Welcome to Holistic Nursing Ethics and Culturally Competent Holistic Nursing! In this virtual chapter, the spotlight is on learning about the ethical implications of holistic nursing and the topic of unconscious bias. The overall purpose of this chapter is to build knowledge about ethical approaches for the holistic nurse for all persons. For more holistic nursing resources about ethical holistic nursing practices and cultural topics, see the resources at the end of this chapter.

By Nancyruth Leibold, EdD, RN, MSN, PHN, CNE, AHN-BC

Terms/Vocabulary

Accountability is judgment, action, and answerability to self and others (ANA, 2015).

Autonomy  is the self-governance of one’s decisions and life plans based on personal beliefs and values (Haahr et al., 2020; Shanaz et al., 2020).

Culture is a collection of beliefs, values, customs, communicating, practices, and ways of thinking of an individual or group (CDC, 2020).

Belonging: the person feels accepted for who they are (Wadors, 2019).

Beneficence  is doing what is “good” for patients by balancing risks, benefits, and values (Shanaz et al., 2020).

Diversity:   a culture that acknowledges and appreciates people with different races, genders, cultures, and backgrounds (Wadors, 2019)

Equality :   equal for everyone with no consideration for individuals

Equity:   equal for everyone with consideration made for the individual

Implicit Bias: see unconscious bias; the term unconscious bias is used in this chapter

Integrity is trustworthiness and a pledge to honesty in that one is not corrupt or false (Merriam-Webster, 2021).

Justice  is treating a person in a fair manner (Shanaz et al., 2020).

Nonmaleficence  is the avoidance of harm to a patient (Shanaz et al., 2020).

Reflection  is an active strategy that involves introspective and retrospective examination and evaluation of experiences, beliefs, knowledge, oneself, and practices to improve the future (Dewey, 1933; Kember et al., 2008).

Respect means holding in high regards or a state of quality (Merriam-Webster, 2020).

Rumination  is the act of re-hashing an event or experience with no intention of moving forward or problem-solving (Kircanski et al., 2015).

Social justice is the participation in society with fair equitable treatment, benefits, resources, and burdens for all people (Beuttner-Schmidt, 2011).

Trust means one can reply that another is honest, credible, and forthright (Merriam-Webster, 2021).

Unconscious bias means deeply ingrained attitudes and stereotypes that affect human thoughts and actions, including a lack of self-awareness (Gordon, 2017).

Ethical and Culturally Competent Holistic Nursing Foundations

Ethical practices are central guiding aspects of holistic nursing practice. This chapter examines selected topics of ethical holistic nursing practice. The American Nurses Association (ANA) Ethical Code of Conduct and the ANA/American Holistic Nursing Association (AHNA) serve as ethical guides. Additionally, the chapter integrates the theories of Caring Science and Peace and Power. The chapter embraces the concepts of accountability, trust, respect, integrity, beneficence, nonmaleficence, and justice. The chapter also includes unconscious bias and social justice specific to awareness as applied to holistic nursing.

ANA and AHNA Holistic Nursing Scope and Standards and ANA Code of Ethics

Holistic Nursing Standards and the ANA Code of Ethics provide the overall structure for this chapter. Two holistic standards are Standard 7 and Standard 8 of the ANA and AHNA Holistic Nursing Scope and Standards (2019). The following items quote the standards:

Standard 7. Ethics. “The holistic registered nurse practices ethically (ANA & ANHNA, 2019, Kindle location 1880).

Standard 8. Culturally Congruent Practice. “The holistic registered nurse practices in a manner that is congruent with cultural diversity and inclusion principles” (ANA & ANHNA, 2019, Kindle location 1925).

Standard 7 and 8 are the organizational standards of holistic nursing practice that guide this chapter. Selected topics that relate to Standard 7 and 8 are in this chapter. Holistic nurses must realize that ethical nursing practice is an area of lifelong learning.

