Analysis and Evaluation of the Theory of Comfort
The Theory of Comfort by Katherine Kolcaba is middle range theory. Middle range theories contain a limited number of concepts and have a more limited scope. However, Kolcaba's Theory of Comfort is classified as a high middle range theory making it a more general and abstract theory. Making it closely related to a "Grande Theory" which is very abstract and general and can be applied to a variety of experiences and responses (McEwen & Wills, 2011). This is very true for The Theory of Comfort as many articles have been written adapting the theory to multiple scopes of nursing.
Middle range theories include something specific related to nursing practice such as a situation or condition of a patient or patient population. Middle range theories also take into account the populations age and location when working on the development of a theory. A middle range theory also includes an intervention, proposed outcome, or an action of the nurse. Middle range theories are developed by interpreting and observing lived experiences with a relation to health and nursing (Tomey & Alligood, 2002). In Katherine Kolcaba's Theory of Comfort she spent much time examining the relationships and outcomes of patients in relation to comfort.
Katherine Kolcaba originally wrote the Theory of Comfort with Alzheimer's and dementia patients in mind. However, Katherine herself has co-written multiple articles about other scopes of nursing related to her theory. Two recent articles were written applying her theory to perianesthesia nursing and hospice nursing (Kolcaba & Wilson, 2002 and Vendlinski & Kolcaba, 1997).When Kolcaba was developing her theory she utilized logical reasoning. She utilized induction, deduction, reduction. Kolcaba utilized a preexisting framework as her antecedent. The framework was written by Henry Murray (Tomey & Alligood, 2002), it was from a book entitled Explorations in Personality. Henry A. Murray was a professor of psychology at Harvard University; he received the Distinguished Scientific Contribution Award from the American Psychological Association and the Gold Medal Award for lifetime achievement from the American Psychological Foundation. "When it first came out in 1938, this book had a provocative and insightful effect, urging psychologists to study personality holistically and in depth and emphasizing the complex interactions between individual, social, and cultural characteristics." --Salvatore R. Maddi, Professor, Department of Psychology and Social Behavior, School of Social Ecology, University of California, Irvine (Explorations in Personality, 2007). This was a very good starting point for the theory as comfort is best achieved through holistic treatment. She also began with a concept analysis of the term, "comfort". Katherine Kolcaba gathered the definition, of "comfort" from many different disciplines. Within The Theory of Comfort the metaparadigm proposition of nursing actions is utilized (Kolcaba, 2001). This is evident in this theory because it is built around evaluating for the lack of comfort and then reevaluating the patient to calculate the success of any implementations made or actions taken.
Katherine Kolcaba utilizes the all four of the metaparadigm concepts: nursing, patient, environment, and health. In nursing there is an assessment of comfort needs, actions to promote comfort, and then the reassessment of comfort levels. The assessment and reassessment can be either subjective or objective. The patient can be an individual or their family. The environment is any part of the patient's surroundings that can be manipulated by the nurse to enhance the patients comfort. Finally, health is the optimum functioning of the patient (Tomey & Alligood, 2002).The author believes that Kolcaba does utilize all four of the metaparadigm because the patient is the center. The nurse is essential because the nurse provides the care to increase the comfort. The environment also plays an essential role in this theory as comfort or discomfort can be found in the patient's environment. Finally the author believes that when all of these three are in cooperation to create comfort the patient will then have an increase in their health.
The philosophical claim that The Theory of Comfort is based on is human needs. There are two core components of this philosophy. There first is the motivational drive that is behind human behavior. The second is the force driven by social and cultural politics that influences the patient's expectations. Patient's comfort needs are driven by their expectations of competent and holistic nursing care (Kolcaba, 2001).
The world view that fits The Theory of Comfort most concisely is the "reciprocal world view" this fits well because human beings are active and holistic. Humans interact with their environment and this interaction may lead to pain, displeasure, or comfort. Humans learn from their experiences and this leads them to the ability to make decisions that can keep them in a more comfortable environment.
The Theory of Comfort has six basic concepts: health care needs, nursing interventions, intervening variables, patient comfort, health seeking behaviors, and institutional integrity (Kolcaba, 2001). Health care needs are defined as the need for comfort that comes from stressful health care situations. The types of needs that can arise are: physical, psychospiritual, social, and environmental, these are the same terms that Kolcaba uses to evaluate the effectiveness. These needs are made apparent through close monitoring (Tomey & Alligood, 2002). Nursing interventions are defined as the commitment of nursing and health care institutions to promote comfort care and meet the comfort needs of patients (Kolcaba, 2001). Intervening variables is anything that affects the outcome (Kolcaba, 2001). Some possible variables include: past experience, age, attitude, emotional state, support system, prognosis, and finances (Tomey & Alligood, 2002). Patient comfort is defined as, "immediate state of being strengthened by having needs met in 4 contexts of human experience, (physical, psychospiritual, social, and environmental)" (Kolcaba, 2001). Health seeking behaviors is defined as, "the pursuit of health as defined by the recipient, in consultation with the nurse," (Tomey & Alligood, 2002). Instructional integrity is an institution that possess qualities of completeness, honesty, sincerity and is also appealing (Tomey & Alligood, 2002).
