Faith And Prayer

COMPLEMENTARY AND ALTERNATIVE THERAPIES FOR NURSING PRACTICE
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F o u r t h E d i t i o n
Karen Lee Fontaine Professor, College of Nursing, Purdue University Calumet,
Hammond, Indiana
 

 
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Dedication
This book is dedicated to Peggy Gerard, Dean, and Kathy Nix, Undergraduate Coordinator, College of Nursing,
Purdue University Calumet for all their support and enthusiasm as complementary and alternative medicine
was integrated into the curriculum.
 

 
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CONTENTS
Preface ix
Acknowledgments xiii
Reviewers xiv
UNIT 1 Healing Practices: Complementary and Alternative Therapies for Nurses 1
Chapter 1 Integrative Healing 3
Chapter 2 Basic Concepts Guiding Alternative Therapies 19
Chapter 3 The Role of Evidence-Based Health Care in Complementary and Alternative Therapies 37
UNIT 2 Systematized Health Care Practices 47 Chapter 4 Traditional Chinese Medicine 49
Chapter 5 Ayurvedic Medicine 70
Chapter 6 Native American Healing and Curanderismo 90
UNIT 3 Botanical Healing 111 Chapter 7 Herbs and Nutritional Supplements 113
Chapter 8 Aromatherapy 133
Chapter 9 Homeopathy 149
Chapter 10 Naturopathy 162
UNIT 4 Manual Healing Methods 169 Chapter 11 Chiropractic 171
Chapter 12 Massage 183
Chapter 13 Pressure Point Therapies 202
Chapter 14 Hand-Mediated Biofield Therapies 217
Chapter 15 Combined Physical and Biofield Therapy 230
UNIT 5 Mind–Body Techniques 239 Chapter 16 Yoga 241
Chapter 17 Meditation 256
Chapter 18 Hypnotherapy and Guided Imagery 269
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Chapter 19 Dreamwork 286
Chapter 20 Intuition 301
Chapter 21 Music as a Therapeutic Tool 311
Chapter 22 Biofeedback 320
Chapter 23 Movement-Oriented Therapies 327
UNIT 6 Spiritual Therapies 339 Chapter 24 Shamans 341
Chapter 25 Faith and Prayer 352
UNIT 7 Other Therapies 367 Chapter 26 Bioelectromagnetics 369
Chapter 27 Animal-Assisted Therapy 378
Appendix Alternative Therapies for Common Health Problems 393
Index 417
vi Contents
 

 
TRY THIS
vii
Energy 34 Massage 88 Positive Thoughts 107 Herbal Remedies 128 Soothing Potions 144 Top 10 Remedies 157 Pet Remedies 158 Visualization 167 Energy Boosters 181 Massage 199 Foot Massage 213 Experience Your Energy Field 227 Emotional First Aid 235 Redirecting the Flow of Energy 236 Heart Breathing 252 Loving–Kindness Meditation 266
Renovating Your Day 283 Shrinking Antagonistic
Forces 283 Improving Dream Recall 298 Positive Affirmations 308 Practice Intuition 309 Music for Stress Reduction 316 Mind Control of Muscular
Strength 324 Feel Your Qi 335 Wave Hands Like Clouds (Water
T’ai Chi) 336 Shamanic Journey 349 Absorbing Earth Energy 375 Going to the Mountains 376 Interacting with Your Pet 389
 

 
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PREFACE
The profession of nursing has advanced beyond the Western biomedical model to incorporate many healing tools used by our Asian, Latino, Native American, African, and European ancestors. We are rapidly rediscovering that these ancient principles and practices have significant therapeutic value. Some see this movement as a “return to our roots.” Others believe it is a response to runaway health care costs, growing dissatisfaction with high-tech medicine, and increasing concern over the adverse effects and misuse of med- ications. The growth of consumer empowerment also fuels this movement.
As nurses, how do you begin to assimilate thousands of years of healing knowledge? How do you begin this journey of integrating practices into your own lives? In your professional practice, how do you model healthful living? How do you help clients choose their own healing journeys? How do you break down the barriers between conventional and complementary and alter- native medicine (CAM)? Learning about CAM practices, like anything else, is a slow process involving a steady accumulation of bits of information and skills that eventually form a coherent pattern called knowledge. Although it is possible to learn a great deal about healing practices from reading, thinking, and asking questions, you must in the long run learn about healing through participation. Without hands-on experience, you can be a good student, but you can never be a great nursing practitioner of the healing arts. I trust this book will be one step in a lifelong exploration of and experiences with healing practices.
Consumers do not wish to abandon conventional medicine, but they do want to have a range of options available to them including herbs and nutri- tional supplements, manual healing methods, mind–body techniques, and spiritual approaches. Some CAM practices, such as exercise, proper nutrition, meditation, and massage, promote health and prevent disease. Others, such as herbs and homeopathic remedies, address specific illnesses. Many other CAM practices do both. The rise of chronic disease rates in Western society is increasingly motivating consumers to consider self-care approaches. As recently as the 1950s, only 30% of all disease was chronic, and curable—largely infectious—diseases dominated, for which medical interventions were both appropriate and effective. Now, 80% of all disease is chronic. Western medi- cine, with its focus on acute disorders, trauma, and surgery, is considered to be the best high-tech medical care in the world. Unfortunately, it is not responding adequately to the current epidemic of chronic illnesses.
Ethnocentrism, the assumption that one’s own cultural or ethnic group is superior to others, has often prevented Western health care practitioners from  learning “new” ways to promote health and prevent chronic illness. With consumer demand for a broader range of options, we must open our minds to the idea that other cultures and countries have valid ways of preventing and curing diseases that could be good for Western societies.
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x Preface
Although the information may be new to us, many of these traditions are hun- dreds or even thousands of years old and have long been part of the medical mainstream in other cultures.
I have titled this book Complementary and Alternative Therapies for Nursing Practice because I believe we need to merge CAM approaches with Western- based nursing practices. I have tried to provide enough information about alternative therapies to help guide practice decisions. This text, as an over- view and practical guide for nurses, does not pretend to be an exhaustive col- lection of all the facts and related research in CAM, nor does it offer meticulous documentation for all claims made by the various therapies. The goal of the text is to motivate you, the reader, to explore CAM approaches, increase your knowledge about factors that contribute to health and illness, and expand your professional practice appropriately.
It is possible to classify alternative practices in any number of ways. I  have chosen to present more than 40 approaches categorized into seven units. In Unit 1, I introduce the philosophical approaches to both Western bio- medicine and complementary and alternative medicine, as well as evidence- based health care in CAM therapies. Concepts common to many approaches are defined and discussed, such as energy, breath, spirituality, and healing. Unit 2 presents a number of health care practices that have been systematized throughout the centuries worldwide. These typically include an entire set of values, attitudes, and beliefs that generate a philosophy of life, not simply a group of remedies. The chapters cover Traditional Chinese Medicine, Ayurvedic medicine, and Native American healing and curanderismo. Unit 3 comprises chapters relating to botanical healings used by 80% of the world’s population. Chapters cover herbs and nutritional supplements, aromather- apy, homeopathy, and naturopathy. Unit 4 presents manual healing methods—some from ancient times and some developed in the latter half of the 20th century. The chapters discuss chiropractic, massage, pressure point therapies, hand-mediated biofield therapies, and combined physical and biofield therapies. The chapters in Unit 5 cover types of mind–body tech- niques for healing and include yoga, meditation, hypnotherapy and guided imagery, dreams, intuition, music as a therapeutic tool, biofeedback, and movement-oriented therapies. Unit 6 presents two spiritual approaches to therapeutic intervention: working with shamans and the use of faith and prayer. Unit 7 includes two chapters on miscellaneous practices: bioelectro- magnetics and animal-assisted therapy.
The appendix provides specific information on managing the types of common health problems that respond well to alternative therapies and life- style modification.
This book does not recommend treatments but, rather, describes alterna- tive practices, their backgrounds and claims, preparation of practitioners, con- cepts, diagnostic methods, treatments, and evidence from research studies. “Integrated Nursing Practice” is an important section of every chapter designed to help you, the nurse, expand your practice by providing you with specific information and suggestions. “Try This” features throughout the
 

