Supportive Care in Cancer (2022) 30:7773–7781

https://doi.org/10.1007/s00520-022-07221-0

ORIGINAL ARTICLE

Impact of discriminant factors on the comfort‑care of nurses caring

for trans‑arterial chemoembolisation patients
Myoung Soo Kim1 · Ju‑Yeon Uhm1

Received: 9 June 2021 / Accepted: 13 March 2022 / Published online: 16 June 2022
© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2022

Abstract
Purpose This study was conducted to identify the levels of comfort-care provided by trans-arterial chemoembolisation
(TACE) nurses and examine the discriminant factors thereof.
Methods Nurses (n = 146) with experience in caring for TACE patients, participated in this study. The data were collected
using an online self-rated questionnaire and analysed with descriptive statistics and discriminant analysis. The discriminat-
ing factors included perception of post-embolisation syndrome and symptom interference, caring attitude, barriers to pain
and nausea/vomiting management, and supportive care competence.
Results The participants were classified into three groups, depending on the level of their comfort-care: “low” (n = 27),
“moderate” (n = 88), and “high” (n = 31) comfort-care groups. One function significantly discriminated between the low
and high comfort-care groups and correctly classified 79.3% of the participants in the cross-validation run. Supportive care
competence (0.864), caring attitude (0.685), perception of symptom interference (0.395), perception of post-embolisation syn-
drome (0.321), and barriers to nausea/vomiting management (− 0.343) were significant discriminant factors of comfort-care.
Conclusion A low proportion of the participants provided high levels of comfort-care, which was determined by five dis-
criminant factors. The study’s findings imply that the development of supportive care competence, authentic human caring
attitude, early detection of patients’ symptoms and symptom interference, and the development of manuals and guidelines
for removing barriers for nausea and vomiting are needed to improve the comfort-care of nurses caring for TACE patients.

Keywords Chemoembolisation · Hepatocellular cancer · Comfort-care · Nurses · Clinical competence

Introduction syndrome (PES), which may include abdominal pain, fever,

Trans-arterial chemoembolisation (TACE) is usually rec-
ommended as the first-choice treatment of intermediate-
stage hepatocellular carcinoma [1], which leads to selective
necrosis of the liver tumour, by administering chemothera-
peutic and vascular occlusive agents. In some cases, no dif-
ference was found in the 1-, 3-, or 5-year overall survival
rates between hepatic resection and TACE [2]; furthermore,
the combination of various therapeutic regimens and TACE
provided better survival benefits than simple TACE [3].
Although it can improve the survival rates of hepatocellular
carcinoma patients, a high recurrence rate of TACE may lead
to low quality-of-life levels, induced by post-embolisation
* Ju‑Yeon Uhm
juyeonuhm@gmail.com
1
Department of Nursing, Pukyong National University,
Yongso‑ro 45, Busan 48513, Korea
nausea, and vomiting [4]. Therefore, comfort-care that
relieves PES for TACE patients is crucial [5].
Comfort is a transient and dynamic state, characterised
by ease of pain and emotional and physical distress [6].
More specifically, it can be categorised as relief (immedi-
ate results), ease (longer lasting results), and transcendence
(highest level of maximal comfort), occurring in four con-
texts: physical, psychospiritual, sociocultural, and environ-
mental [7]. Discomforts caused by TACE must be relieved
immediately, as new discomforts continue to occur, starting
with the TACE procedure [8] and reaching the post-TACE
stage. For example, TACEs are usually performed with the
femoral artery, which requires more than three or four hours
of immobilisation and may be associated with inguinal pain
and the risk of a hematoma or pseudoaneurysm. Addition-
ally, most patients experience one or more instances of PES,
and syndrome-induced interference in their work, mood, and
enjoyment of life [9]. Most patients have been reported to be

