The Integration of Holistic Nursing Practices and Complementary and

Alternative Modalities Into Curricula of Schools of Nursing

Mary V. Fenton, RN, DrPH, FAAN,Donna L. Morris, RN, CNM, DrPH

This article appears courtesy of Alternative Therapies in Health and Medicine.

Mary V. Fenton, RN, DrPH, FAAN,Professor, School of Nursing,

University of Texas Medical Branch, Galveston,Tex.
Donna L. Morris, RN, CNM, DrPH, Associate Professor,College of Nursing,

University of North Dakota,GrandForks, ND.

This study was performed at the School of NursingUniversity of Texas Medical Branch, Galveston, Tex.

Context: Schools of nursing in the United States have responded to the increasing consumer use of complementary and alternative modalities and consumer demand for health professionals knowledgeable in complementary and alternative modalities by incorporating holistic nursing practices and complementary and alternative modalities into their curricula.

Objective: To determine the extent to which US schools of nursing have incorporated holistic nursing practices and complementary and alternative modalities into their curricula.

Design: Electronic web-based survey

Setting: Surveys were sent to 585 US schools of nursing

Participants: Sample (n=125) of deans and directors (or their designees) of Baccalaureate and higher degree US nursing programs at schools holding membership in the American Association of Colleges of Nursing (AACN)

Main Outcome Measures: Demographics of US schools of nursing, percentages of schools who utilized the American Holistic Nurses' Association (AHNA) definition of holistic nursing practice and the Holistic Core Curriculum Guidelines, and percentage of complementary and alternative modalities incorporated into the curricula.

Results: Almost 60% (n=74) of the responding schools used the definition of holistic nursing practice in their curricula and were familiar with the Holistic Nursing Core Curriculum. The majority (84.8%, n=106) included complementary and alternative modalities in their curricula.

Conclusions: The study provides preliminary evidence that US schools of nursing are incorporating holistic nursing practices and complementary and alternative modalities into their curricula reflecting a response to increased consumer use of complementary and alternative modalities and consumer demand for health professionals who are knowledgeable about complementary and alternative modalities.

Nursing as a profession has long claimed the term holistic and has incorporated the word, using various definitions, into nursing literature and practice. Holistic nursing has often been a component of curricular philosophies and conceptual frameworks, as well as standards of practice, policies, and regulations. The adjective holistic relates to the theory that whole entities, as fundamental components of reality, have an existence other than as the mere sum of their parts.¹ This definition is further expanded by the American Holistic Nurses' Association (AHNA) definition of holistic nursing:

"Holistic nursing embraces all nursing which has as its goal enhancement of healing the whole person from birth to death. Holistic nursing recognizes that there are two views regarding holism: that holism involves identifying the interrelationships of the bio-psycho-social-spiritual dimensions of the person, recognizing that the whole is greater than the sum of its parts; and that holism involves understanding the individual as a unitary whole in mutual process with the environment. Holistic nursing responds to both views, believing that the goals of nursing can be achieved within either framework."²

However, since the publication of the AHNA Core Curriculum for Holistic Nursing in 1997,³ there has been no systematic documentation of the utilization of the definition of holistic nursing and the holistic standards in the curricula of schools of nursing in the US. The AHNA Core Curriculum includes many of the modalities and systems of health care that are currently termed complementary and alternative.

Increased consumer use of complementary and alternative modalities has been documented by Eisenberg et al⁴ and Kessler et al⁵ in studies reported in 1993 and 2001, respectively. Results of a mail survey of 125 US medical schools conducted in 1997 showed that 64% of those responding (n=75) offered elective or required courses in complementary or alternative medicine.⁶ The Rosenthal Center for Complementary and Alternative Medicine at Columbia University publishes a listing of complementary and alternative medicine courses taught at US Medical Schools on an annual basis.⁷ There has been no corresponding survey or statistical compilation for the approximately 600 schools of nursing in the US. This is partially due to the fact that medical schools are more homogenous and are affiliated with one major educational organization, the American Association of Medical Colleges (AAMC). Nursing schools are more heterogeneous in terms of the levels of education offered, the types of institutions in which the schools reside, and organizational affiliations. The American Association of Colleges of Nursing(AACN), counterpart to the AAMC, does not collect data in their annual survey regarding the incorporation of holistic concepts and complementary and alternative modalities.⁸

