Ctibbetts_ConceptAnalysis_091116

Running Head: CONCEPT ANALYSIS: HOLISTIC NURSING 1
Concept Analysis: Holistic Nursing
Catherine M. Tibbetts
The Catholic University of America

CONCEPT ANALYSIS: HOLISTIC NURSING 2
Abstract
The goal of this paper will be to explore, define, and perform a concept analysis on Holistic
Nursing and its role in nursing practice and theory through the use of Rodgers (Rodgers, B.L.,
1989) evolutionary concept analysis method. Holistic nursing can be difficult to analyze as it is
broad and encompasses, but also differs from, many related terms. As seen in the literature
reviewed, it is often that one or more of these encompassed terms are emphasized as the primary
aspect of holistic nursing, when in fact it is only one attribute of the concept. The concept
analysis was conducted by selecting the concept, researching the available recent literature, and
studying the current existing definitions and defining aspects of holistic nursing. The
similarities and differences of its related or encompassed terms were also reviewed. The concept
was synthesized and defined, antecedents and consequences listed, and a pertinent case study
was presented in order to illustrate it. Finally, the current available tool with which holistic
nursing is measured was discussed, and proposals were made as to how its accuracy can be
improved by including several more current aspects of holistic nursing, which were not available
when the tool was created. The purpose of this concept analysis is to show the evolution of the
concept itself, how it can be more accurately measured, and give weight to its integral role in the
practice and theory of nursing.
Keywords: Holistic Nursing Care, Holistic Nursing, Concept Analysis, Integrative Health,
Complementary care, Alternative care

Concept Analysis: Holistic Nursing
Introduction
Many frameworks have been developed for concept analysis, but for this paper Rodgers
(1989) framework was most conducive to the concept of holistic nursing, as it is a somewhat
vague term, encompassing many related and associated terms. Rodgers evolutionary method
allows for these more “dynamic” and “fuzzy” concepts to be examined (2000). The purpose of
Rodgers evolutionary method of concept analysis is not simply to define the concept in
dictionary-like terminology, but to promote further inquiry and identify questions that can be
applied in further practical research and application (McEwen & Willis, 2014). For the sake of
this concept analysis, the terms, ‘holistic care’, and ‘holistic nursing care’ were deemed
synonymous with the concept ‘holistic nursing’ when searching for relevant literature. The
terms ‘complementary care’, ‘alternative care’, and ‘integrative health’ are considered related or
associated terms that are encompassed by the larger umbrella of holistic nursing.
Literature Search
With the exclusion of Rodgers’ work, the literature used in this analysis was written and
published within the last twenty-five years. Holistic nursing is a concept that it constantly
evolving and maturing so the most current information available was applied. According to
Professors Bullington and Fagerberg, the concept of ‘Holistic Care’ has been widely used in
various contexts without a singular definition, or any clear idea of what is meant by the term
specifically (2013). However, a search of the Cumulative Index of Nursing and Allied Health
Literature (CINAHL), National Center for Complementary and Integrative Health (NCCIH),
Medline, and EBSCO using the keywords “holistic nursing”, “holistic care”, and “holistic
nursing care”, revealed that the literature is saturated with references to these terms. Although

