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ORIGINAL ARTICLE
Year : 2015  |  Volume : 21  |  Issue : 2  |  Page : 214--224

Effective factors in providing holistic care: A qualitative study

Vahid Zamanzadeh1, Madineh Jasemi2, Leila Valizadeh1, Brian Keogh3, Fariba Taleghani4,  
1 Faculty of Nursing and Midwifery, Tabriz university of Medical Sciences, Tabriz, Iran
2 Uremia University of Medical Sciences, Iran, Iran
3 Trinity College Dublin24 D 'Olier Street, Dublin, Ireland
4 Isfahan University of Medical Sciences, Iran

Correspondence Address:
Madineh Jasemi
Uremia University of Medical Sciences, Iran
Iran

Abstract

Background: Holistic care is a comprehensive model of caring. Previous studies have shown that most nurses do not apply this method. Examining the effective factors in nurses«SQ» provision of holistic care can help with enhancing it. Studying these factors from the point of view of nurses will generate real and meaningful concepts and can help to extend this method of caring. Materials and Methods: A qualitative study was used to identify effective factors in holistic care provision. Data gathered by interviewing 14 nurses from university hospitals in Iran were analyzed with a conventional qualitative content analysis method and by using MAXQDA (professional software for qualitative and mixed methods data analysis) software. Results: Analysis of data revealed three main themes as effective factors in providing holistic care: The structure of educational system, professional environment, and personality traits. Conclusion: Establishing appropriate educational, management systems, and promoting religiousness and encouragement will induce nurses to provide holistic care and ultimately improve the quality of their caring.



How to cite this article:
Zamanzadeh V, Jasemi M, Valizadeh L, Keogh B, Taleghani F. Effective factors in providing holistic care: A qualitative study.Indian J Palliat Care 2015;21:214-224


How to cite this URL:
Zamanzadeh V, Jasemi M, Valizadeh L, Keogh B, Taleghani F. Effective factors in providing holistic care: A qualitative study. Indian J Palliat Care [serial online] 2015 [cited 2019 Dec 10 ];21:214-224
Available from: http://www.jpalliativecare.com/text.asp?2015/21/2/214/156506


Full Text

 INTRODUCTION



Holistic care is a comprehensive model of caring which is believed to be the heart of the science of nursing. [1] The philosophy behind holistic care is based on the idea of holism which emphasizes that for human beings the whole is greater than the sum of its parts and that mind and spirit affect the body. [2] Holistic care is described as a behavior that recognizes a person as a whole and acknowledges the interdependence among one's biological, social, psychological, and spiritual aspects. Holistic care includes a wide range of approaches, including medication, education, communication, self-help, and complementary treatment. [3] In holistic nursing, all aspects of patients and their effects on the treatment process are considered and the patients' thoughts, emotions, cultures, opinions, and attitudes are factored in as contributing to recovery, happiness, and satisfaction. [4] Holistic care respects human dignity [5] : The relationship between the providers of health care and the patients is based on respect, relative openness, equality, and mutuality [2],[5] and patients participate in decision making in this kind of caring. [6]

Providers of holistic care consider a patient as a whole within his/her environment and realize that a patient is made up of a body, mind, and spirit. Respecting the patient's role in the treatment process, having him/her take part in the process and encouraging self-care is another aspect of holistic care which leads to therapeutic consultation, hope, dignity, self-discipline, social growth, a sense of autonomy, vigor, and vitality. [7]

Holistic care increases the depth of care providers' understanding of patients and their needs. Educating patients about self-care and helping them to perform their daily activities independently is part of holistic care. Palliative care is part of holistic care which improves the quality of a patient's life and their emotional and physical well-being. Holistic care increases self-awareness [8] and self-confidence in patients [9] and causes nurses to better understand the effects of an illness on a person's entire life and his/her true needs. It also improves harmony between mind, body, emotions, and spirit in an ever-changing environment; [10] The American Association of Holistic Nurses supports this belief and points out that holistic nursing includes all the nursing practices that heal the whole of a person. [5]

In many hospitals, nurses do not have the freedom to perform their tasks independently and their actions are often observed by doctors. Using holistic care as the framework will result in major changes in the treatment process, [11] a better public view of the nursing profession, and nurses' autonomy. [10] The holistic care paradigm has been presented to the health-care systems in many cultures [4] and it can be used in every area of nursing. [12] Holistic care is not a new method; Florence Nightingale developed this type of nursing as a better model of caring; [4] many other nursing theorists, e.g. Ragers, Newman, and Parse have also emphasized holistic care. [13]

