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Nurses’ communication regarding patients’ use of complementary and alternative medicine
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Collegian journal homepage: www.elsevier.com/locate/coll
Nurses’ communication regarding patients’ use of complementary and alternative medicine Helen Hall a,b,∗ , Caragh Brosnan b,c , Jane Frawley b , Jon Wardle b , Melissa Collins d , Matthew Leach b,e a
Faculty of Medicine, Nursing and Health Sciences, School of Nursing & Midwifery, Monash University, Frankston, Australia Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), University of Technology Sydney, Sydney, Australia c School of Humanities and Social Science, University of Newcastle, Australia d Endeavour College of Natural Health, Australia e School of Nursing and Midwifery, University of South Australia, Australia b
a r t i c l e
i n f o
Article history: Received 10 May 2017 Accepted 7 September 2017 Available online xxx Keywords: Nurse Complementary and alternative medicine Complementary therapies Communication
a b s t r a c t
Background: : Many people integrate complementary and alternative medicine (CAM) into their health care. Nurses potentially play a significant role in communicating with patients about their CAM utilisation. Aim: : The study aimed to explore whether, how and why nurses working in Australia communicate about patients’ CAM use. Methods: : This paper reports on phase one of a mixed methods study. Qualitative data was obtained, via interviews, with nineteen registered nurses who work in a wide variety of clinical environments across all states of Australia. Findings: : Four themes related to nurses’ communication with patients about CAM, were developed from the qualitative data; engaging with patients about CAM, communication with doctors about patients’ use of CAM, connecting with CAM practitioners and barriers to CAM communication. Discussion: : Despite their positive attitudes, nurses are often not comfortable discussing or documenting patients’ CAM use. Furthermore, nurses perceive that patients may be apprehensive about disclosing their use. CAM communication with colleagues is moderated by the workplace culture and the perceived attitude of co-workers. There is very little evidence of nurses referring or collaborating with CAM practitioners. Professional expectation, time restraints and the nurses’ lack of relevant CAM knowledge all have a powerful effect on limiting CAM communication. Conclusion: : Communication about patients’ use of CAM is imperative to support safe therapeutic decisions. Currently, this is limited in the Australian healthcare workplace. The nursing professional needs to consider introducing basic CAM education and flexible guidelines to enable nurses’ to respond appropriately to the patient driven demand for CAM. © 2017 Published by Elsevier Ltd on behalf of Australian College of Nursing Ltd.
1. Introduction Complementary and alternative medicine (CAM) refers to a broad range of healthcare products and practices with a history of use outside of mainstream conventional medical practice (National Centre for Complementary and Integrative Health (NCCIH), 2013). The definition of CAM has continued to evolve and use of these
∗ Corresponding author at: Faculty of Medicine, Nursing and Health Sciences, School of Nursing & Midwifery, Monash University, Peninsula Campus,McMahons Road, Frankston, Victoria, 3199, Australia. E-mail address: [email protected] (H. Hall).
therapies, by both general public and healthcare professionals, is increasing (Frass et al., 2012). However, the evidence of the safety and effectiveness of CAM is mixed, with some therapies remaining controversial while others are broadly accepted in mainstream medicine. Particularly poorly understood is the risk of combining CAM supplements (such as herbal medicines), with conventional medicine, making patients’ disclosure of concurrent use crucial. Nurses potentially play a significant role in communicating with patients about their CAM utilisation. Compared to doctors, nurses typically spend more time with patients, and people may feel more comfortable revealing details of CAM use to them. Hence, nurses may act as important intermediaries, ensuring doctors are aware
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Summary of relevance Issue • Despite the popularity of complementary and alternative medicine (CAM) in Australia, very little is known about how nurses communicate regarding patients’ use of these products and practices. What is already known • People often use CAM without input from a qualified healthcare provider. Some patients are apprehensive about disclosing their use, which increases the associated risks. What this paper adds • Some nurses are not confident to discuss or document patients’ use of CAM. Strategies to improve communication include basic CAM education and the development of flexible CAM guidelines.
of patients’ current CAM use, and potentially directing patients towards, or deterring them from, qualified CAM therapists.
Kitzman, McMullen, & Anson, 2008). Furthermore, these studies indicate that less than half of all physicians feel comfortable discussing CAM with their patients, due to their lack of relevant knowledge. A critical step to delivering safe care and enabling patients to make informed therapeutic decisions, is for practitioners to engage in conversations about their health care behaviour, including the use of CAM. While nurses working in Australia are well-positioned (in terms of workforce numbers and sectoral spread) to communicate with patients about CAM, it is unclear if they take advantage of this opportunity and what barriers and facilitators they encounter. 3. Method This paper reports on phase one of a mixed methods study. The study aimed to explore whether, how and why nurses working in Australia engage with patients regarding CAM use. The first phase, involved collecting qualitative data, via interviews, with registered nurses who worked in Australia. An inductive qualitative research approach was considered ideal to gain insight into the topic of interest. Approval to conduct the study was acquired from the relevant Human Research Ethics Committees and informed consent was gained from all participants. Pseudonyms are used throughout this paper to preserve the participants’ anonymity.
2. Background 3.1. Participants Internationally, around one-third of the Western population use CAM, with surveys from the US and UK reporting usage rates of 38% (Barnes, Bloom, & Nahin, 2008) and 26% (Hunt et al., 2010) respectively. Prevalence rates in Australia are even higher, with national survey data indicating close to 69% of the population use these therapies (Xue, Zhang, Lin, Da Costa, & Story, 2007). Furthermore, there is evidence that people are more likely to seek CAM services for a range of chronic conditions, including diseases identified as National Health Priority Areas by the Australian Government (Reid, Steel, Wardle, Trubody, & Adams, 2016). Research has found that the drivers for using CAM are generally associated with wishing to be more involved with health care decisions, having holistic health beliefs and increased therapeutic options, rather than dissatisfaction with conventional medicine (Shorofi, 2011). It is concerning that a considerable proportion of CAM users self-prescribed, with little or no input from a health professional. A review of studies from fifteen countries revealed that despite the widespread use, only a minority (median of 12.2%) of the general population consult a CAM provider (Harris, Cooper, Relton, & Thomas, 2012). Whilst a patient’s right to self-determination should be respected, it is imperative that their health care decisions (including those relating to the use of CAM) are adequately informed. Unfortunately, many consumers rely on nonprofessional, low quality sources of information (e.g. advice from friends and family) to guide their CAM decisions (Frawley et al., 2014; Yang et al., 2016). In addition, many people do not disclose CAM use to conventional health providers, which increases the associated risks (Chao et al., 2015; Lucas, Kumar, & Leach, 2015; McIntyre, Saliba, Wiener, & Sarris, 2016). Although the issue of CAM communication in conventional health settings has been the topic of significant research examination, most of this has centered on interactions between patients and their medical practitioners. These studies have generally shown that less than half of patients discuss their CAM use with their physician due to; fear of a negative response, their perceptions that the physician lacks appropriate knowledge, a preference to keep their CAM and conventional treatments separate, or simply because their doctor did not ask them (Roberts et al., 2006; Shelley, Sussman, Williams, Segal, & Crabtree, 2009; Sidora-Arcoleo, Yoos,
Nineteen registered nurses, who worked in a wide variety of clinical environments across all states of Australia, were recruited for phase one. The aim was not to obtain a representative sample but rather to capture a wide variety of experiences. The participants were recruited through advertising with a professional association and via snowballing. Participants’ ages ranged from twenty-seven to sixty-six, with all but one, being female. Most participants had been working as a registered nurse for more than ten years and had extensive clinical experience (Table 1). 3.2. Data collection Nurses who contacted the researcher expressing an interest in the study, were sent an explanatory statement via email (or post if preferred). Those wishing to participate were given a consent form to sign before the interview began. Two female researchers (HH and MC), who are experienced in qualitative data collection and analysis, conducted the nineteen interviews. One researcher (HH), has a background in nursing and naturopathy and the other (MC), in public health and naturopathy; neither had a relationship with the participants they interviewed. Due to the distances involved most (n = 15) of the interviews occurred via the telephone however, some (n = 4) were conducted face to face at a place which was convenient for the participant. While an interview guide was used to direct the line of questioning, participants were encouraged to speak freely around the topic generally to enable full exploration of the salient issues. The interviews lasted approximately 50 min and, with the participant’s consent, were audio recorded and then later transcribed. 3.3. Data analysis The qualitative data underwent inductive thematic analysis using the phases recommended by Braun and Clarke (2006). Thematic analysis is a research method that enables identification and analyses of patterns (themes) within data. Firstly the interviews were transcribed and then the researchers (HH and MC), made themselves familiar with the data. Next, initial codes were
