- Email: [email protected]
Cypriot nurses' knowledge and attitudes towards alternative medicine
Complementary Therapies in Clinical Practice 20 (2014) 89e92
Contents lists available at ScienceDirect
Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctcp
Cypriot nurses’ knowledge and attitudes towards alternative medicine Roupa Zoe a, *, Charalambos Charalambous b, Sotiropoulou Popi c, Rekleiti Maria d, Vasilopoulos Aris e, Koulouri Agoritsa f, Kotrotsiou Evangelia g a
University of Nikosia, Makedonitissas 46, Nicosia 1700, Cyprus European University of Cyprus, Cyprus c Technological Educational Institute of Athens, Greece d General Hospital of Korinthos, Greece e General Hospital of Lamia, Greece f Health Center of Salamina, Greece g Technological Educational Institute of Larissa, Greece b
a b s t r a c t Keywords: Nurse Alternative medicine Attitudes
Purpose: To investigate Cypriot nurses’ knowledge and attitude towards alternative treatments. Methods: Two hundred randomly selected registered Nurses from public hospitals in Cyprus were administered an anonymous self-report questionnaire with closed-type questions. The particular questionnaire has previously been used in similar surveys. Six questions referred to demographic data and 14 questions to attitudes and knowledge towards alternative medicine. One hundred and thirty-eight questionnaires were adequately completed and evaluated. Descriptive and inferential statistics was performed. SPSS 17.0 was used. Statistical significance was set at p < 0.05. Results: Over 1/3 of our sample nurses reported that they had turned to some form of alternative treatment at some point in their lives in order to deal with a certain medical situation. Most of these nurses who reported some knowledge on specific alternative treatment methods, (75.9%) also reported using such methods within their clinical practice. The nurses who had received some form of alternative treatment reported using them more often in their clinical practice, in comparison to those who had never received such treatment (ManneWhitney U ¼ 1137, p ¼ 0.006). The more frequently nurses used alternative treatment in their clinical practice, the more interested they got in expanding their knowledge on the subject (Pearson’s r ¼ 0.250, p ¼ 0.006). Conclusion: Most nurses are familiar with alternative medicine and interested in expanding their knowledge on subject, despite the fact that they do not usually practice it. Special education and training as well as legislative actions are necessary for alternative medicine to be broadly accepted. Ó 2013 Elsevier Ltd. All rights reserved.
1. Introduction
limited and have turned towards forms of treatment which focus on human contact and holism. As De Keyser et al. report, the modern patient is aware of his rights, and more specifically the right to consent and choice of treatment regimens [4]. This led to the patients making use of that right and seeking out treatment which would provide a feeling of increased well-being. Richardson et al., add that patients, in addition to trying to control the course of the disease and the treatment regimen, they also use complementary and alternative treatment in an effort to boost the feeling of hope towards a favorable disease outcome. Last but not least, most of the available alternative treatments have either limited or no side effects at all, due to their non-toxicity [5]. In recent years, complementary and alternative medicine is often blended and integrated with conventional medicine. An increase in the usage of complementary and alternative medicine by
Complementary and alternative treatments have spread worldwide, and their implementation has increased during the last 10e15 years among the general population [1]. A research in the USA, using phone interviews, found that 67.6% of the 2055 participants, who responded, had used, at least once, a complementary or alternative form of treatment [2]. Engebrston identified some of the reasons complementary and alternative treatment have such broad appeal [3]. Nowadays, technological and scientific data and research are widely available and accessible to the public. People believe that technologically supported treatment possibilities are * Corresponding author. Tel.: þ357 22841782. E-mail address: [email protected] (R. Zoe). 1744-3881/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ctcp.2013.08.003
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R. Zoe et al. / Complementary Therapies in Clinical Practice 20 (2014) 89e92
Fig. 1. Source of information about complementary and alternative medicine.
