NURSING THEORY

C O M F O R T    T H E O R Y 

BY KATHARINE KOLCABA

PRESENTED BY: UPOU N207 - GROUP E

DEFINITION OF COMFORT

Comfort is the fundamental goal of nursing profession. Each and every time a nurse attends to her patient, comfort is the initial consideration. A nurse is regard as effective when she makes her patient comfortable.Several of the scientific amendments in the medical and nursing practice in the present time have directed more on methods and outcome benefits than on comfort of the patient. Kolcaba defined comfort within nursing practice as “the satisfaction (actively, passively or cooperatively) of the basic human needs for relief, ease, or transcendence arising from health care situations that are stressful.” She explained that client’s needs to take place from a stimulus situation and can cause negative tension. Increasing comfort can result in having negative tensions reduced and positive tensions engaged. Comfort is viewed as an outcome of care that can promote and facilitate health-seeking behaviors. It is speculated that increasing comfort can augment health seeking behaviors, as stated by Kolcaba, “if enhanced comfort is achieved, patients and family members are strengthened to engage health-seeking behaviors.” This can further develop comfort.

According to her theory; patient's comfort existed in 3 forms:

RELIEF, EASE AND TRANSCENDENCE

Relief: the state of having a discomfort mitigated or alleviated.

Ease: the absence of specific discomfort.

Transcendence: the ability to "rise above" discomforts when they cannot be eradicated or avoided.

BACKGROUND OF THE THEORIST

•  Born in December 28,1944 Katharine Arnold (Kolcaba) born in Cleveland, Ohio

• 1965 Graduated with diploma of nursing from St. Luke’s Hospital School of Nursing

• 1987 Graduated with RN MSN from Frances Payne Bolton School of Nursing, Case Western Reserve University (CWRU)

• 1987 Began teaching at The University of Akron College of Nursing

• 1991-2001 Development of Comfort Theory

• 1991 Published article: An analysis of the concept of comfort. Journal of Advanced Nursing.

•  Analysis of the word “comfort,” from its Latin roots to the meaning in everyday language. Article also includes how the word has been used in the history of nursing, from Nightingale (1859), Harmer (1926), Goodnow (1935), Orlando (1961), Watson (1979) and Hamilton (1989)

• 1991 Published article: A taxonomic structure for the concept of nursing. Journal of Nursing Scholarship.

• Began development of cell grid diagraming types of comfort and context in which comfort occurs

• 1994 Published article: A theory of holistic comfort in nursing. Journal of Advanced Nursing.

• Began developing a diagram of the aspects of comfort. Article also includes six defining factors that examine why comfort is a significant middle range theory

• 1995 Published article: The art of comfort care. Journal of Nursing Scholarship.

• Describes benefits of including comfort care into practice. Article includes testimony from a student nurse who applied comfort care to practice. Began development of comfort as a standard outcome of nursing

• 1997 Graduated with PhD Nursing from Case Western Reserve University

• 1997 Developed web site called The Comfort Line 

• Name comes from a method of determining levels of comfort in children in which a vertical 10cm line is drawn and patients rate their level of current comfort between the statements of “ I feel as comfortable as possible” and “I am as uncomfortable as possible”

• 2000 Published article: Empirical evidence for the nature of holistic comfort. Journal of Holistic Nursing.

• Comfort Theory tested and analyzed for validity

•  2001 Published article: Evolution of the mid-range theory of comfort for outcomes research. Nursing Outlook.

• Article written to be a guide on the evolution of comfort as a theory and describing how comfort can be tested and adapted to the rapidly changing health care environment

• 2003 Published book Comfort Theory and Practice: A Vision for Holistic Health Care and Research

• 2005 Published article: Comfort Theory and its application to pediatric nursing. Pediatric Nursing.