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able to tolerate several TACEs without significant deteriora-
tion of quality of life, except physical health [10]. However,
there was a discrepancy as they experienced a decline in
both psychological [9] and social functioning [5], and little
was known about environmental comfort. According to the
Comfort Always Matters (CALM) framework, to maximise
patients’ comfort, it is necessary to incorporate five staff-
related themes: symptom management, holistic care/assis-
tance, engagement/commitment, information/participation,
and perceived/actual competence [6]. After excluding holis-
tic care/assistance, which was not a core issue of important
comfort-care for patients undergoing TACE [9], four themes
were used in this study to investigate comfort-care by TACE
nurses and the discriminant factors thereof.
First, symptom management includes routinely asking
about symptoms and considering the answers seriously [6].
Regarding the symptom management for a TACE patient,
alleviating symptoms is still a core aspect in nursing care
[9] because most patients receiving TACE have an advanced
stage of the disease [10]. The incidence of overall PES is
reported to vary from 36 to 80% [9, 11], and interferes with
daily life and quality of life via fatigue and pain [4]. How-
ever, little is known about nurses’ perception of PES and
symptom interference. Based on the finding that healthcare
providers underestimated the prevalence and importance of
fatigue and pain for cancer patients [12], nurses’ perception
of PES or symptom interference in TACE patients might be
similar. The appropriate perception of PES and symptom
interference is the logical beginning of comfort-care for
nurses treating TACE patients [7]. Second, staff engagement
and commitment indicate the understanding of patients’ dis-
comfort when using therapeutic strategies (e.g., empathetic
listening, maintaining privacy, and having a caring man-
ner during interactions) tailored to individual needs [6],
which can be when nurses practice with an authentic caring
attitude. In chemotherapy administration, commitment to
the provision of individualised care maintaining a balance
between person-centred, holistic care, and task-oriented care
is one of the nurses’ critical roles [13]. Therefore, nurses
with a good caring attitude [14] will provide high-quality
comfort-care.
Information and participation need to be provided by
staff who are knowledgeable on the topic and sensitive to
patients’ preferences for detail [6]. Regarding information/
participation for TACE patients, in the absence of symptom
management barriers, proper comfort-care and unbiased
information should be provided to the patient [15]. Patients
are more likely to engage effectively and express concerns
and symptoms when they are clearly informed of their health
statuses [16]. Nurses usually perceive a knowledge deficit,
lack of pain assessment, and psychological intervention
as barriers to cancer pain management [15]. A common
challenge experienced, outlined in previous research, was
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Supportive Care in Cancer (2022) 30:7773–7781
controlling patients’ nausea/vomiting [17]. Lastly, because a
staff member’s high level of competence can make a patient
feel comfortable and confident [6], it is one of the most
common factors related to comfort-care [18]. According to
a recent study, skill in symptom management offers reas-
surance to patients and families. Thus, an oncology nurse
constantly considers options to promote comfort and relief
of suffering [19]. Specifically, competence to meet physical,
psychological, and social support for patients’ needs and
providing integrated support for various aspects of patients’
self-care or lifestyle management appear to affect nurses’
comfort-care [20].
As comfort-care involves a continuum of holistic nurs-
ing care [19], identifying factors that can classify nurses
into high, moderate, and low comfort-care groups may help
develop guidelines for caring for TACE patients. There-
fore, the research questions for this study are: What level of
comfort-care did TACE nurses think they provided? How
do input independent variables in this study discriminate
comfort-care conducted by the nurses caring for patients
undergoing TACE?
Methods
Study design and participants
This study employed a cross-sectional descriptive design.
A snowball sampling method was used to recruit registered
nurses (RNs) in Korea. Data were collected from Septem-
ber to December 2020. The inclusion criteria for participat-
ing RNs were (a) at least 3 months of clinical experience
and (b) recent experience caring for patients undergoing
TACE. Nurses with administrative roles, such as unit man-
agers, were excluded. The study’s online questionnaire was
designed using Naver Form and a total of 146 RNs partici-
pated in this study. The sample size was evaluated based on
the smallest effect size, 0.0625; the significance level was
set as 0.05 and the power was 0.80 using multivariate analy-
sis of variance: Global effects of G*power 3.1.9.7. For this
study, the number of groups was set to three and response
variables to six. The required sample size was calculated as
147. Therefore, the study’s sample size was deemed appro-
priate for a reasonable approximation of analysis.
Instruments
Comfort‑care
Based on the comfort-care theory [7], comfort-care encom-
passes physical, psycho-spiritual, socio-cultural, and envi-
ronmental care. In this study, it indicates nurses’ descrip-
tions of actual care, in the four categories they provided. It
