ORIGINAL RESEARCH
Nurse practitioner knowledge, use, and referral of complementary/alternative therapies Carol Geisler, PhD, RN (Associate Professor)1 , Corjena Cheung, PhD, RN (Assistant Professor)2 , Stasia Johnson Steinhagen, MA (Graduate Student)1,3 , Peggy Neubeck, MAN, RN, CNP (Assistant Professor)4 , & Alvina D. Brueggeman, PhD (Faculty)5 1
Holistic Health Studies, St. Catherine University, St. Paul, Minnesota University of Minnesota, Minneapolis, Minnesota 3 Minnesota Center for Homeopathy, St Louis Park, Minnesota 4 St. Catherine University, 601 25th Ave. S. Minneapolis, Minnesota 5 Women’s Health Integrative Research Center, Holistic Health Studies, St. Catherine University, St. Paul, Minnesota 2
Keywords Complementary and alternative medicine (CAM); nurse practitioners; beliefs; communication; holistic; healthcare collaboration; descriptive research. Correspondence Carol Geisler, PhD, RN, St. Catherine University, 601 25th Ave. S, Minneapolis, MN 55454. Tel: 651-245-3844; Fax: 651-690-7849; E-mail: [email protected], [email protected] Received: 17 September 2013; accepted: 27 January 2014 doi: 10.1002/2327-6924.12190
Abstract Purpose: The study aims are to (a) describe nurse practitioners’ (NPs’) belief in effectiveness, knowledge, referral, and use of complementary/alternative therapies (C/ATs), (b) explore the initiation of C/AT dialogue between NPs and their patients, and (c) examine the relationships between demographic variables and NP C/AT knowledge, beliefs, use, referrals. Data sources: A mixed-method cross-sectional online survey of licensed NPs (N = 2874) from a Midwestern state was analyzed using descriptive statistics, thematic analysis, and content analysis. Conclusions: NPs (n = 410) report the most knowledge about prayer (40%) and mind–body practices (32%). Many NPs (84%) report using vitamins for personal use and 85% refer their patients for massage/bodywork. Most (95%) believe NPs should have knowledge of the most common C/AT and 81% believe C/AT have a legitimate use in allopathic medicine. NPs’ knowledge, belief, use, and referral of C/AT are significantly correlated. NPs initiate C/AT dialogue with their patients 54% of the time. Factors that impact the NP and patient C/AT dialogue include patient/family openness, nature of the health problem, NP C/AT knowledge, time, and accessibility. Implications for practice: Centralized C/AT sources could help expedite C/AT referrals. Implementing workplace C/AT clinics could help build knowledge, referral, personal use, and acceptance of C/AT.
Introduction The widespread use of complementary/alternative therapies (C/ATs) has garnered growing national attention. The National Institutes of Health (NIH; Barnes, Bloom, & Nahin, 2008) report that nearly 40% of U.S. adults have used some form of C/AT within the past year. With some major insurance companies currently incorporating selected C/AT into their covered services (Cleary-Guida, Okvat, Oz, & Ting, 2001), along with easy accessibility of C/AT products such as herbs and nutritional supplements (Kennedy, 2005) and growing C/AT popularity, these alternative approaches have become increasingly feasible
380
healthcare options. The National Center of Complementary and Alternative Medicine (NCCAM) currently defines C/AT as a group of diverse medical and healthcare systems, practices, and products that are not generally considered part of conventional medicine (NCCAM, 2010). Although commonly called “complementary/alternative medicine,” or “CAM,” this study uses the term complementary/alternative “therapies” to encompass the essence of “healing” versus “curing,” as suggested by Cheung, Wyman, and Halcon (2007). Most healthcare providers underestimate the rate of C/AT use by their patients, suggesting that many patients do not discuss such use with their healthcare providers Journal of the American Association of Nurse Practitioners 27 (2015) 380–388 C 2014 American Association of Nurse Practitioners
NP knowledge, use, and referral of C/ATs
C. Geisler et al.
(Giveon, Liberman, Klang, & Kahan, 2003). Some C/AT may interact with allopathic medications and treatments, increasing risk for both patients and practitioners (Kaufman, Kelly, Rosenberg, Anderson, & Mitchell, 2002). The need for providers to be aware of C/AT use among their clients and engage in meaningful dialogue around C/AT choices is imperative and timely (Caspi & Baranovitch, 2009; Cuellar, Cahill, Ford, & Aycock, 2003). Nurse practitioners (NPs) play a major role in providing primary health care to many patients in the healthcare system and rank as one of the fastest growing groups of healthcare providers (American Association of Nurse Practitioners, 2010). While there has been research on physicians’ attitudes, use of C/AT (Hamilton, Roemheld-Hamm, Young, Ialha, & DiCicco-Bloom, 2008; Kurtz, Nolan, & Rittinger, 2003; Manek et al., 2010; Wahner-Roedler et al., 2006), and some studies on physician assistants’ C/AT attitudes (Houston, Bork, Price, Jordan, & Dake, 2001; Lloyd, Simon, Dunn, & Isberner, 2007), there are limited studies on NPs’ attitudes and knowledge of C/AT (Nottingham, 2006; Sohn & Cook, 2002). Given the increase in NPs as primary health providers along with Americans’ continued increase use of C/AT, there is a need for understanding NPs’ attitudes, beliefs, knowledge, use, and referral of C/AT to inform healthcare practices, education, and policy. The aims of this project are to (a) describe the NP beliefs in effectiveness, knowledge, referral, and use of C/AT, (b) explore the dialogue about C/AT between NPs and patients, and (c) examine the relationships between demographic variables and NP C/AT knowledge, beliefs, use, referrals.
Method We used a mixed-method cross-sectional online survey to assess licensed Minnesota NPs’ attitudes, knowledge, beliefs, use, and referrals of C/AT as well as C/AT dialogue between NPs and patients.
Instrumentation We developed a survey with 17 questions focusing on knowledge, beliefs of effectiveness, use, and referrals of 28 types of C/AT based on the literature. We listed 28 kinds of commonly used C/ATs based on the NCCAM’s classifications of C/AT, but did not provide definitions for each type of C/AT used on the survey. The survey also asked NPs to (a) estimate patient C/AT use, (b) report NPs’ attitudes about C/AT, and (c) describe NP and patient C/AT dialogue. We included two descriptive qualitative questions: (a) What has your experience been with C/AT? (b) What factors influence whether or not you talk with your patients about C/AT? We pilot tested the
survey with 10 graduate faculty members from nursing and holistic health; five completed the survey and provided feedback. We revised the questions based on the feedback from the pilot test, but as with many survey tools, we did not test for reliability and validity other than face validity.
Sample After receiving approval from St. Catherine University’s IRB, we obtained a mailing list from the Minnesota Board of Nursing of all licensed NPs in the state with e-mails (N = 2874). We sent an e-mail, including informed consent, to each licensed NP requesting their participation in the survey. Two additional reminder e-mails were sent. Participants had the option at the end of the survey to submit their contact information, separate from the survey, to be eligible for one of six $75 gift cards to Amazon.com.
Data analysis Quantitative data analysis. A total of 410 usable survey responses of 434 responses were used for data analysis, after deleting those who did not finish the survey (n = 12) based on parameters set by Qualtrics survey software, and those who had completed the survey more than once (n = 12). The statistician analyzed the data using SPSS version 17. Descriptive statistics including mean, frequency, and percentage were run. In situations where participants could respond with multiple choices for an answer (practice setting, practice location, and practice specialty), the total number of cases were counted. Some NPs, for instance, worked in multiple settings, and were therefore counted as a case in each setting. Inferential statistics including chi-square tests of independence on categorical variables and correlations on ordinal data were conducted. In the descriptive results, we report “valid percentages” by calculating the percentage excluding missing cases. In the inferential statistics, certain questions (e.g., knowledge, belief, referral, and use) included the option of answering separately for each of 28 different types of C/ATs. We transformed answer choices to ordinal rather than categorical scales. Sum and average values were then calculated for each question, collapsing across individual C/AT therapies. Spearman’s rho was then conducted to examine relationships between the four variables of interest. Qualitative data analysis. There were 289 responses to at least one of the two descriptive qualitative questions, we each reviewed and coded the data independently and then compared results as a group. We conducted thematic analysis about factors that influence whether or not NPs talk with their patients about C/AT, 381
NP knowledge, use, and referral of C/ATs
and content analysis on the reports of a case where a patient used C/AT and the outcomes. Considerations of rigor. Collecting both quantitative and qualitative data strengthened the rigor of this study. The qualitative data provided us with descriptive factors that contribute to the C/AT dialogue between NPs and their patients. Our interdisciplinary (nursing, psychology, homeopathy, holistic health, statistics) research team provided multiple lenses through which to analyze and interpret the data, helping to broaden our mutual understanding and reduce bias.
Limitations This study has several limitations including use of a survey and a limited sample. When using surveys, researchers cannot be sure if participants understood the questions, and data are subject to recall bias. Survey respondents also tend to offer socially acceptable answers. We suspect that those who view C/AT favorably might have been more likely to respond to the survey, leaving out important data from those who are less likely to use, talk about, and refer C/AT and therefore biasing the sample. Although we had a reasonable response rate from the licensed NPs in Minnesota, a larger sample size including NPs from other geographic locations as well as focusing on areas of specialty would be beneficial in future research. Finally, C/AT use is a complex issue and in this study we only examined NPs’ attitudes, knowledge, use, and referrals. Further research examining healthcare provider factors, patient factors, system factors, and their interactions is needed. Also, research that defines just what kind of knowledge— facts about modalities, understanding evidence-based outcomes, personal experience with C/AT, or knowledge of credible referral sources—is most impactful to NPs’ practice.
