Journal of Nursing Education

Alternative and Complementary Therapies in Nursing Curricula

Fay Carol Reed, PhD, RN; Amy C Pettigrew, DNS, RN; Margaret O King, MS, MEd, RNC

Abstract

ABSTRACT

The growing interest in and use of alternative and complementary therapies by health care professionals and laypersons, the incorporation of these therapies in medical curricula and practice, and the greater acceptance of the legitimacy of such treatment methods require that nurse educators consider how this content may be incorporated into curricula. The authors propose that preIicensure students learn the premises that support such healing practices and develop skill in eliciting and evaluating patients' use of alternative therapies. In-depth study of one or more complementary therapies may be the focus of continuing education or elective courses. Students in graduate programs may investigate the safety and efficacy of nonorthodox therapies.

Abstract

ABSTRACT

The growing interest in and use of alternative and complementary therapies by health care professionals and laypersons, the incorporation of these therapies in medical curricula and practice, and the greater acceptance of the legitimacy of such treatment methods require that nurse educators consider how this content may be incorporated into curricula. The authors propose that preIicensure students learn the premises that support such healing practices and develop skill in eliciting and evaluating patients' use of alternative therapies. In-depth study of one or more complementary therapies may be the focus of continuing education or elective courses. Students in graduate programs may investigate the safety and efficacy of nonorthodox therapies.

The public enthusiasm for therapies that have not been a component of Western science-based health care as well as the interest of professionals trained in objective therapies was illustrated recently by the contents of a mailbox. On the same day there arrived: 1) an invitation to purchase a book on herbal therapies; 2) an announcement of a course for professionals on homeopathy; 3) an advertisement for a book on self-care; and 4) notice of a conference on alternative medicine offered by an Ivy League medical school. Such publications as well as media attention, patients' reports of their positive experiences with alternative therapies (AT)- some of which have been incorporated into standard practice as complementary therapies- as well as growing numbers of articles concerning AT in respected professional journals make it difficult for nurse educators and others to dismiss easily the question: "Should nursing curricula include content about alternative therapies?"

It is difficult to define AT or even to determine what therapies should be included appropriately. According to Aakster (1989), a basic distinction between AT and sciencebased therapies is that Western medicine and AT are established on different philosophic perspectives and methods of care. Western medicine focuses primarily on diseased organs and the nature of their pathology. Treatment seeks to eliminate or control the disease, frequently employing interventions grounded in knowledge validated via the methods of science. In contrast, AT attend typically to patients' holistic functioning within their social and environmental context and do not focus on organs or physiological systems alone. Treatment seeks to restore optimal function, often employing therapy validated primarily by experience.

There are differences also in patient relationships and in the training of those who provide care. In Western medicine, the patient may be relatively passive and the physicianpatient relationship is not commonly considered to be critical to the curative process of disease. With AT, a good relationship with the provider of care is regarded as central to the healing process and patients are expected to be involved actively in the restoration of their health. Those trained in Western scientific methods of care tend to have similar educational backgrounds and approaches to patients. They practice primary, secondary, and tertiary care and are licensed. In contrast, those who provide AT as the only treatment modality have highly varied educational backgrounds and offer primary care for the most part. They may or may not be licensed depending on the mode of therapy and regulations of the state in which the therapies are offered.

Varying degrees of acceptance of AT in the United States is evidenced by the adjectival tags assigned.* The term "quackery" is clearly negative and other terms such as marginal, questionable, unconventional, nonorthodox, and unproven connote a level of negativity. "Alternative Therapy" calls attention to differences and appears to be the most neutral and inclusive term in current use. Terms such as complementary, adjunctive, supportive or integrative are positive and connote some degree of acceptance or synthesis. Labels that describe the dominant approach to medical care in the United States include Western, orthodox, conventional, biomedical, allopathic, mainstream, standard, and scientific medicine. In the West, "traditional" may describe science-based care; however, other cultures, such as in China, define traditional as therapies that have been employed for centuries and are not ordinarily validated by rigorous scientific methods.

