Complementary and alternative medicine: a qualitative study of beliefs of a small sample of Rocky Mountain area nurses
Judith E. McDowell
As a result of improved access to information, consumers can make more choices regarding their personal health care (Simon, 1999; Zollman, 1999). Consequently, many people have turned to complementary and alternative medicine (CAM) for their medical treatment (Astin, 1998; National Center for Complementary and Alternative Medicine [NCCAM], 2001). While there are many forms of CAM, herbal medicine is one of the fastest growing in developed nations; use of herbal products increased by 380% between 1990 and 1997 (Eisenberg et al., 1998; Nahin, 2001; Ness, Sherman, & Pan, 1999). One look at the shelves in the stores in the United States reveals the enormous quantities of herbal preparations used in this country. In recognition of the increased used of CAM and the paucity of information regarding CAM, the U.S. government established the Office of Alternative Medicine (OAM) within the National Institutes of Health (NIH) in 1992 (NCCAM, 2001). The purpose of the OAM was to promote research and evaluation of CAM treatments and to make information available to health care providers and consumers of these therapies. This office became the National Center for Complementary and Alternative Medicine in 1998 (NCCAM, 2001) and had an operating budget of $68.3 million in 2000 (Nahin, 2001). The establishment of this branch of the NIH gave consumers greater access to information and research. However, few rigorous scientific studies have evaluated the efficacy of herbal and vitamin supplements (Nahin, 2001).
As CAM use increases in the United States, more and more people who are admitted to hospitals are likely to be using some form of alternative medicine. It is thus important for those who work in the acute care setting to have an understanding of how these therapies work, and the potential for adverse reactions between CAM modalities and conventional medical treatment. Because many of the patients they see will be using some form of CAM, acute care nurses should understand their own attitudes and beliefs in order to address areas of educational need. The purpose of this study was to examine the beliefs and attitudes held by acute care nurses regarding CAM. Little is known about how acute care nurses view CAM therapies. Specifically, this study sought to answer the following questions: How do nurses define CAM? What role, if any, do nurses feel CAM should play in the acute care setting? How do nurses perceive their knowledge about CAM? Do nurses integrate CAM into their practice?
Because CAM has developed in various cultural and regional settings, evaluation standards are difficult to develop. The research that has been done on CAM has been sketchy and poorly organized, and has lacked a clear purpose for data collection (World Health Organization [WHO], 2002). The literature does include surveys, editorial opinions, and meta-analyses, but lacks reports of scientific investigation of CAM and its providers.
What is CAM? The NCCAM (2001, p. 1) defines CAM as “… a broad range of healing philosophies (schools of thought), approaches, and therapies that mainstream Western (conventional) medicine does not commonly use, accept, study, understand, or make available.” The WHO (2002, p. 7) defines CAM as “… a broad set of health care practices that are not part of a country’s own tradition, or not integrated into its dominant health care system” (WHO, 2002, p. 7). Complementary medicine is usually thought of as that which is used in conjunction with mainstream medicine, and alternative medicine includes treatments that are used in place of mainstream medicine.
NCCAM (2004) further divides CAM into five major areas of practice: alternative medical systems, mind-body interventions, biologically based therapies, manipulative and body-based methods, and energy therapies. Alternative medical systems are systems for health care that have their own theory and practice foundation; examples include homeopathic medicine and Ayurveda, the traditional medicine of India. Mind-body intervention is based on the premise that using techniques to enhance the mind will affect the response of the body positively. Some of these techniques, most notably patient support groups, have become part of the traditional Western approach to medicine. Additional types of CAM that fall into this group include prayer, meditation, and music and art therapy. Biologically based therapies, such as herbal remedies and dietary supplements, use natural substances, either in traditional treatment of illness or as part of the daily routine. Therapies that move body parts to enhance health, also called manipulative and body-based therapies, include chiropractic and massage therapy. Two types of energy therapies are also recognized. Biofield therapies are based on the manipulation of the energy fields that surround the body; examples include Reiki and therapeutic touch. Bioeletromagnetic-based therapies use magnetic fields or alternating or direct current fields to improve energy flow through the body’s energy fields. These areas of practice cover a wide range of treatment modalities; while some are widely accepted and used, others have very little scientific basis.
