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Improving practice
The trouble with aromatherapy, Evidence-based practice, evaluating treatment, the difference between signs and symptoms, using a treatment plan, using the nursing process.
The trouble with aromatherapy
"It is simply understood that it is an ethical obligation or duty of anyone offering a therapy to 'remove what doesn't work and improve what does work ….. Evidence-based medicine is now what is expected of any clinical discipline/therapy and Aromatherapy will be seriously questioned if it doesn't show moves towards this".
(MEMO From: Sylla Sheppard-Hanger and Michael Kirk-Smith to the education committees of the major International Aromatherapy Organisations).
The reputation and acceptance of modern aromatherapy can only be as good as the people who practice it. Much of the existing aromatherapy training is based on unquestioned practice, what has been researched is often from (by admission of the International Federation of Aromatherapy
(IFA) the food and perfume industry, or relics from traditional herbal medicine based on the oral intake of plant material as opposed to chemical distillation or extraction.
After contacting the
IFA, Aromacaring was told that the IFA does not have the funds to finance researched-based practice, and there is no core-curriculum on which to measure
standards. The curriculum being taught at the various 'accredited' schools is
set by private individuals with college/tutor status. College and tutor
status requires an annual subscription to the membership association, meaning
that standards in training are not uniform, and are not validated by an
independent body.
The largest complementary therapy organisation in the
UK is the Federation of Holistic Therapists (FHT). Unfortunately, a lot of
the qualifications accepted by this organisation have evolved from Colleges of
Further Education initially offering aromatherapy as a beauty treatment module
in the 1970's and 80's. While some of the courses are quite comprehensive
there is a lot of variation in standards, some can be achieved over a few days
study and others are more comprehensive. They no means match the depth of some
of the more extensive Aromatherapy Organisations Council recognised courses (see
UK Organisations). One of the main
problems, even with more comprehensive courses, is that no one can agree on a
set standard, and there is no definitive authority of accurate information on
which practitioners can base their practice. Many popular aromatherapy
publications are based on the therapeutic properties of herbal remedies which
has been carried into some of the coursework in the Further Education
Colleges. Even the more reputable texts are full of ambiguities, often basing
precautions and contraindications on evidence from 'in vitro' experiments
and animals, or citing other authors whose methods were either ancient or equally
ambiguous by failing to specify chemotype, the source or variation of the oils
used.
However, this should not exclude some of the really exciting work being done with aromatherapy today by other dedicated practitioners, often by other professionals using aromatherapy to complement existing care. A lot of the of the clinical research currently available is done by people qualified in other disciplines such as chemistry, nursing, midwifery, psychiatry, learning disabilities and elderly care - all using a combination of their knowledge as opposed to insisting on using aromatherapy to the exclusion of other interventions. There is also a lot of useful information from the food, flavouring, and perfumery industry who use essential oils in much greater quantities, so having the finance to fund essential oil research.
There are one or two seemingly more comprehensive and critical sources of information available with access requiring an annual subscription or outright purchase beyond the means of most ordinary therapist. This serves to add a further tier to the hierarchy rather than unite therapists in sharing information (information in other health practices is not owned and argued about in this way - modern methods in nursing, medicine, pharmacy etc. are easily available in affordable textbooks and curriculum course work).
Conclusion
At
present there is no single independent governing body to take charge of aromatherapy
training and standards. There are however, a few associations which do set
higher minimum standards for membership and insist on evidence of continuing
professional development which is a positive move forwards (see UK Organisations and
addresses). If Aromatherapy is to continue to develop, ALL Therapists and the
various associations must agree to work together to set a core curriculum based
on sound evidence, provide a solid platform on which to base sound working
practices, and make knowledge affordable and available to everyone without
discrimination.
Evidence-based practice
The phrase 'evidence-based practice' has only entered the healthcare environment in the last
decade, yet it has quickly become an important aspect of modern care delivery, and has probably been the most instrumental catalyst in moving nursing forwards away from what are regarded now as ritualistic practices.
In order to move the practice of Aromatherapy forwards in the same way, treatment needs to be based on similar evidence, evaluated properly, and records of success shared with other practitioners.
What is evidence-based practice?
Muir Gray (1997) described it as :
"an approach to decision-making in which the clinician uses the best evidence available" .
For the last decade, nurses in particular have been trained to question the effectiveness of existing practice, critically examine the validity of modern research, and incorporate good practice into the clinical environment. There is plenty of research available on massage and the effects of essential oils - if Aromatherapist are not willing to access and share such information and change traditional practice in line with current research, Aromatherapy will never become wholly acceptable, remaining an alternative 'fringe' therapy rather than a positive contribution to complement existing care.
