- Email: [email protected]
Relatives’ lived experiences of complementary therapies in a critical care department – a phenomenological study
147 AUSTRALIAN CRITICAL CARE
Relatives’ lived experiences of complementary therapies in a critical care department – a phenomenological study Bebe Brown • RN ICUCert MRCNA Jenny Barnes • RN CritCareCert RenalCert MN Margaret Clarke • RN CritCareCert BN Lyn Medwin • RN ICUCert Andrea Hutchinson • RN CritCareCert Karen MacMillan • RN CritCareCert BN Gemma O’Rourke • RN CritCareCert Camillus Parkinson • RN CritCareCert PhD Alison Pickering • RN ICUCert Kirsty Roberts • RN CritCareCert RM Department of Critical Care Medicine Royal Hobart Hospital, Tasmania
ABSTRACT:– This phenomenological study examined relatives’ lived experiences of complementary therapies in the Department of Critical Care Medicine at Royal Hobart Hospital. Participants in the study, 20 relatives of critically ill patients, were involved in a nonstructured, audiotaped interview. Subsequently, transcripts were analysed using a phenomenological transformative process to identify common themes in the text. Study findings suggested four emerging conceptual categories, which with further analysis uncovered the essence of the phenomenon as extending and enriching a caring atmosphere. Brown B, Barnes J, Clarke M, Hutchinson A, MacMillan K, Medwin L, O’Rourke G, Parkinson C, Pickering A & Roberts K. Relatives’ lived experience of complementary therapies in a critical care department – a phenomenological study. Aust Crit Care 1999; 12(4):147-53.
INTRODUCTION
Our mission is not only to comfort, cure and relieve, it is also to be vehicles for enlightenment. We can only achieve this spec-ial goal if our purpose is to show that times of illness are times for reflection and opportunities for spiritual awareness and growth. Through touch, smell, taste, sight and hearing, the ill and the grieving can search for light and meaning in their ex-periences 1.
Today, many nurses are embracing therapies such as massage, aromatherapy, music, reflexology, shiatsu and acupuncture, to name but a few, that give their patients a sense of well-being. The use of complementary therapies as an adjunct to orthodox medicine needs to be validated if their effectiveness as forms of therapy/care is to be accepted by health-care professionals. The relevance of research into complementary therapies is justified on the understanding that minimal studies have been undertaken on their application in critical care nursing. The vast majority of the literature on complementary therapies is based on anecdotal information and not informed by a research methodology. This has created a barrier to their acceptance and implementation by many health-care professionals. One of the main reasons given for a lack of such evidence is the difficulty in measuring the results of these therapies3. The perceived outcomes of complementary therapies are highly individual and subjective and any study of such may not easily be conducted using traditional quantitative scientific methodology, which usually aims to provide results that are quantitative, generVOLUME 12
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alisable and replicable 4. However, qualitative methodologies such as phenomenology, which acknowledges the value of individual experiences as a form of knowledge generation, may be more appropriate 3, 4. The aim of this study was to reveal the lived experiences of the relatives of critically ill patients following implementation of a range of complementary therapies in the Department of Critical Care Medicine. They included aromatherapy, massage, music, reiki and either Bach Flower Rescue Remedy ® or Australian Bush Flower Emergency Essence ® (Table 1).
LITERATURE REVIEW A comprehensive review of the literature focused on music therapy, aromatherapy, massage and reiki within the critical/intensive care setting. It appears complementary therapies have been embraced by the nursing profession and this is reflected in the wealth of anecdotal and personal accounts that appear in a wide range of nursing journals 6-11. Although there are many such accounts in the literature, little research has been conducted in the critical care area. Price and Price 12 provide a review of three unpublished studies undertaken in intensive care units (ICUs) in the United Kingdom. At Royal Sussex County Hospital, foot massage with essential oil of lavender was shown to lower the blood pressure, heart and respiratory rates of people in intensive care. A similar trial carried out at the London Middlesex Hospital using the essential oil of neroli DECEMBER 1999
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Table 1. Glossary of terms used. • Australian Bush Flower Emergency Essence ® – preparation of five different remedies from the Bush Flower range of essences designed to aid the return of a positive outlook when comfort and reassurance are needed, particularly during times of emotional demand and stress (physical, emotional, mental and spiritual). • Bach Flower Rescue Remedy ® – the British equivalent of Emergency Essence. A combination of five flower essences from the Bach range of remedies, Rescue Remedy encourages the body’s own potential to look after itself by helping to restore a positive outlook. • Complementary therapies is a term “ … increasingly being used in the Western world to denote a group of Natural Therapies which have a growing legitimacy and wide public support. ‘Complementary’ implies appropriate use in conjunction with, or in place of, orthodox medicine. The most suitable approach is chosen according to the best outcome for the client. Complementary therapies are not considered either inferior or superior to orthodox medicine. All have their area of effectiveness in a comprehensive, flexible and productive system of health care 2 [p5]. • Effleurage – a basic massage stroke in which the movements are superficial or deep, gliding, long, rhythmic strokes with the hand/s moving towards the heart. • Reiki – a technique in which the hands are placed on the body of the recipient in a gentle and non-threatening way. The natural ‘life force energy’ (Chi) is channelled through the hands of the ‘giver’ to the recipient. Reiki treatments are used for relaxation, balance, and the promotion and restoration of vital energy to all levels of our being. • Reiki temporary attunement – a specific process in which the client is given the ability to use the reiki energy, on themselves or another, for a short period of time. • Reiki temporary attunement – a specific process in which a person is given the ability to use the reiki energy, on themselves or another, for a short period of time.
rather than lavender had similar outcomes. Royal Shrewsbury Hospital’s, pilot study on aromatherapy in coronary care found that positive outcomes could be obtained by the inhalation of essential oils without massage. A criticism of Price and Price’s 12 review, how-ever, is that they failed to provide methodological descriptions of these three studies. Henry 13 undertook a review of the research literature on the use of music therapy within ICUs, with the overall finding that it was an effective means of relieving pain and anxiety in many critical care patients. A meta-analysis of nine studies involving massage was undertaken by Labyak and Metzger 14, whose findings suggest that effleurage massage of at least 3 minutes’ duration to the back promotes biological and subjective relaxation. There is little in the literature on the practice of reiki in the acutecare hospital setting. Similarly, there were no reports on the effects of complementary therapies used as a way of supporting relatives of critically ill patients. None of the studies reviewed utilised phenomenology to investigate the subject of complementary therapies. Quantitative methods seem to predominate within critical care, but in recent times phenomenology is providing an insight into the ‘life world’ of both patients and their relatives 15, 16. From a review of the literature it is possible to see that the present study has significance, both in content and methodology.
