Complementary and alternative medicine (CAM) among Australian hospital-based nurses: knowledge, attitude, personal and professional use, reasons for use, CAM referrals, and socio-demographic predictors of CAM users

Complementary Therapies in Clinical Practice 27 (2017) 37e45

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Complementary and alternative medicine (CAM) among Australian hospital-based nurses: knowledge, attitude, personal and professional use, reasons for use, CAM referrals, and socio-demographic predictors of CAM users Seyed Afshin Shorofi a, c, *, Paul Arbon b a

Traditional and Complementary Medicine Research Centre, Mazandaran University of Medical Sciences, Sari, Iran Flinders University, Adelaide, Australia c Adjunct Research Fellow, Flinders University, Adelaide, Australia b

a r t i c l e i n f o

a b s t r a c t

Article history: Received 19 October 2016 Received in revised form 19 March 2017 Accepted 23 March 2017

Objective: This study was intended to examine CAM among Australian hospital-based nurses, identifying their knowledge, attitude, personal and professional use, reasons for use, CAM referrals, and sociodemographic predictors of CAM users. Methods and materials: Nurses holding a qualification in nursing and working in surgical wards were included using a convenience sampling technique. A self-complete questionnaire was developed to achieve the aims of the study. Descriptive and non-parametric statistics were calculated to describe and analyse data. Results: Overall, 95.7% and 49.7% of nurses reported personal and professional use of CAM, respectively. The most popular CAM/CAM domain personally and professionally used by nurses was massage therapy and mind-body therapies. The primary reason for personal use of CAM was “[it] fits into my way of life/ philosophy”. Furthermore, massage therapists were the most commonly recommended CAM practitioners to patients. Only 15.8% of nurses would always ask patients about use of herbal medicines as part of nursing history taking. Over one-fifth (22.4%) of nurses rated their attitude as having a very positive, and 60.3% rated themselves as having very little or no knowledge of CAM. A positive correlation was also found between knowledge and attitude about CAM. Positive attitude and higher knowledge about CAM were positively correlated to CAM referrals. Several socio-demographic factors predicted personal and professional use of CAM. Conclusion: This study revealed that nurses generally believe not to have sufficient knowledge of CAM but are open to use CAM with patients. Nurses' positive attitude toward and personal use of CAM could be an indication that they are poised for further integration of evidence-based CAM into nursing practice to treat whole person. © 2017 Elsevier Ltd. All rights reserved.

Keywords: Attitude CAM referral CAM therapies Knowledge Nurse Socio-demographic predictors

1. Introduction A broad collection of self-care and practitioner-based practices [1], complementary and alternative medicine (CAM) has been a mainstream health care to meet the primary health care needs of people for centuries. CAM has gained popularity in Western

* Corresponding author. Traditional and Complementary Medicine Research Centre, Mazandaran University of Medical Sciences, Sari, Iran. E-mail address: ashorofi@yahoo.com (S.A. Shorofi). http://dx.doi.org/10.1016/j.ctcp.2017.03.001 1744-3881/© 2017 Elsevier Ltd. All rights reserved.

countries over the recent decades inasmuch as it has been partly integrated into conventional health care system. CAM is most often used in conjunction with conventional medical treatments [2,3], which is termed ‘integrative medicine’, emphasizing the biopsycho-socio-spiritual dimensions of individuals [4]. The National Center for Complementary and Integrative Health (NCCIH, formerly known as the NCCAM) at the National Institutes of Health (NIH) defines CAM as “a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicinedthat is, medicine as practiced by holders of M.D. (medical doctor) degrees and their

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allied health professionals, such as physical therapists, psychologists, and registered nurses.” [5]. Although CAM classification differs by country, the NCCIH has classified it into five main categories: alternative medical systems, mind-body therapies, natural products, manipulative and body-based methods and energy therapies [6] (see Table 1). Rational use of CAM has shown a decline in drug consumption [7] and medical expenditure [8], which in turn has the potential for significant cost savings [9e11]. Easily accessible and affordable, use of CAM can help reduce the unwanted effects of chemical drugs [12], which is evidently a common reason to turn to CAM [13]. A desire for more natural and personalized treatments and increased access to health information has additionally gained interest in CAM use [14,15]. The best explanation for this interest is ascribed to the emergence of postmodern values, “a new set of beliefs about nature, science, holistic medicine, rejection of authority, individual responsibility and consumerism” (p.19) [16]. The self-reported reasons to use CAM vary in literature and include improving immune system [17e19], relieving from symptoms [17], reducing side effects [19,20], not missing an opportunity [19], having better efficacy, lower cost of CAM, poor results from conventional western medicine [20], having belief in advantages of CAM, being dissatisfied with conventional therapy, being part of family tradition/culture, having emotional support [21], and having general well-being and pain control [22]. A large number of studies have also explored potential predictors of CAM use in patients with medical conditions, including age [17,23,24], gender [17,23,25], ethnicity [20], employment status [20,26], education [17,18,23,27], marital status [23], place of residence [23], income [23,25,27], prior use of CAM [17,18], psychological support, interest in CAM [18], smoking status, medical noncompliance [25], metastatic cancer, less trust in physicians [27], and knowledge about the effectiveness of CAM [24]. Given the growing popularity of CAM among health care professions [28], and increasing number of nurses and physicians desiring further education or specialty education in CAM [29e31], it has become more important to tease out what health care providers actually do in the context of CAM. The nature of what is thought and practiced under the umbrella of CAM varies among health care professionals. Being in the forefront of health care services and the largest group of health professionals, nurses are in a unique position to “influence this paradigm shift in medicine to provide holistic care” (p.125) [32]. They are in an ideal place to integrate allopathic medicine and CAM [33] and also communicate with patients and educate them about CAM approaches. A growing body of literature reports that nurses have a high level of interest in CAM [34e37]. However, very few studies have comprehensively explored nurses' personal and professional use of CAM. Moreover, the lack of agreement on CAM definitions [38,39] and differences in

