Emma Kirby

Use of complementary and alternative medicine by mid-age women with back pain: a national cross-sectional survey

BackgroundThe use of complementary and alternative medicine (CAM) has increased significantly in Australia over the past decade. Back pain represents a common context for CAM use, with increasing utilisation of a wide range of therapies provided within and outside conventional medical facilities. We examine the relationship between back pain and use of CAM and conventional medicine in a national cohort of mid-aged Australian women.MethodsData is taken from a cross-sectional survey (n = 10492) of the mid-aged cohort of the Australian Longitudinal Study on Women’s Health, surveyed in 2007. The main outcome measures were: incidence of back pain the previous 12 months, and frequency of use of conventional or CAM treatments in the previous 12 months.ResultsBack pain was experienced by 77% (n = 8063) of the cohort in the previous twelve month period. The majority of women with back pain only consulted with a conventional care provider (51.3%), 44.2% of women with back pain consulted with both a conventional care provider and a CAM practitioner. Women with more frequent back pain were more likely to consult a CAM practitioner, as well as seek conventional care. The most commonly utilised CAM practitioners were massage therapy (26.5% of those with back pain) and chiropractic (16.1% of those with back pain). Only 1.7% of women with back pain consulted with a CAM practitioner exclusively.ConclusionsMid-aged women with back pain utilise a range of conventional and CAM treatments. Consultation with CAM practitioners or self-prescribed CAM was predominantly in addition to, rather than a replacement for, conventional care. It is important that health professionals are aware of potential multiple practitioner usage in the context of back pain and are prepared to discuss such behaviours and practices with their patients.

The Troubles of Telling Managing Communication About the End of Life

Communication about palliative care represents one of the most difficult interpersonal aspects of medicine. Delivering the “terminal” diagnosis has traditionally been the focus of research, yet transitions to specialist palliative care are equally critical clinical moments. Here we focus on 20 medical specialists’ strategies for engaging patients around referral to specialist palliative care. Our aim was to develop an understanding of the logics that underpin their communication strategies when negotiating this transition. We draw on qualitative interviews to explore their accounts of deciding whether and when to engage in referral discussions; the role of uncertainty and the need for hope in shaping communication; and their perceptions of how patient biographies might shape their approaches to, and communication about, the end of life. On the basis of our analysis, we argue that communication is embedded in social relations of hope, justice, and uncertainty, as well as being shaped by patient biographies.

Back pain amongst mid-age Australian women: A longitudinal analysis of provider use and self-prescribed treatments

OBJECTIVES To analyse use of conventional and complementary and alternative (CAM) practitioners and self-prescribed CAM amongst mid-age Australian women with back pain. DESIGN Self-completion postal surveys completed in 2004 and 2007, of the mid-age cohort of the Australian Longitudinal Study on Womens health. Questions asked for written responses about the use of conventional practitioners, CAM practitioners and self-prescribed CAM for treatment of back pain. SETTING Analysis of cross-sectional and longitudinal survey data (n=9820), conducted as part of the Australian Longitudinal Study on Womens Health (ALSWH), which was designed to investigate multiple factors affecting the health and well being of women over a 20-year period. MAIN OUTCOME MEASURE Women were asked if they had sought help for back pain in the previous twelve months. RESULTS The prevalence of back pain was 54.8% (n=5383). The percentage of women who sought help for their back pain was 17.3% (n=1700). Of the women who sought help for back pain, 2% consulted with a CAM practitioner only, 35% consulted a conventional practitioner only and 63% with both a conventional and CAM practitioner. CONCLUSIONS Back pain is prevalent amongst mid-age Australian women, although only one third sought help. Women who sought help for their back pack were high users of CAM (practitioners and self-prescribed) and conventional care providers, consulting a CAM practitioner in complement with conventional biomedical consultations rather than as an alternative. Further research is needed to explore the complex contemporary landscapes of back pain negotiation and management.

