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 Holistic Care: Reality or Fantasy?

Stephanie Stephens, C-ARNP, MSN
Assistant Professor, School of Nursing
Graceland University

Sue Popkess-Vawter, ARNP, PhD
Professor, School of Nursing
University of Kansas Medical Center

Abstract

Holism is a construct used in many professional and lay disciplines. The literature revealed, however, that the construct of holism remains diffuse and difficult to integrate into practice. The purpose of this article is to define and clarify the construct of holism through synthesis of the nursing and related literature. The aim is to clarify the meaning of holism and lay the foundation for future research and practice in weight management. Antecedents, defining attributes, and consequences are identified in a concept analysis of holistic care. Model, borderline, and contrary cases are presented for illustration of holistic care related to weight management interventions.  Findings suggest that the nursing profession should consider adopting a universal definition of holism and holistic care to guide practice and to develop mid-range and practice theories.  Although complex in nature, holism is a vital integrating entity of the nursing profession and should be understood fully to guide the process of holistic care.      

KEY WORDS:  Holistic, holism, holistic care, advanced practice nurse, concept analysis, weight management, obesity, nursing theory

INTRODUCTION

Evidence of holistic nursing practice dates back to the 19^th Century when Nightingale conceived that people are integrations of biological, spiritual, psychological, and social components (Nightingale, 1860/1992; Selanders, 1998).  Although she did not speak specifically to the term holism, her writings integrated holistic concepts.  The construct became diffused and integrated within the discipline of nursing (Johnson, 1990).  Holistic care, as a central component of nursing history, guided theory development to encourage viewing patients as whole instead of the sum of their parts (Levine, 1971; Neuman, 1989; Orem, 1991; Newman, 1997).  

Although holism is an integral part of the grand nursing theories, mid-range, and practice level theories may not reflect holism directly. A wide range of definitions of holism has left some nurses questioning how it can be translated in a practice model (Sarter, 1987; Patterson, 1998).  The construct diffused so rapidly throughout western society that some nurses felt that holism lacks meaning for a professional discipline such as nursing. In addition, holism seemed incongruent with the predominant procedure orientation of the nursing profession (Barnum, 1987).  More importantly, advanced practice nurses often viewed holism as counterproductive in the fast-paced, medical-model environment.

The need for clarity and specificity of the term holism arose for the authors’ weight management practices.  Advanced practice nurses working in primary care aim at ameliorating obesity before co-morbid complications occur, including hypertension, coronary artery disease, and type II diabetes.  Rates of obesity in the United States continue to rise despite health care professionals’ efforts to change patients’ behaviors (Robison, 1999).   Current treatments, such as appetite suppressants, protein-supplemented diets, and diets in general, failed to correct and, in fact, contributed to an overweight epidemic (Schwartz, 1985; Robison et al., 1995; Polivy, 1996). Robison and Carrier (1999) argued that diet treatments have proven so unsuccessful that continuing to promote them is unethical and scientifically unsound.

Review of the clinical literature revealed that practitioners are beginning to advocate holistic strategies (Keller, Oveland & Hudson, 1997; Ammon, 1999).  Physiological, psychological, sociocultural, and spiritual parts of an integrated whole are equally indispensable aspects necessary to promote long-term weight management (Ammon, 1999, Popkess-Vawter, 1993, 2000). The challenge remains for healthcare professionals to design multiform interventions aimed at correcting what researchers know causes people to drop out of weight management programs. The authors believed a concept analysis of holistic care could disclose the principles of holism to build stronger weight management intervention models.

Holism defined: A historical perspective

            The noun holism or wholism, derived from the Anglo-Saxon root ‘hal’, means ‘whole’ or ‘to heal’ (Blattner, 1981).  Webster’s New World Dictionary (1969) defined holism as the view that an organic or integrated whole has a reality independent and greater than the sum of its parts. The term holistic is cited as an adjective and holistically is the adverb form (Guralnik, 1984).  Merriam Webster’s Collegiate Dictionary (1993) described holism as living nature correctly seen in terms of interacting wholes (as of living organisms) that are more than the mere sum of elementary particles. 

            Jan Smuts, a South African philosopher and biologist, was credited with coining the term holism (Sarkis & Skoner, 1987; Ham-Ying, 1993; Patterson, 1998).  In his first published book, Smuts (1926) stated that holistic characters are a unity of parts ‘which is so close and intense as to be more than the sum of its parts’ (p. 86).  Through a process he referred to as creative evolution, he noted that holistic organisms are products of organic and inorganic matter as well as the spiritual universe.  Past, present, and future influence organisms and, therefore, are indefinable by nature.

