Reflexology is growing in popularity in its use for a wide range of conditions such as pain management, to ease the effects of cancer treatment, and indeed mental health problems.
Reflexology, a complementary therapy, has been around for many years and its main purpose is ultimately to aid relaxation and restore energy. Literature suggests that it may improve quality of life and promote well-being. An increasing demand for Complementary and Alternative Medicine’s (CAMS) emphasises the need for more research, therefore this research proposal suggests that further research is required to understand more clearly the benefits perceived by clients when reflexology is utilised in conjunction with their exiting plan of care.
A comprehensive literature search was conducted in relation to reflexology for mental health illness, in particular anxiety and anxiety related disorders. It was the intention to locate valid and reliable research carried out within the last ten years, however expanding this period located much more research that was considered relevant, and thus has been included within the literature review.
The main databases for the literature included Cumulative Index to Nursing and Allied Health (CINAHL), Web of Knowledge, Swetwise, PubMed, British Nursing Index (BNI), Internurse,Wiley Interscience, Allied and Complementary Medicine Database (AMED) , EBSCO, and DARE (Centre for reviews and dissemination).
Keywords used within the search strategy included: reflexology, anxiety, mental health, complementary therapies, complementary medicine, perceptions of reflexology, CAMS for enduring mental health, holistic care in psychiatry, holistic approach to mental health, zone-therapy and therapeutic touch. Additional literature was sourced from The Association of Reflexology. A manual search was also conducted for relevant books and leaflets.
Searching literature revealed much quantitative and qualitative research on the topic of reflexology, the majority of which was related to reflexology for physical conditions such as cancer (of various types), multiple sclerosis, and skeletal ailments. A relatively small number was associated with mental health illnesses.
As mentioned there is an abundance of information and research with regards to the perceived benefits of CAMS including reflexology, however methodological flaws exist within some of these studies. Here, the researcher will attempt to give a critical, yet an evaluative account, on some of the research already published on the topic of reflexology. In addition, the researcher will draw upon previous research that has been carried out on ‘why clients use reflexology’, thus understanding reasons as to why it is becoming a popular complimentary therapy.
Complimentary and alternative therapies incorporate a wide spectrum of approaches, however according to the National Centre for Complementary and Alternative Medicine (2007) they can be grouped into five main categories which are alternative medical systems, mind-body interventions, biologically based therapies, manipulative and body based therapies, and energy therapies. It is important to point out that these diverse modalities to not aim to neither diagnose or cure an illness; they merely aim to promote wellness and enhance wellbeing (Mamtani and Cimino, 2002). In recent years complementary therapies have seen an increase in popularity (Harris and Rees, 2000; Kessler et al, 2001; Russinova, 2009) for all age groups (Barnes and Bloom, 2008) and the reasons for this are varied.
The Complementary and Alternative Medicines Project (2008) was commissioned by the Department of Health Social Services and Public Safety (DHSSPS) in 2000. ‘Get Well UK’ a non-profit organisation was appointed to oversee the project. A large sample of 713 clients who had either musculoskeletal or mental health conditions were referred to the study by their General Practitioner (GP) with the aim of exploring the potential use of CAMS within existing primary care services. Utilising the ‘measure yourself medical outcome profile’ allowed data to be generated through a validated measurement. Respondents were asked to complete this before their first treatment and again after their final treatment. Additionally there were independent surveys conducted via post to the participants, the GP’s and the CAMS practitioners involved.
The modalities of CAMS within the study included reflexology, aromatherapy, homeopathy, acupuncture, massage, chiropractor and osteopathy. Upon evaluation, it was concluded that 79% of those who took part felt an improvement in the mental health, 69% reported an improvement on their well being, and 84% reported that improvement of their well being was directly due to the CAM treatments. In addition, 94% stated that they would definitely recommend CAM treatments to others with similar complaints to themselves. Since the research, The Prince of Wales has called for a £10 million investment into research of CAMS.
Whilst the conclusion of this research appears promising for the various therapies involved, a closer look reveals that only a minority of mental health conditions were included in the selection criteria, which were anxiety, stress and depression. If the inclusion criteria allowed for a range of mental health conditions, their findings may have been different. However, strength is that it had a large sample size, which many other studies have failed to have.
