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A nurse's role in complementary medicine
Complementary Therapies in Medicine (1995) 3, 171-174 © Pearson Professional Ltd 1995
NURSING
A nurse's role in complementary medicine M. Hubble and M. Middleton The Centre for the Study o f Complementary Medicine, Southampton, UK.
S U M M A R Y . Nurses at the Centre for the Study of Complementary Medicine work in a unique situation. T h e y are required to be general-trained, but most o f the present team possess additional qualifications. There are opportunities for acquiring new skills as part of the in-service training. It is hoped that, in this relatively new speciality, these nurses will become involved in the education o f their colleagues working in other situations.
means that there are two nurses in attendance at all times, with duties being shared on a part-time basis among 5 nurses, providing cover at holiday times and during sick leave.
INTRODUCTION The Centre for the Study of Complementary Medicine (CSCM) is unique within the UK. It was established in 1982 and has progressed to its present state where a total of 20 000 patients are registered with the practice and, each year, 3000 new patients are seen. During the early years, the role of the nurse at the CSCM involved the running of the dispensary and training its staff to work in that department. Answers to queries on diet and general health matters were given rather than formal advice. The nurses also assisted the doctors in their research projects. The job has evolved considerably since then and this account aims to give a snapshot of the job as it is today. The RGN (or SRN) is the basic qualification needed for appointment to the nursing staff. It is an essential requirement for a nurse applying for a post that he or she has at least 6 months' post registration experience. Competition for a position is such that it has been possible to appoint persons with a wide range of experience and qualifications. The present team has previous experience and qualifications in acupuncture, occupational health, midwifery, and paediatrics. Nurse cover is for 94 hours per week (see Fig.). This
JOB D E S C R I P T I O N
This lists those basic skills required of any trained nurse, and an interest in complementary medicine is essential. However, it is evident from interviewing applicants for nursing posts that many nurses have a substantial knowledge of the subject. On joining the CSCM, a new member has to learn new skills and attain a specifiied level of proficiency. This is rewarding for each individual nurse because the extended role is expected and not considered to be special (a description of duties is included later). Most of the care given by the nurses is prescribed and directed by the doctors; the nursing staff do, however, enjoy a high level of autonomy and are required to make their own clinical judgements. Nurses are aware that they are working in a rapidly evolving field and need to be confident in what they are doing. Provided they follow strictly the guidelines laid down by the professional bodies 1,2 their professional position is as safe as it can be. Thus,
Marian Hubble SRN, RSCN and Maureen Middleton RGN, RMN, PracticeNurses, The Centre for the Studyof ComplementaryMedicine,51 Bedford Place, SouthamptonSO15 2DT, UK.
171
172
A NURSE'S ROLE IN COMPLEMENTARYMEDICINE
the nurses are accountable for all their actions. Membership of a professional organisation is obligatory. The organisations currently represented are the Royal College of Nursing (RCN), the Royal College of Midwives and the Medical Defence Union. The grade levels F or G reflect the degree of responsibility demanded of the nurses. E D U C A T I O N AND T R A I N I N G It is generally accepted that a nurse needs to have been in post for 6 months before being considered 'trained'. There is not, as yet, a formal training for new entrants but it is intended that a structured training programme be developed and introduced by 1995. That training which is given for developing new skills is by the 'apprentice' system - experienced nurses teach, demonstrate to, and supervise their colleagues. Clinical information is acquired from nurses and doctors. Accredited courses in acupuncture and BER medicine are run by the CSCM for doctors and paramedical personnel, and nurses are required to attend these as soon as possible after their appointment. Although the nurses are not performing Vega tests, familiarity with the procedure is essential. The courses on acupuncture provide nurses with a sound introduction to the subject. Supervised practical sessions follow, and clinical tutorials are given by the doctors on a regular basis. It is the responsibility of each individual nurse to extend her knowledge and expertise by reading the relevant literature and attending courses outside the CSCM.
