Nurses' Perceptions of Complementary and Alternative ... - Springer Link

Journal of Community Health, Vol. 26, No. 3, 2001

NURSES’ PERCEPTIONS OF COMPLEMENTARY AND ALTERNATIVE MEDICAL THERAPIES Per Gunnar Brolinson, DO; James H. Price, PhD, MPH; Marcia Ditmyer, MS; Deb Reis, RN, MSN, CS

ABSTRACT: The purpose of this study was to identify the perceptions of nurses toward the effectiveness and safety, as well as their recommendations for and personal use of complementary and alternative medical therapies. A random sample of 1000 nurses throughout the United States were surveyed using a three-wave mailing. About half of the respondents perceived there was conclusive evidence or preponderance of evidence that five therapies were effective: biofeedback, chiropractic, meditation/relaxation, multi-vitamins, and massage therapy. The same amount of nurses also perceived five therapies as definitely safe: hypnotherapy, chiropractic, acupressure, acupuncture, and healing touch. However, the nurses were most likely to recommend (regularly or periodically) four therapies: multivitamins, massage, meditation/relaxation, and pastoral/spiritual counseling. The vast majority (79%) of nurses perceived their professional preparation in this area to be fair or poor. KEY WORDS: complimentary/alternative medicine; nurses.

INTRODUCTION Complementary and alternative medical therapies are terms often used synonymously. Technically, alternative medical therapies imply the use of treatments in place of mainstream medicine.1 Whereas, complementary medical therapies imply the use of treatments that are used along with more conventional medical approaches. Both of these groups represent a large range of therapies outside the arena of conventional Western medicine. Because a universally agreed upon classification of the various therapies as either alternative or complementary medicine does not exist, both terms will be used in this article to describe this collection of medical therapies.

Per Gunnar Brolinson, DO is Medical Director at Sports Care & Welltrack, Toledo Hospital, Toledo, OH; James H. Price, PhD, MPH is Professor of Public Health in the Department of Public Health and Rehabilitative Services, University of Toledo, Toledo, OH; Marcia Ditmyer, MS is a Graduate Assistant in the Department of Public Health and Rehabilitative Services, University of Toledo, Toledo, OH; Deb Reis, RN, MSN, CS is a nurse at Toledo Hospital, Toledo, OH. Requests for reprints should be addressed to: Dr. Per Gunnar Brolinson, Medical Director, Welltrack, Toledo Hospital, Toledo, OH 43606.

175 0094-5145/01/0600-0175$19.50/0  2001 Human Sciences Press, Inc.

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In 1997, 42 percent of the American adult population made 629 million visits to alternative health care practitioners and spent $27 billion out-of-pocket for these services.2 It has been estimated that in the year 2000, Americans will spend $60 billion on complementary and alternative medical therapies.1 This represents over a 47 percent increase since 1990 in total visits to alternative medical practitioners.3 This increasing demand for and purchase of alternative and complementary medical therapies by health care consumers has been fueled, in part, by support from some in conventional medicine. For example, a 1994 survey of physicians found that more than 60 percent of the physicians surveyed recommended alternative therapies to their patients and 23 percent reported incorporating these therapies into their own practices.4 Contrary to common opinion in the health care arena, the majority of alternative medicine users do so not because they are dissatisfied with conventional medicine but mainly because these therapies fit their own values and philosophies regarding health and life.5 Patients choose alternative and complementary medical therapies based on their abilities to judge the credibility of information presented by the mass media. The public seldom conducts literature searches of medical journals. The mass media, family, and friends provide patients with lay information from television talk shows, local newspapers, magazines, television, and by word of mouth testimonials regarding these therapies.6 Often patients are desperate to improve their health and/or quality of life, accuracy of clinical information often takes a backseat to the quest for improved health. As the public increases its use of alternative and complementary medical therapies, it becomes necessary for accurate sources of information on these topics to be readily available to the public. One of the largest groups of health professionals that are in regular contact with the public are nurses, and it seems logical to have nurses take a significant role in assisting patients in making informed decisions regarding alternative and complementary medical therapies. To do so, nurses will need to become well informed regarding the efficacy and safety of alternative and complementary medical therapies. As the evidence increases, so should the awareness and recommended use among traditional health care providers, including nurses. A comprehensive review of the nursing literature found few articles specifically exploring nurses’ knowledge, attitudes, and use of alternative and complementary medical therapies.7,8,9 All of the studies consisted of small local samples (less than 100 nurses), and surveyed specialty areas such as oncology7,8 or certified nurse-midwives.9 Thus, the purpose of this

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study was to investigate the perceptions of a national random sample of nurses regarding the efficacy and safety of alternative and complementary therapies. Additionally, this study was designed to determine the recommended use and personal use of alternative and complementary medical therapies among nurses today.

