Florence Nightingale had been rumored to say, “The integration of body, mind and spirit brings a sense of wholeness or completeness within oneself” (Murphy & Walker, 2013, p. 149). Wholeness is an abstract concept that is multifaceted. To be a “whole person” means that all facets are integrated and balanced with one another, allowing a dynamic state at different levels. Each facet modifies the others to maintain a state of wholeness (Arnheim, 1996; Harris, 2008). Such integration has been identified as an essential attribute to holistic healthcare (Ziebarth, 2016). This means that in assisting an individual to achieve health, all facets of the individual are impacted either positively or negatively by the care received. In order to more positively impact every facet of a person's life, a model of nursing care based on a theory that focuses on wholeness is necessary. The Theory of Nursing for the Whole Person (TNWP) provides such a theory.
Dr. I. T. Tjelta (1993), founder of the Anna Vaughn College of Nursing (AVCON) at Oral Roberts University (ORU) in Tulsa, Oklahoma, stated in her classification of concepts for the TNWP that the goals of nursing service are to “assist individuals, families, and communities to promote, maintain, and restore health in the body, mind, and spirit” (p. 24). Tjelta explained that no matter the setting, there are always aspects of a person that can be maintained, promoted, or restored. When health and wholeness are the goals, the spectrum of needs that the patient has can be better understood and met. There is, however, exponentially more depth in the concept of wholeness than just the manifestation of health (Tjelta, 1993).
Dr. Tjelta (1993) always considered care based on the God of the Bible to be holistic. She defined an individual as a “spiritual being who functions in an integrated biopsychosocial manner to achieve his quest for wholeness” (Tjelta, 1993, p. 21). The difference between the TNWP and other holistic models or theories is largely found in this definition. In holistic models, spiritual matters are often combined with cultural and religious practices under the social aspect of the person (Kaslow et al., 2007). In the definition for an individual within the TNWP, the primary component is that the person is a spiritual being—one that is eternal and made to have communion with God (Tjelta). As spiritual beings, a person functions physically, mentally, and socially, with each aspect integrating with the spirit to determine the wholeness of an individual. When nurses understand this basic premise, it allows them to truly care for the whole person, addressing the body, mind, spirit, family, and community through the use of natural, biological, and social sciences, and appealing to the spirit of an individual through prayer and care (Tjelta).
As nurses provide whole person care, they typically begin with the physical–basic care, assessment, physical interventions, and therapeutic touch (Joseph, Laughon, & Bogue, 2011; Picco, Santoro, & Garrino, 2010). It doesn't take long, however, for nurses to realize that as they care for the patient physically, the need to connect with and care for the mental and spiritual aspects of the person arises. Additionally, the physical domain is affected by factors such as age and developmental stage as well as hereditary attributes and culture. All these factors can affect the experience a person has and the ability to maintain harmony and balance between the physical and other facets (Picco et al.; Ziebarth, 2016).
As nurses continue to interact with their patients, they realize that each patient has his or her own personality, thoughts, and feelings (Picco et al., 2010). The ability of persons to interpret the physical experiences they are going through and the others' ability to cope are central to caring for the mind (Kaslow et al., 2007). Nurses build relationships with patients as they care for them physically, offering empathy and compassion as they listen, inquire, counsel, and support to provide psychological care (Joseph et al., 2011; Ziebarth, 2016).
Finally, nurses attempt to address the spiritual aspects of a patient. The importance of spiritual care cannot be overstated. Unfortunately, many nurses identify spiritual care as simply offering prayer and pastoral services to their patients because they often equate spiritual care to religion (Boswell, Cannon, & Miller, 2013; Joseph et al., 2011). If, however, nurses perceive the spiritual aspect of a person to be wholly integrated with the physical and mental aspects, they will then understand that caring for the physical and mental also touches the spiritual. Likewise, to truly do whole person care, nurses provide active listening, utilizing therapeutic touch and open discussions about faith and beliefs, all necessary components of spiritual care (Boswell et al.). Also, realizing that nursing is a ministry and everyone is meant to care for others through the power of the Holy Spirit can impact the ability of a nurse to do whole person care (Tjelta, 1993).
