University of Arizona College of Nursing Clinical Assistant Professor Patricia Daly, PhD, FNP-BC, ENP-BC, has been an emergency and urgent care nurse practitioner for more than 25 years. A 2013 graduate from the UA College of Nursing PhD program, she has championed integrative nursing techniques throughout her career. Currently, she investigates mindful-eating interventions to address obesity in adolescents and adults. We sat down with her recently to discuss her history with integrative health care.

How do you incorporate integrative health into pain management?

My interest actually began when I was working in emergency room nursing. Back then, adult and child patients were often kept in the same area, and working with children was a real focus of mine. Whenever I’d have to suture someone I’d explain that they’ll want to focus their attention away from the pain. For children the kindest thing you can be is fast, but you also want to engage their mind somewhere else. I began telling children participatory stories to help that distraction. It’s actually a real integrative therapy called guided imagery, a powerful psychological strategy that enhances coping skills. I can time the story to the length of the suture, so if need be it can be a very long story. But the child is always the hero. Interestingly, adults who happened to overhear these stories started asking me to tell them stories, too. They would also be the heroes if the story, but I’d always start out with, ‘You just won the lottery. Where are you going to travel?’ and go from there. It was a really effective use of integrative therapy and I still employ it today.

You’re a big advocate of alternative pain management. Can you tell us about that?

In all my years in the ER, I have never written a prescription for more than six narcotic pills because I think pain management is not done best with pharmacological agents. Considering today’s opioid epidemic, that’s really important. Almost every narcotic addict is addicted because one of us wrote the first script. They told them, ‘Take this for pain,’ when they should have said ‘You’re going to have pain and that’s not going to kill you, but that drug might kill you.’ I teach nurse practitioners that when someone is drug-seeking that person has a health care issue: its addiction. If you just write them a prescription for some medicine you’ve done nothing but perpetuate the problem. I tell students ‘Okay, try to go in that room and make it a win-win. You are not giving the narcotic pain prescription and the patient’s going to leave satisfied. That is your goal.’ That person is suffering and so it’s important to listen to the patient, and that’s what integrative health is about: the whole person.

How has integrative care changed over the years?

From my perspective, nursing has always been integrative. In the ‘70s, the definition of nursing was ‘helping people cope with illness or changes in their life cycle.’ That’s why nursing was always strong in hospice, always strong in end-of-life care. Comparatively, disease-focused models, or germ theory, for the most part doesn’t work. Health has to do with how much sleep you get, what you eat and other lifestyle choices. It’s important to realize that almost all of pharmacology imitates what your body does. Why can a Yogi lower their blood pressure at will without a beta-blocker? How can someone walk across hot coals without serious injury? The receptors that drugs tie to in your brain or other parts of your body didn’t grow there because they thought you might make a drug someday that might go there. That’s your body chemistry.  For some people it’s very controllable, and that’s where eastern medicine kind of came from. There is something more than we can measure, and I feel like nurses always know that.

How do you inform your students about the importance of integrative care?

I talk to students about balance constantly. In nursing, that’s especially true because a lot of them are overachievers. They can work all night. They have so much compassion, and they are so giving of themselves to the point where they don’t fill themselves back up. In the end, it’s about life balance. That’s true for almost every patient, too: You help them try to find some life balance, and integrative nursing is the way that’s done.

Moving toward a more progressive and culturally relevant approach to Native American health care, Indian Health Services (IHS) and the Centers for Medicare and Medicaid Services require culturally sensitive care in health care settings. In an effort to demonstrate this cultural competency, IHS hospitals now offer Native American healing ceremonies provided by traditional practitioners. But native ceremonial practices in these hospital settings are often curbed by hospital policy, according to Dr. Michelle Kahn-John, assistant professor at the University of Arizona College of Nursing. Now in the final stages of a two-year research project, Dr. Kahn-John, along with her collaborative team at the Tsehootsooi Medical Center in Fort Defiance, AZ, is assessing the effects of a traditional Diné (Navajo) healing ceremony on individuals suffering from emotional distress. She intends to make a case for expanding the role of traditional healers/practitioners in Indian health care and tribal settings and bring recognition to the value of traditional Native American healing and ceremonial approaches to health and wellbeing.

