Research Title: Attitudes of Medical, Nursing, and Pharmacy Faculty and Students Toward Complementary and Alternative Medicine (CAM) : A Comparative Analysis
Principal Investigator: Mary Jo Kreitzer, Ph.D., R.N., Director, Center for Spirituality and Healing, University of Minnesota; Denise Mitten, Ph.D., Research Associate, Center for Spirituality and Healing
Medical, nursing, and pharmacy schools need to respond to the growing demand to integrate complementary and alternative medicine (CAM) content into their curricula. Factors that may facilitate or impede attitudes toward CAM need to be identified. In a study conducted at the University of Minnesota Academic Health Center, data was obtained on faculty and student attitudes toward the integration of CAM into curricula and ultimately into clinical practice. The background, purpose, methods, results, and implications of this study are discussed in this paper
Historically, conventional health care providers have received limited or no formal education in CAM and have been perceived by patients as being biased against CAM. Thus, many consumers do not seek advice about use of CAM therapies from physicians, nurses, and pharmacists, nor do they discuss their use of CAM therapies with their primary care providers. Eisenberg1 found that 61% of the CAM therapies used by patients were not disclosed to a physician. This situation is problematic because opportunities are missed to integrate CAM therapies into the overall plan of care in instances when CAM therapies may be beneficial. Conversely, there may be situations in which patients are compromising conventional medical treatment through the unexamined addition of CAM therapies. For example, Matthees et al2 reported that 88% of lung transplant patients use CAM therapies. A recent report documented that the popular herb, St. John's Wort (hypericum perforatum), affects blood levels of the most common transplant drug, cyclosporin A3 Clearly, in situations such as this, effective communication between patients and their health care providers regarding the use of CAM is critical.
A number of studies have assessed physician attitudes and practice patterns related to CAM. In a regional survey conducted by Berman et al4, over 90% of respondents expressed the view that CAM approaches, such as diet and exercise, biofeedback and behavioral medicine, are legitimate medical practices. Over 70% of respondents indicated that they were interested in more training in areas including hypnotherapy, massage therapy, acupressure, herbal medicine, and prayer. A report of a subsequent national survey by Berman et al5 concluded that physicians in practice more than 22 years had the least positive attitudes toward CAM and that attitudes and training were the best predictors of use in their professional practice. In a survey of primary care and medical subspecialties practitioners, Crock et al6 found that, overall, physicians demonstrated an open attitude toward CAM, but had low referrals for CAM therapies. Crock and colleagues suggested that increased referrals might come with increased physician access to CAM information.6
Several studies have focused on attitudes of nurses toward CAM. McPartland and Pruit7 found that nurses in a middle class community in rural Vermont had a positive attitude toward the use of CAM and a more positive opinion of CAM than did physicians or other allied health professionals in the same community. In a Canadian study, all of the 48 oncology nurses interviewed emphasized that information regarding unconventional therapies must be readily available for patients and health care providers.8 A Danish study of 60 oncology and hematology nurses also showed positive attitudes toward CAM.9
Several studies have assessed student interest in CAM. In one report, 72% of medical students wanted to learn about alternative therapies while in medical school, but very few (6%) thought they would receive adequate exposure to this topic.10 Derr et al11 found that 86% of medical students at an American university had little to no personal or professional experience with CAM, though 98% said they think CAM has beneficial effects. Furnham et al12 found that medical students, as well as non-medical students, surveyed had positive attitudes toward CAM tempered with some skepticism. Baugniet et al3 conducted a survey of fourth-year health professions students at two Canadian universities. They concluded that educational exposure to CAM was correlated with perceived usefulness.13 Medical students, with the least amount of education about CAM, viewed CAM as less useful then other health professions students.
The only study reported on faculty attitudes toward CAM is a survey by Boucher and Lenz14 of physicians at a midwestern teaching hospital. This study, designed to assess institutional climate related to CAM, found that most of these physicians were open-minded, if not supportive, toward CAM.
