Essentials of Complementary and Alternative Medicine (June 1999)

Table 18.1. Standards of Holistic Nursing Practice*
History and Development
The formation of the AHNA was a driving force behind the holistic nursing movement in the United States. In 1980, founder Charlotte McGuire and 75 founding 
members began the national organization in Houston, Texas. There are currently 4500 members. The AHNA mission is the renewal of holistic nursing with an 
emphasis on the discipline of holistic nursing and on caring for the whole client and significant others. Although the concepts in holistic nursing are not new, the AHNA 
focuses on holistic principles of health, preventive education, and the integration of allopathic medicine with complementary and alternative interventions for healing 
the whole person.
The key published AHNA works are the  Journal of Holistic Nursing (
3
), the IPAKHN Survey (Inventory of Professional Activities and Knowledge Statements of a 
Holistic Nurse) (
4
), and the American Holistic Nurses' Association Core Curriculum for Holistic Nursing (
5
). There are now many nurse clinicians, educators, authors, 
and researchers who are key figures in holistic nursing at university-based schools of nursing as well as within other professional nursing organizations.
Principal Concepts of the Philosophy and Model of Holistic Nursing
P
RESENCE
, H
EALING
, 
AND
 H
OLISM
Holistic nursing provides both substance and form for the ancient caring–healing practices of nursing. These practices can be used in the modern and demanding 

health care setting of today and the future. The three principal concepts of holistic nursing are presence, healing, and holism.
The first concept, presence, has significant implications in all areas of holistic nursing education, practice, and research. A common definition for presence is “being.” 
As a noun, being is commonly defined as “existence” and “actuality.” As a synonym, being is defined as “essence.” Two components of  presence have been identified: 
the physical “being there” and the psychologicalal “being with,” which includes the nurse's use of spirituality, individuality, and authentic self. A holistic nurse 
integrates presence to be an effective guide. The art of guiding clients to tell their personal stories assists individuals in discovering and recognizing new health 
behaviors and choices, in exploring purpose and meaning in life, and in developing insight on how to cope more effectively. Guiding is a special art and a healing 
intervention that holistic nurses may use at all times. For example, a patient with pain describes the pain as squeezing, hard, and walled-off in a box. After a holistic 
assessment, the nurse will determine the most appropriate treatment. Many times pain can be relieved by guiding patients with relaxation and breathing exercises, 
possibly combined with imagery, music, or massage. Even when pain medication is required, these healing strategies can also be combined for best results.
The second concept, healing, is viewed in holistic nursing as a lifelong journey and process for all individuals. Clients often come to holistic nurses in search of 
healing, but holistic nurses remind these people that they always bring their healing with them. Holistic nurses enter into a state of “healing intention” with a client to 
bring to the present moment a person's fullest potential (
6
). It is a state of presence in the moment to care and to facilitate healing, not curing. Holistic nurses are 
becoming more aware of being an “instrument of healing” (
7
). For holistic nurses to evolve their own personal process, they reflect on their healing journey and ask 
the same questions of themselves as they do their clients, such as:
How do I find meaning in my life?
How do I define spirituality?
When I use the words guiding force, higher power, God, or absolute, what kind of link with a universal wholeness do I experience?
The third concept addressed in holistic nursing,  holism, explores basic assumptions about humans and humankind. Holism is a way of viewing everything in terms of 
patterns and processes that combine to form a whole, instead of viewing things as fragments, pieces, or parts. Natural systems theory, derived primarily from the work 
of von Bertalanffy, provides a way of comprehending the interconnectedness of natural structures in the universe (
8
). According to this theory, natural structures are 
composed of vastly different sizes, from the level of subatomic particles to the level of the entire universe. Each structure possesses definite characteristics at each 
level and is governed by similar principles of organization. Therefore, if any one part of the hierarchy changes, all the other parts are affected. Changes are occurring 
in the other levels simultaneously, which in turn affects the level to which an individual is attending to at the moment and vice versa. For example, the ripple effect of a 
pebble thrown in a body of water changes the water surface while simultaneously changing the air surface above and below as well. The analogy of a kaleidoscope is 
also useful: a slight turn of the kaleidoscope changes the whole configuration. This differs from the traditional Western allopathic view of disease which is usually from 
the level of the organelle to the level of body system or person.
I
NTEGRATION OF
 N
ATURAL
 S
YSTEMS
 T
HEORY IN THE
 H
OLISTIC
 N
URSING
 M
ODEL
The pathogenesis and etiology of health and illness in the holistic nursing model integrates the natural systems approach into nursing, giving a more complete 
perspective of disease. Viewed from a holistic perspective, disease can be caused by a disturbance anywhere from the subatomic to the transpersonal level; and 
disease may be caused by a force that disturbs or disrupts the structure of the natural systems themselves. Health is on a continuum, and the goal is to work with the 
patient to decrease the disturbances and stressors caused by his or her illness. As the patient and his or her family strive to reweave the social fabric of their lives and 
move towards achieving more harmonious interaction, these interactions affect all components of the natural systems hierarchy.
