Table 3.

Staff influences on comfort

Influence	Operational definition	Subthemes and supporting evidence*†
Symptom management	Patients experience a range of distressing symptoms for which effective and sustained relief is crucial for their comfort. Symptom trajectories vary between patients; therefore, individualised assessment and treatment is essential. From patients’ perspectives, staff actions that promote effective symptom management include routinely asking about symptoms, taking patients’ symptoms seriously, pre-emptive or prompt treatment and working with patients to understand barriers to reporting symptoms and accepting treatment. When there are few effective pharmacological options, patient comfort becomes more dependent on other influencing factors such as holistic care and assistance.	The operational definition for the theme ‘Symptom Management’ summarises the findings from two underlying subthemes: ‘Variation in experience of common postoperative symptoms’ Patients’ symptom experience varied in terms of symptom presence, severity and trajectory. Physical and associated emotional discomfort commonly arose from pain. ‘I was in a lot of pain. I couldn’t move. I was really in agony. I couldn’t put my legs flat so I remember clearly having my legs up and if I got them up to a certain point it was just very slightly less painful than anywhere else. You know I remember just lying like that holding my knees because it was the best I could do’ (NZE5). Other distressing symptoms were postoperative nausea (‘… it’s killing me…’ (P2)), fatigue, inability to sleep, loss of appetite, shortness of breath, constipation, low mood, or depression, dreams, hallucinations and visual disturbance, taste disturbance, palpitations, and fluid retention. ‘It’s a very simple thing but it was upsetting, my fingers they were swollen twice the size …it was horrible’ (NZE4). ‘Complexity of effective symptom management’: Complex patient and contextual barriers to effective symptom management were identified. Barriers related to patients’ motivation for reporting symptoms, patients’ beliefs and preferences for treatment regimens, staff competence, underlying attitudes of staff and patients (such as to opioids and sleeping tablets), conflicting opinions on effective treatment, clinical jargon and the ability to personalise care. Patients emphasised the importance of participation in symptom management decisions and of feeling heard. Not feeling listened to or believed about the extent of symptom distress, prolonged physical distress and was emotionally upsetting. ‘I think because I’m big you know I don’t show the full soreness of my body …maybe they think I might be lying or something … I think they thought they were giving me too much painkillers … they were just saying we’re giving as much as we can … they were trying to find the best one for me but weren’t actually asking me which one was the best you know…’ (P7). Regular and competent symptom assessment followed by titrated symptom relief was essential for the duration of the admission. Pre-emptive symptom management and regularly offering analgesics were also important. Overall, symptom management depended on competent application of evidence-based symptom management protocols and on staff working with patients to understand and address barriers to reporting symptoms and accepting treatment (refer ‘Engagement and Commitment’ and ‘Information and Participation’). Other comforting actions become crucial when there were few effective strategies to combat distressing symptoms. These included support from family, empathetic and holistic care, reassurance about ‘normality’ and expected trajectory (refer family’s unique ability to comfort, holistic care and assistance, information and participation).
