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 outdiagrammed 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 (acperson'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 difficulto 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 reThe 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 diseusthat (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
domam of the construd)
of Nursmg, Akron Oho U325-3701, USA
1178
Comfori iheory
COMFORT AS A HOLISTIC OUTCOME
Comfort IS a holishc outcome because it designates a
dynamic and multifaceted state of persons Thinbng
about the outeome of eomfort requires an lntra-adional
perspechve because mtervenhons that are mtended to
enhance one or more aspects of comfort mdirectly
enhance other aspects Consistent with an mtra-adional
perspective, the magmtude of the total direct and mdu-ed
effeds IS expected to be greater than the magmtude of
effeds achieved by addressmg smgle aspects separately
The extent to which comfort is hohstic is based on the
perception of all the aspeds taken together at one time,
because the effects m one have carry-over effects on
other aspeets
Aspeds of eomfort have been anayed m a twodimensional gnd (Koleaba 1992) They were denved from
a review of arehaie, histoneal and eontemporary nursing
literature as well as a review of literature from other
disaphnes (medieme, psychiatry, ergonomics, psychology) (Kolcaba & Kolcaba 1991, Kolcaba 1992) A review
of the previous work follows
Dimension one
The first dimension of comfort consists of three states,
called relief, ease and transcendence Rehef is defined as
the expenence of havmg had a specific need met (Kolcaba
1991) Rehef from needs is necesscuy for retum to former
fundion or a peaceful death Ease is defined as a state of
calm or eontentment (Koleaba 1991) Ease is the state of
eomfort that is a neeessary eondition for effiaent performanee Transeendenee is defmed as the state m eaeh
ordmary powers are enhaneed (Paterson & Zderad 1976)
The charactenstic that differentiates transcendence from
the other two states, rehef and ease, is that the former
designates the patient's potential for extraordmary
performance as an end
Because each of the three states of comfort entail
positive relationships to performance, theoretically they
also imply a strengthemng component This feature of
comfort provides the central rationale for promotmg the
patient's comfort Comfort is a desirable outcome for
nursmg care because it faahtates gams in physical and/or
psychological performance, comfort also is essential for a
peaceful death because a dymg person requires psychic
strength for acceptance and release The states of conifort
are often conhnuous, overlappmg and mterdependent
Dimension two
The second dimension of comfort is the contexts m
which comfort occurs The contexts are denved fi-om the
nursmg hterature about hohsm (Kolcaba 1992) The first
context IS physieal, pertammg to bodily sensations The
seeond eontext is psyehospmtual, pertammg to the
mtemal awareness of self, meludmg esteem, sexuality,
meanmg m one's life, and relahonship to a higher order
or bemg The thu-d context is soaal, pertammg to
mterpersonal, fanuly and cultural relationships Also
mcluded under social comfort are the firwnaal and
mformahonal aspects of soaal hfe The fourth context m
which comfort is expenenced is envirorunental, pertammg to hght, noise, ambience, colour, temperature and
natural versus synthehe elements (Koleaba 1991)
When the two dimensions (three states and four
eontexts) of eomfort are juxtaposed, the result is a
two-dimensional gnd with 12 faeets of eomfort Items for
eomfort questionnaires can be generated fi'om eaeh faeet
that IS relevant to a speeifie research question In a pilot
project, 48 items were constructed usmg the comfort gnd
as a eoneeptual map (Koleaba 1992) In the instrumentation study that followed, the three states of eomfort
(rehef, ease and transeendenee) oeeuned as fadors m eaeh
of the four eontexts (physieal, psyehospmtual, environmental and soeial), as revealed by faetor analysis of 256
eompleted eonnfort questionnaires (Kolcaba 1992) The
emergence of three factors, semantically conespondmg
to the three states, oeeuned m eaeh of the separately
analysed eontexts as well as m tottd eomfort
For eonvemenee m analysmg and diseussmg responses,
the four eontexts were thought of as subseales of
eomfort, eaeh eontammg items from the three states or
