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    2 - Comfort Theory - Dowd - Alligood - 2018 - Com Ref Bib

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    Margarida Reis

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    lacMillen, ath oe Theory of Comfort Jatvine Kocatat E J 3 Preser) chia: ic mission of providing comfort mily members is even more important. Co idote th care situations today, and when comfort is ‘and families are st liations mngthened for the tasks ahead. In addition, y nu ey are giving” (K. Koleaba, personal communication, March 7, " De. Koleaba is retired from the University of Akron as an hie emeritus associate professor. Her nursing interests include ve interventions for and documentation of changes in comfort ent Katharine Kolcaba wasborn and educated in Cleveland, Ohio, for evidence-based practice, She resides in e Cleveland In 1965 she received a diploma in nursing, and she practiced area with her husband, where she enjoys being near her part time for many years in medical-surgical nursing, long- grandchildren. She represents her company, The Comfort term care, and home care before retu aduate school. Line, to assist health care agencies implement the theory of In 1987 she graduated in the first RN to MSN class at Case comfort on a system-wide basis, She is founder and coord Western Reserve University (CWRU) Fr olton nator of a local parish nurse program and a member of the School of Nursing, with a specialty in gerontology. While in ANA. Koleaba continues to work with students and nurses school, she job-shared a head nurse position on a dementia at all levels as they conduct comfort studies. unit, It yas in this practice context that she began theorizing about the outcome of patient comfort Koleaba joined the faculty at the University of Akron College of Nurs raduating with her master’s degree sgan her theoretical work by diagramming het in nursing. She gsined American Nurses Association (ANA) nursing practice, an assignment early in her doctoral stud certification in gerontology. She returned to CWRU to pur- ies. When Koleaba presented her framework for dementia sue her doctorate in nursing on a part-time basis while care (Koleaba, 2003), she was asked, “Have you done a continuing to teach. Over the next 10 years, she used course concept analysis of comfort?” Kolcaba replied that she had work in her doctoral program to develop and explicate her not but that would be her next step, This question began theory in a series of published articles, now summar her long investigation into the concept of comfort. hher book (Koleabs, 2003). The first step, the promised concept analysis, began with an extensive review about comfort from the disciplines of ‘The author wishes to thank Katharine Koleaba forheranisiance nursing, medicine, psychology, psychiatry, ergonomics, and with this chap English language (specifically Shakespeare's use of comfort Photo credit: Barker’ Camera Shop, Chagrin Fills, OF and the Oxford English Dictionary [OED]). From the OED, 527 Koleaba learned thatthe original definition of comfort we iathen greatly.” This definition provided a wonder ul rationale for nurses to comfort patients because patients would do better and nurses would feel more satisfied ;ccounts of comfort 1859) decla pservation is for. It is not fistorical ous. Nightingale sight of what “It must never be lost or the sake of pil or curious facts, but for ng up miscellaneous informatic the sake of saving life an (p.70). From 1900 to 19 nursing and medicine because Koleaba, There were no antibiotics, creasing health and comfort” comfort was the central goal of thro comfort, recovery n & Morse, 1995 apy; or technology speed up the return to health. Nurses were duty bound attend to details influencing patient comfort. Akens (1908) proposed that nothing concerning the comfort of the pa snough to re. The comfort of patients was nursing’s frst and last consideration, Good nucses made patients comfortable, and the provision of comfort was a primary determining factor of nurses’ ability and (Aikens, 1908 farmer (1926) stated that nursing care was concerned charac with providing a “general atmosphere of comfort,” and that personal care of patients included attention to “happiness comfort, and ease, physical and mental” in addition to “rest and sleep, Jimination (p.26) nutrition, cleanliness, and Gooxinaw (1935) devoted a chapter in her book, of Nursing, to the patient’s comfort. She A nurse is judged always by her ability to make her atient comfortable. Comfort is both physical and mental, and a nurse's responsibility does not