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