Research and Theory for Nursing Practice: An International Journal, Vol. 27, No.

2, 2013

Comfort Measures:
A Concept Analysis

Irene Oliveira, RN, BscN

University of Ottawa

Reference to the concept of comfort measures is growing in the nursing and medical
literature; however, the concept of comfort measures is rarely defined. For the comfort
work of nurses to be recognized, nurses must be able to identify and delineate the
key attributes of comfort measures.
A concept analysis using Rodgers’ evolutionary method (2000) was undertaken
with the goal of identifying the core attributes of comfort measures and thereby
clarifying this concept. Health care literature was accessed from the CINAHL and
PubMed databases. No restrictions were placed on publication dates.
Four main themes of attributes for comfort measures were identified during the
analysis. Comfort measures involve an active, strategic process including elements
of “stepping in” and “stepping back,” are both simple and complex, move from a
physical to a holistic perspective and are a part of supportive care. The antecedents
to comfort measures are comfort needs and the most common consequence of
comfort measures is enhanced comfort.
Although the concept of comfort measures is often associated with end-of-life
care, this analysis suggests that comfort measures are appropriate for nursing care
in all settings and should be increasingly considered in the clinical management of
patients who are living with multiple, chronic comorbidities.

Keywords: comfort measures; comfort; concept analysis; evolutionary

method; nurses

A
s early as 1860, Nightingale identified comfort as a primary goal of nurs-
ing care, since then, the concept of comfort has been studied (Morse,
1992), explored (Malinowski & Stamler, 2002; Tutton & Seers, 2003), and
analyzed (Kolcaba & Kolcaba, 1991; Lowe & Cutliffe, 2005; Siefert, 2002). The
importance of comfort as a goal and core value of nursing (Siefert, 2002) has
been well established; however, the comfort process and specifically the comfort
measures employed to achieve an outcome of comfort has yet to be systematically
explored. Furthermore, the concept of comfort measures has yet to be clarified
within the nursing discipline.

© 2013 Springer Publishing Company 95

http://dx.doi.org/10.1891/1541-6577.27.2.95
96 Oliveira

Although the concept of comfort measures is frequently used in practice, its use
in the nursing literature has slowly begun to develop as an emerging but immature
concept. Comfort measures as a concept is rarely defined suggesting that its mean-
ing is universally understood; at other times, it is described exclusively as physical
actions centered on relieving physical discomforts (Hodnett, 1996). Current con-
ceptualizations of comfort have evolved from a mainly physical focus, to include
a multidimensional, holistic definition (Lowe & Cutcliffe, 2005). An examination
of the health care literature on comfort measures is thus required to analyze the
common use of this concept and its evolution over time (Rodgers, 1989, 2000).
At times, the comforting actions of nurses (comfort measures) are so embedded in
practice that they are often unrecognized and invisible even to the nurses employing
them (Bottorff, Gogag, & Engelber-Lotzkar, 1995; Morse, 1992). If the comfort work
of nurses is to be acknowledged, nurses must be able to recognize and delineate
the key attributes of comfort measures. There is also a need to clarify this concept
to direct theory development, research, and inform practice about which measures
contribute to comfort and when these comfort measures are best employed for
maximum effect. A concept analysis using Rodgers’ evolutionary method (2000)
was undertaken with the goal of identifying the core attributes of comfort measures
and thereby clarifying this concept, without attempting to produce a definition or
determine what the concept is or is not (Doyle, 2008).

SEARCH METHODS

The use of the concept of comfort measures is common in nursing and medical
practice, therefore medical and nursing literature was selected as the primary
sample. Allied health literature was also included in the sample to determine the
relevance (if any) of comfort measures to other health disciplines. CINAHL and
PubMed databases were used to obtain literature from nursing, medicine, and allied
health disciplines. The keywords of “comfort measure(s)” were searched in the title
and abstracts of the electronic databases. The primary interest of the search was
to determine how and under which circumstances the specific term of comfort
measures was used in the health care literature, therefore surrogate terms such as
comfort strategies were not included in this analysis.
Changes in the historical context surrounding the use of comfort measures was
also of interest, therefore no publication date restrictions were applied and all lit-
erature including letters, editorials, research articles, and theoretical papers were
included. The only restriction placed was for English articles. The search yielded
204 articles. All articles with comfort measure(s) in their title were selected with
the belief that comfort measures would be the primary topic of the article (n 5 21).
Articles were randomly selected until a 35% sample was obtained. This is consistent
with the guiding principles of evolutionary concept analysis, which state that 20% of
the literature should be included in the analysis (Rodgers, 2000). Literature that may
be considered seminal to the subject of comfort measures were purposely selected
(n 5 7). Books with comfort measures in the title were selected for review (n 5 2).
Comfort Measures 97

DATA MANAGEMENT

Articles were coded with the year of publication and discipline to facilitate identifi-
cation of any interdisciplinary differences and similarities, and identify any changes
in the use of the concept over time. This is in keeping with the evolutionary method
(Rodgers, 1989, 2000) that asserts that concepts evolve over time and must be
analyzed within their sociocultural, situational, disciplinary, and temporal con-
texts. Articles were read at least once in order to allow for immersion in the work
and to obtain a sense of how each author used the concept of comfort measures
(Rodgers, 2000). Rodgers’ (2000) evolutionary method uses an inductive approach
when analyzing the literature to identify important attributes, contextual variables
(antecedents and consequences), surrogate terms, and related concepts to the
concept of interest (Figure 1). Data was recorded on separate sheets of paper titled
with each category of interest (antecedents, attributes, consequences, surrogate
terms, and related concepts) including supporting references, definitions, and state-
ments for later analysis.

