By Kathy Kolcaba, Ph.D., RN, C.
Updated: December 16, 2008
FAQs (Frequently Asked Questions)
Theoretical Development
- How do you define comfort for nursing research?
- Why do you combine psychological comfort and spiritual comfort into one context of experience called psychospiritual?
- How do you define the types and contexts of comfort?
- What is the relationship between comfort and pain?
- What nurse theorists were incorporated into your conceptualization of comfort?
- Why is your definition of comfort so complicated?
- How did you get started in your study of comfort?
- Would you please provide detailed information about your personal background? What were the influences and/or context in which you developed Comfort Theory?
- Why do you call your theory a mid-range Theory of Comfort?
- How do you define the metaparadigm concepts?
- What is borrowed and what is unique about Comfort Theory?
- Do you think Comfort Theory can be used with different cultures?
- On a continuum, what is the opposite of comfort?
- What are the latest developments with Comfort Theory?
- How is comfort different from caring?
- Can you provide definitions, propositions, and assumptions for your theory?
- What are the latest developments with Comfort Theory?
- What are the philosophical underpinnings of your theory?
How do you define comfort for nursing research?
Holistic comfort is defined as the immediate experience of being strengthened through having the needs for relief, ease, and transcendence met in four contexts of experience (physical, psychospiritual, social, and environmental) [Kolcaba, K. (1992). Holistic comfort: Operationalizing the construct as a nurse-sensitive outcome. Advances in Nursing Science, 15(1), 1-10, p. 6.; Kolcaba, K & Fisher, E. (1996). A holistic perspective on comfort care as an advance directive. Critical Care Nursing Quarterly, 18(4), 66-76, p. 68.]How do you define the types and contexts of comfort?
TYPES:Why do you combine psychological comfort and spiritual comfort into one context of experience called "psychospiritual"?
Relief: the state of a patient who has had a specific need met.
Ease: the state of calm or contentment.
Transcendence: the state in which one rises above one's problems or pain.CONTEXTS IN WHICH COMFORT IS EXPERIENCED:
Physical: pertaining to bodily sensations and homeostatic mechanisms.
Psychospiritual: pertaining to internal awareness of self, including esteem, concept, sexuality, and meaning in one's life; one's relationship to a higher order or being.
Environmental: pertaining to external surroundings, conditions, and influences.
Sociocultural: pertaining to interpersonal, family, and societal relationships. Also to family traditions, rituals, and religious practices.
(from Critical Care Nursing Quarterly, 1996, 18(4), p. 69.)
They were combined because indicators of each overlapped and, in some cases, were identical (e.g. meaningfulness, faith, identity, self-esteem). Judith Spross independently combined psychological and spiritual contexts the same way and came up with the same contexts of experience in her work about suffering.What is the relationship between comfort and pain?
Comfort is a larger umbrella term compared to pain. As stated above, there are three types of comfort: relief, ease, and transcendence. Relief is the absence of specific previous discomforts, a common one being pain which can be of varying intensity. Pain that has a physical origin also is influenced by psychospiritual, sociocultural, and environmental factors.I define pain as a multidimensional discomfort including sensory, cognitive, and affective components (Melzak & Wall, 1982). It is a specific sensation in the body that “hurts” with a varying degree of intensity (for example, from mild to severe or from 1 to 10). The discomfort of pain is often a significant detractor from comfort. Looking at pain holistically, pain is intensified by lonliness, fear, anxiety, noxious stimuli, anger, etc.
What nurse theorists are incorporated
into your conceptualization of comfort?
Relief: Orlando
Ease: Henderson
Transcendence:Paterson & Zderad
[See Taxonomic Structure and/or Operationalizing articles for complete references.] Contexts of comfort come from nursing literature on holism. [Explanation for their derivation in same articles.]
Why is your definition of comfort so
complicated?