Holistic care and assistance	Patients experience significant physical and emotional discomfort from the accumulative effect of symptoms, treatment side effects, unpleasant procedures and loss of functional ability. Holistic care involving multiple, non-pharmacological interventions for relieving physical and emotional discomfort is essential and complements efforts to promote comfort through pharmacological symptom management. Assistance provided willingly reduces the substantial emotional and physical impact of loss of function and is an essential aspect of comforting.	The operational definition for the theme ‘Holistic Care and Assistance’ summarises the findings from three underlying subthemes, the first of which provides context for this theme. ‘Physical and emotional discomfort and distress’ Adding to patients’ symptom distress was an accumulation of factors that included treatment side effects (such as dry mouth and itchy skin), unpleasant treatments and procedures (a ‘cocktail’ of pills, venepuncture, echocardiogram, intravenous lines, oxygen therapy and blood pressure monitoring) and restricted mobility (from surgery and from being attached to equipment). ‘I had two days of pure hell, I just felt like I’d been run over by a truck. But there was no pain from the actual surgery it was all of the drugs that they had pumped through me, yeah, I had no energy to get up, no life. There was no life to push to get up’ (M3). Patients had limited ability to self-care, needing assistance getting out of bed, to the toilet, with hygiene, after vomiting or if they ‘made a mess in the toilet’; even pouring a drink of water could not be done without help. ‘I’ve felt like, [I have] been being run over by a bus and then backed over again, I feel terrible. You can’t even take your hands off the table to butter some bread. You just are so out of it, it’s such an awful feeling’ (M2). Worry about finances, returning to work, managing after discharge also contributed to emotional distress. ‘Treating the whole person, not discrete symptoms’: Complementing pharmacological symptom management was holistic assessment and care. ‘[the nurse] asked me really nicely and politely how I was, was this happening or is this happening, have I got any of this … you felt that somebody cared for sure which was, the other guys were saying that too’ (NZE7). Holistic interventions specific to heart surgery included being taught to use a ‘cough pillow’ and providing larger patients with a chest binder to prevent strain on the chest wound. Other interventions were a cooling fan, ice to suck, swift removal of drains, urinary catheters and intravenous lines, shower for itchy skin and positioning. ‘… [W]hen the nurse came in I told her it was getting a bit sore around the back and shoulder blade and she says, get your bum back in that bed, she gets my pillow and straightens them up and, ‘lie there now’ so I lay back down and oh yeah she knows what she’s talking about alright. It felt a hell of a lot better’ (M8). ‘Getting the help needed’ Getting help with personal care and basic tasks was crucial for a sense of comfort (feeling cared for and safe). However, patients felt unprepared for how reliant they would be on nursing staff. Adjusting to dependency was difficult and some were reluctant to ask for help for reasons that included worry about being ‘demanding’ (NZE4) and feeling uncomfortable asking for help with ‘basic bodily things’ (NZE9). Observing staff readily and ‘graciously’ (NZE10) providing help relieved a sense of unease about asking for, and accepting, the help needed. ‘… I didn’t realise that we’d have to be dependent on the nurses as much. I think I thought I could just get up and go, no it was far from it … they’ve been tremendous you know … it’s an eye opener’ (NZE10). Overall, comfort from holistic care and assistance was enhanced when delivered by staff with comforting staff qualities (refer ‘Engagement and Commitment’). Experiencing such care sets the tone for positive patient–staff relationships and satisfaction with the service. ‘I trust them. That’s their work to give life back to people that’s their work. Very hard work, but they never turn their back they try to do their work thoroughly. That’s how I believe them’ (P4). ‘… [P]eople going to hospital, they always talk about the nurses and I basically said it was absolutely true. You know they’re the front-line staff and the ones you deal with every day and they’re all amazing’ (NZE2). Conversely, a failure of staff to appear caring, helpful and responsive to one’s needs harboured resentment and made patients wary of future engagement with that staff member. ‘She didn’t seem to be caring enough, yeah. I woke up having a bad dream and asked her to get me a flannel, which they don’t even ask, can I?, I didn’t have any bedclothes on because I was so hot but they don’t even ask if they can put bedclothes on you know and so it’s little things like that, you know. [How does that affect you]. I think it affects me in the way that when I ring the bell I hope she doesn’t come you know. She was on nights and I was thinking gosh I hope that lady don’t come again’ (M2).
