The Tao of Integrative Nursing Assessment (TINA): An East-West Model for Precision, Complementarity, and Inclusion in Relationship-Centered Care : Holistic Nursing Practice

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The Tao of Integrative Nursing Assessment (TINA)

An East-West Model for Precision, Complementarity, and Inclusion in Relationship-Centered Care

Libster, Martha M. PhD, MSN, APRN-PMHCNS, APHN-BC, FAAN

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Holistic Nursing Practice 37(1):p E1-E13, January/February 2023. | DOI: 10.1097/HNP.0000000000000562
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Abstract

The purpose of this article is to detail how the Eight Principal Patterns (EPP), a thousand-year-old Eastern philosophy foundational to classical traditional Chinese medicine (TCM) rooted in Taoist philosophy, integrated with the Western Roy Adaptation Model to form the Tao of Integrative Nursing Assessment (TINA) model, is used to determine clients' unique health patterns in support of precision nursing assessments. This article continues the work of Hall and Allan's, “Self-in-Relation,”1 a holistic model for the integration of TCM with nursing science and philosophy to advance the practice of demonstrating precision assessment in relationship-centered care. All discussion of classical TCM in this article refers to a philosophy of care rather than the practice of medicine. The classical TCM philosophy described here can be applied by a nurse in an integrative assessment regardless of whether they are an actual practitioner of TCM. The term “TCM” is used for ease of reading; but this term also represents other Asian traditions that utilize Taoist thought.

INTEGRATION AND INCLUSION

Integration, a quality of heart, is demonstrated by the practitioner of nursing science in both the process and the product or outcome of care.2,3 In an integration process, the nurse incorporates ideas, even when they may seem to be opposing ideas, to assist the client in achieving life balance. A specific example of seeming opposing ideas often found in nursing and advanced practice nursing is the integration of biomedical approaches and technologies, such as head-to-toe system assessments, use of instruments, and pharmaceutical drugs, with historical/traditional nursing approaches and modalities, such as health pattern assessments, lifestyle management, and dietary recommendations. Many nurses throughout history have demonstrated integrative care in therapeutic relationships by cultivating a quality of heart that is highly inclusive of both emerging biomedical care and technologies with historical/traditional care.4,5

While Western nursing assessment models typically focus more specifically on the product of care as the transmission of information and skills, the TINA model focuses on guiding the nurse in the process of acquiring and integrating information and skill in the provision of relationship-centered care. The TINA model is an andragogical approach in that it cultivates mutual respect, shared experience, and authenticity as opposed to a prescriptive, “authority-oriented” approach6(p53) valued historically by practitioners and the public as the practice of medicine. Prescriptive practice can likewise be found within the practice of registered nursing and advanced practice nursing levels of care. Prescription is a predetermined action that is directed by a provider whose knowledge and experience may be vast but not necessarily meaningful at the time to the unique person, family, or group seeking care. When that prescribed care is not meaningful, it may not be useful or memorable for its recipient, the client, and it is often disregarded. This resulting behavior is referred to as “noncompliance” when from an andragogical perspective and from the client's worldview, the prescribed care may just not be their choice.

There is a centuries-old history of prescribing for others often without consideration of the person's construct of meaning of illness, health, well-being, and care. That history is recorded as the biomedical philosophy of “one cause-one cure.”7(p81) Integrative nursing, in contrast to one cause-one cure, is defined as a multidimensional relationship-centered approach to demonstrating care that is inspired and informed by both biomedical and traditional/historical beliefs, philosophies, and practices.2,3 Building and maintaining therapeutic relationships is central to integrative nursing. The integrative nurse's intention is to provide an invitational process in which the nurse and the client engage in shared meaning and responsibility within the therapeutic relationship. It is within the structure of the therapeutic relationship that the potential for the change emerges, which can lead to insight and healing.8

The TINA model was developed over 2 decades to integrate Eastern and Western philosophies found to produce precision assessment of health patterns.

BACKGROUND

Taoism (pronounced “Dowism”), the ancient Chinese philosophy of Lao Tsu as recorded in the Tao Te Ching, is about learning to live in relationship with the fundamental forces of cosmos.9 It serves as the foundation for classical TCM practice. “Ching” means, “book.” “Te” is somewhat similar to the word virtue or ethic. The word “Tao” in Chinese is typically translated as “path” or “way” of living. To presume to write about the Tao on any subject compels an apology at the start. Ancient wisdom traditions suggest that words, although they are vessels of thought and energy, cannot fully contain Tao. Tao is, yet is not. The Tao cannot be defined. It cannot be seen or heard and yet it “cannot be exhausted.”9(pp34-37) There is a limit to what can be written or spoken of Tao; hence the apology.

The Tao Te Ching, deemed a psychological work written in the 6th century bc,9 has been translated more often than any other book with the exception of The Holy Bible. Yet, experts in Taoism suggest that its roots reach further than biological or social factors found in most psychological works to an understanding of the “fundamental forces of the cosmos mirrored in our own inner structure.”9(pvi) A reader of the Tao Te Ching works on the inner as well as the outer life as they contemplate the incorporation of the Tao in any part of life, such as the healing arts or nursing. It can be a guide for anyone involved in a healing practice discipline in which internal reflection can support the development of self and relationships. It is not an instruction book on reflection or meditation per se; according to Taoist thought, the essence of meditation practice cannot be taught in a book. But paying attention to the flow of energy as consciousness can be taught in the Tao Te Ching as an expression of love.

