holistic nursing care essay

What is Holistic Care in Nursing? (With Examples, Principles, & Challenges)

If you have been around nursing or healthcare for any time, you have probably heard the word “holistic” more than a time or two. You may be in nursing school and wondering, “What is holistic care in nursing?” Perhaps you are already a nurse who wants to know how to improve your approach to holistic care. Either way, this article is for you. As you read further, I will tell you about holistic care in nursing. You will learn what it is, why it is important, and find some examples of how to use holistic nursing care. Additionally, I will share some of the challenges you will face in holistic nursing and give you some tips on how to overcome them!

What Exactly Is Holistic Care In Nursing?

5 reasons why holistic care is important in nursing, reason #1: holistic nursing embraces the whole person, reason #2: holistic nursing promotes preventive care, reason #3: holistic nursing helps promote self-care, reason #4: holistic care in nursing embraces cultural diversity, reason #5: holistic nursing benefits nurses as well as patients, 5 core principles of holistic nursing, principle #1: holistic philosophy, theories, and ethics, principle #2: holistic caring process, principle #3: holistic communication, therapeutic healing environment, and cultural diversity, principle #4: holistic education and research, principle #5: self-reflection and self-care, what are some good examples of holistic care in nursing, example #1: wellness coaching, example #2: massage therapy, example #3: aromatherapy, example #4: hydrotherapy, example #5: guided imagery, example #6: teaching stress management techniques, example #7: make patient interactions personal, example #8: respecting a patient’s religious beliefs and promoting their right to religious freedom, example #9: providing nutrition advice, example #10: utilizing therapeutic communication, 4 main challenges nurses face in implementing holistic care and how to overcome them, challenge #1: lack of enough education about the holistic care approach, about the challenge:, how to overcome:, challenge #2: getting caregivers involved in patient care, challenge #3: polypharmacy and its effects on patient health, challenge #4: overcoming socioeconomic barriers, my final thoughts, list of sources used for this article.

Principles of Holistic Nursing Care Essay

Considering the term “nursing care” is a complex work that helps the patient to continue his life activity until full recovery. Daily measurement of the main indicators of human vital activity: body temperature, pressure, pulse rate, respiration (Duncan 26). Holistic nursing has been persistent in its scope and innovation in addressing the human experience of health care delivery. This care has offered alternatives that but also consider and value the integrity of human beings and improve patient outcomes (Cowling).

Studying the term “holism” and “holistic nursing” turned out that in the 1980s, scientists actively researched this topic and wrote many different articles with judgments and development of the concept. It has been agreed by various scientists over the years that holistic care has a clear bearing on taking care of the individual not only on a physical but also on a spiritual level (Micozzi 6). Holistic nursing is a practical medicine that focuses on the mind, body, and spirit of the individual in interaction with the environment. Holistic nursing has been recognized by the American Nurses Association (ANA) as a specialty of nursing with a defined scope of practice and standards. Thus, this method is as effective as traditional medicine, which combines physical, mental, and social factors that affect a person.

The task of holistic nursing care is to coordinate scientific and non-scientific methods of therapy for various forms and variants of the course of chronic diseases. The six steps of the holistic care process occur simultaneously, including evaluation, diagnosis, outcomes, therapeutic care plan, implementation, and evaluation. Holistic medicine practitioners believe that the whole person is made up of interconnected parts and if one part does not work properly, all other parts will be affected. This therapy focuses on mind, body and spirit working together and how spiritual awareness in nursing can help heal illness. Holistic medicine focuses on maintaining optimal well-being and prevention, not just treating disease. Thus, if people have an imbalance (physical, emotional, or spiritual) in their lives, it can negatively impact their overall health (Micozzi 8). A holistic nurse can use all forms of medical care, such as conventional medications or alternative therapies.

Among the most common methods of treatment of holistic medicine are acupuncture (impact on human organs and systems with the help of special needles through acupuncture points. Including a traditional Chinese method.); homeopathy (restoration of mobility of the spine and joints, relaxation of the surrounding muscle tissues); naturopathy (the use of various plants for medicinal purposes); reflexotherapy (an effect on the nerve endings on the foot for the purpose of treating diseased organs associated with them); diet; exercise; leeching therapy (treats leeches, or rather, its saliva, which contains more than a hundred bioactive drugs). It is worth noting that many of these methods have even received official status today.

In summary, holistic nursing care is an alternative therapy, this method will never replace traditional medicine. Treatment is about removing the cause of the disease, not just relieving the symptoms. The fact is that in this direction depends on the person himself. Holistic medicine has a wide range of effects on the human body as a complex system. However, this cannot be considered a panacea for all diseases. It is necessary to consider each specific case separately because the factors and causes of the disease are always different.

Works Cited

Cowling, Richard. ” Where Is Holistic Nursing?” Journal of Holistic Nursing , vol. 36, no. 1, 2018, pp. 4-5.

Duncan, Deborah. “Consultation Skills.” General Practice Nursing: Foundational Principles , edited by Deborah Duncan, M&K Update Ltd, 2019, pp. 26-34.

Micozzi, Marc S. Fundamentals of Complementary, Alternative, and Integrative Medicine , Elsevier Health Sciences, 2018.

Noreen Cavan, Frisch, and Rabinowitsch David. “What’s in Definition? Holistic Nursing, Integrative Health Care, and Integrative Nursing: Report of an Integrated Literature Review.” Journal of Holistic Nursing , vol. 37, no. 3, 2019, pp. 260–272.

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Nursing and Holistic Care

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It is important to take a holistic view and prioritize the patient’s needs, as a person is much more than the health problems they are facing.

Holistic care is a nursing approach that considers the whole person, assuming that biological, psychological, and social factors are interrelated. Nurses need to have a holistic view of patients to respond to their real patient or client needs and promote their recovery.

Task-oriented nursing care, which is aligned with the medical view on health and care, has long existed. However, this approach ignores the fact that a person is more than their health problems.

Professionals often work disease-specifically, which leads to insufficient care for patients with multiple (chronic) illnesses, a patient group that has a higher risk of negative effects on health, higher healthcare costs, and lower quality of life.

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Holistic nursing: Focusing on the whole person

Expand your knowledge of holistic nursing by reading the answers to commonly asked questions.

What is holistic nursing?

Holistic nursing is generally defined as all nursing practice that has healing the whole person as its goal. A holistic nurse is a licensed nurse who takes a “mind-body-spirit-emotion-environment” approach to the practice of traditional nursing. Holistic nursing is based on a philosophy of living and being that is grounded in caring, relationship, and interconnectedness. A holistic nurse recognizes and integrates the principles and modalities of holistic healing into daily life and clinical practice. Holistic nursing encourages nurses to integrate self-care, self-responsibility, spirituality, and reflection in their lives.

What is the history of holistic nursing?

Present-day holistic nursing is based on the work of Florence Nightingale. It was not until the mid-20th century that nursing began to emerge as a profession and became linked to developments in western medicine. Since 1970, many nurse scholars have described nursing as being concerned with the whole person. Dossey developed a theory of nursing that includes an integral worldview that builds upon a solid holistic, integrated, and multidimensional theoretical nursing foundation. Unlike previous theories of nursing, this theory serves to explain the function of the inner world of the nurse as a vital component of nursing practice.

These and other influences, such as research linking the mind and body and an emphasis on patient-centered care, have affected the development of holistic nursing. The American Holistic Nurses Association (AHNA) was founded in 1980 to serve as a voice for holistic nurses and to promote the education of nurses and others in the philosophy, practice, and research of holistic caring and healing. The American Holistic Nurses Certification Corporation (AHNCC) was founded in 1997 to credential holistic nurses. AHNCC has a collaborative relationship with AHNA to advance the role of holistic nursing and to provide educational opportunities in holistic nursing.

Is holistic nursing a specialty practice?

The American Nurses Association (ANA) officially recognized holistic nursing as a specialty area of nursing practice in 2006. Specialty status provides holistic nurses with a foundation for practice. It provides a clear depiction of who we are to the rest of the world of nursing, other healthcare professionals, and the public.

What are standards and scope of practice for holistic nursing practice?

The AHNA and the ANA co-published Holistic Nursing Scope & Standards of Practice . The standards are aligned with the definition, values, assumptions, and other standards of nursing as outlined by the ANA.

Standards of Practice reveals the unique intricacies of the specialty’s scope of practice, and describes the standards of practice and professional performance of holistic nursing. It defines holistic nursing, provides an overview and history of holistic nursing, and describes the following regarding holistic nursing: principles, core values, responsibilities, educational preparation (basic, advanced, and continuing education), certification, information about complementary/alternative modalities (CAM), and position statements.

Standards of Practice also shines a light on the philosophy, values, knowledge, and skills on which holistic care, health, and healing are based, and shows the relationship of CAM to the standards. Five core values integrate the art and science of nursing and capture the essence of holistic nursing:

• Holistic philosophy, theories, and ethics
• Holistic caring process
• Holistic communication, therapeutic environment, and cultural diversity
• Holistic education and research
• Holistic self-care.

Do the Standards apply to all nurses in all settings?

Unlike many other specialty areas, holistic nursing is practiced in all settings with individuals, families, communities, and populations throughout the lifespan. Holistic nursing is not specific to a particular patient/client group, disease, setting, or population. Holistic nurses practice in a myriad of roles.

No matter where holistic nursing is practiced, nurses must continually develop knowledge and skills in all aspects of their practice because holistic nursing is a way of thinking, reflecting, practicing, and of life. As a way of life personally and professionally, self-care becomes and is incorporated into one’s existence.

As with some other nursing specialty standards, Standards of Practice provides a blueprint for a nursing curriculum or continuing education programs, validates research and garners funds for research, enables recognition by state boards of nursing, describes to others what they can expect from holistic nurses, and assists the professional practice to better regulate itself.

How is holistic nursing moving into the forefront of health care?

Many developments in nursing and health care have contributed to bringing holistic nursing forward. Increasingly, hospitals and other healthcare settings are creating delivery models that include integrative health. Integrative health merges traditional western and CAM approaches with interventions to facilitate maximum curing and healing. In 2010, the Samueli Institute released Wellness Initiative for the Nation , which included a focus on integrative health care promotion and delivery. Holistic nursing has flourished within these integrative care systems.

