Consumer interest in and use of complementary/alternative therapies has increased exponentially in the past decades. Although many of the over 1800 therapies have not been used in the delivery of nursing care, a number of these therapies have a long tradition of use in nursing. Additionally, nurses have conducted research on selected complementary therapies. Nursing is in an excellent position to be a leader in integrating these therapies into the Western biomedical health model and in continuing the research that will provide a better scientific base for the use of complementary therapies.
Key Words: complementary therapies; nursing; nursing interventions
Introduction
Complementary therapies are currently one of the most discussed and debated health care topics. From television newscasts to popular magazines to health professionals to consumers to government groups, interest in complementary therapies in the United States has grown exponentially. In a recent national survey in the United States, Eisenberg and colleagues found that 42% of those surveyed used one or more complementary therapies (Eisenberg et al., 1998). This was an almost 10% increase in use from the 1990 survey conducted by the same researcher (Eisenberg et al., 1993). What is most remarkable is that the majority of Americans paid for these services out of their own pocket. According to the 1997 survey, over 22 billion dollars were spent on these therapies.
Complementary therapies are not new. Many of the therapies have been used for centuries. Ancients such as Hippocrates, Plato, and Aristotle make reference to the effectiveness of a number of therapies that are now dubbed as being complementary (Snyder & Lindquist, 1998). Practices in Ayruvedic medicine, Traditional Chinese Medicine, and the health systems of indigenous cultures have been validated over millennia. Yet our current Western system of care is slow to accept the long history of anecdotal evidence as proof for the effectiveness of many therapies. In nursing, Florence Nightingale describes the use of a number of complementary therapies, such as music, in the holistic care of patients (Nightingale, 1860/1969). However, the development of surgical procedures, modern pharmacological therapies, and sophisticated diagnostic technology has resulted in the veritable demise of complementary therapies in Western medical/health care in the 20th century.
Complementary therapies have been more popular in Europe than in the United States (Pelletier, 2000). Herbs are an integral part of German health care; much of the research on herbal preparations has been conducted in Germany. Across the world, therapies Americans label as complementary or alternative are the main mode of health care. One estimation is that 70-90% of persons world-wide use complementary therapies as a routine part of their health care (Kreitzer & Jensen, 2000)
Definition and Classification
While complementary therapies is the term preferred by the authors for therapies that are not a part of conventional Western biomedicine, numerous other terms are also used: alternative medicine/therapies, integrative medicine or health care, holistic care, non-allopathic treatments, and non-traditional care. The title selected by the National Institutes of Health for its department on non-biomedical therapies is the National Center for Complementary/Alternative Medicine (NCCAM) <www.nccam.nih.gov>.
The term complementary has been preferred as it conveys that these therapies are used in conjunction with, rather than as replacement for, a biomedical treatment.
The term complementary has been preferred as it conveys that these therapies are used in conjunction with, rather than as replacement for, a biomedical treatment. The designator alternative conveys that a therapy is used in place of a biomedical treatment.
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The designator alternative conveys that a therapy is used in place of a biomedical treatment. For example, progressive muscle relaxation would be added to the treatment of persons with epilepsy rather than used as a replacement for antiepileptic medications. (Studies have shown that use of progressive muscle relaxation improves control of seizures [Whitman, Dell, Legion, Eibhlyn, & Staatsinger, 1990.]) However, complementary therapies are also used alone and not in conjunction with biomedical therapies. This is particularly true when these therapies are used to promote health. For example, persons may obtain massage on a routine basis to prevent the build up of stress.
Integrative care conveys that the system of care incorporates both biomedical and complementary therapies and that the two types of therapies are both considered when planning the care of patients. This term is also used to denote to consumers that both types of therapies are available in a facility. Integrative care more readily applies to medicine than to care provided by other health professionals as some complementary therapies have been an integral part of care provided by these professions over the years.
Holistic therapies is another term that is used to designate non-biomedical therapies. Cartesian philosophy has dominated Western medicine for several centuries. According to this philosophy, the mind and body are separated and do not affect each other; little attention is given to spiritual or social aspects of patients. Eastern health practices and the increasing body of research on psychoneuroimmunology reveal the interactive processes in humans with the mind, body, and spirt influencing the well-being of the entire person. The NCCAM has designated a category of therapies as mind-body therapies; however, a holistic philosophy underpins the majority of complementary therapies. While many biomedical treatments affect the entire person, attention has largely focused on the impact that the therapy has on the eradication or management of a physical problem. When an antihypertensive medication is prescribed, only the blood pressure is evaluated to determine the impact of the medication; minimal attention is given to how the medication affects the spiritual and psychological realms. In contrast to the Cartesian philosophy of medicine, nursing has espoused a holistic approach to persons and health care.
