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Introduction to Complementary, Alternative, and Traditional Therapies

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 Complementary Therapies

Introduction to
Complementary,
Alternative, and
Traditional Therapies
DEBRA KRAMLICH, RN, MSN, CCRN

The use of complementary, alternative, and traditional therapies is increasing in the United States, and patients
and their families are bringing these practices into the acute care setting. Acute and critical care nurses are in
a unique and trusted position to advocate for their patients and to promote safe incorporation of comple-
mentary, alternative, and traditional therapies into the plan of care. (Critical Care Nurse. 2014;34[6]:50-57)

C
omplementary and alternative medicine or modalities (CAM) are defined by the
National Center for Complementary and Alternative Medicine (NCCAM),1 National
Institutes of Health, as “health care approaches with a history of use or origins
outside of mainstream medicine.” Various forms of CAM have been reported for
centuries. Use of CAM declined with the appearance of antibiotics in the early 1900s
and then regained popularity in the 1970s.2 The World Health Organization3 has noted that various
forms of CAM have served as the primary health practice in developing countries for years and are
expanding worldwide in countries where more conventional medicine is predominant. Numerous
social, economic, and political factors have influenced the renewed interest in CAM in the United
States.4 More than 1800 CAM therapies have been identified that can offer both benefits and risks
to the users, so health care providers must have a basic knowledge of these therapies. In this col-
umn, I provide an overview of CAM therapies that nurses may encounter in their practices, with
specific attention to implications for acute and critical care nurses.

CNE Continuing Nursing Education

This article has been designated for CNE credit. A closed-book, multiple-choice examination follows this article,
which tests your knowledge of the following objectives:

1. Distinguish between types of complementary and alternative medicine or modalities

2. Discuss the significance of complementary and alternative medicine use for acute and critical care nurses
3. Identify benefits of nonpharmacologic therapies for critically ill patients

©2014 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2014807

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Background and Significance of CAM have indicated variable change in those disclosure rates;
The use of CAM practices, therapies, and products for instance, in cross-sectional surveys of pregnant women,
continues to increase exponentially as evidenced by analy- disclosure rates of CAM use increased from less than 1%
sis of data from the 2002 and 2007 National Health Inter- in 2006 to 50% in 2013. Disclosure rates in the United
view Surveys conducted by the National Institutes of Kingdom are 20% to 40%.13,14 A systematic review15 of dis-
Health (the most recent years for which data have been closure of CAM use by cancer patients and patient-doctor
analyzed and reported).5 Nearly 40% of adults and 12% communication about CAM use revealed that 20% to 77%
of children reported use of CAM.6 Adults reported spend- of the patients did not disclose that they used CAM. The
ing nearly $34 billion out of pocket on visits to CAM main reasons given for lack of disclosure included the
practitioners and purchase of CAM products, classes, physician’s lack of inquiry; the patient’s anticipation of
and materials.7 The most dramatic growth occurred in the physician’s disap-
provider-based therapies, such as chiropractic care (14.5% proval, disinterest, or Nearly two-thirds of CAM users
increase; P<.01), massage (67.2% increase; P<.01), inability to help; and have reported not discussing their
acupuncture (35.8% increase; P<.01), and folk medicine the patient’s percep- use with their physicians.
(208.3% increase; P<.01). Non–provider-based CAM tion that disclosure of
therapies, such as relaxation techniques, yoga, t’ai chi, CAM use is irrelevant to conventional care.13,15 Disclosure
and qigong, also had a statistically significant increase in seems to be particularly lower among African Americans,
growth (P<.01) during the 5-year span. Data from the Latinos, and Asian Americans than among non-Latino
2012 National Health Interview Survey have not been whites (P<.05), most likely related to differences in
fully analyzed and reported yet, but a preliminary access to and quality of conventional care.16
report8 suggests that nonvitamin, nonmineral dietary The lack of disclosure of CAM use is concerning for
supplements; chiropractic or osteopathic manipulation; several reasons. Herbal and dietary supplements may
yoga; and massage therapy were the most common com- cause adverse interactions with prescription medications,
plementary health approaches used. and use of the supplements may result in unanticipated
According to both the 2002 and 2007 surveys, use of adverse consequences, such as hypertension, hypo-
CAM was more likely when access to conventional care glycemia, and hemorrhage.17,18 Acute and critical care
was restricted, care had been delayed due to cost, or med- nurses are in a unique and trusted position to advocate
ical care needs continued to be unmet (P<.01).5 Data from for their patients. Basic knowledge of CAM may facilitate
the 2001 Health Care Quality Survey suggested that indi- nurses’ communication with patients and patients’ fam-
viduals who experienced unmet medical needs and dis- ily members about the patients’ CAM practices, support
crimination based on ability to pay, ability to speak English, culturally sensitive and competent care, and promote
racial or ethnic background, and sex were statistically safety by helping CAM users make informed decisions.
significantly more likely than other individuals to use CAM
(P<.01).9 Health care workers were more likely than the Definitions and Categories of
general population to use all forms of CAM (P<.01).10 CAM Therapies
Despite the use of CAM by health care workers, nearly Although NCCAM generally applies the term comple-
two-thirds of the users have reported not discussing their mentary health approaches to a broad spectrum of practices,
use of CAM with their physicians.5,11 More recent studies12 distinctions exist among the various approaches1,2:
• Complementary: use of a nonmainstream approach
together with conventional medicine
Author
• Alternative: use of a nonmainstream approach in
Debra Kramlich is an assistant professor of nursing, University of
New England, Portland, Maine. place of conventional medicine
• Traditional: cultural healing systems that have
Corresponding author: Debra Kramlich, RN, MSN, CCRN, Assistant Professor of Nursing,
University of New England, 716 Stevens Ave, Portland, ME 04103 (e-mail: dkramlich persisted for thousands of years
@maine.rr.com). • Integrative: integration of nonmainstream practices
To purchase electronic or print reprints, contact the American Association of Critical- into conventional medical treatment and health
Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949)
362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected]. promotion