A final aspect of whole person care is to realize that an individual belongs to a larger family group and community. The TNWP recognizes this and understands that the health of the individual impacts and is impacted by the health of the family unit and the community. Providing care to an individual can, therefore, affect the family, which can then affect the community (Tjelta, 1993). Likewise, providing care to a community can ultimately impact and affect the family that influences the individual. Care that impacts these aspects positively will assist in progressing each toward a state of wholeness. A brief overview of the TNWP can be reviewed in a previous issue of the Journal of Christian Nursing (Swanson, Thompson, Valentz, Doerner, & Jezek, 2019).
SIGNIFICANCE OF THE STUDY
The ORU AVCON has graduated over 1,300 students with a Bachelor of Science degree in Nursing since 1977. In addition, between 1981 and 1994, the college graduated over 50 students with a Master of Science degree in Nursing. This equates to over 1,400 nurses having been trained in the use and implementation of the TNWP. The current nursing workforce in the United States numbers over 2.9 million (Bureau of Labor Statistics, 2019) and the number of nurses specifically trained to do whole person care from a framework like the TNWP seems miniscule in comparison. However, graduates of the AVCON are trained to go where they are needed and provide whole person care, even if impacting one person at a time.
Fifty-seven percent of the United States population identifies with a personal God and 33% more identifies with some type of higher power, but recognizing an individual as a spiritual being and caring for every aspect of the person is lacking (Barna Group, 2016; Murphy & Walker, 2013). Nurses who have the insight of a whole person perspective can help to promote, maintain, and restore a patient's body, mind, and spirit (Tjelta, 1993). A whole person framework such as the TNWP is needed to assist in giving that perspective and providing care to every facet of any situation.
Due to the challenges nurses face when trying to deliver whole person care, it is important to examine the impact on nursing practice that a whole person framework has had. The purpose of this qualitative descriptive research study was to examine the practicalities, influences, and impact of the TNWP when nurses enter practice. The question this research sought to answer was How has the Theory of Nursing for the Whole Person impacted the practice of Oral Roberts University Anna Vaughn College of Nursing graduates?
To address the topic of the use of the TNWP in the practice of graduates from ORU AVCON, a qualitative descriptive research study was designed to explore graduates' perceptions. Three open-ended questions were asked of participants via a survey link. The questions were determined to be comprehensive enough to answer the overarching question of this research. With the open-ended design, participants were able to expound on their answers and provide rich descriptions.
There was a limited timeframe available for conducting data collection and incomplete contact information of graduates. As a result, 19 responses were received. Two responses were discarded for insufficient information, yielding a total sample of 17 respondents. Of the sample, 88.2% were female and 11.8% were male. Over half (58.8%) of the respondents graduated in the 2010s; 17.6% in the 2000s; 5.9% in the 1990s; 11.8% in the 1980s; and 5.9% in the 1970s. Of the respondents, 94.1% obtained a bachelor's degree and one person obtained both a bachelor's and a master's degree from ORU.
The procedures for this study were reviewed and approved by the Oral Roberts University Institutional Review Board. Consent was implied when participants voluntarily completed the survey. The participants were aware that providing their email was optional and served as consent for further contact regarding the study. Surveys were used only for this study and were kept secure on the principal researchers' password-protected computers.
Data were gathered during the month of October 2016. A cover letter along with the survey link was sent to AVCON graduates via email as well as being posted on the college Facebook page. The survey was left open for 2.5 weeks with a reminder sent and posted at the beginning of week 2. Respondents were informed that the data sought were qualitative and examples and in-depth descriptions were desired. The cover letter clearly stated that leaving an email address was optional and that the information was being kept confidential.
