http://www.nursingworld.org/ojin/topic15/tpc15_2.htm
Frisch, N. (May 31, 2001) "Nursing as a Context for Alternative/Complementary
Modalities" Online Journal of Issues in Nursing. Vol. #6 No. #2, Manuscript 2.
Available: http://www.nursingworld.org/ojin/topic15/tpc15_2.htm
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© 2001 Online Journal of Issues in Nursing
Article published May 31, 2001
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NURSING AS A CONTEXT FOR ALTERNATIVE/COMPLEMENTARY MODALITIES
Noreen Cavan Frisch, PhD, RN, FAAN
Abstract
With increasing consumer and professional interest in alternative and
complementary care, Registered Nurses (RNs) are incorporating
alternative/complementary modalities into their practices. While these
modalities give nurses additional tools to meet client needs, many of these
modalities are taught and used by non-nursing professionals leading nurses to
question if and under what circumstances these modalities are included in
nursing’s scope of practice. Exploration of the two major frameworks that
define nursing and articulate nursing’s worldview, Nursing Theory and
Nursing’s Taxonomies of Care, reveals that complementary/alternative
modalities can easily be brought into a nursing context. Further, professional
nursing thought can provide direction to the practice of
complementary/alternative modalities by adding qualities of assessment,
reflection, and holism to the performance of the techniques. Examples are
provided for incorporating alternative/complementary practices into care that
is clearly identified as professional nursing.
Key words: alternative/complementary modalities; nursing theory; nursing
classifications
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.
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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).
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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. Eachof 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.
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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.