Background
Social, economic, political and health achievements have led to the emergence of a new demographic profile for the aging population [1]. The number of older persons expected to reach two billion by 2050, and three-quarters of these persons will live in less developed countries [1]. Older persons have complex needs, especially in the context of hospitalization, where the conditions of senescence and senility coexist [2], requiring a care management based on individual and circumstantial demands and life context [3]. Comfort, alongside safety and autonomy, is an essential outcome that is intrinsically related to care management, for which nurses are responsible [4].
The task of establishing a balance between comfort and safety is challenging in hospitals [5], however, many interventions tend to sacrifice and compromise comfort in favor of safety [6]. Nursing care tends to adopt a more curative approach and to focus on somatic causes, in which context discomfort occurs as a side effect of efforts to ensure patient’s safety: invasive and painful procedures, limitations on decision-making and action, strict hospital norms and routines [7]. Half of all physical disabilities among older people, including disabilities pertaining to basic activities of daily living, arise during the hospitalization period as a result of interventions aimed at ensuring safety [8], highlighting the need for effective measures to be implemented to support the health-disease process and hospitalization [9].
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The promotion of comfort is associated with shorter hospital stays, better cost‒benefit ratios [10], and improved patient experiences and satisfaction [11]. The literature on this topic has highlighted the need for more researchers to investigate effective ways of increasing patient comfort [11]. Therefore, this study aimed to investigate the production of comfort as a therapeutic outcome of nursing care management for hospitalized older people.
Methods
Study design
This study featured an exploratory descriptive design that included a qualitative approach alongside the form of thematic-categorial content analysis developed by Laurence Bardin [12] as well as Comfort Theory, wich was developed by Kolcaba [13]. Semistructured interviews were conducted with nurses in a Brazilian hospital. To prioritize the quality and transparency of the writing, the text was written in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ), which is a 32-item checklist used for interviews [14].
Study setting
The research setting on which this research focused encompassed 13 wards of a university hospital in Brazil’s public Unified Health System (SUS) in Rio de Janeiro, including three general medical wards, six specialized medical wards and four specialized surgical wards. The Unified Health System (SUS) of Brazil is a complex publicly funded health system grounded in the principles of universality (health is a right for all, and it is the duty of the State to ensure it without distinction), equity (treating unequally those who are unequal, with the aim of reducing disparities), and comprehensiveness (viewing the individual as a whole, integrating actions for health promotion, disease prevention, treatment, and rehabilitation, including coordination with other public policies that impact quality of life) [15].
Because this hospital did not feature a specific unit for older persons, units were selected on the basis of the number of older persons whom they served in 2021, i.e., the year prior to data collection. Units that were characterized as focusing on semi-intensive or intensive care were not included because of their specific characteristics.
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Population and sampling
The sample included nurses in management positions– i.e., nurses who were part of the institution’s formal management structure and who were responsible for activities pertaining not only to leadership but also to resource management and the planning and implementation of institutional policies. Nurses who had a minimum of six continuous months of professional experience in the unit were included in the sample, in light of the need for time to adapt to the service.
The hospital adopted two hiring modalities to fill nursing vacancies: (1) a competitive examination, based on merit and qualifications, which provided job stability; (2) selection based on curriculum, where nurses were hired for a specific period, resulting in temporary contracts with a predefined start and end dates. Nurses from both hiring modalities participated in the research, albeit with a preference for those hired through competitive examinations, because these nurses had longer-standing connections with the hospital.
Nursing residents (i.e., nurses who were pursuing a postgraduate degree at a specialization level and thus participating in in-service training for nurses) were excluded because according to the institution’s residence profile, such students do not remain in the same unit for six continuous months.
The 13 units selected for this research featured 26 permanent nurses (i.e., nurses hired through competitive examinations), and 56 nurses on temporary contracts. Nineteen nurses participated in this study (including 13 permanent nurses and six temporary nurses). At least one nurse from each unit was included. Theoretical saturation was achieved with the 19th participant, when the interviewer observed that the data had begun to exhibit a certain degree of redundancy or repetition, and that further data collection was not productive. This situation was discussed among the researchers, who decided to suspend the inclusion of new participants. No further interviews were conducted.
