Examining the Development and Testing of Nursing Theories
Traditionally, nursing theories took the form of rules, beliefs and customs (Chinn and Kramer, 2004) without any questioning on routine practice. As a result, the experienced nurse was judged by a combination of a caring outlook and some technicalities which were obtained through hospital-based prentice training (Lasiuk and Ferguson, 2005). Moreover, the nursing discipline relied on few theories which were also borrowed from other disciplines [ibid]. Notwithstanding, a significant revolution in the discipline occurred when the American Nurses Association (in 1965) formally declared theory development as the goal of the profession (Meleis, 1997). Few years after this declaration led to the publishing of grand theories and conceptual models which served as the theoretical foundations of nursing programs.
Current trends toward the development and testing of middle range and practice theories resulted from Meleis' (1997: 128) impassionate appeal for a "reVisioning" of the goals of nursing research. The nursing discipline requires an integration of theory, practice and research to achieve professional accountability (Gortner, 1973). This is because each is imperative and mutually beneficial. Theory provides a framework for directing practice and research (McEwen, 2007) and can lead to theory generation (Chinn and Kramer, 2004).
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I am a general nurse who was recently working at the Komfo Anokye Teaching Hospital. It is the second largest hospital and serves as the main referral centre for the Ashanti Region and some parts of the Eastern, Central, Northern and Western Regions of Ghana (Buabeng, Matowe and Plange-Rhule, 2004). I was working on a general surgical ward dealing with preoperative and postoperative patients. From my practice, I realised that postoperative pain was a common problem among surgical patients in spite of various advances in pain management (Carr and Goudas, 1999, Donovan, 1990 and Long, 2000). In my search for a nursing theory that can be applicable in my clinical setting (surgery), I find Kolcaba's middle range theory of comfort to be very useful because it deals with the comfort needs of patients.
The aim of the essay is to apply a nursing theory to a phenomenon of interest in my clinical practice. It will commence with a case study from my practice, followed by a critical reflection based on Carper's epistemological patterns in nursing. The essay will continue with a brief literature review on the main concepts identified in the reflection. Following this, Kolcaba's Comfort Theory will be described, analysed and applied to my practice area (surgical setting). Finally, the essay will end with my conclusions about this nursing theory.
CASE STUDY (Refer to Appendix 1 for an extended description).
Baba Musah, a 34 year old man was admitted into the ward after an emergency operation of appendicectomy. He was assessed and managed as per the hospital's protocol for managing postoperative patients. However, he persistently complained of pain, which was accompanied by unstable vital signs. Upon approaching him and discussing some of his problems, he appeared very comfortable. Subsequently, the vital signs stabilised and he verbalised an improvement in his pain.
CRITICAL REFLECTION USING CARPER'S PATTERNS OF KNOWING
According to Carper (1978, 1992), there are four ways by which knowledge can be acquired: aesthetically, personally, empirically and ethically.
Carper (1978) describes aesthetics as the perception gained from observing an event at a particular time. Aesthetics, at its most developed form, is the ability to understand a situation and act without much consideration (Slevin, 2003). From the cues on Baba Musah's face, I knew there was more to it than the postoperative pain and therefore approached him. This is what Polanyi (1966) describes as the tacit knowledge or Benner's (1984) intuitive expert practitioner; which is the knowing that cannot be explained. I then introduced myself and assured him of confidentiality. I proceeded on and asked him about his problems. He started crying as he began to speak, but I supported and comforted him. Afterwards, he became relaxed and continued with his narration. I inquired about his problems because he looked worried and helpless. Little did I know that this could provoke a person to cry. Notwithstanding, it compelled me to sit by his bedside to probe further into his condition.
From the incidence, I realised that people react differently in certain situations. Initially, I felt guilty because I thought my efforts had compounded his problem. Additionally, I was not very confident about how I could communicate with Baba to give him the support and comfort that he needed. For Baba Musah, I hoped he thought I had been of help and can have trust in me. For the nurses I worked with, they were very happy about the outcome of the intervention and I could easily recognise that from their facial and verbal expressions. It is difficult for me to say how Baba was feeling in the circumstance but he expressed his gratitude to me afterwards. Initially, I could easily recognise that he was upset however, he appeared relaxed and comfortable in bed after the conversation.