JUSTIFICATIONS FOR TEACHING ALTERNATIVE THERAPIES

There are several reasons why nurse educators at all levels need to address AT in planning student learning experiences. First, large numbers of people use AT as illustrated by recent studies. An investigation by Eisenberg, et al. (1993), often referred to as a "landmark study," examined the use of 16 AT by a national sample of 1539 adults. The investigators found that 33.8% of those queried had used unconventional therapy in the past year and that a third of this group had consulted with a provider of AT the previous year for an average of 19 visits. The typical charge was $27.60 per visit ($19.39 out of pocket). Users of AT were mostly older (25-49 years old), nonblack, and better educated persons with higher incomes. AT providers were most commonly consulted for back problems and chiropractic techniques and massage were commonly employed for related symptoms. When the authors extrapolated the findings for the population of the United States, they determined that visits made to providers of AT would exceed those made to primary care physicians trained in Western medicine. According to the authors of this study:

The total projected out-of-pocket expenditure for unconventional therapy plus supplements was $10.3 billion in 1990. This expenditure is comparable to the out-of-pocket expenditure for all hospital care in the United States ($12.8 billion) and is nearly half the amount spent out-of-pocket for all the physicians' services in the United States ($23.5 billion) (p. 250).

These investigators concluded that ". . .unconventional medicine has an enormous presence in the U.S. health care system" (p. 251). When the study was replicated in 1997, Eisenberg et al. (1998) found that the use of the alternative therapies examined had increased in the United States. By extrapolation, visits to receive alternative therapies (629 million) exceeded visits to all primary care physicians. Out-of-pocket payments for alternative therapies was comparable to expenditures for all US physician services ($27.0 billion.) In 1997, Paramore reanalyzed data from 3450 subjects in the Robert Wood Johnson Foundation National Access to Care Survey to investigate the respondent's use of four alternative therapies (chiropractic, therapeutic massage, relaxation techniques, and acupuncture) within the past year. Based on this analysis, the author estimated that 10% of the United States population (25 million persons) consulted AT providers for at least one of the four therapies. Chiropractic was the most used and acupuncture was employed least. Users of AT were about a decade older (mean age of 42) than nonusers and were more likely than nonusers to be white, somewhat better educated, and to have visited a Western-trained physician the previous year. Paramore concluded that, "The findings presented here suggest that the health services research community needs to appreciate better the magnitude of the use of alternative therapies" (p. 88). If the estimates of Cooper and Stoflet (1996) for a growth by the year 2010 of 88% in the numbers of certain AT practitioners (chiropractic, oriental medicine, naturopathy) are correct, accelerated use of AT can be foreseen. The predicted growth of physicians trained in Western medicine during the same period is expected to be 16%, according to the authors.

Growth of interest in and use of AT is not limited to the United States. Fisher and Ward (1994) wrote that in Europe ". . .the public demand (for AT) is strong and growing" (p. 107). In Australia, MacLennan, Wilson, and Taylor (1996) reported that 48.5% of the residents of South Australia used at least one AT. Data extrapolated for the Australian population reported expenditures of $621 million yearly for alternative medicine compared with $360 million in patient contributions for all drugs in 1992/93 (p. 572). Based on the above data, it appears likely that nurses educated currently are certain to encounter AT as part of the health care delivery system within their professional lifetimes.

A second reason to include study of AT in nursing curricula is that many of the patients for whom nurses care embrace perspectives and choose healing approaches that are not in accord with the beliefs and practices of scientific medicine. For example, when Pearl, Leo, and Tsang (1995) studied 76 first and second generation ChineseAmerican patients who visited an emergency department in New York, they found that over 40% had used Chinese therapies (16 herbáis and 6 physical healing measures) during the week before the visit. Because nurse educators have long valued cultural sensitivity and cultural competence among their educational goals, content on diversity is in place in most curricula. Knowledge of healing perspectives and methods now needs to be included with other cultural information that shapes attitudes and the behaviors related to health and illness.

