Dimensions of Nursing Practice Exam #3 Chapter 25

Category 1

Category I includes alternative systems of theory and practice developed outside Western biomedicine. For example, acupuncture and Oriental medicine are grounded in traditional Chinese medicine. Also included in this category are traditional indigenous systems, which include all medical systems other than acupuncture and Oriental medicine that developed outside of Western biomedicine. It also includes unconventional Western systems not classified elsewhere that were developed in the West but are not considered part of biomedicine, such as homeopathy. Finally, this category includes naturopathy, an unconventional medical system that has gained prominence in the United States. This eclectic approach consists of various natural systems, such as herbalism, lifestyle therapies, and diet as therapy.

A capacity for self-healing

A variety of integrative modalities are often needed to diagnose and treat each individual holistically. It often is not obvious when the health problems of the physical body correspond to the dynamics of the energetic body or when the energetic body merges with the spiritual body, and how they all are eventually integrated into the psychosocial body. The mediating role of the psychosocial body in the integrative approach emphasizes each person's capacity for self-healing. The importance of the mind-body interaction to elicit the placebo response and the need for clients to participate actively in the monitoring and maintenance of their health and well-being are positive factors in the diagnosis and treatment of their illness.

Use of integrative therapies

Although forms of integrative therapies have been used for many years in the United States, the passage of the ACA of 2010 has the potential to increase its use even more. Section 2706 of the ACA makes it illegal for insurance companies to discriminate against clients who use integrative therapies. Providers of integrative therapies must be reimbursed by the insurance companies at the same rates as providers of traditional procedures. There are other references to integrative therapies in the wellness and prevention sections of the ACA. The one sticking point is that the individual states can write their own language concerning which practitioners receive how much reimbursement for integrative practices.

Ayurvedic medicine

Ayurvedic medicine is the traditional medical system that has been used in India for thousands of years, and it focuses on producing health by balancing the three key substances of the body. A body out of balance is considered to be in a state of illness, and plant-based substances are used to achieve a balance in the body and restore a state of health. The Ayurvedic system also considers the taste, or "essence," of the herb as an integral element in herbology. Ayurveda recognizes six essences (sweet, sour, salty, pungent, bitter, and astringent) and five elements (ether, water, fire, air, and earth). The elements are manifested as three doshas, or humors (vata, pitta, and kapha), that govern body functioning and that must be kept in balance to maintain or restore a healthy state.

Concerns about herbal therapies

Ayurvedic medicine is the traditional medical system that has been used in India for thousands of years, and it focuses on producing health by balancing the three key substances of the body. A body out of balance is considered to be in a state of illness, and plant-based substances are used to achieve a balance in the body and restore a state of health. The Ayurvedic system also considers the taste, or "essence," of the herb as an integral element in herbology. Ayurveda recognizes six essences (sweet, sour, salty, pungent, bitter, and astringent) and five elements (ether, water, fire, air, and earth). The elements are manifested as three doshas, or humors (vata, pitta, and kapha), that govern body functioning and that must be kept in balance to maintain or restore a healthy state.

Category 111

Biologically based therapies include products, interventions, and practices that are natural in origin and biologically based. They may or may not overlap with conventional medicine and its use of dietary supplements. Phytotherapy, or herbalism, is the use of plant-derived products for purposes of prevention and treatment. Diet therapies use special diets to reduce risk factors or treat chronic diseases. Orthomolecular medicine is the use of nutritional products and food supplements that are not included in other categories for prevention and treatment of disease. Pharmacological, biological, and instrumental interventions are those not covered in other categories and administered in an unconventional manner.

Plants as medicine

Both alternative and conventional health care use plants as medicine. Herbalism, or "botanical medicine," also known as phytotherapy or phytomedicine in England and other parts of Europe, is the study and use of herbs or crude-based plant products for food, medicine, or prophylaxis. They can also be used to heal, treat, or prevent illness and improve the spiritual and physical quality of life.9 Herbs may be angiosperms (flowering plants, trees, or shrubs), algae, moss, fungus, seaweed, lichen, or ferns. Herbs used as medicines come from some part of the plant (leaf, root, flower, fruit, stem, bark, or seed), its syrup-like exudates, or some combination of these. In some herbal traditions, nonplant products are used alone or in combination, with or without plants. They may include animal secretions and parts (e.g., bones, organs, or tissues), stones and gemstones, minerals and metals, shells, and insects and insect products.

