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I S S U E S A N D IN N O V A T I O N S IN N U R S I N G P R A C T I C E

Comfort on a ward for older people


Elizabeth Tutton
BSc MSc PhD RGN PGCEA

Research Fellow, RCN Institute, Oxford, UK

Kate Seers

BSc PhD RGN

Head of Research, RCN Institute, Oxford, UK

Submitted for publication 14 May 2003 Accepted for publication 25 November 2003

Correspondence: Elizabeth Tutton, RCN Institute, Radcliffe Inrmary, Woodstock Road, Oxford OX2 6HE, UK. E-mail: liz.tutton@rcn.org.uk

T U T T O N E . & S E E R S K . ( 2 0 0 4 ) Journal of Advanced Nursing 46(4), 380389 Comfort on a ward for older people Background. Comfort is often considered to be a central part of nursing, although the value placed on it may have diminished over time. Many views of comfort are expressed in the literature but it still remains a diffuse concept that requires further clarication. Research evidence about older people and comfort is limited, and further work is needed to nd out how staff and patients view comfort and how it is achieved in practice. Aims. This paper reports a study to investigate what comfort means both to older people in hospital and their health care workers. Research methods. Ethnography was the methodology chosen, and data were collected using in-depth interviews with 19 older people and 27 staff members, and 130 hours of participant observation, complemented by additional weekly visits to the study ward. Findings. Three themes were identied: the nature of comfort/discomfort; key determinants of comfort/discomfort; and the underlying factors that inuence the achievement of comfort/discomfort. Discussion. In this hospital setting, the focus of nursing on relief of discomfort suggested a tendency to react to problems, rather than proactively to create an environment that facilitated comfort. Staff were aware of ideals of practice but found these difcult to achieve in reality. In this study comfort was not consistently provided, and some ways of working actively promoted discomfort. As comfort is central to nursing and nursing is central to the care of hospitalized older people, it is crucial that practitioners are enabled to full their potential in this area.

Keywords: comfort, qualitative interviews, participant observation, ethnography, older people, nursing

Background
There is a general expectation that when we need health care our comfort will be considered. Nurses have the potential to help full this expectation. Nurse theorists identify comfort as playing a fundamental role in patient care (Orlando 1961, Paterson & Zderad 1988, Kolcaba 1991, Morse 1992), however, over the years it has been relegated to a more minor
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role (McIlveen & Morse 1995, Ersser 1997). This paper identies the importance of bringing comfort to the fore in order to explore and examine its contribution to current nursing practice. Comfort appears to be an essential issue in nursing. Many authors refer to it in passing and others identify it as the overall goal of nursing. However, attempting to understand it more closely in light of the complexity of nursing practice is
2004 Blackwell Publishing Ltd

Issues and innovations in nursing practice

Comfort on a ward for older people

difcult. Comfort is identied in theoretical frameworks of nursing such as those of Orlando (1961), Hall (1964), Paterson and Zderad (1988), Roper et al. (1980). Two key authors, Morse and Kolcaba, present it as an over-riding construct for nursing (Morse 1992, Morse & Field 1996, Morse et al. 1997, Kolcaba 1992a, 1992b, 1994, 1995a, 1995b). A uniform denition of comfort is not evident in the literature. Many denitions exist but these vary according to the authors perspective. Orlando (1961) sees comfort as the overall focus of the nurses role but, in order to achieve it, nurses must rst identify patients perceptions of their needs. Hall (1964, 1969) suggests that comfort is a part of the process of developing closeness with patients which leads to growth and healing. From a psychiatric nursing perspective, Paterson and Zderad (1988) see comfort as an emotional process of releasing the effects of the past and moving towards achievement of ones full potential. In their model of nursing, Roper et al. (1980) were initially concerned with comforting activities that might lead to independence but these were removed from later editions of their work (Roper et al. 1985, 1990, 1996). Kolcaba (1992a, 1994) suggests that comfort is concerned with meeting needs for relief, ease and transcendence and Cameron (1993) portrays it as an individual process of growth and action that leads to health and healing. Denitions of comfort are, therefore, diverse and drawn from different perspectives. They also characterize discomfort as the opposite of comfort by placing them on a continuum (Paterson & Zderad 1988, Cameron 1993, Kolcaba 1995a). Identifying the elements of comfort is also complex. Fourteen key research studies were identied that specically explore the concept (Morse 1983, 1992, Hamilton 1989, Kennedy 1991, Neves Arrunda et al. 1992, Cameron 1993, Morse et al. 1994, Schutz 1994, Walters 1994, Bottorff et al. 1995, Hyland & Morse 1995, Jenny & Logan 1996, Proctor et al. 1996, Wurzbach 1996). These studies cover a range of methodologies and client groups. Only one (Hamilton 1989) considers the views of older people in long term care. Overall, there is a lack of clarity about the meaning of the term comfort which suggests that it is an emerging concept that lacks maturity. Research studies have, however, explored it and have shed some light on its constitutive elements. The only study focusing on older peoples views (Hamilton 1989) did not consider the views of staff or the context of care. Comfort is, therefore, an important concept in nursing but one which requires further exploration, particularly in relation to the care of older people.

