Advocating Holistic Care in Nursing

e medical model which was limited to physical symptoms of the patient’s condition as the premise for diagnosis. The nursing process, therefore, identified gaps in the medical model and championed a more holistic approach to diagnosis and care for patients by addressing the holistic needs of the patients. The nursing process focuses on the physical and practical concerns of the patients, in addition to their medical conditions, the family of the patients, relationship and emotional concerns as well as lifestyle information to comprehensively provide care aimed at alleviating the individual suffering of the patients. Respect for human dignity, the first principle in the ‘‘Code of Ethics for Nurses’’ (American Nurses Association, 2001), guides nurses to provide and advocate for humane and suitable care. Based on the principle of justice, this care is given with kindness and unhampered by consideration of personal attributes, economic status, or the nature of the health problem. In alignment with these ethical doctrines, the International Association for the Study of Pain (IASP) instigated the Declaration of Montreal at the International Pain Summit, a proclamation acknowledging access to pain management as a fundamental human right endorsed by 64 IASP Chapters and many other organizations and individuals (International Association for the Study of Pain, 2011).

The American Society for Pain Management Nursing points out that all persons with pain merit prompt recognition and treatment. Pain should be consistently assessed, reassessed, and documented to expedite treatment and communication among health care clinicians (Gordon et al., 2005). In patients who are unable to self-report pain, other approaches must be used to infer pain and appraise interventions.

Assessment

This is the first step in the nursing process and entails identification and collection of information from the patient, family, and caregivers about the condition of the patients and their respective needs. Assessment is the cornerstone of the nursing process since the other steps in the process rely on this initial step (Hamilton and Price 2013). Information can be collected using different ways and the nurses may mix the methods of information collection to ensure comprehensive data gathering that paints a clear and precise picture of the condition of the patient. Questionnaires bearing structured questions and interviews can be blended during the data collection and assessment. Kozier et al (2008) explain that information collected can be subjective or objective, primary or secondary. During the admission of patients to health facilities, background information is provided. This initial information will help to guide the first stages and should give the nurse a starting point on how to approach the patient, identifying any communication needs and recognizing if any special adjustments need to be made. Of course, in certain situations, this is not always possible, such as where a patient is admitted urgently to the accident and emergency department and care must commence immediately. In such cases, an initial short-term assessment will be made (Hamilton and Price, 2013).

The second phase of assessment occurs during the physical examination of the patient by the nurse upon the encounter. This initial examination helps to gather information about the patient’s medical condition as well as other possible causes of suffering. An initial assessment may record details of the pulse, respiration, blood pressure, oxygen saturation, capillary refill time and anything else that is relevant to the patient’s presenting problems. In clinical practice, A Hierarchy of Pain Assessment Techniques (Pasero & McCaffery, 2011; Hadjistavropoulos, et al., 2007) has been recommended as a framework to guide assessment approaches and is relevant for patients unable to self-report. This comprises of a series of activities aimed at conducting a holistic assessment of the patient and their conditions. First, Attempts should be made to obtain self-report of pain from all patients. A self-report of pain from a patient with limited verbal and cognitive skills may be a simple yes/no or other vocalizations or gestures, such as hand grasp or eye blink. When self-report is absent or limited, explain why self-report cannot be used and further investigation and observation are needed. Patients with the ability to explain or respond to questions about their condition should be encouraged to do so. In the absence of self-report, observation of behavior is a valid approach to pain assessment. Common behaviors that may indicate pain, as well as evidence-based valid and reliable behavioral pain tools for the selected populations, have been identified for each subpopulation. Although weak to moderate correlations have been found between behavioral pain scores and the self-report of pain intensity, these two means of pain assessment measure different components of pain (sensory and behavioral) and should be considered to provide complementary information about the pain experience. However, Pasero & McCaffery, (2005) identify that pain behaviours do not necessarily reflect the magnitude of the pain since some patients may be in great pain but fail to exhibit corresponding behavior.

Credible information can be obtained from a family member or another person who knows the patient well (e.g., spouse, parent, child, and caregiver). Parents and consistent caregivers should be encouraged to actively participate in the assessment of pain. This is called proxy reporting and can be very helpful to the nurse when assessing the pain and suffering of the patients. An empiric analgesic trial should be initiated if there are pathologic conditions or procedures likely to cause pain or if pain behaviors continue after attention to basic needs and comfort measures. Providing an analgesic trial and titration appropriate to the estimated intensity of pain should be based on the patient’s pathology and analgesic history.

