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McGrogan, Spiritual Care Coordinator Hospice of the Western Reserve, Cleveland, Ohio Another Perspective on How Nurses Provide Spiritual Care, Chapter 7 A Perspective on Caring for Patie

Nurse’s Toolbook

forPromoting Wellness

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particu-Nurse’s Toolbook

for Promoting Wellness

Carol A Miller, MSN, RN-BC, AHN-BC

Clinical Nurse SpecialistCare & Counseling Cleveland, OhioClinical FacultyFrances Payne Bolton School of NursingCase Western Reserve University

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Professional

Want to learn more?

for the countless ways in which they promote wellness in my life.

Contents

Contributors ix

Reviewers xi

Preface xiii

Index of Wellness Teaching and Activity Tools xv

PART I: OVERVIEW OF WELLNESS NURSING 1

Chapter 1 Exploring the Wellness Territory 3

Chapter 2 Fitting Wellness into Practice 23

Chapter 3 Fine Tuning Our Wellness Skills 52

PART II: PROMOTING PATIENTS’ WELLNESS IN THEIR DAILY LIVES 89

Chapter 4 Promoting Wellness-Enhancing Actions 91

Chapter 5 Teaching Patients to Protect Their Health .113

Chapter 6 Teaching Patients to Manage Stress 135

Chapter 7 Promoting Spiritual Wellness 167

Chapter 8 Overview of Complementary and Alternative Medicine 197

Chapter 9 Promoting Responsible Decisions about Biologically Based Therapies 227

PART III: PROMOTING SPECIFIC ASPECTS OF PATIENTS’ WELLNESS 253

Chapter 10 Nutritional Wellness 255

Chapter 11 Digestive Wellness 279

Chapter 12 Musculoskeletal Wellness .303

Chapter 13 Sensory Wellness 329

Chapter 14 Breathing Well 364

Chapter 15 Cardiovascular Wellness 396

Chapter 16 Urinary Wellness 412

Chapter 17 Sleeping Well 447

Chapter 18 Sexual Wellness 482

Appendix 499

List of Assessment Tools 499

List of Terminology Boxes 501

List of Clinical Resource Boxes 502

Index 503

Contributors

Anita White, MSN, RN, CCRN

Critical Care Nurse Educator, Elyria Memorial Hospital, Elyria, Ohio

Cardiovascular Wellness: Chapter 15

Jill Bormann, PhD, RN

Research Nurse Scientist,Veterans Administration San Diego Healthcare System

A Nurse’s Perspective: A Quick and Easy Stress Reduction Method for Self-Care, Chapter 6

Wellness Activity Tool 6.1: Frequent Mantram Repetition

Cheryle B Gartley

President and Founder,The Simon Foundation for Continence

Patient’s Perspectives, Chapter 16

Sister Corinne Lemmer, PhD, RN

Mount Marty College,Yankton, South Dakota

Nurse’s Experiences, Chapter 7

Kathleen Lindell, RN, MS

Doctoral Student, University of Pittsburgh School of Nursing

Resource Box: Case Example of Nursing Interventions for Smoking Cessation, Chapter 14

Janice E McGrogan, Spiritual Care Coordinator

Hospice of the Western Reserve, Cleveland, Ohio

Another Perspective on How Nurses Provide Spiritual Care, Chapter 7

A Perspective on Caring for Patients During Times of Suffering, Chapter 7

Nursing Staff

Memorial Medical Center, Springfield, Illinois

Resource Box: Example of a Hospital Protocol for Promoting Sleep Wellness, Chapter 17

Nursing Staff

St Charles Medical Center, Bend, Oregon

Resource Box: Application of the Caring Model in a Hospital Setting, Chapter 3 Resource Box: Hospital Protocol for Praying with Patients, Chapter 7

Belleruth Naparstek, LISW, BCD

Psychotherapist, Author, Guided Imagery Expert

Wellness Teaching Tool 4.2: How to Do Guided Imagery with Patients in a Few Minutes

Wellness Activity Tool 4.1: Using Affirmations for Promoting Health

Barbara Kammerer Quayle

Patient’s Perspectives, Chapter 3

Copyright © 2008 by The McGraw-Hill Companies, Inc Click here for terms of use

Kevin Smith, MSN, RN, CNP

Adjunct Faculty, University of Minnesota School of Nursing and Center for Spirituality and Healing

Perspective of a Nurse Expert on Humor as a Communication Tool, Chapter 6

Marsha Jelonek Walker, PhD, RN, AHN-BC, LMT

Private Practice, Stress Management Consultant

Resource Box: The HeartTouch Technique, Chapter 6

Tina Weitzel, MA, BSN, RNC

Nursing Quality Specialist, Memorial Medical Center, Springfield, Illinois

A Nurse’s Perspective on Promoting a Cultural Norm of Quiet, Chapter 17

A Nurse’s Perspective: The Sh-h-h-h!!! Project, Chapter 17

Dr Elizabeth Click and nursing students in her health promotion class atFrances Payne Bolton School of Nursing, Case Western Reserve University

I am deeply grateful for the advice, assistance, and expertise of the ing people at McGraw-Hill In particular, Quincy McDonald, Senior Editor, hasshared the vision of developing a clinical reference toolbook to help nursesquickly and easily promote wellness for their patients Quincy has steadfastlysupported this text since its inception and his expert guidance has been essen-tial for bringing it to fruition

outstand-On a very personal level, I acknowledge and deeply appreciate the supportfrom my family and friends through all the challenges of developing this book

In particular, I am grateful for the never-ending support and encouragementfrom Pat Rehm, who is at the top of my list of the many significant people whopromote my wellness