Specialists' experiences and perspectives on the timing of referral to palliative care: a qualitative study

BACKGROUND Specialist referral practices regarding palliative care are variable and their decision-making practices regarding timing and communication remains an under-researched issue. More effective referral practices have been shown to enhance patient and carer experiences at the end of life, reduce the burden on pre-palliative care services, and even extend life expectancy in some cases. OBJECTIVE The aim of this study was to examine the logics underpinning the timing of referral to palliative care according to a range of medical specialists in a regional center on the east coast of Australia, in order to facilitate improvements in referral practices. METHODS We conducted semi-structured, qualitative interviews with 20 medical specialists and carried out a thematic analysis of the interview data, utilising the framework analysis approach and NVivo 9 software. Key themes were tested for rigour through inter-rater reliability. RESULTS The major themes identified within this analysis of the interviews were: a) strategies for preparing for palliative care and the importance of planning timely referrals; b) perception of inter-professional variation and reasons for delayed or difficult referrals; and c) the importance of inter-specialty communication and cross-disciplinary dialogue. CONCLUSIONS Significant barriers exist to the timely referral to palliative care, and, in order to improve patient and care quality of life and lessen clinical difficulties, further work is needed to develop streamlined practices that are sensitive to specialty needs and patient desires.

Families and the transition to specialist palliative care

Abstract Families play important roles in transitions to end-of-life care, yet we know little about the social relations between doctors and families at the point of referral to specialist palliative care. In this study, we explore how medical specialists negotiated the transition to specialist palliative care with families. Drawing on data from 20 qualitative interviews, we examine data accounts about the roles of family members in discussions with clinical specialists about palliative care, and how families shape interpersonal dynamics. Our results indicate that families fulfil important ‘functions’ and ‘roles’ in these delicate and emotionally laden conversations. Specialists’ accounts articulated referral processes as distinctly relational moments, with families viewed as potential ‘resources’ but also as ‘complications’, in attempts to encourage the ‘smooth’ transition to end-of-life care. On the basis of these results, we argue that further attention should be paid to the centrality of families in key moments in care (and communication therein) and how they may be utilised, managed and experienced by a range of health professionals.

Negotiating Futility, Managing Emotions Nursing the Transition to Palliative Care

Nurses play a pivotal role in caring for patients during the transition from life-prolonging care to palliative care. This is an area of nursing prone to emotional difficulty, interpersonal complexity, and interprofessional conflict. It is situated within complex social dynamics, including those related to establishing and accepting futility and reconciling the desire to maintain hope. Here, drawing on interviews with 20 Australian nurses, we unpack their accounts of nursing the transition to palliative care, focusing on the purpose of nursing at the point of transition; accounts of communication and strategies for representing palliative care; emotional engagement and burden; and key interprofessional challenges. We argue that in caring for patients approaching the end of life, nurses occupy precarious interpersonal and interprofessional spaces that involve a negotiated order around sentimental work, providing them with both capital (privileged access) and burden (emotional suffering) within their day-to-day work.

What role do pharmacists play in mediating antibiotic use in hospitals? A qualitative study.

Objective To understand Australian hospital pharmacists’ accounts of antibiotic use, and the potential role of pharmacy in antibiotic optimisation within a tertiary hospital setting. Design, setting and participants Qualitative study, utilising semistructured interviews with 19 pharmacists in two hospitals in Queensland, Australia in 2014. Data was analysed using the framework approach and supported by NVivo10 qualitative data analysis software. Results The results demonstrate that (1) pharmacists’ attitudes are ambivalent towards the significance of antibiotic resistance with optimising antibiotic use perceived as low priority; (2) pharmacists’ current capacity to influence antibiotic decision-making is limited by the prescribing power of doctors and the perception of antibiotic use as a medical responsibility; and, (3) interprofessional and organisational barriers exist that prevent change in the hospital setting including medical hierarchies, limited contact with senior doctors and resource constraints resulting in insufficient pharmacy staffing to foster collaborative relationships and facilitate the uptake of their advice. Discussion While pharmacy is playing an increasingly important role in enhanced antibiotic governance and is a vital component of antimicrobial stewardship in Australia, role-based limitations, interprofessional dynamics and organisational/resource constraints in hospitals, if not urgently addressed, will continue to significantly limit the ability of pharmacy to influence antibiotic prescribing.