However, there is preliminary evidence in the literature that the same trend, toward the integration of complementary and alternative modalities, is occurring in schools of nursing as in schools of medicine.^9-12  This trend is not only in basic Baccalaureate nursing programs,¹³ but also in advanced nursing masters' programs such as nurse practitioner, nurse-mid-wifery, and clinical nurse specialist.^14-16  In a joint survey by the AACN and the National Organization of Nurse Practitioner Faculties (2002) over 95% of the responding nurse practitioner programs (n=679 programs in 275 schools) indicated course content in complementary and alternative modalities. Forty-seven of these programs offered separate courses.¹⁷

Currently, the following institutions offer majors or postmaster’s certificate programs in holistic nursing: New York University¹⁸ Tennessee State University,¹⁹ and the University of Colorado-Colorado Springs.²⁰ The College of New Rochelle School of Nursing has offered a post-master's certificate in holistic nursing or a master's degree as clinical nurse specialist in holistic nursing since 1992.²¹ Columbia University offers a subspecialty graduate program, Integrative Therapies in Primary Care.²² The University of Minnesota offers a graduate minor in Complementary Therapies and Healing Practices.²³ The University of California at San Francisco offers an Integrated Complementary Healing program for adult nurse practitioners.²⁴ San Diego State University offers an Integrative Health Care Option in their master's program designed to promote knowledge and skill in complementary and alternative approaches and the holistic diagnosis and treatment of common health problems.²⁵ A number of nursing schools, including the University of Missouri,²⁶ and the Medical University of South Carolina,²⁷ offer either separate courses or a series of courses in complementary and alternative modalities at both the masters and doctoral levels. This list was developed from the literature and institutional web-sites and is not exhaustive.

The National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health (NIH) has awarded grants to Schools of Nursing at the University of Minnesota, Rush University, and the University of Washington specifically for integration of complementary and alternative modalities into their curricula.²⁸ The Center for the Study of Complementary and Alternative Therapies at the University of Virginia at Charlottesville School of Nursing isf unded through NCCAM-NIH.²⁹ These schools and others have taken the lead in incorporating the concepts of holistic nursing and complementary and alternative modalities into their missions of education, research, and practice; however, it is not well documented whether these schools are outliers or if this is a national trend in nursing education.

There is evidence that state regulatory boards are increasingly considering complementary and alternative modalities as part of nursing practice. In a survey of State Boards of Nursing (n=53) by Sparber,³⁰ it was found that 47% (n=25) of the Boards of Nursing have general statements describing complementary and alternative modalities as being within the scope of nursing practice. Thirteen percent (n=7) reported that they had the topic under discussion and 40 % (n=21) reported that they have no formal position. Sixty percent (n=32) of the Boards of Nursing either have a statement that complementary and alternative modalities are within the scope of nursing or are in the process of developing a statement. The Federation of State Medical Boards has recently issued new model guidelines for the use of complementary and alternative modalities in medical practice.³¹ These guidelines are offered as consistent standards for the medical community and are not binding on the state medical boards, but their adoption or adaptation for use by each state board is encouraged.

In summary, there is evidence that consumers are using complementary and alternative modalities in increasing numbers, and that some schools of nursing and medicine are beginning to offer programs in this area. The federal government through NCCAM is offering research and education grants to increase the knowledge of health professionals in this area, and state regulatory systems are issuing guidelines for practice. Documentation is needed of whether or not the integration of complementary and alternative modalities in the curricula of US schools of nursing is a national trend. It is of utmost importance that nursing professionals be prepared to offer safe and knowledgeable care and guidance and counsel to their patients and communities regarding complementary and alternative modalities.

Changes in professional health education can occur in many ways. They may come about because governmental and private sources of funding become available to participating institutions. There may be state or federal regulations that require educational reform, such as in the case of emerging infectious diseases. Professional organizations may lead the reform by developing standards for education that are then used by accrediting, governmental, and regulatory agencies. Since the demand for education about complementary and alternative modalities is consumer driven rather than being required by the government, accrediting agencies, or regulatory bodies, the deans and faculties of schools of nursing must make the decision to embark on curriculum change to include holistic nursing standards and complementary and alternative modalities. A major consideration in this decision is often knowledge about what other schools of nursing are doing. Therefore, an electronic survey was developed, which included questions about the use of the AHNA's holistic nursing definition, the Holistic Nursing Core Curriculum, and complementary and alternative modalities.

