Middle Range Theory: Kolcaba's Theory of Comfort (Research Paper Sample)

Middle Range Theory: Kolcaba’s Theory of Comfort Name Institution Abstract Comfort is an essential patient-focused health care outcome. Katharine Kolcaba discovered the concepts of patient comfort and comfort care while teaching and studying for her PhD on part time basis. She invested the next decades in the exploration, analysis, definition, operationalization, theorizing, and testing of the extent of patient comfort under different situations. The goal of comfort care is to enhance the comfort level of the patients, compared to baseline levels. Under the theory, delivery of care that enhances patient comfort is a necessary feature of professional nursing practice. Enhanced levels of comfort motivate patients and families to engage more fully in internal and external health-seeking behaviors, or embrace peaceful death. Theoretical propositions of the theory focus on the nature of comfort, assessment of comfort needs, implementation of interventions, reassessment of comfort needs, health-seeking behaviors, and institutional integrity. The taxonomic structure of the theory contains three types of comfort and four kinds of contexts within which comfort is experienced. The three types of comfort that might result from comfort care are relief, ease, and transcendence. The four contexts within which the types of comfort are experienced include physical, psychospiritual, environmental, and sociocultural contexts. Comfort theory is diverse and relatable to many clinical settings, which might explain why it has found applications many clinical situations such as cardiac surgery, hospice care and nursing homes. The functioning of the theory has been assessed by reviewing three published studies making use of the theory. The studies are conducted in cardiac surgery and hospice care settings. The review shows that comfort theory may be a reliable framework for designing comfort interventions and comfort-studies. A cardiac surgery clinical situation that might benefit from the theory is presented, with possible nursing assessments and interventions consistent with comfort theory. Middle Range Theory: Kolcaba’s Theory of Comfort Development of the Theory Comfort theory was proposed by Katharine Kolcaba. It is middle-range theory because its fundamental concern is to enable nurses provide care that improves patient comfort. Katharine Kolcaba discovered the concepts of patient comfort and comfort care through her nursing practice in the late 1980s. At the time, she was studying at the Frances Payne Bolton School of Nursing, Case Western Reserve University where she graduated in 1987 with a specialty in gerontology. The explication phase of the theory was done while teaching at The University of Akron College of Nursing and pursuing PhD at CWRU on a part-time basis. She relied on her doctoral program course work and feedback from students at the two universities to develop and explicate the theory. The exploration of comfort concept began with an assignment under “Introduction to Nursing Theory” course. The first comfort diagram was inspired by her dementia care experience as head nurse on an Alzheimer’s unit. The key concepts in the diagram were excess disabilities, facilitative environment, and optimum function, which were the terms they used frequently to describe dementia care at the unit. Excess disabilities were defined as “reversible symptoms that are undesirable and temporary extensions of a specific primary disability” Kolcaba, 2003, p. 3). Excess disabilities were categorized into physical and psychological manifestations. Nursing actions implemented to prevent excess disabilities were called interventions or comfort measures. Facilitative environment referred to “the therapeutic milieu which is adapted to address the needs of frail patients” while optimum function was “the ability to engage in special activities on the unit” (Kolcaba, 2003, p. 4). As head nurse, Kolcaba was deeply concerned with the state of normalcy that the residents had to be in when not engaged in optimum function. She pondered on the kind of behaviors the residents needed to exhibit before and after the optimum function. She was concerned with how to call the resident’s state that indicated the absence of excess disabilities. She considered this state as critical in her nursing practice. With the help of her husband, the concept of “comfort” came up (Kolcaba, 2003). She found comfort to be the most appropriate term because it “represented a relaxed, healthy, peaceful, and individualized condition for each resident” (Kolcaba, 2003). In this state, residents were able to socialize informally, wander casually, sit easily, nap, cooperate with staff, laugh, hum, and generally display ease and contentment within their environment (Kolcaba, 2003). The comfort state appeared to be essential for successful engagement with tasks requiring optimum