faetors A total eomfort seore was aehieved by addmg
the seores for eaeh subseale Total eomfort seores were
useful for differentiatmg between known groups and for
hypothesis testmg (Kolcaba 1992) (Fador analysis of
mdividual subscales that compnse a multidimensional
construct is an adaptation of traditional fador analysis
that was previously apphed with umdimensional scales)
CONCEPTUAL FRAMEWORK
Construds gam sigmficance when they are related to
other concepts An organizing framework for comfort
had to meet the followmg cntena the framework had to
be based on (a) needs ansmg from the environment of (b)
whole persons for whom nurses could mtervene The
effectiveness of (c) the mterventions had to (d) be
perceived by the persons and (e) lead to subsequent
outcomes The efforts of Munay (1938) and colleagues to
synthesize major elements of personahty theones mto a
coherent model led to a theory of human press that is
consistent with the above cntena for a framework for
1179
JCY Kolcaba
ccwnfort Murray called his model 'orgamsmic' (holishc)
and stated, 'Smce the parts of a person carmot be
dissected physicaUy fi-om each other, and smce they ad
together, ideally they should all be estimated
simultaneously' (Munay 1983)
In the model of human press, a stimulus situahon is
that part of the total envirorunent to which people attend
and read durmg a given episode m their life Human
development, whether positive or negahve, is determmed
by the accumulated impressions about one's success
or failure that are formulated durmg encounters with
the situahon For nursmg, a stimulus situation can be
regarded as any health care situahon
The shmulus situahon consists of alpha press and beta
press Alpha press is tixe sum of negahve (obstrudmg)
forces, posihve (faahtahng) forces, and mterachng forces
Beta press is the person's percephon of the total effed of
the forces m alpha press For nursmg, obstrudmg forces
are the total negative stimuh ansmg from the health care
situahon mdudmg side-effects of illness or treatments,
noxious or threatemng environmental and soaal expenences, and emohonal sensahons such as fear, anxiety,
powerlessness or aloneness The faahtatmg forces are
nursmg mterventions designed to meet the needs that
remam after the person's own reserves are depleted by
obstructmg forces
Events also are mterpreted by the person m terms of
the many mterachng forces that mfluence the outcome of
percephon (Munay 1938) The mteradmg forces consist
of the person's past expenences, age, athtude, emohonal
state, support system, and the totahty of elements m the
present expenence Munay states that, because these
parts of persons cannot be dissected physically from each
other and because they act together, ideally they all
should be eshmated sunultaneously (Munay 1938) (With
modem stahshcal methods, mteradmg forces can be
operahonahzed as covanates m analyses of vanance or
beta weights m regression models)
Needs
Needs are defined as hypothehcal dnves or tensions
mduced by obstructmg forces that promote adivihes
designed to sahsfy the dnves (Munay 1938) The result
IS an outcome that is opposite to the arousmg dnves If
needs are met successfully by appropnate mtervenhons,
the immediate outcome is perceived by the person as
bemg relahvely posihve (Murray 1938)
As stated above, beta press is the person's perception
of the total effect of the phenomena m the stimulus
situahon The events m the situation are mterpreted as a
temporal gestalt of shmuh which can be either threaten1180
mg or proimsmg (Murray 1938) Beta press mvolves the
appraisal of how weU the needs that anse from the
obstructmg alpha forces are met by faahtatmg alpha
forces m the stunulus situation If the outcome is posihve,
evaluations accumulate and provide the expedation that
other situahons will end posihvely, contnbutmg to a
umtary trend (Munay 1938) Umtary trend is defined
as behaviourai co-ordmation of activity towards the
achievement of a desired effed
For nursmg, beta press is the person's perception of
how well the nursmg mterventions (faahtatmg forces)
meet the needs ansmg fi-om the health care situation
(obstrudmg forces) for which the patient requires assistance m satisfymg Perceptions of comfort imply that
negahve tensions have been reduced The person's percephon of an mcrease m total comfort leads to the
remforcement of habits and goals that were successful m
reducmg tensions Pattenis of successful habits and goals
lead to an onentmg thema that provides direction for