Students are seeking programs that focus on holistic nursing and integrative health. In 2008, the revised The Essentials of Baccalaureate Education for Professional Nursing Practice , from the American Association of Colleges of Nursing, incorporated terminology that referred to “holistic, patient-centered care” and the expectation that nurses understand complementary and alternative modalities.

The Patient Protection and Affordable Health Care Act of 2010 defines how health care will be delivered for the foreseeable future. Patient-centered care will achieve considerable attention, and patients will become key players in determining which health care outcomes are valued. With an emphasis on effectiveness, coordination of services, and preventive care, a strong foundation in lifestyle change and holistic care strategies are required. In this new climate of healthcare delivery, nurse coaches who practice from a holistic framework are partnering with patients to achieve health and wellness goals.

What lies ahead for holistic nursing?

Holistic nursing will continue to evolve as nurses incorporate holistic principles and practices into their personal and professional lives, and as the needs of patients and society evolve. Yet, no matter the setting or the time, holistic nursing will retain its focus on healing the whole person—the very foundation of holistic nursing.

Nina A. Klebanoff is the retired RN to BSN program director and an assistant professor at the College of Nursing & Health Sciences in Northern New Mexico College, Espanola, New Mexico. Darlene Hess is self-employed and based in Los Ranchos, New Mexico.

Selected references

American Association of Colleges of Nursing. The Essentials of Baccalaureate Education for Professional Nursing Practice . Washington, DC: American Association of Colleges of Nursing; 2008.

American Holistic Nurses Association/American Nurses Association. Holistic Nursing: Scope and Standards of Practice . Silver Spring, MD: Nursesbooks.org; 2007.

Dossey BM. Nursing: integral, integrative, and holistic—local to global. In: Dossey BM, Keegan L, eds. Holistic Nursing: A Handbook for Practice . 6th ed. Sudbury, MA: Jones & Bartlett; 2013:3-57.

Dossey BM, Luck, S, Schaub BG, et al. Nurse coaching. In: Dossey BM, Keegan L, eds. Holistic Nursing: A Handbook for Practice . 6th ed. Sudbury, MA: Jones & Bartlett; 2013:189-204.

Hess D. Defining holistic nurse coaching. AHNA Beginnings . 2011;31(1):16-9.

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Holistic nursing is a practice of nursing that focuses on healing the whole person. This practice recognizes that a person is not simply his or her illness. Holistic healing addresses the interconnectedness of the mind, body, spirit, social/cultural, emotions, relationships, context, and environment. All of these aspects combine to create the person, so in order to heal the person, the holistic nurse looks at all aspects and how they can affect the patient’s health.

The field combines nursing knowledge, theory, intuition, and experience as a guide for building a relationship with the patient to increase healing and promote health. Holistic nurses often integrate alternative medicine and practices into their nursing care. These practices address the patient’s physical needs, as well as their psychological and spiritual needs. Holistic nursing doesn’t try to question the validity of traditional medicine practices. Instead, it tries to complement and broaden them to better help the patient during his or her recovery.

Nurses use their own experiences as a foundation for their care, integrating the patient’s experiences, as well as social, cultural, and spiritual values, to treat the whole person rather than just the illness. Holistic also acknowledges that relationships are everywhere, and humans can affect other humans. This concept is included in the nurse’s care plan , using self-care, self-responsibility, and reflection to help the patient get healthy.

Because holistic nurses focus on the interconnectedness of the patient with his or her world, it often leads the nurse to have a deeper understanding of that interconnectedness, as well as the nurse’s interconnectedness with his or her own world. The nurse can then use that understanding and awareness to better care for the patient. Due to the nature of holistic nursing, it is often considered way more than a nursing practice. It affects every aspect of the nurse, even outside his or her job, and becomes a philosophy and lifestyle.

A liberal arts or alternative medicine background is very beneficial to holistic nursing. Both give a well-rounded foundation of education and experience, which allows the nurse to expand his or her mind, increase critical thinking skills, and grow on a personal level.

Holistic Nursing Theories and Models

• King’s Theory of Goal Attainment
• Neuman’s Systems Model
• Rogers’ Theory of Unitary Human Beings
• Nightingale’s Environment Theory
• Hall’s Care, Cure and Core Theory
• Parse’s Human Becoming Theory
• Roy’s Adaptation Model of Nursing
• Johnson’s Behavior System Model
• Orem’s Self-Care Deficit Nursing Theory
• Erickson’s Modeling and Role Modeling Theory
• Newman’s Health as Expanding Consciousness Theory
• Watson’s Philosophy and Science of Caring
• Humanistic Model
• Helvie’s Energy Theory and Nursing 

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A Concept Analysis of Holistic Care by Hybrid Model

Madineh jasemi.

Department of Nursing, Faculty of Nursing and Midwifery, Urmia University of Medical Sciences, Urmia, Iran

Leila Valizadeh

1 Department of Nursing, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran

Vahid Zamanzadeh

Brian keogh.

2 Department of Nursing, Faculty of Nursing and Midwifery, Trinity College, Dublin, Ireland, UK

Even though holistic care has been widely discussed in the health care and professional nursing literature, there is no comprehensive definition of it. Therefore, the aim of this article is to present a concept analysis of holistic care which was developed using the hybrid model.

The hybrid model comprises three phases. In the theoretical phase, characteristics of holistic care were identified through a review of the literature from CINAHL, MEDLINE, PubMed, OVID, and Google Scholar databases. During the fieldwork phase, in-depth interviews were conducted with eight nurses who were purposely selected. Finally, following an analysis of the literature and the qualitative interviews, a theoretical description of the concept of holistic care was extracted.

Two main themes were extracted of analytical phase: “Holistic care for offering a comprehensive model for caring” and “holistic care for improving patients' and nurses' conditions.”

Conclusion:

By undertaking a conceptual analysis of holistic care, its meaning can be clarified which will encourage nursing educators to include holistic care in nursing syllabi, and consequently facilitate its provision in practice.

I NTRODUCTION

Holistic care is a complex concept which defies a precise definition.[ 1 ] Holistic care provides an in-depth understanding of patients and their various needs for care and has important consequences in health-care systems and has been referred to as the heart of the science of nursing.[ 2 ] Holistic care can contribute to patients' satisfaction with healthcare and help them to accept and assume self-responsibility.[ 3 ] It will also result in a better understanding of the effects of illnesses on patients' responses and their true needs.[ 4 ]

During an illness, complex psychological, social and cultural needs disturb a patient's balance,[ 3 ] and adversely affect his/her ability to carry out everyday activities.[ 5 ] Holistic care, by addressing patients' physical, emotional, social and spiritual needs, restores their balances and enables them to deal with their illnesses, consequently improving their lives.[ 6 ]

Florence Nightingale was the first nurse to emphasize the significance of holistic care.[ 7 ] The philosophy of holistic care is based on unity and a humanistic view of the patient.[ 6 ] A holistic paradigm has been present in the healthcare systems of many cultures,[ 3 ] and it can be used in every area of nursing care, such as medical-surgical nursing, mental health nursing, obstetric nursing, pediatric nursing, and public health nursing.[ 8 ] Patients of all races and religions have the right to receive holistic care;[ 2 ] nevertheless, few patients are provided with it.[ 9 ]

There is compelling evidence that most nurses who have been educated within a biomedical allopathic focus, are not familiar with the concept of holistic care – or at best, have a semi-scholarly understanding of it.[ 8 ] This often leads them to neglect holistic care[ 3 , 8 , 9 ] and to consider only one aspect of the patients' needs – the physical aspect.

Using only the medical model is not only insufficient to restore health but also exposes patients to serious threats, prolongs hospitalization and increases treatment costs.[ 9 ] In many countries, such as the United Kingdom,[ 9 ] Australia,[ 10 ] and Iran,[ 11 ] caring conditions are inappropriate. Many aspects of patients' needs are forgotten, and patients' dignity is often neglected.[ 12 ] The results of several studies show that many factors such as inadequate time, inappropriate professional relations, incomplete nursing reports, inadequate clinical supervision, unavailability of resources,[ 7 ] poor management, insufficient knowledge, motivational factors,[ 3 ] and nurses' misunderstanding of the concept of holistic care contribute to nurses' negligence of holistic care.[ 8 ]

Holistic care is a nebulous and subjective concept.[ 13 ] In general, it describes approaches and interventions that are meant to satisfy a patient's physical, mental, emotional, and spiritual needs.[ 14 ] However, this definition is not comprehensive, and research demonstrates that the concept of holistic care is frequently used by nurses in a variety of contexts without any clear knowledge of what is meant by it.[ 13 ] Thus, the meaning of the concept of holistic care often remains unclear and ambiguous[ 1 ] and usually incorrectly understood.[ 15 ] Most often, “holistic care” is viewed with disapproval and condemned as unspecialized, unscientific, wasteful, and time-consuming.[ 13 ] In general, the literature suggests that the meaning of “holistic care” remains ambiguous and any in-depth studies toward a definition of it are rare.

Having a concreate definition of holistic care enables nurses to identify therapeutic potentials when caring for patients[ 15 ] thereby increasing nurses' knowledge, helping to develop a framework for holistic nursing.[ 2 ] In addition, a comprehensive understanding of holistic care will facilitate professional autonomy[ 15 ] and enable them to consider patients' needs in a more systematic and scientific way.[ 8 , 16 ] Furthermore, a clear conceptual definition of holistic care will provide a concensus on its meaning therby facilitating its application in nursing practice, research, education, and theory development. Therefore, the aim of this study was to conduct a concept analysis of holistic care using an integrative approach facilitated by the hybrid approach.

Study design

To analyze the concept of holistic care, the researcher adopted the hybrid model from among the various available methods of concept analysis. Presented by Schwartz-Barcott and Kim in (1986), this model is a way to create, develop, and expand concepts, especially in nursing where it is widely used for disambiguation of concepts. Application of the hybrid model leads to purification of concepts, new and more comprehensive definitions, and at times the emergence of wholly different definitions from the previous ones. The hybrid model combines the inductive and deductive approaches and aims at identification of the essential aspects of a concept providing clarity based on the actual experiences of participants from observation and interviews.[ 17 ] This model consists of three stages of theory (literature review), fieldwork, and final analysis[ 18 ] [ Figure 1 ]. The theoretical phase begins with carefully selecting a concept and then examining the available literature related to the concept in other fields.[ 19 ]

Hybrid model of concept analysis of holistic care.

