Nurse educators are considering the inclusion of complementary and alternative therapies in nursing curricula with increasing frequency, motivated at least in part by the ever-increasing public enthusiasm for these therapies. This article addresses the differing paradigms between orthodox Western medicine and complementary and alternative therapies, describing the research, language, educational, legal , financial, and ethical issues related to the use of complementary and alternative therapies. Additionally, it presents sources of current standards, along with examples of teaching these therapies at the undergraduate, graduate and continuing education levels and suggests strategies for teaching these therapies.
Key words: complementary and alternative therapies, complementary and alternative therapy education, complementary and alternative therapy curriculum, complementary and alternative therapy teaching strategies, paradigms, alternative systems of medicine
The ever-increasing public enthusiasm for complementary and alternative therapies (CAT) is motivating nurse educators to consider the necessity of including the topic in nursing curricula in the United States and the United Kingdom. Studies in both counties document this enthusiasm (Ching, 1998; Eisenberg, et al. 1998). In 1996 a national conference sponsored by the National Institutes of Health/Office of Alternative Medicine and the Uniformed Services University of Health Sciences, Bethesda, MD, was convened to address the issue in nursing and medical education. The conclusion of this Blue Ribbon Panel was that nursing and medical education should include information about complementary practices (Kligler, 1996). Exactly what information and how much was not specified, although there was commitment to continuing the discussion through the formation of "Centers of Excellence" and to collaboration and the "synergy" of research, education and clinical practice related to CAT (p.541).
In addition to the widespread use of complementary and alternative therapies by the public, other reasons for pursing the issue in nursing education include: media attention to the positive outcomes of CAT, nursing interest and the increasing number of articles on the topic in highly respected professional journals, the inclusion of these therapies in medical curricula, the necessity to provide culturally congruent care, and increasing governmental legitimacy (Reed, Pettigrew, & King, 2000).
| Though skeptics may remain unconvinced, it seems the question at this point is not so much about whether or not complementary and alternative modalities should be included in curricula, but what are the issues and trends in teaching CAT.
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Differing Paradigms: The Issues
CAT and orthodox Western medicine derive from different paradigms (Bartol & Courts, 1993; Ching, 1998; Dossey, Keegan, & Guzzetta, 2000; Kligler, 1996; Purnell, 2001; Reed, et al., 2000). In general, it can be said that the Scientific Revolution fostered the development of modern medicine in the West and as such the principles of that paradigm (reductionism, determinism, objectivism) have created a medical approach that is largely oriented to pathology and treatment aimed at the elimination or control of disease. This approach has been markedly successful with infectious disease and trauma. However, it has also created a dual system of treatment (one for physical pathology and one for psychological pathology) that emphasizes a split between the mind and body. This dual system, as well as increasing specialization, reinforces a mechanistic "parts" approach to treatment and care that is less successful with our increasing focus on chronic disease and wellness promotion; and in the United States, most people employing CAT are seeking to prevent illness or ameliorate the effects of chronic disease (Purnell, 2001). Additionally, from the perspective of this Western medical paradigm, the relationship of provider and patient is one in which the patient is a more or less passive "recipient of care". Because the focus is on diagnosis and treatment, the relationship is not seen as having any significant bearing on the curative process (Reed, et al., 2000).
On the other hand, the new science paradigm, based on discoveries in fields as diverse as physics, biology, chemistry, mathematics, and language (Capra, 1996) and the philosophies of the East from which other systems of medicine have developed, are likely to be identified as providing the philosophical and theoretical foundations for complementary and alternative therapies. The new science paradigm emphasizes systems, interrelationships, complexity, creativity, and subjectivity (Capra, 1996). Likewise, Eastern philosophies tend toward a worldview in which holism is central (Huxley, 1945). Thus, although CAT can be applied mechanistically, it is believed that the theoretical and philosophical foundations of these modalities result in a more holistic approach, emphasizing the integration of the bodymind and viewing the person within social and cultural contexts. Additionally, in contrast to orthodox medicine, the relationship of the practitioner and patient is often viewed as central to a positive outcome (Reed, et al., 2000). This centrality of relationship to positive outcomes is congruent with the ideas expressed by the American Association of Colleges of Nursing (AACN) in describing the essentials of nursing education at both the baccalaureate and master's level (AACN, 1996, 1998), with the assumptions of many nursing theorists, and with the standards of holistic nursing (Frisch, Dossey, Guzzetta, & Quinn, 2000). The integral nature of relationship and healing in both nursing and most CAT may provide the starting point for meaningful curriculum discussions and decisions regarding this content.
