ALTERNATIVE MODALITIES OF CARE INTRODUCTION: We refer to medical practices that evolved with indigenous peoples and that they

have introduced to other countries through emigration as traditional medicine. We refer to approaches that emerged primarily in Western, industrial countries during the past two centuries as scientific or Western medicine, although we acknowledge that not all Western medicine is based on scientifically proven knowledge. The terms complementary and alternative describe practices and products that people choose as adjuncts to or as alternatives to Western medical approaches. Endless varieties of practices are scientifically unproven and poorly accepted by medical authorities. For the sake of organizing an agenda for research into these approaches, the U.S. National Institutes of Health has grouped them into five somewhat overlapping domains as follows: Biologically based practices. These include use of a vast array of vitamins and mineral supplements, natural products such as chondroitin sulfate,which is derived from bovine or shark cartilage; herbals, such as ginkgo biloba and echinacea; and unconventional diets, such as the low-carbohydrate approach to weight loss espoused by the late Robert Atkins. Manipulative and body-based approaches. These kinds of approaches, which include massage, have been used throughout history. In the 19th century, additional formal manipulative disciplines emerged in the United States: chiropractic medicine and osteopathic medicine. Both originated in an attempt to relieve structural forces on vertebrae and spinal nerve roots that practitioners perceived as evoking a panoply of illnesses beyond neuromusculoskeletal pain. Mind-body medicine. Many ancient cultures assumed that the mind exerts powerful influences on bodily functions and vice versa. Attempts to reassert proper harmony between these bodily systems led to the development of mind-body medicine, an array of approaches that incorporate spiritual, meditative, and relaxation techniques. Alternative medical systems. Whereas the ancient Greeks postulated that health requires a balance of vital humors, Asian cultures considered that health depends on the balance and flow of vital energies through the body. This latter theory underlies the practice of acupuncture, for example which asserts that vital energy flow can be restored b placing needles at critical body points. Energy medicine. This approach uses therapies that involve the use of energy²either bio field- or bio electromagnetic based interventions. An example of the former is Reiki therapy, which aims to realign and strengthen healthful energies through the intervention of energies radiating from the hands of a master healer. Alternative systems of medicine use elements from each of these CAM and TM domains. For example, traditional Chinese medicine incorporates acupuncture, herbal medicines, special diets, and meditative exercises such as tai chi.Ayurveda in India similarly uses the meditative exercises of yoga, purifying diets, and natural products. In the West, homeopathic medicine and naturopathic medicine each arose in the late 19th century as reactions to the largely ineffectual and toxic conventional approaches of the day: purging, bleeding, and treatments with heavy metals such as mercury and arsenicals. ALTERNATIVE THERAPIES: . Ayurveda Ayurveda, the traditional medical system of India, originated > 4000 yr ago. It is based on the theory that disease results from an imbalance of the body's life force (prana). The balance of prana is determined by equilibrium of the 3 bodily qualities (doshas): vata, pitta, and kapha. Most people have a dominant dosha; the specific balance is unique to each person.

Evidence: Few well-designed studies of Ayurvedic practices have been done. Use of Ayurvedic herbal combinations to relieve symptoms in patients with RA and to treat diabetes is being studied. Uses: After determining the balance of doshas, practitioners design a treatment specifically tailored to each patient. Ayurveda uses diet, herbs, massage, meditation, yoga, and therapeutic detoxification (panchakarma)²typically with enemas, oil massages, or nasal lavage²to restore balance within the body and with nature. Possible adverse effects: In some of the herbal combinations used, heavy metals (mainly lead, mercury, and arsenic) are included because they are thought to have therapeutic effects. Cases of heavy metal toxicity have been reported. Homeopathy Developed in Germany in the late 1700s, homeopathy is based on the principle that like cures like. A substance that, when given in large doses, causes a certain set of symptoms is believed to cure the same symptoms when it is given in minute doses. The minute dose is thought to stimulate the body's healing mechanisms. Treatments are based on the patient's unique characteristics, including personality and lifestyle, as well as symptoms and general health. Remedies used in homeopathy are derived from naturally occurring substances, such as plant extracts and minerals. Extremely low concentrations are prepared in a specific way. The more dilute the homeopathic remedy, the stronger it is considered to be. Some solutions are so dilute that they contain no molecules of the active ingredient. There is no compelling, scientific explanation for how these dilutions could work. Evidence: Efficacy of homeopathic remedies for various disorders has been studied. No study has clearly shown efficacy for any specific homeopathic remedy, although some studies have shown positive results (eg, one well-conducted, randomized, placebo-controlled clinical study showed a therapeutic benefit greater than placebo in the treatment of diarrhea in children). Homeopathy is commonly incorporated into health care practices in Europe and India. Uses: Homeopathy has been used to treat various disorders, such as allergies, rhinitis, digestive problems, musculoskeletal pain, and vertigo. The effect of homeopathic solutions on joint pain and tenderness and quality of life in fibromyalgia is being studied. Possible adverse effects: Homeopathy is well-tolerated and has few risks; rarely, an allergic or toxic reaction occurs. Unlike herbal and nutritional supplements, homeopathic remedies are regulated by the FDA as drugs; they are available over the counter or by prescription. Because so little active ingredient is left after dilution, active ingredients are tested before dilution. Homeopathic remedies have been temporarily exempted from limits on the amount of alcohol (the usual diluent) that they can contain. However, the label is required to list the following:

