Attitudes, beliefs and knowledge about medical cannabis among nurses and midwives in Cyprus: a cross-sectional descriptive correlational study

The term cannabis refers to pharmacologic agents derived from plants belonging to the genus Cannabis [1]. Cannabidiol (CBD), a cannabis compound, is associated with many therapeutic effects [2]. Healthcare providers have the authority to recommend non-pharmaceutical CBD products for therapeutic purposes, in compliance with state law [3]. In its comprehensive review of the medical literature on the health effects of cannabis and cannabinoids [4], the National Academies of Sciences, Engineering, and Medicine (NASEM) found substantial evidence of the effectiveness of medical cannabis (MC) in alleviating chronic pain, chemotherapy-induced nausea and vomiting, and spasticity associated with multiple sclerosis (MS) [5].

Evidence from the literature supported that MC effectively reduced patients’ chronic disease symptoms, such as chronic pain and their use of opioid medication for pain management [6]. Furthermore, research evidence pointed out, that they are positive effect between MC use and anxiety symptoms. Specifically, the patients reported that the MC use helped them to manage their anxiety symptoms [7]. Finally, qualifying conditions for MC in Minnesota currently include cancer associated with severe/chronic pain, nausea/severe vomiting, and/or cachexia/severe wasting; glaucoma; HIV/AIDS; Tourette syndrome; amyotrophic lateral sclerosis (ALS); seizures, epilepsy; severe and persistent muscle spasms, including those characteristic of MS; inflammatory bowel disease, including Crohn’s disease; terminal illness with a probable life expectancy of less than one year; intractable pain; post-traumatic stress disorder; obstructive sleep apnea; and autism [8].

There are varieties in the cannabis products used in clinical practice, as a result these variations have created uncertainty and reservations for healthcare providers attempting to make decisions and educate patients about MC [9]. Furthermore, there is little evidence on the attitudes, knowledge, and beliefs of healthcare professionals and students toward MC in Cyprus and across the world [10]. In the study of Philpot et. Al. [9], the authors examine the primary care providers’ beliefs and attitudes about MC use and its effects on medical conditions in they are clinical practice. The results show that more of the half of the participants believed that MC is involve positively in the treatment of specific medical conditions such as cancer, terminal illness, and intractable pain [9]. However, half of the participants in the same study reported that they did not have the appropriate theoretical background to answer patient’s questions about MC, and the majority of them wanted to learn more about MC use and its benefits for medical conditions [9]. Additionally, other studies have highlighted the lack of knowledge among healthcare professionals about MC use as well as the lack of clinical practice guidance on the topic [11].

Finally concerning Republic of Cyprus, MC was legalized for medical use during the 2010s. The legislation mainly focused on producers and specified licensing procedures, authorized activities, safety measures, and good production practices [12]. It also mandated that medical prescriptions include the type of hemp, the trade name, the percentage of Delta-9-Tetrahydrocannabinol and CBD content, the route of administration, the dosage, and the total monthly quantity as well as physician and patient contact details [12].

Studying the national and international literature, it seems that, this study is the first attempt to record and evaluate the attitudes, beliefs and knowledge of Cypriot nurses and midwives. Given the relatively high response rate and convenience sampling, it is possible to generalize the present study’s findings to the entire nursing and midwifery population in Cyprus.

The vast majority of previous studies about MC use, have focused on prescribers or a single disease category [6, 11, 18, 19]. Our findings focus on attitudes, beliefs, and knowledge of Cypriot nurses and midwives. The present study adds more evidence to the existing literature providing new data on the attitudes, beliefs, and knowledge among health care professionals.

Our results seem to be rather recommending in favor of MC use. The main findings of the present study showed that, Cypriot nurses and midwives reported lack of knowledge regarding the risks and benefits about MC use to patients. The participants reported lack of confidence when they discussed MC benefits for specific disorders with their patients. However, specific number of participants believed MC use was considered acceptable for the patients with persistent muscle spasms, insomnia/sleeping disorders, mental health conditions, and terminal illnesses.

Our results showed that, the majority of the participants believed that formal training on MC should be integrated into academic programs. Cypriot nurses and midwives expressed the necessity of urgent training under the current curriculum. Specifically, more than the half of participants believed that it is necessary to have formal training about MC use before recommending to their patients. The participants supported that, educational training programs about MC use should be integrated into the practice/clinical practice. Other similar studies associating MC knowledge indicators with relevant attitudes of healthcare professionals in the United States (US), have shown that nurses have higher self-perceived knowledge and more positive attitudes toward MC than other healthcare professionals [20].However, a lack of formal education and training and significant knowledge gaps regarding MC among nurses and physicians have been reported [21]. Furthermore, since MC laws about use is rapidly changing in some countries, such as the US, advanced practice registered nurses during their clinical practice have been authorized to recommend MC use to their patients [22].

Comparing our findings with the results of our previous study [10], both studies presented similarities. Specifically, the majority of the Cypriot nursing students in previous study, believed that formal training on MC should be integrated into academic programs and expressed the necessity of urgent training about MC under the current curriculum. Our results are on the same line with others studies worldwide [20, 21].

