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Keeping the Balance - Whim and Wisdom

by Denise Rankin-Box(more info)

listed in nursing, originally published in issue 24 - January 1998

People who use complementary therapies are spending more and more money on such forms of care and there has been considerable debate concerning efficacy and effectiveness of treatment. Indeed the presence or lack of empirical evidence substantiating claims made about certain therapies does not seem to influence their use. A recent study conducted by Vincent and Furnham (1994) suggested that health care professionals’ perceptions of the efficacy of a given complementary therapy could influence the type of therapy regardless of the extent to which a substantive body of evidence existed or not (Vincent & Furnham 1994; Rankin-Box 1997). Their study also noted that although important, perceived efficacy of a therapy was only one factor influencing therapy selection.

Nursing

In the field of health care, Nurses, Health Visitors and Midwives together comprise the largest group of health care workers in the United Kingdom. In addition, nurses are responsible for the majority of professional care given in Britain (Beardshaw and Robinson 1990).

A nurse advising a patient on complementary therapies.
A nurse advising a patient on complementary therapies.

Recently there has been a move towards integrating complementary therapies within nursing. In response to growing interest in this field, The Royal College of Nursing Complementary Therapy Forum (RCNCTF) was set up as a special interest group in 1990. It achieved formal status in 1994 with the aim of providing a focus for the use of complementary therapies within nursing practice. Membership now exceeds 4,000 and a National Network system has been established, allowing nurses to meet regularly in regions and to network across the UK (Rankin-Box 1997).

The rapid growth of the group has prompted questions concerning safety, efficacy, education, research issues and consumers awareness of complementary therapies. Part of the nurse’s role is to act as the patients advocate and in the realm of complementary therapies nurses should perhaps be as informed as possible not only about a practice but also the medical implications and contraindications of use when caring for immunocompromised clients.

The use of complementary therapies within the NHS also carries with it legal implications for the practitioner. Is a therapy being practiced with the informed consent of the health authority? Is the therapist covered by vicarious liability? Is there substantive research to show that a particular therapy does indeed make a positive difference to a clients condition and is the therapist familiar with the evidence? Some critics have argued that certain therapies may make excessive treatment claims. In turn, inappropriately trained or inexperienced practitioners may attempt to use the therapy on a much wider range of disorders than is appropriate (Rankin-Box 1993).

These important questions can so easily be obscured by a health workers desire to try to alleviate a person’s pain and suffering right now. It is important that we do not muddy the waters too much in our haste to cross the river until we have checked the depth and currents hidden below the surface.

In 1996, a survey of the RCNCTF was conducted to find out which therapies nurses were actually using in daily practice (Rankin-Box 1997). Interestingly respondents to the convenience sample were aged between 41–50 years. This was noteworthy since it may have been assumed that nurses in a younger age bracket would have had increased exposure to CM through their pre-registration training.

Respondents were mainly well experienced in allopathic forms of health care and generally interested in expanding their knowledge base.

The study highlighted four of the principle therapies practiced which were in order of use: massage, aromatherapy, reflexology and relaxation. The most common areas of practice were community, palliative care and oncology.

Although the survey represented a single snap-shot of nurses use of complementary therapies and it would not be appropriate to generalise upon the findings, it is worth perhaps highlighting the focus on tactile therapies which also appear to embody terms such as ‘therapeutic nursing’ and as Wright has suggested, a return to the heart of nursing (Wright 1995). Nurses may perceive such therapies as being easily assimilated into daily nursing care, perhaps because nurses are often in the unique position of providing tactile care already in the form of pressure care, bed baths and the like.

Complementary Therapy as Nursing Care

What constitutes nursing is beyond the scope of this article, however Ersser (1997) provides a fascinating analysis of nursing as a therapeutic activity and it is not difficult to perceive an apparent overlap between concepts surrounding complementary therapies and the provision of nursing as therapy. For instance Ersser identifies 6 main themes from the literature when addressing nursing as therapy.

These are: interacting and forming a relationship, helping with bodily care, helping people to learn, influencing the context of care, being caring and using of complementary therapies (Ersser 1997: p13). On this basis it could be suggested that the nursing profession is ideally placed to expand its remit by providing many of the tactile therapies currently labelled as complementary medicine. Nevertheless these themes do not necessarily create a therapeutic encounter – it would seem that an essential component is how they are done, how a caring compassionate trusting relationship is formed, how people are helped to learn and how a therapeutic environment is created that facilitates a sense of well-being and of healing.

