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Revista Brasileira de Enfermagem

Print version ISSN 0034-7167On-line version ISSN 1984-0446

Rev. Bras. Enferm. vol.70 no.4 Brasília July/Aug. 2017

http://dx.doi.org/10.1590/0034-7167-2016-0636 

RESEARCH

Geriatric care: ways and means of providing comfort

El cuidado geriátrico: maneras y formas de confort

Patricia Cruz Pontifice Sousa Valente RibeiroI 

Rita Margarida Dourado MarquesII 

Marta Pontifice RibeiroIII 

IUniversidade Católica Portuguesa, Institute of Health Sciences. Lisbon, Portugal.

IICentro Hospitalar Lisboa Norte, Intensive Care Unit. Lisbon, Portugal.

IIIUniversidade Nova de Lisboa, Medical Sciences College. Lisbon, Portugal.


ABSTRACT

Objective:

To know the ways and means of comfort perceived by the older adults hospitalized in a medical service.

Method:

Ethnographic study with a qualitative approach. We conducted semi-structured interviews with 22 older adults and participant observation of care situations.

Results:

The ways and means of providing comfort are centered on strategies for promoting care mobilized by nurses and recognized by patients(clarifying/informing, positive interaction/communication, music therapy, touch, smile, unconditional presence, empathy/proximity relationship, integrating the older adult or the family as partner in the care, relief of discomfort through massage/mobilization/therapy) and on particular moments of comfort (the first contact, the moment of personal hygiene, and the visit of the family), which constitute the foundation of care/comfort.

Final considerations:

Geriatric care is built on the relationship that is established and complete with meaning, and is based on the meeting/interaction between the actors under the influence of the context in which they are inserted. The different ways and means of providing comfort aim to facilitate/increase care, relieve discomfort and/or invest in potential comfort.

Descriptors: Geriatric Nursing; Aged; Hospitalization; Delivery of Health Care; Hospice Care

RESUMEN

Objetivo:

Conocer los modos y las formas de confortar percibidas por adultos mayores hospitalizados en un centro hospitalario.

Método:

Se trata de un estudio etnográfico de abordaje cualitativo. Se realizaron entrevistas semiestructuradas entre 22 mayores enfermos con observación participante en las situaciones de cuidados.

Resultados:

Las maneras y formas de consolar se concentran en estrategias promotoras de conforto movilizadas por el enfermero y reconocidas por los enfermos (información/aclaración, interacción/comunicación positiva, toque, sonrisa, presencia incondicional, integración del adulto mayor/familia en los cuidados y el alivio de malestares mediante masaje/movilización/terapéutica) en momentos particulares de conforto (primer contacto, visita de la familia, aseo y cuidados personales), que se constituyen en la base del cuidar/cuidado confortador.

Consideraciones finales:

El cuidado geriátrico se cimenta en la relación edificada con sentido y se fortalece durante el encuentro/interacción entre los actores en el contexto en que están insertados. Las diferentes maneras y formas de confortar tienen como objetivo facilitar/aumentar el consuelo, aliviar el malestar y/o invertir en el cuidado prolífico.

Descriptores: Enfermería Geriátrica; Adulto Mayor; Hospitalización; Cuidados; Promoción del Conforto

RESUMO

Objetivo:

Conhecer os modos e formas de confortar percecionadas pelos idosos hospitalizados num serviço de medicina.

Método:

Estudo etnográfico com abordagem qualitativa. Realizamos entrevistas semiestruturadas com 22 doentes idosos e observação participante nas situações de cuidados.

Resultados:

Os modos e formas de confortar centram-se em estratégias promotoras de conforto mobilizadas pelo enfermeiro e reconhecidas pelos doentes (informação/esclarecimento, interação/comunicação positiva, toque, sorriso, presença incondicional, integração do idoso/família nos cuidados e o alívio de desconfortos através da massagem/mobilização/terapêutica) e em momentos particulares de conforto (contato inaugural, visita da família., cuidados de higiene e arranjo pessoal), que se constituem como alicerces do cuidar/cuidado confortador.

Considerações finais:

O cuidado geriátrico edifica-se na relação que se desenvolve, atribuída de sentido, e assenta-se num encontro/interação entre os atores sob influência do contexto em que está inserido. Os diferentes modos e formas de confortar objetivam facilitar/aumentar o conforto, aliviar o desconforto e/ou investir no conforto potencial.