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 NCCAM identifies 2 broad subgroups of therapies— or body-based therapies. Examples include chiropractic
natural products and mind-and-body practices—classi- medicine, osteopathic manipulative medicine, movement
fied into the following 5 categories, with many individual therapy, massage, and other body work, such as rolfing
therapies crossing categories: biologically based thera- (a form of soft-tissue manipulation). Practitioners of
pies, mind-body therapies, manipulative and body-based these therapies may be licensed or certified and have
therapies, energy therapies, and systems of care.1,19 The received more extensive education and training than
following material is a brief description of each category; have practitioners of other therapies. The practices may
examples and potential risks13,17,20-25 are summarized in often be regulated, as well; credentialing of practitioners
the Table. is established by local and state governments and profes-
sional organizations. No standardized national system for
Biologically Based Therapies credentialing complementary health practitioners currently
Biologically based therapies use substances typically exists in the United States.26 Some concerns about manip-
found in nature and include herbs and essential oils, ulative therapies include delay or avoidance in seeking
special diets (eg, Ayurveda, hot-cold balance), nutritional conventional care and aggravation of existing conditions.13
and food supplements, and other products such as carti-
lage. According to NCCAM, these therapies are the most Energy Therapies
popular of the complementary therapies; nearly 18% of Energy therapies focus on the electromagnetic and
adults have reported use of so-called natural, nonvitamin, biofield energies that are thought to originate in or near
nonmineral the body and on energy from other sources. These eso-
Biologically based therapies are the most
products.6 teric therapies may modify, manipulate, enhance, or sim-
popular of the complementary therapies;
These prod- ply support the energy fields.19 Veritable energy fields,
about 18% of adults have reported use of
ucts may be which are measurable, involve use of magnet or light
natural, nonvitamin, nonmineral products.
consumed, therapy.20 Putative energy therapies are not yet measura-
1
applied topically, or inhaled. NCCAM notes that although ble and are based on the concept that humans (and,
some of these products have been well studied, many some think, animals, plants, and inanimate objects) are
have not had anticipated effects, and research into the infused with subtle forms of energy that connect every-
safety and efficacy of supplements is ongoing. Such prod- thing.20,21 The energy is called by various names, such as
ucts may be disruptive to normal physiological processes, ki by the Japanese, prana by the Hindus, qi or chi by the
such as coagulation and glucose regulation, and interac- Chinese, and oki, orenda, or ton by Native Americans.21
tions with conventional medications may produce dev- Energy therapies may include healing touch, therapeutic
astating effects, as noted in the Table. touch, Reiki, acupuncture or acupressure, and reflexol-
ogy.20 Concerns with some of the energy therapies
Mind-Body Therapies include inaccurate diagnoses of conditions by practition-
Interventions that use a variety of techniques to ers and safety issues associated with the manipulative
enhance the mind’s ability to affect body functions and therapies.13
symptoms are known as mind-body therapies (or mind-
body-spirit therapies, from a holistic perspective). These Systems of Care
therapies are among the most widely used category of Some practices do not fit into the other categories
CAM1 and include guided imagery, visualization, pro- and have evolved from cultural and spiritual traditions,
gressive muscle relaxation, meditation, prayer, music such as Ayurvedic medicine, traditional Chinese medi-
therapy, light therapy, art therapy, journaling, story- cine, folk medicine, homeopathy, and naturopathy.
telling, biofeedback, hypnosis, humor, animal-assisted These practices encompass whole systems of care built
therapy, t’ai chi, qigong, and yoga. on theory and practices that evolved earlier than and
apart from more conventional Western medicine. Some
Manipulative and Body-Based Therapies cultural healing systems, such as Hmong, Samoan,
Therapies that apply pressure to, manipulate, or Somali, Latin American, and Native American, have
move 1 or more body parts are known as manipulative persisted for centuries.19,20

