Introduction
The purpose of this concept analysis is to examine the meaning of the phrase “complementary and alternative medicine” (CAM). The use of CAM is on the rise in the United States and world-wide (National Institute of Health, National Center for Complementary and Alternative Medicine [NCCAM], 2008). With this increase it becomes absolutely imperative that health care clinicians have a grounded and thorough understanding of CAM. It is particularly crucial that practitioners develop comfort speaking about CAM, maintaining an open dialogue with patients about CAM, and exploring their own feelings about CAM use. The following analysis will delve into the meaning and attributes of CAM from the perspective of medicine, nursing, and CAM users in an effort to establish a comprehensive and contemporary understanding of the concept.
Review of Literature
Definitions
The very nature of CAM makes it difficult to define as it exists outside the bounds of (i.e. as an alternative to) conventional treatment. The term encompasses a vast range of practices that are diverse and evolving. Nonetheless, working definitions have been described. The National Institute of Health’s National Center for Complementary and Alternative Medicine (NCCAM) defines CAM as:
a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine. Conventional medicine (also called Western or allopathic medicine) is medicine as practiced by holders of M.D. (medical doctor) and D.O. (doctor of osteopathic medicine) degrees and by allied health professionals, such as physical therapists, psychologists and registered nurses. (National Center for Complementary and Alternative Medicine [NCCAM], 2012, p. 1)
While this basic definition seems widely accepted CAM is also recognized as being quite complex a concept with many differing aspects. It is useful to define the incorporated terms more fully. “Alternative medicine” generally refers to practices that are replacement treatment for conventional medical treatment. “Complementary medicine” is used in conjunction with or in addition to conventional medical treatment. These two terms can be used to refer to the same practice, such as acupuncture, depending on the relationship the practice has to the conventional medical treatment the person is utilizing. Thus these two terms do not distinguish between the types of practice rather they are broad concepts that are usually put together due to their similarities. (Fontaine, 2000; NCCAM, 2012; Spencer & Jacobs, 2003)
A complication faced when grappling with the concept of CAM is trying to determine what practices are included in CAM. Some CAM practices are ancient traditions from various cultures around the world, such as meditation, while some are relatively new using new technology, such as biofeedback. In fact, the term CAM is used to refer to as many as 1,800 different practices. (Fontaine, 2000) The NCCAM groups CAM into 5 sub categories which include: use of natural products such as herbs, vitamins and dietary therapy; mind-body practices such as meditation, acupuncture, prayer and yoga; manipulative body-based practices such as massage and spinal manipulation; energy-based modalities such as Reiki, healing touch, and magnets; and whole medical systems such as Traditional Chinese Medicine (TCM) or Ayurveda. (NCCAM, 2012) These categories provide both health care practitioners and CAM users with a more organized framework within which to understand the options available with CAM.
With such a broad concept as CAM it may be inevitable different groups of people will have vastly differing perspectives. This becomes critical when physicians, nurses and patients each have a different conception of CAM.
Nurses and CAM
Nursing theorists such as Watson have claimed nursing as a unique science that is patient centered and that requires a holistic relationship between the nurse and the patient. In her book on CAM and nursing practice, Fontaine (2005) claims that it has long been part of nursing to conceive of healing as requiring biological, psychological, spiritual and environmental care. This approach may predispose nurses to be open-minded about the use of CAM in treating patients. Many studies have shown that nurses have an openness to and a desire to know more about CAM (Cook et al., Mitchell, Tiralongo, & Murfield, 2012; Smith & Wu & Wu, 2011). In fact, Smith et al. (2011) found that nurses in Taiwan viewed themselves as offering holistic care and wanted to learn more about CAM practices in order to incorporate them. Cook et al. found that 90% of the nurses participating in her study reported openness/eagerness to know more and utilize more CAM.
