Frequently Asked Questions on Theoretical Comfort

What do you say to nurses to claim they don’t have time to apply Comfort Theory?


I tell them that theoretical nursing saves time, is more satisfying, and results in better outcomes. The evidence is there for the efficacy of Comfort Theory. I encourage administrators to enhance staffing ratios so that nurses can practice more holistically and in more “comforting” ways.




What is your take home message?


The take home is to convince the “system” that the comfort needs of the patient come first. And if they allow you to address/meet these needs, the system will benefit. The system will benefit even more if the nurses are comfortable, hence the reason for Magnet Status. Comfort Theory is being used as a guiding framework for the Magnet application process for just these very reasons.




Are there people who are in the health care system (or should be) who need comfort but are not in pain?


Pain signals that something isn’t right Pregnant moms and their babies usually do not have pain. Laboring moms have a different kind of pain: we call it “contractions” and they vary by intensity. They are normal and healthy and produce an expected and desired outcome (the baby). They are made worse by anxiety, so enhancing comfort begins with treating anxiety and education about normal labor and delivery.




How can I spread comfort theory to the nurses on my floor?


I think they learn by example. So be a mentor to them, and if you have the opportunity, tell them you subscribe to Comfort Theory. There is a ready-made simple to use pattern for comforting care in the taxonomic structure: just mentally tick off the four contexts of comfort needs: physical, psychospiritiual, sociocultural, and environmental. Were all of those needs met in your interaction with your patient? If so, they will rest peacefully for a long while.





Frequently Asked Questions on Education and Practice

What do you say to nurses to claim they don’t have time to apply Comfort Theory?


I tell them that theoretical nursing saves time, is more satisfying, and results in better outcomes. The evidence is there for the efficacy of Comfort Theory. I encourage administrators to enhance staffing ratios so that nurses can practice more holistically and in more “comforting” ways.




What is your take home message?


The take home is to convince the “system” that the comfort needs of the patient come first. And if they allow you to address/meet these needs, the system will benefit. The system will benefit even more if the nurses are comfortable, hence the reason for Magnet Status. Comfort Theory is being used as a guiding framework for the Magnet application process for just these very reasons.




Are there people who are in the health care system (or should be) who need comfort but are not in pain?


Pain signals that something isn’t right Pregnant moms and their babies usually do not have pain. Laboring moms have a different kind of pain: we call it “contractions” and they vary by intensity. They are normal and healthy and produce an expected and desired outcome (the baby). They are made worse by anxiety, so enhancing comfort begins with treating anxiety and education about normal labor and delivery.




How can I spread comfort theory to the nurses on my floor?


I think they learn by example. So be a mentor to them, and if you have the opportunity, tell them you subscribe to Comfort Theory. There is a ready-made simple to use pattern for comforting care in the taxonomic structure: just mentally tick off the four contexts of comfort needs: physical, psychospiritiual, sociocultural, and environmental. Were all of those needs met in your interaction with your patient? If so, they will rest peacefully for a long while.





Frequently Asked Questions about Research

What statistical method do you recommend for analysis?


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.




How did students react to learning that, in the clinical course you taught, they would be applying a theory and writing theory-driven care plans?


The students liked using Comfort Theory for their care plans, because they could list all the things they did for the patient and family in any given day. One student asked, after listening to the introductory lecture, “Is comfort a new idea in nursing?” He was at the end of his junior year!




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.

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.




Is comfort care difficult to learn?


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 institutional outcomes (patient satisfaction is the easiest).




How can I experience a comforting intervention?


You may try relaxing with my Guided Imagery audio available to everyone.




Considering cultural competence issues, how difficult has it been to adapt the General Comfort Questionnaire to different cultures?


The General Comfort Questionnaire and variations of thereof 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.




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 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” was 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 in JONA, November 2006 by Kolcaba, Tilton, and Drouin.




What do you say to nurses to claim they don’t have time to apply Comfort Theory?


