COMFORT: THEORETICAL CONTRIBUTION TO NURSING

ABSTRACT

Objective:

The objective of this study is to understand how Kolcaba’s Theory of Comfort has influenced research and clinical practice in nursing through the evolution of the concept.

Development:

This is a study of theoretical nature, resulting from the reading, analysis and reflection of different studies obtained through the literature review conducted in December 2021 in Lisbon, Portugal. The literature evidences the presence of the construct integral to several nursing taxonomies throughout time, and more recently, in several nursing theories. From the conceptual analysis, whatever the theoretical perspective, it is reaffirmed to be a phenomenon of interest, complex and multifaceted.

Conclusion:

It is understood that this reflection allows us to understand the phenomenon of comfort and how this concept has been studied and clarified, affirming its importance for the quality of nursing care.

DESCRIPTORS:
Patient Comfort; Nursing; Nursing Care; Research; Standardized Nursing Terminology.

RESUMO

Objetivo:

o objetivo do estudo é compreender de que forma a Teoria do Conforto de Kolcaba influenciou a investigação e a prática clínica em enfermagem através da evolução do conceito.

Desenvolvimento:

trata-se de um estudo de natureza teórica, resultante da leitura, análise e reflexão de diferentes estudos obtidos por meio da revisão de literatura realizada em dezembro de 2021 em Lisboa, Portugal. A literatura evidencia a presença do construto integrante de várias taxonomias de enfermagem ao longo dos tempos, e mais recentemente, em várias teorias de enfermagem. Da análise conceitual, qualquer que seja a perspectiva teórica, reafirma-se tratar de um fenômeno de interesse, complexo e multifacetado.

Conclusão:

entende-se que esta reflexão permite compreender o fenômeno do conforto e a forma como este conceito tem vindo a ser estudado e clarificado, afirmando a sua importância para a qualidade dos cuidados em enfermagem.

DESCRITORES:
Conforto do Paciente; Enfermagem; Cuidados de Enfermagem; Investigação; Terminologia Padronizada em Enfermagem.

RESUMEN

Objetivo:

el objetivo del estudio es comprender cómo la teoría del confort de Kolcaba ha influido en la investigación y la práctica clínica de la enfermería a través de la evolución del concepto.

Desarrollo:

Se trata de un estudio de carácter teórico, resultado de la lectura, análisis y reflexión de diferentes estudios obtenidos a través de la revisión bibliográfica realizada en diciembre de 2021 en Lisboa, Portugal. La literatura destaca la presencia del constructo integral en varias taxonomías de enfermería a lo largo del tiempo, y más recientemente, en varias teorías de enfermería. Desde el análisis conceptual, independientemente de la perspectiva teórica, se reafirma que se trata de un fenómeno de interés complejo y multifacético.

Conclusión:

se entiende que esta reflexión permite comprender el fenómeno del confort y cómo se ha estudiado y aclarado este concepto, afirmando su importancia para la calidad de los cuidados de enfermería.

DESCRIPTORES:
Comodidad del Paciente; Enfermería; Atención de Enfermería; Investigación; Terminología Normalizada de Enfermería.

INTRODUCTION

Comfort emerges as something inherent and essential to care. It is a concept that has been explored by several authors and appears as a basic human need, as an integral part of nursing care or, still, as one of the desired results of caring for the person¹-². At the center of Nursing care, Comfort as a phenomenon assumes relevant expression in the practice of care, finding its greatest relevance from the perspective of the development and conceptualization of Katherine Kolcaba’s Theory. In this theoretical view, the categorization of comfort in three states emerged: relief, tranquility, and transcendence; and in four distinct contexts: physical, psychospiritual, sociocultural and environmental. The complexity and multidimensionality of comfort require knowledge of the theoretical and philosophical frameworks of care and comfort¹. This phenomenon as a research focus is recognized for its relevance to care practice as a central element in several nursing theories and as a term in professional taxonomies.

Reflections on theoretical concepts in Nursing constitute an important factor for the development of the discipline and profession, delimiting its field of action². Thus, the objective of this study was to understand how Kolcaba’s Comfort Theory influenced nursing research and clinical practice through the evolution of the concept.

DEVELOPMENT

THE EVOLUTION OF THE CONCEPT OF COMFORT IN NURSING

Comfort emerges as a goal in the care provided to the body still in the Middle Ages, as a work of charity and spiritual comfort, and in the 17th to 19th centuries the notion of comfort is changed, following the changes in medicine and hospital structures, in which the focus on the study of the body determines that the nurses’ work on comfort becomes dependent on medical prescriptions¹. It was with Florence Nightingale, in 1859, that comfort appears more clearly, although still in a more physical perspective, demonstrated through expressions such as “the relief and comfort felt by the patient after his skin has been carefully washed and rinsed [...]”³.