This general sense of openness, however, may not translate into enhanced knowledge or practice. Smith et al. (2011) discovered that despite desire, the nurses of Taiwan claimed only limited experience with CAM . Nurses in the study further expressed that CAM lacked a clear definition. In a study of critical care nurses’ attitudes toward CAM in Australia, Cook et al. (2012) found that nurses had no training in or knowledge of 22 out of the 28 CAM practices discussed in the study survey. Cook et al. further discovered that the attitudes toward particular CAM practices would vary greatly depending on the practice and how much scientific evidence supported its use. Practices such as biofeedback, with a relatively large body of supportive scientific evidence, were more accepted than practices such as Reiki, which lack scientific support. The researchers found the nurses claimed an overall desire for scientific validation of the usefulness of a practice before believing a practice would be beneficial. Smith et al., similarly, found that when asked to define their understanding of what CAM is, nurses in Taiwan said that CAM practices are those for which there is no supportive evidence or research.
Cook et al. (2012) asserts that the increased use of CAM therapies in Australia (close to 70% of the population claim to use CAM) requires nurses and other health care professionals to be knowledgeable about their use in order to assure safe care for their patients. A practitioner who is unaware of what health practices the patient engages in will not know if interventions recommended to the patient will be effective or, possibly, even damaging. The majority of Australian nurses in the study reported not asking their patients if they use CAM and only 50% of nurses in the study said they sometimes document CAM use in their patient files. Nurses claimed the lack of space for CAM documentation in the files was a deterrent to documentation. In addition, Cook et al. reported that the majority of the nurses claim that patients do not generally ask about or discuss CAM with nurses; 1/3 of the nurses said they had never been asked about CAM by a patient. (Cook et al., 2012) This study reveals a veil of silence between the patients and the nurses regarding CAM use, despite the commonality of CAM use amongst Australians. This silence can lead to assessment of patients that is negligent and potentially detrimental health care decisions.
According to the NCLEX- RN test plan for the National Council of State Boards of Nursing (NCSBN) (2007) nursing students must be prepared to assess, integrate, incorporate, apply and evaluate CAM in nursing practice. Despite this, the majority of nurses participating in both Cook et al.’s study and Smith et al.’s study claimed they primarily obtained information about CAM from the Internet. Avino (2011) studied knowledge and attitudes about CAM in faculty and students in nursing schools across the state of Delaware. While the researcher reported that 81% of students and 92% of faculty felt positively about CAM, 87% of students and 96% of faculty felt there was a lack of staff training on the topic which lead the curriculum to be deficient. Additionally, 86% of students and 96% of faculty claimed that the lack of evidence to support CAM use in practice was a significant barrier for them. The majority of students (81%) reported wanting sufficient education to provide patients with guidance regarding CAM. A lesser majority, 68%, claimed they would use CAM in their clinical care by either endorsing or referring patients to a CAM practitioner. Still, the majority of nursing students and faculty claimed very little knowledge of CAM. From this study it is clear that although there may be a desire to know more, the current level of knowledge is lacking within nursing and nursing education has not adequately addressed this discrepancy.
In summary, nursing is in an evolving process in its relationship with CAM. While resistant to practice that is not scientifically based such as most CAM practices, nursing has a long history of being patient-centered and many patients are, in fact, using CAM. Fontaine (2005) touches on this contradiction in her description of nursing in most Western countries as following a medical model of care that, for the past 20 years, has seen significant changes toward nursing practice that is distinct from medicine. Fontaine sees this change as lead by nursing theorists such as Watson, Keegan, and Guzetta, noting a call for the focus of nursing to be on person to person caring interactions in a holistic context. The role of nursing with regard to CAM is summarized succinctly when Avino (2011) states “nurses are in a unique position to bridge the gap between traditional health care and CAM because the theoretical core of nursing practice is caring and healing” (Avino, 2011, p. 281).
