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| Home » From CNA - Nursing Now - Issues and Trends in Canadian Nursing, July 1999 Number 6 |
| From CNA - Nursing Now - Issues and Trends in Canadian Nursing, July 1999 Number 6 |
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From CNA - Nursing Now - Issues and Trends in Canadian Nursing, July 1999 Number 6
Complementary Therapies Finding the right balance
The fastest growing consumer trend in health care in North America today is the use of therapies that are considered complementary to, or integrated with, accepted or conventional health care practice.
Canadian registered nurses1, individually and collectively, are involved in carrying out CNA¹s mission, which is to advance the quality of nursing in the interest of the public. To find the right balance in the discussion regarding complementary therapies, nurses seek to gather and provide accurate information to clients, to base their practice on evidence and to make sound decisions based on their ethical, legal and professional responsibilities.
CNA has prepared this paper to help Canadian nurses find the resources and information to make decisions about using complementary therapies.
There are a number of definitions of both complementary and alternative therapies. Some refer to "complementary and alternative therapies," and do not separate the two. Others refer to integration, or integrative care. Some point out that each individual determines whether to use a therapy as a complement or an alternative to conventional health care practices. This paper will concentrate on complementary therapies, that is, those interventions that are generally used in addition to, or alongside, conventional North American health care practices.
Use of complementary therapies is growing dramatically. Statistics Canada reported that, in 1994, at least 15 per cent of Canadians had used some form of complementary therapy within the past year.2 In 1997, a survey done by Angus Reid showed that 42 percent of the respondents had used some type of complementary or alternative therapy.
In many cases, therapies that are termed "complementary" or "alternative" in Canada have in fact been accepted practice in other cultures, perhaps even for centuries as in the case of Chinese herbal medicine, for example. The World Health Organization estimates that 80 per cent of the world¹s population uses medicines traditional to their own cultures that would be considered alternative to North American, or Western, medicine.
As the demographic characteristics of Canada¹s population continue to change, it is important that nurses consider the cultural context of complementary therapies as an integral part of client care. This approach is supported by the value Choice in CNA¹s Code of Ethics for Registered Nurses
(1997.)
What are complementary therapies?
The U.S. Office of Alternative Medicine lists these categories:
* Diet and nutrition (e.g., vitamin megadoses, macro-biotic diet)
* Mind-body therapies (e.g., meditation, bio-feedback, hypnosis)
* Traditional therapies (e.g., Chinese medicine, Aboriginal healing
practices)
* Pharmacological or biological treatments (e.g., chelation, homeopathy)
* Manual healing (e.g., massage, chiropractic, reflexology, Reiki,
shiatsu, Therapeutic Touch)
* Herbal therapies (e.g., herbal preparations, aromatherapy)
Adapted from: National Institutes of Health (US), Office of Alternative Medicine, as quoted in the American Journal of Nursing, Vol.98 No.6, June 1998.
Tzu Chi Institute: Frequently asked questions The Tzu Chi Institute defines complementary therapies, or medicine, as "therapies that are used alongside mainstream medicine, such as massage therapy."
The Institute defines alternative therapies as "independent healing systems or interventions used outside the realm of western medical theory and practice. Some examples include Ayurvedic Medicine and homeopathy."
Also, according to the Institute, integration means "building bridges between complementary and mainstream medicine" and "developing clinical approaches that encourage mainstream and complementary practitioners to work together in the patient¹s best interest."
(Tzu Chi Institute, "Frequently asked questions" and "resources,"
www.tzu-chi.bc.ca)
What are the benefits? What are the risks?
Consumers choose complementary therapies for a number of reasons: a desire for therapy that is more "natural," a search for treatments for chronic diseases that do not respond to conventional therapy, and concern about technology and the perceived impersonalization of medical care.3 Respondents to an Angus Reid poll felt that such therapies "couldn¹t hurt," and could perhaps help a bit. Of those using complementary therapies, 80 per cent found this type of therapy to be either very helpful or somewhat helpful in maintaining personal health.
Research on the benefits and risks of some therapies has been undertaken, and more research funding is becoming available. But some studies prompt other questions. For example, reduction in pain and promotion of relaxation are two commonly cited results from therapies such as Therapeutic Touch.
Some question methods used in the studies and therefore the validity of the results.
Consumers may hold the belief that complementary therapies can "do no harm,"
but in fact there is a potential for problems. Certain herbal products, for example, can pose a risk to health if taken in combination with prescription or non-prescription medications. The products may also have side effects, or may be harmful if taken in large doses.
What¹s the right answer?
There is a great deal of information in the popular media and from retailers on complementary therapies so much in fact that people may be confused by it. In addition, research into the effectiveness of many types of complementary therapies as yet only indicates that more research is required. What is certain is that people want control over their own health, and they want access to the full range of therapies available today, whether conventional or complementary.