Unfortunately, there is compelling evidence that most nurses have been educated with a biomedical allopathic focus and do not have a good understanding of the meaning of holistic care. Furthermore, it has been suggested that nurses are not familiar with holistic care, neglect this model of caring, [4],[6] do not use this method, [2] and consider patients' corporeal needs only. In this regard, patients' other needs and sometimes more serious problems are not addressed. [6] The mental, spiritual, and social needs of patients are neglected [14] and patients are considered as biological machines. [15]

Using the ordinary medical model alone for treatment exposes patients to serious threats, prolongs hospitalization, and raises treatment costs. [6] In many countries, such as the UK, [6] Australia, [16] and Iran, [12] holistic aspects of patients' needs are often overlooked. [6],[16] Similar studies conducted in the USA have revealed that 67% of American patients in hospitals do not receive holistic care, [17] and a study conducted in England showed that only 5% of hospitalized patients were subject to holistic care. [6]

This presents as a major crisis for the nursing profession. [18] Considering the beneficial effects of holistic care, the identification of contributory factors is of importance for providing this method of caring. A review of literature in this field shows that most studies have been limited to specific areas, such as operating rooms or older patients who were terminally sick. [4],[19] Other studies attempt to explain the concept of holistic nursing and nurses' perception of it, [1],[2] or the reasons for failure to employ this method. [4],[6] According to the results obtained from several studies, holistic care is adversely affected by such factors as inadequate time, improper professional relations, incomplete reports from nurses, inadequate clinical control, unavailability of resources, [20] poor professional and administrational perceptions, limited knowledge, and motivational and organizational factors. [4] In view of the great influence of holistic care on treatment and more effective nursing, the health-care systems in many countries in recent decades have tried to promote holistic care by applying changes to the educational and administrational systems, [4] but studies show that their efforts have been fruitless. [21],[22]

Evidently, there are other factors affecting holistic nursing that must be identified. An investigation into this matter using a qualitative approach that includes multiple methods of data gathering and emphasizes reality experience [23] can help us to obtain meaningful and comprehensive data; it will also clarify the existing background and the real situation surrounding the formation of holistic care. Thus, this is a qualitative study and is based on the experience of nurses, who form the core of holistic care provision.

 MATERIALS AND METHODS



Ethical considerations

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.

Method

A qualitative content analysis was conducted to develop an in-depth understanding of nurses' experiences of major factors that affect holistic care formation. This method was used for describing the systematic and objective means of the phenomenon. [24] This study is based on conventional qualitative content analysis in which coding and categorizing are derived directly from the raw data. The advantage of this approach to content analysis is obtaining direct data from participants without imposing pre-supposed categories or theoretical perspectives. Another important attribute of this approach is its emphasis on the subject, context, and differences and similarities among codes and categories. [25] Purposive sampling was used to select 14 participants with abundant information. Three of the nurses selected were male and the others were female. The participants were selected from various wards [intensive care unit (ICU), emergency, general wards] in university hospitals in the Iranian cities of Tabriz, Uremia, Ardebil, and Tehran. Further characteristics of the participants are presented in [Table 1]. The study lasted 6 months, from May until October 2013. In the first stage, participants were informed of the aim of the study by the researchers; if they agreed to participate in the research, they gave written consent. To respect the privacy of the interviewees, numerical codes are used instead of their names.{Table 1}

The data were collected using unstructured interviews. Each interview lasted between 60 and 90 minutes and was performed in a private room in the hospital. Each interview commenced with an opening question such as "what do you do for a patient during your shift?"; this was followed by questions that addressed their experiences of caring for patients and situations and factors which affect the quality of caring and attending to patients' various needs. Based on the initial data analysis, additional questions were asked of the respondents. A second interview was conducted with four participants to help clarify the initial interpretations of the information and emerging results. To ensure accuracy of the data, the interviews were continued until data saturation: Data collection was ended when no new information could be collected and the data became repetitive.

The interviews were tape-recorded, transcribed, and coded line-by-line by MAXQDA 2010 software which was used in the initial stages of coding. [22] The various codes were compared and categorized and themes were constructed based on similar and appropriate categories. In this way, themes and categories were generated inductively from the data.

