Knowledge, Attitudes and Practices of Oncology Nurses towards Complementary and Alternative Medicine for Cancer Care in Qatar

Aim and objectives: The aim of this study is to investigate the knowledge, attitudes and practices of oncology nurses towards CAM in cancer care in Qatar. Background: CAM is widely used by patients with cancer worldwide. Given the wide use of CAM in cancer treatment, cancer authorities have called for an increased awareness of CAM modalities among healthcare professionals with a focus on safety and efficacy. Among healthcare professionals, nurses play a vital role in the integration of CAM into cancer care. Few studies have explored the attitudes, practice and knowledge of nurses towards CAM in cancer care. Design: Descriptive cross-sectional study. Research variables: CAM attitude; knowledge and professional practice. Methods: An anonymous survey of a sample of 156 random oncological nurses was conducted at the National Center for Cancer Care and Research (NCCCR) in Doha, Qatar. A semi-structured novel 17-item questionnaire was administered to 156 participating oncology nurses. The questionnaire collected information on: respondents’ knowledge of complementary therapy; perceived benefits and harm of complementary therapy; history of CAM recommendation to patients; and finally, interest in complementary therapy educational opportunities. Results: Our study showed that 11% of respondent oncological nurses had never heard about CAM therapy. Most nurses had a positive attitude towards CAM and were interested in CAM education opportunities. Conclusion: There is a need for increased knowledge about CAM by oncology nurses; given their vital role in the overall management of cancer patients. This can be achieved through structured and comprehensive education/training programs as well as through the integration of CAM therapy into cancer care guidelines. Relevance to clinical practice: To ensure safe, efficacious and holistic cancer treatment, it is important for nurses to be knowledgeable of complementary therapy; to candidly discuss this topic with patients; and when possible, to offer CAM resources to patients. Copyright: © 2014 PMNOA. This is an open-access article distributed under the terms of the Creative Commons Attribution License, Version 3.0, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Volume 1 • Issue 1 • 101 www.aperito.org ISSN 2378-8909-1-101 Page 2 of 14 Citation: Azza Adel Hassan (2014), Knowledge, Attitudes and Practices of Oncology Nurses towards Complementary and Alternative Medicine for Cancer Care in Qatar. Palliat Med Nurs Open Access 1:101


Introduction
Complementary and Alternative Medicine (CAM) is defined as a diverse group of medical systems, practices, and products that are not presently considered part of conventional medicine [1].
More precisely, complementary medicine (in Arabic: al tibb almukamel) is used as an adjunct to conventional treatment, while alternative medicine (in Arabic: al tibb al-badil) is used in lieu of conventional medicine [2]. The definition in the study can be divided into five main categories: 1) biologically based practices; 2) energy medicine; 3) manipulative and body-based practices; 4) mind-body medicine; and 5) whole medical systems [3]. Among these therapies include interventions such as acupuncture, nutritional therapy, mind-body-spiritual modalities, traditional Islamic medicine, homeopathy, herbal medicine and healing therapies. CAM is widely used by cancer patients globally and the popularity of CAM use is ever increasing. Numerous studies of CAM practices in Middle Eastern countries report between 35% to over 90% CAM use among cancer patients [4,5].
Similarly, about 40% to 90% of cancer patients in America and Europe have used at least one form of CAM therapy [6][7][8]. In an era of information and technological advancement, there is an increasing demand for more individualized health care which the current health care system struggles to provide. Patients look towards CAM to fill the gap left by conventional medicine [9].
In the Tover & Broom study, patients perceived that CAM was a "natural progression" of cancer treatment for nurses to integrate into professional practice [10].
Studies show that the most common reasons given by cancer patients for using CAM are: cure of disease; control of symptoms; boosting immunity; or prolongation of life [11,12].
Other reasons why cancer patients seek CAM therapies include: failure of medical therapies to meet patients' expectations; chemotherapy side effects and patient distrust of conventional medicine [5,13]. CAM is commonly used by patient with cancer diagnosis at a younger age (less than 50 years old); higher level of education; higher income; female gender; advanced disease or metastatic disease [14,15]. Other factors influencing CAM use include palliative treatment and long duration of disease [14,15]. Most cancer patients who used CAM were recommended to do so by: family, friends, other cancer patients, and even local media but rarely by healthcare professionals [15].
Given the wide use of CAM by cancer patients, oncology authorities have called for an increased awareness of CAM modalities among healthcare professionals with a focus on safety and efficacy [16]. In 2002, the White House

