In July, we celebrated Independence Day and our many freedoms, one of which is the freedom of speech. I'd like to consider how we talk with our colleagues about patients in our care as well as the use of complementary and alternative medicine (CAM). Knowledge and information should be shared freely between and among patients and caregivers. However, as nurses, we should talk about patients only with those directly involved in their care. How much medication a patient is taking or which therapies he or she is using may be interesting but should not be shared with staff members who are not caring for the patient. A joke I heard at the American Society of Pain Management Nurses' Annual Meeting is good advice.

Knock, knock!
Who's there?
HIPPA.
HIPPA who?
I can't tell you!

We should provide care in a healing environment of comfort, peace, and support, where patients and families feel safe sharing the therapies they are using and asking for information about those they are considering. Consider the information you share about patients and how it affects staff members assuming their care. Sometimes, reports we share or judgments we make give the next caregiver certain expectations. Share the facts as needed, but reserve judgment. When hearing a report, try to listen objectively and encourage team members to be alert, professional, and nonjudgmental regarding what they share.

I read an e-mail once about perspective. A professor shared a report with his students about a subject who required total care, was uncooperative, cried frequently, drooled, spit, did not follow commands, was incontinent, and had to be fed, bathed, dressed, and watched every minute for safety. The students were dreading caring for this patient until the professor produced a picture of his six-month-old daughter.

One report I sometimes hear is, "You can't do anything for him or her." A response I learned in clown school is, "May I try?" Our most challenging patients can bring us the greatest rewards and, yes, the greatest frustration. Our obligation is to try. I may not be familiar or agree with a therapy a patient is using or asking about, but I can try to give and receive information without making a judgment.

In Jonesborough, TN, about 10 minutes away from where I live, is the International Storytelling Center. A button they have reads, "Do Tell." We should encourage our patients to tell, and we should not be afraid to ask and learn about therapies that are available.

An Integrative Healthcare Clinic Provides Veterans With Additional Care Options

The Salt Lake City Veterans Affairs (SLCVA) Health Care System is leading the way in recognizing the need for an integrative approach to care. This approach includes complementary and alternative medicine (CAM) and a self-empowerment behavioral model used in conjunction with conventional care to assist patients with achieving optimal quality of life. The traditional medical model is based on the Cartesian paradigm of separation and treatment of the mind and body. Sobel (2000) demonstrated that psychosocial distress impacts functional health status and influences quality of life. This article will discuss a method of addressing the psychosocial and physical needs of veterans with chronic pain, stress management issues, and lifestyle issues such as obesity and tobacco use in the SLCVA Health Care System by providing a holistic, integrative model of care.

Integrative Health Care Clinic
The Integrative Health Care Clinic (IHCC) provides 12 nonpharmacological adjunctive therapies that assist patients with mind-body-spirit healing, health promotion, and self-empowerment. The therapies offered include acupuncture, "Choosing to Heal" classes, guided imagery for surgical preparation, herbal and nutritional supplement consultation with a pharmacist, medical hypnosis, meditation, a nondenominational prayer group, qigong movement classes, aquatic classes (e.g., Watsu, aquatic movement), yoga, Native American healing ceremonies, a multidisciplinary tobacco cessation program, and weight management programs.

Clinic Operations
Patients are referred to IHCC by primary care providers or specialty services, such as neurology, neurosurgery, mental health, rheumatology, pain management, women's health, physical medicine and rehabilitation, or cardiology, for an intake assessment. The assessment includes a review of systems, physical health, surgical history, emotional health, quality of life, and spiritual well being. In addition to the intake assessment, patients complete the Beck Depression and Beck Anxiety Inventories as well as the SF-36^® Health Survey (Medical Outcomes Trust, Inc., Boston, MA) as a measure of mental health and quality-of-life indicators over time. Following the assessment and review of integrative health therapies, patients, in partnership with the intake providers, choose the therapies in which they want to participate. Then, appointments are made with therapy providers or patients enroll in one or more of the self-empowerment classes. Eighty percent of patients at the clinic experience chronic pain, with back and neck pain among the top diagnoses. The most prevalent secondary diagnosis is a mental health diagnosis, with depression and anxiety as leading diagnoses. The remaining 20% of diagnoses include lifestyle, stress management, and primary mental health issues.

