Nursing Theory

Joumal of Advanced Nursmg, 1994, 19, 1178-1184

A theory of holistic comfort for nursing

Katharine Y Kolcaba MSN Insirt*dor, The Untverstty of Akron, College of Nurstng, Akron, Ohto, and PhD Shddent,

Case Wesiem Reserve Untverstiy, Cleveland, Ohto, USA

Accepted for publication 27 October 1993

KOLCABA K Y (1994) Journal of Advanced Nursing 1 9 , 1 1 7 8 - 1 1 8 4 A theory of holistic comfort for nursing Although the construct of comfort has been analysed, diagrammed in a two-dimensional content map, and operationalized as a hohstic outcome, it has not been conceptualized withm the context of a broader theory for the disaplme of nursing The theoretical work presented here utilizes an intra-achonal perspective to develop a theory of comfort as a positive outcome of nursing case A model of human press is the framework within which comfort is related to (a) mtervenhons that enhance the state of comfort and (b) desirable subsequent outcomes of nursing care The paper condudes with a discussion about the theory of comfort as a significant one for the disapline of nursmg

INTRODUCTION

The construct of comfort recently has been analysed, diagrammed m a two-dimensional conceptual map, and operahonahzed as a hohstic outcome (Kolcaba 1992) Comfort IS defmed for nursmg as the satisfachon (ac- tively, passively or co-operatively) of the basic human needs for rehef, ease or transcendence ansmg from health care situations that are stressful Nursmg case is designed to meet or contmue meetmg needs that fall under the domam of the disaplme

The purpose of this paper is to postulate relahorwhips between pahents' needs, nursmg interventions, comfort, and subsequent outcomes, from these relationships a theory of comfort is denved It eoneludes with a diseus- sion about the sigruficance of the theory of comfort for nursmg

Holistic outcomes and nursing

Nurse saenhsts are begmnmg to explore the effective- ness of broadly targeted interventions such as progres- sive musde relaxation, unagery and therapeuhc touch

Correspondence Katharine Y Kolcaba Instructor The University of Akron College of Nursmg, Akron Oho U325-3701, USA

These mterventions and others are mtended to ehcit positive whole person responses and thus would be measured most accurately by whole person out- comes Whole person outcomes entail positive or negative carry-over effects between aspeds of the person's response Whole person responses have been difficult to operahonalize because of their complicated content domams, possible carry-over effeds between components of the outcome, and the theoretical difficul- ties of mterpretmg a total score However, comfort is a hohstic outcome that accounts for whole person re- sponses and it has been previously operahonahzed (Kolcaba 1992)

The basic assumphons of the theory of comfort are that (a) human bemgs have hohshc responses to complex stimuli, (b) comfort is a desirable hohshc outcome that is germame to the disciplme of nursmg, and (c) human bemgs stnve to meet, or to have met, their basic comfort needs These assumphons underpm the theory of comfort and are m concert with an mtra-achonal perspechve m which the components of a whole person response are related and assessed comprehensively (Kolcaba 1992) ('lntra' designates withm, comfort is an outcome that consists of many aspeds that are related withm the domam of the construd)

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COMFORT AS A HOLISTIC OUTCOME

Comfort IS a holishc outcome because it designates a dynamic and multifaceted state of persons Thinbng about the outeome of eomfort requires an lntra-adional perspechve because mtervenhons that are mtended to enhance one or more aspects of comfort mdirectly enhance other aspects Consistent with an mtra-adional perspective, the magmtude of the total direct and mdu-ed effeds IS expected to be greater than the magmtude of effeds achieved by addressmg smgle aspects separately The extent to which comfort is hohstic is based on the perception of all the aspeds taken together at one time, because the effects m one have carry-over effects on other aspeets

Aspeds of eomfort have been anayed m a two- dimensional gnd (Koleaba 1992) They were denved from a review of arehaie, histoneal and eontemporary nursing literature as well as a review of literature from other disaphnes (medieme, psychiatry, ergonomics, psychol- ogy) (Kolcaba & Kolcaba 1991, Kolcaba 1992) A review of the previous work follows

