question regarding holistic cares

Practice

Holistic Physical Assessment: A New Framework for Nursing Practice Honoring the Whole Person

Olof Indridadottir, DNP, AHN-BC, CRRN University of Minnesota, USA

Julie Nisco-Madden, DNP, AHN-BC, PHN Pacific College of Health and Science, San Diego, CA, USA

Scholars have argued that standard physical assessment is based on a medical framework instead of nursing theories and philosophy.We argue that standard physical assessment is task-oriented, lacking emphasis on the whole-person and neglecting a least-to-most invasive assessment process. While holistic health assessment is person-centered and multidimensional; addressing aspects such as physical, emotional, and spiritual well- being, there is not a comprehensive explanation on how to holistically perform the physical examination portion of a holistic health assessment. Proposed is a new framework for holistic physical assessment in the hospital environment, honoring the whole-person, their background, and lived experiences. The frame- work builds on the holistic nursing philosophy, integrative nursing principles, and trauma-informed approach, and systematically arranges physical assessment from least invasive to most. The seven sequential assessment steps incorporate self-care and awareness into the preparation and closure of the assessment—(1) the self, (2) the space, (3) least invasive, (4) moderate invasive, (5) most invasive, (6) the space, and (7) the self. This framework can have significant implications for nursing practice and education settings, providing valuable guidance for a holistic physical assessment that emphasizes whole-person care.

Keywords: framework; holistic assessment; nursing education; nursing practice; physical assessment

Introduction

Health assessment, a core competency in nursing practice, constitutes subjective and objective data, col- lected through thorough health history and physical assessment. The ability to effectively perform a health assessment is fundamentally imperative for quality nursing care planning, nursing interventions, and patient care. However, obtaining a holistic health history is often emphasized while performing a truly holistic physical assessment is overlooked (Donnelly & Martin, 2016; Jarvis et al., 2014; Martinez- Martin, 2013; Mills, 2017; Mitchell, 2019; Patz, 2014; Potter & Frisch, 2007;Wilson &Giddens, 2022).

Through clinical experience and education, a noticeable gap in practice associated with the term “holistic health assessment” was identified. Holistic

health assessment seems to be used freely in the liter- ature, textbooks, and other educational documents without a clear definition of its meaning and inclu- siveness. Clinical practice further identified patients frequently emphasizing their preference to be cared for as a person and not as objects. Part of caring for the person instead of the patient is to perform a holis- tic physical assessment that honors the whole human, their lived experiences, and preferences. It is an imperative part of holistic nursing philosophy to lead by an example and walk the talk.

Authors’ Note: Please address correspondence to Olof Indridadottir, DNP, AHN-BC, CRRN, School of Nursing, University of Minnesota, 5-140 Weaver-Densford Hall, 308 Harvard St SE, Minneapolis, MN 55455, USA; e-mail: [email protected]

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The passion to honor the whole person within every patient was a motivation for the primary author to conduct and analyze the current litera- ture related to physical assessment. As a result, pro- posed is a new framework for a holistic physical assessment for clinical practice, honoring the whole-person. It embeds the individual’s physical, emotional, and spiritual well-being, lived experi- ences, and environment into the assessment. This new framework combines the holistic nursing phi- losophy (American Holistic Nurses’ Association [AHNA], 1998b; Cordeau, 2022; Dossey, 2016), integrative nursing principles (Koithan, 2019; Kreitzer, 2015; Kreitzer et al., 2022), and trauma-informed care guidelines (Center for Disease Control and Prevention [CDC], 2020; Substance Abuse and Mental Health Services Administration [SAMHSA], 2014).

Background

Standard Physical Assessment

Scholars describe standard physical assessment as medically focused (Lillibridge & Wilson, 1999). We further argue that standard physical assessment is task-oriented, lacking emphasis on the whole- person and their lived experience, and is neglecting a least-to-most invasive assessment process.

