Original Article Complementary and Alternative Medicine: Nurses’ Attitudes and Knowledge Tracy Trail-Mahan, RN, MS, Chia-Ling Mao, PhD, RN-BC, and Karen Bawel-Brinkley, PhD, RN
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From the Valley Foundation School of Nursing, San Jose State University, Santa Clara, California. Address correspondence to Mrs. Tracy Trail-Mahan, RN, MS, San Jose State University, Valley Foundation School of Nursing, Kaiser Permanente Santa Clara, 700 Lawrence Expressway, Santa Clara, CA 95051. E-mail: tracy.x. [email protected] Received May 18, 2010; Revised April 4, 2011; Accepted June 2, 2011. 1524-9042/$36.00 Ó 2013 by the American Society for Pain Management Nursing doi:10.1016/j.pmn.2011.06.001
ABSTRACT:
Despite significant evidence for the integration of complementary and alternative medicine (CAM) into professional nursing practice, gaps exist regarding nurses’ baseline knowledge, beliefs of efficacy, and learning needs for further education to facilitate the integration of CAM into nursing practice. The top three conditions which adults identified for using CAM were back pain, neck pain, and joint pain. CAM can offer nurses additional treatment options for managing their patients’ pain and discomfort. The California Board of Registered Nursing (BRN) identifies that nurses can help provide the missing link between conventional Western medicine and CAM therapies. Nurses cannot successfully advocate for CAM therapies, nor understand their patients’ prior use of such treatments, unless they themselves are familiar with both the risks and the benefits of these practices. It is necessary to first establish nurses’ baseline knowledge and beliefs related to CAM so that adequate educational programs can be initiated to help mitigate the barriers to incorporating CAM into the acute care setting. This descriptive study explores registered nurses’ attitudes and knowledge related to CAM by using the Nurse Complementary and Alternative Medicine Nursing Knowledge and Attitudes Survey developed by Rojas-Cooley and Grant. Nurses in this study demonstrated limited self-reported knowledge of basic CAM terminology and CAM practices. Ó 2013 by the American Society for Pain Management Nursing Pain management is an integral function of the licensed nurse. In recent years health care has placed increased emphasis on this important component of nursing practice. Forty-two percent of American adults report that they experience pain daily, and 89% report that they experience pain at least monthly (Sammons, 2000). Inadequate pain relief has been linked to not only patient distress but has been shown to have undesirable physiological and psychological consequences (Hutchinson, 2007). Consequences include decreased immune response, poor wound healing, and avoidance of movement, which can contribute to deep vein thrombosis and pulmonary embolism. The concurrent stress Pain Management Nursing, Vol 14, No 4 (December), 2013: pp 277-286
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associated with unresolved pain can lead to anxiety and depression. This can translate into increased length of stay and decreased patient satisfaction. Globally, nursing researchers are focusing on this challenging topic, and looking at a variety of factors that impact the pain management experience. Complementary and alternative medicine (CAM) can supplement conventional medical interventions in the management of acute pain. Although a growing body of research supports the use of CAM as an adjuvant therapy for pain management these practices appear to be underused in nursing practice. Since 2000, the Joint Commission has acknowledged the importance of pain management and assessment by incorporating it in into its accreditation process and stringent national standards (Joint Commission, 2008). The California Board of Registered Nursing (BRN) (2004) declares: A competent California registered nurse will advocate for patients by ensuring that the patient (or a delegated family member or caregiver) has adequate knowledge to make informed decisions about pain management and will intervene in the health care system to assist the patient/client to achieve appropriate management of pain. Given the importance of adequate pain management, it is disturbing to find that many patients continue to experience unacceptable levels of acute pain. A meta-analysis examining postoperative pain management of nearly 20,000 patients revealed that 30% continued to experience moderate to severe pain (Dolin, Cashman, & Bland, 2002). CAM offers patients additional options to increase their level of comfort and increase their satisfaction with their overall pain experience. Numerous studies validate the use of CAM for a variety of health issues and symptom management. Complementary therapies offer nurses the opportunity to provide holistic care and empower patients to actively participate in their care and recovery (Fountouki & Theofanidis, 2009). Holistic care seeks to treat the whole individual, as opposed to treating symptoms exclusively, and recognizes the role of mind, body, and spirit in the healing process. The top three conditions for which adults identified using CAM were back pain, neck pain, and joint pain; among children, back/neck pain was the number one condition for which CAM was used (Barnes, Bloom, & Nahin, 2008). Despite significant evidence supporting the integration of CAM into professional nursing practice, gaps exist regarding nurses’ baseline knowledge, beliefs of efficacy, and learning needs to facilitate the integration of CAM into nursing practice. The White House Commission on Complementary and Alternative Medicine Policy
(2002) recognized the need for increased education and training of health practitioners in CAM. That national policy statement led to many state boards of nursing (47%) issuing policy statements recognizing CAM as being within the nursing scope of practice and consistent with nursing tenets to provide holistic care for their patients (Sparber, 2001). The California BRN (2009) identifies that nurses can help provide the missing link between conventional Western medicine and CAM therapies. CAM can offer nurses an additional tool to help manage their patients’ complex pain management needs. The present study will focus on nurses’, specifically California hospital-based registered nurses’, beliefs, attitudes and knowledge base regarding the use of CAM.