Rigor

To increase the dependability of the study, data were collected and analyzed by one of the researchers; the other researchers checked and verified the data, codes, and analyses. The transcripts were read several times and the categories and themes were discussed by the researchers until consensus was reached. The credibility of the results of the study was confirmed through prolonged engagement with participants in the wards. In addition, individual checking was used to examine the accuracy of the findings, and the results of the primary analysis were shared with the participants to validate the compatibility of the codes with their experiences. Transferability of the findings was made possible by the variety of the characteristics of the participants.

 RESULTS



Following an analysis of the data, three themes were identified as effective factors in holistic care provision: The structure of the educational system, professional environment, and motivational factors. The themes, sub-themes, and codes are shown in [Table 2]. {Table 2}

structure of the educational system

The structure of the educational system was one of the issues which most of the participants talked about. Proper education plays an important role in nurses' preparation for providing holistic care. This theme consists of three sub-themes: The content of educational programs, the teaching methods, and the educators' competence.

The content of educational programs

If the content of educational programs is comprehensive and includes the philosophy of holistic care, it will enable nursing students to address the various needs of patients and provide holistic care. One of the nurses emphasized the role of education in providing holistic care and said:

The content of the courses deeply affected my attitude toward patients and their needs; the courses on "nursing procedures" and "psychological disorders" made me stop looking at a patient only in terms of physicality and understand that an individual is more than a body with certain needs; it made me consider a patient's entire dimensions; I realized that health is the equivalent of harmony and balance among a patient's whole dimensions, not simply physical well-being. (Participant 8)

The above quotation points to the important role of designed courses in training nurses in holistic care. Another participant, similarly, referred to the importance of "nursing procedures" in creating an inclusive perception and promoting holistic care:

The course on nursing procedures broadened my horizons about patients and made me see aspects that I had been unaware of; I understood that well-being is the result of meeting a patient's various needs, from physical needs through emotional and spiritual needs to social, cultural and economic needs. (Participant 2)

The same participant, however, observed that the course of "nursing procedures" did not have enough credits and that they were not adequately trained in providing holistic care:

The course was too short and the training was not enough. But I was interested and regarded it as a specialized part of nursing; I practiced a lot and gradually learned how to exercise it. I wish the trainers had instructed us properly; then I would have realized the importance of it sooner.

Unfortunately, the data show that the content of the educational program is poor and lacks material on the various needs of patients. Regarding this issue, one of the nurses explained:

More than 90% of our lessons were about the physical problems of patients, and their other needs were usually neglected. (Participant 5)

Another participant expressed:

During the course, most of our education was about the physical problems of patients and dealing with them. So, by the end of the course, our knowledge of the physical needs of patients had increased, but we didn't know anything about the whole needs of patients and their role in the treatment. (Participant 6)

Another nurse explained:

Clinical training was too short and we didn't have enough time to establish a relationship with the patients to recognize their various problems. (Participant 13)

Teaching methods

Teaching methods are part of the educational structure and play an important role in holistic care formation. But, according to the results, the teaching methods are not designed to demonstrate holistic care. In this regard, one of the participants said:

The teaching methods were often educator-centered; a limited number of tasks were dictated and we were expected to do them only; we were not free to consider the other needs of patients and satisfy them. (Participant 3)

Practice-based teaching can increase nursing students' understanding of holistic care, but the data showed that the nursing educators did not consider this matter and focused on theory-based teaching. One of the nurses stated:

We did not receive any practical training in considering patients' various needs. In our education, we were not told that a patient is a whole with many different aspects and whose treatment requires that we consider all those aspects; although some of the educators advised us to consider the secondary needs of patients, there was no practical training in this field. (Participant 9)

The educators' competence

The educators' characteristics and competence have been introduced as a component of the educational structure in this study; educators can provide the trainees with a practical model from which to learn the principles of holistic care in practice. A participant said regarding this issue:

One of our educators was sensitive to the various needs of patients, treated them with respect and attended to their various needs. Her manners influenced my behavior. Now, I try to use her lessons in practice and provide my patients with comfort by addressing their various needs. (Participant 6)

Similarly, a participant referring to her trainer's holistic perception and emphasis on holistic care remarked:

One of our trainers always stressed that we view a patient as a whole that has different needs; she was trying to have us realize that well-being is the result of creating a harmony among the various parts of the whole and not just the physical dimensions. My trainer's attitude greatly affected my manner of nursing: I try to attend to my patients' entire needs, not just the physical ones, and consider their emotional, spiritual, cultural and social needs. I believe that meeting all these needs at the same time rather than separately is much more effective.

