VOL: 98, ISSUE: 02, PAGE NO: 40
Denise Rankin-Box, BA, RGN, DipTD, is editor-in-chief of Complementary Therapies in Nursing and Midwifery, Macclesfield, CheshireThe increasing popularity of complementary therapies raises interesting questions for nurses and midwives, not least about the competency of practitioners and the efficacy of treatments. As more people turn to complementary and alternative medicine (CAM), issues such as education and training are coming under the spotlight. And what about ethical issues, such as client safety and the protection of nurses who practice these therapies? This article addresses these concerns.
The increasing popularity of complementary therapies raises interesting questions for nurses and midwives, not least about the competency of practitioners and the efficacy of treatments. As more people turn to complementary and alternative medicine (CAM), issues such as education and training are coming under the spotlight. And what about ethical issues, such as client safety and the protection of nurses who practice these therapies? This article addresses these concerns.
In the UK about 22 million visits a year are made to practitioners of acupuncture, chiropractic, homoeopathy, hypnotherapy, herbal medicine and osteopathy each year (Thomas et al, 2001; Fox, 2001). This figure excludes therapies such as reflexology, massage, nutritional therapy and therapeutic touch. To put this into perspective, Thomas et al (2001) report that there were 14 million visits to A&E during the same period. Fox (2001) says that more than 90% of visits to complementary practitioners - costing a total of about £450m - are purchased privately.
In the USA a total of about $15bn is spent on complementary therapies every year, with about one in four of the population being treated with some form of complementary therapy (Eisenberg et al, 1993).
It is not known how many nurses, midwives and health visitors use complementary therapies in the NHS or private practice.
A straw poll of members of the RCN Complementary Therapies in Nursing Forum, showed that complementary therapies were more commonly practised in the independent sector. In the NHS, such therapies appear to comprise less than 20% of formal nursing care. The respondents said that when it was used, it was often in addition to, rather than integral to, daily nursing care (Rankin-Box, 1997).
In a study of 105 NHS trusts, Graham et al (1998) found that 64 (61%) allowed complementary therapies to be practised. The most common were aromatherapy, reflexology, acupuncture and massage.
The recent growth in the number of complementary therapy courses has, in the main, been encouraged by public interest and the accompanying demand for highly qualified therapists (Isbell, 2001). The House of Lords select committee on science and technology (2000) highlighted the need for quality education and training. In particular, the committee drew attention to the need for therapists to be able to identify when referral to other health care professionals is appropriate.
A global view
Stone (2001) notes that support for CAM has never been greater, reflecting a more tolerant position towards alternative therapies among the medical profession. Indeed, at a conference organised by the Royal College of Physicians and the US National Council for Complementary and Alternative Medicine, participants discussed how integration might be promoted and drew on UK and US experiences regarding the implications of CAM for health care, research and education. That the RCP was willing to host such an event is a reflection of recent advances in this field.
In Europe, as Trevelyan (1998) notes, the status of complementary therapies varies. In the Netherlands, Germany and Denmark non-conventional medicine is practised within certain limits. However, in France, Belgium and Luxembourg only members of the medical profession are entitled to practice health care and treat illnesses.
In the USA, formal structures regulate CAM practice. Each state can set its own laws governing the use of CAM and there is a statutory prohibition against the unlicensed practice of medicine. State statutes define 'medicine' broadly and cover terms such as 'diagnosing' and 'treating' clients. Therapists found to be performing these functions may be deemed to be practising unlawfully (Cohen, 1997).
Despite this, one-third of US medical schools now offer some training in the holistic approach and a general familiarisation with CAM (Foundation for Integrated Medicine, 1997).
Training in the UK
In the UK, non-medically qualified practitioners of CAM are free to practice under common law, irrespective of their levels of training or clinical competence. They are subject to the relevant provisions of statutes only (Foundation for Integrated Medicine, 1997).
It can be difficult for prospective students to work out which is the most appropriate CAM course for them. There are no nationally agreed minimum educational standards in the field. Nor is there consensus on course content and whether it is enough to ensure competent and efficacious practice.
