Download Attitude of oncology/hematology nurses from German speaking

Trace Elements and Electrolytes, Vol. ■■ – No. ■■/2014 (1-7)
Attitude of oncology/hematology nurses from
German speaking countries towards
complementary and alternative medicine
Original
©2014 Dustri-Verlag Dr. K. Feistle
ISSN 0946-2104
DOI 10.5414/TEX01368
e-pub: ■■month ■■day, ■■year
I■■. M. Ott1, K■■. Muenstedt2, Oliver Micke3, R■■. Muecke4, F■■. J. Prott5, B■■.
Senf6, K■■. Paradies7, E■■. Aerts8, J■■. Huebner1, On behalf of PRIO – Working
Group Prevention and Integrative Oncology of the German Cancer Society
■■ Please complete authors firstnames for PubMed citation.
1Dr.
Senckenberg Chronomedical Institute, J.W. Goethe University, Frankfurt,
Clinic Giessen, Department of Gynecology and Obstetrics, Gießen,
3Franziskus Hospital, Department of Radiotherapy and Radiation Oncology,
Bielefeld, 4Lippe Hospital Lemgo, Department of Radiotherapy and Radiation
Oncology, Lemgo, 5RNS Praxisgemeinschaft GbR, Wiesbaden,
6Hospital of the J.W. Goethe University, Department for Psycho-Oncology,
Frankfurt, 7Working Group KOK (Conference of Oncological Nurses of the German
Cancer Society, Berlin, Germany, and 8UniversitätsSpital Zürich, Zürich, Switzerland
2University
Key words
oncology – nursing –
complementary
medicine – alternative
medicine
Accepted for publication
June 2, 2014
Correspondence to
PD Dr. med.
Jutta Hübner
Working Group
Integrative Oncology,
Dr. Senckenberg
Chronomedical Institute,
J.W. Goethe University,
Theodor-Stern-Kai 7,
60590 Frankfurt,
Germany
huebner@med.
uni-frankfurt.de
Abstract. Objective: 40 – 50% of cancer patients use complementary or alternative medicine (CAM). While oncologists
are skeptical regarding CAM, no data has
been published with respect to nurses. The
objective of our study was to learn about
the attitude of nurses with a specialization
in cancer care towards CAM. Subjects and
methods: A survey was performed on nurses
in Germany, Switzerland and Austria using
an online questionnaire, which addressed attitude towards, and experiences with CAM.
Results: 877 participants filled in the questionnaire. 61% have a very positive or positive attitude towards complementary (CM)
and 20% towards alternative medicine (AM).
71% rate their knowledge as high to moderate regarding CM. 43% use some source of
information on CAM and 48% would like
more training on CAM. The most important
reason to use CM is the patient becoming active (50%). CM is a means for reducing side
effects (46%), increasing coping (42%), or
quality of life (47%). For AM, less than 20%
give positive statements. Risks as a result of
interactions and side effects are anticipated
by 40 (CM) and 50% (AM). Conclusion: In
sum, many but not all participants are aware
of the pros and cons of CAM. In general,
they have a positive attitude towards CM. In
order to make CM safer, a structured training
should be offered.
Introduction
In oncology, 40 – 90% of patients use
complementary and alternative medicine
•
[1, 2, 3]. Most oncologists/hematologists
are not familiar with the topic [4] and other
physicians also do not have enough training
in order to feel capable in giving patients
guidance [5]. Thus, sources of information
on complementary or alternative medicine
(CAM) are mostly family and friends, magazines and books, and others who are affected
by the disease [6]. Most patients do not discuss CAM with their oncologists [7, 8]. On
the other hand, data from Germany shows
that physicians are the main source of prescriptions of CAM [9].
Some CAM therapies are provided mostly by nurses (ex. aromatherapy or therapeutic
touch). Yet, in German speaking countries,
patients prefer biologically based therapies
which are mostly provided by physicians
(and at least in Germany by non-medical
practitioners).
As nurses get into an increasingly important position in guiding cancer patients
through their time of therapy and rehabilitation, CAM could become an important topic
for this profession.
To our knowledge, no data exist on the
communication between patients and nurses
on CAM in German speaking countries.