Data collection instrument
Data were collected through a semistructured interview guided featuring a two-part script developed by the autors for this study. The first part included questions that could be used to characterize the participants, while the second part focused on the objective of this research and included questions such as “Regarding the management of care for hospitalized older persons, how do you understand / what elements characterize / how is it performed in the unit to which you belong?” and “How do you assess the skills and competence of nurses involved in the management of care for the older persons?”.
A pilot test of the interview was performed with the members of the research group.
2.5 Data collection
During the initial phase of this research, the gatekeepers established baseline verbal contact with potential participants by introducing the researchers and explaining the study’s purpouse during a meeting. At this meeting, the researchers indicated that an invitantion would be sent to potential participants via email. Twenty nurses were sent such an email invitation, which included participants suggested by the gatekeeper.
The emails included information regarding the research objective, justification, and the author’s interest in the study as well as a consent form. One of the 20 invited nurses did not respond, while 19 nurses responded and accepted the invitations to participate. After the participants accepted the invitation, the interviews were scheduled on the basis of the nurse’s availability; the researchers then held individually scheduled meetings held in a location within the institution that ensured privacy.
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Data collection occurred on various occasions between May and June 2022 after the research ethics committee provided approval for this study. The interviews were conducted by the lead author, who was a nursing master’s student at the affiliated university, and who had previous experience in conducting interviews as a result of her education degree in nursing. After the participants provided permission, to ensure the reliability of oral records, a mobile device was used to record the interviews. The average duration of the interviews was 25 min each.
Data organization and analysis
The interviews were transcribed into a text editor, and each participant identified by the letter ‘P’ (for ‘participant’), followed by a number that corresponded to the order of the testimonies; this approach was used to ensure confidentiality and anonymity. The transcriptions were not returned to the participants, given an additional time would have been required without any guaranteed benefits. However, they were offered the possibility to watch the final presentation of the work and to access the completed dissertation, including all the results and findings [16]. The material was then subjected to Bardin’s thematic-categorial analysis, which is a technique for evaluating communicational that focuses on indicators that could provide information regarding the message [12]. The data were subsequently coded in “registration units” (RUs). Therefore, the results presented here were discussed in light of Kolcaba’s Comfort Theory. No data analysis software was used, given the researchers’ knowledge of this topic, which helped ensure a critical and reflective analysis of the data [17]. The rigor, credibility, dependability and transferability of the research findings of this research were guaranteed as a result of the inclusion of a second researcher. The participation of the second researcher allowed a cross-check of data and analyses, reducing the possibility of errors and increasing confidence in the results.
Ethical considerations
The research ethics committee of the relevant institution approved the study under CAAE 57513722.0.0000.5282. Furthermore, this research was conducted in compliance with the regulations that are currently applicable in Brazil. All the data were preserved and analyzed on a confidential and scientific basis.
Results
Participant characteristics
Approximately 90% (17) of the participants in this study (19) were women, and most participants were aged between the ages of 40 and 44 years. Most of the nurses (17) had graduated more than 10 years ago and had the same amount of experience with professional practice. Most of the nurses had worked in the same unit between 1 and 5 years. Most of the nurses had a weekly working schedule of 60 h, which often involved the accumulation of dual or triple employment bonds, as indicated in Table 1.
