Joumal of Advanced Nursmg, 1994, 19, 1178-1184

A theory of holistic comfort for nursing

Katharine Y Kolcaba MSN
Insirt*dor, The Untverstty of Akron, College of Nurstng, Akron, Ohto, and PhD Shddent,
Case Wesiem Reserve Untverstiy, Cleveland, Ohto, USA

Accepted for publication 27 October 1993

KOLCABA K Y (1994) Journal of Advanced Nursing 1 9 , 1178-1184

A theory of holistic comfort for nursing
Although the construct of comfort has been analysed, diagrammed in a
two-dimensional content map, and operationalized as a hohstic outcome, it
has not been conceptualized withm the context of a broader theory for the
disaplme of nursing The theoretical work presented here utilizes an
intra-achonal perspective to develop a theory of comfort as a positive
outcome of nursing case A model of human press is the framework within
which comfort is related to (a) mtervenhons that enhance the state of comfort
and (b) desirable subsequent outcomes of nursing care The paper condudes
with a discussion about the theory of comfort as a significant one for the
disapline of nursmg

INTRODUCTION These mterventions and others are mtended to ehcit

positive whole person responses and thus would
The construct of comfort recently has been analysed,
be measured most accurately by whole person out-
diagrammed m a two-dimensional conceptual map, and
comes Whole person outcomes entail positive or
operahonahzed as a hohstic outcome (Kolcaba 1992)
negative carry-over effects between aspeds of the
Comfort IS defmed for nursmg as the satisfachon (ac-
person's response Whole person responses have been
tively, passively or co-operatively) of the basic human
difficult to operahonalize because of their complicated
needs for rehef, ease or transcendence ansmg from health
content domams, possible carry-over effeds between
care situations that are stressful Nursmg case is designed
components of the outcome, and the theoretical difficul-
to meet or contmue meetmg needs that fall under the
ties of mterpretmg a total score However, comfort is a
domam of the disaplme
hohstic outcome that accounts for whole person re-
The purpose of this paper is to postulate relahorwhips
sponses and it has been previously operahonahzed
between pahents' needs, nursmg interventions, comfort,
(Kolcaba 1992)
and subsequent outcomes, from these relationships a
The basic assumphons of the theory of comfort are
theory of comfort is denved It eoneludes with a diseus-
that (a) human bemgs have hohshc responses to complex
sion about the sigruficance of the theory of comfort for
stimuli, (b) comfort is a desirable hohshc outcome that is
nursmg
germame to the disciplme of nursmg, and (c) human
bemgs stnve to meet, or to have met, their basic comfort
Holistic outcomes and nursing needs These assumphons underpm the theory of comfort
Nurse saenhsts are begmnmg to explore the effective- and are m concert with an mtra-achonal perspechve m
ness of broadly targeted interventions such as progres- which the components of a whole person response are
sive musde relaxation, unagery and therapeuhc touch related and assessed comprehensively (Kolcaba 1992)
('lntra' designates withm, comfort is an outcome that
consists of many aspeds that are related withm the
Correspondence Katharine Y Kolcaba Instructor The University of Akron College
of Nursmg, Akron Oho U325-3701, USA domam of the construd)

