A Practical Guide for Frontline Workers During COVID-19: Kolcaba’s Comfort Theory

Abstract

On Sunday, April 26, 2020, the world figuratively halted with the heartbreaking news of ED Medical Director of New York-Presbyterian Allen Hospital, Dr Lorna Breen’s death by suicide. The cause of suicide is unknown, but she had consistently treated coronavirus patients. She also contracted COVID-19 (Coronavirus Disease 2019) at one point and fully recovered. Unfortunately, the overexposure and constant burden of caring for coronavirus patients “killed” her, sources say. Those experiences likely induced physical, sociocultural, environmental, and psychospiritual pain (1,2). Her father, Dr Philip C. Breen, stated his daughter had no hint of mental illness and was a successful woman with very caring friends, family, and colleagues. His daughter’s own death impelled him to raise awareness of the psychological consequences of COVID-19 to the public.Two days earlier, John Mondello, Emergency Medical Technician (EMT) of the Fire Department of New York also committed suicide. It is not by pure chance that their suicides coincided within 48 hours of each other as both tragedies grappled the nation and called for greater attention to address the mental health concerns of those working on the frontlines. Research studies (3,4) have reported that nurses and doctors are already at risk for developing mental illnesses “due to their indirect and/or direct exposure to traumatic situations while providing care to vulnerable patient populations” (p. 2770). Researchers from China, Korea, and France have warned the public of the additional psychological and mental health risks of COVID-19 on medical health workers globally (5 –7).In providing patient care, these medical health workers are constantly self-effaced because they are on the frontline. The reality of witnessing suffering and death consistently and communicating complex information to patients and families with poor coping skills increases the risk of developing burnout (3,4). In addition to providing care, nurses have to navigate around the limited supply of physical protective equipment, ventilators, and hospital beds, let alone deal with staff shortages. On top of these challenges, there is fear of contracting the virus itself because it is both novel and invisible to the naked eye. Frontline workers who have been in direct, in-person contact with patients diagnosed with or being treated/evaluated for symptoms related to COVID-19 are more prone to contracting it than someone who works exclusively from home. I work on a per-diem basis at a nonprofit acute care hospital with general medical and surgical inpatient care services in the Greater Boston Area. Two of my nurse managers contracted the disease in the early phases of the pandemic and fortunately recovered. One practicing neurologist died from COVID-19. Numerous others including staff nurses and certified nursing assistants became infected with the virus, lived in self-isolation, and gradually came back to work. Dr Breen succumbed to the virus, recovered, and also returned to work. Yet, she still committed suicide, an outcome likely resulting from provider burnout left unaddressed.Suicide Risk Factors and BurnoutThree sequential features of burnout include exhaustion, detachment and negative reactions to people and tasks and the job itself (cynicism), and feelings of failure (8). Burnout has been linked to other mental health illnesses such as depression. For example, “a new understanding of this linkage comes from a recent longitudinal study in Finland (8), which found a reciprocal relationship between burnout and depression, with each predicting subsequent developments in the other” (p. 108). In another longitudinal study in Japan, researchers examined the link between overwork-related mental disorders and incidences of suicide (9). Cases occurred in 1371 men and 619 women total. Particularly higher cases were seen in men aged 29 years or younger. Significant vulnerable work groups were “accommodation/eating/drinking services,” “information/communication,” and “scientific research, professional and technical services” (9). In Dr Breen’s case, the causes that led to her own death are unknown; however, it is likely that physical illness namely, Coronavirus, was a contributing factor. According to the Centers for Disease Control and Prevention, predictive factors of suicide include, but are not limited to physical illness, isolation, the feeling of having no one to talk to, unwillingness to seek help because of the stigma attached to mental health, substance abuse disorders or to suicidal thoughts, and feelings of hopelessness (10).Aim of the PaperDuring a global crisis, I have been contemplating about the term “vulnerability.” Working at the bedside has been illuminating both professionally and personally. As a practicing RN, it holds a new meaning for me where its focus not only applies to patients but also to the very people, like me, who take care of