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Table 1 Characteristics of participants. Pseudonym
State
Age
Highest educational qualification
Clinical area
Sally John Kathy Claire Heather Jacky Penny Hilary Gill Renee Lisa Judy Katie Alice Brenda Julie Sarah Amie Debbie
Victoria Victoria NT NSW Victoria NSW NSW Victoria Victoria Victoria NSW WA Victoria NSW Tasmania WA QLD Victoria SA
52 27 53 60 53 48 53 47 52 55 55 56 48 66 49 56 44 32 59
Post-graduate Masters degree Post-graduate Post-graduate Bachelor degree Bachelor degree Post-graduate Bachelor degree Masters Post-graduate Post-graduate Masters degree Bachelor degree PhD Bachelor degree Post-graduate Bachelor degree Post-graduate Masters degree
Primary health; refugee nurse, maternal health Acute care; tertiary pubic hospital Remote and rural care, also metropolitan ICU Aged care Aged care Rural hospital and primary health Acute care; tertiary pubic hospital Palliative care Level 2 Hospital Emergency Department Rural Aged care Acute care; tertiary public hospital. Also private practice Refugee nurse. Clinical Nurse Specialist Aged care Mental health, drug and alcohol rehabilitation Primary health; GP practice Continence nurse plus, maternal and child nurse Public Hospital Public hospital- Diabetes educator plus aged care Allergy nurse; public hospital clinic & private practice
Table 2 Example of analysis. Raw data
Codes
. . . some hospitals don’t allow it to be used which is a shame I think because they’re missing out on the benefits of it for their patients, as well as for themselves. If the patients comfortable, pain free and less stressed it works for a happier environment, so the staff is also that way. (Claire) . . .because we’re public health service, we are probably quite restricted . . . we would be quite limited about what we could recommend and what we, we couldn’t. (Hilary) I’ll give them [CAM] suggestions, if they look interested. If they don’t, I don’t go there, . . . It’s really on the openness of the person . . .I don’t pressure people but if they look interested and they pick up on it then I’ll go to it, if they don’t, I don’t go there. (Brenda) I tend not to say anything unless the patients say something about it . . .Only if it’s the patient brings it up directly and asks a very direct question. (Penny) I think the, the culture of care is so not open to considering complementary therapy (Heather) Some places I’ve worked use complementary therapies all the time, it’s not a problem. Other places, like one acute surgical ward where I worked, they treated it like witch craft. (Katie) There are so many other things and we are so busy these days. . . I hardly have time to talk about the stuff I have to. (Julie) . . .often there’s lots of competing. . . .They’ve go physio, they’ve got O.T, they’ve got hand therapy coming, they’ve got the doctors . . . and just the practicalities of actually fitting it [CAM discussion] in. (John) I’ve got so little knowledge I wouldn’t discuss them (CAM therapies) at all. (Alice) . . . if there’s a supplement that I don’t know . . . I’m not educated on then obviously, I wouldn’t, you know, wouldn’t be giving advice on something I don’t know about. But I’m all for complementary medics, medicines, and practices. (Amie)
Professional expectations and policies
generated and collated into potential themes. Following this, the emergent findings were discussed and potential themes were reviewed. Finally, each theme was refined to reflect the dominant characteristics embedded in the data. To ensure dependability of the findings, member checking was used by contacting two participants, to ensure our interpretations resonated with their experiences (Table 2). 4. Findings Four themes related to nurses’ communication with patients about CAM, were developed from the qualitative data. These themes include; engaging with patients about CAM, communication with doctors about patients’ use of CAM, connecting with CAM practitioners and barriers to CAM communication. 4.1. Engaging with patients about CAM A number of participants asserted that, because nurses interact directly with patients, there are many opportunities to engage in conversations about a wide variety of topics, including CAM. Lisa, stated “. . .We are in such a pivotal role in, terms of being able to be
Patient’s preference
Theme
Barriers to CAM Communication
Workplace culture
Time
Knowledge
with people, and . . . educate them, introduce new ways to them. I absolutely see it [talking about CAM] as, important.” Likewise, Jacky claimed “ . . . there’s a lot of opportunity there for nurses to talk to patients about that [CAM use] because as I said, patients can often use these therapies and not actually talk to their doctor about it.” However, despite these opportunities, participants reported that not all patients feel comfortable about discussing their CAM use. Several asserted that nurses need to garner patients’ trust and encourage them to disclose. Debbie, said “. . .we’ve got to get that trust. . . .. Because you know, . . . lots of times, people do not tell the doctor they’re on alternative treatments.” One participant, Penny, reported a variety of behaviours related to disclosure of CAM use; “. . . in oncology a lot of people will try alternative stuff first. . . or they’ll come in with it, and they’re using it as well. Some are quite open about it, and others just don’t tell you, and you sort of find out along the way.” Sometimes, CAM use was actively hidden. Renee, who works in an aged care facility, describe situations where relatives concealed specific therapies due to concerns that they may encounter a negative attitude: “. . .They’ll bring in things [herbal medicine] and hide them in the residence drawers and each family member will come in and give it each day. . . . and the doctors may or may not know about them.” However, in other situ-
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ations, patients may initiate CAM discussions and the nurse later shared this information with others. Julie stated “. . .In my continence role, . . . people, they use a lot of those, over the counter things that help with bladder infections . . . Patients tell me about it and I’ll write it down so I can tell some-one else because people will ask.” Some-times, nurses may raise the option of CAM to patients as an adjuvant to their conventional medical care. Gill stated “. . . with the emergency department we see a broad range of, like, medical, surgical, trauma related. . . . if it was something orthopaedic related or musculoskeletal related, then I might talk about everything, . . . I will talk about, natural herbal, anti-inflammatories . . . massage as well.” However, it was evident from the data that most participants who discussed CAM, did it in response to patient enquiries. Penny, claimed “. . .I tend not to say anything unless the patients say something about it . . .Only if it’s the patient brings it up directly and asks a very direct question.” Likewise, Sarah’s commented, “ . . .I would never initiate it [CAM discussion] in the surgical setting . . .” 4.2. Communication with doctors about patients’ use of CAM Nurses reported that communication about CAM with their medical colleagues was mixed. Like patients, they do not discuss the topic if they perceive the doctor has a negative attitude towards the therapies. Brenda gave a typical example; “. . . There is one doctor in particular that I probably wouldn’t [talk to about CAM] because she is not open at all.” Claire, who works in an aged care facility where various CAM are commonly used by residents said, “. . .I think people can be very narrow minded . . . There are some GP’s that come here and if you mention there’s an acupuncturist, they’ll say yeah they’re all witch doctors.” Other participants described a more positive response from their medical colleagues. Jacky claimed “. . .I work with a lot of GPs and I find that a lot of GPs are very open and accepting of the fact that their patient are going to use comp therapies. I’ve had really interesting discussions with doctors and my nursing colleagues.” A number of participants also claimed that the patients’ perceived attitude of their doctor had a powerful influence on their willingness to discuss CAM use. Penny observed that “. . . some of them have mentioned it to the specialist and got a bit of a [negative] reaction, so they just do it quietly behind their back kind of thing.” As with discussions about CAM, documentation of its use was somewhat haphazard. Sarah, reported, “. . .Yeah. . . it [herbal medicine] is documented. . . . I just document it as their usual medication and tell the surgeons if they were still on fish oils or something like that.” However many participants reported that they did not record CAM at all, while Penny claimed she would document the CAM that were considered less contentious such as massage, but not others, such as herbal medicine. 4.3. Connecting with CAM practitioners When participants were asked about communicating with, or recommending CAM practitioners, they displayed a general lack of collaboration. Very few spoke directly with CAM practitioners, and the ‘referral’ came in the form of an informal suggestion. Despite their support for CAM, most participants considered collaboration with practitioners beyond their professional boundaries. For example Lisa, stated “. . .No that [referral to CAM practitioner] is outside the scope of nursing . . . thinking about it in terms of where we are at in this [healthcare] system right now, no.” Likewise, Kathy stated “. . . Then you’ve also got to have them within the scope of the . . . Health Network. To refer someone outside of that, you can’t do, you’re not covered for that sort of thing.” Participants’ comments indicated that, even if they are supportive of patients visiting CAM practitioners, there are a number of regulatory barriers that inhibit formal referral to them.