• Article applies Comfort Theory to pediatrics, while explaining the current approach to pediatrics as attempting to relieve discomfort

•  2007 Retired from full time teaching, continues to teach part time while developing and researching Comfort Theory

• At present volunteering with the American Nurses Association and The Honor Society of Nursing

DEVELOPMENT OF A THEORY

In the 1980's, a modern inquiry of comfort began. Comfort activities were observed. Meanings of comfort were explored. Comfort was conceptualized as multidimensional (emotional, physical, spiritual). Nurses provided comfort through environmental interventions.

    It was in this decade that Kolcaba began to develop a theory of comfort when she was a graduate student at Case Western Reserve in Cleveland, Ohio. She is currently a nursing professor at the University of Akron in Ohio.

Kolcaba's (1992) theory was based on the work of earlier nurse theorists, including Orlando (1961), Benner, Henderson, Nightingale, Watson (1979), and Henderson and Paterson. Other non-nursing influences on Kolcaba's work included Murray (1938). The theory was developed using induction (from practice and experience), deduction (through logic), and from retroaction concepts (concepts from other theories).

The basis of Kolcaba's theory is a taxonomic structure or grid that has 12 cells (Kolcaba, 1991; Kolcaba& Fisher, 1996). Three types of comfort are listed at the top of the grid and four contexts in which comfort occurs are listed down the side of the grid. The three types are relief, ease and transcendence. The four contexts are physical, psycho-spiritual, sociocultural and environmental.

 MAJOR CONCEPTS OF THE THEORY

  Person

    A person can be an individual, member of a family, community, institutions, or communities who is in need of health care. She described that comfort is existing in 3 different forms, relief, ease and transcendence, and each forms are being achieved primarily by people who are involved during or while caring for the person.

    In a clinical setting relief is a result of the effective delivery of healthcare by the health care providers, and their common goal is to provide comfort through comfort interventions to the person or individual who experiences discomfort, the nurse uniquely functions to provide comfort to the patient and can be manifested through the following; directly assist the patient in his/her needs, like in the administration of prescribed medication, comfort in the nurse also plays an important role as the patient advocate who is concerned with patient education about the use of health plans and how to obtain needed care. Thus relief promotes self-reliance to the client. Other comfort measures can also help ease a distress and help the patient to transcend the experience or condition.

  Health

     Health is viewed as the optimum functioning of the patient.   It is defined as “the person's state of well-being, which can range from high-level wellness to terminal illness.  It is considered to be optimal functioning as defined by the patient, group, family or community.

  Nursing

     

    Nursing is described as the process of assessment, setting of goals, implementing interventions in reference to the patient's comfort needs; it also involves continuous reassessment in order to evaluate patient's comfort after the nursing interventions. Assessment may be objective, such as observing improvement of vital signs or subjective as patient's verbalization of level of comfort.

  Environment

    

    Anything in the surroundings that a nurse or loved ones can manipulate/utilize to enhance comfort of the patient-it may be family or institutional surroundings.

• Environmental comfort “Pertaining to external surroundings, conditions, and influences”. (Kolcaba 1997)

• Manipulating the “color, light, ambience, temperature, views from windows, access to nature, natural versus synthetic elements”. (Kolcaba 1991)

• Decreasing the level of noise, cleanliness of the room which includes the rest of the hospital staff in maintaining the cleanliness of the patient’s room.

• Integrating old patterns of social graces and behaviors so that patients could fit with other residents during special programs.

 

  CHARACTERISTICS OF A THEORY

  The following are the characteristics of the Comfort Theory devised by     Kolcaba:

1. The theory emphasizes the active participation of the patient and family      The patient and the family's participation are integral in the identification of the needs for comfort or discomforts being experienced. More than the assessment of the needs for comforting measures of intervention, the patient and the family are also actively participating with the plan of care for a more positive outcome and early discharge.

2. Comfort interventions are more inclined with preventing discomforts rather than treating already present discomforts.     The importance of keen observation, identification and understanding of patient's needs for comfort will be a very useful skill for this will permit detection of situations that may further increase or add to present discomforts. Preventing such would be much easier than treating them when they are being expressed.

