Debra Griffiths

The use of complementary and alternative medicine by pregnant women: A literature review

BACKGROUND The use of complementary and alternative medicine (CAM) has become increasingly prevalent in industrialised countries, with women being the most prolific users. Some women continue to consume these therapies when they become pregnant. AIM To review the literature exploring prevalence and motivation for use of complementary and alternative medicine by pregnant women. METHOD A search for relevant literature published from 2001 was undertaken using a range of databases and by examining relevant bibliographies. RESULTS Although the estimates vary widely from 1% to 87%, the general trend indicates that a significant number of pregnant women use complementary and alternative medicine. Common modalities used include massage, vitamin and mineral supplements, herbal medicine, relaxation therapies and aromatherapy. Reasons for use are varied and include the belief that these therapies offer safe alternatives to pharmaceuticals, they allow greater choice and control over the childbearing experiences, and they are congruent with their holistic health beliefs. The influence of traditional cultural practices on the use of these therapies is unclear. Most expectant women rely on advice from family and friends, and many do not disclose their use to their pregnancy care providers. CONCLUSIONS Many women use complementary and alternative medicine when they are pregnant. Further research is needed to gain a greater understanding of the true prevalence and expectant womens motivation for the use of complementary and alternative medicine. Health-care professionals are encouraged to ask women about their use of these treatments and seek out relevant information.

At the crossroads of violence and aggression in the emergency department: perspectives of Australian emergency nurses

OBJECTIVE Violence is widespread in Australian emergency departments (ED) and most prevalent at triage. The aim of the present study was to identify the causes and common acts of violence in the ED perceived by three distinct groups of nurses. METHODS The Delphi technique is a method for consensus-building. In the present study a three-phase Delphi technique was used to identify and compare what nurse unit managers, triage and non-triage nurses believe is the prevalence and nature of violence and aggression in the ED. RESULTS Long waiting times, drugs and alcohol all contributed to ED violence. Triage nurses also indicated that ED staff, including security staff and the triage nurses themselves, can contribute to violence. Improved communication at triage and support from management to follow up episodes of violence were suggested as strategies to reduce violence in the ED CONCLUSION :There is no single solution for the management of ED violence. Needs and strategies vary because people in the waiting room have differing needs to those inside the ED. Participants agreed that the introduction and enforcement of a zero tolerance policy, including support from managers to follow up reports of violence, would reduce violence and improve safety for staff. Education of the public regarding ED processes, and the ED staff in relation to patient needs, may contribute to reducing ED violence. What is known about the topic? Violence is prevalent in Australian healthcare, and particularly in emergency departments (ED). Several organisations and government bodies have made recommendations aimed at reducing the prevalence of violence in healthcare but, to date, these have not been implemented consistently, and violence continues. What does this paper add? This study examined ED violence from the perspective of triage nurses, nurse unit managers and non-triage nurses, and revealed that violence is experienced differently by emergency nurses, depending on their area of work. Triage nurses have identified that they themselves contribute to violence in the ED by their style of communication. Nurse unit managers and non-triage nurses perceive that violence is the result of drugs and alcohol, as well as long waiting times. What are the implications for practitioners? Strategies to reduce violence must address the needs of patients and staff both within the ED and in the waiting room. Such strategies should be multifaceted and include education of ED consumers and staff, as well as support from management to respond to reports of violence.

Complementary and alternative medicine for induction of labour

BACKGROUND Induction of labour is a common obstetric procedure. Some women are likely to turn to complementary and alternative medicine in order to avoid medical intervention. AIM The aim of this paper is to examine the scientific evidence for the use of complementary and alternative medicine to stimulate labour. METHOD An initial search for relevant literature published from 2000 was undertaken using a range of databases. Articles were also identified by examining bibliographies. RESULTS Most complementary and alternative medicines used for induction of labour are recommended on the basis of traditional knowledge, rather than scientific research. Currently, the clinical evidence is sparse and it is not possible to make firm conclusions regarding the effectiveness of these therapies. There is however some data to support the use of breast stimulation for induction of labour. Acupuncture and raspberry leaf may also be beneficial. Castor oil and evening primrose oil might not be effective and possibly increase the incidence of complications. There is no evidence from clinical trails to support homeopathy however, some women have found these remedies helpful. Blue cohosh may be harmful during pregnancy and should not be recommended for induction. Other complementary and alternative medicine (CAM) therapies may be useful but further investigation is needed. CONCLUSIONS More research is needed to establish the safety and efficacy of CAM modalities. Midwives should develop a good understanding of these therapies, including both the benefits and risks, so they can assist women to make appropriate decisions.

What is the meaning of palliative care in the Asia-Pacific region?

This paper describes the preliminary work required to understand cultural differences in palliative care in the United Kingdom and three countries in the Asia‐Pacific region, in preparation for a cross‐country study. The study is intended to address cultural understandings of palliative care, the role of the family in end of life care, what constitutes good care and the ethical issues in each country. Suggestions are then made to shape the scope of the study and to be considered as outcomes to improve care of the dying in these countries. It is anticipated that the method used to achieve consensus on cross‐country palliative care issues will be both qualitative and quantitative. Identifying key priorities in the delivery and quality measures of palliative care will involve participants in focus groups, a Delphi survey and in the development of clinical indicators towards creating standards of palliative care common to the Asian Pacific region.