The cost of attending study days is shared between the nurse and the CSCM. Patients are a rich source of information and often provide new insights into their illnesses and treatments. RANGE OF A C T I V I T I E S Administrative tasks are few and quickly accomplished. The size of the CSCM means that communication is swift and direct, so little time is spent pushing information through the system. As with any nursing setting, there are routine tasks to be attended to such as sterilising equipment and ordering and placing stock. Most of the working day for the nurse is spent in contact with the patients. The Figure shows the breakdown of the tasks; the time involved in each patient episode varies - the siting and supervision of an i.v. infusion will obviously take up much more time than a telephone enquiry. 48 hours of nurse time accounts for an average of 108 nurse/patient contacts. It is evident that, in addition to performing practical tasks, much of the nurses' time is spent dealing with enquiries, many of them by telephone. Depending on the nature of the problem the nurse may be able to use his/her own initiative in offering advice based on protocols set by the CSCM. Should a doctor's opinion be required, there is a streamlined system in operation whereby messages are fed to the doctors between consultations and responses passed back to the nurses, who transmit the advice to the patient. The patients are able to make direct contact with the doctors when circumstances
OCCASIONAL CONTACTS: PMF, PARASCOPE SWABS
Key to graph TNS : Transcutaneous nerve stimulation (providing equipment and demonstrating use) DFM: Diagnostic machine for functional medicine
(electrical investigation) AMI: Acupuncture measurement instrument
(electrical investigation) 2
EPD: Enzyme potentiated desensitisation
2
PMF: Pulsed magnetic frequency
(injections of small doses of allergens) (introduction of electrical pulses to promote healing) Parascope: Obtaining of rectal specimens to investigate for parasites.
I. v. infusion Miscellaneous advice (Personal or telephone) Bloodtaking
AouunOure
6
I:
AMI Diet advice Outgoing telephone calls Incoming telephone calls
Fig. Nurse-patient contacts: averageper nurse per week
I12 [ 16 18 28
COMPLEMENTARYTHERAPIESIN MEDICINE demand it. Treatment prescribed by the doctor often necessitates a change in the patient's diet. The nurses talk through the new diet with the patient, offering ideas on how best to implement the new regime; this is particularly challenging in today's world of instant and convenience foods. The aim is to guide the patient towards a healthy diet and lifestyle and patients are encouraged to telephone for further advice and support should they need it. THERAPEUTIC ROLE Nurses frequently administer acupuncture, the prescription having been determined by the doctor. During therapy sessions the nurse may gain added insights into a patient's problems. The giving of time and offering of advice on matters of lifestyle may contribute to an improved quality of life for the patient. Similar opportunities for listening arise during other activities, ranging from the taking of blood to performing investigations. Nurses use these periods of patient contact to listen sympathetically and offer advice. More than a few patients have admitted to revealing a problem to the nurse that has hitherto not been disclosed. It may be perceived that the nurse's role, when in contact with the patient, is entirely therapeutic and may influence and enhance the healing process. CLINICAL SUPERVISION New nurses may be required to learn how to take blood. The CSCM has an arrangement with the local NHS haematology laboratory where a nurse may be taught the necessary skills by the phlebotomists. All nurses are familiar with i.v. infusions; but while most nurses have received instruction in the administration of i.v. medications, few arrive at the CSCM able to site infusions. When a new member of staff feels that the time is appropriate, she will be given instruction on the siting of cannulae by an experienced colleague, under close supervision. Once a level of competence has been reached, the nurse will proceed to function independently. PHILOSOPHY OF CARE The CSCM is forward-looking; complacency is not a word in its vocabulary. New procedures are constantly being investigated and evaluated, and outcomes of treatment are continually audited. Care is patient-centred; the objective is to help the patient to take control of his or her condition by actively participating in the therapy. This holistic approach involves the staff in providing psychological support wherever needed by the patient. Each nurse/patient contact provides an opportunity for the nurse to tune into the patient's concerns about his or her health. No specific period of time is allocated for a
173