Tell us about your research project.

We are exploring symptoms of emotional distress and stress-related inflammation before and after a traditional Native American ceremonial healing intervention, present for centuries within the culture. We are seeking culturally congruent ways to impact the Native populations experience increased rates of mental health conditions, including depression, emotional distress and trauma and suicide. I am interested in knowing more about the innate strengths and protective factors associated with Diné culture and whether partaking in traditional ceremonies will improve physical and psychological health. Overall, the intent of this work is to enhance the health and wellbeing of native communities.

Can you tell us about the healing ceremony?

The Diné ceremony is a cleansing ceremony recommended for those dealing with grief, loss, trauma or a stressful life transition. Very little can be shared about the process of the sacred healing ceremony, as I’m obligated to the Navajo Nation and Hataałii Hózhóni, the medicine man/chanter who conducted the ceremonies, to maintain the privacy of the ceremonial process. Hózhóni works at the Tseéhootsooí Medical Center and conducted 25 ceremonies for this project. The ceremony lasts about two hours and involves chanting, prayer, offerings, and body-mind-spirit purification.

Can you share your inspiration for this project?

In my nursing practice I’ve seen individuals who have sought out Diné traditional healing and have found very effective paths to healing and recovery for their emotional and spiritual distress. Of my 22 years as a nurse, 17 of which have been with the Navajo Nation as a psychiatric mental health nurse practitioner, I’ve focused on patients who have serious depression, post-traumatic stress disorder, complex trauma, anxiety and chronic and severe mental illness.  Typically, we offer them standard western treatment: counseling, medications, group therapy and family therapy, and those approaches are mostly helpful and effective. But I really wanted to explore combining those with the healing potential of traditional practices – and approach we term integrative.

What is particularly unique about this approach?

I recognize that healing ceremonies are sacred to native people. Ceremonial processes are held in high regard by myself, the Hataałii, and Diné. Some may question the intent of assessing outcomes of ceremony within a research agenda, but my intent is to enhance the health of the Diné while exploring the outcomes of ceremonial practices which have been present for hundreds of years. My intention is careful and respectful and therefore we will not share the specific elements of the ceremony, but will focus on outcomes of the ceremony.

How does this project relate to integrative nursing and health?

Integrative nursing principles are congruent with the philosophy of Native American healing and ceremony. The first principle of integrative nursing is ‘human beings are whole systems inseparable from their environment’ and another principle is ‘nature has healing and restorative properties.’ The Diné healing ceremony addresses the complete patient, their body, mind, spirit, family and environment, and places them at the center of a healing intervention. As nurses and healers, it’s critical that we expand our awareness and knowledge of the multiple paths leading to health and wellbeing.

A nurse for 22 years and a psychiatric mental health nurse practitioner for 17, Michelle Kahn-John, PhD, RN, PMHNP-BC, GNP, has spent most of her career working with the Indian Health Service on the Navajo Nation in Arizona. In 2005, she led efforts to establish the first inpatient adolescent psychiatric unit for American Indians on a reservation, where cultural wisdom and healing were integrated into the treatment model. Her work continues to shed light on the beauty and the value in Native American cultural wisdom and healing practices.

“There’s a life lesson here: It’s not about you,” Barbara Rector tells residents and guests gathered on a shaded veranda at The Hacienda at the River, the latest assisted living community in the Watermark Retirement group. Behind her, a pair of majestic horses nibble hay, awaiting the morning’s therapy session. “Approach carefully, respect boundaries and be patient,” continues Rector, the Tucson equine therapy pioneer who directs the program. “If the horse doesn’t respond, don’t take it personally. The experience brings you outside yourself for the needs of another being.”

That caring philosophy extends beyond the horse corral to almost every facet of life at The Hacienda. Located at the base of the Catalina Foothills, within a stone’s throw of the Rillito River, the sprawling Spanish-style facility is peppered with native plants, picturesque gardens and soothing green spaces. Baby hummingbirds quietly nest within the branches of a tree near a burbling fountain. It feels more like a desert-bound luxury getaway than an independent living, assisted living and memory care community. But thanks to a partnership with the University of Arizona College of Nursing and its one-of-a-kind Integrative Nursing Faculty Fellowship (INFF), the Hacienda will be a unique environment where nurse faculty can practice and nurse students can learn relationship-centered, whole-person care that inspires optimal health and wellbeing – person and environment synergy at its max.

