Nursing is the intentional assessment of comfort needs, the design of comfort interventions to address those needs, and reassessment of comfort levels after implementation compared with a baseline. Assessment and reassessment may be intuitive or subjective or both, such as when a nurse asks if the patient is comfortable, or objective, such as in observations of wound healing, changes in laboratory values, or changes in behavior. Assessment is achieved through the administration of verbal rating scales (clinical) or comfort questionnaires (research), using instruments developed by Kolcaba (2003).

Recipients of care may be individuals, families, institutions, or communities in need of health care. Nurses may be recipients of enhanced workplace comfort when initiatives to improve working conditions are undertaken, such as those to gain Magnet status (Kolcaba, Tilton, & Drouin, 2006).

(Hardin & Bishop, 2010). When nurses are earnest about their practice and earnest about nursing as a discipline, they become familiar with implicit or explicit concepts, terms, propositions, and assumptions that underpin their practice. Nurses in graduate school may be asked to diagram their practice as Dr. Rosemary Ellis asked Kolcaba and other students to do, and it is a deceptively easy-sounding assignment.

Such was the scenario during the late 1980s as Kolcaba began. She was head nurse on an Alzheimer’s unit at the time and knew some of the terms used then to describe the practice of dementia care, such as facilitative environment, excess disabilities, and optimum function. However, when she drew relationships among them, she recognized that the three terms did not fully describe her practice. An important nursing piece was missing, and she pondered about what nurses were doing to prevent excess disabilities (later naming those actions interventions) and how to judge if the interventions were working. Optimum function had been conceptualized as the ability to engage in special activities on the unit, such as setting the table, preparing a salad, or going to a program and sitting through it. These activities made the residents feel good about themselves, as if it were the right activity at the right time. These activities did not happen more than twice a day, because the residents couldn’t tolerate much more than that. What were they doing in the meantime? What behaviors did the staff hope they would exhibit that would indicate an absence of excess disabilities? Should the term excess disabilities be delineated further for clarity?

Partial solutions to these questions were to (1) divide excess disabilities into physical and mental, (2) introduce the concept of comfort to the original diagram, because this word seemed to convey the desired state for patients when they were not engaging in special activities, and (3) note the nonrecursive relationship between comfort and optimum functioning. This thinking marked the first steps toward a theory of comfort and thinking about the complexities of the concept (Kolcaba, 1992a).

Deduction occurs when specific conclusions are inferred from general premises or principles; it proceeds from the general to the specific (Hardin & Bishop, 2010). The deductive stage of theory development resulted in relating comfort to other concepts to produce a theory. Since the works of three nursing theorists was entailed in the definition of comfort (Paterson & Zderad, 1975; Henderson, 1966 and Orlando, 1961), Kolcaba looked elsewhere for the common ground needed to unify relief, ease, and transcendence (three major concepts). What was needed was a more abstract and general conceptual framework that was congruent with comfort and contained a manageable number of highly abstract constructs.

The work of psychologist Henry Murray (1938) met the criteria for a framework on which to hang Kolcaba’s nursing concepts. His theory was about human needs; therefore it was applicable to patients who experience multiple stimuli in stressful health care situations. Furthermore, Murray’s idea about unitary trends gave Kolcaba the idea that, although comfort was state-specific, if comforting interventions were implemented over time, the overall comfort of patients could be enhanced over time. In this deductive stage of theory development, she began with abstract, general theoretical construction and used the sociological process of substruction to identify the more specific (less abstract) levels of concepts for nursing practice.

Retroduction is useful for selecting phenomena that can be developed further and tested. This type of reasoning is applied in fields that have few available theories (Hardin & Bishop, 2010). Such was the case with outcomes research, which now is centered on collecting databases for measuring selected outcomes and relating those outcomes to types of nursing, medical, institutional, or community protocols. Murray’s twentieth-century framework could not account for the twenty-first–century emphasis on institutional and community outcomes. Using retroduction, Kolcaba added the concept of institutional integrity to the middle-range Theory of Comfort. Adding the term extended the theory for consideration of relationships between health-seeking behaviors and institutional integrity. In 2007, the concepts of best practices and best policies were linked to institutional integrity. Theory-based evidence organizes the knowledge base for best practices and policies (see Figure 33–2).

