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The takeaway message from this application of the theory to education is (Simes et al., 2018):
-Comfort Theory can be used to identify levels of comfort in nurse educator's uses of simulation
-Kolcaba's Comfort Theory was actually adapted by Goodwin to be used specifically in nursing education

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Moving nurse educators towards transcendence in simulation comfort

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The takeaway message from this application of the theory to leadership is (Kolcaba et al., 2006):
-Comfort Theory can be used to help change a hospital environment for the better, and help to achieve Magnet designation
-Comfort Theory provides a leadership framework

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Comfort theory- a unifying framework to enhance the practice environment

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Theory Origins (McEwen & Wills, 2019):
-First step in developing the theory was a concept analysis in 1988 while Kolcaba was a graduate student
-Theory was published in 1994 and later changed
Primary Works:
-A Theory of Holistic Comfort for Nursing (1994)
-Process and Product of Comfort Care, Merged in Holistic Nursing Art (1995)
-The Art of Comfort Care (1995)
-Evolution of the Mid-Range Theory of Comfort for Outcomes Research (2001)
-Comfort Theory and Practice: A Vision for Holistic Health Care and Research (2003)
Theorist Information (Kolcaba, 2003):
-Born in Cleveland, Ohio and spent most of life there
-Graduated in 1965 with a diploma in nursing from St. Luke's Hospital School of Nursing
-Went back to school for her MSN with a specialization in gerontology
-Graduated with her PhD in Nursing in 1997
-Clinical experience in med-surg, long-term care, as well as home care

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Purpose of Theory (McEwen & Wills, 2019):
-Providing comfort for patients
-Comfort is an outcome of care that can lead to health-seeking behaviors, which lead to further comfort
Scope/Level of Theory (Kolcaba, 2018):
-Middle-range theory
Origin of the Theory (Kolcaba, 2018):
-A Theory of Holistic Comfort for Nursing (1994)
Major Concepts (McEwen & Wills, 2019):
-Comfort
-Comfort care
-Comfort measures
-Comfort needs
-Health-seeking behaviors
-Institutional integrity
-Intervening variables
Major Propositions (McEwen & Wills, 2019):
-Health care workers look at comfort needs of patients/family
-Nurses create interventions for comfort needs
-Intervening variables considered
-Interventions in caring manner-->enhanced comfort
-Desirable/realistic health-seeking behaviors identified
-Enhanced comfort-->increased chance of health-seeking behaviors
-When given comfort care and health-seeking behaviors-->better satisfaction and health-related outcomes
-Healthcare facility will flourish when patients/families/nurses are satisfied with care

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Author - Katharine Kolcaba, RN, MSN, PhD

Year First Published - 1994

Major Concepts

HEALTH CARE NEEDS

COMFORTING INTERVENTIONS

INTERVENING VARIABLES

ENHANCED COMFORT

HEALTH SEEKING BEHAVIORS

Internal behaviors

Peaceful death

External behaviors

INSTITUTIONAL INTEGRITY

BEST PRACTICES

BEST POLICIES

Typology

I consider Comfort Theory to be a middle-range predictive theory because of the limited number of concepts and their lower degree of abstraction compared to conceptual models and grand theories.. The diagram (above) which shows the concepts in relation to the other concepts, I consider to be a conceptual framework.

Brief Description

Nurses identify needs of patients and their families which have not been met. These needs are modified by intervening variables which are factors that nurses cannot change (such as poverty or a diagnosis). With these concepts in mind, nurses formulate a comfort care plan, with the goal of enhancing comfort over a measurement of baseline comfort (Part One). When comfort of patients and/or families is enhanced, they can engage more fully, either consciously or subconsciously, in health seeking behaviors (HSBs). HSBs are mutually agreed upon goals. HSBs can be internal (e.g blood work), external (goals in physical therapy), or a peaceful death (Part Two). When patients and families do better, the institution does better, as in measures of patient satisfaction or improved ratings (Part Three).

Taxonomic Structure of Comfort (or Comfort Grid)

Type of comfort:

Relief - the state of having a specific comfort need met.

Ease - the state of calm or contentment.

Transcendence - the state in which one can rise above problems or pain.

Context in which comfort occurs:

Physical - pertaining to bodily sensations, homeostatic mechanisms, immune function, etc.

Psychospiritual - pertaining to internal awareness of self, including esteem, identity, sexuality, meaning in one's life, and one's understood relationship to a higher order or being.

Environmental - pertaining to the external background of human experience (temperature, light, sound, odor, color, furniture, landscape, etc.)

Sociocultural - pertaining to interpersonal, family, and societal relationships (finances, teaching, health care personnel, etc.) Also to family traditions, rituals, and religious practices.

Adapted with permission from Kolcaba, K. & Fisher, E. A holistic perspective on comfort care as an advance directive. Critical Care Nursing Quarterly,18(4):66-76, 1996.
Primary Sources
Comfort Line
Kolcaba, K. (1994). A theory of comfort for nursing. Journal of Advanced Nursing, 19, 1178 1184.

Kolcaba, K. (1991). A taxonomic structure for the concept comfort: Synthesis and application. Image: Journal of Nursing Scholarship, 23, 237 240.

Kolcaba, K. (1992). Holistic comfort: Operationalizing the construct as a nurse sensitive outcome. Advances in Nursing Science, 15(1), 1 10.

Kolcaba, K. (2003). Comfort Theory and practice: A vision for holistic health care and research. New York, NY, Springer Publishing Co.

"The Theory of Comfort" in "The Nurse Theorists: Portraits of Excellence," Volume 3 (2017). A FITNE Production. Available online.

