More exploration of comfort theory

Case study (entirely fictional, but based on my experiences)

Tracy, the operating room nurse, quickly reviews Mrs. Brown's chart noting the surgeon's orders and pulling out the consent form. She sits down on a stool next to Mrs. Brown puts her hand out to shake and introduces herself and states her role. Tracy has only a few minutes to do a visual head to toe assessment and ask a handful of questions of Mrs. Brown, but she wants her patient to be comfortable. Tracy sits to put Mrs. Brown at the same level; she ensures the environment is quiet and that Mrs. Brown is warm enough. Tracy asks Mrs. Brown to verify her identity and confirms her preferred name, Blanche. Tracy asks if Blanche has anyone waiting for her today. Tracy then explains her plan to communicate with them during surgery. Allergies are confirmed, including a a specific question about iodine and latex just in case Blanche forget to mention any sensitivity to those. Tracy asks Blanche to state in her own words what surgery she is having and has Blanche confirm her signature on the form. This allows Tracy to verify that her patient understands what surgery is to be performed; it also allows the patient to ask questions if she doesn't understand the medical terms. Tracy then does a quick inventory of Blanche's physical status, asking questions about belongings, metal implants, ability to move and any pain. This allows Tracy to do a visual head to toe assessment to understand how to best care for Blanche in the OR. Now Tracy teaches Blanche about what to expect in the OR. She assures her patient that even if she is cold or many people are talking, Blanche only needs to say something to get more warm blankets, to know that Tracy will be there for her. Tracy also mentions things that Blanche may see when she wakes up from surgery. Telling the patient to expect a catheter and orange-tinted skin helps to alleviate anxiety post-operatively. As Tracy is instructing Blanche about the catheter she sees a frown cross the patient's face. Tracy then informs Blanche the reason for needing a catheter during surgery. Since Blanche's surgery will be longer than 3 hours and she will have a large abdominal incision, a catheter is necessary so she will wake up in recovery comfortable and not have to worry about getting up to the bathroom immediately. As soon as Blanche is up walking the catheter will be removed. Blanche's frown eases a little, but she asks if she can be put under anesthesia before the catheter is placed. Tracy assures Blanche that she will not be awake for the catheter placement. Blanche's expression relaxes and Tracy asks one final question, "Do you have any questions for me?" Blanche thinks for a moment then says "No." Tracy states that any time Blanche does have questions she can ask anyone. Tracy then says she will see Blanche in a few minutes and leaves to help prepare the OR.

Using Kolcaba's taxonomic structure for the concept of comfort (1991), we can see that the nurse accomplishes physical ease and social relief. The nurse sits to be at the same level as the patient, limits the environmental noise and makes sure the patient is warm enough. These actions directly contribute to the patient's current physical ease. The nurse also asks about any pain the patient may be experiencing. Knowing about current pain sensations can allow the nurse to address these in several ways: she can ask the surgeon or anesthesiologist to provide an analgesic and she can take special care when moving the patient during the positioning in the OR. These actions also contribute to physical ease immediately and post-operatively. The nurse also tries to contribute to future physical ease through teaching: informing the patient of things that may be anxiety producing following the surgery can help reduce physical discomfort in recovery. The nurse responds to the patient's discomfort about the catheter when she notices the frown. Addressing the patient's concerns allows the patient to achieve calmness about potential unpleasant body sensations. When the nurse informs the patient about her plans to communicate to the family she contributes to social relief. Many patients are concerned about the anxiety their family may be experiencing. Informing the family of the patient's progress intra-operatively can meet the patient need to reduce their family's anxiety. Another way the nurse contributes to social relief is informing the patient that she will be available to the patient during a time that the patient may feel most alone - in the chaotic, noisy and cold environment of the OR. Finally, giving the patient some control over her situation by ensuring any questions that patient has are addressed can reduce anxiety and allow for a greater sense of physical and social ease.

Applying comfort theory to The Death of Ivan Ilyich by Leo Tolstoy

Note: I have an eBook so page numbers may be off, I included page numbers as they were reported in the Kindle application which says the book has a total of 57 pages.

