REVIEW

A review of nurses’ knowledge, attitudes, and ability to communicate the risks and benefits of complementary and alternative medicine Hsiao-Yun Chang and Huai-Lu Chang

Aims and objectives. This study reviewed existing literature to investigate how frequently nurses include complementary and alternative forms of medicine in their clinical practice. In so doing, we investigated nurses’ knowledge of and attitudes towards complementary and alternative medicine as well as their ability to communicate the risks and benefits of these therapies with patients. Background. Little information is available concerning nurses’ knowledge and attitudes towards complementary and alternative medicine or how they incorporate these therapies into their practice. In addition, little is known about the ability of nurses to communicate the risks and benefits of complementary and alternative medicine to their patients. Study design. This study used a scoping review method to map and synthesise existing literature. Data sources. Both electronic and manual searches were used to identify relevant studies published between January 2007 and January 2014. Review methods. The review was conducted in five stages: (1) identification of research question(s), (2) locate studies, (3) selection of studies, (4) charting of data, and (5) collating, summarising, and reporting of results. Results. Fifteen papers met the inclusion criteria for this review, among which 537% referenced how frequently nurses include complementary and alternative medicine in their practice. We found that 664% of nurses had positive attitudes towards complementary and alternative medicine; however, 774% did not possess a comprehensive understanding of the associated risks and benefits. In addition, nearly half of the respondents (473–677%) reported feeling uncomfortable discussing complementary and alternative medicine therapies with their patients. Conclusion. The lack of knowledge about complementary and alternative medicine among nurses is a cause for concern, particularly in light of its widespread application. Relevance to clinical practice. Findings from this study suggest that health care professionals need to promote evidence informed decision-making in complementary and alternative medicine practice and be knowledgeable enough to discuss complementary and alternative medicine therapies. Without involvement of complementary and alternative medicine communication on the part of our profession, we may put our patients at risk of uninformed and without medical guidance.

Authors: Hsiao-Yun Chang, PhD, RN, Associate Professor, School of Nursing, Fooyin University, Kaohsiung; Huai-Lu Chang, MD, MBA, Medical Doctor, Division of Thoracic Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan

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Why is this research or review needed?





Complementary and alternative medicine (CAM) is widely practiced; however, little is known about the expertise of nurses or their attitudes towards CAM procedures. Interactions between conventional medicines and alternative medicines can increase the health risks faced by patients and can lead to serious clinical consequences.

What are the key findings?





Many nurses recommend complementary and alternative medicine (CAM) therapies and medicines to patients, despite a lack of formal education or training in this field. A lack of knowledge related to CAM undermines the ability of nurses to communicate the risks and benefits of these therapies with patients. This situation remains a serious impediment to the safe integration of CAM therapies within the paradigm of conventional medicine.

What does this paper contribute to the wider global clinical community?





Educational programmes to educate nurses about complementary and alternative medicine (CAM) could help these health care professionals communicate the risks and benefits of CAM therapies to patients more effectively. As advocates working for the wellbeing of patients, nurses need to understand the basic principles of what CAM therapies their patients are undergoing and how these treatments will affect prognosis. Nurses are then able to access up-to-date resources to ensure the safety of those in their care.

Correspondence: Hsiao-Yun Chang, Associate Professor, School of Nursing, Fooyin University, 151 Jinxue Rd., Daliao Dist., Kaohsiung City, 83102, Taiwan. Telephone: +886 986502206. E-mail: [email protected]

© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1466–1478, doi: 10.1111/jocn.12790

Review

CAM on nurses

Key words: complementary and alternative medicine, nurses, review Accepted for publication: 2 January 2015

Introduction Complementary and alternative medicine (CAM) is gradually gaining recognition among health care professionals. CAM approaches include a group of diverse beliefs and practices, such as spiritual therapies, products derived from plants, animals, or minerals, manipulative-based techniques, and exercises that are not generally considered part of conventional medicine (World Health Organization 2011, National Centre for Complementary and Alternative Medicine [NCCAM] 2013). In a 2011 study, Wieland et al., examined 396 Cochrane reviews related to CAM and proposed an operational definition of CAM, by classifying 70 relevant therapies into five categories of the NCCAM model. The five categories were: (1) alternative medical systems, (2) natural product based therapies, (3) energy therapies, (4) manipulative and body based methods, and, (5) mind body interventions. (A complete list of CAM therapies under each category are presented in Table 1). The aims of this current study were to identify how frequently nurses include CAM in their clinical practice and to elucidate the knowledge and attitudes of nurses towards CAM as well as their ability to communicate the risk and benefits of CAM with patients.