Copyright © 2008 by The McGraw-Hill Companies, Inc Click here for terms of use

Beth-El College of Nursing and Health Sciences

Colorado Springs, Colorado

Western Michigan University

Bronson School of Nursing

Kalamazoo, Michigan

Mary Anne Osborne Schwenka, BSN, MS

Family Nurse Practitioner

Woodland Integrative Medicine

Woodland Park, Colorado

Jacqueline L Wylie, RN, MSN, MA

Retired Nurse Educator

Western Michigan University

Bronson School of Nursing

Kalamazoo, Michigan

Copyright © 2008 by The McGraw-Hill Companies, Inc Click here for terms of use

Preface

A Nurse’s Reflections on Promoting Wellness

When I reflect on my roles as a nurse, I identify my “raison d’ être´”—my most fundamental reason for being a nurse—as caring about my patients and pro- moting their wellness I think about the many ways in which I use my nursing skills to help bring new life into this world; facilitate healing of body, mind, and spirit; and provide comfort during times of illness and death Then my thoughts focus on the challenge of reconciling my ideals of having time to provide holistic care with the harsh realities inherent in the hurry and scurry of my job These thoughts lead to questions about how I can quickly and easily incorporate well- ness into my usual care I even begin to wonder if I ever really “do” wellness nurs- ing when I care for patients—then I reflect on the many simple ways in which I use my nursing skills to provide holistic care For example, when I was assigned

to take care of Mrs M., I made a conscious effort to promote her wellness, even though other nurses had warned me that she was likely to complain loudly about anything I tried to do for her Before beginning my care I took a moment to cen- ter myself, then I entered her room, looked straight into her eyes, and caringly said “Good morning, Mrs M., my name is Carol and I’ll be caring for you today I understand things have been quite difficult for you and I’m hoping you’ll share your concerns with me so we can find ways of making you more comfort- able.” After attending to her physical needs, I offered to teach her a simple breath- ing technique that she could use to reduce stress and she was most receptive to this It took only a few minutes to empower Mrs M toward a sense of personal responsibility for her wellness and I gained the satisfaction of knowing that I had addressed more than her physical needs Sometimes I hear tangible rewards for

my efforts to promote wellness for my patients, as when a patient recently told me

“I can tell that you really care about me.”

Purpose and Overview

The foundation for this clinical reference is my belief that all people aspire tohave wellness—which I define simply as “I’m OK and I want to be better”—andthat nurses have numerous opportunities to promote wellness by using our skills

to communicate to each patient that “You’re OK and I can help you be better.”Although promoting wellness is an ideal, nurses often feel that they don’t havetime for tasks that are superimposed upon the already overwhelming demandsthat bombard them from many directions A basic premise of this book is thatnurses can quickly, readily, and routinely provide wellness-oriented care in clin-ical settings by using the wellness assessment, teaching, and activity tools in thisbook to develop a “wellness way of thinking” and improve patient care I devel-oped these tools based on both the successful experiences of nurses and the rap-idly increasing body of knowledge related to many aspects of wellness Chapter 1

Copyright © 2008 by The McGraw-Hill Companies, Inc Click here for terms of use

provides details about content and organization as well as tools and otherunique features that are incorporated throughout this book.

Guide to Using Tools in Clinical Settings

This book contains three types of tools that nurses can copy for use in clinical

settings to facilitate wellness-oriented care The intent of the Wellness Assessment Tools is to help nurses focus on a specific aspect of functioning from a broad and

holistic perspective Nurses can copy these tools, which are listed in theAppendix, to use as stand-alone documents or they can incorporate relevant

points in their usual assessments The intent of Wellness Teaching Tools and Wellness Activity Tools is to provide easy-to-use guides for enhancing wellness-

oriented nursing skills or teaching patients about specific aspects of wellness, asdelineated in the following index

Index of Wellness Teaching and

Activity Tools

behaviors

in a few minutes

management

are hard of hearing

18.2 (p 488), & 18.3 (p 490); activity tool 18.1 (p 496)

Copyright © 2008 by The McGraw-Hill Companies, Inc Click here for terms of use

To promote wellness by Give them Wellness

(pp 115 & 130), 5.2 for men (p 118), and 5.3 for women ( p 120)

To promote personal responsibility

of reliable information about . Teaching Tool .

Give Them Wellness

relationships on their wellness

PART I

Overview of Wellness Nursing

Chapter 2 Fitting Wellness into Practice

Copyright © 2008 by The McGraw-Hill Companies, Inc Click here for terms of use

Exploring the Wellness

Territory

BEGINNING THE WELLNESS JOURNEY

A Nurse’s Reflections on Wellness

Chapter Overview

The Itinerary for the Wellness Journey

Guide to Using This Book

EXPLORING THE “WHAT” OF WELLNESS

A Nurse’s Reflections on Exploring Wellness

Discovering the “What” of Wellness

ACHIEVING BALANCE THROUGH ALL PHASES OF HEALTH

A Nurse’s Reflections on the “When” of Wellness

Wellness During All Times

Bob’s Wellness Story

INTEGRATING BODY, MIND, AND SPIRIT

A Nurse’s Reflections on Body, Mind, and Spirit

Integrating Body, Mind, and Spirit in Health Care

Nursing Perspectives on Body–Mind–Spirit Interrelatedness

PROMOTING PERSONAL RESPONSIBILITY

A Nurse’s Reflections on Promoting Personal Responsibility

Personal Responsibility as the Foundation of Wellness

Identifying Interventions to Support Personal Responsibility

Engaging in Wellness Actions

Ann’s Wellness Story

RELATIONSHIPS WITH SELF AND OTHERS

A Nurse’s Reflections on Relationships

Nursing Responsibilities for Relationships with Self and Others

RELATIONSHIPS WITH THE ENVIRONMENT

A Nurse’s Reflections on Environments of Care

Nursing Responsibilities for Environments of Care

CHAPTER HIGHLIGHTS

POINTS FOR PONDERING AND PRACTICE

• Wellness Activity Tool 1.1: Self-Assessment of the Influence of My Relationships

BEGINNING THE WELLNESS JOURNEY

A Nurse’s Reflections on Wellness

I wonder a lot about wellness I see the word everywhere—on buildings and cereal boxes, in newspapers, brochures, and advertisements It pops up on my screen when I’m browsing the Internet I overhear it in conversations; I talk about it with my friends, family, patients I even talk to myself about it So I ask myself: What is wellness? When does it happen? Where do I find it? How can

I get my share of it? As I ponder these questions, I realize that wellness is a ney from being OK to being better I believe that everyone wants wellness and should be able to have it, so I need to learn about successfully navigating this journey Because I want to use my nursing skills to guide my patients on their journeys, I’ve learned how to achieve wellness and help my patients travel toward wellness Because I like to share my discoveries, I’ve written this book about how

jour-we as nurses navigate the path toward jour-wellness and guide our patients on their journeys.

