Knowledge,attitude,and practice of complementary and alternative medicine: a survey of Iranian nurses

Abstract

Background

Development of complementary and alternative medicine (CAM) usage makes it necessary for nurses to be up to date about these treatments. However, much information is needed about the level of knowledge, attitude and practice of nurses in this field.

Aims

The present study was conducted to determine the level of knowledge, attitude and practice of CAM in nurses working in Iranian hospitals.

Methods

It was a descriptive study. A researcher-made questionnaire was completed by nurses working in four hospitals. Descriptive statistics were used to analyse the data.

Results

Two hundred and thirty-three nurses completed the questionnaire (response rate = 83.8%). Most nurses had little knowledge of CAM. The most familiar methods were Nutrition, Massage Therapy and Herbal Medicine. Of the nurses, 71.1% believed that CAM would be effective in disease treatment, showing their positive attitude toward CAM; 1.56% of nurses used CAM, and most nurses did not use CAM in clinical settings.

Conclusions

Although nurses have a positive attitude toward CAM, their knowledge level is low. Regarding nurses’ role in patients’ treatment and the importance of their capability to treat, the need to increase nurses’ knowledge of CAM is felt, and its education should be included in the nursing curriculum.

Keywords

attitude complementary and alternative medicine knowledge nurses practice

Introduction

Nowadays, the methods of complementary and alternative medicine (CAM) are used throughout the world and have been increasingly accepted by health providers. Researchers have found that in spite of the great advances in classical medicine, people in developed and developing countries are increasingly leaning CAM (Adib-Hajbaghery and Hoseinian, 2014). Also, in one study, the usage of CAM was about 75.4% in the south of Iran and the most common reason was cold (Ghaedi et al., 2017). It is not easy to define (CAM) because it includes many methods outside the scope of conventional medical therapies. CAM is a group of various medical and health care systems, practices and products which are not generally considered as a part of conventional medicine. There are diverse purposes, such as disease prevention, improvement of the quality of life and treatment of disease, attributed to CAM usage. Not only do some patients find ordinary treatments inappropriate to meet their values, but, also, probable side effects of drugs may lead them to use CAM (Mousavi and Mahmoudian, 2016; Yin et al., 2010).

Due to the willingness of communities to use CAMs, the knowledge and attitude of physicians and nurses towards these methods are very important. It is recommended that nurses and physicians have comprehensive information on CAMs so that they can warn patients about the risks and side effects of these treatments and respond to their questions (Shorofi and Arbon, 2017).

Studies in different countries on the level of knowledge, attitude and practice of CAM in the clinical setting had different results. In a study in Turkey, it was found that 74.8% of health personnel were practising CAM in the clinical setting (Midilli et al., 2016); also, another study on nurse practitioners showed that 85% of them referred their patients for massage or bodywork, which are types of CAM (Geisler et al., 2015), and results of a study on 362 nursing assistants showed that CAM usage prevalence among nurses was 92.4% (Bahall, 2017). The study in Turkey showed that 81.7% of health personnel had a moderate to good level of knowledge in this regard (Midilli et al., 2016). Also, in one study, 95% of nurses believed that nurse practitioners should have knowledge about CAM (Geisler et al., 2015). More than half of the health personnel in the study conducted in Turkey had a positive attitude towards CAM (Midilli et al., 2016) and a review study supported it and showed that 66.4% of nurses had a positive attitude toward CAM (Bahall, 2017). Iranian research on medical students showed that because of the low to moderate attitude toward CAM, training is necessary to improve the attitude of medical students toward complementary medicine (Soleimani et al., 2013).

Results of a systematic review showed that 65.9% of nurses used CAM to reduce stress and anxiety and to improve patients’ health (Balouchi et al., 2018). In addition, another review conducted between 2007 and 2014 showed that 77.4% of nurses did not have comprehensive understanding of CAM-associated risks and benefits and half of them had uncomfortable feelings about discussing CAM with their patients (Chang and Chang, 2015).