A growing body of literature addresses health care professionals’ beliefs about CAM, particularly focusing on physician beliefs and attitudes. In general, physicians report that their patients use and ask about CAM (Boutin, Buchwald, Robinson, & Collier, 2000; Winslow & Shapiro, 2002), although they tend to underestimate the frequency of patient use (Rosenbaum, Nisly, Ferguson, & Kligman, 2002; Sikand & Laken, 1998). Literature reports that physicians may use CAM personally (Crock, Jarjoura, Polen, & Rutecki, 1999; Sikand & Laken, 1998; Winslow & Shapiro, 2002), and are cautiously open-minded about CAM (Boucher & Lenz, 1998; Ernst, Resch, & White, 1995), but they do not have adequate knowledge and do not feel comfortable recommending CAM (Sikand & Laken, 1998; Winslow & Shapiro, 2002). Specific CAM therapies such as massage, biofeedback, and acupuncture are viewed more positively than others because of widespread use (Astin, Marie, Pellitier, Hansen, & Haskell, 1998; Berman, Singh, Hartnoll, Singh, & Reilly, 1998; Crock et al., 1999; Rooney, Fiocco, Hughes, & Halter, 2001). Medical students also express interest in learning more about CAM and the belief that knowing about CAM is important for clinical practice (Greiner, Murray, & Kallail, 2000). Two studies in the Rocky Mountain region found that physicians fall into one of three categories in their attitudes about CAM: those who actively integrate CAM into their practice, those who react to patient demands but don’t actively integrate it into practice, and those who dismiss CAM completely (Duncan, 2002; Hippert, 2000). Physicians who are younger, female, primary care providers, and/or have personal experience with CAM are more likely to hold positive attitudes about it (Ernst et al., 1995; Rooney et al., 2001; Rosenbaum et al., 2002; Sikand & Laken, 1998).
Nursing attitudes and beliefs regarding CAM are often documented more poorly than those held by physicians. In general, nurses and nurse practitioners in the United States and other countries have been open-minded about CAM (Damkier, Elverdam, Glasdam, Jensen, & Rose, 1998; DeKeyser, Bar Cohen, & Wagner, 2001; Fitch, Gray, Greenberg, Labrecque, & Douglas; 1999). They may use CAM (Damkier et al., 1998; Hayes & Alexander, 2000), although they don’t tend to refer or recommend CAM therapies to their clients (DeKeyser et al., 2001; Hayes & Alexander, 2000). Nurses feel that they have little knowledge and preparation in CAM therapies, and they want more information (Brolinson, Price, Ditmyer, & Reis, 2001; DeKeyser et al., 2001; Fitch et al., 1999; Hayes & Alexander, 2000). In comparison to physicians, nurses have more positive attitudes about CAM (Kreitzer, Mitten, Harris, & Shandeling, 2002; McPartland & Pruit, 1999), although they are cautious about CAM therapies and worry that patients could be taken advantage of unscrupulous practitioners (Fitch et al., 1999). Interestingly, Hayes and Alexander (2000) found that the attitudes of nurse practitioners often reflected the perceived attitudes of their collaborating physicians.
This study adds to this body of literature by focusing specifically on acute care nurses in the northern Rocky Mountain region. Previous studies of nurses have tended to address nurses in specialty areas, including oncology and advanced practice. In addition, a qualitative descriptive approach is appropriate to evaluate the beliefs and perceptions of nurses.
The current study was based on exploratory, descriptive qualitative research methodology. This type of research is suited ideally to investigation of attitudes held by specific social groups. It allows for exploration of phenomena before there is adequate information to quantify findings (Polit & Hungler, 1999).
Sample. The target population for this study was acute care nursing for a Rocky Mountain community. This sample was both a convenience and a purposive sample. It was made a acute care nurses who were willing to be interviewed and were therefore accessible and available, and nurses who were chosen purposely from a range of acute specialty areas because of their expertise (Polit & Hungler, 1999). Because all the nurses initially interviewed were from a rural area, three interviews with nurses in an urban area were conducted at the end of the study to determine if rural residence influenced nurses’ beliefs about CAM.
