Holistic Philosophy, Theories, and Ethics - CORE VALUE 1 - Larry Dossey
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CORE VALUE 1 Holistic Philosophy, Theories, and Ethics
Chapter 1
Nursing: Integral, Integrative,
and Holistic—Local to Global
Barbara Montgomery Dossey
Nurse Healer Personal
OBJECTIVES ■ Create an integral self-care plan.
■ Examine ways to enhance integral under-
Theoretical standing in your personal endeavors.
■ Explore the Theory of Integral Nursing and
■ Develop short- and long-term goals related
its application to holistic nursing. to increasing your commitment to an inte-
■ Examine the United Nations Millennium gral developmental process.
Goals.
■ Link Florence Nightingale’s legacy of heal- DEFINITIONS
ing, leadership, global action, and her work
Global health: Exploration of the emerging
as a nurse and citizen activist to 21st-century
value base and new relationships and inno-
integral and holistic nursing.
vations that occur when health becomes
■ Analyze relationship-centered care and its
an essential component and expression of
three components.
global citizenship; an increased awareness
■ Examine optimal healing environments
that health is a basic human right and a
and their four domains.
global good that needs to be promoted and
protected by the global community.
Clinical Holistic nursing: See Chapter 2 definitions.
■ Apply relationship-centered care principles Integral: Comprehensive way to organize
and components in your practice. multiple phenomena of human experi-
■ Compare and contrast the three eras of ence related to four perspectives of real-
medicine. ity: (1) the individual interior (personal/
■ Examine the Theory of Integral Nursing, intentional); (2) individual exterior (physi-
and begin the process of integrating the ology/behavioral); (3) collective interior
theory into your clinical practice. (shared/cultural); and (4) collective exte-
■ Determine whether you have an integral rior (systems/structures).
worldview and approach in your clinical Integral dialogue: Transformative and vision-
practice and other education, research, hos- ary exploration of ideas and possibilities
pital policies, and community endeavors. across disciplines where the individual inte-
34 Chapter 1 Nursing: Integral, Integrative, and Holistic—Local to Global
rior (personal/intentional), individual exterior to how individuals perceive reality and
(physiology/behavioral), collective interior relationships that includes the individual
(shared/cultural), and collective exterior interior (personal/intentional), individual
(structures/systems) are considered as equally exterior (physiology/behavioral), collective
important to exchanges and outcomes. interior (shared/cultural), and collective
Integral healing process: Contains both exterior (systems/structures).
nurse processes and patient/family and Relationship-centered care: A process model
healthcare worker processes (individual of caregiving that is based in a vision of
interior and individual exterior), and col- community where the patient–practitioner,
lective healing processes of individuals and community–practitioner, and practitioner–
of systems/structures (collective interior practitioner relationships, and the unique
and exterior); an understanding of the uni- set of responsibilities of each are honored
tary whole person interacting in mutual and valued.
process with the environment.
Integral health: Process through which we Q NURSING: INTEGRAL,
reshape basic assumptions and worldviews INTEGRATIVE, AND HOLISTIC
about well-being and see death as a natu-
In the future, which I shall not see, for
ral process of living; may be symbolically
I am old, may a better way be opened!
viewed as a jewel with many facets that
May the methods by which every infant,
is reflected as a “bright gem” or a “rough
every human being will have the best
stone” depending on one’s situation and
chance at health—the methods by
personal growth that influence states of
which every sick person will have the
health, health beliefs, and values.
best chance at recovery, be learned and
Integral health care: A patient-centered and
practiced. Hospitals are only an inter-
relationship-centered caring process that
mediate stage of civilization, never
includes the patient, family, and commu-
intended, at all events, to take in the
nity and conventional, integrative, and inte-
whole sick population. . . .
gral healthcare practitioners and services
May we hope that, when we are all
and interventions; a process where the indi-
dead and gone, leaders will arise who
vidual interior (personal/intentional), the
have been personally experienced in
individual exterior (physiology/behavioral),
the hard, practical work, the difficul-
the collective interior (shared/cultural), and
ties, and the joys of organizing nursing
the collective exterior (structures/systems)
reforms, and who will lead far beyond
are considered in all endeavors.
anything we have done! May we hope
Integral nurse: A 21st-century Nightingale
that every nurse will be an atom in the
who is engaged as a “health diplomat” and
hierarchy of ministers of the Highest!
an integral health coach who is coaching
But she [or he] must be in her [or his]
for integral health.
place in the hierarchy, not alone, not
Integral nursing: A comprehensive integral
an atom in the indistinguishable mass
worldview and process that includes holis-
of thousands of nurses. High hopes,
tic theories and other paradigms; holis-
which shall not be deceived!”1
tic nursing is included (embraced) and
transcended (goes beyond); this integral Florence Nightingale’s (1893) words above em-
process and integral worldview enlarges power us in our mission of service. In 2010, the
our holistic understanding of body-mind- Institute of Medicine Future of Nursing report
spirit connections and our knowing, published a landmark document that presented
doing, and being to more comprehensive four key messages:2
and deeper levels. ■ Nurses should practice to the full extent of
Integral worldview: Process where values, their education and training.