STUDY OBJECTIVES

The study objectives were to:

1. Describe the characteristics of the schools of nursing (eg, number of faculty and students, number of nursing faculty certified by the American Holistic Nurses' Certification Corporation (AHNCC), and number of schools responding who are endorsed by AHNCC.

2. Estimate what percentage and to what extent US Baccalaureate and higher degree schools/departments of nursing incorporate the AHNA definition of holistic nursing and Holistic Nursing Core Curriculum into their curricula.

3. Estimate what percentage and to what extent US Baccalaureate and higher degree schools/departments of nursing incorporate complementary and alternative modalities into their curricula.

METHODS

Survey Design

Initially, it was decided that: the survey must be easy to complete; there must be access to explanatory information, such as the definition of holistic nursing and background regarding complementary and alternative modalities; there must be a quick turn around time; and, available technology should be used. In order to meet these requirements, it was determined that an electronic survey would be the best method.

An electronic web-based survey was developed by which the data could be submitted into an electronic database, which could be easily read into a spreadsheet or statistical package. An expert in survey design reviewed the survey. The data fields were designed so that information could be imported into an Excel file and analyzed using SPSS (Statistical Package for the Social Sciences). Approval was received from the University Institutional Review Board for the Protection of Human Subjects. The survey asked for demographic data about schools such as the number of faculty and students, the number of faculty certified as holistic nurses, and the number of programs endorsed by AHNCC.  In addition, participants were asked about their familiarity with the AHNA definition of holistic nursing and the incorporation of the Holistic Nursing Core Curriculum and complementary and alternative modalities into their curricula. The listing of complementary and alternative modalities was originally grouped by category based on the NCCAM categories, the AHNA classification, and the list of complementary and alternative modalities identified by Sparber ³⁰ in his survey of Boards of Nursing. The final list was revised after the pilot study in consultation with another researcher, who was developing a similar paper survey, so that data could be compared. (See sidebar.)

The survey was piloted with 21 subjects to assess its technical feasibility and ease of comprehension. These subjects included deans of Baccalaureate and higher degree schools of nursing of varying sizes and in different parts of the country, both public and private; faculty at the University of Texas Medical Branch (UTMB) School of Nursing; and, selected members of the American Holistic Nurses’ Association who are knowledgeable about complementary and alternative modalities. The pilot study revealed some technical difficulties such as differences in interpretation of the data fields and the loss of some surveys into cyberspace. Responses indicated that there was too much in depth information, which made the survey too lengthy. All of these issues were addressed before the final survey was distributed.

Sample

The web-based survey was accessed through a link in a cover letter e-mailed to 585 deans and directors of Baccalaureate and higher degree programs at schools holding membership in the American Association of Colleges of Nursing (AACN). The schools represented all regions of the country and all levels of the Carnegie Classification.³² The deans or directors were encouraged to either complete the survey themselves or to refer it to an administrator or faculty member who would have the necessary information.

Because we were aware that the interest and knowledge levels of the deans and faculties would vary from school to school and region to region, it was decided to link the survey to electronic websites such as the AHNA, NCCAM, and the online article by Sparber³⁰ regarding the survey of State Boards of Nursing. It was hoped that these web sites would provide additional information on the topic for respondents, who were interested or did not have current knowledge in the area, and might provide some incentive to complete the survey.

Data Collection

The original survey was sent to all schools in March 2002.  Follow-up surveys were sent two weeks and three weeks after the original distribution. Efforts to increase the response rate included contacting faculty members who had an interest in complementary and alternative modalities and asking them to contact their deans about completing the survey.