Commission on Complementary and Alternative Medicine
Policy recognized the need for increased education and training of health practitioners in CAM [17]. Unfortunately, the current healthcare system provides limited assistance to cancer patients when they seek CAM resources. This is especially true in the gulf region where there is still lack of information, limited access and limited experience with CAM.   [19][20][21][22]. CAM is particularly important in the improvement of patients' overall sense of wellbeing and quality of life during cancer treatment [19][20][21]. CAM helps address aspects of patient care which western medicine often ignores such as spirituality [9]. In addition, it offers patients more options for symptom and disease management. Given this essential role, there are now palliative care guidelines for CAM use in the certain institutions in Europe and the United States [23]. The National Institute for Health and Care Excellence (NICE) has developed guidelines on supportive and palliative care for adults with cancer which include specific guidelines on CAM [24]. Despite these great strides, many healthcare professionals continue to struggle with this issue. Among healthcare professionals, nurses play a vital role in the integration of CAM into cancer care. Nurses can be instrumental in eliciting patents' history of CAM use; however, nursing response to CAM therapy is inconsistent. This inconsistency has been attributed to limited knowledge and insufficient training [25]. Integration of complementary therapies into nursing practice, offer nurses the opportunity to act as totally autonomous therapists [9]. Complementary therapies also offer nurses the opportunity to provide holistic care and to empower patients to actively participate in their care [9]. Knowledge of the relevance, benefits and risks associated with CAM will enable nurses to provide safer, more comprehensive and holistic care.
Few studies have explored the attitudes, practice and knowledge of nurses towards CAM in cancer care. Initial studies discovered significant knowledge gap among nurses with regards to CAM therapies. These studies also reported positive nursing attitudes and increased interest towards CAM [3,25]. To our knowledge, no study has explored the attitudes, practices and knowledge of oncology nurses towards CAM in Qatar or the Middle East. This paper investigates the attitudes, practices and knowledge of oncology nurses regarding the use of CAM in Qatar.

Method
This study involves a descriptive cross-sectional survey of a random sample of oncology nurses in Qatar during the months of January to April 2013.

Setting:
The study was performed at the National Center for Respondents also gave informed consent to participate in this study. All surveys were completed anonymously and took no more than five minutes. Completed surveys were de-identified and entered into a secure data collection program.

Demographics and Characteristics
From the one hundred fifty six (n=156) randomly

CAM Knowledge, Interest and Clinical practices
Knowledge of CAM therapies was assessed by two questions.
Participants were asked if they had heard about complementary therapy and where directed to select specific therapies they were aware of from a list of 14 modalities. In the latter question,   Table 2 for further details on the survey results.     [26].
A study of nursing students and faculty revealed that many nurses lack basic knowledge regarding CAM and feel ill equipped to educate and serve as a resource to their patients regarding these therapies [3,27]. Smith et al. conducted a qualitative study in Taiwan to explore nurses' beliefs, experiences and practices [28]. They concluded that Taiwanese nurses had little experience using CAM in clinical settings because nurses lacked knowledge about CAM [28]. Another study assessing Israeli nurses' CAM knowledge and attitudes discovered that nurses had little knowledge of CAM and that few had used CAM in their nursing practice [29]. A similar study was conducted in Karachi, Pakistan [25]. Among the 132 oncology nurses surveyed more than half of nurses had never heard about many of the CAM therapies used in Pakistan [25]. providers [18]. Various studies have shown that very few patients disclose CAM their use to healthcare providers [32,33].
Patients often fail to divulge CAM use for fear of physician disapproval [32]. If undisclosed by patients who use them, CAM use could potentially cause delay in diagnosis and also severe adverse effects [3,30]. For instance, herbal therapies carry a risk of toxicities, herb-drug or herb-chemotherapy interaction and even non-compliance with conventional medical therapy [9,14,[34][35][36]. It is imperative that nurses take an active role in assessing their patient's CAM use [3]. Insufficient knowledge of CAM impedes nurses' abilities to accurately assess and advice patient regarding CAM use. Ignorance of this topic may also have litigious consequences for clinicians [37].
Consequently, the implementation of CAM education initiatives is one of the biggest steps towards achieving integrative cancer care.
A recent study was conducted across sixteen Middle Eastern countries examining physicians' perspectives on barriers to the integration of CAM into supportive cancer care [4]. 63% of respondents perceived their patients' use of CAM was primarily for cancer cure, while 57% thought that it was for improvement in quality of life [4]. These findings differ from the present study where 78% of oncology nurses believed that the main benefit of CAM was to improve quality of life of patients as well as psychological and emotional well-being.
Only 3% of nurses thought that CAM was used for cancer cure.  [19][20][21]. In this study, statistically significant improvements were noted in fatigue, nausea, depression, anxiety, appetite and general well-being [19][20][21]. Another study based on the use of CAM therapy among oncology patients showed that CAM use was associated with higher spiritual quest in the form of improved daily functioning, coping with disease, lessening chemotherapy side effects and emotionally supporting the patient and family [19][20][21]. In a 2004 study of the effects of nursing-led CAM interventions, consultants observed that fewer laxative and sedative use and overall, less prescribing on a geriatric ward [38,39].
Interventions used in the study included: aromatherapy, nutritional therapies, massage, visualization and herbal medicine [38,39]. Integration of CAM into patient care provides a greater variety of treatment options for patients.
Patients who are empowered to make decisions about their health that better reflect personal preferences often experience more favorable health outcomes such as decreased anxiety and increased patient compliance [40]. To ensure that patients are able to make an informed decision about CAM, nurses should be well prepared to educate patients about CAM.
In conclusion, this study demonstrates the need for increased complementary therapy education among oncology nurses given their vital role in the overall management of cancer patients [41]. This can be achieved through comprehensive education programs such as integration of CAM into nursing school curriculums and continuing education programs in hospitals. We also recommend the incorporation of complementary therapy into institutional cancer care guidelines or nursing care protocols. These initiatives will allow oncology nurses to achieve their goals of increasing their knowledge base and skills set; thus, facilitating the provision of safer and holistic cancer cares [41].

Strengths and Limitations
To our knowledge, no other study has explored the attitudes, practices and knowledge of oncology nurses towards CAM in either Qatar or the Middle East. Our study was also strengthened by a high response rate to distributed surveys.