Sparber, Andrew RN, MS, CS (August 31, 2001) "State Boards of Nursing
and Scope of Practice of Registered Nurses Performing Complementary Therapies"
Online Journal of Issues in Nursing. Vol. #6 No. #3, Manuscript
10. Available: http://www.nursingworld.org/ojin/topic15/tpc15_6.htm
Article published August 31, 2001
STATE BOARDS OF NURSING AND SCOPE OF PRACTICE OF REGISTERED NURSES PERFORMING COMPLEMENTARY THERAPIES
Captain Andrew Sparber RN, MS, CS
Abstract
This article provides a report of State Boards of Nursing (BONs) policies on the use of complementary therapies by registered nurses. This investigation was conducted for the White House Commission on Complementary Alternative Medicine Policy. The target sample for this report was fifty-three BONs in the United States. Forty-seven percent of the BONs had taken positions that permitted nurses to practice a range of complementary therapies; thirteen percent were in the process of discussing this matter; and forty percent, although they had not formally addressed the topic, did not necessarily discourage these practices. The results of this study can be used to encourage more discussion among the BONs and within states about nurses’ practice of complementary therapies. Nurses are encouraged to become aware of their state’s position regarding complementary therapy and to facilitate the integration of complementary therapies into their work environment.
Key words: boards of nursing, complementary therapies, scope of practice, United States
Introduction
Utilization of complimentary and alternative medicine (CAM) therapies in the United States has increased markedly in recent years (Wootton & Sparber 1999). Surveys focusing on physicians (Astin, Marie, Pelletier, Hansen, & Haskell, 1998; Blumberg, Grant, & Hendricks, 1995 ; Berman, Sing, & Lao, 1995; Diehl, Kaplan, & Coulter, 1997; Goldstein, Sutherland, Jaffe, & Wilson, 1988), social workers (Henderson, 2000), and nurses (Taylor, Lin, Snyder, & Eggleston, 1998; Allaire, Moos, & Wells, 2000; Sabo, Michael, & Temple, 1999) indicate that many "main stream" health professionals have integrated CAM practices into their work. Although much is known about consumer utilization of CAM, there is little reference in these professional or nonprofessional publications as to how state practice laws impact professionals’ practices of CAM, particularly the practice of registered nurses.
It has been noted, however, that licensure laws do affect the use of CAM therapies. Investigators have found that liberalization of licensure laws to practice CAM has been associated with a significantly increased use of CAM by physician and non-physician CAM providers. Furthermore, the existence of a practice act that gives non-physicians specific rights to deliver certain services is likely to substantially increase the supply of providers practicing this modality (Sturn, & Unutzer, 2001).
Complementary Therapies in Nursing
Though the term "CAM" is used in this report, "Complementary Therapies" will be utilized to reflect the integrative nature of nursing practice rather than as an alternative method of health care. Complementary therapies
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Due to the theoretical congruence between nursing practice and the practice of complementary therapies, nurses are in a unique position to bridge the gap between traditional, Western health care and complementary therapies.
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Although the increased liberalization of licensing laws may increase the usage of complementary therapies by registered nurses, few studies have begun to address this practice. Until large-scale studies are conducted, it appears that it will be necessary to draw conclusions about these nursing practices from a variety of other sources. Some answers may lie within the states, as State Boards of Nursing (BONs) are required to monitor scope of practice issues. Though employers have a role in the safe practice of complementary therapies by nurses, it is the BON that protects the public through licensure and practice acts. Additionally, the White House Commission on Complimentary Alternative Medicine Policy (WHCCAMP) http://www.whccamp.hhs.gov/ and the National Institutes of Health’s National Center for Complementary Alternative Medicine (NCCAM) http://nccam.nih.gov/nccam/fcp/classify/ have been addressing these practices in their studies of CAM therapies. The study reported in this article was conducted to provide information to the WHCCAMP, NCCAM and the Health and Human Service (HHS) Bureau of Health Professions (BHP) regarding state BON positions related to the practice of complementary therapies by registered nurses. This article will summarize the positions and/or policies on complementary therapies and nursing practice as reported by BONs in the United States.
This study began as an informal nursing department discussion of staff nurses’ use of complementary therapies at the Clinical Center of the National Institutes of Health in Bethesda, Maryland. It quickly evolved to the larger question about BONs’ positions on nurse practice of complementary therapies. Initial discussions with the Maryland BON were followed by further discussions with staff of the White House Commission on Complimentary Alternative Medicine Policy, National Institutes of Health’s National Center for Complementary Alternative Medicine, and the Bureau of Health Professions. All of these agencies were interested in a comprehensive report on BONs’ policies on use of complementary therapies by registered nurses.
