Janice M. Morse
TOWARD UNDERSTANDING COMFORT AND COMFORTING
Nurses who work in the hospital, work with patients who have ongoing irreversible, irretrievable suffering. Physical suffering, emotional suffering, mental suffering—anguish beyond belief …
—Morse, Whitaker, and Tasón (1996, p. 91)
I have been interested in comfort as long as I have been a researcher. In my doctoral program I was uneasy with the concept of caring as the “essence of nursing” (Leininger, 1978) as caring did not encompass the tasks of nursing, and appeared to be focused on the nurse, rather than the patient. I argued that such a perspective on caring frequently led to the outcome of caring as the nurse feeling better; such a perspective on caring was not always a patient-centered concept (Morse, 1992).
My understanding of comfort and comforting came from conducting many studies, starting with masters’ and PhD students’ dissertation’s and later supported by post doctoral students. The early studies were based on patients’ experiences, mainly using grounded theory methods; all were published, but it took the preparation of the Illness-Constellation Model to recognize the relationship between suffering and comforting.
My first federally funded grant from the National Center for Nursing Research (NCNR; now the National Institute of Nursing Research) was to delineate the concept of comfort. We did that, but only partway through the subsequent 5-year extension grant did we recognize that we had to focus on suffering first. Until we understood suffering (that is, what was being comforted), we could not understand comfort.
The problem was that the state of suffering itself interferes with the expression of suffering, so that conducting interviews to understand suffering (which everyone seems to do) is the most ineffective way to understand the suffering experience. People who are enduring suppress the emotions that you are trying to understand, to the extent that your interviews sound like police reports—short sentences devoid of emotion. If the person is in the state of emotional suffering, the emotions themselves often make the interviews unintelligible. And perhaps, some would argue, interviewing that causes such distress is unethical. At best, interviews conducted during the active part of suffering provide only a part of the story. Once the person comes out of suffering he or she gains new insights into the experience. These later interviews are not invalid, as some argue: People do not forget those experiences, as psychologists suggest. In fact, returning to those memories evokes the same emotional responses during interviews, but with less intensity, a phenomenon which I call “emotional re-enactment” (Morse, 2002).
Later in the research program, observational studies of trauma care provided the most useful insights into the mutual interaction between comforting and suffering. Once I understood what the states of suffering were, I could see suffering in my interviews, both enduring and emotional suffering, as well as the transitions between the two. It was present in the statements and descriptions and also in the intonations, expressions, and behaviors of those being interviewed. Most of all, in the videos, I could see the responsiveness of caregivers to suffering, that is, comforting.
Thus, the studies that form a part of this analysis of comfort were also a part of the analysis of suffering (Chapter 36), for comforting is the “flip side” of suffering. These two concepts always occur together, often simultaneously. Comforting rarely occurs unless there is suffering (i.e., a need for comfort) at some level.
With my coinvestigators and graduate students, for more than two decades we analyzed comforting in palliative care, bereavement, major accidental injuries (in emergency departments, including trauma resuscitation), intensive care unit (ICU), spinal cord injury units, transplant units, with post-operative infants in the neonatal intensive care unit (NICU), in oncology units, in rehabilitation, and even a summer camp for children on ventilators who were normally nursed at home. We explored comfort and comforting from the perspective of the patient, the relatives, and the nurses, and we explored techniques of comforting. We used interview research, linguistic analysis, observational methods, video ethnography, grounded theory, phenomenology, and, of course, various types of concept analysis to determine the exact nature of the comforting strategies. We explored self-comforting, nurse comforting, and other comforting, including lay and professional strategies. We studied patients at various levels of discomfort, from minimal to chronic to acute, intolerable agony; states of discomfort and fear, and the emotional pain of losing a loved one and even one’s own dying.
ASSUMPTIONS ABOUT COMFORT AND COMFORTING
1. We know a tremendous amount the individuals’ experience of infirmary, illness, injury, rehabilitation, dying, disability, abnormality, and health seeking and health maintenance behaviors—under the rubric of emotional, physical, and spiritual responses (see, for example, Kolcaba, 2003).
