I SSUES AND INNOVATI ONS I N NURSI NG EDUCATI ON

Nurse practitioner knowledge of complementary alternative health

care: foundation for practice
Patricia M. Sohn MSN APRN BC ANP
Nursing Instructor, Jewish Hospital College of Nursing and Allied Health, Washington University Medical Center, St Louis,
Missouri, USA
and Cynthia A. Loveland Cook PhD RN ACSW
Associate Professor, School of Social Service, St Louis University, St Louis, Missouri, USA
Submitted for publication 15 February 2001
Accepted for publication 2 April 2002
Correspondence:
Patricia Sohn,
Jewish Hospital College of Nursing
and Allied Health,
306 South Kingshighway Blvd,
Mailstop 90-30-625,
St Louis,
MO 63108,
USA.
E-mail: pms8251@bjc.org
SOHN P M & LOVELAND COOK C A ( 2002) SOHN P.M. & LOVELAND COOK C.A. ( 2002) Journal of Advanced Nursing
39(1), 916
Nurse practitioner knowledge of complementary alternative health care: foundation
for practice
Aim. With the increasing use of complementary alternative treatments by the
general public in the United States of America (USA), it is critical that nurse prac-
titioners have the most up-to-date information about the use and safety of these
modalities. A strong knowledge base is crucial in delivering competent and cultur-
ally sensitive care, yet the level and source of nurse practitioner knowledge in this
area is largely unknown. The purpose of this study was to investigate the level and
source of nurse practitioner knowledge of complementary alternative health care
practices, as well as their referral practices involving these treatments.
Methods. Using a cross-sectional descriptive research design, a sample of 151 nurse
practitioners from Missouri and Oregon completed an adapted version of Sapps
self-administered survey that explored these issues. Evaluation of the psychometric
properties of the adapted instrument demonstrated good face validity, testretest
reliability (kappa 081) and internal consistency reliability were 090 and 092 for
two subscales with continuous response categories.
Findings. Eighty-three percent of the nurse practitioners recommended comple-
mentary alternative treatments to their patients with the most frequent being mas-
sage therapy, chiropractic care, acupuncture or acupressure, nutritional therapy and
herbal treatment. However, only 24% reported that formal nurse practitioner
education was a source of knowledge about these treatments. Instead, over 60%
relied on their personal experiences for this knowledge, as well as lay and profes-
sional journals.
Conclusion. Nearly 9 out of 10 nurse practitioners recommend the use of com-
plementary alternative therapies to patients, but their source of knowledge is not
derived from professional education. Attention needs to be given to increasing
content about complementary alternative therapies in formal academic programs,
professional conferences and in-service education opportunities.
Keywords: nurse practitioner, complementary alternative health care, education,
clinical practice
2002 Blackwell Science Ltd 9
Introduction
In the last decade, the use of complementary and
alternative (CA) health care by the general public has
increased dramatically in the United States of America
(USA). In this country, CA treatment is dened as health
care practices outside the realm of conventional Western
medicine. These treatments are not widely taught in
medical schools, not typically used in hospitals, and not
usually covered by health insurance [National Center for
Complementary & Alternative Medicine 1998 (NCCAM)].
Nevertheless, recent studies using nationally representative
samples reported that at least 40% of the American public
annually use some type of CA treatment (Eisenberg et al.
1993, Astin 1998). The NCCAM (1998) estimates the
number of CA health care users to be closer to 45%. As
an example, a recent study of community-residing older
women revealed that 50% used at least one type of herbal
product (Yoon & Horne 2001). The general public, in
their quest for better health, has been making decisions
about self-treatment based upon limited and ambiguous
information. Many individuals believe that because CA
treatments are advertised as natural, they can do no harm
(Herbert 1988). Despite potential adverse interactions
between CA and allopathic medicine (ONeill 1994),
Eisenberg et al. (1993) reported that 72% of the people
in their survey had not informed their physicians when
they used these treatments.
The increasing level of public interest and use of CA
treatments presents a challenge to nurse practitioners (NPs).