Supportive Care in Cancer (2022) 30:7773–7781
consisted of 25 items and four subscales: physical care (4
items), psycho-spiritual care (4 items), socio-cultural care
(12 items), and environmental care (5 items).
Physical comfort-care contained PES assessments and
intervention guideline use, which were developed by the
research team. To develop the items, five databases were
searched: PubMed, CINAHL, Web of science, EMBASE,
and Scopus, with a data range of 2000–2019. The inclu-
sion criterion for literature was as follows: what components
were investigated for managing physical comfort in post-
chemotherapy conditions, as recognised by nurses, patients,
and families. An instrument validation team, including four
oncology nurses and one nursing professor, examined the
content validity of all instruments. The item-level content
validity index (I-CVI) and scale-level CVI (S-CVI) were
both found to be acceptable with values of 1. Exploratory
factor analysis showed that four items explained 63.6% of
the total variance.
Psycho-spiritual comfort-care integrated mental, emo-
tional, and spiritual components for the patients. However,
we only focused on psychological comfort for anxiety and
depression aspects. To assess mental and emotional care for
anxiety and depression, we utilised two core anxiety symp-
toms in the general anxiety disorder (GAD)-2 [21] and two
core depression symptoms such as depressed mood and
anhedonia in the patient health questionnaire (PHQ)-2 scale
[22]. For example, “Do you provide psychological comfort-
care when your patient experiences a depressed mood?”.
To assess socio-cultural comfort-care, we used the
ComOn Coaching scale developed by de Figueiredo et al.
[23] and validated by the instrument validation team, to suit
Korean oncology nurses. We removed the 13th item, which
was not an appropriate item for a self-report. The I-CVI and
S-CVI were both 1, and the cumulative variance of the 12
items explained 58.8% of the total variance.
Environmental comfort-care pertained to one’s external
surroundings, conditions, and influences, which included
colour, noise, light ambience, temperature, view from win-
dows, access to nature, and natural versus synthetic ele-
ments. In this study, environmental comfort-care was catego-
rised as free of noise, appropriate light, safety, undisturbed
sleep, and comfortable bedding or furniture according to
Kolcaba’s theory [7]. The I-CVI and S-CVI were both 1,
and the five items explained 60.7% of the total variance. The
Cronbach’s alpha for the 25-item comfort-care was 0.86.
Responses were rated on a 5-point Likert scale (ranging
from “definitely disagree” to “definitely agree”). A higher
score indicated a better level of comfort-care. After complet-
ing the questionnaire, respondents were then classified into
three groups: low, moderate, and high levels of comfort-
care. Respondents who accumulated more than four points
in at least one category or whose scores were one standard
deviation higher than the mean score, were placed in the
7775
high comfort-care group. Accordingly, those who scored
below two points in at least one category or one standard
deviation lower than the mean score were placed in the low
comfort-care group. The remaining respondents were placed
in the moderate group. This classification method was used
because nurses offering extreme responses are different from
those who offer mainly moderate responses [24] and it mini-
mises the neutral tendency.
Perception of PES and symptom interference
The perception of PES and symptom interference refers to
nurses’ perception of how patients experienced their symp-
toms and symptom interference. The perception of PES
was assessed by four items: upper abdominal pain, nausea,
vomiting, and fever, based on the relevant literature [4,
9]. The perception of symptom interference was assessed
using a 6-item symptom interference subscale from the MD
Anderson Symptom Inventory (http://​www.​mdand​erson.​
org). The original scale included questions on patients’
walking, activity, work, relations with other people, enjoy-
ment of life, and mood. However, nurses were unable to
observe patients working; therefore, that factor was replaced
with sleep. Responses were measured on an 11-point Likert
scale (0 = “not present” and 10 = “as bad as you can imag-
ine”). Higher scores indicate a more severe perception of
PES or symptom interference. Cronbach’s alphas of percep-
tion of PES and symptom interference were 0.77 and 0.93,
respectively.
Caring attitude
To test the caring attitude, we used the Watson Caritas
Patient Score ® developed by Brewer and Watson [25] and
verified in Korean by Im et al. [26]. The instrument contains
five critical questions that assess authentic human caring
practices. “My nurse provides care for me with loving-kind-
ness” in the original scale was modified to “I provide care
for my patient with loving-kindness” in this study. Items
were each scored on a 7-point scale ranging from “not at
all” (1) to “very much” (7), with a higher score indicating
a better caring attitude. The Cronbach’s alpha for this study
was 0.87.
Barriers to pain and nausea/vomiting management
Barriers to pain management were extracted from common
factors from similar instruments [27–29]. This section of
the questionnaire comprised of five items, rated on a 5-point
Likert scale (1 = “definitely disagree” to 5 = “definitely
agree”). The I-CVI and S-CVI were each 1, and therefore,
acceptable. Higher scores on these items indicate greater
barriers to pain management. Cronbach’s alpha of the five
