Why do pregnant women use complementary medicine, and is it safe? We also look at how researchers are helping clinicians identify pain in people with dementia, and celebrate the International Day of the Nurse.

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Presenter: Ellen Leabeater
Producer: Ninah Kopel

Dr Jane Frawley – Researcher from the UTS Faculty of Health
Thomas Fischer – Professor of Aged Care Nursing from Dresden, German
Carla Saunders – Lecturer in the UTS Centre for Health Services Management

TRANSCRIPT

Ellen Leabeater: Hi, welcome to the program. I’m Ellen Leabeater. Today, how researchers are helping clinicians to identify pain in patients with dementia.

Thomas Fischer: We all have specific facial expressions that we have when we’re in pain that are the same for everybody and it’s the same for people with dementia too, however they are not easy to detect when you see somebody in a hospital bed or in a nursing home.

Ellen Leabeater: And, a look at why nurses are so resilient in light of the International Day of the Nurse.

(Music plays)

Ellen Leabeater: Almost 60% of women use complementary medicine during pregnancy. Complementary medicine includes things like yoga, herbal medicines, chiropractics and osteopathy. The jury is still out as to whether complementary medicine is effective full stop, so women using it during pregnancy may be putting their unborn child in danger. Dr Jane Frawley is a researcher from the UTS Faculty of Health. She has been researching why women use complementary medicine during pregnancy.

Jane Frawley: Complementary medicine is really anything that’s outside of formal health care practices in Australia, so it’s things that aren’t generally taught in medical degrees and aren’t practiced by conventional health practitioners like GPs. There are lots of different types of complementary medicines that people use, lots of different types of complementary medical practitioners that people see, and, really, it’s growing in popularity.

Ellen Leabeater: What sorts of examples of complementary medicines are out there?

Jane Frawley: There’s practice-based examples like naturopathy, herbal medicine, nutrition, osteopathy, chiropractors, massage therapists and then there are also products that may either be prescribed in a consultation or may be freely bought in a chemist, health food shop or supermarket, so again, things like herbal medicines, vitamins, minerals… There really is a wide array of things.

Ellen Leabeater: So your research has been looking at how pregnant women use complementary medicines. How many women are using them during pregnancy?

Jane Frawley: Well, interestingly, we had a fairly broad definition of complementary medicine, so we found that 92% were using, so very very high, and in fact, not many weren’t. But I might just add to that, that we had vitamins and minerals in that definition, which means folate, so that –

Ellen Leabeater: And every woman should be taking that in pregnancy –

Jane Frawley: Yes, so we then removed vitamins and minerals from our analysis. We found that 58% of women were using complementary medicines in pregnancies – other than vitamins and minerals – and 48% of women were seeing a complementary medicine practitioner during pregnancy.

Ellen Leabeater: So that’s almost half.

Jane Frawley: Yeah, it is half. It’s very high.

Ellen Leabeater: Do we know about… What sort of things are these women seeking help for during pregnancy?

Jane Frawley: Well, I think that there’s a very wide array of things. So things like aches and pains, so back ache, hip ache, leg pain for example; sleeping; anxiety and depression certainly came up a lot; symptoms of pregnancy, so nausea and vomiting for example… really a wide array.

Ellen Leabeater: So chiropractors, osteopaths – is it evidence-based when it comes to pregnancy? Do we have any evidence backing it up?

Jane Frawley: No. So one of the biggest problems is there is very little evidence for complementary medicine at all across all age groups, but there’s very very little when it comes to pregnancy and I guess that’s the concern and that’s why we felt it was important to do a study like this, to just see how prevalent the use is during pregnancy.

Ellen Leabeater: That’s a bit concerning isn’t it, if you’re thinking about the effects this might have on the unborn child?

Jane Frawley: Yes, so it is concerning…So many complementary medicines are in fact thought to be safe. Many are safe, but many aren’t safe though. So when it comes to pregnancy of course, women are often reluctant to seek medical help for a condition that they feel is a consequence of pregnancy or that perhaps isn’t too severe, but can in fact still be quite difficult to manage. So if they don’t want to take a pharmaceutical medication or an over-the-counter pharmaceutical, they may look for a complementary medicine alternative believing that it’s a safer option. It’s not necessarily a safer option though.

