Comfort and Hope in the Preanesthesia Stage

in Patients Undergoing Surgery

Naima Seyedfatemi, PhD, Forough Rafii, PhD, Mahboubeh Rezaei, PhD,
Katharine Kolcaba, PhD, RN
Purpose: Comfort and hope have been identified as important compo-

nents in the care of perianesthesia patients. The purpose of this study

was to explore the relationship between comfort and hope in the preanesthesia stage in patients undergoing surgery.
Design: A descriptive cross-sectional survey was conducted with 191 surgical patients.
Methods: Data were collected using the Perianesthesia Comfort Questionnaire and Herth Hope Index.
Findings: Direct and significant relationships were observed between
comfort and hope (P #.001, r 5 0.65). Also, significant relationships
were observed between educational level and marital status with comfort
(P #.01). The relationship between educational level and hope was significant (P #.001). Significant relationships were also observed between
gender and marital status with hope (P #.01).
Conclusions: Overall, this study showed that a significant relationship exists
between comfort and hope. Additionally, some demographic characteristics
influenced comfort and hope in these patients. Health care providers should
arrange the environment in a way that allows the surgical patients to experience comfort and hope and recognize the impact of personal characteristics when caring for surgical patients, particularly in the preanesthesia
stage.
Keywords: comfort, hope, preanesthesia, surgery, research.
! 2014 by American Society of PeriAnesthesia Nurses
SURGERY IS A stressful event. The preoperative
period is experienced as threatening and
depressing by most patients. Patients may be preNaima Seyedfatemi, PhD, Associate Professor, Center for
Nursing Care Research, Iran University of Medical Sciences, Tehran, Iran; Forough Rafii, PhD, Associate Professor, Center for
Nursing Care Research, Iran University of Medical Sciences, Tehran, Iran; Mahboubeh Rezaei, PhD, Assistant Professor, School
of Nursing and Midwifery, Qom University of Medical Sciences,
Qom, Iran; and Katharine Kolcaba, PhD, RN, Associate Professor (Emeritus), The University of Akron, Adjunct Faculty, Ursuline College, Pepper Pike, OH.
Conflict of interest: None to report.
Address correspondence to Mahboubeh Rezaei, School of
Nursing and Midwifery, Qom University of Medical Sciences,
Shahid Lavasani Street, Qom 3713649373, Iran; e-mail
address: m4_rezaei@yahoo.com.
! 2014 by American Society of PeriAnesthesia Nurses
1089-9472/$36.00
http://dx.doi.org/10.1016/j.jopan.2013.05.018

Journal of PeriAnesthesia Nursing, Vol 29, No 3 (June), 2014: pp 213-220

occupied with their discomforts, the success of

surgery, or their fear of anesthesia.1 Discomfort
leads to anxiety, and this high preoperative anxiety
leads to physical problems.2,3
Comfort is a basic human need,4 and there is a
general expectation that when we need health
care, our comfort will be considered.5 Attaining
comfort is conducive to better health outcomes.6 Comfort has been identified as important to hospitalized patients and is a word
that is frequently used to describe both
physical and emotional aspects of the hospital
experience.7,8
Comfort is a significant criterion for initial,
ongoing, and discharge assessment and management of the perianesthesia patient.8 A uniform

213

SEYEDFATEMI ET AL

214

definition of comfort is not evident in the literature.

Many definitions exist but vary according to the authors perspective.5 In this study, the definition of
comfort by Kolcaba and Wilson8 will be used,
stated as the immediate state of being strengthened through having the human needs for relief,
ease, and transcendence met in four contexts of
experience (physical, psychospiritual, sociocultural, and environmental). Kolcaba9 also characterizes discomfort as the opposite of comfort by
placing the concepts along a continuum. Williams
and Irurita7 suggest that nursing was founded on
the phenomenon of comfort and noted that Comfort is a strengthening process. Patients who lack
comfort are weakened individuals. Strengthening
is necessary for healing. Kolcaba and Wykle10 theorize that comfortable patients heal faster, cope better, and more thoroughly rehabilitate than do
uncomfortable patients.
Many problems such as anxiety related to anesthesia and surgery, isolation from family, poor social support, and limited resources for ongoing
care at home after discharge have negative effects
on the surgical patients comfort in the preanesthesia stage. Additionally, environmental factors
such as cold, noise, chaos, bad odors, lack of privacy, uncomfortable stretchers, chairs, and beds
lead to holistic discomfort in surgical patients in
the preanesthesia stage. Therefore, attention to patients comfort in this period is very important and
can help to relieve anxiety, provide reassurance
and information, and instill hope.11 In other
words, enhanced comfort is related to increased
hope and can reduce complications related to
high patient anxiety.8

