dnp.musites.orgdnp.musites.org/.../2018/11/Annie-Kuehnel-Scholarly-Proje… · Web viewMore than 30% of U.S. adults have used complementary and alternative medicine (CAM) in 2012

Running head: NURSES’ ATTITUDE AND KNOWLEDGE 1

Oncology Nurses’ Attitude and Knowledge toward

Complementary and Alternative Medicine

Annie Kuehnel

Maryville University

Project Committee

Committee Chair: Richard Pessagno, DNP, PMHNP-BC, FAANPAssociate Professor and Project Chair Maryville University, Missouri

Committee Member: Steven Vanni, D.C., D.O.Associate Professor of Neurological SurgeryUniversity of Miami, Florida

NURSES’ ATTITUDE AND KNOWLEDGE 2

Table of Contents

Acknowledgement...........................................................................................................................8

Abstract............................................................................................................................................9

Chapter I: Introduction.................................................................................................................10

Background....................................................................................................................................11

Problem Statement.........................................................................................................................12

Objectives and Aims......................................................................................................................13

Significance of Study.....................................................................................................................13

Chapter II: Literature Review........................................................................................................17

Search History...............................................................................................................................18

Inclusion and Exclusion.............................................................................................................18

Integrated Review of Literature.....................................................................................................19

Research Studies Common Attributes.......................................................................................19

Nurses’ Attitude on CAM..........................................................................................................20

Perception..............................................................................................................................21

Personal use and recommendation.........................................................................................21

Nurses’ Knowledge of CAM.....................................................................................................22

Barriers to Integrating CAM Practice........................................................................................23

Difficulties locating resources...............................................................................................23

Legal issues............................................................................................................................23

Other barriers.........................................................................................................................24

Oncology Nurses’ Attitude and Knowledge..............................................................................24

Literature Critique.........................................................................................................................26


Strengths....................................................................................................................................26

Weakness...................................................................................................................................26

Gaps...........................................................................................................................................28

Limitations.................................................................................................................................29

Concepts and Definitions...............................................................................................................29

Scope of CAM...........................................................................................................................29

Operational Definitions.............................................................................................................30

Theoretical Framework..................................................................................................................31

Evidence-Based Nursing Practice Model..................................................................................31

Conclusion.....................................................................................................................................33

Chapter III: Methodology..............................................................................................................34

Project and Study Design...............................................................................................................34

Project Design............................................................................................................................34

Setting and Resources................................................................................................................34

Setting....................................................................................................................................34

Study Population........................................................................................................................35

Data Collection Tool.................................................................................................................36

Plan for Data Analysis...............................................................................................................36

Demographic Data.....................................................................................................................37

Attitude Assessment..................................................................................................................37

Knowledge Assessment.............................................................................................................37

Statistical Analysis....................................................................................................................38

Quality...........................................................................................................................................38


Reliability..................................................................................................................................38

Validity......................................................................................................................................38

Project Timeline........................................................................................................................39

Budget........................................................................................................................................39

Direct Cost.............................................................................................................................39

Indirect Cost...........................................................................................................................40

Membership fees....................................................................................................................40

Consultation service...............................................................................................................40

Funding..................................................................................................................................40

Ethics and Human Subjects Protection..........................................................................................40

Voluntary Participation..............................................................................................................41

Research Risks...........................................................................................................................41

Research Benefits......................................................................................................................41

Confidentiality...........................................................................................................................41

Results.......................................................................................................................................42

Conclusion.....................................................................................................................................42

Chapter IV: Discussion..................................................................................................................43

Congruence in Measurement and Data..........................................................................................43

Data Size....................................................................................................................................43

Setting for Data Collection........................................................................................................44

Data Reliability and Validity.....................................................................................................44

Replicating Data Collection Plan..............................................................................................45

Data Analysis.................................................................................................................................45


Statistical Analysis.........................................................................................................................46

Demographics............................................................................................................................46

General Attitude toward CAM..................................................................................................47

Knowledge Score.......................................................................................................................51

Conclusions....................................................................................................................................52

Chapter V: Conclusion.................................................................................................................53

Oncology Nurses’ Attitude toward CAM......................................................................................53

Improving Nurses’ Knowledge through CAM Educational Training...........................................53

Limitations.....................................................................................................................................54

Strengths........................................................................................................................................55

Implication for Nursing Practice...................................................................................................55

Implication for Future Research....................................................................................................56

Conclusion.....................................................................................................................................56

References......................................................................................................................................58

Appendix A: IRB Approval Letter................................................................................................66

Appendix B: Permission Letter from S. A. Shorofi.......................................................................67

Appendix C: BONUS approval letter...........................................................................................68

Appendix D: Invitation Flyer.........................................................................................................69

Appendix E: Invitation Letter........................................................................................................70

Appendix F: Informed Letter........................................................................................................71

Appendix G: Survey Instrument...................................................................................................73

Appendix H: Presentation Slides..................................................................................................79

Appendix I: Dr. Stevens Permission Letter..................................................................................81


Appendix J: CITI Certificate........................................................................................................82


List of Tables

Table 1...........................................................................................................................................47

Table 2...........................................................................................................................................48

Table 3...........................................................................................................................................49

Table 4...........................................................................................................................................50

Table 5...........................................................................................................................................51

Table 6...........................................................................................................................................51

Table 7...........................................................................................................................................52


List of Figures

Figure 1. Stevens Star Model of Knowledge Transformation.......................................................31

Figure 2. Histogram of Changes in Attitude Scores.....................................................................49

Figure 3. Histogram of Changes in Knolwedge Scores................................................................52


Acknowledgement

First, I would like to express my sincere gratitude and appreciation to Dr. Richard

Pessagno, my committee chairperson for his countless hours of reading, editing, critiquing, and

most of all patience throughout the time it took me to complete this project. Also, I wish to

thank Dr. Steven Vanni for agreeing to serve on my committee, providing me with inspirational

guidance and persevering with me as my advisor. His belief that it was, indeed, possible to

achieve my academic pursue kept me going.


Abstract

More than 30% of U.S. adults have used complementary and alternative medicine (CAM)

in 2012 (Clarke, Black, Stussman, Barnes, & Nahin, 2015) and an average of forty percent of

cancer patients used CAM (Horneber et al., 2011). There are an increasing interest and demand

in CAM, yet oncology nurses did not have sufficient CAM knowledge (Hassan et al., 2014;

Rojas-Cooley & Grant, 2009; Somani, Ali, Ali, & Lalani, 2014; Zanini et al., 2008) to properly

provide guidance for these patients. Oncology nurses are in the key position to initiate

discussion, document and monitor CAM use in patients. Failure to assess CAM use in patients

may lead to potential adverse events and drug interactions with conventional therapy. The aim

of this project is to evaluate the oncology nurses’ attitude and knowledge toward CAM. This

project utilized a questionnaire-based survey with a pre and post-test design. Surveys were

administered to participating oncology nurses. They were instructed to fill out the questionnaire

before and after a 15-minute CAM-lecture. Descriptive, parametric as well as non-parametric

statistics were calculated to analyzed and describe the collected data. The results of this project

demonstrated a statistically significant improvement in oncology nurses’ attitude (p = .003) and

knowledge (p = <.001) that is associated with the implementation of educational intervention.

Keywords: Oncology nurses, CAM attitude, knowledge, complementary medicine.


Chapter I: Introduction

Some people consider complementary and alternative medicine (CAM) a “new-age

medicine” while, in fact, this practice exists for centuries in the East. CAM practice is based on

traditional medicine that is not generally supported or accepted by Western medicine. The

primary focus of Western medicine has always been addressing physical or psychological

symptoms alone. The biomedical model recognizes that health is a state of absence of disease,

which is equivalent to the dictionary definition of health. “Health” is defined as, “the condition

of the body and the degree to which it is free from illness, or the state of being well” (Cambridge

dictionary, 2017, para. 1). Eastern medicine, on the other hand, believes that treating the

spiritual aspect of an individual is just as important. In fact, the World Health Organization

claimed that health as “a state of complete physical, mental and social well-being and not merely

the absence of disease or infirmity” (World Health Organization, 2005, p. 1). CAM practice

considers the patient as a whole and focuses on restoring the balance of external and internal

environment of the patient (Zamanzadeh, Jasemi, Valizadeh, Keogh, & Taleghani, 2015). CAM

users were dissatisfied with conventional treatment because of poor patient-centered

communication (Emmerton, Fejzic, & Tett, 2012; Faith, Thorburn, & Tippens, 2015). They also

felt that CAM seemed to be most effective when it is used as long-term therapy; whereas

conventional medicine would be a better choice for the acute setting (Emmerton et al., 2012).

Background

According to the National Health Interview Surveys in 2012, more than 34 percent of

American adults have used CAM which means one-third to one-half of the US population uses

one or more forms of alternative therapy (Clarke et al., 2015). Americans spent nearly $30.2

billion out-of-pocket on CAM in 2012. This accounted for roughly 1.1% of total health care

http://dictionary.cambridge.org/dictionary/english/state

http://dictionary.cambridge.org/dictionary/english/illness

http://dictionary.cambridge.org/dictionary/english/free

http://dictionary.cambridge.org/dictionary/english/degree

http://dictionary.cambridge.org/dictionary/english/body

http://dictionary.cambridge.org/dictionary/english/condition


expenditures, and 9.2 % of total out-of-pocket health care expenditures (Nahin, Barnes, &

Stutsman, 2016). The average out-of-pocket expenditure for visits to a complementary

practitioner was $433, and for purchases of the natural product and supplements were $368

(Nahin et al., 2016). It is evident that CAM has gained increased popularity in the past few

years. To accommodate this growing interest, the White House Commission on Complementary

and Alternative Medicine Policy (WHCCAMP, 2002) was established in March 2000 to focus on

the access of CAM, research priorities and the needs for better education of consumers and

healthcare professionals about CAM. The primary purpose of this policy is to maximize the

potential benefits of CAM therapies to consumers (White House Commission on

Complementary and Alternative Medicine Policy [WHCCAMP], 2002). The 10 principles that

are used as a guide to health care reform, in fact, focused heavily on “wholeness orientation.”

