COMFORT THEORY IN NURSINGBY DR. KATHARINE KOLCABA, RN

Birthdate: December 28, 1944

INTRODUCTION

The comfort theory is a nursing theory that was first developed in the 1990s by Katharine Kolcaba.

Comfort Theory is middle range theory for health practice, education, and research.

Kolcaba's theory has the potential to place comfort once again in the forefront of healthcare. (March A & McCormack D, 2009).

BACKGROUND OF THE THEORIST

Born as Katharine Arnold on December 8th 1944, in Cleveland, Ohio

Diploma in nursing from St. Luke's Hospital School of Nursing in 1965

Graduated from the Frances Payne Bolton School of Nursing, Case Western Reserve University in 1987

Graduated with PhD in nursing and received certificate of authority clinical nursing specialist in 1997

Specialized in Gerontology, End of Life and Long Term Care Interventions, Comfort Studies, Instrument Development, Nursing Theory, Nursing Research

Currently an associate professor of nursing at the University of Akron College of Nursing

Published Comfort Theory and Practice: a Vision for Holistic Health Care and Research

Conceptual Framework:

CONCEPTS AND DEFINITIONS (Kolcaba, 2010)

Kolcaba described comfort as existing in 3 forms: relief, ease, and transcendence. Also, Kolcaba described 4 contexts in which patient

comfort can occur: physical, psychospiritual, environmental, and sociocultural.

Kolcaba described comfort as existing in 3 forms: relief, ease, and transcendence.

If specific comfort needs of a patient are met, for example, the relief of postoperative pain by administering prescribed analgesia, the individual experiences comfort in the relief sense.

If the patient is in a comfortable state of contentment, the person experiences comfort in the ease sense, for example, how one might feel after having issues that are causing anxiety addressed.

Lastly, transcendence is described as the state of comfort in which patients are able to rise above their challenges. 

Health Care Needs are those identified by the patient/family in a particular practice setting.

Intervening Variables are those factors that are not likely to change and over which providers have little control (such as prognosis, financial situation, extent of social support, etc).

Comfort is an immediate desirable outcome of nursing care, according to Comfort Theory

Health Seeking Behavior (HSBs):

Institutional Integrity - the values, financial stability, and wholeness of health care organizations at local, regional, state, and national levels. 

Best Policies are protocols and procedures developed by an institution for overall use after collecting evidence.

Assertions of Kolcaba's theory

In the comfort theory, Kolcaba asserted that when healthcare needs of a patient are appropriately assessed and proper nursing interventions carried out to address those needs, taking into account variables intervening in the situation, the outcome is enhanced patient comfort over time. Once comfort is enhanced, the patient is likely to increase health-seeking behaviors. These behaviors may be internal to the patient (eg, wound healing or improved oxygenation), external to the patient (eg, active participation in rehabilitation exercises), or a peaceful death. Furthermore, Kolcaba asserted that when a patient experiences

health-seeking behaviors, the integrity of the institution is subsequently increased because the increase in health-seeking behaviors will result in improved outcomes. Increased institutional integrity lends itself to the development and implementation of best practices and best policies secondary to the positive outcomes experienced by patients.

Four Broad Assumptions and Theoretical Assertions

Human beings have holistic responses to complex stimuli. Comfort is a holistic outcome of effective nursing care. Human beings have a need for comfort and will seek comfort

wherever possible. Nurses are in a position to identify the comfort needs of their

patients, design comfort measures, and assess outcomes to support enhanced comfort.

PARADIGM OF THE THEORY

Nursing

Nursing is described as the process of assessing the patient's comfort needs, developing and implementing appropriate nursing interventions, and evaluating patient comfort following nursing interventions.

Intentional assessment of comfort needs the design of comfort measures to address those needs, and the reassessment of comfort levels after implementation.

Assessment may be either objective, such as in the observation of wound healing, or subjective, such as by asking if the patient is comfortable. 

Health

Health is  considered to be optimal functioning, as defined by the patient, group, family or community 

Person/Patient

Patients can be considered as individuals, families, institutions, or communities in need of health care.