particular procedure so it is possible for a nurse to spend extra time whenever a patient needs it; this flexibility allows the nurse to act as a counsellor. If a patient reveals a problem hitherto unknown, the nurse may refer back to the doctor for further advice. PROFESSIONAL D E V E L O P M E N T Complementary medicine is a relatively new speciality, and nurses working in this field have a rare opportunity to be involved in widening the frontiers of care. Jewell and Turton3 stress the importance of nurse development in general practice; this notion is already accepted at the CSCM, where nurses are encouraged to undertake new procedures with a view to extending and improving the service provided. Membership of the RCN Special Interest Group is a means of meeting with like-minded colleagues and keeping pace with developments elsewhere. Self-help groups, such as the Wessex Cancer Self Help Centre, organise very informative study days for nurses. It is envisaged that nursing staff should attend more recognised courses, particularly those concerned with specific treatments, thus enabling them to become more effective therapists. THE FUTURE Working in a new speciality may be perceived as providing a golden opportunity for setting standards of care. When initiating practices, it is essential that methods be monitored, and the plans to develop protocols and write standards for those activities which are carried out by the nurses, which will ensure consistency of purpose and action. A by-product of these exercises would be the establishment of outlines for a formal training programme, but for this it will be necessary to involve colleagues from outside the CSCM. Visitors to the CSCM are always welcome. Their value is two-fold: firstly, staff are forced to examine their practices and, secondly, the visitors will spread the gospel of complementary medicine if they like what they see. At present visits are informal, but it is intended to develop structured introductory programmes, varying in length from 2-3 days to 2-3 weeks. Launching such a scheme would involve liaison with Schools of Nursing and other establishments, such as the Royal London Homoeopathic Hospital. The RCN is seeking to gain validation from the United Kingdom Central Council (UKCC) for a Certificate in Complementary Medicine. Modules developed by the CSCM could be offered as options on a certificate course or made available to nurses undergoing Project 2000 training. Complementary medicine is a rapidly expanding branch of medicine and the role of the nurse in this field is evolving equally rapidly. There are numerous oppor-
174
A NURSE'S ROLE IN COMPLEMENTARY MEDICINE
tunities available for nurses to develop and perfect new skills and techniques. With the increase in public interest in complementary medicine, it is inevitable that more units similar to the CSCM will be established. The nursing staff at the Southampton Centre see the induction of nurses into this speciality as part of their future development.
References 1. United Kingdom Central Council for Nursing, Midwifery and Health Visiting. Code of professional conduct for the nurse, midwife and health visitor. London: UKCC, 1992. 2. Barker S. Precarious liability. MDU Nurse 1994; 3: 8. 3. Jewell D, Turton P. What's happening to practice nursing? BMJ 1994; 308: 736.
NURSING
A nurse's role in complementary medicine M. Hubble and M. Middleton The Centre for the Study o f Complementary Medicine, Southampton, UK.
S U M M A R Y . Nurses at the Centre for the Study of Complementary Medicine work in a unique situation. T h e y are required to be general-trained, but most o f the present team possess additional qualifications. There are opportunities for acquiring new skills as part of the in-service training. It is hoped that, in this relatively new speciality, these nurses will become involved in the education o f their colleagues working in other situations.
means that there are two nurses in attendance at all times, with duties being shared on a part-time basis among 5 nurses, providing cover at holiday times and during sick leave.
INTRODUCTION The Centre for the Study of Complementary Medicine (CSCM) is unique within the UK. It was established in 1982 and has progressed to its present state where a total of 20 000 patients are registered with the practice and, each year, 3000 new patients are seen. During the early years, the role of the nurse at the CSCM involved the running of the dispensary and training its staff to work in that department. Answers to queries on diet and general health matters were given rather than formal advice. The nurses also assisted the doctors in their research projects. The job has evolved considerably since then and this account aims to give a snapshot of the job as it is today. The RGN (or SRN) is the basic qualification needed for appointment to the nursing staff. It is an essential requirement for a nurse applying for a post that he or she has at least 6 months' post registration experience. Competition for a position is such that it has been possible to appoint persons with a wide range of experience and qualifications. The present team has previous experience and qualifications in acupuncture, occupational health, midwifery, and paediatrics. Nurse cover is for 94 hours per week (see Fig.). This
JOB D E S C R I P T I O N
This lists those basic skills required of any trained nurse, and an interest in complementary medicine is essential. However, it is evident from interviewing applicants for nursing posts that many nurses have a substantial knowledge of the subject. On joining the CSCM, a new member has to learn new skills and attain a specifiied level of proficiency. This is rewarding for each individual nurse because the extended role is expected and not considered to be special (a description of duties is included later). Most of the care given by the nurses is prescribed and directed by the doctors; the nursing staff do, however, enjoy a high level of autonomy and are required to make their own clinical judgements. Nurses are aware that they are working in a rapidly evolving field and need to be confident in what they are doing. Provided they follow strictly the guidelines laid down by the professional bodies 1,2 their professional position is as safe as it can be. Thus,
Marian Hubble SRN, RSCN and Maureen Middleton RGN, RMN, PracticeNurses, The Centre for the Studyof ComplementaryMedicine,51 Bedford Place, SouthamptonSO15 2DT, UK.