Category 11

Category II includes mind-body practices, religion and spirituality, and social and contextual areas. Mind-body medicine involves a variety of approaches to health care and contains three subcategories. Mind-body systems are seldom practiced alone but are usually combined with lifestyle interventions. Mind-body methods may be used as a supplement to a traditional medical system. They are sometimes used in conventional health-care practices; however, they are characterized as CAM when used for conditions for which they are not normally prescribed. Religion and spirituality include treatments directed toward biological functions or clinical conditions. Social and contextual areas include treatment methods that are not included in other categories, such as cultural and symbolic interventions.

Belief in effectiveness

Clients who use alternative therapies do so because they believe those therapies will work, either alone or when combined with conventional treatments. Persons who consider their health to be poor or who have chronic illnesses report greater benefits from alternative than conventional health care and are more likely to try both at the same time. Referral from conventional health-care professionals, friends, or other users of integrative therapies is also a prominent reason for the simultaneous use of both systems. For many clients, integrative therapies simply make them feel better than conventional health care does.

A different kind of healing

Complementary and alternative health-care practices, now called integrative practices, have been widely used by a large percentage of the population. Their popularity continues to increase dramatically with clients of all ages and backgrounds. Integrative practices include a range of traditional therapies and treatments that are not usually used or taught in conventional Western health care. Although some use the terms alternative health care and integrative health care synonymously, integrative care is more inclusive. It attempts to integrate the best of Western scientific medicine with a broader understanding of the nature of illness, healing, and wellness. It also includes complementary and alternative practices but goes beyond to include the care of the whole person, focusing upon health rather than illness. Based upon evidence from research, integrative practice also involves the individual in his or her own care to achieve the highest level of health and well-being. Integrative health practice is highly inclusive, "integrating approaches to treatment from the allopathic, complementary, alternative, psychological, spiritual, environmental, nutritional, and self-help arenas."1 With integrative health practices, clients are aided in using their illness crises as the starting point to making positive changes in their lives and reaching their full potential in wellness. It is important for nurses to have a solid understanding of this type of health care to ensure their clients' safety and well-being and to be supportive of their practices.

Regulation of supplements

Concern about nutritional supplements also exists because, unlike drugs and most food additives, they are not regulated by the FDA. If manufacturers make no claims that they are effective against a disease, they do not need to be tested for safety and effectiveness before they are sold to the public. However, there has been a gradual increase in the regulation of these products over the past 25 years. The 1994 Dietary Supplement Health and Education Act (DSHEA) created a special category of 20,000 protected substances previously sold as supplements. The DSHEA defined supplements as including vitamins, minerals, amino acids, herbs, botanicals, and other plant-derived products and the extracts, metabolites, constituents, and concentrates of supplements.

Conventional uses of energy

Conventional health care has long used various types of energy systems (e.g., electrical, magnetic, microwave, and infrared) for screening, diagnosis, and some types of treatment. Commonly used modalities include electrocardiograms, magnetic resonance imaging, electroencephalograms, electromyograms, x-rays, radiation treatments for cancer, low-frequency electric current to stimulate growth of bone cells (osteoblasts) to accelerate healing of fractures, types of electric shock therapy for cardiac arrest, cardioversions for cardiac arrhythmia, and pacemakers.

Holistic philosophy

Conventional health care is often faulted for its limited focus on the physiological dimension of health and curing to the exclusion of the unity of mind-body-spirit healing. Another negative characteristic of conventional health care is its excessive dependence on medicine, surgery, and technology rather than on the more natural and noninvasive alternative approach that focuses on self-care and self-healing.

The placebo response

Conventional health practitioners tend to dismiss the effects of healing after integrative and alternative modalities have been used by attributing them to the placebo response. They feel that healing takes place only because the individual believes the treatment is effective. In conventional medicine, the term placebo has come to signify a type of sham treatment instituted to please difficult or anxious clients, or a sugar pill given when health-care professionals have nothing more to offer the client. In biomedical clinical research, a placebo is an inactive or nontreatment given to the control group under the assumption that it will not change any physiological responses and will therefore prove the effectiveness of the active treatments.