The study
Aim
The aim of the study was to explore what comfort means both to older people in hospital and their health care providers.

Design
The study drew on the principles of ethnography (Hammersley & Atkinson 1995), the primary focus of which is to provide a description of a culture by observing, describing and analysing what is happening (Aamodt 1991). This study explored comfort as a specic aspect of a culture and, therefore, is more focussed than traditional ethnographies (Leininger 1985).

Study setting
The ward chosen for the study was identied by senior staff as an average rehabilitation ward for older people in a specialist hospital in which rehabilitation was one specialty. The hospital site drew patients from a multicultural area and was situated in a city in the south of England. The particular ward was chosen because it had a strong team who were interested in developing practice. The ward had 28 beds and normally took patients over 60 years of age with a range of diagnoses but, in particular, patients who had experienced a stroke. Ward organization was based on primary nursing.

Participants
Samples of patients and staff were purposive in nature (Morse 1991). Patients who had experience of comfort and could talk about their experiences, and staff who had experience of providing comfort were all potential interviewees. Many patients on the ward were too ill or unable to communicate verbally and, therefore, unable to take part in the study. A range of male and female patients, who had a variety of diagnoses such as cerebral vascular accident, fractured hip and osteoarthritis, and had experienced side room and main ward areas was obtained. Staff members from all professional groups that worked on the ward were interviewed.

Data collection
Data collection took place between February and October 1998. The two major sources of data were: (i) written eld notes generated through participant observation and
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(ii) in-depth, qualitative, audiotaped interviews. Field notes were handwritten in the eld situation and normally typed up shortly after completion of a period of observation. Sixteen full shifts (130 hours), covering 24-hour care, were undertaken, and weekly visits to the ward were made. The researcher (E.T) undertook the role of a care assistant and managed a small case load of patients. Forty-nine taped interviews were undertaken, the duration of which ranged from 40 minutes to 2 hours. Twenty-seven of these were interviews with staff members and 19 were with patients. Interviews were based around participants views of comfort. The rst question was Could you tell me about your views of comfort whilst you have been a patient on this ward? or, for staff, Could you tell me about your views of comfort whilst you have been working on this ward? Further questions were added in the form of prompts, such as Tell me about? How does that differ from? Can you give me an example of? The interviewers role was to uncover patients and staffs views of comfort. As the study developed, issues identied in earlier interviews were explored further in later interviews and examples of actions that took place in practice were discussed, particularly with staff members. For instance, one staff member challenged the researcher on an aspect of practice; a patient had not sat out of bed as the nurse had expected, and a discussion about interpretations of comfort followed.

