Evolution of the mid range theory of comfort for outcomes research.

constructs. VOLUME 49 • NUMBER 2 NURSING OUTLOOK 88 Evolution of the Mid Range Theory of Comfort for Outcomes Research Kolcaba Figure 2. MR theory of comfort. Reprinted with permission from Aspen Publishers, Inc. Copyright © 1992 Aspen Publishers, Inc. Adv Nurs Sci 1992;15:1. The work of psychologist Murray in 1938 met these criteria. Because his theory was about human needs, it was applicable to patients who experience multiple stimuli in stressful health care situations. This was the deductive stage of theory development: beginning with an abstract, general theoretic construction and substructing downward to more specific levels that included concepts for nursing practice. Each nursing concept then could be operationalized relative to a specific research setting. Murray's intent was to synthesize a grand theory for psychology from existing lesser psychologic theories of his time. His concepts are found in Figure 2, lines 1, 2, and 3. Because comfort was perceived by patients, it was logically substructed under Murray's concept of "perception." "Obstructing forces" were substructed for nursing as health care needs; "facilitating forces" were nursing interventions, and "interacting forces" were intervening variables (line 4). This was the first and altruistic part of the theory, which stated that nurses identified unmet comfort needs of their patients, designed interventions to address those needs, and sought to enhance their patients' comfort, the immediate desired outcome. The second and practical part of the theory addressed the question? "Why comfort?" For nursing, unitary trend was substructed to health thema, which was further substructed to HSBs. HSB was Schlotfeldt's concept and represented the broad category of subsequent desired outcomes. She stated that HSBs could be internal, external, or a peaceful death. Some examples of HSBs are decreased length of stay, improved functional status, better response (or effort) to therapy, faster healing, or increased patient satisfaction. PATIENT COMFORT IN OUTCOMES RESEARCH: THE RETRODUCTIVE STAGE Retroduction is a form of reasoning that originates ideas. It is useful for the selection of phenomena that can be developed further and tested. This type of reasoning is applied in fields in which there are few available theories. Such is the case with outcomes research that, to date, is centered on collecting large databases for selected outcomes and relating those outcomes to types of nursing, medical, or institutional protocols. Adding a nursing theoretic framework to outcomes research would enhance this area of nursing investigation because theory-based practice enables nurses to design interventions that are congruent with desired outcomes, thus increasing the likelihood of finding significant results. Significant results on desired outcomes would provide data to respective institutions about nursing's "productivity" and the importance of nursing in the present competitive market. Murray's 20th century framework could not account for 21st century emphasis on institutional outcomes. However, with the use of retroduction, the concept of institutional integrity was added to the MR theory of comfort (Figure 3). Institutional integrity is conceptualized as the quality or state of health care corporations being complete, whole, sound, upright, honest, and sincere. The term has normative and descriptive components. Adding the term to the theory of comfort extends the theory to a consideration of the relationships between HSBs and institutional integrity. NURSING OUTLOOK MARCH/APRIL 2001 89 Figure 3. Comfort theory adapted for outcomes research. Box 1. Propositions in Theory of Comfort 1. Nurses identify patients' comfort needs that have not been met by existing support systems. 2. Nurses design interventions to address those needs. 3. Intervening variables are taken into account in designing interventions and mutually agreeing on reasonable immediate (enhanced comfort) and/or subsequent (HSBs) outcomes. 4. If enhanced comfort is achieved, patients are strengthened to engage in health-seeking behaviors. 5. When patients engage in health-seeking behaviors as a result of being strengthened by comforting actions, nurses and patients are more satisfied with their health care. 6. When patiencs are satisfied with their health care in a specific institution, that institution retains its integrity; institutional integrity has a normative and descriptive component. Box 2. Assumptions underpinning the Theory of Comfort 1. Human beings have holistic responses to complex stimuli. 2. Comfort is a desirable holistic outcome that is germane to the discipline of nursing. 3. Human beings strive to meet, or to have met, their basic comfort needs; it is an active endeavor. 4. Institutional integrity has a normative and descriptive component that is based on a patient-oriented value system. The theory now predicts that when patients engage fully in essential (comfort care). The concepts are (1) health care needs HSBs, such as their rehabilitation program or medical that include physical, psychospiritual, social, and environregimen, institutional integrity is enhanced also. Institutional mental needs that arise for patients in stressful health care situintegrity can be operationalized as patient satisfaction, ations; (2) nursing interventions, an umbrella term for successful discharges, cost-benefit ratios, or other outcomes commitment by nurses and institutions to promote comfort that are essential to institutional integrity. All of these concepts care (intentional care by nurses directed to meeting comfort are indicators of the integrity of the institution. The definineeds of patients); (3) intervening variables that will affect tions of underlined concepts (Figure 2) will be given; proposioutcomes (for example, institutions that are committed to tions that link the concepts are in Box 1, and assumptions that achieving improved outcomes through comfort care must underpin this theory are in Box 2. provide adequate staffing of registered nurses to meet comfort This theory describes traditional nursing practice as needs associated with existing patient acuity on any given unit); humanistic, needs-related, and holistic. Further, it relates prac(4) patient comfort, defined as the immediate state of being tice to institutional outcomes that make those nursing actions strengthened by having needs met in 4 contexts of human that promote soundness of health care institutions visible and experience (physical, psychospiritual, social, and environ90 VOLUME 49 • NUMBER 2 NURSING OUTLOOK Evolution of the Mid Range Theory of Comfort for Outcomes Research Kolcaba Evolution of the Mid Range Theory of Comfort for Outcomes Research Kolcaba Box 3. Evaluation of the Teory of Comfort 1. Concepts are specific for nursing. 