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Experiences with the use of complementary and alternative medicine in nursing homes: A focus group study
Complementary Therapies in Clinical Practice xxx (2015) 1e5
Contents lists available at ScienceDirect
Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctcp
Experiences with the use of complementary and alternative medicine in nursing homes: A focus group study Berit Johannessen*, Gitte Garvik Institute of Health and Nursing Science, University of Agder, Norway
a b s t r a c t Keywords: CAM Nursing home Aromatherapy Pet therapy Music therapy
Introduction: The use of complementary and alternative medicine is increasing outside the Norwegian public health service. The purpose of this study was to gain insight into the experiences of nurses and auxiliary nurses with the use of CAM in care for nursing home residents. Method: Focus group interviews with a total of thirteen nurses and auxiliary nurses from three nursing homes were conducted. Data were analyzed using systematic text condensation. Results: Participants had experiences from aromatherapy, plant medicine, music therapy and pet therapy. They experienced the use of CAM as effective, exciting and rewarding, but also challenging and dependent on supportive leaders. CAM supported person-centered and holistic care. The participants lacked competence and knowledge. Conclusion: Nurses and auxiliary nurses were enthusiastic about using CAM in their care for nursing home residents, but they lacked knowledge about it. The status of CAM in nursing education programs must be examined. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction The health care service in Norway is free and governmentfunded, but Complementary and alternative medicine (CAM) is not generally available in this service. People who want to be treated with CAM must buy this kind of treatment at the private market. In 2007 the Norwegian government opened and funded a website called nifab.no. Nifab is NAFKAMs (Norway's National Research Center in Complementary and Alternative Medicine) website for providing the Norwegian population with evidencebased information about CAM. The proportion of the population using CAM depends on how one defines the term, but a 2012 survey showed that 45% of the general Norwegian population uses CAM [1]. The young are more frequent CAM users than are the elderly and the most commonly used treatments are massage, acupuncture and reflexology [1].One study found that CAM is increasingly provided at governmentfunded hospitals, and that hospital employee's interest in CAM was the most common reason it is offered, except for integration of * Corresponding author. Institute of Health and Nursing Science, University of Agder, Servicebox 422, 4604 Kristiansand, Norway. Tel.: þ47 38141869, þ47 91380696. E-mail address: [email protected] (B. Johannessen).
acupuncture, which is usually initiated by the administration and offered to women in labor [2,3]. Attitudes toward CAM vary among staff, a survey showed that nurses and auxiliary nurses express positive attitudes far more (70%) than physicians (16%), and nurses and auxiliary nurses are more frequent CAM users (40%) than physicians (12%) [4]. The survey also revealed a desire for more knowledge. The national guidelines for nursing education do not emphasize teaching about CAM. Also international studies show that nurses are positive toward CAM but lack knowledge about it [8e10]. Except for acupuncture, education in CAM therapies is not offered in the Norwegian publicly approved, free health education programs. Education within CAM is offered in private schools and costs money. There are about 900 nursing homes in Norway, but the use of CAM in nursing homes has not yet been explored, and little research has been done on the use of CAM in care of nursing home residents. Work to date has focused on music therapy [5], animalassisted therapy [6], and the use of aromatherapy [7]. A 2012 review [11] showed that there has generally been little research on the use of CAM in nursing homes, although one Australian study showed that many nursing homes are using CAM, with an emphasis on aromatherapy and music [12]. The researchers of the present study work at a nursing school, and some nursing students having their clinical studies in nursing
http://dx.doi.org/10.1016/j.ctcp.2015.04.003 1744-3881/© 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Johannessen B, Garvik G, Experiences with the use of complementary and alternative medicine in nursing homes: A focus group study, Complementary Therapies in Clinical Practice (2015), http://dx.doi.org/10.1016/j.ctcp.2015.04.003
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B. Johannessen, G. Garvik / Complementary Therapies in Clinical Practice xxx (2015) 1e5
homes told that they experienced the use of CAM during this clinical placement. This, connected to the fact that nurses are positive towards CAM, led to the development of a research question: How do nurses and auxiliary nurses experience the use of CAM in care for nursing home residents? There is sparse insight into how nurses and auxiliary nurses experience the use of CAM in nursing homes. Therefore, the purpose of this study was to gain knowledge about their experiences with the use of CAM in care for nursing home residents. This knowledge can also be valuable in planning for a larger national survey about the use of CAM in nursing homes. 2. Method A qualitative research design grounded in phenomenology and hermeneutics was used [13] and focus group interviews were chosen as the method for data collection. Focus group interviews are appropriate when people with a common background gather to discuss a given topic. The method also helps participants to reflect on their own practice. The empirical material comprises the quotations that represent participants’ conversations and interactions [13]. Interviews are conducted so that the participant dynamics allow for an exchange and comparison of experiences. In this context, disagreements can lead to more complete descriptions than would have been gained through individual interviews. The focus group is led by a moderator who facilitates an open atmosphere in which participants feel they can express their personal, and possibly conflicting, views. Although the ideal focus group is 5e8 participants, in this project, the number varied from 4 to 5 because it was difficult to recruit a larger number. That said, smaller groups are easier for the researcher to manage and more comfortable for the participants [13].
inductive approach that started with meaning condensation, categorization and thematization. The four analysis steps were: (i) reading all the material to obtain an overall impression and noting preconceptions; (ii) identifying units of meaning and coding different aspects of the participants' experiences; (iii) condensing and abstracting the meaning within each of the coded groups; and (iv) summarizing the contents of each code group to generalize descriptions and concepts to a main theme reflecting the participants’ most important experiences. All analysis phases were conducted by both authors in close cooperation. The quotations were first read to get an overall impression of the topics that were most important to the participants. All text was then coded, sorted and reviewed again. Each quotation with the same content was combined and condensed. Finally, each quotation was categorized under specific themes. Previous research, relevant theory and the authors' preunderstanding are used to critically interpret the participants’ contributions toward a deeper understanding of the results. 2.3. Ethics The ethical principles of autonomy, beneficence, nonmaleficence and justice were followed, as was the Helsinki Declaration. The study was approved by the Research Ethics Committee at the University of Agder (FEK) and the Norwegian Social Science Data Services (NSD) approved procedures for the storage of personal and audio data. The information letter was repeated verbally before the interviews and the researchers emphasized that participation was voluntary and that data would be anonymous. All study participants signed an informed consent. Potential risk to the participants was evaluated against the potential benefit of study outcomes. The participants expressed joy at being useful and that their experiences were valued.
