WEEK 4Kolcaba’s Comfort Theory to the case study

33

Katharine Kolcaba: Theory of Comfort

Katharine Kolcaba

(1944-Present)'

April Bice*

"In today's technological world, nursing's historic mission of providing comfort to patients andfanily memnbers is even more important. Comfort is an antidote

to the stressors inherent in health care situations today, and when comfort is enhanced, paticnts and families are strengthened for the tasks ahead. In addition,

urses feel more satisfied with the care they are giving"

(K. Kolcaba, personal communication, May 16, 2020)

graduate school. In 1987, she graduaied in the first RN to

MSN class at Case Western Reserve University (CWRU)

Frances Payne Bolton School of Nursing, yitt a specialty in

gerontology. While in school, she job-shared e head nurse position on a dementia unit. It was in is Tactice context that she began theorizing about the ouicome of patient

In the unforeseen and unforgettable time of a coronavirus disease 2019 (COVID-19) pandemic in 2020, nurses have

provided comfort in ways they never thought they would. In 2019 the World Health Organization declared 2020 as the year of the nurse, and that is exactly what it became. Across the globe, nurses have engaged in substituting for

family members and friends. They provided comfort in various ways, even in times of death, when husbands,

wives, mothers, fathers, sons, and daughters could not hold their loved ones due to quarantine. This substitution

comfort was coupled with the growing need for nurses to also be comforted and transcend in a modern world going

through an age-old threat-a novei virus.

comfort. Kolcaba joined the faculty at the University of Akron

College of Nursing after graduating with her master's

degree in nursing and gained an American Nurses Asso- ciation (ANA) certification in gerontology. She returned to

CWRU to pursue her doctorate in nursing on a part-time basis while continuing to teach. Over the next 10 years, she used course work in her doctoral program to develop and

explicate her theory in a series of published articles, now summarized in her book (Kolcaba, 2003). It is in this text

that Kolcaba describes and explains, in detail, the concepts, propositions, and application of comfort theory.

Dr. Kolcaba is retired from the University of Akron as

an emeritus associate professor. Her nursing interests

include interventions for and documentation of changes in comfort for evidence-based practice. She resides in the

Cleveland area with her husband, where she enjoys being near her grandchildren. She represents her company, Ihe Comfort Line, to assist health care agencies implement the theory of comfort on a system-wide basis. She is also

CREDENTIALS AND BACKGROUND

OF THE THEORIST

Katharine Koicat2 orr d rducated in Cleveland,

Ohio. In 1965 ste eVE á in6 in nursing, and she

practiced part time i many :31s in nedical-surgical nurs-

ing, long-term cae, and 101ne Cre belore returning to

*Previous author Thérèse Dowd.

Photo credit: Barker's Camera Shop, Chagrin Falls, OH.

526

underand coordinate

nemberof the

inator of a local parish nurse program

ANA. Kolcaba continues to work with

as a consultant at all cducation levels

USE OF EMPIRICAL EVIDENCE

he seeds of modern inquiry about the outcome of comfort

Were sown in the late 1980, marking a period of collective,

Dul separate, awareness about the concept of holistic Com-

lort. Hamilton (1989) made a leap forward by exploring the meaning of comfort. The theme that emerged

most was

relief from pain, but patients also identified good position- ng in well fitting furniture and a feeling of being indepen-

dcn, encouraged, worthwhile, and useful. Around the

same time that Kolcaba was working to conceptualize com-

fort, other authors were als0 exploring the concept. One

8roup of authors argued that while "the central role of

nursing is to provide comfort, the attainment of total com- fort in nursing is not possible" (Morse et al., 1994, p. 189).

Furthermore, Morse, (1992, p. 92) argues that "the ultimate

purpose of nursing is to promote comfort for the client rather than to simply care for the patient

In these examples, comfort is positive and achieved with the help of nurses. "Intuitively, comfort serves as a code for

life" (T. Dowd, personal communication, May 26, 2020).