them. However, mental health often times goes neglected in the name of certain virtues such as altruism and heroism by which many frontline workers live. In the midst of a worldwide pandemic, the call to serve just cannot go unanswered. My nursing colleagues and I have been flexible while providing nursing care under policies and workplace arrangements which frequently change based upon new information presented to us about Severe Acute Respiratory Syndrome Coronavirus 2 and Centers for Disease Control and Prevention guidelines. The demanding and ever-changing work conditions contribute to work-related stress, nonetheless. Higher levels of burnout have been consistently reported in nurses who work in the following subspecialties: Psychiatric Units, Emergency Department, and especially intensive care unit/critical care units (3,4).The aim of the article is to propose using the theoretical framework of comfort (1,2) as a practical guide to help mitigate the mental impact of COVID-19 on frontline workers.In the following section, I present a brief overview of the Theory of Comfort (TC).Theory of Comfort (1994, 2001)In 1994 Katharine Kolcaba, American middle-range nurse theorist, developed the TC based upon care that was observed or given. She worked in the Operating Room, long-term, home care, and medical/surgical specialties. Theory of Comfort is based upon 3 concepts: (a) relief, (b) ease, and (c) transcendence; and 4 domains: (a) physical, (b) psychospiritual, (c) sociocultural, and (d) environmental. Relief is the experience of having a comfort need met (11). Ease is the experience of care that promotes calm and/or contentment (12). Transcendence is the experience in which care enables a person to rise above problems or pain (13,14). Physical pertains to bodily sensations and functions. Psychospiritual refers to self-esteem, self-concept, sexuality, life meaning, and relationship to a higher power. Sociocultural includes one’s social relationships (eg, family and friends). Environmental pertains to the external world, like nature. Concepts can be plotted against any of the 4 domains in the taxonomic structure below (Figure 1). A patient exemplar is presented from which different nursing interventions are integrated into the taxonomic structure to reflect TC concepts.Figure 1.Taxonomic structure.Patient ExemplarA dying patient diagnosed with COVID-19 can attain physical relief when the nurse takes vitals, offers fluids, and monitors electrolytes. Providing dry, warm blankets to replace wet and soiled ones can provide physical relief. Turning and repositioning the patient can assist in physical ease. Moisturizing a dry mouth or dabbing the patient’s lips with a cotton swab dipped in water or sucrose fluid can enhance all 3 concepts of relief, ease, and transcendence. Providing periods of undisturbed rest can aid in environmental relief and psychospiritual transcendence. Frequent contact with family and friends in-person (eg, 1-hour hospital visitor policy) or via video chat (eg, FaceTime) can increase sociocultural ease and transcendence. The patient can experience environmental relief and ease by dimming the lights as well as psychospiritual relief by minimizing external stimuli to prevent anxiety. Nurses can always provide emotional support which can help facilitate sociocultural relief. Playing instrumentals including harp, cello, or sax, a music genre or song request can increase the person’s overall comfort. This list is far from exhaustive.LimitationsTwo philosophical assumptions are:(1) Do all patients seek and approve such genuine encounters?(2) In how many encounters can a frontline worker be involved in the course of one shift, and is there potential for emotional drainage leading to burnout?Due to varying patient preferences and clinicians’ demands among other variables feasibility of TC may be limited. Dr Meleis, Dean Emeritus and Professor of Nursing and Sociology at University of Pennsylvania and Professor Emeritus at University of California-San Francisco (15) stated:We may not know, for example, what is providing comfort to nursing clients, how comfort is defined, how it is achieved who is expected to participate in providing it, what are the different ways in which it is manifested, and what is feasible and what is not feasible in comforting patients in various stages of health-illness. (p. 364)Limited feasibility may present itself on units with high nurse-to-patient ratios (>1:4), a ratio imbalance which Gustsan et al (16) found to increase hospital mortality by 7%. On the other hand, resilient frontline workers may rely on their strong support systems and coping skills to provide the delicate balance they need on a daily basis to thrive as opposed to survive. For example, Laschinger and Nosko surveyed 631 experienced and 244 newly graduated acute care nurses and found their “psychological capital” or positive psychological state of development characterized by hope, optimism, self-efficacy, and resilience were associated with lower levels of b