As primary care providers who play a key role in health
care delivery, it is likely that NPs will be asked questions
about these therapies by their patients. Considering the high
use of CA treatment and reluctance to inform allopathic
health care providers, the responsibility of the NP actively
to seek out this information is imperative to ensure
competent and culturally sensitive care (Rauckhorst
1997b, Manzella 2000). Nursing philosophy, with its focus
on holism urges NPs to be responsive to the publics
request for CA treatment [American Nurses Association
1995 (ANA)]. Only with an adequate knowledge base,
however, can NPs offer useful answers and counsel patients
effectively so that informed health care decisions can be
made. To date, little is known about the NPs level and
source of knowledge about different CA treatments. Even
less is known about NP practice patterns involving CA
treatment modalities. The primary purpose of this article is
to present the ndings of a multisite study that investigated
both NP knowledge and practice patterns involving CA
treatments.
Review of literature
Little nursing research addresses NP education and practice
in the area of CA health care. Using a modied version of an
instrument originally designed by Borkan et al. (1994),
Kayser (1996) surveyed 100 NPs registered with the Idaho
State Board of Nursing about their practice patterns involving
the following CA therapies: (1) acupuncture , (2) hypnosis,
(3) spinal manipulation, (4) touch therapy (5) homeopathy,
(6) naturopathy, (7) folk healing, and (8) movement therapy.
Nurse practitioners and patients asked each other about CA
treatments less than 40% of the time. The two most
inuential factors in the use of CA therapies were patient
requests for CA treatment, and the NPs opinion that the
treatment t the patients belief system. Thirty-eight percent
of NPs had referred patients for CA therapy in the 6 months
before completing the survey. Spinal manipulation was the
most common referral followed by hypnosis, acupuncture,
spiritual healing, touch therapy, naturopathy and movement
therapy. The NPs reported having the least knowledge in folk
healing and movement therapy, but felt most knowledgeable
about touch therapy. The survey however, did not address the
source of NP knowledge about CA therapies.
Using a self-designed survey instrument, Sapp (1997)
conducted a study of 36 Missouri NPs on their practice and
knowledge of: (1) aromatherapy, (2) acupuncture/acupres-
sure, (3) biofeedback, (4) chiropractic, (5) herbal therapy, (6)
massage, (7) meditation, (8) reexology, (9) tai chi/yoga
(energy form), and (10) therapeutic touch. Fifty-eight per cent
of the NPs reported personal use of CA therapies, particularly
chiropractic, massage and meditation. Sixty-nine per cent of
the NPs recommended CA therapy to their patients. Most
often they recommended massage therapy, followed by
meditation, biofeedback, and chiropractic treatment.
Although the NPs reported some knowledge of biofeedback,
chiropractic, acupuncture/acupressure, and meditation, more
than one-half reported no knowledge of herbal therapy,
aromatherapy, reexology, and tai chi/yoga (energy form).
However, 42% expressed interest in learning more about CA
treatment modalities.
In Israel, DeKeyser et al. (2001) used a self-designed survey
instrument to determine the knowledge level and attitude of
369 staff nurses about CA therapies. The respondents
reported having limited knowledge about CA modalities,
but expressed interest in learning more about them. Few
nurses however, used CA treatments in their practice and
most were wary of them.
King et al. (1999) investigated the CA treatment referral
patterns of 467 registered nurses from the State of Ohio using
a modied instrument originally developed by Verhoef and
P.M. Sohn and C.A. Loveland Cook
10 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(1), 916
Sutherland (1995). Most often the nurses referred their
patients for dietary consultation, prayer, visual/guided ima-
gery, massage, and meditation. Overall, these were the same
therapies about which they reported being most knowledge-
able. The least common referrals involved acupuncture, tai
chi, reexology, and magnet therapy. NPs reported they were
least knowledgeable about tai chi and magnet therapy. When
asked about the effectiveness of CA therapies, their perceived
efcacy of CA therapies was higher than their actual
knowledge about the therapy itself.
Using a self-designed survey of 30 different CA therapies
cited by the Ofce of Alternative Medicine at the National
Institutes of Health, a study was conducted in 19961997 on
the knowledge and personal and professional experiences of
202 members of the Connecticut Nurse Practitioner Group
with these therapies (Hayes & Alexander 2000). Overall,
three-quarters of the NPs reported minimal knowledge of CA
modalities, but expressed interest in learning more about
them. Almost two-thirds of the NPs recommended or referred
clients for CA therapy, particularly massage, chiropractic,
meditation, imagery and biofeedback.