The concept varies semantically as a verb, noun, adjective, adverb, process, and outcome. Kolcaba used ideas from three early nursing theorists to synthesize or derive the

types of comfort in the concept analysis (Kolcaba, 2003; Kolcaba & Kolcaba, 1991).

z they scek

duct comlort studics.

more

knowled on Comtort theory and/or

THEORETICAL SOURCES

caba began her

sing practice,

an assignment

theoretical work by diagramming her carly in her doctoral stud

ba presented her framework for dementia

W'hen Kolkaba

Kolcaba, 1992a),. she was askcd by

a member of the

she had cver complcted

a concept analysis on 2udience ifs,

to this question was no and it The answer mlort.

the concept of the beginning of

holistic comlort

The first step, the concept analysis

(Kolcaba & Kolcaba.

parke

something in olcaba. This question

would lead to

her pioncercd work on

991), began with

thedisciplines

an sive review about comlort from

of nursing, medicine, psychology psychia-

ry, onomics,

and the English language (specifically

shakespearc's use ol comiort and

the Oxford English Dic

tanary |OED}). From the OFD, Kolcaba learned that the

af ginal definition ol comiort was "to strengthen greatly

This definition provided a powerful rationale for nurses to

comfort patients, because patients would have better health

outcomes and nurses would fccl more satisfied. Kolcaba's

next step focused on operationalizing comfort (Kolcaba,

192h), followed by the seminal development of a holistic

comfort theoretical framework (Kolcaba, 1994). Historical accounts of comfort in nursing are numer

ous. From 1900 to 1929, comfort was the central goal of

nursing and medicine because, through comfort, recovery was achieved (Kolcaba, 2003; Mcllveen & Morse, 1995). There were no antibiotics, chemotherapy, or technology to

speed up the return to health. Nurses were duty bound to allend to details influencing patient comfort. Aikens (1908) proposed that nothing concerning the comfort of the patient was small enough to ignore. Good nurses made

patients comfortable, and the provision of comfort was a

primary determining factor of nurses' ability and character Aikens, 1908). Harmer (1926) stated that the standards of Dursing work include "the comfort and happiness of the palient, both mental and physical" (p. 30). Goodnow 1935) devoled a chapter in her book, The Technique o Nursing, to the patient's comfort. She explains that making palients comfortable, both physically and mentally, is a prime focus for nurses; the care involves more than the

Physical body. Other carly nursing accounts of comlort Cluded a warm back rub, the lifting of heels off of a bed, S0lt pillows, and offering liquids (Clark, 1946).

Relief was synthesized from the work of Orlando (1961), who explained that nurses relieved the needs

expressed by patients. Ease was synthesized from the work of Henderson (1966), who described 14 basic functions of human be- ings to be maintained during care. Transcendence was derived from Paterson and Zderad (1975), who proposed that patients rise above their dif- ficulties with the help of nurses. Four contexts of comfort came from the review of nursing

literature about holism and holistic care (Kolcaba, 2003). These contexts are physical, psychospiritual, sociocultural, and environmental and are defined in Fig. 33.1. The contextts are individually important but together create a comprehen- sive group of domains where comfort exists. The four contexts were juxtaposed, in a side-by-side contrast, with the three

types of comfort, creating a taxonomic structure (matrix) from which to consider the complexities of comfort as an outcomne.

The taxonomic structure provides a map of the content domain of comfort. Nurse scientists and other researchers can design, modify, or translate comfort questionnaires for their specific population using Kolcabas taxonomic structure as a guide. Many translations can be found on Kolcaba's website, The Confort Line, where she includes the steps for adaptation of the General Comfort Questionnaire (GCQ).

528 UNIT V Middle-Range Theories

Type of Comfort

Transcendence Relief Ease

Physical

Psychospiritual

Environmental

Social

Type of Comfort: Relief: The state of a patient who has had a specific need met Ease: The state of calm or contentment Transcendence: The state in which one rises above one's problems or pain

Context in Which Comfort Occurs: Physical: Pertaining to bodily sensations Psychospiritual: Pertaining to internal awareness of self, including esteem, concept. sexuality,

and meaning in one's life; one's relationship to a higher order or being

Environmental: Pertaining to the external surroundings, conditions, and influences

Social: Pertaining to interpersonal, family, and societal relationships Fig. 33.1 Taxonomic structure of comfort. (From Kolcaba, K., & Fisher, E. I1996|. A holistic perspective on

comfort care as an advance directive. Critical Care Nursing Quarterly, 1841, 66-76.)

MAJOR CONCEPTS & DEFINITIONS Health care needs are comfort needs arising from stress-

ful health care situations that cannot be met by recipients traditional support systems. The needs may be physical, psychospiritual, sociocultural, or environmental. They be- come apparent through: (a) monitoring, verbal or nonver-

bal reports, (b} needs related to pathophysiological param-

eters, (c) needs for education and support, and (d) needs

sist of past experiences, age, attitude, emotional state, support system, prognosis, finances, education, cultural background, and the totality of elements in the recipients experience (Kolcaba, 2003). Such intervening variables af-

fect planning and success of patient care interventions. In

research, they may be included in the demographic form. Comfort is the immediate state experienced by recip

ents of comfort interventions. It is the immediate, holisticfor financial counseling and intervention (Kolcaba, 2003). Comfort interventions are intentional nursing actions

and referrals designed to address specific comfort needs

of recipients, including physiological, social, cultural, fi-

nancial, psychological, spiritual, environmental, and physi-

cal needs (Kolcaba, 2003).