Results Data were analyzed using 410 usable survey responses. Most of the respondents were women (96%), with an average age of 48 (SD = 10.81), and 52% had practiced 10 years or less. Most NPs reported practicing in an urban (62%) and outpatient (56%) settings, with 28% practicing in multiple settings (see Table 1).
NP knowledge, beliefs, referrals, and personal use of C/AT NPs report a wide range of knowledge of various forms of C/AT. NPs have “lots of knowledge” about prayer (40%), mind–body practices (32%), and meditation (30%). Herbs (79%), acupuncture (79%), aromatherapy (75%), and homeopathy (73%) are the highest ranked C/AT for “some knowledge.” NPs report “no 382
C. Geisler et al.
Table 1 Demographic frequencies of NPs Demographics Gender Male Female Practice setting Academic Hospital Long term Outpatient Retail School Special Other Practice setting type Acute Subacute Community Academic Educational setting Private Public Practice location Urban Suburban Rural Years of practice 30 years Have not practiced
n
(%)
16 386
4.0 96.0
52 115 41 228 14 5 53 49
12.7 28.0 10.0 55.6 3.4 1.2 12.9 12.0
133 299 17 52
32.4 72.9 4.2 12.7
144 251
36.2 63.1
264 85 76
62.1 20.0 17.9
29 100 82 84 47 27 15 24 1
7.1 24.4 20.0 20.5 11.5 6.6 3.7 5.9 0.2
knowledge” of ayurvedic medicine (76%), horse therapy (69%), and indigenous practices (65%; see Table 2). NPs believe in the overall effectiveness of massage/bodywork (90%), meditation (88%), mind/body practices (87%), and acupuncture (84%). Chelation (10%) and electromagnetic therapies (10%) are the top therapies NPs believe to be “ineffective” (see Table 3). Most NPs (95%) believe that NPs should have knowledge of the most commonly used C/AT. Many (78.5%) believe that NPs’ knowledge of C/AT results in better patient outcomes, with 9% having no opinion. Most NPs (81%) agree that C/AT have a legitimate use in allopathic medicine and 71% disagree that C/AT negatively impacts allopathic medicine. Most NPs disagree (60%) that effects of C/AT are generally the result of the placebo effect, with 30% having no opinion (see Table 4). NPs most commonly refer patients for massage/bodywork (85%), vitamins (81%), and dietary supplements (78%; see Table 5).
NP knowledge, use, and referral of C/ATs
C. Geisler et al.
Table 2 NPs’ knowledge of C/ATs
Table 3 NPs’ belief in C/ATs
C/AT
None
Some
Lots
Acupuncture Aromatherapy Art therapy Ayurveda Electromagnetic BioField Chelation Dance therapy Diet supplements Food as medicine Herbal Horse therapy Homeopathy Oxygen therapy Indigenous Massage/bodywork Meditation Mind–body Modified diet Movement Music therapy Naturopathy Pet therapy Prayer Spinal Traditional Chinese medicine (TCM) Vitamin Yoga
10.2 16.1 41.3 75.9 56.2 12.7 61.1 52.6 2.9 21.1 9 69.4 22.1 48.3 64.7 4.4 5.1 5.1 11.3 38.2 15.7 35 12.5 3.9 9.8 50.6 4.9 7.9
78.5 75.1 52.6 22.9 42.3 71.8 37.7 45 72.1 57.6 79 27.1 72.8 46.3 32.8 68.5 64.5 62.6 64.4 54.4 71.3 58.8 72.2 56.4 67.4 45.2 68.6 68.8
11.2 8.8 6.1 1.2 1.5 15.4 1.2 2.4 25 21.3 12 3.4 5.1 5.4 2.5 27.1 30.3 32.3 24.3 7.4 13 6.1 15.2 39.7 22.8 4.2 26.5 12.3
Acupuncture Aromatherapy Art therapy Ayurveda Electromagnetic BioField Chelation Dance therapy Diet supplements Food as medicine Herbal Horse therapy Homeopathy Oxygen therapy Indigenous Massage/bodywork Meditation Mind–body Modified diet Movement Music therapy Naturopathy Pet therapy Prayer Spinal Traditional Chinese medicine (TCM) Vitamin Yoga
Ineffective
Neither
Effective
Don’t know
0.5 2.2 1 1.2 10.1 2.9 10.3 2.5 1.7 0.5 2 1.7 3.9 3.9 2 0.5 0.7 0.2 0.7 0.7 0.5 1.7 0.2 0.7 3.9 1.7
4.9 20.3 11.1 6.2 20.6 11.1 11.8 13 20.4 14.8 22.1 6.6 19.4 7.8 11.1 4.7 4.7 4.9 10 7.4 5.2 16 4.2 7.7 15 8.8
83.5 55.6 50.9 16.5 12.5 63.9 9.1 38.5 67 59.5 60.5 27.7 47.2 37.7 20.2 90.4 88.1 87 70.8 50.1 74.1 39.6 82 81.7 67.6 42.4
11.1 21.8 37.1 76.1 56.8 22.1 68.9 46.1 10.8 25.2 15.4 64 29.5 50.5 66.7 4.4 6.5 7.8 18.4 41.8 20.2 42.8 13.5 9.9 13.5 47.1
0.7 0.7
16.2 6.4
69.8 80.3
13.3 12.6
Note. Percent frequency of NPs’ responses to each item. Note. Percent frequency of NPs’ responses to each item.
NPs report commonly using vitamins (84%), massage/bodywork (82%), prayer (80%), dietary supplements (76%), and mind–body practices (76%) for themselves. The least personally used modalities include hyperbaric oxygen (1.5%), chelation (1.5%), horse therapy (5%), indigenous practices (7%), and ayurvedic medicine (9%; see Table 6). Greater knowledge of C/AT is associated with greater belief, referral, and use (p < .001; see Table 7). The percent frequency of NPs who personally use each C/AT closely parallels the percent of NPs that refer each C/AT to their patients (see Figure 1).
NP–patient C/AT dialogue and estimates of use Sixty percent of NPs estimate “some” to “all” of their patients use C/AT, and 64% believe their patients do not disclose their C/AT use. Most NPs (80%) report they are comfortable discussing C/AT with their patients. NPs estimate that 54% of the time they initiate the dialogue, while the patient initiates it 35% of the time. A nurse’s experience level (defined as years of practice) does not influence
Table 4 Frequency (%) of NPs’ opinions regarding C/ATs
NPs should have knowledge of the most common C/AT NP knowledge of C/AT results in better patient outcomes C/AT have a legitimate use in allopathic medicine C/AT negatively impacts allopathic medicine Effects of C/AT are generally the result of the placebo effect
Disagree
Agree
No opinion
0.5
95.4
3.9
2.7
78.5
18.8
2.5
81.3
16.2
70.9
7.4
21.7
59.6
10.0
30.4
who initiates the dialogue about C/AT, χ 2 (24, n = 405) = 14.56, p = .93. Similarly, the type of institution (public or private) does not influence the initiation of dialogue, χ 2 (6, n = 394) = 9.25, p = .16. Several themes emerge from the qualitative data of C/AT dialogue between NPs and their patients: patient/family openness, beliefs and attitudes, nature of the health problem, NP knowledge and attitude of C/AT, NP knowledge 383
NP knowledge, use, and referral of C/ATs
C. Geisler et al.
Table 6 NPs’ personal use of C/ATs
Table 5 NPs’ referral of C/ATs
Acupuncture Aromatherapy Art therapy Ayurveda Electromagnetic BioField Chelation Dance therapy Diet supplements Food as medicine Herbal Horse therapy Homeopathy Oxygen therapy Indigenous Massage/bodywork Meditation Mind–body Modified diet Movement Music therapy Naturopathy Pet therapy Prayer Spinal Traditional Chinese medicine (TCM) Vitamin Yoga
Yes
No
59.3 35 17.2 4.4 6.4 44.4 3.2 10.9 78 50.2 57 10.1 24.5 13.1 10.2 85.2 63.5 75.4 73.7 30.8 38.5 20 43.3 61.6 57.1 13.1 80.5 60.8
40.7 65 82.8 95.6 93.6 55.6 96.8 89.1 22 49.8 43 89.9 75.5 86.9 89.8 14.8 36.5 24.6 26.3 69.2 61.5 80 56.7 38.4 42.9 86.9 19.5 39.2
Note. Percent frequency of NPs’ responses to each item.
of C/AT referrals, time allotted for patient contact, limits of allopathic medicine, accessibility of C/AT, and lack of availability of evidence-based information. Themes are categorized according to whether they are patient, NP, or larger systems factors.
