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THESIS - ;‘ i /

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This is to certify that the
thesis entitled

Michigan Advance Practice Nurses’ Attitudes and
Practice Patterns Toward Alternative Therapy

presented by '

Susan Lynn Wimpee

has been accepted towards fulfillment
of the requirements for

_Master____ degree in .Alursing-

Z/

Maj professor

Date W

0-7639 MSU is an Affirmative Action/Equal Opportunity Institution

ADVANCE PRACTICE NURSES' ATTITUDES AND PRACTICE
PATTERNS TOWARD ALTERNATIVE THERAPIES

BY
Susan Lynn Wimpee

A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree

MASTER OF SCIENCE IN NURSING

College of Nursing

1997

ABSTRACT

ADVANCE PRACTICE NURSES' ATTITUDES AND PRACTICE
PATTERNS TOWARD ALTERNATIVE THERAPIES

BY
Susan Lynn Wimpee

Patient use of alternative]complementary therapies in
conjunction with standard medicine has become more common in
recent years. Increased use of alternatives has spawned
further investigation, but published studies have focused on
physician use and attitudes towards alternative therapies
(AT). This exploratory study addressed advance practice
nurses (APNs) functioning as primary care providers and
examined attitudes toward alternative therapy as well as
referral/practice patterns. Data were collected from 65
licensed APNs practicing in Western Michigan. The majority
held a negative attitude towards AT (as defined by this
study); however, in actuality, attitudes were predominately
neutral. Positive attitudes were shown to relate to positive
behaviors. But negative attitudes were nearly evenly split
between positive and negative referral/practice patterns.
Overall, mind-body interventions were referred/practiced
more than other clusters of AT. APNs can use these findings
to explore AT, raise awareness, and stimulate both personal

and client education.

I would like to dedicate this thesis to
my husband, Larry, whose love, support and

computer expertise has helped me through this journey

iii

ACKNOWLEDGMENTS

This thesis would not have been possible without the
support, patience, and encouragement of my committee:
Chairperson, Gwen wyatt RN, PhD; Rachel Schiffman RN, PhD;
and Brigid Warren RN, NSN.

Also noted is that my family, peers and colleagues have

supported me in my struggle to be all I want to be.

iv

LIST OF TABLES

LIST OF FIGURES .

INTRODUCTION

TABLE

Statement of the Problem .

Research Questions

Literature Review .

Alternative Therapies

Attitudes

Practice Pattern . . .

Attitudes and Referral/Pr

Theoretical Framework . . .

Proposed Model .

Mathws O O 0

Study Design .

Sample .

OF

Operational Definitions

Instrument .
Data Collection Procedure
Data Analysis

CONTENTS

Protection of Human Rights

Assumptions .
Limitations .

Results . . .

Demographic Characteristics

Attitudes

Referral/Practice Patterns .

Clusters and Referral/Practic

Discussion .
Sample .

17
17
17
19
21
22
22
23

24
24

24
24
26
27
29

3O
30

Attitudes .

APN Referral Patterns . .
APN Practice Patterns . .

Attitude and Referral/Practice Patterns

Clusters . .

Azjen and Fishbein (1967) Theory

Implications . .
Implications
Implications
Implications

smary C O O O 0

APPENDIX A . .
APPENDIX B . .
APPENDIX C . .
APPENDIX D . .
APPENDIX E . .

LIST OF REFERENCES

for
for
for

Practice

Education
Research

vi

31
35
37
41
41
42

43
43
45
47

49

50
53
55
56
57

58

LI ST OF TABLES

Table

1 Demographic Characteristics . . . . . .

2 Rank Order of Referred Alternative Therapies

3 Rank Order of Practiced Alternative Therapies .

4 Cross-Tabulation and Chi-Square Analysis of

Attitudes and Pattern for Alternative Therapies

5 Referred/Practiced Therapies by Clusters

vii

Page

.25

LIST OF FIGURES

Figure Page
1 Adaptation of Ajzen and Fishbein (1967) Theory . . . . 16

viii

INTRODUCTION

Alternative therapies (AT) have had an important role
in the care of people with health problems in this country
(Murray 8 Rubel, 1992). Recently, Eisenberg, Kessler,
Poster, Norlock, Calkins, and DeBlanco (1993) stated that
$13.7 billion were spent on AT in 1990. This increase in the
use of AT by clients and client interaction with advance
practice nurses (APNs) were the areas of interest of this
research. The purpose of this study was to examine the
attitudes and practice patterns of APNs toward AT.

AT are referred to by multiple names, such as holistic,
unconventional, complementary, and unorthodox. One
definition of alternative therapy is 'medical practices that
are not in conformity with the standards of the medical
community," and another definition is “medical interventions
not taught widely in U.S. (United States) medical schools or
generally available at United States hospitals” (Eisenberg
et al., 1993, p. 246).

There are many therapies that are classified under the
heading of AT, such as therapeutic touch, homeopathic
treatments, and acupuncture, to name a few. To some
providers the term “alternative” has a negative connotation,

which puts it on the “fringe" of acceptability to the

1

2
health-care community. Physicians and nurses often require
empirical testing of new treatments or modalities before
accepting them as part of practice. What is considered the
fringe today may be considered state of the art or standard
of practice in the next few years. Keeping this in mind,
further education on AT for primary care providers would
enable clients to seek consultation for AT through their
primary care provider.

The work of Eisenberg et al. (1993) has raised
practitioner's awareness to their clients' interests in AT.
An increased knowledge of client use of AT may enable
primary care providers to explore new areas of treatment in
conjunction with allopathic medicine, osteopathic medicine,
and advanced practice nursing. A better understanding of AT
is needed by physicians and advance practice nurses (APNs)
who increasingly function as primary care providers.

Since its beginning, the focus of nursing has been a
holistic approach, and this continues to the present. The
role of the nurse has been to promote health and prevent
illness, the core concept of primary care. This is
accomplished through many avenues, such as
nonpharmacological treatments and a broad range of treatment
modalities that can be classified as alternative. In the
past, nurses have used AT with clients for health promotion.
For example, nurses have used guided imagery, progressive
relaxation, and therapeutic touch (Daniels, 1994). It is the

assumption of this study that the union of AT and Western

3
medicine in client care may best promote health. APNs in
primary care have a unique opportunity to assist their
clients with the selection and/or utilization of AT.
Statement of the Problem

APNs are in a pivotal position to encourage open
communications among alternative healers, primary care
providers, and patients. Since clients often use AT with or
without the knowledge of the primary care provider, APNs
with a holistic practice can open lines of communication and
promote trust with patients by being nonjudgmental and
knowledgeable about AT.

Literature regarding attitudes, willingness to refer,
and actual practice patterns toward AT have, to date,
primarily addressed their use by physicians. Nurses, also in
the role of primary care providers, have a need for their
own evaluation of these areas and the evaluation of AT
practices on client outcomes. Thus, the purpose of this
study was to provide descriptive data relative to APN
attitude toward AT and practice patterns.

Research Questions
The following research questions were addressed:
1. What are the attitudes of APNs towards alternative
therapies?
2. What are the most frequently referred alternative
therapies?
3. What are the most frequently practiced alternative

therapies?

4

4. Is there an association between APN attitude and a

willingness to refer or practice alternative therapies?
5. What is the proportion of alternative therapies that

are referred versus practiced when therapies are

clustered?

Literature Review

Alternatingrhemies

The literature on AT is quite extensive, but AT were
found to be an aggregate of many different types of
modalities or therapies. Although conceptualizations of AT
were not found, definitions were available from several
sources. For example, Eisenberg et al. (1993) defined AT as
“medical practices that are not in conformity with the
standards of the medical community, " including “medical
interventions not taught widely at 0.8. medical schools or
generally available at hospitals” (p. 246). According to the
Office of Alternative Medicine at the National Institute of
Healthw Aalternative medicine includes nutrition, health
education, lifestyle modification, biofeedback, relaxation
techniques, acupuncture, homeopathy, herbal medicine,
acupressure, chiropractic, massage, anti-oxidant therapy,
bio-electromagnetic therapies, and other healing practices"
(Moffit, 1994, p. 14).

Pietroni (1992) defined AT as “a term that is used as a
catch-all definition for anything that is not taught in the
Western medical school" (p. 564) . Pietroni went further to

“divide therapies into four distinct groups: Complete

5
systems, diagnostic methods, therapeutic modalities and self
care approaches” (p. 564) . The view held by Murray and Rubel
(1992) was that alternative medicine was 'a heterogeneous
set of practices that are offered as an alternative to
conventional medicine for the preservation of health and the
diagnosis and treatment of health-related problems“ (p. 61) ,
such practices including many different options as well as
modalities. Murray and Rubel (1992) classified therapies
into four groups: ”spiritual and psychological, nutritional,
drug and biologic, and treatments with physical forces and
devices” (p. 61).

The National Institute of Health (NIH) has further
grouped alternative therapies into seven areas or clusters
(Workshop on Alternative Medicine, 1994). The first cluster,
'mind-body interventions” (e.g. , yoga and relaxation
techniques) uses:

Extraordinary interconnectedness of the mind and

the body and the power of each to affect the

other. These therapies are based on the importance

of interaction of the mind in producing and

alleviating disease (p. 3).

