International Journal of Caring Sciences September-December 2014 Volume 7 Issue 3 781

O R I G I N A L P A P E R

A Multiparadigmatic Model for a Holistic Nursing

Maria Irene Santos, RN, MSc, PhD Professor of Nursing. Researcher, Polytechnic Institute of Santarém - School of Health, Santarém, Portugal Marta Lima-Basto, RN, MSc, PhD Professor of Nursing. Researcher, UI&DE – Nursing Research and Development Unit, College of Nursing, Lisboa, Portugal Correspondence: Maria Irene Santos, Professor of Nursing. Researcher, Polytechnic Institute of Santarém - School of Health, Santarém, Portugal. E-mail: [email protected]

Abstract

Based on a primary study (Santos, 2011) focusing the integration of non-conventional therapeutic modalities in the nursing care process, a secondary analysis of the findings was performed in order to answer the following questions: What conception guides nursing practice when using non-conventional therapeutic modalities? What is the place of holistic nursing in nursing’s theoretical development? The analytical expansion, as a way of doing secondary analysis, led to organize the reflection in four dimensions: evidence of the utilization by nurses of non-conventional therapeutic modalities; holistic care is nursing’s choice; a multi paradigmatic model for a holistic nursing; the place of holism in health and nursing paradigms. We believe this is a contribution for the clarification of nursing’s identity and consider further research to be necessary. Key-words: model, nursing model, nursing intervention, unconventional therapeutic modalities .

Introduction Background Strengthening nursing as a scientific discipline Paradigms, defined as perspectives of something implies a clear identification of its conceptual, (Taylor et al 2007) are used as approaches to content and method elements as well as the comprehend and develop nursing knowledge and understanding of its natural evolution. The have evolved through time. The traditional diversity and mobility of nursing’s disciplinary scientific paradigm is generally considered a frontiers have hindered this necessary process of positivist approach to science, often called clarification, though allowing at the same time mechanistic. It has been argued that nursing for the emergency of new therapeutic modalities science needs a holistic perspective in order to that slowly take place in the professional develop its knowledge (Rolfe, 1996). practice. The social acceptance and increased use The traditional scientific paradigm - in the form of non-conventional therapeutic modalities by of hypothetico-deductionism and of inductionism nurses, leads to the need to analyze further its – has been considered unsuitable for the conceptual implications. Findings of a primary construction of informal micro theory, whereas study (Santos, 2011) confirm and enlarge the nurse practitioner requires informal, personal Engebretson’s model of holistic nursing (1997) theory constructed from practice (Rolfe, 1996; leading to the present secondary analysis guided Charmaz, 2012). Rolfe (1996) argues for a by the following questions: hypothetico-abductivism as a useful reasoning for What conception guides nursing practice when nursing and proposes “nursing praxis” as a model using non-conventional therapeutic modalities? of including the processes of reflection-in-action and reflection-on-action. What is the place of holistic nursing in nursing’s theoretical development?

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Table 1 - Multiparadigmatic model of Engebretson (1997)

Positivist Metaphysical

Material Paradigms Mechanical Purification Balance Supranormal Modalities Physical / Biomedical Surgery Colonics Magnetic Drumming manipulation Cupping healing polarity Dancing

Applied and ingestion Pharmacology Chelation Humoral Flower remedies substances medicine Hallucinogenic plants Energy Laser Bioenergetics Tai chi Healing touch Radiation Chi gong Laying on of Acupuncture hands Acupressure Psychological Mind-body Sel-help Mindfulness Imagery (confessional type) Spiritual Attendance at Forgiveness Meditation Primal religious organized religious Penance Chakra Experience prayer functions balancing Nonmaterial