171
172
A NURSE'S ROLE IN COMPLEMENTARYMEDICINE
the nurses are accountable for all their actions. Membership of a professional organisation is obligatory. The organisations currently represented are the Royal College of Nursing (RCN), the Royal College of Midwives and the Medical Defence Union. The grade levels F or G reflect the degree of responsibility demanded of the nurses. E D U C A T I O N AND T R A I N I N G It is generally accepted that a nurse needs to have been in post for 6 months before being considered 'trained'. There is not, as yet, a formal training for new entrants but it is intended that a structured training programme be developed and introduced by 1995. That training which is given for developing new skills is by the 'apprentice' system - experienced nurses teach, demonstrate to, and supervise their colleagues. Clinical information is acquired from nurses and doctors. Accredited courses in acupuncture and BER medicine are run by the CSCM for doctors and paramedical personnel, and nurses are required to attend these as soon as possible after their appointment. Although the nurses are not performing Vega tests, familiarity with the procedure is essential. The courses on acupuncture provide nurses with a sound introduction to the subject. Supervised practical sessions follow, and clinical tutorials are given by the doctors on a regular basis. It is the responsibility of each individual nurse to extend her knowledge and expertise by reading the relevant literature and attending courses outside the CSCM.
The cost of attending study days is shared between the nurse and the CSCM. Patients are a rich source of information and often provide new insights into their illnesses and treatments. RANGE OF A C T I V I T I E S Administrative tasks are few and quickly accomplished. The size of the CSCM means that communication is swift and direct, so little time is spent pushing information through the system. As with any nursing setting, there are routine tasks to be attended to such as sterilising equipment and ordering and placing stock. Most of the working day for the nurse is spent in contact with the patients. The Figure shows the breakdown of the tasks; the time involved in each patient episode varies - the siting and supervision of an i.v. infusion will obviously take up much more time than a telephone enquiry. 48 hours of nurse time accounts for an average of 108 nurse/patient contacts. It is evident that, in addition to performing practical tasks, much of the nurses' time is spent dealing with enquiries, many of them by telephone. Depending on the nature of the problem the nurse may be able to use his/her own initiative in offering advice based on protocols set by the CSCM. Should a doctor's opinion be required, there is a streamlined system in operation whereby messages are fed to the doctors between consultations and responses passed back to the nurses, who transmit the advice to the patient. The patients are able to make direct contact with the doctors when circumstances
OCCASIONAL CONTACTS: PMF, PARASCOPE SWABS
Key to graph TNS : Transcutaneous nerve stimulation (providing equipment and demonstrating use) DFM: Diagnostic machine for functional medicine
(electrical investigation) AMI: Acupuncture measurement instrument
(electrical investigation) 2
EPD: Enzyme potentiated desensitisation
2
PMF: Pulsed magnetic frequency
(injections of small doses of allergens) (introduction of electrical pulses to promote healing) Parascope: Obtaining of rectal specimens to investigate for parasites.
