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Thesis survey results in the field of nursing regarding the use of complementary and alternative medical treatments in Turkey.

Byline: Glsah Grol Arslan, Yildiz Denat and Yurdanur Dikmen

Abstract

This descriptive literature review was planned to identify the prevalence of Complementary and Alternative Medicine (CAM) usage, frequency of usage, types/fields of use in master's theses and PhD dissertations based on the CAM methods, which are commonly used in nursing practice in Turkey. Data was collected in Turkey from February to March 2014 through a review of the National Thesis Centre (NTC) Archives at the Chairmanship of the Council of Higher Education and by obtaining the nursing theses/dissertations on CAM done between 1996 and 2013. Data were analysed by distribution of frequencies and percentages for publication year, number in sampling, method, case group, CAM type, and purpose of use/effectiveness. A total of 88 theses/dissertations were located. It was found that a majority of the theses/dissertations investigated were interventional. Investigation of the purpose of CAM use in theses/dissertations showed that the studies examined the effects of CAM on symptom control.

Keywords: Complementary and alternative therapies, Nursing, Master's thesis, PhD dissertation.

Introduction

We have all seen the terms "Complementary and alternative medicine", "complementary medicine", "alternative medicine" and "integrative medicine", but what do they really mean1 All types of health services used in place of medical treatments that are not approved by modern biomedicine or treatments are defined as "Alternative Medicine", whereas, treatment and care services provided together with medical treatment are called "Complementary Medicine".2,3 These methods that are outside the realm of modern medicine are being practised in increasing numbers and in general are defined as Complementary and Alternative Medicine (CAM).4 The National Centre for Complementary and Integrative Health (NCCIH) defines CAMs as healthcare systems, products and applications that are still not regarded as a part of conventional medicine.1,5

The United States National Institute of Health established the NCCIH in 1998 to provide research and advice on CAM, share knowledge and news in the field, organise training programmes and provide guidance.1 In Turkey, the Department of Complementary Medicine was founded at the Istanbul University Oncology Institute in 2001 and the Alternative and Complementary Medicine Advisory Board was established by the Ministry of Health as a part of the Cancer Advisory Board at the end of 2003.6

The use of CAM has recently increased in many developed and industrialised countries,3,7,8 in Turkey as well as other parts of the world, and is gradually increasing among the general population, especially in cancer patients.9 It is impossible to present accurate data on the use of CAM due to a lack of studies in Turkey on the general use of CAM, lack of knowledge about CAM, lack of trust in the practice and a limited number of professional practitioners in the field.10-12

The main philosophy of the CAM methods is the belief that human beings are particles of the grand cosmic energy. According to this philosophy, diseases and disturbances in the body are caused by problems in the flow of energy.13

'Disturbed Energy Field' is one of the 167 nursing diagnoses adopted by the North American Nursing Diagnosis Association (NANDA).13 Nightingale, Rogers, Watson and other nursing theoreticians have emphasised the importance of energy studies among the physical, emotional, mental and spiritual health approaches in nursing.13

The roles and responsibilities of nurses are changing along with technological advances and increased scientific knowledge in the field of health.11 Nurses were regarded as physicians' assistants for many years. This perception started to change with Savege's 1990 description in which the medical model was combined with holistic health approaches, autonomy, professionalism and provision of effective cooperation between the patient and the nurse was emphasised and belief in the therapeutic power of nurses was supported.14,15

A review of the literature shows that CAMs can be implemented as a nursing practice.11 Since the ontological foundations of holism are shared by nursing and CAM, many methods used in CAM (such as deep breathing and relaxation techniques, distraction, massage, etc.) are similar to nursing practices.5,14,16,17

In this context, CAMs can be regarded within the framework of independent nursing roles for professional nurses who possess theoretical knowledge and scientific problem-solving skills.11

Along with the increased scientific power in nursing, studies on CAMs are becoming more and more important in master's theses and PhD dissertations. The current study was planned to identify master's theses and PhD dissertations, which reviewed the prevalence, frequency and methods of CAM commonly used in nursing practices in Turkey.