Supplements as prevention

Conventional health-care professionals typically view nutritional supplements (vitamins and minerals) as replacement or preventive therapy for nutrition-deficient conditions. For example, rickets and osteoporosis can be prevented by adequate vitamin D and calcium intake; adequate ascorbic acid (vitamin C) intake prevents scurvy; and neural tube defects in newborns can be prevented by sufficient maternal intake of folic acid (vitamin B9) during the prenatal period. Niacin has been shown to lower cholesterol levels. On the basis of research by the National Academy of Sciences, the FDA has established maximum recommended daily allowances (RDAs) for vitamin and mineral intake. These levels are usually well above the amount at which deficiency diseases occur but below the level at which the client would experience toxic side effects.

Diagnosis by category

Conventional medicine has developed extensive disease categories, and great emphasis is placed on diagnosis and cure based on the assessment of physical signs and symptoms. Most newly developed medications, when they are in the human testing phase, are tested on men between the ages of 25 and 35 years, with the presumption that they will work similarly in women, elderly people, and children. That presumption is not always accurate, and there is a growing trend at pharmaceutical companies to test medications on groups of persons for whom they are more likely to be used.

Energy in alternative healing

Conventional medicine has long been cynical about integrative practices, and as a result has been slow to recognize how the energy of the body can be used for health promotion and healing. Alternative therapies refer to energy systems as fields, vital essences, balance, and flow that clients can use to prevent illness, promote health, and heal themselves. The basic concept is that external forces are not able to cause harm if the person is in the well state. Alternative healers may be needed to help individuals manipulate the energy system primarily for self-protection or healing. Major alternative and complementary modalities using bioenergy and other energy fields include energy medicine, vital essences and balance, and external energy forces.

Benefits of organic foods

Currently in the United States, there is a trend to use the terms natural foods, all-natural foods, and organic foods interchangeably; however, there are differences. The definitions for natural and all-natural foods remain vague and have little meaning because of the lack of established quality standards. The implication in labeling a product as natural is that the food is unprocessed or only minimally processed, suggesting that it does not contain "unnatural" or manufactured substances. However, these products may contain natural substances such as salt, and they may be grown with the use of pesticides and chemical fertilizers and may be irradiated after harvesting and still be called natural.

Category V

Energy therapies are based on manipulation of biofields with bioelectromagnetically based therapies. Biofields include energy systems and energy fields internal and external to the body that are used for medical purposes. Bioelectromagnetics is the use of electromagnetic fields in an unconventional manner for medical reasons.4 Although it is called therapeutic touch (TT), there is no actual contact with the body or only very light touch. The use of TT is believed to redirect energy flow and treat pain and disease. Research shows that in some individuals TT is effective on wound healing, pain, and anxiety, but the reports of results have been mixed.

Cost of alternative care

Estimated costs of alternative medicines (herbs and nutritional supplements), diet products, equipment, and books and courses totaled $33.9 billion in 2007 (the last year a comprehensive national survey was conducted). Sixty-seven percent of HMOs cover one or more alternative and complementary healing (ACH) modalities, but coverage is uneven and varies regionally. Chiropractic is the most common covered service (65 percent), followed by acupuncture (31 percent), massage therapy (11 percent), and vitamin therapy (6 percent). HMOs expect to increase coverage for acupuncture to 36 percent, acupressure to 31 percent, massage therapy to 30 percent, and vitamin therapy to 27 percent. The most important reasons for adding coverage for these services are public demand, legislative mandate, and demonstrated clinical effectiveness.5

The healing matrix

The Healing Matrix (Table 25.1) contrasts conventional and alternative modalities and practitioners. The alternative modalities shown are (1) representative of those most commonly known by the general public, (2) sought in the United States and the industrialized world, and (3) practiced most often by conventional health-care professionals, including nurses.

