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Developing an integrative therapies program in a tertiary care cardiovascular hospital
Crit Care Nurs Clin N Am 15 (2003) 363 – 372
Developing an integrative therapies program in a tertiary care cardiovascular hospital Sue Sendelbach, MS, RN, CCNSa,*, Linda Carole, PsyD, LPb, Julie Lapensky, MS, RNc, Vib Kshettry, MDd
a
Cardiovascular Services Division, Abbott Northwestern Hospital, 800 East 28th Street, Minneapolis, MN 55407, USA b Healing the Heart Program, Abbott Northwestern Hospital, 800 East 28th Street, Minneapolis, MN 55407, USA c Cardiovascular Patient Care Services, Abbott Northwestern Hospital, 800 East 28th Street, Minneapolis, MN 55407, USA d Minneapolis Cardio – Thoracic Surgery Consultants, Minneapolis Heart Institute, Abbott Northwestern Hospital, 920 East 28th Street, Minneapolis, MN 55407, USA
In 1999, a complementary and alternative medicine (CAM) program for cardiovascular inpatients was initiated at Abbott Northwestern Hospital (ANW). Investigation of the feasibility and potential outcomes of such a program began in the mid-1990s. The prevalence of the public’s use of CAM had been well established in the literature [1,2]. These trends were also noted at ANW, where patient and family demand for such services in the inpatient setting was increasing. Concurrently, the literature was beginning to support the use of integrative therapies as an adjunct to conventional care. For example, when the Agency for Healthcare Research and Quality (AHRQ) developed clinical practice guidelines for acute pain management, specific integrative therapies were also recommended as supplemental interventions [3]. The Nursing Department’s philosophy at ANW supported a patient-centered, holistic framework for practice. ANW, a part of the Allina Health System, is a 627-bed tertiary-care, not-for-profit hospital in Min-
Supported in part by a Medtronic Foundation Healthcare Leadership grant, which has allowed enhancement and expansion of our database and research and network capabilities; and a philanthropic partnership with Penny and Bill George of the George Family Foundation, who have shared our patient care vision and continue to believe in our model of integrative care. * Corresponding author. E-mail address: [email protected] (S. Sendelbach).
neapolis, Minnesota. The Minneapolis Heart Institute is an organized group of cardiovascular physicians including a cardiology group and two cardiovascular surgical groups who provide a full continuum of cardiac services from primary prevention to heart failure and transplant for patients at ANW. In 2001, ANW and the Minneapolis Heart Institute treated more than 7800 inpatient cardiac admissions, and diagnosed and treated greater than 25,000 patients in more than 30 outpatient settings in Minneapolis and community sites in Minnesota. The mission of Allina and ANW is to provide an exceptional healthcare experience. These organizational characteristics combined with patient requests and the beginning of literature support provided the foundation and impetus for the inpatient cardiovascular integrative therapy program’s development at ANW called ‘‘Healing the Heart.’’ Although the National Center for Complementary and Alternative Medicine, a division of the National Institutes of Health, defines complementary therapies as those modalities used together with conventional medicine and alternative therapies as those used in place of conventional medicine, the terms are often used interchangeably [4]. More recently the term integrative medicine has been used to describe an approach that combines conventional and complementary care [5]. Patient involvement in his or her own recovery process is also an important element of integrative medicine [6]. When initially researching the literature before beginning our work, we found few articles pertaining
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to developing an integrative therapies program in an inpatient setting. This article describes how one tertiary care hospital developed an integrative therapies program in a cardiovascular inpatient setting. This includes the program’s inception and development, implementation and growth, outcome measurement, and ultimate expansion beyond the initial program vision.
Inception and development of the program The first step in developing the program was to complete a feasibility study, which could not have happened without administrative vision, creativity, and support. The director of cardiovascular patient care services sanctioned the clinical nurse specialist and the manager from the cardiovascular intensive care unit to focus on this project. A review of the research and literature from CINAHL and Medline was completed. The purpose for the review was to establish which complementary therapies had been studied, for what intent the interventions had been applied, and what patient outcomes were achieved. The initial review of the literature was broadly based, then narrowed to focus on cardiovascular patients. The literature was also searched to determine whether any integrative therapies programs had been created in an inpatient setting; however, no published studies were found that addressed what we had intended. Concurrently, ANW nurses and physicians with an interest in pursuing these ideas were identified; these nurses and physicians were also opinion leaders who were critical to the success of the project. Cardiovascular surgeons, cardiologists, staff nurses, and administrators were enthusiastic about the potential patient benefits of a cardiovascular integrated therapies program. The interested parties formed a ‘‘design team’’ to provide a forum for ongoing investigation and potential program design. The design team enthusiastically endorsed the concept that research and research utilization was foundational to the potential success of an integrative therapies program. Many things were gleaned from the literature review that helped guide the development of the program. For example, early studies of patients after myocardial infarction (MI) revealed that anxiety and depression were the top reasons for a referral for psychiatric evaluation [7,8]. It also was shown that anxiety peaked on days 1 and 2, whereas depression peaked on days 3 and 4 [7]. Because anxiety had been identified as a frequently occurring nursing diagnosis in the cardiovascular inpatient population at ANW, there was an interest in pursuing
potential anxiety-reducing interventions specifically targeted to days 1 and 2 after admission. Other research studies helped to set the initial direction for the program. In addition, the literature helped guide the development of a cardiovascular integrative therapies research study at ANW. There had been some research conducted with patients who had coronary artery disease in coronary care units and the effects of music [9 – 11]. Even fewer studies could be found that studied the effects of music on the patients undergoing a cardiac surgical procedure [12]. Consequently, when contemplating the conduct of research in the area, it was decided to study cardiac surgery patients and the effects of music on pain, anxiety, and other variables. The group anticipated positive outcomes and intended to disseminate results to medical and nursing personnel in the hospital to provide ‘‘local’’ scientific support for the use of integrative therapies. The literature was not able to provide much direction for initiating an integrative therapies program within an inpatient setting, as most of the programs had been operating in outpatient settings. Interviews were conducted with local and national resources identified in the integrative therapy literature review and through networking. This was met with some degree of success, as there were not many programs similar to the one planned. Some programs had been started and eliminated, whereas others were still in operation. We were able to learn as much from the programs that had been eliminated as from the ones that were active. For example, this helped us to decide we would not offer numerous therapies because of the resources required. When we chose which therapies to provide we chose those therapies that had beginning support in the literature and were not controversial. Using these criteria led us to choose music, massage, spiritual care, and dietary intervention. Once the potential for positive patient outcomes had been established, the literature reviewed, interviews with other integrative therapies programs completed, and the music therapy research study initiated, the design team began to discuss the development of a formal program and a proposal for funding was written. It included the purpose of the program, intended outcomes and benefits, scope of services to be provided, a brief description of other integrative therapies programs surveyed, participants of the design team, proposed structure and function for an ongoing advisory committee, a proposed budget, and a description of program staff roles and responsibilities. An essential element of the proposal was the inclusion of the responsibilities for a clinical program manager. Based on input from the design team and
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literature, patient outcomes to be targeted were effective management of pain and anxiety. The proposal was submitted to the Vice-President of Cardiovascular Services for approval and funding. The proposal was approved, and the program’s advisory committee was formed and included members from the original design team along with additional opinion leaders. A job description for the clinical program manager was written, the position posted, and a manager was hired. Because this position was considered critical to the program’s success, criteria were developed before beginning the interviews to assist in the final selection process. The program manager was instrumental in the ongoing development of the program and, if not for the appropriate leadership skills and an ability to understand the organizational culture, could have had a negative impact on the program.