LITERATURE REVIEW Complementary and alternative medicine, as defined by the National Center for Complementary and Alternative Medicine (NCCAM), is a group of diverse medical and health care systems, practices, and products that are not generally considered to be part of conventional medicine (NCCAM, 2001). This definition of CAM is used as the conceptual definition in this study and can be divided into five main categories: 1) biologically based practices; 2) energy medicine; 3) manipulative and body-based practices; 4) mind-body medicine; and 5) whole medical systems. The biologically based practices include products containing vitamins, minerals, herbs, amino acids, enzymes or other ingredients to supplement the diet and promote health. The second group, energy medicine, uses energy fields such as magnetic fields with the intent to impact health. Some examples of energy medicine include magnet therapy, healing touch, and Reiki. Manipulative and body-based practices focus on bodily structures and systems, including the bones, joints, soft tissues, and the circulatory and lymphatic systems. Common examples include massage, chiropractic, and reflexology. Mind-body medicine practices concentrate on the influence of the mind over bodily functions and symptoms: meditation, yoga, tai chi, qi gong, and guided imagery are a few examples. Whole medical systems include homeopathic medicine, naturopathic medicine, Ayurveda, and traditional Chinese medicine. Nurses’ knowledge and attitudes of these therapies are evaluated in this study, these NCCAM definitions provide the framework for knowledge evaluation The NCCAM, which functions as part of the National Institutes of Health, sponsors and conducts rigorous scientific research into complementary and alternative healing practices. The NCCAM website and publications serve as valuable resources to those
CAM: Nurses’ Attitudes and Knowledge
seeking reliable information about CAM practices and therapies. Interest in CAM continues to grow as consumers begin to explore nontraditional therapies and seek more options in their health care. According to the 2007 National Health Interview Survey in the United States, 38.3% of adults use some form of CAM (Barnes, Bloom, & Nahin, 2008). These results show an increase in the use of CAM from the 2002 National Health Interview Survey, which showed American adults usage at 36% (Barnes, Powell-Griner, McFann, & Nahin, 2002). The NCCAM identified research on CAM for chronic pain as a top priority and has specified chronic pain as the primary reason most Americans use CAM (Briggs, 2010). The American Society of Health-System Pharmacists, as a result of their 2003 symposium, released an article in support of multimodal postoperative pain management (Hartrick, 2004). The use of multimodal therapy helps to minimize side effects and contributes to synergistic analgesic effects. Nonpharmacologic treatments cited in their article, including guided imagery, transcutaneous electrical nerve stimulation, relaxation, and music therapy, have been endorsed as beneficial adjuvants with little to no noted adverse effects (Hartrick). The use of multimodal therapy encourages practitioners to explore more than just standard opioids for pain management. Good, Cranston, Ahn, Cong, and Stanton-Hicks (2005) evaluated the impact of relaxation, music, and their combination for relief of pain in an intestinal surgery population. Their findings revealed that the intervention groups using CAM therapies experienced 16%-40% less pain than those using pharmacologic interventions alone. Foot and hand massage as a postoperative pain intervention was found to be an inexpensive, effective, and low-risk intervention to help reduce postoperative pain (Wang & Keck, 2004). The effects of noncontact therapeutic touch on postsurgical pain in an elderly population revealed that 73% demonstrated a decrease in pain intensity scores (McCormack, 2009). These studies are but a sample of the current research supporting the efficacy of CAM therapies in an acute care setting. Given the growing popularity and consumer usage of CAM, understanding nurses’ knowledge and attitudes toward CAM is critical if nursing is to meet the challenge set forth by the California BRN of providing a bridge between conventional Western medicine and CAM. A review of published literature from 2000 to 2009 was conducted using Cinahl, Pubmed, and Psycinfo computerized databases to establish what is currently known regarding nurses’ attitudes and knowledge of CAM. The key words used were complementary
279
therapies, nursing attitudes, and knowledge, and a total of 80 articles were identified. Although numerous studies were found, the majority focused on nursing students and faculty, with few studies focusing on knowledge and attitudes regarding CAM of hospital-based nurses. The importance of assessing nursing knowledge is directly related to the implication that knowledge plays a causal role in attitude/behavior consistency (Fabrigar, Petty, Smith, & Crites, 2006). Staff nurse knowledge levels and attitudes were evaluated with the use of four self-administered questionnaires in an Israeli study that revealed that nurses had little knowledge of CAM and that few use CAM in their nursing practice (DeKeyser, Cohen, & Wagner, 2001). The Israeli nurses did express interest in learning more about CAM, but most were wary of CAM and supported some sort of official oversight of CAM practice. Similar studies were conducted in Taiwan, Korea, and the United Kingdom (Chu & Wallis, 2006; Fearon, 2003; Yom & Lee, 2008). These studies all reflected nurses’ positive attitude toward CAM but unanimously revealed a lack of nursing knowledge regarding these therapies. The Taiwanese study evaluated nurses’ attitudes toward CAM and was significant owing to Taiwan’s high rate of CAM usage, which is reported to be 51%-82% (Chang & Li, 2004). Despite high consumer use in Taiwan, the nurses surveyed demonstrated a knowledge deficit regarding CAM. Patient and nursing knowledge, experience, and attitudes toward CAM were compared in the Korean study using three questionnaires for data collection. The U.K. study used interviews and questionnaires to evaluate doctors’ and nurses’ knowledge and attitudes regarding CAM. These results have shown a strong need for knowledge of CAM. A U.S. national survey (Tracy et al., 2005) of critical care nurses regarding the use of CAM revealed that overall, critical care nurses viewed these therapies positively, wanted additional training in this area, and wished to increase the availability of these therapies for their patients. In another U.S. study, oncology nurses’ experience, knowledge, and resources regarding CAM were evaluated through a national mailed survey to Oncology Nursing Society members (RojasCooley & Grant, 2009). The key points of that study were to assess baseline knowledge, attitudes, and learning needs of oncology nurses to facilitate a future educational program that would enable nurses to educate and advocate for CAM therapy use by their patients. The present study sought to evaluate a broader cross-section of California acute care nursing specialties to assess nurses’ baseline knowledge and attitudes regarding CAM in light of California BRN policy regarding CAM.
