Guest Blog: Integral Nursing in Canada (James Baye)
April 17, 2007 20:51
The following is being posted according to Ken's generous offer. The posting of a submission doesn't imply that Ken or the editors of this site necessarily agree with any or all of it. Thanks, -Eds
James Baye: "Nursing In Canada with the Integral Framework--An Introduction" (right-click to download... you will need to view the pdf to see James' references at the end of the paper....)
Healthcare development is at an amazing place in its evolution. The complexity of this tremendous being is both overwhelming and awe-inspiring. As the general health of our nations decline, as more people are living longer, as diseases and injuries become more elaborate, and as the average age of the population increases - the necessity to master this goliath is crucial.
Integral provides one of the most important methods in viewing, managing and maneuvering Healthcare. The range of Integral's scope combined with the depth of its wisdom, bring forth a capacity to not only understand Healthcare, but also induce the most powerful and compassionate of precise actions. This article uses a nursing lens to show how Integral can be used to view and shape Healthcare. The examples given can easily be extrapolated to other professions within Healthcare, and to the full range of what Healthcare encompasses.
Abstract : Nursing In Canada with the Integral Framework
By James Baye
The motivation behind this article is to aid in the progressive, sustainable and integrative development of Canadian nursing and health care. Presently, for a grand variety of reasons, Canadian health care is in a state of progressing flux and disorder. Nursing, as a significant part of the health care system, is greatly affected by this situation both extrinsically and intrinsically. As it becomes apparent that the world is becoming exponentially complex in its evolutionary growth, nursing, and health care in general, need to move beyond the limited scopes which their present models of management and development possess.
The main focus of this article is to introduce the Integral framework and its application to nursing and health care. The Integral framework is the cutting edge model being used globally for social, political, organizational and institutional reform. It is a mega-theory which allows a mega-perspective on all theories and methodologies. It provides a place for all aspects of reality to exist, demonstrates how they connect to each other and allows the most effective action to ensue with the utmost of integrity and truth.
Interestingly enough, the only thing the Integral framework actually provides is a new way of looking at reality. It is through this new way of looking at reality, of breaking it down into four equally-weighted, irreducible quadrants, that we can then understand how to approach and meet the high-paced, increasingly complex demands of nursing and health care. By utilizing the reports from R.J. Romanow and the Canadian Nursing Advisory Committee, as well as other specific examples to demonstrate the use of the Integral framework, this article will provide an initial understanding and ability to put into practice the brilliance of the Integral framework.
The Integral framework allows us to move with assurance, proof and honesty towards a seamless, collaborative, integrated health care system. Each health-care practitioner and leader can have a clear view of the process and have access to any aspect of reality in order to meet the needs of patient care. There is a freedom in this. A freedom in knowing that we can embrace and engage with all that exists, in order to be all that we are, as nurses and people.
Nursing In Canada with the Integral Framework
By: James Baye
Where we are and what we want
The motivation behind this article is to aid in the progressive, sustainable and integrative development of Canadian nursing and health care. As a step in such a development, the focus of this article is to introduce a new way of looking at nursing and health care. This approach requires only the effort to acknowledge what exists and the desire to move ahead with honesty and integrity. As such, this is an approach that can be accomplished anywhere, by anyone, in collaboration and cooperation with everyone and everything involved in health care. The rationale behind introducing this novel outlook is need. There needs to be a new way of managing, delivering and enhancing health care. Our health care system is not working as well as it could, and nursing is caught within this fray.
As a significant variable within the Canadian health care system, nursing is presently in a very precarious position. The nursing shortage in its present and future conditions has been well examined and documented 1. Even though nursing is a prime player in health care, nurses continue to run into a multiple of barriers which diminish their capacity to effect change 2. According to the 2002 report from the Canadian Nursing Advisory Committee (CNAC) nursing is one of the most undervalued, fragmented, leaderless and abused professions in Canada 3. As we all know, this horrendous state of affairs affects the entire health care system and each nurse individually.
The lack of personal and professional respect for nurses leads to fewer nurses in the work-force and thus affects patient care 3. Varying values and work-ethics leads to inconsistent occupational practices 4. The majority of nurse-doctor relationships continue to be unbalanced in power and respect 5. Strained or tense communications exist between peers, managers, unions and employers with usually no system or motivation for enhancement. This unstable status, coupled with increasing lack of self-care 6, set within the high-paced fluctuating demands of health care, causes nurses to be incredibly vulnerable – physically, mentally, emotionally, spiritually 2,7. No wonder, nurses get injured and sick more than the average Canadian worker, costing the nation $1.5 billion annually 2.
