O conhecimento de discentes de enfermagem sobre uso de plantas medicinais como terapia complementar 1/Nursing students knowledge on use of medicinal plants as supplementary therapy/Conocimiento de estudiantes de enfermería acerca del uso de las planta medicinales en la terapia complementaria

Headnote

ABSTRACT

Objective: To identify the knowledge of nursing students on the use of medicinal plants as a complementary therapy to health care. Methods: Qualitative research conducted through semi structured interviews with eight nursing students from a Federal University of Rio Grande do Sul in October 2012. In thematic content analysis, three categories emerged: "I learned from my family", "I acknowledge the importance of medicinal plants" and "I use plants at home, but do not recommend its use in the practical field". Results: The knowledge of students regarding the use of medicinal plants is of popular source. Insecurity has been observed amongst undergraduates as to their agency as future professionals orienting in the guidelines regarding the use of medicinal plants, pointing to the need of advances in the nursing education. Conclusion: Highlights the need to review the nursing syllabuses in order to contemplate the subject, as a mean of promoting health and comprehensive care.

Descriptors: Nursing Care, Medicinal Plants, Nursing, Nursing Education, Culture.

RESUMO

Objetivo: Investigar o conhecimento de discentes de enfermagem sobre o uso de plantas medicináis como terapia complementar no cuidado da saúde. Métodos: Pesquisa qualitativa, realizada por meio de entrevista semiestruturada com oito acadêmicos de enfermagem em uma Universidade Federal do Rio Grande do Sul em outubro de 2012. Na análise de conteúdo, emergiram três temas: "aprendi em familia"; "reconheço a importância das plantas medicinais" e "uso as plantas em casa, mas nao estimulo o uso em campo prático". Resultados: O conhecimento dos discentes referente ao uso de plantas medicinais é de origem popular. Observou-se a insegurança que os graduandos possuem frente à atuaçao como futuros profissionais nas orientaçoes referentes ao uso das plantas medicinais, apontando à necessidade de avançar no ensino de enfermagem. Conclusao: Destaca-se a necessidade de revisao nos currículos para que deem suporte sobre o tema, com vistas à promoçao da saúde e a integralidade do cuidado.

Descritores: Cuidados de Enfermagem, Plantas Medicinais, Enfermagem, Educaçao em Enfermagem, Cultura.

RESUMEN

Objetivo: Identificar el conocimiento de los estudiantes de enfermería en el uso de plantas medicinales como terapia complementaria a la asistencia sanitaria. Método: Estudio cualitativo realizado con entrevistas semiestructuradas con ocho estudiantes de enfermería de una Universidad Federal de Rio Grande do Sul, en octubre de 2012. En el análisis de contenido, surgieron tres categorías: "aprendí con mi familia", "sé de la importancia del uso de las plantas" y "uso plantas en casa, pero no estimuló el uso en campo práctico". Resultados: El conocimiento de los estudiantes sobre el uso de plantas medicinales es de fuente popular. Observado la inseguridad que los estudiantes tienen en orientar, como futuros profesionales, las directrices relativas a la utilización de las plantas medicinales, se apunta a la necesidad de avanzar en la formación de enfermería. Conclusión: Pone de relieve la necesidad de revisar los planes de estudios que dan apoyo en el tema, cuyo objetivo es promover la salud y la atención integral.

Descriptores: Cuidado de Enfermería, Plantas Medicinales, Enfermería, Educación en Enfermería, Cultura.

INTRODUCTION

The use of medicinal plants and phytotherapics has been growing within the public health care system1, demonstrating the recognition of popular knowledge within the scientific field. In Brazil, as of 2006, the use of medicinal plants has been legitimized as part of the process of patient care, through the perspective of complementation of the official actions in health care. Nonetheless, gaps are still noticeable in the academic formation of health professionals, for, as studies show2, 79% of professionals in the health area are not acquainted with the medicinal plants thematic and/or complementary therapies during their academic formation.

