KEYWORDS: Holism, Caring, Problem types, Science, Reductionism, Data, Theory, Knowledge, Domains, Values, Holistic assurance

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Jones, P. (1998) Holism: Making Sense of IT All

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Introduction

The medical model contrasts with the social perspective. For example, interactions between patient, nurse, relative and medical staff are readily amenable to description and definition in psychosocial terms. Such a description might force us to concede, that we carry out in delivery of health care occur at an individual and group level. This is a basic conclusion, given due accord in the HCM (via the individual-group axis), since all human activity must necessarily be individual or group in nature.

Over the past decades the 'professions' - especially their educational counterparts - have highlighted the relevance of holistic approaches. Holistic in the sense originated by the South African scientist Jan Smuts and explained by Patterson (1998), in which 'the whole is greater than the sum of its parts.' Instead of reducing the person into functional parts, the individual is considered as a 'whole'. Despite this Jacono & Jacono (1995) highlight the way much uncertainty continues about what nurses do, why, and how theory should be utilised in practice. Hancock (2000) takes the debate so far as to pose the question - 'Are nursing theories holistic?'.

In nursing practice it is rather paradoxical that claims of being 'holistic' remain de rigueur, while nursing (and other professions) also contemplate their navel. Such are the problems about definitions of nursing, where the profession is in relation to others, and where it should be - that nursing actually struggles to find its navel at all. Consequently, nursing is envious of those professional groups that appear to have identified theirs.

The difficulties are apparent in scepticism regarding models and theories of nursing. A view proposed by Burnard (1994) and others that models of nursing are counterintuitive. Expressions that nursing has lost its caring role and must claim it back. Biley (1992); Hancock (1989). Barker et al (1995) critique nursing's territorial claims upon age-old intellectual constructions, such as, "care and caring". While Jacono & Jacono (1995) reveal findings that nurses see caring as a subservient activity and seek to move away from 'caring for' - to 'caring about'.

CARING ABOUT PROBLEMS AND PROCESSES

Definitions of nursing could be derived from the nursing role. Other definitions reveal nursing as a 'process'. A series of steps that underpin practice and nursing actions such as assessment, planning, intervention, record keeping and evaluation. Roper, Logan & Tierney (1986) highlight the 'problem solving' role of the nursing process. The nursing process can be likened to the manufacturing, production, and design processes, in each case the process functions as a problem solving algorithm. Jones (1993) The definition of nursing as problem oriented has, however, been called into question by Crow et al (1995). The nursing process constrains the varied contexts down to a sequential process. Varcoe (1996) cites many advocates and critics of the nursing process, critics state that the nursing process:

• ignores the intuition used by nurses;
• the nursing process is reductionist.

To say that the nursing process is a problem solving approach, or a problem solving algorithm hides a great deal of complexity. It is possible to recover intuition and temper reductionist tendencies, if we see nursing simultaneously as several types of problem as per Table 1. These distinctions apply to health care generally.

TABLE 1 NURSING AS SEVERAL PROBLEMS TYPES

Table 1 clearly highlights the eclecticism inherent in nursing, which can be analyzed and represented (and frequently are) in two further ways; in the form of axes and knowledge domains. Health care is often described as being multi axial, represented as a series of continua as shown in reference to information.

FIGURE 2 KNOWLEDGE DOMAINS

Discussion thus far shows how health care can be divided into discrete contexts. Health care professionals also process information according to their (clinical) practice area. Figure 2 should serve to show what is meant by 'domain' here; although the legitimacy of comparing 'nursing', with 'astronomy' and 'philosophy' is acknowledged. The reference to previous work below, highlights the way some characteristics of data are common across clinical domains, while others vary. Change being a key factor.

DOMAIN/CONTEXTUAL

'The data generated and communicated in intensive care, A&E, psychiatry, paediatrics, orthopaedics, home and mental health resource centre, etc., must vary. The question is how? It might possibly vary in terms of total volume generated (kilobytes per person); type and proportion (social, physical, psychological information); value (change of particular data items denotes crisis); access and application.' Jones (1993)

Crow et al (1995) reviewed the literature to determine the cognitive component of nursing assessment. One method found was domain-specific knowledge structures, referring to:

"cognitive strategies which organize problems into broad groups or categories either by core principles or by a set of procedural rules." p.208

FIGURE 3 NURSING'S KNOWLEDGE DOMAINS?

