Participation in a randomised controlled feasibility study of a complex intervention for the management of the Respiratory Symptom Distress Cluster in lung cancer: patient, carer and research staff views.

This paper reports finding from a nested qualitative study designed to elicit the views and perceptions of those who participated in a randomised controlled feasibility trial testing a non-pharmacological intervention, Respiratory Distress Symptom Intervention (RDSI), for the management of the breathlessness-cough-fatigue symptom cluster in lung cancer. Semi-structured interviews were conducted with 11 lung cancer patients, three caregivers and seven researchers involved in recruitment, consent, RDSI training and delivery and participant follow-up. Thematic analysis identified key considerations including: the importance of informed consent emphasising commitment to completion of paperwork and raising awareness of potential sensitivities relating to content of questionnaires; ensuring screening for the presence of symptoms reflects the language used by patients; appreciation of the commitment required from participants to learn intervention techniques and embed them as part of everyday life; conduct of interviews with patients who decline to participate; and conduct of serial interviews with those receiving RDSI to further inform its routine implementation into clinical practice. This study will inform the development of a fully powered follow-on trial testing the hypothesis that RDSI plus usual care is superior to usual care alone in the effective management of this symptom cluster in lung cancer.

Providing acupuncture in a breast cancer and fatigue trial: The therapists' experience.

OBJECTIVE: To explore the experiences of therapists providing acupuncture in a trial context, to women with fatigue, following breast cancer treatment. METHODS: The focus groups were nested within a multi-site randomised control trial. Therapists (n = 15) involved in the trial were invited to participate in one of the focus groups, which took place in the north and south of England. The treatment protocol imposed constraints on dialogue to essential procedural conversation and stipulated needling times of 20 min. RESULTS: All 15 therapists (100%) participated. Whilst they reported learning more about fatigue and cancer, adhering to the trial protocol limited the holistic nature of their practice. Seeing improvements, despite the protocol, made some therapists question their practice, in terms of needling times and limiting dialogue. CONCLUSIONS: The study provided information about the therapists' perspective of working within a trial. This could have implications for providing acupuncture treatments more cost effectively and timely within clinical practice.

A randomized, controlled trial of acupuncture self-needling as maintenance therapy for cancer-related fatigue after therapist-delivered acupuncture.

BACKGROUND: Maintenance acupuncture is advocated by clinicians after successful clinic-based acupuncture. We aimed to assess the effectiveness of maintenance acupuncture in the management of cancer-related fatigue (CRF); treatment delivered by therapists or self-acupuncture/self-needling was compared with no maintenance treatment. METHODS: Breast cancer patients who participated in a randomized trial of acupuncture for CRF management (reported elsewhere) were re-randomized to receive an additional four acupuncturist-delivered weekly sessions; four self-administered weekly acupuncture sessions (self-needling); or no acupuncture. Primary outcome was general fatigue (Multidimensional Fatigue Inventory). Mood, quality of life and safety were also assessed. RESULTS: In total, 197 patients were re-randomized, with 65 to therapist-delivered sessions, 67 to self-acupuncture/self-needling and 65 to no further acupuncture. Primary outcome scores were equivalent between the therapist-delivered acupuncture and self-acupuncture (P > 0.05). A non-significant trend in improving fatigue was observed at the end of 4 weeks in the combined acupuncture arms (P = 0.07). There was no impact on mood or quality of life of the further acupuncture sessions at 18 weeks beyond the improvement observed in initial trial. CONCLUSION: Self-acupuncture is an acceptable, feasible and safe maintenance treatment for patients with CRF. However, overall, maintenance acupuncture did not yield important improvements beyond those observed after an initial clinic-based course of acupuncture. TRIAL REGISTRATION NUMBER: NCT00957112.

Subsidized complementary therapies for staff and volunteers at a regional cancer centre: a formative study.