Dimension one

The first dimension of comfort consists of three states, called relief, ease and transcendence Rehef is defined as the expenence of havmg had a specific need met (Kolcaba 1991) Rehef from needs is necesscuy for retum to former fundion or a peaceful death Ease is defined as a state of calm or eontentment (Koleaba 1991) Ease is the state of eomfort that is a neeessary eondition for effiaent perfor- manee Transeendenee is defmed as the state m eaeh ordmary powers are enhaneed (Paterson & Zderad 1976) The charactenstic that differentiates transcendence from the other two states, rehef and ease, is that the former designates the patient's potential for extraordmary performance as an end

Because each of the three states of comfort entail positive relationships to performance, theoretically they also imply a strengthemng component This feature of comfort provides the central rationale for promotmg the patient's comfort Comfort is a desirable outcome for nursmg care because it faahtates gams in physical and/or psychological performance, comfort also is essential for a peaceful death because a dymg person requires psychic strength for acceptance and release The states of conifort are often conhnuous, overlappmg and mterdependent

Dimension two

The second dimension of comfort is the contexts m which comfort occurs The contexts are denved fi-om the

nursmg hterature about hohsm (Kolcaba 1992) The first context IS physieal, pertammg to bodily sensations The seeond eontext is psyehospmtual, pertammg to the mtemal awareness of self, meludmg esteem, sexuality, meanmg m one's life, and relahonship to a higher order or bemg The thu-d context is soaal, pertammg to mterpersonal, fanuly and cultural relationships Also mcluded under social comfort are the firwnaal and mformahonal aspects of soaal hfe The fourth context m which comfort is expenenced is envirorunental, pertam- mg to hght, noise, ambience, colour, temperature and natural versus synthehe elements (Koleaba 1991)

When the two dimensions (three states and four eontexts) of eomfort are juxtaposed, the result is a two-dimensional gnd with 12 faeets of eomfort Items for eomfort questionnaires can be generated fi'om eaeh faeet that IS relevant to a speeifie research question In a pilot project, 48 items were constructed usmg the comfort gnd as a eoneeptual map (Koleaba 1992) In the instrumen- tation study that followed, the three states of eomfort (rehef, ease and transeendenee) oeeuned as fadors m eaeh of the four eontexts (physieal, psyehospmtual, environ- mental and soeial), as revealed by faetor analysis of 256 eompleted eonnfort questionnaires (Kolcaba 1992) The emergence of three factors, semantically conespondmg to the three states, oeeuned m eaeh of the separately analysed eontexts as well as m tottd eomfort

For eonvemenee m analysmg and diseussmg responses, the four eontexts were thought of as subseales of eomfort, eaeh eontammg items from the three states or faetors A total eomfort seore was aehieved by addmg the seores for eaeh subseale Total eomfort seores were useful for differentiatmg between known groups and for hypothesis testmg (Kolcaba 1992) (Fador analysis of mdividual subscales that compnse a multidimensional construct is an adaptation of traditional fador analysis that was previously apphed with umdimensional scales)

CONCEPTUAL FRAMEWORK

Construds gam sigmficance when they are related to other concepts An organizing framework for comfort had to meet the followmg cntena the framework had to be based on (a) needs ansmg from the environment of (b) whole persons for whom nurses could mtervene The effectiveness of (c) the mterventions had to (d) be perceived by the persons and (e) lead to subsequent outcomes The efforts of Munay (1938) and colleagues to synthesize major elements of personahty theones mto a coherent model led to a theory of human press that is consistent with the above cntena for a framework for

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ccwnfort Murray called his model 'orgamsmic' (holishc) and stated, 'Smce the parts of a person carmot be dissected physicaUy fi-om each other, and smce they ad together, ideally they should all be estimated simultaneously' (Munay 1983)

In the model of human press, a stimulus situahon is that part of the total envirorunent to which people attend and read durmg a given episode m their life Human development, whether positive or negahve, is determmed by the accumulated impressions about one's success or failure that are formulated durmg encounters with the situahon For nursmg, a stimulus situation can be regarded as any health care situahon

The shmulus situahon consists of alpha press and beta press Alpha press is tixe sum of negahve (obstrudmg) forces, posihve (faahtahng) forces, and mterachng forces Beta press is the person's percephon of the total effed of the forces m alpha press For nursmg, obstrudmg forces are the total negative stimuh ansmg from the health care situahon mdudmg side-effects of illness or treatments, noxious or threatemng environmental and soaal expen- ences, and emohonal sensahons such as fear, anxiety, powerlessness or aloneness The faahtatmg forces are nursmg mterventions designed to meet the needs that remam after the person's own reserves are depleted by obstructmg forces