Table 1. A table to show categories and subcategories within the three major themes Key determinants inuencing the experience of comfort/discomfort Approach Engaged Disengaged Underlying factors that inuence the provision of comfort/discomfort Power Loss of control Not being believed Fitting in Powerlessness Control of others Organizational control Organization Follow through Teamwork Time

The nature of comfort/ discomfort Enduring daily life Sitting Boredom

Relief Pain Activities State Pre-emptive Process Individual Holistic

Knowing Practical knowing Making it happen Focus The little things Making it a priority Environment Equipment Sense of place Noise

Ethical considerations
Ethical approval for the study was obtained from the Local Research Ethics Committee. All patients and staff who took part in interviews were provided with written and verbal information, and had at least 24 hours in which to decide whether to take part. A consent form was signed prior to each interview. Consent for participant observation was obtained verbally from patients and staff.

informed by existing research knowledge. Categories that identied issues that linked to a broader element of comfort were then grouped together in themes. For example, approach, knowing and environment were grouped under the theme key determinants inuencing the experience of comfort/discomfort (Table 1). Data generated through participant observation were coded using the same process but coding was done by hand.

Rigour
Trustworthiness of the study is vested in Lincoln and Gubas (1985) concepts of credibility, transferability, dependability and conrmability. The researcher (ET) spent time in the eld and engaged with patients and staff to build up a picture of comfort as the study progressed. Data were collected from several sources and reection on the data took place with supervisors, staff and peers. A decision trail, detailing how data were analysed, was maintained. In this paper, extracts from interviews and eld notes are used to illustrate and validate the categories and themes that emerged.

Data analysis
Data were transcribed verbatim and analysed line by line, drawing on the work of Spradley (1980), Strauss and Corbin (1990) and Miles and Huberman (1994). The computer package QRS.NUD.IST was used to assist with organization of the data. Each line was allocated a code that interpreted the meaning of a particular group of words; codes often took the form of interviewees actual words. Codes with similar underlying meanings were then grouped together into subcategories, such as engaged/disengaged. Subcategories that were related to a similar issue were then grouped into a category, such as approach. These categories were often
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Findings
Findings are presented in terms of three major themes: the nature of comfort/discomfort; key determinants inuencing

2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 46(4), 380389

Issues and innovations in nursing practice

Comfort on a ward for older people

the experience of comfort/discomfort; and underlying factors that inuence the achievement of comfort/discomfort. Findings relating to each of the themes, and issues within them, are presented and illustrated by the words of informants and excerpts from the eld notes on participant observation.

more marked in patients who had experienced a stroke and, in particular, those who had changes in their ability to speak. Relief Patients actively sought relief from discomfort. Relief came in the form of activities or doing something that involved body work. They worked hard, pushing their bodies emotionally and physically to work for them. Although this was tiring, it was a comfort to them because it gave them something to do and some hope for the future. Physiotherapists and nurses who facilitated this process were an important part of this work:
I look forward to her [the physiotherapists] trips down to the punishment cell, and she says she works a lot on this hand as well and she has me putting little models on to the top of other models. But I can do equally well, well, I can do alright with my left hand, but this hand is a different story. No, shes there for one thing to get me to stand. And Im there to make darn sure that between us we do. (Patient 12)

Nature of comfort/discomfort
The theme nature of comfort/discomfort was divided into four categories: (i) enduring daily life, (ii) relief, (iii) state and (iv) process. Data suggest that comfort was a tangible concept that individuals could identify. Nonetheless, patients experiences of comfort were mainly framed in relation to discomfort. They felt that this term more adequately represented their views than the term comfort:
I suppose I can say nothing else but discomfort. I have been talking about nothing else but discomfort. Its all-prevailing, I think. (Patient 3)

Enduring daily life There was a sense that patients spent a lot of time enduring daily life on the ward. The process of group living often meant that individual needs were not prioritized, and both patients and staff struggled to meet these needs. Patients were, therefore, in the position of enduring the discomfort of unmet needs as well as those caused by illness itself. Enduring was recognized as an indication of lack of comfort. This was identied in the participant observation data, as in the following example of a patient enduring both having a dirty mouth and the experience of mouth care:
The nurse comes back and asks him how his mouth is. He sticks out his tongue. It is coated, thick and white. You need some mouth care, Ill see if I can nd a toothbrush. She comes back, no toothbrush, there arent any but she brings some mouth swabs and mouthwash. He doesnt tolerate this very well she says, and Jack gags on the smallest amount of water and indicates to me that he needs to spit. (Field notes 1)