 
Preface xi
chapters provide you with examples of how you can integrate these practices into your own life and also give you ideas for client education. A list of resources is also included in the chapters.
In this new fourth edition, I have continued the “Considering the Evi- dence” feature with all new research relating to the chapter topic. Eight of these features present a systematic review of randomized control trials, while two present primary research . “Considering the Evidence” boxes not only present current studies but also are designed to further critical thinking and perhaps inspire you to design studies to answer your own questions. Each study answers the following questions: What was this study about? How was the study done? What were the results of the study? What additional ques- tions might I have? And how can I use this study?
Changes to the fourth edition:
• Updated all research sections and greatly increased the number of sys- tematic reviews of randomized controlled trials
• Changed the focus of the chapter on music from music therapy to music as a therapeutic tool to broaden the focus for the practicing nurse
• Expanded the lists of resources to include more international resources • Deleted polarity therapy and crystal healing for lack of research and
evidence • Added sections on
• Music thanatology • Aromachology • Restorative yoga • Latest technology for biofeedback self-tracking
• Expanded cautions for pregnant women and young children
Nurses are in a unique position to take a leadership role in integrating alternative healing methods into Western health care systems. Nurses have historically used their hands, heart, and head in more natural and traditional healing interactions. By virtue of their education and relationships with clients, nurses can help consumers assert their right to choose their own healing journey and the quality of their life and death experiences.
My dear friend and colleague has written the following letter to you about her lived experience uniting biomedicine with CAM approaches.
Dear Reader,
It is both a pleasurable and enlightening experience for me to contribute to your text, Complementary and Alternative Therapies for Nursing Practice , through the development of the “Considering the Evidence” feature. I approach this work hopeful that it may inspire you, the reader, to engage in critical thinking, assist in your understanding of the significance of research to inform your  nursing practice and, perhaps, propose studies to answer your own researchable questions. However, with this edition, I have asked Karen Lee Fontaine to allow me the privilege of sharing with you my personal journey with complementary and alternative therapies. I hope I can thus inspire you
 

 
xii Preface
to reflect on and embrace the important content of this text. After learning of my diagnosis of bilateral breast cancer, I actively participated in myriad Western medicine therapies while integrating complementary and alternative therapies. Although the chemotherapy experience was both mentally and physically challenging, I considered the massage therapist as part of “my team,” and I looked forward to this dimension of comfort during this challenging time. Engaging in yoga enhanced “restful sleep” as a response to the overwhelming fatigue that frequently accompanies Western therapies such as chemotherapy and radiation and just the daily awareness that “you have cancer.” Acupressure relieved uncomfortable postoperative symptoms. T’ai chi continues to be an opportunity to focus on myself and reflect on the positives associated with this journey. Reiki and reflexology is my specified “me time.” As I engage in the associated deep breathing exercises, it stimu- lates my mind to drift to affirmative thoughts and so many positive memories from my life. For me, “living with cancer “is more of an “inconvenience” in my life’s journey. I can appreciate this may not be the experience for every- one, but I can personally assure you that integrating many of the therapies discussed in this text allows me a “quality of life” while simultaneously working with conventional medicine’s goal for a “quantity of life.” With the combination of both, I feel I have been given the power to survive!
I hope my story gives you a sense of hope and empowerment in caring for persons both professionally and personally who are embarking on a stren- uous journey related to their health. I can recall in my nursing practice experi- encing feelings of helplessness when caring for persons undergoing complex t reatments with so many uncertainties related to their health outcome. I can attest that your understanding, knowledge, and support in the implementa- tion of complementary and alternative therapies can significantly affect their “quality of life” and allow you the privilege of making a difference in their health journey.
Warm regards, Dolores M. Huffman, RN, PhD
 

