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Clinical nurses' perceptions of the opportunities for using complementary therapies in Iranian clinical settings: A qualitative study
Complementary Therapies in Clinical Practice 24 (2016) 11e18
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Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctcp
Clinical nurses' perceptions of the opportunities for using complementary therapies in Iranian clinical settings: A qualitative study Zahra Tagharrobi, Sima Mohammadkhan Kermanshahi*, Eesa Mohammadi Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, IR, Iran
a r t i c l e i n f o
a b s t r a c t
Article history: Received 12 March 2016 Received in revised form 18 April 2016 Accepted 19 April 2016
Nurses need to use complementary therapies in their clinical practice in order to fulfill community's needs. There are potential opportunities for using complementary therapies in different clinical settings. This study was done to explore nurses' perceptions of these opportunities in Iranian clinical settings. In this qualitative study, sampling was done purposively and ended after reaching data saturation. Semi-structured interviews were done with fifteen nurses. The data were analyzed via the conventional content analysis approach. The participants' perceptions fell into three main categories of ‘consumer demand’, ‘environmental potentials’, and ‘optimal official regulations’ from which, the main theme of ‘A potentially-supportive environment’ was abstracted. The context of Iranian clinical settings is appropriate for using complementary therapies in nursing practice. A potentially-supportive environment automatically directs nurses towards using such therapies. These findings can be used by nursing managers to integrate complementary therapies into nursing practice. © 2016 Elsevier Ltd. All rights reserved.
Keywords: Complementary therapies Contextual conditions Nursing Qualitative research Iran
1. Introduction Complementary and alternative medicine/therapies (CAM) include a wide range of healing resources which are used alongside conventional treatments to prevent or treat diseases, promote health, or improve individuals' general health condition [1]. The National Center for Complementary and Integrative Health attempted to clarify the definition of these therapies through classifying them. Thus, this center classified the therapies into five main categories including natural products, mind-body therapies, alternative medical systems, manipulative and body-based methods, and energy therapies [2]. Besides, these therapies have been classified into two main categories of pharmacological and non-pharmacological therapies [1e3]. These therapies are currently used widely in different communities around the world ndez-Cervilla et al. (2013) noted that in Canada, Germany, [4]. Ferna
* Corresponding author. E-mail addresses: [email protected] (Z. Tagharrobi), kerman_s@ modares.ac.ir (S. Mohammadkhan Kermanshahi), [email protected] (E. Mohammadi). http://dx.doi.org/10.1016/j.ctcp.2016.04.003 1744-3881/© 2016 Elsevier Ltd. All rights reserved.
Ethiopia, Columbia, Chile, and China respectively 70%, 33%, 90%, 40%, 71%, and 40% of people use CAM for preventing or treating health problems [5]. In our country, Iran, 52.5% of people living in Tehran use at least one CAM in a year [6]. Beside the general public, a large percentage of hospitalized patients also use or ask to receive CAM [7,8]. However, only some hospitals provide such services [9]. In most countries, only a small number of CAM users use these therapies due to healthcare professionals' advice [4,7,10]. Moreover, most of these users do not inform conventional healthcare providers about using CAM. This fact can cause different problems [11] and thus, healthcare systems need to be synchronized with the increasing request for CAM in order to fulfill public's healthcare needs. Nurses constitute a large number of healthcare professionals. Given the nursing curricula and the nature of the nursing profession, nurses are in an ideal, unique, and strategic position for providing CAM [12e15]. Shorofi and Arbon (2010) reported that nurses' positive attitudes towards CAM reflect their readiness for addressing community's needs and noted that they should quickly plan for providing CAM [15]. Holistic care, nursing theories, nursing ethics, and classifications in the nursing science justify the necessity to use CAM in nursing practice [7,16e18].
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Some studies showed that nurses in different countries use CAM in their daily practice [11,15,19,20]. A local study in Kashan, Iran, also showed that 64% of nurses had positive attitude towards and great interest in using CAM and hence recommended these therapies to their clients; however, they had limited CAM-related knowledge and skills [21]. Our clinical experiences also show that some Iranian nurses, particularly in oncologic, palliative, critical, and psychiatric care units, occasionally use CAM based on their own, their colleagues, and their family members' experiences. Quality care delivery is the ultimate goal of all healthcare institutions and hence, all nursing managers need to work toward it. They can improve care quality through integrating CAM into nursing care delivery systems [22]. In fact, safe, correct, and effective use of CAM in clinical nursing practice greatly depends on nursing administrators and managers' ambition and support. Some studies also showed that nursing leaders have a pivotal role in successfully integrating CAM into nursing practice [22e25]. A prerequisite to the successful integration of CAM into nursing practice is to evaluate clinical settings [14], particularly the available opportunities for CAM use in such settings [26]. Through identifying and grasping these opportunities, nursing managers can develop practical guidelines and strategies for facilitating and achieving the integration [14]. Known generally as contextual conditions, environmental opportunities and strengths reflect complementary therapists' workplace structure and consist of a wide range of interrelated and dynamic factors which do not directly determine therapists' behavioral patterns and attitudes but have important effects on their interactions. According to Hall et al. (2012), the main reason behind some specialists' greater desire for using CAM in their clinical practice is the general atmosphere of their workplace which encompasses organizational polices, experience, knowledge, and patients' preferences [26]. To the best of our knowledge, there is only a small number of studies into the contextual conditions of clinical settings which guide nurses towards using CAM. The available evidence in this area is limited to the preliminary findings of few studies [22,23,25,27e30]. Hirschkorn and Bourgeault (2005) developed a literature-based conceptual model and reported organizational and physical structural attributes as the main factors behind healthcare providers' CAM -related behaviors [31]. Knowing the importance of contextual factors in using CTs, they conducted a qualitative study to explore structural opportunities which had encouraged physicians, midwives, and nurses to use CAM in their professional practice in Canadian clinical settings and identified some of them [32]. Hall et al. (2012) also highlighted the importance of contextual conditions to midwives' attitudes towards using CAM and found in their qualitative study that main factors such as the context of professional work and women's expectations and health affect such attitudes [26]. However, based on our literature review, no study has yet explored opportunities for using CAM in nursing practice in Iranian clinical settings. In Iran, there is religious and indigenous culture; traditional medicine has a long and rich history; and the different races & ethnic groups live. Also, Islamic and Iranian Traditional Medicine is rapidly expanding in this country. Because of the unique traditional religious and cultural context in Iran and the type of power distribution in Iranian healthcare system, nurses have no significant role in making patient-related clinical decisions. Consequently, contextual conditions in the Iranian healthcare system may be different from those of other countries. Given the scarcity of studies in this area both at national and international level and the potentialities of qualitative studies for in-depth exploration of people's experiences, the present study was done in Iranian clinical settings by using a qualitative design.
2. Objectives This study aimed at exploring nurses' perceptions of the opportunities for using CAM in Iranian clinical settings. 3. Material and methods 3.1. Study design This qualitative study was conducted based on the naturalistic research paradigm [33,34] and by using the conventional content analysis approach. Content analysis is a systematic approach to detailed explorations and description of poorly-known phenomena and is appropriate for exploring people's experiences of certain subject matters [35,36]. 3.2. Participants The purposive sampling method was used to recruit informants with first-hand experiences [33]. The eligible participants were staff nurses who had used at least one of the CAM in their clinical practice (had used and offered the CAM themselves for their clients), were able to communicate verbally in Persian, and were willing to share their experiences. The first participant was introduced by an oncologist and two nursing faculties as an expert in spiritual care, therapeutic relationship, and relaxation techniques. Other participants were recruited through snowball sampling [34]. Sampling was continued until data saturation was achieved [34]. The study participants varied regarding their working ward, professional experience, age, official position, and the type of CAM used by them. They had used at least one of the following CAM: spirituality, relaxation, movement therapy, dietary recommendations, therapeutic relationship, music or other auditory stimulations, touch, massage, creative arts, play, natural oral or topical compounds, aromatherapy, environmental interventions, herbal remedies, hypnosis, guided imagery, and positive thinking. They were recruited from the chemotherapy, rehabilitation, psychiatric, cardiac surgery, and oncologic and palliative care wards and neonatal and adult intensive care units (NICU and ICU) of five public health centers (four hospitals and one nursing home) located in Kashan and Isfahan, Iran. All participants were female and most of them had the experience of working in other hospital wards and cities. The ranges of their ages and work experience were 30e48 and 7e25 years, respectively (Table 1). 3.3. Data collection The study data were collected from June 2014 to July 2015 through doing semi-structured interviews [34,37]. Initially, we contacted each nurse, assessed her eligibility for the study, invited her to the study, and determined the time and the place for doing the interview based on her preferences. None of the approached participants refused to participate in or withdrew from the study. Primarily, we generated a list of questions according to the study aim. The list was revised repeatedly after each interview and based on the data retrieved from that interview. Each interview was opened by a general question, ‘Would you please explain about CAM which you have used or currently use in your clinical practice?’ Given the responses provided by the interviewee, the interview was continued by asking questions such as, ‘How did you get interested in these therapies?’ ‘Why do you use them in your practice?’ Can you explain about your experience of using CAM by hospitalized patients or their family members?’ ‘How do you react when patients or family members ask you to provide one of the CAM to them?’ Besides, we employed pointed questions (such as
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Table 1 Participants' demographic characteristics (n ¼ 15). Variable
Frequency (%)
Age (year)
30e34 35e39 40e44 44e49 bachelor master 5e9 10e14 15e19 20e24 25 Staff nurse Nursing administrator single married
Educational level Work experience (year)
Official position Marital status
‘what do you mean by … ’) in order to collect more detailed data. A large part of the data became repetitive since the sixth interview and saturation was achieved after analyzing the sixteenth interview. Therefore, we changed the study setting for the seventeenth interview. However, no new data was obtained from this interview. All interviews were done by the first author who was a PhD student and a faculty member in nursing and had received educations about doing interview for qualitative studies. In total, fifteen faceto-face interviews were done in a private room located in the participants' workplace. On average, the length of the interviews was 73 min. A small part of interviews with participants 1 and 3 were clarified through doing two 5-min telephone interviews. Thus, the total number of the interviews was seventeen. All interviews were recorded after obtaining the participants' permissions and were immediately transcribed verbatim by using the Microsoft Word Software. Besides, the participants' facial expressions and body movements were written in the interview transcripts. The process of interviewing was supervised by the coauthors who are experts in qualitative research.
3 5 3 4 13 2 1 7 1 3 3 8 7 2 13
(20) (33.33) (20) (26.66) (86.66) (13.33) (6.67) (46.66) (6.67) (20) (20) (53.33) (46.66) (13.33) (86.66)
generating one of the study categories is shown in Table 3.