“Everything we use on this property is healthy. If trees bear fruit, they're edible. The herbs grown here will be used in the kitchen for residents' meals." ~ Dr. Deborah Williams, PhD, MPH, RN

“As the liaison between the College and Watermark Communities, my role is to carry this vision forward,” says Clinical Assistant Professor Deborah Williams, PhD, MPH, RN. “Everything we use on this property is healthy. If trees bear fruit, they’re edible. The herbs grown here will be used in the kitchen for residents’ meals.”

In addition to the equine therapy program, other integrative therapies offered at The Hacienda include aromatherapy, reflexology, acupressure and acupuncture. Horticultural therapeutic programming will also be featured at some of The Hacienda’s green spaces, and aquatic therapies and swimming will be presented at the therapy pool. All of it is geared toward encouraging a personal wellbeing for residents that resonates physically, spiritually and emotionally. The attention to detail benefits the day-to-day wellbeing of the residents, but it’s also part of a larger research initiative that draws on the College’s integrative health expertise.

Thanks to the early planning by Dr. Mary Koithan, UA College of Nursing associate dean for student support and community engagement, The Hacienda’s facilities will be a ‘living laboratory’ for the College of Nursing. “It was essential that we bring in students so they can learn what it really means to take care of someone in an integrative way,” says Dr. Williams. INFF Fellows, bachelor of science in nursing (BSN), doctor of nursing practice (DNP), and PhD nursing students will rotate through the community.

 “Moreover, we intend to quench our thirst for new knowledge. We will be assessing how integrative care therapies affect the quality of life of the residents,” says Dr. Williams. “I’m really interested in propelling nursing science forward so we can say, ‘Look, these techniques do affect health in a positive way, and here’s the evidence behind it.’” A fellow in the first INFF, Williams incorporated the integrative knowledge she gained into the classes she teaches and was encouraged by student responses. She noted that after discussions of aromatherapy and acupressure, students developing care plans for patients broadened their toolkits. “Instead of immediately going to Tylenol, they would ask patients, ‘Are you willing to try this other approach?” she says.

The benefits of integrative health techniques are manifold.  For example, therapeutic equine therapy programs are increasingly recognized as a viable form of occupational therapy and rehabilitative care after injury and illness. Evidence points to increased compassion, sense of purpose and confidence for seniors who interact with horses. Evidence from a recent research project measuring the heart rate of horses and the people interacting with them showed that the meditative heart rate of a horse at peace will actually sync with the person’s and calm their pulse. Gazing into the languid brown eyes of Joe and Prissy, two of the horses at The Hacienda, it’s easy to see why.

A new understanding and appreciation is opening up around integrative health. Thanks to programs like the INFF, which bring together inquisitive nursing faculty from across the country to learn about integrative health, and partnerships like the one with The Hacienda at the River, the UA College of Nursing strives to be on the forefront of that frontier. “It definitely changed my life,” Dr. Williams says of her involvement in integrative care. “Nature heals. And I know it changes the students’ lives, too. They no longer think within the parameters of medication first. It brings a whole new perspective of what it means to holistically care for a person.”

Melanie Begaye

First-year Master of Science for Entry to the Profession of Nursing (MEPN) student
B.S. in Nutritional Sciences with an emphasis in dietetics from the UA; from White Clay, AZ

Why did you decide to pursue a nursing degree?

I wanted to be a caring, compassionate, yet confident figure that advocates for the patient. In the past two years that I’ve conducted research and worked on other projects with Dr. Mary Koithan in the College of Nursing, one of the most important things I’ve learned is that nursing is so much more than just monitoring the patient. It’s important to hear the voice of the patient, help them have control of their care, be the figure that gives them the attention and care when they need it, and play a role in healthy habit promotion and disease prevention outside of the clinical setting.

What drew you to the UA College of Nursing?

