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. 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