Holistic care, Holistic therapies and nursing.

Holistic care refers to addressing all aspects of the person including body, mind, and spirit . A holistic approach links mainstream medical treatments with both traditional and emotional health. Holistic medicine is a part of health care which maintains a cooperative relationship among all those involved, which leads to optimal satisfaction of the physical, mental, emotional, social and spiritual aspects of health. It highlights the necessity to view the person as a whole and that includes analysis of physical, nutritional, environmental, emotional, social, spiritual and lifestyle values.

Holistic therapies also referred to as complimentary therapies have been long-standing practices in nursing and act as an appendage to traditional medical and nursing therapies.  They include massage theraphy, nutritional therapy and hydrotherapy.  Nurses have combined touch care, as well as Reiki, a mix of both energy work and touch, into practice. Concern for providing more effective pain and chronic disease management has led many health care institutions to offer nutritional therapy, yoga,meditation, spiritual learning and mind-body programs for disease management.  Nurses are working alongside a hierarchy of providers from medical specialists, massage therapists, acupuncturists and behavioral psychologists. 

Holistic nursing is a way of thinking, reflecting, practicing, and being as a whole human being. Holistic nursing care practice requires nurses to integrate self-care, self-responsibility, spirituality, and emotional wellbeing. This may resut in greater awareness of the inter-connectivity with self, family & friends, environment, and god. This awareness may further improve the nurse’s understanding of all individuals and their relationships to the human and outside world, and permits nurses to use this awareness to facilitate the healing process.

Holistic nursing includes all nursing practice that has enhancement of healing of 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 person, recognizing that the whole is greater than the sum of the individuals; and that it involves understanding the individual as a unit mutually inclusive with the environment.

Every individual case has a patient at its centre.The patient lives within a social,psychological,economic and relational environment.The major factors which influences the patient are pychological,emotional,financial,legal,scientific,educational and religious as below.

Rationale and Case Study

Having discussed the different approaches to patient care, the important aspects of nursing management, and the various theoretical models of patient management, we move on to considering the appropriate nursing approach for a an Italian woman 92 years diagnosed with Dementia bipolar, diabetes type 2, epilepsy & having problems of eating disorder.She has no much educational background , married in 1941at the age of 25, came to UK in 1965. She has a daughter and a son with 4 grand children.

Demography & epidemiology

Bipolar disorder and dementia are two conditions that often go hand in hand. The risk of developing depressive and manic episodes was increased in patients with dementia. Both disorders have a multidimensional nature. Mood and cognition are considered the core problems in bipolar disorder and Dementia, respectively. However, in recent years, more relay has been given to the behavioral features of Dementia, which are often difficult to manage than cognitive impairment. Thus, in addition to such mood symptoms as euphoria, lability, irritability, anxiety, and dysphoria, recent studies have reported the following behavioral signs in Dementia: agitation, overactivity, aggression, apathy, affective lability,euphoria, disinhibition, impaired self-regulation, and psychosis. Moreover, patients with dementia often have problems with money management, spendthrift or donating money to strangers.

Most consider signs and symptoms of mania in AD(Alzheimer disease) as secondary to its neurodegenerative processs but mood symptoms may also be central and can reflect exacerbations from previous temperament. We emphasize that altered mood symptoms clearly affect perception of real situations and cognition thinking.It has been reported that deterioration in bipolar disorder is associated with mixed episodes and rapid cycling, which often tends to be the clinical presentation of dementia.[  

Pathophysiology

In neuroanatomical studies, alterations in the hippocampus have been reported in both disorders, with more obvious degeneration in AD. Perhaps the most striking difference between both disorders is that the disease process in AD occurs when the brain is much more vulnerable due to aging. Excessive glutamatergic activity is possibly central to both disorders, as shown by the benefits from drugs that either inhibit glutamate release or block glutamate receptors (eg, topiramate ) including acetylcholinesterase inhibitors.

