Holistic Nursing Research: Challenges and Opportunities
Rothlyn P. Zahourek
Nurse Healer OBJECTIVES
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Theoretical
Discuss ways holistic philosophy and theoretical frameworks are reflected in holistic nursing research (HNR) priorities.
Discuss the recent NCCAM strategic plan and its impact on holistic nursing research.
Discuss the complexity of determining adequate evidence for holistic nursing research.
Explore the challenges for holistic nursing research.
Compare and contrast a variety of research methods.
Clinical
Explore how holistic nursing research questions can be developed in your clinical setting.
Read a research article related to a modality you use in your holistic nursing practice.
Collect data from various clients who are participating in some form of holistic therapy to determine their subjective evaluations of the experience and outcome.
Discuss ways to enhance practice through holistic research with colleagues and nurse researchers.
Devise a holistic nursing research question and propose a method of research that would best explore that question.
Personal
Contemplate how a conceptual framework of holism is the foundation for holistic nursing research and practice.
Clarify your own personal definition of holism and holistic nursing.
Consider that you do research every day in clinical practice as you assess patients and their situations, make diagnoses, plan and follow through on actions, and evaluate those actions.
Plan time to learn how to form a research question.
Attend a research conference or a section on research at the American Holistic Nursing Association (AHNA) annual conference or at a local networking meeting.
DEFINITIONS
Bias: Having preconceived ideas and expectations about a research study’s outcome. May be overt or more subtle as a hope or expectation.
Bracketing: Characteristic of qualitative research. The researcher outlines in writing his or her philosophies, biases, or concerns and expectations about the research project process and/or outcome.
Credibility: A term used in qualitative research that accounts for the researcher’s trustworthiness in demonstrating the
process of data collection and interpretation of results.
process of data collection and interpretation of results.
Hawthorne effect: When people know they are being observed in a study, their behavior is affected simply by being observed.
Healing: Both a process and result; defined by the individual as perception of shift or meaningful change. The central concept in holistic nursing research.
Healing relationship: The quality and characteristics of interactions between healer and the one being healed (healee) that facilitate healing, including empathy, care, love, warmth, trust, confidence, honesty, courtesy, respect, and communication, as well as compassion, presence, intent, and intentionality.
Heisenberg’s Uncertainty Principle: The principle that observation of phenomena or objects changes the nature of what is studied.
Integral: The appreciation for the interactions and interrelationships of the many parts within the whole of a system.
Meta-analysis: A statistical technique that combines the results of many studies related to one topic to establish an overall estimate of the therapeutic effectiveness of an intervention.
Mixed methods research: A type of research that combines paradigms, philosophies, and methods on a specific topic to grasp a more complete representation of reality and/or confirm the credibility of the research findings; also may be referred to as triangulation.
Placebo: A medically inert medication, preparation, treatment, technique, or ritual that has no intended effects on the person and no actual therapeutic value. The fact that the placebo is inert is now in question based on the impact of suggestion and intention.
Praxis: The bringing together of practice and research. It is a synthesizing and reflective process in which theory is dynamic and practice reflects research and theory in a unified whole.
Qualitative research: A systematic, subjective research approach that describes life experiences and searches for how participants find meaning in their experiences; based on philosophical, psychological, and sociological theory; focuses on understanding the whole, which is consistent with the philosophy of holistic nursing.
Quantitative research: A systematic, formal, reductionistic, objective approach in which numerical data are used to obtain and interpret information about the world. It embodies the principles of the scientific method and describes variables, examines relationships among variables, determines cause-and-effect interactions between variables, and predicts future responses.
Reductionism: The approach of breaking down phenomena to their smallest possible parts; also called positivism and equated with the linear, logical nature of the scientific method.
Reliability: Generally associated with quantitative research and the ability of a scale or a tool to consistently measure a phenomenon when used repeatedly.
Research: A diligent, systematic inquiry or investigation to validate and refine existing knowledge and generate new knowledge.
Systematic review: A specific form of review of research studies that yields more convincing evidence. Several methods exist; these are invaluable in discovering what has already been discovered about a particular phenomenon.
