Introduction

As nurses consider their role in the movement toward complementary modalities and integrative care, it is also useful for them to examine the standards of practice of the American Holistic Nurses Association (AHNA). The AHNA is a national nursing organization committed to bringing holism, compassion, science, and creativity to nursing practice with a stated mission "to unite nurses in healing" (www.AHNA.org). The AHNA Standards of Holistic Nursing Practice (hereafter called the Standards) provide guidance for nursing care that meets the intent of the description of holistic nursing -- "care . . .that has enhancement of healing the whole person (from birth to death) as its goal (AHNA, 1992/1998)." The Standards grew from an interest in describing holistic nursing, and in articulating the values, knowledge, and skills required for its practice. The Standards represent practice of a nursing speciality, but unlike speciality practice defined by a client group (pediatric nursing) or a disease category (oncology nursing), holistic nursing is practiced by nurses in virtually every area of care. The speciality is based on practice that recognizes the body-mind-spirit connection of persons, and demands its practitioners integrate self-care and self-responsibility into their own lives.

Precisely because holistic nursing recognizes the body-mind-spirit connection of persons, holistic nurses often practice complementary/alternative modalities.

Precisely because holistic nursing recognizes the body-mind-spirit connection of persons, holistic nurses often practice complementary/alternative modalities.

In a 1996 study of 708 nurses who identified themselves as holistic nurses, researchers found that a majority of the nurses defined their practice in relation to modalities practiced (Dossey, Frisch, Forker & Lavin, 1998). The complementary/alternative modalities provide these nurses with a means to treat the body (biofeedback, therapeutic massage), relieve the mind (humor, imagery, meditation), comfort the soul (prayer), and support significant interpersonal interaction (healing presence). Holistic nurses have been interested in complementary/alternative modalities for over two decades, evidenced by the fact that of the early work published in holistic nursing (reprinted in the first compilation of historical writings on the topic) includes 41 scholarly papers addressing specific modalities and their use in practice (Clements & Martin, 1989). As the modalities became the widely visible aspect of holistic nursing practice, it was both important and necessary to develop standards of practice so that the philosophy, values and knowledge that underpin care would be articulated.

This paper will first provide information on the development, refinement and use of the Standards to provide insights into the philosophy, values, knowledge and skills on which holistic care is based, and second, illustrate the relationship of complementary/alternative modalities to these standards.

Development and Refinement of the Standards of Practice

The AHNA Standards of Holistic Nursing Practice were published in 2000 after nearly a decade of review, study, critique and consensus-building regarding the application of holism in nursing practice (Frisch, Dossey, Guzzetta & Quinn, 2000). The process began with reflective questions among members of the AHNA: questions like What defines the practice of holistic nursing? How is holistic nursing the same or different from all nursing practice? What is the relationship of holistic nursing to complementary modalities? Answers to these questions were not automatic, for there was no published authority from which to draw definitive (or even tentative) answers. Thus, the AHNA formed a committee to begin a process that first described holistic nursing, published position papers on social issues and on care/support of the environment, and drafted a Code of Ethics for Holistic Nursing. These position papers were developed through committees of interested nurses, critiqued by experts in the field, published in the association's newsletter (Beginnings) for review, and finally were adopted by the organization's membership. The result was an initial set of statements to the wider nursing community about the concept of 'holistic nursing' and its meaning. The AHNA description of holistic nursing is presented below (Table 1) as an introduction to the concept.

