Susan Kun Leddy-Integrative Health Promotion - Conceptual Bases For Nursing Practice, Second Edition (2005) PDF

INTEGRATIVE
H E A LT H
PROMOTION
CONCEPTUAL BASES FOR
NURSING PRACTICE
Second Edition
Susan Kun Leddy, PhD, RN

Professor Emerita, School of Nursing
Widener University
Chester, Pennsylvania
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Library of Congress Cataloging-in-Publication Data
Leddy, Susan.
Integrative health promotion : conceptual bases for nursing practice / by Susan Kun Leddy. 2nd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-7637-3840-9
1. Holistic nursing. 2. Health promotion. 3. Alternative medicine.
[DNLM: 1. Health Promotionmethods. 2. Holistic Nursing. 3. Health Behavior. 4. Holistic Health.
5. Nursing Theory. WY 86.5 L472i 2005] I. Title.
RT42.L38 2005
610.73dc22 2005024306
2116
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09 08 07 06 05 10 9 8 7 6 5 4 3 2 1
Dedication
To Debbie, Erin, and Katie, with all my love.

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Contents
About the Author ...................................................................................ix

Preface ...............................................................................................xi
Section I: Conceptual Bases of Health Promotion ............................1

Chapter 1. Health, Health Promotion, and Healing ...............................................3
The Disease Perspective of Health ...............................................................................4
The Person Perspective of Health ..............................................................................16
Integrative Health Promotion.....................................................................................26
Chapter 2. Health Strengths................................................................................31
The Strengths Perspective ..........................................................................................32
The Theory of Healthiness .........................................................................................33
Chapter 3. The Meaning of Health: Health Care Belief Systems .........................49
Popular Health Care ...................................................................................................50
Professional Health Care.............................................................................................51
Chapter 4. The Meaning of Health: Models and Theories....................................75
Nursing Conceptual Models and Theories .................................................................76
Psychoneuroimmunology ............................................................................................86
Energy Healing Theory ...............................................................................................90
Using Models/Theories to Guide Practice..................................................................94
Chapter 5. The Meaning of Health: Cultural Influences......................................99
Differentiating Ethnicity, Culture, and Race............................................................100
Racial and Ethnic Disparities in Health Status........................................................100
Health/Illness Beliefs.................................................................................................105
Influence of Indigenous Cultural Beliefs ..................................................................106
Medicocentrism (Medical Ethnocentrism)...............................................................116
Culturally Competent Health Promotion Care........................................................117
Chapter 6. Ethical and Legal Influences on Health Promotion ...........................129
Ethical Influences......................................................................................................130
Categories of Ethical Frameworks.............................................................................130
Conventional Normative Ethical Principles ............................................................131
Critiques of Conventional Ethics .............................................................................135
Power and Ethics .......................................................................................................141
Legal Influences.........................................................................................................143
Chapter 7. Beyond Physical Assessment............................................................157
Physical and Health Assessment...............................................................................158
Frameworks for Health Assessment ..........................................................................158
vi Contents
Selected Categories for Assessment ..........................................................................170

Assessment Techniques from Eastern Traditions......................................................178
Screening for Disease ................................................................................................182
Section II: The Disease Worldview ..............................................195

Chapter 8. Promoting Individual Behavior Change ............................................197
Influences of Behavior Change on Individuals ........................................................197
Strategies for Promoting Behavior Change ..............................................................207
Counseling to Reduce Disease Risk Factors .............................................................212
Promoting the Maintenance of Health Behavior Change.......................................215
Chapter 9. Global Health: The Ecocentric Approach.........................................219
Ecocentric Worldview of Health ..............................................................................220
Global (International) Health ..................................................................................220
Societal (Public) Health Concerns...........................................................................224
Environmental Health Concerns..............................................................................230
Section III: The Person Worldview..............................................241

Chapter 10. The Essence of a Healing Helping Relationship..............................243
Prescriptive Helping Relationship ............................................................................244
Healing Helping Relationship ..................................................................................246
Chapter 11. Empowering Community Health ....................................................265
What Is Community? ................................................................................................266
Elements of Community ...........................................................................................268
What Is Social Change? ............................................................................................268
Community-Level Interventions ..............................................................................270
Principles for Community Organization...................................................................282
Section IV: Integrative Nursing Interventions to Promote

Health and Healing .......................................................................291
Chapter 12. Relinquishing Bound Energy: Herbal Therapy and Aromatherapy .......293
Herbal Therapy .........................................................................................................294
Aromatherapy............................................................................................................315
Chapter 13. Re-establishing Energy Flow: Physical Activity and Exercise..........327
Physical Activity .......................................................................................................328
Physical Exercise .......................................................................................................329
Energy Exercise..........................................................................................................341
Integrative Health Promotion...................................................................................348
Contents vii
Chapter 14. Releasing Blocked Energy: Touch and Bodywork Techniques.........357

Massage Therapy .......................................................................................................358
Acupressure ...............................................................................................................363
Postural/Movement Re-education Therapies ...........................................................368
Chapter 15. Reducing Energy Depletion: Relaxation and Stress Reduction ........379
The Stress Response..................................................................................................380
Relaxation .................................................................................................................381
Chapter 16. Regenerating Energy: Nutrition .....................................................409
The Meaning of Food................................................................................................410
Essential Dietary Nutrients .......................................................................................413
Dietary Guidelines, Goals, and Obesity ...................................................................426
Strategies to Promote Healthy Nutrition .................................................................436
Chapter 17. Restoring Energy Field Harmony: Energy Patterning .....................443
Energy Healing ..........................................................................................................444
Energy Healing Modalities........................................................................................446
Appendix A: Leddy Healthiness Scale ..........................................................469

Appendix B: Nutritional Supplements ..........................................................473
Index .............................................................................................................................483
About the Author
Susan Kun Leddy earned a bachelor of science in nursing from Skidmore College,
Saratoga, New York in 1960, a master of science in nursing (teaching medical-surgical nurs-
ing) from Boston University in 1965, a doctor of philosophy (nursing science) from New
York University in 1973, and did post-doctoral work at Harvard University (1985) and the
University of Pennsylvania (199698).
Dr. Leddy initially taught in diploma schools of nursing for four years and then in the bac-
calaureate program at Columbia University before completing doctoral work. She was then
one of four founding faculty for the RN-BSN program at Pace University. In 1976, after a
year as an NLN consultant, she was asked to do a feasibility study and then write the pro-
posal to the State of New York for a new RN-BSN program at Mercy College. She became
the first chairperson of the program (Mae Pepper was the first faculty member), which
opened in 1977.
Dr. Leddy left Mercy College in 1981 to first become dean of the School of Nursing, and
then dean of the reconstituted College of Health Sciences, at the University of Wyoming.
In 1988, she became dean of the School of Nursing at Widener University, Chester,
Pennsylvania, returning to graduate teaching there in 1993. She is now professor emerita in
the School of Nursing.
In addition to authoring Integrative Health Promotion: Conceptual Bases for Nursing Practice,
Dr. Leddy is the co-author with Lucy Hood of Conceptual Bases of Professional Nursing, 6th
edition, copyright 2006; Health Promotion: Mobilizing Human Strengths to Promote Wellness,
copyright 2006; and is working on a manuscript, Nursing Knowledge and Nursing Science, with
Jacqueline Fawcett. She has authored numerous periodical publications.
Dr. Leddy has two daughters, Deborah and Erin. Deborah is a student of veterinary med-
icine at the University of Pennsylvania, and Erin is a graduate student in the social work pro-
gram at West Chester University. Dr. Leddys granddaughter, Katie, was born October 12,
2001.
Dr. Leddy is an avid traveler, and especially enjoys traveling to exotic places. She also
knits, quilts, weaves (a little), and dabbles in watercolor painting and creative writing.
Preface
I believe that the promotion of health is the core of professional nursing knowledge and
practice. Given this belief, I have been dismayed and frustrated by the overwhelming empha-
sis on disease and illness in most nursing educational programs. It is my hope that this book
will serve as an exemplar of health promotion content that should be taught, particularly in
graduate programs.
I have attempted to present a coherent synthesis of numerous, disparate literatures.
Chapter 1: Health, Health Promotion, and Healing, lays out a conceptual map for the book,
clarifying the critical differences between the disease perspective dominant in the bio-
medical, epidemiological, and public health literatures, and the person perspective, which
appears in nursing and alternative/complementary medical literatures. This edition, where
all chapters have been updated, presents theory and practical strategies from both perspec-
tives, toward the goal of integrative practice.
The content in Chapter 2, in my opinion, is of vital importance for nursing practice, yet
almost completely absent from the nursing literature. It is my long-standing and heartfelt
belief that nurses and clients need to utilize strengths as resources to address client weak-
nesses. Additionally, nurses must stop trying to be the expert who solves all problems, and,
instead, practice within an egalitarian model with power and expertise shared with the
client.
As in practically all other areas of scientific knowledge, definitive research evidence to
support health promotion practice is just not available. Abstracts of research are presented
throughout the book, and the state of the art is reviewed wherever possible. However, the
very limited evidence derived from well designed research continues to be of concern.
Additionally, the health promotion literature is largely atheoretical. I have attempted to
present what theory/models I could find. Theory-based scholarship is critically needed to
advance the science.
My rationale in organizing the book has been to present the conceptual bases of health
promotion in Section I, followed by several chapters in Sections II and III that address pri-
marily either the disease or person worldview. The chapters in Section IV apply the concep-
tual content from both worldviews to nursing practice.
Integrative health promotion is a vision. It is my sincere hope that by presenting a glimpse
of what might be, that this book will further a reality of knowledge-based health promotion
practice as an essential and substantial component of professional nursing.
Susan Kun Leddy, PhD, RN

Section
I
CONCEPTUAL BASES OF
HEALTH PROMOTION
Section I, Conceptual Bases of Health Promotion, includes seven chapters that provide a con-
textual exploration of the meaning of health promotion and healing in a variety of health belief
systems, health strengths models and theories, and cultures. This section also includes chapters
on legal and ethical influences and health promotion, and integrative approaches to client assess-
ment. Chapter 1, Health, Health Promotion, and Healing, differentiates between health protection
(the prevention of disease risk factors and disease), health promotion (facilitating health-related
lifestyle changes), and healing to promote wholeness, integration, harmony, and, therefore,
health. The disease and the person world views, and their implications for beliefs about health,
are compared and contrasted. In Chapter 2, Health Strengths, the theory of healthiness is discussed
as are its various concepts. It is proposed that strengths serve as resources to promote health and
healing. In Chapter 3, The Meaning of Health: Health Care Belief Systems, a number of lay, com-
munity-based (Cuanderismo and Shamanism), and professional (Western biomedicine and tradi-
tionalincluding Chinese, Ayurveda, and naturopathic and homeopathic medicines) health
care belief systems are described, so that the student can appreciate the diversity of belief systems
that provide a context for integrative nursing. Chapter 4, The Meaning of Health: Models and The-
ories, presents 11 models or theories that can guide the promotion of health and healing in nurs-
ing practice. Chapter 5, The Meaning of Health: Cultural Influences, explores the influence on
health promotion of indigenous cultural beliefs of Asian Americans (Vietnamese Americans),
Appalachians, Hispanics (Mexican Americans), African Americans, and Native Americans, and
concludes with a presentation of multiple characteristics, influences, and practices that should be
considered in multicultural health promotion planning. Chapter 6, Ethical and Legal Influences on
Health Promotion, presents issues of power and empowerment, preferential valuing among the eth-
ical principles of autonomy, nonmaleficence, beneficence, and justice, and a non-traditional
model for professional ethics. The chapter concludes with a review of licensing issues, negligence,
electronic transmittal of health information, and implications of food and drug regulation, with
2 Section I Conceptual Bases of Health Promotion
special considerations for integrative health promotion. Chapter 7, Beyond Physical Assessment,
reviews guidelines for risk and disease screening, presents numerous frameworks for the assess-
ment of healthiness, and discusses integrative techniques (tongue and pulse assessment) to
broaden the database from which the client and nurse develop a health promotion plan.
HEALTH, HEALTH PROMOTION,
AND HEALING
1
Acknowledgment: Parts of this chapter were previously published in Leddy, S. (1998). Leddy & Peppers Concep-
tual bases of professional nursing (4th ed.). Philadelphia: Lippincott.
Abstract
This chapter presents a conceptual framework for integrative health promotion. Distinc-
tions among health protection, health promotion, and healing are discussed within two
worldviews of health, the disease and the person perspectives. Health protection and health
promotion are considered to be consistent with the disease perspective. The dominant
approach to health in the literature is health protection, which focuses attention on the
prevention of disease risk factors and disease. Health promotion focuses on facilitating indi-
vidual health-related lifestyle changes. In contrast, healing and holistic nursing are consid-
ered to be consistent with the person perspective. Facilitating healing to promote wholeness,
integration, and harmony is the desired primary emphasis of holistic nursing. Integrative
health promotion is based on a healing philosophy, and utilizes both health protection/pro-
motion strategies and holistic, non-invasive therapeutic nursing modalities to facilitate the
health of individuals, families, and communities, both locally and globally.
Learning Outcomes
By the end of the chapter the student should be able to:
Compare and contrast the disease and person perspectives of health
Discuss health protection and disease risk prevention
4 Chapter 1 Health, Health Promotion, and Healing
Describe elements of behavioral, ecological, and policy approaches to health promotion

Discuss selected conceptual or theoretical approaches to healing
Describe roles for nurses to facilitate healing
Describe selected characteristics of holistic nursing
Describe elements of integrative nursing
Basic philosophic assumptions about the nature of reality, including human beings and the
human-environment relationship, are referred to as paradigms or worldviews. In different
worldviews, the meaning of health can vary significantly. Different interpretations of the
meaning of health are associated with different interpretations of the meaning of health pro-
motion. The author has synthesized two contrasting paradigms of health from the literature,
labeled the disease and the person worldviews. It is proposed that health protection (avoid-
ance of risk) and health promotion (lifestyle change) are consistent with the disease world-
view, whereas healing is consistent with the person perspective. This chapter will explore the
different meanings of health, health promotion, and healing, eventually proposing a combi-
nation of strategies from both worldviews.
The Disease Perspective of Health

In the disease perspective of health, the human being is usually conceptualized as a whole,
comprised of parts. The internal environment of the human being is regarded as a composite
of distinct biological, psychological, and spiritual components. Human beings are physically
separated by boundaries from the external environment. Thus, the human being interacts
with a physically separate environment, which is viewed as a context. The human being is in
the environment. Therefore, a composite of distinct areas such as biological, ecological,
social, cultural, economic, and political components interact to form the total environment.
Human and environmental interactions are linear and result in quantifiable cause and effect
changes. Although both human being and environment may be affected by change, unidi-
rectional change is the usual mode of analysis. For example, in nursing, the impact of the
environment on the human beings health is of interest, and, in ecology, the impact of the
human on environmental conditions is relevant.
Normal human functioning is perceived to be homeostatic, that is, operating within a
relatively narrow range of balance or stability. The environment contains stressors that act on
a person and to which a person must react. The environment acts on the individual through
stressors, and in reacting to the stressors, internal stability of the individual is upset. Change,
although acknowledged to be inevitable, is considered to be a threat. The threat may involve
disease, illness, or sickness, affecting well-being and health.
IDEAS OF HEALTH CONSISTENT WITH THE DISEASE PERSPECTIVE

Health
Health is difficult to define. In many definitions, physiologic and psychological compo-
nents of health are dichotomized. Other subconcepts that might be included in definitions of
The Disease Perspective of Health 5
health include environmental and social influences, freedom from pain or disease, optimum
capability, ability to adapt, purposeful direction and meaning in life, and sense of well-being.
In this book, within the disease perspective, health has been defined as a state or condition
of integrity of functioning (functional capacity and ability) and perceived well-being (feeling
well). This definition is consistent with one perspective of the dictionary derivation of hoelth
(from Old English) as sound, and hale, meaning strength. As a result, a person is able to:
Function adequately (can be objectively observed)
Adapt adequately to the environment
Feel well (as subjectively assessed)
Within the disease perspective, more or less health is viewed as a state of being. Health
may be dichotomized into wellness and illness, or viewed as a continuum from an ideal state
of high-level wellness to terminal illness and death. When conceptualized on a continuum,
the absence of disease defines health. Normal health status is viewed as a standard of ade-
quacy to access capabilities for role or task performance. Disease is dysfunction, the human
experience of disease is illness, and behavioral dysfunctions due to health problems are
sickness.
Disease
Disease is a medical term. It is a dysfunction of the body (Benner et al., 1996, p. 45), and
a deviation from clearly established norms. The objective of the physician is to classify
observable changes in body structure or function (signs) into a recognizable clinical syn-
drome. A correct label, or diagnosis, implies disease course and duration, communicability,
prognosis, and appropriate treatment. Medical intervention is aimed at curing the disease.
Part of nursing intervention supports and promotes the medical regimen through, among
other things, administering treatments, encouraging rest, and evaluating the effectiveness of
interventions.
Historically, diseases were believed to be due to one agent, which in a sufficient dose,
caused certain predictable signs and symptoms. Increasingly, however, a variety of factors
related to the person (host), agent, and environment have been viewed as being interrelated
in the cause and effective treatment of disease. For example, genetic factors, stress, and poor
air quality have all been implicated in the development of asthma. All of the interrelation-
ships must be considered in determining a plan for care.
Illness
Illness is a subjective feeling of being unhealthy that may or may not be related to disease.
A person may have a disease without feeling ill and may feel ill in the absence of disease. For
example, a person may have hypertension (a disease) controlled with medication, diet, and
exercise. This person may have no symptoms and no illness. Another person may have pain
and feel ill, but may not have an identifiable disease. What is important is how the person
feels and what he or she does because of those feelings.
Nursing interventions focus on the clients responses to symptoms. In contrast, medical
care focuses on efforts to label (diagnose) and treat the symptoms. When a persons illness is
accepted by society, and thus given legitimacy, it is considered sickness.
Sickness
Twaddle, a medical sociologist, defined sickness as a status, a social entity usually associ-
ated with disease or illness, although it may occur independently of them (1977, p. 97).
Once the person is defined as sick, various dependent behaviors are condoned that otherwise
might be considered unacceptable. The nurses role is to assist until the person is able to inde-
pendently reassume responsibility for decision-making.
Well-Being
Well-being is a subjective perception of vitality and feeling well that is a component of
health within the disease perspective. It is a variable state that can be described objectively,
experienced, and measured. Experienced at the lowest degrees, a person might feel ill. Expe-
rienced at the highest levels, a person would perceive maximum satisfaction, understanding,
and feelings of contribution. Thus, well-being status can be plotted on a continuum, as shown
in Figure 1-1.
Smith (1981, p. 47), in a now classic work, presented four models of health consistent with
the disease perspective that, initially, were viewed as forming a scalea progressive expan-
sion of the idea of health. Subsequent research, however, has indicated that many people hold
beliefs from all four models of health concurrently. Smiths four models of health are the clin-
ical model, the role performance model, the adaptive model, and the eudaimonistic model.
The clinical model is the narrowest view. People are seen as physiologic systems with inter-
related functions. Health is identified as the absence of signs and symptoms of medically
defined disease or disability; persons are healthy if they are not ill. Thus, health might be
defined as a state of not being sick (Ardell, 1979, p. 18) or as a relatively passive state of
freedom from illness a condition of relative homeostasis (Dunn, 1977, p. 7). Much of our
present health care delivery system is set up to deal with disease and illness after it occurs,
based on this model of health. In the clinical model of health, the opposite end of the con-
tinuum from health is disease.
Next on the scale is the idea of health as role performance. This model adds social and psy-
chological standards to the concept of health. The critical criterion of health is the persons
ability to fulfill roles in society with the maximum (e.g., best, highest) expected performance.
Persons are healthy if they are able to work. If a person is unable to perform their expected
roles, this inability can mean illness even if the individual appears clinically healthy. For
example, somatic health is the state of optimum capacity for the elective performance of
valued tasks (Parsons, 1958, p. 168). In the role performance model of health, the opposite
end of the continuum from health is sickness.
+ ++ +++
Figure 1-1. The Illness Well-being
well-being con-
tinuum.
Incorporating the clinical and role performance models is the adaptive model. Health is
perceived as a condition in which the person can engage in effective interaction with the
physical and social environment. The adaptive meaning of health is related to the ability to
adjust; persons are healthy if they are able to cope. There is an indication of growth and
change in this model. For example, McWilliams, Stewart, Brown, Desai, and Coderre define
health as the individuals ability to realize aspirations, satisfy needs, and respond positively to
the challenges of the environment (1996, p. 1), and Roy and Andrews define health as a
state and a process of being and becoming an integrated and whole human being (1999, p.
54). In the adaptive model of health, the opposite end of the continuum from health is illness.
Smith (1981) considers the eudaimonistic model to be the most comprehensive conception
of health. In this model, health is a condition of actualization or realization of the persons
potential. For example, human health is the actualization of inherent and acquired human
potential (Pender, Murdaugh, & Parsons, 2002, p. 22). Health transcends biological fitness.
It is primarily a measure of each persons ability to do what he wants to do and become what he
wants to become (Dubos, 1978, p. 74). In the eudaimonistic model, health is dichotomized,
with being well at the opposite end of the continuum from disabling illness. Woods and col-
leagues (1992) identified characteristics consistent with the eudaimonistic meaning of health,
including having goals, positive self-concept, positive body image, social involvement, positive
mood, harmony, energy, healthy lifeways, creativity, and rational thinking.
HEALTH PROTECTION AND DISEASE RISK PREVENTION

Pender and colleagues (2002, p. 7) describe health protection as motivated by a desire to
actively avoid illness, detect it early, or maintain functioning within the constraints of ill-
ness. According to Pender (2002), health protection is illness or injury specific, avoidance
motivated, and seeks to prevent insults to health and well-being.
From the perspective of the disciplines of medicine, public health, and epidemiology, dis-
ease is the dominant approach to health. If health is defined as the absence of disease, then
the emphasis becomes the prevention of disease risk factors and disease. Health protection
behavior is defined as actions designed to avoid or ward off threats to health (Kulbok et al.,
1997). Health protection (interchangeably used with illness prevention) activities are those
that protect a person from a specific harm.
Health protection strategies consist of preventative activities and are categorized into
three levels of prevention (Hravnak, 1998, p. 284). In a now classic work, Clark and Leavell
(1965) defined the primary, secondary, and tertiary levels of prevention.
Primary prevention takes place before there are symptoms of disease, with a focus on pro-
motion of general health or protection against disease or environmental influences. There-
fore, primary prevention includes generalized health promotion as well as specific protection
against disease.
Secondary prevention occurs as soon as disease symptoms are identified. The focus is on
early diagnosis and prompt and adequate treatment to prevent complications and limit dis-
ability. Secondary prevention emphasizes early diagnosis and prompt intervention to stop or
control the disease process and reduce disability.
Tertiary prevention occurs within chronic disease. Rehabilitation is intended to restore the
client to an optimal level of functioning within the constraints of any disability.
In the biomedical conception of health, the emphasis in all three categories of prevention
is on disease. Even primary prevention is focused on the reduction of the risk of incidence of
diseases or disorders. However, prevention of specific diseases does not deal with the basic
causes of the health problem.
Risk connotes danger, hazard or peril, chance, fate, or luck, but is based on the scientific
notion of probability. To reduce disease risk, primary prevention is often based on epidemio-
logical data. Epidemiology, as a discipline, focuses on how diseases originate and spread in
populations. Specifically, epidemiology examines the relationships between physiological,
psychological, social, and environmental events, and the incidences (new cases) and preva-
lence (total number of cases) of diseases. Determination of a causal relationship between a
risk factor and a disease is based on retrospective (case control) and prospective (cohort) stud-
ies, using 5 criteria: strength (relative risk), specificity, temporal relationship, coherence (bio-
logical sense and dose response relationship), and preventive clinical trials (Winett, 1995).
Epidemiological data should serve as a basis for understanding risk factors associated with
disease and for the modification of such factors. It is important to remember that disease risk
factors often represent an interaction of agent, host, and environmental factors, and that rel-
ative risk is related to the strength of association between a risk factor and rates of morbidity
and mortality.
Being diagnosed as having disease risks poses challenges for people who have to translate
population characteristics into personal meaning; cope with ambiguity; interpret the possi-
bility of illness in the absence of symptoms; remain vigilant; and possibly attempt risk reduc-
tion (Kavanagh & Broom, 1998). In addition, being labeled at risk presents the individual
with a very ambiguous situation. Because risk is based on statistical probability in a popula-
tion, if action is taken by an individual to try to reduce his or her risk, there can be no clear
confidence in the extent of personal vulnerability or the ultimate effectiveness of the reme-
dial action.
A healthy lifestyle has become almost synonymous with a lifestyle characterized by risk
evasion or risk reduction. Although by increasing anxiety regarding disease, accidents and
other adverse events, the risk epidemic enhances both health care dependence and health
care consumption . . . . fear of disease continues to be the most effective tool for lifestyle
changes (Forde, 1998, pp. 1155-1156). Risks imposed by others, such as environmental
agents, include: 1) natural and synthetic toxic chemicals; 2) pollution with radiation and
nuclear waste; 3) physical objects; 4) pathogenic organisms; and 5) substances used as
nutrients.
The United States health care system remains primarily disease- and disease risk-oriented.
The major portion of national expenditures for medical care goes for the cure and control of
illness; relatively little is spent for prevention and health education, even though health pro-
motion programs are associated with lower levels of workplace absenteeism and health care
costs (Aldana, 2001). Even efforts toward prevention and health education are illness-ori-
ented. For example, children are taught to brush their teeth to avoid cavities (not because the
mouth will feel, look, taste, and smell better) and to dress warmly so they will not catch a
cold (rather than so that they will feel better).
The national preoccupation with disease risk is evident in Healthy People 2010, published
in 2000 by the U.S. Department of Health and Human Services. This report describes
national objectives for health promotion and disease prevention, including two overarching
goals to be achieved by the year 2010 (pp. 8-16):
Increase quality and years of healthy life

Eliminate health disparities
Focus areas (with a total of 467 objectives) have been proposed in 28 categories and are
listed in Box 1-1.
B OX 1-1
Healthy People 2010 Focus Areas
Access to quality health services Immunization and infectious diseases

Arthritis, osteoporosis, and chronic Injury and violence prevention
back conditions Maternal, infant, and child health
Cancer Medical product safety
Chronic kidney disease Mental health and mental disorders
Diabetes Nutrition and overweight
Disability and secondary conditions Occupational safety and health
Educational and community-based Oral health
programs
Physical activity and fitness
Environmental health
Public health infrastructure
Family planning
Respiratory diseases
Food safety
Sexually transmitted diseases
Health communication
Substance abuse
Heart disease and stroke
Tobacco use
HIV
Vision and hearing
Disease prevention and health promotion differ in whether the main emphasis is on resist-
ance to movement toward the negative (disability), or in movement toward the positive
(well-being) (Breslow, 1999).
HEALTH PROMOTION
The Cumulative Index of Nursing and Allied Health Literature (CINAHL) describes health
promotion as the process of fostering awareness, influencing attitudes, and identifying alterna-
tives so that individuals can make informed choices and change their behavior to achieve an
optimum level of physical and mental health, and improve their physical and social environ-
ment (CINAHL, 1992, p. 118). Pender et al., (2002, p. 7) suggests that health promotion is
motivated by the desire to increase well-being and actualize human health potential. Accord-
ing to Pender and colleagues (2002), health promotion is not illness, or injury, specific, is
approach motivated, and seeks to expand positive potential for health.
There are a number of different approaches to health promotion. The medical approach
emphasizes correcting problems or disease through treatment and prevention of risks. How-
ever, medical pain relief and medical reduction of symptoms are not typically accomplished
by enhancing health. . . . Most medications or medical treatments do not actually restore or
fully heal our natural ability to sustain a high level of well-being (Jahnke, 1997, p. 5). The
individual (behavioral) approach focuses on secondary and primary prevention to improve
health status through lifestyle and behavior changes of individuals, the socioenvironmental
approach addresses psychological, social, and environmental aspects of health, so that health
becomes a means of empowerment (Hartrick, 1998; Robertson & Minkler, 1994), and the
societal approach focuses on broader health promotion policy.
The Individual (Behavioral) Approach

Smith & Orleans (2004) describe five levels of health promotion. They are:
1. Basic biological processes (e.g., the physiology of nicotine addition)
2. Individual psychological processes (e.g., stages of change)
3. Family and social group processes (e.g., social support)
4. Larger social, cultural, and environmental factors (e.g., access to safe settings for exercise)
5. Institutional and public policy factors (e.g., taxes on tobacco)
Health promotion is often focused on the individual, as in the following definitions:
1. The process of enabling people to increase control over, and to improve, their health
(World Health Organization, 1986).
2. Any actions or behaviors taken by individuals to improve or promote well-being or
health (Kulbok et al., 1997, pp. 13-14).
3. Health promotion is behavior motivated by the desire to increase well-being and actu-
alize human health potential (Pender et al., 2002, p. 7).
4. Health promotion consists of activities directed toward increasing the level of well-
being and actualizing the health potential of people, families, communities, and soci-
ety (Hravnak, 1998, p. 284).
Some sources relate health promotion for individuals to health education. In the litera-
ture, health education is the label frequently used to refer to individual (lifestyle) and struc-
tural (fiscal or ecological) health promotion elements, whereas health promotion is the term
used for the broader, structural aspect, in which education plays a part (Benson & Latter,
1998; Huff & Kline, 1999). Health promotion emerged out of health education and desig-
nates a broader level of outcomes than does health education. However, health education is
considered a primary approach for achieving health promotion outcomes.
Health education has been defined as any planned combination of learning experiences
designed to predispose, enable, and reinforce voluntary behavior conducive to health in indi-
viduals, groups, or communities (Green & Kreuter, 1991, p. 432). From this perspective,
nursing intervention should focus on helping clients to gain health-related knowledge, atti-
tudes, and practices associated with achieving specific health-related behavior. Breckon, Har-
vey, and Lancaster (1994) identified the following characteristics of health education:
Involves changing habits and attitudes
Individual responsibility
Information dispensing
Planned change
Community advocacy
The Nurses Role in Promoting the Health of Individuals

The [nurse] is not the person who stands back, assesses, plans, and evaluates, but a facilita-
tor who teaches clients how to self-assess, decide on wellness goals, plan on actions to meet
those goals, and self-evaluate success (Clark, 1996, p. 1). Emphasizing the individual approach
to health promotion, Clark (1996), Gillis (1995), and Hravnak (1998) propose that the nurses
roles in health promotion should be focused on promoting lifestyle changes rather than specific
behavior changes, and empowering clients to increase their control over determinants of health
and well-being. Other nursing roles in health promotion are listed in Box 1-2.
B OX 1-2
Nursing Roles in Health Promotion
of Individuals
Direct clients attention to positive Be sensitive to the variety of physical,

cues when health-promoting behav- cultural, social, and ecological dimen-
iors occur sions involved in promoting health
lifestyles
Promote positive self-esteem and self-
efficacy Be an effective role model for well-
ness
Assist clients to understand the deter-
minants of health Facilitate consistent client involvement
in the assessment, implementation,
Decrease illness-related reoccurences
and evaluation of health promotion
and prevent complications, reduce
goals
re-admissions or office visits, and
improve cost effectiveness Teach clients to perceive life experi-
ences as manageable and meaningful
Create environments conducive to
by increasing self-responsibility and
health
commitment to self-care
continued
B OX 1-2 CONTINUED
Teach and facilitate client self-care Assist clients to differentiate them-

strategies to enhance fitness, nutri- selves from the practitioner and sig-
tional status, stress management, pos- nificant others
itive relationship building, coherent Facilitate richness of client social sup-
belief systems, and their environment ports
Facilitate client creative problem Facilitate effective learner, family, and
solving to enhance health work role behaviors in clients
Facilitate client assertive behavior Integrate family members and care-
Maximize functional status givers into the plan, and support
those with caregiver burden
Teach clients effective communica-
tion skills Document nursings contribution to
reduced costs (Anderson, 1997)
Health promotion practice requires the nurse to adopt a consumer model rather than the
traditional professional model. In this shift in thinking, the emphasis is on the empower-
ment of the client instead of the professional expertise of the nurse and other health care spe-
cialists (Gillis, 1995). Traditionally, the professional has tended to be authoritarian,
prescriptive, persuasive, and a generalized information giver from an expert to an ignorant
lay person. We know best, is the covert, if not overt, philosophy of most health profession-
als. However, the role of the professional is shifting to that of consultant, advocate, mediator,
and supporter. In the new paradigm, the professional is empowering, client-centered, and uses
a collaborative approach (partnership). In addition, ONeill (1997) emphasizes that it is cru-
cial that more attention be paid by nurses to the collective, political, and environmental
dimensions of their role (p. 175).
The Socioenvironmental (Ecological) Approach

Although the emphasis of much American health education/promotion is focused on indi-
vidual lifestyle change, there is more emphasis on the environment, and an ecological per-
spective, in other countries. A socioenvironmental or ecological view emphasizes the
interconnectedness of lifestyle and environmental matters when health is being considered
with the person in balance with the family, community, and environment. Ecological analy-
ses include multiple physical, social, and cultural dimensions of the environment (Stokols,
1996).
B OX 1-3
Suggested Nursing Approaches Consistent
with the Socioenvironmental View
Shift from person-focused to environmentally based and community-
oriented health promotion.
Identify various physical and social conditions within environments that
can affect physiologic, emotional, and/or social well-being.
Use comprehensive approaches that integrate psychological, organiza-
tional, cultural, community planning, and regulatory perspectives.
Recognize that people-environment transactions are characterized by
cycles of mutual influence (Stokols, 1996, p. 286). Be aware of the
dynamic interplay among personal and situational factors affecting the
client.
Recognize the fit (or lack of fit) between the clients biological, behavioral,
and sociocultural needs and the environmental resources available to
them.
Integrate knowledge from different disciplines.
Coordinate among the various persons and groups involved with the
client.
Source: Adapted from Stokols, D. (1996). Translating social ecological theory into guidelines for com-
munity health promotion. American Journal of Health Promotion, 10, 282-298.
Nursing approaches emphasize the dynamic interplay between situational and personal
factors. Nursing approaches consistent with the socioenvironmental view are listed in
Box 1-3.
Whereas the socioenvironmental approach focuses on the interaction of individual, fam-
ily, community, and the environment, the societal approach focuses on broader health pro-
motion policy.
The Societal (Policy) Approach

Health promotion can be defined in broader societal terms as:
Any planned combination of educational, political, regulatory, and organizational sup-
ports for actions and conditions of living conducive to the health of individuals, groups, or
communities (Green & Kreuter, 1991, p. 432).
Concern about the creation of living conditions in which a persons experience of health
is increased... A health promotion program can improve health without necessarily reducing
the prevalence of disease or specific risk factors (Hartrick, 1998, p. 219).
Health promotion may be defined as follows: Health promotion is the [political] process
by which the ecologically-driven socio-political-economic determinants of health are
addressed as they impact on individuals and the communities within which they interact
(Whitehead, 2004, p. 314).
Explicit in these definitions is the need for interventions to stimulate, establish, and sus-
tain an appropriate combination of educational, organizational, and political supports needed
to create environments that are conducive to adopting and maintaining a healthful personal
lifestyle (ONeill, 1997). In addition, Kemper (1992) stresses the need to consider broad soci-
etal issues that affect health, fearing that the current focus of health promotion on employed
and insured groups ignores whole segments of our society. He emphasizes that the broader
issues of education, employment, environment, crime, and social support must be addressed
if we are to have a healthy society.
Concepts of empowerment, equity, collaboration, and participation are means or methods
of achieving health promotion. Figure 1-2 displays a possible structure for health promotion
with a multiplicity of intervention levels.
According to Whitehead (2004, p. 315), the attributes of health promotion can be sum-
marized as:
The need and desire to develop and implement community-driven health reform based
on social action, social cohesion, and social capital;
The willingness of communities to become empowered and self-reliant in determining
collective health needs and priorities
The attainment of health gain as a fundamental priority and shared social objective of
community action;
The active development of public health policy by communities as it applies to those
communities.
Kemper (1992, p. 174) describes three elements that are emphasized in societal approaches
to health promotion:
1. Equity. In the world view of health promotion, the goal of equal access to health car-
ries more importance than optimizing each persons individual health. The WHO
emphasizes providing basic health services to all people before moving on to the more
sophisticated needs of subgroups. . . . The universal perception is that large portions of
the American population do not have access to basic health resources.
2. Power. The focus of health promotion is social action for health. The goal is to give
people a voice in changing unhealthy environments.
3. Scope. Good housing, safe transportation, basic education, good food supplies, and
strong social relationships are within the domain of health promotion.
STRUCTURE OF STRUCTURE OF STRUCTURE OF
LIFESTYLE IMPLEMENTATION PROCESS POLICY MAKING
COMPLEXITY OF Intervention from the Top COMPLEXITY OF

RISK FACTORS POLICY MAKING
Complex Forms of Interac- MULTIPLICITY OF INTERVENTION LEVELS Complex Forms of Interac-
tion: tion:
Behavioral Risk Factors Individual Play of Power
Behavior and Resources Organizational Rules Bureaucratization
Social Networks
Policy Networks
SPECIFICITY OF RISK Resources
PATTERN Political Institutions SPECIFICITY OF POLICY
Specific Forms of Constella- PATTERN
tions: CONTEXTUALITY OF INTERVENTION Policy Issue Networks
Behavioral Risk Factors MEASURES Organization Specialization
Behavior and Resources
Intervention from the Bottom
DYNAMIC OF RISK DYNAMIC OF POLICY
The Disease Perspective of Health

PATTERN PATTERN
Reproduction and Change STRUCTURING DEVELOPING Reproduction and Change
Structure <> Agency: HEALTH BEHAVIOR PUBLIC HEALTH Structure <> Agency:
Selective Adaptation Conceptual Utilization
Bounded Rationally Incrementalism
LIFESTYLE AND RISK IMPLEMENTATION AND POLICY AND UTILIZATION

ANALYSIS EVALUATION RESEARCH ANALYSIS
Figure 1-2. A possible structure for health promotion (reprinted from Soc Sci Med, 41, Rutten, A. The implementation of health
15
promotion: A new structural perspective, pp. 1627-1637. 1995, with permission from Elsevier Science).
The Nurses Role in Societal Health Promotion

The most significant shift in conceptualization and emphasis in health promotion has
been from teaching people how to manage their health [individual/behavioral orientation]
to a more socially embedded approach that capitalizes on the inherent capacity of community
members to establish their own goals, strategies and priorities for health. . . . a socioecological,
community development approach to community health (Whitehead, 2004, p. 316).
Policy making is not characterized by overall rationality or systematic planning. In fact,
policy making may be more accurately described as a process of muddling through (Rut-
ten, 1995, p. 1632). One concern is the political opposition of those in power with a vested
interest in the status quo. To be successful in changing policy, policy advocates try to persuade
and negotiate with those in power to find mutually acceptable compromises. One strategy for
muddling through involves making only incremental changes that do not vary very much
from existing policies (Rutten, 1995).
Despite these political realities, nurses can promote healthy public policy by engaging in
widespread public consultation with the public and important policy makers in order to
develop a supportive environment for any possible health promotion interventions. One
objective should be to strengthen community action through self-help groups, community
projects, and neighborhood and community development. It is also essential that personal
skills in obtaining information and resources be fostered, so people can manage and control
their own activities. Health services may need to be reoriented, and advocacy mechanisms
established in order to provide needed services. Chapter 11, Empowering Community Health,
includes an in-depth discussion of nursing actions to promote societal health.
The Person Perspective of Health

In the person perspective of health, the human being is considered to be a unitary, indi-
visible whole. The human, although distinct, is embedded in and is, therefore, of the envi-
ronment. Humans can be distinguished within but not separated from the environment.
Thus, environment, as a whole, is viewed as co-existent with the human being. The human
being and the environment participate (Leddy, 1995) in mutual process associated with
unpredictable and nonlinear changes. Change is inevitable and provides an opportunity for
growth toward increased complexity.
In this perspective, the goal for a person is to develop his or her potential toward increased
diversity. With the emphasis on the process of becoming, health is viewed as a synthesis of
manifestations of an underlying pattern reflecting the whole of the human being. Pattern
manifestations characterize the whole human being and are not differentiated into good or
bad, healthy or not healthy, or better or worse dichotomies. The emphasis for nursing knowl-
edge development and practice is on appreciation of changing pattern manifestations, facili-
tation of self-healing, and deliberate environmental manipulation to promote growth.
Ideas of Health Consistent with the Integration Perspective

Health within the person perspective is defined by the author as the pattern of human-
environment participation. This definition is consistent with another perspective of the dic-
tionary derivation of health (from Old English) as hal, or whole. According to this definition,
the purposes of health are to:
The Person Perspective of Health 17
Enable the individual to enfold or unfold in the process of becoming

Construct meaning
Use choices to participate in change
In the person perspective, health is viewed as encompassing both disease and nondisease
(Newman, 1994). Disease can be considered a manifestation of health. . . a meaningful aspect
of health (Newman, 1994, p. 5) and a meaningful aspect of the whole (p. 7). Illness and
wellness are viewed as a single process of ups and downs that are manifestations of varying
degrees of organization and disorganization. Disputing that death is the antithesis of health,
Newman (1994) maintains that disease and nondisease are not opposites, but rather are com-
plementary facets of health, a unitary process. Illness, like wellness, simply represents a pat-
tern of life at a particular moment. The tension characteristic of disease throws one off
balance, which promotes growth toward a new level of evolving capacities, diversity, and
complexity.
Within this perspective, disease and nondisease are aspects of the unitary phenomenon of
health. Both disease and nondisease are viewed as manifestations of person-environment
mutual process and both represent the underlying pattern of energy. Given this perspective,
disease can be viewed as an integrating factor, [and] can help people see themselves and their
interactions with others more clearly (Newman, 1994, p. 27). Viewing disease this way per-
mits the nurse to focus on the transforming potential of disease rather than on the disabling
outcomes of disease. Health is an evolving or emerging process, a forward movement with
mutual person-environment patterns.
Within the person perspective, health can be conceptualized as an actively continuing
process that involves initiative, ability to assume responsibility for health, value judgments,
and integration of the total person. It is dynamic and evolving, a fluid process rather than an
actual state. Thus, health is difficult to quantify for objective evaluation. Nurses try to help
clients promote growth toward their potential by focusing on strengths, acknowledging needs
for support, and by collaborating with clients. A clients goals and feelings are major deter-
minants of nursing intervention. These ideas of health are basic to the concept of healing.
Healing
Definitions of Healing
In this chapter, the previous discussions of disease prevention and the multiple forms of
health promotion (biomedical, behavioral, socioenvironmental, and societal) have been con-
sistent with conceptions of health within the disease perspective of health. In contrast, heal-
ing is proposed as consistent with conceptions of health within the person paradigm. For
example, definitions of healing emphasize the relationship of healing to wholeness as follows:
1. To be healed is to be whole (Quinn, 1997, p. 1). The root of the word heal is the
Anglo-Saxon word haelan, which means to be or to become whole. . . . Wholeness, or
harmony of body-mind-spirit, may thus be thought of as a dynamic process of being in
right relationship. (Harmony is a synonym for connection. Synonyms for connection
are relationship, congruity, and unification.) When true healing occurs, relationship is
re-establishedrelationship to and within self, to others, with ones purpose (Quinn,
1989, p. 553).
2. Healing is the return of the integrity and wholeness of the natural state of an individ-
ual (McKivergin, 1997, p. 17).
3. Healing is an experiential, energy-requiring process in which space is created through
a caring relationship in a process of expanding consciousness and results in a sense of
wholeness, integration, balance, and transformation, and which can never be fully
known (Wendler, 1996, p. 836).
4. Heal is the activity of becoming whole (Kritek, 1997, p. 11).
5. Healing is the innate, intelligent, and purposeful response of a disordered system to ini-
tiate reordering. It is a process which moves toward order and integration of the whole
person (McCabe, 1998, p. 42).
Cunningham (2001, p. 220) differentiates spontaneous healing from assisted healing.

Spontaneous healing occurs without deliberate intervention by the subjects mind or by
others. In contrast, assisted healing involves some kind of intervention, either exter-
nally assisted (drugs or procedures) or internally assisted, which describes the deliberate
invoking, by the [client], of potentials of his or her own mind and spirit, to facilitate
healing.
Healing is not the same as curing. Curing. . . refers to the elimination of the signs and
symptoms of disease. . . . Diseases may be cured, but people require healing. In addition, indi-
viduals who will never be cured may, in fact, be healed (Quinn, 1989, pp. 553, 555).
Outcomes of Healing
Outcomes reflect a change in a persons awareness, perception, behavior, and relationship
to self, Creator, other, and creation (McKivergin, 1997, p. 24). McKivergin describes a num-
ber of possible healing outcomes, as follows:
1. Whole person outcomes

Physical. Decreased pain, enhanced wound healing, increased energy.
Emotional. Enhanced ability to feel, to name feelings, and to express oneself.
Intellectual. Perceptual reframing of an experience that influences the belief struc-
ture, attitudes, and ways of thinking about life; healing of a painful memory;
increased enthusiasm and expression of self; expansion of consciousness.
Social. Improved relationship with self, self-esteem, improved self-concept;
deeper connection with others and understanding of the reciprocal nature of
relationships.
Spiritual. Deeper sense of connectedness with all of life, self, Creator, creation;
enhanced meaning regarding a life event; forgiveness of self or others.
Vocational. Identification of and alignment with lifes purpose and path of expres-
sion; improved excitement and creativity in work.
Environmental. Harmony with nature and inherent healing rhythms; recognition
of meaning and metaphor in the symbols of the earth.
2. Ability to cope outcomes

Enhanced recognition of the impact of stress on life.
Access to relaxation response, ability to maintain a flow state.
Decreased exhibition of self-destructive behavior.
3. Sense of well-being and quality of life outcomes
Increased happiness.
Life satisfaction.
Sense of security.
4. Functional capacity outcomes
Increased ability to care for self.
Move.
Have less pain.
5. System related outcomes
Greater sense of freedom and openness.
Establishment of healthy boundaries.
Connectedness.
Willingness to change and become less defined by external parameters.
Roles for Nurses in Healing

Healing requires a different view of the role of the nurse. Care has become synonymous
with the provision of things and procedures... The assumption made is that since the patient
got well after the intervention, that he or she got well because of the intervention... The tech-
niques, the interventions per se, are totally besides the point, they are irrelevant (Quinn,
1989, pp. 554-555).
A number of authors argue that healing is an innate capacity of the person, which the nurse
facilitates (Kritek, 1997; Nightingale, 1859; Quinn, 1989; Wells-Federman, 1998). Healing
within professional nursing acknowledges the human condition not so much as something to
be denied, transcended, or controlled, but something to be honored and addressed construc-
tively in active mutuality with the patient (Kritek, 1997, p. 23). A nurse as an instrument of
healing is one who offers unconditional presence and helps remove the barriers to the heal-
ing process; one who creates the space and opportunity for another to feel safe (McKivergin,
1997, p. 17).
Quinn (1992) describes two different theoretical perspectives of the nurse-client-environ-
ment process:
1. The nurse in the environment of the client. Following appraisal and alteration of the
physical environment, the holistic nurse in the environment might then turn attention
to the use of particular healing modalities to assist in patterning a more healing envi-
ronment for the client (p. 27).
2. The nurse as the environment of the client. The nurse turns toward her or his under-
standing of the nurse-self as an energetic, vibrational field, integral with the clients
environment (p. 27).
Regardless of the nurses perspective, activities to facilitate healing include:
Removing barriers to the healing process.
Participating in creating environments that will support healing.
Facilitating wholeness in others through an interaction based on a mutuality of purpose.
Knowingly participate[ing] in the web of interconnectedness toward repatterning and
healing for ourselves and for others through the intentional use of our own conscious-
ness. . . [where] the nurses consciousness becomes a tuning fork, resonating at a healing
frequency (Quinn, pp. 28, 29). This includes repatterning ones consciousness so it is
experienced as unified, harmonious, peaceful, and ordered.
Allowing healing to emerge. The best instrument for the assessment of whether heal-
ing is happening is the subjective knowing of both client and nurse.
Attending to the meaning of disease for the client.
Establishing a healing relationship. This involves mobilizing hope for the nurse as well
as the client, identifying positive achievements, using healing rituals and symbols,
being enthusiastic, committed, encouraging, and attentive, having positive regard and
high expectations for improvement (Integrative Medicine Consult, 1999). Certain char-
acteristics of nurse healers help to facilitate the effective meeting of roles.
Characteristics of Nurse Healers

McKivergin (1997) proposes a number of characteristics of nurse healers. One cluster of
characteristics of nurse healers is related to awareness that self-healing is a continual process,
requiring recognition of personal strengths and weaknesses, openness to self-discovery, and an
awareness of present and future steps in personal growth. Another cluster of characteristics of
nurse healers relates to being in a healthy, centered, and energetic place themselves so that
they have enough personal energy to serve as an instrument of healing to another. According
to McKivergin (1997), the ability of nurses to model self-care and healthy ways of protecting
themselves may include such strategies as:
Giving and receiving only love
Praying for protection of the Creator
Visualizing white light surrounding self and other
Establishing healthy boundaries
Nurse healers are aware that a nurses presence is as important as his or her technical
skills. They engage in active listening, empowering clients to recognize that they can
cope with life processes. Time with clients is perceived as an opportunity to serve and
share with them. Insights are shared without imposing personal values and beliefs.
Through respect and love for clients, regardless of who and how they are, nurse healers
are able to guide the client in discovering creative options. There is a nonjudgmental
acceptance of what clients say, and recognition that clients know the best life choices for
themselves.
In addition, nurse healers act with intention. Intentionality involves the projection of
awareness, with purpose and efficacy (Schlitz, 1995, p. 120). But, a number of questions
about intentionality persist, including how a persons intentions interact with their bodys
natural capacity to heal itself, the roles of rapport, anticipation, hope, and belief in commu-
nication of intentionality, and the processes by which distant healers heal?
Conceptual and Theoretical Approaches to Healing
The literature describes a number of healing process concepts and theories. Examples
include therapeutic capacity, right relationship, integration, the endogenous healing process,
and therapeutic landscapes. Each of these approaches emphasizes a different aspect that con-
tributes to healing.
Therapeutic Capacity. Working within the health protection perspective, many nurses per-
ceive their role as doing battle with the disease process on behalf of the client, getting the
problem solved, but not necessarily responding to the needs of the client (Waters & Dauben-
mire, 1997). In contrast, the concept of therapeutic capacity proposes that the essence of
nursing lies in creating a healing environment and in engaging the clients consciousness in
the healing process. Therapeutic capacity has three dimensions: clinical interventions, car-
ing dynamics, and transpersonal efficacy... defined as the ability to create a shared corridor of
consciousness that facilitates the [clients] endogenous healing process... [client] and nurse
connect (Waters & Daubenmire, 1997, pp. 60-61).
Right Relationship. Quinn (1997) has described right relationship as any pattern of organ-
ization within the system that supports, encourages, allows, or generates actualization and
self-transcendence (p. 2). The emergence of right relationship:
Increases coherence of the whole system.
Decreases chaos or disorder in the whole.
Maximizes free energy in the whole.
Maximizes freedom, autonomy, and choice in the whole.
Increases the capacity for creative unfolding of the whole.
Integration. Self-reintegration is defined as a self-creation process whereby individuals
develop new capabilities by reorganizing the self and the environment so that there is a
meaning and purpose in living that transcends the stressful experience. It is the inner jour-
ney toward wholeness and fulfillment (Rosenow, 1997, p. 505). Quinn (1997) suggests
that people have an innate tendency toward wholeness, autonomy, self-actualization, and
ultimately self-transcendence, and a drive toward belonging, being a part of something
larger, connecting, and interdependency. Integration restores a greater sense of control,
order, and harmony (Medich et al., 1997). Through the bringing together of parts of a
whole in the healing process, movement is mobilized toward actualizing health potentials
and well-being.
Even illness can be thought of as a rite of passage through which a person moves from one
phase of life into another. Rites of passage have three phasesseparation, transition, and return:
Separation. A feeling of vulnerability acts as a trigger for the person to change or sepa-
rate from old ways of being or doing. Responding to the challenge involves the persons
active participation in recovery.
Transition. During this phase, a person may need time alone, experience unusual states
of consciousness, rehearse activities, and/or gather information. Social support through
information giving, feedback, and encouragement, and/or demonstrations of caring by
family, friends, or health care professionals and the recognition of improvement can
facilitate progress through this phase.
Return. The challenges and connections of reentry occur after the healing work (or ritual)
is finished and the person goes back to daily life activities (Achterberg, Dossey, & Kolk-
meier, 1994). Transformation reflects a new state of being (Medich, Stuart, & Chase, 1997).
According to Rosenow (1997), the main characteristics that shape a persons journey
through life are the search for meaning and for fulfillment. Hope, self-control, purpose, com-
petence, devotion, affiliation, production, and renunciation are psychosocial resources or
inner strengths that contribute to a persons perception of well-being. Some defining charac-
teristics within the self-reintegration process are:
Adjustment.
Self-responsibility. A state where an individual develops a desire and tendency for self-
direction and determinism. It is the belief that one is reliable, trustworthy, and account-
able (p. 505).
Returning to a normal lifestyle.
Affirmation of attitudes. Developing an attitude in order to replace negative ideas with
positive ideas that can assist in maximizing ones potential after the illness. This process
allows individuals to 1) reframe the illness to a health challenge; 2) reorder their val-
ues or standards; and 3) reclaim life satisfaction (p. 505).
Obtaining a higher quality of life or well-being. An ongoing journey of self-creation
toward a higher potential of functioning (p. 505).
Integrated resource concepts that promote reintegration include:
Hope or inner strength. Expansion of energy toward wellness. Dimensions of hope
include optimism, courage, meaning in life, attainable goals, personal attributes, peace,
and energy (p. 507).
Growth toward health or sense of direction.
Personal control or competence.
Social support and networks or affiliation.
The Endogenous Healing Process. According to Scandrett-Hibdon (1996), healing is men-
tioned in professional literature in limited ways, focusing primarily on the healer, healing
techniques, and wound healing. Healing involves individuals in their own process. In other
words, only clients can heal themselves. Six separate elements occurring in healing have been
observed in which individuals move from disharmonious to harmonious patterns. These ele-
ments, which comprise the endogenous healing process, include (1996, pp. 18-21):
Awareness. The alerting mechanism that cues people to events within their internal
and external environments. Unless a person is aware of an issue, it cannot be addressed
for change.
Appraisal. The person explores and evaluates what awareness has brought to conscious-
ness, assigns meaning to the disruption or cues, and makes comparisons with previous
experiences.
Choosing. From appraisal emerges a sense of clarity with which one can choose and set
goals to handle disharmony.
Acceptance. Might be considered to be a further aspect of choosing. In the process of let-
ting go, or deciding to accept, tension is released and relaxation occurs. Three charac-
teristics of acceptance are: (1) giving in to what is occurring, (2) letting go or ceasing to
fix the disturbance, and (3) surrendering or passing responsibility of control to another.
Alignment. The energy shifts toward the goal of healing.
Outcome. A sense of being in harmony and experiencing a sense of wholeness, character-
ized by physical and psychological comfort, vitality, and a sense of peace and well-being.
Therapeutic Landscapes. Therapeutic landscapes are those changing places, settings, situations,
locales, and milieus that encompass both the physical and psychological environments associated
with treatment or healing (Williams, 1998, p. 1193). A landscape may also include environ-
ments of the mind through imagery and visualization. A strong sense of place can have a thera-
peutic effect. For example, a long-standing relationship with a certain place can facilitate feelings
of self-identity, security and direction. In contrast, the spatial separateness and isolation found
in uncaring or hostile environments such as hospitals, reduce an individuals feeling of control.
Watson (1999, p. 248) discusses caring-healing architecture as a healing space where
there is an attention to body, mind, and spirit as one. Some of the elements such an envi-
ronment might incorporate include:
Noise control and therapeutic use of music
Concern for air quality and use of aromatherapy
Thermal comfort
Privacy
Lighting and use of color
Views of nature
Textural variety
Concern for aesthetics including the use of art
As Watson (1999, p. 257) points out, in spite of Nightingales attention to environment,
and in spite of the nursing metaparadigm including environment as part of its subject matter
and practice focus, nursing has not systematically heeded this domain in practice.
Table
1-1 Comparisons Between Health Protection, Health Promotion,
and Healing
HEALTH PROTECTION HEALTH PROMOTION HEALING
Actions designed to Actions and supports to A sense of wholeness,
FOCUS
avoid or ward off threats improve or promote well- integration, and harmony in
to health being or health which connections are re-
established to and within
self, and to others, and with
ones purpose
Relative risk Lifestyle behaviors Relationships (connections)

KEY CONCEPTS
(probability of anger) Individual responsibility Presence

Levels of prevention: Planned change Nurse as facilitating
Primary Empowerment environment
Secondary Noninvasive therapies
Tertiary
Medicine Health education Holistic nursing

DISCIPLINES
Public health Nursing Integrative health promotion

Epidemiology Social work Physical and occupational
therapy
Selected distinctions between health protection, health promotion, and healing are pre-
sented in Table 1-1.
Holistic Nursing Practice

Traditionally nurses have practiced according to the beliefs and values of the biomedical
systems disease world view. (See Chapter 3 for a discussion of the beliefs and values of the
biomedical system). Holistic nursing is not a system of nursing practice, but is characterized
by person worldview philosophical values and therapies that contrast with the conventional
way of conceptualizing and practicing professional nursing. For example, in holistic nursing,
the client is viewed as a whole in mutual process with the environment. The emphasis of
care, in active partnership with the client, is on mobilizing strengths to reduce vulnerabili-
ties. Dossey (1999, p. 322) describes holistic nursing as a philosophy and a model that inte-
grates concepts of presence, healing, and holism. Additionally, according to the American
Holistic Nurses Association (AHNA, 1993), holistic practice draws on nursing knowledge,
theories, expertise, and intuition to guide nurses in becoming therapeutic partners with
clients in strengthening the clients responses to facilitate the healing process and achieve
wholeness.
The healing relationship is discussed in depth in Chapter 10. And, noninvasive therapies
are discussed extensively in all of Section IV. Selected characteristics of holistic nursing are
presented in Box 1-4.
B OX 1-4
Selected Characteristics of
Holistic Nursing
The person is viewed as a whole (bio-psycho-social-spiritual aspects) and
in mutual process with the environment.
The focus of nursing is on promoting self-healing by the client.
Nursing emphasizes presence and mutuality in relationship with the
client.
The client is actively involved and empowered in a partnership with the
nurse.
The clients strengths are mobilized to reduce vulnerabilities.
Each person is different and, therefore, care must be individualized.
Noninvasive therapies are used to pattern a healing environment.
Outcomes include increased well-being, quality of life, and growth of the
client and the nurse toward a new level of evolving capacities, diversity,
and complexity.
Advantages of Holistic Nursing Practice to Promote Healing

Noninvasive therapeutic modalities often enhance the well-being of individuals without
the risks of drugs and other invasive therapies. Although they are not, in themselves, cura-
tive, holistic interventions stimulate the healing response. Individuals can learn and use
many mind-body healing modalities independently. This empowers people to heal themselves
more effectively and to independently enhance their quality of life. Empowerment means
that the nurse provide[s] people with the chance to be involved in their own care, to make
vital decisions about their own health, to be touched at deep emotional levels, and to be
changed psychologically in the process (Berman & Larson, 1994, p. 35).
The nurse helps clients to access their own healing capacities. Nurses offer the gift of
walking with a person so that he or she is not alone at the crossroads of healing. . . . It is pos-
sible to cultivate the skill of becoming an instrument and sensing the open door through
which healing can emerge. . . . As nurses offer partnership in the journey of healing, they offer
new insights, ways of coping, and a release from the bondage of fear and pain (McKivergin,
1997, p. 24).
Use of noninvasive therapeutic interventions also fosters professional autonomy, and has
financial efficacy, often reducing or containing the cost of care. Holistic interventions are
appropriately employed and evaluated by nurses in partnership with clients, in contrast to the
limited autonomy for both nurse and client often found in a hospital setting. The inpatient
care system favors the [client] becoming a recipient of care rather than an agent of self-care
(Hravnak, 1998, p. 285).
Integrative Health Promotion

Integrative health promotion is based on a combination of a healing philosophy and the
utilization of both health protection/promotion strategies and holistic, noninvasive therapeu-
tic nursing modalities to facilitate the health of individuals, families, and communities, locally
and globally. Integrative health promotion for nursing practice proposes utilization of the con-
tent of health protection and promotion strategies (disease worldview) within the healing
processes that characterize the person worldview of health. This is consistent with the sug-
gestion that worldviews can be viewed as different ways of perceiving reality, rather than as
views of differing realities (Leddy, 2000, p. 227). Both content and process are recognized as
aspects of reality. As a result, research findings about behavior change strategies implement-
ing primary, secondary, or tertiary prevention to reduce health risk and promote health can be
incorporated within a philosophy and an approach to nursing practice that emphasizes the
processes of healing and holistic nursing. This combination has been labeled here as integra-
tive nursing.
Healing is considered an innate capacity of the person in a healing philosophy. Therefore,
the role of the nurse is to facilitate healing by removing barriers to the healing process and
participate in creating an environment that will support healing (Quinn, 1992). A healing
relationship, based on presence and mutuality, is central to fulfillment of the nurses role.
Healing must emerge rather than result from specific interventions. This shifts the nurses
emphasis from doing to being.
In integrative health promotion, the professional nurse and client enter a partnership, in
which the nurse consults with the client to empower the client for self-healing. The focus is
on mobilizing client strengths, to reduce vulnerability due to environmental risks and lifestyle
behaviors, and to foster growth and meaning. Health is viewed as a process rather than cure
of disease. Care is individualized, based on theory and reflective thought, but also directed
toward environmental and policy contexts that support health.
Viewing the client as a whole in mutual process with the natural and social environment
emphasizes strategies to promote health patterning. A number of noninvasive therapeutic
strategies or modalities (discussed in this book) can be taught to clients. Prevention of risk,
lifestyle behavior change strategies, and holistic modalities may be utilized by clients to enhance
healing. Therefore, the nurses ability to help clients to select and perform relevant strategies or
modalities is relevant to integrative health promotion in all practice settings. It is important
that nurses actualize their essential role in health promotion within acute care settings as well
References 27
as with ambulatory clients in community settings. In addition, it is important that nurses assume
a much more active role in promoting the health of communities, both locally and globally.
Chapter Key Points

Both the disease and the person worldviews of health have important implications for
practice and nursing science.
Disease, illness, sickness, health status, role performance, and wellness are concepts
associated with the disease perspective of health.
Pattern, increased diversity, unitary, and becoming are concepts associated with the per-
son perspective of health.
Health promotion activities need to be applied at behavioral (individual), ecological
(environmental), and policy (societal) levels.
Health protection, as a medical approach, emphasizes the prevention of disease risk fac-
tors and disease.
In the medical approach to health, the emphasis is on disease in primary, secondary,
and tertiary prevention.
Holistic nursing emphasizes the whole person, individualized care, and an empowering
partnership with the client that is based on mutuality and presence, in order to promote
self-healing and growth.
The facilitation of healing toward wholeness, harmony, and therefore health of nurses
and clients, is the essence of holistic nursing.
Integrative health promotion is based on a healing philosophy and utilizes both health
protection/promotion strategies and holistic, noninvasive therapeutic nursing modalities
to facilitate the health of individuals, families, and communities, locally and globally.
References
Achterberg, J., Dossey, B., & Kolkmeier, L. (1994). Rituals of healing: Using imagery for health and wellness.
New York: Bantam.
Aldana, S. G. (2001). Financial impact of health promotion programs: A comprehensive review of the lit-
erature. American Journal of Health Promotion, 15, 296-320.
American Holistic Nurses Association (1993). Description of holistic nursing. Flagstaff, AZ:
American Holistic Nurses Association.
Anderson, C. A. (1997). The economics of health promotion. Nurs Outlook, 45, 105-106.
Ardell, D. B. (1979). The nature and implications of high level wellness, or why normal health is in a
rather sorry state of existence. Health Values, 3, 17-24.
Benner, P., Tanner, C. A., & Chesla, C. A. (1996). Expertise in nursing practice: Caring, clinical judgment and
ethics. New York: Springer.
Benson, A., & Latter, S. (1998). Implementing health promoting nursing: The integration of interpersonal
skills and health promotion. J Adv Nurs, 27, 100-107.
Berman, B. M., & Larson, D. B. (Eds.). (1994). Alternative medicine: Expanding medical horizons. Washing-
ton, DC: U.S. Government Printing Office.
Breckon, D. J., Harvey, J. R., & Lancaster, R. B. (1994). Community health education: Settings, roles and skills
for the 21st century (3rd ed.). Gaithersburg, MD: Aspen.
Breslow, L. (1999). From disease prevention to health promotion. JAMA, 281, 1030-1033.
Clark, C. C. (1996). Wellness practitioner (2nd ed.). New York: Springer.
Clark, E. G., & Leavell, H. R. (1965). Levels of application of preventive medicine. In H. Leavell, & A.
E. Clark (Eds.), Preventive medicine for doctors in the community (3rd ed., pp. 14-38). New York:
McGraw-Hill.
Cumulative Index to Nursing and Allied Health Literature (1992). Glendale, CA: CINAHL Information Systems.
Cunningham, A. (2001). Healing through the mind: Extending out theories, research, and clinical prac-
tice. Adv Mind Body Med, 17, 214-227.
Delaney, F. (1994). Nursing and health promotion: Conceptual concerns. J Adv Nurs, 20, 828-835.
Dossey, B. (1999). Holistic nursing. In W. B. Jonas, & J. S. Levin (Eds.), Essentials of complementary and
alternative medicine (pp. 322-339). Philadelphia: Lippincott Williams & Wilkins.
Dubos, R. (1978, January). Health and creative adaptation. Human Nature, 1, 74-82.
Dunn, H. L. (1977, January/February). What high-level wellness means. Health Values, 1, 9-16.
Forde, O. L. (1998). Is imposing risk awareness cultural imperialism? Soc Sci Med, 47, 1155-1159.
Gillis, A. (1995). Exploring nursing outcomes for health promotion. Nursing Forum, 30, 5-12.
Green, L. W., & Kreuter, M. W. (1991). Health promotion planning: An educational and environmental
approach. Mountain View, CA: Mayfield Press.
Hartrick, G. (1998). Developing health promoting practices: A transformative process. Nurs Outlook, 46,
219-225.
Hravnak, M. (1998). Is there a health promotion and protection foundation to the practice of acute care
nurse practitioners? AACN Clinical Issues, 9, 283-289.
Huff, R. M., & Kline, M. V. (1999). Promoting health in multicultural populations: A handbook for practition-
ers. Thousand Oaks, CA: Sage.
Integrative Medicine Consult. (1999). Boston, MA: Interactive Medicine Communications.
Jahnke, R. (1997). The healer within: The four essential self-care methods for creating optimal health. San Fran-
cisco: Harper Collins.
Kavanagh, A. M., & Broom, D. H. (1998). Embodied risk: My body, myself? Soc Sci Med, 46, 437-444.
Kemper, D. W. (1992). Is health promotion in America misdirected? An international conference report.
American Journal of Health Promotion, 6, 174.
Kritek, P. B. (Ed.). (1997). Reflections on healing: A central nursing construct. New York: National League for
Nursing.
Kulbok, P. A., Baldwin, J., Cox, C., & Duffy, R. (1997). Advancing discourse on health promotion: Beyond
mainstream thinking. Advances in Nursing Science, 20(1), 12-20.
References 29
Leddy, S. K. (1995). Measuring mutual process: Development and psychometric testing of the Person-Envi-
ronment Participation Scale. Visions: Journal of Rogerian Nursing Science, 3, 20-31.
Leddy, S. K. (2000). Toward a complementary perspective on worldviews. Nursing Science Quarterly, 13,
225-233.
McCabe, P. (1998). Revealing common ground: Comparing themes in traditional natural medicine and
holistic nursing. Australian Journal of Holistic Nursing, 5, 41-46.
McKivergin, M. (1997). The nurse as an instrument of healing. In B. M. Dossey (Ed.), Core curriculum for
holistic nursing. Gaithersburg, MD: Aspen
McWilliams, C. L., Stewart, M., Brown, J., Desai, K., & Coderre, P. (1996). Creating health with chronic
illness. Advances in Nursing Science, 18, 1-15.
Medich, C. J., Stuart, E., & Chase, S. K. (1997). Healing through integration: Promoting wellness in car-
diac rehabilitation. J Cardiovasc Nurs, 11, 10-26.
Newman, M. A. (1994). Health as expanding consciousness (2nd ed.). St Louis: Mosby.
Nightingale, F. (1859). Notes on nursing: What it is, and what it is not. London: Harrison & Sons.
ONeill, M. (1997). Health promotion: Issues for the year 2000. Canadian Journal of Nursing Research, 29, 71-77.
Parsons, T. (1958). Definitions of health and illness in light of American values and social structure. In E.
G. Jaco (Ed.), Patients, physicians, and illness, pp. 120-144. Glencoe, IL: The Free Press.
Pender, N. J. (1990). Expressing health through lifestyle patterns. Nursing Science Quarterly, 3, 115-122.
Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2002). Health promotion in nursing practice (4th ed.).
Upper Saddle River, NJ: Prentice Hall.
Quinn, J. F. (1989). On healing, wholeness, and the Haelan effect. Nursing and Health Care, 10, 553-556.
Quinn, J. F. (1992). Holding sacred space: The nurse as healing environment. Holistic Nursing Practice, 6, 26-36.
Quinn, J. F. (1997). Healing: A model for an integrative health care system. Advanced Practice Quarterly,
3(1), 1-7.
Robertson, A., & Minkler, M. (1994). New health promotion movement: A critical examination. Health
Education Quarterly, 21, 295-312.
Rosenow, D. J. (1997). Some core components of healing: A theory of self-reintegration: A journey within
oneself. In P. B. Kritek (Ed.), Reflections on healing: A central nursing construct (pp. 500-517). New
York: National League for Nursing.
Roy, S. C., & Andrews, H. A. (1999). The Roy adaptation model (2nd ed.). Stamford, CT: Appleton & Lange.
Rutten, A. (1995). The implementation of health promotion: A new structural perspective. Soc Sci Med,
41, 1627-1637.
Scandrett-Hibdon, S. (1996). The history of energy-oriented healing. In D. Hover-Kramer, Healing touch:
A resource for health care professionals (pp. 18-21). Albany, NY: Delmar.
Schlitz, M. (1995). Intentionality in healing: Mapping the integration of body, mind, and spirit. Altern Ther
Heatlh Med, , 119-120.
Smith, J. A. (1981). The idea of health. A philosophic inquiry. Advances in Nursing Science, 3, 43-50.
Smith, T. W., & Orleans, C. T. (2004). Prevention and health promotion: Decodes of progress, new chal-
lenges, and an emerging agenda. Health Psychology, 23, 126-131.
Stokols, D. (1996). Translating social ecological theory into guidelines for community health promotion.
American Journal of Health Promotion, 10, 282-298.
Twaddle, A. C. (1977). A sociology of health. St. Louis: Mosby.
U.S. Department of Health and Human Services. (2000). Healthy people 2010. Washington, DC: U.S. Gov-
ernment Printing Office.
Waters, P. J., & Daubenmire, M. J. (1997). Therapeutic capacity: The critical variance in nursing practice.
In P. B. Kritek (Ed.), Reflections on healing: A central nursing construct (pp. 56-68). New York:
National League for Nursing.
Watson, J. (1999). Postmodern nursing and beyond. Edinburgh, UK: Churchill Livingstone.
Wells-Federman, C. L. (1998). Awakening the nurse healer within (pp. 108-122). In C. Guzzetta (Ed.),
Essential readings in holistic nursing. Gaithersburg, MD: Aspen.
Wendler, M. C. (1996). Understanding healing: A conceptual analysis. J Adv Nurs, 24, 836-842.
Whitehead, D. (2004). Health promotion and health education: Advancing the concepts. Journal of
Advanced Nursing, 47, 311-320.
Williams, A. (1998). Therapeutic landscapes in holistic medicine. Soc Sci Med, 46, 1193-1203.
Winett, R. A. (1995). A framework for health promotion and disease prevention programs. Am Psychol, 50,
341-350.
Woods, N. F., Laffrey, S., Duffy, M., Lentz, M. J., Mitchell, E. S., Taylor, D., et al. (1988). Being healthy:
Womens images. Advances in Nursing Science, 11, 36-46.
World Health Organization. (1986). The Ottawa charter for health promotion. Ottawa, Canada: WHO,
Canadian Public Health Association, and Health & Welfare.
2
HEALTH STRENGTHS
Abstract
The chapter begins with a brief review of conceptual approaches to health and illness
and a description of a strengths approach to health promotion. The healthiness theory
(Leddy, 1996) that forms the structure for this book is then introduced. Aspects and con-
cepts of the theory are described, and measurement and empirical research results are
reviewed.
Learning Outcomes
Describe two models of health in terms of their different views of change

Identify five advantages of a strengths approach to health promotion
Understand how a strengths approach affects the nurseclient relationship
Explain the aspects and concepts that compose the healthiness theory
Briefly describe the characteristics of each of the concepts in the healthiness theory and
possible interventions that would foster healthiness
32 Chapter 2 Health Strengths
The Strengths Perspective

The dominant model of health focuses on negatively conceived states such as illness,
sickness, and disease. Health may be dichotomized into wellness and illness, or viewed as a
continuum from an ideal state of high-level wellness to terminal illness and death. When
viewed on a continuum, the absence of disease defines health. From the viewpoint that nor-
mal human functioning operates within a relatively narrow range of balance or stability
(homeostasis), human and environmental interactions pose potential threats to health.
Alternatively, as in this book, health can be perceived as a single process of ups and downs,
in which disease and nondisease are viewed as complementary facets of health. Illness, like
wellness, simply represents a pattern of life at a particular moment. This text primarily focuses
on promoting strengths and positive manifestations such as well-being, harmony, and growth.
In this model, change is inevitable and provides an opportunity for growth and the develop-
ment of potential toward increased complexity. The emphasis for nursing knowledge devel-
opment and practice is on appreciation of changing pattern manifestations, facilitation of
self-healing, and deliberate environmental manipulation to promote growth.
However, although the focus in this book is on the promotion of positive resources for
health, this is not meant to imply that the negative side, comprising responses to threats
and stressors, is unimportant (Held, 2004). Both positive and negative responses that occur
in personenvironment mutual processes function dialectically (growth occurs through syn-
chronizing the contradictions and paradoxes that exist between complementary opposing
views). Examples of such opposing views are happiness/sorrow, gains/losses, and yin/yang, in
which positive/negative are not absolute states but depend on the perspective of the person.
However, given that so much of the literature focuses on the negative, to provide balance, a
positive perspective and positive resources are emphasized in this book.
Health promotion focuses on positive health, and its main aim is the building of strengths,
competencies, and resources. Human strengths are resources for health. By identifying, acknowl-
edging, concentrating on, and increasing strengths and environmental resources, it is believed that
individuals can be helped to improve human functioning and well-being. This requires a shift in
perspective to a practice that is perspective based, that focuses on strengths and solutions, and that
is based on proactive constructionist tendencies rather than reaction, coping, and repair (Naka-
mura & Csikszentmihalyi, 2003, p. 262). Implicitly promoting a proactive and positive approach,
the First International Conference on Health Promotion (held in 1986 in Ottawa, Canada) out-
lined five levels of action: (1) building public health policy, (2) creating supportive environments,
(3) strengthening community action, (4) developing personal skills, and (5) reorienting the
health system (WHO, 1986). This book will emphasize the development of personal skills.
Evidence indicates that depression and anxiety can be prevented and good social rela-
tionships can be promoted by teaching people when to use strengths, rather than focusing
exclusively on repairing damage (Seligman, 2002). Feeling good can make people more opti-
mistic, resilient, and socially connected. Positive beliefs may be tied to physiological changes
by positive affect. Positive beliefs may also be connected to physical disease by promoting
health through better health behaviors, conscientious application of positive health habits,
and appropriate use of health services.
The Theory of Healthiness 33
Positive functioning incorporates self-acceptance, personal growth, purpose in life, envi-

ronmental mastery, autonomy, and positive relations with others including social coherence,
actualization, integration, acceptance, and contribution (Keyes & Lopez, 2002). Examples of
other positive attributes include courage, interpersonal skill, rationality, insight, optimism,
authenticity, perseverance, realism, capacity for pleasure, future-mindedness, personal respon-
sibility, and purpose. Interpersonal or relational attributes include patience, empathy, com-
passion, cooperation, tolerance, appreciation of diversity, understanding, and forgiveness
(Aspinwall & Staudinger, 2003).
Implications of a strengths perspective include a significant alteration in how health pro-
fessionals think about clients and their families with whom they work, how they think about
themselves as professionals, the nature of the knowledge base for practice, and the process of
nursing practice itself. What is needed is an egalitarian, collaborative working relationship in
a practice based on strengths and solutions (Blundo, 2001). Intentional interventions can fos-
ter a clients anticipation of future contingencies, reflection on capability to cope, the ability
to elicit and use information, flexibility to change her or his perspective on a problem and
plan a course of action, and self-regulation (Aspinwall & Staudinger, 2003; Caprara & Cer-
vone, 2003). Pruning, the giving up of the unattainable, and persevering rather than giving
up, are also helpful qualities that can be nurtured. Promoting these outcomes requires the
nurse to understand developmental, material, and social contexts that are promoting or debil-
itating for human strengths.
The Theory of Healthiness

The Theory of Healthiness forms the structural basis for this book. In this theory, health
is conceptualized as a dynamically changing life process that manifests the pattern of the uni-
tary human being. One manifestation of health pattern is healthiness, which is defined as a
measurable process characterized by mutual process among perceived purpose, connections,
and the power to achieve goals. Healthiness reflects a human beings perceived involvement
in shaping change experienced in living. Therefore, healthiness is a resource that influences
the ongoing patterning reflected in health (Leddy, 1997, p. 49).
Purpose, the human beings attribution of significance and direction to the dynamic pat-
tern of humanenvironment mutual process (participation), was initially conceived to incor-
porate the dimensions of (1) meaningfulness as connections (defined as having rewarding
relationships with others) and the characterization of an aspect of the present or the desired
future as having meaning, import, or value; and (2) ends, defined as goals that a person aims
to reach or accomplish. However, when this descriptive theory was empirically tested using
the Leddy Healthiness Scale (LHS) (Leddy, 1996), factor analysis separated the connections
items into a third concept, which was labeled connections. The revised theory is depicted in
Figure 2-1.
The theory proposes that by actively channeling energy, the human being gains power,
which is the perceived ability to direct energy toward the achievement of goals. Power was
conceived to incorporate the dimensions of challenge, which is perceived opportunity, excite-
ment, curiosity, and/or involvement in change toward meaningful goals; confidence, which is
Challenge change
Goals
Meaningfulness
Purpose
Choice possibilities
Confidence - competence
Control
Healthiness
Choice creativity
Capability
Connection Power Capacity
Challenge curiosity
Confidence assurance
Figure 2-1. Empirically derived components of healthiness ( Copyright by Susan Kun Leddy,
2005. Permission to use granted by the copyright holder).
an assurance of the ability to successfully overcome obstacles to achieve goals; capacity, which
is a perceived quantity of available energy; choice, the perceived freedom and creativity to
select from among alternatives (possibilities) for action; capability to function, the perceived
ability to work, play, and carry out activities of daily living; and control, which is the perceived
ability to influence the rate, amount, and/or predictability of change.
MEANINGFULNESS
Meaning indicates both the comprehension of words, concepts, or an experience, and an
appreciation of the significance of what is understood or perceived by the individual or group.
Meaning-as-comprehensibility refers to the extent to which the event makes sense, or fits with
ones view of the world (e.g., as just, controllable, and nonrandom) whereas meaning-as-signif-
icance refers to the value or worth of the event for ones life (Davis, Nolen-Hoeksema, & Lar-
son, 1998, p. 562). Meaning-as-comprehensibility assumes that there is order in the universe, and
that the distribution of negative and positive events are explainable. Meaning-as-significance is
a motivational dimension that has to do with life goals and purpose (Park & Folkman, 1998).
Meaning described in terms of purpose refers to beliefs that organize, justify, and direct a persons
striving. Accordingly, goals (the other concept that, with meaning, comprise purpose in the
healthiness theory) constitute a central element of a persons meaning system.
Meaning is constructed or created by people. Frankl (1978) wrote persuasively that people
need to perceive life as making sense in serving some worthy purpose. When meaning is cre-
ated from experience, life is given a sense of coherence as well as purpose (King, 2004). Three
commonly accepted defining characteristics of meaning are purpose (the present has mean-
ing because of the connection with future events), value (provides a sense of goodness or pos-
itiveness to life and can provide a justification for a particular course of action), and personal
worth (Baumeister & Vohs, 1998). When an outcome perspective is adopted, meaning is
viewed as coming from extrinsic things that a person wishes to accomplish or have. In con-
trast, when a process-oriented perspective is used, it helps a person to understand why life
experiences are significant and meaningful (King, 2004).
The literature describes two different types of meaning: specific meanings in life (situ-
ational meaning) and the ultimate meaning of life (existential meaning). Situational
meaning can be created through cognitive appraisal in daily engagement, commitment,
and the pursuit of life goals. Situational meaning can include finding an explanation for
an occurrence (sense-making) or finding meaning (meaning-making) by trying to under-
stand why a threatening event happened, what impact it has had, and reappraising to find
a positive aspect in a negative event (Schwarzer & Knoll, 2003). Behavior is likely to be
motivated in direct relation to how important the individual considers the beliefs, goals,
or commitments that are harmed, threatened, or challenged in a given situation (Park &
Folkman, 1998).
In contrast, existential (global) meaning is an abstract, generalized sense that may be dis-
covered through religious beliefs, philosophical reflections, and psychological reflection (Wong,
1998). Wong describes existential meaning as the need for order and coherence in the midst
of chaos, the need for personal significance and self-worth in the face of entropy and death, the
need for positive meanings in spite of the negative life events that often overwhelm (p. 396).
Life meaning can be categorized into achievement/work, relationships/intimacy, self-
transcendence/generativity, and religion/spirituality domains. Generativity is related to striv-
ings that involve creating, giving of oneself to others, or having an influence on future
generations. These kinds of activities seem to result in higher levels of life satisfaction and pos-
itive affect (Emmons, 2003). Spirituality includes the desire to establish a relationship with a
transcendent dimension of reality. Intimacy, generativity, and spirituality provide intrinsic
rewards for goal activity, particularly compared to strivings for power or self-sufficiency
(Emmons, 2003).
Schwarzer & Taubert (2002) suggest that cognitive, motivational, affective, relational, and
personal dimensions are involved in the conceptualization of a meaningful life. The cognitive
dimension includes a belief that there is an ultimate purpose in life, moral laws, and an afterlife.
Consequently, the individual pursues worthwhile goals, seeks to actualize his or her potential,
and strives toward personal growth, all of which are examples of the motivational dimension. As
part of the affective dimension, the individual feels content with the person he or she is and what
he or she is doing, feels fulfilled about what he or she has accomplished, and feels satisfied with
life. Reflective of the relational dimension, the individual is sincere and honest with others, has
a number of good friends, and brings happiness to others. The personal dimension is exemplified
by a liking of challenge, acceptance of his or her limitations, and a healthy self-concept.
GOALS
Much of the literature on goals is based on expectancyvalue models of motivation. These
models suggest that effort requires sufficient confidence in the eventual attainment of a goal
(expectancy), and also a goal that matters enough (value) (Carver & Scheier, 2003). Thus, a
sense of optimism leads to confidence about successful outcomes; this results in persistence of
effort to accomplish goals.
To be lived well, life must have purpose (Ryff & Singer, 1998, p. 216). Goals structure
life and add purpose. Goals can reflect core values, are associated with projects and pursuits
that give meaning and dignity to daily existence, compensate for inferiority feelings, provide
meaning in the present and promote hope for the future, and facilitate the realization of an
individuals potential. Purpose in life and personal growth are not only contributors to
health, but in fact are characteristic features of health (Griffith & Graham, 2004; Ryff &
Singer, 1998).
Goals are actions, end states, or values that people see as either desirable or undesir-
able. A goal that matters gives a person a reason to act. By giving meaning and purpose
to peoples lives, goals energize and direct activities and determine the direction, inten-
sity, and duration of action. Commitment is the belief that the goal is important and the
belief that one can achieve or make progress toward it (Locke, 2003, p. 305). Self-
enhancement goals include strivings for achievement, agency, and power. Group-
enhancement goals include affiliation, intimacy, communion, relatedness, and
interpersonal connection. Global-enhancement goals include protecting the environ-
ment, improving the quality of life of all people, and eradicating crime and warfare
(Schmuck & Sheldon, 2001).
Values are achieved by pursuing goals. People pursue multiple values and thus multiple
goals in life, but priorities of values are critical to managing ones life, both in the short range
and in the long range (Locke, 2003). However, in the absence of emotion, values would be
experienced as dry, abstract, and intellectual. By providing energy, emotions provide an
impetus to action. They also serve as a reward for successful action and an inducement to
avoid actions that cause pain or suffering. Emotional intensity reflects subconscious per-
ceived value, threat, or achievement as well as the value in ones value hierarchy (Locke,
2003, p. 302).
The highest task performance is attained when performance goals are both specific and dif-
ficult (Locke, 2003). The discrepancy between input and reference value determines
approach or avoidance goals. Approach goals reduce discrepancy while avoidance goals
increase differences. Goals can be differentiated on the basis of level of abstraction from con-
crete to abstract, and vary in importance, with higher levels usually more important. Addi-
tionally goals can be described as intrinsic or extrinsic in origin.
Although people are inclined toward activity and integration, they are vulnerable to pas-
sivity. Motivation is a critical variable in producing and maintaining change (Ryan & Deci,
2000). Intrinsic motivation is an inherent tendency to seek out novelty and challenges; to
extend and exercise ones capacities; to explore, learn, and achieve personal growth, happi-
ness, and meaningful relationships; and to make a contribution to society (Bauer &
McAdams, 2004; Ryan & Deci, 2000). Tangible rewards, threats, deadlines, directives, pres-
sured evaluations, and imposed goals diminish intrinsic motivation, while choice, acknowl-
edgement of feelings, and opportunities for self-direction enhance intrinsic motivation by
increasing feelings of autonomy. In contrast, external regulation by individuals or groups has
been associated with less demonstrated interest, valuing, and effort toward achievement; a
concern for money, status, possessions, and physical appearance; and a tendency to disown
responsibility for negative outcomes (Bauer & McAdams, 2004).
CONNECTIONS
Connectedness occurs when a person is actively involved with another person (interper-
sonal), object, group (social), or environment (natural or man-made), and that involvement
promotes a sense of comfort, well-being, and reduced anxiety (Hagerty, Lynch-Sauer, Patusky, &
Bouwsema, 1993). All things have a unique connectedness that becomes the respectful, respon-
sible, trusting, and spiritual operative intention between nurse and client (Lowe, 2002, p. 6).
Connectedness occurs through the dynamics of an interdependent and interrelated relationship.
One concept used interchangeably with connection is relatedness. Relatedness refers to an
individuals involvement with other people, groups, or the natural environment (Patusky,
2002). Feeling cared for, as expressed in liking and concern, are critical to feeling comfort-
able, secure, and being willing to be self-expressive or responsive in a relationship (Reis,
2001). Relatedness expresses an individuals worldview beyond his or her own sense of self,
involving connection and commitment to an outside entity (other humans or a spiritual
being) or the environment (natural, physical, or social) (Hanley & Abell, 2002). The sub-
stance of the relationship in terms of mutuality and reciprocity, not just its usefulness, is
important toward the goals of fulfillment and self-actualization. Creative and artistic expres-
sion are inherently relational as are relationships with the natural world and spiritual forces.
Although interaction is a single social event, which may occur between related or unrelated
individuals, involvement requires the dedication of time or resources within a relationship (Ryan
& Solky, 1996) and usually reflects validation. Validation refers to appreciation for ones dispo-
sitions, beliefs, or life circumstances. It contributes to intimacy and meaningful interaction by
suggesting that the other values and respects the emotional core of the self (Reis, 2001, p. 80).
A shared informational base of understanding (getting the facts straight) facilitates relatedness.
Additionally, autonomy support is a concept that is important for relatedness in cultures that
emphasize an individualist focus. The need for autonomy refers to the human desire to have ones
behavior determined by the self, to be capable of action, self-expressive, and spontaneous in
action. Autonomy support refers to the ability to assume anothers perspective and to facilitate
self-initiated expression and action. Autonomy support thus typically involves authentic acknowl-
edgement of the other persons perceptions, acceptance of their feelings, and a lack of attempts to
control the others experience and behavior (Ryan & Solky, 1996). Autonomy support facilitates
development, expression, and integration of the self and buffers one from negative outcomes dur-
ing distress. Consequently, outcomes include increasing self-esteem, self-confidence, feelings of
capability and competence, vitality, and feelings of connectedness with others. Autonomy support
is needed for social contacts to enhance psychological well-being (Ryan & Solky, 1996).
Patusky (2002) describes a nested ecological approach consisting of four levels of relatedness:
the macrosystem (societal beliefs), ecosystem (groups that affect the immediate setting, e.g.,
work), microsystem (family unit), and ontogenetic (individual development). Within each
level, four states of relatedness have been identified: connectedness (comfortable involvement),
disconnectedness, parallelism, and enmeshment. Competencies that were associated with these
states included synchrony, sense of belonging, reciprocity, and mutuality (Patusky, 2002).
A relationship is an enduring association and an ongoing connection between two persons

in which the bond has a sense of history and some awareness of the nature of the relation-
ship; the participants influence each others thoughts, feelings, and behavior; and they expect
to interact again in the future (Reis, 2001). Relationships that heal, soothe, foster growth,
facilitate health, and provide satisfactions are essential to a sense of well-being (Ryan &
Solky, 1996). The capacity for authentic contact draws out and supports real feelings, sensi-
bilities, and choices, providing a sense of support and nurturance (Ryan & Solky, 1996). Con-
sequently, a sense of belonging is experienced when a person perceives a fit with another
person, group, or environment, and he or she feels valued, needed, and important within rela-
tionships (Hagerty & Patusky, 2003).
Relationships have three domains of impact: the affective, the cognitive, and the behav-
ioral. In the affective domain the question is: How do people feel about each other? In the
cognitive domain the question is: what thoughts do people think about each other? And, in
the behavioral domain the question is: how do people treat each other? (Kenny, 1994).
CAPABILITY
The concept capability is defined as the global belief that one has the ability to achieve
desired goals. Broader and more general dispositional measures are usually better suited for
predicting more general patterns of behavior or outcomes that arise across multiple contexts
(Smith, Wallston, & Smith, 1995, p. 52). Similar to the concept of agency, or self-agency, the
person views himself or herself as capable of shaping motives, behavior, and future possibili-
ties. Capability is therefore influenced by choice, control, and confidence in the ability to
accomplish goals. However, in contrast to the concept of competence, capability does not
indicate skill or proficiency in a task. Capability has no action component.
Capability requires confidence, creativity, general cognitive (intellectual) and communi-
cation abilities, and specialized knowledge for performance in a particular content area.
Other, more general abilities include oral and written mastery of ones own language and at
least one foreign language, as well as the following abilities:
mathematical knowledge
reading competence for rapid acquisition and concrete processing of written information
media competence
independent learning strategies
social competencies
divergent thinking, critical judgments, and self-criticism.
In contrast, self-efficacy is related to perceived capability (can is a judgment of capability)

in specific situations. Bandura (1997) claims that self-efficacy should be assessed at the opti-
mal level of specificity that corresponds to the specific task being assessed and the domain of
functioning being analyzed. Self-efficacy also includes an action component, as in feeling
capable to perform a specific task. Self-efficacy is not a personality trait, but a temporary and
easy to influence characteristic that is strictly situation- and task-related (van der Bijl &
Shortridge-Baggett, 2001, p. 190).
CONTROL
Personal control consists of personal and environmental beliefs and expectations about
how the environment can be effectively shaped and altered so that positive events can be
brought about and negative events avoided (Peterson & Stunkard, 1989; Ross & Sastry,
1999). The concept of control is closely related to other concepts that make up power in the
healthiness theory, specifically choice, confidence, and capability. Personal control may be
activated only in the course of meeting challenge.
Perceived control is the expectation of having the power to participate in making deci-
sions in order to obtain desirable consequences and a sense of personal competence in a given
situation (Rodin, 1990, p. 4). Consequently, the person has a feeling that he or she is influ-
ential enough (rather than helpless) to make decisions and affect outcomes. The person also
has a perception of himself or herself as having a definite influence on a structured and
responsive environment through the exercise of imagination, knowledge, skill, and choice.
In addition to the outcome expectancy (contingency beliefs) described above, perceived
control has been understood by Grob (2000) as a composite with an expectation of efficacy
(competence beliefs), and the importance to the person of the domains in which perceived
control can operate (control expectancy). The expectancy component refers to generalized
cognitive estimates of the amount of control one possesses, whereas the appraisal component
refers to the valuation or perceived importance of the situation at stake (p. 333).
Skinner (1996) suggests that constructs of control include agentends relations such as
perceived control, personal control, and sense of control; agentmeans relations such as capa-
bility, beliefs about agency and capacity, and self-efficacy; and meansends relations such as
locus of control, attributions, and responsibility.
The sense of personal control is learned. It is a generalized expectation that events and cir-
cumstances in an individuals life depend on personal choices and actions. Individuals with
high levels of control use persistence and attention to address problems and are more likely
to take action when difficulties arise. In contrast, low levels of control undermine the indi-
viduals will and motivation to cope actively with problems (Sastry & Ross, 1998). Intellec-
tual, emotional, behavioral, and physiological vigor in the face of challenging situations and
events is associated with high personal control (Peterson & Stunkard, 1989).
Although perceived control is a cognitive appraisal of the perceived ability to signifi-
cantly alter events (Skinner, 1996, p. 549) and includes expectations of having the power to
participate in making decisions in a given situation in order to obtain desirable consequences
and a sense of personal competence (Rodin, 1990), perception may not be congruent with
objective data. Objective or actual control is the demonstrated ability to regulate or influence
the attainment, maintenance, or avoidance of intended outcomes through selective responses
(Grob, 2000; Rodin, 1990). Objective control involves the actual ability to regulate or influ-
ence intended outcomes (Rodin, 1990). Ones degree of influence of actual personal control
may be affected by chance, luck, fate, or powerful others. Ideally, perceived control is related
to actual control.
Belief about control can be a cognitive appraisal in a specific context (situational), or a

general, global, dispositional belief (Lazarus & Folkman, 1984). Situational control appraisals
are domain specific, based on the valuing of various domains (e.g., health, work, etc.), simi-
lar to self-efficacy, and involve the persons beliefs that he or she can shape and influence a
particular personenvironment process. Situational control is socially transmitted and thus
based on a socially structured view of the individual as multidimensional and amenable to
relearning and change. Control can also be classified as global. A global sense of control
involves a belief that in general individuals are able to control the conditions of their lives
(Pearlin & Paoli, 2003). Global control is more than an average of goal-specific manifesta-
tions and is related to long-term outcomes.
Perceived control involves the judgment that one can obtain desired outcomes and avoid
undesirable ones (Thompson, 2002). A potentially negative event is not as stressful when it
is accompanied by a belief in personal control. Perceived control is associated with positive
emotions, leads to active problem solving, reduces anxiety in the form of stress, and buffers
against negative psychological responses (Thompson, 2002). Perceived control consists of
two parts: locus of control and self-efficacy (Thompson, 2002). Making progress toward goals
is an important source of perceived control and general well-being.
Control does not have to be realistic to be beneficial. Illusion of control (events that are
objectively random) has a positive effect on various types of behavior. Perception of control
is often enough to reduce stress, increase motivation, and encourage performance (Peterson
& Stunkard, 1989, p. 820). This occurs through (1) self-fulfilling prophecies that perceptu-
ally diminish the magnitude of threats and reduce barriers to taking actions capable of over-
coming the threat; (2) alliances with groups and collectives; (3) social support; (4) appeals to
higher powers; and (5) negotiation.
A balanced sense of control may foster adaptive planning, as individuals with too high a
sense of control may not plan due to a false sense of security, and individuals with too low
a sense of control may not plan because they assume they cannot have any influence over the
outcome (Clark-Plaskie & Lachman, 1999).
CHOICE
Choice means more than its commonsense implication of making conscious decisions.
Choice is motivational rather than cognitive, and is not synonymous with decision making.
Freedom has to do with the extent to which a person is his own master, with decisions
depending on him- or herself and not on external forces or circumstances. Freedom is quin-
tessentially concerned with the absence of restraint and interference by others (Sen, 1988,
p. 273). Deprivation of freedom can be considered a deprivation of power.
This is a freedom to rather than freedom from, and it involves noninterference, meaning
that no constraints are imposed on an individual in the exercise of his or her liberty. The indi-
vidual must make a voluntary, intuitive, and spontaneous choice free from undue influence
or coercion. Freedom is not a property or something an individual possesses, but a relation-
ship between agents (Bavetta & Del Seta, 2001).
An individuals decisions depend on the individual to the extent that there are alterna-
tives to choose from. Greater freedom of choice designates an increased flexibility, a widened
spectrum of possible responses to inner and outer stimuli, and an expanded universe of psy-
chological possibilities (Abend, 2001, p. 3). Thus, freedom is viewed as variety, nonrestrict-
edness in choice, and freedom from constraints (Bavetta & Del Seta, 2001). Availability of
opportunities reflects a certain degree of freedom.
The value of choice is that it will lead to something (Suzuki, 2002, p. 126). Choice is not
just about being able to choose between a bottle of wine and a banana. It is rather about ones
choice of what bottle of wine to buy being totally unrestricted and autonomous (Bavetta &
Del Seta, 2001, p. 220). However, an individual may be unable to enlarge his or her effective
liberty if the options available are similar to alternatives already available. Increased alterna-
tives also lead to increased preference. Choice is assumed to go in the direction of the alter-
native that is perceived to be more attractive.
For example, in a multichoice task study, a students preference for an alternative depended
on opportunity of choice, reinforcement, efficacy of choice, and the number of alternatives.
Undistinguishable options, when one has no reason to choose one option rather than
another, provide another kind of choice that seems to not be very significant. Choiceful
accommodation gives a realistic sense of what is possible (Deci & Ryan, 1985).
CHALLENGE
The literature refers to challenge exclusively from within a perspective of stress and coping.
Stress is relational in nature, arising from some sort of transaction between the individual and
the environment. Stress therefore arises from a judgment that particular demands exceed
resources for dealing with them and thus affect ones sense of well-being. Initially, through pri-
mary appraisal, a person judges what is at stake. Secondary appraisal then, is concerned with
the controllability of the situation. When a situation is appraised as an opportunity for self-
growth and coping strategies available to manage the demands are identified, the stress is per-
ceived in terms of challenge (Drach-Zahavy & Erez, 2002).
A disposition toward challenge is expressed as the belief that change rather than stabil-
ity is normal in life and that anticipation of change is an interesting incentive to growth
rather than a threat to security (Kobasa, Maddi, & Kahn, 1982). Challenge occurs when
the situation relates to goals, and environmental demands are appraised as within the per-
sons resources or ability to cope. A challenge response is associated with a positive affect
or low negative affect and efficient or organized mobilization of physiological resources
(Tomaka, Blascovich, Kibler, & Ernst, 1997). Feeling positive about a demanding
encounter is a hallmark of feeling challenged (Lazarus & Folkman, 1984) and is reflected
in the pleasurable emotions accompanying challenge. Challenge is experienced when
there is an opportunity for self-growth with available coping strategies (Drach-Zahavy &
Erez, 2002, p. 667).
Cognitive appraisal processes intervene between the initial perception and subsequent
experience of a potentially stressful situation (Tomaka et al., 1997). Challenge will lead to
attempts to transform oneself and thereby grow rather than conserve and protect what one
can of the previous existence (Kobasa et al., 1982, p. 170). The challenged person feels more
confident, less emotionally overwhelmed, and more capable of drawing on available resources
than the person who is inhibited or blocked by their response to appraised threat (Lazarus &
Folkman, 1984). Challenge appraisals focus on the potential for gain or growth, and they are
characterized by pleasurable emotions such as eagerness, excitement, and exhilaration. In
contrast, threat focuses on potential harms and is characterized by negative emotions such as
fear, anxiety, and anger. Threat appraisal may be a consequence of adequate strengths that
could buffer stress. In other words, a strong reservoir of strength could increase an individuals
appraisal of potential stressors as challenge rather than threat. However, perception of
inequalities, that life has been unfair, and lower socioeconomic standing decrease the odds of
having positive psychological experiences.
People who strive to accomplish difficult goals when task complexity is high may perceive
their goal as a challenge rather than a threat, leading to high levels of performance (Drach-
Zahavy & Erez, 2002). Complex tasks differ from simple tasks in terms of the number of per-
formance components (component complexity), such as the number of acts to perform or the
amount of information to remember; coordination required to complete the task (coordinat-
ing complexity); and changes in the potential predictability of acts and information cues
(dynamic complexity). Effective performance of complex tasks depends on the amount of
effort exerted in the task and the development of relevant strategies. A challenge requires
stretching ones abilities, in order to try something new (Deci & Ryan, 1985). The emotions
of enjoyment and excitement represent the rewards.
Threat and challenge are not necessarily poles of a single continuum and thus mutually
exclusive (Lazarus & Folkman, 1984). Challenge and threat appraisals have their own distinct
patterns of coping, with challenge leading to a vigilant coping pattern. Associations have
been found between challenge and opportunities for success and social rewards such as recog-
nition and praise, mastery, learning, and personal growth (Skinner & Brewer, 2002), and:
positive emotions such as happiness and hope and challenge cognitions such as expec-
tation of favorable performance, certainty of performance level, perceptions of
increased control, and anticipation of effort
hopechallenge emotions and perceptions of increased problem-focused coping oppor-
tunities and optimistic expectations
challenge emotions and appraisals of effort and interest such as feeling confident, hope-
ful, or eager (Skinner & Brewer, 2002)
CONFIDENCE
Confidence is a strong, generalized positive belief or certainty about oneself. Confidence
leads to increased persistence and perseverance toward goals. The confident person is sure of
him- or herself. Confidence is closely related to self-image and the cognitive decision-mak-
ing process behind taking action (Kear, 2000). Consequently, in the literature, confidence is
implicit in discussions of self-concept and self-esteem. Confidence is associated with sureness
in belief about self and is an antecedent to control. In contrast, beliefs about ability to act in
a specific context to accomplish anything one sets out to do are more closely associated with
capability. Confidence facilitates and may mediate capability.
Self-confidence helps to buffer performance anxiety. Hanton, Mellalieu, and Hall (2004)
found that in the absence of self-confidence, increases in competitive anxiety intensity were
perceived as outside of the performers control and debilitating to performance. Under con-
ditions of high self-confidence, increases in symptoms were reported to lead to positive per-
ceptions of control and facilitative interpretations. To protect against debilitating
Chapter Key Points 43
interpretations of competitive anxiety, performers reported the use of cognitive management

strategies including mental rehearsal, thought stopping, and positive self-talk.
CAPACITY
A unitary perspective of energy includes the concept of a (1) universal essence com-
posed of particles and waves, and three interchangeable facets: matter, which is the poten-
tial for structure and identity; information, which is the potential for coordination and
pattern; and energy, which is the potential for process, movement, and change; (2) the
concept of a field as a nonobservable domain of influence; (3) a pattern; (4) the oscilla-
tion of waves, which determines frequency, amplitude, and resonance of energy; (5) syn-
chronization; and (6) conscious focusing of energy vibrations. It has been proposed that
the nurse can facilitate health patterning by fostering resonance of environmental energy
and information (Leddy, 2003).
It is proposed here that universal essence is manifested in two energy fields. One field,
vital energy, is associated with the informational aspect of universal essence. Vital energy
ensures the cohesiveness and unity of the human. The other field, metabolic energy, is asso-
ciated with the matter aspect of universal essence. Metabolic energy encompasses the poten-
tial processes that ensure the effective functioning of the human. Capacity, as it is
conceptualized in this book, requires system integration, although the ways in which the
fields engage in mutual processes are not articulated yet.
Capacity is composed of both vital and metabolic energy. It enables a quantity of mate-
rial matter and the movement necessary for process. Capacity is an active strength, expressed
in vigor and vitality. Peterson and Seligman (2004, p. 273) describe vitality as a dynamic
aspect of well-being marked by the subjective experience of energy and aliveness. Capacity
can be decreased by factors such as conflict, stress, illness symptoms (e.g., pain and fatigue),
and unbalanced nutrition. Capacity can be increased by contact with outdoor natural envi-
ronments, relatedness, enjoyable physical activity, a nutritious diet, and noninvasive thera-
peutic modalities (e.g., meditation, yoga, and imagery) that facilitate calmness and harmony.
Capacity has a reciprocal relationship with the other strengths in the healthiness theory.
Capacity energizes the other strengths, as it is rejuvenated by them.
Chapter Key Points

Health can be perceived as a single process of ups and downs, in which disease and
nondisease are viewed as complementary facets of health. Illness, like wellness, simply
represents a pattern of life at a particular moment.
The primary focus in this book is on promoting strengths and positive manifestations
such as well-being, harmony, and growth. In this model, change is inevitable and pro-
vides an opportunity for growth and the development of potential toward increased
complexity.
The emphasis for nursing knowledge development and practice is on appreciation of
changing pattern manifestations, facilitation of self-healing, and deliberate environ-
mental manipulation to promote growth.
Health promotion focuses on positive health and the building of strengths, competen-
cies, and resources. Human strengths are resources for health. By identifying, acknowl-
edging, concentrating on, and increasing strengths and environmental resources, it is
believed that individuals can be helped to improve human functioning and well-being.
One manifestation of health pattern is healthiness, which is defined as a measurable
process characterized by mutual processes among perceived purpose, connections, and
the power to achieve goals.
The healthiness theory includes the dimensions of meaningfulness, goals, connected-
ness, challenge, confidence, capacity, choice, capability to function, and control.
References
Abend, S. M. (2001). Expanding psychological possibilities. Psychoanalytic Quarterly, 70, 314.
Aspinwall, L. G., & Staudinger, U. M. (Eds.), (2003). A psychology of human strengths: Some central
issues of an emerging field. A psychology of human strengths. Fundamental questions and future direc-
tions for a positive psychology (pp. 922). Washington, DC: American Psychological Association.
Bandura, A. (1997). Self-efficacy: The exercise of control. New York: Freeman.
Bauer, J. J., & McAdams, D. P. (2004). Growth goals, maturity, and well-being. Developmental Psychology,
40, 114127.
Baumeister, R. F., & Vohs, K. D. (1998). In P. T. P. Wong & P. S. Fry (Eds.), The human quest for meaning:
A handbook of psychological research and clinical applications (pp. 608618). Mahwah, NJ: Lawrence
Erlbaum.
Bavetta, S., & Del Seta, M. (2001). Constraints and the measurement of freedom of choice. Theory and
Decision, 50, 213238.
Blundo, R. (2001). Learning strengths-based practice: Challenging our personal and professional frames.
Families in society: The Journal of Contemporary Human Services, 82, 296304.
Caprara, G. V., & Cervone, D. (2003). A conception of personality for a psychology of human strengths:
Personality as an agentic, self-regulating system. In L. G. Aspinwall & U. M. Staudinger (Eds.),
A psychology of human strengths. Fundamental questions and future directions for a positive psychology
(pp. 6174). Washington, DC: American Psychological Association.
Carver, C. S., & Scheier, M. F. (2003). Three human strengths. In L. G. Aspinwall & U. M. Staudinger
(Eds.), A psychology of human strengths: Fundamental questions and future directions for a positive psy-
chology (pp. 87102). Washington, DC: American Psychological Association.
Clark-Plaskie, M., & Lachman, M. E. (1999). The sense of control in mid-life. In S. L. Willis & J. D. Reid
(Eds.), Life in the middle: Psychological and social development in middle age (pp. 182208). San
Diego, CA: Academic Press.
Davis, C. G., Nolen-Hoeksema, S., & Larson, J. (1998). Making sense of loss and benefiting from the expe-
rience: Two construals of meaning. Journal of Personality and Social Psychology, 75, 561574.
Deci, E. L., & Ryan, R. M. (1985). Intrinsic motivation and self-determination in human behavior. New York:
Plenum Press.
References 45
Drach-Zahavy, A., & Erez, M. (2002). Challenge versus threat effects on the goal-performance relation-
ship. Organizational Behavior and Human Decision Processes, 88, 667682.
Emmons, R. A. (2003). Personal goals, life meaning, and virtue: Wellsprings of a positive life. In C. L. M.
Keyes & J. Haidt (Eds.), Flourishing: Positive psychology and the life well-lived (pp. 105123). Wash-
ington, DC: American Psychological Association.
Frankl, V. E. (1978). The unheard cry for meaning. Psychotherapy and humanism. New York: Simon & Schuster.
Griffith, B. A., & Graham, C. C. (2004). Meeting needs and making meaning: The pursuit of goals. Jour-
nal of Individual Psychology, 60, 2541.
Grob, A. (2000). Perceived control and subjective well-being across nations and across the life span. In E. Diener
& E. M. Suh (Eds.), Culture and subjective well-being (pp. 319339). Cambridge, MA: MIT Press.
Hagerty, B. M. K., Lynch-Sauer, J., Patusky, K. L., & Bouwsema, M. (1993). An emerging theory of human
relatedness. Image: Journal of Nursing Scholarship, 25, 291296.
Hagerty, B. M., & Patusky, K. L. (2003). Reconceptualizing the nurse-patient relationship. Journal of Nurs-
ing Scholarship, 35, 145150.
Hanley, S. J., & Abell, S. C. (2002). Maslow and relatedness: Creating an interpersonal model of self-
actualization. Journal of Humanistic Psychology, 42, 3757.
Hanton, S., Mellalieu, S. D., & Hall, R. (2004). Self-confidence and anxiety interpretation: A qualitative
investigation. Psychology of Sport & Exercise, 5, 477495.
Held, B. S. (2004). The negative side of positive psychology. Journal of Humanistic Psychology, 44, 946.
Kear, M. (2000). Concept analysis of self-efficacy. Retrieved May 5, 2004, from http://www.
graduateresearch.com/Kear.htm
Kenny, D. A. (1994). Using the social relations model to understand relationships. In R. Erber & R.
Gilmour (Eds.), Theoretical frameworks for personal relationships (pp. 111127). Hillsdale, NJ:
Lawrence Erlbaum.
Keyes, C. L. M., & Lopez, S. J. (2002). Toward a science of mental health. In C. R. Snyder & S. J. Lopez
(Eds.), Handbook of positive psychology (pp. 4559). Oxford: Oxford University Press.
King, G. A. (2004). The meaning of life experiences: Application of a meta-model to rehabilitation sci-
ences and services. American Journal of Orthopsychiatry, 74, 7384.
Kobasa, S. C., Maddi, S. R., & Kahn, S. (1982). Hardiness and health: A perspective study. Journal of Per-
sonality and Social Psychology, 42, 168177.
Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer.
Leddy, S. K. (1996). Development and psychometric testing of the Leddy Healthiness Scale. Research in
Nursing & Health, 19, 431440.
Leddy, S. K. (1997). Healthiness, fatigue, and symptom experiences in women with and without breast can-
cer. Holistic Nursing Practice, 12, 4853.
Leddy, S. K. (2003). A nursing practice theory: Applying a unitary perspective of energy. Visions: The Jour-
nal of Rogerian Scholarship, 11, 2128.
Locke, E. A. (2003). Setting goals for life and happiness. In C. R. Snyder & S. J. Lopez (Eds.), Handbook
of positive psychology (pp. 299312). Oxford: Oxford University Press.
Lowe, J. (2002). Balance and harmony through connectedness: The intentionality of Native American
nurses. Holistic Nursing Practice, 16, 411.
Nakamura, J., & Csikszentmihalyi, M. (2003). The motivational sources of creativity as viewed from the
paradigm of positive psychology. In L. G. Aspinwall & U. M. Staudinger (Eds.), A psychology of
human strengths. Fundamental questions and future directions for a positive psychology (pp. 257269).
Washington, DC: American Psychological Association.
Park, C. L., & Folkman, S. (1998). Meaning in the context of stress and coping. Review of General Psy-
chology, 1, 115144.
Patusky, K. L. (2002). Relatedness theory as a framework for the treatment of fatigued women. Archives of
Psychiatric Nursing, XVI, 224231.
Pearlin, L. I., & Paoli, M. F. (2003). Personal control: Some conceptual turf and future directions. In S. H.
Zarit, L. J. Pearlin, & K. W. Schaie (Eds.), Personal control in social and life course contexts (pp.
121). New York: Springer.
Peterson, C., & Seligman, M. E. P. (2004). Character strengths and virtues: A handbook and classification (pp.
273289). Washington, DC: American Psychological Association.
Peterson, C., & Stunkard, A. J. (1989). Personal control and health promotion. Social Science and Medicine,
28, 819828.
Reis, H. T. (2001). Relationship experiences and emotional well-being. In C. D. Ryff & B. H. Singer (Eds.),
Emotion, social relationships, and health (pp. 5786). Oxford: Oxford University Press.
Rodin, J. (1990). Control by any other name: Definitions, concepts, and processes. In J. Rodin, C.
Schooler, & K. W. Schaie (Eds.), Self-directedness: Cause and effects throughout the life course (pp.
117). Hillsdale, NJ: Lawrence Erlbaum.
Ross, C. E., & Sastry, J. (1999). The sense of personal control: Social-structural causes and emotional con-
sequences. In C. A. Aneshensel & J. C. Phelan (Eds.), Handbook of the sociology of mental health
(pp. 369394). New York: Kluwer Academic/Plenum.
Ryan, R. M., & Deci, E. L. (2000). Self-determination theory and the facilitation of intrinsic motivation,
social development, and well-being. American Psychologist, 55, 6878.
Ryan, R. M., & Solky, J. A. (1996). What is supportive about social support? In G. R. Pierce, B. R. Sara-
son, & I. G. Sarason (Eds.), Handbook of social support and the family (pp. 249267). New York:
The Plenum Press.
Ryff, C. D., & Singer, B. (1998). The role of purpose in life and personal growth in positive human health.
In P. T. P. Wong & P. S. Fry (Eds.), The human quest for meaning (pp. 213225). Mahwah, NJ:
Lawrence Erlbaum.
Sastry, J. & Ross, C. E. (1998). Asian ethnicity and the sense of personal control. Social Psychology Quar-
terly, 61, 101120.
Schmuck, P., & Sheldon, K. M. (2001). Life goals and well-being: To the frontiers of life goal research. In
P. Schmuck & K. M. Sheldon (Eds.), Life goals and well-being: Towards a positive psychology of
human striving (pp. 117). Seattle, WA: Hogrefe & Huber.
Schwarzer, R., & Knoll, N. (2003). Positive coping. Mastering demands and searching for meaning. In S.
J. Lopez & C. R. Snyder (Eds.), Positive psychological assessment. A handbook of models and meas-
ures (pp. 393409). Washington, DC: American Psychological Association.
Schwarzer, R., & Taubert, S. (2002). Tenacious goal pursuits and striving toward personal growth. In E. Fry-
denberg (Ed.), Beyond coping: Meeting goals, visions, and challenges (pp. 1935). Oxford: Oxford
University Press.
References 47
Seligman, M. E. P. (2002). Positive psychology, positive prevention, and positive therapy. In C. R. Snyder
& S. J. Lopez (Eds.), Handbook of positive psychology (pp. 39). Oxford: Oxford University Press.
Sen, A. (1988). Freedom of choice. European Economic Review, 32, 269294.
Skinner, E. A. (1996). A guide to constructs of control. Journal of Personality and Social Psychology, 71,
549570.
Skinner, N., & Brewer, N. (2002). The dynamics of threat and challenge appraisals prior to stressful
achievement events. Journal of Personality and Social Psychology, 83, 678692.
Smith, M. S., Wallston, K. A., & Smith, C. A. (1995). The development and validation of the Perceived
Health Competence Scale. Health Education Research, 10, 5164.
Suzuki, S. (2002). Preference for freedom of choice. In S. P. Shohov (Ed.), Advances in psychology research
(Vol 9, pp. 115128). Huntington, NY: Nova Science.
Thompson, S. C. (2002). The role of personal control in adaptive functioning. In C. R. Snyder & S. J.
Lopez (Eds.), Handbook of positive psychology (pp. 202213). Oxford: Oxford University Press.
Tomaka, J., Blascovich, J., Kibler, J., & Ernst, J. M. (1997). Cognitive and physiological antecedents of
threat and challenge appraisal. Journal of Personality and Social Psychology, 73, 6372.
van der Bijl, J. J., & Shortridge-Baggett, L. M. (2001). The theory and measurement of the self-efficacy
construct. Scholarly Inquiry for Nursing Practice: An International Journal, 15, 189205.
Wong, P. T. P. (1998). Meaning-centered counseling. In P. T. P. Wong & P. S. Fry (Eds.), The human quest
for meaning: A handbook of psychological research and clinical applications (pp. 395435). Mahwah,
NJ: Lawrence Erlbaum.
World Health Organization, Health and Welfare Canada, and the Canadian Public Health Association.
(1986). Ottawa charter for health promotion. Copenhagen, Denmark: FADL.
THE MEANING
3
Health Care Belief Systems
OF HEALTH
Abstract
Western biomedicine is assumed to be the worlds standard health care system. How-
ever, this system only provides 10% to 30% of human health care. In this chapter, a num-
ber of popular (lay and community-based) and professional (Western biomedicine and
traditional) health care belief systems are described. The intent is to help the student to
appreciate the diversity of belief systems that provide a context for integrative health pro-
motion.
Learning Outcomes
Differentiate between popular and professional belief systems

Discuss how mechanism, reductionism, and science have affected the development of
values of the Western biomedical model
Describe characteristics of several traditional medical belief systems
Todays rapidly changing environment creates important implications for health and
health care delivery. Because of the conflicts inherent in many issues, the desirability and via-
bility of potential approaches for resolution of an issue are strongly influenced by personal and
cultural values.
50 Chapter 3 The Meaning of Health: Health Care Belief Systems
Values are the criteria a person uses to evaluate the relative desirability, merit, usefulness,
worth, or importance of objects, ideas, acts, feelings, or events (Hester, 1996). They are a stan-
dard for determining a preference between two or more alternatives, and are criteria for decid-
ing what is desirable or desired. Values are also highly subjective. They are an underlying
reason for a preference between choices, and are a motivating force for a particular choice of
action. Discomfort results when choices and decisions are in conflict with a persons values.
Values are the result of multiple influences, which include the societal culture of which the
person or group is a part. In order to better understand the values that underlie health and
health care choices, beliefs within popular and professional medical care systems will be
explored in this chapter. An understanding of these medical care systems provides one con-
text for the integrative promotion of health in nursing practice.
Popular Health Care

LAY HEALTH CARE
Lay health care is what most people practice and receive at home, such as gargling with
hot water and salt to relieve a sore throat. People get information about popular health care
primarily from family or friends, but also learn from magazines, television, and other informal
sources. Use of herbal preparations and food supplements, such as echinacea and zinc at the
first signs of a cold, are examples of practices that are increasingly being popularized. In many
cases, people are committed to popular practices that have the legitimacy of family tradition.
Usually, evidence to support many popular practices is anecdotal rather than research-based.
It is important for nurses to understand common popular beliefs and practices, and differen-
tiate between those that are exclusively tradition-based and those beliefs and practices that
have theoretical, empirical, and/or scientific support.
COMMUNITY-BASED HEALTH CARE

Community-based health care refers to the nonprofessionalized yet specialized health care
practices of both rural and urban people (Berman & Larson, 1994). Community-based health
care is derived from indigenous (endemic) health beliefs and incorporates such concepts as
folk, native, and tribal, that have often been treated stereotypically and assumed to be
primitive, whimsical, exotic, and/or outmoded (Andrews, 1995). For example, in Latin
American cultures, mal de ojo (related to the Mediterranean concept of evil eye) is treated
by rolling an egg over the persons (usually a child) body, then cracking it into a glass of water
and placing it under the childs bed. When the egg and water solution is discarded the next
day, so is the problem (Novey, 2000). Models of community-based health care are discussed
in Chapter 5, The Meaning of Health: Cultural Influences.
The American Heritage Dictionary (Soukhanov, 1992, p. 919) describes indigenous as orig-
inating and growing or living in an area or environment. An indigenous group may be bound
by ethnicity, or may be made up of individuals from diverse ethnic groups and united by cul-
tural role models and norms or religion. Most indigenous groups are distinct from what most
would consider mainstream society. Family may mean the extended family, a clan, a com-
munity, or an entire village. A great deal of importance is placed on social networks to main-
Professional Health Care 51
tain traditions, values, and beliefs, including health beliefs, that have endured over time and
space. When one individual is sick, the entire community is viewed as having a problem
(Berman & Larson, 1994). Health beliefs are often based on common sense and life experi-
ence. Similar to lay beliefs, information about community-based health care is commonly
passed on orally and through informal and popular media sources.
Because the concepts of medicine and religion in community-based systems often are
fused, no sickness can affect only one part of the body. Rather, it affects the whole network
of existence, the natural world, and the spiritual world. Illness may be believed to be due
either to not following the laws of nature or not maintaining harmony in ones life (Wing,
1998). Living in harmony with nature and maintaining balance in ones life are essential for
health. Balance involves an equalization of opposites. The most frequent opposites that must
be in balance are male and female, hot and cold, yin and yang, expulsion and retention, power
or life force of one individual versus another, and good and evil. There is an implicit theme
that a person with a naturally caused illness had a role in precipitating the illness by allowing
him or herself to become stressed, not adhering to a taboo, or violating a law of nature. On
the other hand, unnatural illness results from being an innocent victim of anothers admira-
tion or envy.
Another universal belief is that there is a biological energy that is present in every physi-
cal and mental event. This life energy has been called by many names including chi (qi) in
China, prana in India, doshas in the Vedic tradition, and spirit in the Native American and
Voodoo cultures. It is believed that if this energy is not kept moving, illness will occur due to
imbalance and stagnation. Other aspects of motion are within the surrounding environment.
Wind, rain, flowing water, rustling trees, and animal life all contribute to the motion of the
earth, necessary for peace and tranquility (Wing, 1998, p. 148).
Professional Health Care

In contrast to lay and community-based health systems, professional health systems can be
characterized by a(n):
Tendency to be urban and complexly organized
Theory of health and disease
Educational curricula and schools to teach its concepts
Delivery system involving practitioners who usually practice in hospitals, offices, or clinics
Material support system to produce its medicines and therapeutic devices
Legal and economic mandate to regulate its practice
Set of cultural expectations about the role of the medical system
Means to confer professional status on the approved providers
The values and beliefs that affect many professional health systems will be presented, after
a brief discussion of the values that underpin the professional health system of biomedicine
in the United States.
WESTERN BIOMEDICINE
Contemporary American Values
A number of American societal values have influenced the development of Western bio-
medical health beliefs, including the perceived desirability of morality, individualism,
achievement, and progress.
Morality
Most of the original American pilgrims (settlers) were Puritans, a branch of Protestants
within the Anglican church. Their beliefs were derived from the Judeo-Christian heritage of
morality and belief in the inherent worth of the individual. The Puritans believed in an order-
ing of values, culminating in a supreme good. They were scrupulous in their adherence to a
standard of right and wrong. Products of this religious past include belief in the sanctity of
personal life, a sense of destiny, belief in the moral law that transcends the laws on the books,
and a compulsive commitment to work.
The belief in the value of religion, values, and morality persists to this day. Some people
argue that America is in a state of moral decay (e.g., rise in crime, illegitimacy, and high
divorce rate) and that as individuals and as a society, we need to return religion to its proper
place. Religion, after all, provides us with moral bearings (Bennett, 1995, p. 114). Although
discussion of moral and bioethical issues (e.g., euthanasia, abortion, and rationing of
resources) is still often based on an assumed collective standard of right and wrong, in con-
temporary society, there are now conflicting views of right and wrong (no absolute standards),
and differences in valuing the legislation of morality versus individual belief and judgment.
Individualism
Historically, the hard life on the frontier encouraged self-reliance, which confirmed the
individualism that was inherent in Puritanism. In contemporary society, self-motivation and
willpower are considered to be essential to success. Individualism is now associated with
autonomy, or self control, with an emphasis on both individual responsibility and rights. Per-
sonal freedom and liberty are associated with dignity.
However, an emphasis on individualism sets up a number of conflicts. Equality of rela-
tionships conflict with valuing of upward mobility in social status or standing. Self-reliance,
or inner directedness, is in reaction to being directed by others (government). Therefore, a
focus on independence, standing on ones own, and having a desire for privacy, compete with
the need for community and association with others. In addition, there is concern that indi-
vidualism threatens traditional community morality. Consensus and cooperation (instead of
conformity) in order to succeed, and belongingness in the organization, are current reflections
of the desire for community.
Achievement
With the industrial revolution and the development of business, achievement has come
to be equated with success. Success is achieved through hard work, but also requires aggres-
siveness, competitiveness, courage and toughness in the pursuit of goals. It is believed that
self-sacrifice will be rewarded with productivity. But, achievement may also come to be asso-
ciated with the refusal to admit defeat. The emphasis on conquest over disease in American
medicine may be viewed as an effort to achieve mastery over the ultimate defeat: death.
Within this context, achievement requires an active agency in ones life. A person must
work hard at being fit, strong, and healthy if he or she is to achieve success. As a consequence,
the stereotype for physical attractiveness has become youth and vitality, which are viewed as
functional advantages. For example, erect posture has become a metaphor for social stature.
On the other hand, age has become associated with decline and handicap. Decreased mobil-
ity has become associated with dependence. Disease and dysfunction become a deviation, also
leading to dependency.
Progress
Valuing the achievement of goals is naturally associated with a time orientation focused
on the future rather than the past or present. Change, associated with optimism and faith
in the future, can be viewed as growth, with newness seen as improvement and innovation.
Education is valuable as a tool toward such growth. However, at its extreme, the possibil-
ity of progress without parameters becomes a quest for perfectibility. In addition, in Amer-
ican culture, the concept of progress has also become associated with materialism, as
progress is equated with wealth. Another outcome of this orientation is conspicuous con-
sumption.
Biomedical Health Beliefs

Three major influences that have affected the development of values of the biomedical
model of medicine are mechanism, reductionism, and science.
Mechanism
Western biomedicine developed as a profession during the industrial revolution, with an
emphasis on mechanism and technology. A machine is comprised of separate interchange-
able and replaceable components. Normative functioning (a standard based on group aver-
ages) is taken for granted as the desirable state of being, and any deviation from normal is
labeled a disease with universal form, progress, and treatment. Since a machine is unable to
modify itself, any change is the result of external influences (e.g., invasion of the individual
by a microorganism). A machine is a passive recipient of being fixed. The machine metaphor
applied to medicine leads to dehumanization of the patient with an emphasis on disease as
a deviance from normal to be actively and quickly cured by the expert mechanic.
Reductionism
The machine metaphor is supported by reductionism, an analytical process that involves
the division of a whole into parts to facilitate systematic and orderly thinking. Processes are
broken into sequential steps, and complex systems are viewed in terms of distinct, separable,
and often competitive components. For example, the body (matter) is seen as separate from
the mind (spirit), with illness arising from one or the other. Individuals are viewed as sepa-
rate from their environment and society. Specialization allows for depth of knowledge about
isolated bits while hierarchy allows the division and organization of specialized laborers.
Science
The influence of science can be attributed to the desire for a rational system of truths from
which accurate information about the world can be deduced with certainty and precision.
Science values rationality, logical thinking, and numerical measurement. Subjective feelings
have little value. All facts have a specific cause which can be discovered through objective
and verifiable observation. Effects can be attributed to a specific cause.
Other essential values of the Western biomedical system are (Dacher, 1995; Fulder, 1998;
Larson-Presswalla, 1994):
A healthy person is a symptom-free person; symptoms are defined as abnormalities that

are recognized by professionals. They are not necessarily connected to the clients sub-
jective experiences of illness.
Phenomena must be observable or measurable to be considered real or acceptable.
The aim is to repair biophysiologic abnormality and re-establish health, which is
defined as the restoration of normal function. Health is a fixed, defined condition of the
organism.
The purpose of treatment is to cure, by killing or removing the causative agent (germs,
tumors, faulty parts). The body can then restore balance to the system if intervention
hasnt damaged it beyond the point where it can reestablish balance (Ranjan,1998).
In its short history, modern medicine has proven to be so apparently effective, and so well
adapted to the industrial worldview that it gave the impression that indigenous, ancient, or
traditional medicine had no validity, and was nearly extinct (Fulder, 1998, p. 147). However,
Western biomedicine should be viewed as one of many professional belief systems and not a
standard against which all other healing traditions should be evaluated (Thorne, 1993).
TRADITIONAL MEDICAL BELIEF SYSTEMS

Several labels are commonly used in the literature, often interchangeably, to describe non-
conventional, non-Western biomedical health care systems. Alternative is currently inter-
preted as meaning in the place of mainstream medicine. Complementary is interpreted as
meaning in addition to mainstream medicine. Integrative is interpreted as meaning in combi-
nation with mainstream medicine. In this book, the label traditional is used, to avoid defining
all medical systems in relation to Western biomedicine. All of these labels refer to profes-
sional medical systems to diagnose and treat disease.
In the United States, many people assume that mainstream, Western biomedicine is the
worlds standard health care system and is accepted by most people most of the time. Actually, it
has been estimated that only 10% to 30% of human health care is delivered by the conventional,
biomedically oriented health care system. The remaining 70% to 90% of health care includes
everything from self-care according to folk principles to care rendered in an organized health care
system based on an alternative tradition of practice (Berman & Larson, 1994, pp. 67-68).
Changing needs and values in society, which include a rise in prevalence of chronic dis-
ease, an increase in public access to worldwide health information, reduced tolerance for
paternalism, an increased sense of entitlement to a quality life, declining faith that scientific
breakthroughs will have relevance for the personal treatment of disease, an increased interest
in spiritualism, and concern about the adverse effects and escalating costs of conventional
health care, are fueling the search for more traditional approaches (Jonas, 1998). Traditional
health care systems are safe and practitioners provide patients with understanding, meaning,
and self-care methods for managing their condition. Empowerment, participation in the heal-
ing process, time, and personal attention are essential elements of all medicine. These ele-
ments are easily lost in the subspecialization, technology, and economics of modern
medicine. . . . Conventional medicine can learn from [traditional health care systems] how to
gentle its approach by focusing on the patients inherent capacity for self-healing (Jonas,
1998, p. 1617).
Many traditional health care users are apparently not dissatisfied with conventional
medicine, but find traditional alternatives to be more congruent with their own values,
beliefs, and philosophical orientations toward health and life (Astin, 1998). Use of at
least 1 of 16 [traditional] therapies during the previous year increased from 33.8% in 1990
to 42.1% in 1997 (Eisenberg et al., 1998, p. 1569). According to Eisenberg and col-
leagues, the therapies that increased the most included herbal medicine, massage, megavi-
tamins, self-help groups, folk remedies, energy healing, and homeopathy. Traditional
therapies were used most frequently for chronic conditions such as back problems, anxiety,
depression, and headaches. However, there is a danger that the economic promise of
growing markets may lead to a focus on developing profitable [traditional health care]
products rather than on improving health care and may also lead away from addressing
issues that have prompted the public to seek [traditional health care] practices (Eskinazi,
1998, p. 1623).
Major Values of Traditional Health Systems