The Nurses Social Policy Statement (1996) mandates that
the primary responsibility of graduate NP programmes is
educating their professionals. It also dictates that treatment
and referral must be grounded in a knowledge base of past
experience and practice with solid roots in scientic know-
ledge. This policy coupled with the growing use of CA
therapies implies the need for formal NP education about
these therapies, so that NPs can competently respond to this
growing health care trend. Furthermore, the National
Organization of Nurse Practitioner Faculties (1995) accen-
tuates the need for NP faculty to incorporate education of CA
therapies within their curriculum. Exposing NP students to
the theoretical and scientic basis of these modalities will
enable the NP to critically evaluate their efcacy and use.
Similarly, exposure to CA treatments encourages NPs to
embrace the concept of holism in their practice (Reed et al.
2000). Despite the growing use of CA treatments and the
educational recommendations by nursing and governmental
organizations, a self-designed survey by Rauckhorst (1997a)
revealed that only 37% of NP programmes include formal
education on CA therapies as part of their curricula.
ONeil and the Pew Health Professions Commission (1998)
strongly emphasize that all health professional groups
change professional training to meet the demand of the
new health care system (p. iii). For the NP, the report
suggests that nursing reorient advanced nursing education
progress to prepare advanced practice nurses for the changing
situations and setting in which they are likely to practice (p.
46). If NPs are to practice optimally, an ever-expanding
knowledge base is essential. Formal educational training in
CA therapies is a necessary, but perhaps neglected component
(Chichon 2000).
Little attention has been paid to the sources and levels of
NP knowledge about CA treatments. A more comprehensive
understanding of the different sources of knowledge can play
an important role in identifying educational needs and in
refocusing educational resources. If the primary source of NP
knowledge is material intended for the lay public rather than
professionals, then formal educational strategies need to be
developed and implemented. Furthermore, a more in-depth
assessment of which CA therapies are least understood, yet
most often used in practice, would help clarify more precise
educational needs. Findings from this study should provide
valuable information for nurse educators in their efforts to
better educate NPs in the use of CA treatments.
The study
Aims
The primary aim of this study was to investigate the current
level and source of NP knowledge about complementary
alternative (CA) health care practices. Secondarily, it also
determined the extent of current NP referral practices
involving these modalities. To address these aims, the
research questions were:
What is the NPs current level of knowledge of CA
therapies?
What is the NPs source of knowledge about CA
therapies?
What are NP current referral practices for CA therapies?
Methods
This study used a cross-sectional, descriptive research design
to investigate the research questions in this study. One
hundred 151 NPs registered with the Board of Nursing in two
states completed a self-administered questionnaire about
their knowledge of CA health care, referral practices, and
interest in future education about CA treatments.
Sample
Following approval by the Human Subjects Committee at
Washington University in St Louis, a random sample of 400
NPs registered with the Missouri and Oregon boards of
nursing were selected from their 1998 roster of members. In
a cover letter accompanying the self-administered question-
naire, the subject pool was informed of their anonymity if
they participated in the study and that completion of the
Issues and innovations in nursing education Complementary alternative health care
2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(1), 916 11
questionnaire served as their consent to participate. The two
states were chosen, because they represent different practice
environments for nurse practitioners. The State of Missouri
is considered a more restrictive state for NP practice,
whereas the State of Oregon allows NPs full practicing
privileges independent of physician involvement (Pearson
1998). To select the 400 potential subjects from these two
states, unique numbers were rst assigned to each NP on
board of nursing member rosters. A table of random num-
bers was then used to randomly select 200 NPs from
Missouri and 200 NPs from Oregon. Of the questionnaires
mailed to these potential subjects, 151 (377%) were
returned. Forty-nine percent (n 73) of the questionnaires
were received from Oregon NPs, and 51% (n 78) were
received from Missouri NPs.