Engebretson’s multiparadigmatic model (1997) include: techniques born in eastern medical and (Table 1), is called by its author a multiparadigm healing systems; traditional western techniques approach for nursing, in the sense that includes

therapeutic modalities that span the spectrum from positivist to metaphysical approaches. The lost through time and technical developments, but author’s position seems to be in accordance with with clear therapeutic potential, thus its Rolfe in the sense of getting away from the increasing utilization; and also care modalities traditional perspective reminding that nursing that are central in modern nursing, since Florence care corresponds to the human nature that calls Nightingale (Watson, 1999/2002; Dorsey et al, for approaches that go from material to non- 2005), such as those of an environmental nature. material therapeutic modalities. “Non- Main characteristics of most of these modalities conventional”, instead of “alternative” or are: consider the person/client the center of care; “complementary”, is used in the present article in consider relationship as therapeutic; consider accordance with the philosophy behind it and its patient autonomy more important than use in some countries’ (i.e. Portugal) legislation. dependency; emphasize health and not disease The increasing use of non conventional (Luz, 2005). therapeutic modalities by a great variety of These characteristics have a profound meaning in professionals, and the clear acceptance by the nursing and are considered some of its basic population in general, is due of its benefits for its assumptions – both for the academic discipline well being (Wardel e Engebretson, 2001; Geller and the profession, taking into account the person et al, 2004; Haselen, 2004; Smith, et al, 2006; as a whole (Risjord, 2010; Santos, 2013). Young et al, 2007). Efficacy of these therapeutic modalities seems to We have witnessed that some nurses integrate have empiric evidence and to a certain degree non convectional therapeutic modalities in their scientific evidence (Santos, 2011). Because some daily care practice, based on a rationale and weak points persist, there is a need for exploring paradigm of practice quite different from the further, in the area of disease prevention and dominant health sciences paradigm of the treatment, balance and promotion of well-being. western part of the world. These modalities

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Turning public all elements of practice and It is worth mentioning that the participants characterizing them, allows for a systematic perceived the therapeutic value of these evaluation of its therapeutic outcomes, to learn modalities in a variety of settings, but they more about the underpinned knowledge, giving mention there are differences: from recognition them a conceptual coherence, thus legitimating of an intrinsic value of the different therapeutic its use both from a professional and disciplinary modalities that they perform, to being considered perspectives. a mediator to the utilization of specific therapeutic modalities, according to the Characterizing the primary study possibilities allowed by the environment. The research question was how do nurses The primary study helped to systematize some integrate non-conventional therapeutic outcome indicators of non-conventional modalities in the care process? The study’s therapeutic modalities (Table 4) from the nurses objectives were: to identify innovative practices and researcher’s perspective and also from the (content); to understand its reasoning (conceptual patients’ perspective. There is a strong coherence elements) and modes of action (method); as well among them, mainly in the indicators of well as strategies used to include them in their practice being where the nurse’s observation overlapped and outcomes evaluated by nurses and patients. the patient’s verbalization, which validated Method previous findings, namely decreased preoperative The primary study was based on an inductive anxiety (Bunyuns, et al, 2002) and relaxation and paradigm of science, using grounded theory, stress reduction (Wardel e Engebretson, 2001; following Charmaz’s (2006/2008) constructivist Hanley et al, 2003). perspective. The first part of the study involved The nurses emphasized two important reasons for 15 nurses practicing in nine public hospitals in using these modalities: enriching the content of Portugal, who volunteered, on a basis of a the nursing discipline and enlarging the scope of snowball sample method, and responded to in- their practice. depth interviewing. The second part of the study Non-conventional therapeutic modalities are seen was based on participant observation of a team of as enlarging the discipline with knowledge that 10 nurses’ practice and 17 patients, in a pain unit integrates easily the nursing core conceptual of a cancer hospital in Portugal. Theoretical rationale and is a contribution to its development. sampling was used. The data was collected and analyzed by grounded theory’s constant The nurses consistently state the coherence comparative method. between these modalities and the philosophy of nursing as facilitating factor of their practice. The Results majority of the study participants calls for the The main findings of the primary study were: holistic approach as the rationale and the identification of new non-conventional legitimization to act in a different way, meaning therapeutic modalities, as well as the ways in that while not negating the biological dimension which they are used by nurses and the expansion of the person and the “classic” nursing of Engebretson’s multiparadigmatic model. interventions, bringing in other instruments that A great diversity of non-conventional therapeutic correspond to their global vision of the person. modalities was identified as being used regularly As suggested by Hall (2005), great part of our by hospital nurses. The modalities (Table 2) were knowledge to practice is larger than the cure of classified according to the nature of the disease: it includes the person’s emotional, therapeutic principles they correspond to, adapted physical, and spiritual health, in a way that might from the National Center for or might not include a disease. Complementary/Alternative Medicines, the Whatever helps the patients was felt as a North-American organization that monitors these challenge for the participants that try to respond therapeutic modalities’ practice and research to the patients’ health needs efficiently. Non- (Snyder & Lindquist, 2006): environmental, conventional therapeutic modalities allow nurses manipulative, mental-cognitive, energetic and to give a more global response to patients needs. relationship modalities.

