Katharine Kolcaba's Theory of Comfort

Katharine Kolcaba's Theory of Comfort

Kelly Ferreira

Summer, 2004.

In the early part of the 20th century, comfort was the central goal of nursing and medicine. Comfort was the nurse's first consideration. A "good nurse" made patients comfortable. In the early 1900's, textbooks emphasized the role of a health care provider in assuring emotional and physical comfort and in adjusting the patient's environment. For example, in 1926, Harmer advocated that nursing care be concerned with providing an atmosphere of comfort.

In the 1980's, a modern inquiry of comfort began. Comfort activities were observed. Meanings of comfort were explored. Comfort was conceptualized as multidimensional (emotional, physical, spiritual). Nurses provided comfort through environmental interventions.

It was in this decade that Kolcaba began to develop a theory of comfort when she was a graduate student at Case Western Reserve in Cleveland, Ohio. She is currently a nursing professor at the University of Akron in Ohio.

Kolcaba's (1992) theory was based on the work of earlier nurse theorists, including Orlando (1961), Benner, Henderson, Nightingale, Watson (1979), and Henderson and Paterson. Other non-nursing influences on Kolcaba's work included Murray (1938). The theory was developed using induction (from practice and experience), deduction (through logic), and from retroaction concepts (concepts from other theories).

The basis of Kolcaba's theory is a taxonomic structure or grid that has 12 cells (Kolcaba, 1991; Kolcaba & Fisher, 1996). Three types of comfort are listed at the top of the grid and four contexts in which comfort occurs are listed down the side of the grid. The three types are relief, ease and transcendence. The four contexts are physical, psycho-spiritual, sociocultural and environmental.

Kolcaba does not believe that a focus on comfort is unique to nursing and she believes that her theory can be interdisciplinary. She believes that multiple professions can converge around her theory of comfort and provide holistic care to patients.

Internal Evaluation

Major assumptions underlying Kolcaba's (1992) theory include:

1. Human beings have holistic responses to multiple, complex stimuli

2. Comfort is a desirable outcome and germane to nursing

3. Human beings strive to meet comfort needs. It is a process that is continuous.

4. Having comfort needs met strengthens patients to engage in health-seeking behaviors of their own.

5. Patients who are given the power to engage in health-seeking behaviors of their own have a better perceptions of and about their health care.

6. When an institution's care is based on a system of values that is focused on the patient or those who receive care, that institution is said to have integrity.

Kolcaba defined the concepts of nursing's metaparadigm as follows:

a. Nursing: Intentional assessment of comfort needs, design of comfort measures, implementation and evaluation of comfort measures. The nurse assesses and reassesses the patient by asking questions (e.g., Are you comfortable? How do you feel?) or observing (lab results, wound after a dressing change, or behavioral changes). There is also a comfort questionnaire available on-line at http://www.thecomfortline.com (Kolcaba's web page).

b. Person: all individuals. Patients are care recipients, individuals, families, institutions, communities in need of health care

c. Environment: any aspect of patient, family or institution surroundings that the nurse can manipulate to aide and improve the patient's comfort.

d. Health: optimum functioning, as defined by patient, family or community.

A close critique of these definitions raises some questions about the extent to which Kolcaba's (1992) work is fully intertwined with the metaparadigm of nursing. Kolcaba does an adequate job of describing nursing, its focus and its activities. The definition of the other three concepts are less well-developed. In fact, some of the concepts do not relate well with each other. For example, Kolcaba's definition of health as optimal functioning does not tie in with other concepts in her theory. Functioning is not ever mentioned anywhere in her theoretical definitions. One might expect for Kolcaba to include a perception of comfort in a definition of health. As a second example, Kolcaba (1992) does not describe the Person in much detail. She speaks of the Patient as the recipient of care. Her assumptions suggest that the human being is complex, holistic, and will actively seek to have needs met. Does this mean then that the Person will actively participate in nursing care? How does this type of Person relate to Environment as defined by Kolcaba? What does holistic mean - a unitary being or a multidimensional being? If multidimensional, then what are the dimensions? Her definition of Person lacks the specification that the human is perceptual, which must be true if her definition of Health is to hold up. Health is defined as a perception of functioning. It seems that, at this stage of the theory's development, the concepts of the theory are not firmly grounded in nursing's metaparadigm. However, as a middle-range theory, it is not incumbent on the theorist to address all of nursing but only the segment of nursing that is the focus of the theory. Immediate theory development might include aligning the definition of health with the other definitions and including environment more closely with nursing activities.

Major concepts in Kolcaba's theory include the following:

1. Health care needs: Needs related to well-being that cannot be relieved or bettered by the patient's family/support system. Health care needs include physical, psychological, spiritual, social and environmental needs. The needs are made known by verbal/non verbal communication or by signs that the nurse monitors.

2. Comfort measures: There are interventions by the nurse that are meant to address specific comfort needs of the one receiving the care. There are three types of comfort measures:

a.