Hospital Based Massage Therapy – Dale Healey

Dale Healey DC Canadian Chiropractor Massage Therapy Educator University of Minnesota PhD student Dean, School of Massage Therapy at Northwestern Health Sciences University Serve on Best Practices Committee of the MTF Serve as COMTA site team evaluator

Northwestern Health Sciences University Located in Bloomington, Minnesota Began as Chiropractic College in 1941 School of Massage Therapy and Minnesota College of Acupuncture and Oriental Medicine added in 2000 Strong focus on integration of CAM services within CAM as well as with the allopathic community. Mission: The mission of Northwestern Health Sciences University is to advance and promote natural approaches to health through education, research, clinical services and community involvement. Please come and see us in September – hosting a tour on Sunday – breakfast reception and tour of Penny George Institute

The Vision of Northwestern Health Sciences University Our vision is to be the University of Choice for natural and integrative health care. We promote conservative health care approaches that focus on the whole person. We provide leadership to develop collaborative and integrative health care models, support clinical research, prepare students for successful careers, encourage lifelong learning and service to our community.

Objectives for this session Define HBMT – understanding what it is and what it is not Articulate trends surrounding MT in the hospital environment Discuss benefits of massage therapy to the hospital patient List steps toward becoming a hospital based massage therapist. Identify challenges involved in becoming a hospital based massage therapist. Develop strategies to overcome those challenges.

What is Hospital-Based Massage Therapy? Hospital-Based Massage Therapy is Massage Therapy that is based in a hospital setting Put another way: Massage Therapy that takes place in a hospital setting Massage Therapy that happens in a hospital. HBMT is defined ONLY by its location (simple definition). Focus of Hospital-Based Massage Class is on competencies associated with working in the hospital environment. I’m trying to emphasize the point that HBMT is defined by it’s location – nothing else. If it were a technique, I certainly would not be qualified to be giving this presentation.

These are not your typical massage therapy practice clients Massage Therapy Clinic Clients Relatively Healthy Contra-indications are rare Hospital Patients Often very sick and perhaps dying Contraindications are common

These is not your typical massage therapy practice setting Massage therapy clinic setting Dim or at least controllable lighting Massage table Private, controlled environment Scheduling: regular, predicable Hospital Bright lighting – may or may be controllable Hospital Bed Interruptions common Schedule random and even chaotic

Hospital Based Massage Therapy Practice is NOT for everyone! Unpredictable and sometimes volatile environment Strong interpersonal skills essential Personal sense of resilience required In many ways the environment is opposite to the environments many therapists seek.

What Hospital-Based Massage Therapy is Not Not something your “Pathology” class prepared you for Not “Medical Massage” A massage “technique” Hospital is a highly clinical environment but there is not a strong clinical focus required of massage therapists in the hospital. At least for now, the emphasis in most hospital settings is on massage therapy affecting the areas we are best known for and for which there is the most evidence (i.e. reduction in stress, anxiety, general pain and depressive symptoms). Do something you can be the best at – Good to Great.

Historical Considerations Dr. Johann Mezger – 1839-1909 A physician credited with bringing massage to the scientific community. Presented massage to fellow physicians as a form of medical treatment and physical rehabilitation. Popularity in the medical community grew and early research bolstered support for the emerging field. Any good historian or prognosticator worth his/her salt will tell you that one of the best indicators of the future is the past. The value of understanding our history comes in it’s ability to show us the future.

Nursing and Massage Therapy Massage was part of the curriculum for nurses since the mid 1800’s Physical therapists used massage therapy as treatment for certain medical conditions Nurses used it mostly for comfort. Were perhaps unaware of the physiological benefits Pat Ben

