theory of comfort

THEORY OF

COMFORTKatharine Kolcaba

RN MSN PhD.

Presented by:

Mary Wilther Co& Mary Grace Monroy

What is the meaning

of COMFORT?

Webster (1990) defined COMFORT in several ways:

to soothe in distress or sorrow; relief from distress; a person or thing that comforts; a state of ease and quiet enjoyment, free from worry; anything that makes life easy; & the lessening of misery or grief by cheering, calming, or inspiring with hope.

Why are we making COMFORT so complicated?

“If your discipline is going to progress as a science, you must define your central terms precisely so you can understand each other & develop ways to conduct

research about them, all disciplines must define their concepts.” – Dr. Ray Kolcaba

(Kolcaba, 2003)

Patient’s Illness Experience & Treatment

Nursing Intervention + Empirical Knowledge

= Good Patient Outcome

Patient’s Illness Experience & Treatment

Nursing Intervention + Empirical Knowledge

= Good Patient Outcome

VS

BETTER Nursing Intervention (COMFORT) + FORTIFIED Empirical Knowledge (COMFORT)

= Best Patient Outcome (COMFORT)

1. Attributes of COMFORT (Siefert, 2002)

Communication Family & Relationships Functionality Self-characteristics Psychosocial & Physical Symptom Relief, States

& Interventions Spiritual Activities & States Safety & security

2. Consequences of Experiencing Comfort

(as cited in Siefert, 2002)

A sense of inner peace (Arruda et al., 1992) A pleasant experience (Kolcaba, 1992b) Feeling cared for (Larson, 1987) Relief of symptoms, such as pain relief (McIlveen &

Morse, 1995) Reduced suffring (Fleming et al., 1987) Decreased disequilibrium (Cameron, 1993) Absence of discomfort (Kolcaba, 1991; Morse, 1995)

TOPIC OUTLINEI. Credentials & BackgroundII. Theoretical SourcesIII. Concepts & DefinitionsIV. Conceptual FrameworkV. Empirical EvidenceVI. Metaparadigm ConceptsVII. Theoretical AssertionsVIII. Acceptance by the Nursing CommunityIX. Further DevelopmentX. CritiqueXI. Case Study

I. Credentials & BackgroundStated in Cu, J.E. (2013); Dowd, T. (2010); Kolcaba, K. (2003, 2010);

• 1944 Born in Cleveland, Ohio.• She received a diploma in nursing & practiced part time for many

years in medical-surgical nursing, long term care, & home care.

• 1987 Graduated in the first R.N. to M.S.N. class at the Frances Payne Bolton School of Nursing, Case Western Reserve University (CWRU), with a specialty in gerontology.

• While in school, she job shared in a head nurse position on a dementia unit, began theorizing about the outcome of

comfort.• 1987 Began teaching at The University of Akron College of Nursing.

I. Credentials & BackgroundStated in Cu, J.E. (2013); Dowd, T. (2010); Kolcaba, K. (2003, 2010);

•1997 Graduated with PhD Nursing from Case Western Reserve University.

• 1997 Developed web site called The Comfort LineEmail address: [email protected].

• 2003 Published her book Comfort Theory & Practice: A Vision for Holistic Health Care &

Research.

II. Theoretical Sources

1. Historical Background2. Concept analysis

A. Literature ReviewB. Purpose of Conceptual Analysis

3. Types of Comfort4. Four Contexts of Experience5. Taxonomic Structure of Comfort


• Kolcaba began her exploration of these topics about 15 years ago, after discovering the concepts through her nursing practice.

• She began her theoretical work as she diagrammed her nursing practice early in her doctoral studies.

• Held the position of a head nurse on an Alzheimer’s unit.• Her practice in dementia care helped her formulate the first comfort diagram.