cultural backgrounds [40], study designs and methodologies [40e42], tools for data collection [42,43], sampling [43], and the timeframe of reported use of CAM [43] make it pointless to compare the data in different studies. This study was therefore intended to examine CAM among Australian hospital-based nurses, identifying their knowledge, attitude, personal and professional use, reasons for use, CAM referrals, and the socio-demographic predictors of CAM users. 2. Study design 2.1. Sample and sampling method Nurses holding a qualification in nursing (such as Registered nurses, Enrolled nurses, and Clinical nurses) and working in surgical wards were recruited using a convenience sampling technique. Four hundred and sixty nurses were sampled from surgical wards at five metropolitan hospitals in Adelaide. Due to dissimilarities between nursing students and nursing staff, both in terms of their tasks and experience, nursing students and nurses working in non-surgical wards were excluded from the study. 2.2. Instrument A self-complete questionnaire, based on a literature review, was created to achieve the aims of the study. The questionnaire encompassed a number of questions divided into two sections. The first section explored nurses' personal and professional use of CAM, personal usage patterns and reasons for personal use, CAM therapists recommended to patients, nurses' knowledge and attitude toward CAM, and taking nursing history about CAM. The second section was intended to elicit information about sociodemographic variables. The twenty-five CAMs chosen for this study were based on a standard classification derived from five groups adopted by the NCCIH (see Table 1). CAMs surveyed in this study included those less commonly surveyed, along with the commonly researched, and were therapies that appeared to be highly popular in Australia. The preliminary list of therapies was developed by a consensus of international researchers in the field of CAM, informed by a literature review, and then forwarded to the panel of international experts to be approved. The questionnaire comprised both open- and closed-ended questions that required either a short answer or a tick. Respondents could fill in other CAMs, if they were not listed. 2.3. Validity and reliability of the instrument The face and content validity of the questionnaire was established by both a comprehensive review of the literature and

Table 1 CAMs included in the study.a Alternative medical systems

Mind-body therapies

Natural products

Manipulative and body-based methods

Energy therapies

Aromatherapy Acupuncture Naturopathy Homeopathy

Meditation Relaxation techniques Imagery techniques Art therapy Biofeedback Hypnotherapy Music therapy Prayer/Spiritual healing Yoga Dance Tai chi

Herbal/Botanical therapies Non-herbal supplements

Massage Osteopathy Acupressure Chiropractic

Therapeutic touch Qi gong Magnets Reiki

a

Categories based on NCCIH classification system.

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39

consultation with a panel of international experts. The panel of experts assessed the questionnaire's validity, language clarity, the ease of use, its relevance to nurses, and the appropriateness of therapies listed for the purposes of the study, and reported a high degree of agreement about these items. To check the questionnaire's reliability, internal consistency was determined using Cronbach's alpha coefficient, and was 0.929. Cronbach's alpha coefficients above 0.90 are considered an excellent level of internal consistency.

questionnaires in which CAM use was disclosed were included in the final data set. Table 2 details the socio-demographic characteristics of the respondents. Nurses were mostly female (90.1%), 31e39 years (28.5%), married (54.2%), and Christian (59.2%). Most had Bachelor degree (54.5%) with less than 1e4 years of clinical experience (27.1%). The majority of nurses was influenced by Australian culture (77.8%) and was living in metropolitan regions (94.2%) with gross annual household income
$60.000 (38.1%).

2.4. Pilot study

3.2. Personal use of CAM

The questionnaire was pilot-tested for content, language clarity, ease of use, relevance to nurses, and the amount of time needed to fill in the questionnaire. The pilot study was conducted with 12 nurses, and data emerging from the pilot test were excluded from the final sample. The questionnaire was finally revised as per the results of the pilot study and the feedback from the CAM experts.