Current literature The use of CAM has grown considerably in oncology, from 25% of cancer patients in the 1970s and 1980s, to more than 32% in the 1990s, and moving beyond 49% in the last 15 years (Horneber et al. 2012). Across countries, CAM is used by between 98–76% of individuals in the general population (Harris et al. 2012). In specific patient populations, those rates can be much higher. For example, 809% of patients with cardiovascular disease (Arslan et al. 2012), 87% of pregnant women (Hall et al. 2011), 90% of men with prostate cancer (Bishop et al. 2011), and 728% of patients with diabetes (Chang et al. 2007) have used CAM. In addition, a surprisingly high percentage (34–97%) of health care professionals has reported the use of CAM therapies themselves (Sewitch et al. 2008). Many patients integrate CAM therapies with conventional treatments, and between 20–77% of these do not disclose these ‘self-care strategies’ to their health care providers.

© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1466–1478

This can lead to medical complications (Chang et al. 2012, Davis et al. 2012). For example, adverse interactions among food, synthetic drugs, and herbal therapeutics can increase health risks faced by patients, with potentially serious consequences. Failure to reveal the use of CAM can be attributed to a number of factors, such as: failure on the part of physicians to make relevant inquiries, an expectation that the physician will disapprove of the treatment or disregard it as trivial, or a patient belief that the use of CAM (as a complement) is unrelated to conventional care (Davis et al. 2012). A growing number of studies have reported adverse herb– drug interactions. In a review of 41 case reports and 17 clinical trials, Izzo and Ernst (2009) determined that St. John’s wort (Hypericum perforatum), ginkgo (Ginkgo biloba), ginseng (Panax ginseng), garlic (Allium sativum) and Kava (Piper methysticum) could have adverse pharmacodynamic and/or pharmacokinetic interactions with conventional drugs, including warfarin, digoxin, cyclosporine, tacrolimus, amitriptyline, midazolam, indinavir and irinotecan. For example, St John’s wort has been implicated in multiple herb–drug interactions through the discovery that it reduces the area beneath the plasma concentration-time curve (AUC). St. John’s Wart has also been shown to lower blood concentrations of amitriptyline, cyclosporin, digoxin, indinavir, midazolam, phenprocoumon, tacrolimus, theophylline and warfarin, and can cause intermenstrual bleeding, delirium and mild serotonin syndrome (Izzo & Ernst 2009, Chen et al. 2012, Gouws et al. 2012, Shi & Klotz 2012). The herb–drug interaction is not the only one type of associated risks for the integration of CAM and conventional medicine but also there are adverse effects, contraindications and CAM-conventional treatment interactions. To avoid potentially life-threatening herb–drug interactions, it is essential that nurses, physicians and pharmacists (health care providers that prescribe and/or administer medications) understand CAM therapies and are able to effectively communicate the associated risks and benefits with patients (Chen et al. 2011). Several studies have reviewed the attitudes of health care professionals towards CAM. These studies have considered physicians (Leach 2004, Milden & Stokols 2004), pharmacists (Kwan et al. 2006), health care professionals (Sewitch et al. 2008), maternity care professionals (Adams et al. 2011) and nurses (Leach 2004, Antigoni & Dimitrios

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H-Y Chang and H-L Chang Table 1 A list of types of complementary and alternative medicine practices under each category Categories

Therapies

Alternative medical systems

Ayurvedic medicine, traditional Chinese, Japanese, and Tibetan medicine, homeopathy and naturopathy Chelation therapy, hydrotherapy, nutrition-based therapy (diet therapy, dietary supplements), oxygen therapy, ozone therapy, herbal medicines, other plants or plant extracts, prolotherapy, speleotherapy, topical therapies and unconventional synthetic drugs (laetrile, procaine) Acupuncture (acupressure, acupuncture, electroacupuncture, laser acupuncture, moxibustion), breathing exercises (qi gong, pranayama), distant healing, electric stimulation therapy, magnetic therapy, phototherapy, reiki, therapeutic touch and ultrasonic therapy Alexander technique, chiropractic manipulation/spinal manipulation (craniosacral massage, Feldenkrais method), massage (osteopathic manipulation), reflexology Biofeedback, hypnosis, meditation, play therapy, relaxation techniques, sensory art therapies (aromatherapy, art therapy, colour therapy), dance therapy, drama therapy, music therapy, other sensory therapies, tai chi, unconventional psychotherapies (morita therapy) and yoga

Natural product based therapies

Energy therapies

Manipulative and body-based methods

Mind-body interventions

2009). However, many of these studies were hampered by ambiguous or limited definitions of CAM, regional bias in the adoption of references and a failure to address accepted review methodologies. In particular, there has been a lack of research addressing the communication of CAM-related issues between patients and health care professionals.

Aims and methods Aims Broadly, the aim of this review was to explore the status of CAM in the field of nursing. In so doing, we addressed a

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number of specific objectives: identify the common characteristics of study designs in existing evidence; explore the range of knowledge possessed by nurses as well as their attitudes towards CAM practice; and, determine the competence of nurses in communicating information related to CAM with their patients.

