March/April 2003, Volume 30, Number 2

Leadership and Professional Development
Ellen Giarelli, EdD, RN, CS, CRNP and Terry A. Throckmorton, RN, PhD, Associate Editors

Initiating a Complementary Therapy Internship Program on an Inpatient Oncology Unit

Vicki Norton, RN, BSN, OCN^®, and Carol P. McPherson, MSW, MPH

The medical literature reports an increasing prevalence in the use of complementary and alternative medicine (CAM) by patients with cancer to relieve symptoms caused by cancer and its treatment (Eisenberg et al., 1998; Ernst & Cassileth, 1998; Morris, Johnson, Homer, & Walts, 2000; Rees et al., 2000; Richardson, Sanders, Palmer, Greisinger, & Singletary, 2000). Patients with cancer at Methodist Hospital, a community teaching hospital in suburban Minneapolis, MN, are no exception. Nurses at the hospital struggle with ways to offer these therapies along with traditional treatment in a caring, competent manner that is fiscally responsible. The nurses are particularly interested in the modalities of reflexology and healing touch. The purpose of this article is to describe the step-by-step process of initiating a program for reflexology and healing touch interns to serve the oncology inpatient population at Methodist Hospital.

Reviewing the Literature

A committee started the process by researching the benefits and efficacy of CAM therapy among patients with cancer. A search of the literature produced relatively few published research studies, but the results seemed to indicate that these therapies were effective in relieving cancer symptoms (Brannon, 1999; Giasson & Bouchard, 1998; Merritt & Randall, 2002; Moreland, 1998; Stephenson, Weinrich, & Tavakoli, 2000). A new study also found that healing touch decreased anxiety and depression in caregivers of patients with cancer, although these changes lacked statistical significance (Rexilius, Mundt, Megel, & Agrawal, 2002). Evidence in the literature on CAM's usefulness to patients, albeit limited, and anecdotal reports supported proceeding with the program and conducting additional research.

Determining Feasibility

The committee explored a model that had been established previously in the oncology department. Since 1998, a Park Nicollet Health Services (PNHS) Foundation grant has supported a master's-prepared music therapist to mentor music therapy students in internships needed for their degrees. The program served inpatients, outpatients, and patients in home care or hospice care with cancer. The committee explored whether that model could be applied to other CAM therapies and discussed this with the Complementary Care Committee at PNHS, which reviews available CAM resources throughout the system. The committee decided to investigate the option and formed a subcommittee consisting of the inpatient oncology nurse manager, the music therapist supervisor, and certified practitioners in healing touch and reflexology. The practitioners already were employed as consultants for the PNHS oncology program and received referrals from PNHS.

Both the healing touch practitioner and the reflexologist contacted local schools of complementary therapy to ascertain the availability of interns and their interest in doing their clinical practicums in the hospital with patients with cancer. Finding both interest and availability, the committee proceeded with setting up the program.

Establishing the program required a commitment from the CAM practitioners and financial compensation for their services. To find funding to compensate the practitioners as they mentored the interns, a grant proposal was written to the PNHS Foundation for six months of program support. The foundation agreed to provide seed money for the project.

Program Goals

With the funding and interns secured, the committee set out to achieve the following goals.

• Provide reflexology and healing touch services to hospitalized patients with cancer.
• Give reflexology and healing touch interns the hours of practicum needed under a certified supervisor to receive certification in their specialties.
• Gather and analyze data measuring the effectiveness of these therapies in relieving symptom distress.

Action Plan

The committee needed to ensure that patients would receive safe, high-quality care and that interns would gain practical experience that would be of value in their specialties. First, the committee tried to standardize the process and put policies and procedures in place to guarantee the competency of the care that patients would receive. Criteria were written to guide measurement of the competency of practitioners. Interns were required to

• Complete the classroom instruction for reflexology or healing touch IIIB seminar.
• Apply for the internship and be interviewed by the supervising certified practitioner in their specialties.
• Demonstrate to a qualified observer mastery of the techniques of reflexology and healing touch.
• Apply to the Hospital Volunteer Program for insurance to cover liability while practicing in the inpatient setting.
• Sign a confidentiality agreement.