Finding a definition that encompasses the vast domain of therapies and systems of care has proven to be a challenge. A number of definitions for complementary/alternative therapies have been proposed. An interdisciplinary panel established by the Center for Complementary/Alternative Medicine in the National Institutes of Health proposed the following definition:
Complementary/alternative therapy is a broad domain of healing resource that encompasses health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the dominant health system of a particular society or culture in a given historical period. CAM includes all such practices and ideas self-defined by their users as preventing or treating illness or promoting health and well-being. Boundaries within CAM and between the CAM domain and the domain of the dominant health system are not always sharp and fixed (Panel on Definition and Description, 1997).
The definition uses the term complementary medicine, but the word "medicine" can arguably be changed to "therapies".
Efforts have been made to classify the more than 1800 identified complementary therapies. Similar to the development of a definition for complementary therapies, classifying these therapies is a daunting task since entire systems of care, therapies that are quite widely known and used, variations of these therapies, and practices of indigenous cultures that are largely unknown in the western world are encompassed within the domain of complementary therapies. The underlying mechanism of action for many therapies is unknown, thus providing additional challenges to the development of a classification schema.
The NCCAM has proposed the following categories for complementary therapies: mind-body therapies, alternative health care systems, biological-based therapies, manipulative and body-based therapies, and energy therapies that encompass therapies originally included in the biofield and bioelectromagnetic categories. Table 1 provides a description and examples of therapies in each category. NCCAM has noted that once a complementary therapy has become an accepted treatment for a specific condition it should no longer be classified as being a complementary therapy. This reference, however, is in terms of Western biomedicine. Many of these therapies are an integral part of other systems of health care and of other professions, such as nursing. NCCAM also notes that the boundaries between CAM and the dominant health care system are constantly changing and what may be deemed complementary at one point in time may subsequently be recognized as part of mainstream health care at a later date. This designation usually occurs when research has established that the therapy has proven to be efficacious through the use of randomized clinical trials.
The philosophical base underlying the use of many complementary therapies differs from the conventional Western biomedical model.
The philosophical base underlying the use of many complementary therapies differs from the conventional Western biomedical model. While biomedicine seeks to eliminate or correct the underlying problem, the purpose for using therapies in other systems of health care system is to achieve harmony and balance in the person.
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While biomedicine seeks to eliminate or correct the underlying problem, the purpose for using therapies in other systems of health care system is to achieve harmony and balance in the person. Zollman and Vickers (1999) state:
According to most complementary practitioners, the purpose of therapeutic intervention is to: restore balance and facilitate the body‘s own healing responses rather than to target individual disease processes or stop troublesome symptoms. They may therefore prescribe a package of care, which would include modification of lifestyle, dietary change, and exercise as well as a specific treatment. Thus, a medical herbalist may give counseling and an exercise regimen, guidance on breathing and relaxation, dietary advice, and a herbal prescription (p. 694).
It is the philosophy that underlies the use of complementary therapies that appears to be of equal importance as the therapies themselves.
Merely adding additional therapies to a system of care without implementing a holistic, caring approach to the care of patients will do little to improve health care.
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Merely adding additional therapies to a system of care without implementing a holistic, caring approach to the care of patients will do little to improve health care.
Growth in Use of Complementary Therapies
As noted earlier, a significant number of Americans use complementary therapies. The majority of these persons use these therapies in conjunction with biomedical treatments (Evans, Gillcrist, & Minz, 1997). Numerous factors have been cited for the growth in the use of complementary therapies:
- Believing that biomedical treatments do not take care of a problem
- Wishing to avoid the effects of a medication or treatment that are perceived to be worse than the condition for which biomedical care was sought
- Desiring a care provider who listens and is caring
- Seeking to be treated in a holistic manner
- Wanting input into the decision-making regarding their care (Astin, 1998; Jobst, 1998; Kaptchuk & Eisenberg, 1998; Mitzdorf et al., 1999)
Another factor that has increased the use of complementary therapies is the rise in immigrants from cultures that use a system of health care other than the Western biomedical system.