Method
The target sample for this report was all State and Territorial BONs in the United States. A list of fifty-three BONs in the United States was accessed through the National Council of State Boards of Nursing (NCSBN) on February 15, 2001 (NCSBN, 1996). From this site, the links to the web pages or addresses of all BONs were used to connect with each BON. Information from these BONs regarding positions and policies on complementary therapies and nursing practice was then obtained through a) web page; b) email; and/or c) telephone. The remote United States territories of Guam, American Samoa, and the Northern Mariana Islands were not included in this report. The District of Columbia, Puerto Rico and the Virgin Islands were contacted because of their location on and/or near to the U.S. mainland. Once obtained, the information was coded under three descriptive categories. BONs that had a formal policy, position, or inclusion of complementary therapies under their scope of practice were coded as states who "Permit Practice". BONs that were in the preliminary stages of addressing the issue were coded as "Under Discussion"; and those that had not formally considered the topic were coded as "No Formal Position". All fifty-three BONs responded to this request for information.Discussion of Findings
Forty-seven percent (25) of the BONs who permitted practice had statements or positions that included specific complementary therapies or examples of these practices; thirteen percent (7) were in the process of discussing the topic and, forty percent (21) had not formally addressed the topic, but did not necessarily discourage these practices. The reader is directed to the "Boards of Nursing" (Table 1) to link to the policies/positions provided by the 25 BONs having a described scope of care related to complementary therapies.Historical Development of Position Statements
It was observed in this study that as complementary and alternative medicine gained national attention, BONs began to address the regulation issues.
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...as complementary and alternative medicine gained national attention, BONs began to address the regulation issues.
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Table 1. Results of Boards of Nursing (BON) (N= 53)
| Category Scope of Care Described |
State |
| Permit Practice 47% of BONs N=25 |
Arizona Arkansas California Connecticut Illinois Iowa Kansas Louisiana Maine Maryland Massachusetts Mississippi Missouri New Hampshire New York Nevada North Carolina North Dakota Ohio Oregon Pennsylvania South Dakota Texas Vermont West Virginia |
| Under Discussion 13% of BONs N=7 |
Delaware District of Columbia Georgia Minnesota New Jersey New Mexico Washington |
| No formal Position 40% of BONs N=21 |
Alabama Alaska Colorado Florida Georgia Hawaii Idaho Indiana Kentucky Michigan Montana Oklahoma Puerto Rico Rhode Island South Carolina Tennessee Utah Virgin Islands Virginia Wisconsin Wyoming |
Legal Considerations
It is becoming clear that BONs understand that the very nature of nursing lends itself to a framework that welcomes these non-invasive complementary practices. The Louisiana BON most eloquently describes in their Declaratory Statement that, "The Law Governing the Practice of Nursing authorizes registered nurses to provide care supportive to or restorative of life and well-being" (Louisiana BON, 1999). This premise, as stated by the Louisiana BON, underlies much of the thinking and support throughout the states for the justification of practice of complementary therapies. Although there are some states that do not have any language that describes complementary therapies, their decision-making models could be used to justify the practice of these modalities.
Education Needed
Most BONs now see the close relationship between complementary therapies and nursing.
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Not only would credentialing help assure safe practice, but it would also communicate a strong message to other health professionals that the practice of nursing is based on a learned body of knowledge.
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Examples of Complementary Therapies
A compilation of complementary therapies mentioned by the states is provided
in Table 2. Included in the table are therapies
specifically designated by BONs and/or examples of such therapies. It
should be noted that this listing is instructive but not all-inclusive.
The complementary therapies reported by the states were organized under
four of the five categories that had been developed by NCCAM: a) alternative medical
systems; b) mind-body interventions; c) energy therapies;
d) manipulative and body-based methods; and e) biologically-based treatments. The fifth category, biologically-based treatments, was not included in this table because
requests for information from the BONs focused on the basic level of nursing
practice. The issue of prescriptive authority for herbals and other natural
products was not addressed, though a few boards did refer to advanced
nursing practice and recommendations and/or prescriptions for these natural
products.
Table 2. Compilation of Complementary Therapies
| Categories* | Practices |
| Mind/body interventions | Art Biofeedback Focused breathing Holistic Nursing Humor Meditation Music Visual imagery Yoga |
| Alternative medical system | Acupressure Oriental massage Biological-based therapies Diet and nutrition (not herbs) |
| Manipulative/body-based systems | Aromotherapy Cranial-sacral Deep muscle massage Effleurage Esalen Feldenkreis Friction Heller work Infant massage Lomilorri Lympatic drainage Myotherapy/Myofascial Neuromuscular Petrissage Reflexology Shiatsu Structural integration Swedish massage |
| Energy therapies | Healing Touch Therapeutic Touch Reiki |
| *NCCAM categories | |
Summary and Implications
This article presented the results of a survey of State and Territorial Boards of Nursing in the United States and their positions on nursing practice of complementary therapies. The practice of complementary therapies is becoming more common and state boards are recognizing the need for policies in this arena. Nursing practice requires that one should explore all avenues to help people, and nurses are ideal providers to serve as a bridge between health and medicine. Nurses should become aware of their state’s position regarding complementary therapy and take appropriate action to facilitate the integration of therapies into their work environment.