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items was 0.71. Barriers to nausea and vomiting manage-
ment developed by Salsman et al. [30] were employed in
this study. The original instrument consisted of 42 items for
patients and 32 items for oncologists and oncology nurses;
however, in this study, we used nine items in parallel ques-
tions for both patients and care providers. The items were
rated on a 5-point Likert scale (1 = “definitely disagree” to
5 = “definitely agree”). Higher scores indicated higher bar-
riers to nausea/vomiting management. The Cronbach’s alpha
of the nine items was 0.70.
Supportive care competence
The Cancer Survivor Integrated Supportive Care Compe-
tence scale [31] was used to measure support care com-
petence. It consisted of 22 items and five subscales: pro-
fessionalism enhancement (five items), care coordination
(five items), comprehensive nursing needs assessment (five
items), provision of tailored information and education (four
items), and recurrence surveillance/secondary cancer pre-
vention (three items). Responses were answered on a 5-point
Likert scale. Higher scores indicated better supportive care
competence. The Cronbach’s alpha for this study was 0.92.
Data analysis
All statistical analyses were performed using IBM SPSS Sta-
tistics for Windows version 27.0 (SPSS Inc., Chicago, IL,
USA). Descriptive statistics, t-test, and analysis of variance
were performed to examine the difference of comfort care
according to demographic and job-related characteristics of
the nurses. To conduct multiple discriminant analyses, the
assumptions of the discriminant analysis including multi-
variate normality, linearity, absence of multicollinearity and
singularity, absence of outliers, and homogeneity of vari-
ance–covariance matrices were examined. Two-step discri-
minant analyses were performed; first, we checked whether
the two discriminant functions could significantly discrimi-
nate the low, moderate, and high comfort-care groups. Sec-
ond, an additional analysis was performed on one discrimi-
nant function that was significant in the first step. Internal
consistencies of the instruments were examined using the
Cronbach’s alphas coefficient.
Results
Almost all participants (99.3%) were women in their twen-
ties (mean age = 27.9 years). Most were single (78.8%) and
84.9% held a Bachelor of Science degree in nursing. There
were no statistical differences in the general characteristics
of the nurses, except for the work department (F = 4.33,
p = 0.006) (Table 1). Prior to the discriminant analysis, the
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Supportive Care in Cancer (2022) 30:7773–7781
assumption tests were conducted. Linearity, normality, sin-
gularity, and homogeneity of variance–covariance matrices
(Box’s M = 49.11, p = 0.347) were satisfactory. There were
no outliers or multicollinearity of the predictor variables
(correlation range = 0.06–0.59). The proportions of nurses
in low-, moderate-, and high-level comfort-care groups were
18.5%, 60.3%, and 21.2%, respectively (Table 2). Mean
scores for the perception of PES and symptom interference
were 4.75 ± 1.73 and 4.54 ± 2.01, respectively.
In the first discriminant analysis, two discriminant func-
tions were analysed with six independent variables, and
only one function was significant (Eigenvalue = 0.54, Wilks’
lambda = 0.628, χ2 = 65.36, p < 0.001); low- and high-level
comfort-care groups were significantly discriminant. There-
fore, an additional discriminant analysis with those two
groups (low and high comfort-care groups) was performed.
One discriminant function explained 55.1% (0.7422) of the
variance in the level of comfort-care (Table 3). The structure
loading matrix of correlations between predictors and discri-
minant functions (Table 4) suggests five best predictors for
distinguishing between low and high comfort-care groups:
supportive care competence (0.864), caring attitude (0.685),
perception of symptom interference (0.395), perception of
PES (0.321), and barriers to nausea/vomiting management
(-0.343). The research hypothesis was therefore partially
accepted. Using the five significant discriminant factors, 47
of 58 nurses (81.0%) were correctly classified into low and
high comfort-care groups. For the cross-validation cases,
classification was at a 79.3% hit ratio (Table 5).
Discussion
TACE is one of the three most common treatment modalities
for hepatocellular carcinoma [4]. The 5-year relative sur-
vival rate of hepatocellular carcinoma has increased mark-
edly, from 10.7% between 1993 and 1995 to 32.8% between
2010 and 2014 [32]. Considering these improved figures, it
is clear that more structured care should be provided. While
comfort-care after TACE is crucial for patients, little is cur-
rently known about TACE patients’ comfort- care performed
by oncology nurses. Therefore, this study answers relevant
research questions and has strong implications.
Only 21.3% of nurses perceived that they provided high
levels of comfort-care; most indicated relatively low-per-
formance levels. Three interpretations of these results are
possible. The first is that the nurses’ actual comfort-care
levels are low. In a recent study, fewer than one-third of
healthcare providers assessed cancer-related fatigue and
only a quarter of them carried out appropriate interventions
[33]. For most cases, because comfort-care is not provided
by hospice and medicine specialists, but rather by primary
care providers [34], oncology nurses may have a low interest
Supportive Care in Cancer (2022) 30:7773–7781 7777

