Kolcaba's comfort theory in medical-surgical dialysis care

Medical Theory

Ever since the last century, nursing has becoming a professional discipline and just like every other discipline, it requires some theories to guide it. It has been seen that the nursing theory is split along three levels. One level is grand, then middle-range and then there is the situation specific level. (Meleis, 2012 p 33) As it would be expected, the grand theory is quite broad and takes into context very generalized views. Our basic concern is the middle range theory that is more focused these days. These theories are basically an end product of a research study. The narrow range study is even more selective and is solely based on research findings. (McKenna, 1997 p 17)

Just like any other discipline, theories are present in nursing to guide a person about the major goals and objectives of the nursing discipline. It tells the person about certain situations and allows them to guide through research. Research is done as to refute the theory, modify the theory or even completely eliminate the theory. (Meleis, 2012 p 35)

Middle range theories are merely part of the structure of a certain subject area. They go on to afresh the adequate knowledge of that discipline by expanding on specific phenomena that are linked to the healing process. The more and more these theories are expanded, the discipline of nursing become more enriched. An example of this is if one takes the study that was conducted on how vulnerability or again forces humans to focus on the meaning of life. This basically builds up on the connections with others and the past, present or future. Ultimately, the result was that self-transcendence is linked to healing or well being. Now it is known that healing and well being is a very crucial focus of nursing. Therefore, we saw that these theories not only get applied to nursing but also make a significant impact.

Similar to the example that was discussed earlier, we come to a very important nursing theory known as Kolcaba's comfort theory. It is observed that Kolcaba's theory (1992) is based on the earlier works of nurses like Watson (1979) and Orlando (1961) During the 1980's, a lot of theories revolved around comfort and that is when most of the nurses and doctors began paying attention to his theory. In the early twentiethcentury, comfort was the major and only goal of nursing and medicine. As it is expected, comfort is the major thing that nurses and doctors aim for. Due to this reason, most of the textbooks and theories targeted comfort. They went on to ensure that the nurse provides adequate physical and emotional comfort to the patient. The major concepts of the Theory of Comfort include comfort measures, comfort, comfort care, comfort needs, institutional integrity, health-seeking behaviors and other intervening variables.

Comfort is the major purpose and objective of this theory. Comfort is merely a state that a person feels and there are various ways to measure it. Comfort can be experienced by a person eithersocioculturaly, environmentally, physically and psycho-spiritually. Physical comfort basically is linked to medical diagnosis and does not have any medical significance whatsoever. (Kolcaba, 1997) Other sorts of comforts are pretty self-explanatory.

If one goes into more detail that it is seen that comfort measures are basically the things that the nurse will do in order to respond to the needs of the patient. The three types of comfort measures that are highlighted in this theory include comfort food for the soul, technical care and coaching. It is observed that when the patient is any sort of distress, his mental health suffers a great deal. Kolcaba therefore emphasizes on the importance of relieving that mental stress for the patient. This is done through actions such as reminiscing, hand holding, back massaging and guided imagery. The technical care sort of comfort measure is basically done to keep things at a constant level and relieve any pain that the patient has. Lastly, the patient is provided with coaching which goes on to relieve the anxiety and help the patient in making their condition better.

The health care or the medical needs are such needs that need intervention by an expert. It other words, these needs cannot be fulfilled by the family support system. These need can be social, environmental, spiritual orpsychological. Regardless of what support the family provides, it is crucial for the nurse to monitor all these signs and thus play an important role.

Lastly we come to the health seeking behaviors or the institutional integrity. Health seeking behaviors are basically actions linked to the goal that the person wishes to be healthy. Institutional integrity is along the same lines where it talks about the person's ability to work with the community and the society and walk towards their goal of getting better. It should be noted that the community does go on to play an active role in this scenario. Last but not the least; the intervening variables are such that all of these concepts are somehow linked to each other. Furthermore, this theory supports the notion that the amalgamation of variables such as the prognosis of the disease, family support, age, and attitude affect the person's ability to view comfort.

Apart from the variables, we see that Kolcaba's theory is based on a grid that has 12 cells. (Kolcaba&Fisher, 1996) The three major types of comfort listed in the grid are known as ease, relief and transcendence. The four contexts of the theory are namely sociocultural, environmental, physical and psycho-spiritual.

Structural aspects of the theory

Just like every theory, there are certain assumptions that the theory is based on. The first assumption is that the comfort is a relevant outcome and is quite significant to nursing. The next assumption build up on the earlier one and is that as humans, we work to attain comfort. It is assumed that this proves to becontinuous and we continue to work towards it. A human can respond in variety of ways to a given stimuli. Another assumption is that since everyone is different in their needs and expectations, every person has a different process to attaining a certain comfort level. It is also assumed that patients who have the ability to actively participate in their healing process have a better outlook and a better approach towards the healing process.

This again backs up the assertion that humans should put in their own efforts and ideas that work best towards attaining their comfort level. It is also assumed that if a patient is comfortable, he will work harder towards getting better. In other words, the patient will be more positive on the treatment options that he is getting.

