A concept analysis of holistic care by hybrid model
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0973-1075.197960
Source of Support: None, Conflict of Interest: None
Purpose: Even though holistic care has been widely discussed in the health care and professional nursing literature, there is no comprehensive definition of it. Therefore, the aim of this article is to present a concept analysis of holistic care which was developed using the hybrid model. Methods: The hybrid model comprises three phases. In the theoretical phase, characteristics of holistic care were identified through a review of the literature from CINAHL, MEDLINE, PubMed, OVID, and Google Scholar databases. During the fieldwork phase, in-depth interviews were conducted with eight nurses who were purposely selected. Finally, following an analysis of the literature and the qualitative interviews, a theoretical description of the concept of holistic care was extracted. Results: Two main themes were extracted of analytical phase: “Holistic care for offering a comprehensive model for caring” and “holistic care for improving patients' and nurses' conditions.” Conclusion: By undertaking a conceptual analysis of holistic care, its meaning can be clarified which will encourage nursing educators to include holistic care in nursing syllabi, and consequently facilitate its provision in practice.
Keywords: Holistic nursing, hybrids, qualitative research
Holistic care is a complex concept which defies a precise definition. Holistic care provides an in-depth understanding of patients and their various needs for care and has important consequences in health-care systems and has been referred to as the heart of the science of nursing. Holistic care can contribute to patients' satisfaction with healthcare and help them to accept and assume self-responsibility. It will also result in a better understanding of the effects of illnesses on patients' responses and their true needs.
During an illness, complex psychological, social and cultural needs disturb a patient's balance, and adversely affect his/her ability to carry out everyday activities. Holistic care, by addressing patients' physical, emotional, social and spiritual needs, restores their balances and enables them to deal with their illnesses, consequently improving their lives.
Florence Nightingale was the first nurse to emphasize the significance of holistic care. The philosophy of holistic care is based on unity and a humanistic view of the patient. A holistic paradigm has been present in the healthcare systems of many cultures, and it can be used in every area of nursing care, such as medical-surgical nursing, mental health nursing, obstetric nursing, pediatric nursing, and public health nursing. Patients of all races and religions have the right to receive holistic care; nevertheless, few patients are provided with it.
There is compelling evidence that most nurses who have been educated within a biomedical allopathic focus, are not familiar with the concept of holistic care – or at best, have a semi-scholarly understanding of it. This often leads them to neglect holistic care ,, and to consider only one aspect of the patients' needs – the physical aspect.
Using only the medical model is not only insufficient to restore health but also exposes patients to serious threats, prolongs hospitalization and increases treatment costs. In many countries, such as the United Kingdom, Australia, and Iran, caring conditions are inappropriate. Many aspects of patients' needs are forgotten, and patients' dignity is often neglected. The results of several studies show that many factors such as inadequate time, inappropriate professional relations, incomplete nursing reports, inadequate clinical supervision, unavailability of resources, poor management, insufficient knowledge, motivational factors, and nurses' misunderstanding of the concept of holistic care contribute to nurses' negligence of holistic care.
Holistic care is a nebulous and subjective concept. In general, it describes approaches and interventions that are meant to satisfy a patient's physical, mental, emotional, and spiritual needs. However, this definition is not comprehensive, and research demonstrates that the concept of holistic care is frequently used by nurses in a variety of contexts without any clear knowledge of what is meant by it. Thus, the meaning of the concept of holistic care often remains unclear and ambiguous  and usually incorrectly understood. Most often, “holistic care” is viewed with disapproval and condemned as unspecialized, unscientific, wasteful, and time-consuming. In general, the literature suggests that the meaning of “holistic care” remains ambiguous and any in-depth studies toward a definition of it are rare.
Having a concreate definition of holistic care enables nurses to identify therapeutic potentials when caring for patients  thereby increasing nurses' knowledge, helping to develop a framework for holistic nursing. In addition, a comprehensive understanding of holistic care will facilitate professional autonomy  and enable them to consider patients' needs in a more systematic and scientific way., Furthermore, a clear conceptual definition of holistic care will provide a concensus on its meaning therby facilitating its application in nursing practice, research, education, and theory development. Therefore, the aim of this study was to conduct a concept analysis of holistic care using an integrative approach facilitated by the hybrid approach.