Comfort is a complex concept but, prior to this work, was defined negatively as absence of pain, nausea, and itching. My definition defines comfort as a positive concept and accounts for its many aspects beyond physical comfort. The taxonomic structure enables us to identify comfort needs, design interventions targeted to those needs, and measure the effectiveness of those interventions.
How did you get started in your study
of comfort?
An early assignment in my MSN program (by Dr. Rosemary Ellis) was to diagram my nursing practice. At that time, I was a head nurse on an Alzheimer's unit and I used the concept of comfort to designate the state I wanted my patients to be when they weren't trying to perform special tasks. At a presentation of my "framework" to a gerontological conference, I was asked if I had done a concept analysis of comfort. I replied, "No, but that's the next step." Actually, I hadn't thought about it before, but realized that it should be my next step, and I had an obligation to do so after commiting myself publically. (That was 12 years ago!)
Would you please provide detailed information about your personal background? What were the influences and/or context in which you developed Comfort Theory?
Some of my background is on my personal page of my web site and much more is in my book. But I guess the biggest influences on me were:
- The death of my father when he was 39, I was 8, my brother (John) was 6 and my mom was only 33.
- The courage of my mom to buy a house for the three of us before she had a job, and then her raising of us with the right mixture of trust, encouragement, and hands-off discipline. John and I didn’t need much discipline, as we were good kids. I don’t think we even minded being relatively poor as we were in an ordinary working class school and neighborhood, where we fit quite well. I had wonderful friends in high school whom I still see often.
- My mother was always concerned about what people would say if family “”secrets” became public (not that ours were particularly interesting!). Her mother was rather heavy handed in this regard, and my mom has a hard time even now being straight forward. As a result, I try to be very direct in my writing and speaking. But she never put any limitations on my brother or me, as far as what we could achieve and she was proud when we did well in school. She was supportive of our ideas and accomplishments. But I always missed having a father, still do!
- We continued visiting my father’s family every summer (about a 6 hour drive) and I believe I am more like them than my mother’s family. I particularly admired my paternal grandmother who was more intellectual, strong willed, and direct than my maternal grand mother. Because of her, I have a positive view on aging, and went into gerontology.
- My choice to be a nurse when I was in high school was made because I like people and science. A local diploma program gave me a full scholarship so I could give my half of my insurance money (from my father’s death) to my brother for a state university. At this time, the most common way to be a nurse was with a diploma from a hospital-based “training” program. We were not exposed to nursing theory, and I don’t think much was available at that time (in the 1960’s) anyway.
- I always loved nursing, but also wanted to be a stay at home mom, so I worked part time in a variety of settings while my girls were little. I didn’t go to graduate school until I was in my late 30’s and my children were pretty independent. At that point in my “career” I wanted more responsibility but couldn’t get promoted without a college degree. But I gathered lots of clinical experience in my early years, so I knew what specialties I liked. I was drawn particularly to dementia care, forming the foundations for Comfort Theory, I had to be a nurse-detective because my patients couldn’t verbalize why they were uncomfortable. Our practice was very compassionate, required strong leadership, creativity, and empathy. These were the characteristics of nursing that I valued a lot, rather than technology. (The movie ET aroused in me very negative feelings when he was hooked up to all that equipment. I paid attention because I was about to accept a perioperative nursing position with lots of technological components. I realized that job wasn’t for me, and also began thinking about the importance of comfort in nursing.)
- My brother died of cancer when he was 41, and during his illness I gained more experience with comforting actions of nurses, and how to articulate what they did. Because of that experience and its timing, my dissertation is about women with breast cancer, not dementia or gerontology. And I have done a lot of work with end of life comfort.
- My spirituality, which my mother fostered and role-modeled for me, has also had a strong influence.
Why do you call your theory a "mid-range"
Theory of Comfort?
This is not a broad or grand theory. The working part of the theory, the last FULL line of the conceptual framework (Diagram 2) matches up to the description of the theory on page one (it diagrmas the relationships between the concepts). Also, the theory can be easily operationalized for appropriate settings. When each concept is operationalized, you have a practice level theory.How do you define the metaparadigm concepts?