dynamic life force characterized by a confident yet

uncertain expectation of achieving a future good
which, to the hoping person, is realistically
possible and personally significant. Hope provides
comfort, encouragement, and an ability to look toward a more positive future.21 It is a multidimensional construct that provides comfort while
enduring life threats and challenges.12 The main
purpose of hope is to decrease emotional discomfort.22 Threats to hope include pain, other uncontrolled symptoms, spiritual distress, fatigue,
anxiety, social isolation, and loneliness.12 Hope is
vital to successful surgical outcomes,23 and it
seems that it has a critical role in the preanesthesia
stage as it is considered to be a stress buffer.24
Perianesthesia nurses have long known about the
power of hope on surgical patients. Most perianesthesia nurses have conducted a preoperative
assessment in which they found the patient
depressed, hopeless, and expressing feelings of
doom. Surgical teams may even cancel surgery if
the patient feels these symptoms strongly.23 Nevertheless, there have been very few studies about the
relationship between hope and comfort in surgical
patients, particularly in preanesthesia period.

Purpose

Hope is central to life and is an essential dimension

to successfully dealing with illness. Hope is needed
by all persons throughout the life cycle and across
the health illness continuum.12 Hope and health
are interactive; it is impossible to gain health
without having hope.13 Hope is the subjective probability of a good outcome for ourselves such as expecting a positive medical outcome.14 There is
considerable literature15-18 seeking to define the
concept of hope in relation to the experiences of
illness and health care, but no universal definition
of hope exists in the literature.19

The purpose of this study was to explore the relationship between comfort and hope in preanesthesia patients. This study is a test of the second part
of the Comfort Theory,25 stating that higher comfort (measured by the Perianesthesia Comfort
Questionnaire [PCQ]) is directly correlated with
higher engagement in health-seeking behaviors
(HSBs). The external behavior measured in this
study was hope (measured by the Herth Hope Index [HHI]). The HSBs can be internal, external,
or a peaceful death.26 Internal HSBs are those physiological functions that occur inside the body that
nurses cannot directly observe. Perianesthesia examples include internal wound healing or cell
oxygenation. External HSBs are those functions
that we can observe through our senses or instrumentation, such as ambulation, appetite, or hope
(using conversation or a questionnaire). A peaceful death could be a HSB is that was the most realistic outcome. In most perianesthesia cases,
however, this HSB is not relevant.8

For purpose of this study, we used Dufault and Martocchios20 definition of hope: a multidimensional

Hope was measured in this study using the HHI. To

determine the level of patient comfort and

COMFORT AND HOPE

215

whether or not there was a positive correlation

with hope, the PCQ was used in the postanesthesia period to measure the recalled state of comfort
before anesthesia administration.

48; the higher the score, the higher the level of

hope. The reliability of the HHI was
demonstrated by Cronbachs alpha (r 5 0.67) in a
healthy Iranian population.32

Methods
A descriptive cross-sectional design was used. Participants were patients who were scheduled to
have elective surgery at a teaching general hospital
in Kashan (a city in the center of Iran). Inclusion
criteria were at least 18 years of age and awareness
of their own diagnosis. This was because awareness about diagnosis could affect comfort and
hope levels. Also, patients had to be able to
remember their feelings. A total of 191 patients
completed the PCQ and HHI plus the demographic and surgery information questionnaires.

