Mr. Allmanson, a paraplegic, lay in his bed on the spinal cord injury and disorders (SCI/D) unit. (This case is a composite based on my experience.) The integrative therapy nurse asked the patient, “What's bothering you the most today?” He replied, “Would you be able to work on my shoulders? They're sore and I can't get comfortable.” The nurse arranged his gown, adjusted his pillows, raised the bed, and began to gently massage his shoulders. As the patient began to relax, he started talking to the nurse about his pain. He said he was working very hard in physical therapy to learn how to walk again after his car accident. He was proud of the progress he'd made but noted that pain in his shoulders affected how much physical therapy he could tolerate per day. The patient said, “Things have improved since you started seeing me. You help get the muscles all loosened up so I can take advantage of my therapy. Even my therapists have noticed a difference.” The patient noted that his pain had decreased from an 8 (on a scale of 0 to 10) before the session to a 6 afterward.
A third of adults in the United States now report the use of integrative health approaches,1 and research shows that a symptom management plan that includes integrative therapies is beneficial to the hospitalized patient, especially when addressing pain.2 The spinal cord injury population has a long-standing history of chronic pain, and these patients experience many types of pain, including neuropathic, visceral, and musculoskeletal pain.3 Veterans who have sustained SCI/D often suffer from pain, which can greatly affect quality of life, making them an optimal population within which to implement nonpharmacologic and noninvasive integrative therapies.3 It's important to note that pain may also contribute to other compounding issues, including mood changes, anxiety, depression, and sleep irregularities. Pharmacologic interventions have been the primary form of treatment for many of these symptoms. However, many patients suffer from the adverse effects of these medications, as well as from the adverse effects associated with long-term use of pain medications. Additionally, the current push to decrease the frequency of opioid prescriptions highlights the need for an integrative approach to symptom management.
Integrative medicine is the concurrent use of both integrative therapies, such as massage therapy, meditation, and acupuncture, and Western medical approaches, with the goal of treating each patient's individual needs.4 Integrative therapies are used to support the body's capacity to heal and holistically address the patient's health and well-being in mind, body, and spirit. These therapies may be used to address symptoms and adverse effects, as well as to promote generalized wellness. Massage and other integrative therapies can be used in the rehabilitation setting as an adjunct to traditional hospital care (see Massage Therapy 5-8).
In my first three years as an SCI/D nurse on the inpatient acute rehabilitation unit at the Minneapolis Veterans Affairs Medical Center (MVAMC), I often encountered patients who experienced chronic pain, many of whom wanted to explore integrative therapy options to enhance their symptom management plan. While the MVAMC educated nurses on integrative modalities, such as guided imagery, acupressure, and aromatherapy, and integrative therapies were being used throughout the institution, staff nurses often had difficulty including these therapies on their shifts because they were already busy with complex nursing responsibilities. These time limitations underscored the need for a nurse whose sole responsibility was to assist other nurses in incorporating integrative approaches into their practice. When I began developing the integrative nurse role in February 2014, there were no dedicated integrative therapy nurses at the institution.
With the idea of developing the integrative therapy nurse role, I returned to school in the fall of 2013 to become a massage therapist while I continued to work as an SCI/D nurse at the MVAMC. I designed my course load to focus on hospital-based therapeutic massage and gained additional training in techniques such as reflexology to serve oncology, older adult, and other medically complex patient populations. My training included working as part of a diverse group of practitioners (massage therapists, acupuncturists, music and art therapists, chiropractors, physicians, energy healing practitioners, and others), which helped me develop and refine my vision of an integrative therapy nurse functioning as part of the interdisciplinary team on the SCI/D unit. Throughout my schooling, I collected research, developed electronic health record (EHR) charting templates, and created evaluation tools to assess the role of the integrative therapy nurse that I was planning to initiate.
After completing school in August 2014, I gained board certification in therapeutic massage and bodywork. Both the inpatient nurse manager and the head of the SCI/D department supported the creation of the new nursing role, and together we developed the initiative to add a dedicated integrative therapy nurse to the SCI/D unit. I provided staff education and compiled patient feedback on my work to share with administrators. The purpose of this initiative was to explore the use of integrative therapies (specifically massage therapy) in the SCI/D veteran population and to develop the role of the integrative therapy nurse to safely and effectively deliver massage therapy sessions. I performed traditional Swedish and rehabilitative massage techniques on patients on the SCI/D unit throughout the three-year initiative.
