Nurse Education in Practice (2008) 8, 412–419
Nurse
Education
in Practice
www.elsevier.com/nepr
Holistic practice – A concept analysis
Liz McEvoy a, Anita Duffy
a
b
b,*
AMNCH, Tallaght, Ireland
Faculty of Nursing and Midwifery, RCSI, Dublin, Ireland
Accepted 10 February 2008
KEYWORDS
Summary
Concept analysis;
Holism;
Holistic;
Body, mind and spirit;
Nursing practice
Aims and objectives: This article aims to clarify the concept of ‘‘holism’’ in nursing
through the use of Rodgers [Rodgers, B.L., 1989. Concept analysis and the development of nursing knowledge; the evolutionary cycle. Journal of Advanced Nursing 14,
330–335] concept analysis framework.
Background: The primary author is employed in a urology department which cares for
many clients with end stage cancer. Holistic nursing practice is the philosophy of the
unit, however many nurses struggle to articulate what holistic practice actually means
to them, hence this analysis was deemed very pertinent to practicing nurses to enable
the realization of nurses therapeutic potential when caring for patients in practice.
Method: Rodgers (1989) well-established method of concept analysis was employed
to facilitate the clarification of the concept of holistic nursing practice.
Relevance to clinical practice: The clarification of the concept offered a working definition of holistic nursing practice which practicing nurses can clearly comprehend and
avail of when caring for patients of all race, religion and creed in the clinical practice
area.
Conclusion: By undertaking this methodology of concept analysis the integrity of the
concept was kept intact. The factors that influence holistic nursing practice were
identified and a model case demonstrated the reality of holistic nursing care for practicing nurses.
c 2008 Elsevier Ltd. All rights reserved.
Introduction
Concept analysis is viewed by many as a method for
clarifying overused or vague concepts (McBrien,
2006). As concepts such as ‘‘holism’’ are often sub* Corresponding author. Tel.: +353 1 4028643.
E-mail address: aniduffy@rcsi.ie
jective, it is important that their meaning is clarified, otherwise misuse can dilute their relevance
to practice. Additionally, having concrete definitions assist in implementing the term in question
into practice ultimately supporting research and
theory development (Paley, 1996; Villagomeza,
2005; McBrien, 2006) vital for the professional
development of nursing.
1471-5953/$ - see front matter c 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.nepr.2008.02.002
Holistic practice – A concept analysis
The purpose of this article was to clarify the
concept of ‘‘holism’’ utilising Rodgers (1989) evolutionary concept analysis approach. In order to enhance the comprehension of the concept of
‘‘holism’’, it was necessary to identify the attributes, antecedents and consequences over an extended period of time. The authors critically
analysed the concept and its application to practice through describing a true life model case of
holistic nursing practice. The article concludes
with a clear definition of holism to offer practicing
nurses an understanding of the reality of holistic
nursing care.
Nursing knowledge
Theories are applied to nursing in the form of nursing models which are then adapted and applied to
the particular clinical setting. The development
and refinement of theories creates new quality approaches to care and challenges existing practice
(Wadensten and Carlsson, 2003). Nursing is both
practice and academically based, therefore in order to create new approaches to practice, knowledge is essential. Knowledge must not only be
about the empirics, but also about the how and
why of practice. This, according to Carper (1978)
is what separates nursing from other disciplines.
There are many controversial debates in the
nursing literature concerning the professionalisation of nursing. It is agreed that one of the accepted hallmarks of a profession is the possession
of a unique body of knowledge (Leddy and Pepper,
1993). It is not the possession, but the application
of this knowledge to practice that makes nursing
unique. Building on both practical and propositional knowledge is crucial to assist nurses’ develop
nursing theory that can be applied to practice (Colley, 2003). Walker and Avant (1995) state that concept analysis is the first step of theory
development to clarify and define the phenomenon
in question. Clarifying nursing concepts has the
advantage of empowering nurses and furthermore
it facilitates professional autonomy, which ultimately results in the professional development of
nurses (Ingram, 1991).