Data Analysis
Data analysis occurred at the end of the data collection phase to avoid introduction
of researcher bias or premature closure of analysis because of perceived saturation
of content (Rodgers, 2000). A thematic analysis was performed for “each category
of data (attributes, contextual information, and references)” (Rodgers, 2000, p. 95).
Data was examined for consensus, with particular notations made of differences
across disciplines or areas of disagreement in the literature because these differences
may provide insight into how the concept is changing or developing. As data was
reorganized according to emerging themes, a more theoretical focus to the analysis
began to emerge (Rodgers, 2000) and ultimately four major attributes were identi-
fied: an active, strategic process involving elements of “stepping in” and “stepping
back”; comfort measures as simple and complex; from the physical to the holistic;
and comfort measures as supportive care. An ideal exemplar was not identified
because the application of the concept in a specific context may introduce bias
or distract from the usefulness of the concept in various settings (Rodgers, 2000).

1. Identify the concept of interest and associated expressions (including surrogate terms).
2. Identify and select an appropriate realm (setting and sample) for data collection.
3. Collect data relevant to identify:
a. the attributes of the concept; and
b. the contextual basis of the concept, including interdisciplinary, sociocultural, and temporal
(antecedent and consequential occurrences) variations.
4. Analyze data regarding the earlier-mentioned characteristics of the concept.
5. Identify an exemplar of the concept, if appropriate.
6. Identify implications, hypotheses, and implications for further development of the concept.

Figure 1. The evolutionary concept analysis process (Rodgers, 2000, p. 85).

98 Oliveira

RESULTS

The earliest references to comfort measures in the electronic databases involved stud-
ies examining the effects of primarily physical comfort measures on maternal labor
(Kaufmann, 1964; “Nursing Management of Pain,” 1977; Tryon, 1966). The number of
articles that mention comfort measures in either their title or abstract began to grow
in earnest in the 1990s and since then, have almost doubled over the last decade
(Figure 2). Although most articles are written from a medical or nursing perspective,
recent interest in comfort measures has also been demonstrated in physiotherapy
(Berger, 2010; Simkin, 1997; Simkin & O’Hara, 2002), respiratory therapy (Kacmarek,
2009), pharmacy (Bevans & Shalabi, 2004; Walker, Nachreiner, Patel, Mayo, &
Kearney, 2011; Walker, Peltier, Mayo, & Kearney, 2009), and social work (Waldrop &
Kirkendall, 2009). Comfort measures have also appeared in international studies or
literature from Taiwan (Chen, Wang, & Chang, 2001), India (“Nursing Management
of Pain,” 1977), Australia (Glare & Virik, 2001; Harrison, 2008; Mahar, Wasiak, Bailey,
& Cleland, 2008), Belgium (Carroll & Gompel, 2005), Hong Kong (Li, Chan, & Lee,
2002), and the United Kingdom (Jack, Gambles, Murphy, & Ellershaw, 2003; Walker
& Read, 2010) demonstrating a growing interest in this emerging concept.
Comfort measures appears most commonly in the context of end-of-life care
(LeGrand & Walsh, 2010; Waldrop & Kirendall, 2009; Walker et al., 2011; Walker
et al., 2009) but has also appeared regularly in the areas of maternal labor sup-
port (Berger, 2010; Chen et al., 2001; Hodnett, 1996; Kaufmann, 1964; McNiven,
Hodnet, & O’Brien-Pallas, 1992; “Nursing Management of Pain,” 1977; Simkin &
O’Hara 2002; Tryon, 1966; Walsh, Green, & Shields, 2007) and pain management
in pediatrics (Campbell-Yeo et al., 2009; Corff, Seideman, Venkataraman, Lutes, &

120

100

80

Articles Sampled
60 Articles Listed in
CINAHL & PubMed

40

20

0
1960–1979 1980–1989 1990–1999 2000–2011

Figure 2. Articles sampled from CINAHL and PubMed electronic databases.

Comfort Measures 99

Yates, 1995; Harrison, 2008; Schechter, 2008; Stinson & Nasser 2003). In addition,
there is a scarcity of research articles that explore the concept of comfort measures
from the perspective of the patient (Chen et al., 2001; Dildy, 1996; Li et al., 2002).
Comfort measures are commonly defined as interventions (Corff et al., 1995;
Kolcaba & Wilson, 2002; Simkin & O’Hara, 2002) or actions (Fleming, Scanlon, &
D’Agostino, 1987; Kaufmann, 1964; Kolcaba, 2003; Schoenhofer, 1989) employed in
a process to promote the comfort of patients. In this context, comfort measures are
described as active, decisive strategies or activities specifically designed (Fleming
et al., 1987; Happ, 2000; Kolcaba, 2003; LeGrand & Walsh, 2010) to achieve an
identified comfort goal or meet a particular comfort need (Kolcaba, 1991). Goals
of comfort may include the prevention or relief of discomforts, the enhancement
of comfort, and the support of patients in mastering (Bottorff et al., 1995; Simkin,
1997; Williams, 2006), enduring (Cameron, 1993), or transcending (Kolcaba, 2003)
those discomforts that cannot be completely relieved or removed.