According to Schwartz-Barcott and Kim, the second phase, the fieldwork phase, is important for the confirmation and clarification of the concept. The fieldwork is a separate entity from the theoretical phase and facilitates the recognition of the dynamic and developmental nature of a concept.[ 17 ] This phase is often based on qualitative research and includes the selection of the environment and participants of the study and collection and analysis of data. The final phase, the analytical phase, consists of a conceptual analysis of the findings from the theoretical and fieldwork phases which identifies attributes of the concept further clarifying its meaning. Through this model, the concept is purified and new definitions, sometimes quite different from the initial ones, emerge.[ 20 ] In this study, the three phases of the hybrid model were applied for a conceptual analysis of holistic care as perceived and applied by Iranian nurses. The theoretical phase began with the selection of the concept of holistic care and a review of the literature. CINAHL, MEDLINE, PubMed, Science Direct, OVID, and Google Scholar databases were searched systematically. These databases are sufficiently large and are considered the most reliable databases for searching in the field of nursing. A search was conducted using the Mesh terms “holistic health,” “holistic therapies,” “holistic health,” “holistic medicine,” “holistic therapies,” “holistic nursing,” “holistic,” and their Farsi equivalents. Next, all the collected qualitative and quantitative studies which had been published up until 2013 which described aspects of holistic care for patients were reviewed. The searches were carried out independently by the first and third authors and verified by the second author. In total, 1061 articles were identified, 235 through PubMed, 126 through OVID, 327 from Science Direct, 108 through CINAHL, and 152 through Google Scholar. After irrelevant and duplicate papers had been eliminated, 127 abstracts were left, 78 of which were significantly related to “holistic care.” Forty-two of these were scanned for parts that included references to the concept of “holistic care” [ Table 1 ]. All the selected articles were read and re-read for essential elements that are required for definition and measurement of holistic care. The careful readings shed light on the different aspects of holistic care.

Selected articles for analysis from a comprehensive literature search

The fieldwork phase

The fieldwork phase includes development and validation of the results of the literature review through qualitative study.[ 17 ] In this phase, eight clinical nurses were interviewed to ascertain their understanding and perceptions of the concept under scrutiny to validate the findings of the previous studies and to see if new attributes emerge. In the hybrid model, the thoroughness of interviews is more important than the number of interviews and often 3–6 interviews are deemed sufficient.[ 9 ] To ensure the accuracy of data, the interviews were continued until data saturation, i.e., the data became repetitive.

As the concept of holistic care is poorly defined, it was difficult to approach nurses who were working in a holistic way. However, based on her experience of working in clinical environments and familiarity with nurses' manner of providing care, the researcher purposely selected participants who were experienced, who had an interest in the concept of holistic care, and who considered themselves to be working in a holistic manner.

The participants were selected from the various wards (Intensive Care Unit [ICU], emergencies, and general wards) of university hospitals in the cities of Tabriz and Uremia, Iran. One of the nurses was male, and the rest were female. They had all graduated with a bachelor's degree. Three of the participants belonged to the emergency and ICU wards in two busy urban hospitals in Uremia, the capital city of the province of West Azerbaijan; the rest of the participants was operating in the internal, surgery, and emergency wards of three busy urban hospitals all located in Tabriz, the capital city of the Province of East Azerbaijan.

In the beginning, the objectives were explained to each of the participants; if they consented to take part in the research, they were asked to sign a written consent and grant permission for the interviews to be audio recorded. To protect the privacy of the participants, numerical codes were used instead of their names and any identifying information was removed from the transcripts. The data were collected through semi-structured interviews with a focus on questions about the meaning of holistic care from Iranian nurses' viewpoint. Some of the main questions were:

“What does holistic care mean to you?” “What criteria should be considered to measure holistic care?” “In your opinion, what are the characteristics of a holistic nurse?” “What are the outcomes of holistic care?”

Each interview lasted between 45 and 60 min and was held over one or two sessions in the participant's working environment. We tried to hold the interviews in a private room in the wards where the nurses worked, which is the natural environment for the phenomenon in question. All the computer files and written reports were kept in a safe place and made available only to the researchers working on the project.

To increase the dependability of the findings of the study, data were transcribed by one of the researchers immediately after each interview. Field notes, such as information about the context or environment of the interviews were also collected. The Fieldwork phase lasted for 4 months, from May to August 2013.

The conventional qualitative content analysis was used to analyze the data. To obtain a comprehensive view of the collected data, the transcribed interviews were read closely several times, and the text of similar content was classified into sections. Significant statements were underlined as the units of analysis, and a code was assigned to each. The various codes were compared according to their similarities and differences to obtain categories. To validate the codes, categories, and relationships between the categories and major themes, the transcripts were read again, and the subthemes and themes were discussed among the researchers of the study. A team-based approach to analyzing the data was used to confirm the credibility of the study. Copies of the interview transcripts and the emergent categories were given to the participants for confirmation and all were in agreement with the researchers conclusions.

The final phase: The analytical phase

In this phase, the usages and attributes of the concept were identified by analyzing the data.[ 17 ] Here, to confirm, expand, and complete the definition of the concept, the codes, and categories obtained from the fieldwork phase were compared with the data obtained from the literature review in the theoretical phase, subsequently; the common characteristics of the concept of holistic care were identified and reported.

Ethical considerations

This study was approved by the Ethics Committee of Tabriz University of Medical Sciences. All the participants were informed of the aim of the study and a written consent was obtained from each of them. Participation in the study was entirely voluntary and the participants could withdraw at any stage of the study.

Review of literature: Theoretical phase

The review of literature from various databases revealed several different definitions and aspects of holistic care and its attributes. According to the findings, the concept of holistic care is used interchangeably in medicine and nursing and the concept of “patient-centered care” is considered to be the equivalent of holistic care. Viewpoints on the effects and consequences of holistic care were mixed [ Table 2 ].

Data collected in the theoretical phase

Characteristics and definition of holistic care in nursing

Review literature showed that holistic care is derived from the philosophies of humanism and holistic and it emphasize that the whole is greater than the sum of its parts such as person's mind and spirit affect.[ 6 , 7 ] Holistic care was described as behavior that recognizes a person as a whole and acknowledges the interdependence among their biological, social, psychological, and spiritual aspects.[ 21 ] Providers of holistic care consider a patient as a whole within her/his environment and believe that a patient is made up of body, mind, and spirit. Holistic care includes a wide range of approaches, including: Drugs, surgery, education, communication, self-care, and complementary treatment. Restoring power and responsibility to patients and encouraging them to exercise self-care is another aspect of holistic care which leads to therapeutic consultation, hope, dignity, self-esteem, self-sufficiency, self-regulation, personal growth, vigor, and vitality.[ 4 ] The relationship between a holistic-care provider and a patient is based on relative openness, equality, and mutuality. The need of health-care providers for care and support is treated as equally important as that of patients in this model of caring.[ 6 ] The Holistic Nurses Association confirms that in holistic nursing, health is believed to originate in a balance among a person's physical, spiritual, psychological, and social dimensions. The American Association of Holistic Nurses supports this stance and points out that holistic nursing includes all the nursing practices that heal the whole person and improve harmony among one's mind, body, emotions, and spirit in an ever-changing environment.[ 22 ]

Characteristics and definition of holistic care in medicine

Holistic care in medicine is often equated with complementary or alternative treatments, such as acupuncture, Ayurveda, and homeopathy.[ 1 , 23 , 24 , 25 ] In complementary therapies, intervention and traditional and alternative treatments are meant to generate emotional well-being, a healthier lifestyle, and more satisfaction in the longer term.[ 18 , 24 ]

Characteristics and definition of patient-centered care

Patient-centered care is based on respect and responsiveness; its focus is on the needs, values, instruction, physical comfort, and emotional support of the patients as well as communicating with the patients' friends and families. Patient-centered care providers have a biopsychosocial view and emphasize therapeutic alliance and patients' powers and responsibilities, and consider every patient as a unique individual. High-quality care, health restoration, and an increase in patients' satisfaction are believed to be the consequences of patient-centered care. This model of nursing is characterized by a holistic approach to providing care and a consideration of patients' bio-psychosocial and spiritual needs.[ 2 , 26 ] Some researchers, such as Bullington and Fagerberg equate patient-centered care with holistic nursing.

Consequences of holistic care

In some of the literature reviewed the term “holistic care” is interpreted negatively. It is described as an unspecialized, nontask oriented, and nonstatistical model of caring[ 13 ] that focuses too much on the psychological aspects of patients and leads to nurses' emotional exhaustion, and wastes their time.[ 13 ] Evoy, likewise, is critical of this type of care and regards it as unspecialized.[ 15 ] Such attitudes inevitably hinder the development of holistic care[ 1 ] and challenge nurses' adoption of it. In contrast, other researchers emphasize the positive outcomes of holistic care and acknowledge its contribution to the harmony, health and strength recovery, and personal development of patients, as well as nurses' personal and professional development and satisfaction with themselves and their jobs.[ 4 , 15 , 27 ]

Illustrating the concept of holistic care will facilitate its adoption by educators and make nurses all the more determined to apply it.[ 16 ] Based on the theoretical phase, the researchers in this study concluded that holistic care is a complex phenomenon and seems to be confused with patient-centered care; also, it is used interchangeably in medicine and nursing. Lack of a proper definition for the concept and equating it with traditional care or complementary care or seeing it as an alternative method results in a limited or incorrect understanding of holistic care and consequent unsatisfactory performance on the part of nurses.[ 1 , 6 ] The fieldwork phase was an attempt at clarifying the concept of holistic care and differentiating it from other forms of care.

Working definition of holistic care

Based on the review of the literature, a working definition of the concept of holistic care was constructed:

Holistic care in nursing is a philosophy that guides the care that patients' receive which emerged from the concepts of humanism and holism. It refers to the provision of care to patients that are based on a mutual understanding of their physical, psychological, emotional, and spiritual dimensions. In addition, holistic care emphasizes the partnership between nurse and patient and the negotiation of healthcare needs that lead to recovery. It, therefore, draws from the biological, psychological, sociological, and spiritual dimensions of health among others with a view to achieving harmony that transcends physical wellness.