Nursing diagnosis

This is a stage in the nursing process that follows the assessment of the patients to identify their pains. The information gained from the assessment is used to identify actual and potential problems and strengths. Yildirim and Ozkahraman (2011) explain that Strengths might be self-caring abilities or independence in certain areas, or prior knowledge or experience of the illness. Patients with knowledge about their illness in terms of its causes, behavior, and the management may provide easier work for the nurse to diagnose them. Some patients have medical knowledge which can be tapped by the nurses when providing a diagnosis to their conditions. Actual problems are those that come directly out of the assessment, for example, pain from a fracture. Usually, actual problems are easier to identify by the nurse whether the patients have self-report potential or not. Observation of the patients during the assessment stage helps the nurses to identify the actual problems encountered by the patient. In fact, engagement of a family member may help easily identify and authenticate the actual health problems. Potential problems are those that could arise out of the present problem, for example, the risk of developing a pressure sore if confined to bed (Hogston, 2011). Identifying potential problems help to provide holistic healthcare to the patient. Patients while in the health facilities may be exposed to other problems that may cause pain and suffering and as such, the nurse should consider such occurrences when conducting the diagnosis. This supports the warning by Peate (2013) that diagnosis should be conducted by a nurse who has gained sufficient expertise and experience.

Planning

This stage of the nursing process and can be explained as a stage where interventions are identified to reduce, resolve or prevent the patient’s problems while supporting the patient’s strengths in an organized, goal-directed way (Kozier et al, 2008). This stage is quite critical in determining the success of a pain management intervention by the nurse. During the planning stage, the seriousness of the problem should be identified by piecing together information gathered in the first two stages. However, care should be prioritized and based on the needs of the patient. Hugston (2011) identifies two steps in the planning process; setting goals and identifying an action plan. Hamilton and Price (2013) explain that goals are very important in planning for the care of the patient’s pain. These goals should be specific, measurable, achievable, realistic and timely. The action planning should prioritize the care of patients and Hogston (2011) suggests that an action plan should be realistic, explicit, evidence-based, prioritized, involved and goal centered

Implementation

This is the stage in the nursing process where care is delivered to the patients. In fact, this is usually the most visible step in healthcare since the nurses interact with patients, their family, and caregivers through specific actions to deliver care for the patients. Nursing care, according to the clinical practice should be aimed at not only managing the medical condition of the patient but also the pain and suffering related to the illness. Care is delivered to the patients on a 24-hour basic of routing attendance and monitoring of the patient’s situation as well as administration of treatment and medication to the patients. It is important to note that the implementation stage can be quite complex especially when the nurse is obliged to offer holistic care in a health facility with many patients. However, Alfarao-LeFevre (2010) explains that record keeping in continuous monitoring of the patients is important to help in understanding the patient’s progress and response to the care provided to them. Clinical practice of providing care to pain and suffering is under scrutiny at this stage. Since the nurse’s actions are visible to the patients, family members, and other stakeholders, it is prudent that quality of service, customer service, kindness, and patients be part and parcel of the service delivery.

Evaluation

Evaluation of the final step in the nursing process where the service offered during the implementation stage achieved the desired outcome. It entails a careful examination of the goals and the action plan adopted to ensure achievement of the objectives. The evaluation may occur either at the end of the treatment or as part of the implementation of nursing care. Continuous evaluation in the course of implementation helps to evaluate achievement of short term goals in the course of implementation. Additionally, it also helps to align the services to the goals of nursing care. For instance, a nurse may need to examine whether the services they are offering are bearing fruit and thus would evaluate their services by analyzing the patient’s progress. Additionally, Hogston (2011) states that evaluation is an opportunity to review the entire process and determine whether the assessment was accurate and complete, the diagnosis correct, the goals realistic and achievable, and the prescribed actions appropriate.

Part two: Reflective practice in Nurse’s response to individual pain

Decision making is vital in clinical practice. Nurse’s role to provide care to patients with pains and suffering is accompanied by the responsibility of making prudent decisions to ensure quality service delivery. Reflection is an important aspect of the decision-making process and is thus important when providing care to patients in health facilities. Reflection is a method of using experiential knowledge to enable professional and personal development while reinforcing continuous learning (Gustafsson and Fagerberg 2004). The Code on Professional Standards of Practice and Behaviour for Nurses and Midwives (NMC 2015b) states that to fulfill all registration requirements, nurses and midwives must ensure their knowledge and skills are up to date. The application of reflection in clinical practice should be purposeful, questioning and focused. This directs the mind to a particular set of issues which are contemplated about thoughtfully. This mental evaluation helps in assessing the available options in the provision of care to pain and suffering patients and choosing the best viable option which is then implemented. Rolfe at al. (2010) explains three components of reflection; Reflection before action which involves thinking about what you aim to achieve and understanding the means by which this will be accomplished by drawing on previous experience. Reflection in action relates to your conduct while undertaking the task and allows you to modify what you are doing while you are doing it. This is commonly described as ‘thinking on your feet’. Reflection on action involves looking retrospectively at how practice was executed and analyzing the information gathered in terms of knowledge, new learning, and professional development.