A holistic basis

For the purposes of this discussion, alternative and complementary medicine is defined as the understanding and use of healing therapies not commonly considered part of Western biomedicine. The focus here is mainly on methods of self-care, wellness, self-healing, health promotion, and illness prevention. Therapies and practices are called alternative when used alone or with other alternative therapies, and complementary when used with conventional therapies. The use of the term healing is preferred to medicine. Integrative health care and alternative and complementary modalities typically are based in holistic philosophies, which go beyond treatment or cure of the physiological and psychological dimensions of care commonly associated with modern, scientific biomedicine. Holism refers to treatment of the whole person (body-mind-spirit) in that person's environmental context (i.e., physical, biological, social, cultural, and spiritual).

Chinese medicine

Herbology is used in traditional Chinese medicine to enhance the flow and amount of chi, restore the harmonious balance of the complementary forces of yin and yang, and balance the five elements (fire, earth, metal, water, and wood). In the Chinese system, plants are prescribed according to their effects on the five elements and their corresponding body processes, including organs, tissues, emotions, and temperatures (climates).

Who uses them

In most national studies of alternative therapy users, ethnic and racial minorities are underrepresented, particularly among persons who do not speak English. Such exclusions raise questions about whether the use rate of alternative therapies in the United States may exceed 42 percent because the use of alternative therapies among immigrant populations and those with lower incomes tends to be high. Many such populations have grown up with these therapies as "folk" medicine, and their worldviews encompass different concepts of health, illness, and healing. Conversely, alternative health-care practices are most popular among women, people aged 35 to 49 years, people with higher educational levels (some graduate education), and those with annual incomes of more than $50,000.2

The NCCAM classification

In 1992, Congress mandated the establishment of an Office of Alternative Medicine in the National Institutes of Health to enhance the study of ACH. In 1998, the Office became the NCCAM. Its mission is to conduct and support basic and applied research and training and to disseminate ACH information to conventional health-care professionals, alternative healers, and the public.

Therapy from within

In contrast to traditional medical care, the integrative model views wellness as a state in which individuals are in harmony or balance with their internal and external worlds. A holistic understanding of wellness is much broader than the traditional concept of health. It implies that the client is aware of his or her present and future state of health in all of its aspects (physical, mental, emotional, spiritual, environmental, social, and occupational). To be able to achieve a true state of wellness requires the clients to maintain, alter, balance, and evaluate their health in each one of the health aspects.

The holistic approach

In contrast, the integrative and alternative approach views the person-body as consisting of multiple, integrated elements that incorporate both the materialistic and nonmaterialistic aspects of existence. These elements include the physical (material), spiritual, energetic, and social bodies. This view allows for various interpretations of how the different components of the person-body interact and function to affect health and illness and respond to different therapeutic interventions.

A reductionist philosophy

In general, conventional medicine focuses on the physical or material part of the person, the body. It is concerned with the structure, function, and connections or communication between material elements that compose the body, such as bones, muscles, and nerves. Conventional medicine generally views all humans as being very similar biologically. Disease is seen as a deviation from what is generally considered to be a normal biological or somatic state. Conventional medicine is sometimes considered reductionist because it tends to reduce very complex entities (humans) to seemingly equal and more simple beings who are all anatomically and physiologically similar. From this perspective, it is believed that all individuals will respond in more or less the same ways to causative agents, such as bacteria and viruses, and respond similarly to common treatments, such as medicines and surgery. In other words, a person with measles, cirrhosis of the liver, or breast cancer will have the same course of illness as other persons with those illnesses and will respond to treatments in basically the same manner.

Western pharmacology

The Western herbal tradition relies primarily on the pharmacological action of herbs, most of which are derived from the plant kingdom. There are approximately 123 plant-derived pharmaceutical medicines that are in use today. Almost all of the food supplements and herbal over-the-counter products, except for minerals, are plant based. The compounds and chemicals found in plants constitute about 25 percent of prescriptions by conventional health-care professionals

Self-care

In the integrative model, first-level measures involve self-care aimed at wellness and can generally be performed independently. Some examples include exercising, eating a well-balanced diet, nurturing the spirit, getting enough sleep, cleaning the house, using defensive driving measures, doing breast or testicular self-examinations, applying sunscreen when outside, eliminating destructive habits, and practicing good hygiene. The next level of self-care requires seeking the assistance of others to achieve balance in self and the environment. This level includes getting help to find satisfying employment, seeking prenatal care, taking parenting classes when pregnant, going to community meetings to address environmental safety and citizen quality-of-life issues, seeking conventional health screening examinations (e.g., mammography and dental checkups), obtaining glasses to correct myopia, and getting vaccinations and keeping them up to date. Alternative measures, such as acupuncture and energy therapies, can also be used in this level of care.