Translational research: Taking basic bench highly reductionist (molecular or cellular) research and translating that into clinical application. It generates new research questions that are fed back to the bench. More broadly, translating any research into practice.
Unitary: The recognition that parts cannot be separated from the whole because the whole is greater than, and different from, the parts; contention that separating phenomenon into parts undermines the understanding of the whole.
Validity: Generally associated with quantitative research; internal and external; relates to the interpretation of data; meaningful, appropriate, and useful results are required for validity. Internal validity is related to the controls placed on the research design and process and ensures that the effects of
the independent variable are causing the results in the dependent variable. External validity ensures that the results are generalizable to other populations, settings, and times and depends on internal validity.
the independent variable are causing the results in the dependent variable. External validity ensures that the results are generalizable to other populations, settings, and times and depends on internal validity.
▪ HOLISTIC NURSING RESEARCH
As human beings, we are driven to explore. We strive to understand ourselves and our world and thereby construct belief systems that we want others to accept and act on. Historically, mystics and shamanic healers believed in the healing power of ecstatic experiences of a unified cosmic whole. Pagans believed that all matter, living and nonliving, had spirit and a life force that could communicate. Now philosophers, theoretical physicists, and behavioral scientists study “subtle energy” and theorize about the nature of and actions by consciousness.1
In the 1600s, Descartes’ notion of reductionism separated soul from body by breaking down every research subject into its smallest parts. This liberated medicine from religion and advanced the use of the scientific method in medical research. Since then, science developed and humans become smug about being rational creatures. Depending on the logic of the scientific method, A plus B has to equal C; such logical relationships have to behave predictably to be considered credible and valid. Impassioned controversy wages between a belief in only that which is visible and proven, and faith in what is unseen, experienced, but poorly understood. Is the world flat as it appears to the naked eye, round as the globe in the classroom, or egg shaped as seen from space? Does energy exist as quantifiable sound waves, electrons colliding, or as something nonlocal that we cannot see, touch, or, at present, measure? Surprisingly, invisible cyberspace e-mail messages become visible when they are transduced into images on a computer screen.
Holistic nursing research (HNR), as well as the fields of complementary and integral medicine and complementary and integral nursing, are on the cusp of such a conundrum. Much of what nurses value in interventions and holistic nursing process can’t be seen or measured. Often, effects take time to be realized and are unpredictable. Many concepts that nurses want to study remain ill defined, and some holistic practices appear to others as based in mysticism, magic, or paranormal phenomena. Others use nursing theories to explain holistic nursing practice as well as abstract theories from quantum physics and evolving theories on the nature of consciousness and reality. Although holistic nurses may continue to believe in the power of spirit and unexplained forces, we have a duty to understand the nature of such phenomena and to ethically demonstrate their safety and efficacy in clinical practice. The nurse’s primary mission is to foster healing and, therefore, we must develop a body of credible, reliable, and valid research and sound scholarship.
In 2003, a stellar multidisciplinary group of scholars met to determine the definitions and standards for healing research. Their work continues to influence holistic nursing research. The authors insisted that the healing relationship be the focus for healing research. Healing is both a process and result. “Those physical, mental, social, and spiritual processes of recovery, repair, renewal, and transformation that increase wholeness, and often (though not invariably), order and coherence. Healing is the emergent process of the whole system.”2 Healing is perceived by the individual as a shift, meaningful change, or transformation and is experienced as restored balance or sense of wholeness.3 Quinn and nurse colleagues provide a definition of healing relationship for nursing research: “the quality and characteristics of interactions between healer and healee that facilitate healing. Characteristics of this interaction involve empathy, caring, love, warmth, trust, confidence, honesty expectation, courtesy, respect, and communication.”4 Holistic nurses also consider compassion, presence, and intent and intentionality as components of the relationship and process of healing.
The purpose of this chapter is to provide a matrix framework for HNR that is based on definitions of wholeness and healing, and nursing theories that are based on ways of knowing and viewing the world. We consider the third National Center for Complementary and Alternative Medicine (NCCAM) strategic plan for 2011-2015 and its influence on HNR, review the status of HNR and approaches to HNR, and consider the challenges and opportunities for the future. In addition to the standard approaches
of qualitative, quantitative, and mixed methods designs, other approaches are discussed.
of qualitative, quantitative, and mixed methods designs, other approaches are discussed.