Table 1  Demographic and job- Variables Categories N (%) Comfort care t/F (p)
related characteristics (n = 146) M ± SD

Gender Male 1 (0.7) 3.24 -

Female 145 (99.3) 3.49 ± 0.37
Age (years) 22 ~ 25 38 (26.0) 3.56 ± 0.43 0.98 (.380)
M ± SD = 27.9 ± 3.1 26 ~ 30 86 (58.9) 3.47 ± 0.35
31≦ 22 (15.1) 3.43 ± 0.34
Marital status Married 29 (19.9) 3.44 ± 0.33 0.33 (.718)
Single 115 (78.8) 3.50 ± 0.39
Others* 2 (1.3) 3.42 ± 0.03
Educational status Associate 10 (6.8) 3.35 ± 0.33 0.72 (.487)
Bachelor’ 124 (84.9) 3.50 ± 0.38
Master’s ≦ 12 (8.3) 3.50 ± 0.37
Working department Surgical ward 56 (37.4) 3.36 ± 0.37 4.33 (.006)
Medical ward 72 (49.3) 3.56 ± 0.36
Paediatric ward 4 (2.7) 3.71 ± 0.26
Others** 14 (9.6) 3.57 ± 0.34
Total clinical experience (years) ≦1 44 (30.2) 3.57 ± 0.44 1.34 (.265)
M ± SD = 63.15 ± 36.41 2–3 31 (21.2) 3.40 ± 0.30
4–5 59 (40.4) 3.49 ± 0.35
6≦ 12 (8.2) 3.44 ± 0.37
Clinical experience in the current ≦1 14 (9.6) 3.42 ± 0.41 0.86 (.462)
department (years) 2–3 61 (41.8) 3.55 ± 0.39
M ± SD = 43.15 ± 28.64
4–5 38 (26.0) 3.46 ± 0.35
6≦ 33 (22.6) 3.45 ± 0.33
*
Divorced, bereaved, separation; **gynaecology unit, intensive care unit, outpatient department, rehabilita-
tion ward

