Probiotics. We hear a lot about how we should be taking supplements of these because they’re great for your digestive system. But because supplements aren’t regulated by the FDA, how are you supposed to find the one that’s right for you and your patients?
Fear not. Dragana Skokovic-Sunjic, BScPhm, NCMP, is a Clinical Pharmacist with Hamilton Family Health Team, Hamilton, ON as well as a leader in the knowledge of probiotics both in the United States and Canada. In addition, Skokovic-Sunjic is the author of Clinical Guide to Probiotic Products Available in Canada and Clinical Guide to Probiotic Products Available in the US, both of which are updated annually.
She took the time to answer questions.
For those who don’t know, what are probiotics and how do they help our bodies?
Probiotics are tiny but powerful organisms that, when taken appropriately, can oﬀer substantial health benefits. While many people believe probiotics are for the gastrointestinal tract only, scientific evidence asserts far-reaching and diverse benefits of probiotics which extend far beyond the gut to include: respiratory ailments, mental health, colic in babies, weight management, vaginal health, and more.
Probiotics offer health benefits through several mechanisms: modulation of composition or activity of the microbiome, modulation of the immune system, effect on systemic metabolic responses, improving barrier function in the gut, and increasing colonization resistance against pathogens. Many other new benefits are being discovered every day with the new research. (Source: https://isappscience.org/for-scientists/resources)
There are so many on the market. How can people choose the best one for them?
Probiotics are potentially beneficial; however, it is important to note that the effects and benefits are strain-specific and disease-specific. One needs to know what to use and why. Taking any probiotic, or a probiotic with the best-looking label or best price does not necessarily mean it will provide the desired benefit. It would be similar to walking into the pharmacy and simply asking to be given medication.
Probiotics are similar to medicines. Each one is unique and has a particular intended purpose. Just as taking medication for pain won’t prevent pregnancy, taking a probiotic to prevent traveler’s diarrhea won’t relieve a baby’s colic symptoms. It is essential that probiotics be prescribed or selected, and taken, appropriately.
All probiotics are not created equal, nor is the science that validates their eﬀectiveness. Unlike medicines, probiotics are not strictly regulated yet. Unfortunately, this means there are many probiotic products on the shelves that make claims that are not substantiated by scientific evidence. This is confusing, frustrating, and is resulting in people wasting money buying the wrong probiotic for the condition they are suﬀering from.
Selecting the proper probiotic and taking it appropriately for the symptoms or condition you wish to relieve is imperative. Be informed when choosing a probiotic. The Clinical Guide to Probiotic Products Available in the US is the only comprehensive summary of probiotic brands that reviews, rates, and summarizes the scientific evidence available for specific probiotic strains and related brands.
Clinical studies supporting the recommendations made by our expert review board are all listed for those who would like to dig deeper and learn more. You can also use a free, quick-access app as your reference tool, by downloading the Probiotic Guide free app to your iPhone or Android smart phone. Make sure to select one for your region—one for the US and one for Canada. Both the website and app contain the same information, including the references, level of evidence, reasons for use, dosage formats, and more.
It is essential to know that not everyone needs to be taking a probiotic supplement. If you are eating a balanced diet, including fermented foods often, not taking antibiotics, and are generally healthy, you do not need to take a probiotic all the time. However, in some situations, such as the cold and flu season, you might look at the evidence for specific strains and products that seem to minimize the risk of common infections disease or shorten the duration of cold and flu.
Are there any things to watch out for?
Most importantly: read the label. The probiotic product you select must show the unique name of the probiotic you need to use on the label. The name is a combination of three critical elements: its genus, species, and strain. The strain is particularly important because it not only reﬂects the physical characteristics of the probiotic, but how it will act, interact, and react with your individual microbiome. Dose expressed in CFU (colony forming units) and potency at the time of expiry has to be clearly stated.
Like any other supplements, the label should provide a non-medicinal ingredients lists, such as traces of dairy, gluten, and other potentially harmful allergens.
Most probiotic strains available in the U.S. and Canada have been deemed safe (GRAS status or NPN designation) for the general population. For critically ill patients, severely immunocompromised patients, and other special circumstances, the use of probiotics can be done under strict medical supervision.
Is it best to take them with or without food? In the morning or evening?
Timing and the best ways to administer probiotics is again, very strain-specific. Generally, most commercially available products can be taken at any time of the day, with or without food. Some strains are available in liquid form (drops) and are very effective even in a dose of 0.5B (billion) CFU. Other probiotic strains need to be taken in an enteric-coated capsule in a dose of 50B CFU in order to survive through the acids present in the gut to reach the target areas and provide benefits. This does not mean one is better than the other: it merely illustrates that not all probiotics are the same.
How can people tell if the one they’ve chosen is working?
If the probiotic is working, you will know! And you will know very soon. The best approach is to identify the reason why you would take the probiotic. For example, you suffer from IBS and would like to try a probiotic. Faced with so many choices, you turn to the Probiotic Guide mobile app, and find a few options with the highest level of evidence.
At this point, you could consult your health care practitioner, or decide to give it a try. Most probiotic products are available without a prescription.
