Nurses and CAM

Once considered an adversary of mainstream allopathic medicine, complementary and alternative care has made increasing strides toward respectability and acceptability in the general population. This acceptance has been fueled, at least to some degree, by a willingness of "conventional" practitioners to examine and, in some cases, show open support for forms of care not traditionally utilized by Western physicians. A landmark study published in the Journal of Family Practice in 1994, for instance, found that more than 60% of physicians recommend alternative therapies to their patients.¹

Lesser-known - but no less important -- are the perceptions of nurses toward complementary and alternative medicine. According to the American Nurses Association, there are 2.6 million registered nurses in the United States, a figure that far exceeds the number of medical doctors.² Nurses are also in regular contact with patients and the public more frequently than medical doctors, and often assist in making decisions about the type of care patients will receive. However, most surveys relating to nurses and CAM have used small samples of 100 subjects or less, and these surveys have usually been limited to a particular specialty such as oncology or midwifery.

A recent survey published in the Journal of Community Health³ has brought the opinions of nurses and CAM into a new light. The survey, one of the largest conducted to date, shows that while the type of training and education nurses receive about CAM leaves much to be desired, they believe several of those therapies to be safe and effective, and they routinely recommend CAM treatments to friends, clients and patients.

In the survey, a random sample of 1,000 nurses received a four-page questionnaire consisting of 100 items that covered 22 different complementary and alternative therapies, including acupuncture, acupressure, tai chi, and four popular herbal supplements (garlic, ginseng, ginkgo and St. John's wort). Nurses were asked to rate each therapy in four areas: perceived effectiveness; perceived safety; recommendations made to friends, clients and associates; and personal use. The remaining items were used to obtain background information on the respondents.

Nurse Demographics

An overwhelming number of nurses who returned the survey were female (91%), Caucasian (86%) and between the ages of 30-59 (92%). Sixty-four percent had reached either a bachelor's or master's level of education; 67% were either registered nurses or nurse practitioners.

Self-perceptions of education and training regarding CAM were rather poor overall, as only 21% of the respondents considered themselves to have received "good" or "excellent" professional preparation in dealing with complementary and alternative medicine. When asked where they received the majority of their information on CAM therapies, only 44% cited professional journals as the leading source; 38% cited professional conferences or conventions.

Perceptions of Effectiveness

Of the 22 therapies listed on the questionnaire, 77% of the respondents thought there was either growing evidence, a preponderance of evidence, or conclusive evidence that acupuncture was an effective form of care, ranking in a third-place tie behind massage (85%) and meditation/relaxation (84%). These figures were comparable to other popular forms of CAM such as chiropractic (77%), biofeedback (76%) and guided imagery (76%). Garlic was the highest rated herbal supplement at 73%; acupressure and tai chi were ranked at 50% and 47%, respectively. Only two percent of those surveyed thought there was no evidence on the effectiveness of acupuncture, the lowest rating of any therapy on the questionnaire.

When comparing results across education levels, acupuncture (along with anti-oxidants and body cleansing) was perceived to be more effective among nurses with higher levels of training and education (five or more years of college) than nurses with less education. In addition, nurses with more years of experience on the job considered acupuncture (along with acupressure, hypnotherapy and meditation) more effective.

Perceptions of Safety

Fifty-five percent of the nurses surveyed felt that both acupuncture and acupressure were "probably safe" or "definitely safe," ranking behind only hypnotherapy (59%) and chiropractic (58%). Ginseng was considered the "safest" herbal product; 51% perceived it to be definitely or probably safe for use. Results for other herbal remedies were less clear; for example, while 47% of the respondents considered St. John's wort probably or definitely safe, 37% said its safety was not established or that the supplement was unsafe.

Interestingly, when the survey results were determined by education level, nurses with more education perceived three items -- including two herbal products (coenzyme-Q10, gingko biloba and ginseng) -- as more safe than those with less education, even though a considerable percentage of the survey population considered these items either unsafe or believed their safety was not established.

Personal Use and Recommended Use

Only six percent of nurses surveyed reported personally using acupuncture. Similar results were seen for other aspects of Asian healing, such as acupressure (4%) and tai chi (5%), and herbal supplements like ginkgo (9%), ginseng and St. John's wort (both 7%). However, low usage did not appear to prohibit nurses from recommending those therapies to other people; 29% of nurses recommended tai chi to someone else, while 41% recommended acupuncture to a friend, client or associate. These percentages were slightly higher for herbal and botanical therapies and multivitamins.

Familiarity Breeds Believability

The researchers noted that nurses who responded were more likely to believe in "more familiar and possibly more traditional alternative and complementary medical therapies." For example, the three therapies perceived to be the most effective - biofeedback, chiropractic and meditation/relaxation - also happen to be among the most well-known CAM therapies. The researchers speculated that these results were due to a lack of formal training in CAM. Seventy-nine percent of the nurses surveyed said that their professional preparation in the area of complementary and alternative medicine was "fair" or "poor," and 52% identified the general mass media as their primary source of information on CAM. Thus, many nurses might not be aware of lesser-known (but possibly effective) therapies.

The researchers also discovered that when asked about the safety of certain forms of CAM, nurses were more likely to consider "external" therapies (i.e., chiropractic, acupressure) as safest. "Again, general logic rather than formal training may be at work with these perceptions," they noted, pointing to the fact that the nurses with greater education levels were "more likely" to perceive some of the herbal therapies as safer than nurses with less education.

Potential limitations were noted in the study's conclusions. The response rate to the survey, for instance, was 57%, which the investigators said "indicates a potential non-response bias." In addition, some of the responses could have been interpreted differently by different practitioners, and since the questionnaire was not open-ended and did not attempt to attain additional information from the respondents, there may have been some perceptions about CAM that were not addressed by the survey.

Limits aside, the Journal of Community Health study provides significant insight into the perceptions of nurses toward complementary and alternative medicine. It shows that despite receiving limited professional training and education receive about CAM, nurses believe in the safety and effectiveness of several of these therapies, and regularly recommend CAM treatments such as acupuncture and herbal remedies to friends, patients and clients.

References

1. Borkan J, Nehler J, Anson O, et al. Referrals for alternative therapies. J Fam Pract 1994;39:545-550.
2. ANA: Who we are, what we do, where we come from. Available from the American Nurses Association website (www.ana.org).
3. Brolinson PG, Price JH, Ditmyer M, et al. Nurses' perceptions of complementary and alternative medical therapies. Journal of Community Health June 2001;26(3):175-89.