3.5. Rigor The four criteria proposed by Lincoln and Guba were applied to ensure the rigor of the findings [34,38]. We attempted to make the findings credible through asking the participants to check the congruence between our findings and their own experiences (member checking) as well as allocating adequate time (more than one year) to data collection and analysis (prolonged engagement). In order to maintain the confirmability of the interview transcripts, the generated codes and categories were revised and approved by the coauthors (peer checking) and a faculty member who was external to the study (faculty member check). Moreover, we documented the process of data analysis step-by-step to maintain the dependability of the findings (audit trail). Finally, we attempted to recruit a sample of maximum variation in terms of participants' characteristics (such as workplace, work experience, official position, and the type of CAM used by them) to maintain the credibility and the transferability of the findings.
3.4. Data analysis Concurrently with data collection, we analyzed the data via the conventional content analysis approach proposed by Zhang and Wildemuth (Table 2). Each interview transcript was read and reviewed many times. Based on the study question, meaning units were identified and coded. After analyzing four interviews, the primary codes were categorized into subcategories and labeled according to their conceptual similarities. Thereafter, we compared the subcategories with each other and grouped them into more abstract categories [35,36,38]. Finally, the analytic methods and the study findings were reported. The data were managed using the MAXQDA 10 software. All of the generated codes and categories were revised and approved by the coauthors. The flow of Table 2 The Steps of data analysis based on the Zhang and Wildemuth’ approach. Steps
Action
1 2 3 4 5 6 7 8
Preparation of the data Definition of the unit analysis Development of categories & coding scheme Testing of the coding scheme on a sample of test Coding all the text Assessment of coding consistency Concluding from the coded data Reporting Methods & findings
3.6. Ethics The Ethics Committee of Tarbiat Modares University approved the study (the approval code: 555.5187; November 10, 2014). After explaining the aims and the methods of the study to the participants, their informed consent was obtained. The time, place, and length of the interviews were determined according to the participants' preferences. Besides, we attempted to ensure each interviewee's privacy throughout the interview. The participants were also ensured about the confidentiality of their data and the recorded interviews. We gave all participants the latitude for discontinuing interview without experiencing any disadvantages.
4. Results In total, 97 primary codes about the contextual factors related to CAM use in nursing were extracted from seventeen interviews done with fifteen participants. The main theme of the study is ‘A potentially-supportive environment’ that is an environment in which potentials, rules and regulations, and consumer demand provide a condition which propels nurses into using CAM in their clinical practice. This main theme consists of three main categories of ‘consumer demand’, ‘environmental potentials’, and ‘optimal official regulations’ (Table 4).
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Table 3 The process of generating the ‘Consumer demand’ main category. Sample of meaning units
Sample of primary codes
Men always ask about whether to undergo cupping or not. Women also ask, for example, about leech therapy and its effectiveness. Based on my mothers' experiences, I told them that it is good (P. 1). Mothers or grandmothers ask about the effectiveness of taking cotoneaster. Sometimes, they ask about manna. I answer them that manna would be helpful but cotoneaster is not (P. 11). Some of our patients in ICU requested music therapy and got calm after receiving it (P. 7) We have experienced many instances in which patients' family members had brought herbal distillations and asked us to give them to their patients. I usually don't disagree with such therapies (P. 10). Sometimes, patients' family members make objections that nurses have avoided giving CAM to their patients or did not allow them to visit, talk with, and massage their patients. Therefore, I contacted those nurses and told them that it would have been better if they had done that (P. 6). Some family members had objections against our staffs who avoided attaching sacred wristbands to their patients. I told them, ‘Rub the wristband to your patients and then, take it to your home’ (P. 13).
Facing client's question about the appropriateness of Facing clients' some CAM questions
Subcategories
Category Consumer demand
Facing client's question about herbal compounds for managing neonatal jaundice Facing client's request for music therapy
Facing clients' requests
Facing client's request for using herbal distillations
Client's objection against nurses' inattentiveness to Facing clients' his requested CAM complaints about lack of CAM Family members' complaint against nurses' disagreement with placing sacred things at their patient's bedside
Table 4 The subcategories and categories of the 'potentially-supportive environment ' main theme. Subcategories
Category
Facing clients' questions Facing clients' requests Facing patients' complaints about lack of CAM A respectful atmosphere The presence of expert nurses in clinical settings A supportive learning environment The greater opportunity for using CAM in critical care units Optimal governmental regulations at ministerial level Optimal ward regulations Optimal human resource development regulations Optimal evaluation and supervision regulations
Consumer demand
4.1. Consumer demand The participating nurses noted that they repeatedly face their clients' questions about or request for CAM. In some instances, they even face their clients' complaints about lack of CAM in clinical settings. These conditions propel them into using CAM. 4.1.1. Facing clients' questions All participating nurses referred to situations in which they face their clients' questions (patients or their families) about CAM. They noted that sometimes clients are going to use some CAM or hear something about them and hence, have questions about them based on their own or their family members' experiences. Therefore, the participants attempted to answer their clients' questions. Participant 10 explained her experience of CAM in ICU by saying, For instance, some patients' family members say, ‘Can we massage our patients by using olive oil? Is it good for them?’ They also frequently ask about using CAM for their patients' skin or joint problems. For example, they ask, ‘Will that oil help?’ We usually allow them and they bring olive oil. Then, we and family members massage their patients.
4.1.2. Facing clients' requests There were many instances of clients or family members' requests for CAM in the participants' experiences. The participating nurses noted that sometimes, clients' requests compel them to use CAM in their clinical practice.
Environmental potentials
Optimal official regulations
A few days ago, a female patient asked me to give her a prayer book or the holy Quran to read. Besides, a patient asked us to play music for her while another one asked us to go with her to hospital yard to play. We face such patients frequently. I usually pay attention to their requests (P. 3).
4.1.3. Facing patients' complaints about lack of CAM Some CAM requested by patients or family members may be non-beneficial to them, sound scientifically questionable or not applicable in hospital wards. Therefore, a nurse may disagree with or avoid providing such therapies. Most of our participants noted that in these situations, patients make complaints about not receiving the requested CAM. Such complaints occasionally require nurses to provide the requested therapies. Participant 9 who was a head-nurse stated, In NICU, when my colleagues disagree with family members' requests for giving some oral compounds to their neonates, family members refer to me and make complaint that my colleagues have not allowed them to give that compound to their neonates. I usually back up such decisions of my colleagues. Sometimes, they complain that my colleagues have not allowed them to play some kinds of recorded supplications for their patients. In these situations, I ask them to bring prayer book, read it for their patients, and take it by themselves to their homes [instead of leaving it in the unit].
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4.2. Environmental potentials Another attribute of the potentially-supportive environment is environmental potentials. This attribute shows the potentials of clinical environments for CAM provision. Most participants referred to the different aspects of this attribute. 4.2.1. A respectful atmosphere Respecting and valuing clients' beliefs in clinical settings is one of the environmental potentials. According to the participants, nursing managers and even physicians usually respect clients' beliefs and requests and hence, they can use this opportunity to provide some kinds of CAM without having any serious concern. Of course, some sort of organizational coordination needs to be ensured prior to CAM provision. Participants 6 who was a hospital matron mentioned, We respect families' beliefs [about CAM] though they may not benefit from their beliefs and actions. The minimal benefit is that they become calm and satisfied. Nurses also know that there is no need to coordinate with higher-level managers and hence, allow patients and family members to use CAM.
4.2.2. The presence of expert nurses in clinical settings Another environmental potential is the presence of nurses who are expert in using specialized techniques. These nurses can motivate other nurses to use CAM. Moreover, the presence of such nurses paves the way for the administration of CAM by other nurses who can refer to them once needed to obtain necessary information about CAM. Some colleagues have valuable information about traditional medicine compounds and help us in this area. Two nurses in our ward are expert in this area. I have used their information in many cases (P. 6).
4.2.3. A supportive learning environment Another attribute or potential of the Iranian clinical settings for using CAM is availability of considerable learning opportunities. Valuing human resource development and implementing relevant in-service educational programs are among the potentials which automatically guide nurses towards the use of CAM. A palliative care educational program was held in our hospital. Moreover, we hold educational programs and conferences in our ward. One of our colleagues provided us with educations about managing pain and blocking pain pathways. I use the techniques which he educated to us for managing cancer patients' pain. I even educate these techniques to patients' family members (P. 15). The facilities for attending in-service educational programs and the availability of educational resources are the other environmental potentials highlighted by the study participants.
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and adult ICUs, certain kinds of patients are hospitalized, care services are very diverse, and nurses have more professional autonomy. Besides, in oncologic care units, patients are hospitalized for long periods of time and thus, nurses have considerable opportunities for using CAM in these units. In critical care units, physicians are present only for few hours and hence, nurses are responsible for all patients' affairs. Besides, CAM do not need physicians' prescription. In ICUs, nurses are the main decision makers. If the in-charge nurse permits, there would be no major barrier for other nurses to use these therapies. We administer these therapies in our unit after obtaining the in-charge nurse's permission. Participant 15 also highlighted the greater opportunity for using CAM in oncologic care wards by saying, Patients' hospital stay in this ward is lengthydthree to four days, one week, or even one month. Moreover, our patients are frequently rehospitalized. Therefore, it is possible to visit one patient for many times and hence, we have the opportunity for educating them and asking them to exercise techniques such as positive thinking and guided imagery.
4.3. Optimal official regulations Some governmental and organizational regulations, requirements of personnel development programs, and evaluation and supervision regulations can affect nurses' engagement in the administration of CAM. These factors are explained in what follows. 4.3.1. Optimal governmental regulations at ministerial level One of the governmental regulations which automatically propel nurses into using CAM is accreditation guidelines. The participants noted that through requiring nurses to develop educational pamphlets, accreditation programs have an added role in facilitating CAM use in clinical practice. Participant 8 referred to using oral dextrose for managing venipuncture pain by saying, Recently, accreditation programs have required us to calm babies before implementing painful procedures. I have used dextrose for many years and the developers of accreditation programs also have recently approved its use for calming babies. The Iranian Health System Transformation Project is another program which provides nurses with some sort of facilities and equipment and helps them use CAM in their practice. Besides, the participants noted that working in teaching hospitals, the presence of medical interns and residents in hospital wards, and the training of interns and residents by different physicians who have different attitudes towards CTs provide them with good opportunities for using such therapies. Participant 6 referred to using honey for wound management and said,
We have baby massage pamphlet, booklet, and movie in our ward. I used them as well as books in our in-ward library. Sometimes, I provide these resources to mothers or show the movie to them once the ward isn't too crowded (P. 8).
Interns and residents work in rotational working shifts and hence, they may work one day with Dr. X who allows using CAM and one day with Dr. Y who disagrees with their use. Well, residents have experienced it [i.e. the effectiveness of honey] and therefore, some of them asked us occasionally to use it.
4.2.4. The greater opportunity for using CAM in critical care units Several participants noted that in some wards, such as NICUs
The Research Councils of universities are also required to provide hospital nursing offices with the list of research priorities. Therefore, through getting informed of the titles of these
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researches, nurse managers can trace and follow the findings of studies in the area of CAM and use them at ward level. Participant 7 who was a hospital matron mentioned, The Research Council provided us with the relevant guidelines and regulations and thus, we are aware of all these activities. I also read the reports of some of these researches. For instance, one study was related to mouth wash by using an herbal compound. We removed the barriers to its use and therefore, it was used for providing mouth wash care to patients receiving mechanical ventilation.