the term holistic nursing and its synonyms were used liberally, they were often subjective and
interchangeable with their related or associated terms. This makes the analysis of holistic
nursing difficult, however, extremely necessary. This concept analysis will hopefully lead to
more practical and application-ready knowledge for nursing practice and theory development in
future.
Defining and Developing
The original working definition of ‘Holistic Nursing’ as stated by the American Holistic
Nurses Association (AHNA) is “all nursing that has healing the whole person as its goal” (2007).
This definition is fairly broad and non-specific. The concept itself has even been labeled
redundant as from its earliest historical roots, a holistic approach to nursing has been favored by
both patients and nurses (Lang & Krejci, as cited in Kinchen, 2014). Holistic nursing is
developed from the concept of ‘Holism’, which McEvoy and Duffy determined in their research
was a term developed from the Greek words holos and hale, both of which mean ‘whole’ (2008).
They go on to state:
While most definitions of holism share the same attributes, it is the application to
practice that has led to much discourse. Nursing is indeed holistic in nature, as the
nursing profession has traditionally viewed the person as a whole, concerned with the
interrelationship of body, mind and spirit, promoting psychological and physiological
well-being as well as fostering socio-cultural relationships in an ever changing economic
environment of care. (McEvoy & Duffy, 2008)
It wasn’t, however, until the later half of the 20th century that the term ‘Holistic’ was used
in reference to nursing. Nursing theorists began to use concepts from other disciplines (such as
psychology etc.) as well as those of Eastern philosophies and spirituality to form models of

nursing care that were individual, patient-oriented, and relationally-based (Kinchen, 2014).
More recently the AHNA describes a holistic nurse as a nurse who takes traditional nursing, its
knowledge and skill set, and integrates it with a sense of relationship and interconnectedness of
mind, body, spirit, and emotion (2012).
There are, however, several terms and concepts that appear in the nursing literature
pertaining to or encompassed by holistic nursing, but are in definition separate. These include
complementary care, alternative care, and integrative health. Complementary care, according to
the NCCIH, is care in practice that is used in conjunction with conventional or mainstream
medicine; alternative care is what is used in place of conventional or mainstream medicine
(2008). Complementary care is a large umbrella in and of itself: encompassing mind and body
practices (i.e. yoga, chiropractic, acupuncture, relaxation techniques etc.) as well as homeopathy.
Meditation, natural product supplementation, and other practices, often Eastern in origin, are also
employed. Integrative health is a concept that that involves bringing conventional and
complementary approaches of care together in a synchronized way (NCCIH, 2008). Holistic
Nursing is a larger blanket that may incorporate all three of these concepts. According to the
AHNA, “Holistic nurses may integrate complementary/alternative modalities (CAM) into
clinical practice [and in] doing so […] serve[s] to complement, broaden, and enrich the scope of
nursing practice and to help individuals access their greatest healing potential” (Thornton, 2016).
These three related or associated terms all service the main aspects of the concept of holistic
nursing. They can be individualized and are thus inherently patient-oriented, and they promote
the growth of a healthcare relationship between provider and patient. They also serve to
recognize or bring about wholeness in that they involve modalities that treat the person and not
simply the illness. For example, a patient with a chronic illness may choose to employ the use of

CAM (i.e. relaxation techniques, natural supplementation, or acupuncture etc.) in order to better
cope with the mental, emotional, spiritual, or psychological stress, while simultaneously using
conventional therapies or pharmaceutical treatments to advance further healing. Holistic nursing
is employed when the nurse is aware of the patient’s wholeness and interconnectedness, and
strives to relate to, guide, and treat the patient according to these principles, while involving the
patient (their ideas and preferences) in that process.
Antecedents and Consequences
Identification of the antecedents and consequences are vital in providing a clear picture
of the concept. By showing the concept’s antecedents, or, ideas from which it has evolved,
nurses are better able to better understand is necessity (Rodgers, 1989). Some of the vital
antecedents of Holistic Nursing include, 1) the patient’s desire for a better relationship and
communication, 2) the desire for self-empowerment and an active role in their own care, and 3)
the need for continuity of care in patients with chronic illnesses (McEvoy & Duffy, 2008). It is
important to note, however that antecedents (and consequences) are not always positive;
intrusiveness (into patients lives and management of care) and emotional drain on the part of
nurses have been listed as possible negative antecedents in the concept of holistic care (McEvoy
and Duffy, 2008). Holistic nursing is defined, however, by an empathetic response (individual
and patient oriented) on the part of the nurse as they strive to be aware of the patients needs in
the moment. In order to prevent the emotional strain, nurses must also be self-aware; they must
be aware of their weaknesses and strengths so as to not exceed their emotional limits and be able
to care for the needs of their patients. They must also be aware of the disposition of their
patients and whether or not they are overstepping. Holistic nurses are facilitators, not dictators,