There are a number of values that differentiate traditional health systems from Western
biomedicine. For example, the person and not his or her symptoms is treated and self-healing
is most important. The client is actively involved in partnership with the provider, and the
client is empowered to accept responsibility for part of the task of recovery and future health
maintenance. Major values of traditional health systems, derived from the following sources,
Burton Goldberg Group, 1995, pp. 14-15; Fulder, 1993, pp. 110-111; Fulder, 1998, pp. 148-
155; Lyng, 1990; Wing, 1998, p. 151, are presented in Box 3-1.
Fulder (1998, pp. 155-156) has described the following characteristics of health within tra-
ditional health belief systems:
1. Living a nontoxic life, with emphasis on sound nutrition, a balanced lifestyle, adequate
and appropriate exercise, rest, sleep, and emotional tranquillity.
2. Being sensitive to deep signs of function and dysfunction.
3. Understanding ones own constitution and its patterns and needs.
4. Respecting the unknown, indeterminacy, the wild side of life, and change.
5. Knowing health as a journey, a process.
6. Knowing when to use what remedies or professional help.
7. Having a life-affirming attitude or the will to be well.
B OX 3-1
Values of Traditional Health Systems
Mind-body-heart-spirit and environment-society-individual are viewed as
integrated and without boundaries.
The individual, not his or her symptoms is treated. Each persons back-
ground, condition, and treatment path is different. Symptoms are a guide
in the journey to a cure and an opportunity to learn about oneself. They
are managed, not suppressed. Clients may be essentially symptom-free, or
symptoms can precede the appearance of pathology.
Self-healing is paramount. Resistance is improved by preventive meas-
ures, restoration of vital force, and trust in self-healing energy.
The individual is empowered to accept responsibility for at least a part of
the task of recovery and future health maintenance. Conscious attention
can lead to informed choices.
Health is a process and a journey without a beginning or ending.
Health is considered movement toward balance, which is not synony-
mous with homeostasis.
Active involvement of the client in partnership with the provider. The
practitioner is expected to share information and help the individual use
the power of self-conscious will rather than to use power as a healer.
Tends toward a state of harmony and balance between internal and exter-
nal worlds such as seasons, environment, and social relations. Illness and
wellness are defined contextually and the energetic dimension is often the
best access point for the treatment of bodily dysfunction.
Deals not only with disease but also with vulnerabilities. Disease does not
result from a pathogen attack alone; it results from the interaction of the
pathogen and a susceptible organism. Therefore, in order to decrease dis-
ease susceptibility and risk, the focus should be on increased resistance.
There is a greater sense and respect for the unknown and a trust in empiri-
cism (sensory experience as a source of knowledge) with a lack of
urgency to construct explanatory models.
8. Having longevity.
9. Exhibiting vitalism and energy.
10. Having a subjective sense of well-being.
11. Developing a total accommodation to life and death.
No one major medical belief system has a monopoly over the right to practice medicine.
A variety of traditional professional medical alternatives to the Western biomedical health
care system currently exist. The traditional medical health belief systems of traditional Chi-
nese medicine, Ayurvedic medicine, homeopathic medicine, anthroposophically extended
medicine, naturopathic medicine, osteopathic medicine, chiropractic medicine, bioenergetic
medicine, mind-body medicine, orthomolecular medicine, and environmental medicine will
be reviewed briefly.
Traditional Chinese Medicine

The fundamental concepts of traditional Chinese medicine (TCM) are embedded in the
philosophical and metaphysical worldviews of Taoism, Confucianism, and Buddhism. In the
Eastern philosophies, all living processes are patterns of connected relationships and condi-
tions, with health a result of the proper balance of conflicting influences, while the incidence
of diseases might result from transformations of the seasons and the 24 lunar sections in
every year, day and night, morning and evening, noon and midnight, changes of weather, cold
and hot, rain and wind; bright and dark, different regions, orientations and directions; [and]
the varied changes of the body in the past and now (Chongcheng & Qiuli, 2003, p. 310).
Health is considered to be the ability of the organism to respond appropriately to a wide vari-
ety of challenges while maintaining equilibrium, integrity, and coherence (Beinfield &
Korngold, 1995, p. 45). Thus, purposes of TCM include relief of symptoms, increased physi-
ological competence, enhanced recuperative power and immunity, decreased drug-reliance,
and a contribution to a sense of greater health (Beinfield & Korngold, 1995). The first and
most important principle of TCM is the prevention of illness through an appropriate lifestyle
(Lao, 1999).
Major Concepts of TCM
According to TCM, there are five major concepts that interact to affect health. These are
qi, yin/yang, energy phases, organ networks, and body climates.
Qi. A human being is composed of qi (pronounced chee), moisture (body fluids), and
blood (tissue) existing along a continuum that ranges from intangible to tangible. Shen, or
mind, represents the nonmaterial expression of the individual; qi, the animating force that
manifests as activity (moving, thinking, feeling, working) and warmth; moisture, the liquid
medium that protects and lubricates tissue is tangibly more dense than qi but less so than
blood; blood, the material out of which bones, nerves, skin, muscles, and organs are created,
is yet more substantial; and essence (jing), the most dense substance, is the fundamental seed
of reproduction and regeneration from which the physical body arises. Put simply, health
exists if adequate qi, moisture, and blood are distributed equitably and smoothly (Beinfield
& Korngold, 1995, p. 45).
The most striking characteristic of Eastern medicine is its emphasis on diagnosing distur-
bances of qi, or vital energy, in health and disease. According to TCM theories, energy needs
to flow, in balance, for the body to stay healthy, resistant to disease, and able to activate its
own healing. Imbalances or blockages affect physiology and eventually pathologic changes
(McGee et al., 1996).
Yin/yang. Yin and yang are two stages of cyclical, opposing, but complementary, phenom-
ena that exist in a state of dynamic equilibrium, with one constantly changing into the other.
The concept of yin and yang harmony is a basic description of the interaction between the
active and passive, stimulating and nurturing, masculine and feminine, and heavenly and
earthly qualities that characterize living things (Berman & Larson, 1994, p. 71). Every part
of the human body has a predominantly yin or yang character. Yang corresponds to function
and yin corresponds to structure. Yin and yang can be considered substitutes for inhibition
and excitation (Chongcheng & Qiuli, 2003). All symptoms and signs can be interpreted as a
loss of balance of yin and yang (Maciocia, 1989).
Energy phases. The five-phase theory explains relationships between the human body and
the environment as well as relationships among internal organs. Each phase of energy is rep-
resented by the elemental natures of fire, earth, metal, water, and wood, which define the
various stages of transformation in the recurring natural cycles of seasonal change, growth and
decay, shifting climatic conditions, sounds, flavours, emotions, and human physiology (Reid,
1995, p. 49). Each phase of energy takes its name from the natural element that most closely
resembles its function and character.
Organ networks. In addition, there are five functional systems (not physical organs) known
as organ networks: liver, heart, spleen, lung, kidney. Each organ network refers to a complete
set of functions, physiological and psychological, rather than to a specific and discrete physi-
cal structure fixed in an anatomical location. . . . By treating the organs, emotional and men-
tal processes can be modulated and enhanced (Beinfield & Korngold, 1995, p. 48). Although
some physiologic functions are similar to those in Western biomedicine, others are very dif-
ferent. For example, the heart is said to control mind activities as well as blood circulation.
Body climates. Finally, TCM identifies external, internal, and other factors that are patho-
genic when they are excessive or the defensive qi of the body declines. The external body cli-
mates are described as cold, heat, wind, dampness, and dryness, and sometimes also fire. The
principle of complementarity applies: for cold, warm; for heat, cool; for congested qi, mois-
ture; for blood, encourage movement; for depletion, nourish; for internal wind, subdue; for
external wind, relieve surface congestion; and for phlegm, dissolve (Beinfield & Korngold,
1995, p. 49). The internal factors refer to the seven emotions: joy, anger, melancholy, worry,
grief, fear, and fright. . . [while] the other factors include dietary irregularities, obsessive sexual
activity, taxation fatigue, trauma, and parasites (Lao, 1999, pp. 221-222).
Diagnosis in TCM involves the classical procedures of observation, listening, question-
ing, and palpation, including feeling the quality of the pulses and the sensitivity of various
body parts (Beinfield & Korngold, 1995, p. 71). To reveal the severity, nature, and location
of illness, pulse diagnosis involves palpation along the radial artery at six positions and two
depths (p. 49), while tongue inspection involves observing the size, shape, and texture as
well as the quality of fur. For further discussion of these techniques, see Chapter 7, Beyond
Physical Assessment.
TCM Treatment Modalities

Treatment modalities most associated with TCM and used regularly by practitioners
include acupuncture, moxibustion, acupressure, remedial massage, cupping, qigong, herbal
medicine, and nutritional and dietary interventions.
Acupuncture. The therapeutic goal of acupuncture is to regulate or correct the flow of qi to
restore health. By directly manipulating the network of energetic meridians, acupuncture increases
the circulation of congested qi, moisture, and blood, relieving stagnation and obstruction of the
organ networks associated with the channels. Many of the therapeutic effects of acupuncture can
be clearly related to the mechanism of chemical neurotransmitter release via peripheral nerve
stimulation by puncturing the skin with a needle, heat, direct physical pressure (acupressure), frac-
ture, suction, or impulses of electromagnetic energy to stimulate specific anatomic points, and, by
so doing, enhances the self-regulatory, self-protective, and self-aware capacities of the organism
(Beinfield & Korngold, 1995, p. 50). Studies have shown evidence for the efficacy of acupuncture
for osteoarthritis, chemotherapy-induced nausea, asthma, back pain, painful menstrual cycles,
bladder instability, migraine headaches, chronic pain, and drug addiction.
Moxibustion. Moxibustion refers to the burning of the dried and powdered leaves of the
artemesia vulgaris plant either on or in proximity to the skin. This leads to heating the body
on the energetically active points in order to affect the movement of qi in the channel, locally
or at a distance (Berman & Larson, 1994; Ergil, 2001).
Remedial massage. In remedial massage, vigorous pressing and rubbing hand motions (an-
mo) tonify the system, while thrusting and rolling hand motions (tuina) soothe and sedate
(Berman & Larson, 1994).
Cupping. Cupping involves introducing a vacuum in a small glass or bamboo cup, and
promptly applying it to the skin surface. This [suction] therapy brings blood and lymph to the
skin surface under the cup, increasing local circulation (Ergil, 2001, p. 325).
Qigong. Qi means vital energy; and gong means training. Thus, qigong is the art and
science of using breath, movement, and meditation to cleanse, strengthen, and circulate vita;
life energy and blood. Three basic principles of qigong exercises are relaxation and repose,
association of breathing with attention, and the interaction of movement and rest (Berman
& Larson, 1994, pp. 72-73). Qigong exercise has been shown to affect strength, health, and
longevity, and may reduce symptoms and improve appetite. (McGee et al., 1996). In human
studies, qigong training (in the presence of a master instructor) has demonstrated the capac-
ity to increase parasympathetic and decrease sympathetic activities, and produce analgesia.
For example, qigong training was found to result in transient pain reduction and long-term
anxiety reduction in a sample of 22 patients with late-stage complex regional pain syndrome
(Wu et al., 1999, p. 45). In addition, qigong exercise has been shown to alter serum levels of
epinephrine, dopamine, and serotonin. Some researchers report improvements in energy lev-
els, bowel irregularity, body weight, leukopenia, and other side effects of chemotherapy in ter-
minal cancer patients. Qigong training also appears to improve cardiac reserve in
hypertensive, coronary heart disease (Wu et al., 1999). Qigong is discussed in depth in Chap-
ter 13, Re-establishing Energy Flow: Physical Activity and Exercise.
Herbal medicine. With herbs, active ingredients are enfolded within the whole plant, and
this tends to buffer their side effects. Also, as herbs are often blended together to counteract
undesired effects and enhance intended results, when they are used properly they rarely cause
disagreeable consequences (Beinfield & Korngold, 1995, p. 50). In TCM, medications are
classified according to their energetic qualities and prescribed for their action on correspon-
ding organ dysfunction, energy disorders, disturbed internal energy, blockage of the meridi-
ans, or seasonal physical demands. Herbs are discussed in depth in Chapter 12, Relinquishing
Bound Energy: Herbal Therapy and Aromatherapy. A typical Chinese herbal formula usually
includes the four components listed in Box 3-2.
Dietary interventions. Dietary interventions are individualized. Foods, like herbs, are char-
acterized according to their energetic qualities (e.g., tonifying, dispersing, heating, cooling,
moistening, drying). Emphasis is given to eating in harmony with seasonal shifts and life
activities (Berman & Larson, 1994, p. 73). Nutrition is discussed in depth in Chapter 16.
Ayurvedic Medicine
Ayurveda, one of the oldest health care systems in the world, has its origins in the Sanskrit
roots ayu, which means longevity, and ved, which means knowledge (Mishra et al.,
2001a). In Vedic knowledge, the purpose of life is to know or realize the Creator (cosmic
consciousness) and to express this divinity in ones daily life (Lad, 1999, p. 200). Ayurveda
provides an integrated approach to the prevention and treatment of illness through lifestyle
interventions and a wide range of natural therapies.
The structural aspect of the body is made up of five elements, but the functional aspect of
the body is governed by three metabolic principles, the doshas. The doshas are forces of
energy, patterns, and movements, not substances and structures. Ether and air together con-
stitute vata (the energy of movement); fire and water, pitta (the energy of digestion or metab-
B OX 3-2
Components of Chinese Herbal Medicine
The chief (principal) ingredient, which treats the principal pattern or dis-
ease.
The deputy (associate) ingredient, which assists the chief ingredient in
treating the major syndrome or serves as the main ingredient against a
coexisting symptom.
The assistant (adjuvant) ingredient, which enhances the effect of the chief
ingredient, moderates or eliminates the toxicity of the chief or deputy
ingredients, or can have the opposite function of the chief ingredient to
produce supplementing effects.
The envoy (guide) ingredient, which focuses the actions of the formula on
a certain meridian or area of the body or harmonizes and integrates the
actions of the other ingredients (Lao, 1999, p. 225).
olism); and water and earth, kapha (the energy that forms the bodys structure and holds the
cells together). When balanced, vata creates energy and creativity, pitta creates perfect diges-
tion and contentment, while kapha yields strength, stamina, immunity, and even tempera-
ment (Larson-Presswalla, 1994). In every person, the doshas that make up ones nature
(prakriti) differ in emphases and combinations. To promote health, it is important to know
ones prakriti, choose supportive influences, and avoid undermining influences (Titus, 1995).
According to Ayurveda, health is a state of balance between the body, mind, and con-
sciousness. The body has its own intelligence to create balance, with therapeutic interven-
tions helping in that process. Disharmony among the body and mental doshas constitutes
disease. The essence of disease management is the restoration of harmonious dosha balance
through lifestyle interventions, spiritual nurturing, and treatment with herbo-mineral for-
mulas based on ones mental and bodily constitution (Mishra et al., 2001a, p. 36).
Disease and illness management in Ayurveda has four elements: 1) shodan, cleansing; 2)
shaman, palliation; 3) rasayan, rejuvenation; and 4) satwajaya, mental nurturing and spiritual
healing (Mishra et al., 2001b, p. 45). The primary Ayurvedic therapeutic methods are listed
in Box 3-3.
B OX 3-3
Primary Ayurvedic Therapeutic Methods
Pranayama. The practice of alternative nostril breathing. It has an almost
universal calming effect.
Abhyanga. The practice of rubbing the skin with oil, usually sesame oil,
to increase circulation and move lymph and toxins out of the body
through the skin.
Rasayana. Incorporates dosha-specific herbs and spoken mantras during
meditation for the purpose of rejuvenation.
Yoga (union, or joining in Sanskrit). Meditation through movement. Yoga
has been demonstrated to improve blood pressure, metabolism, respira-
tion, cardiac rhythms, skin resistance, alpha and theta brain waves, and
body temperature.
Panchakarma. A cleansing therapy. Patients are encouraged to sweat,
eliminate fecal waste, and even vomit in an effort to cleanse the body of
toxins (ama). Believed by some to prevent susceptibility to disease with
change of season.
Herbal medicines. Prescribed according to their effects on vayus (energy
flow). Often given with warm milk, ghee (clarified butter), or nasyas (nasal
rinse) (Lad, 1995, pp. 62-63; 1999).
In Ayurveda, all of life and nature are viewed as an interconnected expression of whole-
ness. Adjustment of diet and lifestyle in order to balance the doshic influences of the seasons
is considered an important principle of Ayurvedic living (Titus, 1995). Specific lifestyle inter-
ventions are a major preventive and therapeutic approach in Ayurveda as well. Each person
is prescribed an individualized dietary, eating, sleeping, and exercise program depending on
his or her constitutional type (prakruti) and the underlying energy imbalance at the source of
the illness.
Published studies have documented reductions in cardiovascular disease risk factors,
including blood pressure, cholesterol, and reaction to stress, in individuals practicing
Ayurvedic methods. Ayurvedic therapies have been shown to be potentially beneficial for the
prevention and treatment of breast, lung, and colon cancers; mental health; infectious dis-
ease; health promotion; and aging (Berman & Larson, 1994). A considerable amount of data
from both animal and human trials suggest the efficacy of Ayurvedic interventions in man-
aging diabetes (Elder, 2004).
Homeopathic Medicine
The term homeopathy is derived from the Greek words homeo (similar) and pathos (suffer-
ing from disease). The first basic principles of homeopathy were formulated by the German
physician Samuel Hahnemann in the late 1700s. Homeopathy considers illness to be prima-
rily a disturbance of the vital force producing symptoms that are unique to each person
(Jacobs & Moskowitz, 2001). What is needed is to treat the particular individual with the
unique combination of substances that will relieve those symptoms.
The principle of similars, or like cures like, proposes that a substance that can cause cer-
tain symptoms when given to a healthy person can cure those same symptoms in someone
who is sick. The one remedy that most closely fits all of the symptoms of a given individual
is called the similimum for that person. Homeopathic remedies are produced by a process
called potentization, in which, by diluting them in a water-alcohol solution and then shak-
ing, side effects can be diminished. When potentized to high dilutions, these remedies still
produce a medicinal effect, with minimal side effects. By using the smallest possible doses and
only repeating them if necessary, homeopaths allow remedies to complete their action with-
out further interference. It is exceedingly unlikely that any untoward or dangerous side effects
will occur, given the minuteness of the dose (Berman & Larson, 1994).
The effectiveness of homeopathic remedies has been demonstrated in many studies. For
example, a study by Kuzeff (1998) found evidence for the ability of homeopathic prescribing
to improve sensation of well-being. Studies have suggested a positive effect of homeopathy
on allergic rhinitis, fibrositis, rheumatoid arthritis, and influenza. A 1992 review of homeo-
pathic clinical trials found that 15 of 22 well-designed studies showed positive results
(Berman & Larson, 1994).
Seventeen schools in the United States and four in Canada offer homeopathic training.
There are separate laws in each state governing who can practice homeopathy. Only medical
doctors and osteopathic doctors can practice homeopathy in every state. There is no legal
requirement for these practitioners to have any specific homeopathic qualifications. Many
states also license naturopaths to practice homeopathy as well as physicians assistants and
nurse practitioners. No diploma or certificate is recognized as a license to practice homeopa-
thy in the United States (Bailey, 2002, p. 424).
Anthroposophically Extended Medicine

The foundations of anthroposophically extended medicine were laid down by the Austrian
philosopher and spiritual scientist Rudolf Steiner (1861-1925). Steiners anthroposophy
(anthropos [human]; sophia [wisdom]) builds on naturopathy, homeopathy, and Western biosci-
entific medicine. The model includes the sense-nerve system, which includes the mind and
thinking process; the rhythmic system, which includes the emotional or feeling processes;
and the metabolic-limb system, which includes digestion, elimination, energetic metabo-
lism, and the voluntary movement processes. This model provides a scheme for understand-
ing an illness as a deviation from the harmonious internal balance of the functions of the
bodily self and the spiritual self (Berman & Larson, 1994, p. 86). Medications seek to match
the archetypal forces in plants, animals, and minerals with disease processes in humans.
Naturopathic Medicine
Naturopathic medicine integrates traditional natural therapeutics, including botanical
medicine, clinical nutrition, homeopathy, acupuncture, traditional Eastern medicine,
hydrotherapy, and naturopathic manipulative therapy, with modern scientific medical diag-
nostic science and standards of care. There are eight primary principles of naturopathic med-
icine (Berman & Larson, 1994, pp. 88-89):
1. Recognition of the inherent healing ability of the body.
2. Identification and treatment of the cause of diseases rather than mere elimination or
suppression of symptoms.
3. Use of therapies that do no harm. Use the least invasive intervention.
4. Implementation of the physicians primary role as a teacher.
5. Establishment and maintenance of optimal health and balance.
6. Treatment of the whole person.
7. Prevention of disease through a healthy lifestyle and control of risk factors.
8. Therapeutic use of nutrition to promote health and to combat chronic and degenera-
tive diseases.
Naturopaths emphasize identification and treatment of a disease source more than reduc-
ing the severity of symptoms. In addition to physical and laboratory findings, important con-
sideration is given to the [clients] mental, emotional, and spiritual attitude; lifestyle; diet;
heredity; environment; and family and community life. . . . [Client] education and responsi-
bility, lifestyle modification, preventive medicine, and wellness promotion are fundamental
to naturopathic practice (Pizzorno & Snyder, 2001, pp. 181-182). Other treatment modali-
ties, in addition to the use of diet as therapy, include herbs, homeopathy, acupuncture,
hydrotherapy, therapeutic use of touch, heat, cold, electricity and sound (physical medicine),
endogenous and exogenous toxicity, counseling and lifestyle modification, and minor surgery
(Pizzorno, 1996).
In general, licensing laws in all jurisdictions require completion of a naturopathic degree
and diploma program at one of only five institutions in North America (Washington, Ore-
gon, Arizona, Connecticut, and one in Canada). Laws governing naturopathic medicine
require the successful completion of basic science and clinical board examinations (Smith &
Logan, 2002).
Osteopathy
Osteopathy, a blend of holistic and conventional medical practices, was developed in the
late 1800s by Andrew Taylor. It is based on treating illness through the manipulation of mus-
cles and joints to restore the structure and balance of the musculoskeletal system. Asymme-
try and pain are hallmark diagnoses, but osteopaths holistically consider the clients entire
constitution, lifestyle, and psychology (Integrative Medicine Consult, 1998). Pharmacology
and a symptom-oriented medical model are also integrated.
Osteopaths, whose educational degree is Doctor of Osteopathy (DO), are licensed as med-
ical doctors in the United States. Important therapies include manipulative and re-educative
approaches such as:
Gentle mobilization. Moving a joint slowly through its range of motion, and then gradu-
ally increasing the motion to free the joint from restrictions.
Articulation. A quick thrust (similar to chiropractic) when motion is severely restricted.
Functional and positional release methods. Placing the client in a specific position to allow
the body to relax and release muscle spasms that may have been caused by strain or injury.
Muscle energy technique. Gently tensing and releasing specific muscles to produce relaxation.
Other soft tissue techniques. Techniques to relax and release restrictions in the soft tissues
of the body.
Cranial manipulation. Very gentle and subtle cranial techniques used to treat conditions
such as headaches, strokes, spinal cord injury, and tempromandibular joint syndrome
dysfunction.
Relaxation. Techniques to help reduce levels of excessive tension in muscles of people
with joint and back problems.
Improved breathing methods. Decrease the stress of back and neck muscles.
Postural correction. To use the body in less stressful, more efficient and economical ways,
reduce damage and tension affecting joints and soft tissues, and decrease fatigue.
Individualized nutritional guidance (Integrative Medicine Consult, 1998, pp. 408-409).
Chiropractic
The three largest independent health professions in the Western world are allopathic med-
icine, dentistry, and then chiropractic medicine (Redwood, 1996). The chiropractors scope
of practice excludes surgery and pharmaceutical therapy, and centers on the manual adjust-
ment or manipulation of the spine and nervous system to maintain or restore health.
Core chiropractic principles include (Redwood, 1996, p. 96):
1. Structure and function exist in intimate relation with one another.

2. Structural distortions can cause functional abnormalities.
3. Vertebral subluxation (misalignment) is a significant form of structural distortion and

leads to a variety of functional abnormalities.
4. The nervous system plays a prominent role in the restoration and maintenance of
proper bodily function.
5. Subluxation influences bodily function primarily through neurologic means.
6. Chiropractic adjustment is a specific and definitive method for the correction of verte-
bral subluxation.
Chiropractic treatment has been shown to be effective for controlling acute low back pain
when used within the first month of symptoms and chronic, disabling lower back pain in cases
where standard biomedical interventions have been exhausted. Chiropractic medicine has
been shown to be more effective than the tricyclic antidepressant amitriptyline for long-term
relief of pain from muscle tension headaches, while spinal manual therapy has been shown to
be significantly more effective than a placebo treatment or treatment by a primary physician
for persistent back and neck pain (Redwood, 1996). Studies are underway for migraine
headaches, as is exploration of chiropractys effects on visceral disorders.
Energy Medicine (Bioenergetic Medicine)

Bioenergetic medicine refers to therapies that use an energy fieldelectrical, magnetic,
sonic, acoustic, microwave, or infraredto screen for or treat health conditions by detecting
imbalances in the bodys energy fields and then correcting them (Integrative Medical Consult,
1998, p. 193). Bioenergetic medicine uses diagnostic screening devices to measure various elec-
tromagnetic frequencies in the body, including the electrocardiogram (EKG), electroen-
cephalogram (EEG), electromyelogram (EMG), and magnetic resonance imaging (MRI).
It has been discovered that the electrical resistance of the skin decreases dramatically at
the acupuncture points when compared with the surrounding skin. Each point appears to
have a standard measurement for anyone who is in good health. This principle has been used
in the development of assessment and treatment instruments. One instrument, the Derma-
tron, can be used for assessment of electrical resistance at acupuncture points. Another instru-
ment, the MORA, raises or lowers aberrant electromagnetic waves and feeds the resultant
normal waves back to the client through corresponding acupoints (Integrative Medical Con-
sult, 1998).
Mind/Body Medicine
People have lost sight of the importance of the psychological, social, economic, and envi-
ronmental influences on health and illness and of the extraordinary power of the mind to
affect the body. Internal and external stimuli (e.g., memories, thoughts, emotions, body
movements, sounds, smells, tastes, situations, and settings) can affect a variety of previously
conditioned immune responses. Mind/body approaches focus on personal attitudes and
lifestyle, the assumption of personal responsibility, and proactive self-motivation. The
client/health practitioner relationship is considered a partnership, in which there is concern
for psychological development, individuation, personal transformation, and mastery, to the
extent possible, over the activities of the mind and body (Dacher, 1995, p. 191).
The principles of mind/body medicine (Benson, 1993; Burton Goldberg Group, 1995;
Integrative Medical Consult, 1998) include:
Each person is unique. No two people are alike, so even if they have the same disease,
the paths to recovery may be different. Conversely, the same disease can be the result
of different factors with different people.
Chronic stress and lack of balance contribute to illness. Relaxation, positive methods
of coping with stress, and restoration of balance lead to health.
The client is an active partner in all stages of treatment, rather than a passive recipient
of medical intervention.
The healing process is viewed as a working partnership in which both parties respect
the knowledge and intuition of the other.
Illness may be only a manifestation of imbalance on the physical level, but the imbal-
ance may also originate in other aspects of the self, such as the mental or emotional state.
Part of healing involves the recognition and release of negative emotions. Having a
sense of control, commitment, and connectednessalong with viewing change as a
challenge rather than a threatpromotes the maintenance of good health even when
under stress.
Regulation of breathing plays an important role in mind/body medicine, because it is
capable of bringing about a state of relaxation.
Orthomolecular Medicine
Orthomolecular medicine tries to create optimum nutritional balance in order to treat
conditions such as depression, hypertension, schizophrenia, and cancer (Integrative Medical
Consult, 1998). The types and amounts of the nutrients are determined by blood tests, urine
analysis, and tests of nutrient levels based on biochemical individuality rather than recom-
mended daily allowances (RDA) values. Junk foods, refined sugar, and food additives are
eliminated, while promoting nutritious, whole foods, high in fiber and low in fat, supple-
mented by megavitamin therapy.
In support of orthomolecular medicine, it has been found that:
Higher levels of beta-carotene (a precursor of vitamin A) are associated with lower rates
of certain cancers.
Intravenous magnesium sulfate (a mineral compound) is given in some hospitals to per-
sons having a heart attack to speed recovery time.
Chromium (a trace mineral) may be given to help regulate the bodys response to sugar
and insulin. It may help those with diabetes and hypoglycemia. It can also aid in low-
ering cholesterol.
Essential fatty acids (unsaturated fats that the body cannot make for itself and must
obtain from food sources), including omega-3 and omega-6, are now linked to a
decrease in risk factors for heart disease and a lessening of symptoms of other diseases,
including psoriasis and rheumatoid arthritis (Integrative Medical Consult, 1998,

p. 401).
Environmental Medicine
Environmental medicine, with roots in the practice of allergy treatment by Theron Ran-
dolph in the 1940s, is based on the science of assessing the impact of environmental factors
on health. It is the result of continuing study of the interfaces among chemicals, foods, and
inhalants in the environment and the biological function of the individual. While the bio-
medical model holds that similar illnesses have the same cause in all clients and should be
treated similarly, environmental medicine recognizes that an individuals illness can be caused
by a broad range of substances, including foods and chemicals found in the home and work-
place. Investigators are interested in things like sick building syndrome; the effects of chem-
icals like natural gas; industrial solvents; pesticides; car exhaust; chemicals in air, water, and
food; and inhalant materials including pollens, molds, dust, dust mites, and danders (Berman
& Larson, 1994).
The key to proper treatment is an accurate environmental history. Treatments, including
immunotherapy, environmental controls, dietary management, and nutritional supplements,
have been used to treat arthritis, asthma, chemical sensitivity, colitis, depression, eczema, eye
allergy, fatigue, food allergy, hyperactivity, migraine, psychological complaints, and vascular
disease.
Table 3-1 summarizes the cause of illness, treatment strategy, training, and other comments
for six of the above traditional health belief systems.
Integrating Medical Belief Systems

Because each of the healing traditions has arisen in its own culture, each has its own
strengths and weaknesses. However, Ballentine (1999, p. 6) proposes that by integrating
them, superimposing one upon another in layer after layer of complementary perspectives and
techniques, we can arrive at an amalgam [composite] that is far more potent and thorough
than any one of them taken alone. Ballentine believes that attitudes and emotional postures
embedded in the mind and in the unconscious are hidden impediments to health because
they shape the way in which subtle energy is organized, which in turn influences what hap-
pens in the physical body. By melding the philosophies and methods of the various traditions,
it is proposed (Ballentine, 1999) that:
The profound principles buried in each become clearer and stronger
An intensity of effectiveness becomes possible
Healing and reorganization accelerate and deepen
Spurts of rapid transformation are made possible
These principles have been applied within the context of nursing practice in the remain-
der of this book. Each chapter contributes to a health promotion nursing practice matrix that
draws upon theory and approaches from a variety of traditions. The practitioner is urged to
develop competence in a wide variety of strategies, and to combine them in creative ways
based on the individualized needs of clients.
Table
3-1
Professionalized Health Belief Systems
SYSTEM CAUSE OF ILLNESS TREATMENT STRATEGY

Acupuncture (TCM) Imbalance of vital energies Improve the flow of qi by strategic-
or qi (pronounced chee). ally placing needles along any of
the meridians that conduct energy
between body surfaces and deep
internal organs.
Anthroposophically Physical functioning is in dis- Heal the soul and spirit, as well as
extended medicine cord with the patients spirit- the body.
ual functioning.
Ayurveda Disruption of the elements or Restore the doshas to their original

doshas that form the patients equilibrium with lifestyle tactics.
spiritual functioning.
Environmental Same as conventional medic- A thorough environmental history,

medicine ine with one major exception: physical examination, laboratory
sensitivity to chemicals, foods, assessment, and hypersensitivity
and inhaled substances can testing are used to uncover the
cause signs and symptoms cause of symptoms. Environmental
not usually associated with controls and dietary management
allergies. are basic to treatment. Immuno-
therapy may also be used to reduce
sensitivity to antigens.
Homeopathy A hereditary predisposition Symptoms are treated with highly

to an imbalance of the bodys diluted preparations of naturally
own vital energy. occurring animal, mineral, and plant
substances capable of causing simi-
lar symptoms in a health patient.
continued
Table
3-1
Professionalized Health Belief Systems, continued
SYSTEM PRACTITIONERS TRAINING COMMENT

Acupuncture (TCM) More than 40 schools and colleges Most states regulate the practice
of acupuncture and Eastern medi- in some way: 22 license or regis-
cine exist in the United States.* ter acupuncturists; 12 limit the
Conventional medicinal schools practice to MDs and DOs; two
may teach the subject as well. Cert- to MDs, DOs, and Doctors of
ification is offered by the Washing- Chiropractics; and eight allow
ton, DC-based National Commission the practice if supervised by a
for the Certification of Acupuncture licensed physician.1
and the American Academy of Med-
ical Acupuncture, Los Angeles.
Anthroposophically MDs or DOs who have studied with Western scientific medical prac-
extended medicine others in the field. Board certificat- tices are blended with aspects of
ion is available from the Physicians homeopathy and naturopathy.
Association for Athroposophical
Medicine but not required for
practice.
Ayurveda Centers providing Ayurvedic medi- A subtype of Ayurvedic medicine,

cine frequently offer training prog- known as Maharishi Ayurveda,
rams. These vary in intensity. No includes transcendental medita-
standard qualifications exist. tion in its approach.
Environmental Practitioners are conventionally More than half of those belong-
medicine trained physiciansan estimated ing to the American Academy of
3,000 of them practice worldwide, Environmental Medicine are
though the specialty is most com- board-certified in one or more of
mon in the United States, Great 19 medical specialties.
Britain, and Canada.*
Homeopathy Formal training programs and home- Homeopathy is commonly used

learning courses are available, some in other parts of the world, part-
through the Alexandria, VA-based icularly Asia, Europe, and Latin
Council on Homeopathic Education. America.
No standard qualifications exist,
though practitioners are licensed
health care providers. However,
Arizona, Connecticut, and Nevada
maintain licensing boards for home-
opathic physicians.
continued
Table
3-1
SYSTEM CAUSE OF ILLNESS TREATMENT STRATEGY

Naturopathy Discord with nature. Conventional diagnostic tech-
niques are employed. Therapy is
designed to spur the bodys innate
healing capacity. Nutritional and
herbal tactics are fused with tech-
niques such as acupuncture, home-
opathy, hydrotherapy, and therapeu-
tic massage.
Traditional Eastern Disruption of the vital energies. Balance is maintained or restored

medicine with a variety of tactics, including
acupuncture, dietary intervention,
herbal remedies, and Qigong.
continued
Table
3-1
SYSTEM PRACTITIONERS TRAINING COMMENT

Naturopathy Practitioners receive a Doctor of Eight states have specific licens-
Naturopathy degree after 4 years of ing laws pertaining to natur-
advanced study at a school of naturopaths.1 A handful of others
opathic medicine. Four currently allow naturopathic physicians to
exist in the United States: Bastyr practice. An increasingly com-
College of Natural Health Sciences, mon evaluation tool is a stan-
Bothell, WA; National College of dardized national exam called
Naturopathic Medicine, Portland, the naturopathic physician licen-
OR;Southwest College of Naturo- sing examination.
pathic Medicine, Scottsdale, AZ; and
University of Bridgeport College of
Naturopathic Medicine, Bridge-
port, CT.
Traditional Eastern Acupuncture, as well as herbal med- Questions on herbal medicine

medicine icine, Eastern massage, and pharm- are part of the state acupuncturist
acology are among the courses licensing exam in California and
taught at colleges of traditional Nevada.* Practioners of Eastern
Eastern medicine. Credentialing is medicine have the most authority
the same as for acupunture. in New Mexico, which allows
them to operate much like MDs
or DOs. In addition, other health
care professionals in that state
are not allowed to advertise or
charge for acupuncture and other
practices of Eastern medicine.
*National Institutes of Health. (1994). Alternative medicine: Expanding medical horizons. A report to the
National Institutes of Health on alternative medical systems and practices in the United States. (NIH publication
94-066, pp. 67-112). Washington, DC: U.S. Government Printing Office.
1Collinge, W. (1997). The American Holistic Health Association complete guide to alternative medicine. (pp. 49-
50). New York: Warner Books.
Table reprinted from Starr, C. (1997). Exploring the other health care systems. Patient Care, 140-141, with per-
mission of Patient Care. Medical Economics.
Chapter Key Points

Western biomedicine is one of many medical belief systems, providing 10% to 30% of
worldwide health care.
Mechanism, reductionism, and science are major influences that have affected the
development of the values of the biomedical model.
Traditional medical belief systems are complete diagnostic and treatment systems that
provide many positive effects to promote health and treat disease.
In traditional health systems, the individual, not his or her symptoms, is treated; and
empowered self-healing is paramount.
References
Andrews, M. M. (1995). Transcultural concepts in nursing care. Philadelphia: Lippincott.
Astin, J. A. (1998). Why patients use alternative medicine: Results of a national study. JAMA, 279, 1548-1553.
Bailey, P. (2002). Homeopathy. In S. Shannon (Ed.). The Handbook of Complementary and Alternative Ther-
apies in Mental Health (pp. 401-429). San Diego, CA: Academic Press.
Ballentine, R. (1999). Radical healing. New York: Harmony Books.
Beinfield, H., & Korngold, E. (1995). Chinese traditional medicine: An introductory overview. Altern Ther
Health Med, 1, 44-52.
Bennett, W. J. (1995). Moral conduct is in decline. In J. Hurley (Ed.), American values: Opposing viewpoints
(pp. 106-114). San Diego, CA: Greenhaven Press.
Benson, H. (1993). The relaxation response. In D. Goleman, & J. Gunn, Mind-body medicine (pp. 233-257).
Yonkers, NY: Consumer Reports.
Burton Goldberg Group (1995). Alternative medicine: The definitive guide. Fife, WA: Future Medicine.
Chongcheng, X., & Qiuli, Y. (2003). The model of traditional Chinese medicine., 23, 308-311.
Collinge, W. (1997). The American holistic health association complete guide to alternative medicine (pp 49-50).
New York: Warner Books.
Dacher, E. S. (1995). A systems theory approach to an expanded medical model: A challenge for biomed-
icine. J Altern Complement Med, 1,187-196.
Eisenberg, D. M., Davis, R. B., Ettner, S. L., Appel, S., Wilkey, S., Van Rompay, M., et al. (1998). Trends
in alternative medicine use in the United States, 1990-1997: Results of a follow-up national sur-
vey. JAMA, 280, 1569-1575.
Elder, C. (2004). Ayurveda for diabetes mellitus: A review of the biomedical literature. Altern Ther Health
Med, 10, 44-50.
References 73
Ergil, K. V. (1996). Chinas traditional medicine. In M. S. Micozzi (Ed.), Fundamentals of complementary and
alternative medicine (pp. 185-223). New York: Churchill Livingstone.
Eskinazi, D. P. (1998). Factors that shape alternative medicine. JAMA, 280, 1621-1623.
Fulder, S. (1993). The impact of non-orthodox medicine on our concepts of health. In R. Lafaille, & S.
Fulder (Eds.). Towards a new science of health (pp. 105-117). London: Routledge.
Fulder, S. (1998). The basic concepts of alternative medicine and their impact on our views of health. J
Altern Complement Med, 4, 147-158.
Hester, J. P. (1996). Encyclopedia of values and ethics. Santa Barbara: ABC-CLIO.
Integrative Medicine Consult. (1998). A primer: Integrative medicine. Boston: Integrative Medicine
Communications.
Jacobs, J., & Moskowitz, R. (2001). Homeopathy. In M. Micozzi (Ed.), Fundamentals of Complementary and
Alternative Medicine (2nd ed., pp. 87-99). New York: Churchill Livingstone.
Jonas, W. B. (1998). Alternative medicineLearning from the past, examining the present, advancing to
the future. JAMA, 280, 1616-1617.
Kuzeff, R. M. (1998). Homeopathy, sensation of well-being and CD4 levels: A placebo-controlled, ran-
domized trial. Complement Ther Med, 6, 4-9.
Lad, D. V. (1995). An introduction to Ayurveda. Altern Ther Health Med, 1, 57-63.
Lad, D. V. (1999). Ayurvedic medicine. In W. B. Jonas, & J. S. Levin (Eds.), Essentials of complementary
and alternative medicine (pp. 200-215). Philadelphia: Lippincott Williams & Wilkins.
Lao, L. (1999). Traditional Chinese medicine. In W. B. Jonas, & J. S. Levin (Eds.), Essentials of comple-
mentary and alternative medicine (pp. 216-232). Philadelphia: Lippincott Williams & Wilkins.
Larson-Presswalla, J. (1994). Insights into eastern health care: Some transcultural nursing perspectives.
Journal of Transcultural Nursing, 5, 21-24.
Lyng, S. (1990). Holistic health and biomedical medicine. New York: State University of New York.
Maciocia, G. (1989). The foundations of Chinese medicine: A comprehensive text for acupuncturists and herbal-
ists. Edinburgh, UK: Churchill Livingstone.
McGee, C. T., Sancier, K., & Chow, E. P. Y. (1996). Qigong in traditional chinese medicine. In M. Micozzi
(Ed.), Fundamentals of complementary and alternative medicine (pp. 225-230). New York: Churchill
Livingstone.
Mishra, L., Singh, B. B., & Dagenais, S. (2001a). Ayurveda: A historical perspective and principles of the
traditional healthcare system in India. Altern Ther Health Med, 7, 36-42.
Mishra, L., Singh, B. B., & Dagenais, S. (2001b). Healthcare and disease management in Ayurveda. Altern
Ther Health Med, 7, 44-50.
National Institute of Health. (1994). Alternative Medicine: Expanding Medical Horizons. A Report to the
National Institutes of Health on Alternative Medical Systems and Practices in the United States. (NIH
publication 94-066, pp. 67-112). Washington, DC: U.S. Government Printing Office.
Novey, D. W. (2000). Clinicians complete reference to complementary/alternative medicine. St. Louis: Mosby.
Pizzorno, J. E. (1996). Naturopathic medicine. In M. Micozzi (Ed.), Fundamentals of complementary and
alternative medicine (pp. 163-181). New York: Churchill Livingstone.
Pizzorno, J. E., & Snyder, P. (2001). Naturopathic medicine. In M. Micozzi, (Ed.), Fundamentals of comple-
mentary and alternative medicine (2nd ed., pp. 159-193). New York: Churchill Livingstone.
Ranjan. (1998). Magic or logic: Can alternative medicine be scientifically integrated into modern medical
practice? Adv Mind-Body Med, 14, 43-73.
Redwood, D. (1996). Chiropractic. In M. S. Micozzi (Ed.), Fundamentals of complementary and alternative
medicine (pp. 91-110). New York: Churchill Livingstone.
Reid, D. (1995). The complete book of Chinese health and healing. Boston: Shambhala.
Smith, M. J., & Logan, A. C. (2002). Naturopathy. In A. Perlman (Ed.). Complementary and Alternative
Medicine. The medical clinics of North America (pp. 173-184). Philadelphia: W. B. Saunders.
Soukhanov, A. H. (Ed.). (1992). The American heritage dictionary (3rd ed.). Boston: Houghton Mifflin.
Starr, C. (1997, July 15). Exploring the other health care systems. Patient Care, 140-141.
Thorne, S. (1993). Health belief systems in perspective. J Adv Nurs, 18, 1931-1941.
Titus, G. W. (1995). Providing alternative health care: An ancient system for a modern age. Advanced Prac-
tice Nursing Quarterly, 1, 19-28.
Wing, D. M. (1998). A comparison of traditional folk healing concepts with contemporary healing con-
cepts. Journal of Community Health Nursing, 15, 143-154.
Wu, W., Bandilla, E., Ciccone, D. S., Yang, J., Cheng, S. S., Carner, N., et al. (1999). Effects of Qigong on
late-stage complex regional pain syndrome. Altern Ther Health Med, 5, 45-54.
THE MEANING
4
Models and Theories
OF HEALTH
Abstract
Models and theories have been proposed to try to understand, explain, and promote
health. An overview of health promotion as conceptualized within nursing models and the-
ories by Roy, Neuman, King, Orem, Rogers, Parse, Newman, Watson, and Leddy is provided,
followed by a discussion of the biophysiological theory of psychoneuroimmunology, and a dis-
cussion of energy healing theory. The chapter concludes with a description of alternative
approaches to the selection of a model or theory to guide the promotion of health and heal-
ing in nursing practice.
Learning Outcomes
By the end of this chapter the student will be able to:
Describe approaches to health promotion within selected nursing models and theories
Discuss the theory of psychoneuroimmunology as it applies to the promotion of health
Discuss energy theory as it applies to the promotion of health
Identify personal preferences for a model or theories to guide practice
76 Chapter 4 The Meaning of Health: Models and Theories
Nursing Conceptual Models and Theories

Until fairly recently, nursing practice was guided by social, biologic, and medical science
theories. However, in addition to Nightingales perspective of nursing formulated in the mid-
1800s, from the 1950s to the present, nursing scholars have developed models of nursing that
provide bases for the development of nursing theories and nursing knowledge.
A model, as an abstraction of reality, provides a way to visualize reality to simplify think-
ing. For example, an airplane model provides a representation of a real airplane. A concep-
tual model demonstrates one way that various concepts can be interrelated and guides the
development of theories to predict or evaluate consequences of alternative actions. Accord-
ing to Fawcett (2000), each conceptual model provides a systematic structure and a rationale
for scholarly and practical activities. A conceptual model gives direction to the search for
relevant questions about the phenomena of central interest to a discipline and suggests solu-
tions to practical problems (p. 16).
A conceptual model is made up of concepts and their interrelationships. Four concepts are
generally considered central to the discipline of nursing: the person who receives nursing care
(the patient or client); the environment (society); nursing (goals, roles, functions); and
health. All existing conceptual models of nursing describe these four concepts. But the mod-
els vary in the amount of emphasis placed on each concept, as well as in the kinds of theories
that might explain the interrelationships among the individual or family client, the environ-
ment, and nursing, to promote health.
According to Fawcett (2000, p. 18), a theory consists of one or more relatively concrete
and specific concepts that are derived from a conceptual model, and propositions that
describe the concepts and specify relations between two or more of the concepts. Theories are
less broad than conceptual models in level of abstraction and scope. The purposes of theory
may be describing what a phenomenon is, explaining why it occurs, or predicting how it
occurs (2000, p. 18). As a result, theories provide a specific structure for interpreting and/or
modifying a situation or behavior. Theories are proposals about what might be rather than
definitive fact. Multiple theories that are more or less supported by research findings usually
co-exist in a discipline.
This section of the chapter focuses on health promotion implications of nursing models
and theories: Roys adaptation model, Neumans system model, Kings theory of goal attain-
ment, Orems self-care deficit theory, Rogers science of unitary human beings, Parses human
becoming theory, Newmans theory of health as expanding consciousness, Watsons theory of
human caring, and Leddys human energy model.
ROYS ADAPTATION MODEL

Roys adaptation model focuses on the goal of enhancing the process and outcome through
which humans use conscious awareness and choice to create human and environmental inte-
gration. Focal, contextual, and/or residual stimuli from the external or internal environment
provoke a response by the human system. The humans ability to respond positively is repre-
sented by an integrated, compensatory, or compromised adaptation level, which reflect both
challenges and strengths. Individuals cope through regulator and cognator subsystems, while
groups use stabilizer and innovator subsystems to maintain integrated life processes to meet
Nursing Conceptual Models and Theories 77
human needs. Adaptive responses promote the integrity of the human system in terms of the
goals of adaptation: survival, growth, reproduction, mastery, and person and environment
transformations (Roy & Andrews, 1999, p. 44). The behaviors that result can be observed
in four categories or adaptive modes: physiologic-physical, self-concept-group identity, role
function, and interdependence. The goal of nursing is to promote adaptation in each of the
modes which contributes to health, being and becoming an integrated and whole human
being (p. 54). Health promotion activities guided by this model would focus on the identi-
fication of environmental stimuli that require an adaptive response, and on strategies to pro-
mote adaptation within each of the adaptive modes.
In Roys model, the individual, family, group, social organization, or community may be
the unit of analysis and focus of nursing practice. In the initial assessment using Roys adap-
tation model, behaviors of the human adaptive system and the current state of adaptation are
noted first, and then the stimuli that contribute to those behaviors are explored. The analy-
sis of the assessment data leads to the statement of focal, contextual, and residual stimuli for
the individual or for the family as one entity. Nursing actions are focused on increasing,
reducing, or maintaining the stimuli or strengthening adaptive processes in order to maintain
or promote adaptation. In a study of the relationship among social support, parenting stress,
coping style, and psychological distress in parents when caring for children with cancer with
a sample of 246 mothers and 195 fathers, hypotheses derived from the Roy adaptation model
were supported for both mothers and fathers (Yeh, 2003, p. 255). Table 4-1 summarizes
selected concepts in Roys model.
NEUMANS SYSTEMS MODEL

The focus of Neumans systems model is maintenance of dynamic system stability (optimal
wellness), which may be threatened by intrapersonal, interpersonal, or extrapersonal envi-
ronmental stressors (tension producing stimuli). The client may be an individual, a family, a
group, a community, or a social issue. The human is a composite of five harmoniously inter-
acting variables-physiological, psychological, sociocultural, developmental, and spiritual. The
human is protected by a flexible line of defense, and internal lines of resistance that are acti-
vated following invasion of the normal line of defense by environmental stressors. The nor-
mal range of response to the environment, the normal line of defense, is the usual
wellness/stability state (Neuman, 2002, p. 14). When the flexible line of defense is no
longer capable of protecting against an environmental stressor, the stressor breaks through the
normal line of defense, resulting in system destabilization. Health is equated with optimal
system stability (2002, p. 23), with wellness a matter of degree, a point on a continuum run-
ning from the greatest degree of wellness to severe illness or death (2002, p. 3). Nursing
actions are aimed at retaining, attaining, and maintaining optimal client health or wellness,
using the three preventions as interventions to keep the system stable.
Primary prevention is applicable before a person comes in contact with a stressor and
focuses on protecting the client systems normal line of defense by strengthening the flexible
line of defense. Secondary prevention is applicable after the stressor has penetrated the nor-
mal line of defense and includes activities to strengthen the flexible line of defense and resist-
ance to the stressors, and reduce symptoms. Tertiary prevention accompanies reconstitution,
moving in a circular manner toward primary prevention.
Table
4-1
Roys Adaptation Model
Human System A whole with parts that function as a unit (Roy & Andrews,
1999, p. 31).
Environment The world within and around humans (Roy & Andrews, 1999,
p. 51).
Health A state and a process of being and becoming an integrated and

human being (Roy & Andrews, 1999, p. 54). Integrity implies
soundness or an unimpaired condition. Adaptation is a process
of promoting integrity.
Goal of Nursing To promote the health of individuals and society. To promote

adaptation in each of the four modes, thereby contributing to
health, quality of life, or dying with dignity.
Nursing Process Assess adaptiveness of behaviors in the four modes and the
stimuli influencing ineffective behaviors. State nursing diag-
noses, determine goals and interventions, and evaluate as
behavior changes.
In the Neuman systems model, health promotion is explicitly identified as a component

of the primary prevention-as-intervention modality (Neuman & Fawcett, 2002, p. 29), but
also works with both secondary and tertiary prevention to prevent recidivism and to promote
optimal wellness (p. 29). The nursing process begins with the identification and evaluation
of potential or actual stressors that pose a threat to the stability of the client system, as well
as evaluation of lines of defense and resistance. Goals are negotiated and outcomes are eval-
uated with the client. The major goal for nursing is to reduce stressor impact, whether actual
or potential, and to increase client resistance (p. 29) by augmenting existing strengths
related to the flexible line of defense. No explicit middle-range theories have yet been
derived from the Neuman systems model (Gigliotti, 2003, p. 201). Table 4-2 summarizes
selected concepts in Neumans model.
KINGS GENERAL SYSTEMS FRAMEWORK AND THEORY OF

GOAL ATTAINMENT
The emphasis in Kings general systems framework is on interactions between personal,
interpersonal, and social systems which influence behavior. Each individual is a personal sys-
tem, characterized by the concepts of self, body image, growth and development, perception,
learning, time, and personal space. The interpersonal system (which includes family), com-
Table
4-2
Neumans Systems Model
Client System A composite of physiological, psychological, sociocultural,

developmental, and spiritual variables in interaction with the
internal and external environment.
Environment All internal and external factors or influences surrounding the

client system, including the created environment, a protective,
perceptive coping shield developed unconsciously by the
client.
Health A continuum of wellness to illness, dynamic in nature. Optimal

wellness, or stability, indicates that total system needs are
being met.
.
Goal of Nursing To assist clients to retain, attain, or maintain optimal system
stability (Neuman, 1996, p. 69).
Nursing Process Nursing diagnoses and goals. Primary, secondary, or tertiary re-
vention as intervention.
posed of two or more interacting individuals, is characterized by the concepts of verbal and
nonverbal communication, interaction, stress, role, and transaction. Social systems are groups
that form in a community within a society and are characterized by the concepts of decision
making, organization, power, authority, and status (King, 1995). The personal, interpersonal,
and social systems are the environments within which human beings grow, develop, and per-
form daily activities (King, 1995, p. 18).
Health is dynamic life experiences of a human being, which implies continuous adjust-
ment to stressors in the internal and external environment through optimum use of ones
resources to achieve maximum potential for daily living (King, 1981, p. 5). Illness is a devi-
ation from normal (1981, p. 5). The goal of nursing is to help individuals and groups attain,
maintain, and restore health (King, 1971, p. 84).
The theory of goal attainment includes the concepts of self, perception, communication,
interaction, transaction, growth and development, stress, time, personal space, and role from
the Framework. King (1995, p. 27) describes a nursing situation as the immediate environ-
ment, spatial and temporal reality, in which two individuals establish a relationship to cope
with events in the situation. Transaction is the values element of the interaction, while com-
munication is the informational element. Through an interaction-transaction process,
nurses interact with clients purposefully to mutually set goals and explore and agree on the
means to attain the goals (King, 1995, p. 28). The outcome is goal attainment. The theory
Table
4-3
Kings Theory of Goal Attainment
Human Being A personal system that interacts with interpersonal and social
systems.
Environment A context within which human beings grow, develop, and per-
form daily activities (King, 1995, p. 18).
Health Dynamic life experiences of a human being, which implies

continuous adjustment to stressors in the internal and external
environment through optimum use of ones resources to
achieve maximum potential for daily living (King, 1981, p. 5).
Also, an ability to function in social roles (p. 143). Illness is a
deviation from normal.
Goal of Nursing To help individuals and groups attain, maintain, and restore
health (King, 1971, p. 84).
Nursing Process Assess perception, communication, and interaction of nurse

and client. Agree on goals and means to attain goals. Make
transactions and evaluate if goal was attained.
of goal attainment proposes that health promotion goals are more likely to be attained when
there is mutual goal setting between nurse and client within the interaction-transaction
process. Table 4-3 summarizes selected concepts in Kings theory.
OREMS SELF-CARE DEFICIT THEORY

Self-care is action by persons who have developed the capability to take care of themselves
within their environment (self-care agency). Self-care contributes to human structural
integrity, human functioning, and human development (Orem, 1995, p. 103). There are
three reasons for doing actions that constitute self-care: universal, developmental, and
health-deviation self-care requisites. The self-care actions to be performed that meet known
self-care requisites are the therapeutic self-care demand. When self-care agency is not ade-
quate to meet the therapeutic self-care demand, there is a self-care deficit. The goal of nurs-
ing is to help persons (through nursing systems) to meet therapeutic self-care demands when
they are unable to provide for their own self-care requisites.
Orem (p. 129) suggests that universal self-care and developmental self-care, at the primary
level of prevention, is a requirement of each individual throughout life. Individuals might
also have health promotion needs at the secondary and tertiary levels of prevention, such as
Table
4-4
Orems Self-Care Deficit Theory
Patient A person under the care of a nurse.
Health State characterized by soundness or wholeness of developed

human structures and of bodily and mental functioning (Orem,
1995, p. 101).
Environment Physical, chemical, biological, and social contexts within

which human beings exist.
Goal of Nursing To help patients to meet their self-care needs.
Nursing Process Actions to overcome or prevent the development of a self-care

deficit or provide therapeutic self-care for a patient who is
unable to do so.
prevention of complicating diseases and adverse effects of specific diseases and prolonged dis-
ability, and rehabilitation in the event of disfigurement and disability (p. 131). Nursing
systems and helping actions are performed for or with the client. Table 4-4 summarizes
selected concepts in Orems theory.
ROGERS SCIENCE OF UNITARY HUMAN BEINGS

The essence of Rogers model is the open, continuous, and mutual process of the unitary
energy field that is the human being with the energy field that is the environment (principle
of integrality). The unique pattern of energy fields evolves unpredictably in waves that
change from lower frequency with longer patterns to higher frequency with shorter wave pat-
terns (principle of resonancy), continually creating more diverse and complex field pattern
(principle of helicy).
Health is an indication of field patterning, so an individual or his or her families health
potential can be promoted through deliberate nursing patterning of the environmental field.
To promote health potential, the nurse would first appraise manifest behavior patterns of the
client, including lifestyle parameters, rhythms and flow of energy, and manifestations of pat-
terning. Then, empowering both nurse and client, accepting diversity as the norm, and view-
ing change as positive, the nurse would become attuned to patterning and use wave
modalities for mutual deliberative patterning (e.g. light, color, music, and movement). Table
4-5 summarizes selected concepts in Rogers model.
Table
4-5
Rogers Science of Unitary Human Beings
Human Being Unitary energy field with a unique pattern.
Environment Energy field in mutual process with the human being.
Health An index of field patterning (Malinski, 1986, p. 27). Health

and illness are not separate states, good or bad, nor in a linear
relationship.
Goal of Nursing To promote human health and well-being (Rogers, 1988,

p. 100).
Nursing Process Mutual patterning to enhance health potential. Health pattern-

ing is providing knowledgeable caring to assist clients in actu-
alizing potentials for well being through knowing participation
in change (Malinski, 1986, p. 25).
PARSES HUMAN BECOMING THEORY

The emphasis in Parses theory is on the meaning and values that influence a persons
active choices of behavior. The person is defined as an open being, more than and different
from the sum of parts in mutual simultaneous interchange with the environment who chooses
from options and bears responsibility for choices (Parse, 1987, p. 160). Health is quality of
life and a constantly changing process of becoming that incorporates values. Because it is not
a state, health cannot be contrasted with disease. The human becoming nurses goal is to be
truly present with people as they enhance their quality of life (Parse, 1998, p. 69).
Parse (1987, p. 163) incorporates Rogers principles with concepts from existential phe-
nomenology into three principles. Meaning is structured multidimensionally as humans and
the environment together create (cocreate) reality through the language of valuing and
imaging. In other words, the meaning of human beliefs and values is developed and demon-
strated through words and movement. Rhythmicity of patterns of relating is cocreated
through living the paradoxical unity of revealing-concealing, enabling-limiting, and con-
necting-separating. In other words, human patterns in relating to others are derived from
multiple choices and involve rhythmical processes of moving closer to and away from others.
Contranscendence with possibilities is powering unique ways of originating in the process of
transforming. In other words, it involves the processes of distancing and moving closer in
interrelationships that provide the force for change and creativity. Through presence, a non-
routinized, unconditional loving way of being (Parse, 1996, p. 57), the nurse interacts with
individuals and families to illuminate meaning, synchronize rhythms, and mobilize transcen-
dence. Parse proposes that a discussion of lived experiences, in true presence between client
Table
4-6
Parses Human Becoming Theory
Person An open being, more than and different from the sum of parts.
Environment In mutual process with the person.
Health The human beings way of living day-to-day, a personal com-

mitment, a process originating with the person, a process of
becoming. Emphasizes the meaning and values that influence a
persons active choices of behavior.
Goal of Nursing Nursing aims to affect the quality of life as perceived by the
person and the family (Parse, 1987, p. 167).
Nursing Process Focus is on the meaning constructed by the person. Uses true
presence to explicate meaning, dwell with and synchronize
rhythms, and move beyond in transforming.
and nurse (dialogical engagement), can shed light on the meaning of health for the client,
and lead to moving beyond with changed health patterns. In three studies on feeling very
tired, Bunkers (2003, p. 342) commented on the distinctiveness of each study and the ebb
and flow of rhythmical patterns of human-universe processes. Table 4-6 summarizes selected
concepts in Parses theory.
NEWMANS THEORY OF HEALTH AS EXPANDING CONSCIOUSNESS

The focus of Newmans theory is consciousness, which is defined as the information of the
system: the capacity of the system to interact with the environment (Newman, 1994, p. 33).
Newmans theory incorporates Rogers concept of a unitary person as a center of constantly
changing patterning of energy. The person does not possess consciousness, the person is con-
sciousness. The total pattern of person-environment can be viewed as a network of con-
sciousness (Newman, 1986, p. 33) that is expanding toward higher levels. Pattern has three
dimensions: movement-space-time, rhythm, and diversity. The expansion of consciousness is
health, which encompasses both disease and nondisease. Disease is a manifestation of
health. The goal of nursing is not to make people well, or to prevent their getting sick, but
to assist people to recognize the power that is within them to move to higher levels of con-
sciousness (Newman, 1994, p. xv). Nurses do not try to change the clients pattern, but rec-
ognize it as information that depicts the whole and relate to it as it unfolds (p. 13).
Using this theory for health promotion, the nurse would facilitate the process of evolving
to higher levels of consciousness by rhythmic connecting of the nurse with the client in an
authentic way for the purpose of illuminating the pattern and discovering the new rules of a
higher level of organization (Newman, 1990, p. 40). Within a qualitative interview process,
Table
4-7
Newmans Theory of Health as Expanding Consciousness
Human Being Unitary and continuous with the undivided wholeness of the
universe (Newman, 1994, p. 83).
Environment Undivided wholeness of the universe (Newman, 1994, p. 83).
Health Manifest health, encompassing disease and nondisease, can

be regarded as the explication of the underlying pattern of per-
son-environment (Newman, 1994, p. 11). The patterns of
interaction of person-environment constitute health. . . . Health
is the expansion of consciousness (1986, pp. 3, 18).
Goal of Nursing The pattern of the whole, health as the pattern of the evolving
whole, with caring as a moral imperative (Newman, 1994, p.
xix). Nursing is caring in the human health experience
p. 139).
Nursing Process The process is practice driven and uses hermeneutic and
dialectic approaches in partnership with the client.
participants tell their stories, while the nurse acts as an active listener. As person-environ-
ment patterns in the data emerge over time, they are diagramed and interpreted. The intent
is to foster recognition of the emerging pattern of the whole that is health. Although this the-
ory was developed for use with individuals, it is also applicable to family health promotion.
Table 4-7 summarizes selected concepts in Newmans theory.
WATSONS HUMAN SCIENCE AND THEORY OF TRANSPERSONAL CARING

Watsons theory focuses primarily on the centrality of human caring and on the caring-
to-caring transpersonal relationship and its healing potential (Watson, 1996, p. 141) for the
nurse as a caregiver and the client who receives care. A transpersonal caring relationship is
a human-to-human connectedness (Watson, 1989, p. 131) that is reflected in caring occa-
sions or moments. Transpersonal caring is actualized and grounded through 10 carative
factors (Watson, 1996, p. 156) as follows:
1. Forming a humanistic-altruistic system of values.
2. Enabling and sustaining faith-hope.
3. Being sensitive to self and others.
4. Developing a helping-trusting, caring relationship (seeking transpersonal connection).
5. Promoting and accepting the expression of positive and negative feelings and emotions.
Table
4-8
Watsons Human Caring Theory
Human A unity of mind/body/spirit/nature (Watson, 1996, p. 147).
Environment A field of connectedness at all levels (Watson, 1996, p. 147).
Health (Healing) Manifested by harmony, wholeness, and comfort.
Goal of Nursing Nursing, as a profession, exists in order to sustain caring, heal-

ing, and health (Watson, 1996, p. 146). The ultimate goal can
be stated as protection, enhancement, and preservation of
human dignity and humanity (p. 148). The emphasis is on
helping other(s) to gain more self-knowledge, self-control, and
self-healing potential.
Nursing Process Reciprocal transpersonal relationship in caring moments guid-

ed by carative factors.
6. Engaging in creative, individualized, problem-solving caring processes.

7. Promoting transpersonal teaching-learning.
8. Attending to supportive, protective, and/or corrective mental, physical, societal, and
spiritual environments.
9. Assisting with gratification of basic human needs while preserving human dignity and
wholeness.
10. Allowing for, and being open to, existential-phenomenological and spiritual dimen-
sions of caring and healing.
Watson (1996, p. 147) views the human as a unity of mind/body/spirit/nature. There is

a field of connectedness between and among persons and environments at all levels, into
infinity and into the universal or cosmic level of existence (1996, p. 147). The purpose of
nursing is to expand human consciousness, transcend the moment, and potentiate healing
and a sense of well-beinga sense of being reintegrated, more connected, more whole (p.
160). The theory emphasizes healing potential for both the one who is caring and the one
who is being cared for. Both the individual or family client and the nurse have human free-
dom, choice, and responsibility. Human caring is viewed as the moral ideal of nursing, with a
strong emphasis on human dignity, caring-healing consciousness, and the potential for trans-
formation of self. Table 4-8 summarizes selected concepts in Watsons theory factors.
Watsons latest writings (1996) discuss healing rather than health. By focusing on the car-
ative factors within a transpersonal relationship, the nurse and client can promote healing
and a sense of well-being through the use of caring competencies such as therapeutic pres-
ence, intuition, and active listening; caring modalities such as therapeutic touch, music, and
guided imagery; and caring strategies such as ethics, aesthetics, and caring for the caregiver.
Over 50 doctoral dissertations and masters theses based on Watsons theory have been
conducted. In a review of 40 published studies, Smith (2004) determined that one strength
of published research is a recent focus on the relationship between caring and healing through
evaluation of theory-guided practice models. One weakness is that many of the published
studies have weak theoretical-empirical linkages. One middle-range theory (Swanson) and
several theory-guided practice models have been developed (Smith, 2004).
LEDDYS HUMAN ENERGY MODEL

Influenced by Rogers science of unitary human beings, Leddy (2004) views the human
being (person) as a unitary energy field that is open to and continuously interacting with
an environmental energy field. Self-organization distinguishes the human energy field from
the environmental field with which it is inseparably intermingled. Self-organization is a syn-
thesis of continuity and change, that provides identity while the human evolves toward a
sense of integrity, meaning and purpose in living (Leddy, 1998, p. 192). The human being
also possesses awareness, which makes possible intention, the construction of self-identity and
meaning, and the ability to influence change through choice.
The environment is viewed as dynamic, changing through continuous transformation of
energy with matter and information. These transformations occur as a web of connectedness
in relationships within the self and with the environment, including other humans and/or an
ultimate other. Change is partially unpredictable, but is also influenced by inherent order
in the universe, history, pattern and choice.
Health is the pattern of the whole. This changing pattern of harmony/dissonance varies
over time in quality and intensity. Knowledge-based consciousness in a goal directed rela-
tionship with an individual or family client is the basis for nursing, during which the nurse is
a knowledgeable, concerned facilitator, and the individual or family client is responsible for
choices that influence health and healing. The facilitation of harmonious health patterning
is accomplished through health pattern appraisal and subsequent energetic interventions (see
the Practice Theory of Energy later in this chapter). Table 4-9 summarizes selected concepts
in Leddys model.
The models and theories discussed previously in this chapter have been developed within
nursing, with contributions from the biological and social sciences. Psychoneuroimmunology
utilizes biophysiological concepts to address health and its promotion.
Psychoneuroimmunology
Can thought, emotion, and behavior directly enhance immune function and thereby pre-
vent the onset or alter the course of diseases involving immunity (Hafen et al., 1996)? These
questions are addressed by psychoneuroimmunology (PNI), the study of the mechanisms of
Psychoneuroimmunology 87
Table
4-9
Leddys Human Energy Model
Human Being A unitary, self-organized energy matter and information field.
Environment A dynamic, ordered, connected web in continuous transforma-

tion of energy, matter, and information with the human being.
Health The pattern of the whole. This pattern is rhythmic, varying in

quality and intensity over time. Health is characterized by a
changing pattern of harmony and dissonance.
Goal of Nursing Knowledge-based awareness in a goal-directed relationship

with the client is the basis for nursing. A nurse-client relation-
ship is a commitment characterized by intentionality, authen-
ticity, trust, respect, and genuine sense of connection. The nurse
is a knowledgeable, concerned facilitator. The client is respon-
sible for choices that influence health and healing.
Nursing Process The facilitation of harmonious health patterning is accom-

plished through health pattern appraisal and subsequent ener-
getic interventions.
bidirectional communication between the neuroendocrine and immune systems (Zeller et

al., 1996, p. 657).
Consistent with the disease perspective, medical science considers the body to be a system
composed of separate and interacting subsystems. For some time, it has been recognized that the
nervous and endocrine subsystems interact to coordinate coping and adaptation efforts of the
entire system when stressors affect the body. However, since the 1980s, increasing evidence sup-
ports the expansion of this coordinating framework to include the immune system. The empha-
sis is on the variety of ways in which information from subjective experience, emotions, memory,
and cognition is shared throughout the total system to facilitate resistance and healing.
Zeller, McCain, and Swanson (1996) describe four pathways for neuroendocrine-immune
communication, as depicted in Figure 4-1.
Path A. Direct autonomic (sympathetic, parasympathetic) neural innervation via neu-
rotransmitters (catecholamines, opioid peptides, dopamine) and neuropeptide messen-
gers (vasoactive intestinal polypeptide [VIP], B-endorphin, corticotropin [ACTH] on
the surface of immune system tissues including lymphocytes).
Psychobiological
Stimuli
CNS
Opioid peptides
Hypothalamus
and receptors
CRF Autonomic
nervous system
Path C
Path A
Pituitary Path B
Endorphins ACTH
Adrenal Cortex Adrenal Medulla
Glucocorticoids Catecholamines
encephalins
IMMUNE
SYSTEM
Path D
IL-1 Beta-endorphin
ACTH
Figure 4-1. Psychoneuroimmunology interaction pathways. (reprinted from Zeller, J. M., McCain,
N. L., & Swanson, B. (1996). Psychoimmunology: An emerging framework for nursing research. J
Adv Nurs, 23, 658. Used with permission of Blackwell Scientific Ltd.).
Psychoneuroimmunology 89
Path B. Sympathetic-adrenomedullary system activation results in release of cate-

cholamines and encephalins, which circulate by way of the blood to immune system tissues.
Path C. Hypothalamic-pituitary-adrenocortical activation result in corticotropin
(ACTH), endorphins, and glucocorticoids that have immunopotentiating and
immunosuppressive effects.
Path D. Immune-derived products (cytokines), such as interleukin-1 (IL-1), communi-
cate directly and indirectly with the brain.
The immune system not only recognizes foreign substances and arranges for their destruc-
tion and removal, but also functions as a diffuse sense organ distributed throughout the body
(Maier & Watkins, 1998). As a result, social and physical conditions, emotional states, neu-
ropeptide interactions, and immune surveillance capabilities are inseparable aspects of a
seamless organismic response (Pert et al., 1998, p. 35). While acute stress associated with
activation of the sympathetic nervous system (fight or flight) often causes increases in NK
cell activity, chronic, inescapable, or unpredictable stress that yields a sense of helplessness
and habitual repression of strong emotions results in chronically high levels of endogenous
opioid peptides, which in turn are responsible for immune deficits that reduce resistance to
infections and neoplastic disease (pp. 34-35).
Both brief and longer-term stressors are associated with declines in functional aspects of
immunity, and both the duration and intensity of stressors are related to the breath and mag-
nitude of immune changes (Kiecolt-Glaser, McGuire, Robles, & Glaser, 2002). However, the
ability to unwind after stressful encounters influences the total burden. In general, the nar-
rower the scope of a behavioral intervention and the shorter its time course, the smaller and
less enduring the impact.
Altering subjective feelings of well-being through various interventions such as relaxation
training, hypnosis, exercise, classical conditioning, self-disclosure, cognitive-behavioral
interventions, and support groups may enhance immune function (Kiecolt-Glaser & Glaser,
1992; Micozzi, 2001). In addition, a series of therapeutic touch treatments was associated
with immune changes in both practitioners and recipients (Quinn & Strelkauskas, 1993).
However, it may not be possible to enhance immune function above normal levels.
An association between personal relationships and immune function has been supported by a
number of studies. Distress and poorer personal relationships appear to be associated with the
down-regulation of immunity (Kiecolt-Glaser & Glaser, 1992, p. 574), while social support may
mitigate the harmful effects of stressful life events (Houldin et al., 1991, p. 14). However,
although the preliminary evidence is promising, it is not clear to what extent positive immuno-
logical changes translate into any concrete... alterations in the incidence, severity, or duration of
infectious or malignant disease (Kiecolt-Glaser & Glaser, 1992, p. 569). In addition, minimal
research has investigated relationships between enhanced immunity and the promotion of health.
Booth and Ashbridge (1993, p. 19) suggest that metaphorically, we might profitably con-
sider the immune system less as a soldier and more as a gardener. Evidence from psychoneu-
roimmunology studies could provide a bridge between the disease and person perspectives of
health. There is now increasing scientific support for nursing interventions that enhance sub-
jective feelings of well-being as a way to enhance the environment within which health can
grow and flourish. Some of these approaches are discussed in Chapters 12 through 16.
The concept of energy is integral to several nursing models (e.g., Rogers and Leddy). The
next section will provide an overview of energy healing theory derived from Eastern healing
traditions.
Energy Healing Theory

According to Slater (1997, p. 52), energetic healing occurs through the medium of energy,
a metaphoric term used to mean healing that occurs at the quantum and electromagnetic
levels of a person, plant, or animal. All matter is energy. Matter and energy are now known
to be interchangeable and interconvertible (Gerber, 1988, p. 58). Energy varies in quantity
and quality (vibration), has polarity (yin and yang), and is arranged in specific patterns.
Energy can be viewed as a phenomenon, an actuality or thing with an inherent ability to
change, or as part of a process resulting in change. In the idea of energy as part of a process,
the universe is portrayed as mechanistic; things are viewed as particulate, and change comes
about from efficient causes. In this view, energy is gained, lost, transferred, or transmitted, and
change is a consequence of cause and effect. In the idea of energy as a phenomenon the uni-
verse is portrayed as dynamic; all things are viewed as forming an intricate whole, and change
emerges from the whole. In this view energy isnt exchanged, transmitted, lost, or gained;
instead, it is transforming or manifesting itself eternally and in unique ways (Todaro-
Franceschi, 1999, p. 30).
According to Kaptchuk (2001), energy is known by different names in different health
belief systems.
Homeopathy connects with the spiritual vital force
Chiropractic calls it innate or universal intelligence
Psychic healing manipulates auric, psi, or psionic powers
Acupuncture utilizes qi
Ayurveda is in touch with prana
Naturopaths invoke the vis medicatrix naturae
Energy healing, also known as the laying on of hands, or biofield therapeutics, occurs in
the human energy field surrounding, supporting, and interpenetrating the human body.
Energy healing is a systematic, purposeful intervention which uses focused intention, hand
contact, and aligning with the universal energy field (Starn, 1998, pp. 209-210). A field is
described as a domain of influence, presumed to exist in physical reality, that cannot be
observed directly but that is inferred through its effects (Dossey, 2000, p. 112). For example,
a magnetic field around a bar magnet cannot actually be seen, but it is known that a field
exists because of the pattern demonstrated by iron filings.
ANATOMY OF THE BIOFIELD

Gerber (1988) and Kunz and Peper (1982) provide an extensive description of the anatomy
of human energy fields as follows:
Energy Healing Theory 91
The human organism is a series of interacting multidimensional [interpenetrating, inter-

active] energy fields (Gerber, 1988, p. 91).
The energetic network... is organized and nourished by subtle energetic systems which
coordinate the life-force with the body (Gerber, 1988, p. 43).
The physical body is actually a complex network of interwoven energy fields... the cellu-
lar matrix of the physical body can be seen as a complex energetic interference pattern
(Gerber, 1988, p. 60).
The physical system (nerve, muscle, flesh, and bones) is only one of several systems which
are in dynamic equilibrium.... All of these systems are physically superimposed upon one
another in the very same space (Gerber, 1988, p. 119). Bodies of higher energetic fre-
quencies are interconnected and in dynamic equilibrium with the physical body (Gerber,
1988, p. 120). The difference between physical matter and etheric matter is only a differ-
ence of frequency (Gerber, 1988, p. 120).
The higher the frequency of matter, the less dense, or more subtle the matter (Gerber,
1988, p. 69).
The etheric body (vital field), an energetic form that underlies and energizes all aspects of
the physical body, extends 1 to 6 inches from the body or 2 inches on the average (Kunz
& Peper, 1982).
The astral [or emotional] body... is a subtle substance of even higher energetic frequen-
cies than etheric matter (Kunz & Peper, 1982, p. 136), and extends about 18 to 48 inches
beyond the body. Through thoughts and intention, the individual emotional field can be
stretched to considerable distances, such as 10 to 15 feet.... Relaxation tends to expand
the field while anxiety tends to constrict the field (pp. 398, 400). Figure 4-2 is a depiction
of the human energy fields.
The mental, causal, and astral subtle energetic bodies exist beyond the etheric, in what
might be referred to as a nonphysical or nonspace, nontime level of existence. The mental
body is concerned with the creation and transmission of concrete thoughts and ideas to the
brain. The next highest level of subtle energetic substance from the mental body is the
causal body (intuitional field), which is involved with the area of abstract ideas and con-
cepts. . . . Causal consciousness deals with the essence of a subject while the mental level
studies the subjects details (Gerber, 1988, pp. 154-55). The astral body (emotional field),
through the astral chakras, provides a subtle-energy connection whereby a persons emo-
tional state can disturb or enhance health. . . . The astral body also functions as a vehicle of
consciousness which can exist separately, yet connected to, the physical body (Gerber,
1988, pp. 137, 139).
The chi dynamic force of energy is constantly circulating within the body in 12 well-defined
channels, or physical ducts called meridians, which exist as a series of points following line-like
patterns. Energy always flows from high to low potential (Gerber, 1988). The meridian system
forms an interface between the etheric and the physical body. The meridian system is the first
physical link established between the etheric body and the developing physical body.... Illness is
caused by energetic imbalance within the meridians supplying the nutritive chi energies to the
organs of the body (Gerber, 1988, pp. 126-127).
6th Chakra 7th Chakra

Celestial love Divine mind, cere-
connection to angels, brum, pituitary, upper
spirits, God, Buddha, brain, left eye
ancestors, right eye,
pineal gland, lower
brain stem, seeing and
carrying out purpose
5th Chakra
Divine will, hearing
and speaking, mouth,
ears, thyroid
4th Chakra 3rd Chakra

I-thou relationships Mental thoughts, concepts
with others, heart, of health and power
respiratory systems relationships, digestive
organsstomach, spleen,
pancreas, liver, diaphragm
1st Chakra
2nd Chakra Will to live, grounding
Emotions, self-esteem, connection to earth,
sensuality, sexuality, culture, family values,
pelvic and genito- deep beliefs, immune
urinary organs system and adrenals
Levels of Field
1. Physical (structured)
2. Emotional (unstructured)
3. Mental (structured)
4. Heart (I-thou) (unstructured)
5. Divine will (structured)
6. Divine love (unstructured)
7. Divine mind (structured)
Figure 4-2. The human energy field (reprinted with permission from Stern, J. K. (1998). The path to
becoming and energy healer. Nurse Practitioner Forum, 9, 211. W. B. Saunders).
Energy Healing Theory 93
Special energy centers known as chakras exist within the etheric body. Chakras (Sanskrit
meaning wheels), resemble whirling vortices of subtle energies, that take in higher energies
and transmute them to a utilizable form within the human structure (Gerber, 1988, p. 128).
There are at least seven major chakras associated with the physical body, in a vertical line ascend-
ing from the base of the spine to the head. These are the root chakra (I) near the coccyx, the
sacral chakra (II) located either just below the umbilicus or near the spleen, the solar plexus
chakra (III) in the upper middle abdomen below the tip of the sternum, the heart chakra (IV) in
the midsternal region directly over the heart and the thymus, the throat chakra (V) directly over
the thyroid gland and larynx, the brow chakra (VI) in the region of the mid-forehead slightly
above the bridge of the nose, and the crown chakra (VII) located on the top of the head. Each
is associated with a major nerve plexus and a major endocrine gland (Gerber, 1988).
Because chakras separate vibrations into various frequencies (not the same as frequencies
of visible light and audible sound), a specific color, tone, function, organ, and nervous struc-
ture is associated with each chakra. Chakras seem to have [the more] moment-to-moment
responsibility of receiving, processing, transforming, and transmitting energy, information,
and emotions that may be stored in the aura (Slater, 1995, pp. 215, 218, 221). The specific
frequency of a particular chakra may modulate a particular emotion, need, drive, and/or
organ (Slater, 1997, p. 54).
Connecting the chakras to each other and to portions of the physical-cellular structure are up
to 72,000 fine subtle-energetic channels, known as nadis, that are interwoven with the physical
nervous system (Gerber, 1988). Nadis, or channels of electromagnetic energy, subdivide finally
to the cellular level, supporting the concept that healing can affect the cellular level of the phys-
ical body (Starn, 1998, pp. 211-212). It is assumed that there is a special alignment between
the major chakras, glands, and nerve plexuses that is necessary for optimal human functioning
(Gerber, 1988, p. 131).
MECHANISM OF ACTION OF ENERGETIC HEALING

There are two alternative beliefs about causation in energetic healing (Berman & Larson,
1994). One belief is that the healing force comes from a source other than the practitioner,
such as God, the cosmos, or another supernatural entity. For example, reiki, qigong, and
prayer, are based on channeling of a spiritual energy that has innate intelligence or logic and
knows where and to what extent it is required. A second belief is that a human biofield
directed, modified, or amplified in some fashion by the practitioneris the operative mech-
anism. For example, music, color therapy, and therapeutic touch pattern the vibrations of the
environmental energy field for healing purposes. However, as the biofield is metaphysical
(outside the four observable dimensions of space and time), these causal beliefs are currently
untestable.
A PRACTICE THEORY OF ENERGY INTERVENTION

The practice theory of energy intervention is one of three theories that have been derived
from Leddys human energy model. This theory is based on the assumption that the universe is
composed of an essence that has a dual nature: particle and wave. Universal essence has three
aspects that are not differentiated in reality: matter is the potential for structure and identity,
information is the potential for coordination and pattern, and energy is the potential for
process, movement, and change. Universal essence creates fields of mutually transformable
manifestations such as electromagnetism, light, sound, heat, and gravitation. These fields are
open and in mutual process between living beings and the environment. Through magnetic
emissions from a healers hands, vibrational coupling between similar wave frequencies can
be induced, resulting in resonance (increased wave amplitude and intensity) and entrainment
(harmony of oscillation). Conscious focusing of intention is also suggested as a mechanism to
increase frequency (and therefore intensity), complexity, and harmony of energy (Leddy,
2003).
The theory proposes that nursing interventions to facilitate energy flow, and resonant and
harmonious pattern of both client and nurse are accomplished through energetic patterning
of human-environmental fields. The six proposed domains of energetic patterning are:
1. Connecting. Promotes harmony of energetic patterning.
2. Coursing. Re-establishes free movement of energy.
3. Conveying. Fosters redirection of energy away from excess to depleted areas.
4. Converting. Transforms and augments energy resources.
5. Conserving. Reduces energy depletion.
6. Clearing. Releases energy tied to old patterns.
A number of types of interventions are consistent with this theory, including those found
in Section IV of this book. Table 4-10 presents examples of noninvasive therapies that are
appropriate for each of the domains of energetic patterning.
Using Models/Theories to Guide Practice

Nursing theory provides the language, concepts, and worldview to reflect on nursing care
(Frisch, 2001, p. 4). In selecting a model or theory to guide practice, the nurse should first be
aware of his or her philosophical or worldview beliefs. According to Fawcett (2000), differ-
ent worldviews lead to different conceptualizations of human beings, the environment, health
and nursing, and the nature of the relations between them. After the identification of a
worldview perspective that is consistent with philosophical beliefs, several different
approaches might be used to select model(s) or theories for practice.
In the coherence approach there is a commitment to one specific model based on beliefs
about the nature of metaparadigm concepts or beliefs about how knowledge should be devel-
oped. For example, a nurse who truly believes in the person perspective might select Rogers
model and an energy theory to guide nursing care. Commitment to one model, in this case
Rogers model, is the guideline. Several theories may be consistent with the chosen model.
In the integrative approach, theories and strategies from diverse sources, models and ori-
entations are interwoven. The nurse integrates these to develop a personal approach. For
example, Mantle (2001) suggests that each nurse develops a unique and constantly evolving
model of nursing. The integrative approach has some philosophical similarities with the prag-
matic or eclectic approach in which those knowledge claims and theories that are considered
Using Models/Theories to Guide Practice 95
Table
4-10 Selected Noninvasive Therapies for Each Domain of
Energetic Patterning
CLEARING COURSING
Music/color therapy Massage
Acupressure Yoga
Postural movement Polarity therapy
Aromatherapy Exercise
CONVEYING CONVERTING
Acupressure Nutrition
Reflexology Herbal therapy
Music/color therapy
Exercise
CONSERVING CONNECTING
Relaxation/meditation Guided imagery
Biofeedback Reiki
Sleep and rest Therapeutic touch
Breathing Aromatherapy
Herbal therapy Music/color therapy
to be most capable or useful in solving nursing problems are selected. In the reflective
approach, new theories and empirical approaches are adopted based on congruence with
reflections by the nurse and with the client. The view of situation or meanings of the prob-
lem drive the choice.
It should be clear that there is no one best model or theory, just as there is no correct
model or theory for use by every nurse in every situation. Models and theories are alternative
viewpoints, each with potential strengths and weaknesses. It is suggested that students first
select the perspective (disease or person) that seems the more consistent with their beliefs
about the nature of the person, environment, health, and nursing. Then, the dominant mod-
els/theories within that perspective should be explored. Ideally, one or more model or theory
will seem consistent (coherence approach) with the students beliefs, or potentially useful
(pragmatic or eclectic approach) to guide practice. Some students may try to combine ele-
ments (integrative approach) of different models or theories (within the same worldview per-
spective of course) to develop their own personal model. Some students may feel that it is
necessary to develop their own theory or model to reflect their beliefs. Regardless of how the
particular model or theory is selected, it then becomes a framework that guides assessment,
planning, and facilitation of health and healing with the client.
Chapter Key Points

Models and theories within the disease and person perspectives provide alternative
frameworks to guide health promotion and healing nursing practice and science.
Nursing models and theories are needed to focus on enhancing the awareness, mean-
ing, and potential of families health and healing patterns and experiences.
Roy, Neuman, King, Orem, Rogers, Parse, Newman, Watson, and Leddy have devel-
oped models/theories that provide structures for understanding how nursing can pro-
mote the health of individuals or families within the environment.
Most nursing and non-nursing models and theories emphasize the individual in the con-
text of family and focus on the diagnosis and treatment of health concerns (or deviations
from norms) with the overall goal being the restoration of balance (Hartrick, 1998).
Given that the disease and person perspectives are distinct, one of the two perspectives
will seem more consistent with the nurses beliefs or useful to guide practice.
Once a choice of perspective has been made, a model or theory that seems most con-
sistent with the individuals beliefs, or useful to guide practice is selected.
In-depth study of the selected model or theory will be needed before it will be useful as
a framework to guide practice.
References
ton, DC: US Government Printing Office.
Booth, R. J., & Ashbridge, K. R. (1993). A fresh look at the relationship between the psyche and immune
system. Theolological coherence and harmony of purpose. Advances: The Journal of Mind-Body
Health, 9(2), 4-28.
Bunkers, S. S. (2003). Comparison of three Parse method studies on feeling very tired. Nursing Science
Quarterly, 16, 340-344.
Dossey, L. (2000). Creativity: On intelligence, insight, and the cosmic soup. Altern Ther Health Med, 6, 12-
17, 108-117.
Fawcett, J. (2000). Analysis and evaluation of contemporary nursing knowledge: Nursing models and theories.
Philadelphia: Davis.
Frisch, N. C. (2001, May 31). Nursing as a context for alternative/complementary modalities. Online Jour-
nal of Issues in Nursing, 6(2), manuscript 2. Retrieved March 19, 2002, from http://www.nursing-
world.org/ojin/topic15/tpc15_2.htm
Gerber, R. (1988). Vibrational medicine. Santa Fe, NM: Bear & Company.
References 97
Gigliotti, E. (2003). The Neuman systems model institute: Testing middle-range theories. Nursing Science
Quarterly, 16, 201-206.
Hafen, B. Q., Karren, K. J., Frandsen, K. J., & Smith, N. L. (1996). Mind body health. Boston: Allyn and Bacon.
Hartrick, G. (1998). Developing health promoting practices: A transformative process. Nurs Outlook, 46,
219-225.
Houldin, A. D., Lev, E., Prystowsky, M. B., Redei, E., & Lowery, B. J. (1991). Psychoneuroimmunology: A
review of the literature. Holistic Nursing Practice, 5(4), 10-21.
Kaptchuk, T. J. (2001). History of vitalism. In M. S. Micozzi (Ed.), Fundamentals of complementary and alter-
native medicine (2nd ed., pp. 43-56). New York: Churchill Livingstone.
Kiecolt-Glaser, J. K., & Glaser, R. (1992). Psychoneuroimmunology: Can psychological interventions mod-
ulate immunity? J Consult Clin Psychol, 60, 569-575.
Kiecolt-Glaser, J. K., McGuire, L., Robles, T. F., & Glaser, R. (2002). Psychoneuroimmunology: Psycho-
logical influences on immune function and health. Journal of Consulting and Clinical Psychology,
70, 537-547.
King, I. M. (1971). Toward a theory for nursing. New York: John Wiley.
King, I. M. (1981). A theory for nursing: Systems, concepts, process. New York: John Wiley & Sons.
King, I. M. (1995). A systems framework for nursing. In M. A. Frey, & C. L. Sieloff (Eds.), Advancing Kings
framework and theory of nursing (pp. 14-22). Thousand Oaks, CA: Sage.
Kunz, D., & Peper, E. (1982, December). Fields and their clinical implications. American Theosophist, 70,
395-401.
Leddy, S. K. (1998). Leddy and Peppers conceptual bases of professional nursing (4th ed.). Philadelphia: Lippincott.
Leddy, S. K. (2003). A unitary energy-based nursing practice theory: Theory and application. Visions: The
Journal of Rogerian Science, 11, 21-28.
Leddy, S. K. (2004). Human energy: A conceptual model of unitary nursing science. Visions: The Journal of
Rogerian Science, 12, 14-27.
Maier, S. F., & Watkins, L. R. (1998). Cytokines for psychologists: Implications for bidirectional immune-to-
brain communication for understanding behavior, mood, and cognition. Psychol Rev, 105, 83-107.
Malinski, V. M. (1986). Nursing practice within the science of unitary human beings. In V. M. Malinski
(Ed.), Explorations on Martha Rogers science of unitary human beings (pp 25-32). Norwalk, CT:
Appleton-Century-Crofts.
Mantle, F. (2001). Complementary therapies and nursing models. Complementary Therapies in Nursing and
Midwifery, 7, 142-145.
Micozzi, M. S. (Ed.). (2001). Fundamentals of complementary and alternative medicine (2nd ed.). New York:
Churchill Livingstone.
Neuman, B. (1996). The Neuman systems model in research and practice. Nursing Science Quarterly, 9, 67-70.
Neuman, B. (2002). The Neuman systems model. In B. Neuman, & J. Fawcett, The Neuman systems model
(4th ed., pp. 3-33). Upper Saddle River, NJ: Prentice Hall.
Neuman, B. & Fawcett, J. (2002). The Neuman systems model (4th ed., pp. 3-33). Upper Saddle River, NJ:
Prentice Hall.
Newman, M. A. (1986). Health as expanding consciousness. St. Louis: Mosby.
Newman, M. A. (1990). Newmans theory of health as praxis. Nursing Science Quarterly, 3, 37-41.
Newman, M. A. (1994). Health as expanding consciousness (2nd ed.). St Louis: Mosby.
Orem, D. E. (1995). Nursing: concepts of practice (5th ed.). St. Louis: Mosby.
Parse, R. R. (1987). Nursing science: Major paradigms, theories, and critiques. Philadelphia: Saunders.
Parse, R. R. (1996). The human becoming theory: Challenges in practice and research. Nursing Science
Quarterly, 9, 55-60.
Parse, R. R. (1998). The human becoming school of thought. Thousand Oaks, CA: Sage.
Pert, C. B., Dreher, H. E., & Ruff, M. R. (1998). The psychosomatic network: Foundations of mind-body
medicine. Altern Ther Health Med, 4(4), 30-41.
Quinn, J. F., & Strelkauskas, A. J. (1993). Psychoimmunologic effects of therapeutic touch on practition-
ers and recently bereaved recipients: A pilot study. Advances in Nursing Science, 14(4), 13-26.
Rogers, M. E. (1988). Nursing science and art: A prospective. Nursing Science Quarterly, 1, 99-102.
Roy, S. C., & Andrews, H. A. (1999). The Roy adaptation model (2nd ed.). Stamford: Appleton & Lange.
Rubik, B. (1997). Information, energy, and the unpredictable whole. Advances: The Journal of Mind-Body
Health, 13, 67-70.
Slater, V. E. (1995). Toward an understanding of energetic healing. Part I: Energetic structures. Journal of
Holistic Nursing, 13, 209-224.
Slater, V. E. (1997). Energetic healing. In B. M. Dossey, Core curriculum for holistic nursing (pp. 52-58).
Gaithersburg, MD: Aspen.
Smith, M. (2004). Review of research related to Watsons theory of caring. Nursing Science Quarterly,
17, 13-25.
Starn, J. R. (1998). The path to becoming an energy healer. Nurse Practitioner Forum, 9, 209-216.
Todaro-Franceschi, V. (1999). The enigma of energy: Where science and religion converge. New York: Cross-
road Publishing.
Watson, J. (1989). Watsons philosophy and theory of human caring in nursing. In J. P. Riehl-Sisca (Ed.),
Conceptual models for nursing practice (pp. 219-235). East Norwalk, CT: Appleton & Lange.
Watson, J. (1996). Watsons theory of transpersonal caring. In P. H. Walker, & B. Neuman (Eds.), Blueprint
for use of nursing models: Education, research, practice, and administration (pp. 141-162). New York:
Yeh, C. (2003). Psychological distress: Testing hypotheses based on Roys adaptation model. Nursing Sci-
ence Quarterly, 16, 255-263.
Zeller, J. M., McCain, N. L., & Swanson, B. (1996). Psychoneuroimmunology: An emerging framework for
nursing research. J Adv Nurs, 23, 657-664.
THE MEANING
5
Cultural Influences
OF HEALTH
Abstract
Cultural forces are powerful determinants of health-related behaviors in any group or sub-
population. The beliefs, ideologies, knowledge, institutions, religion, governance, and nearly
all activities (including efforts to achieve health-related behavior change) are affected by cul-
tural influences. Thus, the nurses cultural awareness and sensitivity must be reflected in the
planning, design, and implementation of health promotion activities.
The chapter begins with a consideration of the differences between culture, ethnicity, and
race, and continues with a discussion of racial and ethnic disparities in health status. Next,
the influence of health and illness beliefs and the influence on health promotion of indige-
nous cultural beliefs of Asian Americans (Vietnamese Americans), Appalachians, Hispanics
(Mexican Americans), African Americans, and Native Americans are considered. After a
discussion of the effects of medicocentrism, and models or theories, the chapter concludes
with approaches to understanding cultural and ethnic differences and commonalities for cul-
turally competent health promotion care.
Learning Outcomes
By the end of the chapter the student will be able to:
Differentiate between ethnicity, culture, and race
Describe characteristics of lay/folk theories of health and illness
Discuss indigenous cultural beliefs of Asian Americans (Vietnamese Americans), Appala-
chians, Hispanics (Mexican Americans), African Americans, and Native Americans
100 Chapter 5 The Meaning of Health: Cultural Influences
Describe the implications of medicocentrism

Describe factors to be considered in planning multicultural health promotion programs
Differentiating Ethnicity, Culture, and Race

Ethnicity relates to the sense of identity an individual has based on common ancestry and
national, religious, tribal, linguistic, or cultural origins. . . . Ethnicity, then, helps shape the
way in which we think, relate, feel, and behave within and outside our reference group and
defines the patterns of behavior that provide an individual with a sense of belonging and con-
tinuity with his or her ethnic group over time (Huff & Kline, 1999, p. 8). The primary char-
acteristics of ethnic identification include:
Common geographic origin, language, and religion
A sense of community transmitted over generations by families
An internal sense of distinctiveness
A comfortable sense of security, belonging, and understanding
In contrast, race distinguishes groups of people exclusively on the basis of genetically trans-
mitted physical characteristics.
Although ethnic identity tends to persist through time, culture changes when individuals
and groups modify their beliefs and practices to survive and adapt. Cultural differences exist
among groups with the same ethnic or racial background (Huff & Kline, 1999). Culture is
defined as a learned and shared system of symbolic meanings that shape social reality and
personal experiences (Drew, 1997, p. 82), above all a system of meanings and symbols
(Corin, 1995, p. 273). Culture determines health values and behavior, beliefs about the eti-
ology of disease and illness, and the interpretation of these phenomena (Toumishey, 1993).
Cultural beliefs provide several functions (Drew, 1997, p. 83):
Enables the recognition of health status
Attaches significance to a health problem
Ascribes meaning to health and illness events
Contributes to explanatory models of causation and expected healing outcomes
Identifies acceptable behaviors related to seeking help
Racial and Ethnic Disparities in Health Status

According to Tarlov (1999), health status is influenced by five major categories, including
genes and associated biology (including race); health behaviors such as nutrition, use of
tobacco, alcohol or drugs, and physical activity; medical care and public health services; the
ecology of all living things; and social and societal characteristics (including ethnicity and
culture). These factors are interactive in complex and dynamic ways. An approximation of
the relative influence of the categories on health status is portrayed in Figure 5-1.
Racial and Ethnic Disparities in Health Status 101
Genes & Biology

Social/societal
characteristics Health behaviors
Total ecology Medical care
Figure 5-1. Determinants of population health. Relative influence of the five major determinant cat-
egories of population health: rough approximations (reprinted with permission from Tarlov,
A. R. (1999). Public policy frameworks for improving population health. Annals of the New York
Academy of Sciences, 896, 281-93).
Race and ethnicity are associated with persistent health status disparities among U. S. pop-
ulations. Underlying causes for health status disparities include poverty, lack of access to high-
quality health services, environmental hazards in homes and neighborhoods, and lack of
effective prevention programs designed for specific community needs (USDHHS, 2001).
Socioeconomic position and race (ethnicity) are variables that can affect health care include
affordability and access, transportation, education, knowledge, literacy, health beliefs, atti-
tudes and preferences, provider bias, and competing demands including work and childcare
(Fiscella et al., 2000). Many of these variables, especially macro influences such as socio-eco-
nomic inequalities and disadvantage, require broad societal involvement. In 1996, the
poverty rate among African Americans was 28.4% and among Hispanics was 29.4%, in con-
trast to 11.2% among whites and 14.5% among Asian Americans (Flaskerud & Winslow,
1998). Improved access to appropriate and effective health care services is a variable that can
be influenced by nurses through activities such as identification of need, advocacy within the
health care system, and community empowerment efforts (Yali & Revenson, 2004). In fact,
public health approaches, in general, may provide a better model of health care than indi-
vidually based models as practitioners strive to reach more people, particularly those in under-
served groups (Yali & Revenson, 2004, p. 148). Nurses need to be social advocates who work
with advocacy groups, policymakers, and community-based organizations, and use their
expertise to change policy on the local and national levels.
The U.S. Department of Health and Human Services (USDHHS) Initiative to Eliminate
Racial and Ethnic Disparities in Health has identified several areas for concentrated focus that
affect the health of multiple racial and ethnic minority groups at all life stages. Four areas are
highlighted in Box 5-1.
B OX 5-1
Selected Racial and Ethnic Disparities
in Infant Mortality, Cancer Screening
and Management, Cardiovascular
Disease, and Diabetes
1. Infant mortality rates:
The average rate for whites in 1996 was 6.0 per 1,000 live births, com-
pared with an average rate of 14.2 for African Americans, 9.0 for Native
Americans overall, and 7.6 for Hispanics overall.
In 1996, 84% of white pregnant women, compared with 71% of African
American and Hispanic pregnant women, received early prenatal care.
Sudden Infant Death Syndrome deaths, which account for about 10% of
all infant deaths in the first year of life, are three to four times as high
among Native Americans as among whites.
Reductions will require changes in behaviors such as smoking, substance
abuse, poor nutrition, and conditions such as stress, domestic violence,
lack of prenatal care, medical problems, and chronic illness. Babies
should be placed on their backs to sleep to prevent SIDS.
2. Cancer screening and management:
For men and women combined, African Americans have a cancer death
rate about 35% higher than for whites (171.6 vs. 127.0 per 100,000).
The death rate for cancer for African American men is about 50% higher
than it is for white men (226.8 vs. 151.8 per 100,000).
Vietnamese women in the United States have a cervical cancer incidence
rate more than five times greater than white women (47.3 vs. 8.7 per
100,000). Hispanic womens rates of cervical cancer are also elevated.
The mortality rate from breast cancer is higher for African American
women than for white women.
continued
Racial and Ethnic Disparities in Health Status 103
B OX 5-1 CONTINUED
Hispanic, Native American, and Asian American women also have low
rates of screening and treatment, limited access to health facilities and
physicians, and barriers related to language, culture, and negative
provider attitudes.
Lifestyle change might prevent many cancers. Tobacco use is responsible
for nearly 33% of all cancer deaths, and diet and nutrition may by related
to 30 to 40% of deaths. Reducing sun exposure could prevent many of the
900,000 yearly diagnosed skin cancers. Regular mammography and
appropriate follow-up might reduce deaths from breast cancer by 30% for
women over 50. Pap test screening and follow-up could virtually elimi-
nate cervical cancer, and colorectal cancer screening is now recom-
mended.
3. Cardiovascular disease (the leading cause of death for all ethnic groups):
Compared with rates for whites, coronary heart disease mortality was 40%
lower for Asian Americans, but 40% higher for African Americans in
1995.
Racial and ethnic minorities have higher rates of hypertension, tend to
develop hypertension at an earlier age, and are less likely to be treated.
Among adult women, the age-adjusted prevalence of being overweight
continues to be higher for African American women (53%) and Mexican
American women (52%) than for White women (34%).
Only 50% of Native Americans, 44% of Asian Americans, and 38% of
Mexican Americans have had their cholesterol checked within the past 2
years.
The major modifiable risk factors are high blood pressure, high blood
cholesterol, cigarette smoking, excessive body weight, and physical
inactivity.
4. Diabetes:
Compared with whites, the prevalence of diabetes in African Americans is
about 70% higher and in Hispanics is nearly double. The prevalence rate
of diabetes among Native Americans is more than twice that for the total
population.
Rates for diabetes-related complications such as end-stage renal disease
and amputations are higher among African Americans and Native Ameri-
cans compared to the total population.
continued
B OX 5-1 CONTINUED
African Americans are more likely to be hospitalized for signs of poor dia-
betic control such as septicemia, debridement, and amputations, even
though careful control of blood glucose levels can prevent these compli-
cations.
Source: USDHHS. Initiative to eliminate racial and ethnic disparities in health. Retrieved September 3,
2001, from http://www.omhrc.gov/rah
A major national commitment is necessary if the underlying causes of higher levels of dis-
ease and disability in ethnic and racial minority communities are to be identified and
addressed. Based on a commitment made by President Clinton in February 1998 to eliminate
disparities in selected areas of health status while continuing to improve the overall health of
the American people, Healthy People 2010 was published in 2000. Healthy People 2010 out-
lines national health objectives and provides specific targets and evaluation strategies under
the coordination of the United States Department of Health and Human Services (see Chap-
ter 1, Health, Health Promotion, and Healing).
Research into underlying causes and approaches to elimination of health disparities is
needed. Flaskerud and Winslow (1998) have proposed a conceptual framework for research
and practice with vulnerable populations, that is, social groups who have an increased rela-
tive risk or susceptibility to adverse health outcomes (p. 69). Socioeconomic conditions
have been labeled human capital (such as income, jobs, education, and housing), social con-
nectedness or integration, and social status; environmental resources have been operational-
ized as access to health care and quality of care; and relative risk factors include lifestyle,
behavior and choices, use of screening procedures, immunization programs and health pro-
motion services, and exposure to or participation in stressful events including abuse, violence
and crime. There may be a relationship between increased risk factors, increased morbidity,
and premature mortality.
Flaskerud and Winslow (1998) propose a variety of primary, secondary, and tertiary pre-
vention community nursing intervention strategies, including:
Population-based education efforts

Immunization programs
Safety programs to prevent risk behaviors
Screening for early detection of health problems
Support groups for caregivers of persons with chronic disease
Public policy efforts to change societal and environmental resources
Additional intervention strategies will be discussed at the end of this chapter.

Health/Illness Beliefs 105
Health/Illness Beliefs
An individual or groups definitions of health and illness are culturally determined. The expe-
rience of illness is related to an individuals perception and is not necessarily the same as a bio-
medical interpretation of disease (Toumishey, 1993). When lay or popular beliefs about health
and illness are closely aligned with Western biomedicine (see Chapter 3, The Meaning of Health:
Health Care Belief Systems), for example, cancer as an abnormal growth, there is high potential
for a good exchange of ideas between practitioners and clients with regard to mutually accept-
able treatment options. However, when there is an incompatibility between lay or popular
beliefs and biomedical beliefs, for example, high blood pressure caused by too much blood, there
may be client resistance to Western biomedical assessment and treatment recommendations.
Folk illnesses are based on very different theories of explanation than disease in Western
biomedicine. In addition to a cluster of signs and symptoms, folk illnesses, which are com-
monly recognized or associated with specific cultural groups, also have symbolic meaning to
the individual and the culture from which the folk illness arises. Helman (1994) outlines four
categories of causality of lay/folk theories of illness:
1. Biological causality. Illness may result from malfunctions of the body as a result of factors
such as diet or behavior over which the person has some control. This category also rec-
ognizes that hereditary, social, economic, and personality factors may play a role in ill-
ness causality and response. Here it is important to identify the individuals locus of
control to determine whether he or she will take responsibility for health or regard
health as lying outside of the self.
2. Natural causality. Includes both animate and inanimate factors thought to cause illness.
For example, illness might be attributed to bacteria and viruses (e.g., flu, tuberculosis),
parasitic infections (pinworms), and injuries caused by animals, birds, or fish. Other fac-
tors include environmental irritants such as smog, pollens, and poisons; natural disas-
ters such as earthquakes, floods, and fires; and climatic conditions such as extremes of
heat, cold, wind, rain, or snow.
3. Social causality. Concerned with interpersonal conflicts that include physical injuries
inflicted by people on others (such as personal assaults resulting from gang violence,
war, or other similar causes). Stresses resulting from conflicts with family, friends, or the
work environment also are part of social causality. In more traditional non-Western cul-
tures, illness is often ascribed to sorcery or witchcraft in which certain people have the
power to cast spells, create potions, or carry out rituals that can result in illness or death
for individuals against whom the sorcerer or witch has a personal vendetta.
4. Supernatural causality. Includes ancestral and other spirits and gods who can directly inter-
cede in human life and cause personal difficulties, illness, and death. Illnesses inflicted from
the supernatural world include spirit possessions, spirit aggression, and soul loss as retribu-
tion for behavioral lapses (e.g., sinful behavior such as getting drunk, offending a particu-
lar ancestors spirit, or breaking a particular social taboo). When supernatural causes of
illness are suspected by the client and/or the family or community, neither traditional
home remedies nor a Western medical practitioner is considered useful in treating and cur-
ing the illness. Such situations call for repentance, prayer, and intercession of a shaman,
priest, or other spiritual advisor or healer.
Many clinical encounters can be viewed as an interaction between the culture of the client
and the culture of biomedicine or nursing. Both cultures are likely to have divergent percep-
tions, knowledge, attitudes, behaviors, and communication styles relative to the illness or
health issue as a result of their explanatory models of health, disease, causality, and treatment.
An individuals model is generally a composite of his or her ethnocultural beliefs and values;
personal beliefs, values, and behaviors; and understanding of biomedical concepts (Huff,
1999, p. 25). The meanings people attach to various symptoms and illnesses are key factors
in considering the implications for healing.
In contrast to the biomedical beliefs of most professional providers, the concept of illness (a
subjective feeling of being unhealthy), rather than disease (a medical label for a recognizable
clinical syndrome), is central to the average persons subjective response to not being well.
Beliefs are the basic guidelines for perceiving, interpreting, organizing, and understanding mean-
ingful experiences. Illness beliefs include the meaning and significance of the experience for the
individual and form the cognitive basis of the reasoning processes used by individuals to link
plausible predictions about how to alter or control threats to health (Drew, 1997, pp. 84-85).
Hufford (1995) suggests that too much emphasis on narrowly defined medical goals over the
existential concerns of sick people is responsible for many of the concerns being expressed with
conventional biomedicine. It is important for nurses to begin to understand clients health, ill-
ness, and healing beliefs and behaviors from their own perspectives. Although health practi-
tioners bring their personal cultural beliefs to each interaction with their clients, it is not
acceptable to impose on clients certain cherished and habitual interventions (Toumishey,
1993, p. 117). Provider ethnocentrism, even when unintended, communicates to the client
disregard for perceptions, knowledge, and cultural health beliefs and practices (Drew, 1997).
Most cases of lay illness have multiple causalities and may require several different approaches
to diagnosis, treatment, and cure, potentially including home remedies, care by a nonprofes-
sional healer, treatment by a biomedical physician, and/or intercession by a shaman.
Influence of Indigenous Cultural Beliefs

America is a multicultural society. . . . There is an effort to maintain a respect for differ-
ences while recognizing that differences conspire against equity (Huff & Kline, 1999, p.
504). The relationship of culture to health beliefs and practices is highly complex, dynamic,
and interactive, involving family, community, and/or supernatural agents in cause, effect, pla-
cation, and treatment rituals to prevent, control, or cure illness (Huff, 1999). This section
will review similarities of indigenous beliefs of Asian Americans (Vietnamese Americans),
Appalachians, Native Americans, African Americans, and Hispanics (Mexican Americans)
that can influence their health promotion care.
ASIAN AMERICAN INDIGENOUS HEALTH BELIEFS

Asian and Pacific Islander Americans are the fastest growing ethnic minorities in the
United States (Huff & Kline, 1999). The term Asian American encompasses at least 23 sub-
groups, including Asian Indian, Cambodian, Chinese, Filipino, Hmong, Japanese, Korean,
Laotian, Thai, Vietnamese, and other Asian, with 32 linguistic groups. Although Asian
Influence of Indigenous Cultural Beliefs 107
groups share some similarities based on religious background and the influence of Chinese
culture throughout Asia, health and disease patterns among Asian Americans differ by gen-
erations and immigration dates (Huff & Kline, 1999).
Indigenous beliefs can have a major impact on health. A shift in the balance of natural
forces can result in illness. . . . [A belief] among Vietnamese, Khmer, and Hmong is that illness
is caused by eating spoiled food or eating an excess of hot or cold foods. . . energizing (hot)
or calming (cold). . . . Spiritual beings can also cause illness. Malicious spirits can enter the
body as a result of a violation of a taboo or spells of black magic. Benign spirits, believed to
reside in the trees, can punish an offensive person who fails to show proper respect. . . . There
are also guardian spirits (Frye, 1995, p. 271).
Health is generally viewed as a state of harmony with nature or freedom from symptoms or
illness. The concept of balance is related to health promotion, and the concept of imbalance
is related to disease This balance, or equilibrium, applies to temperature in foods, climate,
body elements, emotions, relationships, work and relaxation patterns, food intake, and spiri-
tual life (Huff & Kline, 1999).
Confucian ideology, Buddhism, and Taoism are prominent in Asian cultures. These reli-
gions focus on upholding a public faade and sanctions against public admission of problems.
For example, mental illness is regarded as shameful and as a punishment for misdeeds (Huff
& Kline, 1999). Buddhism teaches that suffering should be accepted with calm resignation
and expectation of future improvement in another lifetime (Frye, 1995). Therefore, some
Asian cultures value stoicism and restraint of public display of emotion. People of some Asian
cultures believe that suffering is a part of life, which may postpone seeking treatment for
symptoms until they become unbearable.
Traditionally, elderly persons have held critical helper roles. Monks, healers, and tra-
ditional birth attendants have provided stability and have been the bearers and gatekeep-
ers of culture and tradition (Frye, 1995, p. 273). Buddhism advocates merit-making
actions such as feeding the monks or being kind to children and elders as ways to balance
the scales for sinful transgressions in this life or past lives. This balance is further pro-
moted through generosity and nonconfrontational behavior in interpersonal relationships
(Frye, 1995).
An essential characteristic of Asian families is kinship solidarity, the view that the individual
is subservient to the kinship-based group or family.... Most Asian family patterns are characterized
by filial piety, male authority, and respect for elders.... The contentment and happiness of their
children is paramount to the notion of Chinese families of normal family functioning (Huff &
Kline, 1999, pp. 349-350). In threatening situations, family solidarity is paramount (Frye, 1995).
A number of factors have contributed to the decline of the traditional multigenerational
household, including loss of family, breaking of family units into manageable sizes for spon-
sorship, smaller housing units available in America, and challenges to the traditional family
authority over adolescents. Marital roles also have changed. Many Khmer and Vietnamese
refugee women have obtained informal or formal employment, often finding jobs more easily
than their husbands. This factor has created a shift in power and challenged traditional gen-
der roles. In addition, refugee families have frequently settled in cities, which are quite dif-
ferent from their rural backgrounds. They have often responded to the violence of the urban
environment with passivity and withdrawal (Frye, 1995).
Language and literacy barriers are major factors in alienation from the American culture.
Within the health care setting, one barrier is the use of bilingual children as translators for
their elders. This practice, although expedient at times, exposes adult problems to the chil-
dren. This practice does not support the traditional strong sense of hierarchy and authority.
Of concern, in addition to the language barrier, is the illiteracy of much of the older South-
east Asian refugee population (Frye, 1995).
Vietnamese American Health Beliefs (Researched by Eden Zabat)

The Vietnamese are one of the largest Southeast Asian groups resettling in the United
States (DAvanzo, 1992; Frye, 1995). Vietnamese health beliefs are deeply rooted in Eastern
philosophy. Eastern-influenced health assumptions assert that humans are a microcosm of
nature and knowledge is subjective and relative (Beinfield & Korngold, 1995). The principal
assumption is that there is order in the processes of heaven and earth with harmony and reg-
ularity in the order (Calhoun, 1985). Central beliefs of the Vietnamese are harmony with
nature, and the integrative wholeness of the person. Health is one facet of life in the universe,
functioning as part of a unified, comprehensive scheme (Calhoun, 1985, p. 63) and rooted
in a sense of balance and harmony within a person (Healy, 1997, p. 40). The nature of health
is harmony with nature.
Illness is related to a disharmony with nature. Illness is believed to be caused by traditional,
supernatural (animism), and metaphysical (Am [yin] and Duong [yang] theory) factors. Ani-
mists believe in the existence of spirits, with both animate and inanimate things possessing a
soul. While in an induced trance, shamans use rituals and negotiation with spirits to inter-
cede for an ill person.
Excess or insufficiency of either am (cold, female) or duong (hot, male) can lead to illness
through eating rotten foods, bad wind, or excess ingestion of hot or cold food elements
(Frye, 1995). Foods are divided into two groups: hotspices, coffee, beef, wild game; and
coldtea, most fruits, chicken, duck, seafood (Nguyen, 1985, p. 411). Health care practices
center on balancing the hot and cold elements. For example, Chinese herbs are seen as cold,
while Western medicine is considered hot (Calhoun, 1985). Antibiotics are hot, and should
always be taken with vitamin C, which is seen as cooling (Craig, 2000).
Other common indigenous health belief practices related to illness and disease that Viet-
namese Americans use concurrently with professionalized health care include (Giger &
Davidhizar, 1995; Louie, 1995; Nguyen, 1985):
Cao gio (coin rubbing). Use of hot balm oil over the neck, back, chest, and arms to
bring the bad wind to the surface.
Bat gio (skin pinching). Commonly used for a headache.
Gia (cup suctioning). Used for bad wind.
Xong. Herbal steam inhalation for colds or bad wind.
Ingestion of gelatin-like tiger bones. Brings strength.
Ingestion of hot foods. Cures a cold illness.
Chinese herbs. Balance am and duong.
Access and barriers to health care for Asian Americans are similar to those for other eth-
nic groups and focus on socioeconomic factors such as availability of health insurance, access
and location of health care facilities, transportation, poverty, and unemployment.
APPALACHIAN HEALTH BELIEFS (RESEARCHED BY SANDRA ROZENDAL SCHULTZE, BSN, MS)

The term Appalachians refers to individuals who were either born in or live in a large area
known as the Appalachian Mountain region of the United States (Purnell & Counts, 1998).
The region crosses 13 different states. Although the population of the Appalachian Moun-
tain region is diverse, most Appalachians are largely white, primarily of Scottish-Irish or
British descent, and predominantly fundamentalist Protestant. For the most part, the
Appalachian region is classified as a rural, nonfarming area (Small, 1995, p. 263), dominated
by mining, timber, and textile industries. However, not all Appalachians live in the moun-
tains; some have migrated to urban settings in the region.
Given the rural environment within which many Appalachians live, harmony with the
environment is important. Burkhardt (1994) conducted a qualitative study in which she
interviewed 12 Appalachian women about their spirituality. The women frequently spoke of
connecting with the earth. They stated that they derived strength from nature, were knowl-
edgeable regarding various plants and animals, and had a sense of the weather. Burkhardt
noted that there was a general sense that the environment was a source of strength and
health (p. 15).
Fundamentalist religion is an important aspect of the Appalachian culture, although for
the most part, religious convictions are not associated with organized churches (Small, 1995).
This is due in part to the mountainous terrain, which makes travel difficult. Instead, people
develop informal social networks to support their faith. For the Appalachians, good health is
seen as a gift from God (Purnell & Counts, 1998). They believe that Gods will must prevail
(Small, 1995), a present-oriented view that has been labeled by some writers as fatalistic.
Appalachians have an inherent distrust of health care providers, who are considered out-
siders. They are hesitant to discuss personal matters, including health-related issues, with
outsiders (Sortet & Banks, 1997). When they do have contact with Western health care
providers, they want to sit a spell and talk, allowing the health care provider an opportu-
nity to gain acceptance (Reed et al., 1995).
A variety of nonprofessional healers may deliver care. Appalachian folk healers, including
the granny midwife, usually are older women. Many grannies take great pride in knowing
that they delivered all of the children in a particular region (Helton, 1996). Because they are
well known and trusted by those in need of health care, most herbal and folk practitioners are
highly respected for their treatment (Purnell & Counts, 1998). Because of the social, geo-
graphical, or cultural isolation, folk healers are often the primary health care providers.
To restore harmony, folk practitioners may use a variety of items from nature, including
herbal medicines, poultices, or teas. For example, to control bleeding, a spider web may be
placed across the wound, and if a person has a burn, a poultice of egg whites and castor oil
can be used. To treat arthritis, a tea is made by boiling the roots of ginseng. This tea is then
either drunk or rubbed on the arthritic joint. As is the case with any cultural group, profes-
sional health care providers (outsiders) need to gain the support of indigenous providers
(insiders) and work within the indigenous traditions and beliefs in order to influence health.
HISPANIC HEALTH BELIEFS

The term Hispanic originated as an official government label by the Office of Budget and
Management in 1978, creating an ethnic category that included populations bound by a com-
mon ancestral language and cultural characteristics such as persons of Mexican, Puerto Rican,
Central American, South American, or some other Spanish origin (Suarez & Ramirez, 1999).
The majority (61%) of the 22 million Hispanics in the United States are of Mexican origin
(Suarez & Ramirez, 1999, p. 116), three-quarters of whom live in Texas or California. The
other two major Hispanic groups consist of 2.7 million Puerto Ricans and 1.0 million Cuban
Americans, 65% of whom live in Florida. By the next decade, the number of Hispanics will
exceed that of African Americans to become the second largest racial/ethnic group in the
country (Suarez & Ramirez, 1999, p. 116).
Within the Hispanic culture, there is a strong identification with ones family and strong
feelings of support from nuclear and extended family members. Embedded in the structure of
la familia is the authority and protection of the father, the sacrificing nature of the mothers
role, and the respeto (respect) that children must give to family members. . . . For Hispanics,
decisions about the use of medical care or preventive care or treatment are family based
(Suarez & Ramirez, 1999, pp. 120-121). The collective needs and achievements of the fam-
ily take precedence over those of the individual members. Group togetherness and the phys-
ical presence of family and friends are valued. Help and advice are usually sought from within
the family system first, and important decisions are made as a group.
Mexican American Health Beliefs

Within the Mexican American culture, children are highly desired and valued. Mexican
American women are primarily responsible for maintaining the health of the family but may be
uncomfortable touching their own bodies. A female provider can help to address modesty during
health care examinations. However, fatalism, the belief that an individual has little control over
personal health outcomes, is common. There is a hint of fatalism (asi es la vida, or such is life),
accompanied by spiritual faith (Applewhite, 1995, p. 250). The individual perceives little per-
sonal ability or responsibility for success or failure in matters of health and illness (Burk et al.,
1995; Suarez & Ramirez, 1999). The belief that health is a matter of chance and controlled by
forces in nature, may hinder the compliance of Mexican Americans with a health care regimen.
Value is placed on achieving harmony in interpersonal relationships. Simpatia (being nice)
is the Hispanic tendency to avoid conflict in social and personal encounters. Respeto
(respect) toward individuals is acknowledged and reciprocated and is based on age, sex, and
social positions of authority. Respeto dictates appropriate deferential behavior toward others
on the basis of age, sex, social position, economic status, and position of authority. Deferen-
tial behavior is demonstrated by using formal, rather than informal, Spanish language and by
listening attentively to clients and providing information in a courteous manner. It incorpo-
rates diplomacy and tactfulness and discourages confrontation (Suarez & Ramirez, 1999).
Personalismo emphasizes that the clients relationship is with the individual provider rather
than the institution. Therefore, the nurse should greet the client by name and inquire about
his or her general well-being or family before getting to the actual business of the visit. There is
a valuing of physical touch, so a handshake is an appropriate greeting (Burk et al., 1995).
Curanderismo, or Mexican American folk healing, is a coherent, comprehensive system of
healing primarily derived from a synthesis of Mayan and Aztec teachings with the Mexican her-
itage of Spanish Catholicism. The underlying concept is the spiritual focus of the healing (Kripp-
ner, 1995). The curandero, or folkhealer, views illness from a religious and social context. How-
ever, although curanderismo is a traditional healing system, it exists within the modern world.
Biomedical beliefs, treatments, and practices are very much a part of curanderismo, and are sup-
ported by curanderos (Trotter, 1996).
Curanderismo has a community-based theoretical structure based on a duality of natural and
supernatural. There are three primary areas of concentration, called levels (niveles) by the
healers: the material level (nivel material), the spiritual level (nivel espiritual), and the mental
level (nivel mental). Physical (material) treatments are those that do not require supernatural
intervention to assure a successful outcome. Parteras (midwives), hueseros (bone setters), yerberos
(herbalists), and sobadores (people who treat sprains and tense muscles) accomplish cures with-
out any need for supernatural knowledge or practices, while the supernatural aspect of the mate-
rial level is involved in cures for common folk illnesses such as mal de ojo, susto, empacho, and
caida de mollera (Trotter, 2001).
Mal de oyo (evil eye). A person can make another sick by looking at him or her, but it
usually is not thought to have been done on purpose. The one who gets ill is weak (usu-
ally an infant), fussy, and refuses to eat and sleep. Treatment is symbolic, by protecting
with amulets or having the face covered in the presence of strangers.
Susto. Fright, sudden shock. Herb tea and ritual cleansings (barrideas) are used to
restore the harmony of body and soul (Giger & Davidhizar, 1995).
Empacho. Thought to be caused by something getting stuck in the intestines causing
blockage. Symptoms are diarrhea, constipation, indigestion, vomiting, and bloating.
The most common treatment is massage along with herbal teas; the former is for dis-
lodging the blockage and the later is for washing it out.
Caida de mollera (fallen fontanelle). Diarrhea, excessive crying, fever, loss of
appetite, and irritability. Treatment includes raising the fontanelle by pushing up on
the palate.
Most practitioners of curanderismo are women who are typically called to their profession
by spiritual entities. They apprentice themselves to a friend or relative until they are considered
ready to practice. Most are part-time practitioners who do not charge a fee but are given a small
offering or gift.
Supernatural manipulations involve prayers and incantations in conjunction with such
objects as candies, ribbons, water, fire, crucifixes, tree branches, herbs, oils, eggs, and live ani-
mals... Supernaturally induced illnesses are most commonly said to be initiated by either espiri-
tos malos (evil spirits) or by brujos (individuals practicing antisocial magic) (Trotter, 2001, p.
413). The spiritual level is comparable to the channeling found in New Age groups and in
shaman healing rituals around the world. In addition, the mental level might be described as
the ability to transmit, channel, and focus mental vibrations in a way that would affect the
[clients] mental or physical condition directly (Trotter, 2001, p. 414).
Healers work by virtue of a gift of healing (el don) (Trotter, 2001, p. 413). The three levels
are discrete areas of knowledge and behavior, each necessitating a separate gift for healing. They
involve different types of training, and different methods of dealing with both the natural and
the supernatural world. Treatment of natural illnesses is generally carried out by physician spe-
cialists. Herbal treatments are supervised by the herbolaria, medica, and herbalista while the senora
prescribes home remedies. The first person to be consulted at the time of illness is a key family
member who is respected for her knowledge of folk medicine.... The jerbero is a folk healer who
specializes in using herbs and spices for preventive and curative purposes.... The more serious
physical and mental or emotional illnesses are brought to the curandero (Giger & Davidhizar,
1995, p. 219). Illnesses with a supernatural source can be repaired only by the supernatural
manipulations of curanderos.
The priorities and roles of society are to support the patients recovery because the entire com-
munity is concerned and affected when a member becomes ill. The goal of the curanderismo
model is to assist the recovery of the patient, restoring balance within a social framework that
preserves the traditions of the family and the Mexican American subculture. Suffering and ill-
ness are not seen as a punishment from God but as an inevitable part of life, a challenge, and part
of Gods plan to instruct human beings and lead them to salvation (Krippner, 1999).
Another element of the belief in balance is the humoral model for classifying activity, food,
drugs, and illness, in which good health is maintained by maintaining a balance of hot and cold.
This model emphasizes balance in relationships and behavior. A balance of emotional humors
and the avoidance of an excess of hot or cold foods (i.e., foods that stimulate the body ver-
sus foods that have a calming effect) is important as well. Symbolically, cold is related to things
that menace the individual, whereas hot is related to warmth and reassurance (Giger & David-
hizar, 1995, p. 217).
Hispanics have much lower rates of cardiovascular disease and cancer than whites, but have
higher death rates due to diabetes, the seventh leading cause of death in the country. Lack of
health insurance is the major barrier to preventive care for the Hispanic population, which lim-
its participation in dental care, cancer screening, and prenatal care (Suarez & Ramirez, 1999).
The coexistence of curanderismo with biomedicine in Hispanic communities requires both cul-
tural sensitivity and the ability to provide care that acknowledges the beliefs of the contrasting
systems.
AFRICAN AMERICAN HEALTH BELIEFS

African American values are a combination of African heritage and the American experi-
ence. Some 80% of Africans, especially the economically deprived, still use traditional healing
methods grounded on belief rather than knowledge, which have been sustained over the years
because they are acceptable, available, and affordable (Hopp & Herring, 1999).
One important value includes the extended family, the belief that all the aunts and uncles are
responsible parents of all their nieces and nephews, the belief in collectivism as opposed to indi-
vidualism, and respect for age. Women, especially, are affected by a legacy of struggle against
racism, classism, and sexism that is inextricably linked with a parallel struggle for independence,
self-reliance, and self-definition.... The goal of struggle is to live a meaningful life reflective of
the uniqueness of African American culture (Banks-Wallace, 2000, p. 35).
In the traditional African philosophy, knowledge obtained through Western formal edu-
cation is a power that is reserved only for males who will inherit the land. Womens human-
ity is affirmed not only by their ability to have children, but also by their ability to have male
children. Young girls are discouraged from becoming high achievers because of concern over
their difficulty in finding husbands (Airhihenbuwa, 1995).
Traditional African values stress a lifestyle of acquiescence rather than challenge of

nature. It is believed that a state of balance exists within the individual and between the indi-
vidual and the environment. Good health is considered harmony with nature; illness and bad
health, on the other hand, are viewed as disharmony with nature that may be caused by a
variety of factors. In addition, there is an emphasis on oral tradition, in which people learn
by listening. Learning by seeing is important to the extent that what is seen is congruent
with what is heard (Airhihenbuwa, 1995, p. 9).
Illnesses deemed to be due to natural causes often result from stress; cold; impurities in the
water, air, or food; improper eating habits or diet; weakness; or lack of moderation in daily activ-
ities. In contrast, illnesses or mishaps deemed to be due to unnatural causes may be blamed on
the evil influences of the devil, witchcraft, demons, or bad spirits. Worry, according to tradi-
tional beliefs of many African Americans, is the main component in the course of unnatural ill-
ness. Unnatural illnesses can be terrifying because they usually do not respond to self-treatment
or remedies administered by friends, relatives, or practitioners (Hopp & Herring, 1999).
The remedies for treating calamities caused by evil influences include food, medicine,
antidotes, healing, and prayer proposed to God by a medium with unusual powers (Hopp &
Herring, 1999, p. 208). Other traditional cures and treatments include:
External aids such as magic and visible protection in the form of prayer, cards, and
charms.
Eating garlic for hypertension.
Drinking teas made from herbs for colds.
Applying tallow to the chest and covering it with a cloth for colds.
Pouring kerosene into cuts as a disinfectant.
Wearing garlic around the neck to keep from catching disease.
Using vinegar, Epsom salts, pain-relief cream, and copper wire or bracelets for arthritis.
Drinking horehound tea or buttermilk for diabetes, and tea made of rabbit tobacco and
pine top for asthma.
Experience is strongly valued by African American women, and separates knowledge

from wisdom (Banks-Wallace, 2000, p. 37). Opportunities to share experience, through dia-
logue and sharing stories, can build or nurture connections and establish the credibility of a
health promotion intervention. Replenishment as an aspect of spiritual development is inte-
grally associated with health in this group as well as in Native American tribes.
NATIVE AMERICAN (INDIAN) HEALTH BELIEFS

The term Native American is problematic because it implies a uniform culture and heal-
ing system. The indigenous people of North America identify themselves by nation (com-
monly called tribe), band or community, clan, and family (Cohen, 1998, p. 45). Although
there are more than 500 distinct federally recognized tribes, there are many similarities and cul-
tural bonds among them (Lowe & Struthers, 2001). Commonly, health means restoring the
body, mind, and spirit to balance and wholeness: the balance of life energy in the body; the
balance of ethical, reasonable, and just behavior; balanced relations within family and commu-
nity; and harmonious relationships with nature.... A healthy person has a sense of purpose... is
committed to walking a path of beauty, balance, and harmony... and is grateful, respectful, and
generous (Cohen, 1998, pp. 45, 47).
Unlike Western biomedicine, Native American healing tends to consider disease in terms of
morality, balance, and the action of spiritual power rather than specific, measurable causes. As a
result, native healers believe that among adults, some diseases are the [clients] responsibility and
the natural consequence of his or her behavior; to treat these conditions may be to interfere with
important life lessons (Cohen, 1998, p. 47). The health of the land is integral to human health.
Native American medicine is based upon a spiritual rather than a materialistic or Cartesian
world view. The art of traditional healing places an emphasis on: (a) the spirit world, (b) super-
natural forces, and (c) religion (Struthers, Eschiti, & Patchell, 2004, p.142). The term medi-
cine in Native American cultures has come to mean supernatural power. Wholeness and
interrelatedness are basic principles, and illness is associated with imbalance. Healing ability can
be acquired in several ways that include inherited from ancestors, transmitted from another
healer, and/or developed through training and initiation. Healers can be chosen by their own
vision, or by their community (Struthers et al., 2004).
The causes of disease are internal and external. Internal causes include:
Negative thoughts about oneself, including shame, despair, worry, and depression.
Negative thoughts about others, including blame, jealousy, and anger.
Disturbances in flow of life energy and healing power within the individual or to/from the
environment (Cohen, 1998, p. 48).
External causes include:

Pathogenic forces, objects (including microbes), people (sorcerers), and/or spirits.
Environmental poisons, pollution, and contaminants, including alcoholic drinks and
unhealthy food.
Traumatic events that are physical, emotional, and/or spiritual.
Breach of taboo, including unbalanced living and inconsiderate behavior; not demon-
strating proper respect toward an animal, person, place, object, event, or spirit; improper
performance of ritual or care of ritual objects (Cohen, 1998).
In describing characteristics of the Navajo tribe during illness, Bell (1994) notes that families
gather together for consultation during a prolonged visit, often answering questions affirmatively
in the presence of a primary care practitioner because of a desire to please. Direct eye contact is
considered to be unacceptably rude and intrusive. Silence is highly respected, since speech con-
notes power and wisdom as well as communication. Conflict and competitiveness are not val-
ued, as they are not in keeping with a peaceful heart (p. 238).
Lowe and Struthers (2001, p. 280) have identified seven dimensions forming a conceptual
framework of intertwined, related, and overlapping components of nursing in Native Ameri-
can culture. This framework, which clearly demonstrates the uniqueness of the Native Amer-
ican culture, can provide a structure for nursing practice, education, and research with Native
Americans.
Western biomedicine relies heavily on the precision of particular diagnostic techniques.
However, within Native American cultures, diagnostic ability depends more on the intuition,
sensitivity, and spiritual power of the healerthe ability of the healer to see the patient with
the inner eye of spirit, to sense disturbances of energy with the hands and heart, and to com-
mune with higher sources of knowledge (Cohen, 1998, p. 50). Some principles of Native
American healing include (Mehl-Madrona, 1999, pp. 37-39):
Healing takes time and time is healing. One should not begin the task of treating a sick
person unless he or she has sufficient time to give to the client. The act of giving time
to another person is healing in itself. Intent and power from the healer are passed on to
the recipient.
Healing takes place within the context of a relationship.
Achieving an energy of activation is necessary, exerting maximum effort over a
short period of time. As a result, one client at a time may be treated until the job
is done.
The distractions of modern life inactivate catalysts of change. Peace and quiet are
needed for self-exploration and development of an awareness of emotional states.
Modern culture systematically teaches us to ignore emotions and to maintain a low
level of emotional awareness.
Physiological change often requires a break in usual daily rhythms. Rest and quiet are
needed to promote cellular repair.
Ceremony such as a vision quest or purification ceremony is important as a means to
receive help from the spiritual dimension.
Methods of diagnosis, methodology, and treatment vary greatly from tribe to tribe and
healer to healer. Specific skills are utilized to correct imbalance.
Divination or prediction to foretell or forecast events or situations, e.g., a seer can fore-
tell the future. This may include dreaming of events to come.
Natural elements such as water, fire, smoke, stones, or crystals may be used as a projec-
tive field to help to see the reason and/or course of an imbalance.
Prayer
Chanting
Use of music, singing, drums, and rattles
Smudging with medicinal plants such as sage, cedar, and sweet grass
Laying on of hands
Talking or counseling
Medicinal plants or botanical medicines that are made into teas, salves, ointments,
purgatives, and other substances
Ceremony
Sweat lodge
Shake tent
Yuwipi
Dancing
Dreaming
Use of tobacco, either as an offering or smoked
Storytelling (Struthers, Eschiti, & Patchell, 2004, p. 146)
Therapeutic methods include prayer, music, ritual purification, herbalism, massage, cere-
mony, and the personal innovations of individual healers (Cohen, 1998).
Medicocentrism (Medical Ethnocentrism)

Medicocentrism is the bias produced by viewing health through the lens of medicine as it
is currently found in modern society. Mastery over nature, future time orientation, doing, and
individualism are stable, core American values (See Chapter 3, The Meaning of Health: Health
Care Belief Systems). Stein (1990) discusses specific American medical decision making and
treatment values that are associated with the core American values including:
Fantasized omnipotence. Manifested by a compulsion to change others. In addition, the-

ories provide an inexhaustible reserve of explanations and interventions in cases for
which the rest of medicine has nothing to offer, assuring that there are never sicknesses
about which medicine simply cannot say or do anything (Hufford, 1996).
Dichotomy between active and passive. Passively listening, waiting, comforting, non-
directive counseling, going along with nature, or doing nothing are anathema. Actively
intervening, aggressively treating, controlling, curing, and fixing the client increase self-
esteem for the clinician and preserve the illusion of distance between clinician and client.
Health as an ideal. Health is manifested by the absence or resolution of the presenting
problem. Disease is a deviation.
Visualization. Seeing what the pathology is and where is it located spatially is valued.
Technology follows and endlessly elaborates on this visual mode of knowing. Subjective
data are less valuable than objective data.
Control. Medicine tends to move toward administrative control, based on technical
knowledge, over all activities relevant to health.
Culturally Competent Health Promotion Care 117
Male language. Hard science, real medicine, aggressive intervention, the cure and
conquest of real disease are all idealized idioms of masculinity (Stein, 1990, p. 51).
Functionality. Dysfunction, and its associated dependency are dreaded. Consequently,
what works is valued.
Additional, more specific values include certainty, completeness, lack of ambiguity, power
(omnipotence), knowledge (omniscience in the form of facts), [and] goodness (omnibenev-
olence). So long as a [clinician] is able to exercise and fulfill these values, he or she feels com-
petent, successful, good, validated, and vindicated as a [clinician] (Stein, 1990, p. 50).
However, medicocentrism negatively affects the establishment of an authentic therapeutic
relationship between culturally diverse clients and their clinicians. As a result, clients feeling
that their beliefs are not understood nor valued, may not seek biomedical or nursing assis-
tance, or may not adhere to recommended regimens. At the least, medicocentrism leads to
lack of mutual trust and collaboration between client and provider.
Culturally Competent Health Promotion Care

Leininger (1999, p. 9) blends concepts from anthropology and nursing to define transcul-
tural nursing as a legitimate and formal area of study, research, and practice, focused on cul-
turally based care beliefs, values, and practices to help cultures or subcultures maintain or
regain their health (well-being) and face disabilities or death in culturally congruent and ben-
eficial caring ways. Culturally congruent care means to provide appropriate care that is
meaningful and fits with cultural beliefs and lifeways (Leininger, 1999, p. 9). Smith (1998,
p. 8) defines cultural competence as a continuous developmental process of pursuing cultural
awareness, knowledge, skill, encounters, sensitivity, and linkages among services and people.
Mensah (1993) defines terms somewhat differently in differentiating three types of cultur-
ally based care:
1. Transcultural care. Based on a comparative study and analysis of different cultures with
respect to their caring behavior, health and illness values, beliefs and patterns of behav-
ior. The focus is on the care-giver.
2. Cross-cultural care. Based on the assumption that the client and the professional helpers
are of different cultural backgrounds. The focus is on the care.
3. Multicultural care. Health care which is both culturally appropriate and culturally sensi-
tive; the focus is on the total health system.
The next section will present an overview of Leiningers theory of culture care diversity
and universality, and Purnells model for cultural competence. Both initiate a process for cul-
tural competence through assessment of cultural differences in various categories of culture.
MODELS/THEORIES FOR CULTURALLY COMPETENT CARE

A prominent cross cultural nursing theory is Leiningers theory of culture care diversity and
universality. She states that the social structure and worldview of Western and non-Western
cultures are strong influences on care practices leading to health or well-being (Leininger,
1991, p. 57). Selected major elements of the theory of culture care diversity and universality,
which have mutual influence in affecting culture congruent nursing care, are:
1. Culture and social structure dimensions:
Technological factors
Religious and philosophical factors
Kinship and social factors
Cultural values and lifeways
Political and legal factors
Economic factors
Educational factors
2. Care systems:
Generic lay care system. A folk, indigenous, or naturalistic lay care system.
Professional health care system. Care or cure services offered by personnel who have
been prepared through professional programs of study.
3. Three major modalities guide nursing judgments, decisions, or actions so as to provide
cultural congruent care:
Cultural care preservation and/or maintenance. Assistive, supportive, facilitative,
or enabling professional actions and decisions that help people of a particular cul-
ture to retain and/or preserve relevant care values so they can maintain their
well-being, recover from illness, or face handicaps and/or death (Leininger,
1991, p. 48).
Cultural care accommodation and/or negotiation. Assistive, supportive, facilita-
tive, or enabling creative professional actions and decisions that help people
of a designated culture to adapt to, or to negotiate with, others for a beneficial
or satisfying health outcome with professional care providers (Leininger,
1991, p. 48).
Cultural care repatterning or restructuring. Assistive, supportive, facilitative, or
enabling professional actions and decisions that help a clients reorder, change, or
greatly modify their lifeways for a new, different, and beneficial health care pat-
tern (Leininger, 1991, p. 49). Leiningers theory of culture care diversity and uni-
versality posits that emic culture care knowledge from Western and non-Western
cultures shows greater diversity than similarities or commonalties in cultural val-
ues, usage, and meanings (Leininger, 1991, p. 57). The implication is that cul-
ture care knowledge specific to each culture is needed to guide nursing care.
In contrast to Leiningers theory, which is specific to nursing, Purnell (2000) developed a
model for cultural competence to be used by all health disciplines in all practice settings. The
core of the model is comprised of twelve cultural domains each of which relates to and is
affected by all other domains:
Overview/heritage. Concepts related to the country of origin; current residence; eco-

nomics; politics; educational status; and occupation.
Communication. Concepts related to the dominant language and its contextual use; non-
verbal communication; past, present, or future temporality; and clock versus social time.
Family roles and organization. Concepts related to head of the household and gender
roles; family roles; child-rearing practices and roles of the aged; and social status.
Workforce issues. Concepts related to autonomy; acculturation; assimilation; and health
care practices from the country of origin.
Biocultural ecology. Variations in ethnic and racial origins; and differences in the way
drugs are metabolized by the body.
High-risk behaviors. Includes the use of tobacco, alcohol, and recreational drugs; lack of
physical activity; increased calorie consumption; and engaging in risky sexual practices.
Nutrition. Includes having adequate food; the meaning of food; food choices, rituals,
and taboos; and how food and food substances are used for health promotion and well-
ness and during illness.
Pregnancy and childbearing practices. Includes fertility practices; birth control methods;
and practices related to pregnancy, birthing, and postpartum.
Death rituals. Includes behaviors to prepare for death and burial practices; and bereave-
ment behaviors.
Spirituality. Includes religious practices and the use of prayer; behaviors that give mean-
ing to life; and individual sources of strength.
Health care practices. Includes acute or preventive focus of health care; traditional, magi-
coreligious, and biomedical beliefs; individual responsibility for health; self-medicating
practices; and barriers to health care.
Health care practitioner concepts. Includes status, use, and perceptions of providers; and
gender of the health care provider.
According to Purnell (2000, p. 43), cultural competence is the adaptation of care in a
manner that is congruent with the culture of the client. The model provides a structure for
identifying cultural elements to assess, plan, and intervene in a culturally competent manner.
Duffy (2001) directly challenges the current emphasis in providing culturally competent
care by adapting care from the dominant culture of the health care provider to the culture of
the client. Duffy (2001, p. 487) disagrees with the highlighting of unique, exotic, or unusual
differences between groups, contending that by developing a composite portrait, the group is
homogenized and stereotyped, and, in addition, globalization contributes to differences
within cultures that may equal or exceed differences between cultures. This last assertion,
which challenges Leiningers theory of culture care diversity and universality, can be evalu-
ated through ongoing research.
Duffy (2001) contends that the emphasis on understanding stereotypes of another culture
fosters feelings of cultural superiority, with care subsequently focused on changing the indi-
vidual rather than society. She states that the emphasis should be on the shared human
attributes that create a common global culture (p. 491), with emphasis on risk-taking, criti-
cal self-reflection, and shared power interactions co-creating cultural inclusion.
Andrews and Boyle (1999, p. 15) also contend that transcultural nursing has done too little
to encourage nurses to be actively involved in setting political, economic and social policy agen-
das. It is necessary to go beyond awareness of ones own and other cultures. Positive experiences
and a genuine valuing of the contributions of other cultures are needed in order to alleviate and
eventually eradicate prejudice, bigotry, discrimination, and ethnic or cultural violence.
Nurses need knowledge and skills for multicultural assessment and intervention of clients,
organizations, government, and/or community agencies including abilities to:
1. recognize cultural diversity;
2. understand the role that culture and ethnicity/race play in the sociopsychological and
economic development of ethnic and culturally diverse populations;
3. understand that socioeconomic and political factors significantly impact the psychoso-
cial, political, and economic development of ethnic and culturally diverse groups;
4. help clients to understand/maintain/resolve their own sociocultural identification,
and understand the interaction of culture, gender, and sexual orientation on behavior
and needs.
UNDERSTANDING CULTURAL AND ETHNIC DIFFERENCES

Huff and Kline (1999) suggest ways in which understanding and appreciating cultural and
ethnic differences can be used by the nurse to facilitate the success of health promotion efforts.
Guidelines for working with diverse populations can be found in Box 5-2.
Be aware of the many ways of perceiving, understanding, and approaching health and dis-
ease processes across cultural and ethnic groups. Cultural differences can and do present
major barriers to effective health care intervention, as competing values, beliefs, norms,
and health practices may be in conflict with the traditional Western biomedical model.
Understand how the concepts of culture, ethnicity, acculturation, and ethnocentrism
may affect the ability to assess, plan, implement, and evaluate health promotion devel-
opment programs. Be careful in the assessment, intervention, and evaluation planning
processes not to overlook, misinterpret, stereotype, or otherwise mishandle encounters
with those who might be viewed as different.
Assess the degree to which the culture of the target group has been modified through
contact with other cultures (acculturation) when working in a multicultural setting
because there is a natural tendency on the part of many culturally diverse individuals to
resist acculturation. Be aware that ethnicity often is used to stereotype diversity in
human populations and frequently can lead to misunderstanding and/or distrust in all
sorts of human interactions.
Be careful not to become caught in personal ethnocentrism, because culturally diverse
target groups may view the nurse as foreign; ignorant of illness or disease causality; or
uneducated to proper social customs, forms of address, and nonverbal behaviors deemed
appropriate by the groups for dealing directly or indirectly with their health problems
B OX 5-2
Guidelines for Working with Ethnically,
Linguistically, and Culturally Diverse
Populations
1. Incorporate an understanding of the clients ethnic and cultural background.
2. Be aware of how their own culture/background/experiences, attitudes, val-
ues, and biases influence psychological processes.
3. Help clients increase their awareness of their own cultural values and norms.
4. Help a client determine whether a problem stems from racism or bias in oth-
ers.
5. Respect the roles of family members and community structures, hierarchies,
values, and beliefs within the clients culture.
6. Respect clients religious and/or spiritual beliefs and values, including attri-
butions and taboos.
7. Interact in the language requested by the client.
8. Consider the impact of adverse social, environmental, and political factors in
assessing problems and designing interventions.
9. Work to eliminate biases, prejudices, and discriminatory practices.
10. Document culturally and sociopolitically relevant factors in the records.
Source: American Psychological Association. APA guidelines for providers of psychological services to
ethnic, lingistic, and culturally diverse populations. Accessed 1/4/05 at http://www.apa.org/pi/
oema/guide.html.
or concerns. Seek to become more culturally competent and sensitive. The process is
ongoing. Be willing to step out of your own current frames of reference and take the risk
of discovering personal biases and stereotypes and opening up to new and perhaps quite
divergent points of view about the world.
Be acutely aware that in an interaction between two or more individuals representing
divergent cultural orientations, the rules governing the communication process may be
different and the opportunity for miscommunication is significant. Remember that the
typical Western biomedical model for health care communication seeks to quickly
establish facts. This approach may be seen as cold, too direct, or otherwise in conflict
with more traditional beliefs, values, and ways of communicating and of seeking and
receiving health care.
Be aware that the health concepts held by many cultural groups may result in people
choosing not to seek Western biomedical treatment procedures because they do not
view the illness or disease as coming from within themselves (in Western cultures, the
locus of control tends to be more internally oriented). Recognize that individuals from
other cultures might not follow through with health-promoting or treatment recom-
mendations because they perceive the medical or nursing encounter as a negative or per-
haps even hostile experience.
Recognize that the more disparate the differences are between the biomedical model
and the lay/popular explanatory models, the greater the potential for resistance to
Western health development programs. If the more traditional person does seek West-
ern biomedical treatment, then that person might not be able to provide or describe his
or her symptoms in precise terms. Folk illnesses are generally learned syndromes that
individuals from particular cultural groups claim to have and from which their culture
defines the etiology, behaviors, diagnostic procedures, prevention methods, and tradi-
tional healing or curing practices.
Remember that most cases of lay illness have multiple causalities and may require sev-
eral different approaches to diagnosis, treatment, and cure including folk and Western
biomedical interventions. Folk illnesses, which are perceived to arise from a variety of
causes, often require the services of a folk healer who may be a local curandero, shaman,
native healer, spiritualist, root doctor, or other specialized healer.
UNDERSTANDING CULTURAL AND ETHNIC COMMONALTIES

In the spirit of Duffys (2001) recommendation to focus on commonalties across cultural
and ethnic groups, Box 5-3 proposes common strategies for understanding cultural and eth-
nic groups.
B OX 5-3
Common Strategies for Cultural
and Ethnic Understanding
Examine your own perceptions, stereotypes, and prejudices and be will-
ing to suspend judgments (where they exist) in favor of learning who these
people really are rather than who or what you might think they are. This
is a critical first step in developing cultural competence and sensitivity.
continued
B OX 5-3 CONTINUED
All care requires co-participation of nurse and clients working together.
Plans and decisions should be made with clients.
Engage in active listening (rather than talking) and be alert to non-
verbal cues.
Autonomy is not the central value in many cultures. Appreciate the rela-
tive valuing of independence and cooperation.
Appreciate that family and family support is one of the most important
core values. Be aware how devastating separation from family members
can be to a culture that values the nuclear and extended family.
Be aware of the dynamics within the family. Recognize that one adult
might be the spokesperson for the family, but try to elicit all opinions.
Understand that a trusting relationship must be established before con-
cerns are shared with the nurse.
Recognize that belief in folk illnesses still is a strong cultural characteris-
tic among many population groups with strong traditional roots.
Recognize that traditional folk healers often are the first health practition-
ers consulted because they are culturally acceptable, willing to make
house calls, and far less expensive than the Western health care system.
Do not overlook traditional or cultural beliefs of spiritual or supernatural
forces and balance with nature.
Be aware that avoiding conflict and achieving harmony in interpersonal
relationships may be a strong cultural value.
Be aware that many traditional family patterns are characterized by filial
piety, male authority, and respect for elders and that this pattern sometimes
determines decision-making practices relating to health care. Knowledge is
shown in a context of respect rather than through direct asking.
Address illiteracy by using picture stories, videos, sociodrama, and story-
telling with appropriate cultural imagery.
Understand that health beliefs and practices will vary between urban and
rural areas and between cultures of origin.
Recognize that socioeconomic status has a greater impact on health sta-
tus than does ethnicity.
Recognize that lifestyle risk factors are more important predictors of dis-
eases than is ethnicity (e.g. intravenous drug use and HIV infection) (Hopp
& Herring, 1999, p. 218).
Appreciate that there is a healthy suspicion in many communities about
programs and services coming from outside the community.
Source: Adapted from Huff, R. M., & Kline, M. V. (1999). Promoting health in multicultural popula-
tions: A handbook for practitioners (pp. 383-394). Thousand Oaks, CA: Sage.
At the system level, it is clear that the sociopolitical contexts of poverty, racism, immi-
gration, and culture have had a significant bearing on access to health care, utilization of
services, and health status (Chin, 2000, p. 28). In addition to the acknowledged need for
language access, cultural competence in health care requires attention to quick, convenient,
and readily obtainable services (access to care), appropriate utilization of services, and qual-
ity of care. Unfortunately, language, cultural, and financial barriers can result in delayed
entry into care, under utilization of services, and/or over utilization of the emergency room
(Chin, 2000).
Clearly, it is appropriate for the nurse to take the time in an initial needs assessment to
explore the explanatory models of the cultural or ethnic group with which he or she will be
working, but also recognize the influence of the global community, other groups, and indi-
viduals on the individual expression of culture (Duffy, 2001, p. 490). Cultural interactions
should emphasize shared power and mutual communication, learning, and changing. The
individual, not the professional, is the expert. Health promotion activities can best be fos-
tered by focusing on universal commonalities and individual distinctiveness.
Chapter Key Points

Ethnic and cultural beliefs play a significant role in the development of a persons
health beliefs.
Indigenous health beliefs of Asian Americans (Vietnamese Americans), Appalachians,
Native Americans, African Americans, and Hispanics (Mexican Americans) must be
incorporated into multicultural health promotion care.
Multicultural care is needed to reduce medicocentrism (medical ethnocentrism), and
culturally based misunderstandings between nurses and their clients.
Multifaceted assessment is critical to the development of multicultural health promo-
tion interventions.
Both cultural and ethnic differences and commonalties must be considered in planning
for culturally competent health promotion.
References
Airhihenbuwa, C. O. (1995). Health and culture: Beyond the Western paradigm. Thousand Oaks, CA: Sage.
American Psychological Association. APA gruidelines for providers of psychological services to ethnic,
lingistic, and culturally diverse populations. Accessed 1/4/05 at http://www.apa.org/pi/oema/
guide.html.
Andrews, M. M., & Boyle, J. S. (1999). Transcultural concepts in nursing care (3rd ed.). Philadelphia: Lip-
pincott.
Applewhite, S. L. (1995). Curanderismo: Demystifying the health beliefs and practices of elderly Mexican
Americans. Health & Social Work, 20, 247-253.
References 125
Banks-Wallace, J. (2000). Womanist ways of knowing: Theoretical considerations for research with African
American women. Advances in Nursing Science, 22, 33-45.
Beinfield, H., & Korngold, E. (1995). Chinese traditional medicine: An introductory overview. Altern Ther
Bell, R. (1994). Prominence of women in Navajo healing beliefs and values. Nursing & Health Care, 15,
232-240.
Burk, M. E., Wieser, P. C., & Keegan, L. (1995). Cultural beliefs and health behaviors of pregnant Mexi-
can-American women: Implications for primary care. Advances in Nursing Science, 17, 37-52.
Burkhardt, M. A. (1994). Becoming and connecting: Elements of spirituality for women. Holistic Nursing
Practice, 8(4), 12-21.
Calhoun, M. A. (1985). The Vietnamese woman: Health/illness attitudes and behaviors. Health Care for
Women International, 6, 61-72.
Chin, J. L. (2000). Culturally competent health care. Public Health Rep, 115, 25-33.
Cohen, K. B. (1998). Native American medicine. Altern Ther Health Med, 4, 45-57.
Corin, E. (1995). The cultural frame: Context and meaning in the construction of health. In B. C. Amick,
S. Levine, A. R. Tarlov, & D. C. Walsh (Eds.), Society and health (pp. 272-303). Oxford, England:
Oxford University Press.
DAvanzo, C. E. (1992). Barriers to health care for vietnamese refugees. J Prof Nur, 8(4), 245-253.
Drew, J. C. (1997). The ethnocultural context of healing. In P. B. Kritek, (Ed.), Reflections on healing. A
central nursing construct. New York: National League for Nursing.
Duffy, M. E. (2001). A critique of cultural education in nursing. J Adv Nurs, 36, 487-495.
Fiscella, K., Franks, P., Gold, M. R., & Clancy, C. M. (2000). Inequality in quality: Addressing socioeco-
nomic, racial, and ethnic disparities in health care. JAMA, 283, 2579-2583.
Flaskerud, J. H., & Winslow, B. J. (1998). Conceptualizing vulnerable populations health-related research.
Nurs Res, 47, 69-78.
Frye, B. (1995). Use of cultural themes in promoting health among southeast Asian refugees. American
Journal of Health, 9(4), 269-280.
Giger, J. N., & Davidhizar, R. E. (1995). Transcultural nursing: Assessment and intervention (2nd ed.). St
Louis: Mosby.
Healy, E. A. (1997). Health locus-of-control beliefs in vietnamese clients with latent tuberculosis. Nursing
Connections, 10(2), 39-46.
Helman, C. G. (1994). Culture, health and illness (3rd ed.). Oxford, England: Butterworth-Heinemann.
Helton, L. R. (1996). Folk medicine and health beliefs: An Appalachian perspective. Journal of Cultural
Diversity, 3, 123-128.
Hopp, J. W., & Herring, P. (1999). Promoting health among Black American populations: An overview. In
R. M. Huff, & M. V. Kline, Promoting health in multicultural populations: A handbook for practition-
ers (pp. 201-221). Thousand Oaks, CA: Sage.
Huff, R. M. (1999). Cross-cultural concepts of health and disease. In R. M. Huff, & M. V. Kline, Promot-
ing health in multicultural populations: A handbook for practitioners (pp. 23-39). Thousand Oaks,
CA: Sage.
Huff, R. M., & Kline, M. V. (1999). Promoting health in multicultural populations: A handbook for practi-
tioners. Thousand Oaks, CA: Sage.
Hufford, D. J. (1995). Cultural and social perspectives on alternative medicine: Background and assump-
tions. Altern Ther Health Med, 1, 53-61.
Hufford, D. J. (1996). Culturally grounded review of research assumptions. Altern Ther Health Med, 2, 47-53.
Kline, M. V., & Huff, R. M. (1999). Tips for the practitioner. In R. M. Huff, & M. Kline, Promoting health
in multicultural populations: A handbook for practitioners (pp. 103-111). Thousand Oaks, CA: Sage.
Krippner, S. (1995). A cross-cultural comparison of four healing models. Altern Ther Health Med, 1, 21-29.
Leininger, M. M. (1991). Culture care diversity and universality: A theory of nursing (pp. 103-112). New York:
Leininger, M. M. (1999). What is transcultural nursing and culturally competent care? Journal of Transcul-
tural Nursing, 10, 9.
Louie, K. B. (1995). Cultural considerations: Asian-Americans and pacific islanders. Imprint, 42, 41-44, 46.
Lowe, J., & Struthers, R. (2001). A conceptual framework of nursing in Native American culture. Journal
of Nursing Scholarship, 33(3), 279-283.
Mehl-Madrona, L. E. (1999). Native American medicine in the treatment of chronic illness: Developing
an integrated program and evaluating its effectiveness. Altern Ther Health Med, 5, 36-44.
Mensah, L. (1993). Transcultural, cross-cultural and multicultural health perspectives in focus. In R. Masi,
L. Mensah, & K. A. McLeod (Eds.), Health and culture: Exploring the relationships (Vol. 1, pp. 33-
41). Oakville, Canada: Mosaic Press.
Nguyen, M. D. (1985). Culture shock: A review of Vietnamese culture and its concepts of health and dis-
ease. West J Med, 142, 409-412.
Purnell, L. (2000). A description of the Purnell model for cultural competence. Journal of Transcultural
Nursing, 11, 40-46.
Purnell, L. D., & Counts, M. (1998). Appalachians. In L. D. Purnell & B. J. Paulanka (Eds.), Transcultural
health care: A culturally complete approach. Philadelphia: Davis.
Reed, B. W., Wineman, J., & Bechtel, G. A. (1995). Using a health risk appraisal to determine an
Appalachian communitys health care needs. Journal of Cultural Diversity, 2, 131-135.
Small, C. C. (1995). Appalachians. In: J. N. Giger & R. E. Davidhizer (Eds.), Transcultural nursing: Assess-
ment and intervention (2nd ed.). St. Louis, MO: Mosby.
Smith, C. A. (1995). The lived experience of staying healthy in rural African American families. Nursing
Science Quarterly, 8, 17-21.
Smith, L. S. (1998). Concept analysis: Cultural competence. Journal of Cultural Diversity, 5, 4-10.
Sortet, J. P., & Banks, S. R. (1997). Health beliefs of rural Appalachian women and the practice of breast
self-examination. Cancer Nurs, 20, 231-235.
Stein, H. F. (1990). American medicine as culture. Boulder: Westview Press.
Struthers, R., Escheti, V. S., & Patchell, B. (2004). Traditional indigenous healing: Part I. Complementary
Therapies in Nursing and Midwifery, 10, 141-149.
Suarez, L., & Ramirez, A. G. (1999). Hispanic/Latino health and disease: An overview. In R. M. Huff, &
M. V. Kline (Eds.), Promoting health in multicultural populations: A handbook for practitioners (pp.
115-136). Thousand Oaks, CA: Sage.
References 127
Tarlov, A. R. (1999). Public policy frameworks for improving population health. Annals of the New York
Academy of Sciences, 896, 281-293.
Toumishey, H. (1993). Multicultural health care: An introductory course. In R. Masi, L. Mensah, & K. A.
McLeod (Eds.), Health and culture: Exploring the relationships (Vol. 1, pp. 113-138). Oakville,
Canada: Mosaic Press.
Trotter, R. T. (1996). Curanderismo. In M. S. Micozzi (Ed.), Fundamentals of complementary and alternative
medicine (pp. 259-277). New York: Churchill Livingstone.
Trotter, R. T. (2001). Curanderismo. In M. S. Micozzi (Ed.), Fundamentals of complementary and alternative
medicine (2nd ed., pp. 411-428). New York: Churchill Livingstone.
U.S. Department of Health and Human Services. (n.d.). The initiative to eliminate racial and ethnic disparities
in health. Retrieved September 3, 2001, from http://www.omhre.gov/rah
Yali, A. M., & Revenson, T. A. (2004). How changes in population demographics will impact health psy-
chology: Incorporating a broader notion of cultural competence into the field. Health Psychology,
23, 147-155.
ETHICAL AND LEGAL INFLUENCES
ON HEALTH PROMOTION
6
Abstract
Normative ethics, which addresses questions of value and action based on abstract principles,
is the primary standard for ethical decision making in biomedicine and nursing. This chapter will
discuss preferential valuing among the normative ethical principles of autonomy, nonmalefi-
cence, beneficence, and justice, but will also discuss a model with the broader values of integrated
humanity, ecological integrity, naturalism, relationalism, and spiritualism as a basis for profes-
sional ethics in integrative health promotion. This content is followed by issues of power and
empowerment, a review of licensing issues, negligence, electronic transmittal of health informa-
tion, and implications of food and drug regulation, with special consideration for health promo-
tion and healing. The chapter concludes with a brief discussion of the nurses role in promoting
health policy.
Learning Outcomes
Differentiate between values, ethics, and morals

Discuss ethical issues related to power and empowerment
Discuss the differences between the ethical frameworks of utilitarianism, liberalism,
contextualism, and deontology
Differentiate ethical universalism from relational narrative
130 Chapter 6 Ethical and Legal Influences on Health Promotion
Discuss the implications for integrative health promotion of the ethical principles of
autonomy, nonmaleficence, beneficence, and justice
Discuss licensure implications of incorporating noninvasive therapeutic modalities into
integrative nursing care
Describe ways to prevent claims of negligence
Discuss the implications of standard of care
Discuss the nurses role in promoting health policy
Ethical Influences
Values are ideals or concepts that give meaning to an individuals life. They are most com-
monly derived from societal norms, religion, and family orientation and serve as the frame-
work for making decisions and taking certain actions in everyday life. Values are very
important in both moral behavior and ethical decisions. Morals are personal standards for
right and wrong behavior that an individual learns and internalizes. Moral behavior is often
manifested as behavior in accordance with a groups norms, customs, or traditions. Ethics are
societal standards of what is right or wrong, and what ought to be. Ethics, which are usually
presented as systems of valued behaviors and beliefs, serve the purpose of governing conduct
to ensure the protection of individual or group rights.
Most of the ethical issues that affect nurses who incorporate health promotion and heal-
ing into their practice have been addressed with normative ethics. Normative ethics include
questions about what ethical principles and values should be adopted, what reasons count as
ethical reasons, what actions should be performed, and why some principles or values should
be chosen over others (Kuhse, 1997). Traditionally, normative ethics have been considered
reflective, involving sound reasoning, impartial, and universal.
Categories of Ethical Frameworks

Within normative ethics, there are several different frameworks for judging ethical or
moral behavior. To provide a context for ethical decision making, each individual must
decide which ethical worldview provides what seems to him or her to be the most accept-
able framework for judgements. Some individuals will be most comfortable applying one per-
spective in all situations, while other individuals will modify their perspective depending on
the particular situation.
UTILITARIANISM
Utilitarianism posits that behavior that leads to the greatest good, or lessens the greatest
amount of bad for the greatest number, is moral. Utilitarian frameworks focus on the end
(greatest good) and on the responsibility of the individual to the good of the community
(Rothschild, 2000). Several clarifications or questions are indicated below:
Conventional Normative Ethical Principles 131
It is not required that all share equally in happiness or the good or that an attempt be
made to serve all.
By providing the greatest good, or greatest utility, to the greatest number, the ends jus-
tify the means.
How does one decide what is the greatest good?
How does one choose in conflicts between what is good for the individual and the group?
LIBERALISM
Liberalism focuses on individual rights and freedom from coercion. Several clarifications
or questions are indicated below:
Calls for the greatest good for the greatest number.
All persons should have an equal right to free choice without coercion.
Freely chosen behaviors should not impede any other persons ability to equally pursue
free choice.
What are the limits of freedom? (e.g., private liberty vs. public cost)
CONTEXTUALISM
Contextualism relates and binds ethics to time and place. Several clarifications or ques-
tions are indicated below:
In contextualism, there is a moral, bounded, or cultural relativism where ethical standards
are dictated by the society and those in power, judged by the customs, rules, and norms of
the society, and grounded in the history of the community (Rothschild, 2000, p. 31).
What is ethical or moral is seen as being the result of negotiations among those in power.
Nothing is absolute.
DEONTOLOGY
Deontology proposes that absolute ethical standards hold universally and categorically.
Several clarifications or questions are indicated below:
Moral rightness or wrongness is considered separately from the consequences.
What do you do when basic guiding principles conflict?
Under what circumstances are exceptions to the rules applicable?
Conventional Normative Ethical Principles

Principle-based ethics is a systematic method of resolving ethical problems that involves
reflection on general principles such as beneficence (producing benefit), justice (fairness),
autonomy (independence), veracity (truth telling), fidelity (faithfulness to obligations, duties
or observances), and avoidance of killing. In applying these principles to a specific situation,

one must first identify which principles are involved and then weigh and balance the com-
peting claims that each principle obligates us to honor. Furthermore, none of the principles
is assumed to have priority over the other. Principles also allow a distancing from the more
subjective, contextual aspects of a particular situation and thereby help us to avoid bias and
self-interest (Haddad, 1998, p. 37). Ethically, a right is a morally justified claim that oth-
ers should respect, and by extension, it entails a responsibility on the part of others either not
to interfere with that claim or to provide assistance (Schwarz, 2000, p. 64).
In contrast with Haddad (1998), who indicates that none of the ethical principles has
assumed priority, Nash (1999, p. 92) states that in descending order of priority, the four
principles of biomedical ethics are:
Autonomy
Nonmaleficence
Beneficence
Justice
Hall (1996, p. 108) states that the value of doing good [beneficience] is the highest value
for nurses. None of these authors provides justification for their statements. However, it
appears that if the nurses beliefs are consistent with ethical universalism, an accepted hier-
archy of biomedical ethical principles would facilitate clinical decision making, especially
when competing ethical principles are involved. Respect for the autonomy of the client
would always be the first consideration, followed by the avoidance of harm, action to help,
and, finally, fairness. In contrast, it is interesting that much of the discussion of medical ethics
in the popular press seems to put fairness first as, for example, in policies for distribution of
resources.
AUTONOMY
Autonomy requires that a person act in a manner that respects the rights of others to freely
determine their own choices and destiny. A competent [client] has absolute veto power over
our best intentions. The [client] is in chargeethically, legally, and morallywhether we
like it or not (Nash, 1999, p. 92). Autonomy presumes that the client is competent. Telling
the truth, client confidentiality, privacy, informed consent, and allocation of resources are all
part of autonomy. The first part of provision one of the Code of Ethics for Nurses (ANA,
2001) states that the nurse, in all professional relationships, practices with compassion and
respect for the inherent dignity, worth and uniqueness of every individual. . .
The ethical obligation of respect for persons, or autonomy, is the basis for well-established
expectations of shared nurse-client decision making and informed consent. The belief that in
certain circumstances it is acceptable to disregard a persons views in favor of promoting his
or her health is deeply ingrained in the biomedical model view of health care. This benevo-
lent restriction of another persons freedom is called paternalism (from the Latin for father)
or maternalism (from the Latin for mother). The assumption is that others need to be pro-
tected, because they do not know what is best for them (Bournes, 2000). However, pater-
Conventional Normative Ethical Principles 133
nalism is seldom justified, despite our acts of mercy, kindness, and charity. Positive acts to pre-
vent illness and promote health are ethical (Nash, 1999, p. 93).
A high value is placed on individual independence in American culture, but it should be
remembered that in many cultures autonomy is not the central value. Empathy and accom-
modation to the beliefs of a client or family are preferable to an overzealous insistence on
handling all clients in one way. On the other hand, deception is not permissible, and nurses
cannot avoid responsibility for willing participation in group decisions and actions, and physi-
cians cannot assume authority over others in ethical matters. A team can develop a self-
righteous opinion of the good it is doing and thus give its decisions self-justification, thereby
infantilizing the [client] (Pellegrino, 1998, p. 1522).
Informed Consent
Informed consent arises from the ethical principle of respect for autonomy. The essence of
informed consent should be the capacity of the client to understand and make a rational deci-
sion. However, unfortunately the language of consent connotes compliance not collaboration or
agreement (Green, 1999, p. 108), which is contrary to the principle of autonomy. Informed con-
sent should be a voluntary, uncoerced decision based on adequate information and deliberation
by a sufficiently competent person. In addition, consent should be viewed as a process with ongo-
ing discussion and negotiation to confirm the continued agreement of the client (Norton, 1995).
Often, the approach to informed consent is to satisfy an administrative requirement or to
protect oneself from liability, rather than as a meaningful component of enhanced client
involvement in the decision making process (Braddock et al., 1999). What is desired is a
meaningful dialogue about healing methods and outcomes instead of a one-way dutiful dis-
closure of alternatives, risks, and benefits. According to Braddock and colleagues (1999), this
expanded view is termed informed decision making. Green (1999), in turn, proposes a col-
laborative planning model that changes the understanding of professional liability from tort
concepts that are based on standards of care to a contract model that is based on the doctrine
of assumption of risk. He suggests that the scope of professional services should be formalized,
and mutually agreed upon, in an early interview.
In order to enhance client involvement in the decision-making process, the following ele-
ments of informed decision making are proposed (Braddock et al., 1999):
Discussion of the clients role in decision-making. Many clients are not aware that they can
and should participate in decision making.
Discussion of the clinical issue or nature of the decision. A clear statement of what is at issue
helps to clarify what is being decided.
Discussion of the alternatives. A decision is always a choice among certain options,
including doing nothing at all.
Discussion of the pros (potential benefits) and cons (risks) of the alternatives. Discussion of
the pros of one option and the cons of another.
Discussion of the uncertainties associated with the decision.
Assessment of the clients understanding. Fostering understanding is really the central goal
of informed decision making.
Exploration of client preference. It should be clear to the client that it is appropriate to

disagree or ask for more time.
NONMALEFICENCE
Nonmaleficence requires that one avoid doing harm to others. It is a duty that applies gen-
erally, even in the absence of a professional obligation. Not harming clients unnecessarily in
the process of providing care is a well-recognized ethical principle. For example, thorough his-
tory taking is critical in order to prevent potentially harmful interactions between conven-
tional biomedicine and therapeutic noninvasive modalities. The principle of nonmaleficence
(do no harm) is above beneficence, that is the principle to help (Nash, 1999). Nonmalefi-
cence protects the incompetent client. However, good intentions alone dont morally justify
an act (Schwarz, 2000, p. 61). The principles of nonmaleficence and beneficence are com-
bined in provision three of the Code of Ethics for Nurses (ANA, 2001), The nurse promotes,
advocates for, and strives to protect the health, safety, and rights of the patient, and provi-
sion five, The nurse owes the same duties to self as to others, including the responsibility to
preserve integrity and safety, to maintain competence, and to continue personal and profes-
sional growth.
Is it ethical to hold the client personally responsible for behavior that may increase health
risk? In consideration of the ethical principle of causing no harm, Guttman and Ressler
(2001) suggest that a person can only be held responsible if s(he) is self-aware, free not to
engage in potentially hazardous behavior, the behavior deemed risky is deliberate or carried
out for personal gratification, and the undesirable health outcome can only be caused by the
particular behavior(s) in question. There is concern that inappropriate attribution of culpa-
bility, particularly for highly vulnerable groups, may result in added suffering and fatalism or
feelings of guilt.
Nurses who practice integrative health promotion have an ethical obligation to apply the
principle of nonmaleficence. But, how can the nurse do no harm and also promote informed
consent of clients given the limited availability of scientific data regarding the safety, effi-
cacy, optimal dosage, and side-effects or interactions of some therapies (Clark, 2000, p. 448)?
Of specific concern is the risk for potential adverse interactions involving prescription med-
ications and herbal or high-dose vitamin supplements. Nurses must seek appropriate educa-
tion to develop the relevant knowledge and skills to avoid client injury.
BENEFICENCE
Beneficence means taking action to help a client. Nurses have a duty to act positively
and contribute to the well-being of their clients. Accountability extends to lack of care and
the nurse may be asked to justify why certain care, including noninvasive therapies, was not
performed. For example, massage is an essential component of nursing which is an effective
intervention for pain, insomnia, and anxiety (Norton, 1995), but many nurses do not provide
this therapy, relying exclusively on medically prescribed drugs. The principle of beneficence
refers to a professional obligation to act for the good or to benefit others (Milton, 2000).
JUSTICE
A central concern of justice in health care relates to fairness. For example, the health care
delivery system has been severely criticized for uneven access to health care due to a variety
Critiques of Conventional Ethics 135
of societal conditions. Nurses need to be involved in addressing the issues that affect just dis-
tribution of health care. Another concern related to justice is that clients have fair access to
noninvasive therapeutic modalities that are known to be safe, effective, and appropriate as
well as to conventional biomedical therapies (Sugarman & Burk, 1998). The second part of
provision one of the Code of Ethics for Nurses (ANA, 2001) states . . . unrestricted by con-
siderations of social or economic status, personal attributes, or the nature of health problems.
A global perspective is necessary in considering quality of life and justice issues such as liv-
ing in poverty, surviving as victims of war, genocide, or environmental disasters, dealing with
issues of racism and sexism, or living in situations where there is a lack of humanitarian effort
(responses to the struggles of humanity) (Bunkers, 2001, p. 297). Johnstone (1998, p. 43)
stresses the need to advance a genuinely nursing perspective on . . . the otherwise neglected
broader social justice issues associated with promoting the well-being and significant moral
interests of marginalized groups.
Critiques of Conventional Ethics

THE CARE CRITIQUE
During the past 20 years, a number of philosophers have criticized and tried to find alter-
natives to traditional normative ethics. For example, in work that has significant implications
for nursing, Gilligan (1982) suggested that there is a difference between womens and mens
moral perspectives. She asserted that her research showed that many men have a language of
impartiality, which fits comfortably with traditional ethical systems. In contrast, many women
have a relational language, where the emphasis is on individualized caring that is contextu-
alized within a relationship. Gilligan (1987) describes the difference between a care and the
traditional justice approach as follows: From a justice perspective, the self as moral agent
stands as the figure against a ground of social relationships, judging the conflicting claims of
self and others against a standard of equality or equal respect . From a care perspective, the
relationship becomes the figure, defining self and others. Within the context of relationship,
the self as a moral agent perceives and responds to the perception of need. This shift in moral
perspective is manifest by a change in the moral question from What is just? to How to
respond? (p. 23). An ethical approach based on care criticizes the abstraction and the uni-
versal application of principles of conventional normative ethics, arguing for the importance
of the individual context for each particular situation.
SELECTED ETHICAL NURSING CONCERNS

Discussions of nursing ethics have typically tended to emphasize ethical decision making
in clinical situations, with nurses and other health care providers paternalistically viewed as
the primary decision makers. Each of the steps in the process for resolving ethical dilemmas
tends to be described through the value priority lens of the nurse (Milton, 2000). Ironically,
at the same time, nurses views on ethical issues have been either invalidated, trivialized, or
ignored altogether (Johnstone, 1998, p. 43). Fry and Duffy (2001) identified 32 end-of-life
treatment decisions, patient care issues, and human rights issues registered nurses are believed
to encounter frequently in practice. These ethical issues are summarized in Box 6-1.
B OX 6-1
Ethical Issues Frequently
Encountered
in Clinical Practice
1. End-of-treatment decisions:
Prolonging the dying process with inappropriate measures
Treatment or nontreatment despite client or family wishes
Use or removal of support including nutrition and hydration
To resuscitate or not to resuscitate
Treatment or nontreatment of a very disabled infant, child, or adult
Not considering the quality of clients life
Acting against ones own personal or religious views
Acting against clients personal or religious views
Determining when death occurs
Organ transplantation or organ or tissue procurement
Over- or underuse of pain management
Ordering too many or too few procedures, tests, etc.
Participation or refusal to participate in euthanasia or assisted
suicide
2. Patient care issues:
Staffing patterns that limit client access to nursing care
Child, spousal, elderly, or client abuse or neglect
Allocation of human, financial, or equipment resources
Implementing managed care policies that threaten quality of care
Breaches of client confidentiality or privacy
An irresponsible, unethical, incompetent, or impaired colleague
Ignoring client or family autonomy
An uninformed or misinformed client or family about treatment,
prognosis or medical alternatives
Rights of minors versus parental rights
continued
B OX 6-1 CONTINUED

Discriminatory treatment of clients

Unsafe equipment or environmental hazards
Conflict in nurse, doctor, or other professional relationship
Reporting unethical or illegal practice of a health professional or
agency
Implementing managed care policies threatening availability of care
3. Human rights issues:

Use or nonuse of physical or chemical restraints
Issues involving advance directives
Protecting patient rights and human dignity
Informed consent to treatment
Providing care with possible risk to RNs health (e.g., TB, HIV, vio-
lence)
Source: Adapted from Fry, S. T., & Duffy, M. E. (2001). The development and psychometric evaluation
of the Ethical Issues Scale. Journal of Nursing Scholarship, 33, 273277.
Nurses face multiple and frequently conflicting imperatives as organizational members

and subordinates to physicians orders . . . . The realities of business values permeating health
care, work settings operating within severe economic constraints, and redistribution of nurs-
ing manpower away from direct practice are not explicitly addressed in the current ANA
Code for Nurses (Hamric, 1999, p. 106). The ANA Code provides statements of moral ideals
rather than practical guidelines (e.g., commitment to caring for persons, client advocacy,
maintaining competence, accepting responsibility for ones judgments and actions). Conse-
quently, nurses have had limited guidance in how to practice ethically within the real world
of resource allocation decisions.
Nurses also have neglected broader social justice issues associated with promoting the well-
being and significant moral interests of marginalized or stigmatized groups (e.g., those with
mental health problems; survivors of child abuse, sufferers of domestic and elder abuse; the
poor; the homeless; the unemployed; the disabled; people from different cultural backgrounds;
and homosexuals). It is important to avoid stigmatization and assigning blaming the victim
pejorative labels to high-risk individuals.
Reflecting a paternalistic tradition, nurses have often used persuasion to get the client to
follow a prescribed plan. Sugarman and Burk (1998) imply that when there are known effec-
tive therapies for a life-threatening disease (e.g., a treatable bacterial infection), exerting
strong influence against therapeutic non-invasive modalities is appropriate, while influence
is less appropriate for diseases in which there is no clearly effective conventional treatment
(e.g., fibromyalgia). However, consistent with the principle of autonomy, respect for clients
requires that all clients are completely informed of the risks and benefits of all treatment
options and facilitated in their ability to make a choice. Last and Woolf (1996, p. 563) also
point out that when people have few or no other sources of pleasure or solace, clinicians
have a responsibility to ensure that patients really will be better off after they have changed
their behavior, not merely less prone to a particular risk factor (Last & Woolf, 1996, p. 563).
Conventional normative ethics fails to account for important aspects of the moral experi-
ence of nurses, such as interconnection with others and responsibility in relationships. Addi-
tionally, conflicts between principles often seem impossible to resolve (Haddad, 1998).
Haddad (1998, p. 382) points out that societal ethics requires societal definitions of termi-
nal illness, experimental treatment, and quality-of-life issues. Questions at this level always
revolve around the common good rather than that of individuals.
A MODEL FOR PROFESSIONAL ETHICS

Given the concerns mentioned above, Bolletino (1998) has developed a professional ethics
model that he labeled the law of the primacy of the patient. The law of primacy states that a
client is to be viewed and treated as unconditionally inviolate. The law provides a definition
of a client as 1) a total, multidimensional human being; 2) a unique individual; and 3) a per-
son capable of structuring his or her own life. Elaborating, Bolletino (1998) explained that:
1. The client is a total human being. Each client needs to be seen and responded to as an
individual with inseparable aspects: physical, psychological, emotional, intellectual,
historical, relational, creative, social, and spiritual. Practitioners refusal or inability to
extend their emotional boundaries can also be experienced by the client as a kind of
abandonment. If practitioners maintain a professional emotional detachment or
remain uninvolved, or if they are cold, distant, joyless, or out of touch with themselves,
the client is alone (p. 15).
2. The client is a unique individual. The individual is assessed, but not encountered (p.
12). . . . Viewing the [client] as a mechanism to be fixed, a statistic, a test result, an ill-
ness, a body part, a collection of symptoms, a diagnosis, or a member of any classifica-
tion is anti-therapeutic and unethical (p. 13). . . There is more and more evidence that
when the biomedical model underlies professional practice, the resulting view of the
[client] as something less than a whole person is anti-therapeutic. It is harmful, there-
fore unethical (p. 15).
3. The client has the ability to structure his or her own life. [Clients] are the leading authori-
ties on themselves. . . practitioners are the authorities on diagnosis and care (p. 13).
RELATIONAL NARRATIVE APPROACH TO PROFESSIONAL ETHICS

Instead of considering ethical principles as mutually exclusive alternatives, Gadow (1999,
p. 57), proposes an ethical framework with a triad of ethical layers: subjective immersion
(ethical immediacy), objective detachment (ethical universalism), and intersubjective
engagement (relational narrative) corresponding, respectively, to premodern, modern, and

postmodern ethics (see Box 6-2). In this framework, rather than the approaches being
viewed as oppositional, they are instead considered to be intrinsically related and mutually
enhancing, different perspectives that contribute to a better understanding of ethics as a
whole. As with normative ethical frameworks, there is no assumption that any approach is
necessarily superior.
B OX 6-2
Categories of Philosophical Ethics
1. Ethical immediacy:
Reflects an unreflective and uncritical certainty about the good that
reinforces certainty.
From a source that transcends the individual, such as religion, fam-
ily, customs, or the ethos of a profession.
Based on an experience of certainty that needs and allows no expli-
cation.
A strength is solidarity if nurse and client share an unquestioned
view of the good and are united in their attempt to realize that good
(p. 60).
Prevents fragmentation of the self that can result from self-ques-
tioning and critique. Immediacy serves to maintain the self and the
group as a coherent, harmonious whole (p. 60).
2. Ethical universalism:
Counters subjectivity with rational principles that are categorical
and unconditional.
Based on equalizing reason and universality; detachment provides
the distance needed for objectivity (p. 61).
Appreciates that principles can conflict in clinical situations. Inter-
pretation is required, and interpretations differ according to the per-
spectives of the people involved (p. 62).
Does not allow modifications based on individual and contextual
differences.
continued
B OX 6-2 CONTINUED
3. Relational narrative
Reflects personal responsiveness to the particular other. The valu-
ing of persons requires perception of each ones uniqueness, and
perception involves engagement (p. 63). Being present with per-
sons demonstrates a commitment for respecting and acknowledging
individuals as experts of their own lives Nurses do not try to
change the person or the meaning of the situation (Milton, 2000,
p. 113).
Based on intersubjectivity. Contrasts both with subjectivity of uncrit-
ical certainty and the objectivity of universal rules.
There is no uninterpreted basis [exists] from which to decide objec-
tively among meanings (p. 63).
Source: Adapted from Gadow, S. (1999). Relational narrative: The postmodern turn in nursing ethics.
Scholarly Inquiry for Nursing Practice: An International Journal, 13, 5769.
AN INTEGRATIVE MODEL FOR ETHICS

The majority of authors who write on the application of ethics to complementary and
alternative medicine (CAM), integrative medicine, and nursing have tried to modify and
apply normative bioethics to these new areas. However, Guinn (2001) argues that a new eth-
ical understanding is needed that incorporates the holistic, integrative, naturalistic, rela-
tional, and spiritual characteristics of CAM (p. 69).
Guinn (2001) suggests that conventional bioethics is too narrow and limited, and there-
fore characterizes an incomplete understanding of health care ethics. He suggests that each of
five core values: integrated humanity, ecological integrity, naturalism, relationalism, and spir-
itualism, reflect elements of both CAM and biomedicine, and that the principles of norma-
tive ethics are simply a subset within these values.
The concept of integrated humanity recognizes that people are not biological machines,
but are a unified whole. Each person is considered to be inherently unique and special, and
thus deserving of respect (embodies the conventional idea of autonomy). Being respectful of
[clients] time and commitments, greeting them courteously, and providing them with com-
fortable surroundings all reflect an attitude of respect (Guinn, 2001, p. 70). Each individual
is viewed within relationship with others, the world, and the transcendent (p. 70).
The concept of ecological integrity reflects the fact that clients do not live in isolation.
Social communities such as families and work, religious, economic, and political communi-
ties can create conditions that affect health. For example, a client with health insurance,
ample financial resources, and a supportive family is much more likely to get adequate
Power and Ethics 141
health care services than a client living alone in poverty. Nurses need to be sure that clients
are aware of available social services, as well as to promote health services through social
activism. However, as Guinn (2001) points out, the dominance of the autonomous patient
model (p. 70) as the interaction between a client and his or her physician or nurse, and
the principle of privacy, create limits on the ability to engage families or communities in
client care.
The concept of naturalism is based on understanding of health within an interactive exis-
tence within the natural world (p. 70). There are three aspects of this value: normality, com-
plexity, and dynamism. From this perspective, attention must be given to supporting natural
and normal tendencies toward health. Health is complex, not based on simple cause-and-
effect relationships, and therefore not amenable to reductionist empirical measurement.
Given that any change in the environment alters health interrelationships, care cannot be
reduced to commonalities, but rather must reflect the unique and individual environment of
each [client] and his or her reactions (p. 71).
The concept of relationalism acknowledges that the client and the nurse are not isolated
from each other, but rather enter into a relationship. In contrast to the current health care
system, in which relationships between the client and professional caregivers is based on
dynamics of power and the disparities of power (p. 71), relationships should be based on
mutual respect. Guinn suggests that caregivers are justified in sharing their opinions as well
as information in a relationship-based informed consent process. In addition, the manner in
which caregivers are treated by colleagues and the organization in which they work has a
direct bearing on how [clients] are cared for as well (p. 71).
The concept of spiritualism is based on the belief that health is significantly affected by
a persons mental and spiritual aspects. Healing is more than relief of symptoms or imbal-
ance in the body. This concept incorporates the spiritual dimension as an active force in the
care of clients. Implications of this concept include consideration of the ethics of the
placebo effect, which is real and has measurable outcomes. As Guinn (2001, p. 71) indi-
cates, An intention by the caregiver to create a placebo effect (by inducing the [client] to
believe in a treatment that is not proven to be efficacious) violates the caregivers duty of
honesty to the [client]. Although the belief might effect a cure, creating the belief would
require lying.
According to Guinn (2001, p. 72), the ideal of integrative ethics is to understand the
dynamic health of the whole individual in the context of his or her life. Given this purpose,
the core values of the integrative model have the potential to serve as an expanded ethical
framework for integrative nursing. However, an ethical framework for practice is only one of
the factors needed for the empowerment of nurses.
Power and Ethics

Empowerment and the idea that people can form a partnership with their health care
provider are implicit in the concept of health promotion. Financial support for health pro-
motion activities is required for a partnership to be successful. However, neither govern-
ments nor private insurance carriers have recognized or honored their obligation to provide
sufficient financial support for health promotion and disease prevention. Some health pro-
motion policies are clearly opposed for financial reasons. For example, stringent meat inspec-
tion for health protection may conflict with the economic interests of the food industry (Last
& Woolf, 1996).
One of the powers granted to conventional biomedicine by society is the privilege of defin-
ing truth as it pertains to a number of health-related issues. This creates an obvious, if uncon-
scious, temptation within conventional biomedicine to use the power to secure its own
economic dominance over potential competitors and to justify those practices in the name of
scientific truth, to which only regular physicians (and, of course, never their competitors)
have exclusive access (Brody et al., 1999, p. 47). For example, responses to complementary
and alternative medicine (CAM) have ranged from a perceived obligation to stifle harmful
practices, to acceptance of nonharmful modalities, to encouragement of the use of beneficial
interventions (Sugarman & Burk, 1998). Campaigns by organized medicine to protect turf
by disparaging CAM interventions, have the effect of creating confusion and doubt in the
minds of clients and nurses, effectively diminishing client access to potentially helpful non-
invasive therapeutic interventions.
Physicians, even with good intentions, may not realize how their use of power affects peo-
ple, as the exercise of power tends to be relatively invisible to a person in a more powerful
position (Brody et al., 1999). Current theories in ethics are based on the assumption that any
exercise of professional power can trespass on the clients vital rights and interests. Therefore,
ethics demands that exercise of power be critically examined and justifiednot only accord-
ing to what physicians and nurses think is good for the client, but also in terms of the clients
own free and informed choice. Greater influence, greater clinical expertise, more ethical con-
cern, and having ethics education have been associated with greater willingness to act in an
ethically troubling situation (Hamric, 1999).
Power is an important consideration for nurses and their clients. Since professional power
includes the ability to exercise professional judgment and to influence others accordingly,
nurses must balance their sense of purpose in caring for clients and their contextual, role-
dependent, and, especially in hierarchical structures, limited ability to fulfill that sense of pur-
pose (Haddad, 1998, p. 380). When nurses only consider the tasks to be accomplished and
restrict care to doctors orders, the hopes, wants, and desires of those who receive nursing
services go unnoticed (Milton, 2000, p. 114).
Power also needs to be considered in collaborative roles between nurses and other health
care professionals. In the past decade, there has been renewed interest in pursuing profes-
sional collaboration at least in part due to 1) increased complexity of technology and acuity
of patients in every type of practice setting from tertiary care to home care; 2) increased con-
cern about the practical limits of financial resources with the inevitable impact on client care
and patterns of reimbursement; 3) changes in consumer expectations of health care profes-
sionals (e.g., deepening mistrust due to fraud and abuse by health professionals); and 4)
awareness of the influence, both positive and negative, that collaboration among health pro-
fessionals has on client outcomes (Haddad, 1998).
Interprofessional collaboration is not just an issue of how individuals interact with one
another. Institutional and societal structures, such as structures of power, communication, sta-
tus, relationship, autonomy, expression, and respect . . . create an environment that shapes behav-
Legal Influences 143
iors such as ethical decision making (Haddad, 1998, p. 379). However, in situations where
nurses may lack status, an ethical framework can provide an alternative source of authority.
Legal Influences
Ethical considerations focus on personal values about right and wrong. In contrast, legal
influences on practice are generalized regulations that must be adhered to for nursing practice
within a professional license.
Law is the body of rules and regulations that governs peoples behavior as well as their
relationships with others in the society and with the state (Aiken, 1994, p. 3). Law uses
coercion to achieve behavior in a nonvoluntary manner or to threaten punishment for
noncompliance or inappropriate behavior (Rothschild, 2000). Civil law is concerned with
punishment for wrongs against individuals. The wronged individual may bring legal action
(a lawsuit) against the offender, seeking monetary compensation or the performance of a
specific act. A tort is any private (civil) injury or wrongful act (except for breach of con-
tract) committed against the person or property of another. There are different types of
torts, such as:
Intentional torts (for example, assault or battery). An intentional tort is a wrong that
results from a volition act committed with the intent to bring about certain conse-
quences (or with the knowledge that the consequence was likely to occur) and was a
substantial factor in bringing about the consequence (Ely-Pierce, 1999, p. 80).
Quasi-intentional torts (such as defamation or invasion of privacy). Quasi-intentional
torts are those torts in which the intent may not be as clear as with intentional torts.
However, as with intentional torts, the wrongdoer still commits a volitional act, which
brings about certain consequences (Ely-Pierce, 1999, p. 80).
Health care providers are regulated under each states police power, constitutional author-
ity delegated to each state to protect the safety of its citizens. Previous court decisions have
weighed police power more heavily than privacy, liberty, and free speech interests in the pro-
vision of and access to health care (Cohen, 1998). This power to protect citizens health,
safety, and welfare authorizes states to decide who may practice a profession such as nursing
or medicine, and to establish licensing boards that admit or exclude persons from practice.
Essential social values and culturally accepted models of health care are reflected in legal rules
(Cohen, 1998). Regulation is supposed to prevent indiscriminate practice of the healing arts
by unskilled and unlicensed practitioners (Cohen, 1998, p. 24).
The intent of existing legal authority is to protect clients from dangerous or worthless
treatments by relying on legal rules for matters such as licensing, scope of practice, and mal-
practice to sanction inappropriate provider behavior. Limited practice authority is granted by
licensing statutes to nonmedical health care providers, and courts enforce medical practice
acts strictly against providers who cross into diagnosis and treatment. In addition, food
and drug laws restrict the use of nutritional therapies to treat disease. Although such rules
reflect a sound regulatory concern for preventing overreaching by providers, they also can
result in legislative, regulatory, and judicial ratification of biomedical dominance and bio-
medicines attempt to monopolize professional healing (Cohen, 1998, pp. 117-118).
Because licensure is a political process, the power to protect public health, safety, and wel-
fare has been used to exclude or suppress from professional healing practice those persons and
modalities outside the biomedical paradigm (Cohen, 1998, p. 24).
LICENSURE LAWS
Licensure laws represent an example of a states exercise of its police power. Licensure laws
were originally intended to protect the consumer from unprepared or unscrupulous providers.
However, medical licensing has been criticized as protecting the licensed, not the [client], by
insulating physicians from the economic threat of other providers (Cohen, 1998). All states
define the practice of medicine, in part, by using such words as diagnosis, treatment, prevention,
cure, advise, and prescribe. These words are usually used in conjunction with disease, injury,
deformity, and mental or physical condition. The broad reach and interpretation of medical
practice acts expresses biomedical dominance and the conceptual narrowing of professional heal-
ing practice to biomedical diagnosis and treatment (Cohen, 1998, p. 31), providing a threat to
all nonmedical healthcare providers, including professional nurses.
To address the barriers to competition created by the all-encompassing scope in medical
practice acts (ANA, 1996), in 1996, the American Nurses Association (ANA) developed
a revised model practice act that places the primary responsibility for interpreting and enforc-
ing the scope of nursing practice in the Board of Nursing, through regulations, advisory, and
Board opinions. The Model Practice Act identifies nine skills that may be utilized in profes-
sional nursing performance.
However, a number of states have not followed the wording of the model practice act,
retaining language that gives the State Board of Medicine the authority to influence nursing
practice. For example, the Professional Nurse Law in the State of Pennsylvania defines the
practice of professional nursing as diagnosing and treating human responses to actual or
potential health problems through such services as case finding, health teaching, health coun-
seling, and provision of care supportive to or restorative of life and well-being, and executing
medical regimens as prescribed by a licensed physician or dentist. The foregoing shall not be
deemed to include acts of medical diagnosis or prescription of medical therapeutic or corrective meas-
ures, except as may be authorized by rules and regulations jointly promulgated by the State Board
of Medicine and the Board, which rules and regulations shall be implemented by the Board
(Pennsylvania State Board of Nursing, 1999).
Licensure provides a number of benefits, including creating a minimum level of profes-
sional competence, elevating of the image of a profession, reassuring public and legislative
concerns about quality control, preventing other professionals from gaining control over the
licensed profession, and providing a recognized basis for hospital privileges, insurance reim-
bursement, and other professional opportunities (Cohen, 1998).
However, the breadth of medical practice acts puts at least thee groups at risk of prosecu-
tion for unlawfully practicing medicine (Cohen, 1998, p. 29):
1. Providers who lack licensure.
2. Licensed providers (including physicians and nurses) who employ or refer clients to
providers practicing medicine unlawfully and therefore may be liable for aiding and
abetting unlicensed medical practice.
3. Licensed providers, such as chiropractors and, in many states, licensed naturopaths,

massage therapists, nurses, and others who are deemed to violate their legally author-
ized scope of practice by engaging in the diagnosis and treatment of disease. Nonmed-
ical providers such as nurses are limited to specific scope of practice authorized in their
licensing laws and are expressly prohibited from practicing medicinefrom diagnos-
ing, curing, and treating disease . . . . If a nonmedical provider makes an over broad claim
and purports to treat or cure a disease in the medical sense, the provider not only is sub-
ject to potential tort law claims based on fraud and misrepresentation but also risks
prosecution for the unlicensed practice of medicine (Cohen, 1999, p. 52).
In many states, maintaining an office in which to receive, examine, and treat clients con-
stitutes the practice of medicine. More than half the states include the use, administration,
or prescription of drugs or medicine in the definition of the practice of medicine. Thus, broad
definitions of the word drug pose problems for nurses who offer herbal and nutritional thera-
pies as part of their professional practice (Cohen, 1998).
Nurses are legally prohibited from practicing medicine, but it is essential that nurses remem-
ber that statutes can be interpreted as prohibiting the nonphysician only from engaging in the
diagnosis and treatment of biomedically defined pathology and not health promotion. The
prohibition applies to furnishing or purporting to furnish disease care within the biomedical
model, not wellness care within the holistic healing model . . . . A delineation has been sug-
gested between the furnishing of information, products, and/or services to encourage health (by
nourishing, stimulating, and balancing vital energy) and purporting to cure disease as defined
bio-medically (Cohen, 1998, pp. 32-33). It is essential that nurses continue to lobby elected
legislative representatives and appointed professional state board members to increase under-
standing of how professional nursing practice is distinct from medical practice. The ANA rec-
ommends that law be amended if physician assistants can supervise registered nurse practice, or
if the Board of Medicine has control over nursing functions (as in the Pennsylvania statute).
NEGLIGENCE AND MALPRACTICE

Negligence and malpractice are related concepts given that malpractice is one form of pro-
fessional negligence. Malpractice is the violation of the nurses professional duty to act with
reasonable care and in good faith. The standard of practice must be violated in order for the
courts to find malpractice (Brody et al., 1999).
Standard of care has been defined as that minimum level of care which the ordinary, rea-
sonable prudent nurse, in the same or similar circumstances, would provide. . . . The trend is
toward a national standard (Ely-Pierce, 1999, p. 81). Standards of professional performance
focus on the nurses clinical performance, while standards of care focus on patient outcomes
(ANA, 1998, p. 3). The Nurse Practice Act defines nursing practice and establishes the stan-
dards for nurses in each state. The standards of care that are used for judgments of negligence
may be derived from nurse practice acts; published court opinions; state statutes and admin-
istrative code books such as the patients bill of rights and Centers for Medicare and Medic-
aid Services (previously the Health Care Financing Administration) regulations; guidelines,
policies, and procedures for nursing care delivery published by national nursing organizations,
state boards of nursing, credentialing bodies, and the Joint Commission on Accreditation of
Healthcare Organizations; hospital policies; and authoritative nursing texts and journals.
Health care institutions, including hospitals, nursing homes, clinics, and managed care
organizations, face at least two kinds of malpractice exposure when utilizing nurses who pro-
vide therapeutic noninvasive therapies. These are direct liability (for an act or omission of
the institution, also known as corporate negligence) and vicarious liability (for an act or omis-
sion of the individual provider). Under the doctrine of corporate negligence, courts have
imposed direct liability on health care institutions for negligently failing to properly supervise
health care professionals (Cohen, 1998, p. 70).
Negligence is defined as conduct lacking in due care; carelessness; a violation of the duty
to use care; a wrong characterized by the absence of a positive intent to inflict injury but from
which injury nevertheless results (Ely-Pierce, 1999, p. 80). A negligence lawsuit is typically
a civil case, in which a client, through tort law, attempts to right an injury that is claimed to
have resulted from malpractice. The law defines nursing negligence as failure to exercise the
degree of care that a reasonable nurse would exercise under the same or similar circumstances.
According to Showers (2000), four things must be proved for a nurse to be found negligent:
Duty. The nurse had a duty to provide care to the client and to follow an acceptable
standard of care.
Breach. The nurse failed to adhere to the standard of care.
Causation. The nurses failure to adhere to the standard of care caused the clients
injuries.
Damages. The client suffered injury as a result of the nurses negligent actions.
Negligence claims are often alleged in the following situations (Aiken, 1994):
Client falls
Failure to monitor
Failure to ensure client safety
Improper performance of treatment
Failure to respond to client
Medication error
Wrong dosage administered
Failure to follow hospital procedure
Improper technique
Failure to supervise treatment
The important thing for the nurse to remember is to practice within his or her own level
of competence. This may be especially important when performing noninvasive therapeutic
therapies where a nursing standard of care has not been established. In as much as possible
harm has the potential for a negligence claim, in a hospital setting Stone (1999, p. 49) takes
a hard line in suggesting that all potential risks of an intervention should be disclosed . . . .
Nonconventional therapists should not alter the medication or treatment prescribed for
patients by their medical practitioner. An established and agreed upon protocol, and the sup-
port and full knowledge of the line manager, would help to protect the nurse from a negli-
gence claim.
In Box 6-3, Showers (2000) suggests other strategies that nurses can use for protection
from a negligence action.
B OX 6-3
Strategies to Protect from
a Negligence Action
Know your facilitys policies on adverse incidents, and know your respon-
sibilities and meet them.
Follow your facilitys procedures for completing an incident report.
Treat each client as you would like to be treated.
Delegate appropriately.
Report any problems that may endanger your client.
Know where drug references and other resources are located and make
sure they are up-to-date.
Maintain your competency through continuing education.
If you dont understand an order or youre unfamiliar with a procedure,
ask for help.
When you document, keep the acronym FACT in mind; your notes should
be factual, accurate, complete, and timely. Documentation in general can
make or break your defense.
Learn about other professionals who are available to help improve
client care, such as diabetes counselors, respiratory therapists, and risk
managers.
Source: Adapted from Showers, J. L. (2000). What you need to know about negligence lawsuits. Nurs-
ing 2000, 30, 45-48.
The client record should reflect what has occurred during the clients treatment. To avoid
negligence claims, client assessment with concise, factual, accurate, and timely documenta-
tion and communication is essential (Trott, 1998). To effectively document, the nurse must:
Write legibly.
Use the standard date and time abbreviations to accompany the signature after each
chart entry.
Document without defaming the patient, previous nurses, or physicians. Deal with con-
flicts on a one-to-one basis. Defaming a person only reinforces a case and makes the
nurse and the organization look bad from a legal and ethical standpoint.
Document the client assessment as well as what the client has told the nurse.
Document what has been done to protect the client and the clients response to the
intervention.
The increasing use of computers in care settings, including the electronic recording of
client record documentation, creates additional issues for nurses.
ENVIRONMENTAL LEGISLATION
Congress enacts statutes involving environmental protection. The goal of many environ-
mental programs is to reduce human and environmental exposure to environmental con-
taminants to a level of acceptable risks to health and the environment (McGarity, 2004).
There are three kinds of criteria that can be used to establish a legal standard: significant risks
of harm from pollution, reasonable risk balancing, and a mixed strategy. The significant risks of
harm from pollution criterion requires that risks posed by status quo exposures and alternative
exposure levels must be assessed. Then, there has to be a determination of whether a given
level of risk is significant. This typically involves a host of incommensurable considera-
tions, including the robustness of the data and the uncertainties in the risk predictions, the
size of the exposed populations, the intensity of the exposures to particular individuals, the
nature of the harm potentially induced by the exposure, the duration of the exposure, the
value of the resources at risk, the degree to which the exposure is voluntary, the extent to
which society tolerates similar risks in other contexts, and distributional considerations
(McGarity, 2004, p. 535). The significant risk/protective goal does not involve a balancing
of health and environmental risks against costs and other inconveniences entailed in reduc-
ing the risks.
The fundamental premise underlying the cost-benefit balancing goal is that society is will-
ing to accept reasonable risks. The cost of reducing risks has been quantified and compared
to the monetized benefit of the reduced risks. And, in a mixed strategy, the agency has to
establish standards aimed at meeting both pollution reduction and acceptable risk goals, and
further provide that the more stringent standard must be achieved. Our complex regulatory
system allows regulations to meet varying goals; therefore, unidimensional approaches to set-
ting environmental policy are unlikely to be successful.
ELECTRONIC HEALTH INFORMATION

Electronic devices and telemedicine are increasingly being used in health care. Telemedi-
cine uses communications technology to deliver information and services between health
care providers and clients who are geographically separated (Hodge et al., 1999).
There are many advantages for the systematic collection and use of electronic health
data. Better data allow consumers to make more informed decisions about health plans,
providers, diagnoses, products, and treatments. Clinical care is improved through faster
and more accurate medical and nursing diagnoses, increased checks on diagnostic and
therapeutic procedures, prevention of adverse drug interactions, instantaneous research,

and the dissemination of expert information to areas traditionally undeserved. Increased
access to accurate information can facilitate research and public health surveillance of
morbidity and mortality across populations. Electronic security tools including personal
access codes, encryption programs, and audit trails can more efficiently monitor health
care fraud and abuse and protect data from unauthorized use and disclosures (Hodge et
al., 1999).
Protecting the confidentiality of personally identifiable health data is critical. Specifically,
e-mail poses privacy and security concerns. Hodge, Gostin, & Jacobson (1999) suggest that
the nurse:
1. Obtain client informed consent before using e-mail for direct correspondence.
2. Explain and use security mechanisms.
3. Prohibit the forwarding of client e-mail without express authorization.
4. Inform clients about those having access to their messages and whether their messages
will become part of their medical records.
5. Respond to messages responsibly.
6. Avoid references to third parties.
There is an increasing public interest in herbs and over-the-counter natural supple-
ments. These areas are addressed by food and drug laws.
FOOD AND DRUG REGULATION

Legal rules and decisions traditionally have emphasized the dangers of access to untested treat-
ments, which in many cases includes therapeutic noninvasive therapies. The Access to Medical
Treatment Act (AMTA) was introduced in Congress to increase clients access to unapproved
therapies, subject to certain safeguards, and to broaden providers ability to offer nondangerous
non-FDA-approved treatments. The legislation gives an individual the right to be treated by a
health care practitioner with any medical treatment (including a treatment that is not approved,
certified, or licensed by the Secretary of Health and Human Services) that such individual desires
or the legal representative of such individual desires, if the practitioner personally examines and
agrees to treat the individual and the administration of the treatment is within the providers
authorized scope of practice. Furthermore, the treatment may be provided only if:
1. There is no reasonable basis to conclude that the treatment itself, when used as
directed, poses as unreasonable and significant danger to such individual.
2. In the case of a treatment requiring and lacking FDA approval, the individual receives
written notice that the FDA has not approved, certified, or licensed the treatment, and
that the individual uses such treatment at his or her own risk.
3. The provider notifies the patient in writing of the nature of the treatment, including,
among other things, reasonably foreseeable side effects.
4. No advertising claims are made as to efficacy.
5. The label of any drug, device, or food used in such treatment is not false or misleading.
6. The individual signs a written statement indicating informed consent as to items 1
through 4 and acceptance of the treatment (Cohen, 1998, pp. 78-79).
The nurse who recommends nutritional and herbal health promotion therapies needs to
be aware of food and drug laws. The Dietary Supplement Health Education Act (DSHEA)
reaffirms that dietary supplements are foods, thus exempting dietary supplements from the
requirement of new drug or food additive approval. The statute defines dietary supplements
to include products that contain, either individually or in combination, vitamins, minerals,
herbs, or other botanicals, amino acids, or other products for use to supplement the diet by
increasing total dietary intake (Cohen, 1998). However, the standard of care for nurses
includes knowing the possible interactions of dietary supplements with traditional pharma-
ceuticals, as well as the contraindications of the use of various herbs with coexisting medical
conditions.
IMPLICATIONS FOR PROFESSIONAL NURSES

Both federal and state legislative reform use disclosure and agreement rather than prohi-
bition as the primary means of patient protection (Cohen, 1998). In practicing integrative
health promotion, the nurse takes a detailed history, and thus tends to spend more personal
time and have more emotional contact with clients. By structuring the provider-client rela-
tionship as a collaborative venture, the nurse can reduce the malpractice risk, while the client
takes the responsibility for supporting the healing process (Cohen, 1998). Integral health
care entrusts the [client] with greater responsibility for prevention and self-care (Cohen,
1998).
Generally, a nurse who incorporates noninvasive therapeutic modalities in health pro-
motion practice is held to a standard of care appropriate to the profession (Cohen, 1998).
Nurses who use these modalities are vulnerable to malpractice liability when they assume
too much responsibility for the clients biomedical condition and fail to refer the client to
an appropriate conventional physician. The tort of misrepresentation is triggered when
health care providers make claims exceeding the boundaries of professional training and
skill . . . . [However], to show misrepresentation, a plaintiff must introduce evidence of
intent to defraud, deceive, and/or misrepresent; deception alone is insufficient (Cohen,
1998, p. 69).
Of concern when nurses utilize any therapeutic interventions within their practice is
whether they are sufficiently competent to do so. Nurses should be wary of implementing new
therapeutic approaches unless they have satisfactorily completed a training course recognized
by a credible professional body which at the very least subscribes to a Code of Ethics and pro-
vides members with professional indemnity (Stone, 1999).
Just as individuals are responsible for an appropriate standard of care for their practice,
health care institutions are also responsible for the standard of care administered by their
employees. The doctrine of vicarious liability (or respondeat superior) considers individual
providers to be agents of the health care institution rather than independent contractors. In
vicarious liability, negligent acts of the agent are attributable to, and considered to be acts of,
the principal (Cohen, 1998, p. 71).
Ideally, nurses practicing integrative health promotion should have levels of training, skill,
and professionalism at least commensurate with that of peers practicing within the biomed-
ical model. Professional organizations can reduce health care institutions liability concerns
by developing programs and criteria to ensure high standards in provider credentialing and
care. Health care institutions can attempt to meet their duty to non-negligently retain and
supervise individual nurse providers through:
Periodic review and monitoring
Ensuring that providers are delivering services within their legally authorized scope of
practice
Developing recognized protocols for collaborative practice between providers
Peer review of services and practices and utilization review (Cohen, 1998)
From a legal perspective, when nurses decide whether to include noninvasive therapeutic
therapies in their practice, four questions must be considered:
How can the nurse be sure that the therapies being offered have the potential for benefit
for a particular client, since many are still largely unsupported by a scientific research base?
Can the therapy be potentially harmful for the particular client?
Is the nurse competent to perform the modality?
Has the client given fully informed consent?
Given appropriate answers to these questions, the potential for legal challenge should not
prevent the nurse, in collaboration with the client, from incorporating non-invasive thera-
peutic therapies within an integrative health promotion practice.
Health law aims to create an environment in which health promotion, the protection of
individual rights, and the general principles of equality and justice go hand in hand (Lege-
maate, 2002). However, healthful lifestyles are the result of opportunities available to people,
and not a matter of free choice. Policy affects these opportunities (Rutton et al., 2003). Pol-
icy is a plan or course of action selected from alternatives and intended to influence and
determine decisions and actions (Acosta, 2003, p. 2). Both public and private policies can
have major impacts on health care outcomes. For example, health care system interventions
that have demonstrated effectiveness include diabetes disease management and case man-
agement programs, tobacco cessation reminders and education for providers, reduction of out-
of-pocket costs for vaccinations, and standing orders for vaccinations (Fielding et al., 2002).
A number of strategies can be used to promote health-related policies. Building a coalition
of people and organizations working together to achieve shared goals is one of the most effec-
tive vehicles for grassroots impact. Other strategies include lobbying and advocacy. Lobbying
is a particular kind of advocacy, which refers to activities in support of or opposition to legis-
lation or regulations that are governed by one or more federal, state, or local laws. Examples
of lobbying activities include:
Writing to your elected official asking him or her to vote in favor of a specific bill.
Asking members of your organization or the general public to contact elected officials
to vote in favor of a specific bill.
Testifying about your position in support of or opposition to a specific administrative

regulation.
Communicating your position supporting or opposing a proposed ballot initiative to a
member of the general public.
Engaging a lobbyist, public relations firm, or other individual or organization to
undertake the activities listed above in support of a specific bill on your behalf
(Acosta, 2003).
Acosta (2003) suggests that an extreme form of lobbying involves participating in a polit-
ical campaign on behalf of or in opposition to a candidate for political office.
Advocacy is another strategy to affect policy change. Advocacy is much less restrictive
than lobbying. Advocacy refers to all unregulated activities designed to influence public pol-
icy that do not fall under the lobbying definition. The key difference between lobbying and
advocacy is that advocacy entails communicating directly with policymakers and the public
about an issue without requesting action on a specific legislative proposal (Acosta, 2003,
p. 5). Examples of advocacy include:
Inviting elective officials to participate in a community forum to discuss the problem of
traffic safety.
Developing a publication that explains the problem of poor oral health in young children
and developing general recommendations for policymakers, communities, and schools.
Encouraging the community to call your organization for more information about the
benefits of recycling and how to get more involved in preventing toxic dumping.
Writing a press release explaining the high teen pregnancy rates in your county and
how your program has succeeded in developing a new school-based health center that
gives free sexuality education counseling to teens.
Inviting your elected official to visit your program (Acosta, 2003).
This chapter has emphasized that the current standard for ethical decision making in biomed-
icine and nursing is normative ethics, based on abstract principles, impartiality, and universal
application. In this perspective, the professional, viewed as the expert in health, has the obliga-
tion and the power to make ethical decisions. In contrast, integrative health promotion empha-
sizes individualized care and a nurse-client helping partnership with shared ethical decision
making and power. There has also been an emphasis on the ethical and legal requirements for
competence in professional nursing care, based on appropriate education and experience, with
referral to medical practitioners when the goal is curative treatment of disease. Finally, given over-
whelming global health concerns regarding the provision of justice, the valuing of autonomy as
the predominant principle underlying ethical judgments in American culture must be questioned.
Chapter Key Points

There are now challenges to the assumptions of impartiality and universality of tradi-
tional normative ethics.
Any exercise of professional power can trespass on the clients vital rights and interests.
References 153
Ethical frameworks for judging decisions can be viewed as mutually exclusive (e.g., util-
itarianism, liberalism, contextualism, or deontology) or as intrinsically related and
mutually enhancing, different perspectives.
The principles of biomedical ethics are autonomy, nonmaleficence, beneficence, and
justice.
Nurses must address broader social justice issues associated with promoting the well-
being and significant moral interests of marginalized or stigmatized groups.
For a nurse to be found negligent, duty, breach, causation, and damages must be proved.
Malpractice exposure is reduced by structuring the provider and client relationship as a
collaborative venture to health.
References
Acosta, C. M. (2003). Improving public health through policy advocacy. Community-Based Public Health
Policy Practice, 8, 1-8.
Aiken, T. D. (1994). Legal, ethical, and political issues in nursing. Philadelphia: FA Davis
American Nurses Association (1996). Model practice act. Washington, DC: American Nurses.
American Nurses Association (1998). Legal aspects of standards and guidelines for clinical nursing practice.
Washington, DC: American Nurses.
American Nurses Association (2001). Code of ethics for nurses-Provisions. Retrieved on December 15,
2001, from http://www.ana.org/ethics/chcode.htm
Bolletino, R. C. (1998). The need for a new ethical model in medicine: A challenge for conventional,
alternative, and complementary practitioners. Advances in Mind-Body Medicine, 14, 6-28.
Bournes, D. A. (2000). A commitment to honoring peoples choices. Nursing Science Quarterly, 13, 18-23.
Braddock, C. H., Edwards, K. A., Hasenberg, N. M., Laidley, T. L., & Levinson, W. (1999). Informed deci-
sion making in outpatient practice. Time to get back to basics. JAMA, 282, 2313-2320.
Brody, H., Rygwelski, J. M., & Fetters, M. D. (1999). Ethics at the interface of conventional and comple-
mentary medicine. In W. B. Jonas, & J. S. Levin, Essentials of complementary and alternative medi-
cine (pp. 46-56). Philadelphia: Lippincott.
Bunkers, S. S. (2001). On global health and justice: A nursing theory-guided perspective. Nursing Science
Quarterly, 14, 297.
Clark, P. A. (2000). The ethics of alternative medicine therapies. J Public Health Policy, 21, 447-470.
Cohen, M. H. (1998). Complementary and alternative medicine: Legal boundaries and regulatory perspectives.
Baltimore: Johns Hopkins University Press.
Cohen, M. H. (1999). Complementary and alternative medicine policy: The future of regulation. Alterna-
tive and Complementary Therapies, 5, 50-54.
Ely-Pierce, K. (1999). Legal issues for case managers: What you dont know can hurt you. Family and Com-
munity Health, 22, 78-9.
Fielding, J. E., Marks, J. S., Myers, B. W., Nolan, P. A., Rawson, R. D., & Toomay, K. E. (2002). How do
we translate science into public health policy and law? The Journal of Law, Medicine, & Ethics, 30
(Suppl. 3), 22-31.
Fry, S. T., & Duffy, M. E. (2001). The development and psychometric evaluation of the Ethical Issues Scale.
Journal of Nursing Scholarship, 33, 273-277.
Gadow, S. (1999). Relational narrative: The postmodern turn in nursing ethics. Scholarly Inquiry for Nurs-
ing Practice: An International Journal, 13, 57-69.
Gilligan, C. (1982). In a different voice: Psychological theory and womens development. Cambridge, MA: Har-
vard University Press.
Gilligan, C. (1987). Moral orientation and moral development. In E. F. Kittay, & D. T. Meyers (Eds.),
Women and moral theory (pp. 19-33). Totowa, NJ: Rowman and Littlefield.
Green, J. A. (1999). Collaborative physician-patient planning and professional liability: Opening the legal
door to unconventional medicine. Advances in Mind-Body Medicine, 15, 83-94.
Guinn, D. E. (2001). Ethics and integrative medicine: Moving beyond the biomedical model. Altern Ther
Guttman, N., & Ressler, W. H. (2001). On being responsible: Ethical issues in appeals to personal respon-
sibility in health campaigns. Journal of Health Communication, 6, 117-136.
Haddad, A. (1998). The future of ethical decision making in health care. Nursing Clinics North America,
33, 373-384.
Hall, J. K. (1996). Nursing ethics and law. Philadelphia: W. B. Saunders.
Hamric, A. B. (1999). The nurse as a moral agent in modern health care. Nurs Outlook, 47, 106.
Hodge, J. G., Gostin, L. O., & Jacobson, P. D. (1999). Legal issues concerning electronic health informa-
tion: Privacy, quality, and liability. JAMA, 282, 1466-1471.
Johnstone, M. (1998). Advancing nursing ethics: Time to set a new global agenda? Int Nurs Rev, 45, 43.
Kuhse, H. (1997). Caring: Nurses, women and ethics. Oxford, UK: Blackwell.
Last, J. M., & Woolf, S. H. (1996). Ethical issues in health promotion and disease prevention. In S. H.
Woolf, S. Jonas, & R. S. Lawrence (Eds.), Health promotion and disease prevention in clinical prac-
tice (pp. 554-568). Baltimore: Williams & Wilkins.
Legemaate, J. (2002). Integrating health law and healthy policy: A European perspective. Health Policy, 60,
101-110.
McGarity, T. O. (2004). The goals of environmental legislation. Environmental Affairs, 31, 529-554.
Milton, C. L. (2000). Beneficence: Honoring the commitment. Nursing Science Quarterly, 13, 111-115.
Nash, R. A. (1999). The biomedical ethics of alternative, complementary, and integrative medicine. Alter-
native Therapies Health Medicine, 5, 92-95.
Norton, L. (1995). Complementary therapies in practice: The ethical issues. Journal of Clinical Nursing, 4,
343-348.
Pellegrino, E. D. (1998). Emerging ethical issues in palliative care. JAMA, 279, 1521-1522.
Pennsylvania State Board of Nursing. (1999). Professional nurse law. Harrisburg, PA: Department of State,
Bureau of Professional and Occupational Affairs.
Rothschild, M. L. (2000). Ethical considerations in support of the marketing of public health issues. Amer-
ican Journal of Health Behav, 24, 26-35.
References 155
Rutten, A., Luschen, G., von Lengerke, T., Abel, T., Kannas, L., Diaz, J. A. R., Vinck, J., and van der Zee,
J. Determinants of health policy impact: A theoretical framework for policy analysis. Society for
Preventive Medicine, 48, 293-300.
Schwarz, J. K. (2000). Have we forgotten the patient? American Journal of Nursing, 100, 61, 64.
Showers, J. L. (2000). What you need to know about negligence lawsuits. Nursing 2000, 30, 45-48.
Stone, J. (1999). Using complementary therapies within nursing: Some ethical and legal considerations.
Complementary Therapies in Nursing & Midwifery, 5, 46-50.
Sugarman, J., & Burk, L. (1998). Physicians ethical obligations regarding alternative medicine. JAMA,
280, 1623-1625.
Trott, M. C. (1998). Legal issues for nurse managers. Nursing Management, 29, 38-42.
BEYOND PHYSICAL ASSESSMENT
7
Abstract
The approach to assessment for many nurses is limited to physical skills, performed
according to body system, to identify clients physical problems or potential problems. In
contrast, in this chapter, it is assumed that the judicious use of holistic assessment techniques
can identify client strengths and broaden the database from which clients and nurses
develop health promotion plans. Therefore, a number of frameworks for assessment are pre-
sented, selected holistic categories of assessment are discussed, and, to supplement the typi-
cal Western biomedical physical assessment of body systems, two approaches (tongue and
pulse assessment) commonly used in the Eastern traditions of Ayurveda and Chinese medi-
cine are introduced. The chapter concludes with a brief discussion of procedures for disease
screening
Learning Outcomes
Identify a philosophy for health (as opposed to problem) assessment

Describe the components of selected frameworks for assessment
Discuss essential elements of functional ability, mental and nutritional status, and qual-
ity of life assessment
Describe basic procedures for tongue and pulse assessment
158 Chapter 7 Beyond Physical Assessment
Physical and Health Assessment

Physical assessment focuses on identification of clients physical actual or potential prob-
lems in each body system. In contrast, health assessment is a systematic collection of data
about client health status, beliefs, and behaviors relevant to developing a health-protection-
promotion plan (Pender, 1996, p. 116). Health assessment is a collaborative process involv-
ing the nurse and the client that promotes mutual input into decision making and planning
to improve the clients health and well-being. According to Pender (1996), the desired out-
comes of health assessment include:
1. Identifying health assets
2. Identifying health-related lifestyle strengths
3. Determining key health-related beliefs
4. Identifying health beliefs and health behaviors that put the client at risk
5. Determining how the client wants to change to improve his or her quality of life
The initial health assessment provides a valuable baseline against which subsequent assess-
ments can be compared. Health assessment should always take the whole person into
account, including her or his general appearance, and should capitalize on the persons
strengths.
Frameworks for Health Assessment

NURSING CONCEPTUAL MODELS
The many existing nursing models and theories provide diverse frameworks for assessment
of health and organization of data (see Chapter 4, The Meaning of Health: Models and Theo-
ries, for a brief description of nine models and theories). Leddy (1998, p. 207) describes impli-
cations for data collection of these selected nursing models or theories. For example, within
the context of Neumans Health Care Systems model, the nurse would assess the client and
the clients environment for intrapersonal, interpersonal, and extrapersonal stressors that
might have an impact on the lines of resistance and defense. In contrast, within the context
of Rogers Science of Unitary Human Beings, the nurse would assess the mutual process and pat-
terning of the human being-environment energy fields (see Table 7-1 for implications for data
collection in selected nursing models organized by theoretical frameworks, and see Table 7-2
for selected assessment tools derived from nursing models and theories).
PENDERS CATEGORIES FOR ASSESSMENT

Pender (1996, p. 116) proposes that important components of health assessment focusing
on individual clients are:
Functional health patterns
Physical fitness evaluation
Frameworks for Health Assessment 159
Table
7-1 Implications for Data Collection in Selected Nursing Models
Organized by Theoretical Frameworks
NURSING MODELS IMPLICATIONS FOR DATA COLLECTION

Systems Theory
King Perceptions of self, level of growth and development, level of
stress, abilities to function in usual role, decision-making abili-
ties, and abilities to communicate.
Neuman Stressors, indications of disruption of the lines of defense,
resistance factors.
Stress/Adaptation
Roy Adaptation level (related to three cases of stimuli), coping in
relation to modes of adaptation, position on the health-illness
continuum.
Caring
Orem Therapeutic self-care demand, presence of self-care deficits,
ability of clients to meet self-care requisites.
Watson Phenomenal field (self within space and motivational factors for
health), values, needs for information, problem-solving abilities,
developmental conflicts, losses, feelings about the human
predicament.
Complexity
Peplau Physiologic and personality needs, illness symptoms, relation-
ships with significant others, influences on establishment and
maintenance of the nurse-client relationship.
Rogers Characteristics of patterning, health potential, rhythms of life,
simultaneous states of the individual and environment.
Parse Thoughts and feelings about the situation, the synchronizing
rhythms in human relationships, personal meanings, ways of
being alike and different, and values.
Newman Person-environment interactions, patterns of energy exchange,
clients responses to symptoms, transforming potential, clients
feelings and what he does because of those feelings, patterns
of life.
Reprinted with permission from Leddy, S. K. (1998). Leddy and Peppers conceptual bases of professional nurs-
ing (4th ed.). Philadelphia: JB Lippincott. 1998 Lippincott Williams & Wilkins.
Table
7-2 Selected Assessment Tools Derived from Nursing Models and Theories:
The King General Systems Model
INSTRUMENT CITATION DESCRIPTION

Criterion-referenced King, I. M. (1998). Measuring Used to assess, plan, and evaluate nursing in terms of
measure of goal health goal attainment in pati- the clients physical ability to perform activities of
attainment (CRMGAT) ents. In C. F. Waltz & O. L. daily living (ADL), level of consciousness, hearing,
Strickland (Eds.), Measurement vision, smell, taste, touch, speaking ability, listening
of nursing outcomes. Vol 1. ability, reading and writing abilities, nonverbal com-
Measuring client outcomes. munication, and decision-making ability; response
(pp. 108-127). New York: to the performance of ADL; and goals to be attained.
Springer.
Assessment format Swindale, J. E. (1989). The Guides assessment of the minor surgery patients anx-
nurses role in giving pre- ieties, coping strategies, and nature of information
operative information to needing.
reduce anxiety in patients
admitted to hospital for elect-
ive minor surgery. J Adv Nurs,
14, 899-905.
Community health Hanchett, E. S. (1998). Nursing Guides assessment of a community according to the
frameworks and community dimensions of personal, interpersonal, and social sys-
as client: Bridging the gap. tems.
Norwolk, CT: Appleton &
Lange.
continued
Table
7-2 Selected Assessment Tools Derived from Nursing Models and Theories (continued):
The Neuman Systems Model

Neuman systems model Mirenda, R. M. (1986). The Neu- Guides client system assessment and permits docu-
assessment and intervention man model in practice. Senior mentation of goals, intervention plan, and outcomes
tool Nurse, 5, 26-27. Neuman, B. from the perspective of both clients and caregivers.
(1989). The Neuman systems
model (2nd ed., pp. 3-63).
Norwalk, CT: Appleton & Lange.
Nursing assessment guide Beckman, S. J., Boxley-Harges, A modification of the Neuman systems model assess-
S., Bruick-Sorge, C., & Eichen- ment and intervention tool.
auer, J. (1998). Evaluation mod-
alities for assessing student and
program outcomes. In L. Lowry
(Ed.), The Neuman systems model
and nursing education: Teaching
strategies and outcomes (pp. 149-

160). Indianapolis, IN: Sigma Theta
Tau International Center Press.
Assessment and analysis McHolm, F. A., & Geib, K. M. Guides health assessment and formulation of nursing
(1998). Application of the Neu- diagnoses.
man systems model to teaching
health assessment and nursing
process. Nursing Diagnosis:
Journal of Nursing Language
and Classification, 9, 23-33.
continued
161
Table
The Orem Self-Care Model

Nursing history Orem, D. E. (1995). Elements Guides the assessment of changes in a patients ther-
of a nursing history. In D. E. apeutic self-care demand and the patients self-care
Orem (Ed.), Nursing: Concepts of agency as well as the patients conditions and pattern
practice (5th ed., pp. 422-430). of living.
St. Louis, MO: Mosby.
Structured data collection Laschinger, H. S. (1990). Helping Guides assessment of patients in relation to the self-
students apply a nursing concept- care framework.
ual framework in the clinical sett-
ing. Nurse Educator, 15, 20-24.
Nursing assessment tool Fernandez, R., & Wheeler, J. I. Guides the nursing history and assessment in the
(1990). Organizing a nursing areas of the basic conditioning factors and universal
system through theory-based self-care requisites.
practice. In G. G. Meyer, M. J.
Madden, & E. Lawrenz (Eds.),
Patient care delivery models
(pp. 63-83). Rockville, MD: Aspen.
continued
Table
Rogers Science of Unitary Human Beings

Nursing assessment of Madrid, M., & Winstead-Fry, P. Guides assessment of pattern, including relative pres-
patterns indicative of (1986). Rogers conceptual model. ent, communication, sense of rhythm, connection to
health In P. Winstead-Fry (Ed.), Case environment, personal myth, and system integrity.
studies in nursing theory (pp. 73-
102). New York: National League
for Nursing.
Power as knowing Barrett, E. A. M. (1990). An instr- Measures the persons capacity to participate know-
participation in change ument to measure power as ingly in change by means of semantic differential
knowing-participation-in-change. ratings of the concepts awareness, choices, freedom
In O. Strickland, & C. Waltz (Eds.), to act intentionally, and involvement in creating
The measurement of nursing out- changes.
comes. Vol. 4. Measuring client
self-care and coping skills (pp.
159-180). New York: Springer.

Nursing process format Falco, S. M., & Lobo, M. L. (1995). Guides use of a Rogerian nursing process, including
Martha E. Rogers. In J. B. George nursing assessment, nursing diagnosis, nursing plan-
(Ed.), Nursing theories. The base ning for implementation, and nursing evaluation
for professional nursing practice according to the principles of integrality, resonancy,
(4th ed., pp. 229-248). Norwalk, and helicy.
CT: Appleton & Lange.
continued
163
Table
The Roy Adaptation Model

Nursing manual: Cho, J. (1998). Nursing manual: Guides assessment of behaviors and stimuli for the
Assessment tool according Assessment tool according to the physiological, self-concept, role function, and inter-
to the Roy adaptation model Roy adaptation model. Glendale, dependent adaptive modes.
CA: Polaris.
Typology of indicators Roy, C., & Andrews, H. A. (1999). A list of tthe indicators of positive adaptation for
of positive adaptation The Roy adaptation model (2nd individuals and groups in the physiological/physical,
ed., pp. 79-81). Stanford, CT: self-concept/group identity, role function, and inter-
Appleton & Lange. dependent adaptive modes.
Nursing diagnostic Roy, C., & Andrews, H. A. (1999). A list of generic nursing diagnoses within the context
The Roy adaptation model (2nd of indicators of positive adaptation, common adapta-
ed., pp. 139, 161, 184, 214, 247, tion problems, and NANDA nursing diagnoses for all
279, 305, 340, 372, 417, 462, aspects of the physiological/physical adaptive mode,
503). Stanford, CT: Appleton & and the self-concept/group identity, role function,
Lange. and interdependent adaptive modes.
continued
Table
The Watson Theory of Human Caring
INSTRUMENT CITATATION DESCRIPTION

Caring behaviors assessment Harrison, B. P. (1998). Develop- Measures nurse caring behaviors in terms of the cara-
ment of the caring behaviors tive factors.
assessment based on Watsons
theory of caring. Masters
Abstracts International, 27, 95.
Caring assessment tool Duffy, J. R. (1992). The impact of Measures nurses caring activities.
nursing caring on patient out-
comes. In D. Gaut (Ed.), The
presence of caring in nursing
(pp. 113-136). New York: National
League for Nursing.
Caring behaviors inventory Wolf, Z. R., Giordino, E. R., Measures nurses caring behaviors within the context
Osbourne, P. A., & Ambrose, of the carative factors.

M. S. (1994). Dimensions of
nurse caring. Image: Journal
of Scholarship, 26, 107-111.
continued
165
Table
The Leddy Human Energy Model

Person-environment Leddy, S. K. (1995). Measuring Measures the persons experience of continuous
participation scale (PEPS) mutual process: Development human-environment mutual process by means of
and psychometric testing of the semantic differential ratings of 15 bipolar adjectives
person-environment participation representing the content areas of comfort, influence,
scale. Visions: Journal of Rogerian continuity, ease, and energy.
Nursing Science, 3, 20-31.
Leddy healthiness scale Leddy, S. K. (1996). Development Measures the persons perceived purpose and power
and psychometric testing of the to achieve goals by means of Likert scale ratings of 26
the Leddy healthiness scale. items representing meaningfulness, ends, choice,
Research in Nursing and Health, challenge, confidence, control, capacity, capability
19, 431-440. to function, and connections.
Source: Adapted from Fawcett, J. (2000). Analysis and evaluation of contemporary nursing knowledge: Nursing models and theories. Philadelphia: F.
A. Davis; Leddy, S. K. (1998). Leddy and Peppers conceptual bases of professional nursing. Philadelphia: Lippincott Williams & Wilkins.
Nutritional assessment
Health risk appraisal
Life stress review
Spiritual health assessment
Social support systems review
Health beliefs review
Lifestyle assessment
GORDONS FUNCTIONAL HEALTH PATTERNS

Gordons (1995) typology of 11 functional health patterns provides another framework for
assessing individuals, families, and communities. By examining the specific functional pat-
terns and the interaction among the patterns, the nurse can accurately determine and diagnose
actual or potential problems, intervene more effectively, and achieve outcomes that promote
health and well-being. . . . A major goal in assessing each pattern is to determine the clients
knowledge of health promotion, ability to manage health-promoting activities, and the value
that the individual ascribes to health promotion (Edelman & Mandle, 1998, pp. 121, 125).
The patterns included in Gordons typology include:
1. The Health Perception-Health Management Pattern describes the clients perceived pat-
tern of health and well-being and how health is managed:
How has general health been
Most important things done to keep healthy
Relevance of health status to current activities and future planning
Health and safety practices (health risk management)
General health care behavior
Belief in ability to influence ones own health through lifestyle changes
Previous patterns of adherence or compliance and use of the health care system
Knowledge of availability of health services
Patterns indicating at what point health care is sought
Accessibility to health care through financial resources, health insurance, and
transportation factors
2. The Nutritional-Metabolic Pattern describes pattern of food and fluid consumption rela-
tive to metabolic need and pattern indicators of local nutrient supply:
Patterns of food and fluid consumption
Typical food and fluid intake
Appetite
Weight loss or gain

Daily eating times
Types and quantity of food and fluids consumed
Particular food preferences
Use of nutrient or vitamin supplements, caffeine, or alcohol
Food allergies
How foods are prepared
Are there adequate financial resources for an adequate diet
Breast feeding and infant feeding patterns
Condition of skin, hair, nails, mucous membranes, and teeth
3. The Elimination Pattern describes patterns of bowel, bladder, and skin excretory function:
Perceived regularity
Use of routines or laxatives for bowel elimination
Devices employed to control excretion
Changes in time-pattern, mode of excretion, quality, or quantity
4. The Activity-Exercise Pattern describes patterns of exercise, activity, leisure, and recreation:
Activities of daily living requiring energy expenditure (e.g., hygiene, cooking,
shopping, eating, working, and home maintenance)
Sufficient energy for desired or required activities
Type, quantity, and quality of exercise including sports
Activities of high importance or significance for leisure (recreation)
5. The Sleep-Rest Pattern describes patterns of sleep, rest, and relaxation:
Perception of the quality and quantity of sleep and rest
Generally rested and ready for daily activities after sleep
Perception of energy level
Aids to sleep such as medications or nighttime routines
6. The Cognitive-Perceptual Pattern describes sensory-perceptual and cognitive patterns:
Adequacy of vision, hearing, taste, touch, or smell
Compensation or prostheses utilized for disturbances
Pain perception and how pain is managed
Any change in memory lately
Easiest way to learn things
Cognitive functional abilities such as language, memory, and decision making
7. The Self-Perception-Self-Concept Pattern describes self-concept patterns and perceptions

of self:
Attitudes about himself or herself
Perception of cognitive, affective, or physical abilities
Body image
Identity
General sense of worth
General emotional pattern
Pattern of body posture and movement, eye contact, voice and speech pattern
8. The Role-Relationship Pattern describes a pattern of role engagements and relationships:
Individuals perception of major roles and responsibilities
Satisfaction or disturbances in family, work, or social relationships
How does family usually handle problems
9. The Sexuality-Reproductive Pattern describes patterns of satisfaction or dissatisfaction in
sexuality:
Reproductive pattern
Females reproductive stage and any perceived problems
Perceived satisfaction or disturbances in sexuality
10. The Coping-Stress-Tolerance Pattern describes general coping patterns and effectiveness
of the patterns in terms of stress tolerance:
Reserve or capacity to resist challenge to self-integrity
Modes of handling stress
Family or other support systems
Any big changes or crisis in the last year or two
Perceived ability to control and manage situations
How problems are handled
11. The Value-Belief Pattern describes patterns of values, goals, or beliefs that guide choices
or decisions:
What is perceived as important in life
Quality of life
Perceived conflicts in health-related values, beliefs, or expectations
Importance of religion
Important plans for the future
Selected Categories for Assessment

THE HEALTH HISTORY
Regardless of which approach is used for assessment and organization of data, the first step
in the process is to interview the client and determine the health history.
At the core of the data collection process is the nurse-client interview, a highly special-
ized, purposeful, goal-directed interaction. Thus, the first step is to become expert at inter-
viewing skills and techniques. The nurse also must know what information is needed from the
client (Rychlee, 2000). The purpose of the health history is to collect subjective data, what
the person says about himself or herself. The history is combined with the objective data from
the physical examination and laboratory studies, and [subjective data from other assessments]
to form the data base. The data base is used to make a judgment or a diagnosis about the
health status of the individual. . . . For the well person, the history is used to assess his or her
lifestyle, including such factors as exercise, diet, risk reduction, and health promotion behav-
iors (Jarvis, 2000, p. 80). Box 7-1 lists areas usually included in a health history.
The following categories of assessment have been selected as examples of the many types
of assessment that are available to the nurse who seeks a holistic, multidimensional represen-
tation of client health patterns.
B OX 7-1
Areas for Health History Questions
The health history usually proceeds according to questions in the following
areas:
1. Biographical data
2. Reason for seeking care. Which concern prompted the person to seek
help now?
3. Present health or history of present illness. For well person, this is a short
statement about the general state of health; for the ill person this is a
chronological record of the reason for seeking care. Eight critical charac-
teristics of symptoms include:
Location. Be specific.
Character or quality. Burning, sharp, dull, aching.
Quantity or severity. How does the symptom affect daily activities.
Timing. Onset, duration, and frequency.
continued
Selected Categories for Assessment 171
B OX 7-1 CONTINUED
Setting. What brings on the symptom?

Aggravating or relieving factors. What seems to help?
Associated factors.
Patients perception. Meaning of the symptom.
4. Review of systems. Examples of health promotion questions:

Skin. Amount of sun exposure.
Eyes. Last vision check; glasses or contacts?
Ears. Hearing loss; how loss affects daily life.
Mouth and throat. Pattern of daily dental care; use of prostheses; last
dental checkup.
Breast. Performs self-examination; last mammogram.
Respiratory. Last chest x-ray.
Cardiovascular. Last Electrocardiogram.
Peripheral vascular. Any long-term sitting or standing? Avoid cross-
ing legs at knees.
Gastrointestinal. Antacids or laxatives?
Genitals. Testicular self-examination? Last gynecological exam and
Pap smear.
Musculoskeletal. How much walking each day? Any limits on range
of motion?
Mental. Interpersonal relationships; coping patterns.
ASSESSMENT OF HEALTH
Dimension Scales
One common approach to health assessment is to evaluate multiple dimensions of
health (Young, 1997). For example, Keegan and Dossey (1987) developed dimension scales
for self-assessment of physical, mental, social, emotional, and spiritual dimensions of the indi-
vidual. No theoretical basis for these scales is apparent. Examples of items include have a
good level of energy (physical); trust others easily (social); and have a relationship with
a higher power (spiritual). Items are scored as occurring most of the time, often, sometimes,
or seldom. The separate dimension scores can be used to compile a total self-assessment score.
The individual items can also be used by the client and the nurse to identify particular
strengths and weaknesses in each dimension. Reliability and validity of these scales have not
been established.
The Leddy Healthiness Scale

There are scales to measure well-being (psychological) and health status (medical), but
investigators have been slow to develop instruments to measure health within a holistic or
unitary perspective. One exception is the Leddy Healthiness Scale (LHS) (Leddy, 1996),
which measures healthiness, defined as a process characterized by perceived purpose, con-
nections, and the power to achieve goals (Leddy, 1997). As a resource that influences the
ongoing patterning reflected in health, healthiness reflects a human beings perceived
involvement in shaping change experienced in living. The LHS was derived from the Human
Energy Model (Leddy, 1998; 2004).
The LHS is a 26-item, 6-point Likert type scale. Items measure meaningfulness, connec-
tions, ends, capability, control, choice, challenge, capacity, and confidence. The items are
summed for a healthiness score. The LHS has demonstrated internal consistency reliability
and construct validity. In studies with the LHS (Leddy, 1996, 1997; Leddy & Fawcett, 1997),
healthiness has been found to be moderately and negatively related to fatigue and symptom
experience in women with breast cancer, and moderately and positively related to mental
health, health status, and satisfaction with life in a sample of healthy people. The LHS is
available in Appendix A at the end of this book.
The Wellness Inventory

Another example of an approach to holistic assessment is the Wellness Inventory, devel-
oped by Travis and Ryan (1988), which provides an integrated overview of all human life
functions, including wellness and:
1. Self-responsibility and love

2. Breathing
3. Sensing
4. Eating
5. Moving
6. Feeling
7. Thinking
8. Playing or working
9. Communicating
10. Sex
11. Finding meaning
12. Transcending
The authors believe that the harmonious balancing of these life functions results in good
health and well-being (p. xxix), but no theoretical framework was identified as the basis for
the Wellness Inventory.
The Wellness Inventory consists of 120 Likert-type questions abridged from the 380 ques-
tion Wellness Index. Items are ranked on a 3-part scale consisting of yes, usually, sometimes,
and no, rarely; and are then summed by dimension for use in self-evaluation or wellness
assessment with clients. Examples of items from the Wellness Inventory/Index include: How
I live my life is an important factor in determining my state of health, and I look to the
future as an opportunity for further growth. No information is available about reliability,
validity, or psychometric testing of the Inventory. See the additional information at the end
of the chapter for information about how to obtain the Wellness Inventory.
FUNCTIONAL ASSESSMENT
Functional status refers to the entire domain of functioning. . . . It is defined as a multidi-
mensional concept characterizing ones ability to provide for the necessities of life; that is,
those activities people do in the normal course of their lives to meet basic needs, fulfill usual
roles, and maintain their health and well-being. . . . Necessities include, but are not limited to,
physical, psychological, social, and spiritual needs that are socially influenced and individu-
ally determined (Leidy, 1994, p. 197). Functional status is often mistakenly interpreted only
in the physical domain (Haas, 1999), but Leidy (1994) identifies four dimensions of func-
tional status: capacity, performance, reserve, and capacity utilization.
Functional capacity is defined as ones maximum potential to perform those activities people
do in the normal course of their lives to meet basic needs, fulfill usual roles, and maintain their
health and well-being (Leidy, 1994, p. 198). Functional capacity, which consists of strengths and
resources that provide individuals with the potential for activity, may refer to any domain, includ-
ing physical, cognitive, psychological, social, spiritual, and sociodemographic areas.
Functional performance is defined as the physical, psychological, social, occupational,
and spiritual activities that people actually do in the normal course of their lives to meet basic
needs, fulfill usual roles, and maintain their health and well-being. . . . The value an individ-
ual places on an activity or task and his or her need or desire to perform it are important com-
ponents of performance (Leidy, 1994, pp. 198, 200).
In a study of functional status from the clients perspective, Leidy and Haase (1999, p. 68)
found that people who are ill face an ongoing challenge of preserving their personal integrity,
defined as a satisfying sense of wholeness, as they encounter a variety of physical changes that
can interfere with day-to-day activity. . . . Qualities most salient to integrity are a sense of
effectiveness, or being able, and of connectedness, or being with. The major categories of
activity included household maintenance, movement, family activities, social activities,
work, altruistic avocation, and recreation.
Effectiveness was characterized in the Leidy and Haase (1999) study as a sense of being
able, expressed through the physical body and through the perception of competence, con-
tribution, and purpose in daily activities, including self-care, family roles and tasks, and work.
A second characteristic of effectiveness was energy. Energy contributed to an ability to per-
form various activities with spontaneity and ease, while connectedness, or being with, was
defined as a sense of significant, shared, and meaningful relationship with other people, a
spiritual being, nature, or aspects of ones inner self (Leidy & Haase, 1999, pp. 70-72).
Functional reserve is the difference between capacity and performance while functional
capacity utilization (FCU) refers to the extent to which functional potential is called upon
in the selected level of performance. . . . As FCU increases, exertion increases, performance
approaches capacity, and reserve is diminished (Leidy, 1994, p. 199).
Leidy (1994) suggests that assessment of functional status should include the following
aspects:
Self-esteem or self-concept. Value belief system, personal strengths.

Activity and exercise. Leisure activities, exercise pattern.
Sleep/rest. Patterns; any sleep aids used.
Nutrition and elimination. Recall of food and beverages for 24 hours; use of laxatives.
Interpersonal relationships and resources. Social roles; support systems.
Coping and stress management. Current stressors, methods used to relieve stress.
Personal habits. Tobacco, alcohol, street drugs? Any desire to quit?
Environment and hazards. Safety; involvement in community services.
Occupational health. Likes and dislikes about job; any environmental hazards?
Perception of health. Health goals; what is expected from health professionals?
The author is unaware of any one instrument that assesses all of these areas of func-
tional status.
MENTAL ASSESSMENT
Mental assessment includes consideration of emotional and cognitive functioning,
including:
Consciousness. Awareness of surroundings, ability to think coherently.