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Table 2 – Therapeutic modalities encountered in the field of research

Classificatory group Modalities

Environmental procedures The use of music and aromas, the luminosity and temperature, the use of color.

Manipulative procedures Massage (various types): massage therapy, reflexology, shiatsu and lymphatic drainage.

Mental-Cognitive methods Hypnotherapy, pain distraction techniques (guided imagery), the use of humor; various relaxation techniques (guided by voice, yoga); prayer, guided reading.

Arrangements Energy Reiki, "therapeutic touch", acupressure.

Arrangements Relationship Intentional use of silence and conversation, tone of voice, the warmth .

Adapted from: NCCAM – National Center for Complementary/Alternative Medicines or Modalities, Snyder e Lindquist, 2006.

Table 3 – Multiparadigmatic expanded model (2012/13)

Positivist Metaphysical

Material Paradigms Mechanical Purification Balance Supranormal Modalities Physical / Biomedical Colonics Promotion of Intuitive bodily manipulation Surgery Cupping exercise work exercício; Therapeutic massage Applied and Pharmacology Chelation Nutritional Homeopathic ingestion counseling medicines substances Energy Laser Phototherapy Acupressure; Therapeutic Radiation Acupuncture touch; Reiki Psychological Mind-body; Active listening; Counseling; Guided Relaxation Tone of voice; Intentional use visualization; techniques Use of humor. of silence and Hypnotherapy conversation Spiritual Attendance at Forgiveness; Meditation Spiritual support; organized Purification Prayer religious rituals functions Environmental Comfort Use of scents Use of color and Use of music; temperature light Aesthetics of the Nonmaterial environment

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Table 4 – Indicators for assessing therapeutic modalities studied

Physiological Behavioral Wellness The perspective of the nurse / researcher

Vital signs; skin color and lip Degree of agility, altered voice; Physiognomy of the labial mucosa; muscle tone; state of bodily movements (quiet / commissures; gloss and eye mind; body posture; alertness; restlessness); speak of the "turn"; closure; alertness; serenity; smile. body architecture. keep silent.

The perspective of the user / patient

Normalization of biological Decrease in intake of analgesia in Management of pain and emotions functions: quality of appetite; SOS; ability to manage everyday (umbrella effect ); relief; sense of sleep quality; bowel functioning; life. feeling good; feeling at peace; physical strength. Level of pain. release of tension and anxiety; feeling of lightness; energy level; courage; improving mood ; increased stress tolerance; will to live; trust; "out of themselves".

The study’s findings led to suggest the expansion The questions that guided the present analysis of Engebretson’s multi paradigmatic model were: (1997) (Table1), adding to the original 13 What conception guides nursing practice when therapeutic modalities in four categories and using non-conventional therapeutic modalities? proposing a new category: “Environmental” that encompasses five therapeutic modalities (Table What is the place of holistic nursing in nursing’s 3). The original author showed her appreciation theoretical development? in the following way: “… I see (…) that you are Based on discussions between the authors and focusing on nursing. So this is a wonderful further readings, the reflexion was organized in addition to the literature regarding how the four dimensions: evidence of the utilization by model is specifically relevant to nursing. I really nurses of non-conventional therapeutic like the inclusion of environmental actions. As modalities; holistic care is nursing’s choice; a your study was on nursing, yes add that line as I multi paradigmatic model for a holistic nursing; think nurses do this and often may be more the place of holism in health and nursing conscious of the environment that other paradigms. clinicians or even other healers. It is a very important issue in healing and for nursing (...)". Outcomes of the secondary analysis (Joan Engebretson, July 24, 2011, by mail). Evidence of the utilization by nurses of non- The secondary study conventional therapeutic modalities Once the primary study was completed and The identification of therapeutic modalities that, published (Santos, 2013) new questions were though known by many, had not been, until now, raised that led to a secondary research approach, added to Engebretson’s model: therapeutic an “analytic expansion” described by Thorn massage; reiki; relaxation techniques; tone of (2013, p.397) as a “study in which a researcher voice; use of humor; intentional use of silence makes further use of a primary data set in order and conversation; hypnotherapy; spiritual support to ask new or emerging questions that derive and prayer; comfort temperature; use of scents; from having conducted the original analysis but use of color and light; use of music and aesthetics were not envisioned within the original scope of of the environment - adds to the meaning of the primary aims (Heaton, 2004).” nursing care, specifically as therapeutic instruments used by nurses. A systematic review