both nurses and patients, has spawned further investigation [6]. Studies thus far commonly focus on physicians’ attitudes and practice patterns in this regard. Despite the large amount of time that nurses share with their patients and the unique nurseepatient relationship, little research has explored the nurse’s attitudes and practice regarding complementary and alternative medicine. Rankin & Box suggested that nurses interested in practicing alternative medicine should be appropriately trained, in order to understand each patient’s individuality and in which case scenario should or should not be used a particular complementary and alternative treatment [7]. There seems to be no related legislation regarding the field of complementary and alternative treatment in Cyprus and their establishment as practices with real clinical applications. Which as a result there no guidelines as to who should be responsible for their implementation, and under which authority they would act. This leads to the formation of two opposite sides; one that supports the clinical use of these therapies, and one that supports their use as part of an independent profession, differentiated from health professions. These two opposing sides are debating about the issue, trying to identify the boundaries of the field of Complementary and Alternative Medicine. There are various alternative treatments used in Cyprus, but the apparent lack of an efficient recording authority, as well as a uniform professional association, creates a huge problem in identifying and counting these forms of treatment. In this context, the study aims to investigate Cypriot nurses’ knowledge and attitude regarding alternative treatments. 2. Materials and methods The study sample consisted of 138 registered Nurses from public hospitals in Cyprus. The method used was convenience sampling and an anonymous self-completion questionnaire was used as a survey tool. The ward selection, for questionnaire distribution, was based on simple random sampling. The questionnaire was based on one used and calibrated in Israel by Freda G. De Keyser, Bella Bar Cohen and Nurit Wagner, who investigated the knowledge and attitude levels of nurses towards alternative treatment. At the same time, bibliographic research was conducted utilizing the Medline, Cinahl, Scopus and Scholar databases. Thus, the tool for our population sample was appropriately developed. The first 6 questions referred to the participants’ demographic data. The next 14 questions, aimed to reveal the sample’s attitudes and knowledge.
Fig. 2. Male and female nurses’ knowledge about CAM.
Fischer exact test) were used where appropriate, while the Pearson test was applied for data correlation. Statistical significance was set at p ¼ 0.05. SPSS 17.0 was used for statistical purposes. 4. Results The majority of the participants were females (n ¼ 87, 63%). The average age of the participants was approximately 35 years (34.97 11.29 years), while female nurses were significantly older than their male counterparts (37.97 12.04 vs 30.51 8.22 years respectively [t(132.784) ¼ 4.092, p < 0.001]). Eighty eight percent of the nurses reported that they did have some knowledge on alternative treatment, whereas only 48.6% of them could name a specific alternative treatment method. Information about alternative medicine was acquired from nurses’ studies and other health professionals by 55.6% of the respondents aware of alternative medicine (Fig. 1). Females were more informed about complementary and alternative medicine, as 91.9% had some knowledge of CAM in comparison with 76.5% of males (Fisher’s exact test p < 0.05-Fig.2). About 30% of our sample reported that they had turned to some form of alternative treatment at some point in their lives in order to deal with a certain medical situation. As shown in Fig. 3, 45.8% of the nurses do not use such methods in clinical practice and only 12.7% of them apply them often, or very often. Cypriot nurses showed medium to high interest in expanding their knowledge on the subject, as 71.4% of nurses stated that they were much, or very much interested in alternative therapies (Fig.4). Doctors more frequently than nurses applied alternative therapies, according to sample’s opinion (34.6% as compared to 28.7%). Ninety three percent of the respondents felt that scientific evidence is an absolute requirement for the use of such treatments. 74.0% of the nurses stated that the positive responses to alternative treatment cannot be attributed solely to the placebo effect. Regarding the
3. Statistics Descriptive and inferential statistics were performed. Parametric (t-test) and non-parametric tests (ManneWhitney, x2,
Fig. 3. Frequency of CAM practice among participants.
R. Zoe et al. / Complementary Therapies in Clinical Practice 20 (2014) 89e92
Fig. 4. Interest of knowledge expansion about complementary and alternative medicine.
