Journal of Advanced Nursing, 1998, 27, 1171–1176

Complementary therapies as a means ofdeveloping the scope of professional nursingpractice

Alison Cole BN, RGN

Staff Nurse, Accident & Emergency Department, Tameside Acute NHS Trust, FountainStreet, Ashton Under Lyne, England

and Eamon Shanley RN CPN RNT CPsychol AFBPs S BA(Hons) MSc PhD

Professor of Mental Health Nursing, Edith Cowan University/Graylands Hospital, Perth,Western Australia

Accepted for publication 29 May 1997

COLE A. & SHANLEY E. (1998) Journal of Advanced Nursing 27, 1171–1176Complementary therapies as a means of developing the scope of professionalnursing practiceThe development of the extended role in nursing has been seen by some asprimarily a means for nurses taking on tasks that have traditionally been thework of junior doctors. Others object to this view and ascribe to the ‘newnursing’ perspective of Salvage. She sees the extended role as moving towardsincreasing autonomy and operating in a professional rather than a bureaucraticoccupational model. This view militates against the development of nurses asmini-doctors. This paper discusses the controversy surrounding thedevelopment of the extended role, focusing particularly on the use ofcomplementary therapies as a legitimate component of the ‘new nurses’ role.

Keywords: extended role of the nurse, complementary therapy, ‘new nursing’,scope of professional practice

ii) specialist activities covered by post-registration train-BACKGROUND TO THE EXTENDED ROLE OF

ing (e.g. district nursing); andTHE NURSE

iii) activities normally undertaken by doctors but whichmay be delegated in appropriate circumstances, andIn 1977 the United Kingdom’s Department of Health &

Social Security circular The Extended Role of the Nurse which may be performed by nurses with appropriatetraining and competence.defined the role simply as one which is not covered in the

basic training for the register. Its emphasis is, however, onThis third category led to the practice of individual certi-the acquisition of skills to perform tasks traditionally car-

fication for tasks, to define one as competent, for exampleried out by doctors. Later the Department of Health (1989)venepuncture and ECG recording.elaborated on the issue by dividing the nurse activities

The Scope of Professional Practice document (UKCCinto three categories.1992) changed the emphasis from the certification of tasks

i) activities covered by pre-registration training; to a statement of principles to guide practice. A basic tenetof the document is that nurses move away from simplytaking on doctors’ roles and enlarge their role byCorrespondence: Eamon Shanley, Chair in Mental Health Nursing, Schooldeveloping skills within a nursing philosophy. A majorof Nursing, Edith Cowan University, Pearson Street, Churchlands, Perth,

Western Australia 6018. advantage of this approach is that it leaves clinically based

1171© 1998 Blackwell Science Ltd

A. Cole and E. Shanley

nurses with the flexibility and responsibility to determine patient for investigation, writing discharge letters andadministration of drugs. Richardson & Maynard (1995),their own roles provided they can acquire the skills to

work safely and competently. The UKCC (United Kingdom in reviewing North American literature, contended thatbetween 30% and 70% of the tasks performed by doctorsCentral Council for Nursing, Midwifery and Health

Visiting) has been criticized for failing to promote this could be replaced by nurses and hundreds of millions ofdollars could be saved if skill mix could be altered. Inconcept further by backing this with the appropriate pro-

fessional and legal support (Rieu 1994). the current cost-conscious NHS this is often assumed tobe the cheaper option Rowden (1987) However, somestudies have shown that although nurses increase quality

Reasons for development of nurses’ extended rolethere is no decrease in cost (Touche Ross 1994, Fish1995). The assumption that deploying nurses to carry outThe incorporation of medical tasks in the development of

the extended role is fuelled by two factors, namely the tasks traditionally done by junior doctors is cheaperremains questionable.search for increased status for nursing (Walsh 1989, Wright

1991) and economic expediency (Rowden 1987, Gottlieb1994).

