Jurnal Comfort

F E AT U R E S
The Comfort Theory as a Theoretical

Framework Applied to a Clinical Case of
Hospital at Home
■ Carolina Puchi, BN ■ Tatiana Paravic-Klijn, PhD ■ Alide Salazar, PhD
The comfort theory was applied in the development of a nursing process for the clinical case of an older adult with
pneumonia treated under hospital at home. It was observed that the theory is easy to apply in the domiciliary
context and that it allows the implementation of a holistic care plan. KEY WORDS: comfort theory, home care
services, hospital-based, nursing process, patient comfort Holist Nurs Pract 2018;32(5):228–239
INTRODUCTION all levels, whereby wholeness, beauty, comfort, dignity,

and peace are potentiated to provide a high-quality care
Historically, the nursing field’s objective has been and healing environment. Nevertheless, it is Kolcaba,4
focused on assessing patient discomfort and who dedicated her studies to analyzing the concept
implementing interventions to relieve it. Thus, of comfort. She developed a diagram summarizing the
“comfort” has been one of the most studied and most relevant aspects of this concept,5 used comfort as
analyzed concepts by various theorists of this an objective of nursing care,5 contextualized comfort
discipline.1,2 in a mid-range theory,6,7 and demonstrated the theory’s
In general, “comfort” is a desirable result of nursing application in numerous intervention studies.8-11
care for patients and their families in both health In the nursing field, Kolcaba12 defines comfort as
care and academic contexts. Nevertheless, comfort “the state of having met basic human needs for ease,
is still a relative term that can have different meanings. relief, and transcendence.” Relief is the experience of
For some, comfort can mean sufficient pain control a patient who has had a specific need met, ease is a
to have a few hours of rest; for others, comfort can be state of calm or contentment, and transcendence is the
seen as not experiencing physical and mental tension.3 state in which one rises above problems or pain.7
More contemporary nurses also include the concept of According to this author, the contexts of nursing care
comfort within their theoretical approaches. Harmer2 recipients are physical, psychospiritual, social, and
states that comfort is an important part of nursing care environmental. When the 4 contexts are juxtaposed
and should consider not only the physical but also the with the 3 types of comfort, a taxonomic structure
mental dimension. Watson1 considers comfort to be a (matrix) is created from which the complexities of
fundamental element in the process of nursing care. In comfort are considered as a result.13
her Caring Theory and Caritas Processes, she suggests The comfort theory has been applied in diverse
that nurses should try to create a healing environment at health care contexts such as childbirth care,14
palliative care,15 long-term care,16 perioperative
Author Affiliation: Facultad de Enfermerı́a, Universidad de Concepción, nursing,8 reducing stress among university students,10
Concepción, Chile.
and reducing pain and levels of α amylase in the saliva
Carolina Puchi was the recipient of the National Commission for Scientific
and Technological Research (CONICYT).
of patients with dementia.17 As observed, despite
having used this theory in multiple health care
The authors have disclosed that they have no significant relationships with,
or financial interest in, any commercial companies pertaining to this article. situations, it has not yet been applied in domiciliary
Correspondence: Tatiana Paravic-Klijn, PhD, Facultad de Enfermerı́a, Uni-
contexts such as hospital at home (HaH). Hospital at
versidad de Concepción, Vı́ctor Lamas 1134, Concepción, Chile (tparavic@ home seeks to provide diagnostic levels, care, and
udec.cl). treatments similar to those provided in the hospital18
DOI: 10.1097/HNP.0000000000000275 to certain patients but within their own homes.
228
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Comfort Theory as a Theoretical Framework 229
The HaH method was unveiled in 1947 in New stretcher in the emergency department’s corridor; to
York, United States, as an extension of the hospital to his side, a large part of the service team was trying to
the patient’s home. According to the literature, the revive a patient, and on the other side, an unsettled
reasons for creating the first HaH unit in the world elderly man was screaming nonstop, apparently due to
