Margaret Erickson: Changing the healthcare paradigm—A holistic nurse’s perspective

Nursing may be one of the most trusted professions around, but Margaret Erickson believes it needs to be elevated and respected at a new level. Nurses and the care they provide are foundational to the healthcare system and play a prominent role in today’s pandemic crisis. Yet nursing care is usually included in hospital budgets, shockingly, as “lodging expenses.”  Erickson is uniquely qualified to discuss current and future nursing care, having practiced holistic nursing for more than 40 years and holding her PhD, RN, CNS and APHN-BC®.  Since 2000, she has been working to educate and advance the role of nurses as CEO of the American Holistic Nurses Credentialing Corporation (AHNCC).

In this interview, Erickson offers her thoughts on how holistic nursing goes beyond today’s typical nursing tasks and the role it plays in today’s shifting healthcare paradigm, on the importance of self-care for patients and practitioners, and on the mission of AHNCC.  Erickson, as the newly-elected Co-Chair of the IHPC Board of Directors, discusses her expanding role with IHPC.

IHPC: Tell me about the philosophy behind holistic nursing and how it is different from traditional nursing?

Margaret Erickson: Holistic nursing is grounded in the roots of nursing and a philosophy of holism. Holistic nurses believe that people are spirit-mind-body-emotion integrated beings, that all people are greater than the sum of the parts, and that our subsystems are constantly interacting and affecting one another.  People cannot be separated from their environments. Nursing is not something we do as tasks or based on  the policy and procedure manual but rather, it is how you show up, interact, connect with the person; and help them access resources so they can be healthy and have a higher state of wellbeing, even if they are taking their last breath. Holistic nurses are always competent in the tasks and care for the physical needs of the person but that does not define their practice.

If we go back to Florence Nightingale in the 1800s, nursing was about caring for the whole person. Florence recognized the importance of meeting patients’ basic, trust, and safety needs as well as higher needs such as growth, spiritual, and needs for beauty and nature. Care was holistically focused.  She recognized that people have an innate ability within to heal and that as nurses our goal was to facilitate them in that healing process. However, in the 1970s, nurses aligned with the bio-medical paradigm to validate themselves rather than seeing they had their own discipline, a unique perspective and something special to offer. The focus of nursing care within this paradigm is treating and curing–when possible–illness and disease and is task oriented. Again, Holistic Nursing isn’t about doing tasks. However, we do have to be competent in any work or tasks we do. You can’t try to start an IV on someone several times or the patient will be very stressed, their blood pressure and respiratory rate will be elevated, which in turn affects their immune system and ability to heal. How we approach and complete our work–whether it is as an advocate, educator, or with hands on care at the bedside–affects the entire person and their ability to heal and achieve a greater state of well-being. So, you have to be competent in tasks but again that is not what defines nursing. We believe the most important instrument of healing is ourselves. It is not about us telling patients—I call them clients– what they need to do. It is about understanding who they are and facilitating and supporting them in accessing their resources to help them have the highest quality of life they can achieve.

IHPC: How do you use these philosophies in dealing with patients?

ME: The newest research shows that we make an impression in the first 7-10 seconds when we interact with others. When I walk in a room, am present, recognizing that I am in sacred space with another, I might say ‘Mr. Jones I am here to take care of you’– I speak slowly, and quietly respecting his space. My focus is on the person not the equipment, medicine, documentation, etc.  In this first interaction with the client I tell him, he is important to me.

On the other hand, if I hurry into the room and do tasks like checking the IV, foley, or charts it shows that that is what is most important. The patient is then less likely to feel safe and trust you. Consequently, they often don’t share the important information you need to help them get well. When they don’t trust you, they won’t tell you the real story, what their needs are, and what brought them into the hospital or healthcare system. When we focus on tasks and decide what peoples’ needs are, we have a problem. No one knows someone better than they know themselves. Yet, we decide what their problem is, develop a plan of care in which they are not engaged and then we call them non-compliant. This contributes to treating the symptom rather than the root of the problem and then we have clients having multiple admissions for the same problems.

IHPC: Can you give me some examples of how this might have an impact on patient care and treatment?