In 1997 the Centre for Complementary Health Studies at the University of Exeter was commissioned by the Department of Health to survey UK professional associations in CAM in a bid to identify a way forward for responsible practice. The report of the survey (Mills and Peacock, 1997) highlighted the need for educational standards and coordination among member organisations. It also recommended:
- The development of codes of conduct and disciplinary procedures;
- Greater clarity over the limitations of the different CAM therapies;
- That professional organisations became involved in establishing efficacy and safety.
The survey found little evidence that educational material for non-degree courses was subject to external moderation. The report also questioned whether courses provided sufficient training to enable students to master the therapies.
At present, clients cannot judge a therapist's practical competence or knowledge-base simply by looking at his or her qualifications. However, this is set to change, particularly in the fields of osteopathy, chiropractic and acupuncture.
Despite much talk about integrating complementary and orthodox medicine in the UK, moves towards standardising education, training and practice take time. As Stone (1999) comments: 'The pace of integration at any meaningful level is slow and still depends to a large extent on the enthusiasm of committed individuals.'
In 1997 the Foundation for Integrated Medicine produced a key report which contained the results of work carried out by four working parties that had addressed central issues, including the integration of CAM within health care, research and development, education and training, and regulation and delivery mechanisms.
The aim of the education and training working party was to consider how best to:
- Encourage and support the development of a common core curriculum to provide a common foundation for all health care training, both orthodox and complementary;
- Support specialist CAM training and continuing professional training for all health care practitioners;
- Encourage and promote better information on CAM for both patients and health care practitioners.
A national postal survey was sent to all UK universities, medical schools, faculties/colleges of nurse education and science/health studies departments. Of those involved with nursing, 37 (71%) offered courses in CAMs but produced few practitioners from the 68 courses and modules available. The working party found that while many UK nursing students received an introduction to CAM during their training, this was the case for only a small number of medical students. Few courses were run in conjunction with an external CAM organisation or were validated by a CAM professional body.
The report recommended a national review of CAM education and research to establish standards for a core curriculum and guidelines for the validation of courses and assessment of practitioner competence.
When revising its advisory paper on the administration of medicines, the UKCC (1992a) recognised the increasing use of complementary therapies within nursing practice, referring explicitly to the administration of herbal, homoeopathic and complementary and alternative medicine (Rankin-Box, 1995).
But the UKCC is keen to point out that although it regulates nursing, midwifery and health visiting, it does not have responsibility for the standards of other bodies that offer education and training in complementary therapies (Knape, 1998).
It should be noted that the requirements set out in the code of conduct (UKCC, 1992b), and enlarged upon in Guidelines for Professional Practice (UKCC, 1996) apply to registrants when they are practising complementary therapies.
When advertising their complementary therapy status, the UKCC believes that a practitioner's nursing qualification is not needed to support a complementary or alternative therapy course if the course is valid and credible. However, if the nursing qualification gives credibility to the CAM qualification, then the practitioner must ensure that the public is not misled (Knape, 1998).
The education and practice of CAM also raises ethical issues. The UKCC's - and from April the Nursing and Midwifery Council's - remit is to ensure that high standards of professional practice are preserved, so nurses wishing to undertake CAM courses should carefully evaluate their content. Competence to practice is a difficult issue and, as Stone notes (1999; 2001), it is a reflection of the wider problem of defining the competence of complementary therapists. Having a qualification in medicine or nursing does not compensate for not having adequate CAM training and it is important that nurses choose courses that will enable them to practice competently.
There is a profound lack of large-scale research to support health claims attributed to many therapies. However, nurses are answerable to the UKCC and it is up to individual practitioners to justify their practice - particularly if a client claims legal damages after suffering an adverse reaction from, for example, a therapy, oil or herb. Competent practice should ensure that patients are not harmed (Stone, 2001).
CAM in practice
Nurses using CAM as part of their daily practice should also ensure that this formally comprises part of their contracted work, and that codes of conduct or policy protocols are in place before they practice and that they have management approval.
