Janice M. Morse
THE PRAXIS THEORY OF COMFORT AND COMFORTING1
Asked by elderly woman:
“What do you call a group of nurses?”
Answer: “A comfort!”
What, then, is comfort? At the broadest level in Chapter 36, we developed axioms for the Theory of Comfort and Comforting. These were derived from research, from multiple projects. They are assumptions that I held to be reasonable, all things considered, and provided a context for the macro- and microanalytic processes inherent in the theory.
CONTEXTUAL FACTORS INFLUENCING COMFORT AND COMFORTING
There is one more series of factors before we put all of these components together—and that is the context in which comforting (and nursing) occurs. In addition to the overly narrow focus of interaction or the superficial focus of relationship studies, research has ignored many fundamental facts inherent in the nurse–patient situation. These characteristics are as follows.
The Patient Is Usually Cared for by Many Nurses in the Course of a Single Day
Although one nurse may be responsible for the development and implementation of a patient’s care plan, due to the demands of 24-hour care, shift work, the demands of days off and for meal and coffee breaks, care is actually provided by many nurses with different levels of preparation, and holding different relationships with the patient. These nurses may have a “relationship” established with this particular patient or be unfamiliar, presenting a new face to the patient. Furthermore, nursing care is not equally distributed between patients. Some nurses interact with some patients more frequently and for greater periods of time than others.
Surprisingly, despite differences in nursing education, experience, and relationships, these teams of nurses are presumed by administration to being able to provide adequate, and roughly equivalent, care. In short, it is assumed that once these nurses have read the patient’s chart, they are considered, from the administration’s perspective, as interchangeable (Morse et al., 1992). Of course, this attitude—the “warm body” style of nursing administration—acknowledges only entry-level clinical competency. It does not acknowledge the significance of the relationship component of the nurse–patient relationship. In fact, nursing administration intentionally organizes staff to prevent such relationships from developing, and to protect nurses from becoming “involved” with patients. The result is that patients rarely refer to nurses (and even more rarely to one particular nurse), and if they do, they speak of “the nurses” as a collective. It is interesting that nurses, unlike physicians, are almost never referred to by name.
Nursing Care is Often Provided by Groups of Caregivers Working Simultaneously
The second characteristic of the nurse–patient relationship occurs when major procedures are being performed, when the patient requires assistance (such as lifting and, we know, comforting), when urgent care is being provided, or when complex tasks are being performed. In these instances, several nurses may be simultaneously involved in the care, with one nurse directing the team. If the care is painful or the patient is a child and his or her parents are visiting, the nurse may second the parent or a non-nurse (such as an aide or an orderly) to assist. The nurse usually directs, coordinates, and accepts responsibility for the procedure.
The Nurse Does Not Serve as an Independent Therapist, but Rather as an Agent of the Physician or the Institution
Because the individual nurse is considered interchangeable and part of a team, any confidential information given to a particular nurse is recorded in the patient’s chart or passed on informally in the patient’s report. This indicates that the nurses themselves consider such information to belong, albeit for the patient’s good, to the greater arena of pertinent “patient information” to which the team of nursing and medical staff has access. Despite the recording and reporting of such information, the nurse still considers him or herself to have retained patient confidentiality. This action also indicates that nurses consider themselves to be agents of the institution and the physician, something that Wolgast (1992) has labeled an “artificial person.” Nurses are not in an autonomous position in regard to making decisions for patient treatment, and they demonstrate greater allegiance to the medical staff and the institution than to the patient. Such a clinical reality is not explicitly stated to patients, and when disclosure of a confidence occurs, it may result in the loss of trust and profound changes in the nurse–patient relationship.
THE PRAXIS THEORY OF COMFORT AND COMFORTING
Components of Comforting
Comforting consists of caring (as a motivator for the nurse to provide comfort and to monitor the patient condition throughout the process) and a comforting action, or interaction, provided as a process, until the patient reaches an endurable comfort level.