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 Table Common examples, uses, and potential safety concerns of selected complementary, alternative, and traditional therapies
Therapy Examples Uses Potential safety concerns
Biologically based therapies Black cohosh Hormonal balance May potentiate hormone
replacement therapy
Echinacea Colds Liver damage, interference
with immunosuppressants
Garlic Infection, hypertension, Bleeding, hypoglycemia,
hyperlipidemias interference with
antihypertensives
Ginkgo biloba Attention and memory Increased bleeding, decreased
effectiveness of anticonvul-
sants
Ginseng Mood stabilization Potentiated side effects of oral
contraceptives, extreme
mood swings, resistance to
loop diuretics, reduces
effect of warfarin
Licorice Respiratory and gastrointestinal Depletes potassium, interferes
conditions with glucose and thyroid
regulation, potentiates
effects of corticosteroids
Ma huang (ephedra) Allergies, respiratory condi- Hypertension, arrhythmias,
tions, weight loss glucose regulation
St John’s wort Depression Interferes with anticonvul-
sants, prolongs effect of
anesthesia, severe agitation
and confusion, decreased
prothrombin time
Valerian Insomnia, muscle pain, Extreme sedation, prolonged
menstrual cramps effect of anesthesia
Mind-body therapies Biofeedback Trained awareness of physio- Considered safe
logical functions by using
sensors
Hypnotherapy Produces altered state of May aggravate mental
consciousness illnesses
Qigong/t’ai chi Both forms of integrated Can be overdone, causing
physical postures, breathing soreness, and aggravating
techniques, and focused preexisting physical
intention conditions
Yoga Various traditions involving Can be overdone, certain
postures and breath control postures not recommended
for various conditions
Manipulative and body- Alexander technique/Feldenkrais Forms of movement education People may stop taking
based therapies method/Trager psychophysical and mind-body movement, prescribed medications
movement integration, teaches individu-
als efficiency of somatic
awareness, relaxation
Chiropractic medicine Spinal manipulation, may also Syncope, numbness/tingling
include topical and ingested after manipulation, cerebro-
supplements vascular events, people may
stop taking prescribed
medications
Osteopathic manipulative Manipulation of spine, joints, Relatively safe but reports of
medicine and soft tissue aggravation of underlying
conditions/symptoms
Rolfing/structural integration Hands-on manipulation of Should be avoided by those
deep connective tissue with bleeding, connective
tissue, and bone disorders