The lack of direct communication and collaboration with CAM practitioners may also be reflective of nurses’ concerns about their safety and credibility. Many participants were aware of the issues with regulation of some CAM practitioners and this impacted their decision to refer. Some nurses were wary that their patients may be taken advantage of. Renee said “. . .Old people are sitting ducks for charlatans. . . . So, it’s really important that, they’re credentialed. . .” Others, such as Katie, were concerned by the lack of clear education standards and practice boundaries with CAM practitioners; “ . . . some things aren’t well regulated. . . .there’s no real measure of competence.” Although none of the nurses who participated in this study formally referred patients to CAM therapists, a number, suggested they may be of assistance. For example, Jacky said; “. . .so if someone’s got some gut problems . . . they’ve got nothing sinister there. . . .I would consider saying, “Have you consider seeing a naturopath?" Likewise, Judy said; “It would just be a suggestion. . . .We would say in general”, “Have you thought about doing this?” Brenda discussed how recommendation to a CAM practitioner was typically a very informal process; “. . .. . .it is very much on word of mouth. . . .word of mouth is very powerful tool here.” 4.4. Barriers to CAM communication The data revealed that a number of contextual influences had a significant impact on the manner in which nurses communicate about CAM. The context of the nurse’s professional work including both macro (e.g. medical dominance in health care) and micro conditions (e.g. patient preference and workplace culture) were found to play an important role in shaping participants’ behaviour. Claire claimed that “. . . some hospitals don’t allow it to be used which is a shame I think because they’re missing out on the benefits of it for their patients. . ..” Likewise, Hilary stated “. . . . . .because we’re public health service, we are probably quite restricted,. . .”,. . .” In addition, the perceived attitude of the patient had a powerful influence on the nurses’ decision to broach the topic or not. Brenda said “. . . I’ll give them [CAM] suggestions, if they look interested. If they don’t, I don’t go there, . . . It’s really on the openness of the person . . .” Although individual healthcare providers’ attitudes varied widely, there was a general consensus that CAM was becoming more accepted in the medical environment. Penny claimed that, “. . .most people are quite open to it all on our ward. I haven’t had anybody go “Oh, that’s a load of rubbish.” Brenda said, “. . .Yeah, the newer doctors coming through are quite different, they are much more open to it, but you’ve got a lot of doctors that are still out there that have still got the old brainwashed ‘doctors are the only people that can help people’.” Likewise, Gill claimed “. . . I think that’s a changing attitude. I think that, you know, possibly twenty years ago it wasn’t as well accepted. But now it is,. . .” Many of the nurses who were interviewed raised their own lack of knowledge about CAM as a major factor that hindered their ability to discuss use with patients. Alice put it succinctly when she stated “. . .I’ve got so little knowledge I wouldn’t discuss them at all.” Amie articulated a similar sentiment “. . .. . . if there’s a supplement that I don’t know . . . I’m not educated on then obviously, I wouldn’t, you know, wouldn’t be giving advice on something I don’t know about. But I’m all for complementary medics, medicines, and practices.” Although participants asserted that nurses have many opportunities to engage with patients, lack of time was also commonly cited as a barrier to CAM communication. In the business of daily work, discussing CAM was not a priority. When asked if she thought nurses should talk with patients about their CAM use, Julie said, “. . . Maybe, I’m not sure. There are so many other things and we are so busy these days. . . I hardly have time to talk about the stuff I have to.” Penny stated, “. . .we have been so flat out, every shift has been intense. There hasn’t been a lot of opportunity to have any sort of casual, anything
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other than just a basic kind of conversation.” Likewise, Alice claimed “. . . I’m always doing assessments under pressure, often with a reluctant patient and in a tight time frame. . . .I would be very unlikely if I asked them about CAMs.”
5. Discussion This study was undertaken to explore nurses’ communication regarding patients’ use of CAM in the Australian healthcare context. The qualitative data indicates that, although they frequently interact with patients and talk about a wide variety of topics, some nurses are not comfortable discussing CAM. This finding is consistent with earlier research that reveals, despite holding a positive attitude towards CAM, nurses do not usually initiate dialogue about use of these therapies with their patients (Holroyd, Zhang, Suen, & Xue, 2008; Jong, Lundqvist, & Jong, 2015; Osaka et al., 2009; Spencer et al., 2016). It is worth noting however, that a few participants in our study reported that they did sometimes suggest CAM alongside conventional treatment, which has been identified in other research (Hall, Leach, Brosnan, & Collins, 2017). Nurses reported that patients are often cautious about disclosing their use, (particularly to the doctor), with some people going to the extent of physically hiding oral supplements in their hospital room. Whilst it is not possible to understand the patients’ reasons from our research, it may be due to the perception that CAM and conventional medicine are seen to be diametrically opposed and the fear of being admonished by hospital staff. However patients’ concerns about disclosure to nurses may be unwarranted, as many view CAM and nursing as paradigmatically aligned (Hall et al., 2017). It is also feasible that patients may not understand the importance of disclosing this information. People often naively believe that CAM are ‘natural’ and therefore harmless (Hall, McKenna, & Griffiths, 2010), and this may also lead to lack of disclosure. It is interesting that participants in our study, emphasised that a positive therapeutic relationship was an important scaffold for discussion about CAM. Indeed, the need for health providers to demonstrate a respectful and non-judgemental approach has been highlighted in other research as an important factor to promote CAM communication (Schiff et al., 2011). A number of participants raised concerns about communicating a patient’s CAM use to their medical doctor. While nurses are logical conduits between the patient and doctor in relation to CAM use, the reality is nuanced and communication often haphazard. Some nurses described the importance of alerting doctors when they felt there might be a risk to the patient, for example the use of fish oil pre-surgery, while others only discussed or documented CAM that they considered to be ‘harmless’, such as massage. Nurses explained their behaviour was often dependant on their perception of the doctor’s attitude towards complementary approaches to health care. Previous research has also demonstrated that biomedical authority and collegial scepticism influences nurses’ willingness to communicate CAM use (Bertrand, 2010; Shuval, 2006; Wang & Yates, 2006). A survey conducted by Holroyd et al. (2008) found that most of the nurse respondents (n = 187), never (45.7%) or rarely (29.5%) informed a Western medicine doctor about patient’s concurrent use of CAM and Western medicine. Furthermore, an Australian study found that although nurses do sometimes record CAM use, there is rarely allocated space in the patient’s clinical file which further reduces the likelihood of documentation (Cooke, Mitchell, Tiralongo, & Murfield, 2012). These barriers need to be addressed as communication is imperative, given the potential adverse consequences of CAM use alongside conventional pharmaceutical and surgical treatments. Professional connections between nurses and CAM practitioners were not evident in this study. Consistent with Sewitch et al.
