Integrative health care: implications for nursing practice and education.

Integrative health care: implications for nursing practice and education Christine V Little

The significance of complementary and alternative medicine (CAM) to contemporary health care is reflected in the relatively recent integrative health care (IHC) movement. Having emerged in response to the public’s sustained use of CAM, IHC reflects the evolving needs and expectations of modern-day service users, making it consistent with today’s culture of patient-responsive health care. IHC therefore carries important implications for nursing practice but, to fulfil their responsibilities with regard to these implications, nurses need a fundamental knowledge of CAM concepts as well as an understanding of the ways in which CAM and conventional health care might affect one another. An educational strategy that embeds IHC and makes explicit its relation to nursing practice is desirable if nurses are to engage with patients who use CAM. Evidence suggests, however, that neither CAM nor IHC are adequately represented in nursing curricula. This paper considers ways in which IHC could be incorporated into nursing curricula as a means to prepare nurses for this important challenge. Key words: Complementary and alternative medicine ■ Integrative health care ■ Nursing curriculum

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he enduring popularity of complementary and alternative medicine (CAM) in the UK and other industrialised countries (Harris and Rees, 2000) is a trend that shows little sign of diminishing (Tiralongo and Wallis, 2008). In fact, changes observed in the patterns of CAM use suggest that its application is broadening. Early studies tend to associate CAM with the treatment of chronic, difficult-to-treat conditions (White, 1998; Ong et al, 2002), but more recent studies illustrate its use in settings as diverse as oncology, midwifery and physiotherapy (Vapiwala et al, 2006; Tiran, 2009; Boyle, 2010). In respect of lay health care, CAM is also used for a range of everyday conditions that encompass chronic, acute and preventative health care (Little, 2009). The considerable public interest in CAM has not only influenced healthcare practice, but has also led to a flourishing market for the provision of CAM products, services and practitioner courses. Quite possibly the clearest indication of its impact on contemporary health care, however, is the

Christine V Little is Senior Lecturer in Nursing, Bournemouth University Accepted for publication: September 2013

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emergence of the integrative health care (IHC) movement, along with recommendations for the inclusion of CAM education in medical and nursing curricula.Yet, despite this, the extent to which nurses are prepared for dealing with patients who use, or enquire about, CAM is uncertain. In this paper, I consider the implications of IHC for the practice and education of nurses, if they are to be able engage with patients who use CAM. I outline the concepts of CAM and IHC, summarise their broad implications for nursing practice and nurse education, and offer suggestions for the inclusion of an IHC component in nursing curricula. The intention of the paper is to stimulate interest and debate about the use of CAM in contemporary health care; to encourage nurses to think critically about the implications of the CAM phenomenon to their professional practice; and to encourage nurse educators to consider its significance to nurse education across the range of academic levels.

Complementary alternative medicine and integrative health care Although a universal definition of CAM is elusive, its essence is captured particularly well by the Panel on Definition and Description (1997): ‘(CAM) is a broad domain of healing resources that encompasses all health systems, modalities and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture’ CAM therefore refers to those therapies not routinely taught, practised or provided within mainstream UK health care, most notably the NHS. While the range of therapies included under the CAM umbrella is both extensive and dynamic, the US National Center for Complementary and Alternative Medicine (NCCAM) offers the following categorisation, which provides a useful indication of their nature and diversity (adapted from NCCAM, 2003): ■■ Alternative systems, including homeopathy, naturopathy, and Ayurvedic and traditional Chinese medicine ■■ Mind-body interventions, including meditation, healing and art therapy ■■ Biologically-based therapies, including herbal products and dietary supplements ■■ Manipulative and body-based methods, including chiropractic and massage ■■ Energy therapies, including acupuncture, Reiki and therapeutic touch.