A key characteristic of the hierarchy of natural systems is informational flow (
9
). The result of illness causes chaos in the person's family with a temporary disharmony 
that further affects a person's work, the community, and up the hierarchy depending on the individual's involvement in society. The death of President John F. 
Kennedy in the early 1960s is an example of the magnitude of a disturbance at one level affecting the whole hierarchy. The world still reflects on this tragedy over 35 
years after his death. Regardless of where the information originates, it spreads up and down the components of the hierarchy. Information flow has a domino effect 
because the whole system is affected by information originating at any point in the system. Holism and natural systems theory have important implications for 
providing a holistic perspective of caring and healing for individuals in their health or in all aspects of an illness.
T
HE
 B
IO
-P
SYCHO
-S
OCIAL
-S
PIRITUAL
 M
ODEL
When making a holistic nursing diagnosis, holistic nurses use a bio-psycho-social-spiritual model to understand the whole person or situation. This model provides a 
complete and holistic understanding of how human beings function (
10
). This model also guides all of holistic clinical nursing practice, education, and research. In this 
model, all four components—the biological, psychological, sociological, and spiritual—are interdependent and interrelated. The tenants of this model assert that all of 
these components must be addressed to achieve optimal therapeutic results. Regardless of the technology, therapy, or treatment used, the human spirit is also 
included as a major healing force in reversing, stabilizing, and producing remission in all stages of an illness.
The biological dimension of this model includes those basic needs that help individuals maintain their health, such as food, sleep, water, exercise, fresh air, and a 
healthy environment. The psychologicalal dimension includes language, perceptions, cognition, mood, thoughts, symbolic images, memory, intellect, and the ability to 
analyze and synthesize data. The sociological dimension includes aspects that are involved in relationships with oneself as well as with family, friends, the 
community, and the universe.
The spiritual dimension in this model incorporates spirituality in a broad context that encompasses a person's values, meaning, and purpose in life. It reflects the 
human traits of caring, love, honesty, wisdom, and imagination. It may reflect evidence of a higher power or existence, or a guiding spirit. The concept of  spirit implies 
a quality of transcendence, a guiding force, or something outside the self and beyond the individual nurse or patient; this concept may include organized religion, 
which pertains to an organized group worship experience with other people who have a similar belief system. Spirit may suggest a purely mystical feeling or a flowing 
dynamic quality of unity that is ineffable. If one could clearly define the spirit, then it would no longer be the spirit. It is undefinable, yet it is a vital force profoundly felt 
by the individual and capable of affecting life and behavior. The human spirit becomes enfolded in one's being, and one's perceptions of meaning can make the 
difference between life and death.
Holistic nurses distinguish spiritual elements from psychological elements (
11
). Spiritual elements are those capacities that enable a human being to rise above or 
transcend the circumstances at hand. These elements are characterized by the ability to seek purpose and meaning in life, to love, to forgive, to pray, to worship, and 
to transcend, move, or rise above ordinary circumstances.
It is possible to ignore spiritual concerns, meaning, and purpose or confuse them with religion or religious beliefs. However, spiritual factors are crucial in healing, and 
the human spirit plays a major role in who lives and dies. Giving attention to the role of the human spirit helps the treatment plan to be complete. Dissecting spirit 
during the healing process does not interfere with and is not harmful to conventional medical treatment.
Using this model, appropriate traditional, complementary, and alternatives therapies are chosen in a relationship-centered care process (
12
). The holistic nurse never 
heals the client, but uses herself or himself as an instrument of healing by guiding and facilitating clients in their healing process. The holistic nurse continues to 
refine and clarify the use of the most appropriate caring–healing modalities that can heal the human spirit.
PROVIDER–PATIENT/CLIENT INTERACTIONS
Patient Assessment Procedures
The holistic nursing process guides the nurse in all aspects of client interactions. The six parts of the holistic nursing process (
13
) are as follows:
1. Holistic assessment
2. Holistic nursing diagnosis
3. Client outcomes
4. Plan
5. Implementation

6. Evaluation
H
OLISTIC
 A
SSESSMENT
In a holistic assessment, the nurse listens to the client tell his or her story (i.e., history-taking), using both scientific approaches (e.g., physical assessment, 
noninvasive and invasive data) as well as intuitive approaches (e.g., therapeutic touch, presence, intuition). The client's data are recorded and organized according to 
the nine human response patterns of the Unitary Person framework, as described in 
Figure 18.1
, a holistic assessment tool (
14
).