The ANA Code of Ethics (2015) includes Standard 15: Professional Practice Evaluation. Standard 15 “Ensures that nursing practice is consistent with regulatory requirements pertaining to licensure, relevant statutes, rules, and regulations” (ANA, 2015, p. 81). Standard 15 also includes organizational policies and procedures and delegation within legal policy (ANA, 2015). Holistic nurses must be knowledgeable and follow organizational policy and nurse practice legislation where one holds nursing licensure and practices. Other ethical standards of holistic nursing are vital as well, but these two standards were chosen to start this chapter. Throughout this chapter, as well as other book chapters, include other ethical codes and standards for holistic nurses.

Accountability

Accountability  is judgment, action, and answerability to self and others (ANA, 2015). Accountability is foundational to professional nursing practice. According to Drach-Zahavy (2018), accountability in nursing includes responsibility for decisions, actions, transparency with explaining such, and answering to such within the accepted values of society. According to the American Nurses Association (ANA, 2015), nursing accountability requires nurses to be answerable for their actions and act according to a code of ethical conduct. Such ethical conduct includes abiding by beneficence, autonomy, nonmaleficence, justice, and integrity. Holistic nurses follow the ANA Code of Ethics in addition to the ANA and AHNA Scope and Standards for Holistic Nursing.

Code of Ethics and Accountability

The (ANA, 2015)  Code of Ethics  sets forth the values and obligations of the nurse. Provision 4 has a core focus on accountability and responsibility, stating, “The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care” (ANA, 2015, p. 59). The nurse’s ethical obligation is to protect and be accountable to oneself and society (Murphy, 2020).

The following four interpretive statements from Provision 4 further illustrate the depth of accountability and responsibility in nursing practice:

4.1 Authority, Accountability, and Responsibility

Accountable for one’s practice, care ordered by a provider, care coordination (Murphy, 2020).

4.2 Accountability for Nursing Judgments, Decisions, and Actions

Nurses must follow a code of ethical conduct.

Follow the scope and standards of nursing practice (Murphy, 2020).

4.3 Responsibility for Nursing Judgments, Decisions, and Action

The nurse is always accountable for judgments, decisions, and actions, though the employer may be jointly responsible depending on the situation.

Nurses accept or reject an assignment based on education, experience, competence, and risk for patient safety (Murphy, 2020).

4.4 Assignment and Delegation of Nursing Activities or Tasks

Assignments and delegation activities must be consistent with the Nurse Practice Act, organizational policy, and nursing standards of practice.

Assess individual competence before assignments (ANA, 2015, p. 59).

(Parts of the accountability section of this chapter adapted from Murphy, 2020)

Ethical Principles: Autonomy, Justice, Beneficence, Nonmaleficence, Integrity

Ethical principles guide holistic nursing practice. The desire to do the “right” thing in nursing practice is of vital importance. However, complex situations can arise that are challenging for nurses to do the “right” thing, so ethical codes and principles help guide nurses through such cases.

Autonomy  is the self-governance of one’s decisions and life plans based on personal beliefs and values (Haahr et al., 2020; Shanaz et al., 2020). In holistic nursing, this is usually specific to health-related choices and pursuits.

Justice  is the fair treatment of a person (Shanaz et al., 2020). Justice is not the same as equality, as people require different amounts and levels of care. However, justice is consistent with equitable healthcare. For example, females and males should receive just and fair care appropriate for their gender.

Beneficence  is doing what is “good” for patients by balancing risks, benefits, and values (Shanaz et al., 2020). Holistic nurses act in the best interest of patients when practicing with beneficence. However, sometimes autonomy and beneficence can conflict.

Nonmaleficence  is the avoidance of harm to a patient (Shanaz et al., 2020). Avoiding harm is sometimes observed in healthcare when people “err on the side of caution” to promote the safest care possible.

Case Study BoNanza

A patient brought to an emergency room was resuscitated and admitted to the Intensive Care Unit by a hospital physician. However, after admitted to the Intensive Care Unit, the hospital physician finds out the patient is terminally ill and did not want admission to the hospital nor resuscitation.

