Integrative nursing: application of principles across clinical settings

Holistic Physical Assessment: A New Framework for Nursing Practice Honoring the Whole Person

Scholars have argued that standard physical assessment is based on a medical framework instead of nursing theories and philosophy. We argue that standard physical assessment is task-oriented, lacking emphasis on the whole-person and neglecting a least-to-most invasive assessment process. While holistic health assessment is person-centered and multidimensional; addressing aspects such as physical, emotional, and spiritual well-being, there is not a comprehensive explanation on how to holistically perform the physical examination portion of a holistic health assessment. Proposed is a new framework for holistic physical assessment in the hospital environment, honoring the whole-person, their background, and lived experiences. The framework builds on the holistic nursing philosophy, integrative nursing principles, and trauma-informed approach, and systematically arranges physical assessment from least invasive to most. The seven sequential assessment steps incorporate self-care and awareness into the preparation and closure of the assessment-(1) the self, (2) the space, (3) least invasive, (4) moderate invasive, (5) most invasive, (6) the space, and (7) the self. This framework can have significant implications for nursing practice and education settings, providing valuable guidance for a holistic physical assessment that emphasizes whole-person care.

Non-pharmacological interventions feasible in the nursing scope of practice for pain relief in palliative care patients: a systematic review

Background

Palliative care patients desire more symptom management interventions that are complementary to their medical treatment. Within the multi-professional team, nurses could help support pain management with non-pharmacological interventions feasible for their practice and adaptable to palliative care patients' needs.

Objectives

The objective was to identify non-pharmacological interventions feasible in the nursing scope of practice affecting pain in palliative care patients.

Design

A systematic review.

Data sources and methods

A defined search strategy was used in PubMed, CINAHL, PsycINFO, and Embase. Search results were screened double-blinded. Methodological quality was double-appraised with the Joanna Briggs Institute Critical Appraisal Tools. Data were extracted from selected studies and the findings were summarized. The methodological quality, quantity of studies evaluating the same intervention, and consistency in the findings were synthesized in a best-evidence synthesis to rank evidence as strong, moderate, limited, mixed, or insufficient.

Results

Out of 2385 articles, 22 studies highlighted non-pharmacological interventions in the nursing scope of practice. Interventions using massage therapy and virtual reality demonstrated most evidentiary support for pain management, while art therapy lacked sufficient evidence. Mindful breathing intervention showed no significant reduction in pain. Hypnosis, progressive muscle-relaxation-interactive-guided imagery, cognitive-behavioral audiotapes, wrapped warm footbath, reflexology, and music therapy exhibited promising results in pain reduction, whereas mindfulness-based stress reduction program, aromatherapy, and aroma-massage therapy did not.

Conclusion

Despite not all studies reaching significant changes in pain scores, non-pharmacological interventions can be clinically relevant to palliative care patients. Its use should be discussed for its potential value and nurses to be trained for safe practice. Methodologically rigorous research for non-pharmacological interventions in nursing scope of practice for pain relief in palliative care patients is necessary.

Trial registration

The protocol for this study is registered in the International Prospective Register of Systematic Review (PROSPERO registration number: CRD42020196781).

Integrative nursing in Europe - A competency profile for nursing students validated in a Delphi-study

BACKGROUND

Integrative nursing is a framework for providing holistic care and includes complementary therapies and non-pharmacological interventions. There is no common European approach on how to educate healthcare professionals on complementary therapies and non-pharmacological interventions for symptom management. Nurses report a lack of formal education as the main barrier to applying integrative nursing.

OBJECTIVES

The aim of this study is to develop and validate integrative nursing learning outcomes in a competency profile for bachelor nursing students.