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 Comfori iheory

COMFORT AS A HOLISTIC OUTCOME nursmg hterature about hohsm (Kolcaba 1992) The first
context IS physieal, pertammg to bodily sensations The
Comfort IS a holishc outcome because it designates a
seeond eontext is psyehospmtual, pertammg to the
dynamic and multifaceted state of persons Thinbng
mtemal awareness of self, meludmg esteem, sexuality,
about the outeome of eomfort requires an lntra-adional
meanmg m one's life, and relahonship to a higher order
perspechve because mtervenhons that are mtended to
or bemg The thu-d context is soaal, pertammg to
enhance one or more aspects of comfort mdirectly
mterpersonal, fanuly and cultural relationships Also
enhance other aspects Consistent with an mtra-adional
mcluded under social comfort are the firwnaal and
perspective, the magmtude of the total direct and mdu-ed
mformahonal aspects of soaal hfe The fourth context m
effeds IS expected to be greater than the magmtude of
which comfort is expenenced is envirorunental, pertam-
effeds achieved by addressmg smgle aspects separately
mg to hght, noise, ambience, colour, temperature and
The extent to which comfort is hohstic is based on the
natural versus synthehe elements (Koleaba 1991)
perception of all the aspeds taken together at one time,
because the effects m one have carry-over effects on When the two dimensions (three states and four
other aspeets eontexts) of eomfort are juxtaposed, the result is a
two-dimensional gnd with 12 faeets of eomfort Items for
Aspeds of eomfort have been anayed m a two-
eomfort questionnaires can be generated fi'om eaeh faeet
dimensional gnd (Koleaba 1992) They were denved from
that IS relevant to a speeifie research question In a pilot
a review of arehaie, histoneal and eontemporary nursing
project, 48 items were constructed usmg the comfort gnd
literature as well as a review of literature from other
as a eoneeptual map (Koleaba 1992) In the instrumen-
disaphnes (medieme, psychiatry, ergonomics, psychol-
tation study that followed, the three states of eomfort
ogy) (Kolcaba & Kolcaba 1991, Kolcaba 1992) A review
(rehef, ease and transeendenee) oeeuned as fadors m eaeh
of the previous work follows
of the four eontexts (physieal, psyehospmtual, environ-
Dimension one mental and soeial), as revealed by faetor analysis of 256
eompleted eonnfort questionnaires (Kolcaba 1992) The
The first dimension of comfort consists of three states, emergence of three factors, semantically conespondmg
called relief, ease and transcendence Rehef is defined as to the three states, oeeuned m eaeh of the separately
the expenence of havmg had a specific need met (Kolcaba analysed eontexts as well as m tottd eomfort
1991) Rehef from needs is necesscuy for retum to former For eonvemenee m analysmg and diseussmg responses,
fundion or a peaceful death Ease is defined as a state of the four eontexts were thought of as subseales of
calm or eontentment (Koleaba 1991) Ease is the state of eomfort, eaeh eontammg items from the three states or
eomfort that is a neeessary eondition for effiaent perfor- faetors A total eomfort seore was aehieved by addmg
manee Transeendenee is defmed as the state m eaeh the seores for eaeh subseale Total eomfort seores were
ordmary powers are enhaneed (Paterson & Zderad 1976) useful for differentiatmg between known groups and for
The charactenstic that differentiates transcendence from hypothesis testmg (Kolcaba 1992) (Fador analysis of
the other two states, rehef and ease, is that the former mdividual subscales that compnse a multidimensional
designates the patient's potential for extraordmary construct is an adaptation of traditional fador analysis
performance as an end that was previously apphed with umdimensional scales)
Because each of the three states of comfort entail
positive relationships to performance, theoretically they
also imply a strengthemng component This feature of CONCEPTUAL FRAMEWORK
comfort provides the central rationale for promotmg the Construds gam sigmficance when they are related to
patient's comfort Comfort is a desirable outcome for other concepts An organizing framework for comfort
nursmg care because it faahtates gams in physical and/or had to meet the followmg cntena the framework had to
psychological performance, comfort also is essential for a be based on (a) needs ansmg from the environment of (b)
peaceful death because a dymg person requires psychic whole persons for whom nurses could mtervene The
strength for acceptance and release The states of conifort
effectiveness of (c) the mterventions had to (d) be
are often conhnuous, overlappmg and mterdependent
perceived by the persons and (e) lead to subsequent
outcomes The efforts of Munay (1938) and colleagues to
Dimension two synthesize major elements of personahty theones mto a
The second dimension of comfort is the contexts m coherent model led to a theory of human press that is
which comfort occurs The contexts are denved fi-om the consistent with the above cntena for a framework for