A thematic analysis was performed on the responses using the constant comparison method. The two principal researchers used standard and accepted qualitative methods for thematic analysis, first examining sets/responses independently and then together to ensure agreement and continuity of interpretation. Themes were coded by hand from each participant's responses. From each question posed, multiple themes emerged.
From the first question, “How have you utilized the TNWP in your practice?” the themes were seeing and caring for the bigger picture, development as a professional nurse, and having more compassion.
The bigger picture. AVCON participants who were taught based on the TNWP were able to see a bigger picture when looking at a patient's case. One respondent commented, “It [the TNWP] has made me see more than just a patient and their illness. It has caused me to assess the entire picture connected to this one manifestation in their life.” Participants noted this aspect of whole person care and commented on the importance of “addressing each need” and “treating the physical, spiritual, and mental aspects” during their time with patients. One participant commented:
Only looking at a patient's physical symptoms is never good enough in the healthcare setting. Rarely, if ever, does a patient only require physical care. Being sick affects a patient spiritually and mentally, as well as physically. All areas need to be addressed in order for a patient to truly recover.
This theme continued in responses as another claimed:
Through understanding that each patient is made up of more than just a physical diagnosis, but also mental and spiritual components, I focus on all 3 to fully understand my patient and how to best interact with and treat them.
It is clear that through understanding comes better patient care because there are fewer factors undisclosed to the primary caregiver: the nurse. All participants reported using the theory every day when looking at each aspect of their patients.
Development as a professional nurse. Development as a professional nurse and an increase in rapport with managers and patients developed when using the TNWP. One respondent commented, “I have used it to meet the expectations of my manager/unit, to go above people's expectations, and to love people wholeheartedly as I care for them throughout my shift.” When attempting to provide the best care possible as a professional nurse, one alumnus stated:
I have a reason to pursue excellence for their care, because what I am dealing with is far beyond the mere physical aspects that I see at work day after day. The TNWP shapes me into a better nurse, a better caregiver, a better advocate, and a better Jesus-follower.
Another participant indicated that it allowed her “...to provide excellent patient care and oversee programs that meet the needs for body, mind, and spirit.” As these graduates have started practice in their chosen field, the framework of the TNWP has continued to shape their professional development and in turn that of others.
Compassion. Compassion toward patients and their current circumstance is a necessary component of excellent care. Comments from alumni included, “...[it] has also helped me have a larger perspective for patients and families such as remaining compassionate in my care.” Through using the TNWP, graduates also commented on the ability to build “great patient connections.” When patients feel safe and trust their caregivers, greater strides can be made toward health and wholeness. As one participant reported, “I am continually recognized in my yearly evaluations that my compassion and empathy for my patients is one of my greatest strengths.” Nurses have a greater ability to give excellent, compassionate care when they operate under the TNWP.
From the second question, “Describe a/some time(s) in your practice when the TNWP was most effective,” themes emerged concerning difficult times, ability to get to the heart of what is really going on with a patient, and in times when patients feel like they have no hope.
During difficult times. During especially difficult times, patient and family emotions can run high. There are many situations that require delicate conversation and care. One AVCON graduate described:
It was especially effective when taking care of terminally ill patients that could die at any moment. It allowed me not to get caught up in the nursing task but to actually take time to pray for my patients as well as just simply talk to them.
Another respondent reflected on the effectiveness of TNWP by saying:
When dealing with families in crisis I use the theory [TNWP] to help with their crisis remembering that we are not only physical beings but spiritual beings as well. Families are searching for help as their children are passing and remembering the whole person [helps to provide] peace.
No matter if the difficult time revolves around a terminal illness, being separated from loved ones, or some other health crisis, the TNWP provides a framework from which to respond. As one alumnus reflected:
Christmas day many years ago...I had a patient who had no family and who was very lonely. I asked him to teach me to play chess that day and his smile during our time together was worth every minute I spent away from my own family....