Events also are mterpreted by the person m terms of the many mterachng forces that mfluence the outcome of percephon (Munay 1938) The mteradmg forces consist of the person's past expenences, age, athtude, emohonal state, support system, and the totahty of elements m the present expenence Munay states that, because these parts of persons cannot be dissected physically from each other and because they act together, ideally they all should be eshmated sunultaneously (Munay 1938) (With modem stahshcal methods, mteradmg forces can be operahonahzed as covanates m analyses of vanance or beta weights m regression models)

Needs Needs are defined as hypothehcal dnves or tensions mduced by obstructmg forces that promote adivihes designed to sahsfy the dnves (Munay 1938) The result IS an outcome that is opposite to the arousmg dnves If needs are met successfully by appropnate mtervenhons, the immediate outcome is perceived by the person as bemg relahvely posihve (Murray 1938)

As stated above, beta press is the person's perception of the total effect of the phenomena m the stimulus situahon The events m the situation are mterpreted as a temporal gestalt of shmuh which can be either threaten-

mg or proimsmg (Murray 1938) Beta press mvolves the appraisal of how weU the needs that anse from the obstructmg alpha forces are met by faahtatmg alpha forces m the stunulus situation If the outcome is posihve, evaluations accumulate and provide the expedation that other situahons will end posihvely, contnbutmg to a umtary trend (Munay 1938) Umtary trend is defined as behaviourai co-ordmation of activity towards the achievement of a desired effed

For nursmg, beta press is the person's perception of how well the nursmg mterventions (faahtatmg forces) meet the needs ansmg fi-om the health care situation (obstrudmg forces) for which the patient requires assis- tance m satisfymg Perceptions of comfort imply that negahve tensions have been reduced The person's per- cephon of an mcrease m total comfort leads to the remforcement of habits and goals that were successful m reducmg tensions Pattenis of successful habits and goals lead to an onentmg thema that provides direction for future achon A desirable thema that nursmg seeks to promote is a health thema defined as a general onentation to health-seekmg behaviours (Schlotfeldt 1975) A re- aprocal relationship exists between health-seekmg be- haviours and comfort because health-seekmg behaviours also can enhance comfort

Health-seekmg behaviours are conceptualized as mter- nal or extemal m this theory of comfort Intemal behav- iours happen at the cellular or organ level, such as healmg or urunune funchon Extemal behaviours are related to the outer world, such as self-care achvihes, funchonal status and health mamtenance programmes The extemal behaviours named self-care, fundion, health mamtenance programmes, and lengths of hospitalizahon are exphat in Sdilotfeldt's model (1975), while mtemal behaviours are imphat under the categones of survival and fertdity Schlotfeldt also mcludes dignified death m her model under the eategory of health Consistent with holism, eonsaous thought and subeonsaous frame of mmd mfluence health-seekmg behaviours If the person is mcapable of consaous thought, the nurse can look for extemal signs of comfort/discomfort, and promote greater comfort when possible to enhance healmg or a peaceful death

The relahonships between the concepts of human press and nursmg oncepts are depicted m Figure 1 Note the reaprocal relahonships between the shmulus situahon and human development

THEORY OF COMFORT The theory of hohshc comfort is a component erf a normahve and descnphve theory for nursing care The

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Figure 1 The eoneeptual framework for a theory of eomfort

Stimulus situabon •«- Human development

Alpha press- "•Unitary trend

Obstructing + Faalitating + Interacting—«> Perception' forces forces forces

• Thema (health)

V Health care + Nursing -f- Intervening — • Comfort •«-

needs interventions vanables i -*• Health-seeking behaviours

Physical

Psychospintual

Environmental

Social

Internal sehaviours

\

Peaceful death

N External

t>ehaviours

theory is that outstandmg needs anse from the stunulus situation and cause negative tension Negative tension represents an imbalance that exists when obstrudmg forces outweigh the facilitatmg forces at hand The needs for comfort, m any asped of the content domam, are identified and mtervenhons are targeted towards those speafic needs, movmg tension m a positive direction The patient perceives whether the tensions are changed by the mtervention(s), the nurse judges the extent to which the desu-able outcome of comfort has been met by assessmg the pahent's percephon of comfort objectively or subjedively