2.1. Selection and implementation 3. Results About 20 nursing homes in South of Norway were contacted, and invitation to participate in the study were sent to three of the nursing homes that told that they offered CAM. In these three nursing homes, the staff had experiences with aromatherapy, herbal medicine, animal-assisted therapy and music therapy. Requests for permission to conduct the focus group interviews were sent to the head nurses who then distributed information about the study to those who had experience with one or more CAM therapies. One focus group interview was conducted at each of the three nursing homes during spring 2013. The first group was 5 participants (4 nurses and 1 auxiliary nurse, 30e50 years old, with 2e20 years of experience in their current positions). The second group was 4 participants (1 nurse, 3 auxiliary nurses, 25e60 years old, with 2e40 years of experience in their current positions). The third group was 4 participants (2 nurses, 2 auxiliary nurses, 30e50 years old, with 2e25 years of experience in their current positions). Recorded interviews lasted approximately 90 min and were conducted at the nursing homes. The interviews were organized around a semistructured interview guide. The main themes were the types of CAM therapies in which they had participated, their competence, knowledge and attitudes toward CAM, and their experiences of its use and effects. All participants were actively engaged in the interview. 2.2. Analysis A phenomenological hermeneutic approach was used, for which participants' experiences are central and the researchers' preunderstanding is incorporated into the interpretation of the findings. Fifty-two pages of transcribed text were analyzed using an
All focus group participants had experience with aromatherapy in the forms of massage and portable aromatherapy diffusion. Two groups had experience with the use of tea tree oil and aloe vera to treat wounds and skin problems. Furthermore, all groups had experience with music therapy, while two groups had experience with animal-assisted therapy. None of the participants were educated in any form of CAM, but they had joined smaller courses before the methods were implemented in the ward. None of the participants told about any clear policies about CAM. 3.1. CAM was perceived as inspiring and rewarding Participants spoke in various ways about how CAM was an exciting field about which they were curious. They described how inspiring it had been to take courses offered by the administration. In one such course, they learned about aromatic oils about which they had no previous knowledge. Several participants commented that working in a nursing home that offered CAM was professionally inspiring and made their daily work more rewarding. One said: “I think working with patients suffering from dementia is fantastic. It's one of the most exciting things. And I see that in dementia care, we can use a tremendous number of alternatives.” Several participants experienced positive feedback from their use of CAM; one said: “It's a little fun to talk about it privately too. I get to hear that we are a little brave.” Participants liked and were proud to work at an institution that encouraged the use of CAM: “I think it's very exciting with complementary and alternative options in nursing homes, so I fit in very well here!”
Please cite this article in press as: Johannessen B, Garvik G, Experiences with the use of complementary and alternative medicine in nursing homes: A focus group study, Complementary Therapies in Clinical Practice (2015), http://dx.doi.org/10.1016/j.ctcp.2015.04.003
B. Johannessen, G. Garvik / Complementary Therapies in Clinical Practice xxx (2015) 1e5
Their positive experiences with CAM were seen as inspiring. One participant described how she discovered the effect of tea tree oil for wound care: “After a few days the heel was completely different and I just had to share it with the others who were at work. The heel was completely different. The wound was gone.” Others shared how inspiring it was when they could use CAM as a substitute for medications like sleeping pills and sedatives, which they perceived as having multiple side effects. They were inspired when they were able to give holistic care. 3.2. Attitudes to CAM have changed in a positive direction Participants said that in their experience, attitudes toward CAM had changed over time. One of the nurses put it this way: “Before there was more doubt and skepticism, and there are still some reactions, do you really believe in it?’” They perceive themselves as being open to new knowledge and wanting to share their experiences with their colleagues. One group said that there had been a change in attitude among the staff since they first began to use essential oils. They said they now experienced aromatherapy as part of daily care but stressed that this would not have happened without the efforts of the nurse leaders and those who believed in it from the beginning. However, participants also noted that to change attitudes it is critical that they are able to justify their treatment choice. One participant said: “The challenge is that you should know why you do things. It makes it so much easier to explain and justify. When you can show the scientific documentation and explain the effects, it has a great impact on how you are viewed by others.” Several statements concerned how other professionals impact staff attitudes toward CAM. For instance, all the focus groups described their collaboration with physicians as mostly positive and open and believed they were fortunate to work with physicians who did not view CAM negatively. One group described a nurse leader who was a trained aromatherapist and who shared her knowledge about essential oils in an inspiring way. They expressed great confidence in her skills. One of the participants said: “We've kind of had a living encyclopedia.” In another example, a scientific staff seminar by a gerontologist led them to try essential oils on the ward. The nurses and auxiliary nurses described a work environment where they could make their own independent decisions about what kind of methods they wanted to use. One group described how the nurse leader supported them when they wanted to get a cat, only pointing out that they had to take full responsibility for the animal. The managers of two of the nursing homes had given aromatherapy diffusors to each of the employees as a Christmas gift, which was interpreted as their having a positive and open attitude toward aromatherapy. One of the groups commented that when they were hiring new nurses, applicants were informed during their interview about the institution's use of CAM and they were asked about their own attitudes towards CAM. 3.3. CAM had a positive effect on patients All focus group participants referred to successful examples of use of CAM. Music was used often at all three nursing homes. One participant described the first time she experienced the positive effect of music: “The resident liked to dance and I could dance with her to the music; it was positive for both of us e it was a positive day for me too when I used the music.” Others expressed how music could work: “The effect you see there and then, the joy of it, their happy facial expression, they are singing along and they clap and they are moving. Music has a big effect.” Sometimes participants combined music with hand massage to help patients relax. One of the groups had more experience than the others with aromatherapy
