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.