The original versions of PCQ and HHI were translated into Persian (Iranian language) and pilot
tested with 50 postanesthesia patients. The pilot
study was performed in the same venue for the
main study and was conducted to calculate the reliability of the PCQ and HHI. Total scores for each instrument were used. Moderate reliability of these
instruments was demonstrated by Cronbachs
alpha for the PCQ (r 5 0.68) and for the HHI
(r 5 0.79). The content validity of the translated
PCQ and HHI was established by 10 nursing faculty members comprising 8 nurse researchers
and 2 psychiatric nurses.

Instruments

Procedure

Information regarding gender, age, marital status,

educational level, type of surgery, and duration of
disease was collected using a researcher-designed
demographic and surgery information questionnaire.

After the pilot studies of the instruments and

approval by institutional and human subject review
committees, investigators distributed questionnaires to postanesthesia patients and requested
that they recall their feelings before going into the
operating room and then complete the questionnaires. Prompt transfer of patients to the operating
room led to time restrictions for data collection in
the preanesthesia period. Therefore, data collection was conducted in the postanesthesia stage as
soon as the effects of anesthetic drugs wore off
and the patients were cooperative. The short time
interval between the preanesthesia stage and data
collection contributed to patients remembering
their preanesthesia experiences and feelings. Postanesthesia experiences had a lessened effect on
their answers to the survey questions.

The PCQ8 consists of 24 questions developed from

the taxonomic structure of comfort, thus reflecting
the multidimensionality of the state of comfort at
any time point. The PCQ has six Likert-type responses ranging from one to six, where one is
strongly disagree and six is strongly agree.
Negative items were reverse coded for analysis
and the scores could range from 24 to 144; the
higher the score, the higher the level of comfort.
The PCQ was a new instrument, and information
was not available about previous psychometric
properties. However, Wilson and Kolcaba11 indicated that it was adapted from the General Comfort
Questionnaire, which has demonstrated strong
psychometric properties in previous studies.
The HHI27 was designed specifically for use in clinical settings to capture the multidimensionality of
hope. It is based on the definition of hope developed by Dufault and Martocchio20 and has been
used in different studies and many settings.28-31
The HHI has 12 items with Likert scales from one
to four, where one is strongly disagree and four
is strongly agree. Negative items were reverse
coded for analysis with scores ranging from 12 to

The PCQ, HHI, demographic, and surgery information questionnaire were also completed by the patients. Data were collected on four surgical wards
after patients had their surgeries. The corresponding author read the questionnaires to illiterate patients and recorded their responses to all items.
All patients signed an informed consent before
participating in this study.
Data Analysis
Statistical analysis was conducted using SPSS
version 18 (PASW Statistics 18, SPSS Inc, Chicago,

SEYEDFATEMI ET AL

216

IL). Collected data were coded and analyzed using

descriptive statistics and statistical tests including
analysis of variance, Kruskal Wallis, independent
sample t test, and Pearson correlation coefficient.

Results
The total sample size was 191 surgical patients.
More than half of the participants were women
(57.6%). The age range of the sample was between
18 and 86 years (mean 5 40.15, standard
deviation 5 17.22); 79.1% of the patients were
married and more than half of the participants
had primary education (51.8%). Also, 44.5% of
the patients tolerated disease duration of less
than 1 month. The most commonly performed
surgery was general surgery (44%), and the least
performed surgery was neurosurgery (7.3%;
Table 1).
Total scores on the questionnaires varied (Table 2).
Items from each questionnaire with the highest
mean are listed in Table 3. Direct and significant relationships were observed between comfort and
hope in the preanesthesia stage in patients undergoing surgery (P #.001, r 5 0.65). Patients with
university education and those who were married
had higher scores for comfort than the other
groups (Figure 1). Significant differences were
found between educational level and marital status
with comfort (P #.01). Patients with university education, males, and those who were married had
higher scores for hope than others (Figure 2). A significant difference was found between educational
level and hope (P #.001). Significant difference
was also observed between gender and marital status with hope (P #.01).
Mean scores of comfort and hope in patients aged
between 18 and 37 years, duration of disease less
than 1 month, and patients undergoing orthopaedic surgery had higher scores than the other
groups, but no significant differences were
observed between the groups (P ..05). Also, the
mean score of comfort in males was higher than females, but no significant difference was found
(P ..05).