METHODS

A two-round Delphi study was conducted with experts on integrative nursing and/or nurse education from eight European countries. The expert panelists rated their level of agreement with learning outcomes in relation to "Knowledge, Skills, Responsibility and Autonomy" on a nine-point Likert scale (1 = strongly disagree/9 = strongly agree) and were invited to add comments in an open text field. The Rand manual's description of levels of appropriateness was used, and experts' suggestions were analyzed thematically and used for reformulating or adding learning outcomes.

RESULTS

In the first round, 19 out of 23 experts participated, versus 18 in the second round. In all, thirty-five learning outcomes within the three areas Knowledge, Skills and Responsibility/Autonomy were rated. After two Delphi rounds, twenty-four included learning outcomes were classified as appropriate, with median levels of appropriateness between 7 and 9; none had been classified as inappropriate. The learning outcomes include general knowledge about selected complementary therapies and non-pharmacological interventions, safety, national rules and regulations, communication and ethical skills and competencies for self-care actions and for applying simple evidence-based complementary therapies and non-pharmacological interventions in nursing practice.

CONCLUSIONS

The competency profile consist of validated competencies; the high degree of consensus from the expert panelists makes the learning outcomes relevant for structuring a teaching module for nursing students about integrative nursing.

Musculoskeletal Pain in the Neck and Lower Back Regions among PHC Workers: Association between Workload, Mental Disorders, and Strategies to Manage Pain

Scientific evidence indicates that workers in the health sector are commonly exposed to work-related musculoskeletal pain.

OBJECTIVES

We aimed to identify the relationship between the presence and intensity of musculoskeletal pain in the neck and lumbar regions reported by Primary Health Care (PHC) workers with workloads and occupational risks, analyze musculoskeletal pain in the presence and absence of self-reported mental disorders based on a medical diagnosis, and identify workers' strategies to manage pain.

METHOD

This cross-sectional study addressed 338 health professionals working in PHC outpatient services in the extreme South of Brazil. One questionnaire addressed sociodemographic questions concerning occupation, occupational risks, and mental disorders. The Nordic Musculoskeletal Questionnaire was used to assess self-reported musculoskeletal pain. The National Aeronautics and Space Administration Task Load Index (NASA-TLX) measured the workload. A descriptive and inferential analysis was performed using SPSS version 21.0.

RESULTS

Most (55.3%) participants reported neck and (64.5%) lower back pain in the previous 12 months, and 22.5% and 30.5% reported intense neck and lower back pain, respectively, in the previous 12 months. The results showed different independent associations with increased musculoskeletal pain among health workers. Dentists presented the highest prevalence of neck pain, while female workers presented the highest prevalence of lower back pain. Furthermore, the perception of ergonomic risk and virtually all self-reported mental disorders (except panic syndrome for neck pain) were associated with pain in the neck and lower back regions and a higher frustration level (mental demand). Additionally, professionals with graduate degrees, nurses, and professionals working the longest in PHC services reported seeking complementary therapies more frequently, while physicians and those with self-reported mental disorders self-medicated more frequently.

Use of medicinal plants by individuals diagnosed with mental illness: A qualitative study

WHAT IS KNOWN ON THE SUBJECT?: Medicinal plants are a part of everyday life. Medicinal plants have many effects on the lives of individuals diagnosed with mental illness. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Since there is no qualitative study in which individuals diagnosed with mental illness provided a detailed explanation of their views about the use of medicinal plants, this study will fill a gap in the literature and guide mental health nurses. This study provides information for mental health nurses about how individuals diagnosed with mental illness evaluate medicinal plants, what it means to them and the effects of medicinal plants. It provides ideas about the use of medicinal plants as a tool to protect and improve mental health. In addition, since the majority of the studies on mental illnesses and medicinal plants are quantitative studies, it was thought that this study was different from the seminal studies in the literature and could offer new ideas for future studies. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The results of this study show mental health nurses that the positive aspects of medicinal plants can be used to maintain and improve the mental health of individuals diagnosed with mental illness. Mental health nurses should evaluate the treatment and maintenance process in detail, considering that medicinal plants may interact with drug treatment or the risks of using medicinal plants in terms of adverse effects. Moreover, mental health nurses should fight against the negative aspects of medicinal plants. Mental health nurses and individuals diagnosed with mental illness should be made aware of the use of medicinal plants.