METHODOLOGY
the reality of lived experience. Qualitative methodology preserves the uniqueness of the experiences and ‘life world’ of participants, there-by providing an ontological – that is, the way we exist in the world – understanding of their experience 19. A phenomenological study asks: ‘What is it like to have a certain experience?’ A hermeneutic approach was used to reveal the meaning behind the phenomena identified. “Phenomenology describes how one orients to lived experiences, [whereas] hermeneutics describes how one in-terprets the ‘texts’ of life” 22. Phenomenology allowed us to gain a deeper understanding of the meaning of an experience by inquiring about its nature or essence 23. Common meanings were then uncov-ered, to capture the essence of the lived experience as shared by participants in the study. Van Manen 20 stresses that phenomen-ological research should involve a series of interrelated activities: investigating the phenomenon of interest; experiencing the phen-omenon as it is lived; reflecting on the essential themes of the investigation; describing the phenomenon, and bringing it to speech. The technique chosen to interpret the meanings behind the phenomena in this study was an adaptation of the work of Reinharz 2, which uses a five-stage process (see Table 2) to transform experience into knowledge; that is, transform private experiences into public knowledge. The process of epistemological transformation involves not only the researchers and study participants but also a community of readers who will eventually transform the work.
Theoretical framework
PARTICIPANTS
This study adopts a qualitative perspective and complements the work of the many nurses who recognise the failure of the quantitative method to capture lived experiences 17, 18. Interpretive phenomenology was chosen to inform this study, with reference to the work of Heidegger 19 and van Manen 20. As an approach, phen-omenology guides one back from theoretical abstractions to
Participants selected for the study were 20 relatives of patients in the Department of Critical Care Medicine (Table 3). They were approached verbally or by letter following a minimum of two consultations with the complementary therapist. They were of varying backgrounds, ages and prior experiences of such therapies. Both male and female relatives were interviewed (age range 18-75 years) (Table 4).
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Table 2. The five-stage transformative process, as outlined by Reinharz in 1983 2. 1. The researcher creates an environment of trust in which participants’ lived experiences can be transformed into action and language. 2. Information disclosed by the participants’ original experience is then brought to some form of understanding as the researchers’ work with the data is shared. 3. From the researchers’ understanding of the data, conceptual categories or themes are developed to capture the nature of the experience. During this stage, the research team collectively studies the narratives taken from participants’ interviews. They will commonly share their interpretations of the data and reach consensus on the themes emerging from the transcripts. This technique provides an avenue by which such interpretations from the data can be verified. 4. A transformation of such private experiences into validated social knowledge is achieved through written documentation, sharing thoughts about the participants’ original experiences. 5. The written documentation undergoes further transformation by readers of the work, who in turn create their own understanding of the phenomenon/phenomena. Further verification of the researchers’ interpretation is facilitated at this final stage.
Table 3. Characteristics of the study setting. •
Table 4. Demographic data for the 20 participants.
Department of Critical Care Medicine – eight-bed general intensive care unit – six-bed coronary care/high dependency unit – four-bed cardiothoracic intensive care unit
•
• Grade/level III intensive care unit •
Casemix of admissions to intensive care – neurosurgical (trauma and post-operative) – trauma – major surgical (general and specialty) – medical emergencies – respiratory diseases – burns – paediatrics
Age 16-25 26-34 35-44 45-54 55-64 65-74 75-84
• Gender Male Female
N 2 – 8 5 2 2 1 5 15
• Previous personal experience with complementary therapies? Yes 8 No 12
• Average APACHE-II score for day 1 of 14
Procedures Participants signed a consent form indicating their willingness to participate. Pseudonyms were allocated to each, to ensure confidentiality prior to them being interviewed by a member of the research group. The study protocol was approved by the research and ethics committee of the hospital. All participants had aromatherapy, massage and reiki, with 12 choosing either the Rescue Remedy ® or Emergency Essence ® . Participants were asked to respond to the following question: ‘Within the Department of Critical Care Medicine we have been introducing a range of complementary therapies. What has this experience been like for you?’ It served as a starting point for the interview. Each researcher was then able to clarify issues related to the experience of each participant as they arose during a 10- to 30-minute semi-structured interview, which was audiotaped and subsequently transcribed. Each participant took part in a single interview, with no follow-up by the interviewer.
members of the research team. Consensus among all members was imperative, in order to avoid the risk of data manipulation. In an endeavour to maintain a just interpretation of participants’ experiences, a team approach to the transcript analysis was employed.
RESULTS From the lived experiences of participants in this study a central theme, ‘Extending and enriching a caring atmosphere’, was identified by the research team. Prior to their experience of the therapies, many of the relatives said they felt the nurses seemed genuinely concerned for them and their sick loved ones. Some went on to describe this as a special kind of love. Montgomery 23 calls this ‘nursing love’. Our research revealed that the complementary therapies enhanced this notion of caring by way of four sub-themes: ‘inspiring calm and relaxation’; ‘enhancing connectedness’; ‘humanising the technology’, and ‘the essence of being’, a spiritual dimension.
Inspiring calm and relaxation
Data analysis Utilising Reinharz’ 2 five-stage transformative process, the research team worked through each transcript, identifying the themes mani-fested. Interpretation of the text was validated by the 10 VOLUME 12
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Participants described the critical care environment as engendering feelings of intimidation, anxiety and fear. This experience is consistent with the findings of Walters 15 and Halm and Alpen 24, who identified such factors as predominating issues. The study revealed DECEMBER 1999
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that complementary therapies helped address these emotions by in-stilling a sense of comfort. This was succinctly captured in Bob’s description: “ ... all [complementary therapies] go toward a calming effect on a stressful situation.” Susan reinforced this when she stated: “ ... it just makes people feel more relaxed and comfortable; it’s not so daunting; it softens that overall effect.” Calm was also promoted through such interventions as aromatherapy and music (see Figure 1). Jill commented: “I liked the aromatherapy oils; I thought they had a nice effect. It was a much more softening effect within the intensive care unit.” Tanya, too, particularly enjoyed the aromatherapy and music: “I found using the oils and the music I was much more relaxed … I don’t know; it was just different. I’m usually always weepy in there; I was able to relax a lot.” Sleep deprivation was common among the relatives, and 10 said that the complementary therapies had helped them sleep and rest. Reiki and massage in particular alleviated sleep disturbances. Laura stated that her father-in-law “ ... actually slept those nights, where he wasn’t sleeping before.” Gaye stated (after therapy): “ ... it was very relaxing and it helped us an awful lot; we hadn’t slept for quite a few days and we all had a good night’s sleep that night.” Being the relative of a critically ill patient produced feelings of fear and anxiety among study participants. The complementary thera-pies helped minimise, and on occasions dissipated, these feelings, with the effects described as relaxing and calming, and as im-proving the ability to sleep.