Though nursing and medicine have a different focus, nursing has also developed within the scientific paradigm and the values of the paradigm are evident in nursing education.
| Though nursing and medicine have a different focus, nursing has also developed within the scientific paradigm and the values of the paradigm are evident in nursing education.
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Research Considerations
The scientific paradigm has, of course, given rise to the scientific method and that ideal of medical research, the double blind study. Though other research methods are sometimes used, legitimacy of any treatment depends on the demonstration of its efficacy using this research method. Other systems of medicine have developed using an empirical approach to knowledge development; however, these systems are not based on the Western scientific method. A major critique and concern of CAT is that their efficacy is difficult to substantiate using scientific methods with our current technology (Ching, 1998; Clark & Gordon, 1999; Snyder, Kreitzer, & Loen 2001). The concern about the lack of research on CAT effectiveness warrants caution as nursing educators seek to integrate these therapies into nursing curricula. However, acceptable research methodologies need to be broadened. Keine and von Schon-Angerer (1998) argue that the idea of single causality (inherent in double blind studies) is incongruent with a holistic view in which multi-causality and non linearity are significant features. In some cases qualitative methods may be more useful for understanding the effects of these modalities. At a recent summit in Tucson, AZ, convened to "explore collaboration and enhance cooperation among the many stakeholders within the various CAM [Complementary and Alternative Medicine] communities", it was recommended that research methodologies with the broadest possible outcomes are those that best measure integrated care (Weeks, 2001, pp. 30-31). Keegan (2001) has reviewed a significant number of studies regarding the effects of various CAT on patient outcomes. Much of the research on these therapies has been conducted by nurses (Snyder, Kreitzer & Loen, 2001). Presumably, as complementary and alternative practices become more integrated into nursing curricula, nurses will continue to lead the way to knowledge development regarding CAT.
Language
The language of medicine and much of nursing has evolved from the allopathic model of medicine making it difficult to define or discuss other systems of medicine or therapeutics that do not fit this model. The issue of language is demonstrated in trying to make a decision about how to refer to those therapeutic practices that have not derived from allopathic medicine. Reed et al. (2000) note that terms used to denote medical care in the United States include "Western, orthodox, conventional, biomedical, allopathic, mainstream, standard, and scientific medicine"(p. 134). The term "traditional" illustrates the difficulty of language since it may describe allopathic medicine or it may refer to other systems of medicine such as Ayurveda and Traditional Chinese Medicine, or to the health practices of indigenous peoples such as the traditional health practices of the Navajo. Terms used for therapeutics outside the boundaries of orthodox medicine range from the frankly pejorative, such as "quackery" to relatively benign terms such as alternative, complementary, adjunctive, and integrative (Reed, et al., 2000). Although Kritek (2001) suggests "complementary" has "an interesting undertone of patronization in it" (p. 913), this paper uses the term complementary and alternative therapies (CAT) because it is inclusive of those therapies that are most often used in conjunction with conventional approaches and those that are used in place of standard treatment and care. The term CAM (complementary and alternative medicine) is less inclusive because it connotes a system of medicine and many therapeutics are not within a system of medicine. Some schools of nursing may choose to address only those therapies used with current biomedical treatment while others may choose to consider the range of complementary and alternative approaches. In either case, the issue of language will need to be addressed.
Educational, Legal and Financial Considerations
The Western paradigm has also given rise to specific educational, legal, and financial structures that reinforce the exclusivity of sanctioned practices. Practitioners are required to complete formal education culminating in appropriate degrees from institutions of higher learning. The education requirements for CAT practitioners vary widely and may or may not include degrees (Clark & Gordon, 1999). Furthermore, the legal structure includes practice acts, licenses, registrations, certifications, and the development of various regulatory agencies charged with overseeing the institutionalization of the values, approaches, methods, and language of science in the disciplines of both nursing and medicine. Although some other systems of medicine and some therapies, such as chiropractic medicine and massage therapy, are regulated, many are not. Preparation for practice may range from a week-end continuing education course to accredited programs requiring several years of study (Ching, 1998; Clark & Gordon, 1999; Keegan, 2001). Lastly, although the money spent on CAT now surpasses the money spent on conventional medicine and includes an estimated out of pocket expenditure of billions of dollars per year (Eisenberg et al., 1998), the health care reimbursement system does not widely support CAT and this lack of support influences the growth and development of CAM and the financial status of CAT practitioners (Clark & Gordon, 1999). Advanced practice nurses wishing to integrate complementary and alternative services in their practices should understand related third party reimbursement issues. All of these factors, educational, legal, and financial need to be considered in curriculum planning.