To analyze the concept of holistic care, the researcher adopted the hybrid model from among the various available methods of concept analysis. Presented by Schwartz-Barcott and Kim in (1986), this model is a way to create, develop, and expand concepts, especially in nursing where it is widely used for disambiguation of concepts. Application of the hybrid model leads to purification of concepts, new and more comprehensive definitions, and at times the emergence of wholly different definitions from the previous ones. The hybrid model combines the inductive and deductive approaches and aims at identification of the essential aspects of a concept providing clarity based on the actual experiences of participants from observation and interviews. This model consists of three stages of theory (literature review), fieldwork, and final analysis  [Figure 1]. The theoretical phase begins with carefully selecting a concept and then examining the available literature related to the concept in other fields.
According to Schwartz-Barcott and Kim, the second phase, the fieldwork phase, is important for the confirmation and clarification of the concept. The fieldwork is a separate entity from the theoretical phase and facilitates the recognition of the dynamic and developmental nature of a concept. This phase is often based on qualitative research and includes the selection of the environment and participants of the study and collection and analysis of data. The final phase, the analytical phase, consists of a conceptual analysis of the findings from the theoretical and fieldwork phases which identifies attributes of the concept further clarifying its meaning. Through this model, the concept is purified and new definitions, sometimes quite different from the initial ones, emerge. In this study, the three phases of the hybrid model were applied for a conceptual analysis of holistic care as perceived and applied by Iranian nurses. The theoretical phase began with the selection of the concept of holistic care and a review of the literature. CINAHL, MEDLINE, PubMed, Science Direct, OVID, and Google Scholar databases were searched systematically. These databases are sufficiently large and are considered the most reliable databases for searching in the field of nursing. A search was conducted using the Mesh terms “holistic health,” “holistic therapies,” “holistic health,” “holistic medicine,” “holistic therapies,” “holistic nursing,” “holistic,” and their Farsi equivalents. Next, all the collected qualitative and quantitative studies which had been published up until 2013 which described aspects of holistic care for patients were reviewed. The searches were carried out independently by the first and third authors and verified by the second author. In total, 1061 articles were identified, 235 through PubMed, 126 through OVID, 327 from Science Direct, 108 through CINAHL, and 152 through Google Scholar. After irrelevant and duplicate papers had been eliminated, 127 abstracts were left, 78 of which were significantly related to “holistic care.” Forty-two of these were scanned for parts that included references to the concept of “holistic care” [Table 1]. All the selected articles were read and re-read for essential elements that are required for definition and measurement of holistic care. The careful readings shed light on the different aspects of holistic care.
The fieldwork phase
The fieldwork phase includes development and validation of the results of the literature review through qualitative study. In this phase, eight clinical nurses were interviewed to ascertain their understanding and perceptions of the concept under scrutiny to validate the findings of the previous studies and to see if new attributes emerge. In the hybrid model, the thoroughness of interviews is more important than the number of interviews and often 3–6 interviews are deemed sufficient. To ensure the accuracy of data, the interviews were continued until data saturation, i.e., the data became repetitive.
As the concept of holistic care is poorly defined, it was difficult to approach nurses who were working in a holistic way. However, based on her experience of working in clinical environments and familiarity with nurses' manner of providing care, the researcher purposely selected participants who were experienced, who had an interest in the concept of holistic care, and who considered themselves to be working in a holistic manner.
The participants were selected from the various wards (Intensive Care Unit [ICU], emergencies, and general wards) of university hospitals in the cities of Tabriz and Uremia, Iran. One of the nurses was male, and the rest were female. They had all graduated with a bachelor's degree. Three of the participants belonged to the emergency and ICU wards in two busy urban hospitals in Uremia, the capital city of the province of West Azerbaijan; the rest of the participants was operating in the internal, surgery, and emergency wards of three busy urban hospitals all located in Tabriz, the capital city of the Province of East Azerbaijan.
In the beginning, the objectives were explained to each of the participants; if they consented to take part in the research, they were asked to sign a written consent and grant permission for the interviews to be audio recorded. To protect the privacy of the participants, numerical codes were used instead of their names and any identifying information was removed from the transcripts. The data were collected through semi-structured interviews with a focus on questions about the meaning of holistic care from Iranian nurses' viewpoint. Some of the main questions were:
“What does holistic care mean to you?” “What criteria should be considered to measure holistic care?” “In your opinion, what are the characteristics of a holistic nurse?” “What are the outcomes of holistic care?”
