Applied Nursing Research 27 (2014) 147150

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Applied Nursing Research

journal homepage: www.elsevier.com/locate/apnr

Theory Connections

A practical application of Katharine Kolcaba's comfort theory to

cardiac patients
Robin Krinsky, MSN, RN-BC, CCRN , Illouise Murillo, MSN, RN, Janet Johnson, MA, APRN-BC, FAANP
Case Western Reserve University, Frances Payne Bolton School of Nursing, Cleveland, Ohio 44106

a r t i c l e

i n f o

Article history:
Received 1 February 2014
Accepted 5 February 2014
Keywords:
Comfort theory
Cardiac
Kolcaba
Quiet time

a b s t r a c t
Nursing approaches to care as based on Katharine Kolcaba's (2003) middle range nursing theory of comfort
are discussed in reference to patients' suffering from symptoms related to the discomfort from cardiac
syndromes. The specic intervention of quiet time is described for its potential use within this population as
a comfort measure that addresses Kolcaba's four contexts of comfort: physical, psychospiritual, environmental and sociocultural. Without realizing it, many nurses may practice within Kolcaba's theoretical
framework to promote patient comfort. Explicit applications of comfort theory can benet nursing practice.
Using comfort theory in research can provide evidence for quiet time intervention with cardiac patients.
2014 Elsevier Inc. All rights reserved.

Nurses strive to provide comfort to their patients in whatever

environment they practice. A key approach to providing for physical
and emotional comfort is to create an environment conducive to
healing a major principle of nursing rst stated by Nightingale
(1859). Nightingale's philosophy was to place the patient in the best
condition for the natural processes of healing to occur. Along with
fresh air, sunshine, adequate nutrition, and other factors, she
recommended quiet as essential for healing. However, in looking at
the environment in which we practice nursing, we see that it may not
be optimal for nature to act in benecial ways for our patients. We, as
providers of care, have yet to observe a time in which patients on a
cardiac unit are not subjected to noise, interruptions, as well as a
myriad of monitoring alarms.
Comfort theory is a middle range theory developed by Kolcaba
(2003) that has as a foundation Nightingale's environmental
principles of providing care (Selanders, 1998). This theory can be
used to enhance the environment of patients in cardiac care through
the use of a quiet time intervention. A loud and chaotic environment
can negatively affect healing process of patients. The purpose of this
article is to describe comfort theory as applied in care of cardiac
patients and to demonstrate the use of a specic intervention called
quiet time, derived from comfort theory, to improve cardiac patients'
experiences of comfort across four domains of care. We also call
attention to the need for research into the effectiveness and use of this
theory-based intervention.

Corresponding author. Tel.: + 1 917 848 7541, + 1 212 222 2353; fax: + 1 212
222 2353.
E-mail addresses: Robin.Krinsky@case.edu (R. Krinsky), Illousie.Murillo@case.edu
(I. Murillo), Janet.Johnson@case.edu (J. Johnson).
0897-1897/$ see front matter 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.apnr.2014.02.004

1. Case study 1
It has been shown that rest promotes healing, recovery, and wellbeing (Tullmann & Dracup, 2000). However, the hospital environment
presents unique challenges for patients to obtain rest periods.
Consider the following case of a patient admitted to the hospital
with diagnosis of suspected acute coronary syndrome:
John arrived at the emergency department with complaints of
chest pain. He is certain this is the big heart attack his father
had. He is taken to the main emergency department, which is one
large area with stretchers aligned side by side with only a curtain
between each stretcher offering minimal to no privacy. It seems
that someone appears every ve minutes to check his blood
pressure, draw blood or ask him more questions about his health
history. The noise of the other patients, staff and monitoring
equipment is so loud it is difcult for him to hear the providers
questions. Time passes. Now John has been in the emergency
room for over 12 hours and he has not rested. When he nally
starts to close his eyes and relax the nurses aide begins placing
him on a different monitoring device, with no explanation, just
the statement, "You are going upstairs." The cardiac oor where
he arrives is not much quieter. John is placed in a four-person
room. Both patients on the other side of the room have their
televisions on and one of the IV pumps continuously alarms. John
is feeling discomfort in his chest similar to what he felt in the
Emergency Department. He has been unable to contact his wife
because the battery on his cell phone went dead. He is anxious
about what will eventually happen to him.
This case is devoid of any comfort measures provided by John's
care providers and results in the escalation of his chest pain and

