Applied Nursing Research 27 (2014) 147–150

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Applied Nursing Research

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Theory Connections

A practical application of Katharine Kolcaba's comfort theory to

cardiac patients
Robin Krinsky, MSN, RN-BC, CCRN ⁎, Illouise Murillo, MSN, RN, Janet Johnson, MA, APRN-BC, FAANP
Case Western Reserve University, Frances Payne Bolton School of Nursing, Cleveland, Ohio 44106

a r t i c l e i n f o a b s t r a c t
Article history: Nursing approaches to care as based on Katharine Kolcaba's (2003) middle range nursing theory of comfort
Received 1 February 2014
are discussed in reference to patients' suffering from symptoms related to the discomfort from cardiac
Accepted 5 February 2014
syndromes. The specific intervention of “quiet time” is described for its potential use within this population as
a comfort measure that addresses Kolcaba's four contexts of comfort: physical, psychospiritual, environ-
Keywords:
Comfort theory mental and sociocultural. Without realizing it, many nurses may practice within Kolcaba's theoretical
Cardiac framework to promote patient comfort. Explicit applications of comfort theory can benefit nursing practice.
Kolcaba Using comfort theory in research can provide evidence for quiet time intervention with cardiac patients.
Quiet time © 2014 Elsevier Inc. All rights reserved.

Nurses strive to provide comfort to their patients in whatever

1. Case study 1
environment they practice. A key approach to providing for physical
and emotional comfort is to create an environment conducive to
It has been shown that rest promotes healing, recovery, and well-
healing – a major principle of nursing first stated by Nightingale
being (Tullmann & Dracup, 2000). However, the hospital environment
(1859). Nightingale's philosophy was to place the patient in the best
presents unique challenges for patients to obtain rest periods.
condition for the natural processes of healing to occur. Along with
Consider the following case of a patient admitted to the hospital
fresh air, sunshine, adequate nutrition, and other factors, she
with diagnosis of suspected acute coronary syndrome:
recommended quiet as essential for healing. However, in looking at
the environment in which we practice nursing, we see that it may not
be optimal for nature to act in beneficial ways for our patients. We, as John arrived at the emergency department with complaints of
providers of care, have yet to observe a time in which patients on a chest pain. He is certain this is the “big heart attack” his father
cardiac unit are not subjected to noise, interruptions, as well as a had. He is taken to the main emergency department, which is one
myriad of monitoring alarms. large area with stretchers aligned side by side with only a curtain
Comfort theory is a middle range theory developed by Kolcaba between each stretcher offering minimal to no privacy. It seems
(2003) that has as a foundation Nightingale's environmental that someone appears every five minutes to check his blood
principles of providing care (Selanders, 1998). This theory can be pressure, draw blood or ask him more questions about his health
used to enhance the environment of patients in cardiac care through history. The noise of the other patients, staff and monitoring
the use of a “quiet time” intervention. A loud and chaotic environment equipment is so loud it is difficult for him to hear the providers’
can negatively affect healing process of patients. The purpose of this questions. Time passes. Now John has been in the emergency
article is to describe comfort theory as applied in care of cardiac room for over 12 hours and he has not rested. When he finally
patients and to demonstrate the use of a specific intervention called starts to close his eyes and relax the nurse’s aide begins placing
quiet time, derived from comfort theory, to improve cardiac patients' him on a different monitoring device, with no explanation, just
experiences of comfort across four domains of care. We also call the statement, "You are going upstairs." The cardiac floor where
attention to the need for research into the effectiveness and use of he arrives is not much quieter. John is placed in a four-person
this theory-based intervention. room. Both patients on the other side of the room have their
televisions on and one of the IV pumps continuously alarms. John
is feeling discomfort in his chest similar to what he felt in the
Emergency Department. He has been unable to contact his wife
because the battery on his cell phone went dead. He is anxious
* Corresponding author. Tel.: + 1 917 848 7541, + 1 212 222 2353; fax: + 1 212 about what will eventually happen to him.
222 2353.
E-mail addresses: Robin.Krinsky@case.edu (R. Krinsky), Illousie.Murillo@case.edu
(I. Murillo), Janet.Johnson@case.edu (J. Johnson).
This case is devoid of any comfort measures provided by John's
care providers and results in the escalation of his chest pain and