Intervening variables are interacting forces that influ- ence recipients' perceptions of total comfort. They con

experience of being strengthened when one's needs are addressed. The three types of comfort are relief, ease, and transcendence. The four contexts are physical, psy

chospiritual, sociocultural, and environmental (Kolcaba, 2003) (see these types and contexts in Fig. 33.1).

Health-seeking behaviors compose a broad cat egory of outcomes related to the pursuit of health as

MAJOR CONCEPTS& DEFINITIONS-contd

The categories

were synthesized by lotfeldt the

recipient{s) in consultation with the

integrity, best practices and best policies are in evidence

(Kolcaba, 2003) defined bY the

1975) and

proposed

to be interna roposed to be internal, external, or a peace-

Internal behaviors are those

we cannot ee,

ful oE ical healing., -cell formation, or electrolyte

Best Practices Ine use of health care interventions based on evidence to

SUch as

balanc

Tectlytly, such

as ambu

pressure.

external behaviors are those we an see di produce the best possible patient and family outcomes is

known as best practices. ance bulation, or indirectly, such as

Best Policies Institutional or regional policies ranging from protocols for

procedures and medical conditions to access and delivery of health care are known as best policies. Fig. 33.2illus-

trates the relationship among institutional integrity, best

practices, and best policies.

Institutional Integrity

cOuntries that possess the qualities of be-

whole, sound, upright, appealing, ethical, and Corpo

orations, communitie schools, hospitals, regions,

states, and

ing complete,

incere possess

institutic integrity. As institutio display

MAJOR ASSUMPTIONS

. Patients who are empowered to actively engage in

health-seeking behaviors are satisfied with their health Human beings have

holistic responses to complex stimuli. mfort is a value-ad holistic outcome that is ger- care.

mane to the discipline of nursing, is a basic human need that persons strive to 3. Comfort

meet or have met. It is an active endeavor.

4 Enhanced comfort strengthens patients to engage in

health-seeking behaviors of their choice.

6. Institutional integrity is based on a value system ori-

ented to the recipients of care. Of equal importance is an orientation to a health-promoting, holistic setting for families and providers of care (Kolcaba, 2003).

Conceptual Framework for Comfort Theory

Best Practices

Health Nursing

TInterventionsT Variables Care Intervening

Health Enhanced Comfort

Needs

Institutional Seeking

Behaviors Integrity

Best Policies

Internal Peaceful Death

External

Behaviors/ Behaviors

Kolcaba (2007) Fi Fig. 33.2 Conceptual framework for the theory of comfort. (Copyright Kolcaba, 2007 http://www.thecomfortine.com.)

Middle-Range Theories Nursing

ort ing action. She proposes that this type of comfor Nursing is the intentional assessment of comfort necds, the design of comfort interventions to address those needs, and reassessment of comfort levels after implenmentation compared with a baseline. Assessment and reassessment may be intuitive or subjective or both, such as when a 11urse asks if the patient is comfortable. Objective assess-ments include observations of wound healing, changes in laboratory values, or changes in behavior. Assessment of comfort is achieved through the administration of verbal rating scales (clinical) or comfort questionnaires (research), using instruments developed by Kolcaba (200:3).

p action, as well

promotes grcater nurse creativity and satisfactiodctice

nu as high patient satisfaction. To nhance comfort, the must deliver the appropriate interventions and doc e

the results in the patient record. However, when the. priate intervention is delivered in an intentional awPro forting manner, comfort still may not be en nanced m

sufficiently. When comfort is not yet enhanced to its full est, to explain why nurses then consider intervening variables to explais

comfort management did not work. Such variables mo may ting

abusive homes, lack of financial resources, devastat: that render the

most diagnoses, or cognitive impairments appropriate interventions and comrorting actions ineff.

tive. Comfort management or comtorting care includes interventions, comfortig actions, the goal of enhane comfort, and the selection of appropriate health-seekine behaviors by patients, families, and their nurses. Thus comfort management is proposed to be proactive, ner- gized, intentional, and longed for by recipients of care in all settings. To strengthen the role ot nurses as comfort agents documentation of clhanges in comfort before and a after

Person

Recipients of care may be individuals, families, institutions, or communities in need of health care. Nurses may be recipients of enhanced workplace comfort wlhen initiatives to improve working conditions are undertaken (Boudiab & Kolcaba, 2015). Environment The environment is any aspect of patient, family, or institu-tional settings that can be manipulated by the nurse(s), loved one(s), or the institution to enhance comfort.

their interventions is essential. For clinical use, Kolcaha suggests asking patients tO rate their comfort from 0 to 10

with 10 being the highest possible comfort in a given health care situation. This documentation could be a part of the electronic databases in each institution (Boudiab. Kolcaba, 2015). Total comfort may not be possible in most health care situations, but an increase in comfort will

Health Health is optimal functioning of a patient, family, health care provider, or community as defined by the patient or group.

