An analysis of the concept of comfort
Kathanne Y Kolcaba MSN RN C
Instructor, College of Nurstng, The Umverstty of Akron, Akron, Oho
and Raymond J Kolcaba PhD
Associate Professor of PhkKophy, Cuyahoga Community College, Cleveland, Oho, USA
Accepted for publicahon 14 Apnl 1991
KOLCABA K Y & KOLCABA R J (1991) Joumal of Advanced Nursmg 16,
1301-1310
An analysis of the concept of comfort
Comfort IS a term that has a significant histoncal and contemporary assoaahon with nursmg Since the tune of Nightingale, it is ated as designating a desirable outcome of nursmg care Comfort is found m nursmg science, for example in diagnoshc taxonomies, and in references to the art of nursmg, as when practice is descnbed Roy, Orlando, Watson, Paterson and others use comfort m major nursing theones The term can sigrufy both physical and mental phenomena and it can be used as a verb and a noun However, because comfort has many different meanings, the reader has had the burden of deciding if the term is meant in one of its ordinary language senses or if its context reveals some speaal nursmg sense The purpose of this paper is to analyse the semantics and extension of the term 'comfort' m order to clanfy its use m nursmg practice, theory and research The semantic analysis begins with ordmary language because the conunon meanmgs of the term are the pnmary ones used m nursmg
practice and are the ongm of technical nursmg usages Comfort is discussed as the term is found m nursmg, mdudmg texts, standards of care, diagnoses and theory An account of patient needs assessment is used to cull three technical senses of the term from its ordmary language meanmgs After contrastmg these senses m order to justify their separateness, they are shown to reflect differmg aspects of therapeutic contexts Defirung attnbutes of the three senses are then explicated and presented m table format The last section of the paper addresses some of the ways that the extensions of the senses can be measured descnbed Authors of nursmg texts daun that comfort is both physical and mental (Watson 1985, Orlando 1961) and the term is used m its verb and noun forms
In spite of its widespread use, however, meanmgs of the term are not specified The reader has the burden of deading if the term is meant m one of its ordmary language senses or if its context will reveal some speaal nursing seme
COMFORT
Comfort IS a term that has histoncal and contemporary significance for nursmg Smce the tune of Nightingale, it has been ated as designahng a desirable outcome or goal of nursmg care Today, the term's mearung is used to signify acceptable standards of care (DHEW 1974) Comfort
IS also found in nursmg saence, for example m diagnoshc taxonomies, and in nursing art as when prachce is Purpose of the paper
Corrtspomkna
Kaihanm Kolcaba, 165 South hmMm
Srerf Ch^rm Falk
The purpose of this paper is to analyse the semantics and extension of the term 'comfort' m order to darrfy its use m
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K.Y KokakaandRJ Kolcaba
nursmg prachce, theory and researdi The semanhc analysis begms with ordmary language because the common mearungs of the term are the pnmary ones used m nursmg prachce and are the ongm of technical nursmg usages A discussion of the histoncal and contemporary use of the term m nursmg theory follows An account of patient needs assessment is used to cull three technical senses of the term from its ordmary language meanmgs After conhashng these senses m order to justify their separateness, they are shown to reflect diffenng aspects of therapeuhc contexts The last task is to address some of the ways that the extensions of the senses can be measured The paper condudes with a summary of some of the comparahve attnbutes of comfort in the three senses and their use m comfort checklists
MEANINGS O F ' C O M F O R T IN ORDINARY
LANGUAGE
Four meanmgs of comfort occur m ordmary language, as reported m dichonary entnes The first two present the tenn's basic semanhcs
First meaning
state of comfort can exist without a pnor state of discomfort When the discomfort cannot be avoided, it is often neutralized or counteracted with addihonal comforts
Third meaning
Comfort — rehef from discomfort
The third meanmg can be explamed through the first two meanmgs The cause of rehef is speafied by the fiffst While the rehef itself is called a comfort, it need not be equivalent to the state of comfort, it may be rehef that is mcomplete, parhal or temporary Comfort as rehef may be mcomplete because it may be rehef fi"om just one of many severe discomforts Second, it may be parhal because only a degree of rehef is attamed Third, it may last only a short tune until discomfort anses agam
By conhast, the state of comfort (second meanmg) presupposes the absence of severe discomforts, a high degree of reheffi-omdiscomforts, and lashng rather than temporary reheffi'omsevere discomforts
Fourth meaning
Comfort — whatever makes life easy or pleasurable