Gaining Medical Staff Acceptance
The initial identification of baseline physician and midlevel provider knowledge of integrative health in the institution was key. Hospitalwide education was initiated and interviews were conducted. Interviews in the in- and outpatient areas revealed that the staff and administrators were supportive of the holistic concept as long as the therapies were efficacious and cost effective. The hospitalwide interviews also uncovered a wealth of therapy skills the staff already had but did not have an avenue to use. Therefore, all of the therapies at IHCC are provided by SLCVA staff.

The clinic started small and offered therapies that were research-based, such as acupuncture and medical hypnotherapy. The next step was to ensure that IHCC therapies and providers were approved through the same hospital board as conventional treatments and providers. A standardized application and approval process for CAM therapies was developed that requires information about risks, benefits, and reported research on the modality. The CAM therapies offered through IHCC go through the same approval process as Western medicine therapies and are reviewed and approved by the hospital clinical executive board. Therapy providers are required to be certified in the modality they provide. Most providers already were employed by SLCVA as physicians, PhDs, graduate-prepared nurses, social workers, physical therapists, or nutritionists. Even though most of the CAM providers were on the professional staff, they were required to apply for the positions and were reviewed and approved by the hospital credentialing and privileging board.

Developing a Cost-Effective Clinic
The IHCC therapy providers maintain their primary roles of delivering traditional medical care but have been approved through their managers to provide a class or modality during a block of time every week. The IHCC is a virtual model and uses clinic space one day each week for intake assessments. The same space then is used by other clinics on the remaining days of the week. This allows for low overhead cost. The program is operated by two part-time codirectors and a clinical support manager. All classes are held on the SLCVA campus: No referrals are made to outside contactors or clinics, which assists with cost containment. Insurance companies are billed for acupuncture, hypnotherapy, and some of the group classes for patients who carry private insurance. Copayments are required for therapies and classes based on patients' military service connection.

Patient Response
The IHCC has been very successful, and more than 575 patients have been referred to the service. Patients report that they are able to begin to take control of their lives and change their attitudes to have a more positive and proactive outlook on life. Patients still may live with a measure of chronic pain and illness, but they no longer are focused on or controlled by their conditions. Often, with a combination of traditional medical care, acupuncture, and hypnotherapy, patients have been able to significantly reduce their dosages of pain and narcotic medication and gain more freedom in their lives. Other patients report reducing or no longer needing mood-stabilizing medications. Some movement therapies, such as yoga, qigong, and the aquatic program, have improved patient mobility and further reduced pain. Many patients have benefited from the weight management and smoking cessation classes and have lost as many as 100 pounds and quit smoking. Overall, patients who follow through and choose to participate in the integrative health therapies and classes have improved their quality of life as measured by the SF-36 Health Survey and Beck depression and anxiety measures.

Future of Integrative Health
The use of CAM has grown rapidly in the United States (Barnes, Powell-Griner, McFann, & Nahin, 2004), with more than a third of adults reporting that they have pursued some kind of CAM treatment, including herbal remedies, acupuncture, and other holistic therapies ("Complementary and Alternative Medicine," 2005). The substantial increase in CAM use and expenditures is attributed primarily to the greater numbers of people seeking CAM therapies rather than to increased numbers of visits to CAM providers per client (Eisenberg et al., 1998). However, the same rules of evidence of effectiveness and safety must be applied regardless of the origin of the therapy.

The SLCVA integrative healthcare approach offers a beneficial option for managing chronic pain and illness and improving quality of life. The clinic has been in operation for four years and is accepted widely. Patients now have a clinic that offers new options to address psychosocial and physical health that uses a mind-body-spirit approach to managing chronic conditions. Providers also have another option for patients who are difficult to manage or in cases when medication, surgery, physical therapy, and mental health services don't seem to be enough. We believe that integrative health care will be the new medicine of the future.

References

Barnes, P.M., Powell-Griner, E., McFann, K., & Nahin, R.L. (2004). Complementary and alternative medicine use among adults: United States, 2002. Advance Data, 343, 1–19.

Complementary and alternative medicine in the United States. (2005). Washington, DC: National Academies Press.

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.