The purposes of this study were to:
Conduct a comprehensive assessment of attitudes toward CAM, by examining attitudes among medical, nursing, and pharmacy faculty and students in an academic health center and,
Identify the perceptions of faculty and students regarding:
Barriers to use of CAM,
Training needs and the relationship between training and overall attitudes toward CAM,
Personal use of CAM and the relationship between use of CAM and attitudes toward CAM, and
Use or intention to use CAM in their clinical practice.
Sample Selection
The University of Minnesota Academic Health Center is comprised of several professional schools, including the Medical School, School of Nursing, and College of Pharmacy. Faculty directly engaged in the teaching mission of these three schools were invited to participate in the study. Each faculty member received a self-report survey, cover letter, and consent form. Students completing their fourth year of undergraduate medical education, the Baccalaureate nursing program, or the Pharmacy Doctorate program received the student version of the survey along with the cover letter and consent form. To encourage response, a follow up letter and survey were sent to faculty and students within two weeks of the initial distribution of the survey.
The overall response rate was 55% (145/263) for faculty and 63% (228/364) for students. With the exception of Pharmacy faculty (response rate 44%), response rates for all groups exceeded 50%.
Self-Report Survey
The survey was designed to assess overall attitudes toward CAM as well as attitudes and information about training, personal use, perceived barriers, and the intent to integrate CAM into clinical practice. Sociodemographic data, including gender, age, and ethnic/racial background, were also obtained.
Potential participants were advised that the three-page questionnaire would take approximately 20 minutes to complete. Approval to conduct the study was obtained from the Committee for Protection of Human Subjects of the Institutional Review Board of the institution in which the study was conducted.
Statistical Analysis
Descriptive statistics (frequencies, standard deviations, means, ranges, and proportions) were used to summarize the data. Differences in general attitudes, perceived barriers to the use of CAM, personal use, and intended use in teaching and clinical practice by CAM attitudes were analyzed with t-tests and ANOVA, as apropriate. Results were reported as statistically significant at alpha .05 or less. The SPSS 6.1 program was used for the analyses.
Perceived Barriers to Use of CAM in Western Medical Settings
Impact of Personal Use and Training on Attitudes Toward CAM
How CAM is/will be Used in Practice
General Attitudes about CAM Back to Top
Faculty in each of the schools expressed very positive attitudes toward CAM. As shown in Table 1, over 90% of the faculty in medicine, nursing, and pharmacy expressed the views that clinical care should integrate the best of conventional and CAM practices, that CAM includes ideas and methods from which conventional medicine could benefit, and that health professionals should be able to advise their patients about commonly used CAM methods. While the general attitude of the combined faculty group was very positive, nursing faculty consistently reported the most positive attitudes toward CAM. Nursing faculty attitudes were statistically different from medical faculty attitudes in all eleven general attitude categories and statistically different from pharmacy faculty in nine of these categories(Table 2).
Student attitudes toward CAM were strikingly similar to faculty attitudes and there were no statistically significant differences between total students and total faculty. More than 90% of both faculty and students agree that knowledge about CAM is important to them as faculty members or students or as future practicing health professionals. However, nursing faculty and pharmacy faculty were generally more positive about CAM than their students. This reached statistical significance in four categories for nursing: (1) CAM should be integrated into clinical care, (2) CAM is a threat to public health,
(3) CAM should be included in my school's curriculum, (4) CAM knowledge is important to me as a healthcare practitioner); and, three for pharmacy: (1) CAM not tested in a scientific manner should be discouraged, (2) CAM has no true impact on disease, (3) I hope to have some CAM available in my practice.
Among students, there was greater alignment in their general attitudes than among faculty. The largest differences among students in their attitudes toward CAM were found in five areas: (1) impact of placebo effect, (2) scientific testing of CAM, (3) clinical impact of CAM, (4) threat to public health, and (5) hopes to have some CAM practices available to patients in their practices or networks. Nursing students were generally more positive about CAM than medicine or pharmacy students. They were significantly different statistically from medical students in five categories and from pharmacy students in four categories (Table 3). Additionally, pharmacy students differed most from other Academic Health Center students in two categories (Table 3). A statistically significant higher percentage of pharmacy students expressed the views that CAM treatments have no true impact on treatment of symptoms, conditions, and/or treatments, and CAM is a threat to public health.
