Regional Use of Complementary and Alternative Therapies by Critical Care Nurses

The use of complementary and alternative therapies has become increasingly common in the United States.1,2 According to a 7-year study,1 more than 40% of American adults use 1 or more such therapies. Complementary and alternative medicine is generally considered to be “a group of diverse medical health care systems, practices, and products that are not presently considered to be part of conventional medicine.”3 The term “complementary” typically refers to those therapies used in conjunction with traditional therapies; the term “alternative” is commonly viewed as those therapies used instead of traditional ones.4 As used in this article, “complementary and alternative therapies” refers to a broad array of nontraditional therapies. We use this term rather than the term “complementary and alternative medicine” to avoid association of the therapies solely with medicine, because these nontraditional therapies and healing practices have been practiced by nurses and by members of other disciplines for thousands of years.4The significance of complementary and alternative therapies to healthcare is the potential health impact that such therapies may have. However, a specific therapy may have no objective effect on the health or well-being of an individual. A therapy may be sought because of a person’s belief in its efficacy, despite data that indicate no benefit. Ethical issues arise surrounding the costs of therapies to those who seek remedy and get none except for assuaging fear in the embrace of false hopes. It is incumbent on health professionals to develop the scientific evidence base for the practice of complementary and alternative therapies so that factual information about documented outcomes for given conditions and the identification of patients for whom benefits may be expected can be made available to both consumers and clinicians.Complementary and alternative therapies may have potentially adverse effects.5 These adverse effects may be experienced as the result of unsafe use, overuse, unanticipated harm, or interactions of one complementary or alternative therapy with another or with other concurrently prescribed allopathic treatments. For example, the use of an herbal preparation that increases bleeding time would be contraindicated in patients taking a prescribed anticoagulant, because the 2 agents could have synergistic effects that could result in internal bleeding.6 Patients’ use of complementary and alternative therapies may be unsafe. For example, patients’ use of products of the largely unregulated herbal industry may result in unintended adverse effects because herbal remedies may be produced with poor or unknown quality control. Products may contain chemicals that have harmful effects, have contaminants, be flawed in their preparation, or have additional chemicals used in compounding to which some users are sensitive or allergic.7,8Patients in critical care settings may be affected by the use of complementary and alternative therapies. Inappropriate use, overuse, and use of contaminated products or ones that interact adversely with prescribed medications may underlie the principal signs and symptoms that lead to hospital admission. Patients and families may conceal or may not report their use of complementary and alternative therapies. In addition, health providers are often reluctant to assess or may simply overlook the need to acknowledge patients’ use of nontraditional therapies.9 In order to consider possible effects of nontraditional therapies and to prevent inadvertently superimposing a prescribed therapy upon an unconventional therapy, it has been recommended that practitioners not ignore use of complementary and alternative therapies but rather inquire about patients’ use of such therapies during healthcare encounters and then work with patients in a neutral manner to carefully weigh practices or products used outside of the hospital.7–10 The Joint Commission on Accreditation of Healthcare Organizations requires that patients be asked about their use of certain complementary and alternative therapies.Some therapies may have significant benefits to critically ill patients.4 If therapies that have beneficial effects are not considered and used, patients may not be optimally relieved of signs and symptoms. Conversely, they may be treated with more toxic, invasive, or costly allopathic therapies.In critical care settings across the United States, patients may request that complementary and alternative therapies that they have used at home be continued, or they may request that certain nontraditional therapies be initiated. Critical care nurses are the professionals to whom such requests are most often directed.11 In collaboration with patients, patients’ families, and other members of the healthcare team, critical care nurses must weigh the known harmful (or unknown) effects versus beneficial effects of therapies for each critically ill patient.Complementary and alternative therapies may be used to promote the delivery of care in a more optimally humane and caring environment, which is an identified priority area of the American Association of Critical-Care Nurses (AACN).12 Therapies to treat patients’ conditions and adverse responses to the critical care environment have potential benefits. Complementary and alternative therapies