Journal of Advanced Nursing, 1994, 19, 1178-1184

A theory of holistic comfort for nursing

Katharine Y. Kolcaba MSN
Instructor, The University of Akron, College of Nursing, Akron, Ohio, and PhD Student,
Case Western Reserve University, Cleveland, Ohio, U S A

Accepted for publication 27 October I993

KOLCABA K.Y.(1994) Journal of Advanced Ntlrsing 19, 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 holistic outcome, it
has not been conceptualized within the context of a broader theory for the
discipline of nursing. The theoretical work presented here utilizes an
intra-actional 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) interventions that enhance the state of comfort
and (b) desirable subsequent outcomes of nursing care. The paper concludes
with a discussion about the theory of comfort as a significant one for the
discipline of nursing.

INTRODUCTION These interventions and others are intended to elicit

positive whole person responses and thus would
The construct of comfort recently has been analysed,
be measured most accurately by whole person out-
diagrammed in a two-dimensional conceptual map, and
comes. Whole person outcomes entail positive or
operationalized as a holistic outcome (Kolcaba 1992).
negative carry-over effects between aspects of the
Comfort is defined for nursing as the satisfaction (ac-
person's response. Whole person responses have been
tively, passively or co-operatively) of the basic human
difficult to operationalize because of their complicated
needs for relief, ease or transcendence arising from health
content domains, possible carry-over e€fects between
care situations that are stressful. Nursing case is designed
components of the outcome, and the theoretical difficul-
to meet or continue meeting needs that fall under the
ties of interpreting a total score. However, comfort is a
domain of the discipline.
holistic outcome that accounts for whole person re-
The purpose of this paper is to postulate relationships
sponses and it has been previously operationalized
between patients' needs, nursing interventions, comfort,
(Kolcaba 1992).
and subsequent outcomes; from these relationships a
The basic assumptions of the theory of comfort are
theory of comfort is derived. It concludes with a discus-
that (a) human beings have holistic responses to complex
sion about the significance of the theory of comfort for
stimuli; (b) comfort is a desirable holistic outcome that is
nursing.
germaine to the discipline of nursing; and (c) human
beings strive to meet, or to have met, their basic comfort
Holistic outcomes and nursing needs. These assumptions underpin the theory of comfort
Nurse scientists are beginning to explore the effective- and are in concert with an intra-actional perspective in
ness of broadly targeted interventions such as progres- which the components of a whole person response are
sive muscle relaxation, imagery and therapeutic touch. related and assessed comprehensively (Kolcaba 1992).
('Intra' designates within; comfort is an outcome that
C~rrfipcmdmce:Katharine Y.Kolcabn. Instructor, The Univm'ty of Akron, College
consists of many aspects that are related within the
of Nursing, Akron, Ohio 44325-3701, USA. domain of the construct.)