THEORETICAL ASSERTIONS strengthen patients. The theory of comfort contains three propositional asser- tions (parts) that may be tested separately or as a whole. 1. Part l states that comforting interventions, when effec-

tive, result in increased comfort for recipients (patients and families) compared with a preintervention baseline. Care providers may be considered recipients if the insti- tution makes a commitment to the comfort of their

LOGICAL FORM

work setting. Comfort interventions address basic hu- man needs, such as rest, homeostasis, therapeutic com-

munication, and treatment as holistic beings. Comfort interventions are usually nontechnical and complement the delivery of technical care.

2. Part 2 states that increased comfort of recipients of care

results in increased engagement in health-seeking be- haviors (goals) that are negotiated with the recipients.

3. Part 3 states that increased engagement in health- seeking behavior results in increased quality of care, benefiting the institution and its ability to gather evi dence for best practices and best policies.

Kolcaba believes nurses want to practice comforting care and that it can be easily incorporated with every nurs-

Kolcaba used three types of logical reasoning in the devel- opment of the theory of comfort: (1) induction, (2) deduc tion, and (3) retroduction (Hardin & Bishop, 2010). Induction occurs when generalizations are built from a number of specific observed instances (e.g., inductive qualitative research or concept analyses). Deduction occurs when spe- cific conclusions are inferred from general premises or principles; it proceeds from the general to the specific (Har- din & Bishop, 2010). Deduction in comfort theory resulted in relating comfort to other concepts to produce a theory. Retroduction is useful for selecting new phenomena that can be developed further and tested (Hardin & Bishop, 2010). Using retroduction, Kolcaba added the concept of institutional integrity to the middle-range theory of com- fort. Adding the term extended the theory to consideration of relationships between health-seeking behaviors and inst tutional integrity. Later, the concepts of best practices ana best policies were linked to institutional integrity (Kolcaba, 2003).

CHAPTER 33 Katharine Kolcaba: Theory of Comfort 531

comfort during surgery; and (4) continuing with comfort management and measurement in the postsurgical period (Wilson& Kolcaba, 2004).TANCE

EBY THE

JRSING

MUNTY developed

hertheory, she was the

hat changes in comfort could be

first nurse

Education r lo demon

cirg

Comfort theory is incorporated in the Nursing Interven- tion Classification (Bulecheck et al, 2008) and Nursing Out comes Classification (Moorehead et al, 2008) handbooks. The theory is appropriate for students to use in any clinical setting, and its application can be facilitated by use of the Comfort Care Plans available on Kolcabas website. A text- book that is useful for education is the Nursing Diagnosis Handbook (Ackley et al., 2017).

Recently, Bice and Bramlett (2019) published a position paper focused on the necessity for nursing faculty to be

comforting. given the stressful effects of attaining nursing degrees at all levels. Bice and Bramlett argued the unique position that faculty have in applying a holistic comfort pedagogy. Goodwin and Candela (2013) used the theory of comfort as a transitional philosophy in a group of newly practicing nurses. The new nurses were taught to seek relief from stressors, maintain ease with their new settings through trusting their staff members, and achieve tran- scendence from their stressors with use of self-comforting techniques. The authors stated that "all participants referred to holistic comfort (HC) as something they still use with

both colleagues and patients, implying nurses' application of HC can affect practice outcomes" (p. 618).

xperimental design. In.her disser

(comfort needs) associ & Fox,

Osis of early

breast cancer

(Kolcaba & Eo

th a dintervention

was guidied imagery, designed

theircomfortrneeds, and

indings revealed

in women receivingg

needs were those

Iheh hese patients

to meet the

e was

their comfort. The find

her comfort

over time

ed with the usual

care group. ifñi

ally

lor

thes

desredout Exam-

fmorerecentcomfort

int

induction

and mas

ont comfort theory

application studies include:

massage therapy for patients

d imagery compared

pain (Townsend

et al., 2014).

with chro.