In response to the above research project, the Government strongly hold the view that more evidence is required, and recommended that research should attempt to contribute to the existing evidence based using the same rigorous methods that is required and desired of conventional medicine (Department of Health, 2001).
Reflexology has been described as a technique used to promote the healing powers of the body that works on the premise that certain areas of the feet correspond to areas of the body. It is a non-evasive therapy where gentle pressure is applied to areas of the foot. It is believed that reflexology was practiced in china as early as 4000 BC. Reflexology, originally named ‘zone therapy’ emerged from America during early 20th century.
Reflexology is increasing being utilised in palliative care settings and have found to be effective in alleviating anxiety, additionally improving their physical, emotional, spiritual and psychological well being. Gambles et al (2002) carried out semi-structured interviews to identify cancer patients’ perceptions after a course of reflexology was offered. The main aim of this study was to evaluate the usefulness of reflexology offered in outpatients. Positive results were derived from the analysis demonstrating that reflexology was beneficial for this group of clients. The majority of the clients indicated that the main benefits perceived were a reduction in anxiety levels. Other clients highlighted a reduction in pain, and some noted an improvement in their sleep pattern. The lack of negative comments in this study indicates that reflexology was positively received by the client group. However as the findings were mainly gathered from narrative, thus subjective data, it could be said that lack of objective measurement reduces it value. However, the paper included some of the ‘raw data’ in the form of quotations which enhanced the validity and credibility of the research.
While the above research was carried out in Scotland, similar research has been carried out in England (Lewith et al, 2002). Washington Hospices have also seen a significant rise in demand in the utilisation of complementary therapies for individualised, holistic client care (Kozac et al 2009)
Research carried out in Northern Ireland to assess CAM use suggested that Reflexology was among the top six therapies used in Northern Ireland. The main reason for the use of reflexology was to enhance wellness and relaxation (Mc Donagh et al, 2007). The method used to carry out this research was surveys and had a sample of 100 people. Write more about this
Bring in here about the Mind Report (unpublished research)
A qualitative study (Richardson, 2004) found that client’s rationale for using complementary therapies is diverse. Reasons ranged from clients feeling unhappy with orthodox medicine, having poor relationships with their GP, for symptom relief, and the increased availability of many complimentary therapies. Not dissimilar to the findings, although more specific to the reasons why clients avail of reflexology, Bishop et al (2008) found that reasons range from; for pleasure, as a treat, anticipated beliefs, prevention/management or alleviating current physical and mental health problems, and as a supplement or addition to conventional medicine. While this research was carried out in England and had a sample population of 46 clients, a bigger sample may have identified broader variations for their use.
A systematic review by Wang et al (2008) agreed that there is indeed evidence to support that reflexology may have potential benefits; however they hold the view that there is no evidence to support its efficacy. To conclude their review they suggested that the routine provision of reflexology is not recommended for any illness or condition, expect for some symptoms associated with multiple sclerosis. Upon completing a systemic review Ernst (2009) and in agreement with Wang et al (2008) also concluded that there is evidence to suggest the effectiveness of reflexology although the results of previous studies are not convincing as the methodologies utilised within the trials were often poor with small sample sizes, lacked objective data or contained inaccurate measurements. As the systematic review focused on physical conditions and not mental health disorders the Jadad scale was used to assess the quality of the methodology. This instrument, often used for RCT’s within the context of physical therapy has a score range of 0-5 (5 being highest quality) and is based on three criteria, is often used globally for the measurement of RCT’s (Olivio et al, 2008). It is important however to note that research within complementary therapies often face difficulty in obtaining objective data as it is a very individualised approach, therefore client outcomes vary due to the clients’ values and belief system and evidence is placed on client feedback and satisfaction. Health professionals are encouraged to work towards evidence based practice, however, as the evidence mainly comes about as the result of Randomised Controlled Trials (RCT’s) this can often place professionals in a dilemma due to the lack of RCT’s in some complementary therapies (need ref) The underpinnings of RCT’s are that of objective measurement, and often reject or disregard subjective data, which in turn make it more difficult to obtain ‘hard evidence’. CAM practitioners and reflexologists treat clients with individuality, they see their clients as unique therefore the treatment is unique. As a result much of the research into reflexology does not fit adequately in the criteria for RCT’s as emphasis is placed on individualising care, not placed on standardising care. For this reason lack of objectivity should not be lack of effectiveness.
