Copyright © 2015. F.A. Davis CompanyChapter 22Joann.docx

Copyright © 2015. F.A. Davis Company
Chapter 22
Joanne Duffy’s Quality Caring Model
Developed by S. Gordon (2010)
Updated by D. Gullett (2014)
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On completion of this chapter, students will be able to:
Describe Duffy’s Quality-Caring Model.
Discuss the progression of the development of the Quality-
Caring Model.
Discuss the role of the nurse in providing quality care using the
Quality-Caring Model.
Identify caring-based nursing interventions.
Discuss the importance of caring relationships in nursing.
Describe Duffy’s used of the term “feeling cared for.”
Explain recent changes in the model.
Describe how the model is being used in nursing practice and
research.

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About the TheoristJoanne R. Duffy PhD, RN, FAANSt. Joseph’s
Hospital School of Nursing, Providence, RIBSN Salve Regina
College, Newport, RI Master’s and PhD Catholic University in
Washington, DCProfessor at Indiana University School of
NursingAssociate Director of NursingGeorge Washington
University Medical CenterGeorgetown University Medical
CenterDeveloped Cardiovascular Center for Outcome
AnalysisAdminister the Transplant Center at INOVA Fairfax
Hospital in Virginia
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About the Theorist (Continued)
First to examine the link between nurse caring behaviors and
patient outcomesDeveloped the Caring Assessment
ToolInterested in the hidden value of nursing workDeveloped
the Quality-Caring ModelExplores approaches to relationship
building
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Quality–Caring Model (2003) PurposeTo guide practice and
researchPrompted during discussions concerning nursing
interventionsInformed from earlier work on caringPatient
perceptions that “nurses just don’t seem to care”
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Quality Caring ModelThe model has been revised twice (once in
2009 and again in this most recent 2013 version) to meet the
demands of the multifaceted, interdependent and global health
system. 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
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Quality–Caring Model BackgroundFew nursing theories that
could guideDevelopment of caring-based nursing
interventionsSpeak to the relationship between nurse caring and
qualityInitial testing with a group of patients with heart failure
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Core Concept
Caring relationshipsHidden in the daily work of nursingNurse
caring different from caring between relatives and friendsNurse
caring requires Specialized knowledge, attitudes, and behaviors
directed toward health and healing
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Nurse CaringAssists recipients to feel “cared for”Freeing
recipients to:Take risksLearn new healthy behaviorsParticipate
in evidence-based decisions
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Feeling “Cared For”Necessary to influence outcomesNurse-
sensitive outcomes:Knowledge-SafetyComfort-Anxiety
Adherence-Human DignityHealth-Satisfaction
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Major Purposes of Quality-Caring ModelGuide professional
practiceDescribe linkages between quality of care and human
caringFoundation for nursing research
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Quality-Caring ModelDuffy considers the model Middle
RangeViews quality as:DynamicNonlinearEnhanced by caring
relationships
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Main ConceptsHumans in relationshipHumans are unique,
multidimensional beingsImportant to recognized how humans
are different and the sameSocial beings connected to
othersHumans mature, enhance community, and advance
through human connections
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Main Concepts (continued)Relationship-centered professional
encountersIndependent between nurse and
patient/familyCollaborative between nurses and members of
health-care teamOutcome is “feeling cared for”“Feeling cared
for”Nurse-sensitive/Positive emotionSignifies to patients and
families that they matterAllows patients/families to relax and
feel secureAntecedent to quality health outcomesNurse-
sensitive outcomes
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Main Concepts (continued)
Self-advancing systemsIt is a phenomenon that emerges
gradually over time and in space reflecting dynamic positive
progress that enhances the systems’ well-being. Self-advancing
systems are stimulated by caring relationships, but the forward
movement itself cannot be controlled directly; rather, it emerges
over time, driven by caring connections.
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AssumptionsHumans are:Multidimensional beings capable of
growth and changeExist in relationship to themselves, others,
communities or groups, and natureEvolve over timeInherently
worthyCaring is:Embedded in the daily work of nursingA