Students and nurse researchers have frequently selected this theory as a guiding framework for their studies in areas such as nurse midwifery (Schuiling, Sampselle, & Kolcaba, 2011), hospice care (Kolcaba, Dowd, Steiner, et al., 2004), perioperative nursing (Wilson & Kolcaba, 2004), long-term care (Kolcaba, Schirm, & Steiner, 2006), stressed college students (Dowd, Kolcaba, Steiner, et al., 2007), dementia patients (Hodgson & Andersen, 2008), and palliative care (Lavoie, Blondeau, & Picard-Morin, 2011).

When nurses ask patients or family members to rate their comfort from 0 to 10 before and after an intervention or at regular intervals, they produce documented evidence that significant comfort work is being done. A verbal rating scale is sensitive to changes in comfort over time (Dowd, Kolcaba, Steiner, et al., 2007). A list of effective comforting interventions for each patient/family member is readily available and communicated.

Perianesthesia nurses have incorporated the Theory of Comfort into their Clinical Practice Guidelines for management of patient comfort. In this setting, comfort management specifies (1) assessing patients’ comfort needs related to current surgery, chronic pain issues, and comorbidities; (2) creating a comfort contract with patients prior to surgery that specifies effective comfort interventions, understandable and efficient comfort measurement, and the type of postsurgical analgesia preferred; (3) facilitating comfortable positioning, body temperature, and other factors related to comfort during surgery; and (4) continuing with comfort management and measurement in the postsurgical period (Wilson & Kolcaba, 2004).

Goodwin, Sener, & Steiner (2007) described guidelines for applying the Theory of Comfort in accelerated baccalaureate nursing programs. The theory proved to be easy for faculty to understand and apply and provided an effective method to role-model a supportive learning partnership with the students. The Theory of Comfort is included in Core Concepts in Advanced Practice Nursing(Robinson & Kish, 2001). The theory is appropriate for students to use in any clinical setting, and its application can be facilitated by use of Comfort Care Plans available on Kolcaba’s website.

Recently, Goodwin, Sener, and Steiner (2007) utilized the Theory of Comfort as a teaching philosophy in a fast-track nursing education program for students with baccalaureate degrees in other disciplines. The taxonomic structure and conceptual framework guided ways of being a comforting faculty member. The theory provided ways for students to obtain relief from their heavy course work by facilitating questions to their clinical problems, maintaining ease with their curriculum through trusting their faculty members, and achieving transcendence from their stressors with use of self-comforting techniques. The authors anticipate “that this adaptation may assist students to transform into professional nurses who are comfortable and comforting in their roles and who are committed to the goal of lifelong learning” (p. 278).

An entry in the Encyclopedia of Nursing Research speaks to the importance of measuring comfort as a nursing-sensitive outcome (Kolcaba, 2006). Nurses can provide evidence to influence decision making at institutional, community, and legislative levels through studies that demonstrate the effectiveness of comforting care. Kolcaba (2001) called for measurement of comfort in large hospitals and home care to expand the theory and develop the literature on evidence-based comfort.

Using the taxonomic structure of comfort (see Figure 33–1) as a guide, Kolcaba (1992a) developed the General Comfort Questionnaire 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 twenty-four 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 General Comfort Questionnaire demonstrated a Cronbach alpha of 0.88 (Kolcaba, 1992a).

Researchers are welcome to generate comfort questionnaires specific to their areas of research. The verbal rating scales and other traditionally formatted questionnaires may be downloaded from Kolcaba’s website, where she also responds to inquiries in an effort to enhance the use of her theory. Instructions for use of the questionnaires are available on her website. Popularity of the theory seems to be associated with universal recognition of comfort as a desirable outcome of nursing care for patients and their families.

Some of the early articles such as the concept analysis (Kolcaba & Kolcaba, 1991) may lack clarity but are consistent in terms of definitions, derivations, assumptions, and propositions. Clarity is much improved in the article explicating the theory and subsequent articles. Kolcaba applies the theory to specific practices using academic, but understandable, language. All research concepts are defined theoretically and operationally.

The Theory of Comfort is simple because 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 few 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. It is simplicity that allows students and nurses to learn and practice the theory easily (Kolcaba, 2003).

The first part of the theory, asserting that effective nursing interventions offered over time will demonstrate enhanced comfort, has been tested and supported with numerous studies. Furthermore, in the study by Dowd, Kolcaba, & Steiner (2000), enhanced comfort was a strong predictor of increased health-seeking behaviors, meaning when patients are more comfortable, they do better in rehab or recovery. This relationship supports the second and third part of the comfort theory. The comfort instruments have demonstrated strong psychometric properties, supporting the validity of the questionnaires as measures of comfort that reveal changes in comfort over time and support of the taxonomic structure.