Two surveys were performed on professionals in Germany, which also included
nurses – one on the employees of a comprehensive cancer center and one on the professionals in palliative care. Both studies point
1368Ott / 9. July 2014, 1:28 PM
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Ott, Muenstedt, Micke, et al.
Table 1. Demographic data of the participants of the survey.
Specification
Age
Gender
Native from
Place of work
Specialization of
place of work
Age group of
patients
Place of work
Number of
inhabitants of
town of place of
work
Younger than 30 years
30 to 50 years
Older than 50 years
Male
Female
Germany, Switzerland, or Austria
Other countries
University hospital
Other hospital
Outpatient unit
Medical Practice
Hematology
Oncology
Stemcell transplantation
Gynecology
Urology
Children
Adults
Germany
Switzerland
Austria
Less than 20,000
20,000 to 100,000
100,000 to 500,000
500,000 to 1 Mio
More than 1 Mio
Number of
participants (in %)
8.9
52.1
23.2
6.9
80.0
83.5
3.3
30.4
42.4
6.0
6.6
8.3
56.5
6.2
9.9
1.9
6.3
79.0
51.7
26.5
6.4
7.3
25.2
32.2
11.0
7.5
to great differences between the attitudes of
nurses and physicians. Yet, both surveys did
not focus on specialists in oncology in the
different professions.
The aim of the present study was to conduct a survey among nurses specialized in
oncology and hematology in Germany, Switzerland and Austria.
The data will be valuable for professional
associations as well as cancer centers and
those responsible for professional formation
in order to improve cooperation between the
professions in this sensitive issue.
Material and methods
Questionnaire
The questionnaire comprises 27 questions
in total. It differentiates between complementary or alternative medicine as suggested by the NCCAM where complementary
therapy is accompanying, and alternative
medicine being used instead of conventional
medicine (http://nccam.nih.gov/health/wha•
tiscam; last time assessed 08.12.2013). This
definition was provided to participants in the
questionnaire.
The questionnaire was divided into several sections:
1. Demographic data
2. Personal attitude, experiences, and satisfaction with CAM
3. Interest, knowledge and source of information regarding CAM
4. Arguments pro and contra complementary or alternative medicine
5. Current offer of CAM at the center the
participant is working
6. Interest in education and projects regarding CAM
The questionnaire was developed in a
consensus process between members of the
working group “Prevention and Integrative
Oncology” of the German Cancer Society,
(PRIO) and the presidents/chairs of the professional associations of nurses in oncology
and hematology (KP and EA).
Arguments for and against CAM partially were derived from the results acquired
from former surveys by PRIO in professionals. Also, the list of CAM methods provided
in the questionnaire corresponds to similar
lists our group used to analyze the behavior
of users and providers. This list had been
compiled by expert members of the working
group in 2008, based upon existing surveys
on user behavior in Germany and on the
experts’ own practical experience gathered
over many years of patient counseling, and is
continuously adapted to actual user behavior.
Population surveyed:
The members of three associations of
nurses specialized in oncology and hematology were asked to take part in the survey.
All three associations sent the link to the
questionnaire to their members and sent a reminder mail after 6 weeks. For a period of 4
months in 2013 the questionnaire was open
on the internet with access only by the link.
Participation in the survey was voluntary and
anonymous. As the link to the questionnaire
was sent to members with the request to pass
it to other nurses at their institution, we do
not know the number or potential participants.
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Attitude of nurses towards CAM
Table 2. Answers to statements on complementary or alternative medicine in oncology/hematology.
Statement
Application to CM(CM) or
alternative medicine (AM)
These methods are as effective as those of
conventional medicine
Maybe these methods do not help but they do
not do any harm, either.
They help cancer patients to do something by
themselves.
Maybe these methods help to reduce side
effects.
These methods help patients to better cope
with their disease.
These methods can improve the quality of life
of the patients.
These methods offer a holistic approach
which conventional medicine does not offer.
These methods meet patients’ need for a
“soft” therapy.
These methods can help that the patient
complies better with important recommendations on therapy.
The offer of these methods is an advantage in
competition.
These methods can have interactions with
anticancer drugs.
These methods can also have negative
effects.
