Background
The potential use of medical cannabis started with the discovery of the endocannabinoid system (ECS) at the end of the 20th century which resulted in a paradigm shift [1]. The ECS relates to basic functions such as “relax, eat, sleep, forget and protect”. Some authors even suggest that modulating ECS activity may have therapeutic potential in almost all diseases affecting humans [2, 3]. Medical cannabis, with cannabinoids that also act at the level of this widely distributed system, has been used in an attempt to modulate the physiological effects of the ECS. There is evidence of benefits in certain pathologies, but knowledge in this promising area is still limited [4]. With these discoveries, the legal prohibition of cannabis across the world gradually gave way to laws providing for the use of cannabis for medical purposes. Some three decades later, several countries around the world currently allow for the medical use of cannabis and some also allow for recreational use. Europe is no exception: the use of cannabis for medical purposes is regulated in several countries, while regulation on recreational use is not yet significant, although it is a growing trend [5].
The opinions and knowledge of health professionals about cannabis, particularly medical cannabis have been described in several studies. The importance of this analysis has been described in studies involving different healthcare professionals, which highlight knowledge, safety concerns and potential obstacles [6]. Health professionals are interested in the topic, as evidenced by a preliminary study carried out before a large-scale questionnaire on cannabis was distributed to health professionals in Europe. This study involved health professionals from a range of fields, 84,8% of whom showed interest in the subject [7]. In the US, in some states where cannabis is legal, perinatal cannabis use has grown. A study on this topic also involving health professionals, mostly nurses, concluded that there is a need to train health professionals in patient counseling and embracing changes in clinical practices [8]. There is a shortage of studies in Europe. Studies reflecting the knowledge, opinions and experiences of nurses and nursing students concerning medical cannabis are nonexistent in Portugal. We highlight a study at a Spanish university, the neighboring country and quite similar in terms of political, social and legal structures, that aimed to determine the knowledge of nursing students about medicinal cannabis and attitudes towards medicinal and recreational. It concluded that knowledge of medicinal cannabis was poor and that there was a need to reinforce the training of nurses in particular [9]. The extension of nurses’ roles has been discussed to make health systems more accessible and efficient. As part of health teams, they play a role in health promotion, disease prevention, treatment and recovery, and in fostering changes in attitude. Some countries have changed the regulations, particularly about prescriptions, which presuppose that these health professionals have an in-depth knowledge of the indications for medicines [9, 10]. In specific circumstances, nurses can play a leading role in administration, ensuring the highest efficacy and thus being key to the success of the therapy [11]. As key players in the health system, nurses must be informed about the emerging therapy of medical cannabis, although they do not prescribe it. Including nursing students in the study is of major importance as they are future nurses and mirror what is being taught in nursing schools.
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Consequently, this study intends to analyze the knowledge, training, opinions and experiences of nurses and nursing students in Portugal concerning the use of medical cannabis. We also looked into the gender differences of opinions and experiences to identify the differences between the nurse or nursing student cohorts. Data on recreational cannabis use in Portugal consistently shows a higher prevalence of use among men than among women [12]. We wanted to assess whether there would also be gender differences in the context of medicinal cannabis.
Methods
Study design
A cross-sectional study was performed to analyze the knowledge, training, opinions, and experiences of nurses and nursing students in Portugal concerning the use of medical cannabis. We used Google Forms to draw up the questionnaire on cannabis, and we adjusted it to the Portuguese reality. It was based on questionnaires previously used in studies involving health professionals abroad [13‐16].
The questionnaire was divided into three parts: the first addressed socio-demographic information (gender, profession, nursing school, working area and country working region (nurses) and the year they attended (nursing students)), the second part was on the opinions (see Table 1), experiences and knowledge (Tables 1 and 2), and the third part focused on cannabis training (whether they had pre and post-graduate medical cannabis training and if they felt they needed further training).