0897-1897/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.apnr.2014.02.004
148 R. Krinsky et al. / Applied Nursing Research 27 (2014) 147–150

anxiety. Sleep deprivation and anxiety are all precursors that can
comfort needs are indicated in the relief column. Entries in the ease
trigger increased heart rates and elevation of blood pressure, which
column point to interventions for promoting a sense of calm or
in turn can cause additional workload to the myocardium and lead to
contentment in John. Patient-based expressions in the transcendence
exacerbations of chest discomfort. This brief case presentation alerts
column highlight John's expressed concerns that need to be addressed
us to the potential usefulness of a theory on comfort in everyday
to foster his sense of empowerment and ability to overcome the
practice, and to the relevance of a specific intervention that promotes
challenges of the illness. Comfort is dynamic and an ever-changing
quiet time in cardiac care.
state, and the entries in the table may also change over the course of a
patient's hospital stay.
2. Comfort theory

4. Quiet time intervention

Kolcaba (2010a,b) created a conceptual framework (Fig. 1) to
show broadly how her comfort theory fits into the flow of care in the
A quiet time intervention has significant potential for not only
practice setting. Comfort was described as the product of holistic
reducing noxious stimuli but also for creating opportunities for
nursing practice. Fig. 1 illustrates that regardless of the patient and
needed privacy and supportive interactions. Research findings have
family needs for health care, there is always a place for the
shown that quiet time can improve patient outcomes and increase
assessment and promotion of health care regarding comfort needs.
consumer satisfaction with acute care health services, both of which
Kolcaba's theory of comfort was first developed in 1991 when she
are of increasing importance in the contemporary health care
conducted a concept analysis to examine the literature from multiple
environment (Gardner, Collins, Osborne, Henderson, & Eastwood,
disciplines on comfort (Kolcaba & Kolcaba, 1991). The analysis
2009). Other research findings indicate that quiet time in a chaotic,
generated three forms of comfort and four contexts of holistic
noisy neuro-intensive care unit can create an atmosphere of
human experience from which a taxonomic structure was created
recuperation (Dennis, Lee, Woodard, Szalaj, & Walker, 2010).
as a map to guide areas of patient comfort for assessment in practice
The quiet time intervention has not yet been studied in the
and for measurement in research.
emergency department. However, the taxonomy of data from the
In comfort theory, specific concepts in the theory are organized in
cardiac care case in Table 1 indicates targets where this intervention
terms of three forms and four contexts of comfort. The three forms of
can be especially relevant to care of cardiac patients. A quiet time
comfort are relief, ease, and transcendence. Patients experience a
protocol was derived from comfort theory to promote comfort across
sense of relief when their individual comfort needs are met. Patients
the four contexts of care.
are at ease in situations that enable them to be calm or content. The
In the physical domain, quiet time can help minimize events in the
comfort state of transcendence occurs when a person rises above
cardiac care setting that have detrimental physical effects on an
their challenges. The four contexts in which comfort is experienced
already compromised patient. Of particular concern is a patient's
are physical, psychospiritual, environmental, and sociocultural. The
sleep, which is essential for multiple physiological and psychological
physical concerns bodily sensations and homeostatic mechanisms, the
processes. Numerous mechanical devices as well as hospital routines
psy- chospiritual pertains to the internal awareness of self, the
and procedures can significantly impair a patient's ability to sleep.
environmen- tal is the external surroundings and conditions, and
Sleep deprivation has been linked to rising incidence of patient falls,
sociocultural refers to interpersonal and societal relationships
confusion, and increased use of medication and restraints (Mazer,
(Kolcaba & Fisher, 1996).
2006).
The three types of comfort and the four contexts of care can be
incorporated into a hospital's model of care (Kolcaba, Tilton, & Long established recommendations from the U.S. Environmental
Drouin, 2006). In addition, this taxonomy of comfort can be applied to Protection Agency, Office of Noise Abatement and Control (1974)
specific patient cases to delineate various comfort needs of the state that the hospital noise levels should not exceed 45 decibels.
patient. However, studies have shown that the peak hospital noise levels
exceed 90 decibels, which is similar to the levels of heavy truck traffic.
Prolonged effects of excessive noise exposure on patients and staff
3. Comfort theory applied to care of cardiac patients
alike can have deleterious effect on their health and well-being
(Christensen, 2007). The chemical epinephrine and other endogenous
Kolcaba's Comfort Theory is readily applicable to cardiac patients.
stimulants are released in response to environmental stimuli, which
Table 1 presents an example of applying comfort theory to the case
in turn increase the patient's heart rate and blood pressure
study of John and his comfort needs. Data from the case study were
(DeKeyser, 2003). Quiet time interventions can prevent stimulation of
entered into the 12 cells of the table, organized according to the four
the sympathetic nervous system that occurs with an environment of
contexts of care and the three types of comfort needs. John's specific