ATTRIBUTES

An Active, Strategic Process Involving Elements of

“Stepping In” and “Stepping Back”
In analyzing the various types of comfort measures described in the literature
(Table 1), two types of processes for providing comfort measures were consistently
identified; these processes were called stepping in and stepping back.
Stepping in was identified when an individual, often a health care provider (HCP),
entered into a situation and engaged in the act of “doing something” or introducing
an intervention to facilitate comfort. These stepping in activities were not exclusively
physical in nature and could include psychological, sociocultural, spiritual, and
environmental comfort measures. Kolcaba (2003) describes three types of comfort
measures in her theory of comfort care that exemplify the process of stepping in;
these comfort measures include “technical comfort measures” or those measures that
impact physiologic functioning to maintain homeostasis or manage pain; “coach-
ing” to inform, reassure, and relieve patient anxiety (i.e., through the use of active
listening and positive reinforcement); and “comfort food for the soul” measures
(i.e., hand holding and massage) that may strengthen patients against discomforts.
This process of stepping in and introducing supportive comfort measures was noted
across many health care contexts including acute care (Kolcaba & Wilson, 2002),
maternal labor support (Simkin, 1997), and end-of-life care (LeGrand & Walsh, 2010).
By contrast, the process of stepping back was identified when a decision “not to do
something” was initiated; these interventions such as the withholding or withdraw-
ing of treatments were employed to enhance comfort through preventing potential
future discomforts (LeGrand & Walsh, 2010; Printz, 1988). Comfort through selec-
tive withdrawal and withholding was frequently cited in the physician and nursing
end-of-life literature (LeGrand & Walsh, 2010; Moneymaker, 2005). This process
of stepping back, however, was not considered a passive or inactive process; it
occurred through an active, strategic, planned process (LeGrand & Walsh, 2010) most
100 Oliveira

TABLE 1. Types of Comfort Measures

Physical and Physiologic Comfort Measures
Pharmacologic measures
  • Prescribing analgesics (narcotics), sedatives, anxiolytics, bronchodilators,
antisecretory agents, steroids, antibiotics, antiemetics, laxatives, local
anesthetics, epidurals, epidural blocks, antiepileptics, eye lubricants, and
antipruritics
  •  Not prescribing antibiotics or intravenous medications
  • Discontinuing nonessential medications or medications that are difficult
to swallow
  •  Discontinuing medications that are refused
  • Administering subcutaneous medications as needed for pain, agitation,
respiratory secretions, nausea, or vomiting
Medical treatments and physiologic measures
  Assessment, testing, and monitoring
    •  Physical systems assessment
    •  Ongoing assessment/reassessment of comfort needs
    •  Monitoring vital signs, blood chemistries
    •  Discontinuing vital signs unless information used to decrease discomfort
    • Discontinuing/limiting unnecessary treatments/interventions:
venipuncture, diagnostic imaging, procedures (central lines, dialysis),
daily weights
  Respiratory system
    • Administering oxygen, use of noninvasive ventilation, suctioning,
steam vaporizer
  Fluids, hydration, and nutrition
    • Providing hydration (giving water, oral fluids, crushed ice, sips),
nutrition as desired
    •  Withdrawing/withholding hydration, discontinuing artificial feeds
  Elimination
    •  Inserting an indwelling catheter, external catheter
    •  Discontinue indwelling catheter
    •  Prevent constipation, frequent voiding
  Integumentary system
    •  Dressing change orders, skin care recommendations, wound care
    •  Discontinue vacuum assisted closure (VAC) therapy
  Other medical orders/discussions
    •  Discussions about autopsy and organ donation
    •  Diagnose that patient is dying, establishing DNR status
    •  Administering blood transfusions
    •  Discontinuing compression stockings
    •  Preemptive warming in preanesthesia phase of surgery
    • Consulting multidisciplinary team for their expertise
(i.e., social worker, dietitian)
  Making Medical Devices More Comfortable
    •  Padded: procedure table, arm rests, nasal cannula
    •  Use of specialty beds/mattresses
    •  Reducing tension on lines and tubing
    •  Wax on fixation wires, warming instruments (i.e., speculum)
    •  Concealing medical instruments from patient’s view
Comfort Measures 101

TABLE 1. Continued
Physical measures
  Musculoskeletal
    • Use of labor equipment (rolling pin/ball to back, self-massagers, birth balls)
    • Sacral/back pressure, back/foot/hand rub, massage/heat massage,
hot water bottle
    •  Physical therapy, ambulation, positioning, range of motion
    •  Bedrest
    •  Discontinue: turn schedules, routine of getting patient out of bed
  Complementary therapy
    •  Intradermal water blocks, transcutaneous electrical stimulation
    •  Acupuncture, acupressure
    •  Hydrotherapy in maternal labor: bathing, showering
  General physical comfort measures
    •  Energy conservation, avoid talking
    • Applying heat/cold (hot water bottle, cool cloths, ice packs, compresses)
    •  Linen and underpad changes not related to hygiene
    •  Self-help comfort measures
  Integumentary and other symptomatic treatments
    •  Sitz bath
    • Emollient cream, petroleum jelly, poultices, balms, drying agents, anti-itch,
cornstarch
    • Keep area clean and dry, wear loose fitting clothing to avoid irritation/friction
  Hygiene and activities of daily living (ADL)
    • Sponging, bathing, grooming, oral care, assisting with hygiene, and ADLs
    •  Feeding a patient
  Neonate specific
    •  Rocking, pacifiers, nonnutritive sucking (bottle or pacifier)
    •  Facilitated tucking, co-bedding of neonates in one incubator, swaddling
    •  Held by parents or caregiver
Psychological, Behavioral, Emotional Comfort Measures
Breathing strategies
  • Deep breathing, breathing control, pursed-lip breathing, patterned breathing
  • Inspiratory/expiratory muscle exercises, breathing retraining, resting
respiratory muscles
Psychological/behavioral therapies
  • Relaxation exercises, biofeedback, behavior modification
  • Distraction, guided imagery, hypnotherapy, psychotherapy, play therapy, music
  •  Psychosocial support (therapy, counselling)
  • Attention focusing (i.e., visualization, counting breaths, focusing on an object)
Emotional support
  •  Continuous presence, increasing physical proximity, speak in soothing tone
  •  Encouragement, reassurance, coaching, motivation, positive reinforcement
  • Touch: hand holding, patting, stroking, caressing, embracing, reassuring
touch, caring touch, holding
  •  Encourage verbalization of: fears, pain
  •  Active listening, providing positive meaning to a situation
  •  Empathy, sympathy, commiseration, reminiscence
  •  Doula care