However, it is naive and misleading to describe
nursing knowledge as unique-as no single discipline
has exclusive ownership over knowledge. Never the
less, nursing does claim to have a unique focus on
caring, understanding and knowing the whole person (Brockopp and Hasting-Tolsma, 2003). Colley
(2003) argues that knowledge borrowed from other
disciplines only serves to dilute nursing practice,
whilst Junor et al. (1994) argues that shared know-
413
ledge through team work is known to maximise
clinical effectiveness. There is a need to reassess
exclusive claims to specialist knowledge and
authority in order to provide the best possible care
to individual patients. Teams need to have shared
goals and values to understand and respect the
knowledge of other disciplines. In addition Carrier
and Kendall (1995) identify that holistic care will
only be met if there is a readiness to share knowledge and surrender exclusive claims to specialist
knowledge and authority.
It therefore follows that there is no such thing as
unique knowledge and that borrowed theories only
result in enhancing nursing practice (Bradshaw,
1995). This is particularly applicable to holism
and holistic theories, which address the whole person, including mind, body and spirit, cultural,
social and environmental approaches to care.
Therefore, it is inevitable, that knowledge from
other social sciences is considered. The fact that
healthcare is continually evolving with an increased focus on interdisciplinary team work, further enhances this debate. Hence, a balance must
be found considering other health disciplines have
as much to learn from nursing as nursing has from
them. By working together and sharing knowledge
disciplines begin to understand each other’s perspectives and learn and grow in their own practice.
Concept analysis
Concepts have been described by McKenna (1997:8)
as ‘‘the building blocks of theory’’. Paley (1996)
further argued that there is no agreement as to
what constitutes a concept. Concepts are like ice
cubes; just when you think you have grasped them,
a lack of clarity results in their slipping beyond your
grasp. They must therefore be analysed before
they are misused in theory development. The aim
of this analysis was to advance the concept of
‘‘Holism’’ for theory development. In order to do
so, a qualitative enquiry to create meaning through
language, was deemed necessary.
Whilst there are a number of frameworks available for concept analysis, Rodgers (1989) qualitative approach was chosen. Rodgers (1989)
framework presents an inductive, dynamic view
of phenomenon (Cutliffe and McKenna, 2005) as
opposed to that of Walker and Avant’s (1995)
framework, which offers a more restrictive, deductive, quantitative examination (Rodgers, 1989).
Walker and Avant’s (1995) method of analysis is
in contrast to the philosophy of holism and therefore was deemed inappropriate. Holism as a concept is nebulous and subjective, captivating
414
L. McEvoy, A. Duffy
Identify concept of interest
Identify Surrogate terms
the authors researched textbooks in both medical
and public libraries which provided useful information for this analysis. Many articles were discarded
as they were vague, anecdotal and ambiguous.
Articles that were used (n = 27) either defined holism or gave a plausible account of how ‘‘holism’’
was demonstrated in nursing practice.
Data collection
Holism
Analysis of Data
Identify the attributes of the concept
Identify references, antecedents and consequences
Model case
Figure 1
analysis.
Rodgers (1989) framework for concept
nurses over many centuries, with its application to
practice changing over time. This further supported the use of Rodgers (1989) method which
acknowledges that concepts are influenced by significance, use and application over time, resulting
in an analysis that is more practise related and current (Baldwin, 2003). Cutliffe and McKenna (2005)
additionally defend the real life evolutionary approach to concept analysis which uses a real life
model case to demonstrate the attributes, antecedents and consequences of the concept. Other
model cases such as the deviant or borderline cases
as proposed by Walker and Avant’s (1995) model is
not within Rodgers philosophy, hence they were
not incorporated. Cahill (1996) advises authors to
be aware of the philosophical approaches of the
chosen concept analysis framework. Fig. 1 outlines
the steps in Rodgers (1989) framework.