Each interview lasted between 45 and 60 min and was held over one or two sessions in the participant's working environment. We tried to hold the interviews in a private room in the wards where the nurses worked, which is the natural environment for the phenomenon in question. All the computer files and written reports were kept in a safe place and made available only to the researchers working on the project.
To increase the dependability of the findings of the study, data were transcribed by one of the researchers immediately after each interview. Field notes, such as information about the context or environment of the interviews were also collected. The Fieldwork phase lasted for 4 months, from May to August 2013.
The conventional qualitative content analysis was used to analyze the data. To obtain a comprehensive view of the collected data, the transcribed interviews were read closely several times, and the text of similar content was classified into sections. Significant statements were underlined as the units of analysis, and a code was assigned to each. The various codes were compared according to their similarities and differences to obtain categories. To validate the codes, categories, and relationships between the categories and major themes, the transcripts were read again, and the subthemes and themes were discussed among the researchers of the study. A team-based approach to analyzing the data was used to confirm the credibility of the study. Copies of the interview transcripts and the emergent categories were given to the participants for confirmation and all were in agreement with the researchers conclusions.
The final phase: The analytical phase
In this phase, the usages and attributes of the concept were identified by analyzing the data. Here, to confirm, expand, and complete the definition of the concept, the codes, and categories obtained from the fieldwork phase were compared with the data obtained from the literature review in the theoretical phase, subsequently; the common characteristics of the concept of holistic care were identified and reported.
This study was approved by the Ethics Committee of Tabriz University of Medical Sciences. All the participants were informed of the aim of the study and a written consent was obtained from each of them. Participation in the study was entirely voluntary and the participants could withdraw at any stage of the study.
Review of literature: Theoretical phase
The review of literature from various databases revealed several different definitions and aspects of holistic care and its attributes. According to the findings, the concept of holistic care is used interchangeably in medicine and nursing and the concept of “patient-centered care” is considered to be the equivalent of holistic care. Viewpoints on the effects and consequences of holistic care were mixed [Table 2].
Characteristics and definition of holistic care in nursing
Review literature showed that holistic care is derived from the philosophies of humanism and holistic and it emphasize that the whole is greater than the sum of its parts such as person's mind and spirit affect., Holistic care was described as behavior that recognizes a person as a whole and acknowledges the interdependence among their biological, social, psychological, and spiritual aspects. Providers of holistic care consider a patient as a whole within her/his environment and believe that a patient is made up of body, mind, and spirit. Holistic care includes a wide range of approaches, including: Drugs, surgery, education, communication, self-care, and complementary treatment. Restoring power and responsibility to patients and encouraging them to exercise self-care is another aspect of holistic care which leads to therapeutic consultation, hope, dignity, self-esteem, self-sufficiency, self-regulation, personal growth, vigor, and vitality. The relationship between a holistic-care provider and a patient is based on relative openness, equality, and mutuality. The need of health-care providers for care and support is treated as equally important as that of patients in this model of caring. The Holistic Nurses Association confirms that in holistic nursing, health is believed to originate in a balance among a person's physical, spiritual, psychological, and social dimensions. The American Association of Holistic Nurses supports this stance and points out that holistic nursing includes all the nursing practices that heal the whole person and improve harmony among one's mind, body, emotions, and spirit in an ever-changing environment.
Characteristics and definition of holistic care in medicine
Holistic care in medicine is often equated with complementary or alternative treatments, such as acupuncture, Ayurveda, and homeopathy.,,, In complementary therapies, intervention and traditional and alternative treatments are meant to generate emotional well-being, a healthier lifestyle, and more satisfaction in the longer term.,
Characteristics and definition of patient-centered care
Patient-centered care is based on respect and responsiveness; its focus is on the needs, values, instruction, physical comfort, and emotional support of the patients as well as communicating with the patients' friends and families. Patient-centered care providers have a biopsychosocial view and emphasize therapeutic alliance and patients' powers and responsibilities, and consider every patient as a unique individual. High-quality care, health restoration, and an increase in patients' satisfaction are believed to be the consequences of patient-centered care. This model of nursing is characterized by a holistic approach to providing care and a consideration of patients' bio-psychosocial and spiritual needs., Some researchers, such as Bullington and Fagerberg equate patient-centered care with holistic nursing.