Evidence-based practice can either be based on
quantitative evidence (ie: evidence which can be measured, represented statistically and compared).
For example:
 | Evidence from controlled trials |
| Evidence from case-controlled studies |
| Evidence from comparisons between with or without intervention |
| Opinions of respected authorities (based on clinical experience), descriptive studies or reports of expert committees. |
Or evidence based on qualitative research (interpreting and comparing)
For example:
| Evidence based on professional experience |
| Evidence based on theory and not research |
| Evidence based on client or carer evaluation |
| Evidence which requires abstract judgement and comparison |
| Evidence passed on by other experts |
(Sackett et al 1996 and Muir Gray 1997).
How to practice evidence-based therapy
Whether quantitative or qualitative research is used to influence practice, the main point is that practice must be based on the "best evidence available". This requires considerable effort on the part of the therapist to continually seek to acquire sound knowledge on which to base their
treatment, and to be open to change as the profession continues to develop. This can be achieved by post-qualification learning (formal and informal). Informal learning can include studying reputable texts and professional journals; literature searches; accessing internet information including the major complementary therapy research organisations; guidance from professional associations; and getting together with other practitioners to share ideas. There must be the desire to continually improve practice and accept new ideas; show an enquiring mind; and to discriminate between 'good' and 'poor' research material.
A recent Royal College of Nursing Complementary Therapies in Nursing Conference
has proposed including a critical research module as a necessary component
before Nurses already qualified in a Complementary Therapy can practice their
skills on the ward.
Since
Aromacaring went on line 2 years ago, some of the aims have been to critically examine the sources of information on which the public and many practising therapist have based their knowledge; to differentiate between herbal remedies and modern essential oil research; to promote accountability of practice and professionalism by integrating evidence-based practice into complementary medicine; and to share this knowledge by providing links to
research. References have been provided for all the information on the site to enable the reader to access the same sources and make their own judgements.
An integral part of evidence-based practice is the proper evaluation of your own practice. Unless evaluation is realistic and accurate, the treatment cannot be justified. This means having the ability to evaluate treatment in an appropriate way and to change things that don't work. Perhaps this is the most difficult aspect of working with a complementary therapy, as success is often subjective by the very nature of it's holistic approach. However, if modern nursing now incorporates the holistic approach (Roper et al. 1990) but still maintains the ability for effective evaluation, so too can Aromatherapy.
Recommended criteria for effective treatment and evaluation
| Keeping up to date with current research evidence through continuing professional development. |
| Using evidence-based practice as a rationale for
treatment. |
| Setting specific and realistic goals based on experience, research evidence, and selective anecdotal evidence based on similar high professional standards. |
| Evaluate treatment using short and long term observations of physiological
signs*. |
| Evaluate treatment by recording short and long term observations of physiological, psychological and emotional
symptoms* and outcomes. |
| Record rationale, aims and evaluation on treatment documentation. |
| Review each treatment, changing priorities where necessary to reflect newly acquired knowledge, changing client circumstances, prior success, or non-success. |
*The difference between signs and symptoms
A 'sign' is something that is physically observable by the practitioner and client (eg: rash, bruising, swelling etc). A 'symptom' is an experienced feeling, discomfort or pain. Physiological signs are easy to evaluate using measurements, estimations of affected area, colour, swelling, appearance. Symptoms are less easily measured but can be given scores (e.g.: increasing in intensity from a scale of 1 to 10). Similar tolerance scales based on the ability to cope will start to include other variables such as social and emotional factors - it is important to record these as part of a holistic evaluation.
Using the Treatment plan
The client treatment record has been adapted from the nursing process using assessment, planning care, delivering care, and evaluation as an integral part of the treatment process. There is a section provided on the form to note the rationale for treatment and any relevant references to texts. Keeping such records will build into a valuable resource for future reference.
Below is a comparison between the nursing process, and how the Aromatherapist can use similar guidelines to improve practice.
Go to Sound practice, a critical look at other people's evidence
Shepppard-Hanger S,. Kirk-Smith M
Memo: www.atlanticinstitute.com/research.html
Long, A. (1996) Health services research: a radical approach to cross the research and development divide? In: Baker, M., Kirk, S.
(eds) Research and Development for the NHS: Evidence, evaluation and effectiveness Oxford: Radcliffe Medical Press.
Muir
Gray, J. (1997) Evidence-based Healthcare: How to make health policy and management decisions Edinburgh: Churchill
Livingstone.
Roper N,. Logan W W,. Tierney A J (1990) The Elements of Nursing London: Churchill Livingstone
Sackett, D. Rosenberg, W., Muir
Gray, J. et al (1996) Evidence-based medicine: what it is and what it isn't.
British Medical Journal 312: 7023, 71-72