Usefulness Of Kolcaba's Theory Of Comfort example essay topic

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 meta paradigm 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 web (Kolcaba's web page). b. Person: all individuals. Patients are care recipients, individuals, families, institutions, communities in need of health care.

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 meta paradigm 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 meta paradigm. 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. Technical care: reduce pain and maintain homeostasis b.

Coaching: relieves anxiety, instills hope, gives reassurance, listens, assists in planning culturally sensitive measures. Comfort food for the soul strengthens patients in intangible, memorable ways that patients do not expect. They fortify patients through such actions as back massage, guided imagery, music therapy, reminiscence and hand-holding. 3. Intervening variables: There are variables that are connected and communicate with each other to change or influence how the person sees total comfort. These variables are identified as: past experiences, age, attitudes, state of emotion, system of support, prognosis, finances and the totality of elements in the person's experience.

4. Comfort: It is the state that is experienced and perceived by the recipients of comfort measures. The comfort experience can be in four contexts: a. Physical: pertaining to bodily sensations that may or may not be related to medical diagnoses (Kolcaba, 1997) b. Psycho-spiritual: Having meaning in life, involves self-awareness, esteem, sexuality, belief in and relationship with someone "higher" or a supreme being. Sociocultural: Relationships that are interpersonal, in the family, or in the society d.

Environmental: Pertaining to external surrounding, conditions and influences, including color, noise, light, temperature, access to nature and texture. There are 3 types of comfort: a. Relief: how a recipient is when they have had their specific need met; free of discomfort b. Ease: state of relaxation or happiness; "at ease"c. Transcendence: the recipient rising above their level of discomfort, trouble or pain; strengthened, motivated, determined By having these comforts met, the patient is made stronger immediately or holistically. 5.

Health-seeking behaviors: Actions related to the goal of striving for health. These behaviors can be internal, external or dying in peace. They may be defined by the patient or developed in consultation with a nurse. 6. Institutional integrity: These are:" corporations, communities, schools, hospitals, churches, reformatories and others that posses qualities or states of being complete, whole, sound, upright, appealing, honest, and sincere " Inter-relationship of Concepts theory is a system of ideas or concepts that are inter-connected. On Kolcaba's web page, there is a conceptual framework for comfort theory.

A portion of the framework (line 4) represents the mid-range Theory of Comfort. Other portions of the framework (lines 1, 2, and 3) are from Murray's theory of personality and provide framework for relating comfort to other nursing concepts. The diagram shows that the receiver has health care needs (i. e., pain relief). Because there are needs that must be addressed, the nurse does a nursing assessment of subjective and objective data and develops a plan of care.

The nurse needs to assess what the receiver sees as total comfort and consider it in the plan of care. Then she / he will start with the individualized comfort measures (pain medication, soothing music, massage, repositioning). If I am to reposition this patient for pain relief and I turn the patient on the left side, but lying on their left side increases discomfort, then I should not turn them to the left side for any substantial length of time, unless it is medically indicated. Once the comfort measure is provided, the receiver will respond in one way or another with comfort data. It is to be noted that comfort is not what the nurse sees it as, but what the recipient states it is.

Once the nurse sees that the patient is comfortable, then it is time to teach and reinforce so that the receiver (i. e., family and patient) can start their own health seeking behaviors (i.e. guided imaging = internal, back rub / massage = external, the realization that death is imminent and there is no despair). The key concepts are all inter-related in the diagram and the propositions. Propositional statements from Kolcaba's (1992) theory include: 1. Nurses identify patients' comfort needs that have not been met by existing support systems. 2. Nurses design interventions to address comfort needs of patients.

3. Comfort needs in one context may influence comfort needs in another. 4. Expert nurses are expert in comfort care 5. One way to enhance comfort is to manipulate the environment 6. Intervening variables are taken into account in designing the interventions and determining if they have probability for success.

7. If the intervention is effective and delivered in a caring manner, the immediate outcome of enhanced comfort is attained and the intervention can be called a comfort measure. 8. Patients and nurses agree upon desirable and realistic health-seeking behaviors (HSB).

9. If enhanced comfort is achieved, patients are strengthened to engage in HSBs, which further enhances comfort. 10. When patients engage in HSBs as result of being strengthened by comfort care, nurses and patients are more satisfied with health care and demonstrate better health related (diagnosis-specific) outcomes. 11.

A professional working environment produces better patient and institutional outcomes. 12. When patients and nurses are satisfied with health care in a specific institution, public acknowledgement about the institutions' contributions to health in the United States will contribute to institutions remaining viable and flourishing. Consistency of the theory Overall, the theory is consistent, with one exception. The terms of the theory are used consistently, and the structure is clear and easy to grasp. The assumptions that undergird the theory prevail throughout Kolcaba's writings.

