Nursing as a Framework for Alternative/Complementary Modalities

With nationwide interest in complementary healthcare, nurses have actively incorporated alternative/integrative modalities into their practice. Registered Nurses regularly attend continuing educational sessions on techniques such as acupressure, guided imagery, humor, massage, meditation, and therapeutic touch/healing touch. Review of continuing educational offerings advertised in holistic nursing newsletters and websites indicates that many nurses learn these techniques in sessions alongside other healthcare providers and are taught by non-nurses. In such situations, nurses may raise questions related to their legal scope of practice and the use of alternative/complementary modalities within professional nursing. When these techniques are taught by and practiced by individuals who are not nurses as well as by nurses, questions such as, "May a nurse practice guided imagery as an RN?", "May a nurse perform simple massage or therapeutic massage?" and "May a nurse practice therapeutic touch(TT) as a private, independent professional?" become critically important and not easily answered. While the practice of nursing is regulated by each state, ability to bring alternative/complementary modalities into a nursing context assists in defining the practice as part of professional nursing. When operating from a nursing perspective, nurses recognize that the ability to perform and use these techniques can be greatly enhanced when they integrate these techniques into the context of professional nursing. The purposes of this paper are to explore how a professional nursing context provides a discipline-specific direction to the practice of complementary/alternative modalities by adding qualities of assessment, reflection, and holism to the performance of the techniques, and to provide examples for nurses to incorporate alternative/complementary practices into care that is clearly identified as professional nursing.

Alternative/Complementary Modalities

Alternative/Complementary modalities have been defined as treatment techniques whose goals are to evoke healing, taking into account the body-mind-spirit connection of every individual (Dossey, 1995). The use of the word '˜alternative‘ became popular in the 1990s when holistic medicine was considered a new or emerging field. Then, '˜alternative‘ medicine meant practices and healing techniques that were not generally taught in medical schools (Eisenberg, et.al., 1993), thus, alternative to the prevailing view.

Further, the use of the word '˜alternative‘ implied that certain techniques were used instead of recommended, biomedical treatments. The word '˜complementary‘ gained popularity in the field conveying the idea that the modalities or techniques could be used to complement and enhance the biomedical treatments.

The establishment and naming of the National Institutes of Health (NIH) Office of Alternative Medicine in 1992 reflected this definition. Over time, however, it became clear that such a definition was inadequate because many of the modalities were brought into medical school curricula, were taught as legitimate methods of care, and were incorporated in medical practice (Wetzel, Eisenberg, & Kaptchuk, 1998). Further, the use of the word '˜alternative‘ implied that certain techniques were used instead of recommended, biomedical treatments. The word '˜complementary‘ gained popularity in the field conveying the idea that the modalities or techniques could be used to complement and enhance the biomedical treatments. Thus, the branch of practice was renamed '˜CAM‘, complementary and alternative medicine, and when the NIH office was elevated to a center, it was also renamed as the National Center for Complementary and Alternative Medicine (NCCAM) <http://nccam.nih.gov>. According to the current NCCAM factsheet, CAM refers to healing philosophies and approaches that Western medicine does not commonly use, accept, study, understand, or make available (NCCAM,2001).

Many have implied that alternative care means holistic care, however, that notion has been justly criticized on the grounds that holism is defined more by the context of the care, than by the actual treatment techniques employed (Saks, 1997).

Likely, it is because nursing is an holistic discipline that nurses have demonstrated great enthusiasm for the techniques and modalities associated with the field of complementary and alternative care as these techniques assist nurses to address the physical, mental, emotional, and spiritual dimensions of care.

Nursing, however, is an holistic approach at its essence. Review of every nursing theory in use today indicates that each of the theories define nursing by taking into account the whole person (George, 1995). Likely, it is because nursing is an holistic discipline that nurses have demonstrated great enthusiasm for the techniques and modalities associated with the field of complementary and alternative care as these techniques assist nurses to address the physical, mental, emotional, and spiritual dimensions of care. A study conducted in 1996 of nurses who defined themselves as '˜holistic nurses‘ (N=708) revealed that a majority of them defined their practice in relation to alternative/complementary modalities (Dossey, Frisch, Forker, & Lavin, 1998). Modalities most frequently used by these study respondents were: acupressure, aromatherapy, biofeedback, guided imagery, healing presence, humor, journaling, music therapy, meditation, relaxation, and therapeutic touch/healing touch.