Standard physical assessments routinely performed in a head-to-toe (H2T) order, often start with the most invasive assessments, the respiratory and cardiac systems assessment, and conclude with the neurologi- cal system assessment (Huber & Epp, 2022; Jarvis et al., 2014; Wilson & Giddens, 2022). Exposure of the chest, from a whole-person perspective, is an inva- sion of the individual’s emotional space as well as their physical space. Such an invasive gesture can be per- ceived as a threatening, potentially triggering retrauma- tization in instances where individuals have experienced former trauma. Donnelly and Martin (2016) reported exposing the patient’s chest can lead to feelings of vulnerability, emphasizing “sensitivity to privacy and dignity” (p. 1253). Therefore, the approach for a standard physical assessment may not respect the whole person and their lived experiences.

Holistic Health Assessment

Scholars define holistic health assessment as a whole-person approach, including the patient’s

physical, emotional, and spiritual needs (Donnelly & Martin, 2016; Lillibridge & Wilson, 1999; Martinez-Martin, 2013; Mills, 2017; Mitchell, 2019; Patz, 2014; Potter & Frisch, 2007). In 1999, Lillibridge and Wilson argued the need for holistic health assessment guided by nursing theories instead of a medical framework that collects medical data and monitors “medical prescribed ther- apies” (p. 33). They proposed a holistic physical assessment guided by nursing theories emphasizing the whole-person, not only their physical symptoms. Other scholars have emphasized holistic assessment that assesses the whole-person related to symptom and illness management (Martinez-Martin, 2013; Mitchell, 2019), nursing care (Donnelly & Martin, 2016; Potter & Frisch, 2007), patient needs (Donnelly & Martin, 2016; Patz, 2014), and dentistry (Mills, 2017).

While some argue that the healthcare profession- al’s behavior traits determine a successful holistic assessment, such as mindful presence and doing with the patient and not to the patient (Mills, 2017; Patz, 2014; Potter & Frisch, 2007), others argue that obtaining subjective data determines a success- ful holistic assessment (Donnelly & Martin, 2016; Martinez-Martin, 2013). Even though scholars emphasize the importance of a holistic assessment, current holistic health assessment focuses on holistic health history and patient needs, and fails to describe holistic physical assessment.

Physical Assessment in Nursing Practice

Globally, nurses and nursing students in clinical practice use 11% to 30% of the physical assessment skills (PAS) regularly (Birks et al., 2013; Cicolini et al., 2015; Giddens, 2007; Egilsdottir et al., 2019; Shi et al., 2020). The utilization of the PAS varies between specialties and countries (Birks et al., 2013; Cicolini et al., 2015; Egilsdottir et al., 2019; Liyew et al., 2021; Shi et al., 2020; see also Kohtz et al., 2017). In many countries outside of the United States, physical assessments include most often inspection of patient’s general appearance, skin integrity, respiratory effort, and obtaining vital signs (Cicolini et al., 2015; Egilsdottir et al., 2019; Lillibridge & Wilson, 1999; Shi et al., 2020). However, nurses in critical care are more likely to use more of physical assessment skills than other nursing specialties (Cicolini et al., 2015; Liyew et al., 2021). Giddens first pointed out a gap

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between the amount of PAS used in nursing practice and those included in nursing education in the United States in 2007. Global scholars report similar results (Kohtz et al., 2017; Tan et al., 2021). Giddens’s study is yet to be repeated within the United States for the current utilization of PAS. Scholars report lack of training, lack of confi- dence, and ward culture as barriers to performing physical assessments in clinical practice. Participants globally perceived physical assessment as the role of the physician rather than the nurse (Alamri & Almazan, 2018; Lesa & Dixon, 2007; Liyew et al., 2021; Maniago et al., 2020; Shi et al., 2020). The discrepancy between practice and edu- cation among lack of role models can potentially impact student learning in the clinical environment (Alamri & Almazan, 2018; Byermoen et al., 2022; Maniago et al., 2020).

