Holistic practice – A concept analysis

Nurse Education in Practice (2008) 8, 412–419

Nurse

www.elsevier.com/nepr

Educationin Practice

Holistic practice – A concept analysis

Liz McEvoy a, Anita Duffy b,*

a AMNCH, Tallaght, Irelandb Faculty of Nursing and Midwifery, RCSI, Dublin, Ireland

Accepted 10 February 2008

14do

*

KEYWORDSConcept analysis;Holism;Holistic;Body, mind and spirit;Nursing practice

71-5953/$ - see front mattei:10.1016/j.nepr.2008.02.0

Corresponding author. TelE-mail address: aniduffy@

r �c 20002

.: +353 1rcsi.ie

Summary

Aims and objectives: This article aims to clarify the concept of ‘‘holism’’ in nursingthrough the use of Rodgers [Rodgers, B.L., 1989. Concept analysis and the develop-ment of nursing knowledge; the evolutionary cycle. Journal of Advanced Nursing 14,330–335] concept analysis framework.Background: The primary author is employed in a urology departmentwhich cares formany clients with end stage cancer. Holistic nursing practice is the philosophy of theunit, howevermany nurses struggle to articulatewhat holistic practice actuallymeansto them, hence this analysis was deemed very pertinent to practicing nurses to enablethe realization of nurses therapeutic potential when caring for patients in practice.Method: Rodgers (1989) well-established method of concept analysis was employedto facilitate the clarification of the concept of holistic nursing practice.Relevance to clinical practice: The clarification of the concept offered aworking def-inition of holistic nursing practicewhich practicing nurses can clearly comprehend andavail of when caring for patients of all race, religion and creed in the clinical practicearea.Conclusion: By undertaking this methodology of concept analysis the integrity of theconcept was kept intact. The factors that influence holistic nursing practice wereidentified and amodel case demonstrated the reality of holistic nursing care for prac-ticing nurses.

�c 2008 Elsevier Ltd. All rights reserved.

Introduction

Concept analysis is viewed by many as a method forclarifying overused or vague concepts (McBrien,2006). As concepts such as ‘‘holism’’ are often sub-

8 Elsevier Ltd. All rights reser

4028643.

jective, it is important that their meaning is clari-fied, otherwise misuse can dilute their relevanceto practice. Additionally, having concrete defini-tions assist in implementing the term in questioninto practice ultimately supporting research andtheory development (Paley, 1996; Villagomeza,2005; McBrien, 2006) vital for the professionaldevelopment of nursing.

ved.

Holistic practice – A concept analysis 413

The purpose of this article was to clarify theconcept of ‘‘holism’’ utilising Rodgers (1989) evo-lutionary concept analysis approach. In order to en-hance the comprehension of the concept of‘‘holism’’, it was necessary to identify the attri-butes, antecedents and consequences over an ex-tended period of time. The authors criticallyanalysed the concept and its application to prac-tice through describing a true life model case ofholistic nursing practice. The article concludeswith a clear definition of holism to offer practicingnurses an understanding of the reality of holisticnursing care.

Nursing knowledge

Theories are applied to nursing in the form of nurs-ing models which are then adapted and applied tothe particular clinical setting. The developmentand refinement of theories creates new quality ap-proaches to care and challenges existing practice(Wadensten and Carlsson, 2003). Nursing is bothpractice and academically based, therefore in or-der to create new approaches to practice, knowl-edge is essential. Knowledge must not only beabout the empirics, but also about the how andwhy of practice. This, according to Carper (1978)is what separates nursing from other disciplines.

There are many controversial debates in thenursing literature concerning the professionalisa-tion of nursing. It is agreed that one of the ac-cepted hallmarks of a profession is the possessionof a unique body of knowledge (Leddy and Pepper,1993). It is not the possession, but the applicationof this knowledge to practice that makes nursingunique. Building on both practical and proposi-tional knowledge is crucial to assist nurses’ developnursing theory that can be applied to practice (Col-ley, 2003). Walker and Avant (1995) state that con-cept analysis is the first step of theorydevelopment to clarify and define the phenomenonin question. Clarifying nursing concepts has theadvantage of empowering nurses and furthermoreit facilitates professional autonomy, which ulti-mately results in the professional development ofnurses (Ingram, 1991).