Consequences of holistic care
In some of the literature reviewed the term “holistic care” is interpreted negatively. It is described as an unspecialized, nontask oriented, and nonstatistical model of caring  that focuses too much on the psychological aspects of patients and leads to nurses' emotional exhaustion, and wastes their time. Evoy, likewise, is critical of this type of care and regards it as unspecialized. Such attitudes inevitably hinder the development of holistic care  and challenge nurses' adoption of it. In contrast, other researchers emphasize the positive outcomes of holistic care and acknowledge its contribution to the harmony, health and strength recovery, and personal development of patients, as well as nurses' personal and professional development and satisfaction with themselves and their jobs.,,
Illustrating the concept of holistic care will facilitate its adoption by educators and make nurses all the more determined to apply it. Based on the theoretical phase, the researchers in this study concluded that holistic care is a complex phenomenon and seems to be confused with patient-centered care; also, it is used interchangeably in medicine and nursing. Lack of a proper definition for the concept and equating it with traditional care or complementary care or seeing it as an alternative method results in a limited or incorrect understanding of holistic care and consequent unsatisfactory performance on the part of nurses., The fieldwork phase was an attempt at clarifying the concept of holistic care and differentiating it from other forms of care.
Working definition of holistic care
Based on the review of the literature, a working definition of the concept of holistic care was constructed:
Holistic care in nursing is a philosophy that guides the care that patients' receive which emerged from the concepts of humanism and holism. It refers to the provision of care to patients that are based on a mutual understanding of their physical, psychological, emotional, and spiritual dimensions. In addition, holistic care emphasizes the partnership between nurse and patient and the negotiation of healthcare needs that lead to recovery. It, therefore, draws from the biological, psychological, sociological, and spiritual dimensions of health among others with a view to achieving harmony that transcends physical wellness.
The findings of the fieldwork phase
In the fieldwork phase, interviews were conducted to determine the essential aspects and consequences of holistic care and establish the characteristics of holistic nurses. The initial codes were closely analyzed and explored [Table 3]. Finally, three main themes emerged: “holistic care as spiritual, social and clinical care,” “consequences of holistic care,” and “characteristics of a holistic nurse.”
Holistic care as spiritual, social, and clinical care
Based on the participants' responses, the main domains of holistic care were identified as spiritual, social, and clinical care. In other words, the three themes of clinical, spiritual, and social care constitute holistic care. Participant 1 said:
“I believe that holistic care is equivalent to spiritual and physical care and considering patients' social needs. So, I try to pay attention to these kinds of needs of my patients and resolve them” (Participant 1).
Another nurse explained:
“I strive to resolve the clinical needs of my patients and by sympathizing and giving emotional support to them provide holistic care” (Participant 2).
Another participant stated:
“I believe holistic care includes spiritual, social and physical care and if I want to provide holistic care, I should consider these aspects of my patients' needs and resolve them” (Participant 3).
The positive consequences of holistic care
The theme of positive consequences of holistic care is composed of two subthemes:
“Improving the treatment process”
“Nurses' feeling of personal development”
From the subtheme of “improving the treatment process of patients” such codes as “prevention of patients' depression,” “improved physical conditions,” and “decrease in the duration of hospitalization” emerged. One of the participants stated thus:
“Addressing the various needs of patients improves their healing conditions and decreases the length of hospitalization” (Participant 5).
Another participant believed that the emotional aspect of patients affects their physical conditions:
“Stress leads to gastritis and other physical problems in the patients and prolongs the recovery process” (Participant 7).
Participant 8 remarked:
“Emotional support for a patient helps the patient to tolerate the disease better, cooperate with health-care providers more and recover faster” (Participant 8).
With respect to increases in the feeling of personal development in nurses, the participants mentioned that addressing patients' various needs makes them feel satisfied, able, useful and professionally fulfilled.
Participant 1 said:
“When I satisfy the different needs of my patients I feel I'm being useful and helpful and that increases my motivation.”
