Enacting comfort measures

Question 1

Instrumental and relational aspects of nursing practice act synergistically in the pursuit of curing and/or healing the patient

Answer 1

• Venn diagram
• Relational
• Instrumental
• Curing & healing in middle

• A lot of healing work is focused on bearing witness to suffering and attempting to alleviating suffering

Question 2

Comfort as a concept

Answer 2

• Multidimensional in nature
• Sense of positivity and strength characterized by the relief of physical discomfort and integration of positive emotions
• Dynamic and transient in nature
• Experience of total comfort seen as elusive
• Need for comfort can occur at any stage of illness-wellness continuum
• Comfort, a response
• Nursing doing the work as well as researchers deeming what that work is
• Not only as physical; comfort as having a sense of personal control, feeling values, safe, able to trust, and at peace
• Comfort is not a static state someone achieves; patients don’t have the expectation that there will be a total alleviation of suffering
• Patients need for comport is individual, but occurs at any stage of illness/wellness
• Common triggers where comfort is important; separated from family and home life, feeling vulnerable in general, loneliness and dependency arising from the social impact of illness, injury or aging, pain and distress from the illness or treatment, anxiety over signs of illness, and when people are experiencing uncertainly

Question 3

Providing comfort

Answer 3

• Actions that are mobilized with the intent of easing/alleviating/transcending human suffering – inherently restorative in nature
• Informed by principles of empathy, compassion and care
• Involves a complex interplay of assessment, instrumental/technical and relational skills
• Need to use all of the tools in your tool kit to provide comfort

Question 4

Factors influencing patients’ comfort

Answer 4

1) Patient
- Culturally connected
- Self-comfort strategies
- Spiritually connected

2) Family
- Presence and involvement

3) Healthcare staff
- Engagement and commitment
- Perceived and actual competence
- Information and participation
- Symptom management
- Holistic care and assistance

4) Clinical environment
- Physical facilities and ambience

Question 5

The clinical environment

Answer 5

• Places can have therapeutic effects on the people in them and contribute to processes of healing
• Material conditions as well as cultural/social conditions
– Notion of a therapeutic place is an inherently subjective one, steeped in one’s social positionality, personal history, cultural and/or spiritual practices & beliefs, and idiosyncratic preferences

Question 6

Socio-political realities of place

Answer 6

• Places are embedded within our broader social structures and institutions, which create different implications/experiences for different people occupying them/moving through them
• Sidewalks and carding (racial profiling)
• Bathroom and gender policing
• Implications for bedside nursing?
• Young black men are 17x more likely than their young white counterparts to be stopped by police and be interrogated
• The world is shaped by racism and other dynamics (homophobia)
• Places are not benign structures; they are shaped by complex forces including oppression

Question 7

Factors influencing patients’ comfort in a clinical environment

Answer 7

• The material/political/cultural dynamics of different health care settings situate the nurse-patient relationship
• Can affect whether or not your patients experience the care setting as welcoming, safe, and/or therapeutic
• Can shape the way your patients experience the care you provide
• Can influence the kind of care you provide and the ways in which you provide it
• POC receive less pain medication
• POC have longer wait times
• Racism, misogyny, transphobia is recreated in the healthcare environment
• People gain a sense of comfort when they feel they fit in
• Nurses are occupying the space between the client and the
• We become a symbol of what that environment looks like

Question 8

Considerations for healthcare staff in providing comfort

Answer 8

• Be aware of the intersectional nature of identity and the ways in which manifestations of privilege and oppression shape personal experiences
• Also, the way it drives our healthcare facilities
• Engage in practices of self-reflexivity
• Recognize and challenge instances of oppression/discrimination within clinical settings
• Challenge our assumptions of the world and our environment
• Use language in thoughtful and considered ways
• Use pronouns and name, ask them
• Safety is a precondition for experiencing comfort
• If your patient doesn’t feel safe in the care environment or with you as their caregiver, opportunities for achieving comfort will be minimal

Question 9

Healthcare providers and their influence of patient comfort

Answer 9

Engagement and Commitment
• To process of healing and curing
• Available to answer questions, respond promptly to providing comfort

Perceived and Actual Competence
• Allows them to feel safe in your control

Information and Participation
• Helps people understand their situation, be in control
• Symptom Management
• Pain is a big piece of experience