A total of 21 demographic surveys were sent to acute care nurses working in medical-surgical, pediatrics, women’s health and obstetrics, surgery, telemetry, and intensive care units in a Rocky Mountain community. A total of 18 demographic surveys was returned; of those who returned surveys, 2 were unable to participate in interviews. The remaining 16 respondents were included in this study. The selection of the urban nurses was accomplished by a contact, known to the first author, who asked nurses on her telemetry unit if they would be willing to participate. This sample was consistent with the concept of saturation described by Polit and Hungler (1999). As the interviews progressed, it was evident that there was a sense of closure and the participants were providing data that were very similar.
Participants ranged in age from 21 years to 64 years, with the majority falling between the ages of 41 and 60 years (see Table 1). Fourteen of the sixteen of the participants were women. The majority of the participants were married. Most of the participants had an associate degree as their basic education in nursing. However, at the time of the study, half of the participants had a bachelor’s degree and one had a master’s degree in nursing. Ten of the participants had been in their positions less than 10 years, while six had more than 10 years of experience. At the time of the study, all but three of the participants lived in a community of less than 25,000 people.
Approval was obtained from the University Institutional Review Board before the study started. Audiotaped semi-structured interviews were used to obtain perceptions of CAM therapies and their role in health care. The interviews lasted 30 to 60 minutes, and all interviews were conducted by the same person (primary author). Each participant was interviewed once. The rural interviews took place in person son in the setting that was most convenient for the person being interviewed. The three urban nurses were interviewed by telephone and email because of the geographic distances. Although the same questions were asked of all participants, using multiple interview methods could have influenced the responses. Information about nonverbal communication and further probes could be used more readily in the face-to-face interviews. Field notes that were made during the interviews further supported the interview information.
Trustworthiness. The trustworthiness of this study was established through the use of four criteria: credibility, dependability, confirmability, and transferability (Polit & Hungler, 1999). Spending time with each participant to develop trust and therefore improve the quality and depth of the information supported credibility. Observation of the interviewee was an important check of credibility. The data were dependable and confirmable through the use of interview tapes, transcriptions of the tapes, and field notes of the interviews. These tools made it possible to confirm exactly what the participants said. Data collection was accomplished through the use of semi-structured questions and interviews that allowed enough time for complete and detailed answers. The interview guide was refined by piloting questions with four nurses with experience in acute care, but who were not participating in the study. These nurses provided feedback on clarity, understandability, and flow of the interview. Minor revisions were made after this pilot.
Researchers reviewed the transcripts of the interviews both separately and together to analyze the material for internal themes. This immersion in the material and collaboration was necessary for synthesis of what was said and for accurate theme development. According to Polit and Hungler (1999), differing perspectives helped to minimize any idiosyncratic biases that may have been present. After the themes were developed, a member check with some of the participants was carried out on an informal basis. During these member checks, the primary researcher discussed impressions from the interview with the participants in order to verify what was said.
Data analysis. Data obtained from this study were analyzed using an editing analysis style (Polit & Hungler, 1999). The taped interviews were searched for themes that could he used to cluster information and create categories. The first step in analysis was organization of the data into categories, and through constant comparison, determination of their meanings. An open coding method was useful in organizing the interview data, using keys such as colored tabs to flag similar information in the interviews. The processes of comprehending, synthesizing, and theorizing were used to analyze the interviews. Early in the process of conducting this study, it was possible to see a general trend in the attitudes that the interviewees held regarding CAM. This understanding of the phenomenon being studied constituted the process of comprehending. During the synthesizing process the data were examined for elements that were typical and for differences in attitude. The expected outcomes of this study were examined for their fit with the data that were obtained during the interview process, and proven to be valid or invalid.
The major theme that emerged from the interviews was a lack of congruence among what acute care nurses say they believe and do, what they have experienced with CAM, and how they approach CAM use in the acute care setting (see Table 2). Several factors were related to this apparent lack of congruency, including the lack of a clear definition of CAM, lack of ongoing information about CAM and its use, and lack of professional relevance. Researchers also noted participants’ sense of passivity in regard to assessment of CAM use and recommendation of CAM for their patients, with powerlessness to change this (see Figure 1). Little difference existed between urban acute care nurses and rural acute care nurses in the attitudes held about CAM and its use in acute care practice.
