The news of an elder person breaking a hip tends to be more alarming than another bone could. A broken hip is one of the fatal injuries since it is hard to recover from a hip fracture, and afterward, one may not be able to live on their own. Brennan-Olsen (2018) posits that one in three adults older than fifty usually die within twelve months of hip fractures. Older adults have a 5-8 times higher hazard of succumbing to death within the first three months (Centers for Disease Control and Prevention, 2016). Besides, according to the Centers for Disease Control and Prevention (2016), more than 300,000 older adults are admitted to hospitals for hip fractures. Markedly, more than 95 percent of hip fractures are a result of falling, especially sideways fall (Ruel et al., 2021). The prevalence of this condition is varied in different population groups. The risk of a hip fracture is 9-19 percent higher for the population over eighty years (Ruel et al., 2021). Besides, patients suffering from cognitive problems are thrice more in danger of suffering from hip fractures than those without cognitive deficits (Ruel et al., 2021). Women are more prone to having hip fractures since they experience 75 percent of them (Ruel et al., 2021). Alongside pain, hip fractures have a considerable societal impact. Hip fractures lead to increased mortality, inability to return to the initial lifestyle, amplified level of care and supervision, suppressed quality of life, reduced mobility and ambulation, and secondary osteoporotic features (Dixon et al., 2018).
Patients with hip fractures require adequate pain management from the preoperative period. Effective pain management leads to improved outcomes, while poor pain control places patients with hip structure at risk, increasing mortality and morbidity. Different theories define how patients and nurses interact to determine the outcome of their actions. Kolcaba’s theory is among the approaches to analyze pain management in older people with hip fractures. The paper seeks to evaluate the theory of comfort and its applicability to understanding pain management in elderly patients with hip fractures while assessing its application in nursing environments and research.
Kolkaba defines comfort as satisfying basic human needs for relief, ease, or transcendence from stressful healthcare situations (McEwen & Wills, 2022). Relief comfort is achievable through pain management, medication, and other interventions. Patients gain a sense of relief from pain when they take drugs. Ease comfort focuses on a patient’s environment and psychology, while transcendence comfort results from a patient’s capability to withstand challenges that arise during care and recovery (McEwen & Wills, 2022). The theory has eight distinct propositions. According to McEwen and Wills (2022), Kolcaba believed that nurses and healthcare team members should identify the comfort needs of patients and family members. Therefore, nurses are responsible for designing and coordinating interventions to address the comfort needs. When the interventions are expressed carefully and effectively, enhanced comfort is experienced. Patients, nurses, and other healthcare experts determine the desirable and realistic health-seeking behaviors. Further, the model proposes that patients, family members, and nurses are more inclined to participate in health-seeking behaviors once comfort is attained. When patients, family members, and nurses access comfort care and engage in health-seeking behaviors, they become more fulfilled with health care and record enhanced health outcomes. Moreover, when patients, families, and nurses appreciate the healthcare provided, public acknowledgment of the institution’s contribution to healthcare makes the institution remain reputable.
Kolcaba advances that pain emanates from a stimulus situation which can lead to negative tension. Growing a patient’s comfort level can lessen negative tensions and trigger more positive behaviors (McEwen & Wills, 2022). Comfort becomes a bridge to a patient’s welfare as it increases the client’s quest for health-seeking behaviors. The model sees the nursing practice as a process that assesses a patient’s comfort and is consequently essential in developing and implementing commendable nursing care plans and evaluating the patients’ comfort after the care plans have been executed. Nurses must assess patients’ comfort needs and design a care plan to satisfy them. Patients’ comfort needs change with time, requiring nurses to change their interventions to sync with the current needs. As a result, nurses can ensure their patients are properly handled and well taken care of: when patients are comfortable, they will have enhanced emotional and mental wellbeing, accelerating the recovery process. The model has been in practice in several ways. The General Comfort Questionnaire was developed to measure concepts and propositions described in the theory. Besides, other tools have been developed to help in research and practice applications for models. Such tools include the Verbal Rating Scale Questionnaire, the Radiation Therapy Comfort Questionnaire, the Hospice Comfort Questionnaire, the Urinary Incontinence, the Frequency Comfort Questionnaire, and the Healing Touch Comfort Questionnaire.
