Running head: THEORY OF COMFORT

Theory of Comfort Lai W. Harper Ferris State University

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Abstract Kolcabas Theory of Comfort, a middle range nursing theory, has been applied in different practice settings; for example, hospice, oncology, radiation therapy, and surgery. The concept of comfort has been emphasized in the works of many nurse theorists. Kolcabas Theory of Comfort is focused on three types of comfort (relief, ease, and transcendence) by meeting the physical, psychosocial, environmental, and social health care needs of the recipients. The General Comfort Questionnaire (GCQ) can be used or modified as the framework for patients assessments. Patients comfort levels can be measured before and after the implementation of comfort interventions. Kolcabas Theory of Comfort has had significant impacts on the professional nursing education, practice, and research.

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Theory of Comfort According to Kearney-Nunnery (2008), theory, practice, and research are interrelated and interdependent (p. 46). The professional nursing practice should be based on theories. The nursing theories should be validated by research studies (p. 46). Kolcabas Theory of Comfort is the middle range nursing theory which is made up of concepts that are empirically measurable and statements that are empirically testable (p. 70). Histories and Significance of the Theory The concept of comfort has had its historical significance in nursing. Florence Nightingale (1859) stated that It must never be lost sight of what observation is. It is not for the sake of piling up miscellaneous information or curious facts, but for the sake of saving life and increasing health and comfort (p. 70). Goodnow (1935) also emphasized that a nurse is judged always by her ability to make her patient comfortable. Comfort is both physical and mental, and a nurses responsibility does not end with physical care (p. 95). In the 1990s, Kolcaba developed the Theory of Comfort with the focus on three types of comfort (relief, ease, and transcendence) (Tomey & Alligood, 2010, p. 708). Analysis of the Theory Tomey and Alligood (2010) discussed Kolcabas Theory of Comfort. Based on the Theory of Comfort, a person is defined as the recipient of comfort measures. The recipients are patients, students, prisoners, workers, older adults, communities, and institutions (p. 709). The environment is any aspect of patient, family, or institutional settings that can be manipulated by nurse(s), loved one(s), or the institution to enhance comfort (p. 711). The concept of health is defined as the optimal functioning of a patient, family, health care p rovider, or community as defined by the patient or group (p. 711). The concept of nursing is defined as the intentional

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assessment of comfort needs, the design of comfort interventions to address those needs, and reassessment of comfort levels after implementation compared with a baseline (p. 711). Unique Concepts The unique concept of Kolcabas Theory of Comfort is the immediate and holistic experience of being strengthened when needs are addressed for three types of comfort (relief, ease, transcendence) in four contexts (physical, psychospiritual, sociocultural, and environmental) (Tomey & Alligood, 2010, p. 709). Comfort interventions can decrease patients discomfort and increase the likelihood of health-seeking behaviors. Health-seeking behaviors can have positive outcomes and implications; for example, increased functional status, faster progress during rehabilitation, faster healing, or peaceful death when appropriate (p. 715). Based on the positive outcomes of patients health-seeking behaviors, the institutional integrity will be increased. The institution will have the implementation of the best practices and best policies for evidence-based comfort interventions (p. 709). Three Types of Comfort The nurse theorists (Orlando, Henderson, Paterson, and Zderad) had significant influences on Kolcabas concept of comfort. According to Tomey and Alligood (2010), Orlando stated that nurses relieved the needs expressed by patients (p. 708). Kolcabas concept of relief is defined as the state of a patient who has had a specific need met (p. 708). Henderson described the importance of maintaining the 13 basic f unctions of human beings (p. 708). Kolcabas concept of ease is defined as the state of calm or contentment (p. 708). Paterson and Zderad suggested that patients rise above their difficult ies with the help of nurses (p. 708). Kolcabas concept of transcendence is defined as the state in which one rises above ones problems or pain (p. 708).