Enhancing connectedness Walters 15 describes connectedness as involving the sharing of personal space through physical closeness, whereby forms of bodily engagement enable relatives to feel connected with their loved ones (Figure 2). The complementary therapies provided avenues for such expression as they had the added advantage of reducing feelings of helplessness. Laura supported this when she said:
... it was very important for me to feel that I could be doing something for him, not just sitting by his side holding his hand. By giving him massage and reiki I was actually contributing something to his healing, and that is very important, I think.
Melanie described it as a positive feeling: “ ... you were actually trying to do something to help instead of just standing around ... I could actually get in and do some hands-on stuff to help.” Brian described his experience as being the only way that “ … love could be expressed.” By massaging his son’s feet with essential oils, Brian could express his care in a stressful situation. Claire summarised her experience by saying that feelings of negativity were eliminated and positive affirmations conveyed through giving massage and reiki to her partner. All the participants responded in a similar manner to the experience of employing the complementary therapies, which helped reduce feelings of negativity and dispel feelings of useless-ness by allowing them to participate in the care of their loved one.
Humanising the technology A criticism of critical care units is that technology induces feelings of fear, confusion and isolation, and of being overwhelmed 23. The perceptions of these participants were no different; they described
Figure 1. Components of the complementary therapy program, including essential oils, rescue remedies and music.
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the environment as harsh and clinically cold. The complementary therapies balanced these perceptions by cultivating the human element and creating what some described as a ‘homely’ environment. Melanie felt the music and aromatherapy “ … took it away from being a hospital setting … made it a little bit more natural, and a little bit more homely and caring.” Jill found the music gave her something else to concentrate on, rather than the ‘beeps’ of the machines: “ ... it makes you feel a little less alien in the environment.” Susan said the experience of the complementary therapies made it less sterile, “ … making it all a little bit more human and a bit less like a scientist’s lab.” All participants found that the music and aromatherapy helped distract them from the noises of the ventilators, intravenous pumps and monitors. Tanya confirmed this when she said: “I was able to relax a lot; with the aromas and the nice music going, I just didn’t take much notice of all the machines and things.”
The essence of being – a spiritual dimension Chenoweth describes the spiritual dimension of people’s lives in different ways – as a “sense of meaning, purpose and fulfillment in life; as a sense of hope or will to go on; or as a belief and faith in an energy source greater than oneself.” Melanie (following a reiki session) supported this when she said: 1
... it was noticeable the strength I got from it. It was quite relaxing on one side, but very strong and positive on the other. It is very difficult to explain but it brought something out in you that just made you keep going.
Many relatives described the strength of their own individual belief system and the sense of empowerment they gained through the complementary therapies. Tracey validated this (following a reiki session) when she stated:
... in my mind I certainly felt empowered, and I thought that was good for him [her father], because then I could give him the healing powers ... I was transferring my energy onto someone who was also a believer; that’s a positive energy again.
Relatives felt that the complementary therapies actually reinforced and legitimised not only their beliefs and values but those of their loved ones. Mrs Murphy said:
... that would be something he would naturally do himself ... he would give rescue remedy ... he’d feel like he was being looked after in a way that he would identify with. I felt it was the right thing for him, and that we were actually supporting who he was, and the sort of person he was – his own spiritual beliefs.
Jill, the mother of a young man who died while in the critical care unit, talked about her son (Russell) and reiki: “ ... Russell would accept reiki, because it would help us [his family]. In our case, it’s helping us to think that we have an input, into making his life more comfortable or his experience more comfortable for him ... through our acceptance.” Chenoweth 1 states that during periods of ill health people often find it difficult to meet their spiritual needs because of the overwhelming presence of the medical model in healing today. Mrs Murphy summed this up when she said:
Figure 2. Enhancing connectedness – a relative gives a patient reiki surrounded by the technology of the ICU.
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... I was aware that everybody was working in his best interest, but I was very much an outsider; there was nothing I could really do to help him. I was concerned also that my husband, who was very close to our son, felt very disabled by the experience and didn’t have any way of feeling he could help or even bear the situation.
Mrs Murphy then went on to share that once her husband had been shown how to give reiki to their son, “ ... it was very empowering for him ... it helped Josh and my husband through a very critical period.” Alice reinforced Chenoweth’s 1 notion of the medical emphasis when she stated: “ … you find that all the focus is on the sick family member that’s in intensive care.” Complementary therapies provided an avenue for Melanie to meet her needs while surrounded by the medical model:
... it was not all medical, medical, medical – it was something different; it wasn’t always machines and drugs and doctors – it was very natural, very comfortable, very personal, particularly the reiki ... I was very grateful.
Many of the relatives described ongoing benefits that had developed from the introduction of the complementary therapies into their lives. Gaye talked about her use of rescue remedy following her son’s death:
... I definitely believe in the rescue remedy. I’ve used it here [at home] a few times ... I might cry a little bit but I’m not as emotional as what I would normally be without that, and it seems to work. Steve [her husband] isn’t a believer in anything like that but he’s been using it too.
Alice expressed the same feelings following a massage session and the use of rescue remedy:
... we can use it in our life after here; this, I think, has opened my mind that you can use it in your own life outside; it just doesn’t stop in ICU.
Three relatives spoke particularly about the benefits they gained and were able to carry with them to the funeral of their loved one. This aspect was emphasised when Heather said:
... I have never seen the care that was given through these complementary therapies and I just found it was a real warmth. I found it most beneficial up to a week after, when we had to deal with Nathan’s death and get through the funeral. The energy I got from the reiki I found very valuable and would draw on it.
All these participants strongly believed that experiencing the complementary therapies gave them ‘something’ they could take away, that gave them strength and enhanced the essence of their being. Mrs Murphy stated:
… we felt highly supported, beyond what seemed like our due; we felt we were being sort of carried forward to the next stage so that we could cope.