American Journal of Nursing Helen Bartlett was an Instructor in Massage at Johns Hopkins Hospital Training School for Nurses. “Mechano-therapy, in exact definition massage and medical gymnastics, is a method of healing existent in some form during all history. In approximately the last decade it has undergone radical revision, and through a perhaps exceptionally slow evolution has reached a definite status. It is, in brief, a department of the science of medicine, circumscribed, indeed, but of distinct and acknowledged value. The practice of mechano-therapy, no longer, as in earlier struggles for recognition, performed of necessity by the physician himself, is controlled now by him, but assigned to an assistant.” Bartlett, Helen Conkling, The Teaching of Massage to Pupils in Hospital Training-Schools, The American Journal of Nursing, Vol. 1, No. 10 (Jul., 1901), pp. 718-721

American Journal of Nursing “There continues, of course, much general ignorance and distrust of a therapeutic measure for long almost given over to quackery, and the present work, certainly in America, of both teachers and practitioners, is in many ways still that of a pioneer” 3 qualifications for massage specialists: “A good touch in massage” “Sufficient theoretical knowledge to detect abnormal conditions and to distinguish between serious and less serious symptoms.” “An infinite fund of resources which can only be the result of individual experiences; essential alike for normal changes and the emergencies of practice.” Bartlett, Helen Conkling, The Teaching of Massage to Pupils in Hospital Training-Schools, The American Journal of Nursing, Vol. 1, No. 10 (Jul., 1901), pp. 718-721

American Journal of Nursing Helene Biermann, RN was an instructor of massage therapy at the Graduate Training School at the German Hospital, New York “Massage should never be given except on a physician’s orders. When employed as a treatment after injuries and diseases, it should be in the hands of a person who not only possesses the necessary technical skill acquired by painstaking toil in massage, but who has also a thorough knowledge of the movement cure, and understands the nature and course of the disease as well.” Biermann, Helene; Notes on Massage, The American Journal of Nursing, Vol. 7, No. 7 (Apr., 1907), pp. 534-538

American Journal of Nursing “The result [of massage] is usually delightful, sedative and tonic. During massage treatment most patients are in a state of repose. Generally those who relax to their treatment enjoy it and feel gloriously indifferent, and needless apprehensions are dispelled. But without the sympathetic touch the [massage therapist] may fail to cause these desirable results and produce, instead, quite opposite effects. The sympathetic touch is inborn and cannot be taught nor explained. It can be improved, but it cannot be acquired if it is not there. It is a mystery.” Churchill, Anna Quincy, Massage, Its Physiological Effects The American Journal of Nursing, Vol. 15, No. 8 (May, 1915), pp. 635-640

What Happened??? 4 main factors to blame Increase in patient load due to nursing shortages The requirement for additional documentation by governmental regulators New methods of billing demanded by insurance carriers The growth of medical technology and drugs over hands-on methods of care. MacDonald, Gayle (2005), Massage for the Hospital Patient and Medically Frail Client. Baltimore: Lippincott Williams and Wilkins

But the pendulum is swinging back There is a recognition of the high-tech, specialized, fragmented nature of care in the hospital and that hands-on human touch can provide a sense of wholeness. Skyrocketing healthcare costs, including pharmaceuticals and hospitalization have folks scrambling and more open to looking to CAM as a part of the solution. Awareness of CAM and openness to it growing – NCCAM, NARCCIM, CAHCIM CAM education included in medical school training CAHCIM – Consortium of Academic Health Centers for Integrative Medicine – 44 highly esteemed academic medical centers NARCCIM – North American Research Conference on Complementary and Integrative Medicine National Center for Complementary and Alternative Medicine Our healthcare system is like the patient who comes to us as a last resort.

General Employment and Economic Trends in Health Care and the Hospital Environment

Total Prescription Drug Spending, 1980 – 2007(1) Ironically drugs chased Mts out – now their escalating costs are one of the reasons Mt is coming back Source: Centers for Medicare & Medicaid Services, Office of the Actuary. Data released January 6, 2009. (1) CMS completed a benchmark revision in 2006, introducing changes in methods, definitions and source data that are applied to the entire time series (back to 1960). For more information on this revision, see http://www.cms.hhs.gov/NationalHealthExpendData/downloads/benchmark.pdf. (2) Expressed in 1980 dollars; adjusted using the overall Consumer Price Index for All Urban Consumers.