Cortisol-induced neurotoxicity and dysregulation in the HPA-axis have also been postulated as a central role in the pathophysiological processes in both disease(dementia & bipolar)

Epidemiology

The number of people with dementia is steadily increasing.  Alzheimer’s Society believes that careful planning is the order of the future to ensure that the right care and support is available.

There are currently about 750,000 people in the UK with a form of dementia with over 16,000 people under 65 with dementia in the UK .One in 14 people over 65 years of age and one in six people over 80 years of age has a form of dementia

Prevalence and incidence  

When talking about demography it is important to differntiate between prevalence – overall cases both old and new, with which dementia occurs in the population, and incidence – new cases of dementia in a given time period.

The well established prevalence rates for dementia in the UK are:

40-64 years: 1 in 1400

65-69 years: 1 in 100

70-79 years: 1 in 25

80+ years: 1 in 6 (Source : Alzheimer’s society, UK.)

Projected figures 

There is a rough estimate that by 2021 there will be one million people with dementia in the UK and

Is expected to increase to over 1.7 million people(3% of UK population) with dementia by 2051. 

Many people talk about the ‘demographic time bomb’ or ‘tidal wave’ of older people, which the state cannot afford to cater for. However the society believes that these reports are misleading.A steady, rather than exponential growth is expected over the next 25 years. The Society’s contribution to the Royal Commission on Long Term Care highlights the belief that the state can provide for people’s needs as they age. The National Dementia Strategy in England and similar work underway in Wales and Northern Ireland are very vital steps to ensure the people needs with dementia be properly addressed in years to come.

Belief & values

Core Values of Holistic Nursing

The current Standards of Holistic Nursing are based on five Core Values of practice:

1) Holistic Philosophy and Education

2) Holistic Ethics, Theories, and Research

3) Holistic Nurse Self-Care;

4) Holistic Communication, Therapeutic Environment and Cultural Competence

5) Holistic Caring Process.

These core values represent the essence of holistic nursing and are each necessary for holistic practice in the management of dementia in older people with comorbidity such as diabetes typeII and epilepsy.

Core value 1, addresses that holistic nursing is based on a framework under philosophical guidelines embracing holism and a commitment to education, reflection, and knowledge. Core value 2, reiterates that professional nursing is less effective in theory, informed by research and bound by ethical guidelines to guide a competent, thoughtful, and principled holistic practice. Core value 3,is based on the belief that nurses must engage in integrating self-care to promote health and self awareness so that the nurse may act as an instrument of healing. Core value 4  addresses the requirement for nurses to engage with clients to promote mutually-determined goals for health and healing. Lastly, Core Value 5, emphasizes an evolution in the nursing practice to embrace assessment and therapeutic care addressing client patterns, problems, and needs in an atmosphere of caring (4).

Cultural values and belief

Beliefs and practices influenced by culture can affect patient outcome and satisfaction .the increasing cultural diversity may present challenges in trans-cultural ethical decision making for nurses .ethical dilemma may arise from lack of understanding of language, procedures ,expectations and other elements of nature that may lead to unclear decisions.Thus by Incorporating culture assessment into care facilitates better understanding of factors that influence patient’s health behavior and decisions.

Researchers from School of Nursing in Hong kong surveyed nurses in different cultural settings and suggested five broad guiding principles for reviewing ethical perception of cultural values and beliefs:

Respect for persons

Beneficience

Justice

Respect for community

Contextual caring.

The Director and Board of Dementia Voice had, in about 1996, become aware of a developing but uncoordinated interest in the spiritual care of people with dementia. They wanted their statement to affirm a holistic approach, which sees care of the spirit as the essence of, and resulting from, good care practice. They wanted to speak to everyone irrespective of their religious faith. They have therefore used non-religious language with the intention that it is inclusive of both secular and religious understanding. The spirituality of people with dementia, and their families, carers and the professionals who work with them is therefore of the greatest importance.

Professional issues

The AHNA Standards of Holistic Nursing Practice also referred to as Standards provide guidance for nursing care that meets the intent of the description of holistic nursing — ” a care that has enhancement of healing of the whole person (from birth to death) (4).” The Standards grew from an interest in describing holistic nursing, and in articulating the values, skills and knowledge required for its practice.