Patient factors Patient/family openness, beliefs, and attitudes. More than half of the NPs comment on patient and family attitudes, beliefs, and openness as a factor that impacted whether or not they open up a dialogue about C/AT with their patients. They report that they can tell by a “patient’s initial reaction when I mention C/AT” whether or not to pursue the conversation. “You can usually tell when a patient just wants something traditional. If I feel it will be helpful, regardless, I will make the suggestion and provide an avenue for referral or follow up.” “I adjust my information to the level of acceptance/resistance the patient has. For example, I do Healing Touch, however that is ‘too far out there’ for some patients. I meet them where they’re at. If they are inter384
Acupuncture Aromatherapy Art therapy Ayurveda Electromagnetic BioField Chelation Dance therapy Diet supplements Food as medicine Herbal Horse therapy Homeopathy Oxygen therapy Indigenous Massage/bodywork Meditation Mind–body Modified diet Movement Music therapy Naturopathy Pet therapy Prayer Spinal Traditional Chinese medicine (TCM) Vitamin Yoga
Yes
No
29.6 46 12.6 9.1 10.8 40.1 1.5 15.4 75.9 47.3 59.8 4.5 22.9 1.5 6.8 82.4 68 76.3 63.2 37.8 34.2 18.2 31.8 79.8 50.8 15.4 84.2 62.3
70.4 54 87.4 90.9 89.2 59.9 98.5 84.6 24.1 52.8 40.2 95.5 77.1 98.5 93.2 17.6 32 23.7 36.8 62.2 65.8 81.8 68.2 20.2 49.2 84.6 15.8 37.7
Note. Percent frequency of NPs’ responses to each item. Table 7 Correlations between NPs’ knowledge, belief, referral, and use of C/AT: summed values
Knowledge Belief Referral Use
Knowledge
Belief
Referral
Use
– 0.56** 0.54** 0.57**
– 0.56** 0.58**
– 0.64**
–
Note. Variable values were summed across 28 C/AT modalities. **p < .001.
ested in more information, I provide it.” A sense of NP frustration comes through regarding some patients’ lack of willingness to try C/AT: “Some of them seem receptive to any form of assistive therapy; some seem to be only interested in prescription medications.” Others assess the “Family’s willingness to discuss alternative modalities compared to standard Western medicine approaches to treatment.” “If the family brings it up” then they talk about it. Nature of the health problem. Many NPs indicate that the nature of a patient’s health problem influences whether or not they bring up C/AT. “I always offer C/AT for people with repeat sinusitis and bronchitis because I am
NP knowledge, use, and referral of C/ATs
90 80 70 60 50 40 30 20 10 0
Used C/AT Referred C/AT Acupuncture Aromatherapy Art Therapy Ayurveda Electromagnetic BioField Chelation Dance Therapy Diet Supplements Food as Medicine Herbal Horse Therapy Homeopathy Oxygen Therapy Indigenous Bodywork Meditation Mind-Body Modified Diet Movement Music Therapy Naturopathy Pet Therapy Prayer Spinal TCM Vitamin Yoga
Frequency (%) of Nurse Practitioners
C. Geisler et al.
Figure 1 Percent frequency of NPs who personally used each C/AT, and percent that referred each C/AT to patients.
not interested in offering antibiotic therapies when they are not effective.” “When I have the rare patient who has symptoms of PMS or PMDD, headaches, or other problems which may be related to the menstrual cycle, I may discuss C/AT with them.” Pain is frequently mentioned as a symptom likely to result in C/AT dialogue.
NP factors NPs’ knowledge and attitudes of C/AT. NPs report that their knowledge and attitudes of C/AT impact whether or not they open up a C/AT dialogue with their patients. Some cite their lack of understanding about therapies, effectiveness, and “lack of complete understanding of potential effects with prescription medications” as contributing factors. Others report that they are more likely to initiate a dialogue based on “whether or not I think that a C/AT will be beneficial or not.” Some NPs base their C/AT dialogue on the modality itself. For example, “I do not believe in Healing Touch or aromatherapy and would never recommend [it]. I don’t discourage patients from C/AT as long as they don’t forgo treatments backed by science in favor of complementary therapies, and as long as there are not adverse reactions.” NPs’ knowledge of referrals. NPs’ knowledge of referrals impacts whether or not they bring up C/AT. Some report simply not knowing “places to send patients.” Referrals also depend on, “What is available in my area or reputable practices and how much I know about it.” Another NP states, “I also am cautious as to who they are taking their child to as I want to know the specific provider of C/AT and the person’s certifications, knowledge base.” Another cites her own lack of referrals as a factor: “I need to learn more about C/AT providers in my area and develop better relationships with them.” “I was more likely
to discuss these therapies if I knew of an effective reputable provider.”
Systems factors Time allotted for patient contact. “TIME!!!” is the most often cited reason for not initiating a dialogue with patients about C/AT. “Time, time, time. In the current environment of quality measures, RVUs and other time constraints, it is very difficult to discuss more topics than already required. Primary care does not have time to address the issues as it is.” Limits of allopathic medicine. Many NPs discuss C/AT when conventional medical practices are “ineffective” or as “adjuncts to medical treatment.” “I usually consider it for patients who have chronic conditions and are not improving with Western medicine and/or patients who do not like to take pills.” They describe their patients’ “frustrations with traditional medicine or costs of traditional medicine.” Accessibility of C/AT. Many NPs express frustration at the lack of accessibility of C/AT. Funds and lack of insurance coverage are cited frequently. Often, “the cost is not covered by this health system and the patients cannot afford” them. Furthermore, “In Public Health, I might recommend C/AT depending on whether or not they have insurance that covers such therapies.” Some NPs mention specific medical systems that do not recognize C/AT. “I work in the VA system where the practices of C/AT are generally not recognized.” “[I] work with geriatrics and Medicare do not cover most of these therapies.” Transportation to C/AT appointments is another concern raised by NPs. “Most of my patients are not very mobile and transportation is an issue along with cost.” “[The] majority of my patients are frail and unable to go out for most therapies–difficult to bring some 385
NP knowledge, use, and referral of C/ATs
into long-term care so that often limits what I will offer patients and families.” Another states, the “ability to get out of [the] nursing home and to provider also affects whether I talk about these therapies.” In addition, “Many live in rural areas and these methods are not easily available.” For others, the complexity of the current treatment impacts accessibility of C/AT. “Patient has a very hectic treatment schedule and they are not interested in more appointments.”
Lack of availability of evidence-based information. NPs express frustration with the lack of “evidencebased efficacy information” being readily available. In other words, a “lack of resources and research to support outcomes.” Others are aware of the literature but are dissatisfied with the nature of the research. “There is a lack of substantial evidence-based practice literature.” Others suggest that more research is needed. “If they request them [C/AT], I will approve or disapprove but I do not feel they are well studied and therefore do not feel I should be recommending them.”
Discussion and implications of key findings Similar to Nottingham’s (2006) review of NPs and C/AT literature, findings show a positive correlation between knowledge, belief, use, and referral. This suggests that NPs often “go with what they know” and raises the question of how NPs come to know about C/AT in the first place. NPs refer what they personally use. NPs most use (as well as know, believe in, and refer) C/AT that are largely low- or no-cost—therapies that can be used without paying a practitioner (prayer, mind–body, yoga, vitamins, herbs, and homeopathy). This is similar to Cutshall et al. (2010), where the top therapies that Clinical Nurse Specialists (CNSs) personally used were humor, massage, spirituality/prayer, music therapy, and relaxed breathing. A few of the more commonly NP-known C/AT (chiropractic, massage, and acupuncture) do require paying a practitioner. However, those C/ATs are widely accepted as effective, provide more immediate gratification/relief, and are often covered by insurance plans. The C/AT least known, believed in, used, and referred by NPs are less prominent in Western culture, are not commonly included in standards of care, and are not covered by insurance (horse therapy, ayurvedic medicine, and indigenous practices). These findings imply that for NPs to understand and refer for a broader range of C/ATs* in clinical practice, changes must be made in C/AT research, NP education, clinical practice, and public policy, including increasing affordable care and insurance reimbursement. 386
C. Geisler et al.
NP knowledge of C/AT Similar to Cutshall et al. (2010), our results suggest that NPs believe that C/AT is beneficial for both personal and patient use. Ninety-six percent of NPs believe that they should have knowledge of the most commonly used C/AT, 81% believe that C/AT has a place in allopathic medicine, and 79% believe that such knowledge results in better patient outcomes. This implies that NP institutional and continuing education should include improved training about C/AT. Burman’s (2003) survey found that most family NP programs are incorporating some C/AT training, but according to these results, NPs want more. NPs called out a need for some of the core competencies that Burman (2003) identified: “interviewing, critical thinking, evidence-based medicine, knowledge of laws, ethics, and spiritual and cultural beliefs” (p. 28). NP educators can fill this gap by offering C/AT classes in core NP curriculum, continuing education, and conferences. Coursework could teach about C/AT scope of use, evidence of effectiveness, approximate costs and duration of care, insurance reimbursement possibilities, and how to source credible practitioners for referrals.
NP exposure to C/AT Results also imply that an increase in personal C/AT use can increase knowledge, belief, and referral. NP educators, C/AT providers, and practice management leaders can work together to increase NP exposure to C/AT. Similar to Pillsbury’s public, free, interdisciplinary C/AT clinic in Minneapolis, MN, C/AT practitioners could operate interdisciplinary mini-clinics in the NP workplace so that NPs and other staff can try out C/AT (and improve staff well-being). C/AT providers and NPs could offer interdisciplinary seminars together to the public and to peers on various health topics. Opportunities such as these increase NP exposure, build C/AT knowledge, and enhance interdisciplinary bridges and referrals.