ME: In most programs, we currently teach nurses to focus on the presenting symptoms, but that is only part of their care. For example, as a Case Manager in South Dakota, I had a patient admitted with severe respiratory distress. He was medicated and put on oxygen. The physician wanted to intubate him. He demanded that they call me. He told me between gasps that a blizzard was coming and his dog, who was the only person in the world who loved him, kept his home safe from others, would die if left out in cold. He refused to be intubated until I got back from taking care of the dog. I told him I would check on the dog and make sure he was safe. I asked him if while I was taking care of his dog if he could try to slow down his breathing and let the medications he had received begin to work.  I spent a couple of minutes with him, talking quietly, and working with him so he could breathe easier and deeper. I told him I would be back shortly after taking care of his major support system (his dog). I contacted a neighbor and asked him if he would go over and care for the dog. When I got back, and told him his dog was inside, he was better and we didn’t need for him to be intubated. He was so anxious about the dog that it was making his symptoms worse. Some people would have said don’t worry about the dog, you must get intubated first. As holistic nurses we try to listen, understand, and then address a person’s needs as we know that their emotional, spiritual, social, cognitive subsystems all affect their physical wellbeing. People cannot be separated into parts. So, in a biomedical paradigm, nursing and medicine focus on physical health, the body; treating illness and disease. The difference in holistic nursing is we recognize that people are unified beings; we can’t separate them into pieces or systems.

Listening to people is very important. It is essential if we want to understand what is really going on and be able to treat the root of problems versus the presenting symptoms.

I had a gentleman who was a revolving-door patient coming in and out of the hospital, nothing was working for him. His angina was getting worse, and he was identified as a financial problem for the hospital as well as an “impending cardiac event.” I was asked to see him as “he is spending too much time in our hospital and he is getting worse, not better.” I entered his room quietly and respectfully, focusing on his face and eyes.  I didn’t say anything about his admitting symptoms, but rather introduced myself, and asked why he came in?  He told me to check with doctor, and I responded, ‘I don’t care what the doctor or anyone else says or what the records say, I want to know why you think you are here? No one knows you as well as you know yourself.’ His. eyes filled up with tears and he told me his wife of 60 years had died six months ago and that he was broken hearted. He shared that he was a rancher, who lived a long way from town, that he had COPD after decades of dust and exposure to his environment from working outside. Although he had COPD he had managed as his wife had taken care of him, and they had had each other.  He was dealing with unresolved loss, and it was affecting his physical, emotional, and social well-being. I asked him how I could help and what he needed. Then I listened. He said he missed his wife terribly and was very lonely. He needed to be with other people, to talk to someone about his wife, and to have help with his activities of daily living. I worked with him, made some referrals, and he moved into town to assisted living. His chest pains went away, and he no longer needed his medication.

Understanding peoples’ life experiences is another important factor. As a case manager I was asked to follow up with an elderly gentleman who lived on the Pine Ridge Sioux Reservation. I was told I needed to talk to him after the nurse educator (NE) provided his ‘diabetic teaching’ and before he was discharged. I was asked to see him because he was diabetic and non-compliant with his medication and diet. He and his niece came to get instructions before going home. Due to his poor vision and hearing, the niece, as his caregiver, was watching and listening close to the nurse educator. He was very respectful and trying to listen but watching him I was reminded of Snoopy in the Peanuts cartoon, where all he would hear was “blah, blah, blah.” It looked like the ‘education’ was going right over his head.

After the session I asked him if he had any questions. He quietly responded, ‘no,’ at which point I gently said, ‘I noticed when she talked about eating fresh fruit and vegetables that you might have a question.’ He said ‘well yes, I guess I do. I was thinking that fresh fruit and vegetables only come to the reservation once a month. If I am not there, I don’t get any, so what am I supposed to eat?’  Then he asked ‘Did you say insulin must be kept cold?  I don’t have electricity for a refrigerator.’ His healthcare providers had never heard about his real-life experience. For the last 20 years the system had treated him based on their perceptions and assumptions, never understanding his needs or his lived reality. I was really upset. He’d been identified as non-compliant for the last 20 years when in reality the system was neglectful and let him down. Now he was nearly blind and had chronic renal failure. It was outrageous!’

IHPC: Sounds like this comes down to education and training of nurses?