ABSTRACT

AIM: There was no qualitative study found in which individuals diagnosed with mental illness explained their views in detail about the use of medicinal plants. It is therefore thought that this study will fill this gap in the literature and guide mental health nurses in the field. The research was carried out to determine the use of medicinal plants by individuals diagnosed with mental illness.

METHOD

This research was a qualitative study conducted using the case study design. Ten individuals diagnosed with mental illness for at least 10 years, determined by the purposeful sampling method were interviewed. The data were collected between March and April 2022 with information form and semi-structured interview form and analysed with the content analysis method.

FINDINGS

Four of the participants had depression, four had anxiety and two had mood disorders. Themes were determined to be a source of healing (ointment for the soul, body tonic and organic and nature's miracles) and cultural accumulation (faith and inheritance, counselling helpline).

CONCLUSION

Participants described medicinal plants as a source of healing, stating that medicinal plants are good for bodily and mental health and provide purification. Individuals stated that the information about medicinal plants represents cultural accumulation as an inheritance, they applied them as a counselling helpline in case of illness.

IMPLICATIONS FOR PRACTICE

The positive effects of medicinal plant use can be supported by mental health nurses. Considering that medicinal plants may interact with the drug treatment, the use of medicinal plants should be evaluated in detail by mental health nurses.

Educational courses on non-pharmacologic complementary interventions for nurses across Europe: The INES mapping pilot study

BACKGROUND

Pharmacological interventions still form the mainstay of the management of pain, anxiety, sleep problems and discomfort. In Europe, an estimated 100 million people use complementary non-pharmacological interventions (NPIs) for these conditions. In their pre-registration education, nurses do not generally learn about the various types of NPIs and how patients and health care professionals can include NPIs complementary to their standard care. Some nursing schools in Europe offer elective courses on NPIs, often relying on individual initiatives. Little is publicly available about the content of these programmes and how they relate to the current nursing curriculum for EU countries.

OBJECTIVES

This pilot study aims to explore and map the field of nursing education with regard to complementary NPIs for nurses in Europe.

DESIGN

A web-based open-access questionnaire administered through the online survey tool LimeSurvey® was designed by the authors.

PARTICIPANTS

The questionnaire was sent to a purposive sample of 49 experts on nurse education and complementary NPIs from 16 European countries. All levels of education were eligible for inclusion.

METHODS

The questionnaire consisted of 35 items regarding course content, teaching material, teaching methods and methods of assessment. In addition, respondents were invited to perform a strengths, weaknesses, opportunities and threats (SWOT) analysis in relation to their education programme. Qualitative data was analyzed using a directive content analysis approach.

RESULTS

Between January and May 2020, thirty-one completed questionnaires from ten different countries were returned (response rate 63.3%). Massage, meditation, mindfulness and relaxation are the most taught interventions. Anxiety, stress, chronic pain, depression and sleep problems are the most common symptoms addressed.

CONCLUSIONS

Currently, a consistent and European approach to education for nurses on complementary NPIs and integrative nursing is lacking. Although taught at regular nursing educational institutes, the courses discussed here are not yet embedded in mainstream education for nurses.