Language. Communication of thoughts and feelings.
Mood and affect. Prevailing feelings that color ones emotional life.
Orientation. Awareness of the objective world in relation to the self.
Attention. Power of concentration without distraction.
Memory. Recent and remote.
Abstract reasoning. Pondering a deeper meaning beyond the concrete and literal.
Thought process. Logical train of thought.
Thought content. Specific ideas, beliefs, and the use of words.
Perceptions. Awareness through the senses.
The Mental Health Index

The Mental Health Index (MHI) measures cognitive functioning, the balance between
positive and negative affect, and the extent of psychological distress. The MHI is an estab-
lished, 17-item, 6-point Likert type scale that was developed as part of the Medical Outcomes
Study (Stewart & Ware, 1992). The items are scored on a range from all of the time to
none of the time (in the past 4 weeks). Examples of items on the MHI include felt loved
and wanted, been anxious or worried, and been in firm control of your behavior, emo-
tions, feelings, thoughts?
The Perceived Well-Being Scale

Reker and Wong (1984) developed the perceived well-being scale (PWB) to measure
physical and psychological well-being. Psychological well-being was defined as the presence
of positive emotions such as happiness, contentment, joy, and peace of mind and the absence
of negative emotions such as fear, anxiety, and depression, but no theoretical framework has
been identified for this definition. The PWB contains 14 items, scored on a 7-point, strongly
agree to strongly disagree Likert scale. Six of the items comprise the psychological well-being
subscale. Examples of items include, no one really cares whether I am dead or alive, I feel
that life is worth living, and I am often bored. This instrument has documented internal
consistency reliability, stability, and validity.
NUTRITIONAL ASSESSMENT
Nutritional assessment reviews the degree of balance between nutrient intake and nutri-
ent requirements. Nutrition screening is a quick and easy way to identify individuals at nutri-
tion risk. If at risk, they should undergo a comprehensive nutritional assessment. Guided by
the biomedical model, some of the possible considerations are:
Eating patterns; food preferences
Consistency with major dietary guidelines
Usual weight
Changes in appetite, taste, smell, chewing, and swallowing
Recent surgery, trauma, burns, and infection
Chronic illnesses
Vomiting, diarrhea, and constipation
Food allergies or intolerance
Medications and/or nutritional supplements
Self-care behaviors
Alcohol or illegal drug use
Exercise and activity patterns
Family history
Assessment of nutritional intake may be based on one of several paper and pencil instru-
ments such as a food frequency questionnaire (FFQ), or dietary recall diary or questionnaire,
which may be supplemented with standardized measurements such as the body mass index
(BMI), body weight, and/or blood laboratory tests. A typical FFQ asks the client to report the
frequency with which many foods and beverages are eaten, over some time period ranging
from 1 day to 1 year. Many FFQs ask about typical portion sizes. Consequently, the FFQ
requires long-term recall and estimation of both frequency and quantity information. For
research in which reliability is an issue, clients need to be trained to correctly estimate por-
tion sizes. Most FFQs can be self-administered in one client contact, requiring an average of
30 minutes for completion. A variant of one of two published FFQs (Block et al., 1986; Wil-
lett et al., 1987) is often used, although a number of investigators develop their own ques-
tionnaires, making it difficult to assess reliability and concurrent validity. Additionally, it has
been asserted that FFQs measure attitude and subjective inferences about the nature of the
habitual diet more than memory for what was actually consumed (Drewnowski, 2001).
Food records and diaries also have problems. Clients have to be taught how to self-monitor
and score their food and beverage intake. Staff burden is considerable, as several contacts
with the client may be needed, and records are often incomplete and need to be supple-
mented with additional information. Most often, a 24-hour recall is requested, but a record of
up to 4 days is commonly used. When compared with energy expenditure using doubly labeled
water, evidence indicates that systemic error in the reporting of true dietary intake exists with
use of either a FFQ or dietary recall (Trabulsi & Schoeller, 2001).
Recently, Soderhamn and Soderhamn (2002) published a nutritional form for the elderly
(NUFFE) to identify actual and potential undernutrition among older clients. The original
version of the instrument is in the Swedish language. The instrument is a summated three-
point ordinal scale (from zero to two) with 15 items. There are two questions about weight
loss and changes in dietary intake; nine questions related to appetite, food and fluid intake
and eating difficulties; and four questions about obtaining food products, company at meals,
activity, and number of drugs. Initial internal consistency reliability and validity are reported.
SPIRITUAL ASSESSMENT
Although there are many definitions of spirituality, each of them seems to focus on find-
ing meaning and purpose in life and/or developing awareness of and allegiance to something
sacred (Patton, 2001). According to Patton (2001), meaning in a persons life will provide a
sense of peace and serenity, enhance self-understanding and insight, increase energy, promote
hope and encouragement, and preserve a sense of integrity. Areas that provide meaning and
purpose in the clients life can be identified by asking questions such as what gives your life
meaning? What gives you a sense of serenity and peace? What provides joy and fulfillment?
Or, what is your source of strength and hope?
The JAREL spiritual well-being scale (Hungelmann et al., 1989; 1996), based on the ini-
tials of the first names of the four scale developers, is an often used Likert-type instrument
with 21 items scored according to a six-point scale from strongly agree to strongly disagree.
Examples of items include prayer is an important part of my life, I accept life situations,
and I find meaning and purpose in my life. Reliability and validity data have not been
reported. The authors suggest that the scores in each of three identified instrument factors
(faith/belief, life/self responsibility, and life-satisfaction/self-actualization) can be used to

identify needs or concerns.
QUALITY OF LIFE ASSESSMENT

Quality of life (QOL) as been described as primarily a subjective sense of well-being
encompassing physical, psychological, social, and spiritual dimensions (Haas, 1999, p. 219).
According to Haas (1999), indicators of QOL include: satisfaction with life, a subjective indi-
cator; well-being, a subjective assessment concerned with all dimensions of life; and func-
tional status, focused on objective indicators and concerned with all dimensions of life. In
contrast, in their precede-proceed model of health promotion planning, Green and Krewer
(1991) propose quality of life and health as outcomes of health promotion. The PRECEDE-
PROCEED model is discussed in Chapter 8.
Raphael and colleagues suggest that quality of life encompasses the degree to which a person
enjoys the important possibilities of his/her life. The enjoyment of important possibilities is rele-
vant to three major life domains: being, belonging, and becoming (Raphael et al., 1997, p. 120).
Being reflects who one is and has three subdomains: physical being encompasses physi-
cal health, personal hygiene, nutrition, exercise, grooming, clothing, and general appearance.
Psychological being includes the persons psychological health and adjustment, cognition,
feelings, and evaluations concerning the self, such as self-esteem and self-concept. Spiritual
being refers to ones personal values, standards of conduct, and spiritual beliefs.
Belonging concerns the persons fit with his or her environments and also has three subdo-
mains: physical belonging describes the persons connections with the physical environments
of home, workplace, neighborhood, school, and community. Social belonging includes links
with social environments and involves acceptance by intimate others, family, friends, co-
workers, and neighborhood and community. Community belonging represents access to pub-
lic resources, such as adequate income, health and social services, employment, educational
and recreational programs, and community events and activities.
Becoming refers to the activities carried out in the course of daily living, including those
to achieve personal goals, hopes, and aspirations. Practical becoming describes day-to-day
activities, such as domestic activities, paid work, school, or volunteer activities, and seeing
to health or social needs. Growth-becoming activities promote the maintenance or improve-
ment of knowledge and skills, and adapting to change. Leisure becoming includes activities
carried out primarily for enjoyment that promote relaxation and stress reduction.
The relative importance or meaning attached to each particular dimension and the extent
of the persons enjoyment influence the extent of a persons QOL. The domains of QOL may
serve as a determinant of health; improvement in the domains may be seen as a desired goal
of health-promotion activities; assessment within the domains can serve as an indicator of
needs (Raphael et al., 1997, p. 121).
In contrast, Browne, McGee, and OBoyle (1997, p. 738) suggest that needs (as
opposed to wants) are the most important determinant of quality of life. Domains normally
included are physical health status and functional ability, psychological status and well-
being, social interactions and economic status. . . . Above a basic standard of living, indi-
vidually determined criteria, based more on wants than needs, become important in
determining quality of life. . . . Certain needs are assumed to be more important than oth-
ers (p. 739). Each individual has his or her own definition of what constitutes a good or
poor quality of life. More specifically, individuals define life domains in different ways, use
different criteria to evaluate the domains, and place differing emphases on their importance
to overall life quality.
Assessment Techniques from Eastern Traditions

The intent in the following section is to supplement the typical Western biomedical phys-
ical assessment of body systems with an introduction to two approaches (tongue and pulse
assessment) commonly used in the Eastern traditions of Ayurveda and Chinese medicine. It
is assumed that the judicious use of holistic techniques can broaden the database from which
the client and nurse develop a health promotion plan.
Ohashi (1991, p. 15) describes four approaches to assessing the health and character of
another person. These approaches clearly indicate how Eastern approaches differ from the
typical Western assessment techniques.
Bo Shin. Seeing or observing with your entire being. Be open to the clients vibration
and dont become preoccupied with details (p. 16).
Setsu Shin. Touching or feeling the core or inner being of the client (p. 17), using
the hands as if they were knives (p. 18).
Mon Shin. Asking questions for information, listening for what is not being said. Gain
the clients trust. Know your limits by not probing too deeply.
Bun Shin. Listening to the quality of the clients voice and smelling odors given off by
imbalance (e.g., ammonia from a high protein diet smells foul, fat smells rancid, and
hormonal imbalance smells slightly burnt).
Two of the major Eastern health care belief systems are Ayurveda and Chinese medicine.
AYURVEDIC ASSESSMENT
One branch of Ayurveda is known as Maharishi Ayur-Veda (MAV). According to this tra-
dition, the very first step in the development of disease is pragya-aparadh, a change in aware-
ness deep inside. This results in being cut off from ones own innermost nature. As a result,
mistakes are induced in three areas: diet, regimen, and mental activity. MAV diagnostic
techniques reveal the individuals state of balance and weak points. Disease can be detected
so early that symptoms have not yet become evident (Sharma & Clark, 1998).
Classic Ayurvedic texts describe three main modalities of diagnosis: sight, speech, and
touch. Sight includes careful examination for details of imbalance, which can be revealed in
the eyes, tongue, and other physical structures. Speech refers to a process of questioning the
client about complaints, history, and causative factors. Touch involves many aspects includ-
ing palpation and pulse assessment.
Pulse Assessment
In Ayurveda, the body is considered to be a pattern of information and intelligence. Informa-
tion about the body as a whole is carried in the cardiovascular system in the form of fluid vibra-
tory waves. Any imbalance creates a particular wave function, which can be identified by an
Assessment Techniques from Eastern Traditions 179
experienced diagnostician. The main value of pulse [assessment] is in revealing imbalances in

the doshas and subdoshas, and the early stages of disease that result from such imbalances
(Sharma & Clark, 1998, pp. 55). (See Chapter 2 for a review of doshas).
Sharma and Clark (1998) describe the relationship of pulse assessment to Ayurvedic
doshas. The radial artery of the right wrist of males and the left wrist of females is used to take
the pulse using the clinicians index, middle, and ring fingers. The relative strength and char-
acteristic style of pulsation under each finger relates to a specific dosha. The pattern of the
Vata pulse is compared to the motion of a snake: light, quick, rough, thin, and rapidly undu-
lating; Pittas pulse pattern is compared to a frog: sharp, cutting, and jerky; and Kaphas pulse
pattern is compared to the motion of a swan: heavy, full, slow, soft, and graceful. Pulsation in
the wrong finger indicates dislocation of the doshas. The pulse at the surface of the skin (the
vikriti) reflects imbalances present in the physiology, while the pulse felt at one-half of
the arterys thickness (the prakriti), reflects the underlying nature. Also, different parts of the
fingertip relate to different subdoshas; and different techniques reveal information about the
dhatus (1998, p. 55).
To learn pulse assessment, the nurse should monitor his or her own pulse. By doing so
many times a day over a prolonged time, the nurse can become more alert to the subtle infor-
mation carried by the pulse. In the course of a day, of a year, and of different types of activi-
ties, the three doshas vary in their predominance and their states of balance. As you monitor
your own pulse, you become more alert to what, and how, your body is doing (Sharma &
Clark, 1998, pp. 55-56).
ASSESSMENT IN CHINESE MEDICINE

Western biomedicine medicine regards symptoms of disease to be reactions to noxious
stimuli, as errors to be corrected with drugs and surgery. These methods do nothing to elim-
inate the root cause of the symptoms. On the contrary, they only further weaken the clients
system, eventually giving rise to even worse symptoms and more severe disease (Reid, 1995).
In contrast, traditional medical belief systems view symptoms of disease as normal
responses to abnormal stimuli, as alarm signals indicating a defect in the environment or a
mistake in lifestyle that must be corrected at the root source (Reid, 1995, p. 90). Traditional
healing methods such as herbal medicine, diet, fasting, therapeutic exercise, acupuncture, and
massage eliminate the basic causes of disease by removing toxins from the body, restoring vital
functions, and re-establishing optimum balance and harmony among the various organ ener-
gies of the human energy system (p. 90). If successful, all abnormal symptoms naturally dis-
appear and the client is cured. The problem will not recur if the client then takes preventive
measures to eliminate the environmental or lifestyle factors that initially caused the problem
(Reid, 1995).
Western diagnosis often involves evaluation of a battery of laboratory tests and machine meas-
urements. Chinese diagnosis emphasizes methods that rely solely on the clinicians own sense per-
ceptions, judgment, intuition, and experience. The clinician identifies what is seen, heard,
smelled, and felt, asking questions about activities and events that cannot be observed directly,
and listening to the clients feelings and complaints (Beinfield & Korngold, 1991). Using himself
as the instrument, the [clinician] takes the measure of the [client]: focusing mind and perception
upon the gestalt of posture, stature, emotional and behavioral expression; upon specific attributes
of the tongue, pulse, and complexion; and finally upon the areas and quality of pain or discomfort,
restriction or freedom of movement, overall vigor and weakness.... The intent is to know not only
the nature of the problem, but the nature of the [client] (Beinfield & Korngold, 1991, p. 70).
In Chinese medicine, any part of the body (pulse, tongue, eye, ear) gives information
about the whole. Any aspect of a human being can become a window or lens for revealing
the state of the person (Beinfield & Korngold, 1991, p. 70). The objective is to formulate a
picture of healthy and distorted patterns of function, with each set of diagnostic parameters
providing one dimension of the total picture. Causes are really descriptions of underlying rela-
tionships rather than descriptions of material agents or pathogens.
Beinfield and Korngold (1991) describe several holistic methods used for assessment in
Chinese medicine. These methods, in many cases quite different than Western traditions,
include:
1. Observing. Complexion, eyes, tongue, nails, hair, gait, stature, affect, quality of excre-
tions, and secretions.
2. Listening and smelling. Sound of voice and breath, odor of breath, skin, excretions, and
secretions.
3. Questioning. Current complaints, health history, family health history, patterns of sleep,
appetite, weight, elimination, menses, and stress.
4. Touching. Texture, humidity, temperature, elasticity of skin; strength and tone of mus-
cles; flexibility, range of motion of joints; sensitivity of diagnostic points; and radial
pulse assessment and evaluation.
Observation is based on visual analysis. The color and tone of the clients complexion,
eyes, ears, tongue, hair, skin, and nails provide direct reflections of the condition of the
related internal organs. Observing the way she or he walks, talks, breathes, and moves his
or her arms and legs can assess the clients energy and spirit. Chinese physicians care-
fully observe what they call chee seh, literally the color of energy, which is reflected in
facial complexion, the color of the earlobes, and the condition of the facial apertures,
signs which clearly indicate the state of the [clients] vitality and resistance (Reid, 1995,
p. 88).
Listening is based on auditory and olfactory analysis in Chinese diagnosis. Odors of the
clients breath and bodily secretions, and sounds of the clients breath, voice, cough, heart-
beat, and stomach and bowels help determine the nature and location of the disease and the
type of energy imbalance involved (Reid, 1995).
Touching is based on tactile analysis of the clients skin and supporting structures, palpa-
tion of the internal organs, and acupressure massage of the major energy meridians in order
to determine which organs are affected by the disease. Particular vital points along the
meridians, known as alarm points, become very tender and painful to touch when their asso-
ciated organs are ailing, and nerve ganglia along the spine become tight and knotted when
the organs they control are weak or dysfunctional (Reid, 1995, p. 88).
Generally, Chinese medicine recognizes emotions, climate, and lifestyle as the primary
sources of pathogenic stress. Sudden changes in weather or prolonged exposure can leave the
body vulnerable to attack by wind, heat, dampness, dryness, and cold. Intense, persistent or sup-
pressed emotional reactions such as anger, joy, anxiety, sorrow, or fear can cause a disruption of
Assessment Techniques from Eastern Traditions 181
the circulation of qi and blood. Misuse of the body through overwork, overuse of the senses, or
prolonged sitting, lying, or standing wastes the qi and injures the blood. Overindulgence in or
neglect of dietary and sexual needs depletes vital essence (Beinfield & Korngold, 1991).
Pulse Assessment
Ayurveda relates pulse assessment to the dosha constitution. In contrast, in Chinese med-
icine, pulse assessment is based on the principle that qi and blood circulate together as a sin-
gle entity. The movement of blood allows the clinician to infer the activity of qi, moisture,
and blood. The movement of blood in the arteries produces the pulse, but the force of qi ini-
tiates the movement (Beinfield & Korngold, 1991).
In pulse assessment three positions on each wrist are felt along the radial artery, at posi-
tions corresponding to metabolic zones known as the triple-burner or three-heater. The posi-
tion closest to the thumb corresponds to the chest and upper body (the heart and lung). The
middle position corresponds to the upper abdomen (the stomach, spleen, gallbladder, and
liver). The position farthest from the wrist corresponds to the lower abdomen (the kidney,
bladder, small intestine, and large intestine) (Beinfield & Korngold, 1991, p. 74).
The strength, rate, rhythm, and size of the pulse express the integrity of the qi and blood
and the functional activity of the five organ networks. A healthy pulse is regular, with four
to five beats per cycle of respiration and a smooth, flowing feeling as it rises and falls. It is both
elastic and resilient, evoking a sense of relaxed and vigorous rhythm and harmony (Beinfield
& Korngold, 1991, p. 74).
As many as 32 pulse qualities are described in the classical texts, each indicating a partic-
ular type of disturbance. For example, if the pulse is floatingthat is, it can be felt with
light pressure but fades away as the pressure increasesit indicates an adverse climate (wind,
cold, heat, dampness, or dryness) has penetrated the surface from the outside. If the pulse is
floating and rapid, or floating and strong, this reflects the influence of these adverse climates
in conflict with the vigorous defensive qi of the body. The sinking pulse is its counterpart.
It is perceived only with deeper pressure and feels like a stone settling in water. Since it is rel-
atively hidden or buried, it indicates that the problem exists at the deeper internal level
(Beinfield & Korngold, 1991, p. 77).
A frail and weak pulse generally indicates problems of a yin nature, while a strong and full
pulse indicates problems of a yang nature. If one system is hyperactive and another is under-
active, a full and forceful pulse may be felt in one position with a soft and weak pulse in
another. A tense and erratic pulse can be generated by either excess or deficiency and is pro-
duced by stagnation. Heat can be generated by a lack of yin as well as an excess of yang or
fire. Most people are not diagnosed as having problems of a purely yin or yang nature, and
often more than one organ network is involved in their disorder (Beinfield & Korngold,
1991, p. 77).
Tongue Assessment
The tongue can be evaluated by observing its color, texture, moisture, size, and shape. A
healthy tongue fits comfortably in the mouth and is smooth, moist, bright, pink, and firm,
with a thin white fur that covers the upper surface. Changes in the body of the tongue gen-
erally reflect long-term dysfunction of the viscera, whereas changes in the fur reflect short-
term disturbances of digestion, fluid balance, and heat regulation (Beinfield & Korngold,
1991, p. 71). Twenty-four different conditions based on the color, tone, texture of the tongue,
and tongue fur have been distinguished in Chinese medical practice (Reid, 1995).
Each part of the tongue corresponds to the condition or state of an organ network. To see
the condition of the heart network one looks at the extreme tip of the tongue, whereas to
gauge the state of the lung, one looks near the tip. So a very red-tipped tongue indicates not
only the general presence of heat, but heat affecting these two networks. A tongue that is pur-
plish indicates poor circulation, particularly associated with the stagnation of qi or blood in
the liver. And greasy yellow fur in the center of the tongue reports damp heat in the spleen
and stomach (Beinfield & Korngold, 1991, p. 73).
The intrinsic strength and functional capacity of the individual is reflected in the quality
of the fur and color of the tongue, as is the progress of illness. However, many external factors
can also affect the appearance of the tongue, such as smoking, coffee, alcohol, and the use of
pharmaceutical drugs. Under these conditions, the tongue may reflect the effect of these
agents rather than give a true picture of the underlying state (Beinfield & Korngold, 1991).
Although the usual emphasis for assessment in nursing has been on physical methods to
identify health problems and symptoms of disease, the emphasis in this chapter has been on
multiple approaches to the assessment of health, including strengths and resources. Most health
assessment measures are atheoretical and dimensional (e.g., functional ability, mental status,
nutritional status, spiritual beliefs, quality of life), based on the disease perspective that health
is additive. Much more theoretical work needs to be done as the basis for holistic measures (e.g.,
pulse and tongue assessment) that are consistent with a unitary perspective of health.
Screening for Disease

Screening and counseling for risk factors in order to prevent disease, an application of pri-
mary prevention, will be discussed in Chapter 8, Promoting Individual Behavior Change.
Screening for disease conditions, an application of secondary prevention, aims to detect dis-
eases in an early stage, in order to prevent the morbidity and costs associated with disease pro-
gression. Screening procedures include special tests or standardized examinations, usually
with asymptomatic clients, to identify high-risk persons, who can then be referred for follow-
up diagnosis and possible treatment. Based on a systematic review of evidence of clinical
effectiveness, the U.S. Preventive Services Task Force (1996) developed detailed clinical rec-
ommendations on the appropriate use of screening interventions for many common clinically
significant conditions, with existing, potentially effective preventive interventions. For a
screening test to be considered effective, two major elements were required:
The test must be able to detect the target condition earlier than without screening and
with sufficient accuracy to avoid producing large numbers of false-positive and false-negative
results; and screening for and treating persons with early disease should improve the likeli-
hood of favorable health outcomes compared to treating [clients] when they present with
signs or symptoms of the disease (U.S. Preventive Task Force, 1996, p. xiii).
Task Force recommendations are summarized in Tables 7-3 to 7-6.
Screening for Disease 183
Table
7-3
Screening Interventions for the General Population by Age
AGE SCREENING INTERVENTION

Birth to 10 years Height and weight
Blood pressure
Vision screen (age 3 to 4 years)
Hemoglobinopathy screen (birth)
Phenylalanine level (birth)
T4 and/or TSH (birth)
Ages 11 to 24 years Height and weight

Blood pressure
Papanicolaou test (females)
Chlamydia screen (females <20 years)
Rubella serology or vaccination hx (females >12
years)
Assess for problem drinking
Blood pressure
Height and weight
Total blood cholesterol (men ages 35 to 64); (women
ages 45 to 64)
Ages 25 to 64 years Papanicolaou test (women)

Fecal occult blood and/or sigmoidoscopy (>50 years)
Mammogram (women ages 50 to 69)
Rubella serology or vaccination hx (women of child
bearing age)
Age 65 and older Blood pressure

Height and weight
Fecal occult blood and/or sigmoidoscopy
Papanicolaou test (women)
Mammogram (women >69 years)
Assess for hearing impairment
Vision screening
continued
Table
7-3 Screening Interventions for the General Population by Age
(continued)
AGE SCREENING INTERVENTION

Pregnant women Blood pressure
Hemoglobin/hematocrit
Hepatitis B surface antigen
RPR/VDRL
Chlamydia screen (<25 years)
Rubella serology or vaccination hx
D typing, antibody screen
Offer CVS (<13 weeks) or amniocentesis (15 to 18
weeks) (age >35 years)
Offer hemoglobinopathy screening
Assess for problem or risk drinking
Offer HIV screening
Source: U.S. Preventive Services (1996). Guide to clinical preventive services. Baltimore: Williams and
Wilkins.
Truglio-Londrigan and OConnor (1998) discuss ethical issues associated with the use
of screening procedures. Of considerable concern is the possibility for misinterpretation of
the results by the client. Clients should be aware of the possibility of false-positive or false-
negative results and clearly informed that the results of screening tests are not diagnostic.
In addition, consideration should be given to the obligation to clients who have received
a false-positive result, resulting in expense for further testing, stigmatization by a disease
considered to be socially or personally unacceptable, and/or anxiety while waiting for the
results of further testing. What is the ethical obligation to persons who may receive a false-
negative result and lose the opportunity for early intervention? What about borderline
cases?
The periodic health examination provides an obvious opportunity for implementing
screening procedures. However, it should be stressed that only clinically effective screening
tests should be used and only when interventions are available that could improve outcomes
for clients who test positive for the disease. It is vital that screening activities be followed by
appropriate referral and follow-up counseling.
Table
7-4
Interventions for which There Is Insufficient Evidence to
Recommend for or Against Screening Asymptomatic Persons
DISEASE OR PROBLEM SCREENING TEST

Coronary artery disease Resting electrocardiography (ECG)
Ambulatory ECG
Exercise ECG
Routine screening is not recommended as part of the
periodic health visit or pre-participation sports exami-
nation for children, adolescents, or young adults.
There is lack of evidence that earlier detection of CAD
leads to better outcomes. The only interventions
proven to reduce coronary events in asymptomatic
persons are modifications of risk factors such as smok-
ing, high cholesterol, and elevated blood pressure.
Abdominal aortic aneurysm Abdominal palpation or ultrasound
Skin cancer Visual skin examination

There is insufficient evidence to recommend for or
against sunscreen use for the primary prevention of
skin cancer or counseling patients to perform periodic
skin self-examination. Avoidance of sun exposure,
specially between 10 am to 3 pm, and the use of pro-
tective clothing.
Oral cancer Visual examination

Discontinue all forms of tobacco and consumption of
alcohol.
Diabetes mellitus or Routine ultrasound in the second trimester in low-risk

gestational diabetes pregnant women.
Glaucoma
Preterm labor Home uterine activity monitoring (HUAM) in high-risk

pregnancies
continued
Table
7-4 Interventions for which There Is Insufficient Evidence to
Recommend for or Against Screening Asymptomatic Persons
(continued)
Osteoporosis in Bone densitometry

postmenopausal women Women should be counseled about hormone prophy-
laxis, smoking cessation, regular exercise, and ade-
quate calcium intake.
Idiopathic scoliosis in
asymptomatic adolescents
Dementia Standardized instruments

Evaluate mental status in persons who have problems
performing daily activities.
Depression Standardized questionnaires

Be alert for depressive symptoms in persons at high risk
of depression.
Suicide risk Be alert to signs of suicidal ideation in persons with

established risk factors. Be alert to depression and use
of alcohol and other drugs.
Family violence Screening instruments

Ask questions about physical abuse.
Drug abuse Standardized questionnaires or biologic assays

Question adolescents and adults while taking a history.
Source: U. S. Preventive Services. (1996). Guide to clinical preventive services. Baltimore: Williams and
Wilkins.
Table
7-5 Interventions for which Screening of Asymptomatic Persons
Is Recommended
DISEASE SCREENING TEST

High blood cholesterol An interval of 5 years has been suggested. All adults,
(men ages 35 to 65 adolescents, and children over age 2 years, including
and women ages 45 to 65) those with normal cholesterol levels, should receive
periodic counseling regarding dietary intake of fat and
saturated fat.
Hypertension If hypertension is confirmed, should receive counseling

(all children and adults) regarding physical activity, weight reduction, and
dietary sodium intake.
Breast cancer Mammography alone or mammography and annual

(women ages 50 to 69) clinical breast examination (CBE) every 1 to 2 years.
There is insufficient evidence to recommend for or
against the use of screening CBE alone or the teaching
of breast self-examination.
Colorectal cancer Annual fecal occult blood testing or sigmoidoscopy.
Cervical cancer Papanicolaou (Pap) testing for all women who are or
(ages 50 and older) have been sexually active and who have a cervix every
3 years up to age 65.
Height and weight Body mass index (body weight in kilograms divided by
measurements for obesity the square of height in meters) can be used as the basis
for further assessment. All clients should be counseled
to promote physical activity and a healthy diet.
Iron deficiency anemia Hemoglobin or hematocrit for pregnant women and

measurements for obesity high-risk infants. Encourage breast feeding. Insufficient
evidence for routine use of iron supplements for
healthy infants or pregnant women.
Elevated lead levels Measuring blood lead at least once at age 12 months
for all children at increased risk of lead exposure.
continued
Table
Is Recommended (continued)

Hepatitis B Surface antigen (HbsAg) for all pregnant women at
their first prenatal visit. May be repeated in the third
trimester for women at increased risk of HBV infection
during pregnancy.
Tuberculosis Tuberculin skin testing.
Syphilis Serologic screening for all pregnant women and per-

sons at increased risk of infection. Counseling is sug-
gested to prevent sexually transmitted diseases.
Gonorrhea For asymptomatic women at high risk of infection. All

(Neisseria gonorrhoeae) high-risk women should be screened during pregnancy.
Not recommended for the general adult population.
Human immunodeficiency Periodic screening for all persons at increased risk of

virus (HIV) infection. Infants born to high-risk women if the moth-
ers antibody status is not known.
Chlamydial infection For all sexually active female adolescents, high-risk

(Chlamydia trachomatis) pregnant women, and other asymptomatic women at
high risk of infection. Not recommended for the gener-
al population.
Asymptomatic bacteruria Urine culture for all pregnant women. Insufficient evi-
dence for diabetic or ambulatory elderly women.
Rubella History of vaccination or by serology for all women of

childbearing age at their first clinical encounter.
Susceptible nonpregnant women should be offered
rubella vaccination; susceptible pregnant women
should be vaccinated immediately after delivery. An
alternative for nonpregnant women of childbearing age
is vaccination without screening.
continued
Table

Visual impairment or Vision screening with Snellen visual acuity chart.
diminished visual acuity Detection of amblyopia and strabismus is recommend-
(elderly) ed once for all children prior to entering school, prefer-
ably between ages 3 and 4. Older adults should be
periodically questioned about their hearing and coun-
seled about the availability of hearing aid devices.
Insufficient evidence for asymptomatic adolescents and
working-age adults or older adults using audiometric
testing.
Preeclampsia Blood pressure measurement for all pregnant women at

the first prenatal visit and periodically throughout the
remainder of pregnancy.
D (formerly Rh) Blood typing and antibody screening for all pregnant
women at their first prenatal visit. Repeat antibody
screening at 24 to 28 weeks gestation is recommended
for unsensitized D-negative women.
Down syndrome Chromosomal studies of amniocentesis or chorionic

villus sampling (CVS) for pregnant women at high risk
if there are adequate counseling and follow-up servic-
es. Serum multiple marker testing can be used for all
low-risk pregnant women and as an alternative to
amniocentesis or CVS for high-risk women.
Neural tube defects Maternal serum a-fetoprotein (MSAFP) measurement

with adequate counseling and follow-up services.
Daily multivitamins with folic acid to reduce the risk of
neural tube defects are recommended for all women
who are planning or capable of pregnancy.
Sickle hemoglobinopathies Neonatal screeening to identify infants who may bene-

fit from antibiotic prophylaxis to prevent sepsis.
Requires comprehensive counseling and treatment
services.
continued
Table

Phenylketonuria (PKU) Measurement of phenylalanine level on a dried-blood
spot specimen for all newborns prior to discharge from
the nursery. Infants who are tested before 24 hours of
age should receive a repeat screening test by 2 weeks
of age.
Congenital hypothyroidism Thyroid function tests on dried-blood spot specimens

for all newborns in the first week of life.
Problem drinking Standardized screening questionnaires and/or careful

(all adults and adolescents) history of alcohol use counsel about the dangers of
operating a motor vehicle.
Source: U.S. Preventive Services (1996). Guide to clinical preventive services. Baltimore: Williams and Wilkins.
Table
7-6 Interventions for which Routine Screening of Asymptomatic
Persons Is not Recommended

Peripheral arterial disease Should screen for hypertension and hypercholes-
terolemia and counsel regarding the use of tobacco,
physical activity, and nutritional risk factors for athero-
sclerotic disease.
Prostate cancer Digital rectal examinations, serum tumor markers (e.g.,

prostate-specific antigen) or transrectal ultrasound.
Lung cancer Chest radiography or sputum cytology. All patients

should be counseled against tobacco use.
Ovarian cancer Ultrasound, measurement of serum tumor markers, or

pelvic examination.
continued
Table
7-6 Interventions for which Routine Screening of Asymptomatic
Persons Is not Recommended (continued)

Pancreatic cancer Abdominal palpation, ultrasonography, or serologic
markers.
Bladder cancer Urine dipstick, microscopic uninalysis or urine cytol-

ogy; stop smoking.
Thyroid cancer or Neck palpation or ultrasonography.

thyroid disease
Genital herpes simplex Viral culture or other tests.
Routine electronic For low-risk women in labor. Insufficient evidence for

fetal monitoring high-risk pregnant women.
Source: U.S. Preventive Services. (1996). Guide to clinical preventive services. Baltimore: Williams and
Wilkins.
Chapter Key Points

The nurse collects data from a variety of assessment sources to identify health assets and
strengths to improve the clients health and well-being.
There are many different nursing approaches to the organization of assessment
processes including nursing conceptual models or theories and functional health
patterns.
Assessment of client parameters such as functional ability, mental and nutritional sta-
tus, and quality of life can add vital information for the health database.
The judicious use of techniques such as tongue and pulse assessment can broaden the
database from which the client and nurse develop a health promotion plan.
Clinically effective screening procedures can provide early detection of disease, reduc-
ing morbidity and cost. However, consideration must be given to ethical concerns,
appropriate referral, and follow-up counseling.
References
Beinfield, H., & Korngold, E. (1991). Between heaven and earth: A guide to Chinese medicine. New York:
Ballantine.
Block, G., Hartman, A. M., Dresser, C. M., Carroll, M. D., Gannon, J., & Gardner, L. (1986). A data-based
approach to diet questionnaire design and testing. American Journal of Epidemiology, 24, 453-469.
Browne, J. P., McGee, H. M., & OBoyle, C. A. (1997). Conceptual approaches to the assessment of qual-
ity of life. Psychology and Health, 12, 737-751.
Drewnowski, A. (2001). Diet image: A new perspective on the food frequency questionnaire. Nutrition
Review, 59, 370-372.
Edelman, C. L., & Mandle, C. L. (1998). Health promotion throughout the lifespan (4th ed.). St. Louis: Mosby.
Frankish, C. J., Milligan, C. D., & Reid, C. (1998). A review of relationships between active living and
determinants of health. Soc Sci Med, 47, 287-301.
Gordon, M. (1995). Manual of nursing diagnosis: 1995-1996. St. Louis: Mosby.
Green, L. W. & Kreuter, M. W. (1991). Health promotion planning. An educational and environmental approach
(2nd ed.). Mountain View, CA: Mayfield Publishing.
Haas, B. K. (1999). Clarification and integration of similar quality of life concepts. Journal of Nursing Schol-
arship, 31, 215-220.
Hungelmann, J. A., Kenkel-Rossi, E., Klassen, L., & Stollenwerk, R. M. (1989). Development of the
JAREL spiritual well-being scale. In R. M Carrol-Johnson (Ed.), Classification of nursing diagnoses:
Proceedings of the eighth conference, North American Diagnosis Association (pp. 393-398). Philadel-
phia: Lippincott.
Hungelmann, J., Kenkel-Rossi, E., Klassen, L., & Stollenwerk, R. (1996). Focus on spiritual well-being:
Harmonious interconnectedness of mind-body-spirit. Use of the JAREL spiritual well-being
scale. Geriatric Nursing, 17, 262-266.
Jarvis, C. (2000). Physical examination and health assessment (3rd ed.). Philadelphia: W. B. Saunders.
Keegan, L. & Dossey, B. (1987). Self-care: A program to improve your life. Temple, Texas: Bodymind Systems.
Leddy, S. K. (1996). Development and psychometric testing of the Leddy healthiness scale. Research in
Nursing and Health, 19, 431-440.
Leddy, S. K. (1997). Healthiness, fatigue, and symptom experience in women with and without breast can-
cer. Holistic Nursing Practice, 12, 48-53.
Leddy, S. K. (1998). Leddy and Peppers conceptual bases of professional nursing (4th ed.). Philadelphia: Lippincott.
Leddy, S. K. (2004). Human energy: A conceptual model of unitary nursing science. Visions: The Journal of
Rogerian Nursing Science, 12, 14-27.
Leddy, S. K. & Fawcett, J. (1997). Testing the theory of healthiness: Conceptual and methodological issues.
In M. Madrid (Ed.), Patterns of Rogerian Knowing (pp. 75-86). New York: NLN.
Leidy, N. K. (1994). Functional status and the forward progress of merry-go-rounds: Toward a coherent ana-
lytical framework. Nursing Research, 43, 196-202.
Leidy, N. K., & Haase, J. E. (1999). Functional status from the patients perspective: The challenge of pre-
serving personal integrity. Research in Nursing and Health, 22, 67-77.
Additional Information 193
Ohashi, W. (1991). Ohashis book of oriental diagnosis. New York: Penguin.

Patton, G. L. (2001, September-October). Spirituality assessment in health care. Health Progress, 15-18.
Pender, N. J. (1996). Health promotion in nursing practice (3rd ed.). Norwalk, CT: Appleton & Lange.
Raphael, D., Brown, I., Renwick, R., & Rootman, I. (1997). Quality of life: What are the implications for
health promotion? American Journal of Health Behavior, 21, 118-128.
Reid, D. (1995). The complete book of Chinese health and healing: Guarding the three treasures. Boston: Shambhala.
Reker, G. T., & Wong, P. T. P. (1984). Psychological and physical well-being in the elderly: The perceived
well-being scale. Canadian Journal on Aging, 3, 23-32.
Rychlee, A. L. (May 8, 2000). Assessment: The critical first step in the nursing process. Advance for Nurses
Greater Philadelphia, 2, 31.
Sharma, H., & Clark, C. (1998). Contemporary Ayurveda: Medicine and research in Maharishi Ayurveda.
Philadelphia: Churchill Livingstone.
Soderhamn, U., & Soderhamn, O. (2002). Reliability and validity of the nutritional form for the elderly
(NUFFE). J Adv Nurs, 37, 28-34.
Stewart, A. L., & Ware, J. E., Jr. (1992). Measuring functioning and well-being. The medical outcomes study
approach. Durham, NC: Duke University Press.
Trabulsi, J., & Schoeller, D. A. (2001). Evaluation of dietary assessment instruments against doubly labeled
water, a biomarker of habitual energy intake. American Journal of Physiol Endocrinol Metabolism,
281, E891-899.
Travis, J. W., & Ryan, R. S. (1988). Wellness workbook (2nd ed.). Berkley, CA: Ten Speed Press.
Truglio-Londrigan, M., & OConnor, J. M. (1998). Screening. In C. L. Edelman, & C. L. Mandle, Health
promotion throughout the lifespan (4th ed., pp. 195-221). St. Louis: Mosby.
U.S. Preventive Services Task Force. (1996). Guide to clinical preventive services (2nd ed.). Baltimore:
Williams & Wilkins.
Willett, W. C., Reynolds, R. D., Cottreil-Hoehner, S., Sampson, L., & Browne, M. L. (1987). Validation
of a semi-quantitative food frequency questionnaire: Comparison with a 1-year diet record. Jour-
nal of the American Diet Association, 87, 43-47.
Young, A. (1997). Self-assessments. In B. M. Dossey, Core curriculum for holistic (pp. 136-142). Gaithers-
burg, MD: Aspen.
Section
II
THE DISEASE WORLDVIEW
Section II, The Disease Worldview, includes two chapters that emphasize health protection
(risk reduction) and individual behavior change approaches to health promotion. Chapter 8, Pro-
moting Individual Behavior Change, describes a number of theories of health behavior change, with
strategies for promoting behavior change of individuals. And, Chapter 9, Global Health: The Eco-
centric Approach, proposes strategies for nursing involvement in environmental, societal, and
global health issues.
8
PROMOTING INDIVIDUAL
BEHAVIOR CHANGE
Abstract
Influences on health occur at individual, interpersonal, community, environmental, and
health care system levels. This chapter emphasizes psychological theories of individual health
behavior change and strategies for promoting behavior change of individuals, recognizing
that adoption of healthful lifestyle behaviors and decreasing or stopping harmful behaviors is
not easy for most people.
Learning Outcomes
Describe selected social cognitive models and theories of influences on individual
behavior change
Identify ways for the nurse to promote health through an individuals lifestyle changes
Influences on Behavior Change on Individuals

Adopting healthful lifestyle behaviors and decreasing or stopping harmful behaviors is not
easy for most people and do not occur automatically. Currently, most trends for obesity and
weight management, tobacco use, physical activity, and diet are going in the wrong direction
(Orleans, 2000, p. 76). For example, the prevalence of obesity in the United States has risen
from 25% in the 1960s to about 33% of the population today (Jeffery et al., 2000). Declines
in physical activity levels begin at age 6 and continue over the life span, and about 70% of
198 Chapter 8 Promoting Individual Behavior Change
adults over age 45 get no regular exercise (Marcus et al., 2000). Additionally, only 25% of
adult Americans meet the goal of 30% or less of calories from fat, and sodium intake is
increasing (Kumanyika et al., 2000).
Health care providers who want to facilitate health promotion need an understanding of
how and why people change behavior. A number of complex models have used social cogni-
tive theories to explain individual level health behavior change. Social cognitive theories
assume that personal, social, and environmental influences interact to affect behavior and
changes in behavior. Some of the social cognitive models and theories most often cited in the
literature are listed in Box 8-1.
B OX 8-1
Selected Social Cognitive Models
and Theories
Transtheoretical Model (Prochaska, & DiClemente, 1984). Proposes that
stages and processes of change, decisional balance, and self-efficacy
influence the stopping of an addictive behavior or the adopting of a
healthy behavior.
Modified Health Belief Model (Rosenstock et al., 1988). Proposes that per-
ception of susceptibility and seriousness affect a persons perceived threat
of disease, which combined with the balance between perceived benefits
and barriers of action affect the likelihood of a preventative health action
being taken.
Revised Health Promotion Model (Pender, 1996). Depicts individual char-
acteristics and experiences and behavior-specific cognitions and affect
that influence health promoting behavior.
Self-efficacy Theory (Bandura, 1986). Concerned with peoples judgments
of their capabilities to execute given levels of performance and to exer-
cise control over events.
Theory of Reasoned Action (Fishbein & Ajzen, 1975). Emphasizes the
effects of attitude and subjective norms on behavioral intention and actual
behavior.
Theory of Planned Behavior (Ajzen, 1985). Adds perceived behavioral
control to the effects of attitude and subjective norms on behavioral inten-
tion and actual behavior.
continued
Influences on Behavior Change on Individuals 199
B OX 8-1 CONTINUED
Theory of Locus of Control (Rotter, 1954). Proposes that people either

believe that their action controls an outcome (internals), or that they are
controlled by forces other than themselves (externals), such as chance or
powerful others.
Theory of Health Locus of Control (Wallston, 1976). Proposes a disposi-
tion to act in health-related situations based on perceptions of control
over health status and valuing of health as an end in itself or as a means
to a different end.
Common Sense Model (Leventhal, 1980). Proposes that common sense
beliefs, or representations, about identity, cause, timeline, consequences,
and cure or control of illness guide how people cope with health prob-
lems by directing attention to information and serving as bases for select-
ing coping strategies.
The scientific literature has viewed the various models and theories as competitive. As a
result, studies have compared the ability of constructs within a theory or model to explain or
predict behavior change. The emphasis has been on determination of the best predictor
theory or model. However, it has become clear that there is a great deal of overlap of con-
structs among the various theories and models. In addition, it appears that a complex network
of constructs may predict only a portion of each behavior and vary from one behavior to the
other. In most studies, much of human behavior remains unaccounted for (AbuSabha &
Achterberg, 1997).
Another approach is to study the constructs that appear across models and theories. The
intent is to move toward an understanding of how the influences on a specific behavior and
across a variety of behaviors might be combined for the greatest explanatory power. The fol-
lowing section will explore a number of constructs that have demonstrated potential to
explain or predict behavior change.
STAGES OF CHANGE
Stages and processes of change are two of the four constructs in the transtheoretical model
(TTM). Six basic assumptions of this stage model are (Laitakari, 1998, p. 32):
1. Change in health behavior happens through distinct stages or steps.
2. Change takes place optimally in a certain order of stages.
3. The completion of the previous stages promotes the reaching of the subsequent stages.
4. There are factors that promote adoption (e.g., processes or supporting-factors) spe-
cific to each stage.
5. The stage-specific factors can be mobilized through intervention methods (e.g., tech-
niques) to speed up the process of adoption.
6. Relapse is possible from each stage, but relapse can be used to provide valuable infor-
mation to help the individual to make a new attempt to change.
A consistent series of five stages of behavior change have been documented across 12 dif-
ferent health-related behaviors (Prochaska et al., 1992; Prochaska et al., 1994a). The same
pattern of change among TTM variables across stages was documented in a cross sectional
study of high school and undergraduate university students and employed adults (Rodgers et
al., 2001):
Precontemplation. The stage at which there is no intention to change behavior in the
foreseeable future. Resistance to recognizing or modifying a problem is the hallmark of
precontemplation.
Contemplation. The stage at which people are aware that a problem exists and are seri-
ously thinking about overcoming it but have not yet made a commitment to take
action. There is weighing of the pros and cons of the problem and the solution to the
problem. Serious consideration of problem resolution is the central element of contem-
plation.
Preparation. A stage that combines intention and behavioral criteria. Individuals in this
stage are intending to take action in the next month and have unsuccessfully taken
action in the past year. The hallmark of preparation is decision-making.
Action. The stage in which individuals modify their behavior, experiences, or environ-
ment in order to overcome their problems. Modification of the target behavior to an
acceptable criterion and significant overt efforts to change are the hallmarks of action.
Maintenance. The stage in which people work to prevent relapse and consolidate the
gains attained during action. Stabilizing behavior change and avoiding relapse are the
hallmarks of maintenance.
Instead of an orderly progression through the stages, relapse and recycling through the
stages occur quite frequently. During relapse, individuals regress to an earlier stage. Typically
40% of a population with an unhealthy behavior would be categorized in the precontempla-
tion stage, 40% would fall in the contemplation stage, and 20% would self-assess in the prepa-
ration stage (Fava et al., 1995).
Laitakari (1998) suggests many benefits associated with a stage model. One benefit is the
realism of this approach. It is clear that one learning experience or environmental modifica-
tion is usually not sufficient for the adoption of a new behavior. A planned series of learning
experiences or environmental changes in an atmosphere of mutual trust may be needed to
support fully the change or adoption process. The nurse must not try to manipulate an indi-
viduals behavior in a predetermined direction.
Another benefit is the enhancement of a person-centered approach. Instead of standard
interventions, each individual is assessed and given feedback about his or her apparent readi-
ness for change, within the context of supportive environmental and social factors. In addi-
tion, the stage model provides order and direction to health education and health promotion
efforts. Instead of taking the longitudinal process of behavior change for granted, stage-
specific experiences can be planned, while respecting the individuals responsibility for inde-
pendent decision making. Finally, the concept of a stage is fairly easily understood and seen
as meaningful by both lay persons and professionals.
PROCESSES OF CHANGE
Ten different processes that explain how change occurs have received empirical and the-
oretical support across various theories (Prochaska et al., 1992). These processes of change are
matched with representative interventions in Table 8-1.
As a start toward matching particular interventions to key individual client characteris-
tics, particular processes can be applied or avoided at each stage of change, as listed below
(Prochaska et al., 1992, p. 1109):
Precontemplation stage. Change processes are used significantly less than by people in
any of the other stages. Precontemplators process less information about problems,
devote less time and energy to re-evaluation, experience fewer emotional reactions to
the negative aspects of problems, are less open with significant others about problems,
and do little to shift their attention or environment in the direction to overcoming
problems.
Contemplation stage. People are most open to consciousness-raising techniques such as
observations, confrontations, and interpretations, and dramatic relief experiences
which raise emotions and lower negative affect if the person changes. People are also
more likely to reevaluate their values and problems and their effect on the persons with
whom they are closest.
Preparation stage. People use counterconditioning and stimulus control to begin reduc-
ing situations in which triggers for negative behavior occur.
Action stage. People rely increasingly on support and understanding from helping rela-
tionships. They increasingly believe that they have autonomy and willpower.
Maintenance stage. Involves an assessment of the conditions that promote relapse, and
development of alternative (and non self-defeating) responses. Most important is a con-
viction that maintaining change is highly valued by the person and at least one signif-
icant other.
Stages and processes of change have been studied in smoking cessation, stopping cocaine
use, weight control, high-fat diets, adolescent delinquent behaviors, safer sex, condom use,
sunscreen use, radon gas exposure, exercise acquisition, mammography screening, and physi-
cians preventive practices with smokers (Prochaska et al., 1994). One recent longitudinal
study of stage transition for exercise found the strongest support in the action/maintenance
stage retention, with limited impact on progression from the precontemplation and prepara-
tion stages (Plotnikoff et al., 2001). However, in a study of smokers using three outcomes
(habit strength, positive evaluation strength, and negative evaluation strength), movement
from the stages of precontemplation, contemplation or preparation was accurately predicted
1 year later, with 36 of the 40 predictions confirmed (Velicer et al., 1999). Rodgers and col-
leagues found that the behavioral processes were more sensitive than the cognitive processes
Table
8-1 Titles, Definitions, and Representative Interventions of the
Processes of Change
PROCESS DEFINITIONS AND INTERVENTIONS

Consciousness raising Increasing information about self and problem: obser-
vations, confrontations, interpretations, bibliotherapy
Self-re-evaluation Assessing how one feels and thinks about oneself with
respect to a problem: value clarification, imagery, cor-
rective emotional experience
Self-liberation Choosing and commitment to act or belief in ability to
change: decision-making therapy, New Years resolu-
tions, logotherapy techniques, commitment-enhanc-
ing techniques
Counterconditioning Substituting alternatives for problem behaviors:
relaxation, desensitization, assertion, positive self-
statements
Stimulus control Avoiding or countering stimuli that elicit problem
behaviors: restructuring ones environment (e.g.,
removing alcohol or fattening foods), avoiding high
risk cues, fading techniques
Reinforcement management Rewarding oneself or being rewarded by others for
making changes: contingency contracts, over and
covert reinforcement, self-reward
Helping relationships Being open and trusting about problems with some-
one who cares: therapeutic alliance, social support,
self-help groups
Dramatic relief Experiencing and expressing feelings about ones
problems and solutions: psychodrama, grieving losses,
role playing
Environmental re-evaluation Assessing how ones problem affects physical environ-
ment: empathy training, documentaries
Social liberation Increasing alternatives for nonproblem behaviors
available in society: advocating for rights of repressed;
empowering policy interventions
Reprinted from Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change.
Am Psychol, 47, 1108. 1992 by the American Psychological Association. Reprinted with permission.
for distinguishing between stages of exercise behavior (Rodgers et al., 2001). The most impor-
tant implications of the stages and processes of change research is that each clients readiness
for change must be evaluated before any interventions are attempted. Then, specific inter-
ventions need to be tailored to the individual clients stage of readiness for change.
DECISIONAL BALANCE
Part of the decision to move toward action is thought to be based on the relative weight
given to the pros and cons of changing behavior. According to Prochaska, Velicer, Rossi,
Goldstein, Marcus, and Rakowski (1994a), the pros, incentives, or perceived benefits are
advantages or positive aspects of changing behavior (i.e., facilitators of change). The cons, or
perceived barriers, to action are the disadvantages or negative aspects of changing behavior
(i.e., barriers to change).
Benefits and barriers of behavior change have been incorporated into at least five multi-
dimensional models of health behavior (Leddy, 1997). Perceived barriers have been found to
be the most powerful of the dimensions of the health belief model (Becker et al., 1977) in
explaining various health behaviors (Janz & Becker, 1984). The advantages outweighing dis-
advantages have been identified as one of eight critical variables in the theory of reasoned
action (Fishbein & Ajzen, 1975; Fishbein et al., 1991). Benefits and barriers also have been
empirically supported as predictors of health behaviors in the majority of studies using the
health promotion model (Pender, 1996), with barriers receiving the strongest support and
benefits receiving moderate support. In the use of the transtheoretical model (Prochaska &
DiClemente, 1984), incentives (i.e., pros) have accounted for more of the variance in the
movement through behavior change stages, whereas barriers (i.e., cons) have remained rela-
tively stable across the stages of change (Prochaska et al., 1994b). Measures of decisional bal-
ance also have demonstrated predictive utility for smoking cessation (Prochaska et al., 1985)
and exercise readiness (Marcus & Owen, 1992) in studies based on multiattribute utility the-
ory (Carter, 1990).
A meta-analysis of 24 retrospective studies demonstrated significantly large effect sizes for
both benefits and barriers for health-related behaviors (Harrison et al., 1992). However, given
that relapse is the norm for most behavior change attempts (Prochaska et al., 1994), focus-
ing interventions to increase the incentives as well as decrease the barriers for health behav-
ior change for the individual appears to be essential.
SELF-EFFICACY
Bandura (1977) developed the concept of self-efficacy to describe beliefs about how capa-
ble a person feels about performing specific tasks in specific behavioral situations. Self-
efficacy theory proposes that confidence in ones ability to perform a given behavior is
strongly related to ones actual ability to perform that behavior. Although a persons efficacy
expectations will vary greatly depending on the particular task and context, perceived self-
efficacy is believed to influence all aspects of behavior (Strecher et al., 1986) including:
Acquisition of new behaviors (e.g., a sexually active young adult learning how to use a
particular contraceptive device)
Inhibition of existing behaviors (e.g., decreasing or stopping cigarette smoking)
Disinhibition of behaviors (e.g., resuming sexual activity after a myocardial infarction)

Choices of behavioral settings
Amount of effort to be expended on a task
Length of time of persistence in the face of obstacles
Emotional reactions (e.g., anxiety and distress)
Thought patterns (e.g., ruminating about personal deficiencies rather than thinking
about accomplishing a task)
According to Bandura (1977), efficacy expectations vary in magnitude (ordering of tasks
by difficulty), strength (certainty of ability to perform a task), and generality (degree to which
expectations about one task apply to other tasks). In addition, Bandura et al. (1987) linked
judgment of capability to perform with perceived ability to exercise control over events. In a
modification of Banduras concept, the transtheoretical model operationalizes self-efficacy as
both confidence in changing a problem behavior, and situational temptation to engage in the
problem behavior (Prochaska et al., 1994a).
Marcus, Selby, Niaura, and Rossi (1992) found that exercise self-efficacy was significantly
related to stage in the change process, with precontemplators scoring the lowest and those in
maintenance scoring the highest in self-efficacy. Plotnikoff and colleagues (2001), in a longi-
tudinal study, also found moderate to strong support of exercise self-efficacy as a predictor of
forward stage transition. In smoking cessation studies, confidence is an important predictor
of stage movement to action and maintenance, while temptation is an important predictor of
relapse (Prochaska et al., 1994). Self-efficacy has been shown to be related to many other
health behaviors, including contraceptive behavior, cardiac rehabilitation, weight loss, and
nutrition (AbuSabha & Achterberg, 1997). Increased self-efficacy in people with cancer has
also been associated with increased adherence to treatment, increased self-care behaviors, and
decreased symptoms (Lev, 1997).
LOCUS OF CONTROL
Locus of control has been confused with self-efficacy. Locus of control is based on the belief
that people view the ability to attain a particular outcome as either within their control
(internals), where their action determines the outcome, or outside their control (externals),
where reward is controlled by forces other than ones self (Rotter, 1954). Levenson (1974)
extended externals beliefs into two beliefs: chance expectations such as fate or luck and con-
trol by powerful others such as family members or physicians. While self-efficacy is task spe-
cific, locus of control is believed to be domain specific (e.g., health domain, social domain),
which is much more general. However, locus of control has limited stability across time or dif-
ferent domains.
Studies have shown that people with an internal locus of control take responsibility for
their own actions and engage more readily in health-promoting behaviors (AbuSabha &
Achterberg, 1997). However, when used alone, the effect of locus of control on behavior is
small. Wallston (1992, p. 194) suggests a rapprochement of Rotters and Banduras social
learning theories, substituting a generalized expectancy of perceived control for locus of con-
trol, and incorporating perceived competence. The revised formulation states that people
must value health as an outcome, believe that their health actions influence their health sta-
tus, and concurrently believe that they are capable of carrying out the necessary behaviors in
order to have a high likelihood of engaging in a health-directed action (Wallston, 1992, p.
195). The perceived health competence construct appears to hold promise as a predictor of
adherence behavior (Christensen et al., 1996).
HEALTH BELIEFS
A belief is the conviction of truth (or falsehood) of an association between two concepts.
Belief may be based on observation, for example, the experience of feeling energized after
exercise would support a belief that exercise increases vitality. Scientific evidence may also
support belief, for example, much research supports a link between exercise and reduction of
myocardial disease. Some of the specific health beliefs that have been found to influence
behavior include:
Perceived susceptibility. A persons belief of being vulnerable to a particular health problem.
Perceived severity. A persons belief that the health problem has potential serious
consequences.
Perceived consequences (may also be called outcome expectations). A persons beliefs regard-
ing the consequences (positive or negative) of performing a specific health behavior.
Perceived benefits. A persons belief that taking action toward improving health behav-
ior will prevent illness or improve health. This is an example of a positive consequence.
Value of health. A measurement of the importance that a person places on outcome
expectations.
Perceived barriers. A persons belief that certain personal or environmental factors make
it difficult or impossible to take action toward improving health behavior.
Perceived threat. A combination of personal susceptibility and seriousness of a particular
health problem.
Perceived self-efficacy. A persons beliefs about how capable they feel about performing a
specific task in a specific behavioral situation.
Health beliefs have been incorporated into a number of health behavior models. Beliefs are
the fundamental building blocks in the theory of reasoned action, as the totality of a persons
beliefs serves as the informational base that ultimately determines his attitudes, intentions,
and behaviors (Fishbein & Ajzen, 1975, p. 14). However, in a review of 10 years of studies
related to the health belief model (Rosenstock, 1966), Janz and Becker (1984) concluded that
only two of the belief components, perceived barriers and perceived susceptibility, explained
or predicted preventive behaviors. Studies of the health promotion model (Pender, 1996)
have supported perceived benefits and perceived self-efficacy in addition to perceived barriers.
THE PRECEDE-PROCEED MODEL

A dominant planning model in health education is the Predisposing, Reinforcing, and
Enabling Constructs in Educational/Ecological Diagnosis and Evaluation (PRECEDE),
coupled with Policy, Regulatory, and Organizational Constructs in Education and Environ-
mental Development (PROCEED). Through a series of diagnostic steps, the PRECEDE-
PROCEED planning model facilitates consideration of both individual and environmental
factors that influence health and health behaviors. The model begins at the end, focusing on
the outcome of interest, and works backward to determine how best to achieve that outcome.
Factors that predispose, enable, or reinforce the behavioral and environmental determinants
then become the targets of change (Kegler & Miner, 2004).
In the PRECEDE-PROCEED model, a health promotion program is seen as an intervention
whose purpose it is to decrease illness or enhance quality of life through change or development
of health-related behavior and conditions of living. The PRECEDE framework takes into account
the multiple factors that shape health status and helps to arrive at a highly focused subset of those
factors as targets for intervention. PRECEDE also generates specific objectives and criteria for
evaluation. The PROCEED framework provides additional steps for developing policy and initi-
ating the implementation and evaluation process (Green & Kreuter, 1991, p. 22). However, nei-
ther PRECEDE nor PROCEED provides substantive guidance on how to actually intervene.
The PRECEDE framework directs initial attention to outcomes rather than inputs. It
encourages asking why before how. In phase 1 the hopes and problems of concern to the target
population are assessed, and in phase 2, the specific health goals or problems that may con-
tribute to the social goals or problems noted in phase 1 are identified. Phase 3 consists of iden-
tifying the specific health-related behavioral and environmental factors that could be linked to
the health problems chosen as most deserving of attention. The PRECEDE model then groups
them (phase 4) into predisposing, reinforcing, and enabling factors. Phase 5 involves assess-
ment of the organizational and administrative capabilities and resources for the development
and implementation of a health promotion program, while phases 6-8 are involved with eval-
uation. PROCEED highlights the important role of environmental factors as determinants of
health and health behaviors (see Figure 8-1 for the PRECEDE-PROCEED model).
OTHER INFLUENCES ON HEALTH BEHAVIOR

Pender (1996), in the revised health promotion model (HPM), has proposed a complex
combination of individual characteristics and experiences, behavior-specific cognitions, and
behavioral outcomes. Influences that have not been discussed earlier include:
Prior related behavior. Having performed the same or a similar behavior in the past.
Personal factors. Prediction of behavior is shaped by the nature of the target behavior.
Activity-related affect. Subjective feelings before, during, and after a behavior.
Interpersonal influences. Cognitions concerning behaviors, beliefs, or attitudes of others.
Situational influences. Perceptions and cognitions about the context for behavior.
Commitment to a plan of action. Intent to carry out a specific action including intended
strategies.
Competing demands and preferences. Alternative behaviors that become competing
courses of action to an intended health-promoting behavior.
Support has previously been found for many of the behavior-specific cognitions, including
perceived benefits, perceived self-efficacy, and perceived barriers (Pender, 1996). The vari-
Strategies for Promoting Behavior Change 207
PRECEDE
Phase 5 Phase 4 Phase 3 Phase 2 Phase 1
Administrative Educational and Behavior and Epidemiological Social
and policy organizational environmental diagnosis diagnosis
diagnosis diagnosis diagnosis
Predisposing
HEALTH factors
PROMOTION
Health Reinforcing Behavior

Education factors and
lifestyle Quality
Health of
life
Policy Enabling
regulation Environment
factors
organization
Phase 6 Phase 7 Phase 8 Phase 9

Implementation Process Impact Outcome
evaluation evaluation evaluation
PROCEED
Figure 8-1. PRECEDE-PROCEED model of health promotion planning. Reprinted with permis-
sion from Green, L. W., & Kreuter, M. W. (1991). Health promotion planning. An educational
and environmental approach (2nd ed.). Mountain View, CA: Mayfield Publishing. Reproduced
with permission of the McGraw-Hill Companies.
ables of activity-related affect, commitment to a plan of action, and immediate competing

demands and preferences are new variables. The entire revised model is undergoing testing.
Strategies for Promoting Behavior Change

The idea of changing health behavior is uncomfortable for many people. Deeply ingrained
habits, even harmful ones, can be difficult to change, and most people have difficulty making
even minor changes. According to Westberg and Jason (1996, pp. 147-148), people tend to
resist change because of beliefs that a change of behavior may:
Require giving up pleasure (e.g., eating high-fat ice cream)
Be unpleasant (e.g., doing certain exercises)

Be overtly painful (e.g., discontinuing addictive substances)
Be stressful (e.g., facing social situations without alcohol)
Jeopardize social relationships (e.g., engaging in unprotected adolescent sex)
Not seem important anymore (e.g., in the case of older individuals)
Require alteration in self-image (e.g., in the case of a hard-working executive learning
how to play)
As a result, giving up long-standing habits and attitudes is not easy for most people.
Given that health behavior change is difficult for most people, Box 8-2 suggests ways for
the individual to promote what it takes to make meaningful, lasting changes in lifestyle.
However, these are pragmatic suggestions rather than based on theory.
B OX 8-2
Suggested Ways for the Individual to
Promote Lifestyle Changes
Endorse the need for change
Have ownership of the need for change
Feel that there is more to gain than lose
Develop an enhanced sense of self-worth
Identify realistic goals and workable plans
Seek gradual change rather than a quick fix
Have patience
Address starting new behaviors instead of just focusing on what behaviors
should be stopped
Practice new behaviors
Seek the support of family, friends, colleagues, or health professionals
Gain positive reinforcement for the desired behavior
Have a strategy for monitoring progress and making needed changes
Seek constructive, personalized feedback to strengthen motivation for
change
Have a mechanism of follow-up to reduce backsliding
Source: Adapted from Westberg, J., & Jason, H. (1996). Fostering healthy behavior: The process. In S.
H. Woolf, S. Jonas, & R. S. Lawrence (Eds.), Health promotion and disease prevention in clinical prac-
tice (pp. 145-162). Baltimore: Williams & Wilkins.
Health-related behaviors are either protective in nature (e.g., exercise, good nutrition, and
stress management) or negatively impact health (e.g., smoking, drinking, and sedentary
lifestyle). Learning how to help people adopt and sustain healthy attitudes and habits is a
challenge for health professionals. There are no miracle drugs available for helping people
change long-standing patterns of living. Simply telling people to stop smoking, eat less fat,
have safe sex, exercise more, discontinue their abusive practices, or reduce their life stresses
seldom works (Westberg & Jason, 1996, p. 146). Clients often do not follow the advice of
nurses or physicians, particularly when authoritarian orders are given. Clients must be
actively involved as collaborative partners who assess their own current health and develop
and monitor their own long-term health plans. The health professional can best promote and
sustain change by educating, facilitating, and advising.
According to Prochaska and colleagues (1994a), some of the most frequently replicated
strategies and techniques to help clients modify their behavior include consciousness raising,
self-re-evaluation, environmental re-evaluation, self-liberation, social liberation, helping
relationships, stimulus control, counterconditioning, and reinforcement management. These
strategies and techniques have been linked with movement along stages of change (transthe-
oretical model) in one of few theory-based interventions for behavior change.
CONSCIOUSNESS RAISING
During the contemplation stage of behavior change, consciousness raising occurs as the
individual seeks information. The health care provider can share potential information
resources so that the individual can be actively involved. The clients perceived incentives
and barriers to change can be clarified, and the provider can help explain and interpret often
conflicting or unclear information. In addition, the knowledge and interest of family mem-
bers can be assessed. It may be helpful for the individual to talk with others who have suc-
cessfully made the contemplated changes.
SELF- AND ENVIRONMENTAL RE-EVALUATION

As movement occurs toward the preparation and action stages of change, the individual
engages in self- and environmental re-evaluation. The individual considers how the current
problem behavior (or lack of positive behavior) affects the physical and social environment and
personal standards and values. Questions that might be asked include: Will I like myself better
as a (thinner, nonsmoking, less-stressed) person? Is my environment supportive of the proposed
changes? Do I believe that I am able to make and continue the changes needed? The assump-
tion is that changes will not occur unless they are congruent with a persons self-concept.
SELF- AND SOCIAL LIBERATION

A strategy that can assist with self- and social liberation is cognitive restructuring. Cog-
nitive restructuring focuses on clients thinking, imagery, and attitudes toward the self and
self-competencies as they affect the change process (Pender, 1996, p. 171). The provider can
help clients clarify the messages they give themselves about their health and health-related
behaviors. Certain beliefs can be irrational compared with actual reality. Positive affirmations
and imagery, repeated several times a day, can help clients to believe that they have the power
to think positively and make desired lifestyle changes.
HELPING RELATIONSHIPS
Helping relationships with family members, friends, colleagues, or health care professional
can be critical in helping to move the individual through the preparation, action, and main-
tenance stages of change. A self-help group is a strategy that has been found to be very help-
ful for modeling, support, and reinforcement of desired behavior.
STIMULUS CONTROL
Stimulus control, emphasizing activities that precede the desired behavior, can be helpful
during the action and maintenance stages of change. The activities, which must be person-
ally relevant for the individual client, might include a postcard reminder for mammography
screening, a personal call from the provider to encourage continued exercise, or a scheduled
group meeting to practice relaxation. To encourage the development of a desirable behavior
habit it may be helpful to promote the behavior in the same setting or context and time on
a daily basis. For example, the client can be encouraged to exercise in a consistent place, early
each morning before other activities intervene.
COUNTERCONDITIONING
Counterconditioning to break an undesirable association between a stimulus and a
response can be desirable during the later part of the action stage and during the maintenance
stage. Undesirable associations can occur and create a negative emotional response to the
behavior. For example, many people indicate that exercising can become boring. The
provider can encourage a varied routine, walking outside whenever the weather permits, and
at least occasional exercise with a partner to counteract boredom.
REINFORCEMENT MANAGEMENT
Reinforcement management is an effective strategy, especially during the preparation and
action stages of change. It is based on the premise that all behaviors are determined by their
consequences. If positive consequences occur, the probability is high that the behavior will
occur again. If negative consequences occur, the probability is low for the behaviors being
repeated (Pender, 1996, p. 172). Immediate reinforcement of the desired behavior is impor-
tant, especially in the early phases of change. Personalized attention and positive verbal feed-
back are helpful. Eventually, a desirable consequence of the behavior can become an intrinsic
reward. For example, a weekly scale reading indicating decreasing weight can be a reward in
itself for continuing on a weight reduction diet.
The object of these strategies is to decrease barriers and increase incentives to change of
behavior. Barriers to change include lack of knowledge, skills, perception of control, facilities,
materials, clear goals, social support, time, and motivation. In comparison, according to
Leddy (1997), incentives to change behavior include expectation of benefit, sense of personal
responsibility, enjoyment of the activity, previous experience, guilt for not changing behav-
ior, and support from family, peers, or professionals. The choice of appropriate strategies to
foster incentives and reduce barriers and thereby promote behavior change should be based
on an individualized and collaborative assessment by the provider and the client.
Given that maintenance and relapse involve repeated cycles of abstinence and relapse
(Orleans, 2000), a shift in focus from relapse prevention to relapse management is needed.
MOTIVATIONAL INTERVIEWING
Another intervention technique that has been proposed is motivational interviewinga
style of relating that focuses on increasing client readiness for change in behavior. Motiva-
tional interviewing has been defined as a directive, client-centered counselling style for elic-
iting behavior change by helping clients to explore and resolve ambivalence (Rollnick &
Miller, 1995, p. 326). Assuming that the motivation to change cannot be imposed, but comes
from the client, this approach relies upon identifying and mobilizing the clients intrinsic val-
ues and goals in order to stimulate change in behavior. Believing that direct persuasion is not
an effective method for helping a client to resolve ambivalence about behavior, the nurses
goals when using this approach are to facilitate the expression of ambivalence, clarify and
resolve the impasse, and guide the client toward an acceptable resolution that triggers change
in behavior. Specific behaviors that are characteristics of a motivational interviewing style
include:
Relating in a partnership relationship in contrast to taking expert/recipient roles

Being quiet and eliciting rather than using a persuasive, aggressive, or confrontational
style
Developing discrepancies by engaging in a discussion between present behavior and
valued goals
Using reflective listening to understand the clients frame of reference
Expressing empathy, acceptance, and affirmation
Eliciting and selectively reinforcing the clients own self-motivational statements regard-
ing expressions of problem recognition and desire, intention, and ability to change
Monitoring the clients degree of readiness to change
Supporting self-efficacy
Affirming the clients freedom of choice and self-direction
Providing meaningful personal feedback
LEVELS OF INTERVENTION
Successful individual intervention strategies include the use of self-regulatory skill training
(e.g., goal setting, self-monitoring, feedback and social support, and relapse prevention or
preparation training), with ongoing support and guidance. Worksite interventions involving
combinations of competition, individual and group goal setting, and management support can
help change health behaviors. Interventions involving point-of-choice information have had
a positive effect in at least three health behavior areas (i.e., smoking, nutrition, and physical
activity). Policy/legislative level of impact strategies aimed at deterring cigarette smoking
have met with success. Such policies include smoke-free building and transportation regula-
tions, and statewide increases in cigarette taxation. Interventions that include a social-
environmental approach are believed to be more sustainable and cost-effective over the long
term (Ory, Jordan, & Bazzarre, 2002, pp. 506-507).
PATIENT-CENTERED COUNSELING MODEL

The patient-centered counseling model (Rosal et al., 2001) has been shown to facilitate
change and long-term maintenance in dietary behavior by assessing client needs and then tai-
loring an intervention to the clients stage in the process of change. Objectives for the nurse
of the model are to increase the clients awareness of risks of current behavior, provide infor-
mation, increase the clients confidence in her or his ability to make changes in behavior, and
enhance skills needed for long-term maintenance of the behavior change. The steps in the
model include a complete behavioral assessment, personalized advisement based on the
clients health concerns and stated reasons for wanting to change behavior, assistance in
change based on stage of readiness for change, goal setting, re-assessment of self-efficacy, a
behavioral contract, and arrangement for follow-up to prevent relapse and promote mainte-
nance of the behavior change.
Counseling to Reduce Disease Risk Factors

Based on a systematic review of evidence of clinical effectiveness (see Chapter 7, Beyond
Physical Assessment), the U.S. Preventive Services Task Force (1996) has recommended coun-
seling interventions to reduce a number of disease risk factors.
PREVENTING TOBACCO USE

The task force recommends that all children, adolescents, and adults be counseled to stop
using any tobacco products. Strategies to increase the effectiveness of counseling against
tobacco use include (U.S. Preventive Services Task Force, 1996):
Direct, face-to-face advice and suggestions

Reinforcement
Office reminders
Self-help materials
Community programs for additional help in quitting
Drug therapy (nicotine patch or gum)
PROMOTING PHYSICAL ACTIVITY

Evidence exists that physical activity and fitness reduce morbidity and mortality for at
least six chronic conditions: coronary heart disease, hypertension, obesity, diabetes, osteo-
porosis, and mental health disorders (U.S. Preventive Services Task Force, 1996, p. 611).
Unfortunately, studies that have demonstrated benefits from counseling provide little infor-
mation about long-term compliance and have limited generalizability. However, despite the
limited direct evidence that clinician counseling can increase the long-term physical activity
Counseling to Reduce Disease Risk Factors 213
of asymptomatic clients, the relative risk for sedentary individuals supports devoting time and
effort to counseling for all children and adults. The emphasis should be on regular, moderate
intensity physical activity (see Chapter 13, Re-establishing Energy Flow: Physical Activity and
Exercise).
PROMOTING A HEALTHY DIET

The effectiveness of nutritional counseling in changing dietary habits has been demon-
strated in a number of clinical trials. Therefore, the task force recommends counseling chil-
dren over the age of 2 and adults to limit dietary intake of fat, especially saturated fat, and
cholesterol, maintain caloric balance in their diet, and emphasize foods containing fiber. The
task force found that there was insufficient evidence to recommend for or against counseling
the general population to reduce dietary sodium intake or increase dietary intake of iron,
beta-carotene, or other antioxidants. Women should be encouraged to consume recom-
mended amounts of calcium and should be encouraged to breastfeed their infants (see Chap-
ter 16, Regenerating Energy: Nutrition).
PREVENTING MOTOR VEHICLE INJURIES

Although little is known about how effective clinician counseling is in altering these
behaviors, all clients and the parents of young children should be counseled to use occupant
restraints (lap and shoulder safety belts and child safety seats), to wear helmets when riding
motorcycles and bicycles, and to refrain from driving while under the influence of alcohol or
other drugs.
PREVENTING HOUSEHOLD AND RECREATIONAL INJURIES

Unintentional injuries including falls, poisonings, drowning, fires and burns, mechanical
suffocation and aspiration, and firearm injuries were the fifth leading cause of death in 1993
(U.S. Preventive Services Task Force, 1996). Evidence from controlled trials indicates that
counseling the parents of young children can increase safety-related behaviors. On the other
hand, no trials of counseling in elderly adults have demonstrated significant reductions in
serious fall injuries. It appears that the most effective measures to control injuries are pas-
sive interventions such as window guards in high-rise apartments, nonflammable sleepwear,
automatic sprinkler systems, and child-resistant packaging to prevent poisoning. Counseling
is most effective in combination with other compliance inducing measures such as safety
regulations.
PREVENTING LOW BACK PAIN

Low back pain is one of the most expensive health problems in industrialized countries
(U.S. Preventive Task Force, 1996). However, there is insufficient evidence to recommend
for or against counseling clients to exercise to prevent low back pain. Alternatively, educa-
tion such as information on back biomechanics, preferred lifting strategies, optimal posture,
exercises to prevent back pain, and stress and pain management has been effective in reduc-
ing employment-related injuries and relieving chronic low back pain. These comprehensive
educational strategies might also be effective in the clinical setting.
PREVENTING DENTAL AND PERIODONTAL DISEASE

Risk reduction for dental and periodontal disease has been recommended through coun-
seling clients about:
Regular visits to a dental care provider
Daily flossing
Daily teeth-brushing with a fluoride-containing toothpaste
Appropriate use of fluoride for caries prevention
Chemotherapeutic mouth rinses for plaque prevention
Additionally, parents should be counseled not to put infants and children to bed with a
bottle. Data suggest that many persons, especially those in minority groups or those having
low socioeconomic status, lack adequate knowledge about how to prevent oral diseases. How-
ever, the effectiveness of clinician counseling to change any of these behaviors has not been
adequately evaluated.
PREVENTING HIV INFECTION AND OTHER SEXUALLY

TRANSMITTED DISEASES
All adolescent and adult clients should be advised about risk factors for human immuno-
deficiency virus (HIV) infection and other sexually transmitted diseases (STDs), and coun-
seled appropriately about effective measures to reduce the risk of infection. Counseling should
be tailored to individual risk factors, needs, and abilities of each client. Risk reduction has
been shown to be effective, although the effectiveness of clinician counseling in a primary
care setting is uncertain. There is consistent evidence that both men and women have
changed high-risk sexual behavior in response to information about HIV and other STDs,
provided through public education and clinician encounters.
PREVENTING UNINTENDED PREGNANCY

Periodic counseling about effective contraceptive methods is recommended for all women
and men at risk for unintended pregnancy. Hormonal contraceptives, barrier methods used
with spermicides, and IUDs can be recommended as the most effective reversible means of
preventing pregnancy in sexually active persons. Sexual abstinence, the maintenance of a
mutually faithful monogamous sexual relationship, and consistent use of condoms are impor-
tant measures to reduce the risk of STDs (U.S. Preventive Task Force, 1996). Counseling
should be based on information from a careful sexual history and should be individualized
based on preferences, abilities, and risks of each client. Empathy, confidentiality, and a non-
judgmental, supportive attitude are especially important when discussing issues of sexuality
with adolescents.
Promoting the Maintenance of Health

Behavior Change
While there has been some progress in the development of short-term interventions to
change risk behaviors (e.g., tobacco use, improper diet, and insufficient exercise), there has
been much less progress in promoting maintenance of the behavior change; and relapse
remains the norm, with most successfully treated individuals reverting to their old high-risk
behaviors within 6 to 12 months of treatment (Orleans, 2000). Most of the interventions
have targeted individual behavior change aimed at persons who possess the risk factor. How-
ever, it has been proposed (McKinlay, 1995) that given a social system that encourages,
rewards, and profits from at-risk behaviors (Orleans, 2000, p. 79), interventions also need to
be aimed at defined populations involving organizational channels such as schools, worksites,
and communities, as well as interventions aimed at public policy and environments designed
to subvert or redirect strong societal and industry counterforces at the broadest population
levels (Orleans, 2000, p. 77), such as:
Economic incentives such as excise taxes on high-fat or tobacco products
Protection from environmental hazards such as reduced access to dangerous products
Reduced exposure to advertising such as through counter-advertising campaigns
The implication is that success in maintaining long-term behavior change requires broad-
spectrum approaches at all levels. However, very little is known about the mechanisms
responsible for the most effective maintenance strategies, such as extended contact with a
support person, telephone, support, or supplying appropriate foods in diet and weight loss pro-
grams. Most existing maintenance interventions are not effective, and even the most prom-
ising interventions are limited in impact and poorly understood (Orleans, 2000, p. 82).
Theory-based intervention research is badly needed.
The emphasis in this chapter has been on understanding a variety of constructs such as
stages and processes of change, decisional balance, self-efficacy, and health beliefs that are
being applied across various models and theories to foster individual behavior change. How-
ever, although the focus of many interventions has been on the initiation of behavior
change, the high rate of relapse indicates that more attention needs to be paid to the main-
tenance of behavior change. Additionally, despite the emphasis of most behavior change
interventions at the level of the individual, it appears that broad spectrum approaches, with
interventions focused at the social environment, policy, and individual levels, are most
effective.
Chapter Key Points

A number of constructs that appear across models and theories, including stages and
processes of change, decisional balance, self efficacy, locus of control, and health beliefs
have demonstrated potential to explain or predict individual behavior change.
Frequently replicated strategies and techniques to help clients modify their behavior
include motivational interviewing, consciousness raising, self-re-evaluation, environ-
mental re-evaluation, self-liberation, social liberation, helping relationships, stimulus
control, counter-conditioning, reinforcement management, and counseling.
Success in maintaining long-term behavior change requires broad-spectrum interper-
sonal, community, environmental, and health care system approaches as well as indi-
vidual interventions.
References
AbuSabha, R., & Achterberg, C. (1997). Review of self-efficacy and locus of control for nutrition- and
health-related behavior. Journal of the American Diet Association, 97, 1122-1132.
Ajzen, I. (1985). From intentions to actions: A theory of planned behavior. In J. Kuhl, & J. Beckmann
(Eds.), Action-control: From cognition to behavior (pp. 11-39). Hidelberg, Germany: Springer.
Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84,
191-215.
Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ:
Prentice Hall.
Bandura, A., OLeary, A., Taylor, C. B., Gauthier, J., & Gossard, D. (1987). Perceived self-efficacy and pain
control: Opioid and non-opioid mechanisms. Journal Personality and Social Psychology, 53, 563-571.
Becker, M. H., Haefner, D. P., Kasl, S. V., Kirscht, J. P., Maiman, L. A., & Rosenstock, I. M. (1977).
Selected psychosocial models and correlates of individual health-related behaviors. Med Care,
15(Suppl.), 27-46.
Carter, W. B. (1990). Health behavior as a rational process: Theory of reasoned action and multiattribute
utility theory. In K. Glanz, F. M. Lewis, & B. K. Rimer (Eds.), Health behavior and health education
(pp. 63-91). San Francisco: Jossey-Bass.
Christensen, A. J., Wiebe, J. S., Benotsch, E. G., & Lawton, W. J. (1996). Perceived health competence,
health locus of control, and patient adherence in renal dialysis. Cognitive Therapy and Research,
20, 411-421.
Fava, J. L., Velicer, W. F., & Prochaska, J. O. (1995). Applying the transtheoretical model to a representa-
tive sample of smokers. Addiction Behavior, 20, 189-203.
Fishbein, M., & Ajzen, I. (1975). Belief, attitude, intention and behavior: An introduction to theory and research.
Reading, MA: Addison-Wesley.
Fishbein, M., Bandura, A., Triandis, H. C., Kanfer, F., & Becker, M. (1991). Factors influencing behavior and
behavior change: Final report of theorists workshop on AIDS-related behaviors. Washington, DC:
National Institute of Mental Health, National Institutes of Health.
Green, L. W., & Kreuter, M. W. (1991). Health promotion planning. An educational and environmental
approach (2nd ed.). Mountain View, CA: Mayfield Publishing.
Harrison, J. A., Mullen, P. D., & Green, L. W. (1992). A meta-analysis of studies of the health belief model
with adults. Health Education Research, 7, 107-116.
Janz, N.K., & Becker, M. H. (1984). The health belief model: A decade later. Health Education Quarterly,
11(1), 1-47.
References 217
Jeffery, R. W., Drewnowski, A., Epstein, L. H., Stunkard, A. J., Wilson, G. T., Wing, R., et al. (2000). Long-
term maintenance of weight loss: Current status. Health Psychology, 19(Suppl), 5-16.
Kegler, M. C., & Miner, K. (2004). Environmental health promotion interventions: Considerations for
preparation and practice. Health education & behavior, 31, 510-525.
Kumanyika, S. K., Van Horn, L., Bowen, D., Perri, M. G., Rolls, B. J., Czajkowski, S. M., et al. (2000).
Maintenance on dietary behavior change. Health Psychology, 19(Suppl), 42-56.
Laitakari, J. (1998). On the practical applicability of stage models to health promotion and health educa-
tion. American Journal of Health Behavior, 22, 28-38.
Leddy, S. K. (1997). Incentives and barriers to exercise in women with a history of breast cancer. Oncol
Nurs Forum, 24, 885-890.
Lev, E. L. (1997). Banduras theory of self-efficacy: Applications to oncology. Scholarly Inquiry for Nursing
Practice, 11(1), 21-37.
Levenson, H. (1974). Activism and powerful others: Distinctions within the concept of internal-external
control. J Pers Assess, 38, 377-383.
Leventhal, H., Meyer, D., & Nerenz, D. (1980). The common sense representation of illness danger. In S.
Rachman (Ed.), Contributions to medical psychology (pp. 7-30). New York: Pergamon Press.
Marcus, B. H., Dubbert, P. M., Forsyth, L. H., McKenzie, T. L., Stone, E. J., Dunn, A. L., et al. (2000). Physi-
cal activity behavior change: Issues in adoption and maintenance. Health Psychology, 19(Suppl),
32-41.
Marcus, B. H., & Owen, N. (1992). Motivational readiness, self-efficacy and decision-making for exercise.
Journal of Applied Social Psychology, 22(1), 3-16.
Marcus, B. H., Selby, V. C., Niaura, R. S., & Rossi, J. S. (1992). Self-efficacy and the stages of exercise
behavior change. Research Quarterly for Exercise and Sport, 63, 60-66.
McKinlay, J. B. (1995). The new public health approach to improving physical activity and autonomy in older
populations. In E. Heikkinen (Ed.), Preparation for aging (pp. 87-103). New York: Plenum Press.
Orleans, C. T. (2000). Promoting the maintenance of health behavior change: Recommendations for the
next generation of research and practice. Health Psychology, 19(Suppl), 76-83.
Ory, M. G., Jordan, P. J., & Bazzarre, T. (2002). The behavior change consortium: Setting the stage for a
new century of health behavior-change research. Health Education Research, Theory and Practice,
17, 500-511.
Pender, N. J. (1996). Health promotion in nursing practice (3rd ed.) Stamford, CT: Appleton & Lange.
Plotnikoff, R. C., Hotz, S. B., Birkett, N. J., & Courneya, K. S. (2001). Exercise and the transtheoretical
model: A longitudinal test of a population sample. Prev Med, 33, 441-452.
Prochaska, J. O., & DiClemente, C. C. (1984). The transtheoretical approach: Crossing traditional boundaries
of change. Homewood, IL: Dow Jones-Irwin.
Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change. Am Psy-
chol, 47, 1102-1114.
Prochaska, J. O., DiClemente, C. C., Velicer, W. F., Ginpil, S., & Norcross, J. C. (1985). Predicting change
in smoking status for self-changers. Addictive Behavior, 10, 395-406.
Prochaska, J. O., Velicer, W. F., Rossi, J. S., Goldstein, M. G., Marcus, B., Rakowski, W. et al. (1994a).
Stages of change and decisional balance for 12 problem behaviors. Health Psychology, 13, 39-46.
Prochaska, J. O., Redding, C. A., Harlow, L. L., Rossi, J. S., & Velicer, W. F. (1994b). The transtheoretical
model of change and HIV prevention: A review. Health Education Quarterly, 21, 471-486.
Rodgers, W. M., Courneya, K. S., & Bayduza, A. L. (2001). Examination of the Transtheoretical model and
exercise in 3 populations. Am J Health Behav, 25, 33-41.
Rollnick, S., & Miller, W. R. (1995). What is motivational interviewing? Behavioral and Cognitive Psy-
chotherapy, 23, 325-334.
Rosal, M. C., Ebbeling, C. B., Lofgren, I., Ockene, J., Ockene, I. S., & Hebert, J. R. (2001). Facilitating
dietary change: The patient-centered counseling model. J Am Diet Assoc, 101, 332-338, 341.
Rosenstock, I. M. (1966, July). Why people use health services. Milbank Q, 44, 94-127.
Rosenstock, I. M., Strecher, V. J., & Becker, M. H. (1988). Social learning theory and the health belief
model. Health Education Quarterly, 15, 175-183.
Rotter, J. B. (1954). Social learning and clinical psychology (Vol. 80). Englewood Cliffs, NJ: Prentice-Hall.
Strecher, V. J., DeVellis, B. M., Becker, M. H., & Rosenstock, I. M. (1986). The role of self-efficacy in
achieving health behavior change. Health Education Quarterly, 13, 73-91.
U.S. Preventive Services Task Force. (1996). Guide to clinical preventive services (2nd ed.). Baltimore:
Williams & Wilkins.
Velicer, W. F., Norman, G. J., Fava, J. L., & Prochaska, J. O. (1999). Testing 40 predictions from the trans-
theoretical model. Addictive Behavior, 24, 455-69.
Wallston, K. A. (1992). Hocus-pocus, the focus isnt strictly on locus: Rotters social learning theory mod-
ified for health. Cognitive Therapy and Research, 16, 183-199.
Wallston, K. A., Maides, S. A., & Wallston, B. S. (1976). Health related information seeking as a function
of health related locus of control and health value. Journal of Research in Personality, 10, 215-222.
Westberg, J., & Jason, H. (1996). Fostering healthy behavior: The process. In S. H. Woolf, S. Jonas, & R.
S. Lawrence (Eds.), Health promotion and disease prevention in clinical practice (pp. 145-162). Bal-
timore: Williams & Wilkins.
9
GLOBAL HEALTH
The Ecocentric Approach
Abstract
In this chapter the interrelations between human beings and their environments within a
global perspective are explored. The assumptions that humans are the most important of all
the species, and that the worlds resources are inexhaustible and available for the taking have
raised serious concerns about environmental health, and ethical questions about the nature
of our obligations to future generations and to other organisms on the planet. In addition,
health professionals have traditionally been concerned almost exclusively with individual risk
factors for diseases, ignoring social, economic, and political structures that are the underlying
causes for health problems. Strategies are proposed for nursing involvement in environmen-
tal, societal, and global health issues.
Learning Outcomes
Discuss the ecocentric approach to environmental health
Discuss the ethical implications of the view that the worlds resources are inexhaustible
and available for the taking
Describe social, economic, and political structures that are the underlying causes of
health problems
List examples of toxic exposure, exploitation of natural resources, pollution, deforesta-
tion, and climactic change, and their effects on the environment
220 Chapter 9 Global Health: The Ecocentric Approach
List examples of societal health concerns such as childhood health problems, infectious
diseases, accidents, poor access to food, illiteracy, lack of clean water, migration, multi-
national business interests, poverty, and overpopulation and family planning
Explain how empowerment to promote global health can be facilitated
Ecocentric Worldview of Health

The ecocentric worldview of health assumes that everything is connected to everything
else, that the whole is greater than the sum of its parts, that meaning is dependent on con-
text, that biological and social systems are open, and that humans and nonhumans are one
within the same organic system (Kleffel, 1996, pp. 2-4). In the ecocentric approach, envi-
ronment is a factor that predisposes, enables, and reinforces individual and collective behav-
ior (Green et al., 1996, p. 272). Therefore, health promotion can achieve effective results by
empowering people to influence the behavioral and environmental conditions that affect
health.
This chapter will present medical, public health, and epidemiologic approaches to health.
Much of this content seems to focus on the negative and on risks to health. However, the
tenets of primary preventive health care can be applied at the global, societal, and environ-
mental levels (Lane & Rubinstein, 1996, p. 418).
Global (International) Health

Global affairs encompass relations beyond governments and includes individuals and
groups within societies that interact across national boundaries, in contrast to intergovern-
mental relations between states and their governments traditionally defined as international
affairs. The process by which human societies move from international to global relations is
called globalization (Lee, 1998). Some authors have more biased views such as international
health refers to the flow of advice, health professionals, and health technology from the
wealthier nations to the poorer (Lane & Rubinstein, 1996, p. 397). A global perspective pro-
vides a holistic view of the complex interactions between the cultures, economic systems,
political organizations, and ecology of the planet itself (Helman, 1994, p. 338).
The current global context has been described as one of clashing worldviews, economic
instability, environmental crises, and declining health (Hegyvary, 2001, p. 304). Health sta-
tus and general well-being are static, if not deteriorating, for a large proportion of the worlds
population, and there are widening disparities in the burden of disease and access to health
resources (Leuning, 2001).
The Western worldview has been shaped over centuries through the power of the scien-
tific method, analytical philosophy, industrialization, urbanization, democratization, liberal-
ism, and capitalism. The modern perspective emphasizes capitalism, the pursuit of rational
economic self-interest, and the nation-state framework of international relations (Benatar,
1998, p. 295). However, an overemphasis on economic thinking (and underemphasis on
social and economic rights), has also been associated with erosion of spirituality, loss of a
sense of community, and division of the world (and many countries) into a small, rich core
Global (International) Health 221
and a large, poor periphery (Benatar, 1998, p. 296). Exploitation of people and nature in the
pursuit of what is considered to be progress, contributes to the widening national and global
disparities (in health, wealth, and human rights) that now jeopardize human health and sur-
vival (Benatar, 1998, p. 295).
Serious global health problems exist. For example, although in 1996 the global average life
expectancy at birth reached 65 years, chronic diseases were responsible for more than 24 mil-
lion deaths a year, or almost half of the global total. The problems of chronic diseases will
exacerbate as the population of those aged 65 and above increases globally by more than 80%
by 2020. Additionally, poor countries inherit the problems of the rich, including not merely
illness but also the harmful effects of tobacco, alcohol and drug use, and of accidents, suicide
and violence (WHR, 1997, pp. 248-249, 258).
Governments are no longer the sole agents in the global-health arena. Beyond national
programs, the global-health systems now contain:
The private or commercial sector. Including multinational corporations.
The independent sector and nongovernmental organizations. Such as universities, private
foundations, and relief and advocacy organizations.
The multilateral sector. Including multinational organizations such as the World Health
Organization (WHO), and the United Nations (UN) development agencies; regional
health organizations; and the World Bank and regional development banks.
The bilateral sector. Which involves various government and overseas development
agencies that are funded by single governments or regional partners.
This pluralism brings a strong need, and opportunity, for active national engagement in
global health issues (Howson et al., 1998). However, countries do not have equal financial
resources. One distinction that has been made is between developed, or relatively wealthy
countries, and poorer countries that are considered underdeveloped.
DEVELOPED AND UNDERDEVELOPED COUNTRIES

Seventy-seven percent of the worlds population lived in developing countries at the end
of the 20th century (Benatar, 1998), where health care has become increasingly inaccessible
to growing numbers of vulnerable individuals, families, and communities. The concept of
underdeveloped holds the West to be the developed goal to which other countries must
aspire, and in doing so devalues more than half of the world. . . . There are no nonpejorative
terms (Lane & Rubinstein, 1996, pp. 398-399). This view assumes that wealthier (devel-
oped) countries have the money, talent, and knowledge and, therefore, should do the plan-
ning and direction to solve the health problems of the poorer countries. It is also assumed that
Western health care institutions and approaches will work in solving health problems in less
developed countries, and that health care will improve the health of the recipients.
However, in developed countries, economic globalization has been accompanied by an
emphasis on individual responsibility, the downsizing of governments, and the role of the
market as the favored policy instrument. Thus, policies to reduce state expenditure have
placed tremendous pressure on publicly funded health and welfare services. . . . Typically, the
public-health sector receives less than 5% of the total health care budget and, from a policy
perspective, is overshadowed by the demands of acute medical-care services and the power of
the pharmaceutical industry (Beaglehole & Bonita, 1998, pp. 591-592). It will be a chal-
lenge for developed countries to foster a commitment to shared benefits of national wealth,
as well as the establishment of strong and continuing practitioner-community partnerships
despite dominant ideologies of individual responsibility and reliance on market forces (Bea-
glehole & Bonita, 1998).
Dichotomizing countries on the basis of economic concepts such as developed or under-
developed raises a number of moral questions related to health and health care. Given that
worldwide free-market forces are increasingly structuring health as a commodity rather than
as an entitlement (Austin, 2001, p. 9), does the achievement of health development need
an economic rationale, or is it of value in itself? How can health-related resources be distrib-
uted based on need (justice) rather than ability to pay? Does the work of a global health
organization depend on the question whats in it for me? or is there still room for benevo-
lence? (Lee, 1998). Are enduring traditions of humanitarian concern and compelling rea-
sons of enlightened self-interest still valid incentives (Howson et al., 1998)? Can a holistic
harmony global perspective be fostered, emphasizing nature, society, neighborhood, and
mutual aid rather than the autonomous individual (Austin, 2001, p. 14)? What is the right
thing to do (Austin, 2001)?
When health is viewed as a standard, a basic, and essential part of human experience that
encompasses human dignity, human rights, as well as an individuals personal beliefs and val-
ues related to health (Leuning, 2001, p. 298), the emphasis shifts to the degree to which
human rights and human dignity are honored, and the strengthening of a community or
nations political will to uphold these standards. At all levels of global-health systems, nurses
can seek opportunities to be involved in dialogues addressing these issues. Nurses can focus
on basic human rights and dignity as well as health needs through political advocacy, educa-
tion, and access to care for those, for example, displaced by war or terrorism, women and chil-
dren, and people with HIV-AIDS.
GLOBAL HEALTH DEVELOPMENT

The main variations in health status among countries result from environmental, socioe-
conomic, and cultural factors, and medical care is of secondary importance. Poverty is the
most important cause of preventable death, disease, and disability (Beaglehole & Bonita,
1998, p. 590). Given that many of the health problems of the developing world result from
inequality and poverty, the greatest improvement in health would be accomplished by foster-
ing education and literacy, the provision of adequate food, clean water, sanitation, housing,
employment, and freedom from war (Beaglehole & Bonita, 1998; Lane & Rubinstein, 1996).
Lane and Rubinstein (1996) express concern with shortsighted planning that results from
programs that attribute success only on the basis of easily measured outcomes. Examples of
this include the number of children vaccinated, the number of oral rehydration solution pack-
ets distributed, or planning tied to short-term cycles, such as the fiscal year, rather than to
time periods that reflect realistic program spans. Given that health improvements that result
from clean water, adequate housing, or fair wages are much more difficult to measure, they
tend to be discounted in priority. Concerns of the First World provide the major imperatives
for action (Lane & Rubinstein, 1996, p. 421), but exportation of technology and develop-
Global (International) Health 223
ment based on rational, scientific principles reflects a basic ethnocentrism (Lane & Rubin-
stein, 1996).
Health care alone may not be the best method of improving the health of people interna-
tionally, particularly when their health problems stem directly from poverty (Lane & Rubin-
stein, 1996). Some health projects have actually worsened the health of the people they were
trying to help, while many projects have failed to improve health. Despite medical intervention
programs, both the diseases of deprivation such as malaria and tuberculosis, and the diseases of
development such as hypertension, diabetes, and alcoholism, have increased (Kaseje, 1995).
The principles of primary health care can be applied at the global level. The basic com-
ponents of primary health care are community involvement, appropriate health technology,
and reorientation of health services . . . toward country-wide health programs. It includes an
emphasis on preventive medicine and employs community health workers to serve the needs
of their communities (Lane & Rubinstein, 1996, p. 418). Although organization for global
health is international, actual activities and programs take place at the community level.
Therefore, empowerment is very relevant to enhancement of global health. This content will
be discussed in depth in Chapter 11, Empowering Community Health.
EMPOWERMENT FOR GLOBAL HEALTH

An empowered community is one in which individuals and organizations apply their
skills and resources in collective efforts to meet their respective needs (Israel et al., 1994, p.
153). Community organization describes the process of organizing people around problems or
issues that are larger than group members own immediate concerns. Robertson & Minkler
(1994) suggest helpful strategies to increase community problem-solving abilities, or com-
munity competence:
Assisting individuals and communities in articulating both their health problems and
the solutions to address those problems.
Providing access to information. Education is critical in envisioning choices and solu-
tions to problems.
Supporting indigenous community leadership.
Assisting the community in overcoming bureaucratic obstacles to action.
A community empowerment model emphasizes participation, caring, sharing, responsi-

bility to others, and conceives of power as an expanding commodity (Israel et al., 1994, p.
154). People need to listen to each other, identify their commonalities, and construct new
strategies for change (Wallerstein & Bernstein, 1988). Therefore, elements of community
empowerment include a social action process, people being subjects of their own lives, con-
nectedness to others, critical thinking, personal and social capacity building, and transformed
power relations (Wallerstein & Bernstein, 1988, p. 145).
According to Neighbors and colleagues (1995), recommendations to empower individuals
and groups include:
Beginning with an analysis of perceived needs of the target group rather than the needs
and expectations of the program planners
Focusing explicitly on neighborhood issues and community resources

Incorporating factors from the family and neighborhood level
Giving culturally sensitive health messages phrased within the context of self-help and
self-reliance
Providing specific skill-oriented training
Using the expertise of the members of a target group who understand their culture and
health problems, and most important, knowing what solutions are likely to work in
their communities
Many of the needs at the community level are related to societal health problems, which
will be discussed in the next section.
Societal (Public) Health Concerns

Public health is the traditional title for the medically related discipline dealing with the
health of society. The basic causes of many major worldwide societal health problems can be
found in similar sociopolitical and ecological influences. A critical question is whether pub-
lic-health professionals [should] be concerned with the fundamentals of health such as employ-
ment, housing, transport, food and nutrition, and global trade imperatives, or should attention
be restricted to individual risk factors for diseases (Beaglehole & Bonita, 1998, p. 591)?
Beaglehole and Bonita (1998) emphasize that, until now, much of health promotion has
been based on the health education model, which focuses on a high-risk approach to primary
prevention rather than a population approach. Modern public health is focused on health-
services research, evidence-based health care, and the search for new risk factors at the indi-
vidual level to improve the effectiveness and efficiency of medical services. The challenge for
public-health practitioners is to justify and promote global concerns while addressing health
inequalities and proceeding with evidence-based, disease-specific public health programs.
Some of the major worldwide societal health problems are discussed in the following section,
with a particular emphasis on problems in developing countries.
CHILDHOOD HEALTH PROBLEMS

Major leading worldwide killers are communicable, perinatal, and nutritional disorders
largely affecting children. Ninety-eight percent of all deaths in children younger than 15
years are in the developing world. . . . Injuries, which account for 10% of global mortality, are
often ignored as a major cause of death (Murray & Lopez, 1997, p. 1269). Of more than 52
million deaths in 1996 worldwide, over 17 million were ascribable to infectious and parasitic
diseases; more than 15 million to circulatory diseases; over 6 million to cancers; and about 3
million to diseases of the respiratory system. About 40 million deaths occurred in the devel-
oping world (WHR, 1997, p. 252).
Many children are unvaccinated due to factors such as maternal time constraints and com-
peting priorities; socioeconomic factors; lack of knowledge and education; low motivation;
fears and negative community opinion; and insufficient accessibility, availability, acceptabil-
Societal (Public) Health Concerns 225
ity, and affordability of health services. Immunization requires numerous visits to the health
facility, even though there is no illness (Coreil, 1997, p. 187).
In addition, issues related to breast-feeding have a significant impact on infant health.
Coreil (1997, p. 187) describes multiple detrimental feeding practices such as discarding
colostrum, giving prelacteal feeds before breast milk comes in, introducing supplemental food
too early or too late, preparing breast milk substitutes improperly, and using weaning foods
with inadequate nutritional value. A variety of sociocultural variables such as social net-
works, urbanization, womens work patterns, household income, maternal health and nutri-
tion, and the advertising of commercial infant formulas influences infant feeding practices.
INFECTIOUS DISEASES
High infant deaths in the least developed countries are due largely to malnutrition and infec-
tions, which kill about 17 million people a year and afflict hundreds of millions of others. In terms
of setting global health priorities, therefore, the poor stand to benefit much more than the rich
from a continued emphasis on infectious diseases (WHR, 1997, pp. 248, 250). The leading infec-
tious causes of infant and childhood death are diarrhea, respiratory illnesses, malaria, measles, and
neonatal tetanus. Infections in some developing countries are promoted by poverty and a warm
climate (Bradley, 1994). Malaria and tuberculosis are the main diseases of global concern, and
treatment is complicated by resistance, lack of resources, and poverty (Wait, 1998, p. 435).
Emerging new and reemerging old diseases include resistant strains of tuberculosis, Strepto-
coccus pneumoniae, and Staphylococcus aureus, as well as new and potentially fatal viruses includ-
ing HIV, hantavirus, Legionnaires disease, and Ebola virus. The resurgence of infectious diseases
is facilitated by the increased mobility of the worlds population, inappropriate and indiscrimi-
nate use of antimicrobials, and rapid urbanization (Howson et al., 1998). The spread of HIV-
AIDS has reached global pandemic proportions, affected by the fact that many women have
little influence on the risk behavior of their male partners (Coreil, 1997). In addition, major
chronic parasitic diseases such as malaria, schistosomiasis, onchocerciasis, trypanasomiasis, leis-
chmaniasis, filiriasis, dracunculiasis, and the intestinal parasites cause debility, loss of produc-
tivity, and shortened life spans for both children and adults (Lane & Rubinstein, 1996). Many
of the parasitic diseases could be prevented with access to clean drinking and bathing water.
ACCIDENTS
Many cities in the developing world have traffic congestion that rivals that in the indus-
trialized world. For example, in much of rural India, a two-lane, dirt, pockmarked road with
cows roaming at will is used by speeding motorists who lean on their horn instead of brakes.
Accidents, particularly motor vehicle accidents, are common. In addition, the use of open
fires or small kerosene stoves for cooking and heating contributes to frequent burn accidents,
particularly for women and children (Lane & Rubinstein, 1996). The smoke from an open
fire in an underventilated area also contributes to respiratory illnesses, particularly in infants.
ACCESS TO FOOD
Nutritional status is the most important determinant of health (Lane & Rubinstein,
1996). But, dietary inadequacy often results from unequal distribution of food within a coun-
try and between countries, which occurs even when adequate food stores exist (Lane &
Rubinstein, 1996, p. 406). The technology that has produced high-yield hybrid foods (e.g.,
grains such as corn and wheat) also contributes to a cycle in which the expense of necessary
fertilizer and pesticides, which the developing countries are often forced to purchase from the
West, forces many small farmers off their land. Then, the land is bought by agribusinesses and
used to produce cash crops. In many parts of the world, land tenure remains nearly feudal,
with a small percentage of landlords owning the fields on which tenant farmers grow crops
(Lane & Rubinstein, 1996, p. 407).
Lane and Rubinstein (1996, p. 407) explain how the diets of farmers and their families have
been hurt by the shift from subsistence agriculture to growing cash crops. Under the influence
of European colonialism, nonfood items such as cotton or coffee were grown for export, often
on the best land. Farmers then had to grow their families food on smaller and poorer plots of
land, purchase the remainder of the food needed for their families, and purchase seeds, fertil-
izer, and pesticides to grow the next years cash crop. The families diet, which may have been
relatively abundant and varied during subsistence farming, suffers, and the most vulnerable
members of each family, the children and childbearing women, suffer the most.
ILLITERACY
Illiteracy is often high, and in some countries a majority of women are illiterate. In no
society are women treated equally to men, and women, children, and older people are at
greatest risk of poverty (Beaglehole & Bonita, 1998, p. 590). Illiteracy has an indirect impact
on health. For example, being unable to read directions on a medicine container may result
in over- or underdosing. Increasing female literacy is associated with a decrease in the
birthrate and decreased infant mortality rates (Lane & Rubinstein, 1996).
LACK OF CLEAN WATER

In many countries, piped water and sanitation are luxuries of the urban middle and upper
classes (Lane & Rubinstein, 1996, p. 408). Diseases associated with inadequate water sup-
plies include:
Water-borne diseases, which occur when drinking water is contaminated with fecal
organisms, such as cholera, typhoid, amoebiasis, hepatitis A, polio, and diarrhea.
Water-washed diseases, such as skin and eye infections which increase when wash water
is inadequate.
Water-based diseases, such as schistosomiasis, in which the infectious agent is present in
the water and penetrates the skin during washing,. The most ubiquitous water-borne
disease, diarrhea, is the leading cause of death in children under 5 in developing coun-
tries (Lane & Rubinstein, 1996, p. 408).
MIGRATION
Migration, especially rural-to-urban migration and the flight from war and natural disas-
ters, has been increasing every year (Lane & Rubinstein, 1996). As a result, 20% to 50% of
the population live without basic sanitation in crowded, makeshift housing. In Third World
cities, rural-to-urban migrants have swelled the squatter settlements. Most of these residents
were farmers who lost their land due to poverty and must now purchase all of their food. With
high unemployment and lack of literacy and job skills to survive in a city, they and their chil-
dren may starve due to lack of money (Lane & Rubinstein, 1996, p. 407). The health effects
of migration include:
Physiological stresses such as crowding, inadequate food, inadequate water, and
inadequate sewage disposal can both lower resistance to disease and expose
migrants to tuberculosis, parasitism, diarrhea, and respiratory illnesses (Lane &
Rubinstein, 1996).
Psychological stresses such as grief, anxiety, stress, insecurity, marital breakdowns,
depression, alcoholism, smoking, domestic violence, and drug addiction contribute to
both physical and mental illness (Helman, 1994).
Sociocultural stresses such as language barriers and resettlement may lead to such eco-
nomic, family, and social problems as alcoholism (Lane & Rubinstein, 1996).
Direct problems of poverty include unemployment, low income, limited education and
literacy, inadequate diet, lack of breast feeding, and prostitution.
Environmental problems result from poor housing, overcrowding, inadequate sanitation
and water supplies, lack of waste disposal, air pollution, traffic accidents, the siting of
hazardous industries nearby, and lack of land for growth of food.
MULTINATIONAL BUSINESS INTERESTS

Globalization is being driven by the search for inexpensive labor and new markets for
trade by transnational countries (Beaglehole & Bonita, 1998). Businesses often place prof-
its above other considerations, including the health of unsuspecting consumers (Lane &
Rubinstein, 1996, p. 412). Examples of exploitation, especially in developing countries,
include:
The international trade in illegal products and contaminated foodstuffs, inconsistent
safety standards, and the indiscriminate spread of medical technologies . . . [and the] sale
of prescription drugs that have not been approved by national drug-monitoring bodies
(Wait, 1998, p. 436).
Infant formula intensely promoted for economic reasons, even though breast milk is
healthier than formula, and it is free and sterile. However, the formula is so expensive
that mothers have been forced to dilute the strength of the mixture, and one-fourth to
one-third of family income might be needed just to purchase formula. Lack of refriger-
ation and contamination of the water used to mix formula, and the fact that formula
confers no immunoprotection are other concerns.
Outdated drugs, including antibiotics have been dumped in the Third World. In addi-
tion to their lack of effectiveness in treating infections, this practice has led to the pro-
liferation of super bacteria, immune to most available antibiotics.
Cutting down the rainforest increased malaria because it gave the mosquito more open
pools of stagnant water in which to breed (Lane & Rubinstein, 1996).
The extraction of vast quantities of material and human resources from poor develop-
ing countries to rich industrialized nations. The 1 billion people residing in industrial-
ized countries use 10 times the resources and produce 10 times the waste per capita of
the 4 billion people residing in developing countries (Benatar, 1998, pp. 296-297). A
major contributor to environmental degradation is the continued overconsumption of
the worlds resources by wealthy countries (Beaglehole & Bonita, 1998).
POVERTY
Poverty has been growing in many parts of the world. Sociopolitical conditions, including
inadequate food, clean water, stress associated with migration, war, multinational business
interests, and large-scale development projects both cause some health problems and make a
number of existing problems worse (Lane & Rubinstein, 1996). About a fifth of the worlds
population, 1.3 billion people, live on a daily income of less than US$1. Although most of
the worlds poor live in South and East Asia, sub-Saharan Africa has the fastest growing pro-
portion of people who live in poverty (Beaglehole & Bonita, 1998, p. 590). More than 10
million abandoned or orphaned African children live on their own (Howson et al., 1998).
Many of the poorer nations devote a disproportionate share of their economy to main-
taining a military force, leading to disruption of human services, social supports, food distri-
bution, and health care (Lane & Rubinstein, 1996). In addition, unemployment and
underemployment contributes to poverty as the best and brightest emigrate to seek their for-
tunes in other countries. . . . Brain drain disproportionately affects the ranks of physicians and
nurses, the loss of whom directly affects a countrys health care (Lane & Rubinstein, 1996,
p. 405).
OVERPOPULATION AND FAMILY PLANNING

At present, global population growth is about 90 million persons per year, with about 90%
of future growth projected to occur in developing countries (Beaglehole & Bonita, 1998). It
is worth noting that in nearly all other animal species, when population increases have been
as explosive as current human growth, a point has been reached where environmental factors
such as disease, food supply, and predators caused a rapid decline in numbers (Smith, 1994).
For humans, however, environmental factors have not been able to constrain population, and
growth is continuing to accelerate.
In the 1960s through the 1980s, many of the population programs concentrated on pop-
ulation control at the expense of human dignity and rights (Lane & Rubinstein, 1996,
p. 414). Maternal mortality can be lowered by as much as 25% through spacing of births, pre-
vention of unsafe abortions, and prevention of maternal nutritional deficiencies due to fre-
quent breast feeding (Coreil, 1997). Excluding China, the prevalence of modern
contraceptive use in the developing world is 32% (1997). However, some religions disapprove
of all artificial forms of birth control, and the cost or availability of artificial forms of birth
control may be limited.
In most cases, the meaning of family planning is closely related to the value given to chil-
dren. In many cultures, having a child is the visible sign of adult status; and for many men,
the birth of a son is the ultimate proof of their virility (Helman, 1994). Women often do not
have the power to make decisions about fertility. Additionally, cultural beliefs about the body
impact on family planning. Examples of such beliefs include a woman cant get pregnant
except when uterus is open during menstruation, decreased menstrual blood may leave
more poison, and an intrauterine contraceptive device might move and get lost (Helman,
1994). Having many children ensures future economic and social security for the family. An
important role for nurses is to enhance the capacity of poor home-based caregivers, most of
whom are women, to take part effectively in decision making and action for health? (Kaseje,
1995, p. 210).
The global prevalence of all the leading chronic diseases is increasing, with the majority
occurring in developing countries and projected to increase substantially over the next 2
decades, driven by urbanization, trade, foreign investment, and promotional marketing. Car-
diovascular disease is already the leading cause of mortality in developing countries. Between
1990 and 2000 mortality from ischemic heart disease in developing countries was expected to
increase by 120% for women and 137% for men. Predictions for the next 2 decades include a
near tripling of ischemic heart disease and stroke mortality in Latin America, the Middle
East, and sub-Saharan Africa. The global number of individuals with diabetes in 2000 was
estimated to be 171 million (2.8% of the worlds population), a figure projected to increase in
2030 to 366 million (6.5%), 298 million of whom will live in developing countries. Cancer
incidence increased 19% between 1990 and 2000 mainly in developing countries. Death and
disability due to chronic obstructive pulmonary disease are increasing across most regions.
Risks for chronic disease are also escalating. Smoking prevalence and obesity levels among
adolescents in developing countries have risen over the past decade and portend rapid
increases in chronic diseases (Yach et al., 2004, p. 2616).
The emphasis on communicable diseases has excluded consideration of chronic diseases in
low-middle and middle income with the up-to-date evidence about the burden and impacts
of chronic diseases. Tackle chronic diseases upstream. Governments can play a role by alter-
ing economic incentives for businesses and individuals. Expanding markets for fruits and veg-
etables will allow developing countries to gain from increased export earnings and
consumption. Raising the tobacco excise tax to levels that will decrease consumption effec-
tively will increase government revenue and reduce the burden of disease (Yach et al., 2004,
p. 2621).
SOCIETAL HEALTH STRATEGIES FOR THE FUTURE

According to Roemer and Roemer (1990, p. 1191), the solution to poor quality govern-
ment services is not to privatize them but rather to heighten the priority and enhance the sup-
port of governmental activities for advancement of health. Global leadership and a true
global health plan are needed, for which financial resources are vital. However, the total
annual UNICEF budget of $1 billion is equivalent to the expenditures for less than 9 hours
of health care in the U.S. . . . [and] the per capita U.S. annual contribution to UNICEF is
$0.62 while the average Norwegian contributes $13.12 (Foege, 1998, p. 1932).
Private companies, such as pharmaceutical companies, have also provided a significant
investment of resources. For example, Merck has supplied ivermectin (Mectizan) to treat
river blindness (onchocerciasis); Glaxo Wellcome has supplied Malarone, combining ato-
vaquone and progguanil to treat malaria; American Cyanamid (Abate) and Precision Fabrics
Group have provided temephos, a larvicide and nylon filter material to strain drinking water
and eradicate guinea worms; and SmithKline Beecham Pharmaceuticals has supplied alben-
dazole to combat lymphatic filariasis (elephantiasis) (Foege, 1998).
Another societal strategy is to reduce population growth. Birth rates have declined glob-
ally from 32 per 1000 population in 1970 to 23 per 1000 population in 1996, but population
growth continues at a rate of approximately 1.7% per year (Foege, 1998, p. 1932). It has been
shown that programs for family planning, child survival, and education of girls and women
reduce the birth rate (Foege, 1998).
Accountability must be maintained. For example, tobacco companies must be financially
responsible for the adverse health effects of smoking worldwide. . . . The current annual global
tobacco-related mortality of 3 million people will increase to an annual level of 10 million
deaths by 2020 (Foege, 1998, p. 1932). Nurses and other health professionals need to be
aware of and involved in seeking long-term solutions to societal health concerns. The fol-
lowing suggestions, while abstract and very difficult to implement, provide examples of
important areas to pursue:
Facilitate consumer involvement in the planning, policy-making, and operations of

health systems at all levels. This is consistent with the empowerment approach advo-
cated in Chapter 11, Empowering Community Health.
Assure political commitment to making health, education, and human well-being
higher priorities than military expansion in order to achieve security and peace.
Strengthen ministries and departments of health to coordinate, integrate, and assure
high-quality preventive and curative services, and provide trained health personnel to
provide comprehensive health services and to administer those services effectively.
Be alert of hazards from environmental tobacco, addictive drugs, occupational toxins,
trauma, and violence, and take social action to minimize or eliminate these risks. Par-
ticipate in the development of global surveillance systems to detect infectious disease
outbreaks, chemical or bio-terrorist attack, or breakdowns in the safety of the global
food supply.
Provide maximum international collaboration for overall socioeconomic development
to countries, sharing information to analyze risks that contribute to premature death
and disability, and assessing cost-effective interventions to address the greatest health
burdens.
The social environment is only one of the contexts that influence human health. The nat-
ural environment will be discussed in the next section.
Environmental Health Concerns

Nurses need to understand the influences on health of interactions between humans and
their natural and social environments, social determinants of healthhow social and envi-
ronmental inequities contribute to health disparities (Schulz & Northridge, 2004, p. 455).
Environmental Health Concerns 231
The literature (Grady et al., 1997; Green et al., 1996; Rogers & Cox, 1998; Spiegel & Yassi,
1997) suggests that environmental health refers to:
The whole of the physical aspects of our surroundings, including individual and natu-
ral or man-made environmental interactions that may affect health (human ecology).
The ecological balances essential to long-term human health.
The promotion of safe, healthful living conditions, and protection from environmental
factors that may adversely affect human health.
The social, institutional, and cultural contexts of people-environment relations (social
ecology).
One creative way of conceptualizing environment is through the geographic metaphor of
therapeutic landscape (Gesler, 1992). Sense of place includes the meaning and significance
that individuals and groups give to physical places, such as feelings of safety and security, and
as settings for family life, employment, and aesthetic experience. In a positive way, the fresh
air and pure water of the countryside, and magnificent scenery can be healing. In a negative
context, landscape might incorporate nontherapeutic control relationships sometimes
played out between clients and health care providers in physical settings such as hospitals and
doctors offices. As a blend of the place (physical setting) with its meaning to the client, land-
scape is related to, but not identical with, nature, scenery, environment, places, regions, areas,
and geography (Gesler, 1992).
Dixon and Dixon (2002) propose an integrative model for environmental health, encom-
passing four broad domains and their interrelationships: physiological, vulnerability, episte-
mological, and health protection. The physiological domain includes a chemical or physical
agent (potential cause of disease); exposure (contact with an agent); incorporation (accumu-
lation within the body); and health effects (mortality and morbidity indicators such as disease
diagnosis and symptom experience). The vulnerability domain includes individual character-
istics (such as developmental, health, genetic, and gender-related) and community charac-
teristics (such as sociodemographic and cultural). The epistemological domain concerns
elements of personal thought (such as awareness of risks and challenges) and social knowl-
edge (shared beliefs of what is true and who bears responsibility). The health protection domain
includes concerns (appraisal of threat), sense of efficacy (confidence in ability to reduce
health hazards), and actions (personal avoidance or changing the environment). The intent
of the model is to promote thinking and research that encourages proactive changes in pub-
lic policy (upstream thinking) to reduce environmental health hazards. Social and eco-
nomic inequalities (fundamental factors) within the built environment, social context
(intermediate factors) that influence stressors, health behaviors, and social relationships
(proximate factors) ultimately result in individual and population health and well-being
(Schulz & Northridge, 2004, p. 458).
Barriers to successful policy and environmental change interventions include:
Lack of trust in government.
Legal and bureaucratic distractions, particularly in the policy development arena, that
demand more time, the involvement of outside partners, and legal expertise.
Turf issues within the state and local official agencies, communities, nonprofit organ-
izations, business groups, and health care institutions.
Dependence on crisis management or reacting in situations rather than building advo-
cacy over the longer term.
Inability to handle sudden conflict. The fact that stakeholders often lack a shared
vision and agenda does not help.
Confusion over the differences among policy development, advocacy, politics, and lobbying.
Organizational opposition. The tobacco industry and its allies, for example, opposed
tobacco control programs, immediately.
Benefits not immediate or evident. Many programs are under pressure to show results
right away, whereas policy development and environmental change interventions take
time and long-term commitment.
Unfamiliarity with the concept of policy development and environmental change.
Lack of legal capacity. (Hann et al., 2004, p. 380)
Environment can be viewed as a major determinant of disease, particularly in developing
countries (Bradley, 1994). Underlying many current environmental health concerns is the
perspective that the worlds resources are free and inexhaustible (Helman, 1994, p. 381),
and that humans are the most important of all the species and should therefore dominate
nature. These views raise fundamental ethical questions such as the nature of our obligations
to future generations and to other species on the planet (Smith, 1994). For example, envi-
ronmental degradation from the pressures of consumerism, population, increasing traffic
density, technological hazards, land mines, and overexploitation of natural resources leads to
droughts, soil erosion, famine, malnutrition, and related diseases (Kaseje, 1995, p. 210).
Twenty percent of deaths in the United States can be attributed to such factors as pollution
and toxic chemicals in the environment (Bellack et al., 1996, p. 338).
TOXIC EXPOSURE
Toxic exposure is generally a result of human manipulations or an interaction with toxins
in the environment. Environmental exposure occurs by way of inhalation through dust or
fumes, ingestion of lead or pesticides from contaminated materials or foods, or skin absorp-
tion from direct contact with solvents (Rogers & Cox, 1998; Spiegel & Yassi, 1997). Exam-
ples of types of toxic exposure are presented in Box 9-1.
EXPLOITATION OF NATURAL RESOURCES

Non-renewable geochemical substances such as natural gas, oil, copper, lead, zinc, tin,
gold, silver, mercury, and platinum metals will become physically scarce in the 21st century if
we maintain current rates of use (Reijnders, 1993). In addition, renewable natural resources
that are currently most exploited include soil, groundwater, and wood. To sustain renewable
resources, their use should not exceed the current generation of the resource. Sustainable
development, a steady-state relation between society and the environment, is needed to
protect natural resources (1993). However, sustainability appears improbable at the present
B OX 9-1
Types of Toxic Exposure
Chemical hazards. Synthetic fibers, plastics, solvents, fuels, detergents,
pigments, metal alloys, pharmaceuticals, pesticides, and intermediate
byproducts and waste products of these materials. Also included in this
category is radon, a radioactive gas.
Physical agents. Exposure to ultraviolet radiation, heat, cold, nuclear radi-
ation, vibration, noise, and electromagnetic fields, acerbated by the
depletion of the protective filtering effect of the ozone layer by chlo-
roflourocarbons, which are widely used in refrigerants, air conditioning,
and aerosol repellents (Rogers & Cox, 1998).
Car exhaust. Air pollution from car exhaust fumes consists mainly of car-
bon monoxide, ozone, nitrous dioxide, and hydrocarbons.
Biological or infectious agents. E.g., hepatitis or tuberculosis.
Toxic waste. Industrial dumping and inappropriate disposal of medical,
pathogenic, and radioactive wastes.
time as major changes in production and consumption, and restriction of the total world pop-
ulation to its present level would be required. Indeed, the true limits to growth are the capac-
ity of the environment to deal with waste in all its forms and the critical resources, such as
the ozone layer, the carbon cycle, and the global rain forests (Smith, 1994).
POLLUTION
Pollution may lead to the deterioration of an areas resource base. Examples of such
resource-based deterioration include forest die-back due to acidification of soils and increased
airborne ozone, which affects wood production and recreation; the threat to agriculture in
low-lying areas due to the rise in sea level associated with the greenhouse effect; and the
greenhouse effect itselfthinning of the ozone layer, rising levels of carbon dioxide, global
warming, chlorofluorocarbons, and acid rain (Leaf, 1989; Reijnders, 1993).
Groundwater Pollution
Groundwater is the underground reserve of fresh water that supplies lakes and wells with
drinkable water. The importance of groundwater pollution derives from the importance of
groundwater as a resource and ecological determinant, and the long-lasting effect of ground-
water pollution, once it occurs (Reijnders, 1993, p. 147). Intensively farmed and heavily
industrialized areas are subject to pollution, particularly when the groundwater table is
low (1993).
Depletion of the Ozone Layer

Another outcome of pollution is depletion of the atmospheric ozone layer. The ozone layer
shields the earth from the damaging effects of the suns ultraviolet radiation. Ozone is formed
slowly from the action of sunlight on the rare molecules of oxygen in the stratosphere. Chlo-
roflourocarbons, used in aerosols, refrigerants, and other industrial products; nitrous oxide, a
byproduct of internal-combustion engines, industrial processes, and microbial activity; and car-
bon dioxide all absorb the longer infrared waves emitted from the earth, destroying ozone, trap-
ping energy in the atmosphere, and warming the earths surface. The term greenhouse effect
refers to the effect on the balance between the energy the earth receives from solar radiation and
the energy it loses by radiation from its surface back to space.
Since the Industrial Revolution, carbon dioxide, our societys single largest waste product and
the predominant greenhouse gas, has been added to the atmosphere at an accelerating rate. The
atmosphere today still contains half of all the carbon dioxide produced since the start of the
Industrial Revolution (Leaf, 1989). Additionally, in the first half of the 21st century, carbon diox-
ide in the atmosphere is expected to double (Smith, 1994). Once depleted, the ozone layer may
require 8 to 10 years for reconstitution (Leaf, 1989, p. 1579). Ozone depletion and climate
change have major effects on health, including increases in vector-borne and water- and food-
borne diseases, changes in food production, increase in stress from extreme heat or cold, skin can-
cer, cataracts, and immune suppression (Martens, 1998).
Climatic Change
Macro-effects of climatic change are heavily influenced by cycles of geochemicals such as car-
bon, nitrogen, sulfur, and water. These cycles strongly determine atmospheric concentrations of
carbon dioxide, oxygen, and nitrogen compounds and precipitation (Reijnders, 1993). As con-
centrations of these gases build in the atmosphere, the earths surface temperature slowly
increases, creating global climate changes. Unfortunately, industrialized countries with the finan-
cial resources to do something about their tremendous production of waste gases, perceive little
self-interest because global warming has limited effect on industry. Countries that rely on agri-
cultural production (which will be greatly affected) have limited resources to invest (Smith,
1994).
Increases of 2 to 5 Centigrade in the next 50 to 100 years have been predicted, equaling the
largest temperature change since the last ice age. The distribution and timing of climate change
could have many outcomes, including:
Creating drought and desert in areas that are now fertile but creating more arable areas in
higher latitudes.
Shifting patterns of tropical and monsoon rains that are so important to vegetation and
agriculture in Africa, Asia, and South America.
Greatly increasing malaria transmission, possibly up to a hundredfold (Bradley, 1994, p.
136).
Melting the polar ice caps, inundating large population centers and much fertile land.
The expected rise may create 50 million environmental refugees worldwide, more than
triple the number of all refugees today. . . . Displaced people and less arable land would
compound the problem of feeding the worlds increasing population . . . increased pre-
cipitation . . . intrusion of salt into surface water, increased flooding, runoffs contami-
nated with pesticides, salts, garbage, excreta, sewage, and eroded soil are all likely
(Leaf, 1989, pp. 1578-1579).
Examples of the possible health consequences of global climatic change include increased
mortality from heat stress; decreased number of deaths from hypothermia and cold; in-
creased morbidity and mortality from lung diseases such as bronchitis, bronchiectasis, asthma,
and chronic obstructive pulmonary disease; increased incidence of all kinds of skin cancer
among white populations; increased incidence of cataracts; depression of the immune system
leading to an increase in infectious diseases; increased incidence of water- and air-borne dis-
eases; spread of infectious diseases such as enteric infections, measles, pertussis, poliomyelitis,
tuberculosis, leprosy; and malnutrition, hunger, and starvation (Leaf, 1989).
A number of suggestions have been made to reduce environmental pollution (Reijnders,
1993) including:
Limit population size

Limit pesticide and fertilizers through lower-input agriculture
Prevent wastes associated with industrial production through good housekeeping,
changes in production processes, and changes in inputs and internal recycling
Improve energy efficiency. Switch away from nonrenewable primary energy
Recycle organic wastes into fertilizers and/or composts
Foster environmentally conscious buying behavior (green consumerism)
DEFORESTATION
Forests play a crucial role in reducing the greenhouse effect through the stabilization of
global gases and in maintaining patterns of global rainfall. The destruction of forests can have
a number of effects, including:
Reduced rainfall in adjacent areas with irreversible soil erosion-causing crop failures
and a fall in food production.
Destruction of indigenous peoples through destruction of habitat and hunting grounds
and violence.
Species extinction. An estimated one-fourth of all species will become extinct within
the next 50 years, more than 74 per day (Helman, 1994). The global loss [of species]
resulting from deforestation could be as much as 4000 to 6000 species a year, or some
10,000 times more than the naturally occurring rate of extinction that existed before
human beings appeared (Leaf, 1989, p. 1580).
Infectious diseases resulting from the destruction of the natural habitats and ecologi-
cal niches of certain viruses or their vectors, and their release into human populations
(Helman, 1994, p. 379).
Danger of mud-, rock-, and snowslides, as well as loss of topsoil, in mountainous regions.
The current loss of forested land due to human activity is higher than anything previously
experienced (Smith, 1994). The expansion of the worlds population, associated with the
necessary production of food, is the main force driving deforestation, although factors such as
logging, pollution, tourism, and bad productive practices are also involved (Reijnders, 1993).
NURSING IMPLICATIONS OF ENVIRONMENTAL HEALTH CONCERNS

Integrative health promotion emphasizes creating an environment that is conducive to
healthy behaviors, health, and healing. As early as the mid-1800s, Florence Nightingale
maintained that five essential environmental characteristics were needed to promote the
health of individuals: pure air, pure water, efficient drainage, cleanliness, and light (Nightin-
gale, 1859). Now, at the beginning of the 21st century, nurses appreciate Nightingales focus
on the importance of environmental factors in the promotion of health of individuals, com-
munities, and society. At the individual and community levels, assessment may identify envi-
ronmental conditions that are amenable to nursing interventions. Additionally, Bellack and
colleagues (1996) indicate that nurses need to:
Acquire the knowledge and skills to recognize and treat environmentally induced
disease.
Become advocates for environmental issues to protect clients health.
Assess the environment for hazards and risks.
Work with employers and communities to reduce risk and prevent exposure to envi-
ronmental hazards.
Promote healthy behaviors and lifestyles.
Identify resources for accomplishing population focused care related to environmen-
tal health.
Provide careful assessment, detection, and control of exposure sources.
A number of strategies have been proposed for accomplishing these goals. While all of
these strategies are valuable, each nurse cannot do everything, and priorities have to be estab-
lished. All nurses need to be cognizant and vigilant to environmental factors that influence
health, and develop skill in environmental health history taking. Other strategies include
(King & Harber, 1998; Rogers & Cox, 1998):
Identifying a potential irritant or toxic agent.

Identifying an exposure pathway and obtaining a risk assessment.
Strategizing with the client on how to eliminate or minimize exposure.
Administering appropriate screening and/or bio marker tests (e.g., blood lead or
dichlorodiphenyldichloroethylene [DDE] levels).
Recommending treatment or further evaluation as appropriate.
Monitoring the clients health long-term, with follow-up as needed.
Reviewing the effect of the agent on the larger community (is this agent affecting
others?).
Referring for support services as necessary.
Encouraging communication.
Creating networks where possible and educating clients about community action groups.
Lobbying for needed services and funding.
Identifying and encouraging successful coping strategies.
Encouraging general health promotion activities.
Working with interdisciplinary teams and public and private organizations to determine
the impact of environmental health exposures.
Performing risk assessments.
Acting as a resource in providing data and materials about hazards and how to reduce
exposures.
Educating other health care professionals.
Explaining basic environmental health principles, including exposure pathways, vari-
ability in susceptibility, toxicology of chemical of concern and steps to be taken, impor-
tance of dose in determining risk, and personal risk of specific future diseases.
Advocating on behalf of workers and others to alter hazardous conditions and prevent
further health problems.
Identifying environmental health problems and developing a research plan.
Identifying linkages among workplace, home, community, and lifestyle.
The discussions of global, societal, and environmental health in this chapter have empha-
sized that everything is connected to everything else. The environment is predisposing,
enabling, and reinforcing of health, in addition to being a determinant of disease. Although
the main concern of biomedicine has been the treatment of individual risk factors, primary,
preventive health promotion needs to be applied at all levels. Additionally, a focus on inte-
grative health promotion demands consideration of moral and ethical issues for the just dis-
tribution of health and health care resources, locally, nationally, internationally, and globally.
Chapter Key Points

The ecocentric approach assumes that everything is connected to everything else and
that there are links among environment, development, and human health.
Health professionals have traditionally been concerned almost exclusively with indi-
vidual risk factors for diseases, ignoring unequal social, economic, and political struc-
tures that are the basic causes of health problems.
The main variations in health status among countries result from environmental,
socioeconomic, and cultural factors, with medical care of secondary importance.
Underlying many of the current environmental health concerns is the view that the
worlds resources are inexhaustible and available for the taking.
Environmental health concerns include toxic exposure, natural resources, pollution,
deforestation, and climactic change.
Societal health concerns include childhood health problems, infectious diseases, acci-
dents, poor access to food, illiteracy, lack of clean water, migration, multinational busi-
ness interests, poverty, overpopulation, and family planning.
Empowerment involves assisting individuals and communities to articulate both their
health problems and the solutions to address those problems, providing access to infor-
mation, supporting indigenous community leadership, and assisting the community in
overcoming bureaucratic obstacles to action.
References
Austin, W. (2001). Nursing ethics in an era of globilization. Advances in Nursing Science, 24, 1-18.
Beaglehole, R., & Bonita, R. (1998). Public health at the crossroads: Which way forward? Lancet, 351, 590-592.
Bellack, J. P., Musham, C., Hainer, A., Graber, D. R., & Holmes, D. (1996). Environmental health com-
petencies: A survey of nurse practitioner programs. American Association of Occupational Health
Nurses, 44, 337-344.
Benatar, S. R. (1998). Global disparities in health and human rights: A critical commentary. American Jour-
nal of Public Health, 88, 295-300.
Bradley, D. (1994). Health, environment, and tropical development. In B. Cartledge (Ed.), Health and the
environment (pp. 126-149). Oxford, UK: Oxford University Press.
Coreil, J. (1997). Health behavior in developing countries. In D. S. Gochman (Ed.), Handbook of health
behavior (Vol. 3, pp. 179-198). New York: Plenum Press.
Dixon, J. K., & Dixon, J. P. (2002). An integrative model for environmental health research. Advances in
Nursing Science, 24, 43-57.
Foege, W. H. (1998). Global public health: Targeting inequities. JAMA, 279, 1931-1932.
Gesler, W. M. (1992). Therapeutic landscapes: Medical issues in light of the new cultural geography. Social
Science and Medicine, 34, 735-746.
Grady, P. A., Harden, J. T., Moritz, P., & Amende, L. M. (1997). Incorporating environmental sciences and
nursing research: An NINR initiative. Nursing Outlook, 45, 73-75.
Green, L. W., Richard, L., & Potvin, L. (1996). Ecological foundations of health promotion. American Jour-
nal of Health Promotion, 10, 270-281.
Hann, N. E., Kean, T. J., Matulionis, R. M., Russell, C. M., & Sterling, T. D. (2004). Policy and environ-
mental change: New directions for public health. Health Promotion Practice, 5, 377-381.
Hegyvary, S. T. (2001). Editorial. J Nurs Scholarsh, 33, 304.
References 239
Helman, C. G. (1994). Medical anthropology and global health. In C. G. Helman (Ed.), Culture, health and
illness (3rd ed., pp. 328-383). Oxford, UK: Butterworth-Heinemann Ltd.
Howson, C. P., Fineberg, H. V., & Bloom, B. R. (1998). The pursuit of global health: The relevance of
engagement for developed countries. Lancet, 351, 586-590.
Israel, B. A., Checkoway, B., Schulz, A., & Zimmerman, M. (1994). Health education and community
empowerment: Conceptualizing and measuring perceptions of individual, organizational, and
community control. Health Education Quarterly, 21, 149-170.
Kaseje, D. (1995). The role of nursing in health care in the context of unjust social, economic, and polit-
ical structures and systems. Nursing and Health Care Perspectives on Community, 16, 209-213.
King, C., & Harber, P. (1998). Community environmental health concerns and the nursing process. Amer-
ican Association of Occupational Health Nurses, 46, 20-27.
Kleffel, D. (1996). Environmental paradigms: Moving toward an ecocentric perspective. Advances in Nurs-
ing Science, 18(4), 1-10.
Lane, S. D., & Rubinstein, R. A. (1996). International health: Problems and programs in anthropological
perspective. In C. F. Sargent, & T. M. Johnson (Eds.), Medical anthropology. Contemporary theory
and method (Rev. ed., pp. 398-423). Westport, CT: Praeger.
Leaf, A. (1989). Potential health effects of global climatic and environmental changes. New England Jour-
nal of Medicine, 321, 1577-1583.
Lee, K. (1998). Shaping the future of global health cooperation: Where can we go from here? Lancet, 351,
899-902.
Leuning, C. J. (2001). Advancing a global perspective: The world as classroom. Nursing Science Quarterly,
14, 298-303
Martens, W. J. M. (1998). Health impacts of climate change and ozone depletion: An ecoepidemiologic
modeling approach. Environ Health Perspect, 106(Suppl. 1), 241-245.
Murray, C. J. L., & Lopez, A. D. (1997). Mortality by cause for eight regions of the world: Global burden
of disease study. Lancet, 349, 1269-1276.
Neighbors, H. W., Braithwaite, R. L., & Thompson, E. (1995). Health promotion and African-Americans:
From personal empowerment to community action. American Journal of Health Promotion, 9,
281-287.
Nightingale, F. (1859). Notes on nursing: What it is, and what it is not. London: Harrison & Sons.
Reijnders, L. (1993). Health within an ecological perspective. In R. Lafaille, & S. Fulder (Eds.), Towards a
new science of health (pp. 144-155). London: Routledge.
Education Quarterly, 21, 295-312.
Roemer, M. I., & Roemer, R. (1990). Global health, national development, and the role of government.
Am J Public Health, 80, 1188-1191.
Rogers, B., & Cox, A. R. (1998). Expanding horizons: Integrating environmental health in occupational
health nursing. American Association of Occupational Health Nurses Journal, 46, 9-13.
Schultz, A., & Northridge, M. E. (2004). Social determinants of health: Implications for environmental
health promotion. Health Education and Behavior, 31, 455-471.
Smith, D. (1994). How will it all end? In B. Cartledge, Health and the environment (pp. 207-218). Oxford,
UK: Oxford University Press.
Spiegel, J., & Yassi, A. (1997). The use of health indicators in environmental assessment. Journal of Med-
ical Systems, 21, 275-289.
Wait, G. (1998). Globalisation of international health. Lancet, 351, 434-437.
Wallerstein, N., & Bernstein, E. (1988). Empowerment education: Freires ideas adapted to health educa-
tion. Health Education Quarterly, 15, 379-394.
World Health Report. (1997). Conquering suffering, enriching humanity. World Health Forum, 18, 248-260.
Yach, D., Hawkes, C., Gould, C. L., & Hofman, K. J. (2004). The global burden of chronic diseases: Over-
coming impediments to prevention and control. Journal of the American Medical Association, 291,
2616-2622.
Section
III
THE PERSON WORLDVIEW
Section III, The Person Worldview, includes two chapters that emphasize healing approaches to
the promotion of health. Chapter 10, The Essence of Healing Helping Relationship, discusses the ele-
ments of healing as a goal of nursing as contrasted with curing. A helping relationship that is
characterized by presence (being rather than doing), mindfulness, respect, genuineness, active lis-
tening, empathy, and the therapeutic use of self are addressed. And, Chapter 11, Empowering
Community Health, emphasizes community-level empowerment, collaboration, and capacity
building to nurture and build on strengths and resources present in the community.
10
THE ESSENCE OF A HEALING
HELPING RELATIONSHIP
Abstract
Healing is facilitated within a helping relationship that is characterized by such behaviors
as presence (being with rather than doing for), mindfulness, respect, connected caring, gen-
uineness, reciprocity, active listening, empathy, and communication. In this chapter, a help-
ing relationship is viewed as one way to enhance a sense of well-being, lessen feelings of
isolation and vulnerability, and facilitate health.
Learning Outcomes
Differentiate between characteristics of prescriptive and healing helping relationships.

