Introduction
Holistic nursing care emphasises addressing the physical, emotional, social, spiritual, and cultural needs of patients to promote overall well-being (Dossey and Keegan, 2016). This essay critically evaluates how integrating the Fundamentals of Care framework, the Person-centred Practice framework, and cultural safety principles can support such care, drawing on the case of Mrs Aroha Patel, a 68-year-old Fijian-Indian woman admitted with a left hip fracture. The introduction will outline these frameworks briefly, followed by their application to Mrs Patel’s specific concerns, including her refusal of opioids, food-related issues, and spiritual distress. The essay argues that their integration fosters comprehensive care but also highlights tensions and systemic limitations. By maintaining this focus, the discussion demonstrates connections between the frameworks to enhance nursing practice in a multicultural context.
The Frameworks: Definitions and Key Elements
The Fundamentals of Care framework, developed by Kitson et al. (2010), emphasises three core dimensions: establishing trusting relationships, addressing physical needs (such as pain management and nutrition), and meeting psychosocial needs (including emotional support). This framework guides nurses to deliver essential care that is often overlooked in complex clinical settings, ensuring patient safety and dignity. For instance, it underscores the importance of integrating care elements to avoid fragmentation.
The Person-centred Practice framework, as outlined by McCormack and McCance (2017), focuses on placing the individual at the centre of care through attributes like professional competence, interpersonal skills, and commitment to the job, alongside prerequisites such as shared decision-making and holistic assessment. It promotes care that respects the patient’s values, preferences, and life context, aiming to achieve outcomes like patient satisfaction and engagement.
Cultural safety principles, originating from Ramsden’s work (2002) and adapted in nursing contexts, involve professional responsibility (self-awareness of biases), ethical responsibility (respecting cultural differences), and systemic responsibility (addressing institutional barriers to equitable care). In a UK nursing context, these principles align with the Nursing and Midwifery Council (NMC) standards, ensuring care is free from cultural harm and promotes empowerment (Nursing and Midwifery Council, 2018).
These frameworks are not isolated; their integration allows for a synergistic approach where person-centred elements enhance relational aspects of fundamentals of care, while cultural safety ensures ethical and systemic inclusivity. However, critical evaluation reveals potential tensions, such as resource constraints limiting implementation.
Application to Mrs Patel’s Case: Addressing Specific Needs
Applying these frameworks to Mrs Patel’s case illustrates their role in holistic care. Mrs Patel, a Hindu widow with osteoarthritis and osteoporosis, refuses oxycodone due to past hallucinations from morphine and a preference for natural remedies like turmeric and ashwagandha. The Fundamentals of Care framework supports addressing her pain (a physical need) through trusting relationships, encouraging nurses to explore alternatives rather than dismissing her concerns as non-compliance (Kitson et al., 2010). Integrated with the Person-centred Practice framework, this involves shared decision-making, where nurses discuss her fears empathetically, potentially offering non-opioid options like paracetamol, which she uses at home (McCormack and McCance, 2017). Cultural safety adds depth by recognising her scepticism towards “chemicals” as rooted in Ayurvedic beliefs, requiring professional responsibility to avoid imposing Western norms and ethical responsibility to respect her autonomy.
Furthermore, Mrs Patel’s food concerns highlight nutritional challenges; she refuses hospital meals, describing them as lacking “flavour” and “soul,” aligned with her strict vegetarian diet and Ayurvedic “hot” and “cold” food principles. The Fundamentals of Care framework addresses this by ensuring nutritional intake to aid healing, perhaps through dietary consultations (Kitson et al., 2010). Person-centred practice extends this by involving her in meal planning, acknowledging her cultural preferences to enhance engagement and recovery (McCormack and McCance, 2017). Culturally safe care demands systemic responsibility, such as hospital policies providing spiced vegetarian options, preventing cultural harm from generic menus that disregard her Fijian-Indian background (Ramsden, 2002). This integration arguably prevents malnutrition, as seen in her reduced appetite and concentrated urine, fostering holistic well-being.