Literature search
A review of the relevant literature, derived from
the Cumulative Index of Nursing and Allied Health
Literature (CINAHL), Medline and Pub Med – using
the keywords ‘‘holism’’, ‘‘holistic’’ and ‘‘body,
mind and spirit’’ was undertaken (n = 126). The
word ‘‘spirit’’ was used rather than ‘‘soul’’ as
the authors believe soul and spirit are interchangeable terms for our immaterial selves. Additionally,
Holism derives from the Greek word ‘‘holos’’,
meaning whole (Griffen, 1993). Healing and health
stem from the Greek word ‘‘hale’’ which also
means to make whole (Kenney, 2001). Therefore
holism, healing and health are inter-related concepts in the nursing literature. With this in mind
it became evident that the concept of ‘‘holism’’
required clarification to extricate holism from
health and healing.
While most definitions of holism share the same
attributes, it is the application to practice that has
led to much discourse. Nursing is indeed holistic in
nature, as the nursing profession has traditionally
viewed the person as a whole, concerned with
the interrelationship of body, mind and spirit, promoting psychological and physiological well-being
as well as fostering socio-cultural relationships in
an ever changing economic environment of care.
However, holism is not exclusive to nursing and
has been used in banking, where holism is a practice of looking at the various factors that lead people to invest (Wilber and Harrison, 1978). Also, the
Montessori teaching method is based on a concept
of ‘‘holism’’ (Infed, 2005).
Smuts (1870–1950), a South African soldier and
philosopher introduced the word ‘‘holism’’ from
the language of chemistry and in his book ‘‘Holism
and Evolution’’ defined ‘‘holism’’ as, ‘‘. . .the principle which makes for the origin and progress of
wholes in the universe’’ (Smuts, 1926). This philosopher believed that the whole was greater than the
sum of its parts, explaining how South Africa was
greater in its entirety rather than its individual
states. These thought patterns can be further
traced to the Gestalt psychologists of 1920s and
1930s who also believed the whole was greater
than the sum of its parts.
It was in the 1970s that nursing became influenced by the concept of ‘‘holism’’, guided by
humanistic theorists such as Rogers (1970) ‘unitary
nature of human beings’. Rogers believed that the
world is a single whole in which every element is
interconnected with others. In 1971, Levine further
described the role of the nurse as viewing each patient as a unique human being in contrast to the
Holistic practice – A concept analysis
reductionist approach of medicine. Early theorists
such as Rogers (1970) and Levine (1971) describe
patients in terms of the wholeness. Ham-Ying’s
(1993) analysis envisioned two common usages of
holism in nursing – a personal view and an approach to nursing care. The American Holistic
Nurses Association (1992) defined ‘‘holistic nursing’’ as, ‘‘. . . that state of harmony between mind,
body, emotions and spirit in an ever changing environment’’. This perspective is consistent with the
contemporary view of ‘‘holism’’ in nursing, where
the physical, social, cultural and spiritual realms
are interconnected (Govier, 2000; Jackson, 2004;
Smart, 2005). These aspects are incorporated into
Leininger’s theory (1988) where diverse cultures
and religions are taken into account, which is particularly apt in modern healthcare and society. It
could be argued that holism was always the approach of nursing but it was the theorists that put
it into words.
To practice holism, nurses are recommended to
be aware of both their own potential wholeness
and also that of the patient. Our sense of wholeness depends on our own vulnerability and on the
opinions of other (Bright, 1997). Self-awareness is
important and through the artful use of self,
whereby an individual strives toward achieving a
sense of balance within oneself and the world, often achieved through reflective practice; harmony
can enter relationships (Cumbie, 2001). It takes
personal, intellectual and professional maturity to
reach this level of self awareness and personal harmony. In practice, nurses who display the defining
attributes of holism, discussed further in this analysis, are guided by past experience and intuition
(Benner, 1984). The degree of harmony that exists
between nurses and their patients is central to
holistic nursing.
The heart of holistic nursing is helping empower
the patient to utilize their inner resources to improve their quality of life and adapt to changes
caused by the disease trajectory (Buckley, 2002).
The concept of empowerment is frequently used
in nursing, particularly in relation to quality of
care, since the mission of nursing is to provide safe
and quality nursing care, thereby enabling patients
to achieve their maximum level of wellness. The
role of nursing has evolved from being a guardian
to being a creator of empowerment and over the
last decade the generic role of the nurse has been
replaced by the specialist nurse. The changes in
nursing has expanded the role to include increasing
emphasis on health promotion and illness prevention, as well as concern for the patient as a whole.