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Although a growing body of research supports the use of CAM as an adjuvant therapy, these practices appear to be underused in nursing practice. A 2003 study of nursing students and faculty revealed that many nurses lack basic knowledge regarding CAM and feel ill equipped to educate and serve as resource to their patients regarding these valuable therapies (Halcon, Chlan, Kreitzer, & Leonard, 2003). One recent study examining CAM use for self-treatment of pain found 76% of participants had used some form of CAM for pain management, yet 31% stated that their primary care practitioner was unaware of their CAM use (Vallerand, Fouladbakhsh, & Templin, 2003). Nurses are in a unique position to elicit their patients’ CAM use and collaborate with their multidisciplinary to team to ensure optimal patient outcomes and safety when CAM is used as an adjuvant to traditional medical therapies. The present study provides fundamental information for developing a robust educational program that empowers nurses to knowledgeably discuss CAM and assess their patients’ current use of CAM.
CONCEPTUAL MODEL The conceptual model used in this study was created by Fishbein and Ajzen (1975). They developed the theory of reasoned action (TRA), which proposes that behavior is governed by individual behavioral beliefs and social normative beliefs: ‘‘Intention to perform a behavior is a function of attitudes toward engaging in the behavior and perceived normative pressure to perform the behavior’’ (Fishbein & Ajzen, 1980). If an individual believes an action will have positive consequences and is socially accepted by their peers, he or she is more likely to follow that path of action. Individual beliefs are shaped by personal knowledge and experiences. As CAM becomes more publicly accessible, nurses have increased opportunites for personal experience with these modalities, which can in turn affect their personal beliefs regarding the efficacy, validity, and safety of these practices. Positive personal experiences with CAM therapies can also lead to greater acceptance and support of these practices. In relation to nurse’s acceptance and integration of CAM into nursing practice, this theory would support the idea that if nurses had more knowledge of the scientific evidence supporting the use of CAM as well as positive personal experiences, they may alter their beliefs regarding CAM, which in turn would make nurses more likely to support its use in their practice. Normative beliefs refer to an individual’s subjective judgement regarding others’ opinions and support for particular behaviors (Werner, 2004). Regarding
CAM, an individual nurse’s beliefs may be affected by the social acceptability of CAM practices within his or her care setting. A 2001 study of >600 Stanford alumni revealed that perceived barriers to CAM include the belief that CAM treatments in general are ineffective and the perception that CAM produces negative side-effects; lack of knowledge of CAM also predicted disuse and the perception that providers were not accessible (Jain & Astin, 2001). As research continues to validate the safety and efficacy of CAM, its use will only continue to grow as will its social acceptance. If CAM practices are openly accepted and integrated in their practice settings, RNs are more likely to accept and endorse these practices. The relationship among these concepts can be depicted as in Figure 1. This is also true regarding broader social norms as CAM use and acceptance continues to grow among consumers as well as health practitioners. ‘‘Societal determinants that contribute to CAM use include increased acceptance of CAM as ‘legitimate’ and ‘mainstream’ services and activities as well as their greater availability throughout the U.S. (Fouladbakhsh & Stommel, 2007). In this way, the TRA provides the conceptual framework that if nurses have increased knowledge and experience of CAM, then their beliefs regarding CAM become more favorable, which leads to action that may include nursing advocacy for CAM practices and education within their individual care settings. The TRA may also relate to increased consumer use of CAM as information, products, and services related to CAM are more readily available and socially acceptable. Research Question What are registered nurses’ knowledge and attitudes regarding complementary and alternative therapies?
METHODS Research Design This descriptive study used the Nurse Complementary and Alternative Medicine Nursing Knowledge and Attitudes Survey (NrCAM K&A) developed by RojasCooley and Grant (2009) to explore hospital-based nurses’ knowledge and attitudes regarding CAM. CAM definitions used in this survey are based on the NCCAM criteria. Currently practicing acute care registered nurses (n ¼ 153) in California’s ‘‘Silicon Valley’’ volunteered to participate in this project. Institutional Review Board approvals for this study were obtained from San Jose State University and from the participating institution. Recruitment methods included flyers, newsletters, and announcements at staff meetings and nursing forums.
CAM: Nurses’ Attitudes and Knowledge
FIGURE 1.
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Theory of reasoned action conceptual model.
Data Collection Instruments Demographic data were collected: age, ethnicity, type of nursing degree, nursing specialty, and years of practice. An online survey was used for data collection, via Survey Monkey (an electronic survey tool). Survey Monkey is a secure electronic survey administration and analysis tool (Survey Monkey, 2009). The NrCAM K&A survey was originally developed to measure nursing knowledge, attitudes, experiences, resources, and educational interests regarding CAM. Instrument development design methodology was used, including developing a conceptual framework and one multidisciplinary group of 14 subjects that included nurses representing clinical psychology, social work, radiation oncology, clinical nutrition, and supportive care services and another three groups of registered nurses: one national professional organization group of seven oncology nurses, a group of 12 emergency department nurses, and 15 research nurses led by nurse researchers (Rojas-Cooley & Grant, 2009). This comprehensive survey contains 19 items in the knowledge section, 11 scaled items assessing attitudes, 16 items and 2 open-ended questions regarding CAM resources, 68 items and 1 open-ended question regarding nursing experience, and 34 items and 5 open-ended questions exploring educational interests. Cronbach alpha for the knowledge and attitude sections were 0.65 and 0.81, respectively, in Rojas-Cooley and Grant’s study. Data Analysis Descriptive statistics were adapted for data presentation including percentages for the demographic data, and mean scores for the CAM survey data. The CAM survey data were presented as a group mean score in each specific area tested and further analyzed into subscales for each of the primary categories of knowledge and attitudes.
