Helda Pinzón-Pérez¹, Luz Marina Alonso Palacio², Elizabeth Fajardo³

¹ Professor Department of Public Health, California State University Fresno, USA.

² Professor of Department of Public Health, Universidad del Norte. Barranquilla (Colombia).

³ Professor of Nursing in Universidad del Tolima. Tolima (Colombia).

Correspondencia: Helda Pinzón-Pérez. Professor Department of Public Health 2345 East San Ramon Ave M/S MH 30 California State University, Fresno, CA 93740. Tel.: (559)278-5329. Fax: (559)278-4179.2195486.hpinzonp@csufresno.edu

Abstract

Complementary and Alternative Medicine (CAM) is a growing field for health professionals in the United States and Latin America. Since the creation of the Center for Complementary and Alternative Medicine at the National Institutes of Health, new modalities of care have gained acceptance and recognition among health providers. Among health providers are nursing personnel and health educators. In the United States, the difference in the role between health educators and nursing personnel is clear. In Latin America such difference is less clear since in many countries the profession of "Health Educator" does not exist and the functions of this professional are taken by nursing personnel. This article discusses the potential role of complementary and alternative medicine for both professions. The American Holistic Nurses Association and professional associations for the certification of health educators have made a call to these health professionals to become more engaged in the understanding and practice of holistic health. Clinical emphasis on complementary and alternative medicine (CAM) can be a very viable option for clinical nurse specialists (CNS) and Health educators (HE). CAM can be a new professional arena for these health professionals, especially for those interested in teaching future health providers.

Keywords: Complementary and alternative medicine, nursing care, health education.

Resumen

La medicina complementaria y alternativa (CAM) es un área creciente para los profesionales de la salud en los Estados Unidos y en America Latina. Desde la creación del Centro de Medicina complementaria y alternativa de los Institutos Nacionales de Salud en los Estados Unidos, nuevas modalidades de cuidado han ganado aceptación y reconocimiento entre los proveedores de servicios de salud. Entre los proveedores de servicios de salud se encuentran el personal de enfermería y los educadores en salud. En los Estados Unidos la diferencia en el rol de los educadores en salud y el professional de enfermería es clara. En America Latina tal diferencia es menos clara ya que en muchos paises la profesión de "Educador en Salud" no existe y las funciones de éste son asumidas por el personal de enfermería. Este articulo discute el papel potencial que la medicina complementaria y alternativa tiene para las dos profesiones. La Asociación Americana de Profesionales de Enfermería Integral y las asociaciones profesionales para los Educadores en Salud en los Estados Unidos han hecho un llamado a estos profesionales de la salud para que sean más activos en el conocimiento y la práctica de la salud integral.
El énfasis clinico en CAM puede ser una opción muy viable para los profesionales de enfermería clínica (CNS) y para los educadores en salud (HE). La CAM puede ser una nueva área professional para estos profesionales de la salud, y especialmente para aquellos interesados en enseñar a los proveedores de salud del futuro.

Palabras clave: Medicina Complementaria y Alternativa, Cuidado de Enfermería, Educación en Salud.

INTRODUCCIÓN

Alternative and Complementary Medicine [CAM] are now recognized by the National Institutes of Health [NIH] as important modalities for treatment. The National Center for Complementary and Alternative Medicine [NCCAM] of the NIH defines CAM as "a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine" (1). Conventional medicine according to the NCCAM is comprised of the modalities of care provided by medical doctors, doctors of osteopathic medicine, registered nurses, and allied health professionals such as health educators (1).

The NCCAM (2010) makes a distinction between alternative, complementary, and integrative medicine. Alternative medicine includes a group of therapies used instead of conventional medicine. Complementary medicine refers to the use of CAM along with conventional medicine. Integrative medicine is defined as a combination of conventional and CAM therapies that have been tested for safety and effectiveness.