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Table 1
Demographic characteristics of the participants (Rio De Janeiro, 2023)
Nurses’ Characteristics | N | % |
|---|---|---|
Sex | ||
Female | 17 | 89.47 |
Male | 2 | 10.53 |
Age (in years) | ||
35 to 39 | 5 | 26.31 |
40 to 44 | 9 | 47.37 |
45 to 49 | 3 | 15.79 |
50 to 54 | 2 | 10.53 |
Years since nursing degree | ||
1 to 5 6 to 10 | 1 1 | 5.26 5.26 |
11 to 15 | 7 | 36.85 |
16 to 20 | 6 | 31.58 |
21 to 25 | 2 | 10.53 |
26 to 30 | 1 | 5.26 |
31 to 35 | 1 | 5.26 |
Years in professional practice | ||
1 to 5 | 2 | 10.53 |
6 to 10 | 1 | 5.26 |
11 to 15 | 7 | 36.85 |
16 to 20 | 5 | 26.31 |
21 to 25 | 2 | 10.53 |
26 to 30 | 1 | 5.26 |
30 to 35 | 1 | 5.26 |
Years associated with the hospital | ||
Less than 1 | 1 | 5.26 |
1 to 10 | 15 | 78.95 |
11 to 20 | 0 | 0.00 |
21 to 30 | 3 | 15.79 |
Years working in the unit | ||
Less than 1 | 2 | 10.53 |
1 to 5 | 10 | 52.63 |
6 to 10 | 5 | 26.31 |
More than 10 | 2 | 10.53 |
Other employment relationship | ||
Yes | 13 | 68.42 |
No | 6 | 31.58 |
Thematic categories
Nineteen interviews were analyzed on the basis of the content analysis technique proposed by Laurence Bardin [12]. The data were categorized in light of the study objectives, and the following thematic categories and respective subcategories emerged, as illustrated in Fig. 1:
Fig. 1
Distribution of thematic categories and subcategories. Rio de Janeiro, 2023
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Figure 1 Distribution of thematic categories and subcategories (Rio de Janeiro, 2023).
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The construction of care management for hospitalized older persons from the perspective of essential comfort and safety
Given that care management involves the implementation of health technologies that focus on improving patients’ well-being, safety, and autonomy while respecting the individual’s uniqueness during various stages of life [3], the data revealed that, in addition to autonomy, the researchers expected the promotion of comfort and safety to be a product of care. Therefore, if care management aims to promote comfort and safety, then care management = comfort + safety. If care management = comfort + safety, then the inverse equation is comfort + safety = care management. Therefore, from the perspective of comfort and safety, this study aimed explore the care management. The definition of subcategories was derived from an analysis of strengths, weaknesses, opportunities, and threats (SWOT) [18].
With regard to the “obstructing forces” in care management identified by Kolcaba, weaknesses and threats such as inadequate staffing levels were identified as a constant concern by nurses because the older persons whom they assisted tended to exhibit higher levels of dependence and care needs. However, the level of human resources provided for such health production was not suitable for the complexity of such care.
“The demand is much higher […] the patient requires more attention, you know, more care.” (P6)F.“He cannot feed himself […] we have to pay much more attention, whether the patient is taking oral medication, whether he will swallow it or not.” (P6).“[…] sometimes we have 8… 9 bed baths for 12 [patients]. How do you manage that with three technicians? Because you have medication, you have a range of care, so it is demanding. The provision of an adequate number of professionals, human resources, directly affects the workload, the nursing workload […] if we do not have appropriate staffing, we cannot […] You can be the best professional, the most qualified; you’re not God, you will not be able to handle everything, you’re not Iron Man.” (P9).
Therefore, some activities are prioritized at the expense of others.
“[…] there are other complications happening at the same time for a single nurse in the department.” (P8).“It is kind of covering one to discover the other.” (P17).
This process of prioritization caused nurses to tend to distance themselves from activities that may not have seemed to be relevant.
“[…] the focus would be more on the [disease].” (P4).
Another challenge to care management from the perspective of essential comfort pertained to insufficient knowledge. 78,9% (15) of the nurses included in this research had never completed any course in gerontology during their professional trajectory, and 52,6% (10) mentioned deficient gerontological training during their undergraduate and/or postgraduate education, which was reflected in their professional practice.
“In postgraduate school, there was a little bit about gerontology in relation to incontinence-related injuries […], but very little. Very little. During undergraduate studies as well, very little.” (P13).“Is a senior citizen above 65 years old, right? Or 60 years old?” (P1).“The vast majority of patients we care for are older patients, right, and sometimes they have […] diseases related to aging, such as senility or Alzheimer’s, and which are often… the professionals who work with these patients do not know how to deal with them” (P1).
The knowledge of professionals focused predominantly on biological changes and was acquired via practical nursing care experience. Therefore, they had fragmented informations, but may not had developed the knowledge necessary for providing sensitive and individualized care for the older persons.
“Vascular access among older persons is always more challenging; the vessels are always more strained, more sensitive, and the skin as well… Oh, there was a lady there that we even thought her skin might fall apart. Because it was very, very sensitive.” (P11).
