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Presented on The 18th International Symposium on Critical Care and Emergency Nursing 2011, organized by The Indonesian Society ofCritical Medicine (PKGDI), PERDICI, Mount Sinai of School of Medicine, USA, The Asia Pacific Association of Critical Care Medicine (APACCM),
APPLICATION OF THE HOLISTIC NURSING CONCEPT IN CRITICAL CARE
SETTING*
Kusman Ibrahim, PhD Faculty of Nursing, Padjadjaran University
*Manuscript was presented in The 18th International Symposium on Critical Care and Emergency Nursing, organized by The Indonesian Society of Critical Medicine (PKGDI), PERDICI, Mount Sinai of School of Medicine, USA, The APACCM, 21st -23rd July 2011, Bali, Indonesia
INTRODUCTION Health care services are continuing to change in line with the advancement of health science and technology. In addition, the complexity of health problem being faced by community is also demanding on the effective respond of health care services and health care professionals. The capacity of health care professionals to anticipate the needs of society on quality of health care services, and meet the needs by scientifically proved interventions are key to succeed effective and quality of health care services. Critical care nursing is a specialty area of nursing care to respond the need and demand of society on availability health care services for people who have life threatening health problems and need intensive care to help them recover (Urden, Stacy, & Lough, 2006). The advancement of medical technology and interventions have implicated to the raising of acknowledgment the role of nurses in observation and monitoring critically ill patients. Even, medical doctors will much rely on nurses to observe the physiological changes of critically ill patients including taking initial measures to handle unstable patients‟ condition while a medical doctor is unavailable in the intensive care unit. The rapid advancement in the field of critical care, particularly indicated by invention in sophisticated medical technology, has led to a better diagnosis and provided many benefits to guide accurate treatment and care for critically ill patients (Hudak & Gallo, 1994). On the other hand, the impact of advance technology in critical care also has drawn the concentration of nurses on technical procedure of using the sophisticated machines rather than providing a comprehensive holistic care for patients (Relf & Kaplow, NA). This situation contribute to the fragmentation of care which is more isolated on physical and mechanistic matters than psychological, social, spiritual, and cultural aspects. In addition, care is more directed on patients as individual than addressed patients and family in a unity as center of care. In this
Presented on The 18th International Symposium on Critical Care and Emergency Nursing 2011, organized by The Indonesian Society ofCritical Medicine (PKGDI), PERDICI, Mount Sinai of School of Medicine, USA, The Asia Pacific Association of Critical Care Medicine (APACCM),
regard, family is also viewed as a target of care that has needs and potential to participate in care. Historically, the beliefs and values related holistic and humanistic care have been invested in nursing since the era of Florence Nightingale who live at 1820 to 1910 (Dossey, Keegan, & Guzzetta, 2000). Florence Nightingale taught that the focus of nursing was the unity and wellness of human being and reciprocity between human and his environment (Mariano, 2007). Yet, at the era after Florence Nightingale, the progress of nursing was not in line with the ideal as taught by Nightingale. Nursing was dominated by biomedical science that more emphasize on bio-physical aspect of patients. This phenomenon has inspired nursing scientists to refine the nursing philosophy and generate nursing theories to guide nursing practice. A number of researches were carried out to develop models and theories of nursing including in the area of holistic nursing. Theory of holistic nursing was also implemented in clinical practice of nurses and integrated in nursing curricula. Considering the importance of raising the awareness of nurses to think and integrate holistic nursing values into nursing practice, significant efforts are needed to explore, understand as well as implement the values of holistic nursing. Continuing evaluations and reflections on nursing practice are needed to examine whether caring for the patients has met the comprehensive, holistic, and quality standard of care. This will yield not only the cure of disease, but also healing and satisfaction of patients and family toward health care services. This paper aims to highlight and discuss the concepts, beliefs, and values underlying holistic nursing as well as its implementation in nursing practice, particularly for critically ill patients.