Offers for these methods may lead patients to
not comply with important prescriptions.
As science does not know much about these
methods, I do not recommend them.
Any offer of these methods would rather harm
the reputation of our institution.
These methods lead to further costs for the
patient.
These methods lead to more expenses for
the community.
Agreement (in %)
CM
AM
CM
AM
CM
AM
CM
AM
CM
AM
CM
AM
CM
AM
CM
AM
CM
AM
1 = full
4.7
0.8
7.4
3.2
34.9
9.3
26.5
6.5
21.1
6.2
27.7
6.0
21.2
5.4
20.4
9.5
12.8
2.6
2
13.8
2.3
13.7
4.8.
15.5
8.5
19.6
9.1
21.1
8.9
19.2
9.8
16.4
6.3
20.6
13.3
17.2
5.5
3
17.7
6.6
11.2
7.4
5.0
9.6
7.4
11.2
10.6
14.5
7.1
12.5
10.4
10.0
10.7
12.5
14.0
12.0
4
10.0
8.1
7.1
5.2
1.5
6.6
1.4
7.3
2.5.
9.0
1.6
8.2
3.2
7.2
2.8
7.2
5.8
7.7
5
5.0
11.5
5.9
10.7
0.3
6.7
1.1
7.3
1.4
6.7
1.3
8.1
2.8
8.2
1.5
4.8
3.2
8.5
6 = none at all
6.2
26.0
11.7
23.5
0.5
13.3
1.5
12.4
0.3
9.3
0.6
9.3
2.3
16.7
1.1
8.6
2.9
17.2
CM
AM
CM
AM
CM
AM
CM
AM
CM
AM
CM
AM
CM
AM
CM
AM
5.4
21.6
25.5
25.7
19.4
31.0
6.9
19.8
2.5
19.9
1.5
12.3
17.7
26.1
4.7
9.6
6.5
19.2
14.1
12.6
15.0
11.0
12.4
11.7
5.7
6.5
2.6
4.8
16.3
11.3
6.5
6.5
10.5
8.1
10.1
5.8
10.1
3.9
13.6
8.9
10.7
8.4
5.9
7.5
11.2
7.3
13.2
11.2
7.5
2.7
3.2
3.2
4.3
2.5
6.3
3.4
6.8
3.8
4.3
4.3
3.3
1.7
6.2
5.2
5.9
1.6
3.3
1.3
5.2
2.6
8.9
4.9
10.7
5.2
11.8
5.1
3.9
2.5
9.3
6.5
11.5
2.8
0.8
2.7
2.7
2.3
8.8
4.7
19.5
8.9
30.1
12.2
4.3
2.7
16.1
12.1
Statistics
IBM SPSS Statistics 20 was used for data
collection and all statistics. Analyses of frequencies and cross tables with χ2-tests were
performed.
Results
In total, 877 participants took part in our
survey. The demographic data is shown in
Table 1.
Most participants (70%) have experiences with CM either by themselves or in their
family, a quarter using it on a regular basis.
Also, AM is used by nearly half of the par•
ticipants or their family members from time
to time (38%) or frequently (11%).
The attitude of participants towards CM
is mostly positive; more than 60% of participants have a very positive or positive attitude
(Figure 1). In contrast they are more skeptical towards alternative medicine (AM).
Nearly a quarter refute AM. On the other
hand, nearly a third gives a rating between
acceptance and refusal.
Turning to the professional point of view
on CAM, 60% of participants are interested
in CAM, 6.9% are not and 5.7% do not know.
Younger participants are more interested
in CAM than older ones (p < 0.001) as are
female participants (p = 0.002).
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Ott, Muenstedt, Micke, et al.
Figure 1. Attitude towards CAM.
Figure 2. Knowledge on CAM.
Table 3. Knowledge on different types of CAM.
