Student Nurses’ Knowledge and Perceptions of Alternative and Complementary Therapies
Tamara J. Keimig, RN
College of St. Benedict/St. John’s University
Carie A. Braun, PhD, RN, CNP
College of St. Benedict/St. John’s University
Increasingly, patients tend to be discharged from the hospital setting to the home more quickly, are oftentimes quite frail, and require complicated care procedures that fall squarely upon the family caregiver (Ferrell & Borneman, 1999). Despite the rising number of caregivers, little research has focused upon the relationship between caregiver outcomes and patient symptoms (Koop & Strang, 2003; Nijboer et al, 1998).
Caregiver burden has been shown to increase with the length of time spent caring for the patient (Winslow & Carter, 1999). With cancer patients surviving longer and continuing treatment for longer intervals, it is likely that a caregiver will spend a longer period of time caring for a patient. Therefore, the caregiver risks his or her psychological and physiological well-being when the tasks and worry associated with the patient’s care are added to the normal load of life’s tasks. The purpose of this study was to examine the effect of patient pain and fatigue on caregiver depression level and sleep quality.
Alternative and complementary therapies (A/CTs) are defined as “a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine” [National Center for Complementary and Alternative Medicine (NCCAM), 2002, para. 2] and include many different types of modalities including massage, herbal medicines, and acupuncture. Multiple research studies have focused on the use of alternative and complementary therapies (A/CTs) among health care consumers and consistently document increasing use among U.S. adults (Eisenberg, Kessler, et al., 1993; Eisenberg, Davis, et al., 1998).
Along with health care consumers, many health care providers including nurses are interested in and using A/CTs (Burg, Kosch, Neims, et al., 1998). One survey found 74% of nursing faculty and 52% of medicine faculty had used at least one A/CT (Burg et al., 1998). Among nursing students and faculty in other institutions, the current use of and desire to continue use of A/CTs reached well over 80% (Halcón, Chlan, Kreitzer, & Leonard, 2003; Joudrey & Gough, 2003). Similar trends are noted for medical students (Hooper, 1998). In one study, medical students (84%) reported they thought knowledge of A/CTs would be important to them as future physicians and 72% wanted to learn about A/CTs in medical school (Greiner, Murray, & Kallail, 2000). In 1998, Moore found 43% of surveyed medical colleges were incorporating A/CTs into their curriculum. Recently, 77% of 105 surveyed nursing programs incorporated A/CTs (Richardson, 2003).
Despite widespread consumer use, health care provider personal use, and positive opinions of A/CTs, King, Pettigrew, and Reed (2000) reported that practicing nurses had little knowledge about these therapies. Over 95% of nursing students and faculty in one University-based study agreed that nursing care should integrate effective A/CTs (Halcón, Chlan, et al., 2003). In that same survey, few nurses felt qualified to provide A/CT services and believed that formal education in providing A/CTs was lacking.
Statement of the Problem
High consumer use coupled with a perceived lack of nursing knowledge of A/CTs can result in nurses’ frustration in advising clients regarding the safe use of A/CTs (Bronlinson, Price & Ditmyer, 2001). The exposure and knowledge may be important, yet the perception and current knowledge of future nurses, particularly in rural areas where there are lower concentrations of A/CT providers (Breuner, Barry, & Kemper, 1998), has been largely ignored.
The purpose of this study was to explore the A/CT use patterns, knowledge and perceptions of undergraduate nursing students and sought to answer the following questions: 1) What is the level of A/CT familiarity among these undergraduate nursing students? 2) What are the A/CT utilization patterns among these nursing students? 3) What are students’ perceptions regarding A/CT incorporation into a nursing curriculum? 4) What level of learning is perceived to be adequate among respondents who suggest incorporating A/CTs into the curriculum?
To answer these questions, researchers surveyed a convenience sample of 150 baccalaureate nursing students from November 2002-January 2003 at two rural Midwest Catholic liberal arts colleges with a joint nursing department. The development of the survey was based on four major sources: NCCAM (2002), Greiner et al. (2000), Braun, Bearinger, and Halcón (2003), and Snyder and Lindquist (1998). The survey was divided into three sections: demographic information, general A/CT knowledge/perceptions, and participant use and perceptions of 26 select therapies. Investigation of individual therapies also included perceptions of incorporation into a nursing curriculum.
An operational definition of A/CT use was devised based on the NCCAM categorization of A/CT modalities (NCCAM, 2002). This structure was instrumental in guiding the selection of individual modalities considered complementary or alternative and was based on five classifications: alternative medical systems, mind-body interventions, biologically based therapies, manipulative and body-based methods, and energy therapies. Within these categories, 26 therapies were selected for incorporation into the study (Table 1).
The study was approved by the College of St. Benedict/St. John’s University Institutional Review Board. The results of the survey were coded by the principal investigator and entered into the statistical analysis program SPSS (10.0). The analysis was descriptive with a focus on frequencies of responses.
Of the 150 surveys administered, 40 (26.7%) were returned. The majority of the sample was between the ages of 18-22 (90%); the mean age was 20.4 years. Demographic information gathered did not include gender or race as this was deemed a threat to anonymity for some respondents.
Research Question 1: What is the Level of A/CT Familiarity among These Undergraduate Nursing Students?
Respondent familiarity of the 26 therapies was highest for massage therapy (100%), spiritual healing (95%), megavitamins/nutritional supplements (95%), and music therapy (92.5%). Most students had no knowledge of Reiki (85%), Ayurveda (67.5%), homeopathy (60%), and osteopathy (57.5%).