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and spoke about the lead nurse who was a trained aromatherapist: “She mixed a body cream for someone who had very dry skin. She added some aroma oils in avocado oil. It had an incredibly good effect on old, dry skin.” Others told about patients who suffered from anxiety and depression and the positive impact of bergamot oil in an aromatherapy diffusor. One participant referred to the family members’ reaction when they visited their grandmother who used to suffer from depression: “What in the world has happened? She seems so happy.” Some participants shared the positive results they had in using tea tree oil combined with aloe vera in wound care and tea tree oil for nail fungus. All focus groups found that medications were reduced or discontinued while patients received essential oils. One participant who had given patients lavender oil for sleep problems said: “I saw that it worked. Several types of sleeping pills were taken away from the patient, they did not have any effect, but lavender helped her a lot.” Some spoke of the positive impact pets could have on patients with externalizing behavior. One nurse described a patient: “This patient was angry and never let us do anything with her, but she was very calm and quiet, we even got to cut her hair while she was petting the dog in her lap.” Another spoke about a resident who had such a good response to contact with a cat that: “She stopped using sedatives and I think that was due largely to the cat.” One of the nursing homes had an egg incubator and hatched chicks and one participant talked about how excited everyone was when the chickens hatched, how everyone smiled when they carried the chickens around in baskets for everyone to see and hold. One participant described a patient who could not speak Norwegian: “When she held the chickens, she smiled from ear to ear and talked a lot but I could not understand. She was very happy, I could see that she was familiar with chickens. It was a very positive moment.” 3.4. Challenges of using CAM All groups described that it can be difficult to implement CAM. The challenges were connected to residents’ conditions, cooperation between the staff and performing the CAM treatments. The nursing home residents have multiple diagnoses; some receive palliative care, the majority have dementia and many suffer from agitation. One participant noted that they had to protect therapy pets from an agitated and aggressive resident. The participants stated that they could not always plan more than a day ahead. One participant wanted to give two of her patients aromatherapy but: “I was a bit unlucky with the two residents I chose. One died after a few days and the other was transferred to another ward because her disease was worsening.” Participants also noted that implementing CAM requires knowledge, planning, structure and dedication to achieve good results. Except for minor courses, none of the participants were educated in CAM. One group stated that it was a challenge to get all employees to agree on pets because of allergies, hygiene, fear of animals and the extra responsibility involved. One said this about the cat they obtained: “If there are questions about the cat, they are mine to answer. I take responsibility for it even though I'm not very fond of cats.” Another stressed the importance of teamwork and loyalty: “It's important to be clear that everyone must agree to implement what is decided. It worked when we tried out the lavender for patients with sleep problems. We appealed to the staff to carry out what was decided.” Staff shortage could prevent CAM implementation and all the focus group participants talked about how difficult it could be to convince other employees to adopt new therapies e some wanted to do things the way they had always been done.
Please cite this article in press as: Johannessen B, Garvik G, Experiences with the use of complementary and alternative medicine in nursing homes: A focus group study, Complementary Therapies in Clinical Practice (2015), http://dx.doi.org/10.1016/j.ctcp.2015.04.003
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Participants also talked about the importance of a motivator so that they would not lose interest. All participants had experienced skepticism from others. One expressed it this way: “Not everyone is convinced about CAM, we always meet some kind of resistance.” One group described a physician trying to stop them from using essential oils, while another group said that they were working together with the physicians at their ward toward use of CAM instead of sedatives. There were different opinions on this and it led to a great deal of discussion. When it came to the use of aromatherapy diffusors, participants said that the scent could be challenging. Not everyone liked the scent and some even claimed that it gave them headaches. Some participants also stated that it could be challenging to offer CAM to patients suffering from dementia or to inform and cooperate with their relatives. 4. Discussion Study findings show that nurses' and auxiliary nurses' experienced the use of CAM as inspiring and rewarding. This is consistent with findings from other studies showing a positive attitude toward CAM among nurses and assistant nurses [4]. None of the participants in this study were educated in CAM, but they got their training by small courses. One nurse who was also educated aromatherapist held courses and inspired the staff at all the three nursing homes. The training in CAM seems to be weak and unstructured driven by positive engagement more than structured knowledge, this is consistent with former findings [2]. Lack of knowledge has been revealed in several studies [8e10,17]. Knowledge is central to the integration of CAM in nursing care and it is imperative that nurses have in-depth knowledge about how these therapies work and their potential adverse interactions with conventional medicine; nevertheless, the integration of CAM in nursing education programs seem to be weak [17]. The CAM methods offered corresponds to those used in Australian nursing homes [12], and also support nurses' desire for their work to be more holistic [14]. The participants’ experiences with the positive effects of CAM seemed to be a stimulating factor in their everyday work and they enjoyed being able to provide such services. Moreover, they were motivated to try new things and to be included in decisions, which is important for job satisfaction [15]. In a Norwegian national health report [16] emphasizing the need for new working methods and scientific approaches in elder care, John Maynard Keynes were quoted: “The difficulty lies not in getting new ideas, but in escaping the old ones, which branches out to every corner of the mind.” ([16]:83). Participants