Table 1
Nurse and nursing students’ knowledge and opinions about cannabis
Totally agree N (%) | Agree N (%) | Neither agree nor disagree N (%) | Disagree N (%) | Totally disagree N (%) | ||
|---|---|---|---|---|---|---|
MC is a legitimate medical therapy | Nurses | 104 (32,7%) | 149 (46,9%) | 59 (18,6%) | 4 (1,3%) | 2 (0,6%) |
Students | 108 (37,0%) | 138 (47,3%) | 42 (14,4%) | 1 (0,3%) | 3 (1,0%) | |
MC is safer than illegal cannabis | Nurses | 142 (44,7%) | 127 (39,9%) | 41 (12,9%) | 5 (1,6%) | 3 (0,9%) |
Students | 120 (41,1%) | 114 (39,0%) | 44 (15,1%) | 12 (4,1%) | 2 (0,7%) | |
I believe some of my patients are illegally using cannabis to treat symptoms or illnesses. | Nurses | 28 (8,8%) | 94 (29,6%) | 139 (43,7%) | 45 (14,2%) | 11 (3,5%) |
Students | Not applicable | |||||
My knowledge is sufficient to advise patients on the use of MC | Nurses | 3 (0,9%) | 6 (1,9%) | 27 (8,5%) | 111 (34,9%) | 171 (53,8%) |
Students | 1 (0,3%) | 6 (2,1%) | 53 (18,2%) | 101 (34,6%) | 131 (44,9%) | |
I know the differences between THC and CBD. | Nurses | 8 (2,5%) | 32 (10,1%) | 26 (8,2%) | 97 (30,5%) | 155 (48,7%) |
Students | 10 (3,4%) | 49 (16,8%) | 47 (16,1%) | 77 (26,4%) | 109 (37,3%) | |
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Table 2
Answers to questions about the components and functions of the ECS by the study groups
Yes, totally | Yes, I have an idea | No, I have only heard about it | No, I have never heard about it | ||
|---|---|---|---|---|---|
Do you know what are the components of the ECS? | Nurses | 3 (0.9%) | 28 (8.8%) | 61 (19.2%) | 226 (71.1%) |
Students | 1 (0.3%) | 23 (7.9%) | 37 (12.7%) | 231 (79.1%) | |
Do you know what are the functions of the ECS? | Nurses | 3 (0.9%) | 34 (10.7%) | 53 (16.7%) | 228 (71.7%) |
Students | 1 (0.3%) | 23 (7.9%) | 36 (12.3%) | 232 (79.5%) | |
Validation of the survey
The questionnaire was then validated by experts - PhDs and professors in the field of mental health and health sciences statistics, with all suggestions for improvement included - and non-experts – nurses and nursing students, with correction of expressed comprehension difficulties. It has been approved by the Ethics Committee of the Faculty of Medicine of the University of Coimbra.
Data collection
The questionnaire was distributed online (mailing lists, social media, etc.), only in Portuguese institutions, and it was open from 28 December 2022 to 29 May 2023. The inclusion criteria were being a nurse or nursing student. No exclusion criteria were applied.
Study size
The online Raosoft sample size calculator was utilized for sample size calculation [17]. In Portugal, the most recent data at the time of the survey showed a total population of 73 912 nurses (data from the Portuguese Nurses Association for 2018) and 15 493 nursing students (data from the Directorate-General for Education and Science Statistics for the 2021/2022 academic year). For a 90% confidence interval, and a standard error of 5%, a minimum sample of 270 nurses and 266 nursing students was assumed.
Analysis
The data was collected and processed by applying descriptive and inferential statistics using the chi-square test and Fisher’s exact test on the SPSS platform (version 28).
Data was reported using the STROBE cross sectional reporting guidelines.
Results
Out of a total of 610 valid answers, 318 were nurses and 292 nursing students.
Socio-demographic data
Of the 318 nurses, 277 (87,1%) were women, 40 (12,6%) were men and 1 of the participants answered “other”.
