Complementary and Alternative Medicine in Nursing and Midwifery

Towards a Critical Social Science

Jon Adams, Philip Tovey, Jon Adams, Philip Tovey

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781317595250
• Edition: 1
• Topic: Medicina
• Subtopic: Teoría, práctica y referencia médicas

This book explores the historical, social, political and cultural facets of integration between complementary and alternative medicine and nursing/midwifery. It examines the ever-expanding integration in relation to:

• the role and conceptualization of the patient
• the role and responsibilities of different professional healthcare providers (nurses, midwives, alternative therapists, etc)
• the future provision and approach of nursing and midwifery practice
• the challenges and opportunities currently facing healthcare systems as a result of integration.

This innovative book provides the first critical overview of this important field of health research. It is important reading for medical sociologists, nurses and other health professionals - as well as students in these areas - with an interest in complementary and alternative medicine.

Part I

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Inter-professional issues

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Chapter 1

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CAM integration in inter-professional context

Nursing, midwifery and medicine in Canada

Ivy L. Bourgeault and Kristine A. Hirschkorn

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Introduction

A spate of previous articles over the last decade has addressed mainstream health care professionals’ knowledge, attitudes and behaviour regarding complementary and alternative medicine (CAM). Nevertheless, there is a paucity of research: comparing this issue across provider groups and settings (Baugniet et al, 2000; Burg et al. 1998; Straub and Henley 2000; Tovey 1997); that has utilised qualitative methods for greater depth of analysis (Adams 2000; Bernstein and Shuval 1997; Bourgeault 1996; Fitch et al. 1999; Gray et al. 1998; Goldner 2000; Montbriand 2000; Sakala 1988; Verhoef et al. 2002); and even less that draws upon any sort of conceptual framework or theoretical perspective (Adams 2000; Adams and Tovey 2001; Bourgeault 1996; Tovey and Adams 2001; 2002; 2003). This has severely limited our ability to collectively advance understanding in this field of study. In this chapter, we attempt to address some of the limitations of this literature through a comparative examination of the knowledge, attitudes and behaviour of physicians, nurses and midwives regarding CAM in two Canadian provinces – British Columbia and Ontario. We also draw upon existing theoretical contributions to the area of CAM more generally (Saks 1996; 2000; Sharma 2000; Siahpush 1999; Tovey and Adams 2002).

Comparing mainstream professionals’ perspectives on CAM

Much of the research that is available on health care professionals’ views of CAM focuses on physicians’ perspectives, due presumably to the apparent discrepancy in their views and those of CAM providers, but also because physicians hold a great deal of power in defining the terms and conditions under which CAM may be practised. A survey of English language literature reveals that physicians in ‘developed’ nations demonstrate both tolerance for and a moderate interest in CAM but no apparent increase in the perception of its usefulness (cf. Adams 2000; Astin et al. 1998; Berman et al. 1998; 1999; 2002; Bernstein and Shuval 1997; Borkan et al. 1994; Botting and Cook 2000; Chen et al. 1999; Cohen and Eisenberg 2002; Eisenberg et al. 1998; Goldner 2000; Gray et al. 1998; Hasan et al. 2000; Tovey 1997). Summarising across these studies, we can conclude, at minimum, that most physicians express a need for more information and reliable studies. Furthermore, many adopt an attitude of acceptance of patients’ choices and at least half believe in the value of at least one CAM modality. An equivalent number refer patients to alternative practitioners, although very few actually practise any form of CAM (Adams 2004). Canadian physicians have not been found to be atypical in this regard (Bourgeault 1996; Curry and Smith 1998; Goldszmidt et al. 1995; Verhoef et al. 2002; Verhoef and Sutherland 1995a; 1995b).