Comfort Encompasses Caring
Comfort is a concept that incorporates the caring focus of nursing—which enables us to see the cues and signals of suffering and motivates us to comfort—and a comforting action or task (Morse, 2000b). Note that when comfort is the central concept for nursing, nursing care is focused on the patient (in contrast to caring, which is focused on the nurse). Within this framework, nurses’ use of touch and talk are not indicators of caring per se; rather, they are comforting strategies that are responses to signals of suffering. They are strategies for alleviating suffering (Morse, 1992). Comforting therefore cannot be separated from suffering.
What Is a Patient’s Comfort Level?
The patient’s comfort level is the degree of discomfort that is tolerable or bearable, and the goal of nursing is always to minimize the patient’s discomfort and to maximize the patient’s comfort state. The comfort level may thus be perceived as a continuum ranging from complete comfort to extreme agony, and the patient’s comfort level is dynamic, continuously fluctuating on this continuum. Comfort level is used between nurses as a means of quickly communicating the patient’s state of comfort and determining their comfort needs.
The comfort level is not a measure of pain, but rather how well a patient is tolerating or enduring the pain.
Comforting Is a Process
Nurse-comforting interventions are not a “one-shot” intervention, but a process that occurs in many iterative steps at the microanalytic level (as a therapy) and within the interaction and the developing relationship (as a psychosocial intervention). These processes form the comforting-interaction loop in which a need for comfort is observed or requested, the comforting action occurs, the patient is re-evaluated, and another comforting action is provided, and so forth.
Examples of the comforting-interaction loop may be:
• Observing that the patient appears in pain (noting the cues of distress or signals of suffering), verifying the pain with the patient (action), administering an analgesic action (comforting action), and observing signs that the pain was subsequently alleviated
• Observing the patient appears cold and is shivering (noting the behavioral cue), fetching a warm blanket (comforting action), and observing the patient appears more relaxed and warmer
As nursing tasks increase in complexity, so do the comforting actions:
• During childbirth the nurse observes the patient is becoming distressed (a signal of suffering), and uses her voice (comforting interaction, such as “talking through” or an expression of empathy) to assist in synchronizing the second-stage labor until the woman regains control (see Bergstrom et al., 2009).
• In the trauma room during resuscitation, a patient is scared but lying still (caring observation). The nurse provides presence, and a “running commentary,” talking constantly, describing everything that she and the trauma team are doing (Chapter 35). Later, the patient said that she “just listened to that nurse’s voice and held on.”
• During trauma resuscitation, the nurse observes that the patient is terrified (a signal of suffering), and she uses the Comfort Talk Register to enable the patient to hold on, and hold still (a comforting action) until the analgesics take effect (see Morse & Proctor, 1998; Proctor, Morse, & Khonsari, 1996).
The comforting-interaction loop continues until comfort is no longer needed and is no longer demanded by the patient. From this perspective, comforting is a major component of every nursing action, minor or major, transitory or prolonged, including the provision of the technical aspects of care as well as direct and indirect comforting strategies. Making the patient comfortable is the goal of nursing (Morse, 1992).
Comfort is attained as an immediate, short-term goal (i.e., comforting), which is to ease and relieve or to assist the patient to endure and to last through a procedure. This is congruent with the dictionary definition of comfort: to ease, relieve, or to “make strong.” When patients are comfortable, that is, when comfort is attained, they have no need for a nurse (Nightingale, 1860/1969). The long-term goal of comfort is the achievement of relief or optimal health.
Comfort is a relative and optimal state of well-being that may occur during any stage of the illness–health continuum (Morse, 1992).
I suggest that the comforting process consists of the nurse recognizing a patient cue or signal of distress (indicating a patient need), assessing, and intervening with a comforting strategy or procedure. The outcome or patient response cues or signals are then assessed or evaluated by the nurse, another strategy implemented, and so forth. It sounds very simple, but it is extraordinarily difficult to research and to document the efficacy of comforting strategies.