Manufacturer The label ³homeopathic´ At least one indication Instructions for safe use Unless specifically exempted, the active ingredient and degree of dilution Conventional clinicians should not assume that a homeopathic remedy taken by a patient is biologically inactive. Patients often use the term homeopathic erroneously in reference to a dietary supplement they are taking. Also, the FDA allows many medicinal herbs to be registered and labeled as homeopathic if they undergo a particular pharmaceutical process. Naturopathy This therapy began as a formal health care system in the US during the early 1900s. Founded on the healing power of nature, naturopathy emphasizes prevention and treatment of disease through a healthy lifestyle, treatment of the whole patient, and use of the body's natural healing abilities. This system also focuses on finding the cause of a disease rather than merely treating symptoms. Some of this system's principles are not that different from those of traditional healing systems such as Ayurveda and traditional Chinese medicine. Naturopathy uses a combination of therapies, including acupuncture, counseling, exercise therapy, medicinal herbs, homeopathy, hydrotherapy, natural childbirth, nutrition, physical therapies (eg, heat or cold therapy, ultrasound, massage), guided imagery, and stress management. Traditional Chinese Medicine Originating > 2000 yr ago, traditional Chinese medicine is based on the theory that disease results from improper flow of the life force (qi). The movement of qi is restored by balancing the opposing forces of yin and yang, which manifest in the body as heat and cold, external and internal, and deficiency and excess. Various practices (eg, acupuncture, diet, massage, medicinal herbs, meditative exercise called qi gong) are used to preserve and restore qi and thus health. Evidence: Chinese medicine traditionally uses formulas containing mixtures of herbs to treat various disorders. Traditional formulas can be studied; for example, efficacy in the treatment of irritable bowel syndrome has been shown. One herb, used by itself, may not be as effective and may have side effects. Nevertheless, current conventional research favors study of single herbs. For example, Tripterygium wilfordii (thunder god vine) has demonstrated antiinflammatory properties and clinical efficacy in treating RA, and astragalus may benefit patients with lung cancer. Various Chinese herbs have been studied as treatments for hepatitis and hepatic fibrosis. Some studies suggest efficacy, but data are limited. Possible adverse effects: One problem is the standardization and quality control of Chinese herbs. Many are unregulated in Asia; they may be contaminated with heavy metals from polluted ground water or may be adulterated with drugs such as antibiotics or corticosteroids. However, high-quality products are available through certain manufacturers that comply with FDA Good Manufacturing Practices. Advantages of alternative therapies:

1. There are no side effects. This is because alternative medicine works WITH the body, not in suppressing symptoms, as modern medicine does. 2. Medicines are cost effective. This means they are generally affordable by even the most financially compromised families. 3. Alternative medicines are generally 'green'. By that I mean that they use natural substances processed simply. No high tech manufacturing processes which use hazardous and polluting chemicals or carbon polluting energy. 4. Substances or ingredients of 'complexes' are readily available, so you can even grow some of your own medicines, allowing you to keep control of the whole process. No secrecy or patents here! 5. Alternative medicines don't just heal ailments. In the process, they allow for growth. In homoeopathy we see children putting on a growth spurt after they recover from a naturally treated disease. This doesn't happen with a medically treated disease. Rather, it appears to hold the child back. 6. Alternative medicine recognizes the true nature of disease and sickness. That it is necessary for a growing child to experience as only this experience allows the immune system to develop into a healthy one by adulthood. It's a bit like learning to ride a bicycle. You need to practice before you can ride properly. 7. Alternative medicine recognizes that physical symptoms only develop when you ignore the mental and emotional signs and symptoms. Which allows you the freedom to deal with these problems as they arise, and so never develop physical symptoms.
Complementary Medicine