Table 1: AHNA Description of Holistic Nursing

Holistic nursing embraces all nursing practice that has enhancement of healing the whole person from birth to death as its goal. Holistic nursing recognizes that there are two views regarding holism: that holism involves identifying the interrelationships of the bio-psycho-social-spiritual dimensions of the person, recognizing that the whole is greater than the sum of the parts; and that holism involves understanding the individual as a unitary whole in mutual process with the environment. Holistic nursing responds to both views, believing that the goals of nursing can be achieved within either framework. The holistic nurse is an instrument of healing and a facilitator in the healing process. Holistic nurses honor the individual's subjective experience about health, health beliefs, and values. To become therapeutic partners with individuals, families, and communities, holistic nurses draw on nursing knowledge, theories, research, expertise, intuition, and creativity. Holistic nursing practice encourages peer review of professional practice in various clinical settings and integrates knowledge of current professional standards, law, and regulations governing nursing practice. Practicing holistic nursing requires nurses to integrate self-care, self-responsibility, spirituality, and reflection in their lives. This may lead the nurse to greater awareness of the interconnectedness with self, others, nature, and God/LifeForce/Absolute/Transcendent. This awareness may further enhance the nurse's understanding of all individuals and their relationships to the human and global community, and permits nurses to use this awareness to facilitate the healing process. © AHNA, used with permission.

The description makes clear that the views, beliefs, and practices of the nurse are as important as the nurse's view of nursing care. This statement on holistic nursing provided a basis from which to consider the actual practice. With this description of holistic nursing in hand, the AHNA undertook a four-step process to 1) develop initial Standards of Practice, 2) complete a role-delineation study of the actual practice of nurses who consider themselves to be 'holistic', 3) promote certification in the speciality, and 4) revise the Standards based on previous work (Dossey, 2000).

While there was no definitive authority on holistic nursing practice in the early 1990s, there existed a wide literature on holistic nursing.

While there was no definitive authority on holistic nursing practice in the early 1990s, there existed a wide literature on holistic nursing.

The team working on the initial draft of the Standards reviewed all articles published in the Journal of Holistic Nursing, and the journal Holistic Nursing Practice from 1985 to 1995, as well as numerous holistic nursing articles appearing in the literature (Dossey, 2000). It was believed that the content of this literature would cover the domain of the speciality and could form a basis for national standards. The first draft of the Standards was thus created in 1995.

An eight-member task force used these initial Standards to develop a survey instrument that would solicit information about the practice of holistic nursing in the field. This survey, titled an Inventory of Professional Activities and Knowledge of a Holistic Nurse (IPAKHN), was administered to over 700 nurses (Dossey, Frisch, Forker, & Lavin, 1998). Data obtained indicated areas of commonality that crossed over all nursing areas of practice. These data were used to develop a nursing certification exam and to refine the Standards. The revisions of the Standards were then reviewed by a 24-member Advisory Committee, composed of AHNA members noted for leadership in practice, and by a 24-member Review Committee composed of nursing leaders/educators nationally recognized through their publications as knowledgeable of the field. A final draft of the Standards was submitted by the task force to the AHNA Leadership Council in 1999 and gained approval of the Council and the membership at that time.

Core Values of Holistic Nursing

The current Standards of Holistic Nursing are based on five Core Values of practice: 1) Holistic Philosophy and Education; 2) Holistic Ethics, Theories, and Research; 3) Holistic Nurse Self-Care; 4) Holistic Communication, Therapeutic Environment and Cultural Competence; and 5) Holistic Caring Process. These core values represent the essence of holistic nursing and are each necessary for holistic practice. Core value 1, Philosophy and Education, emphasizes that holistic nursing is based on a philosophical framework embracing holism and a commitment to education, reflection, and knowledge. Core value 2, Holistic Ethics, Nursing Theory and Research, emphasizes that professional nursing is grounded in theory, informed by research and bound by ethical principles to guide practice that is competent, thoughtful, and principled. Core value 3, Holistic Nurse Self-care, is based on the belief that nurses must engage in self-care to promote health and personal awareness so that the nurse may serve others as an instrument of healing. Core value 4, Holistic Communication, Therapeutic Environment and Cultural Competence, emphasizes the requirement for nurses to engage with clients to promote mutually-determined goals for health and healing. Lastly, Core Value 5, the Holistic Caring Process, emphasizes an evolution of the nursing process to embrace assessment and therapeutic care addressing client patterns, problems, and needs in an atmosphere of caring (Frisch, Dossey, Guzzetta, & Quinn, 2000).