1. Historical Background (The Concept of Comfort in an Environmental framework)

Discussed in Dowd (2010) and Kolcaba (2003)

II. Theoretical Sources1. Historical Background (The Concept of Comfort in an Environmental framework)

Three terms emerged as the foundation of her diagram:

•ED (Excess disabilities)Defined in dementia care as reversible symptoms that are undesirable & temporary extensions of a specific primary disability (ex. Agitation, fighting with others, refusal to cooperate, temper tantrums). Schwab, Rader, & Doan, 1985.•Facilitative environmentThe therapeutic milieu which is adapted to address the needs of frail patients (Wolanin & Phillips, 1981).•Optimum functionThe ability to engage in special activities on the unit (Wolanin & Phillips, 1981).

Illustrated in Kolcaba (2003)

II. Theoretical Sources1. Historical Background (The Concept of Comfort in an Environmental framework)

A Framework of Care for Gerontological Nursing

Facilitative Environment

Prevent/TreatPsychological Excess

Disabilities

Prevent/TreatPsysical Excess

Disabilities

Comfort

Optimum Function

(Kolcaba, K.,1992a; as cited in Kolcaba, 2003)

II. Theoretical Sources2. Concept Analysis

A. Literature Review

It started with an extensive study of the literature from disciplines:

• Nursing• Medicine• Psychology• Psychiatry• Ergonomics• Oxford English Dictionary [OED]

From the OED, Kolcaba learned that the original definition of comfort was “to strengthen greatly.”

(Kolcaba, 2003)



Historical accounts for comfort in nursing are numerous examples (Kolcaba, 2003) :

• Nightingale (1859, p.70) encouraged. “It must never be lost sight of what observation is for. It is not for the sake of piling up miscellaneous information of curious facts, but for the sake of saving life & increasing health and comfort” (as cited in Dowd, 2010).



• According to Kolcaba (1991) the concept of comfort has been recognized in several nursing theories, but it was not defined clearly (as cited in Siefert, 2002).

Peplau described comfort as a basic need along with food, rest, sleep, companionship & understanding. (p. 1305)

Orlando discussed assessing physical & mental comfort & delivering

comfort measures. (p. 1304)

Comfort is frequently a variable in caring models such as Watson's science of caring. (p. 1304)

Roy's adaptation model uses comfort measures to achieve psychological

comfort. (p. 1304)


B. Purpose of Conceptual Analysis

Contributors who influenced, supported & strengthened Kolcaba’s Comfort Theory (Kolcaba, 2003) :

• Morse• Benner• Rankin-Box• Donahue• Arrington & Walborn• Andrews & Chrzanowski• Hamilton• Gropper• Neves-Arruda• Larson• Meleis


B. Purpose of Conceptual Analysis

Summary of Insights of the contributors

• Comforting words & actions coming from the nurses & other members of the health care team are important for the interventions perceived as comfort measures by patients.• Comfort is a positive & dynamic state which the health care team can do more to enhance comfort.• Better patient outcomes produce with the strengthening properties of comfort.• To measure comfort one must incorporate its holistic nature.• Patterns of comfort care must be applied individually.• Comfort in all human beings is important.• Comfort-seeking behaviors can be constructive & destructive.• Health is comfort• Comfort is contextual• By enhancing patient’s comfort nurses are proud & makes them experts.• Manipulation of the environment enhances comfort.• Coordination of the health care team about comfort care is possible.

New insights about comfort were found and influenced Kolcaba’s work (Kolcaba, 2003)

II. Theoretical Sources3. Types of Comfort

Synthesized/Derived from:(Dowd, 2010)

Kolcaba’s Definition (Dowd, 2010; Kolcaba, 2003)

Relief – was synthesized from Orlando’s work (1961), who postulated that nurses relieved the needs expressed by patient (as cited in Dowd, 2010).

Relief - The state of a patient who has had a specific need met.

Ease – synthesized from the work of Henderson (1966), who described 13 basic functions of human beings to be maintained during care.

Ease - The state of calm or contentment.

