The Historical Emergence of GAHN
Evolving Factors that Initiated the Creation of The Global Academy of Holistic Nursing, 1990-2020
As the country prepared to move into the new millennium in the 1990s, society talked about a need for a shift in paradigm for healthcare services in the United States. The Institute of Medicine launched several studies that provided evidence of large disparities in both the amount and type of services available across the country. Numerous underserved populations were recognized, concurrent with a shortage of healthcare providers and projections of the situation worsening (IOM, Nursing workforce studies, etc.). Recommendations included a shift from a primary focus on disease and conditions to one of health-promotion and disease prevention, and that nurses assume roles and responsibilities consistent with their educational preparation. Nursing recognized the potential for graduate prepared nurses to step into the vacuum created by the shortage of primary care providers and launched educational programs that prepared graduate nurses to assume advanced practice nursing (APN) models of primary care. Without a clear national direction of what these models might look like, many were developed to prepare biomedical-models of APNs; others prepared APNs within alternative models, based on their underlying beliefs of the essence of nursing. Programs proliferated without a common core of knowledge to guide preparation of the APNs.
Challenged to clarify and regulate what was meant by APN status, the National Council for State Boards of Nursing launched a series of nursing dialogues to determine how to meet their challenge. AHNA and AHNCC were invited to the early discussions but soon excluded from the Joint Dialogue group conversations with the explanation that the Joint Dialogue group was designed to discuss the core essence of Advanced Practice Nursing, and Holistic Nursing was more appropriately considered the frosting on the cake.
Holistic Nursing's Activities
AHNA applied for and received ANA Specialty status (2006). Concurrently, AHNCC made a brief phone call to NCSBN's Senior Policy Advisor asking for clarification of the APRN role effects, i.e. What will happen to those nurses who were classified as APNs, but do not meet criteria for the new APRN status. The response was that nurses who didn't qualify for APRN status would have to work under their basic RN license or get certified in specialties as they wished. They would not be recognized as APRNs. When asked about the implications of APRN status, the answer was that it would allow APNs to have prescriptive authority and be reimbursed for their services.
AHNCC followed up with a letter to the Nursing Dialogue Group informing them that their plan for APRN status would disenfranchise thousands of APNs resulting in key outcomes:
- Many graduate prepared nurses would not be able to declare APRN status without first being recognized based on a biomedical model that focuses on the management of conditions and disease, and
- Society would be deprived of nurses who come from a health, wellness, healing perspective.
Silence followed until 2008 when the Consensus Model was published. Confusion and disenfranchisement followed. Many Holistic Nurses identified difficulty with employment, funding, and other barriers to providing services based on their expertise. AHNCC continued to explore a way to ensure that graduate prepared Holistic Nurses credentialed by AHNCC could be recognized as an APRN, but LACE rejected each proposal.
AHNCC Charges The Consensus Model Task Force
Early 2013, AHNCC posted a Position Statement on the APRN Consensus Model and launched a sequence of requests for recognition of the APHN-BC certification examination as documentation for APRN status. Following national accreditation by ABNS in 2014, AHNCC charged a cohort of nurses to pursue recognition of the Holistic Nurse Credentials and related educational requirements paralleling those of the current biomedical model requirements. This consensus model task force (CMTF) continued to pursue recognition of the APHN-BC, with repeated denials that led to publishing a set of standardized curriculum guidelines Foundations, Competencies, and Curricular Guidelines for Basic to Doctoral Holistic Nursing Education, Edition 1 (2017), published on the website of AHNCC. A companion set of webinars were developed and presented online through AHNA's Continuing Education program 2017-2018.
During this time, the CMTF launched a national discussion regarding the need to recognize the discipline of Holistic Nursing, and how knowledge, skills and attitudes relate to educational criteria and practice activities. Holistic Nurses responded, supporting the need to further pursue recognition. Nevertheless, the requests for APRN status recognition based on the APHN-BC and the request for membership in LACE were denied repeatedly.
AACN Essentials for 2020-2030
The situation was compounded by the initiation of AACN's discussion on the Essentials of Nursing Education, 2020-2030. As initially proposed, graduate education for the next ten years would primarily be focused on disease prevention and health promotion based primarily in a biomedical model. The CMTF responded to the proposed Essentials, launched an internal discussion regarding the importance of this work in respect to the international movement toward person-centered, evidence-based care, and spoke in the national arena. While the AACN Task Force restructured and started over, attempting to create a model that embraces whole-person care, the role of the Advanced Practice Holistic Nursing was not recognized by LACE. A dissonance existed between LACE and CMTF members' understanding of the role of the Advanced Practice Nurse. The CMTF continued to meet nearly every week, further exploring the dissonance and possible causes.