The major types of CAM are: a) natural products, b) mind-body medicine, (c) manipulative and body-based practices, and (d) other CAM therapies. Natural products refer to herbal medicines, botanicals, dietary supplements, and probiotics. Mind-body medicine includes meditation, yoga, acupuncture, deep breathing exercises, guided imagery, hypnotherapy, progressive relaxation, qi gong, and controlled breathing. Manipulative and body-based practices involve spinal manipulation and massage therapy. Other CAM therapies include movement therapies such as the Feldenkreis method, the Alexander technique, and Trager psychophysical integration, traditional healing, magnet therapy, light therapy, healing touch, reiki, ayurveda, traditional Chinese medicine, homeopathy, and naturopathy (1).

Complementary and Alternative Medicine (CAM) is a growing field for health professionals in the United States and Latin America. Since the creation of the Center for Complementary and Alternative Medicine at the National Institutes of Health, new modalities of care have gained acceptance and recognition among health providers. Among health providers are nursing personnel and health educators. In the United States, the difference in the role between health educators and nursing personnel is clear. In Latin America such difference is less clear since in many countries the profession of "Health Educator" does not exist and the functions of this professional are taken by nursing personnel.

The American Holistic Nurses Association [AHNA] is a professional body that promotes education and research on CAM. The mission of the AHNA is to "foster a vital community that advances holistic health and nursing" and its vision is to have a "world in which nursing nurtures wholeness and inspires peace and healing" (2).

This organization is the leading professional organization in the U.S. promoting research, publications, teaching, continuing education, liability insurance, networking opportunities, and policy development on CAM and holistic nursing. Holistic nursing is defined by the AHNA as "all nursing practice that has healing the whole person as its goal" (3). Under this definition, nurses are called to become facilitators of healing by acknowledging the subjective nature of health, and recognizing the importance of the client's health beliefs and values (3).

The National Commission for Health Education Credentialing (NCHEC) is the leading accrediting body for health educators. This organization has emphasized seven areas of professional responsibility for health educators. Area VI states that health educators should serve as health education resource (4). This is clearly important in CAM since there are many educational endeavors that need to be taken into consideration regarding the education of consumers and the prevention of CAM misuse.

The American Holistic Nurses Association and the National Commission for Health Education Credentialing have made a call to health professionals to become more engaged in the understanding and practice of holistic health. The two professional organizations have recognized the role of nurses and health educators, respectively, as educators on CAM for the consumers and their peers.

HISTORICAL REVIEW

The NCCAM is one of the 27 institutes and centers of the National Institutes of Health within the Department of Health and Human Services. It is the leading federal organization for research, training of practitioners, information for the public, and integration of CAM and conventional medicine, within the paradigm of rigorous scientific research (5).

According to Fontaine (2011), only until the creation of the NCCAM nurses were primarily trained under the umbrella of biomedicine. Although this emphasis has been evident in nursing practice, it is important to acknowledge that nurses throughout history have embraced the concepts of humanism and holism, hence being in a unique position to integrate the biomedicine and alternative medicine paradigms (6). In response to this challenge, the AHNA was created in 1981 and it currently serves more than 5,000 members and provides scientific guidance to more than 140 chapters in the U.S. and abroad. In the view of the AHNA, "the practice of holistic nursing requires nurses to integrate self-care, self-responsibility, spirituality, and reflection in their lives within a framework of greater awareness of the interconnectedness with self, others, nature, and spirit" (3).

Since 2006, holistic nursing has been officially recognized as a nursing specialty by the American Holistic Nurses Association (7). In an effort to maximize the quality of care in holistic nursing, the AHNA has been affiliated to the American Holistic Nurses Certification Corporation and has been approved by the American Nurses Credentialing Center's Commission on Accreditation (8).

CURRENT STATUS OF COMPLEMENTARY AND ALTERNATIVE MEDICINE USE IN NURSING AND HEALTH EDUCATION

The National Health Interview Survey [NHIS] conducted in 2007 with 23,393 adults and 9,417 children, documented that 38 percent of adults and 12 percent of children use CAM therapies in the U.S. Women and people with higher educational levels and higher incomes are more likely to use CAM (9). According to the NCCAM natural products such as nonvitamin and nonmineral therapies are the most commonly used modalities of CAM among adults in the U.S. An increased pattern of use was documented by the NHIS in the categories of deep breathing exercises, meditation, massage therapy, and yoga (9).