Transcendence – derived from Paterson and Zderad (1975), proposed that patients rise above their difficulties with help of nurses.

Transcendence - The state in which one rises above one’s problems or pain.

II. Theoretical Sources4. Four Contexts of Experience

• Physical - Pertaining to bodily sensations & functions. • Psychospiritual - Pertaining to self-esteem, self-concept, sexuality, meaning in one’s life & one’s relationship to a higher order or being. • Environmental - Pertaining to the external surroundings, conditions & influences. • Social - Pertaining to interpersonal, family & societal relationships.

Contexts in which comfort occurs (Dowd, 2010; Kolcaba, 2003; Kolcaba, 2010)

II. Theoretical Sources5. Taxonomic Structure of Comfort

(Dowd, 2010; Kolcaba, 2003; Kolcaba, 2010)

Adapted with permission from Kolcaba, K. & Fisher, E. A holistic perspective on comfort care as an advance directive . Crit Care Nurs Q,18(4):66-76, (c)1996. Aspen Publishers.

II. Theoretical Sources5. Taxonomic Structure of Comfort

According to Dr. Ray Kolcaba (Dowd, 2010; Kolcaba, 2003; Kolcaba, 2010)

• A 12-cell grid • Resulted from juxtaposing three types of comfort (across the top) & four contexts of human experience (down the left).• Serves as a guide for nurses & health care providers.• Map of the content domain of comfort.

III. Concepts & DefinitionsIdentified in Dowd (2010) and Kolcaba (2010);

• Health care needs

Needs for comfort that arise from stressful health care situations which the patient’s natural support system cannot meet. These needs may be:

PhysicalPsychospiritualSocioculturalEnvironmental

Acknowledged in Kolcaba (1994) these needs became evident through (as cited in Dowd, 2010):

MonitoringVerbal ReportsNonverbal ReportsPathophysiological ParametersEducation & SupportFinancial Counseling & Intervention


• Nursing interventions Comfort measures design & implement by a nurse targeted to the health care needs. Enhancing the patient’s immediate comfort &/or facilitating subsequent desirable health seeking behaviors are the clear goal by using these interventions • Intervening variablesFactors that patients bring to the health care situation, they are interacting forces that nurses cannot change, & have an impact on the success of the interventions. Examples are (Kolcaba,1994; as cited in Dowd, 2010):Past experiencesAgeAttitudeEmotional stateSupport systemPrognosisFinances

EducationCultural backgroundTotality of elements in the recipients’ experience


• Health seeking behaviorsInternal or external behaviors in which the patient engages that facilitate health or a peaceful death (Schlotfeldt, 1975).

Internal behaviors (ex. healing, T-cell formation, oxygenation, etc.)

External behaviors (ex. observable behaviors such as working

in therapy, length of stay in hospital, ambulation, functional status).

• Institutional IntegrityStability and ethics of any hospital, health care system, region, state, or country. It produced evidence for best practices and best policies (Kolcaba, 2001).


• Best practicesEvidence based health care intervention use to produce best possible patient & family outcome. • Best policiesRanging from protocols for procedures & medical conditions to access & delivery of health care. These are from institutional or regional policies.

• ComfortThe immediate experience of being strengthened through having the needs for relief, ease or transcendence met in the physical, psychospiritual, environmental & social contexts of experience (General Comfort Questionnaire).

IV. Conceptual Framework

Figure: Conceptual Framework for Comfort Theory. (Copyright Kolcaba, 2007. Retrieved from www.thecomfortline.com, February 25, 2008).


Figure: A closer look at Kolcaba’s conceptual framework. (Retrieved from http://comfortcareinnursing.blogspot.com/2010/07/closer-look-at-kolcabas-

conceptual.html, July 9, 2010).


• The conceptual framework exhibits the different concepts interrelated in nursing care.

• The conceptual framework for comfort theory can be applied as well to other health care disciplines leading to holistic care for the patients.