Ellen Leabeater: Where are women getting the idea to seek complementary medicine practitioners or other supplements?

Jane Frawley: We wrote a paper about a year ago or 18 months ago looking at information sources for exactly this topic – so we wanted to know this too. So, we can see that almost half of all women are accessing a complementary medicine practitioner but we had no idea how or why or who was recommending them. And what we found, perhaps astonishingly, is that it’s friends and family. It’s almost always a personal recommendation from somebody that the woman trusts.

Ellen Leabeater: That’s quite a common thing in pregnancy anyway – that your decisions will be guided by friends, family, your mother in particular…

Jane Frawley: Yes. And that’s exactly what we found in terms of health care seeking as well. So, women weren’t asking their GPs, they weren’t asking their obstetricians, the midwives or nurses – very clearly they were asking friends and family. I think it’s quite a powerful antidote or a powerful recommendation if a friend or a family member has had a similar problem in their pregnancy and they sought help, say from a chiropractor for a sore back for example, and it helped them – that’s quite a powerful antidote for somebody who is struggling with their own back pain during pregnancy.

Ellen Leabeater: If there is no evidence for this, why do women continue to use complementary medicines?

Jane Frawley: Women that use complementary medicine overwhelmingly are looking for a “safe” and “natural” alternative to conventional medication in pregnancy, and there’s very much the perception that complementary medicines are safe and natural and a better option. It’s not necessarily the case; however that’s often the motivation of women, who are using it. It’s the idea that it’s “safer”. I guess more holistic – the idea that you’re not just treating a symptom – you’re treating the whole body. Those kind of tenants that are important to complementary medicine resonate often with women in pregnancy.

Ellen Leabeater: So, far from it being, you know, “these women are irresponsible” or “just trying something else” – they actually see it as being better than conventional medicine because it’s going to be better for the baby.

Jane Frawley: That’s exactly right – and they’re not irresponsible in that they absolutely believe that they’re doing the right thing for their health and the health of the baby. The problem comes really when either that use isn’t communicated, where it isn’t informed by rigorous information, when they’re taking something that in fact isn’t safe and importantly when they’re not seeking conventional care when they need conventional care.

Ellen Leabeater: Do these women, when they’re not pregnant – do we know if they’re also more likely to use complementary medicine, or is it specifically just when they’re pregnant?

Jane Frawley: Women are high users of complementary medicine, yes. So, we found in our research that women who use complementary medicine prior to pregnancy were more likely to use it during pregnancy as opposed to women who hadn’t used complementary medicine prior to pregnancy, so yes, they are women who use complementary medicine generally and they’ve continued that use during pregnancy. Sometimes they use it a lot more in pregnancy because they’re concerned about the health of the baby.

Ellen Leabeater: Is this something that nurses and midwives need to be aware of? That they should be asking women, “Are you using complementary medicines” when they are visiting them?

Jane Frawley: Yes, absolutely. I suppose the biggest problem that we found and one of the biggest take-home points from this research is that often the use of complementary medicine during pregnancy, the use of complementary medicine practitioners during pregnancy, isn’t declared or discussed or communicated to conventional healthcare practitioners. So, there’s a range of reasons, but one of the biggest reasons that continues to come out in all of the literature around disclosure, is that they weren’t asked. So, I think frequently women aren’t asked if they’re using any complementary medicines during pregnancy and the research also tells us there’s a variety of reasons why, but I think the main point is that it’s very important for maternity healthcare professionals to have that conversation with their patients.

Ellen Leabeater: What about the providers that are giving this care to women? You said it can be a safe option, but it may not necessarily be the safest option and that there’s not always evidence backing it. Do you think it’s in some way up to the care providers to say, “I shouldn’t be giving care to pregnant women”?