Complementary medicine is the term used here to describe additional forms of treatment that may be given along with chemotherapy and traditional Western medicine. In the past, complementary medicine has claimed various types of "miracle" cures for cancer, which have since proved ineffective or even fraudulent. The integration of conventional and complementary medicine therapies however, is of increasing interest. This approach is being adopted at leading cancer treatment centers (such as Cleveland Clinic) and hospices and by self-help groups. Gentle therapies such as massage, relaxation, and other "healing" therapies play a major role in palliative care (symptom relief). Some patients find that complementary medicine, also called integrative medicine and/or holistic healing can help alleviate the side effects, pain and anxiety associated with chemotherapy and cancer treatments in general. Sometimes complementary medicine is mistakenly referred to as "alternative therapy" or "alternative medicine," and it is important to distinguish between the two. Complementary medicine is recognized and approved by many health care professionals, whereas alternative therapy is not. Complementary medicine is given along with chemotherapy whereas alternative medicine is given in place of chemotherapy and includes non-approved, nontested treatments that can be harmful. No matter what type of complementary medicine you may choose to explore, the Cleveland Clinic recommends you consult your physician before beginning any form of additional therapy. Types of Complementary Medicine Therapies:

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


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

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

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



Landscape Therapy is the showing of peaceful, relaxing landscapes to patients, scenes that evoke calm and tranquility. They may be shown in a darkened room via a slide show or video screen, or they may be shown in the form of art books or actual artwork. Landscape therapy is often used as a distraction technique to help manage pain and anxiety. Music Therapy is an expressive art form designed to help individual move into harmony and balance. Music therapy can incorporate both listening to and/or playing music. Music therapists are professionals who are educated to design music programs for patients. Through the use of music, individuals explore emotional, spiritual and behavioral issues. Music therapy can help patients release emotions and relax. Listening to music can be either calming or invigorating. Massage is a form of complementary medicine that relies on the body's nerve endings and pressure points to promote relaxation. There are many forms of massage: Shiatsu, Hellerwork, and Reflexology for example. However, the most widespread variation builds upon the five basic strokes of Swedish massage: effleurage (slow, rhythmic gliding strokes in the direction of blood flow towards the heart) petrissage (kneading, pressing and rolling muscle groups) friction (steady pressure or tight circular movements, often used around joints) percussion, (drumming hands on body) and vibration (rapid movement shaking the muscle back and forth).

There are many benefits to massage therapy for patients undergoing treatment for cancer. There are also concerns and possible risks. Massage therapy has been used to treat stress and anxiety, improve mood, induce relaxation, and control pain. For patients undergoing surgery the application of appropriate massage can promote healing at incision sites and may prevent or reduce scarring. Use of foot massage was shown to have a positive effect on patients' perceptions of pain, nausea and relaxation. There are situations in which massage can be risky or the techniques need to be adjusted. For example; massage should not be given if signs of infection are present at the surgical site. Immediately after surgery when a person is at risk of developing blood clots, massage of the legs is not advised. Patients undergoing radiation should not have massage techniques applied in the area of the radiation field because the massage may further irritate the irradiated skin. During chemotherapy, often patients are at increased risk of infection, anemia or bruising. Special precautions need to be taken with massage at this time. The use of massage therapy as an adjunct to cancer treatment should be discussed with the patient's

treating physician (oncologist, radiation oncologist or surgeon). This is so that any risks can be discussed and details about the patient's condition can be provided so that a licensed massage therapist (LMT) can provide a safe and effective massage to the patient with cancer. When seeking out a massage therapist it is recommended that information regarding the therapist's education and credentials be reviewed. The following are criteria that are recommended in a massage therapist:
y y y y y

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

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

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

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

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

A treatment session lasts about an hour; the practitioner directs reike energy through his hands to the patient. The patient lies clothed on a treatment table and the practitioner holds his hands on or over the body in 12 basic positions for about five minutes each. This is said to balance the body's energy centers or "chakras." Some patients may feel relaxed after treatment; others feel invigorated.

