By Katherine Astaneh, BSN

Meaning of Comfort

“A model of human press is the framework within which comfort is related to interventions that enhance the state of comfort desirable subsequent outcomes of nursing care” (Kolcaba, 1994, p.1178).

“The theory of holistic comfort is a component of a normative and descriptive theory for nursing care” (Kolcaba, 1994, p. 1180).

“First meaning:Comfort — a cause of relief from discomfort and/or of the state of comfort” (Kolcaba & Kolcaba, 1991, p. 1302).

“Fourth meaning:Comfort — whatever makes life easyor pleasurable” (Kolcaba & Kolcaba, 1991, p. 1302).

.

“Second Meaning:Comfort — the state of ease and peaceful contentment” (Kolcaba & Kolcaba, 1991, p. 1302).

“Third meaning:Comfort — relief from discomfort” (Kolcaba & Kolcaba, 1991, p. 1302).

Comfort:

[The construction of Kolcaba’s theory of comfort was the result of different methods for theory development applied during different stages of the process of theory development. In review, those methods were (1) inductive explication of the components of a specific practice, (2) concept analysis and operationalization of components that were yet undefined, (3) deduction from a more general organizing theory with relocation of the main concepts, and (4) retroduction to bring to the model a concept for outcomes research] (Kolcaba, 2001).

Holistic care

[Theoretical ModeMajor Concepts and Definitions used in Conceptual Framework Health Care Needs are those identified by the patient/family in a particular practice setting. Comforting Interventions are nursing interventions that are designed to address specific comfort needs of recipients.  This includes physiological, social, financial, psychological, spiritual, environmental, and physical interventions. Intervening Variables are interacting forces that influence recipients' perceptions total comfort.  This includes factors such as past experiences, age, attitude, emotional state, support system, prognosis, and finances. 

Enhanced Comfort is an immediate desirable outcome of nursing care, according to Comfort Theory.  When comfort interventions are delivered consistently over time, they are theoretically correlated a trend toward increased comfort levels over time, and with desired health seeking behaviors (HSBs).

 Health-Seeking Behaviors (HSBs):  The relationships between comfort and health seeking behaviors are entailed in the second part of Kolcaba's comfort theory. Internal: healing, immune function, number of T cells, etc. External: health related activities, functional outcomes

Peaceful Death] (Nursing Theory, 2011, para. 3).

 

Meaning: Main Concepts

[Theoretical ModelMajor Concepts and Definitions used in Conceptual Framework continued

Institutional Integrity is defined as the values, financial stability, and wholeness of health care organizations at local, regional, state, and national levels.

Best Practices are those protocols and procedures developed by an institution for specific patient/family applications (or types of patients) after collecting evidence. 

Best Policies are protocols and procedures developed by an institution for overall use after collecting evidence

Examples of variables related to this expanded definition of InI include patient satisfaction (HCHAPS scores!), cost savings, improved access, decreased morbidity rates, decreased hospitalizations and readmissions, improved health-related outcomes, efficiency of services and billing, and positive cost-benefit ratios. Relationships between Comfort, HSBs, and

InI constitute the third part of the theory.] (Nursing Theory, 2011,

para. 3).

Meaning: Main Concepts

 

“NURSING: THE INTENTIONAL ASSESSMENT OF COMFORT NEEDS OF PATIENTS, FAMILIES OR COMMUNITIES; DESIGN OF COMFORT MEASURES TO ADDRESS COMFORT NEEDS, INCLUDING RE-ASSESSMENT OF COMFORT LEVEL AFTER IMPLEMENTATION OF COMFORT MEASURES, COMPARED TO A PREVIOUS BASELINE”(Kolcaba, Durr, &

Stoner, 2010, figure FAQ).

“PATIENT: AN INDIVIDUAL, FAMILY, OR COMMUNITY IN NEED OF HEALTH CARE, INCLUDING PRIMARY, TERTIARY, OR PREVENTATIVE CARE” (Kolcaba, Durr, & Stoner, 2010, figure FAQ).