These results suggest that nurses’ attitude towards CAM is positive, but their knowledge of the effects of CAMs, the risks and side effects is generally moderate. The health personnel knowledge of CAM methods helps them guide patients to use or to stop the usage of a specific method and nurses should have comprehensive and accurate information in this field to advise and answer patients’ questions.

Methodology

Study design and setting

It was a descriptive study conducted on nurses working in four educational hospitals of Kerman University of Medical Sciences in Iran.

Sample size and sampling

The sample group included all B.Sc. nurses working in four educational hospitals who had at least six months’ work experience and were willing to cooperate in the study. Convenience sampling was used to select the participants. Two hundred and thirty-three questionnaires were collected out of the 278 distributed. The response rate was 83.8%.

Instrument

A valid researcher-made questionnaire was used to collect data in four parts. The first part of the questionnaire was related to the demographic characteristics of the participating nurses, including age, sex, marital status, work experience and workplace. The second part of the questionnaire consisted of the items related to knowledge. Nurses’ familiarity with the methods of CAM were investigated (13 items including acupuncture, acupressure, therapeutic touch, energy therapy, nutrition therapy, herbal medicine, music therapy, hydrotherapy, massage, relaxation, meditation, yoga and hypnosis). These questions were based on a five-point Likert scale (No knowledge = 1 to Very high knowledge = 5). The third part of the questionnaire included items of attitude in two parts. The first part included 19 items based on a five-point Likert scale (from Strongly disagree to Strongly agree), and in the second part, participants’ attitude toward the effect of each complementary treatment was evaluated (13 items) based on a five-point Likert scale (Strongly disagree = 1 to Strongly agree = 5).

The fourth part included items related to the level of practice. Clinical practice of nurses was evaluated based on a four-point Likert scale (I have not recommended and practised = 1, I have recommended = 2, I have referred = 3, I have practised in the clinic = 4). In a question, subjects under study were asked to prioritise the barriers to the practice of CAM in the clinical settings. The content validity method was used to determine the validity of the questionnaire. Questionnaires were offered to 10 nursing faculty members to evaluate the relevancy of each. The content validity index of knowledge, attitude and practice items was 98.9, 0.97 and 0.98, respectively. In addition, the internal consistency reliability method was used to determine the reliability of different parts of the questionnaire, and the Cronbach’s alpha coefficient for knowledge, attitude and practice items was 0.91, 0.98 and 0.85, respectively.

Data collection and statistical analysis

The researcher referred to the hospitals for collecting data in consecutive times and in the morning, evening and night shifts, and after expressing the research goals for the nurses, the questionnaire was distributed to them and then collected.

The SPSS 14 and descriptive statistics (mean, standard deviation, frequency and percentage) were used to analyse the data.

Ethical consideration

This study was approved by the Ethics Committee of Kerman University of Medical Sciences. Then, permission was issued from the management of the related hospitals. The researcher explained the goals and objectives of the study, confidentiality and anonymity of data, and the participants could withdraw from the study at any time. Verbal consent was taken individually.

Results

As shown in Table 1, most subjects were female (n = 210, 90.1%), married (n = 146, 62.7%) and under 26 years old (n = 77, 33%). The age group of the participants was between 23 and 51 years old with a mean age of 30.43 ± 6.56. The work experience was between one and 27 years. The highest frequency of the work experience was less than six years (n = 111, 47.6%). The mean work experience was 7.71 ± 6.84. Most participants were working in the intensive care unit (n = 63, 27%).

Table 1.

Demographic characteristics.

