Integrative and complementary practices in health, nurses’ profile and care provided to people with hypertension: a mixed study design

Wickert, Daiana Cristina; Dallegrave, Daniela; Piexak, Diéssica Roggia; Mello, Marlise Capa Verde Almeida de; Corcini, Laís Mara Caetano da Silva; Schimith, Maria Denise

doi:10.1590/1518-8345.6287.3915

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Original Article • Rev. Latino-Am. Enfermagem 31 • 2023 • https://doi.org/10.1590/1518-8345.6287.3915 copy

Integrative and complementary practices in health, nurses’ profile and care provided to people with hypertension: a mixed study design ^* * Paper extracted from doctoral dissertation “Profile of nurses about integrative and complementary practices in the care of people with arterial hypertension: a mixed methods study”, presented to Universidade Federal de Santa Maria, Santa Maria, RS, Brazil. Supported by Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Grant # 404534/2021-0, Brazil. This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) - Finance Code 001, Brazil.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objective:

to analyze the profile of nurses regarding integrative and complementary practices in health (ICPH) and understand how they are used in the care of people with arterial hypertension.

Method:

mixed-methods sequential explanatory design. The cross-sectional quantitative stage included 386 nurses who completed an online questionnaire addressing sociodemographic and professional information, training, and practice, with a descriptive and inferential analysis. The qualitative stage was performed via 18 online interviews with professionals who had ICPH training and implemented it in the care provided to individuals with hypertension, with a participatory analysis. Integration occurred through a connecting approach.

Results:

36.8% had ICPH training; most were women, Caucasian, married, public servants, aged 37 (+ 9.4) on average; 14.2% incorporated ICPH into the care provided to people with hypertension; predominantly auriculotherapy (28.2%) and bloodletting in hypertensive crises. The results show that nurses integrally approached patients, and their approach was not limited to the vital sign altered at the time, but they also intervened in anxiety, stress, sleep, and rest. A potentiality observed concerns support treatment adherence.

Conclusion:

the profile of nurses with ICPH training is presented, and such practice has implications for lowering blood pressure. ICPH has been incorporated into the care of people with hypertension, but its use is still incipient, considering its potential in nursing care.

Descriptors:
Nursing; Nursing Care; Complementary Therapies; Traditional Medicine; Integrative Medicine; Hypertension

Highlights:

(1) Presents the profile of nurses with ICPH training in Santa Catarina, Brazil

(2) Evidence of ICPH and how it is incorporated into the care provided to people with hypertension.

(3) Potentialities regarding incorporating ICPH into the care provided to people with hypertension.

(4) Challenges faced when incorporating ICPH into the care provided to people with hypertension.

(5) Strengths and evidence of the nurses’ protagonism in the adoption of ICPH.

	Nurses n (%)	Nurses w/ ICPH* training n (%)
Gender
Female	357 (92.5)	132 (93.0)
Male	29 (7.5)	10 (7.0)
Marital status
Married	146 (37.8)	58 (40.3)
Divorced/Separated	17 (4.4)	6 (4.2)
Single	100 (25.9)	35 (24.3)
Stable union/cohabitate/dating	119 (30.8)	43 (29.9)
Widowed	4 (1.0)	2 (1.4)
Ethnicity
Asian-descendant	2 (0.5)	1 (0.7)
Caucasian	346 (89.6)	130 (91.5)
Mixed race	31 (8.0)	11 (7.7)
Afro-descendant	4 (1.0)	0
None of the above	3 (0.8)	0
Current employment situation
Retired/Pensioner	11 (2.8)	5 (3.5)
Formally employed	93 (24.1)	19 (13.4)
Informally employed	18 (4.7)	5 (3.5)
Self-employed/Social Security	7 (1.8)	3 (2.1)
Self-employed/No Social Security	10 (2.6)	6 (4.2)
Unemployed	7 (1.8)	2 (1.4)
Employer	6 (1.6)	2 (1.4)
Service Provider	31 (8.0)	16 (11.3)
Public servant	225 (58.3)	92 (64.8)
Legal nature of work
Public Health Institution	263 (68.1)	103 (72.5)
Private Health Institution	58 (15.0)	14 (9.9)
Autonomous Health Institution	8 (2.1)	5 (3.5)
Philanthropic Health Institution	27 (7.0)	7 (4.9)
Does not work in nursing	20 (5.2)	6 (4.2)
Weekly workload
20 hours	11 (2.8)	4 (2.8)
36 hours	30 (7.8)	10 (7.0)
40 hours	229 (59.3)	97 (68.3)
44 hours	47 (12.2)	8 (5.6)
More than 44 hours	47 (12.2)	16 (11.3)
Not currently working	14 (3.6)	6 (4.2)
Work by shifts	13 (3.4)	3 (2.1)
Individual income (M.W. ^† R$ 1,035.00)
Up to 2 times the M.W.	36 (9.3)	9 (6.3)
From 3 to 4 times the M.W.	163 (42.2)	59 (41.5)
From 5 to 6 times the M.W.	120 (31.3)	53 (35.9)
From 7 to 8 times the M.W.	40 (10.4)	15 (10.6)
More than 9 times the M.W.	27 (7.0)	8 (5.6)