While Western health care practice may speak to the work of relationships in which love and loving-kindness are expressed, Taoist belief forms a different approach to life, love, and relationships. The practice of Taoism is framed also as nonwork or “nonpractice.” The Tao Te Ching speaks equally of “struggle and discipline as it does of non-doing and letting go.”9(pxxviii) This language of juxtaposition of doing and nondoing, which in the East is purposeful, playful, and mindful, may sound confusing and nonsensical at first, particularly to those who are acculturated to Western thought alone. However, there have also been periods of scientific development in the West that have refocused clinicians on the value of nondoing and letting go in partnership with nature to respect the wisdom and healing in a natural course of disease. One such historical example can be found in the writings of 19th-century medical and nursing leaders,4 who held a belief in what was termed “self-limited disease,” which meant to “aid nature in her salutary intentions or to remove obstacles out of her path.”10(p35) The Tao Te Ching suggests that, “Difficult and easy complement each other.”9(p5) This harmony of seeming opposites, the complementarity of doing and nondoing, acting and letting go, and struggling and yielding, is mirrored throughout many paths in life. This includes practices in which notions of gentleness and nonharm exist side-by-side with that of warfare against disease, pain, and suffering. The integration of TCM philosophy with Western nursing science is an expression of complementarity in which clinicians are challenged to do and not do, to intervene and not to intervene.

Furthering the self-in-relation model

A pursuit of the integration of Eastern TCM/Taoist and Western nursing philosophies is not new. In 2006, Kao et al11 published an article describing the theoretical link between Taoism and Confucianism with Rogers' Science of Unitary Human Beings. In 1994, American nurse scholars Hall and Allan wrote the article titled “Self-in-Relation” reporting the result of “formulating a holistic model of nursing practice derived from and subsequently implemented in joint practice with practitioners of TCM.”1(p110) They adopted the Eastern focus on suffering and disease as “disharmony” and “blockage of energy flow,” which the nurse could address rather than working to fix, ameliorate, or manage disease. Disease does not have to be the focus or end point of health care or nursing. In many healing traditions, such as TCM, disease is an indicator for underlying patterns of energy flow in the body. Therefore, where practitioners in the West might value the ability to narrow a diagnostic pattern to defining a disease, such as diabetes for example, to one pattern perhaps with subsets (type 1 and type 2), in TCM there are numerous symptom-sign patterns that may be expressed by people who have been diagnosed biomedically with diseases, such as diabetes.

Diagnostics and treatment according to the biomedical worldview are valued for being able to detect the one pattern of disease repeated by the many. The purpose of assessment in the biomedical worldview is to find the one best practice or treatment that can be applied to everyone with any expression of that pattern, such as anxiety or pain. But the finer detail of how a particular disease is expressed from person to person in relation to the environment and others within that environment is, in TCM, diagnosed and treated using the language of symptom-sign patterns also referred to as energy flow or the Tao. This self-in-relation, relationship-centered approach also is not a new concept in health care. For years, health professionals have identified best practice as care that is patient-, consumer-, client-, or person-centered. Hall and Allan conceptualized person-centered care in the Self-in-Relation model as “occuring [sic] within the client's world, rather than the professional world.”1(p110) But operationalizing relationship-centered care in contemporary Western social structures remains a challenge. The TINA provides a time-tested traditional approach positioning nursing assessment as client- or person-oriented rather than professional nurse-oriented.

Models focusing on patient or consumer-centered care do not “account for the complexity and comprehensiveness of what falls under the broader umbrella of the person.”12(p147) The use of the word “person” rather than “patient” or “client” sets a different intention and refocuses the nurse to the person, who happens to be a patient/client, rather than on their need to assess, diagnose, and treat. A person-centered care approach is an expression of health culture diplomacy, in which the nurse values the therapeutic relationship and demonstrates respect for another person's culture, beliefs, values, and traditions.13 This is not always easy for the clinician educated from the paternalistic worldview of the biomedical paradigm.14 Integrating clients' thoughts, beliefs, practices, and desires for care provides a climate for the exploration of moving beyond a practice that presumes that there is one “right” way to help and heal and “dismiss evidence that is contrary to their beliefs”14(p13) about medicine, science, and health care. Nurses engage in the advancement of person-centered care; however, some in the United Kingdom, who had experienced that a focus on person-centered care had created an environment of consumerism, suggested movement to a more “appropriate relationship-centered approach.”15(p46) The 2006 American Pew-Fetzer Task Force concluded that key principles of relationship-centered care include personhood, affect and emotion, reciprocal influence, and moral foundation.16 In 2021, relationship-centered care remains a major focus for the provision of care in challenges of a rapidly changing health care delivery system now focused on virtual care.17

In relationship-centered care, a therapeutic healing relationship begins to form when a nurse engages a client and starts to develop rapport. The assessment process provides more structure for relationship development in which the nurse begins to understand the world of the client. In social relationships people assess each other by getting to know each other as persons. When establishing a healing relationship, the nurse goes beyond the social relationship to include an additional element. The nurse seeks to know the health patterns of the unique person. Health pattern, also defined here as “energetic” pattern, is the cornerstone of TCM assessment that is applicable in all health professions' models of care. Identifying energetic patterns is a mental and intuitive process like doing a puzzle where the goal is to take seemingly disparate pieces and organize them into a whole picture. The assumption in puzzle making is that a whole picture exists. The puzzle box suggests that is the case. Nurses enter the world of a client with the assumption that the client is a whole person who knows what their “picture” is and is not. This caring approach to putting together a nursing assessment puzzle is a process in nursing science called “modeling.”18(p94)

While some assessments, such as the head-to-toe, focus solely on the physiological mode, the TINA is holistic in that it focuses on the physiological, psychological, social, and spiritual patterns of the client's world. The Roy Adaptation Model is a good example of this holistic approach to assessment in the West. The nurse assesses a client in 4 modes: physiological, self-concept, interdependence, and role function. These 4 modes provide a holistic and integrative bio-psycho-social-spiritual framework for modeling the worldview of the client and putting the puzzle together. In the East, a TCM symptom-sign pattern assessment is quite similar with the addition of the assessment of 9 pulse positions, tongue tissue, and tongue coating (see the Table).