 
ACKNOWLEDGMENTS
I would like to express thanks to the many people who have inspired, com- mented on, and in other ways assisted in the writing and publication of the fourth edition of this book. On the publishing and production side at Pearson, I was most fortunate to have an exceptional team of editors and support staff. My thanks go to Julie Alexander, Publisher, and Erin Rafferty, Program Manager, who provided support and guidance throughout this project. Maria Reyes, Project Manager, kept this book on schedule and dedicated her time and skill to its completion.
I would like to thank all those who reviewed this text and provided sug- gestions and guidance for the fourth edition.
Karen Lee Fontaine Purdue University Calumet
Contributors Dolores M. Huffman, RN, PhD
Associate Professor College of Nursing Purdue University Calumet Director of Transfer: Northwest Indiana Center for Evidence Based Practice: A Joanna Briggs Institute Collaborating Centre Hammond, IN
Sheila O’Brien Lewis, BScN, MHSc Associate Lecturer Department of Nursing, Faculty of Health York University Toronto, ON, Canada
Leslie Rittenmeyer, PsyD, CNS, RN Professor Collegel of Nursing Purdue University Calumet Research Associate: Northwest Indiana Center for Evidence Based Practice: A Joanna Briggs Institute Collaborating Centre Hammond, IN
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xiv
Dot E. Baker, Ed.D., MSN., BSN.
Professor Wilmington University Georgetown, DE
Debra Rose Wilson, PhD, RN, IBCLC, AHN-BC, CHT
Professor Middle Tennessee State University Murfreesboro, TN Walden University Minneapolis, MN
Lynn Rew, Ed.D, RN, AHN- BC, FAAN
Professor The University of Texas at Austin Austin, TX
Sheila Stroman, PhD, RN Assistant Professor University of Central Arkansas Conway, AR
Susan Cohen, DSN, APRN, FAAN
Associate Professor University of Pittsburgh Pittsburgh, PA
Kimberly Arcoleo, PhD, MPH Professor
Ohio State University Columbus, OH
Lori Edwards, DrPH, RN, APRN, BC
Instructor Johns Hopkins University School of Nursing Baltimore, MD
Rose Mary Gee, PhD, RN Assistant Professor Georgia Southern University Statesboro, GA
Sue Hritz, MEd, PC, RN, CHT, PHN
Lecturer Kent State University Kent, OH
Gretchen Ezaki, MSN, RN Instructor Fresno City College Fresno, CA
Kathleen Murphy, PhD, MMT Assistant Professor University of Evansville Evansville, IN
Vicki Moran, MSN/MPH, RN Instructor Saint Louis University St. Louis, MO
REVIEWERS
 

 
Healing Practices: Complementary and Alternative
Therapies for Nurses
Happiness, grief, gaiety, sadness are by nature contagious. Bring your health and your strength to the weak and sickly,
and so you will be of use to them. Give them, not your weakness, but your energy, so you will revive
and lift them up.
Henri-Frederic Amiel
1 U N I T
 

 
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1 Integrative Healing
Time is generally the best doctor.
Ovid
Most of nursing education in the United States, Canada, the United Kingdom, Europe, and Australia—often referred to as Western countries—has been under the umbrella of biomedicine, and thus Western nurses are familiar and comfortable with its beliefs, theories, practices, strengths, and limitations. Fewer nurses have studied alternative medical theories and practices and as a result may lack information or even harbor misinformation about these healing practices. Unlike the profession of medicine in general, however, the profession of nursing has traditionally embraced two basic concepts embodied by alternative therapies—holism and humanism—in its approach with clients. Nurses have long believed that healing and caring must be approached holistically and that biological, psychologi- cal, emotional, spiritual, and environmental aspects of health and illness are equally important. This humanistic perspective includes propositions such as the mind and body are indivisible, people have the power to solve their own problems, people are responsible for the patterns of their lives, and well-being is a com- bination of personal satisfaction and contributions to the larger community. This theoretical basis gives nurses a solid foot in each camp and places them in the unique position to help create a bridge between biomedicine and alternative medicine ( Buchan, Shakeel, Trinidade, Buchan, & Al-See, 2012 ; Halcon, Chlan, Kreitzer, & Leonard, 2003 ; Peplau, 1952 ; Quinn, 2000 ; Shreffler- Grant, Hill, Weinert, Nichols, & Ide, 2007 ).
BACKGROUND
Many interesting exchanges around the world have debated the appropriate terminology of various healing practices. Some people
3
 

 
4 Unit 1 • Healing Practices
become vested in the use of particular terms and have difficulty getting past the language limitations. For example, many people view the term alternative medi- cine as being too narrow or misleading and are concerned that the term lacks a full understanding of traditional healing practices. It would be helpful for a common language to be developed without these constraints. As language evolves, the terms used today may be quite different from those used 20 years from now. For consistency, the terms chosen for this text are conventional med- icine or biomedicine to describe Western medical practices, and the terms alternative medicine or complementary medicine to describe other healing practices. Traditional medicine refers to indigenous medical systems such as Traditional Chinese Medicine (TCM). There are no universally accepted terms. The following list presents commonly used words and their counterparts:
Mainstream Complementary/Alternative Modern Ancient Western Eastern Allopathic Homeopathic; holistic Conventional Unconventional Orthodox Traditional Biomedicine Natural medicine Scientific Indigenous healing methods
The line between conventional and complementary and alternative medicine is imprecise and frequently changing. For example, is the use of megavitamins or diet regimens to treat disease considered medicine, a life- style change, or both? Can having one’s pain lessened by massage be consid- ered a medical therapy? How should spiritual healing and prayer—some of the oldest, most widely used, and least studied traditional approaches—be classified? Although the terms alternative and complementary are frequently used, in some instances they represent the primary treatment modality for an individual. Thus, conventional medicine sometimes assumes a secondary role and becomes a complement to the primary treatment modality.
Conventional Medicine
Biomedical or Western medicine is only about 200 years old. It was founded on the philosophical beliefs of René Descartes (1596–1650)—that the mind and body are separate—and on Sir Isaac Newton’s (1642–1727) principles of physics—that the universe is like a large mechanical clock in which every- thing operates in a linear, sequential form. This mechanistic perspective of medicine views the human body as a series of body parts. It is a reductionist approach that converts the person into increasingly smaller components: sys- tems, organs, cells, and biochemicals. People are reduced to patients, patients are reduced to bodies, and bodies are reduced to machines. Health is viewed as the absence of disease or, in other words, nothing is broken at present, and sick care is focused on the symptoms of dysfunction. Physicians are trained to
 