These principles emphasized that “health involves all aspects of life-mind, body, spirit,

environment-and high-quality health care must support the care of the whole person”

(WHCCAMP, 2002, para. 9).

As the popularity of CAM continues to rise in the general public, are health care

professionals prepared to care for patients who are CAM users? Most health professionals

especially nurses who are in a key position in patient care, education and advocacy do not feel

that they are well-equipped to manage patients’ use of CAM therapies (Rojas-Cooley & Grant,

2009; Trail-Mahan, Mao, & Bawel-Brinkley, 2013). Studies have shown that lack of knowledge

and training (Ozkaptan & Kapucu, 2014; Zanini et al., 2009; Zoe et al., 2014) appeared to be the

crippling reasons to integrate CAM into nursing practice.

Problem Statement

Studies have indicated that forty percent of cancer patients used CAM (Horneber et al.,


2011), and these patients showed a positive attitude toward CAM due to the positive effects of

CAM practice (de Valois, Asprey, & Young, 2016; Huebner et al., 2014; Kessel et al., 2016;

Upchurch & Rainisch, 2015). There are an increasing interest and demand in CAM among the

population of cancer patients. Yet, cancer patients did not feel comfortable disclosing their use

of CAM to their providers (Gan et al., 2014). Similarly, majority of noncancer patients reported

that they did not inform their providers at the time of their visits about CAM use due to fear of

disapproval from providers and visit time constraints (Davis, Butow, Mullan, & Clarke, 2012;

Gan et al., 2014), but the most common reason was physicians never enquired (Gan et al., 2014;

Huebner, 2014).

In a nursing perspective, nondisclosure of CAM use poses a safety problem in providing

care for patients who are CAM users. Nurses who had limited or no knowledge of CAM felt

reluctant to assess CAM use with patients (Cirik, Efe, Öncel, & Gözüm, 2017; Rojas-Cooley &

Grant, 2009). Meanwhile, when patients felt the lack of support and encouragement from health

care providers, they also withdrew interests to discuss their use of CAM during visits. The

miscommunication between nurses and patients could be detrimental to treatment progress and

result in potential drug interactions. CAM use is common among patients in general, and that

translates to a much greater need for CAM education for nurses who are at the forefront of caring

for these patients.

Objectives and Aims

My PICO question is: will CAM educational training improve oncology nurses’ attitudes

and knowledge toward CAM as compared to no educational training? The purpose of this study

is (1) to evaluate nurses’ baseline knowledge, and their general attitude toward CAM, (2) to

improve their attitude and knowledge through CAM educational training, and (3) to implement


CAM education into nursing practice. It is hoped that providing CAM educational program will

bridge the gap in knowledge of the philosophy and practice of CAM modalities in patient care.

Significance of Study

The American Nurses Association (ANA) Code of Ethics provides guidelines for safe

and compassionate care (American Nurses Association [ANA], 2016). Provision nine states that

“the nurse promotes, advocates for, and protects the rights, health, and safety of the patient”

(ANA, 2016, para. 3). That is, nurses are obligated to advocate for the safety of the patients by

discussing the risks and benefits of CAM with patients. In Chapter 456 of the Florida Statutes, it

states that health care practitioner may recommend any types of treatment in his or her judgment

including complementary or alternative health care treatment (Florida Senate, 2012). Moreover,

the Holistic Nursing Scope and Standards of Practice emphasize that nurses need to support and

assist those who use CAM that other practitioners provide (American Nurses Association &

American Holistic Nurses' Association, 2013).

Holistic care is believed to be the heart of nursing science (Zamanzadeh et al., 2015).

Although the role nursing has evolved from taking care of the sick at the bedside to translating

evidence into practice, the core of nursing that was founded by Florence Nightingale centuries

ago has remained the same. In fact, the philosophy of nursing resembles closely to the holistic

framework of CAM practice. For nurses to become an advocate for CAM education and

continue to provide quality patient care, nursing administration and education need to commit to

more structural planning on how to integrate CAM into nursing practice.

To honor the Code of Ethics and to be a patient advocate, nurses must first be well-

educated with CAM knowledge before they are able to advocate CAM practice. To meet the

standard of care, it is hoped that nursing schools will eventually consider integrating CAM


education fully into the nursing curriculum, and maybe the board of nursing will mandate CAM

continuing education as part of the license renewal requirements. For practicing nurses, they

undoubtedly rely on nurse managers or nurse educators to provide CAM in-service training or

special educational conference. By preparing nurses with formal CAM training, they would be

more competent and confident when discussing the risks and benefits with patients (Cirik et al.,

2017). In addition, they would also be more open, and willing to answering the patients’

inquiries (Buchan, Shakeel, Trinidade, Buchan & Ah-See, 2012; Hassan et al., 2014).

Patients often seek CAM modalities in conjunction with traditional medical practice to

uphold their beliefs in healing the body, spirit, and mind. Following diagnosis, patients started to

investigate information about conventional and CAM treatment that may increase the success

rate of their course of treatment (Balneaves, Weeks, & Seely, 2008). Common reasons why

patients chose CAM practice were negative communication experiences with conventional

healthcare providers (Salamonsen, 2013) and the inclination to use CAM as wellness prevention

(Upchurch & Rainisch, 2015). Unlike the traditional medical treatment decision-making

process, CAM decisions are “highly individualized, complicated and multifaceted, and they

involved dynamic processes that vary throughout the cancer trajectory” (Balneaves et al., 2008,

p. s28). Therefore, it is important for nurses to recognize that CAM decision-making is not a

straightforward but an anxiety-stricken experience for patients (Balneaves et al., 2008).

Allowing patients to participate in their care is to empower them to be their own

healthcare advocate and to respect the decisions they choose. Nurses have to ensure patient’s

safety by informing the risks, benefits of CAM and their potential interactions with conventional

medicine. Establishing an open communication with patients is crucial for nurses to provide

proper counseling. Patients who are fully informed are more likely to disclose their use of CAM,


and more open to discuss their plan of care with nurses who are credible on CAM therapies

(Kim, Lee, & Kim, 2016).

Conclusion

Over past few decades, the demand for CAM has continued to rise among patients.

Similar to the practice of conventional medicine, CAM is associated with both benefits and

probable risks. Surprisingly, the majority of the patients who use CAM are not willing to

disclose the veracity of this practice because of lack of trust and disapproval from providers.

The communication gap between nurses and patients could be detrimental to the patient safety

and treatment progress. When patients simultaneously using CAM in conjunction with

conventional medicine, they need to be fully informed about the nature of these therapies. They

need to be aware of the potential adverse effects and possible interaction with the concurrent

treatment that they are receiving.

Nurses are ethically bound by the code and the scope of nursing practice in relation to

CAM. Although this may be true, evidence (Cirik et al., 2017; Jong, Lundqvist, & Jong, 2015;

Orkaby and Greenberger, 2015; Shorofi & Arbon, 2017; Spencer et al., 2016) suggested that

nurses do not routinely assess CAM use when taking nursing history. They also feel weary about

asking questions pertaining to CAM use because of limited knowledge and resources.

Indisputably, nurses have much to learn about CAM therapies before they can properly care for

these patients. Nurses who bear a favorable attitude have a greater desire to broaden their

knowledge of CAM.

Given that nurses are in the pivotal position to initiate discussion, document and monitor

patient’s use of CAM, an informative, educational program is strongly recommended to enhance

their proficiency in this area. By improving the nurses’ attitude and knowledge, they would be


empowered to address the issues of CAM and deliver quality care with confidence. As we

embrace the holistic concept of healing the body, mind, and spirit, it is foremost important to

invest in CAM education and training to successfully bridge the knowledge gaps in nurses.


Chapter II: Literature Review

Many patients feel that having an appointment with a healthcare provider and leaving

with a prescription is no longer sufficient (Faith et al., 2015; Lindquist & Snyder, 2010).

Patients pursue the use of CAM because of its versatile approach toward preventing and treating

the whole person (mind, body, and spirit) instead of curing the disease itself. While there is an

increasing trend in CAM use among patients, nurses have greater opportunities to provide

counseling about the risks and benefits of these modalities. In order to provide quality care for

this population of patients, the initial step is to assess nurses’ attitudes and knowledge on CAM.

For nurses to deliver safe and informed care, it is only logical to offer formal CAM training and

education to enhance their knowledge base. The purpose of this chapter is to provide a general

overview of the research studies in relation to nurses’ attitudes and knowledge toward CAM.

This chapter will include all of the available research literature relevant to the PICO question

posted: will CAM educational training improve oncology nurses’ attitudes and knowledge

toward CAM as compared to educational training? An evidence-based framework (Stevens Star

Model of Knowledge Transformation [SSMKT]) will be applied to underpin the direction of this

study.

Search History

The articles in this literature review were obtained from EBSCO databases (CINAHL,

Medline, ERIC, and PsycINFO) and Google Scholar. The inclusion dates of these articles were

from January 2008 to June 2017. An electronic search was undertaken to locate previously

published studies on nurses’ attitudes toward complementary and alternative medicine. Boolean

operations were used to combine the following keywords with “and” and “or.” The keywords

included “complementary and alternative medicine,” “nurses,” “attitude,” “knowledge,”


“integrative,” “holistic,” “oncology,” “cancer.” Articles that were relevant but did not have full-

text were searched through the ejournals in the online biomedical library.