Staff engagement and commitment	Knowing that staff (all roles) are watchful and available when needed is fundamental to a sense of comfort. Patients’ comfort is also enhanced when staff make an effort to connect (are welcoming and friendly), when they promote positivity through reassurance and encouragement, are considerate and responsive to patients’ needs and when they demonstrate understanding of patients’ discomfort (distress, uncertainty and vulnerability) using therapeutic strategies tailored to individual need. Strategies include empathetic listening, taking time to explain, comforting touch, careful use of humour/chit chat, maintaining privacy, dignity and a respectful and caring manner during interactions. Being cared for in this way is foundational to a positive patient experience and appears to have therapeutic importance by promoting positive patient–staff relationships and a willingness to engage with staff, the service and health promoting behaviour in general.	The operational definition for the theme ‘Engagement and Commitment’ summarises the findings from three underlying subthemes. ‘Comforting staff presence – layers of surveillance and availability’ Patients’ perceptions that staff are present and available to them promotes emotional comfort associated with feeling safe and cared for. A comforting staff presence consisted of three layers: perception of 24 hours nursing presence; contact with doctors via ward or pain rounds, even if brief; and knowing that staff were available should they be needed. ‘… [S]he [primary nurse] might be attending another person but if she is normally it’s – ‘can you wait?’ but you know they’re going to come’ (NZE8). ‘Comforting staff qualities’ Staff qualities described as comforting were summarised as: Making an effort to connect (welcoming, friendly and smiling). Reassuring, encouraging and promoting positivity. Caring and considerate, and responding to patients’ needs (committed). Empathetic and warm ‘I thought the girl from Melbourne up in the surgery … I thought she had a very comforting and empathetic manner… That’s probably the biggest time where you’re starting to get a bit nervous anyway when you’re in the holding pen to go into the, yeah [became emotional]. And I found she was very good … she just sort of says you’ll be okay and give your arm a pat or something like that’(NZE1). ‘Therapeutic comforting strategies tailored to patients’ individual needs’ Comforting staff were those who combined comforting qualities with individualised strategies in a way that was foundational to a positive patient experience and promoted goodwill towards the staff (and service) that has supported them through a physically and emotionally challenging time. ‘I think they have done all, their faces, smiling faces, that will do. There’s a good treatment, here’ (P4). Comforting staff behaviour also had therapeutic importance by promoting patients’ willingness to disclose concerns, participation in care and treatment, and positive patient–staff relationships. Conversely, patients disengaged from staff with whom they did not connect, some even considering (early) self-discharge when they felt uncared for or disregarded. Comforting strategies tailored to patient’s unique needs included: Taking the time to explain, possible even in rapidly changing clinical situations to promote confidence and acceptance of care. Maintaining patient’s privacy, dignity, being respectful during personal care or bed-side discussions between staff. Supporting patients through unpleasant procedures/mobilisation (emphasising the necessity of the procedure while providing reassurance, empathy, a caring manner and boosting confidence). Use of humour and chit chat, although judgement was needed. Giving patients the chance to talk about concerns; empathetic listening. Using touch to convey empathy, concern and connection. ‘… [S]he took that little bit of time with me and put her arm around me to make me strong and to say listen you can tell me…when I was really bad I just needed someone to put their arm around me and I told her a little bit …’ (NZE6).
Information and Participation	Information promotes comfort by reducing the distress of uncertainty and enables patients to prepare for and accept what lies ahead. Information also comforts by promoting trust and confidence in staff and the care provided. However, informing patients is an art and science; to comfort (and not distress), information needs to be provided by staff knowledgeable in the topic and sensitive to patients’ situation and personal preference for detail. Individualised care is essential for patients’ emotional and physical comfort. Patients who are accurately informed about when, why and how to report symptoms, who feel comfortable with staff and perceive them to be concerned for their welfare are more inclined to seek help, report symptoms, ask for clarification and participate in care and treatment decisions. Feeling disempowered, or unable to participate in care decisions, can distress.	