Jane Frawley: So when we talk about safety, there’s a couple of important things to think about. So there’s the obvious one I suppose which is the safety of the actual medicine that the woman is having – the safety to her, or risk to her and her unborn bub. But the second, and just as important thing in many cases is that that woman may not be getting adequate treatment for a condition that needs to be adequately addressed during pregnancy. So, a great example of that is urinary tract infection. So, women in pregnancy commonly have urinary tract infections more frequently and they may be reluctant to have an antibiotic or seek conventional care because they’re pregnant. And they may use a complementary medicine, and generally speaking that may be a probiotic or a cranberry juice which is pretty innocuous, but the problem there in terms of risk is that that urinary tract infection may not be adequately treated and it may in fact become a kidney infection or something far more severe that could actually effect the baby.

Ellen Leabeater: So, we should really be thinking about these complementary health practitioners in parallel with the GP.

Jane Frawley: Yes, and I suppose one of the really important messages for complementary medicine practitioners who have pregnant women in their care is that they have this open discussion with them as well, and that they’re very clear about seeking help if what they’ve prescribed doesn’t work in the time frames that they should work, and that they should seek alternative help if need be.

Ellen Leabeater: Dr Jane Frawley, researcher from the UTS Faculty of Health.

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Ellen Leabeater: When you are in pain, what do you do? Maybe you go and have a lie down, take a painkiller or see your doctor if it’s really bad. But what about people with dementia? How do you tell if they are in pain? Thomas Fischer is a Professor of Aged Care Nursing from Dresden in Germany. He’s been studying how to identify pain in people with dementia and started off by explaining the source of pain experienced by people with dementia.

Thomas Fischer: Oh, really all sorts. So, dementia in itself is not painful. It doesn’t hurt you to have dementia, but obviously people with dementia are older persons, and when you get older, more people develop pain in their joints with movement – this kind of pain; plus neurological diseases sometimes cause pain…

Ellen Leabeater: So what kind of neurological diseases?

Thomas Fischer: Yeah, like diabetes for example, or a stroke may leave pain behind.

Ellen Leabeater: But, I guess dementia makes it difficult to determine the extent of pain because people can’t communicate.

Thomas Fischer: Yeah, that’s it. When you get very severe dementia, you might lose the ability to talk or to understand what somebody is saying really, and pain is a fascinating thing because you can’t measure it. It’s not like you can do a lab test for pain or you can do a scan or something – it’s just not possible. Pain is totally subjective – you know the pain you feel and nobody else can. So I need to get my patient to be able to communicate.

Ellen Leabeater: With dementia people can also get quite agitated. Is that because of the pain or because of the dementia?

Thomas Fischer: That’s the tricky thing to work out really. So there is a link obviously, because when you’re in pain, you’re not comfortable and that would make you agitated maybe, but really part of research is to find out how you can differentiate in everyday life.

Ellen Leabeater: How do you differentiate?

Thomas Fischer: Oh, well, I don’t have all the answers to that yet. We try to find typical behaviours, so for example, we all have specific facial expressions when we’re in pain. That’s the same for everybody and the same for people with dementia too, however that’s not easy to detect when you see somebody in a hospital bed or in a nursing home. So, that’s one part. Obviously sounds, vocalisations, things you say, maybe not words – but these things are typical for pain. So we try to get together a list that helps nurses and doctors to say, OK, this is typical for pain and this is maybe more typical for dementia or for delirium. But then again, I think just asking how do we see pain is not enough. We really need to see more than just the pain – we need to understand what this person is about: what is it for this person to be in his or her shoes? What is it like? Is he having a good relationship with the clinical practitioner for example? So, can you sort of understand the person; can you see what other problems the person might have.

Ellen Leabeater: So pain is easier to determine when you have a relationship with that individual?

Thomas Fischer: Oh, absolutely, I would say so, yeah. It’s much harder if you don’t know the person, and the more you know about that person, the more you know, for example, how someone during his or her life has treated pain themselves and what their typical reactions were. The more you know, the easier it gets for you to stand by this person when he or she deteriorates, really.

Ellen Leabeater: So a nurse in a nursing home that sees to these patients everyday would have a better understanding than, say, a nurse in an emergency department.