As shown in Table 1, the NPs in the sample were
predominantly white females between the ages of
3150 years old. Over 40 percent (414%) indicated their
NP speciality was family followed by womens health
(146%), paediatrics (139%) and adult (119%). Relatively
few NPs cited gerontology (73%), neonatal (53%) or other
(60%) specialities. Comparisons of the NP sample across
states revealed few differences. However, signicantly more
Missouri NPs practiced in the family speciality compared to
Oregon NPs (500% and 311%, respectively; v
2
179,
P < 001). The Oregon NPs, on the other hand, had
signicantly more years in practice as advanced practice
nurses than the Missouri NPs (102 and 49 years, respec-
tively; t 490, d.f. 68, P < 0001).
Data collection instrument
A modied version of a self-administered questionnaire
originally developed by Sapp (1997) was used in this study.
At the time of this investigation, Sapps instrument had not
been used or adapted in other studies. Modication included
the addition of questions on the professional characteristics
of the sample, as well as three CA therapies: homeopathy,
hypnotherapy and nutritional therapy. The four sections of
the instrument include: (1) sociodemographic and profes-
sional characteristics, (2) personal use of CA treatments, (3)
recommendations and referrals in professional practice, and
(4) level and source of knowledge about complementary
alternative therapies. The specic alternative therapies as-
sessed in the questionnaire included: (1) acupuncture/
acupressure, (2) aromatherapy, (3) biofeedback, (4) chiro-
practic, (5) herbal therapy, (6) massage, (7) meditation, (8)
reexology, (9) energy therapies (e.g. tai chi, yoga), (10)
therapeutic touch, (11) homeopathy, (12) hypnotherapy,
and (13) nutritional therapy. Both face and content validity
were demonstrated with the original instrument, as well as
good testretest reliability (r 089). Assessment of the
psychometric properties of the adapted instrument used in
this study also demonstrated good face and content validity.
Testretest reliability (kappa 081) was determined by
comparing the responses by seven graduate NP students to
the adapted questionnaire at baseline and 1 week later.
Excellent internal consistency reliability was demonstrated
for the two subscales that used continuous response categ-
ories, specically those measuring degree of knowledge
about different CA treatments (090) and NP use of these
therapies in practice (092).
Data collection process
Survey questionnaires were mailed in 1998 to the 400 ran-
domly selected NPs from the States of Missouri and Oregon.
Following approval by the Institutional Review Board, a
cover letter describing the studys purpose, the requirements
of participation and condentiality of questionnaire
responses was mailed with a copy of the self-administered
questionnaire. To encourage prompt responses, a self-
addressed, stamped envelope was also included.
Table 1 Characteristics of sample (n 151)
Characteristic Number Percentage
Age in years
2130 10 66
3140 38 252
4150 76 503
5160 21 139
>60 6 40
Gender
Female 140 927
Male 11 73
Race
American Indian 2 13
Asian or Pacic Islander 1 07
Black non-Hispanic 1 07
Hispanic 2 13
White non-Hispanic 144 960
NP speciality
Family 62 410
Paediatrics 21 139
Gerontology 11 73
Womens health 22 146
Adult 18 119
Neonatal 8 53
Other (mental health) 9 60
State of practice
Missouri 78 520
Oregon 72 480
P.M. Sohn and C.A. Loveland Cook
12 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(1), 916
Data analysis
Univariate analyses were conducted to examine the frequency
distributions of variables in this study. Comparative analyses
involved the use of chi-square tests for those variables
measured at the categorical level. Student t-tests, on the other
hand, were used for comparisons between two groups for
ordinal and interval level variables.
Findings
The ndings of this study are presented in two sections. First,
data on the level of NP knowledge about CA therapies are
presented. The source of their knowledge is described
followed by their interest in learning more about these
modalities and recommendations for better integrating this
content into NP curriculums. The second section focuses on
the use of CA treatments by NPs in their practices. The most
common therapies in NP practice are then discussed, as well
as those factors that contribute to their use in practice.
NP education in complementary alternative therapies
The level of NP knowledge about CA therapies was measured
using a 5-point Likert scale that ranged from 1 no
knowledge to 5 extensive knowledge. As shown in
Table 2, NPs were most knowledgeable about massage
therapy, chiropractic care, meditation, therapeutic touch,
and nutritional therapy. However, they reported only a
moderate level of knowledge about these treatments. Those
CA therapies in which NPs were least knowledgeable were
tai chi/yoga, aromatherapy, and reexology.
