3
Spirituality Within the Context of Holism
Introduction
This chapter explores the place that spirituality has within the context of holism. The adjective holistic is used frequently within the caring professions without taking into account its implications. However, consideration needs to be given to what we mean by holism and how the concept may need to be revised to accommodate changing theory and practice. These debates are presented and examined against the emerging literature surrounding spirituality and the provision of spiritual care. The place that spirituality has within the context of theories and models is briefly discussed.
Activity 3.1
Spend several minutes reflecting upon the terms holism and holistic. Write down any thoughts or ideas that come to mind. Think about how you were introduced to these terms and how frequently you hear these words being used in your practice area.
The terms holism and holistic care are used frequently by health care professionals. Your reflections may have revealed that these terms are associated with treating the ‘whole’ person, or providing care that seeks to address all the dimensions of an individual’s life – for example, the physical, social, psychological and spiritual (Box 3.1).
Box 3.1 The four aspects of holism
Biological
This refers to the physical and biological process or function of an individual essential to maintain life.
Psychological
Usually implies the cognitive, intellectual, emotional aspects of the individual that may shape personality and mental functioning.
Social
The cultural norms, values and beliefs that influence and classify individuals into different groups or communities.
Spiritual
A vague term used normally to indicate an individual’s inner beliefs commonly related to religious affiliation or belief in the existence of a God or supreme power.
You were probably introduced to these terms during your health care training or education. Alternatively, you may have heard the words being used in practice or read them incorporated within a philosophy of care or academic textbook.
If you had been asked to draw a diagram that represents holism, then you may well have drawn one similar to Figure 3.1.
The circle in Figure 3.1 represents the ‘whole’ person while the four different quarters, described in Box 3.1, represent fundamental dimensions. However, this could be classified as a reductionist approach because there is no indication that all four quarters or dimensions are interrelated or dependent upon each other. The diagram reduces the whole into manageable mechanistic units. The diagrammatic representation is void of any interaction or interconnection between the individual, his or her environment or other people – indeed the whole of creation. It assumes that individuals function in isolation. Each aspect of our being is placed in a functional box not overlapping the next (as shown by the black solid lines). Holism is represented in a very narrow insular way. This raises two important questions:
Figure 3.1: A common representation of holism
•What is holism?
•How has the concept been defined within health care?
Holism
The word ‘holism’ originates from the Greek word ‘holos’, meaning whole (Griffin 1993; Ham-Ying 1993). The term holism implies that all dimensions of our lives are equally important to our functioning and well-being: ‘The whole is greater than the sum of its parts’ (Patterson 1998). Yet your reflection reveals that the biological and medical models of care contradict the term since they separate individuals into functional mechanistic units or biological systems (discussed in Chapter 1), often at the expense of seeing the whole person and his or her situation (see Box 3.2).
Several authors (Buckle 1993; Griffin 1993; Kolcaba 1997; Paley 2002; Patterson 1998; Thorne 2001) have explored and discussed the term holism, and their conclusions indicate there may be no single definition because the term is vague and difficult to pin down.
Ham-Ying (1993) implies that nurses do not have an adequate understanding of the concept of holism, nor a sufficient educational preparation, and the result may be that holistic care will not be fully operational within the context of nursing practice. With this point in mind, it might be useful to discuss how the term is defined within nursing.
The Churchill Livingstone (1996, p.176) Dictionary of Nursing does not offer a definition of holism but defines holistic as: ‘In a nursing context, caring for the whole patient – total patient care.’
Box 3.2 Definitions of holism, holistic and reductionism
Holism
The individual is perceived as a ‘whole’. There is acknowledgement that no systems – biological, psychosocial, spiritual or environmental – can be viewed in isolation because they all ‘make up the whole person’.
Holistic
Attending to all dimensions of an individual with equal importance.
Reductionism
The tendency to reduce or divide individuals into functional mechanist units. This is the opposite of holism.