For purposes of this paper, alternative/complementary modalities refers to the techniques such as those listed above and practiced by nurses for the purpose of enhancing client healing. All of these techniques are immediately recognized as complementary/alternative and fit under the definition of NCCAM for CAM.

The Context for Professional Nursing

There are two ways of thinking about nursing that underpin professional nursing practice and help nurses to understand and articulate a worldview. These are the nursing theories/conceptual models for practice and the current nursing taxonomies. Each of these approaches provide a unique and discipline-specific view of care, distinct from the care of other health professionals. Thus, alternative/complementary modalities performed from within a context of a nursing theory/model take on meaning from within the theory as the modalities become part of purposeful action to achieve goals of care prescribed from within the theoretical point of view. Modalities performed and documented according to one of the standard taxonomies explicitly bring the modalities into the domain of nursing and make the performance of the technique part of nursing activities addressing a defined phenomena of concern. Each of these frameworks and their relationship to alternative/complementary modalities will be addressed below.

Nursing Theories/Conceptual Models

Nursing theory is the foundation of professional nursing practice (George, 1995). Theory articulates a worldview, suggesting how nurses interpret practice events and think about care. Each theory addresses the concepts of nursing‘s metaparadigm in a different way, exploring the relationships between and among the concepts of person, health, nurse, and environment. Theory-based practice is reflective practice - nursing is both providing care and thinking about care to ensure it is consistent with stated values and principles.

Modalities incorporated into practice from within a framework of nursing theory are given meaning from within the theory. Some of the modalities are compatible with the principles and concepts of specific nursing theories. In other cases, the theories themselves provide a mandate for a specific kind of nursing intervention. Nursing theory provides the language, concepts and worldview to reflect on nursing care and on the use of alternative/complementary modalities. Several examples from selected nursing theories are discussed below.

The first example of use of alternative/complementary modalities and nursing theory will be drawn from the Modeling and Role-Modeling Theory of Erickson, Tomlin and Swain (1984). The concepts of "Modeling" and "Role-Modeling" are central to the theory. Modeling is the process by which the nurse develops an image of the client‘s world, giving the nurse ability to understand the world from the client‘s perspective, and Role-Modeling occurs when the nurse plans interventions to role-model health behaviors congruent with the client‘s worldview (Frisch & Bowman, 1995; Erickson et al., 1998) The theory is based on adaptation and through a specific assessment of adaptive potential, the Adaptive Potential Assessment Model (APAM), the nurse is guided to assess the client‘s strengths, areas of positive adaptation, and state of arousal (Bowman, 1997; Erickson & Swain, 1982). Professional nursing from within this framework requires that the nurse build a model of the client‘s world and from within that model the nurse must role-model health behaviors to assist the client regain/attain health. Nursing care is planned only after discussion and mutually agreed-upon goals of care.

The concept of '˜modeling‘ guides the nurse to specific modalities. When a nurse models the client‘s world, the nurse attempts to enter into the client‘s worldview. The nurse observes the client, and adapts his/her own timing and pacing to that of the client. If the client is in a state of excitement and breathing at a rapid rate, the nurse matches his/her breathing and actions to that of the client‘s. If the client is in a state of exhaustion, the nurse sits, is slow in movements, and paces him/herself to match the client‘s level of energy. If the client expresses anxiety and a desire to feel more calm, the nurse models the anxiety and, through conscious role-modeling, demonstrates for the client a means to slow breathing rate, relax, and take control of the anxiety first at the physical level and second at the cognitive, reflective level. The modalities of progressive relaxation, imagery, guided imagery, and hypnosis are techniques that are used to carry out the concepts of modeling and role-modeling. Thus, the techniques are used within the theory, not simply as modalities to help a client relax. The techniques become methods to carry out the basic principles of professional nursing practice. As integral to the theory, these techniques permit the nurse to assess the client within a holistic perspective, relfect and use the APAM model, plan care based on level of arousal according to the theory, and evaluate outcomes according to level of arousal and ability to self-regulate these feelings. The modalities, carried out by a professional nurse, have depth that is provided by a theoretical worldview and permit a sophisticated level of assessment.