But the results show that most of the participants had no practical model for learning holistic care during their education. One of the nurses said:

Most of our educators had limited knowledge of the various aspects of patients' needs and their effects on health recovery and paid little attention to these matters. They paid more attention to routine tasks, and we didn't have an actual example of someone who considered all the needs of patients and provided holistic care. (Participant 6)

An educator's good relationship with students is an effective factor in attracting attention to the educator's training, as well as motivation for learning. In this regard, one of the nurses stated:

Our educators didn't usually have a suitable relationship with us and reproached us for unimportant matters, so we didn't have any motivation for learning. (Participant 14)

Professional environment

Professional environment is another factor which most participants emphasized as being important to considering the patients' different needs and providing holistic care. This theme consists of three sub-themes: Workload, management, and the gap between clinical performance and academic learning.

Workload

Workload, one of the components of professional environment, was referred to by most of the participants as a restriction in holistic care provision. Concerning this issue, one of the participants said:



Sometimes, the ward is too crowded and busy; although I understand that patients have different needs, and I want to meet them, but I don't get the opportunity to do it (Participant 2).

Another participant explained:

If the numbers of patients were smaller in the ward, we would have more opportunities to provide better care and we could attend to all of our patients' needs (Participant 12).

One of the participants referred to the sheer number of her working shifts and said:

Because of the huge number of shifts, we are always tired and don't have the required energy for providing suitable care. (Participant 9)

Management

Management-with its different domains, such as evaluation, orientation programs for staff and management approaches-plays an important role in the formation of holistic care. Most of the participants emphasized its impact on the quality of nursing. To quote one of the nurses:

There is no difference between a nurse who considers and attends to the patients' different needs and another who only does the routine tasks. Ironically, the latter is more popular with the managers. Routine tasks are considered as evaluation criteria. (Participant 8)

Another nurse mentioned:

Our head nurse and the supervisors emphasize the routine tasks and unimportant stuff and there is no incentive for considering the patients' secondary needs. (Participant 5)

Orientation programs and managers' competence can decrease nurses' stress and obsession with routine duties and encourage them to consider the patients' other needs and provide holistic care. But data show that the professional environment in Iranian hospitals lacks orientation programs for novice nurses and that most of the managers lack competence for their positions. One of the nurses stated:

We didn't have any orientation programs when we began to work in the hospital and our head nurse was very strict and belittled us for unimportant matters. It was very difficult for me. I was under pressure and lost my motivation to continue my profession, provide proper care and pay attention to the patients and their needs. (Participant 7)

Limited conformity of the clinical environment with professional norms

Conformity of the clinical environment with professional and ethical norms results in nurses' treating patients as human beings with human needs, all of which should be taken into account; upon observing the beneficial effects of holistic care on the treatment process, nurses will acquire a holistic perception: They will realize the importance of attending to patients' needs from various aspects and experience the effectiveness of meeting those needs as a whole compared to satisfying them separately. However, the participants declared that upon entering the clinical environment, they were faced with the limited conformity of their environment with professional norms. Disregard for the principles of proper nursing forms a sub-category of this phenomenon.

The participants stated that upon embarking on their careers, they were faced with a prevalent disregard for the principles of proper nursing, at both the professional and ethical level. Obviously, such disregard for professional and ethical principles leads to professional shortcomings and negligence of nursing ideals, which in turn results in nurses' failure to provide proper care and attend to patients' needs in their entirety. Attention to professional principles is the prerequisite of holistic care; but in most cases they are ignored. To quote a participant:

When I started, I saw that many of the points that were stressed during our education were simply ignored here. For example, we were always told to sterilize a catheter before placing it, but nobody in the ward followed the principle; or antibiotics weren't administered at the right times. It made me feel guilty to witness all the carelessness; they didn't care about the patients and couldn't wait for their shifts to end! Many novice nurses would adopt the same wrong practices and ignore the professional principles; the standards and techniques were pushed aside and the patients forgotten. (Participant 6)

As the above response indicates, disregard for professional principles at work results in novice nurses' loss of interest in professional values and prevents them from attending to patients' various human needs and encourages them to stick to their routine duties.