Within the last two years much focused research has come to fruition, bearing significant implications for nursing. The CNAC report expressed 51 recommendations for employers, governments and the Canadian public to consider for positive growth and transformation within the nursing profession 2. Through its recommendations to invest in health care providers, the Romanow report seeks to promote changes that could directly benefit nursing development 8. The CNAC report expresses a need for a new framework that would lead to improved strategies for nursing bodies 2. The Romanow report echoes that sentiment, but in the larger scale of health care reform, stating the need for a seamless, collaborative, integrated health care system 8. Finally, the Canadian Nursing Association (CNA), as well as the provincial/territorial nursing bodies (both regulatory and union), have consistently been creative and persistent in expressing their recommendations for change.
The breadth of these recommendations, based on the depth of the predicament is immense. As sound as these recommendations are, their multitude leads to an overwhelming awe - there are so many of them, and they are so big. How does one eliminate workplace violence, improve the supply and distribution of health care providers, implement an increase in doctoral nursing programs, enhance the workplace, design flex scheduling, encourage changes in scope and patterns of practice while still decreasing workload and increasing student nurse enrollment 2,8? All these recommendations appear so fragmented, are they actually connected somehow? Each recommendation can be approached from so many angles, which one is the best? Is there a best? Who is responsible for what? How will time effect such undertakings? What sort of framework, model or system could encompass these recommendations in a manner that honors them all, while giving due respect to the needs required for each of them?
With so many questions to answer, let us imagine that a single framework could be developed. What would it look like? It would have to support a nurse’s daily work, allowing nurses to work cohesively together and with other health care practitioners. As well, it would be able to enhance individual and workplace transformation, gather all the recommendations in all the reports, and support the evolution of nursing as a unique profession immersed as an intrinsic component of Canadian health care.
We need a structure that is not limited. We have all seen new ideas, policies, concepts, and reforms come and go; thus, what we are looking for is a framework that can address all present and future needs. As Canadian nurses we want and deserve something that we can really trust, something we can see and understand. We need a tangible framework which expresses integrity and truth, which provides various tools and methodologies for how to meet the recommendations at hand. While, that is a lot to ask for, and a huge amount to accomplish, it is not impossible. It can be done, and in fact, it has.
Emergence of an integrated framework
In 1992, social philosopher Ken Wilber went into solitary research and study 9. During that time he brought together literally hundreds of the world’s theories and practices relating to physical sciences, sociology, psychology, philosophy, religion, spirituality, etc 10. After three years he emerged with the Integral framework, a weaving together “of the many pluralistic contexts of science, morals, and aesthetics, Eastern and Western philosophy and the world’s great wisdom traditions”(p. 38) 10. In its essence, the Integral framework is an overall map of generalization; displaying, in a practical context, how all things can co-exist 11.
An Integral methodology makes room for all types of experiences, data, revelations and phenomena from any practice or discipline, “from hermeneutics to phenomenology to behaviorism to systems theory to meditation to collaborative inquiry to vision quest to quantum physics to depth psychology to molecular biology” 12. The basic premise of any Integral approach is ‘Everybody is Right’, or put another way, ‘nobody can be 100% wrong, 100% of the time’ 9,11, so let us collect all the ‘right’ pieces people have expressed and pull them together so we can use them with integrity and honesty to get where we want to go 13. As the complexity of the world increases exponentially in ways that we are barely able to comprehend, it seems wise to have access to all the tools potentially available to us 14. Nursing, and health care in general, is still relying on assets which have limited scope and is denying the strengths of other methodological resources; it is time to move beyond these self-defeating praxes.
Right now, the Integral framework is being used in business, politics, medicine, religion, arts, education, ecology, spirituality, psychology, feminism and law 10,15. Both Canadian nursing and the Canadian health care system can greatly profit from utilizing the Integral framework. Approaching national problems, progressing provincial developments, enhancing local situations, engaging in daily activities, the Integral framework can be used for them all. An Integral approach will benefit the system, its health care practitioners and the reason we are drawn together…the patients.
