Self-Assessments

Barbara Montgomery Dossey

Susan Luck

Bonney Gulino Schaub

Lynn Keegan

Nurse Healer OBJECTIVES

Theoretical

Explore the Healthy People 2020 initiative and its application for holistic nurses.
Examine the Integrative Health and Wellness Assessment (IHWA) and the eight categories.

Clinical

Use the IHWA with clients who wish to learn new healthcare behaviors.
Incorporate the IHWA into clinical practice.

Personal

Complete the IHWA.
Identify your readiness to change related to your desired health goals.
Create personal action plan goals that lead to new health behaviors.
Increase your awareness of ways to gain access to your inner healing process.

DEFINITIONS

Healing: A process of understanding and integrating the many aspects of self, leading to a deep connection with inner wisdom and an experience of balance and wholeness.

Healing awareness: A person’s conscious recognition of and focused attention on intuitions, subtle feelings, conditions, and circumstances relating to the needs of self or clients.

Health: An individual’s (nurse, client, family, group, or community) subjective sense of well-being, harmony, and unity that is supported by the experience of health beliefs and values being honored; a process of opening and widening of awareness and consciousness.

Nurse healer: A professional nurse who supports and facilitates a person’s process of growth and experience of wholeness through an integration of body, mind, and spirit and/or who assists in the recovery from illness or in the transition to peaceful death.

Process: The continual changing and evolution of one’s self through life that includes reflecting on meaning and purpose in living.

Self-efficacy: The belief that one has the capability of initiating and sustaining desired behaviors with a sense of empowerment and ability to make healthful choices that lead to enduring change.

Transpersonal self: The self that transcends personal, individual identity and meaning and opens to connecting with purpose, meaning, values, unitive experiences and with universal principles.

Transpersonal view: The state that occurs during a person’s life maturity whereby a sense of self expands.

Wellness: An integrated, congruent functioning toward reaching one’s highest potential.

▪ HOLISTIC NURSES, HEALTHY PEOPLE, AND A HEALTHY WORLD

Many 21st-century conversations and initiatives focus on health promotion, health maintenance, disease prevention, and prevention of the catastrophic impact of diseases. Currently, the United States is in an economic crisis and health promotion and cost-effective behavioral change strategies are needed. In 2010, the Institute of Medicine, in collaboration with Robert Wood Johnson Foundation (RWJF), published the Future of Nursing report, a landmark document that presents four key messages:¹

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.

Holistic nurses are leaders practicing at the forefront of this initiative. As change agents, their objective is to increase the health of the nation, focusing on addressing the wellness and “health span” of people. They are sharing this information with nurses and other healthcare colleagues around the world. Their endeavors include using health and wellness assessments, assessing readiness to change, and implementing action plans for healthy lifestyle behaviors and approaches that lead to healthy people living in a healthy nation and on a healthy planet by 2020.

According to the Centers for Disease Control and Prevention, more than 133 million adults, or nearly half of all adults in the United States, are living with at least one chronic disease such as obesity, diabetes, and cardiovascular disease.² The cost of managing their care is an astounding $270 billion a year.³ Seventy percent of today’s healthcare costs are related to preventable, lifestyle-related diseases. There is an urgent need to develop initiatives to help shift the focus of health care by promoting self-efficacy and empowering individuals to recognize their potential to engage in promoting their own health and well-being.

All diseases affect multiple systems of the body. Heart disease and stroke are the first and third causes of mortality, respectively, accounting for one-third of all deaths in the United States.⁴ Cardiovascular problems include hypertension, dyslipidemia, heart failure, congenital heart disease, peripheral vascular disease, and peripheral arterial disease. If every form of cardiovascular disease was eliminated, Americans could add another 7 years to their life expectancy.⁵ Risk factors that can be modified in cardiovascular disease include smoking, dyslipidemia, hypertension, physical inactivity, obesity, and diabetes. Although gender, age, and genetics are not modifiable, many lifestyle factors can be altered.

If the current “obesity epidemic” continues unchecked, 50% of the U.S. adult population will be obese, with body mass index values of 30 or higher, by 2030.⁶ Using a simulation model and data from the National Health and Nutrition Examination Survey (NHANES) series from 1988 to 2008, it has been projected that, compared with 2010, there will be “as many as 65 million more obese adults” in the United States by that year. Obesity prevalence in both men and women in their 40s and 50s would approach 60%. Using this simulation modeling based on current obesity trends in the United States and United Kingdom, investigators estimate that up to 8.5 million additional cases of diabetes, 7.3 million more cases of cardiovascular disease and stroke, and 0.5 million more cancers will occur by 2030, with major increases in healthcare costs.