This is only one strategy, Crow et al describe others. Crow et al (1995) identify differences in nursing's domains and how domain-specific knowledge structures are used by nurses - both novice and expert. "The domain-specific knowledge structures thus specify what actions to take and can best described as 'ways of thinking' about problems met in everyday practice. For example, nurses experienced in looking after patients with diabetes may judge whether a patient's condition is stable very differently from nurses experienced in looking after patients with a myocardial infarction." Crow et al (1995) p.208

In Figure 3 four specific domains are shown, and within each claims of an 'holistic approach' are often made. Equally, within these domains the health career model could be applied using the four quadrants. It is these differences in domains realized in practice and theory that accounts for care plan templates in paediatrics, medicine, orthopaedics, etc. Holistic approaches are as much about philosophy as practice. How can practitioners ensure assessments and discharge packages are holistic in their respective domains? Is there a right time to be holistic?

There is a tension between appeals to holism and health care. During the 1990s and earlier the demand by health care purchasers and insurers analysis for 'value for money' stressed the need for 'discharge planning', which should begin upon admission. Of course the reality is that clinical and social priorities disrupt such ideals.

Integrated Care Pathways (ICPs) represent one attempt to 'join' the dots between the above care stages, and those who deliver it. ICPs are applied and undergoing development in all care disciplines and health settings. To what extent ICPs capture the cognitive differences as opposed to behavioural is a moot point, but having both at the team's disposal might constitute a powerful tool, as per the amalgamation of cognitive-behavioural techniques?

Thus far the focus has (mainly) been on two domains included in the HCM, namely the SCIENTIFIC and the SOCIAL.

In the HCM it is no coincidence that these are diametrically opposite (not opposed!) to each other. Even without trying very hard the distinction between the worlds of medicine and society is a contrast all to often brought into stark relief. It is strange that even though medicine is practised within society, medicine has been criticized as being removed from the very society it treats.

This is part of the potential of the HCM and possibly other conceptual frameworks and models/theories of health care. A user of the HCM acknowledges that health care is not removed. People are indeed more than a diagnosis. Are medicine's difficulties (and by association nursing's) due to medicine not being holistic? Is this why people are turning to alternative medicine, and even mysticism? Or is there something more profound happening, as suggested by Campbell (1972) and Peat (1995), something that involves the position of myth in our (western) culture? Myths that had a role in our culture, but are now seemingly defunct, rejected for other things. Even though, as Campbell's work and legacy points out, fragments of myths pervade our culture today, but fragments are not enough. Our culture is all the poorer, left with a spiritual vacuum?

When it rains there is time to reflect upon Brian's work.

NURSING: A TECHNICAL PROBLEM?

With the health care knowledge frontier past, present and future laid out before them, theorists can lay legitimate claim to various phenomena as suitable subject matter for their theorising. Theorists have problems enough building bridges to negotiate gaps, but they must do their 'think' nursing in the information age. Whether purist in the sense of helping practitioners rediscover nursing's caring role, or not; in technical times theorists must be contemporaneous. The choice is simple:

1. In mechanistic times - "join the club."

2. In mechanistic times seek to preserve (rekindle?) the humanism that nursing comprises.

Choices are rarely simple. This is not the purely binary decision set out below: Internationally, nursing and other health allied professions seem hamstrung, and stressed with four choices or trends:

1. Scientific ('traditional'): nurse as the Dr's assistant.
2. Scientific ('Contemporary')
3. Mysticism
4. Holistic

Tools are needed that can not only ease translation of theory into practice, but dialogue between disparate ideologies. Review of the media demonstrates that nursing (more than most?) are being contemporaneous, incorporating the real world as experienced by the general public. The debate continues, as nursing searches posing the question where is home? A comfortable home. Balance is needed, however, this requires acceptance that:

· Technology is irreversibly embedded in health care delivery systems.

· Nursing is conducted in a technological world.

· Nurses have no choice - they must use technology.

· This technology has the ability to benefit or inhibit the nurse-patient relationship.

· If in future access to ICT facilitates access to health services, those without ICT possess greatest need - how will nursing cover these bases?

· Further rationalisation of health and social service personnel and role change is inevitable.