I tell them that theoretical nursing saves time, is more satisfying, and results in better outcomes. The evidence is there for the efficacy of Comfort Theory. I encourage administrators to enhance staffing ratios so that nurses can practice more holistically and in more “comforting” ways.




What are your values and beliefs about nursing practice? How have these beliefs and values influenced the work that you have done?


I believe that nursing practice must be fully described and then honored for the important comforting work that we do. To do this, nurses must document in the patient record the nature of patients’ comfort needs and how those needs were addressed. Additionally, patients’ rating of their comfort from 0 to 10 with 10 being the highest comfort possible in the health care situation. If patients are unable to rate their own comfort, and Comfort Behaviors Checklist is available on my web site (along with lots of other comfort questionnaires and the children’s Comfort Daisies.

I believe that nursing science is about patient/family comfort primarily, and secondarily about nurses’ comfort. Nurses’ comfort is related to retention and continuity of care, and can be addressed and measured effectively by nurses in management. Further, patient/family comfort is a direct and value-added indicator of quality rather than an indicator or POOR quality, such as skin breakdown or med errors.

Lastly, I believe that theoretical nursing is easier and more efficient than nursing without a theory, because a theory provides a pattern for care by which all elements of nursing can be organized. It is towards these values that all of my work has been directed.




How would/does Comfort Theory impact health care policy?


If nurses care about the comfort and well-being of persons in their community, they will want them to be able to stay healthy and/or return to health. Therefore, a national health care policy which provides basic care for all should be a priority. Many of our demonstration projects for nurse- run clinics and telephone triage, for example, are being scrapped because states do not have enough money to fund them. Yet those governors are not campaigning for a national health policy (nor are many nurses, I might add). The ANA, however, does have a fairly strong lobby in DC and they supported the Patient Affordability Act. Few nurses have joined in that effort.... Maybe, someday, health care for all will become a reality.




Was there ever a time that providing comfort for the patient meant sacrificing their medical care? Was there a situation in which a client asked for something that might compromise their physically healing but would improve their comfort? If so, how did you handle that situation?


First of all, patient autonomy is very important, so they get to decide what they want. Our job is to inform them about all options, including side effects and cost, so they can make an informed decision. Self-comforting strategies that are NOT healthy include smoking, opioids, alcohol, etc. Unhealthy strategies are especially difficult to give up for patients with mental illnesses.




Are client’s ever resistant to your attempts to comfort them?


Sometimes they want to be left alone. But then I come back later and at least ask "Do you feel better now?"




Do client’s ever refuse your interventions to facilitate their healing? How do you break through those walls that clients might have up?


Of course. We try to be subtle. Some medical/nursing treatments hurt physically, and we try to help patients transcend those types of discomforts, like immobility, N & V, etc. Remember, this theory is a pattern for care and can be easily reduced (for that purpose) to assessments of current physical, psychospiritual, sociocultural, and environmental comfort. These four types of comfort can all be addressed in one holistic intervention.




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 measurable. 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 December, 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 cancer 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.




What research have you worked on?


My first research was my dissertation study. After that, I teamed up with Dr. Therese Dowd and we studied comfort in the following populations: Urinary incontinence, end of life, long term care, and stressed college students. All of these efforts resulted in publications which are available on Research Gate.




Can I ask you questions about developing my research design?


Yes. Please use my e-mail address kathykolcaba@yahoo.com. Again, thank you for your interest!




You stated that you hoped to conduct research on health seeking behaviors and institutional integrity. 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.




Are you aware of any research that has compared some outcome measure for
nurses trained in your model versus those trained in a more mechanistic one?


I have asked some of the nursing directors that question and they can give me “Benchmarks” that have been met regarding Comfort Theory and related outcomes. However, I am not aware of any actual research as you describe above, nor any publications that might address your very important question. Of course, this is a critical area of research if we are to promote the theory (posted June 13, 2020).





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