Core of the Integral framework
Wilber discovered that all aspects of reality as we know it can be placed within one of four dimensions: individual exterior, individual interior, collective exterior and collective interior 10 (see figure 1). Medicine, for example, utilizing the physical sciences of biology, chemistry, pharmacology, etc focuses purely on the exterior aspects of an individual. That is to say, medical sciences look at and apply practices that deal with our individual physical forms, namely our bodies. This may include our bones, kidneys, neurotransmitters, mitochondria, toes, brainstem or gluteus maximus, yet all of it is only dealing with our external physical form. Medicine does not look at our intangible interiors. Our feelings, emotions, awareness, imagination, intelligence, morals, and beliefs are just some of what make up our insides, our interior dimension.
The interior dimension is also a very real aspect of our lives; we encounter it every time we think, dream, love or wonder. These amazing aspects of ourselves do not have a physiological area in which they emerge. We can not use a microscope, MRI or lab test to find ethics, beliefs or dreams, for they exist as part of our intangible internal selves. Mainstream western science is slowly beginning to acknowledge that our inner self plays an important and essential part in our physical health processes 16. As nurses, we are already quite aware of the inner dimension of patient care. In fact, the word ‘care’ usually denotes more than just mechanical procedures for a sick body. Much of nursing care acknowledges and attempts to include a patient’s feelings and emotions. Inclusion of this interior domain is where the heart of nursing shines. Exteriority and interiority, two equally valid and real aspects of each person, two dimensions of the Integral framework.
What we have just considered relates to the individual, one person. My imagination, my thoughts, my feet, my brainstem, attributes that we all have, yet unique to each individual. However, we are not alone, we live in relation to others. We have dialogue and relationships, we share values and germs, we interact and coexist, we will always and forever be in relation to something outside of our individual self. This is the we, us and ours of reality.
The Integral approach thus also acknowledges these two dimensions of collective relationship, both interior and exterior. World views, cultural beliefs, and morals are interior aspects of our collective reality. The unspoken fundamentals of social skills, the sense of camaraderie gained from teamwork and the myths that color our collective histories are all invisible. This interior collective dimension can be studied, yet it is subjective, as all interior dimensions are, versus, the objective exterior collective dimension of existence. The rate at which a code team responds to a cardiac arrest can be measured. We can physically map out the transfer of biological pathogens within a stream system to a town’s residents. These exterior elements of our collective reality make up the objective truths that exist regardless of cultural values, social norms, or group-think. For example, the fact that smoking is detrimental to physical health is an objective reality, regardless of perspective and belief. Whereas, the value of smoking is a subjective actuality depending on a multitude of interpretative factors.
Thus we have the four irreducible dimensions of reality, which is evinced by the four quadrants (4Q) of the Integral framework.
The Integral framework is essentially a large map. It places all methodologies, paradigms, theories and beliefs into a place where it has the most appropriate and therefore potentially greatest impact 17. While frameworks of holistic design tend to acknowledge the reality and importance of these four dimensions 13,18, the Integral framework is unique in that it continues to enhance and assert the actual manner in which everything is connected to everything else 19. In fact, a main purpose of the Integral approach is to indicate how everything does relate together 10 (see side bar 1).
So to review, each of the 4Q corresponds to an equal aspect of our existence. Each quadrant represents an equal one-fourth (¼) of reality. Therefore, each quadrant has equal weight in our totality of being. The individual interior subjective, ‘I’ upper-left (UL) quadrant describes anything we have inside of our first-person self. Our self-identity, dreams, hopes, thoughts, fears, imagination, esteem, aspirations, feelings, knowledge, beliefs, values, etc all reside within this domain. Very different from the third-person objective individual exterior ‘it’ upper right (UR) quadrant that focuses solely on cells, neurotransmitters, molecules, physics, behavior, limbic system, senses, chemistry, movement, etc. This includes any exterior individual form that we can perceive with our five senses or measure by the use of equipment, therefore all physical forms of science. The subjective collective interior quadrant, the second-person ‘we’ lower left (LL) quadrant, describes all the ways in which we associate with each other, such as hermeneutics, communication, morality, mutual understanding. Which concludes that, the collective exterior lower right (LR) quadrant looks at anything which is an objective third-person ‘it’, such as systems theory, ecology, sociology, institutional design and astronomy.
The Integral approach allows us to then confidently say that the health of an individual or of a nation does not solely rely on the empirical evidence that allopathic medicine provides. Even nurses and doctors go home ‘emotionally drained’ (UL), seeking ‘comfort’ from a spouse or child (LL), or like to go out and socialize (LL) with friends to ‘loosen up’ (UL). These are all aspects of our ‘interiority’, collective and individual. Thus, medicine, for all the wonders that it is, because it focuses solely on the UR external individual, can only account for and take care of 25% of the total health of a person.