Translating Planetary Health Principles Into Sustainable Primary Care Services

Global anthropogenic environmental degradations such as climate change are increasingly recognized as critical public health issues, on which human beings should urgently act in order to preserve sustainable conditions of living on Earth. "Planetary Health" is a breakthrough concept and emerging research field based on the recognition of the interdependent relationships between living organisms-both human and non-human-and their ecosystems. In that regards, there have been numerous calls by healthcare professionals for a greater recognition and adoption of Planetary Health perspective. At the same time, current Western healthcare systems are facing their limits when it comes to providing affordable, equitable and sustainable healthcare services. Furthermore, while hospital-centrism remains the dominant model of Western health systems, primary care and public health continue to be largely undervalued by policy makers. While healthcare services will have to adapt to the sanitary impacts of environmental degradations, they should also ambition to accompany and accelerate the societal transformations required to re-inscribe the functioning of human societies within planetary boundaries. The entire health system requires profound transformations to achieve this, with obviously a key role for public health. But we argue that the first line of care represented by primary care might also have an important role to play, with its holistic, interdisciplinary, and longitudinal approach to patients, strongly grounded in their living environments and communities. This will require however to redefine the roles, activities and organization of primary care actors to better integrate socio-environmental determinants of health, strengthen interprofessional collaborations, including non-medical collaborations and more generally develop new, environmentally-centered models of care. Furthermore, a planetary health perspective translated in primary care will require the strengthening of synergies between institutions and actors in the field of health and sustainability.

Beyond the Standard of Care: An Exploratory Qualitative Study of an Implemented Integrative Therapeutic Care Program in a Brazilian Pediatric Oncology Unit

Introduction: This article examines the feedback of health care providers within the implementation of an integrative care project in a clinic for pediatric oncology in São Paulo, Brazil. Since 2017, the project has implemented external anthroposophic therapies in the activities of daily nursing. The objective is to evaluate how the project evolved and what impact it had on the daily operation of the hospital. A special focus emphasizes the perspective of study nurses. Materials and Methods: Twelve qualitative semistructured interviews were conducted. Audio files were transcribed, translated to German, and underwent a MAXQDA software-assisted analysis. Using a thematic approach, coherent cross-case topics were defined. Results: Three main topics emerged from analysis of the data. (1) The implementation and its effects on daily patient care demonstrated positive outcomes in patients and were well accepted with minimal changes in daily activities. (2) The perspective of study nurses showed a large motivation due to beneficial and stress-relieving effects of the application and a growing patient-health care provider relationship. (3) Problems and aspirations for improvement were the lack of time and the urge to make the project grow in the future. Conclusion: Not only patients but also health care providers seem to benefit from integrative methods. They have the potential to improve the working atmosphere and to strengthen relations between patients, caregivers, and family members. General feedback was positive and acceptance in the team arose over time when beneficial effects became visible.

Evaluating Systemized Nomenclature of Medicine Clinical Terms Coverage of Complementary and Integrative Health Therapy Approaches Used Within Integrative Nursing, Health, and Medicine

The use of complementary and integrative health therapy strategies for a wide variety of health conditions is increasing and is rapidly becoming mainstream. However, little is known about how or if complementary and integrative health therapies are represented in the EHR. Standardized terminologies provide an organizing structure for health information that enable EHR representation and support shareable and comparable data; which may contribute to increased understanding of which therapies are being used for whom and for what purposes. Use of standardized terminologies is recommended for interoperable clinical data to support sharable, comparable data to enable the use of complementary and integrative health therapies and to enable research on outcomes. In this study, complementary and integrative health therapy terms were extracted from multiple sources and organized using the National Center for Complementary and Integrative Health and former National Center for Complementary and Alternative Medicine classification structures. A total of 1209 complementary and integrative health therapy terms were extracted. After removing duplicates, the final term list was generated via expert consensus. The final list included 578 terms, and these terms were mapped to Systemized Nomenclature of Medicine Clinical Terms. Of the 578, approximately half (48.1%) were found within Systemized Nomenclature of Medicine Clinical Terms. Levels of specificity of terms differed between National Center for Complementary and Integrative Health and National Center for Complementary and Alternative Medicine classification structures and Systemized Nomenclature of Medicine Clinical Terms. Future studies should focus on the terms not mapped to Systemized Nomenclature of Medicine Clinical Terms (51.9%), to formally submit terms for inclusion in Systemized Nomenclature of Medicine Clinical Terms, toward leveraging the data generated by use of these terms to determine associations among treatments and outcomes.