were to decongest hospital wards and to provide pain. In the corridors, there were many students and
patients with a more humane and favorable relatives, and everyone seemed to be in a hurry and
environment for their recovery. Since then, there have stressed. The nurse examined Mr John’s clinical and
been multiple experiences of this type at a global socioeconomic conditions to determine whether he
level, in North America, Europe19,20 and in different met the criteria (Table 1) to be transferred to his home
Latin American countries such as Argentina, Chile, and start his CAP treatment under the supervision and
Venezuela, Brazil, and Colombia.21 care of the HaH18 health care team. After the
The HaH patients are those who, without the interview with Mr John and his wife, the nurse
provision of hospital care in their homes, would be commented that he did meet the criteria to be admitted
traditionally hospitalized in a hospital service to HaH and subsequently asked him whether he
according to their medical and/or social condition.22 agreed to start the treatment at his own home, to which
This care modality allows treatment at home for he responded: “Yes, please, any place is better than
patients with acute health conditions of a severity that this.” The next day, Mr John and his wife were already
would normally require hospitalization such as back at their home. The HaH team visited Mr John in
community-acquired pneumonia (CAP),23 urinary the morning and observed the following: the general
tract infections,24 and heart failure,25-27 among physical examination showed a heart rate of 110 beats
others.28,29 In HaH, nursing professionals are a per minute, blood pressure of 160/92 mm Hg,
fundamental and indispensable resource for the respiratory rate of 25 breaths per minute, and oxygen
provision of almost all health care. These saturation of 95%. The patient did not report pain and
professionals form a large percentage of the human did not have a fever or cough but was disoriented in
resources available to provide health services, from time and space. Blood tests showed mild leukocytosis
the patient’s entrance into HaH until his or her (<10.000 mm3 ) and the chest radiograph showed
discharge, and in care, educational, and management predominantly left alveolar condensation. With the
tasks.30 The intention of providing nursing care that aforementioned evidence, and along with the tests
optimizes patient comfort during HaH, as well as in a results, the HaH doctor confirmed that Mr John
conventional (inhospital) hospitalization, becomes the presented Group II Community-Acquired Pneumonia
main goal and function of nursing practice.16 It is even according to CRB-65.32
better if this task is performed from the perspective of
the nursing process (NP), an efficient and effective Theory of comfort applied to the care of a
method to organize knowledge of this discipline and patient with community-acquired pneumonia
clinical decision making in the provision of planned
care to patients.31 Therefore, the aim of this study was The Conceptual Framework of Comfort Theory33
to apply Kolcaba’s comfort theory in the development applied to the case study (Figure) incorporates the
of the NP for the clinical case of an older adult with a main concepts involved in this mid-range theory.
diagnosis of CAP treated under HaH. Kolcaba poses that this conceptual framework is more
easily understood if it is divided into 3 parts: health
care needs, health-seeking behaviors, and institutional
DEVELOPMENT integrity.34
Clinical case Health care needs are those arising from stressful
health care situations and those that traditional
Mr John, 80 years of age, went to the emergency systems of recipient support cannot meet. These needs
department with his wife, presenting a general health can be physical, psychospiritual, social, and/or
risk, confusion, and respiratory distress for 4 days. environmental.13 In the case of this study, multiple
The nurse of HaH program was notified of Mr John’s health care needs are observed, covering all the
arrival, so she went to the emergency department to dimensions proposed by Kolcaba, since the patient
evaluate the possibility of the patient’s admission to requires his blood pressure and breathing rate to be
HaH. The nurse observed that Mr John was on a stabilized as well as temporarily reorienting him
230 HOLISTIC NURSING PRACTICE • SEPTEMBER/OCTOBER 2018
TABLE 1. Clinical and Socioeconomic Criteria for Hospital at Homea