Continued

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 Table Continued

Therapy Examples Uses Potential safety concerns

Energy therapies Acupuncture, acupressure, Stimulation of specific body Risk of injury of skin or
shiatsu points by using small nerves, infection
needles or the fingers
Magnet therapy Application or wearing of Unproven, may be unsafe for
magnets those with pacemakers or
insulin pumps
Reflexology Application of pressure to Generally safe
specific points and areas on
the feet, hands, or ears
Healing touch, therapeutic Various forms of gentle, non- No known contraindications
touch, Reiki manipulative light touch or or safety issues
slightly hands-off the body
Systems of care Ayurveda—from India, world’s Balancing cooking, timing, Contamination and toxic
oldest medical system and consumption foods, use effects associated with
of herbal compounds, some herbal compounds
behavioral routines
Hmong Use cupping (creating suc- Inflammation, bleeding
tion) and coining (rubbing
coin over skin)
Homeopathy Dilute substances tailored Products may contain sub-
for specific patient, regulated stantial active ingredients,
by the Food and Drug alcohol, and heavy metals
Administration
Naturopathy Combination of nutrition, Same concerns with herbal
herbal medicine, homeopa- remedies and other uncon-
thy, hydrotherapy, and ventional practices
lifestyle adjustment
Traditional Chinese medicine In addition to herbs and Burns, skin inflammation
acupuncture, use moxibus-
tion (“burning of mugwort”)

Implications for Acute and elderly than to younger persons. Compared with younger
Critical Care Nurses and stronger patients, older and frailer patients admitted
The significance of CAM awareness for acute and to the intensive care unit experience higher rates of mor-
critical care nurses cannot be overemphasized. The tality and morbidity, affecting quality of life and placing
demographics of acute and critical care patients are rap- a greater burden on resources.31,32
idly changing because of increased immigration and life The overall increased use of CAM by patients who
expectancy. Cultural beliefs about health and illness may may think that these therapies are safe and who have lit-
delay access to conventional care and decrease medical tle understanding of the potential adverse effects place
adherence, often with catastrophic results.27 For instance, these patients at increased risk for admission to an inten-
Asian and Latino immigrants often see illness as the result sive care unit.13 Examples of these effects (see the Table)
of imbalances in various energies and may seek the advice include acute tubular necrosis (some traditional Chinese
of folk healers and use the immigrants’ traditional meth- and Ayurvedic herbal medicines), severe hemorrhage
ods for restoring balance as a first resort, thus delaying (Gingko biloba, garlic, ginger), hypertensive crisis and
potentially lifesaving interventions.28,29 cardiac arrhythmias (ginseng, yohimbe, ephedra), severe
Use of CAM is reportedly increasing among elderly electrolyte disturbances (licorice), and cerebrovascular
persons, including concomitant use of herbal supplements events (spinal manipulation, particularly when performed
with conventional medications.30 Adverse reactions due by nonlicensed practitioners).
to polypharmacy, increased sensitivity to some medica- Although patients may be admitted to an acute care
tions, and decreased organ function for medication pro- unit because of the adverse effects of CAM, these thera-
cessing and clearance may be of greater concern to the pies may also be safely incorporated to provide comfort

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and enhance care. Critical illness and injury are disruptive are already physiologically compromised.13,21-24 For more
to families. Families of critically ill patients have identi- information, the NCCAM website (http://nccam.nih.gov/)
fied specific needs, such as shared decision making and provides a wealth of resources for health professionals
the recognition of and respect for cultural norms and and consumers to promote safe incorporation of CAM
patients’ preferences.33,34 The critical care environment is into the plan of care, including how to talk to patients
often chaotic, adding to the stress and anxiety patients and patients’ families about their practices.
and patients’ families experience. The inclusion of CAM, Incorporation of CAM therapies may be more chal-
particularly therapies already practiced by a patient and lenging in the critical care setting because of constraints
the patient’s family, may contribute to a healing envi- such as limited space, presence of biomedical equipment
ronment. Nonpharmacological CAM therapies, such as and monitoring devices, and frequent interventions. A
music, guided imagery, massage, and animal-assisted patient’s physiological stability is also of concern. Caring
therapy, may help decrease unpleasant signs and symp- is at the heart of healing, and nurses are skilled at com-
toms and promote healing. Such therapies can amelio- bining scien-
rate the adverse experience of critical illness in countless tific evidence More acute and critical care nurses have
ways: improved sleep; decreased anxiety and discomfort; with caring reported that they use various forms of
lowered heart rate, respiratory rate, and blood pressure; practices to CAM in their own self-care to decrease
decreased levels of stress hormones; immune system meet the stress and enhance health and well-being.
stimulation; normalized intestinal motility; and reduced unique needs
need for analgesics and sedatives.35,36 In patients with of complex, vulnerable, critically ill patients and the
life-threatening illness for whom conventional care may patients’ families. Through awareness, acceptance, col-
have been unsuccessful or escalation of care may be laboration, and creativity, acute and critical care nurses
deemed too risky or no longer beneficial, CAM therapies can create a safe and comfortable setting for patients
may be considered to enhance the patients’ comfort.37 and patients’ families. Open communication, including
The goal of CAM therapies is not to replace modern acknowledgment of the beliefs and preferences of a
medicine, as the term might suggest. Rather, CAM may patient and the patient’s family members, can enhance
be integrated as an adjunct to conventional medical partnerships necessary to promote a healing environ-
practices.38 More acute and critical care nurses have ment. Resources such as those provided by NCCAM can
reported that they use various forms of CAM in their own help nurses expand their awareness and knowledge of
self-care to decrease stress and enhance health and well- CAM therapies. CCN
being.39 Many nurses have reported becoming practition- Financial Disclosures
ers of these therapies to expand their own strategies to None reported.

