Complementary Care

Purpose

This document provides guidance to perioperative registered nurses (RNs) for determining what complementary care interventions will be used in the organization and how to implement them in the perioperative setting. Optimal perioperative nursing practice promotes patient well-being, and implementing patient-centered complementary care interventions can improve the perioperative experience for patients, their families, and health care workers, as well as reduce health care costs. The perioperative experience begins when an operative or invasive procedure is scheduled and ends when the patient is released from follow-up surgical care. Patients can experience preoperative stress, intraoperative discomfort, and problems with postoperative healing, some of which can be addressed with complementary care interventions.

Assessing patients’ individual values, health beliefs, and health experiences concerning physical, mental, emotional, spiritual, and environmental factors that can affect well-being and healing is essential when planning and implementing perioperative complementary care interventions. The use of complementary care has increased in many clinical areas, and an increasing number of researchers are studying perioperative outcomes that can be improved with complementary care interventions. As such, this guideline revision expands on the previous version, which was focused on reducing perioperative pain and anxiety, by including holistic methods for optimizing the overall health and well-being of perioperative patients through the use of a variety of complementary care interventions that can be implemented throughout the perioperative care plan.

The ability to provide complementary care interventions depends on several patient and organizational factors. Patient factors include the patient’s acceptance and engagement, individual values, health beliefs, and experiences with health care. Organizational factors include the clinical experience, the education and competency of the perioperative team to provide complementary care interventions, and procedural and facility constraints. Considerations for cost and feasibility are also discussed in this guideline.

The variable nature of complementary care intervention studies (eg, implementation techniques, assessment, evaluation) limits the reliability and validity of the literature. Researchers have concluded that additional research studies are needed to confirm initial findings and conclusions because intervention techniques, outcomes, and settings have been inconsistent and limit generalizability.^1-10  Complementary care interventions may not be feasible or suitable for every patient; therefore, the perioperative RN plays an integral role in facilitating an optimal perioperative experience for the patient by individualizing complementary care based on the evidence-based practice recommendations in this guideline.

Researchers have examined current use of complementary and alternative medicine (CAM) and age-specific differences in use. In national surveys^11-14  conducted from 2012 to 2016, adults, older adults, and Hispanic respondents reported increased use of complementary care interventions. Clarke et al¹³  found that use of dietary and herbal interventions was the most popular response. Ho et al¹²  found that respondents born between 1946 and 1964 were more likely to use complementary care than other groups. Black et al¹¹  found that older pediatric patients were more likely to use complementary care interventions (eg, yoga). De Moura et al¹⁴  found that younger pediatric patients were more likely to report postoperative pain and 42% of pediatric patients reported having preoperative anxiety.

The recommendations and interventions described in this guideline are intended to complement conventional treatment and not intended to be alternatives to conventional surgical care¹⁰  or integrative treatments for conditions, diseases, or illnesses. The National Institutes of Health defines complementary as an adjunct to conventional medicine and alternative as a replacement for conventional medicine.¹⁰  Complementary and alternative medicine includes the use of natural products (eg, herbs, vitamins and minerals, probiotics, dietary supplements) and mind and body practices (eg, deep breathing, yoga, meditation, massage, homeopathy, relaxation, guided imagery). The definition of complementary care is expanding as new interventions continue to be the focus of study.

Topics outside the scope of this document are

• conventional medical treatment,

• nontraditional forms of conventional medicine prescribed by a licensed independent practitioner (eg, alternative medicine, functional medicine, integrative medicine),

• interventions that have limited use in the perioperative setting (eg, animal therapy, yoga),

• interventions that are implemented outside of the perioperative setting (eg, rehabilitation, physical therapy),

• interventions intended for the purpose of treating a condition or disease (eg, natural hormones, alternative medication, ERAS), and

• interventions to improve health care workers’ well-being.

A discussion of ERAS (Enhanced Recovery After Surgery)¹⁵  and other conventional medical care guidelines is outside the scope of this guideline, but many elements of ERAS can be found in these recommendations.

Evidence Review

A medical librarian with a perioperative background conducted a systematic search of the databases Ovid MEDLINE, Ovid Embase, EBSCO CINAHL, and the Cochrane Database of Systematic Reviews. The search was limited to literature published in English from January 2010 through April 2020. At the time of the initial search, weekly alerts were created on the topics included in that search. Results from these alerts were provided to the lead author until June 2020. The lead author requested additional articles that either did not fit the original search criteria or were discovered during the evidence appraisal process. The lead author and the medical librarian also identified relevant guidelines from government agencies, professional organizations, and standards-setting bodies.

Search terms included acupressure, acupunctur*, adulterants, alternative analgesia, alternative medicine, alternative therap*, anxiety, aromatherap*, audio visual distraction, ayurved*, bioelectromagnetics, biofield, biological field, bleeding, bruis*, carrier oil, chiropract*, chromatography, complementary care, complementary medicine, complementary therap*, conditioned aversion, contusions, cool cloths, cortisol, cough relief, deep breathing, diet therap*, discomfort, dislike smell, distress, electromagnetic fields, emotional distress, energy medicine, environmental trigger, essential oils, fear, flexibility, functional medicine, guided imagery, h*matoma, heart rate, heating pad, herbal medicine, herbal remedies, herbal*, holistic interventions, homeopath*, homeopathic medicine, hypnosis, hypnotherap*, ice, inflammation, integrative health, integrative medicine, LED lights, massage, muscle tension, nasal stuffiness, natural medicine, natural therap*, naturopath*, naturopathy, nausea, nonconventional therapy, nonpharmaceutical, nutrition*, operating room nurse, operating rooms, organic, osteopath*, PACU, pain tolerance, perioperative nursing, physiological stress, phytotherap*, pillows, positioning, postoperative, postoperative nausea and vomiting, postoperative pain, postoperative period, postoperative phase, preoperative, preoperative period, preoperative phase, purity, quality, range of motion, reflexolog*, safety data sheet, scent bias, scope of practice, sedative, skin irritation, stress, supplement, swelling, symptom relief, TENS, therapeutic touch, topical analgesic, traditional Chinese medicine, tranquility, undiluted, virtual reality, vitamin therapy, vomiting, and yoga.

Included were research and non-research literature in English, complete publications, and publications with dates within the time restriction when available. Excluded were non-peer-reviewed publications and older evidence within the time restriction when more recent evidence was available. Editorials, news items, and other brief items were excluded. Low-quality evidence was excluded when higher-quality evidence was available, and literature outside the time restriction was excluded when literature within the time restriction was available (Figure 1).

Figure 1

Flow Diagram of Literature Search Results

Adapted from Moher D, Liberati A, Tetzlaff J, Atman DG; The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA Statement. PLoS Med. 2009;6(6):e1000097.

Articles identified in the search were provided to the project team for evaluation. The team consisted of the lead author and two evidence appraisers. The lead author divided the search results into topics and assigned members of the team to review and critically appraise each article using the AORN Research or Non-Research Evidence Appraisal Tools as indicated. The literature was independently evaluated and appraised according to the strength and quality of the evidence. Each article was then assigned an appraisal score. The appraisal score is noted in brackets after each reference as applicable.

Each recommendation rating is based on a synthesis of the collective evidence, a benefit-harm assessment, and con­sideration of resource use. The strength of the recommen­dation was determined using the AORN Evidence Rating Model and the quality and consistency of the evidence sup­porting a recommendation. The recommendation strength rating is noted in brackets after each recommendation.

Note: The evidence summary table is available at http://www.aorn.org/evidencetables/.