Resident transfers from aged care facilities to emergency departments: Can they be avoided?

Residents from aged care facilities make up a considerable proportion of ED presentations. There is evidence that many residents transferred from aged care facilities to EDs could be managed by primary care services. The present study aimed to describe the characteristics of residents transferred from residential aged care facilities to EDs, and to evaluate the appropriateness and cost of these presentations.

From alternative, to complementary to integrative medicine: Supporting Australian midwives in an increasingly pluralistic maternity environment

BACKGROUND The use of complementary and alternative medicine during pregnancy has become increasingly popular over the past decade in Australia. AIM The purpose of this discussion paper to make recommendations and foster a constructive debate regarding the appropriate response by the midwifery profession. DISCUSSION Midwives should receive basic education regarding the use of complementary and alternative medicine. All women should be routinely question women about their use and this should be documented. While a few therapies could be safely integrated, in most situations interested women should be referred to a qualified practitioner. Referral frameworks and flexible clinical guidelines should be investigated. CONCLUSION With the appropriate education and support, midwives are in an excellent position to engage women in open dialogue and raise awareness of the benefits and risks of CAM practices. The way forwards for midwifery profession is to focus on self-governance, education and flexible clinical guidelines.

Editorial: When is it our time to die?

We write this editorial during Palliative Care Week and at a juncture in health care when a ‘perfect storm’ brews involving escalating healthcare costs, worldwide economic ‘austerity measures’, calls for discussion and action on ‘rationing’ health care and profound ethical disquiet among health professionals about ‘futile’ and almost inhumane treatments and interventions visited on seriously ill older people. As one doctor commented: ‘It feels like we are just playing with these peoples’ lives, giving them these ridiculously complex, painful and expensive medical procedures just because we can, not because they have value’ (Boughton 2012). The sensitivities around these issues are significant. Somehow, even gently alluding to the possibility that there may be a time to say ‘No’ to life-saving treatment for some older, chronically sick people raises spectres of ageism, compulsory euthanasia, callous indifference, eugenics or worse. But talk about this we must, difficult as it may be, for these issues are confronting both clinicians and families daily. To allay such concerns at the outset, we do not advocate compulsory euthanasia or any arbitrary ‘cut-off’ age beyond which older people will be ‘denied treatment’ by death panels or ‘left to die’ in the absence of loved ones and comfort (Goodman 2012). What we do question is a seemingly unstoppable ‘technological imperative’ towards increasingly aggressive investigations and treatments of the oldest and sickest of the population. When we have elderly people with multiple comorbidites in intensive care units, or living with minimal cognitive functioning in nursing homes while receiving dialysis and nutrition via a feeding tube, only to be rushed by ambulance to the nearest emergency department for treatment or routinely being given cardiopulmonary resuscitation (CPR) as a ‘default position’ (Blinderman et al. 2012), we must ask, ‘How did it come to this?’ Defensive medicine and the heightened fear of litigation are widely recognised, to the point where ‘do everything possible’ is seen as the safest option or ‘path of least resistance’ (O’Connor et al. 2011). This mindset is, however, notoriously difficult to roll back on an individual case basis and is a genuine minefield for clinicians who wonder if they could ever keep abreast of the burgeoning plethora of legislation, guidelines, policies, compliance requirements and recommendations that seek to govern their every decision. When even the best medico-legal experts find it hard to agree on confronting cases, the average nurse or doctor must wonder whether they can confidently make the best decision (Lawrence et al. 2012). Paternalism in health care is now so ideologically unfashionable that any semblance of a doctor or nurse actually making a decision or suggesting a ‘best course of action’ smacks of ‘dominance’. We have no wish to return to an era of non-negotiable medical omnipotence and authoritarianism, but we recognise that there may be times in people’s lives when they want and appreciate that a health professional and indeed yes, even an ‘expert’, is prepared to ‘tell it straight’ and to honestly advise what may be the best thing to do, difficult though this may be. Some, such as Williams-Murphy (2012), argue more pointedly that even involving (or should that be implicating?) families and relatives in end of life decisions by telling them that this decision is theirs, is an abdication of professional responsibility, possibly ‘cruel’ and no more than ‘burden(ing) families with CPR decisions in the face of futility’. Advances in health care, technology and therapeutics have been a doubleedged sword and the law of unintended consequences (where a policy or law aimed at a positive benefit in one area inadvertently produces a negative effect in another area) applies with a vengeance. Thanks to better health and general living standards in developed countries, people and especially the baby boomers, are living much longer, albeit with the same chronic, debilitating, expensive illnesses that billions of dollars in research and health funding have not eliminated (Callahan 2011). Worse, people may simultaneously believe that advances in medicine’s ability to save their lives and fix their every ailment will happen just as it does on television (Diem et al. 1996, Godlee 2006). The proliferation of prescribed medicines for chronic illnesses in developed countries attests to this (Busfield 2010). Herein perhaps lies the existential crisis at the heart of the financial one: Have we moved from a view of dying and death as sad but integral elements of life’s natural closure, to a view of death as a cultural and professional embarrassment or failure that is to be postponed and fought against, almost regardless of circumstances? The questions we pose ‘When is the right time to die?’ and ‘What is it OK to die from?’ will always be difficult for health professionals, and even more so for individuals and their families to answer, but we cannot refrain from asking them. Given a contemporary reluctance to acknowledge that ‘old age’ may become a cause of death and that ‘dying’ may make sense as a diagnosis, Heath (2010) is refreshingly direct in her discussion of

How do nurse academics value and engage with evidence-based practice across Australia: Findings from a grounded theory study.