Clinical criteria
The process experienced by the patient can be treated at home.
The patients’ clinical situation is sufficiently compensated so that their worsening is very improbable.
Absence of active toxic habits.
Socioeconomic criteria
Voluntary patient and family acceptance of entrance into HaH
A primary caregiver is required, whether this is a relative or not, who collaborates with the health care team in caring for the
patient:
To perform basic patient care
To control and to administer oral medication
To perform simple tasks (capillary glycemia, temperature, etc)
To assist in the treatment (removal of sera, washing, administration of aerosol therapy, etc)
The patient’s home must meet minimum habitability requirements.
The patient must have a telephone line that allows contact if necessary.
The patient must normally or temporarily reside within the area of the HaH program.
Abbreviation: HaH, hospital at home.

a
Extracted from Alonso and Escudero.18
(physical needs); recovering privacy while being cared The third part of this conceptual framework is
for by the HaH health care team (psychospiritual and institutional integrity, defined as the quality and state
environmental need); continuing his health checks in of health care organizations in terms of being a
primary care; and involving his family in the provider of comprehensive, ethical, and professional
established care plan (social needs). care measured according to costs of care, hospital stay
Health-seeking behaviors are part of a broad duration, and patient satisfaction.34
category of results related to this search as defined by In the presented case, one way of assessing these
the recipient or recipients in consultation with the parameters would be an internal and external user
nursing professional. These behaviors have been satisfaction survey35 ; however, we will not address
conceptualized as internal behaviors, external this aspect further in the present study.
behaviors, and quiet death.13 For the purposes of this Subsequently to the application of this theory’s
study, the latter was eliminated as is not applicable to conceptual framework, the Taxonomic Structure of the
the analyzed case. Internal health-seeking behaviors Concept Comfort5 proposed by Kolcaba was used to
occur at the cellular or organic level, while external plan nursing objectives and interventions that are
behaviors are related to the external world of the care especially relevant for patients with CAP and who are
recipient such as self-care ability, functional capacity, cared for in their own homes by HaH (Table 2). The
or participation in health programs.6 data extracted from the clinical case were organized in
FIGURE. Conceptual framework of the theory of comfort applied to the clinical case under analysis: hospital at home. BP
indicates blood pressure; BR, breathing frequency; HaH, hospital at home; IV, intravenous; PHC, primary health care.
Adapted with permission from Kolcaba.33
TABLE 2. Taxonomic Comfort Structure Applied to the Clinical Case Under Analysis
Types of Comfort
Relief Ease Transcendence
Context in which comfort occurs

Physical Respiratory distress Eupnea The patient seeks to maintain his
Alveolar condensation Clean respiratory tract breathing system free of
Leukocytosis Blood pressure <140/90 mm Hg infection, to resume control of
Bronchial secretions his blood pressure at the health
Tachycardia center, and increase his physical
Tachypnea activity by walking.
Arterial hypertension
Psychospiritual Confusion Temporal-spatial orientation The patient is committed to his
Temporal-spatial disorientation Knowledge of his condition health, asks questions about his
Anxiety Faith in recovery treatment, and actively
Stress participates in his self-care when
Fear the health care team is not in his
home
Environmental Noisy and chaotic environment Suitable temperature The patient maintains a
Hard stretchers Comfortable bed therapeutic environment with his
Cold environment Room in good conditions wife according to his own wishes
Repetitive interviews Daily interview
Visual congestion of stretchers Bright and noise-free environment
Social Anxiety due to being far from home Family environment The support system provided by
Worried grandchildren Scheduled family visits the HaH health care team
Unfriendly health staff Fluid communication with the achieves the commitment of the
Complex medical indications health care team patient and his family to initiating
Health care team provides and maintaining a healthier
adequate education lifestyle
Abbreviation: HaH, hospital at home.