Chapter Overview

Wellness is a journey that each of us takes in our quest for well-being of body,mind, and spirit Key components of wellness include personal responsibility,balance through all phases of health, body–mind–spirit connectedness, and rela-tionships with self, others, and the environment As nurses, we guide ourpatients on their wellness journeys, so we need to be familiar with the wellnesspath and be progressing toward our own wellness In addition, we need to pro-vide maps for our patients so we can assist their discovery of wellness in theirlives This chapter provides an itinerary for the rest of this book, which is filledwith tools that nurses can use as maps for our patients as well as ourselves

The Itinerary for the Wellness Journey

Nurses clearly understand that we use the art and science of nursing to promotewellness, but we are less clear about what wellness actually is Even less evident

is how we can incorporate this idea of wellness into caring for our patients as wework in environments that are wellness unfriendly We also may be less clearabout how to promote self-wellness in our personal lives because we focus somuch on meeting the needs of others

One mission of this book is to provide a succinct base of knowledge aboutwhat wellness is and how nurses promote wellness in our nursing practice andpersonal lives A second mission is to provide a large base of practical tools thatshow quickly and precisely how to practice wellness with the patients for whom

we care and for ourselves Content is developed from the perspective of a nursewho is committed to practicing and teaching wellness as a way of thinking andliving, so it draws on reflections and stories to illustrate application of conceptsand tools Most importantly, this book provides a roadmap for nurses as we

travel our own wellness journeys and guide patients on their journeys to ness Because this itinerary chapter—like an armchair travel guide—outlineswhat we expect to discover along the way, there are many references to otherchapters that contain more details about this journey.

well-Guide to Using This Book

Part I of the book discusses the what, when, how, and where of wellness.Chapter 1 provides descriptive snapshots of our destinations, so we’ll be able torecognize wellness when we see it We’ll learn about when and how we experi-ence and promote wellness, but won’t yet embark on the actual journey.Chapter 2 is a “how-to” planning guide that focuses on skills that are essentialfor fitting wellness into our patient care We’ll visit the territory of the nursingprocess and meet some patients who share their experiences about how nurseshave guided them on their wellness journeys A nurse will accompany usthrough this territory as we learn how to apply wellness concepts in our workand in our personal lives During this part of the journey, we’ll collect some toolsthat we can use to incorporate wellness in our assessments.We’ll also collect somegreat tools that we can give to our patients to promote their wellness Chapter 3

is a guide to “packing our bags”; it will help us fine tune our wellness skills andprovides some tools that can be used to guide patients to wellness We’ll learnabout wellness language so we can be more comfortable communicating withour patients and teaching them about the wellness journey We’ll also exploreaspects of cultural diversity that will be useful in our relationships with others

By the time you have finished the chapters in Part I, your bags will be packedand you will be prepared to guide patients to many wellness destinations.The chapters in Part II focus on topics that are pertinent to patients’ wellness

in their daily lives, and this information is applicable to most patient care tions Chapters 4 and 5 go hand in hand to review health-promotion interven-tions from a holistic nursing perspective, with the emphasis on teaching patients toengage in wellness-enhancing and health-protecting actions.Teaching tools in thesechapters are designed to help patients develop healthy behaviors as well as assumeresponsibility for many aspects of preventive care Chapters 6 and 7, which also

situa-go hand in hand, address stress management and spiritual needs in clinical tings Assessment and teaching tools in Chapter 6 focus on stress managementmethods that nurses can use for self-wellness or to help patients respond effec-tively to stress Nurses can use the assessment and teaching tools in Chapter 7 toovercome some of the barriers to promoting spiritual wellness and address spiri-tual distress for patients Chapters 8 and 9 provide information about comple-mentary and alternative medicine (CAM) practices, with a strong emphasis onteaching patients how to make responsible decisions about these modalities.Thesechapters contain many teaching tools about practices that are most relevant topatient care and patient education In addition, nurses can use the assessment andteaching tools in Chapter 9 to identify and address concerns related to safety andefficacy of herbs and other dietary supplements

set-Topics in Part III focus on aspects of wellness that nurses address in specificpatient care situations For example, nurses can use assessment and teachingtools in Chapter 10 when caring for patients who would benefit from learningabout nutritional wellness Chapters 11 through 18 address the following top-ics: digestive wellness, musculoskeletal wellness, sensory wellness, breathingwell, cardiovascular wellness, urinary wellness, sleeping well, and sexual well-ness These chapters are organized around the nursing process and includeinformation about nursing assessment, diagnoses, outcomes, and interventionsfrom a wellness perspective In addition, all chapters provide assessment andteaching tools that are specific to each aspect of functioning.

The following features, which are identified with icons, are incorporatedthroughout the text to help nurses apply the information to patient caresituations:

Wellness Assessment Tools: checklists or formal nursing assessment tools for

identifying factors that pose threats to wellness

Wellness Teaching Tools: guides for teaching patients about actions to

pro-mote wellness and about reliable sources for further information

Wellness Activity Tools: simple how-to guides for wellness-enhancing

activi-ties that nurses or patients can follow

Points for Pondering and Practice: activities to help nurses apply the

infor-mation to clinical practice or self-wellness

Wellness Awareness: one-sentence statements sprinkled throughout the

clini-cally oriented chapters to highlight easy ways of incorporating a wellness

way of thinking into usual care of patients or applying a certain concept

to self-wellness

Additional features used throughout the text to enhance learning are:

• A Nurse’s Reflections: the author’s thoughts and insights about applying

the information to self-wellness and patient care

• Another Perspective: perspectives of patients, nurses, and other experts

on how nurses can apply the information to clinical situations

• Case Examples in a variety of formats

• Resource Boxes with examples of protocols or other guides to illustrate

application of concepts in clinical settings

• Chapter Outlines to help readers understand the organization and navigate

through the content

• Chapter Highlights to awaken a greater understanding of how the

informa-tion can be applied to patient care

• Terminology Boxes to facilitate documentation of outcomes and

interven-tions using taxonomy established by NANDA International

EXPLORING THE “WHAT” OF WELLNESS

A Nurse’s Reflections on Exploring Wellness

I first met the word “wellness” during my senior year of nursing school, when I was exploring ideas for a paper I had to write about my philosophy of health.