The findings of the fieldwork phase

In the fieldwork phase, interviews were conducted to determine the essential aspects and consequences of holistic care and establish the characteristics of holistic nurses. The initial codes were closely analyzed and explored [ Table 3 ]. Finally, three main themes emerged: “holistic care as spiritual, social and clinical care,” “consequences of holistic care,” and “characteristics of a holistic nurse.”

Themes, subtheme and codes obtained in the fieldwork phase

Holistic care as spiritual, social, and clinical care

Based on the participants' responses, the main domains of holistic care were identified as spiritual, social, and clinical care. In other words, the three themes of clinical, spiritual, and social care constitute holistic care. Participant 1 said:

“I believe that holistic care is equivalent to spiritual and physical care and considering patients' social needs. So, I try to pay attention to these kinds of needs of my patients and resolve them” (Participant 1).

Another nurse explained:

“I strive to resolve the clinical needs of my patients and by sympathizing and giving emotional support to them provide holistic care” (Participant 2).

Another participant stated:

“I believe holistic care includes spiritual, social and physical care and if I want to provide holistic care, I should consider these aspects of my patients' needs and resolve them” (Participant 3).

The positive consequences of holistic care

The theme of positive consequences of holistic care is composed of two subthemes:

“Improving the treatment process”

“Nurses' feeling of personal development”

From the subtheme of “improving the treatment process of patients” such codes as “prevention of patients' depression,” “improved physical conditions,” and “decrease in the duration of hospitalization” emerged. One of the participants stated thus:

  “Addressing the various needs of patients improves their healing conditions and decreases the length of hospitalization” (Participant 5).

Another participant believed that the emotional aspect of patients affects their physical conditions:

  “Stress leads to gastritis and other physical problems in the patients and prolongs the recovery process” (Participant 7).

Participant 8 remarked:

  “Emotional support for a patient helps the patient to tolerate the disease better, cooperate with health-care providers more and recover faster” (Participant 8).

With respect to increases in the feeling of personal development in nurses, the participants mentioned that addressing patients' various needs makes them feel satisfied, able, useful and professionally fulfilled.

Participant 1 said:

  “When I satisfy the different needs of my patients I feel I'm being useful and helpful and that increases my motivation.”

And another participant claimed:

  “Meeting my patients' needs gives me power and makes me more interested in my profession and motivates me to provide better care and consider the various needs of my patients” (Participant 4).

Characteristics of holistic nurses

“Characteristics of holistic nurses” was the final theme and included three subthemes: Sociability, professional commitment, and religious and ethical beliefs.

Sociability was the quality that the nurses emphasized as being essential to providing holistic care:

  “By having a close and good relationship with my patients, I can recognize their needs and satisfy them” (Participant 2).

Participant 6 stated that:

  “Having a good communication with the patient is a characteristic of nurses who provide comprehensive care, and I have often seen this quality in them.”

Professional commitment was another quality that the participants focused on. One of the participants stated:

  “Professional commitment is the main factor that makes me try to respond to the various needs of my patients and provide better care” (Participant 3).

Participant 5 said:

  “Neglecting the patient's needs makes me feel guilty.”

Nurses' ethics help them overcome institutional and educational barriers to holistic care and positively encourage them to provide this kind of care. One of the participants pointed to the compatibility between the philosophy of holistic care and Islamic principles.

  “My religious beliefs help me overcome the problems caused by the authorities and my colleagues: Sometimes they accuse me of hypocrisy or just refuse to cooperate with me. Still, I focus all my attention on my patients because I believe God has chosen me to take care of them and I feel responsible for them. Because of my beliefs, I never neglect my patients' needs; I visit them frequently, take care of their needs, and respect them. My religiousness makes me understand my patients and their needs better” (Participant 6).

Another participant maintained that ethics can greatly enhance one's attentiveness to patients' various needs, hence holistic care:

  “One of the reasons why I always care about my patients' needs is my belief in behaving ethically. I believe ignoring the patients' needs is unethical; it makes me feel guilty to be indifferent to a patient's needs. A moral person cannot ignore the patients' needs” (Participant 1).

The final analysis phase

In the third stage, the data collected in the theory stage – they include “holistic care as more comprehensive than patient-centered care” and “the positive and negative aspects of holistic care” – and the results of the interviews with nurses in the fieldwork stage – they fall into the three major themes of “holistic care as spiritual, social and clinical care,” “the results of holistic care” and “the characteristics of holistic nurses” – were analyzed and compared and two major aspects of the concept of holistic care emerged: “Holistic care as a comprehensive model for providing care” and “holistic care's contribution to the conditions of nurses and patients.”

• In holistic care: All of a patient's needs are addressed, including emotional, educational, and physical needs; each patient is considered as a unique individual; respect is shown for patients' values; communication with patients is stressed; patients' comfort is a primary objective
• In holistic care, not only are patients' whole needs attended to, their culture and spiritual well-being are also taken into account.
• According to the participants and the literature as well, holistic care leads to prevention of patients' depression, improved physical conditions, decrease in the duration of hospitalization, and faster recovery
• Holistic care increases feelings of personal development in nurses: It makes nurses feel satisfied, able and useful, and consequently inclines nurses to stay in their profession.

D ISCUSSION

Using the hybrid approach to concept analysis, this study attempts to clarify the meaning of holistic care through a synthesis of the related literature and nurses first-hand accounts of their experiences of working in a holistic way. Accordingly, holistic care is defined as a comprehensive style of care in which patients' entire needs are addressed as a means of enabling full recovery. While traditional conceptualizations of holistic care focus on the person and their physical, psychological, social, and spiritual dimensions, in Iran the person's cultural context and their situation within the familial system have emerged as central components of the concept. A clear definition of holistic care is an essential prerequisite to ensure that a standard model of this kind of care is achieved in clinical practice. Nurses' attention to holistic care will enable them to consider their patients' whole needs and identify their various spiritual, cultural, physical, social, etc., needs. Likewise, McEvoy and Duffy stress the importance of nurses' familiarity with the concept of holistic care and how it can improve their understanding, make their performance more specialized, and enhance their ability to identify and subsequently satisfy patients' needs.[ 15 ]

Enhancement of nurses' knowledge of holistic care and its contribution to the quality of care is an important topic that needs to be addressed in the Iranian nursing system,[ 28 ] and in many other countries,[ 1 ] where the existing nursing practices are not satisfactory and the medical model is commonly applied in clinical environments. By identifying those needs of patients that are neglected by sole use of the medical model, recovery can be expedited and the period of hospitalization shortened, and the costs be reduced.

Since holistic care in an unfamiliar concept in the Iranian education system,[ 29 ] and in many other countries, attention is paid to the medical model and nurses are trained to be doctors' assistants,[ 1 ] it is necessary that the content of nursing courses be revised and nurses, trainers, and nursing students be educated on the concept of holistic. Strandberg et al .[ 1 ] and McEvoy and Duffy,[ 15 ] among others, have addressed this issue and considered it as an effective way to draw attention to holistic care. However, education in itself may do little to shift the traditional ways that nurses are working within, and a move toward a holistic approach to care may be thwarted by the prevailing illness orientated practices in clinical areas. Consequently, a philosophical shift is required that not just tells nurses about holistic care but encourages them to reflect on their roles within the multidisciplinary team and to reconceptualize their contributions to patient care beyond medical assistants.

In view of the fact that nursing is a team activity, it is important that, in addition to nurses, the other members of the health team be educated on holistic care. since many members of the health team are insufficiently familiar with holistic care and equate it with conventional and complementary medical practices,[ 4 , 15 ] interdisciplinary education is needed to enhance the various members' knowledge of holistic care and their tendency to apply it. Likewise, a reorientation to the role of nursing as a contemporary profession needs to be addressed and a model of partnership rather than subservience needs to be realized.

Although “holistic care” has been described as unspecialized, nontask-oriented, and time-consuming in some of the literature,[ 13 , 15 ] the results of this study show that it not only has positive consequences for patients and improves the treatment process but also boosts feelings of personal development in nurses. This is a confirmation of the results of other studies that emphasize the benefits of holistic care.[ 4 , 9 , 11 ] These findings stress the importance of understanding the concept of holistic care before it can be properly practiced, taught, and studied.

Recognition of the characteristics of holistic care forms the foundation for its provision and will facilitate it. The findings support the premise that good communicative skills and professional commitment are the main characteristics of holistic nurses. This finding is similar to the results of Salsali's work, and Thompson et al . study which shows that nursing is influenced by personal and professional factors and an open and reciprocal relationship with patients.[ 4 , 30 ] In this study, most nurses who provide holistic care tend to be religious and ethical. These features appear to play a key role in attending to patients' entire needs and in many cases help nurses overcome the barriers in the educational and medical systems. Belief in religious and ethical principles can directly influence a nurse's performance and attitude toward patients. it is a powerful motivational factor that encourages holistic care by creating intimacy, solidarity, commitment, and conscientiousness.[ 31 ] Studies show that nurses who believe in religious and ethical principles tend to be more responsible, intelligent, tolerant, and motivated.[ 32 ] McEvoy and Duffy stress the influential role of having religious and moral principles in nursing and regard it as essential to holistic care.[ 15 ]

This study, by providing a comprehensive definition of holistic care, draws care providers' attention to patients' various and complex needs, and by specifying the positive effects of holistic care on patients as well as care providers, the characteristics of holistic nurses and strategies to acquaint nurses and the other members of the health team with the concept of holistic care, encourages the adoption of this style of nursing.

C ONCLUSION

By applying the hybrid model and providing a clear definition of holistic care, nurses' knowledge of such care is increased, and it is more readily employed in research and theory development in nursing, as pointed out by Paley (1996). An explicit definition of holistic care will improve clinical performance and encourage nurses to provide this type of care, which will, in turn, improve the quality of nursing. In addition, providing a clear definition of holism in education can make teachers and students better acquainted with the concept, and train nurses according to the principles of holism. King, likewise, regards explication of the concept of holism in nurses' education as a way to facilitate holistic care provision.[ 8 ] Among the findings of the study is recognition of sociability, professional commitment, and religious and ethical principles as qualities shared by most nurses who provide holistic care; this insight points to the importance of teaching communicative skills, encouraging religiousness, and creating a sense of commitment in nurses and nursing students – which will lead to the development of holistic care.