These CAM modalities are starting to be used by nurses in the U.S. in private practice, hospitals, universities, physician's offices, outpatient surgery centers, long-term facilities, home health care, pediatric centers, oncology clinics, and holistic health clinics (10). In the view of the AHNA, holistic nursing could be used in any specialty area.

Nursing research on CAM has emerged rapidly. Studies published in the Holistic Nursing Practice Journal and the Journal of Holistic Nursing have documented the growing interest of nurses on CAM. Major emphasis has been placed in these journals on evidence-based research (11, 12).

Examples of research on CAM include a study on a comparison of healing touch, coaching, and a combined intervention on comfort and stress in younger college students conducted by Dowd, Kolcaba, Steiner, and Fashinpaur. This study revealed that healing touch had effective results on stress and comfort (13). Another study conducted by Han, Hur, Buckle, Choi, and Lee on the effect of aromatherapy on dysmenorrheal demonstrated a significant reduction in the severity of cramps among those who used aromatherapy as compared to those in the placebo group (14).

A systematic review of research on herbal therapies for the treatment of osteoarthritis conducted by Little, Parsons, and Logan revealed evidence for the benefit of using avocado- soybean unsaponifiables for the management of osteoarthritis but no evidence for other herbal products (15). Another systematic review conducted by Rathbone et al on the use of Chinese herbal medicine for Schizophrenia indicated that two studies found significant clinical improvement among schizophrenic patients when antipsychotics were used in combination with Chinese herbal medicine (11). Smith, Collins, Cyna, and Crowther conducted a meta-analysis of acupuncture and hypnosis to relieve pain in labour, which demonstrated that women using acupuncture and hypnosis required less pain medication and were more satisfied with their pain management (12).

According to Frish , holistic health has been of interest for nursing research for over two decades since more than 41 scholarly papers have been published in peer-reviewed journals related to CAM (16). A 1996 study conducted by Dossey, Frish, Forker, and Lavin with 708 nurses self-identified as holistic nurses revealed that the standards of their practice was based in relation to the modalities of nursing practice (16).

The American Nurses Association [ANA] has approved holistic nursing as an area of specialty since December 2006. The ANA news released recognized the value of holistic nursing for the public and the profession itself. The ANA has made a call to increase evidence-based research on CAM and holistic nursing, and has advocated for certification of this specialty (17). The AHNA has delineated the professional competencies for practice in holistic nursing and has created a system for certification through the American Holistic Nurses' Certification Corporation [AHNCC]. The certification as Holistic Nurse-Certified [HNC] involves a review of portfolio credentials and standardized tests (16).

Health educators in the United States are defined as practitioners who have scientific training in the design, development, and evaluation of educational activities that help to promote and improve the health of all (4). For Health Educators, the National Commission for Health Education Credentialing (NCHEC) sets the standards for professional performance through the promotion of seven areas of responsibility: Area I: Assess Needs, Assets and Capacity for Health Education; Area II: Plan Health Education ; Area III: Implement Health Education ; Area IV: Conduct Evaluation and Research Related to Health Education ; Area V: Administer and Manage Health Education ; Area VI: Serve as a Health Education Resource Person ;and Area VII: Communicate and Advocate for Health and Health Education (4). CAM is relatively a new domain for health educators.

Johnson, Priestley, Porter, and Petrillo in 2010 conducted a national study to examine U.S. health educators' attitudes toward CAM. The results of this study revealed that approximately 90% of health educators have used at least one CAM therapy in the last 12 months (18). This shows the general positive attitude of health educators towards CAM.

CAM AND CLINICAL NURSE SPECIALISTS AND HEALTH EDUCATORS

The American Nurses Association determines the scope of practice of nurses under the Nursing Practice Act, which defines nursing functions as "basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require a substantial amount of scientific knowledge or technical skill including all of the following: direct and indirect patient care services..." (19).

A CNS is defined by the National Council of State Boards of Nursing as a licensed advanced practice registered nurse who has preparation at the master's or doctoral level in nursing and who is a clinical expert in theory or research-based performance. The scope of practice for clinical nurse specialists is centered on their role as clinical experts, educators, consultants, and researchers who work with individuals, patients, nurses, organizations, and systems to ensure a high quality of nursing care (20).