Personal knowledge refers to the awareness of self and others in an interaction (Carper, 1978, 1992). Initially, I was very surprised and uncomfortable when dealing with his tears. This is because in the Ghanaian culture, men do not usually cry in public. As a result of that, I was baffled and did not understand what was going on. This opinion is shared by Zborowski (1952), who proposed that certain pain beliefs are held by people based on their culture of socialisation. Notwithstanding, I expressed empathy and care towards Baba due to my own personal experiences of pain when I had a trauma. This is also in agreement with the findings of a survey that revealed that, previous pain experiences of care-providers influence their attitudes towards others in pain (Brunier, Carson and Harrison 1995; O' Brien, S., Dalton, J., Konsler, G. and Carlson, 1996. The knowledge and attitude of experienced oncology nurses regarding the management of cancer related pain. Oncology Nursing Forum 23, pp. 515-521.O'Brien, Dalton, Konsler et al., 1996). It was noticed after the incident that Baba was ashamed of himself for crying in public but I assured him to remain comfortable.
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Empirical knowledge pertains to the factual and impersonal knowledge that is gained from principles, laws, theories and science. (Carper 1978, 1992). Baba Musah was assessed and managed as per hospital protocol for managing postoperative patients. As a result of that, his vital signs were monitored periodically until stabilisation was achieved. Depending on the pain score, pain medication (intravenous pethidine) was given as appropriate. In the absence of significant improvement in his condition, I reflected on the importance of communication as a therapeutic tool. This influenced me in approaching him to find out the cause of his pain. Upon exploring his prevailing concerns, we discussed ways of dealing with them. Baba was educated about the disease process, management and outcomes. At the end of the interaction, subsequent assessments showed improvement of the pain and stable vital signs.
Ethical knowledge involves reasonable and moral assessment of what is considered right or wrong (Carper, 1978, 1992). Baba Musah was treated with respect and dignity by addressing him with his title, attending to his needs and providing him with the privacy that he requested. Notwithstanding, some of the ethical issues that evolve is about the rightfulness or wrongfulness of nurses to turn away from a patient who is in pain and to attend to other patients who equally needs to be cared for. Another ethical dilemma that arises from this case study is the provision of adequate information prior to an emergent operation in order to reduce the fear of unknown outcomes. However, this quandary can be dealt successfully after assessing the patient.
Some of the salient concepts which arise from this reflection are pain management, communication and comfort. According to Morris (1991), pain management is the alleviation of an individual's pain to an acceptable level. Communication is a reciprocal process of conveying information through verbal and non-verbal means (Arnold and Boggs, 1995; Balzer-Riley, 1996). Slater (1985) defines comfort as a pleasant state of physiological, psychological and physical harmony between a person and the environment.
Successful pain management depends on therapeutic nurse-patient relationship (Briggs, 1995). This implies that positive communication is a key factor in pain management. Subsequently, when pain is effectively managed, patients become comfortable. From the above-mentioned concepts, I will chose comfort as the main concept because it is a broader construct that subsumes pain management. Moreover, nurses become aware of patient's comfort through communication.
For many years, various authors have defined comfort from diverse perspectives. Some consider it as an indispensable factor for patients (Nightingale, 1859), while others view it as the main concern of nursing (Harmer, 1926). Although the meaning of comfort is implied in these descriptions, it can be deduced that it is the principal focus of nursing. Thus, Harmer (1926) emphasises on maintaining an environment of comfort when providing care.
Comfort is regarded as an important nursing action (Morse, 1983) and responsibility (Van Blarcom, 1953). As a result, nurses are judged by their ability to make their patients comfortable (Goodnow, 1935). For this reason, the American Nurses Association (1987) lay emphasis on maintaining patient's life in dignity and comfort until death. Undoubtedly, nurses are regarded as the most effective people in giving comfort to patients (Funk and Tornquist, 1989). Nevertheless, comfort is a subjective state and best determined by the patient (Richards, 1980; Paterson and Zderad, 1988). Moreover, the goal of comfort assists individuals to achieve a state of wellbeing (Gropper, 1992).
