Holistic Nursing: Scope and Standards of Practice
Carla Mariano
This chapter is derived from Holistic Nursing: Scope and Standards of Practice (2007), C. Mariano, primary contributor. Printed with permission of the American Holistic Nurses Association (AHNA) and American Nurses Association (ANA).
Nurse Healer OBJECTIVES
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Theoretical
Describe the scope of holistic nursing.
Describe the standards of holistic nursing.
Discuss the five core values of holistic nursing.
Clinical
Integrate the principles of holistic nursing into practice.
Identify how you implement the standards of holistic nursing in your practice.
Discuss Holistic Nursing: Scope and Standards of Practice with colleagues.
Personal
Reflect on your worldview and how it is similar to or different from the philosophy of holism.
Explore how the concepts of holistic nursing apply to your personal life.
DEFINITIONS
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Allopathic/conventional therapies: Medical, surgical, pharmacological, and invasive and noninvasive diagnostic procedures; those interventions most commonly used in allopathic, Western medicine.
Complementary/alternative modalities (CAM): A broad set of healthcare practices, therapies, and modalities that address the whole person—body, mind, emotion, spirit, and environment, not just signs and symptoms—and that may replace or be used as complements to conventional Western medical, surgical, and pharmacological treatments.
Critical thinking: An active, purposeful, organized cognitive process involving creativity, reflection, problem solving, both rational and intuitive judgment, an attitude of inquiry, and a philosophical orientation toward thinking about thinking.
Cultural competence: The ability to deliver health care with knowledge of and sensitivity to cultural factors that influence the health behavior and the curing, healing, dying, and grieving processes of the person.
Environment: The context of habitat within which all living systems participate and interact, including the physical body and its physical habitat along with the cultural, psychological, social, and historical influences; includes both the external physical space and the person’s internal physical, mental, emotional, social, and spiritual experience.
Evidence-based practice: The process by which integrative healthcare practitioners make clinical decisions using the best integrative philosophy and theories, research evidence, clinical expertise, and patient preferences within the context of available resources.
Healing: A lifelong journey into wholeness, seeking harmony and balance in one’s own life and in family, community, and global relations. Healing involves 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 an emergent process of the whole system bringing together aspects of one’s self and the body, mind, emotion, spirit, and environment at deeper levels of inner knowing, leading toward integration and balance, with each aspect having equal importance and value. Healing can lead to more complex levels of personal understanding and meaning and may be synchronous but not synonymous with curing.
Healing process: A continual journey of change and the evolving of one’s self through life that is characterized by the awareness of patterns that support or that are challenges or barriers to health and healing and that may be done alone or in a healing community.
Healing relationships: The quality and characteristics of interactions between one who facilitates healing and the person in the process of healing. Characteristics of such interactions involve empathy, caring, love, warmth, trust, confidence, credibility, competence, honesty, courtesy, respect, sharing expectations, and good communication.
Healing system: A true healthcare system in which people can receive adequate, nontoxic, and noninvasive assistance in maintaining wellness and healing for body, mind, emotion, and spirit, together with the most sophisticated, aggressive curing technologies available.
Health: An individually defined state or process in which the individual (nurse, client, family, group, or community) experiences a sense of well-being, harmony, and unity such that subjective experiences about health, health beliefs, and values are honored; a process of becoming an expanding consciousness.
Health promotion: Activities and preventive measures to promote health, increase wellbeing, and actualize the human potential of people, families, communities, society, and ecology; such activities and measures include immunizations, fitness and exercise programs, breast self-exam, appropriate nutrition, relaxation, stress management, social support, prayer, meditation, healing rituals, cultural practices, and promoting environmental health and safety.
Holistic communication: A free flow of verbal and nonverbal interchange between and among people and significant beings such as pets, nature, and God/Life Force/Absolute/Transcendent that explores meaning and ideas leading to mutual understanding and growth.