Additional sources with commentary

Kolcaba, K. (1992). Holistic comfort: Operationalizing the construct as a nurse sensitive outcome. Advances in Nursing Science, 15(1), 1 10.

Before I wrote Comfort Theory, I had done two concept analyses of comfort which led to a method of operationalizing (measuring) patient or family or nurse comfort. Many comfort questionnaires have since been constructed using the method described in this article and later in my book. These questionnaires have also been translated into many different languages and customized for different patient populations (see web site) leading me to believe that the concept of comfort is universal. The questionnaires are most appropriate for empirical studies. T best way to assess patient comfort in the clinical setting is through a verbal rating scale, asking patients to rate their comfort from zero to 10, with 10 being the best possible comfort in this situation. This should be done on a regular basis, and especially after comfort measures have been administered. Adaptations have been studied and published for children, moms in labor and delivery, perianesthesia settings, elderly patients, etc. I have pilot tested visual analog scales and find that they are not reliable.

Kolcaba, K. & Steiner, R. (2002). Correlations among measures of bladder function and comfort. Journal of Nursing Measurement,10, (1), 27-38.

This study showed that comfort was a valuable predictor of who would do well functionally. In this research the functional outcomes (HSB) was management of irritable bladder symptoms..

Kolcaba, K. (2003). Comfort Theory and Practice. New York, NY: Springer.

In my book, I define nursing interventions as ˆcomfort measures." They are interventions designed intentionally to enhance patients' or families' comfort. There are three levels of comfort measures: technical, coaching, and comfort food for the soul. They are defined as follows: Technical interventions are designed to maintain homeostasis and manage pain. The nurse is aware of patients' diagnoses and designs technical interventions accordingly. These interventions demand a great deal of skill; at the same time they meet the minimal expectations of patients and their families. Coaching are those interventions designed to relieve anxiety, provide reassurance and information, instill hope, listen, and help plan realistically for recovery, integration, or death in a culturally sensitive way; They consist usually of active listening, touch, and positive reinforcement. Coaching interventions are hoped for by patients and their families. Comfort food for the soul are those interventions that are not expected, are not technical, and are perhaps "old fashioned." They make patients feel strengthened in an intangible, personalized sort of way (e.g., back massage). These interventions go above and beyond expectations, and are most often done by the most expert of nurses. They can provide transcendence for the recipient and convey the nursing attitude of never giving up.

Also in my book, I defined a good death or "peaceful death" which is one type of health seeking behavior. It is defined as "a death in which conflicts are resolved, symptoms are well managed by strategic comfort measures, and acceptance by the patient and family members allows for the patient to "let go" quietly and with dignity. The extent of the peaceful death can be measured through a comfort questionnaire given to the family at an appropriate time.

Kolcaba, K., Tilton, C., & Drouin, C. (2006). Comfort theory: A unifying framework to enhance the practice environment. Journal of Nursing Administration, 36, 538-544.

For one of my earlier consulting jobs, I was asked to focus on the comfort of nurses. This surprised me and I undertook another review of the literature to determine what nurses hoped for in their hospital environments. The above article describes my findings, and places them in the context of Comfort Theory. A Nurses' Comfort Questionnaire has been constructed and tested.

March, A. & McCormack, D. (2009). Nursing theory-directed healthcare: Modifying Kolcaba's Comfort theory as an institution-wide approach. Holistic Nursing Practice, 23, 75-79.
Future Research
Prior to the publication of this article, I usually referred to Comfort Theory as a nursing theory. The above article convinced me to start using broader terms for the providers of comforting interventions. After all, I had previously consulted with architects, dental hygenists, nursing assistants, automobile manufacturers, etc. So my formal terms for the persons providing care are "healthcare providers." For example, "Health care providers assess the unmet comfort needs of patients and their families." Comfort is truly a multi-disciplinary desirable outcome of health care professions as well as other businesses.

Since the retirement of Kolcaba and her research team, many others have been doing comfort studies. However, most of the studies consist of instrument development for the measurement of comfort, and intervention studies to enhance patient comfort (part one of Comfort Theory). Research in the future should also test parts two and three of the theory.

Author

Katharine (Kathy) Kolcaba (1944 - )

Katharine Kolcaba taught nursing theory and gerontology at the University of Akron College of Nursing for 23 years. She retired as Associate Professor Emeritus in 2008 and continued to teach her intensive theory course, as well as guest lectures, upon request for several years post-retirement. She is co-coordinator and volunteer nurse in a Parish Nurse program serving a homeless or low income population. She also serves as consultant for her own company, The Comfort Line. Her invited presentations and workshops are focused on the application of Comfort Theory for improving the work environment and the experiences of patients and their families in health care situations. Kathy has published extensively on the outcome of holistic comfort including an award- winning web site called The Comfort Line and her book entitled Comfort Theory and Practice (2003).

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Contributor: Katharine Kolcaba September 8, 2018 Author - Katharine Kolcaba, RN, MSN, PhD Year First Published - 1994 Major Concepts HEALTH CARE NEEDS COMFORTING INTERVENTIONS INTERVENING VARIABLES ENHANCED COMFORT HEALTH SEEKING BEHAVIORS Internal behaviors Peaceful death External behaviors INSTITUTIONAL INTEGRITY BEST PRACTICES BEST POLICIES Typology I consider Comfort Theory to be a middle-range predictive theory because...

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The takeaway message from this application of the theory to practice is (Vendlinski & Kolcaba, 1997):
-Theory can be applied to hospice nursing
-Comfort theory used to assess/enhance comfort in hospice patients
-This could be used by the nurse practitioner working in hospice care to help ensure quality of care was being met

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Comfort care- A framework for hospice nursing