This patients determination to improve his ability to stand was, therefore, supported by the physiotherapy he received. This also provided relief from the discomfort of sitting and being idle. State Staff data suggested that comfort was seen as a state. Patients were described as feeling at ease or feeling happy with what was going on at a particular time. The state of comfort also encompassed knowing that they had everything they needed, or could get what they needed when they wanted it. Staff attempted to minimize the trauma of being in hospital through activities aimed at providing information and promoting understanding of the processes that occurred in hospital. Process Data also suggested that comfort was an individual process in which everyone is different. Staff tried to nd out what the patients wants/wishes were and tried to full them. The word comfort was also used in relation to the notion of holistic care, and was related to suggestions that patient care should be seen within a broad framework. A potentially simple act could have much broader implications:
I probably think there are three areas of patient comfort. I dont see this as separate but interlinked: physical comfort, emotional comfort and spiritual comfort. But I dont see them in the form of Maslows hierarchy, from the bottom to the top. I think of them running together really and being inseparable, so that washing somebodys

Patients felt that they spent a great deal of their time sitting, stuck in their chairs, conned to the man trap, as one patient referred to his wheelchair. The experience was seen as a burden and the patients used words such as tiring, awful, annoying and spoke of feeling a sense of emptiness:
You get out of bed for breakfast and you are sitting in your chair from breakfast, all day until you go to bed at night. (Patient 19)

They also identied their experience of boredom, which was often linked with the nature of their disability. This seemed

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E. Tutton and K. Seers feet can be a form of physical comfort but it is also a form of emotional and even a spiritual comfort. (Staff member 23)

Key determinants inuencing the experience of comfort/ discomfort


Four data categories related to factors that appeared to inuence the experience of comfort and the process of comforting. They were: approach, knowing, focus and environment. The categories approach and environment were developed from patient and staff data. Knowing and focus were predominantly developed from staff data although there was an element of patient data. Approach On a simple level it appeared that staff were either engaged or disengaged in relation to the patients. Patients often asked for particular nurses, or told me how lovely they were. Staff also identied the members of staff that they would like to care for them if they were in hospital. In contrast, some patients told of their difculty in getting anything they needed when particular members of staff were on duty. Staff and patients displayed a similar polarization of views, and these polarities were labelled engaged or disengaged. The approach of the staff seemed to be very important in relation to the patients experience of comfort. Patients sought and found staff with positive qualities of kindness, gentleness, friendliness and goodness. Particular staff who were seen to have these qualities were named by patients:
Yes. Shed make you comfortable in no time. And she means it. Shes lovely and M [name], shes nice too. Yes, shes good. (Patient 18)

life before hospitalization. It helped staff to provide support by maintaining the patients sense of identity. The process of getting to know patients involved seeking information from relatives and building up a picture by caring for them over a period of time. Knowing the patients seemed to make life easier for both patients and staff:
Some people like their feet tucked in, some dont, some like a cradle. I mean you know all about those little things after a few days, a week or so. I mean, in the beginning you just pop them into bed, you just dont know, but after a while you know what they like; what pillow they like, if they want their bed rest down or whatever. I mean you ask if they want it up; some says no some says yes, after a while you get to know. It is easier for them, its easier for us. (Staff member 8)

Knowing the patient was, therefore, an important aspect of comfort, which operated on a practical level related to daily patterns and routines. In addition, knowing how to communicate with patients who could not talk functioned at a slightly deeper level and drew on intuition. The focus of comfort Care necessary for comfort was focused on the essential basics of daily care, or what was regularly referred to as the little things. These little things were often seen as extras, not essential to the persons survival but essential to how they felt about themselves. Many of these things related to basic body maintenance, such as washing hair, cutting nails, washing and bathing. Participant observation data suggest that attention to the little things demonstrated concern for patient comfort. Examples of this type of care were ensuring that patients had soft pillows on top, and making an effort to nd a mirror so that a patient could see a healing wound. Care assistants, in particular, seemed to focus on ensuring that patients had shaves, and their eyebrows and nose hairs clipped:
It has a lot going for it here, the little things they do, that are nice. I remember one nurse when I was poorly and she was washing my legs and I said Oh, look at the hairs on my legs! and Oh she said dont worry about that. And she got a razor [and] shaved my legs. I did feel good after that. (Patient 2)