Variables	Categories (n)	W/ ICPH * training	p-value ^†	Raw Prevalence Ratio (95%CI ^‡)
Sex	Female (357)	132 (37.0%)	0.80	0.96 (0.73-1.27)
	Male (29)	10 (34.5%)	-	-
Ethnicity ^§	Caucasian (346)	130 (37.6%)	0.55	0.92 (0.73-1.17)
	Asian-descendant. Mixed race or Afro-descendant (37)	12 (32.4%)	-	-
Marital Status	Married/ stable union/ cohabitate/ dating (265)	100 (37.7%)	0.57	0.95 (0.81-1.12)
	Separate/ Divorced/ Widowed/ Single (121)	42 (34.7%)	-	-
Age group	More than 61 y/o (10)	3 (30.0%)	0.002 ^\|\|	0.83 (0.74-0.94) ^¶
	51 to 60 y/o (25)	10 (40.0%)
	41 to 50 y/o (88)	40 (45.5%)
	31 to 40 y/o (161)	61 (37.9%)
	Up to 30 y/o (102)	28 (27.5%)
Time since graduation	More than 60 months (278)	114 (41.0%)	0.005	0.80 (0.69-0.92)
	Less than 60 months (108)	28 (25.9%)
Income (times the Minimum Wage)**	Up to 4 times MW(199)	68 (34.2%)	0.27	1.09 (0.93-1.27)
	More than 4 times MW(187)	74 (39.6%)	-

	QUAN RESULTS*	QUAL RESULTS ^† (NARRATIVES)
ICPH ^‡	n (%)	HOW ICPH ^‡ ARE IMPLEMENTED
Auriculotherapy	40 (28.2)	[...] some specific auriculotherapy points, such as kidney to drain that accumulated fluid, shen men , which gives you a feeling of wellbeing, a treatment for the problems one has, and which are not linked to high arterial pressure only (CITRINE, 41 y/o, specialist, Grande Oeste). I’ll do the anamnesis, see complaints, previous history of diseases, surgeries, and family history in the first appointment, and then, it’s when I also learn about hypertension. In auriculotherapy, I use that hypotension point and also take the chance to give orientation regarding health, diet, and exercises(SELENITE, 40 y/o, MSc., Planalto Norte and Nordeste). I’ve already used auriculotherapy and acupuncture with heart points and seen significant improvement (AMETHYST, 42 y/o, specialist, Sul).
Acupuncture	12 (8.5)	It also has an acupuncture point, which the patient can identify and manipulate (AMAZONITE, 44 y/o, specialist, Grande Oeste).
Reiki	11 (7.7)	In the nursing consultation, I don’t just explain about salt consumption, self-care, and exercises. I also treat with Reiki , massage, and auriculotherapy (OBSIDIAN, 40 y/o, MSc. Grande Oeste).
Flower therapy	10 (7.0)	[...] I use Bach remedies for hypertensive patients who experience difficulty sleeping and resting (MOON STONE, 36 y/o, specialist, Planalto Norte and Nordeste).
Aromatherapy	9 (6.3)	[...]lavender is hypotensive, verbena is sedative, and lemongrass, which we usually use as an individual inhaler, but they can be used in massage and compresses (WHITE QUARTZ, 36 y/o, specialist, Grande Florianópolis ).
Phytotherapy	7 (4.9)	[...] adjustments in diet and phytotherapy (SUNSTONE, 31 y/o, specialist, Grande Oeste).
Meditation	7 (4.9)	Hypertensive patients are often agitated, nervous, and worried, so the focus is to promote relaxation so that they decrease heartbeats, breathing, respiratory rate, and breathing pattern, which is often thoracic, and it also lowers blood pressure (EYE OF TIGER, 39 y/o, MSc., Vale do Itajaí).
Moxibustion	5 (3.5)
Cupping therapy	4 (2.8)
Traditional Chinese Medicine	3 (2.1)	[...] TCM [Traditional Chinese Medicine] guidelines, food, water use, teas, relaxation, and energy massage, massage on specific points, and I even teach them Do in (ÁGATE, 50 y/o, MSc., Meio Oeste and Serra Catarinense).
Foot reflexology	3 (2.1)	[...] through some manipulation points on the soles of the feet, there is a very important process of lowering blood pressure, reducing stress, edema, increasing diuresis, and improving the quality of medications (WHITE QUARTZ, 36 y/o, specialist, Grande Florianópolis).
Anthroposophy	2 (1.4)
Bioenergetics	2 (1.4)
Chromotherapy	2 (1.4)
Geotherapy	2 (1.4)	Sometimes we use abdominal geotherapy to control high blood pressure (TOURMALINE, 46 y/o, Physician, Grande Florianópolis).
Music therapy	2 (1.4)
Yoga	2 (1.4)
Ozone therapy	1 (0.7)
Thermalism	1 (0.7)

