While considering what construct to conceptualize, I was in the process
of recording my three-hour, twice a week interactions in the
demonstration unit. I reflected on these interactions and waited for the
data to reveal to me the major value underlying my nursing practice.
Then the term "comfort" came {99} to mind. Perhaps at this point I
became comfortable in this unit, or perhaps the unit, itself, became a
more comfortable setting. When I had first begun my experience with this
demonstration unit, it was still being planned and the hospital was new
to me. However, the term "comfort" has long been associated with
nursing. One can find it as a historical constant throughout the
professional nursing literature. The term had been used recently in an
ANA publication.[2] When I considered the idea of comforting in nursing
practice I felt such experiences had fulfilled and satisfied me, made me
feel adequate. I could recall specific experiences that went back to my
initial nursing practice settings. I could conceive of comfort as an
umbrella under which all the other terms--growth, health, freedom, and
openness--could be sheltered. Some of my contemporaries scoffed and
viewed this term as much too trivial.
Now, again reviewing my months of gathered clinical data, I sorted out
12 nurse behaviors that I viewed as aiming toward patient comfort. They
were:
1. I focused on recognizing patients by name, being certain I
was correct about their names, and using their names often and
appropriately. I also introduced myself. Names were viewed as
supportive to the internalization of personal identification,
dignity, and worth.
2. I interpreted, taught, and gave as much honest information
as I could about patients' situations when it was sought or
when puzzlement was apparent. This was based in the belief that
it was their life, and choice was their prerogative as they
were their own projects.
3. I verbalized my acceptance of patients' expressions of
feeling with explanations of why I experienced these feelings
of acceptance when I could do this authentically and
appropriately.
4. When verbalizations of acceptance were not appropriate, I
acted out this acceptance by staying with or doing for when
appropriate.
5. I expressed purposely, to burst asunder negative
self-concepts, my authentic human tender feelings for patients
when appropriate and acceptable.
6. I supported patients' rights to agape-type love
relationships with others: families, other staff, and other
patients.
7. I showed respect for patients as persons with the right to
make as many choices for themselves as their current
capabilities allowed.
8. I attempted to help patients consider their currently
expressed feelings and behaviors in light of past life
experiences and patterns, like and unlike their current ones.
{100}
9. I encouraged patients' expression to better understand their
behavioral messages and to enable me to respond overtly as
therapeutically as possible.
10. I verified my intuitive grasp of how patients were
experiencing events by questions and comments and being alert
to their responses.
11. I attempted to encourage hope realistically through
discussing individual therapeutic gains that could be derived
from patients' investment in therapeutic opportunities
available to them.
12. I supported appropriate patient self-images with as many
concrete "hard to denies" as possible.
Each of these nurse behaviors was repeatedly evident in the months of
recording patient-nurse interactions. For the conceptualization of the
term "comfort," a representative clinical example was given to enhance
the meaning of the behavior cited (see Appendix). When compiling
materials for the conceptualization of this term, I found 12 assumptions
about psychiatric nursing that I had written for the theory course in
one of the first class sessions. Although these assumptions were
expressed in different words, their congruence with my 12 selected
behaviors made me believe that these behaviors were somehow verified
both in my conceptualized philosophy of psychiatric nursing and in my
behavior while being a psychiatric nurse.
Next I struggled with an idealistic conception of comfort as opposed to
a continuum of behavior which would indicate a person's degree or state
of discomfort-comfort. Again, reflecting on and teasing out aspects of
my data, I set up four behaviorally recognizable criteria for estimating
a person's discomfort-comfort state:
1. Relationships with other persons which confirm one as an
existent important person.
2. Affective adaptation to the environment in accord with
knowledge, potential, and values.
3. Awareness of and response to the reality of the now with
understanding of the influence of and separation from the past.
4. Appreciation and recognition of both powers and limitations
which enlighten the alternatives of the future.
These behavioral criteria, too, could each be spread on a continuum to
evaluate the effects of this aim of nursing on a patient's actual
comfort status at any particular point in time.
Considering the concept of comfort as a proper aim of psychiatric
nursing brought forth the necessity of considering its opposite,
discomfort, as a concept. Evidence for the existence of discomfort could
be inferred in the absence of the above behavioral criteria. {101}
The basic foundation to justify the concept of comfort as a proper aim
of psychiatric nursing would be both organic and environmental. In our
culture, among the species man, we are moving toward being able to
effect some organic conditions by genetic controls and surgical and
chemical means. The professions have struggled long years to influence
environmental deterrents to comfort. If an individual as a fetus, or as
an infant, or young child never internalizes comfort of any kind from
his environs, the probability of initiating a continuum within himself
as an adult that is propelled toward comfort seems unlikely. Such
individuals, lacking any potential capacity for comfort, I suspect are
rare. There is evidence for the existence of this dormant seed of
comfort in persons with schizophrenia in the hospital setting. Consider
how repetitively and ambivalently they "reach out" to authority figures.