▪ WHAT IS HOLISTIC NURSING RESEARCH?
How do we understand and connect science and spirit? How do we explore the healing relationship and healing itself? What is different about holistic nursing research? Enzman-Hagedorn and Zahourek emphasize that although holistic nurses use a variety of integrative and complementary modalities, HNR must occur within a framework of theory and practice that accepts holism as its base.5,6 The American Holistic Nurses Association (AHNA) white paper on holistic nursing research adopts this caveat: “Solid evidence for the effectiveness of these approaches is often dependent on the interplay of relationships, the passage of time, and interaction of many variables some of which are not easily controlled using standard methods or a conventional scientific frame work.”7
Simply evaluating a modality or providing evidence of safe, effective practice is not necessarily true HNR. The AHNA recognizes two definitions of holism: The whole is viewed as a relational integration of parts (i.e., integral), or the whole is separate from and greater than the parts (i.e., unitary).8 A researcher using the integral framework values interactions, influences, and outcomes and most often utilizes quantitative, mixed methods, evidence-based practice research, meta-analyses, and surveys. The unitary researcher recognizes that separating phenomena into parts undermines total understanding. Research in this framework is most often qualitative, including hermeneutic, phenomenologic, ethnographic, and grounded theory methods, as well as mixed methods and aesthetic, historical, and other approaches. For nursing research to be holistic, it must clearly incorporate one of these frameworks into the question, design, method, analysis, and interpretation of findings. Integrating one framework or developing a unique definition of holism should be evident in the research question and interpretation of results.
The research gold standard, the randomized controlled trial (RCT), is reductionistic as opposed to holistic in nature. However, such a study could be considered holistic if the researcher acknowledges that there is a whole context, or experience, that is greater than, and possibly different from, the smaller interactions of specific variables. The researcher might skillfully qualitatively study a phenomenon by describing the individuals’ experiences and interpreting results in a holistic framework. For example, several patients react positively to Healing Touch treatments. Their reactions remain for that selected population. From such data, however, a beginning theory or hypothesis might emerge. When we use observations and descriptors, devise measurement tools, and quantitatively measure outcomes, we have increasingly reliable, valid, and generalizable results. However, we may have missed understanding the nature of a person’s total experience and the subsequent implications for practice.
▪ BASICS OF HOLISTIC NURSING RESEARCH: WAYS OF KNOWING AND NURSING THEORIES
Holistic nursing research is based in a holistic paradigm. Nurse theorists such as Rogers, Newman, Parse, Watson, and Leininger developed a wealth of unitary and integral theories as they struggled to understand caring, healing, and the nature of the whole. (See Chapter 5.) In addition, they and their protégés created methodologies and tools to conduct research. For example, Margaret Newman developed the theory of Health as Expanding Consciousness (HEC). Newman conceptualizes a unitary time framework that illuminates “the meaning of a person’s present situation within the context of the past and anticipating future action.”9 She proposes a qualitative “hermeneutic, dialectic method,” which is used to “allow the pattern of the person and environment to reveal itself without disrupting the unity of the pattern. The process culminates in intuitive apprehension and expression.”10 For Newman, research is praxis and, therefore, based in practice. Research emanates from the nurse’s engagement with participants during important events and within significant relationships; it “enables pattern recognition and expanding consciousness to occur.”9 Pattern recognition acknowledges the whole. In a classic text on research based on Newman’s work, Jones and Picard present numerous research examples using Newman’s framework
including the pattern of letting the past go in order to move on for parents of persons with bipolar illness11 and recognizing life patterns in women with multiple sclerosis.12 Measurement tools are beginning to appear to document behaviors that illustrate caritas in Jean Watson’s evolving Theory of Caring.13,14
including the pattern of letting the past go in order to move on for parents of persons with bipolar illness11 and recognizing life patterns in women with multiple sclerosis.12 Measurement tools are beginning to appear to document behaviors that illustrate caritas in Jean Watson’s evolving Theory of Caring.13,14
Richard Cowling has developed a research framework, Unitary Appreciative Inquiry, based on Martha Rogers’s Science of Unitary Man. This framework considers the pattern of the unitary whole as the orientation and process for “uncovering human wholeness and discovering life patterning in individuals and groups”15 His unitary pattern recognition with women experiencing despair utilizes data synopses rather than data analysis.