Inclusion and Exclusion

The search included only English language journals that contained full text and peer-

reviewed journals. Articles were then analyzed on the relevance of nursing study and the focus

on attitudes and knowledge. Studies must have measured the attitudes, knowledge, and use of

CAM. Studies that were conducted outside of the United States (U.S.) were included. The

articles that had “abstracts only” were all excluded. Articles with pediatrics and psychiatric

populations were also excluded.

Integrated Review of Literature

Research Studies Common Attributes

In reviewing the studies (n=17) on nurses’ attitudes toward complementary and

alternative medicine, the majority of them were conducted outside of the U.S. These countries

include Australia (n=1), Greek (n=1), Iran (n=1), Israel (n=1), Italy (n=1), Korea (n=1),

Netherlands (n=1), Pakistan (n=1), Qatar (n=1), Sweden (n=1), Taiwan (n=1), Turkey (n=2),

United Kingdom (n=1), and U.S. (n=3). All the measuring instruments were questionnaire

surveys except one was an interview. The sample size varied between 36,000 (van Vliet et al.,

2015) to 132 (Somani et al., 2014). The interview conducted by Smith and Wu (2012) had only

11 participants, but the authors felt that the number of sampling process had reached a saturation

level. Therefore, more interviews would not benefit their research findings.

The overall study designs were descriptive studies. Four studies were cross-sectional

(Buchan et al., 2012; Jong et al., 2015; Orkaby & Greenberger, 2015; van Vliet et al., 2015),

three studies used descriptive as well as nonparametric statistics to report findings (Rojas-Cooley


& Grant, 2009; Shorofi & Arbon, 2017; Zoe et al., 2014) and one study used an exploratory

qualitative descriptive method (Smith & Wu, 2012). The most common instrument of choise

was self-administered questionnaire survey. These surveys (n =12) were either distributed

directly to participants in various medical facilities or academic institutions. Two surveys were

emailed to participants (Trail-Mahan et al., 2013; van Vliet et al., 2015) and two were mailed

directly to them (Rojas-Cooley & Grant, 2009; Zanini et al., 2008). Most sampling methods

were convenient (n=10) followed by random (n=6) and purposive sampling (n=1). The survey

instrument developed by Shorofi and Arbon (2017) has the highest reliability (Cronbach’s alpha

of .929). In reviewing these articles, three major recurring themes were identified as “nurses’

attitude,” “nurses’ knowledge,” and “barriers to integrating CAM practice.”

Nurses’ Attitude on CAM

Studies have found that nurses in general displayed a favorable attitude toward CAM

practice in the U.S. (Rojas-Cooley & Grant, 2009; Trail-Mahan et al., 2013) as well as in other

countries (Balouchi, Rahnama, Hastings-Tolsma, Shoja, & Bolaydehyi, 2016; Cirik, et al., 2017;

Hassan et al., 2014; Jong, et al., 2015; Orkaby & Greenberger, 2015; Ozkaptan & Kapucu, 2014;

Shorofi & Arbon, 2017; Smith & Wu, 2012; Somani et al., 2014; van Vliet et al., 2015). Nurses’

attitude and knowledge were positively correlated (Shorofi & Arbon, 2017; Spencer et al., 2016).

Nurses who were familiar and knowledgeable with CAM had a more positive attitude (Balouchi

et al., 2016; van Vliet et al., 2015). Nurses who favored the biomedical model equally favored

the holistic concept of CAM (Spencer et al., 2016).

Despite the unanimously positive results of attitude scores, nurses were reluctant to

discuss the use of CAM with patients (Trail-Mahan et al., 2013). In fact, more than 50% of the

nurses never inquired about CAM use in patients (Cirik et al., 2017; Jong et al., 2015; Orkaby


and Greenberger, 2015; Spencer et al., 2016). Only 15% would “always” inquire about herbal

medicine use when taking nursing history (Shorofi & Arbon, 2017). Nurses who reported being

“very comfortable” about CAM were more likely to discuss and assess CAM use (Shorofi &

Arbon, 2017).

Perception. Nursing is very much aligned with the concepts of CAM practice (van Vliet

et al., 2015). Nurses in the Netherlands considered CAM as an innovative and important health

care concept (van Vliet et al., 2015). Most nurses perceived CAM as safe, helpful (Hassan et al.,

2014), effective and inexpensive (Buchan et al., 2012; Cirik et al., 2017). They felt that CAM

promote recovery and healing (Jong et al., 2015), and practices like aromatherapy and music

therapy would be beneficial to the patients in the palliative care units (Smith & Wu, 2012).

Seventy-three percent of nurses emphasized that the positive responses to CAM should not be

attributed solely to the placebo effect (Zoe et al., 2014). Furthermore, they strongly believed that

patients had the right to integrate CAM practice into their medical treatments (Rojas-Cooley &

Grant, 2009; Trail-Mahan et al., 2013). However, there were conflicting findings reported in the

study by Ozkaptan and Kapucu (2014). The authors found that 63.5% of nurses believed CAM

practitioners profit from the desperation of those patients who felt that they had run out of

treatment options.

Personal use and recommendation. There was a significant number (50-80%) of

nurses reported to have used CAM in the past (Cirik et al., 2017; Jong et al., 2015; Orkaby &

Greenberger, 2015; Ozkaptan & Kapucu, 2014; van Vliet et al., 2015) and the main reasons were

for relaxation, support, and treatment (Cirik et al., 2017). In Australia, 95.7% of nurses reported

the professional use of CAM (Shorofi & Arbon, 2017). In Cypriot, Greece, over one-third of the

nurses had experimented with some form of CAM to remedy certain medical conditions (Zoe et


al., 2014). Nurses (52.1%) in both Turkey (Ozkaptan & Kapucu, 2014) and (20%) Sweden (Jong

et al., 2015) candidly admitted that they had implemented CAM therapies on their patients in the

past. Among all the CAM modalities, massage appeared to be one of the most popular use

among nurses (Buchan et al., 2012; Cirik et al., 2017; Jong et al., 2015; Shorofi & Arbon, 2017;

Spencer et al., 2016) followed by dietary/herbal supplements (Cirik et al., 2017; Jong et al.,

2015; Shrofi & Arbon, 2017).

Positive attitudes and formal CAM education were found to be positively correlated to

CAM referrals (Shorofi & Arbon, 2017; Spencer et al., 2016). Particularly, female had a higher

referral rate than male (Shorofi & Arbon, 2017; Spencer et al., 2016). Nurses who had positive

attitudes toward CAM were more likely to recommend CAM to their patients (Buchan et al.,

2012; Orkaby & Greenberger, 2015; Shorofi & Arbon, 2017; Zanini et al., 2008). The most

common CAM practices recommended to patients were meditation (Cirik et al., 2017; Jong et

al., 2015), massage (Cirik et al., 2017; Shorofi & Arbon, 2017) and prayer (Cirik et al., 2017;

Ozkaptan & Kapucu, 2014).

Nurses’ Knowledge of CAM

Studies indicated that nurses did not have sufficient knowledge of CAM (Ozkaptan &

Kapucu, 2014; Smith & Wu, 2012; Shorofi & Arbon, 2017; Zanini et al., 2008; Zoe et al.,

2014), and the majority of nurses did not have any formal CAM education (Buchan et al., 2012;

Ozkaptan & Kapucu, 2014). Kim, et al. (2016) reported that nurses scored an average of 67.92

out of 130 points in the knowledge section of their study. The types of CAM modalities that

nurses had most knowledge on were massage (Cirik et al., 2017; Hassan et al., 2014; Jong et al.,

2015; Kim et al., 2016; Ozkaptan & Kapucu, 2014; Somani et al., 2014; Spencer et al., 2016;

Shorofi & Arbon, 2017) and dietary/herbal supplements (Cirik et al., 2017; Jong et al, 2015;


Hassan et al., 2014; Spence et al., 2016). It is alarming to see that nurses were implementing

CAM as part of their professional practices (Shorofi & Arbon, 2017; Zanini et al., 2008; Zoe et

al., 2014) when they had limited knowledge (Balouchi et al., 2016; Jong et al., 2015; Kim et al.,

2016; Rojas-Cooley & Grant, 2009; Trail-Mahan et al., 2013).

Studies also demonstrated that 92 - 97% of nurses had never received CAM training and

education (Buchan et al., 2012; Cirik et al., 2017; Ozkaptan & Kapucu, 2014; Spencer et al.,

2016; Zanini et al., 2008). Yet, they were eager to learn (Ozkaptan & Kapucu, 2014) about CAM

practice and they showed great desire to expand their knowledge of CAM (Rojas-Cooley &

Grant, 2009; Smith & Wu, 2012; Zoe et al., 2014). Nurses also agreed that they should be

knowledgeable about CAM (Somani et al., 2014) in order to better inform their patients about

the risks and benefits of CAM (Jong et al., 2015; van Vliet et al., 2015). For this reason, CAM

training and education are imperative for patient care. In truth, seventy-three percent of

participants in the study by Cirik et al. (2017) believed CAM training is crucial before and after

graduation. Nurses who scored highest on CAM knowledge questions suggested that CAM

education is essential (Rojas-Cooley & Grant, 2009) in meeting the growing demands of CAM

by patients.

