ALTERNATIVE MODALITIES OF CARE

INTRODUCTION: We refer to medical practices that evolved with indigenous peoples

and that they have introduced to other countries through emigration as traditional
medicine. We refer to approaches that emerged primarily in Western, industrial countries
during the past two centuries as scientific or Western medicine, although we acknowledge
that not all Western medicine is based on scientifically proven knowledge. The terms
complementary and alternative describe practices and products that people choose as
adjuncts to or as alternatives to Western medical approaches. Endless varieties of
practices are scientifically unproven and poorly accepted by medical authorities. For the
sake of organizing an agenda for research into these approaches, the U.S. National
Institutes of Health has grouped them into five somewhat overlapping domains
as follows:
Biologically based practices. These include use of a vast array of vitamins and mineral
supplements, natural products such as chondroitin sulfate,which is derived from bovine or
shark cartilage; herbals, such as ginkgo biloba and echinacea; and unconventional diets, such
as the low-carbohydrate approach to weight loss espoused by the late Robert Atkins.
Manipulative and body-based approaches. These kinds of approaches, which include
massage, have been used throughout history. In the 19th century, additional formal
manipulative disciplines emerged in the United States: chiropractic medicine and osteopathic
medicine. Both originated in an attempt to relieve structural forces on vertebrae and spinal
nerve roots that practitioners perceived as evoking a panoply of illnesses beyond
neuromusculoskeletal pain.
Mind-body medicine. Many ancient cultures assumed that the mind exerts powerful
influences on bodily functions and vice versa. Attempts to reassert proper harmony between
these bodily systems led to the development of mind-body medicine, an array of approaches
that incorporate spiritual, meditative, and relaxation techniques.
Alternative medical systems. Whereas the ancient Greeks postulated that health requires a
balance of vital humors, Asian cultures considered that health depends on the balance and
flow of vital energies through the body. This latter theory underlies the practice of
acupuncture, for example which asserts that vital energy flow can be restored b placing
needles at critical body points.
Energy medicine. This approach uses therapies that involve the use of energy—either bio
field- or bio electromagnetic based interventions. An example of the former is Reiki therapy,
which aims to realign and strengthen healthful energies through the intervention of energies
radiating from the hands of a master healer.

Alternative systems of medicine use elements from each of these CAM and TM domains. For
example, traditional Chinese medicine incorporates acupuncture, herbal medicines, special
diets, and meditative exercises such as tai chi.Ayurveda in India similarly uses the meditative
exercises of yoga, purifying diets, and natural products. In the West, homeopathic medicine
and naturopathic medicine each arose in the late 19th century as reactions to the largely
ineffectual and toxic conventional approaches of the day: purging, bleeding, and treatments
with heavy metals such as mercury and arsenicals.

ALTERNATIVE THERAPIES:
.
Ayurveda
Ayurveda, the traditional medical system of India, originated > 4000 yr ago. It is based on the
theory that disease results from an imbalance of the body's life force (prana). The balance of
prana is determined by equilibrium of the 3 bodily qualities (doshas): vata, pitta, and kapha.
Most people have a dominant dosha; the specific balance is unique to each person.
Evidence: Few well-designed studies of Ayurvedic practices have been done. Use of
Ayurvedic herbal combinations to relieve symptoms in patients with RA and to treat diabetes
is being studied.

Uses: After determining the balance of doshas, practitioners design a treatment specifically
tailored to each patient. Ayurveda uses diet, herbs, massage, meditation, yoga, and
therapeutic detoxification (panchakarma)—typically with enemas, oil massages, or nasal
lavage—to restore balance within the body and with nature.

Possible adverse effects: In some of the herbal combinations used, heavy metals (mainly
lead, mercury, and arsenic) are included because they are thought to have therapeutic effects.
Cases of heavy metal toxicity have been reported.

Homeopathy
Developed in Germany in the late 1700s, homeopathy is based on the principle that like cures
like. A substance that, when given in large doses, causes a certain set of symptoms is
believed to cure the same symptoms when it is given in minute doses. The minute dose is
thought to stimulate the body's healing mechanisms. Treatments are based on the patient's
unique characteristics, including personality and lifestyle, as well as symptoms and general
health.

Remedies used in homeopathy are derived from naturally occurring substances, such as plant
extracts and minerals. Extremely low concentrations are prepared in a specific way. The more
dilute the homeopathic remedy, the stronger it is considered to be.

