Junkfood Science Special: Trusting nurses with our lives

My state Nursing Association has become an official accredited approver of continuing educational courses for nurses to maintain their licenses. I just received this quarter’s educational offerings and I can receive 87.7 course hours of credit for classes on Chi Nei Tsang, Energy Medicine, Reiki certification, a Meditation specialty, and Homeopathy for the “whole” family.

In contrast, a mere six hours is offered for emergency medicine and 16 hours for neonatal perinatal medicine.

I don’t mean to scare patients and their families. It would be disturbing to be lying in an intensive care bed or about to be rolled into surgery and learn that this is the sort of education one’s nurse had received, let alone believed. But it is also important that the public understand what is happening and that we hear the voices of nurses who are concerned about the growing adoption into nursing practice of alternative modalities that have no scientifically valid theoretical underpinnings or proven medical efficacy.

Here’s a brief look at how nursing came to adopt these beliefs, the clinical evidence and what it means for us.

Value of nurses — more than warm fuzzies

Nurses are an incredible group of professionals. Most nurses I know went into nursing because they care about people and they value the basic tenets of nursing to advocate for and protect patients. Florence Nightingale (1820-1910) is considered the founder of modern, science-based nursing and it was through her astute clinical observations and fact gathering that she first showed wound infections during the Crimean War were due to improper sanitation. Her hospital reforms significantly lowered death rates. She established a school for nurses in 1860 and is credited with promoting excellence in nursing and training. Nurses quickly proved to have an important role in patient outcomes.

Having sufficient numbers of registered nurses to safely care for hospitalized patients has been soundly shown to be imperative in reducing adverse events and mortalities. Inadequate nurse-patient ratios is one of the most important factors in hospital sentinel events — unanticipated incidences for patients that result in injury, complications or death, according to the Joint Commission on Accreditation of Healthcare Organizations. “Each patient added to a nurses’ workload increased mortality by 7 percent,” said researcher Linda Aiken, PhD, RN at the University of Pennsylvania, who led a 2003 study of nearly 250,000 surgical patients in Pennsylvania hospitals.

But simply legislating national guidelines for adequate nurse-patient ratios isn’t feasible, according to most experts, as each hospital and clinical setting has such varying mix of patients and nursing skills. A Milbank Memorial Fund-sponsored examination of nursing care, led by Claire M. Fagin, PhD, RN, FAAN, added that mandated “minimum” staffing levels tend to become the “standard,” resulting in unintended deleterious effects. “Nursing skill mix has been shown to be as important as nurse-to-patient staffing in achieving good patient outcomes,” said professor Fagin and colleagues.

Just as critical as the number of nurses in safe quality patient care, is the knowledge, skilled training and expertise of those specialized nurses. Today’s healthcare arena is one of rapid change, with new drugs and high-tech innovations introduced at breathtaking speeds and hospital patients more acutely ill than ever before. Patients need and deserve a nurse with a solid background in science and critical thinking. According to Sigma Theta Tau, the nursing honor society I was inducted into many years ago:

Acuity in hospitals has been rising rapidly, due to the declining average length of stay and to new technology that allows rapid assessment, treatment and discharge. Hospitals are increasingly becoming large intensive care units, with cardiac monitoring, respiratory assistance and intense treatment a growing part of the average patient's plan of care. Thus, skilled and specialized nurses are in great demand.

A quality, nursing education at the baccalaureate level has consistently been shown to best equip nurses with the necessary competencies to provide the highest and safest level of care, according to the American Association of Colleges of Nursing. Recent studies in New York and Texas found non-bachelor-degreed nurses are nine times more likely to have care violations than those with bachelor of science in nursing degrees. Professor Aiken and her colleagues found that a bachelor of science degree education was associated with significantly better patient outcomes and fewer patient deaths. Every 10% increase in the proportion of nurses holding a bachelor's degree was associated with a 5% decrease in the likelihood of patients dying within 30 days of admission, they found.

Back when I got my bachelor of science degree, the nursing profession was making a huge effort to gain the kind of respect accorded doctors, beginning with education. So the university program included four years of hard sciences — microbiology, organic and biochemistry, pathophysiology, pharmacology, etc. — statistics, and rigorous clinical training taught by PhD-level instructors, plus additional hours required for a specialty, such as neonatal intensive care. After graduation, nurses traditionally received another three to six months of supervised hospital work and endless inservices and advance certifications. With today’s nursing shortage, however, hospital orientations have been shortened, according to JCAH, making school training even more critical.