in the present study tried new methods and perceived themselves as bold and experimental. This innovative approach is highlighted as important in future care [16]. That our participants’ motivation to use CAM was linked to their own interests and experiences, active engagement of staff as well as support from positive leaders, is consistent with previous research [18,19]. Participants in this study were motivated by their experience that CAM led to decreased use of medication, which is also confirmed by previous research [11]. The use of medications is common and extensive in nursing homes, even though drugs often do not have the desired effects and serious side effects [20]. Some researchers claim that alternative treatments should be selected before medications [21]. For example, for agitation in dementia, several nonpharmacological interventions have been found to be effective. A review from Australia found that aromatherapy was used extensively in elder care facilities to manage dementia symptoms and age-related physical discomfort and that the use of medication was reduced [23]. Music therapy [5,24] and
aromatherapy [25] have also been studied widely and found to be valuable for nursing home residents. When medications and conventional care do not provide the desired results, it may lead to greater openness toward CAM. Further, every positive experience with CAM is perceived as rewarding and supports its use on more patients. However, a lack of health policy interest in CAM [17] inhibits change toward its more widespread use [26]. The participants in this study described how some of their residents were fond of music, some slept better with a lavender aroma, and others relaxed with a cat on their lap. Research confirms that providing such person-centered care is satisfying and motivating for the caregivers [27,28] and that it improves the quality of life for people with dementia in nursing homes [19]. Further, the importance of working with committed colleagues and supportive leaders is highlighted as crucial when offering CAM. Research confirms that visible leaders who give encouraging feedback are important for retaining nursing home staff [15]. However, it is not obvious that colleagues and leaders, or particularly physicians, support the use of CAM [4,11]. Several participants described it as an ongoing challenge that their colleagues did not believe in what they were doing and that they did not support their choices. This might also be connected to a lack of knowledge about the efficacy of CAM and a blurred responsibility between nurses and physicians. Internationally, CAM is becoming integrated into nursing [29,30] but this connection is not yet common in Norway. 4.1. Methodological considerations Using focus groups for data collection may have weaknesses, including a group effect [13]. If a strong individual makes a statement, others may have difficulty contradicting them. The moderator did not detect such patterns in this study but some participants were more active than others. On the other hand, focus groups may also stimulate participant reflections on the topic and thereby enrich the findings. In a focus group study, it is crucial for internal validity that the participants and researchers have a common understanding of the issues under discussion [13]. Further, the use of quotations strengthens the study's validity, so does the consensus of findings between this and other studies. Despite the limited number of study participants, the resulting empirical data were rich and varied. One evident limitation was that the study participants had only experienced four different CAM therapies. Choosing other nursing homes may have provided greater variety. 5. Conclusion The purpose of this study was to gain knowledge about how nurses and auxiliary nurses experience the use of CAM in nursing homes. Their CAM use was limited to music therapy, animalassisted therapy and aromatherapy. The results showed that participants experienced CAM as effective and both professionally and personally interesting and rewarding. CAM support personcentered care and their colleagues and leaders were predominantly supportive, though the participants also experienced some challenges including negative attitudes and lack of knowledge. Knowledge about CAM in Norwegian nursing homes is limited and a national survey about the use of and knowledge about CAM is needed. A decision about the status of CAM in nursing education programs and nursing practice is also needed. Conflict of interest statement There is no conflict of interest.
Please cite this article in press as: Johannessen B, Garvik G, Experiences with the use of complementary and alternative medicine in nursing homes: A focus group study, Complementary Therapies in Clinical Practice (2015), http://dx.doi.org/10.1016/j.ctcp.2015.04.003
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References [1] Fønnebø V. Rapport: NAFKAM undersøkelsen. 2012. http://nifab.no/om_ alternativ_behandling/tall_og_fakta/nafkam_undersoekelsen_2012. [2] Fønnebø V, Launsø L. High use of complementary and alternative medicine inside and outside of the government funded health care system in Norway. J Altern Complement Med 2009;15(10):1061e6. [3] Salomonsen LJ, Skovgaard L, la Cour S, Nyborg L, Launsø L, Fønnebø V. Use of complementary and alternative medicine at Norwegian and Danish hospitals. BMC Complement Altern Med 2011;11:4. [4] Risberg T, Kolstad A. Alternativ medisin- holdninger og bruk blant sykehusansatte leger, sykepleiere og kontorpersonell i Nord-Norge. Tidsskrift Den norske lægeforening 2003;123(6):604e6. [5] Myskja A, Nord PG. “The day the music died” a pilot study on music and depression in a nursing home. Nordic J Music Ther 2008;17(1):30e40. [6] Myren IK, Kvaal K, Braastad BO. Hund og katt i sykehjem- et bidrag i miljøbehandling? Demens Alderpsykiatri 2011;15(2):24e6. [7] Johannessen B. Nurses experience of aromatherapy use with dementia patients experiencing disturbed sleep patterns. An action research project. J Complement Ther Clin Pract 2013;19(4):209e13. [8] Shorofi SA, Arbon P. Nurses' knowledge, attitudes, and professional use of complementary and alternative medicine (CAM): a survey at five metropolitan hospitals in Adelaide. Complement Ther Clin Pract 2010;16: 229e34. [9] Holroyd E, Zang AL, Suen LKP, Xue CCL. Beliefs and attitudes towards complementary medicine among registered nurses in Hong Kong. Int J Nurs Stud 2008;45:1660e6. [10] Trail-Mahan T, Mao C-L, Bawel-Brinkley K. Complementary and alternative medicine: nurses' attitudes and knowledge. Pain Manag Nurs 2013 Dec;14(4): 277e86. [11] Bauer M, Rayner J-A. Use of complementary and alternative medicine in residential aged care. J Altern Complement Med 2012;18(11):989e93. [12] Webber GR. Complementary therapies in dementia care: which therapies are used in South Australian nursing homes? Counterpoints 2003;3:61e71. [13] Malterud K. Fokusgrupper som forskningsmetode for medisin og helsefag. Oslo: Universitetsforlaget; 2012. [14] Johannessen B. Why do Norwegian nurses leave the public health service to practice CAM? J Complement Ther Clin Pract 2009;15:147e51.