Overall, 95.7% (n ¼ 308) of nurses indicated that they personally used CAM. The most often used CAMs were massage therapy (72%), non-herbal supplements (70.2%) and meditation/relaxation techniques/imagery techniques (57.5%). Of the respondents, only 9 (2.8%) nurses used biofeedback for their own (see Table 3). A high proportion of nurses reported using at least a CAM product from mind-body therapies (80.7%, n ¼ 260), and slightly lower percentage of nurses used manipulative and body-based practices (78.6%, n ¼ 253) and natural products (78.3%, n ¼ 252). Alternative medical systems (60.2%, n ¼ 194) and energy therapies (17.7%,

2.5. Ethical considerations Institutional Review Board approval was gained from the recruiting hospitals. Eligible nurses were assured verbally and via information sheets of the anonymity and confidentiality of the information provided. They were also notified that all completed questionnaires would be retained in a locked cupboard and participants' data would be preserved in a computer hard drive that is accessible to the researchers only. All participants were free to withdraw from the study at any time. There was no need for written consents from the respondents as their completion of the questionnaires served as consent to participate in the study. 2.6. Data collection Data were collected at five hospitals in Adelaide, South Australia. All relevant hospital wards involved in the survey were provided with a display box containing survey packages, each encompassed a questionnaire, an information sheet, and a postage-paid return envelope. Flyers with study information and contact details were pinned on the noticeboards of surgical wards inviting nurses to complete the questionnaires. With the permission of Clinical Nurse Consultants, nurses were encouraged to participate in the project by way of their names being written on the envelopes. However, information provided by nurses was kept confidential since they could put their completed questionnaires in unmarked envelopes provided for this. At both 7 and 14 days after the distribution of the survey packages nurses received reminders. All survey packages were collected from surgical wards 20 days after the second reminder. 2.7. Data analysis All data were coded and analyzed using the Statistical Package for Social Science (SPSS) software program (v.12). Descriptive and non-parametric statistics were calculated to describe and analyse data. Those with data missing were excluded from the analysis as were any responses with two answers when only one was required. All comparisons were two-tailed and P < 0.05 was accepted as the level of statistical significance. 3. Results 3.1. Sample Of the 460 questionnaires distributed, 322 completed surveys were received, indicating a response rate of 70%. Only those

Table 2 Socio-demographic characteristics of nurses. Item Gender Female Male Age 20e30 31e39 40e48 49e65 Marital status Never married Married Divorced or separated Widow/widower De facto relationship Cultural origina Australian Non-Australian Mixed cultureb Place of residence Metropolitan areas Rural areas Religion Christian Other religions No religious affiliations Education Diploma/certificate Graduate diploma/certificate Bachelor degree Honours Masters degree Years of practice Less than 1 to 4 5e11 12e20 21e43 Gross annual household income Under $10,000 $10/000e$19,999 $20/000e$29,999 $30,000e$39,999 $40,000e$49,999 $50,000e$59,999 $60,000 or more a b

Unclear words and unknown cultures excluded. Influenced by more than one culture.

N (%) 282(90.1) 31(9.9) 76(25.5) 85(28.5) 82(27.5) 55(18.5) 86(28.1) 166(54.2) 28(9.2) 1(0.3) 25(8.2) 228(77.8) 44(15) 21(7.2) 294(94.2) 18(5.8) 181(59.2) 23(7.6) 102(33.3) 96(31) 30(9.7) 169(54.5) 8(2.6) 7(2.3) 82(27.1) 69(22.8) 77(25.4) 75(24.8) 1(0.4) 2(0.7) 13(4.8) 29(10.7) 61(22.6) 61(22.6) 103(38.1)

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Table 3 Rank order of nurses' reported use of CAMs. CAM type

Overall use [n (%)]

Never use [n (%)]

Massage therapy Non-herbal supplements Meditation/relaxation techniques/imagery techniques Herbal/botanical therapies Music therapy Aromatherapy Self-prayer/spiritual healing chiropractic Yoga/tai chi/dance therapy Pressure point therapy Naturopathy Qi gong/reiki/therapeutic touch/magnets Acupuncture Art therapy Homeopathy Hypnotherapy Osteopathy Biofeedback

232(72) 226(70.2) 185(57.5) 176(54.7) 175(54.3) 173(53.7) 133(41.3) 124(38.5) 100(31.1) 77(23.9) 65(20.2) 57(17.7) 51(15.8) 47(14.6) 42(13) 27(8.4) 14(4.3) 9(2.8)

87(27) 96(29.8) 136(42.2) 143(44.4) 143(44.4) 146(45.3) 185(57.5) 195(60.6) 218(67.7) 244(75.8) 256(79.5) 264(82) 269(83.5) 274(85.1) 276(85.7) 292(90.7) 307(95.3) 308(95.7)

