Nursing: Integral, Integrative, and Holistic—Local to Global



Nursing: Integral, Integrative, and Holistic—Local to Global


Barbara Montgomery Dossey



Nurse Healer OBJECTIVES









image


Theoretical



  • Explore the Theory of Integral Nursing and its application to holistic nursing.


  • Examine the United Nations Millennium Goals.


  • Link Florence Nightingale’s legacy of healing, leadership, global action, and her work as a nurse and citizen activist to 21st-century integral and holistic nursing.


  • Analyze relationship-centered care and its three components.


  • Examine optimal healing environments and their four domains.


Clinical



  • Apply relationship-centered care principles and components in your practice.


  • Compare and contrast the three eras of medicine.


  • Examine the Theory of Integral Nursing, and begin the process of integrating the theory into your clinical practice.


  • Determine whether you have an integral worldview and approach in your clinical practice and other education, research, hospital policies, and community endeavors.


Personal



  • Create an integral self-care plan.


  • Examine ways to enhance integral understanding in your personal endeavors.


  • Develop short- and long-term goals related to increasing your commitment to an integral developmental process.




DEFINITIONS

Global health: Exploration of the emerging value base and new relationships and innovations that occur when health becomes an essential component and expression of global citizenship; an increased awareness that health is a basic human right and a global good that needs to be promoted and protected by the global community.

Holistic nursing: See Chapter 2 definitions.

Integral: Comprehensive way to organize multiple phenomena of human experience related to four perspectives of reality: (1) the individual interior (personal/intentional); (2) individual exterior (physiology/behavioral); (3) collective interior (shared/cultural); and (4) collective exterior (systems/structures).

Integral dialogue: Transformative and visionary exploration of ideas and possibilities across disciplines where the individual interior
(personal/intentional), individual exterior (physiology/behavioral), collective interior (shared/cultural), and collective exterior (structures/systems) are considered as equally important to exchanges and outcomes.

Integral healing process: Contains both nurse processes and patient/family and healthcare worker processes (individual interior and individual exterior), and collective healing processes of individuals and of systems/structures (collective interior and exterior); an understanding of the unitary whole person interacting in mutual process with the environment.

Integral health: Process through which we reshape basic assumptions and worldviews about well-being and see death as a natural process of living; may be symbolically viewed as a jewel with many facets that is reflected as a “bright gem” or a “rough stone” depending on one’s situation and personal growth that influence states of health, health beliefs, and values.

Integral health care: A patient-centered and relationship-centered caring process that includes the patient, family, and community and conventional, integrative, and integral healthcare practitioners and services and interventions; a process where the individual interior (personal/intentional), the individual exterior (physiology/behavioral), the collective interior (shared/cultural), and the collective exterior (structures/systems) are considered in all endeavors.

Integral nurse: A 21st-century Nightingale who is engaged as a “health diplomat” and an integral health coach who is coaching for integral health.

Integral nursing: A comprehensive integral worldview and process that includes holistic theories and other paradigms; holistic nursing is included (embraced) and transcended (goes beyond); this integral process and integral worldview enlarges our holistic understanding of body-mindspirit connections and our knowing, doing, and being to more comprehensive and deeper levels.

Integral worldview: Process where values, beliefs, assumptions, meaning, purpose, and judgments are identified and related to how individuals perceive reality and relationships that includes the individual interior (personal/intentional), individual exterior (physiology/behavioral), collective interior (shared/cultural), and collective exterior (systems/structures).

Relationship-centered care: A process model of caregiving that is based in a vision of community where the patient-practitioner, community-practitioner, and practitioner-practitioner relationships, and the unique set of responsibilities of each are honored and valued.


▪ NURSING: INTEGRAL, INTEGRATIVE, AND HOLISTIC

In the future, which I shall not see, for I am old, may a better way be opened! May the methods by which every infant, every human being will have the best chance at health—the methods by which every sick person will have the best chance at recovery, be learned and practiced. Hospitals are only an intermediate stage of civilization, never intended, at all events, to take in the whole sick population. …

May we hope that, when we are all dead and gone, leaders will arise who have been personally experienced in the hard, practical work, the difficulties, and the joys of organizing nursing reforms, and who will lead far beyond anything we have done! May we hope that every nurse will be an atom in the hierarchy of ministers of the Highest! But she [or he] must be in her [or his] place in the hierarchy, not alone, not an atom in the indistinguishable mass of thousands of nurses. High hopes, which shall not be deceived!”1

Florence Nightingale’s (1893) words above empower us in our mission of service. In 2010, the Institute of Medicine Future of Nursing report published a landmark document that presented four key messages:2



  • Nurses should practice to the full extent of their education and training.


  • Nurses should achieve higher levels of education and training through an improved
    education system that promotes seamless academic progression.


  • Nurses should be full partners, with physicians and other healthcare professionals, in redesigning health care in the United States.


  • Effective workforce planning and policy making require better data collection and information infrastructure.

To fulfill the challenges addressed in the IOM report an integral perspective has never been more important. At the forefront, nurses are now engaged as change agents to improve the health of the nation, to focus on increasing the “health span” of individuals rather than focusing on life span. Integral nursing can be described as a comprehensive integral worldview and process that includes holistic theories and other paradigms; holistic nursing practice is included (embraced) and transcended (goes beyond).3,4,5,6 This integral process and the integral worldview enlarge our holistic understanding of body-mind-spirit connections and our knowing, doing, and being to more comprehensive and deeper levels (Note: See the section titled “Theory of Integral Nursing” later in this chapter for full discussion.)