CAM and Conventional Medical Physicians
Conventional medicine, also called allopathic medicine or biomedicine, became the predominant medical school of thought in the US and other developed countries after the mid-1800s with the advent of disease eradication through bacterium identification and elimination. (National Institute of Health [NIH], 1992) Biomedicine emerged with the influence of rationalist philosophy with an understanding that the body functions like a machine and that disease must be fought with war-like determination. (Fontaine, 2000) Biomedicine came to rely on scientific evidence to guide its treatment and care. This has created a current culture of medicine that is primarily focused on disease treatment. The patient is often seen as passive. This approach is excellent for emergency care and has been successful in eliminating or reducing the impact of many diseases though it is less useful for chronic illnesses. (Clark, 2000) This approach is also in direct contradiction with the core philosophy of CAM which is whole-person centered, focusing on empowering the individual. Spencer (2003) says
The biomedical approach focuses on a disease orientation, which suggests that a specific agent is responsible for a specific illness or disorder. Hypothesis testing and linear reasoning with logic and causation are the main components. CAM therapies are based more on a philosophy that uses a comprehensive approach concerned with multidimensional factors that may or may not be studied independently. Causation and mechanisms of therapeutic action, or how something ‘works,’ are not always seen as important. One central goal of CAM is to improve the ‘wellness’ of the patient, rather than just removing a disease producing agent. (Spencer & Jacobs, 2003, p. 17)
Despite these inherent obstacles, the current increase in popularity of CAM use in the general population may be ushering in a change for the conventional medical practitioner.
Sewtich et al. (2008) conducted a systemic review on professional attitudes about CAM in order to address certain health care concerns that emerge with the increased popularity of CAM usage. Chief among the concerns are that 1) there is no regulation and safety assurance around CAM and 2) physicians are often unaware of CAM use in their patients which may lead to drug interactions or other health risks. Across 21 studies, Sewitch et al. found that among health care professionals, physicians have the most negative attitude toward CAM. Barriers most frequently claimed to stop physicians’ openness to CAM include a lack of evidence of CAM’s efficacy, potential side effects, and potential negative interactions with conventional treatment. The researchers further reported that the majority of physicians were reluctant to ask patients about CAM use. In addition, researchers found that even among physicians that claimed a positive attitude toward CAM, very few changed practices to incorporate CAM use or referrals. (Sewitch, Cepoiu, Rigillo, & Sproule, 2008)
There is evidence, however, that conventional practitioners want to and are willing to change the strict division that exists between them and CAM. Sewtich et al. (2008) found that the majority of practitioners believe that health care should integrate the best practices of CAM into conventional practice. They also found that 81% of health care professionals across the 21 studies wanted more education about CAM in order to provide care to their patients. Physicians who recommend CAM in the US tend to do so for complaints of anxiety, pain, insomnia and depression. (Sewitch et al., 2008)
More recently, Kundu et al. (2011) studied attitudes about CAM amongst pediatric health care providers. The researchers found that the majority of physicians were aware of CAM use by their patients and that 67% had recommended CAM use. A large majority of physicians (94%) said that they sometimes discuss CAM with their patients, though very few reported that CAM is always discussed. In general, the physicians reported that the CAM practices they are most likely to suggest were ones that had a scientific body of evidence to support it efficacy. The majority (92%) also claimed they would research CAM practice and practitioners when asked by patients about a CAM practice. These results suggest that there is not only openness to CAM in the conventional medical community but that there is already a trend to incorporate CAM into practice. Despite these promising results, researchers also noted that only 50% of the physicians occasionally consulted with CAM practitioners and only 4% actually made changes to the plan of care for a patient based on CAM recommendations. Overall, this study suggests there is a positive shift in attitude toward CAM among pediatric physicians that is restrained by a lack of knowledge and evidence and has not yet changed care given. (Kundu et al., 2011)
In Canada, a call was put out in 2006 for researchers to examine the issues surrounding CAM in order to provide clear standards on efficacy and safety for CAM practices. In an essay discussing the proposed research and reviewing the existing research Boon et al. (2006) note that with over half the Canadian population engaging in CAM practices it is imperative that research move forward. The call for research comes from the Canadian Interdisciplinary Network for CAM Research and specifies that research should cover how CAM can be regulated, how outcomes of CAM use can be measured and assessed, and how to transfer knowledge about CAM to health care practitioners and consumers. (Boon, Verhoef, Vanderheyden, & Westlake, 2006) Similarly, the National Institute for Health created the NCCAM with the express purpose of examining and exploring CAM using scientific evidence to guide safe practice. (NCCAM, 2008) These documents demonstrate the recognized need within the governments of both the US and Canada to remove the largest barrier standing between conventional medicine and CAM: the lack of scientific evidence supporting most CAM use.