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Abstract

British Journal of Nursing, 2013, Vol 22, No 20

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alternative medicine IHC has also attracted a range of understandings as to what it really is—at one extreme, an entire new concept of medicine; at the other, the use of a specific CAM therapy by an otherwise conventional practitioner. An inclusive perspective on IHC describes it as a blending of CAM and conventional health care that is interdisciplinary, nonhierarchical, collaborative, holistic and synergistic in terms of the effects of combining therapies (Boon et al, 2004). According to Merrell (2006), the seminal role of IHC is the provision of ‘preventive, gentler and often more effective care’, which demands the incorporation of CAM ‘as it is practised’ rather than ‘co-opted in parts’. Conversely, others believe that IHC should be concerned only with those aspects of CAM that are supported by ‘quality scientific evidence of safety and effectiveness’ (Vapiwala et al, 2006). Given the emergent status of CAM, however, this latter perspective would necessarily exclude many therapies that are under-researched but are, nevertheless, very popular. It is therefore a contentious stance that risks alienating service users, especially in a climate of patient-centred and responsive health care. Despite the lack of consensus in defining IHC, what is clear is that patients themselves already integrate CAM and conventional health care into their private lives (Little, 2012), and it is Coulter et al’s (2010) view that this elevates the position of IHC to one of a serious academic and practice paradigm. For this reason, the emerging IHC movement imposes an obligation on health professionals to be knowledgeable of the core concepts that underpin this important healthcare development.

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Integrative health care and nursing practice According to Engebretson (1999), the viability of a profession is determined by the extent to which it achieves its purpose and, crucially, by whether or not it fulfils a public need. To do this, health professionals are obliged to remain aware of the evolving expectations of their patients or clients, if the care they provide is to continue to satisfy their needs. It is argued here that the sustained and increasing use of CAM does indeed reflect a change in the expectations of modern-day service users and is therefore deserving of attention in the preparation of healthcare practitioners. The significance of CAM to the practice and education of health professionals is also implied in the Department of Health (DH) document Liberating the NHS: Greater choice and control (DH, 2010), which sets out plans for a health service that responds to patients’ needs by supporting and facilitating choice and shared decision-making. As yet, the document makes no specific reference to CAM or IHC, but it does highlight patient choice in relation to chronicity, end of life, maternity care and mental health, each of which is already firmly associated with the use of CAM (Thorne et al, 2002; Lafferty et al, 2006;Tiran, 2009;Werneke, 2009).With specific regard to the nursing profession, the Nursing and Midwifery Council (NMC) (2008) stipulates well-established standards expected of all professional practice and these apply as much to patients’ use of CAM as they do conventional health care. Of particular note: ■■ Collaborate with those in your care. This is especially important during routine nursing assessment that allows for


patients’ personal practices and preferences to be revealed and privileged, and for their right to make healthcare decisions that are respected ■■ Treat people as individuals. In terms of respecting patient choice, the nurse–patient relationship is an ideal opportunity to provide support in accessing appropriately qualified CAM practitioners and/or responsible sources of information ■■ Work as part of a team. The concept of IHC necessarily imposes a need to work collaboratively in an interdisciplinary and multidisciplinary capacity ■■ Use the best available evidence, not least to highlight potential interactions or risks associated with planned conventional interventions. Looking to the future, it is Smith’s (2008) view that providing advice to patients about CAM is likely to become a requirement for nurses, while Hessig et al (2004) believe that nurses are in a key position to do so.

Integrative health care and nurse education The inclusion of IHC in nurse education offers a valuable opportunity to make the preparation of the nursing workforce more contemporary. Conversely, its omission is difficult to defend in a culture that positions patient choice at the heart of healthcare reform—a view acknowledged by Helms (2006), who asserts that CAM is a necessary inclusion in the nursing curriculum to maintain high-quality nursing care. Where IHC has been included in the nursing curriculum, it is encouraging that CAM education has been shown to

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Integrative health care and nursing curricula The addition of new material to an established curriculum is always challenging, but the assimilation of IHC is conducive to a relatively subtle fine-tuning of existing curricula. Specifically, the very notion of integrative health care enables established curricular content to be explicitly related to CAM concepts. For example, approaches to pain management might address the potential contribution of CAM interventions (such as acupuncture) to conventional practice. This brings with it a number of practical advantages for curriculum development: ■■ It eliminates the need to create space for brand new material ■■ It allows CAM literature to be amalgamated with existing reading lists ■■ It enables an IHC focus to be embedded into existing