may be helpful to alleviate conditions of pain, sleep deficits, nausea, and stress and anxiety among patients and patients’ families. Indeed, many nontraditional therapies have been used or their beneficial effects in these conditions, which are common in critical care practice, have been shown.13Complementary and alternative therapies may also be useful in nurses’ self-care. In the current healthcare environment, the shortage of nurses and potential under-staffing of critical care units may add to stress among critical care nurses.14,15 Nurses’ use of complementary and alternative therapies for self-care may increase nurses’ familiarity with these techniques and thus contribute to use of the therapies in practice.14As we build the knowledge underlying the use of complementary and alternative therapies in critical care, many questions remain to be answered, including the following:Even as we build our knowledge base, critical care nurses are seeking knowledge, gaining experience, forming attitudes, and using complementary and alternative therapies for self-care and for the care of critically ill patients and the patients’ families.16Little is known about critical care nurses’ use of complementary and alternative therapies in practice or about variations in how they use the therapies personally or in their nursing practice in different regions of the United States. Even less information is available about the safety and efficacy of the nurses’ use of nontraditional therapies for problematic conditions in critically ill patients. For example, could acupuncture be used to prevent or treat atrial fibrillation after cardiac surgery? Selected complementary and alternative therapies may reduce the physiological stress response and have other physiological benefits in critically ill patients. The judicious use of these therapies could benefit critically ill patients and the patients’ families and could contribute to such beneficial outcomes for patients as relaxation, satisfaction, and reduced stress and anxiety.In this article, we present data from a US survey on critical care nurses’ use of and perspectives on complementary and alternative therapies. The random sample of critical care nurse members of AACN included nurses from all 50 states (placed in 5 geographic regions) and included respondents from all 19 AACN membership regions. Data on nurses’ personal and professional use as well as their attitudes and beliefs, grouped into 5 geographic regions of the United States, are described and compared in an effort to determine whether complementary and alternative therapies are more accepted or used in different parts of the country.A descriptive, correlational design was used to conduct a national survey to determine critical care nurses’ perspectives toward and use of complementary and alternative therapies. The methods have been described elsewhere11,14,17 and are therefore described here in brief. Demographics, professional characteristics, and work settings of critical care nurse respondents are presented according to regions of the United States, along with nurses’ perspectives on complementary and alternative therapies and reports of their personal use of these therapies and their use of the therapies in practice. After we received approval from the institutional review board, 2000 names were randomly drawn from the full database of AACN members to receive the survey mailing. From the mailing, 726 surveys were returned (response rate, 36%).A survey developed by Berman et al18 was modified (with permission) for use with critical care nurses. The survey comprised items requesting nurses’ perspectives on 28 selected therapies that have been categorized according to the National Center for Complementary and Alternative Medicine classification3 (Table 1). Categories include mind-body interventions (eg, imagery, biofeedback), alternative medical systems (eg, Native American medicine), biologically based therapies (eg, herbal medicine), manipulative and body-based methods (eg, chiropractic, acupressure), and energy therapies (eg, therapeutic touch). The survey included requests for demographic information (sex, age, religious affiliation, marital status, education, race, and income), professional information (primary healthcare role, certification, years of experience as a registered nurse, and years of experience in critical care), descriptive information on clinical work setting (perceived stress, number of institutional beds and location), evidence required for use of complementary and alternative therapies versus conventional therapies (eg, proven mechanism, clinical trial evidence), signs and symptoms for which complementary and alternative therapies were perceived to be useful (including headache, nausea, vomiting, back pain, other pain, stress, anxiety, restlessness, and insomnia), and perception of institutional barriers (including physician, peer, or personal reluctance; unavailability or lack of credentialed providers, knowledge, time, reimbursement, equipment, or staff training; institutional legal concerns). Attitudes toward the 28 therapies (views of legitimacy, perceived benefit vs harm), knowledge and/or training for each of the 28 therapies, desire for additional knowledge and training for each of the 28 therapies, and a reporting of the personal and the professional use and recommendations or referral for each of