Initiating and enhancing the program The mandate from the advisory committee to the clinical program manager focused on three areas for development—patient services, staff education, and integrative research. Discussions with the Nursing Council Task Group, informal conversations with bedside staff, and frequent strategy planning sessions with a cardiovascular surgeon who championed the initiative all garnered support for development in those areas. In addition, the program development plan was included in the cardiovascular quality plan to help keep it in the forefront of the work to be accomplished for the year. The manager was also assigned to the cardiovascular Patient Care Leadership Team, a position that allowed her to understand the hospital services and means of initiating new procedures. Other integrative therapies and integrative medicine efforts from across the country were identified and studied, and persons associated with these efforts were engaged in conversations about their program development and progress. A development strategy that encompassed 3 years was formulated, which included identification of philanthropic resources within the community, as these services did not have reimbursement. The advisory committee had recommended that patients would not be charged for these services. Internally, it was most helpful to have the first randomized controlled trial (ie, the music study) underway when the clinical program manager began the position. This alerted medical and nursing staff to the legitimacy of the program as a therapeutic endeavor rather than an attempt to create a spalike atmosphere directed only at customer service.
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Much of the early policy and direction continues today. Language describing program services and techniques is carefully chosen. Jargon or terms unfamiliar to medical staff and patients are avoided. Therapies and techniques are described within the context of stress management and relaxation skills. Family education and participation is always encouraged. Demonstrations of the therapies are offered to individual staff on a regular basis. More formal staff training has encompassed leadership training in integrative therapies/integrative services for managers, skills day training for bedside staff, and experiential presentations to new graduate nurses.
The role of the clinical program manager The manager serves in several capacities, that of practitioner, clinical supervisor, administrator, trainer, and development coordinator. She is introduced to patients as a healing coach when she practices, a role that was created to be cardiovascular care specific. The program manager is a licensed psychologist who provides additional integrative therapies, which include guided imagery, relaxation techniques, and brief cognitive behavioral consultations that span the continuum of care from acute events and procedures to chronic and end-of-life situations. These treatments are used for the purpose of anxiety reduction and to assist in pain management. As the program has expanded, the manager handles less direct patient care on the inpatient units and more therapeutic staff supervision. Development of outpatient integrative care is being piloted, and the program manager is a practitioner and specialist in body – mind therapies as a member of that team. Cases are discussed informally as needed and as regularly scheduled on a weekly basis.
Patient services The development of therapeutic approaches appropriate to inpatient cardiovascular care has been a priority. Music is chosen for its ability to entrain the heart [10]. Massage/touch techniques have been developed with consideration of the patient’s medical condition, age, and receptiveness to integrative therapies as part of the treatment planning, which in our acute care setting is done with input from other healthcare providers including physicians. Treatment sessions are designed to involve the patient and frequently family members to teach skills for postdischarge self-care. Patients are seen two or three times
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during the average length of stay. Complex patients are often treated longer. Initially, the clinical program manager was the only person staffing the program. For that reason, it was essential to select a subgroup of cardiovascular patients and focus on demonstrating patient outcomes to establish the legitimacy of the program. The Elective Heart Surgery (EHS) Clinic was chosen as the initial patient subgroup for a variety of reasons. First, it provided a manageable patient population size for the initial work. The EHS patients arrive at the EHS clinic the day before surgery for education, laboratory work, and other preparation, allowing contact with the clinical program manager. In addition, the cardiovascular surgeon, who was supportive, garnered the agreement of the other cardiovascular surgeons that all patients attending this clinic could be approached and offered integrative therapies. During the education visit, the patient and any family or support persons are treated with the therapies of their choice. As the program has grown, consults are requested from all areas of the inpatient units as well as by patients who call before they are scheduled for a procedure. It is usually patients who have had prior experience with integrative therapies who call to inquire about receiving these services. Additionally, on many occasions the surgeon recommends that a patient contact the service. From April 1999 through 2001, program staff has treated 1008 patients in 1925 sessions (Fig. 1). Many times family members are included in the session through massage or therapeutic touch demonstrations. A retrospective review of patients served in 2002 who agreed to have the outcome (tension) of their treat-
Fig. 2. Change in tension—scores before and after integrative therapy sessions by age.
ment reported is displayed in Fig. 2. Program staff document physical tension scores before and after treatment unless the patient has fallen asleep or is otherwise unable to give this information. No patients reported an increase in physical tension in this brief review. Generally, patients are appreciative of the treatments. Family members are taught to coach the patient in relaxation strategies as needed and if desired by the patient. Follow-up comment cards are also given to patients and family to track patient satisfaction and willingness to practice the therapies after leaving the hospital.
Program growth
Fig. 1. Number of visits for all integrative therapies by year.
It is well known that part of the still tenuous position of integrative therapies inside most hospitals is linked to the difficulties in paying for the additional care [13]. This was an issue that the manager and advisory committee needed to grapple with on an ongoing basis. To enhance program development, grant funding proposals were developed to add staff, increase medical and nursing staff education efforts, and to develop the integrative therapies research group. Because there was significant administrative support, the hospital also provided resources for various aspects of the program. Additional grant funding allowed us to add staff and also enabled us to continue to offer integrative therapies without charging patients. Grants were secured to support both the inpatient operations and the research efforts.