The next set of analyses focused on sources of knowledge
about CA therapies. Over two-thirds of the sample (671%)
reported that their own personal experiences with CA
therapies were a primary source of their knowledge. Other
common sources of knowledge included lay journals
(644%), professional journals (616%), workshops and
seminars (548%), and continuing education opportunities
(541%). Professional mentoring was cited by 366% of the
sample. Only 240% of the NP sample reported that formal
NP education was a source of knowledge about comple-
mentary alternative therapies.
When CA treatments were taught, the most common
therapies covered were therapeutic touch, nutritional ther-
apy, and herbal therapy (see Table 3).
Slightly more than one-half of the NPs (540%) reported
receiving training in CA therapies outside of their NP
programme. The sample was most likely to have received
instruction in therapeutic touch and herbal therapy, followed
by nutritional therapy, meditation and massage therapy.
Three out of every ve NPs expressed an interest in learning
more about complementary alternative therapies. As shown
in Table 3, most interest in future educational opportunities
focused on herbal therapy (601%), nutritional therapy
(449%), acupuncture/acupressure (389%), and massage
therapy (362%).
Use of complementary alternative therapies in NP practice
Eighty-three percent of the NPs (n 122) had recommended
the use of CA therapy to their patients. As shown in Table 2,
Table 2 Patient referrals for CA therapy by NPs and NP level of
knowledge about CA therapy
CA therapy
referrals
Level of NP
knowledge
CA therapy n % Mean SD SD
Massage therapy 72 503 30 10
Chiropractic care 67 469 29 09
Nutritional therapy 55 385 28 11
Herbal therapy 54 378 26 11
Acupuncture/acupressure 47 329 24 08
Biofeedback 43 301 26 09
Meditation 42 294 29 11
Therapeutic touch 26 181 28 12
Tai chi/yoga 25 175 19 11
Homeopathy 25 175 22 10
Hypnotherapy 16 112 22 09
Reexology 9 63 18 09
Aromatherapy 7 49 19 08
Table 3 Type of complementary alternative therapy by educational
experience and NP interest in further education
NP
education
Outside NP
education
Interest in
further education
CA therapy n % n % n %
Massage therapy 10 74 22 163 50 362
Chiropractic care 3 22 8 59 25 181
Nutritional therapy 16 118 28 207 62 449
Herbal therapy 15 111 40 296 83 601
Acupuncture/
acupressure 5 37 19 141 53 389
Biofeedback 11 81 14 104 31 225
Meditation 10 74 24 178 36 261
Therapeutic touch 18 132 41 304 32 232
Tai chi/yoga 4 30 16 119 34 246
Homeopathy 7 51 14 104 41 297
Hypnotherapy 7 51 10 74 20 145
Reexology 2 15 6 45 31 225
Aromatherapy 2 15 10 74 33 239
Issues and innovations in nursing education Complementary alternative health care
2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(1), 916 13
the most frequent referrals were for massage (503%),
chiropractic care (469%), acupuncture or acupressure
(399%), nutritional therapy (385%), herbal therapy
(378%), biofeedback (294%) and meditation (294%).
Few NPs referred their patients for reexology or aroma-
therapy.
The most frequently cited factor that contributed to
recommendations for CA therapy was the modalitys t with
the patients belief system (709%). Other reasons for
referrals included patient requests for CA therapy (560%),
the ability of CA treatment to complement allopathic
treatment (518%) and their own personal experiences with
CA treatment (511%). Less common factors were NP
knowledge of CA therapies (338%), patients lack of
response to allopathic treatment (333%), better treatment
of health problem with CA therapy (312%) and availability
of CA therapy in the community (255%). Few NPs cited
psychological problems of the patient as a factor contributing
to CA treatment referrals.
Across-state comparison of ndings
As discussed earlier, a sample of NPs from the States of
Missouri and Oregon were selected, because they reect
different practice environments for nurse practitioners
(Pearson 1998). Comparative analyses were then conducted
to determine if there were across-state differences in the
ndings.
Although not statistically signicant, a slightly larger
proportion of Oregon NPs had recommended the use of at
least one CA treatment to their patients than had the
Missouri NPs. Oregon NPs were more likely than Missouri
NPs to recommend the following treatments: (a) acupunc-
ture/acupressure (521 and 141%, respectively; v
2
232,
d.f. 1, P < 0001) (b) massage therapy (620 and 394%,
respectively; v
2
720, d.f. 1, P < 001), (c) hypnother-
apy (169 and 56%, respectively; v
2
45, d.f. 1;
P < 005), and (d) biofeedback (380 and 225%, respec-
tively; v
2
40, d.f. 1, P < 005).