Descritores: Enfermagem Geriátrica; Idoso; Hospitalização; Cuidados; Promoção do Conforto

INTRODUCTION

The world population is going through an ageing process, especially in Europe(1). Portugal is no exception from this worldwide trend. This dynamic is a consequence of the decline in birth rates and increase in life expectancy, a process understood internationally as one of the most important demographic trends of the 21st century(2). In 2013, Portugal was the fifth of 28 European countries as the highest old age dependency ratio(2-3).

In any situation of illness with hospitalization, the frail old adult is highlighted, which may cause the appearance or aggravation of health needs and lead to a greater susceptibility to suffering and an increase of discomfort. These circumstances lead to greater vulnerability of older adults, indicating the need of an adequacy of the care provided. People are at the center of the action, facing the daily challenge of broadening their knowledge and defining strategies to provide a flexible care, adapted to their needs(4). This care must be systematized and individualized, in order to promote health(5), maintain and recover their abilities, providing them means to better withstand the moments of discomfort.

Comfort is an important concept and a fundamental value of nursing(6-7). It is a key component for providing nursing care to older adults(8).

Providing comfort is a complex act that goes beyond assuring pain relief and feeding. It also includes paying attention to manifestations of stress, taking into account all dimensions of the human being and providing measures to alleviate suffering(4,9).

Kolcaba considers comfort as a basic need of the human being and "an essential outcome for health care [...] a holistic and complex state [...]"(10), resulting from nursing interventions. The author defines comfort as "the immediate experience of being strengthened by having needs for relief, ease and transcendence met in four contexts (physical, psycho-spiritual, sociocultural, and environmental)"(10). Care, in order to be comforting, has to be centered on the person, attending to individual particularities and needs. This makes it, however, complex, provisional, non-specific, circumstantial, paradoxical, integrative, engaged and individualized(4).

Comfort is promoted through nursing interventions. Comfort is a component of care and a competence of the nurse, and understanding the ways and means of providing comfort to the hospitalized older adults is very important(4).

In the practice of geriatric care, situations of comfort are individualized interventions/strategies, aiming to attend the needs presented by each patient or, also, to provide particular moments of comfort, which are considered a desired outcome of the ways and means of comfort(4). The ways and means of providing comfort are within what stimulates, strengthens and contributes to maintaining and recovering existing abilities, thus allowing the older adult to better withstand the moments of discomfort(4).

Therefore, understanding the meaning of comfort is essential, as well as ways and means of providing comfort, in order to delineate effective interventions to promote comfort. It is only through research that one can provide a state of the art healthcare, effectively including comfort in the care provided(6,11).

OBJECTIVE

The objective of this study was to know the ways and means of providing comfort perceived by older adults hospitalized in a medical service.

METHOD

Ethical aspects

Regarding formal procedures and ethical aspects, before we started data collection, we followed some steps to carry out the study in the chosen institution. Authorizations from the Board of Directors and the Research Ethics Committee of the Institution were requested, making the first contact with the context of the study. The participants signed an Informed Consent Form and their anonymity was ensured. The interviews were conducted in a private space and the names were replaced by the letters Id, followed by numbers that corresponded to the sequence of interviews (Id1, Id2, etc.). The observations were carried out in a progressive approach, starting from a general descriptive observation and then carrying a focused and more selective observation, without identifying the participants and coding the observations with the letters Op, followed by numbers that corresponded to the sequences (Op1, Op2, etc.).

Theoretical and methodological framework and type of study

This is an ethnographic study with a qualitative approach, based on the theoretical framework of Miles and Huberman(12). To understand a particular phenomenon in a micro-social situation and based on interpretation and reconstruction of reality, the researcher used participant observation and a semi-structured audio taped interview to capture the meanings given by the older adults to their experiences and practices. The aim was to describe a concrete reality, without pretending to reach universal validity or make generalizations independent of the context, which justifies the use of this framework in this study(12).

Methodological procedure

We conducted semi-structured interviews with the older adults, based on a script that was submitted to a pre-test in other older adults who were not included in our study. We aimed to test the clarity and understanding of questions related to meaningful experiences during hospitalization and to the moments/situations of care related to the concept of comfort - the actions/interventions that promote comfort and pleasant moments/situations of comfort and well-being. At the same time, in order to better understand the meanings attributed to the ways and means of comfort, the participant observation was guided by a script directed at the moments in which the nurses cared for the older adult. The observation was focused on any nursing intervention that occurred with (or for) the older adult, making detailed observations of certain situations and collecting, recording and interpreting data through participation in the group life, which confirmed the data collected. The guiding scripts were discussed with two judges in order to ensure their validity.