We have to honor the research that continues to demonstrate that contributions within the other three quadrants serve just as important a function in our overall health as the individual physical body does. Support groups (collective interior) contribute to a 30% increase in breast cancer remissions 20. Meditation (individual interior) has been shown to decrease blood pressure, improve mental clarity and reduce anxiety disorders 21. Regular hand washing practices in elementary schools (collective exterior) can decrease chicken pox by 40% 22. These are impressive findings that cannot be ignored or denied, demonstrating that treating illness is more than a bio-physical chemical process. This common reductionistic approach is from the same school of thought that proposes passionate love, care for a child or experiencing the marvel of a sunset are merely chemical processes in the brain. As a nurse, who has seen, experienced and continues to open to the vast riches of the whole human being, you know this not to be true. As you know, compassion cannot be scientifically calculated.
So let us move forward, aware that the overall health of people is made up of more than what the ¼ of the upper right quadrant looks at. Let us look at how the Integral framework will help us engage with greater honesty, focus and effectiveness, by activating all four dimensions of reality. Let’s see how an Integral approach can affect nursing and health care; providing us with a new way to look at, understand and work with the vast realities of patient care and the health care system.
An Integral look at nursing theory
While nursing does utilize methodologies and frameworks from various fields of study and practice, it also has its own unique way of viewing and engaging the world. Since Florence Nightingale nursing has had its own philosophies and theories which have been translated into paradigm and praxis 23. Nursing has thus created its own phenomena based on the experiences of the practicing nurse. These enactments have generated nursing philosophies, theories and meta-theories. To further develop nursing analysis and principles based on the evolution of nursing as both an art and science, can only serve to benefit nursing, and ultimately those whom nurses care for.
To make the most impact with a methodology or theory, it is important to look at what the nursing models individually support and express as their working foundation. In other words, what does a particular nursing theory state it looks at and offers the profession? The Integral framework helps us to see what broad dimensions of reality each nursing theory addresses. This approach allows us to easily utilize, adopt or borrow from a particular nursing model if it meets the needs of our goals. This has great benefit; as nursing theories are divided into the understandable and workable four Integral quadrants, more nurses may actually utilize them in their work.
The following is how the work of some nursing theorists fit within the Integral framework.
Some theorists, such as M.Rogers and B.Neuman, have created models with a near integral ideology. Florence Nightingale, in her mystical brilliance, has been said to have created nursing via an integral awareness 24. Wilber’s four quadrants display that through Nightingale’s life and work she was an integralist; meaning that she had an Integral approach that focused on the individual and collective, the inner and the outer, human and non-human25. It can be seen, however, that the majority of nursing paradigms reside within the upper right – ‘it’ quadrant, that of external, individual, behavioristic, form based sciences; (though it is noted that many theorists do overlap into other quadrants, this diagram reflects where the majority of their assertion resides). This obviously correlates to the predominant allopathic medical model that actuates western health care practices. Medically, patients are usually only treated using methodologies from the ‘it’ quadrant. While nursing may approach the aspects of that quadrant through a different perspective, it is important to remember from where the methodology arises: external, individual, behavior based quantitative research.
For example, the act of choosing a correct needle injection site for a medication is a practice that resides in the ‘it’ quadrant. This is true from both a medical and nursing perspective. From a medical viewpoint it is important to perform this correctly in order to ensure the medication is delivered effectively. From a nursing perspective, the previous is true, yet the nurse is also aware that a well delivered injection provides greater physical comfort to the patient. While the motivation of the nurse has a greater perspective (see sidebar 2), the actual practice itself is the same, the methodology of such originating from the UR ‘it’ quadrant.
However, as a nurse, giving a needle is more than just choosing the correct needle and site to provide effective medication and physical comfort. The nurse is also very aware of interior aspects of being. Nurses will take into account a child’s (internal) fear of getting a needle or a patient’s (internal) disgruntled frustration after being bruised from many heparin injections. Based on acknowledging interior feelings and emotions, subjective items that cannot be measured, we may then decide to wait five minutes until a child’s parents (collective) arrive to provide emotional (interior) comfort. This works in conjunction with the physical (exterior) comfort that we can provide with a well delivered injection.
