1. Heard, Pamela Lichtenberg PhD, RN
  2. Hartman, Sherry DrPH, RN
  3. Beal, Brent D. PhD
  4. Bushardt, Stephen C. DBA


Nurses first focus on patients and often forget about caring for themselves. This article examinesthe issue of burnout and describes how nurse comfort can combat it.


Article Content

The nursing profession is facing new challenges and greater demands than ever before with more government regulation for efficiency, declining hospital budgets, and increasing responsibilities without sufficient support. The healthcare industry is in crisis, and the nation struggles with how to pay for rising healthcare costs and the need to expand healthcare to those who aren't currently insured. An aging population drains Medicare while our government operates with the largest deficit in the history of the nation. These pressures are creating greater stress for practicing nurses called on to cover more patients, work more flexible hours, and assume more responsibility and supervision of other healthcare professionals, while their own job security erodes. The consequences to the nursing profession are costly: higher turnover, lower job satisfaction, and burnout, where the professional nurse either leaves the profession or remains with low self-esteem, apathy, alienation, and depersonalized relationships with patients.1-7

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

Various contextual approaches from better administration, improved compensation, autonomy through job redesign, and professional development opportunities have been suggested to help end burnout.8 Another option to help end burnout is nursing comfort. The construct of comfort presents a more holistic understanding of the psychic conditions leading to burnout in nursing professionals, in contrast with efforts that focus on mechanical changes such as better scheduling, enhanced job descriptions, improved training, and better selection by schools of nursing.1,9-14


Caring about nurse burnout

Burnout is a phenomenon defined as physical and emotional exhaustion and involves a negative attitude toward one's job and/or profession.2 Research on burnout has been conducted extensively over the past 3 decades, and studies have explored burnout in healthcare professionals.1-4,7,13,15-17 Burnout is characterized by low self-esteem, apathy, alienation, callousness, mental exhaustion, psychosomatic complaints, anxiety, inability to concentrate, depression, job dissatisfaction, and depersonalization of patients.2-6 Burnout is an insidious process and, overtime, may cause mental fatigue, feelings of frustration, decreased productivity, and emotional exhaustion.4 It's also been linked to increased propensity to illnesses, both physiologic and psychological, as well as lack of motivation and poor health behaviors.18,19


Research has documented that nurses are more susceptible to burnout than other healthcare professionals.1 The particular study that documented this consisted of 43,329 nurses from the United States (Pennsylvania), Canada, England, Scotland, and Germany. Nurses from the United States (41%) reported higher levels of dissatisfaction with their jobs. Using the Maslach Burnout Inventory, researchers found that nurses had higher burnout scores than other healthcare professionals in the study. Furthermore, burnout in nurse managers and nurse administrators manifested in negative behavior, creating an unhealthy work environment that may eventually lead to burnout and job dissatisfaction in clinical nurses.1,6 Job satisfaction was much lower among hospital nurses compared with the average for the entire U.S. job market. Specifically, researchers found that nurses in all five countries under the age of 30 planned to leave their jobs within the next year (Germany, 26.5%; Canada, 29.4%; United States, 33%; Scotland, 46%; and England, 53.7%).1


Additional research presented a review that included examples of the deleterious effects of stress and burnout on nurses.20 Based on this extensive assessment, it was concluded that there was little research related to the effects of nurse burnout on patient care outcomes.


What's comfort?

The success of dedicated professionals depends, in part, on an environment that nurtures and fosters their well-being. A nonsupportive environment often results in employees who have a lack of engagement with their work and a sense of disconnection with the organization's goals and mission.13 The resulting disassociation may lead to instability of the organization because poor morale, increased stress, and burnout in some employees will eventually erode organizational effectiveness.13


Historically, the primary focus of nursing has been meeting the needs of patients by providing care or comfort to the patient.21 Comfort is a term that's been equated to care. Comfort is a major aspect of patient care; reference to comfort is evident in nursing literature as early as Nightingale's Notes on Nursing.2,22,23 The specific instructions in Nightingale's book were directed to the nurse to assist the patient in achieving optimal health through improving or enhancing the patient's physical and mental comfort. There was no mention of ways to ensure or enhance nurse comfort. As such, the needs and support or comfort of the nurse are often overlooked.