BACKGROUND Integrating evidence-based practice (EBP) into undergraduate education and preparing future nurses to embrace EBP in clinical practice becomes paramount in todays complex and evolving healthcare environment. The role that EBP plays in the practical lives of nursing students will depend on the degree to which it is promoted by academics, how it is incorporated into courses and its application to clinical setting. Hence, nursing academics play a crucial role in influencing its integration into curricula. Drawn from a larger doctoral study, this paper presents findings discussing how nurse academics value and engage with EBP. METHODS Grounded theory was employed to explore processes used by nursing academics while incorporating EBP into teaching and learning practices. Twenty-three academics across Australian universities were interviewed. Nine were also observed while teaching undergraduate students. Data were collected from semi-structured interviews and non-participant observation. In keeping with the tenets of grounded theory, data collection and analysis continued until theoretical saturation was reached. In total, four categories emerged. This paper focuses on the category conceptualised as Valuing and Engaging with EBP. RESULTS How nursing academics valued and engaged with EBP was closely associated with meanings they constructed around understanding it, attitudes and commitment to implementation while teaching and working clinically. Different opinions also existed in regard to what actually constituted EBP. However, they engaged with and valued EBP by keeping themselves up-to-date, being involved in research activities, using evidence in teaching, therefore leading by example. Participants identified a number of barriers influencing their engagement with EBP including heavy workloads, limited time, lack of commitment within their schools, lack of confidence with teaching EBP, and complexity of EBP application. Faculty clinical practice, committed academics, workload management and continuing education were highlighted as facilitators. CONCLUSION A number of barriers prevented academics from fully engaging with EBP at academic or practice levels. Academic institutions and practice settings need to employ strategic planning to overcome such barriers.

Complementary and alternative medicine: Interaction and communication between midwives and women

BACKGROUND Many pregnant women use complementary and alternative medicine. Although midwives are often supportive, how they communicate with women about the safe use of these therapies has received limited research attention. AIM The aim of this study was to explore how midwives interact with women regarding use of complementary and alternative medicine during pregnancy. METHODS We utilised grounded theory methodology to collect and analyse data. Twenty-five midwives who worked in metropolitan hospitals situated in Melbourne, Australia, participated in the study. Data were collected from semi structured interviews and non-participant observations, over an 18-month period. FINDINGS How midwives communicate about complementary and alternative medicine is closely associated with the meaning they construct around the womans role in decisionmaking. Most aim to work in a manner consistent with the midwifery partnership model and share the responsibility for decisions regarding complementary and alternative medicine. However, although various therapies were commonly discussed, usually the pregnant woman initiated the dialogue. A number of contextual conditions such as the biomedical discourse, lack of knowledge, language barriers and workplace constraints, limited communication in some situations. CONCLUSION Midwives often interact with women interested in using CAM. Most value the womans autonomy and aim to work in partnership. However, various contextual conditions restrain overt CAM communication in clinical practice.

Aged care residents in the emergency department: the experiences of relatives

AIMS AND OBJECTIVES The aim of this study was to investigate the experiences of relatives who had a family member in an aged care facility subsequently transferred to an emergency department. BACKGROUND The provision of timely and relevant patient information is vital for assessment and management of older patients presenting to the emergency department from aged care facilities. Older people are commonly accompanied by relatives who are an important resource for emergency department staff, providing medical information and assisting with treatment decisions. Investigating the experiences of relatives may provide key information to enable improvements in the delivery of emergency department care. DESIGN This study used a descriptive qualitative design. METHODS Semi-structured interviews were undertaken with 24 relatives of residents who were transferred from an aged care facility to an emergency department in Victoria, Australia in the previous three years. Inductive content analysis was used to analyse the transcripts. RESULTS Relatives reflected on four main themes following their emergency department visit: The need for clear communication; The role of relatives in emergency department care; How older people are perceived in the health care system and an Ability to provide specialised care. CONCLUSIONS Many people link their emergency department experience to the quality of communication with emergency department staff, and participants in this study felt satisfied with their visit when they were included in discussions about treatment, and their role was recognised by staff members. In contrast, participants were dissatisfied with the care provided to their family member when staff members failed to communicate with them, or recognise their role in the care of the family member. RELEVANCE TO CLINICAL PRACTICE The findings of this study emphasise the importance of effective communication between emergency department staff and family members, in relation to treatment and end-of-life care.