The colloquial use of the term “comfort” has little to do with its true origin, the Latin verb confortare, understood as “giving vigour, will and strength to someone”. Comfort in Nursing has been defined by Pinto et al (1) as “a complex, dynamic, holistic, subjective, and positive experience which includes meeting individual needs”. This multidimensional construct is undoubtedly the main objective of care; it acquires higher relevance in the setting of end-of-life care. However, there are other areas such as Intensive Care Units (ICUs), where the assessment of the numerous aspects conditioning comfort could be of great interest, due to its impact on the physical, psychological and cognitive consequences derived of staying in this type of units, which are known by the term “post-ICU syndrome”. In order to identify these discomfort factors, it is essential to have validated instruments which, at the same time, can be used as support by nurses when faced with the change in critical care paradigm.
 
The importance of comfort in critical patients has been pointed out by Benner as an element encouraging recovery, taking into account the interrelation between the different dimensions of the person, body-mind-spirit, and the influence of the environment. Even though the physical needs of critical patients are acknowledged and met by professionals, current evidence associated with the prevention of post-ICU syndrome shows that, alongside clinical variables, an early detection of discomfort sources such as the difficulty to communicate or the lack of information could contribute to a reduction in the development of psychological morbidity after discharge from the ICU (2), and on the other hand, an increasing number of studies acknowledge the importance of addressing psychological, social and spiritual needs during the stay at ICU. In fact, the psychosocial need to “feel safe”, identified by critical patients as the most important, is closely linked to comfort. The satisfaction of this need includes aspects such as trust in professionals, the presence of the family, receiving information, recovering control, keeping hope, and support by beliefs.

Post-ICU syndrome appears in 30-50% of survivors, and it causes severe consequences at medium and long term, both physical and psychological (anxiety, post-traumatic stress disorder), and even cognitive, which have impact on quality of life, the incorporation to active life, family roles and healthcare costs, and represent a serious health problem (3). That is why different recommendations have been implemented at international levels, such as the Clinical Practice Guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption; the ABCDEF bundle and the HUCI project. These measures entail a reassessment of the current critical care model, because they are directed to keeping patients awake, with adequate analgesia, and with spontaneous ventilation. Thus, patients will be more aware of the environmentand discomfort factors; therefore, it is essential to have validated instruments which allow to identify those symptoms or aspects conditioning comfort (4). Currently available questionnaires assess constructs opposite to comfort, such as stress or discomfort, and most of them are completed at discharge from ICU or subsequently. This can be biased, because patients do not remember or prefer to forget unpleasant things, and moreover, a recent review recommends an update in the contents of items, adding aspects such as communication and mood, and including positive experiences (5). However, comfort had been previously assessed in coronary patients in other countries, through the General Comfort Questionnaire (CGQ) by Kolcaba, and there was a Spanish version of this CGQ which had not been validated.

On the other hand, the decision to research comfort in this population also responds to the influence of my experience as critical care nurse. In these units, meeting physical needs is often the priority, because they are considered the most important. However, the holistic view of the person is always taken into account; and even though the term comfort might not be mentioned specifically, there is a constant assessment of discomfort or distress signs in patients, leading to interventions for improving comfort and the subsequent reassessment of their efficacy. This intuitive way of thought coincides with some of the premises in the Comfort Theory by Kolcaba, and its application in the current critical care setting has been recently suggested (6).
The development of the study, from the scope of a doctoral thesis, with the primary objective of validating the General Comfort Questionnaire in the critical patient population, has not only allowed to have a validated tool to assess the impact of nursing interventions or the efficacy of the measures established in recommendations, but also to incorporate the perspective of patients, therefore being able to identify the comfort needs in an individualized manner. The final solution achieved showed adequate psychometric properties to assess comfort in critical patients; this questionnaire was named Comfort at ICU Questionnaire, and there was a reduction in the number of items from the original version.

The results achieved showed the major psychological and social influence of comfort, which coincides with the current recommendations for Post-ICU syndrome prevention; and there is acknowledgement of the importance of the measures encouraged by the HUCI Project, such as wellbeing and the presence of the family. On the other hand, there was room for improvement in physical aspects such as pain and the information received by patients and, likewise, the need to design better adapted environments which reduce the impact of technology. It is also necessary to highlight the noticeable influence of spirituality upon comfort.

An outstanding aspect for the future design and validation of questionnaires in this population is the need to include the point of view of the patient; this has also been suggested in recent studies, due to the major differences in perception of stress or discomfort aspects among patients, relatives and professionals. During the research, patients considered that using these instruments was important, because they offered an opportunity of meeting in order to convey their comfort needs and communicate their experiences during their stay at the ICU.

Nurses have a very relevant role in terms of preventing and detecting the post-ICU syndrome; therefore, as members of the interdisciplinary critical care team, they must rely upon models of care which allow to give response to this change of humanistic paradigm of person-centred care. The use of validated tools in this population could support the implementation of this type of models, because they allow to measure results based on patient-reported experience (PREM), and they could become an indicator of the impact of nursing interventions. Moreover, with support by the Comfort Theory by Kolcaba, it would allow to identify, in an individualized manner and from the point of view of patients, those factors determining comfort, to define objectives according to types of comfort, and to plan and assess care.

This approach to the study of comfort represents a starting point, which can have continuity in other specific critical care populations and contribute to give visibility to nursing knowledge and patient experience.