Discussion
This study revealed that the mean scores of
comfort and hope were 107.37 6 11.53 and

Table 1. Characteristics of the Sample

Characteristics

N (%)

Gender
Female
Male
Age (y)
18-37
38-57
58-77
78#
Marital status
Single
Married
Widowed
Educational level
Illiterate
Primary school
High school
College/university
Type of surgery
General
Orthopaedic
Gynecologic
Urology
Neurosurgery
Duration of disease (mo)
.1
1-3
4-6
7-9
10-12
, 12

110 (57.6)
81 (42.4)
79 (41.2)
74 (38.8)
28 (14.7)
10 (5.3)
34 (17.8)
151 (79.1)
6 (3.1)
33 (17.3)
99 (51.8)
46 (24.1)
13 (6.8)
84 (44)
52 (27.2)
24 (12.6)
17 (8.9)
14 (7.3)
85 (44.5)
30 (15.7)
13 (6.8)
9 (4.7)
17 (8.9)
37 (19.4)

37.35 6 4.36, respectively. Abdi and Asadi-Lari32

showed that the mean score of hope for the Iranian
healthy population was 35.66 6 3.57. It seems that
Iranian patients enjoy high religious reliance and
family support. This overprotection can foster
hope and comfort in stressful situations such as impending anesthesia and surgery. Religious resources may give emotional comfort and provide
a sense of hope during times of difficulty.33 On
Table 2. Total Scores on the Questionnaires

Parameters

Potential
Score
Mean Standard
Range
Range
Deviation

Perianesthesia 24-144
comfort
Herth Hope
12-48
Index

70-144
25-48

107.37 6 11.53
37.35 6 4.36

COMFORT AND HOPE

217

Table 3. Items With Highest Mean Per

Questionnaire
Mean Standard
Deviation

Item
Perianesthesia comfort*
My anesthetist was gentle
My care helped me feel
confident
My anesthetist took good care
of me
Herth Hope Indexy
I have faith that gives
me comfort
I have a positive outlook
toward life
I am able to give and receive
caring/love

5.29 6 0.89
5.13 6 0.76
5.10 6 0.82

3.64 6 0.54
3.18 6 0.70
3.17 6 0.51

*Range on items 1-6.

y
Range on items 1-4.

the other hand, family support had a strong

connection with psychologic well-being in the
preoperative phase. Low family support can lead
to hopelessness.34
Surgical patients expressed higher scores for the
item my anesthetist was gentle in the comfort
questionnaire. It seems that cultural issues have

an important role in this area because Iranian culture encourages charitable and respectful communication to others, especially with patients.
Therefore, Iranian nurse anesthetists strive to
behave kindly and peacefully to preanesthesia
patients. Iranian nurses believe that the nursepatient relationship is the most important aspect
of caring and that patients are persons who need
to be cared for. As such, they strive to meet patients requests.35
Also, patients scored higher on I have faith that
gives me comfort on the hope instrument. Most
Iranian people are Muslim, and their belief in
God and their confidence following religious principles brings comfort to these patients. This was
emphasized in the verses from the holy Quran,
such as Remembrance of God certainly brings
comfort to all hearts (Rad 28).36
Findings of this study revealed that there was a
direct and significant relationship between comfort and hope in the preanesthesia stage as remembered by postanesthesia patients. Patients who
reported more comfort also had more hope.
Increased levels of comfort were correlated with
increased levels of hope and vice versa. In other
words, this study showed that there is a reciprocal
relationship between comfort and hope, which is

Figure 1. Mean score of comfort in surgical patients. This figure is available in color at www.jopan.org.