And another participant claimed:
“Meeting my patients' needs gives me power and makes me more interested in my profession and motivates me to provide better care and consider the various needs of my patients” (Participant 4).
Characteristics of holistic nurses
“Characteristics of holistic nurses” was the final theme and included three subthemes: Sociability, professional commitment, and religious and ethical beliefs.
Sociability was the quality that the nurses emphasized as being essential to providing holistic care:
“By having a close and good relationship with my patients, I can recognize their needs and satisfy them” (Participant 2).
Participant 6 stated that:
“Having a good communication with the patient is a characteristic of nurses who provide comprehensive care, and I have often seen this quality in them.”
Professional commitment was another quality that the participants focused on. One of the participants stated:
“Professional commitment is the main factor that makes me try to respond to the various needs of my patients and provide better care” (Participant 3).
Participant 5 said:
“Neglecting the patient's needs makes me feel guilty.”
Nurses' ethics help them overcome institutional and educational barriers to holistic care and positively encourage them to provide this kind of care. One of the participants pointed to the compatibility between the philosophy of holistic care and Islamic principles.
“My religious beliefs help me overcome the problems caused by the authorities and my colleagues: Sometimes they accuse me of hypocrisy or just refuse to cooperate with me. Still, I focus all my attention on my patients because I believe God has chosen me to take care of them and I feel responsible for them. Because of my beliefs, I never neglect my patients' needs; I visit them frequently, take care of their needs, and respect them. My religiousness makes me understand my patients and their needs better” (Participant 6).
Another participant maintained that ethics can greatly enhance one's attentiveness to patients' various needs, hence holistic care:
“One of the reasons why I always care about my patients' needs is my belief in behaving ethically. I believe ignoring the patients' needs is unethical; it makes me feel guilty to be indifferent to a patient's needs. A moral person cannot ignore the patients' needs” (Participant 1).
The final analysis phase
In the third stage, the data collected in the theory stage – they include “holistic care as more comprehensive than patient-centered care” and “the positive and negative aspects of holistic care” – and the results of the interviews with nurses in the fieldwork stage – they fall into the three major themes of “holistic care as spiritual, social and clinical care,” “the results of holistic care” and “the characteristics of holistic nurses” – were analyzed and compared and two major aspects of the concept of holistic care emerged: “Holistic care as a comprehensive model for providing care” and “holistic care's contribution to the conditions of nurses and patients.”
Using the hybrid approach to concept analysis, this study attempts to clarify the meaning of holistic care through a synthesis of the related literature and nurses first-hand accounts of their experiences of working in a holistic way. Accordingly, holistic care is defined as a comprehensive style of care in which patients' entire needs are addressed as a means of enabling full recovery. While traditional conceptualizations of holistic care focus on the person and their physical, psychological, social, and spiritual dimensions, in Iran the person's cultural context and their situation within the familial system have emerged as central components of the concept. A clear definition of holistic care is an essential prerequisite to ensure that a standard model of this kind of care is achieved in clinical practice. Nurses' attention to holistic care will enable them to consider their patients' whole needs and identify their various spiritual, cultural, physical, social, etc., needs. Likewise, McEvoy and Duffy stress the importance of nurses' familiarity with the concept of holistic care and how it can improve their understanding, make their performance more specialized, and enhance their ability to identify and subsequently satisfy patients' needs.
Enhancement of nurses' knowledge of holistic care and its contribution to the quality of care is an important topic that needs to be addressed in the Iranian nursing system, and in many other countries, where the existing nursing practices are not satisfactory and the medical model is commonly applied in clinical environments. By identifying those needs of patients that are neglected by sole use of the medical model, recovery can be expedited and the period of hospitalization shortened, and the costs be reduced.
Since holistic care in an unfamiliar concept in the Iranian education system, and in many other countries, attention is paid to the medical model and nurses are trained to be doctors' assistants, it is necessary that the content of nursing courses be revised and nurses, trainers, and nursing students be educated on the concept of holistic. Strandberg et al. and McEvoy and Duffy, among others, have addressed this issue and considered it as an effective way to draw attention to holistic care. However, education in itself may do little to shift the traditional ways that nurses are working within, and a move toward a holistic approach to care may be thwarted by the prevailing illness orientated practices in clinical areas. Consequently, a philosophical shift is required that not just tells nurses about holistic care but encourages them to reflect on their roles within the multidisciplinary team and to reconceptualize their contributions to patient care beyond medical assistants.
