Introduction

Comfort Theory: A Holistic Guide for Practice and Research

What is a Holistic Theory?

Assumptions of a Holistic Theory. Assumptions are an author's understanding or perspective about reality. When an author is writing a theory, her audience needs to know where she is "coming from." If a reader does not share the author's beliefs about reality, the reader may not be interested in learning the theory.

Kolcaba's beliefs, which permeate Comfort Theory, are that: 1. Human beings respond to complex stimuli simultaneously. 2. A whole response is greater than what would be expected by examining separate responses to separate stimuli and adding together the effects of those responses. 3.Whole persons do not disappear into ever-larger wholes (Kolcaba, 2003).

Whole Person Interventions and Outcomes. Nurses are beginning to explore the effectiveness of broadly targeted holistic interventions such as progressive muscle relaxation, music and art therapy, massage, guided imagery, and therapeutic touch. These interventions and others are intended to produce a positive whole person response and thus would be measured most accurately by a whole person outcome. A whole person outcome would measure positive or negative inter-related effects between aspects of that person's response. The instantaneous and comprehensive response would be reported as a total response.

Holistic Theory. Theories are useful for describing, understanding, predicting, and improving reality through meaningful and relevant interventions. Theories about health care enable users to subscribe to common beliefs and to pattern their care to bring about desired outcomes. A holistic theory for health care, then, addresses or describes the total, simultaneous effects of holistic interventions that are purposefully targeted to needs of whole persons. To be congruent with a specific holistic intervention, the desired outcome is also holistic. The outcome of holistic comfort, as described and defined below, is a congruent indicator of the effectiveness of holistic interventions.

Three Types of Comfort

Concept Analysis. In 1986, Kolcaba and her husband (a philosopher interested in semantics and knowledge-building) began a lengthy exploration of dictionary definitions of comfort, looking at both modern and obsolete usages of the term, along with disciplinary usages of comfort. The concept analysis was published in 1991 and presented three technical senses of comfort that were relevant for health care. Those three senses, or types, of comfort were relief, ease, and renewal; the term renewal later was changed to transcendence. Relief was defined as the experience of a patient who has had a specific comfort need met. Ease was defined as a state of calm or contentment and does not necessarily specify a prior need that was relieved. Renewal (transcendence) was defined as the state in which one rises above problems or pain (Kolcaba & Kolcaba, 1991). Transcendence is an important concept for Comfort Theory because nurses can't always alleviate pain and suffering completely. But in these difficult situations, nurses never give up! They attempt to empower or inspire their patients to keep going, work through, or rise above their suffering, at least to a partial extent or to what is possible. Conveying hope, caring, and commitment to the patient and family are vehicles for transcendence and are essential components of Comfort Theory. Thus, the three types of comfort (relief, ease, and transcendence) form the cornerstone of a later structure to define holistic comfort and to build Comfort Theory.

Strengthening Component of Comfort. During the discovery phase of the concept analysis, an important component of comfort emerged from three sources that was to be central to its importance for nursing: its strengthening component. The first source of this component was in its origin which was the Latin word "confortare," meaning to strengthen greatly. The second source was from Paterson, a psychiatric nurse and theorist (Paterson & Zderad, 1976/1988). She stated that comfort freed patients to be all they could be at the time, a belief that conformed to the origin of the term. The third source to speak to the strengthening component of comfort was from the disciplines of ergonomics and psychology. These disciplines were interested in increasing productivity, efficiency, or performance when specific tasks were required. The way to increase performance was to enhance comfort of the worker or athlete through manipulating the environment, the furniture, the psychological messages, etc. Enhanced comfort, therefore, strengthened or inspired the worker or athlete to "do better." Discovering that comfort, in its origins and in its usage in other disciplines, entailed a strengthening component was exciting, because it provided rationale for nurses and other team members to enhance patients' comfort beyond the altruistic reasons advocated by nursing theorists (Kolcaba & Kolcaba, 1991).

Four Contexts of Comfort

Physical Comfort

Hamilton's (1989) first comfort theme was comfort needs related to disease process, and the most prevalent detractor from comfort was pain. We would have expected this. But also on the participants' list of important contributing factors for physical comfort were regular bowel function, prevention or treatment of discomforts related to medical problems (such as leg or eye pain), and better diagnoses of the origins of such discomforts. Hamilton's findings, in the words of patients, supported Kolcaba's view that physical comfort encompassed all the physiological ramifications of medical problems, which may or may not result in physical sensations immediately. Examples of some necessary conditions for physical comfort, in this broad sense, are homeostatic mechanisms such as fluid/electrolyte balance, stable and normal blood chemistries, adequate oxygen saturation, and other metabolic indicators of health. Abnormalities in any of these physiological mechanisms must be treated (Relief) or kept at bay (Ease) in order to maintain physical comfort.

An additional insight about physical comfort came from Hamilton's (1989) comfort theme of positioning. Participants stated that sitting correctly, having freedom to move independently in their chairs, enjoying well-fitting furniture, and being able to return to bed when requested were central to their comfort. The importance of this type of comfort was prominent in ergonomics and was associated with increased function and productivity. Choice also was an important consideration.

Physical comfort, then, is defined as pertaining to all bodily sensations. It requires balance in homeostatic mechanisms and immune function that may or may not be related to specific diagnoses (Kolcaba, on line) and early stages of imbalance may or may not be perceived by the patient. Because of this broad definition of physical comfort, users of Comfort Theory must be acutely aware of all medical problems and risk factors for each of their patients.

