Integrative Care

“Self-care techniques are a mandatory component for all people practicing holism. Recognizing the need for education and the importance of fostering self-responsibility is essential. Self-care is still the predominant mode of health care” (Chernin as cited in Kunz*).

Thirty years have elapsed since Kunz* began to teach patients to care for themselves holistically as part of primary prevention. In my 36 years of developing early intervention techniques and programs to affect individual and family, health, marriage, sexuality, and spiritual direction, I have come to an understanding of prevention and integrative health care that I believe to be unique. Most of what is called “integrative” in medicine, nursing, and counseling is added on to a primary field of interest. Even the concept of “holistic” examines alternative modes and incorporates them into traditional care.

True integrative health care does not add on because the integration is based on another concept altogether—the concept that each person is an integrated being. The individual has an integrity that traditional care fragments through its failure to see the congruence of the entire being. Integrative health care is a radical shift in perspective that views patients as choosing a fundamental, single mode of self-expression across all aspects of their lives.

I spend a great deal of time working with businesses, hospitals, and other organizations teaching them how to shift the view of themselves and the metaphor their lives express. I listen to the “fluff” that is sometimes presented about staff development, patient care, retention, problem solving, and management, and I know why everything eventually sinks back into a morass. Entropy! To truly influence these issues, we must realize that metaphor is everything; it is the essential self-descriptor, whether we are talking about individuals or organizations.

More simply stated, each individual is the metaphor for his or her own unique existence. This metaphor is inclusive of culture, family, community, beliefs, thoughts, and experiences. In our encounters with another human being, we see the conscious and unconscious expression of that person. At the same time, the metaphor for anything that includes individuals is only that, a metaphor. To change the metaphor means we have to see that, without viewing the individual in the metaphor of “whole person,” nothing exists. Take away all of the people and there is nothing—just created “stuff.” Without selves as fully expressive metaphors, nothing exists that is healthy.

We, as practitioners, fragment and interpret diagnostics and treatments to suit what we know, believe, and practice. Then we take our own fragmented worldview and add those fragments in for prevention. The resulting picture is a mosaic of the individual and of ourselves, for that matter.

DEFINITIONS OF PRIMARY PREVENTION

If we examine “primary prevention,” we learn that it embodies interventions in asymptomatic people. A recent research compilation* states that three areas are likely to be of benefit in primary prevention: eating more fruits and vegetables, increasing or maintaining physical activity, and smoking cessation.

Alternatively, the American Heart Association* defines primary prevention as educating about risk factors and lifestyle changes to reduce risk; identifying and altering risk factors to prevent cardiovascular disease leading to heart attack or stroke; smoking cessation; controlling high blood pressure and cholesterol; maintaining physical activity; and addressing obesity, overweight conditions, and diabetes. In either case, the construction of the concept offers prevention measures as part of a risk management assessment with guidelines to follow.

Now, there is nothing wrong with the assessment, guidelines, or prevention areas, except for this: the guides are all physical and consist of things to be either avoided or introduced into the life of an asymptomatic person. Although the funding/research basis of psychoneuroimmunology by the National Institutes of Health supports the need for a cohesive view of ourselves and our patients,* there is no suggestion in primary prevention guidelines based on the “psyche” portion of the psyche/soma equation. This is the fundamental reason we have unhealthy people who are perceived as “noncompliant populations.” I suggest that our populations are not noncompliant with preventive measures but with what is excluded from the equation!

WHAT IS INTEGRATIVE HEALTH CARE?

What is not included are those factors that create truly integrative health care and should precede what we call primary prevention. In this field of integration, we are not practicing nursing, medicine, counseling, or spiritual direction; integrative health care lies beyond all of these health fields as something new altogether and not an add on. If we are to help people (and ourselves) to become healthy and well, we must integrate the psyche. We must teach the foundations for approaching such questions as: Who am I? What is the meaning of my existence? Where am I going? What is my life about? By the answers to these questions, each of us lives and dies. We make choices for lifestyle based on what we choose to live, not by what we avoid. It is here that we choose complementary or alternative options available to us. Once this is understood, both integrated health and primary prevention become feasible.

Yarnell et al* determined that 7.4 hours of preventive education should be performed per day in the average medical practice. This is not being done because of insurance costs and time constraints. According to Mirand et al,* “Spending time to discuss prevention with a patient was perceived by some physicians as not being a prominent element in the role of doctor nor an effective use of physician time. This view, compounded by the practice emphasis on diagnosis and treatment, lessened the likelihood of PCP [primary care physician] delivery of primary prevention.” This approach to health care is as true for many nurse practitioners as for physicians. How are we to integrate the psyche without taking the time to learn about the whole person?

Integrative care is more fundamental than primary prevention. An integrative approach at the primary intake level can intervene into a health care plan; diminish depression; maintain a protocol for the patient, child, couple, and family; support physical, mental, emotional, and spiritual health across a developmental lifetime; and still provide quality, cost-effective health care at a primary prevention level. It supports the premise of the individual as one discovering self and then creating out of the discovery. The fundamental question addresses the meaning of primary prevention and how we teach individuals to seek their own health in an integrated manner. It is plainly foolhardy to believe that “sitting a patient down and asking them what they want to change”* is integrative or educational. It is neither.

Researchers are beginning to say what educators have known and practiced for years: The most powerful and effective education is not the imparting of information but the modeling of those behaviors. Perhaps it is time for advanced practice nursing to consider that our efforts to supplement, support, commandeer the health of the nation, and garner direct reimbursement for those services might not be a sufficient reason for our efforts!  Perhaps it is time not solely for advances in technical clinical approaches but also for a new concept for providing prevention as advanced practitioners in integrative care.

References

1. Chernin D. Holistic medicine: its goals, models, and historical roots. In: Kunz D, ed. Spiritual Healing: Doctors Examine Therapeutic Touch and Other Holistic Treatments. India: Quest Books; 1995.

2. Clinical Evidence Concise. 2003. Available at: www.clinicalevidence.com/lpBinCE/lpext.dll?f=templates&fn=main-hit-h.htm&2.0. Accessed 2003 August 22.

3. American Heart Association. Primary Prevention Guidelines. 2003. Available at: www.americanheart.org/presenter.jhtml identifier=2660. Accessed 2003 August 22.

4. Schwartz S. NIH and the Harkin Directive: Subtle Energies and Social Policy. 1994. Available at www.irva.org/papers/NIH_Harkin_Direct.pdf. Accessed 2003 August 23.

5. Yarnell K, Pollak K, Ostbye T, Krause K, Michener J. Primary care: is there enoughtime for prevention? Am J Public Health. 2003;93(4): 635-641.

6. Mirand A, Beehler G, Kuo C, Mahoney M. Explaining the de-prioritization of primary prevention: physicians’ perceptions of their role in the delivery of primary care. BMC Public Health. 2003;3:15.

7. Marion L, Viens D, O’Sullivan A, Crabtree C, Fontana S, Price M. The practice doctorate in nursing: future or fringe? Available at www.medscape.com/viewarticle/453247. Accessed 2005 August 24.