(Continued)
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TABLE 1. Continued
Informational support
  •  Explaining procedures, anticipatory guidance
  • Education, supplying information, answering questions, assisting patient to
make informed choices
  •  Providing nonmedical advice
Respect for patient as an individual
  •  Respecting right to privacy
  •  Including patient in decisions involving nursing care
  •  Calling patient by name
Sociocultural, Spiritual Comfort Measures
Family as a support
  •  Flexible visiting hours, allowing visitors
  •  Calling family/friends for patient
  •  Noninvasive ventilation (until family can visit at end-of-life)
Communication
  • Regular contact with physician and pastoral care as a means of providing
emotional support to patient and significant others
  •  Facilitating communication between patient and staff
  •  Postdischarge follow-up telephone calls
Health care worker supporting families
  •  Sharing stories/chatting with families
  •  Communication with family to discuss palliative goals of care
  •  Contacting family with changes in condition
  •  Guidance and emotional support for the patient’s family/partner
  •  Caring for family: ask after families’ needs, providing nourishment
Spiritual
  •  Contacting clergy/priest
  •  Providing spiritual care
  •  Facilitating prayer, attendance at religious services
  •  Supporting personal rituals that honor the dying patient
  •  Hold remembrance services as part of bereavement
Decision-making/informational
  •  Discharge planning
  •  Providing financial resources, paperwork support
  •  Discuss advanced care planning
  •  Discuss burial/cremation with families
  • Information about bereavement, connecting family with community
resources
Building therapeutic relationship
  •  Positive body language, optimism, energy, taking time
  •  Caring attitude, kindness, compassion
  •  Friendship, social conversations, gentle humor
  •  Respecting cultural practices

(Continued)
Comfort Measures 103

TABLE 1. Continued
Environmental Comfort Measures
Physical, environmental, and atmosphere
  •  Calming, soothing, quiet, peaceful environment
  •  Minimize sensory stimuli, adjusting lights, windows providing natural light
  •  Spacious, clean environment/free of barriers
  •  Comfortable chairs
  •  Cool air, fan, well-ventilated room
  •  Warm blankets, use of pillows
  •  Concealing/removing nonessential, medical equipment from view
  •  Uninterrupted time for sleep
  •  Privacy, private room
Environmental luxuries
  •  Entertainment provided in room
  •  Bed for family in each room
  • Family lounge in hospital (including vending machines, microwaves,
refrigerator)
Personalizing environment
  •  Shelves for cards/flowers
  •  Space for personal belongings (drawers and counter space)
  • Bring in personal items from home into the health care environment
(pillow, flowers, photographs, scents, lotions)
  •  Wearing own clothes
Home environment
  •  Restructuring the home environment for discharge
Notes. DNR 5 do not resuscitate.
Bold and italic used to differentiate major headings of comfort measures and
their subsections.

f­requently used to avoid introducing symptoms or avoiding nonbeneficial treatment.

Examples of stepping back included withholding intravenous fluids (Billings, 1985;
Printz, 1988) and withdrawing enteral/parenteral nutrition (Leuthner & Pierucci,
2001). The processes of stepping in and stepping back were not mutually exclusive
categories. In other words, a patient receiving end-of-life care may have interven-
tions and treatments introduced to provide relief from pain—treat dyspnea—yet
choose to withdraw fluids and withhold antibiotics. The blend of stepping in and
stepping back activities were largely based on HCP assessments and on patient and
family preferences (LeGrand & Walsh, 2010; Moneymaker, 2005).