TABLE. - Nurse-Herbalist Assessmenta
TCM Roy Model19
Health concerns Physiological mode
Thermal (hot/cold) Oxygenation
Respiratory/breath pattern (rate, quality) Nutrition/Fluid and Electrolytes
Intake (thirst/appetite) Elimination
Outflow (urine and BM color quality consistency) Protection (skin integrity and sensitivity)
Pain (location, quality, better with touch or not) Senses
Skin (dryness, itching) Activity and rest
Senses (hearing, visual field) Neurological function
Sleep/rest (patterns, insomnia, dreams) Endocrine function
Motion (Gait, Speed, Forcefulness, Spasms)
Speech (speed, forcefulness, loudness, pitch)
Pulse diagnosis (quality, rate, depth, rhythm, profile)
Tongue diagnosis (tissue color, shape, fissures; tongue coat presence, color, thickness, moisture)
Behavior (personality, moods, interactions) Self-concept mode
Body image (How does client view self?)
Body sensation (How does client feel in body?)
Self-consistency (Response to situation)
Self-ideal (What would client like to be?)
Moral-ethical-spiritual-self (What does client believe?)
Lifestyle (work, play, habits) Role function mode
What roles does the client play? Age/sex/developmental stage.
Sick role?
How does client feel about roles?
Conflict?
Self-in-relation to others Interdependence mode
Environment (home, work, global) Close relationships
Sense of belonging
Support system
Giving and receiving
Abbreviations: BM, bowel movement; TCM, traditional Chinese medicine.
a©1995 Martha Mathews Libster—used with permission.

Health pattern assessment is not unknown in the West. Nursing diagnoses, for example, are words or phrases that summarize common behaviors that when viewed together suggest health patterns. However, because assessments and diagnoses are often disease-focused and emphasize the assessment of the physical body, puzzle piece by puzzle piece, without context or relationship, a disconnect with the environment and the domain of energy flow often occurs. The TINA suggests incorporation of the energetic philosophy foundational to classical TCM known as “Eight Principal Patterns” (EPP), discussed further on. It is relationship-centered in design and output and provides the structure for precision assessment as mindful reflective practice.

PRECISION ASSESSMENT AS MINDFUL REFLECTIVE PRACTICE

Taoist philosophy of the complementarity of doing and nondoing is expressed in a mindful and reflective practice approach. Nurses also have their own individual frameworks for reflective practice and their own professional philosophies about care as well as personal, religious or spiritual, and cultural beliefs that guide their own internal reflective processes. Being conscious or mindful of those processes activates and focuses the energy of reflection and makes it available for professional choice in demonstrating relationship-centered care. A risk to untapped reflection is involution into thought habits and a stagnation of creativity and innovation. Reflection upon one's own experiences, beliefs, feelings, thoughts, and actions during engagement with another person during the puzzle-making assessment process is a practice in mindfulness.

Psychology professor Ellen Langer's definition of mindfulness is “the process of noticing new things. It is seeing the similarities in things thought different and the differences in things taken to be similar.”20(p16) Langer defines mindlessness as “automatic behavior” and “acting from a single perspective.”21(p10) She differentiates the Eastern concept of mindfulness meditation from her work on mindfulness. She writes that in Eastern mindfulness meditation, a person is encouraged to quiet the mind whereas for her, the mind is actively engaged.

Taoism and TCM support the mindfulness and reflective practice skills that are tapped when learning the TINA assessment. The earlier Self-in-Relation work demonstrates the complementarity that can be achieved in the process of integrating Eastern and Western thought. Physicist Niels Bohr defines complementarity as a general principle that promotes “mutual understanding and respect among diverse cultures and allows for the unity of human knowledge.”22(p340) He acknowledged the profound harmony between Eastern wisdom and modern science initiated by the West. Bohr furthered Western understanding of the complementarity, harmony, or unity of seeming “opposites” that exist in nature. The dynamic interplay of opposites as represented in the yin-yang symbol (see the Figure) is the “essence of all natural phenomena and all human situations.”23(p145) Nurses can observe this yin-yang philosophy in human health behaviors. For example, salt is considered yang (warm) and water (yin). We observe that someone who eats too much salt (yang) then retains fluid (yin). Yang flows into yin hence the reason for the curving of the black and white symbols and encasement within a circle representing the unity of these perceived opposites as they flow, one into the other. The concept of complementarity supports a philosophy of inclusion, relationship, and integration.

F1
FIGURE.:
Yin-Yang symbol.

