Theoretical And Philosophical Foundations In Nursing
Everyone has experienced some type of discomfort or pain. Possibly it may be the most common reason why people seek health care. The role of the nurse is to provide care for clients in many settings and situations in which interventions are provided to promote comfort. Comfort is a concept central to the art of nursing. Nursing Theorists refer to comfort as a basic client need for which nursing care is delivered. The concept of comfort is subjective thus each individual has diverse physiological, social, spiritual, psychological and cultural, characteristics that influences how comfort is interpreted and experienced. For this assignment, a theory of comfort developed by Katherine Kolcaba will be discussed.
The concept of comfort is not a new concept and has been a goal or outcome of nursing since Florence Nightingale. Comfort is a holistic outcome because it designates a dynamic and multifaceted state of persons. Thinking about the outcome of comfort requires an intra-actional perspective because interventions that are intended to enhance one or more aspects of comfort indirectly enhance other aspects (Kolcaba, 1994). During the development of the comfort theory, Kolcaba conducted a concept analysis of comfort that examined literature from several disciplines including nursing, medicine, psychology, psychiatry, ergonomics and English (Dowd, 2002). This review confirmed that comfort is a positive concept and is associated with activities that nurture and strengthen patients.
Kolcaba arrayed different aspect of comfort in a two dimensional grid. First, Kolcaba described comfort as existing in 3 forms: ease, relief and transcendence. In the first sense, the state of ease, comfort does not mean absence of discomfort but rather this state is relative to individual characteristics. That is, persons differ in how they describe and experience discomfort and ease. In the second state, the relief sense, there is relief from conditions that cause or contribute to discomfort. The final state, the renewal sense, refers to a state of being strengthened and having enhanced powers and positive attitudes. The second dimension of comfort is the contexts in which comfort occurs. The contexts were derived from the nursing literature about holism (Kolcaba, 1992). The first context is physical, pertaining to bodily sensations, the second is psychospiritual, pertaining to the internal awareness of self, including esteem, sexuality, meaning in one's life and relationship to a higher order or being. The third context is social, pertaining to interpersonal, family and cultural relationships and the fourth and last context is environmental pertaining to light, noise, ambience, colour and temperature. When the two dimensions are contrasted the result is a two-dimensional grid with 12 facets of comfort. Items for comfort questionnaires can be generated from each facet that is relevant to a specific research question. Making the concept of comfort measurable Kolcaba assembled the basis for the development of the theory of comfort.
Kolcaba published a middle range-theory of comfort in 1994 suggesting that when comfort is enhanced, patients are strengthened and thus able to engage in health seeking behaviours. In 2001, a subsequent article provided an expansion of the theory to include institutional outcomes. In 2003, Kolcaba published a comprehensive book about the development, testing and application of the theory. Kolcaba does not believe that a focus on comfort is unique to nursing while she believes that her theory can be interdisciplinary and that multiple professions can converge around her theory of comfort providing holistic care to patients. One of the main theory assertions is that when healthcare needs of a patient are appropriately assessed and proper nursing interventions are carried out to address those needs, taking into account variables intervening in the situation, the outcome is enhanced patient comfort over time. Once comfort is enhanced, the patient is likely to increase health-seeking behaviours. These behaviours may be internal to the patient (relief from pain or improved oxygenation), external to the patient (eg. active participation in rehabilitation exercises) or a peaceful death. Furthermore, Kolcaba asserted that when a patient experiences health-seeking behaviours, the integrity of the institution is subsequently increased because the increase in health seeking behaviours will result in improved outcomes. Increased institutional integrity lends itself to the development and implementation of best practices and best policies secondary to the positive outcomes experienced by patients.
The goal of this theory is congruent with those theories represented as mid range theories. The goal of the Comfort Theory is to provide comforting measures to patients in their time of need. Middle range theories are narrow in scope and composed of a limited number of concepts and propositions. These are written in a concrete and specific level. Middle range theories address a relatively tangible and specific phenomenon by describing what it is, explaining why it occurs or predicting how it occurs. This theory explains what comfort is as determined by the patient or family and predicts how it occurs as evidenced by the taxonomic grid. This moreover, secures the theory in its classification.
Clarity and Simplicity of Theory: Some of the early articles above all the concept analysis, are difficult to read but are consistent in terms of definitions, origins, assumptions and propositions (Tomey & Alligood, 2006). The conclusive article explaining the Theory of Comfort is easier to read and in consequent articles Kolcaba relate the theory to definite practices using academic but comprehensible language. The instruments to assess comfort needs are also simple in the number of concepts and are easy to utilize. The theory of Comfort is simple because it goes back to basic nursing care and the traditional mission of nursing. Its language and application are of low technology, but this does not preclude its use in highly technological settings (Dowd, 2002). The main thrust of the theory is to return nursing to a practice focused on needs of patients, inside or outside institutional walls. Its simplicity allows students and practicing nurses to learn and practice the theory easily. All research concepts are defined theoretically and operationally. The diagrams associated with the theory help to show the consistency of the principles and use of terms while the concepts of the theory are related in logical ways.