After reading that example you may be thinking that the aspects of the four quadrants are being used all the time, in everything we do, and…you are right. The Integral framework shows us, very openly and clearly that in everything we are and do there is a causal connection to everything else 13,26 (see sidebar 3). From this consciously extensive stance in perception, we can move towards the intended goal of responsible, honest, integrated action. Since reality is equally comprised of I, We, It and Its, the Integral framework asserts that for mindful evolution to occur, each of the quadrants need to be properly acknowledged and engaged by methodologies appropriate to that quadrant 13. The evolution and advancement of any complete system, including nursing and health care, will greatly benefit from use of the Integral framework.
An example: Integral development of emergency care
The development committee of the American Heart Association’s (AHA) Advanced Cardiac Life Support (ACLS) program has greatly enhanced the scope, understanding and wisdom in approaching cardiac arrest events, by unknowingly utilizing an Integral approach. While the primary focus during a cardiac arrest (CA) event is the patient and the medical assessment, practices and pharmakinetics which can potentially aid in this person’s recovery, they are not the only factors to consider. Such aspects of a CA response reside in the UR ‘it’ quadrant; however, with a vast data base of experience and observation, the ACLS committee realized that there was much more to a CA response than just the hands-on practicalities 27. ACLS training now also focuses on how to be a good team leader and team member 27, aspects of the LL ‘we’ and LR ‘its’ quadrants. Being a good team leader requires effective interaction with other people. The only way to become better at interacting with people and potentially becoming a good leader is by utilizing practices that develop those lower quadrant competencies. Many nurses have observed, for example, doctors who may have an incredible grasp of the UR quadrant’s medical knowledge of a CA event, yet have very little skill in being an effective team leader.
Another huge evolution in CA and emergency management has been the progress of including the human dimensions found within emergency care. The AHA recognizes that serious, long-standing, emotional symptoms may occur in rescuers, hence, there is a need to incorporate psychological factors in emergency care and CPR training27. This was an exceptional move in the development of ACLS and emergency team management, incorporating not only the emotional feelings of healthcare workers, but also taking into account the family and friends of the patient 27. The AHA, noting that “the initial contact with the family will have significant impact on the grief response” (p. 1-70)27 demonstrates knowledge that interpersonal communication (LL) is highly crucial for the ongoing health of community development. Inappropriate or incomplete communication can have enduring psychological effects on the family and the staff, leading to chronic depression, anxiety and burnout 27. Subsequently, these emotionally distraught people, who may not be able to cope with everyday life, often require anti-depressants and/or therapy. This can cause disruptive family growth, more health-care dollars spent and loss of effective work time, meaning others may have to take up the excess workload, increasing the potential for further injury. And the cycle continues.
The Integral framework helps us understand that by acknowledging and acting from each of the four quadrants simultaneously, much of the detrimental outcomes of the above example can be eliminated. By including the LL quadrant skills of leadership development, communication and critical incident stress debriefing into nursing/medical training the negative outfalls of stressful emergency events will be reduced. The Integral framework then allows us to see what methodologies would work best in developing those skills. By using the Integral framework to map out various developmental strategies, nursing and health-care leaders can successfully determine what methodologies would be most appropriate for transformation in the areas which need enhancement.
Examining the report recommendations
Now that we have a taste of how to look at events through an Integral lens, let us go back to the CNAC and Romanow reports. A reasonable task is to now take what the reports have to offer and appropriately situate the various recommendations into the four quadrants of the Integral map. The purpose here is twofold: one, to discover what dimensions of reality each recommendation is addressing viewed through the Integral framework; and two, determine what methodologies would be most effective in applying an Integrally informed solution. In this way, the Integral approach constantly reminds us that it is necessary to look at all four quadrants if we want to be the most effective and comprehensive in our transformational designs.
A fully comprehensive examination of these recommendations is beyond the capacity of this article. As you become more familiar with the scope of the Integral framework further aspects of each recommendation within each quadrant will become apparent. This brief look at some of the recommendations is to introduce how to observe with the Integral framework, and not to suggest that this is the only way to approach the mentioned recommendations.
CNAC Recommendation 23. Recognizing that not enough nurses are moving into management and leadership positions, employers, educators and governments should work with nurses to build in succession planning, including moving nurses through management experiences and into formal leadership positions 2.