RESULTS Demographics Of the 825 potential registered nurse participants, 153 surveys were submitted for analysis, representing an
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18% response rate. This represents a convenience sample of acute care registered nurses at a single large Northern California medical center. The survey respondents were primarily Asian/Pacific Islander (58.6%) and European (34.6%). The majority were 30-49 years of age (54.9%) with the range being 20-60þ years, the mean and majority were baccalaureate prepared (64.2%). By nursing specialty, telemetry and surgery made up the bulk of respondents, representing 61.4% of respondents. Years of nursing practice was more evenly distributed: 30% (n ¼ 23) identified themselves as newer nurses with 0-5 years of nursing practice, and 28% (n ¼ 43) had >21 years of nursing experience (Table 1). Knowledge The group average score for the knowledge portion of the NrCAM K&A survey was 51%, indicating respondents’ poor baseline knowledge of CAM. Individual scores ranged from 5% (n ¼ 1) to 100% (n ¼ 1). Measurement of knowledge was based on CAM terms, specific alternative medicine practices, NCCAM domains, and specific CAM therapies (Table 2). Regarding CAM terminology, the accurate responses were even fewer; fewer than half (47%; n ¼ 85) of the respondents could correctly define complementary medicine, and only 33% (n ¼ 34) were able to define complementary and alternative medicine. For the NCCAM domain section, respondents demonstrated 43% (n ¼ 100) accuracy in correctly identifying specific whole medical systems, energy therapy, mind-body interventions, biologically based therapies, and manipulative body-based methods, whereas 26% (n ¼ 100) selected the response ‘ I do not know.’’ In the final knowledge section, aromatherapy appeared more easily defined, with 87% (n ¼ 87) of respondents correctly defining this therapeutic approach. The remaining individual therapies tested, reiki, therapeutic touch, qi gong, and dietary supplements, averaged only 44% (n ¼ 100) correct responses (Table 2). Beliefs The beliefs and attitudes toward CAM were measured based on a 7-point Likert scale, with 1 representing strongly agree and 7 representing strongly disagree; mean scores and standard deviation were calculated for each of the 13 items. The lowest score, 2.69, for ‘‘I believe patients have the right to have CAM therapies integrated into their conventional medical treatment’’ indicated nurses’ strong agreement with this statement. A low score (2.79) was also determined regarding the nurses’ belief that patients should disclose the use of CAM therapies. Strong disagreement was most evident in the high score of 5.10 for ‘‘I am familiar with my Board of Nursing CAM advisory statement.’’
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TABLE 1. Demographic Data n Total no. of subjects Age 20–29 30–39 40–49 50–59 60þ Ethnicity White Black Asian/Pacific Islander Hispanic Nursing education Diploma/ADN BSN MSN Nursing practice specialty area Pediatrics Emergency Medical Surgical Oncology Telemetry ICU/CVICU Years of practice 0–2 3–5 6–10 11–15 16–20 21–25 26–30 30þ
153
% 100
25 46 38 36 8
16.3 30.1 24.8 23.5 5.2
53 3 89 7
34.6 2 58.2 4.6
37 95 16
24.2 62.1 10.5
13 3 14 36 6 58 14
8.5 2 9.2 23.5 3.9 37.9 9.2
23 23 26 24 11 13 14 16
15 15 17 15.7 7.2 8.5 9.2 10.5
Statements regarding the RN role in integrating CAM therapies into their practice had the most varied responses (Table 3).
DISCUSSION The foundation of nursing practice focuses on providing comprehensive, compassionate, holistic nursing care, and many CAM practices embody the ideals of holism and offer patients additional options for healing and nurturing the mind, body, and spirit. For example, the strength of integrating CAM therapies for pain management is that it offers both the patient and the nurse additional options. This empowers patients and nurses to improve the patient care experience in managing their symptoms, such as pain management, by accessing additional resources for symptom management and comfort.
The Institute of Medicine (IOM) (2004) endorses that health profession schools, including schools of medicine, nursing and pharmacy, offer curriculum that provides their students with ‘‘sufficient information about CAM . to competently advise their patients about CAM.’’ Many state boards of nursing (47%) have issued policy statements recognizing CAM as within the nursing scope of practice and consistent with nursing tenets to provide holistic care for their patients (Sparber, 2001). However, nurses in the present study demonstrated limited knowledge of basic CAM terminology and CAM practices based on their self-reported knowledge scores, even though they strongly agreed that patients have the right to have CAM therapies integrated into their conventional medical treatment. When asked to identify the five domains of CAM as designated by NCCAM, 26% (n ¼ 100) of nurses surveyed responded, ‘‘I do not know.’’ When knowledge of individual therapies was assessed, aside from aromatherapy, 36% responded, ‘‘I do not know.’’ Lack of fluency with CAM terminology impairs effective communication between patients and health care providers (Geller, Studee, & Chandra, 2005). Furthermore, with limited common language, nurses face an extra hurdle when their patients disclose their use of CAM therapies. This knowledge deficit would likely preclude nurses from being able to accurately assess their patients’ use of CAM. Moreover, they would likely be ill equipped to educate their patients regarding CAM or to reasonably advocate for CAM opportunities within their specialty areas. Further CAM education based on these findings would assist nurses as they advocate for their patients regarding the use and availability of CAM therapies in an acute care setting. Given its increased consumer use and growing scientific evidence of efficacy, nurses must be knowledgeable about CAM. Recent research shows that pain is a strong predictor of individuals accessing CAM among both cancer and noncancer populations (Fouladbakhsh & Stommel 2008). Nurses have a responsibility to the patients they care for to have at least basic knowledge of CAM practices, including associated risks and its potential benefits, including pain management. In the present sample, nurses reported
