Bo Strangert

On possible meanings of 'holistic' categorization and interpretation

 – in healthcare contexts

Commonly, estimations of care quality from simple surveys and statistics are not sufficient for individual care planning. An individual healthcare plan (IHCP) should involve a combination of concepts from vastly different domains forming a personal data profile. However, the expression 'holistic categorization' in this connection deserves a particular explanation since 'holistic' is often used as a fuzzy term suggesting complexity and a deep level of analysis without giving any scientifically acceptable explication of its conceptual structure. 

Our explication of the concept structure behind 'holistic categorization' to describe a patient’s healthcare status begins with the simple addition of psychological, communicative, and sociocultural categories to the basic somatic categories and ADL (Activities of Daily Living).  Quite simply, more categories and examples of healthcare status descriptions should indicate better quality of IHCP (individual healthcare plan). For example, in the pilot project, adding the three grand categories led the nursing teams to create almost 100 subcategories or examples in a sample of IHCP  (Strangert, Andersson, Brännström & Sandberg, 1983, pp. 46-47; Strangert, Andersson & Brännström, 1985, 1986). 

The following conceptual level of status and goal formation included combinations of different subcategories and examples as expressions of quality of individual care. Increasing the number of new subcategories or examples increases the information value of the healthcare status description or goal states for a patient, thereby hypothetically improving the quality of IHCP. Hence, it should improve the perceived configuration of a patient’s mental and physical states. 

Thus, systematic observation and documentation of combined information sources can ensure an acceptable quality of IHCP and due regard for diversity among patients.  Higher quality analysis is possible by considering the specific relations between categories, such as causal and interactive combinations, which frequently occur in the communication between staff and patients.

The effect of combining categories of information is self-evident from a care perspective. For example, knowledge of a patient's former occupation or interests would make it easier to socialize and communicate,  stimulating the patient psychologically and giving the care worker a better contact and understanding of the need for care. Thus, there are many care possibilities by introducing a functional categorization and getting an instrument for collecting IHCP data on care quality. 

Notice that the analysis of IHCP concerned the conceptual content contingent on the different medical and care operations (Strangert et al, 1983). That is, our analysis focused on how information was generated, interpreted, decided upon, and transferred between the stages of recurrent cycles of diagnosis, goal setting, planning, action, follow-up, and evaluation.¹ Each moment in the cycle concerned a flow or transition between IHCP-states over time, which was observed and recorded for analysis. This structure of information processing and action was the basis for our definition of 'holistic' IHCP in Project 1. The effects of the procedure are assumed to be contingent on a learning process supported by actions rather than the mere IHCP.

However, introducing the advanced form of IHCP was a major part of the OD intervention for quality improvement and a basis for our data collection and interpretation. Consequently, the expected improvement had to be proved by analyzing the internal consistency of the IHCP-documentation and by examining its construct validity through other sources of information about patients’ healthcare states and care workers’ attitudes and skill learning. We conducted concomitant observations of team conferences and patient-nurse contacts recurrently in addition to interviews.

Collecting large amounts of IHCP data from different sources over time required special arrangements. It was necessary to create target patterns for data that indicated critical stages during the introduction and follow-up of the new healthcare routines. We prepared these measures before the action research started and made the data collection safe but still demanding for the research workers.  

A formal set-theoretic description of target patterns used to analyze data from IHCP and observations begins with the five basic categories in IHCP: the somatic functions, ADL, and the psychological, communicative, and sociocultural categories, where the last three are fuzzy sets. All sets can intersect, which enables the construction of more complex knowledge patterns. Let a_i, b_i, c_i, d_i, e_i be specific content elements of the sets A_i, B_i, C_i D_i,  E_i for an individual staff member i about a patient p.

Then more knowledge about a patient means that the staff member i can increase the number of elements in the sets and combine elements from different sets into more complex and mixed knowledge patterns. Another staff member k can either corroborate i:s knowledge or question it. A further possibility for k is to combine i:s information with k:s own. The reasoning about knowledge or understanding can also apply to healthcare operations and other actions. It is essential to collect specific data about the staff's communication and IHCP-documentation of complete healthcare cycles.

The relations between staff members' judgments and actions about a patient during a complete IHC-cycle are decisive for the quality of care. Diversity among the staff members has both pros and cons. Constructive testing of care alternatives demands capability or openness to learning but may trigger personal and social disagreements. Diversity management is an essential key to the high quality of healthcare and, therefore, a significant challenge for action research to develop and support.

One can analyze the dynamic interplay between somatic, psychological, and social conditions and processes on more profound and detailed levels, further clarifying the meaning of ”holistic” treatment of clients. However, that is not viable for large OD projects with solid requirements of applicability and generality, besides budget restrictions. Therefore, a factually based investigation of more profound cognitive and emotional experiences and encounters, such as involving complex conditions behind awareness of 'understanding', 'compassion' or 'confidence', should preferably be made using qualitative case studies with small samples of participants. In our research in progress, we are inquiring into cognitive and emotional aspects about how people perceive combinations of features in complex work situations and how their experiences can involve diverse and yet interconnected associations.

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¹ See Figure 1 in Inducing holistic care strategies for elderly and long-term patients.