There have been significant changes and developments into the way mental health care is delivered, with much focus and emphasis on community based care. This shift from the traditional long stay hospitals has been seen as a positive step towards person centred holistic care. There is indeed much focus on recovery with the aim of supporting clients to manage their illness so that they can continue to reside within their community and live their life to their optimal best. Beresford (2000) and The Mental Health Foundation (2000) found that people wish to play an active role in their recovery from mental illness which includes being involved in the treatment and decision process and would like the opportunity to avail of complementary therapies. Thornicroft et al (2008) hold the view that central to the provision of effective community based care is that services need to reflect the needs of the clients, be holistic, individualised and patient – centred. Keep this paragraph at the end of lit rev.
People with mental health illnesses such as anxiety and anxiety related disorders often require different treatments, therapies and services to help them deal with, thus manage their illness more effectively (Sainsbury Centre for Mental Health, 2005). Regardless of any methodological flaws, it is important that health professionals take into account clients’ motivations for using complimentary therapies such as reflexology. We must listen to the clients perceived benefits and work towards a greater understanding of such benefits.
CHAPTER 2 METHODOLOGY
There are two main approaches to research; qualitative and quantitative. Each have there own advantages and indeed limitations. These approaches do not have to be used alone, they can often be used together. Mc Neill and Chapman (2005) put forward that mixed methods are often desirable as it enables the researcher to overcome some of the inherent weaknesses that many methods possess.
Qualitative research design is often used to gather sensitive information. It aims to gain a more in-depth understanding of people’s beliefs, values, opinions and experiences. The rationale for choosing qualitative over quantitative approaches is that qualitative methods are more holistic; it seeks to understand perceptions held by individuals, and seeks to find out ‘why’ instead of ‘how many’. It is a ‘naturalistic’ approach whereby the research is carried out under natural conditions. Although qualitative data can be hard to objectively measure, it remains valuable because it considers and represents the perception of humans. A frequent criticism is that the qualitative approach lacks rigour (Rolphe, 2006). Bradbury-Jones (2007) suggest that keeping a reflective diary can enhance rigour whereby the researcher can reflect on their own values, beliefs and preconceptions which can all affect how the responses of the respondents are interpreted. Parahoo (2006) holds the view that reflexivity is not always easy to achieve and suggests that allowing the respondents to read the data obtained for agreement or clarification is a way of validating the data obtained.
It is argued that in order to assess the effectiveness and indeed efficacy of any treatment, service or therapy, randomised controlled trails (RCT’s) should be used. RCT’s are seen to be the ‘gold standard’ of research (Kunz et al, 2007), however there are also limitations and criticisms of RCT’s, especially where placebos are used (Vaque and Rossiter, 2001)
Willaims and Garner (2002) proclaim that RCT’s merely provide information about groups rather than individual clients. Many RCT’s often give age restrictions and tend to focus on groups with the same diagnosis, in other words clients with dual diagnosis or mixed diagnosis are often excluded. Whilst we are encouraged to incorporate the results of RCT’s, Naylor’s (1995) viewpoint is that RCT’s lack external validity therefore it is not always possible to use the results and apply them in clinical settings. Using this approach in vulnerable groups also raises several ethical questions and concerns (American Psychiatric Association, 2006; Tharyan, 2006). However Green (2008) exerts that excluding vulnerable groups may also exclude them from gaining benefits
The researcher proposes to use semi structured interviews (qualitative) as a means of collecting data and there are many reasons for taking this approach. This method can provide the researcher with rich and valuable information about the experiences and perceptions of clients with a mental health illness.
Parahoo (2005) reminds us that selecting a sample for research requires much consideration, especially in mental health nursing research. The target population (sample) required for this proposal is 6 clients within the local community who currently have a diagnosis of anxiety or any anxiety related disorder as categorised in the DSM IV or ICD 10. The vulnerability of this group of clients must be considered whilst recruiting clients. Polit and Back (2004) exerts that clients should never feel obliged to take part in any study and no coercion from the researcher must take place. It is therefore important that when discussing the research with clients that it is emphasised that there will be no penalty for refusal to take part.