The physician acted with beneficence by doing good for the patient and did not harm the patient (nonmaleficence). However, the new information that the patient did not want admission to a hospital nor resuscitation (autonomy) provides a new change. Therefore, the physician writes an order for no resuscitation orders.

The patient was treated with justice as the physician provided proper and fair care for a presenting person in a life-threatening emergency. The lack of information about the patient’s wishes changes care the patient might have received had the physician known.

 

Use Critical Thinking to Answer:

What ideas do you have to prevent the initial call for emergency treatment from happening to a person who has requested no hospital admissions and no resuscitations?

What protocols or practices does your organizational workplace have to address such a situation?

Think of your ideas, but you do not need to submit them to the professor.

Note: case study adapted from Shanaz et al., 2020; CC BY NC.

Integrity

Integrity is trustworthiness and a pledge to honesty in that one is not corrupt or false (Merriam-Webster, 2021). Haahr et al. (2020) identify integrity as a hallmark of holistic nursing. In addition, the ANA (2015) Code of Ethics for Nurses includes Provision 9.2 Integrity of the Profession. This ethical provision speaks to the obligation of nurses to uphold fairness, respect, and caring in national and global health to foster health for all populations (ANA, 2015).

 

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Respect

Respect is a key aspect of the American Holistic Nursing Association (AHNA) and the Scope and Standards of Holistic Nursing Practice.  Respect  means holding in high regard or a state of quality (Merriam-Webster, 2020). The ANA and AHNA (2019) describe holistic nurses as respectful and trustful of self, others, and by valuing the contributions of others. Provision 1 of the ANA Code of Ethics states:

“Provision 1. The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person” (p. 1 of online text).

The ANA and AHNA supports this provision and reiterates it in the Scope and Standards for Holistic Nursing (2019). The ANA and AHNA (2019) speaks to respectful communication and care for all persons that includes

“culture, values, religious or spiritual beliefs, sexual orientation, language, socio-economic status, race, gender, and age. The holistic nurse identifies and manages his or her own personal and professional prejudices and biases when planning individual, family, and population-centered care” (Kindle Location 535).

Compassion and respect for every person is ingrained in the standards of practice for holistic nurses by the American Nurses Association and the American Holistic Nurses Association.

Trust

Trustmeans one can reply that another is honest, credible, and forthright (Merriam-Webster, 2021). The ANA and AHNA (2019) describe the overall role of a holistic nurse as one that includes a trust for self and others as part of the healing process. Holistic nurses strive to create a work environment enhancing cooperation, trust, and respect (ANA & AHNA, 2019). Jean Watson included trust in the 10 Carative Processes® as Carative Process number 3 (WCSI, 2021, para 1):

“3. Trust (Transpersonal). Being sensitive to self and others by cultivating own spiritual practices; beyond ego-self to transpersonal presence.”

Trust is a concept of inclusion in quintessential guiding statements for nurses.

One practice for holistic nurses is to use effective communication to develop rapport and build trust. Building trust is the foundation of nurse communication. When nurses are in pre-licensure education, learning about creating trusting relationships with others is crucial. Hammond (2015) writes about effective communication with educators that is applicable for holistic nurses. Key areas include listening and trust generators. Listening includes giving full attention to the speaker. It is essential to listen to what the speaker is saying and the feelings interwoven with the words (Hammond, 2015). The use of nonjudgmental acceptance while listening to others is vital. Hammond (2015) stresses listening with compassion. Holistic nurses should show respect to the speakers culturally ingrained communication (Hammond, 2015).

Trust Generators and Holistic Nursing

A trust generator is a set of actions used to connect with others (Hammond, 2015). Trust generators for holistic nurses are borne out of respect and include similarity of interests, familiarity, concern, and competence. Holistic nurses can use trust generators when building trusting relationships with interprofessionals, co-workers, patients, families, and communities.

