Dr. Katherine Kolcaba Comfort Theory Chapter 21 Florida National University NGR 5101 – Nursing Theory Dr. Barry Eugene Graham Introduction to Dr. Katherine Kolcaba Katharine Kolcaba was born and educated in Cleveland, Ohio. In 1965, she received a diploma in nursing and practiced part time for many years in the operating room, medical–surgical units, long-term care, and home care before returning to school. In 1987, she graduated with the first RN to MSN class at the Frances Payne Bolton School of Nursing, Case Western Reserve University (CWRU), with a specialty in gerontology. While attending graduate school, Kolcaba maintained a head nurse position on a dementia unit. In the context of that unit, she began theorizing about comfort. After graduating with her master’s degree in nursing, Kolcaba joined the faculty at the University of Akron (UA) College of Nursing, where her clinical expertise was gerontology and dementia care. She returned to CWRU to pursue her doctorate in nursing on a part-time basis while teaching full time. Introduction to Dr. Katherine Kolcaba (Continued) Over the next 10 years, she used course work from her doctoral program to further develop her theory. During that time, Kolcaba published a framework for dementia care (1992a), diagrammed the aspects of comfort (1991), operationalized comfort as an outcome of care (1992b), contextualized comfort in a middle range theory (1994), tested the theory in several intervention studies (Kolcaba & Fox, 1999; Kolcaba, 2003; Kolcaba, Dowd, Steiner, & Mitzel, 2004; Kolcaba, Tilton, & Drouin, 2006; Dowd, Kolcaba, Steiner, & Fashinpaur, 2007), and further refined the theory to include hospital-based outcomes (2001). She has an extensive series of publications to document each step in the process, most of which have been compiled in her book Comfort Theory and Practice (2003). Many publications and comfort assessments also are available on her website at www.TheComfortLine.com. Kolcaba taught nursing at UA for 22 years and is now an associate professor emerita. Kolcaba still teaches her web-based theory course once a year, and she represents her own company, The Comfort Line, as a consultant. In this capacity, she works with health-care agencies and hospitals that choose to apply comfort theory on an institution-wide basis. She also is founder and member of her local parish nurse program and is a member of the American Nurses Association and Sigma Theta Tau. Kolcaba continues to work with students at all levels and with nurses who are conducting comfort studies. She resides in the Cleveland area with her husband, and near her two daughters, their children, and her mother. One other daughter resides in Chicago. Overview of the Theory In comfort theory (CT), comfort is a noun or an adjective and an outcome of intentional, patient/family focused, quality care. Despite everyone’s familiarity with the idea of comfort, it is a complex term that ...

1. Dr. Katherine Kolcaba
Comfort Theory
Chapter 21
Florida National University
NGR 5101 – Nursing Theory
Dr. Barry Eugene Graham
Introduction to
Dr. Katherine Kolcaba
Katharine Kolcaba was born and educated in Cleveland, Ohio.
In 1965, she received a diploma in nursing and practiced part
time for many years in the operating room, medical–surgical
units, long-term care, and home care before returning to school.
In 1987, she graduated with the first RN to MSN class at the
Frances Payne Bolton School of Nursing, Case Western Reserve
University (CWRU), with a specialty in gerontology.
While attending graduate school, Kolcaba maintained a head
nurse position on a dementia unit. In the context of that unit,