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(2008), our findings reveal that although nurses commonly support patients’ CAM use, they did not engage with CAM practitioners. Participants identified their role as involving the occasional discussion about CAM but not necessarily advocacy or making recommendations. Where nurses did suggest to a patient that they consider visiting a CAM practitioner, this took the form of a casual mention rather than a formal referral. Nurses’ lack of engagement with CAM practitioners seemed to be in part due to a reluctance to refer outside of local conventional health care networks and the restrictions of their scope of practice and professional autonomy. Additionally, participants in our study were cautious of the level of regulation and education underpinning some CAM therapies and practitioners, with some expressing a desire to protect patients from unproven therapies or unregulated practitioners. There is however some international evidence that nurses are prepared to collaborate with CAM practitioners. A study conducted in the USA by Spencer et al. (2016) found that 42% of the 175 nurses surveyed, referred patients to CAM therapist however, it is not clear if this was done via a formal process. The relative conservatism towards CAM practitioners found among our nurse interviewees may reflect characteristics of the sample (for example, their high level of education, discussed below), or a more general lack of integration between CAM and conventional medicine in Australia, compared to some other countries. Our findings resonate with a study conducted by Penney et al. (2016), that reveal patients are often the bridge between their mainstream and CAM care providers, and they are left in the difficult situation of managing the information and communication. A lack of institutional support and professional governance related to CAM, limits dialogue and acceptance within the mainstream health system (Cant, Watts, & Ruston, 2011; Hall, Griffiths, & McKenna, 2015). Indeed, numerous studies have found that professional and organizational influences exert a powerful effect on the nurses’ behaviour related to CAM (Hall et al., 2017). This was reflected by participants in our study who identified the workplace culture in many medical settings, was a barrier to open communication. Interestingly, the nurses reported changing attitudes towards CAM among younger doctors who were perceived to be more openminded. This is a positive step towards facilitating communication and therefore patient safety. Nevertheless, nurses still felt the need to carefully judge the likely reaction of both doctors and patients when deciding whether to initiate CAM discussions, pointing again to nurses’ crucial role as intermediaries who must navigate the contested terrain of CAM. Many nurses in our study felt that their lack of knowledge was a major barrier to CAM discussions with patients, which is has been highlighted in the literature (Chang & Chang, 2015; Hall et al., 2017). Indeed, numerous studies make it clear that nurses who have basic CAM knowledge are more likely to ask their patients about their use of the products and practice (Holroyd et al., 2008; Jong et al., 2015; Spencer et al., 2016; Trail-Mahan, Mao, & BawelBrinkley, 2013). If patients are relying on advertising or on family and friends for guidance, it is particularly important that nurses, as health care providers, are in a position to offer or guide patients towards, more reliable information. There is a need for further provision of CAM information in nursing education and continuing professional development. A multisite randomized trial found that participants who have increased CAM knowledge are more likely to engage patients in conversations about use of these therapies (Parker et al., 2013). However, such initiatives may have limited effect in the current healthcare environment, given that a major reported barrier to communication was lack of time and the need to prioritise other aspect of care. This suggests that even with greater access to CAM information, nurses’ current working conditions are not conducive to communication around CAM. Lack of CAM communication in clinical settings therefore needs to be understood as
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imbedded in structural conditions that extend beyond the attitudes or knowledge of individual health care professionals. This study has provided a more in-depth understanding of Australian nurses’ experiences of communicating about CAM in the workplace. A strength of the study is its inclusion of nurses working in a wide range of clinical locations. This revealed, for instance, that CAM is discussed broadly across acute and community care settings, including in emergency care where it might be less expected. While the study provides valuable insights that improve our understanding, the qualitative data is limited to the context, and therefore the findings cannot be generalised. Another limitation relates to the high education level of the participants, with the majority having completed qualifications above a Bachelor Degree level. Although the study was not designed to generate a representative sample, future research might seek out nurses with more basic qualifications, who may have different perspectives on issues relating to CAM evidence and nurses’ professional roles. 6. Conclusion Nurses regularly interact with patients, providing an opportunity to communicate with them about the safe use of CAM. Yet, despite their positive views, some are not confident to discuss or document CAM use. Participants in our study emphasised the need for a respectful, open minded approach to overcome the discomfort associated with CAM. In some situations, collegial scepticism and the institutional culture discourage open communication. Furthermore, a lack of appropriate knowledge and time restraints also hinder nurses’ capacity to have meaningful dialogue. This study found very little evidence of collaboration with qualified CAM practitioners which further contributes to the risks associated with use of these therapies. Strategies to address the current gaps may include basic CAM education, direction to reputable sources of CAM information and the development of flexible CAM guidelines and referral frameworks. Funding The study received funding from the Endeavour College of Natural Health: Inaugural Endeavour Research Grant Round, 2015 to the value of $13,991. Acknowledgements The authors wish to thank the nineteen nurses who generously agreed to participate in this study. References Barnes, P., Bloom, B., & Nahin, R. (2008). Complementary and alternative medicine use among adults and children: United States, 2007. National Health Statistics Reports, 12, 1–23. Bertrand, S. (2010). Inroads to integrative health care: Registered nurses’ personal use of traditional Chinese medicine affects professional identity and nursing practice. Complementary Health Practice Review, 15(1), 14–30. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. Cant, S., Watts, P., & Ruston, A. (2011). Negotiating competency, professionalism and risk: The integration of complementary and alternative medicine by nurses and midwives in NHS hospitals. Social Science & Medicine, 72(4), 529–536. Chang, H., & Chang, H. (2015). A review of nurses’ knowledge, attitudes, and ability to communicate the risks and benefits of complementary and alternative medicine. Journal of Clinical Nursing, 24(11) http://dx.doi.org/10.1111/jocn. 12790 Chao, M., Handley, M., Quan, J., Sarkar, U., Ratanawongsa, N., & Schillinger, D. (2015). Disclosure of complementary health approaches among low income and racially diverse safety net patients with diabetes. Patient Education and Counseling, 98(11), 1360–1366. Cooke, M., Mitchell, M., Tiralongo, E., & Murfield, J. (2012). Complementary and alterative medicine and critical care: A survey of knowledge and practices in
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Sewitch, M., Cepoiu, M., Rigillo, N., & Sproule, D. (2008). A literature review of health care professional attitudes toward complementary and alternative medicine. Complementary Health Practice Review, 13, 139–154. Shelley, B., Sussman, A., Williams, R., Segal, A., & Crabtree, B. (2009). They don’t ask me so I don’t tell them’: Patient-clinician communication about traditional, complementary, and alternative medicine. Annals of Family Medicine, 7(2), 139–147. http://dx.doi.org/10.1370/afm.947 Shorofi, S. (2011). Complementary and alternative medicine (CAM) among hospitalised patients: Reported use of CAM and reasons for use, CAM preferred during hospitalisation, and the socio-demographic determinants of CAM users. Complementary Therapies in Clinical Practice, 17(4), 199–205. http://dx.doi.org/ 10.1016/j.ctcp.2011.05.001 Shuval, J. (2006). Nurses in alternative health care: Integrating medical paradigms. Social Science & Medicine, 63(7), 1784–1795.