Before Ivan becomes ill, it is clearly shown that he is especially fond of improving his social comfort. When changes occur in society via "new and reformed judicial institutions (p. 11)", Ivan becomes one of the "new men ... needed (p.11)." He enjoys affairs, visits from people of rank and carousing. He always remains proper "with clean hands, in clean linen, with French phrases, and above all among people of the best society and consequently with the approval of people of rank (p. 11)."  So when he becomes ill, Ivan's thoughts are most concerned with approval from those he considers leaders in society and his own family. His "chief occupation was the exact fulfillment of the doctor's instructions (p. 25)" to ease his social discomfort of having this illness. He was able to "force himself to think that he was better (p. 25)" as long as his social comfort was stable. If he had an unpleasant encounter with his wife or a bad day at work his awareness of his discomfort was immediate. He even blames the negative social interactions and the people causing them as "killing him (p.25)." These bad encounters cause him to be angry and he feels the anger is uncontrollable and contributing to his illness. He feels alone and that none care about what was happening to him; he feels as if he were some obstacle inconveniencing his family (p. 26).

If we apply Kolcaba’s theory of comfort, focusing on the social relief aspect, it is easy to find many examples throughout the story where social interactions could have been different, leading to a more socially comfortable Ivan. It is important for Ivan to feel he is important to his family and to himself. Without the approval and support of his family he feels alone, his social needs are not being met. Ivan needs a calm environment with calming family and friends. His wife and daughter are “in a perfect whirl of visiting (p. 26)” but he feels they do not understand and are “annoyed that he was depressed and so exacting (p. 26).” If these two, who are constantly around Ivan, had been more calm and less irritated at Ivan’s pain, it is possible Ivan may have experienced more social relief. It is apparent that many of Ivan’s social comfort needs were lacking, especially from his family. Ivan has many social needs that could’ve been met better by many of his visitors. Speaking with him, rather than about him would’ve helped Ivan feel more important to his friends and family, meeting Ivan’s need for social comfort.

Truthfully, I’m not sure Ivan would’ve had his needs met, he appears to be a very unhappy person to begin with. He pursues status and material belongings more than healthy social interactions. The interpersonal relationships he does have are all based on gaining more status rather than making connections. I tried to show how social comfort might have improved Ivan’s comfort, but I really doubt anything would have worked better than Gerasim in providing Ivan with any comfort. But even Gerasim’s comfort was more social than physical or environmental. Gerasim provided social comfort by being present with Ivan, not making demands, and allowing Ivan to keep him from his other chores (p. 37). Gerasim was calm and attentive; he met social needs for Ivan when nobody else in his family could. He enabled Ivan to feel that his comfort was important to someone.

When things go well...

...it may still seem like you got run over by a train.
In the room early to look over things and to make sure I can go see the patient as soon as I clock on. Get to the induction room and I am too late. Anesthesia is talking to the patient, not noticing me, and discussing an epidural. I wait a few more minutes to see if they will notice me and let me have a few minutes. Then the surgeon walks in. Well, I am not going to be talking to the patient any time soon and there is lots to do in the room still. I go back to the room and help my stressed out scrub start getting the room open. She's stressed because they put her in the room at the last minute and it's a big set-up with lots too do. I tell her to relax. The patient is getting an epidural so she has time to set up. I also am willing to let them know we can't bring the patient back until we are ready. Get more equipment and supplies and we get her scrubbed in. Others who don't have cases in their room, or they are are turn-over team or the induction room nurse help. I go to interview the patient. The family is outside the patient area waiting. They are taking pictures of everyone who is helping, including me. I take a few minutes to talk to the family about what I will do for them (call every couple hours with an update). I also let them know that even if they leave the waiting area, messages will be communicated when they return.
Anesthesia is done and I let them know that we can't go back until I talk to the patient. And yes, we are ready to go to the room.
That was the easy part. The start of cases can be very busy for the circulator, today was no exception. It was worse than usual because once we finished one part I had to move equipment out of the room. Then there was the pagers. Oh my goodness I hate doctor pagers! I would answer one page and sit down to do charges or charting and another pager would go off.
Well, by the time this case finished I was tired. So even when things go well, sometimes you are exhausted by the end of the case.