Comfort Measures as Simple and Complex

Comfort measures have been described as simple (Billings, 1985; Desmond, 2005;
Mellick, Buckwater, & Stolley, 1992), basic (Carroll & Gompel, 2005; Kolcaba, 2003), and
part of “old fashioned” nursing care (Kolcaba, 2003). Often, simple comfort measures
referred to interventions meant to support the physical or hygienic care of patients
(Billings, 1985; Carroll & Gompel, 2005; Desmond, 2005). However, not all authors are
in agreement regarding the simplicity of comfort measures. Although Kolcaba (2003)
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classifies massage as a part of nontechnical nursing care, Ruffin (2011) points out that
massage has moved from a basic nursing comfort measure to a specialization in the
discipline of physiotherapy. Although appearing simple and not technologically com-
plex, physical comfort measures are highly valued by patients and have the capacity
to greatly affect comfort not only physically but also psychologically (Gauthier, 1999;
Kaufmann, 1964; Kolcaba, 2003; K. O’Brien, 1973). Simple comfort measures applied
without being individualized to patient preference, or administered in an uncaring
manner, can lead to discomforts (Chen et al., 2001; Dildy, 1996).
The complexity in the selection and effect of comfort measures is reflected in
the literature (Simkin, 1997). The selection and effectiveness of the use of comfort
measures relies on many factors such as the skill of the HCP employing the comfort
measure (Simkin, 1997), timing of the intervention (Simkin & O’Hara, 2002), benefits
and risks associated with the comfort measure (Simkin, 1997), and patient factors
(Kolcaba, 2003; Tryon, 1966).
Skills of the HCP and Timing of the Intervention.  Lack of knowledge, skill, or
practical experience in using a comfort measure can impact the effectiveness of
the comfort measure, decrease its usefulness, and increase risk associated with the
intervention (Simkin, 1997). The effectiveness of comfort measures depends in part
on the skill of the provider in knowing when a comfort measure would be most ben-
eficial to introduce (Hodnett, 1996; Kolcaba, 2003; Simkin, 1997; Simkin & O’Hara,
2002; Tryon, 1966). A patient may refuse a comfort measure, particularly if it is not
introduced at a suitable time (Kolcaba, 2003), requires too much effort (Tryon, 1966),
or the patient does not understand the usefulness of the measure (Tryon, 1966). Some
comfort measures are only appropriate to be offered at ­specific times (i.e., during
certain stages of labor), can be tiring, and may lose their effectiveness over time
(Simkin, 1997). Poorly timed comfort measures may cause more distress than benefit
the patient (Tryon, 1966). For example, the introduction of bathing early in labor may
slow the progression of labor and increase pain (Simkin & O’Hara, 2002). A provider’s
skill in employing more than one comfort measure in combination may result in an
enhanced effect on overall comfort that would not be possible using single tech-
niques (Bottorff et al., 1995; Simkin, 1997; Simkin & O’Hara, 2002). The benefit or
effectiveness of comfort measures can change over time (Hodnett, 1996; Salladay,
1999; Simkin, 1997). Because of the changing needs of patients, ongoing assess-
ments and reassessment of the effects of comfort measures are required (Hodnett,
1996; LeGrand & Walsh, 2010; Salladay, 1999; Stinson & Naser, 2003). HCPs must be
capable of continually evaluating the effects of comfort measures and varying their
use of different comfort measures to ensure ongoing patient benefits (Simkin, 1997).
Weighing the Benefits and the Risks of Comfort Measures.  Comfort measures
are not without risks or side effects (Simkin, 1997; Williams, 2006). The use of a
comfort measure should be customized to the individual and involve the weigh-
ing of the benefits of the comfort measure with the risks and, ultimately, the goal
of the comfort measure (Kacmarek, 2009; Simkin, 1997; Williams, 2006). In dis-
cussing the choices between a variety of comfort measures for maternal labor,
Simkin (1997) rates her comfort measures in reference to the amount of pain
relief, physical control, mental control, relaxation, safety, and cost; the patient
Comfort Measures 105

can then choose which aspects of the comfort measure is most important for her
(i.e., the desire for maximum pain relief may make patients more willing to risk
greater side effects). Not all comfort measures may be considered comfortable;
some patients may choose interventions that incur short term discomfort for long
term comfort or well-being. Kolcaba and Wilson (2002) provide the example of
a patient who is motivated to ambulate postoperatively and opts for a painful
ambulation short term to avoid complications, which will in turn improve long
term comfort and well-being.
Patient Factors and Context.  Patients will report varying responses to comfort
measures (Kaufmann, 1964; Kolcaba & Wilson, 2002). Kaufmann (1964) measured
patient physiologic responses to backrubs and concluded that the use of backrubs as
a comfort measure did not produce a standard predicted response. In other words,
patient responses to comfort measures were complex, dynamic, and individual
and involved not only physiologic responses, but were influenced by psychologi-
cal, sociocultural, and environmental factors (Kaufmann, 1964). Despite HCP’s best
interests, appropriate comfort measures may not be effective because of interven-
ing patient and contextual variables (Kolcaba, 2003). What is deemed comfortable
is not universal to all patients or agreed upon by all HCP (Wilt & Cutler, 1991).
Comfort needs may change over time (i.e., from time of diagnosis to treatment)
and context (i.e., comfort measures in end-of-life care are different than those for
a woman in labor). At times families and HCP may have conflicting views regard-
ing what is considered a comfort measure particularly in the context of end-of-life
care (Kacmarek, 2009; Salladay, 1999).
A comfort measure in and of itself is not inherently right or wrong (Salladay,
1999). The administration of intravenous hydration can be perceived as a comfort
measure in reversing dehydration in a curative care context, yet in end-of-life
care, where the benefit of hydration is generally viewed as futile, withdrawal or
withholding of intravenous hydration is perceived as a comfort measure (Billings,
1985). With advancements in technologies and health sciences, interventions that
are not traditionally seen as comfort measures in end-of-life care are now being
considered for palliation of advanced symptoms. Interventions such as surgery
(Dunn, 1994; Salladay, 1999) and palliative chemotherapy (Dunn, 1994) are being
offered to patients as interventions to promote long-term comfort. Kacmarek (2009)
proposes that noninvasive ventilation may be considered a comfort measure when
used in end-of-life care to treat acute respiratory failure, improve symptom control,
or postpone death for patients needing time to settle their affairs. As such, comfort
measures should be considered in each individual context whether they would
increase comfort or burden, and not automatically excluded because they may not
“fit” our working definition of comfort measures (Kacmarek, 2009; Salladay, 1999).
From a Physical to a Holistic Perspective of Comfort Measures.  A large part of
the comfort measures literature is focused on interventions directed toward the relief
of pain (Buchko et al., 1994; Corff et al., 1995; Stinson & Naser, 2003), symptom
management (Denenberg, 1997; B. O’Brien & Relyea, 1998; Williams, 2006), or the
physical comfort needs of patients (Frost & Frost, 1983; Hodnett, 1996; Walsh et al.,
2007). Although comfort measures may be used with a specific focus on achieving
106 Oliveira