F
IGURE
 18.1. Holistic nursing assessment tool. Developed by Pamela Potter Hughes, RN, BSN, MA, and adapted by Barbara M. Dossey, RN, MS, HNC, FAAN and 
Noreen Frish, RN, PhD. (Adapted with permission from Guzzetta CE, Bunton SD, Prinkey LA, Sherer AP, Seifert PC. Clinical assessment tools for use with nursing 
diagnosis. St. Louis: Mosby, 1989.)
According to the North American Nursing Diagnosis Association (NANDA), a Unitary Person framework focuses on a person as an open system who interacts with the 
environment (
15
). After the holistic history data collection, the nurse uses the nine human response patterns of the Unitary Person framework to determine the most 
appropriate nursing diagnoses. Depending on the clinical situation and the client's needs, the holistic nurse may also perform an energetic (energy field) assessment, 
such as is used in therapeutic touch, pain assessment, imagery assessment, and with different caring–healing modalities such as touch therapies, movement, 
exercise, and cognitive therapies. Significant findings are marked on the human figure drawings at the end of the tool.
Another assessment tool, the spiritual assessment tool (
Figure 18.2
), can also be used in diagnosis (
16
). There are three defining characteristics of spirituality in this 
tool: meaning and purpose, inner strengths, and interconnections (
17
). Meaning and purpose refer to one's experience about life's purpose and meaning, mystery, 
uncertainty, and struggles. Inner strengths refer to a sense of awareness, as well as a sense of self, consciousness, inner resources, sacred source, unifying force, 
inner core, and transcendence.  Interconnections include relatedness, connectedness, and harmony with oneself, others, a higher power, and the environment.
F
IGURE
 18.2. Spiritual assessment tool. (Adapted with permission from Burkhardt M. Spirituality: an analysis of the concept. Holistic Nursing Practice 1989;3[3]:69.)
The spiritual assessment tool provides reflective questions for assessing, evaluating, and increasing spiritual awareness in clients and their significant others. The 
reflective questions in this tool can facilitate healing because they stimulate spontaneous, independent, meaningful initiatives to improve the client's capacity for 
recovery and healing. Use of bio-psycho-social-spiritual tools and integration of complementary and alternative therapies also assist nurses in meeting the mandate 
by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to deliver the Patient Bill of Rights and to improve the quality of health care. The 
Patient Bill of Rights (RI.1.1.2) states that “care of the patient must include consideration of the psychosocial, spiritual, and cultural variables that influence the 
perception of illness. The provision of client/patient care reflects consideration of the patient as an individual with personal value and belief systems that impact upon 
his/her attitude and response to the care that is provided by the organization” (
18
).
H
OLISTIC
 N
URSING
 D
IAGNOSIS
A holistic nursing diagnosis can be defined as a clinical judgment about the individual, the family, or the community responses to actual or potential health problems 
and life processes. These diagnoses provide the basis for selecting nursing interventions to achieve the desired client outcomes for which the nurse is accountable. 
The taxonomy of specific holistic nursing diagnoses is described in the nine human response patterns of the Unitary Person framework (see 
Figure 18.1
). Each holistic 
nursing diagnosis has been or is currently being researched to further refine the etiology and defining characteristics of each holistic nursing diagnosis. When making 
a holistic nursing diagnosis, the human response patterns are considered basic for the nurse to perceive the meaning inherent with each person and his or her 
situation.
C
LIENT
 O
UTCOMES
After a holistic nursing diagnosis, client outcomes are established, which direct the plan of holistic nursing care. These client outcomes are direct statements of the 
desired end that the client will reach within a specific time frame. It indicates the maximum level of wellness that is realistically attainable for the client. Each outcome 
will specify something that should or should not occur, the time at which it should occur, and the expected results. Outcome criteria describe the specific tools, tests, 
or observations that will be used to determine whether the client outcomes are achieved. To achieve outcomes, they must be established by the client with the 
assistance of the holistic nurse, the family, and significant others. The client must be motivated and must want to change to establish healthy patterns of behavior.
P
LAN
During planning, the holistic nurse helps the client and family identify methods of instituting new patterns of behavior to achieve a healthier state. The holistic nurse 
generally chooses an intervention by determining if it will be useful in helping the client reach a desired outcome; determining if the intervention should target etiology, 
signs, symptoms, or potential problems; evaluating the intervention; determining the feasibility of administering the intervention based on surrounding circumstances 
(e.g., time, cost, other diagnoses the patient may have) as well as how the client feels about the intervention; and by ensuring the nursing competency needed for 
successful implementation. Compatibility with other treatments and cooperation by the patient and family are essential parts of any comprehensive plan.
