Forces of Nature
Although unsupported by conventional research, more and more nurses discover that alternative, integrative, and complementary healing practices make positive ripples in critical care settings

By Melissa Gaskill
August 2, 2004

Several years ago, when a group of nurses at the University of California, San Diego Medical Center were discussing the benefits of music for critically ill patients, a secretary overheard them and mentioned that he played the flute. Patty Graham, RN, MSN, CNS, CCRN, a critical care clinical nurse specialist, asked him to play right then and there, in the surgical ICU.

“A patient’s family member heard the music and asked him to come to play at the bedside of her father, who was unconscious, awaiting a liver transplant. He went over and played ‘Amazing Grace,’ and it was completely transforming,” Graham said.

People lowered their voices and moved more slowly, and an atmosphere of calm permeated the unit. Later, Graham saw that same patient and mentioned the impromptu performance. The patient thought for a moment and then asked if the song played was “Amazing Grace.”

That is one of many stories, Graham said, that illustrate the power of music, which is just one of many complementary medical therapies that are being adopted by health care providers in the United States — even for the critical care arena.

These are services many patients demand, despite the debate surrounding their efficacy. A recent nationwide survey by the National Center for Complementary and Alternative Medicine (and the national Centers for Disease Control and Prevention’s National Center for Health Statistics showed that 36% of Americans older than 18 use some form of complementary and alternative medicine (CAM). Other studies have estimated that as many as 50% of adults use complementary care, according to a University of Minnesota task force.

“Hospitals understand now when people come in, they know about a lot of this. Mainstream magazines have articles on relaxation, music, nutrition,” said Barbara Dossey, RN, PhD, HNC, FAAN, director of Holistic Nursing Consultants of Santa Fe, N.M.

Patients’ perceptions and opinions are powerful forces in changing attitudes and practice in the medical setting, as Cathie Guzzetta, RN, PhD, HNC, FAAN, a nursing research consultant at Children’s Medical Center Dallas, discovered during a study on music therapy for acute myocardial infarction patients.

Guzzetta said the study made at Catholic University of America, published in 1989 in Heart & Lung: The Journal of Acute and Critical Care, showed patients reported that music therapy helped them get through the anxiety and depression of an acute illness, improved their sleep, and reduced their time on respirators. The study helped sway those who had been resistant to using music therapy at Children’s.

“That opened up the door for critical care nurses to do some of these therapies at the bedside, integrating them with the best practices of medicine,” said Guzzetta, who prefers the term “integrative” to complementary care (See sidebar).

Graham used this research to gain approval for an informal study at UC San Diego, where she is collecting data on the effectiveness of live music, as opposed to music recorded on tapes and CDs.

Helpful distractions

At the University of Minnesota, a similar study seeks to determine whether music therapy can reduce the length of time on ventilators and, therefore, length of stay. That could reduce costs and help prevent complications, important considerations these days, said Mary Jo Kreitzer, RN, PhD, director of complementary and spiritual care at the University of Minnesota Academic Health Center and associate professor at the university’s School of Nursing.

“In the critical care environment, we can’t afford to consider just standard nursing care when there are other options that will help with patient outcomes,” Kreitzer said.

Simple distraction is an amazingly effective complementary therapy, especially with children. “Kids say the needles are the worst,” Guzzetta said, “but if you’re really engaged in one task, you have little mental capacity to think about another, and kids are easily distracted.”

Research has shown that handheld video games and virtual reality glasses are effective with older children, and techniques are as simple as Where’s Waldo books and blowing bubbles with younger ones.

Guzzetta recently was involved in a study published in the American Journal of Critical Care and the Journal of Emergency Nursing that showed multiple benefits from family presence during cardiopulmonary resuscitation and invasive procedures.

Many health care providers are resistant to family presence, but that may be changing. Studies show that most consumers think it should be allowed, and the American Heart Association CPR guidelines recommend offering family members the option of remaining with a patient. The Emergency Nurses Association adopted a resolution supporting that option. It also has an educational program and guidelines for implementing the practice, although 95% of institutions do not have written policies.