Many studies such as the European Prospective Investigation into Cancer and Nutrition (EPIC Study) are designed to investigate the relationships among diet, nutritional status, lifestyle and environmental factors, and the incidence of cancer and other chronic disease.⁷ The EPIC Study is significant because it recruited more than half a million (520,000) people in 10 European countries: Denmark, France, Germany, Greece, Italy, The Netherlands, Norway, Spain, Sweden, and the United Kingdom. It studied the adherence of subjects to four simple behaviors: (1) not smoking; (2) exercising 3.5
hours a week; (3) eating a healthy diet of fruits, vegetables, beans, whole grains, nuts, seeds, and limited amounts of meat; and (4) maintaining a healthy weight (BMI <30). In those adhering to these behaviors, the following were prevented:

93% of diabetes
81% of heart attacks
50% of strokes
36% of all cancers

The EPIC Study is buttressed by another influential report from 2009 by the World Cancer Research Fund and the American Institute for Cancer Research that asserts that better eating habits and more physical activity will prevent one-third of all the cancers in the United States, and smoking cessation will prevent another third.⁸ The next section discusses national initiatives that provide guidelines for healthcare transformation.

Healthcare Transformation

In the United States, actual solutions to health problems guide holistic nurses and healthcare professionals. The Healthy People 2020 initiative continues the work started in 2000 with the Healthy People 2010 initiative for improving the nation’s health. Healthy People 2020 is the result of a multiyear process that reflects input from a diverse group of individuals and organizations.⁹ The leading health indicators are increased physical activity, reduce obesity, tobacco use, substance abuse, injury and violence, increased responsibility sexual behavior, improve mental health, environmental quality, immunizations, and access to health care. These health indicators were selected on the basis of their ability to motivate action, the availability of data to measure progress, and their importance as public health issues.

The Healthy People 2010 vision, mission, and overarching goals provide structure and guidance for achieving the Healthy People 2020 objectives. Although general in nature, they offer specific, important areas of emphasis where action must be taken if the United States is to achieve better health by the year 2020. Developed under the leadership of the Federal Interagency Workgroup (FIW), the Healthy People 2020 framework is the product of an exhaustive collaborative process among the U.S. Department of Health and Human Services (HHS) and other federal agencies, public stakeholders, and the advisory committee. The Healthy People 2020 mission strives to accomplish the following:

Identify nationwide health improvement priorities
Increase public awareness and understanding of the determinants of health, disease, and disability and the opportunities for progress
Provide measurable objectives and goals that are applicable at the national, state, and local levels
Engage multiple sectors to take actions to strengthen policies and improve practices that are driven by the best available evidence and knowledge
Identify critical research, evaluation, and data collection needs

The Healthy People 2020 overall goals are to the following:

Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death
Achieve health equity, eliminate disparities, and improve the health of all groups
Create social and physical environments that promote good health for all
Promote quality of life, healthy development, and healthy behaviors across all life stages

Other important endeavors in national health are the Patient Protection and Affordable Care Act¹⁰ and the National Prevention Strategy.¹¹ (See Chapters 3 and 9 for details.) The following section addresses the use of the Integrative Health and Wellness Assessment (IHWA) in coaching clients to be active participants in increasing health-promoting behaviors, assessing readiness to change, and establishing action plans and goals.

▪ INTEGRATIVE HEALTH AND WELLNESS ASSESSMENT (IHWA)

Holistic nurses use self-assessments and other strategies to assist individuals to learn how to prefer wellness to unhealthy habits. They are
assuming a leadership role in the health-andwellness coaching movement as “pioneers on the vast frontier of our nation’s health care reform.”¹²

The circle is an ancient symbol of wholeness. As shown in Figure 8-1, the Integrative Health and Wellness Assessment (IHWA) wheel has eight components: (1) Life Balance and Satisfaction, (2) Relationships, (3) Spirituality, (4) Mental, (5) Emotional, (6) Physical (Nutrition, Exercise, Weight Management), (7) Environmental, and (8) Health Responsibility. All are important components of the self that are interwoven and constantly interacting. The IHWA assists people in becoming aware of their human potentials in each of these categories, identifying strengths and weaknesses and considering and creating new health goals.

Individuals are complex feedback loops. As we learn about these feedback loops, we are able to understand our body-mind-spirit connections. Each individual body is in a constant state of change. Most of these internal energetic, hormonal, biochemical checks and balances occur outside of any conscious awareness of what is taking place in the body.