beliefs, assumptions, meaning, purpose, ■ Nurses should achieve higher levels of edu-
and judgments are identified and related cation and training through an improvedGlobal Nursing, Nightingale Declaration, and United Nations Millennium Development Goals 5
education system that promotes seamless dence, and makes use of all appropriate ther-
academic progression. apeutic approaches, healthcare professionals,
■ Nurses should be full partners, with physi- and disciplines to achieve optimal health and
cians and other healthcare professionals, in healing.8 The next section provides an overview
redesigning health care in the United States. of how we can globally integrate and translate
■ Effective workforce planning and policy integral and holistic nursing concepts.
making require better data collection and
information infrastructure.
Q GLOBAL NURSING, NIGHTINGALE
To fulfill the challenges addressed in the IOM
DECLARATION, AND UNITED
report an integral perspective has never been NATIONS MILLENNIUM
more important. At the forefront, nurses are now DEVELOPMENT GOALS
engaged as change agents to improve the health Severe health needs exist in almost every com-
of the nation, to focus on increasing the “health munity and country. These are no longer isolated
span” of individuals rather than focusing on life problems in far-off places. Across humankind,
span. Integral nursing can be described as a com- we all face common health concerns and global
prehensive integral worldview and process that health imperatives. With globalization and
includes holistic theories and other paradigms; global warming, no natural or political boundar-
holistic nursing practice is included (embraced) ies stop the spread of disease.11–13 Yet, the health
and transcended (goes beyond).3–6 This integral and well-being of people everywhere can be seen
process and the integral worldview enlarge our as common ground to secure a sustainable, pros-
holistic understanding of body-mind-spirit con- perous future for everyone. In interdisciplinary
nections and our knowing, doing, and being to and interprofessional collaboration with pro-
more comprehensive and deeper levels (Note: See fessional and allied health colleagues, as well
the section titled “Theory of Integral Nursing” as concerned citizens, nurses can play a major
later in this chapter for full discussion.) role in mobilizing new approaches to educa-
Holistic nursing is defined as “all nursing prac- tion, healthcare delivery, and disease prevention.
tice that has healing the whole person as its Global health requires new leadership models
goal.”7 As described and developed later in this in communication, negotiations, resource, man-
text (Chapter 2), holistic nursing has attained agement, work-life balance, and mentor-mentee
new levels of acceptance and is now officially models and relationships.13–14
recognized by the American Nurses Associa- Global health is the exploration of the emerg-
tion (ANA) as a nursing specialty with a defined ing value base and new relationships and agen-
scope and standards of practice.7 Our holistic das that occur when health becomes an essential
nursing challenges as described throughout this component and expression of global citizen-
text include ways to learn and integrate new ship.13 It is an increased awareness that health
theories, models, and information, and how to is a basic human right that is “decent care”15
articulate the science and art of holistic nurs- that addresses the body, mind, and spirit and
ing, complementary and alternative modalities is a global good that needs to be promoted
(CAM), integrative modalities, and healing in and protected by the global community. Severe
all areas and specialties of nursing. Our chal- health needs exist in almost every commu-
lenges and opportunities to interface in inter- nity and nation throughout the world. Thus,
professional conversations related to integral, all nurses are involved in some aspect of global
integrative, and holistic nursing and integrative health because their caring and healing endeav-
medicine with traditional and nontraditional ors assist individuals to become healthier, which
healthcare professionals, healers, disciplines, leads to healthy people living in a healthy world
and organizations can transform health care.8– by 2020.16,17
10
Integrative medicine (IM) is the practice of Currently, there are 17.6 million nurses and
medicine that reaffirms the importance of the midwives engaged in nursing and providing
relationship between practitioner and patient, health care around the world. 18 Together, we
focuses on the whole person, is informed by evi- are collectively addressing human health—the6 Chapter 1 Nursing: Integral, Integrative, and Holistic—Local to Global health of individuals, of communities, of envi- We can unite 17.6 million nurses (Figure 1-1) ronments (interior and exterior), and the world and midwives, along with concerned citizens as our first priority. We are educated and pre- through the Internet to create a healthy world pared—physically, emotionally, socially, men- through many endeavors such as signing the tally, and spiritually—to accomplish effectively Nightingale Declaration (at www.nightingale the activities required to create a healthy world. declaration.net), as shown in Figure 1-2.16 (See Nurses are key in mobilizing new approaches in the section titled “Theory of Integral Nursing” health education and healthcare delivery in all later in this chapter.) areas of nursing. Solutions and evidence-based During the year 2000, world leaders con- practice protocols can be shared and imple- vened a United Nations Millennium Summit mented around the world through dialogues, to establish eight Millennium Development the Internet, and publications, which are essen- Goals (MDGs), as shown in Figure 1-3, that tial as we address the global nursing shortage.19 must be achieved for the 21st century to pro- We are challenged to act locally and think gress toward a sustainable quality of life for all globally and to address ways to create healthy of humanity. 20 These goals are an ambitious environments. For example, we can address agenda for improving lives worldwide. Of these global warming in our own personal habits at eight MDGs, three—MDG 4, Reduce Child home as well as in our workplace (using green Mortality, MDG 5, Improve Maternal Health, products, using energy-efficient fluorescent and MDG 6, Combat HIV/AIDS—are directly bulbs, turning off lights when not in the room) related to health and nursing. The other five and simultaneously address our own personal goals, MDG 1, Eradicate Extreme Poverty and health and the health of the communities where Hunger, MDG 2, Achieve Universal Primary we live. As we expand our awareness of individ- Education, MDG 3, Promote Gender Equality ual and collective states of healing consciousness and Empower Women, MDG 7, Ensure Environ- and integral dialogues, we can explore integral mental Sustainability, and MDG 8, Develop a ways of knowing, doing, and being. Global Partnership for Development are factors 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; Bra- zil, 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: Afghani- stan, in the public domain; India, used under the terms of the GNU Free Documentation License.