In the United Kingdom, the Government has acknowledged workplace stress and burnout in the National Health Service by establishing Improving Working Lives Standards, which recognize the need for a range of support mechanisms. Staff in oncology hospitals experience considerable stress because of the emotional intensity of work that involves limited clinical success, sustained contact with seriously ill/dying people, and serial bereavement. Evidence suggests that providing complementary therapies at work can help to reduce anxiety, depression and blood pressure and, thus, increase well-being. We used a purpose-designed questionnaire to assess awareness of, access to and the value placed on a complementary therapy service for staff and volunteers at a regional cancer centre. Free-text data from 167 completed questionnaires, subjected to qualitative analysis, revealed an overwhelmingly positive view of the service, but concerns about access. The service appeared to be a victim of its own success in that it could not meet demand within its existing resources and, thus, meet its potential for improving working lives; limits to resources also affected the conduct and rigour of our evaluation. We conclude by discussing the impact of the evidence-based practice culture on levels of funding for complementary therapy services operating in hospital settings.

'Reflexology techniques are not an effective tool for symptom recognition or the diagnosis of medical conditions'.

We are pleased to introduce a new series of debates addressing topical issues currently under scrutiny in the field of complementary medicine. In selected issues, two people are invited to argue the case for or against a specific statement. In certain instances the position taken may not necessarily reflect the personal views of the authors. They have been asked to take a specific stance in order to stimulate debate and reflection about particular aspects of complementary and alternative medicine (CAM).

Reflexology: recent research approaches.

The intention of this paper is to examine recent published research in the field of reflexology and healthcare and consider the way forward for research work in reflexology. It will explore the various research approaches and methods, which have and could be used in answering questions about reflexology practice and outcomes for patients. The recommendations of the Foundation for Integrated Medicine Report (FIM 1997) with regard to conducting research and audit will be included in the paper. These are proposed here as a framework for both reviewing past studies and as guidance for future reflexology investigations. The authors themselves have conducted small reflexology studies and they will reflect on their experiences in analysing the research process. This paper does not aim to give a concise review of the literature to date but uses examples of recently published work to illustrate the issues that might confront researchers.

A concept analysis: the effect of reflexology on homeostasis to establish and maintain lactation.

The focus of this paper is to consider whether reflexology can have an effect on homeostasis to establish and maintain lactation. This complementary therapy encompasses the theory of holism to nurture the whole body, mind and spirit (Crane 1997). Parents experience many stressful emotions when their baby is admitted to a neonatal intensive care unit (NICU), which in turn can affect the body, mind and spirit, often contributing to the reduction of lactation for the mother. This paper will utilize a concept analysis approach (Chinn & Jacobs 1987) to provide a focus and sense of direction to the discussion and exploration of the topic.

Tough places to be tender: contracting for happy or 'good enough' endings in therapeutic massage/bodywork?

Listening to others has inspired this paper, as they share their experience and analyze their practice, and in the process uncover what is quintessential to therapeutic work. Of course, stories and insights can illuminate our own reflections and in turn deepen our understanding of what it means to be a nurse and massage therapist. They can also challenge what we think to be truths and sacred cows. This paper is about how confusion can be our best teacher when we seek to understand notions of contact and engagement in therapeutic work. When a patient says 'yes' to massage/bodywork what do they expect? Perhaps the massage will ease backache or leave them feeling profoundly relaxed; or could it be that the human contact is the most important need, but that need may be harder to express or even acknowledge? In examining the issues raised by this paper the author proposes a 'structural, emotional and energetic' (SEE) model for massage/bodywork contracts, and recommends that therapists seek supervision and support for their work.

'Just the ticket': case studies, reflections and clinical supervision (Part III).

An earlier paper in this series of three has detailed the background development and organization of a pilot complementary therapy service. The setting was a neuroscience ward with existing staff carrying out the treatments. Outcome measures including physiological indices and patient feedback were reported on in Part II (Dryden et al. 1999). This paper will now focus on both the records of the practitioner's reflections and the recurring themes of their monthly clinical supervision sessions. Subgroups of four patients with Guillain-Barre Syndrome (GBS) are discussed in detail, as they received the most number of treatments between them.

'Just the ticket': the findings of a pilot complementary therapy service (Part II).