2. she began theorizing about comfort.
After graduating with her master’s degree in nursing, Kolcaba
joined the faculty at the University of Akron (UA) College of
Nursing, where her clinical expertise was gerontology and
dementia care.
She returned to CWRU to pursue her doctorate in nursing on a
part-time basis while teaching full time.
Introduction to
Dr. Katherine Kolcaba (Continued)
Over the next 10 years, she used course work from her doctoral
program to further develop her theory. During that time,
Kolcaba published a framework for dementia care (1992a),
diagrammed the aspects of comfort (1991), operationalized
comfort as an outcome of care (1992b), contextualized comfort
in a middle range theory (1994), tested the theory in several
intervention studies (Kolcaba & Fox, 1999; Kolcaba, 2003;
Kolcaba, Dowd, Steiner, & Mitzel, 2004; Kolcaba, Tilton, &
Drouin, 2006; Dowd, Kolcaba, Steiner, & Fashinpaur, 2007),
and further refined the theory to include hospital-based
outcomes (2001).
She has an extensive series of publications to document each
step in the process, most of which have been compiled in her
book Comfort Theory and Practice (2003). Many publications
and comfort assessments also are available on her website at
www.TheComfortLine.com. Kolcaba taught nursing at UA for
22 years and is now an associate professor emerita.
Kolcaba still teaches her web-based theory course once a year,

3. and she represents her own company, The Comfort Line, as a
consultant. In this capacity, she works with health-care agencies
and hospitals that choose to apply comfort theory on an
institution-wide basis.
She also is founder and member of her local parish nurse
program and is a member of the American Nurses Association
and Sigma Theta Tau.
Kolcaba continues to work with students at all levels and with
nurses who are conducting comfort studies.
She resides in the Cleveland area with her husband, and near
her two daughters, their children, and her mother. One other
daughter resides in Chicago.
Overview of the Theory
In comfort theory (CT), comfort is a noun or an adjective and an
outcome of intentional, patient/family focused, quality care.
Despite everyone’s familiarity with the idea of comfort, it is a
complex term that has several meanings and usages in ordinary
language.
The use of comfort as a noun and an outcome is specific to CT
and different from its alternative usages as a verb, adverb (as in
comfortably), and process (Kolcaba, 1995).
From the Oxford English Dictionary, Kolcaba learned that the
original definition of comfort meant “to strengthen greatly.”

4. Overview of the Theory
Her assumptions were that:
(1) the need for comfort is basic
(2) persons experience comfort holistically
(3) self-comforting measures can be healthy or unhealthy
(4) enhanced comfort (when achieved in healthy ways) leads to
greater productivity.
Overview of the Theory
From the nursing literature, Kolcaba used three nursing theories
to describe three distinct types of comfort (Kolcaba, 2003).
Relief was synthesized from the work of Orlando (1961/1990),
who stated that nurses relieved the needs expressed by patients.
Ease was synthesized from the work of Henderson (1978), who
described 13 basic functions of humans that needed to be
maintained for homeostasis.
Transcendence was derived from Paterson and Zderad (1976),
who believed that patients could rise above their difficulties
with the help of nurses.
These types of comfort were consistent with usages in nursing
textbooks. The four contexts in which comfort is experienced by
patients are physical, psychospiritual, sociocultural, and
environmental and came from a further review of literature

5. regarding holism in nursing (Kolcaba, 1991, 2003).
When these four contexts of experience are juxtaposed with the
three types of comfort, a taxonomic structure (TS), or grid, is
created that covers the nursing meaning of comfort as a patient
outcome.
This TS, with definitions of each type and context of comfort,
provides a map of the content of comfort so that nurses can use
it to pattern their care for each patient and family member.
Kolcaba’s technical definition of the outcome of comfort is: The
immediate experience of being strengthened when needs for
relief, ease, and transcendence are addressed in four contexts of
experience. These are: transcendence and the physical,
psychospiritual, environmental, and sociocultural contexts.
Overview of the Theory
Other uses of the TS of comfort are as follows:
(1) for determining the existence and extent of unmet comfort
needs in patients or family members;
(2) for designing comforting interventions, which often can be
“bundled” in a single patient interaction; and
(3) for creating measurements of holistic comfort for
documentation in practice and research; such measurements
would be conducted before and after comfort interventions
and/or interactions.
A place to note the nature and time of the nursing intervention
next to baseline and subsequent comfort measurements is
essential in medical records.
These strategies are discussed further in a later section of this