Adapted with permission from Kolcaba.7
the table according to the 4 contexts in which care simple and could be used in the domiciliary context.
occurs and the 3 types of comfort. Both the taxonomic structure and the conceptual
Once the conceptual framework of the comfort framework of the theory enabled an adequate
theory was presented for the case under study and its assessment of the presented case. In a simple way, it
data were organized in the taxonomic structure, the NP was possible to obtain a holistic view of the situation
was used. To do this, a table was created incorporating posed in order to propose the nursing care objectives
the 4 comfort needs (physical, psychospiritual, and subsequently, interventions that would enhance
environmental, and social), comfort interventions, the comfort of the care recipient and finally, the
which were subdivided into nursing interventions evaluation of these interventions through both internal
classification, intervention and comfort perception and external behaviors. The conceptual framework of
variables, and the health-seeking behaviors proposed the theory was applied without difficulty, which is
by Kolcaba.36 All this information was organized in consistent with what other authors have observed who
the 5 stages of the NP: assessment, diagnosis, have also used this theory in different health care
planning, implementation, and evaluation (Table 3). contexts,8-10,14,16,37 in general obtaining positive
results such as reductions in pain, stress, and anxiety,
increasing comfort levels.
DISCUSSION Hospital at home is a particular care unit that can
adequately manage care associated with the comfort
The aim of this article was to apply Kolcaba’s comfort of patients and their families, thus achieving holistic
theory in the creation of the NP for the clinical case of nursing care that goes hand in hand with multi- or
an older adult with a diagnosis of CAP treated under interdisciplinary work involving the entire health care
HaH. It was observed that the theory’s application was team.30 Instances occur in the home to assess all the
232
TABLE 3. Nursing Process Based on Comfort Theory and Applied to the Clinical Case in Analysis: Older Adult With Community-Acquired
Pneumonia Treated Under HaH
Comfort Interventions
Planification Nursing
Assessment Nursing Code/ Nursing Outcomes Interventions Intervention Comfort Evaluation
Comfort Needs Diagnosis Classification Classification Variables Perception Healthy Behavior
Physical 00032 Ineffective 410 Respiratory 3160 Airways Age/older adult Subjective perception: Internal conduct:
Respiratory distress Breathing Pattern Status: Airway Suctioning Educational level Mr John claims that Mr John will maintain
Alveolar condensation Domain 4 Patency 3140 Airways he can “breathe his hemodynamic
Bronchial secretions 802 Vital Signs Management with less difficulty.” balance throughout
Tachypnea 3350 Respiratory his hospitalization
Monitoring and discharge.
HOLISTIC NURSING PRACTICE • SEPTEMBER/OCTOBER 2018
6680 Vital Signs External behavior:

Monitoring Mr John must plan
health checkups.
Leukocytosis 00043 Ineffective 702 Immune Status 6550 Protection Objective perception:
Protection Against Infections Blood leukocytes
Domain 1 2314 Medication <10.000 mm3 .
Administration:
Intravenous
Tachycardia 00029 Decreased 802 Vital Signs 6680 Vital Signs Objective perception:
Arterial hypertension Cardiac Output 400 Cardiac Pump Monitoring Mr John is
Domain 4 Effectiveness 4040 Cardiac Care normotensive and
normocardial.
(continues)
Pneumonia Treated Under HaH (Continued)
Psychospiritual 00128 Acute 907 Information 4760 Memory Training Age/older adult Objective perception: Internal conduct:
Confusion Confusion Elaboration 4720 Cognitive Glasgow 15, Mr. John will maintain
Temporal-spatial Domain 5 916 Acute Confusion Stimulation autovalent patient a balance in his
disorientation 00257 Elderly Frailty 901 Cognitive 6440 Delirium (increases consciousness,
Syndrome Orientation Management functionality). attention,
300 Self-care: 4820 Reality knowledge, and
Activities of Daily Orientation perception during
Living 4820 Reality his hospitalization
Orientation and discharge.
1800 Self-care External behaviors:
support Mr John will increase
Domain 1 900 Cognition 5250 Decision-making his physical, social,
1008 Nutritional Support and mental
Status: Food and 4920 Active Listening functionality during
Fluid Intake 4720 Cognitive his hospitalization
Stimulation and discharge.
4820 Reality Mr. John will begin his
Orientation daily hydration
7460 Patient Rights orally without
Protection assistance.
4130 Fluid Monitoring Mr John will feel
1160 Nutritional tranquility during his
Monitoring hospitalization by
his physical and
verbal expression.
(continues)
Comfort Theory as a Theoretical Framework
233
234
Anxiety 00146 Anxiety 1302 Problems 5230 Coping HaH Previous Subjective perception:
Stress Domain 9 Coping Enhancement Experiences Mr John says he
Fear 00068 Readiness for 1402 Anxiety 5820 Anxiety Hospitalization feels “calmer at
Enhanced Spiritual Self-Control Reduction Previous home” and thinks
Well-Being 2002 Personal 5350 Relocation Experiences that “he will be
Domain 10 Well-Being Stress Reduction healthy again.”
1201 Hope 6040 Simple
2001 Spiritual Health Relaxation Therapy
4400 Music Therapy