“We recommended that nurses work closely with physicians, health care administrators, and professional organizations to adopt policies supporting family access,” Guzzetta said. Without written policies, it is a hit-or-miss approach that varies according to prevailing attitudes or even the persistence of the family.

Graham used research to implement a pet visitation program at UC San Diego, a program that rotates artwork through the ICU, and a relaxation channel broadcast to televisions in patients’ rooms.

Proof in the pudding

One of the major obstacles to nurses introducing complementary care into the critical care setting is that many methods and procedures have little conventional research behind them, according to critics as well as advocates of complementary care. The National Center for Complementary and Alternative Medicine, which operates as one of the 27 independent National Institutes of Health centers, began funding research grants for clinical studies only in 1999. With an estimated budget of $121 million in 2005, the center is scientifically investigating a range of complementary care and procedures, such as acupuncture and homeopathy.

A good source of information on existing research is the center’s website search engine, CAM on PubMed [www.nccam.nih.gov/research or www.nlm.nih.gov/nccam/camonpubmed.html], which automatically limits searches to the CAM subset.

Using complementary care procedures in critical care is a matter of weighing risks and benefits, Kreitzer said. Nurses in critical care environments need to look at what is in the profession’s literature, ask whether a therapy has been used to manage a problem, and whether it is safe, effective, and appropriate for this particular patient. Other considerations are the qualifications needed to implement the therapy and whether it falls into the scope of nursing.

Without sufficient research, there are concerns that the time spent applying CAM techniques takes away from other nursing care. “The drawback is wasting a lot of time that could be spent on nursing care that helps,” said Vern Bullough, RN, PhD, a medical historian, sexologist, and emeritus professor at State University of New York. Bullough also has been a contributing editor to the Scientific Review of Alternative Medicine.

“These things need to be tested. We need to find out what kind of patients respond to them. A nurse’s duty is to try therapies that work,” Bullough said. “Critical care nurses have their hands full.”

It’s the little things

“You don’t have to start from scratch” in introducing alternative care, Dossey said, but she warned “[t]he institutions that are most successful at changing to an integrative model of care do so gradually, first with an interested, committed group of their staff. These teams are permitted to create a prototype, and eventually expand their vision to the institution as a whole.”

Nurses don’t necessarily have to wait for institutional change either. Many CAM therapies require no special training or certification and only small changes in existing practice.

“There are so many things nurses can learn to do simply and easily,” Guzzetta said, “like intentional pressure, touch, and distraction. If you go in and talk to a kid about his birthday party, that’s distraction.”

Many nurses do this all the time without thinking about it, she said. The key is being present in the moment and engaging with the whole patient.

Classes on specific CAM therapies are offered by The American Holistic Nurses Association and other groups. Information is available through web courses, journals, workshops, and organizations for various modalities, such as the American Music Therapy Association [www.musictherapy.org] or the National Association for Holistic Aromatherapy [www.naha.org].

Applying CAM therapies in critical care doesn’t necessarily mean more work and, in fact, can mean less.

“It isn’t taking an extra five minutes, but changing the way we do things,” Guzzetta said. “If you have a patient in pain and are giving them powerful medication, just touching their hand, reminding them their jaw is clenched, telling them to picture this powerful medication going directly into their veins — that doesn’t take any more time than drawing up the med and injecting it, but you’ve combined it with touch and imagery.

“That is the kind of stuff we could be doing all the time.”

It is common knowledge that even a potent pain medication won’t work if the patient doesn’t think it will, Dossey said. “Letting the patient know the medicine is being given intravenously and will be in the system and work very fast can be powerful,” she said. “Think about how easy this is. It’s not something you tack on later, but becomes a way you give medication.”

The goal is caring for the whole person, according to Kreitzer. “It’s not just about the therapies, but about how we create an optimal healing environment,” she said. “One that includes everything from the physical environment to who are the care providers and how they provide care, to what kind of therapy we provide, conventional and unconventional.”