Advancing Well-Being and Health of Elderly with Integrative Nursing Principles.

There is a need for holistic care for the survival of the elderly, to increase their independence in their daily life activities, to improve their health and their well-being in order to ensure a healthy aging. Integrative nursing principles are a field of application of holistic philosophy and may be a guide to health professionals in improving the health of individuals, families and communities. These principles were first announced in 2014, and have been described as a health approach that takes the individual, family and society as a whole together with their environment and relationships and adopts the principle of using all the healing methods in health care. Integrative nursing principles can be used as a guide to holistic assessment and improvement of the health of the elderly. Interventions who take care of them with the environment they live in (home visits), support their existing healing process (focusing to patient during nursing care), benefit from the healing effect of the nature (spending time in nature), strengthen the relationship (mobilization of the social environment) and use all evidence-based healing methods (yoga, tai chi) should be included in the care of elderly individuals. Health professionals should learn integrative nursing principles and care for these principles in order to improve the health and well-being of the elderly. Giving care according to integrative nursing principles can increase the quality of life of the elderly and reduce health spending.

INTRODUCTION

One of the most important demographic events in the twenty-first century is the aging of the population. The life expectancy is increasing around the world, birth rates are decreasing and the proportion of the elderly population is increasing. Elderly people need holistic (physical, spiritual, social and spiritual) care for their healthy aging and quality of life.

From the beginning, nursing discipline has been based on holistic philosophy. Holistic nursing care is all nursing practice that assesses the human as a whole and provides for healing (American Holistic Nurses Association, 2017). Integrative nursing is the field of application of holistic philosophy. Integrative nursing offers a conceptual framework that focuses on improving the health and well-being of individuals as well as caregivers, individual-centered, relationship-based when they care for elderly individuals as a whole/system. Integrative nursing reduces health expenditures while increasing patient satisfaction, quality of life, health of populations (Kreitzer, 2015). Integrative nursing principles can be used as a guide in the holistic assessment of the elderly and in the development of health. In order to contribute to the healthy aging of elderly individuals and to increase the well-being, there are need to planned interventions according to integrative nursing principles are needed. This requires planning of interventions that deal with the elder’s environment, promote existing healing processes, take advantage of the healing effect of nature, focus on individual and use evidence-based healing methods and strengthen the relationships. The aim of this review is to explain the importance of integrative nursing principles in advancing the well-being and health of the elderly and to propose solutions based on integrative nursing principles in the maintenance and improvement of the health/well-being of the elderly.

Well-being and Health of Elderly

With the increase of the elderly population, demand for health services and thus health spending are also increasing. In addition, the burden of chronic diseases on total health expenditures is also increasing steadily (Ministry of Health, 2015). In 2050, Turkey is expected to be one of the world’s fastest aging population. For this reason, it should be on the agenda of nurses working in the field of public health that the elderly can live in a healthy and independent environment. The nurse should be in a holistic care approach for the survival of the elderly living in the community and contribute to healthy aging.

In order to protect and improve the health and well-being of the elderly, reducing loneliness, controlling diseases (dementia, stroke, depression, etc.), strengthening relationships with family, relatives and friends, healthy eating, keeping fit living and the end of life must be planned (AgeUK, 2017). Factors indicating the well-being of the elderly are lack of social isolation and inequalities (poverty, deprivation, lack of diagnosis in mental health problems, etc.), strong relationships and an active social life (family and friends relations, live alone etc.), active participation to community and protecting the condition of well-being (exercise, volunteering) (Allen, 2008). To improve the health and well-being situation and to ensure greater independence, care should be taken in line with the holistic philosophy of the elderly.

Holistic Health Care

Holistic health care understanding; indicates that the individual is a physical, mental, spiritual and socio-cultural entity and that each individual carries special qualities (Birol, 2004; Practical Nursing, 2017). In holistic health care, it is necessary to deal with the individual environment and to see it as a whole rather than focusing on the disease or a part of the individual’s body. It is aimed to achieve the maximum well-being condition in which everything works as best as possible in holistic care (Practical Nursing, 2017; Walter, 1999). Integrative health care and integrative nursing, which constitute the field of holistic philosophy, can be used as a guide for developing the health of individuals, families and communities.