“ENVIRONMENT: ASPECTS OF PATIENT/FAMILY/COMMUNITY SURROUNDINGS THAT AFFECT COMFORT AND CAN BE MANIPULATED TO ENHANCE COMFORT”(Kolcaba, Durr, & Stoner, 2010, figure FAQ).

“HEALTH: OPTIMUM FUNCTION OF A PATIENT/FAMILY/COMMUNITY FACILITATED BY ENHANCED  COMFORT” .

METAPARADIGM CONCEPTS AS DEFINED BY KATHARINE KOLCABA

Meaning: Main Concepts

(Kolcaba, Durr, & Stoner, 2010, figure FAQ).

METAPARADIGM CONCEPTS AS DEFINED BY KATHARINE KOLCABA

CONTINUED…

Major concepts described in the Theory of Comfort include comfort, comfort care, comfort measures, comfort needs, health-seeking behaviors, institutional integrity, and intervening variables (McEwen & Willis, 2011).

The concepts affect the other through their relationship. The term used by Kolcaba is “intra-actional”. Interventions intended for one will roll over to all the areas and have a carry-over effect.

Meaning: Main Concepts

(Kolcaba, Durr, & Stoner, 2010, figure FAQ)

(Merkel, 2007)

1994THE BIRTH OF A THEORY

“What is true comfort? Here I am on the beach: relief from heat, ease from worry, transcendence from nature......ahhhh, true comfort in all four contexts,” (Kolcaba, 2012, figure 1).

KATHARINE KOLCABA RN, BSN, PHD

our Txt

Here

Jan. 94 Bobbit trial

Branch Davidian compound; Feb 28, 1994

Winner 66th Academy Awards March, 94

4/ 22/94 Pres. Nixon Passes Away

Michael

Jackson &

Lisa M

arie

Presley

wed M

ay 1994

Jun 26th - 107°F (41.6°C) at

Albuquerque New Mexico

July 94 OJ Simpson –

I am not guilty.

Aug. 1994- Space telescope Hubble photographs Uranus with rings

Ferry boat Estonia capsize & sinks in East Sea, 909 killed-9/28/94

Nobel priz

e for p

hysiology

award

ed to

Alfred

Gilm

an &

Martin Rodbell

10/94

Nov. 1994

Maltese Falcon auctioned for $398,590 12/94

"My momma always said that life was like a box of chocolates, you never know what you're gonna get” (Tom Hanks, 1994)

Origin of the TheoryWhat was going on:

Katherine Kolcaba originally wrote the Theory of Comfort with Alzheimer’s and dementia patients in mind. This is what was going on in her world and she wanted to help out.

[I borrowed the ideas about Relief, Ease, and Transcendence. Later, I "borrowed" the contexts of experience from the literature review about holism. I put these ideas together in a unique way. Later, I borrowed the framework for the First and Second parts of Comfort Theory from Henry Murray. But I hung nursing concepts on his abstract framework in a unique way. The idea of institutional outcomes was unique and was added through a process Tomey and Alligood call retroduction] (Kolcaba, Durr, & Stoner, 2010, figure FAQ).

Motivation to write:

[My brother died of cancer when he was 41, and during his illness I gained more experience with comforting actions of nurses, and how to articulate what they did. Because of that experience and its timing, my dissertation is about women with breast cancer, not dementia or gerontology. And I have done a lot of work with end of life comfort] (Kolcaba, Durr, & Stoner, 2010, figure FAQ).

[My spirituality, which my mother fostered and role-modeled for me, has also had a strong influence] (Kolcaba, Durr, & Stoner, 2010, figure

FAQ).

[Also, my husband has always been a huge supporter and brain stormer about Comfort Theory] (Kolcaba, Durr, & Stoner, 2010, figure FAQ).

.

(Kolcaba, Durr, & Stoner, 2010, figure FAQ)

Origin of the Theory con’t“To describe the origin or development of Comfort Theory, Kolcaba conducted a concept analysis of comfort that examined literature from several disciplines including nursing, medicine, psychology, psychiatry, ergonomics, and English” ("Nursing Theory," 2011, para. 4). “First, three types of comfort (relief, ease, transcendence) and four contexts of holistic human experience in differing aspects of therapeutic contexts were introduced” (Nursing Theory," 2011, para. 4) .