THE HOLISTIC NURSING CONCEPTS The word “holistic” is originally from Greek word “holos” (whole, wholism) meaning “unity” (Dossey, Keegan, & Guzzetta, 2000). Holistic means a unity or integrated parts, more than, or not only accumulation or combination of its components. American Holistic Nurses Association (2007) defined Holistic nursing embraces all nursing which has enhancement of healing the whole person from birth to death as its goal. Holistic nursing recognizes that there are two views regarding holism: that holism involves identifying the interrelationships of the bio-psycho-social-spiritual dimensions of the person, recognizing that the whole is greater than the sum of its parts; and that holism involves understanding the individual as a unitary whole in mutual process with the environment. Holistic nursing responds to both views, believing that the goals of nursing can be achieved within either framework. The holistic
Presented on The 18th International Symposium on Critical Care and Emergency Nursing 2011, organized by The Indonesian Society ofCritical Medicine (PKGDI), PERDICI, Mount Sinai of School of Medicine, USA, The Asia Pacific Association of Critical Care Medicine (APACCM),
both actual and potential and need vigilant nursing care (Urden, Stacy, & Lough, 2006). Changes of normal function resulting from disease progression, sedative medications, medical devices including mechanical ventilator, may contribute to change of mental status of the patients (Urden, Stacy, & Lough, 2006). Sleep disturbance and over stimulations from the environment can deteriorate the cognitive ability of the patients to understand the information, learning, making decision, and adaptation to new environment. It impacts to the process of decision making such as “informed consent” that impossible to be taken by patient alone without any participation from family. Apart of physical problems, psychosocial and spiritual problems are also visible on critically ill patients. These problems commonly resulted from high stress and limited coping capacity to handle the situation. Although individuals may vary in experiencing critical conditions, critical ill patients are commonly faced by one of the following situations (Urden, Stacy, & Lough, 2006):
- Death imminent
- Life with disability
- Pain and discomfort
- Sleep disorder
- Loss of ability to express verbally communication due to intubation
- Separation from family
- Lack of autonomy/independency in activity daily living
- Loss of control toward environment
- Loss of usual role
- Loss of self-esteem
- Anxiety
- Boring, frustration, and negative thinking
- Spiritual distress
- Severity of stressor‟s effect and patients‟ response depend on the following factors:
- Duration of exposure on stressor (acute or chronic)
- Cumulative effect of the simultaneous stressor
- Sequence of stressor coming
- Previous experience expose to the stressor and affectivity of used coping strategy
- Social support
Presented on The 18th International Symposium on Critical Care and Emergency Nursing 2011, organized by The Indonesian Society ofCritical Medicine (PKGDI), PERDICI, Mount Sinai of School of Medicine, USA, The Asia Pacific Association of Critical Care Medicine (APACCM),
Whatever kind of the stress, physical, psychological, or social can yield physical response that affect body defend mechanism. There were a number of studies found the relationships between mind and body with regard to the response of body defend mechanism toward stress (Osho, 1994; Urden, Stacy, & Lough, 2006).
HOLISTIC CARE AND SINERGY MODEL IN CRITICAL CARE SETTING Holistic nursing implementation needs considering various factors both individuals and environmental that affect health and well being of the patients as well as coping ability to handle a critical condition. In order to be able to meet the needs, nurses need strong basic knowledge related to anatomy and physiology, disease process, treatment regimen, behavior, spirituality, and human response. Critical care nurses are not only able to work with high technology medical devices, but also have good understanding about their patients, so they are able to provide holistic, humanistic, and individual focused nursing care. The value of „presence‟ to help patients reflected one aspect of caring in nursing. Caring can also involve early identification of patients‟ problems, decide and implement appropriate intervention based on the understanding of previous patient‟s experience, beliefs, culture, behaviors, feelings, and preferences of patients. Jenny and Logan (1996) found that nurse caring behaviors according patients‟ perspectives were providing comfort, advocacy, encouragement, and respect to the uniqueness of patients. Caring art needs communication skills, interpersonal relationship, personal commitment, and ability to build trust relationship. Interpersonal relationship skills are necessary for nurses to implement holistic care. Wysong and Driver (2009) conducted a study to identify skills needed by nurses in critical care setting according to patients‟ perspectives. They found that:
- Friendly, cheers, and happy
- Attention, kind, compassion
- Self-confidence
- Treat patient humanistic
- Love the job
- Sense of humor
- Having time for patients
- Well organized
- Having good memory
- Good physical performance
Presented on The 18th International Symposium on Critical Care and Emergency Nursing 2011, organized by The Indonesian Society ofCritical Medicine (PKGDI), PERDICI, Mount Sinai of School of Medicine, USA, The Asia Pacific Association of Critical Care Medicine (APACCM),
evaluate outcomes using the Synergy Model. These are outcomes derived from the patient, the nurse, and the health care system. 20 Optimal outcomes are based on what patients define as important. These may include functional change, behavioral change, trust, satisfaction, comfort, and quality of life.
Figure 1: The relationship between the patient/family and the nurse in the Synergy Model (source: Relf and Kaplow, 2005)
CONCLUSION Critically ill patients who admitted in Intensive Care Unit are human as a whole and unique undergoing complex health problem. The way of nurse views patients will determine interaction patterns and approach toward patients and family. The advancement of technology in intensive care area should not neglect the basic philosophy of caring for patients and family. Holistic nursing beliefs and values can be foundation to implement caring values that is core of nursing. Synergy model provide a concrete illustration in implementing caring in a holistic ways in the context of building trust relationships harmoniously between nurse, patient and family. The interaction is directed to achieve a common goal that is health and well being of the patients and family, which is a goal of nursing as well.
Presented on The 18th International Symposium on Critical Care and Emergency Nursing 2011, organized by The Indonesian Society ofCritical Medicine (PKGDI), PERDICI, Mount Sinai of School of Medicine, USA, The Asia Pacific Association of Critical Care Medicine (APACCM),
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