Holism is derived from the Greek holos meaning whole, this term was first introduced in 1926 by South African philosopher Jan Christian Smuts who described it as the tendency in nature to form wholes that are greater than the sum of individual parts through creative evolution (Poynton, 2010). The aim of holism is to view individuals as a whole rather than just the illness they are experiencing and improve health outcomes by considering wider aspects of an individual’s life that could influence future health. Holism recognises that patients are people first and people’s lived experience of mental health challenges occur in the lived experience of their life “as a whole” (The Royal college of Psychiatrists, 2018). This model focuses on what is important to each patient as an individual and seeks understanding of a person’s identity, values and wishes (Parnell, 2014). Holistic nursing is described as “nursing practice that has healing the whole person as its goal” (American Holistic Nurses Association, 2019). This essay will describe an experience I found to be challenging and raised questions about the delivery of holistic care while on placement in an acute admissions ward, where I encountered a situation I felt did not equally provide parity of esteem for a patients physical and mental health or fully address the holistic needs of a patient with severe and enduring mental illness. It will consider the importance of physical exercise as a therapeutic intervention and its effects on the wellness of patients detained under the Mental Health Act Scotland 2003 as well as nursing models that can assist in the delivery of holistic person centred care. The patient was brought to the ward area by the police following an incident where he had attempted dying by suicide. This resulted in him being detained in hospital under a short-term detention under the Mental Health Act Scotland 2003 (Mental Welfare Commission for Scotland, 2018) as he presented a significant risk to himself and others and likely to be suffering from a mental disorder, satisfying the criteria for the use of a short-term detention certificate (Scottish government,2005). The patient had a diagnosis of treatment resistant schizophrenia for a number of years, meaning he had received at least two other antipsychotic medications of adequate dose and duration one being another being another atypical antipsychotic to which he did not respond or could not tolerate the side effects (Lally et al. 2016). He had then been prescribed clozapine which was effective in enabling him to live safely in the community with minimal contact with services (Lally et al. 2016) until his disengagement from community services, leading to re-admission into hospital for commencement of clozapine re-titration as he has not taken the medication for over forty eight hours (NHS Grampian, 2018).
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I was tasked with carrying out informal daily one to one discussions with this patient, Then to clearly and accurately record my observations clearly dated and timed without unnecessary, jargon or speculation in the patient’s electronic records and handover sheet for the oncoming shift (Nursing & Midwifery Council (NMC), 2018). I was friendly and cooperative during these interactions using good verbal communication and open body posture at a distance mindful not to encroach on the patient’s personal space listening without interruption, nurses who listen without being patronising or judgemental are valued and are reported to have a positive effect on improving patient experience (Gilbert, Rose and Slade, 2008). Active listening is important to help nurses gain a deeper understanding of the contributing factors that will impact an individual’s current and future health, this combined with honest and open discussion can help patients feel to share information that could be painful, traumatic or embarrassing (NHS Improvement, 2015). Patients who have experience of a good therapeutic relationship are more likely to be motivated to actively engage in the care they receive and have confidence staff can advise them appropriately (Greenhalgh and heath, 2010). During an informal discussion the patient expressed an interest in using the gym. He stated he enjoyed taking regular exercise when not in hospital, he felt it had a positive effect on both his mental and physical health by reducing his anxiety, improving sleep pattern and providing focus and motivation (Ancil, Dogan and Dogan, 2008). The patient also expressed concerns that he had gained a significant amount of weight since being prescribed clozapine, he said that he found it distressing and that had been a factor in his decision to stop taking it (Perkins, 2019). I communicated this information about the patients request on nursing records and enquired with a senior member of staff during shift handover if this would be possible. The staff nurse said that it would not be possible for the patient to use the gym facilities due to an increase in ward activity, staff and time constraints, further stating that the patient’s current mental health need was at that time of greater importance than his need for physical exercise and that his physical health would be better addressed at a later time.
Successful delivery of holistic care relies heavily on the ability of nurses to form and shape cooperative working relationships with patients based on understanding and consideration of psychological, physical, emotional and spiritual needs (Roberts, 2013). I felt the decision to view the patients physical health need as secondary was contrary to the principle of “parity of esteem” recognised as a key factor in providing holistic care. This principle states that mental health and physical health should be treated with equal priority in order to assist patients with mental health needs have equal access to care and treatments to improve quality of life and life expectancy and enshrined into law by the Health and Social Care Act 2012 (Centre for medical health, 2019). To support the delivery of care, nursing models are used in practice to assist staff identify complex individual needs (McKenna et al., 2014a). The Careful Nursing Philosophy and professional practice model offers a framework that supports educational development to improve quality in nursing practice and help support patients more holistically (Meehan et al., 2018). This framework would support the application of the nursing model six dimensions of wellness, when considering physical, emotional, spiritual, social, academic and financial wellbeing (National wellness institute,2019). This model recognises that attention must be given to all dimensions of wellness, and that neglecting any one will negatively affect health and quality of life. These dimensions do not have to be equally balanced as each individual has their own priorities, aspirations and view of what it means to live a full life (Stoewen, 2017). This model would support exercise as an important dimension in this patients recovery. It would further recognise the positive impact exercise could have on increasing serotonin which helps regulate mood, sleep and appetite, getting sleep patterns back to normal, assisting emotional wellbeing by reducing agitation and promoting resilience. The interconnectedness of this model would see the positive changes in individual areas of wellbeing reflected across all dimensions of the model (National wellness institute,2019).