A third reason to attend to AT is that they have gained recognition and a measure of governmental legitimacy, although this equity is not recognized by all. On one hand, Jacobs (1992) wrote approvingly that the National Institutes of Health had established the Office of Alternative Medicine (OAM) to assess AT and that $1,040,000 had been granted to support 43 projects that evaluate clinical outcomes of AT. On the other hand, Stalker (1995) evaluated the $5.4 million that was awarded to OAM in 1995 as a wasteful expenditure. He asserted that some of the AT are at variance with established scientific information and theories. Recently, 10 complementary and alternative research centers presented their investigational agenda and projects that are underway currently (Villaire, 1997). Seven of these Centers were established in medical schools or hospitals, two appear to be in facilities that address specific diseases, and one was instituted at the University of Virginia School of Nursing. Research has been initiated in such varied areas as women's health, chronic illness, geriatrics, herbal remedies, asthma, AIDS, addictions, and pain management.

A fourth reason to include AT in nursing curricula is that study of these therapies has been integrated into medical curricula and into standard medical practice with which nurses have contact. In 1996, Cassileth and Chapman wrote that more than 24 medical schools and hospitals had established departments to study AT. In addition, 33 medical schools offered courses in AT, according to the Complementary and Alternative Medicine Newsletter (July, 1996). Two years later, 53 medical schools of the 124 surveyed by Moore (1998), reported that required or elective courses or structured learning experiences on alternative/complementary therapies were offered. Approaches ranged from supportive and "hands on" to skeptical; however, there was an underlying desire to include information not heretofore in medical curricula. Practicing Western-trained physicians' interest in AT has been documented as well. When Berman et al. (1995) conducted a survey of 295 family physicians in the Chesapeake region, 90% of the 180 respondents said they used some forms of therapy considered to be alternative (diet, exercise, behavioral medicine, biofeedback). They expressed a strong interest in additional training in AT. A similar study of Canadian physicians found that 73% of the respondents said that they wanted some additional knowledge about significant AT, according to Verhoef and Sutherland (1995). In addition to growing interest of health professionals in AT, available information is expanding. Cassileth and Chapman (1996) reported that in 1995, the National Library of Medicine contained more than 60,000 citations of alternative and complementary medicine reflecting the addition of new journals and of key word expansion.

Nurses are interested in AT also. In a recently completed study, the authors collected data from a random sample of 2740 registered nurses in Ohio (unpublished manuscript, Pettigrew, Reed, & King, 1998). They were asked to rate their knowledge of, and perceived efficacy of AT and to report their utilization (for self and patients) and referral practices. The respondents regarded diet and prayer as the 2 AT of the 20 investigated about which they possessed the most knowledge and they reported that they knew least about Tai Chi and magnets. Prayer and diet were regarded as the most efficacious and reflexology as the least effective treatment investigated. Excluding diet and prayer, 82% of the registered nurse respondents used one or more therapies personally with an average of 3.1 therapies employed. One or more therapies were used by 49.5% of the nurses and their patients with an average of 1.2 therapies applied. The norm was 2.6 referrals made by nurses surveyed to AT providers. Although the data are elicited from a small return (17%) and possible self-selection exists, it appears that a large number of nurses in Ohio may be using ATs personally and in their practice. No comparable studies of nurses were identified.

WHAT TO TEACH

Prelicensure/Education in Nursing

Neophytes need to learn about non western paradigms that may include not only specific therapies and techniques, but also the underlying philosophies and beliefs from which the interventions are derived. For example, Chinese medicine focuses on the connectedness of the whole body rather than the pathology of specific organs. According to Erickson (1995), this perspective is based on the belief that two opposites (Yin and Yang) exist in the world. Acupuncture, one of the most commonly practiced therapies, regards organs as corresponding to channels (meridians) for energy circulation. This treatment uses needles to stimulate points along the meridians to produce a systemic response that promotes healing by restoring the balance of Yin and Yang. Study of AT healing traditions not only furnishes students with clinically useful information, but also develops a perspective on the assumptions and beliefs of Western medicine. These beliefs include the value of objectivity and the reductionistic approach to the study and treatment of disease, as well as the greater emphasis on disease than on illness or well being. In addition, students need to learn about selected specific AT or categories as described below. Determining what to include in a curriculum is difficult because whether a therapy is alternative or conventional may depend on how it is used. For example, mind-body therapies may be usefully incorporated in the treatment regime for cancer. However, as a single therapy for cancer, mind-body approaches such as imagery may jeopardize recovery and would be regarded as dangerous if other treatments of established effectiveness were delayed or rejected.