I found a book called “High-Level Wellness” by Halbert L Dunn, who is often considered the founder of the wellness movement This book is a collection of Dunn’s radio presentations in which he described aspects of high-level wellness in relation to self, family, community, society, and the environment I wanted to dis- cover more about this intriguing idea that was first articulated by a distinguished physician and public health official According to Dunn (1961), essential crite- ria for wellness included (1) a movement toward higher potentials of function- ing, during daily living and times of challenges; (2) attention to the total person, including physical, mental, emotional, social, and spiritual dimensions; and (3) maintenance of balance and purposeful direction of each unique person in his or her environment.

I liked Dunn’s viewpoint that wellness was about maximizing the potential of the individual, regardless of his or her state of health, and this idea fit well in my paper on “The Creation of Health.” I viewed health as “a continual striving toward wholeness that can be reached only in relationship to our environment and the community of people around us” (Miller, 1970) Although I felt obligated to use the term “health” when I wrote the paper, I have always preferred Dunn’s phrase,“high-level wellness.” When I was a nursing student, I lived and volunteered

in an inner-city neighborhood, and I had developed a strong commitment to ing others as an essential component of my own wellness For me, at that time, part of my definition of wellness was an expectation that I would save the world—or at least the people in my neighborhood—as soon as I became a nurse.

serv-Discovering the “What” of Wellness

If you ask 50 nurses to define wellness, you will hear 50 unique statementsabout what wellness is Nurses are inclined to place wellness in the same cate-gory as comfort—we know that we “do” it, but we have a hard time defining it

My uncomplicated answer to the question “What is wellness?” is the statement,

“I’m OK and I want to be better.” Similarly, the brief answer to the question

“What is wellness-oriented nursing care?” is in the statement, “You’re OK andyou can be better.” These two statements reflect the fact that wellness is a jour-ney that all humans are taking As nurses, it is our job to help others, as well asourselves, on this journey This book is a roadmap for nurses as we travel ourown wellness paths and guide others on their wellness journeys Specifically, wewill explore wellness using the following components:

• Balance through all phases of health

• Body–mind–spirit interrelatedness

• Personal responsibility

• Relationships with self, others, and the environment

In summary, wellness is a process that occurs one step at a time and is built

on a foundation of personal responsibility The role of the nurse is to assistpatients in discovering where they are in this journey and where they want to be,and to guide them in identifying and implementing the best steps to achieve ahigher level of wellness In the following sections, we look more closely at when,where, and how we promote wellness for our patients and ourselves

ACHIEVING BALANCE THROUGH ALL

PHASES OF HEALTH

A Nurse’s Reflections on the “When” of Wellness

In nursing school, I learned that health and illness were two ends of a spectrum, with health positioned at the most desired end and illness at the end to be avoided.

As I thought about this, I concluded that best health was associated with peak physical functioning during younger adulthood and was difficult or impossible to attain during old age People with disabilities and those who depended on others for their care belonged at the illness end, as did anyone who was terminally ill In

my first nursing job, most of my patients were older adults, so I wondered how

I would keep them from the predictable progression toward the illness end of the line I hated to think that they would be relegated, inevitably, to the undesirable end just by virtue of moving beyond the youthful point where peak physical per- formance was most achievable As I considered this dilemma, I asked some of my patients how they defined health so I would know where to place them on the health–illness spectrum that I had learned about One older woman, who func- tioned at a wheelchair level because of severe arthritis, defined health as “being helpful to others.” She told me she felt healthy, good about herself, and satisfied with her life (Miller, 1974) I began to learn that, if wellness applied to the whole person, people could achieve it no matter what their level of physical health I was figuring out that if the health–illness continuum was defined only in relation to physical health it was not a good indicator of a person’s well-being My patients were teaching me that the “when” of wellness occurred during all phases of life and health, and they challenged me to broaden my perspective of the so-called health–illness continuum.

Wellness During All Times

The concept of high-level wellness is most frequently applied to people who

already are at a good level of health Health and wellness are closely related terms

that nurses often use interchangeably, especially in the context of health motion (Pender et al., 2006) For the purpose of this book, health is conceptu-alized as the ability to function at one’s highest level, including all aspects ofbody, mind, and spirit.Wellness is a broader concept that is applicable for patients

pro-who are “ready for enhanced” health, as described in wellness nursing noses Although nurses can readily apply wellness nursing diagnoses to somesituations, they usually care for patients who have more prominent needsrequiring immediate attention However, nurses need to recognize that all peo-ple are entitled to have a sense of well-being; and, all people, at a minimum,deserve to be comfortable physically, emotionally, and spiritually Thus, nursescan incorporate wellness-oriented interventions in all their care.

diag-A whole-person perspective emphasizes that wellness is a dynamic and dimensional process aimed at reaching one’s highest potential during all phases

multi-of health People can work toward wellness at any time, whether they feel ically healthy or are dying, and personal wellness goals and choice of interven-tions will vary depending on health status, as in the following examples:

phys-• People who are relatively healthy and functional but experiencing chronicconditions are likely to seek interventions to alleviate pain and discomfortwith the goal of maintaining or improving their level of comfort andfunctioning

• People experiencing acute illnesses or medical crises concentrate on ting through” the immediate situation so they can focus on recovery and

“get-a st“get-able level of functioning, which, ide“get-ally, will be better th“get-an, or “get-at le“get-astequal to, their level before the onset of the acute illness

• People who have incurable and declining conditions focus on achievingcomfort and freedom from pain while they also address the many emo-tional and spiritual issues related to dying

