17 (Part II) Aromatherapy within the National Health Service
Part 2 shows how the use of aromatherapy is now being integrated into clinical settings and how codes of professional conduct for nurses can also be applied to aromatherapists. It gives guidelines for administering medicines and outlines how to write a policy, followed by a draft example of a protocol, which aromatherapists will find useful.
Many healthcare professionals are interested in exploring the potential therapeutic use of a range of complementary therapies, which are maintaining their popularity with the public (Thomas, Nicholl & Coleman 2001).
This continued interest has encouraged the use of CAM therapies in palliative care (Gage et al. 2009), midwifery (Mousley 2005) and nursing (Maddock-Jennings & Wilkinson (2004).
Aromatherapy is a multiple therapy embracing touch, massage and the administration of essential oil remedies – not to mention the accompanying pleasing aroma, which may be partly responsible for its being possibly the most popular complementary therapy nurses wish to study. There have therefore been increasing demands that, in the best interests and safety of patients and clients, complementary therapies should become regulated and observe similar ethical and practical constraints to those of orthodox medicine.
The House of Lords Report (2000) classified therapies according to their evidence base and level of professional organization in relation to regulation (see Part 1 and Table 17.1). with regard to nursing and midwifery, the report identified Group 2 as covering those therapies most often used to complement conventional care. It was felt that the therapies mentioned in this ‘comfort’ category gave appropriate help and support to patients, in particular in relieving stress and pain and alleviating the side effects of drug regimens.
Although there was concern about the lack of scientific evidence – as measured by random controlled trials (RCTs) – the report recognized that there was a growing body of qualitative research. The therapies most frequently used by nurses and midwives, such as massage, aromatherapy and reflexology, come within the ‘comfort’ category. The RCN survey in 2003 confirmed that these were the key therapies used in clinical practice.
The House of Lords report also encouraged the regulating and professional bodies – Nursing and Midwifery Council (NMC) and Royal College of Nursing (RCN) – to collaborate in making familiarization of CAM a part of the pre-registration nursing and midwifery curricula, which would enable nurses and midwives to have some insight into the choices that their patients or clients make and to offer knowledgeable support. The report went on to suggest that these bodies should provide specific guidance on appropriate education and training for nurses and midwives who wish to integrate therapies such as aromatherapy into clinical care.
Integration of aromatherapy is currently threatened on several fronts, involving regulation, financial constraints for both education and the NHS and academic hostility. The regulation process for aromatherapy has stalled because a number of professional bodies have chosen not to align themselves with the newly launched federal regulation body, supported by the Department of Health, the Complementary and Natural Healthcare Council. This will cause problems for nurses and other healthcare professionals who wish to advance the use of aromatherapy, as their employers will expect them to be members of a rigorous and transparent system – still having several ‘regulation’ bodies is confusing for NHS Trusts and the general public alike (Stone 2010).
The recession has meant that financial constraints on universities have seen many courses facing closure as priorities shift. Within the NHS financial cuts have meant that nurses have even less time to attend to their patients’ comfort and emotional needs – an area in which the use of massage and essential oils had demonstrated good possibilities (Hadfield 2001).
Successful regulation depends on increasing the research base of a profession, but recent academic hostility from science faculties has resulted in the closure of many leading complementary therapy degree courses, including degrees or diplomas leading to aromatherapy qualifications, e.g. those at the Universities of Westminster and Central Lancashire. With a diminishing research base, complementary therapies, including aromatherapy, will be less able to maintain the confidence of the public and orthodox healthcare.
There are key principles of professional practice that must be considered before integrating any complementary therapy into clinical care. These involve the following and can be found in policies that have already been developed:
• patient-centred care – identifying patients’ needs or problems and the subsequent outcome of care
• appropriate choice of therapeutic intervention
• identification of the parameters of practice
• pinpointing the evidence supporting integration
• identification of the appropriate integration model
• ensuring education and training needs that will provide safe and effective practice
• the development of effective evaluation strategies and ongoing development needs that will support a sustainable service.
A policy for integration, based on evidence and a valid audit process (Mousley 2005), is essential, otherwise it is difficult to see how nurses and midwives can argue for integrating CAM into clinical practice, especially as therapies are often used as a result of enthusiasm on the part of one or two nurses or midwives. A number of Trusts have already allocated time and effort to developing policies, and it is by such work that standards are defined and patients are assured of care that is safe, appropriate and effective. The appropriate therapy is often determined by the nature of a particular clinical area. The area of cancer and palliative care is one in which national guidelines on the integration of complementary therapies have been published by the Foundation for Integrated Health (PWFIH 2003) (Tavares 2003) and offer a wealth of information, including models of good practice.
As there is no national strategy to collect data, professionals have to rely on publications in journals that describe the use of complementary therapies within the various health fields. A small proportion of these are based on research projects, but most are anecdotal.