Integrative Health Care

Integrative health care is required, which suggests the use of best-suited therapeutic approaches based on evidence that assess the individual as a whole for optimal health and recovery (The Academy of Integrative Health & Medicine, 2017). An integrative approach to health that is pre-existing but gaining importance over time is an approach adopted in many countries. In Woodwinds hospital, which has been serving in the United States since 2000, application of massage, therapeutic touch, as well as biofilm designs demonstrates the adoption of an integrated health care approach (Woodwinds Health Campus, 2017). Royal London Hospital in England is the largest public service hospital in Europe and has adopted an integrative health understanding (University College London Hospitals, 2017). Many treatments and therapies such as acupuncture, hypnosis and reflexology are given with medical treatments in hospitals provided by health professionals in Turkish hospitals (Ministry of Health, 2017).

Integrative Nursing

Health care has shifted from a disease-centered model to an improved model of prevention and well-being without developing the disease (Center for Spirituality and Healing, 2017). According to another definition, it is the knowing-and-doing what an individual will do to improve the health and well-being of families and societies. In the essence of integrative nursing, improvement/well-being of health is aimed beyond treatment. Integrative nurses prefer evidence-based practices for traditional and new interventions that promote the healing of a person as a whole. Integrative nursing that strengthens professionalism can be applied to all patient groups and all clinics (Center for Spirituality and Healing, 2017).

Integrative nursing, starting with Florence Nightingale, which states that it is necessary to take advantage of the healing effect of the circle to bring the patient to the best condition, means that the individual should be provided with a lot of care (body, mind, and spirit)/a system (Center for Spirituality and Healing, 2017). Due to the low number of nurses, nurses are moving away from the focus point of care and spend their time filling documents and performing administrative duties. With lifesaving, easy to maintain and time-saving technology, communication between the nurse and the patient is diminishing and the nurses work like machines away from the focus of care (Kreitzer, 2015).

Integrative nursing creates a framework to care which focuses on person-centered, relationship-based, individuals whom they serve as well as the caregivers for improving health and well-being. Integrative nursing guides many integrative therapies and best care practices to increase the patient’s self-care for nurses. Knowing integrative nursing principles can be used as a guide to shaping and improving care for elderly individuals (Kreitzer, 2015). Interventions that deals with the environment in which the elderly lived, supports their existing healing process, takes advantage of the natural healing effect, strengthens relationships and uses all evidence-based healing methods should be included in the care of elderly individuals (Halcon, Schein & Cheung, 2014; Koithan, 2014).

Integrative Nursing Principles

Integrative nursing has six principles (Figure 1).

Figure 1

Integrative nursing principles

1. Human beings are whole systems inseparable from their environments

Integrative nurses evaluate each individual as a whole system (body-mind-spirit), together with the environment that affects health and well-being. Nurses take into account their relationships, experiences, society and beliefs while accepting that a person is a complex system (Center for Spirituality and Healing, 2017). Nurses need to think together with the environment in the stages of protection, treatment and rehabilitation from the diseases of the elderly and provide care in accordance with this situation. It is important to evaluate physical, mental, emotional and spiritual environment and to make arrangements to facilitate daily life activities, to provide physical activity areas, and to strengthen relations with the environment while giving care to elderly living environment (home, nursing home) (Figure 2).

Figure 2

Examples of interventions planned for elderly according to integrative nursing principles

There are many nursing theorists referring to the effects of the concept of environment on the individual. Florence Nightingale, who held holistic views, based her nursing profession on the concept of the environment and emphasized more physical environment than psychosocial environment (Öz, 2010). According to Virginia Henderson, the environment is the whole of the external conditions and factors that affect the development and survival of the organism. In Rogers’s theory; the patient and his/her environment are unique (Nursing Theory, 2016).

2. Human beings have the innate capacity for health and wellbeing

People an innate healing capacity. This improvement occurs at physical, social, emotional and spiritual levels (Center for Spirituality and Healing, 2017). When a cut, scrape, or wound breaks the integrity of the skin, the body automatically enters the process of inflammation, cell proliferation and finally cell repair. Our minds, thoughts and experiences help us to heal. People have healing capacity after trauma they experience. Goodness, compassion, care, and love shown to others by others are processes that support healing (Kreitzer, 2015). According to Florence Nightingale, nurses should bring the patient to the best possible position for nature to be able to move and healing to occur. Nurses should be able to focus on the elderly, raise hope, increase the patient’s faith, strengthen interpersonal relationships, provide a healing touch, share their feelings, experiences with their friends during care for bringing out/strengthening the healing capacities of the elderly (Figure 2).