end with physic ated 1904, 1914, and 1919, was called mental comfort and was care” (p. 95). In textbooks emotional comfort achieved mostly by providing physical comfort and modi fying the environment for patients (Kolcaba, 2003) in Kolcaba's theory of confor those receiving comfort mea jonts, patients, students, communities, and sures may be refered ta as re soners, workers, older a are comiort neds arising from st heath care situations that cannot be met by 1 ipionts tra ditional support systems, The needs may be physical, psy chospintu Poarent thro pathophysiologial parameters, financal cou ate nursing actions and refer specific comfort needs of Middle-Range Theories In these examples, comfort is postive, achieved with the help of nurses, and, in many cases, indicates improvement from a previous state or condition. Intuitively, comfort is associated with nurturing rom its word activity. Koleaba explicated its strengthening features, and from ergonomics its direct link to job per formance (progress in therapy), However often its meaning context, and ambiguous. The concept s implic , noun, adjective, adverb, process, and outcorn arly nursing theorists to synthesize or derive the types of comfort in the concept Kolcaba used ideas from thre analysis (Koleaba, 2003} was synthesized from the work of Orlando (1961), who posited that nurses relieved the needs expressed by patient: was synthesized (1966), who described 14 basic Functions of human be ings to be maintained during care : ‘was derived from Paterson and Zderad (1975), who proposed that patients tise above their difficulties with the help of nurses, Four contexts of comfort, experienced by those receiving came from the rev (Kol ‘of nursing literature about olism 2, 2003). The contexts are and and are defined in Big 3. The four contexts were juxtaposed with the three types of comfort, creating a taxonomic structure (matrix) from which to consider the complexities of comfort as an outcome he taxonomic structure provides f the content a map domain of comfort. Iti anticipated that in the future, research ers will design, modify or translate comfort questionnaires for the taxonomic structure a8 he many translations can be found on Koleaba’s web- site, The Con tion of the Gi their specific population usin includes the steps for adapta neral Comfort Questionnaire (GCQ), are interacting forces that influe al comfort. They cons cipients' perceptions of experiences, age, attitude tem, prognosis, and the fotalty (Koleaba, 2003}, Such intervening vara et nt care itervertic ‘may be included in the dem elements in the recipient affect planning in research, they [tis the immediate, olisti is the im ents of comfor 'e experien hieved with the + improvement ely, comfort i res, and. trom ce (prog cit, hidden in ng theorists inthe concept lando (1961 by s express of Henderson of human be- mn and Zdered above their about holism sychospirtual, ted in Fig. 33.1 three types of x) from which, of the content ure, research Kolcabals web ps for adapta- search, th CHAPTER 33 Theory of Comfort MAJOR CONCEPTS & DEFINITIONS—cont’d jence of being strengthened when one’s 1 | | addressed, The three typ Institutional Integrity fort are r f physical psy- states, and countries that poss nmental (Koleaba, te, whole, sound, upright, n Fig. 33.1), nd transcendence. The four context 5s the @ prtual, sociocultural, and envi practices and be: n evidence (Kolcaba, 2003), Health-Seeking Beha Health-seeking behaviors compose a broad cateoory of ‘@lted to the pursuit of health as defined by the Best Practices in consultation withthe nurse.Th syntesized by Schott external, 0° a peaceful d res were The use of healt based on e ‘and pros sdto be intemal, produce the best possi intemal behaviors ae thee best practices. cannot see, such as surgical healing, T cal formation extemal Behaviors are those we can see ci- Best Policies recy such as ambulaton or indirectly suchas blo A peacoful death is dafined by Kolcaba (2003) 2s “a death in procedures an which conficts ere resohed, symptoms ate wel manager ure, Institutional or regional policies ranging fr modical conai of health care are kno acceptance by the patient and far memibersalows for lustrates the relationship arn tho patent to et go’ qui best practices, and best policies, institutional id with dignity” 2 “ype of Comfort Relet se anscendence | Peychosointual fone = 4 Eavlormental | | — a} ~ 2S] Sees Type of Comfort: jet! The state of a patient who has had a spect need met Ease: Tho state of calm or contentment Transcendence: The stale in which one ri 1 above one's problems or pain Context in