physical comfort, it has been noted that often physical comfort measures have a
psychological effect on patients and can affect a larger response than expected on
total comfort (Kaufmann, 1964; Kolcaba & Wilson, 2002). A patient response to a
comfort measure is thus affected by a complex interplay of physical, psychospiritual,
sociocultural, and environmental factors that should be considered when imple-
menting comfort measures (Kaufmann, 1964; Kolcaba & Wilson, 2002).
A polarized view of comfort measures exists in the literature surrounding mater-
nal labor support. Some authors view comfort measures as uniquely physical in
nature (Hodnett, 1996), and other authors conceptualize comfort measures as
encompassing both physical and psychosocial supports (Simkin, 1997). Maternal
labor support has been described as an overriding concept that incorporates three
separate forms of support: emotional support, informational support, and physical
support (involving physical comfort measures; Hodnett, 1996; McNiven et al., 1992;
Walsh et al., 2007). From this perspective, comfort measures are uniquely physi-
cal in nature and do not involve psychosocial elements. By contrast, Simkin and
O’Hara (2002) conceptualize comfort measures holistically, as the larger overriding
concept under which labor support is classified. According to Simkin and O’Hara,
the comfort measure called labor support involves physical comfort, emotional sup-
port for patient and partner, informational support, and facilitated communication
between the mother and HCPs.
Recently, several authors have adopted a holistic perspective to conceptualize
comfort measures (Bottorff et al., 1995; Chipman, 1991; Simkin & O’Hara, 2002),
including not only the patient’s holistic needs but also the needs of the patient’s support
systems (Chipman, 1991; Fleming et al., 1987; Kolcaba & Wilson, 2002; Moneymaker,
2005; Simkin & O’Hara, 2002; Waldrop & Kirkendall, 2009). Waldrop and Kirkendall
(2009) describe comfort measures as individualized, “person-centered” care “focus-
ing on the interrelationship between physical, psychosocial and spiritual issues”
(p. 719). Comfort measures involve symptom management, family care, interpersonal
relationships, and interdisciplinary teamwork (Waldrop & Kirkendall, 2009). The con-
cept of family factored prominently in recent literature involving comfort measures.
Families are identified as important participants in the decision-making process in
selecting comfort measures (Billings, 1985; Fleming et al., 1987; Moneymaker, 2005;
Smith, 2007), are involved in administering comfort measures (Corff et al., 1995;
Simkin, 1997; Truman & Reutter, 2002), may act as a comfort measure (Fleming et al.,
1987; Kolcaba & Wilson, 2002), and may be the recipients of comfort measures
(Chipman, 1991; Simkin & O’Hara, 2002).
Several authors allude to the interdisciplinary nature of providing comfort measures
to meet the holistic needs generated at end-of-life (Fleming et al., 1987; LeGrand &
Walsh, 2010; Waldrop & Kirkendall, 2009). In their qualitative study exploring the
use of comfort measures in a nursing home environment, Waldrop and Kirkendall
(2009) describe the complementary roles of nurses, chaplains, social workers and
physicians in providing end-of-life care. LeGrand and Walsh (2010) describe an end-
of-life comfort measures protocol wherein physicians manage the physical symptoms
of patients while the emotional, psychosocial, and spiritual care needs are addressed
by other interdisciplinary partners such as pastoral care and social work.
Comfort Measures 107

Comfort Measures as Supportive Care

In general, comfort measures may be considered palliative or supportive in nature
(Stinson & Naser, 2003; Walker et al., 2011; Williams, 2006). Palliation is not syn-
onymous with death or end-of-life care. To palliate is to “relieve the symptoms or
effects (a disease, etc.) without curing” (Thomas Y. Crowell Company, 1974, p. 471).
Comfort measures in themselves do not provide a cure to disease, but often are
used supportively in managing and alleviating symptoms and is complementary
to medical treatment. A large part of the medical literature surrounding comfort
measures deals with the concept of “comfort measures only” (CMO) as a medical
order or category of care (Mortensen, Restrepo, Anzueto, & Pugh, 2006; Walker et
al., 2009; Walter et al., 1998). The physician order of CMO is often used to signify a
change in the goals of care from acute medical management used to prolong life, to
the goal of providing comfort for a patient at end-of-life (Hause, Kagan, Fleischman,
& Harvey, 1992; Mahar et al., 2008; Walker et al., 2011). In a retrospective chart
review, Walker et al. (2009) compared end-of-life care for those patients who died
in a community hospital with CMO orders and those who died without CMO orders.
The authors found that those patients with a CMO order had more frequent do not
resuscitate (DNR) orders, family meetings, and less antibiotic orders, otherwise
there were no significant ­differences in the prescribing of ­palliative care medication
between groups (Walker et al., 2009). Walker et al. (2009) concluded that a CMO
order alone was not sufficient in directing care at end of life.