Limitations of the study

This study was limited by a lack of access to the full-text copies of some of the required papers. Another limitation of this study was that although it draws on literature from other countries, the analysis does not consider possible similarities and differences between the cultures of the patients and nurses studied in the literature and the cultural backgrounds and viewpoints of the nurses interviewed in this study. Another limitation of the study is the fact that in the fieldwork stage, the environment is limited to Iran. Holistic care is a complicated concept and to provide a comprehensive definition of it, it needs to be studied from the perspectives of nurses from diverse cultures and contexts.

Financial support and sponsorship

This research was supported by Nursing and Midwifery, Tabriz university of Medical Sciences, Iran.

Conflicts of interest

There are no conflicts of interest.

Acknowledgments

This study is part of a larger study conducted for a doctoral dissertation that was approved by the Ethical committee and was supported with a research grant (number 350) for Ph.D. thesis from Nursing Research Team affiliated to Tabriz University of Medical Sciences, Iran. Appreciation goes to the research deputy of Tabriz University of Medical Sciences for financial assistance and all the participants who participated in the study.

R EFERENCES

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Assessing the patient's needs and planning effective care

Benjamin Ajibade

Senior Lecturer, Mental Health Nursing, Northumbria University

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Nurses have an essential role to play in the assessment and planning of patient care. This is emphasised in the Nursing and Midwifery Council's 2018Future Nurse proficiency standards. In this article, the author discusses the importance of person-centred care in assessing needs and highlights the need for all nursing interventions to be evidence based. The topics covered include assessing people's needs, care planning, stages of care planning, benefits of care planning, models of care, care pathways, and care clustering in mental health care. The article also highlights the significance of record-keeping.

The central role of nurses in assessing patient needs and planning care is one of the core areas emphasised in Future Nurse, the Nursing and Midwifery Council's (NMC) (2018a) nursing proficiency standards. The document categorises ‘assessing needs and planning care’ as the third of seven areas of proficiency, which are grouped into ‘platforms’. Future Nurse emphasises that the delivery of person-centred care and evidence-based nursing interventions are vital components for effective patient assessment and care planning. The standards further highlight that the nurse should understand the need to assess each patient's capacity to make their own decisions and to allow them the opportunity to give and withdraw consent.

An assessment is a form of a dialogue between client and practitioner, in which they discuss the needs of the former to promote their wellbeing and what they expect to happen in their daily life ( National Institute for Health and Care Excellence (NICE), 2021 ). Nursing assessment involves collecting data from the patient and analysing the information to identify the patient's needs, which are sometimes described as problems.

The process of planning care employs different strategies to resolve the needs identified as part of an assessment. Ideally, this will include the selection of appropriate evidence-based nursing interventions. When planning care, the patient's needs and wishes should be prioritised, and the individual must be involved in the decision-making process to ensure a person-centred approach. The planned care must take into account the patient's conditions, personal attributes and choices. It is worth noting that the principles of care planning are transferable between hospital, home and care home settings.

Section 2 of the NMC Code highlights the importance of partnership working with patients to ensure the delivery of effective high-quality care and of involving them in their care, which includes empowering patients by enabling them to make their own decisions ( NMC, 2018b ). The patient should be viewed holistically, with importance placed on the physical, psychological, social and spiritual aspects of the person's life, which are inextricable.

The intrinsic factors of a patient's condition will often affect their concordance with the advice and treatment offered. Consequently, it is important to understand the reasons for non-concordance and to tailor treatments/recommendations to each individual, which will improve the quality of care delivered.

Brooker (2007) developed the acronym VIPS to address some of the confusion surrounding what should or should not be perceived as person-centred care. VIPS stresses the following:

• V is a value base that affirms the value of each human being, irrespective of age and cognitive ability. This is the foundation for individualised care
• I is individualised care that considers the individual's distinctiveness and holistic needs
• P is about seeing the world from the patient's perspective, to ensure that the health professional takes the patient's point of view into account when providing care
• S is about maintaining a social environment that supports the patient's psychological needs, including their mental, emotional and spiritual needs.

Health professionals should endeavour to involve the patient in decision-making and enable them to make choices as much as possible, using a range of approaches to achieve this ( Lloyd, 2010 ). Unless proven otherwise, a nurse must assume that a patient has the capacity to make their own decisions, in line with the Mental Capacity Act 2005.

The following draws on the author's experience in mental health nursing but can be applied to other areas of nursing care.

Care planning

Planning care is essential in the delivery of appropriate nursing care. Following assessment of a patient's needs, the next stage is to ‘plan care’ to address the actual and potential problems that have been identified. This helps to prioritise the client's needs and assists in setting person-centred goals. Planned care will change as a patient's needs change and as the nurse and/or other health professionals identify new needs. Care planning assists professionals to communicate information about the patient's care to others ( Department of Health (DH), 2013a ; NICE, 2021 ), to facilitate continuity of care. Communication may be predominantly verbal, but it will also always involve documentation in a variety of formats, including computer-based, handwritten or preprinted care plans.

It is essential for nurses to consider their consultation style when developing a care plan in order to reduce the risk of paternalism when communicating with the patient and discussing their needs. Collaborative consultation encourages patients to participate in their care and improves rapport, while a paternalistic approach will generally minimise an individual's part in, and responsibility for, their own care needs and may compromise care outcomes and concordance ( Leach, 2010 ). A collaborative/partnership consultation style facilitates a person-centred approach by the practitioners and involves the patient in their care. Such an approach can include asking questions such as: ‘We have different types of treatment approaches that could be considered, what are your preferences?’ This is in contrast to a paternalistic consultation style with the health professional announcing any decisions with a statement such as: ‘I am going to prescribe a certain treatment for you.’

When drawing up a care plan with a patient the nurse should take into account a number of considerations ( Box 1 ).

Box 1.Nursing considerations

• The patient should know the reason for the assessment
• The assessment should be flexible and adaptable to the needs of the individual
• The patient must be fully involved and their dignity, independence, and interests should be paramount
• The patient can have someone with them, if preferred
• Appropriate language and terminologies should be used throughout the consultation
• The diversity of the individual client, their beliefs, values, culture and their circumstances must be considered
• It is essential to consider the patient's gender, sexuality, ethnicity, disability and religion as part of the assessment
• Be open to listening to the patient's personal history and life story
• The entire family's needs should be considered, inclusive of the patient and their carers: remember the importance of providing holistic care
• Cost-effectiveness should also be taken into account

Sources: Department of Health, 2011; National Institute for Health and Care Excellence, 2021

Stages of care planning

Care planning has been described as the third stage of the nursing process ( NMC, 2018a ; Toney-Butler and Thayer, 2021 ). It includes assessing the patient's needs, identifying the problem(s), setting goals, developing evidence-based interventions and evaluating outcomes ( Matthews, 2010 ). This will require the health professional to apply high-level critical thinking, decision-making and problem-solving skills. It is important to note that a care plan can be prescriptive: it is devised after a patient has been assessed through the prescription of nursing actions ( Hogston and Simpson, 2002 ) or through collaborative working involving the multidisciplinary team.

In some situations there will be differences between what the nurse sees as a priority in terms of the patient's needs and what the patient wants. An example of this would be a patient with mental health problems who may be at high risk of self-harm, who may need to be put on intermittent 15-minute observation. In such cases, a patient would be deemed as not having capacity to make decisions and the nurse will need to use their clinical judgement to prescribe the best treatment option. The care plan can still be agreed in conjunction with the patient once the nurse has explained the reasons for the interventions and acknowledged in the care plan that this is not the patient's preferred choice.

In situations where the patient has capacity to make decisions, the care plan should be agreed in collaboration with the service user ( NHS England, 2016a ).

Identifying needs

As part of the care planning process, the nurse will identify a patient's needs/problems and propose a set of interventions to address them in order of priority, ensuring that everything is in agreement with the patient. To ensure that appropriate goals are set, a patient's needs will be classified as high, intermediate and low.

Each goal provides an indication as to the expected outcome, along with the proposed interventions required to meet the patient's problems/needs, all of which must be patient centred. It is important, in collaboration with the patient, to set both short-term, achievable goals and longer-term goals that may take days, weeks or months to accomplish. One way nurses can ensure this is to apply the SMART goal-setting approach to ensure that the goals are ( Revello and Fields, 2015 ; NurseChoice, 2018 ):

• M easurable
• A chievable
• T imely (within a defined time frame).

Interventions

Interventions are nursing actions/procedures or treatments built on clinical judgement and knowledge, performed to meet the needs of patients. The actions should be evidence based and indicate who will carry them out, when and how often ( Hogston and Simpson, 2002 ). The scheduled interventions will have been agreed with the patient with the aim of improving their health condition, and each subsequent action should strive to meet the goals set at the previous stage. Brooks (2019) outlined three types of intervention:

• Those independently initiated by nurses
• Those that are dependent on a physician or other health professionals
• Those that are interdependent, that is, those rely on the experience, skills and knowledge of multiple professionals.

Independent nursing interventions are planned and actioned by nurses autonomously ( NMC, 2018a ), and these actions do not require the nurse to have direction from another health professional. When actioning interventions dependent on other health professionals, the nurses must determine the appropriateness of any directions from other health professionals before carrying them out because the nurse remains accountable for the actions, for example, the administration of prescribed medication ( NMC, 2018a ). Due to developments in the nursing profession, some advanced nurse practitioners can now prescribe interventions, eg prescription of medication can be done by nurse independent prescribers or nurse supplementary prescribers ( Royal College of Nursing, 2014 ). Interdependent interventions are usually recorded in collaborative care plans reviewed in multidisciplinary (MDT) meetings and must be agreed by all parties involved. Both the goals and interventions must be communicated in a timely manner to all those involved in the patient's care.

This is the stage when a planned intervention is evaluated to assess whether or not it has been achieved. This can be an ongoing process, and the care plan should document the frequency and time frame for evaluating the intervention. If the initial goal becomes unachievable, the nurse will be required to reassess the patient's needs, and review and revise the interventions.

Benefits of care planning

The DH (2011) highlighted that the aim of care planning is to improve the quality of care and outcomes by respecting individual wishes and enabling patients to acknowledge the ownership of their condition and ensuring they have the ability to influence the outcomes. Health professionals should engage individuals in decision-making and facilitate them to take control of their health by agreeing common goals to improve outcomes. This will have additional benefits for both the patient and health services as it should reduce the number of GP appointments and emergency admissions the patient may require. Promoting self-management of long-term conditions can also help slow progression of illness.