Holistic ethics: The basic underlying concept of the unity and integral wholeness of all people and of all nature, identified and pursued by finding unity and wholeness within the self and within humanity. In this framework, acts are not performed for the sake of law, precedent, or social norms, but rather from a desire to do good freely to witness, identify, and contribute to unity.
Holistic healing: A form of healing based on attention to all aspects of an individual—physical, mental, emotional, sexual, cultural, social, and spiritual.
Holistic nurse: A nurse who recognizes and integrates body-mind-emotion-spiritenvironment principles and modalities in daily life and clinical practice, creates a caring healing space within herself or himself that allows the nurse to be an instrument
of healing, shares authenticity of unconditional presence that helps to remove the barriers to the healing process, facilitates another person’s growth (body-mindemotion-spirit-energetic-environment connections), and assists with recovery from illness or transition to peaceful death.
of healing, shares authenticity of unconditional presence that helps to remove the barriers to the healing process, facilitates another person’s growth (body-mindemotion-spirit-energetic-environment connections), and assists with recovery from illness or transition to peaceful death.
Holistic nursing practice process: An iterative and integrative process that involves six steps that can occur simultaneously: (1) assessing; (2) diagnosing or identifying patterns, challenges, needs, and health issues; (3) identifying outcomes; (4) planning care; (5) implementing the plan of care; and (6) evaluating.
Honor: An act or intention indicating the holding of self or another in high respect, esteem, and dignity, including valuing and accepting the humanity of people with regard for the decisions and wishes of another.
Human caring: The moral ideal of nursing in which the nurse brings one’s whole self into a relationship with the whole self of the person being cared for to protect that person’s vulnerability, preserve her or his humanity and dignity, and reinforce the meaning and experience of oneness and unity.
Human health experience: That totality of human experience including each person’s subjective experience about health, health beliefs, values, sexual orientation, and personal preferences that encompasses healthwellness-disease-illness-death.
Illness: A subjective experience of symptoms and suffering to which the individual ascribes meaning and significance; not synonymous with disease; a shift in the homeodynamic balance of the person.
Intention: The conscious awareness of being in the present moment to help facilitate the healing process; a volitional act of love.
Interdisciplinary: Conversation or collaboration across disciplines where knowledge is shared that informs learning, practice, education, and research; it includes individuals, families, community members, and various disciplines.
Meaning: That which is signified, indicated, referred to, or understood. More specifically: Philosophical meaning is meaning that depends on the symbolic connections that are grasped by reason. Psychological meaning is meaning that depends on connections that are experienced through intuition or insight.
Patient-centered care: Care that is respectful of and responsive to individual patient preferences, needs, and values, and that ensures that patient values guide all clinical decisions. Patient-centered care encompasses identifying, respecting, and caring about patients’ differences, values, preferences, and expressed needs; relieving pain and suffering; coordinating continuous care/listening to, clearly informing, communicating with, and educating patients; sharing decision making and management; and continuously advocating disease prevention, wellness, and promotion of healthy lifestyles, including a focus on population health.1
Person: An individual, client, patient, family member, support person, or community member who has the opportunity to engage in interaction with a holistic nurse.
Person-centered care: The human caring process in which the holistic nurse gives full attention and intention to the whole self of a person, not merely the current presenting symptoms, illness, crisis, or tasks to be accomplished, and that also includes reinforcing the person’s meaning and experience of oneness and unity; the condition of trust that is created in which holistic care can be given and received.
Presence: The essential state or core of healing; approaching an individual in a way that respects and honors her or his essence; relating in a way that reflects a quality of being with and in collaboration with rather than doing to; entering into a shared experience (or field of consciousness) that promotes healing potential and an experience of well-being.
Relationship-centered care: A process model of caregiving that is based in a vision of community where three types of relationships are identified: (1) patient-practitioner relationship, (2) community-practitioner relationship, and (3) practitioner-practitioner relationship.
