Kolcaba’s Comfort Theory: Analysis and Evaluation
In my nursing practice I frequently care for long term elderly residents on ventilators and who suffer from stage 3 or 4 pressure ulcers, diabetic, venous ulcers etc. Instead of simply providing pain medications and wound treatment to ease their pain or giving medications to relax them, I wanted to learn ways to enhance the comfort of these residents. This led me to learn more about Katherine Kolcaba’s theory of comfort. I found her theory to be useful in understanding the theory of comfort. Hence as a nurse, it became important for me to analyze, evaluate and research more on its applicability in the world of nursing and also in other health care disciplines. Level and Scope of the Comfort Theory
The middle range theory has more specific focus and is more concrete than nursing theory in its level of abstraction (Alligood, 2006b, 2006d; Chinn & Kramer, 2008; Fawcett, 2005). They specify such factors as the age group of the patient, and most important the action of the nurse (Alligood, 2006c). Given this information, the comfort theory can be referred to as a middle range theory. I believe that the theory of comfort is at the prescriptive level. Since there is a goal of “comfort” which is to be attained by prescribed actions which come under comfort management. Here the comfort management includes interventions focusing on comfort, actions providing comfort, 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” (Dowd, p713, 2010). When it comes to the scope of comfort theory, it is limited to comfort and is fairly simple to understand with lower level of abstraction. Kolcaba’s Assumptions of Comfort Theory
Kolcaba believes that “comfort is a basic human need which persons strive to meet or have met. It is an active endeavor” (Kolcaba, 1994). One of her assumptions for comfort theory state that human beings react to complex stimuli holistically and that comfort is a desirable holistic outcome. She also claims that enhanced comfort strengthens patients to engage in health seeking behaviors (HSBs) of their choice (Kolcaba & Kolcaba, 1991). This empowerment leads to active engagement in HSBs by the patients. Thus, patients who get empowered with active engagement in HSBs are satisfied with their health care. This leads to institutional integrity which is based on a value system oriented to the recipients of care (Kolcaba, 1997, 2001). Analysis and Evaluation of Comfort Theory
When Kolcaba presented her frame work for dementia care (Kolcaba, 1992, b), she was asked if she had done a concept analysis on 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” (Dowd, p.707. 2010).Three early nursing theorists’ ideas were used by Kolcaba to synthesize or derive the types of comfort in the concept analysis (Kolaba & Kolcaba, 1991). Kolcaba explained two dimensions in her analysis. “The first dimension of comfort consists of three states, called relief, ease, and transcendence” (Kolcaba, 1994, p. 1179). “The second dimension of comfort is the contexts in which comfort can occur…which are derived from the nursing literature about holism” (Kolcaba, 1994, p.1179). The four contexts are physical, psychospiritual, environmental, and sociocultural. When these four contexts are merged with the three types of comfort, a taxonomic structure is made which can be referred to in order to consider the complexities of comfort as an outcome (Dowd, 2010). The theory of comfort has three assertions.
The first assertion states that effective comfort interventions leads to increased comfort for recipients. The second assertion states that increase in comfort leads to increase in participation in health seeking behavior. The third assertion states that increase in health seeking behavior (HSB) leads to increase in quality of care which in turn increases the institution ability to collect data and evidence for allowing best practices. The concepts of the comfort theory are clearly defined and the relationships are easily understood. This theory is simple and basic to nursing care. The taxonomic structure of comfort facilitates researchers’ development of comfort instruments for new settings (Kolcaba,1991).The first assertion of the theory stating that effective comfort interventions leads to increased comfort for patients , has been tested and supported with women with breast cancer (Kolcaba & Fox, 1999), persons with UI (Dowd, Kolcaba, & Steiner, 2000), persons in hospice (Kolcaba, Dowd, Steiner, & Mitzel, 2004). And stressed college students (Dowd, Kolcaba, Steiner, & Fashinapaur, 2007).
Also, the second assertion was supported in the UI study, when patients with enhanced comfort showed increased HSBs. This theory has been a guiding frame for a lot of studies and researches. Some of the areas are nurse midwifery, perioperative nursing, urinary bladder control, orthopedic nursing, etc. For clinical practice, the perianesthesia nurses incorporated comfort theory in managing their patients’ comfort. The comfort theory was also used as a teaching philosophy in a fast- track nursing education program for students. Kolcaba developed the General Comfort Questionnaire to measure holistic comfort in a sample of hospital and community participants. She also asserts that emphasizing and supporting comfort management by any institution or community will result in increased patient/ family satisfaction. Extending the theory of comfort to the community and developing the universal nature of comfort are the two current areas of interest.