The notion of complementarity has become an essential approach to the way physicists think about nature. Bohr has often suggested that it might be a useful concept to employ outside the field of physics.23(p145) Whereas complementarity in physics allows for the inclusion of the notion of existence of particles and waves, complementarity in nursing allows for the inclusion of health beliefs, philosophies, and practices with seemingly different views of the body, mind, spirit, and healing. This inclusive and integrative approach to nature in nursing provides a scaffold for the perceptions about human suffering, health, disease, and illness patterns, and the healing relationship as it exists within the bigger scheme of promoting health as balance in body and peace of mind.24 A focus on complementarity moves the practitioner beyond the prescriptive biomedical doctrine of one-cause-one-cure to greater inclusivity as integrative nursing practice.

Seeking to understand complementarity as the flow of relationship between the yin and yang of life, as well as other seemingly opposite forces, is foundational to the TINA. It may feel quite familiar to some nurse-scientists and practitioners particularly because of the focus on recognizing patterns of self-in-relation to patterns in the environment; however, some in the West may distrust Eastern philosophy especially in terms of its impact on science.

In his foreword to the Taoist classic “book of changes” known as the I Ching, C. G. Jung observes the differences between Eastern and Western thought:

The Chinese standpoint does not concern itself as to the attitude one takes toward the performance of the oracle. It is only we who are puzzled, because we trip time and again over our prejudice, viz., the notion of causality. The ancient wisdom of the East lays stress upon the fact that the intelligent individual realizes his own thoughts, but not in the least upon the way in which he does it ... The I Ching does not offer itself with proofs and results; it does not vaunt itself, nor is it easy to approach. Like a part of nature, it waits until it is discovered.25(p. xxxix)

Jung acknowledges that the phenomenology of the I Ching will be apparent to some in the West as “clear as day” and to others “dark as night.”25(pxxxix) The TINA, which draws upon Taoism and the EPP philosophy of care in which a person is assessed in relationship to contextual conditions, may be apparent or “clear as day” for some and not for others. Entering the process of application of a philosophy of energy flow is a practice. It is also a change of “environment” for the nurse and client alike in which the definition of environment is inclusive of other persons, objects, space, place, time, and thought. The TINA is applied when entering the environment of individuals, families, and communities to offer a healing relationship and care, but the scope of this introduction to the TINA is the care of the individual person informed by their unique pattern that is expressed in relation to their environment.

The TINA suggests that a nurse seek to understand each unique client with the understanding that no 2 clients given the same diagnosis are the same in terms of energetic health patterns. Nurses and nursing students can mindfully incorporate the application of Taoist principles, such as the internal flow of energy or qi (pronounced chee), pattern, and change9,25 in the way that they approach their assessments. A student of the Tao cultivates a quest for understanding the patterns of energy flow in all things and its purposeful expression within the circle of seeming opposites as expressed in people's lives and more specifically their unique health patterns. Through the process of learning to incorporate TCM language and thought in assessment, the nurse naturally begins to engage in an East-West integration that moves beyond the habits of thought and action historically associated with predominant prescriptive biomedical culture.13 The process of integrating TCM philosophy with Western nursing science supports the development of cultural diplomacy skills that are helpful in the formation and maintenance of relationship-centered care.

TCM THREEFOLD FOCUS FOR CLEARING THE PICTURE

The specifics of employing a TCM philosophy are rooted in a practical science known as the “imperial secrets of health and longevity”26(p1) attributed to the centuries-old works of Chinese physicians, such as Sun Si-miao. This philosophical approach to assessment and care is organized with a threefold focus: first lifestyle, then diet, then herbs. Other treatments commonly associated with TCM, such as acupuncture, moxibustion, cupping, and tui na (massage), are incorporated after the threefold focus in a traditional plan of care. This threefold focus enables a nurse to “clear the picture.” Clearing the picture is analogous to separating out the frame pieces of a puzzle and moving internal pieces to the side so that the frame can be assembled first to provide structure for the rest of the puzzle-making process. Clearing the picture is one of the major goals of the assessment process so that a plan of care can be as precise and meaningful to the client as possible. The practice assumption is that a client's underlying or constitutional health patterns are their actual “picture,” which when cleared and then brought into balance, will manifest as greater health and well-being for the person.

So often when the client seeks care, they present with an overlay of health patterns that are the equivalent of dirt on the table where the puzzle pieces lie. To clearly see the puzzle and its picture, the dirt on the table must be cleared away. This is when following the nursing process becomes critical. Introducing specific treatments to a client without first engaging in assessment and clearing the picture through lifestyle and dietary changes and using herbs to catalyze energy flow (to be discussed in more detail further on) is often ineffective in creating the sustainable change that is foundational to healing. For example, consider the client who is not sleeping because they are in an abusive relationship with someone with whom they share a bed. A clinician knows that prescribing a “sleeping pill” or an herb is not the solution. Clearing the picture requires the clinician to first help the person deal with their fears and the abusive relationship. The ancient threefold focus philosophy first lifestyle, then diet, then herbs as best health promotion practice suggests that helping the person with lifestyle concerns first is foundational for clearing the picture that can lead to healing insights and lasting change.

In addition, when the threefold focus is the philosophical structure for assessment, a plan of care is authentically relationship centered. The clinician demonstrates deep attention to modeling the client's pattern. Issues of “compliance” or “adherence” with a plan of predetermined care based on medical diagnosis diminish when care is provided that resonates with the precise constitutional needs of the person in the moment of that specific therapeutic encounter. Clearing the picture, activated through careful observation and empathetic listening that seeks to model the worldview of the person, is the nurse's first therapeutic activity that provides a platform for establishing trust. Rather than running through a list of scripted questions or a head-to-toe assessment, the TINA practice is to mindfully listen during the lifestyle assessment phase to the story of a “day in the life” of the person without mindless precognitions. Additional detailed assessment questions may be posed later after the person has shared their identified concerns and needs.