This lack of knowledge is an important issue in light of the magnitude of the number of hospitalized older persons, that represents the most prevalent demographic in many units, in a hospital that lack a unit specializated in geriatrics and gerontology:
“[…] at least 90% of my patients are older persons.” (P1).
On the basis of an insufficient gerontological theoretical foundation, the nurses initiated dialectical discussions with regard to the concepts of patient comfort and safety, which made decision-making even more challenging.
“[…] we have a patient who has to sleep sitting, may even be lying down, but the leg has to be down. He can’t sleep with the leg up because if he puts it up, the leg hurts […]. So, like, I can’t leave it; there has to be all the handling to see how I’m going to, like, I can’t leave that patient with the rail down so he doesn’t have the risk of falling, but at the same time, his leg is up, you know?” (P17).[…] the patient had both lower limbs amputated; he couldn’t hear and couldn’t see well […]. And then the only thing he could do was leave the stump of his lower limbs sort of sticking out of the bed, sitting upright. So when I lifted the railing on his bed, it was a prison for him. (P9)
With respect to Kolcaba’s Theory of Comfort, in therms of “facilitating forces”, strengths and opportunities, leadership was identified as an important element of care management. Furthemore, in this specific research scenario, such leadership took an autocratic form. Although autocratic leadership may promote rapid decision-making in crisis situations, it has significant limitations in fostering professional autonomy, building positive interpersonal relationships, and encouraging innovation, which can compromise the quality of care as well as the satisfaction of both patients and staff [19].
“At least from Monday to Friday, we’re there, on top of the team.” (P8).“Because, like, I know that when we charge more. unfortunately it’s my role, you know, the team ends. I’ve noticed that when I, for example, if I’m very busy administratively, things happen. You must have perception, you must have billing, you must have signage. If I don’t have it, if I get distracted, if I get tired, everyone gets tired. Unfortunately, that’s how it is. (P11)
Strategies for promoting care management for hospitalized older persons from the perspective of essential comfort and safety
Falls were a triggering theme of the questions that composed the script of the semistructured interviews conducted with nurses, and have emerged as a major concern among older persons. In these cases, interventions involving mobility restrictions were proposed with the aim of promoting safety.
“[…] the majority who are older persons are at risk of falling because even if the patient does not have impaired gait, does not have any condition […] that suddenly leads the patient to have an imbalance, being older persons, we consider that there is a higher risk, that at least they exhibit various risk factors.” (P9).“[…] raised the side rails. We always keep the bed rails elevated.” (P1).
The risk of pressure injury represented another concern for nurses, who intervened in this context by frequently repositioning patients frequently.
“If I do not change the patient’s position, I will easily […] cause an injury to this patient.” (P14).“This requires the team to be committed to changing the position, evaluating the skin, examining the client’s skin.” (P7).
The occurrence of delirium among hospitalized older persons was also a concern for nurses, as were cases of pneumonia and bronchoaspiration. Therefore, similar to the goal of preventing pressure injuries and falls, body positioning represented the most frequently proposed intervention.
“[…] some people exhibit frequent, frequent episodios of delirium. It’s even a risk that gets worse with hospitalization.” (P17).“[…] a high risk of pneumonia, because [the patient] spends a lot of time lying in bed.” (P5).“[…] it is a patient who I ask [to the other nurse] to raise the bed more, to make him sit up a bit, to elevate the headrest slightly more.” (P8).
The promotion of comfort was not directly linked to patient safety, and comfort was associated predominantly with the environment. However, despite the goal of promoting comfort with respect to the environment, the hospital infrastructure (i.e., the set of physical and technological elements that guarantee the functioning of a hospital) occasionally came to represent an obstacle, as well:
“Because we do not have an infrastructure to offer a TV room, a balcony, something for… You go in there, there’s a confined space, they accumulate there. There’s no space to exercise. […] Especially in our isolation unit, which has no window.” (P3).
Interventions focusing on comfort also highlighted the need to encourage the proximity of family members to patients, given their ability to serve as companions. However, this intervention was not always successful because the hospital’s infrastructure did not allow the companion to remain with the patient, or the family member may not have been available as a result of work activities.