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The participating nurses had studied at schools from the north to the south of the country, the archipelagos and some had gone to university abroad. The majority of the participants in the survey had studied at the Nursing School of Coimbra (n = 124). Most of the nurses work in public health and community nursing or are general nurses. Nurses from across the country completed the questionnaire. Beira Litoral was the most represented region, where 154 (48,4%) of the nurses work, followed by Estremadura with 35 (11%) nurses.
The 292 nursing students were divided into 245 (83,9%) women, 46 (15,8%) men and 1 “other”. The majority of the student respondents were from the Nursing School of Coimbra (n = 137). Concerning the distribution by course year, 138 (47,3%) were 4th year students, 68 (23,3%) were in the 1st year, 45 (15,4%) in the 2nd year and 41 (14,0%) in the 3rd year.
Experience, knowledge and opinions
Concerning professional experience, when asked “Have you ever administered medical cannabis and/or informed about this therapeutic option?“, most of the nurses (96,2%) had not and only 12 (3,8%) answered yes. Concerning personal experience, 9 (2,8%) nurses and 19 (5,5%) students had used cannabis to treat symptoms or illnesses.
On knowledge about the ECS, 69 (21,7%) nurses had heard of it and 249 (78,3%) had not. In the case of students, only 59 (20,2%) had heard of it and 233 (79,8%) had not. Table 2 summarises the responses of the two groups when asked about the components and functions of this system. The majority of nurses and students had never heard about the components, 226 (71,1%) and 231 (79,1%) respectively. As for the functions of the ECS, the responses were identical: 228 (71,7%) nurses and 232 (78,5%) nursing students had never heard of it.
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Table 1 shows that 282 (88,7%) nurses believe they do not have enough knowledge to advise their patients on medicinal cannabis, against 232 (79,5%) students. Respondents were also questioned about their knowledge of the differences between what is regarded as the two main cannabinoids - cannabidiol (CBD) and tetrahydrocannabinol (THC): 252 (79,2%) nurses and 186 (63,7%) students answered that they did not know the differences between THC and CBD.
Table 1 further highlights the opinions of the two cohorts: 253 (79,6%) nurses and 246 (84,3%) students consider medical cannabis to be a legitimate medical therapy. Concerning safety, 269 (84,6%) nurses and 234 (80,1%) students believe cannabis for medicinal purposes is safer than cannabis for recreational purposes. More than 10% of all respondents chose “neither agree nor disagree” for both questions. When asked whether they believe they have patients illegally using cannabis as a choice of therapy, 28 (8,8%) nurses said they “totally agree”.
About self-cultivation of the cannabis plant for medical purposes, 166 (52,2%) nurses agreed, 97 (30,5%) disagreed and 55 (17,3%) had no opinion. In the student group, they were more in favor of the practice 220 (75,3%), while 39 (13,4%) were against it and 33 (11,3%) had no opinion.
Pre and post-graduate medical cannabis training
Only a minority of the respondent nurses, 44, (13,8%) said they had discussed the topic of cannabis during their nursing student years, while 274 (86,2%) said they had not. In the student group, on the other hand, 50 (17,1%) said they had addressed the topic and 242 (82,9%) said they had not. After completing higher education, 21 (6,6%) nurses said they had received training in medical cannabis, while 297 (93,4%) said they had not.
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There are 289 (90,9%) nurses who feel they need training in this area, and 255 (87,3%) of the nursing students shared the same opinion.
Gender differences in experiences and opinions
Among the nurses, there are gender differences concerning personal experience of cannabis use to treat symptoms or illnesses (p = 0,045). Men had more experience of use and resorted to illegal use more often than women (p = 0,01) (Table 3).
Table 3 below highlights the correlation between gender and opinions and experiences.