Foundational Philosophies, Clinical Principles, and Guidelines

Holistic Nursing Philosophy. Holistic Nursing is defined as “all nursing practice that has healing the whole person as its goal” (AHNA, 1998a) “and honors relationship-centered care and the intercon- nectedness of self, others, nature, and spirituality” (Cordeau, 2022, p. 3). Holistic nursing stems from five core values: (1) holistic philosophy, theories, and ethics; (2) holistic nurse self-reflection, self- development, and self-care; (3) holistic caring process; (4) holistic communication, therapeutic relationship, healing environment, and cultural care; and (5) holistic education and research (Mariano, 2022). The holistic nursing philosophy emphasizes the importance of the holistic presence of the nurse when interacting with the patient. The holistic nurse role models holistic self-care and leads by an example by doing with instead of doing to the patient (Patz, 2014). The holistic nurse prac- tices and demonstrates self-awareness and mindful presence when caring for the whole person which requires the recognition of what physical, emotional, and spiritual presence they are bringing into each patient encounter. Another core value, the holistic caring process, guides holistic nurses to assess how an illness impacts the patient physically, intellectu- ally, emotionally, and spiritually. The holistic caring process takes into consideration where the patient is at and their care preference. However, holistic nursing philosophy does not guide nurses on how to

perform a holistic physical assessment that honors, guides, and considers all aspects of the whole person.

Integrative Nursing Principles for Clinical Practice. Integrative nursing is a framework for clinical practice that focuses on improving the health and well-being of the patient, their families as well as the healthcare professional providing the care (Kreitzer, 2015). Integrative nursing is defined as “a way of being, knowing, doing that advances a whole health perspec- tive to optimize well-being (Kreitzer et al., 2022), [of persons, families, and communities through caring/ healing relationships]” (Koithan, 2019; Kreitzer, 2015). Integrative nursing is further based on six princi- ples: (1) human beings are whole systems inseparable from and influenced by environments; (2) human beings have an innate capacity for healing and well- being; (3) integrative nursing is person-centered and relationship-based; (4) nature has healing and restora- tive properties that contribute to health and wellbeing; (5) integrative nursing is informed by evidence and uses a full range of conventional and integrative approaches, employing the least intensive intervention possible depending on the need and context; and (6) integrative nursing focuses on the health and wellbeing of caregivers as well as those they serve (Kreitzer et al., 2022; see also Koithan, 2019; Kreitzer, 2015). The six principles guide the nurse in collecting subjective patient information, in choosing integrative modalities in collaboration with the patient, and in other disci- plines. Like, holistic nursing philosophy, integrative nursing principles have yet to explain how to perform a holistic physical assessment.

Trauma-Informed Approach. Trauma is “an event, series of events, or set of circumstances that the individ- ual experiences as physically or emotionally harmful, and has long-lasting impacts on the individual’s functioning and holistic wellbeing” (SAMHSA, 2014, p. 7). Studies show that 61% of American adults have experienced at least one trauma in their lifetime (Center for Health Care Strategies[CHCS], 2024; CDC, 2021; Merrick et al., 2018), emphasizing the importance of trauma-informed approach (TIA) in healthcare. The foundation of the trauma-informed approach rests on the nurse’s general knowledge about trauma, its signs and symptoms, and its impacts on how individuals per- ceive nursing care, as well as the nurse’s self-awareness about their own reactions when caring for patients (CDC, 2020; Fleishman et al., 2019; SAMHSA, 2014). Trauma-informed care is based on six principles

Holistic Physical Assessment: A New Framework / Indridadottir and Nisco-Madden 3

—(1) safety; (2) trustworthiness and transparency; (3) peer support; (4) collaboration and mutuality; (5) empowerment, voice, and choice; and (6) cultural issues (SAMHSA, 2014). Both the patient and the healthcare professional need to feel physically, emotion- ally, and spiritually safe throughout their encounter to be able to establish trusting and caring relationships within a safe space (SAMHSA, 2014). Holistic and integrative nursing characteristics and self-awareness of one’s behavior toward the patient all support trauma-informed nursing approaches and lay the foundation for a holistic health assessment (Pink, 2022; SAMHSA, 2014).