Worldviews and Ways of Knowing
All research is based on a philosophy or worldview. Although differing in language, these systems all tend to view a bifurcated, or particulate, reality in which humans and their world are portrayed through such descriptors as subjective and objective; individual-intrapersonal; interpersonal and cultural; and aesthetic and ethical. Few paradigms try to address the whole other than by describing parts and their relationships. Pattern may be one concept that captures a unitary whole. However, when posing a research question, choosing one of the following ways of knowing can help researchers frame their studies. (See Chapter 1 for more discussion on ways of knowing.)
The AHNA recognizes various patterns of knowing including rational or scientific, intuitive, and aesthetic. Intuitive and aesthetic are emphasized because these approaches are needed to understand the “multidimensional nature of our work, which encompasses the art of care; the wholeness of the client’s experiences and meaning of patterns that emerge; the beauty of authentic interaction; and the knowledge of that which is perceived through nonverbal, nonobjective expression.”16
Historically, nursing research and theory generation have been based on Carper’s classical work. She proposed a system of four ways of knowing:17
Empirical: Objective, logical, and positivistic science
Ethical: Obligations, what should be done in a given situation; what is acceptable practice; requires openness to differences in philosophical positions18p12-13
Personal: Self-knowledge; determined by ability to self-actualize; comfort with ambiguity; commitment to patience and self-care
Aesthetic: Artful knowledge; abstract; defies formal description and measurement; understanding of subjective experiences; creative pattern
Porter recently argued that these patterns are linear and hierarchical rather than holistic.18pp3-14 He critiques both evidence-based practice and Carper’s framework as reductionist, linear, and too weighted in the empirics and simplistic in logic. He believes that too little weight has been given to the personal, aesthetic, and ethical, all of which fall into the ineffable. He advocates for “practice based evidence”18p12 in which “nonempirical patterns of knowing animate practice” and become documented and thereby empirical. The role of empirics, then, is demonstrative rather than deterministic.18p13
Fawcett developed a classic paradigmatic system that describes three frameworks of increasing degrees of abstractness:19
Particulate-deterministic. Reductionist, concrete 2. Interactive-integrative. Reality is multidimensional and contextual; reciprocal relationships
Unitary-transformative. Human beings are unitary, evolving, self-organizing fields, and defined by pattern; highly abstract19
Nurse theorists Watson, Newman, Parse, and Rogers are associated with the unitary-transformative paradigm. Enzman-Hagedorn and Zahourek developed an integrated model that combines Carper’s and Fawcett’s paradigms with specific research approaches for holistic nursing research.20
Mariano provides a slightly different framework described as four “attributes of scholarship”: wide awake, reflective, caring, and humorous.21 By keeping ourselves wide awake, we become aware of our place in humanity, are open to possibility, are attentive to others, and are conscious of our evolving experiences. In research, we are sensitized to ask unexplored questions with which we discover the unique and novel. Reflection is an introspective thoughtful
process in which one’s philosophical stance, values, assumptions, biases, and decision-making process become more evident. The third attribute for scholarship is caring. Drawing from Jean Watson,22 Mariano explains that our research should be ethical, moral, and based on pressing human needs. We must be intellectually empathic, just, and fair minded. Finally, she states that true scholars have a sense of humor. We should expect and embrace the unexpected, keep our goals and accomplishments in perspective, and be willing to admit when we are wrong.21
process in which one’s philosophical stance, values, assumptions, biases, and decision-making process become more evident. The third attribute for scholarship is caring. Drawing from Jean Watson,22 Mariano explains that our research should be ethical, moral, and based on pressing human needs. We must be intellectually empathic, just, and fair minded. Finally, she states that true scholars have a sense of humor. We should expect and embrace the unexpected, keep our goals and accomplishments in perspective, and be willing to admit when we are wrong.21
Munhall describes one additional worldview useful to HNR: the pattern of unknowing. Unknowing captures intuitive experiences.23 Knowledge is shaped, but not completely defined, by the process or context in which it occurs. Larry Dossey continues to discuss the local and nonlocal aspects of healing, arguing that we must grapple with these areas of mystery to understand such fundamental concepts as compassion and intentionality.24 Schwartz and Dossey discuss the unexpected confounds of the observer effect and intention on prayer, “distant healing,” and intention research outcomes.25 Braud and Anderson developed transpersonal research methods based on such alternative ways of knowing as altered levels of consciousness, intuition, setting intention, knowing through art, feminine spirituality, and knowing through movement and through listening.26 Jonas and Crawford analyzed more than 220 reports on nonlocal healing effects (122 controlled laboratory studies and 80 randomized controlled trials).27 Their results support that these unexplainable phenomena do exist, but inconsistently. Any energy-based research must struggle with the inability to see and measure process and effects accurately and consistently. Finally, Ken Wilber developed yet another integral model of how people experience their world that is useful for holistic nurses.28 (See Dossey’s Theory of Integral Nursing in Chapter 1 for a full discussion of this model.)