Working with the robot

Robot really is a misnomer. It is more like remote manipulation. Whatever.
I was in the robot room today. The really small robot room. The room is small, not the robot. About 15 minutes before the day was supposed to start my scrub calls me: the bus is running late, she might be a little late. She gives me a list of things to open, doctor uses the 3rd arm and we need the extra drape and another sealing cap. Got it. I go through the supplies and instruments. Make sure we have everything we need - and we don't. CS sent us two different manipulators, both are large. I need other sizes. No trocars in the supplies and the laparoscopy cart is missing the 5mm sleeves. Call CS, get the other manipulator sizes, get the sleeves from the other laparoscopy cart, open the whole room and my scrub walks in only a few minutes late. She grabs suture and scrubs in. I get her gowned up and go talk to the patient. Sweet couple, nervous but ready for the day. Doctor shows up and that ends my interview.
That really bothers me. I really need to not let it, but it does. Doctor walks in and all conversation stops with anyone else. I understand that the patient knows the doctor better than me, or even our anesthesia staff, but it's just rude. I have important things I need to know!
Get back to the room and get the robot draped and the camera draped. We are golden. Room's ready a few minutes before our goal time. I am even anticipating some of the things I will need. I actually felt really good about the set up. Get the patient in the room and things come to a screeching halt after the surgeon starts. OK, not a screeching halt, but it took a while to make incision. The phrase, I will be rude here, is "Tell her partner she needs to use the strap on more often." Just a joke, but the surgeon had a really difficult time getting the manipulator in the virginal orifice. We all laughed a little to ease the tension. They really are a sweet couple.
Otherwise, the case went well. Got relieved for lunch as we were finishing and came back to chaos. I felt lost. It took me a few minutes to remember all of the things I had to gather for the previous case then I was off and running. Turnover was a little long, but when you have relief staff I expect turnover to run a little longer.
Second case started out great. Then trouble crept in. I looked up from my charting and a fountain of red was giving the surgeon a reason for using the bipolar cautery non-stop. Got that under control, but the adhesions and the bleeding had shaken the surgeon a bit. Called in some help. Ended up with 5 surgeons and finished the procedure as planned.
Really, it was a good day. It's possible it's because the surgeon is really nice, generous with her praise and thanks. Even when things were going tough she was nice. She's awesome with the patients and I am sure she explained to our first patient's partner why it took us a little longer to get done.
Tomorrow is a Whipple. Maybe I can read a bit of my book on making leadership matter for school.

A day in the life of surgery

I was all set to work hard, turning the room over multiple times and getting through 5 quick cases. Well, the best laid plans...
First case went well, started just about as early as is possible. Except our OR lights quit working on us and I had to call engineering to come try to fix them. Called my facilitator to send for the next patient and come to find out s/he is not in the hospital. Can we get a hold of them? No, tried 4 times. Maybe they are on their way in? Finally we get the correct number and they didn't even know they were having surgery today, and they didn't have a ride to the hospital. Well, then let's start calling the next patient in early. Again, no pick up. We're done with the first case now and no next patient. The day is looking like it's getting longer.
Finally as we roll the patient to recovery we find out the 3rd patient is on their way in, will be here at the time they were supposed to check (in an hour) and the rest of the patients have been called moving their check-in time up. 2nd case is cancelled (so sorry, try again some other day when you have a ride and know you are having surgery).
I get a little break even after taking a copy of my degree to HR.
I go interview our next patient, who has been rushed through check-in and who has yet to talk to the pre-op nurse. I take my 2-3 minutes and go get the room ready. For some reason the pre-op nurse took quite a while to get our patient ready. Maybe the patient was chatty, s/he did seem to want to talk to me a bit.
Finally we are moving along again but in a different room because engineering is going to need at least 2 hours to fix the lights, it's not just a burnt out bulb apparently. Finish this case and go to lunch while another team, in another room is supposed to do our now 3rd case. Again, long delay in getting the patient into the room. I finished lunch and relieved the circulator so he could get lunch right before his relief arrived.
As the surgeon came in, I asked if I could send for the next patient. Yes. Went to the induction room and saw that patient. Nice quick interview, get my local and go open the room. Room is completely set up except for scrubbing in to set up the instruments. The facilitator scrubs and we finish getting the room ready. Surgeon walks in and about 3 minutes later our patient is in the room. Like a dream, like it's supposed to be done. Took all day, but we finally had a case go smoothly. For our part.
Still got done more than 2 hours before original schedule said we would, but it sure was a struggle.
As I said, the best laid plans...
Everyone was in a good mood, so no scalpel throwing - not that I could ever see this surgeon doing so, he's a real nice guy. Other surgeons, though, might have been having a bit of an issue with rising blood pressure. I just tried to make sure my part of the whole circus was done, left it up to everyone else to do the same. In the end, it was a nice easy day, long breaks and only 3 cases instead of 5.