Semantically, comfort could be used as a noun, verb, adjective or gerund, in relation to either a process or an outcome. However, the term is described within nursing practice as a state of satisfaction following stressful health care conditions (Kolcaba, 1994). By virtue of the controversies on this contested concept, it can be realised that the concept of "comfort is multi-dimensional, meaning different things to different people" (Hamilton, 1985: 32). Personally, I define comfort as the satisfaction of needs, expectations or desires which when received, motivates an individual towards a sense of well being.
DESCRIPTION OF THE COMFORT THEORY.
Background of the theory
Katharine Kolcaba started her theory development during her masters programme in nursing (MSN) and completed it over a ten year period while pursuing her doctorate degree. In 1997, she graduated with PhD at Case Western University and published a book on Comfort Theory in 2003. The theory of comfort was developed through induction, concept analysis, deduction and retroduction (Kolcaba, 2003).
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At the inductive stage, Kolcaba introduced comfort into her framework for dementia care. She spent two years on comfort analysis and concluded with three types of comfort (relief, ease and renewal). This was later modified to bring about the current taxonomic structure of comfort, which defines comfort as the state of attaining needs for relief, ease and transcendence in the physical, psychospiritual, environmental and sociocultural contexts (Kolcaba 1991).
At the deductive stage, comfort was related to other nursing concepts to produce a theory. Murray's (1938) work provided a framework for accommodating Kolcaba's nursing concepts whereas, the three types of comfort were derived from the work of other nursing theorists. Relief was identified by Orlando (1961), ease by Henderson (1966) and transcendence by Paterson and Zderad (1976). The concept of health seeking behaviours (HSBs) was also adopted from Schlotfeldt (1975). During the retroductive stage, Kolcaba added the concept of institutional integrity into her middle range theory of comfort (Kolcaba, 2003). Comfort theory describes individualised patient care, and also predicts the benefits of continual comfort measures, comfort and involvement in health seeking behaviours (Kolcaba, 2003).
Concepts and Propositions
Major concepts described in the theory of comfort are comfort needs, comfort measures, intervening variables, comfort, health seeking behaviours and institutional integrity. Comfort needs arises from stressful health care situations that cannot be provided by a patient's support system. Nursing measures are designed to meet these needs taking into consideration the patient factors (past experience, age, attitude, emotional state, support system, finances) that can affect the perception of comfort (Kolcaba 1994).
Comfort is a holistic experience and can be provided in the physical, psychospiritual, environmental, and sociocultural contexts of life (Kolcaba, 1994; Kolcaba and Fox,1999). Kolcaba (2001), defines the 3 types of comfort as follows: relief as the provision of a specific health care need, ease as a position of steadiness or happiness and transcendence as a state whereby one rises above life's challenges.
Applying Kolcaba's (1991) taxonomic structure to my case study, the table below depicts the comfort needs I identified.
Patient thinking "how can I tolerate pain when I get up?
Crying, uncertainty about prognosis
Need for emotional and spiritual support.
Noisy ward, surrounded by other surgical patients in a large ward.
Lack of privacy.
Need for calm familiar environment.
Absence of usual routines, family and education.
Absence of family.
Need for support from staff and significant others. Need for information.
Health seeking behaviours refer to outcomes that occur when comfort is achieved; they can be internal, external or to a peaceful death (Schlotfeldt, 1975).Â Kolcaba (2001) describes institutional Integrity as the entire elements in an organisations, and expresses a recursive relationship between comfort and the integrity of institutions.
Kolcaba (2001) defines the metaparadigm concepts as follows: Nursing is the deliberate assessment of comfort needs before and after comfort interventions. Patient is an individual, family or community that requires comfort. Environment as the external background of a patient that can be controlled to increase comfort. Health is the most favourable performance of a patient.
According to Kolcaba (1994), the basic assumptions of the theory are that: comfort is a desired outcome; humans actively strive to meet their comfort needs; patients are strengthened when comfort needs are provided.
ANALYSIS OF THE THEORY OF COMFORT
According to Barnum (1990), the internal and external aspects should be taken into consideration when analysing a theory; internal criticism pertains to the inner structure while the external criticism describes its peripheral relationship.
Clarity: refers to the presentation of a theory and how it is understood by the reader (Barnum, 1990). Apart from the article on concept analysis which is difficult to read (Dowd, 2006), the theory is well presented in the literature and is easy to understand (Wilson, 2009). For additional acknowledgement and understanding, Kolcaba clearly presents the evolution of the theory (Wilson, 2009).