AMindtul

ulness-based stress reduction for elderly resi-

-based nursing

care for women with new

ions (Derya & Pasinlioglu, 2015).

Loated blankets to enhance

comfort of acute

(Parks et al., 2017).

correlation between comfort and

nts in

ng-term care (Kumar

et al., 2014).

omtor

Determ

rmination

of co

funid retention (Estridge

et al., 2018).

vchiatric patients

rluided

imagery nanced comfort among patients

receiv-

ng palliative

care (Coelho et al, 2018).

Pactice

nients. practicing nurses, and

nurse researchers have

siated this theory as a guiding

framework for their stud

Teviews, or innovative Works

such as efficacy of hand

saE Dowd et al. (2006), the effects of healing touch on

mfort and stress (Dowd et al, 2007), the effect of warm-

g on preoperative patients (Wagner et al., 2006), obstet-

nIs (Barbosa et al, 2014), veterans' health (Boudiab &

Kolcaba, 2015), postpartum care (LDerya & Pasinlioglu,

015), teaching of nursing students (Goodwin & Candela,

2013), hospice patients (Hansen et al, 2015), cardiac

paients (Krinsky et al, 2014), prior to anesthesia (Seyedfa-

ami et al., 2014), and pediatric procedural holistic comfort

nterventions (Bice & Wyatt, 2016). Perianesthesia nurses have incorporated the theory of

cumfort into their clinical practice guidelines for manage nent of patient comfort. In this setting. comfort manage- DAnI specihes(1) assessing patients comfort needs related eurent surgery, chronic pain issues, and comorbidities; reating a comfort contract with patients before surgery

ual specihes effective comfort interventions, understand- and efhcient comfort measurement, and the type of NSrgical analgesia preferred; (3) facilitating comfortabie ng body temperature, and other factors related to

Research An entry in the Encyclopedia of Nursing Research speaks to the importance of measuring comfort as a nursing-sensitive

outcome (Kolcaba, 2012). Nurses can provide evidence to

influence decision-making at institutional, community, and legislative levels through studies that demonstrate the effectiveness of comforting care. Kolcaba (2003) called for measurement of comfort in large hospitals and home care to expand the theory and develop the literature on

evidence-based comfort.

ed

Using the taxonomic structure of comfort (see Fig. 33.1) s a guide, Kolcaba (2003) developed the GCQ to measure

holistic comfort in a sample of hospital and community

participants. Positive and negative items were generated for

each cell in the taxonomic structure grid. Twenty-four

positive items and 24 negative items were compiled with a

Likert-type format, ranging from strongly agree to strongly

disagree, with higher scores indicating higher comfort. At

the end of the instrumentation study with 206 one-time

participants from all types of units in two hospitals and 50

participants from the community, the GCQ demonstrated a

Cronbach alpha of 0.88.

r. nat

Op, of

om tion sti- ana

caba,

532 UNITV Middle-Range Theories

Although innovative comfort theory recommendations for pediatric nursing had been disseminated (Kolcaba & DiMarco, 2005), pediatric rescarch has only recently been published. Inductive work and mixcd methods research with comfort theory has been conducted with pediatric patients. Bice and colleagues (2017) explored holistic com- fort surrounding invasive procedures in their qualitative study with 5- to 7-year-old children. This inductive qualita- tive study led to the development of a novel instrument known as the Pediatric Procedural Holistic Comfort

cal assertions for the second and third parts of the theory are

lo be conducted and published. Kolcaba has consultecd

hospital administrators and stalt educators who want t to

enhance the quality of care and include comfort manao

ment in their documentation systems (Boudiab & Kale

with

2015). Kolcaba views quality care as comforting ions

delivered in an intentional manner to create an environmen

Kol- that leads to engagenment in health-seeking behaviors caba postulates that intentional emphasis on and support fa

comfort management by an insttution or communitu

Assessment (PPHCA) that demonstrated feasibility among children in the preoperational stage of development (Bice et al.. 2019).

increases patient and family satisfaction, because personc 18 are

healed, strengthened, and motivated to be healthier. Extend

ing the theory of comfort to the community is her irrent

Kolcaba welcomes researchers to modify her conmfort questionnaires specifie to their areas of research. The verbal

rating scales and other traditionally formatted question- naires may be downloaded from Kolcabas website, where she also responds to inquiries about comfort research sup- porting the use of her theory. Instructions for use of the

questionnaires are available on the website. Popularity of the theory seems to be associated with its simplicity and with universal recognition of comfort as a desirable out- come of nursing care tor patients and their families.

interest. It is well known that some communities are more

comfortable to live in, go to school in, and grow old in than

others. An area of interest for further development is the un

versal nature of comfort. Currently, the GCQ has been

translated into Taiwanese, Turkish, Spanish, Iranian, Por. tuguese, and Italian (see Kolcaba website). Comfort of

children has been accurately observed and documented in

perioperative settings (Nancy Laurelberry, personal com- munication, February 2008). Comtort Daisies for children to self-report their comfort (see Kolcaba website) have

been tested in a hospital setting (Carrie Majka, personal communication, February 2008).