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Medical staff educational presentations on delivery of integrative therapies as adjunctive therapies to conventional care supported the interdisciplinary discussions. For example, at the weekly cardiology conference where updates on research and clinical implications are presented, cardiologists with expertise in integrative therapies were brought in to discuss these same issues with integrative therapies. ANW/Minneapolis Heart Institute physicians, including cardiologists and cardiovascular surgeons, were surveyed to gain their perspective and understanding of integrative therapies (Fig. 3). Although physician resistance is the number one problem facing hospitals that consider implementing an integrative therapies program, this was not a significant issue as we began the program [14]. In fact, several physicians were very interested in pursuing these therapies. Critical care nurses also participated in a survey that examined their attitudes regarding integrative therapies. The results of both surveys were positive and provided supportive information to the interdisciplinary work. In the second year of development, staff expansion was a priority. Included in this hiring phase was a research coordinator who facilitated the design and development of the database program. A fulltime healing coach with massage touch/ skill was hired. All services were provided at no charge to patients due to grant funding, which continues today. In a program in which excellent communication and therapeutic skills are the product delivered, by far
Fig. 3. Minneapolis Heart Institute physician survey. The survey asked, ‘‘ If a carefully chosen cardiovascular integrated medicine team was available to furnish your patients with evaluations, treatments, and a map to improve quality of life that was the result of a consensus of treating practitioners including you, would you refer to and work with this team?’’
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our greatest expense is salaries. We have chosen to hire staff rather than contract with therapists. Initially we found that paying contracted providers what they make in the community was prohibitive. In addition, we wanted staff to feel they belonged in the cardiovascular community and were part of a team rather than coming in for a few hours, providing a service, and returning to the community practice. This approach has allowed staff to develop areas of interest, participate in training medical staff, provide research interventions and follow-up, and become a presence on the nursing units. The team concept has been important in providing continuity of care and staff ownership of the program. In that regard, each staff member of the program is considered a healing coach within differing areas of practice concentration. The job description requires a combination of practice and training skills within the context of integrative therapies and integrative approaches. The research coordinator also has these practice skills and background. In addition to keeping the database and coordinating studies, she can also provide interventions when appropriate and as needed to back up patient services. At present two certified massage therapists share a position (1.1FTE). A music ‘‘technician’’ provides taped music and relaxation therapies to patients as well a doing administrative support (0.5FTE), and a team coordinator (1FTE) who has massage/touch and acupressure skills was hired to practice and provide administrative support to the clinical program manager as her role evolves to that of specialist in integrative care. This evolution includes inpatient and outpatient development. When hiring staff it has been especially important to hire appropriately qualified individuals who are willing to learn a new way of applying their knowledge. Providing services at the bedside for patients who may be gravely ill has required an adjustment of techniques and procedures as well as perception on the part of therapists. In an outpatient setting there is the luxury of more time. In the hospital setting this may not be so. It is important to acknowledge biases that favor one or another form of integrative therapies or conventional medical practice and discourage any attempts to convert colleagues to them. In reality, a collaborative interdisciplinary practice depends upon staff learning from each other to support the patient. Therapists from the community, including those with medical backgrounds, will need more solutionfocused assessment and treatment skills. Independent practice in the community affords a 60-minute or more session and return visits until a condition is healed or the client is satisfied. Providing a variety of therapies in an acute care setting requires consultation
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and collaboration with medical and nursing staff and usually much shorter treatment times. We have found it essential to facilitate team discussions that are directed toward making the program that the hospital system wants and can accept operational rather than an idealized preconceived version that would alienate colleagues and marginalize our efforts. We have planted the seeds of our work and networked informally with physicians, nurse practitioners, staff nurses, cardiovascular catheterization laboratory personnel, and surgical staff to demonstrate the benefits of the use of integrative therapies to manage pain and reduce anxiety. This has fostered a growth in interdisciplinary collaboration. By offering to be present when chest tubes are pulled or patients are extubated, we have developed relationships that produce calls for consultations. In one instance, teaching a congestive heart failure patient to decrease anxiety through breathing techniques to avoid an increase in medication engendered confidence from the patient and his wife as they described his newfound ability to disrupt a panic attack. This anecdote is one of many that supports our decision to combine patient care and research to further define effective integrative therapies that are appropriate for the cardiovascular population.
Research efforts In keeping with our emphasis on having an evidence base for practice, we chose to become a site for the Mantra II study originating at Duke University. This study uses integrative therapies including guided imagery, music, and touch prior to angioplasty and the placement of stents in the catheterization laboratory [15]. The randomized study also has an arm in which both patient and researchers are blinded to the use of prayer. Patients are prayed for at sites around the world. To date we have enrolled 95 patients. The principal researchers anticipate that the eight sites around the United States will enroll 700 patients and have targeted data analysis to begin in 2003. At the recommendation of the interdisciplinary advisory committee, a study was designed and initiated to assess the effectiveness of the treatment package we offer to heart surgery patients. Quality of Life and Patient Satisfaction: A Randomized Survey and Trial of Heart Surgery Patients Treated with an Integrative Therapies Package, has ended enrollment with 115 patients and is in the process of being analyzed for outcomes that include anxiety and pain management indicators as well as patient satisfaction
and quality of life, before and after surgery. Another proposal that would fund the development of research studies that combine conventional biomedical as well as integrative medicine research has been prepared and is being presented for funding. We continue to seek to extend interdisciplinary collaboration through research as well as patient services and education. It is our belief that these therapies are adjunctive to conventional treatments and must be validated through research that is specific to cardiovascular disease and the specific procedures used for treatment.