Care planning empowers patients to care for themselves when they are self-managing their health and when they may have difficulty accessing a health professional. This became evident during the pandemic, with patients often having to go for extended periods between appointments with their health professionals. Care planning has really come into its own in community care in the past few years, which became evident during the pandemic—particularly in the field of mental health—because it leads to better patient concordance with treatment and other care needs without the need for constant input by health professionals. This benefits both health professionals and the NHS: it increases job satisfaction, brings efficiency savings and improves the quality of patient care ( DH, 2011 ).

Model of care

Models of care are used to deliver best practice in health care. An integrated services care model is multifaceted and enables the co-ordination of care by different health and social care professionals to meet individual patient needs. It encompasses patient-centred care and enables care staff across different providers to reduce duplication, confusion, delay and gaps in services ( Monitor, 2015 ). In the modern NHS, this is the preferred model of care.

The care plan is an integral part of this model because it enables the creation of shared care plans that map different care processes. It becomes a point of reference for various providers involved in the care of the patients, ensuring the co-ordination of care across services ( Curry and Ham, 2010 ; World Health Organization, 2016 ).

Care pathways

Care pathways, which are also known as critical pathways, clinical pathways, integrated care pathways, care paths and care maps, are used to describe a specific patient journey that dictates the care to be provided or process to be followed for a patient's particular condition or needs. An evidence-based care process is established for specific conditions by considering expert opinion that takes into account the evidence to recommend interventions that have been shown to achieve better health outcomes cost-effectively ( Centre for Policy on Ageing, 2014 ).

Care pathways are often developed at local level and have been shown to be efficacious at meeting local needs. They are also known to improve cross-setting collaborations. Clinical pathways are aimed at providing effective health care appropriate for the patient group of conditions, thereby reducing hospital stays, leading to cost-effective health care ( Kozier et al, 2008 ).

Care clusters

Care clustering is a needs assessment tool that is used to rate a patient's care need against specific scales:

‘A cluster is a global description of a group of people with similar characteristics as identified from a holistic assessment and then rated using the Mental Health Clustering Tool (MHCT).’

NHS England, 2016b

This framework is used to plan and organise mental health services, including the care and support provided to individuals based on their illness and individual needs. One of the care clustering tools used in the NHS is the Health of the Nations Outcome Scales (HoNOS) ( Wing et al, 1998 ; Yeomans, 2014 ; NHS England, 2016b ).

Mental health services were brought under the scope of Payment by Results (PbR) in the NHS in 2012-2013.

‘Payment by Results (PbR) is the transparent rules-based payment system in England under which commissioners pay healthcare providers for each patient seen or treated, taking into account the complexity of the patient's healthcare needs.’

Consequently, as part of the care planning process, nurses need to take into account the cost-effectiveness of any interventions in order to consider how much funding is likely to be available for an initial completion of assessments, during scheduled reassessment and at any subsequent reassessment after a significant change in the patient's needs.

Box 2.Importance of complying with guidelines when undertaking assessment and planning care

• You must be compliant with the Nursing and Midwifery Council (2018b ; 2021 ) guidelines for record and record-keeping
• Adhere to the employing local organisation's policy on record-keeping, eg local trust policy
• Follow the NHS trust Care Programme Approach (CPA) policy ( Department of Health, 2008 )
• Collaborate with all those involved in a patient's care planning process

Importance of record-keeping

Accurate record-keeping is essential in the assessment of needs and planning care. This complies with the NMC (2018b) which states that record-keeping is fundamental to nursing practice, emphasising that records must be accurate and precise.

Health professionals should be aware of the need for legal accountability when documenting care in a written record because such records could be used in any legal proceedings ( Dimond, 2005 ). A record refers to not only a patient's record, but encompasses all records related to an individual nurse's range of practice. It is important to include the person being cared for in the record-keeping process, who should be asked to sign the plan of care, if they have capacity to do so ( NMC, 2021 ).

It is good practice to make an entry in the care documentation if a service user is unable to sign or agree to their planned care and state the reason for this ( Butterworth, 2012 ). In addition to paper-based records, care plans can be entered into the electronic health/patient record system used in the practitioner's service ( NHS website, 2019 ).

Best practice in writing care plans

There are some critical factors to consider when writing a focused person-centred care plan. One of these is to clearly document in detail the needs of the patient and to use the patient's language whenever possible, for example: ‘Mr D likes to dress smart every morning, but has been finding it difficult to make the choice of clothing to wear.’ An example of a poor way to record the same issue might be: ‘Mr D is unable to dress by himself’ and the aim is ‘Mr D will appear to dress smartly’.

The documented goal/aim of the care plan should be determined by applying the SMART acronym. It is therefore vital to ensure that the aim is specific by focusing on issues that can be measured, with goals that are achievable and realistic. It is also important to suggest and record a time frame within which a patient's short-term and long-term goals could be achieved. In relations to Mr D's clothing, a daily time frame might be appropriate. To come to an agreement over this issue, Mr D might be asked: ‘Mr D, would you like to be able to make your own choice of clothes to wear every day with the support of staff?’ The projected daily goal would then be recorded as part of the care plan documentation.

An intervention must specify how a goal/aim will be achieved, including who will be responsible for implementing each task. This could be the staff nurse on duty, team nurse, team leader, the nurse in charge and/or the patient (please put the patient's name). Evaluation should be carried out regularly and documented, and should conform with the proposed time frame outlined as part of the suggested intervention. Evaluations should be undertaken whenever actions are performed in accordance with each proposed intervention, and details of the progress of the patient's problem/needs documented.

In conclusion, the article has discussed the importance of assessing patients' needs, emphasising person-centred care using the VIPS acronym devised by Brooker (2007) . It has stressed the notion for all nursing interventions to be evidence based. The stages of care planning were discussed, and the application of the SMART goal-setting approach was highlighted. Record-keeping is an integral part of care planning in the communication of patient's care and progress. The benefits of care planning in improving quality of care and outcomes, respecting individual wishes, thereby empowering the patient was recognised.

LEARNING OUTCOMES

• Nurses must ensure that assessment of patient needs and care planning are always focused on the person
• All nursing interventions must be evidence based
• The goals set out in a patient's care plan must be achievable and measurable, and should include time frames within which both short- and long-term goals can be achieved
• Record-keeping is a vital component of care planning and is part of communicating aspects of a patient's care, and their progress towards their goals, with other health professionals involved in their care

CPD reflective questions

• In the context of a patient's health, what should you aim to do when care planning?
• Who should you involve in the care planning and why? Should the patient have a copy of the care plan?
• Is it acceptable to destroy care plans or other records?
• When should care plans be reviewed?

“The Doctor as a Humanist”: The Viewpoint of the Students

Conference Report and Reflection by Poposki Ognen (University Pompeu Fabra); Castillo Gualda Paula (University of Balearic Islands); Barbero Pablos Enrique (University Autonoma de Madrid); Pogosyan Mariam (Sechenov University); Yusupova Diana (Sechenov University); and Ahire Akash (Sechenov University)

The practice of Medicine as a profession has become very technical; doctors rely on fancy investigations, treatment algorithms and standardized guidelines in treating patients. In a lot of universities, medical students and residents are trained without appreciating the importance of art and the humanities in delivering good care to patients and their families. Factual knowledge is imposed on us, as students, from scientific evidence delivered by highly specialized professionals: those who know more and more about niche subjects.

As a result, when someone decides to become a doctor , it seems that scientific training is the sole priority, with most attention being given to the disease-treatment model. As medical students, we are taught very specific subjects, leaving little or no space or time for any cultural enrichment programs. And yet, Personal growth as a doctor and a human being cannot be achieved unless one is exposed to the whole range of human experience. Learning from art and artists can be one such means of gaining these enriching experiences. We can learn from historians, and from eminent painters, sculptors, and writers, as well as from great scientists. How do we achieve these ends? The following essay summarizes and reviews one attempt at providing answers. The 2nd “Doctor as a Humanist” Symposium took place at Sechenov University in Moscow from the 1 st to the 3 rd of April, 2019, to explore the holistic perspective of interpersonal treatment.

To begin our essay, we would like to clarify some key concepts, such as culture, humanism and humanities, as they were employed at the conference. Culture is a complex phenomenon that includes knowledge, beliefs, artistic production, morals, customs and skills acquired by being part of a society, which can be transmitted consciously or unconsciously, by individuals to others and through different generations.

The humanities are academic disciplines that study the cultural aspects and frailties of being human, and use methods that are primarily analytical, critical, or speculative, which distinguish them from the approaches of the natural sciences. Humanism is the practice of making the human story central. Consequently, the studies of humanities, so invested in human stories, is one aspect of practicing humanism.

Technological and practical progress in medicine has been impressive in the past fifty years. Nevertheless, patients still suffer from chronic conditions such as heart failure, chronic lung disease, depression, and many others. These are conditions where technology cannot significantly change the outcomes or reverse the underlying condition. One of the ways to alleviate suffering is through compassion and empathy where the doctor is a professional who listens to, understands and comforts the patient, as well as engaging the patient as a fellow human being. We need arts and humanities as doctors’ tools to comfort and, perhaps, even to heal. We also need them to remind us that we are ‘merely human’ ourselves, and that we share our humanity with our patients, as equals.

Unquestionably, there are fundamental requirements that every physician must internalize; the conference goal was to explain that one such requirement is the humanistic view. Opera, poetry, philosophy, history, the study of dialectics, biographical readings, and even volunteering abroad can be means of engaging the world for positive change. Sometimes called  “soft” skills, these are in fact necessary and valuable qualities to empower ourselves as persons, as well as doctors. The 2nd The Doctor as a Humanist Symposium placed the corner stone in a global project that aims to understand medicine as a multidisciplinary subject, and to establish the concept of humanistic medicine both as a science and an art where the patient and the doctor are human beings working together.

STUDENT PARTICIPATION

The event united experts in Medicine and the Humanities from all over the world. The speakers (doctors, nurses and students) were from Russia, the USA, the UK, Spain, Italy, Germany, Mexico and more. Each day’s program was both intense and diverse, and included plenary lectures and panel sessions. Medical students were highly involved in all parts of the conference, offering us a great chance to introduce our projects, share our opinions on various topics, and discuss our questions connected with the role of the humanities in medicine.We participated in roundtable discussions, which were chaired by experts from different countries. Even though this made us nervous, at the same time it was very important for us, as students, to be a part of it. We discussed the future of medical humanities from various perspectives, and above all our thoughts and ideas were listened to and commented on, on an equal basis with the world’s experts. For once, we could see that our views were being taken into consideration, and we hope that in the future this will be the norm and NOT the exception. We are the future of medicine, and our voices should be heard, too.