Nurses deserve the same comfort and care that they provide to their patients. They also deserve the comfort of a professional environment in which to work.24 Traditionally, nurses have looked to their administrators for the comfort of a good working environment with appropriate compensation, professional development opportunities, and autonomy. Nurses must find ways to nurture themselves even in undesirable conditions if they're going to fully combat the negative consequences of burnout.8,25


Recognizing the importance of nurse comfort for the outcome of patient comfort, a nurse comfort questionnaire was created.24 Identifying and learning ways to increase nurse comfort at work is one method of helping nurses stop the negative cycle of increased burnout and turnover. As such, comfort is a major aspect of the care of the nurse and it should be addressed before patient care may be envisioned. One way to increase nurse comfort is for nurses to gain control of their negative thoughts and learn techniques to prevent stress overload, such as changing negative thinking into positive thinking. A powerful technique for achieving positive thinking is the use of mindfulness.5 Other approaches can involve self-esteem training, stress management, and exercise programs.


Curing nurse burnout

Comfort is both physical and mental and means to soothe, console, reassure, ease, placate, and relieve.26 It also means to have peacefulness, contentment, relief from discomfort, and pleasure. It's an enduring state of ease and peaceful environment, renewal, being strengthened and invigorated, and cessation of discomfort. Nurses provide and facilitate comfort with patients and their families through comfort measures. When families and/or patients are strengthened by the comfort measures of nurses, they're more equipped to engage in health-seeking behaviors.


The state of comfort is strengthened by having physical, psycho-spiritual, social, and environmental needs met.27 There are three types of comfort: relief, ease, and transcendence. Relief comfort is the state of an individual who has had a specific need met. Ease comfort is the state of calm. Transcendence comfort is the state in which one rises above pain. Comfort occurs when the three comfort needs are met in the physical, psycho-spiritual, sociocultural, and environmental contexts. Physical comfort involves all the physiologic aspects of an individual. Psycho-spiritual comfort involves self-esteem, identity, sexuality, and the relationship or lack of relationship with a higher being. Social comfort is derived from family, societal, and interpersonal relationships and family traditions, rituals, and religious practices. Environmental comfort involves the external aspect of experiences, such as room color, light, sound, and odor.28


The theory of comfort was used to develop the nurse comfort questionnaire.28 If nurses are satisfied and "comforted," they'll perform better and be more committed to their patients and the institution. Enhanced nurse satisfaction has a direct positive relationship on patient satisfaction. There are several other advantages to using the theory of comfort in practice. The theory is broad in spectrum and can be applied to patients, as well as all healthcare providers. Much of this is done by including the following in practice: comfort rounds with patients, employee performance reviews, improvement of work environments, outcomes research, and comfort interventions, including implementation and evaluation.


More than a theory

A review of alternative therapies in nursing was conducted, specifically the theory of comfort, in the nursing care of women experiencing the discomfort of childbirth.24,29 The author suggested that since nursing has been considered a holistic practice, any alternative therapy-in particular, the theory of comfort-may guide the practice of nursing when dealing with patient discomfort, as in labor and delivery. (See Table 1.) The author pointed out that the theory of comfort has all the qualities of the common beliefs underlying alternative therapies as listed in the Nurse's Handbook of Alternative and Complementary Therapies.29 As such, the theory of comfort provides a framework for the enhancement of the positive outcomes of the experience of childbirth. Theories such as the theory of comfort provide more than just comfort from physical pain, but also address spiritual, emotional, psychological, and social experiences.

Table 1: Advantages ... - Click to enlarge in new windowTable 1: Advantages of comfort theory in practice

Another study examined the theory of comfort and its application to pediatric nursing.30 The authors wrote that nursing often focuses on the absence of discomfort or pain rather than a more positive focus on increasing comfort. The theory of comfort was used to map out various feelings and reactions to discomfort in the pediatric patient.


Using the four contexts of experience (physical, psycho-social, sociocultural, and environmental) along with the three types of comfort (relief, ease, and transcendence), nurse researchers may create a grid with which to plot a patient's degree of comfort or lack of comfort. A case study utilizing this type of grid is presented in the pediatric research article along with an example patient comfort scale.30 The authors reported that further research in pediatric comfort would include research related to interventions that might improve or increase a child's holistic comfort level.