Knowledge and Skills

The knowledge and skills required for the practice of holistic nursing are summarized in the Core Curriculum for Holistic Nursing (Dossey, 1997) and further detailed in the Handbook for Holistic Nursing (Dossey, Keegan, & Guzzetta, 2000). The description of holistic nursing highlights the fact that holistic practice draws on knowledge, theories, expertise, intuition and creativity. These are five elements necessary for a nurse to function in a fully inclusive or comprehensive manner. Nursing knowledge is necessary for basic, legally-defensible nursing practice. Theories are needed to articulate, understand, and reflect on practice. Expertise is needed to perform tasks easily and for the ability to make accurate decisions about care. Intuition is required to understand the subjective experience of others and interpret its meaning to healing. Creativity is needed to solve problems and to identify new ways of being with clients. Each one of these elements is as important as the others and all must be present for the practice to be called 'holistic'. These elements require the nurse to function across three domains: cognitive (knowledge/theory), experiential (expertise), and affective (intuition/creativity) (Frisch, 2000). A holistic nurse uses and values all of these elements. "A holistic nurse can move back and forth between intuitive knowing and logical reasoning; between a creative approach to care and a standard care protocol; between a hunch of what to do and a considered direction grounded in the predictions of a theory (Frisch, 2000 p. 175)."

Certification in Holistic Nursing

The Standards of Practice and the statements of knowledge and skills required for holistic nursing have been used to establish minimum competencies for practice in the nursing specialty. These are used by the American Holistic Nurses' Certification Corporation (AHNCC) to provide certification for nurses whose practice has advanced to meet speciality standards. AHNCC uses a combination of portfolio review and standardized testing to evaluate candidates for certification. The title "Holistic Nurse - Certified" (HNC) is used by nurses obtaining the credential through AHNCC. Details of the process are available at www.ahna.org/edu/certificatin.html.

Holistic Nursing and CAM

Practicing nursing according to the Standards demands that nurses continually develop knowledge and skills in all aspects of their practice.

Holistic nursing is a way of thinking, reflecting, practicing, and being-in-the-world.

Many holistic nurses use complementary and alternative modalities to meet their client's needs for treatments promoting healing, comfort, and a sense of harmony and peace. Just as professional nursing cannot and should not be defined by tasks and a listing of activities that nurses do, holistic nursing cannot and should not be defined as use of modalities defined as 'alternative'. Holistic nursing is a way of thinking, reflecting, practicing, and being-in-the-world. Many think of holistic nursing as a way of life as the philosophy, thoughts, and self-care become incorporated into one's daily living and professional identity. As nurses increase their use of complementary and alternative practices, study of the Standards can serve as catalyst for reflection on the intents and outcomes of complementary/alternative modalities. The modalities are used to address client needs. Nurses working across cognitive, experiential and affective domains may use the Standards to articulate the philosophies and values that underpin and guide their practice.

Author

Noreen Cavan Frisch, PhD, RN, FAAN
E-mail: nfrisch@uvic.ca

Noreen Cavan Frisch, PhD, RN, FAAN is a Professor of Nursing and Chair of the Department of Nursing at Cleveland State University. She is past-president of the American Holistic Nurses Association and has served as a member of the Advisory Council to the NIH Office of Alternative Medicine. She has published articles on topics of nursing theory, diagnosis and holism. She co-chaired a national committee to produce the AHNA Standards of Holistic Nursing Practice, which were published in 2000 in a book for which she served as first author and editor.

Acknowledgment: Members of the task force that created the Standards of Holistic Nursing Practice are: Barbara Dossey, MSN, RN, HNC, FAAN and Noreen Frisch, PhD, RN, HNC, FAAN, Taskforce Co-Chairpersons, with Cathie Guzzetta, PhD, RN, HNC, FAAN, Lynn Keegan, PhD, RN, HNC, FAAN, Susan Luck, MA, RN, HNC, Johanne Quinn, PhD, RN, HNC Lynn Rew, EdD, RN, HNC, FAAN and Louise Selanders, EdD, RN.

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