SEYEDFATEMI ET AL

218

Figure 2. Mean score of hope in surgical patients. This figure is available in color at www.jopan.org.

consistent with the Comfort Theory.25 Comfort

could foster hope and hope also fostered comfort.
Malinowski and Stamler,37 in their exploration of
the concept of comfort in nursing found that comfort gives strength and hope to patients. Providing
both physical and psychological comfort is a vital
part of a nurses role in all settings. Comfort and
hope are circumstantial and changeable because
of lifespan, disposition, and life experiences.25,31
Both comfort and hope change depending on
time and context.38,39 When patients were in
their preanesthesia period, their physical and
psychological conditions were altered, and their
level of hope could be decreased owing to
discomfort, anxiety, and fear. When individuals
are comfortable, they feel there is hope, and they
also experience relief of anxiety and
discomfort.22,39
Results of this study suggest that patients with university educations and who are married have
higher scores for comfort. Higher levels of education may lead to acquiring more information about
health and illness. Increased anxiety was associated with reduced preoperative information.40
Higher levels of education could decrease anxiety
and make patients more comfortable. On the other
hand, a widowed or divorced person often loses a
major source of family and social support.41 Surgery could exacerbate these problems, and single
patients could have lower levels of comfort than
married patients.
This study indicated that patients with university
education, male, and married had higher scores

of hope than others. Gender differences also appeared to be significant issues. Women reported
more anxiety and depression than men, both preand postoperatively.1,3 Also, people with low
education levels and single individuals were
more vulnerable to anxiety in the pre- and
postoperative period.3 Anxiety threatens hope,
which may be lead to lower levels of hope and
comfort in these patients.12
Study Limitations
This study used a convenience sample of prospective surgical patients from one Iranian hospital
with a wide range of ages and surgeries. Information about diagnoses was not collected; therefore,
we could not determine which of the surgeries entailed frightening diagnoses. Therefore, inferences
about comfort and hope among specific groups
were not possible. The heterogeneity of the sample could be considered a strength; however, a
wide range of patients seemed to recall similar
and moderately high levels of comfort and hope
before anesthesia was administered. A positive correlation between the two variables was found,
which supported the Comfort Theory. The primary data collector believed that the participants
in the study had these levels of comfort and hope
largely because of their religious beliefs, but data
were not collected to measure the extent of spirituality. Assessing levels of spirituality for possible
use as a covariate would be informative. It might
be interesting, as well, to know if the levels of comfort and hope vary according to the provider of
anesthesia (certified registered nurse anesthetist
or physician delivered).

COMFORT AND HOPE

219

In this study, participants were asked to recall their

preanesthesia levels of comfort and hope. These
memories may not be as accurate as asking about
levels of comfort and hope preoperatively. This
study does indicate that future research about preanesthesia comfort and hope before administering
anesthesia is warranted.
In addition, future studies should include information about each patients preoperative diagnosis.
Perhaps, data analysis could examine differences
between known groups on both of these variables
and their correlations. Given the adequate psychometric properties of the PCQ and HHI, these instruments can be used to gain information about
factors in addition to comfort and hope that might
contribute to quick healing and successful surgical
outcomes in homogenous samples of preanesthesia patients. Larger samples involving a variety of
urban hospitals and representing different areas
of Iran should be used when replicating this study.
Clinical Implications
Several implications for clinical practice can be
drawn from this study. Nurses need to support patients comfort and hope because comfort and
hope have mutual relationships to each other

and can be associated with positive outcomes.

Nurses can arrange the environment in a way
that allows surgical patients to experience
comfort and hope.
We recommend that a greater emphasis be placed
on using continuing education programs as a
means of expanding nurses awareness of comfort
and hope and their role in promoting positive surgical outcomes. Also, health care professionals
should recognize the impact of personal characteristics when caring for surgical patients, particularly in preanesthesia period.

Conclusion
This study showed that a direct and significant relationship exists between comfort and hope in preanesthesia patients undergoing surgery. Also,
demographic characteristics such as educational
level, gender, and marital status are influential factors affecting the comfort and hope in these patients.

Acknowledgment
The authors would like to acknowledge the help and support of
all the participating patients.

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