Spiritual distress is evident in Mrs Patel’s inability to perform daily prayers, her clutching of a Krishna pendant, and requests to light a candle, denied due to safety rules. The Fundamentals of Care framework’s psychosocial dimension supports emotional comfort by facilitating spiritual practices (Kitson et al., 2010). Person-centred practice reinforces this through holistic assessment, recognising her grief over her husband’s death and loneliness, perhaps by arranging virtual temple connections (McCormack and McCance, 2017). Cultural safety principles ensure ethical responsibility by respecting Hindu rituals, with systemic adjustments like providing a quiet space for prayer, addressing her anxiety about surgery and last rites (Nursing and Midwifery Council, 2018). Together, these frameworks mitigate her tearfulness and withdrawal, promoting spiritual resilience.
Integration of Frameworks: Benefits, Tensions, and Critical Evaluation
The integration of these frameworks explicitly supports holistic nursing by creating connections that address Mrs Patel’s interconnected needs. For example, her opioid refusal links physical pain management (Fundamentals of Care) with personal values (Person-centred Practice) and cultural beliefs (Cultural Safety), enabling nurses to develop a tailored plan that builds trust and reduces anxiety. This interconnected approach is evident in managing her food concerns, where nutritional fundamentals integrate with person-centred involvement and cultural adaptations, potentially improving her post-operative recovery after tomorrow’s surgery. Similarly, alleviating spiritual distress through relational care and ethical respect can enhance her overall mental state, reducing shallow breathing and helplessness.
However, critical evaluation reveals limitations and tensions. A key tension arises from systemic challenges, such as understaffing in UK wards, which may limit time for person-centred discussions or cultural accommodations, leading to fragmented care (Francis, 2013). For instance, Mrs Patel’s reluctance to use the call bell due to shame could be exacerbated if nurses, under pressure, overlook psychosocial needs, highlighting a limitation in the Fundamentals of Care framework when resources are scarce. Moreover, integrating cultural safety requires ongoing training, yet ethical responsibility might conflict with hospital policies, like flame bans, creating barriers to spiritual support and potentially causing cultural harm (Ramsden, 2002).
Another limitation is the potential for cultural misunderstandings; while person-centred practice promotes shared decision-making, nurses without cultural competence might misinterpret Mrs Patel’s politeness as agreement, ignoring her modesty concerns during bathing (McCormack and McCance, 2017). Systemically, the NMC mandates cultural safety, but implementation varies, with reports indicating disparities in care for ethnic minorities (NHS England, 2020). In Mrs Patel’s case, this could worsen her embarrassment about toileting, underscoring the need for systemic responsibility to address institutional biases.
Despite these challenges, the frameworks’ integration offers a robust foundation for holistic care, arguably outweighing limitations through evidence-based benefits like improved patient outcomes (Dossey and Keegan, 2016). However, without addressing systemic issues, such as funding for cultural training, their full potential remains unrealised.
Conclusion
In summary, integrating the Fundamentals of Care, Person-centred Practice, and cultural safety principles supports holistic nursing for Mrs Patel by addressing her opioid refusal, food concerns, and spiritual distress through connected, patient-specific strategies. This approach enhances trust, autonomy, and cultural respect, yet critical evaluation highlights tensions like resource constraints and policy limitations. For nursing practice, this implies a need for systemic reforms to fully realise these frameworks’ benefits, ultimately improving care quality in diverse populations. As nursing students, recognising these integrations and challenges prepares us for ethical, effective practice.
References
- Dossey, B.M. and Keegan, L. (2016) Holistic Nursing: A Handbook for Practice. 7th edn. Burlington, MA: Jones & Bartlett Learning.
- Francis, R. (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office.
- Kitson, A., Conroy, T., Wengstrom, Y., Profetto-McGrath, J. and Robertson-Malt, S. (2010) Defining the fundamentals of care. International Journal of Nursing Practice, 16(4), pp. 423-434.
- McCormack, B. and McCance, T. (2017) Person-Centred Practice in Nursing and Health Care: Theory and Practice. 2nd edn. Chichester: Wiley-Blackwell.
- NHS England (2020) Workforce Race Equality Standard: 2020 Report. London: NHS England.
- Nursing and Midwifery Council (2018) The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates. London: NMC.
- Ramsden, I. (2002) Cultural Safety and Nursing Education in Aotearoa and Te Waipounamu. PhD thesis. Victoria University of Wellington.