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JCY Kolcaba

ccwnfort Murray called his model 'orgamsmic' (holishc) mg or proimsmg (Murray 1938) Beta press mvolves the
and stated, 'Smce the parts of a person carmot be appraisal of how weU the needs that anse from the
dissected physicaUy fi-om each other, and smce they ad obstructmg alpha forces are met by faahtatmg alpha
together, ideally they should all be estimated forces m the stunulus situation If the outcome is posihve,
simultaneously' (Munay 1983) evaluations accumulate and provide the expedation that
In the model of human press, a stimulus situahon is other situahons will end posihvely, contnbutmg to a
that part of the total envirorunent to which people attend umtary trend (Munay 1938) Umtary trend is defined
and read durmg a given episode m their life Human as behaviourai co-ordmation of activity towards the
development, whether positive or negahve, is determmed achievement of a desired effed
by the accumulated impressions about one's success For nursmg, beta press is the person's perception of
or failure that are formulated durmg encounters with how well the nursmg mterventions (faahtatmg forces)
the situahon For nursmg, a stimulus situation can be meet the needs ansmg fi-om the health care situation
regarded as any health care situahon (obstrudmg forces) for which the patient requires assis-
The shmulus situahon consists of alpha press and beta tance m satisfymg Perceptions of comfort imply that
press Alpha press is tixe sum of negahve (obstrudmg) negahve tensions have been reduced The person's per-
forces, posihve (faahtahng) forces, and mterachng forces cephon of an mcrease m total comfort leads to the
Beta press is the person's percephon of the total effed of remforcement of habits and goals that were successful m
the forces m alpha press For nursmg, obstrudmg forces reducmg tensions Pattenis of successful habits and goals
are the total negative stimuh ansmg from the health care lead to an onentmg thema that provides direction for
situahon mdudmg side-effects of illness or treatments, future achon A desirable thema that nursmg seeks to
noxious or threatemng environmental and soaal expen- promote is a health thema defined as a general onentation
ences, and emohonal sensahons such as fear, anxiety, to health-seekmg behaviours (Schlotfeldt 1975) A re-
powerlessness or aloneness The faahtatmg forces are aprocal relationship exists between health-seekmg be-
nursmg mterventions designed to meet the needs that haviours and comfort because health-seekmg behaviours
remam after the person's own reserves are depleted by also can enhance comfort
obstructmg forces Health-seekmg behaviours are conceptualized as mter-
Events also are mterpreted by the person m terms of nal or extemal m this theory of comfort Intemal behav-
the many mterachng forces that mfluence the outcome of iours happen at the cellular or organ level, such as healmg
percephon (Munay 1938) The mteradmg forces consist or urunune funchon Extemal behaviours are related to
of the person's past expenences, age, athtude, emohonal the outer world, such as self-care achvihes, funchonal
state, support system, and the totahty of elements m the status and health mamtenance programmes The extemal
present expenence Munay states that, because these behaviours named self-care, fundion, health mamtenance
parts of persons cannot be dissected physically from each programmes, and lengths of hospitalizahon are exphat in
other and because they act together, ideally they all Sdilotfeldt's model (1975), while mtemal behaviours are
should be eshmated sunultaneously (Munay 1938) (With imphat under the categones of survival and fertdity
modem stahshcal methods, mteradmg forces can be Schlotfeldt also mcludes dignified death m her model
operahonahzed as covanates m analyses of vanance or under the eategory of health Consistent with holism,
beta weights m regression models) eonsaous thought and subeonsaous frame of mmd
mfluence health-seekmg behaviours If the person is
Needs mcapable of consaous thought, the nurse can look for
Needs are defined as hypothehcal dnves or tensions extemal signs of comfort/discomfort, and promote
mduced by obstructmg forces that promote adivihes greater comfort when possible to enhance healmg or a
designed to sahsfy the dnves (Munay 1938) The result peaceful death
IS an outcome that is opposite to the arousmg dnves If The relahonships between the concepts of human
needs are met successfully by appropnate mtervenhons, press and nursmg oncepts are depicted m Figure 1
the immediate outcome is perceived by the person as Note the reaprocal relahonships between the shmulus
bemg relahvely posihve (Murray 1938) situahon and human development
As stated above, beta press is the person's perception
of the total effect of the phenomena m the stimulus THEORY OF COMFORT
situahon The events m the situation are mterpreted as a The theory of hohshc comfort is a component erf a
temporal gestalt of shmuh which can be either threaten- normahve and descnphve theory for nursing care The