Table-1A: Characteristics of theses/dissertations, which investigated relaxation methods within the framework of the study.

Name of Thesis/Dissertation###Type of Thesis###Year###Sample Scope###Research Design

RELAXATION EXERCISES

Relaxation techniques, the effect of sleep quality in total hip###PhD###2013###70 patients###Methodological model in the first phase of the study,

arthroplasty patients###(35 control, 35 experimental)###experimental model with experimental-control groups

###in the second phase of the study

The effects of relaxation techniques, aromatherapy practices and###PhD###2012###50 patients###Experimental

their combination on postoperative pain###(25 control, 25 experimental)

The effects of progressive relaxation exercises on pain, fatigue and###Master###2012###96 patients###Experimental

quality of life in dialysis patients###(48 control, 48 experimental)

The effects of relaxation exercises on fatigue, depression and level###PhD###2011###70 patients with diagnoses###No information was found in the abstract. It was

of quality of life in patients diagnosed with breast and colorectal###of breast and colorectal###impossible to obtain the entire article.

cancer undergoing adjuvant chemotherapy###cancer

The effects of progressive muscle relaxation exercises on pain###Master###2012###94 patients###Randomized, Single Blind, Controlled, Experimental

before the removal of chest tube

Progressive relaxation training given prior to surgery on surgical###Master###2011###78 patients###Clinical Study

stress responses of the patients who underwent open heart surgery###(39 experimental, 39 control)

The effects of progressive relaxation exercises on procedure, pain###Master###2010###70 patients###Semi-Experimental Model with Control Groups

perception and vital signs in patients who underwent endoscopy###(35 experimental, 35 control)

The evaluation of the impact of progressive relaxation exercises on###PhD###2009###32 patients###Single Group Pretest-Posttest Model Implemented Prior

fatigue and sleep quality in patients with multiple sclerosis###to Trial

The determination of the effect of relaxation exercises on anger and###Master###2009###58 patients under regular###Single Group Pretest-Posttest Model Implemented Prior

anger control in haemodialysis patients###hemodialysis treatment###to Trial

The effects of relaxation techniques and back massage on###PhD###2009###60 patients###Experimental

postoperative pain and anxiety in total hip or knee arthroplasty###(30 experimental, 30 control)

patients

The effects of relaxation techniques on anxiety levels of pregnant###Master###2009###60 pregnant women###Experimental

women in labor###(30 control, 30 experimental)

Evaluation of the effects of progressive muscle relaxation exercises###PhD###2008###70 patients###Experimental

in reducing nausea and vomiting after major gynecological surgery###(35 experimental, 35 control)

using patient-controlled analgesia

The effects on pain control of the relaxation techniques taught by###Master###2008###60 patients###Descriptive, Cross-sectional, with Self-control

the nurses in patients with upper abdominal surgery

The investigation of the effectiveness of progressive relaxation###PhD###2005###84 patients###Single Group Pretest-Posttest Model Implemented Prior

exercises on sleep and quality of life in dialysis patients###to Trial

The effects of relaxation training on symptoms of anxiety and###PhD###2006###27 patients###Repeated Measures, Experimental Design with Control

depression, sleep quality and fatigue in patients with breast cancer###(14 experimental, 13 control)###Groups

undergoing adjuvant chemotherapy

Table-1B: Characteristics of theses/dissertations, which investigated relaxation methods within the framework of the study (continued).

Name of Thesis/Dissertation###Type of Thesis Year###Sample Scope###Research Design