A difficulty for nurses achieving holistic care may
be due to the strong emphasis placed on ‘‘interdis-
415
ciplinary’’ nursing. While acknowledging the expertise of specialist nurses, it could be argued that
what essentially has happened is that specialism
has fragmented the whole back into its component
parts. In terms of concept analysis, the word ‘‘holism’’ has gone full circle. To practice holism as referred to in the Scope of Practice (An Bord
Altranais, 2000), where nurses are required to expand their practice to become more competent,
developing reflectice practice skills, expertise
and clinical skills in order to meet the patients
needs in a holistic manner, nurses must use their
discretion and work within a defined framework
to provide the patient with a truly holistic approach to care rather than fragmenting the care
into bio/social/psycho sub-systems. To overcome
this effect there must be a way of providing holistic
care through shared philosophies amongst interdisciplinary professionals.
Frankl (1984) claimed that characteristics of a
holistic approach to care are the individual’s primary motivational force to search and find meaning
in life. However, many people do not feel the need
for such a psychological approach to care, considering it as intrusive (Griffen, 1993; Smart, 2005).
Many patients in the primary authors clinical practice area – a urology department- are male, over
the age of 65 and do not welcome a holistic approach for this precise reason. In this authors’
experience, men tend to place greater value on
the physical aspects of care, such as assistance
with catheter care and wound care. However, it
is important not loose sight of the psychological,
spiritual, cultural, and social aspects of nursing
care, balancing nursings’ contribution, with all
dimensions of care taken into account, as all too
often, nurses can also be overly focussed on the
physical aspects of care. The rapid patient turnover in the urology department should not be used
as an excuse to neglect holistic care. Spiritual care
can be achieved simply by being present or through
attentive listening (DiJoseph and Cavendish, 2005).
However brief the moment, the authors concur
with Jackson (2004), who believes that spiritual
care can have a profound effect on the patient’s
well-being and also on the nurse in terms of job
satisfaction (Nichols, 1992). ‘‘There is little point
in curing the body if we destroy the soul’’ (Anon
in Martsolf and Mickley, 1998). Being spiritual does
not mean saintly or affiliated with a particular religion (Buckle, 1993; Govier, 2000; Jackson, 2004)
Very often, those who opt for a less formal approach to spirituality can achieve inner harmony
(Narayanasamy, 1999). For many, the more formal
approach is taken, with prayer being the most frequently used spiritual practice among all cultures
416
(DiJoseph and Cavendish, 2005). Research claims
that when people are ill they resort to such practices (Meraviglia, 1999). Indeed, research into the
effect of prayer has demonstrated the positive effects of prayer, in terms of life expectancy in both
AIDS and cancer patients not only when they said
prayers themselves but also when they were prayed
for (Byrd, 1988; Harris et al., 1999; DiJoseph and
Cavendish, 2005). As a consequence of the limited
amount of exposure to spirituality in education and
practice, nurses often lack the confidence to
broach spiritual issues with patients (DiJoseph
and Cavendish, 2005; McSherry, 1998). Therefore,
education to support spiritual outcomes in nursing
programmes must be enhanced and considered in
the nursing curriculum (Belcher and Griffiths,
2005). In today’s climate there are an increasing
number of both patients and staff from different
religious backgrounds. Understanding the concept
of holistic care therefore requires sensitivity and
knowledge of the beliefs of the patient, in the context of his or her own lived values.
Defining attributes
Attributes of a concept are the characteristics of
that concept that appear time and time again in
the literature. The attributes of ‘‘holism’’ identified by this concept analysis are ‘‘mind, body and
spirit’’ ‘‘whole’’ and ‘‘harmony’’ (Buckle, 1993;
Griffen, 1993; Ham-Ying, 1993; Owen and Holmes,
1993; Kolcaba, 1997; Cumbie, 2001). These are in
line with the more traditional approaches to the
concept of ‘‘holism’’ commonly found in the
1990s. However, a more recent paradigm now considers ‘‘healing’’ as a defining attribute of ‘‘holism’’ (Cowling, 2000; Wong and Pang, 2000;
Buckley, 2002; Ernst, 2004; Jackson, 2004).