At the end of the first day there was a students’ session, where we gave our opinions on the relative importance of the medical humanities from a multicultural viewpoint, and on this particular roundtable there were students from Russia, Spain, Iran, Mexico, Italy, as well as a Nursing resident. One of the students during the session shared her view that “I would like to see medicine through the lens of humanism and empathy, and also implement all its principles in my professional life on a daily basis”. All participants agreed, and although we were representing different countries and cultures there was no disagreement about this. Even though we have not yet faced many of the obstacles of the world of medicine, we can see the role of compassion in clinical practice better perhaps than our seniors. We shared our points of view about this question and its relevance in the different countries. It was an incredible moment, as experts and professors demonstrated a great interest in our ideas.

The program was extremely diverse; however, the main idea that most speakers expressed was how to find, sustain and not lose humanist goals. Brandy Schillace gave an impressive presentation entitled “Medical Humanities today: a publisher’s perspective”, which studied the importance of writing and publishing not only clinical trials, but also papers from historians, literary scholars, sociologists, and patients with personal experiences. The nurses Pilar d’Agosto and Maria Arias made a presentation on the topic of the Nursing Perspective that is one of the main pillars of medical practice. Professor Jacek Mostwin (Johns Hopkins University) shared his thoughts on patients’ memoirs. An Italian student, Benedetta Ronchi presented the results of an interview on medical humanities posed to the participants and speakers during the symposium. The plurality of perspectives made this conference an enriching event and showed us how diverse ideas can help us become better doctors. More importantly, it reminded us of our common humanity.

A significant part of the symposium was dedicated to Medicine and Art. Prof Josep Baños and Irene Canbra Badii spoke about the portrayal of physicians in TV medical dramas during the last fifty years. The book “The role of the humanities in the teaching of medical students” was presented by these authors and then given to participants as gifts. Dr Ourania Varsou showed how Poetry can influence human senses through her own experience in communicating with patients. She believed that many of the opinions and knowledge that we have internalized should be unlearned in order to have a better understanding of the human mind. The stimulus of poetry makes this possible. Poetry allows us to find new ways to express ourselves, and thus increase our emotional intelligence and understanding of other people’s feelings.

One of the most impressive lectures was by Dr Joan.B Soriano, who spoke about “Doctors and Patients in Opera” and showed how the leading roles of physicians in opera have changed over the centuries. People used to consider the doctor as the antihero, but with time this view has transformed into a positive one that plays a huge role in history.

It is important to be professional in your medical career, but also to be passionate about the life surrounding you; for instance, Dr Soriano is also a professional baritone singer. For students, this Symposium was full of obvious and hidden messages, which gave us much lot of food for thought. As Edmund Pellegrino, the founding editor of the Journal of Medicine and Philosophy , said: “Medicine is the most humane of sciences, the most empiric of arts, and the most scientific of humanities.”

CHOOSING ONE WORD

To conclude our summary of the students’ viewpoint each of us chose One word to encapsulate our thoughts about the symposium.

The Doctor as a Humanist is a multicultural event where everyone can learn and contribute to this global necessity to put the heart and soul back into medicine. Of course, we are aware and delighted that other organizations are championing the cause of the Humanities in Medicine, and in some cases, such as https://www.dur.ac.uk/imh/ , they have been doing so for many years.

As medical students, we appreciate how we have been placed at the centre of the symposium, which we believe has made this new initiative rather special. We hope that students of Medicine and from other disciplines come and participate in future symposia.

If you want to learn more, and see how you can participate, please contact the International student representatives, Mariam ( [email protected] ) and David ( [email protected] ).

Acknowledgements

Assistance provided by Jonathan McFarland (c) and Joan B. Soriano (University Autonoma de Madrid) was greatly appreciated during the planning and the development of the article.

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Final Project

The nurse workforce has been growing substantially for the past two decades necessitated by the demand for quality care, an ever increasing population, increased complexity of illnesses as well as a new found passion by the current generation to seek career growth in nursing and healthcare. However, the role of education and nursing curriculum in facilitating the increasing number of nurses trained in various ways and for different roles cannot be assumed. The nursing curriculum has been redefined to accommodate many roles which traverse across direct care roles and indirect care roles (Lowe et al., 2012). On the other hand, authorities and stakeholders in the healthcare sector have significantly improved the work conditions for nurses and today nursing colleges can ably compete for the top cream of the society from an academic and scholarly perspective. Previously, the licensed Registered Nurse was regarded as the senior nursing role and qualification and even today, the number of licensed RNs remains high at close to 3 million and unrivalled for the time being (Lowe et al., 2012). However, as the healthcare sector sought to respond to the needs of the population and to allow nurses to practice and grow in their career to administrative and management roles, the advanced nursing practitioner (APN) roles were invented. The APN is basically a nurse who has completed the Masters Degree in Nursing. This implies that an APN has already acquired the qualifications of a RN. Today, the APNs form up to 8% of the nurse workforce and this percentage is continually increasing even as the opportunities for continued education have been expanded within the sector (Lowe et al., 2012). However, there is no risk as to whether the number of RNs could significantly decline going forward as nurses continually seek higher education and pursue APN roles. Since nursing colleges have indicated increased enrollment of students willing to take up the BSN roles and thus achieve RN status. The APN is however an umbrella description of the many roles that emanate from the completion of a MSN. These roles include Nurse Practitioners, nurse educator, nurse informaticist, and nurse administrator all which are generally described within the APN roles (Lowe et al., 2012). Nurse Practitioners (NPs): NPs are required to have a Masters in Nursing and a in future there is a requirement for Doctor of Nursing. Their typical duties include taking the health history of the patient, assessment, diagnosis as well as the treatment of chronic, acute and advance illnesses while acting as the primary care provider. The NPs are also allowed to initiate referrals and they can practice in a host of practice settings including private practice, ambulatory clinics, long term care and community clinics. The NPs can order, perform as well as interpret the diagnostic tests but in some cases, depending on the state they may be required to act under the supervision of the physician. NPs are required to register with the Board of Nursing within the state where they practice (Lowe et al., 2012). Nurse educator: The nurse educator is typically a registered with advanced education preferably n masters in nursing within any specialty or baccalaureate degree but with proven clinical training in some healthcare specialty and substantial experience. They could work in many settings ranging and they may hold various titles such as Administrative Nurse Faculty, Staff Development Officer, Clinical Nurse Educator or Continuing Education Specialist. Some of the major roles for nurse educators include developing courses and study programs, design and redesigning of curricula, evaluating the learning process, teaching learners, engagement in research and scholarly work, peer review functions, leading and organizing professional organizations as well as writing grant proposals for research among many other roles that link education, research and clinical practice (American Association of Colleges of Nursing, 2015). Nurse Informaticist: This role is concerned about the movement of data cross the healthcare facility as well as its maintenance for future use. Is encompasses the utilization of technology to promote good communication to the nurses, patients, consumers, healthcare providers as well as administration and management. It helps or promotes better decision making by enabling access to data and information. Some of the specific tasks for nurse informaticists include policy writing, systems optimization and maintenance, planning and choosing systems, providing support, education and training to system users as well as project management (American Association of Colleges of Nursing, 2015). The minimum requirement for nurse informaticists is the BSN degree and thus qualification a registered nurse. Specialization in some filed such as health informatics, quality management or healthcare management through a masters’ program is regarded a necessary qualification. Nurse informaticists are also required to achieve certification from the American Nurses Credentialing Center (ANCC) as well as the Health Information and Management Systems Society (HIMSS) (American Association of Colleges of Nursing, 2015). Nurse Administrator: A nurse administrator performs roles that do not offer any platform for direct interaction or contact with the patients and are confined to the office setting. Their typical daily duties could include developing work policies, administrating performance reviews, creating work schedules, setting up legal and ethical standards, employee training as well as attending and representing in administrative meetings. They could however work within different settings ranging from nursing homes, hospitals, home health care facility, and urgent care facilities or even within a private doctor’s facility. A nurse administrator’s minimum requirement includes a baccalaureate nursing degree that leads to the qualification as a RN. The standard requirement however is the Master’s in Nursing with a specialty in management and administration (American Association of Colleges of Nursing, 2015).