* Percentages do not total 100 because not all respondents answered every question. Table 4 Nurses' own usage patterns of CAM. CAM type

Herbal/botanical therapies Meditation/relaxation techniques/imagery techniques Massage therapy Qi gong/reiki/therapeutic touch/magnets Aromatherapy Self-prayer/spiritual healing Hypnotherapy Art therapy Osteopathy Acupuncture Pressure point therapy Naturopathy Homeopathy Chiropractic Music therapy Yoga/tai chi/dance therapy Biofeedback Non-herbal supplements

Usage pattern [n (%)] Daily

Weekly

Monthly

Only when needed

67(20.8) 29(9) 7(2.2) 8(2.5) 27(8.4) 45(14) e 3(0.9) e e 2(0.6) 7(2.2) 3(0.9) e 86(26.7) 8(2.5) 4(1.2) 146(45.3)

15(4.7) 40(12.4) 29(9) 8(2.5) 47(14.6) 33(10.2) 1(0.3) 6(1.9) 3(0.9) 3(0.9) 11(3.4) 3(0.9) 5(1.6) 11(3.4) 39(12.1) 42(13) 1(0.3) 13(4)

11(3.4) 21(6.5) 59(18.3) 4(1.2) 35(10.9) 9(2.8) 2(0.6) 17(5.3) 3(0.9) 3(0.9) 8(2.5) 6(1.9) 4(1.2) 32(9.9) 14(4.3) 18(5.6) e 9(2.8)

83(25.8) 95(29.5) 137(42.5) 37(11.5) 64(19.9) 46(14.3) 24(7.5) 21(6.5) 8(2.5) 45(14) 56(17.4) 49(15.2) 30(9.3) 81(25.2) 36(11.2) 32(9.9) 4(1.2) 58(18)

* Percentages do not total 100 because not all respondents answered every question and that some respondents selected “never use”.

n ¼ 57) were the least popular CAM domains among nurses for personal use.

3.3. Personal usage patterns of CAM The nurses' personal usage patterns of CAM are summarized in Table 4. ‘Only when needed’ was found to be the most frequent usage pattern for all given CAM approaches, with the exception of music therapy (daily), yoga/tai chi/dance therapy (weekly), and non-herbal supplements (daily).

3.5. Professional use of CAM Of the 322 nurses, only 160 (49.7%) acknowledged using CAM for their patients. The most widely used forms of CAM in practice were massage therapy (23%, n ¼ 74), music therapy (19.6%, n ¼ 63), and non-herbal supplements (17.4%, n ¼ 56). None of the respondents reported using homeopathy professionally (see Table 5). Furthermore, an estimated 31.4% (n ¼ 101) had used mind-body therapies with patients. Other CAM domains used professionally by nurses were manipulative and body-based methods (23.6%, n ¼ 76), natural products (17.7%, n ¼ 57), alternative medical systems (9.9%, n ¼ 32), and energy therapies (3.4%, n ¼ 11).

3.4. Reasons for choosing CAM 3.6. CAM therapists recommended to patients Of all the 308 nurse CAM users, 37.7% (n ¼ 116) stated that they have chosen CAM because “[it] fits into my way of life/philosophy”, followed by “[it offers] potential improvement in my condition” (37%, n ¼ 114) and “[its] proven benefit in my condition” (29.9%, n ¼ 92). Fig. 1 displays the rank order of nurses' reasons for personal use of CAM.

Nearly half of the nurses (48.4%, n ¼ 156) recommended massage therapists to patients, followed by herbalists/naturopaths (25.8%, n ¼ 83), chiropractors (25.8%, n ¼ 83) and acupuncturists (18.3%, n ¼ 59). Seven nurses indicated a further 6 CAM therapists in addition to those included in the questionnaire (see Table 6).

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Fits into my way of life/philosophy

37.7

Potential improvement in my condition

37

Proven benefit in my condition

29.9

Recommended by family/friends

24

Problem not serious enough to see a doctor

21.4

Self-control over my illness

18.5

Works better or as good as conventional treatments

17.5

Fewer side effects than conventional treatments

16.9

To support effects of prescribed medications

10.4

Easier to access than conventional treatments

9.7

Recommended by a CAM practitioner/doctor

7.8

Dissatisfaction with conventional treatments

6.8

Cheaper than conventional treatments

3.6 0

5

10

15

20

25

30

35

40

Percent Fig. 1. Rank order of nurses' reasons for personal use of CAM (percentage does not total 100 because respondents could select multiple choices).