INTERDISCIPLINARY TEAM INTEGRATION
The education that led to my certification as a massage therapist reinforced the importance of working as part of an interdisciplinary team. It was evident to all team members that this approach encouraged communication between practitioners, provided a collaborative environment in which to address patients’ whole health, and supported the use of an integrated care model. As a member of this team, I attended interdisciplinary team rounds twice a week. My participation in rounds set the stage for integrative therapies to be considered part of standard practice and increased buy-in and support from the entire team. I also had the opportunity to educate the team on how to tailor integrative therapies to a patient's condition, plan of care, and personal goals.
According to the protocol (see Figure 1), any member of the interdisciplinary team, including physicians, NPs, psychologists, registered dieticians, physical therapists, occupational therapists, speech pathologists, and staff nurses, could initiate an integrative therapy consultation (by placing an order in the patient's EHR). Between February 2014 and February 2017, members of the interdisciplinary team placed 113 integrative therapy consultation orders for patients who had pain they hoped could be addressed with massage therapy. These consultations resulted in 591 therapy sessions. New patient consultations ranged from zero to nine per month and averaged three per month. The number of consultations varied based on factors including the patients’ needs, my availability, and the number of patients already receiving massage therapy at any given time. (By clinician type, the number of consultation orders were placed as follows: 51 by physicians, 23 by nurses, 11 by NPs, two by occupational therapists, two by physical therapists, one by a psychologist, and 23 as the result of team discussion.)
Once a member of the interdisciplinary team placed an order, I met with the patient to explain my role as the integrative therapy nurse, discuss commonly addressed symptoms, and review therapy options. While massage therapy was the most frequently requested intervention (and therefore is the one discussed in this article), I was also able to offer aromatherapy, guided imagery, acupressure, and reflexology. To establish clear boundaries in accordance with the MVAMC's policies regarding patients’ behavior, I provided each patient whose plan of care included touch therapy a brief document outlining appropriate behavior in integrative therapy sessions and the consequences of not adhering to this behavior. Patients were free to decline participation in integrative therapies.
NURSING STAFF BUY-IN
At first, I was concerned that other nurses on the unit might not accept my new role, as my new duties would differ greatly from those of a floor nurse. I was able to gain the buy-in of the nursing staff, however, by providing education on the new role (inviting nurses to remain in the patient's room during integrative therapy sessions) and including them in the referral and appointment-making process to ensure that sessions wouldn't conflict with their nursing responsibilities. As a massage therapist and a nurse, I had the ability to assist with unforeseen nursing tasks, such as tracheal suctioning, and with repositioning the patient before, during, and after patient appointments. Therefore, staff nurses appreciated knowing their patients were going to be both comfortable and safe while I was in the room.
I also reinforced the integrative therapy education nurses had already received. I created a bulletin board on integrative therapies for the SCI/D unit that included tools nurses could use for self-care at home and at work. The ability to use integrative therapies independently empowered my nursing colleagues and promoted investment in integrative health. And as the nurses began to see the benefits integrative therapy provided for patients, their support grew. Nurses shared with me that their patients were calm and relaxed after sessions and appreciated the personal attention I provided. By involving nursing staff whenever possible, the role of the integrative therapy nurse became one that was not only appreciated but also respected.
This initiative included 113 patients, 110 men and three women, 21 to 86 years of age (mean age, 61.5 years). These patients had diagnoses including tetraplegia, paraplegia, and spinal cord disorders such as multiple sclerosis and amyotrophic lateral sclerosis (ALS). The number of patients by diagnostic category were as follows: 27 patients with paraplegia; 20 with high tetraplegia; 13 with low tetraplegia; seven with ALS; five with multiple sclerosis; 13 with other conditions; and 28 with an American Spinal Injury Association (ASIA) grade of D (see The ASIA Impairment Scale 9).