A taxonomic structure was developed to guide for assessment, measurement, and evaluation of patient comfort” ("Nursing Theory," 2011, para. 4).

U.S. and Allies at war with Iraq (Jan. 15, 91)

Warsaw Pact dissolves military

alliance (2/ 25/ 91)

Cease-fire ends Persian Gulf War; UN forces are

victorious (April 3, 91)

Last of the three U.S. hostages freed

in Lebanon to come home on: (Dec. 2–4, 91)

World History. (1991) Retrieved from http://www.infoplease.com/ipa/A0005273.html#ixzz2aiQe4ax2

(Kolcaba, Durr, & Stoner, 2010, figure resources)

Happenings of 91

Origin of the Theory con’t

Major influences in the development of Comfort Theory:

[Relief: Ida Jean Orlando (1961 / 1990) Nursing Process TheoryEase: Virginia Avernal Henderson (1978)  Need TheoryTranscendence: Josephine Paterson & Loretta Zderad  (1976 / 1988) Humanistic Nursing TheoryFramework for Comfort Theory:  Murray  (1938) Henry Murray designed a conceptual framework diagrammed in three  lines.  Comfort theory takes that framework to another level to include a fourth line.  This fourth line is the framework for the comfort theory]. 

(Kolcaba, Durr, & Stoner, 2010, figure FAQ).

Origin of the Theory

Sept. 11, 2001 “When the second plane hit the south tower of the World Trade Center in New York City the loaded Navy hospital ship was deployed immediately.

The name of the ship was ... Comfort”.

(Comfort Care in Nursing Blog, 2011, figure 1)

Usefulness of the Theory

“

,” (Kolcaba, 1994, p. 1180).

(Kolcaba, 1994, p. 1181)

Usefulness of Theory

“Physical: pertaining to bodily sensations and homeostasis

Pain relief Regular bowel function Fluid/electrolyte balance Adequate oxygen Saturation Turning & positioning” (Merkel, 2007, p. 3)

“Psycho-spiritual:pertainingto internal awareness of self, esteem, sexuality, meaning in one’s life

Maintaining/improving self esteem Enhancing independence Increasing relaxation Accommodating religious practices”

(Merkel, 2007, p. 3)

“Environmental: the external background of the human experience

Temperature Noise Color Light Views from the window Access to nature” (Merkel, 2007, p. 3)

“Socio-cultural interpersonal, family & societal relationships, family traditions & rituals:

Caring attitude Continuity of care Information & education Enhancing family & friend support Cultural customs” (Merkel, 2007, p. 3)

Usefulness of Theory

The Taxonomic Structure of Comfort

Comfort Daisies

The Theory of Comfort can be used as the framework for patients’ assessments. “Assessment is achieved through the administration of verbal rating scales (clinical) or comfort questionnaires (research), using instruments developed by Kolcaba” (Tomey & Alligood, 2010,

p.711). Pain scales are used to rate levels before and after medications to get a base and acquire a fixed level. The GCQ is based on the Likert scale ranging from “strongly agree to strongly disagree” (Kolcaba, 1992, p.8).

(Kolcaba, Durr, & Stoner, 2010, figure resources (all the above)

Comfort Behaviors Check off List

Case Scenerio:Comfort Theory In Use

Setting: 72 year old female from Nursing home. Patient is admitted with acute mental status change. Patient is dehydrated and results are back with a positive UTI.

Nursing Interventions using the Comfort Theory: Are designed to meet the needs of the patient Physiological, Social, Financial, Psychological, Spiritual, Environmental, and Physical Interventions.