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assessment strategies. The use of case studies is particularly suitable for this approach. With regard to content, it is neither feasible nor reasonable to expect nurses to be expertly informed about the considerable range of CAM therapies or about their uses, risks and contraindications. What would be an appropriate and realistic goal is the provision of a baseline knowledge that equips nurses to respond appropriately to a modern client-base. For prequalifying nursing students, the focus of CAM education might therefore be one of CAM familiarisation, made relevant to nursing practice in a number of possible ways: ■■ In relation to specific client groups. Examples might include people experiencing particular health concerns that are already associated with the use of CAM, such as skin conditions, musculoskeletal disorders or addiction. People of particular demographic denomination, such as women and older people, might also offer a useful focus for CAM application ■■ In relation to specialist areas of practice, in which CAM has actual or potential therapeutic benefit. Health promotion, palliative care and pain management are all good examples ■■ In relation to theoretical and professional concepts. Sociology of health care, healthcare law and ethics, and communication studies all apply just as well to CAM as they do to mainstream health care, thus requiring little more than a broadening of the nursing perspective. Nurses need also to be mindful that global mobility brings with it a potential demand for culturally specific health care, which may well include the use of therapies otherwise perceived as CAM. One example is the relatively common use of CAM, predominantly herbalism, in the treatment of childhood type 1 diabetes among Turkish families (Arykan et al, 2009); this is a situation not likely to be widely encountered in the UK (with the possible exception of some urban areas, such as north London), but a situation that could become more common owing to increasing movement of populations. Examples such as this are an ideal opportunity to give the curriculum a multicultural perspective, in addition to its domestic focus. A curriculum that aims for CAM familiarisation might therefore include, and be cross-linked to: ■■ Concepts and definitions of CAM and IHC, including an introduction to alternative/non-scientific paradigms (sociology of health care) ■■ Prevalence and patterns of use of CAM (specific client groups, specialist areas of practice, internationalisation) ■■ Uses, risks, contraindications and evidence base in relation to the most commonly used CAM therapies (evidencebased practice) ■■ Implications of CAM and IHC to nursing practice (professional practice and professional studies): ■ Accounting for patients’ use of CAM, as part of nursing assessment processes ■ Interprofessional and multidisciplinary impact of IHC ■ Effective and responsible routes for referral to CAM practitioners or sources of CAM information ■ Interpretation of professional, ethical and legal responsibilities in relation to CAM and IHC. As for the best methods for delivering CAM education, it


enhance student nurses’ ability to interact with patients and to achieve a more holistic approach to patient care (Cook and Robinson, 2006). Post qualification, it has also been shown to enhance the knowledge and practice of oncology nurses (Hessig et al, 2004). Even so, CAM is only sporadically represented in British nurse education (Cook and Robinson, 2006; Laurenson et al, 2006) and, where it is, it tends to be limited to the occasional lecture or elective course and frequently reflects the interest of an individual staff member (Smith, 2009). There are also legal and ethical implications associated with the use of CAM in mainstream health care (Ernst et al, 2004) and these would clearly be difficult to contextualise without at least a fundamental knowledge of its underlying concepts. Similarly, the British Medical Association (BMA) (2009) emphasises the need for even greater attention to CAM in healthcare curricula, not only on the basis of its popularity, but also in terms of its potential risks. In relation to these concerns, the under-representation of CAM in nursing curricula is further compounded by the observation that nurses themselves report feeling inadequately knowledgeable about CAM (Laurenson et al, 2006; Buchan et al, 2012), even though they recognise the need to advise or refer patients in the course of their work (Halcon et al, 2003; Buchan et al, 2012). Nurses’ self-reported lack of knowledge is especially pertinent in light of the worrying claim that nurses indirectly endorse the use of CAM by way of recommendation to patients (Fearon, 2003). However wellintentioned, such endorsement is contrary to professional practice, potentially misleading, and possibly even harmful. The apparent paucity of CAM in nursing education also seems to be at odds with the recommendations of the House of Lords Select Committee on Science and Technology (2000), which argued for CAM familiarisation as a core nursing competency. The report strongly encourages the Royal College of Nursing (RCN) and the Nursing and Midwifery Council (NMC) to collaborate on the integration of CAM education into pre-registration nursing and midwifery curricula, and to provide guidance on the integration of CAM therapies into practice. While the RCN (2003) subsequently published a useful guide to the latter, which reiterated the professional accountability of qualified nurses in the delivery of healthcare interventions, the report’s curricular recommendations were less explicitly addressed at that time.