Holistic Care and Assistance
• Care that attend to the whole self and attends to the day-today living
• Like washing someone’s hair, getting their deodorant out of the drawer
• Little things that contribute to someone feel like a whole person

Question 10

Exploring who our patients are and what they need; practices of wondering

Answer 10

• Wondering is a relational practice of curiosity that helps us understand each patient’s unique experience of illness and individual care needs
• Wondering helps us stay open and not make assumptions or rush to conclusions about what will bring someone comfort
• Allows us to discover the unexpected
• Experience of illness is extremely individual; need to understand their hopes, fears, dreams, aspirations, etc.
• While we might know their disease, we don’t know much about their experience of illness
• Comes from a place of humility

Question 11

Enacting comfort measures; practices of following

Answer 11

Elderly patient with pneumonia who keeps taking off their oxygen mask
• Ask him why he keeps taking mask off/what he needs/try a different delivery method

Patient with a diabetic foot ulcer who is getting their dressing wet
• Ask how they’re getting it wet/provide waterproof dressing/connect them to community resources

Patient who is bed bound and critically ill and yelling at staff to get him in a wheelchair
• Ask them why they want to get up/see doctor about nicotine patch/hoier lift and into a geri-chair so they can go outside

Patient who is grimacing while they are swallowing crushed pills mixed with applesauce
• Ask them what’s going on/find appropriate solution

• We usually go right into education mode
• Have to be curious about why this person is having this issue in order to connect them with the best intervention

Question 12

Practices of Following: Comforting Nursing Work

Answer 12

• Necessary Touch: Care of the ‘Fleshy’ Body
• Responsive Touch
• Teaching and Coaching
• Spiritual Care

Question 13

Touch

Answer 13

• Touch is a powerful nonverbal form of communication that is essential for our survival
• Connection between nurturing physical contact and development (social, emotional, etc.)
• Helps us feel connected with others
• Can provide us with a sense of comfort and security
• Can make us feel valued desired, seen

Question 14

Necessary touch: care of the ‘fleshy body’

Answer 14

• Care of the fleshy body is what nurses do
– The work necessitates that we touch and minister to patients’ bodies
– Necessary touch can bring great comfort, but it can also inflict great pain
• “We all have multiple bodies that can be touched in multiple ways” (p.151).
– The intent of the touch and the experience of the touch don’t always match up
– Touch is always an uncertain; a shared interpreted meaning can never be assumed
– Shaped by gender, age, sexual identity, past trauma, relationship with person
• Touch is an uncertain activity- not a universal language with shared meanings
• Ill body becomes terrain of medical practices and care
• Transformed into the body-object to redefine private space/boundaries of the body
– Micro-objectification of our patients
• Nurses straddle boundaries between body-object and body-subject
– In certain moments, nurses think objectively about patient in order to manage experience
– Tension between of how we continue to treat person as individual but also manage our own response and emotions related to the work
• Tremendous intimacy associated with caring for the unbounded, leaky bodies of the ill
– We find nurses at all of these places that are leaking or falling apart, and we put them back together; to alleviate suffering for that person
– The reality is that some of that is gross; can provoke feelings
– This desire to be professionalized into their person who can bear witness to anything; how do we manage that?
– How to “keep your gam face on”
• Care of the ill body is to encounter/engage with the abject
• Can evoke feelings of disgust, shame, guilt or embarrassment for both the patient and the nurse
• Dissonance between these feelings and the self-perception/desire to be an unflappable comforting force for the patient

Question 15

Considerations for necessary touch

Answer 15

• Touch is never experienced as routine by the person receiving care
• Explain what you’re going to do before you do it
• Offer, rather than impose your touch, and wait for the patient’s response, and then follow it
• If your touch is going to inflict pain or discomfort, tell your patient that so they know what to expect
• Remember that avoidance of touch can be experienced by patients as acts of isolation and stigmatization
• Seems like common sense, but it’s easy for things to become routine and forget