Some solutions are so dilute that they contain no molecules of the active ingredient. There is
no compelling, scientific explanation for how these dilutions could work.

Evidence: Efficacy of homeopathic remedies for various disorders has been studied. No
study has clearly shown efficacy for any specific homeopathic remedy, although some studies
have shown positive results (eg, one well-conducted, randomized, placebo-controlled clinical
study showed a therapeutic benefit greater than placebo in the treatment of diarrhea in
children). Homeopathy is commonly incorporated into health care practices in Europe and
India.

Uses: Homeopathy has been used to treat various disorders, such as allergies, rhinitis,
digestive problems, musculoskeletal pain, and vertigo. The effect of homeopathic solutions
on joint pain and tenderness and quality of life in fibromyalgia is being studied.

Possible adverse effects: Homeopathy is well-tolerated and has few risks; rarely, an allergic
or toxic reaction occurs.

Unlike herbal and nutritional supplements, homeopathic remedies are regulated by the FDA
as drugs; they are available over the counter or by prescription. Because so little active
ingredient is left after dilution, active ingredients are tested before dilution. Homeopathic
remedies have been temporarily exempted from limits on the amount of alcohol (the usual
diluent) that they can contain. However, the label is required to list the following:
Manufacturer
The label “homeopathic”
At least one indication
Instructions for safe use
Unless specifically exempted, the active ingredient and degree of dilution
Conventional clinicians should not assume that a homeopathic remedy taken by a patient is
biologically inactive. Patients often use the term homeopathic erroneously in reference to a
dietary supplement they are taking. Also, the FDA allows many medicinal herbs to be
registered and labeled as homeopathic if they undergo a particular pharmaceutical process.

Naturopathy
This therapy began as a formal health care system in the US during the early 1900s. Founded
on the healing power of nature, naturopathy emphasizes prevention and treatment of disease
through a healthy lifestyle, treatment of the whole patient, and use of the body's natural
healing abilities. This system also focuses on finding the cause of a disease rather than merely
treating symptoms. Some of this system's principles are not that different from those of
traditional healing systems such as Ayurveda and traditional Chinese medicine.

Naturopathy uses a combination of therapies, including acupuncture, counseling, exercise

therapy, medicinal herbs, homeopathy, hydrotherapy, natural childbirth, nutrition, physical
therapies (eg, heat or cold therapy, ultrasound, massage), guided imagery, and stress
management.

Traditional Chinese Medicine

Originating > 2000 yr ago, traditional Chinese medicine is based on the theory that disease
results from improper flow of the life force (qi). The movement of qi is restored by balancing
the opposing forces of yin and yang, which manifest in the body as heat and cold, external
and internal, and deficiency and excess. Various practices (eg, acupuncture, diet, massage,
medicinal herbs, meditative exercise called qi gong) are used to preserve and restore qi and
thus health.

Evidence: Chinese medicine traditionally uses formulas containing mixtures of herbs to treat
various disorders. Traditional formulas can be studied; for example, efficacy in the treatment
of irritable bowel syndrome has been shown. One herb, used by itself, may not be as effective
and may have side effects. Nevertheless, current conventional research favors study of single
herbs. For example, Tripterygium wilfordii (thunder god vine) has demonstrated anti-
inflammatory properties and clinical efficacy in treating RA, and astragalus may benefit
patients with lung cancer. Various Chinese herbs have been studied as treatments for hepatitis
and hepatic fibrosis. Some studies suggest efficacy, but data are limited.

Possible adverse effects: One problem is the standardization and quality control of Chinese
herbs. Many are unregulated in Asia; they may be contaminated with heavy metals from
polluted ground water or may be adulterated with drugs such as antibiotics or corticosteroids.
However, high-quality products are available through certain manufacturers that comply with
FDA Good Manufacturing Practices.

Advantages of alternative therapies:

1. There are no side effects. This is because alternative medicine works WITH the body, not
in suppressing symptoms, as modern medicine does.

2. Medicines are cost effective. This means they are generally affordable by even the most
financially compromised families.

3. Alternative medicines are generally 'green'. By that I mean that they use natural substances
processed simply. No high tech manufacturing processes which use hazardous and polluting
chemicals or carbon polluting energy.

4. Substances or ingredients of 'complexes' are readily available, so you can even grow some
of your own medicines, allowing you to keep control of the whole process. No secrecy or
patents here!