Katherine Kolcaba has a total of six propositions that outline her theory of comfort. The first of the six is that a nurse identifies the comfort needs that have not yet been identified by the patients other support systems. The second proposition is that the nurse is then responsible for designing interventions to address those unmet needs of the patient. The third is taking into account the variables that could affect the intervention that has been proposed to help the patient. The forth proposition by Kolcaba is that once the comfort is met or achieved that patients are encouraged to engage in health seeking behaviors. The fifth proposition is that once a patient has been strengthened and are participating in health seeking behaviors they are then more satisfied with their health care. The last proposition of The Theory of Comfort is when a patient is satisfied with their health care in a particular institution that institution retains its integrity (Kolcaba, 2001). All six of the propositions are relational in the streamline. All six of the propositions have to take effect for the patient to be brought to an acceptable level of comfort with that level of comfort being maintained for an extended period of time. All six of Katherine Kolcaba's propositions are relational as they are a streamlined reevaluating process that depends on all parts for success and structurally necessary to have holistic health.
Katherine Kolcaba has listed four major assumptions in her Evolution of the Theory of Comfort. The first is "human beings have holistic responses to complex stimuli" (Kolcaba, 2001). The second is that comfort is a desirable holistic outcome that is relevant to the discipline of nursing. The third is, it is an active endeavor to meet and maintain comfort. The fourth and final assumption is that institutional integrity has a large component that is based on a "patient oriented value system" (Kolcaba, 2001).
Katherine Kolcaba's diagramed conceptual model consists of the basic principles of The Theory of Comfort. The health care needs, nursing interventions, and intervening variables all work in cooperation to become enhanced comfort. Enhanced comfort then leads to health seeking behaviors. The facility or company who has in use best policies and best practices will then be able to promote and relate health seeking behaviors utilizing those policies and practices. Health seeking behaviors then have the ability to become internal and external behaviors which can lead to greater health. The health seeking behaviors may also lead to a peaceful death, (The Comfortliners, 2010) as this is the goal of hospice nursing and the Theory of Comfort has been utilized in hospice nursing (Vendlinski & Kolcaba, 1997). This concept is much easier to visualize than read.
In order to evaluate the success of achieving comfort Katherine Kolcaba has developed a table or taxonomic structure to document comfort. On the left side of the chart are four rows labeled, "physical, psychospiritual, environmental, and social," (Tomey & Alligood, 2002) which are the context for which comfort occurs. The three columns on top are the types of comfort, "relief, ease, and transcendence," (Tomey & Alligood, 2002). Kolcaba defines relief as "the stated of having had a specific need met or mediated," ease is, "the state of calm and contentment," and transcendence is, "the state in which one rises above problems or pain," (Kolcaba, 2001). When evaluating a patient's comfort the nurse fills in the twelve empty squares with what action helps to achieve that level of comfort.
Comfort is a massively important concept of nursing and The Theory of Comfort is designed to bring comfort to patients. The diagrammed conceptual model provides the simplest explanation for the theory. The metaparadigm concepts are not clearly defined by Katherine Kolcaba; however she does clearly states the philosophical claim and its concepts. The conceptual framework and antecedent knowledge is minimally defined within her work, but they are acknowledged and cited.
The content and context reflect each other nicely as they are both centered around holistic comfort, however the clarity throughout the theory is minimal. The six propositions of The Theory of Comfort are clearly stated by Katherine Kolcaba. The six propositions flow consistently to outline the theory well. The assumptions are clearly stated and are consistent with comfort and treating the patient holistically. The theory is reciprocal as all parts are dependent on the others for success.
Throughout The Theory of Comfort there is minimal clarity. The propositions and the conceptual diagram are the clearest components of the work. The theory would be more understandable if it were stated more simply.
The Theory of Comfort does not have a very specific evaluation processes aside from the taxonomic structure that the nurse fills in by documenting what implementations help to achieve comfort, which was previously mentioned. However with regular nursing assessments the nurse will know if comfort has been achieved, either objectively or subjectively. The best way to measure comfort rather a nurse is utilizing this theory or not is to frequently ask and objectively assess a patient and notice nonverbal indications of pain. As with any high middle range theory, The Theory of Comfort is very abstract and proves difficult to measure results in a definitive method.
The Theory of Comfort has been adapted to several different fields of nursing aside from its original focus of dementia care. Perianesthesia nursing has adapted this theory to help patients especially by utilizing the table to document different methods of obtaining comfort. It has also lead nurses in this scope of practice to realize the importance of education (Kolcaba & Wilson, 2002). The theory has also been utilized by hospice nurses, this is the ideal scope of nursing to utilize this theory. It has provided hospice nurses with a broader outlook on how to provide holistic comfort to their dying patients (Vendlinski & Kolcaba, 1997).
The Theory of Comfort is a very practical concept as everyone feels better when they are comfortable. Patients and families are more able and willing to absorb information when they are comfortable and focused. This theory provides simple steps to ensure comfort is being delivered. The Theory of Comfort encourages nurses to think more deeply about rather or not their patient is comfortable, along with what is causing discomfort and what is promoting comfort. It also encourages nurses to document the variation of methods in which a patient becomes comfortable in different settings. A basic nursing knowledge such as an associate's degree is necessary for utilizing this theory, however in order to understand the written theory in its entirety a more advanced knowledge level proves to be a necessity.
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