Vital essences and balance

In the integrative models, illness reflects blockage, loss, or imbalance of body energy or vital essence. Disturbance of internal body energy can result from external or internal factors. Treatment may be directed at removing the blockage of energy flow through such measures as acupuncture, acupressure, chiropractic adjustment, craniosacral therapy, or reflexology. It may also be directed at increasing the amount of energy and vital essence to restore balance in the body.

Mental (psychic) and spiritual therapies

Included in these therapies are group or individual counseling techniques that help the client develop or attain spiritual and personal growth. Examples include intuiting, revelations, visualization, astrological and other readings, and invoking the spirit world.

Defining integrative health practice

Integrative health practice finds its origins in the definition of health presented by the WHO: Health is "a state of complete physical, mental and social well being and not merely the absence of disease or infirmity."2 It is client focused. The integrative approach to health is based on the belief that clients, after an illness or injury, have the capability to regain their overall health and maintain wellness during their life spans. The work of the practitioner using integrative health practices is to become familiar with each client's particular health needs and then personalize their care using the full range of elements that affect health, including physical, mental, spiritual, social, and environmental factors. Taking into consideration the complex relationship between mind, body, and spirit, alternative health care addresses both the short-term care needs and long-term issues of the client.3 Integrative health care has the potential to affect the health status of clients across the spectrum of the health-care system. For nursing practice, it includes the ability to incorporate conventional health-care diagnoses and treatments with evidence-based practice (EBP), nonconventional alternative and complementary treatments, environmental factors, and nutritional therapies into their nursing skills set. Nurses must be able to bring to clients an awareness of how emotional, spiritual, cultural, and environmental factors in their lives affect their health and long-term well-being. On the clients' part, they need to develop a personal understanding of the causes and meanings of their illnesses and be willing to make a commitment to the healing process. Only then will they achieve the best outcomes from their treatments.1

Self-healing

Integrative, alternative, and conventional health care all include the belief that the body has the capacity to heal itself. The integrative and alternative systems place self-healing as the central principle of their models and see it as the basis of all healing. Thus, integrative and alternative healers focus on helping people determine why the cells of their body are sick and search for imbalances from a holistic perspective. Conventional health care views the ability of the body to self-heal primarily through the normal process of replacing cells; examples include the physiological and biological processes involved in wound healing. Conventional care approaches the concept of body self-healing by questioning why the cells are not replacing themselves and attempts to facilitate healing through external means, which are potentially invasive, such as surgery or medications.

Energy systems

It has long been known scientifically that the human body is regulated by its own internal electrical energy system. Human beings cannot survive without the low levels of electricity that sustain and regulate life at the cellular and molecular levels. Electrical-chemical reactions are produced in the nervous system and help regulate other body systems, electrical impulses trigger heartbeats, and minute electrical currents regulate the production of hormones. The blood is composed largely of iron; therefore, magnetic forces exist in all parts of the body.

External energy forces

It is believed that external energy forces have the capacity for healing. Some of these external forces involve treatments with actual external energy sources, such as whole body vibration (WBV) therapy and electroacupuncture. WBV involves stimulating the client's body with low-frequency vibration in the range of 0.5 to 80 Hz. To be most effective, the vibration should be administered over a wide contact area using a platform to stimulate the feet when standing, or a special chair to stimulate the buttocks when sitting, or the whole back when lying on a vibrating surface. For maximal effect, the client should experience some fatigue or low-level stress. It is believed that the vibration causes the body to learn how to adapt to external stress, which produces increased circulation, improved muscle tone, better joint motion, and activation of osteoblasts that increase bone density. By connecting wires to two acupuncture needles at a time and passing a low-voltage pulsating current of electricity between them, it is believed that electroacupuncture augments the acupuncture experience and is especially effective in the treatment of pain. Several pairs of needles can be electrified at the same time and the procedure should not last more than half an hour.