What Is a Patient Cue?
A patient cue may be in the form of a pain response, restlessness, an utterance, expression, or even a request. Patient cues indicate discomfort, and by responding to such cues, nurses provide comfort. For example, nurses may adjust the patient’s position, offer or administer pain medications, and so forth. In other words, patient cues motivate the nurse to provide comforting strategies, even if the patient has not requested such care.
What Is a Signal of Distress?
Signals of distress are larger groupings of patient cues that clearly indicate a patient problem—usually, acute distress. The behavioral signals of distress may be accompanied and reinforced by physiological signs of distress—increased pulse, falling blood pressure, and so forth. A signal of distress may even be a verbal request or complaint.
What Is a Comfort Strategy?
Comforting strategies are methods or techniques of comforting the distressed person. While not unique to nursing, it is nursing’s role, and privilege, to use comfort strategies when caring for the distressed person. Comfort strategies may be as follows.
These are strategies administered directly to the patient. Direct strategies are universal patterns of touch, talking, and listening, which may be used to keep the patient in control by eye contact, voice, such as in talking the patient through painful procedures, and the responsive use of touch. Recall, while comforting strategies are patterned, they are also particular to the patient’s state. They also include providing appropriate explanations, as well as providing competent care; they include providing gender, age, and culturally appropriate care.
It is crucial that the comfort strategies match the patient’s comfort level because using comfort strategies that are intended for a different state will result in the escalation of discomfort. Comfort strategies are variable. An experienced nurse has a large repertoire and changes the strategies in accordance with the patient’s state. Thus, while the comfort strategies used are nurse-controlled, they are patient-led.
These are strategies that control the actions of others or manipulate the environment. Indirect strategies include such actions as providing warmth, quiet, or darkness and are used for protecting the patient, to pace and sequence care to minimize distress, and to manipulate the environment to maximize patient rest and prevent fatigue. They also include monitoring, the administration of an analgesic, and to minimize distress, and to perform the therapies and plan of care for the patient.
The Context of Comforting
Comfort strategies vary in complexity. They may be as simple as placing a hand on the patient’s shoulder; it may be as technical as responding to a code with efficiency, speed, and competence. A comfort strategy may be keeping vigilance while the patient “sleeps,” or it may be forcefully getting the patient out of bed, despite protests of, “It hurts!,” “Not today!,” and “Wait—I’m not ready.”
Nurse-comforting strategies buffer the injury/illness experience and alleviate the intensity of symptoms for the patient. Because comfort strategies are variable and context-dependent, they cannot be formulated. Rather, the expert nurse has an enormous repertoire of comforting strategies and is versatile in their application. An expert nurse “reads the patient” by reassessing situational clues or signals of distress, patient cues, and responds to triggers in the situation. The expert nurse instantly recognizes patient cues or signals of distress. The expert nurse is versatile, so that if a comforting strategy does not work, is ineffective, or causes discomfort, then another comforting strategy is used. Expert nurses have a large compendium of comforting strategies that they provide sequentially according to the patient’s state and perceived need. Assessment of the attainment of the optimal comfort level is ongoing.
What About Self-Comforting? The Patient’s Approach
Recall from the Praxis Theory of Suffering, (Chapter 35) that when encountering loss or an illness that must be endured, individuals try to maintain control and not panic. This is the first step in self-comforting. Individuals tend to “shut down,” and put whatever they are suffering about at the back of their minds (Morse et al., 2014). They suppress emotions of panic, horror, and fear, and in the process, move into a state of enduring. They reassure themselves, and try to maintain normality in their lives, concealing their worry or symptoms. A patient may deny or refuse to acknowledge the illness or the symptom; consider this as another form of self-comforting, which may not be in the patient’s best interest.