The diagrams associated with the theory help to show the consistency of the tenets and use of terms. The concepts of the theory are related in logical ways. Only the definition of health seems inconsistent with the rest of the theory. Simplicity of the theory This theory is simple, rather than complex. The number of major concepts is four, but the number of sub concepts I growing as the theory is developed. The concepts are concrete, not highly abstract, and are clarified by the grid of sub concepts (Kolcaba, 1994).

Relationships among concepts are not complex. If one studies it, one can quickly see that the concepts stem back to basic nursing skills and the traditional mission of nursing. The language of the theory is not difficult to understand. It is easy to read and inherently makes sense to a nurse. The instruments to assess comfort needs are also simple in the number of concepts and are easy to utilize. Adequacy / Generalizability of the theory The theory is comprehensive in scope and can address a broad range of mainstream, independent nursing activities.

Basic nursing is to provide for the comfort of the patient and those in need. This may be in any setting, inside or outside the four walls or an institution and with various ages and cultures. The simplicity of the theory and the ease of application and understanding of the theory does not mean that the theory can not be used in high tech areas. Specific publications have cited the use of the theory in hospice care (Vendlinski& Kolcaba, 1997) and care of patients with rehabilitative needs (Dowd, Kolcaba, & Steiner, 2000). The theory is especially useful for outcomes research (Kolcaba, 2001). External Evaluation Kolcaba (2000) offers a mid-range theory that focuses on the concept of comfort as the essence of nursing care.

Although the theory is relatively new, recent literature reflects the usefulness of the theory as a guide for clinical practice and research. It has been applied in numerous practice settings with a variety of types of patients. In addition, several research studies have been published based on Kolcaba's work. The theory of comfort has not yet been applied to an academic, educational program.

Indeed, as a mid-range theory, it may not be suitable for guiding curricular endeavors. However, it could serve as essential content for undergraduate and graduate nursing students to learn. Application in Practice One article summarized how a nurse can provide comfort in different settings. Comfort is a desired outcome of nursing care, and this article presents a review of the current knowledge concerning holistic comfort.

The article includes a review of the literature. Most articles have to do with "patient needs or deficits or altered comfort. Kolcaba proposed that terminally ill cancer patients can benefit from comfort care since it focuses on the patient's need and perspective. Comfort is not only provided through the relief of pain but also in the holistic venue such as addressing depression.

"Patients who are depressed but not in pain need comfort in the transcendental sense and in the psycho-spiritual context" (Kolcaba, 1992, p. 4). In the article, she explains the use of instruments and how they were used or can be used by others. Kolcaba believes that her instruments to measure comfort are important outcome indicators that are patient driven, sensitive to the effects of nursing care and relevant to the integrity of the health care system. Kolcaba's (1992) theory provided the framework for the Acute Care for Elders (ACE) Model (Landafeld, Palmer, Kresevic, Fortinsky, & Kowal, 1995). The model guided a cost-effective, comprehensive approach to the complex health needs of the hospitalized older adult. With a philosophical emphasis on holistic care, Kolcaba's theory directed the assessment of interventions for patients' physical, spiritual, social and environmental needs, within the context of the family and the patient's home environment.

Other priorities within the model were patient functionality; collaborative interdisciplinary communication; early discharge planning; family-centered care; follow-up after discharge; and fundamental nursing care without expensive technology. Kolcaba's theory was included in staff education for use of the ACE model. Staff were taught that comfort included the concept of strengthening, which fit the rehabilitation focus of the ACE model. The model was tested in a pilot phase and a randomized control clinical trial with elderly orthopedic patients. The outcomes indicated greater functional level at discharge for the patients in the ACE model, resulting in more discharges to home. Other nursing sensitive indicators, such as skin care, self-confidence, nutrition, and sleep, were improved in the ACE group, although not significantly.

The article supports the usefulness of Kolcaba's Theory of Comfort in guiding effective clinical interventions. Kolcaba (1992) developed the General Comfort Questionnaire to measure holistic comfort in a sample of hospital and community participants. The questionnaire is based on 24 positive and 24 negative items. The participants rated these questions from strongly agree to strongly disagree. The higher the score, the higher the comfort. Kolcaba has also made available comfort care templates for use in practice settings.

Different areas in which the theory has been used include burn units, nursing homes, home care, chronic pain, massage therapy, pediatrics, oncology, midwifery, cardiac, critical care, hospice, infertility, radiation therapy, orthopedic nursing and peri operative areas. Application in Research In the first decade of its existence, the theory has stood up to initial empirical testing. It has been shown in studies that, once the nurse or caretaker initiates a comfort measure (intervention) to meet the holistic comfort of the patient, the patient's comfort is increased over a previous baseline measurement. Presently, Kolcaba is creating ways to test the last part of her theory (to demonstrate if a relationship exist between patient comfort in an institutional or community setting and their engagement in HSBs, and the extent of their patient satisfaction with care as they are surveyed after discharge.