alternative medicine has most often been taught to nurses through didactic methods, both here and in the USA (Richardson, 2001; Avino, 2011). While this can be a useful way to introduce core concepts, a multi-method approach offers interesting variety and has the potential to enhance the student experience. Student seminars, case studies, online discussion groups, problem-based learning and directed reading all have the potential to engage the student more actively in the learning process and to relate learning to their personal areas of interest. Such activities are also an ideal opportunity to examine prejudices and encourage healthy debate, as a grounding for students to develop and promote a critical perspective on the provision of contemporary health care. Theoretical learning can be further enhanced through practical placements, observational visits and input from guest practitioners, all of which offer students valuable insight into the reality of CAM use, both in hospital and in the community. Not least, CAM is particularly well-suited to experiential learning methods. Using massage as an example, Cook and Robinson (2006) describe how, after a period of initial anxiety, student nurses found that experiential learning (giving and receiving massage) heightened their perception of the patient experience and provided an effective bridge between theory and practice. Appropriate timing of CAM education is also important in avoiding fragmentation of the curriculum. In particular, the incorporation of CAM across and throughout the curriculum is preferable to its relegation to elective courses or option units, both of which can lead to such fragmentation as to make them non-viable options (Wetzel et al, 2003; Helms, 2006). Given that electives and option units are typically offered during the final year of study, this strategy also accounts for the finding that both nursing and medical students are more receptive to CAM education during the first year of their studies (Furnham and McGill, 2003). Although the reasons for this are uncertain, it may be that students become less receptive to alternative concepts over time as their exposure to conventional practice becomes more entrenched. This possibility can be reduced by thoughtful, timely and genuinely integrated content that emphasises and clarifies the significance of CAM to nursing practice, and which makes explicit the reality of CAM to patients’ health care and its inevitable overlap with conventional practice.


Beyond pre-registration curricula A coherent educational strategy that familiarises student nurses with core CAM concepts makes them especially wellequipped to develop and apply their knowledge to practice through post-qualifying and/or postgraduate study. This is especially the case where their studies relate to practice settings known for CAM use (e.g. palliative care) or where an especially rigorous critique of CAM is required (in relation to child health, for example). A sound knowledge of CAM would also assist nurses in making informed choices about CAM-practitioner training opportunities, where this fits their career development plans. At doctoral level, the possibilities to explore, develop and evaluate CAM and IHC are infinitely wide-ranging. Thus, where the concern of prequalifying education might be CAM familiarisation, postqualifying study might more appropriately be concerned


Key points n The

integrative health care (IHC) movement reflects the public’s sustained use of complementary and alternative medicine (CAM)

n In

the spirit of client-responsive health care, this societal trend carries important implications for health professionals

n To

interact with patients who show an interest in CAM, health professionals need to understand its underpinning concepts

n Inclusion

of IHC in nursing curricula prepares nurses to engage with a modern client base, accords with the notion of patient choice, and encourages a contemporary focus in nurse education

with its application, and postgraduate study with both its development and evaluation.