C/AT use in clinical practice Most NPs believe that C/AT have legitimate use in allopathic medicine (81%) with no negative impacts (71%), and 60% believe that C/AT effectiveness is not because of placebo effect, with 30% having no opinion. These results suggest that NPs have an interest in including C/AT into clinical practice. Most NPs (80%) report that they are comfortable or very comfortable discussing C/AT with their patients; however, the qualitative data clearly suggest they would like more C/AT knowledge, information, and ease of referrals. Over half (61%) of NPs estimate that at least some of their patients are using
NP knowledge, use, and referral of C/ATs
C. Geisler et al.
C/AT, and similar to Giveon, Liberman, Klang, and Kahan’s (2003) findings, 64% believe their patients do not disclose their C/AT use. Different from the finding of Flannery, Love, Pearce, Luan, and Elder (2006), many NPs (68%) ask at least some of their patients about C/AT use. A surprising finding is that NPs report initiating the C/AT dialogue (54%) more often than patients (35%) do.
C/AT dialogue in practice Qualitative results suggest that factors such as patient/family openness, allotted time with patient, NPs’ knowledge of modalities, evidence supporting effectiveness, institutional climate, and referral resources affect NPs’ inclination to have a C/AT dialogue. NPs report that their own knowledge and attitudes toward C/AT impact the dialogues that they have with patients. In some cases, NPs report only pressing forward with the C/AT dialogues when pain is a factor, when conventional treatment is not working or has nothing more to offer. Overall, this gap between perceived legitimate use and actual referral rates suggest that C/AT that may be helpful to a patient’s condition, overall health, and in some cases even stem the onset or progression of chronic disease may be overlooked entirely, or at best, being referred belatedly.
C/AT referral in practice Many NPs report that they want easy access to more C/AT knowledge. In addition, NPs express a desire to know credible C/AT practitioners so that they could make reputable referrals. While it makes sense for NPs to have a general overview of C/AT given the interest and prevalence of use in the general public, the sheer number of C/AT and the fact that several can be indicated for any given medical condition makes expecting NPs to have the necessary level of C/AT knowledge and referral base daunting at best. Given that NPs are already extremely busy, one strategy for having access to better knowledge and referrals is to create a centralized C/AT referral source, similar to other specialty referral sources. The NP could make the referral for C/AT in general, and then a specialist or “C/AT navigator” could follow-up with the patient to find the best-suited therapy and provider. Some colleges and universities have training programs in alternative/holistic health studies in order to fill this need. C/AT navigators can speak medicalese, serve as a triage point for conventional providers, and develop a deeper understanding of and relationship with existing C/AT referral sources. These navigators build reliable partnerships to local and regional C/AT providers/centers and keep abreast of typical fee structures, duration of care, and insurance reimbursement standards for C/AT. These C/AT navigators
can serve as the bridge for NPs, helping interested patients gain access to the most appropriate and affordable C/AT care.
Practice management and public policy The day-to-day realities of daily practice, such as limited appointment times, limits of allopathic medicine, institutional lack of recognition of or support for C/AT, lack of easily available evidence-based information on C/AT, and lack of insurance coverage and referral systems may each contribute to a lower-than-expected rate of NP-client C/AT dialogues and referrals. Certainly, practice managers need to address the ever-growing concern about inadequate patient time to allow for a fuller dialogue with patients, including C/AT. Again, having a centralized referral source and/or navigators could help expedite referrals, when indicated; and implementing workplace C/AT clinics could help build knowledge, referral, personal use, and acceptance institution wide. Lastly, policy makers can insist that NP teaching institutions include basic C/AT knowledge in core curriculum, include it on certification exams, and require it in continuing education. They can work toward increasing the accessibility to and affordability of C/AT via support of C/AT research, expansion and protection of healthcare freedom laws, and lobbying for expanded insurance coverage— including referral listings for qualified C/AT practitioners. All of these initiatives can work toward increasing the accessibility to, knowledge, belief, use, and referral of C/AT in NP clinical practice.
References American Association of Nurse Practitioners. (2010). AANP information. Retrieved from http://www.aanp.org/AANPCMS2/AboutAANP/AANP+ Information/ Barnes, P. M., Bloom, B., & Nahin, R. L. (2008). Complementary and alternative medicine use among adults and children: United States, 2007. National Health Statistics Report, 12, 1–24. Burman, M. E. (2003). Core competencies for family nurse practitioners, Journal of Nursing Education, 42(1), 28–34. Caspi, O., & Baranovitch, O. (2009). Alternative medicine or “alternative” patients: A qualitative study of patient-oriented decision-making processes with respect to complementary and alternative medicine. Medical Decision Making, 13, 997–1006. http://dx.doi.org/10.1177/0272989×03261567 Cheung, C., Wyman, J. F., & Halcon, L. L. (2007). Use of complementary and alternative therapies in community-dwelling older adults: A literature review. Journal of Alternative and Complementary Medicine, 13(9), 997–1006. http://dx.doi.org/10.1089/acm.2007.0527 Cleary-Guida, M. B., Okvat, H. A., Oz, M. C., & Ting, W. (2001). A regional survey of health insurance coverage for complementary and alternative medicine: Current status and future ramifications. Journal of Alternative & Complementary Medicine, 7, 269–273. http://dx.doi.org/10.1089/ 107555301300328142 Cuellar, N. G., Cahill, B., Ford, J., & Aycock, T. (2003). The development of an educational workshop on complementary and alternative medicine: What
387
NP knowledge, use, and referral of C/ATs
every nurse should know. Journal of Continuing Education in Nursing, 34(3), 128–135. Cutshall, S., Derscheid, D., Miers, A. G., Ruegg, S., Schroeder, B. J., Tucker, S., & Wentworth, L. (2010). Knowledge, attitudes, and use of complementary and alternative therapies among clinical nurse specialists in an academic medical center. Clinical Nurse Specialist, 24(3), 125–131. http://dx.doi.org/10.1097/NUR.0b013e3181d86cd1 Flannery, M. A., Love, M. M., Pearce, K. A., Luan, J. J., & Elder, W. G. (2006). Communication about complementary and alternative medicine: Perspectives of primary care clinicians. Alternative Therapies in Health and Medicine, 12(1), 56–63. Giveon, S. M., Liberman, N., Klang, S., & Kahan, E. (2003). A survey of primary care physicians’ perceptions of their patients’ use of complementary medicine. Complementary Therapies in Medicine, 11(4), 254–260. http://dx.doi.org/10.1016/S0965-2299(03)00114-6 Hamilton, J. L., Roemheld-Hamm, B., Young, D. M., Ialha, M., & DiCicco-Bloom, B. (2008). Complementary and alternative medicine in US family medicine practices: A pilot qualitative study. Alternative Therapies, 14(4), 22–27. Houston, E. A., Bork, C. E., Price, J. H., Jordan, T. R., & Dake, J. A. (2001). How physician assistants use and perceive complementary and alternative medicine. Journal of American Association of Physician Assistants, 14, 29–46. Kaufman, D. W., Kelly, J. P., Rosenberg, L., Anderson, T. E., & Mitchell, A. A. (2002). Recent patterns of medication use in the ambulatory adult population of the United States: The Slone Survey. Journal of the American Medical Association, 287, 337–344. http://dx.doi.org/10.1001/jama.287. 3.337
