Lesser-known, but no less important, are the perceptions of nurses toward CAM. There are approximately 2.6 million registered nurses in the United States, a figure that far exceeds the number of medical doctors.2 Nurses are also in regular contact with patients and the public more frequently than medical doctors, and often assist in making decisions about the type of care patients will receive. However, most surveys relating to nurses and CAM have used small samples of 100 subjects or less, and these surveys have usually been limited to a particular specialty such as oncology or midwifery.
A recent survey published in the Journal of Community Health3 has brought the opinions of nurses and CAM forward. In the survey, a random sample of 1,000 nurses received a four-page questionnaire consisting of 100 items that covered 22 different complementary and alternative therapies, including chiropractic. Nurses were asked to rate each therapy in four areas: perceived effectiveness; perceived safety; recommendations made to friends, clients and associates; and personal use.
An overwhelming number of nurses who returned the survey were female (91%), Caucasian (86%) and between the ages of 30-59 (92%). Sixty-four percent had reached either a bachelor's or master's level of education; 67% were either registered nurses or nurse practitioners.
Self-perceptions of education and training regarding CAM were rather poor overall, as only 21% of the respondents considered themselves to have received "good" or "excellent" professional preparation in dealing with complementary and alternative medicine. When asked where they received the majority of their information on CAM therapies, only 44% cited professional journals as the leading source; 38% cited professional conferences or conventions.
Perceptions of Effectiveness and Safety
Chiropractic ranked first (in a tie with biofeedback and meditation/relaxation therapies) in perceived effectiveness. In fact, chiropractic was one of only five therapies that more than half of the respondents believed to be effective. Fifty-one percent of the nurses felt there was a "preponderance of evidence" or "conclusive evidence" supporting the effectiveness of chiropractic care. Another 26% believed that there was "growing evidence" for chiropractic's effectiveness.
Chiropractic also ranked second behind hypnotherapy in terms of perceived safety; 58% of the nurses surveyed believed chiropractic to be "definitely" or "probably" safe. Only seven percent said that chiropractic was not safe. In comparison, many other well-known forms of CAM were considered less safe. For instance, 15% of the nurses said homeopathic remedies were unsafe; another 11% doubted the safety of magnet therapy. Similar concerns about safety were seen for macriobiotic diets (15%), chelation (14%), and herbal therapies such as ginseng, ginkgo and St. John's wort (14% each).
Personal Use and Recommended Use
Chiropractic ranked in the middle of the pack regarding personal and recommended use. Approximately one in seven nurses (14%) reported personally using chiropractic - less than aromatherapy, massage therapy, meditation/relaxation or multivitamins, but significantly higher than acupuncture, biofeedback, homeopathy or yoga. These figures are also in line with the well-known studies published by David Eisenberg et al., which showed that 10.1% and 11.0% of American adults had received chiropractic care in 1990 and 1997, respectively.4
Nearly one-quarter (23%) of the nurses said they "periodically" or "regularly" recommend chiropractic care to their friends, patients and associates; another 27% said they recommend it occasionally. Again, these figures rank chiropractic behind some popular forms of CAM, including massage, meditation/relaxation, pastoral/spiritual counseling and multivitamins, but far ahead of other types of CAM (such as acupuncture, aromatherapy, homeopathy, magnet therapy and yoga).
Familiarity Breeds Believability
The researchers noted that nurses who responded were more likely to believe in "more familiar and possibly more traditional alternative and complementary medical therapies." For example, the three therapies perceived to be the most effective - including chiropractic - also happen to be among the most well-known CAM therapies. The researchers speculated that these results could be due to a lack of formal training in CAM. Seventy-nine percent of the nurses surveyed said that their professional preparation in the area of complementary and alternative medicine was "fair" or "poor," and 52% identified the general mass media as their primary source of information on CAM. Thus, many nurses might not be aware of lesser-known (but possibly effective) therapies.
The researchers also discovered that when asked about the safety of certain forms of CAM, nurses were more likely to consider "external" therapies such as chiropractic as the safest. "Again, general logic rather than formal training may be at work with these perceptions," they noted, pointing to the fact that the nurses with greater education levels were "more likely" to perceive some of the herbal therapies as safer than nurses with less education.
Potential limitations were noted in the study's conclusions. The response rate to the survey, for instance, was 57%, which the investigators said "indicates a potential non-response bias." In addition, some of the responses could have been interpreted differently by different practitioners, and since the questionnaire was not open-ended and did not attempt to attain additional information from the respondents, there may have been some perceptions about CAM that were not addressed by the survey.
Limits aside, the Journal of Community Health study provides significant insight into the perceptions of nurses toward complementary and alternative medicine. It shows that despite limited professional training and education nurses receive about CAM, they believe in the safety and effectiveness of several of these therapies, and routinely recommend CAM treatments to friends, patients and clients.
The Safety of Complementary Care - What Nurses Think
One thousand nurses were asked about the safety of nonmedical therapies. Here's how they rated them for safety:
|Therapy||"Definitely" Safe||"Probably" Safe||Total|
SOURCE: Brolinson PG, Price JH, Ditmyer M, et al. Nurses' perceptions of complementary and alternative medical therapies. Journal of Community Health June 2001;26(3):175-89.
- Borkan J, Nehler J, Anson O, et al. Referrals for alternative therapies. J Fam Pract 1994;9:545-550.
- Who we are, what we do, where we come from. Available from American Nurses Association website (www.ana.org).
- Brolinson PG, Price JH, Ditmyer M, et al. Nurses' perceptions of complementary and alternative medical therapies. Journal of Community Health June 2001;26(3):175-89.
- Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990-1997. Results of a follow-up national survey. JAMA 1998;280(18):1569-1575.
Senior associate editor