Patients with hip fractures usually experience severe pain on admission. The kind of interventions they receive is inconsistent and insufficient to achieve sufficient pain control (Dixon et al., 2018). Pain is often underestimated in patients with hip fractures. The conversation posits that one in three adults older than fifty years usually succumb to death within the first year of suffering from hip fractures. Older adults have a 5-8 times higher risk of dying within the first three months (Centers for Disease Control and Prevention, 2016). CDC posits that more than 300,000 older people are admitted to hospitals because of hip fractures (Centers for Disease Control and Prevention, 2016). Markedly, more than 95 percent of hip fractures are caused by falling, especially sideways fall. Therefore, hip bone fractures are a significant concern among the elderly and require better management.
Researchers in nursing practice have utilized Kolcaba’s theory as the basis of their framework, boosting the appreciation of the concept. Bergström et al. (2018) conducted a study to evaluate the comfort theory in anesthetic nursing by providing and elevating the comfort level. Patients were allowed to gain hope, have reduced anxiety, and strengthen their health-seeking behavior and self-care capability. The participants were subjected to physical, psychospiritual, environmental, and sociocultural factors to help determine the usability of the theory. Physical interventions constituted relieving pain, reducing hypothermia, and lowering the risk of nerve injuries and ulcers (Bergström et al., 2018). Psychospiritual interventions were measures to alleviate anxiety and help meditate an atmosphere of security. Environmental measures include covering patients, protecting integrity, and creating a private space with protection against physical insight. Sociocultural measures included transmitting information, encouraging and validating patients, and having person0centeed conversations. The results showed that the Comfort matrix could be a suitable framework for anesthetist preoperative interventions.
Puchi et al. (2018) used Kolcaba’s theory to create the NP for the clinical case of an older adult with a diagnosis of CAP treated under HaH. The researchers observed that applying the theory was simple and could be utilized in the domiciliary contract. The study presents Mr. John’s case, aged 80, who went to the emergency department accompanied by his wife. He had a general health risk, was confused, and had respiratory distress for four days. A HaH nurse closely followed Mr. John while integrating the tenets of comfort theory. Later, the patient did not report pain and did not have a fever or cough but was disoriented in time and space. The NP nurse developed a conceptual framework for the comfort theory and used it to handle John’s case. The study deduced that comfort theory is practical, can be used in the care, and is fundamental in facilitating the development of the NP and provision of holistic, person-centered nursing care.
Freire et al. (2021) studied 30 patients from a hemodialysis clinic to understand the meaning and dimensionality of the state of comfort from chronic hemodialysis patients’ perspectives. The data was analyzed using Bardin’s content analysis method, which had a basis in comfort theory. It was observed that patients’ comfort on hemodialysis synched with the four contexts provided by initial studies by Kolcaba. The study found that the emphasized interventions proved an interval consistency of the theoretical and conceptual elements presented by Kolcaba. Besides, it made it possible to appreciate that some nursing interventions could significantly promote comfort. All in all, the study amplified the usability of directing nursing interventions to promote comfort.
Melo et al. (2020) conducted a study to analyze the benefits of auriculoacupuncture in nursing professionals working during the COVID-19 pandemic using Kolcaba’s theory of comfort. The research utilized auricular acupuncture to improve comfort. Besides, it showed an explicit manifestation of improvement in the physical domain according to the reports of reduced back pain and headache and increased hours of sleep and muscle relaxation. The study concluded that auricular acupuncture is beneficial in improving the feeling of physical and psychospiritual comfort by nursing professionals. As a result, it presents itself as a care strategy for caregivers who act at the frontline against COVID-19, proving the indispensability of comfort theory.
Moreover, Faria et al. (2018) conducted a study to evaluate the comfort care of patients in intensive care. The study appreciated the conceptual framework for Comfort theory. It affirmed that patients’ comfort needs emanate from the experienced physical and psychospiritual factors. Tranquility measures were the most outstanding in the study. Therefore, the study synchs with the assertions of Kolcaba.
Auyezkhankyzy et al. (2022) aimed to identify the usability of Kolcaba’s theory in nursing. The study uses New England hospital as a benchmark for applying care and values of Comfort theory. The hospital integrates the comfort theory in its operations for patients, their relatives, and nurses working in the institution. The hospital changed its nursing philosophy by incorporating physical, environmental, sociocultural, and psychospiritual comfort for patients, families, and nurses. Comfort interventions were implemented, such as warmed blankets in the emergency apartment, flexible family visiting hours and accommodations, and exceptional comfort food as requested. Moreover, the American Society of Peri Anesthesia Nurses also tried utilizing the theory. Overall, the researchers observed that the theory of comfort is integral in treatment practices.
