Pediatric Nurses' Usage and Experience Toward Complementary Health Approaches

Abstract

Objectives:

The usage of Complementary Health Approaches (CHA) and its popularity have been increasing among both children and pediatric nurses. The aims of this study were to (1) determine the knowledge and usage levels of pediatric nurses about CHA, (2) describe the experiences of nurses about CHA, and (3) evaluate the attitudes of nurses toward CHA.

Methods:

This was multicenter study. A total of 1,450 pediatric nurses who are working at the pediatric departments of different hospitals in Turkey participated in the study between June 2013 and February 2014. Around 1,303 female and 147 male pediatric nurses, in total 1,450, were included in the study. The semi-structured questionnaire had three sections. The first section composed of 14 questions about sociodemographic characteristics. The second section contained seven questions about the nurses' professional practices with respect to CHA. The third section contained eight questions about the nurses' attitudes to CHA.

Results:

The study revealed that 90.6% of the nurses used CHA, and primarily made use of praying (82.3%), massage (76.6%), and vitamins (60.2%), respectively. Most of the nurses used CHA for relaxation. Approximately half of the nurses did not asked the families of their CHA usage. More than half of the nurses (58.8%) stated that nurses were not responsible for informing patients about CHA. It was found that the nurses had negative experiences with CHA such as allergies, pain, and being upset. The most frequently indicated positive experience was “feeling better both physically and psychologically.”

Conclusions:

It is extremely important that nurses have knowledge about CHA. Nurses should question parents' use of CHA and inform parents about CHA' benefits and potential risks. Considering the personal/professional experiences, it is necessary to evaluate the positive/negative effects of CHA. Research may contribute to increased awareness of the potentially important role of nurses in the delivery of CHA.

Introduction

The National Center for Complementary and Integrative Health (NCCIH) defines Complementary Health Approaches (CHA) as “health care approaches developed outside of mainstream Western, or conventional, medicine.”¹

In the world and in Turkey, the usage of CHA is increasing rapidly, sometimes consciously and sometimes unconsciously. In recent years there has been a steady increase in CHA used by adults, and also among infants and children.^2
–4 It is stated that the use of CHA is increased in children and the usage rate is between 9% and 73%.^5

–11 The widespread use of CHA in the treatment of children has also increased the incidence of adverse effects associated with such treatments. Even though there is conflicting evidence about the effectiveness and safety of many complementary health products and practices among children,^11,12 it seems that many pediatric patients have used CHA.^13,14 The American Academy of Pediatrics and other child health organizations recommend that pediatric healthcare providers routinely communicate with families about CHA, in accordance with the existing evidence of efficacy and safety for CHA.^15,16 Studies have demonstrated that CHA use among children in Turkey has increased.^{8,9,17
–19,20}

Integrative therapies are used by nurses to improve symptom management. Nonpharmacologic methods such as massage, progressive muscle relaxation, guided imagery, music, and acupuncture help cancer patients cope with pain.^21

–27 Electro acupuncture²⁸ and muscle relaxation/imagination²⁹ are effective in decreasing the nausea and vomiting due to chemotherapy. For patients to cope with the symptoms, nurses need to inform their patients about CHA, take preventive measures for symptoms, and include these methods in their care. Therefore, it is very important that nurses increase their level of knowledge of CHA.

Healthcare professionals had limited knowledge related to CHA. However, many intended to learn more about these approaches.³⁰ Nurses are frequently asked questions about CHA. However, due to lack of knowledge and experience, they may give negative response to questions of patients and feel uncomfortable when discussing CHA with their patients. Therefore, given the potential of CHA to contribute to more holistic patient-centered care, it is important to gain more insight into current knowledge levels, attitudes, and experiences regarding CHA among nurses in Turkey. A number of studies assessing nurses' knowledge, usage, experiences, and attitudes toward CHA are available in the literature.^{30

–37} On the other hand, we did not find any study conducted on pediatric nurses. It is considered that this study addresses this gap in the literature. Nurses' knowledge, attitudes, and experiences may affect the level of patient exposure to CHA, both now and in the future. Therefore, this study aimed to determine the knowledge, usage, experiences, and attitudes of pediatric nurses toward CHA used by themselves and the parents of the children.