The fourth definition is denved from the first meaning where each factor contnbutes to makmg life easy or pleasurable Such fadors too can be 'comforts' without producmg a state of comfort (second meaning) and do not
Second Meaning require that someone initially needs rehef from discomforts The fourth meanmg is compatible with the hedonishc
Comfort — the state of ease and peaceful contentment goal of maximi23ng pleasure and, m this aspect, its meanmg
Comfort as a cause (first meanmg) is supposed to produce IS foreign to nursing It is thus eliminated from considercomfort as an efiFect (second meanmg) The cause consists ahon m researdi about the technical senses of comfort for of agents and thmgs that supply factors sudi as encourage- nursmg ment or aid In this way, a cause of comfort is said to be, 'a
To comphcate further this analysis, the comfortable/ comfort to me' The state of comfort lmphes an absence of uncomfortable dichotomy is also used m all of the meanconditions that defeat it, such as worry, pain, gnef, houble, mgs A person may say that a comfortable thmg may be the sufifenng, and so on cause of the state of comfort (first meaning), or that he or
Many defeahng condihons of the state are called she IS comfortable meanmg 'm a state of comfort' (second
'discomforts' and can be either a cause or an eSed. The meanmg). Uncomfortable thmgs may lead a person mto an resultmg state of discomfort is contrary to the state of uncomfortable state The rehef of a person's chscomforts (or comfort Causes of comfort initiated by agents or produced uncomfortable thmgs) nfiay make him comfortable, but tfus by thmgs are taken as countervailing forces that ehmm- may be mcomplete, partial or temporary (as with the thu-d ate, neuhahze or counteract the effects of discomforts meanmg)
Thought about producmg comfort, then, mvolves analysmg the relahonships between the causal senes of both
Fifth ami sixtii meaning comfort and discomfort
Agents, aidi as nurses, oft«i idottify and ehminate a The etymology of comfort reveals two meanings that come source of discomfcHt before it affects a pahent Thsxs, tiw firom the Latm word confortare mearung 'to strengthen
Comfort — a cause of rehef from discomfort and/or of the state of comfort
An analysts of comfort
Table 1 Uses of comfort in ordmary language
Meanmgs of comfort
Example
1
1
(a) A cause of rehef from discomfort
(b) A cause of the state of comfort
2
3
4
5
6
The state of ease and peaceful contentment Rehef from pam, mental anguish, or other discomfort Whatever gives pleasure and makes hfe easy Strengthenmg, encouragement and support Physical refreshment or sustenance
greatly' Accordmg to the Oxford English Dictionary, however, they are obsolete in modem language
Comfort — strengthenmg, encouragement, matement, aid, succour, suppjort, countenance
Comfort — physical refreshment or sustenance, refireshmg or mvigorating influence
The meanings mdicate causes of renewal, amphficahons of powers, posihve mindsets, and readiness for action These influences and condihons are usually not the sort that produce or conshtute the typically passive state menhoned m the second meanmg If such influences are potent, then one would expect comforts of these kmds to have shengthened, encouraged, supported, and/or physically refreshed or mvigorated a person It will be demonshated that all except the fourth meanmg can be found m the works of nurse authors
Table 1 contams a summary of these meanmgs In the followmg two sechons, the mearungs of comfort will be exphcated as found m nursmg hterature, both past and present The authors of this paper will designate appropnate meanmgs, if possible, for each example In some cases, a denvahve of comfort, such as comfortable, discomfort and comforting, is ated and the denved meanmg is assigned to it
2
3
(a) Mary was comforted by the removal of the splmter
(b) When I am m my rocMn, I fieel comfortable I feel cMnfortable after my bath
4
I am comfortable now because I am no longer cold
I have enough money to hve m comfort
5
Obsolete m ordinary language
6
Obsolete m ordinary language
Vanous forms of comfort were used to descnbe the art of nursmg For example, Nightmgale (1859) exhorted, it must never be lost sight of what observation is for It is not for the sake of piling up miscellaneous information or cunous facts, but for the sake of savmg hfe and mcreasmg health and comfort (second meanmg)
In 1926, Harmer discussed the importance of the nurse providmg environmental comfort (first meanmg) and she observed that the rehef of pam and discomfort (third meanmg) were central to good prachce
Goodnow (1935) devoted a chapter m her book The
Techmc of Nursing to The Patient's Comfort' She wrote,
A nurse is judged always by her abihty to make her patient comfortable Comfort is both physical and mental, and a nurse's responsibihty does not end with physical care
(Here, one cannot be sure if the second or third meanuig or both are mtended because a specific pnor discomfort is neither menhoned nor implied.)
