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Complementary and alternative medicine (CAM) encompasses a wide range of therapeutic procedures and philosophies that are not traditionally viewed to be part of conventional medicine. This is the second special edition of JCN to focus specifically on CAM and in this issue there are several papers from around the world which examine, either directly or indirectly, the complexities and issues which surround the use of CAM in clinical practice.

As with the first CAM special issue (Smith 2008) one of the main difficulties encountered whilst compiling this issue relates to the lack of clarity as to what actually constitutes CAM. Techniques can be as diverse as gut directed hypnotherapy in irritable bowel syndrome to acupuncture in pain relief to spiritual healing in oncology and manipulation in low back pain. CAM also appears to differ between countries. For example, Traditional Chinese Medicine (TCM) is classified as CAM by the House of Lords Scientific Committee in the UK. However, TCM approaches are viewed very differently in South East Asia (House of Lords Select Committee on Science and Technology 2000).

The National Centre for Complementary and Alternative Medicine (NCCAM) classification has been used to determine the appropriateness of papers for this issue. This classification is supported with the following broad definition of CAM as a group of diverse medical and health care systems, practices and products which are not presently considered to be part of conventional medicine (NCCAM 2004). Regardless of the diversity of CAM approaches and difficulty to define, its popularity has increased in recent years worldwide (Chua & Furnham 2008). It is estimated that more than half of the world’s population have accessed some form of CAM therapy, often in conjunction with traditional medical approaches (Tiralongo & Wallis 2008). Concomitantly, there is an increasing evidence base outlining the potential benefits and adverse effects of CAM therapies (Izzo & Ernst 2001).

As a consequence of this increasing popularity, CAM appears on the curricula of many medical schools. Elective courses on CAM are included in many North American medical schools; however, there is evidence that approaches to education are variable and arguably superficial and, in some instances, the CAM knowledge of medical educators is inadequate (Verhoef et al. 2004). In the UK, the Department of Health (2001) recommended that every medical school in the UK ensures that their undergraduate students are exposed to a degree of CAM familiarisation to help them deal with patients who use or have an interest in trying a CAM approach.

Owen et al. (2001) highlighted several learning opportunities for medical students at the University of Southampton, where they have established a module for CAM for their third year undergraduate students. This module received very favourable feedback from students and it offered them the following learning opportunities:

  •  To facilitate and encourage students to reflect of general issues surrounding the growth and practise of CAM
  •  To introduce the students to the philosophy, historical development and underlying concepts of CAM
  •  To study specific CAM therapies in more depth
  •  To consider the evidence base of CAM therapies and to reflect on the relevance of specific CAM techniques in relation to clinical presentations.

Owen et al. (2001) believe that doctors should have a role as ‘gatekeepers’, advising patients about CAM, arguing that if they are not appropriately educated in CAM then there is the risk that patient care, in relation to CAM, will continue to be patchy and largely out with the conventional care framework.

A similar argument could be made for CAM familiarisation with nursing education. Nurse educators with expertise in CAM are continually being challenged to educate undergraduate and post-registration nursing students about efficacy, safety and assumptions of CAM approaches. Presently, it would appear the level of CAM input varies between institutions and often relates to individual staff interests. CAM education in nursing programmes tends to relate to elective courses or the occasional lecture within core curriculum. Further familiarisation and training in CAM may offer an opportunity for nurses to have greater understanding of their patients, to integrate different approaches into patient care.

Interest in the use of CAM in clinical nursing practice has increased in recent years (Hon et al. 2006). As health professionals on the clinical frontline, nurses are often required to provide information and guidance to their patients about safe and effective CAM (Smith 2008). Nurses play a significant role assessing their patients’ current use of CAM and answering questions about CAM practice (Halcon et al. 2003). Despite increasing interest and positive attitudes towards CAM, nursing knowledge has been shown to be limited (Uzan & Tan 2004). This raises the question of the need and applicability of CAM education in undergraduate nurse education. If a nurse cares for a patient who has accessed CAM therapies, what level of CAM education is required in nurse education? Should nurses be in the position to advise their patients about CAM treatments? Do clinical nurses need to understand its potential benefits and limitations of approaches? For example, how best to advise a patient with liver disease who is thinking of taking a herbal remedy for a cold.

There has been open debate about what level of CAM education is sufficient with undergraduate nursing curricula. There is a diversity of opinion about what constitutes appropriate curriculum content and teaching methods of CAM in undergraduate programmes (Verhoef et al. 2004).

Providing educational information on CAM for clinical and student nurses is potentially challenging for nurse educators. For many CAM therapies there is insufficient rigorous research available for nurses to provide evidence based advice to patient, this is relevant in our current climate of evidence based practice. This lack of scientific evidence relates not only to lack of rigorous research to determine the effectiveness of specific CAM approaches, but also to the difficulties researchers face when applying conventional research methods to CAM treatments (Smith 2006). Additionally, each CAM approach requires to be examined on its own merit, to generalise all CAM therapies collectively is extremely problematic.