Methods

Study design and sample

A descriptive survey was conducted between June 2013 and February 2014, with pediatric nurses who were working at 18 hospitals in Turkey. Based on the data from the Turkish Statistical Institute,³⁸ cities having the highest population density were selected. It was aimed to include all 2,035 pediatric nurses who were working at these hospitals at that time, however, nurses who did not agree to participate, and those who did not complete the questionnaire were excluded (n = 585). The final number of participants was 1,450, and the rate of answering was 71.3%.

Instrument

Data were collected using a semi-structured questionnaire that was developed in accordance with the literature.^{8–9,31

–35,39
–41} Opinions of five experts, who worked at related studies, were obtained to assess the compatibility of the questionnaire. The survey had 3 parts and consisted of a total of 29 questions. The first section composed of 14 questions about sociodemographic characteristics (gender, age, marital status, number of children, educational status, identity of the clinic in which the nurse worked and working time at the current work unit). The second section contained seven questions about the nurses' professional practice with respect to CHA. The NCCIH's list of CHA was presented in Table 3 and the nurses were asked to indicate which therapies they had recommended. The third section contained eight questions dealing with whether the respondent recommended CHA to parents and how frequently he or she did so, in addition to questions evaluating attitudes to CHA. The nurses were also asked where they had obtained information and advice regarding CHA.

Personal experiences of nurses concerning CHA methods were evaluated with two open-ended questions. These open-ended questions were as follows: What are your positive/negative experiences about CHA methods? Clinical experiences of pediatric nurses regarding CHA methods used by parents for their children were also evaluated with two open-ended questions. These open-ended questions included the following: the child's diagnosis, medications used by the child, parents' methods, positive and negative effects of the CHA method used for the child, and how parents and the nurse reacted toward these positive and negative effects.

The questionnaire was tested on 10 pediatric nurses in a pilot study before administration. During the pilot study, unaccountable or missing questions were determined and the draft took its final shape. The researchers and trained interviewers collected data via face-to-face interviews conducted in the nursing room.

Ethical approvals

The study was approved by the relevant hospital and Akdeniz University Non-Invasive Clinical Trials Ethics Committee (Decision No.: 2013-04/91, Number B.30.2.AKD.0.20.05.05/86) and Hacettepe University Ethics Committee (Decision No.: 88600825/240-2238, dated 06.06.2013). Participants were also assured of their right to refuse participation and that all the information obtained would be used for research purposes only.

Statistical analysis

Data were analyzed using the Statistical Package for the Social Sciences software for Windows (version 20.0). Descriptive statistics were produced using totals and percentage for categorical variables and mean, standard deviation and range for interval variables. Pearson's chi square test was performed to determine the correlation between the use of CHA and sociodemographic characteristics.

Results

Sample characteristics

It was found that the demographic variables (gender, age, marital status, educational attainment, and experiences as a nurse) were related to the use of CHA (p < 0.05) (Table 1). As pediatric nurses' educational levels increased, CHA used by patients was reported at higher rates (Table 2).

Table 1.

Sociodemographic Characteristics of Pediatric Nurses (N = 1,450)

Characteristics	CHA users (n)	CHA nonusers (n)	x²	p
Gender
Female	1,190	113	9.046	0.005
Male	123	24	9.046
Age, years
18–24	217	31	9.297	0.010
25–30	428	28
>31	434	51
Marital status
Married	841	72	7.158	0.009
Single	470	65
Educational status
Vocational school of health	180	34	28.90	0.000
Associate degree	153	30
Bachelor's degree	922	71
Postgraduate	53	2
Has at least one child
Yes	653	59	2.259	0.079
No	649	77
Experience as a nurse, years
0–5	521	69	18.334	0.001
6–10	327	19
11–15	184	14
16–20	109	16
>21	64	14
Experience as a pediatric nurse, years
0–5	797	81	1.341	0.854
6–10	257	20
11–15	93	10
16–20	53	5
>21	28	2

CHA, complementary health approaches.

Table 2.