Secondly, Roy‘s Theory of Adaptation will be explored. Central to this theory are the concepts of focal, contextual and residual stimuli (Roy & Andrews, 1991). The focal stimuli are the conditions immediately confronting the client, the contextual are all other stimuli present, and the residual stimuli are those beliefs, attitudes and conditions that have an indeterminate effect on the present condition. The nurse, operating from within this framework, assesses the stimuli and takes action to promote the client‘s adaptation in physiologic needs, self-concept, role function, and relations of interdependence nursing health and illness. Roy states that the "nurse acts as a regulatory force to modify stimuli affecting adaptation" (1980, p. 186).

Particularly with regard to contextual stimuli, there are several alternative/complementary modalities that permit the nurse to alter the stimuli and change unhealthy or noxious environmental stimuli to ones that are either neutral or wholesome.

Music therapy and aromatherapy are specific modalities that change the environment in which the client finds him/herself and are expressly designed to change the context of care from one that is deleterious to one that is supportive.

Music therapy and aromatherapy are specific modalities that change the environment in which the client finds him/herself and are expressly designed to change the context of care from one that is deleterious to one that is supportive. These modalities can easily be seen as nursing activities promoting positive adaptation. Music therapy is a systematic application of music to produce relaxation and desired changes in emotions, behaviors, and physiology (Guzzetta, 2000) and armoatherapy is the use of essential oils to offer symptomatic relief or to enhance a sense of well being (Buckle, 1998; Stevenson, 1994). Used from within Roy‘s Adaptation Model of Nursing, these two modalities take place within the nursing process and are interventions aimed at manipulating stimuli affecting client health. Given the use of the theory, the assessment of the need for the modality becomes part of reflective, holistic nursing care, and outcomes are interpreted from within the framework of adaptation, stimuli, stress and a specific worldview.

Thirdly, there are several nursing theories that incorporate the concept of '˜human energy field‘ and '˜environmental energy field‘, specifically Rogers‘ Theory of Unitary Human Beings, Newman‘s Theory of Expanding Consciousness, and Parse‘s Theory of Human Becoming (Frisch, 2000). All energy-based modalities are congruent with these theories. While Therapeutic Touch (TT) is a modality developed by and researched by nurses (Keiger, 1979; Quinn, 1988; Straneva, 2000), other energy-based modalities such as Reiki and Healing Touch techniques are widely used by and taught to non-nurses. The theoretical frameworks for techniques involving human and environmental energy fields are nursing theories and the philosophies of Eastern traditions (Slater, 2000). For nurses engaged in energy-based techniques, bringing the techniques into a worldview of nursing permits the nurse to assess and practice with the benefit of reflection on the meaning of energy exchange and its effect on creating a reality for the nurse and client.

Lastly, in relation to Jean Watson‘s theory of Humancare, nurses will recognize the most important aspect of all nursing activities are those actions that promote professional, compassionate, human to human interaction (Watson, 2000) . For the theory of Humancare, the very basis of nursing is interaction and connection between two human beings. The modality of healing presence is a significant, important technique to provide trust, support and to initiate the caring encounter necessary for nursing to take place. Healing presence is one of the modalities stated frequently by holistic nurses in the survey of modalities used in nursing practice discussed above. Watson‘s theory elevates the importance of this nursing action to its rightful state in care - it is the pre-requisite for any professional nursing activity. From within the worldview of the theory of Humancare, a nurse will identify presence as a very necessary nursing action. Presence is often described as '˜being in the moment‘ (Dossey,1995), or '˜being with‘ rather than '˜doing to‘ (Paterson & Zderad, 1976). There are three levels of presence defined for nursing practice: physical presence (being there), psychological presence (being with), and therapeutic presence as the nurse‘s reflectively relating to the client as whole being to whole being using all of his or her resources - body, mind, emotion and spirit (McGivergin & Daubenmire, 1994). It is the final level, that of therapeutic presence, that fits best with the notion of Humancare. While many do not consciously think about healing presence as a modality, it requires skills of centering, openness and intuition to employ for the good of client care. The theory of Humancare reminds nurses that healing presence is indeed a modality and one that has not received sufficient attention, development and research as would be assumed, given how fundamental it is to the discipline.