At an even more expansive, organic level, life is a biodance. We are participating in an endless exchange with all living things, with planet Earth, in which all living organisms participate, and at the energetic and cosmic levels as well. This energetic dance exists not only as we live, but also as we die. We do not wait until death to make an exchange with planet Earth, for we are constantly returning to the universe while alive. In every living moment, a portion of the atoms in our body returns to the world outside. This is another idea of wholeness, which explains why the notion of “boundary” begins to seem an arbitrary idea rather than a physical reality.¹³ In the following sections, each of the eight IHWA components is explored.

The Integrative Health and Wellness Assessment is best used as a personal assessment by the nurse or as a coaching tool with clients.

The Integrative Health and Wellness Assessment (IHWA)¹⁴ (Figure 8-2) was developed and is based on 35 years of the authors’ holistic nursing clinical practices, education, and research with clients and patients in changing lifestyle behaviors, health promotion, health maintenance, and disease prevention.^* This includes educating and supporting clients who are learning new self-management skills in living with an acute or chronic illness and/or symptoms. It is expanded from Self-Care Assessments.¹⁵

The IHWA is an effective coaching tool for holistic nurses and is designed to increase both nurse self-development (self-reflection, selfassessments, self-care) and client self-development. It is essential that holistic nurses deepen their personal exploration of self (see Chapters 1, 4, 9, 12, 32, and 37), examine their vulnerabilities (Chapters 9 and 24), and explore their wellness from a functional health perspective (Chapters 9 and 13). This also includes looking at their life balance and satisfaction, as well as recognizing which factors are contributing to imbalance(s) and how they affect well-being. Creating the time for nurse self-development through integrating body, mind, spirit skills, integrative health knowledge, and nutritional, psychological, and other integrative resources is essential for being an effective nurse coach.

In using the IHWA, the holistic nurse skillfully creates and holds sacred space in which the client feels trust, respect, listened to, and not being judged. Depending on the clinical situation, the tool can be given out at one time for the client to fill out in advance of a session or use one section at a time. It is a useful guide in assisting individuals to change health behaviors.

Life Balance and Satisfaction

Assessing our life balance and satisfaction (see the Life Balance and Satisfaction section in Figure 8-2) strengthens our capacities and human potentials. (See Chapters 12 and 37 for details.) It attunes us to our healing awareness that is the innate quality with which all people are born. Healing is recognizing our feelings, attitudes, and emotions, which are not isolated but which are literally translated into body changes. Images cause internal events through mind modulation that simultaneously affect the autonomic, endocrine, immune, and neuropeptide systems (see Chapter 31). Everyone has the capacity to, and can choose to, tap into this innate healing potential. Healing
is more likely to occur on many levels when we attend to our life balance and satisfaction. During times of stress and crisis, focusing only on all the things that are wrong each day can block selfhealing. Therefore, it is necessary for us to continually assess and reassess our wholeness, which includes attention to stress management, time management, and adequate sleep. Recognizing and celebrating the joys and good things in life add to experiencing life balance and satisfaction. Life is a journey. Willingness to be present for all this life journey brings, cultivating the ability to be fully in the moment with “what is,” is a component of a transformative healing process.

FIGURE 8-1 Integrative Health and Wellness Assessment (IHWA) Wheel

Source: Used with permission. Dossey, B. M., Luck, S., & Schaub, B. G. (2012). Integrative Nurse Coaching for Health and Wellness. Huntington, NY: Florence Press (www.iNurseCoach.com).

Assessing our life balance and satisfaction acknowledges our capacity for both conscious and unconscious choices in our lives. Conscious choices involve awareness and skills such as selfreflection, self-care, discipline, persistence, goal setting, priority setting, action steps, discerning best options, and acknowledging and trusting perceptions. We can be active participants in daily living, not passive observers who hope that life will be good to us.

The unconscious also plays a major role in our choices.¹⁶ Jung conceived of the unconscious as a series of layers. The layers closest to our awareness may become known; those farthest away are, in principle, inaccessible to our awareness and operate autonomously. Jung saw the unconscious as the home of timeless psychic forces that he called archetypes, which generally are invariant throughout all cultures and eras. He felt that every psychic force has its opposite in the unconsciousness—the force of light is always counterposed with that of darkness, good with evil, love with hate, and so on. Jung believed that any psychic energy can become unbalanced. Therefore, one of life’s greatest challenges is to achieve a dynamic balance of the innate opposites and make this balancing process as conscious as possible.

Relationships

Healthy people live in intricate networks of relationships and are always in search of new, unifying concepts of the universe and social order. (See Chapter 26.) Learning how to understand and nurture our relationships (see the Relationships section in Figure 8-2) assists us in creating and sustaining meaningful relationships. A healthy person cannot live in isolation. In a

given day, we interact with many people: immediate family, extended family, colleagues at work, neighbors in the community, numerous people in organizations, and now, through the ever expanding web of electronic connection, friends, colleagues, and others around the world.