potential side effects, Cypriot nurses provided conflicting answers, since about half of them stated that there is no chance alternative treatments could be harmful to health, whereas the other half (44.9%) reported that there is a good chance for that. 85.7% of the nurses responded the same regarding whether alternative medicine should be used in conjunction with conventional medicine or not. The only factor that seemed to be associated with the degree of desire for knowledge expansion on alternative treatments was the frequency by which nurses were using them in clinical practice. The more often nurses used alternative treatment in clinical practice, the more interested they got in expanding their knowledge on the subject (Pearson’s r ¼ 0.250, p ¼ 0.006). The Nurses who had received some form of alternative treatment reported to use them more often in their clinical practice, in comparison to those who had never received such treatment (ManneWhitney U ¼ 1137, p ¼ 0.006). The nurses’ age [t(136) ¼ 0.263, p ¼ 0.793], their educational background (Fisher’s exact test, p ¼ 0.462), or their occupational position (Fisher’s exact test, p ¼ 0.481) did not seem to be associated with level of knowledge about alternative treatments and the related applied fields. 5. Discussion According to the findings of this study, nurses have positive attitude towards alternative medicine, although their knowledge is rather fragmental. Over 1/3 of the sample reported that they had turned to some form of alternative treatment at some point in their lives in order to deal with a certain medical situation. These rates are similar to the respective European rates, as shown in various researches. For example, in a large pan-European research, the rate of patients with cancer who were using alternative treatment ranged, depending on the country, from 14.8% to 73.1%, with an average of 35.9% [8]. Alternative treatment, however, is widely popular, not only in the UK but all over the world [9]. European rates are about half of the respective Australian one, where a 74% reported that they had used such a method at least once, or of the respective rates in the USA, which were 67.6% [10,11]. Previous studies show an increased interest and usage of complementary and alternative medicine (CAM) in the general population and among health care workers both internationally and nationally [12]. When registered health professionals (physicians, nurses and physiotherapists) were asked about CAM, it was found that 72.8% were interested in reading CAM-research results, and 27.8% would consider taking part in such research. Half of the participants (55.8%) were positive in learning such therapy. The findings of Cooke et al. suggest that critical care nurses endorse current complementary and alternative medicine use and support further education in the field. Cutshall et al. found that clinical nurse specialists use several CAM therapies personally and also
91
use them for professional practice with patients [13]. Their results indicated that most clinical nurses specialists thought CAM therapies were beneficial and there was some evidence for use of these therapies by nurses themselves. However, ‘lack of a clear definition’, ‘limited experience’ and a ‘high interest’ towards complementary and alternative medicine were the major findings among nurses in a Taiwan survey [6]. Out of the Nurses who had some knowledge on a specific alternative treatment method, most of them (75.9%) use such methods in clinical practice. Although this is not stipulated by law, it seems to be becoming accepted, provided it has a clearly defined role [14]. Similarly, a more positive view was expressed by people who were either using alternative treatment on themselves on a daily basis, or had more knowledge on the subject [15,16]. Most Cypriot nurses feel that patients have little interest in using alternative treatment. This is not consistent with other research findings, such as De Keyser et al., where 85% of the nurses feel differently [4] or Fitch et al., where nurses recognize that alternative treatment is used by many people of a different sociodemographic background [17]. Nevertheless, the view of the nurses in our study is probably somewhat true, since in the wider Greek area, alternative treatments are used less frequently than in the rest of the European countries [8]. Despite the fact that alternative treatments were only used by a few people on a regular basis, Cypriot nurses showed a medium to high interest in expanding their knowledge on the subject, even the ones who responded that they had absolutely no idea of what that is, or how it is implemented. Similar results were found in studies in Canada, Israel, in Nursing students in Turkey, even in Finland, where, even though the majority of the nurses had a negative stance on the subject and were lacking the appropriate training, about half of them showed an interest in participating in the related training courses [4,18,19]. The