Global Nursing, Nightingale Declaration, and United Nations Millennium Development Goals 7 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.
8 Chapter 1 Nursing: Integral, Integrative, and Holistic—Local to Global
that determine the health or lack of health of cerns. Nightingale was concerned with the most
people. For each goal, one or more targets, which basic needs of human beings and all aspects of
used the 1990 data as benchmarks, are set to be the environment (clean air, water, food, houses,
achieved by 2015. Health is the common thread etc.)—local to global.22–26 She also experienced
running through all eight UN MDGs. The goals and recorded her personal understanding of the
are directly related to nurses, as they work today connection with the Divine as an awareness that
to achieve them at grassroots levels everywhere something greater than her, the Divine, was a
and many are engaged in sharing local solutions major connecting link woven into her work and
at the global level. life.22 The entirety of her life, work, and insights
An integral approach can help nurses concep- clearly articulates and demonstrates the sci-
tualize and map what is missing from caregiving ence and art of an integral worldview for nurs-
and care delivery. With an integral worldview, ing, health care, and humankind, as developed
collectively we can move closer to achieving further in the section titled “Theory of Integral
global health. Ensuring basic survival needs has Nursing” and in Figure 1-9, later in this chapter.
been identified as the single most important fac- Nightingale was a nurse, educator, adminis-
tor in building responsive and effective health trator, communicator, statistician, and environ-
systems in all countries. The health and happi- mental activist.22,26 Her specific accomplishments
ness of people everywhere in the global commu- include establishing the model for nursing
nity are the only common ground for a secure schools throughout the world and creating a pro-
and sustainable prosperous future.3 Yet a healthy totype model of care for the sick and wounded
world still requires nurses’ knowledge, expertise, soldiers during the Crimean War (1854–1856).
wisdom, and dedication. If today’s nurses, mid- She was an innovator for British Army medical
wives, and allied health professionals are nur- reform that included reorganizing the British
tured and sustained in innovative ways, they can Army Medical Department, creating an Army
become like Nightingale—effective voices calling Statistical Department, and collaborating on
for and demonstrating the healing, leadership, the first British Army medical school, includ-
and global action required to achieve a healthy ing developing the curriculum and choosing the
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 Nightin-
gale’s legacy in 21st-century terms.
Q 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 FIGURE 1-4 Florence Nightingale
inner and outer, human and nonhuman con- (1820–1910).Eras of Medicine 9 professors. She revolutionized hospital data col- for humanity today. Table 1-1 lists the themes lection and invented a statistical wedge diagram in her Notes on Hospitals (1859),29 Notes on Nurs- equivalent to today’s circular histograms or circu- ing (1860),30 her formal letters to her nurses lar statistical representation. In 1858, she became (1872–1900), 31 and her article “Sick-Nursing the first woman admitted to the Royal Statistical and Health-Nursing” (1893).32 Table 1-2 shows Society. She developed and wrote protocols and Nightingale’s themes recognized today as total papers on workhouses and midwifery that led healing environments. The next section pre- to successful legislation reform. She was a rec- sents an overview of the eras of medicine and ognized expert on the health of the British Army application of this information to integral and and soldiers in India for more than 40 years; she holistic nursing. never went to India but collected data directly from Army stations, analyzed the data, and wrote and published documents, articles, and books on Q ERAS OF MEDICINE the topic. Three eras of medicine currently are operational In 1902, besides her numerous other rec- in Western biomedicine (see Table 1-3).33 Era ognitions, she was the first woman to receive I medicine began to take shape in the 1860s, the Order of Merit. She wrote more than 100 when medicine was striving to become scientific. combined books and official Army reports. Her The underlying assumption of this approach 10,000 letters now make up the largest private is that health and illness are completely physi- collection of letters at the British Library with cal in nature. The focus is on combining drugs, 4,000 family letters at the Wellcome Trust in medical treatments, and technology for curing. London.22,26 Today we recognize Nightingale’s A person’s consciousness is considered a by- work as global nursing: She envisioned what a product of the chemical, anatomic, and physi- healthy world might be with her integral phi- ologic aspects of the brain and is not considered losophy and expanded visionary capacities. a major factor in the origins of health or disease. Her work included aspects of the nursing pro- In the 1950s, Era II therapies began to emerge. cess (see Chapter 7) as well; it has indeed had These therapies reflected the growing awareness an impact on nurses today