In 2008 the World Health Organization (WHO) held a Congress of Traditional Medicine at which a declaration was released that calls on countries around the world to integrate CAM into their health care, to educate biomedical practitioners on CAM, and to encourage communication between CAM and conventional practitioners. (WHO, 2008) Quartey et al. (2012) conducted a systematic review of studies exploring the outcome of medical school curriculum inclusion of CAM. The overall review of 12 studies suggests that physicians’ and medical students’ attitudes, skills and knowledge of CAM are improved with additional CAM education. The researchers call for a more unified and reliable tool for measuring attitudes about CAM. As conventional medicine practitioners begin to implement CAM practices and referrals more frequently it will become imperative that there is a way to assess the impact of that change on patients and practitioners alike. (Quartey, Ma, Chang, & Griffahs, 2012)
Another perspective on the growing need for medical practitioners to work with CAM comes from Bezold (2006) who, in his essay on preventable causes of disease, raises the issue of the increasing emphasis in health care on lifestyle, genetics and environmental factors. Bezold claims that these 3 account for 90% of current morbidity and mortality and that there is an increasing focus on modifying lifestyles to prevent disease. Bezold also discusses the prevalence of chronic illness in the US and the fact that the conventional medical method is inadequate for handling chronic illness. He points to various ways in which CAM therapies can be helpful in lifestyle modification and health promotion. (Bezold, 2006)
Supporting this point of view, Faas & Jonas (2006) point out it is the very success of conventional medicine in eradicating infectious disease as the primary source of death that has made chronic illness and aging a current priority for health care. They recommend not abandoning the successful model of acute care but rather incorporating a more holistic, preventive perspective into care of chronic illness. (Faas & Jonas, 2006) These two essays offer a glimpse of health care that integrates biomedical and CAM practices so that the wisdom and strength of each discipline is utilized for the improved health of the patient. From their perspectives, CAM should be integrated into medical care not only to prevent CAM practices from harming patients or to minimize negative interactions between care approaches. These essays indicate there is something fundamentally incomplete about the biomedical perspective that can be made more whole when used in conjunction with CAM.
In summary it is clear there are significant distinctions between CAM and conventional medicine. There are barriers between the two that include the lack of scientific evidence and safety regulation regarding CAM use. Yet there is a need for the two disciplines to come together being driven by the patients’ use, the practitioners desire to know more, and the need for new perspectives in treating chronic illness. With this need there is an increasing openness among practitioners and a call for a scientifically researched body of knowledge to support CAM practice.
CAM and Patients
The National Institute for Health documented that in 2008 that 38% of adults in the US use CAM; up from 36% in 2002. Patients were most likely to seek CAM for back and neck pain, head and chest colds, arthritis and gout, anxiety or stress, and ADD/ADHD. CAM users tend to have a high level of education and earn above the poverty line. Characteristics of the typical CAM user are also dependent on geographical region, race and presence of multiple diagnoses. (NCCAM, 2008)
In their study on CAM use and medication adherence in patients with inflammatory bowel disease, Weizman et al. (2012) found that patients turn to CAM use due to lack of response to conventional therapy, because they think CAM is safer than conventional therapies, and in order to have a better sense of control over their illness. (Weizman et al., 2012) Similarly, Faas, in her essay on why patients use CAM, found that the majority of studies find that most CAM users are individuals with chronic illness or pain that is not life threatening. While most users claim to want improvement of symptoms there is also a large percentage of CAM users who seek prevention of disease and overall wellbeing. (Faas, 2006) Jong et al. (2012) reported that patients today seek CAM in order to be treated in a more holistic way, as opposed to as a result of negative conventional medical experiences. (Jong, Van de Vijver, Busch, Fritsma, & Seldenrijk, 2012) Thus we see patients are accessing CAM for varying reasons.