“There are not enough chairs for everyone.” (P8).“[…] but here we have a lot of difficulty with the issue of companions. Most older persons here are without a companion… the family does not stay because they say they need to work.” (P13).
Discussion
Most of the participants in this research were women, thus reinforcing the historical trend according to which nursing is associated with characteristics that are viewed as inherent to femininity: patience, affection, servitude, care, dedication, and selflessness [20]. Because comfort is related to concepts pertaining to solidarity and humanity, such as dignity, empathy, kindness, and compassion, these professionals likely possess and promote substantial sensitivity [21]. Professionals have matured in their professional lives, and they have fully developed their technical and cognitive skills [22], a situation which is conducive to the task of promoting comfort. Comfort tends to vary according to the experiences and personal repertoire of each nurse [23].
However, nearly 90% (17) of the participants in this research worked for more than 60 h per week, including by managing household chores, caring for their homes and families, and raising children (namely, because women are the main individuals who bear these responsibilities) [24]. This role represents a continuum in nursing in light of the historically low pay and undervaluation that characterize this profession, which force workers into work overload, thus impacting their health via distraction, automatic behavior, involuntary lapses of sleep, and amnesia [24]. The stress and burnout conditions to which professionals are subjected generate fatigue and dissatisfaction, which impair effective caregiving and expose the service itself and the corresponding patients to the risk of harm [25]. These conditions lead to reduced safety and generate a degree of detachment and indifference on the part of professionals toward the needs of patients [25]. This reduction further compromises the aspect of comfort, which then becomes invisible [25].
According to Kolcaba [13], occupational productivity and efficiency are directly related to worker comfort. Therefore, for a nurse to perform their duties more effective and ensure that comfort remains a therapeutic outcome for the patients under their care, the nurse’s own comfort must also be enhanced via good working conditions and fair remuneration [13].
The construction of care management for hospitalized older persons from the perspective of essential comfort and safety
An initial point pertaining to staffing provisions lies in the notion of workload, which is defined as the amount of time and care that a nurse can dedicate to the workplace and professional development either directly or indirectly [26]. It is directly related to the time spent providing nursing care, which can be measured via the patient classification system (PCS) [26]. The PCS is an instrument that can be used to determine the level or category of patient dependence in relation to the nursing team on the basis of COFEN Resolution 0543/2017 [27]. Therefore, the more dependence the patient exhibits, the greater the number of required care hours, and the greater the need for human resources [24]. However, understaffed human resources represents remnants of neoliberal macroeconomic logic, which focuses on “streamlining of the system” with the aim of increasing revenue [28].
Therefore, comfort becomes a secondary health promotion strategy in comparison with other secondary objectives, such as the prevention of complications [13]. Comfort is a positive and dynamic state that can be enhanced by venturing beyond the treatment of discomfort [13]. Therefore, when care is based on a clinical diagnosis, the patient tends to be viewed as a pathological case, and efforts to promote comfort tend to focus on technical aspects, including measures aimed at pain control and maintenance of homeostasis, thereby preserving or restoring physiological function and preventing complications, such as by monitoring of vital signs, performing tests, and administering medications [13].
These are essential measures should certainly be considered in this context; however, if relevant actors are to achive holistic comfort outcomes, they must consider all four contexts, i.e., environmental, physical, psychospiritual, and sociocultural [13]. Therefore, the patient should be assessed as more than an individual with a disease and thus viewed in their entirety [13]. This perspective involves the integration of measures that can be used to alleviate anxiety, promote safety, and instill hope, such as “coaching”-type comfort measures [13]. Additionally, relevant interventions, such as “comfort food for the soul”, should be implemented via basic and personalized measures [13].
Another relevant aspect in this context is the measurement of nurses’ productivity [13]. As long as nurse productivity is calculated in a manner analogous to that of factory workers, in wich context the number of pieces completed per day determines productivity, relevant outcomes, such as early ambulation and adherence to a rehabilitation plan, remain secondary [13]. This trend is based on the assumption of Taylor’s notion of scientific management, which persisted in the early decades of the 20th century in the United States and continues to impact nursing in the Brazilian context [28]. This approach focuses on tasks and procedures; furthermore, the division of labor in this context emphasizes the care to be provided, which can be grouped with the goals of saving time and expediting the implementation of the service, thus resulting in mass production and the loss of patients’ identity in light of the emerging lists of tasks [28]. If the value system in question is patient oriented, the intentional promotion of comfort by nurses tends to receive increasing appreciation [13]. When productivity is quantified in an appropriate manner and positive outcomes are achieved by patients, nurses’ satisfaction increases and their rates of turnover and absenteeism decrease [13].