Table 2  Predictor variables among the low, moderate, and high comfort-care nurse groups (N = 146)
Variables Total (n = 146) Low comfort- Moderate comfort- High comfort- Wilk’s lambda F-value p-value
care group care group (n = 88) care group
(n = 27) (n = 31)

Perception of post-embolization 4.75 ± 1.73 3.94 ± 1.85 4.85 ± 1.65 5.17 ± 1.67 .945 4.17 .017
syndrome
Perception of symptom interfer- 4.54 ± 2.01 3.54 ± 1.95 4.58 ± 1.88 5.30 ± 2.13 .923 5.97 .003
ence
Barriers for pain management 2.13 ± 0.57 2.33 ± 0.57 2.13 ± 0.51 1.98 ± 0.67 .961 2.90 .058
Barriers for nausea and vomiting 2.68 ± 0.46 2.80 ± 0.33 2.71 ± 0.46 2.48 ± 0.50 .943 4.32 .015
management
Caring attitude 4.92 ± 0.79 4.25 ± 0.75 4.94 ± 0.65 5.42 ± 0.81 .782 19.97 < .001
Supportive care competence 3.51 ± 0.44 3.15 ± 0.34 3.49 ± 0.36 3.90 ± 0.44 .709 29.28 < .001

Table 3  Canonical discriminant Discriminant analysis Function Eigenvalue Canonical Wilks’ lambda Chi-square value d.f P-value
functions correla-
tion

First stage 1 .542 .593 .628 65.36 12 < .001

2 .033 .179 .968 4.56 5 .472
Second stage 1 1.22 .742 .450 42.34 6 < .001

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Table 4  Discriminant loadings Predictor variable Structure matrix Stand-

and standardized weights for the ardized
low and high turnover intention weight
groups (N = 146)
Supportive care competence .864 .655
Caring attitude .685 .422
Perception of symptom interference .395 .229
Perception of post-embolization syndrome .321 − .034
Barriers for nausea and vomiting management − .343 − .207
Barriers for pain management − .261 .019

Table 5  Classification matrix Groups Predicted group membership Total

for the two-group discriminant
analysis (N = 58) Low comfort-care High comfort-care
group group

Original Low comfort-care group 23 (85.2) 4 (14.8)

High comfort-care group 7 (22.6) 24 (77.4)
Hit ratio 81.0%
Cross-validation Low comfort-care group 23 (85.2) 4 (14.8)
High comfort-care group 8 (25.8) 23 (74.2)
Hit ratio 79.3%