A different study investigated the effect of guided imagery on patients undergoing radiation therapy.31 Potential participants were women who had early stage breast cancer. Participants were between the ages of 37 and 81 with the mean of age 58. Most of the women in the sample were married (66%). Participants were asked to complete the radiation therapy comfort questionnaire before the intervention and before radiation, 3 weeks after the intervention, and 3 weeks after completion of radiation therapy. They also completed the state anxiety inventory before the intervention and radiation.


The intervention consisted of listening to a guided imagery tape once a day during the entire course of the study. Certain participants were also asked to keep a diary of their progress and thoughts related to the relaxation tapes during the study and all received a phone call from the researcher once weekly. Participants were randomly assigned to the treatment and control group. Preintervention anxiety scores among the two groups were not significantly different and therefore had no adverse reaction on the results of the study. The authors reported a significant increase in comfort level in the treatment sample as compared with the control group. They also reported a positive relationship between anxiety and comfort, purporting that this was possibly due to women who were more anxious reaching out to others for support and therefore having a greater level of comfort. There was also a positive relationship between comfort and age. Despite some limitations, the study does provide some basis for the importance of psycho-spiritual comfort as an import component of overall comfort. In addition, the study provides an alternative approach to enhance comfort.31


The final study reviewed focused on serenity, which may be defined as "calmness;" one definition of comfort is "calm." Serenity implies a state of harmony of body and spirit, and being serene has been linked to decreased stress.32 Researchers conducted a concept analysis of serenity to learn more about the link between emotions and health. Nurses who have participated in surveys related to patient health indicate that 90% of them think that serenity is important for patient health.33 Based on the information they obtained through investigating research on serenity and the results of their concept analysis, the researchers developed a serenity scale and concluded that serenity does act to decrease stress and is useful in healthcare.


Nurses, patients deserve the same care

Although the literature supports the use of many techniques that enhance nurse comfort, such as a good working environment with appropriate compensation, professional development, and autonomy, little has been done to provide a more holistic approach addressing all three types of comfort: relief, ease, and transcendence.27 Prior efforts to enhance comfort in the nursing profession focused on relief comfort, and, to a lesser extent, ease comfort through the environment contexts of physical and social needs.


We suggest that the concept of nurse comfort represents an organizational framework that might be employed to facilitate strategic efforts to more effectively care for and manage nursing staff in a human resource sense. Healthcare organizations have a moral and social responsibility, while responding to demands to increase organizational output and efficiency, to protect healthcare professionals, both mentally and physically.


Although nurses are taught to provide comfort for others, the literature review strongly suggests the importance of nurses taking care of themselves and each other. The rapid changes in the healthcare field promise to increase the level of alienation among nurse professionals resulting in increased burnout, anxiety, stress, and frustration. A strong focus within organizations and the profession on enhancing all dimensions of nurse comfort may facilitate a more effective transition to the new healthcare environment, with its increase in regulation and stress on efficiency and cost containment. The results of the literature review strongly suggest a holistic approach to comfort as opposed to today's fractured, piecemeal approach.




1. Aiken LH, Clarke SP, Sloane DM, et al. Nurses' reports on hospital care in five countries. Health Aff (Millwood). 2001;20(3):43-53. [Context Link]


2. Freudenberger HJ. Staff burn-out. Journal of Social Sciences. 1974;30(1):159-165. [Context Link]


3. Freudenberger HJ. Burnout: contemporary issues, trends, and concerns. In: Farber B, ed. Stress and Burnout in the Human Service Profession. New York, NY: Pergamon Press; 1983:23-29.