Cuthsall et al. stated that "clinical nurse specialists (CNSs) are in an ideal place to influence [a] paradigm shift in medicine to provide holistic care."A descriptive exploratory correlational study on knowledge, attitudes, and use of complementary and alternative therapies among clinical nurse specialists in an academic medical center revealed that CNS use several CAM therapies such as humor, massage, spirituality/prayer, music therapy, and relaxed breathing in their professional practice with patients. The therapies most frequently requested by patients were massage, spirituality/prayer, healing touch, acupuncture, and music therapy (21).

Clinical nurse specialists can provide information about CAM in congruence with evidence-based scientific research published by the NCCAM. Clinical nurse specialists could pursue certification in holistic nursing and CAM specialties so they can have an independent practice in CAM modalities such as acupuncture, homeopathy, aromatherapy, pressure point, and naturopathy among others.

The ANA indicated that RNs with specialty in Holistic Nursing can provide complementary and alternative therapies in accordance with the standards of practice delineated by the AHNA and the standards of competent performance. According to the ANA (2001), the ability of nurses certified in holistic nursing to practice CAM procedures ought to be rooted on a solid system of undergraduate and postgraduate theoretical and practical education on CAM and holistic health (19). The practice of specialized CAM modalities such as acupuncture requires a specific license in California and other states. CAM practices such as applied kinesiology, herbal therapy, homeopathy, and ayurveda require private certification (19).

A revision of the educational needs of CNS in their master's level preparation should be considered. Postgraduate training in CAM, via at least one course and a practicum, should be included in the training of clinical nurse specialists. This training ought to include the scientific bases of various CAM modalities and the standards of holistic nursing practice developed by the AHNA. The core curriculum for holistic nursing and the handbook for holistic nursing published by the AHNA are good resources in planning such graduate course, as they describe the standards for nurses' knowledge, theories, expertise, intuition, and creativity (16). These standards ought to be taught to CNS in their postgraduate education.

Patricia Benner's Novice to Expert theory is very useful for understanding the role of education on CNS proficiency for CAM. According to Benner, nursing practitioners move in a continuum from novice (no background or prior knowledge), advanced beginner (enough knowledge to understand some components), competent (priorities begin to be recognized), proficient (able to perceive the situation as a whole), to expert (critical thinking and clinical judgment) (22). In the field of CAM, most nursing professionals are at the stage of novices. As the NCCAM and the AHNA promote research and education in this area, the nursing profession will move from a novice to an expert level. Graduate education should help CNS move from a novice to advanced beginner, and competent levels in CAM.

Specialty education (such as AHNA holistic health continuing education training and CAM specialty certification) could help CNS achieve proficient and expert levels.

In the consultation role, clinical nurse specialists provide clinical expertise and make recommendations to physicians, other health care providers, patients, and health care organizations. CNS who want to center their practice on CAM should acquire the appropriate knowledge and skills to provide consultative services on holistic care. Perhaps the major role of CNS is, as suggested by Fontaine, to create healing environments, organizations, and systems (6). The research role of CNS can also be enriched by developing scientifically- based studies on CAM. Research opportunities for CNS could include an assessment of the benefits and risks associated with CAM therapies, as well as a determination of the pathological conditions for which emerging CAM modalities can be of help.

The importance of CAM education for health educators in the United States has been promoted by Synovitz and Larson (23), Pinzon-Perez (24), and Chng, Neil, and Fogle (25). These authors have advocated for education and research on CAM as it applies to the professional practice of health educators. Perez and Luquis (26) have incorporated CAM into their research agenda on cultural competence and health education.

Studies in Latin America have been primarily focused on the role of nurses in complementary and alternative medicine. Not much information is available related to CAM and health educators is latin America. A study conducted by Vanegas de Ahogado, Calderon, Forero, and Marin describes the experiences of nursing professionals with alternative and complementary therapies in pain management (27). Sobrin (2005) advocated for the study of natural therapies in nursing (28). Martin and Ortiz added that alternative medicine can be used by nurses for back pain management (29).