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From the Valley Foundation School of Nursing, San Jose State University, Santa Clara, California. Address correspondence to Mrs. Tracy Trail-Mahan, RN, MS, San Jose State University, Valley Foundation School of Nursing, Kaiser Permanente Santa Clara, 700 Lawrence Expressway, Santa Clara, CA 95051. E-mail: tracy.x. [email protected] Received May 18, 2010; Revised April 4, 2011; Accepted June 2, 2011. 1524-9042/$36.00 Ó 2013 by the American Society for Pain Management Nursing doi:10.1016/j.pmn.2011.06.001
ABSTRACT:
Despite significant evidence for the integration of complementary and alternative medicine (CAM) into professional nursing practice, gaps exist regarding nurses’ baseline knowledge, beliefs of efficacy, and learning needs for further education to facilitate the integration of CAM into nursing practice. The top three conditions which adults identified for using CAM were back pain, neck pain, and joint pain. CAM can offer nurses additional treatment options for managing their patients’ pain and discomfort. The California Board of Registered Nursing (BRN) identifies that nurses can help provide the missing link between conventional Western medicine and CAM therapies. Nurses cannot successfully advocate for CAM therapies, nor understand their patients’ prior use of such treatments, unless they themselves are familiar with both the risks and the benefits of these practices. It is necessary to first establish nurses’ baseline knowledge and beliefs related to CAM so that adequate educational programs can be initiated to help mitigate the barriers to incorporating CAM into the acute care setting. This descriptive study explores registered nurses’ attitudes and knowledge related to CAM by using the Nurse Complementary and Alternative Medicine Nursing Knowledge and Attitudes Survey developed by Rojas-Cooley and Grant. Nurses in this study demonstrated limited self-reported knowledge of basic CAM terminology and CAM practices. Ó 2013 by the American Society for Pain Management Nursing Pain management is an integral function of the licensed nurse. In recent years health care has placed increased emphasis on this important component of nursing practice. Forty-two percent of American adults report that they experience pain daily, and 89% report that they experience pain at least monthly (Sammons, 2000). Inadequate pain relief has been linked to not only patient distress but has been shown to have undesirable physiological and psychological consequences (Hutchinson, 2007). Consequences include decreased immune response, poor wound healing, and avoidance of movement, which can contribute to deep vein thrombosis and pulmonary embolism. The concurrent stress Pain Management Nursing, Vol 14, No 4 (December), 2013: pp 277-286
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Trail-Mahan, Mao, and Bawel-Brinkley
associated with unresolved pain can lead to anxiety and depression. This can translate into increased length of stay and decreased patient satisfaction. Globally, nursing researchers are focusing on this challenging topic, and looking at a variety of factors that impact the pain management experience. Complementary and alternative medicine (CAM) can supplement conventional medical interventions in the management of acute pain. Although a growing body of research supports the use of CAM as an adjuvant therapy for pain management these practices appear to be underused in nursing practice. Since 2000, the Joint Commission has acknowledged the importance of pain management and assessment by incorporating it in into its accreditation process and stringent national standards (Joint Commission, 2008). The California Board of Registered Nursing (BRN) (2004) declares: A competent California registered nurse will advocate for patients by ensuring that the patient (or a delegated family member or caregiver) has adequate knowledge to make informed decisions about pain management and will intervene in the health care system to assist the patient/client to achieve appropriate management of pain. Given the importance of adequate pain management, it is disturbing to find that many patients continue to experience unacceptable levels of acute pain. A meta-analysis examining postoperative pain management of nearly 20,000 patients revealed that 30% continued to experience moderate to severe pain (Dolin, Cashman, & Bland, 2002). CAM offers patients additional options to increase their level of comfort and increase their satisfaction with their overall pain experience. Numerous studies validate the use of CAM for a variety of health issues and symptom management. Complementary therapies offer nurses the opportunity to provide holistic care and empower patients to actively participate in their care and recovery (Fountouki & Theofanidis, 2009). Holistic care seeks to treat the whole individual, as opposed to treating symptoms exclusively, and recognizes the role of mind, body, and spirit in the healing process. The top three conditions for which adults identified using CAM were back pain, neck pain, and joint pain; among children, back/neck pain was the number one condition for which CAM was used (Barnes, Bloom, & Nahin, 2008). Despite significant evidence supporting the integration of CAM into professional nursing practice, gaps exist regarding nurses’ baseline knowledge, beliefs of efficacy, and learning needs to facilitate the integration of CAM into nursing practice. The White House Commission on Complementary and Alternative Medicine Policy
(2002) recognized the need for increased education and training of health practitioners in CAM. That national policy statement led to many state boards of nursing (47%) issuing policy statements recognizing CAM as being within the nursing scope of practice and consistent with nursing tenets to provide holistic care for their patients (Sparber, 2001). The California BRN (2009) identifies that nurses can help provide the missing link between conventional Western medicine and CAM therapies. CAM can offer nurses an additional tool to help manage their patients’ complex pain management needs. The present study will focus on nurses’, specifically California hospital-based registered nurses’, beliefs, attitudes and knowledge base regarding the use of CAM.