When nurses provide care from a wellness perspective, we acknowledge andhonor the patient’s health status and identify ways of facilitating both a state ofbalance and a sense of well-being at the moment Nurses in any practice settingcan assist patients in achieving a state of body–mind–spirit balance by using thewellness-focused nursing skills described in Chapter 2 “Bob’s Wellness Story”illustrates the role of the nurse in supporting wellness for someone who is notlikely to get better Nurses can draw on the information in this book to guidethem in using a variety of interventions to promote wellness in clinical settingsand for self-care Nurses recognize that, in many situations, surrogate decisionmakers are responsible for supporting wellness for others, from conceptionthrough death, when this responsibility does not interfere with the rights ofothers

Bob’s Wellness Story

Bob is 81 years old and was admitted 7 days ago to your acute care unit with a diagnosis of pancreatitis His medical history includes cystostomy for bladder can- cer, chronic renal failure, and shoulder bursitis Before his hospitalization, he relied

on a walker because of peripheral neuropathy and progressive balance problems; however, the recent onset of bursitis made it difficult to continue using the walker His quality of life revolved around his close relationship with his wife of 56 years and their mutual interest in social contacts with their children, grandchildren, and extended family Bob’s condition has worsened daily and his family asks you about

a referral for hospice care Because Bob is alert and aware of his situation, you initiate a conversation about his condition and his expectations.

Nurse: Good morning, Bob How are you feeling? What news did Dr Thomas

have today?

Bob: I’m doing so-so—not great, but OK, considering that this body shop seems

to be running out of new parts for me Dr Thomas said I should consider dialysis because my kidneys are mostly shut down, but I told him I don’t want to be attached to a machine for the rest of my life My life has been good, but in the last few years I’ve been living with constant shoulder pain and it’s getting harder and harder to get around When I had chemotherapy and cancer surgery in 1979, the doctors told my family I would never make it out of the hospital I guess we’ve proved them wrong and I feel like I’ve had 20 good bonus years so I don’t want to keep going if I’m more and more of a burden Besides, I’m tired of living

in pain and I got this pancreatitis because of the last pain medication we tried.

Nurse: It sounds like you’ve done a lot of thinking about your life and your

health What are the most important considerations for your quality of life now?

Bob: I want to be sure my wife will be taken care of, and I think I can count on

the family to do that She’s here every day and it’s taking a toll on her You know

my two daughters are nurses and they said they could take care of me if I went home I’m not sure how much time I have left, but I’d like to spend it with my family.

Nurse: I’ve talked with your family and they care a lot about you and want to do

everything they can to make sure you’re as comfortable as possible Your ters brought up the idea of hospice care Are you familiar with that idea?

daugh-Bob: Isn’t that the program where you go in the front door from earth and out

the back door into heaven?

Nurse: I guess that’s one way to describe it You’ve talked about going to church

every Sunday with your family Is there anything we can do to help you spiritually?

Bob: I’d like to have Fr McNamara give me communion and the sacrament of the

sick.

INTEGRATING BODY, MIND, AND SPIRIT

A Nurse’s Reflections on Body, Mind, and Spirit

My patients teach me many lessons about wellness, but sometimes I am my own best teacher Several years ago, I learned a profound lesson about body–mind–spirit connectedness when I was recovering from a serious hand injury that occurred during a moment of distraction while I was using yard equipment Immediately after the accident, I sought medical care to deal with pain, wound healing, and prevention of infection I was familiar with the course

of physical injuries, but I was surprised that my mind and spirit also were injured.

My mind repeatedly told me I was stupid and it filled me with self-blaming thoughts My emotions emphasized that I should be angry with myself, and my spirit felt disconnected from the Divine One of my most effective self-wellness tools is journaling, so I spent a lot of my recovery time talking and listening to myself as I wrote in my journal with my injured hand I received many messages about forgiving myself and I learned that one momentary mistake did not indi- cate that I was hopelessly stupid Despite my improved perception of this event,

my feelings still were interfering with healing and I still experienced spiritual tress I sought assistance to deal with my anger and self-blame and I found spir- itual support in family, friends, nature, and rituals By addressing my physical, mental, emotional, and spiritual wounds, I gradually achieved a level of wellness that otherwise would not have been possible As I view that experience with new

dis-Nurse: I can arrange that through the chaplain’s office How are you feeling

about your condition and choosing not to have dialysis?

Bob: I’m slowly coming to terms with some questions I have for my Maker, but

I expect I have some time before I get any good answers I don’t think they’re ready for me in heaven yet, but I know I need to think about packing some bags.

Nurse: Would you like to know more about the hospice program? They can help

you and your family make sure you are comfortable at home and they also pay attention to your spiritual needs.

Bob: Sure, but I’d like you to talk with me when my family is here because

I count on them to help with these decisions Can you come back in about an hour when they’re here?

Nursing interventions that promote wellness:The nurse uses sensitive and open-ended questions and responses to elicit and validate Bob’s feelings and perceptions about his health, relationships, spirituality, and goals for quality of life during this phase of health She also identifies interventions to address comfort and spiritual needs In addition, reciprocity occurs because she learns from listen- ing to Bob.

wisdom, I appreciate the healing power of connecting my body, my mind, and my spirit I try to use the valuable lessons I learned in my personal life and when

I care for patients.

Integrating Body, Mind, and Spirit in Health Care

The concept of body–mind–spirit interrelatedness can be traced to ancientChinese and Ayurvedic medicine and is also found in the teachings ofHippocrates, who believed that effective treatment of illness depended on atti-tude, environment, and natural remedies For centuries, the Eastern world hasincorporated this philosophy of body–mind–spirit connectedness into healingtraditions, and it continues to do so today Practices and beliefs of NativeAmericans and other groups also reflect a perspective of body–mind–spirit inte-gration In the Western world, however, the Renaissance and Enlightenment eras

of the 16th and 17th centuries led to an underlying philosophy of viewing thebody, mind, and spirit as separate and independently functioning entities Inrecent centuries, the effectiveness of interventions such as surgery and medica-tions supported the idea that physically based treatments could cure or controldisease conditions independently of anything that influenced the person men-tally or spiritually By the early 20th century, the perspective of separating body,mind, and spirit had become entrenched in Western medicine, and health carepractices were based on the assumption that health and illness are completelyphysical in nature