A growing number of articles focus on the views of nurses regarding CAM, identifying both an interest in evaluating CAM and support for a minimal nursing role as educator/information provider/counsellor for patients (Adams and Tovey 2001; DeKeyser et al. 2001; Frisch 2001a; 2001b; Johnson 2000; King et al. 1999; Lorenzo 2003; Mayer et al. 2001; Montbriand 2000; Salmenpera et al. 1998; Taylor 2002; Tovey and Adams 2003; Trevelyan 1996; Wilkinson and Simpson 2002). Indeed, in line with the holistic focus towards nursing care, the profession has been perceived as ‘naturally’ more responsive towards the use of various CAM modalities. Many nurses use CAM in their work, with aromatherapy and massage being the most popular, followed by therapeutic touch. The one published study of nurses in Canada (Fitch et al. 1999) similarly found they express an open attitude towards and indicate the need for information regarding CAM. These nurses also appear to have an interest in communicating with patients about their use – more so than identified among physicians. Unfortunately, very few of these articles involve primary research whereby nurses have been interviewed or surveyed regarding their opinions and behaviour. These papers do, however, draw attention to the link between holistic nursing, patient-centred care models and CAM, many suggesting that nursing is well situated to undertake a central role in patient education, and to a lesser extent, in delivery of CAM.

Much less is known of other health care professionals, such as midwives, regarding CAM (Adams 2006; Allaire et al. 2000; Dimond 1998; Raisler 2000; Sakala 1988; Silverman 1995; Taylor 2002; Tiran and Mack 2000). Perhaps this is due to how in some jurisdictions, such as Canada and to some extent in the United States, midwives continue to be considered akin to alternative practitioners themselves despite being well integrated into maternity care systems worldwide. Alternately, midwives may not be considered sufficiently distinct from nursing to warrant specific analysis. Whatever the case, what we do know is that there is an increasing interest among midwives towards CAM, with the most widely used modality being aromatherapy (Adams 2006; Burns et al. 2000a; 2000b; Burns and Blarney 1994; Rose 1994; Smith 1991; Tiran and Mack 2000). A UK survey conducted in 1997 indicated that midwives were the highest users of CAM among all professional groups (34%) (Tiran and Mack 2000). Even higher rates of usage – over 90% – have been reported of independent (i.e. non-nurse) midwives in the US (Allaire et al. 2000; Sakala 1988), but the limited geographical range and particular political contexts of these two studies may impose limitations on generalising or transferring these findings to broader populations. To date, no study of CAM among Canadian midwives has been reported in the published literature.

Overall, the picture that emerges from this literature is that nurses and midwives appear much more open towards CAM than physicians, but admittedly there is very little empirical evidence to demonstrate this systematically. Glaus (1988) was one of the first authors to comment on how ‘nursing care is the constant intermediate between school and alternative medicine’ (p. 250) and further that there was a growing trend (at least in the European context they examined) ‘toward a greater separation between school medicine and nursing than between alternative medicine and nursing’ (p. 250). Part of this trend was attributed by Glaus to increasing patient interest and in turn the closer relations nurses tend to have with patients.

Tovey (1997) examined the difference between provider groups more systematically in a large-scale study of non-orthodox practitioners in the UK. He argues that although there has been an overall liberalisation of attitudes among mainstream professionals vis-à-vis CAM, this is not necessarily generalisable across provider groups. Specifically, he found that ‘there is a schism within orthodoxy on this issue and that schism is occupationally based: at the extremes, consultants [i.e. medical specialists] remain characteristically dismissive of alternative practitioners, nurses overwhelmingly enthusiastic’ (p. 1129). Further, Tovey found that the nature of the CAM modality being considered was of little significance but rather the differentiation was within orthodoxy. Another comparative study focusing upon health science faculty members in Florida found that while 52% of medicine faculty reported using CAM (mirroring usage in the general population), usage was much higher among nursing faculty (74%) (Burg et al. 1998). Straub and Henley (2000) surveyed physicians in several specialisations and advanced practice nurses (APNs) regarding their views of CAM practice, CAM effectiveness, patients’ use and CAM education. They found that physicians were the least likely to offer CAM therapies, whereas nurses were most likely to offer chiropractic, herbal medicine, or acupuncture.