4. Heard PL, Hartman S, Bushardt SC. Rekindling the flame: using mindfulness to end burnout. Nurs Manage. 2013;44(11):24-29. [Context Link]


5. Maslach C. Burnout: The Cost of Caring. Upper Saddle River, NJ: Prentice Hall; 1982. [Context Link]


6. Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual. Palo Alto, CA: Consulting Psychologists Press, Inc; 1996. [Context Link]


7. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001;52:397-422. [Context Link]


8. Suzuki E, Itomine I, Kanoya Y, Katsuki T, Horii S, Sato C. Factors affecting rapid turnover of novice nurses in university hospitals. J Occup Health. 2006;48(1):49-61. [Context Link]


9. Cohen-Katz J. Mindfulness-based stress reduction and family systems medicine: a natural fit. Family Systems and Health. 2004;22(2):204-206. [Context Link]


10. Front J. A quiet revolution: therapists are learning a new way to be with their patients. Psychotherapy Networker. 2008;32(1):29-34.


11. Kovner CT, Brewer CS, Fairchild S, Poornima S, Kim H, Djukic M. Newly licensed RN's characteristics, work attitudes, and intentions to work. Am J Nurs. 2007;107(9):58-70.


12. Langer EJ. On Becoming an Artist: Reinventing Yourself through Mindful Creativity. New York, NY: Ballentine Books; 2005.


13. Maslach C. Job burnout: new directions in research and intervention. CurrentDirections in Psychological Sciences. 2003;12(3):189-192. [Context Link]


14. Yung PM, Fung MY, Chan TM, Lau BW. Relaxation training methods for nurse managers in Hong Kong: a controlled study. Int J Ment Health Nurs. 2004;13(4):255-261. [Context Link]


15. Freudenberger HJ. Burnout: past, present and future concerns. Loss, Grief, and Care. 1989;3(1/2):1-10. [Context Link]


16. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288(16):1987-1993.


17. Espeland KE. Overcoming burnout: how to revitalize your career. J Contin Educ Nurs. 2006;37(4):178-184. [Context Link]


18. Selye H. The Stress of Life. New York, NY: McGraw-Hill; 1978. [Context Link]


19. Oman D, Shapiro SL, Thoresen CE, Plante TG, Flinders T. Meditation lowers stress and supports forgiveness among college students: a randomized controlled trial. J Am Coll Health. 2008;56(5):569-578. [Context Link]


20. Agency for Healthcare Research and Quality. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008. [Context Link]


21. McIlveen KH, Morse JM. The role of comfort in nursing care: 1900-1980. Clin Nurs Res. 1995;4(2):127-148. [Context Link]


22. Morse JM. An ethnoscientific analysis of comfort: a preliminary investigation. Nurs Pap. 1983;15(1):6-20. [Context Link]


23. Nightingale F. Notes on Nursing: What it is and What it is not. London, UK: Harrison; 1860:59. [Context Link]


24. Kolcaba KY. Comfort Theory and Practice. New York, NY: Springer Publishers; 2003. [Context Link]


25. Kolcaba K. Evolution of the mid range theory of comfort for outcomes research. Nurs Outlook. 2001;49(2):86-92. [Context Link]


26. Kolcaba KY, Kolcaba RJ. An analysis of the concept of comfort. J Adv Nurs. 1991;16(11):1301-1310. [Context Link]


27. Kolcaba K, Tilton C, Drouin C. Comfort theory: a unifying framework to enhance the practice environment. J Nurs Adm. 2006;36(11):538-544. [Context Link]


28. Koehn ML. Alternative and complementary therapies for labor and birth: an application of Kolcaba's theory of holistic comfort. Holist Nurs Pract. 2000;15(1):66-77. [Context Link]


29. Kolcaba K, DiMarco MA. Comfort theory and its application to pediatric nursing. Pediatr Nurs. 2005;31(3):187-194. [Context Link]


30. Kolcaba K, Fox C. The effects of guided imagery on comfort of women with early stage breast cancer undergoing radiation therapy. Oncol Nurs Forum. 1999;26(1):67-72. [Context Link]


31. Roberts KT, Whall A. Serenity as a goal for nursing practice. Image J Nurs Sch. 1996;28(4):359-364. [Context Link]


32. Kim J. Serenity Nursing Interventions for Older Adults: A Replication Study. Unpublished master's thesis, University of Louisville, Louisville, KY; 1994. [Context Link]


33. Messenger T, Roberts KT. The terminally ill: serenity nursing interventions for hospice clients. J Gerontol Nurs. 1994;20(11):17-22. [Context Link]