An lnaease in comfort mdicates that negahve tensions are reduced and posihve tensions are engaged Posihve tensions lead to a umtary trend of construchve behav- iours Construdive behaviours of mterest to nursmg are health-seekmg behaviours and these behaviours stem directly fi'om the health thema The nurse faahtates the outcome of comfort because theorehcally it is related to mtemal/extemal health-seekmg behaviours or a peaceful death When prachsed, health-seekmg behaviours can cause greater comfort

Evidence (or the relationship hetween comfort and health-seekit^ hehaviours

Contemporary nurse thinkers contmue to explore the significance of the construct comfort for nursmg SdJotfeldt (1981) states that a focus of nursmg is to assist dients to achieve optimal heaith, function, comfort and self-fulfilment The Amencan Nurses' Assoaation's

posihon statement on promotion of eomfort m dymg patients states that the m£un goal m the nursmg care of dymg pahents should be maximizmg comfort as is consistent with the desu-es of the pahent (Hockenberger 1992)

Richeson & Huch (1988) daim that eomfort is nursmg's umque eontnbuhon to health eare, and Morse (1992) states that the ultimate purpose of nursmg is to promote eomfort Gropper (1992) adds that, by promot- mg eomfort, nurses are promotmg health The last asserhon, though not supported m her paper by empineal teshng, provides the theoretieal rationale for nurses to assist patients in adueving or enhancmg comfort

Empincal evidence for a hnk between mtemal and extemal health-seekmg behaviours and comfort is scant at the present tune The rejison for the present state of knowledge about comfort is that the construd has only been recently operationalized (Kolcaba 1992) and the theoretical linkages to health-seekmg behaviours are proposed here for the first time However, empincal research supports the extemal consistency between com- fort and some health-seekmg behaviours The research that IS available for this purpose is presented bnefly m the followmg paragraph

In the field of psychoneurourununology, posihve cor- relahons have been shown between comfort achieved by relaxation and unagery to enhanced immune parameters (Jasnoski & Kugler 1987, McOelland 1988, Zadianzea ei al 1990, Groer 1991) Sumlarly, comfort achieved by relaxahon and imagery have desirable effects on blood pressure (Pender 1985), pulse (Guzzetta 1980) and

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respirahons (Alexander ei al 1979 In a study of abortion, pahents had mcreased comfort after partiapahng m pleasant unagery (Wells 1989) In efforts to mcrease athletic performance and endurance, comfort achieved by imagery was related posihvely to basketball skills (Kendall et al 1990), muscular endurance urespechve of mood state (Lee 1990) and strength (Murphy ei al 1988) Funchonal outcomes were enhanced by the comfortmg effects of relaxahon m adults with traumahc head mjiuies (Lysaght & Bodenhamer 1990), while copmg strategies were enhanced by effeds of a smular mtervenhon m children (LaMontagne ei al 1985), students with test anxiety (Suinn 1972), and m adults with mulhple sderosis (Foley ei al 1987) The mtervenhons ated above are holishc and the outcomes are congruent with mtemal or extemal health-seekmg behaviours These studies and others lend encouragement to nurse researchers who ask the queshoa 'Why comfortT

The significance of a theory of comfort

Comfort has been called a distmguishmg charactenshc of the nursmg profession (Fenell & Fenell 1990), yet heretofore it has not been conceptualized withm a theory for nursmg For this reason, confifort is of mterest Secondly, a theory of comfort can be used to explam and predid phencmiena of mterest to nursmg Tlurdly, com- fort as a psychological phenomenon is of mterest m its own nght

The philosopher of saence. Popper (1959), dehneated charactenshcs of significant theones Ellis (1968) pre- sented these charadenshcs to nurse researchers as guides to developmg theones, statmg that nursmg theones should be about phenomena observed m their own prachce These diaractenshcs of sigmficant theones are presented here so that the adequacy of the theory of comfort can be judged In assessmg the theory of comfort, contrasts will be drawn between the outcome of comfort and the less hohshc outcomes of pam and anxiety

