Abstract
Purpose
Identify nurse factors (e.g., knowledge, practices, clinical habits regarding CAM as well as demographic factors) and patient characteristics (e.g., age, sex, treatment status) associated with nurses' CAM inquiry and referral patterns.
Methods
Baseline data was collected by nurse/patient questionnaires about CAM use and knowledge as part of a multicenter CAM educational clinical trial. Frequencies and nested regression models were used to assess predictors of nurse inquiry about and referral to CAM therapies.
Results
699 patients participated in the study. Patient characteristics of female gender (OR: 1.50, p=0.019) and those with cancer recurrence (OR: 1.45, p=0.05) were predictive of nurse inquiry and referral to CAM therapies. A total of 175 nurses, mean age 45 and median 19 years of experience participated; 82% were staff nurses and 12% were nurse practitioners. 53% asked at least one of their last 5 patients about CAM use; 42% referred patients to CAM therapy. Nurses who reported being “somewhat comfortable” (OR: 2.70, p=0.0001) or “very comfortable” (OR: 3.88, p<0.0001) discussing CAM, self-reported use of massage (OR: 2.20, p<0.0001), and had formal CAM education (OR: 4.14, p=0.0001) were more likely to ask about CAM use. Nurses who reported being “somewhat comfortable” (OR: 2.54, 95%CI: 1.47-4.41, p=0.0008) or “very comfortable” (OR:7.46, p<0.00001) and had formal CAM education (OR: 2.96, p<0.0001) were also more likely to refer patients to CAM therapies.
Conclusions
Both patient and nurse characteristics were associated with discussions about CAM. Oncology institutions that prioritize evidence-based medicine should consider introducing CAM education to their nursing staff.
Introduction
Complementary and Alternative Medicine (CAM) is “a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.” 1 CAM use in Unites States has become increasingly popular, 2-8 with Americans spending over 33 billion out-of-pocket dollars on CAM in 2007 alone. 9 Because CAM has not historically been included in the Western healthcare professional education or standard of care model, CAM is not routinely discussed, 2, 10-12 and many patients use CAM without their healthcare provider knowing.13 Nondisclosure of CAM use may be as high as 77%.11 Thus, communication involving CAM between patients and their providers is an important topic as it may affect patients' clinical and psychosocial outcomes.
Past survey research on CAM has focused on frequency of use and discussion between patients and their physicians about CAM use. Winslow and Shapiro 15 surveyed physicians in a broad range of specialties about factors that influence their discussions about CAM and CAM referral patterns. They found that most physicians do not discuss CAM with patients (8% ask “all the time,” 52% ask “less than ½ the time”) and that fewer than 50% of doctors were “very” or “somewhat” comfortable discussing CAM. They also found that the amount of self-reported CAM education predicted whether a physician thought certain CAM methods were effective, and physicians who had personally used CAM were more likely to recommend it to patients. These results and others 2, 10, 11, 13, 15-17 point to the need for better doctor-patient communication on CAM.
Nurses also engage in CAM discussions 26, 27 since they are the ones who typically take patient histories and information on medication use. Sohn and Cook15 evaluated the level of knowledge about CAM in nurse practitioners working in a variety of healthcare settings and found that 83% had recommended CAM to patients, yet only 24% had received education on CAM and 60% said they relied on “personal experience” for knowledge about CAM. Hayes and Ivy28 reported similar findings in nurse practitioners, with 65% percent recommending CAM despite low self-reported knowledge about CAM. Additionally, 70% said they “rarely” or “sometimes” asked patients about CAM use. As with physicians, nurses relied on personal experience rather than evidence to guide their recommendations and referrals.
Few studies have focused on CAM use and practices among oncology nurses. Up to 88% of cancer patients use CAM therapies, with increased use among those with advanced disease.29 With such a high prevalence, effective communication regarding CAM use is critical to avoid potential harmful interactions between CAM therapies and conventional cancer therapies (i.e., herb-drug interactions).30,31 We previously examined the effects of a CAM educational intervention and found that at baseline 40% of cancer patients reported using CAM after their diagnosis, but nurses believed that fewer than 25% of their patients were using CAM. 32 The brief educational intervention resulted in the nurses being more likely to ask about CAM use than those in the control group. Rojas-Cooley and Grant33 reported on 850 oncology staff nurses' knowledge and attitudes on CAM and found that: (1) attitudes toward CAM varied according to personal beliefs about CAM; (2) practice-related scores for comfort in discussing CAM with patients were low; and (3) ability to find reliable information about CAM was low.