Using CAM without the full approval of line management could result in disciplinary action and misconduct proceedings by the UKCC (Stone, 1999). The UKCC's position (1996) is clear: 'If a complaint is made against you, we can call you to account for any activities carried out outside conventional practice.' Therefore, ensuring client safety and defining competence to practice is the practitioner's responsibility. Ideally, integration and practice management should automatically form part of all CAM training.
The lack of a sound research base to substantiate practice in some therapies raises questions about informed consent. How much information should be given to a client? Does the amount of information available depend on the course completed by the practitioner, the amount of research undertaken or how up to date the practitioner has kept with developments in the field? Finally, there may be dilemmas when patients insist on CAM only and will not consider combining it with more orthodox medicine. In such cases, it is important for nurses to explore all options with the patient. They also need a clear understanding of the patient's condition and must know about other CAM therapies to ensure that patients are referred to the most appropriate therapist.
Mackereth (1997) argues for clinical supervision in CAM and suggests that the supervisor's role is not to solve practitioners' clinical problems or intervene with patient care, but to help them to manage their practices better. This can help practitioners to focus on their strengths and difficulties and should be a feature of basic education and continuing professional development (Hawkins and Shohet, 1989).
Many therapies claim to work simultaneously on physical, emotional and spiritual planes to promote healing or well-being. However, concepts of spirituality are often highly individual. The terms describing, and emphasis placed upon, the concept of 'spirit' also vary according to the cultural origins of a therapy and may include terms such as ki, prana, chakra and aura. This poses a challenge for educators, researchers and practitioners.
It also seems logical to assume that if there is the potential to cause physical and emotional catharsis, it is also possible to damage a client spiritually. Just how far this concept should be pursued as part of the educational curriculum in CAM is questionable.
The House of Lords select committee (2000) identified five main therapies as organised disciplines with their own diagnostic approaches: osteopathy, chiropractic, herbal medicine, acupuncture and homoeopathy. Other therapies, such as yoga, nutritional medicine, shiatsu, bodywork, aromatherapy and reflexology, are also beginning to enter universities (Isbell, 2001). In the select committee's report, this second set of therapies is judged to lack a scientific basis and regulation, but is regarded as giving help and comfort. However, it has been suggested that a lack of evidence does not constitute an absence of evidence. Simply because there is a lack of compelling evidence for a treatment does not mean that it is not effective.
With a disparate range of CAM courses on offer, it is wise to check course content carefully to ensure that future knowledge and practice will uphold the principles established by the UKCC and the duty of care to clients.
There are also moves to develop substantive courses that share a core curriculum. While some professions, including nursing and physiotherapy, have developed CAM courses specifically suited to their discipline, others claim that this may not serve the long-term interests of integrated medicine. Instead, it may unwittingly reinforce professional barriers as various disciplines may be unsure of each other's knowledge base in CAM. It might be valuable to develop multidisciplinary, modular courses that offer a common core curriculum but allow students to pursue individual pathways once they have achieved a certain level of knowledge.
In the university sector there is a move to develop this. For example, the universities of Oxford, Exeter, Westminster, Manchester and Central Lancashire offer a range of CAM courses at diploma and degree level. The University of Westminster has established the UK's first polyclinic to promote and supervise clinical practice during CAM training. In September last year, more than 10 universities enrolled students on full-time degree courses in complementary therapies.
There is no doubt that the number of CAM courses has mushroomed over the past few years. There is a clear need to ensure that these offer prospective practitioners a competent and substantive knowledge base. The move towards a common core curriculum will enhance the status and credibility of CAM education in the UK.
As the Foundation for Integrated Medicine (1997) report comments: 'There is also a common body of knowledge and skills which all health care practitioners need. There appears to be no reason why these could not be incorporated into a common component in the undergraduate curriculum of all health care education and training institutions.'
Nurses are well placed to develop educational programmes and respond to client's needs. As the largest workforce in the NHS, nurses, midwives and health visitors form a powerful barometer from which to record and influence the winds of change in CAM.