Write It Out! CPR for the Soul

Many nurses, although expert caregivers for their patients, often overlook extending this expertise to themselves by neglecting to implement self-care activities to nurture their own well-being. This neglect can precipitate a myriad of physical, mental, emotional, spiritual, and social consequences potentially leading to burnout or even an exit from the nursing profession. Initiating self-care using compassionate purposeful reflection (CPR) journaling, a kind of cardiopulmonary resuscitation for the soul, offers an antidote for self-care neglect and can foster self-compassion creating a protective shield against burnout. CPR journaling can aid in replenishing depleted stores of resilience and compassion enhancing nurses' well-being.

Effects of a mindfulness-based programme on the health- and work-related quality of life of healthcare professionals

BACKGROUND AND OBJECTIVES

The objective of mindfulness-based stress reduction (MBSR) programmes is to promote awareness of the present moment without judging, evaluating or reacting to the different thoughts or emotions that may arise. Development of these abilities appears especially important for healthcare professionals. The objective of this study was to evaluate the effectiveness and medium- and long-term effects of a MBSR programme for primary care (PC) health professionals on their health-related quality of life and quality of work life.

DESIGN

Randomised clinical trial using an intervention and control group with follow-up of the experimental group.

SETTING

Primary Care centres in the Alicante Public Health Service (Spain).

PARTICIPANTS

Participants were PC health professionals (N = 58) divided between an intervention group receiving the 8-week MBSR programme and a control group receiving a theoretical training session alone.

METHOD

Both groups were evaluated at baseline and at 8 weeks, and the intervention group was additionally evaluated at 3-, 6-, 9- and 12-month postprogramme.

RESULTS

In comparison to the control group, the intervention group obtained higher scores postintervention for mindfulness, health-related quality of life, mood and compassion satisfaction and a lower score for burnout. Improvements in mindfulness, mood and burnout syndrome persisted at 12 months after the programme.

CONCLUSIONS

In conclusion, MBSR is an effective intervention to enhance the health-related quality of life and quality of work life of Primary Care Health professionals.

To Identify and Support Youths Who Struggle with Living-Nurses' Suicide Prevention in Psychiatric Outpatient Care

Nurses working in psychiatric care daily encounter youths who are struggling with living. Despite this, nurses' suicide-prevention work is seldom addressed in research or in recommendations for care. The overall aim of this paper is to discuss how nurses, with their caring science perspective, may contribute to suicide prevention. The paper presents how nurses in psychiatric outpatient care may identify and support suicidal youths, according to experts in suicide prevention. The interviews with six experts in suicide prevention resulted in three themes: Engagement necessary but demanding, Acknowledgement of warnings signs and Supportive relationship. The respondents elaborated on how suicide-risk can be assessed. A good rapport with the youths was stressed and the recommended act of care included: to listen openheartedly without interrupting as well as to listen after risk- and protective factors to emphasize or to penetrate. To ask about suicidality as well as to let the person elaborate on what's important for him or her. To endure in the patients' suffering as well as steering the conversations toward hope. The paper also presents warning signs that need to be noticed according to the experts and the literature consensus. Our findings suggest that communication in suicide-prevention is an "art and act" that cannot be reduced to a method or simple guidelines. We argue that the recommended acts of care demand sensitivity and skills and that nurses as well as the domain of caring science may contribute to this competence.