ICT has stimulated the rationalisation of many industries, helping to increase individual productivity while reducing the workforce. Ever since the advent of the industrial revolution 'engineers' have adopted a paradigm that dehumanized work. This process continues with implications for many who thought themselves safe from the ravages of automation. Rosenbrock (1987) Health and related social service areas are not immune. Decision support systems and other tools, may yet pose a threat even to management. Many (former) middle managers now have time to contemplate the flattening of organizational hierarchies.

As nursing has fought to acquire its own unique scientifically grounded terminology and methods, so it has become vulnerable to attack by the manager's knife. Examples include rostering, skill mix, grade mix, and care planning. The upshot of these points: nursing has also become a technical problem.

Concerted and ongoing efforts in resource management, the deployment of information communications technology, and deployment of e-comms (still very gradual for many clinicians) are all part of the commodification of health care.

The ethos of explicit resource management with emphasis on informatics has rendered nursing a technical problem. Ironically, the ongoing development, testing and refinement of nursing theories contribute to this trend. 'Holistic care' can be illustrated by:

'examples of nursing work which are drawn mainly from areas where expertise with technology is required' Stevens & Crouch (1995),

pitfalls await, as Engebretson (1997) observes:

'Two common mistakes occur in the analysis of holism from a modernist perspective based in a scientific or reductionistic paradigm. Alster's analysis of holistic health is an example of such an attempt; it reaches the syllogistic conclusion that holistic health cannot be studied scientifically because it is not scientific.

The opposite pitfall is to romanticize traditional or primitive healing systems and unfavorably compare science and biomedicine. This antiscience position is often seen in lay literature that attributes all social ills to scientific-rational thinking while extolling a holistic framework as the alternative. A consistent holistic framework incorporates science but does not hold that paradigm as sufficient for explaining the human experience or for bringing about health or healing.' (Alster, KB. The Holistic Health Movement. Tuscaloosa, Ala: University of Alabama Press; 1989)

Computerization further eschews the definition of nursing, confirming the arrival of nursing as a technical problem. To table 1 can be added:

WHERE HAVE ALL THE NURSES GONE?

Figure 4 maps out the points discussed thus far. The relationship and interactions of: DATA; THEORY; and VALUES; was debated in the late 1980s, on a U.K. Channel 4 TV programme 'Voices: The Trouble with Truth.' A key theme of the programme forms the apex of figure 4. Science has been and still is accused of being preoccupied with data and theory, to the detriment of the environment and humanity at large. It seems that science creates as many problems as it solves. The application of genetic research causes dilemmas in health care and ecology, for example, in gene therapy and the release of genetically engineered organisms into the wild. Safe disposal of nuclear waste (for 10,000 years?) provokes problems engineers cannot answer satisfactorily.

Just as data is king in science, with values "after hours," health workers are also data gatherers for resource management purposes. This data is often of little relevance to nurse's clinical work. Audit processes in resource management are used to appease critics, but the "artistry" that accompanies all human activity, including audit, allows a high degree of 'license' when managers sell the benefits of data gathering to nurses. Bearing in mind that management is "people management" and people entail values, then if informatics is applied without due attention to values several effects may (and do) occur:

FIGURE 4 VALUES, PRACTICE, THEORIES AND TECHNOLOGY

· benefits go unrealised, BCS & NHS-E IMG (1995); Mumford (1991);

· nursing is dehumanised;

· quality suffers at the hands of quantity, Bagust (1992);

· nurses become disillusioned with (work-based!) ICT (even to the extent of lacking resources) Munro (2001);

· resource management could divert attention from theory based practice;

· uncontrollable projects and/or abuse of power becomes more probable.

Furthermore, if there already exists a gap between nursing theory and nursing practice, then by adding a further factor (technology) the complexity increases exponentially. Values may be ever present (accountability!), but not in focus (Figure 4). What complications does a preoccupation with data, quantity, and informatics add to this historical view? Can nursing be reduced - in both analytical and (economic) rationalistic senses - to data driven humanism? The complexity of health care and contemporary society demands special tools to reconcile the information demands of the manager, clinician, researcher, and most importantly patients and carers.

FINDING A HANDLE: "A PROBLEM WORTHY OF ATTACK..."

A handle is needed on these continua or polarities, a framework of some sort, but what framework can be used? As the saying goes - "a problem worthy of attack, proves its worth by hitting back." If these (meandering?) thoughts are to inform the debate about the health career model, then it must be rigorous and yet incorporate a diverse range of concepts. Surely any framework would be so inclusive as to be useless. Perhaps? A starting point might be to use the reductionism inherent in medicine as per Table 2.