By the 1920s, scientific investigations of physical responses to psychologicalstress began paving the way for challenging the perspective that there is no con-nection between the body and the mind Since the 1960s, there has been a con-siderable expansion of scientific evidence supporting an integral body–mindconnectedness, and this perspective has broadened to include spiritual dimen-sions Significant research-based landmarks that lend credence to the concept ofbody–mind–spirit connectedness are discussed in Chapter 6

In addition to the increasing scientific evidence, recently evolving trends thatsupport the growing acceptance of the body–mind–spirit connectedness include:

• Increasing awareness of and concern about risks associated with tions, surgery, and other Western-based interventions

medica-• Concern about increasing costs of care, in terms of both human sufferingand financial burden

• Recognition of the need for safer, less costly, and more effective ties, especially for treating chronic conditions

modali-• Attention to quality-of-life issues and the need for interventions directedtoward comfort and healing when curing is not possible

• Ready availability of information about integrative therapies that can beused in addition to traditional Western-based modalities

• An evolution of humans toward higher levels of awareness and a quent demand for health care modalities that are consistent with thisexpanding consciousness

subse-Because of all these influences, health care consumers and practitioners usuallyacknowledge at least some connection among body, mind, and spirit dimensions,and many patients look for interventions that promote wellness by focusing on awhole-person perspective.

Nursing Perspectives on Body–Mind–Spirit Interrelatedness

Nursing has always been concerned with health from a broader perspective thanphysical functioning, and nurses have consistently addressed emotional needs ofpatients However, it has only been in recent years that nursing has emphasizedits role in addressing spiritual needs and has broadened nursing interventions toinclude modalities that address the body–mind–spirit connectedness Today,nurses recognize that they are required to address the needs of the whole per-son, but they are challenged by the limitations of health care systems that con-tinue to emphasize physical care and medical and technological interventions.They also are challenged—and sometimes overwhelmed—by countlessdemands on their time, energy, and attention Because nurses identify prioritiesfor addressing patient needs, they address life-threatening and physical comfortneeds immediately However, they usually can identify opportunities to addressbroader needs of the whole person and his or her support people during thecourse of providing nursing care It is in this context that nurses rely onwellness-oriented methods of applying the nursing process to addressbody–mind–spirit needs These methods, which are described throughout thistext, can be applied not only in patient situations but also for personal growthtoward body–mind–spirit wellness

Another challenge for nurses is becoming comfortable in addressingbody–mind–spirit needs in all nursing situations, especially when the nurse orthe patient has little awareness of this connectedness Nurses who are not fullycomfortable with addressing body, mind, and spiritual needs of their patientscan improve their skills by using some of the tools in this book

PROMOTING PERSONAL RESPONSIBILITY

A Nurse’s Reflections on Promoting Personal Responsibility

During my early nursing career as a visiting nurse, I worked with several other nurses to start a weekly “listening clinic” at our neighborhood free clinic.We asked physicians to refer any patients who wanted a prescription for “nerve pills”— usually Valium or Librium—to come and talk with a nurse so we could help them identify nonmedication approaches to solving problems and coping with anxiety.

As I listened to and counseled patients, I learned that an important aspect of ness was empowering patients toward personal responsibility I also learned about self-wellness because I recognized that I felt better about myself when I could help others set and attain realistic goals and achieve a better quality of life.

well-Personal Responsibility as the Foundation of Wellness

Personal responsibility is the foundation of wellness Individuals, ultimately,must choose between behaviors that affect their health positively or negatively.For people who cannot make their own choices, responsibility is assumed bysurrogate decision makers such as parents, spouses, guardians, caregivers, or sig-nificant others For the purpose of this book, emphasis is placed on the personalresponsibility of competent adults It is important to note that, despite this lim-ited context, many of the suggestions for a patient could also include surrogatedecision makers

A major component of personal responsibility is awareness of one’s currenthealth status and the factors that affect one’s health and functioning Nursesfacilitate a patient’s awareness of his or her health status and the factors thatinfluence it by performing nursing assessments from a wellness perspective.Nurses can provide feedback about the patient’s health status and help thepatient address relationships between behaviors and health, as discussed inChapter 4

Another key ingredient to developing personal responsibility is understandingthat this process can lead to a healthier and happier life People with chronicconditions usually develop an ongoing awareness of fluctuating levels of healthand functioning Similarly, people who recover from acute illnesses are usuallyaware of their variable experiences of health during and after these episodes

“Healthy” people, however, may not be aware of the importance of striving forimproved health.The concept of wellness applies to the whole person; it is there-fore imperative that each person recognize that improvements in health statusencompass all aspects of body, mind, and spirit Because the process of reach-ing one’s highest potential is dynamic and ongoing, people need to recognizethat it is always possible to identify a personal wellness goal and improve theirquality of life Chapter 2 focuses on ways in which nurses can assist patients inthis process, and all chapters in Parts II and III apply this concept to specificaspects of health

Identifying Interventions to Support Personal Responsibility

A major step toward personal responsibility is identifying interventions that ter a higher level of health This step is achieved both through self-learning andthrough education provided by health care professionals The range of interven-tions includes medical, surgical, and highly technical treatments; complementaryand alternative therapies; and lifestyle choices implemented during one’s dailyactivities In recent decades, the variety of interventions to promote improvedhealth is increasing rapidly and information about these interventions is widelyavailable from numerous media sources Although health care consumers arebecoming more knowledgeable about the availability of these interventions, theyare not necessarily becoming more knowledgeable about the risks and benefits

fos-of each intervention Because much fos-of this information is slanted toward selling

products and not all of it is based on well-founded evidence, careful evaluation

of health-related information is an essential part of personal responsibility.Nurses are the health care professionals who are highly qualified to assistpatients in identifying interventions that are both safe and effective for achiev-ing health-related goals Nurses begin by assessing the patient’s knowledgeabout—or receptiveness to—the range of interventions that might be appropri-ate for achieving health-related goals Nurses need to be familiar with interven-tions that are likely to be most suitable for a patient’s condition, based on thebest evidence available Nurses also need to be able to guide patients in evalu-ating the risks and benefits of interventions that are widely promoted Thus,nurses use their patient assessments and their own knowledge base to help theirpatients achieve personal responsibility

Engaging in Wellness Actions

Thousands of self-help books promote various methods of improving related behaviors, and people are bombarded with messages endorsing so-calledquick-and-easy ways to achieve health-related goals Despite the plethora ofinformation available, anyone who has attempted to change unhealthy behaviorsunderstands the meaning of the adage “easier said than done.” Thus, an impor-tant role of nurses is to assist patients in identifying not only the barriers butalso the approaches that will best result in the initiation and maintenance ofwellness actions Ann’s wellness story offers an example of nursing interventionsthat promote personal responsibility

health-Ann’s Wellness Story

Ann is 34 years old and her mother recently died from breast cancer She is happily married and the mother of a 4-year-old girl and a 3-month-old boy During a visit

to the family practice clinic for the baby’s checkup, Ann says she is grieving the loss of her mother and she is particularly worried about her mother’s history of breast cancer.