Expanding the vision As the initial work of the Healing the Heart program progressed, planning for a new heart hospital began. The planning work provided the catalyst for the development of a broader vision for integrative healthcare for both inpatients and outpatients. The integrative focus of the Healing the Heart program and the vision of its contributing sponsors became intertwined with the energy surrounding the new heart hospital planning process. In the fall of 1999, five focus groups were conducted to obtain perceptions from cardiovascular patients and family members regarding the experiences they had at ANW. The groups were also asked to answer the questions, ‘‘Tell me what you think the term healing environment means?’’ and ‘‘What would have to be present to provide a healing environment?’’ The comments were grouped into themes for further study. Patients and family members described their ideas for a healing physical environment, such as ease of finding their way through the hospital; a clean, quiet, and uncluttered atmosphere; privacy; soft colors; and the availability of calming music. They also emphasized the importance of emotional and spiritual support, communication and information, and highly skilled nurses and physicians who care about them as an individual. Some participants said they would like to have access to complementary therapies, such as massage and nutritional supplements. In the winter of 2000, five multidisciplinary groups were convened to design a patient care model for the new heart hospital. Participants included physicians, staff nurses, advanced practice nurses (clinical nurse specialists and nurse practitioners), other staff members, managers and administrators. The patient/family focus group comments helped to guide the care model work. Three groups described the ‘‘ideal’’ patient experience for clinic patients, inpatients, and procedural patients. The other two groups designed the role of clinical information
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utilities and support services in providing the infrastructure for the patient experience. The outcome of this work was a care model summarized by a document detailing 30 cornerstones essential to providing a seamless patient experience across the continuum of care. This was believed to be particularly important for our patient population, since 60% come from outside the 11-county Minneapolis/St. Paul metropolitan area. The model was not focused specifically on integrative care but rather on designing the essential building blocks needed to provide a foundation for such efforts. Examples of the cornerstones include an integrated patient record, individual patient care plan, central schedule access, flexible scheduling program, prearrival testing, patient/family education, and many others. The assumption was made that work on these cornerstones could begin immediately and did not have to wait until the new hospital was built. Architectural planning began once the optimal patient experience and functional requirements to support it had been identified. At each step of the design, care providers provided input related to the optimal physical environment to support healing. At this point, it was clear that there was an emerging need for a vision for integrative healthcare to complement the new patient care model, which was focused on optimal systems and processes. In 2001, the advisory board of Healing the Heart was restructured and became the Integrative Practice Advisory Board. Participants from ANW and the Minneapolis Heart Institute met to discuss approaches to further evolve the work completed to date. Three areas for potential growth identified were (1) exploring the development of an organizational model to support integrative healthcare and healing, (2) further developing holistic nursing practice to complement the interventions received by patients through the Healing the Heart program, and (3) development of a prevention and lifestyle management program for cardiovascular outpatients. Each of these areas was incorporated into the cardiovascular quality plan to ensure they became priorities for resource allocation and leadership team attention. Another expansion-related grant in 2001 funded a series of interdisciplinary education and discussion meetings that were held to involve medical and nursing staff in developing the concept of what was becoming an integrated approach to patient services. An administrator with extensive experience in creating ‘‘healing environments’’ was invited to visit ANW and the Minneapolis Heart Institute to provide consultation for the heart hospital project. He defined the ‘‘total healing environment’’ as ‘‘an environment wherein the people . . . work in partnership with
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patients and their families, seeking peace of mind and peace of heart, as well as physical cures and comforts, because we understand the indivisible relationship that exists between the body, the mind, and the human spirit’’ [16]. During his consultation, he described a conceptual model for the healing environment. The model included a vertical continuum related to the external and internal environments of the patient, and a horizontal continuum related to the elements of the patient’s environment that are physical and psychospiritual in nature. The site visit generated much enthusiasm among physicians, nursing staff, and administrators. The model was congruent with ANW hospital and nursing department philosophies stating that ‘‘Patients are the reason we exist, people are the reason we excel,’’ and seemed to complement the 30 cornerstones of the new patient care model. In addition, the total healing environment model supported the value of ‘‘developing positive relationships within and outside the organization that emphasize respect, integrity, accountability, and commitment’’ [17]. Growing evidence indicates that relationships may have an intrinsically healing effect [16]. There is also evidence that indicates that patient outcomes may depend on the quality of the collaborative relationships between nurses and physicians [18]. The cardiovascular executive committee, consisting of administrators and physician leaders, endorsed the total healing environment model as the foundation to further integrative healthcare in the new heart hospital. The cardiovascular patient care leadership team studied the model, discussed all its implications, and developed a new adaptation of the model (Fig. 4). The Vice President of Cardiovascular Services became the President of ANW in 2002 and provided leadership for disseminating the model across ANW. Interest in the healing environment concepts spread quickly across the organization, as the work was aligned with the existing organizational culture. In addition, several other areas of the hospital had already developed integrative clinical programs addressing the needs of specific patient populations, most frequently in the outpatient setting. The healing environment work was incorporated into ANW’s 2002 strategic plan, and a ‘‘shepherd’s’’ group was formed to lead the initiative and carry it out across the organization. In 2002 the model was introduced to all leaders and staff, integrated clinical program development continued, leadership development was initiated, and staff, physicians and leaders were engaged in furthering the model at ANW. In the summer of 2002 a medical director with expertise in integrative approaches was hired.
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Fig. 4. Healing environment: examples of influencing factors. From Journal of Healthcare Management. Vol. 44, p. 499, Chicago: Health Administration Press, 1999. with permission.
The second area for potential growth identified by the cardiovascular integrative practice advisory board was to develop holistic nursing practice further to complement the work of the Healing the Heart program staff. Critical care nurses had earlier participated in a study assessing their attitudes towards integrative therapies (Figs. 5 and 6) [19]. Survey results indicated openness to these therapies and a desire to increase availability of CAT to patients and families in the critical care setting. An associate professor of nursing was consulted in developing a 2-hour educational session funded by
the hospital that all cardiovascular nurses attended in 2002. She worked with the cardiovascular patient care leadership team and the Healing the Heart program staff to develop objectives for the sessions focused on holistic nursing care in a healing environment. The primary goal for the sessions was to provide an experiential climate for learning about integrative therapies, building upon a foundation of holistic nursing practice. The sessions were taught by the nursing professor and Healing the Heart program staff. The clinical expertise of the program faculty has been critical to the program’s credibility for nursing
Fig. 5. Abbott Northwestern critical care nurses survey. The survey asked, ‘‘How strongly do you desire to increase availability of CAM to patients and families in your critical care setting?’’
Fig. 6. Abbott Northwestern critical care nurse survey. The survey asked, ‘‘Overall, how open are you to the utilization of CAM?’’
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staff. In addition, the director of cardiovascular patient care services attended the sessions to listen to nursing staff interests, comments, and concerns; acknowledge their daily contributions to holistic care; and to provide information regarding the vision for the healing environment in the new heart hospital. This session has also been taken to the hospital-wide Nursing Practice Board, and has been positively evaluated by most participants. Additional educational opportunities will be designed for the future to develop these concepts further, based upon nursing staff input and interests. The third area for potential growth identified by the Integrative Practice Advisory Board was the development of a prevention and lifestyle management program for cardiovascular outpatients. A program plan was developed, and the first cohort of patients began the outpatient pilot program in May of 2002.
Summary This article describes one hospital’s approach to developing an inpatient integrative therapies program and the foundation for a broader integrative healthcare vision. Since the program’s inception, additional evidence has accumulated in the literature supporting the impact of integrative therapies strategies on patients’ quality of life during inpatient stays [13]. These findings and our own evaluation processes have encouraged continued program growth. Several elements were critical to the program’s success. Review of the literature and investigation of other programs served as preparation before the actual program started. It was necessary to have administrative, nursing, and physician champions who were able to envision the program and see the value of this approach for patients. We appreciated the need for evidence-based outcomes research and demonstrable patient outcomes. Finally, a program manager was hired who was able to understand the culture of the hospital and the organizational change process. Each of these basic steps, which called for interdisciplinary collaboration, allowed us to accomplish the goal of using integrative therapies as adjuncts to conventional medical care and thereby supported an integrative approach. Consistently linking the integrative vision to patient needs and requirements helped us to identify many new avenues to expand upon this work. The process of program development described may be useful to other inpatient cardiovascular programs inclusive of critical care settings. Adaptations of our experience to other populations in critical care and across other hospital settings may be possible.