1) Patient: She is trying to get out of bed. She is yelling out, she wants her purse. She is confused and she doesn’t know where she is at.

a) Nursing Interventions: Social, Physical Interventions - Put her back in bed, inform the patient that her purse is not here, it is at home. The RN calls her family to see if someone can bring the patient her purse, when they come to visit

2) Patient: Again she is trying to get out of bed. She throws back the blankets and tries to sit up and get out of bed. She continues to yell and beg for her cat, she wants to go home, and she can’t find her purse.

b) Nursing Interventions: Psychological, Physical Interventions The RN returns and has a purse for her out of the lost and found and puts her back in bed. Patient is confused and does not recognize anyone. Patient is concerned about getting her cats some food.. The RN speaks to her about her cats and consoles her. She tells the patient that they are being care for and for her not to worry and the RN stated, she will call her home and check on her cats for her. Patient seems to calm down after that statement.

There are three types of Comfort – 1) Relief- someone who has had a specificneed met 2) Ease – state of calm or contentment 3) Transcendence – someone whorises above problem or pain.

3) Patient: The patient is confused, saying, “I don’t think this is right.” The patient is trying to get out of bed. Patient is trying to get her gown off, to go home. Patient keeps stating she needs to go home, “I need to go.” Patient is getting more and more agitated. She is getting more upset about getting her cats some food.c) Nursing Interventions: Psychological, Physical Interventions, Environmental - The RN tells the patient she needs to stay in the hospital and she is very sick. RN talks with the patient, in a soothing tone and consoles her. Tells the patient she will sit with her and talk. Patient tells RN she is cold. RN puts a warm blanket on the patient and tells her we will get the heat turned up. Patient still concerned about her cats, the RN tells patient she has called her home and someone is caring for them and they have lots of food for them. Patient satisfied with response, warm with the blanket, and feeling secure in her environment she goes to sleep.

There are four Context of Experience – 1) Physical – pertaining to bodilysensations 2) Psychospiritual – pertaining to internal awareness of self 3)Environmental – pertaining to external surroundings 4) Social – pertaining tointerpersonal relationships.

Case Scenerio: Comfort Theory In Use con’t

Theory Testability

“In order to use the theory, three steps are required:

(a) understanding the technical definition of comfort and its origins,

(b) understanding the relationships (propositions) between the general concepts entailed in the theory

(c) relating the general concepts to specific problems/settings in order to enlighten practice and generate research questions”(Kolcaba & DiMarco, 2005, p.

187) .

Below are some examples of Comfort Theory used in research :

Kolcaba, K., & Fox, C. (1999). The effects of guided imagery on comfort of women with early stage breast cancer undergoing radiation therapy. Oncology Nursing Forum, 26(1), 67-72.

Schirm,V., Baumgardner, J.,Dowd, T., Gregor, S., & Kolcaba, K. (2004). NGNA.

Development of a healthy bladder education program for older adults. Geriatric Nursing. 25(5), 301-306.

Apóstolo, K.L.A., & Kolcaba, K. (2009). The effects of guided imagery on comfort, depression, anxiety, and stress of psychiatric inpatients with depressive disorders. Archives of Psychiatric Nursing, 23(6), 403-411..

(Comfort Care in Nursing Blog, 2011, figure 1)

Theory Testability con’tgenerated research

After the implementation of medications the recipient is reassessed. “Kolcaba's technical definition of comfort is the physical, psychological, spiritual, social, cultural, and environmental aspects of human experience which are perceived simultaneously” (Wardell, 2010, para. 1).

Holistic comforting actions are new to be measured in the research field and can be quite sensitive to the material encountered (Wardell, 2010). “These comfort outcomes have been consistently positive and have been found to be reliable predictors for more effective healing and/or management of chronic health concerns” (Wardell, 2010, para. 2).

The General Comfort Questionnaire (GCQ)… 

…is designed to measure holistic changes in comfort levels. There are a vast assortment of the GCQ for various areas and actions. “Notable are the instruments developed by Kolcaba et. al such as the Bladder Function Questionnaire, the Healing Touch Comfort Questionnaire, the

Hospice Comfort Questionnaire, and the Radiation Therapy Comfort Questionnaire” (Wardell,

2010, para. 3). The results shown by these GCQ’s have been a tremendous help in research. The Verbal rating scale is utilized for our practice sessions. (Wardell, 2010).

