JAN
THEORETICAL PAPER
Learning for holistic care: addressing practical wisdom (phronesis) and
the spiritual sphere
Helen L. Leathard & Michael J. Cook
Accepted for publication 12 December 2008
Correspondence to H.L. Leathard:
e-mail: helen.leathard@cumbria.ac.uk
Helen L. Leathard BSc MA PhD
Professor
Faculty of Health & Social Care, University
of Cumbria, UK
Michael J. Cook MSc EdD RN
Deputy Head of Education and Development
East of England Multi-Professional Deanery,
Cambridge, UK
1318
JOURNAL OF ADVANCED NURSING
L E A T H A R D H . L . & C O O K M . J . ( 2 0 0 9 ) Learning for holistic care: addressing
practical wisdom (phronesis) and the spiritual sphere. Journal of Advanced Nursing
65(6), 1318–1327.
doi: 10.1111/j.1365-2648.2008.04949.x
Abstract
Title. Learning for holistic care: addressing practical wisdom (phronesis) and the
spiritual sphere.
Aim. This paper is a discussion of practical wisdom (phronesis) and spirituality in
holistic caring and strategies to facilitate their application in nurse education.
Background. Phronesis, with its inherent spiritual qualities, is an established aspect
of the persona of excellent clinical leaders. There is a strong case for recognizing the
value of this characteristic in all nurses, and a strategy is required for engendering
the development of phronesis during nurse education.
Data sources. Electronic searches of Google Scholar and CINAHL were conducted
for English language publications in the period 1996–2008. Search terms included
combinations of phronesis, spirituality, health, education, pharmacology, medicines
and medication education, holistic care and spiritual care. Selection of items for
inclusion was based on their pertinence to the arguments being developed and their
value as leads to earlier material.
Discussion. The links between the attributes of effective clinical leaders and those
required for holistic caring are explicated and related to phronesis, the acquisition of
which involves spiritual development. An explanatory account of phronesis and its
applicability to nursing leads to an explanation of how its spiritual aspects in par-
ticular might be incorporated into learning for holistic care. Reference to research in
medicines-related education illustrates how the principles can be applied in nurse
education.
Conclusion. Nursing quality could be enhanced if adequate opportunities for
acquiring phronesis through experiential learning were provided in nursing curric-
ula. Phronesis and spiritual care could be incorporated into existing models of
nursing care or new models devised to use these critical concepts.
Keywords: holistic care, learning, nursing education, nursing practice, phronesis,
practical wisdom, spiritual care
 2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd
JAN: THEORETICAL PAPER
Introduction
The concept of phronesis or practical wisdom, encountered
in the literature of practical theology, has been introduced
into the nursing literature with the conclusion that phronesis
is an intrinsic aspect of the persona of effective clinical
leaders – nurses directly involved in providing care, who
continuously improve practice and encourage other nurses
to improve their own practice (Cook 2000, 2001, Cook &
Leathard 2004). Through reflection on this empirically-
derived association between phronesis and clinical leader-
ship, we recognized the value of this type of wisdom, with
its inherent spiritual character, in all nurses who aspire to
give holistic care and, consequently, the need to conceive a
strategy for engendering practical wisdom during pre- and
postregistration education. In this paper, we present a
discussion of practical wisdom (phronesis) and spirituality
in holistic caring and strategies to facilitate their inclusion in
nurse education.
Background
In this paper, we build on Cook and Leathard’s (2001)
model for holistic care that linked phronesis, praxis, being
and doing, and an evolved version (unpublished) that builds
on Benner and Wrubel’s (1989) advocacy of understanding
of mind and body as unified being through the addition of
spirit. Notwithstanding the many and varied concepts of
holism in common currency (Patterson 1998, Taylor 2003),
we believe that regarding patients, clients and colleagues as
bio-psycho-spiritual and social beings offers a secure foun-
dation for learning about holistic caring as integral to
nursing.
We will first explicate the links between the attributes of
effective clinical leaders, defined by Cook (2000, 2001) as
creativity, highlighting, influencing, respecting and support-
ing, and those required for holistic caring. We will then
give an explanatory account of phronesis drawn from the
literatures of practical theology, pastoral care and ethics,
where it is in common usage, and discuss its applicability
to nursing. This will lead to a descriptive explanation of
how the spiritual aspect of phronesis could be incorporated
into the learning experiences of nursing students. There
will be discussion of how the principles elucidated can be
applied in nursing education, based on HLL’s experience of
nurse education in pharmacology and prescribing. As with
spiritual and holistic care, this is an emergent discipline
but, unlike them, it is one in which the effectiveness
of educational practices has been evaluated sufficiently to
inform evaluative discussion of contexts of learning
 2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd
Learning for holistic care
and skill development that can be related to preparation
for holistic care. We will conclude with brief insights for
the implementation of education for holistic care in
nursing.
Data sources
Sources have been accumulated over several years: in
producing earlier papers and during study by HLL for an
MA in Theology. Electronic searches using Google Scholar
and CINAHL were limited to 1996–2008, English language
publications. Search terms included combinations of phrone-
sis, spirituality, health, education, pharmacology, medicines
and medication education, holistic care and spiritual care.
Selection of items for inclusion was based on their pertinence
to the arguments being developed and their value as leads to
earlier material.