The theory of comfort has been included in electronic nursing classification systems such as the North America Nursing Diagnosis Association (Ackley et al., 2017). Use

of the theory has made signiticant contributions to nurs- ing practice and the discipline. Kolcaba continues to

develop and disseminate the theory through presenta-

tions, publications, and discussions since retiring from

full-time teaching. The theory of comfort has been used as an organizing

framework for Magnet Status certification and awards for excellence in health care. Nurses often choose this frame-

FURTHER DEVELOPMENT Kolcaba has persisted in the development of her theory from the original conception as the root of her practice to concept analysis that provided the taxonomic structure of comfort: to development of ways to measure the concept; and currently to its use for practice, education, and research. She uses a full array of approaches to build her

theory The methodical development and documentation of

the concept of comfort resulted in a strong. clearly orga- nized, and logical theory that is readily applied in many settings for education, practice, and research. Kolcaba

developed templates for measurement to facilitate applica- tion of the comfort theory in additional settings. The

comfort management templates she provided for use in

practice settings have been helpful to students and faculty members. Outcomes of research have demonstrated the

work because it describes what they want to do for patients and families and what patients want from nurses during their hospitalization. An array of possible uses of the framework components is offered to the hospital, such as Comfort Rounds, performance review criteria, methods of documentation, clinical ladder criteria, and so on. The "value added" benefit when nurses are sup-

appropriateness of her theory for measuring whole-person changes that were less effectively captured with other types

of instruments. The original theoretical assertion (Part 1) of the theory of

comfort has withstood empirical testing. When a comfort intervention is targeted to meet the holistic comfort needs of patients in specific health care situations, comfort is enhanced beyond baseline measurement. Furthermore, enhanced com- fort has been correlated with engagement in health-seeking behaviors (Schlotfeldt, 1975). Empirical tests of the theoreti-

ported with adequate staffing levels to implement their comforting interventions can be empirically demon- strated through measurement of institutional outcomes, such as patient satisfaction, "Best Hospital" designations, and cost savings.

Most importantly, comfort theory is appropriate for appl cation in a hospital-wide system to provide a theoretical base

to enhance the working environment. Kolcaba collected

CHAPTER 33 Katharine Kolcaba: Theory of Comrort 533

tfirnnalon aboutthe

them on the

and wants of practicing nurses taxonomic structure of comfort.

work, the Nurses Comfort Question-

ut the needs.

the theory of comfort promotes efficient, individualized, holistic practice. The taxonomic structure of comfort facili- tates researchers' development of comfort instruments for

new settings.

t preliminaryy work,

red changes to the working environment, such

vas developed, vhich can be used in pilot tests

r{NCQ)w

Wmuse ible or self-schscheduling, mandatory

lunch breaks

and clean rest area, or debriehng opportuni-

(Boudiab & Kolcaba, focusing on nursing

Accessibility icult patient situations

i et al, 2015). Research

The first part of the theory, asserting that effective nursing interventions offered over time demonstrate enhanced

ynil.apeasant and clear

A; Rondinell

mlortis suggested,

of COVID

comfort, has been tested and supported with numerous studies. Furthermore, in the study by Dowd and colleagues

2000), enhanced comfort was a strong predictor of increased health-seeking behaviors, suggesting when patients are more comfortable, they do better in rehabilitation or recov ery. This relationship begins support of the second and

third parts of the comfort theory. Comfort instruments

have demonstrated strong psychometric properties, sup-

porting the validity of the questionnaires as measures of comfort that reveal changes in comfort over time and sup

port of the taxonomic structure. Verbal rating scales (VRSs) are especially useful for clinical practice; the nurse asks a

patient to rate his or her total comfort from 0 (no comfort at all) to 10 (highest comfort possible in this situation). Such ratings are important for documenting effectiveness of

nursing interventions by comparing baseline comfort to comfort after nursing care. VRSs have been used in research and have strong concurrent validity compared with other

comfort questionnaires (Dowd et al, 2007; Parks et al,

2017).

gested for nurses rldwide following the 2020

undemic Finally an

eory is its application to

children and measure important area

of further development for

ntent of

holistic

comfort wit.