Question 16

Responsive touch

Answer 16

• Necessary touch vs. responsive touch
– Touching for instrumental reasons vs. touching for therapeutic reasons
• Examples of responsive touch
– Massages, back rubs, touching someone’s shoulder, going someone a hug, stroking someone’s brow, energy work
– Intent is providing comfort, not doing something instrumental
– Kangaroo care; provides comfort and relaxes the baby, decreases stress and in turn helps regulate systems
– Needs to be done in thoughtful and considerate ways

Question 17

Considerations for responsive touch

Answer 17

• Responsive touch can be nurturing, comforting, healing but it can also be intrusive, distracting, assaultive
– Every time we touch someone there is a risk of misunderstanding
– Needs to be undertaken after discussion with the patient
• Need to be attentive to following our patients’ cues and knowing:
– when to touch
– where to touch
– how to touch
– how much to touch
– whether to touch at all

Question 18

Patient teaching and coaching

Answer 18

• Relationship between personalized provision of information and feelings of comfort
• If people know what’s going on that’s really helpful in making them feel comfortable
• Important part of nursing work is providing information to families and doing that interpretation work
• While it can be unsettling, it can tell them what’s happen and their roles, so they can prepare and plan accordingly
• “Nurses, when possible, forewarn [patients] about what to expect, correct misinterpretations, and offer explanations for bodily changes…They take what is foreign and fearful to the patient and make it familiar and thus less frightening”

Question 19

Reasons for patient teaching and coaching

Answer 19

• To understand a procedure and inform the decision-making process
• To learn how to manage a new assistive device
• To relearn how to engage in ADLs with a different abled body
• To learn how to manage symptoms/treatment side effects to learn what is considered a medical emergency
• To learn coping strategies
• To alleviate worry/anxiety of the unknown
• To prevent a health condition form occurring or worsening
• Self-Efficacy
• Timing for teaching is nuanced
• Knowledge of the patient key
• Check-ins really important

Question 20

Cues indicating patient is ready to be taught and coached

Answer 20

Cues indicating patient readiness:
• Displays of emotional/psychological readiness (total avoidance vs. engagement)
• Physical cues
• Verbal cues

Cues indicating information overload
• Physical cues
• Verbal cues

Question 21

Considerations when engaging in patient teaching and coaching

Answer 21

• Consider timing; are there any current barriers to learning that need to be addressed before getting started?
• i.e. pain. Nausea, need for translator, etc.
• Start teaching by wondering with the patient
• i.e. what they know about illness
• Consider different types of learning styles
• Avoid use of jargon
• Reinforce teaching with written materials
• Preferably in language of preference for patient
• Check-in/teach back
• Be open to the unexpected

Question 22

Spirituality

Answer 22

• Existential suffering most often ignored by health care providers
• Notion of spirituality is ephemeral
• Often used interchangeably with religiosity but these concepts are very distinct
• “Spirituality involves meaning-making through intrapersonal, interpersonal, and transpersonal connection”
• Related to meaning; what brings people meaning, broader way of talking about fears/hopes/despair and maybe being able to do something meaningful about it

Question 23

Goal of spiritual care

Answer 23

• Decreasing sense of meaninglessness, purposelessness, or hopelessness
• Increasing a sense of relatedness, forgiveness, or acceptance
• Acceptance of illness, impairment of death
• Making meaning
• Goal of spiritual care is not to provide one’s own answers to ultimate questions or for the patient to achieve a particular belief
• Generate sense of hope

Question 24

Sources of hope

Answer 24

• Meaningful shared relationships
• Feeling delight/joy/playfulness
• Recalling joyous, meaningful events
• Acknowledging/affirming personhood
• Focus on the possibilities of the short-term future

Question 25

Following: nursing interventions

Answer 25

• Relational processes
• Rational thought processes
• Experiential processes
• Spiritual/transcendent processes

Question 26

Following: the power of ritual

Answer 26

• Rituals provide guidance and create space for meaning-making in moments of great pain and disruption
• The word ‘ritual’ tends to conjure imagery of formal religious rites of passage, but secular practices performed by patients to forge connections with others, mobilize a sense of hope, forgive or accept themselves/others, or integrate ‘the sacred’ into their everyday life should be recognized as important rituals as well
• This may be ordinary acts of visiting special places, singing a song or reading a poem that had significance for the individual, sharing important memories/stories about the person, or creating moments of meditative, reflective silence