Nurse: I’m sorry about the loss of your mother; she was blessed to have you

pro-vide so much care and be with her when she died It’s good that you’re allowing time for grieving Are you willing to share with me what you do for self-wellness during this time?

Ann: Sometimes when I’m feeding the baby I cry because I think about my

moth-er then, but I don’t like to cry vmoth-ery much because I worry that I’ll pass my sadness

to the baby.

RELATIONSHIPS WITH SELF AND OTHERS

A Nurse’s Reflections on Relationships

When I think about my relationships with myself and others, I think about how

I can use my knowledge and my caring presence as a nurse for healing others Then I think about my responsibility for being well myself, because I know I can- not have healthy relationships with others unless I have a healthy relationship with my authentic self I think about the lifelong journey I take in my endeavor

to discover, honor, accept, and appreciate my authenticity, my uniqueness, my

“me-ness.” I know that everyone takes this journey, and I try to enjoy the time it takes, but I often hear a powerful voice inside of me saying I am selfish when

Nurse: Crying is a normal part of grieving and acknowledging feelings is healthy.

Can you think of concrete ways in which you can express your feelings, perhaps using the time when you are feeding the baby?

Ann: My mother was stoic and she hardly ever cried Sometimes I think I should

be more like her emotionally and other times I worry that I’m like her physically and l’ll die from breast cancer before I ever have grandchildren My husband asked me if taking birth control pills increased my chance of getting breast cancer.

Nurse: What do you know about your risks for breast cancer?

Ann: I think my mother’s mother might have died from breast cancer, but her

family never talked about it so I’m just guessing Do you think I should get a mammogram?

Nurse: That’s a very good question and I suggest you ask Dr Cooley about that

so she can discuss the recommendations for screening mammograms and the two

of you can decide on a plan How often do you check your breasts to see how they are?

Ann: I used to do it occasionally, but I stopped when I was pregnant and I

cer-tainly couldn’t detect anything now that I’m breast feeding Besides, I’m afraid I’ll find something that I don’t want to be there.

Nurse: It’s important to look at the messages we give ourselves out of fear.

Perhaps you could think about sending kind and loving thoughts to your breasts and focusing on how healthy they are as they provide nourishment for your baby I’m sure you can think of other positive messages to give yourself, especially while you’re breast feeding I also suggest that you resume the practice of checking your breasts every month and ask how they’re doing so you can send them caring thoughts instead of a fear-based message This would be a nice act of wellness for yourself.

Nursing interventions that promote personal responsibility for wellness:The nurse acknowledges and supports Ann’s grieving and suggests positive ways in which Ann can address her feelings and her fear about breast cancer.

I focus on my own wellness and I feel guilty about taking time to do things that are “simply” for me and my well-being I have learned to listen to another voice that tells me that it is not only OK, but even necessary, to pay attention to my own wellness because that is exactly what I am encouraging my patients to do But I still hear the self-accusation of being selfish so I wonder,Where did I learn

to feel guilty about paying attention to myself? I know that this is a common ing that nurses experience because our mission is to take care of others I also know that I received countless messages when I was growing up that I am always

feel-to think of others first and myself last.When I think about these messages, I realize that some of the baggage I carry on my wellness journey is heavy and burdensome.

I know that I need to challenge some of my “core beliefs” that I recognize as mental For example, because I’ve learned that I need to take time for myself if

detri-I want to be helpful to others, detri-I try to override the voice of guilt detri-I know that one

of the best ways for me to recharge myself physically, mentally, emotionally, and spiritually is to gift myself with a long solitary walk in nature.When I return from these walks, I know I have gathered what I need for my own wellness and for facilitating wellness in others, so I hush the voice of guilt and trust that I am walking on my wellness path.

Nursing Responsibilities for Relationships

with Self and Others

Because a person’s sense of well-being is strongly affected by self-acceptanceand self-esteem, the relationship with oneself is a major component of wellness

In addition, because humans are social, emotional, and spiritual beings, theirsense of well-being is significantly influenced by their relationships with othersand with all they consider sacred From the whole-person perspective, achiev-ing wellness requires that each person address his or her relationships with selfand others This process can be conceptualized as a multifaceted—andlifelong—journey of self-discovery and personal growth in which each personcontinually moves toward healthier relationships These relationships extendbeyond the personal circle of close relationships to the broad context of the fam-ily, groups, communities, nations, and the global world From the whole-personperspective, relationships with pets, all living beings, and spiritual beings areintegral parts of each person’s wellness Wellness Activity Tool 1.1, included atthe end of this chapter, can be used for self-assessment of some of the ways inwhich relationships with self and others influence wellness

Nurses are responsible not only for being professional in their relationshipswith patients but also for having healthy relationships with themselves and oth-ers By continually working toward healthier relationships, nurses not onlyimprove their own well-being, but they also serve as role models for wellness inothers Because self-wellness activities are an essential component of a healthyrelationship with oneself, nurses are encouraged to personally use pertinent self-awareness and wellness action tools from this text

