Care in nursing is such a commonly used term associated with the performance of professional responsibilities that little thought is often given to what it is. Often, nurses know that care consists of the different interventions they do but beyond its practical application, its evolution into a central concept in nursing theory and the various ways in which it is defined by different theorists is not so known. This paper looks at the concept of care in nursing from the perspectives of Madeleine Leininger and Katharine Kolcaba as culture care and comfort care respectively.
Culture care nursing, developed by Leininger, is research and practice dealing with culturally-defined differences as well as similarities in care with the objective of assisting clients in achieving therapeutic care that is meaningful because it is congruent with their culture. Culture care is essentially the fusion of concepts of culture which were borrowed from anthropology and care which is considered a central and indispensable concept in nursing. Thus, culture care is defined differently from care that does not consider the importance of culture in nursing.
From her experience, Leininger noted that a notion of care without an understanding of culture is insufficient in nursing practice. Her theory assumes that culture care can enhance the nurse’s understanding of a patient’s situation by providing a framework of ascertaining and explaining aspects of this situation which can only be attributed to culture. In this sense, it is a grand theory. It also assumes that cultures are not just different in their concepts of care but there are observed similarities which can guide nurses in providing care that incorporates both the universal and the particular features of different cultures.
Leininger defines culture care as â€œthe synthesized and culturally constituted assistive, supportive and facilitative caring acts toward self or others focused on evident or anticipated
needs for the client’s health or well-being or to face disabilities, death or other human conditionsâ€.Â It is different from conventional nursing care in terms of sources of knowledge. Etic knowledge is that which a nurse derives from her professional training while emic knowledge is held by the patient and is passed on to him as part of his culture (Leininger, 2006). Emic knowledge can be health beliefs and practices. Conflict arises when care based on the nurse’s etic knowledge is imposed on the patient whose emic interpretation of aspects of care is different. For example, physical touch from the nurse during physical examination can mean something else to the patient whose culture defines touch in the context of body, health, illness and relationships in specific ways.
To prevent such conflicts, the nurse incorporates emic knowledge to provide culture care. Since emic knowledge is known, best understood and expressed by persons belonging to a particular culture, the nurse gains this knowledge from the patients themselves. Consequently, the nurse comes to see the care situation from the patient’s perspective. In doing so, etic-based care is redefined into one that fits the patient’s viewpoint so that it becomes patient-centered and meaningful. Eventually, the nurse’s emic knowledge accumulates from her experiences which increase her competence as a nurse.
On the other hand, Kolcaba posits a different definition of care. She makes reference to patient comfort in previous works written by nurses, one of whom is Florence Nightingale, whose concepts of comfort evolved in an era where pharmacologic therapy for pain relief was unavailable and physical comfort measures were the independent functions of the nurse. Kolcaba’s comfort care is set in a modern context and beyond physical comfort confronts the needs of patients with in the areas of physical, psychospiritual, sociocultural, and environmental comfort.
Kolcaba asserts that comfort can be categorized as transcendence, ease or relief. To transcend is to overcome, ease is a feeling of peace and satisfaction, and relief is the result of successfully fulfilling particular comfort needs. Comfort has three components, namely the intervention, the method and the intent. The intervention should be both timely and appropriate, carried out in an empathic and caring manner with patient comfort being the nurse’s goal (Walker & Avant, 2005). Because it concerns a specific aspect of care, and not what nursing is per se, Kolcaba’s comfort theory is deemed a middle-range theory.
The different categories of comfort with its components can be experienced in different scenarios. Physical comfort covers sensory experiences and physiologic balance. Psychospiritual comfort encompasses life’s meaning and issues relating to sexuality, religion and self esteem. Environmental comfort concerns the external, physical surroundings and includes interior arrangement, amenities and ambience. Sociocultural comfort relates to social relationships at different levels, namely interpersonal, familial and societal, which are greatly influenced by culture and translates to economic status, level of education and social support .
For nurses to successfully meet patients’ comfort needs, the three components must be met. Additionally, there are three types of comfort measures that can form the nurse’s repertoire of care. Technical comfort promotes homeostasis and alleviates pain through pharmacotherapy and observing measures of physiologic function. Coaching utilizes active listening, anxiety reduction, providing information and inspiring hope so that the patient can formulate future plans (Walker & Avant, 2005). Comfort food for the soul is any intervention outside of the first two types that are not called for but provided by the nurse such as massage therapy or music therapy.
The two theories differ in terms of scope. While culture care attempts to define the totality of nursing care as a cultural encounter, the comfort theory seeks to explain a particular aspect of nursing care, namely comfort, its different facets as a patient need and how this need can be met by nurses. This reflects their nature as a macro or grand theory and a middle-range theory respectively. Culture care applies to all types of nursing care, whether assistive, supportive or facilitative; all patients needs whether evident or anticipated; and all care situations, whether for health, well-being, disability or dying. Â Comfort care, on the other hand, is applicable in instances where comfort is a documented patient problem but which is also universal. Being the broader of the two, culture care encompasses comfort care but being less complex, the latter is easier to implement. Â Both can also be readily adopted into other health care disciplines.
Both concepts of care are patient centered but differ in areas of care where participation of the patient is elicited. Besides focusing on patient needs, culture care considers the patient’s values, beliefs, practices, preferences and language in the planning and implementation of care. This requires the participation of the patient in the entire process through being the source of information, directing the care received or in providing care to self. Hence, the patient is not only a recipient or participant but can also be the provider of care. Comfort care is also patient centered because it is the patient’s problems and comfort needs which are the focus of the nurse. However, patient participation seems to be limited to planning for the future when coaching is used as a nursing intervention. In most aspects of nursing care, such as in providing technical comfort or comfort food for the soul, the patient is a recipient of care and the nurse the provider.Â Â
Culture care and comfort care are both holistic. Culture care broadens nursing care to embrace culture sensitivity which is important but used to be overlooked. Comfort care is comprehensive when only the concept of comfort is taken into account as it includes not only the physical but also the psychospiritual, sociocultural and the environment. Â Both also require the nurse to be conscious about her actions, i.e. in obtaining culture-related information about the patient in each encounter and always having the intent to successfully meet comfort needs. Â Finally, both enhance esthetic and personal knowledge in different ways. Culture care generates knowledge of many cultures and underscores the need to examine personal biases, beliefs and values. The application of comfort care, on the other hand, demands the creativity of the nurse in expanding the repertoire of interventions.Â Â Â
Applications of the Comfort Care Theory
The comfort care theory posits that the concept of comfort is an essential element of nursing care. It is most applicable in care settings where comfort is a priority problem which may last for significant periods of time and greatly affect patient quality of life as well as outcomes of care. Such settings include pediatric nursing, postoperative nursing, hospice nursing, obstetric nursing and orthopedic nursing. The patients in these settings are in different stages of the lifespan and in various levels of health care but all have difficulty coping with discomfort in its various forms: pain, immobility, symptoms of disease or dying. Comfort care in these settings focuses on the patient and the family as well as the larger community. The aim is to increase the level of comfort in order for the patient, family and community to function in the best way possible, thereby improving their health status.
The philosophy is to provide comprehensive comfort care. The function of the nurse is to perform a deliberate assessment of baseline comfort indicators and needs, formulate a plan of care which incorporates comfort care measures and goals, and evaluate the efficacy of interventions. The theory provides a framework to guide nursing practice and this identifies the areas, categories and contexts of comfort, the components essential to the act of comfort care and the types of comfort measures. One type of intervention is modifying the patient’s environment in ways that enhance comfort.