4.3.2. Optimal ward regulations Given the types of hospital wards and patients' conditions, there are different regulations for ward management which can direct nurses toward using CAM. For instance, some of these regulations include the necessities for performing mouth wash for all patients receiving mechanical ventilation, calming restless neonates in NICUs, educating self-care activities to all patients in all hospital wards, and making it mandatory for mothers to be present in NICUs. It is mandatory for mothers to attend the unit and stay with their neonates. Therefore, they are accessible to us and we can educate them about giving massage to their neonates or we can provide kangaroo mother care to them (P. 9).
4.3.3. Optimal human resource development regulations There are certain educational obligations for nurses who are practicing nursing in hospitals. For example, they are required to participate in in-service educational programs and courses. According to the study participants, these obligations pave their way for using CAM. Besides, the obligation to hold in-ward monthly conferences and transfer to colleagues the information acquired in in-service educational programs can also contribute to the easier use of CAM by nurses in their clinical practice. I participated in in-service educational programs. We have to attend such programs at least 50 hours a year. Well, I try to attend the programs that are beneficial to me and my ward. For instance, I attended a kangaroo mother care course (P. 11).
4.3.4. Optimal evaluation and supervision regulations According to the participants, some regulations on evaluation and supervision, such as round programs and performance evaluation procedures, can help nurses use CAM in their practice. Nursing administrators' periodic rounds can directly and indirectly affect the use of these therapies. During their rounds, they can educate nurses and provide them with constructive feedbacks and thus, help them maintain the continuity of CAM. Participants 7 who was a hospital matron said, During rounds, I see that nurses administer these therapies. I provide them with feedbacks. I have the experience of working in ICU and hence, am able to transfer my experience to ICU headnurses. I have seen that staffs in ICUs administer these therapies. In addition, patient education and patient satisfaction evaluation forms include implicit items on the use of CAM. Such items can be effective in directing nurses toward using CAM. Participant 7 mentioned,
What I want to say is patient education; we have items such as patient education about dietary regimens and stress management in our evaluation forms. Another item is on patient satisfaction. Most patients and family members are satisfied with nurses' practice. Employing these techniques brings about patient satisfaction. Therefore, we pay attention to these items in the way that I told. Of course, some of the relevant items are included in ward round forms explicitly. Participants 13 who was a clinical supervisor referred to this fact by saying, Ward round forms include items on massage, patient education, pressure ulcer prevention and care, and pain and anxiety management. We greatly value these items for the sake of accreditation.
5. Discussion This study explored the opportunities for using CAM in Iranian clinical settings from the perspectives of nurses who used these therapies in their nursing practice. The study findings revealed that ‘consumer demand’, ‘environmental potentials’, and ‘optimal official regulations’ create a potentially-supportive environment’ which directs nurses toward integrating CAM into their nursing care services. One of the attributes of the potentially-supportive environment was consumer demand. The study participants' experiences included instances of clients' questions about or requests for CAM. Previous quantitative studies showed that American nurses have also experienced similar situations [7,14]. Some qualitative studies also reported the same findings [25,39]. The results of a study on nurses' experiences of herbal therapy showed that facing patients' questions makes nurses responsible for obtaining information about medical herbs [29]. The results of several qualitative studies illustrated that healthcare professionals greatly value clients' beliefs, preferences, and requests when they want to decide on recommending CAM to clients or referring them to complementary therapists. Besides, clients' requests, beliefs, and interests have been reported to direct nurses toward greater use of these therapies [26,40,41]. Johannessen (2009) noted that one of the reasons for leaving hospital settings and working in private CAM centers among Norwegian nurses is their greater attention to humanistic values such as respecting clients' requests [42]. The results of a grounded theory study for exploring the process of accepting CAM by Korean nurses also revealed lack of applied evidence and increased social interest as contextual factors. Moreover, nurses who had participated in this study noted that after identifying patients' needs and facing their frequent questions and requests, they attempted to seek solutions, acquire knowledge, resolve their own doubts, and use the best options for overcoming patients' problems [30]. Given the increased public interest in using CAM during recent years, it is not unexpected for nurses to face patients and family members' questions about or requests for CAM. According to Cattell (1999), nurses can grasp the opportunity for attracting public interest in CAM and use these therapies in their practice in order to introduce their profession as the provider of unique and valuable services [43]. The study participants also referred to environmental potentials for using CAM which included a respectful atmosphere, the presence of expert nurses, a supportive learning environment, and the greater opportunity for using CAM in critical care units. Besides, they referred to accreditation programs as one of the attributes of their workplace which facilitate the use of CAM. The accreditation
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program has been developed and offered by the Iranian Ministry of Health and Medical Education and thus, hospitals in Iran need to implement it. This program consists of both general and specific parts. Examples of these two parts respectively include managing pain and providing care to a restless patient in ICU. Operationalizing the items of this program automatically requires nurses to use CAM. Moreover, patient education has a unique position in the program. Although implementing this program necessitates heavy paperwork, none of our participants had perceived the program as a barrier to CAM use. The effects of this program in Iranian hospitals are almost the same as the effect of the Magnet Recognition Program which helps create a favorable environment for using CAM by nurses [22]. Our findings also showed that irrespective of the accreditation program, another key attribute of a potentiallysupportive environment for CAM use was optimal official regulations which included policies for supplying and using necessary equipment, student education, great value of research and evidence-based practice, legal practice, human resource development programs, and evaluation and supervision. The findings of previous studies conducted in different countries support different aspects of our findings. For instance, a qualitative study showed that the structural constraints and the opportunities for professional CAM use in Canadian hospitals fell into three categories including the context of professional practice, organizational policies, and physical factors. Moreover, greater professional autonomy and availability of equipment, facilities, and specific protocols for CAM use were among the factors which directed healthcare professionals toward using CAM [32]. In their conceptual model, Hirschkorn and Bourgeault (2005) also noted that the contextual factors behind CAM use include physical and organizational attributes. According to them, physical attributes include access to educational resources in workplace, availability of complementary therapist, and access to appropriate space, equipment, and atmosphere while organizational attributes are organizational policies and guidelines, general or specialized workplace conditions, open and collaborative managerial relationships, routine procedures, access to research evidence, and adequate time, budget, and staffs [31]. The results of a study into the contextual factors mediating midwives' behaviors toward pregnant women's CAM use in Australia illustrated that midwives' greater professional autonomy, optimal workplace culture and relationships, and availability of relevant guidelines and policies directed midwives toward greater CAM use [26]. In line with our findings, professional autonomy has been also reported by Norwegian nurses as one of the positive workplace-related attributes for CAM use [23,42]. A qualitative study into Thai nurses' experiences of using CAM in rehabilitation centers also indicated that beside professional autonomy, other workplace-related attributes which can direct nurses toward CAM use are mutual respect and having a sense of working as a family [27]. According to Garner (2000) and Kim et al. (2013), one of the key workplace-related attributes that mediate CAM use by nurses is in-service continuing education [29,30]. Cant et al. (2012) also noted that great success in CAM use in England hospitals during the mid-1980s and the late 1990s was due to the presence of motivated, qualified, and committed health practitioners who had high professional power and great communication skills [28]. Besides, a phenomenological study on the experiences of nurses' who used CAM in Pennsylvania, USA, also revealed that some workplace-related attributes such as being a teaching healthcare center, having Magnet certification, being active in research and education, and having specialized trainers contributed to nurses' CAM use. In addition, ‘a supportive organizational culture’dwhich consists of collaborative leadership style, involvement of staffs in decision making, availability of relevant educational programs, and great professional autonomydpaves the way
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for CAM use [22]. A general overview of the findings of the present and previous studies on the contextual conditions for CAM use indicates a series of attributes which is referred to in the literature as ‘healthy work environment’. Kramer et al. (2010) noted that a healthy work environment for clinical practice is an environment in which structures, functions, systems, and policies enable nurses to provide quality and safe patient care. They also reported that the attributes of such an environment include, but not limited to, close nurse-physician relationship and collaboration, nurses' great professional autonomy, colleagues' clinical competence, patientcentered culture, support for educational programs, teamwork, quality improvement infrastructures (such as research and evidence-based practice), decentralized organizational culture, practical accreditation structures, and control over nurses' performance [44]. The Magnet Recognition Program and Magnet hospitals also include the same criteria [45]. All these findings show that creating a healthy work environment for clinical practice can enhance nurses' interest in and desire for CAM use. It is noteworthy that the number of healthy workplace-related attributes which were identified in the present study was greater than what was reported in previous studies. The greatest strengths of the present study were in-depth interviews, management of interviews by one interviewer, and involvement of all authors in the process of data analysis. However, despite our attempt to recruit a maximally varied sample, sampling from only five centers and from two cities may reduce the transferability of the findings.
6. Conclusions The findings of the present study indicate that Iranian clinical settings are potentially-supportive to CAM use. The main attributes of such a potentially-supportive environment are consumer demand, environmental potentials, and optimal official regulations for using CAM in clinical practice. In some instances, these contextual factors automatically guide nurses toward using CAM in their professional practice. Moreover, nurses can use these contextual conditions as great opportunities for administrating CAM to their clients. Health authorities, particularly nursing managers, can use the findings of this study to develop guidelines and policies for CAM use in clinical settings and integrate CAM into nursing practice. Nursing researchers can also use our findings for developing standardized instruments concerning nurses' use of CAM. Future studies are recommended to explore and identify causal conditions, barriers, and facilitators to CAM use in nursing practice, develop relevant research instruments, and construct applied models for promoting CAM use by nurses.
Authors' contribution Zahra Tagharrobi: Study design, data collection, data analysis, data interpretation and drafting of the manuscript. Sima mohammadkhan Kermanshahi, Eesa Mohammadi: Study design, data analysis, data interpretation, critical revision of the manuscript and study supervision.
Funding/Support This study was a part of PhD thesis of the first author, approved and funded by the Tarbiat Modares University, Tehran, IR Iran [No. 552.4504; October 6, 2014].
