How engaging communities in a World Café can inspire integrative nursing research

In 2001, I published Demonstrating Care,[1] my first book on integrative nursing. At that time, researchers in higher education as well as health-care institutions were questioning how to advance the practices surrounding the conduct of quantitative studies, randomized clinical trials (RCTs) in particular, in relation to complementarity therapies and healing traditions. Some have acknowledged that intentions to conduct an RCT involving traditional and complementary modalities by any discipline but especially nursing with its stated values of promoting a healing relationship are fraught with risk to those relationships and therefore the integrity of the practice of those modalities, some of which have been practiced for thousands of years. For example, the very notion that the same herbal treatment must be standardized and applied the same way to a sample of participants whose demographic patterns might match but whose energetic patterns are utterly unique would seem to an indigenous or traditional healer and the nurses who partner with them that the researchers are attempting to "put round pegs in square holes." Integrative nurse researchers are challenged to design and advance a science that preserves the cultural traditions and values of the persons whom they serve. What actually makes integrative nursing research "integrative?" That is a challenging question in that the focus of integrative nursing involves an art and science that may not always be defined let alone controlled. In addition to the challenge of control, any reductionistic approach from isolation of variables to demanding adherence to only one modality in care as an intervention is often not feasible for study participants. The research practices of standardization, randomization, isolation, and control could even be characterized as dehumanizing to the very practices of integrative care that were sought for their humanistic approaches in the first place. Although RCTs rose to prominence as the gold standard for the evidence base of the pharmaceutical industry's testing of products, nurse scientists have known for decades that RCTs are often inadequate for providing the scientific integrative insights into the health beliefs, healing relationships, and the caring modalities with their "products and processes"[2] as well as the patterns that define integrative nursing inquiry, theory, and practice. Nurse scientists called to integrative nursing research in any form from qualitative and quantitative to mixed methods approaches are faced with strong but not insurmountable challenges to research that has integrity in that it is meaningful to the people and communities for whom they care. Research methods must sometimes match the time-honored conduct of complementary and traditional therapies and their associated sociocultural health beliefs and practices rather than adapting, and potentially degrading, the modality in some manner so as to achieve a researcher-desired methodology and design. Method and design follow the research question and then every process of inquiry begins with an historical question: what is known before now? It is this process of historical inquiry that provides a context for the research question as data over time. One option for starting the process of historical inquiry is to turn to the published literature to conduct a review of the literature; however, it is not the only starting point, especially for the researcher of integrative nursing who would explore nursing practice in communities that incorporate complementary and traditional modalities. Integrative nursing and research are creative as well as scientific processes, and as such are changed when the products of those processes are viewed as parts separate from the whole. In integrative nursing, the "whole" has been defined as pattern based on healing relationships.[3] There are two other areas that have been identified through research, practice, and experience that provide foundational structure for building an historical context for the design of integrative nursing research. They are health belief[4,5] and outcomes that include both process (how) and product (what).[2] As integration by definition is an inclusive process, the researcher then decides how they might plan to include one or more of these four areas. One example of an integrative approach to the historical inquiry phase that includes all four areas is the World Café method. It is a meeting format that draws upon several research-supported integrated design principles for hosting conversational leadership in small groups as a core process for collaboration and sharing knowledge.[6] It is similar to action research in that the purpose is engaging communities to explore solutions to tough problems. The process of engaging a community at the outset gives the researcher an opportunity for collecting themes as to those dimensions of the current state of the science that may be most meaningful to the community. Conversations occur at small round tables, each table with its own predetermined topic and facilitator. Each conversation is set for 20 min. After the 20 min pass, participants are invited to relocate to another round table until they have participated in the conversation at each table. Sharing stories and insights as well as drawing and doodling on the paper tablecloths are encouraged. At the end, each table's facilitator shares the themes from their table's conversations with the whole group. The café host then asks if the facilitators have indeed "caught" all stories or themes from the conversations. The host then provides a final synthesis of what solutions have emerged from the conversations on the chosen topic. A World Café can be employed at any stage of an integrative nursing research process; however, its utilization during the conceptualization phase of a research project provides opportunity for that project to naturally align with the major qualities of integrative nursing and provide a historical and cultural context to the research that is meaningful to communities for whom the product of that research is intended. Integrative nursing is not "alternative" or "complementary" to biomedicine because it does not presume that the biomedical culture, which is dominant especially in research circles, is to be considered the gold standard of evidence-based practice as is the RCT. Instead, exploration of relationships and health beliefs, process and patterns is the goal. This is where community-based inclusive approaches like the World Café can support greater clarity in differentiating integrative nursing research from those quantitative studies that simply employ an RCT using an alternative medicine philosophy in which the modalities that have been energetically tailored for the unique person, family, or community for centuries are quickly leveled to the mundane in hit or miss fashion. Integrative nurse researchers engaged in quality studies that align with historical and cultural values advance professional knowledge of nursing as a science and art and become examples to others who could reduce the potential of nursing as a human science. Johann Wolfgang von Goethe wrote of the human tendency to reductionism: In observing objects of nature, especially those that are alive, we often think the best way of gaining insight into the relationship between their inner nature and the effects they produce is to divide them into their constitutional parts. Such an approach may, in fact, bring us a long way toward our goal. In a word, those familiar with science can recall what chemistry and anatomy have contributed toward an understanding and overview of Nature. But these attempts at division also produce many adverse effects when carried to an extreme… Thus, observation of Nature is limitless, whether we make distinctions among the least particles or pursue the whole by following the trail far and wide.[7] Nature and natural states are often perceived as the foe of researchers who seek to strip the context of experience and expression of health and healing in the belief that rigorous inquiry is better assured. However, nursing's growing global expertise in research particularly in true qualitative and blended methods and action research has created a platform for supporting the research of complementary therapies within the context of nature and culture. Integrative nursing research is honoring and preserving the integrity of ethical and scientific congruency with ancient wisdom and healing traditions from which many if not all of these therapies have emerged by clearly detailing the design decisions and analyses made in studies that integrate those ancient traditions even identifying them as necessary "limitations" if need be. Integrative nursing researchers around the world who join others in positioning new inquiries within a meaningful historical context through community engagement activities, such as a World Café, join a scientific movement that holds much potential to ignite the exploration of the enduring expression of whole pattern science through the incorporation of nursing's centuries-old tradition of promoting healing relationships in new ways. "Awe is an emotion involving a feeling of being in the presence of something vast that transcends one's current understanding of the world and is associated with creating a sense of wonder and curiosity that ignite and sustain research endeavors."[8] Having wrestled with the challenges to preserve and advance traditional healing knowledge and having participated in and led numerous World Cafés that explored ways that nursing can partner with traditional healers to do so, I can say without equivocation that the scientific and creative patterns that emerge as a result of conversational leadership during world cafes are truly awe-inspiring.