Consistency: A consistent theory maintains uniformity in its definitions, principles and interpretations (Barnum, 1990). It can be realised that the definition of the concepts, derivations, propositions and assumptions are undifferentiated throughout the literature (Wilson, 2009).
Adequacy: The concepts, propositions and assumptions of the theory are specific to nursing and can be easily operationalised in various settings (Dowd, 2006; Wilson, 2009). The theory does not merely describe what nurses do, but also accounts for outcomes that are important to patients, their health and the integrity of institutions (Kolcaba, 1994; 2001; 2003). Wilson (2009) identifies that each type and context of comfort has been thoroughly explained and relates to the provision of care for any patient.
Logical development: is determined by coherent presentation of arguments that results in the conclusions of a theory (Barnum, 1990). Kolcaba thoroughly discusses the evolution of the theory in the literature (Wilson, 2009). Her conclusions are supported by detailed arguments (Wilson, 2009) and research using appropriate tools such as the visual analog scales, Comfort Behaviour Checklist and various questionnaires which are adapted from the General Comfort Questionnaire to suit the target population (Kolcaba, 2001).
Level of theory development: Comfort theory conforms to the standards of a middle range due to its limited number of concepts and propositions, minimal degree of abstraction and its application in practice (Wilson, 2009). The theory has been tested and supported in some studies (Kolcaba and Fox, 1999; Dowd, Kolcaba and Steiner, 2000), whilst others studies found little significance (Kolcaba, Schirm and Steiner, 2006).
Complexity: is determined by the relationship between variables of a theory (Barnum, 1990). The six concepts of the theory are well related in a conceptual framework (Wilson, 2009), and facilitates its application in both practice and research. The theory is simple, precise, and thoroughly explained (Dowd, 2006). As a result, it can be easily learnt and applied in practice by nurses and nursing students (Panno, Kolcaba and Holder, 2000)
Discrimination: refers to the uniqueness of a theory to a practice discipline (Barnum, 1990). The holistic nature of nursing is depicted by the four context of comfort experience (Wilson, 2009). The theory is predominant in the world of nursing, but can be applied in a wide range of settings (Dowd, 2006; Wilson, 2009). Comfort has been defined as a state and an outcome that is desirable, in spite of the variations in its meaning (Kolcaba, 1994).
Reality Convergence: is measured by the existing relationship between the world and a theory's principles, interpretations and methods (Barnum 1990). As depicted in the literature, the principles and assumptions of the theory are well defined and can be applied to any patient population (Dowd, 2006; Wilson, 2009). According to Wilson (2009), the evolution of the theory enhances clarification and application in practice. In spite of the fact that comfort is perceived as a major component of nursing (Kolcaba 1994), this view is opposed by McIlveen and Morse (1995) who perceive it as a minor nursing strategy in an epoch of medical and societal advancements.
Pragmatic: The theory can be applied in all health care settings where patients have needs for comfort. Comfort theory serves as the basis for assessing the patient needs and implementing nursing measures (Dowd, 2009). Moreover, Kolcaba (1991) has developed instruments (such as General Comfort Questionnaire and Comfort Behaviour Checklist) to objectively measure this subjective concept. Nevertheless, Kolcaba's inclusion of community in her "patient" definition" creates difficulties when implementing nursing measures ,and evaluating outcomes in larger groups of people (Dowd, 2006). Additionally, the desired age for understanding the complexities of comfort is also not specified especially in children (Dowd, 2006). In my opinion, the physical aspect of transcendence is not realistic.
Scope: The theory of comfort is a middle range due to its limited concepts, minimal degree of abstraction and its application into practice (Kolcaba, 2003). Although it can be used in specific patients and settings, it can also be applied in all patient groups and health care settings (Dowd, 2006; Wilson, 2009). As a result, Wilson (2009) regards the scope of the theory to be broad.
Significance: A significant theory addresses issues of importance to a practice discipline and contributes towards knowledge development (Barnum, 1990). The theory of comfort is well known in the world of nursing. On the premise of this theory, comfort is a basic aspect of nursing care (Wilson, 2009) and a desirable patient outcome in any health care setting (Kolcaba 1994). As a result of that, nurses strive to attain goals such as relief, ease or transcendence for their patients (Wilson, 2009). The theory accounts for individualised patient care and predicts the benefits of enhanced comfort and involvement in health seeking behaviours (Dowd, 2006).