Inclusion and exclusion criteria
For the purpose of this research proposal the researcher has suggested ‘convenience sampling’, sometimes referred to as ‘volunteer sampling’. As the name suggests the sample is convenient, and is fairly typical of a qualitative approach to research (Burnard, 2004; Polit and Beck, 2010). However, Convenience sampling is not without its limitations (write about some limitations, also the good points).
There are no set rules concerning samples sizes, although qualitative sample sizes are generally much smaller than quantitative sample sizes. In order to obtain the sample needed the assistance of the community mental health team (CMHT) is required. An information booklet containing the topic and aims of the research will be mailed to members of the CMHT. When nurses are located the researcher intends to arrange a small conference so that any issues can be raised, this will also provide an opportunity for the CMHT to ask questions. It is important that the researcher also leaves their contact details should any further questions arise. When the team are happy with the research topic and aims, they can discuss this (if applicable) with their clients and leave a participant information booklet with their client to read. If clients have any literacy or reading limitations or any sight problems then it is imperative that their nurse read out the information, or if preferred an audio cassette will be prepared so the client can listen to the tape at their own time and pace. A client with literacy or communication difficulties should not be discriminated against and it is important that they are not excluded due to reasons mentioned. It may however pose challenges in the data collection and analysis (Low, 2006)
The researchers contact details will be provided on the information booklet, which will enable the client to contact the researcher for more information if required. When six clients have shown interest and agreed to participate a consent form must be signed (see appendix). Arrangements will then be put in place, at the convenience of the participants and the reflexologist for the reflexology to commence.
2.2 ETHICAL CONSIDERATIONS
Research such as the Milgram experiment (where participants inflicted electric shocks to another participant), The Stanford Prison experiment (where participants became verbally and physically abusive towards one another) and The Monster Study (where an attempt to induce stuttering was conducted on orphans) a number of ethical principles and frameworks have been developed with the main aim being the protection of participants well-being (Kovisto et al, 2001; Keogh and Daly, 2009). Indeed the Numberg trials at the end of the second world also received much controversy. This resulted in the formulation of the Numberg code, which has been noted to be one of the world’s most recognised ethical documentation. The Numberg Code and the Helsinki Declaration provide the basis for research. These basic principles are used globally any can provide researchers with an outline to the ethical, moral and legal obligations of research (Benard and Ficher, 2006)
Ethical considerations are an important element in any type of research and the onus of upholding the ethics of research should be the responsibility of the researcher (Research Council UK, 2009). Clients with a mental health illness are a vulnerable group and many steps must be taken for their protection. Ethical approval will be sought from the relevant bodies (appendix) (University of Ulster, 2006). it is advised that this can be a lengthy process so the letter will be mailed at the earliest available date.
Ethical considerations is not merely about non- maleficience, and beneficence, it is much broader than that. Consideration of the benefits versus the risks must be considered. No research should ever intentionally cause harm. As mentioned in section …. An information booklet will be provided for those who wish to take part. The information provided will be easily read, wherever possible will be free of jargon so that it is comprehensible to the reader. A list of contact numbers of local organisations will also be added to the booklet as the nature of the study is obtaining information from a vulnerable population group and any likelihood of upset must be addressed. Other information included in the booklet is; what will happen when the research is completed, upholding confidentiality, the right to withdraw and complaints procedures (Medical Research Council, 2005). It is important that all this information is capsulated within the booklet as a new procedure, intervention or service may seem confusing at first and provoke unnecessary anxiety to both the client and the staff involved.
Researchers who use qualitative approaches to gain information can use several ways of analysing their data (Elo and Kyngas, 2007). Only the data analysis method applicable to this research proposal will be discussed here.
The first stage of narrative data analysis is to gather all the information that was obtained from the participants, although this may first appear relatively easy task to do, the reality is that it is a lengthy and time consuming process. Furthermore it is not an easy or straightforward task to accomplish. When transcribing the tape recordings it is important that we consider the rate and tone of the speech and be aware of the colloquialisms (slang) used in everyday conversations. Pauses, sighs or any prolonged silences must also be noted as excluding any of these will result in losing valuable information and the transcription will not emphasise or illustrate an understanding of what the participant is trying to put across, in other words we need to be extremely careful when interpreting the data.
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