LITERATURE REVIEW Complementary and alternative medicine, as defined by the National Center for Complementary and Alternative Medicine (NCCAM), is a group of diverse medical and health care systems, practices, and products that are not generally considered to be part of conventional medicine (NCCAM, 2001). This definition of CAM is used as the conceptual definition in this study and can be divided into five main categories: 1) biologically based practices; 2) energy medicine; 3) manipulative and body-based practices; 4) mind-body medicine; and 5) whole medical systems. The biologically based practices include products containing vitamins, minerals, herbs, amino acids, enzymes or other ingredients to supplement the diet and promote health. The second group, energy medicine, uses energy fields such as magnetic fields with the intent to impact health. Some examples of energy medicine include magnet therapy, healing touch, and Reiki. Manipulative and body-based practices focus on bodily structures and systems, including the bones, joints, soft tissues, and the circulatory and lymphatic systems. Common examples include massage, chiropractic, and reflexology. Mind-body medicine practices concentrate on the influence of the mind over bodily functions and symptoms: meditation, yoga, tai chi, qi gong, and guided imagery are a few examples. Whole medical systems include homeopathic medicine, naturopathic medicine, Ayurveda, and traditional Chinese medicine. Nurses’ knowledge and attitudes of these therapies are evaluated in this study, these NCCAM definitions provide the framework for knowledge evaluation The NCCAM, which functions as part of the National Institutes of Health, sponsors and conducts rigorous scientific research into complementary and alternative healing practices. The NCCAM website and publications serve as valuable resources to those
CAM: Nurses’ Attitudes and Knowledge
seeking reliable information about CAM practices and therapies. Interest in CAM continues to grow as consumers begin to explore nontraditional therapies and seek more options in their health care. According to the 2007 National Health Interview Survey in the United States, 38.3% of adults use some form of CAM (Barnes, Bloom, & Nahin, 2008). These results show an increase in the use of CAM from the 2002 National Health Interview Survey, which showed American adults usage at 36% (Barnes, Powell-Griner, McFann, & Nahin, 2002). The NCCAM identified research on CAM for chronic pain as a top priority and has specified chronic pain as the primary reason most Americans use CAM (Briggs, 2010). The American Society of Health-System Pharmacists, as a result of their 2003 symposium, released an article in support of multimodal postoperative pain management (Hartrick, 2004). The use of multimodal therapy helps to minimize side effects and contributes to synergistic analgesic effects. Nonpharmacologic treatments cited in their article, including guided imagery, transcutaneous electrical nerve stimulation, relaxation, and music therapy, have been endorsed as beneficial adjuvants with little to no noted adverse effects (Hartrick). The use of multimodal therapy encourages practitioners to explore more than just standard opioids for pain management. Good, Cranston, Ahn, Cong, and Stanton-Hicks (2005) evaluated the impact of relaxation, music, and their combination for relief of pain in an intestinal surgery population. Their findings revealed that the intervention groups using CAM therapies experienced 16%-40% less pain than those using pharmacologic interventions alone. Foot and hand massage as a postoperative pain intervention was found to be an inexpensive, effective, and low-risk intervention to help reduce postoperative pain (Wang & Keck, 2004). The effects of noncontact therapeutic touch on postsurgical pain in an elderly population revealed that 73% demonstrated a decrease in pain intensity scores (McCormack, 2009). These studies are but a sample of the current research supporting the efficacy of CAM therapies in an acute care setting. Given the growing popularity and consumer usage of CAM, understanding nurses’ knowledge and attitudes toward CAM is critical if nursing is to meet the challenge set forth by the California BRN of providing a bridge between conventional Western medicine and CAM. A review of published literature from 2000 to 2009 was conducted using Cinahl, Pubmed, and Psycinfo computerized databases to establish what is currently known regarding nurses’ attitudes and knowledge of CAM. The key words used were complementary
279
therapies, nursing attitudes, and knowledge, and a total of 80 articles were identified. Although numerous studies were found, the majority focused on nursing students and faculty, with few studies focusing on knowledge and attitudes regarding CAM of hospital-based nurses. The importance of assessing nursing knowledge is directly related to the implication that knowledge plays a causal role in attitude/behavior consistency (Fabrigar, Petty, Smith, & Crites, 2006). Staff nurse knowledge levels and attitudes were evaluated with the use of four self-administered questionnaires in an Israeli study that revealed that nurses had little knowledge of CAM and that few use CAM in their nursing practice (DeKeyser, Cohen, & Wagner, 2001). The Israeli nurses did express interest in learning more about CAM, but most were wary of CAM and supported some sort of official oversight of CAM practice. Similar studies were conducted in Taiwan, Korea, and the United Kingdom (Chu & Wallis, 2006; Fearon, 2003; Yom & Lee, 2008). These studies all reflected nurses’ positive attitude toward CAM but unanimously revealed a lack of nursing knowledge regarding these therapies. The Taiwanese study evaluated nurses’ attitudes toward CAM and was significant owing to Taiwan’s high rate of CAM usage, which is reported to be 51%-82% (Chang & Li, 2004). Despite high consumer use in Taiwan, the nurses surveyed demonstrated a knowledge deficit regarding CAM. Patient and nursing knowledge, experience, and attitudes toward CAM were compared in the Korean study using three questionnaires for data collection. The U.K. study used interviews and questionnaires to evaluate doctors’ and nurses’ knowledge and attitudes regarding CAM. These results have shown a strong need for knowledge of CAM. A U.S. national survey (Tracy et al., 2005) of critical care nurses regarding the use of CAM revealed that overall, critical care nurses viewed these therapies positively, wanted additional training in this area, and wished to increase the availability of these therapies for their patients. In another U.S. study, oncology nurses’ experience, knowledge, and resources regarding CAM were evaluated through a national mailed survey to Oncology Nursing Society members (RojasCooley & Grant, 2009). The key points of that study were to assess baseline knowledge, attitudes, and learning needs of oncology nurses to facilitate a future educational program that would enable nurses to educate and advocate for CAM therapy use by their patients. The present study sought to evaluate a broader cross-section of California acute care nursing specialties to assess nurses’ baseline knowledge and attitudes regarding CAM in light of California BRN policy regarding CAM.