ME:  That’s right. The focus and philosophy that guides nursing education and the curriculum taught determines what the nurse focuses on in their practice. Is the focus tasks or is it holistic, relationship-based care of all aspects of the person’s care? Wholism with a ‘w’ is what is currently taught in most nursing program. In these programs, nurses are taught that people have different subsystems which need to be care for. That people are the sum of these different parts. This is different that the belief that all of our subsystems, are in constant interaction, affecting one another. With “wholistic” care we look at the different parts of the person and treat them accordingly. The focus is usually dealing with the physical domain. For example, when a nurse takes a history and assessment, they focus on the physical or clinical health–they assess the body; whereas in holistic nursing, we do a holistic assessment and include an emotional, cognitive, psychosocial and spiritual as well as the physical assessment. We look at how the spiritual aspects of the person affect the emotional or the emotional aspects/subsystem affect the person’s physical health. Most nursing education programs teach that you must consider the different subsystems, but they don’t teach a holistic approach, where the nurse learns to assess the person holistically.  Nurses need to look at the whole person, not just the heart attack in room 225, the post-surgical hip replacement in room 5, etc.  Nursing education must change if we expect to have nurses provide holistic care vs. focusing on the person’s bio-medical needs and issues.

IHPC: How does AHNCC work to address these issues?

ME: –AHNCC is the national credentialing body for Holistic Nursing and Nurse Coaching. We work closely with the American Holistic Nursing Association (AHNA), which is our membership organization. AHNCC’s mission is to provide rigorous, valid examinations that test holistic nurse and nurse coaches’ knowledge, skills, expertise, attitudes, and values. Although our nurses may use healing therapies/interventions such as massage, aromatherapy, or healing energy, it’s not what defines them.  They are just additional tools that they carry in their tool box.

To apply for holistic nursing certification, AHNCC applicants must complete educational programs and courses that focus on holistic nursing theory, research, practice, spirituality, health, wellness, wellbeing, etc. Many of these educational programs are offered by AHNA or by other accredited institutions or organizations. Recent, active nursing practice is also required. AHNCC also offers nurse coaching certification which is geared toward the skills, knowledge, expertise, values, and attitudes utilized when practicing in the role of nurse coaching. Our nurses work in all settings and with people throughout the lifespan. At this time, we credential only RNs; we don’t have programs for other disciplines.

IHPC: You have been involved with the organization two decades. How have you seen it evolve?

ME: AHNCC started with one exam in 2000: we now have 5 and two certification programs (holistic nursing and nurse coaching). We are very proud of that.  In addition to the two certification programs, AHNCC has acquired national accreditation from the ABSNC, and our examinations are ANCC Magnet approved. Both of these recognitions validate the rigor and value of our certifications. AHNCC also works with universities around the country to create holistic-based nursing curriculum because how we educate nurses is so important. If we educate only about symptoms, illness, and disease then you have nurses prepared to work within and support a sick-care system.

We believe that self-awareness, self-reflection, self-care, and ongoing growth and development is essential to holistic nursing practice. What I learned 20 years ago is not sufficient for what I need to know now. As a holistic nurse, one is expected to continually commit to learning experiences and educational opportunities to support the lifelong learning process.  With that in mind, we have built a repository for current educational programs that will support our certificants’ lifelong learning needs. We have seen a lot of growth and many changes in the last 20 years, but it is not happening fast enough.

IHPC: Nurses are under a lot of pressure in the current COVID-19 crisis. How do you see their role changing as a result?

ME: Self-care is something we have been talking about for 40 years, but COVID is bringing it forward full force. Self-care is not just for patients. It means caring for yourself as a nurse so you can care for others.  You have to have balance and a sense of harmony to do that.  I also facilitate self-care for my patients so they have resources to do what they need to do to get well. It’s a big problem now, as we see nurses and other healthcare providers who are stressed out; nurses leaving the profession or retiring earlier than ever before. But we are making progress. The importance of caring for self and how it impacts a nurse’s or other care providers’ resiliency and decreases compassion fatigue and the need for care providers to have the support and resources so they can care for others is being recognized and valued.