388
C. Geisler et al.
Kennedy, J. (2005). Herb and supplement use in the US adult population. Clinical Therapeutics, 27, 1847–1858. http://dx.doi.org/10.1016/j.clinthera.2005.11.004 Kurtz, M. E., Nolan, R. B., & Rittinger, W. J. (2003). Primary care physicians’ attitudes and practices regarding complementary and alternative medicine. Journal of the American Osteopathic Association, 103, 597–602. Lloyd, L. F., Simon, B., Dunn, L. R., & Isberner, F. R. (2007). The status of complementary and alternative medicine education in U.S. physician assistant programs. Teaching and Learning in Medicine, 19(2), 174–179. http://dx.doi.org/10.1080/10401330701333498 Manek, N. J., Crowson, C. S., Ottenberg, A. L., Curlin, F. A., Kaptchuk, T. J., & Tilburt, J. C. (2010). What rheumatologists in the United States think of complementary and alternative medicine: Results of a national survey. BMC Complementary and Alternative Medicine, 10(5), 1–8. http://dx.doi.org/10.1186/1472-6882-10-5 National Center for Complementary and Alternative Medicine (NCCAM). (2010). What is CAM. Retrieved from http://nccam.nih.gov/whatiscam/ Nottingham, E. N. (2006). Complementary and alternative medicine: Nurse practitioner education and practice. Holistic Nursing Practice, 20(5), 242–246. Sohn, P. M., & Cook, C. A. (2002). Nurse practitioner knowledge of complementary alternative health care: Foundation for practice. Journal of Advanced Nursing, 39(1), 9–16. http://dx.doi.org/10.1046/j.1365-2648.2002.02238.x Wahner-Roedler, D. L., Vincent, A., Elkin, P., Loehrer, L. L., Cha, S. S., & Bauer, B. A. (2006). Physicians attitudes toward complementary and alternative medicine and their knowledge of specific therapies: A survey at an academic medical center. Evidence-Based Complementary and Alternative Medicine, 3, 495–501. http://dx.doi.org/10.1093/ecam/nel036
Nurse practitioner knowledge, use, and referral of complementary/alternative therapies Carol Geisler, PhD, RN (Associate Professor)1 , Corjena Cheung, PhD, RN (Assistant Professor)2 , Stasia Johnson Steinhagen, MA (Graduate Student)1,3 , Peggy Neubeck, MAN, RN, CNP (Assistant Professor)4 , & Alvina D. Brueggeman, PhD (Faculty)5 1
Holistic Health Studies, St. Catherine University, St. Paul, Minnesota University of Minnesota, Minneapolis, Minnesota 3 Minnesota Center for Homeopathy, St Louis Park, Minnesota 4 St. Catherine University, 601 25th Ave. S. Minneapolis, Minnesota 5 Women’s Health Integrative Research Center, Holistic Health Studies, St. Catherine University, St. Paul, Minnesota 2
Keywords Complementary and alternative medicine (CAM); nurse practitioners; beliefs; communication; holistic; healthcare collaboration; descriptive research. Correspondence Carol Geisler, PhD, RN, St. Catherine University, 601 25th Ave. S, Minneapolis, MN 55454. Tel: 651-245-3844; Fax: 651-690-7849; E-mail: [email protected], [email protected] Received: 17 September 2013; accepted: 27 January 2014 doi: 10.1002/2327-6924.12190
Abstract Purpose: The study aims are to (a) describe nurse practitioners’ (NPs’) belief in effectiveness, knowledge, referral, and use of complementary/alternative therapies (C/ATs), (b) explore the initiation of C/AT dialogue between NPs and their patients, and (c) examine the relationships between demographic variables and NP C/AT knowledge, beliefs, use, referrals. Data sources: A mixed-method cross-sectional online survey of licensed NPs (N = 2874) from a Midwestern state was analyzed using descriptive statistics, thematic analysis, and content analysis. Conclusions: NPs (n = 410) report the most knowledge about prayer (40%) and mind–body practices (32%). Many NPs (84%) report using vitamins for personal use and 85% refer their patients for massage/bodywork. Most (95%) believe NPs should have knowledge of the most common C/AT and 81% believe C/AT have a legitimate use in allopathic medicine. NPs’ knowledge, belief, use, and referral of C/AT are significantly correlated. NPs initiate C/AT dialogue with their patients 54% of the time. Factors that impact the NP and patient C/AT dialogue include patient/family openness, nature of the health problem, NP C/AT knowledge, time, and accessibility. Implications for practice: Centralized C/AT sources could help expedite C/AT referrals. Implementing workplace C/AT clinics could help build knowledge, referral, personal use, and acceptance of C/AT.
Introduction The widespread use of complementary/alternative therapies (C/ATs) has garnered growing national attention. The National Institutes of Health (NIH; Barnes, Bloom, & Nahin, 2008) report that nearly 40% of U.S. adults have used some form of C/AT within the past year. With some major insurance companies currently incorporating selected C/AT into their covered services (Cleary-Guida, Okvat, Oz, & Ting, 2001), along with easy accessibility of C/AT products such as herbs and nutritional supplements (Kennedy, 2005) and growing C/AT popularity, these alternative approaches have become increasingly feasible
380
healthcare options. The National Center of Complementary and Alternative Medicine (NCCAM) currently defines C/AT as a group of diverse medical and healthcare systems, practices, and products that are not generally considered part of conventional medicine (NCCAM, 2010). Although commonly called “complementary/alternative medicine,” or “CAM,” this study uses the term complementary/alternative “therapies” to encompass the essence of “healing” versus “curing,” as suggested by Cheung, Wyman, and Halcon (2007). Most healthcare providers underestimate the rate of C/AT use by their patients, suggesting that many patients do not discuss such use with their healthcare providers Journal of the American Association of Nurse Practitioners 27 (2015) 380–388 C 2014 American Association of Nurse Practitioners
NP knowledge, use, and referral of C/ATs
C. Geisler et al.
(Giveon, Liberman, Klang, & Kahan, 2003). Some C/AT may interact with allopathic medications and treatments, increasing risk for both patients and practitioners (Kaufman, Kelly, Rosenberg, Anderson, & Mitchell, 2002). The need for providers to be aware of C/AT use among their clients and engage in meaningful dialogue around C/AT choices is imperative and timely (Caspi & Baranovitch, 2009; Cuellar, Cahill, Ford, & Aycock, 2003). Nurse practitioners (NPs) play a major role in providing primary health care to many patients in the healthcare system and rank as one of the fastest growing groups of healthcare providers (American Association of Nurse Practitioners, 2010). While there has been research on physicians’ attitudes, use of C/AT (Hamilton, Roemheld-Hamm, Young, Ialha, & DiCicco-Bloom, 2008; Kurtz, Nolan, & Rittinger, 2003; Manek et al., 2010; Wahner-Roedler et al., 2006), and some studies on physician assistants’ C/AT attitudes (Houston, Bork, Price, Jordan, & Dake, 2001; Lloyd, Simon, Dunn, & Isberner, 2007), there are limited studies on NPs’ attitudes and knowledge of C/AT (Nottingham, 2006; Sohn & Cook, 2002). Given the increase in NPs as primary health providers along with Americans’ continued increase use of C/AT, there is a need for understanding NPs’ attitudes, beliefs, knowledge, use, and referral of C/AT to inform healthcare practices, education, and policy. The aims of this project are to (a) describe the NP beliefs in effectiveness, knowledge, referral, and use of C/AT, (b) explore the dialogue about C/AT between NPs and patients, and (c) examine the relationships between demographic variables and NP C/AT knowledge, beliefs, use, referrals.
Method We used a mixed-method cross-sectional online survey to assess licensed Minnesota NPs’ attitudes, knowledge, beliefs, use, and referrals of C/AT as well as C/AT dialogue between NPs and patients.
Instrumentation We developed a survey with 17 questions focusing on knowledge, beliefs of effectiveness, use, and referrals of 28 types of C/AT based on the literature. We listed 28 kinds of commonly used C/ATs based on the NCCAM’s classifications of C/AT, but did not provide definitions for each type of C/AT used on the survey. The survey also asked NPs to (a) estimate patient C/AT use, (b) report NPs’ attitudes about C/AT, and (c) describe NP and patient C/AT dialogue. We included two descriptive qualitative questions: (a) What has your experience been with C/AT? (b) What factors influence whether or not you talk with your patients about C/AT? We pilot tested the
survey with 10 graduate faculty members from nursing and holistic health; five completed the survey and provided feedback. We revised the questions based on the feedback from the pilot test, but as with many survey tools, we did not test for reliability and validity other than face validity.
Sample After receiving approval from St. Catherine University’s IRB, we obtained a mailing list from the Minnesota Board of Nursing of all licensed NPs in the state with e-mails (N = 2874). We sent an e-mail, including informed consent, to each licensed NP requesting their participation in the survey. Two additional reminder e-mails were sent. Participants had the option at the end of the survey to submit their contact information, separate from the survey, to be eligible for one of six $75 gift cards to Amazon.com.
Data analysis Quantitative data analysis. A total of 410 usable survey responses of 434 responses were used for data analysis, after deleting those who did not finish the survey (n = 12) based on parameters set by Qualtrics survey software, and those who had completed the survey more than once (n = 12). The statistician analyzed the data using SPSS version 17. Descriptive statistics including mean, frequency, and percentage were run. In situations where participants could respond with multiple choices for an answer (practice setting, practice location, and practice specialty), the total number of cases were counted. Some NPs, for instance, worked in multiple settings, and were therefore counted as a case in each setting. Inferential statistics including chi-square tests of independence on categorical variables and correlations on ordinal data were conducted. In the descriptive results, we report “valid percentages” by calculating the percentage excluding missing cases. In the inferential statistics, certain questions (e.g., knowledge, belief, referral, and use) included the option of answering separately for each of 28 different types of C/ATs. We transformed answer choices to ordinal rather than categorical scales. Sum and average values were then calculated for each question, collapsing across individual C/AT therapies. Spearman’s rho was then conducted to examine relationships between the four variables of interest. Qualitative data analysis. There were 289 responses to at least one of the two descriptive qualitative questions, we each reviewed and coded the data independently and then compared results as a group. We conducted thematic analysis about factors that influence whether or not NPs talk with their patients about C/AT, 381
NP knowledge, use, and referral of C/ATs
and content analysis on the reports of a case where a patient used C/AT and the outcomes. Considerations of rigor. Collecting both quantitative and qualitative data strengthened the rigor of this study. The qualitative data provided us with descriptive factors that contribute to the C/AT dialogue between NPs and their patients. Our interdisciplinary (nursing, psychology, homeopathy, holistic health, statistics) research team provided multiple lenses through which to analyze and interpret the data, helping to broaden our mutual understanding and reduce bias.
Limitations This study has several limitations including use of a survey and a limited sample. When using surveys, researchers cannot be sure if participants understood the questions, and data are subject to recall bias. Survey respondents also tend to offer socially acceptable answers. We suspect that those who view C/AT favorably might have been more likely to respond to the survey, leaving out important data from those who are less likely to use, talk about, and refer C/AT and therefore biasing the sample. Although we had a reasonable response rate from the licensed NPs in Minnesota, a larger sample size including NPs from other geographic locations as well as focusing on areas of specialty would be beneficial in future research. Finally, C/AT use is a complex issue and in this study we only examined NPs’ attitudes, knowledge, use, and referrals. Further research examining healthcare provider factors, patient factors, system factors, and their interactions is needed. Also, research that defines just what kind of knowledge— facts about modalities, understanding evidence-based outcomes, personal experience with C/AT, or knowledge of credible referral sources—is most impactful to NPs’ practice.