Ethics
Paradigms are not value free. In truth, they are the evidence of particular values. Capra (1996) notes "It is generally not recognized that values are not peripheral to science and technology but constitute their very basis and driving force" (p. 11). Nursing education both supports and challenges student values; and values clarification has been an integral aspect of nursing education for many years. Some CAT are based on values that are not congruent with traditional U.S. values of self reliance and individualism or a Judeo-Christian perspective on the great cosmological questions: who are we, what are we doing here, and what happens to us when we die? Achterburg (1991) has suggested that it is in answering these questions that societies determine what health and illness are, who can be the healers, what constitutes healing, and what healing methods can be employed.
| Teaching complementary and alternative practices typically challenges the prevailing Western worldview. It can bring the moral and ethical foundations of both students and faculty into question.
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The different values of the two paradigms have led to an "unspoken taboo" (Breda & Schulze, 1998) against CAT by many orthodox practitioners. This taboo is well understood by people who seek conventional medical care and the care of CAT practitioners. It results in underreporting of the use of these therapies to physicians. In a recent letter to the editor in the juried professional journal Alternative Therapies, (www.alternative-therapies.com) a consumer wrote:
However, until we are met with open minds, I and millions of other healthcare consumers shall continue to seek out intelligent, responsive, well-trained healers of many different stripes, and feel no obligation whatsoever to inform our primary care physicians of theses activities (Giblette, 2002, p.17).
This underreporting can be dangerous if the recommendations of practitioners are in conflict with each other, for example the use of certain herbal remedies might potentiate or exacerbate the effects of specific pharmaceuticals. Can nurses ethically not take CAT into consideration when they are assessing clients? While our moral position may be clearer when clients use frankly dangerous therapeutics, given the power of patient beliefs in healing and our charge to protect patient hopes, what is the morally insightful response to clients who use dubious CAT?
Breda & Shulze (1998) find in their teaching of complementary and alternative therapies that nursing students typically will not admit to using CAT until several weeks into the course. They observe that once students have a better understanding of the physiology of stress and how to elicit the relaxation response, "closet users" feel free to disclose their use of these therapies. They note that the strong taboo against use of CAT indicates a need for educators to develop a nonjudgmental atmosphere where students can participate in open discussions on the topic. They further write that initially many students are skeptical of the modalities. The authors urge educators to cherish the few "hardcore" skeptics that may be in the classroom, noting that these students offer an alternative and important view. Interestingly, they have observed that some "hardcore skeptics begin to embrace holistic healing after the course has ended"(p.397).
The ethical dimensions of teaching CAT are varied and complex. If careful attention is not paid to the values challenging aspects of these practices, faculty may find themselves unprepared for the strong feelings that arise not only among students, but also among colleagues.
Trends in Content and Strategies for Learning
This next section will first address various standards and core curriculum that have been developed for CAT. Next approaches that have been used to teach these therapies in undergraduate and graduate programs will be discussed, along with strategies for teaching this content. Finally, continuing education opportunities for learning about these therapies will be presented.
Standards and Core Curriculum
Guidelines to determine how and which complementary and alternative therapies should be included in nursing curricula are being developed in the US. Kligler (1996) reported that leaders in nursing, medicine, and complementary therapies in the New York area are working on guidelines for education. The American Holistic Nurses Association has established a task force to determine standards of practice for graduate-prepared nurses that should provide some guidance regarding advanced nursing practice and CAT, from which inferences regarding nursing education may be made. The current standards of practice for holistic nursing guidelines (Frisch, et al., 2000) offer examples of the use of these therapies within nursing practice. The Handbook for Holistic Nursing Practice (Dossey, et al., 2000) lists cognitive therapy, self-reflection, nutrition, exercise and movement, humor and play, relaxation imagery, music therapy, and touch in the section on changing outcomes. A core curriculum for holistic nursing (Dossey, 1997) has been developed that also includes these therapies. Other therapies that are noted to be used by nurses are aromatherapy and journaling. Keegan (2001) offers a comprehensive review of complementary and alternative therapies and has identified a variety of categorization approaches that could be useful in curriculum development. Ching (1998) writes that in the U. K. and Australia professional and registration bodies are helping to clarify nursing practice and the use of CAT, but notes that many difficulties remain and more clarification is needed.