Perceived Barriers to Use of CAM in Western Medical Settings Back to Top
As shown in Table 4, students' beliefs generally mirrored faculty beliefs about barriers to use of CAM. Faculty and students expressed the view that lack of evidence is the most significant barrier. Unavailability of credentialed providers, lack of reimbursement, and lack of staff training were also seen as barriers by almost three-fourths of all of the respondents, students and faculty. The time required to provide CAM was the factor least frequently viewed as a barrier. Students, more than faculty, viewed institutional concern about legal issues and lack of appropriate equipment as barriers to use of CAM.
CAM Training Received Back to Top
Both faculty and students reported having received very little training in all areas of CAM. There was no modality for which even half of the total faculty believed that they have enough training to advise patients regarding use, let alone to personally provide the modality. Both faculty and students reported having the greatest amount of training related to nutritional supplements.
Faculty in the three schools differed in the CAM modalities in which they reported having received sufficient training to advise patients. There were five CAM areas in which more than 35% of the nursing faculty felt prepared to advise patients: hypnosis/guided imagery, massage, music, prayer/spiritual healing, and meditation. More than 25% of the medical school faculty reported having sufficient training to advise patients in: chiropractic, hypnosis/guided imagery, and nutritional supplements. Pharmacy faculty reported the least training in CAM modalities, except for herbal medicine and nutritional supplements; 55% reported having sufficient knowledge to advise patients in the former modality and 46% in the latter.
Students in all disciplines reported having very limited training in CAM. Nursing students reported the most training overall; yet, there were four CAM modalities in which none of the nursing students felt competent to advise patients. These modalities were bioelectromagnetic, biofeedback, homeopathy, and Rolfing.
Desire for Future Training Back to Top
Faculty and students reported that they would like more training in CAM modalities. There were significant differences among the groups in the modalities for which further training was desired. Herbal medicine and nutritional supplements were the only CAM modalities for which almost 50% of both the students and faculty wanted more training.
As a whole, the faculty surveyed in this study did not aspire to gain skills in CAM in order to personally provide therapy to patients. However, there was faculty interest in acquiring sufficient skill to advise patients regarding use of CAM modalities. Again, the three groups of faculty differed in their interests. Nursing faculty indicated the highest overall interest in acquiring training in CAM modalities. In each of nine modalities, more than 50% of the nursing faculty wanted sufficient skill to advise patients regarding use of the therapy. The nine modalities are aromatherapy, chiropractic, herbal medicine, hypnosis/guided imagery, massage, music, nutritional supplements, prayer/spiritual healing, and meditation. ) There was no modality for which more than 50% of the medical faculty wanted sufficient skill to advise patients regarding use of the therapy.
A very high percentage of pharmacy faculty expressed interest in receiving training in the areas of herbal medicine (75%) and nutritional supplements (71%). There was no other modality for which more than 50% of the pharmacy faculty wanted sufficient skill to advise patients regarding use of a CAM therapy.
There was considerable variation among groups in their preferences regarding additional training. Pharmacy students expressed the lowest interest in additional training of all groups surveyed. The most striking differences, however, were between faculty and students in medicine and pharmacy. In every category, medical students' interest in additional training exceeded faculty interest. This reached a level of significance (Independent-Sample t-test, P<.05) for eight modalities: acupuncture, biofeedback, chiropractic, herbal medicine, homeopathy, massage, nutrition, and therapeutic touch. The opposite was true in the area of pharmacy; the students' desire for training was less than that of the faculty, though the difference did not reach the level of statistical significance for any modality.
Personal Use of CAM Back to Top
The three therapies that faculty from all schools were most likely to use or consider using were biofeedback, massage, and meditation. The three therapies that all faculty were least likely to consider using were bioelectromagnetic therapies, homeopathy and Rolfing. Additionally, approximately 70% of medical school faculty would not consider using aromatherapy or therapeutic/healing touch.