In view of the fact that nursing is a team activity, it is important that, in addition to nurses, the other members of the health team be educated on holistic care. since many members of the health team are insufficiently familiar with holistic care and equate it with conventional and complementary medical practices,, interdisciplinary education is needed to enhance the various members' knowledge of holistic care and their tendency to apply it. Likewise, a reorientation to the role of nursing as a contemporary profession needs to be addressed and a model of partnership rather than subservience needs to be realized.
Although “holistic care” has been described as unspecialized, nontask-oriented, and time-consuming in some of the literature,, the results of this study show that it not only has positive consequences for patients and improves the treatment process but also boosts feelings of personal development in nurses. This is a confirmation of the results of other studies that emphasize the benefits of holistic care.,, These findings stress the importance of understanding the concept of holistic care before it can be properly practiced, taught, and studied.
Recognition of the characteristics of holistic care forms the foundation for its provision and will facilitate it. The findings support the premise that good communicative skills and professional commitment are the main characteristics of holistic nurses. This finding is similar to the results of Salsali's work, and Thompson et al. study which shows that nursing is influenced by personal and professional factors and an open and reciprocal relationship with patients., In this study, most nurses who provide holistic care tend to be religious and ethical. These features appear to play a key role in attending to patients' entire needs and in many cases help nurses overcome the barriers in the educational and medical systems. Belief in religious and ethical principles can directly influence a nurse's performance and attitude toward patients. it is a powerful motivational factor that encourages holistic care by creating intimacy, solidarity, commitment, and conscientiousness. Studies show that nurses who believe in religious and ethical principles tend to be more responsible, intelligent, tolerant, and motivated. McEvoy and Duffy stress the influential role of having religious and moral principles in nursing and regard it as essential to holistic care.
This study, by providing a comprehensive definition of holistic care, draws care providers' attention to patients' various and complex needs, and by specifying the positive effects of holistic care on patients as well as care providers, the characteristics of holistic nurses and strategies to acquaint nurses and the other members of the health team with the concept of holistic care, encourages the adoption of this style of nursing.
By applying the hybrid model and providing a clear definition of holistic care, nurses' knowledge of such care is increased, and it is more readily employed in research and theory development in nursing, as pointed out by Paley (1996). An explicit definition of holistic care will improve clinical performance and encourage nurses to provide this type of care, which will, in turn, improve the quality of nursing. In addition, providing a clear definition of holism in education can make teachers and students better acquainted with the concept, and train nurses according to the principles of holism. King, likewise, regards explication of the concept of holism in nurses' education as a way to facilitate holistic care provision. Among the findings of the study is recognition of sociability, professional commitment, and religious and ethical principles as qualities shared by most nurses who provide holistic care; this insight points to the importance of teaching communicative skills, encouraging religiousness, and creating a sense of commitment in nurses and nursing students – which will lead to the development of holistic care.
Limitations of the study
This study was limited by a lack of access to the full-text copies of some of the required papers. Another limitation of this study was that although it draws on literature from other countries, the analysis does not consider possible similarities and differences between the cultures of the patients and nurses studied in the literature and the cultural backgrounds and viewpoints of the nurses interviewed in this study. Another limitation of the study is the fact that in the fieldwork stage, the environment is limited to Iran. Holistic care is a complicated concept and to provide a comprehensive definition of it, it needs to be studied from the perspectives of nurses from diverse cultures and contexts.
This study is part of a larger study conducted for a doctoral dissertation that was approved by the Ethical committee and was supported with a research grant (number 350) for Ph.D. thesis from Nursing Research Team affiliated to Tabriz University of Medical Sciences, Iran. Appreciation goes to the research deputy of Tabriz University of Medical Sciences for financial assistance and all the participants who participated in the study.
Financial support and sponsorship
This research was supported by Nursing and Midwifery, Tabriz university of Medical Sciences, Iran.
Conflicts of interest
There are no conflicts of interest.
[Table 1], [Table 2], [Table 3]