Utility: Utility is assessed by the usefulness of a theory in practice (Barnum 1990) and research. Kolcaba (1991) has developed questionnaires to help identify aspects of comfort needed by patients to assist practitioners in assessing the comfort needs of patients. The theory assists nurses to implement appropriate interventions to meet the identified needs. Recently, the comfort theory has been used in different populations to yield practice-level theories for obstetrics (Schoener and Krysa, 1996), hospice care (Vendlinski and Kolcaba, 1997), perioperative nursing (Kolcaba and Wilson, 2002, 2004) and paediatrics (Kolcaba and DiMarco, 2005).
Parts of the theory have been tested and supported in studies involving the use of guided imagery among early stage breast cancer women who were undergoing radiation therapy (Kolcaba and Fox, 1999), and the use of cognitive strategies in people with problems of urinary incontinence (Dowd, Kolcaba and Steiner, 2000). Notwithstanding, a study done using comfort theory found no significant improvement in the comfort of nursing home residents following hand massage as an intervention (Kolcaba, Schirm and Steiner, 2006).
Comfort measures such as presence and a caring nursing approach have been found to be effective in assisting postpartum women (Collins, McCoy, Sale et al., 1994). Hogan-Miller, Rustad, Sendelbach et al. (1995) found the use of sheet-tuck and sand bag immobilisation to be effective in enhancing comfort and reducing haemorrhage. Patient metaphors were also used as a basis for implementing interventions which resulted in the achievement of their physical and emotional comfort (Jenny and Logon, 1996). Comfort measures have been found to be cost-effective by reducing medications required and also empowers labouring women (Schuiling and Sampselle, 1999).
In a study which aimed at describing the effects of comfort interventions at an emergency department, it was found that the use of comforting strategies had a positive impact on the physical and emotional health of participants (Hawley, 2000). According to Koehn (2000), comfort theory can provide an appropriate framework for directing the care of child bearing women due to the multidimensional nature of labour, and the holistic aspects of alternative and complementary therapies. Also, in a phenomenological study conducted on postoperative patients, music was found to have increased the comfort of patients, made their environment more familiar and distracted them from painful and fearful experience (McCaffrey and Good, 2000). Findings of a study which measured the comfort of 38 patient-caregiver dyad/ couple using the End of Life Comfort Questionnaire found the instrument to be very useful in this population (Novak, Kolcaba, Steiner and Dowd, 2001). Comfort was found to be among the main roles of orthopaedic nurses in a grounded theory study (Santy, 2001).
A pilot study conducted by Robinson and Benton (2002) found warmed blankets to be effecting in enhancing the comfort of hospitalised elderly patients. Also, a survey conducted by Wagner, Byrne and Kolcaba (2006) established comfort warming to be effective in preoperative patients, in terms of temperature management and anxiety reduction. The results of a survey showed that nurses' comfort was directly related to the viability of institutions (Kolcaba, Tilton and Drouin, 2006). Moreover, the results of a survey conducted by the National Institute on Aging (2009) on families of dying patients receiving long term care showed that the provision of comfort interventions to these patients were of utmost concern. In a grounded theory study on "therapeutic relationship in day surgery", Mottram (2009) found that aspects of comfort such as building rapport and listening to patients were effective in reducing preoperative anxiety and psychological discomforts. Also, a review conducted by March and McCormack (2009) demonstrated how the comfort theory can be used in guiding other health care disciplines.
APPLICATION OF KOLCABA'S THEORY IN MY PRACTICE (SURGICAL NURSING).
Surgery presents a lot of challenges for many patients and results in fear, anxiety, pain (Martinez-Urrutia, 1975) and other problems. As a result of this, preoperative preparation is very vital for the success and outcomes of surgery. Comfort theory uses the nursing process approach and has been applied in obstetrics (Schoener and Krysa, 1996), hospice care (Vendlinski and Kolcaba, 1997), perianaesthesia (Kolcaba and Wilson, 2002, 2004) and paediatric settings (Kolcaba and DiMarco, 2005).
