The objective of this assignment is to evaluate Holistic care approaches used in healthcare within the acute care setting specifically relating to the role of Assistant Practitioners.
Holistic care takes into consideration an individual’s psychological, sociological and mental health needs. Using a holistic approach to care enhances the experience for my patients and families (Erickson 2007). The Nursing and Midwifery Council (2010) defines holistic medicine as a system of comprehensive or total patient care that considers the physical, emotional, social, economic and spiritual needs of the person, taking into consideration a person as a whole. Over the past few decades the focus of medical care has shifted from treatment of a disease and or injury to treatment of a patient (Henning, 2013).
Holism has a long history derived from a Greek-indo -European root holos or hale, meaning whole, healthy, healing, holy and the act of caring (Auyang,1999). The first published literature in relation to holistic care was produced by Florence Nightingale in her book Notes on Nursing, which described the work of nurses as putting patients in the best condition for nature to act upon them (Nightingale, F 1969). However the concept of holism was first defined by polymath Jan Smuts in 1927, as the tendency in nature to form wholes that are greater than the sum of the parts through creative evolution (Smuts. 1927).
Different theories on holism have been widely supported and promoted in healthcare since the 1960’s, when Florence Nightingale first identified the importance of treating patients individually, as opposed to solely treating the illness (Dossey & Keegan 2009). However this concept is new in Emergency medicine, and has been derived from the recent conflict in Afghanistan. The Army pain management task force published best practice based on a holistic, multidisciplinary, integrative approach to care (Schoolmaker, 2009). The Nursing Midwifery council (2008) states that all nurses must practice in a holistic, non-judgemental, caring and sensitive manner.
Throughout this assignment the names of patients, and family members have been substituted to comply with the Data Protection Act (1998) in order to safeguard their identities and ensure confidentiality is maintained as per NHS Policy (2012). Mr. T attended the Emergency Department (ED) after taking a poly-pharmaceutical overdose and collapsing sustaining superficial lacerations to his arms and face. Mr. T was an unkempt gentleman of middle age who was wearing soiled clothes and looked malnourished.
Mr. T was known to have some minor learning difficulties and was a frequent attendee to the ED, due to his long extensive history of alcohol and illicit drug abuse. Regular attendees to the ED often suffer from alcohol and or substance misuse, where homeless and socially disengaged (Cherpitel C 1995). Little & Watson (1996) found that frequent attendees to the ED where at risk of bias care, because they often did not adhere to medical advice or except support resulting in frustration amongst staff during busy times.
Pirmohamed et.al. (2000) published figures stating that the majority of alcohol-related ED patients are 18–60 years of age, and about 20% of these involve a serious health problem due to long-term alcohol and drug misuse. Blenkiron et.al. (2000) identified that 15-25% of suicides and deliberate self-harm is associated with prolonged alcohol misuse, a battle Mr. T had been fighting against for several years. Mr. T had been using cannabis from a young age which studies have indicated an increased risk of self-harm and suicide attempts, (Beautrais, et.al 1999). Cannabis has also been well documented to contribute to psychiatric and depressive disorders (Andereasson, et al 2002) & (Moore, et.al. 2007).
Abraham Maslow (1908-1970) was a humanistic psychologist who developed his theory, ‘the hierarchy of needs’ (1943) a five stage model of motivational needs often depicted as a pyramid. The five stages are divided into; Psychological, safety, social, esteem and self-actualization. He believed that the lower levels of the pyramid have to be satisfied before a person could move up. Each stage was further defined stating the lowest level was what every human required to survive such as food, shelter, water, sex, air, clothing, to the top being the pinnacle of each person’s potential in life who is able to pursue inner talent, creativity and fulfillment (McLeod, 2007). At this point Mr. T was barley functioning at the lowest level as he was unable to meet his basic nutritional needs and lacked warm clean clothing or shelter. Lack of food can affect a person’s mood, behavior and brain function, (Pessoa, 2008). I provided Mr. T with food and clean warm clothing, in order to assist with some of Mr. T’s basic humanistic psychological needs, as advocated by Maslow (1943) alongside his medical treatment, demonstrating a comprehensive holistic approach to care.
Rutledge (2011) another psychologist disagreed with Maslow’s theory and developed her own theory Maslow Rewired, stating none of these needs starting with basic survival on up, are possible without social connection and collaboration, and that humans require community, Love and the feeling of belonging before harvesting the ability to survive, although this is very much more associated with the 21st century. However substantive evidence has accumulated over the past few decades showing that social ties and social support are positively and casually related to mental health, physical health and longevity (Berkman, 1995). However Mr. T had no relatives other than his brother, who was estranged due to Mr. T’s extensive alcohol abuse. He was disengaged from services, refused social support and often did not adhere to medical advice.
The tablets and quantities Mr. T had taken did not require any immediate treatment likewise the lacerations to his arms and face required minimal intervention, however Holistic nursing as advocated by Dossey & Keegan (2009) treats the entire patient. Therefore as a holistic practitioner I investigated Mr. T’s Psychological issues through gentle discussion whilst a colleague dressed his wounds and administered medication to reduce the effects of alcohol withdrawal, thus assisting with Mr. T’s Physical effects which in turn will assist with his psychological needs. Alcohol is a drug with complex behavioural effects that can be pleasurable when consumed in moderation but can be unpleasant when misused, (Swift, 1999).