Rustam et al. (2021) conducted a study to investigate the effect of nursing comfort care integrating with daily Islamic rituals on comfort among mechanically ventilated Muslim patients. The study found that nursing comfort care integrated into daily Islamic rituals enhanced comfort in the patients while receiving mechanical ventilation. Consequently, the study recommends the integration of the theory of comfort in nurse care.
Góis et al. (2018) conducted a study to describe the first stages of the cross-cultural adaptation process of the general comfort questionnaire for myocardial infarction patients in intensive care units. Katherine Kolcaba developed GCQ to help assess people’s comfort in the general situation of illness and hospitalization. The study observed that for the process of cross-cultural adaptation of the GCQ to people with myocardial infarction, the evaluation of the conceptual framework was relevant and applicable in the case study.
Chandra & Raman (2015) used tools proposed by Kolcaba to assess comfort. Their study evaluated the level of comfort among post-operative children using the Katharine Kolcaba observation checklist and comfort daises at selected hospitals in India. Their study used a general comfort questionnaire, comfort observation checklist, and comfort daises to evaluate the proposed phenomenon. Besides, it established that comfort is a fundamental aspect of nursing care. Assessing the right comfort level can help deliver effective nursing care to children.
Lin et al. (2022) present a study to develop an evidence and gap map of the comfort theory. The researchers use comfort theory as a basis to identify the effectiveness of the interventions of the theory. Their study shows how the theory is incorporated into the international scope to help understand nursing practices and enhance their effectiveness.
Henry, aged 83, had a past medical history of hypertension, dementia, coronary artery disease, hypertension, and diabetes. As he was walking in the evening, he slipped on the stairs, fracturing his right hip. He was rushed to the hospital, and the specialists performed some medical checkups. A head CT scan of the pelvis and hip showed a right hip fracture. An electrocardiogram showed that henry had a normal sinus rhythm and did not show signs of ischemia. He was admitted to the orthopedic surgery section to help fix the fracture. The surgery had been scheduled to be performed after three hours; however, it was delayed for three days because of emergent trauma cases and the unavailability of surgeons. The nurses did not place Henry on venous thromboembolism prophylaxis before the surgery: he had frequent agitations, disorientation, and competitiveness in the evening hours. He later underwent surgery and was discharged to home after two days. However, he was readmitted to the hospital three weeks later due to chest pains and difficulties in breathing. He was further diagnosed with pulmonary embolism, where treatment with anticoagulation was initiated. Additionally, Henry’s rehabilitation was delayed, making his recovery prolonged. Consequently, he was unable to return to his normal functional status. A discussion was initiated with Henry’s family, and the patient was recommended to hospice but succumbed to his condition a few months later.
The indispensability of Kolcaba’s theory can be used to evaluate Henry’s case and determine how its application could have helped save his life. The theory requires nurses and healthcare team members to identify the comfort needs of patients and family members. At first, the nurses and family members played a fundamental role in helping Henry get to the healthcare institution. They took care of him well in the initial stages as nurses checked whether the hip bone structure had caused other dysfunctions in his body. Bleeding was not evident, the sinus rhythm was normal, and his blood count was complete. These tests were among the measures of trying to identify the comfort needed by the patient at the moment. Upon recognizing the intertrochanteric hip fracture, the nurses set Henry up for orthopedic surgery. Unfortunately, the surgery was delayed for some days, proving a failure of nurses to design and coordinate interventions to address comfort needs. Surgery was a current need for Henry; however, it ended up being delayed, subjecting him to more pain. Kolcaba requires nurses to identify intervening variables they should use in designing interventions.