• The ones who give comfort measures so client can feel relief, ease & transcendence are the nurses who play the central role in comfort care.

Explained in Comfort care in nursing (2010); Dowd (2010); and Kolcaba (2003)


Figure: A closer look at Kolcaba’s conceptual framework. (Retrieved from http://comfortcareinnursing.blogspot.com/2010/07/closer-look-at-kolcabas-

conceptual.html, July 9, 2010).

V. Use of Empirical Evidence

1. Measuring ComfortA. Comfort QuestionnairesB. Types of Comfort Questionnaires:

• Kolcaba’s CQs• CQs created by others• Foreign CQs

2. Summary of Experimental Design3. Acute Care for Elders: ACE Model

A. Holistic model for geriatric orthopedic nursing care

B. Research Outcomes


1. Measuring Comfort

A. Comfort QuestionnairesIdentified in Dowd (2010) and Kolcaba (2010).

• Chosen base on all attributes of comfort relevant to the research settings.

• Determine if a specific comforting intervention enhanced the comfort of a group of patients assessing each cell in the Taxonomic structure of comfort (comfort grid).

• Using the Taxonomic Structure (TS) of comfort as a guide to capture change in comfort over time

there should be at least two measuring points, usually three.

V. Use of Empirical EvidenceA. Comfort Questionnaires (Dowd, 2010; Kolcaba , 2010).

•From the General Comfort Questionnaire (Kolcaba, 1997, 2003; as cited in Dowd, 2010).

•Results are scored by reversing the coding of the negative items. For example, if the item states “I am fatigued” that is not comfort. Persons who respond strongly agree (6) will be coded (1), persons who respond (5) will be scored (2) & so on. You can do this when you enter your data into the data analysis spread sheet or the computer can specify which questions need to be reverse coded (Kolcoba, 2010).


B. Types of Comfort Questionnaires

• Kolcaba’s CQs

Identified in Dowd (2010) and Kolcaba (2010).

GENERAL COMFORT QUESTIONNAIRE

•Used the Taxonomic Structure of comfort as a basis. • Filed with the National Quality Measures Clearinghouse for several years.• Composed of 48 items questions (24- positive questions, 24- negative questions).• Covered the content domain of comfort (Kolcaba, 2003).• Items - in the “Present tense”• Comfort questions were “situational,” “State-specific” related to the present moment.• The word comfort was not used to avoid response bias.• Neutral tone- allowing for a wide range of response. (ex. I am able to walk around [speaks basic ability])• Four possible responses (no middle of the road choice).

V. Use of Empirical EvidenceB. Types of Comfort Questionnaires

• Kolcaba’s CQs


SHORTENED GENERAL COMFORT QUESTIONNAIRE The 28-item GCQ is in the same format as the original GCQ (48 items).

COMFORT BEHAVIORS CHECK LIST Developed as a last resort, data collectors are used to rate a patient’s apparent

comfort. While not as desirable as actually asking a patient about his or her comfort, the instrument can fill a gap regarding data collection in comatose, very frail (as in terminal), or cognitively limited patients.

COMFORT DAISIES This instrument was designed for use with young children.

PERIANESTHESIA COMFORT QUESTIONNAIRE RADIATION THERAPY COMFORT QUESTIONNAIRE URINARY INCONTINENCE AND FREQUENCY COMFORT QUESTIONNAIRE END OF LIFE COMFORT QUESTIONNAIRE - PATIENT

V. Use of Empirical Evidence B. Types of Comfort Questionnaires

• Kolcaba’s CQs


END OF LIFE COMFORT QUESTIONNAIRE - FAMILY The family instruments are designed to measure the comfort of the family member, NOT how they perceive the patient's comfort. The theory is that if the patient is comfortable, the family member will be comfortable also.