As in puzzle making, Eastern cultures and language are pictorial. Lifestyle assessment is the first step in a threefold process that clears the picture that a client is presenting. Nurses use their scientific knowledge to select from the person's story the puzzle pieces that make up the frame of the picture. These are the issues of most concern to the person related to lifestyle such as sleep, rest, activity, energy or life force, mood, thought, relationships, and work.

At some level of consciousness, people know what the causes of their health issues are. They often just need different coping strategies to add to their lifestyle repertoire. Modeling the client's world and attending to what they raise, as the most meaningful experiences in their life, communicates and demonstrates caring. The nurse suspends what they know about care and cure to “take the pulse” of the person's lifestyle and lay a foundation for a therapeutic relationship. Then, when the frame for the puzzle has been put into place, the nurse can start to explore the internal pieces of the puzzle, diet and herbs, the second and third parts of the threefold focus.

Internal puzzle pieces—diet

The personal and cultural issues that surround diet, such as eating, nourishment, food choice, and preparation, are the second part of the threefold focus of the TINA. Clinicians in Western culture are often trained to instruct clients in what, when, how, and how much to eat. In classical TCM philosophy, this is not the case. Rather people are taught the energetics of foods and how to choose the foods that will create balance and harmony in their body, mind, and spirit. For example, if a client has a fever and they say that they feel very hot, they will eat foods that are cooling to create energetic balance rather than eat spicy hot foods that would promote greater heat. In another example, construction workers who work outdoors in the winter months often drink hot coffee throughout the day to keep warm. Coffee, a decoction of the seeds of the Coffea arabica plant, can be served at any temperature but is classified energetically as a warming beverage. According to the Tao and the principle of balance, the nurse would not recommend that an outdoor construction worker eat ice cream or any other energetically cold food in winter. This is how TCM philosophy and self-in-relation theory are put into practice. Although these examples may seem to be common sense, the energetics of some foods may not be as apparent and therefore may need to be studied. The evidence base for the energetics of foods and herbs has been developed over centuries.26,27 TCM practitioners have used sensory experience and observation to document the patterns of energetics of foods and herbs in people over time.

The 6 flavors

In TCM, foods and herbs are classified according to 6 flavors: sweet, sour, bitter, pungent, salty, and bland. Five of the flavors nourish the energy that sustains or “enters” the channels of a major organ: sweet enters the spleen channel; sour enters the liver; bitter enters the heart; pungent enters the lungs; and salty enters the kidneys. In small amounts foods or herbs with these tastes can be nourishing and balancing to the organ; however, in large amounts the flavors can damage the organ. The energetics of foods and herbs are described according to their 5 effects on the body's temperature: hot, warm, neutral, cool, and cold. There is more room for differences of opinion about the thermal qualities than about the flavors. Some examples of the energetics of foods are: apples are sweet and cooling and enter the lungs; alcohol is warm, bitter, and sweet and enters the liver, heart, lung, and stomach; chicken is sweet and warm and enters the spleen, stomach, and kidney channels; and wheat is sweet and cool and enters the heart, spleen and kidney channels.27 TCM energetic principles are rooted in knowledge of the digestive system as that which disperses (xiao) pure substances to be retained from foods and herbs and transforms (hua) impure substances to be excreted. These actions are believed to occur through a warming transformational process that begins in the stomach, which in TCM philosophy is likened to a pot on the burner of a stove. The goal of TCM dietary practice, for example, is to maintain a 100°F soup in the stomach “pot” of the middle burner. Drinking cold or iced beverages with a meal, a common practice in some Western countries, is contrary to this goal and considered harmful to human health.

The stomach and the spleen are the “middle burner” of the human body. The upper burner is the heart and lungs and the lower burner is the liver, intestines, kidneys, and reproductive organs. Whatever supports the creation of a 100° soup is beneficial to digestion and metabolism and ultimately overall health. The spleen provides the fire for the stomach to transform food. TCM challenges the health beliefs about the positive nutritional value of raw fruits and vegetables and juices, which are energetically cold and therefore quell the warmth needed for dispersion and transformation of food in the middle burner. In TCM, a nutrient's postdigestion absorption is as important as its nutritional value prior to consumption. Helping people with lifestyle concerns and more specifically adjusting their diet choices to promote greater health and well-being has been the domain of professional nurses for centuries.4 In previous times, Western nurses' expertise in lifestyle management and diet therapy was referred to as “sickroom management” or “domestic medicine.”28,29 It is currently part of the focus of creating optimal healing environments and part of integrative nursing fundamentals.2

It is possible that a person's health concerns will clear as the result of changes in lifestyle and diet that move them toward greater balance. As the person's health picture clears and the puzzle fills in, the person's history also becomes clearer, and their health patterns emerge. The science of the TINA, which centers on organizing the elements of the person's health patterns into a whole picture or puzzle, creates balance by addressing those elements one-by-one and as a whole. The third focus for clearing the picture, assessment, and creating greater balance, is herbs.

Internal pieces—herbs

In TCM, as well as many other healing traditions, illness is defined quite simply as the stagnation of energy. As people understand their patterns and make lifestyle and dietary changes that resolve their imbalances, the energy in channels through various organ systems begins to flow more freely. Free flow of energy or qi is equated in TCM with health. Herbs, or medicinal plants, are catalysts for change. They move energy or qi.

