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

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.


Introduction
Non-communicable diseases (NCDs) are a health problem worldwide, accounting for approximately 41 million deaths every year; it represents 74% of deaths in Brazil (1) . The global and Brazilian targets for decreasing NCDs include the prevention of diseases and health promotion based on reducing risk factors, such as arterial hypertension (AH), characterized by persistently elevated blood pressure (BP) (systolic greater than or equal to 140 mmHg and/or diastolic greater than or equal to 90 mmHg) (2) .

Integrative and Complementary Practices in Health
(ICPH) have been used throughout history to maintain health and prevent and treat diseases, particularly chronic diseases (3) . Scientific evidence shows that ICPH is incorporated into the care of individuals with AH worldwide (4) . However, a recent review of theses and dissertations performed in Brazil shows that 11 manuscripts addressed ICPH in the context of AH management, two were conducted by nurses, and one focused on the nurses' practice, highlighting an important gap in the literature (5) .
In addition to pharmacological interventions, the precepts of integrative nursing, a field on the rise, consider the concomitant use of non-pharmacological interventions scientifically proven to be safe and effective (6) , such as ICPH. The nursing field was the first to recognize complementary therapies as a professional practice in 1997 (7) . Currently, the Resolution of the Federal Nursing Council (COFEN) No, 625/2020 updated and ensured the support of Nursing specialties in ICPH, including phytotherapy, homeopathy, orthomolecular therapy, floral therapy, foot reflexology, Reiki, yoga, therapeutic touch, music therapy, color therapy, hypnosis, and acupuncture (8) .
Nevertheless, the profile of professionals working with ICPH is still unknown in Brazil, though there is an emphasis on nurses implementing it besides research and extension. ICPH can expand the practice of nurses, providing greater autonomy and improving the quality of the care provided (9) .
In line with the strategy of the World Health Organization (WHO) on traditional medicine (2014-2023) (3) , it is worth noting a scarcity of guidelines regulating training programs in the Brazilian context. Additionally, the profile of nurses working with ICPH is unknown, as well as the concepts of this practice and how it is implemented in the nursing care provided to individuals with AH, which is the research problem addressed here.
Filling in such gaps will strengthen the ICPH in the Brazilian Unified Health System (SUS), the ICPH training of nurses, and the care nurses provide to individuals with AH, which justifies this investigation. Thus, this study's objective was to analyze the profile of nurses regarding Traditional, Complementary, and Integrative Medicine and understand how it is incorporated into the care provided to individuals with high blood pressure.

Method Study design
A mixed-methods sequential explanatory design was adopted in this study, in which quantitative data (QUAN) were collected and analyzed first (with greater weight).
The qualitative stage (QUAL) was based on the results obtained in the quantitative stage (10) , and integration occurred through a connecting approach. Mixed methods were used to deepen the understanding of the research problem, with the quantitative stage having a crosssectional design and the qualitative stage based on participatory analysis (11) . The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) and Standards for Reporting Qualitative Research (SRQR) were adopted.

Study setting, population, and sample
As part of a national multicenter project, the study setting was Santa Catarina (SC), Brazil, and the population consisted of the nurses working in that state. There were 16,620 nurses registered with the Regional Nursing Council of SC (12)  one nurse from macro-region 1 refused for not feeling apt due to a lack of experience with ICPH; and one from macro-region 3 refused because she worked in urgency and emergency and did not implement ICPH. These macro-regions were included in new draws following the geographically closest regions. Macro-region 4 did not have nurses who met the inclusion criteria; macroregion 2 had only one nurse. Macro-region 5 had three nurses who met the inclusion criteria, though only one was available to participate.

