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,
This article appears courtesy
of Alternative Therapies in
Health and Medicine.
Fenton, RN, DrPH, FAAN,Professor, School of Nursing,
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
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.
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.
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.
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 were to:
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.
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.
Estimate what percentage and to what extent US Baccalaureate and higher degree
schools/departments of nursing incorporate complementary and alternative
modalities into their curricula.
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.
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.)
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.
Listing of Complementary and Alternative
Modalities Included in Survey
Special Diet Therapies
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.
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.
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
Table 1 Key Survey
faculty certified as holistic nurses by AHNCC
endorsed by AHNCC
with the AHNA definition of holistic nursing (ranging
from "somewhat familiar" to "familiar to a great
with Holistic Nursing Core Curriculum (ranging from
"somewhat familiar" to "familiar to a great extent")
definition of holistic nursing in any course
complementary and alternative modalities in curricula
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.
Table 2 Top 20 Complementary and
* The number of programs
is more than the total sample size because many schools had more
than one program including BSN, Master’s, and Doctoral programs.
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.
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
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.
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.
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
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
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.
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
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,
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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