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Wang, S., & Yates, P. (2006). Nurses’ responses to people with cancer who use complementary and alternative medicine. International Journal of Nursing Practice, 12(5), 288–294. Xue, C., Zhang, A., Lin, V., Da Costa, C., & Story, D. (2007). Complementary and alternative medicine use in Australia: A national population-based survey. The Journal of Alternative and Complementary Medicine, 13(6), 643–650. Yang, L., Sibbritt, D., & Adams, J. (2016). A critical review of complementary and alternative medicine use among people with arthritis: A focus upon prevalence, cost, user profiles, motivation, decision-making, perceived benefits and communication. Rheumatology International, 37(3), 337–351. http://dx.doi. org/10.1007/s00296-016-3616-y
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Contents lists available at ScienceDirect
Collegian journal homepage: www.elsevier.com/locate/coll
Nurses’ communication regarding patients’ use of complementary and alternative medicine Helen Hall a,b,∗ , Caragh Brosnan b,c , Jane Frawley b , Jon Wardle b , Melissa Collins d , Matthew Leach b,e a
Faculty of Medicine, Nursing and Health Sciences, School of Nursing & Midwifery, Monash University, Frankston, Australia Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), University of Technology Sydney, Sydney, Australia c School of Humanities and Social Science, University of Newcastle, Australia d Endeavour College of Natural Health, Australia e School of Nursing and Midwifery, University of South Australia, Australia b
a r t i c l e
i n f o
Article history: Received 10 May 2017 Accepted 7 September 2017 Available online xxx Keywords: Nurse Complementary and alternative medicine Complementary therapies Communication
a b s t r a c t
Background: : Many people integrate complementary and alternative medicine (CAM) into their health care. Nurses potentially play a significant role in communicating with patients about their CAM utilisation. Aim: : The study aimed to explore whether, how and why nurses working in Australia communicate about patients’ CAM use. Methods: : This paper reports on phase one of a mixed methods study. Qualitative data was obtained, via interviews, with nineteen registered nurses who work in a wide variety of clinical environments across all states of Australia. Findings: : Four themes related to nurses’ communication with patients about CAM, were developed from the qualitative data; engaging with patients about CAM, communication with doctors about patients’ use of CAM, connecting with CAM practitioners and barriers to CAM communication. Discussion: : Despite their positive attitudes, nurses are often not comfortable discussing or documenting patients’ CAM use. Furthermore, nurses perceive that patients may be apprehensive about disclosing their use. CAM communication with colleagues is moderated by the workplace culture and the perceived attitude of co-workers. There is very little evidence of nurses referring or collaborating with CAM practitioners. Professional expectation, time restraints and the nurses’ lack of relevant CAM knowledge all have a powerful effect on limiting CAM communication. Conclusion: : Communication about patients’ use of CAM is imperative to support safe therapeutic decisions. Currently, this is limited in the Australian healthcare workplace. The nursing professional needs to consider introducing basic CAM education and flexible guidelines to enable nurses’ to respond appropriately to the patient driven demand for CAM. © 2017 Published by Elsevier Ltd on behalf of Australian College of Nursing Ltd.
1. Introduction Complementary and alternative medicine (CAM) refers to a broad range of healthcare products and practices with a history of use outside of mainstream conventional medical practice (National Centre for Complementary and Integrative Health (NCCIH), 2013). The definition of CAM has continued to evolve and use of these
∗ Corresponding author at: Faculty of Medicine, Nursing and Health Sciences, School of Nursing & Midwifery, Monash University, Peninsula Campus,McMahons Road, Frankston, Victoria, 3199, Australia. E-mail address: [email protected] (H. Hall).
therapies, by both general public and healthcare professionals, is increasing (Frass et al., 2012). However, the evidence of the safety and effectiveness of CAM is mixed, with some therapies remaining controversial while others are broadly accepted in mainstream medicine. Particularly poorly understood is the risk of combining CAM supplements (such as herbal medicines), with conventional medicine, making patients’ disclosure of concurrent use crucial. Nurses potentially play a significant role in communicating with patients about their CAM utilisation. Compared to doctors, nurses typically spend more time with patients, and people may feel more comfortable revealing details of CAM use to them. Hence, nurses may act as important intermediaries, ensuring doctors are aware
http://dx.doi.org/10.1016/j.colegn.2017.09.001 1322-7696/© 2017 Published by Elsevier Ltd on behalf of Australian College of Nursing Ltd.
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Summary of relevance Issue • Despite the popularity of complementary and alternative medicine (CAM) in Australia, very little is known about how nurses communicate regarding patients’ use of these products and practices. What is already known • People often use CAM without input from a qualified healthcare provider. Some patients are apprehensive about disclosing their use, which increases the associated risks. What this paper adds • Some nurses are not confident to discuss or document patients’ use of CAM. Strategies to improve communication include basic CAM education and the development of flexible CAM guidelines.
of patients’ current CAM use, and potentially directing patients towards, or deterring them from, qualified CAM therapists.
Kitzman, McMullen, & Anson, 2008). Furthermore, these studies indicate that less than half of all physicians feel comfortable discussing CAM with their patients, due to their lack of relevant knowledge. A critical step to delivering safe care and enabling patients to make informed therapeutic decisions, is for practitioners to engage in conversations about their health care behaviour, including the use of CAM. While nurses working in Australia are well-positioned (in terms of workforce numbers and sectoral spread) to communicate with patients about CAM, it is unclear if they take advantage of this opportunity and what barriers and facilitators they encounter. 3. Method This paper reports on phase one of a mixed methods study. The study aimed to explore whether, how and why nurses working in Australia engage with patients regarding CAM use. The first phase, involved collecting qualitative data, via interviews, with registered nurses who worked in Australia. An inductive qualitative research approach was considered ideal to gain insight into the topic of interest. Approval to conduct the study was acquired from the relevant Human Research Ethics Committees and informed consent was gained from all participants. Pseudonyms are used throughout this paper to preserve the participants’ anonymity.