Herbal simples are introduced during the assessment phase of care to aid in moving energy and thereby clearing the picture. Simples are 1 or 2 herb remedies, such as a tea taken orally, a compress applied topically, or remedies such as an herbal bath that reflect and change the client's environment. One example of a topical herbal simple that hospital nurses may be familiar with is a witch hazel compress applied to the perineum of a woman after giving birth. A witch hazel (Hamamelis virginiana) distillate is cooling and acts as an astringent, contracting (and therefore clearing) the swollen tissues of the perineum. The TINA includes observation of persons' responses to simples. Providing herbal simples is similar to the practice of testing the temperature of formula in a bottle by shaking some drops on the wrist before giving it to a baby.

Simples are common in domestic medicine and self-care practices. They are often highly effective when used by families and communities that have incorporated the herbal remedies as part of their cultural traditions for centuries. In the TINA, each herb in a simple is assessed energetically and then chosen for application according to the Taoist principle of balance rather than solely for a particular constituent thought to be the reason for the herb's mechanism of action. Plants have many simultaneous mechanisms of action and therefore cannot be evaluated in the same way as pharmaceutical drugs. For example, a family may believe that drinking orange juice will help when someone is sick because it is high in vitamin C. Oranges are very cooling. Orange juice is a highly concentrated plant remedy. If a healthy person lives in a warm climate, the juice might feel very cooling on a hot day and therefore “healthy.” However, if a person exhibits a cold and damp pattern and lives in a cold, snowy climate, the orange juice could aggravate their condition, energetically speaking, regardless of the amount of vitamin C in the juice.

In TCM, herbs may not only be classified as moving energy or qi. They may also move stagnant fluid or blood. In addition, different plants are documented with thousands of years of corroborating evidence to affect certain health patterns in the body as a whole system (eg, cinnamon) or its specific organs by such actions as tonifying, draining, drying, moistening, regulating (moving), warming, and cooling. The study of TCM herbalism includes learning to suggest herbal remedies and then designing formulae specific to an assessment of a client's unique symptom-sign patterns.30

Caring for persons using this threefold focus approach, lifestyle-then diet-then herbs, allows nurses to address multiple patterns at one time even when those patterns may be perceived as conflicting. For example, an older person may have cold feet and heat in the liver. The Taoist approach allows for assessment and treatment of common complexities. It encourages complementarity of thought and a more thorough unified assessment and inclusive pattern diagnosis that can result in a holistic integrative plan of care. Taking time to clear the picture often prevents overtreatment.

APPLYING THE EIGHT PRINCIPAL PATTERNS

Energy flow is observed in a client as a manifestation of behaviors referred to as symptom-sign patterns. These behaviors are physical, mental, emotional, and spiritual. Energy flow patterns in TCM are the focus of precision assessment and treatment rather than biomedical disease because people with the same disease often manifest different energetic symptom-sign patterns. The focus of care is to identify blockages within natural energy flow patterns associated with healthy physiology. The goal of the TINA is the identification of a person's unique symptom-sign patterns and then the organization of those patterns into energy patterns or diagnoses that provide the structure for a precision treatment plan.

Symptoms-sign patterns are recorded exactly as expressed by the client as their experience. A TINA approach suggests that the nurse suspend any judgments and mindfully seek to explore the meaning of the pattern for the person. This also suggests that an advanced practice nurse would suspend the assessment and diagnosis of disease and begin with assessing and diagnosing symptom-sign patterns. Focusing on the pattern allows the nurse to more carefully follow the flow of the changes that the person experiences. The goal in observing these specific and descriptive symptom-sign patterns is promotion of health and longevity.26

People's patterns do evolve over time. Margaret Newman states, in her Health as Expanding Consciousness theory that clients are our “partners in revealing the evolving pattern” and that “meaning is pattern.”31(p85) Incorporating simple questions for the client about the meaning of their health experiences often provides additional insight into the symptom-sign pattern.

Pattern is described by nurse-scientist Martha Rogers as, “the distinguishing characteristic of an energy field ... it is an abstraction ... Pattern is not directly observable. However, manifestations of field patterning are observable events in the real world. The implications of this for increased individualization of nursing services are explicit.”32(p30,31) Newman defines pattern as, “information that depicts the whole, understanding of the meaning of all the relationships at once. An understanding of pattern is basic to an understanding of health ... Pattern recognition comes from within the observer.”31(p71,73)

Pattern recognition takes place throughout the nursing process. Symptoms and signs (behaviors) are first observed when establishing rapport during assessment and then a diagnosis follows, as the symptoms and signs are organized, grouped, and defined as patterns. Examples of categories of symptom-sign health patterns in nursing include “oxygenation,” “nutrition,” “activity,” and “rest.”33(pp109-320) TCM also uses a health pattern approach similar to nursing, but also includes tongue and pulse patterns (see the Table), which are beyond the scope of this article. Mastery of observing and interpreting TCM tongue and pulse patterns requires additional educational preparation and clinical practice with a mentor. In nursing, one pulse pattern is assessed for rate and basic rhythm. In TCM, there are 9 pulse positions that are assessed for rate, rhythm, and profile. In addition, the color, quality, and pattern of the tongue tissue and coating are assessed in TCM.34 A normal tongue is typically pink with a thin white coating. A person's tongue tissue changes throughout their life. It reflects the health of their internal organs and their body as a whole. A person's tongue coating can change daily reflecting the same.