HOSPICE COMFORT QUESTIONNAIRE

HEALING TOUCH COMFORT QUESTIONNAIRE Adapted from the General Comfort Questionnaire

ADVANCE DIRECTIVES COMFORT QUESTIONNAIREThis scale correlates with the Healing Touch Comfort Questionnaire. Please

refer to Dowd, T., Kolcaba, K., Steiner, R. , & Fashinpaur, D. (2007). Comparision of healing touch, coaching & a combined intervention on comfort and stress in younger college students. Holistic Nursing Practice, 21(4), 194-202.


Types of Comfort Questionnaires

• Kolcaba’s CQs


VISUAL DISCOMFORT SCALE QUESTIONNAIRE

NURSES COMFORT QUESTIONNAIRE Developed after consulting & research surrounding magnet status for facilities. This tool can be used to measure the nurses' comfort as a result of a

institutional or smaller unit, change.


• CQs by Others


PEDIATRIC COMFORT ASSESSMENT Developed & used by Intermountain Healthcare.

PSYCHIATRIC COMFORT QUESTIONNAIRE

GLBT COMFORT QUESTIONNNAIRE This questionnaire is designed to explore issues related to the acquisition of self-comfort with sexual identity in gay, lesbian, or bisexual adults.

GENERAL COMFORT QUESTIONNAIRE - ADAPTED FOR DEAF CLIENTS

IMMOBILIZATION COMFORT QUESTIONNAIRE

CHILDBIRTH COMFORT QUESTIONNAIRE


• Foreign CQs


• URINARY INCONTINENCE & FREQUENCY COMFORT QUESTIONNAIRE (TURKISH)

• GENERAL COMFORT QUESTIONNAIRE (TURKISH) • PSYCHIATRIC COMFORT QUESTIONNAIRE (PORTUGUESE) • BREAST CANCER CQ (PORTUGUESE) • CAREGIVERS OF WOMEN W/ TERMINAL CANCER (PORTUGUESE) • GENERAL COMFORT QUESTIONNAIRE (ITALIAN) • GENERAL COMFORT QUESTIONNAIRE (SPANISH) • NURSES COMFORT QUESTIONNAIRE (SPANISH) • PERIANESTHESIA COMFORT QUESTIONNAIRE (FARSI) • PRIMIPARA PATIENTS AFTER PERINEAL CARE (VISAYAN) • COMFORT & ARCHITECTURE (PORTUGUESE)


2. Summary of experimental design Discussed in Dowd (2010)

• Dissertation - used an experimental design to test her theory. (Kolcaba & fox, 1999; as cited in Dowd, 2010).

• Holistic intervention - guided imagery (supported by a lot of literature).HOW?- they could listen everyday to an audio tape.

• Adapted the GCQ to measure their comfort at 3 time points.

• Collected 3 sets of data from 36 patients composed of the treatmentgroup & the control group.

Findings:She found out that the women who had received the guided imagery had increased comfort over time had a significant difference than the control group (Kolcaba, 2010, Video file).


3. Acute Care for Elders: ACE modelStated in Panno et al (2000).

A. Holistic model for geriatric orthopedic nursing care

• Started at University Hospitals of Cleveland (UHC) in Ohio (Palmer et al., 1994; as cited in Panno et al, 2000).

•Holistic model for geriatric orthopedic nursing care

• Provides an effective, proactive, inexpensive, combining it with Comfort theory (Kolcaba,1994 & 1995; as cited in Panno et al, 2000).



•Nurses & physicians observed that many elders admitted for an acute health episode or trauma, experienced a decline in function in activities of daily livings (ADL) during hospitalization that leads to the severity of their conditions. Poor outcomes resulted to a fear that older adults gave overly optimistic reports of their health states to avoid hospitalization (Eberle & Besdine, 1992; as cited in Panno et al, 2000).




• The pilot study at UHC demonstrated that patients who received the ACE intervention were more functional at discharge than patients discharged from a traditional unit (Landefeld et al., 1995; as cited in Panno et al, 2000).