of a patient’s care process, and must strive to be aware of the patient’s needs and desires with
regards to their health care.
Showing the concepts consequences also helps nurses to see the value of the concept and
its integral role in practice. It may also point out any potential negative or harmful implications
of the concept in action. Some of the positive consequences for both patients and nurses within
the concept of holistic nursing included, 1) increased patient satisfaction across the board, and 2)
an increase in personal and professional development. Many studies have shown that patients
were appreciative of being given the option of participating in their own care. They appreciated
the empathetic response of the nursing staff to whatever they are going through in the moment
(McEvoy & Duffy, 2008). There is a great need for these positively correlated results to be
studied further in a methodical and scientific method in order to increase the use of holistic
nursing practices. Despite the potential for emotional drain on nurses, and the patients that may
feel holistic nursing care methods are intrusive, most patients respond better and will report
feeling better when they are taken care of by nurses (and indeed, all medical personnel) who
follow holistic nursing practices (McEvoy & Duffy, 2008).
Model Case Studies
There are many examples of how holistic nursing has affected individuals and
populations. In one such case study, nurse Francie Halderman, reflected on an incident where
Ben, a veteran, was suffering from PTSD (Halderman, 2013). As with any trauma victim,
empathy and sensitivity are key, and, “holistic approaches can create a safe environment to
support the healing process” (Halderman, 2013). Halderman goes on to describe how Ben was
referred to her for biofeedback evaluation for anxiety. She performed multiple assessments on
him, including biopsychosocial and spiritual. The results of these were indicative of PTSD,

which was something he had volunteered as a possibility due to his symptoms prior to her ever
mentioning it. Her primary objective was to create a therapeutic relationship, “so that he would
feel safe and unconditionally accepted” (Halderman, 2013). She also made sure that she was
aware of herself - her own body and emotions - so as to be fully open and aware and respond
appropriately according to his needs throughout the session. He eventually told her the story of
how he was commanded by an officer while stationed at a border post in Iraq, to execute a
hysterical civilian woman who had come to close without an interpreter or authorization to be
there. He refused the command. This act of refusal led to his dismissal from the army for
‘defiance’. This one moment began to shape his perception of everything in his life, including
his recent on the job injury, which is why he had initially come to the hospital. He believed this
injury was, ““bad luck” resulting from his failure to act in Iraq” (Halderman, 2013). Throughout
this story, Halderman remained attentive to her own posture, expressions, and breathing (self-
awareness) so as not to react in a way that might damage the safe and therapeutic environment
they had created to best serve his emotional needs and build trust. As his story came to a close,
he apprehensively asked Halderman what she thought of him, and she decided to be honest and
told him, “[she] thought his action was one of the bravest things [she] had ever heard” (2013).
She went on to thank him for sharing and that she was, “honored that he shared his story with
[her] and that [she] felt he had taken an important step in his healing journey” (2013). Upon
hearing this he let out a few sobs and they shared a few moments of awe and peace before
proceeding to discuss alternatives to treatment, as he did not want to go through the VA system
for various reasons. She ended up finding him a non-profit organization that helped with therapy
and rehabilitation for veterans. Halderman had succeeded in creating an environment in which
the patient’s interconnected needs (psychological, emotional, physical, and perhaps spiritual)