There is no agreed upon list of defined AT; however, the choice of educational content may include representatives of various categories for study, such as those established by the Office of Alternative Medicine. These groups include (with examples): (1) diet and nutrition (macrobiotic diet), (2) mind-body techniques (prayer), (3) bioelectromagnetics (magnets), (4) traditional and folk medicine (Ayur Veda Yoga), (5) pharmacologic and biologic treatments (shark cartilage), (6) manual healing methods (massage), and (7) herbal medicine (Echinacea). Of course, any AT that is used commonly by patients seen in clinical agencies where students practice must be included in their studies.

Undergraduate students need to learn also that patients may consult AT providers or use self-selected AT, often for the same condition for which they are treated by those trained in Western medicine. Some patients, perhaps most, will not reveal this information unless asked. One study (Eisenberg et al., 1993) reported that more than 72% of patients interviewed did not report such data to allopathic physicians (p. 249). A nursing history, therefore, should assess the number, kind, and frequency/duration of use of AT and elicit where patients obtained devices or substances. Alternatively, nurses should record that patients use AT, but do not wish to discuss the matter further, if that is the case. Histories need to determine whether the therapies, if used, are employed for general well being, for symptom management, or for a specific ailment. Whatever their personal beliefs, students should learn to obtain and record this information nonjudgmentally to elicit honest answers. Some AT practices have a long and valued tradition of use. Chinese herbal medicine, for example, was established as a therapeutic modality prior to 770 BC (Liao, 1996), over two millennia before the birth of Western scientific medicine. Because AT are often linked with belief systems, respectful listening conveys that patient autonomy is valued. Whenever possible, patients should be encouraged to discuss their use of AT with their physicians.

Prelicensure students need to learn to evaluate the impact of AT on patients' health. As part of their plan of care for a patient, students should investigate AT to discover what the substances or treatments are, what benefits are claimed, and what evidence conoerning safety and efficacy exists. In addition to the references found in the typical medical library, King (1996) recommended the following sources for learning more about substances used as medication: (1) Marindale: The Extra Pharmacopoeia (Reynolds, ed.), (2) Herbal Drugs and Phytopharmaceuticals (Wichtl and Bisset, ed.), (3) Textbook of Pharmacognoscy (Bisset, ed.), (4) Micromedex's POISINDEX SYSTEM, (Denver Do.), (5) the "health section" of a bookstore, (6) the person or commercial source that provided a device or medication, and (7) Natural Products Alert- a computerized database of the pharmacy school at the University of Illinois-Chicago. Moore (1997) has identified some Web sites with information about AT that are regarded as both useful and reliable. Eisenberg (1997) identified in appendices sources of information on herbs and herb supplements and sources of licensure information for chiropractic, homeopathy, massage therapy, acupuncture, and naturopathy. The Physicians' Desfe Reference for Herbal Medicines (published in cooperation with Phytopharm Consulting) became available in 1998.

Even a diligent search for information about a specific AT may leave the nurse or other health care professional with uncertainties about the use of a substance, treatment, or device by a patient. The possibility of endangerment becomes an issue. Generally, use of AT by healthy persons who merely wish to improve their well-being appears to result in few reported problems. For those with specific health disorders, there are two concerns associated with AT. First, efficacy may be unproven. Second, safety may be an issue. In some cases, patients delay seeking or reject treatments of proven worth and rely on AT of uncertain benefit. Such patients may be convinced to incorporate conventional medicine in their treatment. In other situations, the selected AT may be harmful because of drug interactions or unknowledgeable AT providers. Although there are some studies of safety and of complications related to selected AT, such as neurological deficits following chiropractic manipulation (Lee, Carlini, McCormick, & Alberts, 1995), more studies appear to be directed to evaluating efficacy. Students need to be aware that valid and reliable data regarding the safety and efficacy of AT is sometimes lacking and that the use of AT remains in the realm of judgment in some cases. The quality of that judgment can be enhanced, however, by collecting as much information as possible about AT and relating it to information concerning patients' pathology. As evidence of safety and efficiency is established, AT will be more likely to be integrated into standard care.