Patients also noted an approach which they did not associate with comfort. This related to the subcategory disengaged and was a harsh approach, in which patient needs for relief and ease were not met. Staff exhibiting this approach seemed to show no sympathy, were irritable and could not be bothered to undertake the tasks requested. Patients felt that their need for relief was not met:
A nurse said, Youre not getting back into bed until you eat this. But I couldnt eat it. So I had to sit here. My legs were killing [hurting] me. (Patient 13)

Knowing the patient The staff identied knowing the patient as an important precursor to achieving comfort. Knowing a patients background, likes and dislikes, and simple facts about them was seen as necessary for comfort. Knowledge of the person helped to provide some sense of normality or continuity with

Staff identied the importance of fundamental care for patients comfort. This type of care involved helping patients to feel clean and fresh, and attending to hair and teeth. This essential care was not seen in isolation from patients total care but was a fundamental part of the whole process:
Theyre not little things. Theyre very important things, you know. They go together in a sensethat sort of whole patient interpretation from every aspect. (Staff member 23)

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However, there was an awareness that these things were not always valued and were difcult to attain in the bustle of daily life on the ward. Environment Structure and use of the environment was discussed by patients and staff, with a focus on the inadequacy of the environment for promoting comfort. Participant observation suggested that the ward environment was a place of work, as opposed to a place of living where patients might stay for up to 3 months. Key determinants of this seemed to be the use or lack of equipment, the policy of screening patients for methicillin-resistant Staphylococcus aureus (MRSA) prior to allowing them into the main ward area, the noise and the smell. The ward was a public area with little privacy, and there was uncertainty about obtaining important resources, such as urine bottles and vomit bowls. Pillows, in particular, caused regular comment:
A patient asks me over. Could you tidy up my bed for me? There is one pillow that is as hard as an iron, its (the pillow) full of blankets. (Field notes 4)

Staff also expressed an element of powerlessness. This often seemed to result from their position in the hierarchy. Carers, in particular, found it difcult to deviate from care planned by qualied staff. Qualied staff also found that they were inuenced by the work norms of the carers. This created tensions within the team and conicts about achieving patients comfort:
It is like being a y on the wall. You can see so much but you cant necessarily do anything about it. (Staff member 24)

The position of staff within the organization also caused tensions. This related to the organizations abilities to supply the ward with the equipment it needed. In addition, when staff acted on behalf of the organization by controlling patients access to medication and managing the workload, this added to patients feelings of powerlessness. To make things easy for themselves, patients tended to t in with the wards norms. Participant observation revealed their powerlessness on the ward. Organization Patients comfort was inuenced by the work style of the ward. This style reected an individualistic approach to care that often militated against effective teamwork, leading to missed opportunities for care. Allocating patients in different areas of the ward to one member of staff also caused insecurity in patients because they were not sure who would meet their needs or when. In addition, following the natural rhythm of the day (doing most of the work in the morning) placed constraints on staff that exacerbated existing time limitations. The use of a large nursing station where staff tended to congregate also detracted from the visibility of staff and created a barrier between staff and patients:
That desk should go; it is so imposing. You see patients coming up and they seem so timid. That gaggle of talking women, it needs to go. The nurses need to get out there. Be talking to the patients. Find out what it is like to be there, in hospital. (Field notes 21)

Underlying factors inuencing achievement of comfort/ discomfort


Power The main observation in relation to power was the powerlessness of the patients position on the ward. This was evident in the difculty that they had in getting their basic needs met, and in the fact that were not allowed to take their own drugs. Patients knowledge about their own bodies was often not valued. Issues relating to power were identied in both staff and patients views. Patients characterized their position as one in which they seemed to have little power. They seemed to make continual attempts to work out what was expected of them, and to t in with these expectations. At the same time, they were trying to get their needs met, and to retain or regain some control over their bodies. Patients felt that the process of being ill and in hospital led to a feeling of loss of control over their bodies. The consequences of being powerless to meet their own needs for toileting, and not having these needs met by others caused serious discomfort:
You have no option [but] to mess the bed or mess your trousers. You get caught short. It does happen; its happened to me. The women concerned got me out of trouble when I made an awful mess got me off the bed onto the commode. It was on my trousers and all over the sheet. (Patient 3)

Overall, there seemed to be a dissonance between the ideal of continuity and consistency, and the reality of providing care.