in comfort-care that aims to address patient comfort needs.
The second is that nurses may underestimate their level of
comfort-care. While there are discrepancies and differences
in the perceptions of nurses and patients, oncology nurses
may have rated their comfort-care lower than their actual
performance and provision thereof. Lastly, although the
nurses scored low on this instrument, they might have pro-
vided other types of comfort- care. As comfort care is very
difficult to define [7] and a theory-based rigorous instrument
has not yet been developed [35], the instrument used in this
study may not have measured other important forms of care.
Nurses’ perceptions of PES were slightly higher than the
perceptions of symptom interference; these results are simi-
lar to the findings of studies of oesophageal cancer patients
where symptoms were perceived more than symptom inter-
ference [36]. In contrast, the perception of symptom inter-
ference was higher than the symptoms for advanced cancer
patients [37]. Two factors may have influenced this. First,
the influence of PES after TACE on interference in daily life
may not be significant because hospital stays are up to three
days [38] and it may be difficult for nurses to observe symp-
tom interference in these short intervals. Second, symptom
interference is more difficult to recognise because patients
do not report PES. In Jung, Seon and Kim’s study, the most
common reason for not complaining about pain to nursing
staff after TACE was because patients thought they can bear
it, showing a lack of patient recognition in this area [39].
Therefore, education and training to improve nurses’ percep-
tions of patients’ symptom reporting and the development of
a manual to assess PES or symptom interference accurately
in TACE patients are necessary.
Based on the results of the discriminant analysis, five
factors were significant. First, supportive care competence
was found to be the most important discriminant factor.
As repeated TACE is common, competence in recurrence
surveillance and secondary cancer prevention is necessary.
Supportive care demonstrates effectiveness regarding the
emotional functioning and fatigue of a patient undergoing
chemotherapy [40]; this is also crucial for TACE patients.
However, nurses demonstrate low levels of practical perfor-
mance in this area owing to insufficient knowledge about
cancer patients, unfamiliar practices, decreased confidence,
and incompetency [41]. Cancer patients often receive poor,
fragmented care from multiple settings and providers [42].
Therefore, competence in providing comfort-care must
include care coordination, the provision of tailored informa-
tion and education, and recurrence surveillance [31] based
on the individual needs and background of the patient.
A caring attitude was a discriminant factor for comfort-
care. Engaging authentically, demonstrating compassion,
and making an effort to get to know patients as individuals
were reported as key components in nurse-patient relation-
ships and a person-centred approach [43]. The caring atti-
tude used in this study emerged from the 10 Watson caritas
process as a universal caring phenomenon and indicated lov-
ing kindness, trust, dignity, healing environment, and hon-
ouring of beliefs and values [25]. In line with this, the key
concepts of caring behaviours toward patients undergoing