The first charadenshc of a significant theory is its scope (Popper 1959, Ellis 1^8) A theory of comfort is of broader scope than a theory of pam or fahgue because comfort subsumes stahshcal generalizahons fi-om the study of pam and fahgue and helps explam them The extensions of theoretical terms withm the theory of comfort designate pam and anxiety phenomena as they mterad with other realities sudi as psydiological trans- cendence ki this way, a thewy of comfort has posihve components that theones of psun, etc, do not have, thus, its explanatory powers are greater ttian for the other

theones A good theory of comfort, therefore, promises to have greater explanatory power than theones of pam and anxiety

A second measure of the adequacy of saentific theones IS then- predichve success (Popper 1959, Elhs 1968) We will only know if the theory of comfort has more predichve success than competmg theones by testmg it But the theory provides dear direchon for testability Fu'st, the theory generates hypotheses about mterven- tions that enhance hohstic comfort and, second, the theory generates hypotheses about the relahonsbps between comfort and health-seekmg behaviours The theory is emmently testable and its degree of predichve success readily determmable

The usefulness of a theory for chmcal pradice is the third charadenshc of sigruficant theones (Elhs 1968) Some phenomena occur rarely or require exotic con- dihons to brmg them about Comfort phenomena, by contrast, are observable and ever present m the therapeu- hc context apart from expenmentation It is a small step to brmg these phenomena under expenmental control

A fourth charadenshc of significant theones is com- plexity, meanmg that mulhple relationships among smgle vanables or the complexity of a smgle vanable are addressed (Elhs 1968) The theory of comfort meets both of these cntena, while mdudmg a minimum of imobserv- ables Causation of comfort is more complex than for relief of pam or anxiety, so more complex mtervenhons or sets of mtervenhons are required for enhancmg comfort Because such mtervenhons are targeted broadly, they approximate therapeutic completeness, whereas mtervenhons for pam alone would require adjund mtervenhons to adueve completeness

A fifth attnbute of sigruficant nursmg theones is that they utihze termmology that is meanmgful and relevant for nursmg Comfort is a familiar term to nurses, yet a sdiema for understandmg the complexity of the term and its relationship to mtervenhons and subsequent outcomes has not been previously set forth With the present schema and theory, nurses can design mtervenhons to enhance comfort and measure the rfechveness of their mtervenhons upon the outcome of comfort Moreover, pahents also use comfort to descnbe their responses and condihons, and other health care personnel use the term to descnbe pahents' condihons The term is generally understood to be broad, important, posihve and related to subsequent desirable behaviours

Lastly, a measure of the adequacy of saentific theones IS their urufiabihty with other estabhshed theones (Nage' 1979, Popper 1968) Because the theory erf comfort is umfiabie witti theones of pam and anxiety, it is desirable

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for nursmg researdi because it is an mdusive yet sucanct outcome Comfort takes the place of many separate measurements of more narrow outcomes, yet it is ncher than many separate measurements because it accoimts for the lntra-action between aspeds of comfort The outcome of comfort is nurse-sensitive because it is influenced by nursmg mterventions And the theory of comfort is potentially umfiabie with theones of health and well- bemg that are yet to be developed

CONCLUSION

The imderstandmg of comfort directly gvudes nursmg care that is melusive of physieal, psyehospmtual, soeial and environmental mtervenhons A senes of mterven- tions that target hohshe eomfort, such as tahng the pahent to the bathroom, reassunng him about a treat- ment, givmg him mformation, and deanmg up his room, ean be rendered dunng one nurse-patient eneounter after a bnef assessment of eomfort states m eaeh eontext An aetual or potenhal defiat m any eontext tnggers a eonrfort measure Thus, an unhappy, unhealthy or unwell pahent ean be made more eomfortable, or a patient's diseomfort that is not desenbed as pam ean be diseemed and targeted In this example, eomfort is mversely related to a host of diseomforts and thus it is a 'missmg pieee' m a theory of nursmg praehee

The theory of eomfort provides direetion for nursmg praehee and researeh beeause it entails an outeome that IS measureable, hohstie, positive and mirse-sensitive Chmaans have the eapabihty jmd diseiplmary mterest to effeet eomfort, and patients look to nurses for help m aehievmg eomfort Beeause the eonstruet represents an mtra-adive phenomenon, an operational defimtion linked to theory is sigmfieant for explammg and predietmg the neh relahonships among the reahties of eomfort

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