5. Alternative medicines don't just heal ailments. In the process, they allow for growth. In
homoeopathy we see children putting on a growth spurt after they recover from a naturally
treated disease. This doesn't happen with a medically treated disease. Rather, it appears to
hold the child back.

6. Alternative medicine recognizes the true nature of disease and sickness. That it is
necessary for a growing child to experience as only this experience allows the immune
system to develop into a healthy one by adulthood. It's a bit like learning to ride a bicycle.
You need to practice before you can ride properly.

7. Alternative medicine recognizes that physical symptoms only develop when you ignore the
mental and emotional signs and symptoms. Which allows you the freedom to deal with these
problems as they arise, and so never develop physical symptoms.

Complementary Medicine

Complementary medicine is the term used here to describe additional forms of treatment that
may be given along with chemotherapy and traditional Western medicine. 

In the past, complementary medicine has claimed various types of  "miracle" cures for
cancer, which have since proved ineffective or even fraudulent.  The integration of
conventional and complementary medicine therapies however, is of increasing interest.  This
approach is being adopted at leading cancer treatment centers (such as Cleveland Clinic) and
hospices and by self-help groups.  Gentle therapies such as massage, relaxation, and other
"healing" therapies play a major role in palliative care (symptom relief). Some patients find
that complementary medicine, also called integrative medicine and/or holistic healing can
help alleviate the side effects, pain and anxiety associated with chemotherapy and cancer
treatments in general.

Sometimes complementary medicine is mistakenly referred to as "alternative therapy" or

"alternative medicine," and it is important to distinguish between the two.  Complementary
medicine is recognized and approved by many health care professionals, whereas alternative
therapy is not.  Complementary medicine is given along with chemotherapy whereas
alternative medicine is given in place of chemotherapy and includes non-approved, non-
tested treatments that can be harmful. 

No matter what type of complementary medicine you may choose to explore, the Cleveland
Clinic recommends you consult your physician before beginning any form of additional
therapy.

Types of Complementary Medicine Therapies:

Experts divide complementary medicine into five
categories:  Sensory, Cognitive, Expressive, Physical and Medical Systems

Sensory Complementary Medicine:

Sensory complementary medicine therapies are therapies that work in conjunction with the
five senses: smell, site, taste, sound and touch, as well as the body's overall energy.

 Aromatherapy: The theory of this complementary medicine therapy is that the

essential oils are absorbed into the body either through the pores of the skin during
massage, or by inhalation through the nose.  The scents released by the oil act on the
hypothalamus, a part of the brain that influences the hormonal system.  Thus, in
theory, a smell might affect mood, metabolism, stress levels, and libido. Clinical
research into claims for the effects of essential oils on medical conditions is not
extensive, but the psychological effects of smell have been studied more.

Some common essential oils used are chamomile, lavender, peppermint, rosemary,
sandalwood and tea tree. There are conflicting reports regarding the properties and uses for
oils, and responses to smells are highly personal.   

 Landscape Therapy is the showing of peaceful, relaxing landscapes to patients,

scenes that evoke calm and tranquility.  They may be shown in a darkened room via a
slide show or video screen, or they may be shown in the form of art books or actual
artwork.  Landscape therapy is often used as a distraction technique to help manage
pain and anxiety.  

 Music Therapy is an expressive art form designed to help individual move into
harmony and balance.  Music therapy can incorporate both listening to and/or playing
music. Music therapists are professionals who are educated to design music programs
for patients.  Through the use of music, individuals explore emotional, spiritual and
behavioral issues.  Music therapy can help patients release emotions and relax.
Listening to music can be either calming or invigorating.  

 Massage is a form of complementary medicine that relies on the body's nerve endings

and pressure points to promote relaxation. There are many forms of massage: Shiatsu,
Hellerwork, and Reflexology for example.  However, the most widespread variation
builds upon the five basic strokes of Swedish massage:  effleurage (slow, rhythmic
gliding strokes in the direction of blood flow towards the heart) petrissage (kneading,
pressing and rolling muscle groups) friction (steady pressure or tight circular
movements, often used around joints) percussion, (drumming hands on body) and
vibration (rapid movement shaking the muscle back and forth).