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anxiety. Sleep deprivation and anxiety are all precursors that can
trigger increased heart rates and elevation of blood pressure, which in
turn can cause additional workload to the myocardium and lead to
exacerbations of chest discomfort. This brief case presentation alerts
us to the potential usefulness of a theory on comfort in everyday
practice, and to the relevance of a specic intervention that promotes
quiet time in cardiac care.

comfort needs are indicated in the relief column. Entries in the ease
column point to interventions for promoting a sense of calm or
contentment in John. Patient-based expressions in the transcendence
column highlight John's expressed concerns that need to be addressed
to foster his sense of empowerment and ability to overcome the
challenges of the illness. Comfort is dynamic and an ever-changing
state, and the entries in the table may also change over the course of a
patient's hospital stay.

2. Comfort theory
4. Quiet time intervention
Kolcaba (2010a,b) created a conceptual framework (Fig. 1) to
show broadly how her comfort theory ts into the ow of care in the
practice setting. Comfort was described as the product of holistic
nursing practice. Fig. 1 illustrates that regardless of the patient and
family needs for health care, there is always a place for the assessment
and promotion of health care regarding comfort needs.
Kolcaba's theory of comfort was rst developed in 1991 when she
conducted a concept analysis to examine the literature from multiple
disciplines on comfort (Kolcaba & Kolcaba, 1991). The analysis
generated three forms of comfort and four contexts of holistic
human experience from which a taxonomic structure was created
as a map to guide areas of patient comfort for assessment in practice
and for measurement in research.
In comfort theory, specic concepts in the theory are organized in
terms of three forms and four contexts of comfort. The three forms of
comfort are relief, ease, and transcendence. Patients experience a sense
of relief when their individual comfort needs are met. Patients are at
ease in situations that enable them to be calm or content. The comfort
state of transcendence occurs when a person rises above their
challenges. The four contexts in which comfort is experienced are
physical, psychospiritual, environmental, and sociocultural. The physical
concerns bodily sensations and homeostatic mechanisms, the psychospiritual pertains to the internal awareness of self, the environmental is the external surroundings and conditions, and sociocultural refers
to interpersonal and societal relationships (Kolcaba & Fisher, 1996).
The three types of comfort and the four contexts of care can be
incorporated into a hospital's model of care (Kolcaba, Tilton, & Drouin,
2006). In addition, this taxonomy of comfort can be applied to specic
patient cases to delineate various comfort needs of the patient.
3. Comfort theory applied to care of cardiac patients
Kolcaba's Comfort Theory is readily applicable to cardiac patients.
Table 1 presents an example of applying comfort theory to the case
study of John and his comfort needs. Data from the case study were
entered into the 12 cells of the table, organized according to the four
contexts of care and the three types of comfort needs. John's specic