A related issue for faculty who teach and nurses who incorporate AT into their practice is the legal context. Cohen (1998) pointed out that the current legal structure of the health care is largely determined using the biomedical model as the standard. It defines which AT may be available legitimately and defines the scope of practice for AT providers. Although Cohen does not address nursing practice, he notes that physicians may be liable for malpractice claims when they integrate AT into their practice that are not FDA approved or accepted as part of standard medical care. Some, but not complete, protection against such claims may be found in the informed consent of the recipient of care and evidence that the patient is willing to assume risks associated with certain AT. However, the author foresees acceptance of a more inclusive model of health care that will allow or facilitate integration of AT and biomedical approaches. This view suggests that further investigation of safety and efficacy of AT is required.

Finally, some faculty may wish to teach students how to employ selected AT or to provide observational experiences in the basic curriculum. Criteria for selection may include those ATs that are (1) within the scope of nursing practice and not limited by the license of other providers, (2) used somewhat as a mainstream therapy, and (3) are supported by evidence of safety and efficacy. For example, precisely applied acupressure appears to modify the symptoms of nausea and vomiting. Hyde (1989) found acupressure to be helpful in relieving the morning sickness of pregnancy. In another study, Hu, Stritzel, Chandler, and Stern (1995) found that subjects who were treated with P6 acupressure experienced fewer subjective and objective symptoms (abnormal gastric activity) of motion sickness than the control group or two other groups that received different treatments. Citing other studies, the authors suggest that the reduction of nausea and vomiting via acupressure may be related to increased endorphin production. Therapeutic touch, prayer, relaxation techniques, and guided imagery exemplify other modalities frequently employed by nurses.

In summary, prelicensure students need to appreciate selected systems of healing that are different from Western scientific medicine and they should have some information about representative AT, particularly those that are regarded as complementary. In addition, they should be able to interview patients knowledgeably about their use of AT, and to locate sources of further information concerning the efficacy and safety of the AT that thenpatients use.

Continuing Education and Electives

Some students will become particularly interested in AT and some practicing nurses will be curious about their use and foresee benefits for their patients. These persons may seek more information outside the regular, formal curriculum. One type of course offering may include information about products or treatments that have been studied and found worthless or harmful. For example Brigden (1987) noted that two smugglers of Laetril during its popularity as a treatment for cancer earned $2.5 million and $1.2 million, respectively. In this case, the danger may have been both economic and physiological because efficacy was not demonstrated. Another course topic may review unproven therapies that are under study currently and may be found to be both safe and effective, such as the example of massage therapy discussed below.

Some nursing schools may wish to offer certificate courses for alternative/complementary therapies such as relaxation techniques. Other continuing education courses may expand skills that have been long seen as a part of the nursing practice. For example, the back rub incorporates massage techniques that were taught very early in the history of nursing education (Robb, 1915) and practiced by nurses for many years thereafter. Today, massages have been assigned to unlicensed personnel or altogether abandoned in many settings. Yet, evidence of the therapeutic benefits of massage is growing. For example, Wheeden et al. (1993) found that preterm infants exposed to cocaine who received massage therapy benefited. They gained more weight, exhibited fewer stress behaviors and complications, and were observed to have more mature behaviors than a comparable group of infants who did not receive massage. Scafidi and Field (1996) studied the effect of massage on neonates whose mothers were HTV positive. They discovered that infants who received daily massage for ten days had a greater weight gain and had higher Brazelton acores than infants in the control groups. For adults, Ironson et al. (1996) reported that daily massages for one month increased significantly the cytotoxic capacity of HIV infected men, although the disease progression was unaltered. In another study by Zheng and Guigui (1995), patients with coronary heart disease experienced symptom reduction and improvement in left ventricular function following massage administered according to the practice of Chinese medicine. In yet another study, Field et al. (1997) demonstrated by self-report and biochemical studies that massage therapy alleviated the symptoms of a group of patients with chronic fatigue syndrome. Faculty who wish to plan a course to acquaint nurses with the therapeutic effects and some of the skills of massage will find a review of the techniques and scientific basis of massage by Goats (1994) helpful; additional sources may be found easily in Medline and in other databases. Since therapeutic massage is a licensed practice in many states, the course would need to be planned and taught in conjunction with a licensed therapist.

