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

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.

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 Burnout
Three 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 Paper
During 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.

Patient Exemplar
A 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.

Limitations
Two 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? 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 burnout and post-traumatic stress (17). For frontline workers who are thriving or are particularly barely surviving in this pandemic, implementing Kolcaba's Comfort Theory at work and play will serve as a protective barrier against the mental health impact of COVID-19.

Recommendations for Practice
In order to keep the balance of work and play amid this novel Coronavirus outbreak, the World Health Organization has proposed recommendations (18). The statement includes safe, social distancing activities which aim to promote physical activity, cultivate coping skills, and increase psychosocial support.
Some examples include listening to songs of (self-defined) comfort, karaoke, watching a certain comedy to induce laughter and cultivate humor, learning how to play a new instrument, making arts and crafts, cooking new and old recipes, solving jigsaws, reading, and journaling. These activities can enhance psychospiritual ease. My sister and I have completed three 1000-piece puzzles together which was extremely satisfying. It gave me a sense of normalcy that I could still problem-solve by connecting pieces of the picture puzzle back together all the while living in a world filled with contagious panic and chaos. Taking light walks, running, jogging, fishing, being near the beach to lower stress and anxiety can increase physical, environmental and psychospiritual relief, ease, and transcendence. When I went out for a run, not only did my Fitbit notify me that my physical activity level increased but I also found it to be quite peaceful. I became inspired to take advantage of my hour of recreation more often after seeing 2 to 3 runners along the way as well. Environmental relief, ease, and transcendence can be attained by taking a vacation. Working per-diem at the hospital has afforded me this availability to travel back and forth from Massachusetts to my hometown in Connecticut where I am able to relax on The Cape and Long Island Sound, respectively. Dozens of managers and business owners have urged employees to use their vacation days in the middle of a pandemic (19). They have emphasized, "Your goal is to free your mind from contemplating the pandemic, working from home, cabin fever, the news and your isolation, or lack thereof" (19).
Psychospiritual transcendence can be attained, sustained, and maintained through mediation and tapping into cultural and religious beliefs. For example, I attended a worldwide  mediation challenge curated by Marianne Williamson, American author, spiritual leader, former 2014 candidate of California's 33rd Congressional District and 2020 presidential nominee who reminded me that "prayer, meditation and prayer for others is the ultimate self-care" (20). I have found this to be true after attending a Sunday church service on the "Facebook Watch Party" platform to which my former college pastor invited me to worship alongside a multitude of fellow believers. Participating in the chat box, listening to the sermon, and singing along with the hymns provided me with sociocultural ease and psychospiritual transcendence. "Be gentle with yourself and practice self-compassion to make life easier to bear," my pastor said. These brief, yet durable connections definitely helped ease the pain of social distancing.
Protective factors against suicide include cultural and religious beliefs because they support instincts that foster self-preservation (10). According to Pew Research Center, a poll showed that while 2% of participants surveyed reported that COVID-19 has weakened their faith, 25% declared the virus has deepened it (21). My nursing colleagues and I can attest to the latter response. During a worldwide pandemic, we are constantly learning how to adapt. We have gained moral fortitude by working together consistently with the knowledge that we are making a difference in people's lives, which inspires us to continue making that difference everyday. We are proud to go to work and see it as a privilege to care for and be in the service of others. We have realized that nursing is truly God's calling.

Perception of "Comfort"
Although comfort can be experienced at work collectively, the definition of comfort may look different from one person to the next. For example, turning to colleagues for support can bring sociocultural relief and alleviate psychospiritual stress associated with managing complex care plans for coronavirus patients. Engaging in casual, humorous conversations between nurse coworkers and managers are paramount when the home environment may not be as an ideal place to engage in such conversations as their partners and family members may not fully understand the realities of suffering and death to the extent that their colleagues do. When someone feels like she/he has no one to talk to at all, suicide risk increases (10). It is important for frontline workers to continue to engage their comrades for reasonable levity and emotional support, while facilitating an inclusive work culture as this kind of social milieu fosters sociocultural relief and ease. I am fortunate that my unit is filled with amazing, humorous nurses and optimistic nurse managers and supervisors.
Maintaining connections to social support systems such as family and friends remains paramount. Whether that is done through Zoom, WebEx, or by phone can bring sociocultural relief and ease. Talking to someone professionally about mental health is also invaluable. A mental health provider can give seamless, emotional and instrumental support in a nonjudgmental way. This type of therapy can serve as a bouncing board of ideas while offer an unbiased "listening ear" simultaneously. Easy access to a variety of clinical interventions and support for help seeking and support from ongoing medical and mental health care relationships can serve as protective factors against poor mental health (10). Many mental health care providers in the United States have been offering telemedicine visits for new and established patients during COVID-19. My insurance company has listed in-network providers with the phrase "virtual visits" next to their name for which I have sought. Acquiring coping skills, tips on problem-solving, and learning nonviolent solutions are but a few possibilities of psychotherapy, especially while living in times of uncertainty.
Use of the Suicide Prevention Lifeline @ 1-800-273-8255 (TALK) is encouraged if anyone is ever experiencing emotional distress or a suicidal crisis (10,22). There are ample resources and help out there. Do not hesitate to ask for help nor be afraid to reach out.

Your Definition of "Comfort" During COVID-19
At the end of the day/night, we may find our "batteries" depleted. We must absolutely find ways to recharge them. We must not forget to take inventory of our own mental health as well as identify possible signs of burnout. Let us all learn from the case of the beloved Dr Breen: She seemly had it "altogether" with supportive friends, families, and colleagues, yet still attempted and completed suicide. Moreover, Mr Mondello was a relatively younger EMT with a lifelong career ahead of him, yet still took his own life. These two fallen heroes show that cultivating mental health is indeed a vital practice to invest in during this critical period in which many frontline workers are currently entrenched. If death is the most moving conclusion, then Dr Breen and Mr Mondello's suicide and legacy should not go in vain. Although we solemnly remember the dead, there are many unsung heroes left fighting this war against coronavirus who may need this direction before it is too late. My only ask from YOU is to take some time and reflect on answering this question: When I recover, who or what will be my comfort?

Conclusion
This article has sought for the first time a guide for frontline workers to use in practice and self-care during COVID-19. What comfort means to one person, may not be true for another. However, engaging in self-care practices, an essential part of one's health and well-being, remains paramount to reduce burnout and suicide that the novel coronavirus pandemic has caused (eg, physical illness, turning family members away, self-isolation, prolonged stay-at-home orders, 100Kþ death tolls, etc). Practicing from a theoretical framework of comfort resonates with my nurse colleagues and me because it makes sense. Implementing the Kolcaba Comfort Theory in our daily lives may act as a protective barrier against the mental health impact of COVID-19 in 2020 and beyond.