Method
Vitamin C
Selenium and other trace elements
Supplements (combinations of vitamins,
trace elements and others)
Enzymes
Mistletoe
Other immunological therapies (thymus, …)
Phytotherapy
Medical mushrooms
Cancer diets (Breuss, Budwig, low carb…)
Bioresonance therapy
Energy field therapy (Reiki, therapeutic
touch,…)
Mindfulness based stress reduction
Acupuncture
Yoga, Tai chi, Qi Gong
Hyperthermia
Anthroposophical nursing
Traditional Chinese medicine
Ayurvedic medicine
Homeopathy
Knowledge (self-rating on a likert Offer of the method in the
scale from 1 = good to 4 = bad) institution the participant
works at (%)
1
2
3
4
9.2
19.5 14.7
10.7
15
10.9
23.1 13.3
7.2
19
10.3
23.3 15.5
5.9
19
5.6
16.6
3.9
7.6
0.6
3.4
3.6
5.5
14.1
24.4
11.6
18.6
5.0
13.3
12.8
14.7
16.7
9.7
19.4
15.7
12.2
18.3
16.6
18.5
17.0
4.4
18.1
12.3
34.6
19.0
20.6
15.6
10
19
5
11
1
3
2
3
6.0
16.7
15.4
6.3
7.1
7.9
3.3
14.5
14.2
26.5
23.0
15.5
16.7
17.5
12.1
26.4
14.4
8.7
12.5
18.3
17.1
14.9
20.6
10.7
18.9
2.8
4.2
13.6
13.8
13.2
17.1
3.6
8
16
7
4
6
4
1
15
We offered a list of different statements
and asked the participants to mark their
agreement on a Likert Scale from 1 (full acceptance) to 6 (full denial). Every statement
was to be rated with regard to CM or AM.
The answers are given in Table 2. In general, there are more positive ratings for CM
than for AM. Nearly a fifth of participants
rates CM as being as effective as conventional medicine. The same number agrees to
the statement that CM does not harm at all,
whereas less than 10% agree to this statement
regarding AM. The most important reason to
use CAM is the possibility for the patient to
become active. Half of participants agree to
•
this regarding CM but only 18% regarding
AM. CM is a means to reduce side effects
for 46%, whereas only 15% see this for AM.
Nearly the same is true for better coping and
increasing quality of life: 42% and 47% hold
this to be true for complementary treatments
while only 15% and 17% think so for alternative treatments. A holistic approach, which
is missing in conventional medicine, can be
seen by 48% and better compliance with
conventional treatments by 40%, considering complementary therapies. Only 12%
and 8% agree to this considering alternative
therapies. In contrast offering alternative
treatments is regarded as part of competition.
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Attitude of nurses towards CAM
Most participants are aware of risks of
CAM in the form of interactions and side effects and state that they could possibly stem
from both (40 – 50%). The cost for patients
is seen with complementary as well as alternative therapies while only few participants
also observe costs for the community.
Younger participants consent more often
to the statements that CAM are as effective
as conventional medicine and do not harm
(p = 0.024 and p = 0.049). In contrast, participants aged 30 – 50 state more often that
CAM can also have side effects (p = 0.01)
and may lead to patients not complying
with prescriptions (p = 0.011). Regarding
the statements on CAM, there are no statistically significant differences between the
genders.
Asked whether they had been asked
about CAM by patients, most participants
answered with “yes”, a third with “sometimes”, and a quarter with “on a regular basis”. Asked about who should be responsible
for CAM in institutions caring for cancer patients, 22.7% answered the oncologist, only
1% the general practitioner, and 37.8% a
physician with training in CAM. 15.7% also
think that nurses trained in CAM should be
responsible.
When asked to rate their knowledge on
CAM they are more familiar with complementary methods than with alternative methods (Figure 2).
We asked about knowledge on certain
types of CAM and whether these methods
are offered in the institution the participant
works at. The results are shown in Table 3.
The participants rate their knowledge to be
highest for vitamins and trace elements and
other supplements, mistletoe, acupuncture,
yoga, tai chi, qi gong, and homeopathy. It
is low for methods only seldom offered in
the institutions as cancer diets or Traditional
Chinese Medicine.
42.7% use some source of information
on CAM, ~ 1/3 scientific journals or other
types of professional education, 17% experienced physicians, and 28.5% the internet.
48% would like to have more possibilities
for training on CAM. Written material is
more favored than tutorials at congresses or
internet-based material (31, 28, and 23% of
participants agreeing to these different offers).