and will continue that the actions of a person’s mind or conscious- to affect us far into the future. Nightingale’s ness—thoughts, emotions, beliefs, meaning, work was social action that demonstrated and and attitudes—exerted important effects on the clearly articulated the science and art of an inte- behavior of the person’s physical body.33 In both gral worldview for nursing, health care, and Era I and Era II, a person’s consciousness is said humankind. Her social action was also sacred to be “local” in nature; that is, confined to a spe- activism,27 the fusion of the deepest spiritual cific location in space (the body itself) and in knowledge with radical action in the world. time (the present moment and a single lifetime). In the 1880s, Nightingale began to write that Era III, the newest and most advanced era, it would take 100–150 years before educated originated in science. Consciousness is said to and experienced nurses would arrive to change be nonlocal in that it is not bound to individ- the healthcare system. We are that generation of ual bodies. The minds of individuals are spread 21st-century Nightingales who have arrived to throughout space and time; they are infinite, transform health care and carry forth her vision immortal, omnipresent, and, ultimately, one. Era of social action and sacred activism to create a III therapies involve any therapy in which the healthy world. Using terms coined by Patricia effects of consciousness create bridges between Hinton-Walker, 21st-century Nightingales are different persons, as with distant healing, inter- “health diplomats” and “integral health coaches” cessory prayer, shamanic healing, so-called who are “coaching for integral health.”28 miracles, and certain emotions (e.g., love, empa- Nightingale was ahead of her time. Her dedi- thy, compassion). Era III approaches involve cated and focused 40 years of work and service transpersonal experiences of being. They raise still inform and influence our nursing work a person above control at a day-to-day material and our global mission of health and healing level to an experience outside his or her local self.
10 Chapter 1 Nursing: Integral, Integrative, and Holistic—Local to Global
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 ■ Light
■ Ample space ■ Subdivision of sick into separate buildings or pavilions
Hospital construction defects that prevented health:
■ Defective means of natural ventilation ■ Defective condition of water closets
and warming ■ Defective ward furniture
■ Defective height of wards ■ Defective accommodation for nursing
■ Excessive width of wards between the and discipline
opposite windows ■ Defective hospital kitchens
■ Arrangement of the bed along the dead wall ■ Defective laundries
■ More than two rows of beds between the ■ Selection of bad sites and bad local climates
opposite windows for hospitals
■ Windows only on one side, or a closed corri- ■ Erecting of hospitals in towns
dor connecting the wards ■ Defects of sewerage
■ Use of absorbent materials for walls and ceil- ■ Construction of hospitals without free
ings, and poor washing of hospital floors
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, ■ Provide proper bathing, rubbing, and scrubbing
nursing and the nurses can assist in the of the skin of the patient as well as of the nurse.
reparative process of a disease and in ■ Use proper handwashing techniques that
maintaining health include cleaning the nails.
Nursing and nurses Food
■ Describing the many roles and responsibilities ■ Provide proper portions and types of food at
of the nurse the right time, and a proper presentation of
Patient food types: eggs, meat, vegetables, beef teas,
■ Observing and managing the patient’s coffee, jellies, sweets, and homemade bread.
problems, needs, and challenges, and
Health of houses
evaluating responses to care
■ Provide pure air, pure water, efficient drain-
Health
age, cleanliness, and light.
■ Recognizing factors that increase or decrease
positive or negative states of health, well- Light
being, disease, and illness ■ Provide a room with light, windows, and a
Environment view that is essential to health and recovery.
■ Both the internal (within one’s self) and the
Noise
external (physical space). (See the specifics ■ Avoid noise and useless activity such as
listed in the next 12 categories.)
clanking or loud conversations with or
Bed and bedding among caregivers.
■ Promote proper cleanliness.
■ Use correct type of bed, with proper height,
■ Speak clearly for patients to hear without
having to strain.
mattress, springs, types of blankets, sheets,
and other bedding. ■ Avoid surprising the patient.
Cleanliness (rooms and walls) ■ Only read to a patient if it is requested.
■ Maintain clean room, walls, carpets, furniture,
Petty management
and dust-free rooms using correct dusting ■ Ensure patient privacy, rest, a quiet room,
techniques.
■ Release odors from painted and papered rooms;
and instructions for the person managing
care of patient.
discusses other remedies for cleanliness.Eras of Medicine 11
TABLE 1-1 Florence Nightingale’s Legacy and Themes for Today (continued)
Themes Developed in Notes on Nursing (1860) (continued)
Variety ■ Avoid absurd statistical comparisons of patient
■ Provide flowers and plants and avoid those to recovery of other patients, and avoid mock-
with fragrances. ery of advice given by family and friends.