Each of these interrelated relationships is essential within a reformed integrative healthcare delivery system in a hospital, clinic, community, or in the home. Each component involves a unique set of responsibilities and tasks that addresses the three areas of knowledge, values, and skills.2
Each of these interrelated relationships is essential within a reformed integrative healthcare delivery system in a hospital, clinic, community, or in the home. Each component involves a unique set of responsibilities and tasks that addresses the three areas of knowledge, values, and skills.2
Spirituality: The feelings, thoughts, experiences, and behaviors that arise from a search for meaning; that which is generally considered sacred or holy; usually, though not universally, considered to involve a sense of connection with an absolute, imminent, or transcendent spiritual force, however named, as well as the conviction that meaning, value, direction, and purpose are valid aspects of the individual and universe; the essence of being and relatedness that permeates all of life and is manifested in one’s knowing, doing, and being; the interconnectedness with self, others, nature, and God/Life Force/Absolute/Transcendent; not necessarily synonymous with religion.
Transpersonal: A personal understanding that is based on one’s experiences of temporarily transcending or moving beyond one’s usual identification with the limited biological, historical, cultural, and personal self at the deepest and most profound levels of experience possible; that which transcends the limits and boundaries of individual ego identities and possibilities to include acknowledgment and appreciation of something greater. From this perspective the ordinary, biological, historical, cultural, and personal self is seen as an important, but only a partial, manifestation or expression of this much greater something that is one’s deeper origin and destination.
Wellness: Integrated, congruent functioning aimed toward reaching one’s highest potential.
▪ SCOPE AND STANDARDS OF HOLISTIC NURSING PRACTICE
Extraordinary changes have occurred in health care and nursing during the past decade. During this time, holistic nurses recognized that not only were they practicing a unique specialty within nursing, but that they needed to develop and publish standards of practice to document and define that specialty practice. Holistic nursing was officially recognized as a distinct specialty within the discipline of Nursing by the American Nurses Association (ANA) in November 2006. The American Holistic Nurses Association (AHNA) Holistic Nursing: Scope and Standards of Practice (2007) was written to inform holistic nurses, the nursing profession, students and faculty, other healthcare providers and disciplines, employers, third-party payers, legislators, and the public about the unique scope of knowledge and the standards of practice and professional performance of a holistic nurse.3 The current standards are an updated and substantive revision of previous standards disseminated through the AHNA.* See Appendix 2-1 for development of the original Holistic Standards of Practice: Basic and Graduate, and see Appendix 2-2 for select works of individuals and AHNA documents.
Function of the Scope of Practice Statement of Holistic Nursing
The scope of practice statement describes the who, what, where, when, why, and how of the practice of holistic nursing.3,4 The answers to these questions provide a picture of that specialty nursing practice, its boundaries, and its membership.
Nursing: Scope and Standards of Practice, 2nd ed. (2010) applies to all professional registered nurses (RNs) engaged in practice, regardless of specialty, practice setting, or educational preparation.4 With the Guide to the Code of Ethics for Nurses: Interpretation and Application5 and Nursing’s Social Policy Statement: The Essence of the Profession,6 it forms the foundation of practice for all registered nurses. The scope of holistic nursing practice is specific to this specialty, but it builds on the scope of practice expected of all registered nurses.
Function of the Standards of Holistic Nursing
“The Standards of Professional Nursing Practice are authoritative statements of the duties that all registered nurses, regardless of role, population, or specialty, are expected to perform competently.”4, p.2
Standards reflect the values and priorities of the profession. Standards provide direction for professional nursing practice and a framework for evaluation of this practice. Written in measurable terms, these standards define the nursing profession’s accountability to the public and the outcomes for which registered nurses are responsible.7, p. 1
The standards of holistic nursing practice are specific to this specialty but build on the standards of practice expected of all registered nurses.