Study scenario

Based on the objective of the research, a medical inpatient service at a Central Hospital in Lisbon was chosen as the setting of the study. For the selection of the participants, the non-probabilistic sampling technique was used, with the following inclusion criteria: having a chronic illness; being sixty-five years old or older; being able to answer the questions orally; giving consent to participate in the study. Regarding the observation, we sought to enter to the social world of the actors in the events and situations that have occurred over time.

Data source

Twenty-two older adults with chronic disease admitted to a medical inpatient service at a Central Hospital in Lisbon participated in the study. The participants met the following criteria: (i) being 65 years old or older; (ii) being aware and oriented or able to answer orally and produce a coherent discourse; (iii) faced hospitalization at any stage of their chronic illness, especially due to acute illness; (iii) accepted to participate in the study, sharing their experience of "comfort", the aspect that was carefully analyzed. The selection of participants was made by the researchers, with the collaboration of the nurses during their working shifts, with the concern of checking the availability of each patient through an initial dialogue. Regarding the state of consciousness and the ability to respond orally, we asked nurses to help us solve any doubts. The final size and composition of the sample was determined by data saturation, justified by the abundance of individual experiences, repetition of information or field saturation, in which new information confirmed the previous ones and did not objectively add new data(13).

Data collection and organization

The data collected through the interviews and the reports of the observations were based on the recommendations of Miles and Huberman(12). We observed and documented the actions developed, describing them and their context. Then, we recorded the reflection on the descriptions in relation to the categories that emerged. The interviews were recorded and transcribed and the data collection instrument contained questions related to the characteristics of the participants and open questions addressing the situations of comfort care, specially the strategies used by the nurses to promote comfort and particular moments of comfort. We developed a categorization system with all the data with the purpose of selecting, grouping, simplifying and transforming the data for the analysis.

Data analysis

Regarding the treatment, the qualitative data were analyzed by the method of thematic content analysis(12-13). We organized and systematized the data to conduct its codification, systematic comparison and analysis, aiming to find similarities, relations and differences, bearing in mind the definition of sentences that could constitute units of meanings. The meanings found were grouped in a thematic unit, in a specific domain that encompassed two categories from which subcategories arose. The arrangement elucidated the care situations that promoted comfort, their characteristics and the relationship between them.

RESULTS

Twenty-two elderly patients participated in the study. Most participants were female (68.2%), aged 65-90 years (mean 76.6 years and standard deviation 3.81). All the participants presented multiple pathologies, were conscious and oriented and had had more than one hospitalization.

We addressed the situations that represented comfort, considering the variety of their nature, assessing specifically the activities nurses performed with the elderly and the meaning attributed to them. The situations considered as comforting were identified along with other particular situations/moments of comfort experienced by the different participants. Based on the reports and findings observed, the situations of comfort care are encountered in strategies that promote comfort, carried out by the nurse at particular moments.

Data analysis led to the establishment of two central categories: comforting strategies (C1) and particular moments of comfort (C2).

Among comforting strategies, nine (9) sub-categories emerged: clarifying/informing (C1-Sc1); positive interaction/communication (C1-Sc2), music therapy (C1-Sc3), touch (C1-Sc4), smile (C1-Sc5), unconditional presence (C1-Sc6), the empathy/proximity relationship (C1-Sc7), integrating the elder or the family as partner in the care (C1-Sc8), relief of discomfort through massage/mobilization/therapy (C1-Sc9).

In the particular moments of comfort, three (3) sub-categories emerged: the first contact (C2-Sc1), the moment of personal hygiene and grooming (C2-Sc2) and the visit of the family (C2-Sc3).

In the particular moments of comfort, three (3) sub-categories emerged: the first contact (C2-Sc1), the moment of personal hygiene and grooming (C2-Sc2) and the visit of the family (C2-Sc3).