What’s in a Definition?Holistic Nursing, Integrative Health Care, andIntegrative Nursing: Report of an Integrated Literature Review

Background: Nurses and others have used various terms to describe our caring/healing approach to practice. Because terms used can influence our image of ourselves and the image others have of us, we sought to clarify their meanings. Questions: How are the terms holistic nursing, integrative health care, and integrative nursing defined or described? Do we identify with these definitions/descriptions? Are the various terms the same or are they distinct? Method: We conducted an integrated review of peer-reviewed literature following the process described by Whittemore and Knafl. Using standard search methods, we reviewed full texts of 94 published papers and extracted data from 58 articles. Findings: Holistic describes “whole person care” often acknowledging body–mind–spirit. Holistic nursing defines a disciplinary practice specialty. The term integrative refers to practice that includes two or more disciplines or distinct approaches to care. Both terms, integrative and holistic, are associated with alternative/complementary modalities and have similar philosophical and/or theoretical underpinnings. Conclusions: There is considerable overlap between holistic nursing and integrative nursing. The relationship of integrative nursing to integrative health care is unclear based solely on definitions. Consideration of terms used provides opportunities for reflection, collaboration, and growth.

Advancing Well-Being and Health of Elderly with Integrative Nursing Principles

There is a need for holistic care for the survival of the elderly, to increase their independence in their daily life activities, to improve their health and their well-being in order to ensure a healthy aging. Integrative nursing principles are a field of application of holistic philosophy and may be a guide to health professionals in improving the health of individuals, families and communities. These principles were first announced in 2014, and have been described as a health approach that takes the individual, family and society as a whole together with their environment and relationships and adopts the principle of using all the healing methods in health care. Integrative nursing principles can be used as a guide to holistic assessment and improvement of the health of the elderly. Interventions who take care of them with the environment they live in (home visits), support their existing healing process (focusing to patient during nursing care), benefit from the healing effect of the nature (spending time in nature), strengthen the relationship (mobilization of the social environment) and use all evidence-based healing methods (yoga, tai chi) should be included in the care of elderly individuals. Health professionals should learn integrative nursing principles and care for these principles in order to improve the health and well-being of the elderly. Giving care according to integrative nursing principles can increase the quality of life of the elderly and reduce health spending.

Attitudes Among Nurses Toward the Integration of Complementary Medicine Into Supportive Cancer Care

PURPOSE/OBJECTIVES

To explore the attitudes of nurses treating patients with cancer regarding the use of complementary and integrative medicine (CIM) therapies to reduce symptoms and improve quality of life (QOL). 
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DESIGN

Prospective and descriptive.
 
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SETTING

12 hospital and community care settings in Israel. 
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SAMPLE

973 nurses working in oncology and non-oncology departments.
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METHODS

A 26-item questionnaire was administered to a convenience sample of nurses treating patients with cancer. 
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MAIN RESEARCH VARIABLES

Interest in CIM integration and training in supportive cancer care.
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FINDINGS

Of the 973 nurses who completed the questionnaire, 934 expressed interest in integrating CIM into supportive cancer care. A logistic regression model indicated that nurses with a greater interest in integration tended to be older, believed that CIM improved patients' QOL, and had no structured postgraduate oncology training. Nurses who believed CIM to be beneficial for QOL-related outcomes were more likely to express interest in related training. The goals of such training include improving QOL-related outcomes, such as anxiety, insomnia, gastrointestinal symptoms, and pain. 
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CONCLUSIONS

Most nurses working with patients with cancer are interested in the integration of CIM into supportive cancer care. 
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IMPLICATIONS FOR NURSING

Most nurses would like to undergo training in CIM to supplement conventional care. CIM-trained integrative nurses can help promote the integration of patient-centered CIM therapies in supportive cancer care settings.