In all of these examples, the reader gleans a vague understandmg that the concept is positive, it entails feelmg good and, m some cases, mdicates an improvement from a previous state or condition Tlie reader may assoaate comfort mtuihvely with niuiurmg and/or nursmg However, its meaning is unplicit, hidden m context, and is often ambiguous THE HISTORY OF 'COMFORT IN
NURSING
COMFORT AS A NURSING TERM TODAY
As early as 1869, nuremg was called an art and a saence. idthough the latter was yet to be defined or cfeveloped.
The development of dassificahon schemes for achvihes marks one of the major advanconents m nursing
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KY KoladmitndRJ Kolcaba
saence Comfort is an important part of these schemes called 'nursmg chagnoses' Until 1990, it was found both m llhiess and wellness dassificahons In her book about nursmg diagnoses, Campbell (1984) states.
Nursing theories
Comfort has been an important concept m some nursmg theones For example, Roy built her theory of adaptation around the nurse who helps the pahent adapt to four categones of needs physiological, self-concept, role-funchon
Comfort evolvesfroman awareness that comfort needs will and mterdependence (Roy & Roberts 1981) The nurse was be met and that previously expenenced comforts will be to employ hadihonal comfort measures to achieve comfort repeated m the physiological mode (first meanmg) If one of the
SIX basic physiological needs was compromised, the nurse assessed the problem and provided comfort, thereby
Thus, the dimension of the pahent's anhapahon that rehevmg the discomforts of physiological compromise comfort needs will be met provides mental comfort (first
Orlando (1961) also focused on the needs of patients mearung) and the nurse's abihty to assess and meet those needs The
The term 'comfort measures' is often used to mean a nurse accomphshed this through an effechve nurse-pahent contnbuhng or suffiaent cause of a state of comfort relahonship This process consisted of careful observation
Comfort measures can also cause rehef from discomforts and utihzahon of the pnnaples of nursing that Orlando
(physical comfort) and provide solace or encouragement developed in her theory The nurse was to assess the
(mental comfort) In many cases, comfort measures are patient's physical and mental comfort (second meanmg), called nursmg mtervenhons if the aim is to promote a state before and after a comfort measure was dehvered of physical or mental ease (Of course, other forms of nursIn 1979, Watson pubhshed her theory of nursmg called mg mtervenhons may have nothmg to do with causing the saence of canng m which comfort is a significant part comfort) So, 'comfort measures' replaces the noun form of
Here, comfort was named as a 'vanable that affects extemal thefirstmeanmg m the nursmg vocabulary and mtemal environments' She stated.