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Developing an integrative therapies program in a tertiary care cardiovascular hospital Sue Sendelbach, MS, RN, CCNSa,*, Linda Carole, PsyD, LPb, Julie Lapensky, MS, RNc, Vib Kshettry, MDd
a
Cardiovascular Services Division, Abbott Northwestern Hospital, 800 East 28th Street, Minneapolis, MN 55407, USA b Healing the Heart Program, Abbott Northwestern Hospital, 800 East 28th Street, Minneapolis, MN 55407, USA c Cardiovascular Patient Care Services, Abbott Northwestern Hospital, 800 East 28th Street, Minneapolis, MN 55407, USA d Minneapolis Cardio – Thoracic Surgery Consultants, Minneapolis Heart Institute, Abbott Northwestern Hospital, 920 East 28th Street, Minneapolis, MN 55407, USA
In 1999, a complementary and alternative medicine (CAM) program for cardiovascular inpatients was initiated at Abbott Northwestern Hospital (ANW). Investigation of the feasibility and potential outcomes of such a program began in the mid-1990s. The prevalence of the public’s use of CAM had been well established in the literature [1,2]. These trends were also noted at ANW, where patient and family demand for such services in the inpatient setting was increasing. Concurrently, the literature was beginning to support the use of integrative therapies as an adjunct to conventional care. For example, when the Agency for Healthcare Research and Quality (AHRQ) developed clinical practice guidelines for acute pain management, specific integrative therapies were also recommended as supplemental interventions [3]. The Nursing Department’s philosophy at ANW supported a patient-centered, holistic framework for practice. ANW, a part of the Allina Health System, is a 627-bed tertiary-care, not-for-profit hospital in Min-
Supported in part by a Medtronic Foundation Healthcare Leadership grant, which has allowed enhancement and expansion of our database and research and network capabilities; and a philanthropic partnership with Penny and Bill George of the George Family Foundation, who have shared our patient care vision and continue to believe in our model of integrative care. * Corresponding author. E-mail address: [email protected] (S. Sendelbach).
neapolis, Minnesota. The Minneapolis Heart Institute is an organized group of cardiovascular physicians including a cardiology group and two cardiovascular surgical groups who provide a full continuum of cardiac services from primary prevention to heart failure and transplant for patients at ANW. In 2001, ANW and the Minneapolis Heart Institute treated more than 7800 inpatient cardiac admissions, and diagnosed and treated greater than 25,000 patients in more than 30 outpatient settings in Minneapolis and community sites in Minnesota. The mission of Allina and ANW is to provide an exceptional healthcare experience. These organizational characteristics combined with patient requests and the beginning of literature support provided the foundation and impetus for the inpatient cardiovascular integrative therapy program’s development at ANW called ‘‘Healing the Heart.’’ Although the National Center for Complementary and Alternative Medicine, a division of the National Institutes of Health, defines complementary therapies as those modalities used together with conventional medicine and alternative therapies as those used in place of conventional medicine, the terms are often used interchangeably [4]. More recently the term integrative medicine has been used to describe an approach that combines conventional and complementary care [5]. Patient involvement in his or her own recovery process is also an important element of integrative medicine [6]. When initially researching the literature before beginning our work, we found few articles pertaining
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to developing an integrative therapies program in an inpatient setting. This article describes how one tertiary care hospital developed an integrative therapies program in a cardiovascular inpatient setting. This includes the program’s inception and development, implementation and growth, outcome measurement, and ultimate expansion beyond the initial program vision.
Inception and development of the program The first step in developing the program was to complete a feasibility study, which could not have happened without administrative vision, creativity, and support. The director of cardiovascular patient care services sanctioned the clinical nurse specialist and the manager from the cardiovascular intensive care unit to focus on this project. A review of the research and literature from CINAHL and Medline was completed. The purpose for the review was to establish which complementary therapies had been studied, for what intent the interventions had been applied, and what patient outcomes were achieved. The initial review of the literature was broadly based, then narrowed to focus on cardiovascular patients. The literature was also searched to determine whether any integrative therapies programs had been created in an inpatient setting; however, no published studies were found that addressed what we had intended. Concurrently, ANW nurses and physicians with an interest in pursuing these ideas were identified; these nurses and physicians were also opinion leaders who were critical to the success of the project. Cardiovascular surgeons, cardiologists, staff nurses, and administrators were enthusiastic about the potential patient benefits of a cardiovascular integrated therapies program. The interested parties formed a ‘‘design team’’ to provide a forum for ongoing investigation and potential program design. The design team enthusiastically endorsed the concept that research and research utilization was foundational to the potential success of an integrative therapies program. Many things were gleaned from the literature review that helped guide the development of the program. For example, early studies of patients after myocardial infarction (MI) revealed that anxiety and depression were the top reasons for a referral for psychiatric evaluation [7,8]. It also was shown that anxiety peaked on days 1 and 2, whereas depression peaked on days 3 and 4 [7]. Because anxiety had been identified as a frequently occurring nursing diagnosis in the cardiovascular inpatient population at ANW, there was an interest in pursuing
potential anxiety-reducing interventions specifically targeted to days 1 and 2 after admission. Other research studies helped to set the initial direction for the program. In addition, the literature helped guide the development of a cardiovascular integrative therapies research study at ANW. There had been some research conducted with patients who had coronary artery disease in coronary care units and the effects of music [9 – 11]. Even fewer studies could be found that studied the effects of music on the patients undergoing a cardiac surgical procedure [12]. Consequently, when contemplating the conduct of research in the area, it was decided to study cardiac surgery patients and the effects of music on pain, anxiety, and other variables. The group anticipated positive outcomes and intended to disseminate results to medical and nursing personnel in the hospital to provide ‘‘local’’ scientific support for the use of integrative therapies. The literature was not able to provide much direction for initiating an integrative therapies program within an inpatient setting, as most of the programs had been operating in outpatient settings. Interviews were conducted with local and national resources identified in the integrative therapy literature review and through networking. This was met with some degree of success, as there were not many programs similar to the one planned. Some programs had been started and eliminated, whereas others were still in operation. We were able to learn as much from the programs that had been eliminated as from the ones that were active. For example, this helped us to decide we would not offer numerous therapies because of the resources required. When we chose which therapies to provide we chose those therapies that had beginning support in the literature and were not controversial. Using these criteria led us to choose music, massage, spiritual care, and dietary intervention. Once the potential for positive patient outcomes had been established, the literature reviewed, interviews with other integrative therapies programs completed, and the music therapy research study initiated, the design team began to discuss the development of a formal program and a proposal for funding was written. It included the purpose of the program, intended outcomes and benefits, scope of services to be provided, a brief description of other integrative therapies programs surveyed, participants of the design team, proposed structure and function for an ongoing advisory committee, a proposed budget, and a description of program staff roles and responsibilities. An essential element of the proposal was the inclusion of the responsibilities for a clinical program manager. Based on input from the design team and
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literature, patient outcomes to be targeted were effective management of pain and anxiety. The proposal was submitted to the Vice-President of Cardiovascular Services for approval and funding. The proposal was approved, and the program’s advisory committee was formed and included members from the original design team along with additional opinion leaders. A job description for the clinical program manager was written, the position posted, and a manager was hired. Because this position was considered critical to the program’s success, criteria were developed before beginning the interviews to assist in the final selection process. The program manager was instrumental in the ongoing development of the program and, if not for the appropriate leadership skills and an ability to understand the organizational culture, could have had a negative impact on the program.