In 1995, Mcllveen and Morse grouped the concept in categories, describing its chronological evolution from 1900 until the 1980’s, when, with the advance of technology, comfort was considered only when medical treatment was no longer feasible for the person⁴. It is as of the second half of the 20th century that a greater theoretical development of the concept of comfort emerges, to understand its theoretical meanings, centered in authors such as Ida Orlando, Callista Roy, Hildegard Peplau, Jean Watson, Madeleine Leininger, Josephine Paterson, Loretta Zderad, Janice Morse, and Katharine Kolcaba¹.

For Morse, the focus of the comfort process was limited to nursing actions, but Kolcaba argues that this process only ends with the evaluation of the results of nursing interventions⁵.

In the course of her work as a nurse in an Alzheimer’s care unit, deepening the studies already done by other theoreticians, namely, Ilda Orlando, Henderson, Paterson and Zderad, and Hamilton, Kolcaba⁵-⁶ defines comfort as the immediate experience of being, strengthened by the satisfaction of needs for relief, tranquility, and transcendence, met in four contexts: physical, psychospiritual, sociocultural, and environmental, going far beyond the “[...] absence of pain or other physical discomfort “⁶.

In the comfort types, relief is seen as the condition of a person who has seen a specific need satisfied or a discomfort relieved; tranquility as a state of well-being or contentment; and transcendence as the condition in which a person overcomes his problems and suffering. Regarding contexts, Kolcaba, through holistic theories, defines physical context as the bodily sensations; psychospiritual context as the internal awareness of self, self-esteem, sexuality, and the meaning of life/spirituality; environmental context as the artificial elements of the environment, such as light, noise, temperature, and equipment; finally, sociocultural context is understood as the interpersonal, family, and social relationships⁵,⁷-⁸. These dimensions of comfort emerge for an experience that can be seen as subjective as the perception of meeting and being helped by another human being, which involves physical, psychological, spiritual, social, cultural, and environmental experiences.

The various dimensions that complete the definition of comfort refer on the one hand to the idea of help or support, on the other hand to the subjectively perceived state of one who finds relief, encouragement, or physical and mental satisfaction, freed from difficulty, pain, or anxiety, and in a multidimensional state.

In the relationship with the other, we can notice that some of the comfort measures pass to the condition of preventing, relieving, or reversing a discomfort. However, not always the relief of discomfort takes us to a state of comfort, this can be only partially achieved for a period, demonstrating the need for a constant re-evaluation of the interventions for that individual, family or community.

Comfort is the desirable outcome of nursing care. Morse and colleagues presented a model that mirrors comfort in the relationship and interaction in nursing, which they designated as nursing interventions⁹. In this model, three types of interrelated interventions are identified: comforting strategies; care styles; and relationship patterns or professional behavior. It is in this constant and dynamic interaction between nursing actions that the person’s response to the nurse-patient relationship is negotiated.

In 1992, the first questionnaire designed by Kolcaba was published - General Comfort Questionnaire¹⁰ - from a previously created taxonomic structure⁷, proposing to evaluate holistic comfort in several populations and in different contexts, hospital, and community, to operationalize his theory. Today’s challenge is the operationalization of theories in the actions of nurses in their work contexts, so this theory with its practical component serves as a framework, not only for clinical practice but also for education and research. Since then, this questionnaire has been translated, adapted, and validated for a wide range of populations and contexts, and, since the beginning of the 21st century, this theory has deserved special importance and has been supporting clinical practice and research in several areas.

Comfort is included in nursing taxonomies, namely in NANDA International (North American Nursing Diagnosis Association)¹¹, where it is associated with the nursing diagnoses of “Impaired Comfort” and “Willingness for Enhanced Comfort”. Diagnoses related to the psychospiritual dimension of comfort are not listed, although they are part of one of the contexts defined by Kolcaba6. In turn, in the ICNP (International Classification for Nursing Practice) it is defined as “feeling of physical tranquility and bodily well-being” (code 10004655)¹², making the concept restrictive to the person’s physical dimension.

An evolutionary analysis of the concept of comfort with a view to its evaluation, obtaining as a result “Comfortable” (10025574)¹² showed the restricted way comfort is described in ICNP, reducing it to physical needs¹³. In this study, the antecedents of the concept were identified as: discomfort, anguish, and suffering (all related to the person). And, as consequents were identified: relief of discomfort; satisfaction of the person in face of the care provided; feeling of guilt and concern; improvement of health status; less anxiety; increased self-esteem and capacity for transcendence; improved interaction relationship with the health professional; increased safety and anticipation of needs; and self-control and more tolerance to procedures and equipment.