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Four Contexts of Comfort The physical context of comfort is defined as the comfort pertaining to bodily sensation (Tomey & Alligood, 2010, p. 708). The psychosocial context is the internal awareness of self, including esteem, concept, sexuality, and meaning in ones life; ones relationship to a higher order or being (p. 708). The environmental context is defined as pertaining to the external surroundings, conditions, and influences (p. 708). The social context is defined as pertaining to interpersonal, family, and societal relationships (p. 708). Framework for Patient Assessment The Theory of Comfort can be used as the framework for patients assessments. Assessment is achieved through the administration of verbal rating scales (clinical) or comfort questionnaires (research), using instruments developed by Kolcaba (Tomey & Alligood, 2010, p.711). Nurses can assess patients pain and comfort levels using the verbal rating scale ranging from zero to ten. The General Comfort Questionnaire (GCQ) can also be used for assessing patients comfort levels before and after the implementation of comfort interventions. The GCQ is based on the Likert scale ranging from strongly agree to strongly disagree (see Appendix A). Implications in Nursing Education The Theory of Comfort can have significant impacts on the nursing education. Students can learn more about the application of Comfort Care Plans on Kolcabas website. In fact, Comfort Theory has been included in electronic nursing classification systems such as NANDA (2007-2008), NIC (2001), and NOC (2004) (Tomey & Alligood, 2010, pp. 714 -716). In addition, Goodwin, Sener, and Steiner (2007) advocated Kolcabas concept of holistic comfort as the teaching guideline in the nursing education program. Teachers can relieve and ease students discomforts. Students can transcend into increased motivation, participation, and satisfaction in

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their lifelong learning. To relieve the physical discomfort, teachers encourage students to have good self-care in nutrition and sleep. To provide the psycho-spiritual comfort, teachers give inspiration and positive reassurance to relieve the students anxieties. To relieve the sociocultural discomfort, teachers show caring and respect for students different cultural and social backgrounds (pp. 280-281). Goodwin et al. concluded that teachers and students created an environment with a mutually rewarding learning partnership (p. 278). Implications in Nursing Practice Kolcaba and Wilson (2002) stated that the Theory of Comfort could be applied in perianesthesia nursing. Nurses can relieve patients physical discomfort, such as pain and nausea. Patients psycho-spiritual comfort needs can be met by comfort measures targeted toward transcendence, such as a massage, mouth care, special visitors, caring touch, and special words of continued encouragement (p.105). The socio-cultural comfort needs can be met by providing culturally sensitive reassurance, supportand caring (p. 105). To provide environmental comfort needs, nurses should try to decrease noise, lights, and interrupted sleep to facilitate a peaceful environment (p. 106). Increased patients comfort is closely related to patients positive outcomes for health-seeking behaviors, such as early ambulation and rehabilitation. Health-seeking behaviors are positively related to the improved institutional integrity for the implementation of the best policies and best practices (Kolcaba & Wilson, 2002, p. 108). Strengths of the Theory Kolcabas Theory of Comfort is not an abstract theory. In addition to perianesthesia nursing, the Theory of Comfort can also be applied to the oncology, radiation therapy, and endof-life nursing practices. With the availability of the Comfort Questionnaires for different clinical practices on Kolcabas website, nurses can have easy and free access for using this

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evaluation tool before and after the implementation of comfort interventions. The Comfort Questionnaires has also been translated into different languages including Spanish, Portuguese, Italian, Turkish, and Farsi (Kolcaba, 2010, Comfort Instruments, para 2). The strength of the Theory of Comfort is that patients outcomes are measurable. Limitations of the Theory The Theory of Comfort can be used as the guideline to enhance the nurses comfort and improve the practice environments (Kolcoba, Tilton, & Drouin, 2006, pp 539-540). In reality, the comfort intervention for an adequate staffing is difficult to be accomplished. The institutions may have the intentions to promote comfort environments based on the Theory of comfort. However, hospital administrators have to balance the budget for the operations of the organizations. The health insurance companies have limitations on the reimbursements of health care services provided by the institutions. Nurses have no choice but to take care of an increasing numbers of patients. The increased patient-nurse ratios can increase nurses discomfort in the work environments. New Insights about the Theory According to Kolcaba, Tilton, and Drouin (2006), a New England hospital selected Kolcabas Comfort Theoryas a unifying framework for applying for Magnet Recognition Status (p. 538). The philosophy of the chief nursing officer was that every nurse is a leader (p. 540). The shared leadership can provide a positive insight to enhance the comfort of the nurses in the work environment (p. 539). The nurses can participate to improve the quality performances and work towards the goal of the Magnet recognition. Comfort is the universal concept that nurses strive to provide for the patients in the work environments. The Theory of Comfort has had significant impacts on the nursing education, practice, and research.

