One of the major contributions of the culture change movement in long-term care is that it fosters a rediscovery of the holistic approach to care that was long overshadowed by the powerful growth of the biomedical model. Holistic care recognizes that the body, mind and spirit are interrelated and interdependent; and that the status of one aspect affects the others.

BIOMEDICAL VS. HOLISTIC MODELS

Historically, those who provided health and medical care were known as healers. For centuries, medicine men, shaman and other healers throughout the world treated illness with a variety of approaches, such as herbs, diet, massage, acupuncture, storytelling, prayer and healing rituals. They used these diverse approaches because they believed an individual's physical, mental, emotional and spiritual states to be interrelated. Maintenance of health and promotion of healing from an illness required attention to all facets of the person. Through their lens, a physical symptom could be just as likely to be the result of a sense of hopelessness or disconnection with God as due to a diseased organ.

With the advent of the scientific revolution, the Western world rejected traditional healing practices that could not be explained with objective evidence. The healing arts and role of the mind and spirit in health and healing were considered more folklore than fact. Illness was seen as a pathophysiologic occurrence that could be treated with chemicals, surgery or radiation, leading to the birth of the biomedical model.

The approach changed from the healer working with people to help them maximize their own resources to heal body, mind and spirit, to the health care provider doing things to patients to treat an illness. The focus on care of the whole person shifted to fighting the disease that had to be eradicated. Even a language developed that supported this focus: the war on cancer, searching for a magic bullet, kill the bacteria, a new weapon against heart attacks. 

LONG-TERM CARE DEVELOPMENT

As long-term care facilities developed, they used the biomedical model that was prevalent in hospitals as their guide. Regulations reinforced this approach, focusing on basic physical needs and medical care rather than all facets of the individual and the multidimensional effects of chronic conditions.

While appropriate and effective for many acute conditions, such as fractures, infections and heart attacks, the biomedical model has its limitations in the care of chronic conditions that are the primary problems of residents of long-term care facilities. Granted, expert management of the disease state is essential, but this is barely the tip of the iceberg of long-term care. 

In addition to supporting the treatment plan and monitoring health status, the goals of long-term care from a holistic paradigm include:¹

• maximizing physical, emotional, mental, social and spiritual health, function and well-being
• boosting the body's healing abilities
• preventing complications and avoidable decline
• facilitating residents' connection with the community within and outside the facility
• supporting residents in a peaceful and dignified dying process.

Unlike the biomedical model, the holistic model does not see a worsening of disease as necessarily a failure. A sense of purpose, meaningful interactions, spiritual peace, healing of relationships and satisfaction with the life journey traveled can reflect caregiving success even in the presence of a declining physical state.

HOLISTIC CARE ASSUMPTIONS

There are several assumptions at the core of the holistic model:

Residents are active participants in their care. The concept of allowing residents maximum independence has long been promoted in long-term care, but it has not been practiced as fully as possible. Staff members who support a holistic practice assess for variables that interfere with self-care independence (e.g., insufficient knowledge, low motivation, lack of purpose, insufficient provision of time), help remove constraints to independence and encourage maximum independent function.

Diseases potentially disrupt mental, emotional, social and spiritual status in addition to physical state. Chronic conditions that demand long-term care assistance can lead to depression, altered family relationships, spiritual distress, social isolation and other outcomes that jeopardize quality of life.

Health state and care needs differ within the same person at different times. The Greek philosopher Heraclitus said "you cannot step into the same river twice." So it is with residents. Care plans are general road maps, but flexibility and sensitivity are needed to adjust to daily changes in needs. This requires that staff not only understand the condition that the resident has, but more importantly, the resident who has the condition.

Treatments need to include a wide range of therapeutic options, including complementary and alternative medicine therapies. From the holistic perspective, the least invasive, lowest risk, most natural interventions should be used whenever possible. For example, in the treatment of hypertension, rather than begin with an antihypertensive drug, first consider employing dietary modifications, yoga, meditation, guided imagery and other options. Not only may this be good practice, but with 36 percent of all adults currently using CAM therapies² long-term care facilities can expect that consumers increasingly will desire these treatment options. (See Box 2.)