• Study was repeated in a larger population in both UHC & in a community hospital setting in Akron, OH (Summa Health System) because of the promising results gathered.




• Physicians, nurses & patients were more satisfied with the care they had provided on the ACE unit (Counsell et al., 1997; as cited in Panno et al, 2000).

• Physicians more often rated the ACE Unit staff compared to usual care staff as excellent in caring for older patients & meeting the needs of older patients & planning for discharge (see Figures 2 & 3).


3. Acute Care for Elders: ACE modelStated in Panno et. al. (2000).


VI. Metaparadigm Concepts

Nursing is the intentional assessment of comfort needs, the design of comfort interventions to address those needs, and reassessment of comfort levels after implementation compared with a baseline.

Nursing

Recipients of care may be individuals, families, institutions, or communities in need of health care.

Patient

The environment is any aspect of patient, family, or institutional setting that can be manipulated by nurses, loved ones, or the institution to enhance comfort.

Environment

Health is optimal functioning of a patient, family, health care provider, or community as defined by the patient or group.

Health

VII. Theoretical Assertions

States that comforting interventions, when effective, result in increased comfort for recipients (patients and families), compared to a pre-intervention baseline. Care providers may also be considered recipients if the institution makes a commitment to the comfort of their work setting.

Part I

States that increased comfort of recipients of care results in increased engagement in health seeking behaviors (HSBs) that are negotiated with the recipients.

Part II

States that increased engagement in health seeking behaviors results in increased quality of care, benefiting the institution and its ability to gather evidence for best practices and best policies. She proposes that this type of comfort practice promotes greater nurse creativity and satisfaction, as well as high patient satisfaction.

Part III

◦ Comfort management or comforting care includes interventions, comforting actions, the goal of enhanced comfort, and the selection of appropriate health seeking behaviors by patients, families, and their nurses.

VIII. Acceptance by

the Nursing Community

This theory has been selected frequently by students and nurse researchers as a guiding frame for their studies in such areas as nurse midwifery, labor and delivery, cardiac catheterization, critical care, hospice etc.

Practice

For clinical practice, Kolcaba recommends asking patients or family members to rate their comfort from 0 to 10, with 10 being the highest possible comfort in their situation. This verbal rating scale is sensitive to changes in comfort over time.

The theory is appropriate for students to use in any clinical setting, and its application can be facilitated by the use of Comfort Care Plans available on Kolcaba's website. http://www.thecomfortline.com/

Education

The theory also provided ways for students to obtain relief from their heavy course work (by knowing where to find answers to their questions and clinical problems), to maintain ease with their curriculum (through trusting their faculty members), and to achieve transcendence from their stressors (with the use of self-comforting techniques).

An entry in The Encyclopedia of Nursing Research speaks to the importance of measuring comfort as a nursing-sensitive outcome (Kolcaba, 1992a). Nurses can provide evidence to influence decision making at institutional, community, and legislative levels through comfort studies that demonstrate the effectiveness of holistic comforting care. Measurement of comfort in large hospital and home care data sets is essential to add to the literature on outcomes research (Kolcaba, 1997, 2001).

Research

IX. Further Development

The methodical development of the concept resulted in a strong, clearly organized, and logical theory that is readily applied in many settings for education, practice, and research. Kolcaba has developed templates for instrument development to facilitate measures of comfort in additional new settings.

X. Critique

Some of the early articles such as the concept analysis (Kolcaba, 1991) may lack clarity but are consistent in terms of definitions, derivations, assumptions, and propositions.

Clarity

The Theory of Comfort is simple because it is basic to nursing care and the traditional mission of nursing.

Simplicity

Kolcaba's theory has been applied in numerous research settings, cultures, and age groups. The only limiting factor for its application is how well nurses and administrators value it to meet the comfort needs of patients.