Research Question 2: What Are the A/CT Utilization Patterns among These Nursing Students?
Respondents then indicated the level of utilization for each therapy (1=have never used, 5=extensive use). The therapies most used by the respondents were spiritual healing (85%), massage therapy (85%), music therapy (75%), thermotherapy (72.5%), and journal writing (72.5%) (Table 2). None of the respondents had used Reiki and the vast majority of students had not used bioelectromagnetics (97.5%), Ayurveda (95%), or homeopathy (92.5).
Research Question 3: What are Students’ Perceptions Regarding A/CT Incorporation into a Nursing Curriculum?
A large percentage of the respondents agreed that knowledge of A/CTs would be important for future nurses (80%). Similarly, 72.5% agreed that they would like exposure to A/CT practitioners. Interestingly, 42.5% were convinced that they would not receive adequate exposure to A/CTs during their nursing education and an additional 45% were not sure.
Among individual therapies, respondents indicated which were perceived to be appropriate for incorporation into a nursing curriculum (Table 3). Those deemed most appropriate to include were massage therapy (82.5%), thermotherapy (75%), cryotherapy (75%), and progressive muscle relaxation (65%). Those regarded as inappropriate to include in the curriculum were hypnosis (47.5%), Reiki (42.5%), energy healing (27.5%), and acupuncture (25%).
Research Question 4: What Level of Learning is Perceived to be Adequate among Respondents who Suggest Incorporating A/CTs into the Curriculum?If the respondent agreed or strongly agreed that a therapy should be incorporated into the nursing curriculum, he/she was asked to choose from one of four levels of incorporation: introduction only, basic concepts (overview of the therapy and discussion of related research), information plus observation (basic concepts and clinical observation of therapy), or hands on practicum (concepts, research, and hand-on experience with therapy). Respondents believed that most therapies should be included at the basic concepts level. Introduction only was indicated most often for Reiki (55.6%) and Ayurveda (50%). On the other hand, over half of the respondents indicated massage therapy (52.9%) required a practicum.
The survey indicates that these nursing students, like U.S. adults, are most likely to be familiar with and use those therapies considered “less alternative” (commonly accepted in biomedicine, Eisenberg et al., 1998) including massage therapy, spiritual healing, megavitamins/nutritional supplements, and music therapy. Students are least likely to be familiar with or use those therapies considered “more alternative” (Eisenberg et al., 1998) including Reiki, Ayurveda, and homeopathy. These more alternative therapies often require intervention by specially trained practitioners, who are typically few and far between in rural areas, and this may result in lower levels of familiarity and use.
Similar to medical students (Greiner et al., 2000), the nursing students in this survey indicated a perception that A/CTs will be important as future nurses and that exposure to A/CT practitioners would be valuable, yet inadequate exposure was anticipated. This may, in part, be related to the problem of the “additive curriculum” in nursing education: concepts are continually added and nothing is removed because everything is considered critically important (Ironside, 2004). A/CTs are often considered outside of the nursing scope of practice and the safety and efficiency of many A/CTs are still being studied (Brooke, 1998; NCCAM, 2002; Fortanarosa & Lundberg, 1998).
Despite barriers to familiarity and use, many factors support incorporation into nursing education including the expanding consumer interest and use, governmental recognition and support (NCCAM, 2002), and health care provider interest. Most schools of nursing have gone ahead and incorporated certain A/CTs (Breda & Schulze, 1998; Halcon, Leonard, Snyder, Garwick, & Kreitzer, 2001; Kreitzer, 1997; Pepa & Russell, 2000; Richardson, 2003). Although these authors indicate a broad range of approaches, most nursing students in the current study perceived that an overview of the therapies with a discussion of related research (or lack thereof) was adequate. Hessig, Archand, and Frost (2004) determined that even one 8-hour educational intervention was effective in increasing knowledge and application of some therapies.
Further research is needed to differentiate actual incorporation among current nursing programs and the future impact on nursing practice. Students and practitioners alike may feel unprepared to assist clients with sorting through current evidence related to A/CTs. What and how much do nurses need to know about A/CTs as they emerge as entry-level practitioners of professional nursing? What is the best way to obtain this knowledge? If A/CTs are incorporated, what aspects of the current nursing curriculum are left behind? These are just a few of the questions generated by this research.
Although an interesting depiction of nursing student perceptions, this study is limited by a convenience sample, low response rate, lack of gender, age, or racial/ethnic diversity and potential self-report bias. The results are therefore most representative of the undergraduate nursing students at these institutions and not all undergraduate nursing students.The discipline of nursing focuses on the whole person: not just the physical but also the emotional, psychological, and spiritual (Kelly and Joel, 1999). A/CTs are often used because the therapies and/or alternative practitioners address healing within all human dimensions including mind, body, and spirit (Snyder and Lindquist, 1998). The coherence of nursing and the practice of various A/CTs forces nurse educators, students and practicing nurses to grapple with this issue of A/CT incorporation and the basic preparation of nurses.
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The authors gratefully acknowledge Dr. Kathleen Twohy and Ms. LuAnn Reif for their careful review of this protocol. This study was funded in part by an undergraduate research grant through the College of St. Benedict/St. John’s University. This project was presented at the Undergraduate Research Conference in Salt Lake City, Utah, in March 2003.
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