Thomas Fischer: It would be much harder for nurses or doctors in emergency departments, yes. They need much more help, and it would be good, for example, if patients could come with their relatives to their emergency hospital treatment to help the doctors and nurses there and to support the person with dementia, because they get quite frightened when they come into environments like the emergency rooms.

Ellen Leabeater: So, your research has been looking at the facial expressions and the things that people with dementia are saying when they’re in pain.

Thomas Fischer: Yeah, and how they behave as well, like body postures and other things. So obviously, if your stomach hurts you will sort of curl together, or you will make sure nobody touches you on your stomach. So we try to get together a sheet of paper, an instrument, that nurses and doctors can check to see if they think there is pain or not.

Ellen Leabeater: How effective have these tools been?

Thomas Fischer: Ah, not good enough. There’s quite a number of them around, from Australia, from other places and from around the world, and we’re not satisfied with them. They’re just beginning to help nurses and doctors, so we want to take this a bit further, and get it more into a process, really an algorithm to help pain detection.

Ellen Leabeater: Is it possible to get it into an algorithm?

Thomas Fischer: Yeah, we think so. There is one around which I think is quite good. So, you would start with looking at the diseases and illnesses a person has, then you’d look at possible other causes for discomfort, so make sure a person with dementia who cannot tell you “I’m cold” or “I need to go to the toilet” will be cared for, and if you’re unsure and you’ve gone through the process, give them an analgesic just as a trial and look what happens. Does it get better?

Ellen Leabeater: Sorry, what’s an analgesic?

Thomas Fischer: An analgesic is a painkiller basically.

Ellen Leabeater: And is that how you typically treat pain with people with dementia?

Thomas Fischer: Yeah, just like everybody else. It’s the same medication they would get as everybody else.

Ellen Leabeater: People with dementia – some have more severe forms than others. Of those with less severe forms, can you talk to them a bit about their pain?

Thomas Fischer: Absolutely. Dementia is a progressive disease, so you start very slowly, and it’s very important to take seriously what a person with dementia says, even if you think, “Oh, he or she is a bit funny maybe.” Doesn’t matter – he or she is a person that you have to respect, so we need to teach clinicians to be patient, to listen carefully and to take small cues. And we need to find ways of helping people with dementia. Somebody with a lesser form of dementia for example – it is much easier for them if you have a sheet of paper where different descriptions of pain are on them like “I have no pain” or “It hurts a little”. A big sheet of paper in front of them and they will point to what they feel is most appropriate.

Ellen Leabeater: So basically a scale.

Thomas Fischer: It’s a scale. It’s basically a pain scale, just one that is more accessible than the usual scales we use. So really, making healthcare accessible for people with dementia is what I’m interested in.

Ellen Leabeater: Thomas Fischer, Professor of Aged Care Nursing from Dresden in Germany.

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Ellen Leabeater: When it comes to international healthcare, nurses are on the frontline. As part of teams that respond to crises, they have played a significant role in the health gains the world has made in the 20th and 21st centuries. But as the world becomes smaller and movement between countries increases, nurses on the frontline are facing new threats.

On May 12, Florence Nightingale’s birthday, the world will celebrate International Day of the Nurse. This year, the theme is “A force of change: Improving health systems’ resilience”. To find out exactly what this means, Ninah Kopel spoke with Carla Saunders, lecturer in the Centre for Health Services Management at UTS.

Carla Saunders: The issues that we’re currently facing and the most common threats to health system resilience are, in a nutshell, too few reserves. We have increasing demand for a growing and ageing population, more emerging diseases, technologies that are high-cost but are allowing us to diagnose better, so we need an intervention then once a diagnosis is made, so too few reserves for when that increasing, unexpected demand happens.

Ninah Kopel: When you talk about those reserves that are lacking, are nurses one of the things we are running short of internationally?

Carla Saunders: Not really, unless it’s intentional. So what we’re seeing with a greater demand for healthcare is some approaches to create some efficiencies, and whether that is not employing enough nurses or not having enough workforce to support that demand, that is a risk that is probably happening in some countries. Nurses are quite resilient themselves – they’re part of our resilient health system in its own right.

Ninah Kopel: And that’s the reason why you think they’ve chosen this theme – it’s because nurses are so important in that resilience.