Barriers to Integrating CAM Practice

Difficulties locating resources. The barriers to integrating CAM into nursing practice

appeared to be a lack of formal CAM education (Buchan et al., 2012; Cirik et al., 2017; Jong et

al., 2015; Trail-Mahan et al., 2013) and difficulty locating reputable CAM resources (Rojas-

Cooley & Grant, 2009). Most nurses (75%) obtained CAM resources from media (Cirik et al.,

2017). Some (60%) learned about CAM from family and friends (Buchan et al., 2012) and only

5% found CAM resources in books as primary sources (Buchan et al., 2012). Compared to an


earlier study by Buchan et al. in 2012, using the internet to obtain CAM resources had increased

from 25% to roughly 56 % in two studies in Turkey (Cirik et al., 2017; Ozkaptan & Kapucu,

2014).

Legal issues. Nurses revealed that legal issues were major concerns when CAM practice

was not adequately supported by regulations, laws and insurance companies (Ozkaptan &

Kapucu, 2014). Inconsistent evidence was found regarding one question on whether nurses

should be responsible for informing patients about CAM when they were asked. While 76.8% of

nurses in Turkey (Cirik et al., 2017) disagreed, 59.1% and 90 % of the nurses in the studies by

Jong et al. (2015) and van Vliet et al. (2015) respectively, were in favor of this statement.

Furthermore, nurses were not certain if they were allowed to inform patients about CAM (Jong

et., 2015) or if offering CAM to patients was within her scope of practice (Smith & Wu, 2012).

Other barriers. Other obstacles to the success of integrating CAM into nursing practice

were due to the lack of time, support (Smith & Wu, 2012; van Vliet et al., 2015), and scientific

evidence (Jong et al., 2015). Many felt that CAM practice lacks clear definitions (Smith &Wu,

2012). In order “to prevent doing any harm to their patients” (Smith & Wu, 2012, p. 2665),

nurses felt that scientific evidence was an absolute criterion before implementing CAM therapies

(Zoe et al., 2014). Even though there were many barriers to implementing CAM, nurses

expressed strong interests in CAM education and training opportunities (Hassan et al., 2014;

Jong et al., 2015; Smith & Wu, 2012). Some recommended that CAM education should be part

of the core nursing education track (Kim et al., 2016; Ozkaptan & Kapucu, 2014; Smith & Wu,

2012).

Oncology Nurses’ Attitude and Knowledge

There were only a few studies (n=3) about oncology nurses’ attitudes on CAM in this


literature review. The attitudes of oncology nurses toward CAM were consistent compared to

nurses in general (Balouchi et al., 2016; Cirik et al., 2017; Jong et al., 2015; Orkaby &

Greenberger, 2015; Ozkaptan & Kapucu, 2014; Shorofi & Arbon, 2017; Smith & Wu, 2012;

Trail-Mahan et al., 2013; van Vliet et al., 2015). Oncology nurses displayed positive attitudes

toward CAM practice (Hassan et al., 2014; Rojas-Cooley & Grant, 2009; Somani et al., 2014),

and they, too, believed CAM improved patient’s psychological and emotional well-being

(Hassan et al., 2014; Somani et al., 2014), as well as safe and helpful to patients’ conditions

(Hassan et al., 2014). However, they felt that CAM should only be used if they were evidence-

based (Zanini et al., 2008), regulated by law and with close supervision by certified practitioners

(Rojas-Cooley & Grant, 2009). Interestingly enough, more than 50% of oncology nurses

(Somani et al., 2014; Zanini et al., 2008) had encountered patients who were CAM users, but

only a small percentage (37%) of them in Hassan et al. (2014) and (36%) Somani et al.’s (2014)

studies had recommended CAM to patients. In Pakistan, 50% of oncology nurses (n=132)

reported that they never heard about many of the CAM therapies, but they had knowledge about

(65%) prayers and (49%) spiritual healing (Somani et al., 2014). Similar in Qatar, 11% of

oncology nurses never heard of CAM therapy (Hassan et al., 2014) but 85% believed CAM was

safe to use. In the U.S., the majority of the oncology nurses were uncertain about their roles in

CAM practice (Rojas-Cooley & Grant, 2009).

Apparently, oncology nurses were recommending the use of CAM to patient despite

insufficient CAM knowledge (Hassan et al., 2014; Rojas-Cooley & Grant, 2009; Somani et al.,

2014; Zanini et al., 2008). Studies have found that the most common sources oncology nurses

obtained CAM information was from the internet (48.9%), books (60.6%), and professional

journals (5.3%) (Zanini et al., 2008). Only a small percentage of oncology nurses (17% -25%)


(Somani et al., 2014; Zanini et al., 2008) received CAM information from formal nursing

education. Some nurses chose to attend (30%) conferences, (4%) certification courses (Somani

et al., 2014), (29.8%) workshops and seminars (Zanini et al., 2008). The data reported in

oncology nurses’ desire for knowledge was consistent with nurses in general. Although they

received limited education and training, oncology nurses exhibited a high level of motivation in

expanding their knowledge in CAM (Hassan et al., 2014; Rojas-Cooley & Grant, 2009; Somani

et al., 2014). Some had even suggested the need to integrate CAM into the nursing curricula

(Hassan et al., 2014; Somani et al., 2014; Zanini et al., 2008).

Literature Critique

The thematic analysis was found to be consistent and relevant to this study. The critique

demonstrated the appropriate use of approaches, methods, instruments, and design. Many of

these articles on nurses’ attitude and knowledge on CAM were conducted overseas, and the

findings were very similar to those in the U.S. Their strengths, weakness, limitations, and gaps

in the literature will be discussed in the following section.

Strengths

Qualitative research studies provide findings regarding human behavior, emotion, and

personality characteristics (Polit & Beck, 2012). A questionnaire survey offers a more intimate

understanding of the research subjects that quantitative studies does not. The data of these

studies (n=17) provided a glimpse of each participant’s inner perception and feeling about CAM

practice. Another strength is that these evidence-based findings were able to demonstrate the

dire need to bridge the knowledge gap in CAM, and this need can be fulfilled by providing

nursing education and training for nurses. Most importantly, the findings in each have all made a

significant contribution to the nursing practice.


Weakness

Several weaknesses could be identified in these studies, and the most common weakness

was the response rates. The sample size in these studies appeared to be sufficiently large (Rojas-

Cooley & Grant, 2009; Spencer, 2016; van Vliet et al., 2015), but some of the response rates

were suboptimal. Three studies reported to have a low response rate were (18%) Trail-Mahan et

al. (2013), (24%) Rojas-Cooley and Grant (2009), and (28%) Jong et al. (2015). Another three

studies that had a better but average response rate of approximately 40–60% were Balouchi et al.

(2016), Kim et al. (2016), and Orkaby and Greenberger (2015). Studies with low response rates

could indicate a non-response bias, and it could significantly reduce the reliability of the results

(Kim & Mallory, 2014). Hence, the findings in these articles should not be generalized.

Another weakness is the inconsistency in constructing and selecting the survey

instruments among these studies. Some studies borrowed instruments that were previously used

in other studies (Kim et al., 2016; Orkaby & Greenberger, 2015; Somani et al., 2014; Trail-

Mahan et. al., 2013; Zoe et al., 2014) or clinical settings (Jong et al., 2015; van Vliet et al.,

2015). The knowledge assessment section was designed according to the guidelines in the

National Center for Complementary and Alternative Medicine (Rojas-Cooley & Grant, 2009;

Spencer et al., 2016; Zanini et al., 2008) as well as other literatures (Balouchi et al., 2016;

Buchan et al., 2012; Cirik et al., 2017; Hassan et al., 2014; Ozkaptan & Kapucu, 2014). The

origins of these “other literature” were not further defined. Only five studies reported the

Cronbach’s alpha value of their instruments (Balouchi et al., 2016; Kim et al., 2016; Orkaby &

Greenberger, 2015; Trail-Mahan et al., 2013; Shorofi & Arbon, 2017). Before the final

distribution of the survey, the content validity of these questionnaires was evaluated by a panel

of experts and then piloted among nurses. One survey was piloted among nurses but was not


evaluated by other experts or researchers (Zanini et al., 2008), and some did not report the

content validity (Buchan et al., 2012; Hassan et al., 2014). Several of these questionnaires did

not have further testing for validity and reliability (Jong et al., 2015; Somani et al., 2014;

Spencer et al., 2016; van Vliet et al., 2015). Content validity is measured by the individuals who

are experts or specialists in the field (Polit & Beck, 2012). While some of these instruments were

claimed to be evaluated by a panel of “experts,” the credibility of these “experts” was not

disclosed. The accuracy of the content validity varies upon the reviewers who screened these

questionnaires. It is because of the differences in CAM definitions, instruments for data

collection and study designs, it may be meaningless or even faulty to compare data without the

use of a standardized instrument.

Gaps

Much of these literature showed that nurses have limited experience and knowledge

about CAM, but only three studies were sampled on oncology nurses. CAM plays a significant

role in the field of oncology. Patients with cancer tend to pursue in every aspect of the

healthcare spectrum to find a cure (National Center for Complementary and Integrative Health

[NCCIH], 2016a). Studies across 18 countries demonstrated that 40% of cancer patients

reported current and past CAM use. The highest prevalence CAM use was recorded in the U.S.

and lowest in Italy and the Netherlands (Horneber et al., 2011). Oncology nurses would be ideal

to provide supportive CAM information for cancer patients. Current literature are lacking

information on this population of specialty nurses. Future research studies should emphasize the

assessment of oncology nurses’ attitude and knowledge on CAM.

The next gap is that there was no assessment on the learning needs of nurses. These

studies concluded that lack of knowledge was the common barrier to CAM integration. It had


been suggested that education and training are much needed but no recommendations on how

they should be implemented. Perhaps the first step is to conduct a need assessment among

nurses in order to determine the educational priorities.