Fig. 1. Reprinted with permission from Katharine Kolcaba, The Comfort Line, 2010.
 R. Krinsky et al. / Applied Nursing Research 27 (2014) 147–150 149

Table 1
Kolcaba's Taxonomy Comfort Needs for Cardiac Patients.

Comfort/
Context Relief Ease Transcendence

Physical Chest pain Implement pharmacological and holistic interventions

Psychospiritual Anxiety regarding the “big heart attack”
Environmental Noise, alarms, visual congestion of beds and
stretchers, repetitive questioning
Sociocultural Unable to contact family, lack of sensitive
nursing care
for pain
Provide supportive interactions that promote sense of calm
in the midst of cardiac event.
Organize a social and physical environment that supports
needs for privacy and limits interruptions.
Facilitate family presence and patient advocacy.
“What if this pain gets worse?”“What if I need
heart surgery?”
What if I had the “big heart attack”?
Reflecting on uncertainty of future
Seeking a soothing environment that promotes
healing. “I want to get out of here”
Unfamiliarity with hospital culture. “What does
going upstairs really mean?”

constant noise, bright lights, and interruption of sleep, and promote

Explaining and educating James on what the care plan will be
Kolcaba's form of comfort called relief.
helps reduce his anxiety. The nurse remains within this closed
In the psychospiritual domain, most cardiac patients can express a
unit so there can be quick response to any patient requests,
range of feelings from mild anxiety to impending doom related to
alarms from the monitoring devices, or IV pumps. Comfort
their symptoms. Studies have indicated that there is a positive
measures relating to James’ symptoms of chest pain, shortness
correlation between stress levels and serum cortisol, which can
of breath or anxiety can also be addressed with pharmacological
ultimately result in a depressed immune system (DeKeyser, 2003).
measures as well as holistic measures. The nurse calls James’ wife
Patients' exposure to increased stimuli and noise levels contributes to
to explain what is going on with her husband and then moves the
agitation. Quiet time can be a designated time in which patients may
portable phone to bedside for his use. A patient representative is
meditate, pray, rest, or converse with significant others. The resulting
contacted to obtain a charger for the James’ depleted cell phone
restfulness and decreased anxiety supports what Kolcaba's form of
battery. James reported no further episodes of chest pain and was
comfort called ease.
awaiting the results of pending blood work to rule out acute
In the environmental domain, the nurse can initiate quiet time
coronary syndrome. He was able to close his eyes and sleep. The
procedures that provide all forms of comfort for the patient (Olson,
Comfort Theory-based intervention of Quiet Time provided an
Borel, Laskowitz, Moore, & McConnell, 2001). Dimming the lights in
improved standard of care and outcome for this patient as well as
the patient's room and hallway can reduce unnecessary stimuli.
other cardiac patients.
Maintaining correct limits and volume of cardiac monitoring alarms,
pulse oximetry, blood-pressure cuffs, and IV pumps can minimize
inappropriate alarming. Alarms are addressed quickly, overhead
paging and unnecessary conversations in patient care areas are 6. Research implications: Next steps
limited, and staff and visitors are asked to speak in low tones. Health
care team rounding, consultant visits, routine deliveries, and other Quiet time is an intervention that has been evolving in practice but
services can be scheduled to observe periods of quiet time so as to research is needed to validate its usefulness and refine its
maximize the patient's rest time (Taylor-Ford, Catlin, LaPlante, & applications in specific patient settings.
Weinke, 2008). While anecdotal reports of nurse and patient satisfaction with