Unlike speciality practice defined by a client group (pediatric nursing) or a disease category (oncology nursing), holistic nursing is practiced by nurses in virtually every area of care. The speciality is based on practice that recognizes the body-mind-spirit connection of persons, and demands its practitioners integrate self-care and self-responsibility into their own lives.

In holistic nursing, wellness-illness and health-disease neither mutually exclusive ,nor polar opposite, but are part of the process and the healthcare.Newman and her colleagues identified that proper focus of nursing is caring and described it as whole,unitary and transformatory.Many disciplines claim caring as a part of the profession ,but only nursing has both caring and health as itsgoal. Caring is a constant specific interpersonal process that is characterized by expert nursing practice, interpersonal process, interpersonal sensitivity, and intimate relationships Nurses can focus caring through empowerement in 6 main categories;

Respecting the patient

Not taking the patients behavior personally

Keeping the patient safe

Encouraging the patient’s health

Authentic leadership

Interactive reading.

Professional ethical decisions

Nurses are confronted daily with the need to make professional and personal ethical decisions. This process requires an ongoing evaluation and assimilation of information and have formed a five step process of making ethical decision mainly

1. articulating the problem

2. gathering data and identifying conflicting claims of moral values

3. exploring strategies

4. Implementing strategy

5. Evaluating outcome of the action

Legal and Ethical Issues

Healthcare providers must adhere to the law.All nurses are responsible and accountable to comply with nursing practice act as well as the rule and regulation of the board in the state where they are licensed and work.

Supporting a patient’s right and ability to make choices is an essential element of holistic nursing practice and holistic ethics.

Advance medical directives

The patient self-determination act, effective December 1991requires that all individuals receiving medical care also receive written informationabout there right to refuse medical or surgical treatment and their right to initiate advance directives.advance directives are instructions that induct healthcare intervention to initiate or withhold or designate someone who will act as a proxy in making a decision in the event the decision making capacity is lost.

Advance directives are of two types:

Treatment directives(living will)

Appointment directives

(Power of attorney).

A living will specifies the medical treatment that a patient wishes to refuse in the event that he/she is terminally ill and cannot make those decisions.A power of attorney for healthcare appoints a proxy or surrogate to make the medical decisions on behalf of the patient if he/she can no longer make such decisions. Advance medical directive in the form of living will or power of attorney is a cornerstone in proxy management of end stage of Dementia with bipolar disorders as they lose decision making ability.

As part of the patient assessment , an holistic nurse may consider asking the, following questions

Have you discussed your end of life choices with your family or designated surrogate?

Do you have basic information about advanced medical directives?

Do you wish to initiate it?

If you have already prepared an advance medical directive, can you provide it now?

Informed consent

As nursing is inherently a moral endeavour,nurses may exacerbate challenges in making the right decision and taking the right action.The process of informed consent of medical and other treatment provides the opportunity for the patient to choose a course of action regarding healthcare plans.

An informal consent must include the following:

The nature of health cancerns and prognosis if nothing is done

Description of all treatment options

Benefits, risks an consequences of various treatment a options including non-intervention.

Holistic nurses who offer alternate modalities should explain the int.., and disease risks, expected effects and benefits and treatment options prior to initiating theraphy. Informed consent in research refers to freely choosing to participate in a research study after the research purpose ,commitment ,risks and benefits, anonymity and invasion of privacy.Nurses who assist with research need to be familiar with elements of informe consent.A particular area of concern is protection of human rights, in research studies focus on vulnerable population such as elderly, challenged, pregnant, disabled persons and terminally ill. Thus Informed consent plays a vital role in development of novel research methodologies and an holistic nurse should follow the above mentioned guidelines in getting an informed consent from the patient.