Through examples from four distinct nursing theoretical frameworks, several complementary/alternative modalities have been discussed as appropriate to incorporate into professional nursing. If one accepts the ideas that 1) professional nursing is based on theory and 2) that theory-based practice is reflective practice, the use of the modalities within theory becomes thoughtful and considered as a means to understand and interpret a nurse‘s actions. Nursing theory provides a means to understand modalities and permits nurses to assess and incorporate new aspects of care into a larger, more holistic, and very professional, worldview.

Nursing Taxonomies of Nursing Practice

Taxonomies of nursing practice are the classification systems that provide frameworks for naming and documenting the phenomena of concern of professional nursing. The most widely known and used of these taxonomies is the NANDA Classification of Nursing Diagnoses (NANDA, 2001). Originally presented to the nursing community in the 1970's the NANDA taxonomy is a statement of nursing problems and concerns. Over the years many nurses have worked within this (and other nursing diagnostic systems, for example the Omaha and Saba systems) to identify and name all phenomena of concern to nursing. The current NANDA taxonomy lists over150 nursing diagnoses, organized according to domains based on health patterns. Work presented at the last meeting of NANDA indicated that the nursing diagnostic taxonomy will include statements of problem, risk for problem, and opportunity or readiness to enhance a current condition (Jones, et al., 2000). Thus, the current taxonomy of diagnoses presents a statement of conditions (both problems and opportunities to promote/enhance wellness) that have been identified by nurses as within the autonomous domain of nursing.

Newer taxonomies for nursing include the Nursing Interventions Classification (NIC) , now in its third edition (McCloskey & Bulechek, 2000) and the Nursing Outcomes Classification (NOC), now in its second edition (Johnson, Maas, & Moorhead, 2000). These taxonomies list nursing activities that have been identified by nurses as actions they perform on behalf of patients/clients while providing direct and/or indirect care and measurable, core outcomes that are sensitive to nursing interventions. Taken together, the NANDA, NIC and NOC provide as comprehensive a list as is available of the concerns, actions, and expected outcomes of nursing practice. These lists are remarkably useful for nurses using complementary/alternative modalities in practice.

Complementary modalities may be used by nurses and non-nurses alike; however, when used as part of nursing practice, the care should be documented in a nursing context.

Complementary modalities may be used by nurses and non-nurses alike; however, when used as part of nursing practice, the care should be documented in a nursing context.

While some modalities require additional certification and/or licensure in some states, (for example, massage therapy), most of the modalities used by nurses require a nursing license and documentation that makes clear that the care provided is within the scope of professional nursing practice. When a complementary/alternative modality is used to address a concern identified as a nursing diagnosis, the action becomes an identified nursing intervention planned to address/remedy a nursing problem or concern. For example, when music therapy is provided to assist individuals obtain adequate sleep, the NANDA diagnosis of disturbed sleep pattern is the identified nursing problem and the intervention '˜music therapy as provided through tape recorded music at times of wakefulness‘ is a nursing intervention identified by the nursing community as within the domain of professional nurses. Likewise, when the nursing problem is fear related to undergoing medical diagnostic procedures (such as an MRI), and the nursing intervention is '˜guided imagery to assist the client with relaxation and distraction during the procedure‘, the problem, intervention and outcome can be documented from within the taxonomic frameworks as nursing. To provide an example of a wellness-oriented nursing concern, when the nursing concern is readiness to enhance spiritual well-being related to a time in life when a client is examining his personal beliefs, values, and sense of future, the nursing intervention '˜meditation facilitation to focus awareness on an image or thought and to find a place of inner peace‘is being used to address an identified nursing concern. A last example is the use of the intervention Therapeutic Touch (TT) as a technique to assist the client experiencing impaired comfort related to severe itching. The technique is being used to provide a non-pharmacologic treatment of condition affecting the client‘s comfort and well-being. In each of these cases, the nursing activity is a complementary/alternative modality (music therapy, guided imagery, meditation, TT). Practice within the nursing context emphasizes that the modality is being used to address the human response to actual/potential health problems. Table 1 provides a summary of selected nursing diagnoses and interventions to indicate possible pairings of nursing concerns and actions.