finding, that in our sample nurses who use such methods, are also interested in learning more about them, is mainly attributed to the fact that their interest is not purely Academic, but it concerns the practical, professional implementation of CAM. Similarly, the majority of our sample, and especially the young and inexperienced ones, agreed that these methods require supervision by a highly specialized and experienced personnel. In other studies, nurses, despite their positive stance on the subject, expressed their skepticism regarding the way alternative treatment would be implemented inside the official care provision system [14]. In the study of King, Pettigrew, & Reed, on a Likert-type scale from 1 to 5 (1 ¼ I totally disagree and 5 ¼ I totally agree), nurses reported (3.34/5) that alternative treatment, not backed by scientific evidence, should not be immediately discarded [18]. This is not consistent with our findings, where 93.1% of the respondents on the same question felt that scientific evidence is an absolute requirement for the use of such treatments. Similarly, the nurses in the study of Tracy et al. deemed alternative treatment not sufficiently backed by scientific evidence, compared to conventional treatment [16]. Regarding the potential side effects, Cypriot nurses were conflicted. Their answers give rise to serious questions about their awareness of alternative medicine, since the rate of patients who use alternative treatment and reported any side effect was just 4.4% in the pan-European study [8]. That excessive fear/overreaction by our participants could perhaps be attributed to their partial or complete ignorance; however, this interpretation is not consistent with the fact that, in our study, nurses who had received some form of alternative treatment, in comparison to the ones who had not, reported, at a higher rate, that alternative treatment could, in fact, be harmful to health! A
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research in a sample of Canadian oncology Nurses showed that the attitude of Nurses towards complementary and alternative treatment were positive, showing that Nurses should be the people who act as a physician-patient mediator, when it comes to complementary and alternative treatment issues [17]. Almost all of the nurses reported that they were aware of what constitutes alternative medicine and when it can be implemented, even though the majority of them did not particularly use them. Most of them showed an interest in expanding their knowledge regarding alternative treatment, while 1/3 of them had themselves received such treatment before, with most of them being satisfied by it. For all the above reasons, special education and training courses for nurses are required, as well as related legislative actions and appropriate guidelines, in terms of the techniques and the health professionals certified to provide them, with universally accepted scientific standards, established after further research, in order to obtain reliable data, which will be assessed and applied on respective populations using alternative medicine. Perhaps our main research limitation was the small, from a statistical perspective, sample size. Of course, taking into consideration the overall number of registered nurses in Cyprus, our 200 participants are a substantial sample. However, in order to make comparisons between subgroups, e.g. male and female, users of alternative treatment and non users, etc., further investigation is required. Therefore, due to the small statistical power of the analyses, it is possible that the importance of many of the variables affecting nurses’ attitudes and knowledge has not been underlined sufficiently. Moreover, since the sampling was simple random, and not stratified, the comparison between certain groups, with potential scientific interest (e.g. Junior Nurses vs. Senior Nurses), could not be conducted, due to the statistically expected small number of the latter. The only way to overcome that boundary would be to expand our research sample in the wider Greek area or/and to other health professions, to clarify how the various aspects of health professionals affect their attitudes and knowledge towards alternative treatment. Conflict of interest None declared.