(Wardell, 2010, para. 1-3)

Theory Testability con’tgenerated research

“In total, 32 instruments are known adaptations of the GCQ: 14 by Kolcaba et al., 8 adaptations by other professionals, and 10 foreign language translations” (Wardell, 2010, para. 4).

Dowd, T., Kolcaba, K. & Steiner, R. (2000).  Cognitive strategies to enhance comfort and decrease episodes of urinary incontinence.  Holistic Nursing Practice, 14(2), 91-102.

 Kolcaba, K., Dowd. T., & Steiner, R. (2006). Development of an instrument to measure holistic client comfort as an outcome of healing touch. Holistic Nursing Practice, 20, (3), 122-129. 

 Dowd, T., Kolcaba, K., Fashinpaur, D., Steiner, R., Deck, M., & Daugherty, H. (2007). Comparison of healing touch and coaching on stress and comfort in young college students. PDF Format

 Kolcaba, K., Dowd, T., Steiner, R. & Mitzel, A. (2004). Efficacy of hand massage for enhancing comfort of Hospice Patients. Journal of Hospice and Palliative Care, 6(2), 91-101. 

 Novak, B., Kolcaba, K., Steiner, R., & Dowd, T. (2001). Measuring comfort in families and patients during end of life care. American Journal of Hospice and Palliative Care, 13(3), 170-180. 

 Kolcaba, K. & Fox, C.  (1999).  The effects of guided imagery on comfort of women with early-stage breast cancer going through radiation therapy. Oncology Nursing Forum, 26(1), 67-71.

(Wardell, 2010, para. 4)

Propositions in Kolcaba’s middle-range Theory of Comfort

[Propositions of Comfort Theory 1. Nurses identify comfort needs of patients and family members.2. Nurses design interventions to meet identified needs.3. Intervening variables are considered when designing interventions.4. When interventions are delivered in a caring manner and are effective, and when enhanced comfort is attained, interventions are called “comfort measures”.5. Patients and nurse agree on desirable and realistic health- seeking behaviors.6. If enhanced comfort is achieved, patients and family members are more likely to engage in health-seeking behaviors these further enhance comfort.7. When patients and family members are given comfort care and engage in health-seeking behaviors, they are more satisfied with health care and have better health-related outcomes.8. When patients, families, and nurses are satisfied with health care in an institution, public acknowledgment about that institution’s contributions to health care will help the institution remain viable and flourish]

[These propositions provide a systematic approach to a solution by incorporating a process that involves identifying a need, addressing that need, identifying intervening variable, provide appropriate interventions, assessing if the goal is achieved, and reaffirming the healthy behaviors learned by the client. Essentially, Kolcaba has developed a nursing process that is specific to her Theory of Comfort] (Weller, 1999, para. 8).

(Kolcaba, Durr, & Stoner, 2010, figure FAQ).

Different Evolution of Experimental and Comparisons Psychiatric Inpatients on Total Comfort

This quasi-experimental design was used to measure the differences in comfort, depression, anxiety, and stress between a treatment group and a usual care group (comparison) of short-term psychiatric inpatients diagnoses with depressive mood disorders.

Psychiatric Inpatients Comfort Scale (PICS), PICS evaluated reliability, construct validity, and concurrent validity. The PICS is 5-point Likert type scale with 42 items for self-reporting ranging from 1, “It doesn't correspond to anything that happens with me” to 5, “It totally corresponds to what happens with me.”

“Depression, Anxiety, and Stress Scales (DASS-21). the authors assessed scale reliability, construct validity, and concurrent validity. The DASS-21 contained a set of three 4-point Likerttype subscales for self-reporting. Each subscale consisted of seven items, aimed at assessing depression, anxiety, and stress] (Apostolo & Kolcaba, 2009).

[Imagery creates a bridge between mind and body, linking perception, emotion, and psychological, physiological, and behavioral responses.