A quiet time intervention has signicant potential for not only

reducing noxious stimuli but also for creating opportunities for
needed privacy and supportive interactions. Research ndings have
shown that quiet time can improve patient outcomes and increase
consumer satisfaction with acute care health services, both of which
are of increasing importance in the contemporary health care
environment (Gardner, Collins, Osborne, Henderson, & Eastwood,
2009). Other research ndings indicate that quiet time in a chaotic,
noisy neuro-intensive care unit can create an atmosphere of
recuperation (Dennis, Lee, Woodard, Szalaj, & Walker, 2010).
The quiet time intervention has not yet been studied in the
emergency department. However, the taxonomy of data from the
cardiac care case in Table 1 indicates targets where this intervention
can be especially relevant to care of cardiac patients. A quiet time
protocol was derived from comfort theory to promote comfort across
the four contexts of care.
In the physical domain, quiet time can help minimize events in the
cardiac care setting that have detrimental physical effects on an
already compromised patient. Of particular concern is a patient's
sleep, which is essential for multiple physiological and psychological
processes. Numerous mechanical devices as well as hospital routines and
procedures can signicantly impair a patient's ability to sleep. Sleep
deprivation has been linked to rising incidence of patient falls, confusion,
and increased use of medication and restraints (Mazer, 2006).
Long established recommendations from the U.S. Environmental
Protection Agency, Ofce of Noise Abatement and Control (1974)
state that the hospital noise levels should not exceed 45 decibels.
However, studies have shown that the peak hospital noise levels
exceed 90 decibels, which is similar to the levels of heavy truck trafc.
Prolonged effects of excessive noise exposure on patients and staff
alike can have deleterious effect on their health and well-being
(Christensen, 2007). The chemical epinephrine and other endogenous
stimulants are released in response to environmental stimuli, which
in turn increase the patient's heart rate and blood pressure (DeKeyser,
2003). Quiet time interventions can prevent stimulation of the
sympathetic nervous system that occurs with an environment of

Fig. 1. Reprinted with permission from Katharine Kolcaba, The Comfort Line, 2010.

R. Krinsky et al. / Applied Nursing Research 27 (2014) 147150

149

Table 1
Kolcaba's Taxonomy Comfort Needs for Cardiac Patients.
Comfort/
Context

Relief

Ease

Transcendence

Physical

Chest pain

Implement pharmacological and holistic interventions for

pain
Provide supportive interactions that promote sense of calm
in the midst of cardiac event.
Organize a social and physical environment that supports
needs for privacy and limits interruptions.
Facilitate family presence and patient advocacy.

What if this pain gets worse?What if I need

heart surgery?
What if I had the big heart attack?
Reecting on uncertainty of future
Seeking a soothing environment that promotes
healing. I want to get out of here
Unfamiliarity with hospital culture. What does
going upstairs really mean?

Psychospiritual Anxiety regarding the big heart attack

Environmental
Sociocultural

Noise, alarms, visual congestion of beds and

stretchers, repetitive questioning
Unable to contact family, lack of sensitive
nursing care

constant noise, bright lights, and interruption of sleep, and promote

Kolcaba's form of comfort called relief.
In the psychospiritual domain, most cardiac patients can express a
range of feelings from mild anxiety to impending doom related to
their symptoms. Studies have indicated that there is a positive
correlation between stress levels and serum cortisol, which can
ultimately result in a depressed immune system (DeKeyser, 2003).
Patients' exposure to increased stimuli and noise levels contributes to
agitation. Quiet time can be a designated time in which patients may
meditate, pray, rest, or converse with signicant others. The resulting
restfulness and decreased anxiety supports what Kolcaba's form of
comfort called ease.
In the environmental domain, the nurse can initiate quiet time
procedures that provide all forms of comfort for the patient (Olson,
Borel, Laskowitz, Moore, & McConnell, 2001). Dimming the lights in
the patient's room and hallway can reduce unnecessary stimuli.
Maintaining correct limits and volume of cardiac monitoring alarms,
pulse oximetry, blood-pressure cuffs, and IV pumps can minimize
inappropriate alarming. Alarms are addressed quickly, overhead
paging and unnecessary conversations in patient care areas are
limited, and staff and visitors are asked to speak in low tones. Health
care team rounding, consultant visits, routine deliveries, and other
services can be scheduled to observe periods of quiet time so as to
maximize the patient's rest time (Taylor-Ford, Catlin, LaPlante, &
Weinke, 2008).
In the sociocultural domain, quiet time provides an opportunity to
assess interpersonal and cultural aspects. This is a period of time when
the nurse can have an unhurried and meaningful conversation with
patients and signicant others, and facilitate patient and family needs
for information, respect, validation, and emotional support that
promote comfort in the form of Kolcaba's transcendence.
5. Case study 2
In contrast to the rst case study above, the following case is an
example of a patient admitted to the hospital with diagnosis of
suspected acute coronary syndrome where the care providers applied
quiet time interventions from comfort theory.
James arrived to the Emergency Department with complaints of
chest pain. The Emergency Department has a designated chest
pain observational unit that is completely separate from the main
area. After patients are quickly triaged, they are taken to the quiet
section of this observational unit. The unit itself has only six beds
with ample space in between each stretcher that allows for easy
movement of staff and privacy for the patient. James is placed on
oxygen to help relieve the shortness of breath and the team leader
provider processes and accurately documents patient history to
ensure that questions will not have to be repeated. The nurse
explains the protocol to determine the diagnosis of Acute
Coronary Syndrome to the patient and customizes the time for
the necessary interventions that allows for periods of rest and
reduced stimulation between required blood draws and EKGs.