The second cluster, "bioelectromagnectics application
in medicine” (e.g. Reiki and therapeutic touch) is based on
the science of interaction of living organisms with
electromagnetic fields. These electrical fields are present
in all living organisms. The premise is that the interaction
with electrical fields may produce physical and/or

behavioral changes in living organisms (Workshop on

Alternative Medicine, 1994).

6

The third cluster» fiAlternative systems of medical
practice” (i.e., homeopathic remedies) is described as a
three-tier hierarchy of health: a) professional popular; b)
community-based; and c) professional.

The fourth cluster, termed ”manual healing methods”
(i.e. acupressure or therapeutic massage), describes the
utilization of a ”practitioner's hands as a primary modality
both to access information (that is, to diagnosis) and to
treat the patient” (Workshop on Alternative Medicine, 1994,
p. 113).

While the NIH classification of the first four clusters
identifies external AT (treatments do not require ingestion
of substances), the remaining three are grouped by internal
AT categories (treatments that require ingestion of
substances). TPharmacological and biological treatments”
describes the utilization of drugs and vaccines that have
not been accepted in mainstream medicine. These drugs and
substances are believed to be nontoxic. They are also
believed to be able to stimulate the patient's own immune
system to fight off illness. ”Herbal medicine” is explained
as the use of plant or herbs to assist patient healing. And
finallyq ”diet and nutrition in the prevention and treatment
of disease” is described as the use of vitamins, food
avoidance, or food inclusion as an intervention. This is
termed as alternative dietary lifestyles which are used in
preventing or, in some cases, even treating diseases. The

remaining three NIH clusters were unified for this study

7
into a fifth cluster termed ”home treatments” to simplify
scoring. This combination consisted of the NIH's fifth
cluster (diet and lifestyle choices), sixth cluster (herbal
remedies) and seventh cluster (alternative systems in
homeopathic medical treatments).

AT for this study were defined as a synthesis of
therapies not widely taught in Western nursing education
that were: a) referred to another trained practitioner; b)
practiced by the APN in a primary care setting; and c) were
easily clustered into five groups (mind-body movement, mind
body nonmovement, bioenergic systems, manual healing, and
home treatments). Specifically to APN practice, AT are
nursing interventions that were nonpharmacologic, used in
conjunction with medical interventions frequently taught in
graduate nursing schools and also available in hospitals and
communities. These interventions are utilized to promote
patient well being.

Attitudes

There were many definitions of attitude in the
psychology literature, several in health practice, and a few
relating to attitude and alternative therapies. Zimbardo and
Leippe (1991) described attitudes as:

What we like and dislike, our affinities and

aversions, the way we evaluate our relationship to

our environment. An attitude is a disposition in

the sense that it is a learned tendency to think

about some object, person or issue in a particular
way (p. 31).

8

Ajzen (1988) defined attitude as ”a disposition to
respond favorably or unfavorably to an object, person,
institution or event” (p. 4). Aj zen further described an
attitude as a hypothetical construct manifesting itself in a
wide variety of responses.

These responses are evaluative in nature, and they

are directed at a given object or target (a

person, institution, policy, or event).

Evaluations can change rapidly as events unfold

and new information about a person or issue become

available (Ajzen, 1988, p. 7).

Also, Ajzen and Fishbein (1967) felt their theory could
help predict a behavior by examining attitudes, normative
beliefs, and motivation. Henerson, Morris, and Fitz-Gibbon
(1987) described attitude in a broader sense as an effect of
feelings, values, or beliefs.

Pender and Pender (1986) defined attitude related to
health behaviors as reflecting a belief concerning the
probability of specific consequences following behavior with
a favorable or unfavorable evaluation of those consequences.
Thorston and Powell (1991) defined attitude in relationship
to health and age, based on a person's perception either of
personal health or health-care services. Langer and Warheit
(1992) suggested that health behavior was mediated by
attitude, but the behavior was dependent on available
resources; behavior then became the medium for expression.

. Each of these investigators held similar views: That

attitude was based on feelings—-positive or negative--in

relation to an object, event, person, institution, or issue.

9
There were slight variations as to whether an attitude was a
learned response that could change, or whether it was a
value or belief which could not change. There was also a
difference in definition of the concept of health attitude,
ranging from individual perception based on consequence,
age, to availability of resources.

Several conceptualizations were incorporated from the
literature to define the concept of attitude for this study.
Attitude was viewed as a concept which could change with new
information, and the values of the individual had an
influence on the attitude. In other words, an attitude which
could be either positive or negative was a learned tendency
based on personal beliefs, values, perceptions, and
experiences.

Practine_2attsrn

One study evaluated actual AT practice patterns by
nurses. Keegan (1996) surveyed 270 nurses, over half of whom
reported using AT 16 times in the pervious year. The most
commonly practiced therapies (from a total of 21) utilized
predominately mind-body interventions (e.g., biofeedback,
breathing exercises, meditation, and imagery). Reagan's
survey did not indicate, however, whether participants had
special training in any of the therapies.

Practice pattern was sometimes termed referral patterns
or referral rates in the literature (Fertig, Roland, King 8
Moore, 1993; Roland, 1988; Wharton & Lewith, 1986). Often

times referral pattern and practice pattern were used

10
interchangeably. In regard to referral, Roland (1988)
explained that it was the process of counting the number of
times the physician directed a person for consultation with
another practitioner. Wharton and Lewith (1986), in their
use of the term referral pattern, defined it as sending
patients either to medically or nonmedically qualified
practitioners of alternative therapy. Blumberg et al. (1995)
combined referral pattern and practice pattern and defined
referral pattern as the ”willingness to refer,” or the
voluntary act of sending a patient to another practitioner
for alternative therapy. They also defined practice pattern
as the use of alternative therapy within the practitioner's
office. By general consensus, referral pattern and practice
pattern both referred to the act of sending a person to
another for a consultation. The slight difference in the
definition of practice pattern was in the actual performance
of a service.

Referral/practice pattern here was defined as the act
of directing or the willingness to refer a client for
consultation with another provider for a service not
performed in the primary care practice or the actual
practice by the APN of performing AT for clients.
WW3

Research data on advance practice nurses' attitudes and
practice patterns, including willingness to refer and actual
practice of AT, were not available. However, several studies

evaluated physicians' attitudes and referral/practice

11
patterns in relationship to AT. One such study by Blumberg,
Hendricks, Dewan, Grant and Ramps (1995) randomly sampled
U.S. physicians who practiced in either internal medicine or
family medicine. Attitude was measured by whether the
physician was willing to encourage, remain neutral, or
discourage a client who showed an interest in a specific
alternative therapy. Practice was defined as the willingness
to refer or provide any of the 16 specific AT listed on the
questionnaire. No theoretical framework was mentioned.

Of the 572 responses, half of the physicians (286)
stated they would encourage patients to seek the use of
alternative therapy. Mere than half (57% or 326 surveyed)
were willing to refer patients for treatment to six or more
AT. Blumberg et al. (1995) suggests that ”physician
involvement in unconventional medicine [alternative
medicine] is likely to be higher among younger or female
physicians, physicians practicing in the West [U.S.], and
family practitioners” p. 32. Midwest female family practice
physicians were also reported to refer and practice AT
greater than 50 percent. This study portrayed female
physicians as being more likely to utilize AT than male
physicians. Perhaps the female physician and APN population
relationship could be made. The authors did not discuss the
validity or the reliability of the tool; rather, they
recognized that generalization of their study was a
limitation due to the process of selecting physicians with
only single board certification and not following up with

12
nonresponse physicians for this study. Blunberg et al.,
(1995) recommended the need for further physician education.
Neither advantages nor limitations of AT were discussed.

Borkan, Neher, Anson, and Smoker (1994) examined a
variety of specialty physicians to evaluate their attitude,
knowledge, and practice regarding AT. In their study the
first variable of attitude was measured by a 6-point Likert
scale upon which participants rated the effectiveness of
eight separate AT. The variable of practice pattern was
based on participants' estimation of referrals in the
previous year--whether formal or informal, verbal or
written--given to clients for use of AT. The study utilized
a written questionnaire with a one-month reminder note. Two
of the sites were in the United States (New Mexico and
Washington) and one in Israel. No theoretical framework was
mentioned.

Of the 138 physicians surveyed from a wide variety of
specialties, 60 (approximately 44%), were in primary care.
This study found that 60% of the surveyed physicians made at
least one referral for an alternative therapy in the
previous year, and 38% had done so in the prior month. It
also found that primary care physicians were 2.33 times more
likely to refer to AT than were physicians in a specialty
practice. One limitation of the Borkan et al. (1994) study
was the low response rate in the washington site. Each of

the selected sites was drastically different, either

13
culturally, socio-economically, or in availability of
alternative therapy practices.

Schachter, Weingarten, and Kahan (1993) evaluated
Israeli physician's experiences with AT, attitudes toward
alternative therapy, and opinions about incorporating
alternative therapy in the health-care system. The attitude
variable was determined by one of the following
questionnaire response options: (a) physician objected to
its use, (b) would not recommend any, 0 wanted all legally
banned, or (d) found usefulness of an alternative therapy.
The practice variable was defined in the study as the
willingness to refer or practice alternative therapy. A
total of 89 physicians were evaluated, and of this number
46% were women. Specific areas of practice were not stated,
and no theoretical framework was reported. Of the 89
physician participants, 17% (15 physicians) had formal
training in AT and 11% (10 physicians) believed there was a
scientific basis for alternative therapy; 54% (48
physicians) thought AT were useful in their practice.
However, this study did not show validity or reliability of
the tool utilized. Other limitations to the study were the
small sample size and the lack of information concerning
physician practice areas.