By late 2018 the CMTF concluded that paradigm choice was an underlying factor associated with the identified dissonance. Paradigms are composed of tacit knowledge accrued through our life experiences (Polanyi 1966). They include our values and beliefs of life and human nature, and self-knowing. Tacit knowledge is often carried in our unconscious; it is sometimes talked about as being difficult to explain, it is something I just know.
Paradigms serve as a foundation for interpretation of explicit knowledge acquired through academic studies, research, and other sources. Explicit knowledge is easily retrieved in our conscious thinking; it can generally be explained without difficulty. While nursing has a discipline composed of multiple constructs that we would consider explicit knowledge, paradigms heavily influence what we think, say, and do. As Polanyi stated, humans are able to understand the world from tacit knowledge without explicit knowledge, but they cannot understand explicit knowledge without tacit knowledge.
To translate to the situation addressed in this work, paradigms guide the interpretation of our discipline that guides clinical decision making. Unfortunately, nurses rarely talk about their philosophy, unknowing, or personal knowing, all forms of tacit knowledge; all related to the tacit knowledge that creates the paradigms nurses use. Nevertheless, paradigms guide how we interpret our discipline, and therefore, how apply it.
Experts (Fawcett, 1995, 2015; Newman, 1993, 2008; & Parse 1995, 2000) identified three paradigms used by nurses to guide their practice. The CMTF's evaluation and extrapolation of their work indicates that these paradigms can be differentiated by the nurses perception of the concept whole-person. Nurses accept common concepts as the discipline of nursing, but differ in how they are defined and applied. One such example is the concept whole-person (Smith, 2019) When deconstructed by paradigmatic descriptions (Fawcett, Newman), we note that nurses either view the whole-person from the perspective of wholism or holism (Erickson, 1983/2009; 2006; 2007; 2010). While pronounced the same, and each represents the whole-person, these two words have uniquely different meanings. The first, wholism indicates that the whole is a sum of the parts; the second, holism indicates that the whole is greater than the sum of the parts.
Wholistic nursing is viewed from a reductionist perspective where the person is presumed to be composed of parts or systems, and the body-brain delimits the whole of the human. Practice is generally defined within the bio-medical model, where attention is focused on problems with the functioning of these parts/systems. When the environment is considered, it is thought of an external factor and generally not primary to the problem.
Nurses who use this model try to compartmentalize parts of the person, generally focusing on biophysical or psychological problems, view practice as dealing with these problems and related complications, and view being healthy as having the problems resolved, managed, or cured. Smith (1981) calls this a clinical model of health. Their perception of health promotion is either taking actions to prevent conditions or disease in others or teaching them how to use these strategies. Examples of commonly recognized strategies include recommended dietary intake and restrictions, proper exercise, required pharmaceutical regimes, and other bio-medically related strategies.
Communications between nurses and patients are generally transactional, with a recognition of the dependence on one another that might or might not be based in mutual respect. Interactions are affected by perceptions of dissonance or agreement of roles of one another and how they are enacted. The signs and symptoms of the problem may be affected, but the root of the problem may continue, emerging later as a new problem.
Holistic Nursing is viewed from the gestalt perspective where the person is presumed to be a unitary being with body-brain-mind-spirit-universe, intra-connected in such a way that the whole is continuously interacting as one. Practice is defined within the health and well-being model where attention is focused on the individual's inherent potential to cope, grow, heal and become. Holistic nurses focus on those factors that facilitate and impinge on these natural abilities.
Health is a eudemonistic perception of the individual's quality of life that includes an ability to find meaning in life and life-experiences (Smith, 1981), and a sense of well-becoming (Phillips, 2019). Individuals can be healthy even as they take their last breath
Communications between nurse and client are relationship oriented. The interactions focus on intra-connections with mutual respect for the expertise that each brings to the relationship. When nurses understand that their clients' perceptions of what will help them cope, adapt and heal, clients develop trust in the nurse's professional expertise. Communications focus on the needs of the unitary-being facilitating the two members to works as one, facilitating discovery of the root of the problem, restoration and maintenance of natural, inherent abilities.