The use of complementary therapies within nursing practice not only builds upon this approach to care but seeks to use nursing practice in a specific way – to proactively negotiate and facilitate the healing process using specific therapeutic procedures (Rankin-Box 1995). Several issues are at play here. Whilst there is a need to practice competently and effectively drawing upon well thought through educational and research based evidence, this alone will not necessarily enhance nursing care nor promote a healing environment.

There is increasing evidence that some therapies are being practiced as techniques to augment current practice. As such, whilst they may work to some extent, the context of care and the therapeutic relationship between therapist and client is undervalued. This is sad not least because it overlooks one of the reasons so many people wish to experience complementary therapies. As I mentioned earlier, Vincent and Furnham (1994) noted that perceived efficacy of a treatment was only one factor influencing therapy selection. It would seem that we are back to the how of care.

How care is afforded may be as important as the therapy itself. We should reflect carefully upon this – if complementary therapies become assimilated into daily nursing practice will they be relegated to just another task? The introduction of therapies into nursing carries with it a requirement to be responsible for our actions – not to undervalue the therapeutic relationship or the therapeutic context of care in order to fit in with prevailing systems. This is a big responsibility since by definition it will involve a shift in the way we perceive and practice health care. Such change takes time.

There is another issue which hopefully underpins the reason most nurses choose this profession – an intrinsic desire and to be compassionate and care for others. Such care and compassion cannot be taught; it comes from within and whilst often indefinable is so easily recognisable – we stereotype this quality by saying ‘they’re a good doctor or nurse’. Nursing can often be cathartic to those who practice – we get as much out of it as we put in – at least that is how it seems at the beginning. However, Dossey (1995) has ruefully commented: ‘Whatever happened to the healers? Have we simply run out of them? Surely not; all cultures seem to have produced them in abundance. They continue to abound – those passionate, idealistic young persons whose desire to be involved in healing is mysterious, powerful and often inexplicable. They simply know they must become healers.’ (Dossey 1995)

Dossey suggests that upon entering medical (or nursing) schools a paradox is encountered: the very school that should be nurturing and developing such natural healing talents seems ‘adept at extinguishing them’ (Dossey 1995). It gets worse; if the training does not distance students from the very people they wish to care for then the work environment will. High workloads, low staffing levels, high tech units and limited facilities do not foster notions of healing environments, time care and compassion.

Despite this the move towards the integration of complementary therapies has been initiated from the clinical fields of nursing practice – a bottom up rather than a top-down initiative. As Dossey suggests we are being afforded an opportunity to reappraise the concepts, rites and rituals of education and practice. It also offers us a chance to reflect upon the significance and values we place upon our roles as healers.

Perhaps this is beginning. In 1996 nurses were spearheading the development of generic, under-graduate and post-graduate university validated courses in many aspects of complementary medicine. There was a marked shift away from courses designed exclusively for nurses towards multi-disciplinary education which recognised the value of teamwork and common core educational profiles which include modules on healing and spirituality, cross cultural approaches to healing, shamanism, communication, counselling and the development of hospitals as healing environments. To me this is tremendously exciting, innovative and may mark a turning point for nursing – that we can lead and influence the fabric of care.

Any form of change should reappraise the effective and ineffective elements of care in the previous system. This seems to be occurring in both nursing and medicine. Increasing interest by ever wider groups of doctors and nurses and lay practitioners is spearheading a change in the term ‘complementary’ which is rapidly being superseded by the label ‘Integrative’ medicine implying a coalition of allopathic and alternate systems of health care. Thus health care moves forward taking the best of both worlds with it so providing an informed, compassionate approach to healing.

Feeling Good

In 1996, as Editor of the bi-monthly journal Complementary Therapies in Nursing and Midwifery, we chose to devote one issue to the care of Oncology clients. I had recently given a paper at a conference where a fellow speaker had so eloquently articulated his own perspective of receiving massage as he received care and treatment for testicular teratoma. I contacted him and he kindly wrote an account of his experience (Izod 1996).

He described this time as one in which: ‘chemotherapy removed from my life all the things that made it pleasurable; eating, drinking, having sex, playing sport and laughing. Life was very empty. There was no pain, no real terror, no daily trauma, it was just boring: stodgy, sicky; like living life in a vat of marshmallow. There was nothing to look forward to because I didn’t want to do anything.’ (Izod 1996)

When a friend offered to give him regular massage, David described this as a real treat:

‘Marion’s massages were one of the only things I looked forward to. And that’s the point. Pleasure in life comes from looking forward to things, treats, the points in the day when we do the things that we want to do, that makes us feel good.’ (Izod 1996)

David was under no illusions – saying that his survival was due to surgeons and to cytotoxic drugs not because of the massage – but that would be to miss the point. He felt more able to accept what was happening to him and to deal with the treatment simply because he was in a better frame of mind, there was something to look forward to that made him feel good.