Nursing faculty indicated significantly more personal use of CAM than their medical or pharmacy colleagues (One-Way ANOVA, P<.05). If they had not used particular therapies, a high percent would consider using them. For example, over 86% of the nursing faculty would consider using or had used aromatherapy and 94% would consider using or had used prayer/spiritual healing. Pharmacy faculty indicated higher use of many CAM modalities than medical school faculty. Modalities that over 70% of pharmacy faculty indicated they would consider using or had used are: acupuncture, biofeedback, chiropractic, herbal medicine, meditation, music, nutritional supplements, and prayer/spiritual healing. Therapies that over 70% of the Medical faculty indicated they would consider using or had used are biofeedback, massage, meditation, and nutritional supplements.
Students had more similar patterns of CAM use than faculty, although overall, nursing students were more likely than the other students to use or consider using CAM therapies. Massage, nutritional supplements, and prayer/spiritual healing are the three therapies most students would consider using. Bioelectromagnetic, homeopathy, and Rolfing are the therapies most would not consider using.
In general, medical students were more likely to consider using a particular therapy than were medical faculty. However, nursing and pharmacy faculty were more likely to consider using CAM than were their students. For both faculty and students, there were very few reports of negative outcomes with personal use. These reports of negative outcomes/experiences were for chiropractic, homeopathy, and Rolfing.
Impact of Personal Use and Training on Attitudes Toward CAM Back to Top
Data revealed that, for both students and faculty, training was related to positive attitudes toward CAM. For example, students and faculty in all disciplines who had received training in meditation were more likely to believe that CAM practices should be integrated into their school's curriculum (Independent t-test, P<.05). This relationship between training in various modalities and positive attitudes toward CAM held for all modalities except bioelectromagnetic therapies and nutritional supplements (P>.05). A relationship was also found between personal use of CAM and attitudes towards CAM. If a person had used, for example, clinical hypnosis or meditation, they were more likely to believe that clinical care should integrate the best of conventional and CAM practices, that health professionals should advise patients about commonly used CAM methods, and that CAM practices should be included in curricula.
How CAM is/will be Used in Practice Back to Top
While a relatively low percent of the faculty indicated that they would personally provide CAM in their practice (range of positive response from 0 - 43%), there were many modalities for which faculty indicated that they would refer patients to a CAM practitioner. Over half of the medical and nursing faculty either would personally provide or refer to a CAM practitioner for acupuncture, biofeedback, chiropractic, hypnosis/guided imagery, massage, and meditation. In addition, over half of the nursing faculty would either personally provide or refer to a CAM practitioner for aromatherapy, herbal medicine, homeopathy, music, nutritional supplements, prayer/spiritual healing, and therapeutic touch. Pharmacy faculty were less likely to provide CAM therapies or refer to a CAM practitioner, although over 50% would do so for herbal medicine and nutritional supplements and more than 40% for acupuncture, chiropractic, massage or prayer/spiritual healing.
Students were similar to their faculty counterparts in their intentions regarding use of CAM in their practices. Except for bioelectromagnetic therapies and Rolfing, nursing students were very likely to indicate they would either personally provide the CAM therapy or refer to a CAM practitioner for all of the therapies listed. They surpassed nursing faculty for either personally providing or referring to a CAM practitioner for massage and music. Pharmacy students were the least likely among students to provide or refer to a CAM practitioner and, for most therapies, even less likely than pharmacy faculty. Medical students were slightly less likely then their faculty to provide or refer to CAM practitioners.
In this study, as in previous studies by Berman et al4; Bermnan et al5; Crock et al6, Boucher & Lenz14 open attitudes by physicians toward CAM were found. Additionally, as in McPartland & Pruit,7 the results from this study showed that nurses have even more positive attitudes towards the use of CAM than do physicians. The results of this study support the results reported by Geiner et al10 and Derr et al11 that medical students have an interest in learning about CAM and that education about CAM was associated with more positive attitudes.