Each of these studies had convenience samples of
physicians and utilized a questionnaire for data collection.
None referred to a theoretical framework. They similarly

defined practice pattern as the willingness to refer

14

(Blumberg et al., 1995; Schachter et al., 1993), but
differed in their definition of the variable of attitude. In
Blumberg et al. (1995) attitude was defined by the selection
of choices of encouragement, remaining neutral, or
discouraging patients who wished to utilize AT. Borkan et
al. (1994) described attitude as effectiveness, and
Schachter et al. (1993) offered choices from banning to
usefulness for evaluating attitudes towards AT. Also, while
Blumberg et al. (1995) and Borkan et al. (1994) both cited
specific AT, Schachter et al. (1993) reported findings based
on broad questions about AT. Despite great disparity in
sample size--varying from 89 (Schachter et al., 1993) to 572
(Blumberg et al., 1995)--and the differences in evaluating
attitude and referral/practice pattern (thus making
generalizability difficult), it is notable that all three
studies reported response rates favorable toward AT (>50%).

In summary, the literature showed an increased use of
AT by clients. Though many may be managed by APNs in primary
care settings, clients may also be using AT without the
knowledge of their primary care provider. Preliminary
evaluation of physicians interested in AT has been
addressed, but now the evaluation of APN's practice and
referral rates is essential for comprehensive client care.
In addition, previous studies evaluated attitudes and
referral/practice patterns without the utilization of a

theoretical framework, while this study incorporated Ajzen's

15
and Pishbein's (1967) attitudinal framework as the
foundation for this research.
Theoretical Framework

For this study Ajzen and Pishbein's (1967) Theory of
Attitudes and Behavior provided the theoretical foundation,
suggesting that an attitudinal prediction of a ”specific
behavioral intention in a well-defined situation” (Ajzen 8
Pishbein, 1973, p. 42) can be calculated. Two major factors
determine specific behavioral intentions: 1a personal or
'attitudinal' factor and a specific social or 'normative'
factor” (Ajzen 8 Fishbein, 1973, p. 42). Actual behavior (B)
and behavior intention (BI) are the sum of attitudes towards
an act (Aact) plus a normative belief (NB) multiplied by
motivation to comply (Me) with the normative belief. Both
the attitude towards the act and the product of normative
belief and motivation are weighted. The relationship of
these components is expressed in the equation:

B‘ BI - [Aact] wo + [NB (Mc)] wl

Explanation of attitude towards an act refers to the
person's attitude toward performing the behavior. Unlike the
traditional sense of evaluating attitude based on the
relationship of attitude to a specific object or class of
objects, this theory evaluates attitude in relationship to
performing the particular act itself. Evaluating behavioral
intentions with Ajzen's and Fishbein's (1967) definition of
attitude allows for prediction of specific behavior. The

normative element of the theory NB(Mc) considers the impact

16

of the social environment on behavior, i.e., a person
believes the members of the given peer group expect a
specific individual behavior. The last component of the
equation is motivation, which refers to the person's
perceived expectation of the peer group.
Proposed_nodel

An adaptation of the Ajzen and Fishbein (1967) Theory
was developed for this study (Figure 1). Attitudes of the
APNs towards AT is represented in the left box with a two-
way arrow leading to a second box representing behaviors.
The attitude box symbolizes attitudes towards AT, which are
learned tendencies based on personal beliefs, values,
perceptions, and experiences. The behaviors box is based on
the willingness to refer and actually practice an
alternative therapy. The arrow represents the two way
interaction or relationship between both behaviors and
attitudes. This model postulates that if the attitude is

 

 

ass attitude toward Behavioral
Alternative Therapies
"learned tendency"

 

 

‘Willingness to refer
Personal Beliefs

Values Aotual practice of
Perceptions Alternative Therapy
Experiences

 

 

 

 

 

 

Fisnre.1. Adaption of Ajzen and Fishbein (1967) Theory.

17
positive then behavior should also be positive. The reverse
should also be true: Negative attitudes result in negative
behaviors. This model can aid in the prediction of the
unknown variable, either attitude or behavior, whichever is
unknown. The original theory included motivation and
normative components but were not evaluated in this study.
Methods

Study—Design

This study was an exploratory, descriptive study of
APNs and their attitudes and referral/practice patterns
towards AT. A survey was utilized to measure the concepts of
attitude, referral, and/or practice patterns of western
Michigan APNs. This design was selected to explore unknown
information about the population and AT and was based on a
similar survey by Blumberg et al. (1995) which evaluated
physicians' attitudes, referral, and practice patterns to
AT.
finals

The sample consisted of 65 licensed APNs who responded
from a total of 101 potential respondents. A list of
licensed APNs and their addresses was obtained from the
Board of Commerce in Michigan. From this list, APNs from 12
western Michigan counties were mailed a request to
anonymously participate in the study (Appendix A). The
counties included were Allegan, Grand Traverse, Kent,
Leelanau, Mecosta, Mason, Montcalm, Muskegon, Newaygo,

Oceana, Ottawa, and Van Buren. Inclusion of Muskegon, Kent,

18
and Ottawa counties provided information about urban
communities, since each had greater than 50% of the
population classified as urban dwellers (United States
Department of Commerce, 1993). The selection of Allegan,
Grand Traverse, Leelanau, Mason, Mecosta, Montcalm, Newaygo,
and Van Buren provided the perspective of rural communities
in Michigan. Each of these counties had greater than 50% of
the population living in rural areas (United States
Department of Commerce, 1993).

While this study included both urban and rural
counties, the focus was on their similarities. According to
the 1990 Census, the majority of the counties listed
agriculture and manufacturing as the two primary
occupations. Also, each of the counties reported similar
household incomes averaging between $27,000 and $34,000 per
year, with little difference between urban and rural areas.
There was also at least one primary hospital to support each
county, and in one instance (Kent County) there were seven
(American Hospital Association, 1995). The population make
up for all the counties was primarily Caucasian followed by
Afro-Americans, Native Indian, or Asian. Each of the
selected counties was predominately of a Protestant
religion. There was also a similar ancestry reported
(Germanic and English decent) (Department of Commerce,

1990). Analysis for individual counties was not included.

19
munitions

Alternatixe_1herapies. Of the AT offered in Michigan,
the following 18 were in the survey: Yoga, Tai Chi,

relaxation techniques, biofeedback, meditation, imagery,
hypnosis, spiritual healing, aromatherapy, reiki,
therapeutic touch, energy healing, acupressure, therapeutic
massage, reflexology, lifestyle diets, herbal remedies, and
homeopathy. Definitions of each of the therapies supplied to
the respondents are listed in Appendix B.

Clusters of therapies were identified based on the
report by the NIH (Workshop for Alternative Medicine, 1994).
For this study, the listed AT were separated into five
categories or clusters. Following the NIH format, the first
cluster was mind-body-movement interventions, which included
the items of yoga, Tai Chi, relaxation techniques, and
biofeedback. The second cluster was mind-body-nonmovement
interventions: Meditation, imagery, hypnosis, spiritual
healing, and aromatherapy. The third cluster was
bioenergetic systems, including Reiki, therapeutic touch,
and energy healing. The fourth cluster was manual healing:
Acupressure, therapeutic massage, and reflexology. The
remaining three NIH clusters were unified for this study
into a fifth cluster termed ”home treatments” to simplify
scoring. This combination consisted of the NIH's fifth
cluster (diet and lifestyle choices), sixth cluster (herbal
remedies) and seventh cluster (alternative systems in

homeopathic medical treatments).

20

“We. Attitude toward
AT was measured by responses to the question: 91f patients
express interest in this applicable therapy, you would...,”
followed by three possible responses: eneenrege, zenein
neutrel, dieeeurege. The APN was instructed to circle one of
the choices for each of 18 therapies listed. Each listed
therapy could receive a score of 1 for encouraged and 0 for
neutral or discourage, with a possible range from 0-18.
Neutral responses, although neither positive nor negative,
were combined with the discouraged category and calculated
as a negative attitude for this analysis. Attitude was
calculated by adding the encourage responses; a positive
attitude was a score of 10 or more and negative attitude was
9 or less.

2reetiee_pettezn. Practice pattern was defined by the
responses to two sets of questions. The first, ”Would you be
willing to refer to a trained person who practices this
therapy?”rcould be answered either yes or no. The second
question, ”Do you personally provide this therapy to your
patients?”rcould also be answered either yes or no for each
of the therapies listed. A percentage greater than or equal
to 60% (11 or more yes answers) in either referral or
practice or a combined total indicated a positive practice
pattern. A negative referral/practice pattern was calculated
by less than 10 yes answers in referral, practice, or a

combined total of less than 60 percent.

21
Instrument

Demegzephie_dete_eheet. The first section of the survey
allowed for the collection of personal information of the
participants. It included questions about gender, age,
number of years in practice as an APN, practice setting or
type of specialty, education level, and whether the
respondent currently practiced as an APN (see Appendix C).