In the UK, the House of Lords Scientific Committee recommended the Nursing and Midwifery Council and Royal College of Nurses collaborate to ensure that CAM features as part of preregistration nurse education programme Recommendations were also made for the inclusion of CAM familiarisation with undergraduate medical education (House of Lords Select Committee on Science and Technology 2000). Such a development could enhance CAM familiarisation in undergraduate nursing curricula and potentially provide a standard competency that would be expected of qualified nurses. It is clear that this type of CAM familiarisation education is distinct from courses which aim to equip to practise specific CAM therapies themselves. The Royal College of Nursing (2003) provides a very useful framework Complementary therapies in nursing, midwifery and health visiting which provides clinical nurses with appropriate advice to integrate CAM into their everyday practice within their professional code of conduct. Higher Educational Institutions now provide numerous CAM programmes, many of which work towards integrative healthcare (Isbell 2001).

Additionally, post registration nurses working in clinical areas where CAM is widely used i.e. chronic illnesses, palliative care should be made aware of CAM issues related to these specialities during their post registration training. This presents another challenge to nurse educators. To prepare clinical nurses to advise patients of the potential benefits and risks of CAM therapies to achieve a safe and more effective integration of CAM approaches into mainstream health care, CAM familiarisation is required in undergraduate nurse education.

There are clearly some potential logistical issues, such as what to teach, how to teach and who to teach about CAM. Most nursing programmes have a packed curriculum and for some it may appear indulgent to dedicate time to issues surrounding CAM familiarisation. There are, however, several possible ways to facilitate the integration of CAM related material in undergraduate nurse education programmes, including the creation and development of web based resources that focus on CAM evidence, skills, safety and attitudes. The increasing adoption of problem based learning (PBL) in nurse education also provides a potential opportunity to integrate issues related to CAM familiarisation into an existing teaching throughout the nursing curriculum. Multiprofessional approaches to CAM education is an option that nurse educators may wish to give some attention to. An interprofessional educational approach brings with it the potential benefits of increasing multi-professional collaboration, improving communication and understanding of other professional roles (Tucker et al. 2003). However, in nurse education such developments require close monitoring to identify the different educational needs and preferences between student groups.

In this special issue, the importance of CAM education for nurses is highlighted in several papers. Ip et al. (2009) demonstrate the effective use of an efficacy-enhancing educational intervention to promote coping ability during childbirth and reduce perceived pain and anxiety in the first two stages of labour. Kang et al. (2009) report that meridian acupressure is a potentially effective intervention for the rehabilitation of stroke patients, improving the movement of affected upper limbs and activities of daily living through the use of this CAM approach. A randomised controlled trial conducted in Sweden underlines the potential use of music interventions as part of a multi-modal regime for patients on bed rest following open heart surgery, stressing the importance of nurses being familiar with such non-conventional approaches. In this study, increased relaxation in these patients was directly related to oxytocin release (Nilsson 2009).

Finally, and of particular relevance to this editorial, Arykan et al. (2009) examined the types of CAM being given children with type 1 diabetes mellitus by their parents in Turkey. They reported that over half of one hundred paediatric patients attending an out-patient clinic were using one or more form of CAM, mostly oral herbal preparations. The use of herbal remedies has been shown to have potential safety implications. Smith & Chen highlighted several potentially complex issues, such as toxicity, interactions and contradictions associated with the use of Chinese herbal remedies in the management if irritable bowel syndrome (Smith & Chen 2009). Therefore the findings of this Turkish paper highlight the importance of nurses having up to date knowledge of the use of CAM in the clinical setting.

The findings of this study are of great importance and are potentially far reaching. Clearly it is important for nurses to be familiar with CAM approaches to provide safe and effective care, however the potential risk of not having sufficient CAM knowledge and the risk of contraindication or toxicity from such herbal remedies cannot be underestimated. Nurses should be in a position to give sound advise about the effectiveness, safety or contraindications of CAM therapies.

Given the current rate of evolution of CAM globally in health care systems, serious consideration should be given to the inclusion of CAM related content within all undergraduate nursing programmes. Issues surrounding teaching objectives and core content of CAM related material provide the impetus for open debate regarding what level of CAM education is sufficient for our clinical nurses of the future. Those involved in the delivery of CAM education for nurses need to ensure that educational objectives and goals are met through comprehensive evaluation.

CAM, such as acupuncture and spinal manipulation, are to be recommended by National Institute for Health and Clinical Excellence in the UK as part of NHS treatment for low back pain the first time. Such developments, makes the argument for familiarisation of CAM within nurse education more potent.

In conclusion, further attention is required into the focus and content of CAM education for undergraduate nursing students. It is vital we meet the educational demands of future clinical nurses to ensure the safe and effective integration of CAM therapies for their patients.

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