Which Comfort Occurs: hysica: Peraining to body sensations /chospintual: Pertaining to internal awareness of set, ncluding esteem, concept, sexuality, and meaning in one’s fe: one's relationship to higher order or being Environmental: Pertalcing to the extornal suroundings, conitions, and inuences fal Pertaining to interpersonal, family, and societal rolationships, FIG. 33.1 Taxonomic structure of comfort, (From Kolcaba, K., & Fisher, E, 11996l. A holistic spective on comfor nee directive. Crt schools, hospitals, regions, alitias of being sealing, ethical, and nal integrity. As institutions patient and family outcomes is protec 3s and delivery mn as best policies, Fig. 39.2 Middle-Range Theories IN © kotcaba (2007) ‘The seeds of mod fort were sown in the late lective, But separa tic comfort. Hamilton (19) sm inguiry about the outcome of com 1980s, marking a period of col- sareness about the concept of holis- ) made a leap forward by exploring the meaning of comfort from the patient's per in how each patient ina long-term care facility defined comfort. The theme that spective, She ws jews to ascert ged most was relief from pain, but patients also iden: tified good positioning in well-fitting furniture and a fel ing of bei worthwhile, and he clear message ning different things to independent, encourag useful Hamilton concluded comfort is multi-dimensional, m different people” (p. 32 After Koleaba dev nurse researcher to demonstrate that ch ped her theory; she was the frst ges in comfort in experimental design (Koleaba, 2003). In this dissertation study, health care needs wei those (comfort needs) a ociated with a diagnosis of eat breast cancer. The holistic intervention was guided im designed specifically for these patients to mect their comfort needs, and the desited outcome was their comfort The findings revealed significantly higher comfort over compared with wing guided ima (a. Vataties’ J “Camiont }*{ Sena. Vw ) Bonaviors) Best erin) (nstiutional (> Ny ) (Genertors) HH wae comfort, (Copyright Ké the usual care group. Kolea additional empirical testing which is detailed in her book and cited on her website (Koleaba, 199% nd associates conducted ‘of the theory of comfort, 103, pp. 113-124) hese comf studies demonstrated significantly higher comfort for the groups over time, Examp that have been tested recently include th Still-point induction and mass of interventions herapy for patien 14), ‘Mindfulness-based stress reduction for elderly residents in lox with chronic pain (Townsend etal term eave (Kumar, Adi Comfort-based nursing care for women with new Cesarean sections (Derya & Pasinliogui, 2013) Use of heated blankets to enhance comfort of acute psychiatric patients (Parks et In each study, interventions 1d to all att arch settings, comfor d or translated from the GCQ (Koleaba, 2003), and there were a least two (usually three butes of comfort relevant to the re instruments were adap astement points used to capture changes in comfort cover time. Empirical support for the holistic nature of comfort was found in a study of four theoretical propos tons (Koleaba, 2003): 1. Comfort is generally state-specific 2. The outcome of comfort is sensitive to changes overtime, YY ss conducted of comfort, pp. 113-124), nfort for the for patients erly residents e, 2014), with new 115). fort of acute 1 to all atti ings, comfort m the GCQ sually three $ in comfort ial proposi d holistic nursing intervention with an established history for effectiveness enhances, 3. Any consistently applic 4, Total comfort is greater than th: ests on the data set from Kolcaba's earlier study of women with breast cancer supported each pr Other areas of study included in the Koleaba website are burn units, labor and delivery, infertility, nuts sum ofits pats hhome care, chronic pain, pediatrics, oncology, dental hy giene, transport, and those with mental disabilities, Nursing isthe intentional assessment of comfort needs, the n of comfort interventions to addr reassessment of comfort levels after implementation com pared with a baseline, Assessment and reassessment may be ks if he patient is comiortable. Objective assessments include those needs, and intuitive or subjective or both, such as when a nurs observations of wound healing, changes in laboratory values, or changes in behavior. Assessment of comfort is achieves rough the administration of verbal rating sales (clinical or comfort questionnaires (research), asing instraments veloped by Koleaba (2003). Recipients of care may be individuals, families, institutions, or communities in need of healthcare, Nurses may be recipients of enhanced workplace comfort when initiatives to improve ondlitons are undertaken (Boudiab & Kolcaba, 2015). ‘The environment is any aspect of patient, family, or insti- tutional settings that can be manipulated by the nurse(s loved one(s), oF the institution to enhance comfort Health is optimal functioning ofa patient, family health care provide, or community as defined by the patient or group, Human beings have holistic responses to complex stimuli Kolcaba, 2003). 