Faculty in this study appear both to recognize the contribution that CAM may offer to the conventional health care system and to be open to having CAM content taught within the curricula. As a group, they are not highly trained or experienced in the personal use of CAM modalities, although a high percent indicate willingness to use CAM approaches. From a faculty development perspective, opportunities need to be created for faculty to be exposed to CAM practitioners, learn about various practices and traditions and to gain a perspective on how best to work with CAM practitioners. Attitude data clearly revealed that faculty are less interested in practicing CAM than in having CAM available in their care network and working with CAM practitioners within a system of referral. Of note, while no nursing or medical school faculty members would provide homeopathy, 26% of the medical faculty and 57% of the nursing faculty would refer to a homeopathic practitioner. However, only 7% of the pharmacy faculty indicated that they would refer to a homeopathic practitioner.
While there were similarities among the three faculty groups studied, it was also clear that the faculties within nursing, medicine and pharmacy had different learning interests and needs regarding CAM. Nursing faculty indicated the greatest interest in practicing some CAM modalities and expressed interest in the broadest scope of CAM modalities. There were some modalities, such as therapeutic touch and clinical aromatherapy, for which nursing faculty interest far exceeded the interest of medical and pharmacy colleagues. The areas of greatest mutual interest were herbal medicine, nutritional supplements, biofeedback, and guided imagery. The varying degrees of interest will have an impact on the extent to which interdisciplinary faculty development is feasible and practical. Understanding the learning needs of faculty, their intent as to how the CAM knowledge will be used, and the importance of experiential learning, can provide important direction for faculty development activities.
These findings also suggest that there is a need for curricula that faculty can access and use in their teaching. Faculty believe that teaching about CAM practices is important, but they have limited knowledge and experience that would enable them to do so. A strategy that may help bridge this gap will be to partner with CAM practitioners in developing both didactic and experiential curricula. For this strategy to be effective, CAM practitioners will need to be aware of and incorporate an evidence-based approach to their teaching.
Students' attitudes mirrored faculty attitudes in each of the disciplines. This speaks to the powerful impact of socialization that occurs during health professional training. Faculty and students across disciplines strongly supported integration of CAM practices into clinical care, inclusion of CAM in their school's curricula, and preparing health professionals to advise patients about commonly used CAM methods. It was interesting that the greater differences between faculty and students occurred in nursing and pharmacy. Pharmacy students were far more likely then their faculty to believe that the results of CAM are due to placebo effects and only 80% of pharmacy students believe that CAM approaches hold promise for treatment of symptoms and/or diseases, compared with 94% of their faculty. Additionally, while nursing and pharmacy faculty were generally more positive about CAM than their students, medical faculty were generally less positive about CAM then their students.
Not surprisingly, both faculty and students indicated that the most significant barrier to use of CAM in western settings is the lack of evidence for practice. This finding suggests that using an evidence-based approach in the teaching of CAM within academic settings will be critical.
While the findings from this study suggest that there is significant receptivity to integrating CAM within curricula of Academic Health Centers, additional research is needed to understand whether these attitudes and beliefs can be generalized to other settings, and whether there are regional differences that may reflect unique cultural and political forces. Given the high degree of interest in integrating CAM into health science curricula and practice, it is important to conduct future research to determine what teaching strategies will be most effective. Should CAM, for example, be integrated into the existing curricula, be taught in separate required courses, or be included in elective curricula? What impact could CAM have if it were to become the foundation for all health professional training? Given the relationship demonstrated in the survey between personal use of CAM and the expression of a favorable attitude toward CAM, how might experiential learning be woven into the education of all health professional students?
Medicine, nursing, and pharmacy faculty and students in this study have very favorable attitudes toward the integration of CAM into education and clinical care. Their personal training and use of CAM is limited, and they report that the most significant barrier to use of CAM is the lack of scientific support of CAM. Faculty and students indicated a high degree of interest in acquiring more training in CAM modalities. Rather than personally practicing CAM, the greatest interest was in acquiring knowledge and skill to advise and refer patients to CAM practitioners. While there were many commonalities among the training needs of faculty and students, there were also differences that suggest that both interdisciplinary and discipline-specific education will be required. The findings from this study raise many interesting implications for the future of health care. If the next generation of health care providers truly value a system that integrates the best of conventional and complementary medicine, then it is conceivable that health care teams of the future will be inclusive of communities of healers?