Knowledge, attitude, influences and use of complementary and alternative medicine (CAM) among chiropractic and nursing students

Complementary and alternative medicine practices (CAM) are often classified into broad categories, such as body and mind medicine, natural products, manipulative and body-based therapies [1]. The National Institute of Complementary Medicine states that CAM, “is a broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period” [1]. The range of CAM treatments includes naturopathy, acupuncture, massage therapy, yoga, herbal medicine, chiropractic, and homeopathy [1]. Up to 69.8% of Australians have used at least one form of CAM, and 44.1% have visited a CAM practitioner in the previous 12 months [2].

The increased use of CAM among the general community has been attributed to the increased availability of information on the internet, contacts with other cultures that traditionally use CAM, the view that CAM is safer and less expensive than conventional medications and a growing recognition that many factors contribute to health and well-being [3].

Personal experience, faculty attitudes and family background ranked amongst the most common factors influencing pharmacy students’ attitudes towards CAM and their likelihood of recommending CAM therapies to future patients [4]. More than half of a cohort of pharmacy students had changes in attitudes and beliefs toward CAM, and an increased likelihood of recommending CAM therapies in future practice when they completed a course on CAM therapies [4].

Although the use of CAM therapies has been increasing in recent years, the debate about the clinical efficacy of these therapies has been controversial amongst many medical professionals. This has been largely due to a lack of scientific data surrounding many CAM therapies, compounded by variations in knowledge level and appreciation of the existing evidence about CAM amongst different healthcare professionals.

In the United States osteopathic medical students exhibit a positive attitude toward CAM with 83% reporting self-use of at least 1 CAM modality [5]. Older students were more likely than younger students to use a larger number of CAM modalities [5]. Female osteopathic medical students had more positive attitudes towards CAM therapies compared to their male counterparts and they were more likely to recommend CAM therapies to their patients [5].

A study conducted in 10 pharmacy schools in the United States demonstrated that the majority of students agreed that CAM knowledge would be needed in future pharmacy practice, however they did not necessarily possess that knowledge at the time of questioning. Students also agreed that there are limitations to conventional medicine and that patient’s values and beliefs should be integrated into the patient care process. Furthermore, the study concluded that female students and those who had previous experience with CAM exhibited a more favorable attitude towards CAM [6].

Acute care nurses in the United States reported an increase in patients seeking CAM therapies to cope with pain, particularly when they experienced inadequate pain relief from mainstream medicine [7]. Approximately half (51%) of the nurses surveyed demonstrated poor baseline information regarding CAM and even fewer (47%) were able to accurately describe or define CAM and CAM terminology [7]. This was linked to an inability to educate their patients on the different CAM therapies available and those that may be beneficial in pain management. Nevertheless, attitudes towards CAM were positive with the majority agreed that patients have a right to incorporate CAM therapies into their conventional medical treatments. The nurses also believed that the use of CAM therapies by patients should be disclosed [7].

A further survey of nursing students and staff reinforced these findings that clinical care ought to incorporate the best of CAM therapies and highlighted a positive attitude towards incorporating CAM into nursing practice. However, this study also highlighted the lack of education amongst nurses in relation to CAM therapies [8].

There does not appear to be any previous research on chiropractic students’ or Australian nursing students’ knowledge and attitudes toward CAM.

It seems important that as healthcare providers interact with patients seeking CAM in an age of patient centered care they are able to give patients advice and potentially options (where possible) for the management of disease or pain, and this may involve consideration of CAM therapies. Healthcare providers also need to be able to educate patients regarding the evidence for CAM therapies, their prognosis, adverse events and contraindications. To be able to accomplish this, healthcare providers, including chiropractors and nurses, should have a basic knowledge of other treatment options such as CAM.

A total of 548 nursing and chiropractic students participated in the study in the second half of 2016. There were 321 nursing students and 227 chiropractic students which exceeds the estimated convenience sample size. Of those offered the survey instrument 5 nursing students and 2 chiropractic students declined to participate (response rate is 98.44 and 99.12 respectively). The nursing and chiropractic students who responded to the survey had a mean age of 27.7 years (SD:9.0) and 22.3 years (SD:3.9) respectively. Of those who participated in the study, 93.3% of the nursing students and 56.4% of the chiropractic students were female. The total number of nursing and chiropractic student respondents by course year was as follows: year 1, 189 students; year 2, 198 students; year 3, 96 students; year 4, 28 students (chiropractic only); and year 5, 36 students (chiropractic only).

The overall mean scores of knowledge of different CAM therapies for nursing and chiropractic students were 1.23 (SD: 0.47) and 1.29 (SD: 0.41) respectively. There were no significant differences between the student groups in overall knowledge score. In contrast to nursing students, chiropractic students have more knowledge of osteopathy (p < 0.001), whereas nursing students have more knowledge of spirituality than chiropractic students (p < 0.001). There were no significant differences between nursing and chiropractic students in nutrition, homeopathy, Tai chi, Ayurveda, biofeedback and yoga modalities. However, among all modalities listed, nutrition, massage, chiropractic, meditation and yoga were most known by respondents.