Discussion
Clinical leadership qualities and holistic care
Key characteristics of holistic care, as gleaned inter alia
from the analytical reviews of Patterson (1998) and Taylor
(2003), are that it provides care for the whole person
and recognizes all aspects of personhood and of relation-
ality between the carer and the recipient of care.
This involves Cook’s designated attributes of respecting,
supporting and influencing. Furthermore, because each
person is individual and their problems are different, a
carer needs to be capable of highlighting their particular
vulnerabilities and applying creativity to achieve holistic
care for that person. Therefore, the necessary attributes for
nurses involved in holistic care are similar to those of
effective clinical leaders described by Cook (2000, 2001).
They also resemble some characteristics of scholarly nurses
elucidated by Riley et al. (2007), so a consistent pattern is
emerging.
The attributes fall naturally into two groups, the
discrimination of which is helpful in devising strategies
for engendering learning for holistic care in nursing.
The relational attributes of influencing, respecting and
supporting involve transcendence of interpersonal
boundaries, while the entrepreneurial attributes of creativ-
ity and highlighting (questioning and elucidating) enable
transcendence of routine tasks. These attributes cannot be
achieved by abstract, theoretical learning; their develop-
ment is highly reliant on experiential learning that results
in the attainment of phronesis (Benner 2000, Flaming
2001).
1319
H.L. Leathard and M.J. Cook

Phronesis practice has been done in the context of nursing practice

development, as illustrated by Rolfe’s (2000) collected
Phronesis is an Aristotelian (350 BCE) concept, introduced in
papers. We do not seek to reiterate that work here, but to
his Nichomachean Ethics as a ‘truth-attaining rational
demonstrate that phronesis is an additional, identifiable
quality concerned with action in relation to things that are
attribute that merits deliberate development in nurses who
good or bad for human beings’ (VI, 5: 1140b 6–8). Its usage
are aspiring to be holistic in their practice.
has been developed in relation to pastoral care, and is
Phronesis can be considered as ‘soft’ or transformational
applicable also to nursing. Willows and Swinton (2000, p.
knowledge that involves spiritual engagement and ‘intuition,
14) have described it as wisdom derived from engagement in
wisdom and mystery in contrast to technical control’ (Patton
practice: ‘a way of knowing in which skill and understanding
1990, p. 70). How, then, does phronesis relate to holistic
co-operate; a knowing in which experience and critical
health care? The conceptual model of Cook and Leathard
reflection work in concert; a knowing in which disciplined
(2001) requires further work but it is clear the development
improvisation, against a backdrop of reflective wisdom,
of phronesis involves spiritual development as depicted in
marks the virtuosity of the competent practitioner’ (Willows
Figure 1.
& Swinton 2000, p. 14, quoting Fowler cited by Wesson
1986, p. 60).
In linking wisdom with practice, phronesis is clearly Spirituality, phronesis and holistic care
contiguous with episteme and praxis, but it has been distin-
According to Leathard (2003), the various processes involved
guished from both. Milbank (1993) made a clear distinction
in recovery towards holistic health or a good death are
between phronesis and episteme, in that phronesis is derived
referred to as healing. Within an individual, healing involves
through practical reasoning whereas episteme is derived
physical, mental and spiritual aspects, with emotions drawing
through theoretical reasoning. Going further, Milbank
on both mental and spiritual spheres and affecting physical
(1993) stated that phronesis is not necessarily attained
functioning. The aim of holistic health care is to help people
through conscious effort, has associations with contemplation
attain and maintain a state of well-being in which the self-
and has been identified with prudence. It belongs within the
healing capabilities of body, mind and spirit can proceed
soul; exercised as a response to contingencies, it tries to limit
unhindered, as discussed by Powell (2005) and Weze et al.
the risks posed by the contingencies. Nevertheless, Gunton
(2005). Whereas mental and physical aspects of health care
(2003) insisted that phronesis is a rational faculty (hexis), but
have received abundant attention, the spiritual sphere has
one that is allied to the wisdom of the Old Testament
been relatively neglected until quite recently. The following
philosopher kings, rather than the narrow rationalism of post-
section provides a précis of some emerging insights to inform
Enlightenment thought. He sought to clarify the meaning of
our discussion. In line with the extensive research of Koenig
phronesis by quoting Gaita (1996, p. 223):
et al. (2004) (for a summary of this), we are not defining
The wise are those who…have something to say. That does not mean spiritual/ity but adopting accepted meanings used by authori-
they have information to impart or a new theory to propound. It tative practitioners whose work is cited below.
means that their authority depends upon our acknowledgement of According to Hall (1997, p. 33), effective caring can cross
their individually achieved lucidity about their experiences. Such the boundaries of space and time:
lucidity is necessarily hard won and necessarily won in the course of a
An understanding word or deed, at the right moment, can assist a
life.
person to recover as it is recalled over days, weeks or years. This
This can be interpreted as meaning that phronesis can be a requires a quality of time when the carer is attentive and fully present,
factor in highlighting significant issues and hence in engen- rather than a quantity of time. Spiritual care can therefore be an
dering creativity. inherent part of care rather than an additional extra when time
How, then, does phronesis differ from praxis? Willows and allows.