2. Comfort isa value-added holistic outcome that is ger mane to the discipline of nursing. 3. Comfort is a basic human need that persons strive to meet or have met. It isan active endeavor 4. Enhanced comfort strengthens patients to engage in oftheir choice Theory of Comfort 5. Patients who are empowered to actively enga inhealth ing behaviors are satisfied with their health care. 6. Institutional integrity is based on a ented to the ipients of care. Of equal importance is an orientation to a health-promot holistic setting for families and providers of care. 1s oF propositional assertions that may be tested separately or as a whole Part tive, result in increased comfort for recipients (patients and ates that comforting interventions, when effec families) comp d with a preintervention baseline. Care providers may be considered recipients if the institution rakes a commitment to the comfort of their work setting ‘Comfort interventions address basic human needs, such as rest, homeostasis, therapeutic communication, and treat ment as holistic beings, Comfort interventions are usually nontechnical and complement the delivery of technical cae, Part results in increased engagement in health-seeking behav states that increased comfort of recipients of care iors (goals) that are negotiated with the recipients, sed engagement in health-secking 4 quality of care, benefiting the institution and its ability to gather evidence for best practices and best polices, Part 3 states that incr behavior results in incre Kolcaba believes nurses want to practice comfortin care and that it can be easily incorporated with every nuts ing action. She proposes that this type of comfort practice promotes greater nurse creativity and on, as well patient satisfaction, To enhance comfort, the nurse must deliver the appropriate interventions and document the results in the patient record. However, when the ap: propriate intervention is delivered in an intentional and comforting manner, comfort still may not be enhanced sulficientiy When comfort is not yet enhanced to its fullest nurses then consider intervening variables to explain why comfort management did not work. Such variables may be abusive homes, lack of financial resources, devastating di agnoses, or cognitive impairments that render the most appropriate interventions and comforting actions ineffec tive, Comfort management or comforting care includes interventions, comforting actions, the goal of enhanced comfort, and the selection of appropriate health-secking behaviors by patients, families, and their nurses. Thus comfort management is proposed to be proactive, encr- ized, intentional, and longed for by recipients of care in all settings. It is what nurses clo when they practice the art of sas comfort nursing. To strengthen the role of nur gents, documentation of changes in comfort before and after their interventions is essential, For clinical use, Kolcaba suggests asking patients to rate their comfort from 0 to 10, with 10 being est possible comfort in a given health care situation, This documentation could be a part ofthe electronic databases in each institution (Boudiab & Koleaba, 2015), Note that total comfort may not be possi ble in most health situations, but an increase in com. fort will nevertheless strengthen patients. Kolcaba used three types of logical reasoning in the de pment ofthe theory of comfort (1) induction, (2) deduc tion, and (3) retraduction (Hardin & Bishop, 2010) ‘occurs when generalizations are built from a number of specific observed instances (Hardin & Bishop, 2010). When nurses are earnest about their practice and eat nest about nursing asa discipline, they become familiar with mplict or explicit concepts, terms, propositions, anda ions that ur may be asked to diagram their practice as L asked Kc easy-sounding assignment Such was the scenario during the late 1980s as Kole began. She was head nurse on an Alzheimer unit atthe time and knew some of the terms used t tice of dementia care, such as sump. pin their practice, Nurses in graduate schoo Rosemary Fis other students to do, and it isa deceptively and However, when she drew