Fontaine (2005) concurs with the assessment that people who use CAM have various motives, and adds that a desire for involvement in the decision making about their health is often reported as an overall reason for CAM use. Fontaine posits that many use CAM “for a sense of hope, control, personal attention, physical contact, and regard for the whole person that seems to be overlooked in conventional medicine” (Fontaine, 2005, p. 17). Spencer et al. (2003) has a similar understanding of the nature of CAM use. They cite a low level of patient involvement in decision making as a reason patients report lack of trust in conventional medical practitioners, and subsequently seek out alternative care. (Spencer & Jacobs, 2003) The nature of most CAM practices necessitates some sort of lifestyle change that requires an individual to be active in making health decisions, as well as invest time and personal energy into their health.
A problem with patient CAM use is identified when Fontaine states that fewer than 40% of those that use CAM communicate their CAM use with their conventional practitioner. (Fontaine, 2005) Similarly, Weizman et al. found that 36% of patients discussed CAM use with their practitioner before starting CAM. (Weizman et al., 2012) This well documented phenomenon raises the issue of the safety of CAM use. Some CAM practices involve taking herbal supplements, dietary changes or other practices which may have the potential for interaction with conventional treatment. This can be detrimental, dangerous, and possibly life threatening for patients. In a study of over 400 emergency room visitors, Taylor et al. (2006) found that 68% reported using CAM, 72% of whom did not inform the emergency room physician about the use. More than half of these CAM users were also taking prescription drugs. Of these cases, 15 known drug-CAM interactions and 97 potential drug-CAM interactions were identified by the researchers. The majority of patients that did not disclose their CAM use claimed the physician never asked. (Taylor, Walsham, Taylor, & Wong, 2006) The results of this study point to a dangerous trend in patients to keep their CAM use from their conventional practitioner, leading to potential adverse reactions with conventional medical treatment.
In a comprehensive study examining the communication barrier between patients using CAM and practitioners, Shelley et al. (2009) unveiled interesting, and contradicting perspectives. While the researchers documented the widespread lack of communication, their purpose was to ask “why” there was a lack of communication. Some patients reported previous negative experiences where practitioners dismissed CAM practices negatively. The majority of patients, however, perceived that the physician was not open to hearing about their CAM practice because the practitioner did not initiate discussion about it. Ironically, the physicians reported that they would initiate conversation about CAM if they had more patients using CAM; the physicians reported a low level of CAM use in their patients because patients were not reporting it! This cycle of silence left both practitioner and patient without important information and missing an opportunity for care that is more complete and accurate. Shelley et al. found that both the patients and the physicians expressed openness to CAM and desire for enhanced communication. (Shelley, Sussman, Williams, Segal, & Crabtree, 2009)
In a similar European study, Jong et al. (2012) found that the vast majority of patients that use CAM do not report it to their general practitioners. Reasons for not reporting were: the belief that it is not necessary to tell; that patients think of CAM and conventional medicine as separate worlds; and that they perceived or knew their general practitioner would not approve or support their CAM use. The researchers also found that 92% of the patients wanted a general practitioner that would communicate about CAM, and 70% wanted a general practitioner that would refer them to CAM practices. (Jong et al., 2012) The evidence that patients believe their CAM use has no relationship to their conventional treatments hints at a general lack of knowledge of potential adverse reactions certain treatments can have with medications. This ignorance on the part of the patient is problematic and can potentially be addressed through enhanced communication with their practitioner.
In summary, patients turn to CAM use for many different reasons from the maintenance of wellbeing to management of chronic illness. Patients reportedly seek out care that they can have more control over and be more involved in. Their CAM use is seen as separate from their conventional care and the majority of patients perceive their general practitioners as not needing to know about it. Physicians are also seen as not being open to CAM use. Patients say they want to be able to discuss CAM use with their physicians and want the discussion to be initiated by the physician.