Swinton (2000, p. 14) discerned that praxis ‘denotes a form
Here, Hall has made the transition from implicit to explicit
of action which is value-directed, value-laden and profoundly
reference to spiritual care based on her earlier explanation of
saturated with meaning’. It includes theory as a vital
spirituality as relating to the essence of who we are and our
constituent, and reflection on theory is the key to enhance-
connection to that which is beyond self. Accordingly:
ment of praxis. Hence, phronesis and episteme are distinc-
tively-derived ways of knowing that interact and align with …spirituality cannot be set apart in a church or temple, but is present
praxis. Some very substantial work on praxis and reflective in the everyday reality of disrupted or changed body functions,

1320  2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd
JAN: THEORETICAL PAPER Learning for holistic care

PHRONESIS evidenced in ‘ancient Greek and biblical wisdom’ (Milbank

SPIRITUAL PRACTICE Respecting 1993, p. 129).
Attentive presence & Supporting
relationality Influencing This attentive relationality is remarkably similar to the
+
EXPERIENTIAL Highlighting HOLISTIC concept of ‘being’, as elucidated by Leathard (2004). It also
Creativity
LEARNING CARE resembles closely Buber’s (1947, pp. 3–4, 19–21) concept of
dialogue:
IN
PRAXIS
NURSING Those who engage in dialogue experience a strong sense of
reciprocity... Dialogue is not the same as love but there is no real
EPISTEME love without genuine dialogue [which can] actually occur through
Theoretical
learning silence as well as through spoken discourse.

In cognizance of Buber’s insight, it could be argued that

Figure 1 The development of phronesis and how it can inform
holistic care in nursing. dialogue would be an appropriate label for this aspect of
spiritual practice in nursing, but attentive relationality or,
more simply, attentive presence avoids the risk of any implied
destabilized emotions, disrupted thought patterns and lives changed need for verbal exchange and provides a link between the
or torn apart…[Nurses] accompany people through these life vocabularies of clinical practice and spirituality, the topic to
experiences. We engage in the process of healing as we assist people which we now turn.
to make the extraordinary ordinary and to find the meaning in their
experience. (Hall 1997, p. 24)
Spiritual practice in acquisition of phronesis
Hall’s perspective was endorsed by Fry (1997), who discerned
For two millennia healing has been a significant aspect of
that ‘being with’ and ‘doing with’ clients establishes a
Christian ministry, although recognition of this has declined
connectedness with them which is integral to healing and
as the biomedical model of health has emerged and expanded
spirituality:‘…the skilled [nurse] is focused…alert and
in the past century. The submergence of this practical
responsive to cues that signal whatever is meaningful in the
theology under successive waves of biomedical and psycho-
client’s life. The work is pure being with clients’ (Fry 1997, p.
social predominance is a significant aspect of the loss of
16).
holism from health care. Interest in holistic healing has now
The importance of such attentive engagement in nursing
increased considerably, and so it seems timely to revisit the
has been endorsed by Watson (1999), who made a detailed
philosophy and practicalities of practical theology to seek for
and convincing case that this type of engagement invokes
attributes that could usefully inform nursing. While acknowl-
metaphysical-spiritual dimensions which transcend time,
edging that our phronesis material is derived mainly from
space and physicality. She contrasted this type of caring,
Christianity, we recognize the existence of practical wisdom
which requires an explicit ontology of relation rather than
within other traditions, and the need for sensitivity in
separation, with ‘modern’ caring which, she argued, resides
applying faith-derived practices in nursing environments that
within a separatist ontology, consistent with Western
include people of various faiths or none.
science that separates person from nature, and being from
The importance of personal experience in the development
knowing and doing. These illustrative quotations demon-
of phronesis has been illustrated amply by Cassidy (1994), a
strate clearly the importance of the spiritual dimension for
doctor who developed a career in palliative care after
nurses engaged in holistic care. They identify attentive or
surviving personal experience of torture. She has written:
empathic presence or relationality as the hallmark of
holistic caring, to such an extent that the phrases such as If we are to be privy to that secret earthquake of anguish that erupts
care giving or care provision tend to be undermined by the in the soul of the dying, we should understand something of the
transcendent reciprocity that is inherent in the holistic minds and hearts God created… Perhaps the most important lesson
approach. The key to engendering learning for holistic care learned from years of therapy is the healing power of non-judgmental
must, therefore, lie in the spiritual practice of attentive listening. (p. 94)
presence or relationality, with the acquisition of epistemic
and:
and experiential understanding of the human sciences,
yielding a synthesis that constitutes phronesis, denoting the I believe that the most important route to a knowledge of God, a
‘ineradicable interconnection of theory and practice’ as working theology, is through prayer. We can read all the pious books

 2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd 1321
H.L. Leathard and M.J. Cook
in the world, but unless we sit silently at God’s feet, open our minds
and hearts to him, we will never really know him. This knowing is, of
course, not ordinary knowing. (p. 104–105)
What Cassidy has described so evocatively here is the key to
acquisition of phronesis and the practical distinction between
phronesis and episteme.