DISCUSSION This research can challenge aspects of nursing practice in the critical care environment. The medical technological boundaries VOLUME 12
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that have dominated practice have now been questioned, with the orientation towards addressing the experience of the relatives’ lived world in a critical care environment enabling the research team to uncover the meanings inherent in the experiences related here; others may have different experiences. Phenomenology does not generalise; rather, it puts forward one interpretation or possible experience. Despite the fact that this study elicited positive responses, limitations were recognised by the research team. Team members experienced frustration at their inability to articulate the stories in the manner in which they were shared by the participants. There was a richness and depth in the telling which, inevitably, was difficult to capture in the transcribing. In addition, relatives often used the interview as a means of expressing their gratitude for the care they received. As this was part of their overall lived experience, it had to be acknowledged. The researchers were cognisant of this and able to elicit the particular lived experiences of comple-mentary therapies. From a practical perspective, factors related to time and resources posed some difficulties. The employment of a complementary therapist for only 2 days per week limited the exposure of relatives to certain of the modalities provided, which in turn reflected on the number of participants available for the study. Although other staff members were capable of providing the complementary therapies, this was seldom possible due to their patient workload and associated responsibilities. Some participants had reservations about the type of music played, but this was overcome early on through the provision of personal stereo devices and music appropriate to individual tastes. Overall, the results of this study support Chenoweth’s concept that:
Simply ‘being there’, in itself, has been found to be a powerful motivation for healing. Unfortunately, health care today is so focused on scientific, evidence-based practice and cure of the biological manifestations of disease that just ‘being there’ has all but vanished. It is as if the spiritual dimension to life, while espoused in theory as an integral component of holistic care, is being ignored by most health care practitioners, not because they do wish to, but because it is not funded and therefore not valued 1.
RECOMMENDATIONS It is possible that other forms of nurturing and support may have provided similarly positive experiences for participants. There is thus the potential for further research into alternative mechanisms that may support relatives in the critical care environment. The findings of the study suggest that increasing the availability of a therapist would enhance patients’ and relatives’ access to com-plementary therapies. It is evident that such work could be further enhanced by providing interested staff with opportunities to under-take accredited courses and develop the provision of such therapies. The interviews highlighted the disappointment of relatives at the loss of the therapies when their loved ones were transferred from the critical care department. Thus, it would be desirable to provide ongoing complementary therapies after patients’ transfer to a ward. DECEMBER 1999
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CONCLUSION This research has provided an insight into, and a new understanding of, the care of relatives of critically ill patients within the critical care setting. Phenomenology as a research methodology provided an avenue for relatives involved in the research to tell their story as it was being lived during their loved ones’ time in the ICU. The research team was interested in understanding the relatives’ lived experiences as a way of uncovering the meaning of complementary therapies within a technological space. Results of this study suggest that complementary therapies can positively influence relatives’ lived experience. Relatives of patients in intensive care are under stress, whether they realise it or not, and coping can be facilitated by complementary therapies. The interpretations provided are yet to be transformed by those who read this work and thereby create their own understanding.
ACKNOWLEDGEMENTS The research team wishes to acknowledge the assistance of the Nursing Board of Tasmania’s Scholarship Grant 1998. We thank, too, our nursing, medical and allied health colleagues within the Department of Critical Care Medicine at the Royal Hobart Hospital, whose support and encouragement helped us change the culture within our unit. To the medical directors of our department, the medical division of the hospital management and the hospital auxiliaries goes our sincere appreciation. Recognition and thanks also to all the relatives who gave of their time and told us their stories; this paper is dedicated to them.
REFERENCES 1.
Chenoweth L. The Role of the Healing Arts in Nurturing the Human Spirit. Paper presented at the First National Complementary Therapy Conference, Brisbane, Australia, 1997 p 8.
2.
Reinharz S. Phenomenology as a dynamic process. Phenomenol & Pedagogy 1983; 1(1):77-79.
3.
McGourty H, & Hotchkiss J. Study rules. Nurs Times 1993; 89(36): 42-45.
4.
Hamilton D & Betchel A. Research implications for alternative health therapies. Nurs Forum 1996; 31(1):6-10.
5.
McCabe P, Ramsay L & Taylor B. Complementary Therapies in Relation to Nursing Practice in Australia. Discussion paper No. 2. Royal College of Nursing, Australia, 1995 p 5.
6.
Chigwidden S. Pre- and post-operative aromatherapy and music. Hospital 1997; 202:20-23.
7.
Hudson S. Complementary therapies and high tech care. Nurs J 1996; 4(4):34-36.
Aust
8.
Trevelyan J & Booth B. Fringe benefits. Nurs Times 1993; 89(17): 30-33.
9.
Tattam A. The gentle touch. Nurs Times 1992; 88(32):16-17.
15. Walters AJ. A hermeneutic study of the experiences of relatives of critically ill patients. J Adv Nurs 1995; 22:998-1005. 16. Gow J, Theobald K & Nagle C. A qualitative study of the spouse’s experience following coronary artery bypass surgery: implications for nursing practice. Paper presented, 19th Australian & New Zealand Scientific Meeting on Intensive Care, Brisbane, 1994. 17. Lumby J. Nursing: Reflecting on an Evolving Practice. Deakin University Press, Geelong, 1991. 18. Holmes CA. Resistance to positivist science in nursing: an assessment of the Australian literature. Int J Nurs Practice 1996; (2):172-81. 19. Heidegger M. Being and Time. Translated by Macquarie J & Robinson E. Harper & Rowe, New York, 1962. 20. van Manen M. Researching Lived Experience: Human Science for an Action Pedagogy. The State University of New York Press, Ontario, Canada, 1990. 21. Taylor B. Being Human: Ordinariness in Nursing. Churchill Livingstone, Melbourne, 1994. 22. Walters AJ. Heideggerian hermeneutic study of the practice of critical care nurses. J Adv Nurs 1995; 21:493. 23. Montgomery CL. The spiritual connection: nurses’ perceptions of the experience of caring. In: The Presence of Caring in Nursing. NLN Publication #15, 1993 pp 24-65, 39-52. 24. Halm MA & Alpen MA. The impact of technology on patients and families. Nurs Clin N America 1993; 28(2):443-57.
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10. Buckle J. Which lavender oil? Nurs Times 1992; 88(32):54-55. 11. Wise R. Flower power. Nurs Times 1989; 85(22):45-47. 12. Price C & Price M. Aromatherapy for Health Care Professionals. Churchill Livingstone, New York, 1995. 13. Henry L. Music therapy: a nursing intervention for the control of pain and anxiety in the ICU: a review of the research literature. Dimensions of Crit Care Nurs 1995; 14(6):295-304. VOLUME 12
14. Labyak S & Metzger B. The effects of effleurage backrub on the physiological components of relaxation: a meta-analysis. Nurs Research 1997; 46(1):59-62.