Biomedical discoveries have had a significant impact on the improvement of health through the control of infectious diseases and the effective treatment of many health problems. Weil (1995) noted Western biomedical therapies are the preferred mode of treatment for trauma and other emergency situations. However, he also noted that complementary therapies have an important place in the care of persons with chronic health conditions. Many persons with chronic health problems have voiced dissatisfaction with the treatment(s) prescribed by Western practitioners. Since a chronic condition affects the entirety of a person‘s being, healing/care therapies must encompass the spiritual, social, and psychological realms as well as the physical problem. These have been largely ignored in our current health care system.
Prescription medications have revolutionized the treatment of many health conditions. However, patient adherence in taking medications remains a major health concern (Haynes, McKibbon, & Kanani, 1996). One reason persons may not adhere is that the side effects of numerous medications are deemed by patients to be intolerable (Mitzdorf et al., 1999). The absence or relatively fewer side effects of complementary adds to their appeal.
A frequent complaint heard from patients is that health professionals do not listen to them but hurriedly make an assessment and prescribe a treatment.
A frequent complaint heard from patients is that health professionals do not listen to them but hurriedly make an assessment and prescribe a treatment.
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"Cost-effectiveness," a virtual mantra in the current health care system, may be a factor. However, the educational preparation of health professionals, particularly physicians, has often lacked content on interpersonal skills and a holistic approach to patients. Listening and presence, viewed by these authors as being key components of all complementary therapies, are valued by patients. After visiting a health professional who uses complementary therapies or a complementary therapist, many patients remark that the person took time to listen to their concerns and problems. Patients want to be treated as holistic beings (Jobst, 1998).
Immigrants to the United States come from all parts of the globe and for many, their health care has included therapies that we in the United States classify as complementary therapies. Americans have become familiar with therapies such as acupuncture, meditation, and herbal preparations. There is less familiarity with therapies such as Qi Gong, soul retrieval, Kampo medicine, curanderismo, psychic surgery, panchakarma, and Chinese Tui Na massage. Even herbal preparations typically used in the United States differ from those used in other cultures; the herbal preparations of Traditional Chinese Medicine are different from ones used in the United States and Europe. Not only are different therapies used across cultures, but conceptualizations of health and illness vary greatly. Thus, recent immigrants may use a therapy similar to one used in the United States, but the purpose for which the therapy is used may be significantly different. The book The Spirit Catches You and You Fall Down (Fadiman, 1997) carries a poignant description of the understanding of therapies in two cultures.
Place of Complementary Therapies in Nursing
As noted earlier, Nightingale suggested the use of complementary therapies in the care of patients. Early fundamental nursing texts include therapies such as back rubs (a form of massage), heat and cold, and nutrition. Thus, complementary therapies have a long history in nursing. However, as nurses began to be employed primarily in hospitals that largely supported the Western biomedical approach to care, more of the nurses‘ time was allocated to collaborative activities associated with the medical plan of care including the monitoring of the patient‘s status. Time demands provided nurses with less opportunity to administer those aspects of nursing that included complementary therapies.
In the late 1950s, the nursing process was introduced. This four part problem-solving approach to nursing included assessing, planning, intervening, and evaluating. Eventually a fifth element, diagnosis, was added. In addition to the honing of assessment skills, the process also drew attention to interventions. Distinction was often made between dependent or collaborative actions and independent actions or interventions. The latter was often relegated to more advanced courses. As graduate education of nurses for clinical practice increased, interest in and use of independent nursing interventions grew. Complementary therapies provide opportunities for nurses to function autonomously.
Within nursing, the term intervention has often included therapies that are now classified as complementary therapies. A number of the interventions included in the first two texts on independent nursing interventions (Independent Nursing Interventions [Snyder, 1985] & Nursing Interventions: Treatments for Nursing Diagnoses [Bulechek & McCloskey, 1985]) included complementary therapies such as music, imagery, progressive muscle relaxation, journaling, reminiscence, and massage. The subsequent development of the identification and classification of nursing interventions in the International Council of Nurses Project (ICNP) and the National Intervention Classification Project (NIC) has broadened the scope of the term intervention to encompass all nursing activities (International Council of Nurses, 1997; McCloskey & Bulechek, 1996). Thus, the term intervention as it is conceptualized in nursing does not distinguish complementary therapies from other activities nurses perform such as monitoring the status of a patient or coordinating care. To distinguish complementary therapies from the broader domain of interventions, the authors titled their third edition on independent nursing interventions, Complementary/Alternative Therapies in Nursing (Snyder & Lindquist, 1998).