Describe characteristics and outcomes of presence in a healing helping relationship.
Discuss the use of challenge in a helping relationship.
Discuss Patterson and Zderads, Parses, and Watsons use of presence in their nursing
theories.
Discuss behaviors associated with a healing helping relationship, such as presence,
mindfulness, relating, respect, connected caring, genuineness, reciprocity, active listen-
ing, empathy, and communication.
244 Chapter 10 The Essence of a Healing Helping Relationship
Prescriptive Helping Relationship

Gadamer (1960) describes three kinds of interpersonal understanding. The first kind
applies knowledge of human behavior in order to manipulate another person or serve ones
own purpose(s). A second kind uses knowledge or understanding of another persons point of
view in order to determine what the person needs. These two kinds of interpersonal under-
standing are demonstrated in a prescriptive helping relationship.
A medically oriented risk and illness prevention approach to health promotion is used by
many nurses. This approach is characterized by authoritarian, prescriptive, persuasive, and
generalized information giving from expert to ignorant lay person (Benson & Latter, 1998,
p. 101). A prescriptive helping relationship is often characterized by dominating, generalized,
reassuring, and directive interactions.
In a prescriptive helping relationship, the emphasis is on goal-directed nursing interactions
aimed at problem resolution. An interaction is short and focuses on single dimensions of
behavior such as verbal dialogue or actions (Morse et al., 1997). Relating and communicat-
ing are viewed as something a nurse does using a set of defined communication skills (Har-
trick, 1997, p. 524). There is an emphasis on prescriptive information-giving about illness and
detrimental individual lifestyle factors, with a lack of recognition of the broader social and
environmental determinants of health (Benson & Latter, 1998).
Hartrick (1997, pp. 524-525) describes several constraints of a prescriptive helping
relationship:
The nurses ability to experience and value human relationships is constrained by an
emphasis on functions and productivity. The ability to be in a caring relationship
requires far more than the refinement of behavioral communication skills. Rather, it
requires an appreciation of peoples connectedness, the development of relational
awareness and an interest in the movement of relationship, not just attention to self
and others.
Connection in a relationship is disrupted when the nurse concentrates attention and
interest on her- or himself to the exclusion of the client. By focusing on performing
(e.g., saying the right thing), the nurse may overlook or forget the relationship.
Problem-resolution aims to achieve a conflict-free state of harmony. But, health and
healing are promoted through the development of an increasing openness to learning
and growth, an increasing capacity to tolerate ambiguity and uncertainty, and an
increasing experience of empowerment and choice.
In addition, Newman (1999) noted that the pathway of healing is one of exploration,
not repair (p. 229).
An emphasis on self-focused communication skills and on techniques to accomplish tasks

is based on the mistaken belief that the nurse has to do something to solve client problems.
Nurses, as well as other clinicians, tend to assume that it is the techniques they use which lead
to change for patients. Indeed, nurses make so much investment in terms of time, money, and
effort, in acquiring knowledge and skills, that it would be surprising if they were not highly
Prescriptive Helping Relationship 245
committed to a belief in the effectiveness of their techniques. However, it is the nontechni-

cal factors which are central to healing (Mitchell & Cormack, 1998, p. 77).
Gadamers (1960) third kind of interpersonal understanding based on openness, mutuality,
dialogue, and the possibility of change of both participants is consistent with a healing help-
ing relationship that develops over time. Table 10-1 lists the selected characteristics of pre-
scriptive and healing helping relationships differentiated by Hartrick (1997).
Table
10-1 Differentiating Characteristics of Prescriptive and Healing
Helping Relationships
PRESCRIPTIVE HEALING
Behavioral interpersonal practice Relational caring practice
Subject-object separability Relational inseparability
Objectivity Intersubjectivity
I-It relationship (Buber, 1958) I-Thou relationship (Buber, 1958)
Reciprocal relationship (Lyons, 1988) Responsive relationship (Lyons, 1988)
Behavioral action/interaction Human-to-human process
Method-centered doing Relationship-centered being/knowing/doing
Problem identification and goal Understanding the meaning and complexity

attainment of human experience
Emphasizes increasing behavioural Emphasizes enhancing relational capacity of

skillfulness of nurse nurse
Communication skills: clarification, Relational capacities: initiative, authenticity,

open-ended, questions, empathy, responsiveness, mutuality and synchrony,
listening, attending, self-disclosure, honoring complexity and ambiguity,
confrontation, immediacy intentionality, re-imagining
Reprinted from Hartrick, G. (1997). Relational capacity: The foundation for interpersonal nursing practice.
J Adv Nurs, 26, 525, with permission of Blackwell Science Ltd.
Healing Helping Relationship

When viewed from the perspective of a person as a composite (see the discussion of the
disease perspective of health in Chapter 1), healing has been defined as the process of bring-
ing together the parts of oneself (physical, mental, emotional, spiritual, and relational) at
deeper levels of inner knowing. This leads to an integration and balance, with each part hav-
ing equal importance and value (McKivergin, 2000) and, as an inner process through which
a person becomes whole (Lerner, 1994, p. 13). When the reality of wholeness is viewed not
as an ideal, but as a given (see the discussion of the person perspective of health in Chapter
1), the focus is on appreciating the wholeness of the pattern that arises from human-
environment mutual process (Cowling, 2000).
Given that healing occurs within the client, the nurse healers role is to facilitate another
persons growth, assist with recovery from illness, or assist with transition to peaceful death
(Dossey et al., 1995). The nurse assists and responds to the client, who is the central force in
the healing process. Nurses assume that their actions, as professionals, aim to facilitate
wholeness in others through an interaction based on a mutuality of purpose (Kritek, 1997,
p. 14). Kritek (1997, p. 21) identified four fundamental elements of the healing encounter:
Nurse and client interact within a given context
The encounter is in response to a health experience
The nurse works in a pattern of mutuality with the client
Healing is facilitated in response to a clients elicitation of nursing involvement and
expertise
Cowling (2000, p. 16) conceptualized healing as the realization, knowledge, and appreci-
ation of the inherent wholeness in life that clarifies understanding and opportunities for
action. He proposed a process of pattern appreciation that includes information gathering
about the pattern of the whole and appreciating the transformative nature of a participatory
engagement with people that illuminates the possibilities. Newman (1999) identified mutu-
ality, rhythm, and pattern in dynamic relatedness with ones environment as key features in a
healing relationship. She stated that the development of a tolerance for uncertainty, and a
mutually satisfying rhythm of relating with another persons interactive pattern are necessary
for effective communication.
Lerner (1994) differentiated among universal, common, and unique conditions of healing.
Examples of universal conditions are inner peace and a deep experience of love. Examples of
common conditions are attention and care from friends and family, deeply enjoyed work,
laughter, moving music, and great art. Lerner suggests that the unique conditions of healing
are some of the most important. Thus, the nurse in a healing relationship needs to identify
the unique conditions that are most meaningful for the individual client.
Benson and Latter (1998, p. 104) propose that the nurse should encourage health pro-
motion as an empowering, holistic, individualized approach applicable to any interaction as
opposed to telling people what to do about unhealthy habits. Healers should try to cure
sometimes, relieve often, and comfort always (Mitchell & Cormack, 1998). Nurses offer the
Healing Helping Relationship 247
gift of walking with a person so that he or she is not alone at the crossroads of healing (Mc-
Kivergin, 1997, p. 24). A healing helping relationship is characterized by such principles as
presence (being with rather than doing for), intention and purpose, empathy, guiding, cre-
ativity, imagery, and spirituality (Dossey et al., 1995; Keegan, 1994; Lerner, 1994).
BEHAVIORS ASSOCIATED WITH A HEALING HELPING RELATIONSHIP

Presence
Use of presence can be thought of as a particular way of using the self therapeutically
(Minicucci, 1998). Presence is of Latin and French derivation from the words prae, meaning
in front, and sens, meaning being. Thus, the word presence has both spatial and temporal con-
notations. The same word in its verb form, praesentare, means to place before, to hold out, to
offer, from which the nouns gift and present evolved (Skeats, 1969, p. 409). Absence is the
opposite of presence from ab, meaning away from, and sens, meaning being. Thus, from the
nature of the word itself, nursing presence can be construed as a state in which the nurse is
in the same place, near or in front of a [client], and in the same moment, holding out to the
[client] the gift of care (Doona et al., 1997, p. 6).
Presence as a nursing phenomenon emerged in the 1960s as a coherent and consistent
philosophical term based on the philosophy of Martin Buber and the existentialism of Gabriel
Marcel and Martin Heidegger (Doona et al., 1997). Buber (1970) described I-It and I-Thou
relationships, both of which he considered necessary for existence. The I-It relationship offers
familiar order, reliable experience, and continuity in space and time, while I-Thou rela-
tionships are characterized by reciprocity or mutuality, spontaneity, acceptance, and confir-
mation of otherness or uniqueness, immediacy, wholeness, exclusiveness, [and] inclusion
(Cohn, 2001, p. 171).
For Heidegger (1987), presence means being. Being then is the very personal, individual,
unique attribute, quality, or spirit which makes one human (Gilje, 1992, p. 55). Being as a
noun is commonly defined as existence and actuality. A synonym for being is essence. . . . To be
present implies a quality and essence of being in the moment (Dossey et al., 1995, pp. 67,
69). A major defining attribute of presence is the ability to psychologically or emotionally be
with or attend to a person, place, or object. Valuing being and knowing are essential processes
for understanding the concept and applying it to human experiences (Gilje, 1992).
Easter (2000) identified four distinct modes of presence. These are:
Physical presence. Requires proximity or physical closeness; includes movement, touch-
ing, and being there.
Therapeutic presence. Used to provide support, hope, comfort, relaxation, and an
increased ability to cope (p. 366).
Holistic presence. It requires a nurses mind, body, and spirit to connect with a [clients]
mind, body, and spirit (p. 369).
Spiritual presence. Spirit-to-spirit communion.
Presence is an important part of several nursing theories, including those of Patterson and
Zderad (1976), Parse (1990), and Watson (1985). Patterson and Zderad emphasize mutual
outcomes. Well-being and authenticity are benefits that both the [client] and the nurse
experience. . . . Presence is the medium through which health in and between both the [client]
and nurse is catalyzed. In this way, [clients] and nurses are equal partners in care (Minicucci,
1998, pp. 10-11). Patterson and Zderad explicitly identify two components of presence: the
physical (being there) and the psychological (being with). Table 10-2 differentiates being
there and being with.
Parse (1990, p. 139) suggests that to approach a person as a nurturing gardener rather than
a fix it mechanic, believing that each person lives value priorities is to be truly present to the
person as the person changes patterns of health. . . . It is a subject-to-subject interrelationship,
a loving, true presence with the other to enhance the quality of life. In Parses view, the true
presence of the nurse is a way of being with in which a knowledgeable nurse is authentic,
open, self-giving, and attentive to moment-to-moment changes in meaning within the
relationship.
The concept of presence is mentioned rather than discussed throughout Watsons work.
For example, she indicates that the development of her work was influenced by Peplaus
interpersonal domain and the notion of therapeutic use of self, which later manifested . . . as
presence, authentic caring relationship (Watson, 1997, p. 49). However, it seems clear that
presence is an essential and integral concept to Watson. This is evident when she discusses
transpersonal caring, [which] calls forth an authenticity of being and becoming, an ability
to be present, to be reflective, to attend to mutuality of being and centering ones con-
sciousness and intentionality toward caring, healing, wholeness, and health (Watson, 1997,
p. 51).
Presence has been described by a number of other nurses. For example, Doona and col-
leagues (1997, p. 3) describe nursing presence as an intersubjective encounter between a
nurse and a [client] in which the nurse encounters the [client] as a unique human being in a
unique situation and chooses to spend herself on his behalf. McKivergin (1997, p. 17)
describes presence as a multidimensional state of being available in a situation with the
wholeness of ones individual being; relational style and quality of being with rather than
doing to. . . and creates the space and opportunity for another to feel safe. Moch and Schae-
fer (1998, pp. 159-161) describe presence as a process of being available with the whole of
oneself and open to the experience of another through a reciprocal interpersonal
encounter. . . . Presence implies an openness, a receptivity, readiness, or availability on the part
of the nurse. . . . The union or total presencing that happens through the experience leads to
healing, discovery, and finding meaning.
Romick (1997) frames presence within an encounter between a traveler and guide. Pres-
ence includes the guides willingness to be with anothers reality, concentrate, fully attend,
and let go of the outcome of the session. It includes intuitive inner knowing and requires
trust, empathy, acceptance, honesty, intention, and practice (p. 473).
The core element in presence is being there. . . described as a gift of self . . . that is conveyed
through open and giving behaviors of the nurse (Osterman & Schwartz-Barcott, 1996, p. 24).
Additionally, Fredriksson (1999) describes being with presence as a gift and an invitation, with
the client choosing whether to accept or reject the gift. Osterman and Schwartz-Barcott (1996)
describe four degrees of intensity of presence: presence, partial presence, full presence, and tran-
scendent presence. Presence and partial presence involve being physically present with another
Table
10-2
Differentiating Being There from Being With
BEING THERE BEING WITH

What is it? A state of being in one place A gift of self that is conveyed
and not elsewherein the through being available and at the
context of another, and with disposal of the other person with
attentive attitude focus on the all of self.
other. An intersubjective encounter
between a nurse and a patient in
which the nurse encounters the
patient as a unique human being
in a unique situation and chooses to
spend herself on the patients
behalf, while at the same time the
patient invites the nurse into his
experience.
Preconditions To be physically close to a To be in touch with self and bring

patient while using a quiet tone ones own humanness and accept-
of voice, appropriate choice ance of self to the encounter.
of words, eye contact and To make room internally for the
touch in ways that establish other person, being willing to be
rapport and communicate involved. To remain with the patient,
empathy for the patient. enduring ones feelings of discom-
fort and awkwardness.
What is Physically attending behavior, A flow of feelings between two per-

happening? sensitivity to body language, sons with different modes of being
(process) use of touch in a judicious way in a shared situation, in which the
to comfort or express concern, one caring is touched by the
making eye contact and lean- patients feelings.
ing forward toward the other. Being there in the midst of a help-
Listening, comfortable silence, less situation rather than saying or
and communication of under- doing the right thing. Experience
standing of the patients exper- ones powerlessness in confronting,
ience. not knowing, not curing, and not
healing.
continued
Table
10-2
Differentiating Being There from Being With (continued)
BEING THERE BEING WITH

What does it Assists coping. Alleviation of suffering.
lead to? Diminishes intensity of feelings Growth through difficult experi-
(outcomes) such as fear, powerlessness, ences.
anxiety, isolation, and distress. Lessening of the sense of isolation,
Support, comfort, sustained development of a sense of relation-
assistance, encouragement, and ship and connectedness.
motivation. Lessening of the sense of vulnera-
A sense of security and feeling bilty, development of a sense of car-
reassured. ing and being heard.
Feelings and thoughts put into
words.
New ways of interpreting and
understanding ones self-develop-
ment, leading to new directions,
solutions, decisions, and choices.
Reprinted from Frederiksson, L. (1999). Modes of relating in a caring conversation: A research synthesis on
presence, touch, and listening. J Adv Nurs, 30, 1170, with permission of Blackwell Science Ltd.
person, while full and transcendent presence involve being physically and psychologically pres-
ent. Additional characteristics of these four ways of being there are described in Table 10-3.
The nurse has to be present to her- or himself in order to discover other presences. The
nurse is invited to participate in the clients experience, and the nurse gains affirmation of
herself as a person and as a professional instead of gaining satisfaction for caring for the
clients needs (Doona et al., 1997, pp. 7-8).
Additional, selected descriptors of presence are discussed below:
1. Nursing presence is an all-or-none phenomenon (Doona et al., 1999, p. 57).

2. Presence cannot be used or commanded because it is a choice that a nurse makes
(Doona et al., 1997, p. 11).
3. Presence cannot be made into a technique and cannot be taught, but can be cultivated.
4. Presence does not depend on physical proximity (McKivergin, 1997, p. 19). What is
important is being there with the other person in a way the other person perceives as
full of meaning, not the physical proximity of the nurse being in the same place and at
the same time with a client.
Table
10-3
Presence: Characteristics of Four Ways of Being There
CHARACTERISTICS PRESENCE PARTIAL PRESENCE FULL PRESENCE TRANSCENDENT PRESENCE

Quality of being Physically present in Physically present in Physically present Physically present.
there context of another. context of another. (there) (physical attend- Psychologically present
ing behavioreye con- (metaphysical beliefs).
tact leaning toward). Holistic.
Psychologically present
(with) (attentive listening
behavior).
Focus of energy Self-absorbed. Objects or tasks in Self/other (focusing on Centered (drawing

environment, relevant other influences from universal energy).
to the other individual response-reciprocal). Subject/Subject leads to
but none of the energy oneness.
is directed at the other.
Personal, subjective Mechanical/Technical Present oriented (here Transcending and ori-
reality. reality. and now) anchoring in ented beyond here and
present reality. now; sustaining while at
the same time trans-
Healing Helping Relationship

forming reality.
Nature of No interaction, self- Interaction with part of Interactive; essential Relationship; high
interaction absorbed, intrapers- other encounter. communication; degree of skilled com-
onal encounter. boundariesrole con- munication; role free;
straints; professional human intimacy/love;
relationship dyad humanistic caring, no
caring. boundaries; monad
relationship.
continued
251
Table
10-3
Presence: Characteristics of Four Ways of Being There (continued)
CHARACTERISTICS PRESENCE PARTIAL PRESENCE FULL PRESENCE TRANSCENDENT PRESENCE
Positive outcomes Reduce stress; reas- Reduce stress; solving a Solving of a human Transformations
surance that someone mechanical problem; problem; relief of a decreased loneliness;
is there; may be reduces amount of here-and-now distress. expansion of conscious-
quieting and restor- stimuli in an encounter. ness; spiritual peace,
ative; facilitates hope, and meaning in
creative thinking. ones existence (love/
connectedness); nice
feeling generated in the
environment; transper-
sonal (oneness).
Negative No interpersonal No interpersonal May be too much Fusion and possible

outcomes engagementmissed connectedness. energy for recipient. loss of objective reality;
communication; Energy not always danger of taking on
isolation, withdrawn, available for full pres- recipients problems.
increased anxiety. ence; increased anxiety.
Reprinted from Osterman, P., & Schwartz-Barcott, D. (1996). Presence: Four ways of being there. Nursing Forum, 31, 25. Used with permission.
5. The attitude shifts from What can I do? to How can I be with the person in this
moment? The idea is to be with a client in a way that acknowledges a shared humanity.
6. Being there is being with, an invitation that is accepted or rejected.
7. Presence is self-giving to another at the moment-at-hand, being available and at the
disposal of the other.
8. Presence involves connecting with the clients experience and co-creating the outcome
rather than imposing a preconceived agenda for the moment.
9. The process may be uncomfortable because remaining with the person exposes ones
humanness and vulnerability (McKivergin, 1997).
10. Listening to the other is the context for informed judgment.
Barriers to Presence
The typical nursing work environment contains many barriers to presence. Many nurses
cite a lack of time, high workload, tiredness, competing demands, distractions, and stress as
factors that diminish nurse-client relationships. Other constraints include busyness and a
goal-oriented task focus, feelings of inadequacy, a need to be in control, lack of openness, and
concern about what other people will think. In addition, the client may not welcome pres-
ence, even though the absence of nursing presence leaves [clients] feeling depersonalized and
alone. . . the danger of nursing absence (Doona et al., 1997, p. 5). Finally, there may be a
clash of values between presence and the professional distance taught in many nursing
schools.
Outcomes of Presence
In contrast to the depersonalization that characterizes many nurse-client relationships,
McKivergin (1997) and Godkin (2001) suggest that for the client, presence can result in
increased coping strength, even in the midst of unchanged circumstances; achievement
of client goals; satisfaction with nursing care; healing and a sense of well-being; growth;
a lessened sense of isolation with more connections; a decreased sense of vulnerability;
and neutralization of the intimidating atmosphere of the health care system. For the
nurse, presence can provide increased confidence in ones competence, job satisfaction,
and joy.
A healing helping relationship includes other behaviors in addition to presence, including
mindfulness, relating, respect, connected caring, genuineness, reciprocity, active listening,
empathy, and communication. These behaviors are discussed in the next section.
Mindfulness
A healing helping relationship requires conscious attention (mindfulness). The nurse must
focus and center her- or himself and detach from other distractions. Mindfulness involves the
combination of slowing down and bringing ones full attention (thoughts, feelings, and bod-
ily sensations) to the activity of the moment (Wells-Federman, 1996). See Chapter 15,
Reducing Energy Depletion: Relaxation and Stress Reduction, for a discussion of mindfulness in
relation to meditation and relaxation.
Centering
The centering process promotes openness and readiness for caring, both of which are
essential to interpersonal presence (Moch & Schaefer, 1998). The concept of patterning
energy is the basis for centering. Centering also is used in meditation, therapeutic touch,
guided imagery, and self-hypnosis. The experience of being centered is quiet, relaxed, peace-
ful, and insightful; a sense of well-being is established, whole and unitary, focused, compas-
sionate, and timeless (Dole, 1996, p. 34).
Centering is a powerful and easily achieved skill that can prevent fatigue, stress, depres-
sion, or anger when working with a client who displays these qualities. Centering allows the
practitioner to be separate from, yet open to, input from clients (Clark, 1996, p. 21). The
process of centering can be accomplished sitting or lying down, often with the eyes closed.
The nurse chooses to acknowledge and then to release thoughts and tension. When breath-
ing in, a calming thought is brought into and throughout the body. When breathing out, an
awareness of tension is acknowledged and released naturally with the breath (Dole, 1996).
One technique to facilitate centering is presented in Box 10-1.
B OX 10-1
A Technique to Facilitate Centering
1. Sit in a comfortable chair with feet flat on the floor and hands resting qui-
etly in your lap; close your eyes.
2. Check out your body for tension spots and relax these areas as you exhale.
3. Inhale easily, filling your body with relaxation.
4. Exhale, moving your breathing to your center, about the level of your
navel.
5. Continue breathing in this manner until you feel calm, integrated, unified,
and focused.
6. (Optional) Picture the body surrounded by a protective shield that allows
positive energy in, but keeps negative energy out. The shield may be con-
ceived as a color, light source, or spiritual sense.
Source: Clark, C. C. (1996). Wellness practitioner (2nd ed., pp. 21-22). New York: Springer.
Relating
Relating refers to establishing or demonstrating a connection (Soukhanov, 1992), which
is essential to the establishment of a healing helping relationship. Relating in a healing help-
ing relationship can be a connection with high intersubjectivity or a contact with limited
intersubjectivity. In a connection, the nurse is listening, using caring and connective touch
and is present as being with the [client]. In contrast, in a contact, the nurse is hearing, using
task-orientated touch, and is present as being there for the [client] (Fredriksson, 1999,
p. 1167).
Hartrick (1997) has identified relational capacities as taking initiative, being authentic
and responsive, being open to mutuality and synchrony, honoring complexity and ambiguity,
and relating intentionally. The focus for both the nurse and the client is on being with
another person, sharing commonalties and differences of visions and goals, expanding the
capacity to trust and experience uncertainty, and fostering the clients discovery of choice and
power within his or her experience of health (Hartrick, 1997).
Respect
Respect is feeling or showing deferential regard or esteem (Soukhanov, 1992). Respect is
demonstrated through acknowledgment (Smith, 1992). Respect is a nonpossessive affirma-
tion that builds self-esteem and positive self-image. In a healing helping relationship, respect
is demonstrated by equality, mutuality, and shared thinking about strengths and problems.
Connected Caring
Caring is a nurturing way of relating to a valued other toward whom one feels a personal
sense of commitment and responsibility. . . . The nurse cares without obligating the client to
reciprocate (Swanson, 1991, p. 165). According to Swanson (1991), the five categories or
processes of caring are knowing, being with, doing for, enabling, and maintaining belief.
Caring has been described as overcoming the fear of crossing the boundaries to achieve
connection, intimacy, and mutuality in a sharing of humanness (Gilje, 1992, p. 63). Con-
nection indicates making contact, joining together, and linking through association with oth-
ers to create a bond or special harmonious relationship with another person. Growth,
integration, and healing are outcomes of connection and caring. Connecting takes courage
and a willingness to take a risk (Sherwood, 1997).
The use of touch demonstrates and symbolizes connection with another in ways that can
be both beneficial and harmful: to soothe, calm or comfort; to intervene directly or manipu-
late; to arouse, stimulate and seduce; or to hurt and damage. The sensitive use of touch often
depends on intuition rather than intellect. . . . When [clients] experience medical care as if
their bodies were being dealt with independently of their minds, they complain of being
treated impersonally, as unthinking objects (Mitchell & Cormack, 1998, p. 65).
Genuineness (Authenticity)
In defining genuineness, which is used synonymously with authenticity, phrases such as
being actually and precisely what is claimed, acting in good faith, and being sincere are
used. Being genuine means that you send the other person the real picture of you, not one
distorted by being different than how you really think or feel (Smith, 1992, p. 74). The gen-
uine nurse in a healing helping relationship acts in ways that are unrehearsed and non-
contrived, taking a risk by expressing negative thoughts, and confronting others when
necessary.
Reciprocity
There is a fundamental difference between understanding as an individual achievement
and understanding as a mutual process or dialogue (Widdershoven, 1999, p. 1163). Reci-
procity is an interpersonal exchange that is symmetrical or equivalent in quality (Mendias,
1997). In addition, therapeutic reciprocity is a mutual, collaborative, probabalistic, instruc-
tive, and empowering exchange of feelings, thoughts, and behaviors between nurse and client
for the purpose of enhancing the human outcomes of the relationship for all parties con-
cerned (Marck, 1990, p. 57).
Both Peplau and Watson discuss mutuality as a reciprocal process (Mendias, 1997).
Peplaus concept of mutuality has been described as legitimizing growth in both clients and
nurses, while Watson describes a reciprocal transaction between nurses and patients (Men-
dias, 1997). Mutuality involves mutual exchange, gain, and responsibility; shared meaning for
the participants; empowerment from shared control of the nurse-client relationship; and sta-
tus and power balance between the client and the nurse.
Active Listening
Listening has been described as an active process of searching for meaning (Moch &
Schaefer, 1998, p. 163). Active, or empathetic, listening requires discipline and skilled
interpersonal communication, which can be hard work (Ryden, 1998, p. 170). The nurse
must really concentrate and focus to interpret verbal and nonverbal messages from the client,
recognize themes and patterns, try to determine what is really being said and hear what is left
unsaid, assist the client to communicate a message more clearly, and communicate an under-
standing of the clients verbal and nonverbal messages. Being able to really observe, listen,
and interpret the meaning of a client message is essential to understanding (Ryden, 1998).
Klagsbrun (2001) discusses focusing as an essential part of active listening. As an alterna-
tive to analyzing, focusing is described as a way of getting in touch with vague, embodied
awareness of a felt sense. By paying attention to a particular feeling and then noticing what
is evoked inside the body, a felt sense forms. The nurse needs to stay respectful, friendly, and
welcoming toward whatever emerges (2001, p. 120). Focusing is enhanced when the nurse
clears a space, by taking 5 minutes routinely to inventory and distance from stressors.
Invoking and maintaining positive feelings also helps. Clients can use focusing to get dis-
tance from [the] pain, can hear from it, or befriend it, allay apprehension, promote accept-
ance and acknowledgment of the fearful and anxious place inside, gain a sense of mastery
and control, and feel empowered (2001, p. 124).
Strategies to facilitate active listening are presented in Box 10-2.
Several authors (Clark, 1996, p. 21; McKay et al., 1995, pp. 16-19) suggest that by differ-
entiating oneself from clients through the act of centering, many blocks to listening are
removed. Selected blocks to listening are presented in Box 10-3.
Centering reduces blocks to listening by restoring internal quiet, thereby permitting the
nurse to give attention and listen actively. Ryden (1998, p. 170) states that active listening
is the cognitive and communicative component of empathy.
Empathy
Empathy involves the ability to recognize and to some extent share the emotions and
states of mind of another and to understand the meaning and significance of that persons
B OX 10-2
Strategies to Facilitate Active Listening
When giving external feedback, reflect the essence of what you have
understood the client to say, ask for elaboration, encourage specificity and
concreteness in place of vague global statements, and point out discrep-
ancies in communication
When interpreting the meaning of what is heard, critical thinking skills in
addition to listening are required
Use adeptness and sensitivity when communicating to the client what is
understood
Attempt to match the intensity of the feeling that has been communicated
rather than overstating or minimizing
Phrase interpretation in a tentative way rather than as a dogmatic asser-
tion
Allow the clients response to determine the direction of the subsequent
interaction
Source: Ryden, M. B. (1998). Active listening. In M. Snyder, & R. Lindquist, Complementary/alternative
therapies in nursing (3rd ed., pp. 173-174). New York: Springer.
behavior. Empathy is a feeling that is composed of thoughts and emotions related to under-
standing the clients situation (Baillie, 1996). Components of empathy have been described
as moral compassion and concern for the welfare of others; emotive ability to subjectively per-
ceive and share another persons psychological state or intrinsic feelings; cognitive intellec-
tual ability to understand anothers perspective; and behavioral ability to communicate
empathetic understanding and concern. The actions resulting from empathy can be thera-
peutic (Morse et al., 1992).
The defining attributes of empathy include seeing the world as others see it, being non-
judgmental, understanding anothers feelings, and communicating the understanding (Wise-
man, 1996). Other characteristics include experiential knowledge, and the personal and
human qualities of being able to trust, be honest and self-aware, and have reflective ability.
Getting to know the patient promotes closeness and helps to develop rapport. Empathy is dif-
ferent from sympathy, sympathy being more feeling sorry for another person, while empa-
thy requires more of an understanding of what the other person is experiencing (Baillie,
1996, p. 1302).
Challenges point out discrepancies or contradictions that the client is unaware of or
unwilling to change. Discrepancies and contradictions are important because they are often
signs of unresolved issues, ambivalence, or suppressed or repressed feelings (Hill, 2004, p.
B OX 10-3
Selected Blocks to Listening
Comparing. Only partially listening because of trying to assess who is
smarter, more competent, more emotionally healthy, or suffering more.
Mind reading. Not paying attention to what is being communicated; try-
ing to figure out what the client is really thinking and feeling, rather than
listening closely to what is being said.
Rehearsing. Not listening because of rehearsing what to say next.
Filtering. Listening to only part of what is said.
Judging. Not paying attention because the clients comments have already
been labeled as stupid or unqualified.
Dreaming. Not listening because the client says something that triggers a
chain of private associations.
Identifying. Taking what the client says and referring it back to ones own
experience.
Advising. Not listening for a full expression of the issue prior to suggest-
ing what one should do.
Sparring. Looking for ways to disagree, discount, or put down what the
other person says.
Being right. Unable to listen to criticism.
Derailing. Changing the subject when bored or uncomfortable (e.g.,
joking).
Placating. Agreeing with everything to be pleasant and nice.
227). Challenges are invitations to clients to become aware of their maladaptive issues,
thoughts, feelings, and behaviors.
Our goal as helpers is not to break down or remove all of the defenses, but to give clients
the option of choosing when and how often to use defenses. Another reason for using chal-
lenges is to help clients gain insight (p. 230).
A major task for helpers is presenting challenges in such a way that clients can hear them
and feel supported rather than attacked. With challenges, helpers indicate that some aspect
of a clients life is incongruent or problematic and imply that a client should change to feel,
think, or act differently. Challenges should be done carefully, gently, respectfully, tentatively,
thoughtfully, and with empathy. Challenges are most effective in the context of a caring and
respectful therapeutic relationship.
Helpful hints to consider when using challenge in a relationship (Hill, 2004) are to:
look for specific markers that indicate readiness for receiving challenges. Clients who
are at precontemplation and contemplation stages of change may need a challenge to
jolt them out of their complacency.
use challenge as soon as possible after an example of the clients inconsistent behaviors.
maintain a manner of puzzlement rather than hostility. Do not make judgments. A
challenge should not be a criticism, but an encouragement for deeper examination.
if you think your challenge was accurate but your client denies or dismisses it, you may
need to back off until the client can handle the challenge or until you have more evi-
dence for your observations.
observe your clients reactions carefully. Listen attentively and observe the clients non-
verbal behavior. Keep the lines of communication open.
consider repeating challenges several times, in different ways, and applying them to dif-
ferent situations, so clients can hear the challenge and think about the issue in differ-
ent ways.
be warm and empathetic in challenging. Remember that you are offering your percep-
tion rather than providing the truth.
use nonabrasive words and state the challenge as a hunch rather than an accusation.
not make judgments or interpretations.
be curious and collaborative in working with clients.
not be aggressive or blaming. Do not play a game of gotcha or try to score points by
pointing out the clients inconsistencies. Be careful not to come across as trying to pin
blame on the client.
be alert to the clients culturally based reactions.
use specific examples as evidence. A specific example is easier to respond to than a
global characterization.
give an example of something that just happened rather than a distant example that the
client is not likely to remember.
make sure the challenge is not for your needs (e.g., to appear insightful, to retaliate, or
to elevate yourself in comparison with the client).
not apologize before delivering the challenge or minimize its value.
if the client is upset by the challenge or you feel you have blundered badly, apologize
and ask how the client is feeling. Avoid apologizing too much or too often.
leave enough time after a challenge to talk about it and to help the client learn from it.
It takes time to process the challenge.
follow challenges with reflections of feelings and open questions about feelings. When
clients have come to a new awareness about their thoughts, behaviors, or feelings, you
might go on to interpret or investigate the reason for them.
Communication
One aspect of a healing helping relationship that matters very much to clients is the
nurses ability and willingness to communicate effectively, both in terms of finding out what
is important from the clients point of view and in conveying information and explanations
back to the client. Knowledge and information can provide a feeling of control that helps to
reduce anxiety and may have a direct association with the achievement of better outcomes.
Control comes through being able to do something oneself in order to manage the illness
(Mitchell & Cormack, 1998, p. 55). However, the concept of empowerment becomes fun-
damentally flawed if positive outcomes are only identified as situations when the client makes
the choice the nurse wanted them to make (Benson & Latter, 1998, p. 106).
Mitchell & Cormack (1998, pp. 73-74) propose a number of concrete suggestions to
enhance good communication in nursing practice:
1. Good communication takes place in the context of a respectful and caring therapeutic
relationship. The tasks of the nurse are:
To negotiate an authentic relationship that may change over time and that is
suited to the needs of the particular client
To listen carefully to what the client wants to communicate (both with words and
with the body)
To offer support, encouragement, and realistic hope
To be sensitive to the clients emotional state and needs
2. Good communication requires the ability to take the other persons perspective into
account. The nurse should try to clarify the clients beliefs, thoughts, and feelings about
health and illness.
3. The nurse should also try to convey her perspective at a pace and level relevant to the
clients understanding and desire to know. It is best to do this using the clients lan-
guage, wherever possible, using words and metaphors that will be accessible.
4. Good communication includes trying to understand the persons experiences of the
consequences of illness. Serious attention should be given to the clients account of
their health history.
5. Clear, open, and respectful communication provides a framework for a shared under-
standing between client and nurse, which will change and develop over time.
The emphasis in this chapter has been on a healing helping relationship based on
Gadamers third kind of interpersonal understanding. It has been proposed that health is facil-
itated within a relationship that is characterized by such behaviors as presence, mindfulness,
respect, genuineness, active listening, empathy, and communication. A healing helping rela-
References 261
tionship can be a mechanism for enhanced sense of well-being, growth, and the facilitation
of health of both the nurse and the client.
Chapter Key Points

Many nurses use a prescriptive approach to health promotion.
The nurse healers role is to facilitate another persons growth and wholeness, while
being open to her own growth and change.
Healing occurs within the person, and external interventions mobilize the clients inner
healing resources.
Through presence, being there and being with, the nurse gives of him- or herself.
The client has the choice to accept or reject the gift.
Behaviors associated with a healing helping relationship include presence, mindfulness,
relating, respect, connected caring, genuineness, reciprocity, active listening, empathy,
and communication.
References
Baillie, L. (1996). A phenomenological study of the nature of empathy. J Adv Nurs, 24, 1300-1308.
Benson, A., & Latter, S. (1998). Implementing health promoting nursing: The integration of interpersonal
skills and health promotion. J Adv Nurs, 27, 100-107.
Buber, M. (1970). I and Thou (W. Kaufman, Trans.). New York: Charles Scribners Sons.
Clark, C. C. (1996). Wellness practitioner (2nd ed). New York: Springer.
Cohn, F. (2001). Existential medicine: Martin Buber and physician-patient relationships. Journal of Con-
tinuing Education in the Health Professions, 21, 170-181.
Cowling, W. R. (2000). Healing as appreciating wholeness. Advances in Nursing Science, 22, 16-32.
Dole, P. J. (1996). Centering: Reducing rape trauma syndrome anxiety during a gynecologic examination.
Journal of Psychosocial Nursing, 34, 32-37.
Doona, M. E., Chase, S. K., & Haggerty, L. A. (1999). Nursing presence: As real as a milky way bar. Jour-
nal of Holistic Nursing, 17, 54-70.
Doona, M. E., Haggerty, L. A., & Chase, S. K., (1997). Nursing presence: An existential exploration of the
concept. Scholarly Inquiry for Nursing Practice: An International Journal, 11, 3-16.
Dossey, B. M., Keegan, L., Guzzetta, C. E., & Kolkmeier, L. G. (1995). Holistic nursing: A handbook for prac-
tice (2nd ed.). Gaithersburg, MD: Aspen.
Easter, A. (2000). Construct analysis of four modes of being present. Journal of Holistic Nursing, 18,
362-377.
Fredriksson, L. (1999). Modes of relating in a caring conversation: A research synthesis on presence, touch,
and listening. Journal of Advanced Nursing, 30, 1167-1176.
Gadamer, H. G. (1960). Wahrheit and methods. Tubingen, Germany: J. C. B. Mohr.

Gilje, F. (1992). Being there: An analysis of the concept of presence. In D. A. Gaut (Ed.), The presence of
caring in nursing (pp. 53-67). New York: National League for Nursing.
Godkin, J. (2001). Healing presence. Journal of Holistic Nursing, 19, 5-21.
Hartrick, G. (1997). Relational capacity: The foundation for interpersonal nursing practice. Journal of
Advanced Nursing, 26, 523-528.
Heidegger, M. (1987). An introduction to metaphysics. New Haven, CT: Yale University Press.
Hill, C. E. (2004). Helping skills. Facilitating exploration, insight, and action (2nd ed.). Washington, DC: Usi-
cal Association.
Keegan, L. (1994). The nurse as healer. Albany, NY: Delmar.
Klagsbrun, J. (2001). Listening and focusing: Holistic health care tools for nurses. Nursing Clinics of North
America, 36, 115-129.
Kritek, P. B. (1997). Healing: A central nursing constructReflections on meaning. In P. B. Kritek (Ed.),
Reflections on healing. A central nursing construct (pp. 11-27). New York: National League for Nursing.
Lerner, M. (1994). Choices in healing. Cambridge, MA: Massachusetts Institute of Technology.
Lyons, M. (1988). Two perspectives on self, relationships, and morality. In C. Gilligan (Ed.), Mapping the
moral domain: A contribution of womens thinking to psychological theory and education (pp. 21-48).
Cambridge, MA: Harvard University Press.
Marck, P. (1990). Therapeutic reciprocity: A caring phenomenon. Advances in Nursing Science, 13, 49-59.
McKay, M., Davis, M., & Fanning, P. (1995). Messages: The communication book (2nd ed.). Oakland, CA:
New Harbinger.
McKivergin, M. (1997). The nurse as an instrument of healing. In B. M. Dossey (Ed.), Core curriculum for
holistic nursing (pp. 17-25). Gaithersburg, MD: Aspen.
McKivergin, M. (2000). The nurse as an instrument of healing. In B. M. Dossey, L. Keegan, & C. E.
Guzzetta (Eds.), Holistic nursing: A handbook for practice (3rd ed.). Gaithersburg, MD: Aspen.
Mendias, E. P. (1997). Reciprocity in the healing relationship between nurse and patient. In P. B. Kritek
(Ed.), Reflections on healing: A central nursing construct (pp. 435-451). New York: National League
for Nursing.
Minicucci, D. S. (1998). A review and synthesis of the literature: The use of presence in the nursing care
of families. Journal of the New York State Nurses Association, 29, 9-15.
Mitchell, A., & Cormack, M. (1998). The therapeutic relationship in complementary health care. Edinburgh,
UK: Churchill Livingstone.
Moch, S., & Schaefer, C. (1998). Presence. In M. Snyder, & R. Lindquist (Eds.), Complementary/alternative
Morse, J. M., Anderson, G., Bottoroff, J. L., Yonge, O., OBrien, B., Solberg, S. M., et al. (1992). Explor-
ing empathy: A conceptual fit for nursing practice? Image: Journal of Nursing Scholarship, 24,
273-280.
Morse, J. M., Havens, G. A. D., & Wilson, S. (1997). The comforting interaction: Developing a model of
nurse-patient relationship. Scholarly Inquiry for Nursing Practice: An International Journal, 11,
321-343.
References 263
Newman, M. A. (1999). The rhythm of relating in a paradigm of wholeness. Image: Journal of Nursing
Scholarship, 31, 227-230.
Osterman, P., & Schwartz-Barcott, D. (1996). Presence: Four ways of being there. Nursing Forum, 31, 23-30.
Parse, R. R. (1990). Health: A personal commitment. Nursing Science Quarterly, 3, 136-140.
Patterson, J., & Zderad, L. (1976). Humanistic nursing. New York: Wiley.
Romick P. (1997). Psychosynthesis: A perspective for growth and healing of self. In P. B. Kritek (Ed.),
Reflections on healing: A central nursing construct (pp. 435-451). New York: National League for
Nursing.
Ryden, M. B. (1998). Active listening. In Snyder, M., & Lindquist, R. (Eds.), Complementary/alternative
Sherwood, G. (1997). Patterns of caring: The healing connection of interpersonal harmony. International
Journal for Human Caring, 1, 30-38.
Skeats, W. W. (1969). A concise etymological dictionary of the English language. New York: Capricorn.
Smith, S. (1992). Communications in nursing (2nd ed.). St. Louis: Mosby.
Soukhanov, A. H. (Ed.). (1992). The American heritage dictionary of the English language (3rd ed.). Boston:
Houghton Mifflin.
Swanson, K. M. (1991). Empirical development of a middle range theory of caring. Nurs Res, 40, 161-166.
Watson, J. (1985). Nursing: Human science and human care. A theory of nursing. Norwalk, CT: Appleton-
Century-Crofts.
Watson, J. (1997). The theory of human caring: Retrospective and prospective. Nursing Science Quarterly,
10, 49-52.
Wells-Federman, C. L. (1996). Awakening the nurse healer within. Holistic Nursing Practice, 10, 13-29.
Widdershoven, G. A. M. (1999). Care, cure and interpersonal understanding. Journal of Advanced Nursing,
29, 1163-1169.
Wiseman, T. (1996). A concept analysis of empathy. Journal of Advanced Nursing, 23, 1162-1167.
11
EMPOWERING COMMUNITY HEALTH
Abstract
Traditionally, health promotion activities have been directed at individual behavior
change, and many interventions with the individual as the client may be community-based.
In this chapter, however, the community is the client, and the emphasis is on community-
level intervention to modify the social or power structure or allocation of resources of the
community. It is proposed that the central processes for nursing facilitation of community-
level change are empowerment, a process of increasing personal, interpersonal, or political
power; interdisciplinary collaboration; and capacity building, the nurturing and building on
strengths and resources already present in the community. Finally, principles for community
organization and community-level health promotion are discussed.
Learning Outcomes
Differentiate between community as place, social interaction, and political and social
responsibility
Differentiate between community-based and community-level nursing interventions
Describe elements of community
Describe characteristics of functionalist, conflict, and community-level social change
theories
266 Chapter 11 Empowering Community Health
Discuss processes to empower individuals and communities

Differentiate between coordination, cooperation, and collaboration
Discuss individual, small group, and community levels of capacity building
Discuss strategies for community organizing to promote health
What Is Community?
Community has been defined as a system of people with common values and institutions
who identify with the system and share a locality, social structure, and personal relationships
(Hancock et al., 1997, p. 230). There are various approaches to community, including com-
munity as place, social interaction, and political/social responsibility (Patrick & Wickizer,
1995), as well as a holograph (Davis, 2000), each of which will be explored separately in the
following sections.
COMMUNITY AS PLACE
Laffrey and Kulboks (1999, p. 94) definition of community as a designated area in which
persons live, work, study, and play, is typical of community as place definitions. However, the
field of human ecology, which draws analogies between plant ecology and the urban commu-
nity, has expanded the geographic definition of community. The essential characteristics of
community as defined by human ecology are a population, territorially organized and more
or less rooted in the soil it occupies, whose individual units live in a relationship of mutual
interdependence (Patrick & Wickizer, 1995, p. 49). From this perspective, both the localized
population and the ecological boundaries of the community are influenced by the global
economy, transportation, and mass communication (1995). Consequently, when defined pri-
marily as place, community may be considered as local places with distal influences (1995,
p. 68) such as the social and physical environment.
COMMUNITY AS SOCIAL INTERACTION

When community is viewed as social interaction, the emphasis is on a group of people
sharing values and institutions. For example, Hancock and colleagues (1997, pp. 229-230)
describe community as a grouping of people who share a common purpose, interest or need,
and who can express their relationship through communication face-to-face, as well as by
other means, without difficulty. Israel, Checkoway, Schultz, and Zimmerman (1994, p. 151)
more explicitly define community as a locale or domain (community as place) that is char-
acterized by the following elements:
Membership, in the sense of identity and belonging
Common symbol systems, such as similar language, rituals, and ceremonies
Shared values, beliefs, and norms
Mutual influence, in which community members have influence and are influenced by
each another
What Is Community? 267
Shared needs and a commitment to meeting them

Shared emotional connection, in which members share common history, experiences,
and mutual support
The community as social interaction perspective focuses on societal structures that can be
considered community resources. Societal structures are functionally interdependent, rela-
tively stable, enduring systems whose members share some consensus about societal goals,
norms, and values (Thompson & Kinne, 1990). Patrick and Wickizer (1995) observe that
household and family structure and the church are important sources of economic and social
support. Households can be a source of resources and supports for dealing with social stress.
Health is seen as a resource of everyday life, not the objective of living (Shields & Lindsey,
1998, p. 24)
COMMUNITY AS POLITICAL AND SOCIAL RESPONSIBILITY

The emphasis of health promotion in the community is changing lifestyle by changing
socioeconomic-political structures in the local environment (Guldan, 1996). According to
Patrick and Wickizer (1995), community involves a dynamic interaction in social relation-
ships that creates a sense of solidarity, mutual obligation, and responsibility for social sur-
vival. However, Milio (1996, p. 38) suggests that community in spirit and in a place are two
sides of a coin, in which frequent and sustained contact between people creates a mutual
identity and a sense of social responsibility for creating healthy surroundings. As a result of
the surge in electronic communications in the last quarter of the twentieth century, imag-
ined communities have resulted in social and physical distancing of people, creating a nar-
rower sense of place and social and local responsibility (Milio, 1996, p. 38). There is
concern that electronic communications may well reduce many elements of community,
regardless of the definition.
HOLOGRAPHIC COMMUNITY
Davis (2000) moves beyond sociological or psychological definitions by describing com-
munity in terms of wholeness based on connection experienced through relationships.
Community is defined as a conscious connectedness based on shared values and moral
integrity, where diversity within unity can be expressed, caring relationships experienced,
learning environments that foster empowerment and development are evident, and indi-
vidual and collective efforts are reflected and celebrated in mutual synergy toward greater
levels of health for all (2000, p. 296). Dimensions of this conception, each integral to the
whole, are:
The consciousness of community (awareness). An open connectedness to a greater world.
The heart of community (values). Humanistic values based on human caring.
The soul of community (service). Responsibility of serving others both personally and
professionally.
The voice of community (power). Operationalized as capacity, energy, and competence.
Principle-centered persons are change catalysts who influence without dominance and
facilitate an empowerment process that creates synergistic solutions that are far better
than individual efforts (Davis, 2000, p. 297).
The body of community (space, structure, relationships). The physical, social, economic,
political, and relational structures of the environment.
The mind of community (learning, development). Viewed as a transformative process to
learn to solve problems and open the way for persons to empower themselves.
The spirit of community (celebration, ritual). Common patterns that build bonds of inti-
macy and trust.
The vision of community (health). Environments and expanding resources enable people
to provide mutual support in functioning and developing to maximum potential.
The emphasis in this view of holographic community is on the centrality of moral leader-
ship by nurses to promote public policy, build healthy communities, and strengthen com-
munity action (Davis, 2000, p. 299). The model is promoted as a way to recognize
interconnectedness and interdependence in partnerships for community care, provide a
vision for theory development, and guide decision making, health policy, and leadership skills
such as mentoring, role modeling, advocacy, communication, priority setting, and creating
values frameworks.
Elements of Community
Elements of community reflect all of the conceptions of community discussed in the previous
section. Patrick and Wickizer (1995) have described several elements that are characteristic of
community, including commitment, continuity, cohesion, and sense of community. Social inter-
action is important. Although some support such as informational, emotional, and instrumen-
tal support can be provided from a distance, vulnerable people require committed, direct, and
continuous contact and continuity of leadership. Community cohesion, identity, and stability
are affected by factors such as social mobility, intermarriage, changes in gender roles, the mixing
of cultural traditions, and geographic mobility that contribute to a sense of loss of community.
The sense of community includes a feeling of belonging and personal relatedness, the feeling
that the person makes a difference to a group and that the group matters to them, the expecta-
tion that ones needs will be met through membership in the group, and a shared emotional con-
nection and history. Additional elements of community that have been proposed include
connectedness in social relationships (Patrick & Wickizer, 1995); participation in problem def-
inition, planning, and resolution; maintenance of desired change (Thompson & Kinne, 1990);
and a sense of responsibility or ownership over programs promoting change (Bracht, 1990).
What Is Social Change?

Change theories provides bases for understanding community health promotion. There are
three major types of social change theoriesfunctionalist theories, conflict theories, and
community-level change theories. Characteristics of these major types of social change theo-
ries are summarized in Box 11-1.
What Is Social Change? 269
B OX 11-1
Characteristics of Major Social
Change Theories
Functionalist theories:
Emphasize patterns and processes that maintain a system.
See social change as a gradual, adaptive process oriented toward system
reform.
Systems are based on cooperation and consensus, especially in the areas
of societal goals, norms, and values.
Norms are links that help hold the system together. When the system breaks
down, external or environmental changes overwhelm the system, leading
to new social norms and rules of conduct (Thompson & Kinne, 1990).
Emphasize extrasystemic factors as impetus for change.
Conflict theories:
See imbalance as a constant part of any system, resulting in ongoing
adjustments.
Social change occurs when one of several interests in a system gains
ascendancy.
Social norms help to maintain a system but in a coercive, rather than con-
sensual sense, as those who control economic and political parts of a sys-
tem establish norms and resist change.
Emphasize internal explanations as impetus for change.
Community-level change theories:

Deal with community organization and organizational relationships.
Encourage local participation and ownership.
Emphasize rational planning and problem solving.
Encourage social action through mobilization and activation of disadvan-
taged groups who then demand redistribution of resources.
Thompson and Kinne (1990) have developed an integrated framework for social change.
Consistent with a functionalist view, the system is initially stable, with most individuals and
subsystems in agreement on societal goals, norms, and values. However, within the system are
vested interests that act to preserve the status quo, and social movements that arise to con-
flict with vested interests. Change within the community may be planned either internally or
externally. As the system interacts with the environment, external stimuli, in the form of
laws, policies, and critical events, may influence norms and values within the system. Exter-
nal forces often use social planning or locality development theories to bring about change.
Additional theories can be used to support the major social change theories. For example,
social network and interorganizational theories explain how connections are initiated and
sustained at the subsystem level. Political and economic subsystems are frequently able to
move a change in norms from the organizational level to the community level, after which
the change is spread to other groups in the community through processes explained by diffu-
sion, community development, and organizational development theories. Organizations that
take on leadership roles become important as change agents. Individuals are subjected to
changing norms and practices, with role models reinforcing new norms of behavior change.
Social learning theory explains how individual change may occur in response to such role
models. Eventually, due to organizational change and change in the interrelationships within
subsystems, new norms and widespread individual change can occur.
Community-Level Interventions
Community health promotion is considered a collective rather than an individual
approach to health, with the community involved in implementation and control of the
process of the program (Hancock et al., 1997). Community ownership and program mainte-
nance require early and sustained participation by community members and leaders (Bracht,
1990), although community action does not relieve government of its responsibility to pro-
vide basic services for health to its citizens (Kaseje, 1995, p. 211).
Community interventions may be community-based or targeted at the community-level.
Community-based interventions are individual-directed attempts to modify or reallocate com-
munity social or power structures, whereas community-level interventions are organized to mod-
ify the entire community through community organization and activation (Patrick & Wickizer,
1995). Although most community nursing interventions in the past have been community-
based, there is an urgent need for nurses to become involved in community-level interventions.
Community-level interventions involve active participation of the community at all stages
of the intervention process (called community development in Australia, Canada, and the
United Kingdom and community organizing in the Unite States) (Hancock et al., 1997).
These are based on rejection both of professional dominance in decision making and empha-
sis on individual responsibility for health rather than on social, cultural, economic, and envi-
ronmental determinants of health. This approach values the inclusion or involvement of
historically marginalized individuals and groups, participation in and ownership of interven-
tion programs by the community, and adaptation of strategies to local needs and resources
(Judd et al., 2001).
The community-level approach to health promotion often includes multiple strategies,
including creating healthy public policy and supportive environments, fostering individual
or group skills and capacities, strengthening community action and reorienting health serv-
ices (Judd et al., 2001, p. 370). It is assumed that permanent, large-scale behavior change is
best achieved by developing positive role models for healthful behavior, while changing com-
munity expectations about health-related behavior. The community-level approach targets
Community-Level Interventions 271
broad segments of the community or whole populations, emphasizing the role of social and
environmental factors as key determinants of health.
EMPOWERMENT
Both conceptually and in practice, empowerment is the connecting link between health
and community participation (Robertson & Minkler, 1994). In contrast to reactive
approaches that are associated with a treatment or illness model, the concept of empower-
ment is positive and proactive (Israel et al., 1994). Community empowerment has been
defined as a social-action process in which individuals and groups act to gain mastery over
their lives in the context of changing their social and political environment (Wallerstein &
Bernstein, 1994, p. 142), increasing their capacity to set priorities, control resources, and
expand self-determination (Himmelman, 2001).
Personal, interpersonal, or political power is increased by empowerment (Robertson &
Minkler, 1994). Given that power, the capacity to produce intended results (Himmelman,
2001, p. 278), makes it possible for individuals and communities to anticipate, influence, and
participate with the environment, empowerment enables individuals and communities to
take power and effectively transform their lives and their environment (Robertson & Min-
kler, 1994).
Dictionary definitions (Soukhanov, 1992) of empower include investing or giving power
or authority to others, as well as enabling others, or giving others abilities in order that they
may obtain power through their own efforts. However, if empowering means to give power to
others, the empowering agent, such as the health professional, continues to control the terms
of the interaction. As professionals often have more education, more access to sources of
information, and use a different language to discuss health issues than either individual or
community clients, institutional embeddedness confers a certain power on them (Robert-
son & Minkler, 1994, p. 301). Consequently, clients remain relatively disempowered and con-
tinue to be the objects of professional actions (Labonte, 1994).
The lack of control over destiny that occurs with powerlessness promotes a susceptibility
to disease for people who live in high demand or chronically marginalized situations and who
lack adequate resources, supports, or abilities (Wallerstein, 1992). Relationships between gov-
ernmental institutions and community groups can contribute to disempowerment. A more
empowering relationship between professionals and clients and between institutions and
community groups is needed for healthy social change (Labonte, 1994).
When power is taken rather than given, clients are able to set and achieve their own agendas
(Robertson & Minkler, 1994). Power over clients in traditional hierarchical provider/client rela-
tionships tolerates others views and tries to educate others to ones own terms, whereas power
with clients respects others views, trying to find common ground in a partnership between pro-
fessionals and individuals or communities. (Labonte, 1994; Robertson & Minkler, 1994). How-
ever, Labonte (1994) suggests that one must have power in order to share it. Many nurses perceive
a lack of professional autonomy, especially in acute care situations. Disabling power-over ten-
dencies within professional practice may simply reflect a projection of professional disempower-
ment (p. 256). Figure 11-1 depicts the relationships in powerlessness and in empowerment.
Shields and Lindsey (1998) suggest that listening and critical reflection are important
strategies that nurses can use to enhance empowerment of the community. Respect, trust, and
POWERLESSNESS
Physical and Social Risk Factors
Living in poverty
Low in hierarchy
High demand
Psychological Powerlessness
Physical
Low control
Perceived: External locus Disease
Learned helplessness
Actual: No decision-making
Lack economic/political
Lack of control
power
over destiny
Chronic stress
Lack of social support
Lack of resources
EMPOWERMENT
Reduce social Psychological Empowerment

risk factors Self-efficacy to act
Political efficacy
Motivation to act
Belief in group action
Sense of community
Increased participation in:
Decision-making Critical thinking/Conscientization
Community actions
Increased empathy
Community Empowerment
Increased local action
Stronger social networks
Community competence
Reduce physical Transformed conditions
risk factors Improved health policies
Resource access/equity
Figure 11-1. Relationships in powerlessness and empowerment (reprinted from Wallerstein, N.

(1992). Powerlessness, empowerment, and health: Implications for health promotion programs,
with permission of American Journal of Health Promotion, 6, 201).
a fundamental regard for people can be conveyed by listening, while critical reflection
involves a conscious process of thinking about what is being heard. The notion of voice, of
having voice, and of giving voice to are central to community empowerment (p. 30). Four
components of listening and critical reflection have been proposed, including active engage-
ment through participatory dialogue and critical questioning; identification of an emerging
pattern in the dialogue; recognition of the capacity of the participants, with the nurse as a
facilitator rather than the expert; and movement from dialogue to action.
Falk-Rafael (2001, p. 1) proposes that empowerment be considered as a process of evolving
consciousness, in which increasing awareness, knowledge, and skills interact with the clients
active participation to move toward actualizing potential. In this view, empowerment is an
active, internal process of growth toward actualizing of ones potential. It occurs within the con-
text of a nurturing and trusting nurse-client relationship, in which the nurse facilitates, rather
than creates, empowerment in the community client. The process of becoming empowered
evolves within the community, but nurses are also empowered in a reciprocal effect. Strategies
to foster empowerment include collaborating with other health care professionals and using
positional power, building capacity to help community members to identify the communities
health goals and resources, and using political processes to advocate for the community.
Collaboration
Collaboration is defined as exchanging information, altering activities, sharing resources,
and a willingness to enhance the capacity of another for mutual benefit and a common pur-
pose; it requires the highest levels of trust, considerable amounts of time, and an extensive
sharing of turf (Himmelman, 2001, p. 278). The distinguishing feature of collaborative part-
nerships for community health is broad community engagement in creating and sustaining
conditions that promote and maintain behaviors associated with widespread health and well-
being (Roussos & Fawcett, 2000, pp. 369-370).
Collaboration incorporates but goes beyond cooperation and coordination. Cooperation is
defined as exchanging information, altering activities, and sharing resources for mutual ben-
efit and a common purpose. It requires significant amounts of time, high levels of trust, and a
significant sharing of turf (Himmelman, 2001, p. 277-278). In contrast, coordination is
defined as exchanging information for mutual benefit and altering activities for a common
purpose (Himmelman, 2001, p. 277). It requires time and trust but does not necessitate shar-
ing professional territory. The most direct form of coordination is mutual adjustment, in
which two or more people simply adapt to each other, usually by informal communication, as
their work progresses. A second mechanism is direct supervision, in which a hierarchy of
authority is created by focusing responsibility for coordinating the work on someone who does
not actually do the work, such as a supervisor or manager (Glouberman & Mintzberg, 2001).
Additionally, coordination can also be achieved through standardization of work procedures,
results or consequences, education or training, or socialization to establish common values,
beliefs, and expectations. Glouberman and Mintzberg (2001) suggest that coordination of
professional work through bridge building and mutual adjustment is preferable to the almost
automatic standardization of skills and knowledge that is emphasized in the current health
care system. What is needed is a culture that values attitudes of understanding, commitment,
mutual respect, a sense of belonging, purpose and trust, encourages identification with col-
lective need, and facilitates flexible communication among peers.
Laffrey and Kulbok (1999) emphasize the need for nurses to work in partnership with other
team members to achieve comprehensive and holistic community care. Helman (1994)
describes four different types of community health workers (CHWs) who are found primarily
in indigenous cultures:
1. Workers from the community. They advise the community on preventive strategies; give
advice on child care, healthy nutrition, immunizations, and hygiene; as well as provid-
ing some limited curative and first-aid services. They include barefoot doctors in
China, family welfare educators in Botswana, the village health development workers
in Indonesia, the village health volunteers in Thailand, and the community health
agents in Egypt. They usually have a short course of training (a few weeks to a few
months) and a small amount of equipment such as basic drugs, dressings, disinfectants,
thermometer, and scales and charts. However, the combination of inadequate diag-
nostic and treatment skills, infrequent supervision, and shortage of drugs undermine the
acceptance of CHWs by their communities (p. 370).
2. Community health groups. Are often organized to share information about health issues
such as family planning or breast feeding and give help to their members. Many are
womens groups.
3. Traditional healers. Examples include folk healers, a shaman, or bone-setter. They are
usually trained in an apprenticeship, and often claim to have some contact with the
spirit world that is believed to aid in healing.
4. Community leaders. People of influence due to family position or job title and responsi-
bility in the community. For example, a tribal head would be able to exert the author-
ity of position and the influence of lineage.
In the United States, the emphasis of collaboration is on professional providers. The pur-
pose of interprofessional collaboration is to bring a broader scope of expertise to the efforts to
improve the quality of care outcomes (Schmitt, 2001, p. 53). It is assumed that a collabora-
tive effort is needed for cost efficiencies, quality improvement, and comprehensive continu-
ity of care. However, in a comprehensive review of research relating collaboration to
improved quality of care, Schmitt (2001) described a number of conceptual and method-
ological challenges. Collaboration is a multidimensional construct that is not simply present
or absent but is present to varying degrees. However, in many studies it is not clear whether
the interest is in collaboration as a global concept or in specific components such as colle-
giality, interaction, coordination or communication. The measurement of outcomes has also
been hindered by lack of conceptual clarity, and by the limited number of psychometrically
evaluated instruments. Few studies have assessed longitudinal intervention effects. Schmitt
(2001, p. 63) concludes, if there is an important place for interprofessional collaboration in
health care delivery then it is a high priority task to get on with the research, difficult as that
is, that demonstrates what mix of collaborators, for what purposes, for whom, with what out-
comes, and at what cost matters.
A number of benefits of interprofessional collaboration have been identified, including
increased networking, information sharing, and resource access; attaining desired outcomes;
enjoying working in the partnership; receiving personal recognition; and enhancement of
skills. Costs include the time devoted; possible lack of direction, appreciation, recognition, or
skills; being pressured for additional commitment; and loss of autonomy. A complete focus on
interdisciplinary collaboration can result in loss of the identity of nursing (Disch, 2001). The
degree of reciprosity and mutuality in the relationship between autonomous disciplines is crit-
ical (el Ansari & Phillips, 2001).
Long (2001) stresses incremental approaches to achieving interdisciplinary collabora-
tion, defining interdisciplinary as activities that involve just two disciplines. Suggestions
include focusing on small steps and moderate successes, taking advantage of committed
leadership, and acknowledging the give and take, trust, and goodwill that are needed across
professional boundaries. However, she acknowledges that professional orientation (identity
and stature of ones own profession) and workplace structure (accreditation, licensure,
national rankings, and practice reimbursement) tend to work against the success of inter-
disciplinary activities and toward the achievements, activities, or accomplishments of single
disciplines.
Capacity Building
Capacity building as a process is conceived of as the nurturing of and building upon the
strengths, resources, and problem-solving abilities already present in individuals and commu-
nities (Robertson & Minkler, 1994, p. 303) in order to enhance the capacity of a system to
prolong and multiply health effects (Judd et al., 2001, p. 368). As an outcome, community
capacity is the characteristics of communities that affect their ability to identify, mobilize,
and address social and public health problems (Goodman, 1998, p. 259). In Freudenberg,
Israel and colleagues (1994) suggest that the health professional identify and work within
contexts that already show some sense of community. If community does not exist, then the
initial task is to try to strengthen communality or recognize that the individual, family, or
social network may be more appropriate as the unit of practice. Capacity building can occur
at the individual, small group, or community level, affecting member, relational, organiza-
tional, and/or programmatic capacity.
Individual Level of Capacity Building
Individual or psychological empowerment refers to an individuals ability to make deci-
sions and have control over his or her personal life. Psychological empowerment at the indi-
vidual level combines personal efficacy and competence, a sense of mastery and control, and
a process of participation to influence institutions and decisions. Additionally, empowerment
incorporates an analytical understanding of the social and political context, and the cultiva-
tion of both individual and collective resources and skills for social action (Israel et al., 1994),
contributing to the empowerment of the community.
According to Booker and colleagues (1997) and Foster-Fishman and colleagues (2001),
characteristics of individual collaborative capacity and empowerment include:
Valuing health enhancing outcomes
Holding positive attitudes about the need for and value of collaboration
Making decisions by consensus
Sharing of information and power
Demonstrating mutual respect and support

Participating in supportive and noncontrolling relationships
Having skills to cooperate with and respect others, resolve conflict, communicate, and
understand member diversity
Possessing perceived self-efficacy (a positive social identity)
Having future life goals and perspective
Feeling a sense of coherence in life
Identifying with others and seeing problems in common
Feeling capable of helping others
Understanding member roles and responsibilities to build an effective coalition
infrastructure
An internal feeling of increased efficacy and competence can provide a basis for willing-
ness to take public action. Acceptance of individual responsibility for health is an important
first step toward personal empowerment (Neighbors et al., 1995). Neighbors and colleagues
(1995), in discussing self-help specifically among African Americans, stress that individual
enterprise, mutual aid, and community action exist as fundamental strengths and critical sur-
vival strategies in the black community. However, even well-intentioned paternalistic efforts
inadvertently reinforce dependency, an external locus of control, and a feeling of collective
despair and frustration that are major risk factors in poverty, substance abuse, violence, and
other public health problems. (p. 285).
Small Group Level of Capacity Building

Capacity building can be enhanced with the support of a group. In interacting with oth-
ers, people gain control, capacity, coherence, connectedness, and critical thinking. Both nur-
turing groups and groups that challenge the status quo are needed (Labonte, 1994). In
addition, in group building with ethnic minorities, the health professional must be aware of
the need for cultural competence, knowledge about a particular ethnic group, and cultural
sensitivity (Neighbors et al., 1995).
The creation of positive internal relationships is crucial to the success of community coali-
tions. The working climate needs to be cohesive, trusting, and capable of resolving conflict.
It is helpful if members can identify and unite around a shared vision. And, an inclusive cul-
ture needs to be created where group members share decision-making power. All members
need to be provided with up-to-date information to keep everyone informed and prevent
problems from escalating. Additionally, groups need to develop external relationships with
community organizations to increase visibility, access to resources, and the likelihood of adop-
tion of proposed policies. To increase the chances that group efforts will lead to long- term
system change, relationships also need to be developed with key community leaders and pol-
icy makers. Goups need to interact with other community groups who are addressing similar
issues, to identify new innovations and best practice solutions (Foster-Fishman et al., 2001).
For progress to continue over time, the group must be able to maintain its focus on manage-
able projects and be able to reposition assets, competencies, and resources, colloquially
known as patching, when needs and priorities change. When individuals are personally
empowered, they will come together to form effective community organizations (Neighbors
et al., 1995). This is the macro level of capacity building.
Community (Macro) Level of Capacity Building
Among many influences, community empowerment in public health has been affected by
community and social psychology; the mandate for community participation in the World
Health Organization and Ottawa Health Promotion Charters; the liberating and popular edu-
cational philosophy of Brazilian educator Paulo Freire; and the critical theory, feminist, and
post-modernist schools (Wallerstein & Bernstein, 1994).
Best and colleagues (2003) have proposed an integrative framework to facilitate the trans-
lation of theory into effective community-level health promotion strategy. The components
of the framework are the social ecology model, the PRECEDE-PROCEED model, and the
Life Course Health Development model, integrated by tenets of systems theory. The empow-
erment orientation weighs process heavily, the behavior orientation weighs outcome, and the
organization orientation weighs structure.
Social ecology models suggest that efforts to promote well-being should be based on an under-
standing of the relationships among diverse environmental and personal factors rather than on
analyses that focus exclusively on environmental, biological, or behavioral factors. In turn,
health promotion planning models give increased attention to policy and organizational changes
needed to support people in their efforts to gain greater control over their health. Additionally,
developmental models emphasize multiple determinants operating in a nested genetic, biologi-
cal, behavioral, social, and economic context (Best et al., 2003). A systems thinking perspective
suggests that more comprehensive, participatory, and collaborative approaches to health promo-
tion are potentially more effective than narrowly targeted and less collaborative approaches.
Community organization describes the process of organizing people around problems or
issues that are larger than group members own immediate concerns (Labonte, 1994). Robert-
son & Minkler (1994) suggest helpful strategies to increase community problem-solving abil-
ities, or community competence including:
Assisting individuals and communities to articulate both health problems and their
solutions
Providing access to information
Supporting indigenous community leadership
Assisting the community in overcoming bureaucratic obstacles to action
However, community ownership is often prevented when service providers drive the coali-
tion. The grassroots community must be involved in defining the issues, solutions, and strate-
gies, and must know that it will be given tools and resources to control the implementation
of programs and strategies (Kaye, 2001).
The relevant dimensions of community capacity can be distinguished, made operational,
measured, and then used to compare communities or to design and evaluate interventions to
improve capacity. Some relevant dimensions of community capacity include leadership,
participation, skills, resources, social and organizational networks, sense of community, under-
standing of community history, community power, values, and critical reflection (Freudenberg,
2004).
Organizational capacity requires leaders with strong skills, relationships, and vision.
Effective leaders create an internal work environment that is simultaneously empowering,
efficient, and task oriented, fostering member satisfaction and commitment and coalition
effectiveness (Foster-Fishman et al., 2001, pp. 253-254). Other leadership tasks include set-
ting clear guidelines through formalized processes and procedures, promoting the focus nec-
essary to achieve targeted goals, developing an internal communication system to promote
information sharing and problem discussion and resolution, providing for human and finan-
cial resources, and a continuous learning orientation, consistently seeking and responding to
feedback and evaluation data, adapting to shifting contextual conditions, dialoguing about
problems, and seeking external information and expertise (Foster-Fishman et al., 2001,
p. 255).
Kaye (2001) notes that a community organizer acts as a strategy coach, meeting facilita-
tor, and an identifier and developer of community leadership. Specific suggestions for the
nurse who functions as a community organizer to reach out to the community include:
Setting up town meetings to reach out to the organized community, or meetings in
someones home, apartment, or the local coffee shop where people are usually invited
by word of mouth (Kaye, 2001).
Going door-to-door with face-to-face contact breaking down barriers and suspicions
(Kaye, 2001).
Doing street outreach such as handing out flyers at the factory gate, going out to the
basketball court, or hanging out on a certain street corner with someone credible to the
community (Kaye, 2001).
Setting up a table in front of a busy supermarket, train station, or anywhere else that
people pass by (Kaye, 2001).
Attending local community meetings (Kaye, 2001).
Holding meetings in the evening (after people get out of work), and providing child-
care (Kaye, 2001).
Having materials and meeting agendas translated into languages other than English if
necessary, and providing translators at meetings (Kaye, 2001).
Having regular orientation meetings each month for new members (Kaye, 2001).
Building social time and interaction with people in power into meeting agendas
(Kaye, 2001).
Beginning and ending meetings with an expression of faith or spirituality as a way to
make people feel welcome and connected (Kaye, 2001).
The nurse is a facilitator who, like a midwife, helps people give birth to their own ideas
and initiatives and provides leadership when crisis opens up opportunity for change
(Kaseje, 1995, p. 213).
Working wonders through quick and easy interventions creates dependency. Time is
needed for the processes of dialogue and truly empowered participation (Kaseje, 1995,
p. 212).
Much work in community empowerment is based on the writings of the health educator
Paulo Freire (1973) and his concept of conscientization. Empowerment education, as devel-
oped from Freires writings by Wallerstein and Bernstein (1988), brings people together in
groups to identify the social and historical roots of health problems and to develop strategies
to overcome obstacles in achieving goals.
Freires Concept of Conscientization

Conscientization involves the development of a sense of identification with a group,
of shared fate with that group, and of self and collective efficacy (Israel et al., 1994, p.
153). Freire proposes a dialogue approach in which everyone participates as equals and
co-learners to create social knowledge and foster critical thinking. While health educa-
tion assumes that individuals can make health decisions with enough information, skills,
and reinforcement, Freire emphasizes collective knowledge from shared experience rather
than knowledge from experts giving information. Accordingly, the nurse enters into a dia-
logue with the community group, contributing information once themes have been pro-
posed for mutual reflection. The emphasis is on listening to each other, developing
effective strategies for action, and subsequent reflection to facilitate learning (Wallerstein
& Bernstein, 1988).
As a social action process, a community empowerment model conceives of power as an
expanding commodity, (Israel et al., 1994, p. 154) and emphasizes participation, caring, con-
nectedness and responsibility to others, sharing, critical thinking, and personal and social
capacity building (Wallerstein & Bernstein, 1994). In order to promote empowering educa-
tion, Wallerstein and Bernstein (1988, pp. 382-383) propose a three-stage, problem posing
methodology:
1. Listening to understand the felt issues or themes of the community. Listening is con-
ducted in equal partnership with community members to identify problems and deter-
mine priorities. It is a continual process.
2. Participatory dialogue about the investigated issues using a problem-posing methodol-
ogy. The dialogue is structured in order to reflect the community reality back to discus-
sion participants.
3. Action, or the positive changes that people envision during their dialogue. The envi-
sioned action changes can lead to a deeper cycle of reflection.
Community Empowerment
Community empowerment seeks to enhance a communitys ability to identify, mobilize,
and address the issues that it faces to improve the overall health of the community. Central
to the concept of community empowerment is community capacity, defined as the cultiva-
tion and use of transferable knowledge, skills, systems, and resources that affect community-
and individual-level changes consistent with public health-related goals and objectives (Yoo
et al., 2004, p. 256).
In a study of 668 participants from five community partnerships in South Africa, it was
found that: (a) involvement, commitment, and sense of ownership were associated with high
benefits and low costs; (b) benefits, commitment, and ownership might be more sensitive
monitors of involvement than costs and satisfaction; and (c) an increase in involvement was
initially associated with decreased costs and increased satisfaction up to a point beyond which
costs increased and satisfaction decreased despite increasing benefits. It was established that
for favorable cost-benefit ratios, benefits needed to be at least 60% more than costs (Ansari
& Phillips, 2004).
Social Capital
Social capital is a concept that originated within the discipline of sociology, with the idea
of capital drawn from economics. Bourdieu (1986, p. 248) initially defined social capital as
the aggregate of the actual or potential resources which are linked to possession of a durable
network of more or less institutionalized relationships of mutual acquaintance or recogni-
tionor in other words to membership of a group. In simpler terms, Portes (1998, p. 6)
defined social capital as the ability of actors to secure benefits by virtue of membership in
social networks. The central idea of social capital is that membership in a social group con-
fers obligations and benefits on individuals. Whereas economic capital is durable and tangi-
ble, and builds up a stock of value that can be converted into money, the stock of social
capital is in network relationships with no individual ownership (Hawe & Shiell, 2000).
Social capital can be the source of benefits such as social control, family support, and ben-
efits through extrafamilial networks (Portes, 1998). However, there also are potential nega-
tive consequences. Strong ties enable members of a group to bar others from access, for
potential economic advantage. For example, Korean immigrants have a growing control of
the produce business in several East coast cities, Jewish merchants have a traditional monop-
oly over the New York diamond trade, and Cubans dominate numerous sectors of the Miami
economy (Portes, 1998). In addition, the social network can demand conformity and con-
strain individual freedom. In order to create a unified entity, differences and divisions can be
suppressed, at times to the point of homogenization of the community members (Drevdahl,
2002, p. 10). In situations where there has been a common experience of adversity and oppo-
sition to mainstream society, there can be downward leveling norms, hindering individual
advancement unless the person leaves the group (Portes, 1998, p. 17).
Hawe and Shiell (2000) express concern that the social capital literature emphasizes rela-
tional rather than political and material aspects, potentially diluting social health initiatives
already underway under the labels of empowerment, capacity building, and community health
promotion. Social capital also has been criticized for not advancing social justice (Drevdahl
et al., 2001). Drevdahl and colleagues (2001, p. 23) indicate that access to more substantial
sources of social capital leads to domination, rather than promoting an equitable bearing of
burdens and reaping of benefits in society. The authors emphasize that nurses must expose
and change the overpowering dominance of market philosophies and policies, and the ways
in which they generate health inequalities. Ultimately, it is the development of social poli-
cies directed at decreasing material and social disparities that will have any meaningful effect
on reducing or eliminating health disparities, rather than promoting social capital, cohesion,
or trust in communities (2001, p. 28). Given that supportive relational ties are not a suffi-
cient antidote to material deprivation and learned helplessness (Hawe & Shiell, 2000, p.
879), political action and advocacy to change material, social, and health disparities and
inequities are essential.
Political Action and Advocacy

Advocacy means taking a position on an issue and initiating actions in a deliberate
attempt to influence private and public policy choices (Labonte, 1994). Nurses have a repu-
tation for being trustworthy, building consensus, and getting along with people. Nurses also
can use their breadth of knowledge and experience with health care issues to advance the
desired agenda. According to Neighbors and colleagues (1995) and Feldman and Lewenson
(2000), recommendations to facilitate advocacy and political action include:
Begin with an analysis of perceived needs of the target group rather than the needs and
expectations of the program planners.
Focus explicitly on neighborhood issues and community resources.
Start at the grassroots family and neighborhood level with community service.
Be part of the solution.
Use a nonjudgmental, self-confident approach. Polish problem-solving, team building,
networking, and coalition building skills.
Praise health messages within the context of self-help, self-reliance, community con-
trol, empowerment, and self-pride. Messages should be firm and culturally sensitive.
Incorporate specific skill-oriented training.
Use members of a target group who have expertise concerning their culture and health prob-
lems, and more important, know what solutions are likely to work in their communities.
Build relationships with community leaders and local and state political representatives.
Barriers to Community Empowerment

Despite the numerous advantages inherent in community empowerment, Israel and col-
leagues (1994) suggest that there are also a number of barriers. For example, there are situa-
tions where past experiences and beliefs result in community members feeling that they do
not have influence within the system. Some community members may feel powerless and
therefore remain quiet and uninvolved in an empowerment intervention.
The differences in, for example, social class, race, and ethnicity that often exist between
community members and nurses or health educators may impede trust, communication, and
collaborative work. Swanson and colleagues (2001) propose that people must first know
themselves before forming cross-cultural partnerships. To reduce inherent conflicts and mis-
understandings, they propose a number of characteristics that partners need, including under-
standing; common goals; commitment; persistence; a sense of humor; trust; an open and
flexible approach to others; being willing to change personal attitudes, beliefs, behaviors, and
values; being willing to set assumptions aside and withhold judgment; learning appropriate
foreign languages; curiosity; tolerance and appreciation for differences; acceptance of ambi-
guity; low goal and task orientation; and the ability to understand anothers reality.
Capacity can be undermined as well as created. Some external social processes that may
damage community capacity include urban renewal, crime and fear of crime, war, extreme
poverty, recession or other economic dislocation, job loss, racism, competition for limited
resources, and other types of intergroup conflict. Additionally, certain types of experiences
may dissipate rather than build capacity, and diminish the capacity to act in the future. These
may include unresolved racial, ethnic, gender, or other conflicts within a community coali-
tion; repression that succeeds in demobilizing an initiative; an inability to engage policy mak-
ers in serious discussions; or the long delays that opponents of change can sometimes impose
(Freudenberg, 2004).
In addition, some health educators, their employers, and community members have short
timeframe expectations that are inconsistent with the sustained effort and long-time com-
mitment of financial and personal resources that are required by the community empower-
ment approach. For example, funds may be contributed by a foundation or charitable
organization but require a report with measurable outcomes at the end of a year. Other barri-
ers to community empowerment include the following:
Dealing with role-related tensions and differences arising around the issues of values
and interests, resources and skills, control, political realities, rewards and costs.
Encountering risks and potential resistance when challenging the status quo.
Measuring change in community empowerment. For example, the collection and analy-
sis of extensive amounts of data to be used for action as well as evaluation purposes may
be perceived as slowing down the process.
Principles for Community Organization

Community organization is a process planned primarily by community representatives,
consistent with local values. Individuals, groups, or organizations from within the community
use their own social structures and internal or external resources to accomplish community
goals and attain and then sustain community improvements and/or new opportunities
(Bracht & Kingsbury, 1990).
Community activation or stimulation begins with the creation or presence of an issue.
The community must identify the condition or situation as a priority for community action,
identify and activate community groups and individuals to deal with the issue, institute a
process for change, and establish structures to implement and maintain program solutions.
One important outcome of this ongoing process of community and citizen involvement is
community ownership, with an organizer or change agent potentially facilitating the
process. The change agent must be socially acceptable and trusted by the group (Bracht &
Kingsbury, 1990).
The key areas of community analysis are the assessment of community capacity to support
a project, identification of potential barriers that exist, and determination of community
readiness for involvement. Community analysis is the process of assessing and defining needs,
opportunities, and resources involved in initiating community health action programs. A
community analysis results in a dynamic community profile, done not on the community
but with the community (Haglund et al., 1990 p. 91).
There are several different types of approaches to community analysis (Haglund et al.,
1990). The medical science approach focuses on absence of disease, health improvements
through use of science and technology, and lack of direct citizen involvement, relying on
Principles for Community Organization 283
diagnosis by experts. The health planning approach emphasizes technical needs assessment,
with a focus on improvements in delivering medical and preventive services. The community
development approach views health within the broader context of social and economic
improvement and views citizen empowerment and bottom-up decision-making as vital.
Community is considered both a context and the vehicle for change. Bracht and Kingsbury
(1990, pp. 73-86), propose a community health promotion model with five stages of organiz-
ing. These key elements of community analysis are identified in Box 11-2.
B OX 11-2
Key Elements of Community Analysis
Stage 1: Define the community. Determining the geographic focus and/or com-
munity boundaries of the project.
Collecting data. A community profile should include information on
community resources, history, readiness for action, needs, who can get
things done, and who may be opposed to health promotion efforts.
1. Compile a comprehensive profile of community health, demo-
graphics, resources, history, and readiness for action. (For example,
population by age, sex, and racial or ethnic heritage; family struc-
ture, marital status, housing conditions, education levels, immigra-
tion, divorce rates, crime rates, quality-of-life; employment business
conditions, welfare and social security beneficiary rates).
2. Compile a profile of health risks including behavioral risks such as
dietary habits; use of drugs, alcohol, and tobacco; and patterns of
physical activity; social risks such as long-term unemployment,
isolation, poor education, and social support mechanisms; and
environmental risks such as quality of the physical water, soil, air,
climate, and housing.
3. Compile a profile of health and wellness outcomes such as distri-
bution of illness and well-being in the community through age-
specific death rates, unnecessary deaths, morbidity and mortality
rates.
Assessing community capacities that support change.
Assessing community barriers that hinder or create resistance to change.
People may resist changes not clearly understood, that threaten vested
interests and security, or that do not fit with cultural values of the com-
munity.
continued
B OX 11-2 CONTINUED
Assessing readiness for change. How urgent is the problem? How recep-
tive are top decision makers?
Synthesizing data and setting priorities. It is desirable to use a consensus
decision-making process involving key community leaders.
Stage 2: Design and initiation. Establishing a structure to elicit and/or coordinate

broad citizen support and involvement. The key elements include:
Establishing a core planning group and selecting a local organizer or coor-
dinator.
Choosing a dynamic organizational structure. Examples include an
advisory board, coalition, lead agency, informal network, or grass-roots
or advocacy movement for program planning, community development,
social action, advocacy, or consciousness raising (Shields & Lind-
sey, 1998).
Identifying, selecting, and recruiting organization members. They should
represent all major community institutions and groups including com-
mercial, volunteer, political, minority, religious, recreational, medical,
public health, and media, and can speak and make decisions for the peo-
ple they represent. Ideally, those people would be positive thinkers,
enthusiastic, enjoy a challenge, and believe in the project.
Identifying influential and leadership persons.
Defining the organizations mission and goals. Develop a mission
statement.
Clarifying roles and responsibilities of board members, staff, and
volunteers.
Providing training and recognition.
Stage 3: Implementation. Mobilizing and involving professionals and citizens in

the planning of a sequential set of activities to accomplish their mission. Plans
should be adapted to local constraints and values and make maximum use of
available resources and existing institutions.
Generating broad citizen participation.
Developing a sequential work plan.
Using comprehensive, integrated strategies. More than one-shot inter-
ventions are needed.
Integrating community values into the programs, materials, and messages.
continued
Principles for Community Organization 285
B OX 11-2 CONTINUED
Stage 4: Program maintenance and consolidation. Having gained experience and

success with the programs and dealt successfully with problems, community
members and staff are developing a solid foundation in the community, and the
programs are gaining acceptance. The key elements of this stage include:
Integrating intervention activities into community networks.
Establishing a positive organizational culture.
Establishing an ongoing recruitment plan.
Disseminating results.
Stage 5: Dissemination and reassessment. Reassessment occurs continually

throughout the various stages, but the key elements of this stage include:
Updating the community analysis.
Assessing the effectiveness of interventions and programs.
Charting future directions and modifications.
Summarizing and disseminating results.
Source: Adapted from Bracht, N., & Kingsbury, L. (1990). Community organization principles in health
promotion. In N. Bracht (Ed.), Health promotion at the community level (pp. 66-88). Newbury Park,
CA: Sage.
This kind of a model can provide an organizational and structural framework for commu-
nity health promotion activities. Additionally, Stokols (1996) suggests a number of strategies
that nurses can use to promote community health, including:
1. Exploring the links between facets of well-being and diverse geographic, architectural,
technological, organizational, and sociocultural environmental conditions.
2. Combining active (behavioral) and passive (environmental) interventions, given the
dynamic interaction of intrapersonal and environmental factors on individual and com-
munity well-being.
3. Enhancing the fit between people and their surroundings, giving participants control
over their surroundings with flexibility and freedom to initiate goal-directed efforts to
modify the environment in accord with their preferences and plans.
4. Focusing health promotion interventions on high-impact behavioral and organizational
leverage points. Leverage points are personal health behaviors that directly affect a per-
sons well-being (such as only selecting menu items that are labeled heart-healthy) or
others well-being (such as only heart-healthy foods being included on a menu).
5. Concentrating on leverage points that have the most influence for the individual or the
organization.
6. Addressing interdependencies between multiple settings and life domains such as resi-
dential, educational, occupational, recreational, religious, and health care environ-
ments, which have a cumulative and combined influence on well-being.
7. Integrating multidisciplinary perspectives in the design of health promotion programs
and using multiple and longitudinal methods to gauge the methodologic rigor and the-
oretical adequacy of a research or intervention program.
8. Gauging the societal value and practical significance of a research or intervention pro-
gram with such data as epidemiologic prevalence of particular health problems, eco-
nomic costs and sustainability of programs designed to alleviate those problems, the
number of people who are likely to benefit from or be adversely affected by the inter-
vention program, possible occurrence of undesirable side effects from the program, and
public opinion about community health priorities.
Empowerment cannot be bestowed on a community. Communities need to participate in

an equal partnership with health professionals in setting the health agenda, in defining their
health problems, and developing the solutions to address those problems (Robertson & Min-
kler, 1994). The role of the professional changes from that of an expert who defines the com-
munitys needs and provides the solutions through professionally oriented strategies to that of
a consultant who provides technical and informational support to the community, and builds
community capacity to address health needs. The community and the professionals are equal
partners in setting the health agenda for the community (Robertson & Minkler, 1994).
Although there are obvious advantages to community health promotion, Guldan (1996)
outlines a number of obstacles in our current health care delivery system, including the fact
that current medical training does not yet produce health-promoting physicians. Current
nursing education does not yet produce sufficient health-promoting nurses either. There is a
need for more primary care physicians and nurses alongside other community-based workers.
The system needs to move toward a community-based health system based on health promo-
tion and disease prevention.
In addition, the market shapes demand toward wants rather than health needs. Indus-
trial interests can act as a barrier to health promotion through globally pervasive and
aggressive advertising. Sound, current information promoting health does not reach rela-
tively unconnected and less educated community members quickly enough to promote a
turnaround in attitudes. For example, few programs have been designed for and partnered
with their target audiences in informal centers of health such as shopping malls and hair-
dressers. Therefore, misinformation is often prevalent. Other obstacles to community
health promotion include the long time period necessary for change and for the results of
community health promotion to become evident, the significant financial commitment
necessary for long-term intensive work and the complexity of effective engaging and coor-
dinating many people.
In order to promote community health, nurses need political savvy. Kaseje (1995) suggests
that nurses have to learn how to identify partners and opponents in the political process, do
thorough research, present a cohesive front, carefully work out action plans, and present their
position clearly but not aggressively in order to have the greatest influence at various levels
of policy formulation and implementation.
Community-level health promotion is not a panacea. Some communities may be unable
or unwilling to support the process; there is a high personal cost to those involved in com-
munity mobilization; and the process can emphasize conflict between professional and com-
munity health goals. However, the many advantages of community-level action are sufficient
reasons to encourage nursings involvement and leadership in community-level health pro-
motion. These include the ability to reach inaccessible populations through the use of infor-
mal community networks; the ability to maximize social pressure through social support,
modeling, and peer pressure strategies; and the ability to use local knowledge, expertise, and
resources to address community-wide health-related issues (Hancock et al., 1997).
The emphasis in this chapter has been on empowering strategies, such as collaboration,
capacity building, and political action/advocacy that nurses can use for community-level
organization to promote social and political change toward health. The nurse is viewed as a
consultant who provides the moral leadership to strengthen action and promote public pol-
icy to build healthy communities. However, in this information age, perhaps an even
greater challenge is fostering a sense of community built on shared values, relatedness, a feel-
ing of belonging, and trust, that is necessary for community ownership of change.
Chapter Key Points

Community can be described with the emphasis on place, people with shared institu-
tions and values, social interaction, distribution of power, or a social system.
Characteristics of community include commitment, continuity, cohesion, sense of com-
munity, membership, influence, shared emotional connection, and the expectation that
ones needs will be met through membership in the group.
Community-based interventions are directed at individual health behaviors, with the
individual as the client.
This chapter has emphasized community-level interventions to modify the entire com-
munity through community empowerment, interdisciplinary collaboration, and capac-
ity building.
Empowerment and capacity building can be directed at individuals, small groups, or the
community level.
Examples of barriers to community empowerment include perceived powerlessness by
community members, lack of trust, communication, collaboration, and role-related ten-
sions and differences.
Community health promotion includes analysis of community capacity, potential bar-
riers, and readiness; establishment of a structure to elicit and/or coordinate broad citi-
zen support and involvement; development of an implementation plan; maintenance
and consolidation of the program; and dissemination and reassessment of results.
Nurses need to develop political savvy in order to influence community health promotion.
References
Ansari, W. L., & Phillips, C. J. (2004). The costs and benefits to participants in community partnerships:
A paradox? Health Promotion Practice, 5, 35-48.
Best, A., Stokols, D., Green, L., Leischow, S., Holmes, B., & Buchholz, K. (2003). An integrative frame-
work for community partnering to translate theory into effective health promotion strategy.
Booker, V. K., Robinson, J. G., Kay, B. J., Najera, L. G., & Stewart, G. (1997). Changes in empowerment:
Effects of participation in a lay health promotion program. Health Education & Behavior, 24, 452-464.
Bourdieu, P. (1986). The forms of capital. In Richardson, J. G. (Ed.), Handbook of theory and research for the
sociology of education (pp. 248-258). New York: Macmillan.
Bracht, N. (1990). Introduction. In N. Bracht (Ed.), Health promotion at the community level (pp. 19-21).
Newbury Park, CA: Sage.
Bracht, N., & Kingsbury, L. (1990). Community organization principles in health promotion. In N. Bracht
(Ed.), Health promotion at the community level (pp. 66-88). Newbury Park, CA: Sage.
Davis, R. (2000). Holographic community: Reconceptualizing the meaning of community in an era of
health care reform. Nurs Outlook, 48, 294-301.
Disch, J. (2001). Strengthening nursing and interdisciplinary collaboration. J Prof Nurs, 17, 275.
Drevdahl, D. J. (2002). Home and border: The contradictions of community. Advances in Nursing Science,
24, 8-20.
Drevdahl, D., Kneipp, S. M., Canales, M. K., & Dorcy, K. S. (2001). Reinvesting in social justice: A cap-
ital idea for public health nursing? Advances in Nursing Science, 24, 19-31.
el Ansari, W., & Phillips, C. J. (2001). Interprofessional collaboration: A stakeholder approach to evalua-
tion of voluntary participation in community partnerships. Journal of Interprofessional Care, 15,
351-368.
Falk-Rafael, A. R. (2001). Empowerment as a process of evolving consciousness: A model of empowered
caring. Advances in Nursing Science, 24(1), 1-16.
Feldman, H. R., & Lewenson, S. B. (2000). Nurses in the political arena: The public face of nursing. New York:
Springer.
Foster-Fishman, P. G., Berkowitz, S. L., Lounsbury, D. W., Jacobson, S., & Allen, N.A. (2001). Building
collaborative capacity in community coalitions: A review and integrative framework. Am J Com-
munity Psychol, 29, 241-261.
Freire, P. (1973). Pedagogy of the oppressed. New York: Continuum.
Freudenberg, N. (2004). Community capacity for environmental health promotion: Determinants and
implications for practice. Health Education and Behavior, 31, 472-490.
Glouberman, S., & Mintzberg, H. (2001). Managing the care of health and the cure of disease-Part II: Inte-
gration. Health Care Manag Rev, 26, 70-84.
Guldan, G. S. (1996). Obstacles to community health promotion. Soc Sci Med, 43, 689-695.
Haglund, B., Weisbrod, R. R., & Bracht, N. (1990). Assessing the community. In N. Bracht (Ed.), Health
promotion at the community level (pp. 91-108). Newbury Park, CA: Sage.
References 289
Hancock, L., Sanson-Fisher, R. W., Redman, S., Burton, R., Burton, L., Butler, J., et al. (1997). Commu-
nity action for health promotion: A review of methods and outcomes 1990-1995. Am J Prev Med,
13, 229-239.
Hawe, P., & Sheill, A. (2000). Social capital and health promotion: A review. Soc Sci Med, 51, 871-885.
Helman, C. G. (1994). Culture, health, and illness (3rd ed.). Oxford, UK: Butterworth-Heinemann.
Himmelman, A. T., (2001). On coalitions and the transformation of power relations: Collaborative bet-
terment and collaborative empowerment. American Journal of Community Psychology, 29,
277-284.
Israel, B. A., Checkoway, B., Schulz, A., & Zimmerman, M. (1994). Health education and community
empowerment: Conceptualizing and measuring perceptions of individual, organizational, and
community control. Health Educ Q, 21, 149-170.
Judd, J., Frankish, C. J., & Moulton, G. (2001). Setting standards in the evaluation of community-based
health promotion programmesA unifying approach. Health Promotion International, 16,
367-380.
Kaseje, D. (1995). The role of nursing in health care in the context of unjust social, economic, and polit-
ical structures and systems. Nursing and Health Care Perspectives on Community, 16, 209-213.
Kaye, G. (2001). Grassroots involvement. American Journal of Community Psychology, 29, 269-275.
Labonte, R. (1994). Health promotion and empowerment: Reflections on professional practice. Health
Educ Q, 21, 253-268.
Laffrey, S. C., & Kulbok, P. A. (1999). An integrative model for holistic community health nursing. Jour-
Long, K. A. (2001). A reality-oriented approach to interdisciplinary work. J Prof Nurs, 17, 278-282.
Milio, N. (1996). Engines of empowerment. Chicago, IL: Health Administration Press.
Neighbors, H. W., Braithwaite, R. L., & Thompson, E. (1995). Health promotion and African-Americans:
From personal empowerment to community action. American Journal of Health Promotion, 9,
281-287.
Patrick, D. L., & Wickizer, T. M. (1995). Community and health. In B. C. Amick, S, Levine, A. R. Tarlov,
& D. C. Walsh (Eds.), Society and health (pp. 46-71). Oxford, UK: Oxford University Press.
Portes, A. (1998). Social capital: Its origins and applications in modern sociology. Annual Review of Sociol-
ogy, 24, 1-24.
Educ Q, 21, 295-312.
Roussos, S. T., & Fawcett, S. B. (2000). A review of collaborative partnerships as a strategy for improving
community health. Annu Rev Public Health, 21, 369-402.
Schmitt, M. H. (2001). Collaboration improves the quality of care: Methodological challenges and evi-
dence from US health care research. Journal of Interprofessional Care, 15, 47-66.
Sheilds, L. E., & Lindsey, A. E. (1998). Community health promotion nursing practice. Advances in Nurs-
ing Science, 20, 23-36.
Soukhanov, A. H. (Ed.). (1992). The American heritage dictionary of the English language (3rd ed). Boston:
Houghton Mifflin.
Stokols, D. (1996). Translating social ecological theory into guidelines for community health promotion.
Swanson, E., Goody, C. M., Frolova, E. V., Kuznetsova, O., Plavinski, S., & Nelson, G. (2001). An appli-
cation of an effective interdisciplinary health-focused cross-cultural collaboration. J Prof Nurs,
17, 33-39.
Thompson, B., & Kinne, S. (1990). Social change theory. In N. Bracht (Ed.), Health promotion at the com-
munity level (pp. 45-65). Newbury Park, CA: Sage.
Wallerstein, N. (1992). Powerlessness, empowerment, and health: Implications for health promotion pro-
grams. American Journal of Health Promotion, 6, 197-205.
Wallerstein, N., & Bernstein, E. (1988). Empowerment education: Freires ideas adapted to health educa-
tion. Health Educ Q, 15, 379-394.
Wallerstein, N., & Bernstein, E. (1994). Introduction to community empowerment, participatory educa-
tion, and health. Health Educ Q, 21, 141-148.
Yao, S., Weed, N.E., Lempa, M.L., Mbondo, U., Shada, R.E., & Goodman, R.M. (2004), Collaborative
community empowerment: An illustration of a six-step process. Health Promotion Practice, 5, 256-
265.
Section
IV
INTEGRATIVE NURSING
INTERVENTIONS TO PROMOTE
HEALTH AND HEALING
Section IV, Integrative Nursing Interventions to Promote Health and Healing, provides a compre-
hensive introduction to non-invasive therapeutic modalities that are appropriate as nursing
interventions (with proper supervised training and credentialing) and/or to be taught to clients
for self-use in promoting health and healing. Chapter 12, Relinquishing Bound Energy: Herbal
Therapy and Aromatherapy presents clinical applications for a number of selected herbs and essen-
tial oils. Chapter 13, Re-establishing Energy Flow: Physical Activity and Exercise, proposes a number
of strategies to empower clients to adopt a more active lifestyle. The chapter also introduces the
Chinese energy exercises of tai chi and qigong, which use breathing, mental concentration, and
physical postures to facilitate the flow of energy throughout the body. In Chapter 14, Releasing
Blocked Energy: Touch and Bodywork Techniques, massage therapies, acupressure, and various pos-
tural/movement reeducation therapies are presented. Chapter 15, Reducing Energy Depletion:
Relaxation and Stress Reduction, describes modalities such as different forms of meditation, breath-
ing, yoga, biofeedback, and guided imagery that are designed to reduce stress responses through
relaxation. Chapter 16, Regenerating Energy: Nutrition, explores Western dietary guidelines and
goals, essential dietary nutrients, phytonutrients, antioxidants, nutritional medicine supplements,
and basic diets to affect disease processes and promote health. And, Chapter 17, Restoring Energy
Field Harmony: Energy Patterning, explores Reiki and prayer as examples of modalities that are
based on channeling of a spiritual energy that has innate intelligence or logic, while music, color
therapy, polarity therapy, and Therapeutic Touch pattern the vibrations of the environmental
energy field for healing purposes.
12
RELINQUISHING BOUND ENERGY
Herbal Therapy and Aromatherapy
Abstract
Because herbal therapy and aromatherapy are based on the use of components of natural
plants, they both are presented in this chapter. Clinical applications for a number of selected
herbs and essential oils that have been well studied and appear to be both effective and low
in side effects are presented. Parameters for dosage and administration are also included.
However, the nurse is urged to pursue thorough educational preparation prior to the use of
herbs and essential oils in practice. In addition, there is a professional obligation to restrict
the use of herbs and essential oils to the promotion of health and well-being, and to refer
clients to an appropriate medical practitioner for the treatment of disease.
Learning Outcomes
Describe examples of forms of delivery of herbal preparations

Identify selected herbs and essential oils that have been well studied and appear to be
both effective and low in side effects
Describe the clinical applications of selected herbs and essential oils
Identify selected drug/herbal interactions
Discuss ways of using aromatherapy for self-care
294 Chapter 12 Relinquishing Bound Energy: Herbal Therapy and Aromatherapy
Discuss the professional obligation to restrict the use of herbs and essential oils to the
promotion of health and well-being, and to refer clients to an appropriate medical prac-
titioner for the treatment of disease
Herbal Therapy
Herbal therapy is an established and growing modality used in health care. According to
the World Health Organization (WHO), approximately 75% of the global population
most of the developing worlddepends on botanical medicines for their basic health care
needs (Barrett et al., 1999, p. 41). In the United States, approximately 60 million American
adults, or 30 % of the nations adult population, were estimated to have used herbs or herbal
preparations in 1996 (Integrative Medicine Communications, 1998).
There are a number of reasons why Americans are interested in the use of herbs, includ-
ing (Berman & Larson, 1994; Jonas & Ernst, 1999):
Availability of traditional European and North American herbs, Chinese, Japanese, and
Ayurvedic herbals, herbs from Central and South America and Mexico, and Native
American herbal medicines.
Pharmaceutical drugs are seen increasingly as overprescribed, expensive, and even dan-
gerous. Herbal remedies are seen as less expensive and less toxic.
Therapies labeled as natural are perceived as safer.
Exposure to exotic foreign foods prepared with non-European culinary herbs has led to
exploration of medicinal herbs from those countries.
People are increasingly willing to self-doctor by investigating and using herbs and
herbal preparations as adjuncts to other treatments, especially for chronic illnesses such
as arthritis, diabetes, cancer, and AIDS.
An herb is a plant whose stem does not produce woody persistent tissue and generally dies
back at the end of each growing season (Soukhanov, 1992). Herbs occur naturally in a num-
ber of forms, including flowering plants, shrubs, or trees, or a moss, lichen, fern, algae, sea-
weed, or fungus. The entire plant may be used for an herb, or specifically the flowers, fruits,
leaves, twigs, bark, roots, rhizomes, seeds, or exudates (such as tapped and purified maple
syrup), or a combination of parts. Additionally, nonplants are used as healing agents in many
herbal traditions, including animal parts (organs, bone, tissue), insects, animal and insect
secretions, worm castings, shells, rocks, metals, minerals, and gemstones (Meserole, 1996).
Both herbs and standard pharmaceuticals are absorbed into the blood stream in the same
way. Barrett et al. (1999, p. 40) suggest that regulation, preparation, and degree of chemical
refinement form the primary boundaries that divide botanical medicines from their more con-
ventional prescription and over-the-counter counterparts. However, as a rule, herbal prepa-
rations are less toxic than their synthetically produced counterparts and offer less risk of side
effects. In addition, the mechanism of action of an herb is often to correct the underlying
cause of a health problem, in contrast to the use of a synthetic drug to alleviate a symptom
(Murray, 1995).
Herbal Therapy 295
Herbal therapy is an integral part of Chinese medicine. The goal of therapy is to find and
treat the integrally related underlying causes of a problem, and not just treat isolated, specific
manifestations and symptoms. As a result, the whole plant or crude extract is often much
more effective than isolated chemical constituents, and a formula made up of combinations
of herbs is often prescribed for individualized needs. Herbal therapies are not very effective
when they are used as pharmaceutical substitutes, although they are often labeled and mar-
keted to treat individual symptoms. Herbs tend to work best preventively or therapeutically
as slow-acting, gradual, healing agents. They must be taken consistently, in the correct form
and dose. Additionally, the herbal practitioners familiarity with each medicinal plant or
herbal formula usually is much greater than the medical doctors familiarity with each indi-
vidual pharmaceutical, and this permits the herbalist to precisely select a particular plant or
formula for each [client] (Meserole, 1996, p. 117).
The importance of the individualized use of a whole plant is stressed by Ballentine (1999),
who suggests that each whole plant possesses a pattern of function. Congruence between
the pattern of the plant and that of a particular individual creates an energy field resonance
that can be used therapeutically. When a congruent plant is introduced into a person whose
symptoms reflect a pattern of disorder, something clicks, and a pattern of reorganization
occurs at the energy level. The pattern of energy flow then has an impact on the physical
body and how it functions.
Messerole (1996) describes common aspects of herbalism as follows:
Optimization of health and wellness
Emphasis on the whole person and the community
Enhancement of the quality of life
Promotion of simple self-treatment and preventive self-care
LEVELS OF HERBALISTS
No training is legally required to recommend herbal remedies in the United States and
Canada. Herbal education varies greatly. There are weekend workshops, correspondence
courses, and schools of herbal medicine. Although the American Herbalists Guild, the only
professional group of herbalists in the United States, bestows the title Herbalist AHG upon
herbalists who have passed a peer-review process, there is no official recognition or licensing
of herbalists in the United States (Dog, 1999; Prescribers Letter, 1998).
There also is no recognized standard training program for herbal therapy. However, in the
United States and Europe, a number of professionals have been trained in the use of herbs,
including officially trained medical herbalists, clinical herbalists, registered nurses, licensed
naturopathic doctors specializing in botanical medicine, licensed acupuncturists with train-
ing in Chinese herbal medicine, licensed Aryurvedic doctors, Native American herbalists and
shamans, and Latin American curanderos. A professional herbalist undertakes formalized
training or a long apprenticeship in plant and medical studies, or alternatively in plant and
spiritual or healing studies. This knowledge includes extensive familiarityoften a relation-
shipwith specific plants, which involves their identification, habitat, harvesting criteria,
preparation, storage, therapeutic indications, contraindications, and dosing (Meserole, 1996,
p. 113).
In contrast, a lay herbalist has a broad knowledge of plants useful for health problems, but
does not have extensive training in medical and spiritual diagnosis and management. Evaluation
of medicinal plant quality, strength, uses, and doses are included in the lay herbalists domain.
Additionally, plant gatherers, growers, and medicine makers are to the practicing herbalist
what the contemporary pharmacist is to the clinical physician (Meserole, 1996, p. 114).
Herbs and botanical remedies, when prescribed to treat illness, are part of medical practice
by the physician and, where authorized, the licensed professional nurse. The unauthorized
practice of medicine is a legal misdemeanor. The use of herbs as part of a plan to promote
client well-being, quality of life, and health falls within the jurisdiction of professional nurses
who have formal training and experience within courses offered by a respected institution
that include exposure to a number of different systems of herbology.
SYSTEMS OF HERBOLOGY
A number of health care systems use herbology, including traditional Chinese medicine,
Ayurveda, Western medicine, and Native American medicine. Important elements of her-
bology in each of these systems are described below (Burton Goldberg Group, 1995; Pizzorno,
1997), and are summarized in Table 12-1.
Table
12-1
Elements of Herbology in Selected Health Care Systems
PURPOSE ADMINISTRATION CLASSIFICATION

Traditional Restoration of Given in balanced According to energies
Chinese harmony formulas rather than and flavors
Medicine singly
Ayurveda Balance Formula is based on According to the

regulation of doshas humor (vata, pitta, or
kapha) whose quali-
ties they promote
Western Biochemical Individual herbs Active biochemical

Medicine magic bullets constituents
Native Energy unites all Therapeutic effect According to spiritual

American living beings cannot be reduced to and therapeutic energies
Medicine sum of qualities or
chemical constituents
Herbal Therapy 297
Traditional Chinese Medicine

In Chapter 3, the major concepts that interact to affect health in traditional Chinese
medicine (TCM) were identified as qi, yin/yang, energy phases, organ networks, and body
climates. Herbal therapies are classified according to their energetic qualities and
administered for their action on energy disorders, disturbed internal energy, blockage of the
meridians or corresponding organ dysfunction, or seasonable physical demands. The chief
ingredient of the herbal formula treats the principal pattern of the underlying problem, while
the other ingredients assist, enhance, and integrate actions.
Restoration of harmony is integral to TCM.
Since the goal is balancing the body, medicines are typically given in balanced formu-
las rather than singly.
Each taste is said to have a particular medicinal action: bitter-tasting herbs (goldenseal,
dandelion, and milk thistle) drain and dry, clear, and detoxify; sweet herbs (Panax ginseng
and licorice) tonify and may reduce pain, warm, sooth, build and nourish; acrid herbs
(cinnamon and ginger) disperse and expel cold; salty herbs (oyster shell) nourish the kid-
neys and cool; sour herbs (rosehips and hawthorn berries) nourish the yin and astringe,
preventing unwanted loss of body fluids or qi; bland herbs may have a diuretic effect.
The taste can also indicate the organ to which it has a natural affinity.
Different temperatures are ascribed to herbshot, warm, neutral, cool, and cold.
Ayurveda
As discussed in Chapter 3, in Ayurveda the functional aspect of the body is governed by
three metabolic principles, the doshas. The doshas are forces of energy, patterns, and move-
ments, not substances and structures. Ether and air together constitute vata (the energy of
movement); fire and water, pitta (the energy of digestion or metabolism); and water and
earth, kapha (the energy that forms the bodys structure and holds the cells together). Bal-
anced vata creates energy and creativity; pitta, when balanced, creates perfect digestion and
contentment; and balanced kapha provides strength, stamina, immunity, and even tempera-
ment (Larson-Presswalla, 1994, p. 22). In every person, the doshas that make up ones nature
(prakriti) differ in emphases and combinations.
Application of herbal therapy in Ayurveda is based on taste, as taste is indicative of the
properties of the herb. There are six taste essences: sweet, sour, salty, pungent, bitter, and
astringent:
Sweet (such as licorice or comfrey root) are nutritive and anti-inflammatory.
Sour (such as rosehips or hawthorn berries) encourage salivation, increase digestive
secretions, and induce sweating.
Salty tasting herbs cause heat and so increase pitta (fire).
Pungent (such as peppers or garlic) counteract congestion and stagnation, and stimu-
late the nervous system and digestion.
Bitter (such as goldenseal or barberry) clear, dry, detoxify, and cleanse.
Astringent (such as alum, witch hazel, or bayberry) contract, dry, and clear, and are
cooling and decrease pitta.
For vata imbalance, therapeutic herbs are demulcent, nutritive tonics with a sweet taste
and warm energy. Herbs that are drying, diuretic, bitter, or astringentqualities similar to
vataaggravate vata imbalance (Pizzorno, 1997). Therapeutic herbs that help a pitta person
are drying and cooling with bitter, astringent, and sweet flavors. On the other hand, herbs
that exacerbate a persons pitta are warming and moistening with pungent, sour, or salty fla-
vors (1997). Kapha types should take therapeutic herbs that are drying, warm and elimina-
tive with spicy, bitter, and astringent flavors. Herbs that are moist, demulcent, nutritive,
tonic, sweet, and salty aggravate kapha people (1997).
Western Medicine
Medicines are viewed as biochemical magic bullets.
The philosophy of science-based herbalism is that the primary action produced by
herbal medicines is the result of pharmacological (chemical) actions.
In contrast to the other healing systems, science-based herbalism typically prescribes
herbs individually.
Native American Medicine

Native American medicine promotes respect for an energy that unites all living beings.
Therefore, an herbs therapeutic properties cannot be reduced to the sum of its qualities
or chemical constituents (Pizzorno, 1997).
REGULATION
Medicinal herbs are regulated as dietary supplements under the Dietary Supplement
Health and Education Act (DSHEA) of 1994. Dietary supplements under this law are con-
sidered safe unless proven unsafe by the Food and Drug Administration (FDA). The DSHEA
prohibits labels on dietary supplements from making medical claims. Labels are restricted to
making structure and function claims, which are somewhat general statements about how
the product affects people (Prescribers Letter, 1998). Herbal products may be produced with-
out the assurance of compliance standards for Good Manufacturing Practice (although such
standards are being developed), and they are marketed without prior approval of their efficacy
and safety by the FDA (deSmet, 2002).
The European Economic Community (EEC), recognizing the need to standardize approval
of herbal medicines, developed a series of guidelines, The Quality of Herbal Remedies. The
guidelines outline standards for quality, quantity, and production of herbal remedies and pro-
vide labeling requirements that member countries must meet. The EEC guidelines are based
on the principles of the WHOs Guidelines for the Assessment of Herbal Medicines (1991).
According to these guidelines, a substances historical use is a valid way to document safety
and efficacy in the absence of contradictory scientific evidence (Berman & Larson, 1994).
In Germany, the German Federal Institute for Drugs and Medical Devices established
an expert committee on herbal remedies. This committee became known as the Commis-
sion E. The German Commission E prepared a total of 391 monographs on medicinal
Herbal Therapy 299
plants in use up to 1995. The monographs do not contain references. Many of the materi-
als that the monographs are based on are unpublished studies provided by German herb
manufacturers. The monographs were developed to inform the consumer, not for scientific
debate (Prescribers Letter, 1998). The European Commission (which governs the Euro-
pean Union) has recently developed a draft directive on the licensing of traditional herbal
preparations.
In Europe, herbal remedies fall into three categories. The most rigorously controlled are
prescription drugs, which include injectable forms of phytomedicines (from plant sources)
and those used to treat life-threatening diseases. A second category is over the counter
(OTC) phytomedicines, which are similar to American OTC drugs. The third category are
traditional herbal remedies, products that typically have not undergone extensive clinical
testing but are judged safe on the basis of generations of use without serious incident (Berman
& Larson, 1994).
In more developed Asian countries such as Japan, China, and India, patent herbal reme-
dies are composed of dried and powdered whole herbs or herb extracts in liquid or tablet form.
In China, traditional herbal remedies are still the backbone of medicine. However, in 1984,
the Peoples Republic of China implemented the Drug Administration Law, which said that
traditional herbal preparations were generally considered old drugs and, except for new uses,
were exempt from testing for efficacy or side effects. The Chinese Ministry of Public Health
now oversees the administration of new herbal products (Berman & Larson, 1994).
In Japan, almost half (42.7 %) of Western-trained medical practitioners prescribe kampo
(traditional Japanese) medicines, and the Japanese national health insurance pays for these
medicines. In 1988, the Japanese herbal medicine industry established regulations to manu-
facture and control the quality of extract products in kampo medicine. Those regulations
comply with the Japanese governments Regulations for Manufacturing Control and Quality
Control of Drugs (Berman & Larson, 1994).
ACTIONS OF HERBS
There are a number of possible actions of herbs. Table 12-2 describes selected herbal
actions.
HERBAL PREPARATIONS
The predominant form of delivery of herbal medicines varies among different herbal tra-
ditions. Tinctures are widely used in Britain and the United States; tablets of standardized
extracts of certain herbs (e.g., Ginko biloba) are popular in Germany and the United States;
decoctions are common in Tibetan, Chinese, and African traditions; therapeutic oils are used
topically and internally in Ayurvedic treatments; and teas, smokes, and compresses are used
in the Native American tradition.
Oral Herbal Forms

Whole Herbs
Whole herbs are plants or plant parts that are dried and then either cut or powered. Some
plants are best used fresh, but are seldom marketed fresh since they are highly perishable.
Table
12-2
Selected Actions of Herbs
ACTION DESCRIPTION
Adaptogenic Increase resistance and resilience to stress, enabling the body
to adapt around the problem and avoid collapse. Adaptogens
by supporting the adrenal glands.
Alterative Gradually restore proper functioning of the body, increasing
health and vitality.
Anthelminitic Destroy or expel intestinal worms.
Anti-inflammatory Soothe inflammations or reduce the inflammatory response of
the tissue directly. They work in a number of different ways,
but rarely inhibit the natural inflammatory reaction as such.
Antimicrobial Help the body destroy or resist pathogenic microorganisms.
Herbs help the body strengthen its own resistance to infective
organisms and resist illness.
Antispasmodic Ease cramps in smooth and skeletal muscles. They alleviate
muscular tension and can ease psychological tension as well.
Astringent Have a binding action on mucous membranes, skin, and other
tissue. They have the effect of reducing irritation and inflam-
mation, and creating a barrier against infection that is helpful
to wounds and burns.
Bitter The taste triggers a sensory response in the central nervous sys-
tem, which stimulates appetite and the flow of digestive juices,
aid the livers detoxification work, increase bile flow, and moti-
vate gut self-repair mechanisms.
Carminative Plants that are rich in aromatic volatile oils stimulate the diges-
tive system to work properly and with ease. They soothe the
gut wall, reduce inflammation, and ease gripping pains and
help with the removal of gas from the digestive tract.
Demulcent Rich in mucilage and soothe and protect irritated or inflamed
tissue. They reduce irritation down the whole length of the
bowel, reduce sensitivity to potentially corrosive gastric acids,
help prevent diarrhea, and reduce the muscle spasms that
cause colic.
Diuretic Increase production and elimination of urine. They help the
body eliminate waste and support the whole process of inner
cleansing.
continued
Herbal Therapy 301
Table
12-2
Selected Actions of Herbs (continued)
ACTION DESCRIPTION
Emmenagogue Stimulate menstrual flow and activity. With most herbs, how-
ever, the term is used in the wider sense for a remedy that
affects the female reproductive system.
Expectorant Stimulate removal of mucus from the lungs. Stimulating
expectorants irritate the bronchioles causing expulsion of
material. Relaxing expectorants soothe bronchial spasm and
loosen mucous secretions, helping in dry, irritating coughs.
Hepatic Aid the liver. They tone and strengthen the liver and in some
cases increase the flow of bile.
Hypotensive Lower abnormally elevated blood pressure.
Laxative Promote bowel movements. They are divided into those that
work by providing bulk, those that stimulate the production of
bile in the liver and its release from the gallbladder, and those
that directly trigger peristalsis.
Nervine Help the nervous system. Tonics strengthen and restore the
nervous system. Relaxants ease anxiety and tension.
Stimulants directly stimulate nerve activity.
Stimulating Quicken and invigorate the physiological and metabolic activ-
ity of the body.
Tonic Nurture and enliven. They are used frequently in traditional
Chinese medicine and Ayurvedic medicine, often as a preven-
tative measure.
Teas (Infusion)
Either loose or in teabag form, dried, whole, or chopped herbs can be prepared as infusions
(steeped as tea) or decoctions (simmered over low heat). Flowers, leaves, and powdered herbs
are infused (chamomile or peppermint); while fruits, seeds, barks, and roots require decocting
(rose hips, cinnamon bark, licorice root). When steeped in boiled water for a few minutes,
the fragrant, aromatic flavor and medicinal properties are released. Teas are used to prepare
the more delicate parts of the plants, such as leaves and flowers. Most teas are consumed as
alternatives to caffeinated tea or coffee, with meals for the flavor, or for their mild medicinal
effects. Suggestions for preparation:
Always use a glass or enamel container, as this will best preserve the integrity of the
medicine. Stainless steel may be used also, but aluminum must be avoided because it
can contaminate the formulas. Chemicals can be absorbed from plastic containers. Use
distilled water, as it will pull the medicinal properties of the plant into solution.
General proportions are 1 tablespoon dried herb per cup of water (1 part herb to 16
parts water). If you are using fresh herbs, use 3 tablespoons per cup water.
For general use, the tea is taken warm; however, to produce a sweat, drink it hot.
Decoctions
A decoction is a stronger, more potent tea than an infusion. The purpose of a decoction is
to pull the mineral salts and bitter principles of the plant. Many of the volatile oils and vita-
mins will escape with this process. This method is generally used for the harder parts of the
plant, such as roots, bark, and seeds, but it is also used to reduce or boil down any herbs to
make a stronger preparation, such as cough syrup. Suggestions for preparation:
Proportions are generally 1 ounce dried herbs per 1.5 pints of water (can vary, consult
directions).
Put the herbs into the distilled water, bring the water to boil, and then turn down to a sim-
mer. Simmer for 10 minutes, turn off the heat, let sit for 5 more minutes, strain, and drink.
Capsules and Tablets
These offer convenience and the bonus of not having to taste the herbs. Herbs are avail-
able either powdered or freeze-dried, in bulk, tablets, troches, pastes, or capsules.
Extracts and Tinctures
These provide a high concentration of drug in low weight and space. Many fresh and dried
herbs can be tinctured as preserved medicines in alcohol; some plants are suited to extracts
(vinegar extracts) and others are active and well preserved as syrups, glycerites (in vegetable
glycerine), or miels (in honey). They are quickly assimilated. Alcohol is used as a solvent and
as a preservative to maintain shelf life. Tinctures usually contain more alcohol than extracts.
Fluid and solid extracts are strong concentrates, four to six times the crude herb strength, and
fresh plant juices that are preserved in approximately 25% alcohol (as in the fresh plant echi-
nacea succus).
If an extract or tincture contains known active principles, the strength is commonly
expressed in terms of the content of these active principles. Otherwise, the strength is
expressed in terms of their concentration. For example, tinctures are typically made at a 1:5
concentration. This means one part herb (in grams) is soaked in five parts liquid (in milli-
liters of volume), or that there are five times the amount of solvent (alcohol or water) in a
tincture as there is herbal material. Expressing the strength of an extract by the concentra-
tion method does not accurately measure potency because there may be great variation
among manufacturing techniques and raw materials (Murray, 1995).
The term standardized extract (or guaranteed potency extract) refers to an extract guar-
anteed to contain a standardized level of active compounds. Stating the content of active
compounds rather than the concentration ratio allows for more accurate dosages to be made
(Murray, 1995, p. 17). One minum of the extract represents one grain of the crude drug.
The solvent (menstruum) is usually a combination of food grade grain alcohol and distilled
water. Fresh plants require different proportions. A general rule for dried plant tinctures is
50% alcohol and 50% water, which is the equivalent of 100 proof vodka. General proportional
rules for dried herb tinctures are 8 oz herb per quart of menstruum. To prepare a tincture using
maceration, finely cut, blended or powdered herbs are put in a jar in the quantity specified by
Herbal Therapy 303
the formula, covered with the appropriate menstruum, and closed tightly. Each day for a min-
imum of 14 days, the mixture is shaken. The more the tincture is agitated, the better chance
the menstruum has to work through the herb. The mixture should be poured through a
strainer into a bowl, then placed into a cheesecloth which has been draped over a strainer sit-
ting in a bowl to catch drips. The cheesecloth can be gathered up into a ball, with the remain-
ing menstruum squeezed out. The menstruum should then be filtered through a coffee or milk
filter or a double layer gauze diaper to remove any remaining particles. The remaining tinc-
ture can be transferred to small-mouthed bottles and stored in a dark cool place.
Elixirs
Similar to tinctures, elixirs are made quite sweet using honey or sucanet. They are often
made with brandy and are normally used as tonics.
Nonoral Herbal Forms

Nonoral delivery forms include rectal administration of herbal suppositories or enemas;
application to the skin of creams, ointments, gels, liniments, oils, distilled waters, washes,
baths, poultices, or compresses; or inhalation of steams, smokes, or aromatics (volatile oils).
Salves, balms, and ointments. Made with vegetable oil or petroleum jelly. Semi-solid,
designed to be applied to the skin. Best to use dried herbs, as fresh herbs contain mois-
ture that could lead to spoilage of the formula.
Liniments. Tinctures used externally only. They are the only preparations that use iso-
propyl alcohol, but vodka can be used instead. Alcohol is quickly absorbed and carries
the medicine into the tissues. Sprains, strains, and sore muscles all respond quickly to
liniment therapy. Preparation is the same as with a regular tincture.
Essential oils. Concentrated, with one or two drops often constituting adequate dosage.
They should be diluted in fatty oils or water before topical application (see the section
on Aromatherapy later in this chapter).
USES FOR HERBAL THERAPIES

Herbal remedies can be used for a wide range of minor ailments that are amenable to self--
medication, including stomach upset, the common cold, flus, minor aches and pains, constipation
and diarrhea, coughs, headaches, menstrual cramps, digestive disturbances, sore muscles, skin
rashes, sunburn, dandruff, and insomnia. Other conditions that respond well to herbal medicine
include digestive disorders such as peptic ulcers, colitis, and irritable bowel syndrome; rheumatic
and arthritic conditions; chronic skin problems such as eczema and psoriasis; problems of the men-
strual cycle and especially premenstrual syndrome; anxiety and tension-related stress; bronchitis
and other respiratory conditions; hypertension; and allergies (Burton Goldberg Group, 1995).
SPECIFIC HERBAL THERAPIES

Below are descriptions of 10 herbs that have possible self-care health promotion applica-
tions, as described by Landis (1997). They are widely used, and, in most cases, have demon-
strated effectiveness in at least some scientific clinical studies. For each herb, the common
name is followed by the species name in parentheses.
Astragalus (Membranaceus)
The astragalus root is a traditional Chinese herb from the pea family. Dried, sliced astra-
galus root looks like rough yellow tongue depressors. Astragalus has the following uses:
1. Immune enhancer. As a long-term tonic, it assists healing and recovery in chronic

infection or illness:
Stimulates phagocytosis
Increases macrophage activity
Increases number of stem cells
Increases spleen activity
Increases release of antibodies
Boosts the production of hormonal messenger molecules that signal for virus
destruction
2. Reduces the side effects of steroid therapy and counteracts the immunosuppressive
effects of toxic cancer therapies such as chemotherapy and radiation.
3. Antiviral. Decreases incidence of colds.
4. Tonic. Builds energy:
Reduces sweating
Increases appetite
Cools fever
Diuretic
Digestive tonic
Astragalus is sold in capsules and tinctures. In Asia, it is used in a fresh broth or soup. Use
4 to 8 mL per day of the 1:2 liquid extract or tincture (1:5): 2 to 6 mL (1: 1.5 teaspoons) three
times a day for a cold (Mills & Bone, 2000). There is no toxicity, but note, it is advisable in
acute infections. Astragalus is considered mild and safe.
Chamomile (Matricaria Recutita)

Chamomile flower is used in many cultures for its pleasant-tasting tea, consumed as an
after-dinner beverage to help digestion. Its uses include:
1. Digestive aid, antispasmodic

2. Inflammatory diseases of the digestive tract
Mouthwash for minor mouth irritation or gum infections
Irritable bowel syndrome and infants colic
Chamomile tea is made by pouring boiling water over a tablespoon of the flower heads and
steeping for 10 to 15 minutes; this is drunk three to four times daily. An allergic reaction
Herbal Therapy 305
involving urticaria or bronchoconstriction can occur, though extremely rarely, in a person

who is hypersensitive to daisy or ragweed-type plants.
Echinacea (E. Purpurea)

Echinacea (purple coneflower) species are perennial herbs native to midwestern North
America, from Saskatchewan to Texas.
Although the root is believed to possess the greatest immune enhancing properties,
most studies have used fresh-pressed juice from the aerial portion of E. purpurea. Stan-
dardized preparations are guaranteed to contain a minimum of 2.4% beta-1,2-fructofura-
nosides. Standardizing the product for these compounds guarantees that the plant was
harvested in the blossom stage, the product was carefully prepared and suffered no enzy-
matic or microbiological degradation, and that the product is stabilized (Murray, 1995,
p. 104).
Echinacea is used to treat:
1. Common cold. May be able to moderate the severity and duration of symptoms, but no
benefit for prevention of upper respiratory infection has been demonstrated (Barrett,
Kiefer, & Rabago, 1999).
2. Infections:
Promotes tissue regeneration and reduces inflammation (helps alleviate rheuma-
toid arthritis)
Nonspecific antiviral effect
Mild direct antibacterial activity
3. Low immune status:
Elevates serum white blood cell counts when they are low
Promotes nonspecific T cell activation
Increases number of circulating neutrophils
4. Cancer:
Increases the activity of natural killer cells
Stimulates macrophages to greater cytotoxic activity against tumor cells
As a general immune stimulant during infection, the herb should be given three times
daily. The dose of juice of aerial portion of E. purpurea, stabilized in 22% ethanol (standard-
ized), is 2 to 3 mL (0.5 to 0.75 teaspoon). The usual dose for the root extract is 900 mg 2 to
4 times a day, while the tincture (1:5) dose is 3 to 4 mL (0.75 to 1 teaspoon) (Dog, 1999).
Powdered echinacea administered orally in the form of capsules would probably be rela-
tively inactive (Tyler, 1993, p. 116). However, there is no evidence to suggest that long-
term usage will have an adverse effect on immune function (Mills & Bone, 2000, p. 355).
The usual recommendation for long-term use is 8 weeks on followed by 1 week off. In
patients with impaired immune function, long-term administration can provide long-term
benefit. Echinacea is not toxic when used at the recommended doses, but should not be used
by patients with infectious or autoimmune diseases such as multiple sclerosis, tuberculosis,

Lupus, AIDS, and HIV infection. It also may interfere with immunosuppressive therapy.
Garlic (Allium Sativum)

Garlic, a member of the lily family, is a perennial plant that is cultivated worldwide. The
bulb, either fresh or dehydrated, is used as a medicinal herb and assists with:
1. Cancer prevention; inhibits formation of nitrosamines.

2. Diabetes; hypoglycemia.
3. Protects against heart disease and strokes:
Lowers blood pressure
Lowers cholesterol and hyperlipidemia
Intervenes in the process of atherosclerosis at many steps
Antioxidant
4. Infection:
Broad-spectrum antimicrobial activity against many genera of bacteria, virus,
worms, and fungi
Anti-inflammatory
5. Garlic possesses diuretic, diaphoretic, emmenagogue, and expectorant action. It is also
a carminative, antispasmodic, and digestant, making it useful in cases of flatulence, nau-
sea, vomiting, colic, and indigestion (Murray, 1995, p. 125). A meta-analysis suggested
that across all 13 randomized clinical trials meeting the inclusion criteria, the effect on
total cholesterol was statistically significant but too small to be clinically relevant. The
most rigorous randomized clinical trials did not show a statistically significant effect
(Ernst & Pittler, 2002).
Stability, quality control, and standardization of the content of several active ingredients
is variable from product to product, making treatment effects unpredictable (Dog, 1999).
Therefore, preparations standardized for alliin content provide the greatest assurance of
quality... Make sure that the level of alliin and the total allicin potential is clearly stated and
that the product is stable. The commercial product should provide a daily dose of at least 10
mg of alliin or a total alliin potential of 4,000 micrograms (Murray, 1995, pp. 128-129), an
amount equal to approximately 1 clove (4 grams) of fresh garlic. Garlic is nontoxic at the
dosages commonly used for most people. In large amounts, however, it can cause irritation to
the digestive tract. To avoid the taste or offensive odor of garlic, the best formulations are
enteric coated tablets or capsules of dried garlic or garlic powder. Garlic may potentially inter-
act with anticoagulants such as warfarin.
Ginkgo Biloba
Ginkgo biloba is a deciduous tree that lives as long as 1,000 years. Ginkgo bears a foul-
smelling, inedible fruit and an edible, ivory-colored inner seed that is sold in marketplaces in
Herbal Therapy 307
the orient. Extracts from the leaves of the ginko tree are used medicinally for the following
purposes:
1. Vascular insufficiency:
Reduces symptoms of cerebral insufficiency, including impaired mental function
(senility) in the elderly
Anti-aggregatory effect on platelets
2. Memory enhancing:
Increases cerebral blood flow with oxygen and glucose utilization
Increases the rate at which information is transmitted at the nerve cell level
Delays mental deterioration in the early stages of Alzheimers disease equivalent
to a 6-month delay in the progression of the disease
3. Retinopathy. Addresses the underlying factors in senile macular degeneration.
4. Peripheral vascular disorders. Improves limb blood flow and walking tolerance.
5. Impotence. Erectile dysfunction due to lack of blood flow.
6. Ginkgo biloba extract (GBE) may be of benefit in cases of angina, congestive heart
failure, and in acute respiratory distress syndrome. Its action on inhibiting platelet
activating factor may also make it useful in the treatment of conditions other than
allergies, including various types of shock, thrombosis, graft protection during organ
transplantation, multiple sclerosis, and burns (Murray, 1995, p. 158).
Ginkgo biloba has been shown in several systematic reviews to be effective for the symp-
tomatic treatment of dementia and intermittent claudication (Ernst & Pittler, 2002). Most
of the clinical research has used a standardized extract, containing 24% ginkgo heterosides
(flavone glycosides) at a dosage of 40 mg three times a day. GBE should be taken consistently
for at least 12 weeks in order to be effective. Although most people report benefits within 2
to 3 weeks, some may take longer to respond. GBE is extremely safe and side effects are
uncommon but may include mild gastrointestinal disturbances, headache, dizziness, and ver-
tigo. In contrast, contact with or ingestion of the fruit pulp has produced severe allergic reac-
tions like poison ivy, oak, or sumac group.
Panax Ginseng
Ginseng is a widely cultivated plant, especially in Korea, but also in Russia, China, and
Japan. Old, wild, well-formed roots are the most valued, while rootlets of cultivated plants are
considered the lowest grade. For largely economic purposes, most ginseng in the American
marketplace is derived from the lowest grade root, diluted with excipients, blended with adul-
terants, or totally devoid of active ingredients, that is ginsenosides. High-quality roots and
extracts are available, however. These preparations consist of the main root of plants between
4 to 6 years of age, or extracts that have been standardized for ginsenoside content and ratio
to ensure optimum pharmacological effect (Murray, 1995, p. 266). In China, ginseng is used
to restore the yang quality and as a tonic for its revitalizing properties, especially after a long
illness. The genus name Panax is derived from the Latin word panacea meaning cure all. It
is used to treat:
1. Fatigue and recovery from illness.

2. Stress. Adaptogen:
Spares glycogen utilization in exercising muscle
Promotes secretion of ACTH
3. Diabetes, hypoglycemia.
Products should be standardized by their ginsenoside content. The standard dose for high-
quality ginseng root is in the range of 4 to 6 grams daily. It is best to begin at lower doses and
increase gradually. The Russian approach for long-term administration is to use ginseng
cyclically for a period of 15 to 20 days, followed by a 2-week interval without any ginseng
(Murray, 1995, p. 276). Many clinical trials have been conducted using a dose of 200 mg of
a standardized extract (Mills & Bone, 2000, p. 419). Studies with standardized extracts have
demonstrated the absence of side effects, but women may experience breast tenderness that can
be reversed by lowering the dose or stopping the treatment. However, a systematic review found
no convincing evidence for efficacy in any indication, and another systematic review of all nine
randomized clinical trials available was inconclusive. Many of the studies had poor method-
ological quality (Ernst & Pittler, 2002). Interactions are possible with warfarin, insulin, and
phenelzine.
Siberian Ginseng (Eleutherococcus Senticosus)

Siberian ginseng grows abundantly in parts of the Soviet Far East, Korea, China, and
Japan, north of latitude 38. The root is the most widely used medicinal part, and assists with:
1. Stress and fatigue. Ability to normalize irrespective of the direction of pathology.