www.internationaljournalofcaringsciences.org International Journal of Caring Sciences September-December 2014 Volume 7 Issue 3 786 of the literature looking for evidence of approach to care, will find ways to utilize non- therapeutic instruments used by nurses (Lima- conventional therapeutic modalities that are in Basto, M. et al, 2010), showed there is scientific accordance with their beliefs about holistic care. evidence of the usage of several modalities - i.e. The number and variety of non-conventional humor and non-conventional therapies such as modalities identified in the primary study music, mindfulness, massage - and added that expresses the connection between paradigms and the nurse herself is a therapeutic instrument. The care modalities. This connection confirms the holistic approach of the person by nurses makes holistic perspective of nursing, allowing an necessary the use of therapeutic instruments, as interwoven of therapeutic modalities originally part of professional interventions, plural in their from different paradigms that potentiate the diversity, coming from different paradigms of development of clinical practice. knowledge. From the different concepts of holism, the Positive and generally consistent outcomes of following are the main ideas, common to non-conventional therapeutic modalities have semantic variations of respected authors’ been evaluated by Snyder and Lindquist (2006), positions (Brennan,1993; Kim, 1999; Watson, but there is a need for further reliable research. 1999/2002; Morin, 2008): the idea of the whole The less developed knowledge on non and its parts in mutual interaction; the essential conventional modalities is their therapeutic character of the whole, different from the sum of outcomes. The primary study supports this various parts that constitutes it; the nature of the position. parts, determined by the whole, that gives them Several authors question the validity, relevance an ontological meaning; the whole, as an and clinical importance of randomized controlled emergent entity, evolves continually into a trials (RCT) to measure outcomes of process of increasing diversity and complexity; interventions based on a therapeutic relationship, the whole is in a constant interaction with its as is the case of most of non conventional environment. therapeutic modalities (Walter& Sofaer, 2003). Nevertheless, holistic care requires more than just They state that qualitative research methods are a synthesis of different domains of knowledge. It appropriate when seeking comprehension, requires that, from those domains, the nurse meaning, feelings, beliefs and expectations, achieves a transformative synthesis resulting in a among others. This option does not mean less whole person, different and larger than the sum rigor, on the contrary, the adequacy of the of its parts. As Watson (1999) states, the holistic method to the research questions and the perspective in nursing has yet to be totally epistemological and ontological congruence are a understood and put into practice. guarantee of those criteria, avoiding the biases that come with an inappropriate method (Waker Over the years nursing has integrated practices & Sofaer, 2003). born in other areas, mainly from medicine (Watson, 2002) and, at the same time, has left for The variety of nursing classification systems, other emerging professional groups some of its such as NANDA’s diagnosis (1982), Nursing activities. The increasing number of professional Interventions Classification (1992) and Nursing areas (Dubar, 1997; Rodrigues, 1997) has risen Outcomes Classification (1997), as pointed out the question of inter professional boundaries. by Cruz (2007), all of them in their early development stages, might also be a factor A multi paradigmatic model for a holistic related to the less developed knowledge on non- nursing conventional therapeutic modalities´ outcomes, The primary study findings led to propose an though in accordance with nursing science and expanded version of the original Engebretson’s the profession’s stage of development (Dossey et multi paradigmatic model. It constitutes a al, 2005; Cruz, 2007; Sousa et al, 2008; Lima, position within the disciplinary movement 2009). searching for itself, its identity, stating that non- Holistic care is nursing’s choice conventional therapeutic modalities are a resource for nursing’ self definition and self The primary study showed that nurses, even affirmation. when working in health environments where the dominant paradigm is a deductive/positivist Accepting as a generic concept of “model” – a way of describing what is done and what can be