A goal of nursing prachce, as contamed m statements of standards for care, has been generally to help the pahent be
Comfort activities can be supportive, protective, or even corrective for a person's mtemal and extemal environments comfortable or m a state of comfort The Department of
[first meaning]
Health, Educahon and Welfare (DHEW) pubhshed a methodology for monitonng quahty of care The methcxlology
Supportmg Orlando's (1961) daim that comfort was contamed standarcb stating that the need for comfort must be met by the nurse if the dehvered care is to be deemed physical and mental, Watson (1979) stated that a pahent's environment was cntical for his or her mental and physical
'quality' (1974) well-bemg Therefore, whenever appropnate, the nurse
In 1987, the Amencan Nurses' Assoaahon (ANA) provided comfort through environmental mterventions descnbed the scope of gercmtological nursmg The ANA
(Watson called environmental mterventions carahve factor stated, "Emphasis is placed on mamtammg hfe m dignity number 8) Watson also hsted seven speafic comfort and comfort until death' (meanmgs 2, 3, and/or 5, 6) An measures that the nurse uhhzed m this regard She assessment tool pubhshed by the Amencan Assoaahon used the term 'comfort measures' synonymously with of Htmies for the Agmg (Lmd 1983), consisted of a queshormaire to be completed by nursmg home residents 'mtervenhons' as does Roy (Roy & Roberts 1981) (first
TTie residents were asked if their place was comfortable, meanmg)
In Humanistic Nurstng (Paterson & Zderad 1988), referring to the environment If so, this would be a cause of
Paterson called comfort a constnid that communicated the state of comfort, denoted by thefirstmeaning.
'the nature or expenence of nursmg' She beheved that
Hamilton (1989) explored the meaning of comfort horn comfort was an 'umbrella under which all the other the pahent's perspechve She used mterviews to ascstam terms — growth, health, freedom, and openness — could how each pahent defined cmpam' (third meanmg) defined comfort from a mental pespechve rather than from but pahents also ldenhfied good positions m weU-fittmg a physical one (She believed, however, that mental disfurniture (second meanmg), and a feelmg of bemg mdependent, encouraged, worthwhile and useful (fifth meanmg) comforts could often lead to physical discomforts) Thus,
At the end of the study, Hamilton stated, 'The dear mess- her defwahcm of cc»nfort was age ts that c»mfc»t is mulh-ndanensicmal, nxaiwag cUfferent a state valued by a nurse as an aim m which a perscm is free to things to diffei«it pecq>le' be and becxmie, controlkng and plannmg his own cfestiny, m
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An analysts of contort accordance with his potential at a particular time in a particular question, 'Can nursmg meet needs that anse m ways that situation promote growth?' She concluded that this hypothesis was
(Paterson & Zderad 1988) probably true m nursmg situations
The empowerment that this sense of comfort entails
Paterson was using comfort as a stable state (second mean- conforms to Paterson's construct of comfort, m which mg) but with existenhal properties of hanscendence mto persons' conditions are bemg 'moved through relahonship freedom (fifth meanmg) with others by mtemahzmg fi-eedom from painful conhollmg effects of the past' (Paterson & Zderad 1988) Accordmg to Paterson, this type of comfort fi-ees pahents to be
CLASSIFICATION OF PATIENT NEEDS
'all that they could be' at that tune Here, comfort, as a
Many instances of comfort m the nursmg hterature are therapeutic goal, conforms well to a patient bemg based on needs being met, as was demonshated m the shengthened, encouraged, supported, physically refi-eshed and/or mvigorated So, while the fifth and sixth meanmgs theones of Roy and Orlando Peplau (1952) stated. are not part of current usage, they assume new hfe as
Physical as well as psychological needs of people — for technical meanings m nursing the satisfaction of their wants for food, rest, sleep, comfort, companionship, understandmg — determme to considerable
THE THREE TECHNICAL SENSES OF extent the tasks that anse in nursing situations
COMFORT
A patient with unmet comfort needs has a deficit, and when the needs are satisfied, the deficit is removed In order to provide comfort, then, the nurse must first understand what the need is