Table 5 Rank order of nurses' use of CAM in practice. CAM type

n (%)

Massage therapy Music therapy Non-herbal supplements Meditation/relaxation techniques/imagery techniques Aromatherapy Prayer/spiritual healing Art therapy Herbal/botanical therapies Qi gong/reiki/therapeutic touch/magnets Pressure point therapy Chiropractic Yoga/tai chi/dance therapy Hypnotherapy Biofeedback Osteopathy Acupuncture Naturopathy Homeopathy

74 (23) 63 (19.6) 56 (17.4) 32 (9.9) 32 (9.9) 26 (8.1) 16 (5) 11 (3.4) 11 (3.4) 9 (2.8) 3 (0.9) 2 (0.6) 2 (0.6) 2 (0.6) 1 (0.3) 1 (0.3) 1 (0.3) e

3.7. Taking nursing history about CAM Only 15.8% (n ¼ 51) of nurses would always ask surgical patients about herbal medicine use as part of nursing history taking, while 10.9% (n ¼ 35) would often and 17.7% (n ¼ 57) of nurses would sometimes take nursing history about herbal medicine use. Nearly a quarter of nurses (24.5%, n ¼ 79) would rarely ask their clients about herbal medicine use, and less than one third of nurses (29.5%, n ¼ 95) would never question patients about herbal medicine use. Fewer nurses reported taking nursing history about other forms of CAM than herbal medicines. Only 5.3% of nurses (n ¼ 17) always, 3.4% (n ¼ 11) often, and 15.5% (n ¼ 50) sometimes would take nursing history about CAM (except herbal medicines), and most

Table 6 CAM therapists recommended to patients by nurses. CAM practitioners

Number (%) of recommending nurses

Massage therapists Herbalist/Naturopath Chiropractor Acupuncturist Hypnotherapist Osteopath Homeopath Energy healer Faith healer Aromatherapista Meditation/relaxation therapista Reflexologista Kinesiologista Bowen therapista Body talk therapista

156(48.4) 83(25.8) 83(25.8) 59(18.3) 33(10.2) 24(7.5) 23(7.1) 14(4.3) 13(4) 2(0.6) 2(0.6) 1(0.3) 1(0.3) 1(0.3) 1(0.3)

a

Not included in the questionnaire.

nurses would rarely (28.9%, n ¼ 93) or never (46.6%, n ¼ 150) take nursing history about CAM (except herbal medicines). 3.8. Socio-demographic variables associated with self-use of CAM domains The Chi-square analysis was undertaken to examine the influence of nurses' socio-demographic variables on self-use of CAM domains. To find the relationship between socio-demographic factors and other variables, widow/widower was excluded from nurses' marital status (one nurse), and also new category of annual household income was used to improve the validity of data as following: under $40,000 (16.7%), $40,000-$49,999 (22.6%),

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$50,000-$59,999 (22.6%), and $60,000 or more (38.1%). Female nurses (54.7%, n ¼ 176) were more inclined than male nurses (4%,n ¼ 13) to personally use alternative medical systems [c2 (1) ¼ 4.90, p ¼ 0.027]. Nurses aged 31e39 (23.3%,n ¼ 75) were more likely than nurses aged 20e30 (18%, n ¼ 58), 40e48 (18%, n ¼ 58), and 49e65 (13.3%,n ¼ 43)] to use manipulative and bodybased practices [c2 (3) ¼ 7.93,p ¼ 0.047]. Christian nurses (46.6%,n ¼ 150) were more likely than nurses with no religious affiliation (22%,n ¼ 71), and other religions (5.6%,n ¼ 18) to use CAMs classified as natural products [c2 (2) ¼ 6.71,p ¼ 0.035]. Moreover, after excluding one widow/widower from the analysis, married nurses (42.1%,n ¼ 135) were more likely than never married nurses (22.4%, n ¼ 72), divorced/separated (7.2%, n ¼ 23), and those having de facto relationships (4.4%,n ¼ 14) to use mind-body therapies [c2 (3) ¼ 10.01,p ¼ 0.019]. Use of mind-body therapies was significantly influenced by income so that nurses with higher annual household incomes ($60,000 or more; 23%, n ¼ 74) were more likely than those with annual household incomes under $40,000 (11.8%, n ¼ 38), $40,000-$49,999 (17.7%, n ¼ 57), and $50,000-$59,999 (15.2%, n ¼ 49) to use this CAM domain [c2 (3) ¼ 11.98, p ¼ 0.007]. Besides, Christian nurses (48.1%, n ¼ 155) were more likely than non-Christians (28.3%, n ¼ 91), after excluding other religions, to use mind-body therapies [c2 (1) ¼ 7.73, p ¼ 0.005].

more years of clinical practice [5e11 years (5.3%, n ¼ 17); 12e20 years (3.1%, n ¼ 10); 21e43 (0.9%, n ¼ 3)] to professionally use nonherbal supplements [c2 (3) ¼ 17.15, p ¼ 0.001]. Christian nurses (9.9%, n ¼ 32) were more inclined than nurses with no religious affiliation (9%, n ¼ 29) and other religions (2.8%, n ¼ 9) to use massage therapy in practice [c2 (2) ¼ 8.00,p ¼ 0.018]. Moreover, nurses aged 49e65 (5.9%, n ¼ 19) were more likely than nurses at the age of 20e30 (3.1%, n ¼ 10), 31e39 (5.3%, n ¼ 17), and 40e48 (3.4%, n ¼ 11) to apply music for patients [c2 (3) ¼ 11.98, p ¼ 0.007].

