Integrating CAM into Nursing Curricula: CAM Camp as an Educational Intervention

BRIEF REPORT

INTEGRATING CAM INTO NURSING CURRICULA: CAM CAMP AS AN EDUCATIONAL INTERVENTION B. Jane Cornman, RN, PhD,1# Catherine A. Carr, CNM, DrPH,1 and Margaret M. Heitkemper, RN, PhD2

Background: In 2002, the University of Washington School of Nursing (SON) partnered with Bastyr University on a five-year plan to offer a four-week intensive “CAM Camp” (CAMp) for SON faculty members and medical students from across the country. The four-week educational program introduced attendees to various complementary and alternative medicine (CAM) modalities through didactic and experiential learning. Objective: To enhance complementary and alternative medicine content in a SON curriculum and to increase SON faculty knowledge and understanding about (1) the range of CAM therapies, (2) the theoretic and cultural backgrounds of these therapies, and (3) their potential contributions to the health of diverse populations.

post-CAMp knowledge levels of faculty and course CAM content. Results: On post-CAMp surveys, familiarity with CAM modalities was rated with mixed results as compared with positive reports on the qualitative interviews. Interview results were more positive about CAM in general and were less specific about individual CAM topics. Statistically significant increases in competences were evident in each of 13 competencies rated with four competencies at P ⬍ .01. The number of required and elective courses containing CAM content increased as did the CAM content in continuing education conferences offered by the SON.

Design: A descriptive pretest, posttest design was used to compare pre-CAMp CAM knowledge and CAM course content with

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INTRODUCTION The growing use of complementary and alternative medicine (CAM) by the American public1,2 necessitates that all healthcare providers possess knowledge regarding the assessment of CAM use. This includes understanding of the potential and documented benefits of CAM as well as potential adverse reactions including drug-CAM therapy interactions. At the same time, there is a keen necessity that healthcare providers utilize clinical research critique skills to consider carefully the growing body of knowledge related to CAM therapies. Because the use of complementary therapies is often undisclosed by consumers and overlooked by providers,3 there is a significant potential for unanticipated effects to patient well-being. Nurses are providers of care as well as interpreters of care, and a working knowledge of CAM and the interaction of CAM and conventional medicine are critical for patient safety. As stated by Xu4 with regard to nursing curricula, “the question is not whether CAM should be in the curriculum, but to what extent and in what manner it should be integrated.”4 In 2002 when the University of Washington was funded under the R25 mechanism by the National Center for Comple-

mentary and Alternative Medicine (NCCAM) at the National Institutes of Health (NIH), there were some nursing schools with coursework in the area of CAM at either the undergraduate or graduate level.5 Within the University of Washington School of Nursing, CAM content was dispersed sporadically throughout the curriculum, with little to no course objectives specifically focused on CAM. It was the overarching goal of this educational training program to fill this gap through faculty development. The training award allowed us to collaborate with Bastyr University to broaden and solidify a summer intensive program focused on CAM modalities. This program was named CAM Camp (CAMp). This article describes the outcomes and experience of the investigators and participants in the first two CAMps as determined by formal surveys and qualitative data collection. The basic purpose of this evaluation was to determine (1) whether an interactive summer intensive program increased faculty knowledge regarding CAMp and (2) whether integration of CAM content into undergraduate and graduate courses is increased by CAMp

1 Department of Family and Child Nursing, University of Washington School of Nursing 2 Department of Biobehavioral Nursing and Health Systems, University of Washington School of Nursing This project was funded by NCCAM, NIH 1 R25 AT01240. # Corresponding author. Address: Box 357260, Seattle, WA 98195.

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METHODS Design A descriptive pretest, posttest design was used to compare preCAMp CAM knowledge and CAM course content with postCAMp knowledge levels of faculty and course CAM content. Sample The sample included 10 School of Nursing faculty members who applied to attend the CAMp program. Members of the

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EXPLORE May 2006, Vol. 2, No. 3 doi:10.1016/j.explore.2006.03.040

University of Washington School of Nursing CAM Camp Application Name: Email address: Courses currently taught:

Course number/s -

Course title/s –

Please describe your reason for applying to the CAM Camp: (For example, past experiences with CAM, specific modalities you are interested in learning about?) How do you predict you might integrate CAM content into the course/s you teach:

*Deadline: March 1st; Limited slots available; important to commit for entire scheduled time.