Some of the propositional statements this theory includes are that the nurses need to designs actions that would further provide the patient with the comfort they need. (Kolcaba 1992) Itproposes that comfort requirements in one scenario can overlap and lead to comfort needs in another scenario as well. Manipulation of the environment is a very important route through which adequatelevels of comfort can be attained. It is very crucial for a nurse to take in consideration the intervening variables that were stated earlier. As mentioned above, intervening variables play a great role in how the patient perceives comfort. Therefore, intervening variables give a good idea about what measures the nurse needs to take. This theory also proposes that the nurse and the patient should agree on the measures and tips of attaining comfort. Patient's compliance is increased when patients agree with the methods. It is quite obvious that a patient will not feel comfortable if he feels that certain techniques are merely being imposed on him or her. This theory also proposes that a good working environment and good skills are crucial for the maximum effectiveness.

It is observed that this theory is overall very consistent. The structure and the methods are all very simple to grasp and all the terms remain the same in the theory. The concepts that are present in the theory can be related to in a very practical manner. It appears that the entire diagrams and terms are clear. The assumptions that were stated earlier are also present all over the writings and thus go on to make the theory very consistent. The concepts that were stated earlier on are very rigid and do no not confuse the reader. If a person has the basic nursing skills then he will have no problems in making use of this theory.

It is seen that Kolcaba's comfort theory can be applied to wide range of hospital activities. It is easy to understand and goes on to cover different topics that are quite relevant to health and ethics. As stated earlier, the major aim of nursing is to provide care and comfort to the patient. This theory is simple and easy to use and that makes it very convenient to be applied in different areas in a successful manner.

Application

Application in Practice

There are a number of studies that have been conducted to established ways in which nurses can provide comfort to the patients. As mentioned earlier, the desired outcome of nursing care is comfort and there are many articles in which the researchers have talked about the needs of the patients and the things that alter the comfort of the patients. Kolcaba suggested that the cancer patients who are terminally ill can benefit from comfort care as it pays attention to the perspective and needs of the patients. Through such kind of care, the patient is not only provided with pain relief, but the depression of the patient is also addressed adequately. As she said that patients who are not in pain but are depressed seek comfort in the transcendental sense as well as in the psycho-spiritual sense (Kolcaba, 1992 p 4). In some of her works, she has explained the use of the instruments and their application by the nurses. Kolcaba reckons that the instruments presented by her to evaluate the comfort are significant indicators that are given by the patients, are altered by the kind of nursing care being given to the patient and are associated with the health care system and its integrity. For example, this theory is particularly very significant for application by nurses that interact with the patients before they are being taken to the OR, or when they are in the OR. This is important to reduce the anxiety level, which can hinder the smoothness of any procedure that is being performed.

Application in Research

It has been around a decade since this theory has come up to the surface and during this time it has been subjected to empirical testing. Studies have shown that when the caretaker or the nurse starts giving the patient a comfort measure in the form of any intervention, so as to meet the holistic comfort of the patient, the comfort level of the patient is elevated over a former baseline value. At the moment, Kolcaba is devising ways to test the last part of the theory so that she can establish a relationship, if it exists, between the community or institutional setting and patient comfort. She also seeks to demonstrate the extent of the patient satisfaction with the application of this theory in the healthcare system. She wished to do so by making the patients fill out a survey after they are discharged from the hospital.

Application in Education

It should be noted here that Kolcaba's (1992) theory is of middle range nature and therefore it might not be appropriate for the curricular development as it expands on a few but not all the aspects of nursing care. However, it is also noteworthy that this theory has to offer some very important content for the students of nursing to those of masters, at both the graduate and undergraduate levels. According to the articles that have explained the application of this theory in nursing practice, this theory can prove to be useful for educating students. For instance, Cox (1998) believed that Kolcaba's theory was helpful when it came to teaching nursing students how to take care of older adults and the students found it very easy to apply this theory while addressing the holistic comfort demands of the elders in a setting that would cater their acute needs. This theory has also been suggested to be beneficial to reduce the stress in students in educational settings.

In another article, Kolcaba (1994) has explained her theory in depth and in a way that might suit the students. According to this article, comfort is defined as the characteristic that distinguishes the nursing professions from others. The aforementioned statement makes the application of this theory useful in education. A theoretical work has been presented in this article in which an intra-actional perspective has been used to develop a theory that indicates comfort as being a positive result of nursing. In this article, it was described how an elevation in comfort was an indication of reduction of negative tensions and engagement of positive tensions. It should be remembered here that the facilitator of the results of comfort is the nurse. This is because, according to theory, it has a relationship with external/internal health-seeing attitudes of a peaceful death.

Application of Theory to My Practice

I have made use of this theory in many cases, although I was not aware of the fact that this theory actually existed. There are a number of management protocols that involve a hand massage. I would like to add here that I have performed hand massage on a number of patients. Moreover, in some patients, to decrease the stress level and to increase comfort, I have also performed foot massage on these patients. Such practices are enjoyed by the female patients to a great extent and great degree of relaxation is seen in them when they are being massaged. The reason why I have been hesitant to hand to foot massage the male patients is that in many cultural settings, such actions are considered a taboo. Even though, it is an extremely simple intervention, it can cause significant change in the behavior and comfort level of the patient.