Holistic nursing is defined as “all nursing practice that has healing the whole person as its goal.”7 As described and developed later in this text (Chapter 2), holistic nursing has attained new levels of acceptance and is now officially recognized by the American Nurses Association (ANA) as a nursing specialty with a defined scope and standards of practice.7 Our holistic nursing challenges as described throughout this text include ways to learn and integrate new theories, models, and information, and how to articulate the science and art of holistic nursing, complementary and alternative modalities (CAM), integrative modalities, and healing in all areas and specialties of nursing. Our challenges and opportunities to interface in interprofessional conversations related to integral, integrative, and holistic nursing and integrative medicine with traditional and nontraditional healthcare professionals, healers, disciplines, and organizations can transform health care.8,9,10 Integrative medicine (IM) is the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals, and disciplines to achieve optimal health and healing.8 The next section provides an overview of how we can globally integrate and translate integral and holistic nursing concepts.


▪ GLOBAL NURSING, NIGHTINGALE DECLARATION, AND UNITED NATIONS MILLENNIUM DEVELOPMENT GOALS

Severe health needs exist in almost every community and country. These are no longer isolated problems in far-off places. Across humankind, we all face common health concerns and global health imperatives. With globalization and global warming, no natural or political boundaries stop the spread of disease.11,12,13 Yet, the health and well-being of people everywhere can be seen as common ground to secure a sustainable, prosperous future for everyone. In interdisciplinary and interprofessional collaboration with professional and allied health colleagues, as well as concerned citizens, nurses can play a major role in mobilizing new approaches to education, healthcare delivery, and disease prevention. Global health requires new leadership models in communication, negotiations, resource, management, work-life balance, and mentor-mentee models and relationships.13,14

Global health is the exploration of the emerging value base and new relationships and agendas that occur when health becomes an essential component and expression of global citizenship.13 It is an increased awareness that health is a basic human right that is “decent care”15 that addresses the body, mind, and spirit and is a global good that needs to be promoted and protected by the global community. Severe health needs exist in almost every community and nation throughout the world. Thus, all nurses are involved in some aspect of global health because their caring and healing endeavors assist individuals to become healthier, which leads to healthy people living in a healthy world by 2020.16,17

Currently, there are 17.6 million nurses and midwives engaged in nursing and providing health care around the world.18 Together, we are collectively addressing human health—the
health of individuals, of communities, of environments (interior and exterior), and the world as our first priority. We are educated and prepared—physically, emotionally, socially, mentally, and spiritually—to accomplish effectively the activities required to create a healthy world. Nurses are key in mobilizing new approaches in health education and healthcare delivery in all areas of nursing. Solutions and evidence-based practice protocols can be shared and implemented around the world through dialogues, the Internet, and publications, which are essential as we address the global nursing shortage.19

We are challenged to act locally and think globally and to address ways to create healthy environments. For example, we can address global warming in our own personal habits at home as well as in our workplace (using green products, using energy-efficient fluorescent bulbs, turning off lights when not in the room) and simultaneously address our own personal health and the health of the communities where we live. As we expand our awareness of individual and collective states of healing consciousness and integral dialogues, we can explore integral ways of knowing, doing, and being.






FIGURE 1-1 Global nurses collage.

Source: Global Nurses collage from the World Health Organization (WHO)

Source: Photo Credits: Site, Source, Photographer; clockwise from upper left: Switzerland, WHO, John Mohr; Finland, WHO, John Mohr; Japan, WHO, T. Takahara; India, WHO, T.S. Satyan; Brazil, WHO, L. Nadel; Niger, WHO, M. Jacot; Sweden, WHO, John Mohr; Afghanistan, Wikimedia, Ben Barber of USAID; India, Wikimedia, Oreteki; Morocco, WHO, P. Boucas. All World Health Organization (WHO) photos used with attribution as required. Wikimedia Commons: Afghanistan, in the public domain; India, used under the terms of the GNU Free Documentation License.

We can unite 17.6 million nurses (Figure 1-1) and midwives, along with concerned citizens through the Internet to create a healthy world through many endeavors such as signing the Nightingale Declaration (at www.nightingale declaration.net), as shown in Figure 1-2.16 (See the section titled “Theory of Integral Nursing” later in this chapter.)

During the year 2000, world leaders convened a United Nations Millennium Summit to establish eight Millennium Development Goals (MDGs), as shown in Figure 1-3, that must be achieved for the 21st century to progress toward a sustainable quality of life for all of humanity.20 These goals are an ambitious agenda for improving lives worldwide. Of these eight MDGs, three—MDG 4, Reduce Child Mortality, MDG 5, Improve Maternal Health, and MDG 6, Combat HIV/AIDS—are directly related to health and nursing. The other five goals, MDG 1, Eradicate Extreme Poverty and Hunger, MDG 2, Achieve Universal Primary Education, MDG 3, Promote Gender Equality and Empower Women, MDG 7, Ensure Environmental Sustainability, and MDG 8, Develop a Global Partnership for Development are factors

that determine the health or lack of health of people. For each goal, one or more targets, which used the 1990 data as benchmarks, are set to be achieved by 2015. Health is the common thread running through all eight UN MDGs. The goals are directly related to nurses, as they work today to achieve them at grassroots levels everywhere and many are engaged in sharing local solutions at the global level.






FIGURE 1-2 Nightingale declaration for a healthy world by 2020.

Source: Used with permission, Nightingale Initiative for Global Health (NIGH), http://www.nightingaledeclaration.net






FIGURE 1-3 United Nations millennium development goals and targets.

Source: World Health Organization, WHO Assembly Report: Millennium Development Goals and Targets (Geneva, WHO: 2000), http://www.who.int/mdg/en.