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Comfort theory
~~~

COMFORT AS A HOLISTIC OUTCOME nursing literature about holism (Kolcaba 1992). The first
context is physical, pertaining to bodily sensations. The
Comfort is a holistic outcome because it designates a
second context is psychospiritual, pertaining to the
dynamic and multifaceted state of persons. Thinking
internal awareness of self, including esteem, sexuality,
about the outcome of comfort requires an intra-actional
meaning in one’s life, and relationship to a higher order
perspective because interventions that are intended to
or being. The third context is social, pertaining to
enhance one or more aspects of comfort indirectly
interpersonal, family and cultural relationships. Also
enhance other aspects. Consistent with an intra-actional
included under social comfort are the financial and
perspective, the magnitude of the total direct and indirect
informational aspects of social life. The fourth context in
effects is expected to be greater than the magnitude of
which comfort is experienced is environmental, pertain-
effects achieved by addressing single aspects separately.
ing to light, noise, ambience, colour, temperature and
The extent to which comfort is holistic is based on the
natural versus synthetic elements (Kolcaba 1991).
perception of all the aspects taken together at one time,
When the two dimensions (three states and four
because the effects in one have carry-over effects on
contexts) of comfort are juxtaposed, the result is a
other aspects.
two-dimensional grid with I2 facets of comfort. Items for
Aspects of comfort have been arrayed in a two-
comfort questionnaires can be generated from each facet
dimensional grid (Kolcaba 1992). They were derived from
that is relevant to a specific research question. In a pilot
a review of archaic, historical and contemporary nursing
project, 48 items were constructed using the comfort grid
literature as well as a review of literature from other
as a conceptual map (Kolcaba 1992). In the instrumen-
disciplines (medicine, psychiatry, ergonomics, psychol-
tation study that followed, the three states of comfort
ogy) (Kolcaba & Kolcaba 1991, Kolcaba 1992). A review
(relief, ease and transcendence) occurred as factors in each
of the previous work follows.
of the four contexts (physical, psychospiritual, environ-
Dimension one mental and social), as revealed by factor analysis of 256
completed comfort questionnaires (Kolcaba 1992). The
The first dimension of comfort consists of three states, emergence of three factors, semantically corresponding
called relief, ease and transcendence. Relief is defined as to the three states, occurred in each of the separately
the experience of having had a specific need met (Kolcaba analysed contexts as well as in total comfort.
1991).Relief from needs is necessary for return to former For convenience in analysing and discussing responses,
function or a peaceful death. Ease is defined as a state of the four contexts were thought of as subscales of
calm or contentment (Kolcaba 1991). Ease is the state of comfort, each containing items from the three states or
comfort that is a necessary condition for efficient perfor- factors. A total comfort score was achieved by adding
mance. Transcendence is defined as the state in each the scores for each subscale. Total comfort scores were
ordinary powers are enhanced (Paterson & Zderad 1976). useful for differentiating between known groups and for
The characteristic that differentiates transcendence from hypothesis testing (Kolcaba 1992). (Factor analysis of
the other two states, relief and ease, is that the former individual subscales that comprise a multidimensional
designates the patient’s potential for extraordinary construct is an adaptation of traditional factor analysis
performance as an end. that was previously applied with unidimensional scales.)
Because each of the three states of comfort entail
positive relationships to performance, theoretically they
also imply a strengthening component. This feature of CONCEPTUAL FRAMEWORK
comfort provides the central rationale for promoting the Constructs gain significance when they are related to
patient’s comfort. Comfort is a desirable outcome for other concepts. An organizing framework for comfort
nursing care because it facilitates gains in physical andor had to meet the following criteria: the framework had to
psychological performance; comfort also is essential for a be based on (a) needs arising from the environment of (b)
peaceful death because a dying person requires psychic whole persons for whom nurses could intervene. The
strength for acceptance and release. The states of comfort effectiveness of (c) the interventions had to (d) be
are often continuous, overlapping and interdependent. perceived by the persons and (e) lead to subsequent
outcomes. The efforts of Murray (1938) and colleagues to
Dimension two
synthesize major elements of personality theories into a
The second dimension of comfort is the contexts in coherent model led to a theory of human press that is
which comfort occurs. The contexts are derived from the consistent with the above criteria for a framework for

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KY.Kolcaba

comfort. Murray called his model 'organismic' (holistic) ing or promising (Murray 1938). Beta press involves the
and stated, 'Since the parts of a person cannot be appraisal of how well the needs that arise from the
dissected physically from each other, and since they act obstructing alpha forces are met by facilitating alpha
together, ideally they should all be estimated forces in the stimulus situation. If the outcome is positive,
simultaneously' (Murray 1983). evaluations accumulate and provide the expectation that
In the model of human press, a stimulus situation is other situations will end positively, contributing to a
that part of the total environment to which people attend unitary trend (Murray 1938). Unitary trend is defined
and react during a given episode in their life. Human as behavioural co-ordination of activity towards the
development, whether positive or negative, is determined achievement of a desired effect.
by the accumulated impressions about one's success For nursing, beta press is the person's perception of
or failure that are formulated during encounters with how well the nursing interventions (facilitating forces)
the situation. For nursing, a stimulus situation can be meet the needs arising from the health care situation