Conclusion Central to the provision of contemporary nursing practice is the promotion and facilitation of client-responsive health care. Integrative health care achieves this by reflecting current societal trends, specifically the sustained use of CAM by the public and the centrality of patient choice in matters relating to their own health care. Thus, the notion of IHC imposes a responsibility on health professionals to engage with patients who show interest in CAM—a responsibility that demands a fundamental knowledge of CAM concepts. Yet neither CAM nor IHC appears to be adequately represented in nursing curricula, making it difficult for nurses to facilitate informed choice with respect to CAM, hindering the ideal of a patient-responsive ethos and undervaluing the current and future role of IHC in contemporary society. The inclusion of IHC in nurse education is not concerned with encouraging nurses to agree with or advocate the practice of CAM. Neither is it a license for CAM proponents to promote its therapeutic possibilities unquestioningly. It is simply concerned with the natural evolution of a profession to ensure that it continues to meet the changing needs of its service users. As such, IHC has the potential to contribute to the preparation of a modern nursing workforce that values and honours patient choice in the context of responsible and well-informed practice. As an integral component of nurse preparation and development,IHC lends itself to increasingly critical application across the span of nurse education, from undergraduate through to post-qualifying, postgraduate and doctoral-level study. It also offers the nursing profession an ideal opportunity to enhance the patient’s healthcare experience by influencing the developing face of contemporary health care. Such an BJN opportunity is simply too good to miss. Conflict of interest: none Arykan D, Syvrykaya SK, Olgun J (2009) Complementary alternative medicine use in children with type 1 diabetes mellitus in Erzurum, Turkey. J Clin Nurs 18(15): 2136–44 Avino K (2011) Knowledge, attitudes and practices of nursing faculty and students related to complementary and alternative medicine. A statewide look. Holist Nurs Pract 25(6): 280–8

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Boon H, Verhoef M, O’Hara D, Findlay B, Majid N (2004) Integrative healthcare: arriving at a working definition. Altern Ther Health Medicine 10(5): 48–56 Boyle KC (2010) Effectiveness of acupuncture as an adjunct to standard physiotherapy on pain levels and function in osteoarthritis of the knee. J Acupuncture Assoc Charter Physio Spring 75–82 British Medical Association (2009) Referrals to complementary therapists regulated by statute. Guidance for GPs. http://tinyurl.com/pz2q9yj (accessed 22 October 2013) Buchan S, Shakeel M, Trinidade A, Buchan D, Ah-See K (2012) The use of complementary and alternative medicine by nurses. Br J Nurs 21(11): 672–5 Cook NF, Robinson J (2006) Effectiveness and value of massage skills training during pre-registration nurse education. Nurse Educ Today 26(7): 555–63 Coulter ID, Khorsan MA, Crawford C, Hsiao A-F (2010) Integrative health care under review: an emerging field. J Manipulative Physiol Ther 33(9): 690–710 Department of Health (2010) Liberating the NHS: Greater choice and control. The Stationery Office, London Engebretson J (1999) Alternative and complementary healing: implications for nursing. J Prof Nurs 15(4): 214–23 Ernst E, Cohen M, Stone J (2004) Ethical problems arising in evidence-based complementary and alternative medicine. J Med Ethics 30(2): 156–9 Fearon J (2003) Complementary therapies: knowledge and attitudes of health professionals. Paediatr Nurs 15(6): 31–5 Furnham A, McGill C (2003) Medical students’ attitudes about complementary and alternative medicine. J Altern Complement Med 9(2): 275-84 Halcon LL, Chlan LL, Kreitzer MJ, Leonard BJ (2003) Complementary therapies and healing practices: faculty/student beliefs and attitudes and the implications for nursing education. J Prof Nurs 19(6): 387–97 Harris P, Rees R (2000) The prevalence of complementary and alternative medicine use among the general population: a systematic review of the literature. Complement Ther Med 8(2): 88–96 Helms JE (2006) Complementary and alternative therapies: a new frontier for nursing education? J Nurs Educ 45(3): 117–23 Hessig R, Arcand I, Frost M (2004) The effects of an educational intervention on oncology nurses’ attitude, perceived knowledge and self-reported application of complementary therapies. Oncol Nurs Forum 31(1): 71–8 House of Lords Select Committee on Science and Technology (2000) Complementary and Alternative Medicine 2000, HI Paper 123. HMSO, London Lafferty WE, Downey L, McCarty RL, Standish LJ, Patrick DL (2006) Evaluating CAM treatment at the end of life: a review of clinical trials for massage and meditation. Complement Ther Med 14(2): 100–12 Laurenson M, MacDonald J, McCready T, Stimpson A (2006) Student nurses’ knowledge and attitudes toward CAM therapies. Br J Nurs 15(11): 612–15

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