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 Comfori iheory

Figure 1 The eoneeptual Stimulus situabon •«- Human

development
framework for a theory of
eomfort
Alpha press- "•Unitary trend

Obstructing + Faalitating + Interacting—«> Perception' • Thema (health)

forces forces forces

V
Health care + Nursing -f- Intervening — • Comfort •«- -*• Health-seeking behaviours
needs interventions vanables i
\

Physical
Internal
N External
Psychospintual sehaviours t>ehaviours
Peaceful death
Environmental
Social

theory is that outstandmg needs anse from the stunulus posihon statement on promotion of eomfort m dymg
situation and cause negative tension Negative tension patients states that the m£un goal m the nursmg care of
represents an imbalance that exists when obstrudmg dymg pahents should be maximizmg comfort as is
forces outweigh the facilitatmg forces at hand The needs consistent with the desu-es of the pahent (Hockenberger
for comfort, m any asped of the content domam, are 1992)
identified and mtervenhons are targeted towards those Richeson & Huch (1988) daim that eomfort is
speafic needs, movmg tension m a positive direction The nursmg's umque eontnbuhon to health eare, and Morse
patient perceives whether the tensions are changed by (1992) states that the ultimate purpose of nursmg is to
the mtervention(s), the nurse judges the extent to which promote eomfort Gropper (1992) adds that, by promot-
the desu-able outcome of comfort has been met by mg eomfort, nurses are promotmg health The last
assessmg the pahent's percephon of comfort objectively asserhon, though not supported m her paper by empineal
or subjedively teshng, provides the theoretieal rationale for nurses to
An lnaease in comfort mdicates that negahve tensions assist patients in adueving or enhancmg comfort
are reduced and posihve tensions are engaged Posihve Empincal evidence for a hnk between mtemal and
tensions lead to a umtary trend of construchve behav- extemal health-seekmg behaviours and comfort is scant
iours Construdive behaviours of mterest to nursmg are at the present tune The rejison for the present state of
health-seekmg behaviours and these behaviours stem knowledge about comfort is that the construd has only
directly fi'om the health thema The nurse faahtates the been recently operationalized (Kolcaba 1992) and the
outcome of comfort because theorehcally it is related to theoretical linkages to health-seekmg behaviours are
mtemal/extemal health-seekmg behaviours or a peaceful proposed here for the first time However, empincal
death When prachsed, health-seekmg behaviours can research supports the extemal consistency between com-
cause greater comfort fort and some health-seekmg behaviours The research
that IS available for this purpose is presented bnefly m the
followmg paragraph
Evidence (or the relationship hetween comfort and
In the field of psychoneurourununology, posihve cor-
health-seekit^ hehaviours relahons have been shown between comfort achieved by
Contemporary nurse thinkers contmue to explore the relaxation and unagery to enhanced immune parameters
significance of the construct comfort for nursmg (Jasnoski & Kugler 1987, McOelland 1988, Zadianzea
SdJotfeldt (1981) states that a focus of nursmg is to assist ei al 1990, Groer 1991) Sumlarly, comfort achieved by
dients to achieve optimal heaith, function, comfort and relaxahon and imagery have desirable effects on blood
self-fulfilment The Amencan Nurses' Assoaation's pressure (Pender 1985), pulse (Guzzetta 1980) and