Environment

Any aspect of the patient, family, or institutional surroundings that can be manipulated by a nurse(s), or loved one(s) to enhance comfort.

LIMITATIONS:

What could be considered as comfort could not be considered comfort to another person. This mirrors that both pain and comfort are subjective. Traditionally, pain has been viewed simply as a symptom of an illness or condition. However, at present, pain itself is considered to be a separate disease and merits special consideration. Knowing that pain affects every aspect of a client’s life, pain management and the provision of comfort from that pain is one of the most researched concepts in nursing (Potter & Perry, 2004).

To help a client gain comfort or relief, the nurse must view the experience through the eyes of the client. Pain is tiring and demands energy from the person experiencing it. It interferes with relationships and the individual’s ability to maintain self-care.

Pain is also complex and involves influences as mentioned in the previous paragraphs. Thus this means that each individual’s pain experience is different. The nurse should then therefore consider all factors that affect he client in pain. This is necessary to ensure a holistic approach to the assessment and care of the client who is in pain or discomfort.

APPLICATION OF THE THEORY ON A CASE STUDY:

Marie, an 11-year-old Filipino female patient, diagnosed with Acute Lymphocytic Leukemia, was admitted in a semi-private ward in the Oncology Unit. She is about to receive her combination chemotherapy when the nurse noticed her alone and crying silently while lying on her bed.

Relief Ease Transcendence

Physical

Mouth sores;Nausea and vomiting;Neuropathy;Diarrhea/Constipation

Comfortable resting position which facilitates sleep and relaxation to deteriorate fatigue

Patient resumes most of her ADLs with all the side effects controlled

Psycho spiritual Anxiety;Alopecia;

Anticipation of social stigma

Actual need for reassurance and

Radiation recall

towards baldness and skin problems

support from the healthcare team and significant others

Environmental

Cold room; Patients were cohorted in a single room

Deviation from aseptic technique and standard precaution;Lack of privacy

Need for calm and positive atmosphere which strictly adheres to infection control guidelines; Need for privacy for personal hygienic routine care

SocioculturalAbsence of family

Failure of effective communication due to language barrier

Need for familial support and reinforcement

Taxonomic Structure of Marie's Comfort Needs

When nurses are committed to provide satisfyingly holistic comfort care, needs for relief, ease, and/or transcendence are identified routinely throughout the practice. Assessment could go back and forth to relief, ease, and transcendence until the main focus of health care will be identified and be addressed. However as the patient’s condition varies, it is essential that the nurse identify correctly which context that the patient and his family’s concerns entails priority of comfort measures. When comfort needs are addressed in one context, total comfort is enhanced in the remaining contexts. 

Nurses are the mighty front liners in the health care institution. As active participants on strengthening and enhancing comfort of every patient, they engage themselves on activities to achieve and maintain a certain level of their optimal health. They tend to be the advocates of patients, leading them to be the patients’ first link to normalcy once they face a frightening or painful experience. Coaching and reassuring the clients towards recovery, safety, and rehabilitation, and these activities are identified by Scholtfeldt (1975) as health seeking behaviors (HSB). Kolcaba (2001) states that HSBs are further related to desirable institutional outcomes such as decreased cost, improved family and nurse satisfaction, earlier discharge and low readmission rates. 

Comfort Interventions

Examples Agent

Standard Comfort

Assessment for development and complaints of the side effects of the chemotherapy (may use Comfort daisies, Comfort behavior, Checklist, etc.); Frequently check vitals and watch out for fever or signs of nosocomial infections Administer medications or treatments to relieve the side effects of chemotherapy

Nurse/Consultation with family and doctors

Coaching

Avoiding the word "pain" upon assessment, obtaining data, and rendering health teaching for a pediatric patient Initiate patient and family education as needed

Doctors/Nurses Consultation with family

Comfort Food for the Soul

Practice guided imagery to eliminate factors that could increase physical discomfort Provide privacy as Marie is entering pubescent stage when she will be concerned about her body image and privacy