3. Nature has healing and restorative properties that contribute to health and wellbeing

There is a strong relationship between nature and health/well-being. Positive results arise from contact with nature (Center for Spirituality and Healing, 2017). Being in contact with nature reduces the blood pressure, heart rate, muscle tension, anger, fear and stress, and makes us emotionally better (University of Minnesota, 2016). In health institutions, biophilic designs are used to reflect natural scenes and structures intertwined with nature to enable patients to heal faster. This design contributes to the feelings of the individuals in the natural environment and to the health and well-being situation (Center for Spirituality and Healing, 2017). Nature has many benefits from the physical, social, intellectual and emotional aspects (Crone, 2015). Studies in the literature have found that depression levels, obesity rates and family ties are strengthening in people who spend time in nature (Christensen, Holt, & Wilson, 2013; Corazon, Nyed, Sidenius, Poulsen & Stigsdotter, 2018; Godbey, 2009; Triguero-Mas et al., 2015; Triguero-Mas et al., 2017; White et al., 2016). Outdoor activities (physical exercise, visiting a park, walking, hiking, playing outdoor games, gardening activities) can be organized to take advantage of the healing power of nature to improve the health and wellbeing of the elderly and bioinformatics can be used in the living areas of elderly individuals (Figure 2).

4. Integrative nursing is person-centered and relationship-based

There must be empathy, love, interest, trust, honesty, compassion and respect during the care and healing process. Person-centered care focuses on the individual as a whole (body, mind and spirit). Person-centered care requires over time to assess the elderly individual as a whole and to know the health experiences of the elderly (Olsson, Jakobsson Ung, Swedberg & Ekman, 2013; Starfield, 2011).

Relationship-based care provides an important framework for conceptualizing health care. Relationship-based care is defined as care where all individuals who provide and receive health care services appreciate their relationships with each other. Relationship-based care develops over time in the process of care (Kreitzer, 2015). Relationship-based care means that the nurse is beside the elderly, has excellent listening skills and offers options that best support the healing of the person. The relationship between nurses and other members of the care team is also important (Center for Spirituality and Healing, 2017). Community-based district nurses in society have a longer relationship with older people who care. Nurses working in areas such as nursing homes, villages, family health centers, palliative care centers, hospices are in a longer relationship with the elderly and this principle can be applied. To provide person-centered, relationship-based care, health professionals need to have a deep knowledge and good communication with the elderly they care for (Kreitzer, 2015). It is also important to organize individual meetings, social support systems and voluntary organizations to determine the needs and preferences of the elderly (Figure 2).

5. Integrative nursing practice is informed by evidence and uses the full range of therapeutic modalities to support/augment the healing process, moving from least intensive/invasive to more, depending on need and context

Integrative nursing practices are evidence-based. The evidence-based practice implies integrating the best evidence from research (Aydın, 2015). The integrative nurse decides on the best evidence for the benefit of the individual and decides what evidence is to be used for care in the direction of the individual’s thoughts, opinions and wishes. Integrative nurses use all possible interventions to best support congenital healing. The nursing care plan may include complementary health care approaches such as massages, respiratory exercises or acupuncture as well as medications or surgical treatments supported by western medicine.

Many of the integrative therapies are within the scope of nursing practice (Kreitzer, 2015). The integrative nurses who know that there are many ways to get information think and discuss different forms of evidence from experimental study to individual experience and decide what is best for the individual. Integrative nurses start with the least intensive and least invasive intervention to minimize the side effects of the person’s body, mind and spirit when planning a care plan. Interventions are directed towards more intensive and invasive treatments when needed (Center for Spirituality and Healing, 2017).