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Conflict of interest The authors declare that there are no conflicts of interest. Acknowledgements The research team would like to thank the vice chancellor of research of Tarbiat Modares University and all of the participants in this research. References [1] Committee on the Use of Complementary and Alternative Medicine by the American Public, Complementary and Alternative Medicine in the United States, The National Academies Press, Washington, D.C., 2005. [2] R. Lindqulst, M. Snyder, M.F. Tracy, Complementary& Alternative Therapies in Nursing, sixth ed., Springer Publishing Company, New York, 2014. LLC. [3] M.F. Tracy, L. Chlan, Nonpharmacological interventions to manage common symptoms in patients receiving mechanical ventilation, Crit. Care Nurse 31 (3) (2011) 19e28, http://dx.doi.org/10.4037/ccn2011653. [4] F.L. Bishop, L. Yardley, G.T. Lewith, Treat or treatment: a qualitative study analyzing patients' use of complementary and alternative medicine, Am. J. Public Health 98 (9) (2008) 1700e1705, http://dx.doi.org/10.2105/ AJPH.2007.110072. [5] A.B. Fern andez-Cervilla, A.I. Piris-Dorado, M.E. Cabrer-Vives, A. Barquerolez, Current status of complementary therapies in Spain in nursing Gonza degree, Rev. Latino Am Enferm. 21 (3) (2013) 679e686, http://dx.doi.org/ 10.1590/S0104-11692013000300005. [6] S.A. Tehrani Banihashemi, H. Asgharifard, A.A. Haghdoust, M. Barghamadi, N. Mohammad Hosseini, The use of complementary alternative medicine among the general population in tehran, Iran. Payesh 7 (4) (2008) 355e362. [7] M.R. Tracy, R. Lindquist, Savik, S. Katanuki, S. Sendelbach, M.J. Kreitzer, et al., Use of complementary and alternative therapies: a national survey of critical care nurses, Am. J. Crit. Care 14 (5) (2005) 404e415. [8] S.A. Shorofi, Complementary and alternative medicine (CAM) among hospitalized patients: reported use of CAM and reasons for use, CAM preferred during hospitalization, and the socio-demographic determinants of CAM users, Complement. Ther. Clin. Prac. 17 (4) (2011) 199e205, http://dx.doi.org/ 10.1016/j.ctcp.2011.05.001. [9] L.J. Salomonsen, L. Skovgaard, S. Cour, L. Nyborg, L. Launsø, V. Fønnebø, Use of complementary and alternative medicine at Norwegian and Danish hospitals, BMC Complement. Altern. Med. 11 (2011) 4, http://dx.doi.org/10.1186/14726882-11-4. [10] A.S. Sajadian, A. Kaviani, A. Montazeri, M. Haji mahmoudi, M. Ebrahimi, F. Samiei manesh, et al., Complementary medicine use among Iranian cancer patients, Payesh 4 (3) (2005) 198e205. [11] Y. Yom, K. Lee, A comparison of the knowledge of, experience with and attitudes towards complementary and alternative medicine between nurses and patients in Korea, J. Clin. Nurs. 17 (19) (2008) 2565e2572, http:// dx.doi.org/10.1111/j.1365-2702.2007.02065.x. [12] E. Holroyd, A.L. Zhang, L. Suen, Xue Ch, Beliefs and attitudes towards complementary medicine among registered nurses in Hong Kong, Int. J. Nurs. Stud. 45 (11) (2008) 1660e1666, http://dx.doi.org/10.1016/ j.ijnurstu.2008.04.003. [13] T. Trail-Mahan, Mao Ch, K. Bawel-Brinkley, Complementary and alternative medicine: nurses' attitudes and knowledge, Pain Manag. Nurs. 14 (4) (2013) 277e286, http://dx.doi.org/10.1016/j.pmn.2011.06.001. [14] S. Cutshall, D. Derscheid, A.G. Miers, S. Ruegg, B.J. Roeder, Tucker Sh, Knowledge, attitudes, and use of complementary and alternative therapies among clinical nurse specialists in an Academic Medical Center, Clin. Nurse Spec. 24 (23) (2010) 125e131, http://dx.doi.org/10.1097/NUR.0b013e3181d86cd1. [15] S.A. Shorofi, P. Arbon, Nurses' knowledge, attitudes, and professional use of complementary and alternative medicine (CAM): a survey at five metropolitan hospitals in Adelaide, Complement. Ther. Clin. Prac. 16 (4) (2010) 229e234, http://dx.doi.org/10.1016/j.ctcp.2010.05.008. [16] M. Cooke, M. Mitchell, E. Tiralongo, J. Murfield, Complementary and alternative medicine and critical care nurses: a survey of knowledge and practices in Australia, Aust. Crit. Care 25 (2012) 213e223, http://dx.doi.org/10.1016/ j.aucc.2011.12.055. [17] P. O'Regan, Complementary therapies: a challenge for nursing practice, Nurs. Stand 24 (21) (2010) 35e39. [18] E.N. Nottingham, Complementary and alternative medicine, Holist. Nurs. Pract. 20 (5) (2006) 242e246. [19] F.Y. Chu, M. Wallis, Taiwanese nurses' attitudes towards and use of complementary and alternative medicine in nursing practice: a cross-sectional survey, Int. J. Nurs. Stud. 44 (8) (2007) 1371e1378, http://dx.doi.org/10.1016/ j.ijnurstu.2006.07.001. [20] R. Zoe, Charalambous Ch, S. Popi, R. Maria, V. Aris, K. Agoritsa, et al., Cypriot nurses' knowledge and attitudes towards alternative medicine, Complement. Ther. Clin. Pract. 20 (1) (2014) 89e92, http://dx.doi.org/10.1016/
j.ctcp.2013.08.003. [21] M. Adib-Hajbaghery, M. Hoseinian, Knowledge, Attitude and practice toward complementary and traditional medicine among Kashan health care staff, 2012, Complement. Ther. Med. 22 (1) (2014) 126e132, http://dx.doi.org/ 10.1016/j.ctim.2013.11.009. [22] S. Kristiniak, Exploring the experiences of complementary nurses: a qualitative phenomenological study, Dissertation, MS in nursing, University of Phoenix, Arisona, 2011. [23] B. Johannessen, G. Garvik, Experiences with the use of complementary and alternative medicine in nursing homes: a focus group study, Complement. Ther. Clin. Pract. (2015), http://dx.doi.org/10.1016/j.ctcp.2015.04.003 (in press). [24] B. Johannessen, Nurses experience of aromatherapy use with dementia patients experiencing disturbed sleep patterns. An action research project, Complement. Ther. Clin. Pract. 19 (2013) 209e213, http://dx.doi.org/10.1016/ j.ctcp.2013.01.003. [25] C.E. Fletcher, A.R. Mitchinson, E.R. Trumble, D.B. Hinshaw, jA. Dusek, Perceptions of providers and administrators in the veterans health administration regarding complementary and alternative medicine, Med. Care 52 (12) (2014) S91eS96, http://dx.doi.org/10.1097/MLR.0000000000000225. [26] H.G. Hall, D.L. Griffiths, L.G. McKenna, Contextual factors that mediate midwives' behavior towards pregnant women's use of complementary and alternative medicine, Eur. J. Integr. Med. 5 (1) (2013) 68e74, http://dx.doi.org/ 10.1016/j.eujim.2012.09.002. [27] P. van der Riet, S. Dedkhard, K. Srithong, Complementary therapies in rehabilitation: nurses' narratives. Part 1, J. Clin. Nurs. 21 (5e6) (2011) 657e667, http://dx.doi.org/10.1111/j.1365-2702.2011.03852.x. [28] S. Cant, P. Watts, A. Ruston, The rise and fall of complementary medicine in National Health Service Hospitals in England, Complement. Ther. Clin. Pract. 18 (3) (2012) 135e139, http://dx.doi.org/10.1016/j.ctcp.2012.05.004. [29] V.A. Garner, Nurse Practitioners' Experience with Herbal Therapy, Dissertation MS in nursing, Uniformed Services University of the Health Sciences, Maryland, 2000. [30] A.K. Kim, Y.S. Lee, H.J. Kim, The process of acceptance of complementary and alternative therapies (CATs) among nurses: grounded theory approach, J. Korean Acad. Nurs. 43 (5) (2013) 669e680, http://dx.doi.org/10.4040/ jkan.2013.43.5.669. [31] K.A. Hirschkorn, I.L. Bourgeault, Conceptualizing mainstream health care providers' behaviors in relation to complementary and alternative medicine, Soc. Sci. Med. 61 (1) (2005) 157e170, http://dx.doi.org/10.1016/ j.socscimed.2004.11.048. [32] K.A. Hirschkorn, I.L. Bourgeault, Structural constraints and opportunities for CAM use and referral by physicians, nurses, and midwives, Health (London) 12 (2) (2008) 193e213, http://dx.doi.org/10.1177/1363459307086843. [33] D.F. Polit, C.T. Beck, Essentials of Nursing Research: Methods, Appraisal, and Utilization, seventh ed., Lippincott Williams & Wilkins Co, Philadelphia, 2010. [34] H.S. Speziale, H. Streubert, D.R. Carpenter, Qualitative Research in Nursing: Advancing the Humanistic Imperative, fifth ed., Lippincott Williams & Wilkins, Philadelphia, 2011. €s, The qualitative content analysis process, J. Adv. Nurs. 62 (1) [35] S. Elo, H. Kynga (2008) 107e115, http://dx.doi.org/10.1111/j.1365-2648.2007.04569.x. [36] H.F. Hsieh, S.E. Shannon, Three approaches to qualitative content analysis, Qual. Health Res. 15 (9) (2005) 1277e1288, http://dx.doi.org/10.1177/ 1049732305276687. [37] A. Broom, Using qualitative interviews in CAM research: a guide to study design, data collection and data analysis, Complement. Ther. Med. 13 (1) (2005) 65e73, http://dx.doi.org/10.1016/j.ctim.2005.01.001. [38] Y. Zhang, B.M. Wildemuth, Qualitative analysis of content, in: B. Wildemuth (Ed.), Applications of Social Research Methods to Questions in Information and Library Science, Libraries Unlimited, Westport, CT, 2009, pp. 308e319. [39] S.W. Bertrand, Registered nurses integrate traditional Chinese medicine into the triage process, Qual. Health Res. 22 (2) (2012) 263e273, http://dx.doi.org/ 10.1177/1049732311421681. [40] L.Y. Wong, M. Toh, K. Kong, Barriers to patient referral for complementary and alternative medicines and its implications on interventions, Complement. Ther. Med. 18 (3e4) (2010) 135e142, http://dx.doi.org/10.1016/ j.ctim.2010.05.034. [41] M. Hastings-Tolsma, D. Vincent, Decision-making for use of complementary and alternative therapies by pregnant women and nurse midwives during pregnancy: an exploratory qualitative study, Int. J. Nurs. Midwifery 5 (4) (2013) 76e89, http://dx.doi.org/10.5897/IJNM2013.0100. [42] B. Johannessen, Why do Norwegian nurses leave the public health service to practice CAM? Complement. Ther. Clin. Prac. 15 (3) (2009) 147e151, http:// dx.doi.org/10.1016/j.ctcp.2009.02.014. [43] E. Cattell, Nurse practitioners' role in complementary and alternative medicine: active or passive? Nurs. Forum 34 (3) (1999) 14e23, http://dx.doi.org/ 10.1111/j.1744-6198.1999.tb00989.x. [44] M. Kramer, C. Schmalenberg, P. Maguire, Nine structures and leadership practice essential for a magnetic (healthy) work environment, Nurs. Adm. Q. 34 (1) (2010) 4e17, http://dx.doi.org/10.1097/NAQ.0b013e3181c95ef4. [45] M. Kramer, C. Schmalenberg, P. Maguire, Essentials of a Magnetic work environment, Nursing (2008) 23e27, http://dx.doi.org/10.1097/ 01.NURSE.0000304729.97476.61.