Generality

The comfort instruments have demonstrated strong psychometric properties, supporting the validity of these questionnaires as measures of comfort that reveal changes in comfort over time and support of the taxonomic structure.

Empirical Precision

The theory predicts the benefit of effective comfort measures (interventions) for enhancing comfort and engagement in health seeking behaviors. The Theory of Comfort is dedicated to sustaining nursing by bringing the discipline back to its roots.

Derivable Consequences

Institutions have recognized the value of designing comfort environments for both their patients and their staff. Through Kolcaba's publications & Internet activities, the Theory of Comfort is known worldwide.

XI. Case Study

A 32-year-old African-American mother of 3 toddlers who is 28 weeks pregnant is admitted to the high-risk pregnancy unit with regular contractions. She is concerned because plans for her

family are not finalized. She has many comfort needs (1st table).

TAXONOMIC STRUCTURE OF COMFORT NEEDS FOR CASE STUDY

Context of Comfort Relief Ease Transcendence

Physical Aching back, early strong contractions

Restlessness and anxiety

Patients thinking, “What will happen to my family and to my babies?”

Pshycospiritual Anxiety and cension Uncertainty about prognosis

Need for emotional and spiritual support.

Environmental Roommate is a primigravida, room small, clean, and pleasant

Lack of privacy, phone in room, feeling of confinement with bed rest

Need for calm, familiar environmental elements and accessibility of distraction.

Sociocultural Absence of family and culturally sensitive care

Family not present, language barriers

Need for support from family, need for information, consultation

Types of Comfort CareAction or Intervention

Example

Standard comfort interventions

Vital signsLaboratory test resultsPatient assessmentMedications and treatmentSocial worker

Coaching Emotional supportReassuranceEducationListeningClergy

Comfort food for the soul

Energy therapy such as healing touch if it is culturally acceptableMusic therapy or guided imagery (patient’s choice of music)Spending timePersonal connectionsReduction of environmental stimuli

COMFORT CARE ACTIONS & INTERVENTIONS

REFERENCES:

Comfort Care in Nursing. (2010, July 9) A closer look at Kolcaba's conceptual framework [Web log post] Retrieved from http://comfortcareinnursing.blogspot.com/2010/07/closer-look-at-kolcabas-conceptual.html

Cu, J. E. (2013, June 27) Biography[Web log post] Retrieved from http://2013upoujohanearlman.wordpress.com/2013/06/27/biography-2/

Dowd, T. (2010). Theory of comfort. In M.R. Alligood & A.M. Tomey (Eds), Nursing theorists and their works, seventh edition (pp. 706-721). Missouri:Mosby Elsevier

Kolcaba, K. (2003). Comfort theory and practice: a vision for holistic health care and research. Retrieved from http://www.google.com.ph/books?

hl=en&lr=&id=nduGie_ouQkC&oi=fnd&pg=PR11&dq=katharine+kolc aba%27s+theory+of+comfort&ots=S8Z1zHPdHg&sig=5QFcYBXReQ6Ucll1kCY35ED8HMA&redir_esc=y#v=onepage&q=katharine%20kolcaba's%20theory%20of%20comfort&f=true

Kolcaba, K. (2010). Design and sample [Video file]. Retrieved http://www.thecomfortline.com/resources/media.html

Kolcaba, K. (2010). Education [Web log post]. Retrieved from http://www.thecomfortline.com/about/moreme.html

Panno, J. M., Kolcaba, K., Holder, C., & Hunt, A. H. (2000). Acute care for elders (ACE): A holistic model for geriatric orthopaedic nursing care. Orthopaedic Nursing, 19(6), 53-60. Retrieved from http://search.proquest.com/docview/195966556?accountid=36184

Siefert, M. L. (2002). Concept analysis of comfort. Nursing Forum, 37(4), 16-23. Retrieved from http://search.proquest.com/docview/195002256?accountid=36184

Websters New World Dictionary. (1990). NY: Pocket Books.