Empirical Precision: The first part of comfort theory predicts that effective nursing interventions offered over time, demonstrates enhanced comfort. Kolcaba tested it in experimental design for her dissertation (Kolcaba & Fox, 1999). In this study health care needs were those stressors (comfort needs) associated with a diagnosis of early breast cancer. The holistic intervention was guided imagery, designed specifically for this population to meet their comfort needs, and the desired outcome was comfort. The findings revealed a significant difference in comfort over time between women receiving guided imagery and the usual care group (Kolcaba & Fox, 1999). Other empirical tests of the first part of Comfort Theory have been conducted by Kolcaba and associates which confirmed significant differences between treatment and comparison groups on comfort over time. The interventions tested were types of immobilization for persons after coronary angiography (Hogan-Miller et al., 1995), cognitive strategies for persons with urinary frequency and incontinence (Dowd, Kolcaba & Steiner, 2000) and generalized comfort measures for women during first and second stages of labour (Koehn, 2000). In the Urinary incontinence study (Dowd, Kolcaba & Steiner, 2000), enhanced comfort was related to an increase in Health seeking behaviours, supporting the second part of the comfort theory. The relationship between comfort and institutional integrity has yet to be tested. For patients with breast cancer and urinary incontinence and for those at end of life (Vendlinski & Kolcaba, 1997), the adapted comfort instruments have demonstrated strong psychometric properties which means, that those questionnaires are accurate and reliable measurements of comfort and can reveal changes in comfort over time. These finding support the theoretical foundation for the taxonomic structure of comfort.
Comfort Theory and the metapardigm of nursing: The metapardigm of a discipline has been defined as a statement or group of statements identifying its relevant phenomena (Fawcett, 1984). At the level of the metaparadigm, these statements should be global to the discipline rather than specific to particular philosophies, worldviews, conceptual models or theories. The concepts that comprise the metaparadigm of nursing have been defined as person, environment, health and nursing (Fawcett, 1984). Kolcaba's comfort theory successfully addresses the four concepts embracing the metaparadigm of nursing. Kolcaba defined the metaparadigm concepts as they correspond to her theory (March & McCormack, 2009). Nursing is described as the process of assessing the patient's comfort needs, developing and implementing appropriate nursing interventions and evaluating patient comfort following nursing interventions. Person is described as the recipient of nursing care; the patient may be an individual, family, institution or community. Environment is considered to be the external surroundings of the patient and can be manipulated to increase patient comfort. Finally, health is viewed as the optimum functioning of the patient as they define it. A close analysis of these definitions elicit some questions about the degree to which Kolcaba's (1992) work is fully intertwined with the metaparadigm of nursing (Ferreira,2004). While Kolcaba does an adequate job of describing nursing, its centre and activities the definition of the other three concepts are less well developed. Kolcaba's definition of health as optimal functioning does not correspond with other concepts in her theory. Functioning was never defined or mentioned in Kolcaba's theoretical definitions. Moreover a perception of comfort in Kolcaba's definition of Health was not included and her definition of person lacks specification that the human is perceptual, which must be true if her definition of Health is to hold up. Additionally, Kolcaba's definition of environment is not closely related with nursing activities. It seems that, at this stage of the theory's development, the concepts of the theory are not firmly grounded in nursing's metapardigm (Ferreira, 2004). However as a middle-range theory, only the segment of nursing that is the focus of the theory should be significantly addressed (Tomey, A. & Alligood, 2006).