relationships among them, she recognized that th three terms did not fully describe her practice. An impor piece was missing, and she pondered about shat nurses were doing to prevent excess disabilities (later ) and how to ju the interventions were working, Optimum function hat been conceptualized as the ability to engage in special ac tivities on the unit, such as setting the table, preparing salad, jing to a program and sitting through it. These activities made the residents feel good about themselves, as ifitwere the rig activities did not happen more tha ht activity at the right time. However, those twice a day, because the residents couldn't tolerate much more than that. What were they doing in the meantime? What behaviors did the stat hope they would exhibit that would indicate an absence of ‘excess disabilities? Should the term ¢ Tineated further for clarity? Cont Jed her to reconsider patient care Partial solutions to these questions were to (1) intro duce the concept of comfort to th cause this word seemed to convey the desired state for patients when they were not engaging in special activities; (2) divide excess disabilities into physical and mental; and Middle-Range Theories note the feedback loop between comfort and optimum, functioning. This thinking marked the first ste theory of comfort and thinkin; the concept (Koleabs, 2003) ‘occurs when specific conclusions are inferre irom general premises or principles; it proceeds from the general to the specific (Hardin & Bishop, 2010). The de ductive stage of theory development resulted in relating comfort to thi concepts to produce a theory. Because the works of three nursing theorists were entailed in the defini tion of camfore (Henderson, 1966; Orlanclo, 1961; Paterson & Zderad, 1975), Kolcaba looked elsewhere for the com: mon ground needed to unify velief, ease, and transcen: dence (three major concepts). What was needed more abstract and general conceptual framework that was congruent with comfort and contained a manageable number of highly abstract constructs. The work of psychologist Henry Murray (1938) met the criteria fora framework o concepts, His theory was about human needs; therefore it nultiple stra in stressful health care situations, Furthermore, Murray’ which to hang Koleaba's nursing was applicable to patients who experie idea about unitary trends gave Koleaba the idea that, al though comfort was state-specific, if comforting interven: tions were implemented over time, the overall comfort of patients could be enhanced over time, In this deductive stage of theory development, she began with abstract, general theoretical construction and used the sociological process of substruction to identify the more specific (ess abstract levels of concepts for nursing practice is useful for selecting new phenomena that can be developed further and tested. Ths type of reasoning is applied in fields that have few available theories (Hardin & Bishop, 2010). Such was the case with outcomes re search, which now is centered on collecting databases for _measuiring selected outcomes and relating those outcomes tutional, or communit protocols, Murray's 20th-century framework could not ac 0 types of nu count for the 2Ist-century emphasis on institutional and community outcomes. Using retroduction, Koleaba added to the middle-rany n extended the theory 10 the concept of theory of comfort, Adding the consideration of relationships between health-secking be haviors and institutional integrity. Later, the concepts of and ete linked to institu tional integrity (Koleaba, ‘organizes the knowledg 3). Theory-based evidence ase for best practices and poli optimum ps toward a nplexities of are inferred cds from the 10). The de- in celating Because the n the defini 61 Paterson or the com il transcen reded was a ork that was ‘manageable 138) met the a's nursing therefore it tiple stimli , Murray's dea that, al | comfort of rac, general I process of ss abstract) jomena th ries (Hardin atabases fo ould not ae utional and saba added iddle-range he theory to secking be concepts of Ito institu od evidence es and poli Many students and nurse researchers have sclected this heory as a guid such as obstetrics (Barbosa et al, 2014), veterans’ health if framework for their studies in areas Boudiab & Koleaba, 2015), postpartum care (Derya & Pasinliogla, 2015), teaching of nursing stu & Candela, 2013), hospice patients (Hansen et al, 2015), cardiac patients (Krinsky; Murillo, & Johnson, 2014), long rm care (Kumar, Adiga, & George, 2014), and prior to anesthesia (Seyedfatemi etal, 2014), When nurses ask patients or family me