Cassidy’s road to ‘recovery’ involved an extended period in
a monastery, with spiritual care making a substantial
contribution. The underlying principles of such spiritual
work have been stated persuasively by Leech (1989 p. 21):
‘To be formed…we need to cultivate insight, contemplative
listening. There is emphasis on love as opposed to knowledge
or mental enlightenment’ (p. 10), and:
Nothing is more necessary in pastoral care…than the ability to listen,
an ability which is nourished in contemplation, stillness and inner
silence. It is not a skill that can be learnt. It only comes as a by-product
of a life in which silence and stillness have a major place. (p. 21)
The way in which Cassidy and Leech have described the work
involved in Christian spiritual development seems equally
applicable to the acquisition of the phronesis that is required
for holistic care in nursing, albeit with pertinent ‘scripture’
being lectures and authoritative nursing publications and the
ability to listen being developed by spending time being
present attentively with patients, clients and teachers. Ade-
quate opportunity for learning in this way should enable
future nurses to engage in holistic care that:
…is not just physical and emotional care, understanding and
forgiveness. Sufferers need to know the passion and tenderness with
which they are loved by God. We must deliver this message by
revealing to them that they are lovable; by treating them with all our
skill, compassion & love. Sometimes this is all we can do…if a person
has no faith. (Cassidy 1994, p. 107–8)
Through this exploration of phronesis, we have recognized
that the characteristics required for spiritual care include
experience of ‘being’ and of ‘having been there’ (Cook &
Leathard 2001). We have recognized the importance of
prioritizing time to be with patients and clients, of encour-
aging and enabling them to be content with being and to
resist the culture that overemphasizes and overvalues doing at
the expense of being. Furthermore, the ability of nurses to be
present attentively with others is clearly influenced by their
own prior experience of being in similar situations, and their
ability to facilitate others to ‘be’ depends upon their own
ability to do likewise. This application of the pastoral care
literature is consistent with the findings of Belcham (2004)
that the confidence of occupational therapists in discussing
religious/spiritual beliefs with clients correlated with the
1322
strength of their personal beliefs. It also needs to be
considered carefully in the light of the findings and reflections
of Beagan and Kumas-Tan (2005) that pastoral care profes-
sionals provide spiritual care in a different way from, and ‘go
deeper’ than, even occupational therapists who are confident
in offering spiritual care. These authors and Ross (2006) and
Van Leeuwen et al. (2006) have raised the important issue of
clarifying the scope of practice of healthcare professionals in
relation to spiritual care, suggesting that spiritual care
professionals could be brought in as appropriate.
Although the insights of Cassidy (1994) and Leech (1989)
provide indicators of the qualities of experience required for
holistic caring, there remains the question of how these can
be integrated into or delivered in the context of nurse
education – in classroom or practice settings. It seems to us
that there are three ways, each employing a different one of
Cook’s (2000, 2001) relational attributes of effective clinical
leaders:
• Influencing students by example: being present attentively
with students and demonstrating practical reasoning based
on sound theoretical knowledge.
• Respecting students by valuing their existing experience:
using volunteered examples of their having ‘been there’ to
enrich the topic under discussion.
• Supporting students by securing plentiful opportunities for
them to practise attentive presence with patients and cli-
ents, as well as with qualified staff, to maximize their
opportunities for growing in practical wisdom.
Phronesis in education for administration and prescription
of medicines
Notwithstanding the exemplary and scholarly advocacy of
many authors (Johnson 1998, Ross 1998, Narayanasamy
1999, Narayanasamy & Owens 2001, Swinton 2001,
McSherry & Ross 2002, Swinton & Narayanasamy 2002,
Belcham 2004, Hoyland & Mayers 2005), and some
strategies for (Johnson 1998, Narayanasamy 1999, 2006,
Robinson et al. 2003) education in spiritual care that are
relevant to nursing, there is a dearth of empirical assess-
ment of its acquisition and consolidation in nursing
practice. There is, however, a growing body of evidence
on the development of pharmacological knowledge to
underpin the contribution to nursing practice made by
the administration and prescription of medicines, the
importance of education for which has come to the fore
in recent years (Boggs et al. 1988, Latter et al. 2000, 2001,
Leathard 2001a,b, Bullock & Manias 2002, Manias &
Bullock 2002a,b, Morrison-Griffiths et al. 2002, Sodha
 2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd
JAN: THEORETICAL PAPER
et al. 2002, Grandell-Niemi et al. 2005). It is of relevance
and interest, therefore, to interrogate the pharmacology
education literature to seek evidence of consistency or
inconsistency with the paradigm of the acquisition of
practical wisdom using Cook’s (2000, 2001) relational
attributes.
Influencing
Many nurses experience anxiety in approaching the study of
pharmacology because of their limited familiarity with
chemistry and related subjects, on which understanding of
medicines is built, and yet it is unrealistic to argue for
extensive chemistry education to be a prerequisite to a career
in nursing as it is for medicine. As an alternative, we have
found that a teacher, being attentive to the level of students’
understanding and making creative use of familiar domestic
analogies and images, can succeed in making the principles of
pharmacology meaningful to students (Leathard 2005). This
does, however, require paying empathic attention to each
student, ensuring that they feel at ease in voicing their
uncertainties, and addressing their questions in a courteous
way, even when revising material that they should know
already. Another facet of influencing students to learn effec-
tively is to demonstrate how, in the absence of specific items
of information, it is often possible to work out a solution by
making rational deductions from available clinical and
physiological knowledge. This approach is emphatically not
about encouraging guesswork, but involves influencing
students positively regarding strategies for learning and
reasoning.