Table 3
Correlation between gender and beliefs/opinions and experiences
Gender | P | |||
|---|---|---|---|---|
Female N ( %) | Male N ( %) | |||
Have you ever administered MC and/or informed about this therapeutic option? | Nurses | 9 (3.2%) | 3 (7.5%) | 0.213 |
Students | Not applicable | |||
Do you agree with the self-cultivation of the plant for medical use? | Nurses | 141 (50.9%) | 25 (62.5%) | 0.058 |
Students | 187 (76.3%) | 32 (69.6%) | 0.558 | |
Have you ever used cannabis as a consumer to treat symptoms or illnesses? | Nurses | 5 (1.8%) | 4 (10.0%) | 0.045 |
Students | 12 (4.9%) | 4 (8.7%) | 0.332 | |
If you answered yes to the previous question, did you use it legally? | Nurses | 6 (60%) | 0 (0.0%) | 0.010 |
Students | 2 (11.8%) | 1 (14.3%) | 0.914 | |
MC is a legitimate medical therapy. | Nurses | 220 (79.4%) | 32 (80.0%) | 0.387 |
Students | 205 (83.7%) | 40 (87.0%) | 0.617 | |
MC is safer than illegal cannabis. | Nurses | 236 (85.2%) | 32 (80.0%) | 0.441 |
Students | 195 (79.6%) | 38 (82.6%) | 0.396 | |
I believe some of my patients are using cannabis illegally to treat symptoms or illnesses. | Nurses | 103 (37.3%) | 18 (45.0%) | 0.639 |
Students | Not applicable | |||
Discussion
Experiences
In terms of professional experience, only a small proportion of nurses (3,8%) had been in contact with medical cannabis or had been asked about this therapy option but 38,4% believed they had patients using it illegally to treat illnesses or symptoms. When, in a study in the USA, nurse leaders were asked if they had family members, friends, or patients who have benefitted from medical marijuana use, the positive responses were much higher, 63,9% [18]. It may be a reflection of a longer period of permissive medical cannabis laws in some states.
Most of the nurses and students had never used the cannabis plant to treat symptoms or illnesses, although more students than nurses (5,5% against 2,8%) had used it, even though the former are younger, and thus one would assume they have fewer age-related illnesses. Such findings suggest that students are more open to using this plant. It is worth noting that in Portugal, the Law on Cannabis for Medicinal Purposes, No. 33/2018 of 18 July, governing the use of cannabis-based medicines, preparations and substances for medicinal use, was adopted in 2018 [19]. Considering the academic year they are in, many of the students were not yet enrolled in higher education when the law was passed.
Opinions
On self-cultivation of the cannabis plant for medicinal purposes, both cohorts provided positive answers, although the students were more in favor (75,3% against 52,2%). It should be noted that in both cases the percentage of “No opinion” answers was over 10% (17,3% of nurses against 11,3% of students), which may suggest a lack of knowledge on the subject.
The majority of the nurses, 79,6%, against 84,3% of students, found medicinal cannabis is a legitimate medical therapy, which hints at openness to the subject. Nonetheless, 18,6% of nurses and 14,4% of students answered “neither agree nor disagree”, which suggests a lack of knowledge on the subject. The openness of health professionals in Europe to the use of cannabis or cannabis products for medical purposes has also been noted in other studies on attitudes and knowledge about medical cannabis [6]. Another study in Spain reported that 75% of the nursing students who took part in the study agreed with the regulation of medicinal cannabis [9]. In Cyprus, a study involving nurses and midwives showed that they also support the use of medical cannabis [20].
About the safety of medical cannabis compared to illegal cannabis, 84,6% of nurses believe medical cannabis is safer, against 80,1% of students. In the USA, in a study with nurse leaders, the majority, 78,5%, also considered that legal medical marijuana results in safer marijuana products [18].
We also wanted to test for gender differences in opinions and experiences. We found statistically significant gender differences concerning personal experience of cannabis use to treat symptoms or illnesses only in the nurses’ group (p = 0,045). Men had more experience of use and resorted more to illegal use than women (p = 0,01). A study involving health students in the Republic of Cyprus showed statistically significant gender differences in terms of beliefs/risks associated with the use of medical cannabis. The results indicated that men were more likely to believe that there are significant mental health benefits associated with the use of this therapy, while women were more likely than men to believe that the use of medical cannabis poses serious physical and mental health risks [21].
