According to the National Center for Health Statistics, 33.2% of American adults reported using some form of alternative or complementary medicine in 2012.1 (For the meaning of terms used in this article, see Holistic Nursing Glossary.2, 3) In 2007, consumer out-of-pocket expenditures for complementary and alternative medicine (CAM) providers, products, and services totaled nearly $34 billion.4 Previous studies have shown that the majority of CAM consumers seek relief from chronic issues, such as back and neck pain, joint pain or stiffness, and anxiety or depression, which are difficult to treat with conventional medicine alone.5 The 10 modalities used most often by U.S. adults in 2012 were dietary supplements other than vitamins and minerals; deep breathing exercises; yoga, tai chi, or qigong; chiropractic or osteopathic care; meditation; massage; diet-based therapies; homeopathy; progressive relaxation; and guided imagery.2
With the growing popularity of CAM, an increasing number of hospitals have begun offering complementary services and therapies to augment conventional care. In 2010, the Samueli Institute, a nonprofit research organization founded in 2001 to investigate "the safety, effectiveness and integration of healing-oriented practices and environments," partnered with the American Hospital Association's Health Forum to survey administrators at 5,858 American hospitals about their provision of CAM services.6 Of the responding 714 hospitals (representing a 12% response rate), 299 (42%) reported offering one or more CAM modalities to patients or staff.6
Although the integration of complementary approaches into conventional patient care may seem new, it has its roots in the holistic nursing practices of Florence Nightingale. Nightingale wrote of the interconnectedness of mind, body, and spirit and emphasized the importance of the environment in which healing occurs, inspiring the Samueli Institute's concept of "optimal healing environments."3, 7, 8 Over the past several decades, a number of nurses have sought to apply Nightingale's insights, arguing for greater emphasis on a variety of holistic approaches and practices. During the 1980s, for example, Barbara Dossey promoted such holistic nursing practices as relaxation, the use of imagery, and distraction techniques to help patients cope with illness and gain a sense of control over their health.9 Mary Jo Kreitzer and Mary Koithan continue to advocate holistic concepts and practices, underscoring the value of self-care in nursing and outlining the principles of a person-centered, relationship-based, and evidence-based form of patient care they describe as "integrative nursing."10
In this article, the first in a five-part series on holistic nursing, we discuss many of the integrative care initiatives being introduced in hospitals throughout the country-the services provided, the providers, the recipients, and the costs. We then explore the perspectives of nursing leaders at hospitals that have implemented such programs. These nursing leaders, who represent both teaching and community hospitals in various settings and U.S. geographic regions, discuss the philosophies of care that inspired their organizations' integrative care programs, how their hospitals' programs evolved, the roadblocks they encountered, and program outcomes. They share their experiences and offer advice to nurses interested in collaborating with their institutional leaders to establish integrative programs at their own institution.