thei c nbers to rate mfort from 0 to 10 before and after an intervention or at regular intervals, hey produce documented evidence le is sen: 107; sitive to changes in comfort over time (Dowd etal 2017). A lst of effective comforting interve h patient or family member is readily available and communicated Perianesthesia nurses have incorporated the theory of comfort into their Clinical P ment of patient comfort, In this set ice Guidelines for manage: comfort manage- sds related rent specifies (1) assessing patients’ comfort n to current surgery, chronic pain issues, and comorbidities, 2) creating a comfort contract with patients before sur ery that specifies effective comfort interventions, under standable and efficient comfort measurement, and the type of postsurgical analgesia preferred: (3) facilitating com: fortable positioning, body temperature, and other factors ith comfort management and measurement in the postsurgi- cabs, 2008) elated to comfort during surgery; and (4) continui cal period (Wilson & Ko A textbook that is useful for education is the Nursing Diag nosis: Han Ackley, Ladwig, & Makic, 2017). The nursing diagnoses of Altered Comfort (Koleaba) and Read: ness for Enhanced Comfort (Boudiab) are included in the latest edition. The theory is incorporated in the Nursing Intervention Classification (NIC) and Nursing Outcomes Classification (NOC) handbooks as well. The ory is ap- nd its propriate for students to use in any’clinical setting, application can be facilitated by use of the Comfort Care Plans available on Kolcaba’s website Recently Goodwin and Cant ‘of comfort as a transitional philosophy in a group of new ck relief through Ja (2013) used the theory practicing nurses. The new nurses were taught to from stressors, maintain ease with their new seti trusting their stafT members, and achieve ta Theory of Comfort their stressors with use of se comforting techniques, ‘The authors stated that “all participants referred to holistic com: fort (HC) as something they still use with both collea and patients, implying nurses’ application of HC can practice outcomes” (p. 618), ‘An entry in the Encylo Outcome (Kolebs, 2012). Nurses eth rode dene te legate level through ties that demons te rh speaks 10 fectiveness of comforting care. Kolcaba (2003) called for measurement of comfort in large hospitals and home are to expand the theory and develop the literature on evidence-based comfort. Using the taxonomic structure of comfort (see Fig. 33.1 sa guide, Koleaba (2003) d rloped the GCQ to measure hol > cach cell in the taxonomic structure grid. Twenty-four positive items and 24 negative Likert-type format, ra disagree, with higher the end of the instrumentation study with 206 one-time narticipants from all types of units in two hospitals and 50 participants from the community, the GCQ demon: ronbach alpha of 0,88 ic comfort in a sample of hospital and community cipants. Positive and negative items were generated fo 1 were compiled with a ing from strongly agrce to strongly strated a Researchers are welcome to modify the comfort ques rating scales and other traditionally formatted question aires specific to their areas of naires may be downloaded from Koleaba’s website, where she responds to inquiries about comfort research in sup- port of the use of her theory, Instructions for use of the questionnaires are available on the website, Popularity of the theory seems to be associated with its simplicity and with universal recognition of comfort as a desirable ou’ come of nursing care for patients and the Families Kolcaba has persisted in the development of her theory from the original conception asthe root of her practice to conce analysis that provided the taxonomic structure of comfort to development of ways to measure the concept; and cur rently to its use for practice, education, and research, She sses a full array of apps The methodical development and documentation of the concept of comfort resulted in a strong, clearly organized, and I al theory that is readily applied in many settin ducation, practice, and research. Kolcaba developed ates for measurement to facilitate application of the Middle-Range Theories comfort theory in additional settings. The comfort manag ‘ment templates she provided for use in practice settings have been helpful to students and faculty members. Outcomes of research have demonstrated the appropriateness of her theory for measuring whole-person changes that were less effectively captured with other types of instruments The original theoretical assertion (Part 1) of the theory of comfort has withstood empirical