Limitations

These literature have several limitations. First, the use of convenience sample or a cross-

sectional study conducted in one institution or country may not be generalized to cover all

clinical settings or nursing discipline. Second, self-reported questionnaire in itself is a limitation.

These questionnaires may not accurately reflect the genuine attitude due to the fixed choices of

response format on the Likert scale. In addition, terminologies and questions in the survey may

not be fully understood, and that could result in a misrepresentation of the knowledge level.

Finally, the search history was only limited to English published journals. Since much of CAM

practice was originated in the East, many relevant studies may have been missed in the non-

English published journals.

Concepts and Definitions

Scope of CAM

The National Center for Complementary and Integrative Health (NCCIH) groups CAM

into two subgroups: Natural products or mind and body practices (2016b).

1. Natural products - vitamins, herbs, botanical, foods, dietary supplements, probiotics and

other products that contain substances found in nature (NCCIH, 2016b, para. 8).

2. Mind/body medicine - yoga, chiropractic and osteopathic manipulation, meditation, and

massage therapy. Other mind and body practices include acupuncture, relaxation

techniques (such as breathing exercises, guided imagery, and progressive muscle

relaxation), tai chi, qi gong, healing touch, hypnotherapy, and movement therapies such


as Feldenkrais method, Alexander technique, Pilates, Rolfing Structural Integration, and

Trager psychophysical integration (NCCIH, 2016b, para. 11).

3. Other complementary health approaches that do not fall into either of these groups are the

practices of traditional healers, Ayurvedic medicine, traditional Chinese medicine,

homeopathy, and naturopathy (NCCIH, 2016b, para. 12).

Operational Definitions

Complementary medicine. A non-mainstream practice that is used in conjunction with

conventional medicine (NCCIH, 2016b, para. 3).

Alternative medicine. A non-mainstream practice that is used in place of conventional

medicine (NCCIH, 2016b, para. 3).

Attitude. Eagly and Chaiken (1993) defined attitude as a “psychological tendency that is

expressed by evaluating a particular entity with some degree of favor or disfavor” (p. 1). An

attitude is a configuration of beliefs, feelings, and behavioral propensity towards any meaningful

and valuable objects, people, events or symbols (Hogg & Vaughan, 2005). Several well-known

social psychologists (Fishbein & Ajzen, 1975; Hodges & Logan, 2012; Katz, 1960; LaPiere,

1934) believed that attitude dictates behavior, but other factors such as experience and learning

can also influence a person’s attitude (Hogg & Vaughan, 2005).

Knowledge. Knowledge is one way of getting at the truth, to understand something or

someone and the analysis of knowledge attempts to explain what “getting at the truth” means

(Ichikawa & Steup, 2012). In nursing, there are four fundamental patterns of knowing (Carper,

1978), empirical, esthetic, personal and ethical. Later, Chinn and Kramer (2013), identified a

fifth pattern: emancipatory knowing. Nurses may benefit from recognizing these patterns of

knowing when these elements are being considered and integrated into their daily nursing


practices.

Theoretical Framework

Evidence-Based Nursing Practice Model

Evidence-based practice (EBP) is a fundamental element in guiding the overall quality

improvement in nursing practice (Stevens, 2013). The goal of EBP is to combine clinical

expertise, patient values, and the best research evidence into clinical decision process (Keele,

2011). The Stevens Star Model of Knowledge Transformation (SSMKT) is an example of EBP

model created by Dr. Kathleen Stevens in 2004 (Stevens, 2012). It is a framework that

systematically transforms EBP process into practice through five stages: 1) discovery research,

2) evidence summary, 3) translation to guidelines, 4) practice integration, and 5) process,

outcome evaluation (Figure 1). The SSMKT would be the best EBP model to use to guide this

study. Permission to reprint the SSMKT diagram was granted by Dr. Stevens (Appendix I).

Figure 1. Stevens Star Model of Knowledge Transformation. Reprinted with permission from Stevens, K. R. (2015).


During the initial stage of knowledge discovery (point 1), various research studies were

conducted and published on CAM therapies. In point 2 of knowledge-generating phase,

available evidence and findings were reviewed and analyzed. Studies showed that CAM

popularity continues to rise among patients, but nursing discipline has not been able to

accommodate the need for CAM education. This form of knowledge (summarized research

evidence) can be combined with clinical expertise and personal experience, and then apply to a

specific population like nursing. At the midpoint (point 3) of the cycle, evidence can be

translated into guidelines (point 3) after we determine what type of action is necessary to bring

about the change. In this study, it is hoped that presenting CAM educational training to

oncology nurses would be the appropriate intervention to improve their attitude and knowledge.

If education delivers a desirable and positive outcome, results can then be translated into practice

guidelines. At point 4, consideration is given to which practice is aligned to reflect the best

evidence. Finding of this study would suggest that nursing education or administration is the

best place to recommend practice integration. Supplemental training should be made available

for nurses who care for the CAM users, or for those who simply wish to advance themselves. At

the final stage of knowledge transformation, outcomes can be evaluated through a variety of

methods and techniques (Stevens, 2012). “Quality improvement of healthcare processes and

outcomes is the goal of knowledge transformation” (Stevens, 2013, para. 12). Nurses continue to

have difficulties implementing EBP, yet they do want to gain more knowledge and support from

their institutions (Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012). Therefore, it is

reasonable for nurse leaders and educators to consider providing various learning opportunities

regarding EBP.


Conclusion

Given the increased demand for CAM use in the past decade, nurses are expected to face

the challenge of patients’ inquiries. Personal beliefs and perceptions on CAM can influence

nurses’ willingness to discuss its use with patients. Caring may or may not require knowledge or

expertise,but knowledge and expertise are required to care for those who cannot care for

themselves (Finkelman & Kenner, 2013). How do nurses provide proper patient care if they are

insufficiently prepared to assess CAM use in patients? The evidence of nurses not assessing

CAM use in patients points to the need for higher education. Taken together, nurses’ attitude

toward CAM appeared to be overwhelmingly positive, but their knowledge of these therapies

was far from adequate. The lack of knowledge among nurses can lead to missed opportunities for

proper counseling, documenting and monitoring patient’s use of CAM. In reviewing the

literature, the reasons nurses desired for an in-depth CAM training were to fulfill their own

interests and to benefit the patients with credible information. For nurses to provide appropriate

care for patients who seek CAM practice, health care systems should consider including CAM

in-service training or continuing education program. Through formal CAM education and

training from credible providers, nurses would likely be able to make a knowledgeable decision

concerning its use. Moreover, they would be able to effectively provide counseling for patients

and advise them about the potential interactions with conventional therapies.


Chapter III: Methodology

Chapter III will provide detailed information on the direction of this project and the

procedure used for the methodology proceeding. The goal of this project is to explore the nurses’

attitude and knowledge on CAM. This chapter will discuss the project design, sampling,

instrumentations, procedure, data collection, and analysis of this project.

Project and Study Design

Project Design

This project utilizes a questionnaire-based survey to evaluate nurses’ attitude and

knowledge on CAM. A cross-sectional study with a pretest-posttest design (before-after design)

will be used for this project. This type of design involves obtaining a pretest baseline measure of

the outcomes prior to administering an intervention, followed by a posttest on the same measure

after an intervention takes place (Polit & Beck, 2012). The effectiveness of the educational

intervention can be measured by comparing the difference in responses between both tests.

Setting and Resources

Setting. This project will be conducted in one of the Broward chapter Oncology

Nursing Society (BONUS) monthly dinner meetings. These dinner meetings typically take place

in different restaurants every month and they are sponsored by different pharmaceutical

companies. The location of the restaurant is reserved six months in advanced by the BONUS

committee, and it was announced two weeks before the event. The BONUS president reviews

the content of the program with the committee members before each meeting. The sponsoring

pharmaceutical company will then be notified of the assigned date and time for the educational

meeting six months in advance. The project coordinator was granted permission to conduct this

project at one of the BONUS dinner meetings by the committee of BONUS. An approval letter


to conduct this survey can be found in Appendix C. An email notification will be sent out two

weeks before the event.

After receiving the Institutional Review Board (IRB) approval from Maryville University

(MU), the project coordinator will proceed with the project first by notifying the BONUS

committee. The BONUS committee will confirm the date and time of the next dinner meeting.

An email invitation (Appendix E) with a CAM flyer (Appendix D) will be sent to the potential

participants by the BONUS committee approximately two months prior to the event. Invitations

are opened to members as well as non-members who are interested in attending the dinner

meeting.

Before the lecture begins, participants will be given an informed letter (Appendix F)

explaining the purpose of the survey. The informed letter will also state that any collected data

would be presented anonymously, and participation is entirely voluntary. Any participants who

wish to participate will fill out the self-administered questionnaire (pretest). The purpose of the

pretest is to obtain the oncology nurses’ baseline attitude and knowledge toward CAM. After the

pretest is complete, a 45-minute PowerPoint presentation containing the basic concepts of CAM

will be given at the dinner meeting. Following the conclusion of the lecture, participants will be

given the posttest (without the demographic section) to evaluate the changes in their attitude and

knowledge. Questionnaires should take approximately 5-10 minutes to complete. The survey

will be collected anonymously by the project coordinator in a sealed envelope at the end of the

meeting.

Study Population

This is a convenient sampling where the sample are being drawn at a given time frame.