            Engel (1977) was one of the first persons to integrate the construct in the health care professions.  In trying to move psychiatry out of the medical model, he devised the biopyschosocial model to account for cultural, social, and psychological domains.  Instead of holism, he used the term ‘biopsychosocial.’  Although the terms are similar in meaning, he stated that holism was not appropriate because it is equated with ‘unscientific dogma’  (Engel, 1977; Sarkis & Skoner, 1987). 

Psychiatry was just one of the disciplines attempting to integrate holism into clinical practice.  During the mental health movement of the 1960s, the construct of holism was attractive to various health practitioners dissatisfied with the dominant biomedical model.  The holistic health movement of the 1960s introduced Eastern modalities such as acupuncture, meditation, and created an environment where holistic ideas and approaches to medicine were favored.  Concurrently, social movements, such as the anti-war movement and feminism, also were evolving, helping to create strong interests in new age concepts (Boschma, 1994).   It was during this time that holism became more widely recognized in the nursing profession.   

            Within the nursing literature, definitions of holism were consistent with the original works and dictionary definitions.  Nursing scholars agreed that holism reflects a whole that cannot be understood or reduced to a sum of its parts (Barnum, 1987; Sarter, 1987; Cheek, Gibson & Heartfield, 1993).  The unique qualities of individuals should be appreciated within all domains including physiological, psychological, social, cultural, and spiritual (Barnum, 1987; Hancock, 2000).  Nursing expanded holism to reflect the paradigms of health and wellness in mind, body, and spirit.

REVIEW OF THE LITERATURE

            The following review of literature points out confusion concerning the definition of holism, as well as historical and theoretical shifts that encouraged integration of holism into clinical practice. Confusion about holism may have resulted from historical shifts in the meaning within and outside of the discipline of nursing (Boschma, 1994).  As the concept of health changed over time, so did the concept of holism.  In the beginning, holism was linked to viewing the person as the integration of the body, mind, and spirit.  Later, particularly in the nursing profession, the construct was used to include many alternative therapies such as biofeedback, acupuncture, and therapeutic touch (Sarkis & Skoner, 1987).  Currently, holism suggests self-awareness, self-actualization, self-healing, and self-responsibility, and appears to support recommendations of yoga, natural foods, and herbal therapies (Sarkis & Skoner, 1987; Johnson, 1990; Boschma, 1994).  Some viewed this historical shift as an erroneous use of the term holism, while others valued and embraced nontraditional modalities as useful in holistic care (Blattner, 1981).

The American Nursing Association (ANA) (1996) did not include the term holism or holistic care in the Scope and Standards of Advanced Registered Practice Nursing document. Advanced practice registered nurses were defined as those with expanded autonomy of practice and nurse-initiated treatment regimens. It seems reasonable to expect advanced nurses to promote and model holism in practice; yet integration of the whole of client systems as greater than the sum of the parts was not described within nurses’ scope and standards. Advanced practice registered nurses’ mission statement was to provide expert, quality, comprehensive nursing care for clients, but holism was lacking as a central unifying element throughout the description of nursing scope and standards.

One reason holism is difficult to integrate into practice stems from the wide range of interpretations of the term (Barnum, 1987). Unless authors clearly define holism in their published work, readers may develop different interpretations than what was intended (Patterson, 1998). When the term was originally introduced, it was used interchangeably with terms such as alternative care, complementary care, and holistic health, which lead to confusion about an exact definition.  Sarter (1987) addressed this issue in stating, ‘the word holism is interpreted on a continuum of meanings, ranging from the analysis of all parts of a system, to a synthesis, into an irreducible whole that is greater than the sum of the parts’ (p.1).  Vague definitions of holism may have contributed to uncomfortable feelings among nurses who question whether holistic care goes beyond their scope of practice. Given that holism was not addressed in the ANA Scope of Advanced Practice, any confusion may be related to the lack of clarity about what holism is and how it can be integrated into standard practice. 

How can holism be integrated into practice if practitioners and nurses have multiple interpretations?  Nurse scholars and practitioners took the stance that holistic nursing was not consistent with nursing practice models, particularly nursing process (Barnum, 1987; Kobert & Folan, 1990). A basic premise of holism is viewing patients’ totality in constant interaction with their environments.  Integrated holism appears to be in direct conflict with the traditional nursing process as a mechanistic sequence of unalterable steps of care provision. Kobert and Folan (1990) believed that the nursing process keeps nursing confined to an immature level of professional development. They stressed that holism is essential in developing a central, unifying professional mission.  Similarly, Barnum (1987) argued that holistic nursing is not a procedure, but a guiding force that should be paired with the nursing process as valuable elements that define the profession.  Although their ideas offered rich discussion and debate, there was little written about operationalizing holism in the discipline of nursing.   