I. v. infusion Miscellaneous advice (Personal or telephone) Bloodtaking
AouunOure
6
I:
AMI Diet advice Outgoing telephone calls Incoming telephone calls
Fig. Nurse-patient contacts: averageper nurse per week
I12 [ 16 18 28
COMPLEMENTARYTHERAPIESIN MEDICINE demand it. Treatment prescribed by the doctor often necessitates a change in the patient's diet. The nurses talk through the new diet with the patient, offering ideas on how best to implement the new regime; this is particularly challenging in today's world of instant and convenience foods. The aim is to guide the patient towards a healthy diet and lifestyle and patients are encouraged to telephone for further advice and support should they need it. THERAPEUTIC ROLE Nurses frequently administer acupuncture, the prescription having been determined by the doctor. During therapy sessions the nurse may gain added insights into a patient's problems. The giving of time and offering of advice on matters of lifestyle may contribute to an improved quality of life for the patient. Similar opportunities for listening arise during other activities, ranging from the taking of blood to performing investigations. Nurses use these periods of patient contact to listen sympathetically and offer advice. More than a few patients have admitted to revealing a problem to the nurse that has hitherto not been disclosed. It may be perceived that the nurse's role, when in contact with the patient, is entirely therapeutic and may influence and enhance the healing process. CLINICAL SUPERVISION New nurses may be required to learn how to take blood. The CSCM has an arrangement with the local NHS haematology laboratory where a nurse may be taught the necessary skills by the phlebotomists. All nurses are familiar with i.v. infusions; but while most nurses have received instruction in the administration of i.v. medications, few arrive at the CSCM able to site infusions. When a new member of staff feels that the time is appropriate, she will be given instruction on the siting of cannulae by an experienced colleague, under close supervision. Once a level of competence has been reached, the nurse will proceed to function independently. PHILOSOPHY OF CARE The CSCM is forward-looking; complacency is not a word in its vocabulary. New procedures are constantly being investigated and evaluated, and outcomes of treatment are continually audited. Care is patient-centred; the objective is to help the patient to take control of his or her condition by actively participating in the therapy. This holistic approach involves the staff in providing psychological support wherever needed by the patient. Each nurse/patient contact provides an opportunity for the nurse to tune into the patient's concerns about his or her health. No specific period of time is allocated for a
173
particular procedure so it is possible for a nurse to spend extra time whenever a patient needs it; this flexibility allows the nurse to act as a counsellor. If a patient reveals a problem hitherto unknown, the nurse may refer back to the doctor for further advice. PROFESSIONAL D E V E L O P M E N T Complementary medicine is a relatively new speciality, and nurses working in this field have a rare opportunity to be involved in widening the frontiers of care. Jewell and Turton3 stress the importance of nurse development in general practice; this notion is already accepted at the CSCM, where nurses are encouraged to undertake new procedures with a view to extending and improving the service provided. Membership of the RCN Special Interest Group is a means of meeting with like-minded colleagues and keeping pace with developments elsewhere. Self-help groups, such as the Wessex Cancer Self Help Centre, organise very informative study days for nurses. It is envisaged that nursing staff should attend more recognised courses, particularly those concerned with specific treatments, thus enabling them to become more effective therapists. THE FUTURE Working in a new speciality may be perceived as providing a golden opportunity for setting standards of care. When initiating practices, it is essential that methods be monitored, and the plans to develop protocols and write standards for those activities which are carried out by the nurses, which will ensure consistency of purpose and action. A by-product of these exercises would be the establishment of outlines for a formal training programme, but for this it will be necessary to involve colleagues from outside the CSCM. Visitors to the CSCM are always welcome. Their value is two-fold: firstly, staff are forced to examine their practices and, secondly, the visitors will spread the gospel of complementary medicine if they like what they see. At present visits are informal, but it is intended to develop structured introductory programmes, varying in length from 2-3 days to 2-3 weeks. Launching such a scheme would involve liaison with Schools of Nursing and other establishments, such as the Royal London Homoeopathic Hospital. The RCN is seeking to gain validation from the United Kingdom Central Council (UKCC) for a Certificate in Complementary Medicine. Modules developed by the CSCM could be offered as options on a certificate course or made available to nurses undergoing Project 2000 training. Complementary medicine is a rapidly expanding branch of medicine and the role of the nurse in this field is evolving equally rapidly. There are numerous oppor-
174
A NURSE'S ROLE IN COMPLEMENTARY MEDICINE
tunities available for nurses to develop and perfect new skills and techniques. With the increase in public interest in complementary medicine, it is inevitable that more units similar to the CSCM will be established. The nursing staff at the Southampton Centre see the induction of nurses into this speciality as part of their future development.
References 1. United Kingdom Central Council for Nursing, Midwifery and Health Visiting. Code of professional conduct for the nurse, midwife and health visitor. London: UKCC, 1992. 2. Barker S. Precarious liability. MDU Nurse 1994; 3: 8. 3. Jewell D, Turton P. What's happening to practice nursing? BMJ 1994; 308: 736.