This dormant comfort seed requires nourishment of a high quality for
testing whether it can develop and bear the fruits of health, growth,
freedom, and openness.
When the development of this synthetic construct of comfort was
discussed in the theory course a question was raised: Is a person who
denies all feeling, presents himself as emotionally dead, comfortable?
If feelings are not relegated to the mind alone, as the effects of a
peptic ulcer cannot be relegated to the stomach, if feelings are an
essential of the nature of humanness, a human who denies this essential
of his nature would not fit into this concept as comfortable. This
synthetic construct of comfort, like its synonym contentment, described
by Plutarch A.D. 46-120, does not imply passivity, resignation,
retirement, or a simple avoiding of trouble. Plutarch said, "Contentment
comes very dear if its price is inactivity."[3] I would perceive of
comfort or contentment as implying that a human being was all he could
be in accordance with his potential at any particular time in any
particular situation.
Continuing the aforementioned twelve nurse behaviors, observing behavior
through the four established criteria and conceptualizing the construct
of comfort, I began to wonder. Was I seeing what I had decided was the
state of psychiatric patients' conditions of being? Was I projecting
discomfort onto patients? I did not expect straight answers.
Nonetheless, I decided to ask patients about their discomfort-comfort
states to verify my perception of the condition of their beings. All
fourteen patients I asked assured me by their responses that I was not
projecting or seeing discomfort where it did not exist.
Some described physical discomfort and sought the cause within and
outside themselves (either another caused it, or another could cure it,
pills would cure it), negatively viewed self-images, guilt based in
their behaviors or thoughts. One patient defined comfort by analogy and
stated directly to my surprise that he seldom felt comfortable and that
his excessive ritualistic behavior was his way of coping with his
discomfort. One repetitively stated a happy illusion that he seemed to
hang on to for dear life. When I asked what he would do if this illusion
was not truth, he said that he had never considered {102} this
possibility. I knew he had been confronted with the truth of his
situation many times in many ways. One patient merely looked directly at
me and walked away.
Then I again reviewed my clinical recorded data to see what kinds of
knowledge nursing with an aim to comfort would infer as necessary.
Fifty-two items of knowledge were extrapolated from the clinical
examples selected as representative of the twelve nurse behaviors. These
items were categorized under broad cognitive and affective domains. This
was an arbitrary point of separation. They were teased apart simply as
an aid to conceptualization and understanding. If these knowledge
domains had related to one another in a simple direct manner, I would
have conveyed them in a table in which each would have been across from
its mate. Their relationships to one another were far too complex to be
handled in any such a way. The affective domain knowledge areas were a
dynamic internalized synthesis of several knowledge areas from the
cognitive domain. Thus, the expression of these affective knowledge
areas was evidence of the practice of nursing as an artful form of
expressing cognitive knowing.
In looking directly at the discomfort of long-term hospitalized
psychiatric patients, I found myself faced with behaviors that resulted
possibly from a muddle of many contributories. What in the behavior
resulted from lifetime environmental influences and compounded responses
that deepened scars? What resulted from long-term hospitalization? How
many varieties of ills superimposed like layers on the above were
expressed in what I saw as discomfort in these psychiatric patients?
Diagnostic classifications are necessary for statistical economic
planning reasons. Still, how naively and superficially they convey the
human therapeutic care needs of each person.
At this point of construct development I saw a positive relationship in
my thinking about comfort as a proper aim of psychiatric nursing and
Viktor Frankl's description of his aim in logotherapy toward meaning. I
had struggled with the idea of aiming at comfort while with patients who
possessed ability and a favorable prognosis, often purposefully and
deliberately asking them to consider ideas that caused them immediate
greater discomfort. Frankl's quotes from Nietzsche and Goethe supported
my altruistic intention. Nietzsche said:
"He who has a why to live can bear almost any how."[4]
Goethe said:
"When we take man as he is, we make him worse; but when we take
man as if he were already what he should be, we promote him to
what he can be."[5]
In conclusion to this stage of development of a synthetic construct of
comfort as an aim of psychiatric nursing I can say: Comfort is an aim
toward {103} which persons' conditions of being move through
relationship with others by internalizing freedom from painful
controlling effects of the past. These effects have inhibited their
self-control, realistic planning, and prevented them from being all that
they could be in accordance with their potential at any particular time
in any particular situation. I would project this as an aim for nursing
in all situations although the data for constructing this
conceptualization were gathered in a clinical psychiatric setting.