In any discussion of content, it is important to recognize that both CAT and CAM include reference to systems of medicine such as Ayurveda, Traditional Chinese Medicine, Chiropractic, Naturopathy, and Homeopathy as well as therapeutics that may or may not derive from these systems of medicine, such as herbal remedies, acupuncture, massage, music, and art therapy. Discriminating between systems of medicine and their theoretical and philosophical underpinnings is important in considering what content to include in curricula.
The National Institutes of Health (NIH) established the Office of Alternative Medicine (OAM) in 1992 to evaluate alternative medicine. In 1998 the OAM was changed to a free standing center, The National Center for Complementary and Alternative Medicine (NCCAM). Information about NCCAM is available at www.nih.gov. NCCAM has established categories to classify CAT including alternative systems of medicine, bioelectromagnetic applications, diet, nutrition, lifestyle changes, herbal medicine, manual healing, mind/body control and pharmacological and biologic treatments. Purnell (2001) has added visual reality as a new therapy referring to the use of computer generated therapy which he notes has been used successfully with clients with certain phobias.
Higher Education
Discussion of the CAT content to include in curricula should begin with identification of the educational purposes for their inclusion.
| Discussion of the CAT content to include in curricula should begin with identification of the educational purposes for their inclusion.
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- within the scope of nursing practice and not limited by the licensure of other providers
- used somewhat as mainstream therapy
- supported by evidence of safety and efficacy (p.137)
As examples, Reed, et al., offer the suggestion of acupressure for nausea and recommend that other appropriate CAT include therapeutic touch, prayer, relaxation techniques, and guided imagery. At the graduate level, these authors propose that research investigating the efficacy, mode of action, and safety of these therapies could be incorporated.
Breda and Schulze (1998) have developed a capstone course on CAT for RN to BSN students. They advocate an experiential approach to learning and propose that some interventions are easily acquired, while others require a higher level of mastery. Interventions identified as easier to integrate are prayer, music, art, humor, storytelling, reminiscence, and journaling. Progressive relaxation, guided imagery, hypnosis, therapeutic touch, meditation, and yoga are identified as requiring higher levels of mastery.
Bartol and Courts (1993) have developed a course in the psychoneurological aspects of nursing. In this course, they use Reiser's mind-brain-body theory as a framework and include experiential exercises including imagery, visualization, values clarification, affirmations and writing. Music and movement therapy, use of humor, discussion of dreams, hypnosis, and active and passive relaxation exercises and meditation are used. Emphasis is placed on the importance of nutrition, sleep, exercise, rest and play.
The Center for the Study of Complementary and Alternative Therapies (CSCAT) at The University of Virginia School of Nursing is one of 11 centers funded by NIH to stimulate research on CAT (Taylor & Norris, 1998). They have chosen to focus on the effects of CAT in the management of acute and chronic pain. The CSCAT researchers include nurses, physicians, psychologists and chiropractors who are involved in 15 planned or in-progress studies.
At Beth-El College of Nursing and Health Sciences, University of Colorado at Colorado Springs (http://web.uccs.edu/bethel) several courses are taught integrating CAT into the curriculum. At the undergraduate level students entering as freshman and sophomores and RN to BSN students take a course that explores the philosophical, theoretical and legal foundations of nursing. They use the Handbook for Holistic Nursing (Dossey, et al., 2000) as one of their texts. The course explores the concept of paradigm and culture in relation to health. It is organized around the patterns of knowing identified by Carper (1978). In the unit on personal knowing student are asked to assess their well-being and to read articles that address areas they want to improve. They read about specific therapies that may be of use to them. Students meet in groups to discuss their assessment and readings. Some students go on to incorporate CAT in their lives. Many acknowledge that they have been using these modalities long before the course. Also at the undergraduate level, an elective, Complementary Therapies, is offered to all students on the campus. This course is essentially a survey of many different therapies and the content on specific CAT is taught by accomplished practitioners. Students read about many different therapies and systems of medicine and then select one CAT to experience; they also write a paper describing the theoretical foundations of the practice, presenting research on its use and efficacy, and describing the experience itself. Although the majority of students are nursing students, some come from health sciences, biology, and psychology. By becoming acquainted with area practitioners, students begin to create a resource file for their own use and use with future patients.