However, it is naive and misleading to describenursing knowledge as unique-as no single disciplinehas exclusive ownership over knowledge. Never theless, nursing does claim to have a unique focus oncaring, understanding and knowing the whole per-son (Brockopp and Hasting-Tolsma, 2003). Colley(2003) argues that knowledge borrowed from otherdisciplines only serves to dilute nursing practice,whilst Junor et al. (1994) argues that shared know-

ledge through team work is known to maximiseclinical effectiveness. There is a need to reassessexclusive claims to specialist knowledge andauthority in order to provide the best possible careto individual patients. Teams need to have sharedgoals and values to understand and respect theknowledge of other disciplines. In addition Carrierand Kendall (1995) identify that holistic care willonly be met if there is a readiness to share knowl-edge and surrender exclusive claims to specialistknowledge and authority.

It therefore follows that there is no such thing asunique knowledge and that borrowed theories onlyresult in enhancing nursing practice (Bradshaw,1995). This is particularly applicable to holismand holistic theories, which address the whole per-son, including mind, body and spirit, cultural,social and environmental approaches to care.Therefore, it is inevitable, that knowledge fromother social sciences is considered. The fact thathealthcare is continually evolving with an in-creased focus on interdisciplinary team work, fur-ther enhances this debate. Hence, a balance mustbe found considering other health disciplines haveas much to learn from nursing as nursing has fromthem. By working together and sharing knowledgedisciplines begin to understand each other’s per-spectives and learn and grow in their own practice.

Concept analysis

Concepts have been described by McKenna (1997:8)as ‘‘the building blocks of theory’’. Paley (1996)further argued that there is no agreement as towhat constitutes a concept. Concepts are like icecubes; just when you think you have grasped them,a lack of clarity results in their slipping beyond yourgrasp. They must therefore be analysed beforethey are misused in theory development. The aimof this analysis was to advance the concept of‘‘Holism’’ for theory development. In order to doso, a qualitative enquiry to create meaning throughlanguage, was deemed necessary.

Whilst there are a number of frameworks avail-able for concept analysis, Rodgers (1989) qualita-tive approach was chosen. Rodgers (1989)framework presents an inductive, dynamic viewof phenomenon (Cutliffe and McKenna, 2005) asopposed to that of Walker and Avant’s (1995)framework, which offers a more restrictive, deduc-tive, quantitative examination (Rodgers, 1989).Walker and Avant’s (1995) method of analysis isin contrast to the philosophy of holism and there-fore was deemed inappropriate. Holism as a con-cept is nebulous and subjective, captivating

Identify concept of interest

Identify Surrogate terms

Data collection

Analysis of Data

Identify references, antecedents and consequences

Model case

Identify the attributes of the concept

Figure 1 Rodgers (1989) framework for conceptanalysis.

414 L. McEvoy, A. Duffy

nurses over many centuries, with its application topractice changing over time. This further sup-ported the use of Rodgers (1989) method whichacknowledges that concepts are influenced by sig-nificance, use and application over time, resultingin an analysis that is more practise related and cur-rent (Baldwin, 2003). Cutliffe and McKenna (2005)additionally defend the real life evolutionary ap-proach to concept analysis which uses a real lifemodel case to demonstrate the attributes, ante-cedents and consequences of the concept. Othermodel cases such as the deviant or borderline casesas proposed by Walker and Avant’s (1995) model isnot within Rodgers philosophy, hence they werenot incorporated. Cahill (1996) advises authors tobe aware of the philosophical approaches of thechosen concept analysis framework. Fig. 1 outlinesthe steps in Rodgers (1989) framework.

Literature search

A review of the relevant literature, derived fromthe Cumulative Index of Nursing and Allied HealthLiterature (CINAHL), Medline and Pub Med – usingthe keywords ‘‘holism’’, ‘‘holistic’’ and ‘‘body,mind and spirit’’ was undertaken (n = 126). Theword ‘‘spirit’’ was used rather than ‘‘soul’’ asthe authors believe soul and spirit are interchange-able terms for our immaterial selves. Additionally,

the authors researched textbooks in both medicaland public libraries which provided useful informa-tion for this analysis. Many articles were discardedas they were vague, anecdotal and ambiguous.Articles that were used (n = 27) either defined hol-ism or gave a plausible account of how ‘‘holism’’was demonstrated in nursing practice.