 
Chapter 1 • Integrative Healing 5
fix or repair broken parts through the use of drugs, radiation, surgery, or replacement of body parts. The approach is aggressive and militant— physicians are in a war against disease, with a take-no-prisoners attitude. Both consumers and practitioners of biomedicine believe it is better to
• do something rather than wait and see whether the body’s natural pro- cesses resolve the problem.
• attack the disease directly by medication or surgery rather than try to build up the person’s resistance and ability to overcome the disease.
Biomedicine views the person primarily as a physical body, with the mind and spirit being separate and secondary or, at times, even irrelevant. It is powerful medicine in that it has virtually eliminated some infectious dis- eases, such as smallpox and polio. It is based on science and technology, per- sonifying a highly industrialized society. As a “rescue” medicine, the biomedical approach is appropriate. It is highly effective in emergencies, trau- matic injuries, bacterial infections, and some highly sophisticated surgeries. In these cases, treatment is fast, aggressive, and goal oriented, with the responsi- bility for cure falling on the practitioner.
The priority of intervention is on opposing and suppressing the symp- toms of illness. This approach is evidenced in many medications with prefixes such as an or anti , as in analgesics, anesthetics, anti-inflammatories, and anti- pyretics. Biomedicine characterizes each disease in terms of its mechanisms of action, based on the belief that most individuals are affected in the same way. Thus, treatment is basically the same for most people. Because conventional medicine is preoccupied with parts and symptoms and not with whole work- ing systems of matter, energy, thoughts, and feelings, it does not do well with long-term systemic illnesses such as arthritis, heart disease, and hypertension. Despite higher per capita spending on health care in the United States than in all other nations, in 2013, U.S. life expectancy ranked only 37th, and the infant mortality rate ranked 33rd among the nations studied ( World Health Rankings, 2013 ). The United States has failed to be a world leader in providing a healthier quality of life.
Complementary and Alternative Medicine
Complementary and alternative medicine (CAM) is an umbrella term for as many as 1,800 therapies practiced worldwide. Many forms have been handed down over thousands of years, both orally and in written records. These ther- apies are based on the medical systems of ancient peoples, including Egyp- tians, Chinese, Asian Indians, Greeks, and Native Americans. Others, such as osteopathy and naturopathy, evolved in the United States during the past two centuries. Still others, such as some of the mind–body and bioelectromagnetic approaches, are on the frontier of scientific knowledge and understanding. The National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health (NIH) defines CAM therapies as a broad range of healing philosophies, approaches, and therapies that conventional
 

 
6 Unit 1 • Healing Practices
medicine does not commonly use, accept, study, understand, or make avail- able. NCCAM also defines complementary therapies as those used with con- ventional medicine and alternative therapies as those used instead of conventional medicine (National Center for Complementary and Alternative Medicine, 2012).
Although they represent diverse approaches, CAM therapies share cer- tain attributes. They are based on the paradigm of whole systems and the belief that people are more than physical bodies with fixable and replaceable parts. Rather, mental, emotional, spiritual, and environmental components of well- being are considered to play crucial and equal roles in a person’s state of health. Interventions are individualized within the entire context of a person’s life ( Duncan, Liechty, Miller, Chinoy, & Ricciardi, 2011 ). Even Hippocrates, the father of Western medicine, espoused a holistic orientation when he taught physicians to observe their patients’ life circumstances, emotional state, stresses, environment, inherited constitution, and their subjective experience of an ill- ness. Socrates agreed, declaring, “Curing the soul; that is the first thing.” In alternative medicine, symptoms are believed to be an expression of the body’s wisdom as it reacts to cure its own imbalance or disease. Other threads or con- cepts common to most forms of alternative medicine include the following:
• An internal self-healing process exists within each person. • People are responsible for making their own decisions regarding their
health care. • Nature, time, and patience are the great healers.
When Albert Einstein (1879–1955) introduced his theory of relativity in 1905, our way of viewing the universe changed dramatically. Einstein said that mass and energy are equivalent and interconvertible, and all matter is connected at the subatomic level. No single entity could be affected without all its connecting parts being affected. In this view, the universe is not a giant clock but a living web. The human body is animated by an integrated energy called the life force . The life force sustains the physical body but is also a spiritual entity that is linked to a higher being or infinite source of energy. When the life force flows freely throughout the body, a person experiences optimal health and vitality. When the life force is blocked or weakened, organs, tissues, and cells are deprived of the energy they need to function at their full potential, and illness or disease results.
Alternative medicine is especially effective for people with chronic, debilitating illnesses for which conventional medicine has few, if any, answers. It has much to offer in the arena of health promotion and disease prevention. As costs of conventional medicine increase and people continue to suffer from chronic illnesses and degenerative diseases, alternative medicine is moving closer to the mainstream. A growing number of complementary and alterna- tive therapies are eligible for reimbursement by third-party payers in the United States. The most commonly reimbursed treatments are chiropractic, biofeedback, acupuncture, hypnotherapy, and naturopathy. Box 1.1 provides an overview of the paradigms of conventional and alternative medicine.
 