the 28 therapies included in the survey were also gathered.To analyze survey data by regions of the United States, we examined other prominent published reports1,2,19–21 that described use of complementary and alternative therapies so that we could use similar geographic breakdowns. However, we found no consistency in regional breakdown among these reports. Therefore, we identified a Web-based source22 that provided a breakdown of 5 major regions of the United States; this breakdown was used in our analyses. Regions included Northeast, Midwest, Southeast, West, and Southwest. These regions were matched with the 19 membership regions identified by the AACN to expand the usefulness of our findings for critical care nursing. All 19 membership regions of AACN and all states were represented. Breakdowns of the sample by states, by the 5 geographic regions, and by AACN membership regions are included in Table 2. Analyses were not conducted according to AACN regions because of the limited numbers of respondents in some regions. However, AACN regions, subsample sizes, and geographic locations (by geographic region and state) are included to provide information on specific locations of potential interest and also to help form a perspective on the representativeness of the sample by region and state.Descriptive statistics were used to describe demographic, professional, and work setting characteristics of the sample and nurses’ personal use of complementary and alternative therapies. Summary scores were created in 2 ways. Mean ratings were computed to describe the evidence needed, knowledge about complementary and alternative therapies, desire for training, and attitudes (legitimacy and benefit). Simple totals were used to describe barriers, recommendations, and personal and professional use. Ranked data that were not normally distributed were further categorized for analyses. Because a large number of tests were used on the data and because significant results could occur by chance in comparisons of 28 different complementary and alternative therapies, individual therapies were not compared across geographic regions unless the overall use of complementary and alternative therapies was significant. Pairwise comparisons between geographic areas were not considered unless the analysis of variance, including all 5 regions, for the specific complementary or alternative therapy was significant. Post hoc analyses were performed by using the Tukey honestly significant difference test.As depicted in Table 3, demographic characteristics of the sample of critical care nurses across geographic regions were similar (nonsignificant differences). Across regions, a majority were female (86%–92%), married (64%–74%), white (82%–96%), and ranged in age from 22 to 76 years (median, 42 years). Overall, respondents had a median of 17 years in nursing (range, 0.3–44 years) and 13 years as critical care nurses (range, 0–36 years). Other professional characteristics of the sample (eg, role, education, hours worked per week) had similar patterns across regions.Respondents’ work settings (ie, type of unit, institutional size, location, and environmental stress) also had similar patterns across geographic regions, as did the demographic characteristics (Table 3). Combined intensive/coronary care units and intensive care units/ cardiovascular surgical intensive care units each accounted for approximately a quarter of the sample; the most common hospital size was 151 to 300 beds; and, for all regions, the majority of respondents worked in urban or suburban hospitals. A majority of nurses across regions reported that the stress of their work environment was moderate (57%–67%) or extreme (19%–27%).Overall, critical care nurses’ perspectives on complementary and alternative therapies were similar across geographic regions (Table 4). They reported that the number and types of evidence they required for decisions to use orthodox therapies were similar to those they would require for decisions about using complementary and alternative therapies. Nurses across regions viewed similar numbers of complementary and alternative therapies as legitimate. Regions did not differ in the number of reports of “some” or “a lot” of knowledge or training for the 28 therapies. Likewise, we found no significant differences in perceived effects (ie, negative, neutral, and positive). Nurses across regions recommended a similar number of complementary and alternative therapies in practice; similar numbers of nontraditional therapies were requested by patients or patients’ families. The number of signs and symptoms for which complementary and alternative therapies were perceived to be useful was similar across regions, as was the number of perceived barriers.Overall, nurses in all regions were similar in their views of the helpfulness of complementary and alternative therapies for patients, patients’ families, nurses, and other staff members. The number and types of resources used were similar, as was nurses’ desire to increase availability of nontraditional therapies for practice and personal use (their own use or use by other nursing staff ). Nurses in different regions did not differ in their openness to use of complementary and alternative therapies. The overall mean number of complementary and alternative therapies used in professional practice did not differ significantly across