Intervening variables are elements that are unlikely to change and over which patients have no control over them. These elements include prognosis, financial situation, and extent of social support. Henry did not have social support. His family members did not follow after him much to check whether he was receiving the necessary treatment. Comfort increases when interventions are delivered in a caring manner and effectively. In Henry’s s case, nurses overlooked that the patient did not have family support. Instead, they could have been there for him and offered the most careful care to him. However, he was left unattended when he accessed the surgeon three days later. The nurses should have shown immediate concern and contacted the designated surgeon to complete the procedure as soon as possible. With cold treatment evident, Henry instead experienced pre-discomfort. He often felt agitated and disoriented. Patients, family members, and nurses usually engage in more health-seeking behavior if enhanced comfort is achieved. Markedly, Henry’s health continued deteriorating because of the lack of this proposition. He lacked proper care and thus did not attain any comfort. After discharging, his health continued to worsen, proving that when comfort is suppressed, the patient will not be willing to engage in health-seeking behaviors. Kolcaba claims that when patients and family members are more comfortable, they are more satisfied and have better health outcomes. Henry’s case portrays a lack of concern and comfort. There were delays in his treatment and no follow-up on his wellbeing after discharge. Moreover, family members were unwilling to facilitate hospice care seamlessly. As a result, the prognosis of Henry proved a lack of commitment and neglect by the environment: nurses and family members. Therefore, the institution that attended to him is considered ineffective because it failed to improve patient care.
Application of Kolcaba’s theory would have helped save Henry’s life. The nurses and family members should have worked closely to ensure Henry attained comfort. On arrival at the hospital, the nurses should have engaged the family members to gain further knowledge of the patient’s condition. This step would lead to analyzing the intervening variables, which could be critical in Henry’s prognosis. As a result, the nurses could identify what worked for him. For instance, Henry’s family had financial constraints, which could hinder treatment access in the healthcare institution. While it could be a limitation, the family members could have looked for alternative ways of helping the patient access optimal and effective healthcare. It was evident that Henry was in pain, as he could express it to the nurses who did not examine him to give the required medication. Henry did not show internal behaviors that could propel him to regain his health: he shared with one of the nurses that he felt his death was near. Moreover, he was against taking most medicines given to him to curb pain. A close consultation with the family members showed that they had spent many finances on Henry’s health, owing to his age. Fracturing his hip bone came as an additional burden to them since Henry could do nothing by himself. He relied on nurses and family members to do most of the tasks. Due to increased dependence, the family members were forced to alter their plans and schedules to care for the patient. However, their support in the recovery of Henry was minimal and not promising. Henry was thus not motivated to continue seeking to restore his wellbeing. He later succumbed to death. The case analysis proves that comfort is fundamental to a patient’s recovery.
Transitions theory is an alternative theory that can be used to understand the case further. Meleis coined the theory after observing human experiences when dealing with changes concerning their health, wellbeing, and ability to care for themselves. The theory describes the interactions between nurses and patients and suggests that nurses are concerned with patients’ experiences as they undergo transitions regarding their health and wellbeing (McEwen & Wills, 2022). The theory describes the goal of nursing professionals as conceptualizing and addressing potential problems which individuals encounter during transitional experiences and developing preventative and therapeutic interventions to support patients during these occasions (McEwen & Wills, 2022). The transitions can be either developmental transitions, which include birth, adolescence, menopause, aging, and death: situational transitions, which include changes in educational and professional roles; and health-illness transition, which entail recovery process, hospital discharge, diagnosis of chronic illnesses, and organizational transition, changing of environmental conditions that affect the lives of the patients (McEwen & Wills, 2022).
This theory demands nurses identify the facilitators and inhibitors of the transition conditions. The factors of concern include personal meanings, cultural beliefs and attitudes, socioeconomic status, preparation, and knowledge (McEwen & Wills, 2022). Nurses should help identify the readiness, preparation of transition, and role supplementation. The theory constitutes tenets that could righty fit in Henry’s condition. The levels of frailty among the aging population have significantly grown. The theory has been widely utilized in various instances. For instance, Beaudet and Ducharme used the theory to identify transitions encountered by patients with Parkinson’s disease and their caregivers (McEwen & Wills, 2022). Also, Dossa, Bokhour, and Hoenig performed a grounded theory study to examine the transitions from hospital to home for patients with mobility impairments and family caregivers (McEwen & Wills, 2022).
The rationale for considering this theory is that nursing care and social care for people undergoing transitions were required to help Henry adjust to the new life with a hip bone fracture and hospice care. Transitions require a person to incorporate new knowledge, alter some behaviors, and consequently change the definition of self in the new state (McEwen & Wills, 2022). The transition to hospice care requires nurses to help the patient acknowledge the need for the transition while dealing with concerns that may arise.
Nursing theories help understand clinical situations better. The theory of comfort is vital in expressing pain management among older people with hip bone fractures. Many researchers have utilized the theory to advance their searches and help people understand nursing practices more elaborately. Transitions theory complements the case study provided in this study. Therefore, nursing theories play a fundamental role in appreciating nursing practices.
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