What is borrowed and what is unique about Comfort Theory?
Nursing: the intentional assessment of comfort needs, design of comfort measures to address those needs, and re-assessment of patients' or community comfort after implementation of comfort measures, compared to a previous baseline.Patient: an individual, family, or community in need of health care.
Environment: exterior influences (physical, political, institutional, etc.) which can be manipulated to enhance comfort.
Health: optimum function of a patient/family/community facilitated by enhanced comfort.
Can Comfort Theory be used in different cultures?
I borrowed the ideas about Relief, Ease, and Transcendence as stated above. Later, I "borrowed" the contexts of experience from the literature review about holism. I put these ideas together in a unique way. Later, I borrowed the framework for the First and Second parts of Comfort Theory from Henry Murray (see comfort theory article). But I hung nursing concepts on his abstract framework in a unique way. The idea of institutional outcomes was unique and was added through a process Tomen and Alligood call retroduction.
On a continuum, what is the opposite of comfort?
Comfort has been described in Canadian, Hispanic, and Australian cultures. In addition, I have inquiries from Iran, Turkey, Thailand, China, South America, Normay, etc. So I think COMFORT is a universal concept. The first step to testing comfort theory in other cultures would be to translate the instrument into a different language. I am looking for volunteers!
What are the latest developments with Comfort Theory?
I believe the opposite of comfort is suffering.
I changed social comfort to sociocultural comfort.
I added the concept and definition of Institutional Integrity to the theory to address the trend in nursing research and practice to measure outcomes of nursing care. Recently, the definition of Institutional Integrity (InL) was expanded to include regions, states, and countries and InI was linked to Best Practices and Best Policies. I felt this change was necessary to keep up with current trends in health care. Lately, hospitals are interested in improving patient satisfaction scores, and I think adopting comfort theory for their practice environment is the "way to go."
How is comfort different from caring?
These are the main points I would like you to remember about the concepts of comfort and caring:
1. comfort is a patient outcome. Caring is about how nurses do their work.
2. the effects of caring are difficult to measure; the effects of comfort interventions (including caring) are measureable
3. comfort (as I use it) is a noun (outcome or product), caring is an adjective - it describes a process.
4. comfort theory is testable - I have built my career on testing it. Is Swanson's theory testable? What kind of design for each?
5. there is one taxonomy of comfort, and 12 aspects (cells of the grid). They are inter related - always - because this is a holistic theory.
Can you provide definitions, propositions, and assumptions for your theory?
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Table 1. Definitions of concepts in Kolcaba’s middle range Theory of Comfort
Table 2. Propositions in Kolcaba’s middle-range Theory of Comfort
Table 3. Assumptions underpinning Kolcaba’s middle-range Theory of Comfort
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What are the latest developments with Comfort Theory?
Latest developments with CT: I recently expanded the definition of InI to include health care organizations at local, regional, state, and national levels. In addition to hospital systems, the definition of “institutions” includes Public Health agencies, Medicare and Medicaid programs, Home Care agencies, Nursing Home consortiums, etc. Examples of variables related to this expanded definition of InI include cost savings, improved access, decreased morbidity rates, decreased hospitalizations and readmissions, improved health-related outcomes, efficiency of services and billing, and positive cost-benefit ratios.
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Education and Practice
Isn't comfort care impractical in a downsized setting?Is comfort care difficult to learn?
Does the framework of comfort care account for medical problems of patients?
Care plans are becoming obsolete. Are there other heuristic devices for students to help them learn the art of comfort care?
How can I experience a comforting intervention?
Considering cultural competence issues, how difficult has it been to adapt the General Comfort Questionaire to different cultures?
Students who work in the ICU felt the theory would be quite difficult to apply in their practice setting. Have you any advice for them and has any research been done in this area?
