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The Guideline for Complementary Care Interventions was approved by the AORN Guidelines Advisory Board and became effective January 15, 2015. It was presented as a proposed guideline for comments by members and others. The recommendations in this guideline are intended to be achievable and represent what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings and/or clinical situations that determine the degree to which the guideline can be implemented. AORN recognizes the many diverse settings in which perioperative nurses practice; therefore, this guideline is adaptable to all areas where operative and other invasive procedures may be performed.


This document provides guidance for perioperative registered nurses (RNs) when complementary care interventions are implemented in the perioperative setting. This document includes guidance for music therapy, massage, acupuncture and acupressure, aromatherapy, hypnosis, Reiki, and guided imagery for patients before, during, or after surgery. The goal of complementary care interventions is to minimize the anxiety and pain of the perioperative patient.

Surgical patients experience high levels of anxiety.1  Reasons for this anxiety include fear of surgery, anesthesia, loss of control, and disease.2  The percentage of adult surgical patients who experience anxiety ranges from 11% to as high as 80%.2  Anxiety can have negative effects on pain management.3-5  An anxious patient may require more anesthetics and more opioids to relieve pain.2 

Mitchell6,7  surveyed 214 surgical outpatients to evaluate the effect of the clinical environment on the anxiety of patients who are scheduled to receive local or regional anesthesia. Seventy-seven percent of the patients surveyed reported that they experienced some degree of anxiety, as rated on a 5-point Likert-type scale that ranged from “feeling a little anxious” to “extremely anxious,” on the day of their procedure. The highest percentage of patients (47%) reported feeling a little anxious.

The ability to provide complementary care interventions depends on several factors, including the patient’s acceptance and engagement; the clinical experience, education, and competency of the perioperative team to provide complementary care interventions; and procedural and facility constraints. Complementary care may not be feasible or appropriate for every patient.

The topics of animal therapy, natural hormones, and dietary supplements as complementary care interventions are outside the scope of this document.

Evidence Review

On April 15, 2013, a medical librarian conducted a systematic search of the databases MEDLINE®, CINAHL®, and the Cochrane Database of Systematic Reviews for meta-analyses, systematic reviews, randomized controlled and non-randomized trials and studies, case reports, reviews, and guidelines from government agencies and standards-setting bodies. The librarian also searched the Scopus® database, although not systematically. Searches were limited to literature published in English since January 2006. At the time of the initial searches, the librarian established weekly alerts on the search topics and until July 2014, presented relevant results to the lead author. During the development of this guideline, the author requested supplementary literature searches and additional literature that either did not fit the original search criteria or was discovered during the evidence-appraisal process.

The lead author’s original search request for literature related to moderate sedation and local anesthesia yielded 862 sources deemed appropriate for consideration in guidelines on those topics. Of these, 59 were identified as relevant to complementary care interventions (Figure 1). Search terms that yielded these results included sedation, conscious sedation, moderation sedation, topical anesthesia, local anesthesia, local infiltration, anxiety, anti-anxiety agents, analgesia, surgical procedures, perioperative nursing, and nurse’s role. The literature scope was not expanded to the terms complementary care, integrative medicine, complementary alternative medicine, healing touch, therapeutic touch, reflexology, herbal medicine, nausea, or vomiting. Future review and update of this document will include a literature search that includes these terms.

Figure 1
Flow Diagram of Literature Search Results

Flow Diagram of Literature Search Results

Adapted from Moher D, Liberati A, Tetzlaff J, Atman DG; The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(6):e1000097.

Excluded were non-peer-reviewed publications and studies on the topics of pet therapy, natural hormones, and dietary supplements. Low-quality evidence was excluded when higher-quality evidence was available.

Included articles were independently evaluated and critically appraised according to the strength and quality of the evidence. Articles identified by the search were provided to the project team for evaluation. The team consisted of the lead author and four evidence appraisers. The lead author divided the search results and assigned members of the team to review and critically appraise each article using the AORN Research or Non-Research Evidence Appraisal Tools as appropriate. The literature was independently evaluated and appraised according to the strength and quality of the evidence. Each article was then assigned an appraisal score. The appraisal score is noted in brackets after each reference, as applicable.

Each recommendation rating is based on a synthesis of the collective evidence, a benefit-harm assessment, and consideration of resource use. The strength of the recommendation was determined using the AORN Evidence Rating Model and the quality and consistency of the evidence supporting a recommendation. The recommendation strength rating is noted in brackets after each recommendation.

Note: The evidence summary table is available at

Editor’s note: MEDLINE is a registered trademark of the US National Library of Medicine’s Medical Literature Analysis and Retrieval System, Bethesda, MD. CINAHL, Cumulative Index to Nursing and Allied Health Literature, is a registered trademark of EBSCO Industries, Birmingham, AL. Scopus is a registered trademark of Elsevier B.V., Amsterdam, The Netherlands.

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