Similarity of Interests is when one realizes that another person has similar interests, values, likes, or dislikes (Hammond, 2015). As a result, a bond or connection may form between persons with similar interests. For example, consider the care of a holistic nurse, Becky, who hears a patient remark about their passion for going to the local high school hockey games, which is also an interest of Becky’s. While providing care for the patient, Becky shares comment about the team. This shared interest of the local high school hockey team generates trust between Becky and the patient.

Familiarity is when people see each other often in their daily life routines (Hammond, 2015). For example, when two people often see each other while walking each day at a regional park, a sense of familiarity is cultivated. Ben is a holistic nurse who practices walking nearly every day in his neighborhood and to a nearby park where is walks in the woods on the paths. About four times a week, he sees a couple on the path, and they exchange friendly greetings. One day, while working, Ben is assigned to help a patient. When Ben sees the patient, he recognizes the man he often sees while walking at the park—the man is from the couple. When the patient sees Ben, he is immediately relieved to see a familiar and friendly face. Ben and the man make an immediate connection.

Concern. Persons connect over mutually meaningful life events (Hammond, 2015). For example, births, graduations, weddings, and deaths are momentous life events many people connect over. Shaylyn, a holistic nurse, works in labor and delivery at the local hospital. Shaylyn loves her work and celebrates each birth. She is known for her loving-kindness and compassion for patients and families and receives frequent positive feedback on the patient surveys. Her regard for celebrating life with families is noted and connects her to many as an act of concern.

Gale, a holistic nurse at the local healthcare clinic, has a knack for remembering information about patients families. When patients are in the clinic, Gale remembers the names of their family members, and patients view this as a sign of authentic concern. As a result, the patients feel a connection to Gale.

Competence. People lean toward trusting others that display knowledge and skills (Hammond, 2015). When working with other interprofessionals and nurses, the holistic nurse can firsthand observe many competencies. When watching others with a high level of competence, this can transfer to trust. For example, Carl is a holistic nurse who works in the emergency room at a hospital. A patient brought to the emergency room with severe hemorrhage was tended to by Dr. Morris. The nurses tried to obtain an intravenous line, but because of the hemorrhagic shock were unable to gain access. Dr. Morris inserted a central line quickly and competently so that saline and blood transfusions could immediately begin. Dr. Morris was calm, confident, and soothing during the treatment of the patient. Carl felt a connection to Dr. Morris after observing such outstanding competence. The patient had good outcomes, and Carl believed that Dr. Morris played a large part in improving the patient outcomes.

When communicating with others, holistic nurses should be aware of trust generators. The use of trust generators can help build trusting relationships with others. The bond or connection that trust generators provide in the human-to-human interaction is valuable. Although Hammond (2015) writes of trust generators for culturally responsive teaching, application in holistic nursing practice is also appropriate.

Reflection

Reflection  is an active strategy that involves introspective and retrospective examination and evaluation of experiences, beliefs, knowledge, oneself, and practices to improve the future (Dewey, 1933; Kember et al., 2008). Reflection is a strategy to evaluate situations by thinking back about the ethics applied in the case. The purpose of reflection is to note what went well and what could be better for a future situation. The holistic nurse should refrain from rumination.  Rumination  is the act of re-hashing an event or experience with no intention of moving forward or problem-solving (Kircanski et al., 2015). Rumination is an unhealthy strategy. Instead, holistic nurses must keep a future-focused orientation when reflecting.

When reflecting on a situation to evaluate the ethical aspects, consider:

What were ethical principles upheld in the case?

Were any ethical principles not upheld?

How could future situations improve the application of ethical principles?

Unconscious Bias

Bias  means an unreasonable judgment that is not based on facts (Merriam-Webster, 2021).  Unconscious bias  means deeply ingrained attitudes and stereotypes that affect human thoughts and actions, including a lack of self-awareness (Gordon, 2017). Unconscious bias affects thinking, healthcare delivery, hiring decisions and contributes to the lack of workforce diversity (Gordon, 2017). Yet, because unconscious bias is so deeply ingrained, people are not aware of it. Unconscious bias is sometimes referred to as implicit bias.