STUDY RESULTS

Surveys submitted by schools of nursing totaled 125, which represented a 21% response rate. The responses represented a wide sampling of nursing schools in the US. All regions of the country and 44 states were represented, including Hawaii. All levels of the Carnegie Classification³² were represented in the data. The sample included both large and small schools and all three levels of programs, Bachelor of Science in Nursing, Master of Science in Nursing, and Doctoral. The number of full-time faculty ranged from a minimum of 2 at the smaller schools to a maximum of 66 at the larger schools. The mean for full time faculty was 19.9 (SD=15.17) and part time faculty, 10.4 (SD=12.83). The minimum/maximum numbers for BSN students were 11/700,with a mean of 186.5 (SD=119.91). The minimum/maximum numbers for MSN students were 0/500 with a mean of 82.2(SD=90.42). The minimum/maximum numbers for doctoral students were 0/100 with a mean of 21.6 (SD=29.87).

Table 1 summarizes key survey results. Although 20.8%(n=26) of the schools reporting had faculty certified as holistic nurses by AHNCC, only 7.2% (n=9) responded that they had programs endorsed by AHNCC as meeting the Holistic Nursing Core Curriculum standards. According to AHNCC, at the time of the survey, there were 11 endorsed schools, nationwide. With regard to familiarity with the AHNA definition of holistic nursing, 89% (n=111) of the schools indicated familiarity ranging from "somewhat familiar" to "familiar to a great extent."  Responses indicated less familiarity with components of the Holistic Nursing Core Curriculum with approximately 54% (n=68) indicating that they were "somewhatfamiliar" to "familiar to a great extent." A majority of the schools (59%, n=74) responded "Yes" to the question, "Does your school specifically use or refer to the definition of holistic nursing in any of its courses?"

Eighty-five percent (n=106) of the respondents answered that complementary and alternative modalities were included in their curricula. The top twenty modalities are listed in Table 2.

All of the modalities listed in the survey were included in the responses. The data reflect increasing evidence that complementary and alternative modalities are being incorporated into the curricula of schools of nursing: 97% (n=121) of the sample either had courses or were planning to offer them; 15%(n=19) reported that they had separate required courses; and,36.8% (n=46) had separate electives in complementary and alternative modalities. Although schools indicated that they teach more elective than required courses, the fact that courses are starting to be required reflects a growing interest among the schools. Twenty-eight percent (n=35) of the schools offer continuing education courses in complementary and alternative modalities.

An impressive list of course titles (n=74) was reported with the most common course titles (n=37) being variations including the words "complementary" (n=18), "alternative" (n=14), "holistic" (n=14), and "healing" (n=16). Most courses appeared to be general survey or introductory covering a variety of modalities. There were also specific courses in healing touch, Therapeutic Touch, herbal medicine, humor, massage, Chinese medicine, spirituality, stress reduction, and homeopathic medicine.

DISCUSSION

The high incidence of familiarity with and use of the AHNA definition of Holistic Nursing Practice indicates that the term has been incorporated into the curricula of a representative sample of nursing schools. There is also high familiarity with the Holistic Nursing Core Curriculum in the sample. The low percentage of schools with programs endorsed by the American Holistic Nurses Certification Corporation (AHNCC) may indicate that schools are not aware of the endorsement process or have not determined it to be important at this time. Cost may also be a factor. Deans and directors of the schools would have to be supportive of the endorsement process even if they did not instigate it. So, a question that could have been asked is whether or not the dean or director would support AHNCC endorsement of the school’s programs.

There is growing evidence that US schools of nursing are responding to consumer demand by providing learning opportunities in complementary and alternative modalities for nursing students and practicing nurses. This finding is extremely important as other surveys have found that nurses, more than other licensed health professionals, are not only  interested in having adequate information on complementary and alternative modalities to advise and refer patients to complementary and alternative providers, but they are also interested in providing many modalities themselves, and in becoming certified or credentialed in those modalities.  According to Kreitzer,³³ the modalities that nursing school faculty would most likely practice are: aromatherapy, herbal medicine, homeopathy, music, nutritional supplements, prayer/spiritual healing, and therapeutic touch.  Concurrently, State Boards of Nursing are developing practice guidelines for nurses to provide complementary and alternative modalities. Because the Boards’ main charge is to insure the safety and protection of the public, the next step will be to require approved coursework or certification in the area of practice. Thus, the need for schools of nursing to provide their faculties with formal courses, which provide academic credit as well as continuing education, is critical.