Selected Advanced Practice Role

The role of the Family Nurse Practitioner is essentially derived from the name; the FNP specialize as specialty or primary healthcare providers who serve under the supervision of the nurse. They work with the family across the care continuum. Rather than viewing each member of the family as the client, the FNP considers the family as the client and thus all actions; that is, diagnosis, examination, prescription and care planning are defined within the context of the family in one way or another. The FNP usually has a history with their patients that extend to the year or months depending on the time they have been in service. It is this feature that gives the FNP a significant influence in the patient’s care planning since they have substantial data and information in regard dot the patient and they use that information and data to educate the patients about their health problems and further develop tailored measures that fall within the social, economic and cultural needs of the patient. In Florida, the roles of the FNP and the scope of practice are defined within the roles and scope of the Advanced Registered Nurse Practitioners (ARNPs). The terms are set out by the Florida Board of Nursing which certifies and licenses all FNPs within the state. The Florida statutes describe the APRN as a registered nurse who has achieved post-basic specialized training and education and who has been approved and certified by the Board of Nursing to serve in roles that encompass advanced nursing actions (Florida Board of Nursing, 2007). The ARNPs once licensed by the Board can perform diagnosis and treatment for alterations in the health status of the patient while also being allowed to diagnose, treat, prescribe as well as operate. Unless states otherwise, the Board of Nursing in Florida requires that the APRN performs most of the roles under the supervision of a physician as long as they all fall within the defined scope of practice (Florida Board of Nursing, 2007). However, this supervision is defined in writing and depending on the general rule is that the physician can supervise APRNs in other stations beyond their primary station but not in more than four other different stations. This in essence implies that even as the supervision of the physician exists, the physical presence of the physician is not a necessity as long as there exists a system for consultation between the physician and the APRN. The State Board of Nursing defines that the patient has to be informed whether the physician will be present or absent and make a decision in that regard on whether they would wish the care process to continue in the absence of the physician (Florida Board of Nursing, 2007). While at this, the physicians who have a specialty are only allowed to supervise in not more than two stations including their primary care facility and these should be within a distance of 75 miles between them when supervising the APRNs (Florida Board of Nursing, 2007). Further, the Florida Board of Nursing bars APRNs from prescribing controlled substances and that includes even within the supervision of the physician, In that case, the state laws also set out that APRNs are not allowed to use any physician’s pre-signed prescription forms or in any way use the physician’s DEA number for purposes of prescription. These laws apply for all FNPs working within Florida and there are no exceptions for FNPs in adhering or subscribing to these regulations (Florida Board of Nursing, 2007). Professional organizations are a key component of any sector and within the nursing sector; professional nursing organizations play a key role in the development and progress of the sector. Apparently, these professional bodies have significant authority in matters of certification, licensing and accreditation since they work collaboratively with the Board of Nursing to ensure uniformity and fairness. Within Florida and in my role as a FNP I would consider two professional organizations; the Florida Association of Nurse Practitioners (FLANP) and the Florida Nurse Practitioner Network also referred to as the ENP Network. FLANP is a professional organization that brings together all NPs and ARNPs within the state of Florida to help network and connect members so that they can share valuable experiences as well as increase their voice. FLANP acts on one side as a resource organization that offers NPs within Florida an avenue for professional and educational development by promoting their participation in policy making, research, education and redesign of practice (FLANP, 2015). At a time when states have been accused of promoting legislation that limits the ability of NPs and ARNPs to function optimally as defined by heir certifications and educational preparation, the FLANP has become a major advocate and the voice of reason for nurses in the negotiation of policies that affect this group. The FLANP regularly organizes conferences and workshops for nurses as well as special training and education modules that are driven by health dynamics (FLANP, 2015). These courses and modules are usually certified and recognized by the Florida Board of Nursing and can be used at times as determinants of an individuals’ viability to continue in practice. In most cases such modules are expensive when accomplished individually and thus the organization helps eliminate such bureaucracies that may crop up in seeking such modules (FLANP, 2015). The ENP Network on the other hand is a professional organization that brings in willing NP professionals to enable them to remain up to date with all events that affect their practice as well as facilitate job searching among NPs. It works collaboratively with care facilities, state authorities and other key stakeholders seeking to work through measures that can increase the impact of NPs in the community. For NPs who are new in the market, it is a suitable body that affords one to easily seek jobs and choose from a variety of employees (ENP Network, 2016). As I prepare to get into practice, I have a personal philosophy that will guide me. In my personal philosophy I regard the patient as the epicenter of the care process and the nurse as the interface on which the patient can seek help. I thus consider that nurses have to work towards the betterment of the patient putting into consideration the very fact that patients operate in an environment that is dynamic and controlled by social, economical and cultural aspects. If at all nurses have to afford patients a recovery and restoration ability, the nursing process has to be worked out by a multidisciplinary team. This includes the patient, the nurse, the physician as well as all other members who can facilitate help handle the social, spiritual, cultural and psychological needs of the patient. I therefore look forward to working with nurses and professionals who are willing to work closely with the patient and afford them holistic care. In this perspective, I would look forward to a situation where I get to work in an environment where team work is regarded as a work culture and where communication, cooperation and collaboration are the elements that define that culture. In Florida I have a feeling that the workplace environments all offer such a platform and this would significantly help my personal and professional growth all which are the secondary outcomes I seek to achieve beyond positive patient outcomes as the primary outcomes.

Leadership Attributes of the Advanced Practice Role

The role of the FNP and more so that of the ANP revolves around increased focus on the patient. The fact that ANP requirements are based on specialization implies that the objective is to ensure that the patient is afforded quality care within the very detailed specifics of their health problems. The insistence on holistic and patient-centered care remains key elements even within the definition of the roles of the FNP/ANP to the patient. It is important to recognize that patient-centered care and holistic care are possible within an environment that promotes team work, collaboration and constant communication between the members of the care team. Thus, FNPs/ANPs in their leadership roles at the clinical level have to create an environment that promotes team work. FNP/ANPs are trained and prepared to work as problem solvers and in this case, the democratic leadership style would suitable work well for the FNP/ANP. In democratic leadership, the key feature is participation. Everyone is regarded an equal member of the team with something unique to offer and the decision-making process is based on consultation and negotiation as well as seeking a common ground that accommodates all views (Huber, 2013). While the decision making process is shared across the team, the leader retains all the responsibilities in regard to the decision that is made as well as how that decision impacts the outcomes. This implies that there exists a strong bond of trust between the leader and the team members and the leader entrusts the members to make appropriate decisions at all times (Huber, 2013). In this case, the members are fully aware of their job and the respective tasks they are expected to accomplish and thus the leader only presents the problem to the group and lets them work through it to the end. Another attribute that is associated with democratic leadership is communication and feedback. In resolving problems, the FNP/ANP engage in a multidisciplinary teams and the leader has to keep the flow of information at top notch so that there are no cases of inconsistent and members of the team are well are of the results and outcomes from each member. Simply, the feedback and communication across the group forms the foundations on which the solution is developed (Huber, 2013). The role of the leader is to ensure that communication and feedback is effective, consistent and reachable at all times. As an FNP/ANP I feel that I possess these attributes; effective communication, collaboration as well as ability to control and share feedback. However, this type of leadership style calls for patience as it involves dealing with several people even when solving smaller issues. Since each member knows that they have a role, such smaller problems could be complicated due to the high level negotiations that at time lead to conflict within the group. I would fail terribly in such cases where I have to manage such conflicts and seek fast solutions and this is a sure recipe for the disintegration of the groups and poor outcomes. However, I believe that patience at times develops as someone consistently works with people and learns their weaknesses and strengths. Once I identify these strengths and weaknesses I would actually be in a position to understand each person and thus plan my work in such a way that their strengths work to my advantage and the weaknesses do not manifest significantly (Huber, 2013).

Health Policy and the Advanced Practice Role

The costs of care have been on a dramatic rise and even with the Affordable Care Act seeking to increase access for care to all populations in spite of their financial capabilities, this dream is turning into a nightmare. The current healthcare is so open and empowers the healthcare providers and the insurance companies to take control of the costs trends even when there exists policies that limit the free market. One of the contentious issues that have led to the current state is the current fee-for-service system where the healthcare providers receive payments for each service they perform. This has meant that healthcare providers increase the volume of services even when they are not medically necessary so as to increase the quantity and volumes of total services and subsequently the reimbursements (Robert Wood Johnson Foundation, 2015). Apparently, this has happened due to the uncontrolled nature in which insurance companies operate where the level of accountability is minimal and with loopholes for colluding with healthcare providers for payment of services that were not even medically necessary. There is a need to change from the fee-for-service to the pay-per-performance (value-based purchasing) where the reimbursements are made for the complete package of services offered to the patient at each visit (Robert Wood Johnson Foundation, 2015). This would eliminate the cases of payment for services that are not medically necessary as it would help increase accountability and follow-up. In essence, there would be internal regulation by healthcare providers and eliminate the channels for healthcare providers and insurance companies colluding to receive payments for services that were actually not important. The change process especially because it touches on the pertinent issue of costs and finances will have to involve key stakeholders the healthcare sector as well as the state and federal authorities who are concerned with and law making. On one hand, the need to involve the professional nursing organizations such as the American Nurses Association and the regional professional nursing organizations such as the Florida Association of Nurse Practitioners (FLANP) would help bring into context the basic information and data that justifies the need for change. Nurses are the patient advocates and professional nursing organizations have an obligation to protect and represent the patient as their client. Further, the integration of nurse administrator and managers to help provide a financial and budgetary perspective on the issue would be necessary. Legislators within the state as well as legislators at the federal level have to be involved because ultimately there will be a need for an individual or group that will directly lobby for support of the intended policy change at the legislative level (Jha et al., 2012). However, it is important to recognize that individual nurses will play a key role in the process of policy change and as a nurse I know and recognize that my role is within advocacy. I would thus act as a change agent and I would be a teacher to other nurses to help them recognize the impact of this intended policy change to the patient and population in general as well as to the healthcare sector. The change in policy would mean that healthcare facilities are reimbursed for the each single complete package of care that they afford patients as opposed to where reimbursement is based on each independent service that is afforded. In this case, the commercialization of the patient a would be minimized and the nurses and the care team s would place more focus on quality outcomes as opposed to commercial benefits that they accrue from each patient (Jha et al., 2012). The direct care providers; that is nurses and physicians would be eliminated from the role of determining the financial gains of the organization since all reimbursements would be based on outcomes and not number and magnitude of services offered. There would be increased need for patient volumes with positive outcomes as this is essentially what would determine the volume of reimbursements. Care quality would increase and more importantly, care facilities would seek to optimize the available resources to serve higher patient volumes (Robert Wood Johnson Foundation, 2015).

American Association of Colleges of Nursing. (2015). Expanded Roles for Advanced Practice Nurses. Retrieved from http://www.aacn.nche.edu/media-relations/fact-sheets/apn-roles ENP Network. (2016). The Professional Network for Nurse Practitioners | ENP Network. Retrieved from https://www.enpnetwork.com/ FLANP. (2015). Platform and Policies - Florida Association of Nurse Practitioners. Retrieved from http://www.flanp.org/?page=platformpolicies Florida Board of Nursing. (2007). Nurse Practice Act: Chapter 464 Florida Statutes. Retrieved from http://phsc.edu/sites/default/files/program/files/Nurse-Practice-Act.pdf Huber, D. (2013). Leadership and nursing care management. Elsevier Health Sciences. Jha, A. K., Joynt, K. E., Orav, E. J., & Epstein, A. M. (2012). The long-term effect of premier pay for performance on patient outcomes. New England Journal of Medicine, 366(17), 1606-1615. Lowe, G., Plummer, V., O’Brien, A. P., & Boyd, L. (2012). Time to clarify–the value of advanced practice nursing roles in health care. Journal of advanced nursing, 68(3), 677-685. Robert Wood Johnson Foundation. (2015). Determining and Controlling the Cost of Health Care. Retrieved from http://www.rwjf.org/en/library/research/2015/10/determining-and-controlling-the-cost-of-health-care.html

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