 
Chapter 1 • Integrative Healing 7
Integrative Medicine
Integrative medicine embodies both conventional and complementary and alternative medicine, making use of the best available evidence of all three approaches to healing. It is a multidisciplinary, collaborative, holistic approach that encompasses mind, body, and spirit. It stresses the relationship between the client and the practitioner as well as the human capacity for healing. Inte- grative practitioners believe that clients have the right to make informed choices about their health care options. The focus is on “using the least inva- sive, least toxic, and least costly methods to help facilitate health” ( Willison, 2006 , p. 255 ). The goal of integrative medicine is to find new solutions to pre- vention and treatment of health care problems.
Dr. Andrew Weil has been the driving force for integrative medicine in the United States and hopes to reform the entire medical delivery system by changing the way we look at health and disease and by modifying the educa- tion of physicians. His program at the Arizona Center for Integrative Medi- cine at the University of Arizona College of Medicine was the first to adopt this new curriculum. Nursing must also be open to change to meet the goal of true integrative care. In 2008, the World Health Organization (WHO) stressed the importance of integrative medicine and advocated the inclusion of com- plementary and alternative therapies in biomedical health care education ( Quartey, Ma, Chung, & Griffiths, 2012 ).
BOX 1.1
Paradigms of Medicine
View Conventional Medicine Alternative Medicine
Mind/body/spirit are separate are one The body is a machine a living microcosm of the universe Disease results parts break energy/life force becomes unbalanced when Symptoms dysfunctional and need communicators about the state of the to be fixed whole person Role of medicine to combat disease to restore mind/body/spirit harmony Approach treat and suppress search for patterns of symptoms disharmony or imbalance Focuses on parts/matter whole/energy Treatments attempt to “fix” broken support self-healing; personalized for parts; specific to disease the individual Primary drugs, surgery, diet, exercise, herbs, stress interventions radiation management, social support System sick care health care
 

 
8 Unit 1 • Healing Practices
ASSUMPTIONS
In understanding conventional and alternative medicine, it is helpful to study the assumptions basic to their theories, practices, and research. These assump- tions include the origin of disease, the meaning of health, the curative process, and health promotion.
Origin of Disease
Biomedicine and alternative medicine have widely divergent assumptions regarding the origin of disease. Biomedicine was shaped by the observations that bacteria were responsible for producing disease and pathologic damage and that antitoxins and vaccines could improve a person’s ability to ward off the effects of pathogens. Armed with this knowledge, physicians began to conquer a large number of devastating infectious diseases. As the science developed, physicians came to believe that germs and genes caused disease, and once the offending pathogen, metabolic error, or chemical imbalance was found, all diseases would eventually yield to the appropriate vaccine, antibiotic, or chemical compound.
Conventional medicine has also been influenced by Darwin’s concept of survival of the fittest; that is, all life is a constant struggle, and only the most successful competitors survive. Applied to medicine, this notion means that humans live under constant attack by the thousands of microorganisms that, in the Western view, cause most diseases. People must defend themselves and counterattack with treatments that kill the enemy. Based on this assumption, symptoms are regarded as harmful manifestations and should be suppressed. For example, a headache is an annoyance that should be eliminated, and a fever should be reduced with the use of medications.
Complementary and alternative medicine is based on the belief of a life force or energy that flows through each person and sustains life. Balance refers to harmony among organs in the body and among body systems, and in rela- tionships to other individuals, society, and the environment. A balanced organ- ism presents a strong defense against external insults such as bacteria, viruses, and trauma. When the life force or energy is blocked or weakened, the vitality of organs and tissues is reduced, oxygen is diminished, waste products accu- mulate, and organs and tissues degenerate. Symptoms are the body’s way of communicating that the life force has been blocked or weakened, resulting in a compromised immune system. Disease is not necessarily a surprise encounter with a bacterium or a virus, since these are ever present, but rather the end result of a series of events that began with a disruption of the life force. Based on this assumption, symptoms are not suppressed unless they endanger life, such as a headache from an aneurysm or a body temperature above 105°F. Rather, symptoms are cooperated with because they express the body’s wis- dom as it reacts to cure its own disease. For example, a headache is a signal that one’s whole system needs realignment, and a fever may be the result of the breakdown of bacterial proteins or toxins. When symptoms are suppressed, they are not resolved but merely held in abeyance, gathering energy for renewed expression as soon as the outside, counteractive force is removed.
 

 
Chapter 1 • Integrative Healing 9
Meaning of Health
If you were to ask a healer from the Chinese, Indian, or Native American tra- ditions about the meaning of health, you would receive answers very differ- ent from those given by a Western physician. The biomedical view of health, in the past, was often described as the absence of disease or other abnormal conditions. That definition has been expanded to include the view that health is not a static condition; the body constantly changes and adapts to both inter- nal and external environmental challenges. The majority of conventional medical practitioners would define health as a state of well-being. They may disagree, however, about who determines well-being—the health profes- sional or the individual. With some exceptions, wellness and health promo- tion have, for the most part, been left to the initiative of the individual.
Those practicing complementary and alternative medicine (CAM) describe health as a condition of wholeness, balance, and harmony of the body, mind, emotions, and spirit. Health is not a concrete goal to be achieved; rather, it is a lifelong process that represents growth toward potential, an inner feeling of aliveness. Physical aspects include optimal functioning of all body systems. Emotional aspects include the ability to feel and express the entire range of human emotions. Mental aspects include feelings of self-worth, a positive identity, a sense of accomplishment, and the ability to appreciate and create. Environmental aspects include physical, biologic, economic, social, and political conditions. Spiritual aspects involve self, others, and society. Self-components are the development of moral values and finding a meaningful purpose in life. Spiritual factors relating to others include the search for meaning through relationships and the feeling of connectedness with others and with an external power often identified as God or the divine source. Societal aspects of spiritual health can be understood as a common humanity and a belief in the fundamental sacredness and unity of all life. These beliefs motivate people toward truth and a sense of fairness and justice to all members of society.
Curative Process
The curative process is another area of divergent viewpoints. Conventional medicine promotes the view that external treatments—drugs, surgery, radia- tion—cure people, and practitioners are trained to fix or repair broken parts. The focus is on the disease process or abnormal condition. Alternative practi- tioners look at conditions that block the life force and keep it from flowing freely through the body. Healing occurs when balance and harmony are restored. The focus is on the health potential of the person rather than the dis- ease problem. The cure model and the healing model are presented with greater detail in Chapter 2 .
Health Promotion
Conventional and complementary and alternative medical systems have somewhat different foci on promotion of health. The thrust of conventional
 