I was drawn to the UA College of Nursing through the Partnership for Native American Cancer Prevention (NACP) undergraduate research program. Although I initially wanted to be a clinical dietitian, I began researching with Dr. Koithan. We focused on alternative and palliative therapies for cancer care side effects and quality of life improvement. In addition, I was given the opportunity to work with many nurses of different backgrounds and specialties from the college and from the community. These individuals offered amazing perspectives on the impact that a nurse may have on an individual and the community. I realized that being a nurse would help me achieve my goal of returning to the Navajo Nation and promoting wellness and traditional healing. 

What features of your program are you especially passionate about?

For the MEPN program, I'm excited about the fast pace and the immense amount of knowledge I can gain from an extraordinary range of talented, experienced nurses. I'm most passionate about caring for my future patients on the individual level and providing that important care that is crucial to a patient at their most vulnerable point. 

Share your favorite memory from your time at the CON.

Every day is an adventure for me at the College of Nursing. My favorite memories include the many light-hearted meetings with Dr. Koithan and the Tohono O'odham translators, Darlene and Linus, applying the final touches on my two research posters to present to the NACP panel, and, of course, performing my first head-to-toe physical assessment as a student nurse. 

How do you intend to Build Better Futures?

I intend to build better futures by inspiring future nurses by being a supportive, devoted role model. I also wish to continue my current project which is the creation and dissemination of cancer education materials in the Tohono O’odham (TO) language. This project, a collaboration of the UA CON and Tohono O’odham Cancer Program focuses on the translation of cancer overview guides into TO. These education materials are videos narrated in TO and utilize culturally appropriate images. So far, these materials have been distributed to TO area hospitals and to Community Health Representatives so that they are easily accessible to TO community members. Once I complete my degree program and have more expertise in patient care and the healthcare systems, I hope to expand this project to other chronic disease states, such as diabetes and cardiovascular disease, and to other Native American groups like the Hopi, Navajo, and Apache. This type of community health education should increase the Native American public’s knowledge on disease states and promote health behaviors like disease prevention, early diagnosis, and treatment compliance. These outcomes should increase quality of life in Native American patients and improve overall health in rural and urban native communities.

Arizona is home to 10,000 actively licensed massage therapists, each of whom averages 12 clients per week or roughly 7,000 client encounters a year. What if in addition to soothing cramped muscles those massage therapists could be enlisted and trained to help reduce skin cancer risk?

University of Arizona College of Nursing associate professor Lois J. Loescher, PhD, RN, FAAN, aims to answer that question thanks to a three-year $750,000 award from Arizona Biomedical Research Commission (ABRC) to train massage therapists, with their unique access to skin, to effectively communicate sun safety, identify and recognize suspicious skin lesions and provide resources for appropriate health care follow-up for their clients.

The study, “Massage Therapists Skin Health Awareness, Referral, and Education (MTsSHARE) to Reduce Skin Cancer Risk in Arizonans,” aims to address, expand and evaluate the effectiveness of skin surveillance in an innovative and previously unaddressed way.

According to the American Cancer Society, skin cancer is the most common form of cancer in the U.S., with more than five million cases occurring annually. In Arizona – a state that enjoys 299 sunny days a year – the incidence of non-melanoma skin cancer is three to six times higher than in the northern United States. Besides serious dangers like death and disfigurement, the costs of treating skin cancer exceed billions of dollars every year – another reason that early detection is so crucial.

“Our goal is to have a huge public health impact in skin cancer prevention and early detection...we want to promote a larger role for skin cancer prevention within massage therapy schools curricula and continuing education" ~ Lois Loescher, PhD, RN, FAAN

“We’re not suggesting that massage therapists should become dermatologists,” said Dr. Loescher. “All we’re doing is advocating for another pair of eyes on the skin.” Currently, massage therapists receive little formal training on skin cancer so Dr. Loescher and her team are developing online training that could be successfully adopted by massage schools in Arizona and beyond.