(pols. Bice and

archprogranm witi

pediatric procedural.

iondevelopment of the PPHCA instrument. Holis-

valid and reliable pediatric

colleagues (2017, 2019) have begun this with inductive work focused on explora-

holistic comfort as well as

continuec research according to the con- tic Comfort measurement

nta. nts, toddlers, School-age

children, and adolescents. tand propositions

in Kolcabas theory is needed among

CRITIQUE

Clarity Kolcaba leaves

an extensive trail of articles highlighting her

deps in developing this middle-range theory. They are con-

distent in terms of definitions, derivations, assumptions,

and propositions. Her book clearly presents the theory and

her articles leading to it (Kolcaba, 2003). Kolcaba applies

the theory to specific practices using understandable lan-

guage. All research concepts are clearly defined theoreti-

cally and operationally.

Importance

Simplicity The theory of comfort is simple, as it is basic to nursing

care and the traditional mission of nursing. Its language

and application are of low technology, but this does not

preclude its use in highly technological settings. There are six variables in the theory, and selected variables may be

Used for research or educational projects. The main thrust

of the theory is for nurses to return to a practice focused on

the holistic needs of patients inside or outside institutional walls. Its simplicity allows students and nurses to learn and

practice the theory easily (Kolcaba, 2003).

The theory of comfort describes patient-centered practice and explains how comfort measures matter to patients and

family members, their health and satisfaction, and the

viability of institutions. The theory predicts the benefit of effective comfort measures (interventions) to enhance

comfort and engagement in health-seeking behaviors. The

theory of comfort is dedicated to sustaining nursing by

bringing the discipline back to its roots. Documentation of

comfort strategies and their eftfects empirically supports

the art of nursing. The outcomes of comfort describe the effects of helpful interactions with patients and family

members that go beyond checklists or physician orders. It

encompasses the art and science of nursing. Electronic

data systems inclusive of value-added outcomes such as

comfort are suggested. Collaboration and the openness of

Kolcaba's website facilitates dissemination of the theory for

application. The orientation to patient and family comfort may have

been initially present in nursing, but it has become less

valued in a health care system that focuses on the use of medi-

cations and technology. Theretore retocusing on patient and

family comfort represents a return to the roots of nursing and

Generality Kolcabas theory has been applied in numerous research set-

ings,cultures, and age groups. Her book has been translated nio German, Japanese, and Portuguese. If nurses, institu- Ons, and communities are committed to basic nursing care,

534 UNITV Middle-Range Theories

also to the need for empirical evidence about the importance of caring nurses. It can be demonstrated through rescarch that comfort is foundational to patient recovery, to other health-seeking behaviors, and to institutional viability. The

use of a comfort framework implemented througho

hospital facilitates cveryone bcing "on the same

concepts are understood and

relevant across all health

disciplines.

care

SUMMARY ence. Comfort theory offers nursing faculty a guide for

attending to the comfort needs of students and new gradu- From its inception, the theory of comfort focused on what the discipline of nursing does for patients. As the theory evolved, the definition derived from concept analysis expanded to include broader aspects of the patient, such as cultural and spiritual characteristics. The basic format of the taxonomic structure and conceptual framework did

not change. The development of the GCQ was important to validate that the concept can be measured and docu mented. Comfort theory represents the way most nurses want to practice, and it offers a way to make comfort mea- sures visible through docunmentation and comfort care

plans. The theory easily guides nurses and other health care

professionals in the planning and designing of health care in any setting. It provides a useful framework in education that enables students to organize their assessments and plans of care and learn the art of nursing as well as the sci-

ates as well (Bice & Bramlett, 2019; Goodwin & Candel.

2013). In research, testing

of the theory validated imr

ment in patient comfort after receiving comforting int

ventions. The concept of comfort accounts for the asna

quality care that patients describe as "feeling better Kol-

caba has consistently developed and expanded the imnor

tance of comfort into all realms of health care. Through her

reasoning and interaction with nurses and other heali

professionals, the concept evolved into patient and health

care techniques. Institutions have recognized the value of

designing comfort environments for their patients and for

their staff. Through Kolcabas publications and the website

activities, the theory of comfort is being used by nurses

internationally.

T-

t of

CASE STUDY

(4) "When do I getto leave? Ihe nurse performs a physical and mental health assessment and notes that Derick has

unmet comfort needs in the physical, sociocultural, psy- chospiritual, and environmental contexts (see Table 33.1.