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Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctcp
Clinical nurses' perceptions of the opportunities for using complementary therapies in Iranian clinical settings: A qualitative study Zahra Tagharrobi, Sima Mohammadkhan Kermanshahi*, Eesa Mohammadi Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, IR, Iran
a r t i c l e i n f o
a b s t r a c t
Article history: Received 12 March 2016 Received in revised form 18 April 2016 Accepted 19 April 2016
Nurses need to use complementary therapies in their clinical practice in order to fulfill community's needs. There are potential opportunities for using complementary therapies in different clinical settings. This study was done to explore nurses' perceptions of these opportunities in Iranian clinical settings. In this qualitative study, sampling was done purposively and ended after reaching data saturation. Semi-structured interviews were done with fifteen nurses. The data were analyzed via the conventional content analysis approach. The participants' perceptions fell into three main categories of ‘consumer demand’, ‘environmental potentials’, and ‘optimal official regulations’ from which, the main theme of ‘A potentially-supportive environment’ was abstracted. The context of Iranian clinical settings is appropriate for using complementary therapies in nursing practice. A potentially-supportive environment automatically directs nurses towards using such therapies. These findings can be used by nursing managers to integrate complementary therapies into nursing practice. © 2016 Elsevier Ltd. All rights reserved.
Keywords: Complementary therapies Contextual conditions Nursing Qualitative research Iran
1. Introduction Complementary and alternative medicine/therapies (CAM) include a wide range of healing resources which are used alongside conventional treatments to prevent or treat diseases, promote health, or improve individuals' general health condition [1]. The National Center for Complementary and Integrative Health attempted to clarify the definition of these therapies through classifying them. Thus, this center classified the therapies into five main categories including natural products, mind-body therapies, alternative medical systems, manipulative and body-based methods, and energy therapies [2]. Besides, these therapies have been classified into two main categories of pharmacological and non-pharmacological therapies [1e3]. These therapies are currently used widely in different communities around the world ndez-Cervilla et al. (2013) noted that in Canada, Germany, [4]. Ferna
* Corresponding author. E-mail addresses: [email protected] (Z. Tagharrobi), kerman_s@ modares.ac.ir (S. Mohammadkhan Kermanshahi), [email protected] (E. Mohammadi). http://dx.doi.org/10.1016/j.ctcp.2016.04.003 1744-3881/© 2016 Elsevier Ltd. All rights reserved.
Ethiopia, Columbia, Chile, and China respectively 70%, 33%, 90%, 40%, 71%, and 40% of people use CAM for preventing or treating health problems [5]. In our country, Iran, 52.5% of people living in Tehran use at least one CAM in a year [6]. Beside the general public, a large percentage of hospitalized patients also use or ask to receive CAM [7,8]. However, only some hospitals provide such services [9]. In most countries, only a small number of CAM users use these therapies due to healthcare professionals' advice [4,7,10]. Moreover, most of these users do not inform conventional healthcare providers about using CAM. This fact can cause different problems [11] and thus, healthcare systems need to be synchronized with the increasing request for CAM in order to fulfill public's healthcare needs. Nurses constitute a large number of healthcare professionals. Given the nursing curricula and the nature of the nursing profession, nurses are in an ideal, unique, and strategic position for providing CAM [12e15]. Shorofi and Arbon (2010) reported that nurses' positive attitudes towards CAM reflect their readiness for addressing community's needs and noted that they should quickly plan for providing CAM [15]. Holistic care, nursing theories, nursing ethics, and classifications in the nursing science justify the necessity to use CAM in nursing practice [7,16e18].
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Some studies showed that nurses in different countries use CAM in their daily practice [11,15,19,20]. A local study in Kashan, Iran, also showed that 64% of nurses had positive attitude towards and great interest in using CAM and hence recommended these therapies to their clients; however, they had limited CAM-related knowledge and skills [21]. Our clinical experiences also show that some Iranian nurses, particularly in oncologic, palliative, critical, and psychiatric care units, occasionally use CAM based on their own, their colleagues, and their family members' experiences. Quality care delivery is the ultimate goal of all healthcare institutions and hence, all nursing managers need to work toward it. They can improve care quality through integrating CAM into nursing care delivery systems [22]. In fact, safe, correct, and effective use of CAM in clinical nursing practice greatly depends on nursing administrators and managers' ambition and support. Some studies also showed that nursing leaders have a pivotal role in successfully integrating CAM into nursing practice [22e25]. A prerequisite to the successful integration of CAM into nursing practice is to evaluate clinical settings [14], particularly the available opportunities for CAM use in such settings [26]. Through identifying and grasping these opportunities, nursing managers can develop practical guidelines and strategies for facilitating and achieving the integration [14]. Known generally as contextual conditions, environmental opportunities and strengths reflect complementary therapists' workplace structure and consist of a wide range of interrelated and dynamic factors which do not directly determine therapists' behavioral patterns and attitudes but have important effects on their interactions. According to Hall et al. (2012), the main reason behind some specialists' greater desire for using CAM in their clinical practice is the general atmosphere of their workplace which encompasses organizational polices, experience, knowledge, and patients' preferences [26]. To the best of our knowledge, there is only a small number of studies into the contextual conditions of clinical settings which guide nurses towards using CAM. The available evidence in this area is limited to the preliminary findings of few studies [22,23,25,27e30]. Hirschkorn and Bourgeault (2005) developed a literature-based conceptual model and reported organizational and physical structural attributes as the main factors behind healthcare providers' CAM -related behaviors [31]. Knowing the importance of contextual factors in using CTs, they conducted a qualitative study to explore structural opportunities which had encouraged physicians, midwives, and nurses to use CAM in their professional practice in Canadian clinical settings and identified some of them [32]. Hall et al. (2012) also highlighted the importance of contextual conditions to midwives' attitudes towards using CAM and found in their qualitative study that main factors such as the context of professional work and women's expectations and health affect such attitudes [26]. However, based on our literature review, no study has yet explored opportunities for using CAM in nursing practice in Iranian clinical settings. In Iran, there is religious and indigenous culture; traditional medicine has a long and rich history; and the different races & ethnic groups live. Also, Islamic and Iranian Traditional Medicine is rapidly expanding in this country. Because of the unique traditional religious and cultural context in Iran and the type of power distribution in Iranian healthcare system, nurses have no significant role in making patient-related clinical decisions. Consequently, contextual conditions in the Iranian healthcare system may be different from those of other countries. Given the scarcity of studies in this area both at national and international level and the potentialities of qualitative studies for in-depth exploration of people's experiences, the present study was done in Iranian clinical settings by using a qualitative design.
2. Objectives This study aimed at exploring nurses' perceptions of the opportunities for using CAM in Iranian clinical settings. 3. Material and methods 3.1. Study design This qualitative study was conducted based on the naturalistic research paradigm [33,34] and by using the conventional content analysis approach. Content analysis is a systematic approach to detailed explorations and description of poorly-known phenomena and is appropriate for exploring people's experiences of certain subject matters [35,36]. 3.2. Participants The purposive sampling method was used to recruit informants with first-hand experiences [33]. The eligible participants were staff nurses who had used at least one of the CAM in their clinical practice (had used and offered the CAM themselves for their clients), were able to communicate verbally in Persian, and were willing to share their experiences. The first participant was introduced by an oncologist and two nursing faculties as an expert in spiritual care, therapeutic relationship, and relaxation techniques. Other participants were recruited through snowball sampling [34]. Sampling was continued until data saturation was achieved [34]. The study participants varied regarding their working ward, professional experience, age, official position, and the type of CAM used by them. They had used at least one of the following CAM: spirituality, relaxation, movement therapy, dietary recommendations, therapeutic relationship, music or other auditory stimulations, touch, massage, creative arts, play, natural oral or topical compounds, aromatherapy, environmental interventions, herbal remedies, hypnosis, guided imagery, and positive thinking. They were recruited from the chemotherapy, rehabilitation, psychiatric, cardiac surgery, and oncologic and palliative care wards and neonatal and adult intensive care units (NICU and ICU) of five public health centers (four hospitals and one nursing home) located in Kashan and Isfahan, Iran. All participants were female and most of them had the experience of working in other hospital wards and cities. The ranges of their ages and work experience were 30e48 and 7e25 years, respectively (Table 1). 3.3. Data collection The study data were collected from June 2014 to July 2015 through doing semi-structured interviews [34,37]. Initially, we contacted each nurse, assessed her eligibility for the study, invited her to the study, and determined the time and the place for doing the interview based on her preferences. None of the approached participants refused to participate in or withdrew from the study. Primarily, we generated a list of questions according to the study aim. The list was revised repeatedly after each interview and based on the data retrieved from that interview. Each interview was opened by a general question, ‘Would you please explain about CAM which you have used or currently use in your clinical practice?’ Given the responses provided by the interviewee, the interview was continued by asking questions such as, ‘How did you get interested in these therapies?’ ‘Why do you use them in your practice?’ Can you explain about your experience of using CAM by hospitalized patients or their family members?’ ‘How do you react when patients or family members ask you to provide one of the CAM to them?’ Besides, we employed pointed questions (such as
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Table 1 Participants' demographic characteristics (n ¼ 15). Variable
Frequency (%)
Age (year)
30e34 35e39 40e44 44e49 bachelor master 5e9 10e14 15e19 20e24 25 Staff nurse Nursing administrator single married
Educational level Work experience (year)
Official position Marital status
‘what do you mean by … ’) in order to collect more detailed data. A large part of the data became repetitive since the sixth interview and saturation was achieved after analyzing the sixteenth interview. Therefore, we changed the study setting for the seventeenth interview. However, no new data was obtained from this interview. All interviews were done by the first author who was a PhD student and a faculty member in nursing and had received educations about doing interview for qualitative studies. In total, fifteen faceto-face interviews were done in a private room located in the participants' workplace. On average, the length of the interviews was 73 min. A small part of interviews with participants 1 and 3 were clarified through doing two 5-min telephone interviews. Thus, the total number of the interviews was seventeen. All interviews were recorded after obtaining the participants' permissions and were immediately transcribed verbatim by using the Microsoft Word Software. Besides, the participants' facial expressions and body movements were written in the interview transcripts. The process of interviewing was supervised by the coauthors who are experts in qualitative research.
3 5 3 4 13 2 1 7 1 3 3 8 7 2 13
(20) (33.33) (20) (26.66) (86.66) (13.33) (6.67) (46.66) (6.67) (20) (20) (53.33) (46.66) (13.33) (86.66)
generating one of the study categories is shown in Table 3.
3.5. Rigor The four criteria proposed by Lincoln and Guba were applied to ensure the rigor of the findings [34,38]. We attempted to make the findings credible through asking the participants to check the congruence between our findings and their own experiences (member checking) as well as allocating adequate time (more than one year) to data collection and analysis (prolonged engagement). In order to maintain the confirmability of the interview transcripts, the generated codes and categories were revised and approved by the coauthors (peer checking) and a faculty member who was external to the study (faculty member check). Moreover, we documented the process of data analysis step-by-step to maintain the dependability of the findings (audit trail). Finally, we attempted to recruit a sample of maximum variation in terms of participants' characteristics (such as workplace, work experience, official position, and the type of CAM used by them) to maintain the credibility and the transferability of the findings.