An integral approach can help nurses conceptualize and map what is missing from caregiving and care delivery. With an integral worldview, collectively we can move closer to achieving global health. Ensuring basic survival needs has been identified as the single most important factor in building responsive and effective health systems in all countries. The health and happiness of people everywhere in the global community are the only common ground for a secure and sustainable prosperous future.3 Yet a healthy world still requires nurses’ knowledge, expertise, wisdom, and dedication. If today’s nurses, midwives, and allied health professionals are nurtured and sustained in innovative ways, they can become like Nightingale—effective voices calling for and demonstrating the healing, leadership, and global action required to achieve a healthy world. This can strengthen nursing’s ranks and help the world to value and nurture nursing’s essential contributions.3 As Nightingale said, “We must create a public opinion, which must drive the government instead of the government having to drive us … an enlightened public opinion, wise in principle, wise in detail.”21

Nurses aim to initiate new approaches and connect the dots by empowering both individuals and groups to see through integral nursing lenses and to revisit the integral approach to Nightingale’s legacy in 21st-century terms.


▪ PHILOSOPHICAL FOUNDATION: FLORENCE NIGHTINGALE’S LEGACY

Florence Nightingale (1820-1910) (Figure 1-4), the philosophical founder of modern secular nursing and the first recognized nurse theorist, was an integralist. An integralist is a person who focuses on the individual and the collective, the inner and outer, human and nonhuman concerns. Nightingale was concerned with the most basic needs of human beings and all aspects of the environment (clean air, water, food, houses, etc.)—local to global.22,23,24,25,26 She also experienced and recorded her personal understanding of the connection with the Divine as an awareness that something greater than her, the Divine, was a major connecting link woven into her work and life.22 The entirety of her life, work, and insights clearly articulates and demonstrates the science and art of an integral worldview for nursing, health care, and humankind, as developed further in the section titled “Theory of Integral Nursing” and in Figure 1-9, later in this chapter.

Nightingale was a nurse, educator, administrator, communicator, statistician, and environmental activist.22,26 Her specific accomplishments include establishing the model for nursing schools throughout the world and creating a prototype model of care for the sick and wounded soldiers during the Crimean War (1854-1856). She was an innovator for British Army medical reform that included reorganizing the British Army Medical Department, creating an Army Statistical Department, and collaborating on the first British Army medical school, including developing the curriculum and choosing the
professors. She revolutionized hospital data collection and invented a statistical wedge diagram equivalent to today’s circular histograms or circular statistical representation. In 1858, she became the first woman admitted to the Royal Statistical Society. She developed and wrote protocols and papers on workhouses and midwifery that led to successful legislation reform. She was a recognized expert on the health of the British Army and soldiers in India for more than 40 years; she never went to India but collected data directly from Army stations, analyzed the data, and wrote and published documents, articles, and books on the topic.






FIGURE 1-4 Florence Nightingale (1820-1910).

In 1902, besides her numerous other recognitions, she was the first woman to receive the Order of Merit. She wrote more than 100 combined books and official Army reports. Her 10,000 letters now make up the largest private collection of letters at the British Library with 4,000 family letters at the Wellcome Trust in London.22,26 Today we recognize Nightingale’s work as global nursing: She envisioned what a healthy world might be with her integral philosophy and expanded visionary capacities. Her work included aspects of the nursing process (see Chapter 7) as well; it has indeed had an impact on nurses today and will continue to affect us far into the future. Nightingale’s work was social action that demonstrated and clearly articulated the science and art of an integral worldview for nursing, health care, and humankind. Her social action was also sacred activism,27 the fusion of the deepest spiritual knowledge with radical action in the world.

In the 1880s, Nightingale began to write that it would take 100-150 years before educated and experienced nurses would arrive to change the healthcare system. We are that generation of 21st-century Nightingales who have arrived to transform health care and carry forth her vision of social action and sacred activism to create a healthy world. Using terms coined by Patricia Hinton-Walker, 21st-century Nightingales are “health diplomats” and “integral health coaches” who are “coaching for integral health.”28

Nightingale was ahead of her time. Her dedicated and focused 40 years of work and service still inform and influence our nursing work and our global mission of health and healing for humanity today. Table 1-1 lists the themes in her Notes on Hospitals (1859),29 Notes on Nursing (1860),30 her formal letters to her nurses (1872-1900),31 and her article “Sick-Nursing and Health-Nursing” (1893).32 Table 1-2 shows Nightingale’s themes recognized today as total healing environments. The next section presents an overview of the eras of medicine and application of this information to integral and holistic nursing.


▪ ERAS OF MEDICINE

Three eras of medicine currently are operational in Western biomedicine (see Table 1-3).33 Era I medicine began to take shape in the 1860s, when medicine was striving to become scientific. The underlying assumption of this approach is that health and illness are completely physical in nature. The focus is on combining drugs, medical treatments, and technology for curing. A person’s consciousness is considered a byproduct of the chemical, anatomic, and physiologic aspects of the brain and is not considered a major factor in the origins of health or disease.

In the 1950s, Era II therapies began to emerge. These therapies reflected the growing awareness that the actions of a person’s mind or consciousness—thoughts, emotions, beliefs, meaning, and attitudes—exerted important effects on the behavior of the person’s physical body.33 In both Era I and Era II, a person’s consciousness is said to be “local” in nature; that is, confined to a specific location in space (the body itself) and in time (the present moment and a single lifetime).

Era III, the newest and most advanced era, originated in science. Consciousness is said to be nonlocal in that it is not bound to individual bodies. The minds of individuals are spread throughout space and time; they are infinite, immortal, omnipresent, and, ultimately, one. Era III therapies involve any therapy in which the effects of consciousness create bridges between different persons, as with distant healing, intercessory prayer, shamanic healing, so-called miracles, and certain emotions (e.g., love, empathy, compassion). Era III approaches involve transpersonal experiences of being. They raise a person above control at a day-to-day material level to an experience outside his or her local self.