Relaxation Exercises

The effects of autogenic relaxation and slow rhythmic breathing in###PhD###2005###96 patients###Prospective Experimental-Control Research

reducing nausea and vomiting after laparoscopic surgical###(48 experimental, 48 control)

procedures

Evaluation of the impact of natural pain control methods, such as###Master###2004###50 pregnant women who###Experimental

relaxing, touching and breathing exercises, used for pain anxiety in###had normal births

mothers who give birth

Determination of the impact of progressive relaxation training on###Master###2002###46 patients undergoing###Experimental

anxiety levels and quality of life in dialysis patients###dialysis treatment

Investigation on the effectiveness of the comparison of two non-###PhD###1999###45 pregnant women###Experimental, Descriptive, Cross-sectional and

drug methods (massage/healing touch and music/relaxation) in###Retrospective Analytical

pain control after Cesarean section

Effects of walking and relaxation exercises on control of primary###PhD###2008###30 patients###Experimental

and resistant hypertension

The effects of massage and acupressure as non-pharmacologic###PhD###2013###120 patients###Randomized Controlled

methods used for labour pain control, on perceived labor pain,###(30 massages, 30

anxiety of pregnant women and cost###acupressure, 30 control)

A study on the effects of leg massage for reducing pain in###PhD###2011###99 infants###Double Blind, Randomized, Double-controlled

vaccinated infants###(33 control, 33 experimental)###Experimental

Table-2A: Characteristics of theses/dissertations, which investigated massage methods within the framework of the study.

Name of Thesis/Dissertation###Type of Thesis Year###Sample Scope###Research Design

Massage

Effects of abdominal massage on gastric residual volume and###PhD###2010###80 patients###Randomized, Controlled

complications in patients intermittently fed with enteral nutrition###(40 experimental, 40 control)

The effects of perineum massage with olive oil on perineum###PhD###2011###700 pregnant women###Experimental

integrity and duration of second period of delivery###(350 massage, 350 control)

The effects of hand massage on some symptoms in patients with###Master###2011###60 patients###Experimental

rheumatoid arthritis###(30 experimental, 30 control)

Examination of the effects of back massage with lavender oil on the###Master###2011###68 seniors###Pretest-Posttest Experimental Model

sleep quality of elderly people###Semi-experimental

The effects of baby massage on mother- infant attachment and###PhD###2010###117 mothers###Pretest-Posttest Experimental Model with Control Group

breastfeeding success###(57 experimental, 60 control)

The effects of massage on fatigue in hemodialysis patients###Master###2009###60 patients###Descriptive and Case-controlled

###(30 control, 30 experimental)

Effects of massage in solution of problems experienced by family###PhD###2008###44 patient relatives###Methodological, Cross-sectional, Experimental

caregivers of cancer patients###(22 trials, 22 control)

The effects on anxiety and cost of hand massage and acupressure###PhD###2008###70 patients###Experimental (randomized controlled)

therapy in patients undergoing mechanical ventilation support###(35 control, 35 experimental)

Material and Method

The descriptive study based on literature review was conducted in Turkey from February to March 2014, and comprised master's theses and PhD dissertations on the CAM methods in Turkey. The review of the National Thesis Centre (NTC) archives at the Chairmanship of the Council of Higher Education based on related key words showed that the first thesis in the field was undertaken in 1996. Therefore, the sample of the study was composed of the nursing master's theses and PhD dissertations on CAM registered at the NTC between 1996 and 2013.16

Data was collected through literature review Dissertations were reviewed with the help of the following key words: complementary and alternative therapy, reflexology, relaxation, aromatherapy, massage, acupressure, music, and healing touch.

Data analysis was done with the distribution of frequencies and percentages for publication year, number in sampling, method, case group, CAM type, purpose of use/effectiveness.

Results

A total of 88 theses/dissertations were identified and they were sorted out by name of publication and publication year (Tables-1-2). Of the theses/dissertations, 36(40.9%) were master's theses and 52(59.1%) were PhD dissertations. Distribution of theses/dissertations by years revealed that the numbers increased with passing years (Figure).

Of the theses/dissertations investigated, 41(46.6%) were were experimental, 19(21.6%) were randomised-controlled, 8(9.1%) were pretest-posttest, and 18(20.5%) were with control groups). Besides, 2(2.3%) were descriptive.

I nvestigation of the pur pose of CAM use in theses/disser tations showed that 26(29.5%) examined the effects of CAM on pain, 14(15.9%) studied the effects of CAM on vital signs, 13(14.8%) investigated the effec ts of C AM on fatigue, 12(13.6%) on sleep and 10(11.4%) on nausea/vomiting (Table-3).