Ask the client

It is important to ask clients about their use of integrative therapies. Not doing so may place them at risk for adverse health outcomes. When and how to assess for the use of ACH during the client assessment process is a matter of judgment and should be guided by the nurse's knowledge of individual clients. An appropriate time is often after the chief complaint has been documented because this is when questions are asked about the clients' reasons for seeking health care and what they have already done for their problem.

Category IV

Manipulative and body-based methods include body manipulation, body movement, or both. Chiropractic care specializes in adjustments and manipulation of the spine, returning the body to its optimal alignment. This type of care is most often used when people have pain in their lower back, shoulders, and neck. However, chiropractic is often considered to be holistic and these manipulations may also improve the overall state of wellness. The ancient healing art of acupressure was first recognized in Asia approximately 5,000 years ago. The acupressure practitioner uses his or her fingers to gradually press key points throughout the body. It is believed that this pressure will stimulate the body's own healing mechanisms. It can also be self-performed to relieve stress and tension, boost the immune system, reduce some types of pain, and improve health

Comparing and conventional, alternative, and integrative practices

Many similarities exist among integrative, alternative, and conventional health care. As they attempt to achieve similar goals, they overlap in methodology, even though the methods are derived from different concepts of healing and different theoretical models. Table 25.3 summarizes characteristics often cited as common to alternative healing and contrasts them with those usually associated with conventional health care.

A cross-section of care

Modalities in column 1 of the Healing Matrix are technologies that cut across various healing systems. The technologies are arranged vertically from the most concrete to the most abstract. The remaining columns include various healing modalities from conventional, marginal, and alternative healing systems. Physical Manipulation Technologies. These are also known as "bodywork therapies." They are administered by a therapist or by the clients themselves as part of a self-care program. They include health rituals and breathing exercises to better bring about the union of body-mind-spirit. Ingested or Applied Substances. A number of substances, including herbs, vitamins, and other nutritional supplements, and dietary regimens have the goal of helping the body heal itself, rid itself of toxins, and promote general health and wellness. Energy Therapies. These modes of treatment maintain or restore health through the balancing of energy flow in the body. The goal is to restore the natural movement of vital forces or life essences that may have been disturbed by diseases or psychological factors.

The paradox of integrative healing practices

Nurses often feel uncomfortable with the use of herbal products and unconventional therapies. This is due to unclear definitions of various integrative practices along with the widespread, yet often unregulated, use of alternative products and healers. This paradox arises because most nursing knowledge comes from the biomedical sciences, but most integrative modalities (1) have not yet been scientifically validated or proven safe by the scientific method and (2) are based in concepts of holism, self-care, and theoretical constructs that emanate from worldviews different from that of biomedicine and the scientific perspective.

Nutrition

Nutrition and diet have long been recognized by both integrative and conventional healing systems as important in health promotion and illness treatment. They can also be risk factors for or even cause disease. In conventional health care, nutrition and diet are usually considered as adjuncts to biomedical treatment. In integrative systems, nutrition is commonly seen as a way of life and as a method of preventing illness.

A lack of validation

Put simply, for most integrative treatment modalities, little is known about whether or how they work, their side effects, or their interactions with conventional or other integrative treatments. Although there is increasing scientific research in this area, claims regarding their effectiveness still come largely from testimonials of users or integrative healers rather than from evidence in scientific studies. Equally limited is valid knowledge about the effectiveness of the various integrative modalities in specific conditions and about their short- and long-term effects.

How does it work?

Researchers do not have a good understanding of the mechanism by which the placebo response produces positive results. Some believe that the placebo effect is at work in all therapeutic intervention regardless of whether the intervention is an alternative or a conventional treatment. Four possible factors have been examined: • An endorphin-mediated response • Belief of the client • Belief of the healer • The client-healer relationship • Remembered wellness

Defining alternative and complementary healing

Several definitions are used for alternative and complementary health-care practices. They are sometimes defined as practices outside of conventional, science-based Western medicine and not sanctioned by the official health-care system. A considerable range of practices and concepts is included in alternative and complementary healing. These practices are generally used in place of conventional practices or used to enhance the effectiveness of standard medical treatments. The glossary at the end of this chapter outlines many of these practices.