As mentioned above in the ACLS example and which can also be seen in numerous business mergers 28, the development of leadership does not arise from vast amounts of knowledge in the UR ‘it’ quadrant 4,29. In fact, according to Jeff Immelt, CEO of General Electric, “Leadership is an intensive journey into yourself” (p. 123) 30. Leadership means knowing how to work with others and yourself 29, these are both interior aspects of relation and being. Thus, in order to move more nurses into leadership awareness, a fully Integral approach is necessary; one which honors exterior objective knowledge, yet realizes the strength of leadership relies on interior aspects of development.
The initiation of this development most appropriately takes place in the preliminary education of nurses. Collaborative nursing education has started to encourage such evolution 31. Self-reflection (UL) and peer-review programming (LL) provides students with basic leadership skills. Further explicit Integral leadership training would engage students in becoming more aware of the various facets of leadership and engage in the proficiency of purpose, complexity and relational alignment 32. This would include creating a model for internal and external self-growth.
As students need mentors and to observe more leadership in their elders 33, nurses already in the work force have to be provided the means to actualize and mature their existing foundation of leadership. This can take on many forms. Direct education in various leadership models and confrontation coaching are basic steps that could be promptly initiated. Yet obviously, the broader aspect of truly ingesting leadership development into a health care organization would entail a review of its priorities with time and money.
Within an organization time and money tend to be purely objectively engaged. However, as it has been clearly expressed, leadership is primarily based on the subjective relationship with self and others 29. An Integral approach recognizes that the costs incurred to create, implement and maintain a leadership development program within an organization will actually save that organization much money in the long-run 4. Through fostering collaboration, sharing power and information, Integrally informed leaders help nurture the growth of self-responsibility, respect and maturity in each employee. These interior subjective realities then produce equally positive exterior objective realities. This is a commitment that can not be under-estimated.
Romanow Recommendation 26. Provincial and territorial governments should take immediate action to manage waitlists more effectively by implementing centralized approaches, setting standardized criteria, and providing clear information to patients on how long they can expect to wait 8.
As the Romanow report acknowledges, due to the haphazard manner in which waitlists are presently managed, a standardized and objective system needs to be developed 8. The LR ‘its’ quadrant looks at objective systems methodologies (ie statistical process control, total quality management). Today’s technology allows for an immense array of data variables to be remotely collected and continually re-assessed, allowing consistent appraisal of waitlists. By conducting Integrally informed surveys (ie by understanding individual interior and exterior needs) of both the health-care professionals that are involved in providing the services and the population who is being served, the most appropriate and clear information can be provided to the clients on those wait-lists. These can then be coupled with the exterior collective capacities of the resources available, and, by using interior collective assessment in priority development, will provide an ethically optimized waitlist.
This approach contains a huge amount of complexity. It means utilizing judgment to determine priority. However, this is not new. Nurses and doctors continually judge, assess and re-prioritize their thinking and actions based on the ever-changing environment they work in. An Integrally designed technological waitlist system is an attempt to standardize that multitude of judgments. This would provide a means to place value on and, therefore, prioritize the subjective needs of those involved. We do this all the time when we ask patients to rate their pain on a scale from 0 to 10. Technology, however, allows us to deal with an immense array of complex variables. If designed well, wait-lists could take into account such things as lifestyle impairments, emotional needs, travel distances, and the best times to run an MRI.
Though it may sound removed from the realms of human judgment, such a system is actually designed based on the ever-changing requirements of human need and judgment. A technologically driven wait-list management system, if devised through an Integral lens, would be both empathetic towards individual needs and meet the growing demands of a country requiring more diagnostic and specialized services.
CNAC Recommendation 50. Governments should make particular investments in nurses working in rural and remote settings. These investments should be grounded in the triple goals of recruitment, retention and improved working conditions in rural and remote settings 2.
Compared to high paying American salaries and signing bonuses, northern allowance wages and paid travel expenses are failing motivators. Thus, governments can use the Integral framework to determine in what quadrants (ie in what aspects of reality) they are lacking in recruiting and retaining rural nurses. Externally this may include physical structures for the UR individual self (ie good accommodation, nutritious food resources, exercise equipment) and for the LR collective system they work within (ie technical and practical support resources for the nursing management of others).
The interior individual needs of nurses also need to be given equal consideration. As many rural nurses are on-duty most of the time, they do not have enough personal space or time to meet their own interior individual needs 34. It must be understood how important it is accommodate these needs. This may include training the nurses in UL practices, enhancing personal interior growth, which can aid in coping with isolation and lack of sufficient peer support. Once again, interior growth provides for external ability.
