State Boards of Nursing and Scope of Practice of Registered Nurses Performing Complementary Therapies

Introduction

Utilization of complimentary and alternative medicine (CAM) therapies in the United States has increased markedly in recent years (Wootton & Sparber 1999). Surveys focusing on physicians (Astin, Marie, Pelletier, Hansen, & Haskell, 1998; Blumberg, Grant, & Hendricks, 1995 ; Berman, Sing, & Lao, 1995; Diehl, Kaplan, & Coulter, 1997; Goldstein, Sutherland, Jaffe, & Wilson, 1988), social workers (Henderson, 2000), and nurses (Taylor, Lin, Snyder, & Eggleston, 1998; Allaire, Moos, & Wells, 2000; Sabo, Michael, & Temple, 1999) indicate that many "main stream" health professionals have integrated CAM practices into their work. Although much is known about consumer utilization of CAM, there is little reference in these professional or nonprofessional publications as to how state practice laws impact professionals‘ practices of CAM, particularly the practice of registered nurses.

It has been noted, however, that licensure laws do affect the use of CAM therapies. Investigators have found that liberalization of licensure laws to practice CAM has been associated with a significantly increased use of CAM by physician and non-physician CAM providers. Furthermore, the existence of a practice act that gives non-physicians specific rights to deliver certain services is likely to substantially increase the supply of providers practicing this modality (Sturn, & Unutzer, 2001).

Complementary Therapies in Nursing

Though the term "CAM" is used in this report, "Complementary Therapies" will be utilized to reflect the integrative nature of nursing practice rather than as an alternative method of health care. Complementary therapies

as defined by the Louisiana BON (Louisiana BON, 1999) refer to "a broad domain of healing resources that allow registered nurses to...promote and/or enhance care supportive to or restorative of life and well-being". The proximity of nurses to patients allows many opportunities for the practice of complementary practices. Due to the theoretical congruence between nursing practice and the practice of complementary therapies, nurses are in a unique position to bridge the gap between traditional, Western health care and complementary therapies. Anecdotal reports indicate that although some may consider these therapies as questionable, professional nurses who use these modalities report that patients do experience an increased level of comfort and well being after experiencing these therapies.

Although the increased liberalization of licensing laws may increase the usage of complementary therapies by registered nurses, few studies have begun to address this practice. Until large-scale studies are conducted, it appears that it will be necessary to draw conclusions about these nursing practices from a variety of other sources. Some answers may lie within the states, as State Boards of Nursing (BONs) are required to monitor scope of practice issues. Though employers have a role in the safe practice of complementary therapies by nurses, it is the BON that protects the public through licensure and practice acts. Additionally, the White House Commission on Complimentary Alternative Medicine Policy (WHCCAMP) www.whccamp.hhs.gov/ and the National Institutes of Health‘s National Center for Complementary Alternative Medicine (NCCAM) http://nccam.nih.gov/nccam/fcp/classify have been addressing these practices in their studies of CAM therapies. The study reported in this article was conducted to provide information to the WHCCAMP, NCCAM and the Health and Human Service (HHS) Bureau of Health Professions (BHP) regarding state BON positions related to the practice of complementary therapies by registered nurses. This article will summarize the positions and/or policies on complementary therapies and nursing practice as reported by BONs in the United States.

This study began as an informal nursing department discussion of staff nurses‘ use of complementary therapies at the Clinical Center of the National Institutes of Health in Bethesda, Maryland. It quickly evolved to the larger question about BONs‘ positions on nurse practice of complementary therapies. Initial discussions with the Maryland BON were followed by further discussions with staff of the White House Commission on Complimentary Alternative Medicine Policy, National Institutes of Health‘s National Center for Complementary Alternative Medicine, and the Bureau of Health Professions. All of these agencies were interested in a comprehensive report on BONs‘ policies on use of complementary therapies by registered nurses.

Method

The target sample for this report was all State and Territorial BONs in the United States. A list of fifty-three BONs in the United States was accessed through the National Council of State Boards of Nursing (NCSBN) on February 15, 2001 (NCSBN, 1996). From this site, the links to the web pages or addresses of all BONs were used to connect with each BON. Information from these BONs regarding positions and policies on complementary therapies and nursing practice was then obtained through a) web page; b) email; and/or c) telephone. The remote United States territories of Guam, American Samoa, and the Northern Mariana Islands were not included in this report. The District of Columbia, Puerto Rico and the Virgin Islands were contacted because of their location on and/or near to the U.S. mainland. Once obtained, the information was coded under three descriptive categories. BONs that had a formal policy, position, or inclusion of complementary therapies under their scope of practice were coded as states who "Permit Practice". BONs that were in the preliminary stages of addressing the issue were coded as "Under Discussion"; and those that had not formally considered the topic were coded as "No Formal Position". All fifty-three BONs responded to this request for information.

Discussion of Findings

Forty-seven percent (25) of the BONs who permitted practice had statements or positions that included specific complementary therapies or examples of these practices; thirteen percent (7) were in the process of discussing the topic and, forty percent (21) had not formally addressed the topic, but did not necessarily discourage these practices. The reader is directed to the "Boards of Nursing" (Table 1) to link to the policies/positions provided by the 25 BONs having a described scope of care related to complementary therapies.

Historical Development of Position Statements

It was observed in this study that as complementary and alternative medicine gained national attention, BONs began to address the regulation issues.