Erosion in nursing education

But in the 1970s, a change in how nurses are trained to think, evaluate medical research, assess patients and determine patient care began creeping into university programs. Dolores Krieger, Ph.D., RN, a nursing professor from New York University, and Dora Kunz, a former president of the mystical-religious Theosophical Society, introduced therapeutic touch (TT) to nursing. I distinctly remember just before I graduated, when they visited our university to demonstrate their new modality, saying that the human body was an energy field and that imbalances resulted in illness or pain. They believed their hands could channel healing energy. By moving their hands several inches above the body they said they could detect this energy and redistribute it to relieve congested areas. They concluded with “unruffling,” a flicking-like motion that shooed away excess energy. Most of my classmate never imagined it would ever be taken credibly.

Therapeutic touch was termed the “postmodern paradigm,” and it would become part of a new nursing theory (the Science of Unitary Human Beings) laid out by Martha Rogers, dean of nursing at New York University, which called upon students to reject traditional Western medicine and the scientific process as no longer being necessary. Instead, they were to rely on “qualitative research,” based not on measures, but anecdotes and subjective feelings. Other similar energy-based nursing theories have since been adopted, including those of Jean Watson (the Theory of Transpersonal Caring), Helen Erickson (Modeling and Role-Modeling), Margaret Newman the (Health as Expanding Consciousness) and Rosemarie Rizzo Parse (Theory of Human Becoming). They began taking nursing and healthcare backwards from the efforts begun by Florence Nightingale, a staunch advocate of statistics and science, nearly 150 years earlier.

As Mariah Snyder Ph.D., RN, FAAN, wrote in the Journal of Issues in Nursing:

What is needed is a transformation of the Western health care system so that it is not just adding complementary therapies to the present health care system, but changing the philosophical base for care to one that is grounded in a holistic, caring philosophy. Nursing is in a primary position to assume a leadership role in this transformation.

The early creators and proponents of therapeutic touch went on to hold influential positions in nursing. Jean Watson, Ph.D., RN, AHN_BC, FAAN, for example, became president of the National League for Nursing, which accredits nursing schools, before founding the Center for Human Caring at the the University of Colorado and Denver Health Sciences Center School of Nursing. Professor Krieger founded the Nurse Healthers Professional Associates International, which establishes therapeutic touch educational standards.

Therapeutic touch has been most strongly promoted among nursing professors in academia, and over the past twenty five years, it and other alternative energy-based modalities under the new nursing theories have come to be taught in more than one hundred college and university nursing programs. Professor Snyder credited Noreen Cavan Frisch, Ph.D., RN, FAAN, a professor and Chair of the Department of Nursing at Cleveland State University, with validating the role of alternative modalities into nursing practice and education. Professor Frisch, a prolific author on nursing theories and energy modalities, had been the president of the American Holistic Association and co-chaired a national committee that wrote the AHNA Standards of Holistic Nursing Practice. She also served on the Advisory Council to the NIH Office of Alternative Medicine. Another pioneer of holistic nursing is Barbara Dossey, Ph.D., RN, HNC, FAAN, who coauthored the AHNA Standards of Holistic Practice and nursing standards. Another advocate of alternative modalities in nursing education has been H. Lea Barbato Gaydos, Ph.D., RN, CNS, HNC, of the University of Colorado, Colorado Springs, who also served on the American Holistic Nurses Certification Corporation Board, which administers the Holistic Nurses' Certification process.

University nursing programs have become staffed at the highest levels with holistic nurses and they influence who obtains doctorates and advances in academia. Alternative energy-based modalities (termed “complementary and alternative medicine”) gained a foothold in nursing academia and practice, in part, because of their lucrative financial benefits for nursing schools strapped for funding. Government grants, available through National Center for Complementary and Alternative Medicine’s new Complementary and Alternative Medicine Education Project Grant were established in December, 1999 to “play a proactive role in accelerating” the incorporation of CAM into the Nation’s medical and nursing curriculums and the money has proven irresistible for some. In a series of articles in Alternative Therapies in Health and Medicine, Victor S. Sierpina, M.D., associate professor in the Department of Family Medicine, University of Texas Medical Branch, Galveston, chronicled fourteen nursing and medical schools that had each received about $1.5 million NCCAM education grants as of 2002.

For example, Mary Jo Kreitzer, Ph.D., RN, founder and director at the University of Minnesota’s Center for Spirituality and Healing, was the principal investigator of a $1.6 million NCCAM education grant. She also led a 2002 study at the University of Minnesota which reported that 96 percent of the nursing faculty viewed CAM favorably for use in clinical care and nursing curricula, and 92% believed it worked.