TO DO 37.1. WATCH PATIENTS BEFORE VISITING AND THEN WATCH THEM GREET VISITORS
Describe their changes in behaviors. Describe their “before visitor” and “during visit” behaviors.
Do they report their “complaints” and pains to their visitors as they do to you?
Self-comforting also takes the form of behaviors: We recognize posturing to minimize pain; we see patients moving with an altered gait to minimize pain; we see toddlers rocking or patients lying very still and refusing to move because “it hurts.” All of these behaviors are self-comforting strategies.
Patient Actions in Assessing the Nurse
Behaviors that are unique to the patients as recipients of care are those that evaluate the nurse, decide whether or not to trust the nurse’s care, that is, to relinquish for care, and form patterns of relating. These patient actions influence the relationship and provide the patient with the control that influences the nurse’s response and the nurse’s actions. Each independent contact or interaction results an implicit negotiation from which the nurse–patient relationship evolves.
Patients use strategies to evaluate their nurse. First, the patient determines whether or not the nurse is a “good person.” For example, the patient questions the nurse about her personal life disguised as social conversations such as, “Are you from around here?” and “Do you have children?” Second, the patient determines if the nurse is a “good” nurse. For example, the patient checks whether or not the nurse “likes her job,” where she went to nursing school, and how long she has been nursing. Patients also “get references” from other patients (“Is she a good nurse?”) and evaluate if the nurse has “good hands.” If the nurse rates adequately, and the patient decides to trust the nurse, the patient then makes overtures by being a “good patient” and being friendly. Patients may give gifts (such as chocolates) and compliments either directly to the nurse or deliberately to other patients or visitors within the nurse’s hearing. On the other hand, if the patient does not trust the nurse, the patient uses strategies to prevent the nurse from “knowing” him or her by refusing to make eye contact, focusing dialogue on symptoms and treatments, and may become demanding, coercive, uncooperative, and/or manipulative (Morse, 1991b).
The level of trust developed results in patient-led patterns of relating with the nurse. As stated earlier, if the patient does not trust the nurse, the patient may use behaviors that nurses have labeled as “difficult.” These patients, depending on their needs, condition, and behaviors, control the type of relationship that eventually develops. In this sense, the type of relationship is patient-controlled, and the nurse responds to these patient cues. For instance, if the patient chooses to enter a joking relationship, the patient manifests joking behaviors that, in turn, elicit teasing behavior and responses from the nurse. If the patient is in pain, the responses elicited from the nurse are those behaviors appropriate for a patient in pain. With each nurse–patient contact, the relationship develops and eventually evolves to become one that meets the needs of both the nurse and the patient.
A nursing approach supports the patient’s self-comforting strategies. The nursing approach is a patterned, normative, and professional behavior granted to a nurse by society because of her professional role, education, and responsibilities. They include role behaviors that typify a nurse and provide her with access to the patient and to the patient’s body for particular expected, necessary tasks of greeting, assessment, confidences, surveillance, treatments, care of bodily functions and hygiene, and so forth. The nursing approach includes all of the “scripted” questions and tasks of assessment, treatment, and caregiving.
Styles of Care
A style of care is the nurse’s manner of approaching individual patients. Nurses unconsciously adapt their style of care to match the patient’s perceived needs. Nurses’ styles of care vary according to the patient’s affect, age, gender, culture, and condition. Nurses may greet an elderly patient in pain with quiet respect, or a child with distraction, and an upbeat tone. Or nurses may counter a patient’s affect, cajoling a depressed patient or being stern with a noncompliant. The nurse’s interaction with each patient is different.
A nurse’s posturing and approach is often dictated by, and matches, the style of care. And often, microanalytic comforting strategies accompany the style of care: Consider whether or not the nurse touches or hugs a patient. Embedded in the style of care is the nurse’s personality. Some nurses are quiet and consoling; others are lighthearted and funny. Some nurses find it easy to talk to a patient and “draw” him or her out. Others keep to the nursing “script.”