CREDENTIALS AND BACKGROUND OF THE THEORIST

Katharine Kolcaba was born and educated in Cleveland, Ohio. In 1965, she received a diploma in nursing and practiced part time for many years in medical-surgical nursing, long-term care, and home care before returning to school. In 1987, she graduated in the first R.N. to M.S.N. class at the Frances Payne Bolton School of Nursing, Case Western Reserve University (CWRU), with a specialty in gerontology. While in school, she jobshared in a head nurse position on a dementia unit. It was in the context of that experience that she began theorizing about the outcome of comfort.

After graduating with her master’s degree in nursing, Kolcaba joined the faculty at The University of Akron College of Nursing. She acquired and maintains American Nurses Association (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. She published a concept analysis of comfort with her philosopher-husband (Kolcaba & Kolcaba, 1991), diagrammed aspects of comfort (Kolcaba, 1991), operationalized comfort as an outcome of care (Kolcaba, 1992a), contextualized comfort in a middle range theory (Kolcaba, 1994), and tested the theory in an intervention study (Kolcaba & Fox, 1999).

Currently, Kolcaba is an emeritus associate professor of nursing at The University of Akron College of Nursing, where she continues to teach nursing theory part time. Her areas of interest include interventions for and measurements of comfort for evidence-based practice. She continues to reside in the Cleveland area with her husband, where she enjoys being near her grandchildren and her mother. She represents her own company known as The Comfort Line, to assist healthcare agencies implement Comfort Theory on an institutional-wide basis. She is founder and coordinator of a local parish nurse program and a member of ANA and Sigma Theta Tau International. Kolcaba continues to work with students conducting comfort studies.

THEORETICAL SOURCES

Kolcaba began her theoretical work as she diagrammed her nursing practice early in her doctoral studies. When Kolcaba presented her framework for dementia care (Kolcaba, 1992b), a member of the audience asked, “Have you done a concept analysis of comfort?” Kolcaba replied that she had not but that would be her next step. That question began her long investigation into the concept of comfort.

The first step, the promised concept analysis, began with an extensive review of the literature about comfort from the disciplines of nursing, medicine, psychology, psychiatry, ergonomics, and English (specifically Shakespeare’s use of comfort and the Oxford English Dictionary [OED]). From the OED, Kolcaba learned that the original definition of comfort was “to strengthen greatly.” This definition provided a wonderful rationale for nurses to comfort patients since the patients would do better and the nurses would feel more satisfied.

Historical accounts of comfort in nursing are numerous. For example, Nightingale (1859) exhorted, “It must never be lost sight of what observation is for. It is not for the sake of piling up miscellaneous information or curious facts, but for the sake of saving life and increasing health and comfort” (p. 70).

From 1900 to 1929, comfort was the central goal of nursing and medicine because, through comfort, recovery was achieved (McIlveen & Morse, 1995). The nurse was duty bound to attend to details influencing patient comfort. Aikens (1908) proposed that nothing concerning the comfort of the patient was small enough to ignore. Comfort of the patient was the nurse’s first and last consideration. A good nurse made patients comfortable, and the provision of comfort was a primary determining factor of a nurse’s ability and character (Aikens, 1908).

Harmer (1926) stated that nursing care was concerned with providing a “general atmosphere of comfort,” and that personal care of patients included attention to “happiness, comfort, and ease, physical and mental,” in addition to “rest and sleep, nutrition, cleanliness, and elimination” (p. 26). Goodnow (1935) devoted a chapter in her book, The Technique of Nursing, to the patient’s comfort. She wrote, “A nurse is judged always by her ability to make her patient comfortable. Comfort is both physical and mental, and a nurse’s responsibility does not end with physical care” (p. 95). In textbooks dated 1904, 1914, and 1919, emotional comfort was called mental comfort and was achieved mostly by providing physical comfort and modifying the environment for patients (McIlveen & Morse, 1995).

In these examples, comfort is positive and achieved with the help of nurses and, in some cases, indicates improvement from a previous state or condition. Intuitively, comfort is associated with a nurturing activity. From its word origins, Kolcaba explicated its strengthening features, and from ergonomics, its direct link to job performance. However, often its meaning is implicit, hidden in context, and ambiguous. The concept varies semantically as a verb, noun, adjective, adverb, process, and outcome.