The role of holistic nursing is also becoming more prominent in the COVID era. The ability to be present, hold a hand, support families and people who are dying has often been absent during this pandemic, and these services have been missed. Nurses and those they care for expect and need to have their physical needs met, but what has been missing and is often shared by distraught nurses is their ability to address the client’s spiritual, emotional, and social needs. We need to pay attention because viruses don’t go away. We need to learn to live with them. One of the things we can do is to help people build stronger immune systems and seek higher levels of wellbeing. How we feel and think, what we eat, the stress we experience, toxic relationships, etc. all impact on our ability to stay well and fight off viruses or other health challenges. We also know that the healthcare system we have is broken, and we need to make changes. A paradigm shift is required which moves our focus from illness and disease to health, wellness, and wellbeing. COVID has challenged and highlighted what isn’t working and given us the opportunity to keep what is working, and make the necessary changes that will better serve all of us.

IHPC: You have an expanding role with IHPC. What do you hope to accomplish?

ME: One thing I am encouraging IHPC to do is to continue think about who we are as organization.  Are we a collection of integrative practitioners who practice separately or a holistic integrative organization working together, grounded in our values and philosophy. Who do we serve? We need to dialogue more about the intent of our work and our mission, collectively, as an organization.

The challenge in healthcare is to get out of our silos while respecting and validating what each profession offers and to recognize the expertise, skills, and knowledge each profession can share with the collective group. Traditionally in healthcare we have had a linear, patriarchal system. Our system is top to bottom with clients at the bottom and that needs to change. I believe that all of healthcare providers are my colleagues. We work and collaborate together to empower and facilitate the client in healing. That if anyone is in the driver’s seat, it is the client. I know I have a different perspective than some of my colleagues. We often talk about patients being noncompliant. I believe that is because we are approaching it the wrong way. We need to be empowering the client–who by the way has the most invested and the most to lose–to co-create a plan of care with them that they buy into. When people are supported–given control and choices–they engage and healthcare outcomes become very different.

 

IHPC: You are also working with IHPC to address issues of equity, diversity and inclusion in health care. How can this lead to a change in the system?

We have systemic problems in healthcare, the government, and education. As an organization, IHPC’s intent is to address making healthcare accessible for all. I think we need to become more educated and informed if we are to work towards our goal of equal access and health care services for all people, especially the vulnerable and disenfranchised populations. Our communities, society, and even globally is only as strong as our most vulnerable populations. Learning about equity, diversity, inclusion, and social justice (EDISJ) issues and how we change systemic racism will impact on not just who sits on the Board, but on how IHPC presents ourselves, our policies, and procedures, our committee work, etc. We all have blind spots, so we have to commit to learning opportunities that present themselves and recognize that this is an ongoing process.  Working with Tracy Bowen, Executive Director at IHPC, is helping me to realize some of my own blind spots. The more blind spots we uncover, the more of a holistic understanding and perspective we will have to address these critical issues.

As a starting point, I believe that IHPC needs to begin our EDISJ education, so we will be better able to do our work. Currently, we have a fairly homogenous organization, our diversity is not great. More diversity will broaden and strengthen our world view. Diversity makes us stronger and allows us to have more resources to do our work. As our organizational worldview expands and we have fewer blind spots, we will be better able to serve our stakeholders.

Going back to my American Indian patient, if we had had someone there who could have bridged that gap, we would have been more attuned to his needs. So that is one of the areas I am working on: to see that our world view is expanded. The broader it is, the more effective we will be in supporting health, wellness, and wellbeing for our clients and society at large.

IHPC is a great model for interdisciplinary work, and I believe a team approach is the future in health care systems. IHPC is one of the few organizations I have worked with that sets the intent to honor and respect each other. It has great potential for helping change the paradigm. We just have to get past the growing pains, like all organizations. It is a wonderful inclusive model, and I would like to see this idea accepted, valued, and implemented in all health care systems. By elevating, recognizing, and validating the significance and worth of integrative practitioners like acupuncturists, naturopaths, or chiropractors, we are better able to serve our clients and communities.

Perhaps now, COVID, the continued highlighting of systemic racism, our sense of being disconnected from our loved ones and support systems, extreme economic upheaval, and other issues that have changed how we live our lives as we knew it, etc. are creating a perfect storm which will mandate systemic changes. We need to embrace this opportunity. Change is hard, but we can do it.