In spite of this gap, the World Health Organization3 estimates that 80% of the world population uses medicinal plants in health care, rectifying the distanciation between the formation of the professionals and the reality of the population.

This disaccord between the reality of the population and the academic formation is due to the guidelines of education present in the undergraduate nursing school, as well as in the other health science careers, which are based on a positivist view of the world and of the human being. Given that the formation is based on conceptions imposed by the biomedical model of health, nurses tend to depreciate the popular knowledge concerning health because popular practices are generally based on observation and experimentation, not in scientific evidence.4

After a long time on the sidelines of the official Brazilian health care system, medicinal plants have managed to earn some space. The VIII National Health Conference in 1986 was a starting point for the development of complementary therapies and medicinal plants related policies. The rectifying of this initiative occurred in 2006 through the implementation of the National Policy for Integrative and Complementary Practices and the National Policy for Medicinal Plants and Phytotherapics, which encourages the use of medicinal plants in health care and supports the formation and permanent education of health professionals on the subject of this thematic.

Promoted by this normalization, the Resolution n° 695/13, approved in Rio Grande do Sul (RS) the State's Policy on Integrative and Complementary Practices, intended to implement the PICs in Brazils Universal health care System (SUS)/RS, incorporating the practices already established in the system, aimed at the promotion, prevention and assistance, all health related matters, based on integrative principles and targeting the humanization of procedures and actions in all attention levels.1

However, in order for this process to be effective, the insertion of medicinal plants in health care needs to occur in a safe manner, therefore the professionals must have knowledge on the pharmacological effects and toxicity of the plants.5

From this perspective, the Brazillian Federal Nursing Council (COFEn), through the Resolution 197/97, establishes and recognizes the alternative therapies as specialties and/ or qualifications of the nurse, as long as one has concluded and has been approved in class or congener entity, with a minimum workload of 360 hours.6

Besides the complementary formation, it is necessary that professionals of the health science career acquire, in their formation, knowledge on medicinal plants. To that end, it is necessary that the universities include on their syllabuses disciplines that focus on the study of medicinal plants in order to bring care practices closer to the reality of the population and of the Brazil's Universal Health Care System (SUS).7,8

Thus, this article aims to investigate the knowledge of nursing students on the use of medicinal plants as a complementary therapy on health care.

METHODS

The study is of an exploratory and descriptive nature, structured from a qualitative research. This, on its turn, deepens itself on the world of signification, of essence, of human relations, of attitudes, of belief and value, hence, exploring a reality that can not be captured by quantitative data. 9

The Nursing undergraduate class of a Federal University of Rio Grande do Sul was used as a spatial indicator to ken the knowledge and practices of nursing students on the use of medicinal plants as a health care complementary therapy. The gathering of the data occurred in a classroom at this particular University, through a semistructured interview, realized with eight senior undergraduates, in October 2012, with day and time preestablished.

The semistructured interview "must be constructed in a way that allows flexibility in the conversation and that absorbs new themes and questions brought by the interlocutor as a relevant structure".9:191

For this study, an interview script composed by two parts has been prepared; the first contains ten objective questions on personal data of the participants, such as sex, age, and other things, this information was useful to trace a profile of the researched participants. The second part consists of twelve subjective questions, that approach mainly the knowledge the participant has on medicinal plants, how they acquired this knowledge, a comparison between the experience they had with the use of plants and the use of allopathic medicine, as well an inquiry if they make use of medicinal plants to care for their own health and of their family, or if they use and recommend the use of plants in their practices or academic internships.

The subjects of the study were chosen through the technique of simple casual selection.10 Participants were interviewed up until the point when the goals of the research were achieved, completing a total of eight students. The criteria for inclusion in the research were: to be a senior undergraduate in Nursing and to live in the urban area of the city of the researched University. To assure the anonymity of the participants, the code S followed by the number of the order in which the interview occurred was used in the presentation of the results.