As shown in Table 4, there was considerable across-state
variability on those factors inuencing NP decisions to
recommend alternative therapy. Compared to Missouri
NPs, the Oregon NPs were signicantly more likely to report
the following inuences: (a) community availability of
alternative therapy, (b) their knowledge base on alternative
therapy, (c) their belief that it complements allopathic
treatment, (d) their personal experiences with CA therapy,
and (e) their assessment that a patients health was better
treated with alternative therapy.
In most cases, the NPs in both states had similar ratings on
their perceived levels of knowledge about CA therapies.
However, the Missouri NPs reported signicantly higher
levels of knowledge about aromatherapy than the Oregon
NPs (means 21 and 17, respectively; t 26, P < 001).
On the other hand, the Oregon NPs reported higher levels of
knowledge about meditation (means 31 and 27, respec-
tively; t 21, P < 004). Overall, there were no signicant
differences in the source of their education on alternative
therapies. Only 201% of the Oregon NPs and 280% of the
Missouri NPs learned about these therapies in their formal
NP education programmes.
Discussion
Shirreffs (1996) proposed that integrated medicine, which
combines alternative and traditional treatment approaches, is
the future of health care. Findings from this study suggest
that NPs from liberal and conservative practice environments
are responding positively to societys demand for CA treat-
ment. The majority of NPs comments from the study (64%)
Table 4 Factors that inuence the NPs decision to recommend alternative therapy by state
Missouri Oregon
Inuencing factor n % n % v
2
d.f. P
Patient request 39 549 40 578 01 1 ns
Not better with allopathic treatment 24 338 23 333 00 1 ns
Fits patient belief system 46 648 54 783 31 1 ns
Available in patients community 10 141 26 377 102 1 0001
Patient has psychological disease 7 100 12 174 16 1 ns
Alternative therapy complements allopathic treatment 30 425 43 623 56 1 001
Alternative therapy personally helped NP 425 42 609 48 1 005
NPs knowledge of alternative therapy 15 214 32 470 100 1 001
Health better treated with alternative therapy 17 239 27 391 37 1 005
P.M. Sohn and C.A. Loveland Cook
14 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(1), 916
expressed support for the use of CA health care, frequently
linking its use with the profession of nursings position on
holism. As one Oregon NP wrote, A nurse is a healer,
teacher, counsellor, guide. In that role she/he must know of
and offer to the patient any remedy that may improve the
quality of life with the least harm.
In response to the rst two research questions on the level
and source of knowledge about CA therapy, NPs reported
minimal knowledge and did not rely on scientic evidence as
their primary source of knowledge when incorporating these
modalities into practice. Instead, their knowledge base was
obtained primarily through their personal experience and the
lay literature. Relying on an unsubstantiated knowledge base
is contrary to professional nursing standards and regulations
that stress that NP practice be based on sound scientic
principles (ANA 1997). If NPs deem CA therapies to be an
appropriate expansion of their scope of practice, it is essential
that their work with these modalities be based on the most
up-to-date scientic knowledge that is available. Only 24%
of the sample cited formal NP education as a source of
information about these modalities, despite the recommen-
dations from professional and governmental organizations
that schools of nursing adequately prepare their advanced
practice nurses for the changing health care environment.
The third research question addressed the use of CA
therapies in practice. Compared to Sapps (1997) ndings,
higher rates of NP referrals and recommendations were
found. The ndings also suggest that NPs from more liberal
practice climates are more likely to recommend CA therapy
to their patients than those who practice in a more restrictive
environment. Although some do not incorporate CA treat-
ments into their own practice, NPs generally believed that it
was within their scope of practice to use, recommend, and
refer for certain types of CA therapy. Consistent with Sapps
(1997) ndings, they believed massage therapy, nutritional
therapy, herbal therapy, meditation, therapeutic touch, and
biofeedback were the treatments most appropriate for use
within NP practice. For those NPs using CA treatments in
practice, the most inuential factors underlying their treat-
ment recommendations were the patients belief system about
such treatments, requests for CA therapy, the NPs own
personal experience with the treatment, and the comple-
mentary nature of combining CA and allopathic medicine.