If patients are asked what they think nurses need to know, surely biology and types of operations would be top of the list? Torrance & Jordan (1995) connect knowledge about the body and its modes of description to accountability and professional values.

'Nursing is essentially concerned with looking after ill people and that an understanding of the biological sciences represents a critical, if not central element for safe effective practice.'

Biological sciences have a permanent place on the health care curriculum, but a much wider knowledge base is needed. One that extends the usual nursing/health care knowledge base. What do these points have in common with holism? Well, perhaps 'holism' is just relative (isn't everything?), nursing comforts itself in the knowledge that they are more holistic than most (Western) doctors, but less so than faith healers. From where then does 'holism' and claims for possession of an holistic approach arise? Surrounded as we are by technology does this reduce the veracity of claims for holism, or serve to make proponents of holism more vocal? Amid technological paraphernalia people think they know what they miss. Do they really?

"They consider me to have sharp and penetrating vision because I see them through the mesh of a sieve."
Kahlil Gibran "A Handful of Sand on the Shore"

Holistic approaches are often espoused as a way of not only literally feeling better (via holistic medicine), but feeling comfortable. Comfortable in the knowledge that since the policy makes claims for delivery of holistic care then everything is alright. Right with our patients/clients and the world, that wider, greener world. Is it possible to be holistic without hearing whale song, or relaxing in the green and yellow hues of the waiting room, reception, discharge suite? Commentators, policy makers and politicians, write about quality assurance, when all the time what is needed is 'holistic assurance'. (Perhaps they are one and the same?) What is often portrayed as 'holistic' is no such thing. Use of the term 'holistic' in the unit philosophy pinned to the office notice board, or the ward day lounge, is a 'speech' act - a promise, but not all promises are kept. This includes the promise made to students. Taught in the classroom the principles of holistic care, only to find (still) that the world of practice continues to impose a task oriented approach (Henderson, 2002).

Holistic assurance means quality insurance. Brian and I would like to propose that the HCM could help practitioners achieve holistic assurance, a check that 'all the relevant bases are covered'. Of course the HCM cannot ensure that the 'whole' team possess and express a holistic attitude, but this approach might help make a difference. Many staff know the limitations only too well, but it is what we attribute these limitations to that is crucially important. Amid the variety of meanings that can be ascribed to 'holistic care', one fact stands out. Especially as bureaucrats spin the policy carousel.

In information science AND health - bandwidth holds sway.

© Peter Jones 1998

This page is expanded further:

HOLISTIC INFORMATION LEVELS

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REFERENCES

Bagust, A. (1992) Quality or Quantity, HSJ, 102,5314,23-25

Barker, P.J., Reynolds, W., Ward, T. (1995) The Proper Focus Of Nursing: a critique of the "caring" ideology, Int. J. Nurs. Stud.,32,4

Burnard, P. (1994) More humble, less mumble, Nurs. Standard,8,32,50-51

Campbell, J. (1972) Myths to Live By, Viking Press, NY.

Crow, R.A., Chase, J., Lamond, D. (1995) The Cognitive component of nursing assessment: an analysis, J. Adv. Nurs.,22,206-12

Engebretson, J. (1997) A Multiparadigm Approach to Nursing, Adv. in Nurs. Science, 20: 1,21-33

Henderson, S. (2002) Factors impacting on nurses' transference of theoretical knowledge of holistic care into clinical practice, Nurse Education in Practice, 2: 244-250.

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Monro, R. (2001) Nurses 'left out of revolution',NT,July 19, 97: 29,9.

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Peat, D.F. (1995) Blackfoot Physics, Fourth Estate.

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Stevens, J., Crouch, M. (1995) Who cares about care in nursing education? Int. J. of Nurs. Stud., 32: 3

Sullivan, G.C. (1989) Evaluating Antonovsky's Salutogenic Model for its adaptability to Nursing, J. Adv. Nurs., 14: 4

Torrance, C., Jordan, S. (1995) Bionursing: putting science into practice. Nurs. Standard, 9: 49,25-27

Varcoe, C. (1996) Disparagement of the nursing process: the new dogma? J. Adv. Nurs., 23: 120-125

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