Holistic Nursing: Scope and Standards of Practice (2007) presents a differentiation between practice at the basic and advanced practice levels. The Scope and Standards are organized according to the criteria ANA uses in recognizing a nursing specialty area and build on nursing know ledge, skills, and competencies required for licensure.8,9 Holistic Nursing: Scope and Standards of Practice (2007) provides a blueprint for holistic practice, education, and research. The standards guide clinicians, educators, researchers, nurse managers, and administrators in professional activities, knowledge, and performance that are relevant to holistic nursing basic and advanced practice, education, research, and management. Because holistic nursing emphasizes that human experiences are subjectively described and that health and illness are determined by the view of the individual, Holistic Nursing: Scope and Standards of Practice (2007) is derived from values that are central to the specialty and are consistent with the philosophies and theories of holism.
Evolution of Holistic Nursing
Holism in health care is a philosophy that emanates directly from Florence Nightingale, who believed in care that focused on unity, wellness, and the interrelationship of human beings, events, and environment. Even Hippocrates, the father of Western medicine, espoused a holistic orientation when he taught doctors to observe their patients’ life circumstances and emotional states. Socrates stated, “Curing the soul; that is the first thing.” In holism, symptoms are believed to be an expression of the body’s wisdom as it reacts to cure its own imbalance or disease.
The root of the word heal comes from the Greek word halos and the Anglo-Saxon word healan, which means “to be or to become whole.” The word holy also comes from the same source. Healing means “making whole”—or restoring balance and harmony. It is movement toward a sense of wholeness and completion. Healing, therefore, is the integration of the totality of the person in body, mind, emotion, spirit, and environment.
One of the driving forces behind the holistic nursing movement in the United States was the formation of the AHNA. In 1981, founder Charlotte McGuire and 75 founding members began the national organization in Houston, Texas. The national office is now located in Flagstaff, Arizona. The AHNA’s mission is to advance the philosophy and practices of holistic nursing and unite nurses in healing with a focus on holistic principles of health, preventive education, and the integration of allopathic and complementary caring and healing modalities to facilitate care of the whole person and significant others. From its inception in 1981, the AHNA has been the leader in developing and advancing holistic principles, practices, and guidelines. The association predicted that holistic principles, caring and healing, and the integration of complementary and alternative therapies would emerge into mainstream health care.
The AHNA, the definitive voice for holistic nursing, has as its vision “a world in which nursing nurtures wholeness and inspires peace and healing.” The mission of the AHNA is to advance holistic nursing through community building, advocacy, research, and education. It is committed to promoting wholeness and wellness in individuals, families, communities, nurses themselves, the nursing profession, and the environment. Through its various activities, AHNA provides vision, direction, and leadership in the advancement of holistic nursing; integrates the art and science of nursing in the profession; empowers holistic nursing through education,
research, and standards; encourages nurses to be models of wellness; honors individual excellence in the advancement of holistic nursing; and influences policy to change the healthcare system to a more humanistic orientation.
research, and standards; encourages nurses to be models of wellness; honors individual excellence in the advancement of holistic nursing; and influences policy to change the healthcare system to a more humanistic orientation.
The goals and endeavors of AHNA have continued to map conceptual frameworks and the blueprint for holistic nursing practice, education, and research, which is the most complete way to conceptualize and practice professional nursing. Beginning in 1993, AHNA undertook an organization development process that included the following areas:
Identifying the steps toward national certification in 1993-1994.
Revising the 1990 Standards of Holistic Nursing Practice, completed in 1995.
Completing a role delineation study, the Inventory of Professional Activities and Knowledge Statements of a Holistic Nurse (also known as the IPAKHN Survey) in 1997.
Developing a national holistic nursing certification examination, completed in 1997.
Completing major revisions of the 1995 Standards of Holistic Nursing Practice in 1999, with additional editorial changes in January 2000 and 2005.
Developing a core curriculum for basic holistic nursing based on the basic standards (1997).
Approving and adopting Standards of Advanced Holistic Nursing Practice for Graduate-Prepared Nurses (2002, revised 2005).
Developing a core curriculum for advanced holistic nursing based on the advanced standards (2003). The American Holistic Nurses Certification Corporation (AHNCC) then developed the Certification Exam for Advanced Holistic Nursing Practice first offered in 2005.
Revising both the basic and advanced Standards of Holistic Nursing Practice to meet ANA criteria for recognition of holistic nursing as a specialty (2006, 2007).