Such efforts have proven surprisingly successful. CAM isn’t just taught in a few semester hours as part of university nursing school curriculums, but has been incorporated into every semester hour in growing numbers of undergraduate and postgraduate programs, replacing hours that could be spent on scientific study. The Nursing Competencies at the University of Minnesota provides a disturbing illustration of how far-reaching some BSN programs have been taken up in alternative modalities. Today, there are five graduate programs in the U.S. offering masters degrees in Holistic Nursing that have been endorsed by the American Holistic Nurses’ Association, but nurses can also choose to be certified in holistic modalities a number of different ways.

Today, therapeutic touch is supported by major nursing organizations such as the National League of Nurses and the American Nurses Association; most state Boards of Nursing permit nurses to practice range of alternative energy modalities; and “energy-field disturbance" is even listed as a nursing diagnosis by the North American Nursing Diagnostic Association.

The American Holistic Nurses’ Association had been formed in 1981 to promote efforts to incorporate energy modalities into nursing practice, as well as make holism a nursing specialty. The AHNA developed the core curriculum for holistic nursing practice, and provides and approves continuing education courses. It also drafted the criteria for designating holistic nursing as a nursing specialty that the American Nursing Association officially endorsed this past winter, on December 14, 2006:

Holistic Nursing is defines [sic] as all nursing practice that has healing the whole person as its goal. Holistic Nursing is further defined as practice that draws on nursing knowledge, theories, expertise and intuition to guide nurses in becoming therapeutic partners with clients in strengthening clients’ response to facilitate the healing process and achieve wholeness. The practice of Holistic Nursing is grounded in nursing theory [now you know what that means]... Holistic nurses are committed to care that recognizes the body-mind-spirit connection of the human being.

The modalities practiced by holistic nurses and textbooks embraced by the AHNA and now the ANA include: therapeutic touch, applied kinesiology, astrology, aura cleansing, channeling, detoxification, chelation therapy, colon therapy, self hypnosis and weight mastery, aromatherapy, crystals, iridology, psychic surgery, reflexology, reiki, guided imagery, color light therapy, lymphatic drainage, Tarot cards, flower remedies and spiritual essenses, drumming and sweat lodges, past life regression, Reiki, craniosacral therapy and countless such practices.

“This appears to be the first time in modern history that a mainstream professional organization has embraced a broad array of quack theories and practices,” said Stephen Barrett, M.D. in a recent issue of Consumer Health Digest of the National Council Against Health Fraud. The American Nurses Association is the professional organization representing the 2.9 million registered nurses in the United States. It says it “advances the nursing profession by fostering high standards of nursing practice, promoting the economic and general welfare of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Congress and regulatory agencies on health care issues affecting nurses and the public.” Like other large health bureaucracies, science and evidence-based practice get replaced with politics and consensus building and they turn a deaf ear to those outside the groupthink.

Despite this anti-science leadership, not all nurses have turned their backs on science or are quietly going along.

Therapeutic touch and energy healing

The adoption of alternative healing modalities has been a concern among growing numbers in the profession. By the 1990s, nurses were finally speaking out about questionable nursing practices — modalities that had not been demonstrated in clinical trials or credible scientific testing to provide any medical benefit to patients, and many having a potential to cause harm.

Unlike the demonstrated benefits of actual touch and massage, not only does therapeutic touch and the belief in bioenergy fields defy all known laws of science and two hundred years of physics, chemistry and biology, but there is not a single shred of sound evidence that anyone can actually feel a human energy field. In fact, double-blind studies published in the Journal of the American Medical Association and the Scientific Review of Alternative Healthcare debunked the ability of even its founders to detect energy fields.

Linda Rosa, RN, vice president of the Rocky Mountain Skeptics along with other members began voicing their concerns about therapeutic touch in nursing education to the Colorado Board of Nursing in the early 1990s. They went on to call for an investigation of the University of Colorado Health Sciences Center, saying that “pseudoscientific practitioners have invaded the nursing profession at many levels and in many ways...if these practices continue, the health, safety, and welfare of the public will be at great risk.”

According to the Rocky Mountain Skeptic, the University of Colorado Health Sciences Center held a blue-ribbon panel in 1994 to investigate the inclusion of therapeutic touch in its school’s curriculum. It found insufficient evidence, in quality or quantity, to establish TT as a healing modality and said: “There is virtually no acceptable scientific evidence concerning the existence or nature of these energy fields... It is not adequate to state that TT involves mechanisms which exist beyond the five senses and which therefore cannot be proven by ordinary methods. Such comments are a disservice to science and the practice of healing and demonstrate a commitment to metaphysics and the mystical view of life rather than to a scientific or rational view of life.” Nevertheless, citing academic freedom, the Board of Nursing continued to alllow it to be taught.