Holism

Holism derives from the Greek word ‘‘holos’’,meaning whole (Griffen, 1993). Healing and healthstem from the Greek word ‘‘hale’’ which alsomeans to make whole (Kenney, 2001). Thereforeholism, healing and health are inter-related con-cepts in the nursing literature. With this in mindit became evident that the concept of ‘‘holism’’required clarification to extricate holism fromhealth and healing.

While most definitions of holism share the sameattributes, it is the application to practice that hasled to much discourse. Nursing is indeed holistic innature, as the nursing profession has traditionallyviewed the person as a whole, concerned withthe interrelationship of body, mind and spirit, pro-moting psychological and physiological well-beingas well as fostering socio-cultural relationships inan ever changing economic environment of care.However, holism is not exclusive to nursing andhas been used in banking, where holism is a prac-tice of looking at the various factors that lead peo-ple to invest (Wilber and Harrison, 1978). Also, theMontessori teaching method is based on a conceptof ‘‘holism’’ (Infed, 2005).

Smuts (1870–1950), a South African soldier andphilosopher introduced the word ‘‘holism’’ fromthe language of chemistry and in his book ‘‘Holismand Evolution’’ defined ‘‘holism’’ as, ‘‘. . .the prin-ciple which makes for the origin and progress ofwholes in the universe’’ (Smuts, 1926). This philos-opher believed that the whole was greater than thesum of its parts, explaining how South Africa wasgreater in its entirety rather than its individualstates. These thought patterns can be furthertraced to the Gestalt psychologists of 1920s and1930s who also believed the whole was greaterthan the sum of its parts.

It was in the 1970s that nursing became influ-enced by the concept of ‘‘holism’’, guided byhumanistic theorists such as Rogers (1970) ‘unitarynature of human beings’. Rogers believed that theworld is a single whole in which every element isinterconnected with others. In 1971, Levine furtherdescribed the role of the nurse as viewing each pa-tient as a unique human being in contrast to the

Holistic practice – A concept analysis 415

reductionist approach of medicine. Early theoristssuch as Rogers (1970) and Levine (1971) describepatients in terms of the wholeness. Ham-Ying’s(1993) analysis envisioned two common usages ofholism in nursing – a personal view and an ap-proach to nursing care. The American HolisticNurses Association (1992) defined ‘‘holistic nurs-ing’’ as, ‘‘. . . that state of harmony between mind,body, emotions and spirit in an ever changing envi-ronment’’. This perspective is consistent with thecontemporary view of ‘‘holism’’ in nursing, wherethe physical, social, cultural and spiritual realmsare interconnected (Govier, 2000; Jackson, 2004;Smart, 2005). These aspects are incorporated intoLeininger’s theory (1988) where diverse culturesand religions are taken into account, which is par-ticularly apt in modern healthcare and society. Itcould be argued that holism was always the ap-proach of nursing but it was the theorists that putit into words.

To practice holism, nurses are recommended tobe aware of both their own potential wholenessand also that of the patient. Our sense of whole-ness depends on our own vulnerability and on theopinions of other (Bright, 1997). Self-awareness isimportant and through the artful use of self,whereby an individual strives toward achieving asense of balance within oneself and the world, of-ten achieved through reflective practice; harmonycan enter relationships (Cumbie, 2001). It takespersonal, intellectual and professional maturity toreach this level of self awareness and personal har-mony. In practice, nurses who display the definingattributes of holism, discussed further in this anal-ysis, are guided by past experience and intuition(Benner, 1984). The degree of harmony that existsbetween nurses and their patients is central toholistic nursing.