regarded as any health care situation. (obstructing forces) for which the patient requires assis-
The stimulus situation consists of alpha press and beta tance in satisfying. Perceptions of comfort imply that
press. Alpha press is the s u m of negative (obstructing) negative tensions have been reduced. The person's per-
forces, positive (facilitating)forces, and interacting forces. ception of an increase in total comfort leads to the
Beta press is the person's perception of the total effect of reinforcement of habits and goals that were successful in
the forces in alpha press. For nursing, obstructing forces reducing tensions. Patterns of successful habits and goals
are the total negative stimuli arising from the health care lead to an orienting thema that provides direction for
situation including side-effects of illness or treatments, future action. A desirable thema that nursing seeks to
noxious or threatening environmental and social experi- promote is a health thema defined as a general orientation
ences, and emotional sensations such as fear, anxiety, to health-seeking behaviours (Schlotfeldt 1975). A re-
powerlessness or aloneness. The facilitating forces are ciprocal relationship exists between health-seeking be-
nursing interventions designed to meet the needs that haviours and comfort because health-seeking behaviours
remain after the person's own reserves are depleted by also can enhance comfort.
obstructing forces. Health-seeking behaviours are conceptualized as inter-
Events also are interpreted by the person in terms of nal or external in this theory of comfort. Internal behav-
the many interacting forces that influence the outcome of iours happen at the cellular or organ level, such as healing
perception (Murray 1938). The interacting forces consist or immune function. External behaviours are related to
of the person's past experiences, age, attitude, emotional the outer world, such as self-care activities, functional
state, support system, and the totality of elements in the status and health maintenance programmes. The external
present experience. Murray states that, because these behaviours named self-care, function, health maintenance
parts of persons cannot be dissected physically from each programmes, and lengths of hospitalization are explicit in
other and because they act together, ideally they all Schlotfeldt's model (1975), while internal behaviours are
should be estimated simultaneously (Murray 1938).(With implicit under the categories of survival and fertility.
modem statistical methods, interacting forces can be Schlotfeldt also includes dignified death in her model
operationalized as covariates in analyses of variance or under the category of health. Consistent with holism,
beta weights in regression models.) conscious thought and subconscious frame of mind
influence health-seeking behaviours. If the person is
Needs incapable of conscious thought, the nurse can look for
Needs are defined as hypothetical drives or tensions external signs of comfort/discomfort, and promote
induced by obstructing forces that promote activities greater comfort when possible to enhance healing or a
designed to satisfy the drives (Murray 1938). The result peaceful death.
is an outcome that is opposite to the arousing drives. If The relationships between the concepts of human
needs are met successfully by appropriate interventions, press and nursing concepts are depicted in Figure I.
the immediate outcome is perceived by the person as Note the reciprocal relationships between the stimulus
being relatively positive (Murray 1938). situation and human development.
As stated above, beta press is the person's perception
of the total effect of the phenomena in the stimulus THEORY OF COMFORT
situation. The events in the situation are interpreted as a The theory of holistic comfort is a component of a
temporal gestalt of stimuli which can be either threaten- normative and descriptive theory for nursing care. The

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Comfort theory

Figure I The conceptual Stimulus situation 4 Human

I development
framework for a theory of
comfort.
Alpha press- Beta press 4 ,Unitary trend

Obstructing + Facilitating
I-
+ Interacting +Perception Thema (health)

I
for[ for[ for[

Health care + Nursing +Intervening -b Comfort Health-seeking, behaviours

needs interventions variables

Physical

Peaceful death
Environmental
social

theory is that outstanding needs arise from the stimulus position statement on promotion of comfort in dying
situation and cause negative tension. Negative tension patients states that the main goal in the nursing care of
represents an imbalance that exists when obstructing dying patients should be maximizing comfort as is
forces outweigh the facilitating forces at hand. The needs consistent with the desires of the patient (Hockenberger
for comfort, in any aspect of the content domain, are 1992).
identified and interventions are targeted towards those Richeson & Huch (1988) claim that comfort is
specific needs, moving tension in a positive direction. The nursing’s unique contribution to health care, and Morse
patient perceives whether the tensions are changed by (1992)states that the ultimate purpose of nursing is to
the intervention(s);the nurse judges the extent to which promote comfort. Cropper (1992)adds that, by promot-
the desirable outcome of comfort has been met by ing comfort, nurses are promoting health. The last
assessing the patient’s perception of comfort objectively assertion, though not supported in her paper by empirical
or subjectively. testing, provides the theoretical rationale for nurses to
An increase in comfort indicates that negative tensions assist patients in achieving or enhancing comfort.
are reduced and positive tensions are engaged. Positive Empirical evidence for a link between internal and
tensions lead to a unitary trend of constructive behav- external health-seeking behaviours and comfort is scant
iours. Constructive behaviours of interest to nursing are at the present time. The reason for the present state of
health-seeking. behaviours and these behaviours stem knowledge about comfort is that the construct has only
directly from the health thema. The nurse facilitates the been recently operationalized (Kolcaba 1992) and the
outcome of comfort because theoretically it is related to theoretical linkages to health-seeking behaviours are
interndextemal health-seeking behaviours or a peaceful proposed here for the first time. However, empirical
death. When practised, health-seeking behaviours can research supports the external consistency between com-