■ Be aware of effects of mind (thoughts) on body. ■ Share positive events; encourage visits from a
■ Help patients vary their painful thoughts. well-behaved child or baby.
■ Use soothing colors. ■ Be aware of how small pet animals can provide
■ Be aware of positive effect of certain music on comfort and companionship for the patient.
the sick. Observation of the sick
Ventilation and warming ■ Observe each patient; determine the problems,
■ Provide pure air within and without; open challenges, and needs.
■ Assess how the patient responds to food,
windows and regulate room temperature.
■ Avoid odiferous disinfectants and sprays. treatment, and rest.
■ Help patient with comfort, safety, and health
Chattering hopes and advice
■ Avoid unnecessary advice, false hope,
strategies.
■ Intervene if danger to patient is suspected.
promises, and chatter of recovery.
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, ■ Explore body-mind-spirit wholeness, healing
and purpose. philosophy, self-care, relaxation, music, prayers,
■ Increase communication with colleagues, and work of service to self and others.
patients, and families. ■ Develop therapeutic and healing relationships.
■ Build respect, support, and trusting
Science of nursing
relationships. ■ Learn nursing knowledge and skills, observing,
Environment implementing, and evaluating physicians’ orders
■ Includes the internal self as well as the combined with nursing knowledge and skills.
external physical space Spirituality
Ethics of nursing ■ Develop intention, self-awareness, mindful-
■ Engage in moral behaviors and values and ness, presence, compassion, love, and service
model them in personal and professional life. to God and humankind.
Health
■ Integrate self-care and health-promoting and
sustaining behaviors.
■ Be a role model and model healthy behaviors.
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 Health education curriculum and health
■ Meet with nurses and women at the local, missioners education
national, and global level to explore health ■ Include all components discussed in Notes
education and how to support each other in on Nursing.
creating health and healthy environments. ■ 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).12 Chapter 1 Nursing: Integral, Integrative, and Holistic—Local to Global
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:
O Engages body-mind-spirit wholeness
O Fosters healing relationships and partnerships
O Promotes self-care and health-promoting and sustaining behaviors
O 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 Con-
tinuous 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.Eras of Medicine 13
TABLE 1-2 Total Healing Environments Today: Integral and Holistic (continued)
The External Healing Environment (continued)
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 meditation, and quiet contemplation, as well as
Holistic nurses use both “doing” and “being” the presence and intention of the nurse. These
therapies, as shown in Figure 1-5. These are also techniques are therapeutic because of the power
referred to as holistic nursing therapies, com- of the psyche to affect the body. They may be
plementary and alternative therapies, or inte- either directed or nondirected.32,34 A person who
grative and integral therapies throughout this uses a directed mental strategy attaches a spe-
textbook. Doing therapies include almost all cific outcome to the imagery, such as the regres-
forms of modern medicine, such as medications, sion of disease or the normalization of the blood
procedures, dietary manipulations, radiation, pressure. In a nondirected approach, the person
and acupuncture. In contrast, being therapies images the best outcome for the situation but
do not employ things, but instead use states of does not try to direct the situation or assign a
consciousness.33,34 These include imagery, prayer, specific outcome to the strategy. This reliance14 Chapter 1 Nursing: Integral, Integrative, and Holistic—Local to Global
on the inherent intelligence within oneself to require the use of things, except for biofeedback
come forth is a way of acknowledging the intrin- instrumentation, music therapy, and CDs and
sic wisdom and self-correcting capacity within. videos to enhance learning and experience an
It is obvious that Era I medicine uses doing increase in awareness of body–mind connections.
therapies that are highly directed in their It employs being therapies that can be directed
approach. It employs things, such as medica- or nondirected, depending on the mental strate-
tions, for a specific goal. Era II medicine is a clas- gies selected (e.g., relaxation or meditation). Era
sic body–mind approach that usually does not III medicine is similar in this regard. It requires
TABLE 1-3 Eras of Medicine
Era I Era II Era III
Space-Time Local Local Nonlocal
Characteristic
Synonym Mechanical, material, Mind-body medicine Nonlocal or
or physical medicine transpersonal medicine
Description Causal, deterministic, Mind a major factor Mind a factor in healing
describable by classical in healing within the both within and between
concepts of space-time single person. Mind persons. Mind not
and matter-energy. has causal power; is completely localized to
Mind not a factor; thus not fully explainable points in space (brains
“mind” a result of by classical concepts or bodies) or time
brain mechanisms. in physics. Includes but (present moment or
goes beyond Era I. 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 clas-
sical concepts of space-
time or matter-energy.