Despite the fact that nurses working in oncology settings play an important role in patient assessment, treatment, and overall care,34 few studies exist on the involvement of CAM in cancer patient consultations with oncology nurses, particularly those in the staff nurse role. The current multisite study examined both oncology nurse practitioners and oncology staff nurses to determine how personal opinions, past CAM use, knowledge and attitudes about CAM, and demographic characteristics, influenced their asking and referral behaviors about CAM. We also examined the influence of patient characteristics such as cancer type, age, sex, and chemotherapy status on nurses' asking and referring patterns.
Methods
Study Subjects
The data used in this study was collected as part of a previously described educational randomized clinical trial from 24 community-based oncology clinics around the US that were part of the MD Anderson Community Clinical Oncology Program (CCOP) Research Base.32 The CCOP study base provides a geographically representative sample of United States oncology patients and nurses. Data collection took place between June, 2008, and September, 2011.This study was approved and monitored by Institutional Review Boards at the University of Texas MD Anderson Cancer Center and the additional study sites involved. We report on the data collected before randomization of the educational intervention.
Study Design
CCOP research coordinators provided a brief description of the study at each of the community sites. Interested nurses were asked to fill out one baseline questionnaire asking about their behaviors, knowledge, and practices regarding CAM. All oncology nurses who regularly saw patients were eligible for the study.
Study coordinators obtained schedules of the enrolled nurses and randomly selected patients for recruitment. Nurses were blinded to patient participation in the study. If a patient refused participation, the site coordinator continued asking patients randomly until four patients for each participating nurse volunteered to participate; patients were asked to complete a short questionnaire immediately following their visit with the specified nurse. Patients were eligible for inclusion in the study if they were 18 years of age or older, spoke English, and had received a cancer diagnosis more than one week prior to enrollment and finished treatment less than six months prior to recruitment. In order to avoid counting the same patient multiple times, if they reported previously consulting with a participating nurse during the study period, they were ineligible.
All baseline data for patients and nurses was collected through self-report questionnaires. An expert panel of medical and integrative professionals using previous questionnaires and knowledge of current literature developed the questionnaires. Both assessments contained an identical section that defined CAM by the 2012 NCCAM guidelines and outlined the major CAM categories. The content of each survey was very similar, and most of the questions required dichotomous or categorical responses. Questions on specific CAM modalities contained a comprehensive list of mind-body, energy-based, body-manipulative, and biologically-based practices or supplements.
Oncology nurses' questionnaires asked for demographic information, their institutional role, and number of years nursing. The nurses were asked to estimate the percentage of their patients using CAM, how frequently they discussed CAM with their patients (and if they did, who had initiated the discussion), and how many of their last 5 patients they had asked about CAM. Also, nurses were asked whether they had referred their patients to CAM practitioners. Questions about personal experience, knowledge and education concerning CAM, and inclusion of CAM in their practice recommendations were also included. Although the original study used pre- and post-intervention data for analysis, the current study focused only on baseline nurse data and patient demographic and medical characteristics prior to nurse randomization.
Data Analysis
All data analysis was performed in SAS version 9.2. To assess whether nurse and patient characteristics were associated with nurses' asking and referring patterns, we employed nested, multi-category generalized linear models.34 This was necessary because of the hierarchical nature of the study design (Figure 1). Also, this accounts for the fact that the responses from nurses at the same site or at nearby sites may be more similar to each other because they are in the same geographic region.
Figure 1. Nesting Structure of Mixed Models.