function. Consequently, she included the concept of comfort into the original diagram (see Figure 1). This was the first step towards the generation of theory of comfort. Figure  SEQ Figure \* ARABIC 1. Comfort Framework        She presented the framework after graduating with MSN at the University of Toronto Gerontological Conference. The audience noted that the framework was applicable to many nursing situations, and suggested a need to do concept analysis for the concept of comfort. She spent two years to write and publish the framework (Kolcaba, 1992). After leaving Toronto, she engaged in concept analysis of comfort with the help of her husband, which took them two years to publish the concept analysis (Kolcaba & Kolcaba, 1991). Around the same time, she defined the concept of comfort for nursing to present it at the Sigma Theta Tau International in Indiana. Within the nursing context, three types of comfort were identified: relief, ease, and renewal (Kolkaba, 1991). Unlike the Toronto conference, the audience feedback was hostile. Fortunately, her husband with his skills as a philosopher and educator for 20 years, was able to address the complaints. Inspired by nurse theorists Orlando, she introduced the dimensions of physical and mental comfort the following morning after the conference. She constructed a taxonomic grid of the concept. After presenting her comfort grid to Margaret England, she advised her to replace “renewal” with “transcendence”. She also noted that “physical” and “mental” were not holistic. In the following year, she reviewed literature and came up with four contexts of human experience: physical comfort, psychospiritual comfort, environmental comfort, and sociocultural comfort. She then developed an holistic taxonomic structure of comfort showing the three types of comfort and the four contexts in which comfort is experienced (see Table 1). The work on taxonomic structure of comfort was completed in about 1988. It provided the basis for the development of General Comfort Questionnaire (GCQ), a tool for measuring comfort (Kolcaba, 2003). Table  SEQ Table \* ARABIC 1. Taxonomy of Comfort Needs ReliefEaseTranscendencePhysicalPsychospiritualEnvironmentalSociocultural Structural Aspects of the Theory The purpose of the theory of comfort is to make comfort central nursing care. In 1900s, comfort held importance in nursing. In developing the comfort theory, Kolcaba (2003) hoped to “convince practicing nurses and other health care providers that they can and should provide Comfort Care” (p. 19). The goal of comfort care is to enhance the comfort level of the patients, compared to baseline levels. Under the theory, delivery of care that enhances patient comfort is a necessary feature of professional nursing practice (Kolcaba, 2003). The concepts and propositions of the theory are specific to nursing, where it is applicable to many situations (Kolcaba, 2001). In addition to being readily operationalizable, the theory of comfort is relevant to nurses and patients where it describes nursing-sensitive phenomena (Kolcaba, 2001). The key propositions and assumptions that underlie the theory are discussed in the subsequent subsections. Propositions of the theory. Theoretical propositions of the theory may be categorized into four. The first part concerns the nature of comfort, and contains four propositions (Kolcaba & Steiner, 2000). First, the proportions of state and trait characteristics within the concept of comfort are of equal proportions. Second, comfort may change as time changes. Third, subjects comfort levels tend increase linearly after exposure to an intervention, compared to controls. Fourth, the total comfort is greater that the total sum of the individual parts of comfort (relief, ease, and transcendence). There is empirical evidence in support of these four propositions (Kolcaba & Steiner, 2000). The second part contains three propositions related to assessment of comfort needs, implementation of interventions, and reassessment of comfort needs. First, the theory states that nurses assess the holistic patient comfort needs in all situations with a view of identifying comfort needs that the existing support systems have failed to meet. Second, nurses need to design and implement various interventions designed to meet the identified comfort needs. Third, nurses take into account the presence of mediating variables whose influence on comfort the nurse can do little to control, and mutually agree on reasonable immediate outcomes in relation to improved comfort and/or subsequent health-seeking behaviors. These variables include financial situation of the patient, cognitive status, prognosis, and social support (Wilson & Kolcaba, 2004). Fourth, nurses should measure or assess the patient’s comfort needs after implementing the interventions to determine whether patient’s comfort level has improved. The comfort theory categorizes comfort interventions into standard comf...