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References Goodnow, M. (1935). The technique of nursing. Philadelphia, PA: W. B. Saunders. Goodwin, M., Sener, I., & Steiner, S. (2007). A novel theory for nursing education: Holistic comfort. Journal of Holistic Nursing, 25(4), 278-285. doi: 10.1177/0898010107306199 Kearney-Nunnery, R. (2008). Advancing your career: Concepts of professional nursing (4th ed.). Philadelphia, PA: F. A. Davis Company. Kolcaba, K. (2010, March 4). Kolcaba comfort instrument. Retrieved from http://www.thecomfortline.com/webinstruments.html Kolcaba, K., Tilton, C., & Drouin, C. (2006). Comfort theory. A unifying framework to enhance the practice environment. The Journal of Nursing Administration, 36(11), 538-544. Kolcaba, K., & Wilson, L. (2002). Comfort care: a framework for perianesthesia nursing. Journal of PeriAnesthesia Nursing, 17(2), 102-114. Nightingale, F. (1859). Notes on nursing. London: Harrison Tomey, A. M., & Alligood, M. R. (2010). Nursing theorists and their work. (7th ed.). Maryland Heights, MO: Mosby Elsevier

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Appendix A Kolcabas 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: Strongly I am glad I can fill out this questionnaire about my comfort. Agree 4 3 Disagree 2 1 Strongly

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21.

My body is relaxed right now I feel useful b ecause Im working hard I have enough privacy There are those I can depend on when I need help I dont want to exercis e My condition gets me down I feel confident I feel dependent on others I feel my life is worthwhile right now I am inspired by knowing that I am loved These surroundings are pleasant The sounds keep me from resting No one understands me My pain is difficult to endure I am inspired to do my best I am unhappy when I am alone My faith helps me to not be afraid I do not like it here I am constipated right now I do not feel healthy right now This room makes me feel scared

4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

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Strongly Agree 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Strongly Disagree 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

10

22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48.

I am afraid of what is next I have a favorite person(s) who makes me feel cared for I have experienced changes which make me feel uneasy I am hungry I would like to see my doctor more often The temperature in this room is fine I am very tired I can rise above my pain The mood around here uplifts me I am content This chair (bed) makes me hurt This view inspires me My personal belongings are not here I feel out of place here I feel good enough to walk My friends remember me with their cards and phone calls My beliefs give me peace of mind I need to be better informed about my health I feel out of control I feel crummy because I am not dressed This room smells terrible I am alone but not lonely I feel peaceful I am depressed I have found meaning in my life It is easy to get around here I need to feel good again

Retrieved from http://www.thecomfortline.com/webinstruments.html

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Appendix B Checklist for Submitting Papers CHECK DATE, TIME, & INITIAL 3-25-2010 LWH 3-25-2010 LWH 3-25-2010 LWH PROOFREAD FOR: APA ISSUES

1. Page Numbers: Did you number your pages using the automatic functions of your Word program? [p. 230 and example on p. 40)] 2. Running head: Does the Running head: have a small h? Is it on every page? Is it less than 50 spaces total? Is the title of the Running head in all caps? Is it 1 from the top of your title page? (Should be a few words from the title of your paper). [p. 229 and example on p. 40] 3. Abstract: Make sure your abstract begins on a new page. Is there a label of Abstract and it is centered at the top of the page? Is it a single paragraph? Is the paragraph flush with the margin without an indentation? Is your abstract a summary of your entire paper? Remember it is not an introduction to your paper. Someone should be able to read the abstract and know what to find in your paper. [p. 25 and example on p. 41] 4. Introduction: Did you repeat the title of your paper on your first page of content? Do not use Introduction as a heading following the title. The first paragraph clearly implies the introduction and no heading is needed. [p. 27 and example on p. 42] 5. Margins: Did you leave 1 on all sides? [p. 229]

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6. Double-spacing: Did you double-space throughout? No triple or extra spaces between sections or paragraphs except in special circumstances. This includes the reference page. [p. 229 and example on p. 40-59] 7. Line Length and Alignment: Did you use the flush-left style, and leave the right margin uneven, or ragged? [p. 229] 8. Paragraphs and Indentation: Did you indent the first line of every paragraph? See P. 229 for exceptions.

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9. Spacing After Punctuation Marks: Did you space once at the end of separate parts of a reference and initials in a persons name? Do not space after periods in abbreviations. Space twice after punctuation marks at the end of a sentence. [p. 87-88] 10. Typeface: Did you use Times Roman 12-point font? [p. 228] 9. Abbreviation: Did you explain each abbreviation the first time you used it? [p. 106-111] 11. Plagiarism: Cite all sources! If you say something that is not your original idea, it must be cited. You may be citing many timesthis is what you are supposed to be doing! [p. 170] 12. Direct Quote: A direct quote is exact words taken from another. An example with citation would look like this: The variables that impact the etiology and the human response to various disease states will be explored (Bell-Scriber, 2007, p. 1). Please note where the quotation marks are placed, where the final period is placed, no first name of author, and inclusion of page number, etc. Do all direct quotes look like this? [p. 170-172]

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13. Quotes Over 40 Words: Did you make block quotes out of any direct quotes that are 40 words or longer? [p. 170-172] 14. Paraphrase: A paraphrase citation would look like this: Patients respond to illnesses in various ways depending on a number of factors that will be explored (Bell-Scriber, 2007). Do all paraphrased citations look like this? [p. 171 and multiple examples in text on p. 40-59] 15. Headings: Did you check your headings for proper levels? [p. 62-63].