One of the oldest frameworks for guiding pattern recognition in TCM is called Eight Principal Patterns (EPP). The 4 groups of terms that represent the 8 patterns—heat/cold, excess/deficiency, interior/exterior, and yin/yang—describe a client's energetic qualities; however, the qualities are grouped together, such as in the diagnosis of “damp (excess-interior) heat.” Ultimately, any plan of care designed with a client will harmonize or balance any identified patterns. In the case of damp heat for example, the remedy or remedies considered would be those that would drain dampness and cool the body or organ system in which the heat resides. Often, multiple patterns are present in those with chronic disease, such as older adults. The level of specificity EPP affords during identification and grouping of energetic patterns during assessment allows for addressing complexity as the harmonizing of multiple patterns at once. For example, a client might be low in energy due to dampness in the spleen and have heat in the head. The nurse might suggest a recipe for rice porridge or “jook” to drain the dampness and restore the energy of the spleen known in TCM to govern digestion and assimilation. Second, the nurse might recommend an herbal simple, such as peppermint (Mentha piperita) tea, an herbal remedy that is energetically cold and that is known from centuries of practice evidence to cool and move energy or clear the head area.

The terms “heat” and “cold” rather than referring to actual body temperature represent qualities at opposite ends of an energetic scale—perceptions of heat and cold—with neutral (neither hot nor cold) in the center. People have the potential to experience heat and cold and a range of points in between, such as are described by the words “cooling” or “warming.” When an extreme quality, such as heat or cold, is consistently present and is associated with a symptom-sign pattern that the person associates with discomfort, the nurse offers interventions. It is well understood in cultures in which TCM or similar health philosophies rooted in Taoist philosophy are practiced, that the thousands of years-old practice of EPP assessment allows for the early detection of patterns that lead to disease when not addressed. The EPP endures in its simplicity, exactitude, and ability to prevent the manifestation of disease by bringing harmony and balance, the focus of Taoism, to a variety of common energetic patterns.

The following are the profiles used in identifying the EPP.

Cold pattern includes:

  • Person feels cold or dislikes cold.
  • Person prefers warm or hot drinks.
  • Urine is light in color and stools are loose.
  • Application of heat relieves discomfort.
  • Movement and speech are slow.
  • Person acts withdrawn.
  • Pulse is slow.
  • Tongue tissue is pale and the coating white.

Heat pattern includes:

  • Person feels hot and dislikes heat.
  • Person is thirsty and prefers cold drinks.
  • Urine is dark in color and they may be constipated.
  • Cold applications reduce pain.
  • Movement and speech are rapid.
  • Person is outgoing.
  • Pulse is rapid.
  • Tongue tissue is red and the coating yellow.

A single symptom such as a white tongue coat is not sufficient for assessing a particular principal pattern. A white tongue is also a normal pattern. Several symptoms must be present for assessing a “cold” pattern but not all on the list must be present. It is also possible for a person to have symptoms of both heat and cold at the same time. For example, a person may feel hot in the head and cold in their feet. They may walk slowly but talk fast.

Excess and deficiency, like cold and heat, are qualities at ends of a continuum or scale that can also exist simultaneously in a single client. The thickness of the tongue coating is one of the most important symptoms that differentiate excess from deficiency.

Excess pattern includes:

  • Uses energy forcefully.
  • Breathing is heavy.
  • Touch and pressure aggravate pain.
  • Movements are forceful and speech is loud.
  • Person is outgoing and may be aggressive.
  • Strong pulse.
  • Thick tongue coat.

Deficiency pattern includes:

  • Person is fatigued and perspires easily.
  • Person's breathing is shallow and they may be short of breath.
  • Pressure and touch relieve pain.
  • Movement is weak and speech is quiet.
  • Person is often passive.
  • Weak pulse.
  • Thin tongue coat.

The terms “exterior” and “interior” refer to the relative depth or superficiality of an illness in relation to the entirety of the symptom-sign pattern rather than to the physical expression in the body. Interior, for example, is not a literal term referring to the center of the anatomy, and exterior does not exactly refer to the skin.30

Exterior pattern includes:

  • Sudden onset of acute illness; chills and a low fever.
  • Sinus congestion and discharge.
  • Dull pain in the head and muscles.
  • Pulse is floating (a specific profile in which the pulse is felt more strongly at the surface of the skin and diminishes with increasing pressure).
  • Tongue typically has a normal tongue coating and tissue.

Interior pattern includes:

  • Chronic illness; acute illness that has become more severe.
  • Sensations of excessive cold or heat; high fever.
  • Abnormal changes in breathing not related to exercise.
  • Abnormal urination and bowel symptoms.
  • Pain in the trunk of the body.
  • Changes in speech and behavior.
  • Abnormal pulse.
  • Any abnormality in tongue tissue or coating.

The final 2 principal patterns called “yin” and “yang” are observed in a different way. Yin and yang are central concepts to Taoist philosophy; but they are relative concepts that are explained in relationship rather than as absolutes. In Taoism, yin is “associated with ideas of the female as darkness, death, and dissolution” and that which “returns” while yang is associated with that which is “male, bright, creational, outpouring and moves outward.”9(pxxii) In TCM, the term yin is used more generally when referring to the ability of the body to calm and cool itself. Yang is used in when referring to the ability of the body to heat and energize itself.