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Although a growing body of research supports the use of CAM as an adjuvant therapy, these practices appear to be underused in nursing practice. A 2003 study of nursing students and faculty revealed that many nurses lack basic knowledge regarding CAM and feel ill equipped to educate and serve as resource to their patients regarding these valuable therapies (Halcon, Chlan, Kreitzer, & Leonard, 2003). One recent study examining CAM use for self-treatment of pain found 76% of participants had used some form of CAM for pain management, yet 31% stated that their primary care practitioner was unaware of their CAM use (Vallerand, Fouladbakhsh, & Templin, 2003). Nurses are in a unique position to elicit their patients’ CAM use and collaborate with their multidisciplinary to team to ensure optimal patient outcomes and safety when CAM is used as an adjuvant to traditional medical therapies. The present study provides fundamental information for developing a robust educational program that empowers nurses to knowledgeably discuss CAM and assess their patients’ current use of CAM.
CONCEPTUAL MODEL The conceptual model used in this study was created by Fishbein and Ajzen (1975). They developed the theory of reasoned action (TRA), which proposes that behavior is governed by individual behavioral beliefs and social normative beliefs: ‘‘Intention to perform a behavior is a function of attitudes toward engaging in the behavior and perceived normative pressure to perform the behavior’’ (Fishbein & Ajzen, 1980). If an individual believes an action will have positive consequences and is socially accepted by their peers, he or she is more likely to follow that path of action. Individual beliefs are shaped by personal knowledge and experiences. As CAM becomes more publicly accessible, nurses have increased opportunites for personal experience with these modalities, which can in turn affect their personal beliefs regarding the efficacy, validity, and safety of these practices. Positive personal experiences with CAM therapies can also lead to greater acceptance and support of these practices. In relation to nurse’s acceptance and integration of CAM into nursing practice, this theory would support the idea that if nurses had more knowledge of the scientific evidence supporting the use of CAM as well as positive personal experiences, they may alter their beliefs regarding CAM, which in turn would make nurses more likely to support its use in their practice. Normative beliefs refer to an individual’s subjective judgement regarding others’ opinions and support for particular behaviors (Werner, 2004). Regarding
CAM, an individual nurse’s beliefs may be affected by the social acceptability of CAM practices within his or her care setting. A 2001 study of >600 Stanford alumni revealed that perceived barriers to CAM include the belief that CAM treatments in general are ineffective and the perception that CAM produces negative side-effects; lack of knowledge of CAM also predicted disuse and the perception that providers were not accessible (Jain & Astin, 2001). As research continues to validate the safety and efficacy of CAM, its use will only continue to grow as will its social acceptance. If CAM practices are openly accepted and integrated in their practice settings, RNs are more likely to accept and endorse these practices. The relationship among these concepts can be depicted as in Figure 1. This is also true regarding broader social norms as CAM use and acceptance continues to grow among consumers as well as health practitioners. ‘‘Societal determinants that contribute to CAM use include increased acceptance of CAM as ‘legitimate’ and ‘mainstream’ services and activities as well as their greater availability throughout the U.S. (Fouladbakhsh & Stommel, 2007). In this way, the TRA provides the conceptual framework that if nurses have increased knowledge and experience of CAM, then their beliefs regarding CAM become more favorable, which leads to action that may include nursing advocacy for CAM practices and education within their individual care settings. The TRA may also relate to increased consumer use of CAM as information, products, and services related to CAM are more readily available and socially acceptable. Research Question What are registered nurses’ knowledge and attitudes regarding complementary and alternative therapies?
METHODS Research Design This descriptive study used the Nurse Complementary and Alternative Medicine Nursing Knowledge and Attitudes Survey (NrCAM K&A) developed by RojasCooley and Grant (2009) to explore hospital-based nurses’ knowledge and attitudes regarding CAM. CAM definitions used in this survey are based on the NCCAM criteria. Currently practicing acute care registered nurses (n ¼ 153) in California’s ‘‘Silicon Valley’’ volunteered to participate in this project. Institutional Review Board approvals for this study were obtained from San Jose State University and from the participating institution. Recruitment methods included flyers, newsletters, and announcements at staff meetings and nursing forums.
CAM: Nurses’ Attitudes and Knowledge
FIGURE 1.
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Theory of reasoned action conceptual model.
Data Collection Instruments Demographic data were collected: age, ethnicity, type of nursing degree, nursing specialty, and years of practice. An online survey was used for data collection, via Survey Monkey (an electronic survey tool). Survey Monkey is a secure electronic survey administration and analysis tool (Survey Monkey, 2009). The NrCAM K&A survey was originally developed to measure nursing knowledge, attitudes, experiences, resources, and educational interests regarding CAM. Instrument development design methodology was used, including developing a conceptual framework and one multidisciplinary group of 14 subjects that included nurses representing clinical psychology, social work, radiation oncology, clinical nutrition, and supportive care services and another three groups of registered nurses: one national professional organization group of seven oncology nurses, a group of 12 emergency department nurses, and 15 research nurses led by nurse researchers (Rojas-Cooley & Grant, 2009). This comprehensive survey contains 19 items in the knowledge section, 11 scaled items assessing attitudes, 16 items and 2 open-ended questions regarding CAM resources, 68 items and 1 open-ended question regarding nursing experience, and 34 items and 5 open-ended questions exploring educational interests. Cronbach alpha for the knowledge and attitude sections were 0.65 and 0.81, respectively, in Rojas-Cooley and Grant’s study. Data Analysis Descriptive statistics were adapted for data presentation including percentages for the demographic data, and mean scores for the CAM survey data. The CAM survey data were presented as a group mean score in each specific area tested and further analyzed into subscales for each of the primary categories of knowledge and attitudes.