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Relatives’ lived experiences of complementary therapies in a critical care department – a phenomenological study Bebe Brown • RN ICUCert MRCNA Jenny Barnes • RN CritCareCert RenalCert MN Margaret Clarke • RN CritCareCert BN Lyn Medwin • RN ICUCert Andrea Hutchinson • RN CritCareCert Karen MacMillan • RN CritCareCert BN Gemma O’Rourke • RN CritCareCert Camillus Parkinson • RN CritCareCert PhD Alison Pickering • RN ICUCert Kirsty Roberts • RN CritCareCert RM Department of Critical Care Medicine Royal Hobart Hospital, Tasmania
ABSTRACT:– This phenomenological study examined relatives’ lived experiences of complementary therapies in the Department of Critical Care Medicine at Royal Hobart Hospital. Participants in the study, 20 relatives of critically ill patients, were involved in a nonstructured, audiotaped interview. Subsequently, transcripts were analysed using a phenomenological transformative process to identify common themes in the text. Study findings suggested four emerging conceptual categories, which with further analysis uncovered the essence of the phenomenon as extending and enriching a caring atmosphere. Brown B, Barnes J, Clarke M, Hutchinson A, MacMillan K, Medwin L, O’Rourke G, Parkinson C, Pickering A & Roberts K. Relatives’ lived experience of complementary therapies in a critical care department – a phenomenological study. Aust Crit Care 1999; 12(4):147-53.
INTRODUCTION
Our mission is not only to comfort, cure and relieve, it is also to be vehicles for enlightenment. We can only achieve this spec-ial goal if our purpose is to show that times of illness are times for reflection and opportunities for spiritual awareness and growth. Through touch, smell, taste, sight and hearing, the ill and the grieving can search for light and meaning in their ex-periences 1.
Today, many nurses are embracing therapies such as massage, aromatherapy, music, reflexology, shiatsu and acupuncture, to name but a few, that give their patients a sense of well-being. The use of complementary therapies as an adjunct to orthodox medicine needs to be validated if their effectiveness as forms of therapy/care is to be accepted by health-care professionals. The relevance of research into complementary therapies is justified on the understanding that minimal studies have been undertaken on their application in critical care nursing. The vast majority of the literature on complementary therapies is based on anecdotal information and not informed by a research methodology. This has created a barrier to their acceptance and implementation by many health-care professionals. One of the main reasons given for a lack of such evidence is the difficulty in measuring the results of these therapies3. The perceived outcomes of complementary therapies are highly individual and subjective and any study of such may not easily be conducted using traditional quantitative scientific methodology, which usually aims to provide results that are quantitative, generVOLUME 12
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alisable and replicable 4. However, qualitative methodologies such as phenomenology, which acknowledges the value of individual experiences as a form of knowledge generation, may be more appropriate 3, 4. The aim of this study was to reveal the lived experiences of the relatives of critically ill patients following implementation of a range of complementary therapies in the Department of Critical Care Medicine. They included aromatherapy, massage, music, reiki and either Bach Flower Rescue Remedy ® or Australian Bush Flower Emergency Essence ® (Table 1).
LITERATURE REVIEW A comprehensive review of the literature focused on music therapy, aromatherapy, massage and reiki within the critical/intensive care setting. It appears complementary therapies have been embraced by the nursing profession and this is reflected in the wealth of anecdotal and personal accounts that appear in a wide range of nursing journals 6-11. Although there are many such accounts in the literature, little research has been conducted in the critical care area. Price and Price 12 provide a review of three unpublished studies undertaken in intensive care units (ICUs) in the United Kingdom. At Royal Sussex County Hospital, foot massage with essential oil of lavender was shown to lower the blood pressure, heart and respiratory rates of people in intensive care. A similar trial carried out at the London Middlesex Hospital using the essential oil of neroli DECEMBER 1999
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Table 1. Glossary of terms used. • Australian Bush Flower Emergency Essence ® – preparation of five different remedies from the Bush Flower range of essences designed to aid the return of a positive outlook when comfort and reassurance are needed, particularly during times of emotional demand and stress (physical, emotional, mental and spiritual). • Bach Flower Rescue Remedy ® – the British equivalent of Emergency Essence. A combination of five flower essences from the Bach range of remedies, Rescue Remedy encourages the body’s own potential to look after itself by helping to restore a positive outlook. • Complementary therapies is a term “ … increasingly being used in the Western world to denote a group of Natural Therapies which have a growing legitimacy and wide public support. ‘Complementary’ implies appropriate use in conjunction with, or in place of, orthodox medicine. The most suitable approach is chosen according to the best outcome for the client. Complementary therapies are not considered either inferior or superior to orthodox medicine. All have their area of effectiveness in a comprehensive, flexible and productive system of health care 2 [p5]. • Effleurage – a basic massage stroke in which the movements are superficial or deep, gliding, long, rhythmic strokes with the hand/s moving towards the heart. • Reiki – a technique in which the hands are placed on the body of the recipient in a gentle and non-threatening way. The natural ‘life force energy’ (Chi) is channelled through the hands of the ‘giver’ to the recipient. Reiki treatments are used for relaxation, balance, and the promotion and restoration of vital energy to all levels of our being. • Reiki temporary attunement – a specific process in which the client is given the ability to use the reiki energy, on themselves or another, for a short period of time. • Reiki temporary attunement – a specific process in which a person is given the ability to use the reiki energy, on themselves or another, for a short period of time.
rather than lavender had similar outcomes. Royal Shrewsbury Hospital’s, pilot study on aromatherapy in coronary care found that positive outcomes could be obtained by the inhalation of essential oils without massage. A criticism of Price and Price’s 12 review, how-ever, is that they failed to provide methodological descriptions of these three studies. Henry 13 undertook a review of the research literature on the use of music therapy within ICUs, with the overall finding that it was an effective means of relieving pain and anxiety in many critical care patients. A meta-analysis of nine studies involving massage was undertaken by Labyak and Metzger 14, whose findings suggest that effleurage massage of at least 3 minutes’ duration to the back promotes biological and subjective relaxation. There is little in the literature on the practice of reiki in the acutecare hospital setting. Similarly, there were no reports on the effects of complementary therapies used as a way of supporting relatives of critically ill patients. None of the studies reviewed utilised phenomenology to investigate the subject of complementary therapies. Quantitative methods seem to predominate within critical care, but in recent times phenomenology is providing an insight into the ‘life world’ of both patients and their relatives 15, 16. From a review of the literature it is possible to see that the present study has significance, both in content and methodology.