The participants can be either male or female, between the age of 21 and 65. They could be


members or non-members of BONUS. They need to be practicing nurses who have a Bachelor

of Science in Nursing, Master of Science in Nursing, or Doctoral degree in nursing (Doctor in

Nursing Practice or Doctor of Philosophy) with minimal one year of past oncology experience or

at least three months of current oncology experience. Nursing students and licensed practical

nurses are excluded. The number of participants is expected to be 15 – 20 which is considered to

be adequate for this type of intervention project (Rohde, 2008).

Data Collection Tool

A 28-item survey questionnaire comprised of three sections was developed to assess

attitude and knowledge on CAM (Appendix G). Part one is made up of five demographic

questions inquiring about the age group, gender, level of education and years of oncology

experience, past or current. Part two of the attitude section is based on the survey instrument

developed by Shorofi and Arbon (2017). An explicit email permission to use this instrument was

granted by the first author Dr. Seyed Afshin Shorofi (Appendix B). Only 10 items are selected

for this survey due to time constraint. The participants will rate each item based on a five-point

Likert-type scale (strongly disagree/very negative= 5, disagree/negative = 4, unsure/neutral = 3,

agree/positive = 2, and strongly agree/very positive = 1). Part three of the survey consists of 13

self-assessment knowledge items. These items were constructed based on the information

gathered in the literature review from Complementary/alternative therapies in nursing (Lindquist

& Snyder, 2010), Complementary and integrative modalities (Johnson & Bourgon, 2015), and

the National Center for Complementary and Integrative Health website (2016).

Plan for Data Analysis

The data collected in this project will be entered in the Excel spreadsheet and analyzed by

using the International Business Machines (IBM) Statistical Package for the Social Science


(SPSS) version 25. Descriptive statistics will be used to describe and calculate the demographic

data. The percentage score will be calculated by adding the responses of attitude and knowledge

items for each participant.

Demographic Data

The first section contains five demographic items including age, years of experience,

degree, and gender. Age, years of experience, past or current are “interval variables” measured

in years; summary statistics such as mean, median, standard deviation, and minimum/maximum

will be used to describe these variables (Kim & Mallory, 2017). Degree and gender are

“categorical variables,” where each person fits in a category (Kim & Mallory, 2017). As such,

frequency tables will be applied to illustrate the number and percentage of participants in each

category.

Attitude Assessment

The second section comprised of 10 Likert-type attitude items that were adapted from a

validated instrument (Shorofi & Arbon, 2017) with “strongly disagree/very negative” responses

rated at one and “strongly agree/very positive” responses rated at five. “Strongly agree” or “very

positive” responses would indicate a positive attitude. To determine the attitude scores of each

nurse, the points across all of the questions for the pre- and post-lecture surveys will be added up

then compared.

Knowledge Assessment

The third section of the survey consists of 13 multiple choice knowledge questions that

each participant can answer correctly or incorrectly about CAM. It means that participants can

get a score anywhere from 0 to 13. Each participant’s knowledge scores will be calculated

before and after the lecture by creating a difference score for each person. The difference


between pre- and post-tests reflects the impact of the educational program. The percentage

change can be positive, negative or no change.

Statistical Analysis

A paired t-test may be used to compare the correct responses on the pre- and post-test

composed of 10 attitudes and 13 knowledge assessment questions. A paired t-test assumes that

the changes in the scores from pre- to post-intervention are normally distributed (Kim &

Mallory, 2017). It means that a bell-shaped curve should appear in the histogram with a normal

distribution. If the differences between scores are not normally distributed, a non-parametric test

(ex. Wilcoxon signed-rank test) should be considered when analyzing these data (Kim &

Mallory, 2017).

Quality

Reliability

The most common method for evaluating the internal consistency reliability is the

Cronbach’s alpha (coefficient alpha) (Polit & Beck, 2012). The normal range of values is

between .00 to +1.00. The attitude section of the survey instrument developed by Shorofi and

Arbon (2017) reported having a Cronbach's alpha coefficient of .929. The higher the Cronbach’s

alpha indicates a higher internal consistency (Polit & Beck, 2012).

Validity

Content validity measures whether the questions of an instrument actually measure what

they supposed to and it is often assessed by a panel of experts (Polit & Beck, 2012). For

validation, the content of this survey was reviewed by one CAM expert, one oncology physician,

and one oncology nurse educator. Certain wordings were revised, and some questions were

rephrased for clarity in the knowledge assessment section. Face validity allows anyone to take


the test at its face value and conclude whether the instrument looks like what it is measuring

(Polit & Beck, 2012). The survey was piloted on one oncology nurse and one oncology nurse

practitioner. They both understood the content fully and provided no recommendations for

changes.

Project Timeline

A project timeline was constructed by the project coordinator to ensure timely

achievement of each project milestone. Once a project timeline was created, it would be best to

update the schedule regularly and monitor the progress throughout the entire project. BONUS

approval letter was obtained on October 1, 2017. The completed Institutional Review Board

(IRB) application was sent to the Doctor of Nursing Practice (DNP) committee chair for review

on October 7, 2017 and was approved on October 20, 2017. The application was then submitted

to the Associate Dean for the DNP program on October 21, 2017. After several revisions, the

IRB application was finalized and approved by both the DNP committee chair and the Associate

Dean for the DNP program on December 8, 2017. The application was immediately sent to the

IRB administrator the same day for final reviewed. On January 22, 2018, the final approval from

the IRB committee was receiving and data collection was started the following month.

Budget

Direct Cost. The project coordinator will be responsible for printing and organizing the

questionnaire packages. BONUS provided all the necessary equipment for the presentation

which included all the audio and visual equipment for the lecture such as a laptop computer for

PowerPoint presentation, speakers, microphone and projector screen. The location of the

restaurant was expected to be within Broward County and the parking was free. The project

coordinator was responsible for only the paper used for printing the survey which was


approximately $5.

Indirect Cost. Indirect cost includes the facilities and administrative costs. This project

was conducted at one of the BONUS monthly dinner meetings sponsored by a pharmaceutical

company. The sponsoring pharmaceutical company was responsible for any expenses incurred

in the dinner meeting, which includes meals, beverages, tipping, and room reservation.

Membership fees. Annual BONUS membership fee was $150.

Consultation service. An estimated $100 will be budgeted into the consultation fees for

data analysis.

Funding. Alternatively, funding is available through the American Cancer Society

(ACS). The ACS offers a scholarship of $10,000 a year to graduate students who pursue a

doctoral study in the field of cancer nursing research. The deadline for turning in application this

year is November 17 (American Cancer Society, 2017). Since this project requires minimal

expense, applying for additional funding would not deem necessary.

Ethics and Human Subjects Protection

The project coordinator is ultimately responsible for the ethical issues and the protection

of human subjects. Maryville University (MU) requires all student researchers and project

coordinators complete the Collaborative Institutional Training Initiative (CITI) training program

prior to conducting any research studies or scholarly projects. CITI training involves a web-

based tutorial in the ethics of research with human subjects. The project coordinator has

successfully completed the CITI training for both the Biomedical Research and the Social and

Behavior Research courses (Appendix J). CITI Certificates was submitted along with the IRB

application for review. Although this project involves the use of questionnaire-based survey and

should be eligible for the exemption, the project coordinator still sought the MU IRB approval.


Voluntary Participation

Before the lecture begins, the project coordinator will present an informed letter

(Appendix F) to the participants which will clearly state the purpose of the survey, the clause of

confidentiality, and the right as participants. Any potential participant who wishes to participate

will fill out the self-administered questionnaire. Completing the survey indicates that the

participants have read the letter, have had any questions answered, and voluntarily agreed to

participate in this scholarly project. Participants do not have to answer any questions they do not

wish to, and they may choose to withdraw anytime without penalty.

Research Risks

This survey presents minimal risks to the participants. There are no psychological or

physical risks anticipated from participating in the survey. Answering the survey questions

should not cause any adverse effect on the participants. If participants experience any

discomfort at any time, they are encouraged to skip any questions or withdraw from the survey.

Research Benefits

There will be no compensation or incentives offered for the participants involved in the

project, and no continuing education units rewarded to the participants for attending this

educational lecture. Potential benefits may include: 1) a better understanding of the basic

concepts of various CAM modalities, 2) a more favorable attitude toward CAM, 3) able to

provide counseling to patients about CAM modalities, and 4) able to confidently inquire CAM

use when taking nursing history.

Confidentiality

The project coordinator will take all the necessary steps in order to guarantee the security

of the collected data. No personal identifiable information (like the name of the respondent or


address of the house) will be collected through the use of this survey. Any surveys that might

have inadvertently included names or other identifying information will be immediately

destroyed. Only aggregated data will be reported. Thus, confidentiality is protected. Data will

be stored in the locked files, entered in the Excel spreadsheet, and in password-protected

computer files. Only the project coordinator and the statistician will have access to the data.

After the completion of the project, the original surveys forms will be shredded along with any

information linking the electronic data with the original survey at the project coordinator’s home.

All the project data stored on the computer’s hard drive will be erased using a commercial

software application designed to remove data from the storage device. All data that are backed

up by the USB flash drive will be physically destroyed with a hammer then submerged into the

water.

Results

Data will be available at the conclusion of the study. Findings will be presented upon the

completion of the scholarly project to MU community. The results of this scholarly project may

be submitted to potential journals for publishing.

Conclusion

Chapter three presents all the elements of methodology. In addition to the four main

sections (study design, sampling, data collection and data analysis), project budget and timeline

were also analyzed and discussed. Most importantly, all aspects relating to the protection of

human subjects in research were addressed in detail. The consent form was constructed

according to the MU inform consent template. All required documents including

permission/copyright letters, flyer, instruments and CITI training certificates are available for

review and can be found in the appendices.