Another prominent issue highlighted by nurses with regard to emerging challenges in the context of care management from the perspective of essential comfort is a lack of knowledge, which directly impacts the quality of the nursing care provided to this population [29]. Despite the fact that experience has been identified as a positive factor with regard to care management because it signifies constant learning, it becomes negative when it is used as a foundation of professional practice, which is associated with a dissociation between theory and practice [3]. A clinical practice that is predominantly biologistic and lacks a connection to structured theoretical knowledge is detrimental to the provision of comprehensive, continuous, safe, individualized care and the promotion of comfort [3]. Knowledge of gerontological theories and concepts as well as typical changes in senescence and senility can facilitate more accurate interventions [30].
With respect to “facilitating forces”, positive leadership was revealed to enhance safety and well-being [31], however, this positive effect was not observed when such leadership was of the autocratic type [13]. Kolcaba’s theory maintains that autocratic leadership is not the most suitable for efforts to promote comfort; rather, the most appropriate form of leadership in this context is one in which management occurs from the bottom up, which is conducive to creativity, voting power, and good interpersonal relationships with the team [13]. This model of leadership can increase the morale and comfort of the team, and these positive effects can be reflected in the patients treated by the team [13].
Strategies for promoting care management for hospitalized older persons from the perspective of essential comfort and safety
Older persons are more sensitive to comfort or the lack thereof [32], and the Comfort Theory focused on the need to address discomfort and known risk factors pertaining to each individual on the basis of a recognition of such needs for comfort with regard to the physical, psychospiritual, sociocultural, and environmental contexts, thus allowing relevant actors to establish and maintain a state of relief, ease or transcendence [13]. The nursing interventions were implemented simultaneously, and the satisfaction with the comfort facilitated by the implemented action was then evaluated [13]. To address this health situation, health care was determined to consist of “alpha pressures” (defined in terms of the sum of negative– obstructive - forces; positive– facilitating - forces and interacting forces) and “beta pressures” (the patient’s perception of how well nursing interventions satisfy their comfort needs) [13]. Patients’ perceptions of greater comfort were revealed to reduce negative tensions and promote “health-seeking behaviors” (HSBs), which could be internal or external, or even focus on a peaceful death, thus representing the second phase of the theory [13]. Kolcaba, then, made substructures: “obstructing forces” (negative) were substructured as “health care neeeds” (deficits in any context of comfort that arise from stressful health care situations and which the patient’s natural support system cannot meet); “facilitatin forces” (positive) were “nursing interventions” (comfort measures that nurses design and implement that are targeted to the health care needs) and “interacting forces” were “intervening variables” (factors that nurses cannot change, and that have an impact on the success of the interventions) [13]. This research highlighted a relationship between enhanced comfort and appropriate nursing interventions, that were performed in a caring/comfortable manner, including with the intentional goal of enhancing comfort [13]. Patients who were more comfortable were more likely to engage in HSBs that could promote better responses, faster rehabilitation, or a peaceful death, thus justifying nurses’ adherence to comfort care in this context [13]. The third phase, according to the theory, is institutional integrity, in which the institution and the team are ethically empowered to focus on service quality [13]. This phase includes efforts to improve health policies and practices as well as to reduce costs, morbidities, and readmissions [13].
An analysis of the aforementioned risk assessments (i.e., falls, pressure injury, delirium, pneumonia and bronchoaspiration) revealed that the interventions prioritized safety via the control of the patient’s body position, whereas comfort was sacrificed. However, raising all four bed rails, which were viewed as forms of restraint, entailed the risk of functional decline among older persons and individuals with geriatric syndromes (i.e., immobility, postural instability and iatrogenesis), as well as correspondig risks of pressure injury, delirium, pneumonia and bronchoaspiration [33], which were also mentioned by nurses. Interventions pertaining to the prevention of pressure injury prioritized changing the patient’s position, which could lead to severe sleep deprivation as well as chronic, significant and cumulative neurological deficits, anxiety disorders, delirium, and dementia [34].