Study design To map existing CAM literature, we adopted the methodological framework proposed by Arksey and O’Malley (2005). This framework for systematic reviews involves a critical analysis of existing literature, and scoping for studies is done using clearly defined search terms (Arksey & O’Malley 2005). A systematic literature review involves five stages: (1) identifying the research question(s), (2) identifying relevant studies, (3) selecting relevant studies, (4) charting data, and (5) collating, summarising and reporting results. We also used this framework to assess nurses’ knowledge of/attitudes towards CAM therapies and their ability to communicate associated risks and benefits with patients.

Search methods Search strategy Both electronic and manual searches were undertaken to identify previously published studies that addressed the attitudes of nurses towards CAM. For this, we only included the most recent and relevant papers. Specifically, we considered research performed between January 2007 and January 2014 because Sewitch et al. (2008) performed a similar study (i.e. on the perceptions of CAM by health care professionals) in 2006. Relevant studies were obtained from the following databases: EBSCOhost (CINAHL, Medline, ERIC), ScienceDirect, ProQuest Collection, Cochrane library and Chinese Airiti Library. To maximise the sensitivity of the search, Boolean operators were used to combine the following terms: ‘complementary medicine’, (OR) ‘alternative medicine’, (OR) ‘integration medicine,’ (OR) ‘complementary/alternative medicine’; ‘attitude’ (OR) ‘communication’; and ‘nurse’ (OR) ‘nursing’. After identifying relevant terms in abstracts, a total of 74 references were collected. No references were retrieved from the Cochrane Library or Chinese Airiti Library. Eligibility criteria Abstracts were examined prior to their inclusion in the review. To be included, papers had to meet the following criteria: (1) related to the field of nursing, (2) address atti© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1466–1478

Review

tudes towards CAM, (3) be research oriented, and (4) be conducted within a health care setting. Conversely, papers were excluded if they: (1) dealt with student nurses, nursing assistants, or faculty members, (2) focused on health care professionals such as physicians, CAM practitioners, or pharmacists, (3) were review papers or qualitative research, (4) addressed the use of CAM for personal, rather than clinical practice. In addition, we chose not to limit the types of CAM in order to ensure that our review included all potentially relevant studies.

Search outcomes The first layer search used the terms ‘complementary medicine’, ‘alternative medicine’, and ‘integrative medicine,’ and returned 10,999 references (Fig. 1). A second layer search for articles published since 2006 was then conducted within the results of the first layer search. For this, we also used the terms ‘nurse’ and ‘attitude,’ and this returned 74 potentially relevant references. Search results were managed using ENDNOTE LIBRARY (version X7) Thomson Reuters, Carrollton, Texas, North America. Reference titles and abstracts were screened by researchers according to relevance based on eligibility criteria. A total of 59 references were excluded during the selection process because they failed to meet the inclusion criteria. Finally, we identified three additional references from bibliographies of selected papers. This resulted in a total of 15 papers that met the inclusion criteria for this review.

CAM on nurses

lence of practice, types of practice, knowledge of CAM, attitudes towards CAM and communication with patients about CAM) across studies.

Synthesis The CAM therapies most commonly practiced by nurses are presented according to their frequency of occurrence and popularity ranking in Table 3. The popularity ranking was calculated using a position weight matrix (PWM). For example, the first position was assigned a weight of five points; the second position was assigned a weight of four points; and so on. The score assigned for the ranking of each CAM therapy was then summed to determine its overall popularity. For example, massage therapy was encountered in eight studies and thus scored as follows: (4 [times] 9 5 [highest ranking position]) + (2 9 4) + (2 9 3) + (2 9 2) = 38. To enable comparison across a range of studies using different scales to measure knowledge, attitudes and communication skills, we converted the adjusted mean score to an overall percentage ranging from 0–100%. For this, we adopted the formula presented by Liu et al. (2013), in which a Likert score is converted into a percentage value using the following formula: [(mean score 1)/(scale score 1) 9 100%]. In the event that the range of the Searching databases

Terms: complementary medicine, alternative medicine, or integrative medicine

References identified:

Quality appraisal

EBSCOhost (3892) ScienceDirect (1828) ProQuest (5279)

All the studies identified in this review reported quantitative data; therefore, we used the Health Care Practice Research and Development Unit (HCPRDU) Evaluation Tool for Quantitative Research (Long et al. 2002) to assess the quality of the identified studies. Most of the studies met our established criteria; however, verifying the quality of methodologies is crucial to generating accurate results within a systematic review. In addition, we charted the following criteria into Table 2: study overview, study design, setting, sample, measurement and outcomes.