Health Canada, in a 1998 report on Natural Health Products stated that "a balance must be struck between safety and access." The House of Commons Standing Committee on Health concluded that, with access to balanced and objective information on such products, consumers could use them as part of a strategy to improve health.4
Some practitioners of complementary therapies are regulated under provincial or territorial legislation; in Ontario, for example, chiropractors and massage therapists are regulated. A number of health professionals are incorporating complementary therapies into their practices, although not without controversy. In December 1998, the College of Physicians and Surgeons of Ontario announced that they would not create a permanent section for physicians involved in providing alternative and conventional therapies.
"There is no alternative to good medicine," was the conclusion of a College advisory committee, which also, however, agreed that physicians should be allowed a reasonable degree of latitude in the kinds of therapies they offer to clients.5
What is generally accepted is individual choice of therapy, with access to full information on the alternatives and their benefits and risks. However, a number of studies report that many individuals do not tell their health care providers about their use of complementary therapies and health professionals often do not ask their clients for such information.
Integration of complementary therapies
Complementary therapies have already found a place in several acute care centres. For example, the Toronto East General Hospital, the Hamilton Civic Hospital and the St. Joseph¹s Health Centre have adopted Therapeutic Touch as a useful therapy to complement client care.
Healing Touch has been adopted by several Canadian hospitals (including five hospitals in Newfoundland) and is taught at several institutions.
Professionals training in Healing Touch have access to an international certification process and can follow established international standards for this complementary therapy.
The Tzu Chi Institute in Vancouver, affiliated with the Vancouver Hospital and Health Sciences Centre, is a non-profit research institute that conducts scientific evaluation of both complementary and alternative therapies, with the goal of integrating therapies into mainstream health care, as appropriate.
And in Whitehorse, Yukon, the First Nations Health Programs at the Whitehorse General Hospital provide access to traditional healers, among other services for First Nations people.
Call the nurse
Many nurses are deeply involved in the question of complementary therapies for several reasons.
First, a number of people have access to nurses and ask nurses about complementary therapies, or even how to go about getting them. Second, nurses are key providers of health care in both acute care and community care settings, or as self-employed consultants, and have good opportunities to discover that clients are using or want to use complementary therapies. As Canadian consumers increasingly press for the use of and access to complementary therapies, nurses can assume an active role in helping consumers obtain information and make decisions about such therapies. Third, and most important, many complementary therapies would seem to fall naturally into the practice of nursing. Therapeutic Touch, for example, now has a 25-year history as a nursing intervention, and many nursing studies have demonstrated benefits in providing comfort.6
Nurses can act as client advocates and facilitators by being well informed on the efficacy of individual types of complementary therapy and their risks and benefits, and on their possible integration into a comprehensive plan of care. Others may choose to be actively involved in delivering or participating in complementary therapies.
Before choosing a role, nurses will want to know what the position of their provincial/territorial regulatory body is on the provision of complementary therapies. Nurses will also want to seek reliable, evidence-based sources of information about complementary therapies, and determine whether nursing colleagues or other health care providers can serve as resources.7 Nurses who are considering provision of complementary therapies will want to acquire the necessary competencies.
The regulatory view: Protecting the public The practice of nursing is defined in legislation throughout Canada, and commonly includes promoting, maintaining and restoring health, and the assessment and provision of care for health conditions by supportive, preventative, therapeutic, palliative and rehabilitative means. If a complementary therapy meets these criteria then it falls into the scope of nursing practice.
Most of Canada¹s provincial/territorial nursing regulatory bodies have undertaken a review of the nursing role with regard to complementary therapies. Several have formal statements or sets of guidelines available for the profession, and others plan to do so during 1999.
In the main, the nursing associations take the view that nurses practising complementary therapies must do so in the context of a nursing framework, and that there must be evidence of the nursing process of assessment, planning, intervention and evaluation. The Code of Ethics for Registered Nurses reinforces this approach: any care given by nurses must have value that is recognized as an intervention aimed at improving or maintaining health.
Are there legal implications to involvement in complementary therapies?
Yes. Nurses must be aware that they are accountable for any professional action. It is their role to respect the clients¹ values and wishes but it is also their responsibility to help clients make decisions based on the most accurate information available and further, to recognize the potential for harm or exploitation. Nurses are also accountable to ensure that their practice is based on relevant knowledge, and to acquire new skills and knowledge as necessary for the provision of safe, competent nursing care. If nurses are asked to perform an act, or to assist in the performance of an act that may carry unknown risk, they must refuse to participate.
Nurses will also want to clarify and reconcile their personal values concerning complementary therapies. Discussions with colleagues, employers, and other health care providers may assist in this process.
The role of the nurse
The goal of nursing is to improve the health of clients through partnerships with clients, other health care providers, related community agencies and government.
Since primary health care and its underlying principles are a natural extension of nursing practice, nurses play a vital role in their implementation by acting as an entry point for clients into the health care system; providing nursing care and treatment for health problems; helping clients to identify and use health resources, both formal and informal; and, acting as a source of health information for clients.