Building a Patient Population

After the interns were prepared, the program prepared to offer services to patients. The oncology units cared for patients with cancer, the urology population, and medical overflow patients. Rather than limit the program to patients with cancer, the hospital decided to offer the service to all patients on the unit and to document reasons for admission for future tracking purposes.

The nurses identified patients who were having difficulty managing feelings of nausea, pain, anxiety, fear, and other symptoms. The charge nurse referred patients who could benefit from CAM therapy. The CAM therapy program was presented and explained to each patient by one of the therapists. Each therapist gave specific information about the type of therapy the patients would receive and explained that the program was free to participants because it was funded by a grant. Participants signed a consent form to receive CAM therapy. Before treatment began, patients were asked to complete a questionnaire rating their symptoms of pain, nausea, stress, anxiety, depression, and fear on a symptom intensity scale from 0 (no symptom) to 10 (unbearable symptom). Patients also were asked to rate their well-being and sense of peacefulness. The complementary therapy was given; then, each patient was asked to complete the questionnaire again within 30 minutes.

Program Evaluation

A total of 113 patients participated in the program. Sixty-seven percent were female. About 60% of the participants were hospitalized for cancer management, with the remainder hospitalized for medical and postsurgical diagnoses. Some patients had more than one treatment over the course of their hospitalization (the certification practicum included treating patients multiple times). A total of 83 healing touch treatments were given to 48 patients, and 113 reflexology treatments were given to 53 patients. Twelve patients had both healing touch and reflexology treatments.

Patients' Reactions to Treatments

The committee was pleased to find that the patients who received reflexology reported less pain, nausea, stress, anxiety, and depression; they also expressed increased feelings of well-being and peacefulness. Every patient reported that he or she would recommend the treatment to other patients. Patients who received healing touch treatments reported that every symptom they had experienced before the treatment was lessened after treatment. Following treatment, they reported that they felt a greater sense of well-being and peacefulness. Both men and women reported positive benefits.

Discussion

The initial program objectives were fulfilled. The reflexology and healing touch therapies were available on a weekly or biweekly basis for inpatients in the medical/surgical oncology/urology/hospice unit, although only for six months. This was the allotted time for the pilot program, given the available funds to support the supervising practitioners' salaries. The therapies were free to patients, although they were asked to fill out questionnaires. The interns received valuable experience, as well as hours of practicum toward certification. Four reflexology interns received 50 hours each, and four healing touch interns each received an average of 21 client encounters toward certification. Finally, the data collected indicated a significant, positive effect of the therapies on symptom management, but more rigorous research is needed to validate the results.

Overall, the interns were very grateful for the experience and were impressed by the positive reception they received from nurses, physicians, and patients. They believed that it gave credibility to their choice of therapy. The reflexology practitioner said, "It is a worthwhile experience for interns to see firsthand the benefit of reflexology on people sick enough to be hospitalized and to hear how grateful patients are for the gift of their touch and the benefit of their education."

The results of this program show that symptoms were relieved by CAM treatments and that patients were satisfied by their participation in the program. The patients wrote about their CAM experiences on the post-treatment questionnaire.

• "[CAM] gives me more hope that things are going to work out. [It] connects me to the world around me. I'm not in this alone. There is still hope."
• "The gentle touching soothed my thoughts and body. I am not feeling any nausea at this time. That's amazing since I have been holding back vomiting all day."
• "From the first, I could feel it clears the mind, opens you up, and refreshes you. Stress and tension released; problems with swallowing, opened. Marvelous. I love it."

The positive remarks convinced the committee of the value of the CAM program in providing symptom management and comfort for patients with cancer in the hospital setting.

Limitations

When the committee began the program, its primary goal was to offer the therapies on a regular, low-cost basis for inpatients. They did not include the research department in the project from the beginning. When they realized the impact the therapies were having, they asked the research department to analyze the data. Researchers were impressed by the significance of the findings but pointed out the methodologic limitations of the data. The program did not randomize patients to CAM treatments, use a validated tool, or have a control group. After completing the program, the committee decided to conduct a more rigorous study to confirm the findings. A research proposal has been written, and the researchers currently are looking for funding opportunities.