As mentioned previously, patients who are struggling are searching for an opportunity to be cared for and understood. Nurses who are trained in the TNWP have the opportunity to meet that need and care beyond the basics of nursing tasks.
Finding the root cause. The TNWP was deemed most effective in being able to perceive the root of an issue with more clarity, resulting in a greater ability to treat the true need instead of simply masking symptoms. One alumnus stated:
Sometimes the disease a person feels has a non-biological root. Yes I can give you lorazepam to calm you down, slow your breathing, help with your sleep, but perhaps the root of the anxiety is the unknown related to the recent cancer diagnosis, the loss of control, the sense of hopelessness. I am a more effective nurse by addressing the root of an issue which allows for a more empowered position of treatment.
When describing a similar situation, another alumnus wrote:
Just recently I had a patient who came in for something relatively minor, but she had a very bad attitude and didn't want to participate in her care. After asking some questions we found out her dad had been given two weeks to live and she was severely depressed. Once we were able to identify the cause of her issue, we were able to address her mental and spiritual status, causing her physical one to improve much quicker.
If a nurse is able to see what is really going on, better patient outcomes will ensue. When patients feel safe enough to open up about other factors in their lives that are plaguing them, massive progress can be made. This is what Tjelta (1993) would call groundbreaking nursing care.
When patients have no hope. When patients have lost hope, it is very difficult to continue with treatment, regain preadmission autonomy, or carry on with daily living activities. One graduate reported combatting this loss of hope, saying, “. . . a family had lost hope, and the Lord guided me to encourage them of the hope of their future by explaining potential benefits of medical procedures, and by reminding them that God is constant and trustworthy.” Through the TNWP, this nurse was able to identify the realities of not only hope but of medical treatment.
When a patient has lost sight of the goal to get healthy, it is extremely hard to bring him/her out of a cycle of negativity and hopelessness without proper identification through mental and spiritual assessment.
By recognizing the many facets of a patient, the nurse can address loss of hope more promptly and therefore, act on the inherent need of a sick patient having hope to get better. One respondent shared a pertinent memory that addressed this:
He was frustrated and angry. His wife tried to help him calm down. I was at first hesitant to offer prayer since he was so angry... [finally] I told him I wish I could do more for him, but what I could offer was to pray. I prayed with the patient and his wife. The patient's demeanor shifted. He was more calm, less anxious and had tears in his eyes after prayer. The patient seemed to have renewed hope....
Caring for the whole person in every situation can bring hope to the hopeless and light into dark situations. The TNWP provides the framework needed to allow the nurse to walk alongside the individual, family, and/or community in order to foster that hope and bring a measure of peace as well.
Finally, when participants were asked to “Describe a/some time(s) in your practice when the TNWP was not effective,” 88% could not identify a time when this occurred. This is a profound testament to the effectiveness of the TNWP in the patient care setting. Other responses fell into the themes of when differing perceptions of death or belief are present and emergency situations.
Differing perception. Study participants reported an ineffective use of the TNWP involving differing perceptions of death and spiritual beliefs among patients, nurses, and chaplains. One alumnus explained, “I feel that death is a form of wholeness and a lot of people feel that it is actually defeat.” The respondent later described a difficult situation where this was evident:
We even had a chaplain come in and pray that ‘God's will be done, whether it is recovery or passing into heaven’ and the family got extremely upset and disrupted the prayer and told the chaplain to leave as they proceeded to speak only life and healing over the patient.
These are times when the theory can still be utilized, but caution must also be used to avoid offending a patient or family. The aspects of the theory that are incredibly beneficial such as viewing the patient as a spiritual being and providing care to every component of the person's body, mind, spirit, family, and community are still applicable.