Antecedents and consequences
The identification of antecedents and consequences are an important part of any concept analysis as they provide further clarity regarding the
concept of interest (Rodgers, 1989). Antecedents
are events that take place prior to the occurrence
of the concept, and consequences happen as a result of the concept (Rodgers, 1989). For holism to
take place an authentic nurse/patient relationship,
built on mutual trust and understanding is necessary
(Cumbie, 2001). The nurse requires knowledge,
expertise and good effective communication skills
(Olive, 2003).
L. McEvoy, A. Duffy
Table 1 Antecedents and consequences of holistic
nursing care
Antecedents for patient
Need
Relationship
Communication
Illness
Disharmony
Caring environment
Autonomy
Self empowerment
Antecedents for nurse
Assessment of need
Relationship
Communication
Intuition
Knowledge
Advocacy
Accountability
Environment conductive
to caring
Consequences positive
for patient
Harmony
Healing
Empowering
Consequences positive
for nurse
Self-satisfaction
Increased job satisfaction
Increased personal
development
Professional development
Increased personal
development
Consequences negative
for patient
Intrusive
Can focus too much on
psychological
Consequences negative
for nurse
Emotionally draining
Time consuming
There are both positive and negative consequences for the patient and the nurse (described
in Table 1) Positive consequences for the nurse include personal and professional development. This
outcome can result in a more substantive meaning
of job satisfaction. For the patient holistic care can
result in better patient outcomes by building on patient’s inner strength (Villagomeza, 2005) and the
creation of a person centred health system as
described in the Health Strategy (Department of
Health and Children, 2001) as one which identifies
and responds to the needs of the individual, is
planned and delivered in a coordinated way, and
helps individuals to participate in decision making
to improve their health.
A negative consequence for the patient is intrusion, hence holistic care must be patient led to
avoid intrusion. In patients who do not know their
needs, such as the unconscious patient, patients
with mental health problems or the ill neonate,
the use of the nurse’s antecedent skills, such as
intuition, effective nurse-patient relationships,
advocacy, and accountability all come into
effect. Equally, for some nurses, the consequences of providing twenty four hour holistic care
can be exhausting leaving the nurse emotionally
drained.
Holistic practice – A concept analysis
Surrogate terms
Surrogate terms appear to be related to the
concept of holism but not the same and include concepts such as ‘‘complimentary’’ and ‘‘alternative’’
(Buckle, 1993; Barraclough, 2001). Words such as
‘‘oneness’’, ‘‘inseparable’’ and ‘‘interconnected’’
are also used in synonymously with holism (Patterson, 1998; Barraclough, 2001).
Model case
Liz, the primary author, reflected on an incident
she was involved in, which she felt reflected a
holistic approach to patient care:
‘‘Jim and I chatted away together while I assisted
with his daily wash (harmony).He told me, about
his life and following a rather informal conversation he expressed how he would love ‘‘to go’’
tomorrow, – the Feast of the Immaculate Conception’’. Initially I was struck by the change in direction of the conversation, but I knew it was essential
for Jim that I took the time to listen to him. We
talked candidly about what prayer and life after
death meant to each of us (spirit).I sat down beside
him and I felt the need to hold his hand and listen
(body and mind).
Following our deep conversation (body, mind and
spirit), I noticed he needed his toe-nails cut
(body) It is our practice to call the chiropodist
but instead, I said ‘‘Jim would you like your nails
done?’’ ‘‘That would be lovely. . . but Id like you
to do it, if you have the time’’ he replied, smiling
(harmony and healing) and added ‘‘it will be a
while before I get them done again’’ After I finished, I enquired if he would like to see Sr. Lucy
from Pastoral Care (spirit, healing). ‘‘No, thank
you dear, I’m refreshed in every sense of the
word,, much better now after talking to you’’
(wholeness, body, mind and spirit, harmony
and healing). I left with a sense of satisfaction
knowing that I had contributed to the final
moments of his life, but overwhelmed by our frank
conversation about his impending death. Jim died
that night; the night nurses said he died
peacefully.