Registered nurses, midwives and health visitors have to follow the NMC Code of Professional Conduct (CPC) (2008a), the Standards for Medicines Management (2008b) and Complementary Alternative Therapies and Homoeopathy (2009) and are personally accountable for their practice. Some of the following points would also be applicable to aromatherapy practitioners; all must:
• respect the patient or client as an individual
• obtain consent before giving any treatment or care
• protect confidential information
• cooperate with others in the team
• act to identify and minimize risk to patients and clients.
Aromatherapists and nurses should acknowledge any limitations in their knowledge and competence and decline duties or responsibilities they cannot perform in a safe and skilled manner. Suitable insurance to cover specific use of essential oils is essential. RCN members are covered when working as a nurse; however, when working independently cover can be obtained from one of the professional aromatherapy or aromatic medicine associations on becoming a full member. The International Federation of Professional Aromatherapists (IFPA) and the Institute of Aromatic Medicine (IAM) also insure student aromatherapists during their time of study.
Complementary therapists and nurses should regularly update their knowledge – of paramount importance in a world where ideas and accepted behavioural patterns are changing fast.
Nurses, midwives and health visitors using essential oils, whether for baths, inhalations, topical application (including compresses), suppositories, pessaries and/or massage, should accept that they are administering medicines, and recognize the personal professional accountability they bear for their actions.
Since 1992 medicinal preparations have been prescribed by a physician or nurse, checked and dispensed by a pharmacist and administered by a nurse. An essential oil prescription is prescribed by a competent aromatherapist or aromatologist and administered by that practitioner, or by a nurse suitably trained in its method of administration.
• be based, whenever possible, on the patient’s informed consent and awareness of the purpose of the treatment
• be clearly written, typed or computer-generated and be indelible
• be dated and signed by the authorized prescriber
• not be for a substance to which the patient is known to be allergic or otherwise unable to tolerate
• clearly identify the patient for whom the medication is intended
• clearly specify the substance to be administered, using the generic or brand name (in the case of aromatherapy the scientific plant name/s should be used), together with the strength, dosage, timing, frequency of administration, start and finish dates and route of administration.
Work supporting the regulation of therapies such as aromatherapy, massage and reflexology is presently under way (see Education in Part 1, above), and each healthcare professional must act within the code of conduct of their professional body, for example the NMC Complementary Alternative Therapies and Homeopathy (2009) requires that nurses and midwives ensure that the use of complementary therapies is safe and in the best interest of patients; they should also act in accordance with the policies and protocols set by the particular hospice or hospital in which they work. Collaboration is part of professional practice, hence the need to discuss the use of CAM with members of the multidisciplinary team caring for that particular patient.
In some areas of the NHS services are being developed which include therapies such as massage and aromatherapy, especially in palliative and cancer care, where aromatherapists are either employed or work as volunteers. Patients can be referred by other healthcare professionals or have direct access to aromatherapists – and a full assessment is undertaken to determine an appropriate treatment regime (Gage et al. 2009).
The emphasis is on protocols demonstrating safe and effective clinical decision making, for example where midwives use essential oils to support women in childbirth (Burns, Blamey & Lloyd 2000) at the John Radcliffe Hospital in Oxford.
Two midwives who were also qualified aromatherapists led the initiative in the early 1990s. The reaction of the women who experienced essential oils in the delivery suite was so positive that a decision was made that all women who delivered their babies in the unit would have access to the use of essential oils for symptom management. A basic training programme was set up so that all midwives on the unit could offer women a prescribed range of essential oils under the supervision of trained aromatherapists. The midwives understood that this training did not qualify them as aromatherapists, but provided knowledge to use essential oils appropriately and effectively in their midwifery practice.
The training might or might not be accepted if they moved to another hospital: it would depend on the policy of that hospital and the type and range of care offered on that unit. The midwifery education package continues to be refined and developed.
Polices are framed somewhat differently where independent aromatherapists are employed by the NHS or are volunteers within a service. For example, at St Ann’s Hospice in Manchester, emphasis is placed on establishing a register of therapists with specific qualifications and the establishment of a training and supervision programme which supports aromatherapists working with patients who have complex clinical and psychological needs.
Written polices and protocols are designed to provide a framework of consistency and continuity, which is particularly important during any change of personnel. Once recorded, policies become the means for providing legal indemnity.
• Policies – state clearly what is expected of staff and cover issues the organization considers important for the delivery and management of the integration of complementary therapies.
• Protocols – are the step-by-step methods for achieving policy statements. A policy statement records ‘what the rule is and to whom it applies’ and should indicate clearly ‘what must be done and by whom’.
Operational policies are those for the day-to-day management and practice of individual therapies, including the expectations of therapists.
Developing policy is not an overnight task. The minimum period from planning to ratification is usually 2 years, and many have taken as many as 4½ years … stamina is needed!
Below are some tips from nurses who have been involved in the development of policies:
• Talk to the right people – know who is on your side.
• Know the organizational structure that you are working in.
• Keep up-to-date with national developments.
• Plan the scope of the policy from the beginning, keeping your options open.
• Keep the document simple – detail is more appropriate at the clinical protocol level.