Comfort theory - a bad example within perioperative nursing

As part of the assignment to explore comfort theory without our clinical practice, we are supposed to write a contrary story of comfort. Again I have no specific story to tell, but can glean a few tidbits from things I have seen or experienced (by doing). Enjoy.

Again, I do not have a good specific story to tell related to what comfort theory in the perioperative setting is not. What I can do is provide examples of behavior by some OR nurses that I believe does not promote comfort.

Bringing a patient to the OR can seem like a production line at times, to the staff and especially for patients. In light of this kind of feedback from patients, I question our push to get the next patient into the room as quickly as possible after completion of the previous case. This push to hurry comes through during our interview with the patient. I see nurses talking to patients rather than talking with patients. I see nurses ignore the questions on patient faces - patients want to ask but they can sense the hurry the nurse is in and don't want to interrupt. I also see nurses do an interview in such a way that they do not provide the patient the opportunity to ask questions during or after.
Being a new nurse, I am sometimes too eager to teach a patient about things. This has, on several occasions, brought about distress in the patient. They don't want to think about the drain, or the reasons for needing such a thing.
Catheters are a huge issue for patients. I must inform a patient if there is a need to place a catheter. It's an unpleasant procedure and a catheter can be very uncomfortable to have in place. Many patients ask "Why do you need to give me a catheter?" and ask if we can just skip that part. This does give me the opportunity to teach them the reasons for why it is needed, but it can still be distressing to patients. (Luckily, they get to be under anesthesia when I place it, that sometimes comforts them.)

At my place of work we are supposed to have the ability to "Stop the line" at any point in the process of getting a patient to surgery or even once a patient is undergoing surgery to make sure that safety is maintained. I once had to stop the line as the patient was rolled into the OR because we had just discovered a contaminated set and our Central Services did not have a ready replacement. I am sure this was distressing to the patient to lie on a stretcher in that cold, noisy room for 15 minutes while we scrambled around to get a replacement.

Sometimes a patient wants to know that you are the expert in that particular surgery. I can't lie to a patient, but telling a patient I am new is not the right answer either. I have to deflect the question, skirt around the answer the patient wants, instead I have to say that "We" do many of those surgeries here every month (or something along those lines). I can tell sometimes this is not what the patient wanted to hear.

Patients in surgery struggle with many emotions, most related to the loss of control of what is going to happen to their body. Nurses who do not keep this in mind while interacting with the patient are doing the wrong thing to provide comfort.

Comfort theory - a good example within perioperative nursing

We are exploring comfort theory in class. Our assignment this week is to post an exemplar story about comfort in our clinical setting. Here's my attempt at  this: 

I don't have a specific story of comfort to write about. I will try to gather the ideas that I believe have helped to provide comfort to patients in my nursing care. The most difficult part of providing comfort to a patient coming to the OR is that each of their experiences and circumstances make their situation unique. I must tailor my brief time with them while they are conscious to provide the best care (and comfort) I can.