Psychospiritual Comfort

Hamilton's (1989) second comfort theme was self-esteem, including Faith in God, being independent, feeling relaxed, being informed, and feeling useful. Here there was a blending of spiritual and psychological comfort - a frequent occurrence in the literature. But Howarth (1982) stated that the unifying concepts within a holistic framework were physical, intellectual, and spiritual but the latter was in the generic sense, not related to religiosity.

From the literature about holism, it was not possible to differentiate the experiences of mind from those of the spirit and of the emotions. There were wide definitions of spirituality that overlapped with conceptualizations of "mind" (Labun, 1988). Also encountered were wide definitions of spirituality that were measured by narrow indicators of religion (Reed, 1987). And, there were no specific empirical indicators for transcendence, an important benefit of being a spiritual person (Labun, 1988; Reed, 1987;). It was for these reasons that Kolcaba combined the contexts of psychological and spiritual comfort to form the psychospiritual context.

Psychospiritual comfort combines mental, emotional, and spiritual components of self. It is defined as whatever gives life meaning for an individual and entails self-esteem, self-concept, sexuality, and one's relationship to a higher order or being (Kolcaba, on line).

Environmental Comfort

Myra Levine (1967) proposed a model of holism based on the basic interaction of individuals with their environments (shades of Florence Nightingale!). Similarly, Fuller (1978) said that the focus of nursing was the whole person in interactions with the environment. Wolanin (1981) described a therapeutic milieu as being central for care of confused patients. Clearly, the right environment for healing and health promotion was considered an important source of comfort by nurses interested in holistic care.

Today, environmental comfort is a key aspect of units specifically designed to promote physical and cognitive function of hospitalized elders. These units are called ACE units, an acronym for Acute Care for Elders. Environmental aides such as handrails on the walls, non-glare lighting, calendars and clocks in rooms, high toilets with safety bars, minimal noise, and elder-friendly furniture are integrated throughout to maximize functional health (Panno, Kolcaba, & Holder, 2000). This type of unit is a perfect example of how environments of care can be manipulated to enhance comfort and function of patients.

Environmental comfort is defined as pertaining to external surroundings, conditions, and influences (Kolcaba, on line). Entailed in this definition is color, noise, light, odors, ambience, temperature, views from windows, access to nature, and natural versus synthetic elements (Kolcaba, 1991).

Sociocultural Comfort

Participants in Hamilton's (1989) study stated that the friendliness and caring of all staff members was central in achieving social comfort. This included the staff's approach and attitudes, continuity of care, and a meaningful schedule of events and activities. These elders also wanted to be better informed and more involved in their care, care planning, and decision-making. Notable is the fact that they looked to their nurses and other personnel for their social comfort and did not mention the social support of their families as contributors to their comfort. In such instances, where patients have a limited network of support, nurses may be the most important source of social comfort and "therapeutic use of self" may enhance comfort more than nurses realize.

This may be different today in acute and long-term care settings and/or where "bare-bones" staffing is the norm. In these latter situations, a family member's presence is nearly a requirement for advocacy and safety. However, nurses and other team members can facilitate social comfort of the family unit, making them feel at home, important, intelligent, and valued.

Financial negotiations, transfer of information, and discharge planning occur in social contexts. Thus, these factors are considered to be elements of social comfort. When patients or their families need financial advice, nurses can make timely requests to social workers for assistance. When teaching patients/families about new regimens, it is necessary to inquire about financial burden associated with taking "designer meds." Financial planning for medications or environmental aides such as handrails for the bathroom or the right wheelchair, nurses and/or social workers can help with referrals or assistance with paper work.

Recently, the idea of culture has been added to include family histories, traditions, language, clothes, and customs (Kolcaba, on line). It may be important for the health care team to facilitate some of these customs during hospital stays or home health care to enhance social comfort.

Sociocultural comfort is defined as pertaining to interpersonal, family, and societal relationships including finances, education, and support. It also includes family traditions, rituals, and religious practices (Kolcaba, on line).

Definition of Holistic Comfort

By remembering the three types and four contexts of comfort, nurses and other team members can perform comfort care, not only in the sense of advance directives, but also in a proactive, healing, recovery sense. Comfort care in any setting or population requires that patients' total comfort needs are assessed, interventions are designed to address comfort needs that have not been met by patients' existing support systems, and evaluation of the effectiveness of such interventions is carried out. Evaluations of interventions are done by comparing comfort scores or statements before and after interventions are implemented.

When using the comfort grid, differences between relief and ease are not terribly important except to remind us to attend to all known discomforts or risk factors for each patient in order to keep patients in a state of ease. Also, it is important to remember that, even when relief or ease cannot be achieved, we can intervene with comfort measures targeted towards transcendence in order to inspire or motivate patients to rise above their angst in order to do what must be done. This is very useful when patients must go through painful or unpleasant conditions associated with chemotherapy, rehabilitative therapies, or grief.

If a patient experiences comfort in every cell, or aspect, of comfort we can say that he or she is comfortable. However, such a state would be rare in stressful health care situations, where comfort needs are high. So the goal of health care is to enhance comfort compared to a previous baseline. This is the immediate altruistic outcome of a health care team who practices comfort care.

And, when doing an individual comfort assessment or intervention, it is most useful to identify and address comfort needs in the four contexts (physical, psychospiritual, sociocultural, and environmental). Often, this process can be accomplished with a single intervention or a quick series of interventions. This pattern leads to efficient patient care that is more satisfying to patients and nurses.

Figure 1

                                                     Comfort Grid (Foundation of Holistic Definition of Comfort)

                                                                                        Type of Comfort