However, in a prospective, double-blind, placebo-controlled, randomized clinical trial
with 83 healthy young adults, ginseng supplementation had no effect on positive affect,
negative affect, or total mood disturbance at the clinically recommended level or twice
that level (Cardinal & Engels, 2001):
Inhibit the alarm phase of the stress reaction
Protective and medicinal action in animals exposed to both single and prolonged
x-ray radiation
Chronic fatigue syndrome
2. Atherosclerosis.
3. Impaired kidney function.
The standard dosage of the 33% ethanol extract (fluid extract) used in the majority of
studies ranged from 2.0 to 4.0 mL, one to three times a day, for periods up to 60 consecutive
days. In multiple dosing regimens, there is usually a 2- to 3-week interval between courses.
The dose to be administered three times a day of fluid extract (1:1) is 2.0 to 4.0 mL (Mur-
Herbal Therapy 309
ray, 1995, p. 319). Adult doses used in most studies were in the range of 1 to 4 g daily, which
corresponds to 2 to 8 mL/day of a 1:2 extract (Mills & Bone, 2000, p. 535). Siberian ginseng
extracts are virtually nontoxic, but side effects are often reported at dosages of 4.5 to 6 mL
three times daily. These include insomnia, irritability, melancholy, and anxiety. Individuals
with rheumatic heart disease have reported pericardial pain, headaches, palpitations, and ele-
vations in blood pressure.
Green Tea (Camellia Sinensis)

Both green tea and black tea are derived from the tea plant. The parts used are the leaf
bud and the two adjacent young leaves together with the stem, broken between the sec-
ond and third leaf. Older leaves are considered inferior in quality. Green tea is produced
by lightly steaming the fresh-cut leaf, while the leaves are allowed to oxidize to produce
black tea. Green tea is produced and consumed primarily in China, Japan, and a few coun-
tries in North Africa and the Middle East. One cup of green tea usually contains about 300
to 400 mg of polyphenols and between 50 and 100 mg of caffeine. Green tea is used to
assist with:
1. Antioxidant supplementation
2. Cancer prevention
Blocks the formation of cancer-causing compounds such as nitrosamines sup-
presses the activation of carcinogens and detoxifies or traps cancer-causing agents.
The forms of cancer that appear to be best prevented by green tea are cancers of
the gastrointestinal tract, including cancers of the stomach, small intestine, pan-
creas, and colon; lung cancer; and estrogen-related cancers including most breast
cancers (Murray, 1995, p. 194).
The normal amount of green tea consumed by Japanese and other green tea-drinking
cultures is about 3 cups daily or about 3 grams of soluable components, providing roughly
240 to 320 mg of polyphenols. For a green tea extract standardized for 80% total polyphe-
nol and 55 percent epigallocatechin gallate content, this means a daily dose of 300 to 400
mg. Green tea is not associated with any significant side effects or toxicity. Overcon-
sumption may produce a stimulant effect (nervousness, anxiety, insomnia, irritability,
etc.) as with any caffeine-containing beverage; however, for some reason green tea usu-
ally does not produce those symptoms even in those who are usually quite sensitive to
caffeine.
St, Johns Wort (Hypericum Perforatum)

St. Johns wort is a shrubby perennial plant with numerous bright yellow flowers. It is
native to many parts of the world, including Europe and the United States. It grows especially
well in northern California and southern Oregon. The major compounds of interest in St.
Johns wort leaves and flowers are hypericin and pseudohypericin. In Europe, St. Johns wort
has a long history of use, particularly as a folk remedy in the treatment of wounds, kidney and
lung ailments, and depression. Clinical trials have shown St. Johns wort extract to be more
effective than placebo and equally effective as standard synthetic antidepressants (Dog,
1999). Its clinical applications include the treatment of:
1. Depression. Inhibits monoamine oxidase (MAO) types A and B, which leads to an
increase in nerve impulse transmitters that maintain normal mood and emotional sta-
bility. The results of 26 double-blind controlled studies with the standardized St. Johns
wort extract (0.3% hypericin) indicate that at a dosage of 300 mg three times daily it is
as effective in relieving symptoms of depression as standard antidepressants but is much
better tolerated with fewer side effects (Murray, 1995, p. 298).
2. Sleep disorders.
3. Viral infections. Inhibits herpes simplex virus types 1 and 2, influenza types A and B,
and Epstein-Barr virus. The greatest promise may be in treatment of AIDS.
4. Healing of wounds. As a lotion it will speed the healing of wounds and bruises, varicose
veins, and mild burns. The oil is especially useful for healing sunburn.
A typical regimen is hypericum tablets (1.5 g standardized to contain 0.9 mg TH): 2 to 3
tablets per day (Mills & Bone, 2000, p. 543). Can also be taken as tea prepared from 1 to 2 tea-
spoonfuls of the herb steeped for 10 minutes; 1 to 2 cups of the tea are drunk daily for 4 to 6 weeks.
Advantages of St. Johns wort compared with antidepressant drugs include (Coss & Cott,
2002):
Side effects are generally mild and infrequent
Nonhabituating and nonaddictive, and has no withdrawal symptoms upon discontinu-
ing use
Does not interfere with REM sleep; most often it enhances sleep and dreaming
Shows no adverse effects when mixed with alcohol or most drugs
Far less likely to cause drowsiness or agitation
Not a single reported death from an overdose
St. Johns wort is unlikely to be toxic to humans when used at recommended medicinal doses.
Side effects reported for St. Johns wort are generally mild, including gastrointestinal symptoms
and fatigue (Coss & Cott, 2002). Because of the possibility of photosensitivity, some herbalists
recommend that individuals, especially those with fair skin, avoid exposure to strong sunlight and
other sources of ultraviolet light when using the herb. Those taking the herb should also avoid
foods and medications that are known to interact negatively with MAO-inhibiting drugs. Tyra-
mine-containing foods (cheeses, beer, wine, pickled herring, yeast, etc.) and drugs such as L-dopa
and 5-hydroxytryptophan should be avoided. St. Johns wort should also be taken with food, as
it may cause mild gastric upset in sensitive individuals (Murray, 1995, p. 300).
Valerian
Valerian is a perennial plant native to North America and Europe. The rootstock is the
portion used medicinally for:
1. Insomnia. Binds to the same brain receptors as Valium and other benzodiazepine drugs
without side effects such as impaired mental function, morning hangover, and depend-
Herbal Therapy 311
ency. However, larger, better controlled, and more representative clinical trials are
needed before clear recommendations can be made (Barrett et al., 1999, p. 47).
2. Stress and anxiety.
As a mild sedative, valerian may be taken 30 to 45 minutes before retiring as 2 to 6 mL of

1:2 liquid extract per day, 5 to 15 mL of 1:5 tincture per day (Mills & Bone, 2000), or Valer-
ian extract (0.8% valeric acid): 150 to 300 mg.
For best results, eliminate dietary factors such as caffeine and alcohol, which disrupt sleep.
Valerian is generally regarded as safe and is approved for food use by the FDA. It does not
have a synergy with alcohol. Approximately 5% to 10% of users have reported paradoxical
stimulant effects.
There are a number of tonic, energizing, and endurance herbs that can be used to promote
general well-being based on many years of anecdotal experience particularly in The Peoples
Republic of China. Table 12-3 lists some of the most common herbs used for these purposes.
Table
12-3
Selected Tonic, Energizing, and Endurance Herbs
TONIC HERBS ENERGIZING HERBS STAMINA AND ENDURANCE HERBS

Astragalus membranaceus Short-term energizers: Panax (Asian) ginseng
Echinacea Guarana seed Eleuthero
Triphala (Ayurvedic) Kola nut Triphala
Turmeric root Yohimbe
Ginseng Yerba mate
Eleuthero Ma huang
Dong quai Medium-term energizers:
Licorice root Licorice root
Cubeb berry
Garlic, onion, and ginger
Long-term energizers:
Fo-ti root
Astragalus root
Eleuthero root
Saw palmetto berry
Triphala
Black cohosh root
Prickly ash bark
Muira puama root
Sarsaparilla root
Bladderwack
Unfortunately, a number of herbs may have dangerous interactions with conventional

drugs when they are taken together. Table 12-4 indicates some examples of selected drug and
herbal interactions.
Table
12-4
Selected Herbal Medicine Interactions with Prescribed Drugs
HERBAL MEDICINE HERB AND DRUG INTERACTIONS

St. Johns wort Lowers blood concentrations of cyclosporin, amitriptyline,
(Hypericum perforatum) digoxin, indinavir, warfarin, phenprocoumon, and theo-
phylline.
Causes intermenstrual bleeding when used with oral con-
traceptives (ethinylestradiol/desogestrel).
Causes delirium when used with loperamide.
Causes mild seratonin syndrome when used with selective
serotonin-reuptake inhibitors (sertaline, paroxetine, nefa-
zodone).
Should not be used with monoamine oxidase inhibitors
(MAOI antidepressants), narcotics, reserpine, and photosen-
sitizing drugs.
Discontinue use at least 5 days prior to surgery. Should not
take postoperatively if oral anticoagulation is needed.
May inhibit iron absorption, undermining the benefits of
prescribed anemia drugs.
Ginkgo biloba Causes bleeding when combined with warfarin.
Raises blood pressure when used with a thiazide diuretic.
Causes coma when used with trazodone.
Should discontinue at least 36 hours prior to surgery
(inhibits platelet-activating factor).
Ginseng Lowers blood concentrations of alcohol and warfarin.
(Panax ginseng) May induce headaches, tremulousness, or manic episodes if
used with phenelzine sulfate (antidepressant).
Should discontinue use at least 7 days prior to surgery.
Garlic Changes pharmacokinetic variables of paracetamol.
(Alluim sativum) Decreases blood concentrations of warfarin.
Produces hypoglycemia when taken with chlorpropamide.
Kava Increases off periods in Parkinsons patients taking lev-
(Piper methysticum) adopa.
Can cause a semicomatose state with alprazolam.
Potentiates the sedative effects of anesthetics.
continued
Herbal Therapy 313
Table
12-4 Selected Herbal Medicine Interactions with Prescribed Drugs
(continued)
HERBAL MEDICINE HERB AND DRUG INTERACTIONS

Echinacea May interfere with immunosuppressive drugs.
(E. angustifolia; E. Use with caution in patients with allergic reactions (e.g.,
purpurea; E. pallida) asthma, atopy, or allergic rhinitis)
Potential concern for hepatotoxicity.
Ginger Can cause adverse reactions with acid-inhibiting, anticoag-
ulant, antiplatelet, cardiac, and diabetes drugs
Melatonin Can interfere with central nervous system depressants, ver-
apamil, and immunosuppressive drugs.
Green tea Can cause hypertension with MAOIs.
Can have adverse reactions with chlorpromazine, cimeti-
dine, clozapine, disulfiram, theophylline, and verapamil.
Sources: Adapted from Ang-Lee, M. K., Moss, J., & Yuan, C. (2001). Herbal medicines and perioperative care.
JAMA, 286, 208-216; Coleman, S. (2001, July 30). Proceed with caution. Advance for nurses, 23-24; East-
man, P. (1999). Drugs that fight can hurt you. American Association of Retired Persons Review, 40, 14-16;
Izzo, A. A., & Ernst, E. (2001). Interactions between herbal medicines and prescribed drugs: A systematic
review. Drugs, 61, 2163-75.
KEY CONCERNS
There are a number of concerns with the use of herbal remedies. One concern is that
developing countries have minimal regulation and oversight, even though herbal medicines
are the staple of medical treatment, with visits to Western-trained doctors or prescription
pharmacists reserved for life-threatening or hard-to-treat disorders. Healers rely mainly on
indigenous crude drugs. These are unprocessed herbs, plants or plant parts, dried and used
in whole or cut form. Herbs are prepared as teas (sometimes as pills or capsules) for internal
use and as salves and poultices for external use (Berman & Larson, 1994).
Another concern is the lack of support by the U. S. federal government. Because herbs
have not been discovered, they cannot be patented. Consequently, drug companies are not
motivated to invest money in testing or promotion of herbs. The collection and preparation
of herbal medicine cannot be as easily controlled as the manufacture of synthetic drugs, mak-
ing its profits less dependable (Burton Goldberg Group, 1995, p. 253). The federal govern-
ment has not intervened to promote quality control of herbs.
There is a limited supply of educated botanists, and traditional healers are elderly and have few
disciples. In addition, the academic infrastructure for study of ethnomedical systems has eroded.
Today, only a handful of active full-time ethnobotanists are trained to catalog information on the
medicinal properties of plants, and in the mid-1990s only 12 American pharmacy schools offered
courses on botanical medicine (DEpiro, 1997).
Also of concern is the lack of a holistic approach to studying the efficacy of herbals as phy-
tomedicines (whole plant medicines) rather than individual chemicals. Most herb products
contain a combination of several ingredients because they come from plants. It is possible that
plant composition alone offers an incomplete explanation of the full scope of the properties
and actions of food and healing plants . . . . Many herbalists hold that healing energy is inher-
ent to plants; it is primarily this energy, rather than nutritive or chemical constituents, which
promotes healing (Meserole, 1996, p. 116).
Americans have been conditioned to rely on synthetic, commercial drugs to provide quick
relief, regardless of side effects (Burton Goldberg Group, 1995). Despite the lack of research
models to test herbal preparations that may contain many active ingredients and the fact that,
in many cases, experts have not yet determined which pharmacologically active ingredient or
combination of ingredients is causing the pharmacologic activity, the emphasis of many
herbal manufacturers is to isolate single active ingredients that can be packaged and sold sep-
arately (Prescribers Letter, 1998).
Herbal products can interact with either prescription or nonprescription drugs. However,
providers often do not ask, and [clients] frequently dont tell their health care providers that
they use herbs. Maybe [clients] forget, or they just dont consider herbs as drugs. They might
think herbs are not powerful enough or important enough to bring up (Prescribers Letter,
1998, p. 1). Selected herb and drug interactions were discussed earlier in this chapter.
Natural doesnt necessarily mean safe. Some herbs have toxic effects. However, true
attributable adverse effect rates appear to be in the range of 3% (Jonas & Ernst, 1999, p.
104). Unfortunately, herbal products often lack consistency. Many factors influence the con-
tent of herbal medicine products such as soil, weather, other environmental conditions, time
of harvest, storage, and manufacturing procedures (Prescribers Letter, 1998). Thus, issues of
quality control are of concern.
Herbs are not required to demonstrate bioequivalence. A standardized extract merely
means that the manufacturer asserts that one specific ingredient is present in a certain con-
centration and that subsequent lots of the herbal product contain the same concentration of
the standardized component. But, the other ingredients could be higher or lower depending on
many other factors. Two brands of a standardized herb extract may not be identical (Prescribers
Letter, 1998) and can vary in efficacy and results, even at the same doses (DEpiro, 1997). Mis-
labeling and misrepresentation occur. Without quality control, there is no guarantee that the
herb contained in the bottle is the same as what is stated on the label (Murray, 1995). Qual-
ity assurance is needed to ensure: (a) that the product has the expected effects, (b) the qual-
ity of available product information, and (c) product safety (deSmet, 2002).
Despite these concerns, companies supplying standardized extracts currently offer the
greatest degree of quality control, hence these products typically offer the highest quality. The
European Economic Council (EEC) has proposed guidelines for acceptable levels of impuri-
ties such as parasites (bacterial counts), pesticides, residual solvents and heavy metals, and
product stability. Most standardized extracts are currently made in Europe under these strict
guidelines (Murray, 1995). Extracts made in the United States. do not have to meet these
guidelines.
Aromatherapy 315
Incorrect, inaccurate, or inappropriate diagnosis can result in the application of effective

therapies for the incorrect condition. Misapplication usually occurs because of inadequate
training, knowledge, skills, or experience of the clinician (Jonas & Ernst, 1999). Addition-
ally, treating with herbs with unproven therapeutic potential may delay or replace a more
effective form of conventional medication therapy. These concerns highlight the need for
practitioners to obtain thorough educational preparation before prescribing herbal therapies.
Given these many concerns, there are many challenges for the future including the con-
servation of biodiversity and plant habitat; training professional and other herbalists;
exchanging information with traditional healers; providing health care professionals with a
familiarity with plant medicines; educating the public in the appropriate use of herbs for self-
care; ensuring the funding of medicinal plant research that focuses on public health, clinical
therapeutics, and wellness, and not just drug development; and preserving public access to
inexpensive, tonic, and therapeutic herbs through economic, environmental, market, legisla-
tive, and health policy (Meserole, 1996).
Aromatherapy
Aromatherapy is the therapeutic use of the odor or fragrance of essential oils extracted
from plants (Stevensen, 1996). Essential oils are volatile, organic components extracted from
fragrant plants by steam distillation or expression (Buckle, 2001). Essential oils may be
extracted from the roots, bark, stalks, flowers, or leaves of the plant. Chemical changes occur,
changing the composition of the oil, immediately after the flower is cut.
Essential oils are highly volatile and dissolve in pure alcohol, fats, and oils but not in water.
Because they are sensitive to heat and light, they are preferably kept in dark glass bottles that
should be stored to prevent contamination from other sources. Plastic bottles should never be
used to store essential oils because the oils will interact with the plastic. The oils will evapo-
rate readily if left exposed to the air. Most essential oils have a limited lifespan of approxi-
mately 2 years, and citrus oils such as lemon, orange, and lime do not keep that long
(Glickstein, 1996; James, 1998). Essential oils should not be bought or used unless the smell
is pleasing.
Clinical aromatherapy includes both environmental and personal (esthetic) applications
to calm, balance, and rejuvenate. The purposes of esthetic aromatherapy include pleasure and
healing, whereas commercial aromatherapy relies almost exclusively on use of environmental
fragrances in work, purchasing, and sales settings (Holmes, 1995). In clinical aromatherapy,
the concern is for 100% purity of oil extracted from a specific plant genus, species, and
chemotype, with nothing added, removed, or reconstructed. Good or high quality oils are cru-
cial to the success of clinical treatments.
CLINICAL APPLICATIONS
The basis of the action of aromatherapy is thought to be the same as that of modern phar-
macology, using smaller doses. The chemical constituents are absorbed into the body, affect-
ing particular physiologic processes. In addition, the emotional and psychological benefits of
aromatherapy are important. By affecting the limbic system, the part of the brain involved in
memory and emotion, the inhaled oils exert their effects through learned responses as well as
inherent pharmacological properties (Horowitz, 1999).
The chemical makeup of essential oils gives them a number of desirable pharmacological
properties ranging from antibacterial, antiviral, and antispasmodic, to uses as diuretics,
vasodilators, and vasoconstrictors. Essential oils act on the adrenals, ovaries, and the thyroid
and can energize or pacify, detoxify, and facilitate the digestive process. The therapeutic prop-
erties of the oils also make them effective for interacting with the various branches of the
nervous system and modifying immune response, moods, and emotions (Burton Goldberg
Group, 1995).
Aromatherapy aims first to enhance and balance the individual constitution and thereby
prevent the development of disease. Second, it aims to treat actual sickness when it arises.
Clinical aromatherapy involves numerous treatment modalities, some more preventive, oth-
ers more curative. Aromatherapy can easily be incorporated within a nursing plan for the pro-
motion of well-being and health. In addition, reasons to administer aromatherapy in
conventional biomedical settings include:
Relaxation, stress, and anxiety relief
Headache (e.g., migraine) and chronic pain relief
Reduction of insomnia and restlessness
Reduction of anxiety, depression, and fatigue
Self-image enhancement
Stimulating immune function (e.g., against the Epstein-Barr virus)
Infection fighting
Wound healing
Burn treatment
Addiction treatment
Reduction of compulsive eating
Relief of menopausal symptoms
Constipation
Topical treatment of herpes simplex (shingles) and numerous skin disorders
Ability to relieve muscle spasm
Anxiety and nausea of chemotherapy
Anti-inflammatory effects in treating arthritis
There are few well-designed studies investigating the effects of aromatherapy in humans,
although several in vitro and animal studies have been conducted. Although little is known
about possible interactions with conventional medications or treatments, it is presumed that
because the dosages of essential oils absorbed in the body generally are small, and because
there has been no reported incidence of difficulties, that essential oils administered in physi-
Aromatherapy 317
ologic doses are safe given the contraindications (Stevensen, 1996, p. 145). It is clear that
more scientific evidence is needed concerning basic mechanisms of action and efficacy of par-
ticular oils in particular populations.
Methods of Administering Essential Oils

A number of routes of administration can be used to administer essential oils. Some of the
most common routes of administration are:
1. Through a diffusor. Diffusors disperse microparticles of the essential oil into the air.
They can be used to achieve beneficial results in respiratory conditions, or to simply
change the air with the mood-lifting or calming qualities of the fragrance. Simple
inhalation of the oils is a method used for respiratory conditions, insomnia, and
mood elevation and enhancement, or simply for making an environment more
pleasant.
Electric. 5 to 6 drops added to water in the diffuser.
Candle generated. 8 to 10 drops added to water in dish.
Inhalation. Put 4 to 5 drops of essential oil in a bowl of very hot water. (Eyes
should be closed to avoid a stinging sensation from the steam and essential oils.
The clients head can be covered with a towel, while the client inhales for 5 min-
utes. The nurse should stay with the client and remove the bowl if the client starts
expectorating). This method has a rapid effect. Another technique is to place 1 to
5 drops on a tissue to be inhaled slowly for 5 to 10 minutes.
2. External applications. Oils are readily absorbed through the skin. Therefore, they may
be administered via baths, massages, hot and cold compresses, or a simple topical appli-
cation of diluted oils. Because the essential oils are the same as those used for their
aroma, external applications are discussed briefly here:
Essential oils in a hot bath can stimulate the skin, induce relaxation, eliminate
toxins, and energize the body. Add 6 to 8 drops to the bath. The oils can be mixed
with milk before adding to facilitate dispersion. Gently pat the skin dry afterward
to leave a fine layer of oils on the skin for further absorption.
In massage (gentle rubbing touch rather than vigorous rubbing), the oils can be
worked into the skin and depending on the oil and massage technique, can either
calm or stimulate an individual. Rubbing or heating increases the rate of absorp-
tion of essential oils through the skin. In general, essential oils should not be
applied directly to the skin, but should be mixed in a carrier oil. Clark (1996, p.
238) describes possible carrier oils: apricot kernel oil soothes and smooths dry or
inflamed skin and is high in vitamin A; canola oil promotes skin health and resists
rancidity; olive oil is beneficial to skin and hair but because of its strong odor,
works better with stronger smelling oils such as basil, rosemary, and tea tree; peanut
oil can be used on any skin type and is absorbed readily; and wheat germ oil nour-
ishes dry or cracked skin and soothes eczema and psoriasis, may prevent stretch
marks, and helps reduce scarring.
Caution is appropriate when working with clients who have very sensitive skin or
respiratory disorders such as asthma. For massage, the ratio should be half the
number of essential oil drops to milliliters of base oil.
When used in compresses, essential oils soothe minor aches and pains, reduce
swelling, and treat sprains. Place 3 to 4 drops of essential oil in a bowl of water
(can be diluted in cold-pressed vegetable oil, a cream, a gel, or water). Agitate
water gently to disperse oil, then soak a small cotton or toweling cloth in bowl,
ensuring that the cloth has absorbed the oil. Gently squeeze the cloth of excess
water and apply to skin. Floral waters can be sprayed into the air or on skin that
is too sensitive to touch.
Buckle (2000) describes a gentle and soothing stroking process she has called the
M (for manual) technique, which can be used with aromatherapy. The tech-
nique is done in a distinctive pattern (sequence, number, and pressure) of strokes,
which is never modified, and is completely reproducible for use in research. Each
stroke, within each movement, is repeated three times, with a pressure of 3 on a
scale from 1 to 10. The M technique takes as little as 5 minutes for a clients
hand, or 15 minutes for both feet. The back also may be stroked in a sequence last-
ing no more than 11 minutes. See the additional information at the end of the
chapter to obtain more information about this technique.
3. Internal application. For certain conditions (such as organ dysfunction/disorder), it can
be advantageous to take oils internally. However, when essential oils are taken inter-
nally, the therapy is generally thought to be part of herbal medicine, not aromatherapy
(Buckle, 1999, p. 42). It is essential to receive proper medical guidance for internal use
of oils, as they can cause a toxic reaction if ingested.
SPECIFIC ESSENTIAL OILS AND THEIR APPLICATIONS

Presented below are commonly used essential oils for clinical or self-care aromatherapy
(Burton Goldberg Group, 1995).
Eucalyptus (Eucalyptus Radiata)

Eucalyptus is a classic antiviral (can help deal with herpes and shingles) and expectorant
agent. It is antifungal, antiparasitic, a mosquito repellent and larvicide, and can inhibit gran-
ulation. It is also a muscle relaxant that may be useful in postoperative physiotherapy. It is
best used through a diffusor or topically as a chest rub.
Everlast (Helichrysum Italicum)

When used in dilutions of 2% or lower, everlast can be used for tissue-regenerating on
scars. Applied topically, it is a powerful anti-inflammatory agent and can prevent hemor-
rhaging and swelling after sports injuries or bruising. Because of its ketone content, this oil
should only be used topically and in concentrations not exceeding 2%.
Geranium (Pelargonium Xasperum)

This fragrant oil has both antifungal and antiviral properties. It is gentle on the skin and
gives body to the fragrance of many essential oil compositions.
Aromatherapy 319
Lavender (Lavandula Angustifolia)

Lavender is considered the classic oil of aromatherapy. It can be used undiluted on burns,
small injuries, and insect bites. A high ester content gives it a calming, almost sedative qual-
ity. Two to 5 drops of the essential oil should be diluted in 5 mL of aloe vera gel to produce a
2% to 5% solution for use as a cell rejuvenator (Buckle, 2001). As an antiseptic it can be used
as a gargle or mouth wash, with 1 to 3 drops added to a glass full of warm water (Buckle,
2001). For its analgesic action in earache, 1 drop of lavender should first be diluted with 2
drops of vegetable oil (e.g., sweet almond oil) and then the mixture should be placed on a cot-
ton ball and placed in the childs ear (Buckle, 2001). As an antispasmodic, 1 to 5 drops should
be added to a fixed carrier oil or hand cream and rubbed gently on the affected area (Buckle,
2001). Lavender is known for its calming effects, and inhaling 1 to 5 drops of lavender from
a facial tissue for about 10 minutes can enhance well-being (Buckle, 2001; Robins, 1999). It
is also used topically for pain relief that also seems to enhance the effect of orthodox pain
medication (Buckle, 2001, p. 61).
Mandarin (Citrus Reticulata)

Mandarins calming properties and universally pleasing fragrance make this oil a top
choice to release anxiety. It has also been found to improve immune function (Buckle, 2001).
It is typically dispersed in a room with a diffusor.
Niaouli (Melaleuca Quinquenervia Viridflora)

Niaouli calms respiratory allergies, is a vitalizing, balancing agent for overactive and oily
skin, and helps with hemorrhoids (in the nonacute stage).
Palmarosa (Cymbopogon Martinii)

Palmarosas pleasant fragrance and excellent antiseptic/antiviral activity have uses in skin
care and in the treatment of herpes.
Peppermint (Meentha Piperita)

A drop of this oil on the tongue provides excellent relief for nausea and travel sickness. It
is also effective for irritable bowel syndrome. However, it has up to 30% of ketones, which in
high doses are known to be neurotoxic (Campbell et al., 2001).
Roman Chamomile (Anthemis Nobilis)

Recommended to calm an upset mind or body, a drop of Roman chamomile rubbed on the
solar plexus can bring rapid relief of mental or physical stress.
Rosemary (Rosmarinus Officinalis)

Rosemary activates the metabolism in the outer layer of the skin and improves cell
regeneration.
Spikenard (Nardostachys Jatamansi)

Spikenard is aimed as much toward benefiting the psyche as the skin.
Tea Tree (Melaleuca Alternifolia)

A nonirritating antiseptic, tea tree has antibacterial, antiviral, and antifungal properties.
Applied topically, it is useful in healing pus-filled wounds and for treating many types of mild
or chronic infections. Tea tree can be used in a hand wash, room spray, and body wash. One
percent to 3% can be used as a mouthwash for mouth infections (Buckle, 2001).
Contraindications to the use of aromatherapy agents include the following (dAngelo, 2002):
1. Epilepsy: eucalyptus, lavender, rosemary, basil, fennel, and sage
2. Hypertension: thyme, rosemary, pine, and sage
3. Asthma: rosemary and camphor
4. Pregnancy: lemon balm, cinnamon, basil, and thyme
CAUTIONS IN USING ESSENTIAL OILS

An essential oil has cautions and/or contraindications associated with it for essentially
three possible reasons: the intrinsic toxicity level of the oil itself, irritation to the skin and
mucosa, and spontaneous idiosyncratic reactions (Holmes, 1995, p. 181). The practitioner
must consider a number of factors, including:
Which oils to select
The exact dosage required
The correct dilution of the oils and in what medium
The cautions and contraindications associated with each oil
The duration of the treatment
Although essential oils are considered generally safe (Stevensen, 2001), there are poten-
tial side effects such as neurotoxic and abortive qualities, dermal toxicity, photosensitivity,
allergic reactions, problems with internal usage, and liver sensitivity. Specific untoward
effects include:
Essential oils derived from thuja, wormwood, mugwort, tansy, hyssop, and sage can
cause a toxic reaction if taken internally. Their toxicity is much lower when applied
externally.
Essential oils with a high phenol (disinfectant) content, such as oregano and savory,
should not be taken internally for a period exceeding 10 to 21 days because of negative
effects on liver metabolism.
Clove and cinnamon should be used with caution, as they are known allergens.
Overexposure to oils absorbed via diffuser can result in headaches, fatigue, or allergic
reactions such as streaming eyes and skin problems.
In general, essential oils should not be ingested (Robins, 1999). Balanced formulas rather
than single formulations should be used. However, herbals and essential oils can interact with
prescription and nonprescription drugs, and can have toxic effects. Lack of standardization,
bioequivalence, and limited quality control are also of concern. Education and experience are
Aromatherapy 321
needed in order to learn how to find and treat the root causes of a problem (not just mani-
festations and symptoms). All nurses (as well as other clinicians) should have thorough prepa-
ration before using herbs and essential oils in practice.
SELF-CARE WITH AROMATHERAPY

Aromatherapy can be used for a number of self-care purposes. When used as part of daily
hygiene, gentle antiviral essential oils, such as eucalyptus radiata, ravensera aromatica, and
niaouli can be spread over the skin before, during, or after the morning shower. This practice
strengthens the bodys resistance to sickness during the cold or flu season (Burton Goldberg
Group, 1995). The essential oils of black spruce and peppermint are effective stimulants that
work by strengthening the adrenal cortex. Or, for relaxation, essential oils like citronella and
eucalyptus citriodora can be diffused in the air or rubbed on the wrists, solar plexus and tem-
ples for quick and effective relaxation. Mandarin is favored by children, and its calming qual-
ities can slow down highly active children. Lavender oil added to the bath or sprayed on the
bed sheets reduces tension and enhances relaxation (Buckle, 2001).
Essential oils can also be used to relieve symptoms. For digestive and stress-related dis-
comfort, a drop of anise seed oil taken with a spoon of honey (or by itself) helps to reduce gas-
trointestinal cramping (Burton Goldberg Group, 1995). Tarragon stimulates digestion and
calms the digestive tract. Peppermint is the classic oil for alleviating nausea and travel sick-
ness. It is also beneficial for an irritated colon (1995). Everlast relieves pain after injuries, and
prevents hemorrhaging and swelling. For mosquito and other insect bites, lavender is unsur-
passed in treating itching or stinging (1995). Lavender oil is restorative on burnt skin
(Buckle, 2001). The antihistamines peppermint, anise, and ginger open tightened air passages
(Keville, 1998). Anise and fennel will reduce coughing (1998).
In a randomized study of 51 patients with cancer pain, 1% chamomile nobile was admin-
istered to one group via full body massage once a week for 3 weeks. The other two groups had
either massage without aromatherapy, or neither. When after massage measurements were
compared with before massage, the aromatherapy with massage group had a significant
decrease in anxiety, tension, and pain compared with the other groups. The authors suggest
that since outcomes were measured 1 week after the treatment, aromatherapy using Roman
chamomile can have a lasting effect on pain (Wilkinson, 1995).
NURSING ISSUES
Aromatherapy should be used as only a part of a comprehensive program to enhance well-
being and health. The intent is to balance the body in order to optimize health and wellness
and not wait for signs of illness. Care should be individualized. Given the belief that energy
works at different levels, essential oils work differently in each person. Therefore, the choice
of oil or oils must be individualized for each client.
Clients need to be involved in their own healing. A thorough history is needed as clients
may not think to tell the nurse that they are using essential oils. Historical use is a valid way
to document safety and efficacy in the absence of scientific evidence to the contrary, but aro-
mas should not be released indiscriminately. A smell that is unasked for and that has
unpleasant associations can feel like an invasion of personal space (Avis, 1999, p. 117). The
impact of an aroma decreases over time as the olfactory neurons become accustomed to it, but
people become more aware of a smell each time it is used and, as time passes, are able to detect
smaller amounts. This suggests that constantly bombarding people with an aroma without
altering the concentration is both counter-productive and increases the risk of an adverse
reaction (Avis, 1999).
Aromatherapy is a growing therapeutic modality. As of 2002, aromatherapy has been
accepted as part of nursing practice by the state boards of nursing in Massachusetts, Maryland,
Nevada, New Mexico, New York, Arizona, North Carolina, Oregon, and California, and
other states are considering authorizing its use by nurses (Buckle, 2001).
The emphasis in this chapter has been on the use of herbal therapies and aromatherapies
to promote health and well-being, not to treat disease. Given the lack of regulation, oversight
and standardization of potency, control of quality of herbal preparations and essential oils,
and the possibility of negative interactions with pharmaceutical drugs, the nurse who uses
these therapies needs to have thorough education preparation and supervised experience in
order to practice competently. There is a need for well-designed research to study the holis-
tic effects of phytomedicines and foster individualized therapies that involve clients in their
own healing.
Chapter Key Points

Selected herbs and essential oils have been well studied and appear to be both effective
and low in side effects.
The nurse is urged to pursue thorough educational preparation as a basis for the use of
herbs and essential oils in practice.
There is a professional obligation to restrict the use of herbs and essential oils to the
promotion of health and well-being, and to refer clients to an appropriate medical prac-
titioner for the treatment of disease.
Extracts, which are made with petrochemical solvents, and synthetic chemicals fre-
quently used in perfumes, may cause allergic or sensitizing reactions and should not be
used for aromatherapy.
References
Ang-Lee, M. K., Moss, J., & Yuan, C. (2001). Herbal medicines and perioperative care. Journal of the Ameri-
can Medical Assoication, 286, 208-216.
Avis, A. (1999). When is an aromatherapist not an aromatherapist? Complementary Therapies in Medicine,
7, 116-118.
Ballentine, R. (1999). Radical Healing. New York: Harmony Books.
Barrett, B., Kiefer, D., & Rabago, D. (1999). Assessing the risks and benefits of herbal medicine: An
overview of scientific evidence. Alternative Therapies in Health and Medicine, 5, 40-49.
Berman, B. M., & Larson, D. B. (Eds). (1994). Alternative medicine: Expanding medical horizons. Washing-
References 323
Buckle, J. (1999). Use of aromatherapy as a complementary treatment for chronic pain. Alternative Thera-
pies, 5, 42- 51.
Buckle, J. (2000, February/March).The M technique. Massage and Bodywork, 52-64.
Buckle, J. (2001). The role of aromatherapy in nursing care. Nursing Clinics of North America, 36, 57-74.
Burton Goldberg Group. (1995). Alternative medicine: The definitive guide. Fife, WA: Future Medicine Publishing.
Campbell, L., Pollard, A., & Boeton, C. (2001). The development of clinical practice guidelines for the
use of aromatherapy in a cancer setting. Australian Journal of Holistic Nursing, 8, 14-22.
Cardinal, B. J., & Engels, H. J. (2001). Ginseng does not enhance psychological well-being in health,
young adults: Results of a double-blind, placebo-controlled, randomized clinical trial. Journal of
the American Dietetic Association, 101, 655-660.
Clark, C. C. (1996). Wellness practitioner: Concepts, research and strategies (2nd ed.). New York: Springer.
Coleman, S. (2001, July 30). Proceed with caution. Advance for Nurses, 23-24
Coss, H., & Cott, J. (2002). Herbal medicine. In S. Shannon (Ed.), The handbook of complementary and
alternative therapies in mental health (pp. 377-400). San Diego: Academic Press
d'Angelo, R. (2002). Aromatherapy. In S. Shannon. (Ed.), Handbook of complementary and alternative ther-
apies in mental health (pp. 72-92). San Diego: Academic Press.
DEpiro, N. W. (Ed.). (1997, October 15). Herbal medicine: What works, whats safe. Patient Care, 49-77.
DeSmet, P. A. G. M. (2002). Herbal remedies. New England Journal of Medicine, 347, 2046-2054.
Dog, T. L. (1999). Phytomedicine. In W. B. Jonas, & J. S. Levin (Eds.), Essentials of complementary and alter-
native medicine (pp. 355-368). Philadelphia: Lippincott Williams & Wilkins.
Eastman, P. (1999). Drugs that fight can hurt you. American Association of Retired Persons Review, 40, 14-16.
Ernst, E., & Pihler, M.H. (2002). Herbal medicine. Medical Clinics of North America, 86, 149-161.
Glickstein, J. K. (1996). Motivation in geriatric rehabilitation. Focus on Geriatric Care and Rehabilitation,
9, 1-8.
Holmes, P. (1995, April/May). Aromatherapy: Applications for clinical practice. Alternative and Comple-
mentary Therapies, 177-182.
Horowitz, S. (1999). Aromatherapy: Modern applications of essential oils. Alternative and Complimentary
Therapies, 5, 199-203.
Integrative Medicine Consult. (1998). A primer: Integrative medicine. Boston: Integrative Medicine
Communications.
Izzo, A. A., & Ernst, E. (2001). Interactions between herbal medicines and prescribed drugs: A systematic
review. Drugs, 61, 2163-2175.
James, K. (1998). In M. Snyder & R. Lindquist, Complementary/Alternative therapies in nursing. New York:
Springer.
Jonas, W. B., & Ernst, E. (1999). Evaluating the safety of complementary and alternative products and prac-
tices. In W. B. Jonas & J. S. Levin (Eds.), Essentials of complementary and alternative medicine (pp.
89-107). Philadelphia: Lippincott Williams & Wilkins.
Keville, K. (1998). Breathe easy with aromatherapy. Great Life, 18-20.
Landis, R. (1997). Herbal defense. New York: Warner.
Larson-Presswalla, J. (1994). Insights into eastern health care: Some transcultural nursing. Perspectives:
Journal of Transcultural Nursing, 5, 21-24.
Meserole, L. (1996). Western herbalism. In M. S. Micozzi (Ed.), Fundamentals of complementary and alter-
native medicine. New York: Churchill Livingstone.
Mills, S., & Bone, K. (2000). Principles and practice of phytotherapy. Edinburgh, Scotland: Churchill Livingstone.
Murray, M. T. (1995). The healing power of herbs (2nd ed.). Rocklin, CA: Prima.
Pizzorno, L. (1997, July). Tracing the roots of American herbalism. Delicious, 30-34.
Prescribers Letter. (1998). Continuing education therapeutic use of herbs. Stockton, CA.
Robins, J. L. W. (1999). The science and art of aromatherapy. Journal of Holistic Nursing, 17, 5-17.
Soukanov, A. H. (Ed.). (1992). The American heritage dictionary (3rd ed.). Boston: Houghton Mifflin.
Stevensen, C. J. (2001). Aromatherapy. In M. S. Micozzi (Ed.), Fundamentals of complementary and alterna-
tive medicine (2nd ed., pp. 146-158). New York: Churchill Livingstone.
Tyler, V. E. (1993). The honest herbal. A sensible guide to the use of herbs and related remedies (3rd ed.). Bing-
hamton, NY: Pharmaceutical Products.
Wilkinson, S. (1995). Aromatherapy and massage in palliative care. International Journal of Palliative Nurs-
ing, 1(1), 21-30.
World Health Organization. (1991). Guidelines for the assessment of herbal medicines: Programme on tradi-
tional medicines. Geneva, Switzerland: Author.
Additional Information
ASSOCIATIONS AND CREDENTIALING
Chinese Herbal Medicine
National Commission for the Certification of Acupuncture and Oriental Medicine
1421 16th Street N. W. Suite 501
Washington, D. C. 20036
www.nccaom.org
This is the accrediting body of schools. The student must graduate from an accredited
school before sitting for the state board exam or national certification commission exam. In
some states, NCCAOM certification is the only educational, training, or examination cri-
teria for licensure. Other jurisdictions have set additional eligibility criteria. Training in
Chinese herbal medicine is part of the total training in acupuncture and oriental medicine.
The programs range in length from 2 to 4 years depending on the state requirements and
degree level.
Aromatherapy
National Association for Holistic Aromatherapy
PO Box 17622
Boulder, CO 80308
Tel: (888) ASK-NAHA
www.naha.org
At the moment, there is no recognized national certification examination. There is no

governing body at present, but the steering committee for Educational Standards in Aro-
matherapy in the United States is currently setting up the Aromatherapy Registration Board,
which as a nonprofit entity will be responsible for administering a national exam and pro-
viding the public with a list of registered practitioners.
Jane Buckle is director of R. J. Buckle Associates LLC, an educational consulting firm in
complementary therapies. Her website is www.rjbuckle.com.
13
RE-ESTABLISHING ENERGY FLOW
Physical Activity and Exercise
Abstract
Movement of energy is essential for a persons well-being. Physical activity or physical
exercise (disease perspective) and energy exercise (person perspective) are different
approaches to the movement of energy. Although activity and exercise have many benefits,
most adults are, however, sedentary. Therefore, a number of strategies are proposed to encour-
age clients to adopt a more active lifestyle. In addition, the Chinese energy exercises of tai
chi and qigong are introduced. These exercises use breathing, mental concentration, and
physical postures to facilitate the flow of energy throughout the body.
Learning Outcomes
Differentiate between elements of physical activity and exercise
Describe benefits of physical exercise
Describe positive and negative motivating factors for exercise
Identify strategies to encourage clients to adopt a more active lifestyle
Discuss strategies to encourage walking activity
Discuss special physical activity considerations for the elderly client
Demonstrate tai chi and qigong postures and forms
328 Chapter 13 Re-establishing Energy Flow: Physical Activity and Exercise
Physical Activity
Movement of energy is essential for a persons well-being. In the physical body, energy flow
is associated with the movement of skeletal muscles. In fact, a broad definition of physical
activity is any bodily movement produced by skeletal muscles that results in energy expen-
diture (Caspersen et al., 1985, p. 126). Numerous short bouts of moderate physical activity
that can be planned into activities of daily living has been called lifestyle physical activity (Pen-
der, 2002).
Scientific evidence clearly demonstrates that regular, moderate-intensity physical activity
provides substantial health benefits. However, low levels of physical activity continue to be
a major public health challenge in almost every population group of developed countries
(Dubbert, 2002). Therefore, it is important that integrative health promotion activities
include the encouragement and facilitation of physical activity and exercise by children and
adults.
Many people erroneously believe that to reap health benefits they must engage in vigor-
ous, continuous exercise, although it is clear that regular moderate physical activity provides
substantial health benefits. Pate and colleagues (1995) suggest that 30 minutes or more of
moderate-intensity physical activity is needed on most, preferably all, days of the week. Phys-
ical activity can be accumulated in relatively short bouts, enough to expend approximately
200 calories per day (e.g., walking briskly at 3 to 4 mph), conditioning exercise or general cal-
isthenics, or home care and general cleaning).
The current emphasis for physical activity is on total daily energy expenditure, which can
be achieved in a number of ways. The amount of activity, including the mode, intensity, and
duration, is more important than the specific manner in which the activity is performed.
Physical activity does not need to be continuous, and Pate and colleagues (1995) propose that
most adults do not need to see their physician before starting a moderate-intensity physical
activity program.
Even intermittent activity confers substantial benefits. The recommended 30 minutes of
activity can be accumulated in short bouts of activity, such as 8 to 10 minutes of walking up
the stairs instead of taking the elevator, walking instead of driving short distances, doing cal-
isthenics, or pedaling a stationary cycle while watching television. Gardening, housework,
raking leaves, dancing, and playing actively with children can also contribute to the 30-
minute-per-day total if performed at an intensity that corresponds to brisk walking. Those
who perform lower-intensity activities should do them more often for longer periods of time,
or both, and people who prefer more vigorous exercise may choose to walk or participate in
more vigorous activities, such as jogging, swimming, or cycling for 30 minutes daily. Sports
and recreational activities, such as tennis or golf (without riding a cart), also can be applied
to the daily total.
A more active lifestyle for people who lead sedentary lives would benefit the publics
health and individual well-being (American College of Sports Medicine, 2000). Persons of
all ages can improve their energy circulation and lower their risk for many chronic diseases
(Nieman, 1998). Any level of activity above the sedentary state is helpful for weight loss.
However, the evidence to date shows that to be beneficial in reducing long-term risk for coro-
nary artery disease, exercise (specifically aerobic exercise) is necessary.
Physical Exercise 329
Physical Exercise
Physical exercise has been defined as a subset of physical activity that is planned, structured,
and repetitive and has as a final or intermediate objective towards the improvement or mainte-
nance of physical fitness (Caspersen et al., 1985, p. 126). Therefore, physical exercise is a spe-
cific form of physical activity associated with desired outcomes of fitness, flexibility, and balance.
According to Caspersen, Powell, and Christenson (1985), being physically fit is the
ability to carry out daily tasks with vigor and alertness, without undue fatigue and with
ample energy to enjoy leisure-time pursuits and to meet unforeseen emergencies (pp. 128-
129). Physical fitness encompasses cardiorespiratory and muscular endurance, muscular
strength, body composition, and flexibility. Strength is the ability of a muscle or muscle
group to exert force against resistance (Griffin, 1998). Flexibility is the capacity of a joint
to move freely through a full range of motion without undue stress (1998, p. 72), while bal-
ance involves the ability to maintain equilibrium while standing still or moving (Caspersen
et al.,1985).
The capacity for physical performance is determined by the capacity for energy output (aer-
obic and anaerobic mechanisms), neuromuscular functions (strength, technique, and coordi-
nation), and psychosocial factors (motivation, social support) (Allan, 1992). When intense
enough to lead to a significant increase in muscle oxygen uptake, exercise is defined as aero-
bic. The goal of aerobic exercise is to strengthen the cardiovascular system and increase stam-
ina. In contrast, anaerobic exercise is exercise during which the energy needed is provided
without utilization of inspired oxygen. This occurs during short, vigorous bouts of exercise or
when the bodys oxygen supply capabilities cannot meet the metabolic demands of the exercise.
The heart rate is a simple measure of whether or not exercise is aerobic. If the pulse
reaches or exceeds a level of 60% of the theoretical maximum normal, age-adjusted heart rate
(220 minus the persons age), or 0.6 (220 minus age), the exercise is considered aerobic... To
assure that exercise intensity remains at a safe level, the pulse rate should remain below 85%
of the persons theoretical maximum rate (Jonas, 1996, p. 177). A formula for calculating a
safe rate for aerobic exercise is maximum heart rate age resting heart rate 0.6 and 0.8
resting heart rate.
Treat-Jacobson and Mark (1998) suggest that in order to assess the heart rate, the nurse should:
1. Determine the heart rate one-third to one-half of the way through and immediately
after stopping exercise
2. Assess whether the individual can talk comfortably while exercising
3. Rate the sense of effort from 1 to 10 (10 is maximal)
Another approach to calculating desirable exercise intensity is a rating of perceived exer-

tion (RPE), a subjective measure of exercise intensity that takes into account the clients
feelings of exercise fatigue, including musculoskeletal, psychological, and environmental fac-
tors (Griffin, 1998, p. 96). The Borg Scale of Perceived Exertion assigns a numerical value
to subjectively perceived exertion between 6 (no exertion at all) and 20 (maximal exertion).
RPEs from a graded exercise test can be used independently or in combination with heart rate
to prescribe exercise training intensities (Griffin, 1998).
BENEFITS OF EXERCISE
Exercise improves the cardiovascular system; improves the strength, endurance, and flexi-
bility of the muscular system; induces positive changes in the skeletal, digestive, and immune
body systems; and lowers serum lipids and blood pressure (Zelasko, 1995). Pender (2002) doc-
uments many specific benefits of exercise.
RESEARCH FINDINGS
Physical activity and physical exercise have been found to have a number of beneficial
effects for primary, secondary, and tertiary prevention of a number of chronic diseases. Below
are a sampling of recent research findings:
Regular exercise improves psychosocial well-being (Donker, 2000; Sharkey et al., 2000).
The protective effect of physical exercise is not proportional to frequency or intensity
(Donker, 2000).
Unequivocal evidence for the favorable effects of physical exercise on cardiovascular
morbidity is not yet available, although cardiovascular mortality seems to be reduced
(Sebregts et al., 2000, p. 431).
In general, physical fitness and activity are related to lower levels of cardiovascular
arousal during and following mental stress helps to buffer the body against the ill
effects of mental stress (Nieman, 1998, p. 234), can reduce depression (p. 255), reduce
anxiety (p. 257), and improve self-esteem or self-concept (p. 258).
Even light activity such as walking has been shown to reduce the risk for hyperten-
sion in a dose-related manner and does so independently of other risk factors
(Hayashi et al., 1999). However, the blood pressure-lowering effect of exercise
training depends on a regular schedule of activity (American College of Sports
Medicine, 1993).
Several studies have found a statistically significant inverse relation between physical
activity and the risk of stroke in men and women (Bronner et al., 1995; Hu et al., 2000).
Despite statistically significant improvements in bone density after exercise, fracture reduc-
tion due to exercise remains questionable, but the risk of falls in older persons may be
reduced. Exercise must be continued to maintain gains in bone mass (NIH Consensus
Panel, 2001; Sharkey et al., 2000), but walking does not prevent bone loss (Nieman, 1998).
Given that fairly rigorous activity is necessary to maintain bone mass in post-
menopausal women, building greater bone mass in our younger years is probably a
more realistic and beneficial method of preventing or delaying the onset of osteoporo-
sis (Sharkey et al., 2000).
Carefully controlled exercise in people with osteoarthritis of the knee and hip is asso-
ciated with increased joint mobility, increased strength, reduced pain, reduced reliance
on medication, enhanced proprioception, enhanced activity performance, and reduced
disability (Sharkey et al., 2000), although exercise training does not improve the under-
lying disease process (Nieman, 1998).
In general, exercise programs that facilitate weight loss, trunk strengthening, and the
stretching of musculotendinous structures appear to be most helpful in alleviating low
back pain (Patel & Ogle, 2000, p. 1785). It appears that a return to normal, daily activ-
ities may be superior to either bed rest or specific back exercises in acute low back pain
(Nieman, 1998).
There is convincing support for the role of regular physical activity in the prevention
of noninsulin-dependent diabetes mellitus (NIDDM). For most individuals with
NIDDM, regular exercise improves glycemic control. In addition, regular exercise will
reduce the insulin requirements of well-controlled insulin dependent diabetes mellitus
[clients] by 30% to 50% (Nieman, 1998, p. 97), resulting in smaller than usual insulin
doses or increased food intake.
Moderate exercise provides a short-term boost that appears to reduce the risk of infec-
tion over the long-term (Nieman, 1998).
Regular exercise reduces the odds of gaining weight with age. But exercise does not
accelerate weight loss significantly when combined with a reducing diet (Nieman,
1998, p. 234). In addition, moderate amounts of exercise appear to have little if any
effect in countering the 10% to 30% decrease in resting metabolism associated with
dieting (p. 238).
Nearly all studies have shown that death rates for all causes combined are lower in
physically active and fit people when compared to those who largely avoid exercise. In
practical terms, middle-aged adults who are physically active gain on average about 2
years of life (Nieman, 1998, p. 295).
Prompting, in the form of weekly brief prompts, is a low-cost strategy for increasing exer-
cise and physical activity among older women (Conn et al., 2003). On the other hand, mass
media approaches such as radio and television have not produced physical activity behavior
change, despite good recall (Dubbert, 2002).
EXERCISE EPIDEMIOLOGY
Healthy People 2010 sets goals for 30% of adults and adolescents to engage in moderate
physical activity, preferably daily, for 30 or more minutes (Pender, 2002). Unfortunately, 41%
to 51% of adults are sedentary. Of those already regularly engaged in either group or solitary
exercise, about 50% will discontinue activity at some time in the coming year . . . . The rate of
participation typically drops within the initial 3 to 6 months, then plateaus and continues a
gradually decreasing but linear pattern across the next 12 to 24 months. Individuals who are
still active after 6 months are likely to remain active a year later (Dishman et al., 1985, pp.
159, 162). Lack of physical activity starts early in life. By age 10, more than one-third of chil-
dren have adopted a sedentary lifestyle (Pender, 2002).
Research has shown that exercise participation varies with persons ethnic, gender, educa-
tional, and occupational characteristics. Some examples include (Marcus et al., 1997; Pate et
al., 1995):
African Americans and other ethnic minority populations are less active than white
Americans, and this disparity is more pronounced for women.
People with higher levels of education participate in more leisure-time physical activ-
ity than do people with less education. Differences in education and socioeconomic sta-
tus account for most, if not all, of the differences in leisure-time physical activity
associated with race or ethnicity.
White-collar workers may be more likely to engage in leisure time recreational activities
than blue-collar workers. It has been shown that blue-collar workers and smokers are likely
dropouts from cardiac rehabilitation exercise programs and corporate exercise programs.
Negative health status variables (e.g., smokers, being overweight) appear to predict
inactivity. Overweight persons are unlikely to continue a fitness program. Knowledge
of ones health status may prompt adoption of activity, but it does not appear to facili-
tate maintenance of activity.
Men are more likely than women to engage in regular activity, in vigorous exercise,
and sports.
The total amount of time spent in physical activity declines with age.
MOTIVATION
A number of motivational factors that may affect exercise participation and persistence
have been identified. However, none of these factors alone appears to be able to predict
whether someone will initiate or continue exercise. People drop out of lifestyle activities at a
rate of approximately one-half of that typically seen for vigorous exercise (Dishman et al.,
1985). It appears that an individuals exercise participation and persistence may be affected
by complex and variable interactions among many factors. A number of the most important
possible influencing factors include:
Positive Exercise Factors

Belief in the health benefits of exercise and short-term advantages such as feeling good,
improving personal appearance, and increasing self-esteem are strong incentives for
physical activity and exercise (Jonas, 1996; Marcus et al., 1997).
Risk reduction. In contrast, the reduction of risk for future disease or illness is not an
incentive. Most regular exercisers do not engage in activity to achieve future risk reduc-
tion, and few nonexercisers start for that reason (Jonas, 1996). Many people require a
challenge before they realize that a sedentary lifestyle is a threat (Allan, 1992).
Past participation. Previous participation in exercise or sports activity is related to cur-
rent participation.
Social support. The social support of a spouse has been identified as a strong predictor
of exercise maintenance for women. Individuals who exercise with their spouses have
higher rates of exercise adherence than those who exercise alone (Marcus et al., 1997).
Self-efficacy. Self-efficacy, the degree of confidence individuals have that they can par-
ticipate in a healthful behavior across a broad range of specific, salient situations, is an
important determinant of physical activity.
Decisional balance. The balance between pros and cons of exercise has been shown to
be an important determinant of participation in physical activity.
Convenience. Moderate-intensity home-based exercise programs have higher adher-
ence rates and produce fitness and psychological benefits comparable to those produced
by higher-intensity group programs, at least among retirees.
Self-motivation. Self-motivated persons also appear less sensitive to activity barriers,
such as inconvenience or competing lifestyle behaviors (Dishman et al., 1985, p. 165).
Perceived exercise enjoyment. Feelings related to well-being and enjoyment seem more
important to maintaining activity than concerns about health. Initial involvement may
be motivated by knowledge of and belief in the health benefits of physical activity, but
continued participation seems to be motivated more by feelings of enjoyment and well-
being (Dishman et al., 1985).
Perception of being in good health.
Motivation for Physical Activity

Methods of motivation for physical activity include (Phillips, Schneider, & Mercer, 2004):
Education about activity benefits and practice
Promotion of goal-oriented, gradual activity progression
Addressing costs and affordability
Addressing safety
Adapting activities and equipment for less able-bodied people
Treating concurrent morbidities
Facilitating empowerment
Giving written prescriptions on a prescription pad
Focusing on accessibility and affordability
Promoting socialization
Providing physical and occupational therapy
Negative Exercise Factors

Environmental barriers. Actual and perceived practical factors such as the safety,
availability, and geographic proximity of community facilities, weather, financial consider-
ations, and both work and childcare schedules consistently predict the amount of
participation in vigorous activity in men and women.
Lack of time and energy. Unmarried women report participation in significantly more
vigorous activity than married women. Having children is related to perceived lack of
time for exercise. It has been suggested that dropping out may reflect a lack of inter-
est, intention, or commitment, even though the reason given is lack of time (Marcus
et al., 1997).
Limited access to training and information about physical activity. Few physicians and
nurses routinely give advice about physical activity, therefore the popular media often
serve, by default, as an important source of information (Marcus et al., 1997).
Lack of readiness to exercise. Only about 10% of the population are ready. For exam-
ple, girls experience a substantial reduction in physical activity during adolescence
(Marcus et al., 1997).
Lack of role models. Most women do not have peer role models for appropriate kinds
and levels of physical activity. Perceived barriers may frequently reflect inadequate
motivation to be active rather than reasons for inactivity. This can be a critical dis-
tinction, because no data support the notion that removing stated barriers leads to
increased activity (Dishman et al., 1985, p. 166).
Lack of encouragement by health care providers. Only a minority of physicians per-
ceive exercise as very important for the average person, and fewer than 50% rou-
tinely ask [clients] about their exercise habits... Important barriers to exercise
counseling by physicians include perceived lack of counseling skills, lack of confi-
dence in counseling ability, perceived ineffectiveness of counseling, lack of organiza-
tional support, little or no reimbursement for preventive counseling, and limited
availability of materials to aid both the [client] and the physician (Marcus et al.,
1997, p. 345).
Lack of self-regulatory skills. Interventions that teach goal setting, planning, self-
monitoring, self-reward skills, and how to make plans to prevent relapse, can increase
short-term participation among people who intend to exercise (Dishman et al., 1985).
Disruption of exercise routine. Unexpected disruption in an activity routine or its set-
ting can interrupt or end even a previously continuous exercise program, but there is
less of an impact by stressful events as the activity habit becomes more established
(Dishman et al., 1985).
RISKS OF EXERCISE
Intrinsic injury may be caused by the nature of the activity or sport (e.g., shin splints in
running) and can be decreased or prevented by the use of proper equipment and correct tech-
nique. Extrinsic injury is caused by an external factor (e.g., a cyclist is hit by an automobile)
and overuse injury, which results from trying to go too far, too fast, too frequently, and can be
prevented by choosing a suitable sport and workout schedule, and by maintaining moderation
in distance, intensity, and speed (Jonas, 1996).
Regular exercise presents a definite risk for persons with previous myocardial infarction;
exertion chest pain or pressure, or severe shortness of breath; pulmonary disease, especially
chronic obstructive pulmonary disease; or bone, joint, or other musculoskeletal diseases. In
addition, regular exercise presents a possible risk for persons with hypertension; cigarette
smokers; those with high blood cholesterol; prescription medication users; abusers of drugs or
alcohol; or those with any other chronic illness such as diabetes mellitus.
Given the complexity of positive and negative factors for physical activity and exercise,
nursing interventions must be carefully designed and personalized based on individual needs
and preferences. The following section will discuss factors to be considered in designing an
activity or exercise regimen.
EXERCISE INTERVENTION STRATEGIES

Exercise must be an integral part of personal lifestyle if it is to have optimum effects on
health. However, most interventions have lasted only 3 to 10 weeks (Dishman et al., 1985,
p. 164) despite the fact that it takes adults 20 to 30 weeks of regular physical activity to reach
an optimal training level (Allan, 1992).
Despite the obvious multiple health benefits, few professional nurses even try to intervene
to promote integration of activity and exercise into a clients lifestyle. Part of the problem may
be that relatively few nurses have integrated regular physical exercise into their own lifestyle,
even though role modeling an active lifestyle is an important part of effective physical activ-
ity counseling by health care providers. Not surprisingly, physically active nurses are more
likely to counsel patients regarding physical activity than nurses with sedentary lifestyles.
Another concern is the possible lack of knowledge among health professionals. Many
physicians and nurses have not received adequate training about exercise science or behav-
ioral counseling in their educational programs. Due to currently limited curricular content, it
is improbable that nurses prepared at the baccalaureate and graduate levels are prepared to
deliver health promotion and prevention services, including physical-activity counseling.
The following discussion highlights a number of nursing considerations and strategies that
can empower clients to adopt a more active lifestyle.
Goals and Motivation

It is important to consider what goals the person wants to accomplish and why? Realistic
goal setting by the client in terms of limits and limitations is essential (e. g., become fit, lose
weight, look and feel better, reduce future risk of disease and conditions).
In addition, what is the clients inner motivation? The only kind of motivation that works
in the long run for positive lifestyle and behavior change comes from within . . . Purely exter-
nal motivation... almost invariably leads to guilt, anxiety, anger, frustration, and, usually,
injury and/or quitting (Jonas, 1996, p. 181).
Gradual Changes
Changes should be introduced gradually in order to promote permanent change. The previ-
ously sedentary person should start with ordinary walking, at a normal pace, for 10 minutes or
so, three times a week. After a couple of weeks, the length of each session can be increased, fol-
lowed by an increase in the frequency of sessions. After several more weeks, the speed with
which the exercise is performed can also be increased (Jonas, 1996). The activity should be
stopped if untoward symptoms occur. Warm-up exercises should be done for 10 minutes, involve
all major body parts, and achieve a heart rate within 20 beats per minute of the target heart rate
for the following aerobic exercise (Treat-Jacobson & Mark, 1998). For cool down, 5 to 10 min-
utes are needed for the body to adjust to a slower pace. Cooling down exercises may include
walking slowly, deep breathing, and stretching exercises (Treat-Jacobson & Mark, 1998).
Regularity of Exercise
Regularity is critical to the effectiveness of physical exercise. The focus of the first 2 to 4
weeks of an exercise program should focus on the challenge of making the time. A total of 30
minutes daily of moderate-intensity physical activity should be performed on as many days of
the week as possible (Jonas, 1996). A daily routine helps to reinforce participation. Weil (1999,
p. 3) suggests an unthinking routine, such as exercising first thing in the morning before youre
really awake and can talk yourself out of it, as a strategy for establishing discipline.
Integrating Activity and Exercise into Daily Life

Activity and/or exercise should be integrated into daily life. Opportunities to get physical
are everywhere, and include parking the car in a far corner of the mall parking lot, walking
down the hall to speak with a co-worker rather than sending an e-mail message, jumping rope
during TV commercials, and cleaning up the house (Weil, 1999). It is important for the client
to take control of his or her behavior. The client must have and be aware of options and con-
sider some of the options feasible.
Making Exercise Fun

How can exercise be made to be fun? Exercise actually increases energy. So if you feel run
down, recharge your batteries by moving around (Weil, 1999, p. 3). Jonas (1996) suggests a
number of strategies to make exercise more fun:
Positive anticipation is very important.
Set appropriate goals. Avoid doing too much, too soon.
For distance sports, train by minutes, not miles. Recognize that, in many distance sports
in which concentration on technique is not required, time spent is uniquely private,
thinking time.
While exercising, listen to music, the news, or talk shows through a headset.
Set nonexercise-related goals, like getting an errand or two completed in the course of
a workout.
Periodically reward oneself, with a new piece of clothing, or a long-denied snack treat.
Exercise outdoors.
Vary activity from day to day.
Incorporate activities already enjoyed (e.g., working in the garden, bike-riding with the
kids) into an exercise program.
Social Support
A positive therapeutic relationship with the nurse or other health care provider is a strong
source of social support. Other sources of social support include a spouse (the spouses attitude
can be more important than that of the participant), other family members, an activity part-
ner, or a friend. Follow-up visits should be scheduled on a regular basis to assess progress and
concerns. Manifestations of exercise patterns are identified through the frequency/intensity
and strength/harmony of the behaviors (Weil, 1999).
Cognitive-Behavioral Strategies
King (1994) identified a number of cognitive-behavioral strategies that appear useful in pro-
moting at least short-term exercise adherence. These include goal-setting, feedback through
progress charts, decision balance sheets, relapse-prevention training, written agreements and
contracts, stimulus control strategies, contingency management, face-to-face individual coun-
seling by health care professionals or personal trainers, videotapes, booklets, self-help kits and
correspondence courses, telephone-based interventions, and/or recognition of
accomplishments through a system of rewards, and provision of qualified, enthusiastic leaders.
Health communications that are tailored for the individual have promise as a strategy to pro-
mote the adoption and maintenance of physical activity and exercise (Robbins et al., 2001).
Group or class formats have particular advantages and disadvantages that are presented in
Box 13-1.
B OX 13-1
Advantages and Disadvantages of Using
Groups to Promote Exercise
Advantages of group or class formats include:
Potentially more cost-effective
On-site supervision
Visual modeling by the instructor (culturally and demographically similar
to the population segment being targeted)
A set structure with respect to location, exercise format, and time
Face-to-face encouragement by the instructor
Potential peer support.
Social reinforcement, camaraderie, and companionship
Disadvantages of a group format include:

The inconvenience of getting to class several times a week, along with
constraints related to class schedules
A limited variety of activities, which, in contrast with many peoples pref-
erences, typically take place indoors
Constraints on individualizing the regimen for the individual.
The expense of fees, equipment, and special attire
Social costs, such as embarrassment or discouragement, that may develop
from the social comparisons that inevitably occur in groups
Group leader effects. May involve dislike of the leaders style or disruptions
in the class or group that inevitably occur with leader absence or turnover
ENVIRONMENTAL AND POLICY APPROACHES TO EXERCISE PROMOTION

Given the documentation of intrapersonal, interpersonal, social/cultural, and physical
environmental correlates of physical activity, a multilevel ecologic approach seems to be
demanded (Bauman, Sallis, Dzewaltowski, & Owen, 2002).
The health belief model has failed to receive clear support in the literature on adult phys-
ical activity correlates (Bauman et al., 2002).
Linkages between individual, environmental, and policy interventions improve the likelihood
of impact (Orleans et al., 1999). Many environmental or policy approaches focus on changing
aspects of a setting/environment or establishing public policy to promote physical activity or exer-
cise. Some examples are providing security escorts for groups of participants walking in dangerous
neighborhoods; installing curtains on the windows in the exercise room to ensure privacy; mak-
ing free transportation and child care available; adjusting the physical education curriculum in
schools to include more class time spent in moderate and vigorous physical activity; addressing
physical activity in work sites, places of worship, and to an increasing degree, senior centers and
senior residential settings; organizing races and fun runs or walking events to increase community
awareness concerning physical activity; providing safe and accessible pedestrian and bicycle lanes
available throughout the community; making stairways more open, accessible, and attractive;
requiring activity promotion ads on TV and after movies; providing funding for walking or bik-
ing trails; subsidizing health club memberships for employees; and providing public transportation
that allows residents ready access to community exercise settings (Sallis et al., 1998).
PHYSICAL ACTIVITY FOR WEIGHT REDUCTION

When trying to lose weight, physical activity should be targeted in combination with other
behaviors. A combined program of dietary change and regular exercise is more effective at
facilitating weight loss than either strategy alone. In addition, successful weight loss may serve
as an incentive for maintaining exercise adherence. Regular exercise may also help moderate
the weight changes that many smokers fear following smoking cessation and, thus, enhance
mood and other psychological outcomes during and after quitting.
WALKING AS PHYSICAL ACTIVITY

Walking requires no special equipment, facilities, or new skills. It is also safe and rela-
tively easy to maintain. Intensity, duration, and frequency are easily regulated and adjusted
(Treat-Jacobson & Mark, 1998, p. 28). Zelasko (1995) and Jonas (1996) suggest an emphasis
on consistency first, then duration, intensity, and frequency. Workouts should be measured in
minutes not miles, with a goal of maintaining a lifetime of increased physical activity. Strate-
gies to encourage walking activity are presented below:
Wear well-fitting lace-type shoes that provide good support and shock absorption.
Proper fit means that the shoe should be shaped like ones foot; it should touch ones
foot in as many places as possible, except over the toes; it should be flexible under the
ball of the foot; and it should have a firm heel counter to keep the heel down in the
shoe (Jonas, 1996, p. 188).
Wear thick socks that will absorb perspiration and protect the feet.
Wear comfortable, loose-fitting clothing appropriate to the temperature and weather.
Walk at a rate designed to bring the heart rate to target levels; 3 to 3.5 mph may be a
good training pace for the average person.
Walk in an easy, balanced position, head upright, looking ahead rather than directly at
the ground, arms swinging easily with each stride, using a slight push-off step with the
rear foot and leaning forward just slightly with each step. Take long, easy steps from the
hip, landing on the heel and rolling over the foot in a smooth motion. Avoid reaching
for too long a step.
Walk continuously, frequent stops and starts interfere with the aerobic effect.
Walk in an interesting area at a suitable time of day. Try to set aside the same time each
day for the walk. Walk with others, if desired.
When walking up or down steep hills, lean forward slightly and shorten the stride a bit
to maintain a balanced pace.
Start slowly, but gradually increase distance and time until desired maximums are
achieved. Keeping a log of accomplishments enhances motivation.
Cool down with a flexibility program, a slower paced walk for another block or two, or
some gently conditioning exercises.
SPECIAL CONSIDERATIONS FOR THE ELDERLY CLIENT

Physical activity is one of the most significant health interventions in the lives of older
individuals (OBrien & Vertinsky, 1991). Benefits within weeks include short-term enhance-
ment of physical, social, and emotional well-being. Intervention studies generally provide
support for positive cardiovascular changes with exercise, although results are inconsistent
(Houde & Melillo, 2002). There are also numerous long-term contributions to prolonged
good health, including:
Resistance to illness
Optimization of self-care and functional independence
Reduced mortality risk
Reduced bone loss in postmenopausal women
Overall increased quality of life with extended longevity
Stress reduction
Better sleep
Muscle relaxation and improvement in joint mobility
Positive mood states
Improved self-image and self-concept
Short-term improvements in memory, intelligence, and cognitive speed

Higher levels of self-efficacy, internal locus of control, and sense of life control
However, many older individuals are afraid to exercise. Nigg and colleagues (1999), in a
study using the transtheoretical model (TTM), found that most older individuals were in pre-
contemplation for exercise (See Chapter 8, Promoting Individual Behavior Change, for discus-
sion of the transtheoretical model). Among older women, factors such as fear of wearing out
the body, concern about the likelihood of serious injury, and the threat of sudden death caused
by physical exertion contribute to an avoidance of exercise. Many older people do not believe
that they can improve their health through exercise and question their ability to participate in
exercise. However, research indicates that by strengthening self-efficacy and outcome expec-
tations, exercise participation by older individuals can be increased (Resnick et al., 2000).
A wellness program for the elderly should include activities designed to improve strength,
increase (shoulder, trunk, and hip) flexibility, promote endurance, improve balance and coor-
dination, be enjoyable, and fit into the persons lifestyle (May, 1990). May (1990) suggests
guidelines for an overall fitness program for well older individuals that are listed in Box 13-2.
B OX 13-2
Guidelines for a Fitness Program
for Healthy Older Individuals
A fitness program for healthy older individuals should be:
Safe, in that the potential for injury is minimized
Designed to improve muscle strength, flexibility, endurance, coordina-
tion, balance, and functional capabilities
At an intensity level to provide a training effect
Designed to include a variety of slow and fast activities including a warm-
up and cool-down period
Structured to allow participants to lower the level of participation, if
desired
Designed to give participants an understanding of the purpose of the exer-
cise and what sensations may be elicited
Performed regularly, at least three to five times per week
Performed for at least 30 minutes and preferably 1 hour each time
Designed to fit within the lifestyle and interests of the client to encourage
consistency of participation over time.
Energy Exercise 341
It is unclear which physical activity interventions are most effective among older adults.
Van der Bij and colleagues (2002) evaluated 38 randomized controlled trials. All three of the
types of interventions identified, home-based, group-based, and educational resulted in small
and short-lived changes in physical activity, but participation declined the longer the dura-
tion of the intervention. It was not evident that behavioral reinforcement strategies were
beneficial. The authors concluded that comparative studies evaluating the effectiveness of
diverse interventions are needed.
Resnick (1999) suggests that exercise programs for older individuals can be designed using
a seven-step approach. The steps are presented in Box 13-3.
B OX 13-3
A Seven-Step Approach to Exercise
Programs for Older Individuals
Step 1: Education
Step 2: Exercise prescreening
Step 3: Setting goals or making a contract
Step 4: Exposure to exercise
Step 5: Exposure to role models
Step 6: Verbal encouragement
Step 7: Verbal reinforcement and rewards
Physical activity and/or exercise to prevent disease is consistent with the disease worldview.
In contrast, moving energy through energy exercise is consistent with the person worldview.
Energy Exercise
According to Ballentine (1999), some forms of exercise are really exercising the energy
body rather than the physical body (p. 357). These include the Chinese movement forms of
tai chi and qigong.
TAI CHI (CHOREOGRAPHY OF BODY AND MIND)

Tai chi, (pronounced tie chee, and also known as tai chi chuan) can be translated as the
ultimate or supreme ultimate which means improving and progressing toward the unlim-
ited (Shaller, 1998). Tai chi integrates the connections between mind, body, and spirit in a
quest for the highest form of harmony in life through the combination of exercise and medi-
tation (Bottomley, 1997, pp. 134, 136). While meditation aims to increase yang and reduce
and diminish yin, the goal of exercise is to reduce Yang and to increase and enhance yin.
Theory proposes that the combined practice of meditation, breathing, and exercise balances
these opposing, yet complementary, forces of equal strength energies, promoting health. See
Chapter 3, The Meaning of Health Care: Health Belief Systems, for an additional discussion of
yin/yang.
There are five main schools of tai chi, each named after the styles founding family: Chen,
Yang, Sun, Wu (Jian Qian), and Wu (He Qin). The relaxed, evenly paced, and graceful Yang
style is the most popular style being practiced today. There are 24, 48, 88, and 108 forms, and
Li and colleagues have recently proposed an easy eight-form sequence that is suitable for eld-
erly adults (Li, Fisher, Harmer, & Shirai, 2003).
Tai chi involves a series of fluid, continuous, graceful, dance-like postures, and the per-
formance of movements known as forms, performed in a slow, rhythmical, and well-
controlled manner. These body movements are integrated by mind concentration, balance
shifting of body weight, muscle relaxation, and breathing control. Tai chi is a convenient
exercise that can be practiced in any place, at any time, and without any equipment (Chen
& Snyder, 1999). The emphasis on softness, continuity, and relaxation allows the chi to move
freely along meridians.
Examples of tai chi exercises are depicted in Figure 13-1.
Tai chi is regarded as a method of moving meditation. While outwardly at rest, and with
inner peacefulness and quiet, the meditator uses abdominal or inner breathing and mental
concentration to facilitate the flow of energy throughout the body. Inhalation stores energy
while exhalation releases energy (Bottomley, 1997).
Principles of Tai Chi Movement

Principles of tai chi movement include (Shaller, 1998):
1. Wear loose-fitting clothes and soft shoes or bare feet.

2. The movements are best learned from an instructor in a group setting. Once the move-
ments are learned, the form can be performed alone or in a group.
3. Begin and maintain complete relaxation with natural breathing.
4. Stand with the sacrum pressed slightly forward and with the head and torso erect as if
suspended from above by wire.
5. Shoulders are relaxed with slight drooping; fingers are spread apart and slightly cupped.
6. Concentration is on the soles of the feet or the tan tien (area slightly below the umbilicus).
7. Knees are slightly bent with the weight being shifted from right to left and forward and back.
8. Movements are slow and fluid, performed meditatively. The emphasis is on softness,
continuity, and relaxation. Postures and movements should be performed with the feel-
ing of swimming through very heavy air.
9. Circulation of chi can be noted by the amount of tingling felt in the fingers and hands.
10. Practice should be approximately 25 to 30 minutes daily.
Salutation to the Grasp Birds Tail Grasp Birds Tail Single Whip White Crane White Crane
Buddha Spreads Its Wings Spreads Its Wings
Brush, Knee,
Parry Punch Closing Embracing Tiger Fist Under Elbow Repulse Monkey Diagonal Flying
Twist, Step
Energy Exercise
Raise Left Hand Fan Through Green Dragon Step Up and Push Cloud Hands Cloud Hands
the Arms Dropping Water
Figure 13-1. Double stance tai chi exercises (reprinted with permission from Bottomley, J. M. (1997). Tai chi: Choreography of the mind.
In Davis, C. M. (Ed.), Complementary therapies in rehabilitation. Thorofare, NJ: SLACK Incorporated).
343
Uses for Tai Chi Movement

Potential uses for tai chi (Bottomley, 1997; Olsen, 1990) include:
Strengthening and toning the muscles of the lower body, which enhances trunk con-
trol, strengthens the lower back, and expands the base of support.
Improving balance. Balance, muscular strength, and aerobic power are three compo-
nents of physical fitness that are important for the preservation of function.
Improving flexibility and posture.
Improving cardiorespiratory fitness.
Improving blood and lymph circulation.
Improving rotation of the trunk and coordination of isolated extremity motions.
Helping to facilitate awareness of movement and position.
Warding off illness and fatigue through increased energy flow.
Cultivating poise and a tranquil spirit.
Aiding waste elimination through gentle leg-raising movements that massage and
strengthen the intestines.
Calming both body and mind, and relieving stress and anxiety. The stress-reducing
effect of tai chi is comparable to the physiological changes produced by moderate exer-
cise (Bottomley, 1997).
Opening joints, especially the knees, alleviating inflammatory diseases such as arthritis
and rheumatism.
Increasing longevity, good health, vigor, mental alertness, and creativity (Bottomley, 1997).
Research studies on tai chi support improved balance, postural stability, decreased falls,
enhanced cardiovascular and ventilatory functions, and reduced pain in people of all ages
(Chen & Snyder, 1999), as well as foster social support, independence, and autonomy in the
elderly (Jancewicz, 2001). Tai chi chuan is beneficial to cardiorespiratory function, strength,
balance, flexibility, microcirculation, and psychological profile. It can be prescribed as an alter-
native exercise program for selected patients with cardiovascular, orthopedic, or neurological
diseases, and can reduce the risk of falls in elderly individuals (Lan, Lai, & Chen, 2002).
Below are abstracts of two tai chi research studies:
1. An 8-week tai chi pilot study was conducted with a sample of 19 patients diagnosed
with multiple sclerosis to explore psychosocial and physical benefits. Walking speed
increased by 21% and hamstring flexibility increased by 28%. Patients experienced
improvements in vitality, social functioning, mental health, and ability to carry out
physical and emotional roles. The authors concluded that tai chi and other health pro-
motion programs offer help toward achieving the goals of increasing access to services,
maximizing independence, and improving quality of life for people with chronic dis-
abling conditions (Husted et al., 1999).
Energy Exercise 345
2. A 6-month pilot study was conducted with a sample of 94 healthy, physically inactive
older adults to determine whether a tai chi exercise program can improve self-reported
physical functioning limitations. The sample was divided into 49 experimental partici-
pants and a control group of 45. The experimental group attended two 60-minute ses-
sions each week for 6 months. Overall, the tai chi participants reported improvement
in daily activities such as walking and lifting and in moderate-vigorous activities such
as running. Compared to the tai chi group, the control group did not show any statisti-
cally significant improvement on any of the measures. It was concluded that the 6-
month tai chi exercise program was effective for improving functional status in healthy,
physically inactive older adults (Li et al., 2001).
A programmed tai chi chuan exercise intervention is beneficial for retarding bone loss in
weight-bearing bones in early postmenopausal women (Chan et al., 2004). In a study with 34
relatively sedentary, normotensive middle-aged women, dynamic balance was significantly
improved following a three times per week, 12-week tai chi exercise program, and there were
significant decreases in both mean systolic and diastolic blood pressure (Thornton, Sykes, &
Tang, 2004).
Qigong (Chi Gung)

Another method of energy exercise is qigong (also known as chi gung). Qigong is one of
three aspects, along with herbs and acupuncture, of traditional Chinese medicine (Ai et al.,
2001). The term qigong is the phonetic juxtaposition of two Chinese characters: qi, meaning
flow of air in a literal sense, or vital energy in a symbolic sense; and gong meaning
perseverant practice (Ai et al., 2001, p. 83). In comparison with tai chi, which focuses pri-
marily on identifying the chi within the body, qigong specializes in mentally generating,
balancing or harmonizing, and utilizing this energy (Carnie, 1997).
Qigong is an ancient Chinese exercise that combines movement, meditation, and breath
regulation to stimulate and balance the flow of qi, or vital life energy, along the acupuncture
meridians. Qigong practice can range from simple calisthenics-type movements with breath
coordination to complex exercises where brain wave frequency, heart rate, and other organ
functions are altered intentionally. When practiced regularly, qigong is believed to improve
blood circulation, enhance immune function, cultivate inner strength, calm the mind, and
promote relaxation, awareness, and healing (Burton Goldberg Group, 1995). Qigong is a
method that can be used to cure and prevent diseases, to promote health, and to avoid pre-
mature aging while prolonging life.
The several branches of qigong (Carnie, 1997; Burton Goldberg Group, 1995) include:
Mental Qigong. Where the primary emphasis is on teaching control of the mind so that
the brain is active and alert. Personal self-healing and health maintenance practice is
called internal qigong, which can be performed with little or no movement (quiescent).
When internal qigong includes movement, it is called dynamic qigong.
Medical Qigong. Used for healing oneself and, at advanced levels, healing others. The
practitioner learns how to move chi throughout the body in order for it to flow prop-
erly (internal qigong). The primary idea here is that physical movement is essential for
the movement of chi. When a qigong master or practitioner projects or emits his or her
own qi to serve or heal another, it is considered external qigong.
Martial Qigong. Concentrates on learning how to fight and how to defend oneself. This
training covers ways to increase ones muscular strength and endurance by using inter-
nal energy.
Spiritual Chi Gung. One tries to learn how to control ones emotions and spirit by culti-
vating will, patience, and endurance in order to learn to live longer as well as to reach
spiritual enlightenment (Carnie, 1997).
Qigong enhances a number of physiological mechanisms (Burton Goldberg Group, 1995),

including:
Initiating the relaxation response that decreases the sympathetic function of the auto-
nomic nervous system (triggered by any form of mental focus that frees the mind from
its many distractions). This decreases heart rate and blood pressure, dilates the blood
capillaries, and optimizes the delivery of oxygen to the tissues.
Altering the neurochemistry profile moderating pain, depression, and addictive crav-
ings, as well as optimizing immune capability.
Enhancing the efficiency of the immune system through increased rate and flow of the
lymphatic fluid.
Improving resistance to disease and infection by accelerating the elimination of toxic
metabolites (metabolic byproducts) from the interstitial spaces in the tissues, organs,
and glands through the lymphatic system.
Increasing the efficiency of cell metabolism and tissue regeneration through increased
circulation of oxygen and nutrient rich blood to the brain, organs, and tissues.
Coordinating the right and left brain hemisphere dominance promoting deeper sleep,
reduced anxiety, and mental clarity.
Inducing alpha and, in some cases, theta brain waves, which reduce heart rate and
blood pressure, facilitating relaxation, mental focus, and even paranormal skills; this
optimizes the bodys self regulative mechanisms by decreasing the activity of the sym-
pathetic nervous system.
Moderating the function of the hypothalamus, pituitary, and pineal glands, as well as
the cerebrospinal fluid system of the brain and spinal cord, which mediates pain and
mood and enhances immune function.
Qigong exercises are done in short movement groups that are repeated many times, in con-
trast to the flow of positions in tai chi. Repetitions of coordinated physical motions with men-
tal concentration and directive efforts move the qi in the body. The mind moves the chi and
the chi moves the blood and oxygen (Berman & Larson, 1994).
Chi supply can be increased in several ways. The first way is the simplest and involves con-
tracting muscles in a series of exercises called wai dan. The next method, called nei dan, is the
Energy Exercise 347
most advanced and involves using your mind. The third method requires a trained acupunc-
turist, and the final method consists of various forms of massage (Carnie, 1997).
Wai dan involves using a variety of physical postures in order to create a surplus of chi
in the arms and legs. Once the chi builds up to a high enough level, it will clear through
most any tension or blockage. In still wai dan (zhan zhuang), a particular position is held
while the muscles are relaxed. In a typical position, a person might stand with feet shoul-
der width apart and knees slightly bent while also having the arms extended straight out
at the sides at shoulder height, palms facing forward and elbows slightly bent. After
standing in this position for up to 20 minutes, the arms will feel quite fatigued. When the
arms are lowered, the energy that has built up in the shoulders will flow down into the
arms and eventually circulate through the body. According to Chinese medical statistics,
about 80% of clients who practice these positions are healed of their medical problems
(Carnie, 1997).
Moving wai dan involves repeatedly tensing and relaxing various muscle groups while mov-
ing from one position to another. There should be as little tension in the muscles as possible
so the chi has the greatest chance of moving through the various meridians. In one exercise
resembling a bird flapping its wings as it flies, the person stands in a comfortable position with
feet about shoulder width apart and arms hanging loosely at the sides. The arms are slowly
raised until they are level with the shoulders while concentrating the mind on the feeling as
each muscle moves. Palms should be facing down. Once the arms have reached shoulder
height, they should be lowered back down to the sides as slowly as possible. The exercise should
be repeated until the arms and shoulders feel like they are starting to warm up (Carnie, 1997).
Nei dan, on the other hand, builds chi by using mental effort. It is generally considered more
complex and challenging to learn than wai dan, but is more effective once it is learned. Nei dan
works by building up abdominal chi through a series of breathing exercises. Once the chi has built
up in this area, the mind controls and circulates the chi throughout the body (Carnie, 1997).
It is best to study qigong with a qualified teacher to avoid side effects (Sancier, 1996), but
almost anyone can learn and practice the exercises. Following are some suggestions for qigong
practice (Burton Goldberg Group, 1995):
Take it easy, dont strive for any particular result, and dont rush. Excess effort and try-
ing too hard go against the natural benefits of qigong.
Although qigong may seem simplistic, a dedication to these practices can mobilize ones
inherent healing forces.
Qigong can be performed standing, walking, sitting, or lying down. Qigong exercises
can even be performed by those confined to bed or a wheelchair.
Results come over time, so dont overdo it or expect too much too soon.
If performed correctly, qigong is safe to practice as often as desired.
Feel free to make up an individualized routine and to change the practices to suit per-
sonal needs, likes, and limitations.
Always approach each practice with an intention to relax. The mind should be directed
toward quiet indifference.
Regulate the breath so that both the inhalation and exhalation are slow and deep, but
not urgent or exaggerated.
There are few research studies of qigong in the English language literature. However, two
abstracts of qigong studies are presented below:
1. Twenty-six adult patients (aged 18 to 65 years) with complex regional pain syndrome
type I (a disease involving malfunction of the sympathetic nervous system following
minor tissue or nerve injury) were randomly assigned to experimental and control
groups. Each patient assigned to the experimental group received six sessions (40 min-
utes, twice a week) of qigong training with two recognized Asian qigong masters. After
3 weeks of formal instruction, participants were told to continue their qigong exercises
on a daily basis at home for an additional 7 weeks. Each patient assigned to the control
group received 6 sessions of simulated qigong training. In the experimental group, 82%
reported less pain by the end of the first training session compared with 45% of control
patients. By the last training session, 91% of qigong patients reported analgesia com-
pared with 36% of control patients. Anxiety was reduced in both groups over time, but
the reduction was significantly greater in the experimental group. The authors con-
cluded that qigong training resulted in transient pain reduction and long-term anxiety
reduction (Wu et al., 1999).
2. To explore the effectiveness of qigong therapy on detoxification of heroin addicts
(N = 34) compared to medication treatment (lofexidine-HCl) (N = 26) and treatment
only of severe withdrawal symptoms (N = 26), male heroin addicts in the Peoples Repub-
lic of China (aged 18 to 52) were randomly assigned to one of the three groups. The
qigong group practiced pan gu qigong and received qi (chi) adjustments daily from a
qigong master. The medication group was on a 10-day gradual reduction method. The
control group received only basic care and medications to treat severe withdrawal symp-
toms. Reduction of withdrawal symptoms occurred more rapidly in the qigong group than
in the other groups. From day 1, the qigong group had significantly lower mean symptom
scores (p < .01) and lower anxiety scores (p < .01). It was concluded that qigong may be
an effective alternative for heroin detoxification without side effects (Li et al., 2002).
Integrative Health Promotion

ASSESSMENT
The process of using activity and exercise in integrative health promotion should begin
with client assessment. Four important areas for an initial assessment of the client include 1)
the purpose for proposing an activity or exercise modality; 2) energy ebb and flow; 3) client
readiness for activity or exercise; and 4) client priorities.
Determining the purpose for proposing an activity/exercise intervention is an important
initial consideration. The purpose for the intervention is basic to determining the most
appropriate modality. For example, if the purpose is risk reduction for cardiac problems in an
Integrative Health Promotion 349
obese client, the appropriate modality might be an aerobic exercise regimen, whereas primary
prevention of falls in the elderly suggests a tai chi exercise intervention.
An initial assessment of energy ebb and flow will determine if energy augmentation is
needed, or if energy is blocked in any area. Touch for health can be used to assess local energy
blockages, and qigong is very effective in smoothing energy flow. See Table 4-10 for
appropriate energetic patterning modalities to clear, convey, conserve, course, convert, and/or
connect energy. Additionally, an initial assessment of energy ebb and flow provides a baseline
for evaluating outcomes of any intervention.
Client readiness for adoption of activity/exercise is another important area to assess. As dis-
cussed in Chapter 8, Promoting Individual Behavior Change, the TTM suggests that there are
five stages of behavior change: precontemplation, contemplation, preparation, action, and
maintenance. Given the proposal that stage-specific factors to promote adoption can be mobi-
lized through intervention methods, the stage of readiness provides a guide for appropriate
intervention approaches. For example, during the contemplation stage of behavior change,
consciousness raising through increased information or confrontation might be appropriate
strategies. In contrast, stimulus control, emphasizing activities that precede activity and exer-
cise can be helpful during the action and maintenance stages of change. Rodgers and col-
leagues (2001), in a cross-sectional study, found the same pattern of change among the TTM
variables across stages of exercise behavior in three populations (high school students, uni-
versity undergraduate students, and employed adults), supporting the claim that the pattern
of change among TTM variables across the stages is the same regardless of the population
examined (Rodgers et al., 2001, p. 40).
Client priorities are another important area for assessment. Does the client consider the
adoption of an activity or exercise program to be important? If not, the nurse might consider
using a precontemplation strategy to encourage reconsideration. But, if the client does not
value activity or exercise behavior, external pressure by the nurse is useless. If the client is
internally motivated, what are the reasons that the client values adoption of an activity or
exercise program? An understanding of the clients motivation is essential to selection of
appropriate strategies and effective support.
DEVELOPMENT OF A PLAN
The process of using activity and exercise in integrative health promotion should continue
with development of a plan. Four important areas for development of a plan with the client
include 1) mutuality with the client; 2) individualizing the plan for each client; 3) targeting inter-
ventions toward the stage of readiness of the client; and 4) choosing an appropriate modality.
As discussed in Chapter 10, The Essence of the Healing Helping Relationship, presence,
respect, listening, and reciprocy are some of the key elements of a healing relationship. Rec-
iprocy involves a mutual exchange and shared control, status, and power in the nurse-client
relationship. The role of the nurse is to share information and facilitate desired lifestyle
behavior change rather than to prescribe or attempt to control client behavior.
Behavior change strategies need to be individualized for each client. Because of the com-
plex mix of purpose, motivation, perceived self-efficacy, and strengths or constraints, each
intervention must be careful crafted for the specific individual. Based on basic assessment
data, the nurse can not only select the most appropriate intervention, but can combine the
modality with a plan for support and follow-up.
The need to target interventions toward the stage of readiness was discussed above. In
many cases there are alternative interventions that may be equally effective in achieving the
desired outcome. The selection of a specific intervention modality depends on a number of
the factors discussed above. One modality or a combination of several modalities may initially
be planned. However, on the basis of continued monitoring and evaluation, this plan may be
modified and other modalities substituted.
IMPLEMENTATION OF THE PLAN

The process of using activity and exercise in integrative health promotion should continue
with implementation of the plan. Three important areas for implementation of the plan with
the client include 1) consistency; 2) meaningful involvement; and 3) building in maintenance.
Earlier in this chapter it was suggested that 30 minutes or more of moderate-intensity phys-
ical activity is desirable on most, and preferably all, days of the week. Consistency in the per-
formance of activity or exercise is needed to achieve desired outcomes. A regular routine is
also helpful for maintaining the behavior, even when other priorities intrude. Meaningful
involvement of the client in the activity/exercise is essential to its consistent performance.
Given that almost half of adults are sedentary and that participation in exercise programs
often drops within the initial 3 to 6 months, it is essential that attention be paid to mainte-
nance of an exercise program once it has been started. This requires knowledge by the nurse
and client of the conditions that promote relapse and stabilizing change through the devel-
opment of non self-defeating responses. Counterconditioning is one strategy that can address
negative emotional associations that may arise. For example, if exercise becomes boring, some
strategies that the nurse can suggest include encouraging a varied routine, walking outside
(whenever weather permits), and at least occasional exercise with a partner.
EVALUATION
Finally, the process of using activity and exercise in integrative health promotion should
continue with evaluation of the plan. Two important areas for evaluation of the plan with the
client include 1) assessing progress and 2) modifying as needed.
Evaluation should address two assessment factors. Regular observations should determine
if there been change toward desired outcomes when progress is compared with baseline data.
Reassessment of purpose, priorities, and motivation are also needed. If necessary, the plan may
need to be modified. Relapse and recycling through the stages of change occur frequently with
activity or exercise behaviors. During relapse, the client will probably regress to an earlier
stage. This will necessitate a reconsideration of appropriate strategies, and possibly a change
in intervention modalities. In other words, nursing assessment, planning, intervention, and
evaluation to promote activity/exercise adoption are components of a continuous process.
Movement of energy is essential for well-being. Physical activity and exercise move the
energy body as well as the physical body and provide significant health benefits and reduced
health risks. Yet, lack of physical activity starts early in life, and at least half of all adults,
including nurses, do not exercise. Also of concern is the sharp drop in participation in exer-
cise programs within the initial 3 to 6 months. This chapter has emphasized the need for
References 351
development and testing of theory-based interventions to promote physical activity initiation

and maintenance at individual, environmental, and policy levels. Professional nurses need to
role model and actively promote regular and sustained activity or exercise by clients.
Chapter Key Points

Movement of energy is essential for a persons well-being.
Exercise is a specific form of physical activity associated with desired outcomes of fit-
ness, flexibility, and balance.
Regular moderate physical activity provides substantial health benefits.
Nursing strategies to empower clients to adopt a more active lifestyle include consider-
ation of the clients goals and motivation, introducing changes gradually, promoting
regularity of activity, integrating the activity into daily life, making exercise fun, and
having the client take control of his or her behavior.
Walking is an ideal physical activity that requires no special equipment, facilities, or
new skills.
The Chinese movement forms of tai chi and qigong exercise the energy body and pro-
mote harmony through the combination of exercise and meditation.
References
Ai, A. L., Peterson, C., Gillespie, B., Bolling, S. F., Jessup, M. G., Behling, A., & Pierce, F. (2001). Design-
ing clinical trials on energy healing: Ancient art encounters medical science. Alternative Thera-
pies in Health and Medicine, 7, 83-90.
Allan, J. D. (1992). Exercise program. In G. M. Bulechek, & J. C. McCloskey (Eds.), Nursing interventions:
Essential nursing treatments (2nd ed., pp. 406-424). Philadelphia: W. B. Saunders.
American College of Sports Medicine. (1993). Physical activity, physical fitness and hypertension. Medi-
cine and Science in Sports and Exercise, 25, i-x.
American College of Sports Medicine. (2000). Guidelines for exercise testing and prescription (6th ed.).
Philadelphia: Lippincott, Williams & Wilkins.
Ballentine, R. (1999). Radical healing. New York: Harmony.
Bauman, A. E., Sallis, J. F., Dzewaltowski, D. A., & Owen, N. (2002). Toward a better understanding of the
influences on physical activity. American Journal of Preventive Medicine, 23, 5-14.
Bottomley, J. M. (1997). Tai chi. Choreography of body & mind. In C. M. Davis, (Ed.), Complementary ther-
apies in rehabilitation (pp. 133-156). Thorofare, NJ: SLACK Incorporated.
Bronner, L. L., Kanter, D. S., & Manson, J. E. (1995). Primary prevention of stroke. New England Journal
of Medicine, 333, 1392-1400.
Burton Goldberg Group. (1995). Alternative medicine: The definitive guide. Fife, WA: Future Medicine.
Carnie, L. V. (1997). Chi gung. Chinese healing, energy, and natural magick. St. Paul, MN: Llewellyn.
Caspersen, C. J., Powell, K. E., & Christenson, G. M. (1985). Physical activity, exercise, and physical fit-
ness: Definitions and distinctions for health-related research. Public Health Reports, 100, 126-131.
Chan, K., Qin, M., Woo, J., Au, S., Chay, W., Lee, K., & Lee, S. (2004). A randomized, prospective study
of the effects of tai chi chan exercise on bone mineral density in postmenopausal women. Archives
of Physical Medical Rehabilitation, 85, 717-722.
Chen, K., & Snyder, M. (1999). A research-based use of tai chi/movement therapy as a nursing interven-
tion. Journal of Holistic Nursing, 17, 267-279.
Clark, C. C. (1996). Wellness practitioner. New York: Springer.
Conn, V. S., Burks, K. J., Minor, M. A., & Mehr, D. R. (2003). Randomized trial of 2 interventions to
increase older women's exercise. American Journal of Health Behavior, 27, 380-388.
Dishman, R. K., Sallis, J. F., & Orenstein, D. R. (1985). The determinants of physical activity and exercise.
Public Health Reports, 100, 158-171.
Donker, F. J. (2000). Cardiac rehabilitation: A review of current developments. Clinical Psychological
Review, 20, 923-43.
Dubbert, P. M. (2002). Physical activity and exercise: Recent advances and current challenges. Journal of
Consulting and Clinical Psychology, 70, 526-536.
Griffin, J. C. (1998). Client-centered exercise prescription. Champaign, IL: Human Kinetics.
Hayashi, T., Tsumura, K., Suematsu, C., Okada, K., Fujii, S., & Endo, G. (1999). Walking to work and the
risk for hypertension in men: The Osaka health survey. Annals of Internal Medicine, 131, 21-26.
Houde, S. C., & Melillo, K. D. (2002). Cardiovascular health and physical activity in older adults: An inte-
grative review of research methodology and results. Journal of Advanced Nursing, 38, 219-234.
Hu, F. B., Stampfer, W. J., Colditz, G. A., Ascherio, A., Rexrode, K. M., Willett, W. C., & Manson, J. E.
(2000). Physical activity and risk of stroke in women. Journal of the American Medical Association,
283, 2961-2967.
Husted, C., Pham, L., Hekking, A., & Niederman, R. (1999). Improving quality of life for people with chronic
conditions: The example of tai chi and multiple sclerosis. Alternative Therapies in Health and Medi-
cine, 5(5), 70-74.
Jancewicz, A. (2001). Tai chi chuans role in maintaining independence in ageing people with chronic dis-
ease. Journal of Bodywork and Movement Therapies, 5, 70-77.
Jonas, S. (1996). Exercise. In S. H. Woolf, S. Jonas, & R. S. Lawrence. (Eds.), Health promotion and disease
prevention in clinical practice (pp. 176-192). Baltimore: Williams & Wilkins.
King, A. C. (1994). Clinical and community interventions to promote and support physical activity par-
ticipation. In R. K. Dishman (Ed.), Advances in exercise adherence (pp. 183-235). Champaign ,IL:
Human Kinetics.
Lan, C., Lai, J., & Chen, S. (2000). Tai chi chuan. An ancient wisdom on exercise and health promotion.
Sports Medicine, 32, 217-224.
Li, F., Harmer, P., McAuley, E., Duncan, T. E., Duncan, S. C., Chaumeton, N., & Fisher, K. J. (2001). An
evaluation of the effects of tai chi exercise on physical function among older persons: A ran-
domized controlled trial. Annals of Behavioral Medicine, 23, 139-46
References 353
Li, F., Fisher, J., Harmer, P., & Shirai, M. (2003). A simpler eight-form easy tai chi for elderly adults. Jour-
nal of Aging and Physical Activity, 11, 206-218.
Li, M., Chen, K., & Mo, Z. (2002). Use of qigong therapy in the detoxification of heroin addicts. Altern
Ther Health Med, 8, 50-59.
Marcus, B. H., Bock, B. C., & Pinto, B. M. (1997). Initiation and maintenance of exercise behavior. In D. S.
Gochman (Ed.), Handbook of health behavior research, (Vol. 2, pp. 335-352). New York: Plenum Press.
May, B. J. (1990). Principles of exercise for the elderly. In J. V. Basmajian, & S. L. Wolf (Eds.), Therapeu-
tic exercise (5th ed., pp. 279-298). Baltimore: Williams & Wilkins.
Nieman, D. C. (1998). The exercise-health connection. Champaign, IL: Human Kinetics.
Nigg, C. R., Burbank, P. M., Padula, C., Dufresne, R., Rossi, J. S., Velicer, W. F., et al. (1999). Stages of
change across ten health risk behaviors for older adults. Gerontologist, 4, 473-82.
NIH Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy. (2001). Osteo-
porosis prevention, diagnosis, and therapy. Journal of the American Medical Association, 285, 785-795.
OBrien, S. J., & Vertinsky, P. A. (1991). Unfit survivors: Exercise as a resource for aging women. Geron-
tologist, 31, 347-357.
Olsen , K. G. (1990). The encyclopedia of alternative health care. New York: Pocket Books.
Orleans, C. T., Gruman, J., Ulmer, C., Emont, S. L., & Hollendonner, J. K. (1999). Rating our progress in
population health promotion: Report card on six behaviors. American Journal of Health Promotion,
14, 75-82.
Pate, R.R., Pratt, M., Blair, S. N., Haskell, W. L., Macera C. A., & Bouchard, C. (1995). Physical activity and
public health: A recommendation from the Centers for Disease Control and Prevention and the
American College of Sports Medicine. Journal of the American Medical Association, 273, 402-407.
Patel, A.T., & Ogle, A. A. (2000). Diagnosis and management of acute low back pain. American Family
Physician, 61, 1779-1786, 1789-90.
Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2002). Health promotion in nursing practice (4th ed.).
Upper Saddle River, NJ: Prentice Hall.
Phillips, E. M., Schneider, J. C., & Mercer, G. R. (2004). Motivating elders to initiate and maintain exer-
cise. Archives of Physical Medicine Rehabilitation, 85 (Supp. 3), S52-57.
Resnick, B. (1999, March). Exercise for the older adult: The seven step approach to wellness. Advance for
Nurses, 20-21.
Resnick, B., Palmer, M. H., Jenkins, L. S., & Spellbring, A. M. (2000). Path analysis of efficacy expecta-
tions and exercise behavior in older adults. Journal of Advvanced Nursing, 31, 1309-15.
Robbins, L. B., Pender, N. J., Conn, V. S., Frenn, M. D., Neuberger, G. B., Nies, M. A., et al. (2001). Phys-
ical activity research in nursing. Journal of Nursing Scholarship, 33, 315-321.
Rodgers, W. M., Courneya, K. S., & Bayduza, A. L. (2001). Examination of the transtheoretical model and
exercise in 3 populations. American Journal of Health Behavior, 25, 33-41.
Sallis, J. F., Bauman, A., & Pratt, M. (1998). Environmental and policy interventions to promote physical
activity. Am J Prev Med, 15, 379-397.
Sancier, K. M. (1996). Medical applications of qigong. Alterntive Therapies in Health and Medicine, 2, 40-46.
Sebregts, E. H. W. J., Falger, P. R. J., & Bar, F. W. H. M. (2000). Risk factor modification though nonphar-
macological interventions in patients with coronary heart disease. Journal of Psychosomatic
Research, 48, 425-441.
Shaller, K. (1998). Tai chi/movement therapy. In M. Snyder & R. Linduist. (Eds.), Complementary/alterna-
tive therapies in nursing (pp. 37-47). New York: Springer.
Sharkey, N. A., Williams, N. I., and Guerin, J. B. (2000). The role of exercise in the prevention and treat-
ment of osteoporosis and osteoarthritis. Nursing Clinics of North America, 35, 209-221.
Thornton, E. W., Sykes, K. S.,& Tang, W. K. (2004). Health benefits of tai chi exercise: Improved balance
and blood pressure in middle-aged women. Health Promotion International, 19, 33-38.
Treat-Jacobson, D., & Mark, D. L. (1998). Exercise. In M. Snyder & R. Lindquist (Eds.), Complemen-
tary/alternative therapies in nursing (pp. 23-35). New York: Springer.
Van der Bij, A. K., Laurant, M. G. H., & Wensing, M. (2002). Effectiveness of physical activity interven-
tions for older adults: A review. American Journal of Prevntitive Medicine, 22, 120-133.
Weil, A. (1999, April). Exercise: The best health tonic. Self-Healing, 2-3.
Wu, W., Bandilla, E., Ciccone, D. S., Yang, J., Cheng, S. S., Carner, N., et al. (1999). Effects of qigong on late-
stage complex regional pain syndrome. Alternative Therapies in Health and Medicine, 5(1), 45-54.
Zelasko, C. J. (1995). Exercise for weight loss: What are the facts? Journal of the American Dietetic Associa-
tion, 95, 1414-1417.
Tai Chi
There is no national agency for licensing or credentialing in the United States. Tai chi
associations are as varied as the styles and systems.
Internet Links
www.chebucto.ns.ca/Philosophy/Taichi/other
www.nih.gov/nia/new/press/taichi
http://frank.mtsu.edu/~jpurcell/Taichi/tc-links.htm
Qigong
National Qigong Association USA
PO Box 20218
Boulder, CO 80308
Tel: (888) 218-7788
www.nqa.org
Currently there is no official credentialing or licensing of qigong instructors in the United

States or guidelines for what is required to be called a Master of Qigong therapist. The
National Qigong Association is working to establish a recommended minimum curriculum,

hours of training, and ethical guidelines for both general qigong and medical qigong therapy.
The Qigong Institute

561 Berkeley Avenue
Menlo Park, CA 94025
www.qigonginstitute.org
14
RELEASING BLOCKED ENERGY
Touch and Bodywork Techniques
Abstract
Touch, used with sensitivity, allows the clinician to locate areas of muscle tension, reduce
pain, soothe injured muscles, stimulate blood and lymphatic circulation, and promote deep
relaxation. Bodywork techniques, with touch as their fundamental medium, discussed in this
chapter include massage therapies, acupressure, and various postural/movement reeducation
therapies. Additional information about organizational resources and certification for each of
the therapies is located at the end of the chapter.
Learning Outcomes
Identify the therapeutic effects of massage

Differentiate between types of soft tissue manipulation used in massage strokes
Compare and contrast types of massage from European and Chinese traditions
Describe techniques for reflexology, shiatsu, Touch for Health, jin shin do, and self-acu-
pressure
Differentiate between techniques for the Alexander method, the Feldenkrais method,
Trager integration, and the structural integration (Rolfing) method of postural move-
ment or re-education
358 Chapter 14 Releasing Blocked Energy: Touch and Bodywork Techniques
Touch is tactile communication from one person to another for the primary purposes of the
transmission and receipt of signals of recognition, acceptance, protection, and caring con-
cern. Used as a verb, touch means to make contact with. To be touched by something also
has the meaning of being emotionally affected. Physical touch is reciprocal, such that whom
or what a person touches also touches the person (Mackey, 2001; Routasalo, 1999).
Sensitive touch can convey a sense of caring, which is an essential element in a therapeu-
tic relationship. Touch also has a comforting and calming effect. Touch used with sensitivity
allows the clinician to receive useful information about the body, such as locating areas of
muscle tension and other soft tissue problems. Bodywork helps to reduce pain, soothe injured
muscles, stimulate blood and lymphatic circulation, and promote deep relaxation (Berman &
Larson, 1994). Bodywork techniques (with touch as their fundamental medium) discussed in
this chapter include massage therapy, acupressure, and postural or movement re-education
therapies.
Massage Therapy
Massage, a word that comes from both the Greek masso, to knead, and the Arabic mass, to
press gently (Olsen, 1990), is a systematic, therapeutic stroking and kneading of the skin and
muscle. Through the systematic and scientific manipulation of the soft tissues of the body,
soft-tissue massage blends mechanical proficiency and artistic sensibility to aid the ability of
the body to heal itself. Specifically, the purposes of massage include promotion of relaxation,
reduction of stress, improving skin and muscle tone, stimulating venous and lymphatic
circulation, and producing therapeutic effects on the respiratory and nervous systems, and the
subtle interactions between all body systems (Huebscher, 1998).
MASSAGE METHODS
Traditional European methods are the dominant approaches to massage practiced in the
United States. Massage is supported by the physiology-based theory that muscle tension,
whether from normal activity or from awkward movement or stress, contributes to muscle
fatigue and pain by compressing nerve fibers in the muscle. Prolonged muscle contraction
interferes with the elimination of chemical wastes in the muscles and surrounding tissues, and
can cause frequent nerve and muscle pain (Berman & Larson, 1994). Massaging soft tissue
and muscles speeds up the metabolic re-absorption or release of the fluid toxins. Massage may
be indicated for personal growth, balance, and emotional release as well as for release of mus-
cle tension.
Based on traditional Western concepts of anatomy and physiology, the basic categories of
soft tissue manipulation used in massage (Clark, 1996; DEpiro, 1997; Olsen, 1990) include
effleurage, petrissage, kneading, tapotement, touch, vibration, brushing, range of motion, and
nerve compression:
Effleurage. Consists of light stroking, firm and gentle movements. Slow, rhythmic, glid-
ing strokes are often used to begin and end a session. Gradual compression on the skin
encourages relaxation by reducing muscle tone, firm pressure speeds blood and lymph
flow to reduce swelling, and rapid strokes enhance muscle tone. Centripetal effleurage
Massage Therapy 359
moves toward the heart, stimulating circulation, and rotary or spiral effleurage stimu-
lates the smaller blood vessels in the skin.
Petrissage. Consists of firm friction stroking, both deep and superficial. Confined to
fleshy areas, this technique is more powerful than kneading. Folds of skin, subcutaneous
tissue, and muscle are compressed, lifted, and rolled against underlying tissue in a cir-
cular manner to lengthen contracted or adherent fibrous tissue, soothe muscle spasm,
and propel motion of body fluids, which relieves swelling.
Kneading. Consists of a rhythmic lifting and squeezing of flesh. It involves slow, circular
squeezing of soft tissue against underlying bone to improve swelling and inflammation.
A more energetic motion is intended to reduce muscle spasm and elongate tissues.
Tapotement. Consists of percussive motions such as lightly hitting the skin with cupped
hands (clapping), the ulnar edge of the hand (hacking), loosely flexed fingers (tapping),
or closed fists over muscles and the fleshy parts of the body to induce cutaneous reflexes
and vasodilation. It results in increased muscle tone and distribution of accumulated
interstitial fluid, so swelling is diminished. The movement is done parallel to the muscle
fibers to prevent trauma or spasm. This stroke is especially effective on tight muscles in the
shoulders or neck.
Vibration. Consists of rapid shaking and pulsating, done by hand or with a machine. A
fine, tremulous movement, sometimes only fluttering above a body part, can be used for
its soothing effect. When more crude and vigorous than tapotement, both hands are
shaken while pressed against the skin to condense swollen tissue and diminish edema.
Touch. Consists of simple placing or molding of the hand over a part of the body. If
desired by the recipient, the physical contact of holding the hand or touching the
shoulder while interacting can be very effective in reducing the muscle tension associ-
ated with anxiety and encouraging relaxation.
Brushing. Consists of light fingertip contact done slowly and rhythmically to spread gen-
eral sensations over the body. This is often done as a finishing stroke, but pressure
should be strong enough to avoid a tickling sensation.
Range of motion. Consists of passive exercising by rotating, flexing, and extending body
and limbs to mobilize joints and boost secretion of synovial fluids.
Nerve compression. Consists of exerting firm pressure to relieve knots or pain at nerve points.
In addition to the European methods described above, traditional Chinese massage can be
used to treat and relieve many medical conditions through both tonification (energizing)
and sedation techniques. Traditional Chinese massage is based on the principle that chi
must flow harmoniously through the meridians for proper functioning of the muscles and
organ systems. Symptoms occur when chi is blocked, stagnant, or excessive. Massage can
remove energy blocks or excesses and restore harmony. Berman and Larson (1994) list some
of the major massage methods:
Ma. Rubbing with palm or fingertips.
Pai. Tapping with palm or fingertips.
Tao. Strong pinching with thumb and fingertip.

An. Rapid and rhythmical pressing with thumb, palm, or back of the clenched hand.
Nie. Twisting, with both thumbs and tips of the index fingers grasping and twisting the
area being treated.
Ning. Pinching and lifting in a stationary position.
Na. Moving, while performing ning.
Tui. Pushing, often with slight vibratory effect.
TYPES OF MASSAGE
Berman and Larson (1994) describe a number of massage traditions that are based on tra-
ditional European methods, including:
Swedish massage. Involves use of long gliding strokes, kneading, and friction techniques
on the more superficial muscles, generally in the direction of blood flow toward the
heart, sometimes combined with active and passive movements of the joints. This type
of massage is used to promote general relaxation, improve circulation and range of
motion, and relieve muscle tension.
Deep tissue massage. Involves use of slow strokes, direct pressure, or friction directed
across the grain of the muscles with the fingers, thumbs, or elbows. It is applied with
greater pressure and to deeper layers of muscle than Swedish massage. It is used to
release chronic patterns of muscular tension.
Neuromuscular massage. A form of deep massage that is applied specifically to individ-
ual muscles. It is used to increase blood flow, release trigger points (intense knots of
muscle tension that refer pain to other parts of the body), and release pressure on nerves
caused by soft tissues. It is often used to reduce pain.
Manual lymph drainage. A form of deep tissue massage that uses firm rhythmic strokes to
direct lymphatic fluid from the tissues into the lymphatic ducts and back to the heart.
It is primarily used for conditions of the extremities related to poor lymph flow such as
edema, inflammation, and neuropathies.
PRINCIPLES FOR MASSAGE PRACTICE

Before starting therapeutic massage, observation and palpation, using a firm but light
touch, should be used to assess areas of tenseness or immobility, tenderness, changes in tem-
perature, or edema. This information will help to determine areas and methods for massage
emphasis. Mackey (2001) stresses that in addition to being aware of the client, the environ-
ment, and precautions, the nurse needs to be self-aware, centered, confident, relaxed, and
self-prepared. The nurse should take care of her hands, wrists, and fingers by stretching and
strengthening the muscles regularly. Permission to touch should always be obtained.
Care should be taken to ensure client privacy and a comfortable room temperature during
the procedure. The nurse should be careful to use correct body mechanics to avoid personal
fatigue and strain. The hands should be warm, and fingernails should be short and trimmed.
Massage Therapy 361
Use of a lubricating oil or lotion will prevent a feeling of burning due to skin friction. The
techniques of massage can be combined with other methods, such as aromatherapy and music
therapy, to induce relaxation and relieve muscle tension. Basic massage techniques to pro-
mote circulation and relaxation can be practiced by all nurses. However, advanced techniques
for other therapeutic effects or for a full body massage require additional continuing educa-
tion and training (see sources at the end of the chapter).
Massage has been found to be therapeutic for hospitalized cancer patients, according to a
recent massage study detailed in Box 14-1.
B OX 14-1
Massage Study Abstract
In a quasi-experimental design without random assignment to groups, 41 prima-
rily male cancer patients hospitalized for chemotherapy or radiation therapy
received either three 15- to 30-minute treatments with light Swedish effleurage
and petrissage massage within 1 week (the experimental treatment), or 20 minutes
of deliberate focused communication (the control treatment) with the same
nurse. Compared with scores on admission, at the end of 1 week, mean scores
for pain, sleep quality, symptom distress, and anxiety improved from baseline for
the subjects who received therapeutic massage; only anxiety improved from base-
line for participants in the comparison group. However, lack of random assign-
ment to groups and a sample comprised primarily of Caucasian men prevents
generalizability of these findings. The authors stress the need for randomized clin-
ical trials to determine the efficacy of therapeutic massage in decreasing symptoms
in hospitalized patients.
Source: Adapted from Smith, M. C., Kemp, J., Hemphill, L., & Vojir, C. P. (2002). Outcomes of thera-
peutic massage for hospitalized cancer patients. Journal of Nursing Scholarship, 34, 257-262.
Lloyd (1995, p. 30) describes a procedure for neck massage based on effleurage and knead-
ing methods. Lloyd stresses that the experience of administering and receiving massage
increases confidence and understanding of what feels good. The procedure for neck massage
is described in Box 14-2.
It is believed that massage has many therapeutic effects, including (Berman & Larson, 1994;
Moyer et al., 2004; Smith et al., 2003):
A sedative effect on the nervous system and promotion of voluntary muscle relaxation
Promoting recovery from fatigue produced by excessive exercise
Help in breaking up scar tissue and lessening fibrosis and adhesions that develop as a
result of injury and immobilization
Relief from certain types of pain
B OX 14-2
A Procedure for Neck Massage
Stand behind seated client.
Lightly place your hands on the clients shoulders.
Using a kneading motion, begin to pick up flesh between your thumb and
fingers.
Keep strokes smooth and rhythmic.
Move outward from the base of the neck along the shoulder.
Ask the client for feedback on any sore spots and the degree of pressure
he or she likes.
Using the same kneading motion, work from the base of the neck up the
base of the skull.
Using a circular motion, work your fingertips out along the base of the
skull to the ears.
Ask the client to drop her or his head forward. Support the forehead with
your hand. Using your thumb and index finger, use a circular and pinch-
ing motion on either side of cervical spine.
With your index and middle finger on either side of the spine, rub up and
down.
For headache, use a circular motion on the temple region and stroking
across the forehead.
To finish, very gently stroke from top of the head, down the neck, and
along the shoulders several times.
Treatment of chronic inflammatory conditions by increasing lymphatic circulation

Reduction of swelling from fractures
Increased blood flow through the muscles, affecting circulation through the capillaries,
veins, and arteries
Loosened mucus and promote drainage of sinus fluids from the lungs by using percus-
sive and vibratory techniques
Increased peristaltic action in the intestines to promote fecal elimination
Altered psychological and neurological complications associated with chemotherapy
during bone marrow transplant (Smith, Reeder, Daniel, Baramee, & Hagman, 2003)
Acupressure 363
Single applications of massage therapy can reduce state anxiety, blood pressure, and heart
rate, but not negative mood, immediate assessment of pain, and cortisol level. Reductions of
trait anxiety and depression are the largest effects, with a course of treatment providing ben-
efits similar in magnitude to those of psychotherapy (Moyer, Rounds, & Hannum, 2004).
In contrast to the many therapeutic effects of massage, there are few contraindications.
Hill (1995) suggests that the contraindications to massage are primarily skin lesions, blood
clots or bruises, fractures, severe arthritic pain, and fever. General precautions also should be
exercised in cases of severe pain or an acute condition with unknown cause, enlarged varicose
veins, burns, infections, new surgery, and pregnancy (Mackey, 2001).
When presenting symptoms are considered to be secondary manifestations of dysfunction
elsewhere in the body, a form of touch known as acupressure may be an appropriate alternative.
Acupressure
Acupressure massage is defined as the application of finger pressure to any of 657 specific
sites or points along the bodys 14 energy meridians for the purpose of relieving tension and
re-establishing the flow of energy along the meridian lines. A meridian is one of a series of
channels running longitudinally on the body. These pathways are conduits for the bodys cir-
culating energy, or chi. Each pathway is associated with particular organs and psychologi-
cal/physical functions. The various acupressure points (acupoints) are located on their
respective meridians. These areas are particularly sensitive to bioelectrical impulses in the
body (Kahn & Saulo, 1994).
In disease and pain, there is disruption in this energy pattern and organization caused by
an accumulation, blockage, or loss of energy. The essential energy is contingent on adequate
blood flow. Accupressure massage enhances circulation of both blood and lymph, which
increases the dispersion of nutrients and aids in the disposal of metabolic wastes.
The clinician uses finger pressure on acupoints to balance the energy body, thus bring-
ing about optimal function. The purpose is to stimulate the bodys own recuperative powers.
In most people, when all pathways are open and energy flow is unhindered, the bodys energy
can be balanced. Balance brings good health, vitality, and a sense of well-being (Olsen, 1990,
p. 48). There are specific acupressure points to relieve common ailments such as asthma,
arthritis, constipation, insomnia, nosebleeds, sciatica, bedwetting, dizziness, fatigue, sore
throat, and impotence (Olsen, 1990). Acupressure also can be used to support other treat-
ments or to give temporary relief for both chronic and functional problems such as back pain,
hypoglycemia, migraines, and menstrual cramps. Hand or mechanical (e.g., Acuband) pres-
sure on P6, the Neiguan point on the pericardial meridian, has been used effectively to treat
nausea and vomiting and prevent motion sickness (Stern et al., 2001). Additionally, in a
blind, randomized trial, 24 healthy adult males received either pressure on acupoints, stroking
along the meridians, or a control stimulation. The acupoint group had significantly lower
diastolic and mean arterial pressures when compared with the two other groups, supporting
the assertion that pressure on acupoints can significantly influence the cardiovascular system
(Felhendler & Lisander, 1999).
Acupressure is effective as a health maintenance method with regular, periodic sessions
(once a week or once a month, for example) to reduce stress, increase circulation, and tune
up energy. Accupressure is also used for general preventive health care, warding off upper res-
piratory infections, improving muscle tone, and increasing energy levels (Kahn & Saulo, 1994).
All acupressure therapies use finger pressure on specific meridian points (acupoints), to
stimulate or to sedate them (Berman & Larson, 1994). In the following section, myotherapy,
reflexology, shiatsu, Touch for Health, and jin shin do will be presented as examples of spe-
cific acupressure methods. Guidelines for self-acupressure will also be discussed.
TRIGGER POINT/MYOTHERAPY
Trigger point technique is similar to shiatsu or acupressure. Trigger points are tender, con-
gested spots on muscle tissue or fascia that may radiate pain to other areas. Practitioners of
this modality apply pressure to specific points on the body to relieve tension.
REFLEXOLOGY
This accupressure method is often called zone therapy. The body, according to reflexology
theory, is divided into 10 zones running longitudinally from the head to the feet, with five
zones on each side, each corresponding to one of the five toes. In addition to the longitudi-
nal zones, there are transverse zones that enable clinicians to draw up a grid for the identifi-
cation of reflex points. There are also cross-reflexes, in which a relationship exists between
different points on each side of the body (Booth, 1994). Specific zones on the feet are
related to specific organs. Thus, every part of the body, including organs and glands, can be
affected by stimulating the appropriate reflex areas on the hands or the feet. When the energy
flow through these zones is impeded, disease can result.
Reflexology stimulates deep relaxation, improves the blood supply, and promotes the
unblocking of nerve impulses to normalize and balance the entire body. Reflexology provides
tactile stimuli that are carried by large, type-A, beta-sensory fibers that can depress the trans-
mission of pain signals. This produces local, lateral inhibition via the dorsal horn of the spinal
cord (Stephenson & Dalton, 2003). Stimulating blocked or congested reflexes through mas-
sage of the appropriate area on the foot can release the stagnation and congestion related to
a particular structure and allow energy to flow to it. Any congestion shown by tenderness in
the extremities should correspond to a disorder in the body (Lynn, 1996). The emphasis is on
targeting the breakup of lactic acid and calcium crystals accumulated around the 7,200 nerve
endings in each foot (Berman & Larson, 1994). Blood circulation and the nervous system are
stimulated, and this promotes self-healing and restores homeostasis within the body.
Clark (1996) and Mackey (2001) describe a number of strategies to improve reflexology
technique:
1. Prior to attempting reflexology, strength and sensitivity of the fingers need to be devel-
opedparticularly the thumb. Practice in sensing a thread under the page of a book is
a good exercise. When that can be sensed, try two pages, then three, and so on. Differ-
ent materials such as dental floss, rubber bands, and seeds of different sizes can also be
used. To estimate the pressure needed, practice pressing a bathroom scale to 20 to 25
pounds of pressure.
2. As with other body therapies, it is not wise to practice reflexology when feeling
depleted or ill oneself, because it is possible to drain energy from the client.
Acupressure 365
3. Use information gathered from the clients history, palpatory assessment, and intuition
to determine areas for reflexology. Reflex points on the left hand or foot have zones cor-
responding to the organs and glands on the left side of the body and the same for the
right side.
4. Pressure in reflexology should evoke a good hurt or pressure that is comfortably tol-
erated. Start with a light pressure with the fingers and thumb, and move to deeper pres-
sure when the appropriate area is located. Once the appropriate amount of pressure is
found, hold it until a rhythmic pulsation is felt or until the client experiences a release
of stress and tension. Observe for a change to a deeper breathing pattern, change to a
better skin tone, relaxation in facial expression, and/or the clients words. For very
painful spots, return to them again and again rather than trying to relieve the pain all
at once; too much work all at once may bruise the capillaries.
Reflexology is not intended as diagnostic or as a treatment for a specific illness (Kunz &
Kunz, 1995). In a blind study in which two reflexologists examined the feet of each of 18
adults and rated the probability that each of six conditions was present, inter-rator reliability
scores were very low. It was concluded that the results did not support relexology techniques
as a valid method of diagnosis (White et al., 2000). The main benefit of reflexology is the
release of stress and tension. Other reported benefits include relief of pain, release of kidney
stones, and recovery from the effects of stroke, sinsusitis, sciatica, and menstrual disorders
(Berman & Larson, 1994). Regular use has a general toning effect, which enhances other
treatments and ones vitality and feelings of well-being. However, reflexology can produce
side effects, which are referred to as healing crises (Lynn, 1996). Contraindications to reflex-
ology include circulatory disorders of the lower limb, pregnancy, renal calculi, gallstones, and
pacemakers (Booth, 1994). Box 14-3 presents a reflexology study abstract.
B OX 14-3
Reflexology Study
Two hundred and twenty patients with migraine and/or tension headache were
treated for a maximum of 6 months by 78 reflexologists systematically drawn from
the membership lists of five alternative therapist associations in Denmark. Data
collection methods included headache diaries, questionnaires, and qualitative
interviews. Medication was continued as needed. At the 3-month follow-up, 81%
of patients reported that they were helped by the treatments or were cured of their
headache problems. Nineteen percent of those who had formerly taken drugs to
control their headaches were able to stop medication support following participa-
tion in the study. The investigators indicated that additional studies are needed.
Source: Adapted from Launso, L., Brendstrup, E., & Arnberg, S. (1999). An exploratory study of reflex-
ological treatment for headache. Alternative Therapies in Health and Medicine, 5(3), 57-65.
SHIATSU
Meridians were discussed earlier in this chapter. The technique of using finger pressure on
specific points is also used in a form of massage known as shiatsu. Shiatsu relies largely on
sequenced applications of pressure applied from one end of each meridian to the other. Shi-
atsu is literally, finger (shi) pressure (atsu); a rhythmic series of finger pressures over the
entire body along energetic meridians, or pathways, that also includes stretching and tapping
methods. Points are held only 3 to 5 seconds (Olsen, 1990).
The client reclines, usually lying on the back and then the abdomen, for approximately
equal periods as the clinician uses thumb pressure to stimulate the point through a combina-
tion of direct pressure and transference of chi to the point from the clinicians thumb. An
extremely soothing intervention is to place one hand on the lower abdomen (hara) of the
patient and the other on the third eye area on the center of the forehead (Hare, 1988, p.
72). Barefoot shiatsu can use foot pressure to stimulate the meridian points.
Sessions, which can be stimulating as well as relaxing, typically treat the meridians of the
entire body in an attempt to induce relaxation, harmony, and balance (Berman & Larson,
1994; Olsen, 1990). In a study in which 66 individuals with lower back pain received four shi-
atsu treatments, pain and anxiety were significantly decreased over time (2 days after treat-
ment) (Brady et al., 2001).
TOUCH FOR HEALTH (APPLIED KINESIOLOGY)

Using the acupuncture meridian system in addition to acupressure touch and massage,
Touch for Health (TFH), or applied kinesiology, focuses on the relationship of muscle
strength to energy flow. In this approach, each muscle corresponds to a related organ or bod-
ily process. The theory is that if a particular muscle is strong, this indicates that the energy
flow, neurological impulses, circulation, and lymphatic drainage to the muscle and corre-
sponding organ are also strong. TFH is not testing the mechanical strength of the muscle, but
rather the energy in the meridian associated with that muscle and the ability of the body to
replenish energy (Clark, 1996). Energy flow is assessed through testing one muscle on each
meridian pathway, identifying imbalances that are then corrected through acupressure mas-
sage techniques. Muscles that previously tested weak are found to be strong once the energy
balance is restored (Gottesman, 1992).
Six different types of balancing techniques within THF (Gottesman, 1992, pp. 315-316) are:
1. Massaging the skin over the spinous process (the center portion of the vertebrae) at the
level indicated by muscle testing, moving the skin over the bone in a headward to foot-
ward fashion for 10 to 20 seconds.
2. Gentle massage of the neurolymphatic points to stimulate the reflexes.
3. Stroking meridian pathways, over clothing if desired, which also has the effect of rebal-
ancing the energy flow. Coming within 2 inches of the meridian is all that is necessary.
4. Sustained stationary touch to the neurovascular points.
5. Sustained stationary touch to the acupressure holding points.
Acupressure 367
6. Massaging the origin and insertion points of the muscle toward one another in a quick
jiggling motion using hard, heavy pressure.
In the process of TFH, one muscle is manually tested on each side of the body to see if it
locks, indicating energy is flowing, or is weak or gives way, indicating an energy blockage.
Then, the balancing techniques are performed one at a time, followed by a repeat of the mus-
cle test to determine whether a correction has been made. If the muscle does not lock solidly
and hold effortlessly in place, the next technique is performed and the muscle test is repeated.
This procedure is repeated until 14 muscles have been tested and balanced on each side of the
body. Once the tester has massaged, stroked, or touched the appropriate points for any weak
muscles, the result is an immediate strengthening of the muscle, which can be seen and felt
as the muscle locks solidly in place and holds effortlessly when tested. This indicates that the
proper energy flow to the muscle has been restored. This also stimulates the organ sharing the
same meridian (Gottesman, 1992).
TFH techniques can be used for self-care to improve health and obtain optimal-level well-
ness. Putting a hand across ones forehead, which covers the neurovascular points, enhances
emotional stress release. This has a very relaxing effect and facilitates objectivity and prob-
lem solving. Additionally, stroking of the meridians can be incorporated into the bath or
shower by washing with the proper flow of the meridians, down the inside of the arms, up the
outside of the arms, up the inside of the legs, and down the outside. Stroking meridians can
also be used as a pain relief technique by using the meridian closest to the painful area
(Gottesman, 1992, pp. 317-318).
Theory predicts that when energy is out of balance over a period of time, physical illness
is manifested. TFH is a method for identifying and correcting imbalances in the energy sys-
tem before they become illness. TFH can be thought of as a manual biofeedback technique
that assists individuals to develop their intuitive ability through sensing and feeling their
body signals (Gottesman, 1992, pp. 311, 313). Muscle testing also can be used to bring
unconscious material into consciousness, and to enhance flexibility, balance, coordination,
range and ease of motion, and body symmetry. Through the testing and balancing procedure,
changes occur posturally and structurally as habitual patterns of muscle tension are broken
down. Other benefits claimed for TFH, as yet not supported by a body of evidence, are
increased energy, increased resistance to illness, accelerated healing when sick or injured,
improved ability to tolerate stress, decreased pain and tension, and alleviation of mood swings
(Gottesman, 1992).
JIN SHIN DO
In comparison with TFH, which tests for areas of energy weakness, jin shin do (JSD),
another form of acupressure, most often focuses on the parts of the body with an excess of
energy, with the goal of releasing undesired blocked energy and restoring balance to body,
mind, and spirit (Mik & Treppmann, 1997).
The English translation of jin shin do is way of the compassionate spirit. Developed in the
1970s by Iona Marsaa Teeguardenn, an American psychotherapist, it is a synthesis of Western
psychology, Taoist philosophy, and traditional Chinese medicine (Mik & Treppmann, 1997).
Jin shin do consists of a pattern of gentle, prolonged point-holding of key acupressure

points on selected meridians and channels. The so-called local point of a blockage is held
with one finger for 1 to 5 minutes, while the other hand successively touches two or three
energetically connected distal points on other parts of the body to release the tension in the
local point. Time devoted to therapy should be limited to one hour per week (Olsen, 1990).
JSD treatments are done in a meditative state to balance energy and body systems. The
process of JSD starts with a thorough history of physical and/or emotional problems in order to
detect patterns of disharmony. For the manual examination, the client preferably lies supine
and the therapist starts from the neck and shoulders. Since each person has an individual dis-
tribution of tension and armorings (repressed, locked-in emotions), similar symptoms are not
necessarily caused by the same tension patterns in different people (Mik & Treppmann, 1997).
Mik and Treppmann (1997) place special emphasis on self-care of the JSD practitioner. They
point out that many professionals tend to burn out because they pour their energy into trying to
cure or fix their patients, take too much responsibility for the outcome, and often feel as if they
dont get anything back. However, as JSD therapists, first of all, we are required to take good care
of ourselves.... It is important for the therapist to be in a comfortable place, as his/her energy
highly affects the state of the recipient and the outcome of a treatment.... It is the therapists com-
passion and empathy that is required.... We dont have to fix anything for anyone. Our role is
more that of an amplifying catalyst. We dont channel energy from outside of us, we simply sup-
port redistribution of what there is. The recipient and his/her energy do the job (pp. 260, 264).
This approach requires being nonjudgmental and present to each experience as it happens.
Applications of JSD are specific to the symptoms being addressed. Treatments are believed to
be especially effective in improving disorders of function. Symptoms of low back pain often are
accompanied by breathing or digestion problems. All three of these difficulties are affected by JSD
energy release. As a gentle relaxation technique, JSD also can be used to relieve stress. With a
series of treatments, the armorings can be released and experienced (Mik & Treppmann, 1997).
However, JSD is contraindicated for patients in radiation therapy. Additionally, combining JSD
with other energy therapies at the same time might alter the outcome of both. It is safer not to
mix energy approaches but apply different approaches after a sufficient treatment-free interval.
SELF-MASSAGE
Any of the preceding methods can be used for accupressure self-massage.
In the preceding section, a number of approaches were discussed that use accupressure touch
and/or massage to move body energy. In this section, four therapies that use postural or move-
ment re-education as the mechanism to alter the flow of energy through the body, including
Alexander technique, Feldenkrais method, Trager integration, and Rolfing, will be discussed.
Postural/Movement Re-education Therapies