The data analysis contemplated the thematic analysis proposed by Bardin.11 It is considered one of the content analysis techniques, its operalisation is distinguished in three stages: pre-analysis; exploration of the material; and the treatment of results, regarding inference and interpretation. The results were organized on emerging issues, according to the participant's speeches: "I learned from my family", "I acknowledge the importance of medicinal plants" and "I use plants at home, but do not recommend its use in the practical field."

It is noteworthy that all ethical principles applicable to human research were respected. The research subjects signed the Free and Enlightened Consent Form. The article is in accordance with Ministry of Health (MS) Resolution 196 of October 10th 1996, which defines the legal principles for research with human beings.12

This project was approved by the Ethics Committee of the Federal University of Santa Maria, under number 129945 and CAAE 07550812.7.0000.5346.

RESULTS AND DISCUSSION

This topic presents the study results starting with the characterization of the participants, and, next, with the presentation of themes built from the thematic analysis of the material.

Characterization of the participants

The participants of the study were eight students of the last semester of Nursing undergraduate school, their ages ranged from 21 to 40 years old. The vast majority of respondents were women, which shows that nursing is still a predominantly female major. It is believed that this predominance of the female sex is by the perpetuation of the belief that the woman is the caregiver par excellence, given that, culturally, she is the one who cares for the family. 13

"I learned from my family"

When asked of the students: "how did you start using medicinal plants?", It was observed that the meaning they attach to the use of medicinal plants is related to the knowledge and experience they have gained from their families, especially their mothers and grandmothers. The transmission of knowledge on medicinal plants is sustained by the relation of affection between the women-mother figure and the child, in an attempt to pass the knowledge on to the next generation.14 The first contact with the use of medicinal plants was, according to respondents, aimed at the cure of diseases. These experiences were mentioned as of great significance, because satisfactory results were reported, which encouraged the subjects to use plants routinely. These are examples that can be observed in the speeches of some respondents, who are very clear to point out the household as the source of their knowledge.

"[...] I started because of my mother, ever since I was a child, she would tell me to take a cup of tea of this, a cup of tea ofthat [...]" (S1)

"In fact, I started using [medicinal plants] when I was a kid, my mother forced me to take some teas. And it's kind of a habit of her to make tea for the flu, tea for other things." (S2)

I" started to use [medicinal plants] at home with my mother and my grandparents [...] I use them because I have seen [good] results"(S3)

The statements show that contact with medicinal plants begins within the family. In accordance with this finding, a study conducted in 2009 showed that the construction of knowledge related to the use of medicinal plants by farmers families is predominantly oral, conducted through daily interaction between its members, providing the transmission of information, beliefs and values, also shared amongst the other members of the community to which they belong.15

There is a manifestation in the statements of the respondents that supports the idea that women have always had the role of caretaker within their families since the beginning of civilization. This finding corroborates the study conducted with residents of the coverage area of a Family Health Unit, in which a close relationship becomes evident between women and the plants, for their use was the main therapeutic resource used to treat people's health and of their families.14

The care of the family members is usually assigned to women, and this female predominance highlights the importance of women in the transmission of knowledge between generations and the responsibility for the implementation of health care in the family, making use of medicinal plants for its realization.15

"I acknowledge the importance of medicinal plants"

When asked if they used medicinal plants on a daily basis, all respondents said they used them, and when asked them to make a comparison between the use of allopathic medicine and the use of medicinal plants, it became evident that the respondents knew how to differentiate them, as observed if the following lines :

"The plants are there, you do not need to purchase them [lower cost], are within reach [easy to obtain] [...] as of the efficacy, plants have always been effective in my use" (S4)

"In fact, I believe that plants have fewer side effects than the drugs we buy" (S1)

"I believe one takes the medicine from the pharmacy and one complements it with plants because it actually helps to alleviate the problem" (S5)

"[...] Here is what I think: pharmacy drugs, as they are studied, they are put into practice (tested), (therefore), I think the effects are faster. While complementary therapy I think it is great too. [...] Also it (complementary therapy) is a treatment for a long time [...]" (S6)

Respondents consider that medicinal plants are of easier access than allopathic drugs, implicate in lower economic costs and lower health risks, therefore, complement the allopathic treatment. Regarding allopathic drugs, respondents mentioned it shows effects in a fast manner, as plants, on the other hand, must be consumed for a long period of time to show results.