2. We know that if we alleviate symptoms the individual is more physically comfortable, but that the meaning of the symptoms, that is, what the symptom represents, remains.
a. The physical easing is important, but in itself, is not enough (e.g., consider palliative care and dying; physical easing does not remove the prognosis, disability, etc.).
b. Most illness impairs, scars, changes body image, and changes the self. (These are rehabilitation and chronicity models; also models of adjustment, adaptation and normalization.)
c. Even curing (removal of symptoms and restoration of self) changes people forever—and results in changes to self. While curing is a significant goal, it is incomplete.
3. Suffering is a social event. I maintain that the most basic response to infirmary, illness, injury, rehabilitation, dying, disability, abnormality, and mental disability, is one of suffering—enduring and emotionally suffering. The response extends beyond the individual affected, and also affects the family, friends, caregivers and, in fact, those who come in contact or who know of (or even hear about) the affected individual.
4. Enduring and emotional suffering vary in intensity and form, depending on the nature of the individual’s needs. For example, so far we have identified three types of enduring (enduring to live, enduring to survive, and enduring to die), a trajectory of enduring to emotional suffering, to the reformulated self, and the intersection of some other concepts involved in the process (Morse, 2001, 2011; see also Chapter 5).
5. How enduring and emotionally suffering are manifest is culturally and contextually prescribed, within the most basic parameters of preserving self (Morse, 2012).
6. Medical treatment is necessary, is usually selected and is morally right. Technically competent care is a necessary right. Similarly, comforting is a necessary right, as are the obligation of health care professionals and the moral obligation of family, and society.
7. Comfort is a relative state, an optimal state achieved by each individual. Comforting is an effort expended by the individual and by others to assist the individual to reach that goal. Comfort may also be a state attained by a family, group, community, or nation.
8. Comforting consists of curing. Comfort consists of symptom relief. Comforting consists of providing technically competent care. Comforting consists of supporting the individual to endure, easing the individual through the process of suffering. Comforting is aiding the individual to attain a state free of distress/discomfort. Comfort is healthy living; a comfortable life is a healthy life.
9. For nursing, the primary responsibility for providing comfort is targeted toward monitoring and alleviation of symptoms, supportive and restorative functions, including psychosocial and spiritual support, moving the individual toward health.
10. For nursing, the act of comforting consists of caring, which motivates the provision of comfort and keeps the technical aspects of care humanistic, and providing comforting actions/procedure(s). The procedure may be a routine intervention (such as giving an injection in a way that causes minimal distress), providing a comforting strategy, which uses the nurses’ self (such as touch being there or verbal interaction), or supporting a comforting environment.
DOING THEORETICAL COALESCENCE
Building a Database
In order to conduct theoretical coalescence (Chapter 34), one needs a comprehensive database. Recall that these studies, as a set, must contain studies at different levels of analysis, from different perspectives and at different times of the process. These studies need to be comprehensive and derived from different methods. Thus, these studies enable the phenomenon of interest to be viewed from different perspectives, from micro to macro, and focus on different aspects of the process.
Box 36.1 shows these studies sorted into categories according to the areas that they cover. Some of these studies have been introduced earlier in the book. For all of these studies I have these data and also additional unpublished data in interviews and videotapes. I first discuss the evidence derived from each area and number the references to the key in Box 36.1 to expedite reading. Then, later in this chapter, I put the theory together as a whole.
BOX 36.1. STUDIES CONTRIBUTING TO THE VARIOUS DIMENSIONS OF COMFORT AND COMFORTING
Three studies contributed to the development of insight into the nature of comfort and the concept of comfort:
1. Morse, J. M. (1983). An ethnoscientific analysis of comfort: A preliminary investigation. Nursing Papers/Perspectives in Nursing, 15(1), 6–19.
2. Morse, J. M., Bottorff, J. L., & Hutchinson, S. (1994). The phenomenology of comfort. Journal of Advanced Nursing, 20, 189–195.
3. Morse, J. M., Bottorff, J. L., & Hutchinson, S. (1995). The paradox of comfort. Nursing Research, 44(1), 14–19.
B. THE NEED FOR COMFORTING
1. Côté, J. J., Morse, J. M., & James, S. G. (1991). The pain experience of the post-operative newborn. Journal of Advanced Nursing, 16, 378–387.
2. Dewar, A., & Morse J. M. (1995). Unbearable incidents: Failure to endure the experience of illness. Journal of Advanced Nursing, 22(5), 957–964.