TABLE 1-1 Florence Nightingale’s Legacy and Themes for Today



















































Themes Developed in Notes on Hospitals (1859, 1863)


The hospital will do the patient no harm. Four elements essential for the health of hospitals:


▪ Fresh air


▪ Ample space

▪ Light


▪ Subdivision of sick into separate buildings or pavilions


Hospital construction defects that prevented health:


▪ Defective means of natural ventilation and warming


▪ Defective height of wards


▪ Excessive width of wards between the opposite windows


▪ Arrangement of the bed along the dead wall


▪ More than two rows of beds between the opposite windows


▪ Windows only on one side, or a closed corridor connecting the wards


▪ Use of absorbent materials for walls and ceilings, and poor washing of hospital floors

▪ Defective condition of water closets


▪ Defective ward furniture


▪ Defective accommodation for nursing and discipline


▪ Defective hospital kitchens


▪ Defective laundries


▪ Selection of bad sites and bad local climates for hospitals


▪ Erecting of hospitals in towns


▪ Defects of sewerage


▪ Construction of hospitals without free circulation of external air


Themes Developed in Notes on Nursing (1860)


Understand God’s laws in nature

Cleanliness (personal)


▪ Understanding that, in disease and in illness, nursing and the nurses can assist in the reparative process of a disease and in maintaining health

▪ Provide proper bathing, rubbing, and scrubbing of the skin of the patient as well as of the nurse.


▪ Use proper handwashing techniques that include cleaning the nails.


Nursing and nurses

Food


▪ Describing the many roles and responsibilities of the nurse


Patient


▪ Observing and managing the patient’s problems, needs, and challenges, and evaluating responses to care


Health


▪ Recognizing factors that increase or decrease positive or negative states of health, wellbeing, disease, and illness


Environment


▪ Both the internal (within one’s self) and the external (physical space). (See the specifics listed in the next 12 categories.)


Bed and bedding


▪ Promote proper cleanliness.


▪ Use correct type of bed, with proper height, mattress, springs, types of blankets, sheets, and other bedding.


Cleanliness (rooms and walls)


▪ Maintain clean room, walls, carpets, furniture, and dust-free rooms using correct dusting techniques.


▪ Release odors from painted and papered rooms; discusses other remedies for cleanliness.

▪ Provide proper portions and types of food at the right time, and a proper presentation of food types: eggs, meat, vegetables, beef teas, coffee, jellies, sweets, and homemade bread.


Health of houses


▪ Provide pure air, pure water, efficient drainage, cleanliness, and light.


Light


▪ Provide a room with light, windows, and a view that is essential to health and recovery.


Noise


▪ Avoid noise and useless activity such as clanking or loud conversations with or among caregivers.


▪ Speak clearly for patients to hear without having to strain.


▪ Avoid surprising the patient.


▪ Only read to a patient if it is requested.


Petty management


▪ Ensure patient privacy, rest, a quiet room, and instructions for the person managing care of patient.


Variety


▪ Provide flowers and plants and avoid those with fragrances.


▪ Be aware of effects of mind (thoughts) on body.


▪ Help patients vary their painful thoughts.


▪ Use soothing colors.


▪ Be aware of positive effect of certain music on the sick.


Ventilation and warming


▪ Provide pure air within and without; open windows and regulate room temperature.


▪ Avoid odiferous disinfectants and sprays.


Chattering hopes and advice


▪ Avoid unnecessary advice, false hope, promises, and chatter of recovery.

▪ Avoid absurd statistical comparisons of patient to recovery of other patients, and avoid mockery of advice given by family and friends.


▪ Share positive events; encourage visits from a well-behaved child or baby.


▪ Be aware of how small pet animals can provide comfort and companionship for the patient.


Observation of the sick


▪ Observe each patient; determine the problems, challenges, and needs.


▪ Assess how the patient responds to food, treatment, and rest.


▪ Help patient with comfort, safety, and health strategies.


▪ Intervene if danger to patient is suspected.


Themes Developed in Letters to Her Nurses (1872-1900)


All themes above in Notes on Hospitals and Notes on Nursing plus:


Art of nursing

Personal aspects of nursing


▪ Explore authentic presence, caring, meaning, and purpose.


▪ Increase communication with colleagues, patients, and families.


▪ Build respect, support, and trusting relationships.


Environment


▪ Includes the internal self as well as the external physical space


Ethics of nursing


▪ Engage in moral behaviors and values and model them in personal and professional life.


Health


▪ Integrate self-care and health-promoting and sustaining behaviors.


▪ Be a role model and model healthy behaviors.

▪ Explore body-mind-spirit wholeness, healing philosophy, self-care, relaxation, music, prayers, and work of service to self and others.


▪ Develop therapeutic and healing relationships.


Science of nursing


▪ Learn nursing knowledge and skills, observing, implementing, and evaluating physicians’ orders combined with nursing knowledge and skills.


Spirituality


▪ Develop intention, self-awareness, mindfulness, presence, compassion, love, and service to God and humankind.


Themes Developed in “Sick-Nursing and Health-Nursing” (1893 Essay)


All themes above in Notes on Nursing and Letters to Her Nurses (1872-1893) plus:


Collaboration with others


▪ Meet with nurses and women at the local, national, and global level to explore health education and how to support each other in creating health and healthy environments.

Health education curriculum and health missioners education


▪ Include all components discussed in Notes on Nursing.


▪ Teach health as proactive leadership for health.


Source: Used with permission. B. M. Dossey, “Florence Nightingale’s Tenets: Healing, Leadership, Global Action,” in Florence Nightingale Today: Healing, Leadership, Global Action, eds. B. M. Dossey et al. (Silver Spring, MD: Nurses books.org, 2005).