•
Discussion
To our knowledge, this is the first survey
regarding CAM in oncology/hematology focusing on specialized nurses. Most state that
they are asked by patients on this topic. One
important result of our survey is that the participants clearly distinguished complementary from alternative medicine. More than
60% have a positive attitude towards CM
and only 20% towards AM. Accordingly,
there is a high interest in information as well
as in training and education.
Depending on the method, up to one fifth
of the participants state that CAM is used at
their institution. Most often used are supplements (including vitamins and trace elements), mistletoe, acupuncture, and homeopathy (each 15% or more). Less often are
phytotherapy and enzymes (11 and 10%). In
contrast to other immunological therapies,
medical mushrooms, cancer diets, energy
field therapy, mindfulness based stress reduction or yoga, tai chi, qi gong as well as anthroposophical nursing, Traditional Chinese
Medicine or Ayurvedic Medicine are seldom
used. As most of the participants work at oncological institutions, these numbers might
at first glance be astonishing, even more so
as most of the therapies mentioned do not belong to the profession of nursing but belong
to the field of physicians’ prescriptions. F.ex.
mistletoe is often used, yet if this was only
true for anthroposophical clinics, anthroposophical nursing should also have a higher
importance. In sum, biologically based
therapies are far more common than mindbody or energy based treatments. This must
be kept in mind while analyzing participants’
attitude towards CAM for cancer patients.
Considering the effectiveness in relation
to conventional medicine, only a few participants rate AM as equally effective, whereas
more than 35% agree to this fully or partially
for CM. Accordingly, more than a third rate
CM as having no or few risks. Yet more than
half of the participants are aware of interactions and more than 40% of participants are
aware of side effects from CM or AM. On
the other hand, there are a number of oncologic nurses who are not aware of the risks
stemming from CAM. This is of special importance as we have shown, that substance
bound treatments are offered by some insti-
1368Ott / 9. July 2014, 1:28 PM
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Ott, Muenstedt, Micke, et al.
tutions of the participants and as we know
from surveys among patients [3], biologically based therapies are preferred by them.
Lack of knowledge considering these risks
of CAM is common among professionals
(physicians as well as nurses; [4] and nonmedical professionals [10]).
These risks seem to be outweighed by the
advantages attributed to CM more than AM.
The capability of reducing side effects is one
of these advantages, which has been shown
for some CM treatments to some extent of
evidence (ex. honey, aloe or glutamine are
discussed in Cochrane reviews). Increasing
quality of life and coping may result from
these physical effects as well as from the
possibility for the patient to do something by
himself. In fact, nearly 50% of participants
state that a holistic approach (the combination
of physical, mental, social and spiritual care)
is an advantage of CM. Most participants realize that AM does not offer these positive effects and only few rate AM as holistic. CM,
according to the nurses’ point of view, may
also have an influence on compliance. More
agree to the statement that CM may improve
compliance than reduce it. For AM the numbers are in the opposite direction.
In conclusion many, but by far not all,
participants are aware of the pros and cons
of CM as well as AM. In general, they have
a positive attitude towards CM and are motivated to get more education on the topic.
When asked who should be responsible for
CAM in institutions caring for cancer patients, most would prefer a physician. Yet,
16% think that nurses with special training
could give advice to patients on CAM. Considering the fact that most oncologists are not
trained in CAM, this offers an opportunity to
increase facilities for patient counseling on
CAM in oncologic institutions. As CM mostly should enhance patients’ autonomy, giving them access to methods they may decide
on by themselves, may be done just as well
by physicians as by nurses [11, 12]. Only
in special cases (mostly biologically based
therapies) specialized knowledge of physicians seems to be necessary (e.g., to exclude
interactions). In fact, in institutions willing
to provide information on CAM to their patients as part of shared decision making, a
close cooperation between both professions
offers some advantages:
•
–– More professionals in a team being able
to provide information
–– Higher number of patients finding
professional advice
–– Higher probability of a holistic approach
–– More knowledge in both professions in
order to detect risks of CAM
–– Lower threshold for patients.
Acknowledgment
The authors thank Kerstin Paradies, Head
of Working Group KOK (Conference of Oncological Nurses) of the German Cancer Society for her contributions to the article and
helping us contact all members of the KOK.
Conflict of interest
■■■?
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