The staff is an important caregiving tool. The interactions and connections made between residents and caregivers are important elements of care. Residents may not recall how many times they were toileted or turned, but they often remember the few minutes that a CNA spent holding a hand and listening to their concerns. Managers need to send the message to staff that time spent connecting and being with residents is well spent.

Staff must commit to their own self-care. In the holistic model, employees are models of the positive health practices that they promote to others, which implies that they pay attention to their own self-care needs. Management can foster this by providing education on topics such as healthy eating, stress management, weight reduction, smoking cessation and exercise; and connecting employees with resources to assist them in seeking health care or dealing with health challenges.

Culture change models integrate holistic concepts and practices. This has obvious advantages for residents who receive the benefit of individualized, comprehensive, whole-person care. Also, there are benefits for employees who can derive greater satisfaction from their work as they see themselves---their presence, interactions and being---as crucial elements in the care process.

References

1. Eliopoulos C. Gerontological Nursing, 6^th ed. 2005; Philadelphia: Lippincott;2005.

2. Barnes P, Powell-Griner E, McFann K, Nahin R. CDC Advance Data Report #343. Complementary and alternative medicine use among adults: United States (2002). May 27, 2004.

Charlotte Eliopoulos is the executive director of the American Association for Long Term Care Nursing and a specialist in gerontological and long-term care nursing. She is certified in gerontological nursing, nursing administration in long-term care and naturopathy. Contact her at charlotte@ltcnursing.org.

Box 1: Comparison of Biomedical and Holistic Models

Biomedical Model

• physician in charge
• focus on symptoms, medical care
• minimal knowledge of emotional, social, spiritual and environmental variables
• interventions for diagnosing and treating condition
• treatments external to resident (done to); use of conventional medicine
• resident expected to comply and viewed as noncompliant if he/she does not
• caregivers/providers detached with contact for purpose of performing tasks
• physical environment designed for efficiency of staff

Holistic Model

• resident-provider partnership, primary provider may not be physician
• focus on state and balance of body, mind, spirit and emotions
• knowledge of emotional, social, spiritual and environmental variables essential
• interventions to build resident's ability to manage or improve health status
• interventions use resident's internal resources (boosting immunity, diet, imagery, meditation, yoga, prayer, stress management); can include complementary and alternative therapies
• resident's input and feedback encouraged
• caregivers'/providers' presence and interactions integral part of residents' health, healing and quality of life
• physical environment used as a therapeutic tool for residents. 

Source: Charlotte Eliopoulos RN, MPH, ND, PhD

Box 2:  Classifications of Complementary and Alternative Medicine (CAM) Therapies

Alternative medical systems are built upon complete systems of theory and practice. Often, these systems have evolved apart from and earlier than the conventional medical approach used in the United States. Examples of alternative medical systems that have developed in Western cultures include homeopathic medicine and naturopathic medicine. Examples that have developed in non-Western cultures include traditional Chinese medicine and Ayurveda.

Mind-body interventions use a variety of techniques designed to enhance the mind's capacity to affect bodily function and symptoms. Some techniques that were considered CAM in the past have become mainstream (for example, patient support groups and cognitive-behavioral therapy). Other mind-body techniques are still considered CAM, including meditation, prayer, mental healing and therapies that use creative outlets such as art, music and dance.

Biologically based therapies in CAM use substances found in nature, such as herbs, foods and vitamins. Some examples include dietary supplements, herbal products and the use of other so-called natural, but as yet scientifically unproven, therapies, such as using shark cartilage to treat cancer).

Manipulative and body-based methods in CAM are based on manipulation or movement of one or more parts of the body. Some examples include chiropractic or osteopathic manipulation and massage. 

Energy therapies use energy fields and fall intotwo types. Biofield therapies are intended to affect energy fields that purportedly surround and penetrate the human body. The existence of such fields has not yet been scientifically proven. Some forms of energy therapy manipulate biofields by applying pressure and/or manipulating the body by placing the hands in or through these fields. Examples include therapeutic touch, Reiki, and qi gong. Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields, such as pulsed fields, magnetic fields, or alternating-current or direct-current fields.

Source:  What is CAM? National Center for Complementary and Alternative Medicine, National Institutes of Health. Retrieved from nccam.nih.gov/health/whatiscam/index.htm on March 3, 2008.