Figure 1. CAM Camp application form.

faculty were invited to apply for the first year’s CAM Camp via e-mails and a posted message on the program’s Web site (www. son.Washington.edu/cam/), using the form in Figure 1. Faculty was selected from three departments in the School of Nursing and represented all faculty ranks. Because integrating CAM content into undergraduate courses was the planned focus for the first year of the grant, first priority was given to faculty teaching undergraduate courses. Additional criteria included candidate’s willingness and ability to commit to four weeks of camp and current involvement in high-enrollment courses that would increase the number of students introduced to the CAM content. All faculty members held PhD degrees, and they had been on faculty a range of 3 to 30 years. None had a focused program of research related to CAM, although many had established (eg, NIH) funded research. Protocol The Camp is a four-week educational program developed in partnership with Bastyr University to introduce attendees to

various CAM modalities through didactic and experiential learning. By using the camp model, the participants are removed from their offices, classes, research, and daily work distractions to a site more conducive to an immersion learning process. The curriculum for the CAM Camp built on a 2002 program offered by Bastyr University to medical students as a month-long summer program. In 2003, the first year of the interdisciplinary Camp, five School of Nursing faculty members joined 22 medical students from schools across the country. The program was modified from the previous year by using evaluation data from the medical student attendees, surveys of nursing school faculty for most requested CAM topics, and individual consultations with CAM grant advisory board members and by reviewing the nursing literature.6-8 New topics added for nursing faculty included, meditation, mind/body medicine, massage, music/ sound healing, reiki, and therapeutic touch. Topics such as traditional Chinese medicine, Ayurvedic medicine, naturopathic medicine, and homeopathy were considered primary or required for all participants, whereas other topics, such as the daily morning practice of yoga or Qigong, whole foods (emphasis on minimal processing, organic produce) cooking sessions, and medicine making labs were offered as an optional choice. In the second year, the cooking sessions were required after reviewing the Camp evaluations. Table 1 lists topics included in the Camp curriculum. The Camp program offered hands-on demonstrations and experiential components whenever possible. Presenters for each treatment approach/modality dealt with the topics of credentialing/licensing requirements for practitioners, evidence-based information, as well as providing further resources such as handouts and electronic sources. For example, the nurse/licensed massage therapist who presented on massage reviewed the available literature on the benefits of massage in patient treatment and the Washington State requirements for licensure and provided Web sites and references for further investigation. She then demonstrated a head, neck, and shoulder massage and coached paired class members through the techniques. The program was held at Bastyr University, which is an accredited private institution located in Kirkland, Washington, an

Table 1. Topics for Camp year 1 and 2 Didactic

Experiential

Acupuncture and Oriental medicine (AOM) AOM research AOM diagnosis Nutrition/whole foods Top 10 herbs and herbal overview Ayurvedic medicine Homeopathy

Ropes course Qigong Medicine-making labs Whole foods cooking lab Mt. Rainier botanical field trip

CAM and Education

Combination Didactic and Experiential Mind/body medicine Therapeutic touch Reiki Sound healing Native American medicine Meditation and health Art therapy Massage Spiritual health Library CAM database training Bastyr Clinic observation

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Table 2. Difference in Degree to Which You Are Familiar With the CAM Approach Between Pre-CAM Camp and Post-CAM Camp Mean ⫾ SD Acupuncture and Oriental medicinea Ayurvedaa Homeopathya Naturopathya Biofeedback Imagery Meditationa Prayer/distance healinga Yoga Chiropractic Massagea Craniosacral Reflexology Tai Chi/Qigonga Reikia Therapeutic/healing toucha Herbsa Megavitamins Aromatherapy a