Policy Statement: The Role of the Nurse in Primary Health Care (CNA, 1995.)
Nurses¹ responsibilities
Every nurse considering involvement in complementary therapy, to whatever extent, should carefully consider each of the following responsibilities.
Competence: Nurses involved in providing care that could be classified as a complementary therapy must possess the knowledge, skill and judgement to assess the appropriateness of providing such care to any client, and to provide the therapy safely and effectively. Some therapies require technical skill; nurses who provide such therapies must be competent in the technical aspects. Nurses should consider: What is the client¹s exact health need?
What are the interventions available? Do I know the benefits and the risks of each intervention? What evidence indicates the effectiveness of the intervention? Am I prepared to anticipate the effect of the therapy? What is the expected outcome of the therapy?
Information: Clients must have access to accurate, timely and impartial evidence-based information about a complementary therapy in order to make an informed decision, and their consent, or that of their guardian, is required for any intervention. Both these conditions are critical to professional accountability.
Nurses require information to advise clients, and the skills in obtaining information from clients about their use of complementary therapies and in presenting information to them.
Authority: Nurses who are performing or participating in or advising on complementary therapies must have the authority to do so. Is the therapy within the exclusive scope of practice of another profession?
Recognition: Nurses who are employees should determine whether their employer accepts the proposed therapy. All nurses should also know the position of their provincial/territorial regulatory body.
Results: Nurses should fully understand the possible results or outcomes of the therapy. Are plans in place to cope with any effects on the client¹s health status? Is there a mechanism for recording results of the therapy and evaluating outcomes in order to advance professional knowledge?
RESOURCES FOR NURSES
There is a great deal of information available on complementary therapies typically in the popular media, but in professional resources as well.
Nurses must be critical readers and go beyond mere claims of effectiveness and anecdotal reports.8
When reading the results of formal studies examining therapies, nurses will want to evaluate how the study was designed, how the subjects were selected, how the treatment was provided, what outcomes were assessed and what factors existed that could influence the results. For example, information about the subjects¹ diagnoses and other forms of treatment should be provided, particularly when the results are presented as a collection of anecdotal reports.
There are many sources of information on complementary therapies including individual practitioners, organizations and publications. Some sources of information include:
Nursing organizations, including provincial and territorial nursing associations and the Canadian Holistic Nurses Association (http://www.cna-nurses.ca).
Organizations of other health professionals (for example:
http://www.cma.ca).
Organizations or societies dedicated to the study of specific diseases, such as the Canadian Cancer Society.
Health Canada/Health Protection Branch
(www.hc-sc.gc.ca/hpb/lcdc/bc/links_e.html#unconventional).
Provincial or territorial ministries of health, for information on regulation and licensing of providers of health care.
A number of web sites provide results of research on complementary therapies. A list of web sites is provided by several Canadian universities including McMaster (http://www-hsl.mcmaster.ca/tomflem/altmed.html) and the University of Victoria (http://www.hsd.uvic.ca/HIS/chear/index.html). The web site of Office of Alternative Medicine, National Institutes of Health
(http://altmed.od.nih.gov/nccam) lists a number of studies.
The Canadian Nurses Association has prepared a short list of resources on complementary therapies. To obtain a copy, please call 1-800-385-5881.
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1. Subsequent use of "nurses" refers to registered nurses.
2. Millar, W. J. (1997). Use of alternative health care practitioners by
Canadians, Canadian Journal of Public Health, Volume 88, No. 3, p. 154-158.
3. Montbriand, M. J. (1993). Freedom of choice: An issue concerning
alternate therapies chosen by patients with cancer, Oncology Nursing Forum, Vol. 20, No 8, p.1195-1201.
4. Public Works and Government Services Canada. Natural Products: A New
Vision. Report of the Standing Committee on Health. Joseph Volpe, Chair.
November 1998. Note that the Committee used the term "natural health products" to cover three categories: traditional medicines; homeopathic preparations; and vitamin and mineral supplements.
5. College of Physicians and Surgeons of Ontario. News release: "CPSMO
Committee says OThere is No Alternative to Good Medicine.¹" Toronto, September 22, 1997.
6. Note that while there is research to support the use of Therapeutic
Touch, other studies have failed to corroborate its value. Nurses should be aware that differing points of view exist for virtually every therapy and that these issues are far from resolved.
7. Canadian Nurses Association (1998). Policy Statement: Evidence-based
Decision-making and Nursing Practice. Ottawa: CNA.
8. Readers may want to consult the text, Reading Nursing Research (see
CNA¹s web site at www.cna-nurses.ca under publications or call sales at
1-800-385-5881) for additional information.
Nursing Now is a series of short papers that explore issues and trends in Canadian Nursing. This is the sixth in the series.
Nursing Now is published by the Policy, Regulation and Research Division of the Canadian Nurses Association (CNA).
Free copies are available to all CNA members. For additional information and/or additional copies contact CNA Publications. A list of additional references is available upon request.
ISSN 1206-3878
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