Tobos explored the importance of alternative therapies for health professionals in the promotion of healthy lifestyles (30). Although specific applications for health educators are not mentioned by Tobos, this author's analysis can be extended to professionals who engage in health education in Latin America (30).

CNS practitioners, nurse educators, and health educators should be knowledgeable of Occidental and Oriental health care modalities so they can exercise critical judgment in the selection of the most appropriate modality of care or offer integrative health care in their professional practice. Nurses and health educators who want to center their professional expertise on CAM should be equally knowledgeable of the Western and Eastern paradigms of care so they can provide treatments that are scientifically based. They should be able to discern when alternative therapies such as acupuncture and homeopathy are appropriate for the treatment of a particular illness, and when not. This professional judgment and critical thinking should be strengthened in their training since each modality of care (Oriental and Occidental) has limitations.

CONCLUSIONS

Complementary and Alternative Medicine (CAM) is a growing field for health educators and nursing professionals in the United States and in Latin America. CAM represents a new professional arena for these health professionals. CAM knowledge is important for the clinical, consultative, and research roles of nurses and health educators. CAM training should be given to all nurses and health educators as part of their master's level preparation. Additional training could be pursued by clinical nurse specialists and health educators interested in specializing in holistic care. The American Nurses Holistic Association offers certification on holistic nursing via the American Holistic Nurses' Certification Corporation. Certification bodies in CAM and holistic health for health educators and nurses need to be developed in the United States and Latin America.

Interest conflict: None.

Funding: California State University, Fresno.

REFERENCES

(1) National Center for Complementary and Alternative Medicine [NCCAM]. What is CAM. National Institutes of Health 2010. Retrieved from http://nccam.nih.gov/health/whatiscam/

(2) American Holistic Nurses Association [AHNA]. About us. 2010 Retrieved from: http://www.ahna.org/AboutUs/MissionStatement/tabid/1931/Default.aspx

(3) Thornton L. What is holistic nursing? American Holistic Nurses Association. 2010. Retrieved from http://www.ahna.org/AboutUs/WhatisHolisticNursing/tabid/1165/Default.aspx

(4) National Commission for Health Education Credentialing [NCHEC]. Responsibilities and Competencies for Health Education Specialists. 2008. Retrieved from http://www.nchec.org/credentialing/responsibilities/

(5) National Center for Complementary and Alternative Medicine [NCCAM]. Facts-at-a- glance and mission. National Institutes of Health. 2010. Retrieved from http://nccam.nih.gov/about/ataglance/

(6) Fontaine K. Healing practices. Complementary & alternative therapies for nursing practice. 3rd ed. Boston, MA: Pearson Education Inc; 2011.

(7) American Holistic Nurses Association [AHNA]. Holistic nursing specialty status. 2010. Retrieved from http://www.ahna.org/AboutUs/ANASpecialtyRecognition/tabid/1167/Default.aspx

(8) American Holistic Nurses Association [AHNA]. Certification in holistic nursing. 2010. Retrieved from http://www.ahna.org/Education/Certification/tabid/1211/Default.aspx

(9) National Center for Complementary and Alternative Medicine [NCCAM]. The use of complementary and alternative medicine in the United States. National Institutes of Health. 2010. Retrieved from http://nccam.nih.gov/news/camstats/2007/camsurvey_fs1.htm

(10) American Holistic Nurses Association [AHNA]. Who are our members. 2010. Retrieved from http://www.ahna.org/AboutUs/WhoAreOurMembers/tabid/1166/Default.aspx

(11) Rathbone J, Zhang L, Zhang M, Xia J, Liuy X, Yang Y. Chinese herbal medicine for schizophrenia. Cochrane Database of Systematic Reviews 2005; DOI: 10.1002/14651858.CD003444.pub2.

(12) Smith CA, Collins CT, Cyna AM, Crowther CA. Complementary and alternative therapies for pain management in labour. Cochrane Database of Systematic Reviews 2006; (4) DOI: 10.1002/14651858u.CD003521.pub2.