Initiating and enhancing the program The mandate from the advisory committee to the clinical program manager focused on three areas for development—patient services, staff education, and integrative research. Discussions with the Nursing Council Task Group, informal conversations with bedside staff, and frequent strategy planning sessions with a cardiovascular surgeon who championed the initiative all garnered support for development in those areas. In addition, the program development plan was included in the cardiovascular quality plan to help keep it in the forefront of the work to be accomplished for the year. The manager was also assigned to the cardiovascular Patient Care Leadership Team, a position that allowed her to understand the hospital services and means of initiating new procedures. Other integrative therapies and integrative medicine efforts from across the country were identified and studied, and persons associated with these efforts were engaged in conversations about their program development and progress. A development strategy that encompassed 3 years was formulated, which included identification of philanthropic resources within the community, as these services did not have reimbursement. The advisory committee had recommended that patients would not be charged for these services. Internally, it was most helpful to have the first randomized controlled trial (ie, the music study) underway when the clinical program manager began the position. This alerted medical and nursing staff to the legitimacy of the program as a therapeutic endeavor rather than an attempt to create a spalike atmosphere directed only at customer service.
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Much of the early policy and direction continues today. Language describing program services and techniques is carefully chosen. Jargon or terms unfamiliar to medical staff and patients are avoided. Therapies and techniques are described within the context of stress management and relaxation skills. Family education and participation is always encouraged. Demonstrations of the therapies are offered to individual staff on a regular basis. More formal staff training has encompassed leadership training in integrative therapies/integrative services for managers, skills day training for bedside staff, and experiential presentations to new graduate nurses.
The role of the clinical program manager The manager serves in several capacities, that of practitioner, clinical supervisor, administrator, trainer, and development coordinator. She is introduced to patients as a healing coach when she practices, a role that was created to be cardiovascular care specific. The program manager is a licensed psychologist who provides additional integrative therapies, which include guided imagery, relaxation techniques, and brief cognitive behavioral consultations that span the continuum of care from acute events and procedures to chronic and end-of-life situations. These treatments are used for the purpose of anxiety reduction and to assist in pain management. As the program has expanded, the manager handles less direct patient care on the inpatient units and more therapeutic staff supervision. Development of outpatient integrative care is being piloted, and the program manager is a practitioner and specialist in body – mind therapies as a member of that team. Cases are discussed informally as needed and as regularly scheduled on a weekly basis.
Patient services The development of therapeutic approaches appropriate to inpatient cardiovascular care has been a priority. Music is chosen for its ability to entrain the heart [10]. Massage/touch techniques have been developed with consideration of the patient’s medical condition, age, and receptiveness to integrative therapies as part of the treatment planning, which in our acute care setting is done with input from other healthcare providers including physicians. Treatment sessions are designed to involve the patient and frequently family members to teach skills for postdischarge self-care. Patients are seen two or three times
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during the average length of stay. Complex patients are often treated longer. Initially, the clinical program manager was the only person staffing the program. For that reason, it was essential to select a subgroup of cardiovascular patients and focus on demonstrating patient outcomes to establish the legitimacy of the program. The Elective Heart Surgery (EHS) Clinic was chosen as the initial patient subgroup for a variety of reasons. First, it provided a manageable patient population size for the initial work. The EHS patients arrive at the EHS clinic the day before surgery for education, laboratory work, and other preparation, allowing contact with the clinical program manager. In addition, the cardiovascular surgeon, who was supportive, garnered the agreement of the other cardiovascular surgeons that all patients attending this clinic could be approached and offered integrative therapies. During the education visit, the patient and any family or support persons are treated with the therapies of their choice. As the program has grown, consults are requested from all areas of the inpatient units as well as by patients who call before they are scheduled for a procedure. It is usually patients who have had prior experience with integrative therapies who call to inquire about receiving these services. Additionally, on many occasions the surgeon recommends that a patient contact the service. From April 1999 through 2001, program staff has treated 1008 patients in 1925 sessions (Fig. 1). Many times family members are included in the session through massage or therapeutic touch demonstrations. A retrospective review of patients served in 2002 who agreed to have the outcome (tension) of their treat-
Fig. 2. Change in tension—scores before and after integrative therapy sessions by age.
ment reported is displayed in Fig. 2. Program staff document physical tension scores before and after treatment unless the patient has fallen asleep or is otherwise unable to give this information. No patients reported an increase in physical tension in this brief review. Generally, patients are appreciative of the treatments. Family members are taught to coach the patient in relaxation strategies as needed and if desired by the patient. Follow-up comment cards are also given to patients and family to track patient satisfaction and willingness to practice the therapies after leaving the hospital.
Program growth
Fig. 1. Number of visits for all integrative therapies by year.
It is well known that part of the still tenuous position of integrative therapies inside most hospitals is linked to the difficulties in paying for the additional care [13]. This was an issue that the manager and advisory committee needed to grapple with on an ongoing basis. To enhance program development, grant funding proposals were developed to add staff, increase medical and nursing staff education efforts, and to develop the integrative therapies research group. Because there was significant administrative support, the hospital also provided resources for various aspects of the program. Additional grant funding allowed us to add staff and also enabled us to continue to offer integrative therapies without charging patients. Grants were secured to support both the inpatient operations and the research efforts.