Table-2B: Characteristics of theses/dissertations, which investigated massage methods within the framework of the study (continued).

Name of Thesis/Dissertation###Type of Thesis###Year###Sample Scope###Research Design

Massage

The effects of foot massage on postoperative pain in breast###PhD###2009###70 patients###Semi-experimental

surgery patients###(35 experimental, 35 control)

Effects of massage practices on fatigue and anxiety levels in###Master###2008###40 patients###Experimental

chemotherapy patients###(20 experimental, 20 control)

Effects of foot massage on decreasing physiological edema###PhD###2007###80 patients###Pretest-Posttest Experimental Model with

observed in feet and ankles in the last stage of pregnancy###(40 experimental, 40 control)###Control Group

The effects of regular fundus massage on the involution of###Master###2007###60 patients who had normal births###Experimental Model with Control Group

uterus and loshia rubra during the early postpartum period###(30 experimental, 30 control)

Study on the effects of ice-massage applied to hands of###PhD###2006###150 patients###Randomized, Controlled Experimental Model

pregnant women for reducing the perceived labour pains###(50 experimental, 50 placebo, 50 control)

The effectiveness of the hand and foot massages on pain###Master###2006###75 patients###Randomized, Controlled, Pretest-Posttest

management after post-Cesarean section operation###(25 control, 25 hand-foot massages, 25 foot###Experimental Model

The effects of perineal massages in vaginal births###PhD###2005###massages)

Investigation of the effects of simple lymph drainage###PhD###2005###100 pregnant women (50 massages, 50 control)###Randomized, Experimental

massage and simple lymph drainage massage with###64 patients###Descriptive-Comparative Experimental

aromatic oils for the prevention of lymphedema after###(23 control, 21 lymph drainage massages, 20 simple

breast cancer operations###lymph drainage massages with aromatic oils)

Table-2C: Characteristics of theses/dissertations, which investigated massage methods within the framework of the study (continued).

Name of Thesis/Dissertation###Type of Thesis###Year###Sample Scope###Research Design

Massage

The investigation on the effects of baby massage on sleep-###Master###2004###60 babies###Experimental

time and growth-development of babies and on maternity###(30 control, 30 massage)

state-trait anxiety level

Effects of position change and back massage on arterial###Master###2004###60 patients###Clinical Prospective

blood gas, pulse rate and blood pressure in intensive care###(left lateral to 30 patients,

patients###right lateral to 30 patients)

The investigation of the impacts of back massage on sleep###Master###2004###33 seniors###Clinical Experimental

in elderly persons residing in rest homes

Effects of regular baby massage on growing, mental and###PhD###2003###104 newborns###Experimental

motor development of healthy full-term babies###(52 experimental, 52 control)

The effects of massage applied by mothers on the growth###Master###2002###30 babies###Semi-experimental

and development of premature low birth weight babies###(15 control, 15 experimental)

The effects of massage on pain and the blood endorphin###PhD###1997###20 patients###Experimental

levels

The effects of aromatherapy, music therapy and vibration###PhD###2013###80 preterm newborns###Randomized-controlled Experimental

applications on neonatal stress and behaviors###(20 aromatherapy, 20 music therapy, 20 vibration

###exercise, 20 control)

Besides, 37(42%) studies were conducted at university hospitals. The distribution of methods used in the studies investigated showed that 72(81.8%) theses/dissertations assessed the effectiveness of a single method, whereas, 16(18.2%) investigated the effectiveness of two (such as, aromatherapy and relaxation) or three methods (such as, massage, healing touch and music therapy). The most often used methods were massage 27(30.7%), relaxation 19(21.6%) and music 18(20.5%) (Table-4).

Table-3: Distribution of the CAM methods used in theses/dissertations according to purpose of use*.

Impact###n###%

Quality of Life###8###8.0

Nausea/Vomiting###10###11.4

Sleep###12###13.6

Fatigue###13###14.8

Vital signs###14###15.9

Pain###26###29.5

Other (Anxiety, stress, etc.)###19###21.6

Table-4: Distribution of the CAM methods used in theses/dissertations*.