Knowledge
When asked about the ECS, 78,3% of nurses had never heard of it; 71,1% said they had never heard of its components and 71,7% had never heard of the functions of the system. The lack of knowledge about this subject was also high among students: 79,8% had never heard about the ECS, and 79,1% and 79,5% had never heard of the components of the ECS and its functions, respectively. In Canada, nurse practitioners with the power to prescribe medical cannabis reported having a low level of knowledge about it, particularly concerning ECS [22].
The majority of nurses and students felt that their knowledge was not sufficient to advise patients on the use of cannabis for medical purposes. Only 2,8% of nurses and 2,4% of nursing students felt that they had sufficient knowledge to advise patients on this topic. The results mirror what is happening at the European level. A systematic review of the literature on the knowledge and attitudes of health professionals in Europe found a lack of knowledge in several areas associated with medical cannabis, particularly among students in medicine, nursing and pharmacy [6]. A study with nursing students in Spain highlighted the poor knowledge in several areas, suggesting that nurses need to be trained before they start working with cannabis for medicinal purposes [9].
On knowledge about the differences between THC and CBD, 79,2% of nurses said they did not know the difference, against 63,7% of students.
Pre and post-graduate medical cannabis training
There were 13,8% of nurses who said they had discussed the topic “cannabis” in higher education. The percentage rose to 17,1%of nursing students. Since student respondents were from different course years, this percentage is expected to increase towards the end of the course, as greater importance is currently awarded to the topic in higher education. Only 6,6% of nurses had received cannabis training after higher education. A study with health professionals in Canada, including nurses, found they were not familiar with the subject. The percentage of health professionals who had been taught about “medical cannabis” in higher education was also low (6%), but 60% had received further training [23]. In Cyprus, participants in a study with nurses and midwives proposed enriching curricula on this subject [20].
The need for more training is strongly present in both groups – 90,9% of nurses and 87,3% of students feel they need more training in this area. Furthermore, both cohorts preferred online training.
Although students are more in contact with the subject in higher education, and therefore possibly an opening up of the curricula to this topic, the knowledge of both nursing students and nurses about several aspects of medical cannabis is low, and they feel that they do not have the necessary knowledge to advise their patients about this therapeutic option. It is important to make scientific knowledge available to these health professionals and future health professionals. Other studies on the knowledge and attitudes of health professionals and future health professionals about medicinal cannabis in Europe and other countries around the world arrived at the same conclusions [6, 24]. Some studies point to positive outcomes of training in this area [25]. A study published in 2024 refers to the importance of education for health professionals, with increasingly permissive legislation, and also points out that training can be very effective in preventing misinformation [26].
As suggested in international studies, nurses and future nurses in Portugal as well should receive pre and post-graduate cannabis training, ideally before they start working with it, allowing them to provide the best possible service in this emerging field in Portugal, Europe and the world [9, 27].
The study has some limitations, i.e. it must be completed online, which means that people who do not have access to these technologies are excluded. The surveys were disseminated on social media, so the results may be biased by enhanced interest in the topic.
Conclusion
The findings suggest that these health professionals and future nurses are open to the subject of medical cannabis.
It was clear that daily contact with the subject is low, even though the Law on Cannabis for Medicinal Purposes was passed around five years ago in Portugal.
Statistically significant gender differences were found in personal experience with medicinal cannabis, but only in the nurse cohort. Among nursing students (a younger cohort) there were no differences.
In Portugal, the course curriculum should include this area of study and further nurse training in this emerging area is needed.
Acknowledgements
Not applicable.
Declarations
Competing interests
The authors declare no competing interests.
Ethics approval and consent to participate
The survey and the consent to participate in it were assessed by the Ethics Committee of the Faculty of Medicine of the University of Coimbra, which granted their approval, CE_Proc. CE -185/ 2022. Participants gave electronic consent. Informed consent was obtained from all of the participants.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
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