provide holistic care to patients and families.38 More recent

studies conducted in the United States,40 Australia,41 Hong Now that you’ve read the article, create or contribute to an online discussion
about this topic using eLetters. Just visit www.ccnonline.org and select the article
Kong,42 and Scotland43 have had similar findings. Despite you want to comment on. In the full-text or PDF view of the article, click
“Responses” in the middle column and then “Submit a response.”
the availability of information, the majority of critical care
nurses responding to a survey reported limited training in
or knowledge of numerous CAM therapies.44 Of particular
To learn more about complementary therapies in the critical care
concern is the respondents’ relatively limited knowledge of setting, read “Use of Complementary and Alternative Therapies: A
CAM therapies that could potentially cause serious adverse National Survey of Critical Care Nurses” by Tracy et al in the Amer-
effects, such as herbal and traditional Chinese medicines. ican Journal of Critical Care, September 2005;14:404-415. Available
at www.ajcconline.org.
Nurses need to be aware of the legal and ethical
aspects of incorporating CAM into the plan of care, References
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tutes of Health. http://nccam.nih.gov/sites/nccam.nih.gov/files/D347 questionnaire survey. BJOG. 2014:121(8):1015-1019. doi:10.1111/1471-
_05-25-2012.pdf. Published October 2008. Updated May 2012. 0528.12618.
Accessed September 9, 2014. 44. Cooke M, Mitchell M, Tiralongo E, Murfield J. Complementary and alter-
21. Fontaine KL, ed. Complementary and Alternative Therapies for Nursing native medicine and critical care nurses: a survey of knowledge and
Practice. 2nd ed. Upper Saddle River, NJ: Pearson Prentice Hall; 2005. practices in Australia. Aust Crit Care. 2012;2(4):213-223. doi:10.1016
22. Sweet ES, Standish LJ, Goff BA, Andersen MR. Adverse events associ- /j.aucc.2011.12.055.
ated with complementary and alternative medicine use in ovarian 45. Ernst E, Cohen MH, Stone J. Ethical problems arising in evidence-based
cancer patients. Integr Cancer Ther. 2013;12(6):508-516. doi:10.1177 complementary and alternative medicine. J Med Ethics. 2004;30:156-159.
/1534735413485815. doi:10.1136/jme.2003.007021.
23. Ventola CL. Current issues regarding complementary and alternative
medicine (CAM) in the United States, part 2: regulatory and safety con-
cerns and proposed governmental policy changes with respect to
dietary supplements. P T. 2010;35(9):514-522.
24. Klempner SJ, Costa DB, Wu PA, Ariyabuddhiphongs KD. Safety of cup-
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729-731. doi:10.1089/acm.2011.0791.
25. Haynes MJ, Vincent K, Fischoff C, Bremner AP, Lanlo O, Hankey GJ.
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.2012.03004.x.