ANTECEDENTS

The most frequently cited antecedent of comfort measures was the identifica-
tion of an unmet comfort need (Fleming et al., 1987; Kolcaba, 1991; Kolcaba
& Wilson, 2002; Waldrop & Kirkendall, 2009). Comfort needs were individual-
ized, multidimensional, and context driven (Fleming et al., 1987; Waldrop &
Kirkendall, 2009). Most comfort needs were brought about by discomforts, in
which case, comfort measures were directed at relief of pain, anxiety, and other
symptoms. In some cases, comfort needs were anticipatory (Bottorff et al., 1995;
Guaglianone & Tyndall, 1995; LeGrand & Walsh, 2010). A HCP’s expertise with
a diagnosis, procedure, or population allowed for anticipatory comfort mea-
sures to be in place, such as medication (LeGrand & Walsh, 2010) or emotional
support (Guaglianone & Tyndall, 1995), to prevent discomfort or to strengthen
patients in coping with the stresses of illness (Bottorrf et al., 1995) or procedures
(Guaglianone & Tyndall, 1995).
Holistic comfort needs were most frequently identified in the end-of-life lit-
erature, particularly in the treatment of cancer, where the patient experiences a
multitude of physical, psychosocial, and spiritual stressors and distress in facing
a life-threatening condition (Bottorff et al., 1995). Illness was the most frequent
stressor precipitating comfort needs followed by developmental changes such as
maternal labor. The comfort needs of patients must first be perceived, identified, or
108 Oliveira

acknowledged (Fleming et al., 1987; Kolcaba, 2003) by the HCP for comfort measures
to be employed. In the case of self-comfort measures, patients may recognize and
employ their own self-comfort measures (Berger, 2010).

Consequences
The effectiveness of comfort measures is infrequently measured or evaluated
from the perspective of the patient (Buchko et al., 1994). The consequences
of comfort measures are as varied and individualized as the comfort needs of
patients. Decreased anxiety (Bottorff et al., 1995; Guaglianone & Tyndall, 1995;
Mao, 2002), reduced suffering (Billings, 1985; Dildy, 1996; Fleming et al., 1987),
increased tolerance to procedures and equipment (Guaglianone & Tyndall, 1995;
Happ, 2000), creation of a soothing environment (Bottorff et al., 1995; Chipman,
1991; Tone, 1999), enhanced well-being (Guaglianone & Tyndall, 1995), and pro-
moting a sense of security (K. O’Brien, 1973; Simkin, 1997) have been cited as
consequences of comfort measures. The reduction or relief of pain and distress-
ing symptoms are often identified as the outcome of comfort measures (Buchko
et al., 1994; Simkin & O’Hara, 2002; Stinson & Nasser, 2003). In other cases, an
increased sense of control or mastery over discomforts has been identified as a
consequence of comfort measures, particularly when the source of discomfort
cannot be immediately relieved (Bottorff et al., 1994; Simkin, 1997; Williams,
2006). The most frequent consequence of comfort measures cited in the literature
is enhanced comfort (Billings, 1985; Kolcaba, 1991, 2003; Kolcaba & Wilson, 2002;
Moneymaker, 2005; Williams, 2006).

Surrogate Terms
Surrogate terms used synonymously with comfort measures include comfort or com-
forting strategies (Bottorff et al., 1995) and providing comfort (Fleming et al., 1987).

Related Terms
The term “comfort care” was frequently used interchangeably with comfort mea-
sures (LeGrand & Walsh, 2010; Waldrop & Kirkendall, 2009). However, it was evi-
dent that comfort care was most often used to define a particular philosophy for
end-of-life care whereas comfort measures were used in end-of-life care (without
being exclusive to this context). Supportive measures (Stinson & Naser, 2003), pal-
liative measures (Simkin & O’Hara, 2002), and conservative measures (Wickham,
Engelking, Sauerland, & Corbi, 2006) were also used interchangeably with the con-
cept of comfort measures, however, support only represents one aspect of comfort
measures and does not encompass the whole concept. The following section will
address the implications of the attributes, antecedents, consequences, and other
key findings that emerged from this analysis. It will also include a brief discussion
of the limitations of this analysis.
Comfort Measures 109