Defining Attributes
Defining attributes are a cluster of attributes most frequently associated with the concept (Walker & Avant, 2005). Defining attributes for CAM are: unconventional practices, holistic, empower the patient, involves lifestyle changes.
Definition
CAM is a set of unconventional practices that are holistically based and empower the patient to make lifestyle changes to achieve health related goals.
Cases
Model Case
A model case is defined as a scenario or situation that includes all of the defining attributes of a concept (Walker & Avant, 2005). The following case is a model case of complementary and alternative medicine.
Jane is a 35 year old woman with rheumatoid arthritis. She suffers from painful joints that are, at times, debilitating and prevent her from functioning. Jane sees a primary care physician and a rheumatologist to direct her treatment. She takes NSAIDs for pain and takes steroids to help with the joint inflammation. The side effects from the medications are horrible for Jane and she often skips her medications, claiming the side effects are worse than the pain from her arthritis. Despite her complaints, her doctors are unable to provide suggestions for relief and urge her to take her medications as scheduled.
Jane hears about a holistic health retreat center from an on-line support group she participates in. She decides to attend a month long retreat. At the center she learns that all autoimmune illnesses are connected to systemic inflammation which can be reduced through diet and alternative treatments. She takes part in a dietary overhaul and begins eating an organic, raw, vegan diet. She has many treatments including: lymphatic massage, chiropractic care, colonics, cranial sacral treatment, yoga, and meditation. Jane is empowered to continue this self-care at home and is introduced to a support network on-line to help her stay on track. Jane learns that the food she eats, the way she moves her body and the actions she engage in can help reduce inflammation in her body. She is taught some methods for handling acute attacks of pain that include dietary alterations, use of hot mineral water baths, and physical manipulations. She is able to eliminate her dependence on medication. Jane embraces this as a long term lifestyle change.
In this case, Jane seeks help outside of the care that she receives from her conventional physicians. The care is holistic and Jane discovers all the ways her whole body, including unwitting physical aspects of herself such as digestion, are affecting her arthritis. Jane is empowered to be active in taking care of herself and gaining a level of control over her symptoms. She makes lifestyle changes to achieve this goal. This is a model case of CAM.
Borderline Case
Walker and Avant (2005) define a borderline case as one that includes some of the defining attributes but not all of them or may contain most or all of the attributes but differ significantly in length of time, intensity or occurrence. The following is a borderline case of complementary and alternative medicine.
B.L. is a 50 year old mother of 5. She has been smoking 2 packs of cigarettes a day for 28 years and has wanted to quit for more than 10 years. She has tried many different methods of quitting smoking including use of nicotine substitutes and support groups. B.L. has learned of an alternative care center that specializes in smoking cessation and signs up to attend. The center requires a 2 week attendance in order to “cleanse the body of its addiction.” Through the center’s literature B.L. learns that her body’s addiction to smoking is physical and spiritual and she will need to clean her body on both levels in order to be free from smoking.
B.L. attends the retreat and participates in cleansing techniques that include massage, sweat lodges, and fasting. She receives spiritual cleansing through Reiki and a Native American cleansing circle using sage and other herbs to “smudge” the negative spirit out of her. The practitioners at the center perform all rituals and manipulations on B.L. At the end of 2 weeks, B.L. is declared addiction free and sent home.
B.L. returns home feeling great and immediately re-enters her life in the same way as before. After 10 days at home with no changes in her lifestyle or tools from her retreat, B.L. begins smoking again.
In this case B.L. engages in an unconventional course of treatment that is holistic and attempts to cleanse her body and spirit. The care does not, however, empower B.L. to take care of herself and make real lifestyle changes. While this alternative medicine treatment may have the potential to be successful, without the empowerment needed to make life changes, it failed to achieve its goals. This is a borderline case.