2. Background 3.1. Participants Internationally, around one-third of the Western population use CAM, with surveys from the US and UK reporting usage rates of 38% (Barnes, Bloom, & Nahin, 2008) and 26% (Hunt et al., 2010) respectively. Prevalence rates in Australia are even higher, with national survey data indicating close to 69% of the population use these therapies (Xue, Zhang, Lin, Da Costa, & Story, 2007). Furthermore, there is evidence that people are more likely to seek CAM services for a range of chronic conditions, including diseases identified as National Health Priority Areas by the Australian Government (Reid, Steel, Wardle, Trubody, & Adams, 2016). Research has found that the drivers for using CAM are generally associated with wishing to be more involved with health care decisions, having holistic health beliefs and increased therapeutic options, rather than dissatisfaction with conventional medicine (Shorofi, 2011). It is concerning that a considerable proportion of CAM users self-prescribed, with little or no input from a health professional. A review of studies from fifteen countries revealed that despite the widespread use, only a minority (median of 12.2%) of the general population consult a CAM provider (Harris, Cooper, Relton, & Thomas, 2012). Whilst a patient’s right to self-determination should be respected, it is imperative that their health care decisions (including those relating to the use of CAM) are adequately informed. Unfortunately, many consumers rely on nonprofessional, low quality sources of information (e.g. advice from friends and family) to guide their CAM decisions (Frawley et al., 2014; Yang et al., 2016). In addition, many people do not disclose CAM use to conventional health providers, which increases the associated risks (Chao et al., 2015; Lucas, Kumar, & Leach, 2015; McIntyre, Saliba, Wiener, & Sarris, 2016). Although the issue of CAM communication in conventional health settings has been the topic of significant research examination, most of this has centered on interactions between patients and their medical practitioners. These studies have generally shown that less than half of patients discuss their CAM use with their physician due to; fear of a negative response, their perceptions that the physician lacks appropriate knowledge, a preference to keep their CAM and conventional treatments separate, or simply because their doctor did not ask them (Roberts et al., 2006; Shelley, Sussman, Williams, Segal, & Crabtree, 2009; Sidora-Arcoleo, Yoos,
Nineteen registered nurses, who worked in a wide variety of clinical environments across all states of Australia, were recruited for phase one. The aim was not to obtain a representative sample but rather to capture a wide variety of experiences. The participants were recruited through advertising with a professional association and via snowballing. Participants’ ages ranged from twenty-seven to sixty-six, with all but one, being female. Most participants had been working as a registered nurse for more than ten years and had extensive clinical experience (Table 1). 3.2. Data collection Nurses who contacted the researcher expressing an interest in the study, were sent an explanatory statement via email (or post if preferred). Those wishing to participate were given a consent form to sign before the interview began. Two female researchers (HH and MC), who are experienced in qualitative data collection and analysis, conducted the nineteen interviews. One researcher (HH), has a background in nursing and naturopathy and the other (MC), in public health and naturopathy; neither had a relationship with the participants they interviewed. Due to the distances involved most (n = 15) of the interviews occurred via the telephone however, some (n = 4) were conducted face to face at a place which was convenient for the participant. While an interview guide was used to direct the line of questioning, participants were encouraged to speak freely around the topic generally to enable full exploration of the salient issues. The interviews lasted approximately 50 min and, with the participant’s consent, were audio recorded and then later transcribed. 3.3. Data analysis The qualitative data underwent inductive thematic analysis using the phases recommended by Braun and Clarke (2006). Thematic analysis is a research method that enables identification and analyses of patterns (themes) within data. Firstly the interviews were transcribed and then the researchers (HH and MC), made themselves familiar with the data. Next, initial codes were
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Table 1 Characteristics of participants. Pseudonym
State
Age
Highest educational qualification
Clinical area
Sally John Kathy Claire Heather Jacky Penny Hilary Gill Renee Lisa Judy Katie Alice Brenda Julie Sarah Amie Debbie
Victoria Victoria NT NSW Victoria NSW NSW Victoria Victoria Victoria NSW WA Victoria NSW Tasmania WA QLD Victoria SA
52 27 53 60 53 48 53 47 52 55 55 56 48 66 49 56 44 32 59
Post-graduate Masters degree Post-graduate Post-graduate Bachelor degree Bachelor degree Post-graduate Bachelor degree Masters Post-graduate Post-graduate Masters degree Bachelor degree PhD Bachelor degree Post-graduate Bachelor degree Post-graduate Masters degree
Primary health; refugee nurse, maternal health Acute care; tertiary pubic hospital Remote and rural care, also metropolitan ICU Aged care Aged care Rural hospital and primary health Acute care; tertiary pubic hospital Palliative care Level 2 Hospital Emergency Department Rural Aged care Acute care; tertiary public hospital. Also private practice Refugee nurse. Clinical Nurse Specialist Aged care Mental health, drug and alcohol rehabilitation Primary health; GP practice Continence nurse plus, maternal and child nurse Public Hospital Public hospital- Diabetes educator plus aged care Allergy nurse; public hospital clinic & private practice
Table 2 Example of analysis. Raw data
Codes
. . . some hospitals don’t allow it to be used which is a shame I think because they’re missing out on the benefits of it for their patients, as well as for themselves. If the patients comfortable, pain free and less stressed it works for a happier environment, so the staff is also that way. (Claire) . . .because we’re public health service, we are probably quite restricted . . . we would be quite limited about what we could recommend and what we, we couldn’t. (Hilary) I’ll give them [CAM] suggestions, if they look interested. If they don’t, I don’t go there, . . . It’s really on the openness of the person . . .I don’t pressure people but if they look interested and they pick up on it then I’ll go to it, if they don’t, I don’t go there. (Brenda) I tend not to say anything unless the patients say something about it . . .Only if it’s the patient brings it up directly and asks a very direct question. (Penny) I think the, the culture of care is so not open to considering complementary therapy (Heather) Some places I’ve worked use complementary therapies all the time, it’s not a problem. Other places, like one acute surgical ward where I worked, they treated it like witch craft. (Katie) There are so many other things and we are so busy these days. . . I hardly have time to talk about the stuff I have to. (Julie) . . .often there’s lots of competing. . . .They’ve go physio, they’ve got O.T, they’ve got hand therapy coming, they’ve got the doctors . . . and just the practicalities of actually fitting it [CAM discussion] in. (John) I’ve got so little knowledge I wouldn’t discuss them (CAM therapies) at all. (Alice) . . . if there’s a supplement that I don’t know . . . I’m not educated on then obviously, I wouldn’t, you know, wouldn’t be giving advice on something I don’t know about. But I’m all for complementary medics, medicines, and practices. (Amie)
Professional expectations and policies
generated and collated into potential themes. Following this, the emergent findings were discussed and potential themes were reviewed. Finally, each theme was refined to reflect the dominant characteristics embedded in the data. To ensure dependability of the findings, member checking was used by contacting two participants, to ensure our interpretations resonated with their experiences (Table 2). 4. Findings Four themes related to nurses’ communication with patients about CAM, were developed from the qualitative data. These themes include; engaging with patients about CAM, communication with doctors about patients’ use of CAM, connecting with CAM practitioners and barriers to CAM communication. 4.1. Engaging with patients about CAM A number of participants asserted that, because nurses interact directly with patients, there are many opportunities to engage in conversations about a wide variety of topics, including CAM. Lisa, stated “. . .We are in such a pivotal role in, terms of being able to be
Patient’s preference
Theme
Barriers to CAM Communication
Workplace culture
Time
Knowledge