Disregard for ethical matters in nursing is another component of negligence of proper nursing principles. Many nurses are guilty of such disregard and ignore their patients and their various needs. In this regard, one of the participants stated that:

I used to work in ICU and I often witnessed the nurses' lack of care about professional ethics. They were indifferent to those of the patients' needs which were not physical; if the orderly was away and a patient had a basic need, they wouldn't care; if a patient was in pain, they were not quick enough to administer a painkiller. In many cases they weren't honest: They would write down things they hadn't done; they would turn a blind eye to the patients' needs. If a patient, for example, wished to see his or her family, they wouldn't allow it. They would close the doors and drink tea and chat away! It was not easy to act morally under those circumstances: You could be ostracized. It was like swimming against the current. Unfortunately, many of my friends would imitate them, too, and were totally indifferent to the patients and their needs, as if they were machines. (Participant 8)

Motivational factors

Motivational factors play an important role in encouraging nurses to provide holistic care as well as facilitating such provision. Motivational factors include personality traits, personal experiences of hospitalization, and input sources.

Personality traits

Personality traits, identified as one of the sub-categories of motivational factors, are among the major factors generating internal motives: They encourage and facilitate holistic care, influence nurses' performance and relations with patients, and help develop rapport between nurses and patients. According to the participants, sociability and sensitivity to people's needs-which go under the subcategory of personality traits-are influential in encouraging attention to patients' various needs, thus nurses' developing holistic perception.

Sociable and genial nurses are more likely to establish a close rapport with patients, which results in a better identification and holistic perception of patients' needs. One of the participants pointed out that:

I'm a very good mixer, highly sociable; I make sure to greet my patients warmly; I even shake hands with the old patients, because I believe that lifts their spirits and makes them trust me and cooperate. For example, if they won't let others perform venipuncture on them, they will definitely let me. They also confide in me, which lets me know about and satisfy many of their needs. This quickens the treatment process, because attending to a patient's physical needs alone won't lead to recovery. My sociability has helped me realize the importance of knowing about and satisfying the patients' needs and how it affects the recovery process; now I believe that human is a complicated creature with many different needs all of which should be taken care of before complete recovery is achieved. (Participant 7)

Being sensitive and compassionate contributes to providing holistic care on the part of nurses. The more emotional a nurse is, the more sympathy he/she will feel for patients, which in turn will result in feeling more responsible for patients: The nurse will not simply perform the routine tasks but try to identify and satisfy his/her patients' whole needs. One of the nurses stated:

Well, I'm quite emotional and love to help others if I can. I help my family too and enjoy being a comfort. That's why I feel good when my patients are satisfied. Satisfying my patients' needs gives me a feeling of pleasure; the feeling is so strong that I believe my best moments are when I'm with my patients and helping them. (Participant 9)

Personal experiences of hospitalization

Nurses' personal experiences of hospitalization is another factor which enhances nurses' sympathy for and understanding of patients and their needs; it also contributes to regarding a patient's whole needs as important and refusing to attend to the physical needs alone. Naturally, being subject to similar experiences leads to a better understanding of patients' needs. Most of the participants referred to their personal experiences of hospitalization as unpleasant ones in which their needs or their families' needs-physical or otherwise- were not satisfied.

According to the input from many of the participants' experiences, when a participant or a family member was hospitalized, he/she was frustrated at the neglect of their basic and secondary needs. The participants stated that the unpleasant experience influenced their perception of patients and their various needs. One of the participants stated that:

I had to undergo cholecystectomy last year. Now I realize how painful an operation can be. Though I was in great pain, the nurses often neglected me and didn't give me painkillers. I understand now what a patient goes through. I promised myself I would never be indifferent to my patients' pain. If every nurse had a taste of his/her patient's trouble, that'd make a difference! You would understand your patients better and treat them as humans with a variety of needs all of which should be satisfied; you wouldn't focus on one aspect only, and you'd recognize the importance of attending to all one's needs simultaneously rather than one at a time. (Participant 1)

Another participant pointed out that after the experience of the hospitalization of a family member; she began to view holistic care in a different light:

One of the reasons why I attend to my patients' needs more carefully now is my Dad's time in hospital. He had to undergo a heart surgery and we were worried to death. I was waiting nervously outside the operation room, but the ICU nursing staff did not treat me well. Though I was one of their colleagues, they weren't very nice to me, and didn't allow me to see my father, nor did they give me any hope. I was totally anxious; now I understand patients and their families better. I put myself in their shoes and that makes me feel closer to them. This can help one understand patients and their multiple dimensions a lot better. (Participant 13)