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[15] Bergland Å. Hvordan få sykepleiere til å se på sykehjem som en fremtidig arbeidsplass? Tidsskriftet Sykepleien 2010;98:52e4. [16] Helse og Omsorgsdepartementet. Meld. St. 29. 2012e2013. Morgendagens omsorg. [17] O'Reagan P, et al. Complementary therapies: a challenge for nursing practice. Nurs Stand 2010;24(21):35e9. [18] Johannessen B. Realization and development of self in CAM nurses and CAM treatment: a qualitative study. Int J Hum Caring 2011;15. 14-2029. [19] Lawrence V, Fossey J, Ballard C, Moniz-Cook E, Murray J. Improving quality of life for people with dementia in car homes: making psychosocial interventions work. Br J Psychiatry 2012;201:344e51. [20] Selbæk G, Kirkevold Ø, Engedal K. Psychiatric and behavioural symptoms and the use of psychotropic medication in special care units and regular units in Norwegian nursing homes. Scand J Caring Sci 2008;22:568e73. [21] Dewing J. Responding to medication in people with dementia. Nurs Older People 2010;5:83e92. [23] Bowles EJ, Cheras P, Stevens J, Myers S. A survey of aromatherapy practices in aged care facilities in northern NSW Australia. Int J Aromather 2005;15(1): 42e50. [24] Wall M, Duffy A. The effects of music therapy for older people with dementia. Br J Nurs 2010;19(2):108e13. [25] Fung JK, Tsang HWT, Chung RCK. A systematic review of the use of aromatherapy in treatment of behavioral problems in dementia. Geriatr Gerontol Int 2012;12:372e82. [26] Knox K, Fønnebø V, Falkenberg T. Emerging complementary and alternative medicine policy initiatives and the need for dialogue. J Altern Complement Med 2009;15:959e62. [27] van den Pol-Grevelink A, Jukema JS, Smits CHM. Person centered care and job satisfaction of caregivers in nursing homes: a systematic review of the impact of different forms of person centered care on various dimensions of job satisfaction. Geriatr Psychiatry 2012;27:219e29. [28] Wallin OA, Jacobsen U, Edberg A-K. Job satisfaction and associated variables among nurse assistants working in residential care. Int Psychogeriatr Assoc 2012;24:1904e18. [29] Snyder M, Lindquist R. Complementary/alternative therapies in nursing. New York: Springer Pub; 2006. [30] Rankin Box D. The Nurse's handbook of complementary therapies. London: re Tindall/Royal College of Nursing; 2001. Baillie
Please cite this article in press as: Johannessen B, Garvik G, Experiences with the use of complementary and alternative medicine in nursing homes: A focus group study, Complementary Therapies in Clinical Practice (2015), http://dx.doi.org/10.1016/j.ctcp.2015.04.003
Contents lists available at ScienceDirect
Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctcp
Experiences with the use of complementary and alternative medicine in nursing homes: A focus group study Berit Johannessen*, Gitte Garvik Institute of Health and Nursing Science, University of Agder, Norway
a b s t r a c t Keywords: CAM Nursing home Aromatherapy Pet therapy Music therapy
Introduction: The use of complementary and alternative medicine is increasing outside the Norwegian public health service. The purpose of this study was to gain insight into the experiences of nurses and auxiliary nurses with the use of CAM in care for nursing home residents. Method: Focus group interviews with a total of thirteen nurses and auxiliary nurses from three nursing homes were conducted. Data were analyzed using systematic text condensation. Results: Participants had experiences from aromatherapy, plant medicine, music therapy and pet therapy. They experienced the use of CAM as effective, exciting and rewarding, but also challenging and dependent on supportive leaders. CAM supported person-centered and holistic care. The participants lacked competence and knowledge. Conclusion: Nurses and auxiliary nurses were enthusiastic about using CAM in their care for nursing home residents, but they lacked knowledge about it. The status of CAM in nursing education programs must be examined. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction The health care service in Norway is free and governmentfunded, but Complementary and alternative medicine (CAM) is not generally available in this service. People who want to be treated with CAM must buy this kind of treatment at the private market. In 2007 the Norwegian government opened and funded a website called nifab.no. Nifab is NAFKAMs (Norway's National Research Center in Complementary and Alternative Medicine) website for providing the Norwegian population with evidencebased information about CAM. The proportion of the population using CAM depends on how one defines the term, but a 2012 survey showed that 45% of the general Norwegian population uses CAM [1]. The young are more frequent CAM users than are the elderly and the most commonly used treatments are massage, acupuncture and reflexology [1].One study found that CAM is increasingly provided at governmentfunded hospitals, and that hospital employee's interest in CAM was the most common reason it is offered, except for integration of * Corresponding author. Institute of Health and Nursing Science, University of Agder, Servicebox 422, 4604 Kristiansand, Norway. Tel.: þ47 38141869, þ47 91380696. E-mail address: [email protected] (B. Johannessen).