Thus, in-depth attention to specific topics via elective and continuing education courses can respond to the special interests of nurses and the requirements of their patients. It should be emphasized that AT not clearly within the domain of nursing practice require patients' consent and their physicians' cognizance or approval when appropriate or when legal standards require such considerations.

Graduate Education

Research to study the efficacy, mode of action, and safety of specific AT can be incorporated into graduate education. Some faculty who teach graduate students will take the position that any study of or inquiry into AT is antiscience and should be rejected. Others may be willing to apply scientific methods to examine the outcomes of AT. Two of our faculty colleagues, for example have completed a pilot study to investigate the relative safety of a modified form of Tai Chi exercise for patients with cardiac dysfunction (unpublished manuscript, Fontana & Colella, 1998). They concluded that patients with poor exercise tolerance benefited. Although this study used a quantitative design, in some situations, quantitative research methods may need to be set aside or become adjunctive. Edwards (1997) cautioned that the common process of randomized, controlled trials and typical outcomes research be recognized as methodologies, ". . .that are based on linear and mechanistic Newtonian relationships" (p. 100). Such approaches, Edwards assessed, may not be suited to phenomena such as healing, that are integrated, individual, dynamic, and complex. Questioning of the linear paradigm as the sole basis for research is the genesis of recent interest in chaos theory as well as the post modern philosophy of science that underlies it. Members of graduate faculties should discuss also and agree whether some graduate students will be supported if they express interest in examining selected AT that require a "nonscientific" investigational approach. Such research may include looking outside the nursing faculty for resources and may include some faculty retraining. A potentially fruitful area of study is the investigation of the effect of AT on conditions that have no specific treatment via scientific medicine. Studies to determine whether an AT has specific therapeutic properties or whether benefits are related to the placebo effect would elicit important information about efficacy (Ernst, Resch, & White, 1995).

It is likely, however, that most nursing studies will continue to be based on the assumptions and methods of science for the foreseeable future. Nevertheless, the question is not, "Which investigational method is best?" but, "Which paradigm or approach is most appropriate to investigate the specific research question?" The search for precise causes and outcomes has revolutionized the treatment of disease and must be honored. However, the same methodologies and expected specific outcomes may be ill suited to the study of illness (in distinction from disease) which Kleinman (1978) described as representing ". . .the human experience of sickness" (p. 251). In this dilemma, Aristotle's wisdom remains sound, "Now our treatment of this science will be adequate if it achieves that amount of precision which belongs to its subject matter" (Capps, Page, & Rouse, 1926, p. 7).

CONCLUSION

The demand for alternative therapies is widespread and appears to be growing. According to Cassileth (1989), this trend is supported by general societal beliefs that include individual self-reliance, desire to control illness, and the unknown and skepticism about the authority of science. This demand requires that nurse educators at all levels determine what should be taught about AT. For nurses in education or active practice, the public's embrace of AT reminds us that good relationships with patients are important and even therapeutic, that those who are sick are enmeshed in their culture and environment, that illness has meaning, that healing is best achieved in partnership with the patient, and finally that patients are autonomous. For the profession, AT raise broader questions about health care: (1) What accountability/liability do nurses incur when they recommend or use AT in their practice? (2) Should scientific research methodology be the only standard for evaluating the safety and/or efficacy of AT? (3) Which (if any) AT should be incorporated into standard nursing practice? (4) Should more AT practitioners be licensed and regulated? (5) Should there be third-party payment for some AT? These are questions that nurses must ponder and, with other stakeholders, attempt to answer.

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