These frameworks provide a malleable matrix on which to ground HNR. Each framework acknowledges holism and reductionism. All include experiential qualitative approaches that enrich our understanding of complex phenomena as well as the quantitative comparative approaches, program evaluation, and other forms of evidence from practice. We need better and more diversified approaches and more sensitive instruments to assess and document the interactive nature of holistic nurses with each client’s bio-psycho-social-spiritual patterns in wellness and in illness. Table 34-1 summarizes these paradigms and provides a reference for holistic nurse researchers’ planning, executing, and interpreting their research. In addition, research frameworks from the behavioral and social sciences and psychoneuroimmunology provide useful methods, theories, and models for HNR.
▪ IMPACT OF THE NCCAM 2011 STRATEGIC PLAN
The National Center for Complementary and Alternative Medicine (NCCAM) is the agency dedicated to scientific research on complementary and alternative medicine (CAM). CAM is defined by NCCAM as a group of diverse medical and healthcare interventions, practices, products, and disciplines that are not generally considered part of conventional medicine.29p1 Early in 2011, NCCAM released its new strategic plan. Because many of the interventions classified as CAM are also holistic nursing interventions, this plan has implications for holistic nurse researchers. The plan will shape not only what NCCAM and other government agencies fund but also the national direction and focus of research for the next few years. In her introduction, NCCAM Director Josephine Briggs states that the previous plans emphasized that CAM research focus on basic evidence to discover biological properties of interventions and conduct RCTs to ensure effectiveness and safety. In this current plan, translational research, effectiveness and outcomes research, and real-world results are emphasized. Training new researchers and multidisciplinary teams is encouraged.
NCCAM Strategic Plan: Goals and Objectives
Within the strategic plan are three goals and five strategic objectives. The three overarching goals are the following:
Advance the science and practice of symptom management.
Develop effective, practical, personalized strategies for promoting health and well-being.