Postural or movement re-education techniques use as their approach the re-education of
the body through movement and physical touch. Patients are taught how to retrain their bod-
ies to come into alignment to release and change postural faults, to improve coordination and
balance, and to relieve structural and functional stress. A major principle underlying the
Postural/Movement Re-education Therapies 369
Alexander technique, Feldenkrais method, and Trager integration, is that awareness has to be
experienced rather than taught verbally. The awareness may then lead to more effective use
of ones whole self (Berman & Larson, 1994).
ALEXANDER TECHNIQUE
The Alexander technique uses lessons to re-educate the body and mind to overcome poor
habits of posture and movement and to reduce physical and mental tension. A Shakespearean
actor developed this technique after he realized that bad posture was responsible for his own
chronic voice loss. F. M. Alexander felt that understanding is necessary to break habits, and
that understanding occurs with repetition of small, simple movements. Consequently, simple,
efficient movements designed to improve balance, posture, and coordination and to provide
pain relief are taught in this technique.
The Alexander method is a body dynamics approach, especially in respect to the head,
neck, and shoulders. It is assumed that the body reacts to gravity and the stresses of modern
life with learned stress responses of poor posture and inhibited movements. The key to the les-
sons is learning a new repertoire of posture and movement. The clinician calls attention to
certain ways of holding, which interfere with an innate ease of movement. Clients then use
awareness of body position, action, and movement to distinguish between poor and fluid
movements, allowing use of the body with less tension and more awareness and efficiency
(Berman & Larson, 1994; Olsen, 1990). A study evaluating the Alexander technique is
abstracted in Box 14-4.
B OX 14-4
Alexander Technique Study
To test the effect of the Alexander technique on the management of disability and
feelings of depression in patients with Parkinsons disease, seven volunteers
received a median of 12 lessons in the Alexander technique. Post-lessons, the sub-
jects were significantly (p<0.05) less depressed. They had a significantly more pos-
itive body concept and had significantly less difficulty performing daily activities.
It was concluded that further, controlled research is desirable.
Source: Stailbrass, C. (1997). An evaluation of the Alexander technique for the management of dis-
ability in Parkinsons diseaseA preliminary study. Clinical Rehabilitation, 11, 8-12.
The challenge of the Alexander technique is the need for continued practice. Results for
this healing modality very much rest on the motivation and discipline of the client. Lessons
are only introductions, reminders, and feedback on progress and improvement in use of the
technique (Olsen, 1990).
FELDENKRAIS METHOD
Moshe Feldenkrais was a physicist, a mechanical engineer, and a black-belt judo practi-
tioner. He developed his method when he was told that a worsening chronic knee injury
might cause him to be wheelchair bound in the future. Through the use of his method he was
able to successfully rehabilitate his knee.
The Feldenkrais method uses movement as a model and means to facilitate creating a
new sense of ones self as a physical being (Olsen, 1990, p. 138). The keys to the Feldenkrais
method are awareness, touch, and discussion to assist clients to create freer, more efficient
movement. Awareness involves an attentiveness to both internal experience and external
environment, developed through experience of the skeleton and its muscles, and their ori-
entation and movement in space. There is no attempt to structurally alter the body.
The Feldenkrais approach begins by inviting the individual to choose to participate, while
trust in the clinician is purposefully fostered. The clinician takes on the roles of teacher, facil-
itator, and guide to assist the individual using verbal, visual, and kinesthetic information.
Rather than first evaluating the client and then treating with massage and strengthening or
range of motion exercises, the client is invited to learn using the discovery model. The
[client] is asked to explore a new focus of movement by attending to altered kinesthetic cues
during a desired action. Evaluation is not performed separately from the learning process.
The therapist constantly observes and adapts stimuli in order for the patient to maximally
explore and adapt during a particular session; to experience, at best, a sense of success or, at
least, the novelty of discovery (Jackson-Wyatt, 1997, pp. 189, 191).
The notion of self-image is central to the Feldenkrais method. It is believed that if the
negative habitual patterns of movement are interrupted, the body will learn to function with
greater ease, fluidity, and motion. This would, in turn, improve ones self-image and
simultaneously increase awareness and health (Berman & Larson, 1994). The starting point
for self-observation is to help the client discover his or her current habitual responses in a
particular situation. Intervention cues are initially small, gentle, and paced so that the
learner perceives that this feels doable and worth doing again (Jackson-Wyatt, 1997).
Feldenkrais takes two forms. In individual hands-on sessions of functional integration,
the clinicians touch is used to improve the clients breathing and body alignment. In a series
of classes of slow, nonaerobic motions (awareness through movement), clients relearn the
proper ways their bodies should move.
Functional integration, which uses positioning, contact, pressure, and movement, com-
bined with verbal and visual stimuli, is used as a strategy when the individual is not able, for
whatever reason, to actively initiate the exploration (Jackson-Wyatt, 1997). In this method,
words and gentle, noninvasive touch are used to guide a client to an awareness of existing
and alternative movement patterns. The use of touch is for communication, not correction,
and no special techniques of pressing or stroking are used (Berman & Larson, 1994).
Awareness through movement, which uses primarily verbal and visual stimuli, is the
approach of choice as long as the learner is prepared to initiate the movement experiment
that will create new awareness and a variety of responses that are different from the habitual
actions (Jackson-Wyatt, 1997, pp. 195-196). This verbally directed form of the Feldenkrais
method consists of gentle exploratory movement sequences organized around a specific
human function (such as reaching, bending, or walking) with the intention of increasing
awareness of multiple possibilities of action. Thinking, sensory perception, and imagery are
also involved in examining each function (Berman & Larson, 1994). The method is fre-
quently used to help reduce stress and tension, to alleviate chronic pain, and to help athletes
and others improve their balance and coordination (Kahn & Saulo, 1994).
Feldenkrais attempts to give the brain, and therefore the body, new messages, new
images, and patterns for movement. The task is to help clients free themselves from old
patterns of distorted position and movement and learn to transmit new patterns and ways
of moving to their bodies. The goal is to regain the potential to move with grace and free-
dom. Clients take responsibility for themselves, but cleverness, not force, stretches and
releases muscles and reorganizes how to move body parts (Olsen, 1990). Thus, the method
imparts a sense of exploration, experimentation, and innovation that allows each person
to find his or her optimal style of movement (Berman & Larson, 1994, p. 101).
As with most touch and bodywork methods, only limited clinical studies have been con-
ducted to document outcomes of the Feldenkrais method (Berman & Larson, 1994). How-
ever, an abstract of one randomized, controlled study is presented in Box 14-6.
TRAGER PSYCHOPHYSICAL INTEGRATION

The intention of Tragering is to allow the client to give up unconscious muscular con-
trol and relax deeply in order to increase flexibility and joint range of motion (Berman &
Larson, 1994). Clinicians use light, gentle, nonintrusive hand and mind movements to
break up and release deep-seated physical and mental patterns that restrict range of
motion of the muscles. Trager targets the unconscious mind, the central nervous system,
rather than the local tissue. It goes directly to the source of the disturbance (Stone, 1997,
p. 201).
Key is the ability of clinicians to perform their work in a relaxed, meditative state, or
hook-up, which is intended to enhance sensory, kinesthetic, and other pleasurable
experiences for the client (Olsen, 1990). The emphasis for the clinician is on mindful-
ness while moving. Mindfulness is the high level of conscious awareness and focus that
the clinician assumes while working. This almost meditative state of alertness, sensitiv-
ity, and nonjudgment allows a clear open connection between the clinician and the
client (Stone, 1997).
This method of movement reeducation is distinguished by compressions, elongations, light
bounces, rhythmic rocking, and shaking movements to the clients head, torso, and
appendages, which loosen joints, ease movement, and release chronic patterns of tension.
These actions cause clients to begin to experience freedom of movement of their body parts.
The clinician feels how the client is holding his or her body. The Trager practitioner uses his
or her hands with the aim of influencing deep-seated psychophysiological patterns in the
clients mind and interrupting the projection of those patterns into body tissues (Berman &
Larson, 1994, p. 132).
A session consists of gentle passive movements of the client while lying on a treatment
table. The Trager approach is based in feeling, not in doing... The fluffing, jiggling, length-
ening, and shimmering of muscle tissue is communicated to the patients mind (Stone, 1997,
p. 200). The emphasis of this subtle approach is on comfort, gentleness, effortlessness, play-
fulness, and gentle, painless movements. Balance, gait, and strengthening may also be
addressed. Each session, viewed not only as a treatment but also a lesson, is modified and
adapted to fit the needs of the individual.
After each session, homework is assigned in Mentastics, a series of mentally directed, active,
effortless, physical movements developed to maintain and enhance a sense of lightness, freedom,
and flexibility. Mentastics is the active, self-guided version of the passive, individualized Trager
session. Exercises are chosen to support progress made at each particular session (Olsen, 1990).
The lesson is in how to feel movement in a manner that is correct for that body, thus increasing
body awareness. Employing the weight of the body, a person is instructed to initiate a movement
and then let go. This release and allowing the weight of the body part to carry the motion to
completion with mindfulness helps separate Mentastics movements from exercise (Stone, 1997).
The goals of Trager work are general functional improvement, creating a feeling of pleas-
ure in being able to move body parts more freely, decreased muscular tension, improved body
alignment, renewed and greater ease of movement, the experience of total relaxation and
peace, and a sense of functional integration (Stone, 1997). Despite lack of research-based evi-
dence of its effectiveness, Trager work has been indicated for those who want to learn to relax,
improve posture, prevent pain, reduce tension, or move with greater ease. Box 14-5 describes
a pilot study using the Trager approach.
B OX 14-5
A Feldenkrais Method Study
To investigate whether physiotherapy or Feldenkrais interventions resulted in a
reduction in neck and shoulder complaints, 97 female industrial workers were
randomized to 1) a physiotherapy group treated for 50 minutes twice a week in
groups of five to eight subjects and a program of home exercises according to the
ergonomic program of the physical therapists of the occupational health service;
2) a Feldenkrais group with 50 minute per week interventions done individually
four times, in a group of seven to eight subjects 12 times, and eight exercises for
home practice on audio cassette; and 3) a control group that received no inter-
vention but were promised participation in group exercise after termination of the
study. The two interventions lasted 16 weeks during paid working time. An aver-
age of 1.5 months after the interventions, the Feldenkrais group showed significant
decreases in complaints from neck and shoulders and in disability during leisure
time. The other two groups showed no change (physiotherapy) or worsening of
complaints (control). The authors concluded that more randomized and controlled
studies with a longer follow up period are needed.
Source: Lundblad, I., Elert, J., & Gerdle, B. (1999). Randomized controlled trial of physiotherapy and
Feldenkrais interventions in female workers with neck-shoulder complaints. Journal of Occupational
Rehabilitation, 9, 179-194.
STRUCTURAL INTEGRATION (ROLFING)

In a study with 33 volunteers with a self-reported history of at least one headache per week
for at least 6 months, analysis of variance demonstrated significant improvement in health-
related quality of life for the medication and Trager group, and the medication and attention
control group (compared with the medication-only control group), and reduction in medica-
tion usage for the Trager group. Participants randomized to Trager demonstrated a significant
decrease in the frequency of headaches, and a 44% decrease in medication usage (Foster et
al., 2004).
Structural integration, or Rolfing, consists of a series of 10 basic bodywork sessions of deep
connective tissue manipulation involving stretching the fascia sheaths (sheets of connective
tissue) by applying sliding pressure to the affected area with fingers, thumbs, and occasionally
elbows. Bones support the body, and muscles connect the bones; the enwrapping fascias that
support and hold not only the normal relationship of bone and muscle but also whatever pos-
tural misalignment the body might adopt. For example, when the body attempts to distribute
the stress of an injury, the result is likely to be shortened and thickened fascias, which may in
turn lead to symptoms somewhere other than the site of the original trauma (Berman & Lar-
son, 1994). Manipulation of the fascias frequently elicits a strong emotional response, such as
crying from clients.
The aim is to increase muscular length and overall balance for optimal posture. By aligning
and structurally and functionally integrating the bodys major anatomic segments (head, neck,
shoulders, torso, pelvis, and legs) in balance with gravity, it is believed that the body will be able
to use energy more efficiently (Olsen, 1990). Major offshoots of structural integration include
Aston patterning, developed by Judith Aston, and Hellerwork, developed by Joseph Heller.
Rolfers recommend 10 sessions to obtain the maximum benefit from Rolfing. The sessions
last approximately 1 hour and can be spaced anywhere from once a week to once a month.
There is also a five session advanced series and a Rolfing movement series. Progressive tissue
unfolding and restructuring keeps the client in balance between each session. Psychotherapy
or a Rolfing movement session between manipulation sessions might also help the client
process and integrate changes. After the initial 10 sessions, some people return for periodic
tune-up work or a mini series of two or three sessions (Bernau-Eigen, 1998).
There are varied benefits of Rolfing. Changes have the potential to affect the total well
being of the person (Bernau-Eigen, 1998, p. 240). General benefits include:
Reduced chronic stress

Increased flexibility
Better circulation (older people comment on this effect)
Pain relief
A sense of expansion and feeling taller and lighter
Greater self-acceptance
Positive postural changes
More energy
A sense of support
The emphasis in this chapter has been on the use of touch to locate areas of muscle ten-
sion, reduce pain, soothe injured muscles, stimulate blood and lymphatic circulation, and pro-
mote deep relaxation. Noninvasive therapeutic modalities discussed include massage
therapies, acupressure approaches such as reflexology, shiatsu, and TFH, and various pos-
tural/movement reeducation therapies. An extensive training program leading to certification
is necessary for competent practice of many of these modalities (see additional information at
the end of the chapter).
Chapter Key Points

Sensitive touch can convey a sense of caring, which is an essential element in the ther-
apeutic relationship.
Bodywork in all its forms helps to reduce pain, soothe injured muscles, stimulate blood
and lymphatic circulation, and promote deep relaxation.
Types of massage include Swedish, deep tissue, neuromuscular, and manual lymph
drainage from European traditions, and traditional Chinese methods.
Types of acupressure include trigger point/myotherapy, reflexology, shiatsu, TFH, jin
shin do, and self-acupressure.
Forms of postural movement/reeducation include the Alexander technique, Feldenkrais
method, Trager integration, and structural integration (Rolfing).
References
Bernau-Eigen, M. (1998). Rolfing: A somatic approach to the integration of human structures. Nurse Prac-
titioner Forum, 9, 235-242.
Booth, B. (1994). Reflexology. Nursing Times, 90, 38-40.
Brady, L. H., Henry, K., Luth, J. F., & Casper-Bruett, K. K. (2001). The effects of shiatsu on lower back pain.
Journal of Holistic Nursing, 19, 57-70.
Clark, C. C. (1996). Wellness practitioner: Concepts, research and strategies (2nd ed.). New York: Springer.
DEpiro, N. W. (Ed.). (1997, October). Herbal medicine: What works, whats safe. Patient Care, 49-77.
Felhendler, D., & Lisander, B. (1999). Effects of non-invasive stimulation of acupoints on the cardiovas-
cular system. Complementary Therapies in Medicine, 7, 231-234.
Foster, K.A., Liskin, J., Cen, S., Abbott, A., Armisen, V., Globe, D., et al. (2004). The Trager approach in
the treatment of Chronic headache: A pilot study. Alternative Therapies in Health and Medicine,
10, 40-46.
Gottesman, C. (1992). Energy balancing through Touch for Health. Journal of Holistic Nursing, 10, 306-323.
Hare, M. L. (1988). Shiatsu acupressure in nursing practice. Advances in Nursing Science, 2, 68-74.
References 375
Hill, C. F. (1995). Massage in intensive care nursing: A literature review. Complementary Therapies in Med-
icine, 3, 100-104.
Huebscher, R. (1998). An overview of massage: Part I. Nurse Practitioner Forum, 9, 197-199.
Jackson-Wyatt, O. (1997). Feldenkrais method and rehabilitation: A paradigm shift incorporating a per-
ception of learning. In C. M. Davis (Ed.), Complementary therapies in rehabilitation (pp. 189-196).
Thorofare, NJ: SLACK Incorporated.
Kahn, S., & Saulo, M. (1994). Healing. A nurses guide to self-care and renewal. Albany, NY: Delmar.
Kunz, K., & Kunz, B. (1995). Understanding the science and art of reflexology. Alternative and Comple-
mentary Therapies, 1, 183-186.
Lloyd, K. (1995, January). The power to heal colleagues and clients with a two-minute massage. Lamp, 30.
Lundblad, I., Elert, J., & Gerdle, B. (1999). Randomized controlled trial of physiotherapy and Feldenkrais
interventions in female workers with neck-shoulder complaints. Journal of Occupational Rehabili-
tation, 9, 179-194.
Lynn, J. (1996). Using complementary therapies. Reflexology. Professional Nurse, 11, 321-22.
Mackey, B. T. (2001). Massage therapy and reflexology awareness. Nursing Clinics of North America, 39,
159-169.
Mik, G. H., & Treppmann, U. (1997). Jin shin do. In C. M. Davis (Ed.), Complementary therapies in reha-
bilitation (pp. 257-265). Thorofare, NJ: SLACK Incorporated.
Moyer, C. A., Rounds, J., & Hannum, J. W., (2004). A meta-analysis of massage therapy research. Psycho-
logical Bulletin, 130, 3-18.
Olsen, K. G. (1990). The encyclopedia of alternative health care. New York: Pocket Books.
Routasalo, P. (1999). Physical touch in nursing studies: A literature review. Journalof Advanced Nursing, 30,
843-850.
Smith, M. C., Kemp, J., Hemphill, L., & Vojir, C. P. (2002). Outcomes of therapeutic massage for hospi-
talized cancer patients. Journal of Nursing Scholarship, 34, 257-262.
Smith, M. C., Reeder, F., Daniel, L., Baramee, J., & Hagman, J. (2003). Outcomes of touch therapies dur-
ing bone marrow transplant. Alternative Therapies in Health and Medicine, 9, 40-49.
Stailbrass, C. (1997). An evaluation of the Alexander technique for the management of disability in
Parkinsons diseaseA preliminary study. Clinical Rehabilitation, 11, 8-12.
Stephenson, N. L. N., & Dalton, J. A. (2003). Using reflexology for pain management. Journal of Holistic
Nursing, 21, 179-191.
Stern, R. M., Jokerst, M. D., Muth, E. R., & Hollis, C. (2001). Acupressure relieves the symptoms of
motion sickness and reduces abnormal gastric activity. Alternative Therapies in Health and Medi-
cine, 7, 91-94.
Stone, A. R. (1997). The Trager approach. In C. M. Davis (Ed.), Complementary therapies in rehabilitation
(pp. 199-212). Thorofare, NJ: SLACK Incorporated.
White, A. R., Williamson, J., Hart, A., & Ernst, E. (2000). A blinded investigation into the accuracy of
reflexology charts. Complementary Therapies in Medicine, 8, 166-172.
Massage
American Massage Therapy Association
820 Davis Street Suite 100
Evanston, IL 60201
Tel: (847) 864-0123
www.amtamassage.org
National Association of Nurse Massage Therapists

Tel: (800) 262-4017
www.nanmt.org
Massage therapists are currently licensed by 29 states, the District of Columbia, and a num-
ber of localities. Most states require 500 or more classroom hours of training from a recognized
training program and passing an examination. The National Certification Board for Thera-
peutic Massage and Bodywork (NCBTMB) developed an exam that most states have adopted
for their licensing examination. Those certified can use the title NCBTMB. The Commission
on Massage Therapy Accreditation, and the Accrediting Commission of Career Schools and
Colleges of Technology and the Accrediting Council for Continuing Education and Training
also accredit massage training programs.
Trager Approach
The Trager Institute
21 Locust Avenue
Mill Valley, CA 94941
Tel: (415) 388-2688
www.trager.com
Trager practitioners are not regulated by any state. However, some states may require prac-
titioners to obtain a massage license. Trager practitioners are certified by the Trager Institute,
which monitors training and continued competency. To become a practitioner, an individual
must experience the work from a certified practitioner before entering the training track.
After a week-long initial training the student must complete and log at least 30 practice ses-
sions, receive at least 10 sessions, and attend additional tutorials to be eligible for the inter-
mediate training. Achieving practitioner status typically takes 1 to 2 years.
Rolfing
Rolf Institute of Structural Integration
205 Canyon Blvd.
Boulder, CO 80302
Tel: (800) 530-8875
www.rolf.org
The Rolf Institute is the sole certifying body for Rolfers.
Feldenkrais Method
Feldenkrais Guild of North America
524 Ellsworth St. SW
PO Box 489
Albany, OR 97321
Tel: (541) 926-0981
www.feldenkrais.com
The training required to be a certified Feldenkrais practitioner requires 160 days of train-
ing spread over a period of over 3 years. The educational director of training programs grants
initial certification after students have passed a supervised clinic.
Certification must be maintained through continuing education requirements on a bi-
annual basis.
Alexander Technique
The American Society for the Alexander Technique (ASAT)
3010 Hennepin Avenue South, Suite 10
Minneapolis, MN 55408
Tel: (800) 473-0620
www.alexandertech.com
Alexander Technique International (ATI)

USA Regional Office
1692 Massachusetts Avenue
Cambridge, MA 02138
Tel: (617) 497-2342
Both of these organizations certify teachers of the Alexander technique. In the United
States, there are 18 ASAT-approved teacher training courses and five training courses affili-
ated with ATI. To become a certified ASAT teacher, an individual must complete 1,600
hours of training over a minimum of 3 years at an ASAT-approved teacher training course.
Applied Kinesiology
The International College of Applied Kinesiology (ICAK)
6405 Metcalf Avenue, Suite 503
Shawnee Mission, KS 66202
Tel: (913) 384-5336
www.icakusa.com
There is no specific degree for Applied Kinesiology; rather, it is practiced by those already
possessing a doctorate degree (such as DC, DO, MD, and others) and a license to diagnose.
The ICAK provides various levels of certification for physicians.
Reflexology
International Institute of Reflexology
PO Box 12642
St. Petersburg, FL 33733
Tel: (727) 343-4811
www.reflexology-usa.net
No formal credentialing exists for reflexology. Certification is provided by certain educa-

tional institutions specializing in this training, which can range from 100 to 1,000 hours of
instruction.
Acupressure
American Oriental Bodywork Therapy Association (AOBTA)
Laurel Oak Corporate Center
1010 Haddonfield Berlin Road, Suite 408
Voorhees, NJ 08043
Tel: (856) 782-1616
www.AOBTA.org
The hands-on nature of acupressure has put acupressure under the auspices of massage
therapy. The National Committee on Certification for Acupressure and traditional Eastern
medicine recently created national examination and credentialing standards for oriental
bodywork and acupressure. Among the many requirements are a minimum of 500 hours of
training including at least 100 hours of anatomy. Although the industry standard is 500 hours
of training, each state has different requirements for licensure.
15
REDUCING ENERGY DEPLETION
Relaxation and Stress Reduction
Abstract
The goals of stress management are to help people deal with short-lived stressful events
and to defuse the effects of chronic stress. The parasympathetic nervous system helps to com-
pensate for periods of high arousal and stress. All of the techniques described in this chapter,
including different forms of meditation, breathing, yoga, biofeedback, and guided imagery, are
designed to induce a positive parasympathetic state and reduce stress responses through relax-
ation. Additional information about organizational resources and certification for each of the
therapies is located at the end of the chapter.
Learning Outcomes
Describe symptoms of stress
Differentiate between concentrative and mindfulness meditation
Discuss how to elicit the relaxation response
Differentiate between a body scan to practice mindfulness meditation and progressive
muscle relaxation
Describe the essential breath technique
Discuss the use of yoga as a preparation for meditation
Describe different types of biofeedback instrumentation
380 Chapter 15 Reducing Energy Depletion: Relaxation and Stress Reduction
The Stress Response

At the beginning of the 19th century, the Harvard physiologist Walter B. Cannon first
described the fight-or-flight response, the internal adaptive response of the body to a
change perceived as a threat. In this response, the body secretes catecholaminesstress hor-
monesthat prepare a person under threat to fight or run. Epinephrine (adrenaline), which
is produced by the adrenal glands, is the best known of these hormones.
The fight-or-flight response was essential to survival in a time when human beings faced
physical threats, such as wild animals, that caused acute stress and could be dealt with effec-
tively by either fighting or running away. By contrast, todays stresses, such as weather, noise,
crowding, time pressures, performance standards, threats to security and self-esteem, lack of
exercise, poor nutrition, and perception of an experience as stressful, are not resolvable
through fight-or-flight. It is ones reaction to stressful experiences that can create a stress
response.
There are two forms of stress: short-term (acute) and long-term (chronic). Acute stress,
caused by stressors such as a near miss on the highway or the reaction to a sudden loud noise,
is associated with a cascade of physiological changes that prepare the body for fight or flight.
During acute stress, heart rate, blood pressure, and muscle tension all rise sharply; the stom-
ach and intestines become less active; and the blood level of glucose rises for quick energy.
The physiological responses are associated with psychological responses, such as racing
thoughts, anxiety, and even panic.
Under conditions of chronic, long-term stress, the typical and normal responses that occur
during short-term stress are abnormally extended and can contribute to the development of
chronic disease. With chronic stress, the immune system tends to be suppressed or become
less active, the blood cholesterol level rises, and calcium is lost from the bones. When pro-
tracted, the normal short-term increases in blood pressure can become hypertension,
increased muscle tension can lead to headaches or aggravate pain, unusual changes in the
activity of the intestinal tract can lead to diarrhea or spasms, and increases in heart rate can
raise the risk of an arrhythmia. In addition, depressed immunity may make an individual sus-
ceptible to colds and the flu or possibly to more serious diseases. Indeed, more than 80% of
all illnesses have stress-related etiologies (Bottomley, 1997).
Pelletier (1993) describes a number of symptoms associated with chronic, long-term stress:
Cognitive symptoms such as anxious thoughts, poor concentration, and difficulty
with memory.
Emotional symptoms such as feelings of tension, irritability, restlessness, and depression.
Behavioral symptoms such as sleep problems, crying, and changes in drinking, eating,
or smoking behaviors.
Physiological symptoms such as grinding teeth, sweating, nausea, constipation, tired-
ness, and weight loss or gain.
Social symptoms such as withdrawal and change in the quality of relationships.
Stress responses are regulated by the autonomic nervous system, a part of the nervous sys-
tem not usually under voluntary control. The sympathetic branch of the autonomic nervous
Relaxation 381
system regulates the kind of arousal described above. The parasympathetic branch of the auto-
nomic nervous system, on the other hand, induces relaxation and helps to compensate for
periods of high arousal. The goals of stress management are to help persons deal with short-
term stressful events and to defuse the effects of chronic stress. All of the techniques described
in this chapter are designed to induce a positive parasympathetic state and reduce stress
responses through relaxation.
Relaxation
Relaxation begins with an inward focus and a mental retreat from ones surroundings.
When thoughts are stilled, muscular relaxation and stress reduction follow. Given that the
relaxation response can be elicited by any one of a number of Eastern and Western practices
(Horowitz, 1999), there is a great deal of room for individual choice from among the possible
techniques. In fact, there is no evidence of a clear benefit of one relaxation technique over
another. It is possible that client preference is the most important consideration in the effec-
tiveness of any intervention (Snyder & Chlan, 1999).
There are a number of possible uses of relaxation therapy, including to:
Decrease anxiety
Promote sleep
Reduce or prevent the physiological and psychological effects of stress
Serve as a coping device or skill
Reduce the perception of pain and enhance the effectiveness of pain relief measures
Alleviate muscle tension
Increase suggestibility
Combat fatigue
Increase perceived energy
Warm or cool parts of the body
Slow the heartbeat
Decrease blood pressure (Zahourek, 1988)
However, despite the numerous indications, there are several precautions for relaxation
that should be considered. These include making an illness worse by indiscriminate symptom
removal or masking other illnesses; providing superficial relief, particularly with psychiatric
difficulties, or promoting withdrawal, intensifying anxiety or panic; causing a counterproduc-
tive physiological response, a hypotensive state, or an unwanted drug reaction; or intensify-
ing pain because of the focus on the body (Zahourek, 1988).
Olsen (1990, p. 262) clearly describes the possible consequences of profound relaxation:
Done to an extreme, one can get too relaxed, ones mind too plastic. Profound relaxation
over a prolonged period heightens suggestibility. . . . Stimulated too often or too fast, the new
emotional awareness may be too intense. The individual becomes one raw nerve, suffering the
impact of things and people inordinately in everyday life. . . . Some people may become
addicted to the seeming euphoria or relaxation and withdraw from active lifephysically
and/or emotionally. Meditation or another form of relaxation becomes a shield, a way not to
deal with real life.
In moderation, any one of the approaches to meditation can be a useful approach to induce
relaxation. The next section will describe the relaxation response, autogenic training, and
transcendental meditation as examples of the concentrative type of meditation, and progres-
sive muscle relaxation as an example of the mindfulness type of meditation.
MEDITATION
The word meditate comes from the Sanskrit word, medha, meaning wisdom. Meditation
simply means getting in touch with our inner wisdom (Gimbel, 1998).
According to Kuhn (1999, p. 199), meditation is defined in several ways: a systematic and
continued focusing of the attention on a single target perceptiona sound or mantraor
continually holding a specific attention set; or a technique that allows a person to investigate
the process of his or her consciousness and experiences to discover the more basic underlying
qualities of existence; or simply any activity that keeps the attention pleasantly anchored in
the present moment.
As a person continues to meditate, the general trend is toward greater calm, positive emo-
tions and perceptual and introspective sensitivity. Exactly how meditation produces its many
effects remains unclear. However, possible physiological processes include lowered arousal and
increased hemispheric synchronization. Possible psychological mechanisms include relax-
ation, desensitization, development of self-control skills, insight and self-understanding
(Walsh, 1996). However, Walsh (1996, p. 119) expresses concern that more attention has
been given to heart rate than . . . transpersonal goals such as enhanced concentration, ethics,
love, compassion, generosity, wisdom, and service.
Many meditative and religious disciplines have moral, psychological, social, and spiritual
requests for those who join their tradition. In Buddhism this includes the Noble Eightfold or
Middle Path, as follows (Lowenstein, 2002):
Right Understanding and Perception
Right Thought and Aspiration
Right Speech
Right Action and Conduct
Right Means of Livelihood
Right Effort and Endeavor
Right Mindfulness-Concentration
Right Concentration-Contemplation
Wright (2001) identifies and rebuts several misconceptions about meditation that create
obstacles to its practice. For example, one misconception is that meditation is somehow a sin
Relaxation 383
because it is connected to Eastern mysticism. In fact, meditation can be found in all reli-
gions (2001, p. 96). Its universal nature transcends all religions and all cultures. Another
misconception is that the mantra is of utmost importance and must be especially selected for
the individual by a holy man. Wright (2001, p. 96) states that in reality the choices for
mantras are endless, and their importance is minimal. Yet another misconception experi-
enced by adults is that meditation must be done perfectly. Actually, there is no way to get it
wrong. Meditation is the only state I know in which ones intent is to have no intention
(2001, p. 97). Finally, is the idea that if one does not see God or is not levitating then he or
she is doing it wrong (2001, p. 97).
There are two basic approaches to meditation: concentrative and mindfulness meditation.
Concentrative (Reflective) Meditation

Concentrative meditation involves focus, or awareness without thought (Fugh-Berman,
1997, p. 167). Focus is attained in one of the following ways:
1. Mental meditation. Concentration on a word or phrase, commonly called a mantra.
2. Physical repetition. Concentration on breathing or the sound of ones feet hitting the
ground in jogging.
3. Problem contemplation. Attempts to solve a problem with paradoxical components. Zen
terms this the koan.
4. Visual concentration. Akin to imagery, with the focus on an image.
Two specific concentrative meditation techniques that are widely used are the relaxation
response and Transcendental Meditation (Maharishi Vedic Education Development Corpo-
ration)
The Relaxation Response

The relaxation response, which is based on mental meditation to achieve focus, consists of
muscle relaxation, relaxed breathing, and repetition of the focus word/phrase. One set of
instructions (Benson, 1993, p. 240) used to elicit the relaxation response is described below:
Step 1. Pick a focus word or short phrase thats firmly rooted in your personal belief sys-
tem. For example, a nonreligious individual might choose a neutral word like one, or
peace or love, while a religious Christian person desiring to use a prayer could pick the
opening words of Psalm 23, The Lord is my shepherd, and a religious Jewish person
could choose Shalom.
Step 2. Sit quietly in a comfortable position.
Step 3. Close your eyes.
Step 4. Relax your muscles.
Step 5. Breathe slowly and naturally, repeating your focus word or phrase silently as
you exhale.
Step 6. Throughout, assume a passive attitude. Dont worry about how well youre
doing. When other thoughts come to mind, simply say to yourself, Oh, well, and gen-
tly return to the repetition.
Step 7. Continue for 10 to 20 minutes. You may open your eyes to check the time, but
do not use an alarm. When you finish, sit quietly for a minute or so, at first with your
eyes closed but later with your eyes open. Then do not stand for 1 or 2 minutes.
Step 8. Practice the technique once or twice a day.
Benson and colleagues have found that the relaxation response also can be elicited by
physical repetition during exercise. They found that adding the relaxation response to run-
ning decreased the metabolic rate and stimulated a mild euphoria (joggers high) within the
first mile or two. The following are steps to elicit the relaxation response during walking or
jogging (Benson, 1993, pp. 254-255):
Step 1. Get into sufficiently good condition so that you can jog or walk without becom-
ing excessively short of breath.
Step 2. Do your usual warm-up exercises before you jog or walk.
Step 3. As you exercise, keep your eyes fully open, but attend to your breathing. After
you fall into a regular pattern of breathing, focus in particular on its in-and-out
rhythm. As you breathe in, say to yourself, silently, in, when you exhale, say out.
In effect, the words in and out become your mental devices or focus words, in the
same way that you would use your personal focus words or phrases with other relax-
ation response methods. If this in/out rhythm is uncomfortable for you (you might
feel that your breathing is too fast or too slow), you may focus on something else. For
example, you can become aware of your feet hitting the ground, silently repeating,
One, two, one, two or left, right, left, right. Alternatively, focusing on a faith-
oriented word or phrase during exercise may be helpful and perhaps make exercise
more satisfying.
Step 4. Remember to maintain a passive attitude, simply disregarding disruptive
thoughts. When they occur, think to yourself, Oh, well, and return to your repetitive
focus word or phrase.
Step 5. After you complete your exercise, return to your normal after-exercise routine.
The relaxation response comprises an assortment of physiological changes, including a

decrease below resting levels in oxygen consumption, heart rate, breathing rate, and muscle
tension, plus a decrease in blood pressure in some people, and a shift from normal waking
brain wave patterns to a pattern in which slower brain waves predominate (Benson, 1993).
The relaxation response was developed to help people recognize that stressors have multiple
meanings, not all necessarily negative, and that one can work, through increased awareness,
to get away from the victim role and from self-destructive cognitive and behavior patterns
(Horowitz, 1999, p. 15).
Relaxation 385
The relaxation response can be very useful in enhancing health, to the extent that any dis-
order is caused or made worse by stress. However, Canter (2003, p. 1049) asserts that a review
of the literature indicates current evidence for the therapeutic effectiveness of any type of
meditation is weak.
The nonjudgmental mindset required of the relaxation response attained via meditation
facilitates the realization that ones identity entails more than pain. Mastery attained through
the voluntary self-regulation of meditation (focused breathing, body scans, etc.) may help
partly by increasing confidence in ones ability to have some control over symptoms or at least
developing attitudes that render symptoms more bearable (Horowitz, 1999, p. 14).
Benson (1993, p. 248) states that at The New England Deaconness Hospital we have
taught the relaxation response to people with muscle tension pains (which can include some
headaches), infertility, insomnia, psychological problems, cardiac arrhythmia, premenstrual
syndrome, and several common symptoms related to cancer and AIDS (anticipatory nausea
and vomiting of chemotherapy). For these conditions, there is good evidence that the relax-
ation response can undo some or all of the damage caused by stress and have a significant clin-
ical impact.
Outcomes of the relaxation response include:
Slowed rate of breathing
Slowed heart rate
Relaxed muscles (muscle ache may be gone)
Slight welling of tears in the eyes
Sensation of warmth in hands and feet
Feeling peaceful and calm but also more alert and less fatigued
The relaxation response can be elicited through a variety of techniques that share an
emphasis on a repetitive mental focus and a passive attitude. Another such concentrative
meditation technique is autogenic training.
Autogenic Training
Autogenic means self-generated. Developed in Germany by physician J. H. Schultz, auto-
genic training is a kind of self-hypnosis, a highly systematized series of attention-focusing
exercises designed to generate deep relaxation and enhance ones recuperative and self-heal-
ing powers. (Olsen, 1990).
In autogenic training, there is a focus on feelings of heaviness and cultivating a sense of
warmth in the limbs, combined with a passive focus on breathing [the] attitude toward the
exercises should be one of passive concentrationnot intense or compulsive, but rather of a
let it happen nature (Benson, 1993, p. 242). Simple phrases are used to cue the body to
elicit the relaxation response. The phrases should theoretically elicit specific physiological
responses; for example the phrase, My arms are heavy and warm, is meant to increase blood
flow to the arms. Benson suggests that the client be instructed to get comfortable and have
someone slowly read the instructions in Box 15-1, or make a tape recording to use until the
process has been memorized.
B OX 15-1
Autogenic Training to Elicit the
Relaxation Response
Close your eyes and focus on the sensations of breathing. Imagine your breath
rolling in and out like ocean waves. Think quietly to yourself, My breath is calm
and effortless. . . calm and effortless. . . . Repeat the phrase to yourself as you imag-
ine waves of relaxation flowing through your bodythrough your chest and
shoulders, into your arms and back, and into your hips and legs. Feel a sense of
tranquility moving through your entire body. Continue for several minutes. . . .
Now focus on your arms and hands. Think to yourself, My arms are heavy and
warm. Warmth is flowing gently through my arms into my wrists, hands, and fin-
gers. My arms and hands are heavy and warm. Stay with these thoughts and the
feelings in your arms and hands for several minutes. . . .
Now bring your focus to your legs for a few minutes. Imagine warmth and heav-
iness flowing from your arms down into your legs. Think to yourself: My legs are
becoming heavy and warm. Warmth is flowing through my feet . . . down into my
toes. My legs and feet are heavy and warm.
Now scan your body for any points of tension, and if you find some, let them go
limp, your muscles relaxed. Notice how heavy, warm, and limp your body has
become. Think to yourself: All my muscles are letting go. Im getting more and
more relaxed.
Finally, take a deep breath, feeling the air fill your lungs and down into your
abdomen. As you breathe out, think, I am calm. . . . I am calm. . . . Do this for a
few moments, feeling the peacefulness throughout your body.
Then, as your practice session ends, count to three, taking a deep breath, and
exhaling with each number. Open your eyes and get up slowly. Stretch before
going back to everyday activities (Benson, 1993, p. 244).
Source: Benson, H. (1993) The relaxation response. In D. Goleman & J. Gurin (Eds.), Mind-body
medicine: How to use your mind for better health. Yonkers, NY: Consumer Reports. Used with per-
mission of the author.
There are six basic meditative exercises that can be used to increase resistance to stressors,
reduce or eliminate sleep disorders, and modify pain reactions (Clark, 1996). It may take up
to 10 months to master the six exercises. The exercises focus on:
Relaxing the neuromuscular system
Relaxing the vascular system
Regulating and adjusting the heart rate
The breathing mechanism
Relaxation 387
Creating warmth in the abdomen

Cooling the forehead
After mastery of the first set of exercises has been achieved, several advanced exercises can
be studied (Olsen, 1990). These include:
Autogenic meditation. A series of structured meditations designed to help reach more
deeply into the unconscious mind.
Autogenic modification. Directed toward a specific organ or body part to promote func-
tional changes in order to overcome chronic conditions.
Autogenic neutralization. Uncovers particularly introspective psychophysical blockages
using stream-of-consciousness verbalization to trigger more powerful or intense releases.
In addition to the relaxation response, with or without autogenic training, another con-
centrative meditation technique that is widely used is Transcendental Meditation.
Transcendental Meditation
There are two basic components to Transcendental Meditation (TM). First, the silent rep-
etition of a sound, called a mantra, to minimize distracting thoughts, and second, the passive
disregard of thoughts that do intrude, followed by a return to the repetition (Benson, 1993).
TM is simple. To prevent distracting thoughts a client is given a mantra (a word or sound) to
repeat silently over and over again while sitting in a comfortable position. The mantra is
selected not for its meaning but strictly for its sound. Clients are instructed to be passive and,
if thoughts other than the mantra come to mind, to notice them and return to the mantra. A
TM client is asked to practice for 20 minutes in the morning and again in the evening
(Berman & Larson, 1994). Transcendental Meditation is not a philosophy and does not
require specific beliefs or changes in behavior or lifestyle (Kreitzer, 1998, p. 127).
Mindfulness Meditation
In comparison with concentrative meditation, mindfulness meditation is a type of recep-
tive meditation. With receptive meditation, instead of focusing on one sound or image, one
clears the mind of all thoughts, cultivating silence (Gimbel, 1998).
Mindfulness meditation was developed at the Stress Reduction Clinic at the University of
Massachusetts Medical Center in Worcester by Kabat-Zinn and colleagues. Based on the Bud-
dhist practice of vipassana meditation, the goal of this meditative practice is to increase insight
by becoming a detached observer of the stream of changing thoughts, feelings, drives, and visions
until their nature and origin is recognized. The process includes eliciting the relaxation response,
centering on breath, and then focusing attention freely from one perception to the next. In this
form of meditation, no thought or sensation is considered an intrusion (Kreitzer, 1998).
Insight or mindfulness meditation means to see clearly (Pettinati, 2001). Much more than
a technique, it is a practice and a discipline that affects the individuals way of being in the
world, increasing self-awareness, patience, relaxation, and an ability to live more in the pres-
ent moment (Zahourek, 1988). An expectant, nonstriving attitude of loving acceptance (pas-
sive volition) is desired (Kolkmeier, 1995). Without becoming emotionally involved, the
individual remains present and aware of unpleasant and painful sensations when these are
present, as opposed to ignoring or escaping from them (McDowell, 1995).
According to McDowall (1995), the critical aspects of the practice of mindfulness include:
1. Nonjudging (impartial) witness to your experience
2. Patience (some things must unfold in their own time)
3. Beginners mind (free of expectations from past experience)
4. Trust (in yourself and your feelings)
5. Nonstriving (no goal other than to be yourself)
6. Acceptance (a willingness to see things the way they are)
7. Letting go (refers both to pleasant and unpleasant experiences/thoughts)
Progressive Muscle Relaxation
The meditation approaches discussed thus far focus primarily on mental relaxation strate-
gies, with secondary effects on body tension. In contrast, the technique of progressive muscle
relaxation (PMR) can induce the relaxation response directly through its effect on muscle
tension.
Developed by Jacobson, an American physiologist, PMR is defined as the progressive tens-
ing and relaxing of successive muscle groups (Snyder, 1998, p. 1). Eventually, by discriminating
between the feelings experienced when a muscle group is relaxed and when it is tensed, an indi-
vidual can sense muscle tension without having to progress through the tensing and relaxing of
specific muscle groups. To facilitate the PMR experience, the client should be encouraged to:
Lie down on his or her back, with arms along the sides of the body, in a quiet room. This
technique can be done in any large chair that supports your head and neck, but is best
done lying on your back on a firm but soft surface, such as a thick carpet or workout mat
(a bed is too softyoure more likely to glide off to sleep) (Benson, 1993, p. 246).
Make sure there will be no interruptions.
Loosen any clothing thats uncomfortably tight, and take off shoes, and glasses or con-
tact lenses
Quiet music and reduced lighting may be helpful.
Use the bathroom before sessions. Sessions, particularly initial ones, may last 45 to 60
minutes.
Assume a passive attitude. You are taught to recognize even the slightest muscle con-
tractions so that you can release them and achieve a deep degree of muscular relax-
ation (Benson, 1993, p. 242).
The tightening and relaxing of the muscle groups should last about 5 to 7 seconds for
each group. Check for relaxation before moving to the next muscle group.
Either have someone read the instructions at a slow, easygoing pace, or make a tape for
yourself.
Practice sessions of at least 15 minutes once or twice each day should become part of
your routine.
Benson (1993, pp. 246-7) describes a basic script for progressive muscle relaxation as pre-
sented in Box 15-2.
Relaxation 389
B OX 15-2
A Basic Script for Progressive
Muscle Relaxation
First, tense the muscles throughout your body, from head to toe. Tighten your feet
and legs, tense your arms and hands, clench your jaw, and contract your stomach.
Hold the tension while you sense the feelings of strain and tightness. Study the ten-
sion and notice the difference between how the muscle feels when it is tensed and
when it is relaxed. Then take a deep breath, hold it, and exhale long and slowly
as you relax all your muscles, letting go of the tension. Notice the sense of relief
as you relax.
Now youre going to tense and relax individual groups of muscles, keeping the rest
of your body as relaxed as you can. Youll hold the tension for a few seconds in each
part of your body while you get a clear sense of what the tension feels like; then
breath deeply, hold the breath for a moment, and let go of the tension as you exhale.
Start by making your hands into tight fists. Feel the tension through your hands
and arms. Relax and let go of the tension. Now press your arms down against the
surface theyre resting on. Feel the tension. Hold it . . . and let go. Let your arms and
hands go limp.
Shrug your shoulders tight, up toward your head, feeling the tension through your
neck and shoulders. Hold . . . then release, letting go. Drop your shoulders down,
free of tension.
Now wrinkle your forehead, sensing the tightness. Hold . . . release, letting your
forehead be smooth and relaxed. Shut your eyes as tight as you can. Hold . . . and
let go. Now open your mouth as wide as you can. Hold it . . . and gently relax, let-
ting your lips touch softly. Then clench your jaw, teeth tight together. Hold . . . and
relax. Let the muscles of your face be soft and relaxed, at ease.
Take a few moments to sense the relaxation throughout your arms and shoulders,
up through your face. Now take a deep breath, filling your lungs down through
your abdomen. Hold your breath while you feel the tension through your chest.
Then exhale and let your chest relax, your breath natural and easy. Suck in your
stomach, holding the muscles tight . . . and relax. Arch your back . . . hold . . . and
ease your back down gently, letting it relax. Feel the relaxation spreading through
your whole upper body.
Now tense your hips and buttocks, pressing your legs and heels against the sur-
face beneath you . . . hold . . . and relax. Curl your toes down, so they point away
from your knees . . . hold . . . and let go of the tension, relaxing your legs and feet.
Then bend your toes back up toward your knees . . . hold . . . and relax.
continued
B OX 15-2 CONTINUED
Now feel your whole body at rest, letting go of more tension with each
breath . . . your face relaxed and soft . . . your arms and shoulders easy . . . stomach,
chest, and back soft and relaxed . . . your legs and feet resting at ease . . . your whole
body soft and relaxed.
Take time to enjoy this state of relaxation for several minutes, feeling the deep
calm and peace. When youre ready to get up, move slowly, first sitting, and then
gradually standing up.
Source: Benson, H. (1993) The relaxation response. In D. Goleman & J. Gurin (Eds.), Mind-body
medicine: How to use your mind for better health. Yonkers, NY: Consumer Reports. Used with per-
mission of the author.
Although the procedure is very gentle, Snyder (1998) describes several cautions for PMR:
May affect the pharmacokinetics of medications so that a lower dose is needed
May produce a hypotensive state
The client may have heightened awareness of pain in muscles
In an exploratory study, relaxation exercises (including progressive muscle relaxation,
breathing exercises, guided imagery, and listening to soft music) lasting approximately 20
minutes were conducted with a group of 39 patients on a hospital general psychiatric unit.
There was a significant reduction in anxiety. The author recommends future research with a
larger, randomly selected sample and a control group (Weber, 1996).
Nineteen participants undergoing organ transplant experienced improvement from base-
line symptom scores for depression and anxiety after a mindfulness meditation intervention.
Global and health-related quality of life scores, however, were not improved (Gross, Kreitzer,
Russas, Treesak, Frazier, & Hertz, 2004).
As discussed above, meditation techniques to promote relaxation can be very powerful.
Another technique to promote relaxation is conscious, proper breathing.
BREATHING
Achterberg and colleagues (1994) indicate that being conscious of ones breathing is a
powerful way to achieve relaxation. In addition, proper breathing improves circulation, nor-
malizes muscle tone, and enhances clear thinking. These effects often result in a more posi-
tive mood (Wang & Snyder, 1998, p. 16). Nineteen participants undergoing organ
transplant experienced improvement from baseline symptom scores for depression and anxi-
ety after a mindfulness meditation intervention. Global and heath-related quality of life
scores however, were not improved (Gross, Kreitzer, Russas, Treesak, Frazier, and Hertz, 2004).
Or 5 consecutive weeks.
Jahnke (1997, pp. 86-98) describes a breathing technique that he calls the essential
breath. This technique uses abdominal breathing. Practice usually is needed before really sat-
isfying and full breaths are experienced. Elements of the essential breath technique are pre-
sented in Box 15-3.
Relaxation 391
B OX 15-3
Elements of the Essential Breath Technique

1. Essential breath:
Adjust posture so that the lungs, chest, and abdomen can expand freely
(standing or sitting erect; lying down).
Breathe in through the nose, filling the lower portion of the lungs first
(abdomen expands).
Allow the upper lobes of the lungs to fill (ribs and chest cavity expands to
reach fullness) providing an enormous sense of satisfaction.
Rest for an instant.
Exhale slowly through the noserushing of warmth or flowing feeling
throughout body.
Try 10 as you fall asleep and 10 before you rise.
Repeat.
2. Remembering breath
Done every time you can remember to do it.
Focus on a purposeful, positive thought.
3. Sigh of relief
Audible sigh expressing restfulness and trust (visualize peace and safety)
or loud groan freeing accumulated frustration, anxiety, and other tensions
(visualize traffic jams, the boss, too much work) on exhalation
Do several times.
4. Gathering breath
Sit down with the hands in the lap or stand with hands dangling at the
sides.
Begin to inhale and move the hands outward and upward as if you are
scooping something useful, even precious, from the air around you.
When the hands are slightly above and in front of you, inhalation should
be complete.
Bring hands, side by side, palms facing you, toward your head.
Move the hands slowly down in front of your face, in front of your chest,
in front of your abdomen while exhaling.
When the hands reach the navel area, linger for a moment.
Repeat.
Proper breathing is a powerful relaxation technique, even when used alone. Breathing
(pranayama) also is an essential part of other relaxation techniques such as yoga.
YOGA
Hindu texts define yoga as a means of deliverance from suffering, pain, and sorrow by mas-
tering that which disturbs ones peace and harmony on the path to perfect union with God or the
universal spirit (Olsen, 1990, p. 312). The meaning of the word yoga is union, the integration
of physical, mental, and spiritual energies that enhance health and well-being (Berman & Lar-
son, 1994).
Classical yoga is organized into eight limbs [paths] that provide a complete system of
physical, mental, and spiritual health. The eight limbs of yoga are systematically arranged to
outline specific lifestyle, hygiene, and detoxification regimens, as well as physical and psy-
chological practices that can lead to a more integrated personal development. Ultimately,
yoga helps prepare one for heightened vitality and spiritual awareness (Berman & Larson,
1994, p. 469). The paths include ethical (yamas and hiyamas), physical (pranayamas and
asanas), mental (dharma), supramental (dyyama), and god-consciousness (samadhi). Some of
the most common yoga practices or branches are:
Bhakti. For those seeking the pathway to God through devotion and love.
Jnana. The yoga of knowledge has as its goal to attain prajna, or transcendental wisdom
through meditation and thought; this is the yoga of the intellect.
Karma. A yoga of service in action, emphasizing doing for others as a remembrance of
God, and surrendering the rewards to God.
Raja. Its object is to realize directly the absolute self by stilling the mind through con-
centrated meditative effort (via asanas and pranayama breathing exercises) so the light
of the internal spirit can shine through.
Mantra or Nada. Focuses on vibrations and radiations of life energy using sound.
Kundalini. Awakens the primal force through contemplation and/or tantra, a sexual way
to raise kundalini.
Hatha. Seeks integration of different aspects of self to attain a relaxed health and har-
mony of mind and body. Identified with the sun (ha) and moon (tha), it is sometimes
called the gentle yoga. Breathing routines and asanas focus on mastery over the body
and the chakras, or energy centers, in the body (Olsen, 1990, pp. 315-316).
For the most part, the West has adopted three aspects of entirely different yoga prac-
tices: the breathing techniques of pranayoga, meditation, and the postures (or asanas) of
hatha yoga.
Pranayama, or yogic breathing, is an ancient practice of deep breathing techniques. Prana
in Sanskrit means universal energy. Prana is brought into the body through the breath.
Pranayama literally means regulation or control of prana, or life force through various deep
breathing techniques. The connection of the breath and the mind is a basic principle of yoga.
Relaxation 393
Gimbel (1998, p. 251) describes a pranayama for balancing and stress reduction as follows:
Take in a few cleansing breaths, inhaling through the nose and exhaling through the
mouth. Move into the three-part breath, breathing into your diaphragm, the middle lungs,
and the upper lungs. Combine this breath with the yogic sound, which is created by dragging
the air across the back of the throat, with a saaa sound on the inhalation and haa sound on
the exhalation. Take several complete breaths, inviting the exhalation to be a real letting go,
letting go of any physical or mental tension, and each inhalation bringing you deeper into the
present moment. Invite your mind to become totally absorbed in the breath. Invite any extra-
neous thoughts that may come into your awareness to float by without attachment as if they
were flowing downstream in a bubbling brook.
To begin pranayama:
Take a billows breath, blowing out through the mouth, totally emptying the lungs to
start from a place of freshness.
Inhale through the nose, using your yogic sound to a count of four.
Hold the breath without holding tension in the body to a count of eight.
Exhale through the nose using your yogic sound, to a count of eight.
Repeat the cycle, continuing your pranayama for at least 7 minutes.
Pranayama is often performed as a preparation for meditation. The final stage of yoga is
samadhi, or spiritual realization, the culmination of a long, disciplined and dedicated prac-
tice. In samadhi, one is said to enter a fourth state of consciousness, separate from and beyond
the ordinary states of waking, dream, and sleep (Berman & Larson, 1994).
Among the approaches to yoga are hatha (self-transformation primarily through physical dis-
ciplines), raja (primarily mental discipline), jnana (emphasis on discriminative knowledge by
which the real is distinguished from the unreal or illusionary), karma (self-transcending action in
the world in the form of selfless service), bhakti (love and devotion focusing on the higher real-
ity conceived as a divine personality), and tantra (nondualist approach that seeks to utilize all
human experience and convert it into a trigger for self-transcendence; there is a particular
acknowledgment of the hidden transformative potential of sexuality) (Criswell & Patel, 2003).
For many people, asana (which means ease in Sanskrit), the yogic postures known as
Hatha yoga, are the element most commonly associated with yoga. Asana includes a vari-
ety of physical postures and exercises that create immediate changes in the body. . . . Medita-
tive asanas (corpse, childs posture, posterior stretch) bring the spine and head into perfect
alignment, promoting proper blood flow throughout the body and bringing the mind into a
state of relaxation and stillness that facilitates increased concentration during meditation. At
the same time, these asanas keep the glands, lungs, and heart properly energized. Therapeu-
tic asanas (cobra, locust, spinal twist, and shoulder stand) are geared toward improving
health and physical well-being, and have been commonly prescribed for clients with back,
neck, and joint pain. . . . Although yoga postures may involve very little movement, the mind
is involved in the performance of every asana, to provide discipline, awareness, and a relaxed
openness. The discipline and awareness help maintain the posture, and the relaxation and
openness help stimulate the circulation of prana (life energy). . . . According to the Yoga
Figure 15-1. Examples of yoga exercises: The cobra and posterior stretch (reprinted with permis-
sion from Burton Goldberg Group. (1995). Alternative medicine: The definitive guide. Fife, WA:
Future Medicine).
Sutras, a properly executed asana creates a balance between movement and stillnessexer-
tion and surrenderthe precise state of a healthy body (Berman & Larson, 1994). Figure
15-1 shows the correct posture for the posterior stretch and the cobra positions.
However, the yoga poses, if done incorrectly, for too long, or too strenuously, can cause
physical damage, particularly to the back. Aerobic yoga requires all the cautions of doing aer-
obics, including a complete cardiovascular and structural evaluation to determine whether,
how hard, and how long to exercise; stretching before and after the workout; and including
warm-up, cool-down, and relaxation periods in the routine (Olsen, 1990).
A typical yoga session as practiced in the United States lasts 20 minutes to an hour. Some
people practice daily at home, while others practice one to three times a week in a class. A
session usually begins with gentle postures to relax tension in the muscles and joints, then
moves to more difficult postures. Every movement should be made gently and slowly, and
clients are urged not to stretch beyond what is comfortable for them. Rather, practice should
Relaxation 395
be easeful. Emphasis is placed on breathing slowly from deep in the abdomen. Specific
pranayama breathing exercises also are an important part of the practice. Guided (or self-
guided) relaxation, meditation, and sometimes visualization follow the asanas. The session
frequently ends with chanting, such as a repeating Om shanti (Let there be peace), to bring
the body and mind into a deeper state of relaxation (Berman & Larson, 1994).
Kuhn (1999) describes several contraindications of yoga:
Sciatica. Do not do forward bends or intense stretching.

Menstruation. Do not do inverted poses.
Hypertension. Do not do breath retentions or inverted poses.
Glaucoma or ear congestion. Do not do breath retentions or inverted poses.
Pregnancy. Do not do breath retentions, inverted poses, or breath suspensions.
Box 15-4 presents a yoga study abstract.
B OX 15-4
Yoga Study
Twenty-eight volunteers with mild depression were randomly assigned to either a
yoga course or a wait-list control group. The yoga group attended a 1-hour lyenger
yoga class each week. The yoga group demonstrated significant decreases in self-
reported symptoms of depression and trait anxiety. Changes were also observed in
acute mood, with subjects reporting decreased levels of negative mood and
fatigue following yoga classes. Finally, there was a trend for higher morning corti-
sol levels in the yoga group.
Source: Adapted from Woolery, Meyers, Sternlieb, & Zeltzer, 2004.
Yoga can be self-taught through books or tapes, or by a yoga teacher. There is no national
certification.
BIOFEEDBACK
Biofeedback, meaning life-feedback, refers to any technique that uses noninvasive, sim-
ple, electronic devices to give a person immediate and continuing signals of changes in a body
function of which the person is usually not conscious. The instruments measure, amplify, and
display involuntary physiological processes in order to provide information, but nothing is
done to people. The machine and the training itself do not stimulate the brain or change
muscle activity. Using the machine is like stepping on the bathroom scale or looking in a
mirror. It tells you how you are doing (Olsen, 1990, p. 112).
Biofeedback works by way of operant conditioning. It is believed that a new association

between a stimulus and a response is developed. The response is instrumental in producing a
reward or removing a negative stimulus. Reinforcement then shapes subsequent behavior and
function.
There are several different types of biofeedback instrumentation, including:
Electromyographic (EMG) biofeedback. A modality for measuring and displaying mus-

cle activity, used primarily where any modification of muscular behavior is indicated.
Skin resistance/conductivity monitors such as galvanic skin response (GSR). GSR reg-
isters general levels of autonomic arousal. Activity increases during tension and
reduces during relaxation.
Skin temperature monitors. Register skin temperature changes related to vasodila-
tion/vasoconstriction, an indication of the stress response in some people.
Electroencephalographic (EEG) monitors. Register brain wave activity, enabling
trainees to generate wave forms such as alpha waves, associated with a relaxed state.
Heart and pulse rate or rhythm monitors.
In addition to instrumentation for feedback purposes, treatment techniques often include

guided imagery training or progressive muscle relaxation, which are forms of autogenic relax-
ation techniques. Deep breathing techniques have been shown to effectively regulate mental
states and are often employed in combination with biofeedback techniques to enhance a state
of relaxation. Among the best tools to assist a client in decreasing muscle tension are deep
breathing techniques focusing in on the abdominal region, music, relaxation tapes, and pro-
gressive relaxation exercises (Bottomley, 1997).
Clinical training sessions generally last 15 to 40 minutes, several times per week, for a few
weeks to a few months (Bray, 1998). The technique, which includes several stages, is pre-
sented in Box 15-5.
B OX 15-5
Biofeedback Training Technique
1. Contact:
The explanation of biofeedback should clarify that it involves the
learning of a skill, is not an instant answer, and will take time and
practice. The key factors for success are high motivation and com-
pliance.
A baseline of assessment data should be established.
continued
Relaxation 397
B OX 15-5 CONTINUED
2. Initial sessions:
Involve familiarization with the instrument. An autonomic body
response is measured using instrumentation. The signals are inter-
preted, and the client is guided through the techniques that are
designed to achieve the desired response. When ready, a stressor
should be added so that the client can learn how to return the pat-
tern to normal.
3. Follow-up sessions:

Emphasize practice. Keep practice simple, meaningful and interest-
ing. The client should learn to recognize the desired pattern during
the practice sessions.
Help to motivate.
4. Completion of training:
Can the client self-regulate without the instrumentation and inte-
grate the process into everyday life?
Source: Bray, D. (1998). Biofeedback. Complementary Therapies in Nursing and Midwifery, 4, 23.
Used with the permission from Harcourt Publishers.
The benefits or strengths of biofeedback include:

Teaching a person how to change and control his or her bodys vital functions.
Allowing people to take responsibility for controlling their own health. The method
enables people to take an active part in their own recovery. It fosters self-reliance, inde-
pendence, and responsibility for improvement in health (Bray, 1998, p. 24).
Strengthening the immune system by relaxing the stress response.
However, there are several cautions to biofeedback, including (Steefel, 1995):
Severe psychopathology (acute psychosis, major affective disorder, history of disassoci-
ation experience, and borderline personality disorders).
Need for clinician coordination when the client is taking insulin, thyroid replacement
or seizure medications, or anti-hypertensives.
Unexpected sensations, images, experiences, emotional feelings, and thoughts some-
times occur during biofeedback training.
GUIDED IMAGERY
Guided imagery is defined as the process of purposeful use of mental images by working
with another person to achieve a desired therapeutic goal (Bazzo & Moeller, 1999, p. 319).
Guided imagery involves the deliberate formation of a mental representation while in a

deeply relaxed state (Giedt, 1997, p. 115). The client is led with specific words, symbols, and
ideas to elicit a mental image. Additionally, devices such as commercial audiotapes of verbal
suggestions, music or sounds of nature, pictures of objects or places, aromas from scented oils
or candles, or another person giving suggestions in a soft, pleasant voice to assist in relaxation
and image formation may be used to facilitate relaxation.
There are different forms of imagery. In active imagery there is a conscious and delib-
erate effort to construct concrete and symbolic images. These may be general healing
images such as events, persons, or things; light, warmth, or heat; or a wise entity or inner
guide. This approach may be most helpful when used to address symptoms. In contrast, in
receptive imagery, images are allowed to bubble up into the conscious mind without con-
scious creation. This approach may be helpful to understand the emotional meanings of
symptoms. Additionally, there are different imagery processes. In process imagery the
imagery moves step by step toward the goal one wishes to achieve... Mechanics or action
must follow a pattern consonant with physical reality (Achtenberg et al., 1994, p. 41). In
contrast, in end state imagery, the client imagines the final, healed state. However, at pres-
ent, research has not advanced sufficiently to determine absolutely what kind of imagery
works best with which kind of client, symptom, or with which diagnostic category
(Zahourek, 1988).
Achtenberg and colleagues (1994, p. 50) describe a general format for an imagery session
as follows:
1. Identify the problem, disease, or goal of imagery.

2. Begin with several minutes of relaxing, meditating, or attention on breath.
3. Develop images of the problem or disease, inner healing resources, external (or treat-
ment) healing resources.
4. End with images of the desired state of well-being.
Images are thoughts that draw on the senses; they may involve one, several, or all of
the following senses: sound, taste, movement (kinesthesis), vision, touch, and inner sen-
sation, or the felt sense (Achterberg et al., 1994, p. 38). It is important to remember
that mental imagery is not just the creation of a picture but is integrated thoroughly with
the individuals entire physiological pattern. The imagination may be the hypothetical
bridge between conscious processing of information and physiologic change (Hoekstra,
1994, p. 9).
A number of examples of therapeutic images can be found in the literature. To induce
relaxation, some examples include a beach at dawn, hearing the waves, feeling the warm sand
beneath the body, smelling the salty sea breeze, seeing the colors of the horizon change from
purple to red to golden as the sun emerges from the water (Gimbel, 1998, p. 245), a lush green
meadow, blue sky, puffy clouds, fresh and crisp mountain air, singing birds, grass that feels like
a pillow, and a babbling brook. For healing, images might include good monsters eating bad
ones, or an immune system actively attacking and destroying cancer cells; while for ego build-
ing an internal rose developing from a tightly closed bud to a beautiful glorious flower might
be an effective image.
Relaxation 399
Characteristics that lend imagery great value for healing are (Burton Goldberg Group, 1995):
Imagery directly affects physiology. Individuals can use imagery to control sympathetic
nervous system stress responses.
Through the mental processes of association and synthesis, imagery provides insight
and perspective into health. Individuals can use imagery to understand and control
their patterns of thinking.
Relaxation makes the mind more receptive to new information.
Imagery has an intimate relationship with emotions, which are often at the root of
many common health conditions.
Imagery can help to find meaning in events and situations.
As a result of these characteristics, the purposes or applications of imagery may include any
of the following (Achtenberg et al., 1994; Zahourek, 1988):
To tune in or become sensitive to (or diagnose) what is going on inside the body.
To send new or healing messages to the body which may promote healing, without rais-
ing unrealistic expectations for disease cure.
To complement or enhance other therapies.
To alter physiological responses, such as blood flow.
To change behaviors or attitudes.
As mental preparation for treatment procedures.
Promote relaxation.
To reduce fear, anxiety, and pain.
For habit control.
For problem solving or goal development, ego building (strong, capable, and moti-
vated), or to explore inner processes (improve problem-solving, develop insight).
For behavior rehearsal (phobias).
To facilitate peaceful dying (death imagery).
In contrast to some other modalities, there have been a number of studies of guided
imagery. There is extensive evidence that there is a relationship between imagery of bodily
change and actual bodily change, although studies are still needed to document whether
imagery has an ultimate impact on health or on the course of disease. Thirty-three adults with
symptomatic asthma received individual imagery instruction (week 1) and follow-up (weeks
4, 9, and 15). Participants were given 7 imagery exercises to select from and practiced 3 times
a day for a total of 15 minutes. Eight of 17 (47%) participants in the imagery group reduced
or discontinued their medications. Three of 16 (19%) in the control group reduced their med-
ications as well. It was concluded that the efficacy of imagery needs further exploration
(Epstein et al., 2004). In one review of 46 studies published between 1966 and 1998, it was
concluded that there is preliminary evidence for the effectiveness of guided imagery in the
management of stress, anxiety, and depression, and for the reduction of blood pressure, pain,
and the side effects of chemotherapy. . . . [However], there is a need for systematic, well-
designed studies (Eller, 1999, p. 57). Clinical reports suggest that the technique may help
treat a wide range of conditions including:
Chronic pain
Allergies
High blood pressure
Irregular heartbeats
Autoimmune diseases
Cold and flu symptoms
Stress-related gastrointestinal, reproductive, and urinary complaints.
Speed healing after an injury (Rossman, 1993, pp. 297-298).
Stimulating immune function by increasing numbers of natural killer cells.
Box 15-6 presents a guided imagery study abstract.
B OX 15-6
Guided Imagery Study
In this pilot study, guided imagery instructional tapes were listened to in the morn-
ing and in the evening every day perioperatively for coronary artery bypass graft
surgery and for 7 days postoperatively by 50 subjects in the intervention group. 50
subjects in the control group listened to music-only tapes at the same times. Find-
ings demonstrated clinically relevant improvement with reduced pain, fatigue,
anxiety, narcotic use, length of stay (LOS), and increased patient satisfaction in the
intervention group.
Source: Adapted from Deisch, P., Soukup, M., Adams, P., & Wild, M. C. (2000). Guided imagery:
Replication study using coronary artery bypass graft patients. Nursing Clinics of North America, 35(2),
417-425.
A specific type of guided imagery is interactive guided imagery, in which the guide facil-
itates the process for the client, and the client describes and shares images rather than hav-
ing the guide present images to work with (Shames, 1996, p. 72).
Interactive Guided Imagery

The term interactive guided imagery was coined by the Academy for Guided Imagery in Mill
Valley, CA. The individual creates his or her own experience and images while the facilita-
tor, or guide, assists the individual in dialoguing with the images to gain insight into a par-
Relaxation 401
ticular health problem or emotional issue (Gimbel, 1998, p. 245). It is assumed that an effec-
tive imagery intervention is one that is specific to the clients personality, to their preferences
for relaxation and specific settings, and to the desired outcomes. Imagery is learned more rap-
idly with guidance and is perfected with practice. Independent of the method of intervention,
the nurse should assist with the interpretation or processing of the images and emotional
responses. In addition, practicing imagery oneself is extremely helpful in guiding others (Post-
White, 1998).
An example of interactive guided imagery is the inner advisor technique. An inner advi-
sor is a representation of the inner knowledge and innate wisdom we all possess, but to which
we may not have conscious access. In a relaxed state, the individual invites an image of a wise,
caring figure to come into their mind. The image can be anything, plant, animal, or rock, as
long as it feels supportive, caring, and wise. The facilitator, or guide, then assists the indi-
vidual in dialoguing with the image about a particular health concern or other issue. This
technique can be extremely useful in helping individuals to gain a better understanding of
their issues and to bring about resolution (Gimbel, 1998).
The modern use of therapeutic imagery usually entails a 20- to 25-minute session that
begins with a relaxation exercise to help focus attention and center the mind. During a typ-
ical session of imagery, the client focuses on a predetermined image designed to help to con-
trol a particular symptom (active imagery) or the client allows his or her mind to provide
images that give insight into a particular problem (receptive imagery). It is helpful to use as
many senses as possible during guided imagery sessions (Rossman, 1993). Dossey (1997)
stresses that the sessions need to be pleasant, and that the guide should not interpret for the
client. The person in actual control of the imagery is the client (Sodergren, 1985). However,
Sodergren (1985, p. 122) cautions that the nurse with little knowledge of psychotherapy
should use caution in helping patients interpret symbolic material.
Post-White (1998) presents a technique for general guided interactive imagery. The first
step is to help the client to achieve a relaxed state by:
Finding a comfortable sitting or reclining position, but not lying down.
Uncrossing the extremities.
Closing the eyes or focusing on one spot or object in the room.
Focusing on breathing with abdominal muscles; with each breath saying to themselves
in and out.
Feeling the body becoming heavy and warm from the top of the head to the tips of the
fingers and toes.
If thoughts roam, bringing the mind back to thinking of ones breathing and relaxed body.
Specific suggestions for the imagery session (Post-White, 1998, p. 109) include:
1. In your mind, go to a place you enjoy and feel good.

2. What do you see, hear, taste, smell, and feel?
3. Take a few deep breaths and enjoy being there.
4. Now imagine yourself the way you want to be (describe the desired goal specifically).
5. Imagine what steps you will need to take to be the way you want to be.
6. Practice these steps nowin this place where you feel good.
7. What is the first thing you are doing to help you be the way you want to be?
8. What will you do next?
9. When you reach your goal of the way you want to be, feel yourself, touch yourself,
embrace yourself, listen to the sounds surrounding you
After the actual imagery experience, Post-White (1998) suggests that the nurse summarize
the process and reinforce practice. Examples of language might be:
1. Remember that you can return to this place, this feeling, this way of being . . . anytime
you want.
2. You can feel this way again by focusing on your breathing, relaxing, and imagining your-
self in your special place.
3. Come back to this place and envision yourself the way you want to be every day.
Finally, the client should be helped to return to the present. Examples of language might be:
1. When you are ready you may return to the room we are in.
2. You will feel relaxed and refreshed and be ready to resume your activities.
3. You may open your eyes and tell me about your experience when you are ready
In Table 15-1, Dossey and colleagues (1995, pp. 619-622) suggest a number of words and
phrases to empower interactive guided imagery.
Table
15-1
Words to Empower Guided Imagery
WORDS DEFINITION
Metaphors Implied comparisons (relaxation as a warm waterfall).
Truisms Statements that the intellectual mind accepts as accurate or

as true (as you take your next breath, oxygen is flowing
into your lungs and into every cell in your body).
continued
Relaxation 403
Table
15-1
Words to Empower Guided Imagery (continued)
Embedded commands Short phrases that stand out in a sentence because of

changes in quality of voice, pitch, and tone (you can relax
more deeply . . . if you want to).
Linkage Diversion of intellectual thoughts by connecting certain

statements, behaviors, and actions with thoughts (once
more . . . relax more deeply . . . and really sink into the surface
of the chair . . . feeling yourself being supported by this sur-
face).
Therapeutic double-bind Relaxation through involvement in the intellectual process

of making different choices (as you are stretched out in the
chair . . . you might be able to relax more deeply by changing
the position of your arms . . . or your head . . . or your feet).
Synesthesia Cross-sensing, combination of several senses simultaneous-
ly (can you hear the color of the wind).
Reframing Ability to contact the part of a behavior/s that may be pre-

venting or prohibiting healthier behaviors or thoughts (I
dread the pain to I am opening and softening around the
discomfort and it is floating away).
Mirroring Repetition of the clients words or descriptions rather than

using your own.
Source: Dossey, B. M., Keegan, L., Guzzetta, C. E., & Kolkmeier, L. G. (Eds.). (1995). Holistic nursing: Hand-
book for practice (2nd ed.). Sudbury, MA: Jones and Bartlett.
The emphasis in this chapter has been on noninvasive modalities, including different forms
of meditation, breathing, yoga, biofeedback, and guided imagery, that are designed to reduce
chronic stress responses through relaxation. Biofeedback and yoga should be supervised by an
experienced health professional who has been certified for practice. In contrast, meditation,
breathing, and guided imagery practices require no special training or certification. These
techniques also can be easily taught to clients for their own self-care to promote health and
well-being.
Chapter Key Points

The internal adaptive response of the body to a change perceived as a threat is known
as stress. It is ones reaction to stressful experiences that can create a stress response.
The parasympathetic nervous system induces relaxation and helps to compensate for
periods of high arousal.
The goals of stress management are to help persons deal with short-lived stressful events
and to defuse the effects of chronic stress.
All of the techniques described in this chapter are designed to induce a positive
parasympathetic state and reduce stress responses through relaxation.
References
Achterberg, J., Dossey, B., & Kolkmeier, L. (1994). Rituals of healing: Using imagery for health and wellness.
New York: Bantam.
Bazzo, D. J., & Moeller, R. A. (1999). Imagine this! Infinite uses of guided imagery in womens health. Jour-
Benson, H. (1993). The relaxation response. In D. Goleman & J. Gurin, (Eds.), Mind body medicine. How
to use your mind for better health (pp. 233-257). Yonkers, NY: Consumer Reports Books.
Bottomley, J. M. (1997). Biofeedback: Connecting the body and mind. In C. M. Davis (Ed.), Complemen-
tary therapies in rehabilitation (pp. 101-123). Thorofare, NJ: SLACK Incorporated.
Bray, D. (1998). Biofeedback. Complementary Therapies in Nursing & Midwifery, 4, 22-24.
Canter, P. H. (2003). The therapeutic effects of meditation. British Medical Journal, 326, 1049-1050.
Clark, C. C. (1996). Wellness practitioner. New York: Springer.
Criswell, E., & Parel, K. C. (2003). The yoga path: Awakening from the dream. In S. G. Mijaras. Modern
psychology and ancient wisdom: Psychological healing practices from the world's religious traditions (pp.
201-225). New York: Haworth.
Deisch, P., Soukup, M., Adams, P., & Wild, M. C. (2000). Guided imagery: Replication study using coro-
nary artery bypass graft patients. Nursing Clinicsof North America, 35(2), 417-425.
Dossey, B. M. (1997). Imagery. In B. M. Dossey (Ed.), Core curriculum for holistic nursing. Gaithersburg,
MD: Aspen.
Dossey, B. M., Keegan, L., Guzzetta, C. E., & Kolkmeier, L. G. (Eds.). (1995). Holistic nursing: Handbook
for practice (2nd ed.). Gaithersburg, MD: Aspen.
Eller, L. S. (1999). Guided imagery interventions for symptom management. In J. J. Fitzpatrick (Ed.),
Annual review of nursing research. New York: Springer.
References 405
Epstein, G. N., Italper, J. P., Barrett, E. A. M., Birdsall, C., McGee, M., Baron, K. P., & Lowenstein, S.
(2004). A pilot study of mind-body changes in adults with asthma who practice mental imagery.
Alternative Therapies in Health and Medicine, 10, 66-71.
Fugh-Berman, A. (1997). Alternative medicineWhat works: A comprehensive, easy-to-read, review of the sci-
entific literature, pro and con. Baltimore, MD: Williams & Wilkins.
Garfinkel, M. S., Singhal, A., Katz, W. A., Allan, D. A., Reshetar, R., & Schumacher, H. R. (1998). Yoga-
based intervention for carpal tunnel syndrome. Journal of the American Medical Association, 280,
1601-1603.
Giedt, J. F. (1997). Guided imagery. A psychoneuroimmunological intervention in holistic nursing prac-
tice. Journal of Holistic Nursing, 15, 112-127.
Gimbel, M. A. (1998). Yoga, meditation, and imagery: Clinical applications. Nurse Practitioner Forum, 9,
243-255.
Gross, C. R., Kreitzer, M. J., Russas, V., Treesak, C., Frazier, P. A., & Hertz, M.I. (2004). Mindfulness med-
itation to reduce symptoms after organ transplant: A pilot study. Alternative Therapies in Health
and Medicine, 10, 58-66.
Hoekstra, L. S. (1994). Exploring the scientific bases of holistic nursing. Nursing Connections, 7, 5-14.
Horowitz, S. (1999). Aromatherapy: Modern applications of essential oils. Alternative and Complementary
Jahnke, R. (1997). The healer within: The four essential self-care methods for creating optimal health. San Fran-
cisco: Harper Collins.
Kolkmeier, L. G. (1995). Relaxation: Opening the door to change. In B. M. Dossey, L. Keegan, C. E. Guzzetta,
& L. G. Kolkmeier (Eds.), Holistic nursing: Handbook for practice (2nd ed.). Gaithersburg, MD: Aspen.
Kreitzer, M. J. (1998). Meditation. In M. Snyder (Ed.), Independent nursing interventions (pp. 123-137). New
York: John Wiley & Sons.
Kuhn, M. A. (1999). Complementary therapies for health care providers. Philadelphia: Lippincott Williams &
Wilkins.
Lowenstein, K. G. (2002). Meditation and self-regulatory techniques. In S. Shannon (Ed.), The Handbook of
complementary and alternative therapies in mental health (pp. 159-178). San Deigo: Academic Press.
McDowell, B. (1995). Body-mind medicine: From the relaxation response to mindfulness. Alternative and
Complementary Therapies, 1(2), 80-87.
Pelletier, K. R. (1993). Between mind and body: Stress, emotions, and health. In D. Goleman & J. Gurin
(Eds.), Mind body medicine. How to use your mind for better health (pp. 19-38). Yonkers, NY: Con-
sumer Reports Books.
Pettinati, P. M. (2001). Meditation, yoga, and guided imagery. Nursing Clinics of North America, 16, 47-56.
Post-White, J. (1998). Imagery. In M. Snyder, & R. Lindquist (Eds.), Complementary/alternative therapies in
nursing (pp. 103-122). New York: Springer.
Rossman, M. (1993). Imagery: Learning to use the minds eye. In D. Goleman, & J. Gurin (Eds.), Mind/body
medicine. How to use your mind for better health (pp. 291-300). Yonkers, NY: Consumers Union.
Shames, K. H. (1996). Creative imagery in nursing. Albany, NY: Delmar.

Snyder, M. (1998). Progressive muscle relaxation. In M. Snyder & R. Lindquist (Eds.), Complemen-
tary/alternative therapies in nursing (pp. 1-13). New York: Springer.
Snyder, M., & Chlan, L. (1999). Music therapy. In J. J. Fitzpatrick (Ed.), Annual review of nursing research.
New York: Springer.
Sodergren, K. M. (1985). Guided imagery. In M. Snyder (Eds.), Independent nursing interventions (pp. 103-
124). New York: John Wiley & Sons.
Steefel, L. (1995). Establishing a biofeedback program in your clinical practice. Alternative and Comple-
mentary Therapies, 1, 103-108.
Walsh, R. (1996). Meditation promotes well-being. In S. Barbour & K. L. Swisher (Eds.), Health and fit-
ness: Opposing viewpoints (pp. 114-119). San Diego, CA: Greenhaven.
Wang, J. J., & Snyder, M. (1998). Breathing. In M. Snyder & R. Lindquist (Eds.), Complementary/alterna-
tive therapies in nursing (pp. 15-21). New York: Springer.
Weber, S. (1996). The effects of relaxation exercises on anxiety levels in psychiatric inpatients. Journal of
Holistic Nursing, 14, 196-205.
Woolery, A., Myers W., Sternlieb, B., & Zelter, L. (2004). A yoga intervention for young adults with ele-
vated symptoms of depression. Alternative Therapies in Health and Medicine, 10, 60-63.
Wright, L. D. (2001). Meditation: Myths and misconceptions. Alternative Therapies in Health and Medicine,
7, 96-97.
Zahourek, R. P. (Ed.). (1988). Relaxation and imagery: Communication and intervention. Philadelphia: W. B.
Saunders.
Meditation
Center for Mindfulness in Medicine, Healthcare, and Society
University of Massachusetts Medical Center
Worchester, MA 01655
Tel: (508) 856-5849
www.mbst.com
Offers training and workshops for health professionals interested in teaching mindfulness-
based stress reduction. There is no formal credentialing.
The Transcendental Meditation Program
Tel: (800) LEARN TM
www.tm.org
Formally recognizes TM instructors.
Biofeedback
Association for Applied Psychophysiology and Biofeedback
10200 West 33th Avenue #304
Wheat Ridge, CO 80033
Tel: (303) 422-8894
Biofeedback Certification Institute of America (BCIA)

Tel: (303) 420-2902
Many private biofeedback schools train and certify clinicians, but BCIA is the only certi-
fying agency. Certification includes a rigorous examination and supervised training. They do
not monitor practitioners.
Guided Imagery
The Academy for Guided Imagery
PO Box 2070
Mill Valley, CA 94942
Tel: (800) 726-2070
www.interactiveimagery.com
Certification program is based on 150 hours of academy-approved training, including

direct observation and a written examination.
Relaxation
No formal credentialing of relaxation therapies is currently available.
For information:
American Holistic Nursing Association
PO Box 2130
Flagstaff, AZ 86003
Tel: (800) 278-AHNA
www.ahna.org
National Institute for the Clinical Application of Behavioral Medicine

Tel: (800) 743-2226
www.nicabm.org
Yoga
The American Yoga Association
513 S. Orange Avenue
Sarasota, FL 34236
Tel: (800) 226-5859
Himalayan Institute Teachers Association

RR1, Box 400
Honesdale, PA 18431
Tel: (717) 253-5551 ext 1305
www.himalayainstitute.org
Presently, each style of yoga or school offers a teacher training program with some form of
certification. There is no national standard of teacher certification.
16
REGENERATING ENERGY
Nutrition
Abstract
Healthy nutritional and eating patterns are major factors influencing health. However, the
promotion of healthy dietary habits has been problematic. Cultural meanings assigned to
food, as well as multiple societal factors, influence eating habits and nutritional intake. Addi-
tionally, food habits are acquired early in life, and once established, are likely to be long-last-
ing and resistant to change. After a brief discussion of influences on the meaning of food, the
chapter will summarize standard Western dietary guidelines and goals, and present a discus-
sion of essential dietary nutrients, phytonutrients, antioxidants, nutritional medicine supple-
ments, and selected diets, providing a scientific foundation for the development of
nutritionally based health promotion interventions.
Learning Outcomes
Appreciate that cultural, geographical, social, psychological, religious, economic, and

political factors shape food intake
Discuss meanings of food and appropriate dietary guidelines and goals to provide and
conserve energy for health and well-being
Describe therapeutic considerations of selected essential dietary nutrients, phytonutri-
ents, antioxidants, and nutritional supplements
410 Chapter 16 Regenerating Energy: Nutrition
Describe essential elements of the macrobiotic, Pritkin, Gerson, Ornish, Atkins, and
Ayurvedic diets to prevent or treat various diseases
Identify individual/family and environmental strategies that can promote healthy nutrition
The Meaning of Food

FOOD AND CULTURE
Food intake is shaped by a wide variety of geographical, social, psychological, religious,
economic, and political factors. Food habits are maintained because they are practical or sym-
bolically meaningful behaviors in a particular culture (Fieldhouse, 1995). Food habits are
acquired early in life as part of learned culture and tend to be long-lasting and resistant to
change. As a result, it is important to develop sound nutritional practices in childhood as a
basis for life-long healthy eating (1995). In practice, however, malnutrition remains a signif-
icant problem for youth and adolescents worldwide, along with an increasing prevalence of
obesity (Schneider, 2000) in all income groups. In developed countries, social pressures to
achieve a distorted body image are creating a malnutrition of affluence among some groups of
adolescents (2000, p. 963).
Food is one of the basic mediums through which adult attitudes and sentiments are com-
municated. Early eating experiences readily become associated with family sentiments of hap-
piness and warmth or of anger and tension; it is not surprising then that foods may unlock
childhood memories when they are encountered in later life. The socialization process
teaches social, cultural, and psychological meanings and uses of food.
As children grow older, they are exposed to diverse experiences and viewpoints and to
multiple influences. Socializing influences may complement or conflict with one another, but
the habits learned earliest are most likely to persist in later life and to be most resistant to
change. Thus, when there is a conflict, such as between what is taught at school and what is
taught in the home, the latter is most likely to dominate. This reinforces the idea that the
creation of early likes and dislikes consistent with healthy eating habits is a desirable nutri-
tion strategy (Fieldhouse, 1995).
Cultural beliefs have the potential to influence most aspects of nutrition and diet intake,
including:
What substances are regarded as food and what are not

How food is cultivated, harvested, prepared, and served
The actual manner of eating the food
Who prepares and serves the food, and to whom
Which individuals eat together, where, and on what occasions
The order of dishes within a meal
The Meaning of Food 411
FOOD AND HUMAN NEEDS

Maslow (1970) proposed that human needs occur hierarchically. Box 16-1 demonstrates
how nutrition fits within each stage of Maslows hierarchy of human needs.
B OX 16-1
Nutrition Within Stages of Maslows
Hierarchy of Human Needs
Survival. Food is fundamental for individual survival.
Security. Security needs can be met through storage and hoarding of food.
Love-belongingness. Use of foods as rewards or gifts. Traditionally, Amer-
ican women have expressed love of family through careful selection,
preparation, and service of meals (Fieldhouse, 1995, p. 23).
Self-esteem. Pride in food preparation. However, advertising stresses suc-
cess and reliability over individual innovation and experimentation. As
the expanding convenience food industry sought new markets, it offered
women self-esteem in a can (Fieldhouse, 1995, p. 23).
Self-actualization. Expressed by the innovative use of foods, new recipes,
and food experimentation. Food becomes a personal trademarka
source of personal satisfaction and achievement.
Source: Adapted from Fieldhouse, P. (1995). Food and nutrition: Customs and culture (2nd ed.).
London: Chapman & Hall.
FOOD IDEOLOGY
Food ideology is the sum of the attitudes, beliefs, customs, and taboos affecting the diet of
a given group. It is the idea of what is food, as much as the food itself, which evokes both
physiological and psychological feelings (Fieldhouse, 1995, p. 31). Ideology includes sym-
bolic meanings associated with food, such as religious connotations, rewards, prestige, or sta-
tus. Advertising influences food ideology, in that advertising utilizes powerful symbolic
meanings of foods, so that what is being sold is not just a product, but a lifestyle, a dream, and
a source of emotional fulfillment (1995). In the business of selling transformation, adver-
tising perpetuates envy and a sense of dissatisfaction with ones body (Nichter & Nichter,
1991, p. 249). The message is that we are inadequate as we are, but that when beauty (as a
commodity) has been purchased at a cost, we are told we are worth it! Advertising has a major
impact on food intake.
FOOD CATEGORIZATIONS
With the possible exception of modern Western society, no cultural group evaluates the
individual foods and combinations that it ingests in terms of the scientific categories of
energy, fat, protein, vitamins, and minerals. Most commonly, foods are assigned values
according to their functional role, as well as their perceived nutritional and non-nutritional
effects (Fieldhouse, 1995). Fieldhouse (1995, p. 49) points out that approaches to food clas-
sification by nutritional professionals have resulted in a diversity of food guides, which while
claiming justification in scientific rationality nevertheless show themselves as cultural con-
structs with built-in biases. Some of the possible categories in worldwide food classifications
(Fieldhouse, 1995; Helman, 1994) are presented in Table 16-1.
Table
16-1
Food Classification Groups
CLASSIFICATION DESCRIPTION
Cultural superfoods The dominant staple foods of a society. Much effort is
expended in producing and preparing them and they
are often involved in the religious rituals and the
mythology of the society.
Prestige foods Reserved for important occasions or for important peo-
ple. They are characterized by relative scarcity and
high price.
Body-image foods Contribute to good health by maintaining balance in
the body. Yin-yang (Chinese medicine beliefs) and hot-
cold (allopathic beliefs) food are examples of systems
which embody this idea. In Western culture, we hold
the idea of fattening and slimming foods.
Sympathetic magic foods Believed to have special properties that are imparted
to those who eat them.
Physiological group foods Foods restricted to persons of a particular age, sex, or
physiological condition.
Core foods Universal, regular, staple, important, and consistently
used foods. Form the mainstay of the diet for most
members of the society (e.g., milk, meat, vegetables,
cereal).
Secondary foods Widespread but not universal. Are of less emotional
importance and include recently introduced and store-
bought foods (e.g., cake mixes).
continued
Essential Dietary Nutrients 413
Table
16-1
Food Classification Groups (continued)
CLASSIFICATION DESCRIPTION
Peripheral foods Least common and are infrequently consumed. May
be new foods or only included through economic
necessity (e.g., oysters, sweetbreads).
Food versus nonfood Definitions of what is considered edible and what is
not tend to be flexible, especially under conditions of
famine, economic deprivation, and foreign travel.
Virtually no human groups in the world define human
flesh as food.
Sacred versus profane Profane food is seen as unclean and dangerous to
health; taboos forbid physical contact. Junk versus
whole foodsadditives are unclean and dangerous,
while vegetarianism is whole and spiritual (sacred).
Parallel Health is balance
Food as medicine Vitamins; food illnesses such as high blood pressure.
Social foods Symbolic family meal or religious feast. Expresses rela-
tionships and important occasions in the life of the
group; can symbolize social status.
Essential Dietary Nutrients

Essential nutrients are those nutrients derived from food that the body is unable to manu-
facture on its own. These are absolutely necessary for human life and include eight amino
acids, at least 13 vitamins, and at least 15 minerals, plus certain fatty acids, water, and carbo-
hydrates:
Amino acids are the building blocks of protein. The essential amino acids are L-lycine,
L-isoleucine, L-leucine, L-valine, L-methionine, L-threonine, L-phenylalanine, and
L-tryptophan.
Essential vitamins are broken up in two groups: fat-soluble and water-soluble. The
essential vitamins classified as fat-soluble include vitamins A, D, E, and K. The
water-soluble essential vitamins are C (ascorbic acid), B1 (thiamine), B2 (riboflavin),
B3 (niacin), B5 (pantothenic acid), B6 (pyridoxine), B12, folic acid, and biotin.
The essential minerals include calcium, magnesium, phosphorus, iron, zinc, copper,
manganese, iodine, chromium, potassium, sodium, and a number of trace elements.
Essential fatty acids required for proper metabolism include linoleic and linolenic acid,
found in seafood and unrefined vegetable oils, plus oleic and arachidonic acids, found
in most organic fats and oils and peanuts.
Accessory nutrients that help support metabolism include vitamin C-complex co-
factors choline and inositol, as well as coenzyme Q10 (a close relative of the B-
vitamins), and lipoic acid. Other accessory nutrients that have demonstrated
preventative functions include B-complex cofactor PABA (para-aminobenzoic
acid), and substance P or bioflavonoids that work with vitamin C (Burton Goldberg
Group, 1995).
FOOD MYTHS
Clark (1996) describes several food myths that nurses should be aware may affect nutri-
tional patterns of clients:
Meat contains more protein than other foods. Actually, meat contains only about 25% pro-
tein and is in the middle of the protein quantity scale, ranking below soybeans, fish,
milk, soybean flour, and eggs.
Large quantities of meat must be eaten to provide sufficient protein to grow and replace body
tissues. In fact, most Americans eat twice the amount of protein their bodies can use;
the recommended daily allowance of protein, 50 to 60 grams, can be reached even
when all meat, fish, and poultry are eliminated from the diet:
1. Wheat and beans, milk and rice, milk and peanuts, or beans and rice are complete
proteins (all amino acids).
2. All soybean products (tofu, tempeh) are complete proteins.
3. Fortifying cornmeal with the amino acid lysine also results in a complete protein.
4. Vegetarians must fortify their diet with vitamin B12.
Meat offers the highest quality protein available. Actually, eggs and milk are more useable
by the body than meat, and soybeans and unrefined rice are as useable.
There are good and bad forms of sugar. Actually, sugar is sugar. Sugar occurs naturally
in milk, fruits, and vegetables, so the sugar is being ingested with fiber, minerals, vita-
mins, and proteins.
Sugar is a good source of energy. In fact, refined sugar leads to less energy because the food
is digested quickly, and the blood glucose level rises, insulin is released, and liver stores
of glycogen are used, resulting in fatigue, shakiness, irritability, faintness, and, in some
people, violent behavior. Eating refined sugar results in highs and lows. For high energy,
frequent, high-protein meals or complex carbohydrates such as grains or vegetables are
recommended.
Starchy foods lead to weight gain. Actually, complex carbohydrates such as whole grain
pasta, baked potatoes, unrefined rice, and whole grain breads and cereals contain a great
deal of fiber that is filling; it is only when butter, margarine, sour cream, or other fill-
ings or toppings are used that calories accrue.
MINERALS AND VITAMINS

The term nutritional supplementation refers to the use of vitamins, minerals, and other food fac-
tors to support good health and prevent or treat illness. The key function of nutrients like vita-
mins and minerals in the human body is to serve as essential components in enzymes and
coenzymes (Murray, 1996). Nutritional supplementation has become a major business in the
United States. Many people believe that all that is needed to make up for a limited diet is to take
a multivitamin pill. However, Murray (1996, p. 9) points out that a person cannot make up for
poor dietary habits, a negative attitude, and a lack of exercise by taking pillswhether the pills
are drugs or nutritional supplements For the long-term, it is absolutely essential that individ-
uals devote attention to developing a positive mental attitude, a regular exercise program, and
a healthful diet. Safe and toxic levels of vitamins and minerals are listed in Appendix B.
Iron
Iron functions in oxygen transportation from the lungs to body tissues and in carbon diox-
ide transportation from the tissues to the lungs. Iron also functions in several key enzymes in
energy production and metabolism, including DNA synthesis. Iron deficiency may be caused
by an increased iron requirement (e.g., pregnancy), decreased dietary intake, diminished iron
absorption or utilization, blood loss, or a combination of factors. Some degree of iron defi-
ciency occurs in 35% to 58% of young, healthy women (Murray, 1996).
Heme iron is in animal products and is the most efficiently absorbed form of iron. The absorp-
tion rate of heme iron is as high as 35%. Heme iron doesnt have the side effects (nausea, flatu-
lence, and diarrhea) associated with nonheme sources of iron. Although the recommended dietary
allowance (RDA) for iron is 10 mg for males and 15 mg for females, the recommended dose of
(heme) iron supplement is 30 mg bound to either succinate or fumarate twice daily between meals.
If the supplement causes abdominal discomfort, 30 mg can be taken with meals three times a day.
High intakes of other minerals, particularly calcium, magnesium, and zinc, can interfere
with iron absorption (Murray, 1996). Iron is best absorbed when taken separately from pan-
creatic enzymes and should not be taken with vitamin E. Vitamin C taken with iron provides
maximum absorption. To enhance absorption, iron supplements should be taken between
meals with water or juice.
Zinc
Adequate zinc levels are essential to good health. Zinc is by far one of the most critical
minerals for overall immune functioning. Zincs ability to optimize the immune system works
directly and indirectly. Preventing zinc deficiency can help to ensure that the body manu-
factures adequate supplies of T cells and thymic hormones and maintains proper white-blood-
cell functioning (Meletis, 1999, p. 45). Zinc supplementation has also been found to
improve progressive hearing loss and other related ear problems. When recovering from sur-
gery, a person may need a higher level of zinc than usual.
The average American consumes about 10 mg of zinc per day. The dosage range for zinc
supplementation for general health support is 15 to 20 mg. Zinc forms bound to picolinate,
acetate, citrate, glycerate, or monomethionine are better absorbed and utilized than zinc sul-
fate (Murray, 1996). Zinc competes with copper for absorption, and other minerals (most
notably calcium and iron) can adversely affect zinc absorption if supplemented at a high
dosage. Zinc supplements should be taken apart from high-fiber foods for best absorption.
Zinc does not appear to interact in a negative fashion with any drug (Murray, 1996). How-
ever, excess zinc intake interferes with the bodys use of copper, another essential mineral
(Kava, 1995).
Calcium and Magnesium

In addition to its major function in building and maintaining bone and teeth, calcium is
important in much of the bodys enzyme activity. The contraction of muscles, release of neu-
rotransmitters, regulation of the heart beat, and the clotting of blood all depend on calcium
(Murray, 1996). It has been suggested that an intake of 1,500 mg of calcium daily will inhibit
age-related bone loss in postmenopausal women (Clark, 1996). This amount usually requires
dietary supplementation in the range of 1,000 to 1,200 mg daily.
Calcium citrate and other soluble forms (lactate, aspartate, orotate) are the best supple-
ments available for optimal absorption (Murray, 1996). Both achlorhydric and normal indi-
viduals efficiently absorb calcium citrate more than calcium carbonate (Gaby & Wright,
1988). However, a number of other substances can affect calcium blood levels, as, for example:
A diet high in phosphorus, a mineral found in animal protein, can cause lowered cal-
cium levels
A diet high in soy protein maintains calcium levels
A high level of caffeine consumption may increase the risk of calcium deficiency
High dosages of magnesium, zinc, fiber, and oxalates negatively affect calcium absorption
Caffeine, alcohol, phosphates, protein, sodium, and sugar increase calcium excretion
Aluminum-containing antacids ultimately lead to an increase in bone breakdown and
calcium excretion
Bone health depends not just on estrogen and calcium, but on a wide range of other nutri-
ents, including vitamins B6, C, D, K, folic acid, magnesium, manganese, boron, zinc, copper,
strontium, and silicon (Gaby & Wright, 1988). When accelerated bone formation is desir-
able, as in osteoporosis or after a fracture, a greater amount of vitamin K is required. Vitamin
D is required for intestinal calcium absorption, and manganese is required for bone mineral-
ization. Zinc is essential for normal bone formation. This mineral also enhances the bio-
chemical actions of vitamin D (Gaby & Wright, 1988).
Magnesium functions in the development, distribution, and function of immune cells and
soluble factors that are critical for humoral and cell-mediated immunity. Alterations of potas-
sium, calcium, phosphorus, and sodium metabolism are associated with magnesium deficiency
(Kubena & McMurray, 1996). Alkaline phosphatase, an enzyme involved in forming new cal-
cium crystals, is activated by magnesium. Many drugs adversely effect magnesium status, par-
ticularly many diuretics, insulin, and digitalis (Murray, 1996).
Excessive calcium prevents the absorption of magnesium. Because magnesium suppresses
parathyroid hormone and stimulates calcitonin, it helps move calcium into bones. Dairy
products contain nine times as much calcium as magnesium. A magnesium-rich diet contains
whole grains like brown rice, millet, buckwheat (kasha), whole wheat, triticale, quinoa, and
rye, as well as legumes, including lentils, split peas, and all varieties of beans (Fuchs, 1993).
Magnesium supplementation is as important as calcium supplementation in the treatment
and prevention of osteoporosis. However, most Americans do not get the RDA for magne-
sium of 350 mg per day for adult males and 280 mg for adult females (Murray, 1996). Lactat-
ing women need additional magnesium and protein, and post-menopausal women require
increased calcium and vitamin D to maintain strong bones.
Vitamin D
Vitamin D is actually a hormone that is activated by the sunlight. Calciferol, the active
form, is needed for the transport of calcium from the intestine into [cells]. Ergocalciferol (D2),
which is equally potent, is derived from the diet and is most commonly used for food fortifi-
cation and supplements (Kroll, 1995, p. 172). Fat-soluble vitamin D has properties of both
hormones and vitamins. It is needed for the absorption and metabolism of calcium and phos-
phorus from the small intestine for depositing in bones and teeth; for bone mineralization; for
improving renal absorption of calcium; for preventing excessive urinary loss of calcium and
phosphorus; and for maintaining serum calcium and phosphorus levels. In addition, vitamin
D maintains and keeps nerves, skin, heart, and muscles healthy by regulating the level of cal-
cium in the blood. It is also believed to aid in the regulation of normal blood sugar.
Vitamin D deficiency exacerbates osteoporosis and causes the metabolic bone disease
osteomalacia. The effectiveness of supplemental vitamin D in treating osteoporosis and pre-
venting bone loss and fractures is not clear (Kroll, 1995). Other conditions that may be pre-
vented or treated by vitamin D are arthritis, acne, alcoholism, herpes simplex and herpes
zoster, cystic fibrosis, and hearing loss (lack of vitamin D causes the cochlea to become
porous). Hypothyroidism requires very large doses of vitamin D, 50,000 units per day or
greater (Kroll, 1995).
Sufficient intake and/or absorption of vitamin D requires 10 to 20 minutes per day of exposure
to sunlight and fat equal to at least 10% of total calories. Most milk (400 units per quart), infant
feeding formulas, and cereals are fortified. Vitamin D is also present in such fatty foods as egg yolk,
butter, milkfat, cheese, liver, beef, shrimp, fatty fish, and cod liver and halibut liver fish oils.
Older patients are more vulnerable because the skin gradually loses its ability to convert
vitamin D to the active hormone that is necessary for dietary calcium to be incorporated into
bone. The most vulnerable patient groups are the aged, children, and premature infants, dark
skinned, and those who cover their skin much of the time. The drugs cholestyramine, Dilan-
tin (Parke-Davis, NY, NY), phenobarbital, and mineral oil all interfere with the absorption
and/or metabolism of vitamin D (Murray, 1996).
If the diet is not adequate, a daily multivitamin tablet that contains 200 to 400 units of
vitamin D can be taken. The latest U.S. recommendations for vitamin D intake, based on
amounts that have retarded the rate of bone loss, are 200 IU/day for men and women 19 to
50 years old, 400 IU for men and women 51 to 70 years old, and 600 IU for men and women
more than 70 years old (Abramowicz, 1998). Toxic and adverse effects such as hypercalcemia
can result from doses four to five times greater than the RDA. Vitamin D is not readily
excreted and is stored in the liver, skin, brain, bones, and other tissues. However, the body
self-regulates the development of the vitamin from sunlight, so an accumulation can only
come from diet or supplements. An extensive listing of vitamin and mineral supplementation
ranges can be found in Appendix B.
FAT
A fat or lipid describes compounds composed of carbon, hydrogen, and oxygen and that
are not soluble in water. The three major classes of dietary fats are triglycerides, phospho-
lipids, and sterols (like cholesterol). Approximately 95% of all ingested fats are triglycerides
(Murray, 1996). A triglyceride is a saturated fat because the carbon molecules in the fatty
acids are saturated with all the hydrogen molecules they can carry. If some of the hydrogen
molecules were removed, what remains is an unsaturated fatty acid and thus an unsaturated
fat. The American Heart Association recommends fewer than 10% of daily calories come
from saturated fats and fewer than 10% come from polyunsaturated fats. Monounsaturated
fats should make up the rest (Keegan, 1996). A description of categories and effects of fats can
be found in Table 16-2.
After digestion of fat, free fatty acids and monoglycerides are absorbed into the body and,
along with cholesterol, are transported by special protein-wrapped molecules known as
lipoproteins. Cholesterol is a waxy substance made primarily in the liver and in the cells lin-
ing the small intestine. It is an essential constituent of cell membranes and nerve fibers, and
is a building block of certain hormones. It is found in all body tissues, but the cholesterol that
circulates in the blood creates the most concern. The National Cholesterol Education Pro-
gram designates blood levels less than 200 mg/dL as desirable; levels between 200 and 240
mg/dl as borderline-high; and those over 240 mg/dL as indicative of a greater risk of heart dis-
ease. People with blood cholesterol over 265 mg/dL have two and a half times the risk of
developing coronary heart disease (CHD) as those with 190 mg/dL or less. However, a low
total cholesterol does not guarantee protection against heart disease (Sebastian, 1997). The
American Heart Association recommends a reduction in dietary cholesterol to less than 300
mg per day for healthy American adults. For those with CHD, cholesterol intake is usually
reduced to less than 200 mg per day.
The major categories of lipoproteins are very low-density lipoprotein (VLDL), low-den-
sity lipoprotein (LDL), and high-density lipoprotein (HDL). HDL cholesterol is consid-
ered good because it is thought to carry cholesterol away from the arteries and to the
liver for elimination. HDL can be raised by eating foods containing monounsaturated fats
(such as olive oil), and avoiding foods high in unhealthy saturated fat (such as palm or
coconut oil), losing weight, exercising, and stopping smoking. LDL cholesterol is consid-
ered bad, because after the cholesterol actually needed by the cells is delivered, any
excess is deposited in arterial walls and other tissues. Elevations of either LDL or VLDL
are associated with an increased risk for developing atherosclerosis, the primary cause of a
heart attack or stroke, and elevations of HDL are associated with a lower risk of heart
attacks.
Murray (1996) offers the following practical dietary advice about the consumption of fats:
Reduce the amount of saturated fat and total fat in your diet by eating less animal and
more plant foods.
Table
16-2
Categories and Effects of Fat
CATEGORY EFFECTS
Saturated fat Mostly from animal products and lard.
Tropical vegetable oils (palm kernel, palm, and coconut).
Increase total blood cholesterol, especially LDLs.
Hydrogenated fats Give liquid fat more consistency and stability against rancidity
(transfatty acids) Transfatty acids (hydrogenated margarine) raise LDL choles-
terol almost as much as saturated fats (butter) and also lower
HDL cholesterol.
No more healthy than comparable animal-based saturated
fats (butter).
Polyunsaturated fat When substituted for saturated fat, polyunsaturated fat pro-
duces a decline in LDL levels. Includes the omega-6 (veg-
etable oils such as corn, safflower, and soybean) and omega-
3 (cold water fish such as salmon, mackerel, and tuna) fatty
acids (Sebastian, 1997, p. 13).
Corn, cottonseed, soybean, and safflower oils also contain
linoleic acid that may enhance the growth of certain cancers.
Monounsaturated fats Canola, olive, and high-olein safflower oils. The best oils for
cooking and baking are liquid canola and olive vegetable
oils.
Reduce levels of LDLs while preserving the beneficial HDLs.
Essential fatty acids Transformed into regulatory compounds known as

prostaglandins, which are important in a host of bodily func-
tions. However, according to Murray (1996), approximately
80% of the U. S. population consumes an insufficient quan-
tity of essential fatty acids. The three primary factors con-
tributing to the current essential fatty acid deficiency are:
1. Unavailability of high-quality oils rich in essential fatty
acids because of mass commercialization and refinement
of fats and oil products.
2. Transformation of healthful omega-3 and omega-6 oils
into toxic compounds (hydrogenated and transisomers).
3. Metabolic competition of hydrogenated and transfatty
acids with the essential fatty acids.
Eliminate the intake of margarine and foods containing transfatty acids and partially
hydrogenated oils.
Take 1 or 2 tablespoons of flaxseed oil dailythe worlds richest source of omega-3
fatty acids.
Some dietary fat is necessary, but the total dietary fat intake should be limited to 20 to
30 percent of calories consumed.
FIBER
Since fiber, found mainly in fruits, vegetables, and grains, is not digested, it is not used as
an energy source by the body. However, studies associate fiber with normal digestion, control
of blood glucose, blood pressure, and cholesterol levels, and protection against cancer and
heart disease. Unfortunately, average intake of fiber in the United States is less than half the
amounts recommended. The average low-fiber, refined diet provides about 10 to 20 grams of
fiber per day; while the suggested optimal amount ranges from 30 to 50 grams per day (Kee-
gan, 1996).
Insoluable Fiber
Includes cellulose, hemicellulose, and lignin.
Found in wheat bran, whole grains, fruits, vegetables, and nuts.
Decreases food transit time and increases the weight and softness of the stool.
Needs large amounts of water to prevent cramping, flatulence, or constipation.
Soluble Fiber (Nonlaxative)

Lowers the absorption of cholesterol, regulates blood sugar by slowing the absorption of
sugar into the bloodstream, and absorbs and removes toxic materials and carcinogens
from the body.
Oat bran. Refrigerate or store in the freezer for no more than 2 months.
Flax seeds. The outer walls of the seeds swell and absorb water to form a mucilage coat-
ing that provides bulk and lubrication.
Guar gum (from legumes) and pectin (from apples). Form a jelly-like substance.
Psyllium seeds. Swell rapidly by absorbing water, so preparations should be used
immediately.
The best way to increase fiber in the diet is to eat whole grain foods that are high in complex
carbohydrates. However, increasing fiber intake may cause flatulence and bloating, therefore any
increase should be gradual in order to give the digestive system time to adjust. Just one serving
of a high-fiber food should be added each week, and liquid should be increased to 8 to 10 glasses
to account for the extra liquid that will be absorbed by the fiber. Large amounts of dietary fiber
may result in impaired absorption and/or negative balance of some minerals and reduce the need
for insulin and other medications. Fiber supplements may also inhibit the absorption of certain
drugs, so the fiber supplement should be taken hours apart from any medication (Murray, 1996).
PHYTONUTRIENTS
Phytonutrients are biologically active substances in foods that have health-enhancing or
possibly curative abilities. Non-nutritive substances, such as fibers and phytochemicals,
have been identified as bioactive agents or biological response modifiers (BMRs) from the
plant world. These substances modulate key disease-related mechanisms, such as immune
function, oxidative stress, homeostasis, inflammatory activity, and hormonal balances
(Block, 1999, p. 490).
Soy
Soy is comprised of plant estrogens (phytoestrogens) such as isoflavones. Genistein is an exam-
ple of a prominent isoflavone. Estrogen links to both types of estrogen receptors, but alpha- and
beta-phytoestrogens may link only to one or the other. When phytoestrogens link to either recep-
tor, they may have the same effect as estrogen or they may act as antiestrogens, linking to the
receptor, but failing to initiate the necessary reaction to activate a gene. Phytoestrogens are also
weaker than animal estrogens. They are broken down in the body more readily and are not stored
in fat. Thus, they are associated with fewer side effects (Harvard Womens Health Watch, 2000).
The role of isoflavones in breast and prostatic cancer is unclear. It has been suggested that soy
proteins may promote, but not initiate, breast tumors (Harvard Womens Health Watch, 2000).
However, phytoestrogens have shown promise in alleviating hot flashes (so has the herb black
cohosh, which is marketed as Remifemin) It [genistein] can reduce many of the risk factors that
contribute to cardiovascular disease. In randomized controlled trials, soy-protein supplements
have consistently lowered both total cholesterol and LDL (bad) cholesterol in perimenstrual
women, and in most cases have increased HDL (good) cholesterol as well. Soy has also been
shown to improve the elasticity of blood vessels and to lower systolic blood pressure (2000, p. 4).
Phytoestrogens may relieve symptoms of perimenopause and reduce the risk of heart disease and
osteoporosis with fewer adverse effects than hormone replacement therapy. The available infor-
mation suggests that the beneficial effects of phytoestrogens outweigh the negative effects (2000).
Consuming soy protein, approximately 30 grams (2 scoops) of soy protein or more each day
has been shown to lower total and LDL cholesterol in humans (Megna, 1997). The RDA is
1 to 2 cups. Many foods are made from the soybean, such as tofu, soy protein isolate, soy flour
textured vegetable protein (TVP), miso, and tempeh. Soy protein is essentially equal in qual-
ity to animal protein. In addition, soy foods are rich in other nutrients, including calcium,
iron, zinc, and many of the B vitamins.
Garlic and Onions

Allyl sulfide (allicin) and ajoene decrease risk of stomach cancer, lower LDL cholesterol,
and reduce blood clotting. If eaten raw, all of the breakdown compounds are available and
each has specialized activity. Garlic may encourage the production of gluthathione S-trans-
ferase, an enzyme that helps rid the body of carcinogens. Garlic possesses
antimutagenic/anticarcinogenic, immune enhancing (raw), antitumor, antifungal, antipara-
sitic, anticholesterol (cooked), decongestant (cooked), and antiplatlet/ antileukocyte adhe-
sion (cooked) action. It is generally recommended that people eat about two cloves a day,
both raw and cooked.
Other Phytonutrients
Other beans. Kidney beans, chickpeas, and lentils have saponins, which may slow can-
cer-cell production and spread.
Tomatoes. Lycopene is a carotenoid antioxidant (protects against cell damage). P-
coumaric acid (also in berries) stops the production of cancer-causing nitrosamines and
is anti-inflammatory.
Citrus. Limonene in red grapefruit stimulates cancer-killing immune cells.
Orange vegetables and fruits. Carotenes (squash, sweet potatoes, carrots, mangoes, pump-
kins, and cantaloupes). Alpha-carotene increases vitamin A activity and boosts general
immunity, beta carotene improves immunity. Other carotenes are lycopene, lutein,
zeaxanthin, and cryptoxanthin.
Crucifers. Indoles (broccoli, Brussels sprouts, cabbage) weaken cancer-promoting entro-
gens and increase general immunity. Sulforphanes inhibit breast-cancer tumor growth.
Chemoprotective action on liver, colon, lung (specifically against tobacco
nitrosamines), mammary glands, the fundic region of the stomach, and esophagus. RDA
is 1 to 2 cups.
Grapes and turnips. Ellagic acid blocks cancer-helper enzymes.
Berries. Polyphenols are found in red grapes and red wine, strawberries and blueberries,
artichokes, and yams. They may flush carcinogenic toxins and lower risk of heart dis-
ease. Flavonoids interfere with carcinogenic hormones, fight cell damage from oxida-
tion, strengthen blood vessels, decrease capillary permeability, protect skin integrity,
and are anti-inflammatory and good for the eyes.
Flax seed. Contains lignin precursors that may help prevent some estrogen-related can-
cers by binding to estrogen receptors. Also contains omega-3 fatty acids.
Leafy greens. Lutein in spinach, mustard, turnip, and collard greens, as well as yellow squash,
are carotenoid antioxidants that appear to protect against some cancers, slow degenerative
eye disease, and increase immunity. Dark, leafy greens also contain indoles (see crucifers).
Grains. Supply lignins and vitamin E. RDA is 1 to 2 cups cooked.
It has been suggested that foods containing phytonutrients are best eaten fresh and raw, or
lightly steamed. Juicing is also a good way to concentrate nutrients. Canned and frozen fruits
and vegetables are probably better than none at all. However, isolated extracts in a pill may
not work as well as the whole food (Landis, 1997; Zimmerman, 1995).
ANTIOXIDANTS
Antioxidants are compounds that help protect against free-radical damage. The bodys
cells use oxygen to produce energy. During these normal metabolic processes, oxygen some-
times reacts with body compounds to produce unstable molecules known as free radicals
molecules with unpaired electrons. An unpaired electron is unstable and highly reactive; it
needs to pair with another electron in order to return to a stable state. Free radicals quickly
react with other compounds in an attempt to capture that needed electron. Antioxidants
neutralize free radicals by donating one of their own electrons.
Free radicals not only arise spontaneously during metabolism, but also are made by cells of
the immune system to help inactivate viruses and bacteria. In addition, environmental fac-
tors such as radiation, pollution, cigarette smoke, and herbicides can generate free radicals.
Free radicals cause cell damage. They commonly attack lipoproteins and unsaturated fatty
acids in cell membranes, starting chain reactions called lipid peroxidation. Left uncontrolled,
lipid peroxidation damages cell structures and impairs their functions. Free radicals also dam-
age proteins and DNA. Rampant free-radical formation and the resulting damage is referred
to as oxidative stress. This stress has been implicated in the aging process and in the devel-
opment of diseases such as cancer, arthritis, cataracts, and heart disease.
It appears that a combination of antioxidants will provide greater antioxidant protection
than any single nutritional antioxidant (Murray, 1996, pp. 10-11). Antioxidants (protector
nutrients) that prevent or delay degenerative processes, include vitamins E, C, and beta carotene
(a close relative of vitamin A) and the minerals zinc, copper, manganese, and selenium.
Vitamins E, A, and C work together as a team
There are relationships between low intakes of beta carotene (pro-vitamin A), vitamin
E, and vitamin C and higher incidences of cancer
Vitamin B3 (niacin) can help combat heart disease, while vitamin B6 can help prevent
atherosclerosis
Smokers require more vitamin E, C, and beta carotene than nonsmokers, and persons
who consume a significant amount of alcohol require more vitamin B1 and magnesium
than the average person
Women taking oral contraceptives may need to increase their zinc, folic acid, and vitamin
B6 intakes, while pregnant women may require more folic acid for proper fetal development
Individuals who are exposed to smog or other pollutants require higher levels of the pro-
tector nutrients such as selenium, and vitamins E and C
Anyone who is under heavy emotional or physical stress will need higher intakes of all
the B vitamins
The best way to supplement antioxidant nutrients is to eat five generous servings of fruits
and vegetables daily, especially citrus fruits and green and yellow vegetables. Supplements
should not exceed daily doses of 750 retinol equivalents of vitamin A, 30 mg of vitamin E,
and 100 mg of vitamin C from supplements.
Vitamin E
Vitamin E (tocopherol) is the most abundant fat-soluble antioxidant. The principal use of
vitamin E is as an antioxidant in the protection against heart disease, cancer, and strokes. It func-
tions as a free radical scavenger, protecting lipids from oxidation, preventing the formation of
arterial plaque, and subsequently lowering the incidence of coronary artery disease and fatal
myocardial infarction. Individuals taking 100 IU of vitamin E daily for 2 years had a 37% to 41%
reduction in heart disease risk (Massey, 2002). Vitamin E may stimulate wound healing and pre-
vent adhesions, and autoimmune disease may be affected positively. Anecdotally, vitamin E has
been reported to be beneficial in reducing the symptoms of restless leg syndrome and nocturnal
calf cramps. Large doses of vitamin E have also been found to strengthen immune functioning
and reduce the severity of age-related diseases such as Parkinsons disease. It is thought that daily
supplements of vitamin E enhance the action of insulin by stabilizing the membranes of respond-
ing cells. The result is to improve glucose control in diabetes. The antioxidant properties of vita-
min E also provide protection to the thymus gland and to white blood cells (Meletis, 1999).
Vitamin E is found in nuts, vegetable oils, whole grains, egg yolks, and leafy green vegeta-
bles. There are no significant toxicities associated with normal amounts of vitamin E. It should
be taken with meals to optimize absorption. However, the benefits of taking high doses of vita-
min E remain to be established (Abramowicz, 1998), and excessive amounts of vitamin E may
cause possible gastrointestinal disturbances and may enhance the anticoagulant effects of drugs.
Vitamin C
Vitamin C is the most abundant water-soluble antioxidant in the body. High intakes and
serum concentrations of vitamin C have been associated with low incidences of senile cataract,
cancer, coronary artery diseases, and higher high-density lipoprotein (HDL) cholesterol con-
centrations (Abramowicz, 1998). Some factors that deplete the body of vitamin C include cig-
arette smoke, stress, birth control pills, alcohol, and the consumption of fast foods (Clark, 1996).
Meletis (1999, p. 45) suggests that supplementation with 1 to 3 gm per day can enhance
immunity. However, Abramowicz (1998) indicates that short-term randomized trials have
shown that taking vitamin C does not prevent upper respiratory infections, and there is no
convincing evidence that taking supplements of vitamin C prevents any disease.
Vitamin C regenerates oxidized vitamin E in the body and potentiates its antioxidant benefits
(Murray, 1996). Therefore, supplemental vitamins C and E might be effective in minimizing the
chemotherapy and radiotherapy used for treatment of patients with cancer (Kubena & McMur-
ray, 1996). In addition, long-term supplementation of elderly people with moderate amounts of
vitamins C and E can significantly reduce serum peroxide levels and protect against free-radical
damage, and thereby, aging and degenerative diseases (Clark, 1996). However, an antagonistic
effect between vitamins E and A has been noted in several studies. Although supplements of both
vitamin E and A were observed to increase antibody production and phagocytosis, when either
one was increased, immune function was less (Kubena & McMurray, 1996). Also of concern is
that vitamin E in supplements is mostly alpha-tocopherol, which in vivo may block the antiox-
idant activity of gamma-tocopherol and have a pro-oxidant effect (Abramowicz, 1998, p. 75).
Selenium
The trace mineral selenium functions primarily as a component of the antioxidant
enzyme glutathione peroxidase, which works with vitamin E in preventing free radical dam-
age to cell membranes (Murray, 1996, p. 223). Supplementation with selenium stimulates
leukocyte activity and thymus-gland function (Meletis, 1999).
When selenium and vitamin E are not present in adequate levels, immune function is
impaired more severely than when only one is inadequate. Both nutrients are needed for opti-
mal response. However, limited evidence exists about the relationship between supplementa-
tion of vitamin E and selenium and the effect on immune response. The adverse effect of
excessive intake of selenium on immune function has been documented (Kubena & McMur-
ray, 1996).
For adults, a daily intake of 50 to 200 g is often recommended (Murray, 1996). Patients
receiving chemotherapy drugs may have increased requirements.
Coenzyme Q10
Coenzyme Q10 functions like a vitamin that provides critical energy for proper
immune functioning, while conferring antioxidant protection (Meletis, 1999). There are
no known significant side effects of a basic level of coenzyme Q10 supplementation at 30
mg daily:
Biochemically functions much like vitamin E in that it participates in antioxidant and

free radical reactions.
Required for the production of cell energy in the mitochondria and serves as an antioxidant.
Improves the heart tissues ability to survive under low oxygen conditions. Also has
a stabilizing effect on heart rhythm, and has been effective in normalizing blood
pressure.
Vitamin A and Beta Carotene

Vitamin A is critically important to the maintenance and integrity of tissue, normal
growth, and healthy immune system function. Epidemiologic studies have revealed that
higher levels of carotenoids in the diet and higher serum levels of beta carotene are associ-
ated with a lower incidence of cardiovascular disease and cancer, particularly lung cancer
(Abramowicz, 1998). Vitamin A nutrition is clearly linked to optimal immune responses
(Kubena & McMurray, 1996).
Beta carotene is the most nutritionally active of approximately 50 provitamin A
carotenoids. It is found primarily in vegetables such as carrots, other orange and dark green
leafy vegetables and tomatoes, and orange-colored fruits such as cantaloupes and mangos.
One large carrot is estimated to contain 11,000 units of vitamin A in the form of beta
carotene. However, Meletis (1999) indicates that supplemental carotenes are absorbed better
than those from carrots and other vegetables. Palm oil carotenes appear to give the best
antioxidant protection (Murray, 1996).
The most recognizable form of vitamin A deficiency is night blindness. People with
chronic vitamin A deficiency have more respiratory illness, dry skin, kidney stones, and diar-
rhea. Epidemiologic studies have strongly implicated low intake of vitamin A with the devel-
opment of precancerous cells in the mouth, throat, and lungs. Although vitamin A may be
given to counteract any symptom of deficiency, symptoms will not be alleviated unless they
are caused by a vitamin A deficiency (McDowell, 1995).
The RDA for vitamin A is 5,000 IU for men and 4,000 IU for women. If necessary, 25,000
IU a day may be used as a long-term supplement. For persons older than 60 years, the dosage
may be reduced to 10,000 IU a day, taken shortly following a meal. Small amounts of vitamin
E and zinc will increase the capacity of all body tissues to store vitamin A.
Women must avoid vitamin A supplementation during pregnancy (Murray, 1996). In fact,
large-dose supplements of vitamin A in its active form cause toxicity. No one should take beta
carotene supplements (Abramowicz, 1998).
Dietary Guidelines, Goals, and Obesity

Optimal diets should provide energy and the full complement of essential nutrients in pro-
portions that maximize health and longevity, prevent nutritional deficiencies as well as condi-
tions related to nutritional excesses and imbalances, and be obtained from foods that are
available, palatable, acceptable, and affordable (Nestle, 1996, p. 193). Large areas of the world
still experience widespread famine and starvation. However, ironically in the developed coun-
tries, with improvements in economic status, dietary patterns throughout the world have
tended to shift from a dependence on plant foods as sources of energy and nutrients to an
increasing reliance on animal foods that are higher in fat, saturated fat, and cholesterol. This
shift has been accompanied by a decline in the prevalence of health problems related to under-
nutrition and by an increase in the prevalence of diet-related chronic diseases (Nestle, 1996).
Proper total nutrition is by far the most critical factor in maintaining overall optimal immune
function (Meletis, 1999). In the simplest sense, the strategy for strengthening the system is to
increase positive life influences and reduce negative life influences as much as possible. Exam-
ples of what this would mean is reducing mental stress; consumption of simple sugar, alcohol,
saturated, and certain other harmful fats; and eliminating smoking and drug use. It would mean
increasing intake of whole grains, legumes, fresh fruits and vegetables; getting plenty of fresh,
clean water, rest, relaxation, and sleep; doing moderate exercise; and experiencing as much gen-
uine joy, happiness, and self expression as possible (Landis, 1997). Figure 16-1 displays the
nutrition pyramid and describes what constitutes a nutritious serving.
Since the 1940s, chronic diseases such as coronary heart disease, certain cancers, diabetes,
and stroke have replaced infectious diseases and conditions related to undernutrition as lead-
ing causes of death among adults in the United States. The role of diet in chronic disease pre-
vention is well established. Substantial evidence indicates that the typical American
diethigh in fat, saturated fat, cholesterol, salt, sugar, and alcohol, but low in starch and
fibercontributes to chronic disease incidence and severity. Some estimates suggest that as
much as one-third of coronary heart disease and cancer incidence can be attributed to dietary
factors. Diet and physical inactivity account for an estimated 300,000 deaths each year in the
United States (Nestle, 1996). Moreover, an estimated 60 million adults have elevated blood
cholesterol levels, 60 million have high blood pressure, and 30 million are obese; many of
these individuals could benefit from improved dietary intake.
Another major nutritional problem in the United States today is overconsumptive under-
nutrition, or too much junk food! Foods low in nutrient density are often termed empty-
calorie or junk foods, which refers to the relative ratio of nutrients to calories. Most
Americans do not even come close to meeting all their nutritional needs through diet alone
(Murray, 1996). Nutritional needs, in terms of specific amounts of nutrients that a healthy
individual should receive every day, have been called recommended dietary allowances since
the term was introduced in 1973, as a reference value for vitamins, minerals, and protein in
Anatomy of MyPyramid
One size doesnt fit all
USDA's new MyPyramid symbolizes a personalized approach to healthy eating and physical activity.
The symbol has been designed to be simple. It has been developed to remind consumers to make
healthy food choices and to be active every day. The different parts of the symbol are described below.
Activity
Proportionality
Activity is represented by the steps and
the person climbing them, as a reminder Proportionality is shown by the different
of the importance of daily physical activity. widths of the food group bands. The widths
suggest how much food a person should
choose from each group. The widths are
just a general guide, not exact proportions.
Check the Web site for how much is
right for you.
Moderation
Moderation is represented by the narrowing
of each food group from bottom to top.
The wider base stands for foods with Variety
little or no solid fats or added sugars.
These should be selected more often. Variety is symbolized by the 6 color bands
The narrower top area stands for foods representing the 5 food groups of the
containing more added sugars and solid Pyramid and oils. This illustrates that
Dietary Guidelines, Goals, and Obesity

fats. The more active you are, the more of foods from all groups are needed each
these foods can fit into your diet. day for good health.
STEPS TO A HEALTHIER YOU

Personalization Gradual Improvement
Personalization is shown by he person on Gradual improvement is encouraged by
the steps, the slogan, and the URL. Find the slogan. It suggests that individuals can
the kinds and amounts of food to eat each benefit from taking small steps to improve
day at MyPyramid.gov. their diet and lifestyle each day.
Figure 16-1. The nutritional pyramid. Source: U.S. Department of Agriculture and the U.S. Department of Health and Human Services.
427
voluntary nutritional labeling. In 1992, the term was renamed reference daily intakes (RDIs).
Daily reference values (DRVs) are figures for nutrients such as fat and cholesterol for which
no standards previously existed. The figures are based on the number of calories consumed per
day. For labeling purposes, 2,000 calories have been established as the reference for calculat-
ing percent daily values. The United States Department of Agriculture (USDA) has found
that a significant percentage of the U.S. population receives well under 70% of the U.S. rec-
ommended daily allowance (U.S. RDA) for vitamin A, vitamin C, B-complex vitamins, and
the essential minerals calcium, magnesium, and iron. Most typical diets contain less than 80%
of the RDA for calcium, magnesium, iron, zinc, copper, and manganese; the people most at
risk are young children and adolescent to elderly women (Burton Goldberg Group, 1995).
For the most part, we Americans consume more calories than we need. Caloric require-
ments depend on your size, age, and level of activity (Keegan, 1996, p. 46). Sedentary
women and some older adults need 1,600 calories, whereas teenage boys and most active men
need 2,800 calories per day. Whatever the caloric level, DRVs for the energy-producing nutri-
ents are always calculated as follows:
Fat based on 30% of calories
Saturated fat based on 10% of calories
Carbohydrates based on 60% of calories
Protein based on 10% of calories
Fiber based on 11.5 grams per 1,000 calories (Keegan, 1996)
RDAs focus on the prevention of nutritional deficiencies in population groups only; they
do not define optimal intake for an individual (Murray, 1996, p. 9).
DIETARY GUIDELINES
The food guide pyramid recommends that the daily diet contain 6 to 11 portions (1 oz of
cereal foods) or (1 slice of bread), 2 to 4 servings (one-half cup) of fruits, 3 to 5 servings (one-
half cup) of vegetables, 2 to 3 servings (2 to 3 oz) of meats or meat substitutes, and 2 to 3 serv-
ings (1 cup milk) (1.5 oz cheese) of dairy foods. However, less than 10% of the population
consumes the recommended number of fruits and vegetables on any given day (Nestle, 1996,
p. 195). In Box 16-2, the USDA dietary guidelines are presented.
DIETARY GOALS AND OBESITY

Obesity has been proclaimed a major health problem by medicine and the pharmaceutical
industries (Kumanyika, 2001). It is alleged that the direct and indirect costs of obesity are 7%
of the total health care costs in the United States (Visscher & Seidell, 2001). Fatness as
chronic disease and weight reduction as cure stand as almost universally accepted medical
dogma (Robison, 1999, p. 47) based on medical premises that weights above recommended
levels predispose to disease and decreased longevity, and that weight loss increases longevity
and improves health. However, these premises are not well supported by existing studies
(Robison, 1999). Instead, the common pattern of weight loss followed by weight gain (weight
Dietary Guidelines, Goals, and Obesity 429
B OX 16-2
Department of Agriculture
Dietary Guidelines
Eat a variety of foods
Maintain healthy weight, dont starve yourself
Choose a diet low in fat, saturated fat, and cholesterol
Choose a diet with plenty of vegetables, fruits, and grain products
Try to eat as few animal products, especially meats, as possible
Avoid foods with stimulants, drugs, hormones, and chemicals
Use sugars only in moderation
Use salt and sodium only in moderation
If you drink alcoholic beverages, do so in moderation
Source: U.S. Department of Agriculture. (1995). Nutrition and your health: Dietary guidelines for Amer-
icans (4th ed.). Washington, DC: US Government Printing Office.
cycling) experienced by most dieters is associated with increased risk for heart disease, hyper-
tension, and diabetes (Robison, 1999).
Body mass index (BMI) is a means of expressing weight relative to height. BMI is calcu-
lated by dividing weight in kilograms by height in meters squared (weight in pounds, multi-
plied by 705, divided by height in inches, and divided again by height in inches). A BMI from
19 to 25 is considered to be a healthy target for adults. However, the majority of American
adults has a BMI of 25 to 30 and is considered overweight. Twenty-three percent of Ameri-
can adults have a BMI of 30 or more and are considered obese.
Robison (1999) suggests that health professionals should not prescribe weight loss, because
it is ineffective, potentially harmful, and associated with negative psychological effects, guilt,
and disordered eating. Instead, he suggests that the goal of interventions should be behavior,
lifestyle, and/or attitude change. Instead of weight loss, appropriate outcomes might include
decreased reliance on medications, improved quality of life, increased physical activity, decrease
in health risks, normalized eating behaviors, and improved quality of food intake. However, the
biomedical health care system continues to focus on diet as a treatment for obesity.
Healthy People 2010 (USDHHS, 2000) presents national objectives for health promotion
and disease prevention, to be achieved by the year 2010, to address the overarching goal to
promote health and reduce chronic disease associated with diet and overweight. These are
presented in Table 16-3.
Table
16-3
Healthy People 2010 Nutrition Objectives
GOAL METHODS
Area 1. Weight status and Increase the proportion of adults who are at a healthy
growth weight.
Reduce the proportion of adults who are obese.
Reduce the proportion of children and adolescents
who are overweight or obese.
Reduce growth retardation among low-income chil-
dren under age 5 years.
Area 2. Food and nutrient Increase the proportion of persons aged 2 years and
consumption older who consume at least two daily servings of fruit.
Increase the proportion of persons aged 2 years and
older who consume at least three daily servings of
vegetables, with at least one-third being dark green or
deep yellow vegetables.
Area 2. Food and nutrient Increase the proportion of persons aged 2 years and
consumption older who consume at least six daily servings of grain
(continued) products, with at least three being whole grains.
older who consume less than 10% of calories from
saturated fat.
older who consume no more than 30% of calories
from fat.
older who consume 2,400 mg or less of sodium daily.
older who meet dietary recommendations for calcium.
Area 3. Iron deficiency Reduce iron deficiency among young children and
and anemia females of childbearing age.
Reduce anemia among low-income pregnant females
in their third trimester.
continued
Table
16-3
Healthy People 2010 Nutrition Objectives (continued)
GOAL METHODS
Area 4. Schools, worksites, Reduce iron deficiency among pregnant females.
and nutrition Increase the proportion of children andadolescents
counseling aged 6 to 19 years whose intake of meals and snacks at
schools contributes proportionally to good overall
dietary quality.
Increase the proportion of worksites that offer nutrition
or weight management classes or counseling.
Increase the proportion of physician office visits made
by patients with a diagnosis of cardiovascular disease,
diabetes, or hyperlipidemia that include counseling or
education related to diet and nutrition.
Area 5. Food security Increase food security among U. S. households and in

so doing reduce hunger.
NUTRITIONAL MEDICINE
Nutritional medicine goes beyond the correction of nutrient imbalances toward modulat-
ing specific disease processes by nutritional means. Successful long-range management of
chronic disease requires a biologically based approach that is grounded in an understanding
of the biochemical synergisms and antagonisms that influence disease progression (Block,
1999, p. 492). It is estimated that about half the diseases a primary care physician sees have
a nutrition-related cause, and at least five of the top 10 causes of death in the United States
are linked to diet. Randomized placebo-controlled trials have demonstrated that modest sup-
plementation with vitamins and minerals significantly improves immunity and decreases the
risk of infection in old age (Block, 1999).
Nutrigenomics tries to explain how common dietary chemicals (i.e., nutrition) affect
health by altering the expression and/or structure of an individuals genetic makeup. The
tenets of nutrigenomics are (Hyman, 2004):
Common dietary chemicals act on the human genome, either directly or indirectly, to
alter gene expression or structure.
Under certain circumstances and in some individuals, diet can be a serious risk factor
for a number of diseases.
Some diet-regulated genes (and their normal, common variants) are likely to play a role
in the onset, incidence, progression, and/or severity of chronic diseases.
The degree to which diet influences the balance between healthy and disease states may
depend on an individuals genetic makeup.
Individualized dietary interventions based on knowledge of nutritional requirement,
nutritional status, and genotype can be used to prevent, mitigate, or cure chronic disease.
Nutritional medicine involves therapeutic application of dietary and nutritional modifi-

cations to reestablish harmony of the body (Block, 1999). Nutritional biotherapy is the clin-
ical use of diet and nutrition to influence host-disease relationships as well as the
relationships between nutritional biochemistry and standard treatment (Block, 1999).
Nutritional biotherapy bridges complementary and conventional care. This emergent field
consists of three major areas of clinical application:
1. Prescriptive dietetics. The selective use of foods and diets specifically designed for differ-
ent diseases, depending on many individual factors.
2. Nutritional pharmacology. The supplemental use of specific vitamins, minerals, phyto-
chemicals, and botanicals (herbal or plant-derived substances), which are tailored to
the individual.
3. Nutrition support. The use of intravenous or parenteral nutrition when a general diet
cannot be consumed (Block, 1999).
Prescriptive dietetics and nutritional pharmacology incorporate therapeutic strategies and
prophylactic strategies. Therapeutic strategies address biochemical imbalances or physiologi-
cal disturbances, while prophylactic strategies are aimed at preventing the expression of a
particular disease-related genotype and enabling patients to enjoy reasonably good health if
they select foods and food preparation methods within certain parameters. Noninvasive
interventions may be used to prolong the success of a standard medical therapy by adding a
specific biomodulation effect (e.g., reducing serum cholesterol) and thus reducing the relapse
rate (Block, 1999, p. 491). Complementary applications of nutritional biotherapy may trans-
late into considerable reductions in treatment costs as well as reductions in overall disease
burden and suffering (Block, 1999).
According to Block (1999), the principal concepts of nutritional medicine include:
1. Core dietary regimen
2. Dietary fat as a separate food
3. Variety and meaningful quantification
4. Individual nutritional tailoring
5. Safe and appropriate supplementation
The first step in effective nutritional medicine is assessment of the patients current nutri-
tional status, using the ABCDs of nutritional assessment, which stands for anthropometric,
biochemical, clinical, and dietary assessment. In anthropometric assessment, weight is con-
sidered in relation to height. The body mass index (BMI) can be calculated from this and used
in risk factor assessment if needed. Clinical assessment includes consideration of nutrition-
related problems and risk factors, such as anorexia and nausea, as well as potential treatment-
nutrient interactions.
As part of nutritional assessment, the nurse should ask clients about their diets, including:
Food and income resources

Housing
Employment
Family and social patterns
Ethnic and cultural background
Cooking facilities
Availability of shopping and transportation
Food preferences and dislikes
Counseling is most likely to be successful when:
The client is motivated to change
Recommendations are consistent with the clients cultural background, food prefer-
ences, belief systems, and economic status
Suggestions are positive
Changes are made gradually and reinforced over time
USE OF NUTRITIONAL SUPPLEMENTS

Today, an estimated 46% of adult Americans take nutritional supplements, many on a
daily basis (Burton Goldberg Group, 1995). Although the quality and number of subjects
in blind, controlled clinical trials of nutritional and dietary supplements is variable, and
few supplements have been shown to be effective (Fillmore et al., 1999), glucosamine sul-
fate (1,500 mg) and condroitin sulfate (800 mg) per day have sufficient controlled trials
to warrant their use in osteoarthritis, having less side effects than currently used nons-
teroidal anti-inflammatory drugs, and are the only treatment shown to prevent progression
of the disease (Fillmore et al., 1999, p. 693). Improvement may not be evident for 1 to 3
months.
The following are suggested strategies to facilitate absorption and utilization of nutritional
supplements:
Nutritional supplements should be taken with meals to promote increased absorption.