[FIGURE 1 OMITTED]
Lack of congruence between beliefs/Experiences and professional practice. All participants used at least one type of CAM with lifestyle changes, relaxation techniques, diet therapy, and herbal therapy, the most common choices. Thirteen participants used lifestyle changes. Eleven participants used diet therapy and relaxation, while massage and herbal therapies were each used by ten participants. Debbie said that CAM was useful for her: “Yeah, definitely, especially the chiropractic. I get migraines, so especially the chiropractic.” Wendy used many therapies and said, “Yes, massage, aromatherapy, chelation therapy, yoga, herbal, and chiropractic also.” All of the participants felt that they had positive experiences with the chosen therapies and expected to continue to use CAM in their personal health care. Moreover, the majority of the participants perceived a definite place for CAM in acute care. Responses ranged from Wendy’s enthusiastic statement, “Yes, there is room in the acute care facility, which would provide a more holistic approach. Holistic approach!” to a simple belief that it would be beneficial. Rachel said, “Yes, I think it gives the patient another alternative. You know, I mean, I just think, I think it would be beneficial.”
However, the personal, positive perceptions were inconsistent with what the nurses said about their professional practice. Despite the overall feeling that CAM could be useful and beneficial in the acute setting, most of the participants admitted to not asking about their patients’ use of CAM or their preferences for therapies while in the hospital, and not actively recommending CAM therapies. Until recently, the nurses described very little use of alternatives by patients in these Rocky Mountain hospitals; the CAM therapies that were available at one of the hospitals studied (massage and therapeutic touch) were not often recommended. The reasons may have been as simple as a reluctance to offer therapies that require extra time, or the perception that clients weren’t interested. As Carol pointed out, “For example, if I ask an older person if I can use therapeutic touch, they may be skeptical about the benefit.” Employing a CAM nurse at one of the hospitals resulted in a greater effort to get massages for clients. As clients continued to request some of these alternatives, nurses began to show greater comfort with providing them. However, the position of the CAM nurse was controversial and was eliminated after 1 year. Without a job description for the position, it was difficult to evaluate the impact on patient care. The nurse who was employed to fill this role was a certified massage therapist and had extra training in therapeutic touch. In the acute medical and surgical areas, massage is still available but not consistently recommended or suggested.
Powerlessness. Despite the endorsement of CAM by these nurses, there was a sense of passivity and helplessness to effect change in the hospital setting. Powerlessness may be clarified by looking at two components: internal powerlessness and external powerlessness. The nurses had an internal powerlessness that was expressed as apathy about CAM use, which was perceived as meaningless in the acute setting. These two aspects of powerlessness were intensified by nurses’ lack of personal knowledge about CAM. The external facets of powerlessness had to do with the perception that nurses could not change policy on their units and there was no leadership for change. The lack of physician endorsement of CAM contributed to this sense of inability to change. Connie said, “I think that in my experience in working in this smaller hospital, that people are set in their ways and not real open to change.” In regard to admission assessment about CAM, Rachel remarked, “Well, where I work they have [computerized] templates and they give us no room for comments, and by the time you get done with the template and get everything done, you know it’s … you know gone [entered].” Alice stated, “I’m not sure if it would be any value for me to ask [about CAM], because the doctor isn’t necessarily going to do anything with that information.” She continued to say, “… in the hospital you are limited in what you can tell …” The nurses gave the impression of a sense of powerlessness to do anything differently. These two aspects of powerlessness were intensified by the personal lack of knowledge about CAM and the lack of a clear definition of CAM that came through in the majority of the interviews.