CRITICISM OF THE EXTENDED ROLEHagell (1989) describes nursing as attempting to

increase its own status by rejecting its own low status‘Old nursing’

knowledge of relationships, emotions and caring byreplacing it with inductive, scientific knowledge, which The literature on the extended role appears to voice the

same concerns, that nurses are being led away from essen-is self-defined as higher status. Hagell argues that nursesdevalue their own attributes and instead see the medical tial, patient-centred nursing to pseudo medicine. Rowden

(1987) stated that he is concerned that nurses are becom-paradigm as a more appropriate way to gain status.Knowledge derived from the logical, empirical scientific ing increasingly less patient-centred. He also noted that

before nurses move on to taking on the roles of otherparadigm forms the basis of modern medicine, and isdescribed by authors such as Cull Wilby (1987) as the professionals there is a need to review the consequences

of such a development. In 1989 Walsh, while acknowl-‘esteemed paradigm’.The medical profession’s growth in influence and edging that the professions must change, contended that

recent changes appear to be one-way process, with nursespower was underpinned by this prevailing belief in therational inductive approach to science. This approach has accepting tasks handed down by doctors. Nurses in

accepting them are more concerned with increasing theirresulted in the development of the medial modeldescribed by Parson (1951) and more recently criticized status than improving patient care. He calls for nursing

research into patients’ needs to form the basis forby Illich (1975) and Oakley (1976) for disregarding theimportance of the person’s perceptions, values and beliefs defining the extended role, Sheperd (1993) again stated

that nurses are not putting patient care as a priority,that influence his/her state of well-being. This modelfocuses on parts in order to understand the whole which instead they are simply taking on other professions’

unwanted tasks. Swann (1993) continued this theme,is the antithesis of the philosophy of ‘new nursing’ andcomplementary therapies. The shift can be seen in the saying that an extended role leads us away from our core

skills. Gottlieb (1994) saw it as a backward step, becom-utilization of a medical research model to expand nursingknowledge, and the acceptance of high status medical ing doctors’ assistants rather than a separate profession.

She was also alarmed that nurses were being remuneratedextended roles.Economic expediency has also influenced the develop- for their medical tasks rather than nursing skills and

experience.ment of the extended role. The ‘New Deal’ in reducingjunior doctor’s hours and limiting their work to thatwhich is ‘appropriate to their medical training’ will

‘New nursing’result in nurses taking on the unwanted medical tasks(Hoover & Ooijen 1995). This view is supported by many In contrast ‘new nursing’, described by Savage (1990), is

characterized by a rejection of the medical model andin the medical profession. For example in a survey byGorman et al. (1992) junior doctors stated that their replacement with a holistic approach, autonomy, pro-

fessionalism and an active partnership between patientworking conditions could be improved by nurses takingmore responsibility for intravenous medication. The and nurse and a belief in the therapeutic power of nursing.

Oakley (1984) argues for the unique position of nurses,Department of Health commissioned research byGreenhalgh & Co. (1995) which identified activities that with their roots in a caring environment model of healing,

to become the supportive client-centred healers of tomor-could be shared by nurses and junior doctors. Amongthese activities are taking patients’ histories, venous row. She contrasts this with the technically focused, inter-

ventionist, patriarchal medical profession.blood sampling, inserting peripheral IVs, referring a

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Complementary therapies

A good example of supportive client-centred healing be generalized as Daily Telegraph readers are not typicalof the general population. Explanations for the high use ofmay be seen in the practice of complementary therapy.

There are strong parallels between ‘new nursing’ and the complementary therapies by this section of society is attri-buted to their having educational and financial resources,beliefs and practices of complementary therapies as

described by Grainger (1991). The most notable similarit- different attitudes and the motivation to fund the treat-ments themselves (Fulder & Munro 1985, Thomas et al.ies are the emphasis on the patient as healer and the

therapist as facilitator, a holistic approach to assessing 1991, Doyle 1993). However, with the increased avail-ability of complementary therapies it is expected thatpatient needs and an emphasis on the promotion of posi-

tive health. greater uptake by other groups is likely to occur.