METHODOLOGY
the reality of lived experience. Qualitative methodology preserves the uniqueness of the experiences and ‘life world’ of participants, there-by providing an ontological – that is, the way we exist in the world – understanding of their experience 19. A phenomenological study asks: ‘What is it like to have a certain experience?’ A hermeneutic approach was used to reveal the meaning behind the phenomena identified. “Phenomenology describes how one orients to lived experiences, [whereas] hermeneutics describes how one in-terprets the ‘texts’ of life” 22. Phenomenology allowed us to gain a deeper understanding of the meaning of an experience by inquiring about its nature or essence 23. Common meanings were then uncov-ered, to capture the essence of the lived experience as shared by participants in the study. Van Manen 20 stresses that phenomen-ological research should involve a series of interrelated activities: investigating the phenomenon of interest; experiencing the phen-omenon as it is lived; reflecting on the essential themes of the investigation; describing the phenomenon, and bringing it to speech. The technique chosen to interpret the meanings behind the phenomena in this study was an adaptation of the work of Reinharz 2, which uses a five-stage process (see Table 2) to transform experience into knowledge; that is, transform private experiences into public knowledge. The process of epistemological transformation involves not only the researchers and study participants but also a community of readers who will eventually transform the work.
Theoretical framework
PARTICIPANTS
This study adopts a qualitative perspective and complements the work of the many nurses who recognise the failure of the quantitative method to capture lived experiences 17, 18. Interpretive phenomenology was chosen to inform this study, with reference to the work of Heidegger 19 and van Manen 20. As an approach, phen-omenology guides one back from theoretical abstractions to
Participants selected for the study were 20 relatives of patients in the Department of Critical Care Medicine (Table 3). They were approached verbally or by letter following a minimum of two consultations with the complementary therapist. They were of varying backgrounds, ages and prior experiences of such therapies. Both male and female relatives were interviewed (age range 18-75 years) (Table 4).
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Table 2. The five-stage transformative process, as outlined by Reinharz in 1983 2. 1. The researcher creates an environment of trust in which participants’ lived experiences can be transformed into action and language. 2. Information disclosed by the participants’ original experience is then brought to some form of understanding as the researchers’ work with the data is shared. 3. From the researchers’ understanding of the data, conceptual categories or themes are developed to capture the nature of the experience. During this stage, the research team collectively studies the narratives taken from participants’ interviews. They will commonly share their interpretations of the data and reach consensus on the themes emerging from the transcripts. This technique provides an avenue by which such interpretations from the data can be verified. 4. A transformation of such private experiences into validated social knowledge is achieved through written documentation, sharing thoughts about the participants’ original experiences. 5. The written documentation undergoes further transformation by readers of the work, who in turn create their own understanding of the phenomenon/phenomena. Further verification of the researchers’ interpretation is facilitated at this final stage.
Table 3. Characteristics of the study setting. •
Table 4. Demographic data for the 20 participants.
Department of Critical Care Medicine – eight-bed general intensive care unit – six-bed coronary care/high dependency unit – four-bed cardiothoracic intensive care unit
•
• Grade/level III intensive care unit •
Casemix of admissions to intensive care – neurosurgical (trauma and post-operative) – trauma – major surgical (general and specialty) – medical emergencies – respiratory diseases – burns – paediatrics
Age 16-25 26-34 35-44 45-54 55-64 65-74 75-84
• Gender Male Female
N 2 – 8 5 2 2 1 5 15
• Previous personal experience with complementary therapies? Yes 8 No 12
• Average APACHE-II score for day 1 of 14
Procedures Participants signed a consent form indicating their willingness to participate. Pseudonyms were allocated to each, to ensure confidentiality prior to them being interviewed by a member of the research group. The study protocol was approved by the research and ethics committee of the hospital. All participants had aromatherapy, massage and reiki, with 12 choosing either the Rescue Remedy ® or Emergency Essence ® . Participants were asked to respond to the following question: ‘Within the Department of Critical Care Medicine we have been introducing a range of complementary therapies. What has this experience been like for you?’ It served as a starting point for the interview. Each researcher was then able to clarify issues related to the experience of each participant as they arose during a 10- to 30-minute semi-structured interview, which was audiotaped and subsequently transcribed. Each participant took part in a single interview, with no follow-up by the interviewer.
members of the research team. Consensus among all members was imperative, in order to avoid the risk of data manipulation. In an endeavour to maintain a just interpretation of participants’ experiences, a team approach to the transcript analysis was employed.
RESULTS From the lived experiences of participants in this study a central theme, ‘Extending and enriching a caring atmosphere’, was identified by the research team. Prior to their experience of the therapies, many of the relatives said they felt the nurses seemed genuinely concerned for them and their sick loved ones. Some went on to describe this as a special kind of love. Montgomery 23 calls this ‘nursing love’. Our research revealed that the complementary therapies enhanced this notion of caring by way of four sub-themes: ‘inspiring calm and relaxation’; ‘enhancing connectedness’; ‘humanising the technology’, and ‘the essence of being’, a spiritual dimension.
Inspiring calm and relaxation
Data analysis Utilising Reinharz’ 2 five-stage transformative process, the research team worked through each transcript, identifying the themes mani-fested. Interpretation of the text was validated by the 10 VOLUME 12
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Participants described the critical care environment as engendering feelings of intimidation, anxiety and fear. This experience is consistent with the findings of Walters 15 and Halm and Alpen 24, who identified such factors as predominating issues. The study revealed DECEMBER 1999
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that complementary therapies helped address these emotions by in-stilling a sense of comfort. This was succinctly captured in Bob’s description: “ ... all [complementary therapies] go toward a calming effect on a stressful situation.” Susan reinforced this when she stated: “ ... it just makes people feel more relaxed and comfortable; it’s not so daunting; it softens that overall effect.” Calm was also promoted through such interventions as aromatherapy and music (see Figure 1). Jill commented: “I liked the aromatherapy oils; I thought they had a nice effect. It was a much more softening effect within the intensive care unit.” Tanya, too, particularly enjoyed the aromatherapy and music: “I found using the oils and the music I was much more relaxed … I don’t know; it was just different. I’m usually always weepy in there; I was able to relax a lot.” Sleep deprivation was common among the relatives, and 10 said that the complementary therapies had helped them sleep and rest. Reiki and massage in particular alleviated sleep disturbances. Laura stated that her father-in-law “ ... actually slept those nights, where he wasn’t sleeping before.” Gaye stated (after therapy): “ ... it was very relaxing and it helped us an awful lot; we hadn’t slept for quite a few days and we all had a good night’s sleep that night.” Being the relative of a critically ill patient produced feelings of fear and anxiety among study participants. The complementary thera-pies helped minimise, and on occasions dissipated, these feelings, with the effects described as relaxing and calming, and as im-proving the ability to sleep.
