Current Trends and Issues in Holistic Nursing
Carla Mariano
Nurse Healer OBJECTIVES
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Theoretical
Describe the major issues in health care and holistic nursing today.
Identify changes needed in health care to promote health, wellness, and healing.
Discuss recommendations of the Institute of Medicine (IOM) report The Future of Nursing.
Clinical
Evaluate how current trends in health care will affect clinical nursing practice.
Discuss with other health professionals the unique and common contributions of each other’s practice.
Personal
Become a member of the American Holistic Nurses Association (AHNA) to participate in improving holistic health care for society.
The American public increasingly demands health care that is compassionate and respectful, provides options, is economically feasible, and is grounded in holistic ideals. A shift is occurring in health care where people desire to be more actively involved in health decision making. They have expressed their dissatisfaction with conventional (Western allopathic) medicine and are calling for a care system that encompasses health, quality of life, and a relationship with their providers. The National Center for Complementary and Alternative Medicine’s Strategic Plan for 2011-20151 and Healthy People 2020 2 prioritize enhancing physical and mental health and wellness, preventing disease, and empowering the public to take responsibility for their health. The vision of Healthy People 2020 is “A society in which all people live long, healthy lives” and its goals are as follows:
Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.
Achieve health equity, eliminate disparities, and improve the health of all groups.
Create social and physical environments that promote good health for all.
Promote quality of life, healthy development, and healthy behaviors across all life stages.2
▪ HEALTH CARE IN THE UNITED STATES
Western medicine is proving ineffective, wholly or partially, for a significant proportion of common chronic diseases. Furthermore, highly technological health care is too expensive to be universally affordable. In a May 2011 poll, 55% of Americans indicated that the healthcare system has major problems, 50% indicated that the
healthcare system needs fundamental changes, and 36% stated that there is so much wrong with the healthcare system that it needs to be completely rebuilt.3
healthcare system needs fundamental changes, and 36% stated that there is so much wrong with the healthcare system that it needs to be completely rebuilt.3
Although medical advances have saved and improved the lives of millions, much of medicine and health care have primarily focused on addressing immediate events of disease and injury, generally neglecting underlying socioeconomic factors, including employment, education, and income and behavioral risk factors. These factors, and others, impact health status, accentuate disparities, and can lead to costly, preventable diseases. Furthermore, the disease-driven approach to medicine and health care has resulted in a fragmented, specialized health system in which care is typically reactive and episodic, as well as often inefficient and impersonal.4
Chronic diseases—such as heart disease, cancer, hypertension, diabetes, depression—are the leading causes of death and disability in the United States. Chronic diseases account for 70% of all deaths in the United States, which is 1.7 million deaths each year. These diseases also cause major limitations in daily living for almost 1 out of 10 Americans, or about 25 million people.5
Stress accounts for 80% of all healthcare issues in the United States. Super Stress “is a result of both the changing nature of our daily lives and our choices in lifestyle habits, as well as a series of unfortunate events. Extreme chronic stress … has silently become a pandemic that disturbs not only how we perceive our quality of life but also our health and mortality. … The APA [American Psychological Association] issued a report on stress, revealing that nearly half of all Americans were experiencing stress at a significantly higher level than the previous year and rated its level as extreme.6
Healthcare costs have been rising for several years. Expenditures in the United States for health care surpassed $2.3 trillion in 2008, more than three times the $714 billion spent in 1990, and more than eight times the $253 billion spent in 1980. Healthcare expenditures are projected to be $2.7 trillion in 2011 and $4.3 trillion by 2017.7
