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Australian herbalists' perceptions of professional clinical support

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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.
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Aust J Med Med Herbalism 18(3) 2006
82
Australian herbalists’ perceptions of
professional clinical support
Mavourneen Casey BA(hons) MEd ND DBM, J Adams PhD, D Sibbritt PhD
Centre for Clinical Epidemiology and Biostatistics, School of Medical Practice and Population Health,
Faculty of Health, University of Newcastle, Level 3 DMB, Royal Newcastle Hospital, Newcastle 2300,
Australia
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,
Aust J Med Med Herbalism 18(3) 2006
89
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 an 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 (α=0.05*) and highly
significant level (α=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).
Representative-ness
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) 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
Aust J Med Med Herbalism 18(3) 2006
89
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.
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 2=2.75; df =3;
p=0.43).
Levels of satisfaction with the professional
association (NHAA) were clustered around the
middle range responses (63.69%, n=235, somewhat
and a little supportive.) In contrast to their training
institutions, a majority or herbalists (65.59%,
n=244) 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.
Figure 1
Perceived levels on intra-professional support
0
10
20
30
40
50
60
Very Somewhat A little Not
Levels of Support
% Repondents
Training Institute
Professional Assoc.
Other Practitioners
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)
Source of Support
Very supportive
A little
supportive
Total
Mean
Training Institute
8.31%
(n=31)
23.86 %
(n=89)
100
(n=373)
3.17
Professional
Association
22.49 %
(n=83)
29.54 % (n=109)
100
(n=369)
2.35
Other Practitioners
33.33 %
(n=124)
22.85 %
(n=85)
100
(n=372)
2.13
Aust J Med Med Herbalism 18(3) 2006
89
Table 2
Mean ratings of support by State
State
Training Institute
Professional
Association
Other
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 States*
Mean
3.00
2.33
2.16
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 test
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 intra-professional 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.
Aust J Med Med Herbalism 18(3) 2006
89
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 pre-
tested 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 under-
reporting 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.
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