Chapter IV: Discussion

This chapter describes the analysis of the data collected for the project. Data were

analyzed to explore oncology nurses’ attitude and knowledge on CAM. As Polit and Beck

(2012) explained, the antecedent cause is the independent variable, and the consequent effect is

the dependent variable. The dependent and independent variable can be viewed as a cause-and-

effect relationship. It means that while the value of the independent variable can be manipulated

by the project coordinator, the value of the dependent variable will only vary in response to the

independent variable.

In this project, a survey was implemented to inquire a series of questions regarding the

oncology nurses’ attitude and knowledge. A pre-test/post-test design was used to evaluate the

effectiveness of the education intervention (independent variable). The differences in response

from the oncology nurses’ attitude and knowledge would suggest whether the CAM lecture has a

positive or negative impact on their attitude and knowledge.

Congruence in Measurement and Data

Data Size

Of the 33 oncology nurse participants, 29 surveys were completed, yielding a response

rate of 87.87%. Sample size measures the number of individual samples used in a survey (Kim

& Mallory, 2017). The larger the sample size, the more certain the participants’ answers truly

reflect the population. Whereas, small sample size can negatively impact the ability to make

inferences (Kim & Mallory, 2017). The four incomplete surveys were treated as missing data

and were deleted. This scholarly project is an intervention project in which the goal is to

evaluate the effectiveness of an educational program. Although statistical power can be affected

by intervention effect size, and a larger sample size may yield a higher statistical power (Kim &


Mallory, 2017), these factors do not apply to this type of project for reason that no matter how

large the design is, a weak intervention will not give us meaningful effects (Rohde, 2008). In

this scholarly project, instead of increasing the statistical power, we can increase the vigor of the

content in the educational program (Rohde, 2008). Therefore, a sample size of 29 was

considered adequate and acceptable. When conducting an evidence-based project, it would be

unnecessary to perform a power analysis because it would be meaningless to attempt to

generalize our findings.

Setting for Data Collection

The setting for the data collection was intended to be in a local restaurant which was

strategically planned for this project. BONUS typically hosts one meeting each month in

different restaurants where oncology nurses gather and learn about the latest development in

oncology. These dinner lectures are sponsored by different pharmaceutical companies. It was an

opportune place to conduct this project because of the number of potential participants in these

meetings, but it was certainly not an ideal setting for this project.

Data Reliability and Validity

Reliability implies the consistency in a study and should deliver the same results every

time whereas validity refers to whether an instrument measures what it is supposed to (Polit &

Beck, 2012). Part two of the survey was the attitude assessment which was originally developed

by Shorofi and Arbon (2017). Their survey instrument was reported to have a Cronbach's alpha

coefficient of .929. Cronbach’s alpha (coefficient alpha) is one of the most common methods for

evaluating the internal consistency reliability (Polit & Beck, 2012) and a value of .929 indicates

a relatively high internal consistency.

Face and content validity were previously tested before data collection. The


questionnaires were piloted on one oncology nurse and one oncology nurse practitioner. The

amount of time it took to complete the pre-test and post-test was about 15 minutes each. It was

believed that there was sufficient time to allow participants to complete the survey. The only

data collector in this study was the project coordinator. Duration of the presentation had to be

reduced from 45 minutes to 20 minutes due to time constraint, but fortunately, all material was

delivered within the allotted time, and all data was collected in the same evening without any

problems.

Replicating Data Collection Plan

Reliability refers to whether data are measured and collected consistently, and the results

are the same when measurements are repeated (Polit & Beck, 2012). It would not be possible to

obtain test-retest reliability for this project because the survey contains no personal information

that can identify the participants. As such, repeating the same measure to the same group of

oncology nurses would not be a feasible process. On the other hand, the data collection plan

itself could likely be replicated on a different group of participants.

Data Analysis

This survey comprised of three sections and the data will be examined as follow:

(1) the first section includes demographic information such as age, gender, education, years

oncology experience, past or current, level of education, (2) the second section contained 10

items related to attitude about CAM, and (3) the third section contained 13 items related to

knowledge about CAM. All data were analyzed by using the IBM SPSS version 25.

Descriptive statistics were applied to the collected data. Survey responses were aggregated in

frequencies and percentages.


Statistical Analysis

Demographics

Of the 33 oncology nurse participants, 29 surveys were completed, yielding a response

rate of 87.87%. The four incomplete surveys were treated as missing data and were deleted.

Table 1 details the characteristics of the participants. Overall, 62.0% of the participated

oncology nurses were 50 years old or older. Only 17.2% were under the age of 40. Participants

were mostly female (89.7%). The survey was made up of participants with bachelor’s degree

(55.2%) as well as master’s degree (44.8%). None of them held a doctoral degree. The majority

of the nurses (93%) had current oncology experience.


Table 1

Demographic Characteristics of Oncology NursesCharacteristics n %

Sample size 29 100.0

Age group21 - 29 2 6.930 - 39 3 10.340 - 49 6 20.750 - 59 9 31.060+ 9 31.0

GenderFemale 26 89.7Male 3 10.3

EducationBachelor 16 55.2Master 13 44.8Doctoral 0 0.0

Years Oncology experienceLess than 3 months 3 10.32 - 10 years 11 37.911 - 20 years 10 34.521 - 30 years 2 6.930+ years 3 10.3

ExperienceCurrent 27 93.1Past 2 6.9

General Attitude toward CAM

The attitude score was based on the 10 attitude items. The questionnaire was

administered using a 5-point Likert scale range from 5 = strongly agree/very positive, 4=

agree/positive, 3= unsure/neutral, 2= disagree/negative, and 1 = strongly disagree/very negative.

The final score ranges from 10 (if the respondent “strongly disagreed” with all of the positive

statements) to 50 (if the respondents “strongly agreed” with all the positive statements).


Oncology nurses’ general attitude toward CAM revealed the following results.

In Table 2, the mean attitude score increased from 34.07 before the intervention to 36.28

after the intervention. The median score also increased, from 35 to 37. The standard deviation is

a measure of variability among the responses; it can be interpreted as the “typical” pre-

intervention response was within +/- 6.117 points of the average of 34.07 (and the typical post-

intervention responses was within +/- 4.810 points of the average of 36.28). Finally, the

minimum and maximum represent the lowest and highest attitude scores, respectively, at each

time point. In order to determine the most appropriate statistical test, distribution of the changes

in the attitude scores need to be analyzed.

Table 2

Summary Statistics of Pre- and Post-Intervention Attitude ScoresTime Mean Median Standard deviation Minimum Maximum

Pre-Intervention 34.07 35 6.117 20 46

Post-Intervention 36.28 37 4.810 22 42

Figure 2 is a histogram of the score changes, which were calculated for each participant

by subtracting the pre-intervention attitude score from the post-intervention attitude score. The

figure is roughly symmetric and bell-shaped and can be considered approximately normal for the

statistical analysis. Therefore, a paired t-test was used to determine whether the scores have

increased (Table 3).


Figure 2. Histogram of Changes in Attitude Scores

Table 3

Results of Paired t-Test for Attitude Scores95% CI

Mean SD Standard Error Mean Lower Upper t df p2.207 3.658 0.679 0.815 3.598 3.249 28 *.003

Note. CI=confidence interval; df = Degree of freedom; SD=Standard Deviation. *p< .05.

The mean is the average change from pre-intervention to post-intervention attitude (the

participants increased their attitude scores by an average of 2.207 points). The standard

deviation is how close the typical participant will be to this average (within +/- 3.658 points of

the average score change of 2.207 points). The standard error of the mean is a measure of how

“close” the average of 2.207 from this sample might be to the overall average you would find if

all members of this population went through the intervention. The 95% confidence interval

indicates that we are “95% confident” that this overall average change for the population (not

just for this sample of nurses) is between 0.815 and 3.598.

The t statistic of 3.249 is a standardized version of the difference between the two groups

that can be interpreted through the p-value. The degree of freedom is the sample size of 29

minus 1. The p-value of 0.003 means that if there is no change in the general group of oncology

nurses, the probability we would have seen a change in the attitude score in this particular


sample as large as 2.207 is 0.3% (very small). For changes to be considered significant, the p-

value has to be less than 0.05. Therefore, it can be concluded that there is a statistically

significant increase (at the 0.05 level of significance) of the attitude scores that is associated with

the implementation of the educational intervention.

In addition to the attitude score, there was an isolated question that asked directly about

the attitude toward CAM, which was item 10 (“Overall, how would you describe your attitude

toward CAM?”). Responses ranged from “very positive” to “very negative.” Table 4 shows the

distribution of responses to this question in both pre- and post-intervention. The distribution

does appear as if the responses have shifted toward the positive end of the scale. In order to

determine whether this shift was statistically significant, the Wilcoxon signed -rank test was

selected for this statistical calculation. This test can be used for paired data (pre/post responses

from the same individuals) or ordinal responses (the ordered categorical responses in this survey)

that do not have a normal distribution. This is considered a test of the “median” response

between two groups.

Table 4

Pre- and Post-Intervention for Attitude Question Item 10Attitude toward CAM

TimeVery Positive Positive Unsure Negative

Very Negative Total

Pre-Intervention Count 8 14 4 3 0 29 Percent 27.6% 48.3% 13.8% 10.3% 0.0% 100.0%

Port-Intervention

Count 12 13 2 2 0 29Percent 41.4% 44.8% 6.9% 6.9% 0.0% 100.0%

The following table (see Table 5) displays the results of the Wilcoxon signed- rank test.