In my clinical setting, this theory can be used as a guiding framework when care is being provided to patients before and after surgery. During the preoperative phase, the perianaesthesia comfort questionnaire can be used to assess the comfort needs and expectations of the patients. Based on a holistic patient assessment, appropriate comfort interventions can be implemented to achieve homeostasis, and also to make the patient comfortable for the impending operation.
Following surgery, appropriate interventions can be provided depending on both subjective and objective assessment findings. Generally, comfort measures can be grouped as standard interventions (patient assessment, treatments), coaching (reassurance, information, listening) and comfort food (warmth, music, massage) (Kolcaba and Wilson, 2002: 105). As these interventions are provided, patients will be strengthened to consciously or subconsciously engage in health seeking behaviours that would lead to the promotion of their well being. Thus, institutional outcomes such as earlier discharge, low readmission rate, decreased cost, improved patient and nurse satisfaction would be achieved (Kolcaba, 2003).
In addition to directing practice, the theory can be used in guiding research and the teaching of staff and students on how to holistically assess patient needs and to provide appropriate interventions which are safe, convenient and cost-effective.
It was the aim of this essay to apply a nursing theory to a phenomenon of interest in my clinical practice. From my theory search, I found Kolcaba's theory of comfort to be simplistic and very comprehensive in dealing with the needs of patients in my setting.
The theory of comfort provides a model for directing nurses in the assessment, planning, implementation and evaluation of care given to patients. The theory can be used in directing practice as well as research and nursing education. Through the use of this theory, nurses and nursing students can learn to provide an alternate care or supplement it to medical practice (Koehn, 2000).
Undeniably, an increase in holistic practice, research and education will significantly contribute towards a nursing shift away from the biomedical paradigm, thereby lowering hazards to clients and improving patient outcomes (Koehn, 2000).
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During my practice as a general nurse, I have had various encounters with patients in different settings but one of them which I will never forget is that of a patient whom I have named Baba Musah for the sake of confidentiality. Baba Musah, a 34 year old man was admitted into the ward at around 7.30am after an emergency operation of appendicectomy.
He was assessed postoperatively and put into an already prepared operation bed. His vital signs (temperature, pulse rate, respiratory rate and blood pressure) were assessed as per hospital protocol for monitoring postoperative patients, however, they were persistently unstable. When he was asked to rate his pain on a verbal rating scale of 10 (where 0 means no pain and 10 indicates very severe pain), he scored it at 8 signifying that he was in the worst pain possible. His medication (intravenous pethidine 5mg) was administered as prescribed with the aim of reducing his pain and stabilising the vital signs. Nevertheless, all these proved futile since there seemed to be no significant improvement in his pain and the vital signs were still not stabilised.
This incident really puzzled all the nurses around, however, we had to attend to other patients as well. This issue kept bothering my mind and left me thinking of how I could help in the situation. From the cues on his face, there seems to be more to it than just the postoperative pain. In an attempt to help, I went for a chair and sat by his bed side for a conversation. Prior to the conversation, I introduced myself and assured him of confidentiality. I proceeded on and asked him about his problems. As he began to speak, tears filled his eyes and he started crying. I had to comfort him and wipe off the tears. Afterwards, he became a bit more relaxed and started narrating his story.
From the interaction, I realised that he had a lot of issues to deal with and this might have had an influence on his condition. He was a self employed carpenter, whose wife had delivered 3 days ago and a father of 2 children. According to him, this was the first time he was being hospitalised and having a surgical operation at the same time. I realised from the interactions that, he was concerned about the welfare of his family and payment of the hospital bills. He was also worried about how he was going to resume work after surgery since he was not adequately informed about the expectations after surgery. I noticed from the conversation that he had given up on life and felt very helpless. Notwithstanding, I encouraged him and we had a discussion on ways of dealing with the problem. Various pain management strategies were discussed as well and he appeared very much relieved afterwards.
At the end of the interaction, I asked him to assess his pain and he rated it at 6; signifying that the pain had reduced from severe to moderate. Coincidentally, his subsequent vital signs checked had stabilised considerably. He was very appreciative of what I did and kept on saying "thank you, God bless you". This incidence was an enigma, however, I really appreciated the nursing care given and realised that there was more to it than just the technicalities.
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