3.4. Data analysis Concurrently with data collection, we analyzed the data via the conventional content analysis approach proposed by Zhang and Wildemuth (Table 2). Each interview transcript was read and reviewed many times. Based on the study question, meaning units were identified and coded. After analyzing four interviews, the primary codes were categorized into subcategories and labeled according to their conceptual similarities. Thereafter, we compared the subcategories with each other and grouped them into more abstract categories [35,36,38]. Finally, the analytic methods and the study findings were reported. The data were managed using the MAXQDA 10 software. All of the generated codes and categories were revised and approved by the coauthors. The flow of Table 2 The Steps of data analysis based on the Zhang and Wildemuth’ approach. Steps
Action
1 2 3 4 5 6 7 8
Preparation of the data Definition of the unit analysis Development of categories & coding scheme Testing of the coding scheme on a sample of test Coding all the text Assessment of coding consistency Concluding from the coded data Reporting Methods & findings
3.6. Ethics The Ethics Committee of Tarbiat Modares University approved the study (the approval code: 555.5187; November 10, 2014). After explaining the aims and the methods of the study to the participants, their informed consent was obtained. The time, place, and length of the interviews were determined according to the participants' preferences. Besides, we attempted to ensure each interviewee's privacy throughout the interview. The participants were also ensured about the confidentiality of their data and the recorded interviews. We gave all participants the latitude for discontinuing interview without experiencing any disadvantages.
4. Results In total, 97 primary codes about the contextual factors related to CAM use in nursing were extracted from seventeen interviews done with fifteen participants. The main theme of the study is ‘A potentially-supportive environment’ that is an environment in which potentials, rules and regulations, and consumer demand provide a condition which propels nurses into using CAM in their clinical practice. This main theme consists of three main categories of ‘consumer demand’, ‘environmental potentials’, and ‘optimal official regulations’ (Table 4).
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Table 3 The process of generating the ‘Consumer demand’ main category. Sample of meaning units
Sample of primary codes
Men always ask about whether to undergo cupping or not. Women also ask, for example, about leech therapy and its effectiveness. Based on my mothers' experiences, I told them that it is good (P. 1). Mothers or grandmothers ask about the effectiveness of taking cotoneaster. Sometimes, they ask about manna. I answer them that manna would be helpful but cotoneaster is not (P. 11). Some of our patients in ICU requested music therapy and got calm after receiving it (P. 7) We have experienced many instances in which patients' family members had brought herbal distillations and asked us to give them to their patients. I usually don't disagree with such therapies (P. 10). Sometimes, patients' family members make objections that nurses have avoided giving CAM to their patients or did not allow them to visit, talk with, and massage their patients. Therefore, I contacted those nurses and told them that it would have been better if they had done that (P. 6). Some family members had objections against our staffs who avoided attaching sacred wristbands to their patients. I told them, ‘Rub the wristband to your patients and then, take it to your home’ (P. 13).
Facing client's question about the appropriateness of Facing clients' some CAM questions
Subcategories
Category Consumer demand
Facing client's question about herbal compounds for managing neonatal jaundice Facing client's request for music therapy
Facing clients' requests
Facing client's request for using herbal distillations
Client's objection against nurses' inattentiveness to Facing clients' his requested CAM complaints about lack of CAM Family members' complaint against nurses' disagreement with placing sacred things at their patient's bedside
Table 4 The subcategories and categories of the 'potentially-supportive environment ' main theme. Subcategories
Category
Facing clients' questions Facing clients' requests Facing patients' complaints about lack of CAM A respectful atmosphere The presence of expert nurses in clinical settings A supportive learning environment The greater opportunity for using CAM in critical care units Optimal governmental regulations at ministerial level Optimal ward regulations Optimal human resource development regulations Optimal evaluation and supervision regulations
Consumer demand
4.1. Consumer demand The participating nurses noted that they repeatedly face their clients' questions about or request for CAM. In some instances, they even face their clients' complaints about lack of CAM in clinical settings. These conditions propel them into using CAM. 4.1.1. Facing clients' questions All participating nurses referred to situations in which they face their clients' questions (patients or their families) about CAM. They noted that sometimes clients are going to use some CAM or hear something about them and hence, have questions about them based on their own or their family members' experiences. Therefore, the participants attempted to answer their clients' questions. Participant 10 explained her experience of CAM in ICU by saying, For instance, some patients' family members say, ‘Can we massage our patients by using olive oil? Is it good for them?’ They also frequently ask about using CAM for their patients' skin or joint problems. For example, they ask, ‘Will that oil help?’ We usually allow them and they bring olive oil. Then, we and family members massage their patients.
4.1.2. Facing clients' requests There were many instances of clients or family members' requests for CAM in the participants' experiences. The participating nurses noted that sometimes, clients' requests compel them to use CAM in their clinical practice.
Environmental potentials
Optimal official regulations
A few days ago, a female patient asked me to give her a prayer book or the holy Quran to read. Besides, a patient asked us to play music for her while another one asked us to go with her to hospital yard to play. We face such patients frequently. I usually pay attention to their requests (P. 3).
4.1.3. Facing patients' complaints about lack of CAM Some CAM requested by patients or family members may be non-beneficial to them, sound scientifically questionable or not applicable in hospital wards. Therefore, a nurse may disagree with or avoid providing such therapies. Most of our participants noted that in these situations, patients make complaints about not receiving the requested CAM. Such complaints occasionally require nurses to provide the requested therapies. Participant 9 who was a head-nurse stated, In NICU, when my colleagues disagree with family members' requests for giving some oral compounds to their neonates, family members refer to me and make complaint that my colleagues have not allowed them to give that compound to their neonates. I usually back up such decisions of my colleagues. Sometimes, they complain that my colleagues have not allowed them to play some kinds of recorded supplications for their patients. In these situations, I ask them to bring prayer book, read it for their patients, and take it by themselves to their homes [instead of leaving it in the unit].
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4.2. Environmental potentials Another attribute of the potentially-supportive environment is environmental potentials. This attribute shows the potentials of clinical environments for CAM provision. Most participants referred to the different aspects of this attribute. 4.2.1. A respectful atmosphere Respecting and valuing clients' beliefs in clinical settings is one of the environmental potentials. According to the participants, nursing managers and even physicians usually respect clients' beliefs and requests and hence, they can use this opportunity to provide some kinds of CAM without having any serious concern. Of course, some sort of organizational coordination needs to be ensured prior to CAM provision. Participants 6 who was a hospital matron mentioned, We respect families' beliefs [about CAM] though they may not benefit from their beliefs and actions. The minimal benefit is that they become calm and satisfied. Nurses also know that there is no need to coordinate with higher-level managers and hence, allow patients and family members to use CAM.
4.2.2. The presence of expert nurses in clinical settings Another environmental potential is the presence of nurses who are expert in using specialized techniques. These nurses can motivate other nurses to use CAM. Moreover, the presence of such nurses paves the way for the administration of CAM by other nurses who can refer to them once needed to obtain necessary information about CAM. Some colleagues have valuable information about traditional medicine compounds and help us in this area. Two nurses in our ward are expert in this area. I have used their information in many cases (P. 6).
4.2.3. A supportive learning environment Another attribute or potential of the Iranian clinical settings for using CAM is availability of considerable learning opportunities. Valuing human resource development and implementing relevant in-service educational programs are among the potentials which automatically guide nurses towards the use of CAM. A palliative care educational program was held in our hospital. Moreover, we hold educational programs and conferences in our ward. One of our colleagues provided us with educations about managing pain and blocking pain pathways. I use the techniques which he educated to us for managing cancer patients' pain. I even educate these techniques to patients' family members (P. 15). The facilities for attending in-service educational programs and the availability of educational resources are the other environmental potentials highlighted by the study participants.
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and adult ICUs, certain kinds of patients are hospitalized, care services are very diverse, and nurses have more professional autonomy. Besides, in oncologic care units, patients are hospitalized for long periods of time and thus, nurses have considerable opportunities for using CAM in these units. In critical care units, physicians are present only for few hours and hence, nurses are responsible for all patients' affairs. Besides, CAM do not need physicians' prescription. In ICUs, nurses are the main decision makers. If the in-charge nurse permits, there would be no major barrier for other nurses to use these therapies. We administer these therapies in our unit after obtaining the in-charge nurse's permission. Participant 15 also highlighted the greater opportunity for using CAM in oncologic care wards by saying, Patients' hospital stay in this ward is lengthydthree to four days, one week, or even one month. Moreover, our patients are frequently rehospitalized. Therefore, it is possible to visit one patient for many times and hence, we have the opportunity for educating them and asking them to exercise techniques such as positive thinking and guided imagery.
4.3. Optimal official regulations Some governmental and organizational regulations, requirements of personnel development programs, and evaluation and supervision regulations can affect nurses' engagement in the administration of CAM. These factors are explained in what follows. 4.3.1. Optimal governmental regulations at ministerial level One of the governmental regulations which automatically propel nurses into using CAM is accreditation guidelines. The participants noted that through requiring nurses to develop educational pamphlets, accreditation programs have an added role in facilitating CAM use in clinical practice. Participant 8 referred to using oral dextrose for managing venipuncture pain by saying, Recently, accreditation programs have required us to calm babies before implementing painful procedures. I have used dextrose for many years and the developers of accreditation programs also have recently approved its use for calming babies. The Iranian Health System Transformation Project is another program which provides nurses with some sort of facilities and equipment and helps them use CAM in their practice. Besides, the participants noted that working in teaching hospitals, the presence of medical interns and residents in hospital wards, and the training of interns and residents by different physicians who have different attitudes towards CTs provide them with good opportunities for using such therapies. Participant 6 referred to using honey for wound management and said,
We have baby massage pamphlet, booklet, and movie in our ward. I used them as well as books in our in-ward library. Sometimes, I provide these resources to mothers or show the movie to them once the ward isn't too crowded (P. 8).
Interns and residents work in rotational working shifts and hence, they may work one day with Dr. X who allows using CAM and one day with Dr. Y who disagrees with their use. Well, residents have experienced it [i.e. the effectiveness of honey] and therefore, some of them asked us occasionally to use it.
4.2.4. The greater opportunity for using CAM in critical care units Several participants noted that in some wards, such as NICUs
The Research Councils of universities are also required to provide hospital nursing offices with the list of research priorities. Therefore, through getting informed of the titles of these
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researches, nurse managers can trace and follow the findings of studies in the area of CAM and use them at ward level. Participant 7 who was a hospital matron mentioned, The Research Council provided us with the relevant guidelines and regulations and thus, we are aware of all these activities. I also read the reports of some of these researches. For instance, one study was related to mouth wash by using an herbal compound. We removed the barriers to its use and therefore, it was used for providing mouth wash care to patients receiving mechanical ventilation.