Evidence has shown that patients with severe and enduring mental illness are at greater risk of poor physical health and reduced life expectancy, estimated to be dying as much as twenty years earlier than in the general population (Milard and Wessely, 2014). Mortality rates among individuals with schizophrenia are nearly three higher than those among the general population (World Health Organisation, 2008). Patients with schizophrenia are more likely to be overweight or obese than others in the general population. A sedentary lifestyle often associated with the use of A-typical antipsychotic medication is strongly linked to significant weight gain among patients, this combined with poor diet and not enough exercise leads to poorer physical health and reduced life expectancy (Dayabandara et al, 2008) Physical exercise is recognised to positively effect psychological wellbeing by reducing the effects of stress and improving mood. Patients with schizophrenia who took part in regular exercise reported increased fitness levels, reduced blood pressure and showed improvements at controlling weight, decreasing the risk of further co-morbidities such as diabetes and metabolic syndrome (Gorczynski,2010). Studies suggest that moderate intensity exercise is related to increased performance in working memory and cognitive flexibility, high intensity exercise improved information processing (Mandolesi et al, 2018). Evidence further suggests that reductions in daily physical activity are a primary cause of chronic disease and that physical exercise is a rehabilitative treatment from inactivity-caused dysfunctions (Booth, Roberts and Laye, 2014). I raised the issue of physical exercise a number of times with different members of nursing staff, on each occasion I was told it was not a priority. I feel this was not holistic or person centred and did not fully consider the individual need of the patient who now reported feeling restless and very agitated on the ward. The patient at this point was gaining even more weight due to the fact he was consuming a one litre tub of ice cream brought in daily by another patient, staff were aware of this but did not address or challenge this issue in any significant way. I believe that providing a consistent exercise program for this patient would have supported to good effect physical and emotional wellness by positively addressing risk factors such as high blood pressure, obesity and unhealthy lifestyle that can decrease life expectancy, Life quality and self-perceived wellbeing reported to be lower among those diagnosed with schizophrenia than in the general population (Booth, Roberts and Laye, 2014). Exercise can help patients get a better quality of sleep which is accepted to contribute to improved emotional wellness (Dozel et al, 2017). Schizophrenia is reported to create shifts in circadian rhythm causing patients to be awake at night and sleep during the day, difficulty falling, staying asleep and diminished sleep quality are common among those suffering from schizophrenia (Krystal, 2012). Adverse health outcomes linked to sleeping less than the recommended amount include hypertension and heart disease (Dozel et al, 2017).
I feel that the staff could have communicated more effectively to overcome barriers to collaborative working in an area that prioritised patient safety over individual preference, in line with a tradition of psychiatric paternalism that exists in acute services where patients are often detained (Haines et al, 2019).
Staff engagement has a direct correlation with an increase in the patient experience, building trust and rapport breaks down barriers to communication and increases the opportunity for therapeutic engagement (Korthauer et at, 2016).
The attitude and behaviours of staff towards this care issue appeared to create a barrier within the ward to holistically meeting the needs of this individual, potentially damaging the possibility of a therapeutic relationship (Health Foundation, 2014).
I was disheartened by the failure of staff to apply a more proactive approach to this patient’s care, it was clear that the priority for staff was to keep the patient safely contained while clozapine was recommenced before a quick discharge back into the community.
I feel this approach did not provide parity of esteem for the patients physical health and overlooked what should have been a red flag given that the patient had reported weight gain as a significant contributing factor in the sequence of events that led to his admission.
I feel the prevailing attitude on the ward towards parity of esteem did not create a milieu to support therapeutic engagement and development based on the belief that every individual could change and function more effectively (Kornhaber et al. 2016).
I believe that the staff on the ward were doing their best to provide the best holistic care with the resources available, the unit did not have an adequate number of nurses to maintain a therapeutic milieu and deliver individual interventions that would support and promote better physical health
. However, staff on the ward would point to the fact they did everything required of them by the standards set out by NHS Tayside, providing person centred care by working in partnership with the patient to engender hope, opportunity and promote recovery (NHS Tayside, 2019).
I did my best to draw attention to this issue, but as a student nurse I did not feel confident enough to take it any further.
I feel this was a failure by the health board to provide the resources needed to provide an integrated approach to health with a greater focus on supervised exercise programs for those with severe and enduring mental illness. I feel that parity of esteem between physical and mental health needs was a relevant issue to raise, because if nursing staff are cannot provide it they will be unable to effectively deliver holistic person centred care which could result in further co-morbidities for patients (Mitchell et al., 2017).
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