Respecting
An associated component of engendering successful learning
of pharmacology by nurses is to respect and build on their
wealth of clinical experience. The students may have little
idea of what, for example, an ACE (angiotensin converting
enzyme), beta-receptor or proton pump is that is being
blocked or inhibited by the medicines their patients are tak-
ing, but they do have accurate knowledge about routes and
frequency of administration.
A good place to start building their understanding of
pharmacology is, therefore, with the administration of
medicines. This can lead logically to the construction of a
generic pharmacological profile outline that can help students
to contextualize existing knowledge and identify what
remains to be learned. The sequence of topics in the
recommended outline reflects the sequence experienced in
clinical practice of drugs being administered, producing
effects and then being inactivated and/or eliminated
(Leathard 2002, 2007).
 2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd
Learning for holistic care
This respecting and valuing of extant knowledge is
supported by some published studies. Although Boggs et al.
(1988) found a stronger association of drug knowledge
with educational level than with experiential background
and Cason et al. (1999) found attainment in a test of
knowledge of pain management to relate to education
level, in a more extensive study, Ives et al. (1996) found an
association between test scores for pharmacological knowl-
edge and numbers of years of nursing practice. In a careful
appraisal of this study, Leathard (2001a) discerned also
that practical clinical experiences reinforced learning of
those areas that were subject to discussion and critical
appraisal in the workplace, but had less impact on areas
where competence was assumed but was less subject to
scrutiny by colleagues or clients. Similarly, Grandell-Niemi
et al. (2005) reported that, according to their self assess-
ment, the best pharmacological skills of nurses and
students were ‘dosage forms (such as tablets, injections),
administration routes, notes used in prescriptions and
searching information on the medicines packages’.
This extensive study of nurses and students revealed that
nurses performed better than nursing students in a medi-
cation skills test, and that nurses who had worked over
20 years in their present ward performed well in the whole
test – the latter finding being consistent with those of
Ives et al. (1996) and Manias and Bullock (2002a). With
regard to engendering learning, it is interesting that Bullock
and Manias (2002) found that students did not agree that
learning pharmacology takes place in clinical practice,
whereas Morrison-Griffiths et al. (2002) concluded that
preregistration nursing students do learn pharmacology in
clinical practice, and Latter et al. (2001) highlighted the
need for both sufficient taught pharmacology and the
importance of practice-based learning. As a whole,
this research provides evidence that respectable levels
of learning can occur through practice in the clinical
environment, and that the material that is learned experi-
entially is that which is encountered commonly. The
diverse findings were identified in various countries, and
it is clear that differing arrangements to support students’
learning of pharmacology in clinical practice could explain
the different findings (Latter et al. 2000, 2001, Bullock &
Manias 2002), a concept that brings us to the third
attribute.
Supporting
It is self evident that students will learn best where they are
supported most appropriately in doing so. The 12 days of
supervised practice included in the UK Nursing and Mid-
wifery prescribers’ curriculum (http://www.nmc-uk.org) is
1323
H.L. Leathard and M.J. Cook
clearly intended to give ample opportunity to develop prac-
tical wisdom (phronesis) in relation to prescribing. In con-
trast, the consequences of the lack of appropriate support for
learning is well illustrated by Banning’s (2005) findings of
independent nurse prescribers’ weaknesses in comprehension
of concepts of evidence and evidence-based practice in rela-
tion to prescribing and medicines management. Banning
argued, therefore, that educators need to support the evi-
dence-related preparation of nurses for extended prescribing
by explicating clearly for them the nature and different forms
of evidence, and illustrating how it can be analysed and
interpreted in relation to their own practice. Furthermore, she
advocated engagement with the concept of ‘situated gener-
alization’, as presented by Simons et al. (2003), as a tool to
support prescribers in their learning to use evidence and
research-based knowledge and to improve their practice. It
seems reasonable to deduce, therefore, that effective learning
can take place in both academic and practice settings if
students are supported appropriately.
This exploration of education for medicines-related prac-
tice has demonstrated that the transpersonal attributes of
influencing, respecting and supporting are highly relevant to
the preparation of nurses for a novel aspect of their practice.
We expect that what has been demonstrated empirically for
medicines-related practice is likely to be equally applicable to
preparation for spiritual or holistic caring. When engaged
with in this way, in a context that facilitates a teacher to
highlight those parts of the curriculum that cause students
anxiety and those that are familiar and to be creative in
employing innovatory solutions to assist their learning,
students experience holistic educational care. In this way,
the educational experience can provide a model for their
nursing practice.
Engendering learning for holistic care
We have demonstrated that the attributes required for holistic
care in nursing can be identified with those discerned by
Cook (2000, 2001) as being characteristic of effective clinical
leaders. The development of these attributes can be facilitated
by engendering the development of phronesis. Other writers
have emphasized the importance of a holistic way of knowing
for the provision of holistic care (Fawcett et al. 2001, Flaming
2001, Purkis & Bjornsdottir 2006). Fawcett et al. (2001, p.