This report can be used by the WHCCAMP, NCCAM, the Bureau of Health Professions, and other agencies and associations to gain a better appreciation of the contribution that nurses make in this important area of health care delivery. Additionally, this report can be used by nurses to advise legislators, program development officers, and key leaders regarding policy, education and/or funding issues related to CAM. It can be used as BONs initiate a collective dialogue, perhaps through the National Council of State Boards of Nursing, to assist BONs in policy development. Sometimes just asking a question can stimulate change as this author noted during this study when the request of information for this survey resulted in the addition of this topic to the agenda for at least one BON meeting. BONs that have not addressed these nurse practice issues can benefit by dialoguing with states that have already done so. BONs that already support complementary therapies can use these discussion to clarify and strengthen present complementary therapy practice statements.
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...there is national recognition of nurses’ leadership, and their ability to act as gatekeepers for consumers.
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The nursing profession can not afford to fall behind in an increasingly popular area of health care that is so reflective of the basic values of nursing care. Currently, there is national recognition of nurses’ leadership, and their ability to act as gatekeepers for consumers. It is essential that nurses use this front line position to enhance the safe and effective use of complementary therapies.
The Author
Captain Andrew Sparber RN, MS, CS
Email: andrew53@comcast.net
Andrew Sparber RN, MS, CS, is a Captain in the US Public Health Service and an Integrative Medicine Clinical Nurse Specialist in the Nursing and Patient Care Service at the Clinical Center of the National Institutes of Health. He serves as the staff coordinator for the newly established Clinical Center- Wide Task Force on Integrative Medicine. Captain Sparber has lectured throughout the United States on a variety of complementary and alternative medicine topics, and is an author, investigator, and consultant. His groundbreaking leadership on the issue of patients’ use of herbal and nutritional supplements while enrolled in clinical trials has resulted in the passage of a new NIH Clinical Center Medical Executive Committee policy regarding these supplements. Captain Sparber is also a practitioner of Healing Touch, visual imagery and relaxation modalities.
References
Allaire, A., Moos, M., & Wells, S., (2000). Complementary and alternative medicine in pregnancy: A survey of North Carolina Certified nurse-midwives. Obstetrics & Gynecology, 95(1), 19-23.
Astin, J. A., Marie, A., Pelletier, K. R., Hansen, E., Haskell, W. (1998). A review of the incorporation of complementary and alternative medicine by mainstream physicians. Archives of Internal Medicine, 158, 2303-2310.
Berman, B.M., Sing, B., & Lao, L., (1995). Physicians attitudes toward complementary alternative medicine: A regional survey. Journal of American Board of Family Practice, 8, 361- 366.
Blumberg, D. L., Grant, W., Hendricks, S., (1995). The physician and unconventional medicine. Alternative Therapies in Health & Medicine, 1,31-35.
Diehl, D. L., Kaplan, G., & Coulter, I., (1997). Use of acupuncture by American physicians. Journal of Alternative Complementary Medicine, 3,119-126.
Goldstein, M. S., Sutherland, C., Jaffe, D., & Wilson, J., (1998). Holistic physicians and family practitioners: Similarities, differences and implications for health policy. Social Science Medicine, 26(8), 865-861.
Henderson, L. (2000). The knowledge and use of alternative therapeutic techniques by social work practitioners: A descriptive study. Social Work in Health Care, 30(3), 55-71.
Louisiana BON. (1999, August 8). Declaratory Statements; Baton Rouge, LA: Author. Retrieved July 20, 2001 from the World Wide Web: http://www.lsbn.state.la.us/publicat.htm
National Council of State Boards of Nursing. (1996). Contact information and web pages. Chicago: Author. Retrieved February 1, 2001 from the World Wide Web: http://www.ncsbn.org/public/regulation/boards_of_nursing_board.htm
Sabo, C., Michael, S., & Temple, L. (1999). The use of alternative therapies by diabetes educators. The Diabetes Educator , 25(6), 945-956.
Sturn, R. & Unutzer, J. (Winter 2000/2001). State legislation and the use of complementary and alternative medicine. Inquiry, 37, 423-429.
Taylor, A., Lin, Y., Snyder, A., & Eggleston, K., (1988). ED staff members’ personal use of complementary therapies and their recommendations to ED patients: A southeastern U.S. regional study. Journal of Emergency Nursing, 24, 495-9.
Wootton, J. & Sparber, A. (1999). Surveys of complementary alternative medicine. In M.S. Macozzia (Ed.), Current review of complementary medicine (pp. 139-153). Philadelphia: Current Medicine.
Article published August 31, 2001
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