We found no uniform definition of the concept 'holistic view' in the literature. In the present study the content analysis revealed three different categories of the concept and the meaning and significance to the clinical life of Swedish GPs and DNs.
The concept 'holistic view' was first used in political documents, with the intention to characterise primary care in Sweden. In other descriptions and definitions, the concept of a holistic view seems to be implied in other concepts, for example in Starfield's definition or in the concept of personal care [2]. Continuity could be seen as one aspect of holistic care. Patients' perceptions were illuminated by Donahue et al. They found that patients were more satisfied with care given by physicians if they had had a longer period of seeing the same doctor. [15]. In another study Guthrie and Wyke found that it was especially important to have continuity of care if the patient had a chronic, multifaceted disease or emotional problems [16]. The results from these two studies correspond well with the findings from our focus group interviews, where especially the GPs discussed if continuity was necessary from a holistic viewpoint.
Tarrant et al. identified holistic care or 'whole person' care as a main feature of personal care among patients and providers in primary care settings in the UK [17]. In a recently published Swedish interview study, patients have expressed the importance of a holistic approach among GPs. This means that the doctor should be informed about a patients' whole life situation in order to be able to create a sense of security and coherence in the patient [18]. Particularly the nurses in the present study described themselves as specialists in this respect. Among the participants, the GPs put an emphasis on the consultation process as being an important tool for achieving a holistic view of the patients and their problems. Olesen et al has identified a number of important tools required to perform a multidimensional therapy as well as a balanced diagnosis and the consultation process is one such tool. Balanced diagnosis has to do with biomedical conditions, culture and context conditions, medico-psychological and social conditions. Another important tool is knowledge, theoretical and biomedical and also knowledge achieved by experience [19]. This relates well to our findings in both factual and tacit knowledge.
Both GPs and DNs mentioned the house call as being important in the process of achieving a holistic view of the patients and their special conditions. The nurses expressed the necessity of making the house calls themselves, whilst the GPs would rather acquaint themselves with nurses' experiences from their house calls. In many other countries GPs do house calls and in this aspect it is reasonable to believe that nurses' opinions could be transferred to GPs. When speaking of continuity and the individual patient, emphasis is on the integration and coordination of services. In this aspect nurses play a very important role for communication between nurses, but according to a Canadian study on delivery of acute care services in the home, the nurse practitioner also plays a central role both as a clinical expert and as case manager in order to integrate physician services in the home [20, 21].
According to all the participants, how primary care is organised is important. The organisation can either facilitate or complicate the possibility to accomplish holistic and personal care. The primary care team, with its varied competence, will therefore facilitate a holistic view. Tarrant et al. expressed for example the importance of both the nurse and the receptionist together with the GP, in making care personal [17]. Also when talking about informational, management and relational continuity according to Haggerty et al. different professions have a role in linking information about the patient's preferences and context to ensure that the services are responsive to a single patient's needs [19].
There is always a risk of complications when translating complex concepts from one language to another. We have therefore made great efforts to find congruous terms. Ambiguities might also exist due to the difference in primary care systems in Sweden and in the UK and the US. The Swedish primary care system is based on organisational and administrative conditions with a publicly financed health care and a team based primary care, where district nurses have patients of their own and are independent co-workers to the GPs. In the UK and US systems, the nurses have a less independent role. We do not know whether these differences are reflected in the different languages and therefore influence the meaning of the concept. This deserves further study. The Swedish equivalents to 'comprehensive' and 'holistic' express similar differences as the English concepts. The Swedish district nurse is more concerned with primary care from a comprehensive viewpoint as 'the spider in the web', i.e. someone who considers the patients in their contexts, including their families and social circumstances. The statements from the GPs seem more holistic, i.e. more equal with general practice outside Sweden. The GP considers the patient in the context of the whole person, from biomedical, psychological and social perspectives [16, 22].
There were few studies to be found that include the concept holistic view in the way we have defined it since it is not a MeSH-term. This meant that research on this topic might exist but was not retrievable. We found studies with different spellings of the concepts 'holism' and 'holistic'. Studies with the spelling 'wh' were more in alignment with our results, while studies with a simple 'h', were of a more philosophical or religious nature [4, 23]. From the literature it would seem that holism is a subject that nurses have in their commission and not an assignment for GPs or other physicians, except in the case of very special groups of doctors such as the members of the American Holistic Medical Association [4].
However, in the present study it was obvious that GPs found a holistic view both meaningful and present in their daily work, only they did not name it as such. One could say that the concept was introduced by politicians and policy makers as a new brand of primary care, but was incorporated into Swedish primary care by the two main professional groups the GPs and DNs. Maybe a holistic view was already in place by the time of the introduction of the Swedish primary health care system and maybe all the policy makers did was to put a name on an already existing phenomenon. From the participants' narratives about their daily clinical work, it was evident that a holistic view characterised primary care as a whole. Their statements were distinguished by a homogeneous approach to the identity, the culture and the image of primary care, factors significant for an established brand [24]. We had an inductive approach when we asked our participants about their experiences. We were curious about what the concept 'holistic view' meant to the two main professional categories in Swedish primary care and we found a concept that was vividly alive in spite of the different theoretical backgrounds of the two professions: GPs' natural sciences against nurses' caring and behavioural sciences. The analysis of the interviews gave us a meaning of the concept. When we compared our findings with what is already known from the two research areas, nursing science and medicine, we found that spelling holistic with 'wh' instead of 'h' corresponded better to our participants' mutual understanding of the concept.
As the aim of this study was to explore the perceived meaning of a holistic view among GPs and DNs, a qualitative design was judged as relevant to gain a deeper understanding how the professions perceived the concept in their daily work, as the concept has not earlier been clearly defined. Focus group interviewing was deemed to be a suitable data collecting method. The purpose of focus group interviewing is to use group interaction to produce data. To prevent GPs or DNs from feeling uncomfortable and unable to speak freely in the group discussions we chose to interview the doctors and nurses separately. Focus groups are valid if they are used carefully for a problem suitable for focus group inquiry, and if they follow established procedures [11].
To do group interviewing needs training and the role of the moderator is to facilitate discussions between the group members. The two moderators (ELS, SW) have earlier conducted group interviews and were aware of the difficulties and were familiar with group processes and interviewing.
The findings from this study cannot be generalised but this is not the intention in qualitative studies, the main aim of which is to contribute to increased understanding. It is nevertheless reasonable to assume that our findings can be transferred to similar contexts.