I
MPLEMENTATION
Awareness is critical when a holistic nurse approaches the implementation of an intervention. The basic framework when implementing care is that the holistic nurse 

is aware that clients are active participants in their care, that the care must be performed with purposeful and focused intention, and that a client's humanness is an 
integral factor in implementation.
E
VALUATION
Data about the clients' responses to intervention, as well as their bio-psycho-social-spiritual status, are continually collected and reported during the holistic nursing 
process. In evaluation, the holistic nurse attempts to determine if the client outcomes are successful and to what degree. The evaluation process includes not just the 
holistic nurse and client, but also the client's family and other members of the health care profession involved with the client.
THERAPY AND OUTCOMES
Treatment Options
After the holistic assessment, holistic nursing diagnosis, client outcomes, and planning, the most appropriate treatment options are determined by using a 
relationship-centered care approach with the client and significant others. From this coparticipatory perspective, the holistic nurse helps the client and his or her 
significant others choose the most appropriate therapies that integrate technology when needed along with complementary and alternative therapies. Another nursing 
taxonomy, the Nursing Interventions Classification (NIC), is also being used with increasing frequency (
19
). The complementary and alternative therapies listed in 
Table 18.2
 are those most frequently used by holistic nurses in clinical practice (
20
). These therapies are usually referred to in holistic nursing as caring–healing 
modalities.
Table 18.2. Most Frequent Complementary and Alternative Therapies Used in Holistic Nursing*
Description of Treatment Interventions and Evaluation
Descriptions of many of the treatments, outcomes, and treatment evaluations used in holistic nursing are developed throughout this book. The reader is referred to 
specific chapters within this book which correspond to therapies in 
Table 18.2
 for details.
USE OF THE SYSTEM FOR TREATMENT
Meanings of Health and Illness
Holistic nursing considers the meanings a person attaches to symptoms or illness as integral to practice. These meanings are an important factor and influence the 
journey of one's life through a crisis (
21
). Human beings often view illness from one or more of at least eight frames of reference (
22
). Illness can be viewed as 
challenge, enemy, punishment, weakness, relief, strategy, irreparable loss or damage, or value.
Holistic nurses explore the meanings of health and illness with each individual and encourage these individuals to explore and share their story (
23
). Meanings are 
individual and personal and are congruent with the person's experience, belief systems, rationality, expectations, and context of the event. Context assumes 
significance in uncovering meaning and involves a person's past and present life story as well as what one believes about future events (
24
). The holistic nursing 
assessment explores these meanings with the individual clients looking at wholes, broad relationships, insights, and patterns.
Specific treatments are used depending on the holistic assessment, nursing diagnoses, client outcomes, and plan. These therapies include many mind-oriented 
therapies to treat physiological as well as psychological and spiritual sequelae of illness. Mind therapies are used as means of activating inner healing, thus 
augmenting the effects of drugs, surgery, and technological therapies and significantly improving morbidity and mortality rates and the quality of life. Holistic nurses 
consider complementary and alternative therapies as adjuncts or complements to conventional medical treatments and not necessarily as replacements for them. 
They advocate a both/and instead of either/or approach.
Doing and Being Therapies
Both doing and being therapies are used in holistic nursing.  Doing therapies involve many forms of modern medicine, such as medications, procedures, dietary 
manipulations, radiation, acupuncture, and so forth.  Being therapies do not employ medications or procedures; instead, these therapies use states of consciousness 
through imagery, prayer, meditation, quiet contemplation, and the use of presence and intention by the holistic nurse. Being therapies are therapeutic because of the 
psyche's power to affect the body.
These therapies generally are used in either of two ways: directed or nondirected (
25
, 
26
). When a patient employs a directed mental strategy, he or she attaches a 
specific outcome to the imagery, prayer, meditation, and so forth. For example, a patient may imagine coronary artery disease regressing or the blood pressure 
normalizing. When a nondirected approach is used, the patient does not assign a specific outcome to the strategy. Instead, the patient imagines the best outcome for 
the particular situation, without trying to steer the situation in any particular direction. The patient relies on the inherent intelligence within him- or herself to come forth 
and manifest, acknowledging the intrinsic wisdom and self-correcting capacity within nature. Doing therapies are highly directed in their approach. These therapies 
employ things and actions (e.g., medication, procedures) and they have a specific goal of outcome. The classic body–mind approach, however, employs the use of 
being therapies that can be directed or nondirected, depending on the mental strategies one decides to use, such as entering a state of relaxation or meditation. The 
individual moves to a level in which he or she feels a sense of interconnectedness that is beyond ordinary day-to-day involvement. It is actually a “not-doing,” to 
become conscious of releasing, emptying, trusting, and acknowledging that we have done our best, regardless of the outcome.