Across-state variability was found on those factors inuen-
cing NP decisions to recommend CA therapy. Oregon NPs
reported signicantly more factors that inuenced their use of
CA, including easy access to CA treatment in their area, their
own personal experiences with themand their belief that these
methods complement allopathic treatment. Another contri-
buting factor is that Oregon NPs have been in clinical practice
in an independent environment longer than NPs in Missouri.
Other factors could include greater exposure to CAmodalities
in Oregon NPs, as well as their having a more in-depth
understanding of them. These inuences, in turn, are likely to
contribute to the integration of CA philosophies into NP
beliefs about holistic approaches to health and patient care.
The ndings that many NPs are recommending or referring
for CA therapy, despite their lack of formal training and/or
inadequate foundation of scientic knowledge, raises several
areas of concern. Recommending or prescribing CA therap-
ies, failing to adjust allopathic treatment when used with CA
modalities, or referring patients to unlicensed or uncertied
providers may jeopardize patient care and conict with
federal and state practice laws. Secondly, it may expose NPs
to potential legal liability if a patient suffers injury or adverse
effects while participating in CA treatment that the NP
recommended without adequate scientic evidence to support
its efcacy (Stanley 1990, Sale 1996). NPs who attempt to ll
the void of formal education in CA therapy and provide
medical guidance to patients based on personal experience or
anecdotal information unsupported by scientic knowledge,
risk losing credibility not only with their patients and the
general public, but with the medical profession as well.
Whether one does or does not support the use of CA
therapy, the discovery that NPs are responding to these health
care demands without a solid knowledge base makes it
imperative that the NP curriculum be expanded. The NPs in
this study expressed a strong desire for additional instruction
on CA treatments. Guidance from educators will help NPs
remain safely within the scope of their professional practice as
set forth by the ANA standards and the state Nurse Practice
Act. Inclusion of formal education about CA modalities in the
NP curricula will promote decisions based upon scientic
foundations rather than personal experience. Furthermore,
concentration on the advancement of knowledge in CA health
care will enhance the practice of nursing and broaden the NPs
scope of practice. A supportive scholarly environment in turn
may stimulate further scientic inquiry into the safety and
efcacy of these treatments. Given continued academic and
professional support, future nurse researchers of CA modal-
ities will make valuable contributions to clinical practice and
the continued health care of our community.
Limitations of study
Several limitations of the study must be considered when
interpreting its ndings. First, inherent in survey methodo-
logy, respondent perceptions may differ from what actually
happens or exists. In this study, NP perceptions about their
use of CA modalities cannot be veried with their actual
Issues and innovations in nursing education Complementary alternative health care
2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(1), 916 15
practice behaviour. Secondly, the characteristics of those NPs
who did not respond to the questionnaire are unknown,
thereby limiting the generalizability of ndings to all NPs in
the States of Missouri and Oregon. Lastly, formal NP
education in this study included both graduate level instruc-
tion and earlier certication programs. Although the ndings
cannot specically target curriculum needs in current gradu-
ate level programmes, it does illustrate the need to evaluate
the availability of formal CA content and to facilitate
community-based education for practicing NPs.
Conclusion
NPs are embracing the profession of nursings holistic
philosophy of patient care and are incorporating this philos-
ophy into their practice through the use of CA treatments.
This study demonstrated their need for more formal infor-
mation about CA treatments, particularly information groun-
ded in scientic inquiry. Nursings response to societys
changing health care demands is not limited solely to NPs,
but is also directed to nursing educators as well (ANA 1996).
A closer partnership between nursing education and the
practice community can help guarantee that formal NP
curriculum adequately prepares NPs to meet the changing
health care demands in this country.
Acknowledgements
We would like to extend our appreciation to Dr Elizabeth
Buck, Dr Sharon Pontious and Dorothy Helen Aiken Cook
for their contributions to this article.
References
American Nurses Association (1995) The Scope of Practice of the
Primary Health Care Nurse Practitioner. Author, Washington, DC.
American Nurses Association (1996) Nursings Social Policy State-
ment. Author, Washington, DC.