with people, and . . . educate them, introduce new ways to them. I absolutely see it [talking about CAM] as, important.” Likewise, Jacky claimed “ . . . there’s a lot of opportunity there for nurses to talk to patients about that [CAM use] because as I said, patients can often use these therapies and not actually talk to their doctor about it.” However, despite these opportunities, participants reported that not all patients feel comfortable about discussing their CAM use. Several asserted that nurses need to garner patients’ trust and encourage them to disclose. Debbie, said “. . .we’ve got to get that trust. . . .. Because you know, . . . lots of times, people do not tell the doctor they’re on alternative treatments.” One participant, Penny, reported a variety of behaviours related to disclosure of CAM use; “. . . in oncology a lot of people will try alternative stuff first. . . or they’ll come in with it, and they’re using it as well. Some are quite open about it, and others just don’t tell you, and you sort of find out along the way.” Sometimes, CAM use was actively hidden. Renee, who works in an aged care facility, describe situations where relatives concealed specific therapies due to concerns that they may encounter a negative attitude: “. . .They’ll bring in things [herbal medicine] and hide them in the residence drawers and each family member will come in and give it each day. . . . and the doctors may or may not know about them.” However, in other situ-
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ations, patients may initiate CAM discussions and the nurse later shared this information with others. Julie stated “. . .In my continence role, . . . people, they use a lot of those, over the counter things that help with bladder infections . . . Patients tell me about it and I’ll write it down so I can tell some-one else because people will ask.” Some-times, nurses may raise the option of CAM to patients as an adjuvant to their conventional medical care. Gill stated “. . . with the emergency department we see a broad range of, like, medical, surgical, trauma related. . . . if it was something orthopaedic related or musculoskeletal related, then I might talk about everything, . . . I will talk about, natural herbal, anti-inflammatories . . . massage as well.” However, it was evident from the data that most participants who discussed CAM, did it in response to patient enquiries. Penny, claimed “. . .I tend not to say anything unless the patients say something about it . . .Only if it’s the patient brings it up directly and asks a very direct question.” Likewise, Sarah’s commented, “ . . .I would never initiate it [CAM discussion] in the surgical setting . . .” 4.2. Communication with doctors about patients’ use of CAM Nurses reported that communication about CAM with their medical colleagues was mixed. Like patients, they do not discuss the topic if they perceive the doctor has a negative attitude towards the therapies. Brenda gave a typical example; “. . . There is one doctor in particular that I probably wouldn’t [talk to about CAM] because she is not open at all.” Claire, who works in an aged care facility where various CAM are commonly used by residents said, “. . .I think people can be very narrow minded . . . There are some GP’s that come here and if you mention there’s an acupuncturist, they’ll say yeah they’re all witch doctors.” Other participants described a more positive response from their medical colleagues. Jacky claimed “. . .I work with a lot of GPs and I find that a lot of GPs are very open and accepting of the fact that their patient are going to use comp therapies. I’ve had really interesting discussions with doctors and my nursing colleagues.” A number of participants also claimed that the patients’ perceived attitude of their doctor had a powerful influence on their willingness to discuss CAM use. Penny observed that “. . . some of them have mentioned it to the specialist and got a bit of a [negative] reaction, so they just do it quietly behind their back kind of thing.” As with discussions about CAM, documentation of its use was somewhat haphazard. Sarah, reported, “. . .Yeah. . . it [herbal medicine] is documented. . . . I just document it as their usual medication and tell the surgeons if they were still on fish oils or something like that.” However many participants reported that they did not record CAM at all, while Penny claimed she would document the CAM that were considered less contentious such as massage, but not others, such as herbal medicine. 4.3. Connecting with CAM practitioners When participants were asked about communicating with, or recommending CAM practitioners, they displayed a general lack of collaboration. Very few spoke directly with CAM practitioners, and the ‘referral’ came in the form of an informal suggestion. Despite their support for CAM, most participants considered collaboration with practitioners beyond their professional boundaries. For example Lisa, stated “. . .No that [referral to CAM practitioner] is outside the scope of nursing . . . thinking about it in terms of where we are at in this [healthcare] system right now, no.” Likewise, Kathy stated “. . . Then you’ve also got to have them within the scope of the . . . Health Network. To refer someone outside of that, you can’t do, you’re not covered for that sort of thing.” Participants’ comments indicated that, even if they are supportive of patients visiting CAM practitioners, there are a number of regulatory barriers that inhibit formal referral to them.
The lack of direct communication and collaboration with CAM practitioners may also be reflective of nurses’ concerns about their safety and credibility. Many participants were aware of the issues with regulation of some CAM practitioners and this impacted their decision to refer. Some nurses were wary that their patients may be taken advantage of. Renee said “. . .Old people are sitting ducks for charlatans. . . . So, it’s really important that, they’re credentialed. . .” Others, such as Katie, were concerned by the lack of clear education standards and practice boundaries with CAM practitioners; “ . . . some things aren’t well regulated. . . .there’s no real measure of competence.” Although none of the nurses who participated in this study formally referred patients to CAM therapists, a number, suggested they may be of assistance. For example, Jacky said; “. . .so if someone’s got some gut problems . . . they’ve got nothing sinister there. . . .I would consider saying, “Have you consider seeing a naturopath?" Likewise, Judy said; “It would just be a suggestion. . . .We would say in general”, “Have you thought about doing this?” Brenda discussed how recommendation to a CAM practitioner was typically a very informal process; “. . .. . .it is very much on word of mouth. . . .word of mouth is very powerful tool here.” 4.4. Barriers to CAM communication The data revealed that a number of contextual influences had a significant impact on the manner in which nurses communicate about CAM. The context of the nurse’s professional work including both macro (e.g. medical dominance in health care) and micro conditions (e.g. patient preference and workplace culture) were found to play an important role in shaping participants’ behaviour. Claire claimed that “. . . some hospitals don’t allow it to be used which is a shame I think because they’re missing out on the benefits of it for their patients. . ..” Likewise, Hilary stated “. . . . . .because we’re public health service, we are probably quite restricted,. . .”,. . .” In addition, the perceived attitude of the patient had a powerful influence on the nurses’ decision to broach the topic or not. Brenda said “. . . I’ll give them [CAM] suggestions, if they look interested. If they don’t, I don’t go there, . . . It’s really on the openness of the person . . .” Although individual healthcare providers’ attitudes varied widely, there was a general consensus that CAM was becoming more accepted in the medical environment. Penny claimed that, “. . .most people are quite open to it all on our ward. I haven’t had anybody go “Oh, that’s a load of rubbish.” Brenda said, “. . .Yeah, the newer doctors coming through are quite different, they are much more open to it, but you’ve got a lot of doctors that are still out there that have still got the old brainwashed ‘doctors are the only people that can help people’.” Likewise, Gill claimed “. . . I think that’s a changing attitude. I think that, you know, possibly twenty years ago it wasn’t as well accepted. But now it is,. . .” Many of the nurses who were interviewed raised their own lack of knowledge about CAM as a major factor that hindered their ability to discuss use with patients. Alice put it succinctly when she stated “. . .I’ve got so little knowledge I wouldn’t discuss them at all.” Amie articulated a similar sentiment “. . .. . . if there’s a supplement that I don’t know . . . I’m not educated on then obviously, I wouldn’t, you know, wouldn’t be giving advice on something I don’t know about. But I’m all for complementary medics, medicines, and practices.” Although participants asserted that nurses have many opportunities to engage with patients, lack of time was also commonly cited as a barrier to CAM communication. In the business of daily work, discussing CAM was not a priority. When asked if she thought nurses should talk with patients about their CAM use, Julie said, “. . . Maybe, I’m not sure. There are so many other things and we are so busy these days. . . I hardly have time to talk about the stuff I have to.” Penny stated, “. . .we have been so flat out, every shift has been intense. There hasn’t been a lot of opportunity to have any sort of casual, anything
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other than just a basic kind of conversation.” Likewise, Alice claimed “. . . I’m always doing assessments under pressure, often with a reluctant patient and in a tight time frame. . . .I would be very unlikely if I asked them about CAMs.”