Lack of professional relevance. The participants in this study seemed to believe that CAM use in the acute setting was not particularly relevant to their practice. The majority of interviewees indicated that they did not have enough knowledge to make good choices when it came to CAM use for their clients. They also expressed a reluctance to discuss CAM with patients because what they said could be taken as a recommendation. Alice pointed out, “… you can’t go around telling people, ‘Oh, don’t listen to your doctor, take this instead.’ They’d be out hunting my head for sure.” Nurses perceived that this was not part of their job and actually might he disapproved by the physicians. The respondents indicated that they would be more willing to incorporate CAM into their work if there was clear leadership from physicians and administration. Rachel said, “I would hope that eventually the medical establishment will (see the role for CAM in acute care). I would hope they would see there is a place for it, you know. I’m not saying it should take the place of it (Western medicine). Because, alternative is not of value–if you break your arm you need it set … We don’t work enough with preventive medicine, I don’t think, and that to me is where alternative really comes in.”
The participants implied that the physicians and the administrators were the decision makers for their institutions, and nurses had little choice in terms of how things were done. They did not seem happy with this, but also expressed little inclination to change the status quo.
Lack of a clear definition of CAM. For many in the sample, the definition of CAM was ambiguous. Something that was CAM to one respondent was mainstream practice to another. Alice said, “Some people would put chiropractic in there, although I never, until later, considered that alternative, because I went to a chiropractor since I can remember. My family always went.” She continued, “Like I have said, nutrition is something I have done–I can’t ever remember when my mother wasn’t sprinkling wheat germ on every little thing I ate.” For some, CAM was “herbal therapies” and, for others, the definition was much broader to include dietary and lifestyle choices. As Carol put it, “… Any kind of treatment other than what is considered the norm or traditional, whether it be spiritual, herbal, acupuncture, anything out of the realm of traditional medicine.” Jenny remarked, “I think of those modalities that will enhance your health–not substitutes for allopathic or conventional health care–but they enhance your health in combination with conventional health care.” Bob said, “That could include just about anything–herbals, I already mentioned–relaxation therapy, massage, acupuncture.”
Lack of knowledge regarding CAM. Overall, the interviewed nurses indicated a need for more training and continuing education on CAM, and the place it should have in the acute care setting. They were in general agreement that there is a place for CAM use, but they thought that more guidelines would be useful. Carol reflected this need when she said, “I think we need to educate our nurses, and I think that’s happening. I see it more.” Alice said, “I’d like to see more nursing education workshops or seminars in the area to heighten the awareness (of CAM).” Interestingly, all of those interviewed said they would take advantage of continuing education on the subject of CAM, if it were available. Susan qualified that with “… if I have the time.” All of the respondents stated that their nursing care would be enhanced by more information on this subject.
The attitudes and beliefs that acute care nurses hold with regard to CAM are important to assess. The impact of nursing on health care is pivotal for patient well-being. To provide quality care, nurses must understand what CAM is, assess their patients’ use of CAM, and incorporate this information into their care. This study identified great interest in CAM on the part of nurses. However, the study also found a disturbing lack of congruence between their personal interest and their professional practice related to CAM in the acute setting. Little difference existed between urban and rural acute care nurses in the attitudes held about CAM and its use in acute care practice.
The major theme that emerged was a lack of congruence between what acute care nurses say they believe and how they approach CAM use in the acute care setting. The participants in this study saw a place for CAM in acute care and used it personally, but they did not actively assess for CAM use or use it in that setting. This lack of congruence is consistent with other studies on nurse attitudes about CAM.
Powerlessness, a sense of being unable to change the status quo, seemed to be in part responsible for the lack of congruence found in the nurses in this study. This is consistent with other studies of nurses. For example, Fitch et al. (1999) found that nurses believe patients have the right to information and nurses have an obligation to learn about the therapies being used by their patients in order to provide that information. However, this may place the nurse between the client and the physician, especially if the physician has a guarded approach to these types of therapies.
Attitudes held by the nurses in this study seemed to reflect the prevailing physician attitude regarding CAM, which is one of cautious acceptance but not recommendation. These findings are consistent with previous findings of physician attitudes in the Rocky Mountains (Duncan, 2002; Hippert, 2000). Duncan (2002) found that most of the physicians in her study were interested in CAM, but that client requests seemed to be the driving force behind that interest. Nurses’ attitudes in this study were similar; they responded to client requests for massage or implementation of birth plans, but they did not routinely suggest CAM use in acute care. Hayes and Alexander (2000) reported similar findings; nurse practitioner attitudes tended to reflect those of their collaborating physicians.