The Holistic Physical Assessment Framework

Based on a critical review of the literature, pro- posed is a new framework for holistic physical assess- ment in nursing practice. The new framework is based on the author’s clinical experience, the founda- tional philosophy of holistic nursing, and guided by the principles of integrative nursing and a trauma-informed approach to clinical practice. The framework proposes to decrease the number of physical assessment skills and divide the assessment into smaller segments based on their invasiveness. The Information Processing Theory by George A. Miller inspires breaking the PAS down into smaller segments where learning builds on previous learning (Phillips, 2018). We believe that this method can facilitate nursing students’ learning (Nielsen, 2009) by giving more clarity and decreasing anxiety and confusion. Therefore, we propose that the holistic physical assess- ment be performed systematically in a least-to-most invasive order. Dividing the physical assessment into the least-to-most invasive order, respects the whole person, and their lived experience, and includes the least amount of threat of triggering retraumatization of the patient (Fleishman et al., 2019; SAMHSA, 2014). This means that assessments of the respiratory and cardiac systems, for example, are performed later during the assessment to allow the patient time to adjust to the invasiveness of the assessment (see Figure 1). We further differentiate between holistic physical assessments performed in a hospital environ- ment compared to clinical primary practice.

The proposed new holistic physical assessment framework includes seven sequential assessment steps—(1) the self, (2) the space, (3) least invasive, (4) moderately invasive, (5) most invasive, (6) the

space, and (7) the self (see Figure 2). Each step is defined and explained from a holistic approach for both the healthcare professional and the patient and is inclusive of mind, body, spirit, and TIA. On each step of the holistic physical assessment, the healthcare professional collaborates with the patient by explaining the procedures, asking for consent, and ensuring safe holistic well-being throughout the process.

Step 1—Assess Self

Mind—Mindful presence Body—Don relevant personal protective equip-

ment (PPE), hand hygiene Spirit—Centering and clearing energy TIA—Open nonjudgmental mindset, awareness

of own biases, and holistic presence The first step in the holistic physical assessment

includes the healthcare professional’s holistic prepa- ration before entering the patient’s room. The health- care professional is bringing their physical, intellectual, emotional, and spiritual presence into the patient’s private space, and comfort zone. In this step, the healthcare professional takes a deep breath, to clear their mind, to be able to be mindfully present in the moment, and for clearing any energy from previous counters. They perform hand hygiene and don any relevant PPE before stepping into the patient room.

Step 2—Assess Space

Mind—Clinical judgment and self-awareness Body—Environmental and safety assessment Spirit—Holistic presence of healthcare team

members and assessing the energy in the room TIA—Creating a space for a trusting and welcom-

ing environment The second step assesses the space and begins

when the healthcare professional steps into the patient’s room. This step contains a two-way assess- ment and the collection of objective data. After step- ping into the patient room, the healthcare professional, while physically and spiritually furthest away from the patient, finishes their hand hygiene and introduces themselves, simultaneously assess- ing the space for physical safety, general energy, and optimal healing environment (see Figure 1). By assessing the space while furthest away from the patient, the healthcare professional creates an opportunity for the patient [and their family] to

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adjust to their holistic presence. The other side of the assessment is from the patient’ perspective. It is imperative for establishing trust that both the healthcare professional and the patient feel safe throughout their encounter. The patient has the innate capacity to pick up on the healthcare profes- sional’s holistic presence when they step into the room. With unconscious awareness, assessed is the healthcare professional’s body language, tone of voice, and holistic presence during the first 2 min of the encounter. The patient’s assessment of the situation impacts their decision to trust the health- care professional with their care.