Physically, he is in need of a bronchodilator treatment for

breathing. Derick will also need prophylactic topical skin anesthetic and some good distraction techniques to assist

in optimal comfort during his IV insertion. It is also appar

ent that Derick has unmet comfort needs in the sociocul- tural context because he has had no visitors today and he

is missing his family (parents). Derick is asking when he

gets to leave so he may be uncertain about his diagnosis,

which is a psychospiritual unmet need. Lastly, Derick's en vironmental comfort is threatened in two vways: cluttered surroundings and dirty linens. The night shift nurse knows

she needs to implement comfort interventions. Begin- ning with the most significant, the nurse immediately

calls the respiratory therapist and helps to administer

albuterol according to medication rights. Next, the nurse

applies topical anesthetic on two potential N insertion sites for prophylactic needle-related pain management. The anesthetic needs 30 to 60 minutes of application time before removal for optimal efficacy. The nurse then

The night shift staff nurse receives a report at 6:55 p.m.

on Derick, a 15-year-old male admitted to the hospital with

an asthma exacerbation. The day shift nurse reported that

Derick was stable on 2 liters O, via nasal cannula all day which is down from 3 liters yesterday. However, he has been a bit quiet today, with his parents gone to work and

no other visitors. His parents are supposed to return by

11 p.m. The hospitalist provider just made rounds and has

ordered a new IV placed for intravenous fluids because De- rick was not eating or drinking well today. His respiratory assessment has remained the same with mild subcostal

retractions and coarse wheezing throughout his lungs. The day shift nurse states, "he could probably use another alb- uterol treatment because he has not had one since noon" Upon arriving to the room, the nurse notes a child on oxy-

gen in mild respiratory distress but able to talk in full sen- tences. The nurse also notes the room is disorderly with lots of chairs and belongings surrounding the bed. The bed

linens are dirty with crumbs and debris. The nurse talks to

Derick for a few minutes and he makes some important comfort need statements including: (1) "Have my parents called? I wish they were here" (2) "It feels so cluttered in

here" (3) "Can you give me a breathing treatment?, and

CHAPTER 33 Katharine Kolcaba: Theory of Comfort 535

CASL STUDY-contd

ns on the bed and Cleans up the room

setting belongings neatly out of

the bed to go to the bathroom

ving chairs and

erick gets out of the b

"t looks and feels

better in here. Then the

and focusing on how his body will get better so that he

can leave the hospital. Derick nods in understanding and

tells the nurse he knows what he needs to do to help hanges

the

inens

on

by rem

and

states

Tt looks

calls Derick'sr

theway.Derio

himself get better. The night shift nurse has used all types of comfort interventions in this scenario (see Table 33.2). She has implemented technical comfort (administration of medications), coaching comfort (supportive discussion, explanation, and listening), and comfort food for the soul (calling Derick's mother and making special arangements for him to speak with her). The patient responded well and

nuse phonetrom work

mother who speaks to him over the

about 5 minutes, supporting him and

to the

that she, and Derick's father,

will return

at about 11 p.m. to

be with him. Derick smiles ital at about

hout the phone

call andh

verityn

d his facial grimacing is gone.

thoughout

the nurse spends

time talking with Derick about

Lastly,

asthma diagnosis, supporting and encourag him

his

enhanced comfort was evident or stated.

TABLE 33. RLE 33.1 Taxonomic Structure of Comfort Needs for ( Case Study

Contextof Comfort Relief Ease

Breathing difficulty Transcendence

PhysIca

Restlessness Patient thinking, "What will happen ifI do not get better?"

Need for emotional support Need for information and consultation

Wants to leave hospital Fear, anxiety, uncertainty Psychospirtual

about prognosis

Feeling of confinement Environmental

Room is cluttered

Absence of family

Need for calm, familiar environment

Sociocultural Family not present Need for support from family

TABLE 33.2 Comfort Care Actions and Interventions

Type of Comfort Care Action or Intervention Example Technical comfort interventions Albuterol medication

Topical anesthetic

Patient assessment

Coaching Emotional support

Reassurance Education

Comfort food for the soul

Listening Arranging call to parernt

Spending time

Reduction of environmental clutter

CRITICAL THINKING ACTIVITIES Dagram your practice with concepts. Where is com-

of practice? Describe your comtort measures in relation to the taxonomic structure? (See Fig. 33.1.)

3. Consider a comtort need you met tor someone you

cared for recently. What suggested to you that it was

ort in your diagram? With which other concepts doesit interact?

4. Select a patient and apply the theory of comfort in your nursing practice. How did the theory change your style

successful?