4.3.2. Optimal ward regulations Given the types of hospital wards and patients' conditions, there are different regulations for ward management which can direct nurses toward using CAM. For instance, some of these regulations include the necessities for performing mouth wash for all patients receiving mechanical ventilation, calming restless neonates in NICUs, educating self-care activities to all patients in all hospital wards, and making it mandatory for mothers to be present in NICUs. It is mandatory for mothers to attend the unit and stay with their neonates. Therefore, they are accessible to us and we can educate them about giving massage to their neonates or we can provide kangaroo mother care to them (P. 9).
4.3.3. Optimal human resource development regulations There are certain educational obligations for nurses who are practicing nursing in hospitals. For example, they are required to participate in in-service educational programs and courses. According to the study participants, these obligations pave their way for using CAM. Besides, the obligation to hold in-ward monthly conferences and transfer to colleagues the information acquired in in-service educational programs can also contribute to the easier use of CAM by nurses in their clinical practice. I participated in in-service educational programs. We have to attend such programs at least 50 hours a year. Well, I try to attend the programs that are beneficial to me and my ward. For instance, I attended a kangaroo mother care course (P. 11).
4.3.4. Optimal evaluation and supervision regulations According to the participants, some regulations on evaluation and supervision, such as round programs and performance evaluation procedures, can help nurses use CAM in their practice. Nursing administrators' periodic rounds can directly and indirectly affect the use of these therapies. During their rounds, they can educate nurses and provide them with constructive feedbacks and thus, help them maintain the continuity of CAM. Participants 7 who was a hospital matron said, During rounds, I see that nurses administer these therapies. I provide them with feedbacks. I have the experience of working in ICU and hence, am able to transfer my experience to ICU headnurses. I have seen that staffs in ICUs administer these therapies. In addition, patient education and patient satisfaction evaluation forms include implicit items on the use of CAM. Such items can be effective in directing nurses toward using CAM. Participant 7 mentioned,
What I want to say is patient education; we have items such as patient education about dietary regimens and stress management in our evaluation forms. Another item is on patient satisfaction. Most patients and family members are satisfied with nurses' practice. Employing these techniques brings about patient satisfaction. Therefore, we pay attention to these items in the way that I told. Of course, some of the relevant items are included in ward round forms explicitly. Participants 13 who was a clinical supervisor referred to this fact by saying, Ward round forms include items on massage, patient education, pressure ulcer prevention and care, and pain and anxiety management. We greatly value these items for the sake of accreditation.
5. Discussion This study explored the opportunities for using CAM in Iranian clinical settings from the perspectives of nurses who used these therapies in their nursing practice. The study findings revealed that ‘consumer demand’, ‘environmental potentials’, and ‘optimal official regulations’ create a potentially-supportive environment’ which directs nurses toward integrating CAM into their nursing care services. One of the attributes of the potentially-supportive environment was consumer demand. The study participants' experiences included instances of clients' questions about or requests for CAM. Previous quantitative studies showed that American nurses have also experienced similar situations [7,14]. Some qualitative studies also reported the same findings [25,39]. The results of a study on nurses' experiences of herbal therapy showed that facing patients' questions makes nurses responsible for obtaining information about medical herbs [29]. The results of several qualitative studies illustrated that healthcare professionals greatly value clients' beliefs, preferences, and requests when they want to decide on recommending CAM to clients or referring them to complementary therapists. Besides, clients' requests, beliefs, and interests have been reported to direct nurses toward greater use of these therapies [26,40,41]. Johannessen (2009) noted that one of the reasons for leaving hospital settings and working in private CAM centers among Norwegian nurses is their greater attention to humanistic values such as respecting clients' requests [42]. The results of a grounded theory study for exploring the process of accepting CAM by Korean nurses also revealed lack of applied evidence and increased social interest as contextual factors. Moreover, nurses who had participated in this study noted that after identifying patients' needs and facing their frequent questions and requests, they attempted to seek solutions, acquire knowledge, resolve their own doubts, and use the best options for overcoming patients' problems [30]. Given the increased public interest in using CAM during recent years, it is not unexpected for nurses to face patients and family members' questions about or requests for CAM. According to Cattell (1999), nurses can grasp the opportunity for attracting public interest in CAM and use these therapies in their practice in order to introduce their profession as the provider of unique and valuable services [43]. The study participants also referred to environmental potentials for using CAM which included a respectful atmosphere, the presence of expert nurses, a supportive learning environment, and the greater opportunity for using CAM in critical care units. Besides, they referred to accreditation programs as one of the attributes of their workplace which facilitate the use of CAM. The accreditation
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program has been developed and offered by the Iranian Ministry of Health and Medical Education and thus, hospitals in Iran need to implement it. This program consists of both general and specific parts. Examples of these two parts respectively include managing pain and providing care to a restless patient in ICU. Operationalizing the items of this program automatically requires nurses to use CAM. Moreover, patient education has a unique position in the program. Although implementing this program necessitates heavy paperwork, none of our participants had perceived the program as a barrier to CAM use. The effects of this program in Iranian hospitals are almost the same as the effect of the Magnet Recognition Program which helps create a favorable environment for using CAM by nurses [22]. Our findings also showed that irrespective of the accreditation program, another key attribute of a potentiallysupportive environment for CAM use was optimal official regulations which included policies for supplying and using necessary equipment, student education, great value of research and evidence-based practice, legal practice, human resource development programs, and evaluation and supervision. The findings of previous studies conducted in different countries support different aspects of our findings. For instance, a qualitative study showed that the structural constraints and the opportunities for professional CAM use in Canadian hospitals fell into three categories including the context of professional practice, organizational policies, and physical factors. Moreover, greater professional autonomy and availability of equipment, facilities, and specific protocols for CAM use were among the factors which directed healthcare professionals toward using CAM [32]. In their conceptual model, Hirschkorn and Bourgeault (2005) also noted that the contextual factors behind CAM use include physical and organizational attributes. According to them, physical attributes include access to educational resources in workplace, availability of complementary therapist, and access to appropriate space, equipment, and atmosphere while organizational attributes are organizational policies and guidelines, general or specialized workplace conditions, open and collaborative managerial relationships, routine procedures, access to research evidence, and adequate time, budget, and staffs [31]. The results of a study into the contextual factors mediating midwives' behaviors toward pregnant women's CAM use in Australia illustrated that midwives' greater professional autonomy, optimal workplace culture and relationships, and availability of relevant guidelines and policies directed midwives toward greater CAM use [26]. In line with our findings, professional autonomy has been also reported by Norwegian nurses as one of the positive workplace-related attributes for CAM use [23,42]. A qualitative study into Thai nurses' experiences of using CAM in rehabilitation centers also indicated that beside professional autonomy, other workplace-related attributes which can direct nurses toward CAM use are mutual respect and having a sense of working as a family [27]. According to Garner (2000) and Kim et al. (2013), one of the key workplace-related attributes that mediate CAM use by nurses is in-service continuing education [29,30]. Cant et al. (2012) also noted that great success in CAM use in England hospitals during the mid-1980s and the late 1990s was due to the presence of motivated, qualified, and committed health practitioners who had high professional power and great communication skills [28]. Besides, a phenomenological study on the experiences of nurses' who used CAM in Pennsylvania, USA, also revealed that some workplace-related attributes such as being a teaching healthcare center, having Magnet certification, being active in research and education, and having specialized trainers contributed to nurses' CAM use. In addition, ‘a supportive organizational culture’dwhich consists of collaborative leadership style, involvement of staffs in decision making, availability of relevant educational programs, and great professional autonomydpaves the way
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for CAM use [22]. A general overview of the findings of the present and previous studies on the contextual conditions for CAM use indicates a series of attributes which is referred to in the literature as ‘healthy work environment’. Kramer et al. (2010) noted that a healthy work environment for clinical practice is an environment in which structures, functions, systems, and policies enable nurses to provide quality and safe patient care. They also reported that the attributes of such an environment include, but not limited to, close nurse-physician relationship and collaboration, nurses' great professional autonomy, colleagues' clinical competence, patientcentered culture, support for educational programs, teamwork, quality improvement infrastructures (such as research and evidence-based practice), decentralized organizational culture, practical accreditation structures, and control over nurses' performance [44]. The Magnet Recognition Program and Magnet hospitals also include the same criteria [45]. All these findings show that creating a healthy work environment for clinical practice can enhance nurses' interest in and desire for CAM use. It is noteworthy that the number of healthy workplace-related attributes which were identified in the present study was greater than what was reported in previous studies. The greatest strengths of the present study were in-depth interviews, management of interviews by one interviewer, and involvement of all authors in the process of data analysis. However, despite our attempt to recruit a maximally varied sample, sampling from only five centers and from two cities may reduce the transferability of the findings.
6. Conclusions The findings of the present study indicate that Iranian clinical settings are potentially-supportive to CAM use. The main attributes of such a potentially-supportive environment are consumer demand, environmental potentials, and optimal official regulations for using CAM in clinical practice. In some instances, these contextual factors automatically guide nurses toward using CAM in their professional practice. Moreover, nurses can use these contextual conditions as great opportunities for administrating CAM to their clients. Health authorities, particularly nursing managers, can use the findings of this study to develop guidelines and policies for CAM use in clinical settings and integrate CAM into nursing practice. Nursing researchers can also use our findings for developing standardized instruments concerning nurses' use of CAM. Future studies are recommended to explore and identify causal conditions, barriers, and facilitators to CAM use in nursing practice, develop relevant research instruments, and construct applied models for promoting CAM use by nurses.
Authors' contribution Zahra Tagharrobi: Study design, data collection, data analysis, data interpretation and drafting of the manuscript. Sima mohammadkhan Kermanshahi, Eesa Mohammadi: Study design, data analysis, data interpretation, critical revision of the manuscript and study supervision.
Funding/Support This study was a part of PhD thesis of the first author, approved and funded by the Tarbiat Modares University, Tehran, IR Iran [No. 552.4504; October 6, 2014].
