Middle-Range Theory: Comfort in the Operating Room

Kolcaba’s Theory of Comfort is considered in the nursing scholarship as a middle-range theory not only because of its specificity in addressing the practice concept of nurse-provided comfort but also due to its straightforward description of the process by which comfort may be consistently delivered to patients and assessed by nurses (Sitzman & Eichelberger, 2010).

The theory has found increasing usage in many practice settings requiring the application of a multiplicity of comforting strategies to patients due to its limited number of conceptualizations and prepositions, low level of abstraction, and ease of application to actual clinical practice (Fawcett, 2005; Kolcaba & DiMarco, 2005). The present paper attempts to demonstrate the implementation of Kolcaba’s Theory of Comfort in the operating room.

In her seminal work on the theory, Kolcaba defined comfort in terms of an “immediate state of being strengthened through having the human needs for relief, ease, and transcendence addressed in four contexts of experience (physical, psychospiritual, sociocultural, and environmental” (Kolcaba & DiMarco, 2005, p. 188).

Consequently, the major premise in Kolcaba’s theory is that patient comfort exists in the mentioned three forms (relief, ease, and transcendence), with relief comfort arising from having a specific need met, ease in comfort arising from a state of calm or contentment, and transcendence arising from a state of being in which a patient develops the capacity to rise above own problems or pain (Kolcaba, 2003; Kolcaba, Tilton, & Drouin, 2006).

In further illuminating this theory, it is important to note that the three forms of comfort described above occur in four contexts of experience, namely physical (about bodily sensations and homeostatic mechanisms), psychospiritual (about internal awareness of self, including esteem, concept, sexuality, the meaning of one’s life, and one’s relationship to a supernatural being), sociocultural (about interpersonal, family, and community relationships, as well as family traditions, rituals, and religious practices), and environmental (about the external background of human experience) (Kolcaba & DiMarco, 2005).

It is also imperative to underscore that the Theory of Comfort as posited by Kolcaba can be used in a wide variety of nursing settings due to its consistency with values such as the provision of care, holism, homeostasis, pain and symptom management, patient-nurse relationships, healing environment, and identification of patient needs (Kolcaba et al., 2006).

Available literature demonstrates that most adult patients presenting in the operating room for the surgical removal of esophageal cancer are faced with a lot of distress due to limited treatment options, physical and emotional complications related to recovery, as well as local recurrence and distant metastases (Logue & Griffin, 2011).

As postulated by these authors, “nursing care revolves around complex care managing multiple body systems and providing effective education and emotional support for both patients and patients’ families” (p. 69). In the operating room, it is evident that the forms and contexts of the comfort theory highlighted in this paper are not only specific but can be targeted to address the comfort concerns of adult patients presenting with this type of cancer.

The underlying principle is that, if patients undergoing esophagectomy (surgical removal of esophageal cancer) are made to feel comfortable during the pre-operative and post-operative phases, they will feel better both emotionally and physically, which will, in turn, help them to undergo the operation process with ease and recover quicker after the operation.

Most patients with esophageal cancer demonstrate increased anxiety levels and reduced information retention levels not only due to the knowledge that they have to undergo surgery soon after cancer has been diagnosed but also because of the little time they have to absorb information and develop realistic expectations (Logue & Griffin, 2011).

These authors further note that the “anxiety is often intensified by the fact that a reliable prognosis can be given only after surgical resection, when pathology results are available” (p. 69). In such a practice setting, Kolcaba’s Theory of Comfort can be used to strengthen the state of patients through the provision of the human needs for relief, ease, and transcendence.

For example, owing to the fact esophageal cancer is particularly painful (Logue & Griffin, 2011), nursing professionals should ensure that pain medication is administered to the patients pre-operatively and post-operatively to ensure that such patients feel relief from the medication’s effect on their pain. During the operation, nurses should always ensure that these patients receive the correct doses of anesthesia (morphine) and other related medications to help them achieve comfort in the relief sense (Kolcaba, 2001; Logue & Griffin, 2011).

Because ease of comfort is to a large extent embedded in the psychological state of patients, it is common knowledge that the patients will become at ease when the pain starts to subside (Sitzman & Eichelberger, 2010). In the operating room, most patients presenting with esophageal cancer undergo general anesthesia before being operated on (Logue & Griffin, 2011), implying that their ease of comfort in the strict sense of the theory comes from being unconscious.

Lastly, transcendence among patients presenting for esophagectomy happens when they develop the capacity to rise above their challenge of being victims of esophageal cancer and related pain (Kolcaba et al., 2006). Transcendence for this group of the population can be achieved by sharing knowledge of the disease with the patients, keeping patients and their families informed of daily progress, improving patients’ tolerance of treatment regimens, maintaining stability, and realizing recovery in an attempt to assist patients to attain the optimal quality of life (Logue & Griffin, 2011).

To achieve optimal outcomes in the operating room, nurse professionals also need to consider the contexts of experience as conceptualized in the theory. In the physical context, for example, nurses should provide patients with warm blankets to increase their body temperature after esophagectomy with the view to assisting them to achieve comfort in the relief sense.

Similarly, in both sociocultural and psychospiritual contexts, nurses should consider sharing information with patients, following their religious rituals if any, and consulting a religious leader to pray for them before being operated upon, as these will not only address their comfort needs by reducing anxiety and stress but also enable them to rise above health-related challenges.

Additionally, in the environmental context, nurses in practice settings may consider providing patients with private, serene rooms before and after the operative procedure with the view to addressing their comfort needs.

Lastly, it is important to mention that the evaluation plan for the implementation of the theory in the operating room consists of the following:

  1. nurses verbally asking the patients if they are feeling alright, with responses being indicated in a documentation form as “yes”, “no”, or “not sure”,
  2. providing patients with Comfort Daisies so that they can self-rate their level of comfort on a scale of one to four, and
  3. using an adaptation of the General Comfort Questionnaire to measure comfort levels prior and after the operation (Kolcaba 2004; Kolcaba & DiMarco, 2005).

The deficits in the implementation plan should be improved by developing and implementing more comfort-oriented interventions to address the comfort needs of patients.

Overall, it is evident from this discussion that Kolcaba’s Theory of Comfort can be successfully applied in the operating room to strengthen adult patients undergoing esophagectomy by effectively reinforcing their relief comfort, ease of comfort, as well as transcendence.

References

Fawcett, J. (2005). Middle-range nursing theories are necessary for the advancement of the discipline. Aquichan, 5(1), 32-43.

Kolcaba, K. (2001). Evolution of the mid range theory of comfort for outcomes research. Nursing Outlook, 49(2), 187-194.

Kolcaba, K. (2003). Comfort theory and practice: A vision for holistic health care. New York, NY: Springer.

Kolcaba, K. (2004). Comfort. In S.J. Peterson & T.S. Bredow (Eds.), Middle range theories: Application to nursing research (pp. 255-273). Philadelphia: Lippincott Williams & Wilkins.

Kolcaba, K., & DiMarco, M.A. (2005). Comfort theory and its application to pediatric nursing. Pediatric Nursing, 31(3), 187-194.

Kolcaba, K., Tilton, C., & Drouin, C. (2006). Comfort theory: A unifying framework to enhance the practice environment. Journal of Nursing Administration, 36(11), 538-544.

Logue, B., & Griffin, S. (2011). Road map to esophagectomy for nurses. Critical Care Nurse, 31(4), 69-86.

Sitzman, K., & Eichelberger, L.W. (2010). Understanding the work of nurse theorists: A creative beginning (2nd ed.). Sudbury, MA: Jones & Bartlett Learning.

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