Similar findings are reported in Canada. Specifically, Montbriand (2000) reports that Canadian ‘nurses were about twice as likely as other professionals [physicians and pharmacists] to be users of alternative therapies, but were half as likely to suggest these products or therapies to patients’ (p. 23). This is an interesting discrepancy which may point to the influences of broader structural barriers to professional referral to CAM. She does, however, note that there was a general association between practitioners who did not suggest CAM to patients and negative attitudes towards CAM. Another Canadian study focused on the views of a variety of students in health professional programmes including medicine, nursing, physiotherapy, occupational therapy and pharmacy (Baugniet et al. 2000). It was found that compared to medical students, nurses are more likely to have consulted a CAM practitioner, report more knowledge about CAM as well as hold more positive attitudes towards CAM.

Thus, similar to what we find in the non-comparative literature, the major trend in these comparative studies is that the philosophy and practice of nursing (and we will argue here midwifery as well – cf. Adams 2006) is amenable to CAM and thus less problematic. There is an implicit assumption in much of this literature that because they are less powerful groups nurses and midwives are therefore less ‘oppositionary’. This assumption would appear to translate into their also being less of a focus of study. Physicians’ practices and paradigms of practice are viewed as inherently more contradictory (and the power relation between them and CAM practitioners most discrepant). What is less clear from the literature are the reasons why this might be the case. We turn now to the more conceptually based literature to provide some insights in this regard.

Inter-professional relations

As part of their development of a sociology of CAM and nursing, Tovey and Adams (2002) highlight how ‘given that nursing practice is located within a web of professional interaction there is much to be gained from work that seeks to explicitly explore various points of interface with other stakeholders’ (p. 13). This argument can be extended to other health professions including medicine and midwifery. Tovey and Adams (2002) further identify a number of intersections with nursing practice such as: the relations between nursing and medicine; the complex relations between nursing and lay CAM practitioners; the intersection between nursing and health management; and the relationship between nursing and location (i.e. the relevance of the health care system and location in the private or voluntary sector).

These intersections as identified by Tovey and Adams parallel some of the key concepts from the broader sociological literature on the professions. For example, Freidson (1970) outlines how medical dominance consists of a variety of levels of influence including the control over the content and context of medical work, control over other health professions and over patients. Likewise, others have acknowledged that professions do not exist in a vacuum, but rather in relationship to one another, both in the workplace as well as on a broader structural level (Abbott 1988).

Given the far-reaching effects of status relations and jurisdictional boundaries among professions, it is surprising that these insights have thus far largely escaped analyses of professionals’ behaviours regarding CAM, with only a few exceptions. Tovey (1997: 1132), for example, points out that ‘the unequal distribution of autonomy, authority and financial reward within orthodoxy’ supports the notion of what he refers to as a ‘status related schism: a greater flexibility to the non-orthodox being expressed among those least effectively rewarded by the existing arrangements’. Tovey argues further that the affinity between nurses and alternative medicine might also be related to a gendered compatibility. Adams and Tovey (2001: 138) further highlight the use of strategies that ‘naturalise CAM to the nursing environment’ and how ‘CAM practice provides nurses with an opportunity to distance themselves from a range of specific (and negatively interpreted) features of conventional medicine’. In addition to this ‘distancing’ strategy, they argue that CAM is utilised to advance nursing: ‘as a dynamic and flexible profession with CAM integration portrayed as an opportunity for nurses to be proactive and to drive change in healthcare’ (Adams and Tovey 2001: 138).

Inter-professional status differentials have also been found to influence midwives’ behaviour. Tiran (2003), for example, points out that, erroneously, ‘many midwives are under the impression that they are not allowed to administer or advise on [CAM] if the obstetric medical staff disagree, but this is simply not the case’ (Tiran 2003: 12). Sakala (1988) also notes the hostility t...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Notes on contributors
• Acknowledgments
• List of abbreviations
• Introduction: Towards a critical social science of CAM in nursing and midwifery
• Part I Inter-professional issues
• Part II Intra-professional issues
• Part III Public health and patient issues
• Index