Carla Saunders: Yes, absolutely. So they’re the largest number within our health workforce as health professionals. Often they have personal characteristics that help them to be resilient. So the first need for a resilient health system is to make that nurses and other members of the health workforce are themselves resilient. The natural ability to adapt to a new circumstance is often a personal trait, but that doesn’t mean resilience can’t also be learnt.

Ninah Kopel: How do you do that? How do you teach a nurse to be resilient?

Carla Saunders: There are approaches like practicing to respond to negative experiences in ways that don’t exacerbate the situation. Nurses are very good at calming a crisis situation. They tend to self-reflect and identify their own risks and protective factors in a complex work environment. They’re often optimistic, especially with patients, so that factor in itself helps them to be resilient. They seek out supportive relationships during a crisis situation. They rally the troops, they rally a team together to support patients or support a crisis situation. They also – the important thing about nurses is they make assessments about the challenges ahead. They look further. They look around them and have a situation awareness that really places them well to be contributing to a resilient health system. They tend to be the bigger picture thinkers, whereas other health professionals tend to be very patient-focussed, which is also an important characteristic of nurses, but they have the ability to look broadly, to understand what’s coming.

Ninah Kopel: And that’s the quality that makes them desirable in crises, but do those crises often put nurses at risk, and is that something we need to consider when we talk about a resilient situation?

Carla Saunders: Yes. They are the go-to people for patients and for other staff. They’re seen as the ones that know and understand what’s going on around them, so they need support to support others, in building others capacity to also act in a resilient manner, so that the health system is sustained and the work is sustained. They need help to support a changing, an ever-changing environment normally and we help them do that, but when a crisis situation happens, they’re often the quick thinkers; they have the understanding of the resources and capacities that are available to them to rally. They help others to understand that and be prepared as well.

Ninah Kopel: You also mentioned something earlier about nations who have a better control on their own health system, helping other countries. So how does that play into the system of resilience?

Carla Saunders: We are a global health system. In one way or another, viruses cross boundaries, cross nations… emerging threats of disease cross nations often. We need to now plan broadly to have a national and international health system that is resilient so that we don’t get pockets of absolute despair. Health systems disintegrate with challenges and an unsupportive environment around that nation is not helpful in anyway, in fact it threatens the resilience of health systems that are already lacking resilience. And often the demands are then placed on those vulnerable systems anyway.

Ninah Kopel: And we did see that with the outbreak of Ebola and just how catastrophic that was and how quickly it moved, and suddenly the world was asking those questions about how we need to address health from a global perspective. So how did we deal with that from a perspective of resilience for nurses? Was it manageable at all?

Carla Saunders: No, we didn’t do well in West Africa in terms of resilience, but we didn’t do well internationally. We didn’t support those that weren’t in West Africa. We didn’t support those nations very well that were willing to support and help them additional resources to go in because their own systems weren’t that resilient to cope with that increasing demand and pressure.

It’s a combination of issues. When you think of West Africa and Ebola and the local customs and beliefs, helping that community generally to understand a complex situation like the Ebola virus was very challenging. The sheer mobility of the population in that region meant that helping communities to understand that we needed to contain that virus wasn’t happening very well. After years of violence and turmoil in that country, there was a lack of public trust, and getting that trust is so important. That’s where it fell down more than anything else.

Ninah Kopel: When we train young Australian nurses, is this the type of conversation that is happening about how to tackle these global problems and crossing those international borders?

Carla Saunders: Rather than train them to actually do that when many will be nurses in this country alone, what we have introduced is an understanding of advocacy and the important role of nurses in advocating for health systems that are sustainable, but also fair. So, nurses understand the importance of a universal health system. The funding arrangements that allow the most vulnerable people to access healthcare are so important. So, nurses themselves are a good cohort to advocate on behalf of other nations, to work internationally when they can, but there’s a presence in our country of nurses who have a good understanding of the international environment, can foresee challenges and advocate for a much fairer, resilient international health system.

Ellen Leabeater: Carla Saunders, speaking there with Ninah Kopel. Carla is a lecturer in the Centre for Health Services Management at UTS.