116) emphasized how ‘…the pattern of personal knowing
refers to the quality and authenticity of the interpersonal
process between each nurse and each patient’. The literature
of practical theology complements and enriches recent
research and scholarship in healthcare education and
practice. While the effectiveness of learning for holistic care
1324  2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd
remains to be evaluated in empirical studies, there is sufficient
research into the contemporaneously-emergent field of med-
icines-based nursing practice to illustrate the applicability of
the attributes of influencing, respecting, supporting, high-
lighting and creativity to healthcare education. We feel
confident, therefore, in advocating the following precepts for
engendering learning for holistic care.
Enabling the transcendence of interpersonal boundaries
by:
• Influencing students to attend to spiritual as well as mental,
physical and social spheres of a person, and to recognize
how they influence people by their way of being, attentive
presence being beneficial.
• Respecting the existing tacit and explicit understanding that
students have of holistic care, and encouraging them to
respect patients’ and clients’ tacit and explicit understand-
ings of their conditions and possibilities for healing.
• Supporting their further development by making ade-
quate provision for students to develop phronesis
through practicing attentive presence with patients,
clients and teachers, as well as to acquire epistemic
understanding; and
Enabling transcendence of routine care provision by:
• Highlighting the diverse ways in which theories can be
understood and applied to practice, and
• Creativity in selecting for an individual patient or client the
most appropriate balance of available care options to
promote their mental, physical and spiritual well-being.
Conclusion
Recognition of the concept of phronesis and gaining an
understanding of how this can be developed, by drawing on
the literature of practical theology, has profound implications
for nursing education and practice. To justify the adoption, or
explicit recognition, of phronesis in nursing it is important that
this way of knowing and its relationship to other informants of
practice is well understood. This account of phronesis reveals it
to be a highly spiritual way of knowing and being, and thereby
provides a conceptual basis for the well-recognized need for
spiritual care as part of nursing practice.
There is considerable potential for nursing quality to be
enhanced if adequate opportunities for acquiring practical
wisdom through experiential learning are provided in nursing
curricula. To consolidate the place of phronesis in the theory
and practice of nursing, phronesis and spiritual care need to
be incorporated into existing models of care or new models
that use these critical concepts need to be devised. Such
consolidation has great potential support the development of
nursing as a truly holistic practice.
JAN: THEORETICAL PAPER
What is already known about this topic
• Phronesis, or practical wisdom, is an integral aspect of
the persona of effective clinical leaders.
• The literature of practical theology and pastoral care
identifies phronesis as a rational and practical form of
wisdom with a marked spiritual component.
• Holistic caring requires that patients and clients are
regarded as bio-psycho-spiritual and social beings with
whom carers sustain an attentive presence.
What this paper adds
• An enriched understanding of the nature of spiritual
caring and how the attributes required resemble those
of effective clinical leaders.
• Phronesis-related attributes that enable transcendence
of interpersonal boundaries are influencing, respecting
and supporting; and those enabling transcendence of
routine care provision are: highlighting and creativity.
• The potential benefit of incorporating opportunities for
students to develop phronesis during their educational
preparation.
Implications for practice and/or policy
• Spiritual care, for which there is well-recognized need in
nursing, should be conceptualized and developed within
the precepts of phronesis or practical wisdom.
• Phronesis as a way of knowing should be recognized
explicitly and be well understood in nursing education
and practice.
• The attributes of influencing, respecting, supporting,
highlighting and creativity provide a conceptual
framework within which phronesis should be presented
in nurse education.
Author contributions
HLL and MJC were responsible for the study conception and
design. HLL and MJC performed the data collection. HLL
performed the data analysis. HLL was responsible for the
drafting of the manuscript. MJC made critical revisions to the
paper for important intellectual content.
Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
 2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd
Learning for holistic care
Conflict of interest
No conflict of interest has been declared by the authors.
References
Aristotle 350 B.C.E Nicomachean Ethics. Translated by W. D. Ross.
Retrieved from http://classics.mit.edu/Aristotle/nicomachaen.html
on 27 October 2005.
Banning M. (2005) Conceptions of evidence, evidence-based medi-
cine, evidence-based practice and their use in nursing: independent
nurse prescribers’ views. Journal of Clinical Nursing 14, 411–417.
Beagan B. & Kumas-Tan Z. (2005) Witnessing spirituality in prac-
tice. British Journal of Occupational Therapy 68(1), 17–24.
Belcham C. (2004) Spirituality in occupational therapy: theory in
practice? British Journal of Occupational Therapy 67(1), 39–46.
Benner P. (2000) The roles of embodiment, emotion and lifeworld for
rationality and agency in nursing practice. Nursing Philosophy 1,
5–19.
Benner P. & Wrubel J. (1989) The Primacy of Caring: Stress and
Coping in Health and Illness. Addison-Wesley Publishing Com-
pany, Wokingham, England.
Boggs P., Brown-Molnar C.S. & DeLapp T.D. (1988 cited by
Grandell-Niemi et al. 2005) Nurses’ drug knowledge. Western
Journal of Nursing Research 10, 84–93.
Buber M. (1947) Between Man and Man. Translated by Ronald
Gregor Smith. Kegan Paul, London.
Bullock S. & Manias E. (2002) The educational preparation of
undergraduate nursing students in pharmacology: a survey of lec-
turers’ perceptions and experiences. Journal of Advanced Nursing
40, 7–16.