Examples Any form of therapy Any therapy emphasizing Any therapy in which
focusing solely on the the effects of conscious- effects of conscious-
effects of things on ness solely within the ness bridge between
the body is an Era I individual body is an different persons is an
approach—including Era II approach. Era III approach. All
techniques such as Psychoneuroimmunology, forms of distant
acupuncture and counseling, hypnosis, healing, intercessory
homeopathy, the use biofeedback, relaxation prayer, some types of
of herbs, etc. Almost therapies, and most shamanic healing,
all forms of “modern” types of imagery-based diagnosis at a distance,
medicine—drugs, “alternative” therapies telesomatic events,
surgery, irradiation, are included. and probably
CPR, etc.—are included. 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.Eras of Medicine 15
a willingness to become aware, moment by conform to our worldview of commonsense
moment, of what is true for our inner and outer notions. Often, the professional can follow an
experience. It is actually a “not doing” so that algorithm that dictates a step-by-step approach.
we can become conscious of releasing, empty- Examples of rational healing include surgery,
ing, trusting, and acknowledging that we have irradiation, medications, exercise, and diet. On
done our best, regardless of the outcome. As the other hand, being therapies fall into the
the therapeutic potential of the mind becomes paradoxical healing category because they fre-
increasingly clear, all therapies and all people quently happen without a scientific explana-
are viewed as having a transcendent quality. tion. In psychological counseling, for example,
The minds of all people, including families, a breakthrough is a paradox. When a patient
friends, and the healthcare team (both those in has a psychological breakthrough, it is clear
close proximity and those at a distance), flow that there is a new meaning for the person.
together in a collective as they work to create However, no clearly delineated steps led to the
healing and health.35 breakthrough. Such an event is called a break-
through for the very reason that it is unpredict-
Rational Versus Paradoxical Healing able—thus, the paradox.
All healing experiences or activities can be
arranged along a continuum from the ratio-
nal domain to the paradoxical domain. The Paradoxical Healing
degree of doing and being involved determines
these domains, as shown in Figure 1-6. Ratio-
nal healing experiences include those therapies Miracles
or events that make sense to our linear, intel-
lectual thought processes, whereas paradoxical Prayer
healing experiences include healing events that
may seem absurd or contradictory but are, in
fact, true.34 Placebo effects
Doing therapies fall into the rational heal-
ing category. Based on science, these strategies
Biofeedback
Paradoxical Healing Psychological counseling
Drugs
Doing
Being
Irradiation
Surgery
Rational Healing Rational Healing
FIGURE 1-5 “Being” and “Doing” FIGURE 1-6 Continuum of Rational
Therapies and Paradoxical Healing
Source: Reprinted with permission from Source: Reprinted with permission from
L. Dossey, Meaning and Medicine: A Doctor’s L. Dossey, Meaning and Medicine: A Doctor’s
Tales of Breakthrough and Healing, p. 204, Tales of Breakthrough and Healing, p. 205,
New York, Bantam Books, 1991. Copyright New York, Bantam Books, 1991. Copyright
Larry Dossey. Larry Dossey.16 Chapter 1 Nursing: Integral, Integrative, and Holistic—Local to Global
Biofeedback also involves a paradox. For situations. To further integrate these concepts,
example, the best way to reduce blood pressure relationship-centered care is discussed next.
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
Q RELATIONSHIP-CENTERED CARE
being, or passive volition, in which they let these In 1994, the Pew Health Professions Commission
physiologic states change in the desired direc- published its landmark report on relationship-
tion. Similarly, the phenomenon of placebo is a centered care.37 This report serves as a guideline
paradox. If an individual has just a little discom- for addressing the bio-psycho-social-spiritual
fort, a placebo does not work very well. The more dimensions of individuals in integrating caring,
pain a person has, however, the more dramatic healing, and holism into health care. The guide-
the response to a placebo medication can be. In lines are based on the tenet that relationships
addition, a person who does not know that the and interactions among people constitute the
medication is a placebo responds best. This is foundation for all therapeutic activities.
referred to as the “paradox of success through In integral and holistic nursing, relationship-
ignorance.” Prayer and faith fall into the domain centered care serves as a model of caregiving
of paradox because there is no rational scientific that is based in a vision of community where
explanation for their effectiveness. Many scien- three types of relationships are identified:
tific studies have been conducted, however.32,34 (1) patient–practitioner relationships, (2) com-
Miracle cures also are paradoxical because munity–practitioner relationships, and (3) prac-
there is no scientific mechanism to explain titioner–practitioner relationships.37 The three
them.32,34,35 Every nurse has known, heard of, or components of relationship-centered care are
read about a patient who had a severe illness shown in Table 1-4, Table 1-5, and Table 1-6.
that had been confirmed by laboratory evidence Each of these interrelated relationships is essen-
but that disappeared after the patient adopted tial within a reformed system of health care, and
a being approach. Some say that it was the nat- each involves a unique set of tasks and responsi-
ural course of the illness; some die and some bilities that address self-awareness, knowledge,
live. At shrines such as Lourdes in France and values, and skills.