The heart of holistic nursing is helping empowerthe patient to utilize their inner resources to im-prove their quality of life and adapt to changescaused by the disease trajectory (Buckley, 2002).The concept of empowerment is frequently usedin nursing, particularly in relation to quality ofcare, since the mission of nursing is to provide safeand quality nursing care, thereby enabling patientsto achieve their maximum level of wellness. Therole of nursing has evolved from being a guardianto being a creator of empowerment and over thelast decade the generic role of the nurse has beenreplaced by the specialist nurse. The changes innursing has expanded the role to include increasingemphasis on health promotion and illness preven-tion, as well as concern for the patient as a whole.A difficulty for nurses achieving holistic care maybe due to the strong emphasis placed on ‘‘interdis-

ciplinary’’ nursing. While acknowledging the exper-tise of specialist nurses, it could be argued thatwhat essentially has happened is that specialismhas fragmented the whole back into its componentparts. In terms of concept analysis, the word ‘‘hol-ism’’ has gone full circle. To practice holism as re-ferred to in the Scope of Practice (An BordAltranais, 2000), where nurses are required to ex-pand their practice to become more competent,developing reflectice practice skills, expertiseand clinical skills in order to meet the patientsneeds in a holistic manner, nurses must use theirdiscretion and work within a defined frameworkto provide the patient with a truly holistic ap-proach to care rather than fragmenting the careinto bio/social/psycho sub-systems. To overcomethis effect there must be a way of providing holisticcare through shared philosophies amongst interdis-ciplinary professionals.

Frankl (1984) claimed that characteristics of aholistic approach to care are the individual’s pri-mary motivational force to search and find meaningin life. However, many people do not feel the needfor such a psychological approach to care, consid-ering it as intrusive (Griffen, 1993; Smart, 2005).Many patients in the primary authors clinical prac-tice area – a urology department- are male, overthe age of 65 and do not welcome a holistic ap-proach for this precise reason. In this authors’experience, men tend to place greater value onthe physical aspects of care, such as assistancewith catheter care and wound care. However, itis important not loose sight of the psychological,spiritual, cultural, and social aspects of nursingcare, balancing nursings’ contribution, with alldimensions of care taken into account, as all toooften, nurses can also be overly focussed on thephysical aspects of care. The rapid patient turn-over in the urology department should not be usedas an excuse to neglect holistic care. Spiritual carecan be achieved simply by being present or throughattentive listening (DiJoseph and Cavendish, 2005).However brief the moment, the authors concurwith Jackson (2004), who believes that spiritualcare can have a profound effect on the patient’swell-being and also on the nurse in terms of jobsatisfaction (Nichols, 1992). ‘‘There is little pointin curing the body if we destroy the soul’’ (Anonin Martsolf and Mickley, 1998). Being spiritual doesnot mean saintly or affiliated with a particular reli-gion (Buckle, 1993; Govier, 2000; Jackson, 2004)Very often, those who opt for a less formal ap-proach to spirituality can achieve inner harmony(Narayanasamy, 1999). For many, the more formalapproach is taken, with prayer being the most fre-quently used spiritual practice among all cultures

Table 1 Antecedents and consequences of holisticnursing care

Antecedents for patient Antecedents for nurseNeed Assessment of needRelationship RelationshipCommunication CommunicationIllness IntuitionDisharmony KnowledgeCaring environment AdvocacyAutonomy AccountabilitySelf empowerment Environment conductive

to caring

Consequences positivefor patient

Consequences positivefor nurse

Harmony Self-satisfactionHealing Increased job satisfactionEmpowering Increased personal

developmentIncreased personaldevelopment

Professional development

Consequences negativefor patient

Consequences negativefor nurse

416 L. McEvoy, A. Duffy

(DiJoseph and Cavendish, 2005). Research claimsthat when people are ill they resort to such prac-tices (Meraviglia, 1999). Indeed, research into theeffect of prayer has demonstrated the positive ef-fects of prayer, in terms of life expectancy in bothAIDS and cancer patients not only when they saidprayers themselves but also when they were prayedfor (Byrd, 1988; Harris et al., 1999; DiJoseph andCavendish, 2005). As a consequence of the limitedamount of exposure to spirituality in education andpractice, nurses often lack the confidence tobroach spiritual issues with patients (DiJosephand Cavendish, 2005; McSherry, 1998). Therefore,education to support spiritual outcomes in nursingprogrammes must be enhanced and considered inthe nursing curriculum (Belcher and Griffiths,2005). In today’s climate there are an increasingnumber of both patients and staff from differentreligious backgrounds. Understanding the conceptof holistic care therefore requires sensitivity andknowledge of the beliefs of the patient, in the con-text of his or her own lived values.