Results Data were analyzed using 410 usable survey responses. Most of the respondents were women (96%), with an average age of 48 (SD = 10.81), and 52% had practiced 10 years or less. Most NPs reported practicing in an urban (62%) and outpatient (56%) settings, with 28% practicing in multiple settings (see Table 1).
NP knowledge, beliefs, referrals, and personal use of C/AT NPs report a wide range of knowledge of various forms of C/AT. NPs have “lots of knowledge” about prayer (40%), mind–body practices (32%), and meditation (30%). Herbs (79%), acupuncture (79%), aromatherapy (75%), and homeopathy (73%) are the highest ranked C/AT for “some knowledge.” NPs report “no 382
C. Geisler et al.
Table 1 Demographic frequencies of NPs Demographics Gender Male Female Practice setting Academic Hospital Long term Outpatient Retail School Special Other Practice setting type Acute Subacute Community Academic Educational setting Private Public Practice location Urban Suburban Rural Years of practice 30 years Have not practiced
n
(%)
16 386
4.0 96.0
52 115 41 228 14 5 53 49
12.7 28.0 10.0 55.6 3.4 1.2 12.9 12.0
133 299 17 52
32.4 72.9 4.2 12.7
144 251
36.2 63.1
264 85 76
62.1 20.0 17.9
29 100 82 84 47 27 15 24 1
7.1 24.4 20.0 20.5 11.5 6.6 3.7 5.9 0.2
knowledge” of ayurvedic medicine (76%), horse therapy (69%), and indigenous practices (65%; see Table 2). NPs believe in the overall effectiveness of massage/bodywork (90%), meditation (88%), mind/body practices (87%), and acupuncture (84%). Chelation (10%) and electromagnetic therapies (10%) are the top therapies NPs believe to be “ineffective” (see Table 3). Most NPs (95%) believe that NPs should have knowledge of the most commonly used C/AT. Many (78.5%) believe that NPs’ knowledge of C/AT results in better patient outcomes, with 9% having no opinion. Most NPs (81%) agree that C/AT have a legitimate use in allopathic medicine and 71% disagree that C/AT negatively impacts allopathic medicine. Most NPs disagree (60%) that effects of C/AT are generally the result of the placebo effect, with 30% having no opinion (see Table 4). NPs most commonly refer patients for massage/bodywork (85%), vitamins (81%), and dietary supplements (78%; see Table 5).
NP knowledge, use, and referral of C/ATs
C. Geisler et al.
Table 2 NPs’ knowledge of C/ATs
Table 3 NPs’ belief in C/ATs
C/AT
None
Some
Lots
Acupuncture Aromatherapy Art therapy Ayurveda Electromagnetic BioField Chelation Dance therapy Diet supplements Food as medicine Herbal Horse therapy Homeopathy Oxygen therapy Indigenous Massage/bodywork Meditation Mind–body Modified diet Movement Music therapy Naturopathy Pet therapy Prayer Spinal Traditional Chinese medicine (TCM) Vitamin Yoga
10.2 16.1 41.3 75.9 56.2 12.7 61.1 52.6 2.9 21.1 9 69.4 22.1 48.3 64.7 4.4 5.1 5.1 11.3 38.2 15.7 35 12.5 3.9 9.8 50.6 4.9 7.9
78.5 75.1 52.6 22.9 42.3 71.8 37.7 45 72.1 57.6 79 27.1 72.8 46.3 32.8 68.5 64.5 62.6 64.4 54.4 71.3 58.8 72.2 56.4 67.4 45.2 68.6 68.8
11.2 8.8 6.1 1.2 1.5 15.4 1.2 2.4 25 21.3 12 3.4 5.1 5.4 2.5 27.1 30.3 32.3 24.3 7.4 13 6.1 15.2 39.7 22.8 4.2 26.5 12.3
Acupuncture Aromatherapy Art therapy Ayurveda Electromagnetic BioField Chelation Dance therapy Diet supplements Food as medicine Herbal Horse therapy Homeopathy Oxygen therapy Indigenous Massage/bodywork Meditation Mind–body Modified diet Movement Music therapy Naturopathy Pet therapy Prayer Spinal Traditional Chinese medicine (TCM) Vitamin Yoga
Ineffective
Neither
Effective
Don’t know
0.5 2.2 1 1.2 10.1 2.9 10.3 2.5 1.7 0.5 2 1.7 3.9 3.9 2 0.5 0.7 0.2 0.7 0.7 0.5 1.7 0.2 0.7 3.9 1.7
4.9 20.3 11.1 6.2 20.6 11.1 11.8 13 20.4 14.8 22.1 6.6 19.4 7.8 11.1 4.7 4.7 4.9 10 7.4 5.2 16 4.2 7.7 15 8.8
83.5 55.6 50.9 16.5 12.5 63.9 9.1 38.5 67 59.5 60.5 27.7 47.2 37.7 20.2 90.4 88.1 87 70.8 50.1 74.1 39.6 82 81.7 67.6 42.4
11.1 21.8 37.1 76.1 56.8 22.1 68.9 46.1 10.8 25.2 15.4 64 29.5 50.5 66.7 4.4 6.5 7.8 18.4 41.8 20.2 42.8 13.5 9.9 13.5 47.1
0.7 0.7
16.2 6.4
69.8 80.3
13.3 12.6
Note. Percent frequency of NPs’ responses to each item. Note. Percent frequency of NPs’ responses to each item.
NPs report commonly using vitamins (84%), massage/bodywork (82%), prayer (80%), dietary supplements (76%), and mind–body practices (76%) for themselves. The least personally used modalities include hyperbaric oxygen (1.5%), chelation (1.5%), horse therapy (5%), indigenous practices (7%), and ayurvedic medicine (9%; see Table 6). Greater knowledge of C/AT is associated with greater belief, referral, and use (p < .001; see Table 7). The percent frequency of NPs who personally use each C/AT closely parallels the percent of NPs that refer each C/AT to their patients (see Figure 1).
NP–patient C/AT dialogue and estimates of use Sixty percent of NPs estimate “some” to “all” of their patients use C/AT, and 64% believe their patients do not disclose their C/AT use. Most NPs (80%) report they are comfortable discussing C/AT with their patients. NPs estimate that 54% of the time they initiate the dialogue, while the patient initiates it 35% of the time. A nurse’s experience level (defined as years of practice) does not influence
Table 4 Frequency (%) of NPs’ opinions regarding C/ATs
NPs should have knowledge of the most common C/AT NP knowledge of C/AT results in better patient outcomes C/AT have a legitimate use in allopathic medicine C/AT negatively impacts allopathic medicine Effects of C/AT are generally the result of the placebo effect
Disagree
Agree
No opinion
0.5
95.4
3.9
2.7
78.5
18.8
2.5
81.3
16.2
70.9
7.4
21.7
59.6
10.0
30.4
who initiates the dialogue about C/AT, χ 2 (24, n = 405) = 14.56, p = .93. Similarly, the type of institution (public or private) does not influence the initiation of dialogue, χ 2 (6, n = 394) = 9.25, p = .16. Several themes emerge from the qualitative data of C/AT dialogue between NPs and their patients: patient/family openness, beliefs and attitudes, nature of the health problem, NP knowledge and attitude of C/AT, NP knowledge 383
NP knowledge, use, and referral of C/ATs
C. Geisler et al.
Table 6 NPs’ personal use of C/ATs
Table 5 NPs’ referral of C/ATs
Acupuncture Aromatherapy Art therapy Ayurveda Electromagnetic BioField Chelation Dance therapy Diet supplements Food as medicine Herbal Horse therapy Homeopathy Oxygen therapy Indigenous Massage/bodywork Meditation Mind–body Modified diet Movement Music therapy Naturopathy Pet therapy Prayer Spinal Traditional Chinese medicine (TCM) Vitamin Yoga
Yes
No
59.3 35 17.2 4.4 6.4 44.4 3.2 10.9 78 50.2 57 10.1 24.5 13.1 10.2 85.2 63.5 75.4 73.7 30.8 38.5 20 43.3 61.6 57.1 13.1 80.5 60.8
40.7 65 82.8 95.6 93.6 55.6 96.8 89.1 22 49.8 43 89.9 75.5 86.9 89.8 14.8 36.5 24.6 26.3 69.2 61.5 80 56.7 38.4 42.9 86.9 19.5 39.2
Note. Percent frequency of NPs’ responses to each item.
of C/AT referrals, time allotted for patient contact, limits of allopathic medicine, accessibility of C/AT, and lack of availability of evidence-based information. Themes are categorized according to whether they are patient, NP, or larger systems factors.