3. Morse, J. M., & Carter, B. (1996). The essence of enduring and the expression of suffering: The reformulation of self. Scholarly Inquiry for Nursing Practice, 10(1), 43–60.
4. Hogan, N., Morse, J. M., & Tasón, M. C. (1996). Toward an experiential theory of bereavement. Omega, 33(1), 43–65.
5. Morse, J. M., & Carter, B. J. (1995). Strategies of enduring and the suffering of loss: Modes of comfort used by a resilient survivor. Holistic Nursing Practice, 9(3), 33–58. [Reprinted in Danish: Ed. Nete Gress Klinisk Sygrpleje, bd 1,11, og 111, 2000]
6. Morse, J. M. (1989). Cultural responses to parturition: Childbirth in Fiji. Medical Anthropology, 12(1), 35–44.
C. RESPONSES TO SIGNS OF DISTRESS
1. Solberg, S., & Morse, J. M. (1991). The comforting behaviors of caregivers toward distressed post-operative neonates. Issues in Comprehensive Pediatric Nursing, 14(2), 77–92.
2. Wilson, S., & Morse, J. M. (1991). Living with a wife undergoing chemotherapy: Perceptions of the husband. Image: Journal of Nursing Scholarship, 23(2), 78–84.
3. Morse, J. M., Miles, M. W., Clark, D. A., & Doberneck, B. M. (1994). Sensing patient needs: Exploring concepts of nursing insight and receptivity used in nursing assessment. Scholarly Inquiry for Nursing Practice, 8(3), 233–254.
4. Siegl, D., & Morse, J. M. (1994). Tolerating reality: The experiences of parents with HIV+ sons. Social Science & Medicine, 38, 959–971.
5. Morse, J. M., Mitcham, C., & van der Steen, V. (1998). Compathy or physical empathy: Implications for the caregiver relationship. Journal of Medical Humanities, 19(1), 51–65.
6. Penrod, J., Morse, J. M., & Wilson, S. (1999). Comforting strategies used during nasogastric tube insertion. Journal of Clinical Nursing, 8, 31–38.
7. Olson, K., Morse, J. M., Smith, J., Mayan, M., & Hammond, D. (2000–2001). Linking trajectories of illness and dying. Omega, 42(4), 293–308.
1. Johnson, J. L., & Morse, J. M. (1990). Regaining control: The process of adjustment following myocardial infarction. Heart and Lung, 19(2), 126–135.
2. Flaming, D., & Morse, J. M. (1992). Minimizing embarrassment: Boys experiencing pubertal changes. Issues in Comprehensive Pediatric Nursing, 14, 211–231.
3. Laskiwski, S., & Morse, J. M. (1993). The spinal cord injured patient: The modification of hope and expressions of despair. Canadian Journal of Rehabilitation, 6(3), 143–153.
4. Morse, J. M., & Carter, B. J. (1995). Strategies of enduring and the suffering of loss: Modes of comfort used by a resilient survivor. Holistic Nursing Practice, 9(3), 33–58.
5. Morse, J. M., & O’Brien, B. (1995). Preserving self: From victim, to patient, to disabled person. Journal of Advanced Nursing, 21, 886–896. doi:10.1046/j.1365-2648.1995.21050886.x
6. Penrod, J., & Morse, J. M. (1997) Strategies for assessing and fostering hope: The hope assessment guide. Oncology Nurses Forum, 24(6), 1055–1063.
7. Morse, J. M. (1997). Responding to threats to integrity of self. Advances in Nursing Science, 19(4), 21–36.
8. Morse, J. M., & Mitcham, C. (1998). The experience of agonizing pain and signals of disembodiment. Journal of Psychosomatic Research, 44(6), 667–680.
9. Morse, J. M., Wilson, S., & Penrod, J. (2000). Mothers and their disabled children: Refining the concept of normalization. Health Care for Women International, 21(8), 659–676.
10. Morse, J. M., Pooler, C., Vann-Ward, T., Maddox, L., Olausson, J. M., Roche-Dean, M., … Martz, K. (2014). Awaiting the diagnosis of breast cancer: Strategies of enduring for preserving self. Oncology Nursing Forum, 41(4), 350–359.