Related Case
A related case is a case that is related to the concept but does not contain the defining attributes (Walker & Avant, 2005). The following is an example of a related case for complementary and alternative medicine.
Hannah is a nurse on a medical-surgical unit of a busy hospital. She offers excellent conventional care to her patients and is always careful to follow the appropriate plan of care. Before performing any task, such as inserting a catheter or dressing a wound, Hannah takes a deep breath and silently prays that the procedure is successful and helpful for the patient. No one knows she does this. Hannah believes in the power of prayer and fills her day in this manner with prayer.
This is a related case because, while prayer is considered part of CAM, this case does not meet any of the attributes. The treatment Hannah is performing is always completely conventional. It is not necessarily holistic as she prays very for the procedures and body parts she is treating. Her practice does not empower the patient as the patient is unaware of its occurrence and is not taught to incorporate a lifestyle change. This is an example of how a CAM practice can avoid incorporating the defining attributes.
Contrary Case
Walker and Avant (2005) define a contrary case as a case that is the opposite of the concept. The following case represents a contrary case of complementary and alternative medicine.
Stanley is a 60 year old business executive that is divorced with 2 grown children. He works more than 60 hours a week, often on weekends as well. He mostly eats in restaurants, does not exercise, lives alone, and has very little contact with his children. His company has recently had some financial setbacks. Stanley presents to his general practitioner with a recent onset of sleep disturbance and difficulty concentrating. Stanley is diagnosed with high blood pressure, high cholesterol, and anxiety.
Stanley’s practitioner begins discussing lifestyle changes that Stanley can make to improve his health including regular exercise, more vegetables in his diet, and perhaps engaging in meditation to relieve his anxiety. His practitioner also gently suggests Stanley may want to engage in some social activities and tries to communicate with him about his social life. Stanley will not discuss it, refuses to consider any lifestyle changes and rejects anything he considers “flaky” like meditation. He wants medication for his problems and wants to continue his life as is. He leaves his doctor with medication to lower his blood pressure and cholesterol and an anti-anxiety medication.
In this case, Stanley is committed to receiving the most base level of conventional care. He sees a problem and wants to fix it without any holistic examination of why he has those problems to begin with. He refuses lifestyle changes and is not empowered to care for himself. This is a contrary case.
Invented Case
An invented case is a case that is a fictitious representation of the concept (Walker & Avant, 2005). The following is an example of an invented case for complementary and alternative medicine.
Shoe is a shoe. He is a good shoe made of the finest Italian leather, hand crafted with a thick weather resistant sole, plush lining, and top of the line shock resistant in-soles. As shoes go, Shoe is an elite specimen. He was expensive to purchase and his owner takes him regularly to get polished and, when Shoe got attacked by a wild thing called a “puppy,” to the shoemaker for some slight repairs. His owner works in a fine office building with polished marble floors and expensive rugs, rides in a limousine with vacuumed carpet floors, lives in a luxury home with gleaming hardwoods and imported tile floors, and has a designated solid cedar rack for Shoe to sleep on at night in the closet.
Despite his blessings, Shoe is miserable. Most other shoes are focused on the ground, becoming nervous when they are lifted up and immediately seeking return to solid surface. Shoe, on the other hand, dreams of seeing the world from a loftier vantage point. What would it be like to see faces or the sky or what is on the top of the table? That is where the noise is, the action, the interaction that Shoe craves. Shoe would like to be a hat.
One day Shoe’s owner stops by the shoemaker to pick something up for his wife. While there, Shoe engages the shoemaker in conversation (all shoemakers talk shoe-talk). He asks the shoemaker what Shoe can do to become a hat. The shoemaker laughs and says that it is impossible. Shoe is a shoe and needs to stay a shoe. Shoe is devastated. He resigns himself to giving up his dream.