Discussion
Nature of comfort/discomfort
Our study built on the work of Hamilton (1989) by providing a richer view of the context of care. Data from the study suggest that the focus of comfort within the hospital setting was on managing the day-to-day aspects of patients lives. In

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ORGANIZATION
Teamwork Consistency Community Creating time

Figure 1 Framework for comfort based on the ndings.

have been recognized using other methodologies. The resulting framework could be used in practice, to focus attention on comfort as a central element of nursing care.

Key determinants of comfort/discomfort


The approach of staff had a powerful effect on patients comfort. Patients and staff clearly identied that some staff had a positive effect on patient comfort and other staff actively caused discomfort. This nding is supported by literature which suggests that staff who engage with the patient are more likely to have a positive effect and that those who are disengaged are more likely to have a negative effect (Hamilton 1989, Kennedy 1991, Neves Arrunda et al. 1992, Jenny & Logan 1996, Kalick et al. 1997, Madjar 1998, Redfern & Norman 1999). Kalick et al. found that an engaged nurse was seen to connect with the patients humanness, whereas disengaged nurses remained detached and created feelings of vulnerability and insecurity in patients. Morse et al. (1998) argue that emotions associated with concepts such as caring, empathy and compathy acted as motivators for people to act on someone elses behalf. This suggests that, without some positive emotional connection, interaction between staff members and patients might not have a positive outcome for the patient. The ndings of this study suggest that some staff were not making connections

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e ag

Dis en

line with Kolcabas (1992a, 1994) characterization of comfort as relief, ease and transcendence, the ndings of this study suggest that relief from discomfort was the primary focus. Patients identied the importance of relief from discomfort related to sitting, boredom, noise and control. The state of ease, or feelings of calmness and contentment described by Kolcaba (1991, 1992a) were evident only in an implicit way, through the engaged activities of the staff. Whilst staff have the potential to create positive feelings in patients that might relate to a state of ease, there was no real evidence in the study of a state of transcendence, or a capacity to rise above problems such as pain, as described by Kolcaba (1991, 1992a, 1994). Morse et al. (1997) identied a model in which staff respond to patient distress with a range of patterns of relating. In our study, patients were enduring the realities of group living in a hospital environment and suffering from the effects of illness. Patterns of relating that helped patients to endure, such as warm positive interactions facilitated their comfort. Conversely, a negative pattern of relating detracted from patients ability to endure and led to further discomfort. Morse and Proctor (1998) identied the importance of endurance as a way of coping with pain and maintaining control. Furthermore, endurance is linked to suffering (Morse & Carter 1995), as suffering is seen as an emotional response to that which is being endured. The words used by patients such as man trap and awful and the participant observation data suggest that patients were suffering, but that overt emotional expression of this was not normal practice on the unit. Comfort, as dened by Paterson and Zderad (1988) and Cameron (1993), was not described in the data in this study. There was evidence to suggest that lack of patient involvement reected the wider issues of lack of autonomy (McCormack 1998) and lack of control (Draper 1977) in this patient group. It may be that emotional work in relation to illness and dying, and patients involvement in their own care are complex activities that require a high level of skill that was not evident in the setting in this study. A framework for comfort developed as the study progressed (see Figure 1). The central tenet was that comfort was largely mediated through interpersonal processes. However, focus of care, environment and knowing the person were crucial elements. These were closely linked to the issues of organization and power. The framework, therefore, reects the nature of comfort within a particular context of care and through use of the methodology chosen for this study. Using ethnography enabled comfort to be explored from staff and patient perspectives, within a particular context of care. It highlighted issues of power and organization that may not