In the sociocultural domain, quiet time provides an opportunity to quiet time are positive, systematic study is needed of measurable
assess interpersonal and cultural aspects. This is a period of time outcomes in cardiac patients to see if and how it affects patient
when the nurse can have an unhurried and meaningful conversation anxiety, physiologic parameters (heart rate and blood pressure), pain
with patients and significant others, and facilitate patient and family and comfort. Additionally, research into the effects on nurses by the
needs for information, respect, validation, and emotional support that use of comfort care theory is also needed since applications of this
promote comfort in the form of Kolcaba's transcendence. theory may enhance the work environment and well-being among
health care providers as well as the patients.
5. Case study 2 There is a plethora of comfort questionnaires that have been
developed for specific populations such as: pediatric, peri-anesthesia,
In contrast to the first case study above, the following case is an and end of life and hospice. However, to date none have been found
that are unique for the cardiac population (Kolcaba, 2010a,b). Some of
example of a patient admitted to the hospital with diagnosis of
these questionnaires may be useful in studying cardiac patient
suspected acute coronary syndrome where the care providers applied
perceptions of comfort in their care. Many can be found at Kolcaba
quiet time interventions from comfort theory.
(2010a,b) Comfort Line Web site. In addition, outcome data on how
James arrived to the Emergency Department with complaints of organizations provide comfort care can be collected from responses
chest pain. The Emergency Department has a designated chest on Hospital Consumer Assessment of Healthcare Providers and
pain observational unit that is completely separate from the main Systems (HCAHPS) results and patient interviews.
area. After patients are quickly triaged, they are taken to the quiet
section of this observational unit. The unit itself has only six beds
7. Conclusions
with ample space in between each stretcher that allows for easy
movement of staff and privacy for the patient. James is placed on
Nurses have resources from their theories and their practice to
oxygen to help relieve the shortness of breath and the team leader
guide research into comfort-focused interventions for patients. Night-
provider processes and accurately documents patient history to
ingale's ideas provide a significant foundation for considering all
ensure that questions will not have to be repeated. The nurse
dimensions of the patient and environment that relate to comfort.
explains the protocol to determine the diagnosis of Acute
Kolcaba's middle range theory identifies a taxonomy of factors to
Coronary Syndrome to the patient and customizes the time for
consider in assessment and intervention. Nurses' practice experiences
the necessary interventions that allows for periods of rest and
and anecdotal evidence provide additional insights into what
reduced stimulation between required blood draws and EKG’s.
comprises comfort care. These resources coupled with clinical
research
150 R. Krinsky et al. / Applied Nursing Research 27 (2014) 147–150
can help equip hospitals and nurses with effective methods to
improve patient comfort and facilitate healing. As Kolcaba and Fisher
(1996) stated, if patients experience comfort, then they are more
satisfied with the care given, and the nurses as well as the institution
will benefit. What can be more germane to nursing than comfort?
Acknowledgments
We would like to acknowledge Dr. Pamela Reed, PhD, RN, FAAN
and Dr. Joyce Fitzpatrick, PhD, MBA, RN, FAAN for their support,
guidance, patience and useful feedback in the preparation of this
manuscript.
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