In 2008, U.S. healthcare spending was about $7,681 per resident and accounted for 16.2% of the nation’s gross domestic product (GDP); this is among the highest of all industrialized countries. Total healthcare expenditures continue to outpace inflation and the growth in national income.8 The U.S. healthcare system is the most expensive in the world, but it yields worse results than the systems in Britain, Canada, Germany, Australia, and New Zealand. U.S. residents with below-average incomes are more likely than their counterparts in other countries not to have received needed care because of cost. The Centers for Medicare and Medicaid Services (CMS) compare what healthcare costs per capita have been and will be over the next few years:9
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Healthcare cost for a family of four rose again in 2011, with employees paying a much larger share of the rising expense. The total cost of health care for a typical family of four is $19,393, an increase of 7.3% over 2010. This is double the cost families had to pay in 2002 ($9,235). As costs continue to grow, the cost for health care constitutes a larger and larger portion of the household budget.8 And what are families paying for? The 2011 Milliman Medical Index indicates that physician costs represent 33% of the overall health costs; hospital inpatient costs account for 31%; outpatient costs, 17%; pharmacy, 15%; and other expenses such as medical equipment, about 4%.10
Additionally, workers paid 47% more in 2010 than they did in 2005 for the health coverage they get through their jobs, while their wages have increased only 18%. Employers, in contrast, pay 20% more toward their employees’ health insurance than they did 5 years ago. Premiums for employer-sponsored health insurance have risen from $5,791 in 1999 to $13,375 in 2009, with the amount paid by workers rising by 128%.11
In addition to the rising costs, there is disparity in the numbers of Americans insured for health coverage. The U.S. Census Bureau cites the number of uninsured Americans at 50.7 million, 16.7% of the population, rising from 13.7% in 2000, or almost 1 in 6 U.S. residents.12 The number of underinsured has grown 60% to 25 million over the past 4 years.13 The reasons for the rise in both categories include workers losing their jobs in the recession, companies dropping employee health insurance benefits, and families going without coverage to cut costs—primarily as a result of the high costs of health care. Additionally, in 2009, an average of 7% of the population failed to obtain needed medical care because of costs, with the percentages of Hispanics and blacks and those 18 to 64 years of age being the largest.14
The Kaiser Family Foundation identifies the following forces driving healthcare costs:8
Technology and prescription drugs: Because of development costs and generation of consumer demand for more intense, costly services even if they are not necessarily cost effective.
Chronic disease: Chronic disease accounts for more than 75% of national healthcare expenditures and places tremendous demands on the system, particularly the increased need for treatment of ongoing illnesses and longterm services. One-quarter (25%) of Medicare spending is for costs incurred during the last year of life.
Aging of the population: Health expenses rise with age. The baby boomers begin qualifying for Medicare in 2011 and many of their costs will shift to the public sector.
Administrative costs: At least 7% of healthcare expenditures are for marketing, billing, and other administrative costs. Overhead costs and large profits are fueling healthcare spending.
The Kaiser Family Foundation also offers the following proposals to contain costs:8
Invest in information technology (IT). Make greater use of technology such as electronic medical records (EMRs). This is a major component of the health reform plan.
Improve quality and efficiency. Decrease unwarranted variation in medical practice and unnecessary care. Experts estimate that 30% of health care is unnecessary.
Adjust provider compensation and increase comparative effectiveness research (CER). Ensure that fees paid to physicians reward value and health outcomes rather than volume of care, and determine which treatments are most effective for given conditions.
Increase government regulation in controlling per capita spending.
Increase prevention efforts. Provide financial incentives to workers to engage in wellness and to decrease the prevalence of chronic conditions. Improve disease management to streamline treatment for common chronic health conditions.
Increase consumer involvement in purchasing. Encourage greater price transparency and use of health reimbursement accounts (HRAs).
