The main findings in this paper of Swedish healthcare professionals in surgical care shows perceived classifications of CAM therapies, their lack of knowledge in CAM and CAM research, and their low level of communication regarding CAM usage with their patients.
The classification of the assigned therapies emerged into definitions of the four domains (conventional, complementary, alternative, and integrative) as follows;
Conventional therapy included treatment given by healthcare disciplines working in public health (nursing, physiotherapy, occupational and psychotherapy). Complementary therapies included those accepted for use in the public health system (acupuncture, acupressure, massage, chiropractic, etc.). Alternative therapies were those not accepted for use in the public health system (homeopathy, healing forms, reflexology, and herbal medicine). This classification can be compared to Risberg et al.'s  conclusion where they found that the term "Alternative therapy" was perceived as much more negative then the term "Complementary therapy" by healthcare professions in the field of oncology in Norway.
Surprisingly, no therapy was clearly classified as integrative by the participants. This might be due to the wide interpretation of the term , and the recent definition of the term in Swedish literature  as well as the introduction of the MeSH term in 2009.
The results of this study in comparison to a German study show that CAM is less frequently recommended to patients in Sweden than in Germany . However, German and Swedish healthcare systems, cultures and attitudes towards CAM might not be comparable.
Massage and acupuncture/acupressure were the therapies most commonly referred to in this study. Interestingly, Berman et al.  report almost identical results in referral of patients to different CAM therapies by American rheumatologists in the beginning of the 21st century. It is also notable that previous studies have found that rural healthcare providers are more likely to recommend it to their patients in comparison with their urban colleagues . The results of our study, where the professions worked in surgical wards at university hospitals, may therefore be interpreted from this perspective.
The present study displays differences to a previous report among Norwegian oncology professionals . The oncology study classified a greater number of therapies as complementary in contrast to the present study, where classification into alternative was much higher for the comparative therapies. Also the classification of "unknown therapy" was higher in this study compared with the Norwegian, with exception of Ayurveda (68% versus 73%). This may be due to a difference in perceptions of CAM between professions in surgical care and oncology, or/and between Sweden and Norway.
Some therapies were obviously difficult to sort into the complementary or alternative domain (meditation forms, yoga, tai chi, qi gong, sense therapies). This might be explained as therapies being in transition of perceived definition. Some therapies have been tested and used in public health during the last decades and moved from alternative to complementary e.g. acupuncture and manual therapies. Therapies that are in transition from alternative towards complementary become diffuse in classification. Yoga and meditation are good examples of such therapies, which have been tested in public health and used in health centres, and thereby gained more acceptances.
Lack of knowledge among registered Swedish healthcare professions in surgical care as shown in this study, has been reported in a previous qualitative study . Similar findings of lack of knowledge among healthcare workers have also been reported internationally [9, 12, 32, 33]. In contrast, 60% of Italian nurses claim, in a questionnaire study, to have knowledge about CAM .
Bjerså et al. , as well as Hirschkorn and Bourgeault , found that obstacles to retrieve the knowledge were lack of time and a perceived difficulty to access CAM knowledge and research results. The results of the present study showed that registered healthcare workers felt that possessing knowledge regarding CAM was of average importance. This is also supported in other international publications that healthcare workers want to learn more about CAM [6, 13].
In this paper, as well as in the previous study by our research group , knowledge about CAM research was very low or non existent. The previous study also showed that conceptions in the result to be contradictive. Despite the low knowledge level, CAM research was criticised for being of low quality with many biases. It was also perceived that it was vital to create evidential research in the process for judging whether to use therapies or not. This may explain why over 60% of the participants in this study thought that more resources should be addressed to CAM research. The conclusion of a national review of CAM states that more research should be addressed to measure current consumption, effect, risks and adverse effects, and the economical dimensions in CAM usage .