Chart 1 Comforting strategies (C1) 

C1-Sc1 -Clarifying/informing:
[...] when they explain things to us, it's satisfying... it is comforting! (Id2)
[...] I've been on IV and faced problems [...] , the nurses explain everything to me...I like that! [...] when they explain stuff, it is fulfilling... it is comforting! (Id3)
They explain things [the nurses] they explain clearly so I can know what is happening to me! This is important. I get calmer! (Id17)
C1-Sc2 - Positive interaction/communication:
[...] when I need, the nurses come and talk to me… I feel good, it really comforts me... it comforts me. (Id6)
C1-Sc3 - Music therapy:
Music is very good to us... it helps us overcome and it warms the heart... in fact, it comforts us. (Id11)
C1-Sc4 - Touch:
Touching is comforting... I assure you. (Id7)
They don't even have to talk ... just touch ... it's worth a lot! (Id 20)
Observation on the nurse who administered the medication. Leaning on the patient, he took his hand and asked: «Do you still have back pain?» the patient replied: «I still have a little» The nurse kept holding the patient's hand, making soft gestures: «I will see what I can give you». He let go of the patient's hand and walked away.(Op1)
C1-Sc5 - The smile:
[...] There are nurses here who are wonderful, their smile comforts us... (Id4)
The nurse goes to the patient who is waiting to be called for the installation of a new access for hemodialysis. Showing a smile, he said to the patient: «It's time to go! It must be...» the patient answered: «All right, sir, with this smile I can't even say no...».(Op2)
C1-Sc6 - Unconditional presence:
[...] the nurses are always here... it is good... it comforts us. (Id1)
They are constantly here...the nurses... their presence makes us feel good! It is unconditional. (Id14)
Sometimes there's nothing to say… just being there is enough. (Id 18)
[...] they are very present, [the nurses], very present... that's good! You know...comfort is this... Being always present...!(Id10)
C1-Sc7 - The empathy/proximity relationship:
Here, my nurse is attentive to my needs and tries to understand my concerns and what I need to handle this situation better...it really comforts me. (Id6)
The presence of a nurse, close to the patients, to listen to us[...] to see our side... I recognize that this is very important for our comfort.(Id21)
C1-Sc8 - Integrating the older adult or the family as partner in the care :
During the period of hygiene the nurse explains to the patient the importance of being without a diaper and trying to go to the bathroom. The patient was grateful for the suggestion. (Op3)
C1-Sc8 - Integrating the older adult or the family as partner in the care :
It was about ten o'clock in the morning. The nurse approached the 73-year-old who was bedridden. The patient was conscious, but with mobility limitations on the left side. The bowl with the meal was on the bedside table, left by the assistant. «Shall we eat? » asked the nurse. The patient nodded in agreement. The nurse places the patient in an adequate position and asks «Do you want me to help? » the patient again nods his head agreeing. The nurse begins the procedure. The nurse feeds the patient and asks: «So you like it? Are you liking it? ». The older adult swallows slowly, with difficulty. With a serene, calm attitude, the nurse waits for the patient to eat at his pace.(Op4)
C1-Sc9 - Relief of discomfort through massage/mobilization/therapy:
[The nurses] massage the backs and legs... because of the pain [...]. (Id1)
They relieve my pain... they turn me over! That's it! (Id7)
They [nurses] , try to relieve everything [...] this relief makes me feel good... they relieve the pain [...] massaging my the body! (Id8)
During the afternoon and evening, the care they give us is care that brings comfort. (Id9)
It's early in the evening shift. The nurse approaches an older adult who is bedridden and aphasic, but who moans. Slightly inclined over the old man, he asks in a quiet voice: «So, what's going on?». The patient moans again. The nurse touches the patient's face and adds: «Let's see what's going on. Are you tired of being in this position? We will turn you over». The patient looks at the nurse, seeming to agree. The nurse begins to move the older adult and notices that the bed is wet and says: «In fact, you are right. It 's all wet! You must be very uncomfortable...Let ›s change it all and you ›ll see it will get better » Turning to the older adult patient again, he says: «Let 's make you comfortable! ». (Op4)

Chart 2 Particular moments of comfort (C2) 