5. Discussion This study was undertaken to explore nurses’ communication regarding patients’ use of CAM in the Australian healthcare context. The qualitative data indicates that, although they frequently interact with patients and talk about a wide variety of topics, some nurses are not comfortable discussing CAM. This finding is consistent with earlier research that reveals, despite holding a positive attitude towards CAM, nurses do not usually initiate dialogue about use of these therapies with their patients (Holroyd, Zhang, Suen, & Xue, 2008; Jong, Lundqvist, & Jong, 2015; Osaka et al., 2009; Spencer et al., 2016). It is worth noting however, that a few participants in our study reported that they did sometimes suggest CAM alongside conventional treatment, which has been identified in other research (Hall, Leach, Brosnan, & Collins, 2017). Nurses reported that patients are often cautious about disclosing their use, (particularly to the doctor), with some people going to the extent of physically hiding oral supplements in their hospital room. Whilst it is not possible to understand the patients’ reasons from our research, it may be due to the perception that CAM and conventional medicine are seen to be diametrically opposed and the fear of being admonished by hospital staff. However patients’ concerns about disclosure to nurses may be unwarranted, as many view CAM and nursing as paradigmatically aligned (Hall et al., 2017). It is also feasible that patients may not understand the importance of disclosing this information. People often naively believe that CAM are ‘natural’ and therefore harmless (Hall, McKenna, & Griffiths, 2010), and this may also lead to lack of disclosure. It is interesting that participants in our study, emphasised that a positive therapeutic relationship was an important scaffold for discussion about CAM. Indeed, the need for health providers to demonstrate a respectful and non-judgemental approach has been highlighted in other research as an important factor to promote CAM communication (Schiff et al., 2011). A number of participants raised concerns about communicating a patient’s CAM use to their medical doctor. While nurses are logical conduits between the patient and doctor in relation to CAM use, the reality is nuanced and communication often haphazard. Some nurses described the importance of alerting doctors when they felt there might be a risk to the patient, for example the use of fish oil pre-surgery, while others only discussed or documented CAM that they considered to be ‘harmless’, such as massage. Nurses explained their behaviour was often dependant on their perception of the doctor’s attitude towards complementary approaches to health care. Previous research has also demonstrated that biomedical authority and collegial scepticism influences nurses’ willingness to communicate CAM use (Bertrand, 2010; Shuval, 2006; Wang & Yates, 2006). A survey conducted by Holroyd et al. (2008) found that most of the nurse respondents (n = 187), never (45.7%) or rarely (29.5%) informed a Western medicine doctor about patient’s concurrent use of CAM and Western medicine. Furthermore, an Australian study found that although nurses do sometimes record CAM use, there is rarely allocated space in the patient’s clinical file which further reduces the likelihood of documentation (Cooke, Mitchell, Tiralongo, & Murfield, 2012). These barriers need to be addressed as communication is imperative, given the potential adverse consequences of CAM use alongside conventional pharmaceutical and surgical treatments. Professional connections between nurses and CAM practitioners were not evident in this study. Consistent with Sewitch et al.
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(2008), our findings reveal that although nurses commonly support patients’ CAM use, they did not engage with CAM practitioners. Participants identified their role as involving the occasional discussion about CAM but not necessarily advocacy or making recommendations. Where nurses did suggest to a patient that they consider visiting a CAM practitioner, this took the form of a casual mention rather than a formal referral. Nurses’ lack of engagement with CAM practitioners seemed to be in part due to a reluctance to refer outside of local conventional health care networks and the restrictions of their scope of practice and professional autonomy. Additionally, participants in our study were cautious of the level of regulation and education underpinning some CAM therapies and practitioners, with some expressing a desire to protect patients from unproven therapies or unregulated practitioners. There is however some international evidence that nurses are prepared to collaborate with CAM practitioners. A study conducted in the USA by Spencer et al. (2016) found that 42% of the 175 nurses surveyed, referred patients to CAM therapist however, it is not clear if this was done via a formal process. The relative conservatism towards CAM practitioners found among our nurse interviewees may reflect characteristics of the sample (for example, their high level of education, discussed below), or a more general lack of integration between CAM and conventional medicine in Australia, compared to some other countries. Our findings resonate with a study conducted by Penney et al. (2016), that reveal patients are often the bridge between their mainstream and CAM care providers, and they are left in the difficult situation of managing the information and communication. A lack of institutional support and professional governance related to CAM, limits dialogue and acceptance within the mainstream health system (Cant, Watts, & Ruston, 2011; Hall, Griffiths, & McKenna, 2015). Indeed, numerous studies have found that professional and organizational influences exert a powerful effect on the nurses’ behaviour related to CAM (Hall et al., 2017). This was reflected by participants in our study who identified the workplace culture in many medical settings, was a barrier to open communication. Interestingly, the nurses reported changing attitudes towards CAM among younger doctors who were perceived to be more openminded. This is a positive step towards facilitating communication and therefore patient safety. Nevertheless, nurses still felt the need to carefully judge the likely reaction of both doctors and patients when deciding whether to initiate CAM discussions, pointing again to nurses’ crucial role as intermediaries who must navigate the contested terrain of CAM. Many nurses in our study felt that their lack of knowledge was a major barrier to CAM discussions with patients, which is has been highlighted in the literature (Chang & Chang, 2015; Hall et al., 2017). Indeed, numerous studies make it clear that nurses who have basic CAM knowledge are more likely to ask their patients about their use of the products and practice (Holroyd et al., 2008; Jong et al., 2015; Spencer et al., 2016; Trail-Mahan, Mao, & BawelBrinkley, 2013). If patients are relying on advertising or on family and friends for guidance, it is particularly important that nurses, as health care providers, are in a position to offer or guide patients towards, more reliable information. There is a need for further provision of CAM information in nursing education and continuing professional development. A multisite randomized trial found that participants who have increased CAM knowledge are more likely to engage patients in conversations about use of these therapies (Parker et al., 2013). However, such initiatives may have limited effect in the current healthcare environment, given that a major reported barrier to communication was lack of time and the need to prioritise other aspect of care. This suggests that even with greater access to CAM information, nurses’ current working conditions are not conducive to communication around CAM. Lack of CAM communication in clinical settings therefore needs to be understood as
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imbedded in structural conditions that extend beyond the attitudes or knowledge of individual health care professionals. This study has provided a more in-depth understanding of Australian nurses’ experiences of communicating about CAM in the workplace. A strength of the study is its inclusion of nurses working in a wide range of clinical locations. This revealed, for instance, that CAM is discussed broadly across acute and community care settings, including in emergency care where it might be less expected. While the study provides valuable insights that improve our understanding, the qualitative data is limited to the context, and therefore the findings cannot be generalised. Another limitation relates to the high education level of the participants, with the majority having completed qualifications above a Bachelor Degree level. Although the study was not designed to generate a representative sample, future research might seek out nurses with more basic qualifications, who may have different perspectives on issues relating to CAM evidence and nurses’ professional roles. 6. Conclusion Nurses regularly interact with patients, providing an opportunity to communicate with them about the safe use of CAM. Yet, despite their positive views, some are not confident to discuss or document CAM use. Participants in our study emphasised the need for a respectful, open minded approach to overcome the discomfort associated with CAM. In some situations, collegial scepticism and the institutional culture discourage open communication. Furthermore, a lack of appropriate knowledge and time restraints also hinder nurses’ capacity to have meaningful dialogue. This study found very little evidence of collaboration with qualified CAM practitioners which further contributes to the risks associated with use of these therapies. Strategies to address the current gaps may include basic CAM education, direction to reputable sources of CAM information and the development of flexible CAM guidelines and referral frameworks. Funding The study received funding from the Endeavour College of Natural Health: Inaugural Endeavour Research Grant Round, 2015 to the value of $13,991. Acknowledgements The authors wish to thank the nineteen nurses who generously agreed to participate in this study. References Barnes, P., Bloom, B., & Nahin, R. (2008). Complementary and alternative medicine use among adults and children: United States, 2007. National Health Statistics Reports, 12, 1–23. Bertrand, S. (2010). Inroads to integrative health care: Registered nurses’ personal use of traditional Chinese medicine affects professional identity and nursing practice. Complementary Health Practice Review, 15(1), 14–30. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. Cant, S., Watts, P., & Ruston, A. (2011). Negotiating competency, professionalism and risk: The integration of complementary and alternative medicine by nurses and midwives in NHS hospitals. Social Science & Medicine, 72(4), 529–536. Chang, H., & Chang, H. (2015). A review of nurses’ knowledge, attitudes, and ability to communicate the risks and benefits of complementary and alternative medicine. Journal of Clinical Nursing, 24(11) http://dx.doi.org/10.1111/jocn. 12790 Chao, M., Handley, M., Quan, J., Sarkar, U., Ratanawongsa, N., & Schillinger, D. (2015). Disclosure of complementary health approaches among low income and racially diverse safety net patients with diabetes. Patient Education and Counseling, 98(11), 1360–1366. Cooke, M., Mitchell, M., Tiralongo, E., & Murfield, J. (2012). Complementary and alterative medicine and critical care: A survey of knowledge and practices in
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