www.internationaljournalofcaringsciences.org International Journal of Caring Sciences September-December 2014 Volume 7 Issue 3 787 done - (Adam, 1994; Lima-Basto, 2009) – we Logan and Tierney’s model (1995) based on a believe that a complex phenomenon, such as model of life that identifies living activities in health-disease process, is better represented as a which the nurse can intervene, is an example. complex model. Considering it is nursing’s - ERA III (since 1970, starting to be recognized): intention to care for sick persons, persons with Unitary-transforming paradigm potential health problems or going through (Multiparadigmatic model), along with quantum situational or developmental transitions (Meleis, physics development and the concept of 2010), a guiding model of practice, reflecting the unlimited human consciousness, in time and various levels of complexity involved, is needed. space. It corresponds in nursing to the post- This epistemological position clarifies and modern paradigm, open to new concepts such as legitimizes several possible choices, based on the energy, consciousness, intentionality, and singularity of each caring situation. Several well- transpersonal caring-curing (Watson, 2002). known nursing scholars such as Rolfe (1996) have argued for models of nursing praxis, that include deductive and inductive thinking, which Discussion is another way of saying that nursing practice is guided by both paradigms. Engebretson Wisdom and knowledge develops in cycles and it overcomes the traditional dichotomy proposing is interesting to note that some of the “new” two types of orientation guiding nursing concepts have been found in societies that existed interventions: from positivist to metaphysical and millions of years ago, making these “new” from material to non material. concepts more powerful. An example is man’s seven dimensions construction, proposing seven The emergence of new caring professions and the types of manifestation of human nature. It was growing value of multidisciplinary endeavors, developed in Ancient Egypt and India, with a intensifies the need to clarify the specific strong influence of Hinduism and certain schools contribution of each caring profession, its of Buddhism that continue to be studied today. theoretical representation, in order to organize Using our present language, human nature is and guide each discourse and practice. presented as a triangle (man’s spirituality) linked The place of holism in health and nursing to a square below (mortal part of human nature). paradigms The triangle contains – upwards – three levels: man’s intuition/pure mind, In modern history of the health-disease understanding/enlightenment, and man’s will. phenomenon there are three scientific The square contains – upwards – the physical eras/periods in the health sciences field, each one body (organs), the vital body (energy), the astral characterized by a model (Table 5) – specific body (emotions) and the mental body (concrete perspective and praxis, with the corresponding rationality and desires). These levels are nursing paradigms (Reed & Ground, 1997; Reis, simultaneously ways of manifesting and of 1998b; Dossey, 1991, cited by Watson, 2002): receiving (Blavatsky, 1982. p.153-158). - ERA I (1860-1950, still influential): Within the health sciences, in this post-modern mechanistic paradigm (biomedical model), era, nursing is developing a leading movement, characterized by a physical and mechanistic not only at the praxis level, such as therapeutic medicine. Emphasis is given to the body and touch (Krieger, 1970), but also with philosophies disease as an objective entity, giving preference and grand theories (Tomey & Alligood, 2004) for chemical medication and surgery. In nursing, emerging, such as Philosophy and Science of emphasis was on functional tasks, and doing, Human Caring formulated by Jean Watson centered in the role of the caring professional. (1979/1985/1999/2002), Parse’s (1998) Human - ERA II (since 1951; continues to develop): Becoming Theory and Martha Rogers’ Theory of Interactive-integrated paradigm (biopsychosocial Unitary Human Being (1970/1992). model), recognizing the importance of Remembering Nightingale’s spiritual tradition, perceptions, feelings and emotions in health, a the nursing paradigm of Era III unites pre- body-mind medicine, in the sense of brain-body. modern with post-modern, moving towards new In nursing, the value of the person as the centre concepts and an ontological change (Watson, of care emerges, with the subsequent attendance 1999/2002). to its psychosocial and emotional needs. Roper,

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Table 5 – Characterization of the main models of health and illness

Model Biomedical Biopsychosocial Multiparadigmatic (mechanistic (Interactive-integrated paradigm – Era II) (Unitary-transforming Dimensions paradigm – Era I) paradigm –Era III) Interactionist Dialectic