Pretest

Posttest

Mean difference

t

P value

2.6 ⫾ 1.4 1.8 ⫾ 1.3 1.9 ⫾ 1.1 2.3 ⫾ 1.3 4.0 ⫾ 1.5 4.4 ⫾ 1.2 4.4 ⫾ 1.1 3.4 ⫾ 1.8 3.3 ⫾ 1.0 2.9 ⫾ 1.6 5.0 ⫾ 1.2 1.8 ⫾ 1.1 1.4 ⫾ 0.7 2.0 ⫾ 1.0 1.7 ⫾ 0.7 2.2 ⫾ 1.1 2.8 ⫾ 1.6 2.1 ⫾ 1.1 2.8 ⫾ 1.6

2.7 ⫾ 4.2 2.1 ⫾ 4.1 1.5 ⫾ 3.9 2.6 ⫾ 4.4 3.6 ⫾ 4.7 3.7 ⫾ 4.7 3.9 ⫾ 4.6 2.6 ⫾ 4.3 2.7 ⫾ 4.3 2.3 ⫾ 4.6 3.8 ⫾ 4.9 1.2 ⫾ 4.2 0.9 ⫾ 3.9 2.6 ⫾ 4.7 1.3 ⫾ 4.2 2.3 ⫾ 4.5 3.2 ⫾ 4.7 1.9 ⫾ 4.3 1.1 ⫾ 4.2

0.1 ⫾ 4.4 -0.3 ⫾ 3.9 -0.4 ⫾ 2.8 .0.3 ⫾ 4.2 ⫺0.4 ⫾ 4.2 ⫺0.7 ⫾ 4.5 ⫺0.5 ⫾ 4.5 ⫺0.8 ⫾ 5.2 ⫺0.6 ⫾ 4.2 ⫺0.6 ⫾ 3.7 ⫺1.2 ⫾ 4.5 ⫺0.6 ⫾ 3.8 ⫺0.6 ⫾ 3.8 0.6 ⫾ 4.5 ⫺0.3 ⫾ 4.1 0.1 ⫾ 4.8 0.4 ⫾ 4.1 ⫺0.2 ⫾ 3.8 ⫺1.7 ⫾ 5.0

.071 .242 ⫺.330 .226 ⫺.298 ⫺.492 ⫺.355 ⫺.488 ⫺.447 ⫺.445 ⫺.821 ⫺.437 ⫺.430 .370 ⫺.243 .070 .326 ⫺.174 ⫺.990

.945 .814 .749 .826 .773 .634 .731 .637 .666 .668 .435 .673 .679 .721 .814 .946 .753 .866 .351

Items included in CAM Camp curricula.

approximate 30-minute drive from the University of Washington Health Sciences Center. Bastyr offers a broad range of programs, including naturopathy, nutrition, acupuncture, Oriental medicine, and applied behavioral science at the graduate level and herbal sciences, exercise science, health psychology, and nutrition at the undergraduate level. In addition to classrooms and research laboratories, Bastyr campus also has other facilities geared to CAM modalities. These include large medicinal plant and culinary gardens as well as kitchen facilities specifically designed for food preparation demonstrations and group participation. A critically important component of the Camp experience for nursing faculty was the weekly two-hour debriefing session. In year one, these were held on the School of Nursing campus but were moved to the Bastyr University Camp site in year two, based on faculty feedback regarding more efficient use of time for debriefing rather than commuting back to home campus. These sessions provided faculty with an opportunity to review the week’s materials/experiences and, more importantly, to discuss plans for how to integrate CAM into the nursing curriculum at both undergraduate and graduate levels. The objectives for these discussions included reviewing aspects of Camp that challenged, expanded, and/or complemented previous knowledge; investigating a CAM topic/modality in greater depth; and analyzing selected strategies that support a personal, healthy lifestyle. Outcome Measures A two-fold evaluation process was utilized. The first component was a survey that faculty members attending camp were

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given pre- and post-Camp. The survey asked about familiarity with various CAM approaches and personal use of CAM modalities and the respondent’s opinion on whether or not various CAM therapies provide health benefits— or whether more information was needed to form an opinion. A list of 13 CAM competencies was included with the competency rated in each category on a Likert-type scale. This tool was adapted from a survey originally constructed by the Rush University School of Nursing (Chicago, IL).