C2-Sc1 - The first contact:
When I arrived, it was the nurse who received me and brought me to this room ... and explained things to me at that time ... you know, the nurse was very tender to me and that's really memorable for us [...] . (Id5)
[...] the welcoming is very important ... it comforts us. (Id7)
When I arrived, that nurse, who is a sweetheart, came... she is very friendly and nice. She asked me if I wanted another blanket or if I wanted to eat something...(Id19)
C2-Sc2 - The moment of personal hygiene and grooming:
[...] hygiene is very important... it provides a lot of comfort... In the beginning, the nurses bathed me in bed, they washed my head, brushed my hair, put on cream and I was all set. Now I go to the shower and I like it even more...I really like it, really really. (Id1)
Even here, bathing in the bed is good to me ... it's wonderful ... they always close the door so there is more privacy. (Id2)
The moment the nurses bathe me... oh... you can't imagine how good I feel! (Id16)
The bath in here... you don't even know! I think it's worth everything... it's a moment of extreme comfort.(Id21)
C2-Sc3 - The visit of the family:
The moment is important... the presence of the visits... it is necessary... it comforts. (Id2)
[Our family] helps a lot...the visit of my family is our bit of comfort. (Id1)
A brother-in-law and a sister come visit, the relatives I still have, and it is a moment I really want and that comforts us. (Id8)
The visit gives me strength and encouragement... it comforts me.(Id21)

DISCUSSION

The data found on the ways and means of providing comfort value the uniqueness of the Person and the respect for the identity of the older adults, showing that the nurses provide comforting actions based on values and principles of the profession. Providing a comfort care implies in establishing with the patient a relationship based on humanization, through an encounter that can lead to informed decision-making, allowing the patient to have some control on his own life situation. In the encounter between the older adult and the nurse, despite the limitations that the hospital environment can pose, a series of human and professional qualities that contribute to a comforting relationship can be found. In the ways and means of providing comfort, professional knowledge is important and contains certain tools. Among them, the means that stands out is the way to live the relationship as an intersubjective, interpersonal and reciprocal process, combining the expressions of gestures and affections that show the human behavior of the actors, in general, and of the nurse, in particular.

Within the scope of the structure geriatric care, clarifying/informing appears as the main factor for the older adult to understand and decide their treatment, and it is a decisive and comforting intervention that can put the patient's mind at ease. It is a value associated to human dignity, and it implies the perception that every person is autonomous in decisions concerning themselves and their life(14). It seems important that the patient feels satisfied and comforted by the information and that they find answers to questions and doubts, without any inconsistencies or contradictions. This process is based on knowledge sharing though an open and transparent communication with patients/family members, which is essential for a successful interaction(5). Information management, as a type of intervention that provides comfort, is linked to feelings management. Along with the way information is transmitted and considering its organizing function with the patient/family, this is a strategy for promoting comfort.

The information dimension refers us to positive interaction/communication as a way and means of providing comfort. In order to establish this, there must be an exchange of information and understanding between the actors, with an implicit process of mutual interpretation. The nurse must be attentive not only to words, but also to gestures, expressions and attitudes, as well as desires and the way of thinking and acting of the person. In geriatric care, this form of positive interaction/communication emphasizes the interpersonal relationship and aims, intentionally, to understand the person as a whole, valuing their experiences in the social environment where they are inserted(4). Open and clear communication with patients is fundamental for a successful interaction and for the construction of an adequate communicative dynamic, in which there is harmony between instrumental and behavioral care. Communication, therefore, is the pillar of care/comfort care(5).

This study also showed that music therapy and touching are forms of non-verbal communication that constitute care interventions. Those actions are essential for the establishment of communication and sharing of ideas and emotions, as they convey comfort, affection, well-being, trust, safety and sharing.

In the search for comforting, music therapy is experienced as a strategy of proximity, an invitation to meet the person, a singular moment in which the relationship happens, giving support to the feelings of pleasure and happiness.

In trying to disclose the situations that represent comfort, touching also appears as a powerful form of comfort, which conveys interest and ease the older adult. Touching can show affection, tenderness and protection, and is also a facilitating element in the nurse/patient interaction. It is essential to understand the importance of touch for providing a comforting care, considering all the feelings that the touch involves and represent(15).

The natural display of the smile was another sign of communication that provided comfort, through the warm affection it conveys to the person. Studies show that smile and humor have an effect on the interaction, promoting a therapeutic effect in people who feel depressed or pessimist and also serving as a form of relaxing(16). Based on our observation, we noticed that the smile was often used in the interaction between caregivers and the older adult, as an expression of sympathy, joy or even in situations of greater tension, so that they become lighter.