Terms: Attitude or communication and Nurse or nursing and Year > 2006 References identified: EBSCOhost (7) ScienceDirect(47) ProQuest (20) Exclusion criteria: Duplicate (9) Faculty or students (6) Nonresearch articles (37) Nonrelevant (5) Qualitative research (5)

Data abstraction To facilitate comparisons, we recorded critical appraisals and data from the included studies in tabular form. We then identified differences, similarities, and patterns in years of publication, countries of study, research designs, sampling methods, measurements, and outcomes (i.e. preva© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1466–1478

3 Tracking references 15 Eligible studies for data exaction

Figure 1 Retrieval of references.

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H-Y Chang and H-L Chang

scale is reversed, the score is converted in the same direction [100%- the result]. However, one study employed a scale ranging from 0–10; therefore, a normalisation formula: [real score/10 9 100%] was used. The converted data were then categorised into attitudinal outcomes as follows: negative/insufficient (60%). No evidence was found to indicate that these data conversion methods distorted any of the findings. Finally, attitudinal outcomes were examined across time and in relation to the variables reported in the selected studies.

(n = 9), oncology (n = 2), acute care (n = 2), surgical treatment (n = 1) and palliative care (n = 1). Ages of the respondents surveyed in these studies ranged from 31–64 years old. Four studies1,3,9,14 also examined a small percentage of allied health care professionals, including physiotherapists, occupational therapists, public health professionals, dietitians, social workers and medical technicians. The number of respondents in the quantitative studies varied between 72 (Kam et al. 2012) and 993 (Wong et al. 2010) (see Table 2).

Discrepancies in the design of studies Ensuring rigor in the review Several steps were taken to minimise error and bias in this systematic review. First, studies were screened and data was extracted by two reviewers working independently. The aim of this step was to select articles according to the relevance of their abstracts. After obtaining the original articles and reapplying the inclusion and exclusion criteria, researchers independently extracted data and then verified the extracted data by evaluating with other researchers. Second, we applied the same inclusion and exclusion criteria. This resulted in the inclusion of only a small number of studies, indicating the comprehensive nature of our search strategy. Third, to minimise research bias resulting from inappropriate decisions, we consulted a panel of experts with 10-year experiences either in the fields of research, nursing, and health care systems to examine methodologies employed by included studies and provide suggestions. Finally, two researchers assessed the validity of each study with regard to data extraction. This process enabled us to resolve disagreements by consulting with a statistician.

Results Study characteristics The 15 studies included in this review were performed separately in Asia (n = 5) (Chu & Wallis 2007, Holroyd et al. 2008, Yom & Lee 2008, Osaka et al. 2009, Wong et al. 2010), North America (n = 4)(Brown et al. 2007, RojasCooley & Grant 2009, Cutshall et al. 2010, Trail-Mahan et al. 2013), Australia (n = 3) (Shorofi & Arbon 2010, Cooke et al. 2012, Kam et al. 2012), the Middle East (n = 2) (Samuels et al. 2010, Koc et al. 2012) and Northern Europe (n = 1) (Bjers a et al. 2012). These studies included professional nurses working in all relative fields

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Inclusion criteria stipulated that all studies must investigate the attitudes of nurses towards CAM therapies or the ability of nurses to discuss CAM with patients. As a result, we anticipated that most of the reviewed studies would not be experimental or observational (cross-sectional or longitudinal). Convenience sampling was used in all of the studies, and investigation strategies included selfreport surveys, face to face surveys, mail out surveys and online surveys. Most of the instruments used for data collection were self-designed questionnaires based on the definition of CAM provided by the NCCAM in the USA; however, they accumulated their own lists of CAM therapies, citing between 14–28 types, including herbs, diet, supplements, mind-body medicine, manipulative body-based therapies, relaxation and energy-based medicine. Respondents were asked to rate each type of CAM therapy using a Likert scale in terms of the following: belief in benefits of the therapy, knowledge/ training in application of the therapy, interest and attitudes towards the therapy, practical experience with the therapy, and consultation with patients. Various options were adopted in different Likert scales, including the following: ‘never heard’ to ‘sufficient knowledge’, ‘never’ to ‘more than once a day’, ‘strongly disagree’ to ‘strongly agree’, ‘harmful’ to ‘beneficial’, ‘have used’ to ‘not considered using’ and ‘none’ to ‘a lot’. A number of studies also used yes/no questions to determine nurses’ knowledge of CAM and willingness to discuss CAM with their patients. Two of the studies5,11 used the Nurse Complementary and Alternative Medicine Nursing Knowledge and Attitudes Survey (NrCAM K&A) developed by Rojas-Cooley and Grant (2009). This survey contains five sections: (1) knowledge, (2) attitudes, (3) resources, (4) experience and (5) educational interests. One study7 used the CAM Health Belief Questionnaire, comprising three sections: (1) demographic data, (2) CAM needs assessment and (3) attitudes

© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1466–1478

Trail-Mahan et al. (2013), USA Bjers a et al. (2012), Sweden

Cooke et al. (2012), Australia

Kam et al. (2012) Australia

Koc et al. (2012), Turkey

Cutshall et al. (2010), USA

Samuels et al. (2010), Israel

1

3

4

5

6

7

2

Authors/year

No

© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1466–1478

173 nurse-midwives (RR:727%) (40–59 y/o)

76 CNSs (RR: 64%) (50–64 y/o)

72 oncology professionals with 736% nurses (45 y/o) 129 nurse-midwives (RR: 811%) (37 y/o)

153 acute care nurses (RR:18%) (30–49 y/o) 737 health professionals with 704% nurses (RR: 420%) (37 y/o) 376 critical care nurses (RR: 268%) (46 y/o)

Sample

CS

CHBQ 14 CAM list

18 CAM list

Self-designed 18 CAM list

CS

Online CS

Self-design

CAMQCCN 28 CAM list

Self-designed 21 CAM list

NrCAM K&A

Tool

CS

Online CS

Online CS

Online CS

Design

70%

42%

589%

581%

NA

NA

60%

Prevalence of Practice

1. Herbs 2. Exercise 3. Diets 4. Massage 5. Music therapy 1. Relaxed breathing 2. Music therapy 3. Journaling 4. Spirituality and prayer 5. Guided imagery 1. Massage 2. Meditation/yoga 3. Acupuncture 4. Herbs/supplements 5. Spirituality/prayer

1. Massage 2. Chiropractic 3. Yoga 4. Acupuncture 5. Meditation 1. Exercise 2. Diet 3. Counselling 4. Massage 5. Relaxation NA

NA

Types of Practice

Table 2 Prevalence CAM use, knowledge of CAM, attitudes towards CAM and ability to discuss CAM with patients

NA

31% Yes 28% Educated 8% Certificated

NA

NA

777% No

957% No

51% Accuracy

Knowledge of CAM

796% Open

NA

612% Open

70% Open 33% Belief

906% Open 94% Close

NA

383% Belief 50% Responsible

Attitudes towards CAM

NA

NA

NA

503% Sometimes 231% Always 101% Assigned formal section on charts NA

38% Never 45% Rarely 17% Sometimes

NA

Communication of CAM

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Rojas-Cooley and Grant (2009), Canada

Holroyd et al. (2008), HK

11

12

Brown et al. (2007), Canada

Osaka et al. (2009), Japan

10

14

Wong et al. (2010), Singapore

9

Yom and Lee (2008), Korea

Shorofi and Arbon (2010), Australia

8

13

Authors/year

No

Table 2 (Continued)

321 health professionals (RR: 236%) (31–50 y/o)

485 nurses (RR: 97%) (31–50 y/o)

850 cancer nurses (RR: 24%) (45 y/o) 187 nurses

118 palliative units

Mailed survey

CS

CS

Mailing survey

CS

CS

CS

322 surgical nurses (RR: 70%) (39 y/o)

993 health care professionals with 716% nurses (RR: 619%)

Design

Sample

Self-designed

Self-designed 26 CAM list

Self-designed

NrCAM K&A

Self-designed 17 CAM list

Self-designed

Self-designed 25 CAM list

Tool

NA

27%

NA

337%

64%

641%

497%

Prevalence of Practice

1. Reflexology 2. Massage 3. Prayer 4. Cupping 5. Acupressure Support for 1. Massage 2. Therapeutic touch 3. Herbs 4. Chiropractic 5. Reflexology

NA

1. Massage 2. Music therapy 3. Nonherbal supplements 4. Meditation/ relaxation 5. Aromatherapy Support for 1. Acupuncture 2. Herbal medicine 3. Chinese massage 4. Chiropractic 5. Ayurveda 1. Aromatherapy 2. Music 3. Massage 4. Reflexology 5. Manual lymph drainage NA

Types of Practice

69% No

726% No

759% No 936% Want

70% Accuracy

67% No

965% No 20% Yes for acupuncture and herbs

65% No

Knowledge of CAM

80% rarely use for patients

563% Open

58% Open

80% Obstacles to providing CAM 42% Rejected some types of CAM 655% Belief 95% Responsible

771% Open

67% Open

Attitudes towards CAM

59% felt uncomfortable; 65% rarely assessed CAM; 78% rarely discussed CAM

28–355% Done 415% felt uncomfortable

NA

20% rarely 71% sometimes 9% often

529% Done 647% felt uncomfortable

NA

Communication of CAM

H-Y Chang and H-L Chang

© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1466–1478

Chu and Wallis (2007), Taiwan 15

© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1466–1478

RR, Response rate; CS, Convenience survey; CAM, complementary and alternative medicine; CAMQCCN, CAM questionnaire for critical care nurse; NrCAM K&A, Nurse complementary and alternative medicine nursing knowledge and attitudes survey; CHBQ: CAM health belief questionnaire.