6482 Environmental
Management:
Comfort
6485 Environmental
Management:
Home Preparation
5480 Clarification of
Values
5426 Spiritual Growth
Facilitation
5310 Hope Instillation
5420 Spiritual Support
(continues)
Environmental 00214 Discomfort 1608 Symptom 4470 Self-Modification Standardized Objective Perception: Internal conduct:
Noisy and chaotic Domain 12 Control Assistance protocols availability The nurse asks Mr John will verbally
environment 2010 Comfort Status: 5395 Self-Efficacy Mr John to rate his express, in his own
Hard stretcher Physical Enhancement comfort from 0 to words, physical,
Cold environment 2010 Comfort Status: 840 Position Change 10 before and after psychospiritual,
Repetitive interviews Psychospiritual 6482 Environmental the interventions. environmental, and
Visual congestion of 2012 Comfort Status: Management: social comfort.
stretchers Sociocultural Comfort External behaviors:
6040 Simple Mr John will increase
Relaxation Therapy communication with
202 Exercise the HaH health care
Enhancement: team during his
Extension hospitalization.
5420 Spiritual Support Mr John will receive
5820 Anxiety positive visits made
Reduction by his relatives
5390 Self-Awareness during his
Enhancement hospitalization.
5440 Support System
Enhancement
4920 Active Listening
7560 Visitation
Facilitation
7110 Family
Involvement
Promotion
(continues)
Comfort Theory as a Theoretical Framework
235
236
Social 00174 Risk for 1606 Participation in 5250 Decision-Making Methods of Subjective perception: Internal conduct:
Anxiety about the Compromised Health Care Support communication Mr John says that Mr John will verbally
remoteness of his Human Dignity Decisions 4410 Mutual Goal Family support system he feels “better express, in his own
home Domain 6 2605 Family Setting accompanied and words, physical,
Worried grandchildren 00126 Poor Participation in 4480 Self- cared at home.” psychospiritual,
Unfriendly health staff Knowledge Professional Care Responsibility environmental, and
Complex medical Domain 5 1805 Knowledge: Facilitation social comfort.
indications Health Behavior 5250 Decision-Making External behavior:
1804 Knowledge: Support Mr John will give
Energy 7110 Foster Family positive feedback
Conservation Involvement about the health
1837 Knowledge: 5510 Health education provided
Hypertension Education by the HaH team.
Management 5612 Teaching:

1842 Knowledge: Prescribed
Infection Activity/Exercise
Management Energy
1824 Knowledge: Management
Medical Care 5616 Teaching:
(Pneumonia) Prescription
Medication
5602 Teaching:
Disease Process
6540 Infection Control
6610 Hazards
Identification
5602 Teaching:
Disease Process
5618 Teaching:
Procedure/
treatment
Abbreviations: HaH, hospital at home.
comfort needs that patients may have to be met in integrating the physical, psychospiritual,
detail. Nurses have the opportunity to accompany environmental, and social dimensions. This is
patients and their families throughout the entire consistent with the aim of health care developed in
hospitalization process under the closest environment domiciliary contexts and even more so with the care
of these care recipients, their own home.30 that should be provided to older adults, users who
As mentioned before, different countries in the require special and interdisciplinary attention that
world possess this care modality; however, it is must always consider family support.3
important to mention that the way in which health care It is surprising that there is no homogeneous
is provided in each of these places may vary. Some application of this theory in the studies we found in
HaH units specialize in providing care to people with the literature. Some studies mention the taxonomic
acute pathologies (as in the clinical case presented), structure and the conceptual framework of the
while others focus on treating people with theory,37 while others use only one of the
decompensated chronic diseases or also caring for aforementioned structures40 or simply use all the
people in the final stage of their lives. There are structures indicated previously plus others created by
domiciliary hospitalization units that assist only adults the study authors in particular.34 According to the
and older adults, and other units treat only children, aforementioned text, it is relevant to unify criteria to
and so forth. Patients can enter into HaH from the apply Kolcaba’s work more uniformly and completely
hospital or directly from the community. Shepperd and in all clinical cases and possible care contexts as a way
Iliffe38 identified 2 main care modalities: HaH for to further facilitate the use of the theory. The work
early discharge (early discharge, early supported methodology used in this study could be replicated by
discharge, or facilitated discharge) and HaH schemes other authors in clinical cases of patients with
to avoid hospital admission. pathologies similar to CAP such as chronic obstructive
The early discharge or discharge facilitator model is pulmonary disease and asthma and even in patients
based primarily on interdisciplinary teams that have with very dissimilar diseases or health situations such
focused their efforts on the early discharge of patients as dementia, cardiovascular diseases, stress, and
with comprehensive care and domiciliary terminal diseases, among others, as detailed
rehabilitation needs. Various groups of early previously. To develop the application of the theory,
supported discharge in stroke cases have been able to we recommend beginning the assessment phase by
obtain better results than those from conventional considering the patient’s comfort needs.12 Then, make
hospitalization, not only at a functional level but also the nursing diagnoses according to North American
in mortality and prevention of institutionalization, in Nursing Diagnosis Association41 to then continue with
the short and long terms.39 In HaH as a substitute for the development of the care objectives (Nursing
conventional hospitalization (hospital admission Outcomes Classification) and to subsequently propose
avoidance or substitutive hospital at home), patients the comfort interventions that include the comfort
do not even occupy beds in a hospital ward, since they variables and both the subjective and objective comfort
are admitted directly from the emergency department perceptions to finish with the last phase of evaluation
after receiving the complementary tests needed to through reviewing patient’s healthy behavior using his
clarify the medical diagnosis.18 or her external and internal behaviors.5,6,36
To apply comfort theory in the domiciliary context,
the possible organizational and infrastructural CONCLUSIONS
differences must be recognized in order to adapt the
work methodology proposed by the authors of this The comfort theory can be applied in the context of
study to the reality of care. HaH care and facilitates the development of the NP
This article proposes the incorporation of the and the provision of holistic, person-centered nursing
taxonomic structure and the conceptual framework of care, incorporating family into the care plan.
Kolcaba’s theory from the perspective of the NP, since In the teaching field, we suggest that comfort theory
little development has been observed in this type of should be used in the NP during the academic training
study in the consulted databases.34,40 of new nurses with the aim of learning to create
The use of comfort theory in a different type of care nursing care plans centered on the person and family,
than the traditional one, such as HaH, is based on the consistent with the holistic view of this conceptual
fact that it allows the development of a complete NP, framework.
238 HOLISTIC NURSING PRACTICE • SEPTEMBER/OCTOBER 2018
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F E AT U R E S

The Comfort Theory as a Theoretical

INTRODUCTION all levels, whereby wholeness, beauty, comfort, dignity,

TABLE 1. Clinical and Socioeconomic Criteria for Hospital at Homea

Abbreviation: HaH, hospital at home.

Context in which comfort occurs

Abbreviation: HaH, hospital at home.

6680 Vital Signs External behavior:

4400 Music Therapy

Management 5612 Teaching:

Abbreviations: HaH, hospital at home.

REFERENCES 21. Molina E. Evaluacion de la calidad del cuidado de enfermerı́a en un

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