METHODS The research design used for this study was a cross-sectional mail survey that measured the results of a written questionnaire designed to ascertain the familiarity, perceptions and knowledge of nurses in the United States regarding alternative and complementary medicine. Instrument A four-page questionnaire was developed consisting of 100 items that covered 22 different alternative and complementary therapies. The first section pertained to the perceived effectiveness of each of the 22 therapies. The respondents were asked to select from one of five choices; (a) unfamiliar with, (b) no evidence of effectiveness, (c) growing evidence supports effectiveness, (d) preponderance of evidence supports effectiveness, and (e) conclusive evidence of effectiveness. The next section focused on the perceived safety of each of these therapies. The respondents were asked to select their responses from; (a) safety not established, (b) not safe, (c) probably safe, (d) definitely safe, and (e) do not know. Section three pertained to the recommendations made to clients, friends, and associates, followed by their own personal use of these therapies. The potential response choices for recommendations were; (a) never recommend, (b) recommend occasionally, (c) recommend periodically, and (d) recommend regularly. The respondents were then asked to indicate whether they personally use these therapies (yes or no). The remaining 12 items assessed respondents’ demographic and background information. A comprehensive review of the literature was performed to establish face validity of the questionnaire. The questionnaire was subsequently sent to two nurses and two survey researchers in the field of alternative and complementary health care to assess content validity. Minor changes in wording were incorporated into the questionnaire prior to conducting the stability-reliability assessments. Test-retest was used to establish the stability-reliability of the instrument. A convenience sample of 25 nurses was

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selected for this assessment. There was a period of two weeks between the two administrations. The result of the test-retest (Pearson’s Correlation Coefficient) was a coefficient of .66. Subsequently, Cronbach’s alpha was used with the final sample to establish the internal reliability of the instrument. This produced a coefficient of .73. Subjects A random sample of 1000 nurses was obtained from the American Nurses Association (ANA) through the CMG Direct List Management Corporation. The database was comprised of nurses from various professional disciplines, including care of the aged, clinical nurse specialists, medical/surgical nursing, nurse practitioners, pediatric and obstetrics nursing, psychiatric nursing, and general nursing. The Human Subjects Committee of the university, as well as the hospital institutional review board with which the authors are associated approved the research project. Procedure A 3-wave mailing was used to assure maximum response rate. The 4-page survey instrument, printed on colored paper, was sent with postage paid self-addressed return envelopes. A hand-signed, personalized cover letter assured respondents that their responses would remain confidential. The surveys were sent first-class mail rather than bulk-rate mail, with a one dollar incentive. Approximately two weeks later, non-respondents from the first wave mailing were identified and sent a second survey instrument with another hand signed cover letter, encouraging them to respond. The third mailing took place two weeks later. A hand-signed color-matched postcard was mailed indicating the importance of their prompt reply. The procedures used in this study are techniques proven to maximize response rates.10 Analysis A series of multivariate analyses of variance (MANOVAs) was run to determine if there were significant differences across perceived effectiveness, safety, and recommended use of complementary and alternative medical therapies. These were compared with various age groups, years of practice, perceived preparation regarding their knowledge of, and belief

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of whether complementary medical therapies are only powerful placebos. Subsequently, univariate post hoc analysis of variance (ANOVA) tests were conducted in those areas that produced significant results in the multivariate analyses.

RESULTS Demographics/Background One hundred three of the potential 1000 respondents were eliminated from the sample because of retirements, incorrect addresses, or deceased. Of the remaining 897 who received the surveys, 515 (57%) respondents returned the questionnaires used in the analysis. As expected, the vast majority of respondents were female (91%), Caucasian (86%), and worked in a clinical/hospital setting (72%) (Table1). Two-thirds (67%) of the respondents were 30–49 years of age, had bachelor or master levels of education (64%), and were RNs or nurse practitioners (67%). Sources of Information The respondents were asked how well prepared they perceived themselves to be in dealing with alternative and complementary medicine. Nearly half of the nurse respondents perceived their professional preparation in this area to be fair (43%) while 36 percent felt that their professional preparation was poor. When asked to identify from a list of seven sources where they received the majority of their information on alternative and complementary therapies, they indicated that their peers (64%), the general mass media (52%), and professional journals (44%) were their leading sources. They were less likely to obtain their information from professional conferences/conventions (38%), coursework (26%), in-service education programs (25%), and the Internet (19%). Perceptions of Effectiveness of Alternative and Complementary Therapies Of the 22 alternative and complementary therapies listed on the questionnaire, only five of the items were perceived by about half of the nurses as having conclusive evidence or the preponderance of evidence

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that they were effective: biofeedback (51%), chiropractic (51%), meditation/relaxation (51%), multi-vitamins (49%), and massage therapy (48%) (Table 2). Whereas, there were four items with which the majority of nurses were unfamiliar: chelation therapy (60%), macrobiotic diets (54%), ergogenic aids (53%), and Rolfing (52%). A series of four MANOVAs were conducted for education level (4 years or less vs. 5 years or more) (F = 96.8, df = 34, p ≤ .05); whether nurses perceived alternative and complementary medical therapies to be powerful placebos (F = 62.2, df = 34, p ≤ .05); years of nursing experience (