future achon A desirable thema that nursmg seeks to
promote is a health thema defined as a general onentation
to health-seekmg behaviours (Schlotfeldt 1975) A reaprocal relationship exists between health-seekmg behaviours and comfort because health-seekmg behaviours
also can enhance comfort
Health-seekmg behaviours are conceptualized as mternal or extemal m this theory of comfort Intemal behaviours happen at the cellular or organ level, such as healmg
or urunune funchon Extemal behaviours are related to
the outer world, such as self-care achvihes, funchonal
status and health mamtenance programmes The extemal
behaviours named self-care, fundion, health mamtenance
programmes, and lengths of hospitalizahon are exphat in
Sdilotfeldt's model (1975), while mtemal behaviours are
imphat under the categones of survival and fertdity
Schlotfeldt also mcludes dignified death m her model
under the eategory of health Consistent with holism,
eonsaous thought and subeonsaous frame of mmd
mfluence health-seekmg behaviours If the person is
mcapable of consaous thought, the nurse can look for
extemal signs of comfort/discomfort, and promote
greater comfort when possible to enhance healmg or a
peaceful death
The relahonships between the concepts of human
press and nursmg oncepts are depicted m Figure 1
Note the reaprocal relahonships between the shmulus
situahon and human development
THEORY OF COMFORT
The theory of hohshc comfort is a component erf a
normahve and descnphve theory for nursing care The
Comfori iheory
Figure 1 The eoneeptual
framework for a theory of
eomfort
Human
development
Stimulus situabon •«-
"•Unitary trend
Alpha press-
Obstructing + Faalitating + Interacting—«> Perception'
forces
forces
forces
V
Health care +
Nursing -f- Intervening — • Comfort •«needs
interventions
vanables
i
• Thema (health)
-*• Health-seeking behaviours
\
Physical
Psychospintual
Internal
sehaviours
Peaceful death
N
External
t>ehaviours
Environmental
Social
theory is that outstandmg needs anse from the stunulus
situation and cause negative tension Negative tension
represents an imbalance that exists when obstrudmg
forces outweigh the facilitatmg forces at hand The needs
for comfort, m any asped of the content domam, are
identified and mtervenhons are targeted towards those
speafic needs, movmg tension m a positive direction The
patient perceives whether the tensions are changed by
the mtervention(s), the nurse judges the extent to which
the desu-able outcome of comfort has been met by
assessmg the pahent's percephon of comfort objectively
or subjedively
An lnaease in comfort mdicates that negahve tensions
are reduced and posihve tensions are engaged Posihve
tensions lead to a umtary trend of construchve behaviours Construdive behaviours of mterest to nursmg are
health-seekmg behaviours and these behaviours stem
directly fi'om the health thema The nurse faahtates the
outcome of comfort because theorehcally it is related to
mtemal/extemal health-seekmg behaviours or a peaceful
death When prachsed, health-seekmg behaviours can
cause greater comfort
Evidence (or the relationship hetween comfort and
health-seekit^ hehaviours
Contemporary nurse thinkers contmue to explore the
significance of the construct comfort for nursmg
SdJotfeldt (1981) states that a focus of nursmg is to assist
dients to achieve optimal heaith, function, comfort and
self-fulfilment The Amencan Nurses' Assoaation's
posihon statement on promotion of eomfort m dymg
patients states that the m£un goal m the nursmg care of
dymg pahents should be maximizmg comfort as is
consistent with the desu-es of the pahent (Hockenberger
1992)
Richeson & Huch (1988) daim that eomfort is
nursmg's umque eontnbuhon to health eare, and Morse
(1992) states that the ultimate purpose of nursmg is to
promote eomfort Gropper (1992) adds that, by promotmg eomfort, nurses are promotmg health The last
asserhon, though not supported m her paper by empineal
teshng, provides the theoretieal rationale for nurses to
assist patients in adueving or enhancmg comfort
Empincal evidence for a hnk between mtemal and
extemal health-seekmg behaviours and comfort is scant
at the present tune The rejison for the present state of
knowledge about comfort is that the construd has only
been recently operationalized (Kolcaba 1992) and the
theoretical linkages to health-seekmg behaviours are
proposed here for the first time However, empincal
