Title: Holistic Nursing and Complementary/Alternative Modalities (Formally Advisory Ruling "Holistic Nursing and Complementary Therapies" and incorporating former Advisory Ruling 9601: "Massage")

Advisory Ruling Number: 9801

Authority:
The Massachusetts Board of Registration in Nursing issues this Advisory Ruling on Nursing practice pursuant to Massachusetts General Laws, chapter 30A, section 8 and chapter 112, section 80B.

Date Issued: September 10, 1997

Date Revised: September 25, 2002; March 9, 2011; September 12, 2012

Scope of Practice: Registered Nurse and Licensed Practical Nurse

Purpose: To guide the practice of Registered Nurses and Licensed Practical Nurses who, within their practice, incorporate complementary/alternative modalities (CAM) to meet such nursing and client goals including, but not limited to, increased comfort, relief of pain, relaxation, improved coping mechanisms, reduction of stress, an increased sense of well-being comprehensive health promotion and health risk reduction.

Such practice must be in compliance with Massachusetts General Laws (G.L.) c. 112, s. 80B; 244 CMR 3.02: Responsibilities and Functions – Registered Nurse; 244 CMR 3.04: Responsibilities and Functions – Practical Nurse; 244 CMR 9.03(5): Adherence to the Standards of Nursing Practice; 244 CMR 9.03(8): Identification Badge; 244 CMR 9.03(9): Responsibility and Accountability; 244 CMR 9.03(10): Acts within the Scope of Practice; 244 CMR 9.03(11): Performance of Techniques and Procedures; 244 CMR 9.03(12): Competency; 244 CMR 9.03 (14): Asepsis and Infection Control; 244 CMR 9.03 (16): Patient Confidentiality; 244 CMR 9.03 (17): Patient Dignity and Privacy; 244 CMR 9.03 (23): Sexual Contact; 244 CMR 9.03 (24): Professional Boundaries; 244 CMR 9.03(38): Administration of Drugs; 244 CMR 9.03(44): Documentation; 244 CMR 9.03(46): Responsibilities of Nurse in Management Role; M.G.L. Chapter 94C: Section 1: Definitions; M.G.L. Chapter 94C: Section 18: Issuance of prescription by practitioner or physician; 105 CMR 700.001: Controlled Substance, Drug definitions.

Advisory:
For the purpose of this Advisory Ruling on Nursing Practice, the application of acupuncture or body manipulative methods such as chiropractic or craniosacral therapy are not modalities considered to be within the scope of generic nursing practice. Nurses who integrate homeopathy, herbal medicines and/or dietary supplements (a vitamin, a mineral, an herb or other botanical, an amino acid, a dietary substance for use by man to supplement the diet by increasing the total daily intake, or a concentrate, metabolite, constituent, extract, or combinations of these ingredients [1]) into their practice require an order(s) from duly authorized prescribers identifying the minimum required elements [2] of a prescription prior to incorporation in the overall plan of care.

A model of holistic nursing incorporates a philosophy of nursing practice that involves recognition of the individual as an integrated whole interacting with and being acted upon by both internal and external environments. Holistic nursing emphasizes practices of self-care, intentionality, presence, mindfulness, and therapeutic use of self as pivotal for facilitation of healing and patterning of wellness in others. It involves studying and appreciating the interrelationships of the bio-psycho-social-spiritual dimensions of the person.

Nurses who practice holistic nursing integrate complementary/alternative modalities (CAM) into clinical practice as a nursing intervention to treat individual’s physiological, psychological, and spiritual needs.

Examples of CAM include, but are not limited to:

  • Mind-body interventions
    • Meditation, relaxation, imagery, hypnosis, yoga, t’ai chi, prayer, art, music and dance therapies, cognitive-behavioral therapy, biofeedback, therapeutic counseling, stress management
  • Energy therapies
    • Therapeutic touch, Reiki, Qi Gong, Acupressure, Healing Touch, magnet therapy
  • Other modalities, but may not be limited to:
    • Massage
    • Reflexology
    • Shiatsu
    • Aromatherapy
    • Guided imagery
    • Animal-assisted therapy
    • Use of essential oils

Nurses may employ CAM as part of an overall plan of care. Patients must grant informed consent in writing or orally, with substantiating documentation by the nurse. In obtaining informed consent for a CAM nursing intervention, the nurse will provide the client with information about the modality, including its intended benefits and potential risks, as well as conventional treatments or procedures that are available. As part of the assessment process, medication reconciliation efforts must include a query of herb, vitamin, mineral, homeopathy, herbal medicines and/or dietary supplement use by the patient. Collaboration and consultation between members of the health care team are essential. When CAM is incorporated into the plan of care as a nursing intervention documentation of consent, assessment information, plan of care, interventions and evaluation must adhere to standards of nursing practice.

Utilization of CAM requires that the nurse have documented knowledge, skills and competency in the application of the modality. Education programs which have as their objective the preparation of nurses in the use of CAM must be guided by the minimum requirements for nursing continuing education at 244 CMR 5.00. When such education programs include a clinical component, a licensed qualified nurse must provide supervision. Nurses may incorporate massage into their practice after successful completion of a formal educational program, beyond what is taught as basic comfort measures in generic nursing educational programs, leading to a competency in massage. Unless currently licensed as a massage therapist by the Board of Registration of Massage Therapy (pursuant to M.G.L. C.112), a licensed nurse may not hold him/herself out to others as a massage therapist. A nurse must hold a current Massage Therapy license to practice massage independent from an organized healthcare business and/or independent from a nursing plan of care.

In any health care setting, an infrastructure of current, evidence based policies and procedures must be available to guide the practice and use of CAM.

References:

American Holistic Nurses Association, American Nurses Association. (2007) Holistic Nursing: Scope and Standards of Practice.

American Holistic Nurses Association. (2007). Position on Holistic Nursing Ethics.

American Holistic Nurses Association. (2007). Position on the Role of Nurses in the Practice of Complementary and Alternative Therapies.

National Association of Nurse Massage Therapists (NANMT)

National Center for Complementary and Alternative Medicine accessed 2/23/11 at http://nccam.nih.gov/

Institute of Medicine. (2005). Complementary and Alternative Medicine in the United States.

U. S. Food and Drug Administration accessed 9/12/12 at http://www.fda.gov/Food/DietarySupplements/default.htm

Dietary Supplement Health and Education Act (DSHEA) of 1994


[1] Pursuant to the U.S. Food and Drug Administration guidelines and the Congress defined term "dietary supplement" in the Dietary Supplement Health and Education Act (DSHEA) of 1994

[2] Name of ultimate user, name of the medication/substance, dose and route of the medication/substance, frequency of the medication/substance administration, a valid medication/substance order date, specific directions for administration, signature of the duly authorized prescriber, signature of the individual accepting/verifying the order. Adapted from The Institute for Safe Medication Practices (ISMP) and the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) recommendations to reduce medications errors.

 


This information is provided by the Division of Health Professions Licensure within the Department of Public Health.