(13) Dowd T, Kolcaba K, Steiner R, Fashinpaur D. Comparison of health touch, coaching, and a combined intervention on comfort and stress in younger college students. Holistic Nursing Practice 2010; 21(4), 194-202.

(14) Han SH, Hur MH, Buckle, Choi J, Lee M.S. Effect of aromatherapy on symptoms of dysmenorrheal in college students: A randomized placebo-controlled clinical trial. Journal of Alternative and Complementary Medicine 2006; 12(6), 535-41.

(15) Little C.V, Parsons T, Logan S. Herbal therapy for treating osteoarthritis. Cochrane Database of Systematic Reviews 2000; (4). DOI: 10.1002/14651858.CD002947.

(16) Frish, N. Standards for holistic nursing practice: A way to think about our care that includes complementary and alternative modalities. The Online Journal of Issues in Nursing 2011; 6(1). Retrieved from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume62001/No2May01/HolisticNursingPractice.aspx#Dossey97

(17) American Nurses Association [ANA]. News released. ANA protects the public through formal recognition of specialty nursing practice 2008. Retrieved from http://www.nursingworld.org/FunctionalMenuCategories/MediaResources/PressReleases/2008PR/SpecialtyPracticeRecognition.aspx

(18) Johnson P, Priestley J, Porter K, Petrillo J. Complementary and alternative medicine: Attitudes and use among health educators in the United States. 2010. American Journal of Health Education. Retrieved on March 28, 2012, from http://www.aahperd.org/aahe/publications/ajhe/upload/MayJune-2010-2.pdf

(19) American Nurses Association [ANA]. State boards of nursing (BONs)-California. 2001. Retrieved from http://cms.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume62001/No3Sept01/ArticlePreviousTopic/BONsList/CABON.aspx

(20) Medscape Nurses. Regulatory credentialing of clinical nurse specialists: Issues and purpose. 2003. Retrieved from http://www.medscape.com/viewarticle/455980_2

(21) Cutshall S, Derscheid D, Miers A, Ruegg S, Schroeder B, Tucker S, Wentworth L. Knowledge, attitudes, and use of complementary and alternative therapies among clinical nurse specialists in an academic medical center. Clinical Nurse Specialist 2010 24(3). Retrieved from http://journals.lww.com/cns- journal/Abstract/2010/05000/Knowledge,_Attitudes,_and_Use_of_Complementary_and.5.aspx

(22) Blais K, Hayes J, Kozier B, Erb G. Professional nursing practice: Concepts and perspectives. Theoretical Foundations of Professional Nursing 2006.

(23) Synovitz L, Larson K. (2013). Complementary and Alternative Medicine for Health Professionals: A Holistic Approach to Consumer Health. Brulington, MA: Jones & Bartlett Learning

(24) Pinzon-Perez H. Complementary and alternative medicine, holistic health, and integrative healing: Applications in health education. American Journal of Health Education 2005; 36(3):174-178.

(25) Chng C, Neil K, Fogle P. Predictors of college students' use of complementary and alternative medicine. American Journal of Health Education 2003; 34(5): 267-271.

(26) Perez M, Luquis R. (2008). Cultural Competence in Health Education and Health Promotion. San Francisco, CA: Jossey-Bass. American Association of Health Education/American Alliance for Health, Physical Education, Recreation, and Dance.

(27) Vanegas de Ahogado B, Calderón A, Lara P, Forero A, Marin D, Celis A. Experiencias de profesionales de Enfermería en terapías alternativas y complementarias aplicadas a personas en situaciones de dolor. Avances de Enfermería 2008;26(1):59-64.

(28) Sobrín CV. Las terapias naturales entran en escena en Enfermería. Excelencia en Enfermería. Revista Científica y de Divulgación 2005;12:12.

(29) Martin I, Ortiz A. Cuidado de Enfermería y terapia del color como medio de liberación de energías en dolor de espalda. Avances en Enfemería 2001; 10:58-67.

(30) Tobos L. Promoción de la vida saludable complementada con terapia alternative. Revista Colombiana pra los profesionales de la salud 2002;8:241-242.