In part I of this series of articles (Dryden et al. 1998) the authors detailed the background to a project offering hand and foot massage incorporating reflexology techniques. The following paper reports back on the findings and evaluation. Over a 4-month period a total of 61 recorded treatments were given to 18 in-patients. Each session was to last approximately 30 minutes and included recordings of physiological data as well as pre- and post comments from the patient. The six practitioners, who were already working within the ward setting in various capacities, were asked to record reflective comments after each treatment. This paper will conclude by discussing future recommendations. Part III of this series (CTNM 5: 2, 1999) will focus on a subgroup of patients within the study highlighting the experiences of both practitioners and patients.

An introduction to catharsis and the healing crisis in reflexology.

This paper explores the concept of healing through catharsis in relation to the practice of reflexology. The literature will be reviewed to inform a critical analysis of the role of the reflexologist and specifically the therapeutic relationship. This area was chosen as I have had experiences of reflexology clients reporting feeling 'emotional', 'being tearful', and 'thinking more about their lives' past and present'. These observations have been illuminated by a recent study that suggests reflexology can be helpful for people with emotional needs (Trousdall 1997). Emotional and physical responses to reflexology are traditionally attributed to 'detoxification' and the signs of it occurring known as a 'healing crisis' (Sahai 1993, Griffiths 1995). Consideration will be given to the practitioner's skills and support, issues of boundaries to practice, and the effective management of patient's emotional and physical responses. The safety and potency of the therapeutic work will be key elements to the discussions.

'Just the ticket': integrating massage and reflexology in practice (Part I).

The purpose of these papers is to describe and discuss the piloting and evaluation of an inpatient complementary therapy service. This was a single site case study without a control group and involving practitioners themselves collecting data, recording reflections on their own practice and engaging in monthly clinical supervision sessions. The service was aimed at providing treatments of hand and foot massage incorporating reflexology techniques for a total of 18 patients. In part 2 of this paper, an evaluation of the project will be presented including the findings of this pilot service from the perspective of both the patients and practitioners, and the analysis of some of the physiological data collected. Part 3 will focus on a subgroup of the patient cohort to illuminate the experience from both patient and practitioner perspective.

Therapeutic touch: nursing activity or form of spiritual healing?

There is a major movement in nursing which is exploring the part that a wide range of complementary therapies can play in expanding the therapeutic role of the nurse. Courses have been developed that will enable nurses to apply these skills to their daily practice (Faltermeyer 1995). Therapeutic Touch (TT) is being advocated as one such therapy, primarily developed and researched by nurses for nurses (Sayre-Adams & Wright 1995). Early writings and thinking on TT speak of origins in the ancient practice of the 'laying on of hands'; the purpose of which was and is to 'heal or encourage healing in a sick person' (Krieger 1979). Its application in practice can be helped or hindered by this statement since this might be interpreted as spiritual healing, a term which can be confusing, open to misinterpretation and can spark controversy.

Clinical supervision for 'potent' practice.

The author has received regular supervision since completing his training in biodynamic massage therapy. This is a requirement of the Code of Conduct for the Association of Holistic Biodynamic Massage Therapists. Initially, this proved difficult to arrange as supervisors familiar with this form of bodywork were based either in London or Cambridge, UK and the author has been living and working in the North West of England. One-to-one supervision was tried over the telephone, supported by 3-monthly meetings with a supervisor in London. Four years ago, the author was able to obtain monthly one-to-one supervision locally. He is now a member of a small supervision group who meet for 3 hours per month. More recently, he has taken on the role of supervisor with a focus on working with nurses involved in either complementary therapies and/or in developing clinical supervision. The following article explores the concept of supervision with the intention of sharing these experiences and promoting discussion on an understanding of the process and potential application within therapeutic nursing work.

HIV and homophobia: nurses as advocates.

Nurses are frequently encouraged in colleges of nursing and professional journals to consider themselves as ideally placed to act as advocates for vulnerable patients. This paper sets out to challenge this assumption in the light of the stigma and discrimination experienced by people affected by HIV and AIDS. Sexuality and in particular homophobia--the fear and aversion of gay and lesbian behaviour--need to be addressed by the nursing profession. The paper considers concerns about and evidence of discrimination in the light of nurses' claim to be best placed to adopt the role of advocate in representing any patient's health care needs. It is argued that such an assumption is problematical in the face of homophobia and fears around contagion.