A limitation of the study is the sample size. Although the sample size is small, it seems representative of all sizes and types of schools of nursing in all regions of the US. However, because of the low response rate (21%), it is possible that those who responded were most favorable toward holistic nursing and alternative and complementary modalities, which would bias the results. It was noted that only 9 of the 11 AHNCC endorsed programs responded to the survey. Yet, a cursory review of web sites showed that a considerable number of non-responding schools of nursing include holistic concepts and complementary and alternative modalities in their programs.

A major reason for the low response rate was technology issues. Many respondents notified us via e-mailed that their computers could not open the survey. Our computer staff provided assistance for those who contacted us, but there may have been many potential respondents who did not notify us that they were having difficulty. Most of the problems were related to the state of technology at the schools or the respondent’s lack of computer skills in responding to an electronic survey. There were a number of instances of responses being submitted, but not received. When we knew a survey had been returned by a respondent but not received, we contacted the respondent and asked them to resend it. In retrospect, a disadvantage of an electronic survey is that incompatible levels of technology and lack of computer experience on the part of the respondents will affect the response outcomes. A major advantage of an electronic survey is that the data analysis is much less time consuming as the data can be automatically entered into a database when they are received and analyzed immediately. In retrospect, an electronic survey may be too challenging for the level of technology available in many schools of nursing. For future research, the response rate might be improved by sending follow-up paper surveys to non-responding schools.

CONCLUSIONS AND IMPLICATIONS FOR NURSING

This exploratory study is one of the first to provide in-depth information about nursing curricula, nationwide, that include holistic concepts and complementary and alternative modalities. It is one of the first electronic surveys of US schools of nursing of this scope. There is evidence that holistic nursing practice, as defined by the AHNA, is being incorporated into the curricula of schools of nursing in the US.  Almost 60% (n=74) of the responding schools stated that they use the definition of holistic nursing practice in their curricula and were familiar with the Holistic Nursing Core Curriculum (n=68). However, it is not known to what extent faculties are actually incorporating the holistic core curriculum into their nursing programs. Less than 10 % (n=9) of the respondents reported programs endorsed by AHNCC and only 20.8%(n=26) of the schools had faculty certified in holistic nursing.  The vast majority (84.8%, n=106) of the responding schools included complementary and alternative modalities in their curricula, reflecting a response to consumer demand for health professionals knowledgeable about complementary and alternative modalities.

Based on findings in this study, it appears that there may be a trend among schools of nursing to integrate the concepts of holistic nursing and complementary and alternative modalities into their curricula.  Annual follow up surveys need to be conducted to document this trend. 

Accrediting agencies such as the Council on Collegiate Nursing Education (CCNE) or the National League of Nursing (NLN) could accomplish this by including questions in their annual surveys of schools of nursing.

The study has many implications for nursing education and research. More evidence based research needs to be conducted in those complementary and alternative modalities that are being integrated into nursing practice. Faculty development needs to be vigorously addressed. Competencies in complementary and alternative modalities for baccalaureate and advanced practice levels must be identified if schools of nursing are to pro-vide competent practitioners in these areas. Consensus needs to be reached as to the areas of nursing practice, which would be most conducive to use of complementary and alternative modalities. Nursing professionals must be prepared to meet the challenges presented by the integration of complementary and alternative modalities into the healthcare system.

Acknowledgments

The authors extend our appreciation to the American Holistic Nurses’ Association and the following people at the University of Texas Medical Branch for their expertise and support in the development and conduct of this study: Robin Froman, RN, PhD, Derrick Karacostas, BS, Olusanya Koleosho, MBA, Betty Littleton, BA, Zena Mercer, MS, Isaac Ohalete, MS, Steve Owen, PhD, Trish Richards, RN, PhD, Ajaz Shah, MS, and Victor Sierpina, MD. 

This publication was made possible in part by Grant #AT00586-02, "Evidence-based Curriculum in Alternative Therapies" from the National Center for Complementary & Alternative Medicine of the National Institutes of Health (NIH), Principal Investigator: Victor Sierpina, MD. Its contents are solely the responsibility of the authors and do not necessarily represent the views of NCCAM.

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