The evaluation of the initiative was based on patients’ responses to the massage therapy intervention. I asked patients to rate their pain before and after each session on a 0-to-10 scale, with 0 representing no pain and 10 the worst pain imaginable. This numeric rating scale is widely used and one of the standard instruments for measuring pain.10 I also sought patients’ verbal feedback on how they felt before and after each session, as well as their relaxation response based on either their verbal report of increased relaxation or their presentation of signs of relaxation, including eyes closing or closed, lower rate and greater depth of respiration, and/or relaxation of the muscle tissue addressed by therapeutic massage.
A total of 701 massage therapy sessions were provided to the 113 participating patients, resulting in a mean of 6.2 sessions per patient. Sessions in which patients reported no pain at the beginning (110 sessions) were not included in the data analysis; only sessions in which patients reported a pain rating of 1 or greater were included. In 507 sessions, patients verbally provided pain scores on a 0-to-10 scale both before and after therapy; in 84 sessions, patients appeared to be deeply relaxed at the end of the massage, with their eyes closed (or possibly asleep), and were not disturbed to obtain a postintervention pain score. In the 507 sessions in which patients rated their pain, the mean presession pain score was 5.16 and the mean postsession pain score was 3.44, for a decrease of 1.72 points. Patients verbally reported decreased pain in 65.25% of sessions and increased relaxation (or showed it by signs such as closed eyes) in 98.82% of sessions. At the end of 14.25% of sessions, patients were resting comfortably and were not disturbed for postsession scoring. Patient feedback was entirely positive; no patients gave negative responses (see Patient Feedback).
These outcomes were presented to management and to other hospital committees, increasing their awareness of the benefits of integrative therapy in veterans with SCI/D. These results supported the idea that having a dedicated integrative therapy nursing staff member improves patient outcomes and adds value to the patient services our institution provides.
IMPLICATIONS FOR PRACTICE
The integrative therapy nurse role that was created by this initiative has many implications for nursing practice. First, the delivery of integrative therapy services by a dedicated staff member with advanced training could be expanded to other inpatient units within the hospital. Pain and associated symptoms, such as anxiety, stress, and negative changes in quality of life, are seen in every clinical setting and thus an integrative therapy nurse could benefit other patient populations, such as oncology, hospice, pre- and postsurgical patients, and many others.
Second, integrative therapy nurses with different skill sets could be added. For example, a team of nurses skilled in diverse integrative modalities, such as acupuncture; energy healing; and music, art, and movement therapies could provide opportunities for patients to try multiple interventions to address their symptoms. Because patients have different histories, medical conditions, and/or personal beliefs, each patient may be drawn to a different integrative therapy intervention.
Finally, the integrative therapy nurse role could be expanded to outpatient and/or home care settings. There are many patients who receive care in their homes, leaving them without access to the services offered in the hospital setting. However, an integrative therapy nurse would have the skills and knowledge to safely conduct home visits to address a patient's symptoms. The outpatient model could be as successful as the inpatient model if a space for therapy and scheduling assistance were provided.
As a staff nurse working with veterans on the SCI/D unit at the MVAMC, I cared for patients struggling with pain and its associated symptoms. Many of these patients were interested in exploring integrative therapies for symptom management. By obtaining education in therapeutic massage and implementing an initiative that used my knowledge and skills as an integrative therapy nurse, I was able to provide a type of comprehensive care that was not previously available to these patients. The success of this initiative was facilitated by my involvement with the interdisciplinary team. Additionally, staff members felt a sense of investment in the integrative therapy nurse role, as they were invited to participate and were provided with education that not only benefited their patients but also encouraged self-care both in and out of the workplace.
In the future, outcomes could be further explored by classifying patients by the type of pain (neuropathic, visceral, musculoskeletal) they are experiencing, whether they are participating in an acute or subacute rehabilitation program, and whether they are concurrently participating in other integrative therapies. Additionally, it would be beneficial to measure any changes in the use of medications throughout the patients’ participation in integrative therapies.
My patients experienced a decrease in pain, along with an increase in relaxation, as a result of the use of massage therapy. The integrative therapy nurse was shown to be a valuable member of the interdisciplinary team, one who can offer reliable options for symptom management. Moreover, implications for the expansion of this role to other patient populations and care settings are extensive. This initiative showed that with the right support and a vision for the future, a staff nurse can successfully bring integrative therapies to the bedside.