Fat-soluble vitamins (such as vitamins A, E, beta carotene, and the essential fatty acids
linoleic and alpha linolenic acid) should be taken with the meal that contains the most
fat during the day.
Amino acid supplements should be taken on an empty stomach at least an hour before
or after a meal, with fruit juice to help promote absorption. A liquid form, diluted in a
beverage, may help if a tablet causes nausea.
If nauseated or ill within an hour after taking nutritional supplements, the client may need
a bowel cleansing program prior to beginning a course of nutritional supplementation.
If high doses are being taken, the supplements should not be taken all at one time, but
divided into smaller doses taken throughout the day.
Digestive enzymes can be taken with meals to assist digestion. Pancreatic enzymes taken
for other therapeutic reasons should be taken on an empty stomach between meals.
Mineral supplements should be taken separate from the highest fiber meals of the day,
as fiber can decrease mineral absorption.
Whenever an increased dosage of an isolated B vitamin is taken, be sure there is also
supplementation with a B-complex.
When nutrients are taken, an adequate amount of liquid must be taken to mix with
digestive juices and prevent side effects.
Nutritional supplements should never take the place of proper dietary habits or appro-
priate medical care when warranted.
Prolonged intake of excessive doses of vitamins A, D, and B6, for example, may produce
toxic effects.
Additives have been suspected as possible cancer causing agents. Therefore, as Kahn and
Saulo (1994) suggest, advise clients to stay away from any food containing artificial sweeten-
ers, artificial coloring, flavor enhancers, or sodium nitrite or nitrate.
BASIC DIETS TO AFFECT DISEASE PROCESSES AND WEIGHT LOSS

A number of therapeutic diets have been developed to help to prevent or treat various dis-
eases, or to promote weight loss. In general, there is evidence that regardless of macronutri-
ent composition, diets that reduce caloric intake result in weight loss (Freedman et al., 2001).
The moderate-fat balanced nutrient reduction diet is optimal for ensuring adequate nutri-
tional intake, while low-fat, low-calorie diets are most effective for maintenance of weight
loss (Freedman et al., 2001). Participation in a therapeutic dietary regimen should be super-
vised by a health professional. A few selected examples of well-known therapeutic diets
(Block, 1999) are discussed in the next section.
High-Fiber, High-Carbohydrate, Low-Fat Diets

The Macrobiotic Diet
The so-called standard macrobiotic diet consists of 50% to 60% whole grains, 20% to
25% vegetables, 5% to 10% beans and sea vegetables (typically combined), and 5% veg-
etable soups. Other foods such as nuts and seeds, fruits, and fish are consumed on an occa-
sional basis. Red meat, dairy, sugar, and raw fruits are generally avoided. Each persons dietary
needs vary according to level of activity, gender, age, climate, season, and various individual
factors.
The Pritikin Diet
The Pritikin program is a low-fat, low-cholesterol, low-sodium, and high-complex-carbo-
hydrate diet (5% to 10% fat, 10% to 15% protein, and 80% carbohydrate) combined with
regular aerobic exercise. The diet is similar to the macrobiotic diet, but with more rigid
emphasis on restricting fat intake, as well as the inclusion of low-fat dairy products and greater
variety in choices of animal products. Protein consumption is limited to 3.5 ounces of lean
meat a day to reduce total fat and cholesterol intake.
Ayurvedic Diet
The Ayurvedic system is primarily vegetarian, although meat may be prescribed for certain
doshas (e.g., one with a predominance of vata). There are limited published reports of the
therapeutic effects of Ayurvedic dietary practices per se.
The Ornish Diet
Developed to reverse the development of atherosclerosis and coronary heart disease, this
diet is very similar to the Pritikin diet. In terms of total calories, the diet is 10% to 12% fat,
70% to 75% carbohydrates, and 15% to 20% protein. Egg whites, nonfat yogurt, and skim
milk are allowed as sources of complementary proteins. Ornish emphasizes the importance of
gentle exercises, such as yoga and walking, and of relaxation and visualization techniques to
help relieve the body of stress and tension.
Evidence indicates that overweight subjects eat fewer calories, lose weight, and lose body
fat related to decreased fat and energy intake, increased energy expenditure, or both. How-
ever, the diet is low in vitamins E, B12, and zinc, and the diet often lowers HDL cholesterol
in addition to LDL cholesterol (Freedman et al., 2001).
The Gerson Diet
This vegetarian diet consists mainly of raw vegetables and fruit juices, raw calf liver
juice (now largely discontinued because of the chemical residues found in calves), and
coffee enemas to stimulate bile elimination. The program initially includes a period of
juice fasting and enemas, after which patients are placed on a low-sodium, high-
potassium diet.
High-Protein, Low-Carbohydrate Diet

The Atkins Diet
There are four stages to the Atkins diet, including the fortnight induction diet, the ongo-
ing weight loss diet, premaintenance, and maintenance. The diet emphasizes the consump-
tion of nutrient-dense, unprocessed foods, avoidance of processed or refined carbohydrate
foods, and use of a full-spectrum multivitamin and an essential fatty acid nutrient supplement.
Supplementation is necessary because the basic diet is nutritionally inadequate, providing
lower than recommended intakes of vitamins E, A, thiamin, B6, and folate, and calcium, mag-
nesium, iron, zinc, potassium, and dietary fiber (Freedman et al., 2001). The diet is high in
saturated fat, cholesterol, and animal protein.
Moderate-Fat, Balanced Nutrient Reduction Diets

Moderate-fat, balanced nutrient reduction diets contain 20% to 30% fat, 15% to 20% pro-
tein, and 55% to 60% carbohydrates. Popular diets include commercial weight loss centers
such as Weight Watchers, Jenny Craig, and Nutri-Systems, and diets based on the USDA food
guide pyramid if calories are reduced. The underlying philosophy of these diets is that weight
loss occurs when the body is in negative energy balance. Diets are calculated to provide a
deficit of between 500 to 1,000 kcal/day, but a minimum of 1,000 to 1,200 daily calories for
women and 1,200 to 1,400 daily calories for men are recommended. Increased energy expen-
diture through physical activity is also promoted. The goal is to provide a wide range of food
choices, allowing for nutritional adequacy and compliance, while still resulting in a slow but
steady rate of weight loss (e.g., 1 to 2 lbs/week). Evidence indicates that low-calorie diets
(1,000 to 1,200 kcal/day) can reduce total body weight by an average of 8% over 3 to 12
months (Freedman et al., 2001).
Strategies to Promote Healthy Nutrition

According to the American Dietetic Association, health promotion activities include
personal, environmental, organizational, community, policy, and social change interventions
that facilitate changing societal and personal behavior to reduce risks to health (Anderson
et al., 1998, p. 205). Behavior change needs to be viewed in the context of social, economic,
and cultural considerations, and not as an isolated task controlled by an individual.
One categorization of behavior change strategies based on system level of environmen-
tal intervention uses the analogy of a swiftly flowing river. Approaches that target indi-
viduals and families are downstream, local and community approaches are midstream,
and broad-based societal approaches that focus on modifying economic, political, and
environmental factors are designated as upstream (McKinlay, 1979). In this analogy,
physicians and nurses are so caught up rescuing victims with downstream, short-term indi-
vidual-based interventions that they dont look upstream where the real problems are (to
see who is pushing people into the river). It has been suggested that full-spectrum (down-
stream to upstream) interventions are needed for greatest impact across populations (But-
terfield, 1990; McKinlay, 1979, 1995), a premise that is being supported by increasing
evidence (Orleans et al., 1999). The following section presents selected downstream, mid-
stream, and upstream interventions that can be applied concurrently to promote healthy
nutrition.
INDIVIDUAL AND FAMILY-BASED (DOWNSTREAM) APPROACHES

Case finding (e.g., cholesterol screening), counseling, group education, and mediated
strategies have been effective in reducing dietary fat intake in high-risk persons
(Glanz, 1999).
Therapeutic diets for chronic disease management (e.g., the Ornish diet is effective for
primary prevention of cardiovascular disease).
Minimal-contact interventions such as print guides, tailored messages, and supportive
telephone counseling have been found to be effective in promoting healthy eating
(Glanz, 1999).
Targeting stage of readiness for change with appropriate strategies (see Chapter 8).
Promote lower pricing for low-fat vending machine choices (e.g., fresh fruit).
Encourage walking and bicycling instead of automobile use for transportation.
Reduce calorie-dense foods such as regular milk, sugar-sweetened beverages, high-fat foods.
Strategies to Promote Healthy Nutrition 437
Reduce the time spent snacking and watching commercials promoting unhealthy
food (and limiting energy expenditure through physical activity), particularly for
children.
Modify food preparation to reduce fat or oil in cooking and cream, butter, and high-fat
cheeses in recipes.
Encourage family meals with reduction of eating out at restaurants and fast-food meals.
Away-from-home meals have larger portion sizes (French et al., 2001).
Use nutrition messages that are limited in number, simple, targeted, practical, and
reinforced.
Encourage an interactive process, with client involvement in setting goals and evaluat-
ing the effectiveness of the intervention (Sahyoun, Pratt, & Anderson, 2004).
Goal setting has shown some promise in promoting dietary and physical activity behav-
ior change among adults, but methodological issues still need to be resolved (Shilts,
Horowitz, & Townsend, 2004).
Interventions should use the learners own experience and expertise, be problem-based,
and relevant to the challenges they face (Higgins & Barkley, 2003).
Use practical application of information rather than facts.
The nurse should act as a facilitator rather than a know-it-all.
Encourage physical activity as part of the daily routine (e.g., walking to school, doing
errands with parents, safe outdoor play).
MIDSTREAM APPROACHES
School-based programs including classroom instruction and modifying food service
choices (e.g., vending machines and cafeteria), especially targeted at younger children.
Results have been positive but inconsistent (Glanz, 1999).
Nutrition information programs at point-of-choice (e.g., grocery stores, restaurants).
Worksite nutrition education programs.
Increase physical education classes with individualized fitness goals. Only 15% of
schools require individualized fitness programs (Dietz & Gortmaker, 2001).
Small signs near stairways have been effective in increasing their use instead of escala-
tors or elevators (French et al., 2001).
Increase availability of safe jogging and bike paths.
UPSTREAM APPROACHES
Change reimbursement policy for nutrition counseling.
Point-of-purchase nutrition information (e.g., product labeling). Survey data suggest
that nutrition information labels are used (French et al., 2001).
Dietary guidance, nutrition information, and regulatory strategies. For example, chain
restaurants and hospitals could be required to provide information about fat and calo-
ries of menu choices.
Tax soft drinks, candy, and high-fat, high-sugar snacks to fund subsidies for fruits and
vegetables.
Add more water drinking fountains in public buildings and outdoor areas.
Modify the social, physical, and community (home and neighborhood) environments
that have an influence on how persons make lifestyle decisions (Sahyoun, Pratt, &
Anderson, 2004).
Address the wider issues of who controls the food supply and thus the influences on the
food chain and the food choices of the individual and communities (Caraher &
Coveney, 2004).
Food intake is shaped by a wide variety of geographical, social, psychological, religious,
economic, and political factors. This chapter has emphasized the importance of meaning of
food in shaping dietary intake. An understanding of dietary guidelines and goals, nutrients,
and supplements is essential as the basis for teaching clients about healthy nutrition and ther-
apeutic diets. A variety of strategies can be used at individual, community, and policy levels
to promote healthy nutrition for health and well-being.
Chapter Key Points

An understanding of essential dietary nutrients, phytonutrients, and antioxidants is
essential as the basis for teaching clients about healthy nutrition.
Nutritional supplements should never take the place of proper dietary habits or appro-
priate biomedical care when warranted.
A number of therapeutic diets, including the macrobiotic, Pritkin, Gerson, Ornish,
Atkins, and Ayurvedic diets have been developed to help to prevent or treat various
diseases.
Downstream, midstream, and upstream approaches can be used concurrently to pro-
mote healthy nutrition and dietary habits.
References
Abramowicz, M. (Ed.). (1998). Vitamin supplements. Medical Letters on Drugs and Therapeutics, 40, 75-77.
Anderson, J. V., Palombo, R. D., & Earl, R. (1998). Position of the American Dietetic Association: The role
of nutrition in health promotion and disease prevention programs. Journal of the American Dietetic
Association, 98, 205-208.
Block, K. I. (1999). Nutritional biotherapy. In W. B. Jonas, & J. S. Levin (Eds.), Essentials of complementary
and alternative medicine. Philadelphia: Lippincott Williams & Wilkins.
References 439
Butterfield, P. G. (1990). Thinking upstream: Nurturing a conceptual understanding of the societal context
of health behavior. Advances in Nursing Science, 12, 1-8.
Caraher, M., & Coveney, J. (2004). Public health nutrition and food policy. Public Health Nutrition, 7, 591-598.
Clark, C. C. (1996). Wellness practitioner (2nd ed.). New York: Springer.
Dietz, W. H., & Gortmaker, S. L. (2001). Preventing obesity in children and adolescents. Annual Review of
Public Health, 22, 337-353.
Fieldhouse, P. (1995). Food and nutrition: Customs and culture (2nd ed., pp. 1-49, 165-205). London: Chap-
man & Hall.
Fillmore, C., Bartoli, L., Bach, R., & Park, Y. (1999). Nutrition and dietary supplements. Physical Medicine
and Rehabilitation Clinics of North America, 10, 673-703.
Freedman, M. R., King, J., & Kennedy, E. (2001). Popular diets: A scientific review. Obesity Research,
9(Suppl 1), 1S-40S.
French, S. A., Story, M., & Jeffery, R. W. (2001). Environmental influences on eating and physical activ-
ity. Annual Review of Public Health, 22, 309-335.
Fuchs, N. K. (1993). Calcium controversy. Womens Health Letter.
Gaby, A. R., & Wright, J. V. (1988). Nutrients and bone health (pp. 1-4). Baltimore, MD: Wright/Gaby
Nutrition Institute.
Glanz, K. (1999). Progress in dietary behavior change. American Journal of Health Promotion, 14, 112-117.
Harvard Womens Health Watch. (January, 2000). Phytoestrogens (pp. 4-5). Boston: Harvard Health
Publications.
Helman, C. G. (1994). Culture, health, and illness (3rd ed.). Oxford, UK: Butterworth-Heinemann.
Higgins, M. M., & Barkley, M. C. (2003). Concepts, theories, and design components for nutrition educa-
tion programs aimed at older adults. Journal of Nutrition for the Elderly, 23, 57-75.
Hyman, M. (2004). Paradigm shift: The end of normal science in medicine. Understanding function in
nutrition, health, and disease. Alternative Therapies in Health and Medicine, 10, 10-15, 91-94
Kahn, S., & Saulo, M. (1994). Healing. A nurses guide to self-care and renewal. Albany, NY: Delmar.
Kava, R. (1996). The benefits of vitamin supplements are unproven. In S. Barbour & K. L. Swisher (Eds.),
Health and fitness: Opposing viewpoints (pp. 44-52). San Diego: Greenhaven Press.
Keegan, L. (1996). Healing nutrition. Albany, NY: Delmar.
Kroll, D. (1995). Vitamin D: The easy-to-get vitamin. Alternative and Complementary Therapies, 1, 172-176.
Kubena, K. S., & McMurray, D. N. (1996). Nutrition and the immune system: A review of nutrient-nutri-
ent interactions. Journal of the American Dietetic Association, 96, 1156-1164.
Kumanyika, S. K. (2001). Minisymposium on obesity: Overview and some strategic considerations. Annual
Review of Public Health, 22, 293-308.
Landis, R. (1997). Herbal defense. New York: Warner Books.
Maslow, A. H. (1970). Motivation and personality (2nd ed.). New York: Harper & Row.
Massey, P. B. (2002). Dietary supplements. In Perlman, A. (Ed.), Complementary and alternative medicine.
The medical clinics of North America. Philadelphia: WB Saunders.
McDowell, B. (1995). Vitamin A and beta carotene: Broad therapeutic applications. Alternative and Com-
plementary Therapies, 1, 67-75.
McKinlay, J. B. (1979). A case for refocussing upstream: The political economy of illness. In E. G. Jaco
(Ed.), Patients, physicians, and illness (3rd ed., pp. 9-25). New York: Free Press.
McKinlay, J. B. (1995). The new public health approach to improving physical activity and autonomy in
older populations. In E. Heikkinen et al. (Eds.), Preparation for aging. New York: Plenum Press.
Megna, J. (1996). Nutrition Quarterly, 1, unpaginated.
Meletis, C. D. (1999). Basic nutrient support for proper immune function. Alternative and Complementary
Murray, M. T. (1996). Encyclopedia of nutritional supplements. Rocklin, CA: Prima.
Nestle, M. (1996). Nutrition. In S. Woolf, R. Lawrence, & S. Jonas (Eds.), Health promotion and disease pre-
vention in clinical practice (pp. 193-216). Baltimore: Williams & Wilkins.
Nichter, M., & Nichter, M. (1991). Hype and weight. Medical Anthropology, 13, 249-284.
Orleans, C. T., Gruman, J., Ulmer, C., Emont, S. L., & Hollendonner, J. K. (1999). Rating our progress in
population health promotion: Report card on six behaviors. American Journal of Health Promotion,
14, 75-82.
Robison, J. I. (1999). Weight, health, and culture: Shifting the paradigm for alternative health care. Alter-
native Health Practitioner, 5, 45-69.
Sahyoun, N. R., Pratt, C. A., & Anderson, A. (2004). Evaluation of nutrition education interventions for
older adults: A proposed framework. Journal of the American Dietetic Association, 104, 58-69.
Schneider, D. (2000). International trends in adolescent nutrition. Social Science and Medicare, 51, 955-967.
Sebastian, L. A. (1997, December). Fat and cholesterol. Nursing Spectrum, 12-14.
Shilts, M. C., Horowitz, M., & Townsend, M. S. (2004). Goal setting as a strategy for dietary and physi-
cal activity behavior change: A review of the literature. American Journal of Health Promotion,
19, 81-93.
U.S. Department of Agriculture. (1995). Nutrition and your health: Dietary guidelines for Americans (4th ed.).
Washington, DC: U.S. Government Printing Office.
U.S. Department of Health and Human Services (2000). Healthy people 2010 (Conference Edition, in two
volumes). Washington, DC: Author.
Visscher, T. L. S., & Seidell, J. C. (2001). The public health impact of obesity. Annual Review of Public
Health, 22, 355-375.
Zimmerman, M. (1995). Phytochemicals and disease prevention. Alternative and Complementary Therapies,
1, 154-157.
Two certifying examinations exist for nutritional therapy. Licensing varies greatly from
state to state. Advanced training in nutrition is available at many universities.
Certification Board for Nutrition Specialists

Hospital for Joint Diseases
301 E. 17th Street
New York, NY 10003
Tel: (212) 777-1037
The Certification Board for Nutrition Specialists provides certification as a Certified

Nutrition Specialist (CNS). Eligibility requires an advanced degree (masters or doctoral
level) from a regionally accredited university program in the field of nutrition, nutritional sci-
ences, or a field allied to nutrition and relevant to the practice of nutrition in a professional
setting.
Clinical Nutrition Certification Board

5200 Keller Springs Road, Suite 410
Dallas, TX 75248
Tel: (972) 250-2829
The Clinical Nutrition Board provides the title of Certified Clinical Nutritionist (CCN). Eli-
gibility requires a bachelors degree or equivalent, plus a 900-hour clinical nutrition internship.
American Dietetic Association

216 West Jackson Boulevard
Chicago, IL 60606
Tel: (312) 899-0040
www.eatright.org
17
RESTORING ENERGY FIELD HARMONY
Energy Patterning
Abstract
Harmonious flow of vital energy is basic to health. Energy healing occurs in the human
energy field surrounding, supporting, and interpenetrating the human body. When energy in
the human energy field is blocked, deficient, or excessive, illness manifests in the body.
Energy healing is a systematic, purposeful intervention aimed to help another person by
means of focused intention, hand contact, and/or aligning with the universal energy field.
Reiki and prayer are examples of modalities that are based on channeling of a spiritual energy
that has innate intelligence or logic, whereas music, color therapy, polarity therapy, thera-
peutic touch, and thought field therapy pattern the vibrations of the environmental energy
field for healing purposes. Additional information about organizational resources and certifi-
cation is presented at the end of the chapter.
Learning Outcomes
By the end of the chapter, the student will be able to:
Perform an instant centering technique
Discuss the 49th vibrational technique for color therapy
Describe the elements of music therapy that can produce therapeutic outcomes
Describe the techniques that comprise polarity therapy
Discuss types of prayer
444 Chapter 17 Restoring Energy Field Harmony: Energy Patterning
Demonstrate hand positions in reiki

Describe the process of therapeutic touch
Discuss the components of thought field therapy
Energy Healing
Energy field therapeutics is also known as the laying on of hands, or energy healing. A field
is described as a domain of influence, presumed to exist in physical reality, that cannot be
observed directly but that is inferred through its effects. For example, we do not actually see
a magnetic field around a bar magnet; but because iron filings arrange themselves in a certain
pattern, we know the field exists (Dossey, 2000, p. 112). The human being is a unitary energy
field that is open to and continuously interacting with an environmental energy field (Leddy,
1998), which in turn continuously interacts with the universal energy field. Self-organiza-
tion distinguishes the human energy field from the environmental field with which it is insep-
arable and intermingles (1998, p. 192). The environment is dynamic, changing through
continuous transformation of universal energy field matter and information (1998).
Energy healing is an integrative therapy defined as a systematic, purposeful intervention
aimed to help another person by means of focused intention, hand contact, and aligning with
the universal energy field (Starn, 1998, pp. 209-210). According to Slater (1997, p. 52),
energy healing occurs at the quantum and electromagnetic levels of a person, plant, or ani-
mal. Energy varies in quantity and quality (vibration), has polarity (yin and yang), and is
arranged in specific patterns. In traditional Chinese medicine, the chi dynamic force of
energy is constantly circulating within the body in 12 well-defined channels called meridians,
which exist as a series of points following line-like patterns.
The American Nursing Diagnosis Association has classified energy field disturbance as a
legitimate nursing diagnosis, defining it as a disruption of the flow of energy surrounding a
persons being which results in disharmony of the body, mind, and/or spirit. Disruptions in
energy occur as blockages, deficiencies, and excesses. In illness, the energy flow is obstructed,
disordered, or depleted. Illness manifests in the human field long before it is obvious in the
body (Starn, 1998). The prevention of disease doesnt so much depend on avoiding
pathogens as cultivating a healthy vital chi energy (Selby, 1997, p. 270). Through augment-
ing his or her own relatively healthy human energy field, the energetic practitioner can,
through resonance and induction, reinforce the overall resonant field of his or her [client]
by identifying diseased resonant patterns of specific organs and harmonizing the energy by
sending health qi [chi] (1997, pp. 274-275). Healing is fundamentally the restoration of
harmony from disharmony (Gaynor, 1999).
Energy healing occurs in the human energy field surrounding, supporting, and interpene-
trating the human body. The human energy field is composed of seven layers, reaching out to
about 3.5 feet beyond the body. The lowest frequency layer, the physical body, contains
meridians that circulate chi and chakras, which transmute higher-frequency energy into a
form useable by the physical body (Gerber, 1988). Radiating from the chakras are nadis, or
channels of electromagnetic energy, that subdivide finally to the cellular level, supporting the
concept that healing can affect the cellular level of the physical body (Starn, 1998). The
specific frequency of a particular chakra may modulate a particular emotion, need, drive,
Energy Healing 445
and/or organ (Slater, 1997, p. 54). (See Chapter 4, Models and Theories for additional dis-
cussion of qi, chakras, and levels of energy fields.)
It is often not necessary for the energy healer to do anything. The person heals him or
herself, with the healer merely acting as a booster to accelerate the clients healing process
(Sharp, 1997). Actual physical touch and exchange of energy are not needed for any of the
energetic healing modalities discussed in this chapter, because of the outward extension from
the body of the field that permeates a physical body. It is assumed that the energy field of the
practitioner and that of the client are in constant interaction, or mutual process (Rogers,
1990, p. 246). The actual mechanism for energy healing could be a bioelectronic wave that
moves between healer and client, initiated by intention or expectation in the therapists men-
tal energy field (Leddy, 2002). The healer may focus human/environment field energy by
placing his or her hands very near, not necessarily touching, the physical body of the person
being treated. Energy field interaction may be experienced as:
A cool breeze
A tingling or prickling feeling
A pulsation
A vibration
Heat or other changes in temperature
An expanding force
Electricity (sensation of light static)
Pressure or magnetism
There are two alternative beliefs about causation in energetic healing (Berman & Larson,
1994). One belief is that the healing force comes from a source other than the practitioner, such
as God, the cosmos, or another supernatural entity. For example, reiki and prayer are based on
channeling of a spiritual energy that has innate intelligence or logic and knows where and to what
extent it is required. A second belief is that a human energy fielddirected, modified, or ampli-
fied in some fashion by the healer is the operative mechanism. For example, music, color therapy,
and therapeutic touch pattern the vibrations of the environmental energy field for healing pur-
poses. As the energy field itself is metaphysical (outside the observable dimensions of space and
time), these causal beliefs are currently testable only through manifestations of the energy field.
The lack of a solid research base is one of the major barriers to the acceptance of energetic
healing modalities. Until recently, few testable hypotheses have been proposed, an adequate
outcomes database has not been available, and accumulation of empirical evidence has not
been systematic. In addition, conceptual confusion and conflicting claims as to causal factors,
best methods, and procedures have obscured the extent of efficacy of modalities. As a result,
many scientists regard energetic healing modalities with disdain.
Despite the lack of empirical evidence, energetic treatment modalities have been used for
many conditions:
Stress relief, improvement of general health and vitality.
Biologic reduction of inflammation, edema, pain, change in hematocrit and T-cell lev-
els, and acceleration of wound healing and fracture repair.
Vegetative functions. Improvement of appetite, digestion, and sleep patterns.

Emotional states. Reduction of anxiety, release of pent-up grief, reduction of recurrent
panic attacks, depression, and improved feelings of self-worth.
Dysfunctions (psychosomatic). Relief of irritable bowel syndrome, premenstrual syn-
drome, post-traumatic stress disorder, migraine, anorexia and bulimia, nonbiological
sexual dysfunction, drug, alcohol, and codependence recovery.
Pain. Reduction of acute and chronic pain, reduction of the pain of thermal burns and
acceleration of healing time, reduction of sunburn pain and coloration.
CENTERING
Essential to energetic healing is the protection and balancing of the healers energy field.
One way that this is accomplished is through the process of centering. Krieger (1986) defines
centering as a sense of self-relatedness that can be thought of as a place of inner being where
one can feel truly integrated, unified, and focused. Slater (1997, p. 57) suggests that cen-
tering may be the act of altering ones electromagnetic characteristics through a type of self-
referencing meditative-type biofeedback. The nurse should be sure to center the energy field
before performing any type of energetic healing modality.
An instant centering technique is the following:
1. Sit comfortably, but in postural alignment.

2. Relax. Check possible tension spots and relax those areas. If there is tension in the neck
or shoulder muscles, strongly push your shoulders down so that they are not hunched
upward toward your neck.
3. Inhale deeply and gently.
4. Slowly exhale.
5. Inhale again.
Another technique is to stand or sit, with the feet firmly planted flat on the floor. Relax and
imagine a line going through the center of your body to connect you to the earth below and
the universe above. Inhale and exhale deeply and slowly a few times as you visualize the line.
Energy Healing Modalities

COLOR THERAPY (CHROMATHERAPY)
All of the cells in the body vibrate (Gerber, 1988). Color therapy is based on the concept
that a chemical imbalance, a state of disease, and an inappropriate energy vibration in the
body are all synonymous. Color deals effectively with disease because it treats the bodys
etheric field, and the physical, psychological, and spiritual planes or levels are all connected
by the mind for an integrated understanding (Klotsche, 1993).
Energy Healing Modalities 447
Vibrating colors generate electrical impulses and magnetic currents or fields of energy.
Light or color rays are characterized by their specific wavelength (i.e., measurement in space)
and frequency (measurement in time). As the rays accelerate (raise their speed or frequency),
the wavelengths are shortened. Each color has its own wavelength, which can be attuned to
the other colors (or vibrations) to alter a function or balance the system. Particular vibrations
raise, lower, or neutralize energy levels. Specific arrays of vibrations are harmonizing, neu-
tralizing, or distorting to each other. In every organ, there is an energetic level at which the
organ best functions (Klotsche, 1993).
The colors visible to our eyes are those that are reflected away from an object. Color ther-
apy utilizes different characteristics of the colors: red for its stimulating effects; blue for its
sedating effects; and green for its ability to balance. Food colors have the same vibrational
effect on our bodies as light therapy, but to a lesser degree. Color also affects the functioning
of each system or organ in the body. Thus, color therapy can heal not only the energy body
(aura/emotions) by the energy properties of colors, but also the physical body by the colors
chemical properties (Klotsche, 1993). Our bodies are made up of chemical elements consist-
ing of a certain balance of color waves or vibrations. A specific disease thus constitutes a spe-
cific imbalance of color waves.
Klotsche (1993) describes a specific color therapy program he calls the 49th vibrational
technique. The colors used in the system vibrate in the visible spectrum (the 49th octave)
between 397 trillion (red) and 665 trillion (violet) times per second. According to the
49th vibrational technique, the warm colors of the spectrum (red, yellow, orange, and
lemon) are stimulating and detoxifying. They are, as a rule, not to be used with fevers or
inflammations:
Red, a primary color, is located at one end (the infrared) of the visible spectrum. Red,
which has a connotation of heat or fire, is a stimulant, and when used properly activates
all five senses, the sensory nervous system, and the liver, as well as the generation of red
blood platelets and hemoglobin. Red vibrates at 436 trillion times per second.
Orange is next to red moving toward the center of the visible spectrum. Orange boosts
the energy in the lungs and stomach, even assisting vomiting if necessary. It raises the
pulse rate but not the blood pressure. This color also stimulates the thyroid and the
growth of bone, producing life energy that then radiates throughout the entire body.
Orange vibrates at 473 trillion times per second.
Yellow, the third color from the infrared end, is a vibrational combination of red and
green. This secondary color is a stimulant for the sensory and motor nervous systems.
Yellow tones the muscles, activates the lymph glands (which in turn cleanse the blood)
and improves the digestive system, stimulating the intestines, pancreas, and digestive
fluids. Yellow, the color of the mind or intellect, can raise low-energy emotional states
(depression, apathy, discouragement). Yellow vibrates at 510 trillion times per second.
Lemon is a combination of yellow and green. It stimulates the colon like a mind laxa-
tive and activates the thymus gland, an important organ in the immune system. It is a
bone builder and an excellent detoxifier of harsh chemicals. It dissolves blood clots
often within hours, rejuvenates the body, and stimulates the brain. Lemon vibrates at
547 trillion times per second (Klotsche, 1993).
Green is the master color, the middle of the spectrum. This balancing color builds cells
and tissues, and is the stabilizing color for all dysfunctions, whether chronic or acute.
Green relieves tension and regulates the etheric body. Green vibrates at 584 trillion
times per second.
On the other side of the spectrum toward the ultraviolet end are the colors turquoise, blue,
indigo, and violet. They relieve fevers and soothe many types of pains:
Turquoise (a combination of blue and green) is the opposite of the color lemon. It reju-
venates the skin and is useful for the repair and nourishment of cells in acute disorders.
When used with green or blue, it is extremely effective for healing infections, burns,
and wounds. Turquoise is cerebrally calming and is an effective vibration for sound
sleep. It vibrates at 621 trillion times per second.
Blue increases the elimination of toxins through perspiration, stimulates intuitive pow-
ers and is a vitality builder. Blue activates the pineal gland; it is the color of the spirit.
Blue vibrates at 658 trillion times per second.
Indigo is a cooling color that activates the parathyroid and calms the thyroid. It controls
abscesses and relieves or eliminates discharges and bleeding. It also calms the respira-
tory system, reduces swelling, and has an anesthetic effect. Indigo can improve ones
emotional state by its sedative effect, and it has a generally calming, inward-turning
energy vibration. It also has contractive characteristics whereby it can firm, tone, and
tighten up the flesh and arrest or shrink tumors, swellings, and unhealthy growths.
Indigo vibrates at 695 trillion times per second.
Violet has the shortest wavelength of the visible colors. It has the capability to control
hunger (and thus weight) through calming the metabolic process. It relaxes muscles and
has antibiotic characteristics. Calming the nerves, it is an aid to meditation and sleep.
Violet may act as a pain reliever after first trying indigo. Violet vibrates at 731 trillion
times per second.
In addition to these nine warm, neutral, and cool colors, there are three more colors in the
visible spectrum that further fine-tune the energy for specific healing purposes, especially
heart, kidney, and circulatory functions. These three additional colors are magenta, purple,
and scarlet:
Purple (a combination of violet and yellow) calms the emotions as well as the activity
in the arteries. It stimulates activity in the veins and relieves headaches and excessive
pain from pressure by decreasing sensitivity. It lowers blood pressure and induces sleep.
Purple can eliminate recurrent high fevers associated with such diseases as malaria and
rheumatic fever. Purple vibrates at 621 trillion times per second.
Magenta (a combination of red and violet) balances the emotions. It levels blood pres-
sure, automatically raising or lowering it to normal. Magenta stimulates and nourishes
the kidneys, the adrenals, the heart and the circulatory system. It is also an aura builder
and is similar to green in that it can be used for most energy disorders. It vibrates at 584
trillion times per second.
Scarlet (a combination of red and blue) speeds up the heartbeat, stimulates the arteries,
and sedates the activity of the veins (the reverse of purple). Scarlet is a general stimu-
lant. It is the strongest of the twelve healing colors and needs to be used with utmost
care. Scarlet vibrates at 547 trillion times per second.
Ten of the 12 healing colors have a complementary color or vibration that is used to bal-
ance or counterbalance their vibratory effects. It is important, in some cases, to use the exact
complementary color for this purpose. The 49th vibrational technique generally establishes a
rule of seven: For every six uses of predominantly one color, a color of the opposite side of the
spectrum should be used once for balance. The main color for counterbalancing the warm col-
ors is turquoise; lemon counterbalances the cool colors. There is a lack of scientific evidence
of the effectiveness of color therapy. The 49th vibrational technique for color therapy
(Klotsche, 1993) is presented in Box 17-1.
B OX 17-1
The 49th Vibrational Technique
for Color Therapy
Uses plastic color transparencies (filters or gels). The transparencies are
assembled, using tape or staples, with specific combinations of 10 col-
ored sheets. Klotsche (1993, p. 101) specifies that only Roscolene and no
other gels should be used.
A heat shield is placed between the light source and the filters.
Any incandescent lamp (60 to 100 watt) with a single opening for the light
can be used.
The room should be quiet, totally dark, and at 80 degrees.
The client should not eat or bathe at least 1 hour before or after a tona-
tion.
The tonation is applied for 1 hour on the bare skin.
The individual must be as relaxed as possible for optimal absorption of the
colored rays by the aura. The eyes may be closed or open at the individ-
uals option. One can meditate, relax, or sleep.
continued
B OX 17-1 CONTINUED
The technique is most effective when the individual lies on his or her back
or side with the crown of the head toward magnetic north. If for any rea-
son it is undesirable to lie down for the color treatment, an alternative
approach is to sit facing south during the treatment (back of the head
toward north), to keep the bodys polarity in alignment with the earths
magnetic field.
The lamp should be a meter (or yard) or more above and behind the feet
or, alternatively, above or beside the body.
Tonation time is ideally 1 hour. One should wait at least 1 hour (2 is pre-
ferred) after one tonation before staring a second one.
Light therapy should be used in combination with an appropriate diet.
Source: Adapted from Klotsche, C. (1993). Color medicine. Sedona, AZ: Light Technology.
Color therapy can be learned by careful study with an instructional guide and experience
with a clinician using this modality. There is no national certification for this modality. The
author is not aware of any organized courses. Another energy field modality that is based on
vibration theory is music therapy.
MUSIC THERAPY
When music is used for therapeutic purposes it is termed music therapy. Music therapy has
been defined as a behavioral science concerned with the systematic application of music to
produce relaxation and desired changes in emotions, behavior, and physiology (Guzzetta,
1997). Music therapy may include therapies designed to increase ones social, physical, or
mental well-being via such methods as songwriting or lyric analysis, expression of feeling
through music, or relaxation through listening to music (Harding, 1999).
Music therapy is based on the physics and physiology of sound. The earth vibrates at a fre-
quency of 8 cycles per second. The body acts as a vibratory transformer that gives off and takes
in sound, at an inaudible frequency of approximately 8 cycles per second when it is in a
relaxed state. During relaxed meditation, the frequency of brainwaves produced is also about
8 cycles per second (Brewer, 1998). Every human cell has its own frequency, and the fre-
quency of every human organ may be a harmonic of its component cells (Gaynor, 1999).
Results with sound are not a function of volume (amplitude, or quantity) but pitch (fre-
quency, quality). The sound waves of vibration are measured in frequencies according to how
many waves are formed per second, and these units are called hertz (Hz). Human hearing nor-
mally exists within a range of 16,000 to 25,000 Hz, although many people cannot hear sound
above 10,000 Hz (Harding, 1999).
Sound is defined as oscillating energy waves within the audible range. The ear is not only
the primary organ of hearing (the passive ability to perceive sound), but also has powerful
influences on eye movement, the rhythms of the physical body, prebirth brain growth, and
general regulation of stress levels in the body. People respond to sound vibrations in two main
ways: via rhythm entrainment and resonance (Burton Goldberg Group, 1995).
1. Entrainment. There is a tendency in the universe toward harmony, a phenomenon

known as entrainment. This is a process whereby two objects vibrating at similar fre-
quencies will tend to cause mutual sympathetic resonance. Part of what promotes
healing in a therapy situation is the entrainment that occurs between therapist and
client.
2. Resonance. The ability of a vibration to set off a similar vibration in another body. It
is vibrational language that helps the body-mind attune itself with its own resonance
(Brewer, 1998, p. 11). Different frequencies of sound (different pitches) stimulate the
body to vibrate in different areas.
As the human body vibrates, some sounds assault the body because they are not in har-
mony with its fundamental vibratory pattern. . . . Musical vibrations can help restore regula-
tory function to a body out of tune (e.g., during times of stress) and help maintain and
enhance regulatory function of a body in tune (Guzzetta, 1997, p. 197).
When considering the use of music as an intervention, there are several things to keep
in mind. The type of music and personal preferences of the client are critical. Other choices
include active versus passive involvement (listening via cassette tape or compact disc), use
in a group or on an individual basis, and length of time to use music. An argument can be
made for group therapy as a way to foster social interaction in the elderly and in persons
with psychiatric disorders. However, diversity in the preferences of individuals in a group or
the lack of an appropriate site for a group session may necessitate implementing music on
an individual basis (Chlan, 1998). Left and right ears may have different thresholds in dif-
ferent frequency ranges (Campbell, 2001). There are cultural differences in music prefer-
ence (Good et al., 2000). A minimum of 20 minutes is probably necessary to induce
relaxation, with some form of relaxation exercise, like deep breathing, before initiating the
music intervention.
Music is most commonly used as a relaxation technique, utilizing a pleasant stimulus to
block out sensations of anxiety, fear, and tension, and to divert attention from unpleasant
thoughts. Guzzetta (1997) suggests that the healing capabilities of music are intimately
related to the personal experience of inner relaxation. Music that contains many changes of
mood and tempo can stimulate the listener, whereas music that stays on a steady and pre-
dictable course can be used as a sedative (Harding, 1999).
Four necessary elements have been suggested for promoting relaxation: a quiet envi-
ronment, a comfortable position, a passive attitude, and focused concentration on the
music (Chlan, 1998). Slow-moving music lengthens our perception of time because our
memory has more time to experience the events (tensions and resolutions) and the spaces
between the events. So, the time clock becomes distorted and clients can actually lose
track of time for extended periods, enabling them to reduce anxiety, fear, and pain
(Brewer, 1998, p. 10).
As illness is viewed as a manifestation of disharmony within the body, healing can be

achieved by restoring the normal vibratory frequency of the disharmonious (Gaynor, 1999)
through music therapy. Music therapy evokes psychophysiologic responses because of its
influence on the limbic system. This system is influenced by musical pitch and rhythm,
which, in turn, affect emotions and feelings. Our emotional reaction to music may occur
because the limbic system is the seat of emotions, feelings, and sensations (Brewer, 1998,
p. 10). By enhancing melatonin release via pineal gland stimulation, music may unlock and
restore the expression of emotional connections with our deeper self, whether in a state of
health or disease (Kumar et al., 1999, p. 56).
The elements of music that can influence therapeutic outcomes (Chlan, 1998) are pre-
sented in Box 17-2.
B OX 17-2
Elements of Music That Can Affect
Therapeutic Outcomes
Pitch. Produced by the number of sound vibrations per second. Rapid
vibrations (high-pitched sounds) tend to act as a stimulant, whereas slow
vibrations bring about relaxation.
Intensity. Refers to the volume of the sound. It is related to the amplitude
of the vibrations. Intensity can be used to produce effects such as intimacy
(soft music), protection (loud music), and power. Emotions are affected by
the intensity of the music.
Tone color (or timbre). A nonrhythmical, purely sensuous property that
results from the harmony present or the characteristics of a voice or instru-
ment.
Interval. The distance between two notes. It is related to pitch. The
sequence of intervals results in the melody and harmony of a piece.
Duration. Refers to the length of sounds.
Rhythm. A time pattern fitted into a certain speed. Musical tempos may be
used to harmonize, synchronize, or entrain the physiological state. The
pitch and rhythm of music affect the limbic system, which is integrally
involved in emotions and feelings.
Source: Adapted from Chlan, L. (1998). Music therapy. In M. Snyder & R. Lindquist (Eds.), Comple-
mentary/alternative therapies in nursing (3rd ed., pp. 243-257). New York: Springer.
Harding (1999) discusses the idea of patterning alpha and theta brainwaves through
entrainment via rhythm and sound (e.g., drumming). An alpha-level drum frequency (7 to
13 cycles per second sustained for at least 13 to 15 minutes) stimulates an alpha-wave cycle
in the brain. High alpha states are associated with meditation and holistic modes of con-
sciousness (1999, p. 88). Another apparent benefit from drumming is a higher state of brain
hemispheric synchronicity, in which both hemispheres cooperate in harmonic resolution.
Bittman and colleagues (2001) found that group drumming altered stress-related hormones
and enhanced immunologic measures associated with natural killer-cell activity and cell-
mediated immunity.
In music therapy, it is essential to choose the appropriate music for the desired response.
Gaynor (1999) suggests a number of categories and specific music selections from which to
choose depending on the purpose for the therapy.
Chlan (1998) suggests several basic steps for utilizing music intervention to promote relaxation:
1. Ascertain the client has adequate hearing
2. Ascertain the clients like or dislike for music
3. Assess music preferences and previous experience with music for relaxation; assist with
tape selection as needed
4. Determine mutually agreed upon goals for music intervention with the client
5. Complete all nursing care prior to the intervention; allow at least 20 minutes of unin-
terrupted listening time
6. Gather equipment and ensure it is in good working order. Provide the client a choice
of soothing selections for relaxation
7. Assist the client to a comfortable position as needed; ensure call-light is within
easy reach
8. Assist the client with equipment as needed
9. Enhance environment to suit the client (draw blinds, close door, turn off overhead
lights, etc.)
10. Post a do not disturb sign to minimize unnecessary interruptions
11. Encourage and provide the client with opportunities to practice relaxation with music
The goal of music therapy is the reduction of psychophysiological stress, pain, and anxiety
(Brewer, 1998). The rhythmicity, melody, and harmony of music are often effective in alleviating
emotional conflict (1998). There are many desired outcomes of music therapy (Chlan, 1998;
Guzzetta, 1997; Kumar et al., 1999), including minimizing disruptive behaviors; decreasing anxi-
ety; managing pain; reducing stress; relaxing; stimulation; decreasing isolation; developing self-
awareness and creativity; improving learning; clarifying personal values; improving alertness,
recall memory, and motor and verbal skills (in clients with Alzheimers disease); coping with a
variety of psychophysiologic dysfunctions; and coping with dying. Music therapy for people with
Alzheimers disease can promote interactions with other patients, foster communication with
caregivers, and may enhance retention and recall, and effectively manage behavior problems,
reducing the need for restraints or medications (Brotons et al., 1997).
Box 17-3 presents a music therapy study abstract.
B OX 17-3
Music Therapy Study
Twenty male inpatients with Alzheimers disease received 30 to 40 minute morn-
ing sessions of music therapy five times per week for 4 weeks. Blood samples were
obtained before initiating the therapy, immediately at the end of 4 weeks of music
therapy sessions, and at 6 weeks follow-up after cessation of the sessions. Mela-
tonin concentration in serum increased significantly after music therapy and was
found to increase further at 6 weeks follow-up. The authors concluded that
increased levels of melatonin following music therapy may have contributed to
patients relaxed and calm mood.
Source: Adapted from Kumar, A. M., Tims, F., Cruess, D. G., Mintzer, M. J., Ironson, G., Loewenstein,
et al. (1999). Music therapy increases serum melatonin levels in patients with Alzheimers disease.
Alternative Therapies in Health and Medicine, 5(6), 49-57.
Although music therapy is generally safe and effective, there may be a lack of effectiveness
after 3 minutes of continuous exposure (due to neural adaptation), music may increase
intracranial pressure following head injury, and decibels (volume) higher than 90 dB can
cause discomfort (Chlan, 1998).
Like color therapy, music therapy lacks organized instructional courses, as well as national
certification. The modality is best learned through careful study of instructional guides and
experimental study with practitioners using this modality. In contrast, practice of the inte-
grated therapeutic system called polarity therapy, requires extensive organized study and certi-
fication by the American Polarity Therapy Association.
POLARITY THERAPY
Polarity therapy was developed in the mid 1900s by Randolph Stone, a chiropractor, natur-
opath, and osteopathic physician. According to Polarity Therapy, the process of life, or becom-
ing as the Buddhists would say, is a flow of energy. However, physical form is better visualized as
pulsations of light in specific patterns, rather than as moving energy in channels. For any energy
to arise or for physical form to come into being, there must be movement. Movement of energy
is based on or due to a relationship (polarity) that sets up two opposing fields. Yang is the posi-
tive, outgoing pole, and yin is the negative, receptive pole. According to polarity theory, energy
flows via a positive outward movement from a neutral source, through a neutral field, to some
form of completion. It is then drawn back to the source by a negative, receptive pull (Sills, 1989,
p. 11). The bonding, balancing force between and within all forms of energy and matter is clearly
the polarity of positive and negative (Klotsche, 1993, p. 29).
An energy anatomy that precedes and creates physical anatomy exists in several layers.
Polarity theory predicts that the relative freedom and balance of the energetic and physical
movement patterns in mental, emotional, and physical fields create differences between
health and disease. The free flow of energy is needed for health. When energy is not moving
in a fluid and balanced way, vitality is low.
Polarity therapy supports the healing process by promoting cleansing, building, and ton-
ing, on physical and energetic levels (Olsen, 1990). Polarity balances subtle or electromag-
netic energy through:
Touch or working with polarity trigger points.

Stretching exercises called polarity yoga or polar energetics that give clients tools to use to
work with their physical contractions and patterns without a dependency on the clinician.
An approach to eating and nutrition based on the disciplines principles. Cleansing and
health-building diets not only help to clean the body of toxicity and waste products but
also promote an exploration of relationships to food and nourishment. Knowledge of both
the cleansing and energetic properties of food are used as therapeutic tools (Sills, 1989).
Attitude or mental-emotional balancing (Olsen, 1990).
The main focus of much of polarity work is bodywork. Polarity therapy does not manipu-
late muscles or bones but works through the bodys own energy system by placing hands on
the bodys energy centers and poles to redirect the flow (Olsen, 1990). In the bodywork, the
imbalances are literally touched on, with the clinicians hands used to reflect patterns back for
client awareness. The clinician is not only a guide, but a facilitator (Sills, 1989). The purpose of
polarity manipulation is to locate blocked energy and release it. When energy is blocked, it man-
ifests itself as soreness, tenderness, or pain (Sharp, 1997). When energy is released, healing can
take place naturally, and organs and systems can regain normal function.
All this focus on body energy needs the support of positive thinking. . . . Thoughts are
vibrations of energy that move faster than light or sound. Thoughts and emotions as vibra-
tions affect the flow of energy in the body (Olsen, 1990, p. 240). See Chapter 4, Models and
Theories, for a discussion of energy anatomy.
The techniques of polarity therapy are very simple and gentle. They involve simple touching
using bipolar contacts (use of two contacts on the patients body simultaneously). For example,
a positive contact (right hand or firemiddlefinger) pushes energy and is stimulating while
a negative contact (left hand or airsecondfinger) is relaxing and receives energy. These
contacts balance the chakras to each other and the energy flowing through the longitudinal and
horizontal energy currents. Once the appropriate contacts have been made, the clinician should
concentrate on feeling energy, which is usually experienced as a tingling or warmth between the
hands and the clients body. After stimulating for a couple of minutes, the nurse should hold and
feel the energy for 30 to 60 seconds and then move to another manipulation. If after 2 minutes
energy is not felt, the nurse should hold for another minute and then move on (Sharp, 1997).
The treatment session is concluded by chakra balancing to produce overall relaxation and
facilitate deep energy flow. The chakra balance is performed by placing the client supine, with
the clinician standing on the right side of the body. With loose fists the right thumb is used
to touch the umbilicus and the left thumb to touch between the eyebrows. When these posi-
tions are held for 2 minutes, the energy flow through the body can be felt (Sharp, 1997).
Polarity therapy includes multiple hands-on techniques including manipulation of pressure
points and joints, massage, breathing techniques, hydrotherapy, exercise, reflexology, and even
simply holding pressure points (acupressure) on the body. These techniques, combined with
dietary and nutritional counseling, as well as the emotional balancing work that is also part of
polarity therapy, help clients achieve a heightened level of well-being. In addition to an enhanced
sense of well-being, the benefits of polarity therapy can include improvement in physical health,
increased energy, and a deeper understanding of oneself (Burton Goldberg Group, 1995).
Box 17-4 presents a polarity therapy study abstract.
B OX 17-4
Polarity Therapy Study
In order to assess the fluctuation (but not the effectiveness) of extremely high-frequency
electromagnetic fields, or gamma rays, during polarity therapy treatment, 30 volunteers
were divided among 10 treatment and 20 control (10 sham and 10 standing-observer)
subjects. Marked decreases in gamma counts were found at every anatomical site loca-
tion for all subjects during polarity therapy, with less change noted during the standing-
observer and sham sessions. Gamma radiation decreased in 100% of subjects during
therapy sessions. The authors strongly recommend the collection of additional data,
especially on subjects with cancer, whose long-term survival might be enhanced as a
result of the radiation hormesis effects of alternative energy therapies.
Source: Adapted from Benford, M. S., Talnagi, J., Doss, S., Boosey, S., & Arnold, L. E. (1999). Gamma
radiation fluctuations during alternative healing therapy. Alternative Therapies in Health and Medicine,
5(4), 51-56.
PRAYER
Prayer has been described as a form of distant healing through the act of communing with
God, the divine, the supernatural, or the universal mind. Sicher and colleagues defined dis-
tance healing as a conscious, dedicated act of mentation attempting to benefit another per-
sons physical and emotional well-being at a distance (cited in Koopman & Blasband, 2002,
p. 100). The essence of prayer is faith (Thomson, 1997, p. 95).
There are basically two kinds of prayer: meditative/worshipful and supplicative. In the for-
mer, one prays for faith, understanding, and a state of grace. Examples include prayers of
thanksgiving, adoration, confession, lamentation, contemplation, and surrender, in which
nothing is asked and any outcome is accepted. Supplicative prayer, by contrast, is the more
selfish version, in which one prays for rain, to pass an examination, to recover from an illness
(or, less selfishly, for someone else to recover from an illness). The result prayed for is direct
divine interventiona miracle (Thomson, 1997). Examples of supplicative prayer include:
1. Petition. Individuals ask for something for themselves, generating a mental request for a
particular outcome of Gods will.
2. Intercession. Individuals ask for help for another person. Intercessory is derived from the
Latin inter, between, and cedere, meaning to go. Intercessory prayer is therefore a go-
betweenan effort to mediate on behalf of, or plead the case of, someone else. Inter-
cessory prayer is often called distant prayer, because the individual being prayed for is
often remote from the person who is praying (Dossey, 2000).
Feelings that are central to prayer include love, empathy, compassion, and a sense of con-
nectedness, oneness, and unity with the object that the client is attempting to influence
(Dossey, 1997). The key issue in understanding distant healing is the separation of the distant
effect from effects that may be due to other causes. Factors such as hope, expectation, or relax-
ation can influence or bias results if they are not controlled. It is possible that so-called psy-
chic healing effects may in fact represent a synergistic effect of distant healing intention and
the nonparanormal, psychological benefit of the presence or knowledge of the attention of a
caring person (Targ, 1997, pp. 74, 77).
Distant mental intentions require a model of consciousness that recognizes a nonlocal
quality of mind, in which consciousness cannot be completely localized or confined to spe-
cific points in space (such as brains or bodies), or to discrete points in time (such as the pres-
ent moment). Quantum-scale events share three salient characteristics: they are said to be
immediate (i.e., they occur simultaneously), they are unmediated (i.e., they do not depend on
any known form of energy for their transmission), and they are unmitigated (i.e., their
strength does not diminish with increasing spatial separation). Distant, intercessory prayer
bears a strong resemblance to these events (Dossey, 1997, pp. 116-117).
Dossey (1997, p. 118) states that there are a sufficient number of well-designed, well-exe-
cuted studies demonstrating statistically significant effects to support an assertion that healing
is a potent intervention. . . . Our major difficulty is that we seem to be suffering from a failure of
the imagination. Unable to see how prayer could work, too many people insist that it cannot
work. For example, in a meta-analysis of 30 studies, single-mean t-tests produced independ-
ently significant evidence for the remote intentionality or remote observation effect (i.e., an
associated p of .05 or less) in 14 of the possible 30 cases, yielding an experiment-wide success
rate of 47%, compared with a success rate, expected on the basis of chance alone, of 5%. . . .
Results across the experiments showed a significant and characteristic variation during distant
intentionality periods, compared with randomly interspersed control periods (the average effect
size was +.25) (Schlitz & Braud, 1997, p. 62).
In a coronary care unit (CCU), 201 clients in a control group required ventilatory assis-
tance, antibiotics, and diuretics more frequently than the 192 clients in the intercessory
prayer group. The data suggest that intercessory prayer to the Judeo-Christian God has a
beneficial therapeutic effect in [clients] admitted to a CCU (Byrd, 1997, p. 87). However,
no published studies have yet replicated this study. In a randomized trial of nearly 1,000 hos-
pitalized heart clients, half of the clients were prayed for daily by volunteers for 4 weeks, while
the other half did not have anyone assigned to pray for them. None of the clients were aware
of the study. After 4 weeks, the prayed-for-clients had experienced 11% fewer complica-
tionsa small but statistically significant difference (Weil, 2000). Koopman and Blasband
(2002, p. 101) conclude that distant healing is real and transcends chance occurrence. The
full range of its applicability and longitudinal effect has yet to be explored.
REIKI
The National Institutes of Health Center for Complementary and Alternative Medicine
(NCCAM) has classified energy medicine therapies into two basic categories: bioelectro-
magnetic-based therapies and biofield therapies that include reiki, qigong, and therapeutic
touch (Miles & True, 2003). Reiki has its roots in Tibetan scriptural narratives (sutras) and was
reintroduced by Japanese physician, Mikau Usui, in the 19th century. It means free passage of
the universal (rei) life force energy (ki) (Nield-Anderson & Ameling, 2001). Following the
Eastern concept of balancing energies, a reiki healer is initiated into the art of a gentle placing
of hands in specific positions on the body through energy attunement by a reiki master. The
healers energy field is attuned to enable him or her to act as a conduit to facilitate another or
the self in balancing energies or healing. The reiki practitioner is a facilitator, not a provider. . . .
There is no attempt made to evaluate the recipients energy field or condition. There is no
manipulation of the recipients body or energy field (Nield-Anderson & Ameling, 2000, p.
22). Reiki can be used for mental, emotional, physical, or spiritual balancing (Olsen, 1990).
Engebretson (1996) emphasizes that the act of healing is not an intellectual rational activ-
ity but a spiritual intuitive activity that uses human touch as the medium for healing. This
touch is gentle, expressive, and compassionate, and involves feelings of lightness and love.
Physical sensations associated with reiki include warmth, tingling, pulling, drawing, and
energy transfer. Reiki is not intrusive, does not demand any technology, can be practiced
anywhere at any time, and does not require a practitioner or recipient to engage in verbal
exchange. Reiki is not for diagnosing disease conditions and therefore does not require a prac-
titioner to collect information, and there are no body manipulations in a reiki treatment (p.
26). . . . The healing of self and others is viewed as reciprocal and integral to the practice of
reiki (Nield-Anderson & Ameling, 2000, p. 27). Both the clinicians and the client are
mutually healed. Clinicians are not depleted during sessions and rarely reported aftereffects
(e.g., heightened symptoms of pain, stiffness, or headache) subside quickly.
Reiki requires no particular spiritual practice, discipline, or faith requirements. A reiki cli-
nician does not provide nor direct energy. It is believed that energy goes naturally to the
places where it is needed. A reiki master links a student to a cosmic, radiant energy, opens
chakras, or attunes that individual as a receiver for universal life energy vibrations or uncon-
ditional love (Olsen, 1990, p. 252).
The reiki energy is drawn in and focused through the hands to make a link between two liv-
ing beings. The first degree training or attunement is for physical healing and can be taught in a
weekend. Hand positions are taught and experienced in hands-on practice sessions. Four attune-
ments (initiations), spiritual, sacred, and confidential rituals involving symbols and mantras
activate the chakras and heighten a practitioners abilities to self-heal and to serve in the heal-
ing process (Nield-Anderson & Ameling, 2001, p. 46). The second degree focuses on absent or
distant healing, plus amplification of the initiates energy. It can be taught in a day. Two attune-
ments are administered that deepen the practitioners own healing and increase their energy
vibrations (2001, p. 46). The third degree, the master level, prepares the practitioner to teach
reiki as well as heal with reiki and involves several stages. The higher the degree of initiation, the
more power that is available to channel. This, the most intense attunement process, provides
the life force vibration for personal growth on all levels (2001, p. 46).
Clients usually start with a series of three or four full treatments lasting about an hour each.
Hand positions are each held for 3 to 5 minutes. A session can be as long or short as needed.
Full treatments typically last 45 to 75 minutes. The receiver need not be conscious so reiki
can be offered during surgery (Miles & True, 2003). The experience can range from feeling
more calm and centered to more energized, or both. Reiki can be applied to anybody or to
any condition to enhance a treatment program, help relieve pain, or as a general energy
tune-up (Olsen, 1990).
Each treatment begins at the clients head as the clinician proceeds through a series of 13
to 16 hand positions that are designed to cover all body systems. The clinician holds each
position for 5 minutes or until the flow of energy is perceived in the targeted tissues (Van Sell,
1996). Hand positions in reiki therapy are depicted in Figure 17-1.
Reiki therapists believe that, with proper training, its possible to transmit healing energy to specific parts of a patients
body by placing ones hands on or above those locations. That energy may then help heal conditions that reside in those
organs or tissues.
Memory loss and epilepsy Poor vision and

Hyperactivity
balance problems
Energy Healing Modalities

Chronic pain and Nosebleeds
Headache and metabolic disorders Oral problems addictions
459
Figure 17-1. Hand positions in reiki therapy (reprinted from Sell, S. L. (1996). Reiki: An ancient touch therapy. RN, 59, 58. 1996 Med-
ical Economics. Montvale, NJ with permission).
Little controlled research has been done with reiki. The preponderance of reiki studies reported
in the literature to date consists of a limited number of case reports, descriptive studies, or ran-
domized controlled studies conducted with a small number of participants (Miles & True, 2003).
Box 17-5 presents a more recent study abstract.
B OX 17-5
Reiki Study
In a study of outpatients with HIV/AIDS at an inner hospital clinic, 30 subjects
experienced either 20 minutes of reiki self-treatment or treatment by a reiki stu-
dent. The first degree reiki training was given in 4-hour sessions on consecutive
weekdays. Evaluation indicated a decline in reported pain and anxiety after the
reiki treatment. There was no significant difference in pain or anxiety reduction as
a function of whether the reiki was self-administered or administered by another
(Miles, 2003).
Source: Adapted from Wardell, D. W., & Engebretson, J. (2001). Biological correlates of reiki touch
healing. Journal of Advanced Nursing, 33, 439-445.
Nield-Anderson and Ameling (2001) recommend that regular self-Reiki be performed

daily during the first 21 days cleansing period to enhance clinician balance and centering,
and continued increase in confidence in and mastery of ability. Practice research is needed to
answer questions of how much, how often, for how long (Nield-Anderson & Ameling, 2001).
Some examples include: which hand positions are most appropriate for specific conditions,
how long certain hand positions should be held for maximum benefit, and how many treat-
ments are needed and for what length of time for specific conditions?
THERAPEUTIC TOUCH
Therapeutic touch (TT), developed by Dolores Krieger (a nurse) and Dora Kunz (an
energy healer), proposes that in an orderly universe, when conscious intent to help or to heal
is guided by compassion, it can have a powerful healing influence (Meehan, 1998, p. 118).
The primary experience of TT is opening to the flow of the universal life energy and involves
three key concepts: compassion, intention, and nonattachment.
Compassion is described as pure caring such that the person wants to help, but is without
expectations for the outcome. Intentionality is the intent to help or heal and is the conscious
direction of the energy to the patient with a deficit of energy. Compassion serves as the catalyst for
the energy exchange process and intentionality serves as the means of transmitting energy (Egan,
1998, p. 51). Nonattachment is a deliberate detachment from personal feelings or emotions.
Meehan (1998) insists that a specific procedure must be followed for TT. Significant
changes from the standard practice of TT can result in practices which may or may not
involve the therapeutic use of touch, but they are not TT (p. 120). The five-step technique
consists of (Horowitz, 1999; McCormack & Galantino, 1997):
1. Centering, physically and psychologically, on the intent to help the client. This is a
process by which the nurse finds a calm, focused state of being. This is done by con-
scious direction of attention inward. It can be achieved by various methods, such as
deep breathing, visualization, and focusing.
2. Assessing the clients energy field. This is a process by which the nurse notes areas of bal-
ance and imbalance in the clients energy field by using the hands to scan the clients
energy field from head to toe. Perception of heat, cold, tingling, congestion, or pressure
indicates imbalances or obstructions in the field.
3. Unruffling the clients energy field. This is a process by which the clients energy field
congestion, sluggishness, or static is removed or lessened. This is performed by making
slow brushing sweeps with the nurses hand over the clients body without touching the
body itself, sweeping from head to toe. This allows the energy to move freely.
4. Directing or modulating that energy. Once the field has been cleared, areas that have been
blocked or congested are treated. The nurse lets the hands rest on or near the body
where the block or congestion was detected or in other areas of energy imbalance.
Energy is directed to the area in order to balance or correct the blockage or modulate
energy by changing the outflow to meet the clients needs. This is performed as an act
of consciousness as the nurse images a flow or movement of particles, color, fluid, or
whatever visualization is clearly formulated in the mind.
5. Scanning or recognizing when the process is complete and it is time to stop. Stop when there
are no longer any cues, when the body is symmetrical and there are no perceivable dif-
ferences bilaterally, such as magnetic-like repulsions, heat, cold, static electricity,
emptiness, or fullness.
Meehan (1998, pp. 119-120) integrates these steps in her description of TT process. Prepa-
ration for TT is begun by achieving an inner focus on a center of calm, quiet, and balance
(centering). While the nurse remains quite aware of the physical environment, this is not the
primary focus of attention. The nurse attunes to the universal healing energy so she may
become an instrument for its healing influence. Her attitude becomes one of clear, gentle, and
compassionate attention to the patient and of focused intent to help facilitate the patients
own natural healing tendency. The nurse remains detached from any personal feelings or
emotions. For the experienced clinician, centering takes about 10 seconds. The nurse remains
centered throughout the process.
The assessment is done in relation to two principles: openness and symmetry. In a state
of health, the [client] as an energy field is perceived as a gentle, symmetrical, open flow from
head to feet. In a state of illness, the flow is perceived as congested, asymmetrical, and
impeded. The hands are moved in a smooth, gentle movement, with the palms facing toward
the client, about 1 to 2 inches over clients clothed body, from head to feet. The nurse per-
ceives the pattern of the energy flow through differences in sensory cues in her hands. These
subtle cues are typically described as warmth, coolness, tightness, heaviness, tingling, or
emptiness (Meehan, 1998, pp. 119-120). The overall pattern of the energy flow and any area
of imbalance or impeded flow are noted. The initial assessment takes about 30 seconds, but
assessment also continues throughout the process.
During the treatment phase, the focus is on the specific repatterning of areas of imbalance
and impeded flow, with the hands as focal points. The nurses intention is to dissipate areas
of imbalance and facilitate a gentle, symmetrical, and open flow. The process begins with the
nurse moving her hands in gentle sweeping movements from head to feet. Attention is then
focused on areas of imbalance or congestion. For example, if an area of heat is felt over the
left side of the clients abdomen, the nurse will project an image of coolness as she moves one
hand repeatedly through that area. Simultaneously, she will move the other hand over the
right side of the abdomen, bringing the left and right side into balance. If areas of heaviness
or tingling are perceived over the clients chest, the nurse will project an image of a flowing
or smoothing movement as she moves her hands repeatedly through the area until she begins
to feel the quality of the energy flow change. To complete the treatment, the hands are placed
over the area of the solar plexus (just below the sternum) and the nurse focuses specifically
on facilitating the flow of universal healing energy in the client. Physical touch can be incor-
porated into the treatment.
Subjective observations following TT include generalized feelings of warmth expressed, spon-
taneous verbal response, a sigh or comment (I feel relaxed), or description of change in pain lev-
els. Objective observations include lowering of the clients voice; slowing and deepening of the
clients respiration; peripheral flush of the skin, especially in areas treated; physiological changes
in the relaxation response, such as decreased pulse, lowered blood pressure. TT not only allevi-
ates pain, but produces a relaxation response which is known to ameliorate levels of state anxiety
or the situational occurrences of anxiety (McCormack & Galantino, 1997, p. 88). Among the
outcomes of TT are a relaxation response, relief of pain, and accelerated healing (Egan, 1998).
However, Engle and Graney (2000) unexpectantly found evidence of vasoconstriction in a short-
term study of 11 adults as evidenced by decreased total pulse amplitude (large effect size of .57 to
1.32) and decreased time perception (time passing faster) (medium effect size of .40) after a stan-
dardized protocol of TT. The authors concluded that TT may have adverse and positive outcomes.
There is increasing research evidence that purports to support the effectiveness of TT.
Twenty-three articles in 14 refereed journals from 1981 to 1996 indicated positive regard for the
use of TT (Easter, 1997). A meta-analytic review of 9 out of 36 studies published between 1986
and 1996 indicated that TT has a positive, medium effect on physiological and psychological
variables (Peters, 1999). A meta-analysis of 13 of 38 studies performed between 1975 and 1997
had an average effect size of .39, which is described as moderate (Winstead-Fry & Kijek, 1999).
However, as Peters (1999) states, it is impossible to make any substantive claims at this time
because there is limited published research and because many of the studies had significant
methodological issues that could seriously bias the reported results. . . . It appears that TT can
produce a medium effect for physiological outcomes and psychological outcomes within treated
subjects. It also appears that TT produces a medium effect on physiological outcomes when
comparing treatment with control groups. . . . There is not enough empirical data to support TT
as more effective than control measures in improving psychological well-being (pp. 52, 59).
Winstead-Fry and Kijek (1999) also indicate concerns with the quality of the research lit-
erature. The review demonstrated that there are many approaches to TT research, samples
are described incompletely, and the TT practices vary in the studies (p. 58). Concerns iden-
tified by Winstead-Fry and Kijek include:
Use of healthy persons as a sample. It is possible that persons with diseases or illnesses
have different responses.
The use of 5-minute research TT treatments, even though clinicians allow an average
of 20 minutes for a treatment.
Inadequate sample size.
Lack of sophisticated statistical analysis.
Researcher also serving as healer.
Mathuna (2000) goes even further in her critique of reviews of TT literature published in
nursing journals between 1994 and 1998. She found that literature reviews often cited only
research with favorable findings and only mentioned the favorable findings even in research
with contradictory findings. Of concern, many reviews actually indicated that TT was inef-
fective, but the research was cited as indicating the efficacy of TT. Every review examined had
at least one significant mistake concerning how research studies were represented (p. 279).
However, there appear to be no risks to [clients] associated with TT when it is used appro-
priately as a nursing intervention. . . . In extrapolating from data on placebo effectiveness, it
could even be suggested that for a [client] in a stress-related situation where the physician,
nurse, and patient believe in TT, it could have at least a positive effect 70% of the time and
an excellent effect 40% of the time. . . . It seems clear that TT is intrinsically interrelated with
the powerful placebo effect (Meehan, 1998, p. 123).
Several precautions for TT have been proposed. As a general rule, the client will take the
amount of energy that is needed and then will stop drawing from the energy source, however,
in some instances precautions must be taken. Infants and children are very sensitive to treat-
ments. Energy should be given slowly and gently in small amounts by an experienced clini-
cian. Aged, extremely ill, or dying individuals may require modifications in treatment or
gentle energy input. The head is also very sensitive and only cooling, sweeping motions are
used in the head area. Patients with cancer are treated in such a way that energy is not con-
centrated in a particular area (Egan, 1998).
TT should be learned through an apprenticeship with a mentor over 1 to 2 years to per-
fect a knowledgeable practice. The supporting organization for TT is the Nurse Healers Pro-
fessional Organization, Inc. (see Additional Information at the end of the chapter). Nurse
Healers provide a three-step process: beginning, intermediate, and advanced. The Nurse
Healers Association does not provide certification. The Holistic Nursing Association, which
incorporates TT into a process they call healing touch, provides an extensive program lead-
ing to certification as a healing touch practitioner. However, the Nurse Healers-Professional
Associates International (NH-PAI) does not endorse the Healing Touch Program as a suit-
able source of training for therapeutic touch practitioners (Bonadonna, 2002).
Thought field therapy is an integrated, meridian-based, mind-body-energy psychotherapy
that includes diagnostic and therapeutic procedures performed while patients are attuned to
their problem. The goal is to enhance ones bioenergetic level of functioning while a specific
problem is being attuned, so that the subtle energetic codes associated with the perturbations
in the field can be removed. The negative emotions are alleviated through gentle activation of
designated acupuncture points, which neutralizes or eliminates the energetic cause of the prob-
lem (Diepold, 2002). Treatment procedures have primarily involved tapping the beginning or
end points of the designated meridians or vessels to reversal, g-gamut, collarbone breathing,
thought recognition, the healing energy light process, and the eye roll (Gallo, 2002).
Energy healing is based on a view of person-environment process as unitary and open. It is
theorized that intentional focus by the healer can foster harmonious entrainment of energy
field vibration. Restoration of energy field harmony is associated with healthiness and heal-
ing. The emphasis in this chapter has been on patterning of the energy field through non-
invasive therapeutic modalities such as color, music, polarity therapy, prayer, reiki,
therapeutic touch, and thought field therapy. These modalities are accepted by many states as
legitimate components of the professional nurses scope of practice.
Chapter Key Points

Energy healing is also known as the laying on of hands or biofield therapeutics.
Energy healing is a systematic, purposeful intervention aimed to help another person by
means of focused intention, hand contact, and aligning with the universal energy field.
Reiki and prayer are based on channeling of a spiritual energy that has innate intelli-
gence or logic, while music, color therapy, polarity therapy, TT, and TFT pattern the
vibrations of the environmental energy field for healing purposes.
References
Benford, M. S., Talnagi, J., Doss, D. B., Boosey, S., & Arnold, L. E. (1999). Gamma radiation fluctuations
during alternative healing therapy. Alterntive Therapies in Health and Medicine, 5, 51-56.
Bittman, B. B., Berk, L. S., Felten, D. L.,Westengard, J., Simonton, O. C., Pappas, J., et al. (2001). Com-
posite effects of group drumming music therapy on modulation of neuroendocrine-immune
parameters in normal subjects. Alterntive Therapies in Health and Medicine, 7, 38-47.
Bonadonna, J. R. (2002).Therapeutic touch. In S. Shannon (Ed.), The handbook of complimentary & alter-
native therapies in mental health (pp. 231-248). San Diego: Academic Press.
Brewer, J. F. (1998). Healing sounds. Complementary Therapies in Nursing & Midwifery, 4, 7-12.
Brotons, M., Koger, M., & Pickett-Cooper, P. (1997). Music and dementias: A review of literature. Journal
of Music Therapy, 24, 204-245.
Byrd, R. C. (1997). Positive therapeutic effects of intercessory prayer in a coronary care unit population.
Alterntive Therapies in Health and Medicine, 3, 62-73.
Campbell, D. (2001). Do you hear what I hear? Alterntive Therapies in Health and Medicine, 7, 34-35.
References 465
Chlan, L. (1998). Music therapy. In M. Snyder & R. Lindquist (Eds.), Complementary/alternative therapies in
nursing (3rd. ed., pp. 243-257). New York: Springer.
Diepold, J. H. Jr. (2002). Thought field therapy: Advancements in theory and practice. In F. P. Gallo (Eds.),
Energy psychology in psychotherapy (pp. 3-34). New York: Norton.
Dossey, L. (1997). The return of prayer. Alterntive Therapies in Health and Medicine, 3, 10-17, 113-120.
Dossey, L. (2000). Creativity: On intelligence, insight, and the cosmic soup. Alterntive Therapies in Health
and Medicine, 6, 12-17, 108-117.
Easter, A. (1997). The state of research on the effects of therapeutic touch. Journal of Holistic Nursing, 15,
158-175.
Egan, E. C. (1998). Therapeutic touch. In M. Snyder & R. Lindquist (Eds.), Complementary/alternative ther-
apies in nursing (3rd ed., pp. 49-62). New York: Springer.
Engebretson, J. (1996). Urban healers: An experiential description of American healing touch groups.
Qualitative Heath Research, 6, 526-541.
Engle, V. F., & Graney, M. J. (2000). Biobehavioral effects of therapeutic touch. Journal of Nursing Scholar-
ship, 32, 287-293.
Gallo., F. P. (2002). Energy diagnostic and treatment methods. In F. P. Gallo (Ed.), Energy psychology in
psychotherapy (pp. 35-51). New York: Norton.
Gaynor, M. L. (1999). Sounds of healing. New York: Broadway Books.
Gerber, R. (1988). Vibrational medicine: New choices for healing ourselves. Santa Fe, NM: Bear & Co.
Good, M., Picot, B. L., Salem, S. G., Chin, C., Picot, S. F., & Lane, D. F. (2001). Cultural differences in
music chosen for pain relief. Journal of Holistic Nursing, 18, 245-260.
Guzzetta, C. A. (1997). Music therapy. In B. M. Dossey (Ed.), Core curriculum for holistic nursing (pp. 196-
204). Gaithersburg, MD: Aspen.
Harding, S (1999). More noise or sound theory? Alternative and Complementary Therapies, 5, 85-92, 164-174.
Horowitz, S. (1999). Rehabilitation medicine. The mainstreaming of a more holistic approach. Alternative
and Complementary Therapies, 12-17.
Klotsche, C. (1993). Color medicine. Sedona, AZ: Light Technology.
Koopman, B. G., & Blasband, R. A. (2002). Distant healing revisited: Time for a new epistemology. Altern-
tive Therapies in Health and Medicine, 8, 100-101.
Krieger, D. (1986). The therapeutic touch: How to use your hands to help or to heal. New York: Prentice-Hall.
Kumar, A. M., Tims, F., Cruess, D. G., Mintzer, M. J., Ironson, G., Loewenstein, D., et al. (1999). Music
therapy increases serum melatonin levels in patients with Alzheimers disease. Alterntive Thera-
pies in Health and Medicine, 5, 49-57.
Leddy, S. K. (1998). Leddy and Peppers conceptual bases of professional nursing (4th ed.). Philadelphia:
Lipppincott.
Leddy, S. K. (2002). A practice theory of energy. Manuscript submitted for publication.
Mathuna, D. P. (2000). Evidence-based practice and reviews of therapeutic touch. Journal of Nursing Schol-
arship, 32, 279-285.
McCormack, G. L., & Galantino, M. L. (1997). Non-contact therapeutic touch. In C. M. Davis (Ed.),
Complementary therapies in rehabilitation (pp. 83-97). Thorofare, NJ: SLACK Incorporated.
Meehan, T. C. (1998). Therapeutic touch as a nursing intervention. Journal of Advanced Nursing, 28, 117-125.
Miles, P. (2003). Preliminary report on the use of reiki for HIV-related pain and anxiety. Alternative Ther-
apies in Health and Medicine, 9, 36.
Miles, P., & True, G. (2003). Reiki- Review of a biofield therapy. History, theory, practice, and research.
Alternative Therapies in Health and Medicine, 9, 62-72.
Nield-Anderson, L., & Ameling, A. (2000). The empowering nature of reiki as a complementary therapy.
Holistic Nursing Practice, 14, 21-29.
Nield-Anderson, L., & Ameling, A. (2001). Reiki: A complementary therapy for nursing practice. Journal
of Psychosocial Nursing and Mental Health Services, 39, 42-49.
Peters, R. M. (1999). The effectiveness of therapeutic touch: A meta-analytic review. Nursing Science Quar-
terly, 12, 52-61.
Rogers, M. E. (1990). Nursing: Science of unitary, irreducible human beings. Update 1990. In E. A. M.
Barrett (Ed.), Visions of Rogers science-based nursing (pp. 5-11). New York: National League for
Nursing.
Schlitz, M., & Braud, W. (1997). Distant intentionality and healing: Assessing the evidence. Alterntive
Therapies in Health and Medicine, 3, 62-73.
Selby, P. (1997). Subtle energy manipulation and physical therapy. In C. M. Davis (Ed.), Complementary
therapies in rehabilitation (pp. 267-278). Thorofare, NJ: SLACK Incorporated.
Sharp, M. B. (1997). Polarity, reflexology, and touch for health. In C. M. Davis (Ed.), Complementary ther-
apies in rehabilitation (pp. 235-255). Thorofare, NJ: SLACK Incorporated.
Sills, F. (1989). The polarity process: Energy as a healing art. Longmead, Dorset: Element Books Ltd.
Slater, V. E. (1997). Energetic healing. In B. M. Dossey (Ed.), Core curriculum for holistic nursing (pp. 52-
58). Gaithersburg, MD: Aspen.
Starn, J. R. (1998). The path to becoming an energy healer. Nurse Practitioner Forum, 9, 209-216.
Targ, E. (1997). Evaluating distant healing: A research review. Alterntive Therapies in Health and Medicine,
3, 74-78.
Thomson, K. S. (1997). Miracles on demand: Prayer and the causation of healing. Alterntive Therapies in
Health and Medicine, 3, 92-96.
Van Sell, S. L. (February, 1996). Reiki: An ancient touch therapy. RN, 59, 57-59.
Wardell, D. W., & Engebretson, J. (2001). Biological correlates of reiki touch healing. Journal of Advanced Nurs-
ing, 33, 439-445.
Weil, A. (2000, January). Can spirituality heal? Self healing, 8. Retrieved January 2, 2002, from
http://www.drweilselfhealing.com/show_document.asp?iDocumentID=120&iBDC=1440&iPa
geNumber=1
Wetzel, W. S. (1989). Reiki healing: A physiologic perspective. Journal of Holistic Nursing, 7(1), 47-54.
Winstead-Fry, P., & Kijek, J. (1999). An integrative review and meta-analysis of therapeutic touch
research. Alterntive Therapies in Health and Medicine, 5, 58-67.
Music Therapy
American Music Therapy Association
8455 Colesville Road, Suite 1000
Silver Spring, MD 20910
Tel: (301) 589-3300
www.musictherapy.org
For new music therapists, the MT-BC (music therapist-board certified) is the only avail-
able credential. The Certification Board for Music Therapists requires education, clinical
training, and a national examination. Continuing education is required for recertification.
Prayer
American Association of Pastoral Counselors
9504-A Lee Highway
Fairfax, VA 22031
Tel: (703) 385-6967
www.aapc.org
Provides certification for pastoral counselors.
Light (Color) Therapy

College of Syntonic Optometry
21 E. 5th Street
Bloomsburg, PA 17815
Tel: (717) 387-0900
www.syntonicphototherapy.com
Training is achieved by attending seminars and continuing education in the field. The
annual Conference of Light and Vision, sponsored by the College of Syntonic Optometry, pro-
vides basic and advanced courses with certification. There is no regulation of practitioners.
Polarity Therapy
American Polarity Therapy Association (APTA)
2888 Bluff Street #149
Boulder, CO 80301
Tel: (303) 545-2080
www.polaritytherapy.org
There are no states that license polarity therapy by itself. The APTA oversees the devel-
opment of standards for training at two levels and for continuing education. Currently, the
first level of associate practitioner (155 required course hours) provides a basis for beginning
to practice, with an additional 460 hours required for achieving the status of Registered polar-
ity practitioner.
Reiki
Center for Reiki Training
Tel: (800) 332-8112
www.reiki.org
The therapy is not regulated anywhere in the world and there are no registration processes.
An apprenticeship to a reiki master is a common way in which the teachings are passed on.
Therapeutic Touch
The Nurse Healers and Professional Associates Cooperative
175 Fifth Avenue, Suite 2755
New York, NY 10010
(212) 886-3776
Practitioners of TT may receive certificates of completion of classes.
American Holistic Nurses Association

PO Box 2130
Flagstaff, AZ 86003-2130
Directions:
A APPENDIX
Leddy Healthiness Scale
Circle the number that best indicates your degree of agreement with each of the follow-
ing statements. Please answer all of the questions the way you feel right now.
e
sagre
ree
e
isagre
ly Ag
sagre
ly Di
gree
ree
ly Ag
tly A
tly D
ly Di
plete
plete
Sligh
Sligh
Most
Most
Com
Com
1. I think that I function pretty well. 6 5 4 3 2 1
2. I have goals that I look forward to 6 5 4 3 2 1

accomplishing in the next year.
3. I am part of a close and supportive family. 6 5 4 3 2 1
4. I dont feel there is much that is meaningful 6 5 4 3 2 1

in my life.
5. I have more than enough energy to do what 6 5 4 3 2 1

I want to do.
6. I feel I can accomplish anything I set out 6 5 4 3 2 1

to do.
470 Appendix A
e
sagre
ree
e
isagre
ly Ag
sagre
ly Di
gree
ree
ly Ag
tly D
tly A
ly Di
plete
plete
Sligh
Most
Sligh
Most
Com
Com
7. There is very little that I value in my life 6 5 4 3 2 1
right now.
8. Having change(s) in my life makes me feel 6 5 4 3 2 1

uncomfortable.
9. I have rewarding relationships with people. 6 5 4 3 2 1
10. I enjoy making plans for the future. 6 5 4 3 2 1
11. I feel free to choose actions that are right 6 5 4 3 2 1

for me.
12. I feel like I have got little energy. 6 5 4 3 2 1
13. I am pleased to find that I am getting better 6 5 4 3 2 1

with age.
14. I dont communicate much with family or 6 5 4 3 2 1

friends.
15. I get excited thinking about new projects. 6 5 4 3 2 1
16. I feel good about my ability to influence 6 5 4 3 2 1

change.
17. Im not what you would call a goal-oriented 6 5 4 3 2 1

person.
18. I feel energetic. 6 5 4 3 2 1
19. I feel good about my freedom to make choices 6 5 4 3 2 1

for my life.
20. I have a goal that I am trying to achieve. 6 5 4 3 2 1

Leddy Healthiness Scale 471
e
sagre
ree
e
isagre
ly Ag
sagre
ly Di
gree
ree
ly Ag
tly A
tly D
ly Di
plete
plete
Sligh
Sligh
Most
Most
Com
Com
21. I dont expect the future to hold much 6 5 4 3 2 1
meaning.
22. I like exploring new possibilities. 6 5 4 3 2 1
23. I feel full of zest and vigor. 6 5 4 3 2 1
24. I feel fine. 6 5 4 3 2 1
25. I feel pretty sure of myself. 6 5 4 3 2 1
26. I feel isolated from people. 6 5 4 3 2 1
The Leddy Healthiness Scale is scored by reversing items 4, 7, 8, 12, 14, 17, 21, and 26
(positive responses are scored higher). The summative score can range from 26 to 156, with
higher scores indicating higher healthiness.
BAPPENDIX
Nutritional Supplements
474 Appendix B
Vitamin and Mineral Supplement Ranges
FAT-SOLUBLE VITAMINS
SUPPLEMENT DESCRIPTION U.S. RDA ADULT* ADULT DAILY SIDE EFFECTS
SUPPLEMENT RANGE
Beta carotene Converted by the body Not established 10,000-50,000 IU Prolonged ingestion of relatively
pro-vitamin A to vitamin A as needed. high doses may cause a non-
Primary antioxidant harmful yellowing of the skin
that helps protect the especially palms and soles.
lungs and other tissue. Avoid beta carotene supplement
while taking the prescription
drug Accutane (Roche USA,
Nutley, NJ), especially during
pregnancy.
Vitamin A Essential for growth and 4,000-5,000 IU 5,000-10,000 IU Prolonged ingestion of excess
(preformed and development, main- vitamin A (50,000 IU+/day) may
retinol) tenance of healthy skin, be toxic. Avoid vitamin A sup-
hair, and eyes. Involved in plement while taking the pre-
wound healing. scription drug Accutane, espe-
cially during pregnancy.
Vitamin D Essential for calcium and 400 IU 200-400 IU Prolonged ingestion of excess
(cholecalferol) phosphorus metabolism, vitamin D (1,000 IU+/day) may
required for strong bones be toxic and cause hyperca-
and teeth. cemia (excess of calcium in
blood).
Vitamin E Primary antioxidant that 12-15 IU 200-800 IU Prolonged ingestion of vitamin E
protects the red blood cells may produce adverse skin reac-
and is essential in cellular tions and upset stomach.
respiration.
continued
Vitamin and Mineral Supplement Ranges (continued)
FAT-SOLUBLE VITAMINS
SUPPLEMENT RANGE
Vitamin K Integrally involved in the 65 50-500 Unlike other fat-soluble vitamins,
(phylloquinone) blood clotting mechanism. vitamin K is not stored in signifi-
cant quantity in the liver. Syn-
thetic vitamin K (menadione) is
toxic in excess dosages.
WATER-SOLUBLE VITAMINS
Vitamin C Primary antioxidant, ess- 60 mg 300-3,000 mg Essentially nontoxic in oral
(ascorbic acid) ential for tissue growth, doses. However, excessive inges-
wound healing, absorption tion may cause abdominal bloat-
of calcium and iron, and ing, gas, flatulence, and diarrhea.
utilization of the B vitamin- Acid-sensitive individuals should
folic acid. Involved in take buffered ascorbate form of
neurotransmitter biosynth- vitamin C supplement.
esis, cholesterol regulation,
and formation of collagen.
Vitamin B1 Essential for food metabol- 1.2-1.5 mg 5-100 mg Essentially nontoxic in oral doses.
(thiamine) ism and release of energy
for cellular function.
continued
475
476 Appendix B
Vitamin and Mineral Supplemental Ranges (continued)
WATER-SOLUBLE VITAMINS
SUPPLEMENT RANGE
Vitamin B2 Essential for food metabol- 1.4-1.8 mg 5-100 mg Essentially nontoxic in oral
(riboflavin) ism and release of energy doses. Moderate to high doses
for cellular function. Import- of vitamin B2 may cause non-
ant in the formation of red harmful bright yellow coloration
blood cells and activation of urine.
of other B vitamins.
Vitamin B3 Essential for food metabol- 16-20 mg 20-100 mg Essentially nontoxic in oral
(niacin) ism and release of energy doses. High doses (100 mg+)
for cellular function. Vital may cause transient flushing and
for oxygen transport in the tingling in the upper body area,
blood, and fatty acid and as well as stomach upset.
nucleic acid formation. A Prolonged ingestion of excess
major constitute of several vitamin B3 (1,000-2,000 mg+/
important coenzymes. day) may elevate liver enzymes
and cause liver damage.
Vitamin B5 Involved in food metabol- 4-7 mg 10-1,000 mg Essentially nontoxic in oral
ism and release of energy. doses. Extremely high doses
Vital for biosynthesis of (10,000 mg+) will produce diar-
hormones and support of rhea.
adrenal glands.
continued
WATER SOLUBLE VITAMINS

SUPPLEMENT RANGE
Vitamin B6 Involved in food metabol- 2.0-2.5 mg 5-200 mg Prolonged high doses (500 mg+
(pyroxidine) ism and release of energy. /day) may be toxic and cause
Essential for amino acid neurological damage. Prescript-
metabolism and formation ion oral contraceptives may cause
of blood proteins and anti- deficiency of vitamin B6.
bodies. Helps regulate
electrolytic balance.
Vitamin B12 Essential for normal form- 3.0-4.0 10-500 Essentially nontoxic in oral doses.
(cobalamin) ation of red blood cells.
Involved in food metabol-
ism, release of energy and
eptithelial cells (cells that
form the skins outer layer
and the surface layer of
mucous membranes), and
the nervous system.
Folate Essential for blood format- 400 200-800 Essentially nontoxic in oral doses.
(folic acid, ion, especially red blood An excess intake of folate can
folicin) cells and white blood mask a vitamin B12 deficiency.
cells. Involved in the bio-
synthesis of nucleic acids
including RNA and DNA. continued
477
478 Appendix B
WATER SOLUBLE VITAMINS

SUPPLEMENT RANGE
Biotin Essential for food metabol- 150-300 300-600 mg Essentially nontoxic in oral doses.
ism and release of energy.
Assists in the biosynthesis
of amino acids, nucleic
acid, and fatty acids.
Utilization of other B
vitamins.
B vitamins should also be taken in a B-complex form because of their close interrelationship in the metabolic process.
MINERALS
The function of minerals are highly interrelated to each other and to vitamins, hormones, and enzymes. No mineral can
function in the body without affecting others.
Calcium Essential for strong bones 800-1,200 mg 200-1,200 mg Prolonged ingestion of excess
(Ca++) and teeth. Serves as a vital calcium, along with excess vita-
cofactor in cellular energy min D, may cause hypercal-
production and nerve and cemia of bone and soft tissue
heart function. (such as joints and kidneys)
and may also cause a mineral
imbalance.
continued
MINERALS
SUPPLEMENT RANGE
Magnesium Essential catalyst for food 300-350 mg 150-600 mg Extremely high doses (30,000
(Mg++) metabolism and release of mg+) may be toxic in certain
energy. A cofactor in the individuals with kidney prob-
formation of RNA/DNA, lems. Doses of 400 mg+ may
enzyme activation, and produce a laxative effect, caus-
nerve fuction. ing diarrhea.
Potassium A primary electrolyte, Not established 1,875-5,625 mg Extremely high doses (25,000
(K+) important in regulating (A typical healthy mg+/day) of K chloride may be
pH (acid/base) balance diet contains ade- toxic in instances of kidney
and water balance. Plays quate K. Very active failure.
a role in nerve function individuals may
and cellular integrity. require additional
electrolytes.)
Sodium A primary electrolyte, Not established Limit daily intake Prolonged ingestion of excess
(Na+) important in regulating to 1,500 mg sodium has been linked to high
pH (acid/base) balance blood pressure and increased
and water balance. Plays incidence of migraine head-
a role in nerve function aches. Extremely high intakes of
and cellular integrity. sodium can result in swelling of
tissues (edema).
continued
479
480 Appendix B
MINERALS
SUPPLEMENT RANGE
Phosphorus Constituent of the molecule 900-1,200 mg 300-600 mg Although essentially nontoxic,
(P) phosphate, which plays a a disproportionately large amount
major role in energy prod- of phosphorus relative to calcium
uction and activation of B intake may cause a deficiency
vitamins. Component of in calcium and mineral imbalance.
RNA/DNA, bones, and teeth.
Zinc Cofactor in numerous enzy- 15 mg 15-30 mg Extremely high doses (2,000 mg/
(Zn++) matic processes and react- day) can be toxic. Excess zinc in-
ions. Structural constituent take (50 mg+/day) may cause
of nucleic acids and insulin. copper deficiency and mineral
Involved in taste, wound imbalance.
healing, and digestion.
Iron Combines with other nutr- 10-18 mg 10-30 mg Prolonged ingestion of excess
(FE++ or ients to produce vital blood iron can be toxic, affecting the
FE+++) proteins. liver, pancreas, heart, and nucle-
us, also increasing susceptibility
to infection. Poorly utilized forms
of iron (FE sulfate or FE gluconate)
may cause constipation and/or
stomach upset. Iron supplements
should be taken with food and
supplemental vitamin C.
continued
MINERALS
SUPPLEMENT RANGE
Manganese Important catalyst and co- 2.5-5.0 mg 2-10 mg Prolonged ingestion of excess
(Mn++) factor in many enzymatic manganese may result in non-
processes and reactions. harmful elevated concentrations
Helps maintain skeletal and in the liver and may cause a
connective structural tissue, mineral imbalance.
as well as cellular integrity.
Copper Essential for production of 2-3 mg 2-3 mg Prolonged ingestion of excess
(Cu++) red blood cells. Involved in copper may be toxic, especially
the maintenance of skeletal with Wilsons disease, a rare
and cardiovascular systems. metabolic disorder resulting in
Works with vitamin C in the an excess accumulation of cop-
biosynthesis of collagen and per in the liver, red blood cells,
elastin. and the brain.
Iodine Essential component of thy- 150 50-300 Prolonged ingestion of excess
(I-) roid hormones, which regu- iodine may cause iodine goi-
late growth and rate of meta- ter, an enlargement of the thy-
bolism. roid gland. May also induce acne-
like skin lesions or aggravate pre-
existing acne conditions.
continued
481
482 Appendix B
MINERALS
SUPPLEMENT RANGE
Chromium Vital as a cofactor of GTF 50-200 200-500 Essentially nontoxic in oral doses.
(Cr+++) (glucose tolerance factor),
which regulates the function
of insulin. Involved in food
metabolism, enzyme activ-
ation, and regulation of
cholesterol.
Selenium Important constituent of the 55-200 100-200 Prolonged ingestion of excess
antioxidant enzyme gluath- selenium may be toxic.
ione peroxidase, which is
contained in white blood
cells and blood platelets.
Synergistic nutritional part-
ner of vitamin E.
*Because the current U.S. RDAs are an inadequate guide to the therapeutic benefits of nutritional supplements, research
should be made to develop an accurate guide to the ranges of supplementation.
Reprinted with permission from Burton Goldberg Group. (1995). Alternative medicine: The definitive guide. Tiburon, CA: Future Medicine.
INDEX
Acceptance, healing and, 23 American Dietetic Association, 441

Access to Medical Treatment Act American Holistic Nurses Association
(AMTA), 149150 (AHNA), 2425
Accidents/injuries American Nurses Association (ANA)
in developing countries, 225 Code of Ethics, 137
household and recreational, 213 Model Practice Act, 144
motor vehicle, 213 Anthroposophically extended medicine,
Achievement, 5253 63, 6869
Activity-exercise pattern, 168 Antioxidants, 422426
Acupressure massage Appalachian health beliefs, 109
associations and credentialing, 378 Applied kinesiology, 366367, 377
benefits of, 363364 Appraisal, healing and, 23
defined, 363 Aromatherapy
jin shin do, 367368 associations/credentialing, 324325
reflexology/zone therapy, 364365, 378 cautions in using oils, 320321
self-massage, 368 clinical applications, 315318
shiatsu, 366 concerns, key, 321322
Touch for Health (applied kinesiology), defined, 315
366367, 377 methods of administering essential oils,
trigger points, 364 317318
Acupuncture, 59, 6869 self-care with, 321
Adaptive model, 6, 7 specific oils and their applications,
Roys, 7677, 78, 159, 164 318320
Advocacy, 281 Asian American health beliefs, 106109
African American health beliefs, Assessment, health
112113 Ayurvedic, 178179
Air pollution, 234 Chinese medicine, 179182
Alexander technique, 369, 377 defined
Alignment, healing and, 23 dimension scales, 171172
Alternative medicine, 54 functional, 173174
484 Index
Gordons functional health patterns, Behavior change

167169 decisional balance, 203
history, health, 170171 health beliefs, 205
Kings general systems framework and influences on, 197207
goal attainment theory, 7880, 159, locus of control, 204205
160 maintaining, 215
Leddys healthiness scale, 172, 469471 PRECEDE-PROCEED model, 177,
Leddys human energy model, 86, 87, 205206, 207
159, 166 processes of, 201203
mental, 174175 self-efficacy, 203204
Neumans systems model, 7778, 79, stages of, 199201
159, 161 strategies for promoting, 207212
nutritional, 175176 Being there versus being with,
Orems self-care deficit theory, 8081, 248253
159, 162 Beliefs. See Health beliefs
Penders categories for, 158, 167 Beneficence, 134
purpose of, 158 Beta carotene, 425426, 474
quality of life, 177178 Bioenergetic medicine, 65
Rogers science of unitary human beings, Biofeedback, 395397, 407
8182, 159, 163 Biological causality, 105
Roys adaptation model, 7677, 78, 159, Biomedicine
164 beliefs, 5354
screening for disease, 182191 values, 5253
spiritual, 176177 Biotin, 478
Watsons human science and transper- Body climates, 58
sonal caring theory, 8486, 159, Body mass index (BMI), 429, 432
165 Bodywork techniques. See Touch and
wellness inventory, 172173 bodywork techniques
Assessment, physical, defined, 158 Borg Scale of Perceived Exertion,
Astragalus, 304 329
Atkins diet, 435 Breathing, relaxation and, 390392
Autogenic training, 385387 pranayama (yogic), 392393
Autonomy, 13234
Awareness, healing and, 23 Calcium, 416417, 478
Ayurvedic medicine Cannon, Walter B., 380
assessment, 178179 Capability, 3839
basic concepts, 6062, 6869 Capacity, 43
diet, 435 Capacity building
herbs and, 296, 297298 community/macro, 277279
defined, 275
Back pain, preventing low, 213214 individual, 275276
Behavioral approach. See Individual small group, 276277
(behavioral) approach Caring, connected, 255
Index 485
Centering, 254, 446 Concentrative/reflective meditation,

Certification Board for Nutrition 383387
Specialists, 441 Confidence, 4243
Chakras, 9193 Conflict theories, 268, 269
Challenge, 4143 Connections, 3738
Chamomile, 304305 Conscientization, 279
Chi gung (qigong), 345348, 354355 Consciousness
Childhood health problems, 224225 Neumans theory of health as expand-
China, regulation of herbs, 299 ing, 8384
Chinese Herbal Medicine, 324 raising, 202, 209
Chiropractic medicine, 6465 Contextualism, 131
Choice, 4041 Control, 3940
Choosing, healing and, 23 Coping-stress-tolerance pattern, 169
Chromium, 482 Copper, 481
Climatic changes, effects of, 234235 Counseling
Clinical model, 6 patient-centered, 212
Clinical Nutrition Certification Board, to reduce disease risk factors, 212214
441 Counterconditioning, 202, 210
Criterion-referenced measure of goal
Coenzyme Q10, 425
attainment (CRMGAT), 160
Cognitive-behavioral strategies, physical
Cultural care, types of, 117
exercise and, 337
Cultural differences
Cognitive-perceptual pattern, 168
health/illness beliefs, 105106
Collaboration, 273275
influence of indigenous beliefs, 106116
Color therapy (chromatherapy), 446450,
models/theories for handling, 117120
467
understanding, 120124
Communication, 260261
Culture
Community defined, 100
analysis, elements of, 283285 influence on food, 410
elements of, 268 Cumulative Index of Nursing and Allied
empowerment, 271282 Health Literature (CINAHL),
health workers, types of, 274 health promotion defined, 910
holographic, 267268 Cupping, 59
interventions, role of, 270271 Curing, difference between healing and, 18
organization, principles for, 282287
as place, 266 Data collection. See Assessment, health
political and social responsibility and, Decisional balance, 203
267 Deforestation, 235236
social change theories and, 268270 Dental and periodontal disease, prevent-
social interaction and, 266267 ing, 214
Community-based health care, 5051 Deontology, 131
Community-level change theories, 268, Diet(s)
269 Atkins, 435
Complementary medicine, 54 Ayurvedic, 435
486 Index
Gerson, 435 community, 271282

high-fiber, high-carbohydrate, low-fat, conscientization, 279
434435 defined, 271273
high-protein, low-carbohydrate, 435 ethics and, 141143
Jenny Craig, 435 global health and, 223224
macrobiotic, 434 political action and advocacy, 281
moderate-fat, balanced, 435436 social capital, 280
Nutri-Systems, 435 Endogenous healing process, 2223
Ornish, 435 Energy (bioenergetic) medicine, 65
Pritikin, 434435 Energy exercise
promoting a healthy, 213 qigong (chi gung), 345348, 354355
Weight Watchers, 435 tai chi, 341345, 354
Dietary guidelines, 426431 Energy healing
Dietary Supplement Health Education Act associations and credentialing, 467468
(DSHEA), 150, 298 benefits of, 445446
Dimension scales, 171172 centering, 446
Disease color therapy (chromatherapy),
counseling to reduce risk factors for, 446450, 467
212214 defined, 444
screening for, 182191 music therapy, 450454, 467
use of term, 5 polarity therapy, 454456, 467
Disease perspective of health prayer, 456457, 467
disease, 5 reiki, 457460, 468
health, 45 theory, 9094
illness, 5 therapeutic touch, 460464, 468
sickness, 6 Energy phases, 58
well-being, 67 Environment
Disease risk prevention, 79 Kings general systems framework and
Drugs, legal issues regarding access to, goal attainment theory, 7880
149150 Leddys human energy model, 86, 87
Neumans systems model, 7778, 79
Echinacea, 305306, 313 Neumans theory of health as expanding
Ecocentric worldview of health, 220 consciousness, 8384
Ecological approach. See Socioenviron- Orems self-care deficit theory, 8081
mental (ecological) approach Parses human becoming theory, 8283
Elderly patients, physical activity and, Rogers science of unitary human beings,
339341 8182
Electronic health information, legal issues, Roys adaptation model, 7677, 78
148149 Watsons human science and transper-
Elimination pattern, 168 sonal caring theory, 8486
Empathy, 256260 Environmental health issues
Empowerment deforestation, 235236
capacity building, 275279 natural resources, exploitation of,
collaboration, 273275 232233
Index 487
nursing implications of, 236237 Fat, categories and effects of, 418420
overview of, 230232 Feldenkrais method, 370371, 372, 377
pollution, 233235 Fiber, 420
toxic exposure, 232, 233 Fight-or-flight response, 380
Environmental legislation, 148 Folate, 477
Environmental medicine, 67, 6869 Folk health/illness beliefs, 105106
Environmental re-evaluation, 202, 209 Food
Epidemiology, 8 See also Nutrients
Ethics access to, 225226
autonomy, 132134 classification groups, 412413
beneficence, 134 culture and, 410
care critique, 135 frequency questionnaire (FFQ), 176
categories of philosophical, 139140 human needs and, 411
contextualism, 131 ideology, 411
critique of conventional, 135141 legal issues regarding access to, 149150
deontology, 131 myths, 414415
empowerment and, 141143 Food and Drug Administration (FDA),
frequently encountered issues, 135138 regulation of herbs, 298
informed consent, 133134 Freires concept of conscientization, 279
integrative model, 140141 Functional assessment, 173174
justice, 134135 Functional capacity utilization (FCU), 174
liberalism, 131 Functional health patterns, Gordons,
narrative approach, 138140 167169
nonmaleficience, 134 Functionalist theories, 268, 269
principles of biomedical, 131135
professional model, 138 Garlic, 306, 312, 421
screening techniques and, 184 Genuineness (authenticity), 255
utilitarianism, 130131 Geranium, 318
Ethnicity German Federal Institute for Drugs and
See also Cultural differences medical Devices, regulation of
defined, 100 herbs, 298299
disparities in health status, 100104 Gerson diet, 435
health/illness beliefs, 105106 Ginger, 313
Ethnocentrism, medical, 116117 Ginkgo biloba, 306307, 312
Eucalyptus, 318 Ginseng
Eudaimonistic model, 6, 7 Panax, 307308, 312
European Economic Community (EEC), Siberian, 308309
regulation of herbs, 298, 314 Global health
Everlast, 318 See also Societal health issues
Exercise developed and underdeveloped countries
energy, 341348, 354355 and, 221222
physical, 329341 development, 222223
empowerment for, 223224
Family planning, 228229 overview of, 220221
488 Index
Goals, 3537 behaviors associated with, 247261

Kings general systems framework and caring, connected, 255
goal attainment theory, 7880 centering, 254
Leddys human energy model, 86, 87 characteristics of, 245
Neumans systems model, 7778, 79 communication, 260261
Neumans theory of health as expanding elements of, 246
consciousness, 8384 empathy, 256260
Orems self-care deficit theory, 8081 genuineness (authenticity), 255
Parses human becoming theory, 8283 listening, active, 256, 257, 258
Rogers science of unitary human beings, mindfulness, 253
8182 presence, 247253
Roys adaptation model, 7677, 78 reciprocity, 256
Watsons human science and transper- relating, 254255
sonal caring theory, 8486 respect, 255
Gordons functional health patterns, Health
167169 defined, 45
Green tea, 309, 313 Kings general systems framework and
Group exercise, 337 goal attainment theory, 7880
Guided imagery Leddys human energy model, 86, 87
benefits of, 400 Neumans systems model, 7778, 79
characteristics, 399 Neumans theory of health as expanding
credentialing, 407 consciousness, 8384
defined, 397398 Orems self-care deficit theory, 8081
forms of, 398 Parses human becoming theory, 8283
interactive, 400402 Rogers science of unitary human beings,
words to empower, 402403 8182
Roys adaptation model, 7677, 78
Hahnemann, Samuel, 62 Watsons human science and transper-
Healing sonal caring theory, 8486
assisted, 18 Health assessment. See Assessment, health
compared with health protection and Health beliefs
health promotion, 24 African American, 112113
conceptual and theoretical approaches Appalachian, 109
to, 2123 Asian American, 106109
definitions of, 1718 behavioral change and, 205
endogenous healing process, 2223 cultural differences, 105106
integration, 2122 Hispanic American, 110112
nurses, role of, 1921 influence of cultural, 106116
outcomes of, 1819 Native American, 113116
right relationship, 21 Vietnamese American, 108109
spontaneous, 18 Health care belief systems
therapeutic capacity, 21 acupuncture, 59, 6869
therapeutic landscapes, 23 anthroposophically extended, 63, 6869
Healing helping relationships Ayurveda, 6062, 6869
Index 489
biomedicine, 5254 nurses and socioenvironmental

chiropractic, 6465 approach, role of, 13
community-based, 5051 societal (policy) approach, 1314, 16
energy (bioenergetic), 65 socioenvironmental (ecological)
environmental, 67, 6869 approach, 1213
homeopathic, 62, 6869 structure for, 15
integrating, 67 Health protection
lay, 50 compared with health promotion and
mind/body, 6566 healing, 24
naturopathic, 6364, 7071 disease risk prevention and, 79
orthomolecular, 6667 Health status, disparities in racial and eth-
osteopathy, 64 nic, 100104
popular, 5051 Healthy People 2010
professional, 5171 goals for physical activity/exercise, 331
traditional, 5471 goals of, 89
traditional Chinese medicine (TCM), health disparities and, 104
5760 nutrition objectives, 429431
Helping relationships, 202, 210
Health education, defined, 1011
See also Healing helping relationships
Healthiness, theory of
prescriptive, 244245
capability, 3839
Herbalists, training/education of, 295296,
capacity, 43
324325
challenge, 4142
Herbal remedies, 50, 5960
choice, 4041
Herbs/herbal therapy
components of, 3334
actions of, 299, 300301
confidence, 4243 Ayurveda, 296, 297298
connections, 3738 capsules and tablets, 302
control, 3940 concerns, key, 313315
defined, 33 decoctions, 302
goals, 3537 elixirs, 303
meaningfulness, 3435 energizing, 311
Health information, legal issues, 148149 extracts and tinctures, 302303
Health perception-health management interactions with prescribed drugs,
pattern, 167 312313
Health promotion Native American medicine, 296, 298
attributes of, 14 nonoral forms, 303
compared with health protection and oral forms, 299, 301302
healing, 24 reasons for using, 294295
defined, 910 regulation of, 298299
individual (behavioral) approach, 1012 specific, 303311
integrative, 2627 stamina and endurance, 311
nurses and individual approach, role of, teas (infusion), 301302
1112 tonic, 311
nurses and societal approach, role of, 16 traditional Chinese medicine, 296, 297
490 Index
uses for, 303 Krieger, Dolores, 460

Western medicine, 296, 298 Kunz, Dora, 460
whole, 299, 301
Hispanic American health beliefs, Lavender, 319
110112 Lay health care, 50
History, health, 170171 Leddy Healthiness Scale (LHS), 33, 172,
HIV infection, preventing, 214 469471
Holistic nursing Leddys human energy model, 86, 87, 159,
advantages of, 2526 166
characteristics of, 25 Legal issues
defined, 2425 Access to Medical Treatment Act and
Holographic community, 267268 food and drug regulation, 149150
Homeopathic medicine, 62, 6869 civil, 143
Human becoming theory, Parses, 8283 electronic health information, 148149
Human energy model, Leddys, 86, 87, 159, environmental legislation, 148
166 implications for nurses, 150152
Human needs, Maslows hierarchy of, 411 licensure laws, 144145
Human science and transpersonal caring negligence and malpractice, 145148
theory, Watsons, 8486, 159, 165 torts, 143
Liberalism, 131
Illiteracy, health and, 226
Lifestyle physical activity, 328
Illness, defined, 5
Listening, active, 256, 257, 258
Immune system, psychoneuroimmunology,
Locus of control, 204205
8690
Individual (behavioral) approach, 1012
nurses, role of, 1112 Macrobiotic diet, 434
Individualism, 52 Magnesium, 416417, 479
Infectious diseases, 225 Maharishi Ayur-Veda (MAV), 178
Informed consent, 133134 Malpractice, 145148
Integration, 2122, 54 Mandarin, 319
Integrative health promotion, 2627 Manganese, 481
Intervention, levels of, 211 Maslow, Abraham, 411
Iodine, 481 Massage
Iron, 415, 480 benefits of, 361363
credentialing, 376
Japan, regulation of herbs, 299 defined, 358
JAREL spiritual well-being scale, 176177 methods, 358360
Jenny Craig diet, 435 neck, 362
Jin shin do (JSD), 367368 principles for, 360363
Justice, 134135 remedial, 59
self, 368
Kava, 312 types of, 360
Kings general systems framework and goal Meaningfulness, 3435
attainment theory, 7880, 159, 160 Mechanism, biomedicine, 53
Index 491
Medicocnetrism (medical ethnocentrism), Watsons human science and transper-

116117 sonal caring theory, 8486, 159,
Meditation 165
associations and credentialing, 406408 Morality, 52
autogenic training, 385387 Motivation, for physical exercise, 332334
concentrative/reflective, 383387 Motivational interviewing, 211
defined, 382 Motor vehicle injuries, preventing, 213
mindfulness, 387390 Moxibustion, 59
progressive muscle relaxation, 388390 Multinational businesses, health affected
relaxation response, 383385 by, 227228
transcendental, 383, 387 Music therapy, 450454, 467
Melatonin, 313 MyPyramid, 427
Mental assessment, 174175
Mental Health Index (MHI), 175 National Association for Holistic
Mexican American health beliefs, Aromatherapy, 324325
110112 Native American medicine
Migration, health affected by, 226227 health beliefs, 113116
Mind/body medicine, 6566 herbs and, 296, 298
Mindfulness, 253, 387390 Natural causality, 105
Minerals and vitamins, 415417, 478482 Natural resources, exploitation of, 232233
Model Practice Act, 144 Naturopathic medicine, 6364, 7071
Models and theories Negligence, 145148
for culturally competent care, 117120 Neumans systems model, 7778, 79, 159,
energy healing theory, 9094 161
Kings general systems framework and Neumans theory of health as expanding
goal attainment theory, 7880, 159, consciousness, 8384
160 Neuroendocrine-immune communication,
Leddys human energy model, 86, 87, 8690
166 Niaouli, 319
Neumans systems, 7778, 79, 159, 161 Nonmaleficence, 134
Neumans theory of health as expanding Nurse healers, characteristics of, 2021
consciousness, 8384 Nurse Practice Act, 145
Orems self-care deficit theory, 8081, Nurses, healing and role of, 1921
159, 162 Nurses, health promotion and role of
Parses human becoming theory, 8283, individual approach, 1112
159 societal approach, 16
psychoneuroimmunology, 8690 socioenvironmental approach, 13
Rogers science of unitary human beings, Nursing, holistic, 2426
8182, 159, 163 Nursing process
Roys adaptation, 7677, 78, 159, 164 Kings general systems framework and
selecting and using, 9496 goal attainment theory, 7880
social change, 268270 Leddys human energy model, 86, 87
social cognitive, 198199 Neumans systems model, 7778, 79
492 Index
Neumans theory of health as expanding Patients/clients

consciousness, 8384 Kings general systems framework and
Orems self-care deficit theory, 8081 goal attainment theory, 7880
Parses human becoming theory, 8283 Leddys human energy model, 86, 87
Rogers science of unitary human beings, Neumans systems model, 7778, 79
8182 Neumans theory of health as expanding
Roys adaptation model, 7677, 78 consciousness, 8384
Watsons human science and transper- Orems self-care deficit theory, 8081
sonal caring theory, 8486 Parses human becoming theory, 8283
Nutrients Rogers science of unitary human beings,
antioxidants, 422426 8182
dietary guidelines, 426431 Roys adaptation model, 7677, 78
essential, 413414 Watsons human science and transper-
fat, 418420 sonal caring theory, 8486
fiber, 420 Penders categories for health assessment,
minerals and vitamins, 415418, 158, 167
474482 Peppermint, 319
phyto-, 421422 Perceived well-being (PWB) scale, 175
Nutri-Systems diet, 435 Person perspective of health, 16
Nutrition healing, 1723
associations and credentialing, 440441 holistic nursing, 2426
strategies to promote healthy, 436438 Phosphorus, 480
Nutritional assessment, 175176 Physical activity
Nutritional form for the elderly (NUFFE), See also Physical exercise
176 benefits of, 328
Nutritional medicine, 431433 elderly patients and, 339341
Nutritional-metabolic pattern, 167168 lifestyle, 328
Nutritional supplementation, 415, motivation for, 333
433434 promoting, 212213
walking as, 338339
Obesity, 428429 for weight reduction, 338
Orems self-care deficit theory, 8081, 159, Physical activity/exercise program
162 assessment for, 348349
Organ networks, 58 development of, 349350
Ornish diet, 435 evaluation of, 350351
Orthomolecular medicine, 6667 implementation of, 350
Osteopathy, 64 Physical assessment. See Assessment, phys-
Outcome, healing and, 23 ical
Overpopulation, health affected by, Physical exercise
228229 See also Physical activity
benefits of, 330331
Palmarosa, 319 changes, making gradual, 335
Parses human becoming theory, 8283 cognitive-behavioral strategies, 337
Patient-centered counseling model, 212 defined, 329
Index 493
environmental and policy interventions, Chinese medicine, 181

338
epidemiology, 331332 Quality of life (QQL) assessment, 177178
group, 337 Qi, 5758
heart rate, calculating, 329 Qigong (chi gung), 59, 345348, 354355
intervention strategies, 335337
making, fun, 336 Race
motivation for, 332334, 335 See also Cultural differences
regularity of, 336 defined, 100
risks of, 334335 disparities in health status, 100104
social support, 336 health/illness beliefs, 1056
Phytonutrients, 421422 Randolph, Theron, 67
Polarity therapy, 454456, 467 Rating of perceived exercise (RPE), 326
Policy approach. See Societal (policy) Reciprocity, 256
approach
Reductionism, biomedicine, 53
Political action and advocacy, 281
Reference daily intakes (RDIs), 428
Pollution, 233235
vitamin and mineral supplement ranges,
Postural/movement re-education therapies,
474482
368
Reflexology, 364365, 378
Alexander technique, 369, 377
Reiki, 457460, 468
Feldenkrais method, 370371, 372, 377
Reinforcement management, 202, 210
structural integration (rolfing), 372374,
Relatedness, 37
376
Trager psychophysical integration, Relating, 254255
371372, 376 Relaxation
Potassium, 479 associations and credentialing, 407
Poverty, health affected by, 228 benefits of, 381
Prayer, 456457, 467 biofeedback, 395397, 407
PRECEDE-PROCEED model, 177, breathing and, 390392
205206, 207 guided imagery, 397403, 407
Pregnancy, preventing unintended, 214 meditation, 382390, 406
Prescriptive helping relationships, 244245 response, 383385
Presence, 247253 yoga, 392395, 407408
Primary prevention, 7, 8 Remedial massage, 59
Pritikin diet, 434435 Respect, 255
Professional health care systems, character- Return, healing and, 22
istics of, 51 Right relationship, 21
Progress, 53 Rogers science of unitary human beings,
Progressive muscle relaxation (PMR), 8182, 159, 163
388390 Role performance model, 6
Psychoneuroimmunology (PNI), 8690 Role-relationship pattern, 169
Public health. See Societal health issues Rolfing, 372374, 376
Pulse assessment Roman chamomile, 319
Ayurvedic, 178179 Rosemary, 319
494 Index
Roys adaptation model, 7677, 78, 159, food, access to, 225226
164 future and, 229230
illiteracy, 226
St. Johns wort, 309310, 312 infectious diseases, 225
Schultz, J. H., 385 migration, 226227
Science, biomedicine, 5354 multinational business interests,
Science of unitary human beings, Rogers, 227228
8182, 159, 163 overpopulation and family planning,
Screening for disease, 182 228229
age of patient and, 183184 poverty, 228
of asymptomatic persons, 187190 water, lack of clean, 226
ethical issues, 184 Socioenvironmental (ecological)
insufficient evidence and, 185186 approach, 1213
routine, of asymptomatic persons, nurses, role of, 13
190191 Sodium, 479
Secondary prevention, 7 Soy, 421
Selenium, 424425, 482 Spikenard, 319
Self-care deficit theory, Orems, 8081, Spiritual assessment, 176177
159, 162 Steiner, Rudolf, 63
Self-confidence, 4243 Stimulus control, 202, 210
Self-efficacy, 3839, 203204 Stone, Randolph, 454
Self-liberation, 202, 209 Strengths perspective, 3233
Self-massage, 368 Stress, 41
Self-perception-self-concept pattern, 169 See also Relaxation
Self-re-evaluation, 202, 209 response, 380381
Separation, healing and, 22 short-term versus long-term, 380
Sexuality-reproductive pattern, 169 Structural integration (rolfing), 372374
Sexually transmitted diseases, preventing, Supernatural causality, 105
214 Systems model, Neumans, 7778, 79
Shiatsu, 366
Sickness, defined, 6 Tai chi, 341345, 354
Sleep-rest pattern, 168 Taylor, Andrew, 64
Social capital, 280 Tea tree, 320
Social causality, 105 Teeguardenn, Iona Marsaa, 367
Social change theories, community and, Telemedicine, legal issues, 148149
268270 Tertiary prevention, 7
Social cognitive models and theories, Theories. See Models and theories
198199 Theory of Healthiness. See Healthiness,
Social liberation, 202, 209 theory of
Societal (policy) approach, 1314 Therapeutic capacity, 21
nurses and societal approach, role of, 16 Therapeutic landscapes, 23
Societal health issues Therapeutic touch (TT), 460464, 468
accidents, 225 Threat, challenge and, 42
children and, 224225 Tobacco use, preventing, 212
Index 495
Tongue assessment, 181182 Vietnamese American health beliefs,

Touch and bodywork techniques 108109
acupressure, 363368, 378 Vitamin A, 425426, 474
massage therapy, 358363, 376 Vitamin B1, 475
postural/movement re-education, Vitamin B2, 476
368374 Vitamin B3, 476
purpose of, 358 Vitamin B5, 476
therapeutic, 460464, 468 Vitamin B6, 477
Touch for Health (TFH), 366367 Vitamin B12, 477
Toxic exposure, 232, 233 Vitamin C, 424, 475
Traditional Chinese medicine (TCM) Vitamin D, 417418, 474
assessment in, 179182 Vitamin E, 423424, 474
basic concepts, 5758
Vitamin K, 475
herbs and, 296, 297
treatment modalities, 5960
Traditional health care beliefs, 5471 Walking, as physical activity, 338339
Trager psychophysical integration, Water
371372, 376 lack of clean, 226
Transcendental Meditation (TM), 383, pollution, 233
387, 406 Watsons human science and transpersonal
Transition, healing and, 22 caring theory, 8486, 159, 165
Transpersonal caring theory, Weight reduction, 338
Watsons human science and, Weight Watchers, 435
8486 Well-being
Transtheoretical model (TTM), 198, defined, 67
198200 perceived scale, 175
exercise for elderly patients and, 340 Wellness inventory, 172173
Utilitarianism, 130131 Western medicine, herbs and, 296, 298
Valerian, 310311
Yin/yang, 58
Validation, 37
Yoga, 392395, 407408
Values, 50
-belief pattern, 169
biomedicine, 5253 Zinc, 415416, 480
traditional health system, 5557 Zone therapy, 364365

Susan Kun Leddy-Integrative Health Promotion - Conceptual Bases For Nursing Practice, Second Edition (2005) PDF

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Susan Kun Leddy-Integrative Health Promotion - Conceptual Bases For Nursing Practice, Second Edition (2005) PDF

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INTEGRATIVE

Susan Kun Leddy, PhD, RN

Printed in the United States of America

To Debbie, Erin, and Katie, with all my love.

About the Author ...................................................................................ix

Section I: Conceptual Bases of Health Promotion ............................1

Selected Categories for Assessment ..........................................................................170

Section II: The Disease Worldview ..............................................195

Section III: The Person Worldview..............................................241

Section IV: Integrative Nursing Interventions to Promote

Chapter 14. Releasing Blocked Energy: Touch and Bodywork Techniques.........357

Appendix A: Leddy Healthiness Scale ..........................................................469

Susan Kun Leddy, PhD, RN

Describe elements of behavioral, ecological, and policy approaches to health promotion

The Disease Perspective of Health

IDEAS OF HEALTH CONSISTENT WITH THE DISEASE PERSPECTIVE

HEALTH PROTECTION AND DISEASE RISK PREVENTION

Increase quality and years of healthy life

Access to quality health services Immunization and infectious diseases

The Individual (Behavioral) Approach

The Nurses Role in Promoting the Health of Individuals

Direct clients attention to positive Be sensitive to the variety of physical,

Teach and facilitate client self-care Assist clients to differentiate them-

The Socioenvironmental (Ecological) Approach

The Societal (Policy) Approach

COMPLEXITY OF Intervention from the Top COMPLEXITY OF

DYNAMIC OF RISK DYNAMIC OF POLICY

The Disease Perspective of Health

LIFESTYLE AND RISK IMPLEMENTATION AND POLICY AND UTILIZATION

The Nurses Role in Societal Health Promotion

The Person Perspective of Health

Ideas of Health Consistent with the Integration Perspective

Enable the individual to enfold or unfold in the process of becoming

Cunningham (2001, p. 220) differentiates spontaneous healing from assisted healing.

1. Whole person outcomes

2. Ability to cope outcomes

Roles for Nurses in Healing

Characteristics of Nurse Healers

Relative risk Lifestyle behaviors Relationships (connections)

(probability of anger) Individual responsibility Presence

Medicine Health education Holistic nursing

Public health Nursing Integrative health promotion

Holistic Nursing Practice

Advantages of Holistic Nursing Practice to Promote Healing

Integrative Health Promotion

Chapter Key Points

Describe two models of health in terms of their different views of change

The Strengths Perspective

Positive functioning incorporates self-acceptance, personal growth, purpose in life, envi-

The Theory of Healthiness

A relationship is an enduring association and an ongoing connection between two persons

In contrast, self-efficacy is related to perceived capability (can is a judgment of capability)

Belief about control can be a cognitive appraisal in a specific context (situational), or a

interpretations of competitive anxiety, performers reported the use of cognitive management

Chapter Key Points

Differentiate between popular and professional belief systems

Popular Health Care

COMMUNITY-BASED HEALTH CARE

Professional Health Care

Biomedical Health Beliefs

A healthy person is a symptom-free person; symptoms are defined as abnormalities that

TRADITIONAL MEDICAL BELIEF SYSTEMS

Major Values of Traditional Health Systems