This definition reinforces the notion that holistic care concerns the entire person. A possible reason why these terms are open to misinterpretation is because, like spirituality, a great deal of uncertainty still surrounds them. Buckle (1993) argues that the term holism is used inaccurately because it is used interchangeably with the word complementary, thus underlining the confusion and misconceptions surrounding the use of the term. From this brief analysis of the term holism, it would appear that there is some degree of ambiguity about the precise meaning of the word. Despite these uncertainties, the relevance and benefits of using these terms in the provision of health and nursing care cannot be dismissed. Holism is a common feature in many nursing models (Pearson, Vaughan and Fitzgerald 2005), and has guided and shaped the direction of nursing care throughout its inception and evolution.
In summary, the word holism is used to describe the ‘whole’ and the adjective holistic is used to describe the application of the term to practice – for example, the provision of holistic care. There is recognition that all parts of an individual share equal importance in a balanced manner. If we are providing holistic care, then we attend to all dimensions of an individual, giving each the same amount of importance.
Reductionism
A reductionist approach would be to reduce the individual into manageable units. From within my own professional discipline, the Roper, Logan and Tierney (1980) nursing model could be classified as a reductionist model because it divides the individual into a set of systems or activities that are required for daily living, such as breathing, elimination, eating and drinking, and sexuality. These types of approach to case management have been adopted within other professional groups to aid assessment and diagnosis. Yet the reality in the systems highlighted is that all these systems are related to and dependent upon each other. A purely reductionist approach focuses upon specific aspects of the person without giving due consideration to the other dimensions and their relationships with each other. However, clinical experience shows that there may be some benefits from implementing a reductionist approach. Different aspects of care can be delegated and managed by the appropriate professionals. It would appear that this approach to patient management is used in many health care settings. This is illustrated by the following Case study 3.1.
Case study 3.1 A case for reductionism
A middle-aged man with Type I diabetes mellitus is admitted with a ‘diabetic foot’. He has a large ulcer affecting his right big toe and is unable to cope at home with his illness. The man complains that his life has been altered dramatically by the condition.
The chances are that you identified a number of professionals who may be asked to contribute to this man’s care needs (Box 3.3).
Box 3.3 How reductionism addresses the ‘whole’ – achieving total patient care
| Doctors | Overall management of medical care |
| Nurses | Overall responsibility for nursing care interventions |
| Dietician | Nutritional support |
| Podiatrist | Management of diabetic foot |
| Occupational therapist | Adaptation and adjustment in activities of living |
| Religious/spiritual leader | Religious and spiritual needs |
| Social worker | Advice on support services available |
| Physiotherapist | Mobility |
| Diabetes specialist nurse | Advice concerning management of diabetes |
Closer inspection of the list reveals how reductionism delegates areas of responsibility to other professionals. It could still be said that the man is receiving ‘holistic care’ or total patient care, because the key aspects are being addressed. Problems with this approach are that a breakdown in communication can mean that important information is not communicated. Likewise, professionals may only focus upon their own specific areas of responsibility, which can sometimes mean that problems the patient may have remain undetected. The greatest danger is that care can appear fragmented and an holistic perspective of how the different dimensions affect and are affected by each other is lost. Some practice areas remove this risk by holding multidisciplinary or case conferences where information is exchanged, progress discussed and further interventions decided.
Models of health care: A brief overview
It is not the intention of this chapter to provide a detailed analysis of all the health care or indeed the nursing models that have been developed; that is beyond the scope of this book. This section will look at the place that spirituality has within some of these models, demonstrating how the growing awareness of the importance of spirituality to an individual’s sense of well-being has led some theorists to revisit and revise their theories to incorporate the spiritual dimension. An example of this in nursing would be Neuman (1995).
Activity 3.3
Spend some time reflecting upon any health care model that you have heard about or that you use or have used in your practice. Write down your understanding of the model, paying particular attention to any aspect of spirituality that it might address.
Undertaking Activity 3.3 may have proved difficult for two main reasons. First, our knowledge of health care is dependent upon two fundamental factors:
1.The models we have been introduced to during our training or programme of education. Related to this is the manner in which they were taught and applied to practice. Often if they are taught very theoretically and not applied you can be left more confused, finding it difficult to see the relevance of such material.