Data collection
Quantitative data were collected online using a 63-item questionnaire, 26 of which were answered by all the nurses. Thirteen questions addressed sociodemographic information, eight concerned the participants' professional profiles, and five addressed their qualifications. The remaining 36 questions were specific to nurses who attended a training program on ICPH (18 questions concerned ICPH training, and 18 addressed professional practice). The final question asked whether they would be available for an online interview (qualitative stage). Consent was manifested by reading the free and informed consent form and checking the box "I agree to participate in the study." The questionnaire was developed in the LimeSurvey software and was peer-reviewed by four nurses from the south qualified in ICPH and/or mixed methods.
The objective was to adapt the questions' language and organization. Next, a pilot study was implemented with six participants from five Brazilian regions. Using the Google Meet Platform, the first author held the online interviews individually (to minimize dissonance in the data collection process) from January 11 th , 2021, to December 20 th , 2021. The video calls were made using an institutional e-mail to protect data and lasted 47 minutes on average. The consent form had been previously sent via e-mail, which was read and video recorded before initiating the interviews; the participants also agreed with the interviews being video recorded.
The framework adopted for analysis demanded that a consensus be reached on the narrative that resulted from each interview; hence, two video calls were needed, one for the interview and one for its validation. The latter lasted 31 minutes on average. After calculating the prevalence of ICPH training and associated factors, the relationship between the variables was assessed using the Chi-square test, with significance established at a p-value <0.05 in the two-tailed test.

Data treatment and analysis
The Fisher's Exact Test was adopted for small samples (below five in each subcategory).
The measure of association adopted was the prevalence ratio (PR), with its respective 95% confidence intervals. In addition, the hypothesis of a linear relationship between the two variables was investigated for variables with more than two categories using the Mantel-Haenszel Chi-Square. When the Breslow-Day Test for the ratio interaction showed a value >0.05, the PR was adjusted for the variable under analysis.
The interviews were recorded and manually transcribed in Microsoft Word. The 18 participants were identified by the names of crystals, followed by their ages, higher academic training, and health macro-region to which they belonged.
Participatory analysis of the interviews occurred at three points: 1 st (narrative construction), in which the interviews were recorded and transcribed verbatim.
The transcriptions originated the narratives, which were previously analyzed; 2 nd (hermeneutics or validation): the narratives were presented to the participants via a video call (Google Meet) to validate data and produce intervention effects, more deeply discussing issues or subjects not much elaborated on in the first discussion; 3 rd (building consensus): discussion, review of opinions, agreements, and disagreements. After consensus, the narrative was ready for analysis and identifying meaning cores (11) .
After analyzing the quantitative and qualitative data, we proceeded to interpret the mixed methods to integrate the findings according to a connecting approach; data from the quantitative stage were connected to determine the questions and the participants for the qualitative stage. Joint displays show this integration to facilitate visualizing the findings (13) .

Ethical aspects
The study project was approved by the Institutional

Results
A total of 386 (100.0%) nurses participated in the quantitative stage; 142 (36.8%) of these had ICPH training, and 55 (14.2%) mentioned they incorporated ICPH in the care provided to people with AH. The sociodemographic profile is presented in Table 1. On average, the participants were 37 years (+ 9.4), and most were between 31 and 35.  The nurses' reports show that they sometimes use different ICPH practices or assess which one(s) to use, depending on each case. Therefore, many practices were mentioned and used differently as the primary intervention or to complement other practices.   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. Of the 142 nurses with ICPH training, 55 reported using these practices to care for people with AH.
In order to integrate QUAN and QUAL data, a joint display was developed, including this specific portion of respondents and representative excerpts of their reports, focusing on the challenges and potentialities faced when implementing ICPH to manage AH ( Figure 3).

Discussion
The profile of nurses with ICPH Integrative

Complementary Practices in Health training in Santa
Catarina, Brazil, is similar to that shown by the Nursing Profile Survey in Brazil (14) . As for the participants' gender, the predominance of women reflects an ageold aspect of identifying the practice of care as being of a female nature rather than a profession. Historically and culturally, nursing is a field composed of women who used to provide care as a charitable or religious activity, or from a layman's perspective, consistent with low remuneration (15) ; such identity aspects affect the profession even today.