TABLE 1-2 Total Healing Environments Today: Integral and Holistic























































































































































The Internal Healing Environment


▪

Includes presence, caring, compassion, creativity, deep listening, grace, honesty, imagination, intention, love, mindfulness, self-awareness, trust, and work of service to self and others.


▪

Grounded in ethics, philosophies, and values that encourage and nurture such qualities as are listed above and in a way that:


  • Engages body-mind-spirit wholeness



  • Fosters healing relationships and partnerships



  • Promotes self-care and health-promoting and sustaining behaviors



  • Engages with and is affected by the elements of the external healing environment (below).


The External Healing Environment


Color and texture


▪

Use color that creates healing atmosphere, sacred space, moods, and that lifts spirits.


▪

Coordinate room color with bed coverings, bedspreads, blankets, drapes, chairs, food trays, and personal hygiene kits.


▪

Use textural variety on furniture, fabrics, artwork, wall surfaces, floors, ceilings, and ceiling light covers.


Communication


▪

Provide availability of caring staff for patient and family.


▪

Provide a public space for families to use television, radio, and telephones.


Family areas


▪

Create facilities for family members to stay with patients.


▪

Provide a comfortable family lounge area where families can keep or prepare special foods.


Light


▪

Provide natural light from low windows where patient can see outside.


▪

Use full-spectrum light throughout hospital, clinics, schools, public buildings, and homes.


▪

Provide control of light intensity with good reading light to avoid eye strain.


Noise control


▪

Eliminate loudspeaker paging systems in halls and elevators.


▪

Decrease noise of clanking latches, food carts and trays, pharmacy carts, slamming of doors, and noisy hallways.


▪

Provide 24-hour continuous music and imagery channels such as Healing Healthcare Systems Continuous Ambient Relaxation Environment (C.A.R.E., www.healinghealth.com) and Aesthetic Audio Systems (www.aestheticas.net), and other educational channels related to health and well-being.


▪

Decrease continuous use of loud commercial television.


▪

Eliminate loud staff conversations in unit stations, lounges, and calling of staff members in hallways.


Privacy


▪

Provide a Do Not Disturb sign for patient and family to place on door to control privacy and social interaction.


▪

Position bed for view of outdoors, with shades to screen light and glare.


▪

Use full divider panel or heavy curtain for privacy if in a double-patient room.


▪

Secure place for personal belongings.


▪

Provide shelves to place personal mementos such as family pictures, flowers, and totems.


Thermal comfort


▪

Provide patient control of air circulation, room temperature, fresh air, and humidity.


Ventilation and air quality


▪

Provide fresh air, adequate air exchange, rooftop gardens, and solariums.


▪

Avoid use of toxic materials such as paints, synthetic materials, waxes, and foul-smelling air purifiers.


Views of nature


▪

Use indoor landscaping, which may include plants and miniature trees.


▪

Provide pictures of landscapes that include trees, flowers, mountains, ocean, and the like for patient and staff areas.


Integral and integrative practice


Throughout hospitals, clinics, schools, and all parts of a community:

▪

Combine conventional medical treatments, procedures, and surgery with complementary and alternative therapies and folk medicine.

▪

Engage in integral and interdisciplinary dialogues and collaboration that foster deep personal support, trust, and therapeutic alliances.

▪

Offer educational programs for professionals that teach the specifics about the interactions of the healer and healee, holistic philosophy, patient-centered care, relationship-centered care, and complementary and alternative therapies.

▪

Develop and build community and partnerships based on mutual support, trust, values, and exchange of ideas.

▪

Use strategies that enhance the interconnectedness of persons, nature, inner and outer, spiritual and physical, and private and public.

▪

Use self-care and health-promoting education that includes prevention and public health.

▪

Provide support groups, counseling, and psychotherapy, specifically for cancer and cardiac support groups, lifestyle change groups, 12-step programs and support groups, for leisure, exercise, and nutrition and weight management.

▪

Use health coaches for staff, patients, families, and community.

▪

Provide information technology and virtual classroom capabilities.


Source: Used with permission. B. M. Dossey, “Florence Nightingale’s Tenets: Healing, Leadership, Global Action,” in Florence Nightingale Today: Healing, Leadership, Global Action, eds. B. M. Dossey et al. (Silver Spring, MD: Nurse-Books.org, 2005).




“Doing” and “Being” Therapies

Holistic nurses use both “doing” and “being” therapies, as shown in Figure 1-5. These are also referred to as holistic nursing therapies, complementary and alternative therapies, or integrative and integral therapies throughout this textbook. Doing therapies include almost all forms of modern medicine, such as medications, procedures, dietary manipulations, radiation, and acupuncture. In contrast, being therapies do not employ things, but instead use states of consciousness.33,34 These include imagery, prayer, meditation, and quiet contemplation, as well as the presence and intention of the nurse. These techniques are therapeutic because of the power of the psyche to affect the body. They may be either directed or nondirected.32,34 A person who uses a directed mental strategy attaches a specific outcome to the imagery, such as the regression of disease or the normalization of the blood pressure. In a nondirected approach, the person images the best outcome for the situation but does not try to direct the situation or assign a specific outcome to the strategy. This reliance
on the inherent intelligence within oneself to come forth is a way of acknowledging the intrinsic wisdom and self-correcting capacity within.

