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Australian herbalists' perceptions of professional clinical support.

Objective To describe the perceptions held by members of the National Herbalists Association of Australia (NHAA) regarding the levels of intra-professional support available to them upon entering clinical practice.

Design A national postal survey sent to all full members of the NHAA.

Setting Nationwide herbal clinics of NHAA practitioners in Australia.

Main outcome measures Rating scales of perceptions of support (1=very supportive, 2=somewhat supportive, 3=a little supportive, 4=not supportive) provided by the respondents in regard to their educational institution, professional association (NHAA) and other practitioners, reported as frequencies and means.

Results Herbalists appear to receive most support from informal inter-professional relationships with other practitioners (mean=2.13) and some support from their professional association (mean=2.35). The majority of herbalists do not perceive their training institution (mean=3.18) as being very supportive.

Conclusion The survey results show a significant degree of consistency in attitudes across Australia by members of the NHAA towards perceptions of available post-graduate support. The survey data indicates that support available to herbalists when entering clinical practice is on an informal, practitioner to practitioner basis, as opposed to the result of any formal structures. This research highlights how herbalists perceive formal support structures available to them as post-graduates as insufficient.

Introduction

Research in Australia suggests that significant numbers of people are now involved in the professional practice of complementary and alternative medicine (CAM) (Druss 2003, Bensoussan 2004). Of all the CAM modalities herbal medicine is reported as being one of the most popular (Eisenberg 1998; MacLennan 2002). Bensoussan (2004) reported that Western herbalism and Naturopathy make up a large portion of the Australian healthcare sector. The recent NHAA survey estimated professional consultations of Western herbal and naturopathic practitioners to total $AUD 85 million annually, excluding the price of medicines, equating to 1.9 million consultations annually (Bensoussan 2004).

The herbal profession in Australia is currently at an interesting junction. There are increasing numbers of graduates of herbal medicine and naturopathy (Hale 2003) and increasing calls for registration of the herbal profession from both inside and outside the profession (NHAA 2002, Carlton 2004, Australian Government 2005, DHS 2005). It is clear these calls must also be matched by training programs which deliver competent and safe healthcare professionals. Successful training programs for health care professionals must be able to satisfy the competencies required by their graduates for clinical practice to ensure that practitioners are able to meet the needs and demands of their patients (Smith 1995). Implicit in this is the importance of ongoing clinical research as well as ongoing support and education for qualified practitioners to achieve the most beneficial management program for all patients and for the growth of the profession.

Although there are many instances of how knowledge is transmitted within the orthodox medical world there is no comparable study of CAM training institutions (Cant 1996). However studies overseas and in Australia have consistently found that the length and standard of training amongst CAM professions is varied (Fulder 1982, British Medical Association 1993, Bensoussan 2004). Earlier findings in the UK suggest that irrespective of the quality of their training, the clinical experience of CAM practitioners is often somewhat limited (Fulder 1985). Bensoussan (2004) reported that the members of the NHAA and ANTA (Australian Natural Therapists Association) who practice Herbalism and Naturopathy are diverse in terms of education and clinical experience.

There is little formal documentation available about the profile of naturopathy and herbal practitioners in Australia, including educational pathways and other forms of preparation for practice (DHS 2005).

To date the education of Western herbal therapists in Australia has largely been centred within private colleges. More recently the profession has established its presence in a small number of universities (Evans 2000). The NHAA survey (2004) reported that a majority of naturopathic and herbal medicine practitioners were satisfied that their training was either adequate or good in its ability to prepare them for professional practice. However one aspect of training reported to be unsatisfactory was in the area of inter-professional communications.

Earlier research by the ATMS (Australian Traditional Medicine Society) has reported similar levels of satisfaction with clinical training but also that training did not prepare practitioners to run a business (Hale 2002).

This study aims to build upon these findings and presents data relating to an aspect of post-graduate development of herbal therapists. The paper focuses specifically on members of the NHAA and their perception of intra-professional support structures or networks available to them upon entering clinical practice.

Methods

A postal survey was sent to all full members of the national association in Australia for Western herbal medicine practitioners, the NHAA. The survey was distributed with the association's quarterly professional journal (Australian Journal of Medical Herbalism) in December 2003 and again in March 2004. Membership at the time of survey was 844 registered herbalists.

Survey measures

Ratings scores were reported of perceived levels of support provided by NHAA members' training institution, professional association (the NHAA) and from other practitioners upon entering clinical practice as a herbalist. In addition background demographic measures were taken as indicators of population parameters.