Perioperative nursing is quite different from bed-side nursing. We have limited contact with conscious patients; rather our patients must trust us to care for them when they have lost all ability to care for themselves while under anesthesia or sedation. Patient advocacy is one of our biggest responsibilities. Some patients are well-prepared for surgery or are in such a state that surgery is something to "just get done with it." Other patients are not ready for the loss of control that they must experience just getting to the OR. We take their clothes away, we pry into their private information, question after question after question. Does anyone read the chart?
Interviewing the patient preoperatively is one of the most important forms of advocacy I do. I do an extremely brief head to toe assessment, gathering information about my patient in a multitude of ways. Some of the ways in which I comfort a patient during my interview are interesting to consider:

I introduce myself so I am no longer a stranger,
I assure the patient that I will be caring for them during surgery,
I make sure the correct patient is getting the proper treatment,
I make sure to verify important information about the patient (i.e., allergies),
I also make sure to ask about particular concerns, just in case the patient forgot (i.e., allergy to iodine or latex)
I make sure that the patient has an adequate understanding of what surgery they are having,
I inform the patient about the environment of the OR (cold, bright lights, narrow table, noisy, etc.),
I assure that patient that if they need anything at anytime they only need to say so,
I also inform the patient about what to expect in those first few minutes in the OR (i.e., lots of people talking, attaching monitors, placing SCDs, safety strap),
I then instruct the patient about what to expect when they wake up (i.e., hair removal, tubes and drains, catheters, funny looking skin from dyed soaps).

For the most part, patients seem to be calm and ready for what's next by the time I am finished with my interview. Some aren't, especially when I start seeing them get nervous about what it will be like after surgery ("I'm going to have tubes/a catheter?"). These patients are sometimes the most challenging. I try to pay attention to their expressions and tailor my instruction to what they can emotionally handle at that time. Some patients will state "The less you tell me about what you're doing the better." These are a rare exception, but it does cut my interview down significantly. Just as rare is the patient that thanks me when I am done for telling them everything.
The last question I have for my patient is, I think, one of the most important. It can also convey comfort because it lets the patient take control: Do you have any questions for me? If the patient does, I can offer them answers that usually provide further comfort (or find someone who can). If they do not have any questions, then I assure them that at any time if they do think of a question, they are encouraged to ask. I think giving the patient some sense of control of their situation can provide them with a great deal of comfort.

And now I return, an essay on leadership

It's been over a month since I posted, I realize that. It's been a busy month or so, getting ready to start my masters' program, etc. I feel a drive to get back to blogging though, so expect to see more activity. To start, here's an essay I had to write in class about leadership:

What do you think makes a good leader?

A good leader has the ability (vision) to see the ways that will lead the team (organization, class, group, etc.) toward the goals that have been given to or agreed to by the leader (and hopefully, group). Often leaders have some behaviors that are commonly found in those who manage people, but good leaders seem to always have these behaviors: integrity, fairness, honesty and a good grasp of how to best treat people with respect to get their cooperation or buy-in and enthusiasm for their work and goals. Some of the best leaders usually have the ability to figure out the strengths of those they work with and how to best utilize these (resource management).

What I have found makes a good leader for me is trust in that person to keep my best interests in mind when recruiting me to their cause. Knowing my values is not necessary, but not requiring me to do anything that is counter to my values to achieve the outcome desired by the leader is necessary.

A supportive manner is usually present in the best of leaders. Support to achieve the outcomes that are best for me, my patients, my family, the organization (this really can happen).

Excellent communication skills, the ability to express ideas in ways that inspires the team. Clear, open communication about organizational processes - keeping the team together on where they are going and how it is better for the team and our patients. Being consistent in how they treat their team, as a group and on an individual level. Nonjudgmental unless absolutely necessary for safety or discipline situations, but it should always be fair, non-biased.

I invite feedback and input. I only had a few minutes to write this essay in class, so I know I missed a huge number of ideas that could easily help me describe what I feel are the basics for a good leader. Some of the above stems from bad leaders I have had and me identifying that essential characteristic (or characteristics) missing that make our relationship rocky. I have had too many leaders that I have struggled to have any kind of trust in, maybe it's me, but I know that I have had leaders I trusted and those experiences helped me identify the reasons why I am not trusting a particular leader.