The purpose of this information about unconscious bias is to increase awareness and identify how unconscious bias may impact others. Unconscious bias affects thinking, healthcare delivery, hiring decisions and contributes to the lack of workforce diversity (Gordon, 2017). Gordon (2017) explains that unconscious bias affects the treatment of people in many areas of life, such as employment and salary. In addition, Healthcare and education are other areas of life that are impacted by unconscious bias. Next is a short literature review of healthcare areas undercut by unconscious bias.

Unconscious Bias

Unconscious bias impacts communications and healthcare. Narayan (2019) explains that attitudes and feelings of the unconscious mind are quite powerful and reminds us that Sigmund Freud popularized this idea. Yet, people are unaware of how these attitudes and feelings can impact behavior. Narayan (2019) explains that biases nurses have may manifest as less compassion, time spent caring for the patient, and a detrimental effect on therapeutic relationships with patients. Nurses may provide different levels of care based on their own unconscious bias without being aware (Rebar & Heimgartner, 2021). Unintentional discrimination may be causes by unconscious bias (Stamps, 2021). Quinn et al. (2017) describe microaggressions as a type of unconscious bias because people may not be aware they are doing such. Examples of microaggressions are telling a person, “I don’t see color,” or assuming that a person is not American born by the way they look or their name (Quinn et al., 2017). Microaggressions are examples of saying something without the awareness of the statement being inappropriate and offensive.

Unconscious bias is an aspect interwoven in systems that impact the healthcare system in the US. When women present at emergency rooms with chest pain, they receive different care than men. Significant gaps in healthcare equity of cardiovascular care exist based on gender (Shaw et al., 2017). Men were often given immediate attention and received quick interventional cardiology. In contrast, females were asked about stress levels and given medications. Females were 40% less likely to be referred to cardiac rehabilitation than males (Stewart Williams, 2009). Wright and Merritt (2020) found healthcare disparities with African-Americans related to COVID19 with links to systemic bias. Gaddam and Singh (2020) found that those who live in poverty have a statistically significantly lower rate of the return of spontaneous circulation than those who are not poverty-stricken in out-of-hospital cardiac arrests. Unconscious bias is an issue for holistic nurses to be well-versed in, aware, and engaged advocates.

Improve Awareness of Bias

Striving to increase awareness of one’s own bias is a challenging act. Bias is so deep-rooted that it is challenging for a person to see the bias. Yet, Narayan (2019) explains that nurses can increase their awareness of their own bias and improve patient outcomes. Changes in one’s bias may take a long time as it is a developmental process (Rebar & Heimgartner, 2021). Next are some strategies to employ to increase one’s awareness of bias.

Holistic nurses may build their awareness in unconscious bias by:

1. Learning about the cultural lifeways of people is a lifelong quest. Take a course, read a book, watch a video, and attending a workshop or conference are excellent ways to enrich oneself about cultures.

2. Learning about myths and stereotypes about different sociocultural identifies.

3. Reflect upon situations to assess for any bias. Checking for bias is challenging because of the nature of bias. The more a person strives to be aware, the more likely awareness will increase.

4. Complete a bias assessment. See options in the resources area at the end of this chapter.

5. Project Implicit at Harvard University has some tests available for free to explore bias. When visiting this website, it is recommended to not enter any personal information such as name or email address. Instead, directly below the email address box, you can continue as a guest by selecting the preferred language. Protect any identity information as you take the tests and visit websites online for safety. For any questions you wish not to answer, select the “Prefer not to Answer” button on the right side of the screen. Pick one or more of the tests and to explore bias at https://implicit.harvard.edu/implicit/

Knowledge Check

Click the link here to go to the knowledge check (external): https://softchalkcloud.com/lesson/serve/6ScGqlIVMehPFd/html

 Ethics, Belonging, and Social Justice

Social justice is the participation in society with fair, equitable treatment, benefits, resources, and burdens for all people (Beuttner-Schmidt, 2011). The ethics of social justice are guided by the ANA Code of Ethics (2015) and the ANA and AHNA Scope and Standards for Holistic Nursing (2019). Additionally, theory and evidence support the position and actions of nurses to promote social justice. The ethical duty of the nurse includes the promotion of belonging and social justice.