Intrusive Emotionally drainingCan focus too much onpsychological

Time consuming

Defining attributes

Attributes of a concept are the characteristics ofthat concept that appear time and time again inthe literature. The attributes of ‘‘holism’’ identi-fied by this concept analysis are ‘‘mind, body andspirit’’ ‘‘whole’’ and ‘‘harmony’’ (Buckle, 1993;Griffen, 1993; Ham-Ying, 1993; Owen and Holmes,1993; Kolcaba, 1997; Cumbie, 2001). These are inline with the more traditional approaches to theconcept of ‘‘holism’’ commonly found in the1990s. However, a more recent paradigm now con-siders ‘‘healing’’ as a defining attribute of ‘‘hol-ism’’ (Cowling, 2000; Wong and Pang, 2000;Buckley, 2002; Ernst, 2004; Jackson, 2004).

Antecedents and consequences

The identification of antecedents and conse-quences are an important part of any concept anal-ysis as they provide further clarity regarding theconcept of interest (Rodgers, 1989). Antecedentsare events that take place prior to the occurrenceof the concept, and consequences happen as a re-sult of the concept (Rodgers, 1989). For holism totake place an authentic nurse/patient relationship,built on mutual trust and understanding is necessary(Cumbie, 2001). The nurse requires knowledge,expertise and good effective communication skills(Olive, 2003).

There are both positive and negative conse-quences for the patient and the nurse (describedin Table 1) Positive consequences for the nurse in-clude personal and professional development. Thisoutcome can result in a more substantive meaningof job satisfaction. For the patient holistic care canresult in better patient outcomes by building on pa-tient’s inner strength (Villagomeza, 2005) and thecreation of a person centred health system asdescribed in the Health Strategy (Department ofHealth and Children, 2001) as one which identifiesand responds to the needs of the individual, isplanned and delivered in a coordinated way, andhelps individuals to participate in decision makingto improve their health.

A negative consequence for the patient is intru-sion, hence holistic care must be patient led toavoid intrusion. In patients who do not know theirneeds, such as the unconscious patient, patientswith mental health problems or the ill neonate,the use of the nurse’s antecedent skills, such asintuition, effective nurse-patient relationships,advocacy, and accountability all come intoeffect. Equally, for some nurses, the conse-quences of providing twenty four hour holistic carecan be exhausting leaving the nurse emotionallydrained.

Holistic practice – A concept analysis 417

Surrogate terms

Surrogate terms appear to be related to theconcept of holism but not the same and include con-cepts such as ‘‘complimentary’’ and ‘‘alternative’’(Buckle, 1993; Barraclough, 2001). Words such as‘‘oneness’’, ‘‘inseparable’’ and ‘‘interconnected’’are also used in synonymously with holism (Patter-son, 1998; Barraclough, 2001).

Model case

Liz, the primary author, reflected on an incidentshe was involved in, which she felt reflected aholistic approach to patient care:

‘‘Jim and I chatted away together while I assistedwith his daily wash (harmony).He told me, abouthis life and following a rather informal conversa-tion he expressed how he would love ‘‘to go’’tomorrow, – the Feast of the Immaculate Concep-tion’’. Initially I was struck by the change in direc-tion of the conversation, but I knew it was essentialfor Jim that I took the time to listen to him. Wetalked candidly about what prayer and life afterdeathmeant to each of us (spirit).I sat down besidehim and I felt the need to hold his hand and listen(body and mind).Following our deep conversation (body, mind andspirit), I noticed he needed his toe-nails cut(body) It is our practice to call the chiropodistbut instead, I said ‘‘Jim would you like your nailsdone?’’ ‘‘That would be lovely. . . but Id like youto do it, if you have the time’’ he replied, smiling(harmony and healing) and added ‘‘it will be awhile before I get them done again’’ After I fin-ished, I enquired if he would like to see Sr. Lucyfrom Pastoral Care (spirit, healing). ‘‘No, thankyou dear, I’m refreshed in every sense of theword,, much better now after talking to you’’(wholeness, body, mind and spirit, harmonyand healing). I left with a sense of satisfactionknowing that I had contributed to the finalmoments of his life, but overwhelmed by our frankconversation about his impending death. Jim diedthat night; the night nurses said he diedpeacefully.