56 CriticalCareNurse Vol 34, No. 6, DECEMBER 2014 www.ccnonline.org

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CNE Test Test ID C1463: Introduction to Complementary, Alternative, and Traditional Therapies
Learning objectives: 1. Distinguish between types of complementary and alternative medicine or modalities 2. Discuss the significance of complementary and
alternative medicine use for acute and critical care nurses 3. Identify benefits of nonpharmacologic therapies for critically ill patients

1. Which of the following is the definition of complementary and alter- 7. According to the National Center for Complementary and Alternative
native medicine or modalities (CAM)? Medicine, which type of therapy is the most popular among adults?
a. Approaches with a history of use or origin outside of mainstream medicine a. Biologically based therapy
b. Approaches that evolved from cultural and spiritual traditions b. Energy therapy
c. Approaches that evolved from Eastern medicine traditions c. Manipulative therapy
d. Approaches used primarily in developing countries d. Mind-body therapy

2. What percentage of adults reported use of CAM in recent studies 8. Which of the following techniques enhances the mind’s ability to
conducted by the National Institutes of Health? affect body functions and symptoms?
a. 20% c. 40% a. Acupressure c. Reiki
b. 30% d. 50% b. Healing touch d. Visualization

3. According to the National Institutes of Health Surveys, which 9. Which of the following therapies is considered a manipulative or
provider-based therapy experienced the most dramatic growth? body-based therapy?
a. Acupuncture a. Qigong c. T’ai chi
b. Chiropractic care b. Massage d. Yoga
c. Folk medicine
d. Massage 10. Which of the following therapies focuses on electromagnetic and
biofield energies?
4. Which of the following is a non–provider-based CAM therapy that a. Biofeedback c. Light therapy
has experienced a statistically significant increase in growth? b. Healing touch d. Yoga
a. Healing touch c. Reflexology
b. Massage d. Yoga 11. Which of the following is a potential adverse effect of CAM therapy?
a. Hypotension c. Severe hemorrhage
5. Why is lack of disclosure of CAM use concerning? b. Liver failure d. Sleep disturbance
a. Herbal and dietary supplements may cause adverse interactions with
prescription medications. 12. Which of the following is a reported benefit of nonpharmacologic
b. Herbal and dietary supplements are not regulated by the Food and Drug CAM therapy?
Administration. a. Decreased levels of stress hormones
c. Patients tend to take megadoses of vitamin and mineral supplements. b. Improved wound healing
d. The recommended daily allowance of dietary supplements is not known. c. Increased intestinal motility
d. Stabilized heart and respiratory rates
6. Which of the following is considered a biologically based therapy?
a. Acupuncture c. Essential oils 13. Which of the following biologically based therapies is of immedi-
b. Biofeedback d. Light therapy ate concern for a patient undergoing general anesthesia?
a. Echinacea c. Licorice
b. Ginseng d. Valerian
Test answers: Mark only one box for your answer to each question. You may photocopy this form.
1.  a 2.  a 3.  a 4.  a 5.  a 6.  a 7.  a 8.  a 9.  a 10.  a 11.  a 12.  a 13.  a
b b b b b b b b b b b b b
c c c c c c c c c c c c c
d d d d d d d d d d d d d
Test ID: C1463 Form expires: December 1, 2017 Contact hours: 1.0 Pharma hours: 0.0 Fee: AACN members, $0; nonmembers, $10 Passing score: 10 correct (77%)
Synergy CERP Category A Test writer: Lori Williams, DNP, RNC-NIC, CCRN, NNP-BC

Program evaluation Name Member #

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Address
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For faster processing, take nursing practice  
E-mail
this CNE test online at My expectations were met  
This method of CNE is effective RN Lic. 1/St RN Lic. 2/St
www.ccnonline.org for this content  
or mail this entire page to: The level of difficulty of this test was: Payment by:  Visa  M/C  AMEX  Discover  Check
AACN, 101 Columbia  easy  medium  difficult
To complete this program, Card # Expiration Date
Aliso Viejo, CA 92656.
it took me hours/minutes. Signature
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AACN has been approved as a provider of continuing education in nursing by the State Boards of Nursing of Alabama (#ABNP0062), California (#CEP1036), and Louisiana (#LSBN12). AACN
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Introduction to Complementary, Alternative, and Traditional Therapies
Debra Kramlich
Crit Care Nurse 2014;34 50-56 10.4037/ccn2014807
©2014 American Association of Critical-Care Nurses
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