INTEGRATIVE INITIATIVES IN U.S. HOSPITALS
In 2006, the Samueli Institute surveyed executives at 125 Midwestern hospitals about the use of initiatives that support "optimal healing environments" through the practice of 33 "collaborative healthcare services"-ranging from conventional approaches (nutritional education, for example) to those falling under the umbrella term CAM (Reiki, for example)-these hospitals offered to four distinct populations: patients, patients' family members, staff, and members of the local community.11 The 55 completed surveys (representing a 44% response rate) indicated that the hospitals offered an average of eight different services to community members, 6.8 to patients, 6.3 to staff, and 3.8 to patients' families, though the services most commonly offered to each population differed considerably (see Table 111). Although hospitals tended to offer more services that would be described as "conventional" or "mainstream Western medicine" to all of these populations, the services that would be described as CAM were more commonly offered to community members than to any of the other populations.11
CAM SERVICES OFFERED TO PATIENTS
The Samueli Institute also looked specifically at 14 services offered to patients, most of which would be considered forms of CAM, to determine how the service was accessed, who provided it (physician, nurse, other hospital staff, or independent contractor), whether the patient was charged a fee, and whether providers underwent a credentialing process. These services were acupuncture, aromatherapy, art therapy, biofeedback, chiropractic, guided imagery, hypnosis, massage therapy, meditation, music therapy, pet therapy, reflexology, Reiki, and therapeutic touch.11
Access and providers. Patient request was the most common means by which patients accessed the services, though some (chiropractic, acupuncture, hypnosis, and biofeedback) were accessed most often via a physician order.11 (The investigators speculate that this may be because of the charges associated with these services and the likelihood that insurance coverage is more often provided if such services are ordered by a physician.) Hospital staff other than nurses or physicians usually provided the services, but nurses were the second most frequent provider. In more than half of the responding hospitals, nurses provided meditation classes or training, guided imagery, therapeutic touch (sometimes called "healing touch"), Reiki, reflexology, and aromatherapy. In most cases (80% to 100%), services were provided to patients at no cost, but chiropractic care was always associated with a fee, and usually acupuncture, hypnosis, and biofeedback were as well. In the responding hospitals, naturopaths, energy practitioners, and Ayurvedic practitioners underwent no credentialing process. In the case of all other therapies, at least one of the surveyed hospitals required practitioners to undergo a credentialing process. Credentialing was most often required for acupuncturists (50%), chiropractors (47.8%), and massage therapists (31.4%).
Profile of hospitals instituting CAM. The 2010 Samueli Institute-Health Forum study offered insight into the types of hospitals offering CAM services and the institutional rationale for doing so. Most of the 714 responding hospitals that offered CAM were of medium (50 to 299 beds) or large (more than 500 beds) size and located in urban settings.6 In addition, nonteaching hospitals were more likely than teaching hospitals to offer CAM. The top reasons given for offering CAM modalities were:
* patient demand (85%)
* clinical efficacy (70%)
* organizational mission (58%)
* desire to attract new patients (37%)
* physician request (36%)
* desire to differentiate institution from competitors (33%)
Patient demand may be a particularly significant motive, since Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores are now tied to Centers for Medicare and Medicaid Services reimbursement.12
Most hospitals were conservative in introducing CAM services, initially offering noninvasive modalities that were likely to appeal to the broadest array of patients in the community. The CAM modalities offered most commonly in both inpatient and outpatient settings were acupuncture, guided imagery, relaxation training, and therapeutic touch.6
Costs and coverage. Responding to the needs of their communities, many of these hospitals offered services for which consumers were willing to pay out of pocket when insurance coverage was limited. Most programs reported start-up costs of under $200,000. Almost half of responding hospitals (44%) reported not charging patients for CAM modalities. Rather, the costs of services were included as part of the patient's overall care or covered by philanthropy.
NURSING LEADERS' REFLECTIONS ON INTEGRATIVE PROGRAMS
To showcase some of the ways nurses have collaborated with their health care institutions to implement integrative modalities, in early 2014 we identified U.S. hospitals with known integrative care programs and invited nursing leaders at each to participate in an e-mailed survey. We identified hospitals through use of both word of mouth and the directors' listserv of the American Nurses Credentialing Center's Magnet program, and intentionally sought participation from those in disparate geographic regions whose integrative programs were at different phases of maturation. Seven nurse leaders, representing both teaching and community hospitals in urban settings, responded. Below they reflect on the inspiration behind and the evolution of their organizations' programs, the hurdles they faced, and the lessons learned.
Philosophies of care. The integrative care programs adopted by this cross section of hospitals were originally inspired by nursing philosophies founded in theories of caring and compassionate holism, such as Jean Watson's and Kristen Swanson's theories of caring. As Mary Mazzer, RN, HNB-BC, HWNC-BC, integrative healing practitioner at Valley Hospital in Ridgewood, New Jersey, said, "Our nursing community commits to providing compassionate holistic care to patients and their families in a competent, ethical, caring manner." Within these holistic caring philosophies, collaboration and innovation were key to promoting health and healing.