tangible concept that can be measuredDone in
relationshipConsists of processes that are used individually or
in combination and often concurrently
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Assumptions (continued)Caring relationships:Benefit both the
carer and the one being cared forBenefit societyProfessional
nursing work is done in the context of human
relationshipsFeeling cared for is a positive emotion
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Propositions Human caring capacity can be developedCaring
relationships:Are composed of process or factors that can be
observedRequire intent, choice, specialized knowledge and
skills, and timeEngagement in communities through caring
relationships enhances self-caringIndependent caring
relationships between patients and nurses influence feeling
“cared for”
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Propositions (continued)Collaborative caring relationships
among nurses and health-care team members influence feeling
“cared for”Caring relationships facilitate growth and
changeFeeling “cared for”:Is an antecedent to self-advancing
systemsInfluence is the attainment of immediate and terminal
health outcomes
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Propositions (continued)Self-advancement is a:Nonlinear,
complex process that emerges over time and in space Self-
advancing systems are:Naturally self-caring or self-
healingCaring relationships contribute to:Individual, group, and
system self-advancement
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Role of the NurseAttain and continuously advance knowledge
and expertise in caring processes.Initiate, cultivate, and sustain
caring relationships with patients and families.Initiate,
cultivate, and sustain caring relationships with other nurses and
all members of the health care team.Maintain an ongoing
awareness of the patient/family point of view.Carry on self-
caring activities, including personal and professional

development.Integrate caring relationships with specific
evidenced-based nursing interventions to positively influence
health outcomes.Engage in continuous learning and practice-
based research.Use the expertise of caring relationships
embedded in nursing, to actively participate in community
groups.
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Role of the nurse (cont)Contribute to the knowledge of caring
and, ultimately, the profession of nursing using all forms of
knowing.Maintain an open, flexible approach.Use measures of
caring to evaluate nursing care
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Caring RelationshipsRelationship with selfRelationships with
patients and familiesCollaborative relationshipsCaring for the
communities nurses live
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Caring FactorsMutual problem-solvingAttentive
reassuranceHuman respectEncouraging mannerHealing
environmentAppreciation of unique meaningAffiliation
needsBasic human needs
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Caring Factors (cont) The caring factors are used “in
relationship” with others and comprise the basis for the
“knowledge and skills” required to practice according to the
Quality-Caring Model.©
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Applications to PracticeThe Quality-Caring Model© provides
individual clinicians, teams of health professionals, educators,
and leaders with a relationship-centric approach to healthcare.
In doing so, it honors the interdependencies necessary for
human advancement.
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Many health systems are using the Quality-Caring Model©
to:provide a foundation for patient -centered careenhance
interprofessional practicefacilitate staff-directed practice
changesre-design professional workflowgenerate guiding
principles for human resource practicesguide nurse residency
programsimprove collective relational capacityrenew the
meaning of nursing workextend caring to others FIRSTbuild
relationships with community groupscreate a legacy of
caringsustain professionalismrevise nursing curriculabalance
“doing” with “being”
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Practice Improvement (Tools)The revised Caring Assessment
Tool© (CAT) (Duffy, Hoskins, & Seifert, 2007; Duffy, Brewer
& Weaver, 2012), a 27-item instrument designed to capture
patients’ perceptions of nurse caring, has been used with
success in several health care institutions (Duffy, 2013).
*
Practice Improvement (Tools, cont)Another instrument that was
adapted from the CAT© is the Caring Assessment Tool for
Administration (CAT-adm) (Duffy, 2002). This tool is a 39-item

questionnaire that assesses how nurses perceive nurse manager
caring behaviors and has become important in the assessment of
caring practice environments.
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Researching Caring Relationships Because the Quality-Caring
Model© provides a set of concepts, assumptions, and
propositions, questions generated from these theoretical ideas
can provide the basis for research. For example, the proposition,
“feeling ‘cared for’ influences the attainment of intermediate
and terminal health outcomes” (Duffy, 2013, p. 38) could be
tested by linking the results of an instrument measuring caring
with a set of specific patient outcome.
*
References
Duffy, J. (2002). The Caring Assessment Tool – Adm version.
In: J. Watson (Ed.), Instruments for assessing and measuring
caring in nursing and health sciences. New York: Springer.
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. (2009). Quality caring in nursing: Applying theory to

clinical practice, education, and leadership. New
York: Springer Publishing.
Duffy, J, Brewer, B., & Weaver, M. (2010). Revision and
Psychometric Properties of the Caring Assessment Tool
Clinical Nursing Research. May 17, published ahead of print.
Duffy, J. (2013). Quality caring in nursing and health systems:
Implications for clinicians, educators, and leaders. New York,
NY: Springer Publishing.
*
Chapter 21
Katharine Kolcaba’s Theory of Comfort
Developed by S . Gordon (2010)
Updated by D. Gullett (2014)
*
On completion of this chapter, students will be able to:
Describe Kolcaba’s Theory of Comfort care.