Pediatric Nurses Ask Patients About Complementary Health Approaches (N = 1,450)

Characteristics	Never asked about CHA (n)	Sometimes asked about CHA (n)	Always asked about CHA (n)	x²	p
Age, years
18–24	97	126	10	17.475	0.002
25–30	197	213	17
>31	266	186	19
Educational status
Vocational school of health	111	78	9	15.229	0.004
Associate degree	96	70	1
Bachelor's degree and above	472	481	53
Has at least one child
Yes	369	285	27	11.615	0.003
No	308	340	36
Experience as a nurse, years
0–5	240	287	20	34.859	0.000
6–10	185	131	20
11–15	118	66	5
16–20	64	51	8
>21	64	51	8
Nurses' personal use of CHA
Yes	615	583	58	3.220	0.200
No	69	46	5
Nurses' knowledge of CHA
Yes	662	629	63
No	22	0	0

CHA, complementary health approaches.

Knowledge, use, and experience of pediatric nurses regarding CHA

The study demonstrated that of pediatric nurses, 98.1% deliberately used at least one sort of CHA and 90.6% used one or more sorts of CHA(s) during their life. Of pediatric nurses, 95.6% used CHA for relaxation, and 97.8% obtained information related to CHA from the media. More than half of the nurses (69.9%) stated that trainings on CHA were required to be provided before and after graduation. The following are statements by nurses about their personal experiences about CHA. More than one nurse said each of the following expressions.

Of the pediatric nurses who used drawing/music/art/dance therapies as a CHA, 98% (Table 3) considered them effective, positive comments on personal use included; it calmed me down (n = 170), and it enabled me to get out of depression (n = 52). Of 1,002 pediatric nurses who reported using prayer as a CHA, 846 (97.8%) had found it effective; they expressed their positive experiences as follows: prayers psychologically relieved me and I felt peaceful (n = 200), prayers made me happy (n = 132), prayers helped me heal faster (n = 40), and prayers reduced my pain (n = 35).

Table 3.

Knowledge, Use, and Opinion of the Effectiveness of Pediatric Nurses Regarding Complementary Health Approaches (N = 1,450)

	Knowledge of method	Personal use of method	State of benefit^a,b
	Yes	Yes	Effective
CHA	n (%)	n (%)	n (%)
Acupressure	531 (37.6)	132 (10.6)	110 (83.3)
Acupuncture	868 (63.4)	100 (8.1)	80 (80.0)
Aromatherapy	852 (61)	197 (13.6)	169 (85.8)
Ayurveda	307 (22.2)	35 (3.2)	15 (44.1)
Herbs	1,060 (84.9)	535 (45.5)	455 (87.2)
Bioenergy	707 (51.7)	131 (10.8)	83 (82.2)
Ozone treatment	526 (44.9)	64 (6.0)	58 (96.7)
Feng Shui	743 (53.9)	137 (11.4)	99 (86.8)
Relaxation techniques/meditation	1,087 (79.5)	472 (38.0)	391 (94.2)
Hydrotherapy/thermal springs	1,160 (85.8)	583 (46.1)	526 (97.2)
Hypnosis	599 (44.5)	39 (3.2)	25 (73.5)
Homeopathy	197 (14.1)	44 (3.7)	38 (86.4)
Prayer	1,309 (96.3)	1,002 (82.3)	846 (97.8)
Massage	1,220 (91.3)	947 (76.6)	868 (96.0)
Special diets	829 (60.4)	346 (27.0)	277 (81.2)
Reflexology	490 (35.6)	105 (8.9)	97 (94.2)
Reiki	375 (27.8)	49 (4.2)	33 (73.3)
Color therapy	474 (38.2)	121 (11.0)	110 (96.5)
Drawing/music/art-dance therapies	884 (66.1)	379 (30.8)	343 (98.0)
Therapeutic touching	439 (33.1)	177 (15.2)	161 (94.7)
Vitamins	1,172 (86.6)	739 (60.2)	721 (97.3)
Yoga	753 (56.9)	112 (9.6)	77 (81.9)

Only positive parts (yes, yes and effective) are given in Table 3 so that the table is more understandable. Negative statements (no, no and ineffective) were removed from the table.