Comfort theory has been included in electronic nursing classification systems such as NANDA (2007-2008), NIC (2001), and NOC (2004). The taxonomic structure of comfort was utilized to create a Portuguese instrument for hospitalized psychiatric patients to test the effectiveness of Guided imagery for increasing comfort ( immediate outcome) and decreasing depression, anxiety, and stress (subsequent outcomes). Repeated measures revealed that the treatment group had significantly improved comfort and decreased depression, anxiety, and stress over time (Apostolo & Kolcaba, 2009). “The theory of comfort describes patient-centered practice and explains how to determine if comfort measures matter to patients, their health, and the viability of institutions.” (Dowd, p.716, 2010). Conclusion
The theory of comfort from its very beginning has focused on what is germane to nursing. The development of the General Comfort Questionnaire has helped to validate and measure the outcomes of the concepts. It is an easy guide for nurses in planning nursing care. It has also provided a framework for students to organize their assessment and plan of care. In research, the theory provides a way to validate improvement in patient comfort after receiving comforting interventions (Dowd, 2010).The theory has been used to test the effectiveness of specific holistic interventions for increasing comfort, to demonstrate the correlation between comfort and subsequent HSBs, and to relate HSBs to desirable institutional outcomes. Use of Kolcaba’s framework in nursing care can lead to enhanced comfort, a desirable patient outcome for nursing worldwide.
Alligood, M.R. (2006b). Models and theories in nursing practice. In M.R. Alligood & A.M. Tomey (Eds.) Nursing Theory: Utilization & Application (3rd ed., pp17-42). St. Louis: Mosby.
Alligood, M.R. (2006c). Models and theories: Critical thinking structures. In M.R. Alligood & A.M. Tomey (Eds.) Nursing Theory: Utilization & Application (3rd ed., pp 43-65). St. Louis: Mosby. Apostolo, J., & Kolcaba K. (2009). The effects of guided imagery on comfort, depression, anxiety, and stress of psychiatric in patients with depressive disorders. Archives of Psychiatric Nursing, 23(6), 403-411.
Chinn,P.L., Kramer, M.K. (2008). Integrated Knowledge development in nursing (7th ed.). St.Louis: Elsevier-Mosby.
Dowd, T. (2010). Theory of Comfort. In M. Alligood & A. Tomey (Eds.), Nursing Theorists and
Their Work (pp 705 – 721). Missouri: Mosby Elsevier
Dowd,T., Kolcaba,K., & Steiner, R.(2000). Using cognitive strategies to enhance bladder control and comfort. Holistic Nursing practice, 14 (2), 91-103.
Dowd, T.,Kolcaba, K.,Steiner, R.,& Fashinpaur, D. (2007). Comparison of healing touch and coaching on stress and comfort in young college students.Holistic Nursing Practice, 21(4), 194-202. Fawcett, J. (2005). Contemporary nursing knowledge : Conceptual models of nursing and nursing theories (2nd ed.). Philadelphia: F. A. Davis
Kolcaba,K.,& Kolcaba, R. (1991). An analysis of the concept of comfort. Journal of Advanced Nursing, 16, 1301-1310.
Kolcaba, K. (2001). Evolution of the mid range theory of comfort for outcomes research. Nursing Outlook, 49 (2), 86-92.
Kolcaba, K. (1997). The ComfortLine.com. Akron, OH: The University of Akron College of Nursing.
Kolcaba, K. (1992b). The concept of comfort in an environment framework.
Journal of Gerontological Nursing, 18 (6), 33-38.
Kolcaba, K. (1994). A theory of holistic comfort for nursing. Journal of Advanced Nursing, 19, 1178-1184.
Kolcaba, K., Dowd,T., Steiner, R., Mitzel, A. (2004). Hand massage to enhance comfort for
hospice patients. Journal of Hospice and Palliative care, 6(2), 91-102. Kolcaba, K., & Fox,C. (1999). The effects of guided imagery on comfort of women with early stage breast cancer undergoing radiation therapy. Oncology Nursing Forum, 26 (1), 67- 92.
NANDA:Herdman, TH.,Heath,C., Meyer, G., Scroggins,L., & Vassallo,B., (2007-2008). Nursing Diagnoses: Definitions & Classification. St.Louis: Mosby, 34. NIC: Johnson,M.,Bulechek, G.,Dochterman, J.,Maas, M.,& Moorhead,S. (2001). Nursing Diagnoses, Outcomes, & Interventions. St. Louis: Mosby, 221. NOC: Moorhead, S., Johnson, M., & Mass,M.(2004). Nursing Outcomes Classification. St.Louis:Mosby, 228.
March, A., & McCormack, D. (2009). Nursing theory-directed healthcare: modifying Kolcaba’s comfort theory as an institution-wide approach.