Application of reflection in clinical practice is occasionally manifest when negative outcomes are experienced. For instance, when the nurses approach the patients in a bid to build the rapport and provide care to them but receive aggressive behavior from the patients, they may reflect on the incident in an attempt to find answers to the incident. In professional practice, reflection requires a focused and strategic approach in contrast to reflection on personal and social circumstances. Driscoll (2007) developed a model of reflection by including prompt questions for each stem question to complete the process of reflection. Driscoll’s model is made up of three steps which provide structured questions whose answers can help in effective reflection. Step one involves describing the situation. This entails examining in detail the situation by examining the series of events that transpired leading to the situation. The aim of this step is to provide a vivid picture of the occurrence or the situation in question. Having described the situation, step two entails exploring the situation. This involves refining the situation and developing logical reasons and rationalizations relating to the events that made up the situation. The third and final step in Driscoll model is identifying new learning or lessons from the situation that can be translated into practice. Having developed a clear picture, and analyzed the situation with the possible reasons behind the occurrences, lessons from the situation are drawn and then integrated into practice. In clinical practice, Driscoll model can be applied to different conditions that require detailed analysis in order to offer sucking solutions. Nurses relying on the Driscoll method can interrogate the situations causing the pain and suffering of their patient by examining all the possible reasons (physical, emotional, cognitive) that could amount to the situation of the patient. Utilizing this model of reflection in practice can provide a comprehensive plan for managing the pains of the patients which will be helpful in the nursing practice.

Successful reflection depends on some key elements. When analyzing the situation, critical thinking is a crucial element as it provides knowledge and understanding to help in developing succinct decisions. Critical thinking provides a structured and guided reasoning approach to analyze the situations objectively and help develop viable solutions to manage future occurrences and increase productivity. Self-awareness is another crucial element in reflections and nurses ought to utilize it when reflecting on the situations that occur in the course of their duties. The desire to care for individuals and their families is integral to nursing. Therefore, the basis of any learning is to achieve this goal. The importance of self-awareness in nursing is not a new phenomenon. Rolfe et al (2010) explain that there are occasions in practice that this can evoke uncomfortable feelings of vulnerability, doubt, distrust, and anxiety. Nevertheless, to become self-aware requires a conscious process to know what makes us feel and act the way we do. Reflective practicing in nursing helps to provide quality services, and better manage the situations that arise whose impacts are both negative and positive. In an environment where the nurses are tasked with providing care to patients with pains and sufferings accompanying their medical conditions, reflective practicing empowers the nurses to discharge their duties with courage and motivation. This will ultimately result in quality clinical practice in taking care of patients and personal pains and sufferings.

References

Alfaro-LeFevre R. 2010. Applying Nursing Process: A Tool For Critical Thinking. 7th edn. Lippincott Williams & Wilkins, Philadelphia PA

American Nurses Association, 2001. Code of ethics for nurses with interpretive statements. Silver Springs, MD: American Nurses Publishing.

American Pain Society, 2009. Principles of analgesic use in the treatment of acute pain and cancer pain, (6th ed.) Glenview, IL: American Pain Society.

Gordon, D. B., Dahl, J. L., Miaskowski, C., McCarberg, B. et al. 2005. American Pain Society Recommendations for Improving the Quality of Acute and Cancer Pain Management: American Pain Society Quality of Care Task Force. Archives of Internal Medicine, 165(14), 1574–1580.

Hadjistavropoulos, T., Herr, K., Turk, D. C., Fine, P. G., Dworkin, R. H., et al. 2007. An interdisciplinary expert consensus statement on assessment of pain in older persons. The Clinical Journal of Pain, 23(1 Suppl), S1–S43

Hamilton P, Price T 2013. The nursing process, holistic assessment and baseline observations. In: Brooker C, Waugh A (eds) Nursing Practice: Fundamentals of Holistic Care. Mosby Elsevier, London. 303–36

Kozier B, Erb G, Berman A et al 2008. Fundamentals of Nursing: Concept, Process and Practice. Pearson Education, London

Peate I 2013. The Student Nurse Toolkit: An Essential Guide For Surviving Your Course. Wiley-Blackwell, Chichester

Yildirim B, Ozkahraman S 2011. Critical thinking in nursing process and education, Int J Human Soc Sci Res 1(13): 257–62

Driscoll J 2007. Practising Clinical Supervision: A Reflective Approach for Healthcare Professionals. Second edition. Baillière Tindall Elsevier, Edinburgh.

Gustafsson C, Fagerberg I 2004. Reflection, the way to professional development? Journal of Clinical Nursing. 13, 3, 271-280.