Step 3—Least Invasive

Mind—Clinical judgment Body—General survey, and airway, breathing and

circulation (ABC) Spirit—Providing space to adjust to the invasive-

ness of the physical assessment

TIA—Clear communication, asking about sleep patterns, asking for consent before touching the patient, and explaining procedures

Least invasive, the third step of the holistic physical assessment begins after the healthcare professional has finished their environmental and safety assessments. After the initial introduction, the healthcare profes- sional assesses the patient’s general survey, signs of acute distress (ABCs) that might require immediate reaction, level of consciousness, pain, and sleep. The questions are purposely superficial, and least invasive, yet important to allow the healthcare professional and the patient (and their family) to get to know each other on a holistic level. Further, asking questions about sleep can give an indication about potential pre- vious experienced trauma.

Step 4—Moderately Invasive

Mind—Critical thinking and analyzing objective data clues

Figure 1. Original holistic physical assessment.

Holistic Physical Assessment: A New Framework / Indridadottir and Nisco-Madden 5

Body—Vital signs, neurological, musculoskeletal, partial cardiac, and skin assessments of extremities

Spirit—Offering the patient to join a trusting, caring, and supportive relationship

TIA—Respect of privacy, performing less invasive body systems first, creating space and time for the patient to adjust to the invasiveness of the assessment

Moderate invasive, the fourth step in the holistic physical assessment, begins when the healthcare pro- fessional collects data about the patient’s vital signs before assessing muscle strength, sensation, pulses, edema, capillary refill, joint integrity, and skin integ- rity. The healthcare professional assesses bilateral grip strength and, at the same time offers the patient a welcoming touch to establish a trusting, caring, and supportive relationship throughout the hospital stay. Extremities are assessed in an H2T manner, from the shoulders down to fingers, to lower extremities in the same manner (see Table 1).

Step 5—Most Invasive

Mind—Critical thinking and analyzing objective data clues

Body—Respiratory, cardiac, and skin assess- ments of chest, abdomen, and back, and patient holistically exposed

Spirit—Mindfulness of patient’s holistic wellbeing

TIA—The most invasive part of the physical assessment performed last

Most invasive, the fifth step of the holistic physi- cal assessment begins after assessing the extremities. Included are the head, eyes, ears, nose, throat, respi- ratory, and cardiac systems, in a H2T order. The assessments require invading the patient’s personal space, and exposing the patient’s chest area and heart chakra. The heart chakra represents love towards oneself, compassion, and empathy, and holds any emotional pain from lived experiences. Therefore, this is considered the most physically, emotionally, and spiritually invasive part of the phys- ical assessment. After respiratory and cardiac assess- ments, the healthcare professional proceeds to do the abdominal assessment. After receiving consent, the healthcare professional exposes the abdominal area by moving the top sheet to the patient’s waist and the gown up to keep the chest covered. The gown contributes to an increased sense of holistic safety for the patient while other body parts are exposed. A pelvic assessment is performed last.

Step 6—Assess Space

Mind—Closure through verbalization, scan of the room, and patient for optimal healing environment

Figure 2. The holistic physical assessment framework.

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Table 1. The Holistic Physical Assessment Guide

Steps Notes

Step 1—Assess self Preparation—Self Prepare self by taking a deep breath before entering the patient room and

starting the assessment. Perform hand hygiene and put on relevant PPE, if applicable Introduce yourself to the patient and ask the patient how they would like to be addressed

Step 2—Assess space Environment and safety Assess environment for atmosphere/energy, clutter, and presence of a family

member Assess space for safety: (a) Inspect potential objects on the floor, bed safety, location of the bedside table, and call light.