Integrative assessment of the energetic qualities of the EPP can lead to insights, particularly in relationship to blockages of energy flow that lead to a person's discomforts and health challenges. Integrative insight, the result of reflective practice, is evidence for having moved beyond simple data collection to an assessment of the subtle relationships between the EPP unique to any given person, family, or community. Integrative insight is that outcome of the assessment, organization, and consideration of the patterns that emerge in the consciousness of the nurse who experiences 2 or more patterns in a single client that may seem initially to be in opposition.30

This individualized TINA approach used with those with chronic disease, such as older adults, is an alternative to standardized system-based or head-to-toe assessment. TCM energy flow-based whole system clinical assessment and pattern recognition process represents “biological individuality rather than a standardized nosology. In clinical science, systems of correspondence, that is, whole system models are used as a foundation for practice.”35(p54) Nursing science and TCM are complementary in that the emphasis on pattern recognition provides the structure for integrative care that is oriented to the care and comfort of the person, family, or community as a whole.

The burden of suffering that nurses often witness in their patients during an assessment can be immense. As is clear from Taoist philosophy and written in Hall and Allan's work,1 people do not exist in isolation. Their symptom-sign patterns are a result of their relationship with those people, plants, animals, and objects within an environment. When first starting EPP work, it helps to review the details of all 8 patterns when seeking to identify and synthesize a client's unique symptom-sign pattern. Over time, nurses become more adept at synthesizing multiple and sometimes seemingly contradictory patterns despite the fact that they are often a challenge because the client's ability to communicate their experience is hampered by the physical, mental, emotional, and spiritual burdens that they might be facing. People seek help because their coping skills no longer serve them, as they try to adapt to the stressors that challenge them. Therefore, clearing the picture of the initial presenting burdens through the threefold focus so that the deeper constitutional pattern can be recognized is one best practice that may ultimately save time, effort, and cost. The EPP is a time-tested theory for organizing observations, identifying, and naming patterns common to human health and illness. Clear energetic pattern recognition leads to care and coaching with person-centered lifestyle, diet, and herb choices.

CASE STUDY

A client with a medical diagnosis of uterine fibroids has persistent pelvic pain made worse with palpation (excess-interior). Her tongue coating is thick in the back of the tongue, suggesting excess, specifically “dampness,” in her lower abdomen or “burner.” The purple hue of her tongue tissue and menstrual history suggested “blood stagnation” also in the lower burner, which results in accumulated dampness. She also lives in the southern part of the United States and has sought care during a humid (damp) time of the year. When asked about her diet, she mentioned that she “eats a sweet potato every day.” The young woman is a very healthy, active, and health-conscious person. Sweet potatoes would not seem to many in the biomedical field to be a risky food. But from an EPP symptom-sign pattern perspective, the food was a concern for this woman. Sweet potatoes are classified as neutral to warming, tonifying (building), sweet, and moistening or damp. Part of the pattern diagnosis for this client is “blood and dampness stagnation” in the “lower burner” potentially aggravated by daily ingestion of sweet potato. The potato had not “caused” the dampness, but it was a part of her daily lifestyle that was supporting and aggravating rather than moving and draining the dampness. The client was taught about the energetic patterns and she decided to engage with her nurse in an experiment. She abstained from sweet potato for 1 week and monitored her pain levels using a pain scale. Her pain diminished exponentially within a few days. In this case, simple self-care, clearing the picture by abstaining from a food rather than adding an herbal intervention or formulation, pain medication, or medical treatment, was all that was necessary for creating greater balance in body, harmony in her pattern, and peace of mind24 that for this client manifest as relief of pelvic pain. After the clearing of the effects of the sweet potato, the client drank an herbal formula for a few weeks, after which she achieved pregnancy and delivered a healthy baby boy.

During the assessment and diagnosis phase, it is good to have clients experiment with herbs and foods that they know. The sweet potato abstention experiment says a lot about the nature of the client's pelvic pain. We learn that the pattern assessment was accurate and that the client's belief and understanding that plants/herbs would help her was a driving force in the supported self-care strategy. She responded to a simple diet change involving a plant food. She had solutions that were accessible, engaging, affordable, and cost-effective.

CONCLUSION

Integrating Western nursing science, such as the 4 modes of the Roy Adaptation Model, with Eastern EPP Taoist philosophy and approach is one way that nurses can place themselves in a position to perceive clients' patterns with greater precision. The threefold focus on clearing of the picture, followed by the EPP assessment, analysis, and interventions, provides a structure for holistic nursing care that is relationship-centered. The resulting relationship-centered care in which a nurse engages with the patterns of an individual, family, or group is a spiritual practice that promotes a client's exploration of meaning in their patterns, which can bring them greater balance in body and peace of mind.

Cultivation of a practice of integrating Eastern and Western thought as a framework for precision holistic care can be challenging at first. C.G. Jung writes simple advice about a Taoist approach to change that may be helpful for nurses reading this article who are considering whether they might try refocusing their practice to include the energetics of assessment in integrative nursing. Jung writes, “He who is not pleased by it does not have to use it, and he who is against it is not obliged to find it true. Let it go forth into the world for the benefit of those who discern its meaning.”25(pxxxix) There are some nurses and students, eager to engage in a path of integration, who will advance this labor of the heart toward the reconciliation of seeming opposites East and West in nursing practice. For those nurses and their clients, attention to ancient Taoist philosophy and specifically the EPP in the art and science of nursing practice put forth by the TINA may be a welcome change in consciousness and scientific structure. The process of using the TINA has the potential to lead to greater inclusion and precision in nursing practice and promotion of transformative, therapeutic healing relationships for nurses and clients.

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    Keywords:

    complementarity; herbal medicine; inclusion; integrative nursing; person-centered care; precision assessment; relationship-centered care; Roy Adaptation Model; Taoism; therapeutic relationships; traditional Chinese medicine

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