The next step is to take the selected probiotic as recommended in the Probiotic Guide or on the product label. After you achieve symptom relief, you can stop taking it and see what happens.
Quite a few of my patients with IBS do safely stop taking probiotics after the initial treatment while others may need to take the probiotic continuously.
The length of time one needs to stay on a probiotic may different for each individual and the reason the probiotic is taken. Once symptoms are gone, you can try to stop and see what happens.
Sometimes, people who entering a “caring” profession, like nursing, love helping people. So while the money they make is important, it often takes a backseat to what they’re doing as a profession. But nurses need to look out for themselves, too. We asked Dina Neilsen, PhD, Senior Manager of Learner, Career, and Alumni Services as well as the Emergency Committee Co-Chair at Nightingale College to offer nurses tips for negotiating a better salary when applying for a new job.
What is the first thing nurses should do when they find out they have a job interview? Should they immediately prepare and do research so that they will be ready to discuss salary? Or should they wait to see if they’re called back for another interview? Should the research be on the place where they’re interviewing? On the type of job? Both? Where can they find out what salary they should be asking for?
Yes, preparing for an interview is always a good plan. Understand what the specific job description is and also spend time on the organization’s website to get a sense of its culture, history, etc.
Visit sites like Glassdoor to review salary ranges for the position you seek; also review other organizations with similar job descriptions to understand the market range for your position.
What other aspects should they take into consideration? Geography? Years of experience? Education? Certifications? Please explain.
There are locations in the U.S. where the nursing shortage is quite dire, so geography does play a role. This collection of data can help you to factor in geography if needed.
It is likely your education, experience, and certifications are already in the hands of the organization seeking an interview with you. You should feel free, though, to reiterate all of those things and to make a case of how you bring added value.
Suppose they are asked what they want to make? Should they give a number?
We generally believe it’s better to “get” a number than “give” a number because then you won’t have locked yourself into a starting salary that might be lower than what would have been offered.
Talking about money is uncomfortable for some people. How can they prepare while calming their fears?
If you’ve gathered the data from sites like Glassdoor, you are operating from a place of knowledge which should help to calm any fears.
If it’s not brought up on a second or third interview, should the nurses bring up the topic of salary? Why or why not?
It’s perfectly reasonable, especially in places where nursing shortages exist, to politely ask the salary range.
Should they say that money isn’t the most important aspect of the job? Or will this lead to them getting shortchanged?
Everyone expects to—and should be—paid what they are worth. Minimizing the salary question doesn’t help anyone on either side of the equation.
Suppose they are offered their dream job, but the salary isn’t what they wanted/needed? What should they do? Are there other factors they should ask about—hours, vacation, health care, etc.?
Perhaps the best way to deal with this situation is to ask for a six-month salary review. That way, you can take the dream job for a minimal period of time before being reviewed for a salary increase.
When women are released from prison, they have a lot to learn—including how to manage their mental health, build strong relationships, and prioritize caring about themselves. When the students, alumni, and faculty of Walden University College of Nursing found out that these women could use guidance, they began working with former prisoners who live in a Washington, D.C. halfway house. The nurses are helping these women integrate back into the community through presentations they are giving via videoconference, known as “Coffee Talks.”
Sara Thimmes, RN-BSN, a Walden graduate and current MSN student and Lisa Trogdon, MSN, also a graduate of Walden, explain what the group is doing and why.
How did you initially become involved with the halfway house? Why did you begin this videoconferencing series?
Sara: We became involved with this project by meeting Dr. Avon Hart-Johnson at Walden’s commencement ceremony. Dr. Hart-Johnson, faculty in Walden’s PhD in Human and Social Services program, founded a nonprofit to ease the adverse impacts of incarceration on families and children. After commencement, we began talking about how Walden’s Sigma Phi Nu Chapter could help her through donation drives or other opportunities.
We came up with the idea of having a nurse speak at a series of videoconferences that connect experts with women at a local halfway house. In the video meetings, called Coffee Talks, nurses share health information to help the women learn to take care of themselves and their families. Our chapter also buys breakfast for the women. Our Coffee Talks have taken off from there—they have been amazing.
Lisa: When Sara presented this concept to Phi Nu’s board, I knew that I wanted to participate. I thought it sounded like an amazing opportunity to serve and educate those in great need, especially during the COVID-19 pandemic.
What are the topics that you’ve covered so far?
Sara: For our first talk, at the start of the pandemic, we spoke on COVID-19.
Lisa: We have also educated the women on dealing with hypertension, becoming your own health advocate, managing your breast health, and developing a sleep routine. Another topic we addressed was setting SMART goals, which are objectives that are smart, measurable, achievable, relevant, and time-based. The participants selected most of the topics, and we chose others based on their potential needs. The speakers we chose were students from Walden’s College of Nursing and other volunteers from the Phi Nu chapter.
What are you planning on covering in the future?
Sara: We give the participants a survey after each education session to list any health topics they would like to know more about.