Desire for control

Some people who use integrative therapies believe conventional care is too intolerant, authoritarian, and impersonal. They feel that some conventional health-care professionals lack sensitivity to the wishes of clients and their families when developing treatment plans. Clients believe they should be partners in decision-making about their care rather than just having decisions handed down to them. In the United States, the majority of people report being reluctant to tell conventional health-care professionals that they use integrative therapies. Although almost all (89 percent) who use integrative therapies do so under the supervision of an integrative healer, about half of this same group do not consult a conventional health-care professional before they begin. Fourteen percent of persons see both conventional health-care professionals and integrative healers. Similar patterns of self-care and nondisclosure to conventional health-care professionals are found throughout the industrialized world.

Dietary supplements

The FDA defines dietary supplements as "a product intended for ingestion that contains a 'dietary ingredient' intended to add further nutritional value to (supplement) the diet. A 'dietary ingredient' may be one, or any combination, of the following substances: • A vitamin • A mineral • An herb or other botanical • An amino acid • A dietary substance for use by people to supplement the diet by increasing the total dietary intake • A concentrate, metabolite, constituent, or extract

A challenge to nurses

The challenge presented to nurses by integrative healing modalities relates to professional accountability. Nurses must learn about integrative modalities, their general safety and efficacy, and their use in specific health and illness conditions. Human caring and cultural competence require that nurses be able to develop therapeutic partnerships with culturally diverse clients and empower them to take charge of their lives and health care. They need to preserve the client's right to self-determination and to practice alternative lifestyles, as well as to pursue a variety of conventional or integrative therapies, with or without consulting alternative healers or conventional health-care professionals. Nurses must keep an open mind while relying on sound evidence for recommendations about alternative practices and practitioners.

Dissatisfaction

The increasing use of integrative therapies is due in part to the feeling that conventional health care is unable to deal with major health problems or improve a person's general health. People who have a high degree of distrust in conventional health care often rely primarily on integrative therapies. This lack of trust has increased recently for several reasons, including:

The multiple-body view

The integration of multiple aspects into a unified but distinctly individual person-body results in the belief that the person-body responds as a whole to factors that affect its state of well-being. Although the signs and symptoms of illness for one person are similar to another person's, they may indicate different underlying causes based on variable risk factors. From this viewpoint, diagnostic measures and interventions cannot be based on only one aspect of the person's being but must be tailored to the person-body of each individual.

Combining modalities

The integrative philosophy includes both the material and nonmaterial aspects of the individual, stimulation of the self-healing forces, and the determination of a person's unique needs. It uses the concepts and treatment modalities of both alternative and conventional healing traditions simultaneously. These modalities are based on different worldviews or concepts of reality and address the individual healing needs of each person.

Licensed integrative care

The modalities in column 3 (marginal) are generally learned through the study of the standard curricula in institutions of higher education. Integrative healers practicing such modalities are usually licensed by the state, and most have credentialing and a professional body that sets standards for their practice. These modalities are not considered conventional therapies in the United States but may be part of conventional health-care systems in other nations. For example, acupuncture is an essential mode of treatment in traditional Chinese medicine, which, along with biomedicine, forms the conventional health-care system in the People's Republic of China. In 1997, the National Institutes of Health Consensus Panel on Acupuncture reviewed research studies and other information on its safety, efficacy, and effectiveness. The studies showed sufficient evidence to approve acupuncture as an intervention for adult general and dental postoperative pain and to treat nausea and vomiting associated with chemotherapy.6

Conventional health care

The modalities listed in column 2 (orthodox [conventional]) are part of the official health-care system in the United States. They are based on knowledge rooted in scientific and biomedical principles.

Intuitively based care

The modalities presented in columns 4 and 5 are less physiological. They are based on a more intuitive type of knowledge. Most alternative healers practicing such modalities are self-taught, have learned through working with more experienced practitioners, have attended courses or workshops on particular modalities, or have learned by a combination of methods. The integrative modalities in the bottom cell on the far right have the most intuitive knowledge base; that is, insights about the spiritual or physical self are gained through direct revelations or interpreted by another.7 These include readers (e.g., astrologers or seers) and spiritual healers in touch with divine forces.