2.The regularity with which we use or encounter such models within practice.
What is a model?
A model represents a personal view of how individuals are made, function and interact with the world. Walsh (1991, p.8), discussing nursing models, summarizes these as:
Nursing models, therefore, are not watertight theories, but rather sets of ideas about the way patients and nurses interact. The dangers of reductionism and losing touch with reality are such that model development must take place with at least one foot in the real world of practical nursing care.
Therefore, models represent the world of nursing or health care from different perspectives, offering a set of ideas or a framework for the delivery of care. Conceptual models of nursing and health care present a set of ideas concerning the way that individuals may live, react to illness or interact with their world. It must be stressed that they represent only one world view. For example, Orem’s (1985) theories concerning self-care or Neuman’s (1995) systems model address the different systems involved in people’s reaction to health and illness. It could even be argued that there are as many nursing and health care models as there are thinking professionals, since we all have our own individual and personal philosophies concerning what makes us think, feel and react differently to stressful situations.
These points bring into question the direct relevance and purpose of nursing models in the delivery of nursing. Walsh (1991) believes nursing models are useful because they provide structure and direction in the provision of care, while other authors are very sceptical and critical of their relevance to nursing (Cash 1990; Draper 1990; Kenny 1993; Luker 1988). Despite recent criticism of nursing models (Tierney 1998), it would appear that they are here to stay.
Spirituality and health care models
It was stated earlier that the majority of health care and in particular nursing models embrace a holistic approach. If this statement were accurate, then such models by their very nature should address the concept of spirituality explicitly within their theories and frameworks. Recent debates indicate that this is not the case and only a minority of health care, and from within my own profession, nursing models incorporate or address the spiritual nature of individuals. Oldnall (1995, p.418) provides some reasons why the spiritual dimension is not adequately addressed within nursing and these arguments could be extended to include all health care theories:
Perhaps one reason why many conceptual and theoretical models and theories do not appear to work in clinical practice is because they have evolved in the echelons of academia and have been devolved down to the practitioners to operationalize at a clinical level. This may explain, to some degree, why the concept of spirituality has been omitted totally, or at least not developed sufficiently, in existing theories and models.
Oldnall implies that the assumption that most nursing models have an holistic approach to care is inaccurate and misguided. If nursing models and theories embraced holism, then they would address the spiritual dimension. Oldnall (1995, 1996) implies that there needs to be a cultural shift – a change in emphasis. Models should not be solely developed in the ‘ivory towers of academia’ and then expected to work in practice. This top-down approach to theory development may overlook and fail to incorporate many issues that are being faced by health care professionals working on the front line. This approach may have prevented the spiritual dimension from being incorporated within contemporary health care theories and models.
It appears that the academic era of health care is being challenged within the UK, and that the change in emphasis that has been sought by chief nurses and those in practice has arrived. In the mid-1980s, there was a move to improve the educational and professional credibility of nursing and, through a recent quality initiative, the education and preparation of all health care professions by integrating their education within universities. This initiative took place before other health professions were already located within higher education. However, recent discontent and levels of dissatisfaction among managers in health and social services have resulted in a change of opinion.
For example, in the government’s document Making a Difference: Strengthening the Nursing, Midwifery and Health Visiting Contribution to Health and Health Care (Department of Health 1999), the need for education and practice to work more closely in the education and training of student nurses was emphasized. The pendulum has swung (at the right too much emphasis on academia, and at the left signalling an all apprentice style of learning with no academic recognition) too far to the right, and it would seem that NHS Trusts and the voice and concerns of the consumer now have a greater say in the education of all health care professionals. This approach is of particular importance to matters concerning spirituality and the provision of spiritual care.
Importantly, this shift in emphasis must be reflected in subsequent theory development. There is a need to have a ‘bottom-up’ approach whereby practice is put into theory, or theories and models will remain detached from practice and in the realm of academics or theorists.
CAUTION
If the concerns of those in practice relating to this dimension of care are not listened to, then any attempt to develop this aspect of care will remain an academic exercise unrelated to and divorced from the reality of practice.
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