The primary outcomes tested were nurses' self-reported assessment of how many of their last 5 patients they asked about CAM use or discussed CAM with, and whether or not they had referred patients to CAM practitioners during their previous patient consultations. After examining the data on how many patients were asked about CAM use, we dichotomized the response to “did not ask” (those who reported asking zero patients) and “asked” (those who reported 1-5 patients) CAM referral was determined from a dichotomous “yes/no” response. Details on covariates assessed, and their coding schemes can be found in Appendix A. From a full model containing all predictors, backwards selection was used to determine the most parsimonious model based off of the lowest Akaine Information Criteria, likelihood ratio tests and clinical relevance. Interactions among variables included in the best-fitting model with main effects only were also tested by the same methods. All predictors were modeled as fixed effects, along with random intercept terms. Additionally, linear trend was assessed in the categorical variables by comparing the model including the null model with the categorical term to a model with the same term coded as a continuous variable using the likelihood ratio test. Non-significant p-values indicated evidence for linear trend.
Results
Overall, 175 nurses participated from the 20 CCOP component sites. Ninety-seven percent were female and 96% were non-Hispanic white, with a mean age of 45 (SD=8.9). Most of the nurses involved described themselves as staff nurses (82%); those remaining identified themselves as nurse practitioners (see Table 1). The total number of patients, matched to each nurse at a ratio of approximately 4:1, was 699. After dropping missing observations, the nurse and patient cohorts were reduced to 167 and 634, respectively.
Table 1. a. Patient Characteristics (N=699).
| N (%) | |
|---|---|
| What is your gender? | |
| Male | 230 (33) |
| Female | 461 (66) |
| Missing | 8 (1) |
| What is your education level?* | |
| Less than high school | 44 (6) |
| High school graduate | 429 (61) |
| College graduate | 134 (19) |
| Graduate Degree | 80 (11) |
| Missing | 12 (2) |
| What is your race? | |
| Black (non-hispanic) | 54 (8) |
| White (non-hispanic) | 605 (87) |
| Asian, Hispanic, Native American or other | 31 (4) |
| Missing | 9 (1) |
| Have you had chemotherapy? | |
| No | 162 (23) |
| Yes | 537 (77) |
| Missing | 0 (0) |
| Have you had radiation therapy? | |
| No | 532 (76) |
| Yes | 167 (24) |
| Missing | 0 (0) |
| Have you had a cancer recurrence? | |
| No | 484 (69) |
| Yes | 169 (24) |
| Missing | 6 (1) |
| What is your age? | 59 |
| Missing | 14 (2) |
|
| |
| *this variable was dichotomized using college degree as cut off in analysis | |
| Table 1b. Nurse Characteristics (N=175) | |
|---|---|
|
| |
| N (%) | |
| How many patients were asked about CAM* | |
| 0 | 81 (46) |
| 1 | 31 (18) |
| 2 | 27 (15) |
| 3 | 22 (13) |
| 4 | 3 (2) |
| 5 | 10 (6) |
| Missing | 1 (1) |
| Have you referred a patient for CAM therapy? | |
| No | 101 (58) |
| Yes | 73 (42) |
| Missing | 1 (1) |
| What is your current role at your center or institution? | |
| Staff Nurse | 17 (10) |
| Advanced Practice Nurse | 139 (79) |
| Nurse Practitioner | 3 (2) |
| Other | 10 (6) |
| Missing | 6 (3) |
| How comfortable do you feel discussing CAM with patients? | |
| Very Uncomfortable | 42 (24) |
| Somewhat Uncomfortable | 53 (30) |
| Neutral | 45 (26) |
| Somewhat Comfortable | 30 (17) |
| Very Comfortable | 5 (3) |
| Missing | 0 (0) |
| What is your level/source of knowledge on CAM?** | |
| Completely unfamiliar | 0 (0.0) |
| Familiar but no education or training | 117 (67) |
| Attended conferences where CAM was discussed | 13 (7) |
| Taken CME/CEU courses | 6 (3) |
| I have a CAM degree or certification | 3 (2) |
| Missing | 1 (1) |
| Have you ever personally used massage therapy? | |
| No | 57 (33) |
| Yes | 118 (67) |
| Missing | 0 (0) |
| How many years have you practiced nursing? (Range = 1-41 years) | 20 |
| Missing | 8 (5) |
| What is your age? (Range = 23-66 years) | 45 |
| Missing | 3 (2) |
this variable was dichotomized as “no” (0) or “yes” (1-5) in final analysis
this variable was dichotomized as “no” or informal education (completely unfamiliar,familiar but no education, conferences) or “yes” (courses, degree or certification) in final analysis
In response to the question, “How many of the last 5 patients did you ask about Complementary and Alternative Medicine use?” almost half (46.5%) reported they had not asked. If they had asked, 1 (17.8%) was the most common response, followed by 2 (15.5%) and 3 (12.6%). Only 5.8% reported asking each of their last 5 patients about CAM use. For the question, “Have you ever referred a patient to a CAM practitioner?” most reported they had not (58%). Most nurses reported they were comfortable discussing CAM with patients (24.0% “very comfortable” and 30.2% “somewhat comfortable”), followed by “neutral” (25.7%) and “somewhat uncomfortable” (17.1%); less than 3% reported being “very uncomfortable.” Most nurses were familiar with CAM (67.2%) but had not taken any coursework or formal training; some had attended conferences where CAM was discussed (7.8%) and a few had taken a course (3.5%) or had a degree or certification in CAM (1.7%). Almost all reported having used at least one form of Complementary or Alternative Medicine personally (93.1%); the most common CAM modality used by this population was massage therapy (67.4%).