The model case is a true account of Liz nursingrelationship with a patient who was facing death.The model case touches on many of the key attri-butes of holism identified through this analysis suchas assessment of need, effective nurse patientrelationships, and intuition. The harmonious rela-tionship between the pair, allowed Jim share his

thoughts while he prepared for his final transitionto death.

The case demonstrates the therapeutic nursingrelationship that existed between the practitionerand her patient, which encompassed the patientsmind, body and spirit to achieve wholeness, har-mony and healing whilst attending to the patient’sdaily activities of living in a holistic nursing man-ner. Liz felt that in some way- perhaps simply fromher presence, she had eased Jim’s mental suffer-ing. This caring relationship involved the therapeu-tic use of self within the human–human encounter(Johns, 2004). By cutting his toe-nails herself,rather than referring him to the chiropodist, Lizhad refrained from fragmenting Jims care, thusaffording Jim holistic nursing care. The holisticcare given in this model case offered Jim mental,bodily and spiritual care which resulted in har-mony, healing and wholeness. Liz was enabled tospend this valuable time with Jim in a culture thatvalues holistic caring by putting the patientfirst.

Impact on nursing education andpractice

Nurses, whether specialists or generalist practitio-ners must respond sensitively to the patient’s spiri-tual and cultural belief systems, demonstratingcaring, presence and integrating spirituality intothe nursing care plan in order to meet the needsof the patient in a holistic manner. More emphasisshould be placed on the concept of holism andholistic practice in nurse education and practicein order to treat individual’s social, cognitive,emotional and physical problems. Holistic nursingis a complete way to practice professional nursing(Montgomery Dossey et al., 2005) hence, holisticnursing must be integrated into the nurse educa-tion curriculum. Holistic nursing draws on nursingknowledge, theories, expertise and intuition, allof which can be developed through reflective prac-tice. A paradigm shift is required to embrace holis-tic nursing. Nursing need to be committed to thecore values of caring, critical thinking, holism,nursing role development and accountability.These values focus on the key stakeholders inhealth care- the clients, their families and the al-lied health care teams involved in patient care.The achievement of these five core values is essen-tial to form the foundation in order to practice theart and science of nursing in a holistic manner.

Nurse specialisation should not fragment thewhole. Post graduate nurses should be encouraged

418 L. McEvoy, A. Duffy

to undertake further education to develop skills,competence and expertise in clinical practice.The provision of stand alone modules in specialistnursing care is perhaps one answer to encourageholistic nursing care in the future. Furthermore,interdisciplinary education, where scientific knowl-edge is shared amongst allied professionals couldultimately lead to mutual understanding and appli-cation of holistic care to practice. An all for oneand one for all ‘‘Musketeer’’ approach to healthcare education may be the solution to the chal-lenges of providing holistic patient care with moreemphasis placed on the development of team-building skills and the development of a collabora-tive approach to patient care.

Conclusion

Concepts are a means through which nursing carecan be articulated. Concept analysis can be a veryeffective way of ensuring that the integrity of aconcept is maintained, even as the boundaries ofknowledge and practice become more permeable.

One surprising outcomes of this concept analysiswas that the term ‘‘holism’’ has been linked to theconcept ‘‘interdisciplinary’’. It emerged in thisanalysis that interdisciplinary care can fragmentpatient care. A current focus on nursing is theadvancement of nursing practice and encourage-ment of nurse specialisation. Is nursing looking atthe trees instead of the forest? Adjustments needto be made, so that nurses can view and appreciatethe landscape in its entirety rather than focussingon isolated parts. Then, and only then, the scenecan be re-set for ‘‘holism’’ and holistic practicein its purest sense.

In conclusion a working definition of ‘‘holisticnursing practice’’ is hereby offered by the authors:

‘‘Holistic nursing care embraces the mind, bodyand spirit of the patient, in a culture that supportsa therapeutic nurse/patient relationship, result-ing in wholeness, harmony and healing. Holisticcare is patient led and patient focused in orderto provide individualised care, thereby, caringfor the patient as a whole person rather than infragmented parts.’’

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