TABLE 34-1 Summary: Ways of Knowing Theoretical Frameworks
Research Approach
Carper’s Ways of Knowing:
Fawcett’s Paradigms
Wilber’s Integral Model
AHNA’s Way of Knowing
Mariano’s Attributes of Scholarship
Quantitative:
RCT, EBP, experimental, quasi-experimental, descriptive
Empirical
Objective, logical, positivistic; provides measurement and generalizability
Particular-Deterministic:
Reductionist, concrete
Objective “it,” material body, biochemistry, behaviors, scientific observations on time and space
Rational/Scientific
Quantitative:
Descriptive, correlational
Mixed methods
Interactive and Integrative:
Multidimensional reality, contextual, reciprocal relationships
Objective “its,” collective exterior, social systems, regulatory structures
Rational/Scientific
Being Wide Awake:
Thinking about our place in humanity, open to possibility, attentive to others and conscious of our evolving experiences, posing questions from descriptive data
TRANSITION
TRANSITION
TRANSITION
TRANSITION
TRANSITION
TRANSITION
Qualitative:
Postmodern feminist mixed method approaches
Ethical:
Obligation about what should be done, open to different philosophies
Interactive and Integrative or Unitary Transformative:
Human beings are unitary, evolving self-organizing fields defined by patterns
Subjective “I” and subjective “we,” imagination, internal experience
Intuition
Caring:
Ethics, fair mindedness, human and society needs, intellectually empathic
Qualitative:
Reflective, transpersonal
Mixed methods
Personal:
Self-knowledge, ability to self-actualize, comfort with ambiguity, commitment to patience and self-care
Unitary Transformative:
Human beings are unitary, evolving self-organizing fields defined by patterns
Subjective “I” and subjective “we,” shared values and meaning
Reflective:
Introspection, displays one’s thought process, values, biases, ethics, etc., to others; critical thinking
Qualitative:
Transpersonal, aesthetic creative approaches
Aesthetic:
Artful knowledge, abstract, defies formal description, creative
Unitary Transformative:
Human beings are unitary, evolving self-organizing fields defined by patterns
Subjective “I” and subjective “we,” changing states of consciousness and emphasis
Aesthetic
Humor:
Expect and embrace the unexpected, willingness to admit when we are wrong or failed
Enable better evidence-based decision making regarding CAM use and its integration into health care and health promotion.
These goals resonate with holistic nursing philosophy, research, and practice. The plan stresses research to understand more clearly how, and if, interventions augment other treatments. For example, does yoga practice augment standard approaches for treating back pain? According to the NCCAM plan, recent epidemiologic data indicate that people who use CAM engage in other health-seeking behaviors.29p5 At present, this remains a good hypothesis that needs further testing. Health promotion is a standard nursing (especially holistic) practice, goal, and activity on which we also are compiling research evidence. Currently, the term evidence based is being expanded to include multidisciplinary research teams conducting research “across the continuum of basic, translational and efficacy and effectiveness research.”29p11 The definitions of those terms according to the new strategic plan are useful in that they are now used with increasing frequency:29p11
Basic science: Investigates biological effects and mechanisms of action; it clarifies hypotheses and answers the question: “How does it work?”
Translational research: May identify markers of biological effect; develops and validates measures of outcome; develops algorithms and preliminary clinical efficacy; estimates sample size for future studies. Answers the question: “Can it be studied in people?”
Efficacy studies: Highly controlled studies to determine specific effects of an intervention. Answers the question, “What are the specific effects?”
Effectiveness and outcome studies: What is the usefulness and safety of the intervention in general populations and healthcare settings? Answers the question: “Does it work in the real world?”
The five strategic objectives of the 2011-2015 NCCAM plan are as follows:
Advance research on mind and body interventions, practices, and disciplines.
Advance research on CAM natural products.
Increase understanding of real-world patterns and outcomes of CAM use and its integration into health care and health promotion.
Improve the capacity of the field to carry out rigorous research.
Develop and disseminate objective, evidencebased information on CAM interventions.
Holistic nurse researchers already are addressing many of these strategies. The following discussion gives specific examples of selected strategies. Researchers, educators, and clinicians are all encouraged to become aware of this plan as it relates to a portion of what holistic nurses do and how they might consider crafting their research. Recognizing national trends helps frame potential problems to be studied and provides additional research methods to use. The following discusses the strategic objectives and provides examples of related holistic nursing research.
Strategic Objective 1: Advance the Research on Mind-Body Interactions
This objective includes elucidating biological effects and mechanisms of action. Developing a greater understanding of the placebo response, the influence of expectancy and the relationship, and discovering creative and innovative research designs that account for issues of treatment burden and the ethics of random assignment are included in this category. Coakley and Duffy report a pilot study to investigate the effect of a single Therapeutic Touch treatment on pain perception and biological markers of stress such as cortisol and natural killer cells (NKCs) in patients recovering from vascular surgery.30 The design incorporated both physiologic measures as well as subjective reports of pain. Their sample included 21 patients, 12 in the experimental group and 9 in the control usual treatment group. After adjusting their statistics using standard approaches, the results indicated that preoperative pain and cortisol levels dropped significantly and NKC levels increased significantly. The authors recommend that further study be done in a more controlled fashion.
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