Emergencies. During emergency or disaster situations, respondents commented that the theory might become secondary to lifesaving measures. An alumnus explained, “In emergency situations, there may not always be extra time to ponder the spiritual or mental components [of a patient].” Another respondent had a differing opinion to this and stated:
Working [the] pediatric ER with patients who are often arriving in critical condition . . . requires excellent assessment skills to be able to quickly identify issues and then begin implementing interventions. This requires being able to work with the patient and the family. On so many occasions, I have found myself . . . responding to the needs of the WHOLE patient and family... I have prayed with so many parents, hugged so many anxious moms, rocked babies, got hungry kids fed, helped educate families, and so much more because I could see beyond one limited perspective.
Even through emergency and crisis situations, a patient can still be viewed as a whole person with needs that extend beyond the physical and individual. An offer of prayer may be inappropriate for the time, but compassion and caring will never be.
The TNWP provides a solid framework from which to practice whole person nursing. The aspects mentioned above such as seeing and caring for the bigger picture, developing as a professional nurse, having more compassion, and providing hope are a few instances of utilizing the TNWP to implement excellent care.
Most individuals who seek care for a health issue have many details and life events other than their illness that contribute to their stress (Salamonsen, Kiil, Kristoffersen, Stub, & Berntsen, 2016). Addressing the needs of patients from a whole person perspective can positively impact outcomes (Jasemi, Valizadeh, Zamanzadeh, & Keogh, 2017). Nurses who can contribute to the reduction of stress and promotion of health in each of the areas that the TNWP addresses will continue to be paramount in healthcare.
Development as a professional nurse is enhanced by utilizing the TNWP. Alumni consistently responded that they integrate consideration of the whole person into their everyday nursing practice, augmenting excellence in patient-centered care, and creating effective working relationships. Professional commitment has been found to be a characteristic of nurses who practice whole person care (Jasemi et al., 2017). Wagner and Gregory (2015) detail the importance of commitment and compassion in a nursing staff saying that it is far more vital than aspects of the physical environment. When a nurse is able to have a strong professional commitment, the cycle of excellent care can be an ongoing example for all staff. Whole person nurses can contribute to a workplace that is productive, nonreactive, and overall builds rapport with patients and co-workers (Wagner & Gregory, 2015).
Nurses are constantly exposed to situations fraught with distress and are particularly vulnerable to developing compassion fatigue and stress related to their professional role unless they can effectively regulate how they empathize in such situations (Duarte, Pinto-Gouveia, & Cruz, 2016). Having compassion and fostering caring in every patient encounter is foundational in whole person care (Enzman Hines & Gaughan, 2017). Similarly, providing hope results in a better experience for the individual, family, and community. Hope was found to be one of the leading factors for persevering in instances where recovery from a health issue was long and hard (Lohne & Severinsson, 2006). Utilizing the TNWP on oneself can also promote health and wholeness for the nurse and is one of the tenets of the theory.
Continuing to implement the teaching of the TNWP can impact nursing education and practice. In general, if whole person care is taught to students and delivered at the bedside, patients will receive superior care and their outcomes may be positively impacted. By helping co-workers perceive the different aspects of the physical symptoms exhibited in a patient and continuing to explore mental, spiritual, familial, and community portions of such physical symptoms, TNWP nurses can impact the practice of nursing.
Study limitations included a small sample size (n=17) and lack of formal member checking of data. However, constant comparison of the data occurred both to information received from other participants and to the constructs of the theory providing triangulation of the data. Although questions were not validated, they were developed based on the theory constructs. Future research could include more formal qualitative methods and evaluation including member checks, peer debriefing, and journaling.
The TNWP is a tool that provides a framework for delivery of excellent, compassionate whole person care. The research question was answered by participants revealing that when nurses who have been exposed to this style of nursing utilize it to the greatest degree, patients have increased potential for improved outcomes in all facets of their being. Through thorough assessment and focusing on patients as innately spiritual, multifaceted beings, ORU AVCON graduates provide excellent care and rely on a theory that greatly impacts their practice for the better. Finally, nurses who base their practice on TNWP are striving to be whole persons themselves. As such, they can appropriately and positively impact their patients, families, and communities physically, mentally, and spiritually.
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