Patient Characteristics Associated with CAM Asking and Referral Patterns
The final model used to assess patient predictors associated with nurse asking patterns included patient sex, education, past chemotherapy and radiation use, and whether or not they had a recurrence. Patient sex as female was significantly associated with increased nurse asking (OR: 1.50, 95% CI: 1.07, 2.09, p=0.019) compared to males and positive recurrence status was also significantly associated with nurse asking (OR: 1.45, 95% CI: 1.01, 2.10, p=0.05) compared to those without a recurrence.
The final model used to assess patient predictors associated with nurse referral patterns included the same variables previously listed for asking. Patient sex as female was significantly associated with increased nurse referrals (OR: 1.50, 95% CI: 1.06, 2.12, p=0.02) compared to males and positive recurrence status was also significantly associated with nurse referral (OR: 1.48, 95% CI: 1.01, 2.17, p=0.02).
Nurse Characteristics Associated with CAM Asking and Referral Patterns
The final model for examining nurses' personal characteristics associated with asking patterns contained the variables for whether or not that nurse had personally used massage in the past, comfort level in discussing CAM with patients, and whether or not they had formal CAM training (Table 4). Nurse comfort was significantly associated with asking in a dose-response fashion (p>0.05) indicating evidence of a linear relationship and possible threshold effects. Nurses who reported being “somewhat comfortable” (OR: 2.70, 95% CI: 1.63-4.48, p=0.0001) or “very comfortable” (OR: 3.88, 95% CI: 2.74-6.71, p<0.0001) discussing CAM with patients were more likely to ask compared to those who reported being uncomfortable discussing CAM with patients. Past use of massage therapy was also associated with an increase in odds for asking (OR: 2.20, 95%CI: 1.52-3.16, p<0.0001) compared to those who had not used massage previously. Those who reported having formal CAM education (coursework, degree or certification) also had increased odds of asking (OR: 4.14, 95%CI: 2.77-6.21, p=0.0001) compared to nurses without such education.
Table 4. Nurse Predictors of Nurse Asking.
| Variable | OR | 95% CI LL | 95% CI UL | p value | Chi Squared P value* |
|---|---|---|---|---|---|
| Personal Use of Massage Therapy | |||||
| No | 1.00 (REF) | ||||
| Yes | 2.20 | 1.52318 | 3.164516 | <0.0001 | NA |
| Comfort discussing CAM with patients | |||||
| Uncomfortable | 1.00 (REF) | ||||
| Neutral | 1.57 | 0.94 | 2.61 | 0.081 | |
| Somewhat Comfortable | 2.70 | 1.63 | 4.48 | 0.0001 | |
| Very Comfortable | 3.88 | 2.24 | 6.71 | <0.0001 | 0.98 |
| Knowledge of CAM | |||||
| No or informal Education | 1.00 (REF) | ||||
| Formal Education | 4.14 | 2.77 | 6.21 | 0.0001 | NA |
p value >0.05 indicates evidence of linear trend in comparing two GLIMMIX models
The final model for nurse personal characteristics associated with nurse referral patterns contained only the multi-category comfort and dichotomous knowledge variables (Table 5). Similar to the asking outcome, nurses who reported being “somewhat” or “very” comfortable had increased odds for referring patients for CAM therapy (OR: 2.54, 95% CI: 1.47-4.41, p=0.0008, 7.46, 95% CI: 4.20-13.26, p<0.0001 respectively) compared to those who were uncomfortable. A linear trend was present in levels of increasing nurse comfort and odds of nurse referral (p>0.05). Parallel to the asking result, nurses with formal CAM education (coursework, degree or certification) were at increased odds of referring (OR:2.96, 95%CI: 2.05-4.26, p<0.0001) compared to nurses without such education.