Much has been written about the current healthcare crisis: the high cost of health care, the lack of universal access to health care and the resulting 51 million uninsured Americans, the insurance morass and that industry’s control of healthcare spending, the disenchantment and disempowerment of healthcare providers, the frustration of clients/patients and healthcare consumers, the lack of incentive for practitioners or insurers to foster prevention and health promotion, and the startling lack of measures being taken for high-quality healthcare outcomes. Hyman states that the national healthcare dialogue omits discussions about the nature and quality of care:
We speak of evidence-based medicine, not quality-based medicine. Although evidence is important, it is not enough, particularly when the evidence is limited mostly to what is funded by private interest or grounded in the pharmacologic treatment of disease. The fundamental flaw in our approach to the discussion about evidence-based medicine versus quality-based medicine is the lack of focus on prevention and wellness and the lack of funding and research on comparative approaches to chronic healthcare problems. Though
it is still a matter of public debate, there is ample evidence that lifestyle therapies equal or exceed the benefits of conventional therapies. Nutrition, exercise, and stress management no longer can be considered alternative medicine. They are essential medicine, and often the most effective and cost-effective therapies to treat chronic disease, which has replaced infectious and acute illnesses as the leading cause of death in the world, both in developed and developing countries. It is hoped then that the next 10 years will see a focus on not just the mechanisms of complementary and integrative therapies, but also on measuring their role in improving overall healthcare quality and reducing healthcare costs. It is hoped the discourse begun by the IOM report will spur policy makers to refocus federal efforts and funding on quality, disease prevention, and health promotion and will help us find the right medicine, regardless of its origin.15
it is still a matter of public debate, there is ample evidence that lifestyle therapies equal or exceed the benefits of conventional therapies. Nutrition, exercise, and stress management no longer can be considered alternative medicine. They are essential medicine, and often the most effective and cost-effective therapies to treat chronic disease, which has replaced infectious and acute illnesses as the leading cause of death in the world, both in developed and developing countries. It is hoped then that the next 10 years will see a focus on not just the mechanisms of complementary and integrative therapies, but also on measuring their role in improving overall healthcare quality and reducing healthcare costs. It is hoped the discourse begun by the IOM report will spur policy makers to refocus federal efforts and funding on quality, disease prevention, and health promotion and will help us find the right medicine, regardless of its origin.15
Use of CAM in the United States
The American public has pursued alternative and complementary care at an ever-increasing rate. In 1993, David Eisenberg and colleagues published a now-classic study that indicated that one-third of (61 million) Americans were using some form of alternative or complementary medicine.16 The researchers’ ongoing study on the use of alternative/complementary care in 1998 indicated that the use of such modalities not only continued, but sharply increased to 42% (83 million Americans). The total number of visits to providers of complementary care increased by 47% from 427 million in 1990 to 629 million in 1997.17 The out-of-pocket dollars the American public spent on CAM was $12.2 billion, which exceeded the out-of-pocket expenditures for all U.S. hospitalizations and compared with total out-of-pocket expenses for all physician services.
The most recent survey, the 2007 National Health Interview Survey,18 indicates that 38.3% of adults in the United States aged 18 years and older (almost 4 of 10 adults) and nearly 12% of children aged 17 years and younger (1 in 9 children) used some form of CAM within the previous 12 months. Use among adults remained relatively constant from previous surveys. The 2007 survey provides the first population-based estimate of children’s use of CAM. Americans spent $33.9 billion out-of-pocket on CAM during the 12 months prior to the survey. This accounts for approximately 1.5% of total U.S. healthcare expenditures and 11.2% of total out-of-pocket expenditures. Nearly two-thirds of the total out-of-pocket costs that adults spent on CAM were for self-care purchases of CAM products, classes, and materials ($22.0 billion), compared with about one-third spent on practitioner visits ($11.9 billion). Despite this emphasis on self-care therapies, 38.1 million adults made an estimated 354.2 million visits to practitioners of CAM.19
Barnes and colleagues found that people who use CAM approaches seek ways to improve their health and well-being, attempt to relieve symptoms associated with chronic or even terminal illnesses or the side effects of conventional treatments, have a holistic health philosophy or desire a transformational experience that changes their worldview, and want greater control over their health. The majority of individuals using CAM do so to complement conventional care rather than as an alternative to conventional care. Other findings include the following:18
CAM therapies most commonly used by U.S. adults in the past 12 months were nonvitamin, nonmineral natural products (17.7%), deep breathing exercises (12.7%), meditation (9.4%), chiropractic or osteopathic manipulation (8.6%), massage (8.3%), and yoga (6.1%).