Even when comfort was the primary focus of the intervention, it was not successful [13]. This lack of success was due to the fact that various intervening variables, over which the nurse had little or no control, were not considered [13]. A therapeutic environment can help individuals cope with physical and psychological conditions, thus increasing comfort, health promotion, and healing in this context [13]. A healthy and tranquil environment can encourage patients to socialize, sing, cooperate with the team, and exhibit a higher level of contentment [13]. In other words, nurses can ensure that the patterns and behaviors that are necessary for coping with adversities are available [13]. Therefore, the environment can be manipulated with the goals of maximizing the institution’s functional capacity and promoting comfort [13]. However, during the process of planning the intervention, the intervening variable (i.e., inadequated hospitalar infrastructure), over which the nurse had little or no control, was not considered, thus limiting the effectiveness of the corresponding actions, even in cases in which they were appropriate [13].
Similarly, sociocultural comfort can be facilitated by the presence of a family member, which elicits a sense of security and defense among older persons and enables them to feel at home, important, and valued [13]. Patients do not readily abandon their family roles and responsibilities as a result of their hospitalization conditions, and if this connection is maintained, it can increase calmness and comfort [21]. Patients struggle to remain connected to the real world, and the presence of their families can help anchor them to reality [23]. Although this intervention took an assertive form, once again, intervening variables (such as the unavailability of friends and family members as a result of work activities) were not considered.
Because the interventions were not effective, no enhancement of comfort or achievement of relief, ease or transcendence was observed. Without variations in patients’ levels of comfort, no stimulus for health-seeking behaviors emerged in this context, as illustrated in Fig. 2, which depicts the inferences pertaining to these categorical relationships and their connections to analysis theory.
Fig. 2
Perceived relationships between the various categories and Comfort Theory– Rio de Janeiro, 2023
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Conclusion
Nurses were able to identify the risks faced by hospitalized older persons, such as falls, pressure injuries, delirium, pneumonia and bronchoaspiration. However, the proposed interventions mechanically replicated generalized orientations without taking gerontological specificities into account, thus raising questions regarding the benefits of these interventions for this population. However, measures aimed at promoting comfort have little connection to the safety risks identified in this context, thus reforcing the dichotomy between safety and comfort. This dichotomy does not imply a lack of public policies or concern for comfort on the part of nurses; however, it highlights the fact that challenges in the management of care for older persons play a secondary role in this context.
The production of comfort was not a therapeutic outcome of nursing care management because the proposed interventions did not take intervening variables over which the professional had no influence into account. The findings of this research revealed that, despite the facts that care management focuses on promoting comfort, safety, and autonomy, and nursing practices prioritize patient safety, comfort and autonomy seem to be sacrificed in this context. These findings were influenced by various macro and microstructural factors. Finally, the study highlighted the impact of nurses on relevant outcomes among hospitalized older persons, even following discharge. In light of the specific needs exhibited by this population, a care management model that is coordinated by a nurse who specializes in gerontology is recommended, especially because older persons are present in many nongeriatric hospital units.
The use of data from a single institution is a limitation of this study, restricting the generalizability of the findings. However, the results are relevant to the field of nursing, as they highlight the need for future research to explore patients’ perceptions of the proposed interventions and enable the development of a broader understanding of the topic.
Acknowledgements
The authors would like to thank all the study participants, the Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ) process E-26/202.543/2022 (277517) and the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior do Ministério da Educação (CAPES) process 88887.629729/2021- 00.
Declarations
Ethical approval and consent to participate
The present study was conduced in accordance with the principles of the Declaration of Helsinki. Before the professionals who participated in this study were approached, ethical authorization was obtained from the Research Ethics Committee of the University of the State of Rio de Janeiro under CAAE 57513722.0.0000.5282. Authorization to conduct this study was obtained from the coordinator of the health unit and the head of the service to perform the study. After the researchers received this approval, the professionals were invited to participate in the research, and they indicated their approval by signing the consent form. All of the data collected as part of this research were preserved and analyzed in a confidential and scientific manner.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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