3. Comfort is measurable on most patient populations.
     Comfort can be expressed objectively with the use of scales, subjective expression of comfort can be charted. Through this, comforting interventions can be evaluated for effectiveness.

4. The Comfort Theory aims to promote a value-added outcome rather than a negative one.

     Another characteristic is that the comfort theory aims to promote value-added outcomes. Meaning, the goal of the nursing interventions is the alleviation of discomfort and thus increasing comfort. This is a positive connotation compared to nursing researches investigating on what is "lacking" or negative in the nursing practice.

KEY CONCEPTS

1. Health Care needs are those needs identified by the patient and the patient's family.

2. Comforting Interventions are nursing actions intended to address a certain comfort need of the patient. These nursing actions can be physiologic, social, financial, psychological, spiritual, environmental or physical.

3. Intervening Variables are interconnecting forces that affects the patients perception of comfort. These factors are inherent to the effected person and practitioners have little control over it like, past experiences, age, attitude, emotional state, support system, prognosis, and financial status.

4. Enhanced Comfort is the immediate end result of nursing care. Theoretically, as comfort measures are delivered in a consistent way, it increase comfort levels thereby also promoting desired health seeking behaviors.

5. Health Seeking Behaviors are behaviors of a patient in an effort to find health. It can be:

• Internal-healing, immune function, number of T cells, etc.

• External-health related activities, functional outcomes

• Peaceful Death

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

• Best Policies are protocols and procedures designed by the institution for overall use after collecting evidence.

• Best Practices are those protocols and procedures developed by an institution for a specific patient or family after collecting evidence

 CONCEPTUAL FRAMEWORK

A need must exist identified by patient or family, based on this need, nurse will act and perform comforting measures overcoming any intervening variables leading to enhanced comfort. Moreover, desired health seeking behaviors are also increased if enhanced comfort are delivered in a consistent manner. Institutional integrity affected by best policies and best practices likewise improve the way patients behave regarding their health in the same way positive patient's behavior improve institutional integrity.

PROPOSITIONS

• Nurses recognize the unmet comfort needs of the patient from the current support system.

• Nurses design interventions to meet the identified needs.

• The Intervening Variables are used in designing interventions and mutually agreeing upon reasonable immediate (enhanced comfort) and/or subsequent (health seeking behaviors) outcomes.

• Patients are committed in health seeking behaviors once Enhanced Comfort is attained.

• When patients are cooperatively seeking health behaviors fully, institutions are positively motivated to facilitate highly health seeking behaviors.

• When interventions are delivered in a caring manner and are effective, and when enhanced comfort is attained, interventions are called "comfort measures"

ASSUMPTIONS

• Human beings have holistic reaction to complex stimuli.

• Comfort is the projected holistic outcome of an efficient nursing care.

• Human beings work hard to meet their basic comfort needs.

• Patients are strengthened when comfort needs are met.

STRENGTHS

• Comfort theory by Katharine Kolcaba was first developed in 1990s and considered to be modern and relatively new.

• Kolcaba is still actively teaching and expanding her theory. She uses collaborative technologies and social media tools to reach out the modern nurses and nursing students regarding the use of comfort theory.

• It is simple, understandable, relevant to the nursing profession.

• In the past, the term “comfort” was subjective. After Kolcaba’s definition of comfort, it became defined, used in concepts and became a theory.

• Her theory aims to reduced costs of care, reduced length of hospitalization, enhanced financial stability and increased patient satisfaction by giving comfort measure to the client, family and their environment.

• She did not rely on past nursing theorist work to design her theory. She only relied on past definitions of comfort.

• The comfort theory can be applied to patients of all ages, cultures backgrounds and communities. It is also applicable to patients and family in all settings such as in the hospital, clinic or home.

• The theory can be used in nursing education. It can be used in comforting the learner or student in an educational environment.