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Medical staff educational presentations on delivery of integrative therapies as adjunctive therapies to conventional care supported the interdisciplinary discussions. For example, at the weekly cardiology conference where updates on research and clinical implications are presented, cardiologists with expertise in integrative therapies were brought in to discuss these same issues with integrative therapies. ANW/Minneapolis Heart Institute physicians, including cardiologists and cardiovascular surgeons, were surveyed to gain their perspective and understanding of integrative therapies (Fig. 3). Although physician resistance is the number one problem facing hospitals that consider implementing an integrative therapies program, this was not a significant issue as we began the program [14]. In fact, several physicians were very interested in pursuing these therapies. Critical care nurses also participated in a survey that examined their attitudes regarding integrative therapies. The results of both surveys were positive and provided supportive information to the interdisciplinary work. In the second year of development, staff expansion was a priority. Included in this hiring phase was a research coordinator who facilitated the design and development of the database program. A fulltime healing coach with massage touch/ skill was hired. All services were provided at no charge to patients due to grant funding, which continues today. In a program in which excellent communication and therapeutic skills are the product delivered, by far
Fig. 3. Minneapolis Heart Institute physician survey. The survey asked, ‘‘ If a carefully chosen cardiovascular integrated medicine team was available to furnish your patients with evaluations, treatments, and a map to improve quality of life that was the result of a consensus of treating practitioners including you, would you refer to and work with this team?’’
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our greatest expense is salaries. We have chosen to hire staff rather than contract with therapists. Initially we found that paying contracted providers what they make in the community was prohibitive. In addition, we wanted staff to feel they belonged in the cardiovascular community and were part of a team rather than coming in for a few hours, providing a service, and returning to the community practice. This approach has allowed staff to develop areas of interest, participate in training medical staff, provide research interventions and follow-up, and become a presence on the nursing units. The team concept has been important in providing continuity of care and staff ownership of the program. In that regard, each staff member of the program is considered a healing coach within differing areas of practice concentration. The job description requires a combination of practice and training skills within the context of integrative therapies and integrative approaches. The research coordinator also has these practice skills and background. In addition to keeping the database and coordinating studies, she can also provide interventions when appropriate and as needed to back up patient services. At present two certified massage therapists share a position (1.1FTE). A music ‘‘technician’’ provides taped music and relaxation therapies to patients as well a doing administrative support (0.5FTE), and a team coordinator (1FTE) who has massage/touch and acupressure skills was hired to practice and provide administrative support to the clinical program manager as her role evolves to that of specialist in integrative care. This evolution includes inpatient and outpatient development. When hiring staff it has been especially important to hire appropriately qualified individuals who are willing to learn a new way of applying their knowledge. Providing services at the bedside for patients who may be gravely ill has required an adjustment of techniques and procedures as well as perception on the part of therapists. In an outpatient setting there is the luxury of more time. In the hospital setting this may not be so. It is important to acknowledge biases that favor one or another form of integrative therapies or conventional medical practice and discourage any attempts to convert colleagues to them. In reality, a collaborative interdisciplinary practice depends upon staff learning from each other to support the patient. Therapists from the community, including those with medical backgrounds, will need more solutionfocused assessment and treatment skills. Independent practice in the community affords a 60-minute or more session and return visits until a condition is healed or the client is satisfied. Providing a variety of therapies in an acute care setting requires consultation
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and collaboration with medical and nursing staff and usually much shorter treatment times. We have found it essential to facilitate team discussions that are directed toward making the program that the hospital system wants and can accept operational rather than an idealized preconceived version that would alienate colleagues and marginalize our efforts. We have planted the seeds of our work and networked informally with physicians, nurse practitioners, staff nurses, cardiovascular catheterization laboratory personnel, and surgical staff to demonstrate the benefits of the use of integrative therapies to manage pain and reduce anxiety. This has fostered a growth in interdisciplinary collaboration. By offering to be present when chest tubes are pulled or patients are extubated, we have developed relationships that produce calls for consultations. In one instance, teaching a congestive heart failure patient to decrease anxiety through breathing techniques to avoid an increase in medication engendered confidence from the patient and his wife as they described his newfound ability to disrupt a panic attack. This anecdote is one of many that supports our decision to combine patient care and research to further define effective integrative therapies that are appropriate for the cardiovascular population.
Research efforts In keeping with our emphasis on having an evidence base for practice, we chose to become a site for the Mantra II study originating at Duke University. This study uses integrative therapies including guided imagery, music, and touch prior to angioplasty and the placement of stents in the catheterization laboratory [15]. The randomized study also has an arm in which both patient and researchers are blinded to the use of prayer. Patients are prayed for at sites around the world. To date we have enrolled 95 patients. The principal researchers anticipate that the eight sites around the United States will enroll 700 patients and have targeted data analysis to begin in 2003. At the recommendation of the interdisciplinary advisory committee, a study was designed and initiated to assess the effectiveness of the treatment package we offer to heart surgery patients. Quality of Life and Patient Satisfaction: A Randomized Survey and Trial of Heart Surgery Patients Treated with an Integrative Therapies Package, has ended enrollment with 115 patients and is in the process of being analyzed for outcomes that include anxiety and pain management indicators as well as patient satisfaction
and quality of life, before and after surgery. Another proposal that would fund the development of research studies that combine conventional biomedical as well as integrative medicine research has been prepared and is being presented for funding. We continue to seek to extend interdisciplinary collaboration through research as well as patient services and education. It is our belief that these therapies are adjunctive to conventional treatments and must be validated through research that is specific to cardiovascular disease and the specific procedures used for treatment.