References [1] Ernst E, White A. The BBC survey of complementary medicine use in the UK. Complement Ther Med 2000;8:32e6. [2] Kessler RC, Davis RB, Foster DF, Van Rompay MI, Walters EE, Wilkey SA, et al. Long-term trends in the use of complementary and alternative medical therapies in the United States. Ann Intern Med 2001;135(4):262e8. [3] Engebretson J. Alternative and complementary healing: implications for nursing. J Prof Nurs 1999;15:214e23. [4] DeKeyser FG, Bar Cohen B, Wagner N. Knowledge levels and attitudes of staff nurses in Israel towards complementary and alternative medicine. J Adv Nurs 2001;36(1):41e8. [5] Richardson MA, Sanders T, Palmer JL, Greisinger A, Singletary SE. Complementary/alternative medicine use in a comprehensive cancer center and the implications for oncology. J Clin Oncol 2000;18:2505e14. [6] Smith GD, Wu SC. Nurses’ beliefs, experiences and practice regarding complementary and alternative medicine in Taiwan. J Clin Nurs 2012;21(17e18): 2659e67. [7] Rankin-Box D. Innovation in practice: complementary therapies in nursing. Complement Ther Med 1993;1:30e3. [8] Mollasiotis A, Fernandez-Ortega P, Pud D, Ozden G, Scott JA, Panteli V, et al. Use of complementary and alternative medicine in cancer patients: a European survey. Ann Oncol 2005;16:665e73. [9] Trevelyan T, Booth B. Fringe benefits. Nurs Times 1993;89:30e3. [10] Wilkinson JM, Simpson MD. Personal and professional use of complementary therapies by nurses in NSW, Australia. Complement Ther Nurs Midwifery 2002;8(3):142e7. [11] Kessler RC, Soukup J, Davis RB, Foster DF, Wilkey SA, Van Rompay MI, et al. The use of complementary and alternative therapies to treat anxiety and depression in the United States. Am J Psychiatry 2001;158(2):289e94. [12] Bjerså K, Stener Victorin E, Fagevik Olsén M. Knowledge about complementary, alternative and integrative medicine (CAM) among registered health care providers in Swedish surgical care: a national survey among university hospitals. BMC Complement Altern Med 2012;12(12):42. [13] Cutshall S, Derscheid D, Miers AG, Ruegg S, Schroeder BJ, Tucker S, et al. Knowledge, attitudes, and use of complementary and alternative therapies among clinical nurse specialists in an academic medical center. Clin Nurse Spec 2010;24(3):125e31. [14] Rojas-Cooley M Teresa, Grant Marcia. Complementary and alternative medicine: oncology nurses knowledge and attitudes. Oncol Nurs Forum 2009:217e24. [15] Salmenpera L, Suominen T, Lauri S. Oncology nurses attitudes towards alternative medicine. Psycho-oncol 1998:453e9. [16] Tracy MF, Lindquist R, Savik K, Watanuki S, Sendelbach S, Kreitzer MJ, et al. Use of complementary and alternative therapies: a national survey of critical care nurses. Am J Crit Care 2005;14:404e16. [17] Fitch MI, Gray RE, Greenberg M, Douglas MS, Labrecgue M, Pavlin P, et al. Oncology nurses perspectives on unconventional therapies. Cancer Nurs 1999;22:90e6. [18] King MO, Pettigrew AC, Reed FC. Complementary alternative, integrative: have nurses kept pace with their clients? Medsurg Nurs 1999;8:249e56. [19] Uzun Ö, Tan M. Nursing students’ opinions and knowledge about complementary and alternative medicine therapies. Complement Ther Nurs Midwifery 2004;10(4):239e44.
Contents lists available at ScienceDirect
Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctcp
Cypriot nurses’ knowledge and attitudes towards alternative medicine Roupa Zoe a, *, Charalambos Charalambous b, Sotiropoulou Popi c, Rekleiti Maria d, Vasilopoulos Aris e, Koulouri Agoritsa f, Kotrotsiou Evangelia g a
University of Nikosia, Makedonitissas 46, Nicosia 1700, Cyprus European University of Cyprus, Cyprus c Technological Educational Institute of Athens, Greece d General Hospital of Korinthos, Greece e General Hospital of Lamia, Greece f Health Center of Salamina, Greece g Technological Educational Institute of Larissa, Greece b
a b s t r a c t Keywords: Nurse Alternative medicine Attitudes
Purpose: To investigate Cypriot nurses’ knowledge and attitude towards alternative treatments. Methods: Two hundred randomly selected registered Nurses from public hospitals in Cyprus were administered an anonymous self-report questionnaire with closed-type questions. The particular questionnaire has previously been used in similar surveys. Six questions referred to demographic data and 14 questions to attitudes and knowledge towards alternative medicine. One hundred and thirty-eight questionnaires were adequately completed and evaluated. Descriptive and inferential statistics was performed. SPSS 17.0 was used. Statistical significance was set at p < 0.05. Results: Over 1/3 of our sample nurses reported that they had turned to some form of alternative treatment at some point in their lives in order to deal with a certain medical situation. Most of these nurses who reported some knowledge on specific alternative treatment methods, (75.9%) also reported using such methods within their clinical practice. The nurses who had received some form of alternative treatment reported using them more often in their clinical practice, in comparison to those who had never received such treatment (ManneWhitney U ¼ 1137, p ¼ 0.006). The more frequently nurses used alternative treatment in their clinical practice, the more interested they got in expanding their knowledge on the subject (Pearson’s r ¼ 0.250, p ¼ 0.006). Conclusion: Most nurses are familiar with alternative medicine and interested in expanding their knowledge on subject, despite the fact that they do not usually practice it. Special education and training as well as legislative actions are necessary for alternative medicine to be broadly accepted. Ó 2013 Elsevier Ltd. All rights reserved.