Nurses are accountable to professional stanards, for reporting research findings. An important consideration in this regard is the ethical treatment of data which demonstrates the integrity of research protocols and honesty in reporting data

Policy

Three major policy face holistic nursing in the future:

Reimbursement

Regulation

Access

Access

There are many barriers to the access of holistic therapies providing yet another challenges for holistic nursing.They include:

Lack of awareness

Uncertainity about their effectiveness

Inability to pay for them

Limited availability of qualified providers.

Access is normally difficult for rural population, uninsured, racial and ethnic minorities and vulnerable population such as elderly and terminally ill.Holistic nursing have a responsibility to educate the public more fully about health promoters,completely moderate to assist people in making informal chance among healthcare alternatives and individual providers They need to ensure quality, increased focus on wellness and access and affordability to all.

Reimbursement

Public or private policies in relation to coverage and reimbursement for healthcare expenditure play a crucial role in shaping the healthcare system and in deciding the future of health promotion and holistic medicine in the nations healthcare system.holistic nurses need to work with Medicare and other third party payers,insurance groups,oards of nursing,healthcare policy makers to ensure that holistic nurses are reimbursed appropriately for services rendered.

Regulation

Thus by developing theoretical and empirical knowledge as well as caring and healing approaches ,holistic nurses will advance holistic nursing practice and education and contribute significantly to the formalization and credibility of this work and in integrating a more holistic approach in nursing practice and health care.

Access to an informed care and reimbursement for hospice care is the requirement in the elderly patients with late stage onset dementia as the patient is terminally ill.

Resources

In caring for individuals, those who have negative health beliefs and attitude, an effective resource and perhaps a strategy would be to develop a social support network. The social support network of the patient can strengthen and facilitate healthy patient choices. Cognitive strengthening through training in assertiveness, relation, imagery, problem solving, good s coping skills. Patient interaction with community agencies and self-help group may also be appropriate. Encouraging involvement of family an friends with recommended theraphy or value clarification session increase and strengthen social support.

Because Alzheimer’s disease is incurable and progressive, most holistic treatments focus on enhancing the person’s quality of life; for example, some might suggest using “memory books” and other strategies to reduce the impact of symptoms. A Florida State University researcher found memory books, which might include notes, photos and other keepsakes, can help reconnect Alzheimer’s indiviuals with their loved ones.

Although the research on holistic approaches remains limited, it suggests everything from pet therapy to art therapy can improve quality of life for those with Alzheimer’s. A 2006 study, for example, reported older people with dementia showed less agitation and had more positive social interactions when they interacted with an animal daily; however, the duration of the benefit was not established, nor was it proven that an animal living with the individuals had more impact than a visiting animal.

A holistic approach can also include the use of herbs and supplements, such as Ginkgo biloba and omega-3 fatty acids.

Conclusion

In this study, we reflect back at the various holistic goals set to provide care for an Italian woman 92 years diagnosed with Dementia bipolar, diabetes type 2, epilepsy & having problems of eating disorder.She has no much educational background , married in 1941at the age of 25, came to UK in 1965. She has a daughter and a son with 4 grand children.

Based on the projected figures it is estimated that by 2021 there will be one million people with dementia in the UK with expected to rise to over 1.7 million people with dementia by 2051. This is often referred to as a demographic tidal bomb. There has been a developing but uncoordinated interest in the spiritual care of people with dementia.Thus the spirituality of people with dementia, and their families, carers and the professionals who work with them is therefore of the greatest importance in an holistic care towards dementia.

Advance medical directive in the form of living will or power of attorney is a cornerstone in proxy management of end stage of Dementia with bipolar disorders as they lose decision making ability. Informed consent also plays a role in development of novel research methodologies and an holistic nurse should follow the above mentioned guidelines in getting an informed consent from the patient. As alzheimer’s disease is incurable and progressive, most holistic treatments focus on enhancing the person’s quality of life by using memory books, which might include notes, photos and other keepsakes which can help reconnect Alzheimer’s indiviuals with their loved ones.

Access to an informed care and reimbursement for hospice care is the requirement in the above case study as the patient is terminally ill belonging to an ethnic minority. Thus holistic nursing needs to ensure quality, increased focus on wellness and access and affordability to all.