Additionally, in the present study nurses and midwives strongly supported that, educational training programs on MC use should be integrated into the practice/clinical practice. Our results supported from the relevant literature. Research evidences supported that, health practitioners have insufficient theoretical and clinical knowledge about MC use and benefits [20, 21]; these specific knowledges important and necessary to increase their competency about the benefits of MC use [21].

In the present study, concerning the socio-demographic characteristics of the participants, we examined the association among gender, age, religion, and years of work experiences in the clinical sectors and attitudes, beliefs, and knowledge about MC use of the sample. As a result, the present study adds more evidence to the existing literature concerning the socio-demographic characteristics of the health care professionals. Our results pointed out that, gender had a statistically significant positive effect on participants’ attitudes and beliefs about MC. More specifically, male participants reported higher frequency about cannabis use for recreational purposes, compared with female group. Regarding reported higher frequency about cannabis use for recreational purposes amongst male participants, this might a result of low and undervalued social stigma amongst males who use cannabis for recreational purposes [2, 3],compared with females. Generally, a higher frequency about cannabis use for recreational purposes amongst male participants, has been associated with socio-cultural explanations, including factors related to gender role, as well as with biological and psychological parameters. The impact of personality traits also involved. Males, might express themselves more easily and may not be afraid of being cultural stigmatized by their society. However, evidences from the international literature concerning the gender, showed contradictory results [23, 24].

Concerning the patients, a larger number of female participants in this study, agreed that healthcare professionals who prescribe MC should have ongoing contact with their patients compared with male group. On the other hand, more than twice as many males compared with females’ participants group, believed that they were prepared to answer patients’ questions about MC. Male participants expressed in strong percentages that healthcare professionals should have formal training on MC before recommending it to a patient compared with female group. In this study, our results showed that, the vast majority of the sample (male and female), agreed that, additional research about MC use must be integrated into academic programs, while almost all of them agreed that educational training for MC must be integrated into academic programs.

Moreover, concerning the age of year-old groups among the participants, our results showed similarities among these groups. The vast majority of the sample in all groups, strongly agreed that additional research about MC use must be integrated into academic programs; almost all of them pointed out that educational training for MC must be integrated into academic programs.

Furthermore, concerning the relational status, our results showed that all participants included in this study, agreed that educational training about MC must be integrated and additional research about MC use should be encouraged.

Additionally, the marital status, the study showed that, the unmarried participants expressed their positive preference about cannabis use for recreational purposes in twice as strong, compared with married participants group. Concerning the social transactions among married and unmarried participants, almost the half of unmarried participants reported that, had friends who use cannabis for recreational purposes, compared with married participants group, whom reports less percentages. However, although they had friends who use cannabis for recreational purposes, unmarried participants agreed that using cannabis might develop serious permanent mental health symptoms/diseases. Their answers may arise from their attitudes, knowledge, and beliefs about cannabis for recreational purposes as healthcare professionals.

Although that there is no statistically significant difference between years of work experiences in the clinical sectors and MC use among nurses and midwives in Cyprus, it seems that there is a positive trend about years of work experiences and MC among nurses and midwives in Cyprus. Nurses and midwives in Cyprus having more years of work experiences in the clinical sectors, might have a more positive attitudes concerning MC use. Similar results found among other professionals worldwide concerning MC use [14].

In this study, our results seem to be rather recommending in favor of MC use; additionally, a small number of nurses and midwives supported the legalization of marijuana for recreational use. The vast majority of the participants in the present study would recommend MC to their patients if it were legalized. However, the majority of the sample population strongly disagreed with the legalization of marijuana for recreational use. This result is in contrast with our previous study of Cypriot nursing students, in which the third-year students were more in favor of legalizing marijuana for recreational use [11]. Low rates of support for the legalization of marijuana for recreational use were also observed in a US study of healthcare professionals [19, 25]. Although, the literature has shown that healthcare professionals support MC use and its legalization [22, 26‐29]. In our study, most of the participants seemed to have lack of basic knowledge of the content, effects, and legality of MC. These results confirm prior reports of significant gaps in the MC knowledge of healthcare professionals [19, 30]. Since the nuances of developing MC education frame are critical, Cypriot nurses and midwives need to be educated about the advantages and disadvantages of MC use for specific disorders.

Finally, the above findings need to be viewed in the context of certain methodological limitations. The data collection took place during the 26^th Nurses and Midwives Congress in Cyprus, which took place on November 28–30, 2019, in Limassol. In the 26^th Nurses and Midwives Congress, hence, nurses and midwives that were absent on that days were excluded, along with those who refused to participate. As a result, the observed results may be underestimated or might be were slightly different. Additional limitations include lack of triangulation with qualitative data, as well as possible underestimation of the actual frequency of cannabis use, or positive attitudes towards MC. This may be attributed to one’s need to preserve a positive personal image, thus avoiding to report adverse behaviours (i.e. illegal substance use or socially unpopular attitudes).

More importantly, the cross-sectional nature of the study does not permit any inference with regard to the direction of the observed association between nurses and midwives’ attitudes, beliefs and knowledge and medical cannabis used. Nevertheless, the large sample and the use of more appropriate and robust instrument in the present study allow for a more accurate estimation of the occurrence of nurses and midwives’ attitudes, beliefs and knowledge and medical cannabis used.