DEFINING ALTERNATIVE AND Why do they use complementary therapies?COMPLEMENTARY THERAPIES

The vast majority of those who use complementary therap-ies reported that they turn to these therapies because of

What are complementary therapies?disillusionment with their orthodox treatment, after itappeared to fail or the side-effects of treatments becameThe multitude of non-orthodox therapies are commonly

termed alternative or complementary therapies. The term unbearable (Consumers Association 1986, Doyle 1993,Illman 1996). Users of complementary therapies are also‘alternative therapies’ began to be used in the late 1970s

and was defined by WHO (1983 p. 292) as those therapies convinced of its efficacy (Consumers Association 1986,Doyle 1993, Illman 1996).that ‘usually lie outside the official health sector’.

Complementary therapy is an umbrella term for the same The increasing popularity of complementary therapymay be due to a paradigm shift to ‘new science’, in thetreatments used to enhance nursing and medical inter-

ventions (Rankin-Box 1988, Gates 1994, Trevelyan & general population. Laffan (1993) described the ‘new sci-ence’ as embracing holism, perceiving life not as a collec-Booth 1994).

Trevelyan & Booth (1994) divide complementary therap- tion of parts but as an integrated whole, each partinfluencing the rest. New science also acknowledges theies used by nurses into three categories. The first group

are therapies that nurses can directly incorporate into prac- importance of spiritual aspects of life which tends to beforgotten in conventional science.tice, e.g. massage, shiatsu, reflexology, aromatherapy and

therapeutic touch. The second category includes those The British Medical Association’s (BMA’s) (1986)response to such views has been to describe these concernstherapies that can be incorporated to some extent into the

work of nurses, e.g. homeopathy, herbal medicine, as ‘hardly rational’ and as a ‘reversion to primitive beliefs’.It could be argued that the BMA’s negative response is duenutritional therapies and hypnotherapy. The third group

are the therapies that cannot easily be incorporated into to the belief that alternative therapies offer some threat todoctors’ monopoly of medical practice.nursing practice but nurses can offer advice on, e.g.

acupuncture, chiropractice and osteopathy.A survey of 393 readers of a weekly nursing journal NURSING AND COMPLEMENTARY

carried out by Jackson for the Alternative HealthTHERAPIES

Information Bureau and cited in Trevelyan (1996) appearsto reflect these divisions. He found that the majority of So far we have discussed the shortcomings of the medi-

cally oriented extended role. We have also examinednurses who used complementary therapies used those inthe first category, namely massage (68%), aromatherapy Salvage’s (1990) ‘new nursing’ concept which outlines a

different perspective. This perspective sees the incorpor-(59%), reflexology (18%) and therapeutic touch (13%).ation of a number of complementary therapies as a part ofthe nurse’s extended role.

Who uses complementary therapies?As we have indicated earlier, nursing and complementary

therapies share a similar world view, seen in their holisticSurveys have indicated that a high percentage of the gen-eral population of the UK are using complementary therap- approach, in the supportive role of therapist, the active role

of the patient and the emphasis on health promotion.ies. The Consumers Association (1986) showed that onein seven people have visited a complementary prac- Both nursing and complementary therapies use a

common philosophy and approach in developing theirtitioner. The most frequent users of complementary therap-ies have been shown to be predominately females of knowledge base and practice. They use methods of evalu-

ation involving inductivist and qualitative processesworking age in the higher social classes. A survey of DailyTelegraph readers (Doyle 1993), the majority of whom rather than the traditional scientific deductive quantitative

approach used in the traditional medical sciencesbelong to social class 1 and 2, showed that 96% had usedsome form of complementary therapy. This finding cannot (McGourty & Hotchkiss 1993, Gates 1994). They also face

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A. Cole and E. Shanley

similar problems in having their practices recognized as of treatment for human ailments (Price 1987). Studies indi-cate that massage decreases anxiety scores, blood pressure,science-based disciplines. This originates from the low

esteem in which both qualitative approaches are held by heart rate and respiratory rate (Longworth 1982, Ferrell-Torry & Glick 1993, Stevenson 1994). One study also indi-the more traditional scientific communities. However,

increasingly, recognition is being given to the value of cates that massage reduces pain levels (Ferrell-Torry &Glick 1993). Other effects of massage have been re-inductive and qualitative methods of inquiry particularly

in the social sciences. searched, and they include: easing insomnia, headachesand migraine, bereavement, angina, backache, drugAnother common feature between nursing and the