Table 5. Nurse Predictors of Nurse Referral.
| Variable | OR | 95% CI LL | 95% CI UL | p value | Chi Squared P value* |
|---|---|---|---|---|---|
| Comfort discussing CAM with patients* | |||||
| Uncomfortable | 1.00 (REF) | ||||
| Neutral | 1.68 | 0.95 | 2.97 | 0.0725 | |
| Somewhat Comfortable | 2.54 | 1.47 | 4.41 | 0.0008 | |
| Very Comfortable | 7.46 | 4.20 | 13.26 | <0.0001 | 0.25 |
| Knowledge of CAM | |||||
| No or informal Education | 1.00 (REF) | ||||
| Formal Education | 2.96 | 2.05 | 4.26 | <0.0001 | NA |
p value >0.05 indicates evidence of linear trend in comparing two GLIMMIX models
Discussion
To our knowledge, this study is the first to examine patient and nurse characteristics associated with oncology nurses communication with their patients about CAM, using a community based nation-wide sample. Although some have examined characteristics of physicians and non-specialized nurses in this context, this is the first study to examine predictors of CAM communication exclusively in oncology nurses. Because the study was multi-site and included a large number of nurses and their patients from regions throughout the United States, it provides important information about communication between oncology nurses and their patients about CAM.
Our study reveals a deficit in nurse-patient communication with the majority of oncology nurses (64%) asking zero or one of their last 5 patients about CAM, in a patient population with known high CAM use. Fewer than 5% of nurses had formal CAM training, yet the majority reported being at least somewhat comfortable discussing CAM with patients (97%) and a high proportion were making referrals to CAM (42%). Our observations suggest ongoing deficits in patient-provider communication regarding CAM, consistent with reports in the literature dating back more than 10 years.14,15
Patient characteristics were found to influence CAM communication behaviors in this population of oncology nurses. Nurses were more likely to inquire about CAM use of female patients who had undergone chemotherapy and refer females and those with recurrence of disease to CAM therapies. Past research has found that females use CAM modalities at a higher rate than males,32 which is consistent with the current findings. Referring more patients with disease recurrence may be indicative of advanced disease and failure of previous therapeutic options, although stage of disease was not assessed in these analyses.
Although several nurse characteristics were examined, the current study found that formal CAM education, although low, was the only variable associated with nurses' asking about CAM. CAM education and nurse comfort level for discussing CAM were both associated with CAM referral patterns. The results are consistent with previous literature. For example, Sohn and Cook14 found that 83% of nurse practitioners surveyed had recommended CAM to patients, yet only 24% said they had received education on CAM. Also, they found 60% of the nurse practitioners said they relied on “personal experience” for knowledge about CAM. Hayes and Ivy29 reported 65% of nurses said they had recommended CAM despite low self-reported knowledge about CAM, with 74.8% identifying themselves as “slightly” or “not at all” knowledgeable about CAM overall.
The collective results suggest that both patient and nurse characteristics influence nurse CAM inquiry and referral patterns. Nurses who had taken courses or been certified in CAM were more likely to ask patients about CAM or refer them to CAM compared with nurses who had more casually studied or had some familiarity with CAM. As part of an effort to improve patient care and safety, it would seem wise to explore opportunities for more formal CAM education for oncology nurses. In addition to improving safety, if nursing staff is more well informed about CAM this will lead to more evidence-based referrals to CAM services increasing the chances that they will use interventions and programs to improve their quality of life and possibly clinical outcomes. These findings can be used to inform standardized protocols for communicating with patients about CAM at oncology institutions, ultimately helping to improve patient care and treatment outcomes.