Enhancing connectedness Walters 15 describes connectedness as involving the sharing of personal space through physical closeness, whereby forms of bodily engagement enable relatives to feel connected with their loved ones (Figure 2). The complementary therapies provided avenues for such expression as they had the added advantage of reducing feelings of helplessness. Laura supported this when she said:
... it was very important for me to feel that I could be doing something for him, not just sitting by his side holding his hand. By giving him massage and reiki I was actually contributing something to his healing, and that is very important, I think.
Melanie described it as a positive feeling: “ ... you were actually trying to do something to help instead of just standing around ... I could actually get in and do some hands-on stuff to help.” Brian described his experience as being the only way that “ … love could be expressed.” By massaging his son’s feet with essential oils, Brian could express his care in a stressful situation. Claire summarised her experience by saying that feelings of negativity were eliminated and positive affirmations conveyed through giving massage and reiki to her partner. All the participants responded in a similar manner to the experience of employing the complementary therapies, which helped reduce feelings of negativity and dispel feelings of useless-ness by allowing them to participate in the care of their loved one.
Humanising the technology A criticism of critical care units is that technology induces feelings of fear, confusion and isolation, and of being overwhelmed 23. The perceptions of these participants were no different; they described
Figure 1. Components of the complementary therapy program, including essential oils, rescue remedies and music.
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the environment as harsh and clinically cold. The complementary therapies balanced these perceptions by cultivating the human element and creating what some described as a ‘homely’ environment. Melanie felt the music and aromatherapy “ … took it away from being a hospital setting … made it a little bit more natural, and a little bit more homely and caring.” Jill found the music gave her something else to concentrate on, rather than the ‘beeps’ of the machines: “ ... it makes you feel a little less alien in the environment.” Susan said the experience of the complementary therapies made it less sterile, “ … making it all a little bit more human and a bit less like a scientist’s lab.” All participants found that the music and aromatherapy helped distract them from the noises of the ventilators, intravenous pumps and monitors. Tanya confirmed this when she said: “I was able to relax a lot; with the aromas and the nice music going, I just didn’t take much notice of all the machines and things.”
The essence of being – a spiritual dimension Chenoweth describes the spiritual dimension of people’s lives in different ways – as a “sense of meaning, purpose and fulfillment in life; as a sense of hope or will to go on; or as a belief and faith in an energy source greater than oneself.” Melanie (following a reiki session) supported this when she said: 1
... it was noticeable the strength I got from it. It was quite relaxing on one side, but very strong and positive on the other. It is very difficult to explain but it brought something out in you that just made you keep going.
Many relatives described the strength of their own individual belief system and the sense of empowerment they gained through the complementary therapies. Tracey validated this (following a reiki session) when she stated:
... in my mind I certainly felt empowered, and I thought that was good for him [her father], because then I could give him the healing powers ... I was transferring my energy onto someone who was also a believer; that’s a positive energy again.
Relatives felt that the complementary therapies actually reinforced and legitimised not only their beliefs and values but those of their loved ones. Mrs Murphy said:
... that would be something he would naturally do himself ... he would give rescue remedy ... he’d feel like he was being looked after in a way that he would identify with. I felt it was the right thing for him, and that we were actually supporting who he was, and the sort of person he was – his own spiritual beliefs.
Jill, the mother of a young man who died while in the critical care unit, talked about her son (Russell) and reiki: “ ... Russell would accept reiki, because it would help us [his family]. In our case, it’s helping us to think that we have an input, into making his life more comfortable or his experience more comfortable for him ... through our acceptance.” Chenoweth 1 states that during periods of ill health people often find it difficult to meet their spiritual needs because of the overwhelming presence of the medical model in healing today. Mrs Murphy summed this up when she said:
Figure 2. Enhancing connectedness – a relative gives a patient reiki surrounded by the technology of the ICU.
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... I was aware that everybody was working in his best interest, but I was very much an outsider; there was nothing I could really do to help him. I was concerned also that my husband, who was very close to our son, felt very disabled by the experience and didn’t have any way of feeling he could help or even bear the situation.
Mrs Murphy then went on to share that once her husband had been shown how to give reiki to their son, “ ... it was very empowering for him ... it helped Josh and my husband through a very critical period.” Alice reinforced Chenoweth’s 1 notion of the medical emphasis when she stated: “ … you find that all the focus is on the sick family member that’s in intensive care.” Complementary therapies provided an avenue for Melanie to meet her needs while surrounded by the medical model:
... it was not all medical, medical, medical – it was something different; it wasn’t always machines and drugs and doctors – it was very natural, very comfortable, very personal, particularly the reiki ... I was very grateful.
Many of the relatives described ongoing benefits that had developed from the introduction of the complementary therapies into their lives. Gaye talked about her use of rescue remedy following her son’s death:
... I definitely believe in the rescue remedy. I’ve used it here [at home] a few times ... I might cry a little bit but I’m not as emotional as what I would normally be without that, and it seems to work. Steve [her husband] isn’t a believer in anything like that but he’s been using it too.
Alice expressed the same feelings following a massage session and the use of rescue remedy:
... we can use it in our life after here; this, I think, has opened my mind that you can use it in your own life outside; it just doesn’t stop in ICU.
Three relatives spoke particularly about the benefits they gained and were able to carry with them to the funeral of their loved one. This aspect was emphasised when Heather said:
... I have never seen the care that was given through these complementary therapies and I just found it was a real warmth. I found it most beneficial up to a week after, when we had to deal with Nathan’s death and get through the funeral. The energy I got from the reiki I found very valuable and would draw on it.
All these participants strongly believed that experiencing the complementary therapies gave them ‘something’ they could take away, that gave them strength and enhanced the essence of their being. Mrs Murphy stated:
… we felt highly supported, beyond what seemed like our due; we felt we were being sort of carried forward to the next stage so that we could cope.