Data analysis

Each item in the questionnaire was analysed using basic descriptive statistics. Results of statistical tests, including t-tests and chi-square tests, were reported at both a significant (a=0.05*) and highly significant level (a=0.01**) if appropriate. A small number of participants did not respond to several survey questions. This number varied according to the question and was small in relation to the sample size. All data was analysed using the statistical software package SPSS (V 14).

Results

Response rate

The total membership of the NHAA at the time of survey was 1593 members. Of this number full membership of the NHAA equalled 844. The response rate for the first mailing was 21.68% n=183) and 23.10% (n=195) for the second mailing. The total response rate of members who were mailed the survey equalled 44.78% (n=378). However the official NHAA website listed 649 practitioners as currently in practice as of the closure date for the survey (NHAA 2004). The adjusted response rate of members who were currently in practice at the date of the survey n=649) equalled 58.24% (n=378).

Representativeness

Postcodes of herbal clinics at the time of the survey were used as a measure to ensure a representative spread of responses from across Australia and as a measure of external validity by comparing the regional distribution to that of the NHAA membership. The survey population did not have a statistically significantly different regional distribution from the target population (NHAA membership) ([chi square]2=7.49; df=6; p-value=0.278). There was no apparent difference in the baseline measures of the mean age (43.49 years, n=376, SD=9.9) and the sex distribution (female=82.93%, n=311, males=17.07%, n=64) of respondents compared to the data from the Bensoussan (2004) survey of the NHAA. Therefore it would appear that the survey is representative of the population and the results are generalisable to the NHAA membership.

Measures of support

A summary of responses to the question "How do you rate the support you received as a new graduate when beginning clinical practice from your training institution, your professional association (in this case the NHAA), and from other practitioners" is shown in Figure 1.

[FIGURE 1 OMITTED]

Responses were coded from 1 to 4 (1=very supportive, 2=somewhat supportive, 3=a little supportive, 4=not supportive) and an average of perceived support calculated for comparative purposes. Mean levels of perceived support in order of most satisfaction was 'other practitioners' (mean=2.13), 'the professional association' (mean=2.35) and 'training institutes' (mean=3.17) (see Table 1). Thus respondents were most satisfied with the support they received from other practitioners.

Over half of respondents perceived their training institution as not supportive (51.08%, n=190) and a cumulative total of 40.86% (n=152) as only somewhat or a little supportive. There were no significant difference in attitudes about support provided from their training institute by either university or college graduates ([chi square]=2.75; df =3; p-value= 0.43).

Levels of satisfaction with the professional association (NHAA) were clustered around the middle range responses (63.86%, n=235, somewhat and a little supportive.) In contrast to their training institutions, a majority or herbalists (65.50%, n=243) reported a positive perception of support (either very supportive or somewhat supportive) from other practitioners. However over one third of the members (34.41%, n=128) felt they received little or no support from any source.

These results are summarised in Table 1.

Table 2 shows a high level of consistency nationwide when comparing attitudes between the different states. An ANOVA revealed no significant difference in attitudes between the states in perceived levels of support provided by training institutions (F=2.467, df=3;363, p=0.06) and the professional association (F=1.009, df=3;359, p=0.37). However there was a significant difference in ratings of support received from other practitioners (F=2.72, df=3;362, p=0.04) between the states. Interestingly while all states consistently recorded positive ratings, Victorian herbalists reported the highest levels of satisfaction with support from colleagues (see Table 2).

Discussion

The survey results show a significant degree of consistency in attitudes across Australia by members of the NHAA towards perceptions of available post-graduate support. The results indicate that on the whole new graduates perceive support levels from their fellow practitioners to be greater than that which they receive from organised institutions.

Reports of levels of professional support available to practitioners from their training institution were less positive than that of the professional association and other practitioners. Herbalists appear to receive most support from informal intraprofessional relationships and some support from their professional association.

Quite recently it was argued that most CAM therapists in Australia practice in relative isolation (MacLennan 2002). Thus the formation of support networks would assume a high degree of significance. The current survey shows that professional support for less experienced practitioners appears to be reliant on the formation of informal inter-personal relationships as opposed to any formalised intra-professional support structures or networks.

Cant and Sharma (1996) have reported that in herbal medicine there are relatively small numbers of practitioners with extensive periods of clinical experience. Cant and Sharma (1996) suggest these circumstances create potential problems in providing the necessary clinical practice for new waves of students and graduates into the profession.