Not all the nurses who used CHA gave information about the state of benefit.

Nurses' self-experiences as patient.

CHA, complementary health approaches.

Of the pediatric nurses who used herbs as CHA, 87.2% (Table 3) considered them effective, positive comments on personal use included the following: we relieved my daughter from the repetitive bronchiolitis disease by using herb mixtures (n = 7), green tea calms me down (n = 105), and herbal oils reduced my hair loss (n = 110). However, some nurses reported negative experiences: herbs were allergenic (n = 100), and they had nonadherence to my treatments (n = 88).

Of the pediatric nurses who used hydrotherapy/thermal springs as a CHA, 97.2% (Table 3) considered them effective, positive comments on personal use included the following: relaxed me (n = 96), reduced my pain (n = 135), and reduced my fatigue (n = 87). However, some nurses reported negative experiences: thermal springs increased my pain even more (n = 21), and caused burns (n = 18). Pediatric nurses who reported using massage expressed their positive experiences as follows: enabled me psychologically and physically to relax (n = 116), reduced the pain in my feet (n = 44), and reduced my back pain and headaches (n = 60). Of 105 pediatric nurses who reported using reflexology as a CHA, 97 (94.2%) (Table 3) had found it effective; they expressed their positive experiences as follows: enabled reducing the infantile colic of my infant (n = 104), and enabled my baby to fall asleep more easily (n = 100).

Opinions of pediatric nurses concerning CHA use by parents for their children

Of the pediatric nurses, 49.7% stated that they never asked about CHA while taking information about related medical history of the children. Moreover, 77% of nurses indicated that they did not know the information source used by parents for CHA. According to nurses, reasons behind why parents used CHA for their children were as follows: trial as a recommendation (88%) and relief of their children's pain (85.3%).

In the study, 36.6% of nurses recommending CHA stated that they mostly recommended such methods to patients for psychological support. The most common CHA recommended by nurses to parents were prayer (47.9%), massage (46.1%), and vitamins (37.8%) (Table 4). Furthermore, the nurses who were not knowledgeable about CHA and did not use them, did not recommend CHA to parents and a statistically significant difference was observed (x² = 12.954, p = 0.000).

Table 4.

Pediatric Nurses' Frequently Suggested Complementary Health Approaches to Patients

	Recommendation frequency ^a
CHA	Often %	Sometimes %	Never %
Massage (n = 395)	46.1	49.1	4.8
Prayer (n = 359)	47.9	48.5	3.6
Drawing, music, art, or dance therapy (n = 339)	36.3	60.2	3.5
Relaxation Techniques or Meditation (n = 323)	31.0	65.6	3.4
Vitamins (n = 315)	37.8	57.8	4.4
Herbs (n = 249)	16.5	68.3	15.3

Gave more than one answer.

CHA, complementary health approaches.

Attitudes of pediatric nurses toward effects, safety, and availability of CHA

In this study, it is revealed that 92.7% of the pediatric nurses did not agree with the statement “It [CHA] is unhealthy.” More than half of the nurses (59.5%) agreed that “Doctors are responsible for informing the patient about CHA” (Table 5).

Table 5.

Attitudes of Pediatric Nurses Toward Effects, Safety, and Availability of Complementary Health Approaches

	Responses^a
Characteristics	Strongly agree %	Agree %	Disagree %	Strongly disagree %
Nurses are responsible for informing the patient about CHA (n = 1,385)	3.1	20.4	58.8	17.5
Doctors are responsible for informing the patient about CHA (n = 1,377)	14.1	45.4	29.6	5.9
In the hospital must be a unit for applications of CHA (n = 1,390)	21.6	56.8	18.6	3.1
Patients and their relatives become satisfied with the use of CHA (n = 1,362)	15.3	71.3	11.6	1.8
It [CHA] has a placebo effect (n = 1,223)	10.8	54.0	26.8	8.4
It [CHA] is unhealthy (n = 1,369)	2.8	4.5	64.1	28.6
It [CHA] is expensive and ineffective (n = 1,289)	3.5	13.1	65.6	17.8
It [CHA] should be restricted with laws and regulations (n = 1,350)	17.1	43.5	32.4	7.0

For the statistical analysis we combined responses into two categories: agree (strongly agree + agree) and disagree (strongly disagree + disagree).