After 25 years of research, there is no quality evidence of a benefit of therapeutic touch on actual health outcomes (infection rates, pain medication usage, bone healing, chronic fatigue syndrome, blood pressure, breast milk production, multiple sclerosis, heart disease, etc.) over a placebo. Scientists attribute subjective reports to the placebo or relaxation response.

No matter. Countless alternative energy modalities now fall under the umbrella of accredited holistic nursing. Remember, once something has met science-based criteria for safety and effectiveness, it’s no longer alternative. “Experimental” alternatives have a plausible rationale but are unproven in credible research. But most CAM therapies fall into the questionable category: are groundless and lack a scientifically plausible rationale. Confusing consumers is that oftentimes a number of therapies used in mainstream medicine such as relaxation and biofeedback are lumped together with CAM to lend an air of legitimacy. The report of the Council on Science and Public Health of the American Medical Association on the medical and scientific evidence for alternative modalities provides an excellent overview of the full range of energy healing, herbal remedies and dietary quackery that is increasingly finding its way into medical and nursing practice. The Council found “reason for concern” that “political decisions allow licensing of alternative practitioners without any scientific basis.”

With the American Nursing Association and state nursing associations approving education in alternative modalities, nursing professionalism is threatened, as is the care of patients. An opinion piece by JeanneE Hand-Boniakowski, RN, of Manchester, Vermon, is representative of the objections raised by science-minded nurses:

When a practice and/or its theoretical underpinnings conflict with scientifically verified facts, when it fails scientific testing or is so bizarre that it cannot be tested, it should be discarded from medical and nursing care. Allowing appropriate room for a patients to engage in their religious rituals is an ethical imperative. But granting such religious practices (homeopathy, qigong, therapeutic touch) the status of adjunct medical or nursing therapy is an ethical mistake.

This notion of different, culturally defined, distinct and equally valid versions of science is spreading. There is no such thing Western science, Eastern science.... There is only science.

For years, Sigma Theta Tau — dedicated to developing excellence in nursing practice, education and research — has recommended repositioning “nursing as a profession where young people can learn science and technology, critical thinking and decision-making.”

Chi and Ki

Let’s come back to the energy modalities that make up two-thirds of the continuing education courses available to the nurses in my state. As we’ve covered homeopathy and energy modalities extensively here, we’ll look at two that might be new to readers: Reiki and Chi Nei Tsang. They illustrate just how far from the scientific process nurses are heading.

Chi Nei Tsang is a Taoist healing technique that is said to use “cosmic” energy, “universal” energy and “earth” energy to bring vitality to the physical body and a harmony with the natural world. Its proponents say it “detoxifies, regenerates and balances each one of your body’s vital functions. It is a system of healing that focuses on the internal organs, as well as the circulation, lymphatic system, digestive, eliminative, nerve centers of the body, tendon muscle system and the acupuncture meridians (Chi system). These systems concentrate and cross paths in the abdomen, which acts as their control center.”

Reiki is the Japanese counterpart and manipulates the ki, the Japanese version of chi. Reiki masters also use therapeutic touch, believing they serve as a conduit for energy and healing involving balancing and nourishing auras, chakras and meridians. As Kathie Lipinski RN, a holistic nurse on Long Island, NY, wrote:

Our body is comprised of energy vibrating at different speeds. Our physical body, our thoughts, emotions, and our spiritual center, all vibrate at a particular frequency or speed. These varying vibrations or pulsations create a field around them which are often referred to as our aura or energy field. The aura is an information center and a highly perceptual system that transmits and receives messages from the external and internal environment....

The Etheric Field is the first layer of our energy body and is 1/4 to 2 inches from the body. It is the energy duplicate of the physical body. The Emotional Field is where we experience feelings. It extends about 1 to 3 inches beyond the physical body. The Mental Field is associated with thoughts and mental processes. It can be sensed 3 to 8 inches from the body. The Spiritual Field is made up of four or more layers, which help us relate to our higher self and spiritual dimensions.

This registered nurse also advocates distant healing using Reiki, explaining:

First, empower your hands and chakras with the Usui power symbol. Then give yourself Reiki for 10-15 minutes. Then invoke or visualize the distant healing symbol and say its name three times. Visualize the person you will be sending Reiki to. Intend to send Reiki to each level of being for 10-20 minutes.... After the session is finished, let them rest. Visualize a power symbol over them and seal the session with light and love. Do dry bathing (Kenyoku) to disconnect from their energy field. Give yourself Reiki for a few minutes. You can call them afterwards to see what they experienced and share what you sensed.