Adapting a prior intervention developed by Dr. Loescher and her co-investigators, Myra Miramoto, MD, MPH and Amy Howerter, PhD, from the UA College of Medicine – Tucson’s Department of Family and Community Medicine, the team will conduct pilot testing on 20 Tucson-based massage therapists. After fine-tuning the intervention, they will expand to a larger group of 80 massage therapists throughout Arizona. Effectiveness of the training will be tested after participants complete the online learning program. Additionally, the massage therapists’ ability to deliver sun safety information and assess skin lesions in their clients will be tested through specific visits from ‘secret shoppers,’ who are simulated clients with removable tattoos of questionable skin growths.

“Massage therapists see their clients more often than primary care providers see their patients,” said Dr. Loescher. “Although most melanomas are diagnosed by physicians, they typically are detected through observations from the patients themselves or someone who is close to the patient.” Dr. Loescher wants to empower massage therapists to assist in detection and help clients understand the importance of sun safety, recognize suspicious skin lesions and recommend follow-up with a dermatologist.

“Our goal is to have a huge public health impact in skin cancer prevention and early detection,” said Dr. Loescher. “Overall, we want to promote a larger role for skin cancer prevention within massage therapy school curricula and continuing education.”

Not only would a creative, expert online training program be an affordable way to impart knowledge, but it would have the capacity to be widely disseminated across the country, said Dr. Loescher.

Dr. Loescher sees this study as only a beginning to expanding the number of informed eyes that are trained on skin, including service providers such as hair stylists, estheticians and even tattoo artists. “We’ve done a lot of due diligence,” said Loescher, citing two recently submitted manuscripts from pilot work on this topic. “We have set the stage in a very rigorous way to take this study the distance and beyond.”

Since the inception of telehealth, remote care has become increasingly widespread, enabling areas with limited access to health care to connect with providers from afar. To reach remote communities, more than half of all U.S. hospitals currently have a telemedicine program and the global telemedicine technologies market is predicted to grow at a compound annual growth rate of 18.4 percent by 2020. But there’s a key area where the technology’s potential remains untapped: Nursing school, and the University of Arizona College of Nursing’s Rene Love, PhD and Jane Carrington, PhD are about to change that with a new federally-funded grant project.

The “Using 21st Century Technology for NP Student-Patient Interview and Interprofessional Care Coordination” project, funded by a $26,000 Graduate Nursing Education grant from Centers for Medicare & Medicaid Services (CMS), has two main thrusts: to develop a telehealth learning program designed to be embedded in the College’s curriculum, and to evaluate the telehealth education experience for students.

“When nursing graduates go for interviews, employers are asking if they have experience with telehealth,” said Dr. Love, clinical associate professor for the Community and Systems Health Science Division at the College. The answer to the question is no, because although telehealth is widely used in health care, no training is currently offered on the scholastic level. “Our study is unique because telehealth exists in the working world, but not in the education setting,” said Dr. Love.

One hundred students will be chosen to participate in the program. They will videoconference with actor-patients who will participate via video call with a variety of health-related conditions. “Our students will call them computer-to-computer and do a health assessment just like you would do in an office setting,” explained Dr. Love. Students will then electronically communicate with volunteer health care providers that partner with the College to develop a patient summary, including treatment.

“We want to hear what it’s like to talk to a patient through a computer rather than in person,” said Dr. Love. “How comfortable are they with that dynamic? This is something they may have to do one day, so we want to know more about their interactions with it.” Also, learning to collaborate on services with another provider, Dr. Love points out, is a big part of successful telehealth programs. “They’ll get experience working with both patients and with a provider,” she said.

While Dr. Love coordinates with students, providers and the simulated patients, Dr. Carrington, will employ her informatics expertise in the evaluation of the technology and usability components of the project. “We want the program to be clear, easy to read, and easy to navigate, so that it becomes what I call ‘invisible technology,’” she said. “In other words, the technology should be so easy to use that it’s nearly invisible to the user for accomplishing the tasks. You should be able to go in, get what you need and leave. When it’s not invisible, the technology may be preventing you from doing your work in some way.”

Dr. Love and Dr. Carrington’s innovative research combines education, preparation and practice to emphasize learning about the telehealth process. “Our goal is that students who go through our program will have contemporary learning experiences within their education so they can accommodate whatever telehealth growth occurs wherever they go in the future,” said Dr. Carrington.