It is obvious that Era I medicine uses doing therapies that are highly directed in their approach. It employs things, such as medications, for a specific goal. Era II medicine is a classic body-mind approach that usually does not require the use of things, except for biofeedback instrumentation, music therapy, and CDs and videos to enhance learning and experience an increase in awareness of body-mind connections. It employs being therapies that can be directed or nondirected, depending on the mental strategies selected (e.g., relaxation or meditation). Era III medicine is similar in this regard. It requires
a willingness to become aware, moment by moment, of what is true for our inner and outer experience. It is actually a “not doing” so that we can become conscious of releasing, emptying, trusting, and acknowledging that we have done our best, regardless of the outcome. As the therapeutic potential of the mind becomes increasingly clear, all therapies and all people are viewed as having a transcendent quality. The minds of all people, including families, friends, and the healthcare team (both those in close proximity and those at a distance), flow together in a collective as they work to create healing and health.35








TABLE 1-3 Eras of Medicine

Era I

Era II

Era III


Space-Time Characteristic

Local

Local

Nonlocal


Synonym

Mechanical, material, or physical medicine

Mind-body medicine

Nonlocal or transpersonal medicine


Description

Causal, deterministic, describable by classical concepts of space-time and matter-energy. Mind not a factor; “mind” a result of brain mechanisms.

Mind a major factor in healing within the single person. Mind has causal power; is thus not fully explainable by classical concepts in physics. Includes but goes beyond Era I.

Mind a factor in healing both within and between persons. Mind not completely localized to points in space (brains or bodies) or time (present moment or single lifetimes). Mind is unbounded and infinite in space and time—thus omnipresent, eternal, and ultimately unitary or one. Healing at a distance is possible. Not describable by classical concepts of spacetime or matter-energy.


Examples

Any form of therapy focusing solely on the effects of things on the body is an Era I approach—including techniques such as acupuncture and homeopathy, the use of herbs, etc. Almost all forms of “modern” medicine—drugs, surgery, irradiation, CPR, etc.—are included.

Any therapy emphasizing the effects of conscious-ness solely within the individual body is an Era II approach. Psychoneuroimmunology, counseling, hypnosis, biofeedback, relaxation therapies, and most types of imagery-based “alternative” therapies are included.

Any therapy in which effects of conscious-ness bridge between different persons is an Era III approach. All forms of distant healing, intercessory prayer, some types of shamanic healing, diagnosis at a distance, telesomatic events, and probably noncontact therapeutic touch are included.


Source: Reprinted with permission from L. Dossey, Reinventing Medicine: Beyond Mind-Body to a New Era of Healing. San Francisco: HarperSanFrancisco, 1999. Copyright Larry Dossey.



Rational Versus Paradoxical Healing

All healing experiences or activities can be arranged along a continuum from the rational domain to the paradoxical domain. The degree of doing and being involved determines these domains, as shown in Figure 1-6. Rational healing experiences include those therapies or events that make sense to our linear, intellectual thought processes, whereas paradoxical healing experiences include healing events that may seem absurd or contradictory but are, in fact, true.34

Doing therapies fall into the rational healing category. Based on science, these strategies conform to our worldview of commonsense notions. Often, the professional can follow an algorithm that dictates a step-by-step approach. Examples of rational healing include surgery, irradiation, medications, exercise, and diet. On the other hand, being therapies fall into the paradoxical healing category because they frequently happen without a scientific explanation. In psychological counseling, for example, a breakthrough is a paradox. When a patient has a psychological breakthrough, it is clear that there is a new meaning for the person. However, no clearly delineated steps led to the breakthrough. Such an event is called a breakthrough for the very reason that it is unpredictable —thus, the paradox.






FIGURE 1-5 “Being” and “Doing” Therapies

Source: Reprinted with permission from L. Dossey, Meaning and Medicine: A Doctor’s Tales of Breakthrough and Healing, p. 204, New York, Bantam Books, 1991. Copyright Larry Dossey.






FIGURE 1-6 Continuum of Rational and Paradoxical Healing

Source: Reprinted with permission from L. Dossey, Meaning and Medicine: A Doctor’s Tales of Breakthrough and Healing, p. 205, New York, Bantam Books, 1991. Copyright Larry Dossey.


Biofeedback also involves a paradox. For example, the best way to reduce blood pressure or muscle tension, or to increase peripheral blood flow, is to give up trying and just learn how to be. Individuals can enter into a state of being, or passive volition, in which they let these physiologic states change in the desired direction. Similarly, the phenomenon of placebo is a paradox. If an individual has just a little discomfort, a placebo does not work very well. The more pain a person has, however, the more dramatic the response to a placebo medication can be. In addition, a person who does not know that the medication is a placebo responds best. This is referred to as the “paradox of success through ignorance.” Prayer and faith fall into the domain of paradox because there is no rational scientific explanation for their effectiveness. Many scientific studies have been conducted, however.32,34

Miracle cures also are paradoxical because there is no scientific mechanism to explain them.32,34,35 Every nurse has known, heard of, or read about a patient who had a severe illness that had been confirmed by laboratory evidence but that disappeared after the patient adopted a being approach. Some say that it was the natural course of the illness; some die and some live. At shrines such as Lourdes in France and Medjugorje in Yugoslavia, however, people who experience a miracle cure are said to be totally immersed in a being state. They do not try to make anything happen. When interviewed, these people report experiencing a different sense of space and time; the flow of time as past, present, and future becomes an eternal now. Birth and death take on new meaning and are not seen as a beginning and an end. Premonition literally means “forewarning.”36 Premonitions are a heads-up about something just around the corner, something that is usually unpleasant. It may be a health crisis, a death in the family, or a national disaster. But premonitions come in all flavors. Sometimes they provide information about positive, pleasant happenings that lie ahead—a job promotion, the location of the last remaining parking space, or, in some instances, the winning lottery numbers.

These people go into the self and explore the “not I” to become empty so that they can understand the meaning of illness or present situations. To further integrate these concepts, relationship-centered care is discussed next.