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16. General Guidelines for References: A. Did you start the References on a new page? [p. 37] B. Did you cut and paste references on your reference page? If so, check to make sure they are in correct APA format. Often they are not and must be adapted. Make sure all fonts are the same. C. Is your reference list double spaced with hanging indents? [p. 37]

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PROOFREAD FOR GRAMMAR, SPELLING, PUNCTUATION, & STRUCTURE 3-25-2010 LWH 13. Did you follow the assignment rubric? Did you make headings that address each major section? (Required to point out where you addressed each section.) 14. Watch for run-on or long, cumbersome sentences. Read it out loud without pausing unless punctuation is present. If you become breathless or it doesnt make sense, you need to rephrase or break the sentence into 2 or more smaller sentences. Did you do this? 15. Wordiness: check for the words that, and the. If not nece ssary, did you omit? 16. Conversational tone: Dont write as if you are talking to someone in a casual way. For example, Well so I couldnt believe nurses did such things! or I was in total shock over that. Did you stay in a formal/profe ssional tone? 17. Avoid contractions. i.e. dont, cant, wont, etc. Did you spell these out?

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18. Did you check to make sure there are no hyphens and broken words in the right margin? 19. Do not use etc. or "i.e." in formal writing unless in parenthesis. Did you check for improper use of etc. & i.e.? 20. Stay in subject agreement. When referring to 1 nurse, dont refer to the nurse as they or them. Also, in referring to a human, dont refer to the person as that, but rather who. For example: The nurse that gave the injection. Should be The nurse who gave the injection Did you check for subject agreement? Likewise, dont refer to us, we, our, within the paperthis is not about you and me. Be clear in identifying. For example dont say Our profession uses empirical data to support . . Instead say The nursing profession uses empirical data.. 21. Did you check your sentences to make sure you did not end them with a preposition? For example, I witnessed activities that I was not happy with. Instead, I witnessed activities with which I was not happy. 22. Did you run a Spellcheck? Did you proofread in addition to running the

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Spellcheck? 23. Did you have other people read your paper? Did they find any areas confusing? 24. Did you include a summary or conclusion heading and section to wrap up your paper? 25. Do not use we us our you I etc. in a formal paper! Did you remove these words? 26. Does your paper have sentence fragments? Do you have complete sentences?

27. Did you check apostrophes for correct possessive use. Dont use apostrophes unless it is showing possession and then be sure it is in the correct location. The exception is with the word it. Its = it is. Its is possessive.

Signing below indicates you have proofread your paper for the errors in the checklist:

_____Lai Harper__________________________________Date:_____3/25/2010____________

A peer needs to proofread your paper checking for errors in the listed areas and sign below:

_____Jann Angell_____________________________Date:_____3/28/2010________________

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Appendix C

Grading Rubric for Theory Paper 1. Introduction of theory/model a. Introduction clear and well focused b. History and significance of model 2. Analysis of Model a. Explain the model in terms of: Person, Environment, Health, and Nursing. b. Explain other concepts that are unique to the model. c. Demonstrate how the model can be used in clinical practice. d. Explain how the model can be used as a Framework for patient assessment. e. Explain the model within the context of nursing education. f. Identify strengths and limitations of the model. g. Analyze the model overall, demonstrating new insights about the model. 3. Evidence of Academic Writing a. Development of a clear, logical, well-supported paper; demonstrating original thought and content. b. Evidence of research with a minimum of 2 research articles in addition to the course required texts. Correct acknowledgement of sources using APA style referencing. Attaches APA checklist c. Overall presentation; grammar, spelling, punctuation, clean and legible. d. Stays within page limit which includes: one cover page, one reference page, body of paper is to have a maximum of 5 pages and a minimum of 3 full pages. Total Possible Points Very well done. Thank you. Total Points Earned

Possible points 5 5

Points Earned 5 5

10 10 10 10 10 10 10

10 10 10 10 10 10 10

5 5

5 5

5 5

5 5

100

100