RESULTS On the posttest survey, attendees rated themselves as more familiar with six of the therapies and less familiar with five of the therapies listed that were part of the Camp curriculum (See Table 2). Eight other therapies not included in the Camp were rated as less familiar to campers post-Camp. Only one CAM approach scored on the surveys as being utilized to a greater degree post-Camp, and that was Qigong. Faculty had higher scores related to positive benefit of CAM therapies on the postCamp questionnaire. For example, naturopathic medicine and the use of herbs were both rated by 30% more campers as “an approach believed to provide health benefits” on the post-Camp survey (See Table 3). As shown in Table 4, there were statistically significant increases in all 13 competencies, with four competencies at P ⬍ .01. The second part of the evaluation process was follow-up interviews with attendees to determine whether and how CAM Camp changed the CAM content in their courses. In post-Camp interviews, faculty thought that Camp had expanded their

CAM and Education

Table 3. Frequency in Opinion on CAM Approach Pre (N ⫽ 10) Acupuncture and Oriental medicinea Ayurvedaa Homeopathya Naturopathya Biofeedback Imagery Meditationa Prayer/distance healinga Yoga Chiropractic Massagea Craniosacral Reflexology Tai Chi/Qigonga Reikia Therapeutic/healing toucha Herbsa Megavitamins Aromatherapy

Post (N ⫽ 9)

Y, N (%)

?, N (%)

N, N (%)

Y, N (%)

?, N (%)

N, N (%)

8 (80) 2 (20) 2 (20) 4 (40) 9 (90) 10 (100) 10 (100) 7 (70) 9 (90) 5 (56) 10 (100) 3 (33) 3 (33) 5 (50) 2 (20) 3 (30) 5 (56) 4 (40) 5 (50)

2 (20) 7 (70) 8 (80) 6 (60) 1 (10) 0 (0) 0 (0) 3 (30) 1 (10) 3 (33) 0 (0) 6 (67) 6 (67) 5 (50) 8 (80) 6 (60) 3 (33) 4 (40) 4 (40)

0 (0) 1 (10) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (11) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (10) 1 (11) 2 (20) 1 (10)

8 (89) 4 (44) 2 (22) 7 (78) 9 (100) 9 (100) 9 (100) 9 (100) 8 (89) 6 (67) 9 (100) 3 (33) 2 (22%) 7 (78) 3 (33) 5 (56) 8 (89) 3 (33) 3 (33)

1 (11) 5 (56) 4 (44) 1 (11) 0 (0) 0 (0) 0 (0) 0 (0) 1 (11) 3 (33) 0 (0) 6 (67) 7 (78) 2 (22) 5 (56) 3 (33) 0 (0) 5 (56) 5 (56)

0 (0) 0 (0) 3 (33) 1 (11) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1(11) 1 (11) 1 (11) 1 (11) 1 (11)

Y, I believe this approach provides health benefits; ?, I need more information to form an opinion; N, I am skeptical about the value or effectiveness of this approach. a Items included in Camp curricula.

knowledge of CAM and linked them to professional resources— community programs and practitioners as well as clinical and research literature—and stimulated them to integrate CAM content into their courses. Exemplars of differences included greater use of articles from the Camp-required reading list and introduction of new content. Examples of the latter include moxibustion for correction of breech presentation at term (midwifery program course), integrating CAM into theoretical perspectives in nursing (a required nursing PhD course), and managing stress (a learning module for undergraduate nursing students in the undergraduate psychiatric nursing course). During the subsequent academic year, two instructors from Bastyr University provided guest lectures about the “Top Ten Herbs” used by patients and “Treatment of Children with ADHD.” In the midwifery program, the students now have a required seminar CAM assignment. Case studies: A case study on a patient with cardiac disease developed by two campers is included in both an undergraduate course and graduate nursing course. In the case study, three CAM strategies; Tai Chi and Qigong as forms of exercise, meditation for relaxation and stress management, and a whole foods low-sodium diet, were integrated with allopathic management.