National Health Expenditures(1), 1980 – 2018(2) Source: Centers for Medicare & Medicaid Services, Office of the Actuary. Data released February 23, 2009. (1) Years 2008 – 2018 are projections. (2) CMS completed a benchmark revision in 2006, introducing changes in methods, definitions and source data that are applied to the entire time series (back to 1960). For more information on this revision, see http://www.cms.hhs.gov/NationalHealthExpendData/downloads/benchmark.pdf.

National Supply and Demand Projections for RNs,2000 – 2020 Shortage of over 1,000,000 nurses in 2020 Source: National Center For Health Workforce Analysis, Bureau of Health Professions, Health Resources and Services Administration. (2004). What Is Behind HRSA’s Projected Supply, Demand, and Shortage of Registered Nurses? Link: ftp://ftp.hrsa.gov/bhpr/workforce/behindshortage.pdf.

Number of Hospital Employees, 1993 – 2007 Source: Avalere Health analysis of American Hospital Association Annual Survey data, 2007, for community hospitals.

Hospital Employment vs. Employment in Other Industries, 2008(1) Source: Department of Labor, Bureau of Labor Statistics, Current Employment Statistics (CES) Survey, customized tables. Data released 2009. Link: http://www.bls.gov/ces. (1) 2008 figures reflect annual projections.

Average Weekly Earnings of Workers, Hospitals(1) vs Average Weekly Earnings of Workers, Hospitals(1) vs. All Service-providing Industries, 1990 – 2007 Source: Department of Labor, Bureau of Labor Statistics, Current Employment Statistics (CES) Survey, customized tables. Data released 2009. Link: http://www.bls.gov/ces. (1) Includes physicians employed by hospitals.

Percent Change in Employment Hospital vs. All Industries, 06 – 08 2006 2007 2008 Source: Department of Labor, Bureau of Labor Statistics. Link: http://www.bls.gov/bls/employment.htm.

American Hospital Asssociation President and CEO – Rich Umbdenstock: “Complementary and alternative medicine has shown great promise in supporting and stimulating healing," said.  "It's one of the many tools hospitals look to as they continue to create optimal healing environments for the patients they serve."

Trends Related to Massage Therapists in Health Care and Hospital Environments

Current Trends - “What” Sept. 2008 report in Health Forum – An affiliate of the American Hospital Association found: A growing proportion of hospitals are responding to patient demand and integrating complementary and alternative medicine (CAM) services with conventional services In 2007, more than 37% of hospitals offered one or more CAM therapies, up from 7.7% in 1998 The survey found that massage therapy is the top CAM service provided on an outpatient basis and is the second most popular service behind pet therapy in an inpatient setting.

Notice 2006 is missing

Current Trends – “Why” When asked primary rationale: Patient demand 84% Clinical effectiveness 67% Reflects organizational mission 57% Attract new patients 40% Physician’s request 40%

Reasons Hospitals want to add MT Patients are demanding it Competition for patients. Clinical outcomes Ultimate goal of reducing costs – pharmaceuticals and length of stay. It’s OK to be viewed as a “perk” at first – just need to get in the door. Last point is in comparison to chiro’s trying to get in – they can’t do it.

Current Trends – “Why” Reasons for massage in an hospital environment: Pain management 66% Massage for cancer patients 57% Pregnancy massage 55% Part of physical therapy 53% For mobility/movement training 45% Palliative care 41%

“Effects of Massage in Acute and Critical Care” Discussion of a systematic review of 22 articles examining the effect of massage on relaxation, comfort, and sleep. Most consistent effect: reduction in anxiety. 8/10 studies reported that massage significantly decreased anxiety or perception of tension. 7/10 studies found that massage produced physiologic relaxation, as indicated by significant changes in the expected direction in one or more physiologic indicators. In the 3 studies in which the effect of massage on discomfort was investigated, it was found to be effective in reducing pain. Richards, Kathy Culpepper RN, PhD et al, AACN Clinical Issues: Advanced Practice in Acute & Critical Care: February 2000 - Volume 11 - Issue 1 - pp 77-96 American Association of Critical Care Nurses