Comfort needs can be divided mto three dasses In the first, the need is for bemg m a comfortable state An example of this class of needs is the DHEW statement about standards for care ated above This outcome is appropnate when it is the most desirable condition of which the pahent is capable or if comfort provides a respite fi-om the shess and anguish of disease, debihtation or injury Given the need for rest, the limited powers of the patient, and the usual restnchng environments of hospitals, the state of comfort as one of ease and peaceful contentment is a desirable goal (second meanmg)
In the second class, the need is for relief from discomfort
Carpenito (1987) defines discomfort (or altered comfort) as a state m which the mdividual expenences an uncomfortable sensation m response to a noxious stunulus This is a partially arcular definition, but Carpenito further descnbes the discomforts as acute pam, chrome pain, pam m children, pnmtus (a desire to itch) and nausea/vomitmg Here, comfort needs are discussed as m the third meanmg where rehef
IS given from discomfort
From the six ongmal meanmgs of comfort, three dasses of comfort needs emerge that are relevant for nursmg and each IS assoaated with a specific sense of comfort Each sense is also a prospechve technical sense for nursmg
These associations are presented m Table 2 and the technical senses of comfort are defined and labelled as (a) the state sense, (b) the rehef sense, and (c) the renewal sense In nursing prachce, comfort measures are causes of the referents of these senses Since each technical sense denotes different realihes, the dishndions and funchonal relahonships between tham are unportant for prachce, theory and research Their conhastmg attnbutes cilso estabhsh that the senses and their extensions are separate A discuss of their differentiatmg attnbutes follows
The passive nature of a state of ease has led some psychologists to suggest that the state of comfort is no more than a verbal mvenhon that signals an absence of discomforts ' people do not expenence comfort at all, they expenence only chscomfort, and comfort is simply a verbal mvention' (Parsons 1977) The state is not supposed to have positive attnbutes Only because discomforts are relieved is a {jerson said to be m a state of comfort
Conhary to this pomt of view, the authors argue that the state of comfort often exhibits detectable features
In the third dass, the comfort need is for educahon, motivation and/or mspiration These needs are typically found m pahents who are prepanng to resume their normal hves Nurses do not division normal hvmg for most pahents as bemg just the state of comfort, that is 'ease' or
'peaceful contentment' When possible and ethical, nurses aim to empower people to resume their o c c i ^ h o n s and/or major achvihes In her early work, Peplau (1952) raised the
First, the state of comfort does not presuppose complete absence of discomfort A person may be in some discomfort yet be at ease This is possible because sensitivity to discomfort is relative to the mdividual A stohd person may be able to withstand discomfort and be at ease while a squeamish one cannot withstand any discomfort and is ill at ease Also, persons may be highly sensihve to certam bnds of discomforts, e.g rmgmg m the ears, but quickly leam to
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KY KolcabaartdRJ Kolcaba
Table 2 Qasses of comfort needs and three technical senses of comfort
Comfort needs
The senses of comfort
First class comfortable state
The state sense an endunng state of ease and peaceful contentment
The rehef sense relief from discomfort
Second dass rehef from conditions that
Interfax with comfort
Third class personal growth
disregard others, e g aching musdes The state of comfort, then, may be assoaated with personahty charactenstics that can be present with or without the absence of discomforts A second important difference between the state of comfort and rehef from discomforts is that the state is of the whole person The full range of factors both mental and physical can be descnbed as being involved m the state, that IS, the concept of ease can be considered 'm mmd' and
'm body' and so on mto the more detailed categones of each Discomforts mdude adverse stimuh and thoughts that can affect only aspects of persons A sore ankle is not a sore person How the person chooses to hve with the sore ankle may, but need not, unply a full range of whole-person effects Thus, the expenence of rehef fi-om an imtatmg discomfort may not be a whole-person response, but it usually IS of short durahon as with the immediate liftmg of a burden Also, the cessahon of the expenence of relief does not necessanly cause additional states The usual scenano is that after it serves as a pimctuahon mark, ordmary conditions and states resume normalcy