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chemotherapy were respect, nurse-patient connection, and
empathy [13]. Cancer patients often do not receive appropri-
ate psychological care from healthcare providers, although
they did perceive their disease as an illness of the mind [44].
Nurses’ empathic concern and encouragement to not endure
alone based on an authentic caring attitude can be of great
comfort to cancer patients [45]. TACE patients are prone to
negative psychological conditions, which increase their psy-
chological burden and affect their physical and mental health
as well as prognosis. Therefore, in the nurse-patient relation-
ship, oncology nurses need to exert authentic engagement
beyond superficial engagement, while protecting themselves
by maintaining emotional etiquette, so as not to be too emo-
tionally connected to the patient [46].
The perceptions of PES and symptom interference were
also determinant factors for comfort- care. PES, an early
predictor of overall survival after TACE [11], lasts for 1 to
5 days [47] and is characterised by decreased physicality
and social functioning and increased symptom interference,
including fatigue and loss of appetite for approximately two
weeks after TACE [5]. As nurses who had assessed a patient
within the last 24 h were more accurate in their prognosis
predictions than nurses who had not [48], nurses should
assess their patients once or more daily. Furthermore, nurses
should inform the family caregiver or home-care oncology
nurse that symptom interference requires a closely moni-
tored two-week assessment. However, based on the CALM
framework, the meaning of distress and care should be first
defined because distressing symptoms may differ by condi-
tion, ethnicity, and age [6].
Barriers to nausea and vomiting management can influ-
ence comfort-care. The causes of post-TACE nausea and
vomiting were diverse. They included operative trauma,
aseptic inflammation, chemotherapeutic drugs, ischemia
of liver and bile duct, stress and pain, and patient factors
[49]. TACE is different from a surgical operation, owing
to the use of local anaesthesia in the operation, and the use
of tumour feeding artery, not vascular route. Moreover, it
varies from chemotherapy owing to the significantly lower
dose of chemotherapeutic agents. Although three therapeutic
interventions were identified (i.e., 5-HT3 receptor antago-
nists, dexamethasone and ginsenosides, and dexamethasone
and scopolamine patches), no guidelines currently exist for
nausea and vomiting management for TACE patients [4].
Therefore, there are currently barriers to nausea/vomit-
ing management and comfort-care is likely to be affected.
Patient-centred management, including a brief response plan
based on the level of nausea and vomiting reported by the
patients, should be established via shared responsibility for
goal-setting and by sharing the benefits of the antiemetic
regimen.
Barriers to pain management were not a determinant fac-
tor in this study. Abdominal pain during or after TACE is
7779
reportedly due to ischemic changes in the hepatic paren-
chyma and swelling of the membrane surrounding the liver
[4]. Fears of addiction, medication tolerance, and side effects
of opioids, shared by both professionals and patients, have
been reported as the main barriers to pain management [50].
However, post-embolisation pain can be controlled by dexa-
methasone, rather than an analgesic agent such as oxyco-
done [51]. Dexamethasone has promising anti-inflammatory
effects, inhibits immunoreactions, and is expected to prevent
PES [52]. Therefore, it is possible that the barriers to pain
management are not significant because there are alternative
medicines to control patients’ pain.
Strengths and limitations of the study
This study has several strengths. First, a discriminant func-
tion showed a relatively high correct-classification rate
(81.0% in the original classification and 79.3% in the cross-
validation run); the stability of the classification procedure
was checked by cross-validation and showed a high degree
of consistency in the classification scheme [53]. Second, it
was approached from a nurse’s perspective and based on
theory. While previous studies dealt with comfort from the
patient perspective [54], this study focused on the nurses’
perspective in regard to comfort-care performance, provid-
ing basic data for the development of care guidelines based
on relevant theory.
There are also, however, several limitations to this study.
First, the sample size of the smallest group in a study should
exceed the number of predictors in the discriminant analysis
[53]; however, in this study, the sample size of the small-
est group was four and there were six predictors. Over
fitting can occur if the number of cases does not notably
exceed the number of predictors in the smallest group. Sec-
ond, although barriers to survivorship via care provision,
encompasses both care challenge factors, such as the lack
of standard treatment, and system challenge factors, such
as communication with other clinicians [55], we could not
examine the system challenges in this study. Finally, because
of the nature of self-reporting, we must be cautious when
interpreting the findings of this study. Additional samples,
discursive predictors, and observational data would rectify
these limitations.
Conclusion
Only a small fraction of nurses perceived that they provided
a high standard of comfort-care. There were five discrimi-
nant factors of comfort-care performance determined in this
study: supportive care competence, caring attitude, percep-
tion of symptom interference, perception of PES, and barri-
ers to nausea and vomiting management. The study findings
13
7780
suggest that the development of supportive care competence,
an authentic caring attitude, early detection of patients’
symptoms and symptom interference, and the development
of manuals and guidelines for removing barriers to nausea
and vomiting management are needed to improve comfort-
care for TACE patients. Future research may identify other
discriminant factors for effective comfort-care for TACE
patients.
Author contribution All authors contributed to the study conception
and design. Material preparation, data collection, and analysis were
performed by Myoung Soo Kim. The first draft of the manuscript
was written by Ju-Yeon Uhm, and all authors commented on previous
versions of the manuscript. All authors read and approved the final
manuscript.
Funding This work was supported by the National Research Founda-
tion of Korea (NRF) funded by the Korea government Ministry of
Science and ICT (MSIT) (No. 2020R1A2C1010378).
Data availability Not applicable. The datasets generated during and/
or analysed during the current study are not publicly available due to
[REASON(S) WHY DATA ARE NOT PUBLIC] but are available from
the corresponding author on reasonable request.
Code availability Not applicable.
Declarations
Ethical approval This study was conducted after review and approval by
the institutional review board (IRB No:1041386–202009-HR-53–01).
On the survey’s first web-page, the purpose of the study, research meth-
ods, voluntary participation, assurance of anonymity, and the possibil-
ity of withdrawal from participation were explained to participants in
detail. Informed consent was then obtained online from participants
prior to the initiation of the survey.
Consent to participate Informed consent was obtained from all indi-
vidual participants included in the study.
Consent for publication Not applicable.
Competing interests The authors declare no competing interests.
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