There are many benefits to massage therapy for patients undergoing treatment for cancer. 
There are also concerns and possible risks.  Massage therapy has been used to treat stress and
anxiety, improve mood, induce relaxation, and control pain.  For patients undergoing surgery
the application of appropriate massage can promote healing at incision sites and may prevent
or reduce scarring.  Use of foot massage was shown to have a positive effect on patients'
perceptions of pain, nausea and relaxation. 

There are situations in which massage can be risky or the techniques need to be adjusted. For
example; massage should not be given if signs of infection are present at the surgical site. 
Immediately after surgery when a person is at risk of developing blood clots, massage of the
legs is not advised.  Patients undergoing radiation should not have massage techniques
applied in the area of the radiation field because the massage may further irritate the
irradiated skin.  During chemotherapy, often patients are at increased risk of infection,
anemia or bruising.  Special precautions need to be taken with massage at this time.  The use
of massage therapy as an adjunct to cancer treatment should be discussed with the patient's
treating physician (oncologist, radiation oncologist or surgeon).  This is so that any risks can
be discussed and details about the patient's condition can be provided so that a licensed
massage therapist (LMT) can provide a safe and effective massage to the patient with cancer.

When seeking out a massage therapist it is recommended that information regarding the
therapist's education and credentials be reviewed.  The following are criteria that are
recommended in a massage therapist:

 Graduated from an accredited program, which meets the standards set by the
Commission on Massage Therapy and Accreditation.
 Holds a current state license in massage therapy
 Is certified by the National Certification Board for Therapeutic Massage and
Bodywork
 Is a member of a professional association, such as the American Massage Therapy
Association
 Has received special training in massage of patients undergoing cancer treatment.

Massage therapy can be very beneficial to a person undergoing cancer treatment.  However,
be sure to discuss with your health care provider so this therapy can be used safely.

 Therapeutic Touch is a complementary medicine form that presupposes that people

have individual "energy fields" that interact with one another and with the
environment as part of a universal energy force.  These fields are thought of in
scientific, rather than in mystical terms.  In the late 1960's Dr. Dolores Krieger,
Professor of Nursing at New York University learned the technique of "laying on of
hands" from a healer, Dora Kunz.  She began to teach what she called Therapeutic
Touch to her students.  

In a Therapeutic Touch (TT) session, the practitioner attempts to attune their energy fields
with the patient so that disturbances in the "energy flow" are balanced and the body's healing
powers can work freely.  Hands are placed inches above the body and gently moved over it to
assess any changes or blockages in the energy field.  Using sweeping movements, the
practitioner will try to treat the area of imbalance, perhaps by visualizing healing energy
directed from her body to the patient.  A session may last 10-15 minutes.  TT is used to treat
stress-related conditions, such as fatigue and headaches.  It is also used for pain relief,
especially from muscle strain and following surgery.  It also has been used to promote wound
healing, and for lymphatic and circulation disorders.

 Reiki is a form of Japanese spiritual healing.  This complementary medicine has its
foundation in ancient Tibetan Buddhism, apparently forgotten until its rediscovery in
the late 19th century.  The aim of reiki is to promote health, maintain well-being, and
help people attain a higher consciousness.  Practitioners draw on "reiki energy"
channeling it to areas of need in themselves and their patients.  They borrow
terminology from physics, claiming that reiki acts at an atomic level, causing the
body's molecules to vibrate with higher intensity and thus dissolving energy
blockages that lead to disharmony and disease. 

A treatment session lasts about an hour; the practitioner directs reike energy through his
hands to the patient.  The patient lies clothed on a treatment table and the practitioner holds
his hands on or over the body in 12 basic positions for about five minutes each.  This is said
to balance the body's energy centers or "chakras."  Some patients may feel relaxed after
treatment; others feel invigorated.
  Reflexology:  According to practitioners, the feet are a mirror of the body, and
applying pressure to areas on the foot that correspond to the affected organs may help
to relieve symptoms such as pain, constipation, and nausea.  Reflexology is
increasingly available in many hospices, and is often given by nurses.

 Acupuncture is an ancient Chinese system of health care. This type of

complementary medicine aims to prevent and cure specific diseases and conditions by
sticking very fine, solid needles into points of the body.  Acupuncture is believed to
encourage the release of endorphins, natural painkillers that can also increase feelings
of well-being.  Acupressure, in which the same acupoints are stimulated by hand, may
be effective in the same way, but to a lesser degree.