CAM therapies with increased use between 2002 and 2007 were deep breathing exercises, meditation, yoga, acupuncture, massage therapy, and naturopathy.
Adults used CAM most often to treat a variety of musculoskeletal problems, including back pain or problems (17.1%), neck pain or problems (5.9%), joint pain or stiffness or other joint condition (5.2%), arthritis (3.5%), and other musculoskeletal conditions (1.8%).
CAM therapies used most often by children were for back or neck pain (6.7%), head or chest colds (6.6%), anxiety or stress (4.8%), other musculoskeletal problems (4.2%), and attention-deficit hyperactivity disorder or attention-deficit disorder (ADHD/ADD) (2.5%).
CAM use was more prevalent among women, adults aged 30-69 years, adults with higher levels of education, adults who were not poor, adults living in the West, former smokers, and adults who were hospitalized in the last year.
CAM usage was positively associated with number of health conditions and number of doctor visits in the past 12 months; however, about one-fifth of adults with no health conditions and one-quarter of adults with no doctor visits in the past 12 months used CAM therapies.
In both 2002 and 2007, when worry about cost delayed the receipt of conventional medical care, adults were more likely to use CAM than when the cost of conventional care was not a worry. When unable to afford conventional medical care, adults were more likely to use CAM.
The survey of consumer use of CAM by the American Association of Retired Persons (AARP) and National Center for Complementary and Alternative Medicine (NCCAM) found that people 50 years of age and older tend to be high users of complementary and alternative medicine:20
More than one-half (53%) of people 50 years and older reported using CAM at some point in their lives, and nearly as many (47%) reported using it in the past 12 months.
Herbal products or dietary supplements were the type of CAM most commonly used, with just more than a third (37%) of respondents reporting their use, followed by massage therapy, chiropractic manipulation, and other bodywork (22%); mindbody practices (9%); and naturopathy, acupuncture, and homeopathy (5%).
Women were more likely than men to report using any form of CAM.
In most cases, the use of CAM increased with educational attainment.
The most common reasons for using CAM were to prevent illness or for overall wellness (77%), to reduce pain or treat painful conditions (73%), to treat a specific health condition (59%), or to supplement conventional medicine (53%).
Chronically and terminally ill persons consume more healthcare resources than the rest of the population does. The great interest in CAM practices among those who are chronically ill, those with life-threatening conditions, and those at the end of their lives suggests that increased access to some services among these groups could have significant implications for the healthcare system. With the number of older Americans expected to increase dramatically over the next 20 years, alternative strategies for dealing with the elderly population and end-of-life processes will be increasingly important in public policy. If evaluations show that some uses of CAM can lessen the need for more expensive conventional care in these populations, the economic implications for Medicare and Medicaid could be significant. If safe and effective CAM practices become more available to the general population, special and vulnerable populations should also have access to these services, along with conventional health care. CAM would not be a replacement for conventional health care but would be part of the treatment options available. In some cases, CAM practices may be an equal or superior option. CAM offers the possibility of a new paradigm of integrated health care that could affect the affordability, accessibility, and delivery of healthcare services for millions of Americans.
A significant aspect of the AARP/NCCAM study was that respondents were asked if they had discussed CAM use with any of the healthcare providers they see regularly:
More than two-thirds (67%) of respondents reported that they had not discussed CAM with any healthcare provider (HCP).
If CAM was discussed at a medical appointment, it was brought up by the patient 55% of the time, by the healthcare provider 26% of the time, or by a relative/friend 14% of
the time. Respondents were twice as likely to say that they raised the topic rather than their healthcare provider.