A1ternetige_treetment_enrgey. The tool developed by
Blumberg et al. (1995) was intended to measure physician
attitudes toward AT and was adapted for this study to
evaluate APN attitudes toward AT. Neither reliability nor
validity were tested by the original authors. However,
reliability for this study was calculated by the use of the
Kuder Richardson Formula (KDR-20). A KDR coefficient of .61
was calculated and was considered an adequate level of
reliability, for survey research; however, the results
should still be interpreted with caution. Neither content
nor construct validity were known and were beyond the scope
of this study.

The Alternative Treatment Survey (ATS) (Appendix D)
listed 18 AT along with two open areas for the respondents
to add therapies not mentioned. A glossary of therapies was
also provided with each survey for consistent interpretation
of AT. There were three sections of the ATS. Attitudes of
the respondents were evaluated by their responses to each of

the therapies in the first column of responses. Response

choices were encourage. remaineutral. or discourage

22
therapies when clients inquired about an AT. Practice

patterns of the respondents were evaluated by the response

choices of uillinqneee_te_zefen, or net in the middle column
and W or not in the last

column.
W

A list of 101 potential respondents was obtained from
the Board of Commerce in Michigan on current certified APNs
of Michigan. Instructions on how to complete the
questionnaire and the deadline for inclusion in the study
were explained in the cover letter. A questionnaire was sent
to each of the potential respondents with a cover/consent
letter (Appendix A). A return stamped and addressed envelope
was mailed along with each questionnaire to promote
participation. Two weeks after the initial mailing, a
reminder postcard was sent to each of the prospective
respondents to encourage the return of their Alternative
Therapy Survey questionnaire (Appendix B).
W

Frequency, percent, mean, and cross tabulation with chi
square were used to describe the variables. Demographic
characteristics of the sample were described by using
percents and frequencies. Demographics included information
on gender, age, ethnicity, area of certification, primary
area of practice, years of practice, practice setting, nurse

practitioner preparation, and work status.

23

Analysis of the data included the following:
Research Question 1. Percentage and frequency of respondents
whose attitudes were either positive or negative toward AT.
Research Question 2. Rank order by percent and frequency of
the most frequently referred AT.
Research Question 3. Rank order by percent and frequency of
the most frequently practiced alternative therapies.
Research Question 4. Cross tabulation with chi square
analysis to determine any statistically significant
proportional differences on practice/referral patterns
between APNs with positive and negative attitudes.
Research Question 5. Percent and frequency of clustered AT
that were referred versus percent and frequency of clustered
AT that were practiced.
Protection_of_fluman_Bishts

The approval from the University Committee on Research
Involving Human Subjects (UCRIHS) through the Michigan State
University was obtained on January 1996 prior to
distribution of the survey (see Appendix A). The
questionnaire's cover letter informed the respondents of the
purpose, benefits, risks, and right to participate or not
participate in this study (see Appendix B). The
questionnaire ensured anonymity by avoiding respondents'
names on the returned materials. Each participant was
assured that group data were to be reported from this study.
Survey information was reviewed by the principal

investigator and a three member thesis committee.

24
Assumptions

1. Respondents of the study were able to follow and answer

the questionnaire supplied.
2. The information elicited from the respondents was

honest.
3. All potential respondents in selected counties were

given an opportunity to participate.
4. The union of AT and Western medicine in client care may

best promote health.

Limitations

The study was limited to a sample of registered APNs
who were listed as of April 1995 by the Department of
Commerce in Michigan. The absence of a random sampling
procedure was a limitation to external validity of the
study. Each of the respondents was self selected, and the
sample size was small (65), thus decreasing the ability to
generalize the findings to the study. The instrumentation,
lacking strong reliability (KDR=.61) and no validity testing
was also a limitation. A KDR=.60 is acceptable for a survey-
based research, but reliability of at least .8 is standard
for all other types of research.

Results

W

The sample size consisted of 65 respondents from a
possible 101 for a response rate of 65 percent (see Table
1). Of this sample, 94%, (n = 61) were female and 97% (n -

63) were Caucasian. All of the respondents were over the age

Table 1

25

Wigs (n=65)

 

 

Characteristic Frequency 96
Gender: Female 61 93.8
Male 4 6.2
Ethnicity: Caucasian 63 96.9
African American 1 1.5
Native American 1 1.5
Age: 20-29 0 0.0
30-39 1 4 21 .5
40-49 29 44.6
50-59 1 6 24.6
60-69 6 9.2
Area of Certification: OB/GYN 23 35.4
Pediatric 1 6 24.6
Family 1 3 20.0
Adult 8 1 2.3
Gerontological 3 4.6
Neonatal 2 3.1
Primary Area of Practice: Private Physician 28 43.1
Free-Standing Primary Care Clinic 6 9.2
ln-Patient Hospital 4 6.2
Private NP Practice 3 4.6
Out-Patient Clinic 3 4.6
HMO 2 3.1
College Health 1 1.5
Extended Care Facility 1 1.5
Home Health Care 1 1.5
School Health K-12 1 1.5
Other 1 5 23.1
NP Preparation: Certificate Program 33 50.8
Master Program 32 49.2
Practice Setting: Urban 26 40.0
Rural 23 35.4
Suburban 1 3 20.0
Years of Practice: Less than 1 year 3 4.6
1-5 years 10 15.4
6-15 years 22 33.8
16-25 years 13 20.0
More than 25 years 5 7.7
No response 1 2 18.5

 

26
of 30 (n - 65), with the largest representation being
between 40-49 years (45%, n - 29). Certification reported by
the respondents covered six areas, of which 80% (n - 52)
covered the primary care areas (Starfield, 1992) of OB/GYN
(35%, n - 23), pediatric (25%, n = 16), and family
specialties (20%, n - 13). Nonprimary care certification
accounted for only 20% (n - 13) of the participating APNs.
The sample functioned most frequently in private physician
practice (43%, n - 28) and areas of practice not listed on
the demographic data sheet, e.g. Planned Parenthood and Teen
Health Clinic, (23%, n =15). Settings of practice were 40%
urban (n s 26), or rural 35% (n s 23). The sample was split
by the type of nurse practitioner preparation. Most common
response to years of practice was between 6-15 years (34%, n
- 22).
Attitndsfi

Reeeergn_nneetien_1. What are the attitudes of APNs
towards AT?

The overall mean attitude score for the sample was 8,
which included only the listed 18 therapies. Results showed
28 respondents (43%) to have had a positive attitude
(selected encourage response) toward AT (M = 13, SD - 2.9).

Thus the remaining 37 respondents (57%) had a negative
attitude (selected a neutral or discourage response) (M = 5,
SD! 2.5). However, of the negative responses only one
respondent discouraged 11 of the 18 therapies as compared

with the remaining 36 (55%) who predominately responded

27
neutrally. Three therapies were written in--acupuncture,
prayer, and Rubenfeld Synergy-~but these were not calculated
into the mean.
Bsferrallzractice_2atterns

Beeeenen_gneetien_z. What is the most frequently
referred AT?

All of the listed AT were referred. Ten were referred
by more than 75% of the APNs and 13 by more than 50 percent
(see Table 2). The most frequently referred AT were
relaxation techniques (n - 64, 98.5%), biofeedback (n - 60,
92.3%), and therapeutic massage (n - 57, 87.7%).

Reeeezeh_gneetien_1. What is the most frequently
practiced AT?

Of the 18 therapies, only two were reported practiced
by more than 50% of the APNs. Respondents cited meditation
(n - 38, 58%) and relaxation techniques (n a 38, 58%) as the
most frequently practiced AT (see Table 3). Sixteen AT were
practiced by at least one of the respondents. No one
indicated having practiced the therapies of reflexology or
Reiki. There were three therapies written in: acupuncture,
prayer, and Rubenfeld Synergy by three separate respondents.

Reeeenen_gneetien_1. Is there an association between
APN attitude and the willingness to refer or practice?

The cross tabulation and chi-square analysis of
attitude and pattern (willingness to refer/practice) is
illustrated in Table 4. There was a significantly higher

proportion of respondents with positive attitudes who also

28

Table 2
Wales (n=65)

 

 

 

 

 

Therapy Frequency %
Relaxation 64 98.5
Biofeedback 60 92.3
Therapeutic Massage 57 87.7
Imagery 54 83.1
Meditation 53 81 .5
Hypnosis 50 76.9
Therapeutic Touch 50 76.9
Yoga 50 76.9
Lifestyle Diets 50 76.9
Accupressure 49 75.4
Spiritual Healing 48 73.8
Tai Chi 38 58.5
Herbal Remedies 36 55.4
Reflexology 30 46.2
Homeopathy 29 - 44.6
Energy Healing 28 43.1
Aroma Therapy 27 41.5
Reike 26 40.0
Table 3

BanLQLdeLeLELantineiAltematixelbmpjes (n= 65)

Therapy Frequency 96
Meditation 38 58.5
Relaxation 38 58.5
Imagery 17 26.1
Lifestyle Diets 17 26.1
Spiritual Healing 15 23.1
Herbal Remedies 5 7.7
Therapeutic Touch 5 7.7
Therapeutic Massage 5 7.7
Homeopathy 2 3. 1
Tai Chi 2 3.1
Accupressure 1 1 .5
Aroma Therapy 1 1.5
Biofeedback 1 1 .5
Energy Healing 1 1.5
Hypnosis 1 1.5
Yoga 1 1.5
Reflexology 0 0.0
Reiki O 0.0