• Her theory is beneficial to the patient, family, the nurse and those who are giving comfort to the patient. 

LIMITATIONS

• The definition of comfort is constantly evolving and expanding to include and encompass a wider array of health behaviors. Expanding of theory can aid to deal with all these health behaviors modifications.

• Kolcaba did not include how health-seeking behaviors can improve companies where the patients may work, insurance companies, local clinics and other health institutions.

• She fails to expand adequately on how comfort measures can be used outside of the hospital setting.

• Kolcaba does not discuss in her core definition of the theory, the importance of providing comfort of the nurses. She failed to verbalize the benefit of using comfort to those who are giving the care. When the comfort of nurses is enhanced, patients and the family are more satisfied. Thus, these make the nurses contented and boosting their self esteem and job satisfaction. They become more committed to the institution and provide better health care.

• Her theory is patient and family centered. Kolcaba expressed most of the advantages of this theory to the patient and family only excluding the nurse and other health team members who are giving the care. 

APPLICATION TO THE NURSING PRACTICE

Nursing Process on Comfort

The following tables shows the application of the theory of Comfort to the Nursing process.

   

Nursing Process	Application to Comfort Theory
Assessment - assessing the patient's comfort needs - objective- observation of wound healing - subjective- asking the patient if he or she is comfortable	Physical- Comfort needs real to bodily sensations and the physiologic problems associated with medical diagnosis and condition. Psychospiritual- Comfort needs relate to the internal awareness of self, including esteem, concept, sexuality, and meaning in one’s life. They can also include the person’s relationship to a higher or being. Social- Comforts needs relate to interpersonal, family and social relationships. Environmental- Comfort needs relate to the external background of human experience and can include light, noise, ambience, color, temperature, and natural versus synthetic elements. They may also include culturally specific food and language. (Kozier, 2004)
Planning - developing a design of comfort measures	Depending on the area and degree of discomfort will are goals to be achieved. Specific comfort needs of a patient are met as Kalcoba implied, for example, the relief of postoperative pain by administering prescribed analgesia, the individual experiences comfort in the relief sense. If the patient is in a comfortable state of contentment, the person experiences comfort in the ease sense, for example, how one might feel after having issues that are causing anxiety addressed. Lastly, transcendence is described as the state of comfort in which patients are able to rise above their challenges.
Intervention - implementing appropriatenursing care plans and addressing those needs	Comforting actions or measures is providing of either or both direct or indirect interventions to address the discomfort. Indirectly by maintaining the environment suitable for resting, coordinating with other health personnel’s with regards to the activities and supporting the significant others. Those measures are initiated when the nurse perceives that the client is distress or comforting needs is necessary. While on direct comforting is a simple physical action such as holding their hands open cannula insertion, providing warm blanket or applying lotion on dry skin. However knowledge and skills are necessary to perform other comforting measures like, infection, airway clearance, managing pain etc. The measures encompass the clients psychospiritual by talking in soothing manner, acknowledging and accepting their feelings; Socially by encouraging the family and friends to visit regularly and Environmentally by allowing ample light and ventilation.
Evaluation - evaluating the patient's comfort after the care plans have been carried out - reassessment of comfort levels after implementation	As planned, the discomfort to have ease, relief or transcendence will be our client’s response. We will able to a identify it as objective by observation or subjective as the patient experience the comfort.

Johaira, an 11-year-old Saudi female patient, diagnosed with Acute Lymphocytic Leukemia, was admitted in a semi-private ward in the Oncology Unit. She is about to receive her combination chemotherapy when the nurse noticed her alone and crying silently while lying on her bed.