The model case is a true account of Liz nursing
relationship with a patient who was facing death.
The model case touches on many of the key attributes of holism identified through this analysis such
as assessment of need, effective nurse patient
relationships, and intuition. The harmonious relationship between the pair, allowed Jim share his
417
thoughts while he prepared for his final transition
to death.
The case demonstrates the therapeutic nursing
relationship that existed between the practitioner
and her patient, which encompassed the patients
mind, body and spirit to achieve wholeness, harmony and healing whilst attending to the patient’s
daily activities of living in a holistic nursing manner. Liz felt that in some way- perhaps simply from
her presence, she had eased Jim’s mental suffering. This caring relationship involved the therapeutic use of self within the human–human encounter
(Johns, 2004). By cutting his toe-nails herself,
rather than referring him to the chiropodist, Liz
had refrained from fragmenting Jims care, thus
affording Jim holistic nursing care. The holistic
care given in this model case offered Jim mental,
bodily and spiritual care which resulted in harmony, healing and wholeness. Liz was enabled to
spend this valuable time with Jim in a culture that
values holistic caring by putting the patient
first.
Impact on nursing education and
practice
Nurses, whether specialists or generalist practitioners must respond sensitively to the patient’s spiritual and cultural belief systems, demonstrating
caring, presence and integrating spirituality into
the nursing care plan in order to meet the needs
of the patient in a holistic manner. More emphasis
should be placed on the concept of holism and
holistic practice in nurse education and practice
in order to treat individual’s social, cognitive,
emotional and physical problems. Holistic nursing
is a complete way to practice professional nursing
(Montgomery Dossey et al., 2005) hence, holistic
nursing must be integrated into the nurse education curriculum. Holistic nursing draws on nursing
knowledge, theories, expertise and intuition, all
of which can be developed through reflective practice. A paradigm shift is required to embrace holistic nursing. Nursing need to be committed to the
core values of caring, critical thinking, holism,
nursing role development and accountability.
These values focus on the key stakeholders in
health care- the clients, their families and the allied health care teams involved in patient care.
The achievement of these five core values is essential to form the foundation in order to practice the
art and science of nursing in a holistic manner.
Nurse specialisation should not fragment the
whole. Post graduate nurses should be encouraged
418
to undertake further education to develop skills,
competence and expertise in clinical practice.
The provision of stand alone modules in specialist
nursing care is perhaps one answer to encourage
holistic nursing care in the future. Furthermore,
interdisciplinary education, where scientific knowledge is shared amongst allied professionals could
ultimately lead to mutual understanding and application of holistic care to practice. An all for one
and one for all ‘‘Musketeer’’ approach to health
care education may be the solution to the challenges of providing holistic patient care with more
emphasis placed on the development of teambuilding skills and the development of a collaborative approach to patient care.
Conclusion
Concepts are a means through which nursing care
can be articulated. Concept analysis can be a very
effective way of ensuring that the integrity of a
concept is maintained, even as the boundaries of
knowledge and practice become more permeable.
One surprising outcomes of this concept analysis
was that the term ‘‘holism’’ has been linked to the
concept ‘‘interdisciplinary’’. It emerged in this
analysis that interdisciplinary care can fragment
patient care. A current focus on nursing is the
advancement of nursing practice and encouragement of nurse specialisation. Is nursing looking at
the trees instead of the forest? Adjustments need
to be made, so that nurses can view and appreciate
the landscape in its entirety rather than focussing
on isolated parts. Then, and only then, the scene
can be re-set for ‘‘holism’’ and holistic practice
in its purest sense.
In conclusion a working definition of ‘‘holistic
nursing practice’’ is hereby offered by the authors:
‘‘Holistic nursing care embraces the mind, body
and spirit of the patient, in a culture that supports
a therapeutic nurse/patient relationship, resulting in wholeness, harmony and healing. Holistic
care is patient led and patient focused in order
to provide individualised care, thereby, caring
for the patient as a whole person rather than in
fragmented parts.’’
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