Third, the absence of discomforts is not a suffiaent condihon for the state of ease In ordinary hvmg, our activities may be free fi-om discomforts but we may be m an mvolved, committed and rather tense state. In health care situahons, pahents may be tense about an impendmg procedure, a diagnosis or a family problem. Thus, the state of comfort requires more than the absence of discomforts, it also requires peace of mind and cessation of mtense achvihes The renewal sense bemg strengthened and mvigorated fort but fail to be shengthened and mvigorated, she may be depressed so that the nurse's comfort measures do not have the desired effect With these qualifiers m mind, it is usually observed that a reduchon m discomfort promotes or at least prepares the way for entenng a renewed condihon
While bemg mamtamed m a state of comfort, a person can begm the process of renewal This process imphes enhanced powers, shengthened mohvahon, and posihve athtudes and outlooks for meetmg the life challenges normal for that person Unhke the state of comfort, which requires the cessahon of stressful achvities, renewal is somehmes assoaated with them
C O M F O R T IN NURSING PRACTICE
The therapeutic context
The difiference among the three senses and their tations mdicate that nurses woiiung in therapeuhc settings consider all three senses when desigrung and orgaruzmg environments, estabhshmg nursing objechves, and selectmg mtervenhons to meet them. This process is somewhat simphfied by the standardizahon of therapeuhc contexts and the nursmg roles within them. Therapeuhc contexts have become speaahzed mto broad divisions accordmg to the condihon of patients In the first division, very til pahoits are in envirorunents that are designed not to overstimulate and tax them emohonally and physically The state of comfort is appropnate for these pahents Of course, they are also observed for signs of discomfort, and comfort measures are aimed toward rehef
Renewal
llie second division of therapeutic contexts is for
Relahonships between the third sense (renewal) and the patients who are recovenng with the aim of gradually other two (state and rehef) reveal that the renewal saise is mcreasu^ their levels of achvity to what is normal for independent firom but has a funchonal relahonship with them In this settmg, nurses attempt to relieve relevant discomforts Ccnnfort nwasures can strengthen a perscm disoKnfbrts and contnbute to rmewmg pahents through even though he remams uncomfortable Programmes of strengthom^ and helping to mvigorate them "Htus, physical therapy often are attended by pam while the the three %nses of ccunfort have been operationahzed therapist helps shengthen the patent through ^ ^ ^ tm{^C3tly m e^abhshed nursu^ practice with the relief encouragonent Conversely, a person can Vutve no dtsccnn- sense bor^ apj^ed m aU therapeutic contexts. Tlw tehei
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An analysts of comfort
Figure 1 The comfort needs of patients
Patients with comfort need8
1
Padents that need to be In a state of comfbrt
2
Patients that need to be in a state of comfort and need relief from cSscomfofts 3
Patients that need relief from (ftsoomfofts
4
Patients that need relief from (fiscomfbrts and renewal 5
Patients with comfort needs met
Patients that need renewal sense is augmented by the state sense m the first division and therenewalsense m the second
Figure I lllushates these divisions based on the comfort needs of pahents For example, sechon A contams pahents who have no unmet comfort needs, as when a pahent consults a nurse about a mmor health problem or a hfestyle change Should the patient develop a condihon requinng care in a first division context, he or she would be withm sechon B, with a need for the state of comfort, or subsection C m the case where the condihon is accompanied by discomfort Should the patient require care m a second division context, he or she would be withm sechon F or sub-sechon E m the case where the condihon is accomparued by chscomforts As is indicated, sub-sechons
C and E are formed by the intersection of sechon D, the dass of pahents needmg relief fi-om discomforts, v«th sedions B and F
Figure I does not develop all of the mathemahcally possible combuiahons of the three dasses of comfort needs The condihon of pahents detennmes their needs and the therapeuhc contexts m which they can be sahsfied
The addihonal combmahons of dasses of comfort needs can be used m a further study about nursmg prachce that is more cktaikd and less abshact than the present study The
%ure, however, does illustrate that the broad divisions of therapeutu: context parallel the diffenng dasses