6. chapter. One way to think about the grid is that comfort is an
umbrella outcome that entails relief from discomforts such as
anxiety, pain, environmental stressors, and/or social isolation.
Because the TS represents a holistic definition of comfort, the
cells on the grid are interrelated; and as a whole, comfort
interventions directed to one part of the grid have effects on all
parts of the grid.
Total comfort at any one time is also greater than the sum of its
individual parts. Therefore, comfort interventions to treat
anxiety also may reduce the dosage of analgesia needed for
adequate pain relief. On a comfort continuum, the concept of
total comfort (as much as can be expected given the
circumstances) is at one extreme end, and suffering is at the
other end.
Application of the Theory in Practice
As noted earlier, according to CT, there are three types of
comforting interventions:
technical, coaching, and comfort food for the soul.
Technical interventions are those that are specified by other
disciplines or by nursing protocols; they include medications,
treatments, monitoring schedules, insertion of lines, and so
forth.
For patients, competency in the administration and
documentation of technical interventions is the minimum
expectation for nurses. Coaching consists of supportive nursing
actions, active listening, referrals to other members of the
health-care team, advocacy, reassurance, and so forth.

7. Comfort food for the soul comprises those extra special,
holistic, and more time-consuming nursing interventions such as
back or hand massage, guided imagery, music or art therapy, a
walk outside, or special arrangements for family members.
The latter two types of interventions require more expertise and
confidence of nurses and are what patients most remember. And
they are what Benner (1984) would ascribe to “expert” nurses.
Application of the Theory in Practice
However, most nurses focus on technical interventions first and,
when time permits, implement coaching techniques.
Interestingly, charting usually accounts only for technical
interventions and the effects of analgesia; there are no places in
traditional hospital records to record the more important healing
interventions.
But patients rarely remember the technical interventions; the
important interventions to patients and their families are those
that are not documented, such as coaching and comfort food for
the soul, the most important work of expert nurses.
Thus, there is a perpetual disconnect between legal charting and
actions that patients want and need from their nurses and which
we claim to be the essence of nursing. It is no wonder that,
when pressed, nurses cannot describe the impact they make with
patients and their families—coaching and comfort food
interventions are not valued by administrators and are not even
visible in patient care records.
This can result in the value of nursing being understated or even
invisible. CT provides the language and rationale to once again

8. claim and document essential nursing activities that are most
beneficial to patients and family members in stressful health-
care situations.
It is also important to remember that the outcome of enhanced
comfort is positive outcome and a true measure of quality care,
rather than a measure of what quality care is not, such as the
currently measured outcomes of nosocomial infections, falls,
decubitus ulcers, medication errors, and failure to rescue.
(Would you want to go to a hospital that was looking only at
negative outcomes such as medication errors or “failures to
rescue”?)
The Comfort Theory developed by Dr. Kolcaba has been applied
by multiple healthcare agencies to enhance the workplace
environment for the benefit of staff and patients alike.
References
Kolcaba, K. (1991). A taxonomic structure for the concept
comfort. Image: The Journal of Nursing Scholarship, 23(4),
237–240.
Kolcaba, K. (1992a). The concept of comfort in an
environmental framework. Journal of Gerontological Nursing,
18(6), 33–38.
Kolcaba, K. (1992b). Holistic comfort: Operationalizing the
construct as a nurse-sensitive outcome. ANS Advances in
Nursing Science, 15(1), 1–10.
Kolcaba, K. (1994). A theory of holistic comfort for nursing.
Journal of Advanced Nursing, 19, 1178–1184.
Kolcaba, K. (1995). The art of comfort care. Image: The Journal