DISCUSSION This research can challenge aspects of nursing practice in the critical care environment. The medical technological boundaries VOLUME 12
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that have dominated practice have now been questioned, with the orientation towards addressing the experience of the relatives’ lived world in a critical care environment enabling the research team to uncover the meanings inherent in the experiences related here; others may have different experiences. Phenomenology does not generalise; rather, it puts forward one interpretation or possible experience. Despite the fact that this study elicited positive responses, limitations were recognised by the research team. Team members experienced frustration at their inability to articulate the stories in the manner in which they were shared by the participants. There was a richness and depth in the telling which, inevitably, was difficult to capture in the transcribing. In addition, relatives often used the interview as a means of expressing their gratitude for the care they received. As this was part of their overall lived experience, it had to be acknowledged. The researchers were cognisant of this and able to elicit the particular lived experiences of comple-mentary therapies. From a practical perspective, factors related to time and resources posed some difficulties. The employment of a complementary therapist for only 2 days per week limited the exposure of relatives to certain of the modalities provided, which in turn reflected on the number of participants available for the study. Although other staff members were capable of providing the complementary therapies, this was seldom possible due to their patient workload and associated responsibilities. Some participants had reservations about the type of music played, but this was overcome early on through the provision of personal stereo devices and music appropriate to individual tastes. Overall, the results of this study support Chenoweth’s concept that:
Simply ‘being there’, in itself, has been found to be a powerful motivation for healing. Unfortunately, health care today is so focused on scientific, evidence-based practice and cure of the biological manifestations of disease that just ‘being there’ has all but vanished. It is as if the spiritual dimension to life, while espoused in theory as an integral component of holistic care, is being ignored by most health care practitioners, not because they do wish to, but because it is not funded and therefore not valued 1.
RECOMMENDATIONS It is possible that other forms of nurturing and support may have provided similarly positive experiences for participants. There is thus the potential for further research into alternative mechanisms that may support relatives in the critical care environment. The findings of the study suggest that increasing the availability of a therapist would enhance patients’ and relatives’ access to com-plementary therapies. It is evident that such work could be further enhanced by providing interested staff with opportunities to under-take accredited courses and develop the provision of such therapies. The interviews highlighted the disappointment of relatives at the loss of the therapies when their loved ones were transferred from the critical care department. Thus, it would be desirable to provide ongoing complementary therapies after patients’ transfer to a ward. DECEMBER 1999
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CONCLUSION This research has provided an insight into, and a new understanding of, the care of relatives of critically ill patients within the critical care setting. Phenomenology as a research methodology provided an avenue for relatives involved in the research to tell their story as it was being lived during their loved ones’ time in the ICU. The research team was interested in understanding the relatives’ lived experiences as a way of uncovering the meaning of complementary therapies within a technological space. Results of this study suggest that complementary therapies can positively influence relatives’ lived experience. Relatives of patients in intensive care are under stress, whether they realise it or not, and coping can be facilitated by complementary therapies. The interpretations provided are yet to be transformed by those who read this work and thereby create their own understanding.
ACKNOWLEDGEMENTS The research team wishes to acknowledge the assistance of the Nursing Board of Tasmania’s Scholarship Grant 1998. We thank, too, our nursing, medical and allied health colleagues within the Department of Critical Care Medicine at the Royal Hobart Hospital, whose support and encouragement helped us change the culture within our unit. To the medical directors of our department, the medical division of the hospital management and the hospital auxiliaries goes our sincere appreciation. Recognition and thanks also to all the relatives who gave of their time and told us their stories; this paper is dedicated to them.
REFERENCES 1.
Chenoweth L. The Role of the Healing Arts in Nurturing the Human Spirit. Paper presented at the First National Complementary Therapy Conference, Brisbane, Australia, 1997 p 8.
2.
Reinharz S. Phenomenology as a dynamic process. Phenomenol & Pedagogy 1983; 1(1):77-79.
3.
McGourty H, & Hotchkiss J. Study rules. Nurs Times 1993; 89(36): 42-45.
4.
Hamilton D & Betchel A. Research implications for alternative health therapies. Nurs Forum 1996; 31(1):6-10.
5.
McCabe P, Ramsay L & Taylor B. Complementary Therapies in Relation to Nursing Practice in Australia. Discussion paper No. 2. Royal College of Nursing, Australia, 1995 p 5.
6.
Chigwidden S. Pre- and post-operative aromatherapy and music. Hospital 1997; 202:20-23.
7.
Hudson S. Complementary therapies and high tech care. Nurs J 1996; 4(4):34-36.
Aust
8.
Trevelyan J & Booth B. Fringe benefits. Nurs Times 1993; 89(17): 30-33.
9.
Tattam A. The gentle touch. Nurs Times 1992; 88(32):16-17.
15. Walters AJ. A hermeneutic study of the experiences of relatives of critically ill patients. J Adv Nurs 1995; 22:998-1005. 16. Gow J, Theobald K & Nagle C. A qualitative study of the spouse’s experience following coronary artery bypass surgery: implications for nursing practice. Paper presented, 19th Australian & New Zealand Scientific Meeting on Intensive Care, Brisbane, 1994. 17. Lumby J. Nursing: Reflecting on an Evolving Practice. Deakin University Press, Geelong, 1991. 18. Holmes CA. Resistance to positivist science in nursing: an assessment of the Australian literature. Int J Nurs Practice 1996; (2):172-81. 19. Heidegger M. Being and Time. Translated by Macquarie J & Robinson E. Harper & Rowe, New York, 1962. 20. van Manen M. Researching Lived Experience: Human Science for an Action Pedagogy. The State University of New York Press, Ontario, Canada, 1990. 21. Taylor B. Being Human: Ordinariness in Nursing. Churchill Livingstone, Melbourne, 1994. 22. Walters AJ. Heideggerian hermeneutic study of the practice of critical care nurses. J Adv Nurs 1995; 21:493. 23. Montgomery CL. The spiritual connection: nurses’ perceptions of the experience of caring. In: The Presence of Caring in Nursing. NLN Publication #15, 1993 pp 24-65, 39-52. 24. Halm MA & Alpen MA. The impact of technology on patients and families. Nurs Clin N America 1993; 28(2):443-57.
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10. Buckle J. Which lavender oil? Nurs Times 1992; 88(32):54-55. 11. Wise R. Flower power. Nurs Times 1989; 85(22):45-47. 12. Price C & Price M. Aromatherapy for Health Care Professionals. Churchill Livingstone, New York, 1995. 13. Henry L. Music therapy: a nursing intervention for the control of pain and anxiety in the ICU: a review of the research literature. Dimensions of Crit Care Nurs 1995; 14(6):295-304. VOLUME 12
14. Labyak S & Metzger B. The effects of effleurage backrub on the physiological components of relaxation: a meta-analysis. Nurs Research 1997; 46(1):59-62.
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