One example of using the theory in research follows. Kolcaba's (1992) Theory of Comfort provided the conceptual framework for a research study on comfort levels in patients with do-not-resuscitate orders (Kaplow, 2000). The purpose of the study was to explore the relationship between comfort levels and the amount of nurse resources devoted to patients with and without do-not-resuscitate (DNR) orders. The design was quasi-experimental, as the convenience sample of DNR patients was not randomized (n = 30).

Patients without DNR orders (n = 30) were randomly selected into the study. Sample criteria included being between the ages of 18 and 72 years and diagnosed with a solid, malignant tumor or a hematological type of cancer. The PACK Behavioral Pain Scale measured discomfort, which operational ized comfort as a variable per Kolcaba's conceptualization. The Therapeutic Intervention Scoring System (TISS) measured amount of nursing resources used in patient care.

Reliability and validity information on the two tools, taken from previous studies and from a pilot phase of the current study, supported adequate reliability and validity in adult samples. Patients with and without DNR orders were admitted into the study simultaneously. Data were collected on four different days. Results showed that there was no significant relationship between use of nursing resources and comfort levels between the two groups of patients, suggesting that nurses continue to care for DNR patients and do not make their comfort care less of a priority. A large percentage of participants reported no discomfort, which supports the effectiveness of nursing interventions but skewed the comfort data and reduced variance of comfort in the study. It is recommended that the study be replicated at other sites and with a more diverse sample in varying degrees of discomfort.

A second article that demonstrates the applicability of this theory in research is a study of the effects of guided imagery on comfort of women with early state breast cancer undergoing radiation therapy (Kolcaba & Fox, 1999). The purpose of the study was to measure the effectiveness of a customized guided imagery program for cancer patients and its effect in comfort of the patient. Nurses in the radiation therapy were given a chance to review the literature, and they were the ones that approved the music to be used. The researchers used two questionnaires. The control variable was assessed with the state anxiety inventory (SAI) and the dependent variable was assessed with the radiation therapy comfort questionnaire (RTC Q). Consent was obtained from those participating in the study.

The results showed that the guided imagery was helpful in relieving the stress of radiation therapy in most of those receiving it. I think that the positive side is that the tapes and imagery were tailored to the specific person receiving the treatment. Application in EducationKolcaba's (1992) theory is middle range and may not be suitable to guide curricular development, since it explains some but not all of nursing care. It does, however, offer important content for students of nursing to master, at both the undergraduate and graduate levels. Articles that describe the usefulness of this theory in practice indirectly affirm that the theory is useful for educating students. For example, Cox (1998) found Kolcaba's theory was useful as a teaching guide for care of older adults and that students could readily apply Kolcaba's theory in providing nursing care of older adults and addressing holistic comfort needs in elders in an acute-care setting.

Guided images have also been used in educational settings to reduce student stress. Another article by Kolcaba (1994) explains her theory in detail and in a way that could be suited for students to read. Comfort is defined in this article as a distinguishing characteristic of the nursing profession. Because of this statement, I see this article as useful in education. The theoretical work presented in this article, used an intra-action al perspective to develop a theory of comfort as a positive outcome of nursing. The article described how an increase in comfort indicated that negative tensions were reduced and positive tensions were engaged.

The positive tension in turn became positive HSBs. The nurse is the facilitator of the outcome of comfort because theoretically it is related to internal / external health-seeking behaviors or a peaceful death. Kolcaba herself teaches a course in her theoretical work through the University Of Akron College Of Nursing, hence demonstrating that graduate students are interested in her work and its implementation. Application of Theory to My Practice have used this theory in different settings, even though I did not know the theory existed.

There are protocols on hand massage and that is one of the things that I have been doing with my patients in the mission field. Because there is a language barrier, sometimes I use hand signals and offer a hand and foot massage. The ladies love it! I have not tried it with men, since in some cultures a woman touching a man in certain ways is taboo. I have witnessed firsthand the change in attitude and comfort of the patient with such a simple intervention.

I see this theory used quite often in the surgery setting. From the peri operative stage of surgery, the circulator's concern should be how the patient is feeling and his / her reaction to the surgical procedure. I am to ensure that the stress levels are reduced and that the patient is comfortable with my care. I will do anything is my power to ensure the patient and their family have had all their questions answered and their stress and anxiety level is decreased. As I take the patient to the OR, it is my job to ensure the patient's comfort through anesthesia administration, positioning and stress reduction. I will stand by the patient and ensure that it is ok and explain to him / her what is going on, noises in the surrounding and ensuring they are comfortable.

Post-op, I again ensure the patient is safe and comfortable as they are being carted to recovery. Kolcaba's theory is basic nursing, it should be the ultimate goal of the nurse to have a patient that is comfortable so healing can begin and stress can be reduced.

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