Individuals’ characteristics	Number (percentage)
Sex
Male	23 (9.9%)
Female	210 (90.1%)
Age
<26	77 (33%)
26–30	57 (24.5%)
31–35	49 (21%)
>35	50 (21.5%)
Marital status
Single	87 (37.3%)
Married	146 (62.7%)
Work experience years
<6	111 (47.6%)
6–10	47 (20.2%)
11–15	47 (20.2%)
>15	28 (12%)
Department
The Intensive Care Unit	63 (27%)
Internal Medicine Ward	58 (24.9%)
General Surgery Unit	41 (17.6%)
Emergency Department	39 (16.7%)
Others	32 (13.8%)

Table 2 shows that most participants had no knowledge about different methods of CAM. The lowest level of knowledge was related to acupressure, relaxation and touch therapy (with a frequency of 68.3%, 54% and 47.2% respectively). The most familiar methods (High and Very high knowledge) were related to nutrition, herbal and massage therapies (with a frequency of 24.5%, 19.3% and 16.8%, respectively).

Table 2.

Self-assessment of nurses’ level of knowledge of complementary and alternative medicine.

Method	No knowledge n (%)	Low n (%)	Moderate n (%)	High n (%)	Very high n (%)
Acupuncture	69 (29.7)	76 (32.6)	82 (35.1)	6 (2.6)	0
Acupressure	159 (68.3)	38 (16.3)	35 (15)	1 (0.4)	0
Touch therapy	110 (47.2)	58 (24.8)	50 (21.5)	12 (5.2)	3 (1.3)
Reiki	67 (28.8)	67 (28.8)	82 (35.1)	13 (5.6)	4 (1.7)
Nutrition therapy	24 (10.3)	32 (13.7)	120 (51.5)	45 (19.3)	12 (5.2)
Herbal therapy	39 (16.7)	51 (21.9)	98 (42.1)	38 (16.3)	7 (3)
Music therapy	45 (19.3)	67 (28.8)	89 (38.2)	21 (9)	11 (4.7)
Aqua therapy	51 (21.9)	62 (26.6)	86 (36.9)	26 (11.2)	8 (3.4)
Massage	54 (23.1)	56 (24)	84 (36.1)	30 (12.9)	9 (3.9)
Relaxation	126 (54)	48 (20.6)	44 (18.9)	13 (5.6)	2 (0.9)
Meditation	100 (42.9)	55 (23.6)	52 (22.4)	22 (19.4)	4 (1.7)
Yoga	79 (33.9)	69 (29.6)	61 (26.2)	17 (7.3)	7 (3)
Hypnotism	66 (28.3)	60 (25.8)	80 (34.3)	18 (7.7)	9 (3.9)

The mean score of attitude was 3.56 out of 5. Nurses’ attitudes towards the effects of CAM are reported in Table 3. As seen in Table 3, 71.1% of participants agreed with the effectiveness of CAM. According to the nurses, the methods that are most effective in improving the patients’ health and the treatment of the disease (I agree and Strongly agree) include nutrition therapy, music therapy and herbal therapy (with the frequency of 96.5%, 96.2% and 95.6% respectively). Most nurses had no opinion on the effect of hypnosis, touch therapy and energy therapy (15.4%, 12.4% and 10.7%, respectively).

Table 3.

The attitudes of nurses towards the effect of complementary and alternative medicine.

Method	Strongly agree n (%)	Agree n (%)	No idea n (%)	Disagree n (%)	Strongly disagree n (%)
Acupuncture	24 (10.3)	192 (82.4)	16 (6.9)	1 (0.4)	0
Acupressure	28 (12)	184 (78.9)	21 (9.1)	0	0
Touch therapy	29 (12.4)	175 (75.2)	29 (12.4)	0	0
Reiki	49 (21)	156 (67)	25 (10.7)	3 (1.3)	0
Nutrition therapy	86 (36.9)	139 (59.6)	8 (3.5)	0	0
Herbal therapy	62 (26.6)	161 (69)	10 (4.4)	0	0
Music therapy	65 (27.9)	159 (68.3)	8 (3.4)	1 (0.4)	0
Aqua therapy	47 (20.2)	172 (73.8)	13 (5.6)	1 (0.4)	0
Massage	49 (21)	165 (70.8)	19 (8.2)	0	0
Relaxation	49 (21.1)	163 (69.9)	21 (9)	0	0
Meditation	50 (21.4)	168 (72.1)	13 (5.7)	0	2 (0.8)
Yoga	49 (21)	165 (70.8)	15 (6.5)	4 (1.7)	0
Hypnotism	38 (16.3)	156 (66.9)	36 (15.4)	3 (1.4)	0

