NR 520 Week 2 Framework Comparison, One Blood Draw Example

Framework Comparison: Kolcaba's Comfort Theory and Donabedian's Quality Model Applied to One 0400 Blood Draw, and the Exact Point Where They Recommend Different Things

Student Name

College of Nursing, Chamberlain University

NR 520: Applied Theoretical Foundations, Scientific Inquiry, and Decision-Making

Instructor Name

Month Day, Year

Framework Comparison: Kolcaba's Comfort Theory and Donabedian's Quality Model Applied to One 0400 Blood Draw, and the Exact Point Where They Recommend Different Things

The Case

Mr. R. is 78 and on his fourth day on our medical unit with community-acquired pneumonia. He is improving on oral antibiotics. His blood counts and chemistry panel have been stable for three days. He has mild cognitive impairment at baseline and was briefly confused on his second night. His daily labs were ordered on admission as "daily until discontinued." At 0400 each night, he is woken for a blood draw, and on two of three nights he has been unable to fall back asleep. His daughter asked the day nurse why her father is "stabbed every night when he's getting better." This paper applies two frameworks to that single situation and follows each until it recommends an action.

Framework 1: Kolcaba's Theory of Comfort

Kolcaba's middle-range theory treats comfort as a state of being strengthened when needs for relief, for ease and for rising above a problem are answered in each of four contexts: physical, psychospiritual, sociocultural and environmental. Nurses identify comfort needs, design interventions to meet them, and assess whether comfort increased, which the theory links to health-seeking behaviors and institutional outcomes (Kolcaba, 2001).

Applied to Mr. R., the framework directs attention first to his experience. His physical comfort need is uninterrupted sleep. His psychospiritual need is to feel that his care makes sense; his daughter's question suggests he does not. His environmental need is a quiet, dark room at night. The framework asks the nurse to act on those needs tonight and to measure whether his comfort improves.

Framework 2: Donabedian's Structure, Process and Outcome

Donabedian's model judges care through three linked lenses: structure, meaning the setting, staff and equipment; process, meaning what clinicians actually do; and outcome, meaning what happens to patients as a result (Donabedian, 1988).

Applied to the same case, the framework directs attention to the system that produced the 0400 draw. The structure includes a phlebotomy schedule built around 0700 rounds and an order set whose default is daily labs until someone stops them. The process is a daily draw continued for a patient whose results have not changed. The outcomes include lost sleep, possible delirium, blood loss and results that nobody used to change the plan. The framework asks which structure or process should change and how outcomes will be measured.

Where They Agree

Both frameworks describe the situation in the same way. Both see that the draw disturbs Mr. R.'s sleep, that the result is unlikely to change his care, and that the practice continues by default. Neither framework needs research to reach that description; the facts of the case supply it. Evidence supports the concern from both directions: patients in Dutch hospitals slept 83 minutes less than at home, with more than a third woken by staff (Wesselius et al., 2018), and more blood drawn for tests has been associated with hospital-acquired anemia (Salisbury et al., 2011).

Where They Part

The frameworks part at the next move. Kolcaba's theory points to an action for this patient tonight: the night nurse contacts the covering physician, asks whether tomorrow's draw can be dropped or moved to 0600 with his vital signs, explains the plan to Mr. R. and his daughter, and closes his door and dims the hallway light. Success is judged by whether Mr. R. sleeps and feels his care makes sense.

Donabedian's model points to a different action: change the order set so that daily labs expire after 48 hours unless renewed with a reason, and ask the laboratory whether the draw time can shift for stable patients. Tonight's draw for Mr. R. is a symptom; the order set is the cause. Success is judged by measures across all patients over months: the proportion of daily labs continued without change, the number of patients woken, rates of delirium and anemia.

Neither recommendation is wrong. The first helps Mr. R. tonight and leaves the next patient exposed to the same default. The second protects future patients but does nothing for Mr. R.'s next night unless someone also acts at the bedside.

What Each Framework Misses

Each framework also leaves something out, and the gaps matter for the decision. Kolcaba's theory is built around the patient's comfort, and it does not by itself tell the nurse how to weigh comfort against the physician's need for information. If Mr. R.'s sodium had been drifting down, dropping the draw for comfort would have been the wrong call, and the theory offers no rule for when a clinical need outweighs a comfort need. That judgment has to come from outside it.

Donabedian's model, for its part, is silent on the individual. It is designed to evaluate quality across many patients, and it can lead a unit to focus on measures and structures while the person in front of the nurse spends another sleepless night. It also treats outcomes as things to be measured, while Mr. R.'s daughter's question, why her father is woken when he is getting better, is not a measure but an expression of distrust. A system change can prevent that question for future patients; it cannot answer it for this family.

Seeing what each framework cannot do is part of using it well. It explains why a nurse who relied on only one of them would either help Mr. R. and leave the default intact, or fix the default and leave Mr. R. awake.

Choosing Between Them, or Using Both

In practice, a nurse can act on both, but not with the same authority. The bedside action is within a night nurse's reach: a call to the covering physician and changes to the room. The order set change requires the unit's practice council and the medical staff. The Society of Hospital Medicine's recommendation against repetitive laboratory testing in stable patients (Bulger et al., 2013) gives the system-level change a professional basis. The comparison suggests a sequence: act on Kolcaba's recommendation tonight for Mr. R., and carry Donabedian's recommendation to the practice council this month, using Mr. R.'s case, without identifying him, as an example of the default at work.

The comparison also taught something about the frameworks themselves. Each was chosen for this case because it pointed at a different level, the person and the system, and the case needed both levels. A pair of frameworks that pointed at the same level would have agreed all the way through and taught less.

References

Bulger, J., Nickel, W., Messler, J., Goldstein, J., O'Callaghan, J., Auron, M., & Gulati, M. (2013). Choosing wisely in adult hospital medicine: Five opportunities for improved healthcare value. Journal of Hospital Medicine, 8(9), 486-492. https://doi.org/10.1002/jhm.2063

Donabedian, A. (1988). The quality of care: How can it be assessed? JAMA, 260(12), 1743-1748. https://doi.org/10.1001/jama.1988.03410120089033

Kolcaba, K. (2001). Evolution of the mid range theory of comfort for outcomes research. Nursing Outlook, 49(2), 86-92. https://doi.org/10.1067/mno.2001.110268

Salisbury, A. C., Reid, K. J., Alexander, K. P., Masoudi, F. A., Lai, S.-M., Chan, P. S., Bach, R. G., Wang, T. Y., Spertus, J. A., & Kosiborod, M. (2011). Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. Archives of Internal Medicine, 171(18), 1646-1653. https://doi.org/10.1001/archinternmed.2011.361

Wesselius, H. M., van den Ende, E. S., Alsma, J., ter Maaten, J. C., Schuit, S. C. E., Stassen, P. M., de Vries, O. J., Kaasjager, K. H. A. H., Haak, H. R., van Doormaal, F. F., Hoogerwerf, J. J., Terwee, C. B., van de Ven, P. M., Bosch, F. H., van Someren, E. J. W., & Nanayakkara, P. W. B. (2018). Quality and quantity of sleep and factors associated with sleep disturbance in hospitalized patients. JAMA Internal Medicine, 178(9), 1201-1208. https://doi.org/10.1001/jamainternmed.2018.2669