While CAM practitioners acquire generalisable knowledge in training institutions, much of CAM knowledge remains 'local' - a tacit form of knowledge central to clinical skills and based upon personal experience (Cant 1996). As such the provision of reliable ongoing support and/or training for individual practitioners and the profession is of vital importance. The issues of experience acquisition and practice sustainability are inextricably bound and require further research.

Both the quality of professional training and ongoing professional support are issues of importance to the continued strength and growth of a profession. Training programs must be able to satisfy the competencies required by their graduates and to ensure therapists are able to meet the needs and demands of their patients. However reports of levels of professional support available to herbalists from their training institution seem less positive than reputed assessments of the quality of their education.

Institutions providing education for these practitioners as well as professional associations representing their interests have responsibilities not only to their graduates/members but also to future patients and the profession at large.

It is necessary to acknowledge the potential limitations inherent in all survey work. No pretested survey instruments were available for adoption in the project. The method of participant recruitment meant that participants for both the survey and the interviews were self selecting. More specifically, potential problems associated with the study which relied upon practitioner responses, may be both recall and/or response bias. The potential for incorrect responses must be acknowledged due to recall bias and for practitioners over or underreporting on certain issues.

The response rate is consistent with the typical response rate for this industry (Bensoussan 1996, Hale 2003, Bensoussan 2004) and health professionals (Asch 1997). It is considered relatively good especially considering the difficulty obtaining reasonable response rates in previous studies of herbal therapists (Barnes 1998).

In terms of intra-professional issues the survey also highlighted issues of ongoing practitioner education, experience and ongoing support once formal education is completed. At present most professional practitioner support appears to be on an informal basis, practitioner to practitioner as opposed to the availability of any formal structures.

The results indicate that on the whole new graduates perceive support levels from their fellow practitioners to be greater than that which they receive from organised institutions.

A nationally significant finding of this research is the apparent need for an expansion of formalised support structures available for herbalists once in clinical practice.

References

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Mavourneen Casey (BA(hons), MEd, DBM, ND)

Lecturer in Herbal Therapies

School of Environmental & Life Sciences

Faculty of Science and Information Technology

University of Newcastle

Dr Jon Adams (BA, MA, PhD)

Senior Lecturer in Social Science Related to Health

School of Population Health, University of Queensland

Dr David Sibbritt (BMath, MMedStat, PhD)

Senior Lecturer in Biostatistics

Centre for Clinical Epidemiology and Biostatistics

School of Medical Practice and Population Health

Faculty of Health, University of Newcastle
Table 1
How would you rate the support you received as a new graduate when
beginning clinical practice from the following sources?

Level of Support % (n = responses)

 Very Somewhat A little
Source of Support supportive supportive supportive

Training Institute 8.31% 16.89% 23.86%
 (n = 31) (n = 63) (n = 89)

Professional 22.49% 34.15% 29.54%
Association (n = 83) (n = 126) (n = 109)

Other Practitioners 33.33% 32.26% 22.85%
 (n = 124) (n = 120) (n = 85)

Source of Support Not supportive Total Mean

Training Institute 50.94% 100 3.17
 (n = 190) (n = 373)

Professional 13.82% 100 2.35
Association (n = 51) (n = 369)

Other Practitioners 11.56% 100 2.13
 (n = 43) (n = 372)

Table 2
Mean ratings of support by State

 Training Professional Other
State Institute Association Practitioners

NSW Mean 3.15 2.32 2.07
 N 163 162 163
 Std.
 Deviation .947 .982 1.025

Victoria Mean 3.46 2.54 1.93
 N 68 67 67
 Std.
 Deviation .905 1.005 1.078

Queensland Mean 3.14 2.28 2.36
 N 85 85 85
 Std.
 Deviation 1.002 .946 .924

Other Mean 3 2.33 2.16
States * N 51 49 51
 Std.
 Deviation 1.114 .987 .925

Total Mean 3.19 2.35 2.12
 N 367 363 366
 Std.
 Deviation .983 .979 1.006

* South Australia, Western Australia, Nth Territory and Tasmania were
combined in one category because of small % of total responses to
ensure integrity of test
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Author:Casey, Mavourneen; Adams, Jon; Sibbritt, David
Publication:Australian Journal of Medical Herbalism
Article Type:Survey
Geographic Code:8AUST
Date:Sep 22, 2006
Words:2920
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