1. Introduction
limited and have turned towards forms of treatment which focus on human contact and holism. As De Keyser et al. report, the modern patient is aware of his rights, and more specifically the right to consent and choice of treatment regimens [4]. This led to the patients making use of that right and seeking out treatment which would provide a feeling of increased well-being. Richardson et al., add that patients, in addition to trying to control the course of the disease and the treatment regimen, they also use complementary and alternative treatment in an effort to boost the feeling of hope towards a favorable disease outcome. Last but not least, most of the available alternative treatments have either limited or no side effects at all, due to their non-toxicity [5]. In recent years, complementary and alternative medicine is often blended and integrated with conventional medicine. An increase in the usage of complementary and alternative medicine by
Complementary and alternative treatments have spread worldwide, and their implementation has increased during the last 10e15 years among the general population [1]. A research in the USA, using phone interviews, found that 67.6% of the 2055 participants, who responded, had used, at least once, a complementary or alternative form of treatment [2]. Engebrston identified some of the reasons complementary and alternative treatment have such broad appeal [3]. Nowadays, technological and scientific data and research are widely available and accessible to the public. People believe that technologically supported treatment possibilities are * Corresponding author. Tel.: þ357 22841782. E-mail address: [email protected] (R. Zoe). 1744-3881/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ctcp.2013.08.003
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R. Zoe et al. / Complementary Therapies in Clinical Practice 20 (2014) 89e92
Fig. 1. Source of information about complementary and alternative medicine.
both nurses and patients, has spawned further investigation [6]. Studies thus far commonly focus on physicians’ attitudes and practice patterns in this regard. Despite the large amount of time that nurses share with their patients and the unique nurseepatient relationship, little research has explored the nurse’s attitudes and practice regarding complementary and alternative medicine. Rankin & Box suggested that nurses interested in practicing alternative medicine should be appropriately trained, in order to understand each patient’s individuality and in which case scenario should or should not be used a particular complementary and alternative treatment [7]. There seems to be no related legislation regarding the field of complementary and alternative treatment in Cyprus and their establishment as practices with real clinical applications. Which as a result there no guidelines as to who should be responsible for their implementation, and under which authority they would act. This leads to the formation of two opposite sides; one that supports the clinical use of these therapies, and one that supports their use as part of an independent profession, differentiated from health professions. These two opposing sides are debating about the issue, trying to identify the boundaries of the field of Complementary and Alternative Medicine. There are various alternative treatments used in Cyprus, but the apparent lack of an efficient recording authority, as well as a uniform professional association, creates a huge problem in identifying and counting these forms of treatment. In this context, the study aims to investigate Cypriot nurses’ knowledge and attitude regarding alternative treatments. 2. Materials and methods The study sample consisted of 138 registered Nurses from public hospitals in Cyprus. The method used was convenience sampling and an anonymous self-completion questionnaire was used as a survey tool. The ward selection, for questionnaire distribution, was based on simple random sampling. The questionnaire was based on one used and calibrated in Israel by Freda G. De Keyser, Bella Bar Cohen and Nurit Wagner, who investigated the knowledge and attitude levels of nurses towards alternative treatment. At the same time, bibliographic research was conducted utilizing the Medline, Cinahl, Scopus and Scholar databases. Thus, the tool for our population sample was appropriately developed. The first 6 questions referred to the participants’ demographic data. The next 14 questions, aimed to reveal the sample’s attitudes and knowledge.
Fig. 2. Male and female nurses’ knowledge about CAM.