3.9. Socio-demographic variables associated with use of CAM/CAM domains in practice

The correlation between ‘attitude’ toward CAM and ‘knowledge’ of CAM was examined by Spearman's rho and a weak correlation was found between these two variables [r ¼ þ0.363]. This suggests that nurses' knowledge and attitude toward CAM are positively correlated.

The Chi-square test was used to analyze the influence of nurses' socio-demographic variables on the professional use of CAM/CAM domains. Nurses aged 20e30(14.6%, n ¼ 47) were more inclined than older nurses [31e39 (13%, n ¼ 42), 40e48(9.6%, n ¼ 31), 49e65 (9.6%, n ¼ 31)] to use CAM for patients [c2 (3) ¼ 9.99,p ¼ 0.019]. Nurses with the least years of clinical experience (less than 1e4 years; 16.1%, n ¼ 52) were more likely than other nurses [5e11 years (11.2%, n ¼ 36); 12e20 years (11.5%, n ¼ 37); 21e43 years (8.4%, n ¼ 27)] to use CAM for patients [c2 (3) ¼ 12.03, p ¼ 0.007]. Of the nurse respondents who used CAM in practice, those with annual household incomes
$60,000 (13.7%, n ¼ 44) were more likely than nurses with annual household incomes under $40,000 (8.4%,n ¼ 27), $40,000-$49,999 (12.4%, n ¼ 40), and $50,000$59,999 (8.7%, n ¼ 28) to use CAM for patients [c2 (3) ¼ 10.08, p ¼ 0.018]. Nurses aged 31e39 (8.4%,n ¼ 27) were more inclined than other nurses at the age of 20e30 (6.2%, n ¼ 20), 40e48(6.5%, n ¼ 21), and 49e65 (8.4%, n ¼ 27) to use mind-body therapies for patients [c2 (3) ¼ 10.07, p ¼ 0.018]. Younger nurses [20e30 years of age (6.5%,n ¼ 21)] were more likely than nurses aged 31e39 (4.3%, n ¼ 14), 40e48 (2.8%, n ¼ 9), and 49e65 (2.5%, n ¼ 8) to professionally use natural products [c2 (3) ¼ 8.23,p ¼ 0.041]. The Chisquare analysis indicated that nurses with the least years of clinical practice (less than 1e4 years; 6.8%, n ¼ 22) were more inclined than nurses with more years of clinical practice [5e11 years (5.3%, n ¼ 17); 12e20 years (3.1%, n ¼ 10); 21e43 (0.9%, n ¼ 3)] to use natural products in practice [c2 (3) ¼ 18.19, p ¼ 0.001]. In addition, the Chi-square analysis was calculated for the effect of nurses' religion on their professional use of CAM domains. Christian nurses (10.6%, n ¼ 34) were more inclined than nurses with no religious affiliation (9%,n ¼ 29) and other religions (2.8%, n ¼ 9) to employ manipulative and body-based practices professionally [c2 (2) ¼ 6.74, p ¼ 0.034]. Further significant relationships were found using the Chisquare test between nurses' socio-demographic variables and professional use of non-herbal supplements, massage therapy and music therapy. Nurses with the least years of clinical practice [less than 1e4 years (6.5%, n ¼ 21)] were more likely than nurses with

3.10. Attitudes toward and knowledge of CAM Over one-fifth of the nurses (22.4%, n ¼ 72) rated their attitude as having a very positive and 36.6% (n ¼ 118) as having a slightly positive attitude toward CAM. About one third of nurses (32.6%, n ¼ 105) were neutral, and 4.7% (n ¼ 15) of nurses had a slightly negative and 2.5% (n ¼ 8) had a very negative attitude toward CAM. When asked to rate their knowledge levels of CAM, 7.8% (n ¼ 25) of nurses rated themselves as having no knowledge and 52.5% (n ¼ 169) as very little knowledge of CAM. Only 3.4% (n ¼ 11) of nurses perceived themselves as knowing a lot about CAM and 34.8% (n ¼ 112) perceived their knowledge of CAM as some. 3.11. Association between knowledge and attitude toward CAM