One Reiki master said that after receiving Reiki attunement, his aura was so strong that it was blowing out lightbulbs everywhere he went. Reiki is also believed to have the power to bring prosperity and abundance. According to Laurelle Shanti Gaia, director of the International Center for Reiki Training Licensing Program, Reiki can “transmit our words into pure light and they become even stronger than the mere thoughts themselves:”

I suggest that you use the Reiki distant symbol to connect to the consciousness each word holds, and the mental/emotional symbol to help you discern how your thoughts and feelings respond. For example, take that “M" word … money. How do you FEEL when you tune into the energy of money? What do you THINK about money? Do you feel and think … “YES…bring it on...

We can attract anything we want into our life and truly realize our heart's desire. Money, love, peace, and joy are all simply energy.

Reiki proponents say it is used for everything. According to Reiki master, Carol Denicker:

Reiki is universal, spiritually guided life force energy — It is the God-consciousness called Rei that guides the life force called Ki in the practice we call Reiki.... Since Reiki uses universal life force energy, the essence that creates and binds all forms of life, as its healing force. Universal life energy, by its very nature, is both effective and harmless when applied to any situation. Instead of creating a specific predetermined effect, like a medicine or massage technique might, Reiki changes whatever is necessary to restore the unbalanced life force energy of the patient.

A recent article in Nurse Week offers the best inside look into the belief systems and “other ways of knowing” that are being taught and taken up by nurses. It opened with:

Soft music paints the background as hands rest gently on a head of blond hair. Eyes are closed, bodies still, breathing slow. A sleepiness bathes the room. Such is the tranquil picture of Reiki, an ancient healing technique based on the idea of universal energy—that pain and disease result when energy is blocked or imbalanced.

“You literally put your hands on the person and the energy pours through,” said Meg Siddheshwari Sullivan, MS, RN, who became a Reiki master. “There’s a magnificence, there’s a subtlety, there’s a sweetness,” said Vicki Slater, Ph.D., RN. “The human being is an electromagnetic field.” Like an “energetic Roto-Rooter,” Reiki rids the field of debris and allows energy to flow freely, she said. Joan Furman, MSN, RN, a certified holistic nurse, said Reiki “will basically transcend time and space.” When she teaches, she puts half the class in one room, half in another. “It’s astounding. They always come back in with their eyes wide open.”

Among the “Facts about Reiki,” nurses are taught: “ It is used on any ailment, from headaches to broken bones to cancer.... In some programs, a student can become a master in a $400 weekend session; others require several years and lessons that cost up to $10,000.”

The article concluded by saying that Reiki works for those with open minds. It can’t be proven, said Betty Stadler, MSN, FNP, RN, a certified holistic nurse, but experience is proof for her. “I don’t care who laughs at me,” she said. “It works.”

William T. Jarvis, Ph.D., past president and now Board member of the National Council Against Health Fraud, echoes the response of the scientific community: “There is no evidence that clinical Reiki's effects are due to anything other than suggestion, or that they are superior to massage.”

Despite the fact that energy fields defy all known laws of science and these healing modalities have failed to be supported in well-designed, double-blind tests, impressionable nurses aren’t being given the critical thinking skills and foundation in science to understand why bogus modalities can seem to work. Without this grounding, intelligent people (both patients and healthcare practitioners) can be taken in by alternative modalities that aren’t actually effective and by evidence that isn’t, according to Barry L. Beyerstein, Ph.D., a biopsychologist at Simon Fraser University in Burnaby, British Columbia, Canada, a founding member of Canadians for Rational Health Policy, and a contributing editor to the Scientific Review of Alternative Medicine. He outlined seven sources of error that can mislead people to be taken in by fallacies — information tragically missing in nursing education. [A respected and tireless defender of science and critical thinking, Dr. Beyerstein passed away last week and will be greatly missed.]

Given the direction nursing education is being led by some educators and our professional nursing organizations, unless nurses and consumers educate themselves and resoundly call for quality, science-based education and training, both the profession and patients will lose.

As our nation faces rising healthcare needs with an aging population and medical care becomes increasingly expensive and technologically advanced, our lives may depend on what we choose to support and ask of our nursing schools and our nurses. Can nurses who reject science really provide the care necessary to save lives in today’s medicine, let alone tomorrow’s?

© 2007 Sandy Szwarc