RESULTS Demographics Of the 825 potential registered nurse participants, 153 surveys were submitted for analysis, representing an
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18% response rate. This represents a convenience sample of acute care registered nurses at a single large Northern California medical center. The survey respondents were primarily Asian/Pacific Islander (58.6%) and European (34.6%). The majority were 30-49 years of age (54.9%) with the range being 20-60þ years, the mean and majority were baccalaureate prepared (64.2%). By nursing specialty, telemetry and surgery made up the bulk of respondents, representing 61.4% of respondents. Years of nursing practice was more evenly distributed: 30% (n ¼ 23) identified themselves as newer nurses with 0-5 years of nursing practice, and 28% (n ¼ 43) had >21 years of nursing experience (Table 1). Knowledge The group average score for the knowledge portion of the NrCAM K&A survey was 51%, indicating respondents’ poor baseline knowledge of CAM. Individual scores ranged from 5% (n ¼ 1) to 100% (n ¼ 1). Measurement of knowledge was based on CAM terms, specific alternative medicine practices, NCCAM domains, and specific CAM therapies (Table 2). Regarding CAM terminology, the accurate responses were even fewer; fewer than half (47%; n ¼ 85) of the respondents could correctly define complementary medicine, and only 33% (n ¼ 34) were able to define complementary and alternative medicine. For the NCCAM domain section, respondents demonstrated 43% (n ¼ 100) accuracy in correctly identifying specific whole medical systems, energy therapy, mind-body interventions, biologically based therapies, and manipulative body-based methods, whereas 26% (n ¼ 100) selected the response ‘ I do not know.’’ In the final knowledge section, aromatherapy appeared more easily defined, with 87% (n ¼ 87) of respondents correctly defining this therapeutic approach. The remaining individual therapies tested, reiki, therapeutic touch, qi gong, and dietary supplements, averaged only 44% (n ¼ 100) correct responses (Table 2). Beliefs The beliefs and attitudes toward CAM were measured based on a 7-point Likert scale, with 1 representing strongly agree and 7 representing strongly disagree; mean scores and standard deviation were calculated for each of the 13 items. The lowest score, 2.69, for ‘‘I believe patients have the right to have CAM therapies integrated into their conventional medical treatment’’ indicated nurses’ strong agreement with this statement. A low score (2.79) was also determined regarding the nurses’ belief that patients should disclose the use of CAM therapies. Strong disagreement was most evident in the high score of 5.10 for ‘‘I am familiar with my Board of Nursing CAM advisory statement.’’
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TABLE 1. Demographic Data n Total no. of subjects Age 20–29 30–39 40–49 50–59 60þ Ethnicity White Black Asian/Pacific Islander Hispanic Nursing education Diploma/ADN BSN MSN Nursing practice specialty area Pediatrics Emergency Medical Surgical Oncology Telemetry ICU/CVICU Years of practice 0–2 3–5 6–10 11–15 16–20 21–25 26–30 30þ
153
% 100
25 46 38 36 8
16.3 30.1 24.8 23.5 5.2
53 3 89 7
34.6 2 58.2 4.6
37 95 16
24.2 62.1 10.5
13 3 14 36 6 58 14
8.5 2 9.2 23.5 3.9 37.9 9.2
23 23 26 24 11 13 14 16
15 15 17 15.7 7.2 8.5 9.2 10.5
Statements regarding the RN role in integrating CAM therapies into their practice had the most varied responses (Table 3).
DISCUSSION The foundation of nursing practice focuses on providing comprehensive, compassionate, holistic nursing care, and many CAM practices embody the ideals of holism and offer patients additional options for healing and nurturing the mind, body, and spirit. For example, the strength of integrating CAM therapies for pain management is that it offers both the patient and the nurse additional options. This empowers patients and nurses to improve the patient care experience in managing their symptoms, such as pain management, by accessing additional resources for symptom management and comfort.
The Institute of Medicine (IOM) (2004) endorses that health profession schools, including schools of medicine, nursing and pharmacy, offer curriculum that provides their students with ‘‘sufficient information about CAM . to competently advise their patients about CAM.’’ Many state boards of nursing (47%) have issued policy statements recognizing CAM as within the nursing scope of practice and consistent with nursing tenets to provide holistic care for their patients (Sparber, 2001). However, nurses in the present study demonstrated limited knowledge of basic CAM terminology and CAM practices based on their self-reported knowledge scores, even though they strongly agreed that patients have the right to have CAM therapies integrated into their conventional medical treatment. When asked to identify the five domains of CAM as designated by NCCAM, 26% (n ¼ 100) of nurses surveyed responded, ‘‘I do not know.’’ When knowledge of individual therapies was assessed, aside from aromatherapy, 36% responded, ‘‘I do not know.’’ Lack of fluency with CAM terminology impairs effective communication between patients and health care providers (Geller, Studee, & Chandra, 2005). Furthermore, with limited common language, nurses face an extra hurdle when their patients disclose their use of CAM therapies. This knowledge deficit would likely preclude nurses from being able to accurately assess their patients’ use of CAM. Moreover, they would likely be ill equipped to educate their patients regarding CAM or to reasonably advocate for CAM opportunities within their specialty areas. Further CAM education based on these findings would assist nurses as they advocate for their patients regarding the use and availability of CAM therapies in an acute care setting. Given its increased consumer use and growing scientific evidence of efficacy, nurses must be knowledgeable about CAM. Recent research shows that pain is a strong predictor of individuals accessing CAM among both cancer and noncancer populations (Fouladbakhsh & Stommel 2008). Nurses have a responsibility to the patients they care for to have at least basic knowledge of CAM practices, including associated risks and its potential benefits, including pain management. In the present sample, nurses reported