SUBJECT	QUAN RESULTS*	QUAL RESULTS ^† (NARRATIVES)	INTEGRATION
CHALLENGES		The nurses seek training and pay for it themselves
	52 (94.5%) attended graduate studies	I’ve sought most of my training myself because the city does not always make training programs available or even facilitate workers attending a training program (SUNSTONE, 31 y/o, specialist, Grande Oeste).	Even though most nurses have a graduate degree or specialization, the initiative to seek training is personal, and managers provide little support.
		Stigma due to a lack of knowledge
		[...] professionals who do not know and undervalue ICPH^‡, lack of knowledge, of reading and studying. We have to change our process because the health system will not be able to deal with how we currently treat people (PYRATE, 35 y/o. MSc., Sul).	Even with proper training, the nurses must show their knowledge to defend the effectiveness of ICPH ^‡ constantly.
		Limited time to implement practices
	41 (74.5%) adopt ICPH ^‡ in their daily practice, and most of these, 34 (61.8%) spend from one to four hours per week with ICPH ^‡	I work in an FHS [Family Health Strategy Unit], and implement ICPH^‡in my practice less frequently than I’d like. It is implemented in a cross-sectional manner in my practice, it’s an additional tool. [...] (EMERALD, 32 y/o, specialist, Grande Florianópolis).	Workload due to the many activities hinders the implementation of ICPH ^‡ in daily practice when it is not a priority or is not seen as a cross-sectional tool to be used in the care and treatment of diseases.
		Medicalization and biomedical culture
	23 (41.8%) nurses have a co-worker to discuss cases and determine the conducts related to treatments that include ICPH ^‡	[...] overcoming barriers that prevent the valorization of therapies. We have a society where pharmacological treatments are more powerful, especially economically. So, these treatments overlap with other issues. We are in a totally medicalized society; it’s more attractive to think that a pill will make you happy, healthy, and beautiful than recognizing that it all depends on ourselves, and our choices (LÁPIS-LAZULI, 66 y/o, Physician, Grande Florianópolis). The legal support nurses have when adopting the ICPH^‡is seldom mentioned. We need to consolidate nursing as a profession to be appreciated as autonomous, independent, and trained professionals (RUBY, 46 y/o, specialist, Grande Florianópolis).	The devaluation of ICPH ^‡ on the part of managers and professionals may influence the number of professionals with ICPH ^‡ training, contributing to the perpetuation of the biomedical care model. Additionally, there is a constant dispute between professions and the need to validate practices.
POTENTIALITIES		Treatment adherence
	55 (100%) believe that having knowledge, contact with, or using ICPH ^‡ positively influences the patients’ autonomy	The benefit is better treatment adherence. It is easier to give up if you take only pharmacological drugs, so this support with ICPH^‡is much more effective (MOON STONE, 36 y/o, specialist, Planalto Norte and Nordeste).	ICPH ^‡ contributes to treatment adherence, both pharmacological and non-pharmacological treatment, and also influences a decrease in the use of medications, encouraging patients to be more active in their self-care.
		Patient autonomy and health promotion
		ICPH ^‡ helps a lot to change the [hypertensive patient’s] profile and quality of life. Many interventions are not implemented weekly; sometimes, they start weekly, but the idea is to generate autonomy and not replace the medication with integrative practices (TURMALINE, 46 y/o, Physician, Grande Florianópolis). [...] the benefit is one’s own wellbeing and quality of life (ONYX, 30 y/o, MSc., Grande Oeste).	Changes in people’s lifestyles were observed when ICPH ^‡ was implemented, besides an influence in decreasing risk factors such as stress, insomnia, and anxiety, for the development of other cardiovascular diseases.
		Research
	44 (80.0%) performed studies on evidence-based practices to support a technique or practice; most 27 (4.1%) in the VHL ICPH ^§	It’s very good to be able to talk about and participate in studies addressing ICPH ^‡ , because if we don’t talk about it, if we don’t show the population what we do, it won’t get disseminated (EYE OF TIGER, 39 y/o, MSc., Vale do Itajaí).	The possibility of giving visibility to the practice and encouraging a reflection upon care practices and the incorporation of ICPH ^‡.

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[1] Corresponding author:
Daiana Cristina Wickert E-mail: daianacristinaw@gmail.com https://orcid.org/0000-0001-7180-1428