Patient factors Patient/family openness, beliefs, and attitudes. More than half of the NPs comment on patient and family attitudes, beliefs, and openness as a factor that impacted whether or not they open up a dialogue about C/AT with their patients. They report that they can tell by a “patient’s initial reaction when I mention C/AT” whether or not to pursue the conversation. “You can usually tell when a patient just wants something traditional. If I feel it will be helpful, regardless, I will make the suggestion and provide an avenue for referral or follow up.” “I adjust my information to the level of acceptance/resistance the patient has. For example, I do Healing Touch, however that is ‘too far out there’ for some patients. I meet them where they’re at. If they are inter384
Acupuncture Aromatherapy Art therapy Ayurveda Electromagnetic BioField Chelation Dance therapy Diet supplements Food as medicine Herbal Horse therapy Homeopathy Oxygen therapy Indigenous Massage/bodywork Meditation Mind–body Modified diet Movement Music therapy Naturopathy Pet therapy Prayer Spinal Traditional Chinese medicine (TCM) Vitamin Yoga
Yes
No
29.6 46 12.6 9.1 10.8 40.1 1.5 15.4 75.9 47.3 59.8 4.5 22.9 1.5 6.8 82.4 68 76.3 63.2 37.8 34.2 18.2 31.8 79.8 50.8 15.4 84.2 62.3
70.4 54 87.4 90.9 89.2 59.9 98.5 84.6 24.1 52.8 40.2 95.5 77.1 98.5 93.2 17.6 32 23.7 36.8 62.2 65.8 81.8 68.2 20.2 49.2 84.6 15.8 37.7
Note. Percent frequency of NPs’ responses to each item. Table 7 Correlations between NPs’ knowledge, belief, referral, and use of C/AT: summed values
Knowledge Belief Referral Use
Knowledge
Belief
Referral
Use
– 0.56** 0.54** 0.57**
– 0.56** 0.58**
– 0.64**
–
Note. Variable values were summed across 28 C/AT modalities. **p < .001.
ested in more information, I provide it.” A sense of NP frustration comes through regarding some patients’ lack of willingness to try C/AT: “Some of them seem receptive to any form of assistive therapy; some seem to be only interested in prescription medications.” Others assess the “Family’s willingness to discuss alternative modalities compared to standard Western medicine approaches to treatment.” “If the family brings it up” then they talk about it. Nature of the health problem. Many NPs indicate that the nature of a patient’s health problem influences whether or not they bring up C/AT. “I always offer C/AT for people with repeat sinusitis and bronchitis because I am
NP knowledge, use, and referral of C/ATs
90 80 70 60 50 40 30 20 10 0
Used C/AT Referred C/AT Acupuncture Aromatherapy Art Therapy Ayurveda Electromagnetic BioField Chelation Dance Therapy Diet Supplements Food as Medicine Herbal Horse Therapy Homeopathy Oxygen Therapy Indigenous Bodywork Meditation Mind-Body Modified Diet Movement Music Therapy Naturopathy Pet Therapy Prayer Spinal TCM Vitamin Yoga
Frequency (%) of Nurse Practitioners
C. Geisler et al.
Figure 1 Percent frequency of NPs who personally used each C/AT, and percent that referred each C/AT to patients.
not interested in offering antibiotic therapies when they are not effective.” “When I have the rare patient who has symptoms of PMS or PMDD, headaches, or other problems which may be related to the menstrual cycle, I may discuss C/AT with them.” Pain is frequently mentioned as a symptom likely to result in C/AT dialogue.
NP factors NPs’ knowledge and attitudes of C/AT. NPs report that their knowledge and attitudes of C/AT impact whether or not they open up a C/AT dialogue with their patients. Some cite their lack of understanding about therapies, effectiveness, and “lack of complete understanding of potential effects with prescription medications” as contributing factors. Others report that they are more likely to initiate a dialogue based on “whether or not I think that a C/AT will be beneficial or not.” Some NPs base their C/AT dialogue on the modality itself. For example, “I do not believe in Healing Touch or aromatherapy and would never recommend [it]. I don’t discourage patients from C/AT as long as they don’t forgo treatments backed by science in favor of complementary therapies, and as long as there are not adverse reactions.” NPs’ knowledge of referrals. NPs’ knowledge of referrals impacts whether or not they bring up C/AT. Some report simply not knowing “places to send patients.” Referrals also depend on, “What is available in my area or reputable practices and how much I know about it.” Another NP states, “I also am cautious as to who they are taking their child to as I want to know the specific provider of C/AT and the person’s certifications, knowledge base.” Another cites her own lack of referrals as a factor: “I need to learn more about C/AT providers in my area and develop better relationships with them.” “I was more likely
to discuss these therapies if I knew of an effective reputable provider.”
Systems factors Time allotted for patient contact. “TIME!!!” is the most often cited reason for not initiating a dialogue with patients about C/AT. “Time, time, time. In the current environment of quality measures, RVUs and other time constraints, it is very difficult to discuss more topics than already required. Primary care does not have time to address the issues as it is.” Limits of allopathic medicine. Many NPs discuss C/AT when conventional medical practices are “ineffective” or as “adjuncts to medical treatment.” “I usually consider it for patients who have chronic conditions and are not improving with Western medicine and/or patients who do not like to take pills.” They describe their patients’ “frustrations with traditional medicine or costs of traditional medicine.” Accessibility of C/AT. Many NPs express frustration at the lack of accessibility of C/AT. Funds and lack of insurance coverage are cited frequently. Often, “the cost is not covered by this health system and the patients cannot afford” them. Furthermore, “In Public Health, I might recommend C/AT depending on whether or not they have insurance that covers such therapies.” Some NPs mention specific medical systems that do not recognize C/AT. “I work in the VA system where the practices of C/AT are generally not recognized.” “[I] work with geriatrics and Medicare do not cover most of these therapies.” Transportation to C/AT appointments is another concern raised by NPs. “Most of my patients are not very mobile and transportation is an issue along with cost.” “[The] majority of my patients are frail and unable to go out for most therapies–difficult to bring some 385
NP knowledge, use, and referral of C/ATs
into long-term care so that often limits what I will offer patients and families.” Another states, the “ability to get out of [the] nursing home and to provider also affects whether I talk about these therapies.” In addition, “Many live in rural areas and these methods are not easily available.” For others, the complexity of the current treatment impacts accessibility of C/AT. “Patient has a very hectic treatment schedule and they are not interested in more appointments.”
Lack of availability of evidence-based information. NPs express frustration with the lack of “evidencebased efficacy information” being readily available. In other words, a “lack of resources and research to support outcomes.” Others are aware of the literature but are dissatisfied with the nature of the research. “There is a lack of substantial evidence-based practice literature.” Others suggest that more research is needed. “If they request them [C/AT], I will approve or disapprove but I do not feel they are well studied and therefore do not feel I should be recommending them.”
Discussion and implications of key findings Similar to Nottingham’s (2006) review of NPs and C/AT literature, findings show a positive correlation between knowledge, belief, use, and referral. This suggests that NPs often “go with what they know” and raises the question of how NPs come to know about C/AT in the first place. NPs refer what they personally use. NPs most use (as well as know, believe in, and refer) C/AT that are largely low- or no-cost—therapies that can be used without paying a practitioner (prayer, mind–body, yoga, vitamins, herbs, and homeopathy). This is similar to Cutshall et al. (2010), where the top therapies that Clinical Nurse Specialists (CNSs) personally used were humor, massage, spirituality/prayer, music therapy, and relaxed breathing. A few of the more commonly NP-known C/AT (chiropractic, massage, and acupuncture) do require paying a practitioner. However, those C/ATs are widely accepted as effective, provide more immediate gratification/relief, and are often covered by insurance plans. The C/AT least known, believed in, used, and referred by NPs are less prominent in Western culture, are not commonly included in standards of care, and are not covered by insurance (horse therapy, ayurvedic medicine, and indigenous practices). These findings imply that for NPs to understand and refer for a broader range of C/ATs* in clinical practice, changes must be made in C/AT research, NP education, clinical practice, and public policy, including increasing affordable care and insurance reimbursement. 386
C. Geisler et al.
NP knowledge of C/AT Similar to Cutshall et al. (2010), our results suggest that NPs believe that C/AT is beneficial for both personal and patient use. Ninety-six percent of NPs believe that they should have knowledge of the most commonly used C/AT, 81% believe that C/AT has a place in allopathic medicine, and 79% believe that such knowledge results in better patient outcomes. This implies that NP institutional and continuing education should include improved training about C/AT. Burman’s (2003) survey found that most family NP programs are incorporating some C/AT training, but according to these results, NPs want more. NPs called out a need for some of the core competencies that Burman (2003) identified: “interviewing, critical thinking, evidence-based medicine, knowledge of laws, ethics, and spiritual and cultural beliefs” (p. 28). NP educators can fill this gap by offering C/AT classes in core NP curriculum, continuing education, and conferences. Coursework could teach about C/AT scope of use, evidence of effectiveness, approximate costs and duration of care, insurance reimbursement possibilities, and how to source credible practitioners for referrals.
NP exposure to C/AT Results also imply that an increase in personal C/AT use can increase knowledge, belief, and referral. NP educators, C/AT providers, and practice management leaders can work together to increase NP exposure to C/AT. Similar to Pillsbury’s public, free, interdisciplinary C/AT clinic in Minneapolis, MN, C/AT practitioners could operate interdisciplinary mini-clinics in the NP workplace so that NPs and other staff can try out C/AT (and improve staff well-being). C/AT providers and NPs could offer interdisciplinary seminars together to the public and to peers on various health topics. Opportunities such as these increase NP exposure, build C/AT knowledge, and enhance interdisciplinary bridges and referrals.