were attended to with empathy, and a personalized, individual, patient oriented plan was created
for him through the relationship they had formed. She goes on to state how if holistic nursing
had not been employed - being empathetic and perceptive to the needs of the patient, and
recognizing the “story beneath the story” - and had she rushed in and actively taken charge in
conventionally treating the presenting symptoms of PTSD in Ben (i.e. anxiety), she, “could have
missed his hidden pain and actually missed him” (2013). As Halderman so poignantly puts it,
“Holistic nurses understand that we are already whole, just as we are. By listening for the “story
beneath the story,” we are creating the environment for wholeness to be recognized” (2013).
Measurement Tools
As the concept of holistic nursing becomes more and more honed and developed, it
becomes even more important to have a means to measure it. A scale that accurately measures
the broad aspects and encompassed terms of holistic care is hard to find, if not impossible. It is,
however, easy to find scales for each of its individual aspects (i.e. spiritual needs, relationship,
empathy etc.). The literature revealed that the most complete and relevant scale for the
measurement of holistic nursing was the Holistic Caring Inventory (HCI) by Latham (1988).
According to Latham, “The HCI was developed to measure patients’ perceptions of nurse caring
– specifically, humanistic caring from a holistic nursing perspective” (1996). The HCI uses four
subscales (Physical Caring, Spiritual Caring, Interpretive Caring, and Sensitive Caring) to
explore the holistic nursing domains of social, physical, mental, and spiritual care (Kinchen,
2014). As stated in Kinchen’s article, “The HCI is a 40-item, 4-point Likert-type scale scored by
summating responses, with the total score divided by the number of items to produce a definitive
score between 1 and 4. A core of 1 indicates that the patient does not feel cared for, and a score
of 4 indicates that caring is evident to the patient” (2014). This scale was evaluated and its

reliability determined early on by content specialists, a pilot study, and several studies since. All
of these indicated strong scores in each of the four subscales (Kinchen, 2014). The flaw to this
scale, however, lies in the fact that it is not as complete as it could be, as it is limited to those
four subscales. It does not take into consideration some important and more recent concepts
within holistic nursing, such as shared decision-making, the use of CAM as adjuvants to care,
and the development of self-knowledge as part of self-care (Mariano, as cited in Kinchen, 2014).
Shared decision making includes the patient’s perception of the nurse’s presence and openness to
the patient’s input, especially with regards to anything the patient prefers that is not considered
conventional (i.e. CAM).
Questions related to shared decision-making that might improve the HCI include: ‘Was
the nurse interested in the patient’s ideas as to what might be the causes or influencing aspects of
their illness?’ or ‘Does the nurse support the patient’s plan decisions for their current and future
health?’ The development of self-knowledge as a part of self-care explores the patient’s
awareness of the mind-spirit-body-emotion connection, and how that knowledge can lead the
patient to recognizing patterns, either constructive or detrimental, within their lived experience,
thereby gaining self-knowledge (Kinchen, 2014). Some examples of questions pertaining to the
idea that might improve the HCI include: ‘Does the nurse guide me in discovering areas or
patterns of weakness or strength?’ or ‘Does the nurse help me to understand these patterns as a
natural part of the human experience?’ These types of questions could be helpful in developing a
more complete measurement scale for holistic nursing, and will improve the ability of nurses to
understand the concept of holistic nursing in practice more fully, as well as lend itself to further
understanding and development of its theory.
Conclusion

Concept analysis is a way in which nurses can express and maintain the integrity of
nursing care, as well as discover the boundaries of its practice (McEvoy & Duffy, 2008). The
use of Rodgers evolutionary method was employed in this concept analysis, as it was conducive
to the broad concept of holistic nursing. The concept itself has evolved over time, however, it
has always in some way been an aspect of nursing, and shall continue to be an imperative part of
its practice. Caring for patients in a relational way, as individual, whole beings, and not simply
the sum of their parts, is not a new idea in nursing practice. Holistic nursing involves nurses as
facilitators of care, and patients as involved decision makers. It requires nurses to be perceptive
and empathetic towards the patient’s needs, mindful of the interconnectedness of mind, body,
spirit, and emotion at all times (AHNA, 2012). These are the tried and true aspects of the concept
of holistic nursing, and will remain as the concept continues to evolve.

References
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