One of the greatest advancements toward integrating holism into practice was the establishment of the American Holistic Nurses’ Association (AHNA), their standards of practice, and related journals and texts. The AHNA Standards of Holistic Nursing Practice expanded the ANA standards to include five core values of holism, including the holistic caring process. The Holistic Nursing: A Handbook for Practice (Dossey, Keegan, & Guzzetta, 2000), endorsed by the AHNA, bolstered the art and science of holistic nursing (Watson, 2000).  In a recent editorial, Rew (1999) endorsed the holistic movement and believed advances in nursing research and theory can move holistic care to a higher plane.  In order to continue this work, a critical analysis of current literature and development of the construct is necessary for clearer operationalization at the practice level.    

            Nurse scholars continue to debate whether nursing science should advance through a single, unifying paradigm (Watson, 1999) or as a multi-paradigm discipline (Polifroni & Welch, 1991); either way, holism will prevail as central within philosophy of nursing science.  At present, nursing has yet to fully develop a coherent and comprehensive foundation for the generation of holistic theories representing humans in relationships with the universe (Sarter, 1987). Still lacking is a paradigm to clearly differentiate holistic care from process-oriented, medical-model practice (Engebretson, 1997).  Clarification of the construct can promote integration of holism into practice.

The format used for this concept analysis specifies antecedent conditions, defining attributes, and consequences (Walker & Avant, 1995). The concept of holistic care, versus holism, was chosen for analysis to link directly with practice. Holistic care is contrasted in case examples in weight management. Holism involves a continuous interactive process of individuals’ internal and external environments.  It follows that holistic care involves interaction among care providers and patients’ internal and external environments. For the purpose of this concept analysis, holistic care is defined as professional care provider-patient partnerships in the diagnosis and treatment of individuals’ positive and negative health responses as an integrated whole of physiological, psychological, sociocultural, and spiritual systems.

HOLISTIC CARE: A CONCEPT ANALYSIS

            Antecedents are necessary conditions that must be present for holistic care to occur (Walker & Avant, 1995). Defining attributes are essential characteristics that make the concept unique and identifiable. Consequences are the results or outcomes of the concept. Table 1 summarizes antecedents, defining attributes, and consequences found in a literature review. Antecedents necessary for holistic care to occur include three systems—care provider, patient, and institution. Institutional environments are necessary to provide adequate time and referral bases for the ongoing holistic processes to occur. Care providers and patients share the belief that together a goal of improved health and wellbeing can occur.

The holistic care process is a reciprocal exchange between caregiver and patient to review internal and external physiological, psychological, sociocultural, and spiritual systems as an integrated whole. Mutual goal setting, planning, intervening, and evaluating responses feed a cyclical, ongoing process with consequent mutual satisfaction, improved health and wellbeing, and empowerment. Ongoing activities of the processes are modified constantly to integrate new and changed information and responses. Interchange among care provider and patient systems is active and continually seeing balance. Holistic care in weight management is exemplified as cases in the next section. The model case has all defining attributes present (indicated by italics in parentheses after the example). The borderline case contains only some defining attributes, while the contrary case contains none.

Case examples of holistic care

The following cases are designed to illustrate holistic care related to weight loss management interventions.  The cases are based on the same patient clinical scenario to contrast the presence and absence of defining attributes:

            Tina is a 46-year-old farm wife and mother of two boys (ages 8 and 10) who presents for a physical exam and pap smear.  At 260 pounds and 5”2’tall, she is significantly obese (BMI=48; normal <25).   She postponed having a pap smear for 4 years.  When asked why, she started to cry and said, ‘I was too embarrassed for anyone to see me without clothes because I’m so fat! I’ve tried so many times to lose weight and I just seem to get fatter the harder I try! I’m totally disgusted with myself’.

Model case

             Before proceeding with the exam, the practitioner sat down with Tina and asked her if she would like help in losing weight. Tina was relieved to express her feelings and was grateful for the offer (open reciprocal exchange). Then the practitioner performed a detailed physical assessment, administered a depression inventory, and drew lab work to check for underlying pathological conditions (physiological and psychological systems).  After a comprehensive assessment was completed, the practitioner and patient began a process of exploration and education in bi-weekly or monthly 15-minute sessions (reciprocal information gathering, goal setting, planning, and intervention). Tina’s diet and exercise habits were explored, along with her emotional overeating tendencies.