Reflexology: According to practitioners, the feet are a mirror of the body, and applying pressure to areas on the foot that correspond to the affected organs may help



to relieve symptoms such as pain, constipation, and nausea. Reflexology is increasingly available in many hospices, and is often given by nurses. Acupuncture is an ancient Chinese system of health care. This type of complementary medicine aims to prevent and cure specific diseases and conditions by sticking very fine, solid needles into points of the body. Acupuncture is believed to encourage the release of endorphins, natural painkillers that can also increase feelings of well-being. Acupressure, in which the same acupoints are stimulated by hand, may be effective in the same way, but to a lesser degree. Chiropractic Medicine: system of therapy based on establishment of good self image through awareness and correction of body movements. Application of the knowledge of the relationship between structure and function to diagnose and treat dysfunctions that effect the nervous system. Treatment frequent involve the manipulation of the spinal column and may also include the psychotherapy and diet therapy.

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

y y y



Guided Imagery (visualization) is a process where the patient is assisted in imagining positive images and desired outcomes to specific situations. The practitioner works with the patient initially to discover what is they are trying to accomplish with the therapy. Then a mental image is created. For example, patients are asked to focus on feeling stronger or better, or to picture the destruction of tumor cells while in a state of relaxation. In one technique, patients visualize various aspects of treatment, from the least frightening to the most painful, remaining calm and relaxed at each step. This method has helped patients to control nausea before chemotherapy. Hypnotherapy would be similar to guided imagery, however a physician or licensed hypnotherapist would be needed to induce deep relaxation. Prayer Meditation is a method of relaxing and quieting the mind to relieve muscle tension and facilitate inner peace. There are numerous forms of meditation, taught individually or in group settings. Relaxation and Deep Breathing: Patients are taught these types of complementary medicine techniques to help to release muscle tension, relieve breathlessness, lessen anxiety and encourage a greater sense of control, particularly when receiving unpleasant or stressful treatments. Biofeedback: A training technique in which people are taught to improve their health and performance by using signals from their own bodies, is particularly found to be useful for managing pain and side effects.

Expressive Complementary Medicine:

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

Psychotherapy and Counseling Support Groups



Journal Writing: Writing in a journal is an effective way to handle some of the emotions that living with cancer triggers. Often people facing a serious illness find it difficult to express their feelings to others. Journal writing can allow a person to express difficult feelings in a safe and private way. Regular journal writing also helps people to clarify their thoughts and make good choices. Art Therapy: Drawing, painting and sculpting, especially when carried out in a group environment, encourage pleasure in creativity and enable people to find a way of expressing their feelings that cannot be easily put into words.

Physical Complementary Medicine:




Physical Exercise: When possible for the patient, physical exercise has been shown to release endorphins (mood elevating hormones) and promote better general health, relief of tension and positive attitudes. Even something as simple as walking and certain forms of dance have been helpful to patients. Yoga is a form of gentle exercise consisting of body postures and breathing techniques. It has been practiced for thousands of years in India, and has now become popular around the world. In the West it is valued more for its physical than spiritual benefits, such as its ability to increase suppleness and vitality, and to relieve stress and fatigue. T'ai Chi is a noncombative martial art that uses breathing techniques and sequences of slow, graceful movements to improve the flow of qi, or "life energy," calm the mind, and to promote self-healing. It is often described as "meditation in motion." It is practiced more as a form of preventive health care than as a response to an ailment. Qi Gong is an ancient system of movement, breathing techniques, and medita tion, which is designed to develop and improve the circulation of "qi" or "life energy" around the body.