Input sources

Input sources-which include religious beliefs, the participants' upbringing, and commitment-constitute another major factor in holistic care provision. Regarding religiousness, one of the participants stated:

My religious beliefs help me to consider a patient's various needs despite the problems at work. I believe God has given me the power to give care to my patients; this idea gives me more energy for a better caring for the patients. (Participant 7)

The same participant mentioned that religiousness can lead to recognition of the greater effectiveness of meeting a patient's whole needs simultaneously rather than separately:

By satisfying their needs and witnessing the effect of that on their recovery, I now see every patient as a whole with a number of needs all of which should be taken care of as a whole, and not individually, to quicken treatment.

Another nurse stated:

My beliefs make me attend to the different needs of the patients. Neglecting a patient's needs makes me feel guilty, and I try to keep my conscience clear by satisfying my patients' needs. (Participant 4)

The manner in which one has been reared has an important impact on the formation of these beliefs. In this regard, one of the participants said:

My father usually advised me to view the patients as my own family and provide the best possible caring for them and attend to all their needs. (Participant 8)

Commitment, which can increase during work, is usually effective before entering the nursing profession; it is considered as a component of input sources that plays a key role in the formation of holistic care. One of the nurses remarked:

I try to perform my duties in the best way. I think our duty is not limited to some routine tasks. Addressing all of the needs of my patients is my duty as a nurse and I try to resolve their entire problems. When I resolve them, I feel good and my interest in my profession increases. In addition to giving me a sense of fulfillment, satisfying the patients' various needs is so effective that I've grown more attentive to my patients' multiple dimensions and try to have an overall view of them. (Participant 3)

 DISCUSSION



The results of the study show that factors that affect holistic care provision the most are the educational structure, professional environment, and motivational factors.

Educational structure

Educational structure-which includes the content of educational programs, teaching methods, and educators' competence-has an important impact on the adoption of holistic care by nurses. Ahmadi et al., reach similar results in their study and introduce educational structure as an effective factor in the quality of care and extent of attending to patients' different problems. [26] The results of this study show that none of the components of the educational structure in Iran are appropriate enough to prepare nurses for holistic care. The content of educational programs is not based on the philosophy of holistic care. King and Gates' study points to the same results and shows that teaching holistic nursing to undergraduate nursing students is ignored in the curriculum of nursing and the content of educational programs emphasizes the medical model of. [27] Similarly, the results of Strindberg's study in Sweden show that most nursing lessons are based only on biological science. Revising nursing lessons seems to be required for the inculcation of holistic care in nursing students. Strandberg has also suggested this matter in his study. [1] Robinson, likewise, emphasizes the role of the lessons' content in the adoption of holistic care by nursing students and suggests using art and behavioral lessons in nursing courses. [18]

Teaching methods and educators' competence, the other components of the educational structure, play an important role in learning and the transference of theoretical knowledge of holistic care into clinical practice. However, according to the findings of this study, most nurses believe that their main concern in their courses has been with becoming competent in doing routine tasks and that they had little opportunity to consider the other needs of patients. If educators provide practical models of holistic care, students' confidence will increase and they will be able to provide holistic care. Meleis (1975) and Davies (1993) referred to this issue and emphasized its importance. King and Gates, also, stress the role of practical models, teaching methods, and explaining the philosophy of holistic care in the formation of holistic care (King and Gates, 2006). Similarly, Henderson's study suggests that defective teaching methods and educators' incompetence are barriers to holistic care provision. [16]

Professional environment

Professional environment, which consists of workload, management, and the limited conformity of the clinical environment with professional norms, can affect the formation of holistic care and act as a barrier or facilitator to it. When unsuitable, these components are identified as barriers to holistic care provision in this study. Workload is one of the aspects of practice in nursing environments which affects the quality of caring. In his study, Ahmadi refers to the effects of workload and states that most Iranian nurses suffer from heavy workload and do not have the opportunity to consider patients' various needs and provide holistic care. [26] Similarly, Olive introduces workload as a barrier to the formation of holistic care. [6] Management, another component of professional environment, includes various domains such as evaluation methods, orientation programs for staff and management approaches. The results of this study show that nursing management is inefficient and that the nurses in this study were dissatisfied with the style of management, and do not have any orientation programs. The above-mentioned issues play an important role in the formation of holistic care and, when suitable, can enhance the provision of this mode of caring by creating motivation in nurses and increasing their knowledge. Strindberg's study in Sweden confirms this fact and emphasizes the role of management in promoting holistic care. [1] Duffy and McEvoy, likewise, call attention to the importance of professional environment and its various effects on nurses' performance; they consider a suitable environment as a prerequisite of holistic care. [10]