Nurses in all settings address relationships of patients in their cultural contexts;and, in many settings, they address relationships with families, groups, and broader

communities In some circumstances, nurses are responsible for addressing apatient’s relationship with self or others For example, significantly negative self-esteem may interfere with interventions that are necessary for stability in apatient who feels unworthy of getting better In such a situation, the nurse wouldidentify nursing interventions directed toward improved self-esteem so health-related goals could be achieved An example of a situation in which nurses areresponsible for addressing a patient’s relationships with others is one in whichthe person is affected by interpersonal violence or other harmful behaviors Inthese situations, nurses are obligated to address relationships that threaten theirpatient’s safety At other times, nurses may choose to address relationship issues

in their care plans because patients identify health-related goals that are enced by personal relationships For example, a patient seeking to lose weightmay need to address issues related to self-esteem and relationships with otherswho may affect eating and exercise patterns

influ-The provision of culturally competent care in all situations is essential foraddressing relationships with self, others, and environments, as discussed indetail in Chapter 3 When nurse–patient backgrounds are significantly different,

it is imperative that nurses have at least a minimal knowledge about cultural tors that affect their patient’s health needs In addition, nurses are responsiblefor exploring their own ethnocentric tendencies and becoming comfortable inworking with people whose cultural backgrounds differ from theirs

fac-RELATIONSHIPS WITH THE ENVIRONMENT

A Nurse’s Reflections on Environments of Care

My nursing practice takes me into a variety of health care environments, including homes, clinics, hospitals, nursing homes, high-rise apartments, and a wide range of long-term care accommodations and I pay close attention to the impact of the environment on patients, caregivers, and their families I attend to environmental factors that pose risks to safety, but I also try to find opportunities to adapt the environment to enhance comfort and quality of life For example, I adjust lighting, temperature, and noise as much as possible to create an atmosphere that is most conducive to wellness Because I know that I am an important part of my patient’s environment, I pay attention to the qualities that come with me I make an effort

to bring a sense of love, hope, peace, humor, wellness, and caring presence Sometimes I use cues from the patient’s environment to initiate small acts of well- ness For instance, when I notice cards or flowers in a patient’s room, I acknowledge the caring remembrance and ask about the sender.This usually opens the door for

a brief conversation about a positive relationship in that person’s life, and I know I’ve contributed to his or her wellness by reminding the person about love.

Nursing Responsibilities for Environments of Care

People have always recognized that physical environments affect health and tioning, and in recent decades, they have developed a much broader and deeper

func-recognition of the multidimensional relationships between humans and theirenvironments This broader perspective is reflected in the increasing focus onthe effects of the environment on the well-being of one’s body, mind, and spirit.

It also is reflected in the increasing attention to the responsibility of humans toassure that limited natural resources are used wisely and efficiently so they areavailable for future generations

Scientists have long recognized that physical environments directly affectmany aspects of health and functioning; and this recognition has influenced

health care in many ways A recurring theme in Florence Nightingale’s Notes on Nursing is that nurses promote healing by optimizing the patient’s environment.

Nurses and other health care professionals not only assess the influence of theenvironment on health and functioning, but they also recognize environmentalconditions as interventions for preventing disease and promoting health Forexample, routines such as hand washing and maintenance of sterile techniqueduring many procedures are standard nursing practices

As knowledge about the multidimensional relationships between humans andtheir physical environments has increased, nurses have been able to apply thisinformation to address many aspects of health Pertinent examples of ways inwhich physical environments influence the health of individuals and groupsinclude the following:

• Noise affects hearing, communication, stress levels, and mental and ical health

phys-• Toxic air interferes with breathing and air quality and causes cancer,allergic reactions, respiratory and cardiovascular disease, and other serious health problems

• Light levels affect mood, emotions, skin condition, sleep cycles, and synthesis of vitamin D

• Exposure to or ingestion of lead, mercury, and other metals causes healthproblems, especially in fetuses, infants, and children

• Physical environments can limit and influence safety, functioning, and allaspects of daily living, particularly for people who are not able to functionindependently

• Fertilizers, pesticides, and chemicals from industry and agriculture taminate food and water supplies for humans and animals and causehealth problems through direct and indirect effects

con-• Eating food from animals treated with hormones and antibiotics altersthe human response to medications

• Environments affect one’s ability to engage in health-promoting iors, such as performing exercise or movement therapies, obtaining andpreparing nutritious foods, and establishing a nurturing space for relax-ation interventions

behav-In addition to addressing physical environments, nursing care needs toaddress multidimensional aspects of environments, including mental, spiritual,and sociocultural influences Similarly, nurses also pay close attention to the

influence of their own caring presence as an essential component of ments for their patients In addition, some nurses specialize in healing modal-ities that depend primarily on sensory and environmental factors, such asaromatherapy and music therapy.

Although health is significantly affected by broader and even global mental factors, the scope of this book is limited to the effects of the immediateenvironment on particular aspects of functioning and well-being When perti-nent, aspects of mental, emotional, and spiritual environments are addressed;however, the primary focus is on the relationships between humans and theirphysical environments Assessment and intervention tools address the influence

environ-of the environment in relation to specific aspects environ-of functioning and can be used

in patient care In addition, nurses are encouraged to engage in self-wellness

by fostering environments that support or improve their well-being and menting interventions to diminish environmental factors that are detrimental totheir own health.Wellness Activity Tool 1.1 includes questions for self-assessmentabout how environments affect personal wellness

imple-Chapter Highlights

• A simple definition of wellness is, “I’m OK and I want to be better.”

• A more detailed description of wellness uses the following components:balance through all phases of health, body–mind–spirit connectedness,personal responsibility, and relationships with self, others, and the

environment

• Because wellness is a dynamic and multidimensional process aimed atreaching one’s highest potential during all phases of health, people canwork toward wellness at all times (refer to Bob’s Wellness Story for anexample of how nurses promote wellness for patients who are not likely

to get better)

• Nurses have key roles in addressing body–mind–spirit connectedness as

an integral component of health care

• Nurses have many opportunities to promote personal responsibility byteaching patients about actions they can take to foster a higher level ofhealth (refer to Ann’s Wellness Story for an example of nursing interven-tions that promote personal responsibility)

• Wellness Activity Tool 1.1 is a self-assessment tool for exploring how tionships with self, others, and the environment influence wellness

rela-POINTS FOR PONDERING AND PRACTICE

• Take a minute to develop your personal definition of what wellness means for you.

• Take minute to describe how you promote wellness when you care for patients.