 
10 Unit 1 • Healing Practices
medicine is disease prevention. Consumers are taught how to decrease their risk of cancer, cardiac disorders, obesity, and other life-threatening diseases that kill most people prematurely in Western society. Although these behav- iors are important, disease prevention is only one piece of health promotion. From the complementary and alternative perspective, health promotion is a lifelong process that focuses on optimal development of people’s physical, emotional, mental, spiritual, and environmental selves. An individual’s worldviews, values, lifestyles, and health beliefs are considered to be of criti- cal importance. Consumers are encouraged to adopt healthier lifestyles, to accept increased responsibility for their own well-being, and through greater self-reliance, to learn how to handle common health problems on their own. As the Healthy People 2020 report illustrates ( U.S. Department of Health and Human Services, 2010a ), the health care delivery system of the future must make use of all approaches that effectively promote optimal health using best available evidence and knowledge. Box 1.2 describes the strategic plan 2011– 2015 of NCCAM. In the United States, the Patient Protection and Affordable Care Act, a federal statute, was signed into law by President Barack Obama in 2010. One goal of this act is to provide affordable health care for every American. ( U.S. Department of Health and Human Services, 2010b .)
RESEARCH
Scientific beliefs rest not just on facts but on paradigms (broad views of how these facts are related and organized). Differences in views among groups of nursing and medical researchers are a reflection of the different scientific paradigms—quantitative and qualitative research. Although each method results in a different type of knowledge, both provide information to research- ers and consumers. Evidence-based practice is covered in Chapter 3 .
Quantitative research represents the principles of the Western scientific method, which include formulating and testing hypotheses and then rejecting
BOX 1.2
NCCAM Strategic Plan 2011–2015
• Advance the science and practice of symptom management of CAM approaches. • Develop effective, practical, personalized strategies for promoting health and
well-being. • Enable better evidence-based decision making regarding CAM use and its integra-
tion into health care and health promotion.
Source: National Center for Complementary and Alternative Medicine ( 2011 ).
 

 
Chapter 1 • Integrative Healing 11
or accepting the hypotheses. Every question is reduced to the smallest possi- ble part. Results can be replicated and generalized, and outcomes can be pre- dicted and controlled. Quantitative research is said to be objective in that the observer is separate from what is being observed. Another part of this objec- tive paradigm is that all information can be derived from physically measur- able data. This type of research has been extremely effective for isolating causative factors of disease and developing cures. However, it cannot explain the whole person as an integrated unit.
Qualitative research seeks to understand events in context-specific set- tings. It studies the context and meaning of interactive variables as they form patterns reflective of the whole. Researchers observe, document, analyze, and qualify the interactive relationship of variables. In the science of physics, it is believed that objectivity is ultimately not possible. The Heisenberg uncer- tainty principle states that the act of observing phenomena necessarily influ- ences the behavior of the phenomena being observed. Another part of the paradigm relates to the belief that interactions between living organisms and environments are transactional, multidirectional, and synergistic in ways that cannot be reduced. This holistic approach (the whole is greater than the sum of the parts) is basic to qualitative research.
Practitioners of conventional medicine believe that procedures and sub- stances must pass blinded randomized controlled trials (RCTs) to be proven effective. As a testing method, an RCT examines a single procedure or sub- stance in isolated, controlled conditions and measures results against another existing therapy or the best available treatment. This approach is based on the assumption that single factors cause and reverse illness, and these factors can be studied alone and out of context. In contrast, practitioners of complemen- tary and alternative medicine (CAM) believe that no single factor causes any- thing, nor can a magic substance single-handedly reverse illness. Multiple factors contribute to illness, and multiple interventions work together to pro- mote healing. RCTs are incapable of reconciling this degree of complexity and variation.
Although major complementary and alternative medical systems may not have been subjected to a great deal of quantitative research, they are gen- erally not experimental therapies. They rely on well-developed clinical obser- vational skills and experience that is guided by their explanatory models. Likewise, many biomedical practices are guided by observation and experi- ence and have not been tested quantitatively. New medicines must have rigor- ous proof of efficacy and safety before clinical use. Tests, procedures, and treatments, however, are not similarly constrained. Western physicians, like alternative practitioners, use the same well-developed clinical observational skills and experience, guided by their explanatory biomedical model. Some of these discrepancies are disappearing, and the emphasis is now on evidence- based practice and the rapid growth of CAM research.
This text does not offer meticulous documentation for all claims that are made by the various therapies. The National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health (NIH) has
 

 
12 Unit 1 • Healing Practices
been mandated to explore complementary and alternative healing practices in the context of rigorous science, to train researchers, and to provide the public with authoritative information. NCCAM has established 16 research centers to explore the safety and efficacy of a wide range of therapies. In addition, NCCAM funds hundreds of research projects and grants every year. The NIH Office of Dietary Supplements is conducting scientific studies regarding the role of dietary supplements in the improvement of health care. As a result of these and other international efforts, the evidence base for alternative thera- pies has grown significantly.
The results of scientific studies can be accessed at two websites. NCCAM and the National Library of Medicine (NLM) have partnered to create CAM on PubMed ( nccam.nih.gov/research/camonpubmed/ ). This site provides access to citations from the MEDLINE database and links to many full-text articles at journal websites. The Cochrane Library ( www.update-software. com/cochrane/ ), an international effort, consists of a regularly updated col- lection of evidence-based medicine databases, including the Cochrane Data- base of Systematic Reviews. This site lists thousands of randomized trials for various alternative therapies. This information is extremely helpful for both consumers and providers of health care. The reader is advised to access these sites for information regarding the latest research results. Chapter 3 covers evidence-based nursing practice in more detail.
CONSUMERS
Many Americans are looking beyond conventional medicine for relief from illness and improvement of health. According to a number of random sur- veys, two thirds of adults in the United States use one or more types of alter- native medicine, often to treat a chronic medical condition such as one of those listed in Box 1.3 . Most of these consumers fail to discuss the use of alter- native therapies with their primary conventional practitioner, even though the vast majority of people use both approaches simultaneously. In general, alternative therapies are more commonly used by women than by men, as well as by people with higher levels of education. Latinos have a higher rate of use (50%–90%) compared with European Americans ( Buchan et al., 2012 ; Lachance et al., 2009 ; Ortiz, Shields, Clauson, & Clay, 2007 ; Sirois, 2008 ). A random study of 1,261 adults in Australia found that 61.7% of the individuals had used self-prescribed CAM or visited a CAM practitioner. A significant proportion of the sample did not seek advice from their primary care physi- cian before using CAM ( Thomson, Jones, Evans, & Leslie, 2012 ).
The mainstream medical community can no longer ignore alternative therapies. The public interest is extensive and growing. One has only to look at the proliferation of popular health books, health food stores, and clinics offering healing therapies to realize that this interest cannot be dismissed. In March 2000, President Clinton ordered the establishment of the White House Commission on Complementary and Alternative Medicine Policy in an attempt to integrate conventional and alternative medicine. The mission of
 