 

29

 

 

 

Table 4
0“-;e $.0|3|0 |.-o ::;|: ‘:o :1 o:.;|o':q:| e ; ;|:
Ibecanies (n=BSl
Pattern
Attitude
Positive Negative

Positive Observed 25 3

90% 10%
Negative Observed 1 6 21

44% 56%

 

X2 (1, n=65l = 16.9, p<.05

had a positive practice patterns (90%), as compared to
respondents with negative attitudes.
WWW
Reeeenen_gneetien_§. What is the proportion of AT that
are referred versus practiced when therapies are clustered?
When therapies were clustered, mind-body movement
(yoga, Tai Chi, relaxation techniques, and biofeedback) was
the most frequently referred (92%, n a 60) and practiced
(65%, n - 65). Following this was mind-body nonmovement
therapies (mediation, imagery, hypnosis, spiritual healing
and aromatherapy) with 77% (n - 50) referred and 63% (n a
41) practiced. Home treatments, though referred by 58% (n a
38) was only practiced by 40%(n - 26). The two remaining
clusters reported a wide range of slightly below 50% to
above 50% in referral rates (manual healing, 74%, n = 48,

and bioenergics, 48%, n = 31). Despite the support of

30
referral by the respondents, both of these clusters were
reported to be negligibly practiced (9%, n - 9 and 8%, n a
5, respectively) (see Table 5).
Discussion
Semis

With the exception of primary care practice areas, no
comparisons of this study's sample could be made with those
of the literature. The 12 counties surveyed were selected
because of homogeneity (caucasian, Protestant) of the
population and the balance between urban and rural settings.
Gender and ethnic backgrounds were consistent with county
demographics. For example by gender, certified Advance
Practice Nurses in Michigan registered in 1995 (Michigan
Department of Commerce) showed that of the 806 APNs listed,
14 or 2% were male. This study had a comparably low number
of men (4 or 6% of the 65).

As for the findings relating to areas of practice, the
sample was mainly comprised of primary care specialties
(80%): OB/GYN, pediatric, and family. Blumberg et al. (1995)
found 59% of their physician population were in a primary
care or family practice setting. A serendipitous finding was
that the sample was considered to be seasoned, with the
majority (62%, n - 40) having 6 or more years of experience.
It can be concluded, that the questions under research were
not biased by gender, ethnic background, or setting as

compared with all APN's in the surveyed areas of Michigan.

3 1
Table 5

WWW (n=65)

 

 

 

 

Referred Practiced
Cluster
Frequency % Frequency %
Mind-Body Movement 60 92.3 65 64.6
Mind-Body Nonmovement 50 76.9 41 63.1
Home Treatments 38 58.5 26 40.0
Bioenergic 31 47.7 9 9.2
Manual Healing 48 73.8 5 7.7
Attitudes

An important study result was that APNs' attitudes
toward AT were negative (56%), as measured by this study.
There were 28 respondents (M - 13, SD - 2.9) who had a
positive attitude and 40 with a negative attitude ( M a 5,
SD 2.5). Both groups had a small standard deviation, which
would indicate similarities in each of the groups. The
negative attitude group mean (M - 5) ranged toward the
middle of the possible 0-9 (encourage 5 9), as did the
positive group mean (M - 13) between 10-18 (encourage 2 10).
Only a few of the therapies (e.g. reflexology and Reiki)
were actually discouraged by a few respondents, and one
respondent discouraged 11 of the 18 therapies. These
findings were not supported by the literature in which over
50% of the physicians and nurses supported AT (Schachter et

al., 1993, Borkan et al., 1994, Blumberg et al., 1995, 8

32
Keegan, 1995). Perhaps the neutral attitude toward a therapy
implied the respondent had no strong feelings of like or
dislike for an individual therapy. This could also mean that
if a client showed interest in one of these neutrally ranked
therapies, the APN might refer the client for this therapy.

One possible explanation for negative outcome was this
study's calculation of negative attitude: Neutral responses
were tallied and included in the negative category. While
the survey design was intended to evaluate attitude toward
AT, the use of the neutral position actually confounded
analysis. The choices of encourage and discourage categories
allowed for clear interpretation of either positive or
negative attitudes. But the neutral category, by definition,
was neither positive nor negative. Attitudes for this study
were originally defined as being only positive or negative,
calculated from adding the encourage responses (210) to show
positive response pattern. Negative attitudes (59
encouraged) however were a combination of nentnel and/or
dieeennege responses, so by default the neutral category was
classified as negative. If the neutral responses were
separated from negative (discourage) ones, 61% of the APNs
would have been neutral and only one negative.

Only one therapy, Lifestyle Diets, was reported equally
in eneennege and nentne1_categories by respondents. This was
especially interesting since information about nutrition]
diet has been taught as a foundation of nursing education

and has come to a new height of awareness in present western

33

society. The public's obsession and concern for diet and
exercise offer an opportunity for APNs to guide clients
toward participation in healthy living through diet changes.
Certainly health-care research has demonstrated positive
effects of diet/nutrition on diseases such as diabetes,
cancer, and coronary artery disease (Whitney, Cataldo, 8
Rolfes, 1996), and greater support by APNs was expected.

A possible explanation for the even split between
encourage and neutral could have been that Lifestyle Diets
was not viewed by respondents as an alternative therapy. If
this was so, then diet may have been viewed as mainstream
health-care, but still does not account for it being
marginally used, or the reported neutral attitude. Further,
respondents may have viewed Lifestyle Diets differently from
conventional diets, e.g. vegetarian or macrobiotic diets. In
addition, APNs in the study asked whether using AT was in
place of already established medical therapies or in
conjunction with them. Perhaps Lifestyle Diets, as well as
the other AT, were interpreted as ”instead of” conventional
therapies rather than ”with” conventional therapies. Though
a glossary was provided to define each alternative therapy,
an overall definition of AT in relation to standard practice
was not provided.

As described in the adapted model for this study,
attitude was based on personal beliefs, values, perceptions,
and experiences which all are components of comfort level.

Perhaps the definition of AT offered to the respondents

34
(practices not in compliance with the standards of the
medical community and interventions not taught widely at
U.S. medical schools) influenced their responses.

The term ”alternative” may also have given the APN a
negative connotation, which, in turn, may have accounted for
negative responses. Though the adjective ”alternative” has
become more commonly used, the APNs in this study were all
over the age of 30 years (78%, n - 51 were over 40 and 34%
were over 50 years old). Alternative therapy as used in the
study might not have been as familiar to these mature
nurses. Indeed, several APNs wrote they were not
knowledgeable or lacked experience in a given therapy. Thus,
the use of the phrase ”complementary therapies” as opposed
to ”alternative therapies” may have elicited more favorable
results.

Another and likely possible explanation for the
negative attitudes could have been that the sample came from
a highly conservative geographical region. The blend of the
population characteristics--Protestant, white, female, and
over 30 years old--could support the possibility for
resultant negative attitudes. Western Michigan is known for
conservative stances on many issues. Taking this into
consideration, AT might be considered by many to be
sufficiently outside traditional health-care practices that
the population would reject their usage. This would help
explain the negative or neutral attitude and practice

patterns by this population.

35

By study design, participating APNs had negative
attitudes towards AT. The only conclusive result on negative
attitudes was that one respondent was classified as having a
true negative feeling toward AT. The majority of the
remaining respondents were scored as negative since they
answered neutral, at least indicating a nonadverse approach
to the use of AT. This nonadverse posture would seem to have
support in that all the listed AT had been referred and all
but 2 had been practiced (see Table 2 and 3). In future
research, perhaps neutral responses should be omitted or
grouped with positive attitudes.
A2N_Eeferral_2atterns

All of the listed AT were referred, with 10 being
referred by more than 75% of the respondents. Relaxation and
biofeedback dominated referral patterns, with over 90% of
the APNs indicating referral practice. More than 80%
referred therapeutic massage, imagery, meditation; and over
70% referred hypnosis, therapeutic touch, yoga and diet.
This tendency likely resulted from nurses and clients being
more familiar with these therapies, and the increased
empirical testing, and greater research base. Since the
1990's a notable change in research (e.g. therapeutic touch,
imagery and meditation, to name a few) has demonstrated
documented outcomes utilizing a scientific basis for
evaluation. Higher client and APN familiarity, increased
support in health-care literature, and empirical research of

AT could result in greater availability and demand of AT.

36

Lack of APN knowledge of AT could have resulted in more
referrals over practice of AT. The neutral attitude would
then reinforce the noncommittal attitude, making referrals
easier for clients who show an interest in AT. An increase
in client interest, increase in availability of AT, and AT
becoming more mainstream could potentially support the
increased referral data in this study.

Eight therapies were referred less than 75% of the
time: Spiritual healing, Tai Chi, herbal remedies,
reflexology, homeopathy, energy healing, aroma therapy and
Reiki. A logical explanation could be lack of a research
base for these therapies. Indeed, some respondents (n - 5)
added remarks expressing their unfamiliarity with listed
therapies. A lack of knowledge or information would
certainly inhibit referrals. Any responsible APN would
hesitate to make decisions regarding appropriate referrals
without suitable background information and substantiation
of the benefit of AT (Berman 8 Anderson, 1994, Engebretson 8
Wardell, 1993). Whereas the allopathic model of medicine has
been well supported by scientific research, alternative
therapy research for these eight therapies has commonly been
anecdotal in its support (Owen, 1995). In the last 5 years
the increase in empirical research of AT has expanded to
include some of these eight AT. Clearly the 10 most
frequently referred AT described by this study have had more
empirical research and thus have a larger group of

respondents willing to refer.