Table 1: Selected Nursing Diagnoses and Nursing Interventions: Possible Pairings of Nursing Concerns and Complementary/Alternative Interventions
Nursing Diagnosis/concern	Nursing Intervention(s)	Rationale
Impaired Comfort	Acupressure, TT	to decrease perceived pain
Disturbed Sleep Pattern	Massage	to promote relaxation, rest
Social Isolation	Animal-Assisted Therapy	to provide affection
Impaired Coping	Humor	to facilitate appreciation of that which is funny, to relieve tensions
Hopelessness	Hope instillation	to promote a positive sense of the future
Spiritual Distress	Spiritual support	to facilitate a sense of inner peace
Spiritual Well-Being	Spiritual growth facilitation	to support growth/reflection reexamination of values
Anxiety or Fear	Guided imagery, relaxation therapy, biofeedback, calming techniques	to reduce sense of anxiety
Impaired Communication	Art therapy	to facilitate expression

When documented from a nursing framework, the nurse is making it clear that the modality is being used to address an issue that has been accepted by the nursing community as within the domain of nursing and within the phenomena of concern to professional nurses. Nurses documenting practice using these systems are accomplishing three important things: appropriate documentation of care, identification of work as within the scope of professional nursing, and building a body of knowledge for nurses on the use of specific interventions.

The taxonomies provide both a framework that helps nurses think in a holistic manner about what they are doing as nurses and increased justification for having a nurse perform the activities. The taxonomies themselves are atheoretical, meaning that they are not grounded in any of the nursing theories, they are simply a list of diagnoses, interventions and outcomes. These diagnoses, interventions and outcomes, however, can be used with nursing theory to guide the reflective interpretation of client conditions and selection of appropriate nursing interventions. Within the framework of nursing taxonomies, the alternative/complementary modalities become part of the nursing process - the documentation of nursing assessments, concerns, interventions and outcomes.

Discussion

Alternative/complementary modalities are techniques used in healthcare practice to help clients achieve specific outcomes.

Techniques, however, are just techniques, and can be used at the level of "doing things" without the reflection, thought, or interpersonal exchange required of and expected from professional nursing.

Techniques, however, are just techniques, and can be used at the level of "doing things" without the reflection, thought, or interpersonal exchange required of and expected from professional nursing. Nurses are in an excellent position to adopt complementary/alternative modalities into practice that addresses assessed client needs and to use these techniques to achieve the goals of nursing. Use of theory and nursing classification systems help nurses use these complementary/alternative modalities professionally. Documentation of these techniques through either nursing theory or current nursing taxonomies makes the practice explicitly that of professional nursing. Care directed by nursing theory and/or care according to a standard nursing taxonomy is care that is generally regarded by the profession as within the domain of nursing. Thus, documentation of care from a nursing framework provides for practice which is recognizable as nursing, and legally defensible as within nursing‘s scope of practice. Addtionally, using modalities within nursing practice gives nurses an enhanced set of tools for practice - making the practice professional, whole and client-centered.

Author

Noreen Cavan Frisch, PhD, RN, FAAN
E-mail: nfrisch@uvic.ca

Noreen Cavan Frisch, PhD, RN, FAAN is a Professor of Nursing and Chair of the Department of Nursing at Cleveland State University. She is past-president of the American Holistic Nurses Association and has served as a member of the Advisory Council to the NIH Office of Alternative Medicine. She has published articles on topics of nursing theory, diagnosis and holism. She co-chaired a national committee to produce the AHNA Standards of Holistic Nursing Practice, which were published in 2000 in a book for which she served as first author and editor.

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