 
Chapter 1 • Integrative Healing 13
the advisory committee was to make legislative and administrative recom- mendations for the education and training of health care professionals and to make suggestions for access and delivery of health care.
What are consumers seeking from alternative medicine? Some have the same goal for both types of medicine, such as control of chronic pain with pain medications and acupuncture. Other consumers may have a different expectation for each approach, such as seeing a conventional practitioner for antibiotics to eradicate an infection and using an alternative practitioner to improve natural immunity through a healthy lifestyle. A person receiving chemotherapy may use meditation and visualization to control the side effects of the chemotherapeutic agents. People who combine conventional and alter- native therapies are making therapeutic choices on their own and assuming responsibility for their own health.
It is important for nurses to understand the reasons consumers choose alternative practitioners. Some utilize alternative healers because of financial, geographic, and cultural barriers to biomedical care. Many turn to alternative healers for a sense of hope, control, personal attention, physical contact, and regard for the whole person that seems to be overlooked in conventional med- icine. Some of the common reasons for seeking alternative practitioners are listed in Box 1.4 .
It may be difficult for consumers to figure out how and where to get the best health care. At times it may be problematic to find reliable information to
BOX 1.3
Frequently Reported Conditions of Those Seeking Alternative Therapies
Back pain Head cold Neck pain Joint pain Arthritis Anxiety/depression Stomach upset Headache Chronic pain Insomnia
Source: National Center for Complementary and Alternative Medicine. 2007 Statistics on CAM Use in the United States. Retrieved from http://nccam.nih.gov/news/camstats/2007/index.htm
 

 
14 Unit 1 • Healing Practices
help separate the healers from those who pretend to have medical knowledge. Consumers should be wary of healers who
• say they have all the answers. • maintain that theirs is the only effective therapy. • promise overnight success. • refuse to include other practitioners as part of the healing team. • seem more interested in money than in people’s well-being. ( Tiedje, 1998 )
Some alternative specialties are more regulated and licensed than oth- ers, but none come with guarantees any more than conventional medicine comes with guarantees. Consumers may want to research the background, qualifications, and competence of any health care provider—alternative, con- ventional, or integrative. Most types of alternative practices have national organizations of practitioners that are familiar with legislation, state licensing, certification, or registration laws. Many of these organizations are found in the resource section at the back of each chapter in this text.
INTEGRATED NURSING PRACTICE
Nursing has been moving away from a biomedical orientation that has largely defined and directed it toward a nursing-caring-healing model. Watson (1997) described it as a shift from a nursing qua medicine paradigm (nurses helping
BOX 1.4
Reasons for Choosing Alternative Therapies
Pursue therapeutic benefit Seek a degree of wellness not supported in biomedicine Attend to quality-of-life issues Prefer high personal involvement in decision making Practitioners spend more time with clients Believe conventional medicine treats symptoms, not the underlying cause Find conventional medical treatments to be lacking or ineffective Avoid toxicities and/or invasiveness of conventional interventions Decrease use of prescribed or over-the-counter medications Identify with a particular healing system as a part of cultural background
Sources: Clement, Chen, Burke, Clement, & Zazzali, 2006 ; National Center for Complementary and Alternative Medicine, 2012. 2007 Statistics on CAM Use in the United States. Retrieved from http:// www.nccam.nih.gov/news/camstats/2007/index/.htm ; Saydah & Eberhardt, 2006 .
 

 
Chapter 1 • Integrative Healing 15
physicians practice medicine) to a nursing qua nursing paradigm (practicing the distinct art and science of nursing). This movement has reconnected nurses with the finest tradition of Florence Nightingale in using their hands, heart, and head in creating healing environments. The modern nurse–healer draws on biomedical and caring–healing models by utilizing technology and focusing on caring relationships and healing processes. Dossey, Keegan, and Guzzetta ( 2005 ) have described the modern nurse–healer as having a hybrid of scientific skills and spiritual commitment. Nurses need scientific principles, methods, and skills, but they also need to teach people ways to become more self-reliant as they shift from caregivers to healers.
In 1979, Watson published her text Nursing: The Philosophy and Science of Caring, which evolved from her experiences of nursing within the limitations of traditional biomedical models. She sought to bring new meaning to the nursing paradigm of caring-healing and health. Her caritas process was devel- oped to balance the “cure” stance of Western medicine. Watson’s theory has since evolved into “clinical caritas processes.” This perspective describes nurse–client relationships based on spirituality, love, caring, healing environ- ments, wholeness, and unity of being ( Watson, 2007 ).
The art of nursing is in being there, with another person or persons, in an atmosphere of caring. Caring involves compassion and sensitivity to each person within the context of her or his entire life. In the past, the biomedical model urged nurses not to care too much or get too involved. Caring, success- ful nurses, however, do get involved with clients as they practice nursing as an art instead of nursing as just a day-to-day job. Caring is a philosophy or context within which nurses practice nursing. Their practice is made caring not by the tools they use but by the attitude or perspective they bring. It is possible, of course, to use the tools of alternative therapies in the same reduc- tionist way of biomedicine. For example, if one knows the pressure point for headaches and simply uses this pressure point for pain relief without any fur- ther assessment, it can hardly be considered holistic or healing. The symptom of headache has been addressed, but the meaning of the headache and the person’s experience of the pain has been totally ignored.
The plurality of the sick care, health care system may be one of its great- est strengths. It enables us to meet the diverse needs of diverse populations. The question is, How can we combine the best ideas of conventional nursing practice and complementary and alternative healing practices? First, we must have education. At the basic level, our nursing curricula must include courses in caring and alternative therapies. All nurses could learn Therapeutic Touch (TT), healthy dietary plans, the use of basic herbs, as well as the use of visual- ization in the healing process. Since 2004, basic alternative therapies content is included in the NCLEX-RN examination. Because state boards of nursing vary in their detail of criteria for alternative therapies and nursing practice, it is critical that you check the Nurse Practice Act of your state.
The White House Commission on Complementary and Alternative Medicine states that “since the public utilizes both conventional health care and complementary and alternative medicine (CAM), the Commission
 