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

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

Herbal medicine

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

y y y y y y

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

ROLES OF NURSE IN COMPLEMENTARY AND ALTERNATIVE THERPIES. There are two ways of thinking about nursing that underpin professional nursing practice and help nurses to understand and articulate a worldview. These are the nursing theories/conceptual models for practice and the current nursing taxonomies. Each of these approaches provide a unique and discipline-specific view of care, distinct from the care of other health professionals. Thus, alternative/complementary modalities performed from within a context of a nursing theory/model take on meaning from within the theory as the modalities become part of purposeful action to achieve goals of care prescribed from within the theoretical point of view. Modalities performed and documented according to one of the standard taxonomies explicitly bring the modalities into the domain of nursing and make the performance of the technique part of nursing activities addressing a defined phenomena of concern. Each of these frameworks and their relationship to alternative/complementary modalities will be addressed below. Nursing Theories/Conceptual Models Nursing theory is the foundation of professional nursing practice (George, 1995). Theory articulates a worldview, suggesting how nurses interpret practice events and think about care. Each theory addresses the concepts of nursing¶s metaparadigm in a different way, exploring the relationships between and among the concepts of person, health, nurse, and environment. Theory-based practice is reflective practice ± nursing is both providing care and thinking about care to ensure it is consistent with stated values and principles. Modalities incorporated into practice from within a framework of nursing theory are given meaning from within the theory. Some of the modalities are compatible with the principles and concepts of specific nursing theories. In other cases, the theories themselves provide a mandate for a specific kind of nursing intervention. Nursing theory provides the language, concepts and worldview to reflect on nursing care and on the use of alternative/complementary modalities. Several examples from selected nursing theories are discussed below. The first example of use of alternative/complementary modalities and nursing theory will be drawn from the Modeling and Role-Modeling Theory of Erickson, Tomlin and Swain (1984). The concepts of "Modeling" and "Role-Modeling" are central to the theory. Modeling is the process by which the nurse develops an image of the client¶s world, giving the nurse ability to understand the world from the client¶s perspective, and Role-Modeling occurs when the nurse plans interventions to role-model health behaviors congruent with the client¶s worldview (Frisch & Bowman, 1995; Erickson et al., 1998) The theory is based on adaptation

and through a specific assessment of adaptive potential, the Adaptive Potential Assessment Model (APAM), the nurse is guided to assess the client¶s strengths, areas of positive adaptation, and state of arousal (Bowman, 1997; Erickson & Swain, 1982). Professional nursing from within this framework requires that the nurse build a model of the client¶s world and from within that model the nurse must role-model health behaviors to assist the client regain/attain health. Nursing care is planned only after discussion and mutually agreed-upon goals of care. The concept of µmodeling¶ guides the nurse to specific modalities. When a nurse models the client¶s world, the nurse attempts to enter into the client¶s worldview. The nurse observes the client, and adapts his/her own timing and pacing to that of the client. If the client is in a state of excitement and breathing at a rapid rate, the nurse matches his/her breathing and actions to that of the client¶s. If the client is in a state of exhaustion, the nurse sits, is slow in movements, and paces him/herself to match the client¶s level of energy. If the client expresses anxiety and a desire to feel more calm, the nurse models the anxiety and, through conscious role-modeling, demonstrates for the client a means to slow breathing rate, relax, and take control of the anxiety first at the physical level and second at the cognitive, reflective level. The modalities of progressive relaxation, imagery, guided imagery, and hypnosis are techniques that are used to carry out the concepts of modeling and rolemodeling. Thus, the techniques are used within the theory, not simply as modalities to help a client relax. The techniques become methods to carry out the basic principles of professional nursing practice. As integral to the theory, these techniques permit the nurse to assess the client within a holistic perspective, relfect and use the APAM model, plan care based on level of arousal according to the theory, and evaluate outcomes according to level of arousal and ability to self-regulate these feelings. The modalities, carried out by a professional nurse, have depth that is provided by a theoretical worldview and permit a sophisticated level of assessment. Secondly, Roy¶s Theory of Adaptation will be explored. Central to this theory are the concepts of focal, contextual and residual stimuli (Roy & Andrews, 1991). The focal stimuli are the conditions immediately confronting the client, the contextual are all other stimuli present, and the residual stimuli are those beliefs, attitudes and conditions that have an indeterminate effect on the present condition. The nurse, operating from within this framework, assesses the stimuli and takes action to promote the client¶s adaptation in physiologic needs, self-concept, role function, and relations of interdependence nursing health and illness. Roy states that the "nurse acts as a regulatory force to modify stimuli affecting adaptation" (1980, p. 186). Particularly with regard to contextual stimuli, there are several alternative/complementary modalities that permit the nurse to alter the stimuli and change unhealthy or noxious environmental stimuli to ones that are either neutral or wholesome. Music therapy and aromatherapy are specific modalities that change the environment in which the client finds him/herself and are expressly designed to change the context of care from one that is deleterious to one that is supportive. These modalities can easily be seen as nursing activities promoting positive adaptation. Music therapy is a systematic