Conception Reductionist: the Multidimensional; Multidimensional; Holistic primacy of Hierarchical Integrated physical / biological Production of Quantitative Quantitative and Quantitative and Triangulation of knowledge / methods; qualitative methods qualitative methods methods; valorization investigation objective data of subjectivity; phenomenological approach Interdisciplina- Authoritarian: Vertical: doctor is Horizontal: power Horizontal: ontological ry relationship medical power epistemological of team development of skills authority decentralized; contingencial Epistemologi- Mechanistic: the Dualistic: body- Dialectic: body- Transpersonal body, cal and body as a machine object, property object and lived body, spirit ontological Physician subjective body embodied status of the person Conceptual- Not recognized: Neglected: Prized: promoting Prized: Caregiver and emotional medical promoting passive patient autonomy receiver are co- autonomy knowledge role in patient participants in the process Professional- Medical decision Based on the Epistemological Relationship of pacient epistemic authority partnership intersubjectivity. relationship of the therapist Intentional and conscious Meeting Didactic of Normativity of Patient processes Promotion of Philosophy of human health and medical and reproduces reflection and freedom, choice and disease knowledge information autonomous responsibility transmitted to it construction of meanings

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Within the profession and the discipline of Conclusion nursing, some values, concepts, wisdom, With this article we introduced evolutionary knowledge and practices from various paradigms movement of a nursing model - the co-exist. Developing at different paces, multiparadigmatic model, formulated by questioning the status quo , showing new paths, Engebretson in 1997 and expanded in 2013 by updating old therapeutic modalities, and Santos, fitting the paradigm shift in the sciences attributing them new meaning, nursing expands in general and nursing. The investigation which its theoretical space and makes use of led to the expansion of the model was developed corresponding practices, in response to new in some hospitals in Portugal, verifying a concepts of health and well being and identified membership of nurses’ unconventional practices care-cure needs. Nursing finds, in this context, its by recognizing the therapeutic effects of the historical responsibility of caring (Bittes-Júnior, same, which is corroborated by patients. 2003). The congruence of this practice with the Science in general and health sciences in philosophy of nursing is another strong reason particular continue to change. Engebretson for this membership, based mainly on the holistic proposes a multi paradigmatic model, bringing principle widely stated in the disciplinary together classic with post modern paradigms of literature and assumed by the participants. care. Within this theoretical context and based on scientific evidence and reflection, the authors Multi paradigmatic models were confronted with suggest that non-conventional therapeutic the models developed in the health sciences, in modalities are a feature of self-definition and self modern style, highlighting the leading role of affirmation of nursing. Simultaneously this nursing in openness to new scientific paradigms. model offers a range of therapeutic instruments We closed the cycle, identifying the date of the that allow responding to human complexity of pre-modern knowledge with the post-modern; a the nursing client. The expanded model (Santos, movement that, from Nightingale, expands and 2013) offers more opportunities of integrating diversifies, allowing nurses to provide holistic newly identified modalities. care, translating into practice what they have long been complaining in discourse. Nurses who value holistic care, use non- conventional therapeutic instruments that mediate We believe this reflection is a contribution for the their caring relationship with patients, even when clarification of nursing’s identity. Further the environment is not friendly. This probably research is needed to confirm the influence of shows how holistic care characterizes nursing non-conventional therapeutic modalities used by even if nurses do not always act accordingly, nurses in strengthen nursing practice and the fit having difficulty in verbalizing their beliefs. The between practice and guiding conceptual models traditional logic used in health care does not help / theories. the theoretical development of nursing. Does The main place where the work was carried holistic care synthesize the influence of out: Portuguese Institute of Oncology of paradigms considered opposing each other until Coimbra Francisco Gentil, E.P.E. Coimbra. now? As stated by Risjord (2010), non- conventional therapeutic modalities, bringing a Acknowledgment new look to the theory, knowledge and values of nursing, can contribute to its development. We thank Joan Engebretson authorization granted in July 2011, to expand multiparadigmatic model Certain concepts and values used for a long time that's the author. with different names and not being visible might have a similar meaning, but different weight in References different periods of time. Holistic care Adam, E. (1994), Being a nurse, (Ser enfermeira), characterizes post-modern nursing in accordance Piaget Institute, Lisbon. with western society’s development, illuminating Bittes-Júnior, A. (2003), Caring in the perspective of concepts, values and innovative therapeutic Nichiren Daishonin and the Science of Unitary practices in nursing, that help clarify its position Human Beings: a history of human revolution , in the academic world as well as improving care. PhD thesis in nursing, presented to the University of S. Paulo, S. Paulo. Brasil (in Portuguese)

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