Cason C.L., Jones T., Brock J., Maese P. & Milligan C. (1999 cited
by Grandell-Niemi et al. 2005) Nurses’ knowledge of pain man-
agement: implications for staff education. Journal for Nurses in
Staff Development 15, 228–235.
Cassidy S. (1994) Towards a theology of hospice care. In Light from
the Dark Valley. Ch 8, (the author, ed), DLT, London, pp. 84–108.
Cook M.J. (2000) Uncovering the Attributes of Effective Clinical
Nurse Leaders: A Grounded Theory Approach. EdD Thesis, Uni-
versity of Lincolnshire & Humberside, Lincoln, UK.
Cook M.J. (2001) The attributes of effective clinical leaders. Nursing
Standard 15(35), 33–36.
Cook M.J. & Leathard H.L. (2001) Phronesis – insights for health
care from practical theology. In Proceedings of Fourth Interna-
tional Conference on Faith in Healing & Health Care Provision
(Leathard H., ed.), July 2001, St. Martin’s College, Lancaster, UK,
pp. 19.
Cook M.J. & Leathard H.L. (2004) Learning for clinical leadership.
Journal of Nursing Management 12, 436–444.
Fawcett J., Watson J., Nueman B., Hinton P. & Fitzpatrick J. (2001)
On theories and evidence. Journal of Nursing Scholarship 33, 115–
119.
Flaming D. (2001) Using phronesis instead of ‘research-based-prac-
tice’ as the guiding light for nursing practice. Nursing Philosophy
2, 251–258.
Fry A.J. (1997) Spirituality: connectedness through being and doing.
In Spirituality, The Heart of Nursing (Ronaldson S., ed.), Ausmed
Publications, Melbourne, pp. 5–21.
1325
H.L. Leathard and M.J. Cook
Gaita R. (1996) Response to Sue Patterson, ‘Dressing the Wounds of
People’. In Beyond Mere Health: Theology and Health Care in a
Secular Society (Regan H., Horsfield R. & McMullen G., eds),
Australian Theological Forum, Kew, Victoria, pp. 221–227.
Grandell-Niemi H., Hupli M., Leino-Kilpi H. & Puukka P. (2005)
Finnish nurses’ and nursing students’ pharmacological skills.
Journal of Clinical Nursing 14, 685–694.
Gunton C.E. (2003) Father, Son and Holy Spirit: Essays Towards a
Fully Trinitarian Theology. T & T Clark/Continuum, London and
New York.
Hall J. (1997) Nurses as Wounded Healers. In Spirituality, The Heart
of Nursing (Ronaldson S., ed.), Ausmed Publications, Melbourne,
pp. 23–43.
Hoyland M. & Mayers C. (2005) Is meeting spiritual need within the
occupational therapy domain? British Journal of Occupational
Therapy 68(4), 177–18.
Ives G., Hodge K., Bullock S. & Marriott J. (1996) First year RNs’
actual and self-rated pharmacology knowledge. Australian Journal
of Advanced Nursing 14(1), 13–18.
Johnson A. (1998) The notion of spiritual care in professional
practice. In The Spiritual Challenge of Health Care (Cobb M. &
Robshaw V., eds), Churchill Livingstone, Edinburgh, pp. 151–166.
Koenig H.G., George L.K. & Titus P. (2004) Religion, spirituality,
and health in medically ill hospitalized older patients. Journal of
the American Geriatric Society 52, 554–562.
Latter S., Rycroft-Malone J., Yerrel P. & Shaw D. (2000) Evaluating
educational preparation for a health education role in practice: the
case of medication education. Journal of Advanced Nursing 32(5),
1282–1290.
Latter S., Rycroft-Malone J., Yerrel P. & Shaw D. (2001) Nurses’
educational preparation for a medication education role: findings
from a national survey. Nurse Education Today 21(2), 143–154.
Leathard H.L. (2001a) Understanding medicines 1: a conceptual
analysis of nurses’ needs for knowledge and understanding of
pharmacology. Nurse Education Today 21(4), 266–271.
Leathard H.L. (2001b) Understanding medicines 2: a conceptual
analysis of nurses’ needs for knowledge and understanding of
pharmacology. Nurse Education Today 21(4), 272–277.
Leathard H.L. (2002) Principles of pharmacology. In Watson’s
Clinical Nursing and Related Science, 6th edn (Walsh M., ed.),
Bailliere Tindall, Edinburgh, pp. 95–110.
Leathard H.L. (2003) Healing in the Christian tradition. Sacred
Space: The International Journal of Spirituality & Health 4(2), 33–
39.
Leathard H.L. (2004) The nature of being: a Thomistic perspective
related to health and healing. Spirituality & Health International
5(2), 107–117.
Leathard H.L. (2005) Teaching pharmacology to those with limited
background in chemistry. Invited lecture in British Pharmacolog-
ical Society Symposium on ‘Education for New Prescribers’, part
of the society’s Winter Meeting; Tuesday 20th December 2005.
Institute of Education, London.
Leathard H.L. (2007) Principles of pharmacology. In Watson’s
Clinical Nursing and Related Science, 7th edn (Walsh M. &
Crumbie A., ed.), Bailliere Tindall, Edinburgh, pp. 99–114.
Leech K. (1989) Spirituality & Pastoral Care. Part 1. Foundations of
Spirituality Cowley Press, Cambridge & Boston MT.