. Different Evolution of Experimental and Comparisons Psychiatric Inpatients on Total Comfort

Example Case Study where Comfort Theory Utilized-(Apostolo & Kolcaba, 2009)-all cited so not to loose meaning of test

Overall EvaluationGeneralizability

The Comfort theory is a mid range theory, less generalized than the grand theories yet more concrete and specific. STRENGTHS: Requires only a simple, common sense approach. Comforting interventions enhance patients’ comfort. “When patients’ and families engage in health-seeking behaviors, institutions have better outcomes,” (Kolcaba, Durr, & Stoner, 2010, figure FAQ). WEAKNESS: Research on the concept of Comfort is limited and the meaning of Comfort has not been ‘definitively’ defined.. Implementation will be used for the benefit of my patients and personal ease of mind. I personally believe in this theory and I place into practice comfort theory each and every day with my patients.

A Closer Look at Kolcaba's Conceptual Framework

Providing comfort is definitely within the nurses’ realm today. Nurses are the ones in direct contact with their patients, providing relief from certain discomforts, continuously assessing, monitoring and providing care that will ensure the client is at ease. According

to Kolcaba, “Comfort is the desirable state that nurses would want for their patients,” (Comfort Care in Nursing Blog, 2011)

(Comfort Care in Nursing Blog, 2011, figure 1)

ReferencesApostolo, J. L., & Kolcaba, K. Y. (2009). The effects of guided imagery on comfort,

depression, anxiety, and stress of psychiatric in patients with depressive disorders. Archives

of Psychiatric Nursing, 23(6), 403-411. http://dx.doi.org/10.1016/j.apnu.

2008.12.003

Comfort Care in Nursing Blog. (2011, September 11). Kolcaba’s activity [Blog comment].

Retrieved from http://comfortcareinnursing.blogspot.com/p/comfort-theory-major

Current Nursing. (2013). Retrieved March 25, 2010, from http://currentnursing.com/

nursing_theory/application_nursing_theories.html

Kolcaba, K. (1994). A theory of holistic comfort for nursing. Journal of Advanced Nursing, 19,

1178-1184. http://dx.doi.org/10.1111/j.1365-2648.1994.tb01202.x

Kolcaba, K. (2001). Evolution of the mid range theory for outcomes research. Nursing

Outlook, 49(2), 86-92. http://dx.doi.org/10.1067/mno.2001.110268

Kolcaba, K., & DiMarco, M. A. (2005). Comfort theory and its application to Pediatric

nursing. Pediatric Nursing, 32(3), 187-194. Retrieved from http://

www.medscape.com/viewarticle/507387_2

Kolcaba, K., Durr, K., & Stoner, M. [Comfort Line]. (2010, June). FAQ [Blog comment].

Retrieved from http://www.thecomfortline.com

Kolcaba, K., & Kolcaba, R. (1991). An analysis of the concept of comfort. Journal of Advanced Nursing,

16(11), 1301-1310. http://dx.doi.org/10.1111/j.1365-2648.1991.tb01558.x

Kolcaba, K. Y. (2012, July 12). True Comfort [Blog comment]. Retrieved from http://

www.thecomfortline.com

McEwen, M., & Willis, E.M. (2011). Theoretical Basis of Nursing, (3rd ed.). Philadelphia: Lippincott.

Merkel, S. (2007). Comfort Theory: A Framework for pain management nursing practice.[PowerPoint

slides]. Retrieved from http://www.aspmn.org/conference/documents/sandramerkelfull.pdf

Nursing Theory. (2011). Retrieved July 14, 2013, from http://nursing-theory.org/theories- and-models/

Kolcaba-theory-of-

Tomey, A. M., & Alligood, M. R. (2010). Nursing theorists and their work. (7th ed.). Maryland Heights,

MO: Mosby Elsevier

Wardell, D. W. (2010). Measurement tools: Comfort touch. American Holistic Nurses Association, 2(2).

Retrieved from http://www.ahna.org/portals/4/docs/Research/ eNews/Connections_R-

eNews_1-10.htm

Weller, K. [KWeller Nursing Blog]. (1999, Summer). Scholarly [Blog comment]. Retrieved from http://

kweller99.wordpress.com/scholarly-work/

References Cont’d