Medjugorje in Yugoslavia, however, people who
experience a miracle cure are said to be totally Patient–Practitioner Relationship
immersed in a being state. They do not try to In integral health care, the patient–practitioner
make anything happen. When interviewed, these relationship is crucial on many levels. The prac-
people report experiencing a different sense of titioner incorporates comprehensive biotechno-
space and time; the flow of time as past, pres- logic care with psycho-social-spiritual care. To
ent, and future becomes an eternal now. Birth work effectively within the patient–practitioner
and death take on new meaning and are not relationship, the practitioner must develop spe-
seen as a beginning and an end. Premonition lit- cific knowledge, skills, and values, as shown in
erally means “forewarning.”36 Premonitions are Table 1-4.37 This includes an expanding self-
a heads-up about something just around the awareness, understanding the patient’s expe-
corner, something that is usually unpleasant. rience of health and illness, developing and
It may be a health crisis, a death in the family, maintaining caring relationships with patients,
or a national disaster. But premonitions come and communicating clearly and effectively.
in all flavors. Sometimes they provide informa- Active collaboration with the patient and fam-
tion about positive, pleasant happenings that lie ily in the decision-making process, promotion
ahead—a job promotion, the location of the last of health, and prevention of stress and illness
remaining parking space, or, in some instances, within the family are also part of the relation-
the winning lottery numbers. ship. A successful relationship involves active lis-
These people go into the self and explore tening and effective communication; integration
the “not I” to become empty so that they can of the elements of caring, healing, values, and
understand the meaning of illness or present ethics to enhance and preserve the dignity andRelationship-Centered Care 17
TABLE 1-4 Patient–Practitioner Relationship: Areas of Knowledge, Skills, and Values
Area Knowledge Skills Values
Self-awareness Knowledge of self Reflect on self and work Importance of self-
Understanding self awareness, self-care,
as a resource to others self-growth
Patient experience of Role of family, culture, Recognize patient’s Appreciation of
health and illness community in life story and the patient as a
development its meaning whole person
Multiple components View health and illness Appreciation of the
of health as part of human patient’s life story and
Multiple threats and development the meaning of the
contributors to health health-illness condition
as dimensions of
one reality
Developing and Understanding of Attend fully to the patient Respect for patient’s
maintaining caring threats to the integrity Accept and respond to dignity, uniqueness,
relationships of the relationship (e.g., distress in patient and self and integrity (mind-
power inequalities) body-spirit unity)
Respond to moral and
Understanding of ethical challenges Respect for
potential for conflict self-determination
Facilitate hope, trust,
and abuse and faith Respect for person’s
own power and self-
healing processes
Effective Elements of effective Listen Importance of being
communication communication Impart information open and nonjudgmental
Learn
Facilitate the learning
of others
Promote and accept
patient’s emotions
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
integrity of the patient and family; and a reduc- family, relatives, friends, coworkers, neighbor-
tion of the power inequalities in the relationship hoods, religious and community organizations,
with regard to race, sex, education, occupation, and the hospital community. The knowledge,
and socioeconomic status. skills, and values needed by practitioners to par-
ticipate effectively in and work with various com-
Community–Practitioner Relationship munities are shown in Table 1-5. This includes
In integral health care, the patient and his or understanding the meaning of the community,
her family simultaneously belong to many recognizing the multiple contributors to health
types of communities, such as the immediate and illness within the community, developing18 Chapter 1 Nursing: Integral, Integrative, and Holistic—Local to Global
TABLE 1-5 Community–Practitioner Relationship: Areas of Knowledge, Skills,
and Values
Area Knowledge Skills Values
Meaning of Various models Learn continuously Respect for the
community of community Participate actively in integrity of the
Myths and community develop- community
misperceptions ment and dialogue Respect for
about community cultural diversity
Perspectives from
the social sciences,
humanities, and
systems theory
Dynamic change—
demographic, politi-
cal, industrial
Multiple contributors History of community, Critically assess the Affirmation of rel-
to health within the land use, migration, relationship of evance of all determi-
community occupations, and their healthcare providers nants of health
effect on health to community health Affirmation of the
Physical, social, and Assess community and value of health policy
occupational environ- environmental health in community services
ments and their effects Assess implications Recognition of the
on health of community policy presence of values
External and internal affecting health that are destructive to
forces influencing health
community health
Developing and main- History of practitioner– Communicate ideas Importance of being
taining community community Listen openly open minded
relationships relationships Honesty regarding the
Empower others
Isolation of the health- limits of health science
Learn
care community from Responsibility to
the community at large Facilitate the learning
contribute health
of others
expertise
Participate appropri-
ately in community
development and
activism
Effective community- Various types of care, Collaborate with Respect for commu-
based care both formal and other individuals nity leadership
informal and organizations Commitment to work
Effects of institutional Work as member for change
scale on care of a team or healing
Positive effects of community
continuity of care Implement change
strategies
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.Relationship-Centered Care 19
TABLE 1-6 Practitioner–Practitioner Relationship: Areas of Knowledge, Skills,
and Values
Area Knowledge Skills Values
Self-awareness Knowledge of self Reflect on self Importance of
and needs self-awareness
Learn continuously
Traditions of Healing approaches of Derive meaning from Affirmation and value
knowledge in various professions others’ work of diversity
health professions Healing approaches Learn from experience
across cultures within healing
Historical power community
inequities across
professions
Building teams Perspectives on team- Communicate Affirmation of mission
and communities building from the effectively Affirmation of diversity
social sciences Listen openly
Learn cooperatively
Working dynamics of Perspectives on team Share responsibility Openness to
teams, groups, and dynamics from the responsibly others’ ideas
organizations social sciences Collaborate with others Humility
Work cooperatively Mutual trust,
Resolve conflicts 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.