complementary therapies is the philosophy that the care rehabilitation (reducing tension, easing muscle cramps),(Maxwell Hudson 1988). These are conditions that nursesdelivered should be patient/client led. According to the

nurses’ governing body (the UKCC) ‘The Registered Nurse, commonly face and are within the nurse’s role for treating.Aromatherapy is the second most commonly used comp-Midwife and Health Visitor must be satisfied that each

aspect of practice is directed to meeting the needs and lementary therapy by nurses (Trevelyan 1996). It is definedas the ‘use of essential oils to promote and maintain healthserving the interests of the patient or client’ (UKCC 1992,

clause 9.1). As indicated earlier the growth of complemen- and vitality’ (Metcalf 1989). Aromatherapy has beenshown in studies to decrease heart rate and blood pressuretary therapies is as a result of the demand of a large pro-

portion of the population who, in using various forms of (Hewitt 1992, Buckle 1993, Stevenson 1994), reduce painscores (Hewitt 1992) and decrease anxiety (Buckle 1993,complementary therapies, believe them to be meeting their

needs. Many are willing to pay for complementary therap- Stevenson 1994). A study also showed that tea tree oil isas effective as clotrimazole in treating a fungal infectionies and others wants complementary therapies to be avail-

able on the NHS (Doyle 1993). The same report found that (Buck et al. 1994).Writers claim aromatherapy treats the same ailments as66% of GPs also think they should be available on the

NHS. Nurses are ideally placed to meet the demands for above including conditions such as flatulence, cystitis,indigestion, sinusitis, thrush and toothache (Metcalfcomplementary therapies. They operate within a statutory

regulatory body that controls the standards of care deliv- 1989), which again are conditions nurses are often con-fronted with. There is obviously not only scope to useered. The alternative facing the prospective user is to seek

help from one of the many therapists who are not subjected these therapies with the presenting conditions but alsothere is the challenge facing nursing to conduct researchto the same rigorous regulations concerning their training

and practice and whose practice may at worse be into their properties.detrimental to the person’s health.

CONCLUSIONARE COMPLEMENTARY THERAPIES

The origin of the debate about the extended role of theEFFECTIVE?

nurse is firmly routed in that of doctors’ tasks, and themotivation for nurses accepting this role based on a pursuitThere is a growing body of research that supports the view

that complementary therapies can be effective. However, of increased status and economic imperatives. The Scopeof Professional Practice document (UKCC 1992) givesresearch into complementary therapies is slow to take

place. There is a reluctance by the National Health Service nurses the freedom to move in more imaginative ways, andauthors such as Salvage (1990) motivate nurses to develop(NHS) and funding organizations to fund research into

treatments without double blind, randomized, clinical their therapeutic skills. The rise of complementary therap-ies reflects the growing disillusionment with technicaltrials (Kleijen et al. 1991). While clinical trials are

extremely useful as an approach in evaluating treatments interventionist treatments that are failing to alleviate manyof the population’s chronic ailments.whose outcomes are easily discernible, there are many

treatments, particularly those aimed at changing cognitive In contrast to medical tasks these non-orthodox treat-ments offer interventions that are commensurable with theand emotional aspects of a person’s well-being, that are

not amenable to clinical trials. There seems to be a failure paradigm as nursing, and build on the unique relationship-oriented functions of nursing.to acknowledge the complexity of human experiences by

insisting on reducing physical, cognitive, emotional, social Nursing appears to be at a cross-roads. Although not anew experience, the route taken will define the future ofand spiritual aspects to quantifiable measures.

Despite the difficulties in evaluating outcome, some nursing. The first road leads to highly educated andrespected practitioners, developing skills from medicalresearch has been carried out on complementary therapies

performed by nurses. colleges, releasing them to make bigger and better medicalbreakthroughs. The second route demands we challengeMassage is the most widely used complementary ther-

apy in nursing practice (Trevelyan 1996). The term orig- the contemporary pursuit of status and prestige to evolvethe unique therapeutic patient centred function of nursing.inates from the Greek ‘to knead’ and is one of oldest forms

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Complementary therapies

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