The presence makes a difference in the experience of the comforting relationship. It is a way of "being there" revealed in the capacity to "be with", and it shows interest, producing a positive change in the patient's state, generating well-being and comfort(4). The unconditional presence along with affective proximity has a considerable importance in the comforting action. In this sense, being silent in the presence of a person is a powerful form of communication, representing in this study a way of showing attention, interest, respect and recognition of the person's needs.

The existence of an empathy/proximity relationship results in coming closer to understanding the older adult's internal reference framework(problems, needs/desires of the older adult), enabling the nurse to construct a path for providing a better adaptation, greater satisfaction and ability to transcend the situation. Without ignoring the concrete circumstances that surround and condition the encounter, the nurse provides a comforting care by listening and supporting with humanity. In addition, they seek a relationship able to provide a greater well-being, a greater state of comfort and, therefore, a greater growth.

The ways and means to provide comfort are also based on an interpersonal relationship, in which the intention to help is shown though interventions capable of providing autonomy and capacity to the older adult, which is related to the patient's decisions/wills/desires.

Maintaining autonomy and capacities is related to the wills and the decisions of the patients. In the context of the study, in which patients are dependent and vulnerable, specific care was taken to maintain their autonomy and responsibility. Stimulating the older adult to perform the activities they are capable of, instead of doing these activities for them, even if it takes longer, it can help the patients to develop their own internal resources and increase their autonomy and self-esteem. Enabling the patients is a way to make them capable of taking care of themselves and of making decisions(17). Based on this idea, nurses use as comfort strategies the participation of the patient in their own care, as well as the involvement and integration of the older adult and the family as partners in the care. The joint actions, negotiated between nurse/older adult/family, increase the patient's comfort, as they are encouraging and allow for an increase in autonomy and internal resources in face of the problems encountered. This strategy transmits a sense of usefulness and promotes an increase in self-esteem. Involving family members in their own actions allows them to feel that they are doing something positive, reinforcing their role in the recovery, well-being, and comfort of the patient.

In the situational context, there is an essential demand for a care focused on the person's real needs. The ways/means of providing comfort also appear in strategies/actions carried out on a day-to-day basis, which aim to satisfy particular needs, either through massage, decubitus change or in the hygiene and grooming care(18). The implicit act of touching, as we have already mentioned, is an important comforting measure, since it is an excellent method of approximation between the nurse and the older adult. In addition, changing the bedding when it is wet and keeping it well stretched, avoiding that the "wrinkles" of the clothing cause discomfort, as well as massaging the patient, are frequent comforting actions in the studied context, which provide a sense of relief from discomfort and a state of comfort(18). The presence and sensation of pain are related to the discomfort and its relief is the immediate objective of the nursing interventions. To do this, pain control is promoted through the administration of therapy, massage and decubitus changes, which are considered providers of comfort and well-being.

In addition to the strategies used by nurses, ways and means of providing comfort also appear in particular moments of comfort, which include the first contact, the moment of hygiene care, grooming and the visit of the family.

The first contact is of utmost importance in seeking for comfort, since it can show availability and kindness, allowing, from the beginning, a greater proximity with the older adult and the family(17). The effect of the care for the older adult is a form of comfort care that facilitates the adaptation to hospitalization, as reported by the older adult, through a constructive relationship established with affection and attention and associated with the psycho spiritual context defined by Katherine Kolcaba. Without ignoring the concrete circumstances that surround and condition the encounter, the first contact is the beginning of the relationship. This moment, recognized as a situation of care, emerges as the first way through which the nurse interacts with the older adult and it is a space for recognizing/evaluating the situation of the older adult/family and a decisive moment for the patient to feel comfortable, confident and safe. It is particularly important to establish a positive relationship and a bond of trust between the nurse and the patient(14). The first contact is, therefore, a relevant bidirectional activity for the construction of the comfort care relationship. Thus, the bond created by the nurse who care for the older adult at the time of the first contact becomes important for a relationship of trust and comfort, established between the actors in the context on which care is developed(15).

The moments of hygiene and grooming care were also valued by the older adult. The study shows that, in addition to providing hygiene, hygiene care and grooming refer the patient to the notion of a good appearance (clothing and other accessories) and provide an image of a body free of pathogenic microorganisms, promoting the sensation of relief and lightness and improving the state of comfort. In fact, bathing is a real act of care in which there is an interrelation between caregiver and care recipient. The periods in which nurses provide hygiene care to the older adults are moments of private interaction appropriate to getting to know the patient better. These periods are reported as important and comforting and allow nurses a moment to establish a more comfortable and intimate contact with the older adult.