CHA, complementary health approaches.

Pediatric nurses' experiences regarding CHA used by parents for their children

Pediatric nurses' negative comments on their patients' experiences of using herbs included the following: making a crying baby drink a herbal mixture caused the development of allergies (n = 9). Nurses reported that parents using hydrotherapy/thermal springs stated that it had caused burns in a child with sensory and motor loss in the lower extremities (n = 5). Pediatric nurses who heard about the complications induced by CHA told parents to give up CHA, and informed physicians about this issue.

Regarding the use of herbs, pediatric nurses gave positive account on the patients' experiences: herbs like linden and mint-lemon used by children suffering from upper respiratory tract diseases symptomatically had relieved the children (n = 7); the use of herbal oils on mouth sores, induced by chemotherapy, healed the mouth sores (n = 6). Praying was reported to have enhancing effects on hope and motivation for mothers whose child was receiving treatments against chronic diseases (n = 20). Drawing/music/art/dance were reported to give children, who were receiving chemotherapy treatments, the possibility to have a good time and relax (n = 16). Massage was reported to have soothed the baby (n = 14). Reflexology was reported to have reduced the crying of a baby with infantile colic (n = 4). Nurses expressed that parents with positive experiences were happy, and suggested CHA to other families.

Discussion

This study revealed that the most of pediatric nurses used one or more CHA(s) during their lives, most often prayer, massage, and vitamins. Other studies have reported personal use of CHA among nurses.^30,36 In this study, prayer is considered to be one of the most frequent methods used by Turkish pediatric nurses. The spiritual and religious approaches of people in Turkey contribute to the use of traditional approaches, such as taking the patient to hodja and resorting to personal prayers for treatment.^37,42,43 Additionally, it was observed that nurses found CHA beneficial and they had a positive attitude toward CHA. Literature has shown that nurses or nursing students have a positive attitude toward CHA.^{30,32
–34,36,44} In this study, more than half of the pediatric nurses felt that they needed training on CHA use. The results of our study showed a parallelism with the literature.^30,32,45,46 There is a significant difference between the level of education of nurses and the use of CHA and the recommendations of these methods. Nurses who had education at undergraduate level had higher use of CHA. Additionally, nurses recommend the methods they know and use. Nurses should continuously receive trainings and courses about CHA and consequently increase their knowledge levels.

Turkey has culturally rich history of complementary and integrative practices. The Turkish bath, including a deep rubbing of the skin with a silk cloth to provide stimulation for circulation, and general relaxation, has a traditional place in Turkish culture. Even some nurses working in some of these thermal spring baths take an active role with the treatments.⁴⁷ Medical leeches (Hirudo medicinalis) have been used for the management of venos diseases of the lower extremities, migraines, and headaches. Remedies such as cupping, thermal spring baths, plant and food therapies, praying, and spiritual practices have all been found to be effective, easy to access, cost effective, and supported by conventional medicine in Turkey. Additionally, herbal therapies are also often used by chronically ill patients with cancer, hypertension, diabetes, arthritis, asthma, kidney problems, and allergies. Patients' rationale for using complementary and integrative therapies is to strengthen the immune system, to improve the quality of life, and to reduce the side effects of the treatment.⁴⁷ In this study, more than half of the nurses expressed that nurses are not responsible for informing the patient about CHA. Additionally, almost half of the nurses never asked parents about CHA while receiving medical history of the children, which was in line with the literature.^48,49 The increasing of studies on integrative practices in Turkey and in the regulations to be given the responsibility for integrative practices are the ground for the development of integrative nursing practice. Integrative nursing has a very important place for the patient to be given holistic care. Integrative approaches become core to integrative nursing practice.⁵⁰ Nurses use some integrative therapies as independent nursing functions in patient care.^47,51 Nursing, however, has been slow in adopting these practices.⁴⁷ Many nonpharmacological nursing practices support the medical care and treatment that nurses give their patients. For this reason, a bridge should be established between the independent functions of the nurse and noninvasive complementary practices such as music, relaxation techniques, prayer, aromatherapy, and acupressure.^47,52 In general, these practices are mostly being used in private healthcare facilities/or as part of personal improvement programs. The number of nurses with certification for integrative practice in Turkey is thought to increase with the expansion of integrative practices.⁴⁷ Some methods (chiropractic and osteopathic manipulation, reflexology, music therapy, and cupping therapy) have stated to be possible under the supervision of a physician with special certificated nurses in Turkey.⁵³ For this reason, it is very important for the nurses to know these methods within their responsibilities and to receive training on CHA. Professional integrative nurses are responsible for informing and guiding the patient about all treatment options within their independent roles. Evidence-based integrative practices should be included in the curricula of schools providing nursing education. In the development of integrative healthcare, interdisciplinary training needs to be initiated. It is considered that the training given to nurses and nursing students to gain the understanding of integrative care will be reflected in clinical patient care.