Nurses as Antibiotic Brokers: Institutionalized Praxis in the Hospital

We are likely moving rapidly toward a post-antibiotic era, as a result of escalating antimicrobial resistance, rapidly declining antibiotic production and profligate overuse. Hitherto research has almost exclusively focused on doctors’ prescribing, with nurses’ roles in antibiotic use remaining virtually invisible. Drawing on interviews with 30 nurses, we focus on nurses as brokers of doctors’ antibiotic decisions, nursing capacity to challenge doctors’ decisions, and, “back stage” strategies for circumnavigating organizational constraints. We argue that nurses occupy an essential and conscious position as brokers within the hospital; a subject position that is not neutral, facilitates (short-term) cohesion, and involves the pursuit of particular (preferred) nursing outcomes. Illustrating how authority can be diffuse, mediated by institutionalized praxis, and how professionals evade attempts to govern their practice, we challenge the reification of physician prescribing power, arguing that it may work against the utilization of nurses as important stakeholders in the future of antibiotics.

The role and significance of nurses in managing transitions to palliative care: a qualitative study

Objectives Nurses are generally present, and often influential, in supporting patient and family acceptance of medical futility and in assisting doctors in negotiating referral to palliative care. Yet the specificities of the nursing role and how nurses may contribute to timely and effective referrals is not well understood. This study aimed to systematically explore hospital-based nurses’ accounts of the transition to palliative care, and the potential role of nurses in facilitating more effective palliative care transitions. Design Qualitative study using semistructured interviews. Setting Two health services with public as well as private clinical environments in a major metropolitan area of Australia. Participants Hospital-based nurses (n=20) who regularly work with patients at the point of referral and in managing transitions to palliative care. Results Four significant themes emerged from thematic analysis. These include: (1) professional dynamics and the roles played by nurses in initiating the transition to palliative care; (2) the value of nurses’ informal interactions in timely and effective transitions; (3) the emerging challenge of managing task-oriented nursing versus intense emotional nursing work at the point of medical futility and (4) the emotional burden experienced by nurses within this clinical context. Nurses self-reported occupying critical albeit complex roles in the management of medical futility and the transition to palliative care. They reported experiencing significant emotional burden in balancing interpersonal and interprofessional relationships during this time. Conclusions The results suggest that nurses may be utilised in a more formalised and systematic fashion in the context of managing medical futility and the need to topicalise the transition, with the focus shifted away from medical referrals towards more team-based and patient-centred timely transitions. Further research focused on the experiences of doctors, allied health professionals, patients and families is required to provide a broader interdisciplinary understanding of futility and contributions to the negotiation of palliative care.

Health care utilisation and out-of-pocket expenditure associated with back pain: a nationally representative survey of Australian women

Background Back pain impacts on a significant proportion of the Australian population over the life course and has high prevalence rates among women, particularly in older age. Back pain care is characterised by multiple practitioner and self-prescribed treatment options, and the out-of-pocket costs associated with consultations and self-prescribed treatments have not been examined to date. Objective To analyse the extent of health care practitioner consultations and self-prescribed treatment for back pain care among Australian women, and to assess the self-reported costs associated with such usage. Methods Survey of 1,310 women (response rate 80.9%) who reported seeking help for back pain from the ‘1946-51 cohort’ of the Australian Longitudinal Study on Women’s Health. Women were asked about their use of health care practitioners and self-prescribed treatments for back pain and the costs associated with such usage. Results In the past year 76.4% consulted a complementary and alternative practitioner, 56% an allied health practitioner and 59.2% a GP/medical specialist. Overall, women consulted with, on average, 3.0 (SD = 2.0) different health care practitioners, and had, on average, 12.2 (SD = 9.7) discrete health care practitioner consultations for back pain. Average self-reported out-of-pocket expenditure on practitioners and self-prescribed treatments for back pain care per annum was AU