Method###Number###%

Reflexology###5###5.7

Relaxation###19###21.6

Massage###27###30.7

Acupuncture###1###1.1

Acupressure###12###13.6

Aromatherapy###15###17.0

Music###18###20.5

Reiki / healing touch###8###9.1

Discussion

CAM, whose use is increasing in the developed Western countries, is a social concept that is not fully comprehended.16 Why is CAM, whose "scientific characteristics" are open to discussion, progressing so rapidly in a period where some branches of medicine are displaying crucial advancements The increase in the demand for CAM is thought to be related to the rise in chronic diseases among the aging population and the growing impact of lifestyles on these diseases.8,11,19-21 Other reasons for the increase may be related to a decrease in the belief that science and technology can solve life's problems, a desire to have more control and influence on one's own life, health service movements that support the right to choose, increase in education, environmental problems, feminism, personal development movements and migration, which have increased in the past few decades.9,16,19

CAM use seems to be a worldwide phenomenon that is not limited to a specific geography, ethnic group, social or economic status.20,22,30 Results of studies conducted in Turkey and other countries revealed the fact that patients with chronic diseases especially resorted to the use of CAM methods along with modern treatment methods or used these methods alone before or after they were diagnosed or in both periods.7,8,19-21,23

When the theses/dissertations in our compilation were examined for sample characteristics, it was found that groups with chronic diseases (25%), groups in post-op period (19.3%), in pregnancy (14.8%), and cancer patients (8%) were the subjects in most of the studies. In literature cancer, cardiac diseases and diabetes) resorted to CAM use more often.3,9,20,21,24 Turan et al.11 reported that increases in chronic, degenerative and malignant diseases in which care and treatment are hard and costly raised interest in the CAM methods. A systematic review by Karada22 showed that 7-64% of cancer patients, 27% of patients who visited gastroenterological clinics and 20% of the patients with inflammatory bowel diseases used CAM, while 29% of individuals in physiotherapy polyclinics in New York chose to use CAM.

According to Rogers, the science of nursing is a humanist science, which presents individuals with a holistic approach, and examines the development and nature of human beings.13 Although the holistic health approach was defined recently in the 1990s, but nurses have used this approach for many years in their practices. Though not included under the CAM headings, many of the nursing practices correspond to CAM.5,17 It is stated in literature that the complementary therapies used by nurses are separated into three groups. The first group includes the therapies that can be implemented directly by nurses, such as massage, reflexology, aromatherapy and therapeutic healing touch.4,10 In this context, CAMs can be regarded within the framework of the independent nursing roles of professional nurses who possess theoretical knowledge and scientific problem-solving skills.4,11

The CAM fields in which nurses took part in the compilations of theses/dissertations also pointed to massage (30.7%), aromatherapy (17.0%) and acupressure (13.6%). In their study, which examined the frequency of CAM use, Araz et al.25 found that 33.4% of the participants used massage, 4.1% used aromatherapy, 9.9% used music therapy, 4.9% used reiki and 6% used acupuncture once or twice in their lives. It is stated that the CAM methods specified in the literature differ according to geographical location of the country, ethnic origin, education, socioeconomic factors, beliefs, lifestyles and culture.3,22,30

Nurses are professionals who are responsible for providing high-quality care and improving the quality of life of patients, such as sustaining life and identifying and controlling the symptoms during all phases of illness.10,26,30 According to zdemir,26 many studies point to the important role of nurses in symptom management and symptom relief. The CAM methods were used to handle the symptoms in all of the nursing theses/dissertations investigated. Although the ratio of the theses/dissertations, which investigated the effects of the CAM methods on "Quality of Life" was found to be 8%, all of the other symptoms (pain 29.5%, fatigue 14.8%, sleep 13.6% and nausea/vomiting 11.4%) indirectly affect the quality of life. The concept of quality of life was defined as related to how one feels and to what extent and how one can undertake daily life activities. Symptoms, such as fatigue, pain, sleep disorders, nausea, vomiting and constipation affect all areas of individuals' lives and their quality of life.4

