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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 2 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. 1368Ott / 9. July 2014, 1:28 PM 3 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). 1368Ott / 9. July 2014, 1:28 PM 4 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. 1368Ott / 9. July 2014, 1:28 PM 5 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 6 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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