9. of Nursing Scholarship, 27(4), 287–289.
Kolcaba, K. (2001). Evolution of the midrange theory of
comfort for outcomes research. Nursing Outlook, 49(2), 86–92.
Kolcaba, K. (2003). Comfort theory and practice: A vision for
holistic health care and research (pp. 113–124). New York:
Springer.
Kolcaba, K., Dowd, T., Steiner, R., & Mitzel, A. (2004).
Efficacy of hand massage for enhancing comfort of hospice
patients. Journal of Hospice and Palliative Care, 6(2), 91–101.
Kolcaba, K., & Fox, C. (1999). The effects of guided imagery
on comfort of women with early-stage breast cancer going
through radiation therapy. Oncology Nursing Forum, 26(1), 67–
71.
Kolcaba, K., Schirm, V., & Steiner, R. (2006). Effects of hand
massage on comfort of nursing home residents. Geriatric
Nursing, 27(2), 85–91.
Kolcaba, K., Tilton, C., & Drouin, C. (2006). Comfort theory: A
unifying framework to enhance the practice environment.
Journal of Nursing Administration, 36(11), 538–544.
Kolcaba, K., & Wilson, L. (2002). The framework of comfort
care for perianesthesia nursing [with posttest for 1.2 contact
hours]. Journal of Perianesthesia Nursing, 17(2), 102–114.
Smith, M. C. (2015). Nursing Theories and Nursing Practice.
[VitalSource Bookshelf]. Retrieved
from https://bookshelf.vitalsource.com/#/books/9780803674844
/

10. Dr. Joanne Duffy’s
Quality-Caring Model
Chapter 22
Florida National University
NGR 5101 – Nursing Theory
Dr. Barry Eugene Graham
Introduction to
Dr. Joanne Duffy's Quality-Caring Model
Introducing the Theorist
Joanne R. Duffy, PhD, RN, FAAN, has had an extensive career
encompassing clinical, administrative, and academic roles.
Currently, she is the West Virginia University Hospitals
Endowed Professor of Research and Evidence-based Practice
and Interim Associate Dean for Research and PhD Education at
the Robert C. Byrd Health Sciences Center, West Virginia
University, Morgantown, WV, and is an Adjunct Professor at

11. the Indiana University School of Nursing in Indianapolis, IN.
She has directed four graduate nursing programs (critical care,
care management, nursing administration, and a PhD program)
and was a former Division Director of a school of nursing.
She actively teaches nursing theory, research, and leadership in
PhD, DNP, masters and honors programs, directs dissertations
and scholarly projects, and interfaces with acute care health
professionals and leaders to advance evidence-based practice.
Introduction to
Dr. Joanne Duffy's Quality-Caring Model
Introducing the Theorist (Continued)
Dr. Duffy graduated from St. Joseph’s Hospital School of
Nursing in Providence, RI, completed her BSN at Salve Regina
College in Newport, RI, and her master’s and doctoral degrees
at the Catholic University of America in Washington, DC.
Dr. Duffy has held clinical positions in intensive care, coronary
care, and emergency services and is a cardiovascular clinical
nurse specialist.
She was an associate director of nursing at one urban hospital
and two large academic medical centers, developed a
Cardiovascular Center for Outcomes Analysis, and
administrated a transplant center while simultaneously serving
in academic appointments. Her special expertise in outcomes
measurement has led to the focus of her work: maximizing
health outcomes, particularly among older adults, through
caring processes.
Dr. Duffy was the first to examine the link between nurse caring
behaviors and patient outcomes and developed the caring
assessment tool (including the newest version, the e-CAT) in

12. multiple versions.
Dr. Joanne Duffy's Quality-Caring Model
Introducing the Theorist (Continued)
She developed the middle-range quality-caring model© to guide
professional practice and research, ultimately exposing the
hidden value of nursing work.
Dr. Duffy was the principal investigator on the national
demonstration project, “Relationship-Centered Caring in Acute
Care,” has been the principal investigator for two caring-based
intervention studies and served as consultant to several
multidisciplinary studies.
Dr. Duffy was a consultant to the American Nurses Association
(ANA) in the development and implementation of the National
Database of Nursing Quality Indicators and the former chair of
the National League for Nursing’s Nursing Educational
Research Advisory Council.
Dr. Duffy is a Commonwealth Fund Executive Nurse Fellow, a
recipient of several nursing awards, a Fellow in the American
Academy of Nursing, a frequent guest speaker, and a former
Magnet Appraiser.
The first edition of her book, Quality Caring in Nursing:
Applying Theory to Clinical Practice, Education, and Research
received the AJN book of the year award in 2009.
The second edition, Quality Caring in Nursing and Health
Systems: Implications for Clinical Practice, Education, and
Leadership (2013), focuses on caring relationships as the central