Mr. T was initially withdrawn and reluctant to discuss his mental health problems, however through gentle questioning whilst undertaking basic tasks, a skill often used by nurses as indicted by Berg et al (2007). Mr. T started to disclose information in relation to his psychological behaviour. Whilst discussing such issues with Mr. T it is important to maintain good eye contact and engage in a moderate amount of social touch, as this is perceived by patients as a more empathetic clinician (Montague 2013). A similar approach is advocated by, McCann & McKenna (1993) whilst Bamford – Wade & Kimble (2013) promote compassionate listening in addition to touch when dealing with patients in crisis. Therefore it was essential to speak slowly and use appropriate body and facial language to demonstrate empathy and understanding to the patient. Throughout the discussion non-verbal listening skills are respectfully used. Egan (1994) offers the acronym ‘SOLER’, an approach used in counselling which stands for; S – Sit square
O – Open Posture
L – Lean slightly forward
E – Eye contact
R – Relax
However according to Stickley (2011) the school of nursing and midwifery has introduced a new model to student nurses, the Acronym SURETY, which stands for;
S – Sit at an angle
U – Uncross legs
R – Relax
E – Eye contact
T – Touch
Y – Your intuition
This approach subsequently adds in ‘touch’ as advocated by McCann & McKenna (1993) along with your intuition. A nurse’s intuition is not a new concept and studies have been carried out since 1978, (Gerrity 1987) however it is a skill widely associated with experience (Hams 2000). Intuition has been acknowledged by clinicians and scholars as a vital component of clinical judgment and decision making (Rew 2007). Mr. T responded well to this approach of communication.
Carl Rogers (1961), another humanistic psychologist developed the theory Core conditions which is the basic attitudes that councillors should display in order to show acceptance of the client and valuing them as a human being, and include Congruence, empathy and respect. Like Rutledge’s (2011) approach, Rogers (1959) believed everyone needs to feel loved, valued and unconditional regard, to achieve Maslow’s findings that all humans aim to ‘self-actualize’ and fulfill their potential (1961). During the assessment it is essential to communicate effectively, minimise barriers such as using medical terminology in discussion as advocated by, Minardi & Riley (2007). Physicians frequently use medical words during consultations leading to ‘jargon’ that is potentially misunderstood thus impairing effective communication (Blackman & Sahebjalal 2014)
Good communication skills allow patients and relatives alike to express their concerns and needs, subsequently building trust between them and the healthcare professional, demonstrating a two way circle of communication, identified as the most effective method by Schramm (1954). The Johari Window is a model created by Luft & Ingham (1995) and used by healthcare professionals whilst communicating with patients, that encourages self-awareness and understanding of others, ensuring practitioners are aware of their own beliefs, principles, attitudes and strengths in order to help their patients.
There are some barriers to providing effective communication, as the ED is a very busy loud environment which can hinder effective communication and possibly result in communication overload Woloshynowych et al (2007). However by simply taking a patient or relative away from these areas and into a quiet room, communication barriers can be minimised.
Mr. T responded well to the approaches used, and had not spoken of his feelings or depression for a long time. Mr. T explained that he had lived with his mother up to the age of twelve when she passed away following a lifetime of alcohol abuse and that this was the only life he knew. Psychologist Albert Bandura believed children imitate behaviors witnessed as they grow up which was illustrated in the experiment ‘The Bobo Doll’, (McCleod 2007).
Since becoming reliant on drugs and alcohol Mr. T’s mental state had significantly deteriorated thus exacerbating his addiction and leading to unemployment and subsequently homelessness. Due to the fact Mr. T was disengaged from services and had no family support he was feeling increasingly isolated and unloved thus amplifying Rogers. C (1961) theory OF “Core Conditions” however Mr. T was reluctant to change. DiClemente & Prochaska (1998) developed the “Transtheoretical Model of Change” which is primarily associated with addiction and the willingness to change. The five stages of this are; 1. Precontemplation – Unwillingness to change
2. Contemplation – Consideration of change
3. Preparation – Commitment to change
4. Action – modification of behaviour takes place
5. Maintenance – lifelong avoidance of relapse
Mr. T was currently at the precontemplation phase and unwilling to make changes to his current circumstances. Due to increasing pressure from NHS targets, Emergency practitioners have a very limited amount of time to address such varied and extensive issues due to all patients needing to be transferred or discharged within four hours of arrival. As strong advocates of holistic practice the department strives to ensure all patients are treated holistically and provided with the relevant knowledge and support required to address and manage their problems.
Mr. T was referred to the mental health team for further assessment of his psychological needs assisted with housing, and referred to the Alcohol and Drug Misuse Team in order to address his addictions. These services work in both the interests of staff and patients providing support to patients with complex alcohol and drug dependence in order to reduce the number of attendances to the ED and help to reduce care costs. The home office published data relating to alcoholism which showed the cost to the NHS is in excess of £3.5 billion annually (Government’s Alcohol Strategy 2012). Layard (2005) concurs with these statistics stating that ‘Mental Health’ is our biggest social problem.
In conclusion a Holistic approach to care considers the physical, emotional, social, economic and spiritual needs of a patient taking in to account a person as a whole not only treating the physical and medical needs of a patient. It is evident that treating patients as a whole and not the presenting complaint alone is key to providing effective healthcare for the patient and can result in fewer admissions and reduce pressure on resources. The evidence provided in this assignment has shown that the emergency department uses all resources available, working as a multi-disciplinary team to assess and treat patients with complex mental health needs and drug and alcohol dependencies fairly without passing judgement.
Effective communication plays a vital part in effective treatment of a patient although there is potential for communication to be hindered. The communicative approaches used proved favourable with Mr. T and enabled the practitioner to gain the relevant information required. The psychological approaches used with Mr. T proved effective and by treating Mr. T in a holistic manner contributed to the effective management of his care. Based on the research and evidence published holistic care significantly improves patient outcomes leading to greater patient satisfaction and contribute to reducing healthcare costs which will subsequently assist in providing a longer sustainable national health service.