While it is easy to say that more money will solve the problem, more money does not always exist and it does not change all situations. The cost of satellite internet communications may give the outpost nurse access to technical, emotional and intellectual support, yet it does not provide another set of hands. Providing the tools and legislation needed to train a few local community members in basic nursing skills, gives the RN another set of helping hands, it enhances relationship between the nurse and community, and it promotes the community to foster its own self-development.
CNAC Recommendation 40. The federal government should fund an annual national survey of nurse’ health, to continue at least until the illness, absenteeism and injury rate of nurses has been reduced to the national average for Canadian workers 2.
Such a survey would benefit tremendously by utilizing the Integral framework. By asking questions that arise from the essence of each Integral quadrant, government will gain an incredibly comprehensive view of what nurses need to reduce these infirmities. Then, by using technological system strategies from the LR ‘its’ quadrant, a cost-efficient, streamlined program can be designed to dispatch, gather and collate the survey’s data in a minimal amount of time.
The next important aspect is then cost-efficient follow-through. The correct use of technology would allow immediate distribution of the survey’s findings to the appropriate change-agents. There is no need for expensive, glossy printing and mailing of results. Email and internet communication can cost effectively ensure the correct data is sent to where it is needed. Nursing bodies and government members at all levels will then be responsible for their own Integral strategies of implementation, as the results will effect each sector differently. In this manner, a collaborative approach from the federal to the local level, deems all parties responsible for their own specific aspect of the project.
Romanow Recommendation 43: The consolidated budgets should be used to fund new Aboriginal Health Partnerships that would be responsible for developing policies, providing services and improving the health of Aboriginal peoples. These partnerships could take many forms and should reflect the needs, characteristics and circumstances of the population served 8.
Due to the multitude of stake-holders interests and ideologies involved, determining the needs, characteristics and circumstances of a population’s health requirements is always a difficult endeavor 8,18. Health promotion models express the necessity of determining a community’s health needs by soliciting information from that specific community 18. By super-imposing the Integral framework on a health promotion model, a complete, inclusive, all-quadrant schematic of a community’s needs can accurately be determined.
Via an Integral assessment, the most appropriate methodologies could then be determined for the best in policy development, service provision and partnership creation. If, for example, the health priorities of a specific Aboriginal population reside mostly within the LL ‘we’ (cultural) quadrant, it would be essential to focus more resources on the interior/subjective aspects of collective health (ie community process theory, shared visioning), versus providing education on UR ‘it’ objective/behavioral health determinants (ie heart health risk factors). Methodologies and budget allocation should then reflect these findings.
A new look is all it takes
At the onset of this article it was noted that the sheer magnitude of the CNAC and Romanow report recommendations was a little overwhelming. The territory which they span is so vast that it can be incomprehensible to know how to approach the primary stages of nursing and health-care transformation. As we saw in the handful of examples, each recommendation can be placed on the map of the Integral framework. Then, each recommendation itself can be looked at through the various quadrant lenses. Some will require methodologies, insight and knowledge from only one quadrant, while others may require the expertise of two or more quadrants to provide the best, most comprehensive results in health care transformation.
Remember, the purpose of the Integral framework is to show that everything has a place. It allows us to see that reality is made up of four equal irreducible dimensions; and that we need to completely acknowledge the influence these quadrants have upon each other, and therefore us and our lives. The Integral framework thus allows us to also find solutions by looking at methodologies that reside in the same quadrant from which the problem arises. For example, to fix a broken bone, an UR measurable fact, we employ the objective medical skills of casting found in the UR quadrant. That quadrant also provides us with nutritional information which promotes bone healing. However, it is the cultural specific communication skills of the LL quadrant, which allows us to effectively share that information to a person whose primary language is not English. To acknowledge this person’s UL emotional needs, we empathize with their pain, an LL quadrant approach, which engages our own UL emotional memories. Finally, we utilize a LR technological system to email the X-ray report to the patient’s physician.
Once again, the Integral framework does not provide us with anything new, except a new way to look at the world. This provides the rationale and means to use any and every thing we need in order to accomplish our goals in the most honest, effective and integrated fashion. By engaging with the proficiencies and responsibilities of others, we can ensure that as much that can be done, is done. And that is something both nursing and Canadian health care can greatly benefit from.