3.12. Comparison of nurses referring/not referring patients to CAM therapists in terms of CAM knowledge The Mann-Whitney test demonstrated that referring/not referring patients to CAM therapists was significantly related to nurses' self-perceived knowledge of CAM. Nurses with higher knowledge of CAM were most likely to refer patients to CAM therapists. Table 7 compares nurses advising/not advising CAM therapists to patients in terms of self-perceived knowledge of CAM. 3.13. Comparison of nurses referring/not referring patients to CAM therapists in terms of attitude toward CAM The Mann-Whitney test revealed that referring/not referring patients to CAM therapists was also significantly related to nurses' attitude toward CAM. Nurses with positive attitude toward CAM were most likely to refer patients to CAM therapists. Table 8 compares nurses advising/not advising CAM therapists to patients in terms of attitude toward CAM. 4. Discussion This study is an attempt to further understand the current trend of CAM among hospital-based nurses in Australia. The present

Table 7 Comparison of nurses referring/not referring patients to CAM therapists in terms of CAM knowledge. Knowledge level [n (%)]

Not referring Referring

None

Very little

Some

A lot

Z

P value

18(5.6) 5(1.6)

80(24.8) 87(27)

30(9.3) 81(25.2)

2(0.6) 9(2.8)

4.95

0.001

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Table 8 Comparison of nurses referring/not referring patients to CAM therapists in terms of attitude toward CAM. Level of agreement [n (%)]

Not referring Referring

Very positive

Slightly positive

Neutral

Slightly negative

Very negative

Z

P value

11(3.4) 61(18.9)

42(13) 76(23.6)

61(18.9) 41(12.7)

11(3.4) 4(1.2)

5(1.6) 2(0.6)

6.74

0.001

study provides several key findings on nurses' personal and professional use of CAM, attitude toward and knowledge of CAM, and socio-demographic predictors of CAM users. This study is rather novel in that it explored the sociodemographic predictors for personal and professional use of CAM/CAM domains by nurses, which is dependent on the therapy, gender, age, religion, marital status, gross annual household income, and years of clinical practice. The results also demonstrated that the personal use of CAM was prevalent among nurses (95.7%), reporting massage therapy, non-herbal supplements, and meditation/relaxation techniques/imagery techniques to be the most personally used CAMs. The most popular CAM domains personally and professionally used by nurses were in the following order: mind-body therapies, manipulative and body-based practices, and natural products. On the other hand, only 49.7% of nurses used CAM professionally with the three most widely employed being massage therapy, music therapy, and non-herbal supplements. This finding is in congruent with a recently published study by Balouchi et al., reporting that nurses poorly employ CAM in clinical nursing practice [44]. This is a striking finding of the present study which raises a query about incomparable use of personal and professional use of CAM by nurses. The finding may not be surprising, given that significant barriers still exist to incorporating CAM into clinical practice by nurses. There is no solid scientific evidence to determine the effectiveness and safety of a range of CAM [45e47], which makes it legitimately harder for health professionals, including nurses, to practice them in conventional medical settings. One other finding of note is that only a small fraction of nurses rated their perceived knowledge of CAM as a lot, which is consistent with that by Cooke et al. [36], Bjerså et al. [28] and Trail-Mahan et al. [48]. Rojas-Cooley and Grant indicated that oncology nurses often did not discuss CAM use with patients because nurses reported insufficient knowledge and assessment skills, and inability to find reliable sources for specific CAMs [49]. Not only do nurses need to be knowledgeable about potential contraindications of CAMs as well as their possible interactions with allopathic medications, but they also need to be well informed of these therapies so that CAM therapies can be offered to patients safely and effectively [50]. It is of concern that nurses' lack of adequate knowledge and skills related to CAM hinders the evidence-based CAM to be fully incorporated into health care systems, because, as identified by our study, nurses with higher knowledge of CAM are most likely to have positive attitude toward these therapies and to refer patients to CAM practitioners. It is worthy of note, however, that nurses' lack of knowledge is not the only significant obstacle to the creation of integrative medicine in clinical settings. To fully integrate CAM into clinical practice, nurses should be knowledgeable about these therapies so they can effectively and comfortably recommend and use them in their practice [51]. It appears important to acknowledge that our participants were not asked whether they have had any either professional training or formal education on CAM to practice them in their clinical settings. Nor were they questioned about whether they were using CAM based on their own decision or with permission from treating physicians. In this case, we did not investigate whether nurses utilized CAM on their clients' request or as part of patients' routine care. However, there are other important barriers