1 Comfort has been called the essence of nursing. 2. Concepts and propositions are readily operationalized. The theory has been tested in many settings. The outcome of comfort is opera-tionaiized easily using the taxonomic structure of comfort as a guide for item generation. 11 3. The theory can be applied to many situations. Through The Comfort Line, students and researchers are working with the author to adapt the theory to micro-level situations. 4. Propositions range from causal to associative. Propositions generated from the theory are shown in Box 1 and have the desired range. 5. Assumptions fit the theory. The theory is holistic and needs based and theoretically empowers patients to engage in health-seeking behaviors. Institutional integrity is an important theoretic link to outcomes research. 6. The theory is relevant for potential users of the theory. Nursing students learn this theory easily and apply it to practice and research. 7. The theory is oriented to an outcome chat is important to patients. Qualitative research indicates chat patients want, and often need, their nurses to assist them in meeting their comfort needs. 8. The theory entails a nursing-sensitive outcome. A traditional goal of nursing has been to attend to patient comfort. Patients expect this from nurses and give them credit when comfort is delivered. Through deliberate actions of nurses, patients receive what they need and want from their nurses. This theory explicates how and why to do so. mental) that can be operationalized by the general comfort questionnaire; (5) HSBs, defined as patient actions of which they may or may not be aware and which may or may not be observed that are predictors or indicators of improved health (categorized as internal [eg, healing, immune function], as external [eg, functional status, perception of health], or as a peaceful death; HSBs are more accurate indicator of nurse productivity than the number of patients cared for; and (6) institutional integrity (previously defined). The definition of comfort has grown from its early definition9 to one that incorporates the strengthening component of comfort, the immediate desired outcome of nursing care. It is this strengthening component that facilitates patients' increased engagement in HSBs, the subsequent outcome. These subsequent HSBs, as indicators of nurse productivity, are of great interest to health care administrators because they facilitate decreased lengths of stay, successful discharges, and improved public relations when patients and families are happy with their health care. The 3 parts of the theory can be tested separately, or all concepts can be tested in one study. Path analysis can indicate which variables have direct or indirect influences on desired outcomes. Now, by linking HSBs to institutional integrity in an explicit way, outcomes research is theoretically based in nursing. CRITERIA FOR ADEQUACY OF MR THEORIES The expanded theory of comfort meets the following criteria for MR theory: (1) its concepts and propositions are specific to nursing, (2) it is readily operationalized, (3) it can be applied to many situations, (4) propositions can range from causal to associative, depending on their application, and (5) assumptions fit the theory. These are characteristics of good MR theory as described by Whall.' Nolan and Grant suggested 2 other criteria if a theory is to be applied in practice: (6) it should be relevant for potential users of the theory (ie, nurses) and (7) it should be oriented to outcomes that are important for patients, not merely describe what nurses do. In addition, (8) this theory describes nursing-sensitive phenomena that are readily associated with the deliberate actions of nurses, and their productivity, and are theoretically related to enhanced institutional integrity. An evaluation of how the theory of comfort meets those criteria is presented in Box 3. UTILIZATION OF THE MR THEORY OF COMFORT Accessibility of the theory on the "World Wide Web has led to many applications of the theory of comfort. Currently, comfort studies are being conducted with many different populations, all using the MR level to generate practice-level comfort theories for specific situations. These situations include, among others, midwifery, postpartum care, a burn unit, nursing homes, medical-surgical units, angiography, hospice, perioperative care, ambulatory surgery, osteoarthritis, and parish nursing. In irs simplicity, the theory of comfort has found popularity. It is hoped that the theory also will generate outcomes research rhat is strengthened by being rooted in a testable nursing theory. SUMMARY The construction of Kolcaba's theory of comfort was the result of different methods for theory development applied during different stages of the process of theory development. In review, those methods were (1) inductive explication of the componenrs of a specific practice, (2) concept analysis and operationalization of components that were yet undefined, (3) deduction from a more general organizing theory with relocation of the main concepts, and (4) retroduction to bring to the model a concept for outcomes research. Because of the congruence of this theory with evidence-based practice, it is an example of a new orientation for theories, from an emphasis on what nurses do ro an emphasis on outcomes in large patient populations. Nursing theory, explicit in nursing practice and research, must he congruent and relevant for proactive evidence production and collection. It is expected that nurse researchers will continue formulating or refining grand theories and developing new MR theories. At least some of the classic theories will be revised, modified, and qualified. This building and adapting of theories at both levels will drive new science. As nursing science NURSING OUTLOOK MARCH/APRIL 2001 91 Evolution of the Mid Range Theory of Comfort for Outcomes Research Kolcaba accumulates knowledge at the levels of observation and evidence, global thinking may give way at times to MR theory, which is grounded in observable concepts. Efforts such as these are particularly important throughout this current evolution in health care. Nursing theory, explicit in nursing practice and research, must be congruent and relevant for proactive evidence production and collection. At some future time, nurse theorists can harvest the fruits of MR theories, such as the theory of comfort, and return to grand theorizing from a newly conceived and informed point of view. •