This study was not without limitations. As with any self-reported questionnaire data, the participant responses are subject to recall bias. As mentioned in the study design, the nurses were asked to answer the questions used for analysis based on their last five patients as a surrogate for their usual clinical behaviors. However, if their last five patients were special cases, this may not reflect their typical behavior. Also, this convenience sample of nurses was largely white and female, so studies including greater racial and ethnic diversity, as well as male nurses, might have different findings.
Conclusion
This study tested factors that might affect communication between oncology nurses and their patients about CAM. Important findings included the fact that these nurses generally lacked training or education about CAM and infrequently asked patients about CAM, yet were largely comfortable discussing CAM with patients and referred patients to CAM therapy close to half the time. Patient characteristics such as recurrence, use of chemotherapy, and gender, specifically female, were predictive of nurses' CAM inquiry and referral behaviors. In addition, nurse characteristics such as those who had used massage, had more knowledge of CAM, and were more comfortable discussing CAM with patients, were associated with asking patients about CAM use. Nurses who had more formal education on CAM and were most comfortable discussing CAM were those most likely to refer patients to CAM therapies. We reported a linear relationship between nurse comfort and their odds of both asking and referring patients to CAM practitioners, indicating that any increase in comfort, even in small increments, can have a measurable impact on practice behavior. It is important to distinguish between simply being comfortable making more referrals versus making more informed, evidence-based referrals. Formal education on CAM supports nurses making informed referrals and is critical to support evidence-based models of care.
Our findings suggest lack of standardization when discussing CAM, with patient factors and nurse characteristics influencing whether a discussion of CAM takes place in the consultation. With increasing use and availability of CAM therapies across the cancer care continuum and the potential for their positive and negative impact on patient outcomes, it is important to move forward with initiatives that promote the safe, evidence-based use of CAM approaches. Formal CAM education for nurses may help not only increase the overall number of CAM referrals, but, more importantly, may help increase the number of informed referrals. Oncology institutions that prioritize evidence-based medicine and efforts to improve quality of care should consider including CAM education as part of nursing staff training to help promote consistency of communication and practice.
Table 2. Patient Predictors of Nurse Asking.
| Variable | OR | 95% CI LL | 95% CI UL | p value |
|---|---|---|---|---|
| Sex | ||||
| Male | 1.0 (REF) | |||
| Female | 1.50 | 1.07 | 2.09 | 0.019 |
| Education | ||||
| Less than college degree | 1.0 (REF) | |||
| College degree or above | 1.03 | 0.94 | 1.14 | 0.49 |
| Chemotherapy | ||||
| No | 1.0 (REF) | |||
| Yes | 0.90 | 0.61 | 1.33 | 0.59 |
| Radiation Therapy | ||||
| No | 1.0 (REF) | |||
| Yes | 1.07 | 0.73 | 1.58 | 0.71 |
| Cancer Recurrence | ||||
| No | 1.0 (REF) | |||
| Yes | 1.45 | 1.01 | 2.10 | 0.05 |
Table 3. Patient Predictors of Nurse Referral.
| Variable | OR | 95% CI LL | 95% CI UL | p value |
|---|---|---|---|---|
| Sex | ||||
| Male | 1.0 (REF) | |||
| Female | 1.50 | 1.06 | 2.12 | 0.02 |
| Education | ||||
| Less than college degree | 1.0 (REF) | |||
| College degree or above | 1.06 | 0.96 | 1.17 | 0.23 |
| Chemotherapy | ||||
| No | 1.0 (REF) | |||
| Yes | 1.23 | 0.83 | 1.81 | 0.30 |
| Radiation Therapy | ||||
| No | 1.0 (REF) | |||
| Yes | 0.82 | 0.56 | 1.20 | 0.30 |
| Cancer Recurrence | ||||
| No | 1.0 (REF) | |||
| Yes | 1.48 | 1.01 | 2.17 | 0.02 |
Acknowledgments
This research was supported by grant number U10CA045809 from The National Institutes of Health and in part by the National Institutes of Health through MD Anderson's Cancer Center Support Grant CA016672. Partial support for LC provided by the Richard E. Haynes Distinguished Professorship in Clinical Cancer Prevention. We thank the CCOP sites and the nurses and patients who participated in this study.
Footnotes
There are no financial disclosures from any authors. Additionally, the trial was registered in the clinical trials.gov database (#NCT00608933). Informed consent was obtained from all study participants.
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