and maintaining relationships with the com- relationship requires the knowledge, skills, and
munity, and working collaboratively with other values shown in Table 1-6, including developing
individuals and organizations to establish effec- self-awareness; understanding the diverse knowl-
tive community-based care.37 edge base and skills of different practitioners;
Practitioners must be sensitive to the impact developing teams and communities; and under-
of these various communities on patients and standing the working dynamics of groups, teams,
foster the collaborative activities of these com- and organizations that can provide resource ser-
munities as they interact with the patient and vices for the patient and family.37
family. The restraints or barriers within each Collaborative relationships entail shared plan-
community that block the patient’s healing ning and action toward common goals with joint
must be identified and improved to promote the responsibility for outcomes. There is a difference,
patient’s health and well-being. though, between multidisciplinary care and inter-
disciplinary care. Multidisciplinary care consists
Practitioner–Practitioner Relationship of the sequential provision of discipline-specific
Providing integral care to patients and fami- health care by various individuals. Interdisciplin-
lies can never take place in isolation; it involves ary care, however, also includes coordination,
many diverse practitioner–practitioner rela- joint decision making, communication, shared
tionships. To form a practitioner–practitioner responsibility, and shared authority.20 Chapter 1 Nursing: Integral, Integrative, and Holistic—Local to Global
Because the cornerstone of all therapeutic and the expert panel showed that health profes-
healing endeavors is the quality of the relation- sions students need continuous development of
ships formed among the practitioners caring for interprofessional competencies as an essential
the patient, all practitioners must understand part of their learning process. When this type of
and respect one another’s roles. Conventional education occurs, they are more likely to enter
and alternative practitioners need to learn about the workforce ready to practice effective team-
the diversity of therapeutic and healing modali- work and team-based care.
ties that they each use. In addition, conventional Each expert panel group contributed its
practitioners must be willing to integrate comple- competencies, which resulted in interprofes-
mentary and alternative practitioners and their sional collaborative practice competencies
therapies in practice (i.e., acupuncture, herbs, identified in the following four domains:
aromatherapy, touch therapies, music therapy, (1) values/ethics for interprofessional practice,
folk healers). Such integration requires learning (2) roles/responsibilities, (3) interprofessional
about the experiences of different healers, being communication, and (4) teams and teamwork.9
open to the potential benefits of different modal- Teaching of these interprofessional col-
ities, and valuing cultural diversity. Ultimately, laborative competencies must extend beyond
the effectiveness of collaboration among prac- profession-specific education so that students
titioners depends on their ability to share prob- are more likely to work effectively as members
lem solving, goal setting, and decision making of clinical teams. In teaching interprofessional
within a trusting, collegial, and caring environ- competencies and collaboration with the goal of
ment. Practitioners must work interdependently practicing relationship-centered care, new theo-
rather than autonomously, with each assuming ries must be applied such as complexity theories
responsibility and accountability for patient care. and positive psychology to transform organiza-
In the next section, the role of the Pew report on tions.39,40 To cross the patient-centered divide
relationship-centered care is discussed. and apply relationship-centered care, faculty
development must include mindfulness prac-
tice, formation, and training in communication
Q CORE COMPETENCIES skills. The next section explores several examples
FOR INTERPROFESSIONAL of how these concepts are being translated.
COLLABORATIVE PRACTICE
In 1998, following a decade of leadership and
advocacy for health professions education, the
Q CREATING OPTIMAL HEALING
Pew Health Professions Commission published its ENVIRONMENTS
fourth and final report on relationship-centered The Samueli Institute for Information Biology
care. The report assesses the challenges facing (www.siib.org) studies relationship-centered care
professionals in the 21st century and recom- and ways to transform organizational culture
mends general and professional-specific actions.38 through research and innovative projects that
In 2011, the Interprofessional Education articulate and demonstrate a complete opti-
Collaborative Expert Panel9 came together with mal healing environment (OHE) framework of
an inspired vision for identifying the necessary actionable practices and evaluation methods.41
core competencies for interprofessional collab- The institute defines an optimal healing environ-
orative practice that would be safe, high qual- ment as one in which “the social, psychological,
ity, accessible, and inclusive of patient-centered spiritual, physical and behavioral components
care. The six organizations that comprise the of health care are oriented toward support and
expert panel were the American Association of stimulation of healing and the achievement of
Colleges of Nursing, American Association of wholeness.” From this perspective, facilitating
Colleges of Osteopathic Medicine, American healing is thought to be a crucial aspect of man-
Association of Colleges of Pharmacy, American aging chronic illness and the basis for sustain-
Dental Education Association, Association of able health care.
American Medical Colleges, and Association of Key concepts in optimal healing environ-
Schools of Public Health. To achieve its vision ments are awareness and intention. AwarenessYou can also read