In this study, some of the nurses stated that some CHAs used by parents for their children resulted in positive effects on them. It is shown in the literature that the use of CHA in children causes positive effects. Massage therapy was effective in reducing transepidermal water loss,⁵⁴ the level of transcutaneous bilirubin,⁵⁵ and increasing weight gain⁵⁶ in preterm infants. Mind–body interventions may be effective to pharmacological interventions, in managing procedure-related pain, and distress in pediatric oncology.⁵⁷ Another study revealed that listening to Mozart K.448 reduced the seizure recurrence rate in children.⁵⁸ A meta-analysis of the effects of acustimulation showed that acustimulation significantly reduced both vomiting and nausea in children.⁵⁹ The use of aromatherapy reduce salivary cortisol and pulse rate due to child anxiety state.⁶⁰ Aromatherapy has been reported to reduce stress⁶¹ and decrease anxiety and increase sleep quality in cancer patients.⁶² Reflexology is effective on acute pain in infants.^63

–66 The type of the method, which disease group the method is used for, and physical characteristics of patients may change the effectiveness of the method.

In this study, the negative experiences of nurses about CHA should be examined in more detail. For example, this study has determined that children are burned because of the inadequate use of hydrotherapy/thermal springs. The negative experiences included allergies, burning, pain, and constipation. Therefore, the negative effects of these methods can be due to misuse by the pediatric nurses and/or parents. Jacobsson et al. reported that the most frequent side effects were urticaria, eruption, and contact dermatitis.⁶⁷ In a study, nurses reported negative experiences of CHA for allergies, pain, and stres.³⁷ Nurses should develop awareness about the potential damages of CHA used by patients and warn patients in advance.

Limitations

The limitations of the study were that the data related to the observations/experiences of pediatric nurses were based on self-report, these data were subjective, and could not be measured. The Ministry of Health of Turkey has been allowed to officially open centers where these approaches are applied in 2014. These centers were not opened if the survey questionnaire was not applied. For this reason, it is another limitation of the research that pediatric nurses working in these centers cannot be compared with other pediatric nurses.

Conclusions and Implications

The study demonstrated that almost half of the nurses never asked about CHA while taking medical history of patients and did not take these methods into account in the care provided by them. Moreover, they stated that nurses were not responsible for informing patients about CHA. It is required to organize in-service training programmes, increase nurses' knowledge to the extent that they offer consulting to parents, and make legal regulations to give responsibilities to nurses in regard to these areas. This study is important because it describes the personal and professional experiences about CHA of pediatric nurses in Turkey. It should be questioned in detail whether these positive/negative effects are caused by CHA or different reasons.

Footnotes

Acknowledgments

This research has been produced from a Master's thesis. We are grateful to all the pediatric nurses who participated in this study. The authors of this study are grateful to Professor Dr. Mehmet Ziya Fırat for statistical consultation. This study was presented at the 13th National Pediatric Nurses Congress, Antalya, Turkey, Oct 23–24, 2014 and was awarded with Nursing Verbal Statement Third Prize.

Author Disclosure Statement

No competing financial interests exist.

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