All nurses recognize the necessity of practice based on evidence. However, how evidence is derived is based on paradigms. Nurses practicing from a wholistic paradigm generally seeks scientific evidence that informs the nurse how to think about and treat a biomedical problem. They may consider how this information relates to the perspectives of the nursing discipline, or may simply build on the bio-medical model of care. Integration of this information is then presented to the patient for consideration.
Care plans are primarily designed based on best medical practices with consideration of patient response, aim of practice, and evaluation of outcome goals. Knowledge and skills of professional nursing are usually secondary or even unrecognized; the patient's preferences are considered within the context of the medical problem and associated complications. While this model of EBP varies by nurse, some variant is often associated with the wholistic nursing paradigm.
Holistic nursing practice is based on evidence-informed caring processes (EIC), rather than evidence-based care (EBC). EIC processes assert that the client's perspective is essential when assessing the situation, identifying the presenting issues and planning best practices. While the perspectives of the professionals involved provide important information, the individuals need for a sense of quality of life and wellness, and what will give meaning to their life, is essential information needed to co-plan processes Science guides these processes; therefore, how a nurse defines whole-person, health, anticipated outcomes, etc. will determine the science needed.
By 2019, the members of CMTF concluded that it was essential to continue to address the issues resulting from differences in paradigms, and find a formal, sustainable venue to do this work. Leaders in AHNA and AHNCC were informed, and the CMTF Members continued to explore, discuss, and debate best moves forward. As they did, a few ideas became clear:
- Mason, Jones, Roy, Sullivan, Wood (2015) studied exemplar models of care that are cost-savings and demonstrated enhanced quality of life and diminished bio-medical problems. They found that these nurses identified health identified holistically, client-centered care, and relationship-based care that facilitates engagement and client activation as three of four components of their practice.
- These nurses were entitled Edge Runners of nursing. While their work was described by the Robert Wood Johnson Foundation as Nursing's Prescription for a Reformed Health System.
- Nevertheless, nursing education has consistently moved toward programs that teach to the wholistic bio-medical models of care, without a clear distinction between nursing and medicine.
- This state of affairs results in legislation in nursing based on the bio-medical model of education, creating a cyclic relationship between education and legislation.
- In the interim, national and international studies have indicated that society needs nurses who practice from person-centered, holistic models of care.
- Internationally, there is a large number of holistic nurses who are conversant with and committed to holistic praxis but, due to lack of understanding of paradigmatic differences in practice, are confronted with some of the barriers experienced by the CMTF.
- An autonomous, international venue where scholars would come together to network, brain-storm, and plan programs based in the holistic paradigm with the potential to transform healthcare globally.
While the idea of an academy had germinated, it took several more meetings before the idea came to fruition. In early 2019, AHNA and AHNCC were informed that the CMTF was in the process of creating an organization specifically focused on the promulgation of the relationships among the values and beliefs of holistic nursing and the ontology, epistemology, pedagogy, and praxes unique to holistic nursing.
The first meeting of the group for the specific purpose of creating an academy occurred May 2, 2019. CMTF members committed to serving as the Founding Members of GAHN continued to meet weekly with occasional breaks for holidays or respite. The intent was to develop an organization that compliments AHNA and AHNCC, and avoide replicating the services of either organization. The Founding Members concluded that the purpose of GAHN was to create an international venue and culture that would support advancement of Holistic Nursing but not replicate the services or activities or AHNA or AHNCC.
Discussions initially focused on articulating the vision, mission, purpose, outcomes and related goals of GAHN. Next, the group focused on the infrastructure, formal roles, internal operations, and external affiliations of GAHN. The President and Chair of AHNA and AHNCC respectively were informed that the GAHN Board was moving forward. Dates were set for November 2020 to meet with AHNA and AHNCC Boards to further explore relationships among the three organizations. Relations were established between GAHN and AHNA and AHNCC respectively during late 2020 and early 2021.Concurrently, Charter Members were invited to join Founding Members to continue work on the infrastructure while planning for inclusion of Inaugural Members in spring of 2021. An announcement was released to the Holistic Nursing Community in early March. Concurrently, GAHN's website was published and a companion press release informing the community that applications for the first cohort of Scholars would be open April 1-30, 2021.
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