At the Scripps Center for Integrative Medicine, Scripps Health, San Diego, the philosophy of healing the whole person-body, mind, and spirit-is applied to both patients and staff. Claire D'Andrea, RN, CHTP, CCRC, the supervisor of patient care, said, "When staff go through a personal crisis, we [the health care team] rally around to support them in all ways-healing touch, essential oils, acupuncture, biofeedback, meditation."
Both the nurses we surveyed and their health care institutions had a wide range of experience with holistic, integrative care. Two of the facilities, University of Florida Health in Gainesville and Scripps Health, began integrating aspects of such care in 1990, while others were in earlier stages of development. As Teresa Tungseth, MAN, RN, deputy nurse executive of the Minneapolis Veterans Affairs (VA) Health Care System explained, at the Minneapolis VA, there had been "pockets of integrative modalities going on since about 2000. It began in the oncology department with a nurse practitioner seeking to offer alternatives to medication as the sole treatment plan for symptom management."
The major impetus for adopting integrative care was similar among the facilities. As Mazzer described it, "The desire was to offer a more 'complete' experience than a model focusing on a bone, an organ, a disease process, or an injury-to create and nurture the entirety of a human being." In two of the facilities we surveyed, University of Florida Health and Valley Hospital, the staff interest in holistic nursing-initially sparked by such educational opportunities as formal presentations and complimentary "mobile relaxation stations" for staff-led to the development of integrative care programs and the creation of such positions as "integrative medicine nurse coordinator" and "integrative healing practitioner."
Approaches used to introduce holistic and integrative nursing at these facilities varied. D'Andrea of Scripps Health recalled that "a patient and his wife came forward to the foundation wanting to donate money to help with research on alternative-complementary modalities. Through their desire and the vision of a cardiologist, Dr. Mimi Guarneri, and [an RN] Rauni Prittinen King[horizontal ellipsis] the Center for Integrative Medicine was born." Typically, however, the introduction of integrative care involved employee education, incorporated research and experiential components, and initially targeted interested staff. At Baptist Health in Lexington, Kentucky, Cathrine Weaver, MSN, RN, HN-BC, integrative C.A.R.E. services coordinator, explained that they began by surveying nursing staff to determine their knowledge of, personal experience with, and interest in complementary practices. "That survey showed the need for education[horizontal ellipsis], which led to the creation of [a] biannual lecture series open to all staff." The lectures, she says, made staff "more aware of the variety of integrative practices."
In some facilities, nurses, physicians, and other hospital staff were so accepting that integrative education was eventually mandated for all staff. Leaders presented evidence demonstrating the effectiveness, practicality, and feasibility of using integrative modalities, both in practice and in self-care. To develop protocols for approved modalities, some hospitals created integrative therapy councils, which included nurses and clinicians from multiple disciplines and employees from nonclinical departments. Although generally the evidence base for CAM is not as well established as it is for conventional health care modalities, ongoing research continues to generate findings that can guide practice. Hospitals need to determine the level and type of evidence they require to demonstrate safe and effective use of any particular therapy.
For the surveyed hospitals, marketing was an essential component of implementation. Many created brochures to inform patients, families, staff, and community members of available CAM modalities. Some practitioners recommended using several forms of communication (e-mail, newsletters, bulletins, staff meetings, and executive meetings) to spread the word about newly implemented initiatives.13
Roadblocks encountered. While survey respondents described minimal roadblocks, one cited the lack of informed champions-experienced clinicians who could answer questions and help nurses explain to patients the use of integrative practices-as a roadblock on some hospital units. Another felt that mandating any integrative practice is generally ineffective. For example, when her institution mandated that the nursing staff start shifts by "setting intention" (a practice in which people make a "conscious determination" to improve the health, well-being, and hope of others or themselves, understanding the personal meaning attached to suffering and believing that healing will occur3), nurses resisted. Upon meeting this resistance, the integrative care team decided to take a step back and focus on providing educational opportunities that would lay the groundwork for staff to learn the value of this and other integrative practices. In addition to providing education, the care team began including intention setting in integrative therapy council meetings and other staff meetings to increase familiarity with the practice. The process allowed for professional growth and development of both individuals and the team as a whole. Similar successes in overcoming initial resistance through education were recounted by nurse leaders from other organizations, which may account for the fact that few respondents mentioned having experienced roadblocks.