▪ SCOPE OF HOLISTIC NURSING
Holistic nursing is defined as “all nursing practice that has healing the whole person as its goal.”10 Holistic nursing is a specialty practice that draws on nursing knowledge, theories of nursing and wholeness, expertise and intuition to guide nurses in becoming therapeutic partners with people in strengthening human responses to facilitate the healing process and achieve wholeness. Holistic nursing focuses on protecting, promoting, and optimizing health and wellness; assisting healing; preventing illness and injury; alleviating suffering; and supporting people to find peace, comfort, harmony, and balance through the diagnosis and treatment of human response.
Holistic nursing care is healing oriented and centered on the relationship with the person in contrast to an orientation toward diseases and their cures. Holistic nursing emphasizes practices of self-care, intentionality, presence, mindfulness, and therapeutic use of self as pivotal for facilitation of healing and patterning of wellness in others. In some sense, all nursing practice can be comprehensive, that is, all nursing practice may have a biopsychosocial perspective. What makes holistic nursing practice a specialty is that there is a philosophy, a body of knowledge, and an advanced set of nursing skills applied to practice that recognize the totality of the human being and the interconnectedness of body, mind, emotion, spirit, energy, society, culture, relationships, context, and environment. Philosophically, holistic nursing is a worldview, a way of being in the world, not just a modality. This philosophy honors the unique humanness of all people regardless of who and what they are. Knowledge for holistic nursing practice derives not only from nursing, but from theories of wholeness, energy, and unity as well as from other healing systems and approaches. Holistic nurses incorporate both conventional nursing and complementary/alternative/integrative modalities (CAM) and interventions into practice.
Through unconditional presence and intention, holistic nurses create environments conducive to healing, using techniques that promote empowerment, peace, comfort, and a subjective sense of harmony and well-being for the person. The holistic nurse acts in partnership with the individual or family in providing options and alternatives regarding health and treatment. Additionally, the holistic nurse assists the person to find meaning in the health and illness experience.
Holistic nursing focuses on simultaneously integrating as an iterative process all of these realms: a philosophy of being and living, using theories of nursing and wholeness with related knowledge and skills, focusing on the unity and totality of humans, incorporating healing approaches, creating healing environments, partnering with and empowering individuals, and assisting in the exploration of meaning in the care of people. In holistic nursing, the nurse is the facilitator of healing, honoring that the person heals him- or herself. The holistic nurse assists individuals in identifying themselves as the healer and accessing their own innate healing capacities.
The practice of holistic nursing requires nurses to integrate self-care and self-responsibility into their own lives and to serve as role models for others. Holistic nurses strive for an awareness of the interconnectedness of individuals to the human and global community. Thus, holistic nurses also attend to the health of the ecosystem.
Holistic nurses are instruments of healing and facilitators in the healing process. They honor the individual’s subjective experience of health, health beliefs, and values. To become therapeutic partners with individuals, families, communities, and populations, holistic nurses draw on nursing knowledge, theories, research, expertise, intuition, and creativity, incorporating the roles of clinician, educator, consultant, coach, partner, role model, and advocate. Holistic nursing practice encourages peer review of professional practice in various clinical settings and provides care based on current professional standards, laws, and regulations that govern nursing practice. The major phenomena of concern to holistic nursing are listed in Table 2-1.