testing, When a comfort intervention is targeted to meet the holistic comfort needs of patients in specific health ca hanced beyond baseline measurement. Furthermore, en henced comfort has been correlited with engagement in health- seeking behaviors (Schloxfelat, 1975). Empirical tests of the theoretical assertions fos the second and third parts of he theory should be conducted and published. Outcomes chaviors could include in- ter progress during rehabilta- for desirable health-seeki creased functional status, tion, faster healing, or peaceful death when appropriate health-secking behaviors are negotiated among the patient, family members, and care providers. Institutional outcomes, would include decreased length of stay for hospitalized pa: achievement of national awards such as the Beacon Award nts, smaller number of readmissions, decreased costs, and Koleaba consults with hospital administrators and staf edu- cators who want to enhance quality of care (Boudiab & Kolcaba, 2015). She views quality care as comforting actions delivered in an intentional manner to create an environment that leads to engagement in health-seeking behaviors. Kolcaba postulates that intentional emphasis on and support for comfort management by at institution or community increases patient and family satisfaction, be- cause persons are healed, strengthened, and motivated to be healthier, Extending the theory of comfort to the com munity is also of current interest. It is well known that some communities are more comfortable to live in, go to school in, and grow old in than are others. n area of interest for further development is the univer sal nature of comfort. Currently, the GCQ has been trans- lated into Taiwanese, Turkish, Spanish, Iranian, Portuguese, and Italian (see Kolcaba website). Comfort of children has peen accurately observed and documented in perioperative settings (Nancy Laurelberry, personal communication, February 2008). Comfort Daisies for children to self-report their comfort (see Koleaba website) have been tested in @ 2, personal communication, hospital setting (Cartie Maj February 2008 The theory of comfort has been included in electronic nursing classification systems such as the North America Nursing Diagnosis Association (NANDA) (Ackley, Ladwig, & Maki, 2017), NIC (2008), and NOC (2008). Koleaba consults with hospitals to include comfort management in their documentation systems (Boudiab & Koleaba, 2015) Use of the theory has made significant contributions to nursing practice and the discipline, Kolcaba continues to spend time and energy developing and disseminating the theory through presentations, publications, and discus. sions since retiring from full-time teaching. The theory of comfort is ofien used as an organizi framework for Magnet Status certification and other awards for excellence in health care. Nurses often choose this framework because it describes what they want to do for patients and families and what patients want from nurses uring their hospitalization. An array of possible uses of the framework components is offered to the hospital, such as Comfort Rounds, performance review criteria, methods of documentation, clinical l “value added” benefit when nurses are supported with quate staffing levels to implement their comforting interventions can be empirically demonstrated throu measurement of institutional outcomes such as patient satisfaction, "Best Hospital” des ‘Another way in which comfort theory is appropriate for wide application in a hospital system is to provide a theoretical base to enhance the working environment, Koleaba collected information about the needs and wants sd them on the taxonomic of practicing nurses and arran structare of comfort. From this preliminary work, the Nurses Comfort Questionnaire (NCQ) was des which can be used in pilot tests of nurse-inspired changes to the working environment, such as flexible or selfscheduling, mandatory lunch breaks off unit, a pleasant and clean rest area, or debriefing opportunities ater dificult patient situa tions (Boudiab & Kolcaba, 2015; Rondinel tal, 2015). For an empirical study, nurses would complete the NCQ before the suggested char ‘months after imple comfort had increased over time. Institutional outcomes was implemented and again a few sentation to determine whether nurses’ such as absenteeism, tardiness, or turnover could be added to the study, because comfort theory predicts that these sub- sequent outcomes would be correlated with enhanced nurse comfort and satisfaction Jcaba leaves an extensive paper trail of articles that high: ight her step in creating this