(b) Inspect the presence and integrity of urinary catheter, oxygen device, IVs, drains, Wound vac, SCDs, and chest tube

Provide privacy as needed and ensure adequate lighting Step 3—Least invasive General survey Inspect Inspect perspiration, muscle tension, and breathing effort

Inspect level of consciousness and affect Inspect dress, hygiene, and skin color Inspect facial expression, tone of voice, flow, and rate of speech Inspect gait, posture, and movements Inspect any mobility aids, mechanical equipment, dressings, or ostomies

Mental status LOC Verify the client’ identification

Assess level of consciousness (A&Ox4) Allergies Ask if the patient has any allergies Pain Ask if the patient has any pain Sleep Ask about sleep—amount, feeling rested upon waking, and presence of

dreams* * Pay attention to nightmares

Vital signs Take vital signs—T, BP, HR, RR, and SaO2

Skin Preparation Cover the parts of the patient that are not being examined Inspect Inspect skin throughout the examination for lesions, moles (ABCDE),

texture, pallor, cyanosis, jaundice, erythema, hypo- and hyperpigmentation.

Step 4—Moderately invasive Upper extremities (UE) Inspect UE for equality of height, symmetry, skin integrity, edema, and color

Inspect UE’s joints for alignment, symmetry, edema, and deformities * Palpate UE for sensation, numbness, and tingling (N/T) * Done in one motion * Palpate UE for joint swelling, deformities, and pain * Palpate skin for texture, temperature, thickness, moisture, and edema Palpate radial pulses for presence, amplitude, and rhythm. Compare L/R Inspect fingernails and nail beds for clubbing Assess capillary refill Assess turgor Assess muscle tone, strength, and ROM—(grip strength, pull, and push) Assess UE drift

Lower extremities (LE) Inspect LE for symmetry, skin integrity, edema, and color Inspect LE’s joints for alignment, symmetry, edema, and deformities Palpate LE for sensation, numbness and tingling (N/T) * Done in one motion—

pay attention to heelsPalpate LE for joint swelling, deformities, and pain * Palpate skin for texture, temperature, thickness, moisture, and edema

(continued)

Holistic Physical Assessment: A New Framework / Indridadottir and Nisco-Madden 7

Body—Cover the patient, document findings, perform environmental, and safety assessment

Spirit—Cover the patient, and ensure an optimal healing environment

TIA—Ensuring the patient’s wellbeing before leaving the space

Assessing the space, the sixth step and holistic closure of the holistic physical assessment begins after completing the assessment of all body systems. The closure includes ensuring a safe and optimal healing environment for the patient, assessing for signs of potential retraumatization, and guaranteeing

the patient’s belongings and call light is within reach in a decluttered, clean space.

Step 7—Assess Self

Mind—Closure through verbalization and mindful presence

Body—Doffing PPE and hand hygiene Spirit—Centering and clearing energy TIA—Awareness and acknowledgment of own

responses, biases, and holistic presence from the patient encounter

Table 1. (continued)

Steps Notes

Palpate posterior tibial, and dorsalis pedis pulses for rate, rhythm, and amplitude

Assess capillary refill Assess muscle tone, and strength (quads, step on the gas, and toes up)

Step 5—Most invasive HEENT Inspect the head for size, shape, and symmetry This can be done while

talking to the patientInspect the head for masses, and signs of trauma Inspect the face for symmetry at rest, and with movement (CN V and VII) Inspect the eyes for transparency, color, drainage, and surface characteristics

Inspect the pupils for size, shape, and symmetry Inspect the external ear for skin color, lesions, and deformities Inspect the neck for lesions, lumps, and masses Inspect for JVD Assess eye movement—extraocular movement (EOMs) Assess pupils for PERRLA Finger-to-nose test

Thorax Inspect the patient’s appearance, posture, breathing effort, breathing pattern, and chest expansion

Auscultate anterior, posterior, and lateral thorax for breath sounds Auscultate the heart for sounds

Abdominal Inspect the abdomen for skin color, surface characteristics, and venous pattern

Inspect the abdomen for contour and surface movement Auscultate the abdomen for bowel sounds Auscultate the abdomen for bruit over aorta, renal, and iliac arteries Palpate all four quadrants for tenderness and muscle tone (light palpation)

Closure Step 6—Assess space Space Ensure patient comfort and privacy

Prepare space for optimal healing by decluttering the space and placing personal items and call light within patient’s reach

Step 7—Assess self Self Doff PPE and perform hand hygiene

Take a deep breath to clear energy from the encounter and to prepare self for any encounter when exiting the patient room

Abbreviations: A&Ox4 = alert and oriented to self, time, place, and situation; ABCDE = asymmetry, border, color, diameter, and evolving; ROM = range of motion; JVD = jugular venous distension; PERRLA = pupils equal, round, and reactive to light and accommodation; HEENT = head, eyes, ears, nose, throat; PPE = personal protective equipment.