13. organizing principle of health systems.
Overview of the Theory
The Quality-Caring Model© was initially developed in 2003 to
guide practice and research (Duffy & Hoskins, 2003).
The seeds of the model were sown during discussions
concerning nursing interventions, but it was informed from
earlier work on caring (Duffy, 1992).
While examining the outcomes variable of patient satisfaction
in the late 1980s, Dr. Duffy uncovered that hospitalized patients
who were dissatisfied often expressed, “Nurses just don’t seem
to care.”
This concern was corroborated in the literature and represented
a clinical problem that significantly affected patients’
perceptions of quality.
Over time, Dr. Duffy continued to study human interactions
during illness, developing tools to measure caring (Duffy, 2002;
Duffy, Brewer, & Weaver, 2014; Duffy, Hoskins, & Seifert,
2007) and studying the linkage between nurse caring and
selected health-care outcomes (Duffy, 1992, 1993).

14. Overview of the Theory
In 2002, it became apparent that there were few nursing theories
that could guide the development of a caring-based nursing
intervention while simultaneously speaking to the relationship
between nurse caring and quality.
As part of a research team, Drs. Duffy and Hoskins developed
and tested the model in a group of heart failure patients (Duffy,
Hoskins, & Dudley-Brown, 2005).
Caring relationships were the core concept in this model and
were believed to be integrated, although often hidden, in the
daily work of nursing.
This form of caring was considered different from the caring
that occurs between family and friends because professional
nurse caring requires specialized knowledge, attitudes, and
behaviors that are specifically directed toward health and
healing.
Through this specialized knowledge, recipients feel “cared for,”
which was theorized as a positive emotion necessary for taking
risks, feeling safe, learning new healthy behaviors, or
participating effectively in decision making based on evidence.
This sense of “feeling cared for” was considered an antecedent
necessary to influence improved intermediate and terminal
outcomes, particularly nursing-sensitive outcomes such as
knowledge (including self-knowledge), safety, comfort, anxiety,
adherence, human dignity, health, confidence, engagement, and
positive experiences of care.

15. Overview of the Theory
Furthermore, the model was considered supportive to
professional nursing because nurses themselves were theorized
to benefit. Blending societal needs for measurable outcomes
with the unique relationship-centered processes central to daily
nursing practice represented a practical, postmodern approach.
The major purposes of the Quality-Caring Model© at that time
were to:
• Guide professional practice
• Describe the conceptual–theoretical–empirical linkages
between quality of care and human caring
• Propose a research agenda that would provide evidence of the
value of nursing Because of the complexities of modern society,
individuals, the health system, and the professionals who work
in it, the Quality Caring Model© has evolved from its initiation
in 2003.
Since that time, the model has been revised twice to meet the
demands of the multifaceted, interdependent, and global health
system that “requires a more sophisticated workforce, one that
understands the significance of systems thinking, whose
practice is based on knowledge, multiple and oftentimes
competing connections, and one that values relationships as the
basis for actions and decision-making” (Duffy, 2009, p.192).
In this revised version, the link between caring relationships
and quality care is even more explicit, challenging the nursing
profession to use caring relationships as the basis for daily
practice.
The revised model is considered a middle-range theory because
it draws on others’ work, is practical, and can be tested. It
views quality as a dynamic, nonlinear characteristic that is
influenced by caring relationships. “Quality is not an endpoint
per se, but a process of continuous learning and improvement …
that treats patients as full partners … and is fully integrated into
the work of health professionals” (Duffy, 2013, p. 31).