regions. However, the mean number of complementary and alternative therapies that nurses reported they used for self-care did differ significantly among geographic regions. Nurses in the Northeast used fewer nontraditional techniques for self-care relative to nurses in the Southeast (P=.001), Southwest (P=.001), and West (P=.003); use of complementary and alternative therapies for self-care by nurses in the Northeast did not differ from use of such techniques by nurses in the Midwest. Because the mean number of complementary or alternative therapies used for self-care differed across regions, the data were examined to determine differences in the use of specific therapies for personal use (see following).Overall, we found no substantial regional differences in the use of the 28 selected complementary and alternative therapies in practice (Table 5). Patterns in the most commonly used and least commonly used therapies were also similar across regions. Exercise, diet, massage, prayer and spiritual direction, relaxation techniques, and counseling/psychotherapy were the most commonly used in practice. In general, qi gong, Native American medicine, environmental medicine, hypnotherapy, traditional Chinese medicine, tai chi, and acupuncture were the least commonly used in practice across regions. Personal use of acupuncture, Native American medicine, Chinese medicine, therapeutic touch, and pet therapy differed significantly across regions (Table 5).We found no significant regional differences in the number of nurses who reported that they use complementary and alternative therapies in practice. However, the mean number of complementary and alternative therapies used for self-care did differ across geographic regions; although differences between regions were also apparent in the use of several specific therapies for self-care, we found clear and consistent patterns across regions in the overall use of complementary and alternative therapies. Indeed, the use of selected therapies such as massage, music, diet, exercise, counseling, and prayer (which were the most frequently used in practice and self-care) may be considered mainstream. Also, we found no significant differences in perceived effects, barriers, or desire to use and to increase the availability of nontraditional therapies.Data from AACN membership regions were not analyzed separately because the number of respondents in several states was relatively low, and patterns in geographic areas were of greater interest. However, we included Table 2 to present a breakdown of respondents according to AACN regions and states in an effort to allow consideration of how data may represent perspectives and use in given states and AACN regions.Less use of some therapies might be explained by the philosophic or cultural adoption or full understanding of the beliefs or set of assumptions underlying particular therapies. For example, Native American medicine or Chinese medicine may require extensive training and knowledge of the theories underlying use or training related to techniques of assessment and administration of specific therapies. The fact that few ethnic minorities were represented in the sample is an additional factor that might explain the lack of use of therapies of other ethnic origins. The usefulness of these complementary and alternative therapies remains to be explored and deserves our attention so that their potential to benefit critically ill patients can be determined.Use of complementary and alternative therapies is increasing in the public realm in the United States. Our survey results indicate that selected complementary or alternative therapies are commonly used in practice by critical care nurses, and this pattern was consistent across geographic regions. Personal use of nontraditional therapies had generally similar patterns in amounts and types across regions. However, some regional differences were apparent in degree of use and in the specific therapies used. Whether the number and types of complementary and alternative therapies used will change over time remains to be seen in future surveys of this nature. A majority of nurses were interested in obtaining more knowledge about complementary and alternative therapies, identified significant potential benefits for these therapies, and were open or eager to increase their use of such therapies in practice. To maximize benefit, critical care nurses are encouraged to contribute to the growing evidence base for complementary and alternative therapies through research to determine whether these techniques are efficacious when used in the care of critically ill patients and the patients’ families, to further refine interventions to enhance the suitability of these therapies and their benefit to patients and patients’ families, and to define those subgroups of patients for whom selected complementary or alternative therapies have significant usefulness in terms of measurable outcomes to warrant use of the therapies.We thank Patricia Minor and Marguerite Clemens for their expert word processing and efforts in the preparation of this manuscript. The project was funded by the Densford Clinical Scholar Program, the Katharine J. Densford International Center for Nursing Leadership, University of Minnesota, and the Genentech Research Award of the Greater Twin Cities Area Chapter of the American Association of Critical-Care Nurses.