In line with what was mentioned in the statements above, on May 3rd 2006 the National Policy on Integrative and Complementary Practices (PNPIC) in SUS was created, established by Ordinance n° 971 of the Ministry of Health (MS) aiming to expand the therapeutic options available to SUS users, amongst these, medicinal plants, guaranteeing access to herbal medicines and herbal medicine-related services, with safety, efficacy and quality, according to the perspective of integrative health care. Adding to this, it was established in 2007 the National Program for Medicinal Plants and Herbal medicines, which aims to "ensure safe access and rational use of medicinal and herbal plants to the Brazilian population, promoting the sustainable use of biodiversity, the development of the productive chain and the domestic industry".167

In order to achieve its goal, amongst the propositions of the Program just mentioned, there is one to "promote and recognize the popular and traditional practices of use of medicinal plants, herbal and home remedies.167 Thus, in February 2009, the Ministry of Health issued the National List of Medicinal Plants of Interest to the SUS (Renisus), in which are present 71 plant species used by popular wisdom and confirmed scientifically.17

It is believed that the care provided by means of medicinal plants is favorable to human health, since the user has prior knowledge of their purpose, risks and benefits. In addition, health professionals, especially nurses, should consider such popular source as a resource in their care practice, enabling a singular care, focused on the beliefs, values and lifestyle of the people cared for.18

It is known that the plants should be used with caution for its use can cause harm just as any industrialized drug. What determines the effect of a plant is the context in which it is used, its preparation and dosage and the concepts of health and disease of a particular culture. When a plant is used outside of this context, it can produce unwanted and unexpected effects.19

To make proper use of plants, it is necessary to go through a thorough research on the subject in order to acquire the necessary knowledge and, thus, attain the healing of the acquired disease.

"I use plants at home, but do not recommend its use in the practical field"

During the data collection, the respondents were asked if they encouraged the use of medicinal plants at home and/or practical fields. From the responses, it was noticeable that all of them encourage the use of plants in their homes, however, they do not feel at ease to recommend its use while practicing in their professional internships:

"[...] In my house yes, we use them constantly. But not in practical activities and internships. [...]" (S6)

"At home yes. Not at internships." (S5)

This finding is consistent with the study, which mentions that the use of medicinal plants is a current practice within the health professionals daily routine, but absent in their workspace.20 This absence is justified in a study that points out the insecurity shown by the professionals who feel unable to prescribe the use of medicinal plants due to the scarce dissemination of its scientific validation.21

However, considering that the care prescribed and developed by nurses aims at solving problems listed by the nursing and health staff, the theme medicinal plants lies duly in their professional area. Therefore, with advances in new studies and the equipping of nurses with scientific tools and popular knowledge, the process of prescribing and indicating the use of medicinal plants will be carried out by the professional category.22

It is noteworthy that the standard-setting entity of the profession, the Federal Nursing Council (COFEN) approved the Resolution 197/97, that contains Art. 1 which establishes and recognizes alternative therapies as a specialty and/or qualification of nursing professionals.6

Another question asked to the students was if they "considered themselves able to work with medicinal plants after graduation", all were unanimous in answering that they do not consider themselves able or self-confident to encourage the use of medicinal plants in their care practices, as can be found in the following lines:

"[...] I do not consider myself [able to work with medicinal plants] because as I told you, what I know is a matter of popular knowledge. Nothing scientific. [...] I would be apprehensive in prescribing them to people because I do not know the exact quantities [...]" (S6)

In this regard, ANVISA through Resolution RDC n° 267/200523 made public the list of plant species and parts of plant species permitted for use by the population, which endorsed greater legal support to the form of preparation and proper use of medicinal plants.

