Healing environments and therapeutic relationships don't happen through checklists; they require visionary leadership and the courage to step onto a new path. Developing a holistic practice environment at a 451-bed full-service acute care metro area community hospital started with a desire to improve the nurse-patient relationship. Today, The Valley Hospital (TVH) in Ridgewood, N.J., is recognized as a national resource for holistic and integrative patient care. During our 2008 Magnet® redesignation site visit, our holistic program was recognized as an exemplar of nursing practice. In June 2015, our organization was presented the first Institutional Excellence in Holistic Nursing Practice Award by the American Holistic Nurses Association (AHNA).
This article outlines a 15-year journey that fundamentally changed the organizational culture at TVH. The nursing innovation described here created healing environments and sparked a culture change that significantly impacted the entire organization. The principles of holism, nurse resilience, presence, integrative therapies, and compassionate care contributed to the change. Education, continued innovation, and positive outcomes helped expand and sustain its success.
Assessing the landscape
The topic of nurse work environments has been covered in the literature extensively and is recognized as a critical factor in achieving high-quality patient outcomes and greater nurse job satisfaction.1-7 Therapeutic healing environments incorporate the best elements of nurse work environments while introducing therapeutic relationships and compassionate presence as key processes to improve and enrich the patient and provider experience.8 The roots of therapeutic healing environments lie in Nightingale's concept of ministering to the whole person—body, mind, and spirit—while being mindful of the environmental circumstances in which healing occurs.
The AHNA defines holistic nursing as “all nursing practice that has healing the whole person as its goal.”9 The nurse is viewed as a partner, advocate, and facilitator of the patient's healing experience, always cognizant of the patient's subjective experience regarding health, health beliefs, and values. The nursing leadership team at TVH recognized that for nurses to practice holistically, they need to be empowered to create healing practice environments for patients and families, as well as healthcare professionals.
In 2001, our nursing leadership team sought to reestablish the bond between nurses and patients and their families. The nursing workforce was highly efficient in technical skills but lacking in the interpersonal aspects of patient care. Unfortunately, completing tasks had taken priority over connecting with patients. Low patient satisfaction, high RN turnover, and feedback from frontline nurses indicated that the facility needed to return to the core of nursing.10 The organization partnered with nurse experts to implement The BirchTree Center for Healthcare Transformation (BTC) Model, a holistic framework for delivering patient care that reconnects nurses with the essence of their profession—caring.11
Collaborating for change
The BTC Model begins with the nurse adopting a self-care skill set and drives toward unfolding a holistic healing culture. (See Figure 1.) As the nurse integrates the framework, five areas of personal-professional transformation emerge: proficiency in articulating, practicing, and modeling self-care for others; redefining the nurse patient/family value proposition using compassion and presence as key components of patient and provider satisfaction; confidence in one's ability to deliver holistic person-centered care and create a therapeutic healing environment; awareness and ownership of one's contribution to the work environment; and strategic empowerment expertise (defined as the development of the skills, language, strategies, and measurements needed to demonstrate a significant shift in culture, circumstance, or environment) in personal and professional transformation.
A pilot program of a structured holistic curriculum, called the Integrative Healing Arts Academy (IHAA), was initially tested with 20 nurse participants and received excellent feedback. A second group of 36 nurses from two patient care units were trained on RN retention through developing healthy practice environments and improving nurse job satisfaction with a grant from the Robert Wood Johnson Foundation and New Jersey Health Initiatives. The curriculum focused on the principles of holistic health, nurse self-care, therapeutic presence, healing environments, integrative therapies, and person-centered care. On the two patient care units where a number of RN clinical nurses were trained (36% and 56% of staff members, respectively), positive improvements were found in RN turnover, patient satisfaction, and nursing morale.10
Cultivating an environmentof innovation
Encouraged by nursing feedback, a reduction in turnover rates, and dramatic improvements in patient satisfaction, nursing leadership could now expand on their gains by increasing the number of participating nurses. As more nurses completed the program, key metrics improved and nursing focused on creating an innovative environment that reflected the emerging culture change. Frontline nurses and unit managers designed and implemented quality improvement projects in their area of practice. (See Table 1.) Project results were presented to several internal and external audiences, and best practices identified and implemented across departments or the entire organization as appropriate.