It has only two statistics. The Z statistic is the standardized difference in the responses that


participants provided between the pre- and post-intervention periods and is interpreted through

the p-value. The p-value of .021 indicates that there is a statistically significant increase (at

the .05 level of significance) in the self-reported attitudes associated with the implementation of

the educational intervention.

Table 5

Results of Wilcoxon Signed Rank Test for Attitude Question Item 10Z p

2.309 *.021*p< .05.

Knowledge Score

The knowledge score was based on the 13 knowledge questions; the score is the number

of the knowledge questions that were answered correctly. Table 6 summarizes the number of

knowledge questions answered correctly before and after the intervention. The average score

increased from 6.59 before the intervention to 8.76 after the intervention. The median score also

increased, from 7 to 9. In order to determine the most appropriate statistical test, we need to

examine the distribution of the changes in the knowledge scores.

Table 6

Summary Statistics of Pre- and Post-Intervention Knowledge Scores

Time Mean MedianStandard deviation

Minimum Maximum

Pre-Intervention 6.59 7 2.413 2 11

Post-Intervention 8.76 9 1.662 4 11

Figure 3 is a histogram of the score changes, which were calculated for each participant

by subtracting the pre-intervention knowledge score from the post-intervention knowledge score.

The figure is roughly symmetric and bell-shaped and normal for the statistical analysis.

Therefore, it would be appropriate to use a paired t-test to determine whether the scores have


increased. The results of the t-test are given in Table 7.

Figure 3. Histogram of Changes in Knolwedge Scores

In table 7, the p-value was less than .001, which means that there is a statistically

significant increase (at the 0.05 level of significance) of the knowledge scores associated with

the implementation of the educational intervention.

Table 7

Results of Paired t-Test for Knowledge Scores95% CI

Mean SD Standard Error Mean Lower Upper t df p2.172 2.285 0.424 1.303 3.041 5.121 28 *< .001

Note. CI=confidence interval; df = Degree of freedom; SD=Standard deviation. *p< .05.

Conclusions

This survey compared attitude scores, responses to a single item about attitude, and

knowledge scores before and after an educational intervention surrounding CAM practices.

Statistical analyses indicated that an overall scores improvement following the educational

intervention. The intervention is associated with a more positive attitude and a stronger

knowledge of CAM.


Chapter V: Conclusion

Given the prevalence of CAM use among patients, it is critically important to determine

oncology nurses’ attitudes and knowledge toward CAM in order to successfully integrate CAM

educational training. The purpose of this project is (1) to evaluate nurses’ baseline knowledge

and their general attitude toward CAM, (2) to improve their knowledge through CAM

educational training, and (3) to implement a CAM educational program that can be utilized to

continue to enhance knowledge of CAM for nurses into nursing practice. This chapter will

disuss the findings in this project as well as its strengths and limitations.

Oncology Nurses’ Attitude toward CAM

In item 10 of this survey “overall, how would you describe your attitude toward CAM”,

oncology nurses demonstrated a positive attitude toward CAM in the initial pre-test (75.86%)

and as well as in the post-test (86.21%). Additionally, the number of nurses who initially had a

“neutral” attitude toward CAM (13.79%) was reduced in half (6.89%) following the lecture.

These results are congruent with the findings in other literature (Hassan et al., 2014; Rojas-

Cooley & Grant, 2009; Somani et al., 2014) in oncology nurses’ attitude toward CAM. In

addition, there was a statistically significant increase (p = .021) of these self-reporting attitude

scores, as well as in the general attitude scores (p = .003), suggesting that there was a positive

association with attitude and the implementation of the educational intervention.

Improving Nurses’ Knowledge through CAM Educational Training

Oncology nurses in this survey scored an average of 6.59 out of 13 points. The results of

the knowledge assessment in this project resembled the knowledge scores in the study by Kim et

al. (2016) which was insufficient. Other studies that provided evidence of nurses with limited

knowledge of CAM were Ozkaptan and Kapucu (2014), Smith and Wu (2012), Shorofi and


Arbon (2017), Zanini et al. (2008), and Zoe et al. (2014). Although there had been evidence of

knowledge deficit in oncology nurses in CAM (Hassan et al., 2014; Rojas-Cooley & Grant,

2009; Somani et al., 2014), results in this survey indicated that there was a slight increase in the

mean knowledge scores from 7 to 9 with a statistical significance increase (p = < .001) after the

CAM lecture. Much like in the attitude scores, the improvement in knowledge scores was

associated with the implementation of the educational intervention.

Limitations

This scholarly project has several limitations. First, although the knowledge assessment

questions in the survey instrument had been evaluated by a panel of oncology experts, the

accuracy of the content validity varies upon the reviewers’ level of expertise. Also, the post-

scores may be even higher if the CAM lecture was presented by an integrative medicine

physician or a CAM practitioner with a more in-depth knowledge in the field of CAM.

Second, a non-traditional learning environment may also impact the knowledge scores as

the distractions in the restaurant may diminish the participants’ concentration to analyze

questions and comprehend the lecture material. That is to say, it is uncertain whether

participants were able to fully engage in the learning process while the lecture was presented in a

social setting instead of a formal learning environment. Factors such as food delivery, service

workers bring out the entrees and clearing out the dishes as well as the sedative effect of the

alcohol combined with postprandial somnolence could affect the participants’ attention to retain

information from the lecture. Places like traditional classroom, auditorium or conference center

would be more ideal to conduct this type of project as it would allow participants to fully engage

in the learning process.

A lack of honesty in responding to the attitude questions could be another element that


can influence the results as these questionnaire surveys rely solely on participants’ truthfulness to

answer the questions. Although questionnaires are the most convenient manner to gather

information, some of the disadvantages of using this type of design are the subjectivity of the

results and the limited choices of response. This is a convenient sample consists of mostly

female with BSN and MSN degrees. Studies including nurses with doctoral degrees and equal

gender ratio might have given different results. Lastly, findings are limited to only the oncology

nurses attended the BONUS dinner meeting. Therefore, findings should not be generalized.

Strengths

Despite these limitations, this project provides useful information that can guide future

development of implementation of CAM education training . One other strength of this project is

achieving a high response rate of 87% (N=33). Further, the survey instrument itself was reported

to have excellent internal consistency reliability (Cronbach's alpha coefficient = .929).

Implication for Nursing Practice

Based on the findings of this project, the positive impact of CAM intervention on attitude

and knowledge in oncology nurses suggests that a comprehensive CAM educational training

course would likely be beneficial. Nurse administrators and managers should take advantage of

their favorable attitude toward CAM and structurally establish an educational training program

that is dedicated to CAM practice. Health care systems should consider incorporating CAM

continuing education program to strengthen their knowledge and skill set.

Given the growing popularity of CAM, nurses should therefore require to assess and

document CAM usage when taking nursing history. By inquiring and communicating with

patients about CAM usage, nurses may be able to reduce the risk of potential adversed effects,

toxicities, and interaction with conventional therapy.


Moreover, early CAM education is vital for nursing students, so they can be more

familiar with different CAM modalities and be accustomed to assessing CAM usage in patients

Although it may be challenging for nursing school to integrate CAM course into the already

crowded nursing curricular, preparing future nurses to provide safe and holistic care should be a

priority to consider. Patients deserve to be cared for by nurses who are knowledgeable and

sensible about their preferences in CAM approaches.

Implication for Future Research

Additional studies should focus on assessing CAM learning needs among oncology

nurses. A more reliable knowledge assessment tool would be useful to accurately measure CAM

knowledge. Future studies should also include assessing the knowledge level of nursing

students, nurses in general as well as nurse practitioners.

Conclusion

Western medicine extends millions of lives through evidence-based practice, advance

technologies and scientific discoveries, but the greatness of modern medicine fails to recognize

other important aspects such as social, emotional and psychological beings are all contributing

factors to a person’s state of illness. Although the duality of mind and body exist, but their

connections should not be overlooked. CAM encompasses the philosophy of healing the

physical and non-physical self. Because human beings exist as “wholes”, maintaining a good

health involves adequate exercise, proper diet, and care of the body, most of all, creating a

harmony between body, mind and spirit.

Nightingales believed individuals are complex, holistic beings and the duty of a nurse is

to foster health within the patient (Selanders & Crane, 2012). The holistic concept of CAM

aligns with Florence Nightingales’ timeless philosophy in nursing which is to promote optimal


wellness in all aspects of a person. CAM practice offers a holistic approach that heals the

patient’s the body, mind, and spirit. When facing cancer, patients may seek other options that

can provide support, versatility, and autonomy in conjunction with conventional medicine.

Insufficient knowledge hinders oncology nurses’ ability to assess and counsel patients regarding

CAM use. For this reason, oncology nurses must be educated in different CAM modalities, as

well as their benefits and potential adverse effects to deliver safe and effective care. There is

critical need to expand CAM knowledge in oncology nurses given their roles in the overall

management of this special population of patients. Integrating CAM educational training is an

integral part in achieving holistic care, and it can be achieved with the support of nurse

administrators and nurse educators.


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Appendix A: IRB Approval Letter


Appendix B: Permission Letter from S. A. Shorofi


Appendix C: BONUS approval letter


Appendix D: Invitation Flyer


Appendix E: Invitation Letter


Appendix F: Informed Letter



Appendix G: Survey Instrument







Appendix H: Presentation Slides

1 5

2 6

3 7

4 8


9 13

10 14

11 15

12 16


Appendix I: Dr. Stevens Permission Letter


Appendix J: CITI Certificate

Documents

dnp.musites.orgdnp.musites.org/.../2018/11/Annie-Kuehnel-Scholarly-Proje… · Web viewMore than 30% of U.S. adults have used complementary and alternative medicine (CAM) in 2012