Fischer exact test) were used where appropriate, while the Pearson test was applied for data correlation. Statistical significance was set at p ¼ 0.05. SPSS 17.0 was used for statistical purposes. 4. Results The majority of the participants were females (n ¼ 87, 63%). The average age of the participants was approximately 35 years (34.97 11.29 years), while female nurses were significantly older than their male counterparts (37.97 12.04 vs 30.51 8.22 years respectively [t(132.784) ¼ 4.092, p < 0.001]). Eighty eight percent of the nurses reported that they did have some knowledge on alternative treatment, whereas only 48.6% of them could name a specific alternative treatment method. Information about alternative medicine was acquired from nurses’ studies and other health professionals by 55.6% of the respondents aware of alternative medicine (Fig. 1). Females were more informed about complementary and alternative medicine, as 91.9% had some knowledge of CAM in comparison with 76.5% of males (Fisher’s exact test p < 0.05-Fig.2). About 30% of our sample reported that they had turned to some form of alternative treatment at some point in their lives in order to deal with a certain medical situation. As shown in Fig. 3, 45.8% of the nurses do not use such methods in clinical practice and only 12.7% of them apply them often, or very often. Cypriot nurses showed medium to high interest in expanding their knowledge on the subject, as 71.4% of nurses stated that they were much, or very much interested in alternative therapies (Fig.4). Doctors more frequently than nurses applied alternative therapies, according to sample’s opinion (34.6% as compared to 28.7%). Ninety three percent of the respondents felt that scientific evidence is an absolute requirement for the use of such treatments. 74.0% of the nurses stated that the positive responses to alternative treatment cannot be attributed solely to the placebo effect. Regarding the
3. Statistics Descriptive and inferential statistics were performed. Parametric (t-test) and non-parametric tests (ManneWhitney, x2,
Fig. 3. Frequency of CAM practice among participants.
R. Zoe et al. / Complementary Therapies in Clinical Practice 20 (2014) 89e92
Fig. 4. Interest of knowledge expansion about complementary and alternative medicine.
potential side effects, Cypriot nurses provided conflicting answers, since about half of them stated that there is no chance alternative treatments could be harmful to health, whereas the other half (44.9%) reported that there is a good chance for that. 85.7% of the nurses responded the same regarding whether alternative medicine should be used in conjunction with conventional medicine or not. The only factor that seemed to be associated with the degree of desire for knowledge expansion on alternative treatments was the frequency by which nurses were using them in clinical practice. The more often nurses used alternative treatment in clinical practice, the more interested they got in expanding their knowledge on the subject (Pearson’s r ¼ 0.250, p ¼ 0.006). The Nurses who had received some form of alternative treatment reported to use them more often in their clinical practice, in comparison to those who had never received such treatment (ManneWhitney U ¼ 1137, p ¼ 0.006). The nurses’ age [t(136) ¼ 0.263, p ¼ 0.793], their educational background (Fisher’s exact test, p ¼ 0.462), or their occupational position (Fisher’s exact test, p ¼ 0.481) did not seem to be associated with level of knowledge about alternative treatments and the related applied fields. 5. Discussion According to the findings of this study, nurses have positive attitude towards alternative medicine, although their knowledge is rather fragmental. Over 1/3 of the sample reported that they had turned to some form of alternative treatment at some point in their lives in order to deal with a certain medical situation. These rates are similar to the respective European rates, as shown in various researches. For example, in a large pan-European research, the rate of patients with cancer who were using alternative treatment ranged, depending on the country, from 14.8% to 73.1%, with an average of 35.9% [8]. Alternative treatment, however, is widely popular, not only in the UK but all over the world [9]. European rates are about half of the respective Australian one, where a 74% reported that they had used such a method at least once, or of the respective rates in the USA, which were 67.6% [10,11]. Previous studies show an increased interest and usage of complementary and alternative medicine (CAM) in the general population and among health care workers both internationally and nationally [12]. When registered health professionals (physicians, nurses and physiotherapists) were asked about CAM, it was found that 72.8% were interested in reading CAM-research results, and 27.8% would consider taking part in such research. Half of the participants (55.8%) were positive in learning such therapy. The findings of Cooke et al. suggest that critical care nurses endorse current complementary and alternative medicine use and support further education in the field. Cutshall et al. found that clinical nurse specialists use several CAM therapies personally and also
91