Rejected: Feng-shui, Osteopathy, Homoeopath NA Relaxation Massage Music therapy Therapeutic touch Aromatherapy 1. 2. 3. 4. 5. 635% Self-designed 15 CAM list CS

Types of Practice Tool Design Sample Authors/year No

170 nurses (33 y/o)

Attitudes towards CAM Knowledge of CAM Prevalence of Practice Table 2 (Continued)

NA

CAM on nurses Communication of CAM

Review

towards CAM. This survey was initially developed by Lie et al. (2007) for use by medical students and was later used by pharmacy students.

CAM therapies popular in clinical practice The average prevalence of CAM in clinical practice was 537%, ranging from 27% (Yom & Lee 2008) to 70% (Samuels et al. 2010) among the 11 studies.3,4,5,6,7,8,9,10,11,13,15 However, differences in the operational definition of CAM between studies may have skewed the results. Three of the authors in Table 2 cite spirituality and prayer or prayer by itself as a type of CAM practice (Yom & Lee 2008, Cutshall et al. 2010, Samuels et al. 2010). With this inclusion, prayer alone makes the definition of CAM very broad. This point alone is one reason why there needs to be a clear operational definition. Most studies sought to determine the experience of respondents in recommending CAM to their patients. Other studies focused on interventions in clinical practice. Unfortunately, the time frame in which CAM treatments were administered was not clearly elucidated in all of the studies. The CAM therapies that appeared most frequently were massage, meditation/relaxation/yoga, herbal/supplements and music therapy. However, the popularity scores of some therapies (even those with the same frequency of occurrence) varied after weighting the position rankings (see Table 3). For example, acupuncture proved to be more popular with nurses than other therapies which appeared in the same number of studies. Following weighting adjustment, the five most popular CAM therapies were massage, meditation/relaxation/yoga, herbal/supplements, music therapy and acupuncture.

Knowledge of CAM In eight of the studies, between 62–965% (mean: 774%) of respondents reported a lack of knowledge/training/education in CAM.1,2,8,9,10,12,13,14 A minority of the respondents had formal education (28%) or certification (8%) in CAM therapies (Cutshall et al. 2010). These differences in education may be due to the wide variety of questions that were asked. Two of the studies5,11 evaluated the knowledge of respondents according to their ability to accurately define CAM. In the studies by Rojas-Cooley and Grant (2009) and Trail-Mahan et al. (2013), the percentage of respondents that answered accurately were 70 and 51% respectively. These scores are far higher than those obtained in the other studies. Resources cited as sources of CAM knowledge included magazines, friends, the Internet, books,

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H-Y Chang and H-L Chang Table 3 Types of complementary and alternative medicine used in clinical practice Lists

1st

2nd

3th

4th

5th

Massage Meditation/relaxation/yoga Herbs/supplements Music therapy Acupuncture Reflexology Chiropractic Aromatherapy Spirituality/prayer Exercise Diet Therapeutic touch Relaxed breathing Counselling Journaling Cupping Acupressure Guided imagery Manual lymph drainage Ayurveda

4 1 1

2 1 1 3

2 2 2 1 1

2 1 1

1

1 1 1 1

1 1

1 1 1

1

1 2 1

1 1

1 1 1

professional journals and family members (Brown et al. 2007, Holroyd et al. 2008).

Attitudes towards CAM Wide variations were observed between 10 studies with regard to attitudes towards CAM;2,3,4,5,7,8,9,11,12,13 however, the average was 664%, which could be classified as positive. Some studies2,4,8,9,12, investigated attitudes towards the integration of CAM with conventional medicine, and most respondents were in favour of this (51–906%). Other studies3,5,7,13 that used scales to assess attitudes provided similarly positive results, ranging from 563–796%. In all of the studies, respondents reported being open to CAM. When questioned about their beliefs, the percentage of 655% of Canadian nurses reported a belief that CAM therapies could be effective11, which is similar to the findings listed above. However, approval ratings dropped to 338% in the USA5 and 32% in Australia.3 In addition, more than 80% of the respondents10,14,15 noted obstacles to the provision of CAM and expressed negative opinions with regard to a number of CAM therapies, such as qi gong, homeopathic medicine, electromagnetic/magnetic treatments, environmental medicine, biofeedback, osteopathy and art therapy. Cutshall et al. (2010) claimed that these negative attitudes may be due to a lack of experience or training with these treatments or a lack of institutional support, time, resources, equipment and physician support.