Sobel, D.S. (2000). The cost-effectiveness of mind-body medicine interventions. Progress in Brain Research, 122, 393–412.

An Oncology Nurse Shares Her Experience With Cancer

I love being an oncology nurse. When I was diagnosed with colon cancer in October 2001, I thought I could work during treatment. I thought that I was different from my patients. A few months passed before I realized that I was just another person with cancer. Being an oncology nurse did not make me immune to side effects. I was very strong and matter-of-fact while receiving my diagnosis. I tried to find oncology nurses who had experienced cancer and were undergoing treatment. I got in contact with a few nurses, but they had gone through treatment 20 years previously. I thought that I wanted to connect with a colleague who was going through the same experiences. I joined the Survivorship and PNI and Complementary Therapies SIGs.

Nausea was a problem I faced even though I didn't lose any weight. One of my patients, who was an RN receiving treatment for lymphoma, suggested acupuncture. She had met a woman, Fran, who was doing Body Talk, a noninvasive centering of energy through muscle testing. After I met Fran, she taught me Reiki and Body Talk. I also received acupuncture, which helped to alleviate the nausea I was experiencing. I wanted to absorb all I could to help my body heal itself. I had always been interested in complementary therapies but had never incorporated them into practice.

In January 2003, I received a flyer about the Comprehensive Cancer Care Conference sponsored by the Center for Mind-Body Medicine in Washington, DC, where credible medical oncologists and herbalists would present. Keith Block, MD, from Chicago, IL, has an integrative oncology practice. Mitchell Gaynor, MD, from New York, NY, has written a book on sound therapy. Ben Carson, MD, a pediatric neurosurgeon from Johns Hopkins University in Baltimore, MD, shared a story of a family who was referred to him because their young son had a brain stem tumor. The child now is graduating from college. Donnie Yance, Jr., CN, MH, AHG, an herbalist from Ashland, OR, has been working with patients with cancer for 20 years and has written a wonderful book titled Herbal Medicine, Healing and Cancer. James Gordon, MD, the director of the Center for Mind-Body Medicine, has been incorporating complementary and alternative medicine (CAM) therapies with conventional chemotherapy for years. He teaches first-year medical students as part of a five-year grant from the National Institutes of Health designed to develop and implement a comprehensive program that integrates complementary and alternative therapy into the School of Medicine curriculum at Georgetown University in Washington, DC.

In August 2004, I found out that I had metastatic disease to my lungs. How could that be? I thought that the cancer would come back in my liver if it ever did. The experience was totally different for me this time. I knew the statistics for metastasis. I sometimes think that as an oncology nurse I know too much. I read all of the literature and attended programs sponsored by drug companies that discussed the outcomes for many types of cancer. I was scared this time. I wanted my family to be close. My husband has come to every office visit and treatment even though I told him in 2001 that he didn't need to take time off from work to take me to treatments. Family and support groups are so important. I often wondered where our wonderful patients got their strength to fight. Now I know.

My experience with cancer is grounded in my firm belief in God and that my life is in His hands. I find that being proactive by educating myself about the diagnosis and possible integrative treatments is very important. Even though I have told my patients about many resources to help with nausea, fatigue, hair loss, and other side effects, I seem to have forgotten them and need to be reminded about what to do. Of course, I blame a lot of it on "chemo brain." My children have said that I was that way before chemotherapy. Never lose your sense of humor. Laughter is the best medicine!

I had the most remarkable experience at Congress this year. I had not attended since 2001. Jody Owens, BSN, RN, asked me to help her with the Rejuvenation Room. I did Reiki for three days on everyone who wanted it. What a great experience! Everyone was so receptive. I felt honored to be able to give to my fellow oncology nurses. I think that recognizing the mind-body-spirit connection through this clinical practice at Congress is important. Please let me hear from you about your experiences as a practitioner or recipient of CAM.

Listening Can Be a Therapeutic Modality

A classic Simon and Garfunkel song is titled "The Sound of Silence," and as I contemplated trying to hear what silence sounds like, I realized what a difficult task I undertook. In our beautiful world, silence, or the total absence of sound, seems to exist only for those who are deaf. Even in a remote campground during the still of the night, an intent listener can hear the sounds of nature and one's own breathing and heartbeat. In the everyday world of modern professional people, we are inundated with a cacophony of sound. This barrage of sounds would make us crazy if we focused on each one, so we've learned to tune out and ignore the majority and focus only on what we need to hear.