Current Trends – “Who” Support for initiating CAM programs: Administration 53% Nursing 23% Physicians 22% Board 3%

Relationship with Medical Staff Critical to long term success of the program Need “champions” Referrals can be an indication of the quality of the relationships

Current Trends – “How” Criteria Hospitals Used to Select CAM Therapies: Patient Demand 79% Evidence Based 72% Practitioner Availability 62% Market Research 27% Other 15%

According to the Bureau of Labor Statistics…. “Employment for massage therapists is expected to increase 20 percent from 2006 to 2016, faster than average for all occupations.” “Massage therapy’s growing acceptance as a medical tool, particularly by the medical provider and insurance industries, will have the greatest impact on new job growth for massage therapists.” Fastest growing employment opportunity is in health care settings

According to the AMTA 2009 industry report, the number of massage therapists reporting practicing in a health care setting increased from 10% in 2005 to 25% in 2009.

The Baby Boomer Effect According to a study by the American Hospital Association “When I’m 64 – How Boomers Will Change Health Care”: “The wave of aging Baby Boomers will reshape the health care system forever. There will be more people enjoying their later years, but they’ll be managing more chronic conditions and therefore utilizing more health care services. By 2030: The over 65 population will nearly double as a result of the aging Boomers. More than six of every 10 Boomers will be managing more than one chronic condition.” “When I’m 64: How Boomers Will Change Health Care”, American Hospital Association Report, Washington, DC, May 2007

The Baby Boomer Effect The convergence of four key factors drives how Boomers will impact U.S. health care: There are significantly more of them and, as they age, they will require more health care services than any other generation of Americans. The prevalence of chronic diseases is increasing among Boomers. They have different needs and expectations than past generations. More medical services and technologies are available to them than ever before. “When I’m 64: How Boomers Will Change Health Care”, American Hospital Association Report, Washington, DC, May 2007

By 2030 Hospital Admissions of Boomers will more than double…

Leading to a majority of hospital patients being over 65

The Baby Boomer Effect “Going Beyond the Medical Model of Care: Finally, hospitals are undertaking initiatives to offer the more personalized care, comfort, service and convenience that Boomers have come to expect. From accommodating family caregivers and reducing sound, to complementary and alternative medicine programs (including massage and acupuncture) and a broad range of fitness programs, the focus is on wellness not simply restoring health.” “Health Care Response: Innovative new approaches to meeting patient needs reflect a broader care focus that encompasses acute-care needs and enhances the overall patient experience.” “When I’m 64: How Boomers Will Change Health Care”, American Hospital Association Report, Washington, DC, May 2007

The Baby Boomer Effect “Seventy percent of Boomers have used some form of complementary or alternative medicine. The most popular treatments include massage therapy, chiropractic services and other types of body treatments. Complementary and alternative medicine is being used equally to treat specific health conditions and to improve overall wellness.” “Health Care Implication: Aging Boomers with higher expectations of service will demand more innovative, personalized health care programs that cater to their needs.” “When I’m 64: How Boomers Will Change Health Care”, American Hospital Association Report, Washington, DC, May 2007

Costs and Payment

Planning 55% of hospitals offering CAM services do NOT have CAM as part of their overall strategic plan. Only 30% of hospitals offering CAM services have a strategic plan for their CAM program. Is this a good thing or a bad thing?

Steps to Starting a HBMT Practice Self Assessment Environmental Assessment Build the relationships Negotiate the terms of the practice

1. Self Assessment Does a HBMT practice fit with my personal and professional goals? Am I qualified to practice in a hospital environment? Will I be able to manage the emotional challenges of a hospital based position? What about the complex patient population? How do I feel about working with patients who are very sick and perhaps dying? Is my personality well suited to working with doctors, nurses and other hospital employees? Don’t do it if it doesn’t fit the mission – avoid mission creep – will not fly if people see you as the local spa school

