nurses can include in the pain management plan in order to make the care offered acceptable to the patient by meeting the particular needs of the patients. Thus, the Kolcaba’s Comfort Theory is critical in providing comfort care to patients. Comfort is vital to improve health outcome, functioning and leads to satisfaction. Nurses should identify the comfort needs of patients and implement interventions to meet them. Nurses should be aware of the different forms of comfort including relief, ease and transcendence to offer quality care to patients. Comfort theory is applicable in other nursing areas, such as end of life, pediatric, hospice, peri-operative among others as it is simple and can be generalized. Kolcaba has clearly defined the concepts and their relationships and nurses can easily comprehend the theory. Nurses can assess a patient’s comfort by collecting data using questionnaires. Finally, comfort theory is the key to transforming patient care.
References
Alligood, M. & Tomey, A. (2010). Nursing theorists and their work (7th ed.). St. Louis, MO: Mosby/Elsevier.
Altmann, T. (2007). An evaluation of the seminal work of Benner & Wrubel: Theory and Philosophy? Contemporary Nurse, 25(1-2), 114-123.
Benner, P, & Wrubel A., (1989). An evaluation of the seminal work of Benner & Wrubel: Theory and Philosophy? In Altmann, T. (2007) Contemporary Nurse, 25(1-2), 114-123.
Brawley, O., Smith, D., & Kirch, R. (2009). Taking action to ease suffering: advancing cancer pain control as a health care priority. CA: a cancer journal for clinicians, 59(5), 285-289.
Caraceni, A., Hanks, G., Kaasa, S., Bennett, M. I., Brunelli, C., Cherny, N., & Zeppetella, G. (2012). Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC. The lancet oncology, 13(2), e58-e68.
Deandrea, S., Montanari, M., Moja, L., & Apolone, G. (2008). Prevalence of undertreatment in cancer pain. A review of published literature. Annals of Oncology, mdn419.
Gordon, D., Dahl, J., Miaskowski, C., McCarberg, B., Todd, K., Paice, J., & Carr, D. (2005). American pain society recommendations for improving the quality of acute and cancer pain management: American Pain Society Quality of Care Task Force. Archives of Internal Medicine, 165(14), 1574-1580.
Jarrin, O. (2012). The Integrality of Situated Caring in Nursing an the Environment: Center for health and policy, 13(1-2), 200-212.
Katharine, K. (2006). Comfort Theory: A Unifying Framework to Enhance the Practice Environment. Journal of Nursing Administration, 36(11), 538-544.
Kolcaba, K. (2003). Comfort theory and practice: A vision for holistic health care and research. New York: Springer Publishing Company.
Kolcaba, K. (2010). Comfort Theory. Retrieved from The Comfort Line: http://www.thecomfortline.com/theory.html
Kolcaba, K., & Dimarco, M. A. (2005). Comfort Theory and Its Application to Pediatric Nursing. Pediatric Nursing, 31(3), 187-194.
Krinsky, R., Murillo, I., & Johnson, J. (2014). A practical application of Katharine Kolcaba's comfort theory to cardiac patients. Applied Nursing Research: ANR, 27(2), 147-150. doi:10.1016/j.apnr.2014.02.004
Kristen, M. & Swanson, C. (1991). Empirical Development of A Middle Range Theory of Caring. Journal of Advanced Nursing, 40(1-3)
Novak, B., Kolcaba, K., Steiner, R., & Dowd, T. (2001). Measuring comfort in caregivers and patients during late end-of-life care. The American Journal of Hospice & Palliative Care, 18(3), 170-180.
Peterson, S. & Bredow, T. (2009). Middle range theories: Application to nursing research. Philadephia: Lippincott Williams & Wilkins.
Portenoy, R. (2011). Treatment of cancer pain. The Lancet, 377(9784), 2236-2247.
Swanson, K. (1991). Empirical development of a middle range theory of caring. Nursing Research, 40(3), 161-166.
Wilson, L., & Kolcaba, K. (2004). Practical Application of Comfort Theory in the Perianesthesia Setting. Journal of Perianesthesia Nursing, 164-173. Retrieved September 29, 2014, from http://www.ncbi.nlm.nih.gov/pubmed/15195275