Clinical environments' lack of conformity with professional norms is another factor which makes nurses loose interest in professional and ethical values, and acts as a disincentive to providing holistic care. [28] The results show that most nurses have encountered this problem and experienced it on the first days of working. Various studies-e.g. Silva, [29] Abedi [30] and Valdez [31] -recognize the limited conformity of the clinical environment with professional norms as a big challenge which most novice nurses encounter. Many of the participants in the study referred to clinical environments' poor conformity with professional and ethical norms as a deterrent to providing holistic care; they also stated that many of the novice nurses would follow their colleagues' example and neglect patients and their needs. Henderson, likewise, points out in his study that clinical environments' poor conformity with norms greatly contributes to novice nurses' disregard for holistic care and encourages them to stick to the routine duties and ignore the patients' various needs. [16]

Motivational factors

The findings of this study prove that motivational factors-input data, personality traits, and personal experiences-are influential in identifying patients' various needs and generating holistic perceptions of the patient, which in turn encourage nurses to attend to patients' diverse needs and provide holistic care. Personality traits play a major role in expanding relationship with patients, identifying their various needs and developing holistic perception on the part of nurses. Also, religiousness and morality can induce one to satisfy patients' needs and provide holistic care, and in many cases overcome the defects in the educational and clinical systems. Obviously, one's behavior is decided by his/her personality traits; thus, a nurse's performance, behavior toward patients, and attempts at expanding relationship with them are decided by his/her personality traits. As the most important internal factor influencing motivation, personality traits are influential in achieving success at college and at work by creating intimacy, commitment and conscientiousness. [13] Studies show that nurses who are temperamentally sociable and emotional tend to be cheerful at work and more capable at identifying patients' needs and nursing. The same studies reveal that these nurses, compared to their colleagues, are not only more dependable, intelligent, flexible, and conscientious, but also more highly motivated. [32] McEvoy and Duffy point to the importance of compatibility between personality and profession as well as the impact of beliefs and principles on a nurse's performance, and regard them as vital to the provision of holistic care. [10]

Nurses' personal experiences of hospitalization, either on their own part or their families', can also lead to a better understanding of patients' needs, or encourage holistic perception. In other words, such experiences can lead to viewing a patient as a whole whose needs should be met in their entirety rather than separately, hence the need for holistic care. Not many studies have addressed the effects of nurses' personal experiences of hospitalization on their perception of patients' needs and the need for holistic care; however, it has been revealed that such experiences can enhance nurses' attention to their patients' various needs and induce them to provide holistic care. Gates and King [27] and Strandberg, [1] for instance, point to the influence of nurses' knowledge and experiences on their understanding of patients' various needs and the importance of holistic care. McEvoy and Duffy believe that sympathy for and a better understanding of patients can lead to the provision of holistic care. [10]

 CONCLUSION



The results of the study show that the educational system, working environment, and motivational factors are major factors in providing holistic care. However, the findings reveal that these factors are not appropriate enough in Iran to lead to holistic care, and Iranian nurses tend to stick to their routine duties and satisfy patient's clinical needs only. Earlier studies conducted in other countries-e.g. Strindberg (2007), King (2006), Henderson (2002), Olive (2003)-have attested to the importance of the above-mentioned factors in the provision of holistic care, hence the need for closer attention to the compatibility of the educational system with the idea of holistic care, revision of the contents and methods of education, and modification of the conditions at work in order to encourage holistic care. Personality traits, personal experiences of hospitalization, and beliefs and principles-which go under the heading of motivational factors-also contribute to and facilitate holistic care. McEvoy and Duffy (2008) suggest that these factors are vital to holistic care. As a result, to develop holistic care it is necessary to attach more importance to motivational factors, compatibility between nurses' personalities and their profession, improvement of nurses' communicative skills, promoting religiousness, and encouragement of commitment in practicing nurses and nursing students alike.

 ACKNOWLEDGMENT



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. The authors would like to express their sincere gratitude to this center and all the participants for cooperating in this study.

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