acupuncture, which is usually initiated by the administration and offered to women in labor [2,3]. Attitudes toward CAM vary among staff, a survey showed that nurses and auxiliary nurses express positive attitudes far more (70%) than physicians (16%), and nurses and auxiliary nurses are more frequent CAM users (40%) than physicians (12%) [4]. The survey also revealed a desire for more knowledge. The national guidelines for nursing education do not emphasize teaching about CAM. Also international studies show that nurses are positive toward CAM but lack knowledge about it [8e10]. Except for acupuncture, education in CAM therapies is not offered in the Norwegian publicly approved, free health education programs. Education within CAM is offered in private schools and costs money. There are about 900 nursing homes in Norway, but the use of CAM in nursing homes has not yet been explored, and little research has been done on the use of CAM in care of nursing home residents. Work to date has focused on music therapy [5], animalassisted therapy [6], and the use of aromatherapy [7]. A 2012 review [11] showed that there has generally been little research on the use of CAM in nursing homes, although one Australian study showed that many nursing homes are using CAM, with an emphasis on aromatherapy and music [12]. The researchers of the present study work at a nursing school, and some nursing students having their clinical studies in nursing
http://dx.doi.org/10.1016/j.ctcp.2015.04.003 1744-3881/© 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Johannessen B, Garvik G, Experiences with the use of complementary and alternative medicine in nursing homes: A focus group study, Complementary Therapies in Clinical Practice (2015), http://dx.doi.org/10.1016/j.ctcp.2015.04.003
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homes told that they experienced the use of CAM during this clinical placement. This, connected to the fact that nurses are positive towards CAM, led to the development of a research question: How do nurses and auxiliary nurses experience the use of CAM in care for nursing home residents? There is sparse insight into how nurses and auxiliary nurses experience the use of CAM in nursing homes. Therefore, the purpose of this study was to gain knowledge about their experiences with the use of CAM in care for nursing home residents. This knowledge can also be valuable in planning for a larger national survey about the use of CAM in nursing homes. 2. Method A qualitative research design grounded in phenomenology and hermeneutics was used [13] and focus group interviews were chosen as the method for data collection. Focus group interviews are appropriate when people with a common background gather to discuss a given topic. The method also helps participants to reflect on their own practice. The empirical material comprises the quotations that represent participants’ conversations and interactions [13]. Interviews are conducted so that the participant dynamics allow for an exchange and comparison of experiences. In this context, disagreements can lead to more complete descriptions than would have been gained through individual interviews. The focus group is led by a moderator who facilitates an open atmosphere in which participants feel they can express their personal, and possibly conflicting, views. Although the ideal focus group is 5e8 participants, in this project, the number varied from 4 to 5 because it was difficult to recruit a larger number. That said, smaller groups are easier for the researcher to manage and more comfortable for the participants [13].
inductive approach that started with meaning condensation, categorization and thematization. The four analysis steps were: (i) reading all the material to obtain an overall impression and noting preconceptions; (ii) identifying units of meaning and coding different aspects of the participants' experiences; (iii) condensing and abstracting the meaning within each of the coded groups; and (iv) summarizing the contents of each code group to generalize descriptions and concepts to a main theme reflecting the participants’ most important experiences. All analysis phases were conducted by both authors in close cooperation. The quotations were first read to get an overall impression of the topics that were most important to the participants. All text was then coded, sorted and reviewed again. Each quotation with the same content was combined and condensed. Finally, each quotation was categorized under specific themes. Previous research, relevant theory and the authors' preunderstanding are used to critically interpret the participants’ contributions toward a deeper understanding of the results. 2.3. Ethics The ethical principles of autonomy, beneficence, nonmaleficence and justice were followed, as was the Helsinki Declaration. The study was approved by the Research Ethics Committee at the University of Agder (FEK) and the Norwegian Social Science Data Services (NSD) approved procedures for the storage of personal and audio data. The information letter was repeated verbally before the interviews and the researchers emphasized that participation was voluntary and that data would be anonymous. All study participants signed an informed consent. Potential risk to the participants was evaluated against the potential benefit of study outcomes. The participants expressed joy at being useful and that their experiences were valued.
2.1. Selection and implementation 3. Results About 20 nursing homes in South of Norway were contacted, and invitation to participate in the study were sent to three of the nursing homes that told that they offered CAM. In these three nursing homes, the staff had experiences with aromatherapy, herbal medicine, animal-assisted therapy and music therapy. Requests for permission to conduct the focus group interviews were sent to the head nurses who then distributed information about the study to those who had experience with one or more CAM therapies. One focus group interview was conducted at each of the three nursing homes during spring 2013. The first group was 5 participants (4 nurses and 1 auxiliary nurse, 30e50 years old, with 2e20 years of experience in their current positions). The second group was 4 participants (1 nurse, 3 auxiliary nurses, 25e60 years old, with 2e40 years of experience in their current positions). The third group was 4 participants (2 nurses, 2 auxiliary nurses, 30e50 years old, with 2e25 years of experience in their current positions). Recorded interviews lasted approximately 90 min and were conducted at the nursing homes. The interviews were organized around a semistructured interview guide. The main themes were the types of CAM therapies in which they had participated, their competence, knowledge and attitudes toward CAM, and their experiences of its use and effects. All participants were actively engaged in the interview. 2.2. Analysis A phenomenological hermeneutic approach was used, for which participants' experiences are central and the researchers' preunderstanding is incorporated into the interpretation of the findings. Fifty-two pages of transcribed text were analyzed using an
All focus group participants had experience with aromatherapy in the forms of massage and portable aromatherapy diffusion. Two groups had experience with the use of tea tree oil and aloe vera to treat wounds and skin problems. Furthermore, all groups had experience with music therapy, while two groups had experience with animal-assisted therapy. None of the participants were educated in any form of CAM, but they had joined smaller courses before the methods were implemented in the ward. None of the participants told about any clear policies about CAM. 3.1. CAM was perceived as inspiring and rewarding Participants spoke in various ways about how CAM was an exciting field about which they were curious. They described how inspiring it had been to take courses offered by the administration. In one such course, they learned about aromatic oils about which they had no previous knowledge. Several participants commented that working in a nursing home that offered CAM was professionally inspiring and made their daily work more rewarding. One said: “I think working with patients suffering from dementia is fantastic. It's one of the most exciting things. And I see that in dementia care, we can use a tremendous number of alternatives.” Several participants experienced positive feedback from their use of CAM; one said: “It's a little fun to talk about it privately too. I get to hear that we are a little brave.” Participants liked and were proud to work at an institution that encouraged the use of CAM: “I think it's very exciting with complementary and alternative options in nursing homes, so I fit in very well here!”