Shinrin-Yoku (Forest Bathing) and Nature Therapy: A State-of-the-Art Review

Background: Current literature supports the comprehensive health benefits of exposure to nature and green environments on human systems. The aim of this state-of-the-art review is to elucidate empirical research conducted on the physiological and psychological effects of Shinrin-Yoku (or Forest Bathing) in transcontinental Japan and China. Furthermore, we aim to encourage healthcare professionals to conduct longitudinal research in Western cultures regarding the clinically therapeutic effects of Shinrin-Yoku and, for healthcare providers/students to consider practicing Shinrin-Yoku to decrease undue stress and potential burnout. Methods: A thorough review was conducted to identify research published with an initial open date range and then narrowing the collection to include papers published from 2007 to 2017. Electronic databases (PubMed, PubMed Central, CINAHL, PsycINFO and Scopus) and snowball references were used to cull papers that evaluated the use of Shinrin-Yoku for various populations in diverse settings. Results: From the 127 papers initially culled using the Boolean phrases: “Shinrin-yoku” AND/OR “forest bathing” AND/OR “nature therapy”, 64 studies met the inclusion criteria and were included in this summary review and then divided into “physiological,” “psychological,” “sensory metrics” and “frameworks” sub-groups. Conclusions: Human health benefits associated with the immersion in nature continue to be currently researched. Longitudinal research, conducted worldwide, is needed to produce new evidence of the relationships associated with Shinrin-Yoku and clinical therapeutic effects. Nature therapy as a health-promotion method and potential universal health model is implicated for the reduction of reported modern-day “stress-state” and “technostress.”.

Addressing holistic healthcare needs of oncology patients: Implementation and evaluation of a complementary and alternative medicine (CAM) course within an elective module designed for healthcare professionals

BACKGROUND

Patients, and especially oncology patients, increasingly demand information and application of complementary therapies to supplement their conventional medical treatment and follow-up care. Due to the widespread interest in holistic treatment opportunities in oncology populations, healthcare professionals need to be prepared in differentiating evidence-based methods of the complementary and alternative medicine (CAM) spectrum and how to consult with patients about it.

OBJECTIVE

This paper reports on the implementation and evaluation of a newly designed module "Complementary and Alternative Medicine in oncological healthcare" in the bachelor degree program Interprofessional Health Care (B.Sc.).

DESIGN

The study applied a developed evaluation questionnaire to capture students' perspectives on the CAM contents. This assessment instrument was administered pre and post the CAM teaching unit.

SETTING

Interprofessional medical education, University Hospital Heidelberg, Germany.

RESULTS

The integration of the CAM elective module was possible and was met by positive response. Students' interest was reflected in an increase of their self-reported knowledge gain and positive CAM attitude. Comparison of pre and post evaluation data demonstrate that, particularly, students' expectations on developing their own opinion about CAM, and getting an overview of the evidence-base of different CAM methods have been met.

CONCLUSIONS

Evaluation results indicate that the module content was in line with the students' expectations and may have positively impacted on their general CAM attitude. The results support us in continuing to offer this CAM course within the elective module to prepare today's healthcare professionals for patient-oriented healthcare delivery.

Curricular Inclusion of Complementary and Alternative Medicine Content in Occupational Therapy Education in the United States

An exploratory, cross-sectional survey design was used to explore the extent to which CAM was included, what factors impacted its inclusion, topics and student learning outcomes covered, who taught the material, and what sources were used to prepare for delivering course content. While the vast majority of responding occupational therapy educators reported curricular inclusion of CAM, educational experiences for occupational therapy students varied widely. This overview of the curricular inclusion of CAM by faculty in occupational therapy programs in the United States indicated that many occupational therapy educators are responding to the demands of a more integrative healthcare system. Resolving ethical and pragmatic issues, providing faculty development opportunities, and standardizing student learning outcomes would align all stakeholders and mitigate ambiguities that currently exist surrounding the inclusion of CAM in occupational therapy education.

Integrative Nursing Principles in Action: A Summary From the First International Integrative Nursing Symposium

The first International Integrative Nursing Symposium was held in May 2015 in Reykjavík, Iceland, to foster discourse about providing whole person/whole systems care that is relationship-based and person-centered. A discussant format was used to ensure that symposium participants could fully operationalize the principles of integrative nursing in practice, research, education, and policy development. Sessions varied widely to communicate the full spectrum of nursing scholarship with participants envisioning a future when all nursing care is integrative.