37
A2N_2139t193_23ttatn3

Only meditation and relaxation techniques were reported
to be practiced by more than half (58%) of the respondents;
the remaining 16 AT had considerably lower use (0-26%).
There are several explanations for such low practice rates,
including lack of training/credentialing (Engebretson 8
Wardell, 1993), lack of physician support, and lack of
insurance support.

From a training/credentialing standpoint APNs who were
prepared in certificate programs may not have had the
exposure to AT in their programs, the primary focus having
been on acquiring technical skills to perform as an APN.
Though masters-prepared APNs may have had a greater
introduction to AT, both groups would typically have to
pursue outside sources for training/credentialing in most of
the AT, since only a few have generally been incorporated
into the traditional APN curricula. A problem finding
competent instruction for the various AT and unavailability
of courses and workshops on AT would even further restrict
APNs ability to practice AT.

Even where an instructor was available, the APNs may
not want to expand their knowledge/skills in AT. The APNs in
this study were well established in their practices, with
approximately 40 respondents having 6 or more years of
experience. As in most professions, the more established an
individual becomes in practice, the less willing they may

become to incorporate unfamiliar routines; hence the longer

38
APNs are out of school, the more entrenched they would
become in their routine practice. Newly graduated and less
experienced APNs might be more willing to embrace AT into
their practice because their routines are not yet
established, and they may have had greater exposure to AT.

This may not be true for all seasoned APNs in primary
care. The formation of various managed health-care systems
along with competition client populations and limited
health-care dollars, we may see a change in some experienced
APN positions on AT. Many seasoned APN's realize they often
need more than tangible tools to care for their patients,
and are professionally drawn to pursue AT. A greater demand
by clients for AT in conjunction with traditional health-
care regimes may also boost an interest in AT. Managed care
dictates that primary care should have less referrals to
specialists, requires increased access to members, and
promotes case management. Further development of the APN
practice with the utilization of AT is eminent.

A discouraging finding was that of the therapies taught
in nursing schools as nursing interventions, practice was
less than expected among respondents (meditation 58%,
imagery 26%, and diet 26%). It seemed remarkable that APNs
were not practicing these techniques more frequently, since
nurses are socialized and educated in a holistic model.

The introduction of AT into practice with the
realization that AT may not offer a cure to a current

health-care problem is probably another hindrance. The focus

39
of integrating AT into practice needs to emphasis benefits
which support traditional health regimes. The intended
results of some of the AT are relaxation, a sense of well
being, or spiritual enlightenment. Addressing these areas,
in conjunction with traditional regimes with clients, may
serve to offer holistic treatment of their illnesses.

Lack of physician support of AT might also have limited
APN's practice. The APNs in this study worked primarily in
traditional family practice settings in conservative
communities. If the physician did not value or approve of a
specific alternative therapy, an APN in many instances may
have been restricted from practicing it, despite potential
APN support. The APN might also have been working under an
agreed set of guidelines, with responsibilities of the
physician and the APN clearly defined. The APN would then
have to refer clients to AT rather than practice AT. Indeed,
two respondents commented that their physician's practice
protocol was their reason for not practicing AT. Physician
nonsupport would also impede newly graduated APNs from
practicing AT because they would initially focus on
developing confidence and credibility in their traditional
roles as APNs, both with physicians and clients. Therefore
APNs who are more receptive to practicing AT might more
readily be able to introduce AT after becoming established
in a practice.

Lack of physician support might arise from financial

operational considerations. The optimal balance between

40

provision of quality of care and profit/debit margins might
be difficult to achieve with implementation of some AT. For
example, biofeedback and imagery take added time above the
normally scheduled office appointment and thus make it
difficult to initiate without prior planning. This is
further compounded by the fact that there is greater
emphasis on scheduling shorter office visits. Less time in
the office would reduce the chance for AT being practiced.

Lack of support by insurance companies (hence physician
lack of support for financial reasons) may have also
accounted for such a low practice rate of AT. In current
literature, the relationship between AT ( e.g., relaxation
techniques) and specific diagnosis (e.g. fibromyalgia) is
not available. Under insurance guidelines, office treatments
and procedures must have measurable outcomes to receive
reimbursement. At present, insurance compensation for AT
must be coded under stress, anxiety, or pain, and some
insurance carriers cover such AT as diet and massage.
Surprisingly, neither diet or massage were practiced by APNs
in this study: 26% and 6.2%, respectively. Most other AT are
not covered by insurance. So even if the practitioner was
willing to provide AT, the lack of insurance support could
impact financial stability of the practice and increase the
burden of payment on the client. Clients unwilling to pay
out-of-pocket for AT would further hinder their use in a
practice. Some AT (e.g. therapeutic massage or therapeutic

touch) also require special equipment or additional space,

41

both of which may be costly and threaten the profits of a
practice due to the initial investment costs.
Warns

This study supported that APNs with positive attitudes
had positive referral/practice rates, and that negative
attitudes were fairly evenly divided between positive and
negative referral/practice patterns. This finding was
supported by the literature in which over 50% of the
physicians and nurses supported AT in both attitude and
referral/practice pattern (Blumberg et al., 1995, Borkan et
al., 1994, 8 Keegan, 1995, Schachter et al., 1993). Perhaps
the neutral responses in the sample were the explanation for
the close proportion between those respondents with a
similar negative attitude and negative pattern. Hence a
proportion of positive and negative referral/practice
pattern among respondents with a negative attitude was
perhaps distorted by the neutral responses being coded as
negative:
Clnntatfl

When AT were clustered, the most frequently referred
and practiced were mind-body movement and nonmovement
interventions. Both of these clusters are noninvasive and
induce a state of relaxation, either with assistance or
independently.

These therapies [mind body movement and

nonmovement interventions] can help individuals

appreciate the sources of their stress and reduce
that stress by quieting the mind and using it to

42

mobilize the body to heal itself (National Health
Institute, 1992, p. 3).

This finding was supported in the Keegan (1996) study
that showed nurses most frequently practiced mind-body
interventions (e.g., biofeedback, breathing exercises,
meditation, and imagery) when incorporating AT for patient
care. This was also consistent with findings in this study
regarding the most frequently practiced and referred AT (see
Tables 2 and 3).

In this study, the positive trend towards mind-body
interventions may have stemmed from early experiences in
nursing education, including theory and techniques (e.g.
relaxation methods, meditation, and imagery) as a means of
assisting patients to optimal levels of health through
noninvasive measures. Holistic nursing explores mind-body
interconnectedness and has been taught to nurses through the
use of theories developed by nurse theorists such as Rogers
and Levine (Meleis, 1991). These types of therapies may have
been more familiar to more nurses and perhaps were the basis
for their encouragement. The sample may have had a limited
range of exposure to AT-- and perhaps only mind-body
interventions.

Won

The results of this study partially supported the
adapted model of the Azjen and Fishbien (1967) Theory. The
original theory postulated an association between behavior
and attitude. The results of this study postulated a bi-

43
directional association between attitude and behavior of
APNs toward AT. There were proportional differences between
attitude and behavior when the total sample's attitudes and
patterns were evaluated. The hypothesized relationship that
positive attitudes would induce positive referral and/or
actual practice of AT was found not to be false. As for the
negative attitude equating negative referral and/or actual
practice this was only partially supported by the findings.
Negative attitudes were represented by both negative and
positive patterns of referral/practice, and were not
significant in regards to proportional differences, but
demonstrated a fairly even division of both positive and
negative practice patterns. There is a need for further
model development to clarify definitions of the variables
(positive, neutral, and negative attitudes).
Implications

Wartime

This study examined attitudes of APNs toward AT.
Results showed that a negative attitude (as defined by the
study) was more common than a positive attitude. However,
although APN attitudes were calculated as negative, the
majority of respondents in this category answered neutrally.

Strategies to turn neutral practice attitudes and
patterns to more positive ones need to be designed. Since
the study showed attitudes and behavior are associated. So
if attitudes towards AT are positive, then AT will be

utilized in practice. One strategy would be to objectively

44
evaluate practices in which AT are used. An alternative
therapy prescribed for a specific diagnosis should be
closely monitored to determine its benefit to patient
outcomes. If it is found that outcome measures and cost
effectiveness are decisive, physicians and APNs should be
more likely to merge the alternative therapy into their
practice patterns.

Positive attitudes toward AT will better assist clients
and APNs alike in selecting and assimilating AT into
practice. Including AT into practice draws on the nursing
premise of being holistic: Nurses view the client in light
of mind, body, and spirit. APNs must be knowledgeable to be
advocates for their clients, filtering out potentially
harmful AT and being ”supportive of his/her client through
education, counseling, documentation and close monitoring”
(Slagle, 1996, p. 17).

Creating a network directory of primary care providers
using AT would give colleagues easier access to information
on specific AT. Such a directory would be helpful both to
the beginning (novice) practitioners and experienced
(expert) ones by linking the two, serving as a starting
point for consultation and collaboration of APNs wanting to
use or learn more about an alternative therapy and its
benefits. Knowing alternative therapy resources can help in
modeling a practice applying AT and reinforce positive
practice behaviors. As networking becomes more widespread,

neutral attitudes toward AT should become more positive.