1181
K Y Kolcaba

respirahons (Alexander ei al 1979 In a study of abortion, theones A good theory of comfort, therefore, promises
pahents had mcreased comfort after partiapahng m to have greater explanatory power than theones of pam
pleasant unagery (Wells 1989) In efforts to mcrease and anxiety
athletic performance and endurance, comfort achieved A second measure of the adequacy of saentific theones
by imagery was related posihvely to basketball skills IS then- predichve success (Popper 1959, Elhs 1968) We
(Kendall et al 1990), muscular endurance urespechve of will only know if the theory of comfort has more
mood state (Lee 1990) and strength (Murphy ei al 1988) predichve success than competmg theones by testmg it
Funchonal outcomes were enhanced by the comfortmg But the theory provides dear direchon for testability
effects of relaxahon m adults with traumahc head mjiuies Fu'st, the theory generates hypotheses about mterven-
(Lysaght & Bodenhamer 1990), while copmg strategies tions that enhance hohstic comfort and, second, the
were enhanced by effeds of a smular mtervenhon m theory generates hypotheses about the relahonsbps
children (LaMontagne ei al 1985), students with test between comfort and health-seekmg behaviours The
anxiety (Suinn 1972), and m adults with mulhple sderosis theory is emmently testable and its degree of predichve
(Foley ei al 1987) The mtervenhons ated above are success readily determmable
holishc and the outcomes are congruent with mtemal or The usefulness of a theory for chmcal pradice is the
extemal health-seekmg behaviours These studies and third charadenshc of sigruficant theones (Elhs 1968)
others lend encouragement to nurse researchers who ask Some phenomena occur rarely or require exotic con-
the queshoa 'Why comfortT dihons to brmg them about Comfort phenomena, by
contrast, are observable and ever present m the therapeu-
hc context apart from expenmentation It is a small step
The significance of a theory of comfort to brmg these phenomena under expenmental control
Comfort has been called a distmguishmg charactenshc of A fourth charadenshc of significant theones is com-
the nursmg profession (Fenell & Fenell 1990), yet plexity, meanmg that mulhple relationships among smgle
heretofore it has not been conceptualized withm a theory vanables or the complexity of a smgle vanable are
for nursmg For this reason, confifort is of mterest addressed (Elhs 1968) The theory of comfort meets both
Secondly, a theory of comfort can be used to explam and of these cntena, while mdudmg a minimum of imobserv-
predid phencmiena of mterest to nursmg Tlurdly, com- ables Causation of comfort is more complex than for
fort as a psychological phenomenon is of mterest m its relief of pam or anxiety, so more complex mtervenhons
own nght or sets of mtervenhons are required for enhancmg
The philosopher of saence. Popper (1959), dehneated comfort Because such mtervenhons are targeted broadly,
charactenshcs of significant theones Ellis (1968) pre- they approximate therapeutic completeness, whereas
sented these charadenshcs to nurse researchers as guides mtervenhons for pam alone would require adjund
to developmg theones, statmg that nursmg theones mtervenhons to adueve completeness
should be about phenomena observed m their own A fifth attnbute of sigruficant nursmg theones is that
prachce These diaractenshcs of sigmficant theones are they utihze termmology that is meanmgful and relevant
presented here so that the adequacy of the theory of for nursmg Comfort is a familiar term to nurses, yet a
comfort can be judged In assessmg the theory of sdiema for understandmg the complexity of the term and
comfort, contrasts will be drawn between the outcome its relationship to mtervenhons and subsequent outcomes
of comfort and the less hohshc outcomes of pam and has not been previously set forth With the present
anxiety schema and theory, nurses can design mtervenhons to
The first charadenshc of a significant theory is its enhance comfort and measure the rfechveness of their
scope (Popper 1959, Ellis 1^8) A theory of comfort is of mtervenhons upon the outcome of comfort Moreover,
broader scope than a theory of pam or fahgue because pahents also use comfort to descnbe their responses and
comfort subsumes stahshcal generalizahons fi-om the condihons, and other health care personnel use the term
study of pam and fahgue and helps explam them The to descnbe pahents' condihons The term is generally
extensions of theoretical terms withm the theory of understood to be broad, important, posihve and related
comfort designate pam and anxiety phenomena as they to subsequent desirable behaviours
mterad with other realities sudi as psydiological trans- Lastly, a measure of the adequacy of saentific theones
cendence ki this way, a thewy of comfort has posihve IS their urufiabihty with other estabhshed theones (Nage'
components that theones of psun, etc, do not have, thus, 1979, Popper 1968) Because the theory erf comfort is
its explanatory powers are greater ttian for the other umfiabie witti theones of pam and anxiety, it is desirable