1326  2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd
Manias E. & Bullock S. (2002a) The educational preparation of
undergraduate nursing students in pharmacology: clinical nurses’
perceptions and experiences of graduate nurses’ medication
knowledge. International Journal of Nursing Studies 39, 773–784.
Manias E. & Bullock S. (2002b) The educational preparation of
undergraduate nursing students in pharmacology: clinical nurses’
perceptions and experiences of lecturers and students. Interna-
tional Journal of Nursing Studies 39, 757–769.
McSherry W. & Ross L. (2002) Dilemmas of spiritual assessment:
considerations for nursing practice. Journal of Advanced Nursing
38(5), 479–488.
Milbank J. (1993) Theology and Social Theory: Beyond Secular
Reason. Blackwell, Oxford.
Morrison-Griffiths S., Snowden M.A. & Pirmohamed M. (2002) Pre-
registration nurse education in pharmacology: is it adequate for the
roles that nurses are expected to fulfil? Nurse Education Today 22,
447–456.
Narayanasamy A. (1999) ASSET: a model for actioning spirituality
and spiritual care education and training in nursing. Nurse Edu-
cation Today 19(4), 274–285.
Narayanasamy A. (2006) The impact of empirical studies of spiri-
tuality and culture on nurse education. Journal of Clinical Nursing
15, 840–851.
Narayanasamy A. & Owens J. (2001) A critical incident study of
nurses’ responses to the spiritual needs of their patients. Journal of
Advanced Nursing 33(4), 446–455.
Patterson E.F. (1998) The philosophy and physics of holistic health
care: spiritual healing as a workable interpretation. Journal of
Advanced Nursing 27(2), 287–293.
Patton J. (ed.) (1990) From Ministry to Theology. Abingdon Press,
Nashville, TN.
Powell A. (2005) Spirituality, healing and the mind. Spirituality &
Health International 6(3), 166–172.
Purkis M. & Bjornsdottir K. (2006) Intelligent nursing: accounting
for knowledge as action in practice. Nursing Philosophy 7, 247–
256.
Riley J., Beal J.A. & Lancaster D. (2007) Scholarly nursing practice
from the perspectives of experienced nurses. Journal of Advanced
Nursing 61(4), 425–435.
Robinson S., Kendrick K. & Brown A. (2003) Spirituality and the
Practice of Health Care. Palgrave Macmillan, Basingstoke.
Rolfe G. (2000) Nursing Praxis and the Reflexive Practitioner. Col-
lected Papers 1993–1999. Nursing Praxis International, London.
Ross L. (1998) The Nurse’s Role in Spiritual Care. In The Spiritual
Challenge of Health Care (Cobb M. & Robshaw V., eds), Chur-
chill Livingstone, Edinburgh, pp. 119–135.
Ross L. (2006) Spiritual care in nursing: an overview of the research
to date. Journal of Clinical Nursing 15, 852–862.
Simons H., Kushner S., Jones K. & James D. (2003) From evidence-
based practice to practice-based evidence: the idea of situated
generalisation. Research papers in Education 18, 347–364.
Sodha M., McLaughlin M., Williams G. & Dhillon S. (2002) Nurses’
confidence and pharmacological knowledge: a study. British
Journal of Community Nursing 7, 309–315.
Swinton J. (2001) Spirituality and Mental Health Care: Rediscover-
ing a ‘Forgotten’ Dimension. Jessica Kingsley Publishers, London
& Philadelphia.
JAN: THEORETICAL PAPER Learning for holistic care

Swinton J. & Narayanasamy A. (2002) Response to: ‘A Critical View
of Spirituality and Spiritual Assessment’ by P Draper and W
McSherry (2002) Journal of Advanced Nursing 39, 1 – 2. Journal
of Advanced Nursing 40(2), 158–160.
Taylor B. (2003) Emancipatory reflective practice for overcoming
complexities and constraints in holistic health care. Sacred Space:
The International Journal of Spirituality & Health 4(2), 40–45.
Van Leeuwen R., Tiesinga L.J., Post D. & Jochemsen H. (2006)
Spiritual care implications for nurses’ professional responsibility.
Journal of Clinical Nursing 15, 875–884.
Watson J. (1999) Postmodern Nursing and Beyond. Churchill
Livingstone, Edinburgh.
Wesson J. (1986) ‘How Cinderella must get to the ball: past-
oral studies and its relation to theology’. In The Foundations
of Pastoral Studies and Practical Theology (Ballard P.H.,
ed.), Faculty of Theology, University College, Cardiff, pp. 57–
63.
Weze C., Leathard H.L. & Stevens G. (2005) Healing by gentle touch
in musculoskeletal disorders. Spirituality & Health International
6(4), 200–211.
Willows D. & Swinton J. (2000) Introduction. In Spiritual Dimen-
sions of Pastoral Care (Willows D. & Swinton J., eds), Jessica
Kingsley Press, London, pp. 11–16.

The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the
advancement of evidence-based nursing, midwifery and health care by disseminating high quality research and
scholarship of contemporary relevance and with potential to advance knowledge for practice, education, management
or policy. JAN publishes research reviews, original research reports and methodological and theoretical papers.

For further information, please visit the journal web-site: http://www.journalofadvancednursing.com

 2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd 1327