 Chiropractic Medicine: system of therapy based on establishment of good self

image through awareness and correction of body movements. Application of the
knowledge of the relationship between structure and function to diagnose and treat
dysfunctions that effect the nervous system. Treatment frequent involve the
manipulation of the spinal column and may also include the psychotherapy and diet
therapy.

Cognitive Complementary Medicine:

Cognitive Therapy promotes mind-body healing by using the power of positive thinking to
facilitate recovery.  Types of cognitive therapy include:

 Guided Imagery (visualization) is a process where the patient is assisted in

imagining positive images and desired outcomes to specific situations.  The
practitioner works with the patient initially to discover what is they are trying to
accomplish with the therapy.  Then a mental image is created.  For example, patients
are asked to focus on feeling stronger or better, or to picture the destruction of tumor
cells while in a state of relaxation.  In one technique, patients visualize various aspects
of treatment, from the least frightening to the most painful, remaining calm and
relaxed at each step.  This method has helped patients to control nausea before
chemotherapy.

 Hypnotherapy would be similar to guided imagery, however a physician or licensed

hypnotherapist would be needed to induce deep relaxation.

 Prayer

 Meditation is a method of relaxing and quieting the mind to relieve muscle tension
and facilitate inner peace.  There are numerous forms of meditation, taught
individually or in group settings. 

 Relaxation and Deep Breathing:  Patients are taught these types of complementary
medicine techniques to help to release muscle tension, relieve breathlessness, lessen
anxiety and encourage a greater sense of control, particularly when receiving
unpleasant or stressful treatments.

 Biofeedback: A training technique in which people are taught to improve their health
and performance by using signals from their own bodies, is particularly found to be
useful for managing pain and side effects.

Expressive Complementary Medicine:

  Expressive Therapies are treatments in which patients are encouraged to express
their thoughts.  Expressive therapies are thought to alleviate anxiety by allowing the
patient to release fear and frustration in a positive, creative fashion.  These therapies
include:

Psychotherapy and Counseling

Support Groups

 Journal Writing: Writing in a journal is an effective way to handle some of the

emotions that living with cancer triggers.  Often people facing a serious illness find it
difficult to express their feelings to others. Journal writing can allow a person to
express difficult feelings in a safe and private way.  Regular journal writing also helps
people to clarify their thoughts and make good choices.

 Art Therapy: Drawing, painting and sculpting, especially when carried out in a
group environment, encourage pleasure in creativity and enable people to find a way
of expressing their feelings that cannot be easily put into words.

Physical Complementary Medicine:

 Physical Exercise: When possible for the patient, physical exercise has been shown
to release endorphins (mood elevating hormones) and promote better general health,
relief of tension and positive attitudes. Even something as simple as walking and
certain forms of dance have been helpful to patients. 

 Yoga is a form of gentle exercise consisting of body postures and breathing

techniques.  It has been practiced for thousands of years in India, and has now become
popular around the world.  In the West it is valued more for its physical than spiritual
benefits, such as its ability to increase suppleness and vitality, and to relieve stress and
fatigue.

 T'ai Chi is a noncombative martial art that uses breathing techniques and sequences
of slow, graceful movements to improve the flow of qi, or "life energy," calm the
mind, and to promote self-healing.  It is often described as "meditation in motion."  It
is practiced more as a form of preventive health care than as a response to an ailment.

 Qi Gong is an ancient system of movement, breathing techniques, and meditation,

which is designed to develop and improve the circulation of "qi" or "life energy"
around the body.

Medical Systems Complementary Medicine:

Medical Systems is an overall term used to describe the types of different, alternative, or
non-traditional medicines that may be called upon in addition to western medicine.  Some of
these include naturopathy, Anthroposophical medicine, Western herbalism,  Chinese
herbalism, and ayurveda.

General Precautions Regarding Complementary Medicine: 

 Cleveland Clinic recommends that you consult a doctor before starting any
nonconventional form of treatment.
 Do not stop taking any prescribed medication without first consulting your doctor.
 Tell your complementary practitioner about any prescribed medication you are taking,
and any other complementary treatments you are receiving.
 Tell your doctor about any complementary treatments or remedies you are taking.
 Do not start on a vigorous exercise program without first consulting a doctor.  
 Advise your practitioner if you have any sexually transmitted disease.
 See your doctor if symptoms persist or worsen.