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Assessing self, the seventh and the last step in the holistic physical assessment includes the healthcare professional’s holistic preparation to exit the patient room. Any PPE used in the encounter is removed and hand hygiene is performed while clearing all energy associated with the encounter. The healthcare professional takes a deep breath, performs an ener- getic scan of self, any biases, and responses that might have surfaced, and clears their mind to be mindfully present for the situation that will present itself when exiting the room.

Conclusion

Proposed is a new framework for a baseline holistic physical assessment in the hospital environ- ment. The new framework is based on holistic nursing philosophy and theories and integrative nursing principles; honors the whole person and their lived experiences; and provides a systematic least-to-most invasive approach. There are many nursing theories that have impacted holistic nursing philosophy in one way or another, and each one is acknowledged. The primary author does not differentiate between their impacts, however, the framework shares more similarities with nursing theories by Barbara Dossey, Martha Rogers, and Jean Watson (Dossey, 2022; Lutjens, 1991; Rogers, 1970; Watson, 2008). To our knowl- edge, this is the first publication of a holistic physical assessment that is based on nursing theories, princi- ples, and guidelines; that honors the whole person and their lived experiences.

The benefits of the framework are first and fore- most the respect for the person within the patient, and collaboration with the patient. It further teaches nurses and nursing students to view the patient using a clinical holistic thought process. The framework does not take into account primary care, pediatric settings, nor critical care settings but can easily be adjusted to those care set- tings. The framework focuses on foundational data collection for stable patients but takes into account frequently changing patient conditions. Therefore, it is expected that nurses demonstrate clinical judg- ment while performing an initial general survey during the least invasive phase of the assessment, and perform a focused assessment when it is rele- vant. Focused assessments for each system are not included in the framework. Critical situations are bound to be holistically invasive for the

patient depending on the severity of the situation. It is our hope that healthcare professionals can provide holistic care and create an opportunity for the patient to heal from the encounter.

Implication for Nursing Education

The proposed framework includes a detailed check- list that can be used in nursing education. Our experi- ence teaching and using the framework in education has been positive. Students like the flow of the checklist and honoring the whole person. We have very briefly experienced more holistic nursing care provided by the nursing students, honoring the person within each patient. It is our hope that improved clinical prac- tice can improve nursing student outcomes. Improving clinical practice goes hand in hand with improving nursing education. One cannot happen without the other. The new framework can support learning among nursing students, decrease the gap between clinical practice and education, and teach a holistic approach from the beginning. Scholars report nursing students’ struggles to learn physical assessment (Huber & Epp, 2022). Potential reasons relate to over- whelming amounts of required skills, lack of role models, and the discrepancy between education and practice (Giddens, 2007; Kohtz et al., 2017). The framework’s detailed checklist format can give nursing students increased clarity and confidence when learning physical assessment.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Olof Indridadottir https://orcid.org/0009-0006-1552-4618

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Olof Indridadottir is a professor of nursing at University of Minnesota. She teaches holistic health assessment, critical care, response to health and illness, and clinical practicum. Her areas of interests and expertise include rehabilitation nursing, holistic and integrative nursing, and inclusivity, equity and diver- sity in nursing education.

Julie Nisco-Madden is an Associate director of nursing at pacific College in California. She is passionate about increasing access to holistic nursing education in her community. Her areas of interest and expertise is to bring integrative approach into pallia- tive care and public health.

Holistic Physical Assessment: A New Framework / Indridadottir and Nisco-Madden 11

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