Expanding the vision As the initial work of the Healing the Heart program progressed, planning for a new heart hospital began. The planning work provided the catalyst for the development of a broader vision for integrative healthcare for both inpatients and outpatients. The integrative focus of the Healing the Heart program and the vision of its contributing sponsors became intertwined with the energy surrounding the new heart hospital planning process. In the fall of 1999, five focus groups were conducted to obtain perceptions from cardiovascular patients and family members regarding the experiences they had at ANW. The groups were also asked to answer the questions, ‘‘Tell me what you think the term healing environment means?’’ and ‘‘What would have to be present to provide a healing environment?’’ The comments were grouped into themes for further study. Patients and family members described their ideas for a healing physical environment, such as ease of finding their way through the hospital; a clean, quiet, and uncluttered atmosphere; privacy; soft colors; and the availability of calming music. They also emphasized the importance of emotional and spiritual support, communication and information, and highly skilled nurses and physicians who care about them as an individual. Some participants said they would like to have access to complementary therapies, such as massage and nutritional supplements. In the winter of 2000, five multidisciplinary groups were convened to design a patient care model for the new heart hospital. Participants included physicians, staff nurses, advanced practice nurses (clinical nurse specialists and nurse practitioners), other staff members, managers and administrators. The patient/family focus group comments helped to guide the care model work. Three groups described the ‘‘ideal’’ patient experience for clinic patients, inpatients, and procedural patients. The other two groups designed the role of clinical information
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utilities and support services in providing the infrastructure for the patient experience. The outcome of this work was a care model summarized by a document detailing 30 cornerstones essential to providing a seamless patient experience across the continuum of care. This was believed to be particularly important for our patient population, since 60% come from outside the 11-county Minneapolis/St. Paul metropolitan area. The model was not focused specifically on integrative care but rather on designing the essential building blocks needed to provide a foundation for such efforts. Examples of the cornerstones include an integrated patient record, individual patient care plan, central schedule access, flexible scheduling program, prearrival testing, patient/family education, and many others. The assumption was made that work on these cornerstones could begin immediately and did not have to wait until the new hospital was built. Architectural planning began once the optimal patient experience and functional requirements to support it had been identified. At each step of the design, care providers provided input related to the optimal physical environment to support healing. At this point, it was clear that there was an emerging need for a vision for integrative healthcare to complement the new patient care model, which was focused on optimal systems and processes. In 2001, the advisory board of Healing the Heart was restructured and became the Integrative Practice Advisory Board. Participants from ANW and the Minneapolis Heart Institute met to discuss approaches to further evolve the work completed to date. Three areas for potential growth identified were (1) exploring the development of an organizational model to support integrative healthcare and healing, (2) further developing holistic nursing practice to complement the interventions received by patients through the Healing the Heart program, and (3) development of a prevention and lifestyle management program for cardiovascular outpatients. Each of these areas was incorporated into the cardiovascular quality plan to ensure they became priorities for resource allocation and leadership team attention. Another expansion-related grant in 2001 funded a series of interdisciplinary education and discussion meetings that were held to involve medical and nursing staff in developing the concept of what was becoming an integrated approach to patient services. An administrator with extensive experience in creating ‘‘healing environments’’ was invited to visit ANW and the Minneapolis Heart Institute to provide consultation for the heart hospital project. He defined the ‘‘total healing environment’’ as ‘‘an environment wherein the people . . . work in partnership with
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patients and their families, seeking peace of mind and peace of heart, as well as physical cures and comforts, because we understand the indivisible relationship that exists between the body, the mind, and the human spirit’’ [16]. During his consultation, he described a conceptual model for the healing environment. The model included a vertical continuum related to the external and internal environments of the patient, and a horizontal continuum related to the elements of the patient’s environment that are physical and psychospiritual in nature. The site visit generated much enthusiasm among physicians, nursing staff, and administrators. The model was congruent with ANW hospital and nursing department philosophies stating that ‘‘Patients are the reason we exist, people are the reason we excel,’’ and seemed to complement the 30 cornerstones of the new patient care model. In addition, the total healing environment model supported the value of ‘‘developing positive relationships within and outside the organization that emphasize respect, integrity, accountability, and commitment’’ [17]. Growing evidence indicates that relationships may have an intrinsically healing effect [16]. There is also evidence that indicates that patient outcomes may depend on the quality of the collaborative relationships between nurses and physicians [18]. The cardiovascular executive committee, consisting of administrators and physician leaders, endorsed the total healing environment model as the foundation to further integrative healthcare in the new heart hospital. The cardiovascular patient care leadership team studied the model, discussed all its implications, and developed a new adaptation of the model (Fig. 4). The Vice President of Cardiovascular Services became the President of ANW in 2002 and provided leadership for disseminating the model across ANW. Interest in the healing environment concepts spread quickly across the organization, as the work was aligned with the existing organizational culture. In addition, several other areas of the hospital had already developed integrative clinical programs addressing the needs of specific patient populations, most frequently in the outpatient setting. The healing environment work was incorporated into ANW’s 2002 strategic plan, and a ‘‘shepherd’s’’ group was formed to lead the initiative and carry it out across the organization. In 2002 the model was introduced to all leaders and staff, integrated clinical program development continued, leadership development was initiated, and staff, physicians and leaders were engaged in furthering the model at ANW. In the summer of 2002 a medical director with expertise in integrative approaches was hired.
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Fig. 4. Healing environment: examples of influencing factors. From Journal of Healthcare Management. Vol. 44, p. 499, Chicago: Health Administration Press, 1999. with permission.
The second area for potential growth identified by the cardiovascular integrative practice advisory board was to develop holistic nursing practice further to complement the work of the Healing the Heart program staff. Critical care nurses had earlier participated in a study assessing their attitudes towards integrative therapies (Figs. 5 and 6) [19]. Survey results indicated openness to these therapies and a desire to increase availability of CAT to patients and families in the critical care setting. An associate professor of nursing was consulted in developing a 2-hour educational session funded by
the hospital that all cardiovascular nurses attended in 2002. She worked with the cardiovascular patient care leadership team and the Healing the Heart program staff to develop objectives for the sessions focused on holistic nursing care in a healing environment. The primary goal for the sessions was to provide an experiential climate for learning about integrative therapies, building upon a foundation of holistic nursing practice. The sessions were taught by the nursing professor and Healing the Heart program staff. The clinical expertise of the program faculty has been critical to the program’s credibility for nursing
Fig. 5. Abbott Northwestern critical care nurses survey. The survey asked, ‘‘How strongly do you desire to increase availability of CAM to patients and families in your critical care setting?’’
Fig. 6. Abbott Northwestern critical care nurse survey. The survey asked, ‘‘Overall, how open are you to the utilization of CAM?’’
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staff. In addition, the director of cardiovascular patient care services attended the sessions to listen to nursing staff interests, comments, and concerns; acknowledge their daily contributions to holistic care; and to provide information regarding the vision for the healing environment in the new heart hospital. This session has also been taken to the hospital-wide Nursing Practice Board, and has been positively evaluated by most participants. Additional educational opportunities will be designed for the future to develop these concepts further, based upon nursing staff input and interests. The third area for potential growth identified by the Integrative Practice Advisory Board was the development of a prevention and lifestyle management program for cardiovascular outpatients. A program plan was developed, and the first cohort of patients began the outpatient pilot program in May of 2002.
Summary This article describes one hospital’s approach to developing an inpatient integrative therapies program and the foundation for a broader integrative healthcare vision. Since the program’s inception, additional evidence has accumulated in the literature supporting the impact of integrative therapies strategies on patients’ quality of life during inpatient stays [13]. These findings and our own evaluation processes have encouraged continued program growth. Several elements were critical to the program’s success. Review of the literature and investigation of other programs served as preparation before the actual program started. It was necessary to have administrative, nursing, and physician champions who were able to envision the program and see the value of this approach for patients. We appreciated the need for evidence-based outcomes research and demonstrable patient outcomes. Finally, a program manager was hired who was able to understand the culture of the hospital and the organizational change process. Each of these basic steps, which called for interdisciplinary collaboration, allowed us to accomplish the goal of using integrative therapies as adjuncts to conventional medical care and thereby supported an integrative approach. Consistently linking the integrative vision to patient needs and requirements helped us to identify many new avenues to expand upon this work. The process of program development described may be useful to other inpatient cardiovascular programs inclusive of critical care settings. Adaptations of our experience to other populations in critical care and across other hospital settings may be possible.
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