Please cite this article in press as: Johannessen B, Garvik G, Experiences with the use of complementary and alternative medicine in nursing homes: A focus group study, Complementary Therapies in Clinical Practice (2015), http://dx.doi.org/10.1016/j.ctcp.2015.04.003
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Their positive experiences with CAM were seen as inspiring. One participant described how she discovered the effect of tea tree oil for wound care: “After a few days the heel was completely different and I just had to share it with the others who were at work. The heel was completely different. The wound was gone.” Others shared how inspiring it was when they could use CAM as a substitute for medications like sleeping pills and sedatives, which they perceived as having multiple side effects. They were inspired when they were able to give holistic care. 3.2. Attitudes to CAM have changed in a positive direction Participants said that in their experience, attitudes toward CAM had changed over time. One of the nurses put it this way: “Before there was more doubt and skepticism, and there are still some reactions, do you really believe in it?’” They perceive themselves as being open to new knowledge and wanting to share their experiences with their colleagues. One group said that there had been a change in attitude among the staff since they first began to use essential oils. They said they now experienced aromatherapy as part of daily care but stressed that this would not have happened without the efforts of the nurse leaders and those who believed in it from the beginning. However, participants also noted that to change attitudes it is critical that they are able to justify their treatment choice. One participant said: “The challenge is that you should know why you do things. It makes it so much easier to explain and justify. When you can show the scientific documentation and explain the effects, it has a great impact on how you are viewed by others.” Several statements concerned how other professionals impact staff attitudes toward CAM. For instance, all the focus groups described their collaboration with physicians as mostly positive and open and believed they were fortunate to work with physicians who did not view CAM negatively. One group described a nurse leader who was a trained aromatherapist and who shared her knowledge about essential oils in an inspiring way. They expressed great confidence in her skills. One of the participants said: “We've kind of had a living encyclopedia.” In another example, a scientific staff seminar by a gerontologist led them to try essential oils on the ward. The nurses and auxiliary nurses described a work environment where they could make their own independent decisions about what kind of methods they wanted to use. One group described how the nurse leader supported them when they wanted to get a cat, only pointing out that they had to take full responsibility for the animal. The managers of two of the nursing homes had given aromatherapy diffusors to each of the employees as a Christmas gift, which was interpreted as their having a positive and open attitude toward aromatherapy. One of the groups commented that when they were hiring new nurses, applicants were informed during their interview about the institution's use of CAM and they were asked about their own attitudes towards CAM. 3.3. CAM had a positive effect on patients All focus group participants referred to successful examples of use of CAM. Music was used often at all three nursing homes. One participant described the first time she experienced the positive effect of music: “The resident liked to dance and I could dance with her to the music; it was positive for both of us e it was a positive day for me too when I used the music.” Others expressed how music could work: “The effect you see there and then, the joy of it, their happy facial expression, they are singing along and they clap and they are moving. Music has a big effect.” Sometimes participants combined music with hand massage to help patients relax. One of the groups had more experience than the others with aromatherapy
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and spoke about the lead nurse who was a trained aromatherapist: “She mixed a body cream for someone who had very dry skin. She added some aroma oils in avocado oil. It had an incredibly good effect on old, dry skin.” Others told about patients who suffered from anxiety and depression and the positive impact of bergamot oil in an aromatherapy diffusor. One participant referred to the family members’ reaction when they visited their grandmother who used to suffer from depression: “What in the world has happened? She seems so happy.” Some participants shared the positive results they had in using tea tree oil combined with aloe vera in wound care and tea tree oil for nail fungus. All focus groups found that medications were reduced or discontinued while patients received essential oils. One participant who had given patients lavender oil for sleep problems said: “I saw that it worked. Several types of sleeping pills were taken away from the patient, they did not have any effect, but lavender helped her a lot.” Some spoke of the positive impact pets could have on patients with externalizing behavior. One nurse described a patient: “This patient was angry and never let us do anything with her, but she was very calm and quiet, we even got to cut her hair while she was petting the dog in her lap.” Another spoke about a resident who had such a good response to contact with a cat that: “She stopped using sedatives and I think that was due largely to the cat.” One of the nursing homes had an egg incubator and hatched chicks and one participant talked about how excited everyone was when the chickens hatched, how everyone smiled when they carried the chickens around in baskets for everyone to see and hold. One participant described a patient who could not speak Norwegian: “When she held the chickens, she smiled from ear to ear and talked a lot but I could not understand. She was very happy, I could see that she was familiar with chickens. It was a very positive moment.” 3.4. Challenges of using CAM All groups described that it can be difficult to implement CAM. The challenges were connected to residents’ conditions, cooperation between the staff and performing the CAM treatments. The nursing home residents have multiple diagnoses; some receive palliative care, the majority have dementia and many suffer from agitation. One participant noted that they had to protect therapy pets from an agitated and aggressive resident. The participants stated that they could not always plan more than a day ahead. One participant wanted to give two of her patients aromatherapy but: “I was a bit unlucky with the two residents I chose. One died after a few days and the other was transferred to another ward because her disease was worsening.” Participants also noted that implementing CAM requires knowledge, planning, structure and dedication to achieve good results. Except for minor courses, none of the participants were educated in CAM. One group stated that it was a challenge to get all employees to agree on pets because of allergies, hygiene, fear of animals and the extra responsibility involved. One said this about the cat they obtained: “If there are questions about the cat, they are mine to answer. I take responsibility for it even though I'm not very fond of cats.” Another stressed the importance of teamwork and loyalty: “It's important to be clear that everyone must agree to implement what is decided. It worked when we tried out the lavender for patients with sleep problems. We appealed to the staff to carry out what was decided.” Staff shortage could prevent CAM implementation and all the focus group participants talked about how difficult it could be to convince other employees to adopt new therapies e some wanted to do things the way they had always been done.