Three early nursing theorists’ ideas were used by Kolcaba to synthesize or derive the types of comfort in the concept analysis (Kolcaba & Kolcaba, 1991). Relief was synthesized from the work of Orlando (1961), who posited that nurses relieved the needs expressed by patients. Ease was synthesized from the work of Henderson (1966), who described 13 basic functions of human beings to be maintained during care. Transcendence was derived from Paterson and Zderad (1975), who proposed that patients rise above their difficulties with the help of nurses.

Four contexts of comfort, as experienced by those receiving care, came from the review of nursing literature (Kolcaba, 2003). The contexts are physical, psychospiritual, sociocultural, and environmental. When these four contexts are juxtaposed with the three types of comfort, a taxonomic structure is created from which to consider the complexities of comfort as an outcome (Figure 33-1).

The taxonomic structure provides a map of the content domain of comfort. It is anticipated that future researchers will design instruments using the structure such as the questionnaire developed from the taxonomy for the end-of-life instrument (Novak, Kolcaba, Steiner, & Dowd, 2001). Kolcaba includes the steps for adapting the General Comfort Questionnaire on her website for future researchers.

MAJOR CONCEPTS & DEFINITIONS

Those receiving comfort measures are referred to as recipients, patients, students, prisoners, workers, older adults, communities, and institutions in Kolcaba’s theory.

HEALTH CARE NEEDS

Health care needs are needs for comfort arising from stressful health care situations that cannot be met by recipients’ traditional support systems. These needs may be physical, psychospiritual, sociocultural, and environmental. The needs become apparent through monitoring, verbal or nonverbal reports, pathophysiological parameters, education and support, and financial counseling and intervention (Kolcaba, 1994).

COMFORT INTERVENTIONS

Comfort interventions are nursing actions designed to address specific comfort needs of recipients, including physiological, social, cultural, financial, psychological, spiritual, environmental, and physical interventions (Kolcaba, 2003).

INTERVENING VARIABLES

Intervening variables are interacting forces that influence recipients’ perceptions of total comfort. They consist of past experiences, age, attitude, emotional state, support system, prognosis, finances, education, cultural background, and the totality of elements in the recipients’ experience (Kolcaba, 1994).

COMFORT

Comfort is the state experienced by recipients of comfort interventions. It is the immediate and holistic experience of being strengthened when needs are addressed for three types of comfort (relief, ease, and transcendence) in four contexts (physical, psychospiritual, sociocultural, and environmental) (Kolcaba, 2003). Types and contexts are defined in Figure 33-1.

HEALTH-SEEKING BEHAVIORS

A broad category of outcomes related to the pursuit of health as defined by recipient(s) in consultation with the nurse Health-Seeking Behaviors (HSBs) was synthesized by Schlotfeldt (1975) and proposed to be internal, external, or a peaceful death.

INSTITUTIONAL INTEGRITY

Corporations, communities, schools, hospitals, regions, states, and countries that possess qualities of being complete, whole, sound, upright, appealing, ethical, and sincere. When an institution displays this type of integrity, it produces evidence for best practices and best policies (Kolcaba, 2001).

BEST PRACTICES

Use health care interventions based on evidence to produce best possible patient and family outcome.

BEST POLICIES

Institutional or regional policies ranging from protocols for procedures and medical conditions to access and delivery of health care. Figure 33-2 depicts the relationship of these last three concepts.

USE OF EMPIRICAL EVIDENCE

The seeds of modern inquiry about the outcome of comfort were sown in the late 1980s, marking a period of collective, but separate, awareness about the concept of holistic comfort. Hamilton (1989) made a leap forward by exploring the meaning of comfort from the patient’s perspective. She used interviews to ascertain how each patient in a long-term care facility defined comfort. The theme that emerged most frequently was relief from pain, but patients also identified good position in wellfitting furniture and a feeling of being independent, encouraged, worthwhile, and useful. Hamilton (1989) concluded, “The clear message is that comfort is multi-dimensional, meaning different things to different people” (p. 32).