C/AT use in clinical practice Most NPs believe that C/AT have legitimate use in allopathic medicine (81%) with no negative impacts (71%), and 60% believe that C/AT effectiveness is not because of placebo effect, with 30% having no opinion. These results suggest that NPs have an interest in including C/AT into clinical practice. Most NPs (80%) report that they are comfortable or very comfortable discussing C/AT with their patients; however, the qualitative data clearly suggest they would like more C/AT knowledge, information, and ease of referrals. Over half (61%) of NPs estimate that at least some of their patients are using
NP knowledge, use, and referral of C/ATs
C. Geisler et al.
C/AT, and similar to Giveon, Liberman, Klang, and Kahan’s (2003) findings, 64% believe their patients do not disclose their C/AT use. Different from the finding of Flannery, Love, Pearce, Luan, and Elder (2006), many NPs (68%) ask at least some of their patients about C/AT use. A surprising finding is that NPs report initiating the C/AT dialogue (54%) more often than patients (35%) do.
C/AT dialogue in practice Qualitative results suggest that factors such as patient/family openness, allotted time with patient, NPs’ knowledge of modalities, evidence supporting effectiveness, institutional climate, and referral resources affect NPs’ inclination to have a C/AT dialogue. NPs report that their own knowledge and attitudes toward C/AT impact the dialogues that they have with patients. In some cases, NPs report only pressing forward with the C/AT dialogues when pain is a factor, when conventional treatment is not working or has nothing more to offer. Overall, this gap between perceived legitimate use and actual referral rates suggest that C/AT that may be helpful to a patient’s condition, overall health, and in some cases even stem the onset or progression of chronic disease may be overlooked entirely, or at best, being referred belatedly.
C/AT referral in practice Many NPs report that they want easy access to more C/AT knowledge. In addition, NPs express a desire to know credible C/AT practitioners so that they could make reputable referrals. While it makes sense for NPs to have a general overview of C/AT given the interest and prevalence of use in the general public, the sheer number of C/AT and the fact that several can be indicated for any given medical condition makes expecting NPs to have the necessary level of C/AT knowledge and referral base daunting at best. Given that NPs are already extremely busy, one strategy for having access to better knowledge and referrals is to create a centralized C/AT referral source, similar to other specialty referral sources. The NP could make the referral for C/AT in general, and then a specialist or “C/AT navigator” could follow-up with the patient to find the best-suited therapy and provider. Some colleges and universities have training programs in alternative/holistic health studies in order to fill this need. C/AT navigators can speak medicalese, serve as a triage point for conventional providers, and develop a deeper understanding of and relationship with existing C/AT referral sources. These navigators build reliable partnerships to local and regional C/AT providers/centers and keep abreast of typical fee structures, duration of care, and insurance reimbursement standards for C/AT. These C/AT navigators
can serve as the bridge for NPs, helping interested patients gain access to the most appropriate and affordable C/AT care.
Practice management and public policy The day-to-day realities of daily practice, such as limited appointment times, limits of allopathic medicine, institutional lack of recognition of or support for C/AT, lack of easily available evidence-based information on C/AT, and lack of insurance coverage and referral systems may each contribute to a lower-than-expected rate of NP-client C/AT dialogues and referrals. Certainly, practice managers need to address the ever-growing concern about inadequate patient time to allow for a fuller dialogue with patients, including C/AT. Again, having a centralized referral source and/or navigators could help expedite referrals, when indicated; and implementing workplace C/AT clinics could help build knowledge, referral, personal use, and acceptance institution wide. Lastly, policy makers can insist that NP teaching institutions include basic C/AT knowledge in core curriculum, include it on certification exams, and require it in continuing education. They can work toward increasing the accessibility to and affordability of C/AT via support of C/AT research, expansion and protection of healthcare freedom laws, and lobbying for expanded insurance coverage— including referral listings for qualified C/AT practitioners. All of these initiatives can work toward increasing the accessibility to, knowledge, belief, use, and referral of C/AT in NP clinical practice.
References American Association of Nurse Practitioners. (2010). AANP information. Retrieved from http://www.aanp.org/AANPCMS2/AboutAANP/AANP+ Information/ Barnes, P. M., Bloom, B., & Nahin, R. L. (2008). Complementary and alternative medicine use among adults and children: United States, 2007. National Health Statistics Report, 12, 1–24. Burman, M. E. (2003). Core competencies for family nurse practitioners, Journal of Nursing Education, 42(1), 28–34. Caspi, O., & Baranovitch, O. (2009). Alternative medicine or “alternative” patients: A qualitative study of patient-oriented decision-making processes with respect to complementary and alternative medicine. Medical Decision Making, 13, 997–1006. http://dx.doi.org/10.1177/0272989×03261567 Cheung, C., Wyman, J. F., & Halcon, L. L. (2007). Use of complementary and alternative therapies in community-dwelling older adults: A literature review. Journal of Alternative and Complementary Medicine, 13(9), 997–1006. http://dx.doi.org/10.1089/acm.2007.0527 Cleary-Guida, M. B., Okvat, H. A., Oz, M. C., & Ting, W. (2001). A regional survey of health insurance coverage for complementary and alternative medicine: Current status and future ramifications. Journal of Alternative & Complementary Medicine, 7, 269–273. http://dx.doi.org/10.1089/ 107555301300328142 Cuellar, N. G., Cahill, B., Ford, J., & Aycock, T. (2003). The development of an educational workshop on complementary and alternative medicine: What
387
NP knowledge, use, and referral of C/ATs
every nurse should know. Journal of Continuing Education in Nursing, 34(3), 128–135. Cutshall, S., Derscheid, D., Miers, A. G., Ruegg, S., Schroeder, B. J., Tucker, S., & Wentworth, L. (2010). Knowledge, attitudes, and use of complementary and alternative therapies among clinical nurse specialists in an academic medical center. Clinical Nurse Specialist, 24(3), 125–131. http://dx.doi.org/10.1097/NUR.0b013e3181d86cd1 Flannery, M. A., Love, M. M., Pearce, K. A., Luan, J. J., & Elder, W. G. (2006). Communication about complementary and alternative medicine: Perspectives of primary care clinicians. Alternative Therapies in Health and Medicine, 12(1), 56–63. Giveon, S. M., Liberman, N., Klang, S., & Kahan, E. (2003). A survey of primary care physicians’ perceptions of their patients’ use of complementary medicine. Complementary Therapies in Medicine, 11(4), 254–260. http://dx.doi.org/10.1016/S0965-2299(03)00114-6 Hamilton, J. L., Roemheld-Hamm, B., Young, D. M., Ialha, M., & DiCicco-Bloom, B. (2008). Complementary and alternative medicine in US family medicine practices: A pilot qualitative study. Alternative Therapies, 14(4), 22–27. Houston, E. A., Bork, C. E., Price, J. H., Jordan, T. R., & Dake, J. A. (2001). How physician assistants use and perceive complementary and alternative medicine. Journal of American Association of Physician Assistants, 14, 29–46. Kaufman, D. W., Kelly, J. P., Rosenberg, L., Anderson, T. E., & Mitchell, A. A. (2002). Recent patterns of medication use in the ambulatory adult population of the United States: The Slone Survey. Journal of the American Medical Association, 287, 337–344. http://dx.doi.org/10.1001/jama.287. 3.337
388
C. Geisler et al.
Kennedy, J. (2005). Herb and supplement use in the US adult population. Clinical Therapeutics, 27, 1847–1858. http://dx.doi.org/10.1016/j.clinthera.2005.11.004 Kurtz, M. E., Nolan, R. B., & Rittinger, W. J. (2003). Primary care physicians’ attitudes and practices regarding complementary and alternative medicine. Journal of the American Osteopathic Association, 103, 597–602. Lloyd, L. F., Simon, B., Dunn, L. R., & Isberner, F. R. (2007). The status of complementary and alternative medicine education in U.S. physician assistant programs. Teaching and Learning in Medicine, 19(2), 174–179. http://dx.doi.org/10.1080/10401330701333498 Manek, N. J., Crowson, C. S., Ottenberg, A. L., Curlin, F. A., Kaptchuk, T. J., & Tilburt, J. C. (2010). What rheumatologists in the United States think of complementary and alternative medicine: Results of a national survey. BMC Complementary and Alternative Medicine, 10(5), 1–8. http://dx.doi.org/10.1186/1472-6882-10-5 National Center for Complementary and Alternative Medicine (NCCAM). (2010). What is CAM. Retrieved from http://nccam.nih.gov/whatiscam/ Nottingham, E. N. (2006). Complementary and alternative medicine: Nurse practitioner education and practice. Holistic Nursing Practice, 20(5), 242–246. Sohn, P. M., & Cook, C. A. (2002). Nurse practitioner knowledge of complementary alternative health care: Foundation for practice. Journal of Advanced Nursing, 39(1), 9–16. http://dx.doi.org/10.1046/j.1365-2648.2002.02238.x Wahner-Roedler, D. L., Vincent, A., Elkin, P., Loehrer, L. L., Cha, S. S., & Bauer, B. A. (2006). Physicians attitudes toward complementary and alternative medicine and their knowledge of specific therapies: A survey at an academic medical center. Evidence-Based Complementary and Alternative Medicine, 3, 495–501. http://dx.doi.org/10.1093/ecam/nel036