Years later Shoe is getting a bit old and newer models of Shoe are coming out. Shoe’s owner decides to get a new pair of shoes and gives Shoe to his brother, who is a poor artist. The artist accepts Shoe and brings him to his converted warehouse loft. Shoe notices that the artist dresses very unconventionally with a belt made out of a bicycle tire tube. Shoe asks the artist about it (artists can speak to anything) and the artist explains he likes objects to choose what they want to be and he helps them do it. He says that objects are not just physical, but have a spirit that must be honored as well. The artist asks Shoe what Shoe would like to be. Shoe remembers his old dream of being a hat and, in a sad voice, replies that he used to want to be a hat but he gave up hoping it could happen. The artist tells Shoe he can be a hat, if he wants.
Shoe becomes a hat and changes his name to Hat. He had to make some radical changes to his appearance in order to fit on the artist’s head but he is still himself and he feels great. There is so much to see up here on the head! Hat is very happy with his life now. (Incidentally, the artist received critical acclaim for his innovative shoe-hat and is now quite famous and wealthy)
In this case, Shoe had to find unconventional treatment to move forward with his goal. The artist was able to see Shoe holistically, as having more than just physicality. Shoe was empowered to state his goals and ask for what he wanted. He made lifestyle changes by changing his name, his body, and his habits. This is an invented case about CAM.
Antecedent
An antecedent is an event or incident that occurs preceding the occurrence of the concept (Walker & Avant, 2005). An antecedent from the literature relating to complementary and alternative therapy is “medicine.” In order for CAM to be defined as outside of conventional medicine, conventional medicine needed to exist. Although some CAM practices predate allopathic or conventional medicine, the emergence of the current predominant medical model has marginalized many of these practices. (Spencer & Jacobs, 2003)
Consequences
Consequences are events or incidents that emerge as a result of the occurrences of the concept (Walker & Avant, 2005). The consequences of complementary and alternative medicine are a broader range of available approaches to health care and a sense of empowerment for the patient. Many patients do not find improved wellness with a conventional medical approach and appreciate options that go beyond pharmaceutical response to illness. One oft cited reason for patients with inflammatory bowel disease to seek out alternative care is dissatisfaction with conventional care offered. (Weizman et al., 2012) Another reason patients claim as impetus for using CAM is a desire to be more involved in their care. Hilsden et al. (1998) found that patients felt they were left out of the decision making process with their conventional practitioners, and wanted to have a sense of control over their health management. (Hilsden, Scott, & Verhoef, 1998)
Empirical Referents
Empirical referents are classes and categories of actual phenomena that demonstrate the actual occurrence of the concept. They are useful for instrument development in research and can be applied to the theoretical basis of the concept (Walker & Avant, 2005). One category of phenomena that exists is the attitudes of individuals regarding the use of CAM. While some people live with CAM as a valid and empowering part of life, others dismiss it as lacking empirical evidence. There have been several tools created to assess attitudes about CAM. One tool developed for this assessment is the Integrative Medicine Attitude Questionanaire (IMAQ), created by Schneider et al. to measure health care provider attitudes regarding complementary and alternative medicine. (Schneider, Meek, & Bell, 2003)
The IMAQ is a questionnaire of 29 statements with a 7 point Likert-scale agreement rating response. The scores can be calculated to provide a researcher with an “openness score” for the responding provider. Statements include “a patient is healed when underlying diseases processes are controlled,” and, “therapeutic touch has been completely discredited as a healing modality” (Schneider et al., 2003). The IMAQ has proven validity and reliability and has been adapted by other researchers to fit different populations. This tool has been useful in understanding the attitudes of health care providers toward CAM.
Conclusion
While
complementary and alternative medicine can seem like a diverse and unwieldy
concept to understand, there are attributes that emerge as important hallmarks
for CAM. The prevalence of CAM use in the United States is forcing and
inspiring health care providers to become more knowledgeable and comfortable
discussing CAM. This concept analysis provides some insight into complementary
and alternative medicine which may serve to make the concept less daunting to
approach.
References
Beijing Declaration [Adopted by the WHO Congress on Traditional Medicine]. (2008). Retrieved from http://www.who.int/medicines/areas/traditional/TRM_BeijingDeclarationEN.pdf