	Relief	Ease	Transcendence
Physical	Mouth sores; Nausea and vomiting; Neuropathy; Diarrhea/Constipation	Comfortable resting position which facilitates sleep and relaxation to deter fatigue	Patient resumes most of her ADLs with all the side effects controlled
Psychospiritual	Anxiety; Alopecia; Radiation recall	Anticipation of social stigma towards baldness and skin problems	Actual need for reassurance and support from the healthcare team and significant others
Environmental	Cold room; Patients were cohorted in a single room	Deviation from aseptic technique and standard precaution; Lack of privacy	Need for calm and positive atmosphere which strictly adheres to infection control guidelines; Need for privacy for personal hygienic routine care
Sociocultural	Absence of family	Failure of effective communication due to language barrier	Need for familial support and reinforcement

Case Study Taxonomic Structure of Johaira's Comfort Needs

When nurses are committed to provide satisfyingly holistic comfort care, needs for relief, ease, and/or transcendence are identified routinely throughout the practice. Assessment could go back and forth to relief, ease, and transcendence until the main focus of health care will be identified and be addressed. However as the patient’s condition varies, it is essential that the nurse identify correctly which context that the patient and his family’s concerns entails priority of comfort measures. When comfort needs are addressed in one context, total comfort is enhanced in the remaining contexts. Nurses are the mighty front liners in the health care institution. As active participants on strengthening and enhancing comfort of every patients, they engage themselves on activities to achieve and maintain a certain level of their optimal health. They tend to be the advocates of patients, leading them to be the patients’ first link to normalcy once they face a frightening or painful experience. Coaching and reassuring the clients towards recovery, safety, and rehabilitation, and these activities are identified by Scholtfeldt (1975) as health seeking behaviors(HSB). Kolcaba (2001) states that HSBs are further related to desirable institutional outcomes such as decreased cost, improved family and nurse satisfaction, earlier discharge and low readmission rates.

Comfort Interventions	Examples	Agent
Standard Comfort	·         Assessment for development and complaints of the side effects of the chemotherapy (may use Comfort daisies, Comfort behavior, Checklist, etc.); ·         Frequently check vitals and watch out for fever or signs of nosocomial infections ·         Administer medications or treatments to relieve the side effects of chemotherapy	Nurse/Consultation with family and doctors
Coaching	·         Avoiding the word "pain" upon assessment, obtaining data, and rendering health teaching for a pediatric patient ·         Initiate patient and family education as needed	Doctors/Nurses Consultation with family
Comfort Food for the Soul	·         Practice guided imagery to eliminate factors that could increase physical discomfort ·         Provide privacy as Marie is entering pubescent stage when she will be concerned about her body image and privacy	Nurse/Family

Comfort interventions have three categories: (a) standard comfort interventions to maintain homeostasis and control pain; (b) coaching, to relieve anxiety, provide reassurance and information, instill hope, listen, and help plan for recovery; and (c) comfort food for the soul, those extra nice things that nurses do to make children/families feel cared for and strengthened, such as massage or guided imagery. (Kolcaba, 2003)

CONCLUSION

In conclusion, Comfort theory by Katharine Kolcaba was first developed in 1990s, thus, considered to be relatively new.

We, the advocates of this Comfort Theory, believe that comfort is indeed the product of holistic nursing care. The more satisfied and comfortable the patient is, the more satisfied nurses are in the care that they have provided and the more there is institutional integrity.

It is a mid-range theory that is simple and easy to understand. It is multidisciplinary and can be applied in various settings.
However, its uses, importance and application to nursing as well as other disciplines cannot be ignored. 

This theory does not only benefit the patient, but also the nurse as well as the institution.   Comfort, according to Kolcaba is the product of holistic nursing art; It is what nurses desire for their patients. Comfort comes in three forms: relief, ease and transcendence. Relief is said to be provided if patient’s specific need is met. Example is giving of pain medicine to post surgery patient who is in pain. Ease is achieved if the patient is in the state of calmness and contentment. 

It is focused more on the environment and psychological state of the patient, example of which is addressing the anxiety issues of the patient and making him or her at ease. Finally, transcendence comfort is achieved once the patient has risen above the challenges. In in this state, the patient is said to have coped already with the discomfort.
The four contexts in which patient comfort can occur are: physical, psychospiritual, environmental, and sociocultural.