Conclusions

Those involved learned valuable lessons while managing the project. First, because patients reported that CAM therapies were effective in symptom management, nurses should advocate these noninvasive, nondrug treatments for patients when the primary concerns are pain, stress, anxiety, depression, and other symptoms that are not easily treated by pharmacologic modalities alone. Second, the committee should have consulted with the research department during the planning stage to help with protocol development and the data analysis plan. Third, resources may be available in the community; for example, nurses can use grants and CAM interns to assist in patient care.

The authors will apply this knowledge as they pursue sources of funding for the follow-up study. In addition, monetary gifts from supporters have allowed the reflexology program to be available for three hours per week.

Having administered the pilot program, members of the committee are empowered to launch a consistent CAM program on the oncology floor and to conduct a more scientifically rigorous research study. In some ways, the program has transformed cancer care at Methodist Hospital. Also, committee members improved their ability to positively impact the lives of the patients and families for whom they care.

The authors would like to acknowledge Karen Teagarden, BA, NBCR, Lynda Whisney, RN, MA, Holistic Health Specialist, and Dawn Miller, MME, MT-BC, for their contributions to this program and to Kyla Dropkin, RN, BSN, MS, AOCN®, for her editorial assistance.

References

>Brannon, J. (1999). A patient satisfaction survey for cancer patients experiencing healing touch at the Cancer Wellness Center. Healing Touch International Research Report. Lakewood, CO: Healing Touch International.

Eisenberg, D.M., Davis, R.B., Ettner, S.L., Appel, S., Wilkey, S., Van Rompay, M., et al. (1998). Trends in alternative medicine use in the United States, 1990-1997: Results of a follow-up national survey. JAMA, 280, 1569-1575.

Ernst, E., & Cassileth, B.R. (1998). The prevalence of complementary/alternative medicine in cancer: A systematic review. Cancer, 83, 777-782.

Giasson, M., & Bouchard, L. (1998). Effect of therapeutic touch on the well-being of persons with terminal cancer. Journal of Holistic Nursing, 16, 383-398.

Merritt, P., & Randall, D. (2002). The effect of healing touch and other forms of energy work on cancer pain [Abstract]. Healing Touch International Research Survey. Lakewood, CO: Healing Touch International.

Moreland, K. (1998, August). The lived experience of receiving healing touch therapy of women with breast cancer who are receiving chemotherapy: A phenomenological study. Healing Touch Newsletter, 8, 3-5.

Morris, K.T., Johnson, N., Homer, L., & Walts, D. (2000). A comparison of complementary therapy use between breast cancer patients and patients with other primary tumor sites. American Journal of Surgery, 179, 407-411.

Rees, R.W., Feigel, I., Vickers, A., Zollman, C., McGurk, R., & Smith, C. (2000). Prevalence of complementary therapy use by women with breast cancer: A population-based survey. European Journal of Cancer, 36, 1359-1364.

Rexilius, S.J., Mundt, C.A., Megel, M.E., & Agrawal, S. (2002). Therapeutic effects of massage therapy and healing touch on care-givers of patients undergoing autologous hematopoietic stem cell transplant. Oncology Nursing Forum, 29, E35-E44. Retrieved December 27, 2002, from http://www.ons.org/publications/journals/ONF/Volume29/Issue3/290335.asp

Richardson, M.A., Sanders, T., Palmer, J.L., Greisinger, A., & Singletary, S.E. (2000). Complementary/alternative medicine use in a comprehensive cancer center and the implications for oncology. Journal of Clinical Oncology, 18, 2505-2514.

Stephenson, N.L., Weinrich, S.P., & Tavakoli, A.S. (2000). The effects of foot reflexology on anxiety and pain in patients with breast and lung cancer. Oncology Nursing Forum, 27, 67-72.>

Vicki Norton, RN, BSN, OCN^®, is nurse manager of the inpatient oncology units at Methodist Hospital in Minneapolis, MN, and Carol P. McPherson, MSW, MPH, is an epidemiologist in the Oncology Research Department at Park Nicollet Health Services in Minneapolis.

Ellen Giarelli, EdD, RN, CS, CRNP, Associate Editor, can be reached at imlng@aol.com and Terry A. Throckmorton, RN, PhD, Associate Editor, can be reached at tthrockm@mail.mdanderson.org.