DISCUSSION Evaluation Process Results on the surveys as compared with faculty interviews seemed somewhat contradictory. On the post-Camp survey, faculty rated only six of 11 CAM topics addressed in the

CAM and Education

Camp curricula as more familiar, although the change was not significant. In the faculty interviews, comments such as “expanded and sharpened my CAM knowledge” were common. On surveys, faculty only checked using Qigong more postCamp versus pre-Camp, yet interviews suggest that faculty self-care post-Camp now included meditation and whole foods. The faculty rated eight out of the 11 Camp topics more frequently with the favorable opinion of “I believe this approach provides health benefits.” There was no trend toward “I am skeptical about the value or effectiveness of this approach” in the other three topics. The question of whether this survey is an accurate rating of Campers familiarity, use, and opinions has to be posed given the apparent contradictions between survey ratings and interviews. It is possible that faculty became more generally positive about CAM methods as a result of Camp participation or were motivated to do further investigation on their own but held a variety of opinions, some less positive, about specific modalities. Lessons Learned at Camp Experiential learning combined with cross-disciplinary opportunities to interact and discuss views with the medical students and CAM faculty proved to be a useful combination. Faculty identified the experiential opportunities (eg, Qigong, whole foods cooking, meditation, therapeutic touch, library tutorial on accessing CAM resources) as one of the most appreciated aspects of Camp. The dialogue that took place across disciplines—nursing, medicine, and CAM practitioners/educators—whether in

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Table 4. Faculty (N ⫽ 10) Pre and Post Competency Scores Mean Comp 1: Describe the biological basis for selected CAM therapies. Comp 2: Discuss the wide range of health and healing practices of populations with various cultural backgrounds. Comp 3: Identify scientific and consumer information resources for selected CAM therapies. Comp 4: Evaluate the quality of CAM research literature and consumer information. Comp 5: Incorporate assessment of CAM practices into history with cultural sensitivity. Comp 6: Practicing CAM approaches for self. Comp 7: Discuss the interaction of drugs with commonly used herbal/nutrient therapies. Comp 8: Describe how selected CAM therapies influence the health status of individuals. Comp 9: Discuss the training, licensing, and credentialing of CAM practitioners. Comp 10: Provide education to patients about use of CAM therapies. Comp 11: Identify indications for patient referrals to CAM practitioners. Comp 12: Make referrals to CAM providers when indicated by patient situation. Comp 13: Describe ethical, societal, and cultural issues pertaining to CAM therapies. a

Pretest

Posttest

Mean difference

T

1.9 ⫾ 0.7 2.5 ⫾ 1.1

3.3 ⫾ 1.5 4.0 ⫾ 1.6

1.4 ⫾ 1.2 1.5 ⫾ 1.3

3.772 3.737

P value .004a .005

2.7 ⫾ 1.3

4.5 ⫾ 0.9

1.8 ⫾ 1.1

5.014

.001a

2.7 ⫾ 1.5

4.2 ⫾ 1.6

1.5 ⫾ 1.4

3.503

.007a

2.4 ⫾ 1.2

4.0 ⫾ 1.9

1.6 ⫾ 1.4

3.539

.006a

2.6 ⫾ 1.4 2.0 ⫾ 1.2

4.5 ⫾ 1.4 3.5 ⫾ 1.6

1.9 ⫾ 0.9 1.5 ⫾ 1.1

6.862 4.392

⬍.001a .002a

2.1 ⫾ 0.9

4.7 ⫾ 0.9

2.6 ⫾ 10

8.510

⬍.001a

1.5 ⫾ 0.7

3.7 ⫾ 1.5

2.2 ⫾ 1.4

4.975

.001a

1.9 ⫾ 0.7

4.0 ⫾ 1.7

2.1 ⫾ 1.2

5.547

⬍.001a

1.9 ⫾ 1.0

4.2 ⫾ 1.9

2.3 ⫾ 1.6

4.445

.002a

1.9 ⫾ 1.2

4.0 ⫾ 2.1

2.1 ⫾ 1.8

3.455

.009a

2.1 ⫾ 1.0

4.0 ⫾ 1.5

1.9 ⫾ 1.0

6.042

⬍.001a

P ⬍ 05.

class, clinic, cafeteria, cooking kitchen, or garden served to educate, enlighten, and enhance future collaboration.