Please cite this article in press as: Johannessen B, Garvik G, Experiences with the use of complementary and alternative medicine in nursing homes: A focus group study, Complementary Therapies in Clinical Practice (2015), http://dx.doi.org/10.1016/j.ctcp.2015.04.003
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Participants also talked about the importance of a motivator so that they would not lose interest. All participants had experienced skepticism from others. One expressed it this way: “Not everyone is convinced about CAM, we always meet some kind of resistance.” One group described a physician trying to stop them from using essential oils, while another group said that they were working together with the physicians at their ward toward use of CAM instead of sedatives. There were different opinions on this and it led to a great deal of discussion. When it came to the use of aromatherapy diffusors, participants said that the scent could be challenging. Not everyone liked the scent and some even claimed that it gave them headaches. Some participants also stated that it could be challenging to offer CAM to patients suffering from dementia or to inform and cooperate with their relatives. 4. Discussion Study findings show that nurses' and auxiliary nurses' experienced the use of CAM as inspiring and rewarding. This is consistent with findings from other studies showing a positive attitude toward CAM among nurses and assistant nurses [4]. None of the participants in this study were educated in CAM, but they got their training by small courses. One nurse who was also educated aromatherapist held courses and inspired the staff at all the three nursing homes. The training in CAM seems to be weak and unstructured driven by positive engagement more than structured knowledge, this is consistent with former findings [2]. Lack of knowledge has been revealed in several studies [8e10,17]. Knowledge is central to the integration of CAM in nursing care and it is imperative that nurses have in-depth knowledge about how these therapies work and their potential adverse interactions with conventional medicine; nevertheless, the integration of CAM in nursing education programs seem to be weak [17]. The CAM methods offered corresponds to those used in Australian nursing homes [12], and also support nurses' desire for their work to be more holistic [14]. The participants’ experiences with the positive effects of CAM seemed to be a stimulating factor in their everyday work and they enjoyed being able to provide such services. Moreover, they were motivated to try new things and to be included in decisions, which is important for job satisfaction [15]. In a Norwegian national health report [16] emphasizing the need for new working methods and scientific approaches in elder care, John Maynard Keynes were quoted: “The difficulty lies not in getting new ideas, but in escaping the old ones, which branches out to every corner of the mind.” ([16]:83). Participants in the present study tried new methods and perceived themselves as bold and experimental. This innovative approach is highlighted as important in future care [16]. That our participants’ motivation to use CAM was linked to their own interests and experiences, active engagement of staff as well as support from positive leaders, is consistent with previous research [18,19]. Participants in this study were motivated by their experience that CAM led to decreased use of medication, which is also confirmed by previous research [11]. The use of medications is common and extensive in nursing homes, even though drugs often do not have the desired effects and serious side effects [20]. Some researchers claim that alternative treatments should be selected before medications [21]. For example, for agitation in dementia, several nonpharmacological interventions have been found to be effective. A review from Australia found that aromatherapy was used extensively in elder care facilities to manage dementia symptoms and age-related physical discomfort and that the use of medication was reduced [23]. Music therapy [5,24] and
aromatherapy [25] have also been studied widely and found to be valuable for nursing home residents. When medications and conventional care do not provide the desired results, it may lead to greater openness toward CAM. Further, every positive experience with CAM is perceived as rewarding and supports its use on more patients. However, a lack of health policy interest in CAM [17] inhibits change toward its more widespread use [26]. The participants in this study described how some of their residents were fond of music, some slept better with a lavender aroma, and others relaxed with a cat on their lap. Research confirms that providing such person-centered care is satisfying and motivating for the caregivers [27,28] and that it improves the quality of life for people with dementia in nursing homes [19]. Further, the importance of working with committed colleagues and supportive leaders is highlighted as crucial when offering CAM. Research confirms that visible leaders who give encouraging feedback are important for retaining nursing home staff [15]. However, it is not obvious that colleagues and leaders, or particularly physicians, support the use of CAM [4,11]. Several participants described it as an ongoing challenge that their colleagues did not believe in what they were doing and that they did not support their choices. This might also be connected to a lack of knowledge about the efficacy of CAM and a blurred responsibility between nurses and physicians. Internationally, CAM is becoming integrated into nursing [29,30] but this connection is not yet common in Norway. 4.1. Methodological considerations Using focus groups for data collection may have weaknesses, including a group effect [13]. If a strong individual makes a statement, others may have difficulty contradicting them. The moderator did not detect such patterns in this study but some participants were more active than others. On the other hand, focus groups may also stimulate participant reflections on the topic and thereby enrich the findings. In a focus group study, it is crucial for internal validity that the participants and researchers have a common understanding of the issues under discussion [13]. Further, the use of quotations strengthens the study's validity, so does the consensus of findings between this and other studies. Despite the limited number of study participants, the resulting empirical data were rich and varied. One evident limitation was that the study participants had only experienced four different CAM therapies. Choosing other nursing homes may have provided greater variety. 5. Conclusion The purpose of this study was to gain knowledge about how nurses and auxiliary nurses experience the use of CAM in nursing homes. Their CAM use was limited to music therapy, animalassisted therapy and aromatherapy. The results showed that participants experienced CAM as effective and both professionally and personally interesting and rewarding. CAM support personcentered care and their colleagues and leaders were predominantly supportive, though the participants also experienced some challenges including negative attitudes and lack of knowledge. Knowledge about CAM in Norwegian nursing homes is limited and a national survey about the use of and knowledge about CAM is needed. A decision about the status of CAM in nursing education programs and nursing practice is also needed. Conflict of interest statement There is no conflict of interest.
Please cite this article in press as: Johannessen B, Garvik G, Experiences with the use of complementary and alternative medicine in nursing homes: A focus group study, Complementary Therapies in Clinical Practice (2015), http://dx.doi.org/10.1016/j.ctcp.2015.04.003
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Please cite this article in press as: Johannessen B, Garvik G, Experiences with the use of complementary and alternative medicine in nursing homes: A focus group study, Complementary Therapies in Clinical Practice (2015), http://dx.doi.org/10.1016/j.ctcp.2015.04.003