45

Yet another strategy to encourage APNs and clients to
view AT in a more positive light might be through free
treatment programs. Results in this study showed clustered
mind-body movement (e.g. yoga, relaxation techniques, Tai
Chi, biofeedback) and nonmovement interventions (e.g.
mediation, imagery, hypnosis, spiritual healing, and aroma
therapy) were not only encouraged but were referred and
practiced either singly or in clusters more often than other
AT. The more familiar, noninvasive, low technological, and
cost-effective aspects of these interventions thus make them
an excellent choice for such treatment programs and can open
the door for other alternative therapy use. The greater the
exposure to AT, the greater the likelihood a neutral
attitude towards their benefits will become positive.
W

The neutral attitude demonstrated by the APNs in the
study may become more positively directed through increased
education. Providing a strong theory and knowledge base of
AT by APN nursing students in their clinical programs would
change perceptions relative to the value of enhancing
traditional regimes with AT. A number of opportunities
currently exist to increase awareness of AT through
workshops and seminars tailored to the community and a range
of health-care providers.

Several APNs in this study felt they lacked knowledge
about specific AT, suggesting these therapies were not a

part of their nursing education. Many nursing programs offer

46

only limited courses in AT, but most incorporate at least
some introduction to relaxation techniques, imagery and
massage. Since relaxation (mind-body movement) and imagery
(mind-body nonmovement) were two therapies positively
referred (relaxation also positively practiced) in this
study, it would be logical to expand curricula to other AT
in these two clusters, as an initial introduction to the
many AT available. And as more research data become
available, classes should be augmented to include the
theoretical and practical benefits of specific AT. Similar
programs could be designed for practicing APNs to augment
their education and practice, as well as to facilitate
continuing education required for license renewal.
Increasing participation in these programs can only increase
the effectiveness of APNs in their practice settings. The
more members of the primary care network are exposed to AT,
the more likely AT will be embodied into patient care. The
current neutral attitudes toward AT would shift toward a
more positive position of acceptability and credibility.

The client population could similarly benefit from
educational materials/seminars to boost their own
understanding of AT and how AT may be used for personal well
being. Certainly the general public has developed a
heightened interest in AT, as evidenced by increasing
numbers of health foods and spas and the use of herbal and
other natural remedies. In some instances, an individual is

ignorant of the consequences of using AT and may, in fact,

47
try a alternative therapy contrary to the desired outcome.
Seminars sponsored by knowledgeable APNs become a natural
vehicle to properly educate and guide clients toward
appropriate AT as well as building a relationship between
the APN and the community.
WW1.

This study needs to be repeated using a larger sample
and surveying broader population areas (e.g. Detroit) to
validate findings of Michigan APN attitudes and practice
patterns. Eisenberg et al. (1993) proposed that, Tphysician
involvement in unconventional alternative medicine is likely
to be higher among females, younger physicians, family
practitioners, or those who practice in the western United
States. This statement could be extrapolated to APNs who
practice in primary care. A further study, although not
explored in this study, would be to compare other states'
APN populations, e.g. California (liberal) to Michigan
(conservative) to see if there were a difference in attitude
or behavior toward AT and whether Eisenberg et al. (1993) is
correct.

Further refinement of the instrument with emphasis on
clarification of the terms ”alternative” versus
”complementary" and a clearer definition of AT is essential
for the explanation of AT in conjunction with current
medical regimes. In addition, the survey should separate the
three categories of attitude (encourage, remain neutral,

discourage) and score each separately. Interpretation of

10.

11.

53
GLOSSARY

Acupressure-the utilization direct physical pressure by
fingertips or hands to treat energy points and channels
by a therapist.

Aromatherapy - the therapeutic use of the essential
oils of plants.

Biofeedback- the use of electronic devices that measure
blood pressure, pulse rate, muscle tension, skin
temperature, perspiration, brain waves or other
variable bodily functions. Once identified through
these instruments relaxation techniques are used to
change and later the patient learns to control body
function subconsciously.

Energy Healing- the use of the practitioners ability to
view or sense an individual's energy field or etheric
body.

Herbal Remedies- the use of plants or herbs to
alleviate a symptom or ailment.

Homeopathy - based on the ”law of Similars” that the
symptoms of disease can be cured by substances of
minerals, botanical, zoological as well as other
sources that produce similar symptoms in healthy

people.

Hypnosis - a state of attentive and focused
concentration in which people can be relatively
unaware, but not completely blind to, their
surroundings.

Imagery- mental process that is imagined through all
the senses while a person its fully awake.

Lifestyle Diets - a variety of eating styles that
requires different regimes of vegetables or vitamins
and sometimes requires the elimination or moderation of
intake of certain foods, such as sugar and meats.

Mediation - a class of techniques intended to influence
and individual's consciousness through the regulation
of attention.

Reflexology - a system of diagnosis and treatment based
on the theory that pressing on certain areas of the
hands or feet can help relieve pain and remove the
cause of disease in other parts of the body.

12.

13.

14.

15.

16.

17.

18.

54

Reiki - a healing System said to ”utilize life force
energy to vitalize and balance the entire
physical/mental, emotional, spiritual dynamic”
(American Medical Association, 1993). It is also used
for stress-reduction and relaxation as well as a
complete preventative self-health care method.

Relaxation Techniques - a conscious effort made for the
decrease of stress and anxiety through the use of self;
or example, by either deep breathing or tensing of
muscle group followed by relaxing of the muscles.

Spiritual Healing - the use of prayer to alleviate
illness or disease.

Tai Chi - a Chinese art of exercise for self defense
and meditation.

Therapeutic Massage - a scientific manipulation of the
soft tissues of the body to normalize tissues.

Therapeutic Touch - a system in which the hands of a
practitioner are used to redistribute energies to help
or heal someone who is ill or distressed. Sometimes
used for relaxation.

Yoga - based on ancient Indian beliefs that the use of
exercise improves physical and emotional health. Used
are breathing, mediation, other relaxation techniques,
bending, stretching, holding various postures, and
dietary measures.

Definitions adapted from Alternative Health Methods, 1995,
and Alternative Medicine: Expanding Medical Horizons, 1992.

APPENDIX C

DEMOGRAPHIC DATA SHEET

55

Please complete the information. Circle the responses that apply.

1. Gender

A
B

. Female
. Male

2. Age in years

mmoow>

20-29
30-39
. 40-49
. 50-59
60-69
70+

3. Ethnicity

A
B
C
D

. Asian-Pacific Islander
. African-American

. Caucasian
. Hispanic

E. Native American
F. Other. Please write in:

6. Are you currently in

practice?

Yes

No

7. Years of practice

A.

91.0.0!”

Less than
one year
1-5 yrs.
6-15 yrs.
16-25 yrs.
more than
yrs. 25

8. Practice Setting

A.
B.
C.

 

4. Area of Nurse Practitioner certification

0093.)

.0 TWP??? 9‘

Adult E. Family

Gerontological, F. Pediatric
. School G. OB/GYN
. Neonatal

Primary area of practice

Private NP Practice

College Health

Extended Care Facility

Home Health Care
Occupational/Employee Health
Free Standing Primary

Care Clinic

NP Faculty

I"

xsr;

.2

A.

Rural
Urban
Suburban

9. NP Preparation
NP Certificate

Program

8. Master’s

Program

Private Physician Practice

Correctional Facility

School Health K-12

ln-Patient Hospital Unit

Outpatient Clinic

M. Health Maintenance

Organization
Other, Specify

APPENDIX D

ALTERNATIVE THERAPIES SURVEY

 

Instructions:

56

For this survey, please indicate the response you give
when patients ask you about the following alternative therapies. Please

circle an appropriate response for each column. You may enter other
alternative therapies at the end of the survey. Use the attached
glossary for definitions of the therapies.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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E R D NO YES No YES

E R D NO YES NO YES

 

 

 

 

 

 

APPENDIX E

UCRII'IS APPROVAL

 

flfllfiflll
FAX: 511102-1171

mules-mam
woman».
We“

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ems-mm

 

£17

MICHIGAN STATE

UNIVERSITY

February 15. 1996

 

To: Susan L. Wispee
2323 Cress Creek Dr.
Muskegon, MI 49444

RE: IRES: 96-055
TITLE: HIGIGAN mares PRACTICE NURSES ATTITUDE AND
PRACTICE PATTERNS TOWARDS ALTERNATIVE THERAPY

REVISIW Rm: N/A
CATEWRY 1-7
APPROVAL :DATE: 02 1.5/96

The university Committee on Research Involving Human Subjects'IOCRIHSI
review of thisfproject is complete. Iamrpleased to adv mt the
rights and wel of the human subjects appear to be adequately
pgztected and methods to obtain informed consent are appm Wis

refore, the UCRIHS approved this project and any rev sicns listed

RIIIIAL: UCRIHS approval is valid for one calendar beginning with
' the approval date shown above. Investigators plenningt
continue a project be rmust use the green renewal
when a

form (enclosed with original t:gproval letter or
i l to seek certification. There is a
mum of four such expedit renewals ssible. Investigators
wishi to continue a reject beyond the time used” submit it
again or complete rev ew.