use them for professional practice with patients [13]. Their results indicated that most clinical nurses specialists thought CAM therapies were beneficial and there was some evidence for use of these therapies by nurses themselves. However, ‘lack of a clear definition’, ‘limited experience’ and a ‘high interest’ towards complementary and alternative medicine were the major findings among nurses in a Taiwan survey [6]. Out of the Nurses who had some knowledge on a specific alternative treatment method, most of them (75.9%) use such methods in clinical practice. Although this is not stipulated by law, it seems to be becoming accepted, provided it has a clearly defined role [14]. Similarly, a more positive view was expressed by people who were either using alternative treatment on themselves on a daily basis, or had more knowledge on the subject [15,16]. Most Cypriot nurses feel that patients have little interest in using alternative treatment. This is not consistent with other research findings, such as De Keyser et al., where 85% of the nurses feel differently [4] or Fitch et al., where nurses recognize that alternative treatment is used by many people of a different sociodemographic background [17]. Nevertheless, the view of the nurses in our study is probably somewhat true, since in the wider Greek area, alternative treatments are used less frequently than in the rest of the European countries [8]. Despite the fact that alternative treatments were only used by a few people on a regular basis, Cypriot nurses showed a medium to high interest in expanding their knowledge on the subject, even the ones who responded that they had absolutely no idea of what that is, or how it is implemented. Similar results were found in studies in Canada, Israel, in Nursing students in Turkey, even in Finland, where, even though the majority of the nurses had a negative stance on the subject and were lacking the appropriate training, about half of them showed an interest in participating in the related training courses [4,18,19]. The finding, that in our sample nurses who use such methods, are also interested in learning more about them, is mainly attributed to the fact that their interest is not purely Academic, but it concerns the practical, professional implementation of CAM. Similarly, the majority of our sample, and especially the young and inexperienced ones, agreed that these methods require supervision by a highly specialized and experienced personnel. In other studies, nurses, despite their positive stance on the subject, expressed their skepticism regarding the way alternative treatment would be implemented inside the official care provision system [14]. In the study of King, Pettigrew, & Reed, on a Likert-type scale from 1 to 5 (1 ¼ I totally disagree and 5 ¼ I totally agree), nurses reported (3.34/5) that alternative treatment, not backed by scientific evidence, should not be immediately discarded [18]. This is not consistent with our findings, where 93.1% of the respondents on the same question felt that scientific evidence is an absolute requirement for the use of such treatments. Similarly, the nurses in the study of Tracy et al. deemed alternative treatment not sufficiently backed by scientific evidence, compared to conventional treatment [16]. Regarding the potential side effects, Cypriot nurses were conflicted. Their answers give rise to serious questions about their awareness of alternative medicine, since the rate of patients who use alternative treatment and reported any side effect was just 4.4% in the pan-European study [8]. That excessive fear/overreaction by our participants could perhaps be attributed to their partial or complete ignorance; however, this interpretation is not consistent with the fact that, in our study, nurses who had received some form of alternative treatment, in comparison to the ones who had not, reported, at a higher rate, that alternative treatment could, in fact, be harmful to health! A
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research in a sample of Canadian oncology Nurses showed that the attitude of Nurses towards complementary and alternative treatment were positive, showing that Nurses should be the people who act as a physician-patient mediator, when it comes to complementary and alternative treatment issues [17]. Almost all of the nurses reported that they were aware of what constitutes alternative medicine and when it can be implemented, even though the majority of them did not particularly use them. Most of them showed an interest in expanding their knowledge regarding alternative treatment, while 1/3 of them had themselves received such treatment before, with most of them being satisfied by it. For all the above reasons, special education and training courses for nurses are required, as well as related legislative actions and appropriate guidelines, in terms of the techniques and the health professionals certified to provide them, with universally accepted scientific standards, established after further research, in order to obtain reliable data, which will be assessed and applied on respective populations using alternative medicine. Perhaps our main research limitation was the small, from a statistical perspective, sample size. Of course, taking into consideration the overall number of registered nurses in Cyprus, our 200 participants are a substantial sample. However, in order to make comparisons between subgroups, e.g. male and female, users of alternative treatment and non users, etc., further investigation is required. Therefore, due to the small statistical power of the analyses, it is possible that the importance of many of the variables affecting nurses’ attitudes and knowledge has not been underlined sufficiently. Moreover, since the sampling was simple random, and not stratified, the comparison between certain groups, with potential scientific interest (e.g. Junior Nurses vs. Senior Nurses), could not be conducted, due to the statistically expected small number of the latter. The only way to overcome that boundary would be to expand our research sample in the wider Greek area or/and to other health professions, to clarify how the various aspects of health professionals affect their attitudes and knowledge towards alternative treatment. Conflict of interest None declared.
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