DISCUSSION

An analysis of the concept of comfort measures was approached with the intent
of identifying the defining attributes of this concept as used in the health care
literature. A potential limitation to the analysis may have occurred as a result of
random sampling. Literature that may have provided new insight on the concept
of comfort measures may have inadvertently been excluded because of sampling.
It is also important to highlight that lay literature and Web-based resources were
not included in the analysis, which may have restricted access to the perspective
of patients on comfort measures. Throughout the process of analysis, implica-
tions for theory, practice, research, and education were identified as a means of
further developing the concept of comfort measures (Rodgers, 2000). Specific
recommendations were also formulated to inform future work on this concept
within the nursing discipline.
There is confusion in the literature surrounding the synonymous use of the
concept of comfort measures with end-of-life care (Waldrop & Kirkendall, 2009).
The medicalization of the concept of comfort measures has led to a conceptual-
ization in which comfort measures is viewed in opposition to acute therapeutic
management and subsequently omitted from the plan of care (Glare & Virik, 2001)
or devalued (McIlveen & Morse, 1995; Morse, 1992). The association of comfort
measures with terminal care may have led to this concept’s limited use in other
contexts. A broadening of the conceptualization of comfort measures across health
care disciplines and its appropriateness for various care settings (Kolcaba, 2003)
must be pursued to ensure that comfort measures are provided concomitantly with
other therapeutic care.
In practice, CMO as a physician order has been found ineffective in directing
end-of-life care (Walker et al., 2009) because it only provides a vague idea of the
goals of care. Orders for CMO do not specifically direct care (Fleming et al., 1987;
Walker et al., 2009), or express the individual patient’s wishes or needs regarding
specific therapies and treatments (Townsend, 2011), leaving the decision of what
constitutes comfort measures up to the judgment of each individual practitioner,
which is contrary to the individualized nature of comfort measures. Standardized
end-of-life CMO order sheets have been devised, but are mainly focused on
pharmacologic symptom management (Walker et al., 2011). Care must be taken
that decisions to withhold or withdraw treatments are not made according to a
standard protocol but as the result of individualized decisions made in consulta-
tion with patients and families regarding the benefit and burden of each comfort
measure. Standardized CMO physician order sheets are focused on the physical
care of patients but do not address the holistic needs of patients and loved ones.
The implementation of pathways such as the Liverpool End-of-Life Pathway
(Ellershaw & Wilkinson, 2011) that incorporates aspects of holistic assessment
and management of comfort needs, while involving and supporting families in
the decision-making process, could ensure that comfort measures are addressed
from a holistic perspective.
110 Oliveira

More research that operationalizes and measures the effects of specific comfort
measures is required. Many of the studies involving comfort measures have been
conducted from the perspective of HCPs (Waldrop & Kirkendall, 2009), or through
observations by researchers (Fleming et al., 1987). Because of the individualized
nature and responses to comfort measures, more qualitative research is required to
identify the various comfort needs of patients according to setting, timing, patient
condition, and so forth. Descriptive and explorative studies would allow HCPs to
have a better understanding of what patients identify and prioritize as comfort mea-
sures. They would allow HCPs to become more familiar with the conditions under
which specific comfort measures should be employed. Future research should also
address the effects of technology on comfort measures. The need for this type of
research to be conducted was highlighted in several articles (Halm & Alpen, 1993;
Happ, 2000; Guaglianone & Tyndall, 1995; McNiven et al., 1992).
Kolcaba’s (2003) middle range comfort theory provides a useful theoretical
framework to conduct research on comfort measures. It also offers a range of
validated tools such as the General Comfort Questionnaire that can be used to
measure the effectiveness of specific comfort measures (Kolcaba, 2003). In her
theory of comfort, Kolcaba also outlines a taxonomic structure of comfort that can
be used as a template to organize an assessment of the comfort needs of patients
and develop specific comfort measures to meet these needs in ways that enhance
patient comfort. This concept analysis on comfort measures provides the beginning
of a descriptive middle range theory of comfort measures. The attributes identified
in this analysis could guide the development of this theory and further work on the
conceptualization of comfort measures—one that moves beyond the biomedical
framework and the restrictive definition of CMO that prevails in clinical settings.
If conceptualizations of comfort measures are to continue to broaden, comfort
measures as appropriate for application in all settings of health care must be included
as a part of general nursing and medical education. References to comfort measures
in fundamentals of nursing textbooks make brief, scattered references to comfort
measures, and mainly apply to the experience and minimization of the discomfort
of pain (Potter & Perry, 2009) and the application of physical and environmental
comfort measures (Wilkinson & Treas, 2011). Education on the strategic selection
of comfort measures based on a holistic assessment of the needs of patients with
ongoing evaluation of effectiveness is required. Interprofessional education on
comfort measures is recommended in order to meet the holistic needs of patients
that should extend to meeting the comfort needs of family and loved ones.

CONCLUSION

Historically, the concept of comfort in health care has been polarized on one end of a
continuum opposite to the concept of cure (McIlveen & Morse, 1995; Rome, Luminais,
Bourgeois, & Blais, 2011; Smith, 2007). In the early 1900s, when few medical treatments
were available, the prescription of physical and environmental comfort measures was
common. However, as advances were made in medical technologies such as surgical
Comfort Measures 111

procedures and medications, a devaluing of comfort measures as “simple” and non-

technical tasks became apparent (McIlveen & Morse, 1995). The cure versus comfort
dichotomy is no longer an appropriate model for nursing practice (Rome et al., 2011).
The current health care system is faced with an aging population living with multiple,
chronic comorbidities. Cure, for most of these patients, is not an option (Glare & Virik,
2001; McIlveen & Morse, 1995). For the aging population, the goal of comfort requiring
the skilled use of comfort measures may supersede the desire for aggressive medical
treatments (McIlveen & Morse, 1995). In fact, the future management of chronic comor-
bidities may lie in a “mixed management model” in which active “disease-modifying”
treatments are provided simultaneously with supportive care (Glare & Virik, 2001; Stuart,
2007). A broadening of the concept of comfort measures as interventions relevant to
all care settings is required and can be achieved through ongoing, creative strategies
directed at theory development, education, practice, and research.

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Acknowledgments. The author would like to thank Dr. Marilou Gagnon for her valuable com-
ments and feedback in preparation for this article as well as recognize Catherine McCumber
for her indispensable input and support.

Correspondence regarding this article should be directed to Irene Oliveira, RN, BscN, School of
Nursing, Faculty of Health Sciences, University of Ottawa, 451 Smyth Road, Ottawa, Ontario,
Canada. E-mail: ioliv102@uottawa.ca
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