cause greater comfort. fort and some health-seeking behaviours. The research
that is available for this purpose is presented briefly in the
following paragraph.
Evidence for the relationship between comfort and
In the field of psychoneuroimmunology, positive cor-
health-seeking behaviours
relations have been shown between comfort achieved by
Contemporary nurse thinkers continue to explore the relaxation and imagery to enhanced immune parameters
significance of the construct comfort for nursing. Uasnoski & Kugler 1987, McClelland 1988, Zacharizea
Schlotfeldt (1981)states that a focus of nursing is to assist ef al. 1990, Groer 1991). Similarly, comfort achieved by
clients to achieve optimal health, function, comfort and relaxation and imagery have desirable effects on blood
self-fulfilment. The American Nurses’ Association’s pressure (Pender 1985), pulse (Guzzetta 1980) and
 13652648, 1994, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1365-2648.1994.tb01202.x by UNIOESTE - Universidade Estadual do Oeste do Parana, Wiley Online Library on [26/05/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ICY. Kolcaba

respirations (Alexander et al. 1979. In a study of abortion, theories. A good theory of comfort, therefore, promises
patients had increased comfort after participating in to have greater explanatory power than theories of pain
pleasant imagery (Wells 1989). In efforts to increase and anxiety.
athletic performance and endurance, comfort achieved A second measure of the adequacy of scientific theories
by imagery was related positively to basketball skills is their predictive success (Popper 1959, Ellis 1968). We
(Kendall et al. 1990), muscular endurance irrespective of will only know if the theory of comfort has more
mood state (Lee 1990) and strength (Murphy et al. 1988). predictive success than competing theories by testing it.
Functional outcomes were enhanced by the comforting But the theory provides clear direction for testability.
effects of relaxation in adults with traumatic head injuries First, the theory generates hypotheses about interven-
(Lysaght & Bodenhamer 1990), while coping strategies tions that enhance holistic comfort and, second, the
were enhanced by effects of a similar intervention in theory generates hypotheses about the relationships
children (LaMontagne et al. 1985), students with test between comfort and health-seeking behaviours. The
anxiety (Suinn 1972),and in adults with multiple sclerosis theory is eminently testable and its degree of predictive
(Foley et al. 1987). The interventions cited above are success readily determinable.
holistic and the outcomes are congruent with internal or The usefulness of a theory for clinical practice is the
external health-seeking behaviours. These studies and third characteristic of significant theories (Ellis 1968).
others lend encouragement to nurse researchers who ask Some phenomena occur rarely or require exotic con-
the question, W h y comfort?'. ditions to bring them about. Comfort phenomena, by
contrast, are observable and ever present in the therapeu-
tic context apart from experimentation. It is a small step
The significance of a theory of comfort
to bring these phenomena under experimental control.
Comfort has been called a distinguishing characteristic of A fourth characteristic of significant theories is com-
the nursing profession (Ferrell & Ferrell 1990), yet plexity, meaning that multiple relationships among single
heretofore it has not been conceptualized within a theory variables or the complexity of a single variable are
for nursing. For this reason, comfort is of interest. addressed (Ellis 1968).The theory of comfort meets both
Secondly, a theory of comfort can be used to explain and of these criteria, while including a minimum of unobserv-
predict phenomena of interest to nursing. Thirdly, com- ables. Causation of comfort is more complex than for
fort as a psychological phenomenon is of interest in its relief of pain or anxiety, so more complex interventions
own right. or sets of interventions are required for enhancing
The philosopher of science, Popper (1959), delineated comfort. Because such interventions are targeted broadly,
characteristics of significant theories. Ellis (1968) pre- they approximate therapeutic completeness, whereas
sented these characteristics to nurse researchers as guides interventions for pain alone would require adjunct
to developing theories, stating that nursing theories interventions to achieve completeness.
should be about phenomena observed in their own A fifth attribute of significant nursing theories is that
practice. These characteristics of significant theories are they utilize terminology that is meaningful and relevant
presented here so that the adequacy of the theory of for nursing. Comfort is a familiar term to nurses, yet a
comfort can be judged. In assessing the theory of schema for understanding the complexity of the term and
comfort, contrasts will be drawn between the outcome its relationship to interventions and subsequent outcomes
of comfort and the less holistic outcomes of pain and has not been previously set forth. With the present
anxiety. schema and theory, nurses can design interventions to
The first characteristic of a significant theory is its enhance comfort and measure the effectiveness of their
scope (Popper 1959, Ellis 1968).A theory of comfort is of interventions upon the outcome of comfort. Moreover,
broader scope than a theory of pain or fatigue because patients also use comfort to describe their responses and
comfort subsumes statistical generalizations from the conditions, and other health care personnel use the term
study of pain and fatigue and helps explain them. The to describe patients' conditions. The term is generally
extensions of theoretical terms within the theory of understood to be broad, important, positive and related
comfort designate pain and anxiety phenomena as they to subsequent desirable behaviours.
interact with other realities such as psychological trans- Lastly, a measure of the adequacy of scientific theories
cendence. In this way, a theory of comfort has positive is their unifiability with other established theories (Nagel
components that theories of pain, etc., do not have; thus, 1979, Popper 1968). Because the theory of comfort is
its explanatory powers are greater than for the other unifiable with theories of pain and anxiety, it is desirable

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Comfort theory

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