Respondents also reported that some physicians resisted the distribution of educational information or the launch of programs about integrative approaches. Some expressed skepticism or challenged the safety and effectiveness of integrative practices. Over time, however, many became more accepting of a variety of approaches and began referring their patients for integrative care. Some even became champions of the cause. At Valley Hospital, patients were recognized as the best potential advocates for integrative programs. As patients shared experiences of supported healing with their physicians, the integrative care programs grew.
Educational funding. Administrative support for educating staff on integrative practices was common. Requests to fund educational events were required and usually granted, or nurses were allowed to use allocated educational monies to attend off-site integrative educational programs. On the other hand, the funding of integrative care positions, such as integrative medicine nurse coordinator or licensed massage therapist, was not nearly as available in the early stages of the programs. When such funding was provided, it could often support only part-time positions. Hospitals depended on unit budgets to absorb the cost of some services, while others relied on grants or philanthropic support. One organization reported that it explored charging for CAM modalities. But at United Hospital, part of Allina Health in St. Paul, Minnesota, when nurses started using aromatherapy sticks at a cost of $2 per stick, the hospital absorbed the cost.
Evolution of care programs. Nurse leaders reported that once integrative care was initiated, its use spread across units, and hospitals began adding new modalities to the repertoire of integrative care options. Many respondents reported that new integrative modalities were required to undergo council review prior to implementation to ensure safe, evidence-based practice. Standards were created around the education and competency of staff members, and certification in specific modalities was often encouraged. As hospitals included more integrative modalities, some expanded to include full-time clinical positions for practitioners providing integrative care. Program expansion created a need for more educational programs. Over time, staff participation in these programs increased. As Lauren Arce, MSN, RN, AHN-BC, OCN, integrative medicine nurse coordinator at the University of Florida Health Shands Arts in Medicine program, said, "We respond to evolving needs, interests, and concerns of patients, families, staff, and the organization." At Scripps Health, D'Andrea reported that "integrative medicine began [with the slogan] Healing People and Changing Lives Through Science and Compassion. The health system soon developed this philosophy and now embraces healing touch, mindfulness-based stress reduction, fitness, cooking classes, stress management, yoga, and nutrition [as part of a staff] wellness program," as well as a program for patients. A number of hospitals offered integrative practices to both patients and staff members (see Table 2).
Outcomes differed among the seven programs we surveyed. The evolving support from patients and staff at Valley Hospital, Baptist Health, University of Florida Health, the Minneapolis VA, and Scripps Health led to significant infrastructure growth. Centers for holistic care or integrative programs with full-time practitioners were initiated and have been sustained over time.
Arce; Katie Westman, MS, RN, CNS, clinical nurse specialist at United Hospital; and Misti Shilhanek, BSN, RN, RN discharge caller at Salem Health in Salem, Oregon, reported that their facilities embedded integrative modalities into flow sheets in the electronic medical record. The standard language used in documentation allowed staff to collect and track data on symptoms and thus to evaluate the outcomes of the modalities provided. At United Hospital, Westman explained, "Several modalities (massage, guided imagery, [and] aromatherapy) are now embedded into RN flow sheets. This is a major accomplishment [that came about] only after general acceptance and popularity of their use." Shilhanek explained that at Salem Health the electronic medical record was modified so that outcomes could be demonstrated through "the implementation of a clear tracking mechanism [that allows clinicians] to see results [of a specific modality over] a short period of time [and potentially] validate the need for [its] continuation."