Belonging

A sense of belonging  means the person feels accepted for who they are (Wadors, 2019). A sense of belonging is a basic human need. According to Maslow’s Hierarchy of Human Needs (see Figure 1), love and belonging are survival needs after safety and physiological needs are met (Williams, 2020). The holistic nurse meets physiological and safety needs while incorporating love and belonging.

Belonging Meditation

External link: https://softchalkcloud.com/lesson/serve/6ScGqlIVMehPFd/html 

More About Belonging

Belonging has a connection with social justice. Holistic nurses create healing environments in which all persons are welcome and belong. The use of compassion and respect for all persons is a vital foundation of creating the healing climate in which all people are welcome and belong. Belonging and healing environments are also congruent with the ANA Code of Ethics, specifically provision 1:

Provision 1 of the ANA Code of Ethics states:

“Provision 1. The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person” (p. 1 of online text).

The ANA Code of Ethics (2015), ethical principles, and the ANA/AHNA (2019) Scope and Standards for holistic nursing practice blend well together as a firm base to guide nurses. Lifelong continuing nurse education about the ethical codes and standards are imperative for holistic nurses.

Perkins (2021) writes of the ethics of belonging with Jean Watson’s Unitary Human Caring Science. As nurses may expand their consciousness, they move through a transformative experience of increasing awareness of openness, loving-kindness, and a higher understanding of self and others. The nurse expands their perceptions, authentic caring, insight and a thriving spirit as a result of Caritas Processes® (Perkins, 2021). The expansion of consciousness through the lens of Unitary Human Caring Science creates a sacred experience of how nurses can become more aware of belonging and justice.

Walter studied and developed Emancipatory Nursing Praxis (ENP) using a grounded theory study of factors for nurses’ viewpoints related to social justice (2017). Walter explains that social justice is primary to nursing yet not well understood (2017). Nurses need to learn about bias, health disparities, and inequities. But, first, they must be explicitly aware of and engage in social justice to promote health equities. Walter found four key concepts:

• Becoming
• Awakening
• Engaging, and
• Transforming.

Becoming is described by Walter (2017) as the early realization that something was unfair and not right. Awakening is the recognition that they had a role in the more extensive system or status quo that impacts the “health and well being of others” (Walter, 2017, p. 231). Engaging is exhibited by the consciousness and analysis of power strategies, praxis, and persistence. Transforming is from the experience of exchange and developing consciousness and social justice. Holistic nurses should continue their own development of ENP and disseminate information with other nurses to narrow the gap of social justice in nursing.

Knowledge Check

External link: https://softchalkcloud.com/lesson/serve/6ScGqlIVMehPFd/html

Summary

This chapter focused on ethical, legal, inclusion, and diversity. In addition, the chapter described holistic nursing standards, ethics, ethical principles, culturally congruent practice, social justice, and unconscious bias. Holistic nurses practice based on the ANA code of ethics (2015), ethical principles, and the ANA/AHNA (2019) Scope and Standards for holistic nursing practice. Knowledge checks provided a check of one’s comprehension of the information. Proceed to the bottom of the reference page to claim the certificate of completion.

References

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Wright, J. E. & Merritt, C. C. (2020). Social equity and COVID-19: The case of African Americans. Public Administration Review, 80(5), 820-826. https://doi.org/10.1111/puar.13251

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Attribution

Case study adapted from Shanaz et al., 2020; CC BY NC.

Adapted from Holistic nursing and culture: Body, mind, and spirit by Nancyruth Leibold under a CC BY-NC license.