According to data obtained from the National Centre for Complementary and Alternative Medicine (NCCAM), one of the leading reasons for the use of CAM is pain.1 Studies undertaken in developed countries pointed to the fact that pain symptoms affected societies to a great extent and that the use of CAM played a major role in relieving chronic pain.8,27,28

CAM practices which are rather common in many countries have an important place in modern medicine since they facilitate improvement in various diseases that are resistant to known treatments. They are safe and effective due to fewer side-effects than those caused by other medical treatments, can be more easily adopted and are economical.7,13 It was found in the literature that many of the patients believed that CAM was beneficial.9,10,20 The theses/dissertations selected for the review were found to be related to symptom management and that nurses used CAM methods, which were considered to be related to the nature of many care practices and were identified by the NCCIH.2

It was found in the literature that many of the patients and/or relatives did not provide information about their CAM use to the physicians/nurses for fear of "negative responses".7,9,17,19,22 aliskan et al.17 reported that individuals did not share CAM Usage with their physicians. There are no studies about CAM use covering the entire country in Turkey.10,13 Studies state that alternative treatments are more widely utilised in the eastern regions of Turkey.11 zkaptan23 pointed to the fact that actual CAM use may be even higher considering the fact that patients do not provide information about their CAM use and that they practically hide their use.18

The importance of assessment of CAM use by health personnel becomes clearer when one considers the potential risks of some of the CAM methods. Theses/dissertations in the field of nursing are also believed to be important from this aspect.

Although patients have the right to select, accept or reject treatment, it is unethical to avoid modern treatment methods or to hide CAM use from health personnel just by overlooking the use of some CAM methods that lack scientific foundations.23 Among the reasons for preferring CAM are included the fact that it is low-cost, the sharing of popular information related to the activity, negative thoughts about the effects of medical treatments and the anxiety of unsuccessful results. The negative attitudes of health workers towards the use of CAM is the cause of patients hiding its use. The probability of patients not finding answers to their questions makes them prefer the use of CAM despite the side-effects.

The Alternative and Complementary Medicine Advisory Board was established in 2003 as a part of the Cancer Advisory Board by the Ministry of Health in Turkey and the directive on the "Regulation Concerning the Application of Treatment and Private Health Institutions in Which Acupuncture is Applied" went into force in this field.29 It is expected that with these legal regulations, ethical problems concerning the use of CAM may be reduced.23

As a result of increase in the use of CAM, it is important for physicians and nurses to be a part the CAM implementations and for them to be conscious of these implementations. Consequently, scientific studies should be carried out on the subject of CAM, the benefits and probable side-effects of these methods should be studied and the healthy/ill individuals and/or their families and society should be informed on these subjects.

CAM has not been included within the curricula of medical/nursing education in Turkey. In recent years, CAM has been added as an elective course in the curricula for bachelor's and postgraduate degrees at several nursing schools in Turkey. However, these courses are given theoretically, not practically.

The implementations related to CAM are gradually becoming more widespread, both in Turkey and in the world. This situation has made it imperative to make many regulations on this subject, such as in which professions these implementations could be made and the areas of indication of the minimum educational standards and implementations that the individuals are required to possess. The adoption of definite regulations unique to this field and the regulation of the limitations together with the conditions of implementation would be an important step.

Conclusion

Considering the fact that CAM is based on holistic approach, it is believed that patient care can be enriched with the help of nurses, who have holistic viewpoints, and with patient care planned around the philosophy and conceptual framework of CAM. There are thousands of scientific articles - in favour of or against - CAM in the international scientific databases in recent years. This situation is an indicator that a sounder environment of debate will be formed in the field of CAM.

Disclaimer: The study was presented as a poster at The Complementary and Alternative Medicine Congress in Manisa, Turkey (tat2014.cbu.edu.tr).

Conflict of Interest: None.

Source of Funding: None

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Publication:Journal of Pakistan Medical Association
Date:Sep 28, 2017
Words:5725
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