 
16 Unit 1 • Healing Practices
believes that this reality should be reflected in the education and training of all health practitioners” ( National Institutes of Health, 2002 , p. 51 ). The Com- mission goes on to say that “although there has been notable progress in introducing CAM into medical, nursing, and other fields of conventional health care education in recent years, more needs to be done” (p. 51 ). We must also participate in continuing education courses to expand our knowledge beyond the basic level. With additional education, we can learn such thera- pies as basic massage and reflexology, meditation, and yoga. Some nurses will choose to continue their education through master of science in nursing degrees with a holistic nursing concentration or through certificate programs for nurse practitioners. Other nurses will choose to complete formal programs in alternative medicine such as naturopathy, Ayurveda, homeopathy, chiro- practic medicine, or hypnotherapy. Advanced practice nurses should provide leadership in research and education in alternative therapies ( Denner, 2007 ).
Next, we must provide community education. We must provide people with information, tools, skills, and support to enable them to make healthy decisions about life and negotiate their way through the health care systems. As nurses, we have the opportunity to initiate conversations about alternative therapies. Growing immigrant populations call for more attention to a variety of health expectations, needs, and preferences. We must also become familiar with the alternative practices immigrants bring with them. An important con- sideration in evidence-based practice is patient preference. We must also attempt to keep ourselves healthy and to exemplify good health because teaching by example is a powerful influence. We can teach wherever our prac- tice is located: acute care, long-term care, community nurse-managed centers, and in areas of advanced practice nursing. And, finally, we must document our  findings, utilize and participate in nursing research, keep current with evidence-based practice, and design new studies to measure the effectiveness of various healing practices.
Self-Care
Before we nurses can care for clients, we must first learn to value and care for ourselves. One of your goals in reading this text might be to discover how to care for yourself more effectively, because only then will you have the energy to care for your clients. Caring for yourself means reducing unnecessary stress, managing conflict effectively, communicating clearly with family and friends, and taking time out for yourself. Caring for yourself may include developing a daily routine in practices such as relaxation, meditation, prayer, yoga, communion with nature, and other such forms of contemplation. In Watson’s words, “If one is to work from a caring-healing paradigm, one must live it out in daily life” ( Watson, 1997 , p. 51 ). The following guidelines will help you maintain your self-care practices ( Jahnke, 1997 ):
• Choose self-care activities that appeal to you and fit into your lifestyle. • Do one or more of these practices every day. Consider them as impor-
tant as food and sleep.
 

 
Chapter 1 • Integrative Healing 17
• Seek guidance and support from teachers/practitioners if appropriate. • Find a good spot for your practice that is physically and mentally com-
fortable. • Build up your practice slowly. Success is not gained by aggressive or
compulsive practice. • Look for opportunities to practice with others. • Focus on relaxing. The foundation of all self-healing, health enhance-
ment, stress mastery, and personal empowerment is deep relaxation.
References
Buchan, S., Shakeel, M., Trinidade, A., Buchan, D., & Ah-See, K. (2012). The use of complementary and alternative medicine by nurses. British Journal of Nursing, 21(11): 672–675.
Clement, J. P., Chen, H. F., Burke, D., Clement, D. G., & Zazzali, J. L. (2006). Are consumers reshaping hospitals? Complementary and alternative medi- cine in U.S. hospitals, 1999–2003. Health Care Management Review, 131(2): 109–118.
Denner, S. S. (2007). The advanced prac- tice nurse and integration of comple- mentary and alternative medicine. Holistic Nursing Practice , 21(3): 152–159.
Dossey, B. M., Keegan, L. G., & Guzzetta, C. E. (2005). Holistic Nursing: A Hand- book for Practice (4th ed.). Sudbury, MA: Jones & Bartlett.
Duncan, A. D., Liechty, J. M., Miller, C.,  Chinoy, G., & Ricciardi, R. (2011). Employee use and perceived benefit of a complementary and alternative med- icine wellness clinic at a major military hospital. Journal of Alternative and Com- plementary Medicine, 9(17): 809–815.
Halcon, L. L., Chlan, L. L., Kreitzer, M. J., & Leonard, B. J. (2003). Complementary therapies and healing practices: Faculty/student beliefs and attitudes and the implications for nursing edu- cation. Journal of Professional Nursing , 19(6): 387–397.
Jahnke, R. (1997). The Healer Within . San Francisco, CA: Harper.
Lachance, L. L., Hawthorne, V., Brien, S., Hyland, M. E., Lewith, G. T., Verhoef, M. J., . . . Zick, S. (2009). Delphi-derived development of a common core for mea- suring complementary and alternative medicine prevalence. Journal of Alterna- tive and Complementary Medicine, 15(5): 489–494. doi: 10.1089/acm.2008.0430
National Center for Complementary and Alternative Medicine. (2011). Third strategic plan: 2011–2015. Retrieved from www.nccam.nih.gov/about/ plans/2011?nav=gsa
National Institutes of Health. (2002). White House Commission on Complemen- tary and Alternative Medicine Policy, Final Report . Washington, DC: U.S. Government Printing Office. Retrieved from www.whccamp.hhs.gov

 

ADDITIONAL INSTRUCTIONS FOR THE CLASS

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Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.

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Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

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Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.

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I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.

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For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.

• Late Policy

The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

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