Holistic nursing became a significant component of the care delivery model and was incorporated into the Magnet application process. In addition, nurse participants were required to sit for national board certification in holistic nursing. TVH has the largest number of national board-certified holistic nurses employed in one organization in the United States.
A core concept threaded throughout the curriculum is self-care and resiliency. Nurses are encouraged to view self-care as a part of the professional RN role and competency, and to model self-care behaviors for their colleagues. Nurses slowly began adopting self-care and self-renewal practices at the unit level. They articulated holistic nursing as being essential to their nursing practice model and standard of clinical excellence. Soon, other disciplines took notice of the changes happening in nursing, allowing for interprofessional collaboration. Physicians, physical therapists, and other providers began to participate in nurse-led education programs developed to encourage wellness and stress reduction. Attendees at these educational offerings included employees from every area in the organization, including executive leadership.
Holistic practice at TVH started as a leader-supported intervention, but it became a grassroots phenomenon that influenced the organization and changed its culture. As it grew, nurses became more comfortable with associating holistic practice and personal renewal with increased capacity for therapeutic presence and compassionate care, and the organization demonstrated the impact in continuously innovative ways.
In addition to the IHAA curriculum, the Center for Advancement of Integrative Healing opened in 2005 to support the holistic practice community. The center's mission is dedicated to the delivery of integrative care, advancement of holistic knowledge, and the cocreation of a healing environment. Activities include consultation, partnerships, education, mentorship, and building the holistic and integrative practitioner community. The center provides classes in holistic nursing practice, clinical aromatherapy, guided imagery, and energy modalities. To date, over 2,300 nurses and other professionals have completed the courses.
The integrative healing practitioner RN role was created in 2004. Due to the significant growth of the service and exploding demand for holistic education, a second practitioner was added in 2007. These holistic nurses have advanced training in multiple integrative modalities and provide holistic care to patients and families during their hospitalization. Additionally, these practitioners are responsible for providing holistic education and integrating holistic philosophy into the professional practice environment. They speak at community events and lead efforts to promote person-centered holistic care locally, regionally, and nationally. The practitioners also provide integrative services for colleagues, meeting on a one-to-one basis to offer support for achieving health and well-being. The integrative healing service receives approximately 1,000 annual consults from nurses, physicians, and other caregivers, as well as patient self-referrals. Feedback from patients and families has been extraordinarily affirming.
A second role, the integrative healing resource nurse, was developed in 2012 to recognize and promote clinical leadership in holistic practice at the unit level. Nurses qualify for this role upon completion of the holistic curriculum and are expected to contribute to the expansion of holistic practice within the organization. We currently have over 125 resource nurses.
The Integrative Healing Arts Council consists of 35 interprofessional members who meet monthly. The council is responsible for overseeing project and research initiatives, reviewing holistic practice standards and competencies, developing policies and procedures, directing the quarterly journal club, planning the spring and fall town hall-style meetings, planning and hosting the annual holistic nursing conference, and interacting with the education department to maintain the curriculum and contact hours.
Town hall meetings are held twice yearly to bring nurses and other interested providers together to network, learn, and stay inspired. The meetings, which typically consist of 50 to 60 attendees, offer an open forum to discuss new innovations, holistic practice updates, and special recognition of nurses exemplifying excellence in holistic practice. Guest speakers are frequently on the agenda, and nurses look forward to the meetings to renew their professional relationships.
Clinical care improvements
Every clinical practice setting has embraced the healing environments concept, often with exceptional results. In 2009, the Holistic Birth Program was created to empower women to make informed decisions regarding the many options open to them for their birth experience.12 The Holistic Birth Program coordinator, board-certified as a holistic nurse and nurse midwife, receives referrals from obstetricians, midwives, or patients, particularly if patients want a natural birth or limited interventions during birth. For women who participate in the program, the C-section rate for expected spontaneous, term, vaginal, primipara, or uncomplicated births is 14.2% compared with the hospital's internal 36% rate for women who aren't enrolled in the program. A unique aspect of the program allows women and their partners to meet with the program coordinator free of charge during their pregnancy, whether or not they decide to give birth in the hospital. In 2015, the Holistic Birth Program saw 437 patients.