2. Environmental Assessment Is there a local hospital need that I could help satisfy? Does the compensation and schedule meet my needs? Will I be the one massage therapist on staff or joining a well established team? Will I be a lone pioneer, struggling to create a program or coming into a massage friendly environment? The instructor is key Must have the right qualifications and credentials Who could teach this class for you? A nurse massage therapist A graduate that works in the hospital as a massage therapist or other

3. Build the relationships Importance cannot be underestimated. More than gift baskets Relationships with: Hospital administration Onsite supervisors Educational partners Reference chiro experience

4. Negotiate the Details and Terms of the Practice Get clarity of the non-negotiable needs of the hospital Criminal background checks Immunization requirements Insurance requirements Licensure Educational requirements National certification Negotiate and understand the responsibilities of both parties Patient access Documentation requirements Compensation and schedule

Consider getting additional education Most massage therapy schools and programs do not focus on preparing hospital-based therapists. Avoid: Courses that focus on “pathology” only. Courses that focus on “technique” only. Programs that do not include a clinical component in a hospital setting. Look for: A well established program. A program with a track record of completers gaining employment in hospitals. Programs that focus on preparing you for the unique patient and environmental considerations.

I. Educational Objectives Perform appropriate massage techniques for comfort care on diverse patient populations. Obtain information from patient's charts and record documentation of session. Interact comfortably with hospital staff. Describe common medical devices and procedures. Apply appropriate massage pressure, avoid applicable site restrictions, and use appropriate positioning for patients according to their specific medical condition. Describe appropriate boundaries for both therapist‑patient and therapist‑ hospital staff interactions. Apply appropriate infection control practices with all massage encounters in the hospital. Understand common medical conditions and symptoms and how they relate to the massage session. Discuss hospital research involving massage therapy. Demonstrate correct body mechanics for the hospital environment.

II. The Textbook “Massage for the Hospital Patient and Medically Frail Client” by Gayle MacDonald “This is an essential resource for learning massage in the acute care setting. As the need for massage in hospitals has grown, many massage therapists and massage students are developing their skills in this environment to broaden their practice and meet market demand.” “The text explores pressure adjustments, site restrictions, and positioning needs for hospital patients and medically frail clients. An easy-to-use conceptual format covers common medical devices and procedures, standard precautions, the relationship between pharmaceuticals and massage, charting, and collecting patient data. Illustrations demonstrate body mechanics, draping, room preparation, and more.”

Contents The revival of hospital massage Reviewing the research Adapting to hospital culture Infection control practices Pressure, site, and position – a clinical framework Common reasons for hospitalization or medical treatment Common conditions and symptoms Common medical devices and procedures Medications Referrals, orders, and intake The massage session Documentation Notice very limited on the “techniques” or “pathology”

III. Teaching methods Didactic Portion Clinical Portion At least a portion should take place at the hospital. Plenty of role playing Include roles for hospital staff that the students will interact with. Emphasis on communication, documentation, safety issues, emotional issues (i.e. reactions to serious illness and death) Clinical Portion Well defined roles for both student and supervisor Include observation expectations Scheduling Who is the supervisor?

IV. Assessment Tools and Methods Journaling Technical component Emotional component Observation rubric Group presentation Evidence Informed Practice assignments

Quotes from past student journals: “The second patient that I saw with Molly was a women in her early 50’s who had just been diagnosed with Lung Cancer the day before. Molly and I read in her chart that the patient had said “well I guess I’m just here to die”. When we stopped in the patient looked very depressed and withdrawn. It was a very sad situation to see. The patient did not want any services from us.”

“I would have to say that the highlight of my day was spending the last hour with Kim the music therapist. We saw an 81 year old woman who was dying. I gave the patient a foot massage while Kim played her guitar and sang songs for her. The patient would request a song and she would sing along with Kim. She looked so incredibly happy and so grateful that we were there with her. She was the sweetest woman, you just wanted to reach over and give her a big hug.”

“It is so different giving massage to patients in the hospital vs “It is so different giving massage to patients in the hospital vs. what I am learning in school. I think it is very satisfying to do this type of massage and to see what a difference I can make for someone in such a short amount of time.”

Dale Healey dhealey@nwhealth.edu 800-888-4777 ext. 348