After Kolcaba developed her theory, she tested it using an experimental design in her dissertation (Kolcaba & Fox, 1999). In that study, health care needs were those (comfort needs) associated with a diagnosis of early breast cancer. The holistic intervention was guided imagery, designed specifically for this patient population to meet their comfort needs, and the desired outcome was their comfort. The findings revealed a significant difference in comfort over time between women receiving guided imagery and the usual care group (Kolcaba & Fox, 1999). Additional empirical testing of the Comfort Theory has been conducted by Kolcaba and associates. They are detailed in her book (Kolcaba, 2003, pp. 113-124) and cited on her website. These comfort studies demonstrated significant differences between treatment and comparison groups on comfort over time. The following interventions have been tested:

In each study, interventions were targeted to all attributes of comfort relevant to the research settings, comfort instruments were adapted from the General Comfort Questionnaire (Kolcaba, 1997, 2003) using the taxonomic structure (TS) of comfort as a guide, and there were at least two measurement points, usually three, to capture change in comfort over time. The evidence for efficacy of hand massage as an intervention to enhance comfort is published in Evidence-Based Nursing Care Guidelines: Medical-Surgical Interventions (Kolcaba & Mitzel, 2008).

Further support for the Theory of Comfort has been found in a study of the following four major theoretical propositions about the nature of holistic comfort (Kolcaba & Steiner, 2000):

The results of tests with data from Kolcaba and Fox’s (1999) earlier study of women with breast cancer supported each proposition. Other areas of study included in the Kolcaba website are burn units, labor and delivery, infertility, nursing homes, home care, chronic pain, pediatrics, oncology, dental hygiene, transport, prisons, deaf patients, and those with mental disabilities.

MAJOR ASSUMPTIONS

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).

ASSUMPTIONS

THEORETICAL ASSERTIONS

The Theory of Comfort contains three parts (assertions) to be tested separately or as a whole.

Part I states that comforting interventions, when effective, result in increased comfort for recipients (patients and families), compared to a pre-intervention baseline. Care providers may also be considered recipients if the institution makes a commitment to the comfort of their work setting. Comfort interventions address basic human needs, such as rest, homeostasis, therapeutic communication, and treatment as holistic beings. These comfort interventions are usually non-technical and complement delivery of technical care.

Part II states that increased comfort of recipients of care results in increased engagement in health-seeking behaviors (HSBs) that are negotiated with the recipients.

Part III states that increased engagement in HSBs results in increased quality of care, benefiting the institution and its ability to gather evidence for best practices and best policies.

Kolcaba believes that nurses want to practice comforting care and that it can be easily incorporated with every nursing action. She proposes that this type of comfort practice promotes greater nurse creativity and satisfaction, as well as high patient satisfaction. In order to enhance comfort, the nurse must deliver the appropriate intervention in a caring manner. However, when the appropriate intervention is delivered in an intentional and comforting manner, comfort still may not be enhanced sufficiently. When comfort is not yet enhanced to its fullest, nurses then consider intervening variables to explain why comfort management did not work. Such variables may be abusive homes, lack of financial resources, devastating diagnoses, or cognitive impairments that render the most appropriate interventions and comforting actions ineffective. Comfort management or comforting care includes interventions, comforting actions, the goal of enhanced comfort, and the selection of appropriate HSBs by patients, families, and their nurses. Thus, comfort management is proposed to be proactive, energized, intentional, and longed for by recipients of care in all settings.

LOGICAL FORM

Kolcaba (2003) used the following three types of logical reasoning: (1) induction, (2) deduction, and (3) retroduction (Bishop & Hardin, 2006) in the development of the Theory of Comfort.

Induction

Induction occurs when generalizations are built from a number of specific observed instances (Bishop & Hardin, 2006). 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 to do), and it is a deceptively easy-sounding assignment.

Such was the scenario during the late 1980s. Kolcaba was head nurse on an Alzheimer’s unit at the time and knew some of the terms then used to describe the practice of dementia care, such as facilitative environment, excess disabilities, and optimum function. When she drew relationships among them, she recognized that these 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 non-recursive relationship between comfort and optimum functioning. These efforts marked the first steps toward a theory of comfort and thinking about the complexities of the concept (Kolcaba, 1992a).

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