Quiet Time was initiated to promote rest and reduce stimulation for hospitalized patients.13 During this 2-hour daily practice, lights are dimmed, voices are lowered, and patients and families are encouraged to rest and suspend use of electronics such as phones and TV. Interruptions are kept to a minimum and any unnecessary activity is avoided. Nurses also find Quiet Time to be a needed respite from the activity of the unit. Quiet Time occurs on seven inpatient units, including mother/baby and critical care. Most of the units schedule Quiet Time in the late afternoon.
Evidence-based practice and nursing research
Nurses are encouraged and supported to pursue research and incorporate evidence-based practice in holistic interventions. All nursing research with human subjects is reviewed by our Institutional Review Board. For example, the “M” technique is a specialized massage technique that's been found to increase relaxation and decrease agitation in hospitalized adults. It's used widely in the hospital by specially trained nurses. A nurse researcher interested in the “M” technique's effects in the neonatal population conducted a study on the neonatal ICU. Among other findings, the results indicated that mothers were eager to learn the technique for their babies, which strengthened the mother-baby bond and promoted skin-to-skin contact.14
Another study found that a nurse-facilitated drumming circle could produce a statistically significant decrease in adults' perceived anxiety scores.15 A drumming circle consists of a group of people seated in a circle experiencing the spontaneous creation of music with a variety of percussion instruments. Using the Spielberger State-Trait Anxiety Inventory for Adults on a convenience sample of 53 adults, the findings were consistent between male and female patients. The organization offers a monthly drumming circle that's open to the community.
Building the business case
The pilot program and the follow-up holistic curriculum helped us recognize that there was a compelling business case for implementing holistic practice in the organization. We've kept a close eye on RN turnover, patient satisfaction, and nurse satisfaction over time to assess if we were truly realizing a return on our investment. High RN turnover is costly and can significantly impact an organization's bottom line. Furthermore, the Centers for Medicare and Medicaid Services now rewards or penalizes hospitals based on certain quality metrics and patient satisfaction results.16 For an organization to achieve its mission, it must sustain a respectable financial margin and perform well across these areas.
According to a 2016 report from NSI Nursing Solutions, Inc., the average turnover cost for a bedside RN ranges from $37,700 to $58,400, and each percent change in RN turnover costs a hospital $373,200.17 TVH has avoided such costs by experiencing a much lower RN turnover rate than comparable hospitals. In 2016, the RN turnover rate stood at 7.6% in comparison with the national average of 17%. When compared with hospitals in the northeast region, where the turnover rate stands at 14.2%, the cost avoidance for TVH is between $2.1 million and $3.2 million when compared with hospitals with 350 to 500 beds on the national level.
Employing two full-time integrative healing practitioners and paying for staff to attend the IHAA classes amounts to approximately $380,000 per year. Based on turnover alone, this cost is easily covered. Of greater significance, however, is the return on investment in avoiding between $1.7 million and $2.8 million in turnover costs. Admittedly, other factors contribute to low turnover, but sustaining a therapeutic healing environment is a major one.
Other relevant factors that contribute to the business case for integrative practice are high patient satisfaction and good quality outcomes that avoid unnecessary costs related to issues such as hospital-acquired conditions, which increase length of stay and treatment costs. And, lastly, some of our innovative programs, such as the Holistic Birth Program, contribute to lower costs by decreasing our C-section rate.
Looking at our organizational outcomes, we consistently surpass the state and national Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) indices for the patient experience. (See Table 2.)
Our rewarding journey has created a therapeutic healing environment in which our nurses flourish and our patients and their families receive holistic-based care. There have been many lessons learned over the past 15 years, the most significant one being that holistic and integrative practice is within the scope of nursing and we shouldn't need to ask permission to initiate related practices. It's also important to measure outcomes and encourage research on modalities used as part of integrative practice. In particular, measuring outcomes to support the business case for this model of care is critical if the organization intends tosustain it.