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1 1 1 2

1 1 1 1 1

Frequency

Weighted

10 6 6 5 3 3 3 3 3 2 2 2 1 1 1 1 1 1 1 1

38 18 17 16 10 8 8 7 6 9 7 6 5 3 3 2 1 1 1 1

Communication and documentation about CAM Six of the studies1,2,9,10,12,14 investigated the discussion of these issues with patients, indicating that between 17% of the nurses (Bjers a et al. 2012) and 529% of the nurses (Wong et al. 2010) expressed a willingness to communicate with their patients regarding the use of CAM. Only 9%10 to 231%2 of respondents reported often discussing the use of CAM with patients. Many respondents1,2,10,12,14 (503– 71%) reported occasionally discussing these issues; however, most respondents in Canada14 (78%) and Sweden1 (83%) rarely discussed these issues. Approximately half of the respondents (473–677%)9,12,14 reported feeling uncomfortable discussing CAM with patients. In the study by Cooke et al. (2012), only 101% of respondents reported that patient charts included a specific area to document CAM use.

Discussion Several limitations became evident while conducting this review. Inconsistencies among the instruments used in these studies strongly influenced the results, conclusions and types of available information. Although we normalised the data (i.e. into percentages) to minimise the effects of this variation, it is probable that bias still existed, particularly due to the diversity of operational definitions used in the various studies. The availability of studies was largely determined by the availability and nature of previous research in this field. It is worth noting that a number of geographical areas © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1466–1478

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have been overlooked in CAM research, including Central and South America, Europe, Southwest Asia and Africa, which may have resulted in selection bias and could limit the generalizability of our conclusions.

Comparison of results from the current literature review with those of previous reviews In our study, the mean prevalence of CAM in clinical practice was 537% (range: 27–70%). These results are similar to those reported by Sewitch et al. (2008), in which the prevalence of CAM use among conventional health care professionals was 482% (range: 141–80%). The prevalence of CAM use in this study was lower than in the review conducted by Adams et al. (2011), in which 763% of midwives practiced CAM in maternity care (range: 41– 100%). However, it was difficult to determine the actual prevalence of CAM use among nurses due to inconsistencies with regard to research questions and questionnaires, the operational definition of CAM practice and the time-frames in which CAM was implemented. In addition, we found that massage was the most common CAM therapy used in conventional clinical practice, followed by meditation/relaxation/yoga, herbal/supplements, music therapy and acupuncture. These results are similar to those of Leach (2004), but differ considerably from previous reviews by Antigoni and Dimitrios (2009) and Adams et al. (2011) in which homeopathy, acupuncture, dietary manipulations, massage and osteopathy ranked as the five most popular therapies. It was difficult to determine the reasons for discrepancies between this study and previous reviews because previous studies (Leach 2004, Antigoni & Dimitrios 2009) failed to present a number of details related to research design, sampling methods/sample size, region/setting and/or extracted information. However, such differences may relate to the care context and the cultural context, for example, Ayurveda in favour of Indian, traditional Chinese medicine in favour of Asian culture and naturopathy origin in European culture. In this review, nurses are more likely to use complementary therapies such as massage in the maternity and surgical environment to promote relaxation; or critical care in using exercise rehabilitation for patients with critical illness; and, palliative care in using aromatherapy and music therapy as nonpharmacological pain management strategies. In our review, more than three quarters of nurses reported a lack of training and CAM-related knowledge. This is slightly higher than results in the review by Milden and Stokols (2004), in which 61% of physicians did not feel they possessed sufficient knowledge to comment on the © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1466–1478

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safety or efficacy of CAM. Possible reasons for this discrepancy are as follows: (1) a lack of CAM knowledge among faculty that teach nursing courses, (2) limited emphasis on CAM in standard nursing courses and (3) the small cadre of CAM-informed educators that teach elective courses on CAM (Booth-LaForce et al. 2010). Most of the CAMrelated courses provided by nursing faculty comprised three modules: (1) an overview of CAM with a list of databases applicable to self-learning activities, (2) a focus on a specific CAM treatment and its applicability to standard health care and (3) a discussion of profession-related topics, such as cultural, ethical and legal issues pertaining to CAM (Pearson & Chesney 2007, van der Riet et al. 2011). Considering the lack of strong evidence to support the efficacy of many CAM therapies, perhaps the key to optimising patient care is improving the ability of nurses to communicate the risks and benefits of CAM with patients, rather than the integration of CAM into clinical nursing practice. An average of 664% of nurses reported being positively inclined towards the provision of CAM. No previous reviews reported this level of approval; however, they all provided evidence to suggest that nurses are generally positive about CAM (Leach 2004, Sewitch et al. 2008). The global prevalence of CAM use among nurses is high, including 80% in England, (Buchan et al. 2012), 873% in Israel (Samuels et al. 2010), 78–98% in USA (Burke et al. 2005, Hastings-Tolsma & Terada 2009), and 635% in Taiwan (Chu & Wallis 2007). However, a comparison of studies revealed that there were discrepancies in terminology adopted by surveys, inconsistencies in the scope of the content, and variations in the scales used to measure attitudes. In addition, between 473–677% of nurses did not feel that they possessed sufficient knowledge about the safety and efficacy of CAM to discuss these issues with their patients. The positive attitudes of nurses towards CAM in fact contradict their knowledge of CAM. Specifically, most nurses tend to acquire CAM knowledge from media sources, magazines and the Internet (Brown et al. 2007, Holroyd et al. 2008). Even though nurses have an open-mind attitude towards CAM, they exhibit several gaps in knowledge pertaining to CAM, and the resource of CAM information, which may further prevent them from effectively communicating the risks and benefits associated with various types of CAM to patients, As stated above, between 473–677% of nurses in our review felt unable to discuss CAM with patients due to insufficient knowledge about the safety and efficacy of CAM therapies. This finding differed from that of Sewitch et al. (2008), in which two-thirds of the respondents felt comfortable discussing CAM with their patients. This inconsistency