E. ATTRIBUTES OF COMFORT
1. Morse, J. M., Solberg, S. M., Neander, W. L., Bottorff, J. L., & Johnson, J. L. (1990). Concepts of caring and caring as a concept. Advances in Nursing Science, 13, 1–14.
2. Morse, J. M., Bottorff, J., Neander, W., & Solberg, S. (1991). Comparative analysis of the conceptualizations and theories of caring. Image: Journal of Nursing Scholarship, 23(2), 119–126.
3. Hupcey, J., Penrod, J., Morse, J., & Mitcham, C. (2001). An exploration and advancement of the concept of trust. Journal of Advanced Nursing, 36(2), 282–293.
4. Morse, J. M., Bottorff, J., Anderson, G., O’Brien, B., & Solberg, S. (1992). Beyond empathy. Expanding expressions of caring. Journal of Advanced Nursing, 17, 809–821.
5. Morse, J. M., Anderson, G., Bottorff, J., Yonge, O., O’Brien, B., Solberg, S., & McIlveen, K. (1992). Exploring empathy: A conceptual fit for nursing practice? Image: Journal of Nursing Scholarship, 24(4), 274–280.
6. Estabrooks, C., & Morse, J. M. (1992). Toward a theory of touch: The touching process and acquiring a touching style. Journal of Advanced Nursing, 17, 448–456.
7. Morse, J. M., & Doberneck, B. M. (1995). Delineating the concept of hope. Image: Journal of Nursing Scholarship, 27(4), 277–285.
F. THE COMFORTING RELATIONSHIP
1. Morse, J. M. (1991). Negotiating commitment and involvement in the patient-nurse relationship. Journal of Advanced Nursing, 16, 455–468.
2. Bottorff, J. L., & Morse, J. M. (1994). Identifying types of attending: Patterns of nurses’ work. Image: Journal of Nursing Scholarship, 26(1), 53–60.
3. Hupcey, J. E., & Morse, J. M. (1995). Family and social support: Application to the critically ill patient. Journal of Family Nursing, 1(3), 257–280
4. Morse, J. M., & Mitcham, C. (1997). Compathy: The contagion of physical distress. Journal of Advanced Nursing, 26, 649–657.
5. Morse, J. M., & Intrieri, R. (1997). Patient-patient communication in a long-term care facility. Journal of Psychosocial Nursing & Mental Health Services, 35(5), 34–39. [Abstracted in American Journal of Nursing, 97(7), 9–10]
6. Morse, J. M., Havens, G., DeLuca, A., & Wilson, S. (1997). The comforting interaction: Developing a model of nurse-patient relationship. Scholarly Inquiry for Nursing Practice, 11(4), 321–343.
7. Wilson, S., Morse, J. M., & Penrod, J. (1998). Developing reciprocal trust in the caregiving relationship. Qualitative Health Research, 8, 446–465.
8. Wilson, S., Morse, J. M., & Penrod, J. (1998). Absolute involvement: The experience of mothers of ventilator-dependent children. Health & Social Care, 6(4), 224–233.
G. THEORETICAL EXPANSION USING OTHER MODELS; OTHER POPULATIONS
1. Hupcey, J. E., Penrod, J., & Morse, J. M. (2000). Establishing and maintaining trust during acute care hospitalizations. Scholarly Inquiry for Nursing Practice: An International Journal, 14(3), 227–242.
2. Morse, J. M., & Pooler, C. (2002) Patient-family-nurse interactions in the trauma-resuscitation room. American Journal of Critical Care, 11(3), 240–249.
3. Bergstrom, L., Richards, L., Proctor, A., Bohrer-Avila, L. Morse, J., & Roberts, J. (2009). Birth talk in second stage labor. Qualitative Health Research, 19, 954–964.
4. Bergstrom, L., Richards, L., Morse, J., & Roberts, J. (2010). How caregivers manage pain and distress in second stage labor. Journal of Midwifery and Women’s Health, 55(1), 38–45.
5. Morse, J. M. (2011). Hearing bad news. Journal of Humanistic Medicine. 32, 187–211. doi:10.1007/s10912-011-9138-4
H. UNDERSTANDING THE MICROANALYTIC MECHANISMS OF COMFORTING