Is the Comfort Theory being used in any hospitals as their philosophy to guide nursing practice? Or being used in universities to guide curriculum?
Isn't comfort care impractical in a downsized setting?
Comfort care is efficient and satisfying to patients and nurses; thus, it is even more important in a time of limited resources. Plus, comfort care offers a framework for making nurses recognizable and indispensable because of what they do. When patients and families associate enhanced comfort with Registered Nurses, they will DEMAND that RNs are readily available.Is comfort care difficult to learn?
Also, Comfort Care is a framework for interdisciplinary health care, as it focuses on patients. As such it is a unifying framework for care for the future.Note: when presenting comfort care to students last semester, one earnest young man who had some prior experience working in nursing homes raised his hand and asked, "Is this a new concept? I have never seen it being practiced!" I think this is a wake-up call to us in nursing practice and education to get back to the basics.
No. Comfort care is intuitive because we are all familiar with our own comfort. The template for comfort care can be applied repeatedly but individualistically to most patients, so that it becomes automatic., thorough, and satisfying.
Does
the framework of comfort care account for medical problems of patients?
Yes! Physical comfort includes oxygenation, elimination, mobility, cognitive abilities, electrolyte balance, hydration, pain management, and all aspects of the medical problem(s).
Care
plans are becoming obsolete. Are there other heuristic devices for students?
Yes! On clinical preparation sheets, students can identify comfort needs in four contexts: physical (see above definition of physical comfort), psychospiritual, social, and environmental. Students should list, in another section, the intervening variables so a full picture of each patient emerges. Then, they can list interventions, patients perception of comfort after the interventions, what next, realistic health seeking behaviors, and expected insitutiional outcomes (patient satisfaction is the easiest).
What is your current initiative with Comfort Theory?
See section on Magnet Status.
How can I experience a comforting intervention?Considering cultural competence issues, how difficult has it been to adapt the General Comfort Questionaire to different cultures?
You may try relaxing with my Guided Imagery audio available to everyone by clicking here
Students who work in the ICU felt the theory would be quite difficult to apply in their practice setting. Have you any advice for them and has any research been done in this area?
The General Comfort Questionairre and variations of there of have been adapted for many other languages, most lately Korean, Portuguese, Italian, Japanese etc. (See instrument section). It seems to have wide applicability across cultures.
The assessment of comfort needs is certainly different in ICU, especially if the patient is non-verbal. However, I think nurses are astute as discerning if a patient is comfortable, and possible detractors from comfort when they seem restless, are grimacing, etc. Families are often very useful in this detective work, and their presence alone, is a comfort measure. Maintaining homeostasis is an important part of physical comfort, so interventions to assure homeostasis, in this theory, are called comfort interventions too. I think having a basic pattern to apply for assessment, intervention, and evaluation makes our nursing care more efficient where ever the setting. Refer also to the Comfort Behaviors Checklist as a guide to assessment of non-verbal patients. To view other nurses' use of CT in practice, see our message board.
Is the Comfort Theory being used in any hospitals as their philosophy to guide nursing practice? Or being used in universities to guide curriculum?
My “pet project” now is to consult with large health care systems to enhance their working environments. This is important for retention of nurses, better patient outcomes, and is also useful when applying for national recognitions. Several hospitals are using CT for the Magnet Status application process. An article about this is out in JONA in November 2006 by Kolcaba, Tilton, and Drouin. See Enhancing Your Work Environment link.
What are the philosophical underpinnings of your theory?
Please see the attached article: Evolution
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Research
What was the topic of your dissertation?What statistical method do you recommend for comfort research?
What research have you worked on?
Can I ask you questions about developing my research design?
You stated that you hoped to conduct research on health seeking behaviors and institutional integrity in the next 5 years (which would have been 2002-present). Were you able to document a positive correlation between HSB and institutional integrity?
Use of taxonomic structure?
What was the topic of your dissertation?