Before coming to the practitioner, Tina drank two liters of soda everyday while doing farm chores, an obvious detriment to health as well as weight. Although she realized this, Tina did not believe she could change this habit with two boys wanting soda on a daily basis (physiological, psychological, sociocultural systems responses).  After discussing alternatives with the practitioner, Tina chose to learn some cognitive restructuring techniques to eat only when hungry and to stop emotional eating (physiological, psychological systems).  She started attending a weekly support group to work on her relationships with herself and others (sociocultural and spiritual systems). Gradually, with the assistance of the practitioner, she began to understand and modify her habits as well as gain a sense of accomplishment from her success as she lost weight (positive responses to treatment). For instance, Tina’s love of music (positive health response) was reinforced to counter her negative health response of drinking soda while driving a tractor. An unlimited supply of ice water and her favorite music through a headset quenched her thirst and fed her soul, rather than fueling her adipose.

            In this example, the practitioner provided individualized care with a focus on wellness and self-care modalities.  The patient and the practitioner worked together on determining the course of action and decided on mutually-agreeable goals.  Through this process, Tina began to see herself as an empowered being and felt satisfied that her needs were addressed. The practitioner, in turn, was satisfied and empowered to continue a long-term partnership with Tina.

Borderline case

Upon hearing her history, the practitioner comforted Tina.  Before proceeding, the practitioner asked if Tina would like to discuss weight loss strategies (open reciprocal exchange). Then she performed a detailed physical assessment, administered a depression inventory, and drew lab work to check for underlying pathological conditions (physiological and psychological systems).  When the lab work and testing showed no secondary causes for her obesity, the practitioner inquired about Tina’s dietary and exercise habits (information gathering) and gave her detailed instructions about dietary and exercise changes to make in order to lose weight (non-reciprocal goal-setting and planning).  There were no follow up appointments made.

            Although a comprehensive assessment of Tina’s physical and psychological status was performed, the provider neglected to formulate a plan of care that was designed mutually with Tina.  There was no discussion of other factors that could be affecting her lifestyle habits, such as eating and drinking because of unpleasant emotional states.  The plan did include self-care, but there was no long-term process in place to aid Tina in attaining wellness through her struggles. Because no follow-up appointments were scheduled, Tina could not be assessed and supported over time and her positive and negative health responses could not be monitored. Sociocultural and spiritual systems were not assessed. Although some defining attributes of holistic care were present, this case scenario lacked important attributes of reciprocal goal-setting, planning, interventions, and responses to treatment. The borderline case exemplified less than holistic care or transient physical care.

Contrary case

             After hearing her history, the practitioner performed the physical assessment and prescribed an appetite suppressant. The nurse instructed Tina to cut down on fast food, “watch her diet”, join Pound Watchers, and start an exercise program.

            This is an example of a contrary case because the health care provider only addressed Tina’s physiological condition and treated it simply by administering medication and giving recommendations.  The practitioner did not interact with Tina to understand her current level of interest in losing weight.  The practitioner did not address Tina’s physiological or psychosocial issues as an integrated whole, and there was no reciprocal exchange. This type of care could be called unethical erratic care.

CONCLUSION

            A concept analysis of holistic care supported the integration of holism in all aspects of nursing. Throughout history, the construct of holism was adapted and developed to fit current standards of health. In contemporary nursing, although it appears straightforward to attend to patients’ bodies, minds, and spirits, holistic care is unwieldy to accomplish in today’s fast-paced healthcare systems. At the same time, caregivers often find it uncomfortable to attend to patients’ total being. Nonetheless, holism requires that all parts of individuals be considered as equally crucial in making positive, healthy, lifelong changes, especially in weight management.

    Holistic care can be used effectively in weight management and generalized to many human science disciplines that promote healthy behaviors using cognitive-behavioral models (Popkess-Vawter & Turner, 2001). Helping patients become aware of their physical, psychological, sociocultural, and spiritual parts can empower them to recognize what keeps them from eating and exercising in a healthy manner. Holistic care involves thorough multi-system examination to assess patients’ weight problems, identify underlying causes of imbalance, and design solutions with patients to make individualized long-term lifestyle changes.

In conclusion, findings suggest that the nursing profession consider adopting a universal definition of holism and holistic care to guide practice and to develop mid-range and practice theories.  Although complex in nature, holism is a vital integrating entity in the nursing profession and should be understood fully to guide the process of holistic care.

References

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Table 1. Antecedents, defining characteristics, and consequences of holistic care

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