Sounds abound. We, too, make sounds, adding our voices to the oceans of vibrations surrounding us. Many of us have said, "I can't even hear myself think," when the turmoil of inner sounds and those voices in our heads that are observing, evaluating, and advising us, are working diligently. Those who work as healers understand the importance of learning to focus, quiet the body and mind, and become grounded and tranquil before beginning a treatment on someone else. One's energies cannot be scattered. Mindfulness, or focusing with intent, changes the energetic body of the healer, creating a powerful field of coherent resonance.

Billions of human beings live on this planet, and each has a unique story in his or her DNA. The human infant whose cries are ignored soon withers and dies, losing its will to live. Communication is vital to survival. Unfortunately, though, we've conditioned ourselves to block out sounds and become selective in our hearing. We may be inadvertently neglecting an activity that could be profoundly beneficial to ourselves or others.

To listen intently and compassionately to another without judging or giving advice requires an emptying of ego and frees the listener to exist in a state of peace. The speaker is honored as a person of worth who has the responsibility for making the choices that will guide his or her life path. Listening validates the uniqueness of the speaker and the tapestry of life that the speaker has woven. The listener is given the opportunity to personify compassion. By focusing on the present, the listener reaps the benefits of contemplation, which can include decreased blood pressure and stress and increased relaxation. The speaker becomes more relaxed as the story is uninterrupted by criticism or evaluation. Ultimately, no one can solve a problem for another, but we can provide an environment in which another is free to see the implications of his or her choices.

An "Ears to You" listening service could be practiced by people other than medical professionals. Many people feel great stress relief after their hairdresser or bartender listens to them. We, as healers, can raise people's awareness of the value of the acts of listening that they perform naturally. They can be taught to raise their intention to promote the body-mind-spirit wellness of others.

Patients who may feel worthless because of physical limitations can be made aware of the tremendous power they have to help others through active listening and paying attention. We are all planetary pilgrims, helping and being helped. As the Simon and Garfunkel lyrics indicate, people can talk without speaking and hear without listening. May this be transformed by the energetic dynamic created between the compassionate listener and the honored speaker. Both will benefit.

Get Your Copy of the Clinical Practice Guidelines for Quality Palliative Care

The National Consensus Project for Quality Palliative Care, a task force under the guidance of the American Academy of Hospice and Palliative Medicine, the Hospice and Palliative Nurses Association, and the National Hospice and Palliative Care Organization, has released the Clinical Practice Guidelines for Quality Palliative Care. The guidelines describe the essential components of an evidence-based palliative care program and are intended to be used to establish definitions of palliative care, develop new palliative care initiatives and improve existing strategies, create goals for patient access to this type of care, and ensure continuity of palliative care in various healthcare settings. The guidelines are divided into the following eight domains.

• Structure and processes of care
• Physical aspects of care
• Psychological and psychiatric aspects of care
• Social aspects of care
• Spiritual, religious, and existential aspects of care
• Cultural aspects of care
• Care of the imminently dying patient
• Ethical and legal aspects of care

The Clinical Practice Guidelines for Quality Palliative Care can be downloaded at no charge at http://www.nationalconsensusproject.org/. To learn more about the guidelines or the National Consensus Project for Quality Palliative Care, contact Project Coordinator Ken Zuroski at 412-787-1002 or kenz@hpna.org.

Membership Information

PNI and Complementary Therapies SIG Officers

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ONS Membership/Leadership Team Contact Information

Angie Stengel, Director of Membership/Leadership
astengel@ons.org
412-859-6244

Diane Scheuring, Manager of Member Services
dscheuring@ons.org
412-859-6256

Carol DeMarco, Membership/Leadership Administrative Assistant
cdemarco@ons.org
412-859-6230

The Oncology Nursing Society (ONS) does not assume responsibility for the opinions expressed and information provided by authors or by Special Interest Groups (SIGs). Acceptance of advertising or corporate support does not indicate or imply endorsement of the company or its products by ONS or the SIG. Web sites listed in the SIG newsletters are provided for information only. Hosts are responsible for their own content and availability.

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