Communication between patients and the caregiver regarding CAM was perceived as rare in this study as well as in previous international publications [6, 9, 11, 13]. Maybe lack of knowledge discourages the caregiver from bringing up the subject and having to face questions they are not capable of answering, which is supported by a previous study among paediatricians . A suggestion on how to approach this problem as a clinician is by using the communication recommendation developed by Schofield et al. .
It is also important to put the results from this study in a national perspective. In the late seventies, Jacobsson  found that 22% of a random sample of Swedish physicians asked their patients frequent or sometimes about their use of CAM. He also found that 56% of the physicians believed that patients rarely told their physician about CAM usage. Now, 30 years later, that rate still remains as shown in Figure 2. In a questionnaire study among Swedish physicians in the early 1990's, Lynöe and Svensson  asked for attitudes toward different therapies in the field of CAM. Complementary therapies in this study were acupuncture, homeopathy, manual therapies, reflexology and natural remedies. Comparisons of the percentage of "unknown therapies" with the present study shows that only acupuncture was less known by the professions in surgical care and the physicians in this study. Why this has not been affected by the increased usage of CAM in the general Swedish population is unclear. Jacobsson  reports that 52% of the physicians did not find it valuable to gain further knowledge in the area. This view has however changed drastically as shown in Figure 1.
There were significant differences between the professions in this study. Physicians were generally more interested in learning about CAM therapies and were most frequently asked about it by patients. Nurses regarded it as less important to have knowledge about CAM in comparison to the other professions. Physiotherapists were, as a group, more educated in CAM therapies and used it in more often their professional practice. They also made most recommendations to patients in comparison to the other professions. Due to the low answering frequency, it is difficult to generalise these results to the population of professionals working in Swedish surgical care. As Hirschkorn and Bourgeault  points out; there is no simple conclusion to draw in differences between healthcare professions in their thoughts about CAM due to the extensive numbers of both personal, professional and organisational affecting variables.
According to Wang et al. [19, 20] and Norred  the majority of surgically treated patients use CAM, including prayer. A more recent study shows a general CAM usage of approximately 27% among surgical patients . How this distribution correlates with Swedish patients is not yet studied. It is however concluded that the use of CAM in the Swedish general population has increased during the last decades. It is thus important to give attention to the patients' usage, knowledge and attitude towards CAM in future research.
This study has several methodological limitations. There is always a risk choosing a questionnaire survey as a method for measuring. One risk is the reliability and validity of the questionnaire. The questions in this study were created from the results of previous studies [15, 16, 25–27]. The purpose has not been to create a new questionnaire, but to use previous knowledge and adjust it to the present aim. Also, the questionnaire was tested and adjusted in the present context twice before distribution, which justifies its usability.
Willson et al.  call attention to two factors to errors in response. Definition of terms used in the survey is the first factor. It is a risk that the researcher's definition of the terms does not correlate with the participants. This could be managed by including definitions in the survey, which has been made in this study. The other factor is the notion of self-concept. This implies to the participants' own view of themselves in relation to the term. For example, a participant view of how they are and what they should be doing does not correspond with the true fact. This error is hard to account for and minimize. Also the fact that some therapies in this study are merged into concepts (e.g. herbal medicine, natural remedies and nutritional supplements) could affect the participants' response and the study result.
Another risk is low response rate. In this study, 42.0% of the questionnaires were answered and returned. Similar, international studies have reported a response rate of between 18% and 61% [7, 10, 11, 15, 30, 36, 41, 42], which make this study comparable. Hence, it is of importance to be aware of differences in health care systems, organisations, or responsibilities and characters in the different professions when comparing the content of this result with other international studies. The rather extensive questionnaire of five pages may also have contributed to a low response rate.
Just another risk is that the participants in this study could be more emotionally reactive to the subject CAM than those who did not participate. It is therefore important to be aware that there may be differences between the participants and the target population. It is not possible, from these results, to draw any general conclusions. Thus, these results confirm findings from our previous qualitative study  and puts in into a national perspective. The result should be regarded as a first insight into Swedish registered healthcare professions approach towards CAM.