The main reasons that respondents and their healthcare providers do not discuss CAM are as follows: the provider never asks (42%), respondents did not know that they should bring up the topic (30%), there is not enough time during a visit (17%), the HCP would have been dismissive or told the respondent not to do it (12%), or the respondent did not feel comfortable discussing the topic with the HCP (11%).
People aged 50 years and older who use CAM get their information about it from a variety of sources: from family or friends (26%), the Internet (14%), their physician (13%, or 21% for all healthcare providers), publications including magazines, newspapers, and books (13%) and radio or television (7%).
It is clear that people aged 50 years and older are likely to be using CAM. It is also clear that this population frequently uses prescription medications. Common use of CAM as a complement to conventional medicine—and the high use of multiple prescription drugs—further underscores the need for healthcare providers and clients, patients, and families to have an open dialogue to ensure safe and appropriate integrated medical care. The lack of this dialogue points to a need to educate both consumers and healthcare providers about the importance of discussing the use of CAM, how to begin that dialogue, and the implications of not doing so.
Nondisclosure raises important safety issues, such as the potential interactions of medications with herbs used as part of a CAM therapy. In addition, a majority of adults who use CAM therapies use more than one CAM modality and do so in combination with conventional medical care. In the literature, there are few data about the extent to which use of a CAM therapy may interfere with compliance in the use of conventional therapies. It is not known whether clients/patients use products as directed or even for the purpose recommended. Such information is important. Even if a therapy is efficacious, it may have little or no effect if it is taken or used incorrectly. Furthermore, medicines and other CAM products and procedures may be the source of iatrogenic health problems if they are used incorrectly. Clients/patients who believe that herbal medicines are harmless may be more willing to selfregulate their medication in unsupervised ways.
Healthcare Reform and Integrative Health Care
On March 23, 2010, President Obama signed comprehensive health reform, the Patient Protection and Affordable Healthcare Act (HR 3590), into law. This law and subsequent legislation focus on provisions to expand health coverage, control health costs, and improve the healthcare delivery system. Discussion of the specifics of this legislation is beyond the scope of this chapter; however, sections that will shape policy relative to integrative healthcare practices in the future are discussed here.21
Inclusion of Licensed Practitioners Insurance Coverage (SEC. 2706. NON-DISCRIMINATION IN HEALTH CARE). Providers: A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any healthcare provider who is acting within the scope of that provider’s license or certification under applicable state law.
Inclusion of Licensed Complementary and Alternative Medicine Practitioners in Medical Homes (SEC. 3502. ESTABLISHING COMMUNITY HEALTH TEAMS TO SUPPORT THE PATIENT-CENTERED MEDICAL HOME). The Secretary of Health and Human Services shall establish a program to provide grants to or enter into contracts with eligible entities to establish community-based interdisciplinary, interprofessional teams(referred to as ‘health teams’) to support primary care practices. Such teams may include medical specialists, nurses, pharmacists, nutritionists, dietitians, social workers, behavioral and mental health providers, doctors of chiropractic, licensed complementary and alternative medicine practitioners.
Integrative Health Care and Integrative Practitioners in Prevention Strategies (SEC. 4001. NATIONAL PREVENTION, HEALTH PROMOTION AND PUBLIC HEALTH COUNCIL). This council will provide coordination and leadership at the federal level, and among all federal departments and agencies, with respect to prevention, wellness and health promotion practices, the public health system, and integrative health care in the United States; develop a national prevention, health promotion, public health, and integrative healthcare strategy that incorporates the most effective and achievable means of improving the health status of Americans and reducing the incidence of preventable illness and disability in the United States; propose evidence-based models, policies, and innovative approaches for the promotion of transformative models of prevention, integrative health, and public health on individual and community levels across the United States.