REVISIONS: UCRIHS must reviewm changes rccedures inw wlving human
subjects, rior to tiation of intge change. If this is done at

the time o renewal, please use the can renewal form.

revise an a roved pm mtocol at o r time duringm

send your wr tten request£ mthe IHS Chair, requesting revised

approval and referenc project's IRB I and title. Incm

in your request a descr ptionp ofm change and any revised
Mts, consent tforms or advertisements that are applicable.

Should either of the fo llcwing arise during them wee of the
work, investi ators must noti UCRIHS Em mtly: Mvil) roblems
(unexpecteds sde effects comp aints, e c.)
subjects or 2) wchang them ”ch vironment or new

information floating greater risk to the human sub ects than
existed when the protocol was previously reviewed appm .

If" who of any fut ms lease do not hesitate to contact us
at (511)355- 21:0 or as: (51714 2- 171.

cc: Gwen Wyatt

LI ST OF REFERENCES

LIST OF REFERENCES

American Hospital Association. (1995). AHA_gn1de;_The
- . Chicago, IL: American
Hospital Association.

Ajzen. I- (1988). Attitudei_personalit¥_and_behaxier.
Chicago, IL: Dorsey Press.

Ajzen, I., 8 Fishbein, H. (1973). Attitudinal and
normative variables as predictors of specific behaviors.
, 21, 41-57.

Berman, B. H., 8 Anderson, R. W. (1994). Improving
health-care through the evaluation and integration of

complementary medicine. Cemnlementar¥_Theranies_in_nedicinei
2, 217-220.

Blumberg, D. L., Grant, w. D., Hendericks, s. R.,
Ramps, C. A., 8 Dewan, M. J. (1995). The physician and

unconventional medicine. Alternatiye_1hezaniea‘_l(3), 31-35.

Borkan, J., Neher, J. 0., Anson, 0., 8 Smoker, B.
(1994). Referrals for alternative therapies. The_zonznal_gz

Eamil¥_2racticei_12. 545-550-

Daniels, G. J., 8 McCabe, P. (1994). Nursing diagnosis
and natural therapies. Jonrnal_91.nelistic_nnrsinsi_12i2).
184-192.

Eisenberg, D. u., Kessler, R. C., Foster, C., Norlock,
F. E., Calkins, D. R., 8 DeBlanco, T. L. (1993, January).
Unconventional medicine in the United States. Hen_England
Journal_efsuedisine. 246-252.

Engebretson, J., 8 Wardell, D. (1993). A contemporary
view of alternative healing modalities.
13(9), 51-55.

Henerson, H. 3., Morris, L. L., 8 Fitz-Gibbon, C. T.
(1987). An introduction to the measurement of attitudes and

attitude change. In neu_To_neasnre_Attitndes (pp- 9-13)-
Newbury, CA: Sage.

Keegan, L. (1996). Nurses are embracing holistic
healing. RH, pp. 59-60.

Langer, L. M., 8 Warheit, G.J. (1992). The pre-adult
health decision-making model: Linking decision-making
directedness/orientation to adolescent health-related
attitudes and behaviors. AdnlcaCCDC§i_Zl, 919-948.

58

59

Meleis, A. (1991).
progress. Philadelphia, PA: J. B. Lippincott Company.

Michigan Department of Commerce (April 1995)._A_11§3_of
. Lansing, MI: Michigan
Department of Commerce.

Moffit, 8.3. (1994). Alternative medicine and managed
care. MW. 14-16o

Murray, R. 3., 8 Rubel, A. J. (1992). Sounding board:
Physicians and healers unwitting partners in health-care.

WU) . 61-64.

Owen, A (1995). Surveying the alternatives. Nursing
Tinsel 2106), p. 42.

Pender, N. J., 8 Pender, A. R. (1986). Attitudes,
subjective norms and intentions to engage in health

behaviors. W. 15-18 -

Pietroni, P. C. (1992). Beyond the boundaries:
Relationship between general practice and complementary

medicine. WWW. 564-6 -

Roland, M. (1988). General practitioner referral rates.

Wan._291(6646) , 437-38.

Schachter, L., Weingarten, M. A., 8 Kahan, E. E.
(1993). Attitudes of family physicians to nonconventional
therapies. WW. 1268-1270 .

Slagle, M. (1996). The nurse practitioner and issues of
alternative therapies._Nnrse_2ractitimen__Amsrican_Jenrnal
W410). 16. 18-19-

Starfield, B. (1992).
and_pgligy. New York, NY: Oxford University Press.

Thorston, J. A., 8 Powell, F. C. (1991). Age difference
in health attitudes and beliefs. 2sysholosical_nenertsi_§9,
1111-1115.

United States Department of Commerce. (1993). 1220

Michigan. Washington D C : U. S. Government Printing Office.

Wharton, R. 8 Lewith, G. (1986). Complementary medicine
and the general practitioner. Britiah_uediga1_ignzng1*
222(6534), 1498-500.

 

60

Whitney, E. N., Cataldo, C. 3., 8 Rolfes, S. R.,

(1996).
York, NY: west Publishing Company.

Workshop of Alternative Medicine. (1994). Alternatiye
' . Washington DC: U.S.

. New

Government Printing Office.

Zimbardo, P. G., 8 Leippe, M. R., (1988).The_psyghg1ggy
. New York, NY:

McGraw .

 

48
each category in regards to attitude, and comparisons with
this study are needed to validate findings and make possible
generalizations. unlike the survey for this study, which
only loosely measured attitude and broadly measured
behavior, a new tool might include analysis using a 6-point
Likert scale with ranges of strongly agree to strongly
disagree. Such a scale would help to more accurately
evaluate attitudes toward AT.

It would also be interesting to conduct a correlational
study of APN's years of experience and likelihood of
practicing AT. Perhaps this would provide insight into APN's
attitude and practice behaviors (expert versus novice), and
show if there is a relationship between years of experience,
and the use of AT. In addition, studying the relationship of
APN's practice with AT using focus groups or qualitative
research may also help explain data regarding use or non-use
of AT.

In addition, empirical research, especially with
outcomes of AT on specific medical diagnosis is needed. This
research is essential in order to document the effect of AT
on client outcomes--thus shifting neutral attitudes to
positive attitudes. This shift would increase the
marketability of APNs incorporating AT into their practice
in the managed care area. The APN is certainly well suited
for this change. But more data are needed to demonstrate the
uniqueness of AT as well as their cost effectiveness and

client satisfaction rates.

49
Summary

The use of AT is growing. Yet limited APN knowledge of
AT has hampered incorporation into primary care settings.
Both physicians and APNs need a better understanding of what
role AT can play in fostering client wellness. In today's
high technology health-care, APNs have an opportunity to
facilitate client health and wellness through the use of
inexpensive AT. Many clients are already using AT but are
now challenging primary care providers--such as APNs--to

learn more about AT to facilitate both client trust and high
quality care.

APPENDIX A

COVER LETTER
CONSENT FORM TO STUDY RESPONDENTS
REMINDER POSTCARD

50

COVER LETTER

Dear Potential Participant,

I am a graduate student in the College of Nursing at
Michigan state University and I am working on the completion
of my master's thesis.

I an utilizing a questionnaire about Alternative Therapy and
its application to Advance Practice Nurses in Michigan. I am
inviting you to participate by completing this anonymous
written questionnaire.

By completing this questionnaire you will have provided
information that is greatly appreciated. As a nurse, I am
interested in providing quality care to people in the
community and this information will provide information
about unexplored areas of APNs and Alternative Therapy.
Hopefully this questionnaire will provide information for
planning treatment options for patients.

Once again, thank you for considering participation in this
study.

Sincerely,

Susan L. Wimpee, R.N., B.S.N.

51

CONSENT FORM TO STUDY RESPONDENTS

This study is a requirement for a graduate thesis through
Michigan State University. It is designed to obtain
information about advance practice nursing, and attitudes
towards alternative therapies. The information obtained
through this study may be used to develop further research
on this topic. The completion of the enclosed questionnaire
will take approximately 15 minutes.

If you wish to participate, please complete the two--part
questionnaire. Place both parts of the questionnaire in the
pre-addressed envelope provided and mail. By completing and
mailing the questionnaire, you voluntarily agree to
participate in the study and imply consent. Participation in
the study consists of completing and mailing the
questionnaire.

Your participation is voluntary; you may refuse to
participate or stop your participation at any time without
penalty. By participating you help further information on
practitioner use of alternative therapy in advance practice
nursing.

All individual responses will remain anonymous. Only group
data will be reported in the study. Your responses on the
questionnaire will be analyzed only by the principal
investigator, Susan Wimpee, R.N., B.S.N. and her thesis
committee.

If you have any questions or concerns about this study,
please call me or write to the address below.

Thank you for your assistance,

Susan Wimpee, RN., B.S.N.
2323 Cress Creek Dr.
Muskegon, MI, 49444

(616) 733-7585

52

REMINDER POSTCARD

Just a reminder to send in your Alternative Therapies
Survey. If you have already done so, I would like to thank
you for your participation. If you need another
questionnaire, please call 1(616) 733-7585, leave your
address, and one will be sent to you.

Thank you,

Susan Wimpee R.N., B S.N.
MSU Graduate Program

APPENDIX 8
GLOSSARY

       

          

 

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