application of music to produce relaxation and desired changes in emotions, behaviors, and physiology (Guzzetta, 2000) and armoatherapy is the use of essential oils to offer symptomatic relief or to enhance a sense of well being (Buckle, 1998; Stevenson, 1994). Used from within Roy¶s Adaptation Model of Nursing, these two modalities take place within the nursing process and are interventions aimed at manipulating

stimuli affecting client health. Given the use of the theory, the assessment of the need for the modality becomes part of reflective, holistic nursing care, and outcomes are interpreted from within the framework of adaptation, stimuli, stress and a specific worldview. Thirdly, there are several nursing theories that incorporate the concept of µhuman energy field¶ and µenvironmental energy field¶, specifically Rogers¶ Theory of Unitary Human Beings, Newman¶s Theory of Expanding Consciousness, and Parse¶s Theory of Human Becoming (Frisch, 2000). All energy-based modalities are congruent with these theories. While Therapeutic Touch (TT) is a modality developed by and researched by nurses (Keiger, 1979; Quinn, 1988; Straneva, 2000), other energy-based modalities such as Reiki and Healing Touch techniques are widely used by and taught to non-nurses. The theoretical frameworks for techniques involving human and environmental energy fields are nursing theories and the philosophies of Eastern traditions (Slater, 2000). For nurses engaged in energy-based techniques, bringing the techniques into a worldview of nursing permits the nurse to assess and practice with the benefit of reflection on the meaning of energy exchange and its effect on creating a reality for the nurse and client. Lastly, in relation to Jean Watson¶s theory of Humancare, nurses will recognize the most important aspect of all nursing activities are those actions that promote professional, compassionate, human to human interaction (Watson, 2000) . For the theory of Humancare, the very basis of nursing is interaction and connection between two human beings. The modality of healing presence is a significant, important technique to provide trust, support and to initiate the caring encounter necessary for nursing to take place. Healing presence is one of the modalities stated frequently by holistic nurses in the survey of modalities used in nursing practice discussed above. Watson¶s theory elevates the importance of this nursing action to its rightful state in care ± it is the pre-requisite for any professional nursing activity. From within the worldview of the theory of Humancare, a nurse will identify presence as a very necessary nursing action. Presence is often described as µbeing in the moment¶ (Dossey,1995), or µbeing with¶ rather than µdoing to¶ (Paterson & Zderad, 1976). There are three levels of presence defined for nursing practice: physical presence (being there), psychological presence (being with), and therapeutic presence as the nurse¶s reflectively relating to the client as whole being to whole being using all of his or her resources ± body, mind, emotion and spirit (McGivergin & Daubenmire, 1994). It is the final level, that of therapeutic presence, that fits best with the notion of Humancare. While many do not consciously think about healing presence as a modality, it requires skills of centering, openness and intuition to employ for the good of client care. The theory of Humancare reminds nurses that healing presence is indeed a modality and one that has not received sufficient attention, development and research as would be assumed, given how fundamental it is to the discipline. Through examples from four distinct nursing theoretical frameworks, several complementary/alternative modalities have been discussed as appropriate to incorporate into professional nursing. If one accepts the ideas that 1) professional nursing is based on theory and 2) that theory-based practice is reflective practice, the use of the modalities within theory becomes thoughtful and considered as a means to understand and interpret a nurse¶s actions. Nursing theory provides a means to understand modalities and permits nurses to assess and incorporate new aspects of care into a larger, more holistic, and very professional, worldview. Nursing Taxonomies of Nursing Practice Taxonomies of nursing practice are the classification systems that provide frameworks for naming and documenting the phenomena of concern of professional nursing. The most widely known and used of these taxonomies is the NANDA Classification of Nursing Diagnoses (NANDA, 2001). Originally presented to the nursing community in the 1970's the NANDA taxonomy is a statement of nursing problems and concerns. Over the years many