As shown in Table 4, the highest frequency of practice in the clinical settings was related to massage, herbal, nutrition and music therapies (with a frequency of 6.9%, 4.3%, 2.6% and 2.6% respectively). Nutrition, herbal and music therapies (52.4%, 43.3% and 38.6%, respectively) were the most recommended treatments.

Table 4.

The level of nurses’ practice of complementary and alternative medicine.

Method	I have neither recommended nor practised n (%)	I have recommended n (%)	I have referred n (%)	I have practised in the clinicn (%)
Acupuncture	195 (83.7)	35 (15)	3 (1.3)	0
Acupressure	220 (94.4)	12 (5.2)	1 (0.4)	0
Touch therapy	203 (87.1)	26 (11.2)	1 (0.4)	3 (1.3)
Reiki	177 (76)	53 (22.7)	3 (1.3)	0
Nutrition therapy	93 (39.9)	122 (52.4)	12 (5.2)	6 (2.6)
Herbal therapy	116 (49.8)	101 (43.3)	6 (2.6)	10 (4.3)
Music therapy	134 (57.5)	90 (38.6)	3 (1.3)	6 (2.6)
Aqua therapy	144 (61.8)	80 (34.3)	8 (3.4)	1 (0.4)
Massage	150 (64.4)	62 (26.6)	5 (2.1)	16 (6.9)
Relaxation	200 (85.8)	29 (12.5)	1 (0.4)	3 (1.3)
Meditation	173 (74.2)	51 (21.9)	4 (1.7)	5 (2.1)
Yoga	169 (72.5)	55 (23.6)	8 (3.4)	1 (0.4)
Hypnotism	182 (78.1)	40 (17.2)	11 (4.7)	0

Discussion

In the present study, it was found that most participants have little knowledge of CAM. Adib-Hajbagheri and Hoseinian (2014), by studying the level of knowledge, attitude and practice of health care providers, reported that the level of knowledge of the participants in the research was low. Shorofi and Arbon (2017) studied knowledge, attitude, personal and professional use of CAM among Australian hospital-based nurses: 60.3% of nurses reported that they did not know CAM or their level of knowledge was very low.

Results of similar studies support the results of the present study (Hooshangi et al., 2017), which suggests that nurses have little knowledge of CAM. However, nurses are important members of the treatment team and have an important role in advising and directing patients towards effective therapy methods and health behaviours. It is therefore necessary for nurses to have sufficient knowledge about CAM treatments and the influence and side effects of different methods so that they can train patients and individuals about the correct and safe use of CAM and warn of possible side effects that may result from inappropriate use.

In this study, there were three CAM therapies in which nurses had the highest level of knowledge: nutrition therapy (24.5%), herbal therapy (19.3%) and massage therapy (16.8%). In the study by Midilli et al. (2016), herbal and massage therapies were the first and fourth methods used by nurses. In the study by Gyasi et al. (2017), spiritual therapy, massage therapy, relaxation techniques, non-herbal supplements and music therapy were types of CAM for which nurses had the highest knowledge and it seemed that they had no knowledge about imagery techniques, osteopathy, and chiropractic care.

Also, the present research showed that although most participants had no formal training in the field of CAM, 85% of them were interested in improving their knowledge in this field. In the research of Adib-Hajbagheri and Hoseinian (2014), more than two-thirds of the participants were interested in CAM.