▪ RELATIONSHIP-CENTERED CARE

In 1994, the Pew Health Professions Commission published its landmark report on relationshipcentered care.37 This report serves as a guideline for addressing the bio-psycho-social-spiritual dimensions of individuals in integrating caring, healing, and holism into health care. The guidelines are based on the tenet that relationships and interactions among people constitute the foundation for all therapeutic activities.

In integral and holistic nursing, relationship-centered care serves as a model of caregiving that is based in a vision of community where three types of relationships are identified: (1) patient-practitioner relationships, (2) community-practitioner relationships, and (3) practitioner-practitioner relationships.37 The three components of relationship-centered care are shown in Table 1-4, Table 1-5, and Table 1-6. Each of these interrelated relationships is essential within a reformed system of health care, and each involves a unique set of tasks and responsibilities that address self-awareness, knowledge, values, and skills.


Patient-Practitioner Relationship

In integral health care, the patient-practitioner relationship is crucial on many levels. The practitioner incorporates comprehensive biotechnologic care with psycho-social-spiritual care. To work effectively within the patient-practitioner relationship, the practitioner must develop specific knowledge, skills, and values, as shown in Table 1-4.37 This includes an expanding selfawareness, understanding the patient’s experience of health and illness, developing and maintaining caring relationships with patients, and communicating clearly and effectively.

Active collaboration with the patient and family in the decision-making process, promotion of health, and prevention of stress and illness within the family are also part of the relationship. A successful relationship involves active listening and effective communication; integration of the elements of caring, healing, values, and ethics to enhance and preserve the dignity and
integrity of the patient and family; and a reduction of the power inequalities in the relationship with regard to race, sex, education, occupation, and socioeconomic status.








TABLE 1-4 Patient-Practitioner Relationship: Areas of Knowledge, Skills, and Values






























Area

Knowledge

Skills

Values


Self-awareness

Knowledge of self


Understanding self as a resource to others

Reflect on self and work

Importance of self-awareness, self-care, self-growth


Patient experience of health and illness

Role of family, culture, community in development


Multiple components of health


Multiple threats and contributors to health as dimensions of one reality

Recognize patient’s life story and its meaning


View health and illness as part of human development

Appreciation of the patient as a whole person


Appreciation of the patient’s life story and the meaning of the health-illness condition


Developing and maintaining caring relationships

Understanding of threats to the integrity of the relationship (e.g., power inequalities)


Understanding of potential for conflict and abuse

Attend fully to the patient


Accept and respond to distress in patient and self


Respond to moral and ethical challenges


Facilitate hope, trust, and faith

Respect for patient’s dignity, uniqueness, and integrity (mind-body-spirit unity)


Respect for self-determination


Respect for person’s own power and self-healing processes


Effective communication

Elements of effective communication

Listen


Impart information


Learn


Facilitate the learning of others


Promote and accept patient’s emotions

Importance of being open and nonjudgmental


Source: Pew Health Professions Commission at the Center for the Health Professions, University of California, San Francisco, 1388 Sutter Street, Suite 805, San Francisco, California 94109, (415) 476-8181. http://futurehealth.ucsf.edu/Content/2/1994-12_Health_Professions_Education_and_Relationship-centered_Care.pdf



Community-Practitioner Relationship

In integral health care, the patient and his or her family simultaneously belong to many types of communities, such as the immediate family, relatives, friends, coworkers, neighborhoods, religious and community organizations, and the hospital community. The knowledge, skills, and values needed by practitioners to participate effectively in and work with various communities are shown in Table 1-5. This includes understanding the meaning of the community, recognizing the multiple contributors to health and illness within the community, developing

and maintaining relationships with the community, and working collaboratively with other individuals and organizations to establish effective community-based care.37








TABLE 1-5 Community-Practitioner Relationship: Areas of Knowledge, Skills, and Values






























Area

Knowledge

Skills

Values


Meaning of community

Various models of community


Myths and misperceptions about community


Perspectives from the social sciences, humanities, and systems theory


Dynamic change—demographic, political, industrial

Learn continuously


Participate actively in community development and dialogue

Respect for the integrity of the community


Respect for cultural diversity


Multiple contributors to health within the community

History of community, land use, migration, occupations, and their effect on health


Physical, social, and occupational environments and their effects on health


External and internal forces influencing community health

Critically assess the relationship of healthcare providers to community health


Assess community and environmental health


Assess implications of community policy affecting health

Affirmation of relevance of all determinants of health


Affirmation of the value of health policy in community services


Recognition of the presence of values that are destructive to health


Developing and maintaining community relationships

History of practitioner-community relationships


Isolation of the health-care community from the community at large

Communicate ideas


Listen openly


Empower others


Learn


Facilitate the learning of others


Participate appropriately in community development and activism

Importance of being open minded


Honesty regarding the limits of health science


Responsibility to contribute health expertise


Effective community-based care

Various types of care, both formal and informal


Effects of institutional scale on care


Positive effects of continuity of care

Collaborate with other individuals and organizations


Work as member of a team or healing community


Implement change strategies

Respect for community leadership


Commitment to work for change


Source: Pew Health Professions Commission at the Center for the Health Professions, University of California, San Francisco, 1388 Sutter Street, Suite 805, San Francisco, California 94109, (415) 476-8181.