The nursing field addresses all stages of life and
is present in all Brazilian cities. Nurses represent more than half of all health professionals and are essential for delivering quality health care (17) . ICPH is an important tool to meet the principle of integrality and can potentially expand access and supply, besides the qualification of health services. The nurses' reports regarding how ICPH is incorporated into the care provided to individuals with AH reveal a concern with looking at patients from an integral and comprehensive perspective to promote health, considering that "[...] the ICPH's central focus is based on human responses, rather than diseases" (5) .
Because AH is a modifiable condition and a public 80% of these are prescribed treatment; and 80% of those receiving treatment achieve BP control targets), which is intended to decrease all-cause mortality from 4% to 7% (i.e., 76 to 130 million deaths are expected to be averted between 2022 and 2050). Most risk factors for AH are modifiable, and the target is directly related to achieving global targets to decrease overweight and obesity, the harmful use of alcohol, and high salt consumption (18) . The possibilities to achieve such targets include using ICPH (3) .
Health promotion to decrease risk factors is an important global and national target for reducing NCDs.
Considering primary prevention, stress control is a non-drug treatment recommended for people with AH (2) .
Psychological factors deserve attention. A recent study reports that 60.6% of women feel stressed, and 33.6% presented AH (19) . These aspects reflect the reports of nurses adopting ICPH to deal with emotional issues, such as sleep and rest, stress, depression, and anxiety, which boost BP alteration-related imbalances.
Auriculotherapy stood out among ICPH practices adopted in the care provided to people with AH.
Auriculotherapy is an acupuncture microsystem in which needles, crystals, seeds, laser, Moxibustion, or infrared are used in ear points to treat the signs and symptoms of varied diseases (20) .
Regarding the procedures mostly frequently performed, data concerning ICPH implemented in Brazilian Primary Health Care in 2019 (21) show that auriculotherapy was the procedure most frequently applied in a universe of 628,239 procedures, with 423,774 sessions, followed by 129,207 sessions of acupuncture with insertion of needles, corroborating this study's findings.
Research addressing the effectiveness of ICPH has shown positive results (22)(23)(24) , among which is auriculotherapy, in which some protocols guide the practice in the care provided to people with AH (25) ; kidney, hypotensive, shen men, and heart are some auricular points addressed by the nurses.
One of the auricular acupuncture techniques, known as bloodletting, is performed by piercing the ear capillaries with a needle to release a few drops of blood (25) . Bloodletting at the apex of the ear is the most frequent practice to treat hypertensive crises. A study conducted in Santa Catarina used bloodletting only once in the brain reflex point and showed a reduction in systolic BP in 80% of the volunteers (26) .

E v i d e n c e s h o w s t h e p o s i t i ve e f f e c t s o f
auriculotherapy on AH (4)(5) . However, studies with a low methodological quality indicate the need for more investments, considering that many potentialities are pointed out in clinical practice. In addition, given the specificity of the ICPH paradigm, traditional research methods may be challenging to apply.
"Even though studies addressing ICPH are still scarce in Brazil, research has grown in recent decades. Such growth is evidenced by analyzing three aspects: the promotion of research, research groups/ lines, and publications" (27) . This reflection is relevant, considering that only in 2013, ICPH research in Brazil had its first public notice for specific funding (28) . indicating an inclination towards its use in managing AH and diabetes mellitus and more frequent use of phytotherapy. However, although the legislation provides for various practices, ICPH is still seldom adopted, and the lack of professional training is apparent (32) .
The nurses' reports show a lack of knowledge concerning legal support, which is of concern, considering that the nursing field pioneered recognizing ICPH as a professional practice (7) . The dispute between professions is commonplace, and some ICPH practices are still in an accreditation process that requires advancements in the profession's legal aspects.
In addition to the COFEN/COREN system, the Brazilian

Association of Acupuncturist Nurses and Integrative
Practice Nurses (ABENAH) deserve mention as these are working toward this direction.
The potential highlighted in the nurses' reports concerns a decrease in medication use, also reported in another study (33)  The nurses' concern with lifestyle stood out in their reports. It was a variable considered in care planning, and health education was used to encourage selfcare and co-responsibility. ICPH was mentioned as a preventive measure to prevent AH or its worsening.
The auriculotherapy bleeding technique with a hypotensive effect stood out in the care provided to hypertensive crises.
Among the challenges experienced by nurses when applying ICPH in the care provided to people with AH, the biomedical culture, centered on disease and medicalization, was frequently mentioned, and nurses emphasized that health professionals, managers, and the general population undervalued ICPH. Additionally, the reports indicated a deficit in training on the subject.
Research is considered one of the potentialities because it has the potential to provide further visibility to this practice and encourages a reflection upon care practices that include ICPH. The implementation of ICPH can contribute to reducing the use of allopathic