American Nurses Association (1997) Scope and Standards of
Advanced Practice Registered Nursing. Author, Washington, DC.
Astin J.A. (1998) Why patients use alternative medicine: results of a
national study. Journal of American Medical Association 279,
15481553.
Borkan J., Neher J.O., Anson O. & Smoker B. (1994) Referrals for
alternative therapies. Journal of Family Practice 39, 545550.
Chichon P. (2000) Herbs and the common cold. Advance for Nurse
Practitioners 8, 3132.
DeKeyser F.G., Cohen B.B. & Wagner N. (2001) Knowledge levels
and attitudes of staff nurses in Israel toward complementary and
alternative medicine. Journal of Advanced Nursing 36, 4148.
Eisenberg D.M., Kessler R.C., Foster C., Norlock F.E., Calkins D.R.
& Delbanco T.L. (1993) Unconventional medicine in the United
States prevalence, cost, and patterns of use. New England Journal
of Medicine 328, 246252.
Hayes K.M. & Alexander I.M. (2000) Alternative therapies and
nurse practitioners: knowledge, professional experience, and per-
sonal use. Holistic Nursing Practice 14, 4958.
Herbert V. (1988) Unproven (questionable) dietary and nutritional
methods in cancer prevention and treatment. Cancer 58,
19301941.
Kayser J. (1996) Use and knowledge of alternative therapy by nurse
practitioners. Unpublished masters Thesis. Gonzaga University,
Spokane, WA.
King M.O., Pettigrew A.C. & Reed F.C. (1999) Complementary,
alternative, integrative: have nurses kept pace with their clients?
Medsurg Nursing 6, 249255.
Manzella S. (2000) Complementary healthcare for practices and the
implications for nurse practitioners. Clinical Excellence for Nurse
Practitioners 4, 205211.
National Center for Complementary and Alternative Medicine
(1998) General Information. Author, Bethesda, MD.
National Organization of Nurse Practitioner Faculties (1995)
Advanced Nursing Practice: Curriculum Guidelines and Program
Standards for Nurse Practitioner Education. National Organiza-
tion of Nurse Practitioner Faculties, Washington, DC.
ONeill A. (1994) Danger and safety in medicine. Social Science
Medicine 38, 497507.
ONeill E. & the Pew Health Professions Commission (1998)
Recreating Health Professional Practice for a New Century. Center
for the Health Professions, UCSF, San Francisco, CA.
Pearson L. (1998) Annual update of how each state stands on legis-
lative issues affecting advanced nursing practice. Nurse Practi-
tioner; the American Journal of Primary Care 21, 435.
Rauckhorst L. (1997a) Balancing therapeutic options: Integration of
complementary and mainstream medical therapies. Clinical
Excellence for Nurse Practitioners 1, 6368.
Rauckhorst L. (1997b) Integration of complementary therapies in the
nurse practitioner curriculum. Clinical Excellence for Nurse
Practitioners 1, 257265.
Reed F.C., Pettigrew A.C. & King M.O. (2000) Alternative and
complementary therapies in nursing curricula. Journal of Nursing
Education 39, 133139.
Sale D.M. (1996) Overview of Legislative Developments Concerning
Alternative Health Care in the U.S. John E. Fetzer Intstitute,
Kalamazoo, MI.
Sapp A. (1997) Complementary/alternative therapies and the nurse
practitioner. Unpublished masters Thesis. University of Missouri,
Columbia, MO.
Shirreffs J. (1996) Its time to consider the alternative even the
controversial ones. Journal of Health Education 27, 119121.
Stanley T. (1990) Ethical reflection on the Tuma case: Is it part of the
nurses role to advise on alternative forms of therapy or treatment?
In Ethics in Nursing: an Anthology (Pence T. & Cantrail J. eds).
National League for Nursing, New York, pp. 204211.
Verhoef M.J. & Sutherland L.R. (1995) Alternative medicine
and general practitioners. Canadian Family Physician 41, 1005
1011.
Yoon S.L. & Horne C.H. (2001) Herbal products and conventional
medicines used by community-residing older women. Journal of
Advanced Nursing 33, 5159.
P.M. Sohn and C.A. Loveland Cook
16 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(1), 916