Integration of nonmaterial factors

The physical body is the primary focus of conventional medicine. Because of this almost exclusive focus on the physical body, conventional medicine often does not consider or include the nonmaterialistic aspects of health and illness in diagnosis and treatment decisions. Thus, spiritual, psychological, sociocultural, behavioral, and energy system aspects play little or no role in conventional medical treatment.

Few regulatory standards

The technical competence and knowledge of integrative healers are of considerable importance to nurses caring for clients who pursue integrative practices. Nurses and the general public are accustomed to determining the qualifications, assumed competency, and scope of practice of conventional health-care practitioners through externally regulated mechanisms. These external regulations include graduation from an accredited school, state-regulated licenses, credentialing, and attainment of specialty certifications from professional organizations or institutions of higher education. No such external processes or criteria exist to validate the competence and knowledge of most integrative practitioners.

Wellness and holism

The term wellness is often used interchangeably with good health, generally meaning an absence of disease or illness; however, in the context of this chapter, it includes much more. The term holism, first used in discussion of systems theory, is often defined as the totality or entirety of a system that is more than the sum of its parts. The system being looked at in health care is the human person.

Classifying integrative methods

The underlying goals of any type of health care include preventing illness, promoting and maintaining health, and caring for people while alleviating the suffering caused by illness. However, despite these common elements, health-care practices vary profoundly in their modalities (technologies), practitioner education and monitoring, underlying concepts (models) of health and illness, modes of care delivery, and social and legal mandates to provide care. Because of the large number of variables, a confusing array of health-care systems, practitioners, and healing modalities has developed. Two systems that can be used to help define and classify alternative and complementary therapies are the Healing Matrix and the NCCAM classification. 4

Herbal traditions

The use of herbal therapies varies according to culture and tradition. The three major groups of herbal therapies recognized throughout the world are from Western medicine, traditional Chinese medicine, and Ayurvedic medicine.

An outdated definition

There is no universally accepted definition. Many alternative health-care practices originated a number of years ago within cultural belief systems and healing traditions. A commonly used definition in the United States for alternative and complementary modalities comes from the National Center for Complementary and Alternative Medicine (NCCAM), an agency of the National Institutes of Health. The NCCAM definition is "those treatments and health-care practices not taught widely in medical schools, not generally used in hospitals, and not usually reimbursed by medical insurance companies." This definition is quickly becoming outdated. Several medical and nursing schools now include courses on alternative and complementary health-care practices. Also, the practice of alternative medicine is gradually becoming part of conventional health care. Physicians, nurses, and other health-care professionals are responding to the growing public use of these practices by incorporating selected modalities into their own client care. Physicians have begun referring clients to a variety of alternative healers and using alternative therapies for their own health.

Energy medicine

This therapy includes a number of techniques that use external energy sources to stimulate tissue regeneration or improve the immune system response. Relaxation of muscles through electrical stimulation is thought to promote general body relaxation, increase circulation, enhance waste removal, improve nutrition and oxygenation, and restore energy balance. Examples of energy medicine include biofeedback, magnet therapy, and sound and light therapy.

Why their use has increased

Three general theories have been advanced to explain the growing use of integrative healing: (1) dissatisfaction with conventional health care, (2) a desire for greater control over one's health, and (3) a desire for cultural and philosophical congruence with personal beliefs about health and illness. Many other client-specific reasons have also been postulated, such as belief in the effectiveness of integrative therapies and the individual's health status (Box 25.1). The rising cost of conventional health care may play a role as well.

Therapy from outside

Wellness, from the perspective of traditional medicine, tends to focus on individuals who are seen as being at risk for illness. Prevention often begins when signs or symptoms arise and is directed at alleviating them rather than treating or removing their underlying cause. Because of the strong belief in the ethical principal of autonomy or self-determination, at-risk individuals are often permitted to engage in risky behaviors as long as conventional health care can find treatments or palliative measures for the symptoms of diseases it cannot prevent. For example, a client who smokes develops a chronic cough but does not yet have any of the smoking-related diseases (i.e., emphysema, bronchitis, lung cancer). This person would likely receive from a nonholistic physician a strong warning about smoking, but the major focus of care would be to provide the client with medication to eliminate the cough. From this perspective, the absence of an active specific disease is considered synonymous with wellness.