Integrative health approach is to accept that the individual is exclusive and unique as well as applications such as yoga, therapeutic touch, reiki, massage, aromatherapy. At the core of these practices it is important to create a healing environment, to raise awareness, to increase self-sufficiency and to reveal the capacity of self-healing (Bahonar, Najafi-Ghezeljeh & Haghani, 2019; Hee-Cho, Lee & Hur, 2017; Margenfeld, Klocke & Joos, 2019; Michael et al., 2019; Yang et al., 2019). In a study, acupuncture was found to be positive effective in reducing chronic pain in individuals with musculoskeletal disorders (Moura et al., 2019). According to the study by Watson et al. (2019), it was found that lavender and lemon grass decreased the agitation in the elderly (Watson, Hatcher & Good, 2019).

Complementary therapies in studies conducted in recent years in Turkey positively affects the health of individuals (Bekiroglu, Ovayolu, Ergun & Ekerbicer, 2013; Ciğerci, Kısacık, Özyürek & Çevik, 2019; Gok-Metin & Ozdemir, 2016; Gözüm & Platin, 2019; Turten-Kaymaz & Ozdemir, 2017; Yagli & Ulger, 2015). To improve the health and well-being of the elderly, it is necessary to present the integrative therapies (pet therapy, acupuncture, yoga, aromatherapy, homeopathy, reflexology) that are high in evidence and most appropriate for the elderly (Figure 2).

6. Integrative nursing focuses on the health and wellbeing of caregivers as well as those they serve

Nurses are burned out due to adverse working conditions, heavy workload and work in intense, stressful environments. This affects both their health/well-being and their care. Self-awareness and self-care are the basic principles of integrative nursing. Nurses should develop their own health and well-being to provide effective care for the individual, the family, and the community. The exhaustion of family members who live with the elderly as well as nurses working in nursing homes should be reduced. In a study in which the caregiver provided home care for the elderly, burnout increases as the burden of care increases, and the burden of care causes emotional exhaustion and depersonalization (Kalınkara & Kalaycı, 2017). In a study that examined the factors affecting the care burden of the elderly care staff working in the institution, it was determined that the caregivers experienced sleep disorders, physical fatigue, low back pain, headache, ulcers and gastritis (Işıkhan, 2018).

Nurses and caregivers of elderly should engage in body, mind, spirit-nurturing activities (imagination etc.) and think about the goal/goal of life in order to reduce their exhaustion and to care for themselves (Figure 2). Moreover, the nurse/caregiver needs to make cognitive changes related to attitudes, decision making and problem solving approaches and to clarify his/her values, perceptions and expectations. In addition, stress management (take time for yourself, sharing of feelings, meeting physical and emotional individual needs, etc.), improving working conditions can reduce exhaustion (Kapucu, 2017; Sarsılmaz, Yıldırım & Fadıloğlu, 2015). In a study in which the patients who received inpatient and outpatient treatment were taken as a sample, family intervention such as communication with caregivers, education about diseases, creating a supportive family environment, problem solving and communication skills, social skills training and relaxation techniques, simple exercises was applied to family caregivers for 12 weeks. It was determined that this intervention significantly reduced the burden of caregivers, stress, depression, and anxiety levels and improved quality of life (El-Bilsha, 2019).

Well-being and Health of Elderly with respect to Integrative Nursing Principles

Interventions should be included in the care of the elderly to evaluate the elderly environment, to support the healing capacities of the elderly, to benefit from the healing of the nature, to strengthen relationships and to use all evidence-based practices. Some interventions designed with respect to integrative nursing principles to improve the health and well-being of the elderly are shown in Figure 2.

CONCLUSION

With the aging population all over the world, the protection and development of the health and well-being of the elderly is gaining importance. Increased chronic diseases and use of health services in the elderly, inadequate number of nurses, lack of holistic care, dissatisfaction in the given care, lack of multidisciplinary cooperation is a global problem. To solve this problem, integrative nursing principles that constitute a framework for the holistic care of elderly are an important guide. Integrative nursing allows the individual to provide comprehensive, coordinated and systematic care that considers the body, mind and spirit as a whole/system and takes into account the needs of individuals and their families. Integrative nursing principles can be a guide in holistic assessment and care planning of the elderly. Nurses who give care in accordance with integrative nursing principles can contribute to increased satisfaction of elderly individuals, cost effectiveness in health services and healthy aging.