CONCLUSION The CAM Camp’s influence on the University of Washington School of Nursing is evident as course content changes continue to include CAMp-inspired integrative healthcare interventions. The CAM CAMp has also stimulated faculty research in CAM topics. One of the campers is now working on a collaborative research project with a Bastyr faculty member on “Mushroom vaccine adjuvants in an ovarian cancer model.” A recently submitted proposal by a CAM camper included CAM modalities in examination of beliefs and rituals in childbirth. There has been an increase in the number of graduate student master’s degree projects and doctoral dissertations on CAM-related topics. Two campers have incorporated CAM into their textbook in MedSurg nursing and developed CAM continuing education in their specialty area. CAMp alumni are also leading the effort to develop a CAM certificate for graduate nursing students. There has been a noted shift in the nursing school atmosphere with guided relaxation exercises included in the annual faculty retreat; self-care approaches (such as minichair

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massage sessions) supported for administrative staff; and open meditation sessions offered for faculty, student, and staff participation weekly. On a personal level, a testimonial to CAM Camp’s influence was expressed in a postcamp evaluation: “Camp has changed my life. I’ve lost 15 pounds and lowered my cholesterol by 30 points!” Implications: Faculty and students within nursing and medicine recognize the importance of integrating CAM into education.9 The Institute on Medicine Report on CAM in the United States has recommended “health profession schools (eg, medicine, nursing, pharmacy, allied health) incorporate sufficient information about CAM into the standard curriculum at the undergraduate, graduate, and postgraduate levels to enable licensed professionals competently to advise patients about CAM.”10 The model for CAMp could be adapted for schools attempting to integrate CAM that lack the support of a local natural science university. An alternate approach would include a school’s partnering with local CAM and communitybased clinics and practitioners to develop their own unique curricula. A more formalized program similar to the University of Michigan’s Faculty Scholars Program (www.med.umich. edu/umim/education/scholars.htm) is another option for providing the information by incorporating CAM into continuing nursing education and continuing medical education

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offerings. In all of these approaches, the cross-disciplinary, intellectually stimulating interaction among nursing, medicine, and CAM practitioners is essential as is the use of experiential components to translate the theory and philosophy of CAM modalities into new, more integrative, and effective patterns of health practice.

REFERENCES 1. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA. 1998;280:1569-1575. 2. Tindle HA, Davis RB, Phillips RS, Eisenberg DM. Trends in the use of complementary and alternative medicine by US adults: 19972005. Altern Ther Health Med. 200;11:42-49. 3. Astin JA, Pelletier KR, Marie A, Haskell WL. Complementary and alternative medicine use among elderly persons: one-year analysis of a Blue Shield Medicare supplement. J Gerontol A Biol Sci Med Sci. 2000;55A:M4-M9.

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4. Xu Y. Complementary and alternative therapies as philosophy and modalities: implications for nursing practice, education, and research. Home Health Care Manage Pract. 2004;16:534-537. 5. Fenton MV, Morris DL. The integration of holistic nursing practices and complementary and alternative modalities into curricula of schools of nursing. Altern Ther. 2003;9:62-67. 6. Gaydos HLB. Complementary and alternative therapies in nursing education: trends and issues. Online J Issues Nurs. 2001;6(2) article 5. 7. Melland H, Clayburgh TL. Complementary therapies: introduction into a nursing curriculum. Nurse Educ. 2000;25:247-250. 8. Reed FC, Pettigrew AC, King, MO. Alternative and complementary therapies in nursing curricula. J Nurs Educ. 2000;39:133-139. 9. Kreitzer MJ, Mitten D, Harris I, Shandeling J. Attitudes toward CAM among medical, nursing, and pharmacy faculty and students: a comparative analysis. Altern Ther. 2002;8:44-53. 10. Committee on the Use of Complementary and Alternative Medicine by the American Public Board on Health Promotion and Disease Prevention, Institute of Medicine of the National Academies. Complementary and Alternative Medicine in the United States. 2005, Washington, DC: The National Academies Press; 2005.

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