Herbal medicine

Herbal medicine has always attracted some scientific interest and many well known drugs are
plant-derived, for example digoxin from foxgloves and morphine from poppies. The
following are some of the herbs commonly thought to be effective:

 St John's Wort (Hypericum perforatum) is a safe and effective treatment (if taken as
the only treatment) for mild to moderate depression. It may also help fatigue -
possibly because fatigue is a common aspect of depression.
 Ginkgo Biloba may be effective in relieving the symptoms of dementia and it may
also support memory in all older people.
 Ginger is an effective remedy for nausea and vomiting.
 Phytodolor (a standardised extract of Populus tremula and other herbs) is as effective
as synthetic drugs in relieving rheumatic pain.
 Horse chestnut seed extract can alleviate the symptoms of varicose veins.
 Tea tree oil may be effective against fungal infections such as athlete's foot.
 Vegetables from the allium family (onions and garlic) may protect against certain
cancers if eaten regularly, especially cancers of the digestive tract, though further
studies need to be done.

ROLES OF NURSE IN COMPLEMENTARY AND ALTERNATIVE THERPIES.

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. Each of 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.
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.

Lastly, in relation to Jean Watson’s theory of Humancare, nurses will recognize the most
important aspect of all nursing activities are those actions that promote professional,
compassionate, human to human interaction (Watson, 2000) . For the theory of Humancare,
the very basis of nursing is interaction and connection between two human beings. The
modality of healing presence is a significant, important technique to provide trust, support
and to initiate the caring encounter necessary for nursing to take place. Healing presence is
one of the modalities stated frequently by holistic nurses in the survey of modalities used in
nursing practice discussed above. Watson’s theory elevates the importance of this nursing
action to its rightful state in care – it is the pre-requisite for any professional nursing activity.
From within the worldview of the theory of Humancare, a nurse will identify presence as a
very necessary nursing action. Presence is often described as ‘being in the moment’
(Dossey,1995), or ‘being with’ rather than ‘doing to’ (Paterson & Zderad, 1976). There are
three levels of presence defined for nursing practice: physical presence (being there),
psychological presence (being with), and therapeutic presence as the nurse’s reflectively
relating to the client as whole being to whole being using all of his or her resources – body,
mind, emotion and spirit (McGivergin & Daubenmire, 1994). It is the final level, that of
therapeutic presence, that fits best with the notion of Humancare. While many do not
consciously think about healing presence as a modality, it requires skills of centering,
openness and intuition to employ for the good of client care. The theory of Humancare
reminds nurses that healing presence is indeed a modality and one that has not received
sufficient attention, development and research as would be assumed, given how fundamental
it is to the discipline.

Through examples from four distinct nursing theoretical frameworks, several

complementary/alternative modalities have been discussed as appropriate to incorporate into
professional nursing. If one accepts the ideas that 1) professional nursing is based on theory
and 2) that theory-based practice is reflective practice, the use of the modalities within theory
becomes thoughtful and considered as a means to understand and interpret a nurse’s actions.
Nursing theory provides a means to understand modalities and permits nurses to assess and
incorporate new aspects of care into a larger, more holistic, and very professional, worldview.

Nursing Taxonomies of Nursing Practice

Taxonomies of nursing practice are the classification systems that provide frameworks for
naming and documenting the phenomena of concern of professional nursing. The most
widely known and used of these taxonomies is the NANDA Classification of Nursing
Diagnoses (NANDA, 2001). Originally presented to the nursing community in the 1970's the
NANDA taxonomy is a statement of nursing problems and concerns. Over the years many
nurses have worked within this (and other nursing diagnostic systems, for example the
Omaha and Saba systems) to identify and name all phenomena of concern to nursing. The
current NANDA taxonomy lists over150 nursing diagnoses, organized according to domains
based on health patterns. Work presented at the last meeting of NANDA indicated that the
nursing diagnostic taxonomy will include statements of problem, risk for problem, and
opportunity or readiness to enhance a current condition (Jones, et al., 2000). Thus, the current
taxonomy of diagnoses presents a statement of conditions (both problems and opportunities
to promote/enhance wellness) that have been identified by nurses as within the autonomous
domain of nursing.