Dietary Supplements in Individualized Wellness Plans (SEC. 4206. DEMONSTRATION PROJECT CONCERNING INDIVIDUALIZED WELLNESS PLAN). Establish a pilot program to test the impact of providing at-risk populations who utilize community health centers funded under this section an individualized wellness plan that is designed to reduce risk factors for preventable conditions. An individualized wellness plan prepared under the pilot program under this subsection may include one or more of the following as appropriate to the individual’s identified risk factors:
Nutritional counseling
A physical activity plan
Alcohol and smoking cessation counseling and services
Stress management
Dietary supplements that have health claims approved by the Secretary
Licensed Complementary and Alternative Providers and Integrative Practitioners in Workforce Planning (SEC. 5101. NATIONAL HEALTH CARE WORKFORCE COMMISSION). The term healthcare workforce includes all healthcare providers with direct patient care and support responsibilities, such as physicians, nurses, nurse practitioners, primary care providers, preventive medicine physicians, optometrists, ophthalmologists, physician assistants, pharmacists, dentists, dental hygienists, and other oral healthcare professionals, allied health professionals, doctors of chiropractic, community health workers, healthcare paraprofessionals, direct care workers, psychologists and other behavioral and mental health professionals, social workers, physical and occupational therapists, certified nurse midwives, podiatrists, the emergency medical services (EMS) workforce, licensed complementary and alternative medicine providers, integrative health practitioners, public health professionals.
Experts in Integrative Health and State-Licensed Integrative Health Practitioners in Comparative Effectiveness Research (SEC. 6301. PATIENT-CENTERED OUTCOMES RESEARCH). Identify national priorities for research, taking into account factors of disease incidence, prevalence, and burden in the United States (with emphasis on chronic conditions); gaps in evidence in terms of clinical outcomes, practice variations and health disparities in terms of delivery and outcomes of care; the potential for new evidence to improve patient health, wellbeing, and the quality of care; the effect on national expenditures associated with a healthcare treatment, strategy, or health conditions, as well as patient needs, outcomes, and preferences; the relevance to patients and clinicians in making informed health decisions. Advisory panel consisting of practicing and research clinicians, patients, and experts in scientific and health services research, health services delivery, and evidence-based medicine who have experience in the relevant topic and, as appropriate, experts in integrative health and primary prevention strategies.
Trends
In addition to the data already cited, a number of trends affect and will continue to affect the health of society, delivery, and holistic practices.
Workplace Clinics
Interest has intensified in recent years (particularly with the newly enacted healthcare reform law) as employers move beyond traditional occupational health and convenience care to offering clinics that provide a full range of wellness, health promotion, and primary care services. This is seen as a tool to contain medical costs, such as specialist visits, nongeneric prescriptions, emergency department visits, and avoidable hospitalizations, boost productivity, reduce absenteeism, prevent disability claims and workrelated injuries, and enhance companies’ reputations as employers while attracting and retaining competitive workforces. Types of clinical services for new workplace programs can include traditional occupational health; acute care ranging from low-acuity episodic care to exacerbations of acute chronic conditions; preventive care including immunizations, lifestyle management, mind-body skills, screenings; wellness assessments and follow-up, health coaching, and education; and disease management for chronic conditions.22
Many of the nation’s largest employers are focusing on prevention and disease management by adopting an integrative medicine approach. At present, the Corporate Health Improvement Program (CHIP) members include the Ford Motor Company, IBM, Corning, Kimberly Clark, Dow Chemical, Medstat, Nestlé, NASA, Canyon Ranch Resorts, and American Specialty Health. Walmart will open health clinics at approximately 400 U.S. stores over the next 3 years, and at 2,000 stores in the next 5 to 7 years. The clinics will offer preventive and routine care. More than half of the people visiting the existing workplace clinics lack health insurance, and 15% said they would have to go to an emergency department if the clinics were unavailable.
Primary Care
The Institute for Alternative Futures, funded by the Kresge Foundation, forecasts the following aspects of the future of primary care in 2025:23
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