The comfort measures that a nurse can use to address the specific need of a patient can be in the form of technical care, coaching and comfort food for the soul. Technical care includes those measures to reduce pain and maintain homeostasis. Coaching involves active listening and relieving anxiety. Comfort food for the soul fortifies the person through back rubs, guided imagery, music therapy and hand-holding.

Nursing involves the intentional assessment of comfort needs, by observation and by asking the patient, while taking into considerations the intervening variables that are not likely to change and which nurses has little control over; designing of comfort measures to address those needs; and lastly, the reassessment of comfort levels after implementation. If comfort has not been achieved, nursing care plan must be changed accordingly or the patient’s needs must be reassessed. Comfort is what the patient state it is and not only merely the nurse sees it as.

The first part of the theory is focused on increasing the desires comfort level. Pain relief falls on this part. Kolcaba believes that when a patient achieves a certain level of comfort, his sense of achievement and health-seeking behavior is positively affected. The patient then feels strengthened and more likely to engage in positive health-seeking behavior which can be internal (T cells, immune function healing), external (health related activities), or peaceful death. This is the second part of the theory. The third part of the theory constitutes the relationship among comfort, health seeking behavior, and institutional integrity.

Institutional integrity, as defined by Kolcaba, is the value, financial stability, and wholeness of health care organizations at the local, regional, state, and national levels. Institution include Public Health agencies, Medicare and Medicaid programs, Home Care agencies, Nursing Home consortiums. Enhanced hospital integrity happens when specific patient’s needs have been met, hospital stay is shortened, patient is satisfied, and there is cost saving and decreased morbidity rates. When patients do better, hospitals do better as well and vice versa.Comfort is a universal concept and the opposite of which is suffering. Kolcaba believes that comfort care is efficient and satisfying both to the patient and the nurse.

She developed the the general comfort questionnaire developed to measure holistic comfort in the hospital and in the community settings. According to Kolcaba, holistic comfort is defined as the immediate experience of being strengthened through having the needs for relief, ease, and transcendence met in four contexts of experience. She also emphasized the documentation of patient’s comfort and how those needs were addressed.

The concept of comfort accounts for that quality in which the patient describes " feeling better".Comfort is understood readily by persons from all walks of life and its complexity can account for the whole patient response.

It is an ELEGANT, FLEXIBLE,  and HIGHLY useful concept for nursing.

REFERENCES

http://www.thecomfortline.com/home/enhancepatient.html


http://www.thecomfortline.com/home/faq.html


http://www.ehow.com/list_6821213_main-points-nursing-comfort-theory_.html


http://nursing-theory.org/theories-and-models/kolcaba-theory-of-comfort.php


http://essaysforstudent.com/essay/Katharine-KolcabaS-Theory-Comfort/28846.html


http://currentnursing.com/nursing_theory/comfort_theory_Kathy_Kolcaba.html


http://currentnursing.com/nursing_theory/comfort_theory_Kathy_Kolcaba.html


http://currentnursing.com/nursing_theory/comfort_theory_Kathy_Kolcaba.html

http://www.slideshare.net/KathyKolcaba/erin-kolcaba

Kolcaba, K. (1997). The comfort line. Retrieved from www.uakron.edu/comfort


Kolcaba, K. (2001). Evolution of the mid range theory of comfort for outcomes research. NursingOutlook,   49(2), 86-92.


Kolcaba, K. (2003). Comfort theory and practice: A vision for holistic health care and research. New York, NY: Springer Publishing Company.


Schlotfeldt, R. (1975). The need for a conceptual framework. In P. Verhonic (Ed.) Nursing research (pp.    3-25). Boston: Little & Brown.

Wolf, Alyssa A. Comfort Theory and its Application to an Institution Wide Approach. University of Virginia.