16. Overview of the Theory
When caring relationships are the basis of nursing work,
positive human connections are formed with patients and
families that influence future interactions and positively
influence intermediate health outcomes.
Thus, caring is a process that involves a reciprocal relationship
(characterized by caring factors) between human persons,
whereby the positive emotion, “feeling cared for,” is attained.
It is this feeling of being “cared for” that matters in terms of
enabling the conditions for self-advancing systems.
As such, it is an essential performance indicator of quality
nursing care. Caring relationships also are theorized to enhance
interprofessional practice and benefit nurses themselves by
maintaining congruence with professional values and
contributing to meaningful work.
Transforming the learning environment with meaningful
learning activities, clinical experiences, and frequent reflection
on the salience of caring relationships helps students share
meanings, elicit relevant data, listen, notice cues, establish
rapport, and develop mutually caring interactions.

17. Theory Usage/Summary
Implications of the revised quality-caring model© exist for
educators to help students learn how to care. Transforming the
learning environment with meaningful learning activities,
clinical experiences, and frequent reflection on the salience of
caring relationships helps students share meanings, elicit
relevant data, listen, notice cues, establish rapport, and develop
mutually caring interactions.
Redesigning professional workflow so that its primary function
is relationship centered and making decisions in a participatory
manner are paramount to quality sharing. Finally showing
evidence of nursing foremost professional purpose which is
caring through ordinary everyday caring actions blended with a
culture of continuous inquiry creates novel possibilities for
advancing the profession.
References
Duffy, J. (1992). Impact of nurse caring on patient outcomes. In
D. A. Gaut (Ed.), The presence of caring in nursing (pp. 113–
136). New York: National League for Nursing Press.
Duffy, J. (1993). Caring behaviors of nurse managers:
Relationships to staff nurse satisfaction and retention. In D.
Gaut (Ed.), A global agenda for caring (pp. 365–377). New
York: National League for Nursing Press.
Duffy, J. (2002). Caring assessment tools and the CAT-admin
version. In J. Watson (Ed.), Instruments for assessing and
measuring caring in nursing and health sciences (pp. 131–148).

18. New York: Springer.
Duffy, J. (2009). Quality caring in nursing: Applying theory to
clinical practice, education, and leadership. New York: Springer
Publishing.
Duffy, J., & Hoskins, L. (2003). The quality-caring model©:
Blending dual paradigms, Advances in Nursing Science, 26(1),
77–88.
Duffy, J. (2013a). Quality caring in nursing and health systems:
Implications for clinicians, educators, and leaders. New York,
NY: Springer. Duffy, J. (2013b). Theories focused on caring. In
J. B. Butts & K. L. Rich (Eds). Philosophies and theories for
advanced nursing practice (pp. 507-524). Sudbury, MA: Jones &
Bartlett Learning, LLC.
Duffy, J., Hoskins, L. M., & Dudley-Brown, S. (2005).
Development and testing of a caring-based intervention for
older adults with heart failure. Journal of Cardiovascular
Nursing, 20(5), 325–333.
Duffy, J., Hoskins, L. M., & Seifert, R. F. (2007). Dimensions
of caring: Psychometric properties of the caring assessment
tool. Advances in Nursing Science, 30(3), 235–245.
Duffy, J., Brewer, B., & Weaver, M. (2014). Revision and
Psychometric Properties of the Caring Assessment Tool.
Clinical Nursing Research, 23(1), 80–93.
Duffy, J., Kooken, W., Wolverton, C., & Weaver, M. (2012).
Evaluating patient-centered care: Feasibility of electronic data
collection in hospitalized older adults. Journal of Nursing Care
Quality, 27(4), 307–331.
Smith, M. C. (2015). Nursing Theories and Nursing Practice.
[VitalSource Bookshelf]. Retrieved
from https://bookshelf.vitalsource.com/#/books/9780803674844
/