research supports the extemal consistency between comfort and some health-seekmg behaviours The research
that IS available for this purpose is presented bnefly m the
followmg paragraph
In the field of psychoneurourununology, posihve correlahons have been shown between comfort achieved by
relaxation and unagery to enhanced immune parameters
(Jasnoski & Kugler 1987, McOelland 1988, Zadianzea
ei al 1990, Groer 1991) Sumlarly, comfort achieved by
relaxahon and imagery have desirable effects on blood
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
A second measure of the adequacy of saentific theones
athletic performance and endurance, comfort achieved
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 conthe queshoa 'Why comfortT
dihons to brmg them about Comfort phenomena, by
contrast, are observable and ever present m the therapeuhc context apart from expenmentation It is a small step
The significance of a theory of comfort
to brmg these phenomena under expenmental control
A fourth charadenshc of significant theones is comComfort has been called a distmguishmg charactenshc of
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 imobservpredid 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
or sets of mtervenhons are required for enhancmg
own nght
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
A fifth attnbute of sigruficant nursmg theones is that
should be about phenomena observed m their own
they
utihze termmology that is meanmgful and relevant
prachce These diaractenshcs of sigmficant theones are
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
schema and theory, nurses can design mtervenhons to
anxiety
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
Lastly, a measure of the adequacy of saentific theones
mterad with other realities sudi as psydiological transcendence 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
1182
Comfori theory
Groer M (1991) Psyehoneurounmunology Amertcan Joumal of
Nurstng, 91, 33
Gropper E (1992) Promotmg health by promotmg eomfort
Nurstng Forum 27(2), 5—8
Guzzetta C (1980) Effeets of relaxation and musie therapy on
patients in a eoronary eare umt with presumphve aeute
myoeardial uifarehon Heart and Lung 18, 609-616
Hoekenberger S (1992) Amenean Nurses' Assoeiation position
statement on promotion of eomfort and rehef of pain in
dying patients Plashc Surgtcal Nurstng 12(12), 32, 36
lasnoski M & Kugler J (1987) Relaxahon, unagery, and
neurounmunodulation Annals of ihe New York Academy of
CONCLUSION
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
basketball game performanee Joumal of Sport and Exerase
and environmental mtervenhons A senes of mtervenPsychology 12, 157-166
tions that target hohshe eomfort, such as tahng the
pahent to the bathroom, reassunng him about a treat- Koleaba K (1992) Hohstie eomfort operationalizing the eonstmet as a nurse-sensitive outeome Advances tn Nurstng
ment, givmg him mformation, and deanmg up his room,
Sctence 15(1), l-IO
ean be rendered dunng one nurse-patient eneounter after
Koleaba
K (1991) The taxonoime strueture of eomfort Image
a bnef assessment of eomfort states m eaeh eontext An
The
Joumal
of Nursing Scholarshtp 13, 235-238
aetual or potenhal defiat m any eontext tnggers a
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
training to enhanee funetional outeomes m adults with
IS measureable, hohstie, positive and mirse-sensitive
fraumatie head injunes The Amencan Joumal of Occupaiional
Chmaans have the eapabihty jmd diseiplmary mterest to
Therapy 44, 797-802
effeet eomfort, and patients look to nurses for help m
MeQelland
D (1988) The effeet of motivahonal arousal
aehievmg eomfort Beeause the eonstruet represents an
through
films
on sahvary lmmunoglobuhn A Psychologtcal
mtra-adive phenomenon, an operational defimtion linked
Healih
1,
31-52
to theory is sigmfieant for explammg and predietmg the
Morse I (1992) Comfort the refoeusing of nursmg eare
neh relahonships among the reahties of eomfort
Chmcal Nurstng Research 1(1), 91-106
Murphy S, Woodfolk R & Budney A (1988) The rffeets of
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measurements of more narrow outcomes, yet it is ncher
than many separate measurements because it accoimts for
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nursmg mterventions And the theory of comfort is
potentially umfiabie with theones of health and wellbemg that are yet to be developed
1183
K Y Kolcaba
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