nurses have worked within this (and other nursing diagnostic systems, for example the Omaha and Saba systems) to identify and name all phenomena of concern to nursing. The current NANDA taxonomy lists over150 nursing diagnoses, organized according to domains based on health patterns. Work presented at the last meeting of NANDA indicated that the nursing diagnostic taxonomy will include statements of problem, risk for problem, and opportunity or readiness to enhance a current condition (Jones, et al., 2000). Thus, the current taxonomy of diagnoses presents a statement of conditions (both problems and opportunities to promote/enhance wellness) that have been identified by nurses as within the autonomous domain of nursing. Newer taxonomies for nursing include the Nursing Interventions Classification (NIC) , now in its third edition (McCloskey & Bulechek, 2000) and the Nursing Outcomes Classification (NOC), now in its second edition (Johnson, Maas, & Moorhead, 2000). These taxonomies list nursing activities that have been identified by nurses as actions they perform on behalf of patients/clients while providing direct and/or indirect care and measurable, core outcomes that are sensitive to nursing interventions. Taken together, the NANDA, NIC and NOC provide as comprehensive a list as is available of the concerns, actions, and expected outcomes of nursing practice. These lists are remarkably useful for nurses using complementary/alternative modalities in practice. Complementary modalities may be used by nurses and non-nurses alike; however, when used as part of nursing practice, the care should be documented in a nursing context. While some modalities require additional certification and/or licensure in some states, (for example, massage therapy), most of the modalities used by nurses require a nursing license and documentation that makes clear that the care provided is within the scope of professional nursing practice. When a complementary/alternative modality is used to address a concern identified as a nursing diagnosis, the action becomes an identified nursing intervention planned to address/remedy a nursing problem or concern. For example, when music therapy is provided to assist individuals obtain adequate sleep, the NANDA diagnosis of disturbed sleep pattern is the identified nursing problem and the intervention µmusic therapy as provided through tape recorded music at times of wakefulness¶ is a nursing intervention identified by the nursing community as within the domain of professional nurses. Likewise, when the nursing problem is fear related to undergoing medical diagnostic procedures (such as an MRI), and the nursing intervention is µguided imagery to assist the client with relaxation and distraction during the procedure¶, the problem, intervention and outcome can be documented from within the taxonomic frameworks as nursing. To provide an example of a wellness-oriented nursing concern, when the nursing concern is readiness to enhance spiritual well-being related to a time in life when a client is examining his personal beliefs, values, and sense of future, the nursing intervention µmeditation facilitation to focus awareness on an image or thought and to find a place of inner peace¶is being used to address an identified nursing concern. A last example is the use of the intervention Therapeutic Touch (TT) as a technique to assist the client experiencing impaired comfort related to severe itching. The technique is being used to provide a non-pharmacologic treatment of condition affecting the client¶s comfort and wellbeing. In each of these cases, the nursing activity is a complementary/alternative modality (music therapy, guided imagery, meditation, TT). Practice within the nursing context emphasizes that the modality is being used to address the human response to actual/potential health problems. Table 1 provides a summary of selected nursing diagnoses and interventions to indicate possible pairings of nursing concerns and actions. Table 1: Selected Nursing Diagnoses and Nursing Interventions: Possible Pairings of Nursing Concerns and Complementary/Alternative Interventions Nursing Nursing Intervention(s) Rationale

Diagnosis/concern Impaired Comfort Disturbed Pattern Social Isolation Impaired Coping Hopelessness Spiritual Distress Spiritual Well-Being Anxiety or Fear Sleep

Acupressure, TT Massage Animal-Assisted Therapy Humor Hope instillation Spiritual support Spiritual growth facilitation

to decrease perceived pain to promote relaxation, rest to provide affection to facilitate appreciation of that which is funny, to relieve tensions to promote a positive sense of the future to facilitate a sense of inner peace to support growth/reflection reexamination of values

Guided imagery, relaxation to reduce sense of anxiety therapy, biofeedback, calming techniques Art therapy to facilitate expression

Impaired Communication

When documented from a nursing framework, the nurse is making it clear that the modality is being used to address an issue that has been accepted by the nursing community as within the domain of nursing and within the phenomena of concern to professional nurses. Nurses documenting practice using these systems are accomplishing three important things: appropriate documentation of care, identification of work as within the scope of professional nursing, and building a body of knowledge for nurses on the use of specific interventions. The taxonomies provide both a framework that helps nurses think in a holistic manner about what they are doing as nurses and increased justification for having a nurse perform the activities. The taxonomies themselves are atheoretical, meaning that they are not grounded in any of the nursing theories, they are simply a list of diagnoses, interventions and outcomes. These diagnoses, interventions and outcomes, however, can be used with nursing theory to guide the reflective interpretation of client conditions and selection of appropriate nursing interventions. Within the framework of nursing taxonomies, the alternative/complementary modalities become part of the nursing process ± the documentation of nursing assessments, concerns, interventions and outcomes. Bibliography : "">Types Alternative Medicine</a> of

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