Eight of the women respondents in this study graduated from associate degree nursing programs, and four others graduated from diploma programs. Of this number, six have gone on to obtain further education in nursing or other related fields. Associate degree nurses compose the majority of nurses graduated and employed in the study area. Helliwell (1996) asserts that education may well be the most powerful predictor of social involvement and power. Therefore this educational background, coupled with the historical tradition of hierarchy in health care, may explain the passive nature of these respondents.
According to the American Academy of Nursing (Gaffney, 2002), the majority of practicing nurses believe that the time that they have for patient care has decreased. They attribute this to decreased staffing and more time spent on nondirect care activities (Gaffney, 2002; Pacific Healthcare Resources, 2001). Acute care nurses may be reluctant to incorporate CAM into their practice because of the heavy workloads that they are experiencing. Nurses in acute care positions are busy, and it takes time to assess patient use of CAM and to include CAM therapies in their patient care routines. The time to use relaxation techniques, help clients to use guided imagery, or clean the Jacuzzi after a laboring client has used it are examples of some time-consuming activities.
This study found that the definition of CAM is often unclear. Eisenberg et al. (1993) agreed that CAM is difficult to define because it includes such a wide variety of different therapies. Nurses in this study had a range of definitions of CAM. There was agreement that herbal therapy, therapeutic touch, and acupuncture fit the definition. For some, however, diet, relaxation therapy, and lifestyle changes were not CAM. Similar to other studies of nursing (Brolinson et al., 2001; DeKeyser et al., 2001; Fitch et al., 1999), lack of knowledge was consistently cited by the nurses. The participants in this study were all in favor of continuing education programs that would increase their knowledge of CAM therapies.
Implications for Further Research
The lack of congruence between attitudes and practice may warrant further study. Obtaining more information from nurses in a variety of settings and examining the contributing findings more closely would allow for better understanding of the reasons for that lack of congruence. With a greater understanding, nurses can take steps to better meet their patients’ health care needs. The need for further research into the efficacy and safety of CAM therapies is ongoing. Because they are committed to providing safe health care to their patients, nurses may be reluctant to try therapies that they believe have little scientific basis. They may believe that allopathic medicine is based on scientific evidence and CAM is not. Research into the types of CAM that may be most useful in acute care would be of value because some of the therapies labeled as CAM do not have practical application in the workplace.
Implications for Nursing Education
An apparent need exists for extensive education about CAM therapies for nurses in the acute care setting, greater research into the efficacy of CAM therapies, recognition of the negative impact that heavy patient care loads have on nursing care, and the creation of health care teams where all opinions are valued. More extensive teaching of CAM in nursing schools would help to familiarize nurses with this practice. When nurses have a greater understanding of the value of CAM and how it can be incorporated effectively into acute care, they will be more able to assess patient use and to assist patients in making appropriate choices. Nurses should be educated in ways that promote self-confidence and the ability to act as advocates for their clients, including information regarding use of CAM. With a broad knowledge of the impact of conventional treatment on and the potential for CAM use in acute care, nurses will gain confidence in their ability to make suggestions for patient care. Bob said, “I don’t really talk to patients much about it because I don’t know much about it … but I think knowledge is power …” With a greater understanding of the importance of all members of the health care team, nurses may be able to effect change that is in their patients’ best interests.
Demographic Characteristics of Participants
Demographic Characteristic Number
20-30 years 2
31-40 years 2
41-50 years 7
51-60 years 4
Over 60 1
Basic Nursing Education
Associate Degree 9
Length of Service in
Less than 10 years 10
More than 10 years 6
* Lack of congruence between beliefs/experiences and
* Lack of professional relevance
* Lack of a clear definition of CAM
* Lack of knowledge regarding CAM
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Judith E. McDowell, MS, RN, is a Nursing Faculty Member, Sheridan College, Sheridan, WY.
Mary E. Burman, PhD, RN, FNP, is a Professor, School of Nursing, University of Wyoming, Laramie, WY.
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