The operational definition for the theme ‘Information and Participation’ summarises the findings from three underlying subthemes: ‘Importance of personalised care, personalised information’ Underpinning the operational definition of this theme is the importance of personalising symptom management and holistic care. As such, patients needed to feel empowered to initiate non-standardised care and participate in treatment decisions. ‘I had a bit of nausea but as soon as I mentioned it people tried to help me with it’ (M4). Similarly, the right ‘dose’ of information was crucial to patients’ sense of comfort because information could either comfort or frighten and distress. Patients’ information needs were variable and personal. ‘I came to see the anaesthetist and the only question I asked him was you just make sure I wake up … that’s the only thing that really frightened me’ (M2). ‘When delivered well, information underpins comfort (feeling prepared, reassured, accepting; can personalised care)’ Patients gained a sense of comfort from understanding what is currently happening and what is likely to happen. This information helps them prepare for and accept what lies ahead. ‘… the surgeon has been very comforting. He came along and explained, nice warm eyes you know’ (M2). Information about what, when and how to report symptoms or other causes of discomfort supported patient’s ability to personalise care, including safe self-triage, which was common. ‘I never ring the bell straightaway. No, I just hang on [and think] whether why this pain comes in, why the pain, why I got a pain? …I try to play fair and square’ (P4). Information was also important for addressing attitudinal barriers to symptom management. ‘[T]hey did say, however little your pain is it’s good to let them know. Don’t be a tough boy and handle the pain you know which is what I would probably do’ (M8). Information also comforted by reassuring patients their symptoms and side effects they were experiencing was normal and likely to pass. However, sometimes information does not (and indeed cannot) comfort. Under these circumstances, staff experienced in the art and science of informing are pivotal. Balancing information about risk with positivity was important, as was being believable. For one patient, this meant staff being ‘confident but not cocky’ (NZE5). ‘[T]here was one nurse [who] was just very, very good at just calming me down in general and just saying the right things to make me just feel a little bit more comfortable. Others have been very good at explaining the technical side of things…’ (NZE5). ‘Feeling comfortable with staff – the subtle factor influencing personalised care, patient participation’ Feeling comfortable with staff underpinned patients’ willingness and ability to personalise care. For example, patients could be reluctant to ask questions, disclose concerns or use the call bell between times of staff-initiated contact for reasons that included expectations of an unfavourable reaction from staff, not wanting to ‘annoy’ staff, a reluctance to question the ‘experts’ or take up valuable time. ‘I just sort of you know let them do what they’ve got to do. I just want them to do their job yep. And just say nothing to them like I’m alright’ (M6). Staff who demonstrated comforting qualities (refer Engagement and Commitment) helped to minimise these barriers. ‘They’ll show you, there’s the buzzer if you need me, when you need me, just push the buzzer don’t be worried about what time it is’ (M1). However, patients’ preferences for participation varied, and there was a level of comfort to be gained from having confidence in staff to step back from decision making. Patients tended to seek greater involvement when symptoms were poorly controlled, when they were anxious to avoid complications or worried about their safety. At these times, feeling unable to participate in care decisions placed patients in an uncomfortable situation of reluctant (rather than willing) acceptance of care and treatment. This was emotionally distressing and delayed effective symptom management. As such, comfort and participation are inextricably linked. ‘[Discussing pain management] It could be better I think but who am I you know? These guys are professionals. They know what they’re talking about…’ (P5).
Perceived and actual competence	The perception of clinical competency promotes a sense of comfort (safety and ease) because patients feel confident in the care provided. However, all staff—clinical and ancillary—have the potential to be comforting by being competent in their role while mindful of patients’ comfort needs.	The operational definition for the theme ‘Perceived and Actual Competence’ summarises the findings from two underlying subthemes: ‘Perception of competence’ Perceiving that staff were competent was comforting in the sense that patients felt at ease and confident in the care provided. ‘… [T]he doctors and the nurses they’re very confident in how they attend you.(How does that make you feel?) Relaxed. And in good care’ (M7). ‘Actual competence – expert comforters’ Staff competence related to each influence is essential. Staff whom patients particularly remembered for their comforting qualities were those that seemed to blend competence and commitment with comforting qualities. In some cases, care was not protocol driven; indeed, some staff had deviated from protocols to make a difference, such as ancillary staff enabling family to visit outside of visiting times, or a nurse letting a sleep-deprived patient sleep in a spare room. Other examples were the surgeon who expertly managed a patients’ pain, the sonographer who described to one patient how well her new heart valve was working and the kaumātua who had knowledge of tikanga Māori (Māori protocols and practices). ‘… [H]e said to me oh you from [place]? I said yeah. And he’s been up there too and that’s where I’m from. That’s my marae. … I identified with him for being from the same place as he is, somebody from home … being Māori and him coming to talk to me it’s good, made a big difference … [It was] uplifting…’ (M5).

* Patient interviews were coded by ethnicity and interview order, that is, M1 is the first Māori interview, P1 for the first Pacific interview and NZE1 is the first New Zealand European (NZE) interview.

†Examples are from Stage 2 two semi-structured interviews of patients undergoing heart surgery.

NZE, New Zealand European.