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for nursmg researdi because it is an mdusive yet sucanct Groer M (1991) Psyehoneurounmunology Amertcan Joumal of
outcome Comfort takes the place of many separate Nurstng, 91, 33
measurements of more narrow outcomes, yet it is ncher Gropper E (1992) Promotmg health by promotmg eomfort
than many separate measurements because it accoimts for Nurstng Forum 27(2), 5—8
the lntra-action between aspeds of comfort The outcome Guzzetta C (1980) Effeets of relaxation and musie therapy on
of comfort is nurse-sensitive because it is influenced by patients in a eoronary eare umt with presumphve aeute
nursmg mterventions And the theory of comfort is myoeardial uifarehon Heart and Lung 18, 609-616
Hoekenberger S (1992) Amenean Nurses' Assoeiation position
potentially umfiabie with theones of health and well-
statement on promotion of eomfort and rehef of pain in
bemg that are yet to be developed
dying patients Plashc Surgtcal Nurstng 12(12), 32, 36
lasnoski M & Kugler J (1987) Relaxahon, unagery, and
CONCLUSION neurounmunodulation Annals of ihe New York Academy of
Sctences 496, 722-730
The imderstandmg of comfort directly gvudes nursmg Kendall G, Hryeaiko D & Marhno G (1990) The effeets of
care that is melusive of physieal, psyehospmtual, soeial an imagery rehearsal, relaxahon, and self-talk paekage on
and environmental mtervenhons A senes of mterven- basketball game performanee Joumal of Sport and Exerase
tions that target hohshe eomfort, such as tahng the Psychology 12, 157-166
pahent to the bathroom, reassunng him about a treat- Koleaba K (1992) Hohstie eomfort operationalizing the eon-
ment, givmg him mformation, and deanmg up his room, stmet as a nurse-sensitive outeome Advances tn Nurstng
ean be rendered dunng one nurse-patient eneounter after Sctence 15(1), l-IO
a bnef assessment of eomfort states m eaeh eontext An Koleaba K (1991) The taxonoime strueture of eomfort Image
aetual or potenhal defiat m any eontext tnggers a The Joumal of Nursing Scholarshtp 13, 235-238
Koleaba K & Koleaba R (1991) Analysis of the eoneept
eonrfort measure Thus, an unhappy, unhealthy or unwell
eomfort Joumal of Advanced Nurstng 16, 1301—1310
pahent ean be made more eomfortable, or a patient's
La Montagne L, Mason ] & Hepworth S (1985) Efeets of
diseomfort that is not desenbed as pam ean be diseemed
relaxahon on anxiety m ehildren unpheations for eopuig
and targeted In this example, eomfort is mversely related with stress Nurstng Research 34, 289-292
to a host of diseomforts and thus it is a 'missmg pieee' m Lee C (1990) Psyehing up for a museular enduranee task.
a theory of nursmg praehee effeets of image eontent on performanee and mood state
The theory of eomfort provides direetion for nursmg Joumal of Spori and Exerase Psychology 11, 66-73
praehee and researeh beeause it entails an outeome that Lysaght R & Bodenhamer E (1990) The use of relaxahon
IS measureable, hohstie, positive and mirse-sensitive training to enhanee funetional outeomes m adults with
Chmaans have the eapabihty jmd diseiplmary mterest to fraumatie head injunes The Amencan Joumal of Occupaiional
effeet eomfort, and patients look to nurses for help m Therapy 44, 797-802
aehievmg eomfort Beeause the eonstruet represents an MeQelland D (1988) The effeet of motivahonal arousal
mtra-adive phenomenon, an operational defimtion linked through films on sahvary lmmunoglobuhn A Psychologtcal
to theory is sigmfieant for explammg and predietmg the Healih 1, 31-52
neh relahonships among the reahties of eomfort Morse I (1992) Comfort the refoeusing of nursmg eare
Chmcal Nurstng Research 1(1), 91-106
Murphy S, Woodfolk R & Budney A (1988) The rffeets of
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