"[...] No because I think it has to be more specific. We learned it superficially [the theme of medicinal plants in graduation]." (S5)

"[...] I do not consider myself apt. I think we still have a lot to learn, I mean, at graduation, we learn the basics, a slight sense of what it is, but not enough to be prepared [...]" (S7)

Reinforcing this finding, there is a study also performed with nursing students, which showed that most students never discussed complementary therapies with teachers. This research also reinforces that if knowledge about complementary therapies such as the use of medicinal plants is obtained, for the most part, outside the academic world, its professional indication can not be guided by common sense but by scientific guidelines, as expected for any nursing intervention or prescription.24

Research indicates the importance of professional improvement on the subject medicinal plants and the insertion of these therapies in their work place.25 Therefore, the assembly of a syllabus that incorporates the popular practices of care is an essential piece of the puzzle that would enable the nurse to scientifically support the knowledge about medicinal plants and indicate their use safely and effectively to the assisted population.

When asked respondents if the same had contact with the subj ect ofcomplementary therapies, the lack ofencouragement given to students by the curriculum of universities appears once again, in regards of complementary therapies and specifically the medicinal plants in their daily work:

"We had a class on alternative therapies where we talked about various therapies, including that one, herbal medicine, right?" (S8)

"In the 4th semester we had some classes on complementary therapies such as plants, reiki [...] but it was only superficial, nothing concrete." (S5)

"[...] I once had a class [in college], it wasn't even on complementary therapy,it was on alternative therapy that they spoke of plants. But I do not remember, it was only once a long time ago." (S2)

The speech of the respondents refers, once again, to the fragility of university education, as popular knowledge in health care remains on the margins of scientificity as it is recognized by the biomedical model.4 This way, the nurse tends to reproduce this model uncritically, disregarding sometimes, other possible manifestation of knowledge on health, such as those resulting from popular wisdom.4 This might explain the fact that, despite having been published in 05/04/2006, Ordinance n° 971 of the Ministry of Health that established the PNPIC is still unknown by many health professionals.20

Justifying, once again, the need to incorporate the issue into the syllabuses of universities, for the use of medicinal plants as a complementary health therapy, because it is not clearly discussed in classes nor trained during activities in the practice field, for the course syllabus does not contemplate the approach on complementary therapies, in spite of the existence of COFEN's resolution, which gives nurses the use of medicinal plants as one of its specialties.

Therefore, nursing should appropriate the study of medicinal plants and encourage its use in hospitals and in Family Health Strategy (ESF) as one more option for treatment for the health of its members, exchanging information with users on how they use plants and allow this approach between popular and scientific knowledge.

CONCLUSION

With this research, we observed that the respondents believe in the efficacy of medicinal plants through the experiences and information exchanged with their families, which occurs mainly with mothers and grandmothers, showing the permanence of the female figure in health care.

The study also highlights a weakness in the undergraduate nursing syllabuses, which is still very focused on the biomedical model, compromising the integral formation of students. With education disassociated from the reality of the population, student and future nursing professional tend to devalue popular knowledge in the use of medicinal plants, which impairs the user's autonomy in health care.

The statements of the students also show that they feel insecure to offer guidance to users of medicinal plants without scientific basis. So, it is important that the academy gives support on the whole process covering the care of plants: from farming to consumption.

In acting as a student and nursing professional, one needs to view the user in their culture, seeking to approach scientific and popular knowledge. This congruence is essential and necessary to remove the medicinal plants from the periphery of scientificity as it is recognized by the biomedical model. Both forms of knowledge add up when one aspires to health promotion and integrative care.

Sidebar

How to quote this article:

Badke MR; Heisler EV; Ceolin S; et al. Nursing students knowledge on use of medicinal plants as supplementary therapy. Rev Fund Care Online. 2017 abr/jun; 9(2):459-465. DOI: http://dx.doi. org/10.9789/2175-5361.2017.v9i2.459-465

Footnote

1 Research funded by the National Council for Scientific and Technological Development - CNPq - Brazil.

References

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Received on: 19/02/2016

Reviews required: No

Approved on: 15/06/2016

Published on: 10/04/2017