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may be attributed to differences in the sample population. Our study focused on nurses working closely with patients, whereas Sewitch et al. recruited professionals from all areas of health care system. However, a comparison of actual CAM-related conversations revealed that percentage of nurses that discuss CAM with patients in our study (9–231%) was similar to the number in previous studies (21%). Nonetheless, a lack of communication and familiarity with the risks and benefits of CAM with patient could prevent nurses from successfully integrating CAM into clinical practice and providing high-quality holistic care.

they are using other CAM therapies and what they are. It is also the responsibility of the physicians (nurse practitioners who prescribe) and pharmacists (who fill and advise on drug combinations) and then the nurses who may administer medications. In addition, future researchers should consider conceptual and operational definitions related to CAM and how they pertain to the knowledge and attitudes of nurses regarding these issues as well as the study design with a reliable sampling method. We recommend that the operational definition of CAM established by Wieland et al. (2011) be adopted as they examined 396 Cochrane reviews related to this subject.

Relevance to clinical practice According to Sparber (2001), nearly half of the State Boards of Nursing in the USA suggest that CAM should be included within the scope of nursing practice. Numerous studies have shown that CAM increases the comfort level of patients and improves their sense of satisfaction with the treatment (Chang et al. 2012, Trail-Mahan et al. 2013). However, a decade later, many nurses still feel that they lack knowledge, education, training, institutional support, resources, equipment and the support of colleagues when considering the implementation of CAM (Cooke et al. 2012). CAM is becoming increasingly prevalent among patients seeking forms of self-care and more widely accepted in mainstream culture as well as in established health care systems. Thus, it is important to develop innovative ways to find the best evidence of CAM, and expand the availability of CAM-related knowledge that is both relevant and applicable to nursing practice. This suggestion underlines the need to establish education programmes that address the use of CAM in clinical nursing practice to help overcome communication barriers between health care professionals and patients. These programmes could be primarily conducted through distance education, and would help to raise the baseline knowledge of nurses with regard to CAM, thereby empowering them to discuss these issues and assess the risks and benefits of combining traditional and CAM medications. Despite a growing body of research to support the efficacy of CAM, debates about the integration of CAM and conventional medicine are still common, and most of these debates arise from concerns regarding adverse effects of herb–drug interactions. Considering the importance of patient management and safety, the first step in adopting CAM therapies should be an assessment of how conventional medicines and their CAM counterparts are used by patients; there should not be a rush to combine CAM into clinical nursing practice (Trail-Mahan et al. 2013). The responsibility lies first with patients to advise health care providers who they see that

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Conclusions Patients are expressing greater interest in CAM, and this has led to the mainstream adoption of some CAM therapies. Nonetheless, CAM is generally viewed as complementary to conventional medical practice or as a self-care strategy. We are pleased to report that most nurses considered by this study are open to the adoption of CAM into clinical nursing practice; however, their ability to communicate the risks and benefits of CAM with patients has been undermined by a lack of knowledge. As advocates working for the well-being of patients, nurses need to understand the nature of all therapies their patients are undergoing. Nurses also have to understand how these therapies affect patients and be able to access up-to-date resources to ensure that patients are using CAM safely. Creating a safe treatment environment requires open dialogue between nurses and patients to clarify expectations and share in the decision-making process.

Acknowledgements The authors acknowledge a panel of experts who contributed to the process of this research at various stages, and we are grateful to all researchers who published their studies and shared their findings to increase understanding in this area of practice. We thank both the reviewers for their thorough review and highly appreciate the comments and suggestions, which significantly contributed to improving the quality of the publication.

Disclosure The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethical_1author.html), as follows: (1) substantial contributions to conception and design of, or acquisition of data or © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1466–1478

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analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content and (3) final approval of the version to be published.

Conflicts of interest No competing financial interests exist.

Ethical approval None.

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A review of nurses' knowledge, attitudes, and ability to communicate the risks and benefits of complementary and alternative medicine.

This study reviewed existing literature to investigate how frequently nurses include complementary and alternative forms of medicine in their clinical...
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