midale-range theory. They are consistent in terms of definitions, derivations, assumptions, and propositions. Clarity is heightened in her bool, whic presents the theary and her articles leading to it (Koleaba 2003). Koleaba applies the theory to specific practices using academic, but understandable, language. All research com cepts are defined theoretically and operationally not § be w thre foe butions to ntinues to nating the 1d discus ner awards r00se this 1 do for uses of the i such as methods 0 on. The rted with I through 8 patient ‘propriate > provide ironment. ind wants, work, the eveloped, hinges to heduli 1015), For ‘Q before in af ne added hese sub- bat high: They are mptions, k, which Koleaba, rch con imp! The theory of comfort is simple, fe and the traditional mission of nursing. Its la ause it is basic to nurs ‘guage and application are of low technology, but this does ly technological settings. There not preclude its us. are six variables in the theory, and selected variables may be used for research or educational projects. The main thrust of the theory is for nurses to return to a practice facused on the holistic needs of patients inside or outside nstitutional walls, Its simplicity allows students and nurses to learn and practice the theory easily (Kolcaba, 2008). Generality Koleaba theory has been applied in numerous research ettings, cultures, and age groups. Her book has been trans lated into German, Japanese, and Portuguese. The onl limiting factor for its application is how well nurses and administrators value addressing the comfort needs tients, If nurses, institutions, and communities are commit- ted to basic nursing care, the theory of comfort promotes cflicient, individualized, holistic practice. The taxonomic structure of comfort facilitates researchers’ development of comfort instruments for new sett Accessi The first interventions offered over time will demonstrate enhanc ity hat effective mursi comfort, has been tested and supported with numerous stu ies. Furthermore, in the study by Dowd, Kolcaba, and Steines (2000), enhanced comfort was strong predictor of increased health-seeking behaviors, meaning when patients are more do better in rehabilitation or recovery. This comfortable, th relationship begins to support the second and third p the comfort theory. Comfort instruments have demonstrated strong psychometric properties, supporting the validity of the questionnaires as measures of comfort that reveal changes in comfort overtime and support ofthe taxonomic structure. Verbal rating scales (VRSs) are especially useful for ctinical practices the nurse asks a patient to rate his or her total com: fort from 0 (no comfort at all) to 10 (highest comfort possible [Lsummary From its inception, the theary of comfort focused on what for patients. As the theor the discipline of nursing do« evolved, the definition derived from concept analysis ex panded to include broader aspects of the patient such as cultural and spiritual aspects. The basic format of the taxo- and conceptual framework did not change. 0 validate that ds it is postive, institutional nomic structur The development of the GCQ was important he concept can be measured and document and itis related to desirable patient, family CHAPTER 33 _ Theory of Comfort in this situation). Such ratings are important for document ing effectiveness of nursing interventions by comparing baseline comfort to comfort after nursing care. VRSs are als useful forbs members about detractors from total comfort. They have been used in prior research and have strong concurrent valid ity compared with other comfort questionnaires (Dowd et 20075 Patks etal, 2017), Importance The theory of comfort describes patient-centered practice and explains how comfort measures ta otto patients and family members, their health and satisfaction, and the viability of institutions. ‘The theory predicts the benefit of effective comfort measutes (interventions) to enhance comfort and agement in health-seekn fort is dedicated to sustaining nurs on behaviors. The th cory of com: by bringing the disc pline back to its roots. Documentation of comfort strat and ther effects empirically demonstrates the art of nuts The outcome of comfort clescribes the effects of memorab nelping interactions with patients and family members that go beyond checklists or physician orders. It encompasses the art and science of nursing. Making electronic data systems inclusive of value-added outcomes such as comfort isimper tive. Collaboration and the openness of Koleaba’s website fa

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