Among the factors that influenced respondents’ beliefs in relation to CAM, personal experience was the main factor for both nursing (mean = 5.37) and chiropractic students (mean = 5.13). Chiropractic students were more influenced by university training (mean [SD] 4.99, 1.6 vs. 4.56, [1.8]), attitudes of lecturers (mean [SD]4.64, 1.6 vs. 4.23, [1.8]) and opinions of practitioners (mean [SD] 5.22, 1.4 vs. 5.03, [1.6]) compared to nursing students (p < 0.05). Moreover, media had a greater impact on nursing students (mean 3.96, SD 1.6) than on chiropractic students (mean 3.27, SD 1.6) p < 0.05 (Fig. 1).

Regarding recommending CAM therapies to patients, chiropractic students (mean = 5.21) were more likely to recommend CAM compared to nursing students (mean [SD] 4.52, 1.5) (p < 0.001).

This study was designed to assess the knowledge, attitudes and beliefs of chiropractic and nursing students towards CAM. We also looked at factors that influenced their views and the likelihood of recommending CAM to their future patients. Nursing students demonstrated limited knowledge regarding CAM with mean self-rated knowledge of 9 out of the 15 CAM modalities falling between “aware” and “some knowledge” and 5 out of 15 modalities falling between “not aware” and “aware”. Another study measuring nurse’s knowledge and attitudes towards CAM⁷ revealed similar results in that nurses demonstrated poor baseline knowledge of CAM modalities. Similarly chiropractic students’ self-rated knowledge was also limited with 8 of the CAM modalities (other than chiropractic) falling between “aware” and “some knowledge” and 6 out of 15 modalities falling between “not aware” and “aware”. As a whole, their levels of knowledge were not significantly different and it can be argued that for both groups their knowledge could be enhanced. Despite the limited knowledge nursing and chiropractic students had regarding CAM, both groups still demonstrated positive attitudes towards CAM. However, it is noted there was a minority of chiropractic students who agreed with the statement “complementary and alternative therapies are a threat to public health” and would not recommend CAM to future patients despite chiropractic generally being categorized as a CAM profession. This counter-intuitive finding may reflect some chiropractic students’ views that they are more part of mainstream medicine or allied health rather than CAM. These findings are comparable to previous studies on medical students which also indicated that despite having limited knowledge regarding CAM, medical students still reported positive attitudes towards CAM and would welcome education on CAM in their curriculum [12].

When questioned about the belief that “A patient’s expectations, health beliefs and values should be integrated into the patient care process” both chiropractic and nursing students gave similar responses to this statement with strong agreement from both groups. This agreement between chiropractic and nursing students on patient centred care is consistent with previous studies involving nurses and pharmacy students [6, 7].

Among nursing and chiropractic students the main factors that influenced their attitudes and beliefs towards CAM were the same, with personal experience with CAM, the opinions of chiropractors or nurses (respectively) outside their current university training and scientific evidence ranking among the top three most influential factors respectively shaping their attitudes and beliefs about CAM. A previous study also showed a similar result for pharmacy students with personal experience and university training being factors that heavily influenced them [6]. It was interesting to note that personal experience and the opinions of senior practitioners was a stronger factor than the influence of their respective lecturers. This may have positive or negative consequences depending on what influences are brought to bear on the students by external practitioners. It can be argued that scientific evidence should be the number one influence on health professional students.

For nursing students, their fellow student’s attitudes and beliefs were the least influential whereas for chiropractic students it was the media that was the least influential. Chiropractic has at times attracted controversy in the media and has been portrayed negatively [13–15]; it is possible that this may be one reason why the media was the least influential among chiropractic students while greater reliance on evidence by chiropractic students may also be another determining factor. Likewise, fellow student’s attitudes and beliefs along with the media were the least influential factors for pharmacy students [6].

With regards to recommending CAM to future patients, chiropractic students leaned more favourably towards recommending CAM than nursing students. A previous study conducted with medical students displayed comparable results to the nursing students in that the majority of students would neither persuade nor dissuade patients from using CAM [12]. The authors of this study attributed these results to the students’ lack of knowledge or confidence in CAM modalities, and this may also be a factor for the nurses in our study.

This study provides information regarding knowledge, attitudes and beliefs, factors that influence and the likelihood of recommending CAM to future patients among two different health professions, chiropractic and nursing students. The results in this study demonstrate relatively positive attitudes and beliefs towards CAM from both nursing and chiropractic students, despite them having limited knowledge concerning different CAM modalities. Personal experience and the influence of external practitioners were noted to be the most influential factors in shaping both chiropractic and nursing students’ CAM attitudes and beliefs, and although nursing students would not dissuade future patients from CAM, chiropractic students were more likely to recommend CAM to their future patients.