• Be prepared – there will no doubt be compromises, so don’t have unrealistic expectations.
• Make sure firm review dates are built into the system to keep the document alive.
It won’t happen overnight, so be prepared for the long haul. Nor will it necessarily be a smooth path – there will be times when you think the way has been blocked, which is when you need to be able to think laterally and be flexible about what you want to achieve.
Because organizational cultures differ there is no one template that can be used. However, a review of existing policy documents would suggest that the following headings might be taken as core requirements:
• Title of policy – needs to communicate clearly what the policy is about.
• Identification of aims of the policy – tells people what the document will cover.
• Definition of terms used in the policy document – sometimes presented as an appendix.
• Identification of objectives that can be evaluated and measured – will describe the outcomes that are hoped to be achieved.
• Identification of what will be covered by the policy – sometimes only a particular aspect or technique of aromatherapy will be used, and this needs to be defined.
• Reasoning behind the use of aromatherapy – will include clinical information and any relevant research or evidence of efficacy.
• Identification of who should deliver the aromatherapy treatment – may involve setting up a register of available practitioners.
• Definition of competency to practise – will include a description of the aromatherapy knowledge and skills needed to practise in a particular clinical area.
• Identification of educational criteria to determine competent practitioners within a particular clinical area – may identify specific aromatherapy training courses.
• Identification of lines of accountability – may include medical authorization.
• Safety issues – will include contraindications and risk assessment.
• Informed consent – clear guidelines about how and when this is obtained.
• Documentation to be used within the clinical area – ideally based on multiprofessional collaboration.
• Equity of access – do all patients in a particular clinical area have equal access at any one time to suitably trained aromatherapists?
• Environmental issues – providing peace and privacy etc.
• Methods of evaluation – what tools will be used to audit and evaluate the service?
• Financial considerations – a) who should pay for essential oils used? b) will the aromatherapy be carried out within the existing contract of the practitioner or will there be additional hours and payment?
• A timetable for the review of the policy – must be stipulated.
This list is not exhaustive and extra ideas can be found in the Nurses’ Handbook of Complementary Therapies by Denise Rankin-Box and Maxine McVey (2001). Also, Tavares (2004) has produced a comprehensive guide on writing policies, procedures and protocols for complementary therapies in supportive and palliative care. It contains examples of several policies – some relatively simple.
A draft example of a protocol for using essential oils, by nurses at St Gemma’s Hospice, Leeds, is included in Tavares’ guide and is divided into the following headings:
• Preamble – describing situations for using essential oils, e.g. to help mask offensive odours or to help patients enjoy better sleep.
• Electrical diffusers – explanation of diffusers and precautions to be observed.
• Choice of oils – a limited range of oils is used, under the supervision of a nurse/aromatherapist. These include bergamot, grapefruit, lemongrass, lavender and sandalwood. (NB: Editor’s note: Latin names should always be used to ensure the correct variety or chemotype is used).
• Method of use – three different methods of application are described: Aromastream, Aromastone, and via a tissue or external dressing. There is detailed instruction on how to proceed, depending on the method used.
• Storage – how and where the essential oils should be stored.
• Advice – staff are reminded that if they have any queries they must consult the complementary therapy coordinator for the unit, who is a qualified aromatherapist.
• Accidents and adverse reactions – instructions about how these should be reported.
At the bottom of the protocol is a section for the date when it will be ratified, a date for review, and the person responsible for the review. An interesting issue that falls within policy development is that of informed consent. Because aromatherapy is not part of mainstream healthcare, explicit consent must be obtained from the patient, who must understand not only the potential benefits but also the limits of a treatment. Any safety issues must also be highlighted. Many units are producing leaflets explaining the services offered, making sure patients have access to the information before they arrive, so that they can raise any concerns during the initial assessment.
Policy development for integrating aromatherapy within the NHS is a complex process. While there is undoubted enthusiasm within many healthcare professions, the development of policy is most often ‘guarded’ by the medical establishment. Naturally, all healthcare professionals understand the need to base any care on evidence, and wish to provide a service to patients which is responsive to needs, appropriate and effective. For many, the use of essential oils adds another dimension to care, to complement the often harsh orthodox regimes – and to enhance a patient’s quality of life. Unfortunately, the preoccupation of the medical establishment with randomized controlled trials means that qualitative research methods which, for example, explore patient outcomes, are denigrated. Winning the support of medical colleagues is part of the complex process.
The practical approach would be for the use of essential oils to be limited to a relatively small range of therapeutic interventions in appropriate clinical settings, which should be fastidiously evaluated. The evaluation should then be published so that success is well documented and will build a foundation from which the use of essential oils can be appropriately spread throughout the health service.
Part 1 of this chapter showed the great steps that have been taken towards self-regulation of aromatherapy in the UK and the current legislation situation directed by the European Union. Part 2 has demonstrated how nursing policy and practice guidelines can be put into practice by aromatherapists also, and it is to be hoped that more health provision agencies will follow the lead already made in the UK.
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