In this study, most nurses (68%) had a positive attitude towards CAM. In the study by Baluchi et al. (2018), 51.6% of nurses had a positive attitude. In the study by Midilli et al. (2016), 80.2% of the research subjects agreed with the positive effect of CAM. The results of this study are similar to some other studies (Adib-Hajbaghery and Hoseinian, 2014). In this study, although nurses are highly unfamiliar with the concept of CAM, they had a positive attitude towards it. The reason for this may be that CAMs are more consistent with nursing philosophy due to being holistic. Most nursing theories focus on the physical, psychological and social function of patients, and their goal is the holistic improvement of patients and an increase in their quality of life (van Vliet et al., 2015).

In the present study, the participants believed that the most effective methods were nutrition therapy, music therapy and herbal therapy, respectively. In the research of Adib-Hajbagheri and Hoseinian, the participants also agreed that herbal therapy had the greatest effect.

In this study, the four methods most practised by health personnel in the clinic were massage, herbal therapy, nutrition therapy and music therapy. In evaluating other studies, the methods commonly practised by health personnel included herbal therapy (Adib-Hajbaghery and Hoseinian, 2014; Midilli et al., 2016), massage, meditation and nutrition therapies (Gok Metin et al., 2018).

In the present study, 25% of nurses recommended the use of CAMs to the patients, among which nutrition, herbal and music therapies had the highest frequency. In the study by Adib-Hajbagheri et al., 56% of the research samples recommended patients to use CAMs, among which herbal therapy had the highest (54.4%) frequency. The use of herbal medicines in Iran has a long history, and it seems that the positive attitude of the participants towards herbal therapy and its frequency are influenced by tradition, cultural factors and vegetation in different regions of Iran. Results also showed that nurses had the lowest knowledge and practice in acupressure treatment, relaxation and touch therapy so that these treatments have not been recommended so much.

A nurse delivers care to patients with compassion and respect and nursing is an integration of art and science together to benefit patients and their families. Since the level of familiarity with CAM in the present research is low and is not often based on scientific education, the level of CAM use is low as well, because it is contrary to the standards of the nursing profession to practise any treatments in which a nurse has no scientific knowledge.

In the present study, the most practical barrier was medical personnel’s lack of knowledge (42.5%). Other practical barriers, in order of priority, include lack of education and relevant training, lack of knowledge of the legality of the treatment type, doctors’ reluctance, lack of motivation, patients’ reluctance, lack of equipment in the clinical setting and time limitation for the medical personnel.

Emotional status and time limitation of samples could affect their responses. For this matter to be controlled, the questionnaire would not have been completed if proper responses had not been obtained. Also, they were ensured that their information would remain confidential.

Conclusion

In the present study, most participants assessed their level of knowledge of different CAM methods as at a low level and had no training in this field. Although most of them did not use CAM in the clinical settings, they had a positive attitude and interest in learning about CAMs.

The results of similar studies indicate that the practice of CAM is growing and valuable knowledge in this field is necessary for proper counselling and guiding of patients.

It seems that the entrance of training related to CAM in the nursing curriculum, holding workshops and training courses for graduates, is a good way to make sure that they acquire sufficient knowledge.

Key points for policy, practice and/or research

Most nurses had no knowledge of different methods of complementary and alternative medicine. Therefore, much information is needed for nursing practice, and education of the complementary and alternative medicine should be introduced to the nursing curriculum in the colleges where complementary and alternative medicine training is not available. Nurses had the lowest knowledge in acupressure treatment, relaxation and touch therapy. Nurses were more familiar with to nutrition, herbal and massages therapies.

Most nurses agreed with the effectiveness of complementary and alternative medicine and had a positive attitude. The most effective methods for improvement of the patients’ health and the treatment of the disease included nutrition therapy, music therapy and herbal therapy. Most nurses had no opinion on the effect of hypnosis, touch therapy and energy therapy.