Prior to 1991, BON responses were characterized by states responding to individual requests by nurses. Gradually, states took a proactive position and established task forces to make recommendations. The first formal statement found was by the Arizona BON in 1991 (See Table 1). This BON published an advisory opinion within a statement on Dual Health Care Licensure/Certification. Kentucky followed in 1996 by responding to individual nurses who were seeking an official opinion about the legalities of their practice of energy-based (healing touch, therapeautic touch and Reiki) and massage therapies. The next year, Massachusetts and Pennsylvania BONs made overall general statements describing complementary therapies as being within the scope of nursing practice and noting nurses‘ responsibilities for safe practice. Since then, there has been action by many BONs to establish policies about a range of complementary therapies, publish opinions to nurse‘s inquires and/or include these modalities under the general definition of scope of practice.

Table 1. Results of Boards of Nursing (BON) (N= 53)

Legal Considerations

It is becoming clear that BONs understand that the very nature of nursing lends itself to a framework that welcomes these non-invasive complementary practices. The Louisiana BON most eloquently describes in their Declaratory Statement that, "The Law Governing the Practice of Nursing authorizes registered nurses to provide care supportive to or restorative of life and well-being" (Louisiana BON, 1999). This premise, as stated by the Louisiana BON, underlies much of the thinking and support throughout the states for the justification of practice of complementary therapies. Although there are some states that do not have any language that describes complementary therapies, their decision-making models could be used to justify the practice of these modalities.

Education Needed

Most BONs now see the close relationship between complementary therapies and nursing.

It is the responsibility of state BONs not only to identify what is within the scope of nursing practice in the state, but also to identify the basic education and competencies that are required for that practice. A central theme highlighted by states having a described scope of care related to complementary therapies was for licensed nurses to have documented knowledge, skills and competency in application of the therapy. Also mentioned is the need for credentialing that will further assure the nurses‘ competence when such credentialing is available. Not only would credentialing help assure safe practice, but it would also communicate a strong message to other health professionals that the practice of nursing is based on a learned body of knowledge. A point often made by the states is that nurses, cannot use some titles, such as "nurse massage therapist" unless specifically certified in a given modality, such as massage.

Examples of Complementary Therapies

A compilation of complementary therapies mentioned by the states is provided in Table 2. Included in the table are therapies specifically designated by BONs and/or examples of such therapies. It should be noted that this listing is instructive but not all-inclusive. The complementary therapies reported by the states were organized under four of the five categories that had been developed by NCCAM: a) alternative medical systems; b) mind-body interventions; c) energy therapies; d) manipulative and body-based methods; and e) biologically-based treatments. The fifth category, biologically-based treatments, was not included in this table because requests for information from the BONs focused on the basic level of nursing practice. The issue of prescriptive authority for herbals and other natural products was not addressed, though a few boards did refer to advanced nursing practice and recommendations and/or prescriptions for these natural products.

Table 2. Compilation of Complementary Therapies

Summary and Implications

This article presented the results of a survey of State and Territorial Boards of Nursing in the United States and their positions on nursing practice of complementary therapies. The practice of complementary therapies is becoming more common and state boards are recognizing the need for policies in this arena. Nursing practice requires that one should explore all avenues to help people, and nurses are ideal providers to serve as a bridge between health and medicine. Nurses should become aware of their state‘s position regarding complementary therapy and take appropriate action to facilitate the integration of therapies into their work environment.

This report can be used by the WHCCAMP, NCCAM, the Bureau of Health Professions, and other agencies and associations to gain a better appreciation of the contribution that nurses make in this important area of health care delivery. Additionally, this report can be used by nurses to advise legislators, program development officers, and key leaders regarding policy, education and/or funding issues related to CAM. It can be used as BONs initiate a collective dialogue, perhaps through the National Council of State Boards of Nursing, to assist BONs in policy development. Sometimes just asking a question can stimulate change as this author noted during this study when the request of information for this survey resulted in the addition of this topic to the agenda for at least one BON meeting. BONs that have not addressed these nurse practice issues can benefit by dialoguing with states that have already done so. BONs that already support complementary therapies can use these discussion to clarify and strengthen present complementary therapy practice statements.

The nursing profession can not afford to fall behind in an increasingly popular area of health care that is so reflective of the basic values of nursing care. Currently, there is national recognition of nurses‘ leadership, and their ability to act as gatekeepers for consumers. It is essential that nurses use this front line position to enhance the safe and effective use of complementary therapies.

Author

Captain Andrew Sparber RN, MS, CS
Email: andrew53@comcast.net

Andrew Sparber RN, MS, CS, is a Captain in the US Public Health Service and an Integrative Medicine Clinical Nurse Specialist in the Nursing and Patient Care Service at the Clinical Center of the National Institutes of Health. He serves as the staff coordinator for the newly established Clinical Center- Wide Task Force on Integrative Medicine. Captain Sparber has lectured throughout the United States on a variety of complementary and alternative medicine topics, and is an author, investigator, and consultant. His groundbreaking leadership on the issue of patients‘ use of herbal and nutritional supplements while enrolled in clinical trials has resulted in the passage of a new NIH Clinical Center Medical Executive Committee policy regarding these supplements. Captain Sparber is also a practitioner of Healing Touch, visual imagery and relaxation modalities.