Whim and wisdom

The therapies we are beginning to use in nursing may simply be about making people feel good – when everyone else is giving the patient drugs, drawing bloods or operating on them – it may simply be a case of being there and doing something nice. I suspect it is much more than this – it offers those people who entered the healing professions an opportunity to heal and for therapeutic relationships to be valued. Compassion and real care come from within – they cannot be taught in a classroom – but we should learn to recognise these qualities and nurture them so that they can grow and blossom.

Perhaps the development and integration of complementary therapies in nursing practice is about leading the way in health care and of promoting and encouraging balance – between what we know, what we would like to believe and the wisdom to tell the difference between the two.

We should tread carefully and not embrace all ‘new age’ concepts just because they seem like a good idea. Our choice to explore innovative ways of caring and healing people is laudable if we choose to evaluate all therapies equally and to critically review our methods of doing so along the way. It is also essential to learn and use skills developed in complementary and integrative medicine wisely and to challenge and question assumptions in order to avoid accepting mythologies, treatment whims as fact when there is little or no evidence to support claims made about them – so creating what Carl Sagan referred to as the demon-haunted world. He commented: ‘I worry that, especially as the millennium edges nearer, pseudo-science and superstition will seem. . . more tempting, the siren song of unreason more sonorous and attractive. Where have we heard it before? In times of scarcity, challenges to national self-esteem. . . when we agonise about our diminished cosmic place and purpose. . . then, habits of thought familiar from ages past reach for the controls.

‘The candle flame gutters. Its little pool of light trembles. Darkness gathers. The demons begin to stir’ (Sagan 1997).

In what was sadly to be his last book, Sagan wrote about hope and spirituality in science which I feel is also of value in these changing times: ‘Science is not only compatible with Spirituality; it is a profound source of spirituality. When we recognise our place in an immensity of light years and in the passage of ages, when we grasp the intricacy, beauty and subtly of life, then that soaring feeling, that sense of elation and humility combined, is surely spiritual’ (Sagan 1997 p. 32).

The balance between whim and wisdom then may be about having the courage to challenge and question the world around us whilst maintaining our sense of wonderment at our own planet, the stars and as Sagan used to comment – the stardust of which we are made.

References

Beardshaw V & Robinson R (1990) New for Old? prospects for nursing in the 1990s. London. Kings Fund Institute.
Dossey L (1995) Whatever happened to the healers? Alternative Therapies Vol. 1 No. 5 Pp 6–13.
Ernst E (Ed) (1996) Complementary Medicine – an objective appraisal. Butterworth Heinnemann.
Ersser SJ (1997) Nursing as a Therapeutic Activity –  An ethnography. Developments in nursing and Health Care 14. Pp13. Avebury. Aldershot.
Izod D (1996) A patient’s perspective Complementary Therapies in Nursing and Midwifery Vol. 2 No. 3 Pp. 66–67.
Kitson A (1988) On the concept of nursing care. In: Fairbairn G. Fairbairn S (Eds). Ethical issues in caring. Gower Aldershot.
Palmer M Palmer N (1997) Sacred Britain p34. Piatkus. London
Rankin-Box D (1997) Therapies in practice: a survey assessing nurses’ use of complementary therapies. Complementary Therapies in Nursing and Midwifery Vol. 3 No. 4 Pp. 92–99.
Rankin-Box D (1993) Innovation in Practice: complementary therapies in Nursing. Complementary Therapies in Medicine Vol. 1 No. 1 Pp. 30–33.
Rankin-Box D (1995) (Ed.) The Nurses’ Handbook of Complementary Therapies. Churchill Livingstone. Edinburgh, Scotland.
Wright SG (1995) Bringing the heart back into nursing. Complementary Therapies In Nursing and Midwifery Vol. 1 No. 1 Pp. 15–20
Sagan C (1997) The Demon-Haunted World. Science as a candle in the dark. Headline Book Publishing
Vincent C Furnham A (1994) The perceived efficacy of complementary and orthodox medicine: preliminary findings and the development of a questionnaire. Complementary Therapies in Medicine 2 (3): 128–134.

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About Denise Rankin-Box

Denise Rankin-Box heads up Management of Change Initiatives, providing support for individuals, organisations and health care workers in the field of Stress Management and management of life changes. She was Chair of the Royal College of Nursing Complementary therapy forum between 1990 and 1996.
Denise is Editor in Chief of a bi-monthly journal, Complementary Therapies in Nursing and Midwifery and has published widely on the topic of Complementary medicine, including two books – the latest being The Nurses’ Handbook of Complementary Therapies. She can be contacted at MCI on 01625 820898, Fax: 01625 820029.

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