Explaining and educating James on what the care plan will be

helps reduce his anxiety. The nurse remains within this closed
unit so there can be quick response to any patient requests,
alarms from the monitoring devices, or IV pumps. Comfort
measures relating to James symptoms of chest pain, shortness
of breath or anxiety can also be addressed with pharmacological
measures as well as holistic measures. The nurse calls James wife
to explain what is going on with her husband and then moves the
portable phone to bedside for his use. A patient representative is
contacted to obtain a charger for the James depleted cell phone
battery. James reported no further episodes of chest pain and was
awaiting the results of pending blood work to rule out acute
coronary syndrome. He was able to close his eyes and sleep. The
Comfort Theory-based intervention of Quiet Time provided an
improved standard of care and outcome for this patient as well as
other cardiac patients.

6. Research implications: Next steps

Quiet time is an intervention that has been evolving in practice but
research is needed to validate its usefulness and rene its applications
in specic patient settings.
While anecdotal reports of nurse and patient satisfaction with
quiet time are positive, systematic study is needed of measurable
outcomes in cardiac patients to see if and how it affects patient
anxiety, physiologic parameters (heart rate and blood pressure), pain
and comfort. Additionally, research into the effects on nurses by the
use of comfort care theory is also needed since applications of this
theory may enhance the work environment and well-being among
health care providers as well as the patients.
There is a plethora of comfort questionnaires that have been
developed for specic populations such as: pediatric, peri-anesthesia,
and end of life and hospice. However, to date none have been found
that are unique for the cardiac population (Kolcaba, 2010a,b). Some of
these questionnaires may be useful in studying cardiac patient
perceptions of comfort in their care. Many can be found at Kolcaba
(2010a,b) Comfort Line Web site. In addition, outcome data on how
organizations provide comfort care can be collected from responses
on Hospital Consumer Assessment of Healthcare Providers and
Systems (HCAHPS) results and patient interviews.
7. Conclusions
Nurses have resources from their theories and their practice to
guide research into comfort-focused interventions for patients. Nightingale's ideas provide a signicant foundation for considering all
dimensions of the patient and environment that relate to comfort.
Kolcaba's middle range theory identies a taxonomy of factors to
consider in assessment and intervention. Nurses' practice experiences
and anecdotal evidence provide additional insights into what
comprises comfort care. These resources coupled with clinical research

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can help equip hospitals and nurses with effective methods to improve
patient comfort and facilitate healing. As Kolcaba and Fisher (1996)
stated, if patients experience comfort, then they are more satised
with the care given, and the nurses as well as the institution will
benet. What can be more germane to nursing than comfort?
Acknowledgments
We would like to acknowledge Dr. Pamela Reed, PhD, RN, FAAN and
Dr. Joyce Fitzpatrick, PhD, MBA, RN, FAAN for their support, guidance,
patience and useful feedback in the preparation of this manuscript.

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