Newer taxonomies for nursing include the Nursing Interventions Classification (NIC) , now
in its third edition (McCloskey & Bulechek, 2000) and the Nursing Outcomes Classification
(NOC), now in its second edition (Johnson, Maas, & Moorhead, 2000). These taxonomies list
nursing activities that have been identified by nurses as actions they perform on behalf of
patients/clients while providing direct and/or indirect care and measurable, core outcomes
that are sensitive to nursing interventions. Taken together, the NANDA, NIC and NOC
provide as comprehensive a list as is available of the concerns, actions, and expected
outcomes of nursing practice. These lists are remarkably useful for nurses using
complementary/alternative modalities in practice.

Complementary modalities may be used by nurses and non-nurses alike; however, when used
as part of nursing practice, the care should be documented in a nursing context.

While some modalities require additional certification and/or licensure in some states, (for
example, massage therapy), most of the modalities used by nurses require a nursing license
and documentation that makes clear that the care provided is within the scope of professional
nursing practice. When a complementary/alternative modality is used to address a concern
identified as a nursing diagnosis, the action becomes an identified nursing intervention
planned to address/remedy a nursing problem or concern. For example, when music therapy
is provided to assist individuals obtain adequate sleep, the NANDA diagnosis of disturbed
sleep pattern is the identified nursing problem and the intervention ‘music therapy as
provided through tape recorded music at times of wakefulness’ is a nursing intervention
identified by the nursing community as within the domain of
professional nurses. Likewise, when the nursing problem is
fear related to undergoing medical diagnostic procedures (such as an MRI), and the nursing
intervention is ‘guided imagery to assist the client with relaxation and distraction during the
procedure’, the problem, intervention and outcome can be documented from within the
taxonomic frameworks as nursing. To provide an example of a wellness-oriented nursing
concern, when the nursing concern is readiness to enhance spiritual well-being related to a
time in life when a client is examining his personal beliefs, values, and sense of future, the
nursing intervention ‘meditation facilitation to focus awareness on an image or thought and
to find a place of inner peace’is being used to address an identified nursing concern. A last
example is the use of the intervention Therapeutic Touch (TT) as a technique to assist the
client experiencing impaired comfort related to severe itching. The technique is being used to
provide a non-pharmacologic treatment of condition affecting the client’s comfort and well-
being. In each of these cases, the nursing activity is a complementary/alternative modality
(music therapy, guided imagery, meditation, TT). Practice within the nursing context
emphasizes that the modality is being used to address the human response to actual/potential
health problems. Table 1 provides a summary of selected nursing diagnoses and interventions
to indicate possible pairings of nursing concerns and actions.
Table 1: Selected Nursing Diagnoses and Nursing Interventions: Possible Pairings of
Nursing Concerns and Complementary/Alternative Interventions
Nursing
Nursing Intervention(s) Rationale
Diagnosis/concern
Impaired Comfort Acupressure, TT to decrease perceived pain
Disturbed Sleep
Massage to promote relaxation, rest
Pattern
Social Isolation Animal-Assisted Therapy to provide affection
Impaired Coping Humor to facilitate appreciation of that
which is funny, to relieve tensions
Hopelessness Hope instillation to promote a positive sense of the
future
Spiritual Distress Spiritual support to facilitate a sense of inner peace
Spiritual Well-Being Spiritual growth facilitation to support growth/reflection
reexamination of values
Anxiety or Fear Guided imagery, relaxation to reduce sense of anxiety
therapy, biofeedback, calming
techniques
Impaired
Art therapy to facilitate expression
Communication

When documented from a nursing framework, the nurse is making it clear that the modality is
being used to address an issue that has been accepted by the nursing community as within the
domain of nursing and within the phenomena of concern to professional nurses. Nurses
documenting practice using these systems are accomplishing three important things:
appropriate documentation of care, identification of work as within the scope of professional
nursing, and building a body of knowledge for nurses on the use of specific interventions.

The taxonomies provide both a framework that helps nurses think in a holistic manner about
what they are doing as nurses and increased justification for having a nurse perform the
activities. The taxonomies themselves are atheoretical, meaning that they are not grounded in
any of the nursing theories, they are simply a list of diagnoses, interventions and outcomes.
These diagnoses, interventions and outcomes, however, can be used with nursing theory to
guide the reflective interpretation of client conditions and selection of appropriate nursing
interventions. Within the framework of nursing taxonomies, the alternative/complementary
modalities become part of the nursing process – the documentation of nursing assessments,
concerns, interventions and outcomes.

Bibliography :

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Alternative Medicine</a>