The Integrally informed nurse
One of the greatest gifts the Integral framework gives nurses and other health-care workers is freedom. For example, a nurse on a renal-unit has very specific UR quadrant knowledge and duties; it can not be expected that she has a working ability in LL quadrant family counseling. Accordingly, she can rest assured that her primary function in this patient’s care resides in her abilities that come from UR methodologies. However, by using an Integral approach she can also become aware of what aspects of care her patient may require from the other quadrants. Thus, this nurse has the freedom to be comfortable in what she knows and what she can do, without feeling she is responsible to do more. At the same time, she can, if she chooses, contact others whose specialty resides in the other quadrants, thus creating a cooperative, full-spectrum all-quadrant, Integral care plan.
The Integrally informed nurse realizes that to some degree specialization will always be necessary 16. However, as one becomes more familiar with the diseases, treatments and theories within each quadrant, one can feel more comfortable in accessing those practices for your patients. As s/he opens to the full-ness that each quadrant contains, it becomes more apparent that health is affected equally by the I, we and it of self, culture and nature. Inhabiting a new awareness makes room for new unimagined outcomes to occur. By engaging in Integral patient care, the nurse can feel incredibly informed and relaxed in her/his role, while at the same time confident and humble, thereby creating the greatest potential in compassionate healing care 16.
The Integral approach, while ultimately creating positive outcomes in patient care, also greatly provides the healers of our society with the means to take care of themselves 16. An Integral approach acknowledges and respects that each of us are made up of more that just our bodies, as such, we are more complex than the medical sciences appreciate. We know for ourselves that our emotions affect our physical health, just as much as relationships induce change in how way we act. By being Integrally informed we can more accurately understand and consequently accept, that we may become physically ill because of the relationships we have at work; or that if we do not honor our own individual interior needs we may not be able to function as a good team member.
The Integral framework provides an observable, practical method to utilize and combine existing ideas and practices in a truly integrated format. It can be used anywhere, by anyone. Since everybody has something right to say, an Integral approach allows it to be heard and used appropriately, now and in the future. As such, the Integral framework will continue to provide the proof we need to show where transformation must occur in order to make our functioning as nurses as truly healing and caring as it can be. Whether it be for the collective or the individual, the interior or the exterior, our leaders can use the Integral map to find the most appropriate solutions to meet our needs, and thus also meet theirs and our patients. Together, in cooperation, we will then be moving with the utmost of integrity and honesty in our quest for a seamless, collaborative, integrated health care system.
Side Bar 1
The present day claims of holistic theory and practice often lack consistent tangible defining characteristics. Holism, in its attempt to ensure the ‘whole’ of existence is acknowledged, unfortunately tends to deny the unique and indispensable importance of the parts which make up that whole. Ironically, holistic ideology does not define a clear procedure by which to engage in holistic practice, it lacks a method to its theory. Integral ‘activates’ the holistic approach. It recognizes and promotes the parts within the whole, clearly defining the different characteristics of each methodology. Progressively we see that each whole is only a part in a more encompassing whole; a whole, where admittedly, its capacity is more than the sum of its parts. The Integral framework allows us to see how to be integral. It transcends and includes the holistic approach, doing more than just expressing whole-ness, by showing it.
Side Bar 2
Perspective is the capacity to view things in their true relations or relative importance. Thus, a greater perspective takes into account more of reality. One can see more, and therefore have greater perspective, standing on a ladder versus standing on the ground. It can be understood then that nursing, with its primary focus on care of both the exterior and interior of an individual, contains a fundamentally greater perspective than medicine. What this does not mean is that the perspective of nursing is better than the perspective of medicine; just as the perspective on the ladder is no better or worse than the perspective on the ground. This is important to understand for it is a common mistake to think that more is better. A greater breadth of perspective or awareness is only beneficial to a patient, if the practitioner can access a depth of knowledge and ability to meet the patient’s needs. In this manner, the enhanced perspective of a nurse can then access a doctor, physiotherapist, nutritionist, social worker, psychologist, etc to meet the specific needs of a patient within each Integral quadrant. This is one of the greatest strengths of nursing. (Please refer to the works of Don Beck and Robert Kegan for more on developmental perspective and capacity.)
Side Bar 3
Further examination of the Integral framework would show that within each quadrant there are actual levels, lines, waves, states and types of reality and development.
This enhanced complexity matrix further defines the actual relationship of everything to each other. This augmentation evinces that any event in one quadrant then ripples through causing effect within the other quadrants. While most of this can be studied and mapped out, further research is constantly adding to the details of these connections. (For more information please refer to any of Ken Wilber’s works.) For our purposes now, let us utilize the fundamental essence of the four quadrants (4Q) themselves.