Exploring the implementation of acupuncture and acupressure practice in Australian perioperative care: a national survey and semi-structured interviews
Creators: name: Zhang, Ming
Publisher: name: RMIT University
Year: 2024
Subjects: classificationCode: 320201
subject: Anaesthesiology
classificationCode: 420803
subject: Traditional Chinese medicine and treatments

description: Acupuncture and acupressure (AA) are included in international guidelines, such as those from the International Anesthesia Research Society, Australia and New Zealand College of Anesthetists and Faculty of Pain Medicine, for managing postoperative nausea and vomiting (PONV) and pain (Lee et al., 2015; Schug et al., 2020). AA is however not systematically used in perioperative settings. Albeit limited evidence, one Australian study identifies that over 65% of surveyed surgical patients would be willing to try AA to manage PONV (Weeks et al., 2017).

The aims of this project are to (1) examine existing research that explores healthcare professionals’ perceptions and attitudes towards AA in healthcare; (2) determine the barriers and enablers associated with AA and its integration into mainstream medicine (both aims will be addressed in mixed-methods systematic review); (3) examine the beliefs, attitudes, perceptions, clinical use and knowledge of Australian doctors and nurses/midwives toward the use of AA in perioperative care (national survey); (4) identify any potential barriers that may impact on the implementation of the use of AA in perioperative care (national survey); and (5) explore the knowledge dissemination process for implementing AA in a perioperative setting (semi-structured interviews).

Rogers (2003)’s diffusion of innovations (DOI) theory provides the theoretical framework for this project. This project specifically focused on the first two stages of the innovation-decision process: the knowledge and persuasion stage. The Consolidated Framework for Implementation Research (Damschroder et al., 2022) provides a strategic guide for systematically assessing potential barriers and facilitators in preparation for implementing AA as an innovation.
This PhD project comprises three phases. The first phase, a mixed-method systematic review, is followed by a quantitative survey and qualitative interviews adopting a mixed-method sequential explanatory design. The methodology and key findings that have been used to address the aims of this project are outlined below.

Phase 1: A mixed-method systematic review on healthcare professionals’ attitudes towards AA

A mixed-methods systematic review was conducted resulting in 26 studies, comprising 19 survey and seven interview studies being identified as suitable to investigate healthcare professionals’ attitudes towards AA. Findings from this review revealed positive attitudes in 24 articles (92%), supporting the integration of acupuncture into Western medicine. Enablers identified include prior positive experience, a belief in acupuncture’s efficacy and patient demand, while barriers involved lack of evidentiary knowledge or experience, resources such as time, providers and funding and paradigm differences. Twenty studies (77%) focused on medical doctors or medical students. A conceptual framework for integrating acupuncture into Western medicine is proposed.

Barriers to integrating acupuncture into the hospital system exist at intrapersonal, interpersonal and external levels with lack of resources being the key obstacle. The role of nurses in facilitating integration in pain management practice warrants future research. The proposed conceptual framework guides nursing researchers interested in the role of acupuncture and integrated medicine in patient-centred care.

Phase 2: A quantitative national survey

The purpose of the survey is to examine the beliefs, attitudes and knowledge of Australian nurses/midwives and doctors toward the perioperative use of AA and to explore the barriers and enablers influencing AA integration into hospital settings. This cross-sectional, descriptive study adapted a pre-validated 42-item questionnaire; a mixed-mode approach of paper and electronic questionnaire was utilised for data collection. Respondents were recruited from three hospitals from three different states in Australia via convenience sampling and the Australian College of Perioperative Nurses and Royal Australasian College of Surgeons via online platforms.

A total of 453 health professionals responded with 421 completing the survey in full. The sample comprised 14% doctors and 73% nurses/midwives (13% missing data). Of the respondents, 69% were female, 85% were trained in Australia with 35% and 51% having knowledge or personal exposure to AA in general, respectively. Over 60% of the respondents agreed AA should be integrated into routine perioperative care, and over 80% would recommend it to their patients if it was provided at their hospital for PONV and pain, while 75% would be willing to receive further education. The three main barriers were perceived lack of scientific evidence (81%), unavailability of credentialed provider (77%) and lack of reimbursement (60%). There were 14% of respondents who believed patient response to AA was placebo only and 4% considered AA to be unsafe.

Australian nurses and doctors demonstrated generally positive attitudes towards AA for perioperative care in spite of limited knowledge and personal exposure. Further research is needed to overcome implementation barriers and address educational needs.

Phase 3: Qualitative semi-structured interviews

The aim of this study was to investigate knowledge dissemination for the implementation of AA in perioperative settings. A total of 22 semi-structured interviews were conducted to explore the key factors required in AA education. Through the analysis of the interview transcripts, key elements within the five domains of the Consolidated Framework for Implementation Research (CFIR) – innovation, outer setting, inner setting, individuals and implementation process – were identified as significant influencers of AA knowledge dissemination. A mixed inductive/deductive analysis approach was employed, wherein the findings were systematically mapped against the five CFIR domains. The study identified several key determinants of knowledge dissemination, including the scope of practice, social climate in terms of organisational and hierarchical relationship and availability of resources. Notably, the provision of holistic and patient-centred care emerged as a primary motivator.

The findings of this study contribute valuable insights into the factors that influence the dissemination of AA knowledge in perioperative care. Moreover, the study extends the existing literature on the implementation science and knowledge dissemination by highlighting the crucial role of nurses in the implementation of AA.