The highest frequency of practice in the clinical settings was related to massage, herbal, nutrition and music therapies. Nutrition, herbal and music therapies were the most frequently recommended treatments.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Ethics

This study was approved by the Ethics Committee of Kerman University of Medical Sciences. Then, permission was issued from the management of the related hospitals.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this paper.

ORCID iD

Maryam Zeighami

Maryam Zeighami has been teaching nursing students at the Faculty of Nursing and Midwifery in Kerman, Iran for about 15 years. She also teaches research and teaching. She has recently done some research in the field of complementary medicine and herbal medicine.

Somayeh Soltani-Nejad has been teaching nursing students at the School of Nursing and Midwifery in Kerman, Iran for about 11 years. She is very interested in researching and working with herbal medicine.

References

Adib-Hajbaghery

Hoseinian

(2014) Knowledge, attitude and practice toward complementary and traditional medicine among Kashan health care staff, 2012. Complementary Therapies in Medicine 22(1): 126–132.

Bahall

(2017) Knowledge, attitudes, and practices among health care providers regarding complementary and alternative medicine in Trinidad and Tobago. BMC Complementary and Alternative Medicine 17(144): 1–9.

Balouchi

Mahmoudirad

Hastings-Tolsma

, et al. (2018) Knowledge, attitude and use of complementary and alternative medicine among nurses: A systematic review. Complementary Therapies in Clinical Practice 31: 146–157.

Chang

(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: 1466–1478.

Geisler

Cheung

Johnson Steinhagen

, et al. (2015) Nurse practitioner knowledge, use, and referral of complementary/alternative therapies. Journal of the American Association of Nurse Practitioners 27(7): 380–388.

Ghaedi

Dehghan

Salari

, et al. (2017) Complementary and alternative medicines: Usage and its determinant factors among outpatients in southeast of Iran. Journal of Evidence-Based Complementary & Alternative Medicine 22(2): 210–215.

Metin

Izgu

Karadas

, et al. (2018) Perspectives of oncology nurses on complementary and alternative medicine in Turkey: A cross-sectional survey. Holistic Nursing Practice 32(2): 107–113.

Gyasi

Abbas

Adu-Gyamfi

, et al. (2017) Nurses' knowledge, clinical practice and attitude towards unconventional medicine: Implications for intercultural healthcare. Complementary Therapies in Clinical Practice 29: 1–8.

Hooshangi M, Mohammadi S, Alizadeh J. et al. (2017) Knowledge, attitude and practice of students of Gonabad University of Medical Sciences toward famous methods of complementary and alternative medicine. Traditional and Integrative Medicine 2(2): 67-73.

10.

Midilli

Baysal

Akarsu

(2016) Complementary and alternative medical methods: Attitude, knowledge and use by health personnel. Spatula DD-Tamamlayıcı Tıp ve İlaç Geliştirme Alanında Hakemli Dergi 6: 39–47.

11.

Mousavi

Mahmoudian

(2016) Frequency of using complementary and alternative medicine in patients with type II diabetes in Isfahan in Iran 2013. Complementary Medicine Journal 6(19): 1470–1479.

12.

Shorofi

Arbon

(2017) Complementary and alternative medicine (CAM) among Australian hospital-based nurses: Knowledge, attitude, personal and professional use, reasons for use, CAM referrals, and socio-demographic predictors of CAM users. Complementary Therapies in Clinical Practice 27: 37–45.

13.

Soleimani

Jalali

Ahmadi

(2013) Attitude of clinical medical students and residents of Guilan University of Medical Sciences about complementary and alternative medicine. Research in Medical Education 5(1): 13–21.

14.

Van Vliet

Jong

Busch

, et al. (2015) Attitudes, beliefs, and practices of integrative medicine among nurses in the Netherlands. Journal of Holistic Nursing 33(2): 110–121.

15.

Yin Wong L, Paul Han Sim Toh M, He Kong K. (2010) Barriers to patient referral for complementary and alternative medicines and its implications on interventions. Complementary Therapies in Medicine 18(3–4): 135–142.