FOCUS
The little things The environment, noise, equipment Daily life, activities Shared philosophy

KNOWING
The person Practical daily routines Valuing and transferring knowledge

ER

R PE

SONAL PR O
CE

INT

SS

COMFORT DISCOMFORT

d ge ga

Eng

POWER
Able to make decisions Being believed Timely care Feeling empowered

Issues and innovations in nursing practice

Comfort on a ward for older people

What is already known about this topic


Comfort has been identied as being important to nursing. Many denitions of comfort exist and these are based on a variety of perspectives.

Patients and staff identied the environment as an important source of discomfort. This is supported by other studies that identify the hospital environment as uncomfortable and unhomely (Kalick et al. 1997) and recognize that high noise levels disrupt patients recovery (Fife & Rappaport 1976, Bayo et al. 1995).

What this paper adds


A framework of elements that inuence comfort is provided, built on data gathered in a hospital setting for older people. Comfort is a useful concept for examining the tensions between ideals and the reality of hospital care. Further research is needed into how comfort as a concept can be used to improve patient care and how it is viewed in settings other than wards for older people.

Underlying factors inuencing achievement of comfort/ discomfort


This theme identies the difculties of comfort provision in an institution that tended to have a work as opposed to patient-centred culture (Binnie & Titchen 1998). Focusing on comfort from the patient perspective provided insights that challenged cultural norms and suggested that new ways of working needed to be found to address these issues. The powerless position of patients is clearly identied in other research literature (Draper 1996, Johnson 1997, McCormack 1998). Opportunities are needed for patients to work though their feelings of powerlessness and feel that they have some control over their care. Members of staff need to revisit nursing ideology and develop new ways of providing care that meet patients needs for comfort and their own needs for support and teamwork. This requires a fundamental shift in how health care workers see their work and communicate with patients and other staff. To achieve this, a higher value would need to be placed on care of older people and its associated skills and abilities by society, the professions and universities.

with patients and were projecting negative feelings that exacerbated patients feelings of discomfort. Staff identied knowing the patient as an important facet of providing comfort. The importance of this was identied by staff in studies by Jenny and Logan (1992), Tanner et al. (1993), Radwin (1995) and Henderson (1997). However, in this study, knowledge of the patient tended to be on a practical level, relating to hygiene preferences or how they liked to sit or lie. This practical form of knowing was seen as important for patients, as it gave them some security and routine. A deeper level of knowing was achieved by some nurses who could interpret certain patients nonverbal cues. Morse et al. (1997) noted that expert nurses became skilled at reading patient cues and, hence, had a better knowledge of the patient. An essential focus in both patient and staff data was the little things, and the importance of these for patients comfort. Research with older people in acute care supports this focus (Davies et al. 1999). Patients in this study identied these things as essential for their comfort but they often had difculty in getting access to them. Staff also placed value on the little things but identied the difculty of continually paying attention to these things when other activities were seen as more urgent. The difculty of placing value on basic nursing care has been well documented (Evers 1981, Melia 1987, Pearson 1988, Smith 1992, Spilsbury et al. 1999). Lawler (1991) aptly summed up the situation by identifying nursings ambivalence to basic care, in that, verbally, it is highly valued but, in practice, it is delegated to lower status workers.

Conclusion
Our study was aimed at providing a deeper understanding of comfort within a setting specializing in care for older people. This aim has been fullled through identication of key themes that highlight factors which inuence the experience of comfort. These themes emerged through systematic gathering and analysis of data, using participant observation, and patient and staff interviews. The ndings suggest that comfort was largely perceived as the opposite of discomfort. Staff tended to react to problems, rather than proactively creating an environment that facilitated comfort. Comfort was not consistently provided, and some ways of working actively promoted discomfort. As comfort is central to nursing, and nursing is central to the care of hospitalized older people, it is crucial that practitioners are enabled to full their potential in this area. Further research is needed to discover how comfort as a concept can be used to improve patient care and whether comfort is a useful concept in other areas of practice.
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