In the relationship with other actors that promote comfort, the family/significant person represents for the patient a great help/support associated with the sociocultural context. The moment of the visit, reported as the most important moment of comfort for the patient, is seen as important and considered as a way/means to provide comfort to the patient. The situation of chronic illness and hospitalization is a stage of life that causes a great emotional impact on the patients and their family, and the moment of the visit is an important way of providing comfort to the patient. When present, relatives/significant people try to create a personalized environment, bringing the patient's personal objects, flowers, water, food, among others, which increases the family proximity and affection. In this context, the adoption of affable attitudes by nurses allows a progressive trust and the construction of a comforting relationship between the actors in context. With this understanding, nurses try to establish a helping relationship, given its facilitating and developmental function, implying that they know how to apprehend and recognize what is meaningful for each person, and allowing a greater state of comfort.

Study limitations

Considering these results and aware of the importance of this topic in older adults care area, and given the complexity and specificity of the problems that older adults experience in different contexts, the need to conduct research on the phenomenon in other contexts is evident. Further study with greater extent addressing the ways and means of providing comfort to the older adults and its problematic should be developed. Knowing that each ethnographic study cannot be reproduced, these results can serve as a guide for the construction and consolidation of knowledge about a phenomenon considered noble and associated with nursing interventions.

Contributions to the area of nursing, health or public policy

The results provided the conceptual clarification of the ways and means of providing comfort, with data capable of promoting models of organization of an evidence-based care and with the belief that scientific progress in the area of nursing care knowledge can be crucial for ensuring health care quality. The results clarify the nature of nursing care around the phenomenon of comfort, which may influence the health policy of the country, bringing benefits especially for the older adults. The results contribute to understanding the reality of the older adult and the meanings of the ways and means of providing comfort. This can have an organizing and inspiring effect for questioning and reformulating the principles and practices related to the management of nursing care and human resources, in the current socioeconomic situation. Therefore, we understand that this study can raise questions and originate new investigations that will certainly demonstrate the essence of the nursing intervention.

FINAL CONSIDERATIONS

Placing the older adult at the center of care, the intention of benefiting is the basis of the nurses' action and of their way of being in the relationship and their proximity with the older adult. It is a process made together, in harmony, which implies in an active reciprocity and in the acceptance of the older adult as they are. It seeks to meet, which helps understanding the ways through which each one experiences their problems, manifests their needs and expresses their anxieties and anguishes.

The different ways and means of providing comfort have as their express purpose facilitating/increasing comfort, relieving discomfort and/or investing in potential comfort. This leads the patients to an increased awareness of control over their life and the circumstances experienced, and it helps in the perception of reality and perspective of the future.

The comforting action is replete with meaning. The nurses seek to, at the same time, take care of details and respond to the totality of the person, reaffirming their commitment to alleviate the pain/suffering, to help and to comfort. Therefore, the geriatric caregiving process is built on the relationship that is established and replete with meaning, which constitutes an interpersonal process with therapeutic intention and is valued not only for what is done, but for how it is done.

It is fundamental that the nurse values the particular situations and provides the appropriate intervention. In a process of growth and joint development, the nurse meets the older adult with an attitude focused on their desires, wishes and needs, which guide the comforting intervention.

With an integrality view, the professional tries to find complex answers inherent to the circumstances, respect the preferences of the patients and create an informal space capable of assisting in the readjustment. This implies in the establishment of permanent forms of negotiation, which allows a greater qualification of the person. The decision-making process put into practice and the negotiation/partnership of care with the patient/family are standardized interactions that favor a greater and better comfort.

Within a perspective of an interpersonal context of "acceptance of the older adult" as they are, comforting geriatric care is determined by individuality and flexibility with a holistic approach to the person. It is based on a trustworthy relationship of interest and attention to the comfort needs of the older adult, showing comprehension for the suffering of the older adult and their family.

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Received: December 05, 2016; Accepted: April 07, 2017

CORRESPONDING AUTHOR: Patricia Cruz Pontifice Sousa Valente Ribeiro. Email: patriciapontificesousa@gmail.com

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