TABLE 1-6 Practitioner-Practitioner Relationship: Areas of Knowledge, Skills, and Values






























Area

Knowledge

Skills

Values


Self-awareness

Knowledge of self

Reflect on self and needs


Learn continuously

Importance of self-awareness


Traditions of knowledge in health professions

Healing approaches of various professions


Healing approaches across cultures


Historical power inequities across professions

Derive meaning from others’ work


Learn from experience within healing community

Affirmation and value of diversity


Building teams and communities

Perspectives on team-building from the social sciences

Communicate effectively


Listen openly


Learn cooperatively

Affirmation of mission


Affirmation of diversity


Working dynamics of teams, groups, and organizations

Perspectives on team dynamics from the social sciences

Share responsibility responsibly


Collaborate with others


Work cooperatively


Resolve conflicts

Openness to others’ ideas


Humility


Mutual trust, empathy, support


Capacity for grace


Source: Pew Health Professions Commission at the Center for the Health Professions, University of California, San Francisco, 1388 Sutter Street, Suite 805, San Francisco, California 94109, (415) 476-8181.


Practitioners must be sensitive to the impact of these various communities on patients and foster the collaborative activities of these communities as they interact with the patient and family. The restraints or barriers within each community that block the patient’s healing must be identified and improved to promote the patient’s health and well-being.


Practitioner-Practitioner Relationship

Providing integral care to patients and families can never take place in isolation; it involves many diverse practitioner-practitioner relationships. To form a practitioner-practitioner relationship requires the knowledge, skills, and values shown in Table 1-6, including developing self-awareness; understanding the diverse knowledge base and skills of different practitioners; developing teams and communities; and understanding the working dynamics of groups, teams, and organizations that can provide resource services for the patient and family.37

Collaborative relationships entail shared planning and action toward common goals with joint responsibility for outcomes. There is a difference, though, between multidisciplinary care and interdisciplinary care. Multidisciplinary care consists of the sequential provision of discipline-specific health care by various individuals. Interdisciplinary care, however, also includes coordination, joint decision making, communication, shared responsibility, and shared authority.


Because the cornerstone of all therapeutic and healing endeavors is the quality of the relationships formed among the practitioners caring for the patient, all practitioners must understand and respect one another’s roles. Conventional and alternative practitioners need to learn about the diversity of therapeutic and healing modalities that they each use. In addition, conventional practitioners must be willing to integrate complementary and alternative practitioners and their therapies in practice (i.e., acupuncture, herbs, aromatherapy, touch therapies, music therapy, folk healers). Such integration requires learning about the experiences of different healers, being open to the potential benefits of different modalities, and valuing cultural diversity. Ultimately, the effectiveness of collaboration among practitioners depends on their ability to share problem solving, goal setting, and decision making within a trusting, collegial, and caring environment. Practitioners must work interdependently rather than autonomously, with each assuming responsibility and accountability for patient care. In the next section, the role of the Pew report on relationship-centered care is discussed.


▪ CORE COMPETENCIES FOR INTERPROFESSIONAL COLLABORATIVE PRACTICE

In 1998, following a decade of leadership and advocacy for health professions education, the Pew Health Professions Commission published its fourth and final report on relationship-centered care. The report assesses the challenges facing professionals in the 21st century and recommends general and professional-specific actions.38

In 2011, the Interprofessional Education Collaborative Expert Panel9 came together with an inspired vision for identifying the necessary core competencies for interprofessional collaborative practice that would be safe, high quality, accessible, and inclusive of patient-centered care. The six organizations that comprise the expert panel were the American Association of Colleges of Nursing, American Association of Colleges of Osteopathic Medicine, American Association of Colleges of Pharmacy, American Dental Education Association, Association of American Medical Colleges, and Association of Schools of Public Health. To achieve its vision the expert panel showed that health professions students need continuous development of interprofessional competencies as an essential part of their learning process. When this type of education occurs, they are more likely to enter the workforce ready to practice effective teamwork and team-based care.

Each expert panel group contributed its competencies, which resulted in interprofessional collaborative practice competencies identified in the following four domains: (1) values/ethics for interprofessional practice, (2) roles/responsibilities, (3) interprofessional communication, and (4) teams and teamwork.9

Teaching of these interprofessional collaborative competencies must extend beyond profession-specific education so that students are more likely to work effectively as members of clinical teams. In teaching interprofessional competencies and collaboration with the goal of practicing relationship-centered care, new theories must be applied such as complexity theories and positive psychology to transform organizations.39,40 To cross the patient-centered divide and apply relationship-centered care, faculty development must include mindfulness practice, formation, and training in communication skills. The next section explores several examples of how these concepts are being translated.


▪ CREATING OPTIMAL HEALING ENVIRONMENTS

The Samueli Institute for Information Biology (www.siib.org) studies relationship-centered care and ways to transform organizational culture through research and innovative projects that articulate and demonstrate a complete optimal healing environment (OHE) framework of actionable practices and evaluation methods.41 The institute defines an optimal healing environment as one in which “the social, psychological, spiritual, physical and behavioral components of health care are oriented toward support and stimulation of healing and the achievement of wholeness.” From this perspective, facilitating healing is thought to be a crucial aspect of managing chronic illness and the basis for sustainable health care.

Key concepts in optimal healing environments are awareness and intention. Awareness
is a state of being conscious and “in touch” with one’s interior and exterior self that is cultivated through reflective practices (meditation, prayer, mindfulness, spiritual practices, journaling, dialogue, art, etc.). Table 1-7 shows that an OHE contains four environmental domains—internal, interpersonal, behavioral, external. Under these four domains are eight constructs that each have several elements. The shading shows how these components, elements, and specific areas are integrated with all others. Figure 1-7 depicts this information, showing how all aspects are connected from the internal environment to the outer environments of the individual and the collective. Optimal healing environments always starts with the individual, whether it is the practitioner, healer, healee (client/patient), a significant other, and/or the community as an entity. When these steps are implemented it can lead to more cost-effective, efficient organizations in which the environment truly facilitates healing and where practitioners are fully supported to connect to the “soul of healing” and the mission of caring.

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Jun 21, 2016 | Posted by in NURSING | Comments Off on Nursing: Integral, Integrative, and Holistic—Local to Global

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