Identify the theorists who influenced the development of
Comfort theory.
Define the terms comfort, comforting care, comfort
management, and comfort interventions from the perspective of
Comfort Theory.
Discuss the meaning of Comfort Theory for practice.
Identify the different tools used to measure comfort.
Discuss the propositions of Comfort Theory and their
application to practice.
Define the theoretical definitions of diagram concepts for the
Comfort Theory.
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Overview of the TheoristKatherine KolcabaBorn/educated in
Cleveland, OhioReceived a diploma in nursingGraduated 1st
RN-MSN class at Case WesternJoined Faculty of University of
AkronAssociate Professor Emeritus at University Akron
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Overview (continued)Practice focused on gerontology and
dementia careFramework for dementia care (1992)Diagrammed
aspects of comfort (1991)Operationalized comfort as an
outcome of care (1992)Published book Comfort Theory and
Practice (2003)

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Overview of Comfort Theory (CT)Comfort defined
as:NounAdjectiveOutcome of intentional, patient/family-
focused quality care
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Comfort: To strengthen greatly
The need for comfort is basic.Persons experience comfort
holistically.Self-comforting measures can be healthy or
unhealthy.Enhanced comfort leads to greater productivity.
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Kolcaba Influenced byOrlandoSynthesized reliefNurses relieve
needsHendersonSynthesized ease 13 basic functions of human
beingsPaterson and ZderadTranscendence

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Four Contexts of Patient
ComfortPhysicalPsychospiritualSocioculturalEnvironmental
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Outcome of Comfort“The immediate experience of being
strengthened when needs for relief, ease and transcendence are
met in 4 contexts of experience.”
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Uses of Comfort Taxonomic StructureDetermine the existence
and extent of unmet comfort needsDesign comforting
interventionsCreate measurements of holistic comfort
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Propositions of Comfort TheoryPart I Effective comforting
interventions result in increased comfort for recipients (patients
and families) when compared to a preintervention baseline.Part
IIIncreased comfort of recipients results in their being
strengthened for their tasks ahead (health-seeking behaviors).
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Propositions of Comfort TheoryPart III:Increased engagement in
health-seeking behaviors results in increased Institutional
Integrity.
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Diagram ConceptsHealth-Care NeedsNeeds for comfort arising
from stressful health-care situations that cannot be bet by
recipients’ traditional support systems
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Diagram ConceptsComfort InterventionsNursing actions
designed to address specific comfort needs of recipients: social,
cultural, financial, psychological, environmental, and physical
interventionsIntervening variablesInteracting forces that
influence recipients’ perception of total comfortPast experience,
age, attitude, emotional state, support system, prognosis ,
finances, education, cultural background and the tonality of
elements in recipients’ experience.
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Diagram Concepts (continued)ComfortThe state that is
experienced immediately by recipients of comfort
interventionsHolistic experience of being strengthenedHealth-
Seeking Behaviors (HSBs)Broad subsequent outcomes related to
the pursuit of health (synthesized by Scholfeldt,
1975).InternalExternal
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Diagram Concepts (continued)Institutional
IntegrityCorporations, communities, school, hospitals, regions,
states, and countries that possess qualities of being complete,
whole, sound, upright, appealing, ethical, and sincere Best
PracticesHealth-care interventions that provide the best possible

patient/family outcomes based on empirical evidenceBest
Policies Basic protocols from procedures to access and care
delivery systems based on empirical evidence
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Types of Comforting InterventionsTechnical
Intervention:Specified by other
disciplinesMedicationsTreatmentsMonitoring schedulesInsertion
of lines
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Types of Comforting InterventionsCoachingSupportive nursing
actionsActive listeningReferrals to other members of the health-
care teamAdvocacyReassurance
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Types of Comforting InterventionsComfort Food for the
SoulExtra special, holistic and more time-consuming nursing

interventionsBack or hand massageGuided imageryMusic or art
therapyWalks outsideSpecial arrangements for family members
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How Comfort Theory Lives in PracticeBest PracticesElectronic
DatabaseBest Policies
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Tools Used to Measure ComfortGeneral Comfort
QuestionnaireComfort Behaviors ChecklistComfort
DaisiesVerbal Rating ScaleMany other tools can be found at the
following website
http://www.thecomfortline.com/webinstruments.html
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Summary“Comfort Theory provides the language and rational to
once again claim and document essential nursing activities
which are most beneficial to patients and family members in

stressful health-care situations.”
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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. (2003). Comfort theory and practice: A vision for
holistic health care and research (pp. 113–124).
New York: Springer.
Schlotfeldt, R. (1975). The need for a conceptual framework.
In: P. Verhonic (Ed.), Nursing Research (pp. 3–
25). Boston: Little, Brown.
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