Patient feedback was another means by which care teams assessed the value of their integrative modalities. The 2010 Samueli Institute-Health Forum study found that patient experience is the metric of choice when hospitals evaluate CAM services.6
Nurse education was another key outcome that respondents considered. Integrative therapy councils, which created educational standards and coordinated informational programs, supported and sustained the nursing philosophy of compassionate holistic care. Many hospitals had completed pilot investigations or original research, which were disseminated internally, on the merits of various integrative modalities, including mindfulness-based stress reduction for health care professionals, music therapy, dance, theater, mind-body integration, self-care for general well-being, essential oils, acupressure, art therapy, and animal-assisted therapy.
Appropriate licensure and credentialing, when feasible, are important to ensure the knowledge, skill, and competency of practitioners and, for billing purposes, when services are provided for a fee. Credentialing processes should include verification of licensure or membership in a regulated health profession if the practice is so regulated, satisfactory completion of continuing education requirements, an acceptable history related to disciplinary action and malpractice liability, liability insurance coverage for employee practitioners, and proof of adequate insurance coverage for nonemployee practitioners.14 Ongoing assessment of practitioner competence is also paramount.
Lessons learned. When asked what advice they would offer to other hospitals interested in providing integrative care modalities, respondents emphasized the need to create a long-term vision and build on small successes. They suggested starting slowly and on a small scale, gradually incorporating integrative modalities with known evidence-based outcomes. Tungseth feels it's important "to have patience and plan for the long run[horizontal ellipsis] integrat[ing] 'pieces' at a time." Shilhanek advises advocates to "start with small measures [that have] known outcomes supported by the literature. This approach creates quicker wins, decreases safety concerns, and allows practitioners to increase their comfort with new modalities." Others suggest surveying staff on their knowledge and experience with integrative modalities. Arce suggests asking members of the health care team "exploratory questions" about what the "whole person perspective" means to them.
It's also important to elicit support from senior leaders, nurses, physicians, other practitioners, and staff members who value and have an interest in or passion for aspects of holistic care and optimal healing environments.13 One way to accomplish this, advises Arce, is to "make your program committee open to nursing and individuals from other disciplines. Some of your most creative ideas come from nonclinical staff." Westman adds that "staff engagement is tremendously aided by letting them experience every modality you plan to adopt for[horizontal ellipsis] patients, families, and staff." At United Hospital, she explains, they have an annual tradition: "Every year during Nurses Week, the Holistic Committee sponsors a fair where they show off everything available and let staff try things. It is a favorite! Once the staff experiences the modalities for themselves, you have instant converts." Westman's experience echoes the findings of a 2003 study by Lindquist and colleagues in which critical care nurses who reported personal use of CAM modalities were significantly more likely to use them in their practice.15
INTRODUCING INTEGRATIVE CARE
Conducting an environmental assessment is the first step in establishing an integrative care program. Such assessments can reveal gaps between an organization's current and desired states, serving as a roadmap on the journey toward creating optimal healing environments.16
Likewise, as with any organizational change, institutional buy-in is critical.17 As respondents to our survey suggested, this is best accomplished when everyone feels involved-administrators, staff, physicians, nurses, other practitioners, patients, and community members. Surveys or focus groups can be used to assess the needs, desires, and values of stakeholders.13, 16 Opening a dialogue about holistic care will increase awareness and intention, the first domain of an optimal healing environment.16 In addition, dialogue provides a means of assessing CAM support among medical staff, the lack of which has been identified as a major barrier to implementing integrative care.6
As depicted in the snapshots from our survey, organizations may avail themselves of what Sita Ananth and Wayne Jonas call "multiple pathways to transformation."16 A hospital can start anywhere along the continuum of optimal healing environments, as a change in any one domain will inevitably influence the others.16 Principles of holistic and integrative nursing are the foundation for creating optimal healing environments in which self-care, healing presence, patient-centered care, and relationship-based care are the standard; where staff and providers are partners in health and well-being; and where patients are empowered to direct their care.
REFERENCES