Recently in 2021, SNOMED International14 which represents the largest clinical terminology in the world, based on essential ontological principles when applied in research and planning, in agreement with the International Council of Nurses (ICN), starts to integrate and represent ICNP, in view of the increase in global health scanning. In SNOMED, the term comfort appears described as “Feeling comfortable” (1148784009), giving greater breadth of meaning to the concept, considered as a state of satisfaction of the need for comfort that leads the person to achieve self-actualization.

In the last decade, there has been an increase in research focused on comfort in different populations, health conditions, and in several contexts. One of the studies focused on the relationship between experiences of comfort and discomfort in women undergoing brachytherapy for treatment of cervical cancer¹⁵. More recently, an attempt was made to understand which are the social representations of comfort for family members of the person admitted to an intensive care unit in the situation of palliative care, having identified as comforting factors, communication, and humanized care by nurses to the palliative patient¹⁶.

Focusing on the comfort of the hospitalized elderly person, Sousa set out to understand what underlies the nature of the comforting process in the elderly patient experiencing a situation of chronic illness and hospitalization¹. This study evidenced that the comfort care process is established by a multisystemic and multifactorial interaction. It is in the interaction between the nurse, the elderly patient and his/her family that the integrative and intentional action of the nurse is determinant in meeting the comfort needs of the elderly patient. Sousa groups the comfort needs perceived by the participants into four domains: changes in the health/disease process, attitudes towards “self and life”, structure/functioning of the service, and family/significant people¹. In addition to highlighting the needs of this population, the author emphasizes the nurse’s action as a privileged comforting actor, in the globality of the human being. The implementation of the comforting intervention goes beyond the act itself, it is an action “that attends to the singularity, needs and respect for the Other [...]”¹.

The concept of comfort as a sensation was explored through literature review and hermeneutic analysis of the data. This study identified as antecedents: any experience that a person can live, product of any physical, psychospiritual, sociocultural, or environmental interaction; as attributes: security, control, realization of the self, belongingness, peace and plenitude, relaxation, and normality of life; and as consequents: it strengthens people, increases their ability to deal with the adversities of life, provides a serene death, and increases institutional results¹⁷. We also found recent studies in pediatric nursing, analyzing the concept of comfort for hospitalized children, in which measures that favor well-being, tranquility, warmth, and safety are shown to promote comfort¹⁸.

The research developed around the concept of comfort over time illustrates the importance it represents in the life of the person, family, and community subjected to nursing care. From this research, the development of the concept of comfort emerges for its effective use in a dynamic process, although involved in subjectivity⁶,¹⁹. As Kolcaba states, it is not possible to reach a state of full comfort, in all its dimensions⁶.

FINAL CONSIDERATIONS

The temporal evolution of the concept of comfort and the journey made by theorists who have dedicated themselves to the study of this phenomenon mirror comfort as a universal, contemporary, dynamic, and inseparable concept of the human condition in the physical, social, cultural, psychological, and spiritual realms.

Comfort happens through care that is considered comforting through a process that results from the interaction between nurse/patient, characterized by a high degree of complexity, resulting from the uniqueness of the person and the competence and characteristics of the person who promotes comfort.

It is important to look at the person at the center of nursing care, determine whether there is discomfort, what factors trigger it (antecedents), which dimensions of comfort are affected, and what needs exist to meet them, implementing interventions and assessment strategies that allow us to interpret whether full comfort has been achieved (consequents).

Kolcaba’s Comfort Theory allows stating that nursing interventions promoting comfort will be considered a good practice in nursing care if this intervention is perceived as comforting by the person, family, or community targeted by this intervention. This theory presents itself as a reference that consolidates nursing as a science and discipline, encouraging interaction, autonomy, and valuing the person’s needs by valuing and promoting comfort, with a view to improving quality of life.

Kolcaba’s studies mirror the need to clarify the concept of comfort and provide a more comprehensive view of this term to all populations and contexts, awakening in other theorists and researchers the interest in continuing the study of the concept of comfort, enabling his theory to serve as a basis of support for multiple research studies over the years, demonstrating that the phenomenon of comfort is not exhausted in its essence, but remains a contemporary and pertinent focus of study for research in the spheres: of the person/family ; hospital/institutional; community; national; and global.

The conceptualization of the phenomenon of comfort brought benefits for training by the appropriation of the concept for the practice of care by the importance of sensitization of nurses in care and for research by the constant search for it in various contexts and populations.

However, despite the studies that have been conducted, it is recognized that further research is needed to spread the phenomenon of comfort through different types of study/research methodology that can contribute to the development of the concept.

ACKNOWLEDGMENTS

Thanks to FCT - Fundação para a Ciência e a Tecnologia, I.P.( Foundation for Science and Technology), for funding the study with national funds, under project UIDB/04279/2020.

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Edited by

Associate editor: Dra. Luciana Kalinke

Publication Dates

• Publication in this collection
  16 Dec 2022
• Date of issue
  2022

History

• Received
  16 Mar 2022
• Accepted
  25 July 2022