TABLE 2-1 Phenomena of Concern to Holistic Nursing | ||||||||||||||||||||||||
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The Core Values of Holistic Nursing: Integrating and the Art and Science of Nursing
Holistic nursing emanates from five core values summarizing the ideals and principles of the specialty. These core values are listed here and then are discussed:
Philosophy, Theory, and Ethics
Holistic Caring Process
Holistic Communication, Therapeutic Environment, and Cultural Diversity
Holistic Education and Research
Holistic Nurse Self-Care
Core Value 1: Holistic Philosophy, Theory, and Ethics
Holistic nurses (HNs) recognize the human health experience as a complicated, dynamic relationship of health, illness, and wellness, and they value healing as the desired outcome of the practice of nursing. Their practice is based on scientific foundations (theory, research, evidencebased practice, critical thinking, reflection) and
art (relationship, communication, creativity, presence, caring). Holistic nursing is grounded in nursing knowledge and skill and guided by nursing theory. Florence Nightingale’s writings are often referenced as a significant precursor of the development of holistic nursing. Although each holistic nurse chooses which nursing theory to apply in any individual case, the nursing theories of Jean Watson (the Theory of Human Caring), Martha Rogers (the Science of Unitary Human Beings), Margaret Newman (Health as Expanding Consciousness), Madeleine Lein-inger (Theory of Cultural Care), Rosemarie Rizzo Parse (Theory of Human Becoming), Josephine Paterson and Loretta Zderad (Humanistic Nursing Theory), and Helen Erickson (Modeling and Role-Modeling) are most frequently used to support holistic nursing practice.
art (relationship, communication, creativity, presence, caring). Holistic nursing is grounded in nursing knowledge and skill and guided by nursing theory. Florence Nightingale’s writings are often referenced as a significant precursor of the development of holistic nursing. Although each holistic nurse chooses which nursing theory to apply in any individual case, the nursing theories of Jean Watson (the Theory of Human Caring), Martha Rogers (the Science of Unitary Human Beings), Margaret Newman (Health as Expanding Consciousness), Madeleine Lein-inger (Theory of Cultural Care), Rosemarie Rizzo Parse (Theory of Human Becoming), Josephine Paterson and Loretta Zderad (Humanistic Nursing Theory), and Helen Erickson (Modeling and Role-Modeling) are most frequently used to support holistic nursing practice.
In addition to nursing theory, holistic nurses use other theories and perspectives of wholeness and healing to guide their practice. These scientific theories and philosophies present a worldview of connectedness. Examples include the following:
Theories of Consciousness
Energy Field Theory
C. Pribram’s Holographic Universe
D. Bohm’s Implicate/Explicate Order
C. Pert’s Psychoneuroimmunology
K. Wilber’s Integral Vision and Unified Field Theory of Consciousness
Spirituality
Alternative medical systems such as Traditional Oriental Medicine, Ayurveda, Native American, and indigenous healing
Eastern contemplative orientations such as Zen Buddhism and Taoism
Holistic nurses further recognize and honor the ethic that the person is the authority on his or her own health experience. The holistic nurse is an “option giver” and helps the person develop an understanding of alternatives and implications of various health and treatment options. The holistic nurse first ascertains what the individual thinks or believes is happening to him/her, and then assists the person to identify what will help the situation. The assessment begins from where the individual is. The holistic nurse then discusses options, including the person’s choices across a continuum and the possible effects and implications of each. For instance, if a person diagnosed with cancer is experiencing nausea caused by chemotherapy, the individual and nurse may discuss the choices and effects of pharmacologic agents, imagery, homeopathic remedies, and so on, or a combination of these. The holistic nurse acts as partner and coprescriber versus sole prescriber. The relationship is a copiloting of the individual’s health experience where the nurse respects the person’s decision about his or her own health. It is a process of engagement versus compliance.
Client narratives, whether they arise from individuals, families, or communities, provide the context of the experiences and are used as an important focus in understanding the person’s situation. Holistic nurses hold the belief that people, through their inherent capacities, heal themselves. Therefore, the holistic nurse is not the healer but the guide and facilitator of the individual’s own healing.
In the belief that all things are connected, the holistic perspective espouses that an individual’s actions have a ripple effect throughout humanity. Holism places the greatest worth on individuals’ developing higher levels of human awareness. This, in turn, elevates the whole of humanity. Holistic nurses believe in the sacredness of one’s self and of all nature. One’s inner self and the collective greater self have stewardship not only over one’s body, mind, and spirit but also the planet. Holistic nurses focus on the meaning and quality of life deriving from their own character and from their relationship to the universe rather than that imposed from without.
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