- I did a pilot study of the General Comfort Questionnaire while in graduate
school. At CWRU, I was told, this was not sufficient for graduation.
My advisor then "suggested" I do an intervention study to see if comfort
was really measureable. Therefore, I chose a population which had acute
comfort needs (women with early-stage breast cancer), a holistic intervention
that was practical for implementation (audiotaped guided imagery), and
three repeated measures in order to demonstrate a trend if any existed.
I graduated in Dec., 1996 after 11 years in the doctoral program at FPB!
(Eleven years sounds awful but I took one course at a time while working
full time at The University of Akron and raising a family.) My dissertation
article was published in Kolcaba, K. & Fox, C. (1999). The effects
of guided imagery on comfort of women with early stage breast cnancer undergoing
radiation therapy.
Oncology Nursing Forum,26(1), 67-72..
A second article that tests theoretical assumptions of comfort can be found
in Kolcaba, K. & Steiner, R. Empirical evidence for the nature of holistic
comfort. Journal of Holistic Nursing,18 (1), 46-62..
What statistical method do you recommend
for comfort research?
- Because comfort theoretically is state specific, it should be measured
prior to your intervention and at least two times after the intervention.
Repeated Measures MANOVA is recommended for statistical analysis because
time is used as a contrast on the mean of the dependent variables (your
measurements of comfort at each time point). Also, subjects serve as their
own controls. Trend analysis can be used to demonstrate the model of differences
in comfort over time between treatment and control groups.
Data from verbal or numeric rating scales (see instruments section) are quick and reliable for clinical use or research. I no longer recommend visual analog scales because they are not sensitive enough for research. For reliability, use test-retest methods asking patients about comfort at no less than 10 minute intervals, without an intervention. (Test-retest reliability is not appropriate when considerable time has elapsed, especially in stressful health care situations, because the state of comfort is too variable.
Can I ask you questions about developing my research design?Urinary incontinence was the first program of research I conducted with my partner, Dr. Therese Dowd. (see references below)
Schirm, V., Baumgardner, J., Dowd, T., Gregor, S., & Kolcaba, K. (2004). Development of a healthy bladder education program for older adults. Geriatric Nursing, 25(5), 301-306.
Dowd, T., Kolcaba, K., & Steiner, R. (2003). The addition of coaching to cognitive strategies. Journal of Ostomy and Wound Management, 30(2), 90-99.
We developed a hand massage intervention that theoretically would enhance the comfort of dying patients. (link to reference page for article on hand massage and hospice patients).
We are also doing health promotion studies, and relating the immediate outcome of comfort to subsequent HSBs such as using Healing Touch to reduce stress symptoms in college students. (article in press, November 2007, Holistic Nursing Practice)
**A chapter about Comfort Theory is published in the nursing textbook, Nursing Theorists and Their Work (5th Edition) by Tomey and Alligood. (Chapter 24).
Yes. Please use my e-mail address kolcaba@uakron.edu. Again, thank you for your interest!
You stated that you hoped to conduct research on health seeking behaviors and institutional integrity in the next 5 years (which would have been 2002-present). Were you able to document a positive correlation between HSB and institutional integrity?
Actually, I am depending on other nurses to do this for me, especially as institutions apply for Magnet Status. Patient satisfaction is a InI measure that is already obtained and can be related to other HSBs. However, I as an outside consultant to hospital systems, do not have access to those satisfaction data.
I am working on a presentation of your theory of comfort and can't quite grasp how the GCQ is used with the taxonomic structure. I see how each cell has a negative or positive number based on the question in the GQC, but it is unclear to me how you can score the results. I would appreciate any help I can get on this? (submitted by a student)
You score the results by reverse coding the negative items. For example, if the item states "I am fatigued" that is not comfort. Persons who respond strongly agree (6) will be coded (1), persons who respond (5) will be scored (2) and so on. You can do this when you enter your data into the data analysis spread sheet, or the computer can specify which questions need to be reverse coded.
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