which have stifled integration of CAM into health care systems. In short, most medical facilities are not structurally and administratively designed to accommodate teams comprising conventional medical and CAM providers and that nonpharmacological interventions are not adequately reimbursed by health insurance policies [52]. Besides, Australian nurses are required to have access to clear policies towards the safe use of complementary health products and practices. They also require access to policies about referring clients appropriately to accredited CAM therapists [53]. Keep in mind, too, that nurses who practice CAM may face added liability risks because of the lack of consensus on the efficacy or safety of some forms of CAM therapies [54]. Our study also explored that highly personally used CAMs/CAM domains were amongst those most frequently practiced by nurses in clinical settings. Consistent with our finding, a study conducted in the United States indicated that personally experienced CAMs by nurses were amongst therapies most often recommended to others [55]. It is evidenced that “… personal use of CAM by health care workers is related to the provision of, referral for, or general openness to the integration of CAM therapies in health care practices. … Thus personal use of CAM by health care workers may be a principal determinant in the movement toward ‘integrative care’d the mainstreaming of CAM with allopathic medicine” (p.223) [56]. It is also clear that nurses were more likely to be familiar with or knowledgeable about CAMs they highly used for patients, although personal use of CAM might have also made nurses feel confident to incorporate CAM into clinical practice and respond to patients' demands for CAM. Nurses with the least years of clinical practice more than those with more clinical experience had used CAM with patients, because of the fact that holistic nursing practice has been included and addressed in the nursing curriculum in recent years. In keeping with this study, the majority of nurses held a positive attitude toward CAM, which may have been affected by their positive experience of CAM for themselves [57]. According to Helmrich et al., nurses' positive attitude toward CAM can positively affect their use of these therapies with patients [58], and as shown by our study, nurses with positive attitude toward CAM are more likely to refer patients to CAM practitioners. In addition, an Australian study revealed nurses to be open/eager to utilize CAM in their practice [36]. These make it in turn easier to assign a wider range of health care responsibilities to nurses in order to provide CAM for patients. Little is known about personal and professional use of CAM by clinical nurses in Australia. Wilkinson and Simpson found that 74% of nurses had personally used CAM in the last year and CAMs used were comparable to those utilized by the general population. The study reported aromatherapy, relaxation, meditation, chiropractic and herbal therapy to have been the top five CAMs used by nurses for their own, and relaxation, aromatherapy, other (e.g. massage), meditation and herbal therapy as the top five CAMs used with patients [59]. In addition, the primary reason for the use of CAM amongst our participants was “[it] fits into my way of life/philosophy”, which is in agreement with that found for patients by an Australian study [13]. However, our findings are not directly comparable with earlier Australian studies because of disparities in CAM definitions and the inclusion of various CAMs in the surveys. Ironically, over half of our participants rarely or never would ask

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patients about their use of herbal medicine. Furthermore, only 5.3% of nurses claimed they would ask patients about their use of other forms of CAMs. This finding is inconsistent with that identified by Cooke et al., who reported that the majority of critical care nurses would document patients' use of CAM in their clinical record. One possible explanation for this finding is that patients' medical/ nursing records do not include any documentation of current use of CAM. This could also be due to the fact that nurses' lack of knowledge impairs effective communication between nurses and patients about CAM use [49]. Our results must be considered in light of several limitations. As is the case in survey-based research, the self-report nature of the questionnaire is a limitation. Another limitation lies in the questionnaire's failure to list, (although reasonably impracticable to do so), all possible herbal and non-herbal preparations and products. Therefore, the study represents information only about common and well-known CAMs. Moreover, the details of some CAMs, such as non-herbal supplements and herbal/botanical therapies, were not recorded in the present study. It was also beyond the scope of this study to explore all aspects of knowledge and attitude and disparate reasons for the use of various CAMs by nurses. Accordingly, the results of the present study are not representative for the general attitude and knowledge of nurses in Australia, nor do the given reasons for the use of CAM encompass all possible motives for taking advantage of CAM. Further, Australia is a multicultural country and nurses with non-Australian origins or influenced by more than one culture might have underestimated their personal use of CAM on account of the limitation in CAM choices on the questionnaire and exclusion of traditional healing exercises. These limitations may decrease the generalizability of the findings to a larger population. Despite limitations mentioned above, this study can draw attention to the current trends of CAM among clinical nurses in Australia.

[2]

[3]

[4]

[5]

[6]

[7]

[8]

[9]

[10]

[11]

[12]

[13]

5. Conclusion [14]

This study revealed that nurses generally believe not to have sufficient knowledge of CAM but are open to use CAM with patients. There is a need to improve nurses' knowledge of CAM as nurses play a critical role in healthcare systems and should be knowledgeable about those CAMs that have a long history in nursing practice, such as massage therapy. Besides, nurses are one of the most appropriate health professionals for the reference of clients to accredited CAM practitioners for those CAMs that they are not lawfully allowed to practice, providing that they prove their competency. Nurses' positive attitude toward and personal use of CAM could be an indication that they are poised for further integration of evidence-based CAM into nursing practice to treat whole person. Areas for the future research arising from this study include exploring the appropriateness of referral by nurses to CAM therapists. Further research is also warranted to interpretively describe nurses' professional experience of CAM. More research could be conducted to explore how nurses' knowledge and attitude about CAM will impact their use of CAM in clinical practice. Conflict of interest

[15] [16]

[17]

[18]

[19]

[20]

[21]

[22]

We have no conflict of interest. [23]

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