Nurse/Family

Comfort interventions have three categories: (a) standard comfort interventions to maintain homeostasis and control pain; (b) coaching, to relieve anxiety, provide reassurance and information, instill hope, listen, and help plan for recovery; and (c) comfort food for the soul, those extra nice things that nurses do to make children/families feel cared for and strengthened, such as massage or guided imagery. (Kolcaba, 2003)

ASSESSMENT TOOL RESEARCH SAMPLE:

Code #____________________

GENERAL COMFORT QUESTIONNAIRE

Thank you VERY MUCH for helping me in my study of the concept COMFORT. Below are statements that may describe your comfort

right now. Four numbers are provided for each question; please circle the number you think most closely matches your feeling. Relate these questions to your comfort at the moment you are answering the questions.

Below is an example:

I am glad I can fill out this questionnaire about my

comfort……. Strongly Strongly

Agree Disagree

4 3 2 1

1. My body is relaxed right now 4 3 2 1

2. I feel useful because I’m working

Hard 4 3 2 1

3. I have enough privacy 4 3 2 1

4. There are those I can depend on when

I need help 4 3 2 1

5. I don’t want to exercise 4 3 2 1

6. My condition gets me down 4 3 2 1

7. I feel confident 4 3 2 1

8. I feel dependent on others 4 3 2 1

9. I feel my life is worthwhile right now 4 3 2 1

10. I am inspired by knowing that I am

Loved 4 3 2 1

11. These surroundings are pleasant 4 3 2 1

12. The sounds keep me from resting 4 3 2 1

13. No one understands me 4 3 2 1

14. My pain is difficult to endure 4 3 2 1

15. I am inspired to do my best 4 3 2 1

16. I am unhappy when I am alone 4 3 2 1

17. My faith helps me to not be afraid 4 3 2 1

18. I do not like it here 4 3 2 1

19. I am constipated right now 4 3 2 1

20. I do not feel healthy right now 4 3 2 1

21. This room makes me feel scared 4 3 2 1

22. I am afraid of what is next 4 3 2 1

Strongly Strongly

Agree Disagree

4 3 2 123. I have a favorite person(s) who makes me feel cared for 4 3 2 1

24. I have experienced changes which make me feel uneasy 4 3 2 1

25. I am hungry 4 3 2 1

26. I would like to see my doctor more often 4 3 2 1

27. The temperature in this room is fine 4 3 2 1

28. I am very tired 4 3 2 1

29. I can rise above my pain 4 3 2 1

30. The mood around here uplifts me 4 3 2 1

31. I am content 4 3 2 1

32. This chair (bed) makes me hurt 4 3 2 1

33. This view inspires me 4 3 2 1

34. My personal belongings are not here 4 3 2 1

35. I feel out of place here 4 3 2 1

36. I feel good enough to walk 4 3 2 1

37. My friends remember me with their cards and phone calls 4 3 2 1

38. My beliefs give me peace of mind 4 3 2 1

39. I need to be better informed about my health 4 3 21

40. I feel out of control 4 3 2 1

41. I feel crummy because I am not dressed 4 3 2 1

42. This room smells terrible 4 3 2 1

43. I am alone but not lonely 4 3 2 1

44. I feel peaceful 4 3 2 1

45. I am depressed 4 3 2 1

46. I have found meaning in my life 4 3 2 1

47. It is easy to get around here 4 3 2 1

48. I need to feel good again 4 3 2 1

BIBLIOGRAPHY/ RESOURCES:

http://www.nursingcenter.com/prodev/ce_article.asp?tid=851431

http://nursingtheory.net/mr_comfort.html

http://currentnursing.com/nursing_theory/comfort_theory_Kathy_Kolcaba.html

http://ivythesis.typepad.com/term_paper_topics/2008/06/theory-of-comfo.html#ixzz2ixzRJbz0

http://comfortcareinnursing.blogspot.com/p/comfort-theory-major-concepts.html