At the advanced studies level, Beth-El offers a certificate in holistic nursing comprised of four courses. All four courses are taught in weeklong formats that create intensity and intimacy. One course, The Dynamics of Unity, explores the philosophical and theoretical basis for holistic thinking in science and religion. World Views, another course, examines other systems of medicine including folk practices and shamanism. A third course explores psychonueroimmunology and therapies that focus on mind-body integration. In the course Art of Holistic Nursing, students explore the effect of aesthetics on healing. This course considers healing environments and patient stories from an archetypal perspective and includes content on therapies that arise from aesthetics such as music, art, and Feng Shui. In the Graduate Clinical Nurse Specialist option, students take courses exploring the use of therapeutic touch and other energy-based CAT along with therapies that use the imagination such as dream work and guided imagery. CNS students also take a practicum course in which they explore and use a specific therapy in depth.
Experience at Beth-El has shown that in integrating CAT in nursing courses, students of all levels need to understand the changing scientific paradigm, the philosophical underpinnings of therapies associated with Eastern religions and other cultures, and theories that are useful in explaining therapeutic effects, such as systems theory, the stress response theory, and theories of immune function.
| Skill development, through practice of therapies that are easily integrated in nursing practice, helps students become aware of the variety of ways in which they can promote wellness.
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Research is needed to provide information on which schools of nursing are incorporating CAT in curricula, what content is being taught, and the strategies for learning that are most effective. At least 50 medical schools now incorporate some CAT content, representing an increase of 29% over three years ago (Keegan, 2001). Exactly what higher education in nursing is doing about integrating these approaches remains unclear and needs to be described more thoroughly in nursing literature.
Continuing Education
For nurses seeking continuing education opportunities about CAT, there are several certificate programs endorsed by The American Holistic Nurses Association (AHNA: www.ahna.org). They include: the Healing Touch Program (www.healingtouch.net), Nurses Certificate Program in Imagery (http://imageryrn.com), The National Nurses Certificate Program in Amma Therapy (www.nycollege.edu, e-mail: mbholz@nycollege.edu), and Aromatherapy for Health Professionals (www.rjbuckle.com). Seeds and Bridges Center for Holistic Nursing Education (www.seedsandbridges.com) offers an integrated program that includes CAT content. Other continuing education programs approved for continuing education credit by AHNA include programs on Reiki, healing touch/massage, aromatherapy, holism, herbal medicine, energy fields, inquiry and holism, somatic psychology, clowning and humor, and developing a wellness practice. Keegan (2001) provides several pages of resources for the study of CAT including various associations and educational options in alternative medicine and courses in specific therapeutics.
Conclusions
Consumers are changing the acceptability of complementary and alternative therapies in medical and nursing education by their persistent and increasing use of these practices to meet a variety of health needs. However, including CAT in nursing education raises some difficult questions. Issues arising from the differing paradigms of most therapies and biomedicine confront nursing educators who seek to integrate these approaches into their programs.
| Creating an accepting learning environment is essential in overcoming the unspoken taboo against complementary and alternative therapies.
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Author
NH. Lea Barbato Gaydos, Ph.D., RN, CNS, HNC
E-mail: hlgaydos@al.com
H. Lea Barbato Gaydos, Ph.D., RN, CNS, HNC teaches at the University of Colorado, Colorado Springs, Beth-El College of Nursing and Health Sciences where she also is the advisor for the Advanced Studies in Holistic Nursing certificate program and graduate option. She has developed and taught several courses integrating complementary and alternative therapies. She is certified in holistic nursing and also serves on the American Holistic Nurses Certification Corporation Board. In addition Dr. Gaydos is a professional artist and her practice, study, and research interests focus on working with people to tell their biographies in visual art. She is currently principal investigator for a study to explore the biographies of hospice nurses.
Article published May 31, 2001
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