Nurses have and do use numerous complementary therapies to help patients achieve positive health outcomes. Table 2 lists complementary therapies commonly used by nurses. A subsequent article in this journal discusses the educational preparation of nurses to administer complementary therapies and which therapies should be included in the various curricula. Many nurses have pursued courses to prepare them to administer other therapies such as acupuncture, hypnosis, spiritual direction, and Reiki.
Are there any complementary therapies that are not within the purview of nursing?
...where possible, therapies that have a research base should be selected.
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These authors believe that competence in performing a therapy and its use to achieve an outcome that is within the scope of nursing are the guiding principles to use to determine if a therapy can be administered by a nurse. The Royal College of Nurses (RCN) has formulated 11 beliefs to guide the use of complementary therapies (Buckle, 1997). One of the beliefs is that the nurse works in partnership with the patient to determine the suitability of a therapy. Another belief notes that, where possible, therapies that have a research base should be selected. What is paramount, according to the RCN, is that the nurse must have the necessary preparation to administer the therapy and that she/he follows the established practice protocols and standards of care and practices within the local legal requirements.
In recent years, exposure to other cultures has increased the scope of therapies classified as being complementary therapies. It is incumbent on nurses to increase their knowledge about various complementary therapies. This does not necessitate a nurse becoming prepared to administer a multitude of therapies but rather to have a broad knowledge so as to understand therapies patients may be using or considering to use. It is also important that health histories obtain information about a patient‘s use of complementary therapies.
It is also important that health histories obtain information about a patient‘s use of complementary therapies.
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Patients are sometimes reluctant to convey this information as they may feel that the health professional is not accepting of these practices. Obtaining this information requires an openness on the part of the nurse, and it may require the nurse to re-state the question or use probes. Seeking this information is important as interactions between some herbal preparations and prescribed medications and the impact that other complementary therapies may have on a biomedical treatment requires that health professionals be aware of all therapies a patient is using so that the plan of care is coordinated and safe.
The increasing public interest in complementary therapies provides an opportunity for nursing to share with the public and colleagues in other disciplines how these therapies have been a part of nursing for centuries. Also, nursing needs to convey that a holistic, caring philosophy has been and is an integral part of nursing. Additionally, nurses have conducted a considerable amount of research on complementary therapies such as imagery, music, therapeutic touch, massage, humor, reminiscence, animal-assisted therapy, and prayer. With the knowledge gained from these studies nurses are in a prime position to take the lead on interdisciplinary complementary therapy research teams.
Use of complementary therapies is a part of nursing‘s heritage. Administration of complementary therapies provides an opportunity for nurses to act autonomously in the delivery of care. Also, inclusion of complementary therapies in the plan of care allows nurses to demonstrate caring in a holistic fashion, which is a key characteristic of nursing.
Authors
Mariah Snyder PhD, RN, FAAN
Email: snyde002@tc.umn.edu
Dr. Mariah Snyder is a professor at the University of Minnesota School of Nursing and a faculty member in the Center for Spirituality and Healing in the Academic Health Center. She was one of the developers of that Center and of the graduate minor in Complementary Therapies and Healing Practices. Dr. Snyder has developed courses on complementary therapies and is the director of a summer institute on complementary therapies in nursing. She has made numerous presentations, both nationally and internationally on nursing interventions and complementary therapies and has published extensively on the topic.
Ruth Lindquist PhD, RN
Email: lindq002@umn.edu
Dr. Ruth Lindquist is an associate professor and Division Head of Adult, Geriatric, and Psychiatric/Mental Health Nursing at the University of Minnesota School of Nursing and a faculty member in the Center for Spirituality and Healing in the Academic Health Center. Her research as a Densford Scholar in the Densford International Center for Nursing Leadership focuses on critical care nurses' attitudes towards and use of complementary/alternative therapies.
Drs. Snyder and Lindquist are editors of Complementary/Alternative Therapies in Nursing (3rd edition, Springer Publishing Company); a 4th edition is forthcoming.
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