Application in practice: Comfort Theory provides a framework for clinical practice guidelines, which state that the provision of holistic care oriented to comfort must be explicit and well documented (Di Marco & Kolcaba, 2005). In turn, the desirable outcome of comfort is related to engagement in Health Seeking Behaviours (important to patients, families and the health care team) and to better institutional outcomes (important to administrators). The application of the theory is strengthening and satisfying for clients and families and nurses, and benefits institutions where a culture of comfort is valued. However, the application of comfort theory to practice is complex. It is not straight forward as it appears or as it is probably explained in the theory. The largest challenge to using this theory is the staffing ratios. Staffing ratios have a direct relation between task oriented nursing and the more emotional and personal connections that can be offered when caring for fewer patients. The assessment of comfort needs is certainly different in non verbal patients as in ITU. Still, nurses are perceptive if a patient is comfortable and possible detractors from comfort when patients seem restless. Families are often very useful in this detective work and their presence alone is a comfort measure. Using Kolcaba's framework of holistic comfort, nurses can be comprehensive and consistent in assessing comfort and in designing interventions to enhance the comfort of patient and families. Nevertheless, compared to other nursing theories, the comfort theory is easy to understand and learn because every person is familiar with their own needs for comfort. The need for comfort is innate and thus the concept of the comfort theory is easier understood. In 1992 Kolcaba developed the General Comfort Questionnaire hence facilitating the assessment of comfort needs. The questionnaire is based on 24 positive and 24 negative items. The participants rate these questions from strongly agree to strongly disagree. Higher the score, higher the comfort obtained. Kolcaba has also made available comfort care templates for use in practice settings. Although this theory is quite new, it is being recognised increasingly by nursing students and staff who are choosing it as a guiding frame for their studies and practice such as in labour and delivery (Koehn, 2000), nurse midwifery (Schuiling & Sampselle, 1999), cardiac catheterization (Hogan-Miller, Rustad, Sendelbach & Goldenberg, 1995), critical care (Jenny & Logon, 1996), hospice (Vendlinski & Kolcaba, 1997), infertility (Schoerner & Krysa, 1996), radiation therapy (Cox, 1998), orthopaedic nursing (Panno, Kolcaba & Holder, 2000), perioperative nursing (Wilson & Kolcaba, 2004) and in hospitalized elderly (Robinson & Benton, 2002).
Comfort theory as an institution wide approach: Kolcaba positions comfort theory within the domain of nursing: however, she hypothesize that in an institution committed to meeting the healthcare need of patients, comfort theory could potentially work as an institution wide approach (March & McCormack, 2009). Because this variation of Kolcaba's theory is yet to be tested, the potential benefits can only be speculated. It could be assumed that if Kolcaba's comfort theory is indeed adapted to include all healthcare providers and implemented as an institution wide framework for practice, that comfort for patients would be enhanced even further. Kolcaba's comfort theory implementation to an institution-wide level, necessitate a change to the theoretical framework. Currently, Kolcaba's comfort theory describes the application of 'nursing interventions' thus limiting the implementation of interventions leading to enhanced comfort as a function of only those healthcare providers who specialize in nursing (Kolcaba, 2003). A modification of this term, however to the term 'comfort interventions', expand the potential application of this theory to any healthcare practitioner choosing to adopt this theoretical structure for practice (March & McCormack, 2009). The intervention strategies emerging from the consistent application of comfort theory across disciplines is likely to result in quality outcomes for the patient leading subsequently to an increase in patient health seeking behaviours. Kolcaba's theoretical framework maintains that if patients' health seeking behaviours are increased, institutional integrity will result. This therefore may imply that if all healthcare practitioners within an institution delivered care guided by the comfort theory, that institutional integrity would be enhanced even more greatly than if the theory were used to guide nursing only. Additionally, structuring a healthcare institution around the concepts of the comfort theory would hypothetically improve societal recognition and appreciation of the institution, as well as increase patient satisfaction, due to the aforementioned positive implication of the concept.
Comfort Theory application in Nursing Education: During their education nursing students are trained for routine hospital activities including vital signs, monitoring, physical assessment techniques and giving medications. Maintaining patient's privacy and dignity is emphasized during nursing courses. In other words before students first lay their hands to their first patient, educators have incorporated them the science and art of giving comfort measures. Comfort has always been included in nursing education, and Katharine Kolcaba's theory seems simple yet an effective one to enhance learning. However since Kolcaba's theory is middle range it may not be suitable to guide curricular development as it explains some but not all of nursing care (Ferreira, 2004). It does however offer important content for students of nursing to master at both the undergraduate and graduate levels. Comfort Theory offers guidelines for teaching comfort and provides an effective method to assess and address holistic comfort needs of patients. Articles that describe the usefulness of this theory in practice indirectly affirm that the theory is useful for educating students. Cox (1998) found Kolcaba's theory 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 elderly in an acute care setting. The theory is not limited to gerontoligical or advanced practice education. It would be difficult to bring to mind a nursing setting or practice in which comfort would not be appropriate (Dowd, 2002).
Holistic comfort theory provides a framework for guiding nurses as they assess, plan, provide and evaluate care for patients while viewing them as whole persons interacting with their environment. Besides guiding nursing practice comfort theory can guide nursing education. This theory can be used to guide the teaching of nurses and nursing students to learn how to provide care that is independent of or in conjunction with medical practice. In research the theory provides a way to validate that there has been improvement in patient comfort after comforting interventions. During 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 initiates a comfort measure to meet the holistic comfort of the patient, the patient's comfort is increased over a previous baseline measurement. Also, enhanced comfort has been correlated with engagement in Health Seeking Behaviours (Dowd, 2002). Kolcaba has made consistent and persistent efforts to develop and expand the concept into all areas of nursing. Through own thinking and interaction with nurses the concept has evolved continually, including care products. Through Kolcaba's prolific writing and active Internet activities, the Theory of Comfort is now known worldwide.
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