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Conflict of interest The authors declare that there are no conflicts of interest. Acknowledgements The research team would like to thank the vice chancellor of research of Tarbiat Modares University and all of the participants in this research. References [1] Committee on the Use of Complementary and Alternative Medicine by the American Public, Complementary and Alternative Medicine in the United States, The National Academies Press, Washington, D.C., 2005. [2] R. Lindqulst, M. Snyder, M.F. Tracy, Complementary& Alternative Therapies in Nursing, sixth ed., Springer Publishing Company, New York, 2014. LLC. [3] M.F. Tracy, L. Chlan, Nonpharmacological interventions to manage common symptoms in patients receiving mechanical ventilation, Crit. Care Nurse 31 (3) (2011) 19e28, http://dx.doi.org/10.4037/ccn2011653. [4] F.L. Bishop, L. Yardley, G.T. Lewith, Treat or treatment: a qualitative study analyzing patients' use of complementary and alternative medicine, Am. J. Public Health 98 (9) (2008) 1700e1705, http://dx.doi.org/10.2105/ AJPH.2007.110072. [5] A.B. Fern andez-Cervilla, A.I. Piris-Dorado, M.E. Cabrer-Vives, A. Barquerolez, Current status of complementary therapies in Spain in nursing Gonza degree, Rev. Latino Am Enferm. 21 (3) (2013) 679e686, http://dx.doi.org/ 10.1590/S0104-11692013000300005. [6] S.A. Tehrani Banihashemi, H. Asgharifard, A.A. Haghdoust, M. Barghamadi, N. Mohammad Hosseini, The use of complementary alternative medicine among the general population in tehran, Iran. Payesh 7 (4) (2008) 355e362. [7] M.R. Tracy, R. Lindquist, Savik, S. Katanuki, S. Sendelbach, M.J. Kreitzer, et al., Use of complementary and alternative therapies: a national survey of critical care nurses, Am. J. Crit. Care 14 (5) (2005) 404e415. [8] S.A. Shorofi, Complementary and alternative medicine (CAM) among hospitalized patients: reported use of CAM and reasons for use, CAM preferred during hospitalization, and the socio-demographic determinants of CAM users, Complement. Ther. Clin. Prac. 17 (4) (2011) 199e205, http://dx.doi.org/ 10.1016/j.ctcp.2011.05.001. [9] L.J. Salomonsen, L. Skovgaard, S. Cour, L. Nyborg, L. Launsø, V. Fønnebø, Use of complementary and alternative medicine at Norwegian and Danish hospitals, BMC Complement. Altern. Med. 11 (2011) 4, http://dx.doi.org/10.1186/14726882-11-4. [10] A.S. Sajadian, A. Kaviani, A. Montazeri, M. Haji mahmoudi, M. Ebrahimi, F. Samiei manesh, et al., Complementary medicine use among Iranian cancer patients, Payesh 4 (3) (2005) 198e205. [11] Y. Yom, K. Lee, A comparison of the knowledge of, experience with and attitudes towards complementary and alternative medicine between nurses and patients in Korea, J. Clin. Nurs. 17 (19) (2008) 2565e2572, http:// dx.doi.org/10.1111/j.1365-2702.2007.02065.x. [12] E. Holroyd, A.L. Zhang, L. Suen, Xue Ch, Beliefs and attitudes towards complementary medicine among registered nurses in Hong Kong, Int. J. Nurs. Stud. 45 (11) (2008) 1660e1666, http://dx.doi.org/10.1016/ j.ijnurstu.2008.04.003. [13] T. Trail-Mahan, Mao Ch, K. Bawel-Brinkley, Complementary and alternative medicine: nurses' attitudes and knowledge, Pain Manag. Nurs. 14 (4) (2013) 277e286, http://dx.doi.org/10.1016/j.pmn.2011.06.001. [14] S. Cutshall, D. Derscheid, A.G. Miers, S. Ruegg, B.J. Roeder, Tucker Sh, Knowledge, attitudes, and use of complementary and alternative therapies among clinical nurse specialists in an Academic Medical Center, Clin. Nurse Spec. 24 (23) (2010) 125e131, http://dx.doi.org/10.1097/NUR.0b013e3181d86cd1. [15] S.A. Shorofi, P. Arbon, Nurses' knowledge, attitudes, and professional use of complementary and alternative medicine (CAM): a survey at five metropolitan hospitals in Adelaide, Complement. Ther. Clin. Prac. 16 (4) (2010) 229e234, http://dx.doi.org/10.1016/j.ctcp.2010.05.008. [16] M. Cooke, M. Mitchell, E. Tiralongo, J. Murfield, Complementary and alternative medicine and critical care nurses: a survey of knowledge and practices in Australia, Aust. Crit. Care 25 (2012) 213e223, http://dx.doi.org/10.1016/ j.aucc.2011.12.055. [17] P. O'Regan, Complementary therapies: a challenge for nursing practice, Nurs. Stand 24 (21) (2010) 35e39. [18] E.N. Nottingham, Complementary and alternative medicine, Holist. Nurs. Pract. 20 (5) (2006) 242e246. [19] F.Y. Chu, M. Wallis, Taiwanese nurses' attitudes towards and use of complementary and alternative medicine in nursing practice: a cross-sectional survey, Int. J. Nurs. Stud. 44 (8) (2007) 1371e1378, http://dx.doi.org/10.1016/ j.ijnurstu.2006.07.001. [20] R. Zoe, Charalambous Ch, S. Popi, R. Maria, V. Aris, K. Agoritsa, et al., Cypriot nurses' knowledge and attitudes towards alternative medicine, Complement. Ther. Clin. Pract. 20 (1) (2014) 89e92, http://dx.doi.org/10.1016/
j.ctcp.2013.08.003. [21] M. Adib-Hajbaghery, M. Hoseinian, Knowledge, Attitude and practice toward complementary and traditional medicine among Kashan health care staff, 2012, Complement. Ther. Med. 22 (1) (2014) 126e132, http://dx.doi.org/ 10.1016/j.ctim.2013.11.009. [22] S. Kristiniak, Exploring the experiences of complementary nurses: a qualitative phenomenological study, Dissertation, MS in nursing, University of Phoenix, Arisona, 2011. [23] B. Johannessen, G. Garvik, Experiences with the use of complementary and alternative medicine in nursing homes: a focus group study, Complement. Ther. Clin. Pract. (2015), http://dx.doi.org/10.1016/j.ctcp.2015.04.003 (in press). [24] B. Johannessen, Nurses experience of aromatherapy use with dementia patients experiencing disturbed sleep patterns. An action research project, Complement. Ther. Clin. Pract. 19 (2013) 209e213, http://dx.doi.org/10.1016/ j.ctcp.2013.01.003. [25] C.E. Fletcher, A.R. Mitchinson, E.R. Trumble, D.B. Hinshaw, jA. Dusek, Perceptions of providers and administrators in the veterans health administration regarding complementary and alternative medicine, Med. Care 52 (12) (2014) S91eS96, http://dx.doi.org/10.1097/MLR.0000000000000225. [26] H.G. Hall, D.L. Griffiths, L.G. McKenna, Contextual factors that mediate midwives' behavior towards pregnant women's use of complementary and alternative medicine, Eur. J. Integr. Med. 5 (1) (2013) 68e74, http://dx.doi.org/ 10.1016/j.eujim.2012.09.002. [27] P. van der Riet, S. Dedkhard, K. Srithong, Complementary therapies in rehabilitation: nurses' narratives. Part 1, J. Clin. Nurs. 21 (5e6) (2011) 657e667, http://dx.doi.org/10.1111/j.1365-2702.2011.03852.x. [28] S. Cant, P. Watts, A. Ruston, The rise and fall of complementary medicine in National Health Service Hospitals in England, Complement. Ther. Clin. Pract. 18 (3) (2012) 135e139, http://dx.doi.org/10.1016/j.ctcp.2012.05.004. [29] V.A. Garner, Nurse Practitioners' Experience with Herbal Therapy, Dissertation MS in nursing, Uniformed Services University of the Health Sciences, Maryland, 2000. [30] A.K. Kim, Y.S. Lee, H.J. Kim, The process of acceptance of complementary and alternative therapies (CATs) among nurses: grounded theory approach, J. Korean Acad. Nurs. 43 (5) (2013) 669e680, http://dx.doi.org/10.4040/ jkan.2013.43.5.669. [31] K.A. Hirschkorn, I.L. Bourgeault, Conceptualizing mainstream health care providers' behaviors in relation to complementary and alternative medicine, Soc. Sci. Med. 61 (1) (2005) 157e170, http://dx.doi.org/10.1016/ j.socscimed.2004.11.048. [32] K.A. Hirschkorn, I.L. Bourgeault, Structural constraints and opportunities for CAM use and referral by physicians, nurses, and midwives, Health (London) 12 (2) (2008) 193e213, http://dx.doi.org/10.1177/1363459307086843. [33] D.F. Polit, C.T. Beck, Essentials of Nursing Research: Methods, Appraisal, and Utilization, seventh ed., Lippincott Williams & Wilkins Co, Philadelphia, 2010. [34] H.S. Speziale, H. Streubert, D.R. Carpenter, Qualitative Research in Nursing: Advancing the Humanistic Imperative, fifth ed., Lippincott Williams & Wilkins, Philadelphia, 2011. €s, The qualitative content analysis process, J. Adv. Nurs. 62 (1) [35] S. Elo, H. Kynga (2008) 107e115, http://dx.doi.org/10.1111/j.1365-2648.2007.04569.x. [36] H.F. Hsieh, S.E. Shannon, Three approaches to qualitative content analysis, Qual. Health Res. 15 (9) (2005) 1277e1288, http://dx.doi.org/10.1177/ 1049732305276687. [37] A. Broom, Using qualitative interviews in CAM research: a guide to study design, data collection and data analysis, Complement. Ther. Med. 13 (1) (2005) 65e73, http://dx.doi.org/10.1016/j.ctim.2005.01.001. [38] Y. Zhang, B.M. Wildemuth, Qualitative analysis of content, in: B. Wildemuth (Ed.), Applications of Social Research Methods to Questions in Information and Library Science, Libraries Unlimited, Westport, CT, 2009, pp. 308e319. [39] S.W. Bertrand, Registered nurses integrate traditional Chinese medicine into the triage process, Qual. Health Res. 22 (2) (2012) 263e273, http://dx.doi.org/ 10.1177/1049732311421681. [40] L.Y. Wong, M. Toh, K. Kong, Barriers to patient referral for complementary and alternative medicines and its implications on interventions, Complement. Ther. Med. 18 (3e4) (2010) 135e142, http://dx.doi.org/10.1016/ j.ctim.2010.05.034. [41] M. Hastings-Tolsma, D. Vincent, Decision-making for use of complementary and alternative therapies by pregnant women and nurse midwives during pregnancy: an exploratory qualitative study, Int. J. Nurs. Midwifery 5 (4) (2013) 76e89, http://dx.doi.org/10.5897/IJNM2013.0100. [42] B. Johannessen, Why do Norwegian nurses leave the public health service to practice CAM? Complement. Ther. Clin. Prac. 15 (3) (2009) 147e151, http:// dx.doi.org/10.1016/j.ctcp.2009.02.014. [43] E. Cattell, Nurse practitioners' role in complementary and alternative medicine: active or passive? Nurs. Forum 34 (3) (1999) 14e23, http://dx.doi.org/ 10.1111/j.1744-6198.1999.tb00989.x. [44] M. Kramer, C. Schmalenberg, P. Maguire, Nine structures and leadership practice essential for a magnetic (healthy) work environment, Nurs. Adm. Q. 34 (1) (2010) 4e17, http://dx.doi.org/10.1097/NAQ.0b013e3181c95ef4. [45] M. Kramer, C. Schmalenberg, P. Maguire, Essentials of a Magnetic work environment, Nursing (2008) 23e27, http://dx.doi.org/10.1097/ 01.NURSE.0000304729.97476.61.