Lisa: Future topics will include diabetes, stress management, and dealing with uncomfortable emotions. We’ll choose additional subjects based on our participants’ requests and needs. Diabetes is a common issue in our country. Factors such as socioeconomic status may put the members of our audience at the halfway house at a higher risk of diabetes. In these challenging times, we also want to help the women learn positive ways to manage their stress and process their uncomfortable emotions.
What do you hope women learn from this?
Sara: We hope the participants learn to be their own advocates for health. They should learn to build trusting relationships with their health care providers and plan preventive health visits along with sick visits. Our talks emphasize the importance of seeking reliable, trusted resources for health information on the internet. We really want to make sure they are using the internet to benefit their health rather than falling down the online rabbit hole of inaccurate information.
Lisa: We want to empower the participants and encourage them to trust their health care providers enough to have open, honest conversations.
How have the women in the halfway house benefitted from this?
Sara: The women express their gratitude in the surveys they fill out after each talk. Many participants speak up during the Coffee Talk sessions to share that they have learned something and will follow up with a health care provider for specific health questions.
How have the faculty, alumni, and students benefitted or learned from this project?
Sara: The faculty and students who have presented in Coffee Talk say they have benefitted from the experience. I provide feedback to the faculty members, including sharing any comments from the participants’ surveys. This series of talks is an informative way for nursing students to gain real-world experience and serves as a great tool to assess each nursing student’s ability to interact with and adapt to their audience. These are critical skills for practicing nurses.
Lisa: As alumni, we are inspired to implement Walden’s call for social change in our own communities, not just in Washington. Our experience with Walden as an online university prepared us well for today’s social distancing requirements, making us completely comfortable with the new normal of online presentations and interactions.
Why do you think it’s important for nursing students to get involved in the community?
Sara: As an MSN student, this has been an amazing opportunity for me to make a difference with a vulnerable population. It is so rewarding to engage with this group and provide them with informational health education and an hour of undivided attention. The Coffee Talks also give me insight into knowledge gaps in the community and get me thinking about how I can make a difference in my own nursing practice.
Sara: If you have the opportunity to make a difference in your community, absolutely take it! I also recommend that you join a nursing organization such as Sigma Theta Tau International, Honor Society of Nursing®, which provides many opportunities for volunteering, networking and overall growth. I would not have had this fantastic opportunity without Walden’s Sigma Theta Tau chartered chapter, Sigma Phi Nu.
Lisa: Being a member of the Phi Nu chapter reinforces all we were taught at Walden. Having the support of Phi Nu leadership and friends like Sara has opened the doors of opportunity for me to serve others.
In research released late this summer, Brad N. Greenwood, PhD, the lead author of “Physician-patient racial concordance and disparities in birthing mortality for newborns,” concluded that when Black newborns had care from a Black pediatrician, their mortality rate was decreased by half when compared to white babies.
Dr. Greenwood, an associate professor at George Mason University School of Business, took time to answer questions about this research.
Did you determine why Black babies have a better chance of survival?
I want to emphasize how cautious we need to be about speculating about the “why” question, because it is speculative. This is secondary data, so nailing down the exact mechanism is difficult, even if we do see the effect get larger in some places (hospitals that deliver more Black newborns) and smaller in others (Black newborns without comorbidities). But there are several possible explanations:
- We want to be careful not to pathologize Black newborns, but there is evidence that Black newborns can be more medically challenging to treat due to social risk factors and cumulative racial and socioeconomic disadvantages of Black pregnant women. As a result, it may be that Black physicians are more aware and attuned to these challenges than white physicians.
- Issues of spontaneous racial bias, which research does suggest manifest towards both adults and children, could also be at play. As a result, it is conceivable that the newborns are treated differently.
- There may also be challenges accessing preferred caretakers for Black mothers, or an inefficient process of allocating physicians at the hospital level.
- There is evidence in the literature that racial concordance increases trust and communication between patients and providers. While the newborn obviously won’t be speaking to the pediatrician, the mother may be, and this might have an effect.
All of these are possible, so we want to be very careful about the interpretation, since we cannot come down firmly on one mechanism or another. Likely, it is a mix of all these things and potentially more. What we do know is that the effect is persistent under a lot of conditions and gets bigger when Black newborns are born in hospitals which deliver many Black babies. This at least suggests part of the explanation may be institutional.
Your findings state that it doesn’t matter if the birth mothers share the same race as the physician. So if a white mom gives birth to a Black baby, the chances of the baby surviving are increased here as well if the doctor is Black?
When we are investigating the mother, the physician changes from being the pediatrician to being the obstetrician (the two physicians are almost always different). There is no spillover examination where we look at the effect of the mother’s physician on the newborn.
Why the effect doesn’t manifest for mothers is also speculative. While absence of evidence is not evidence of absence, it could simply be that maternal mortality is an order of magnitude lower than newborn mortality. It is also possible that there is no effect of concordance in these situations.
According to the Association of American Medical Colleges (AAMC) in 2018, 5% of all physicians identified as Black. If there are so few Black physicians overall, what will need to happen so that babies of color get the care they need to survive? What do your results mean for the care of newborn babies of color now and in the future? How can your study’s results impact the health care system for the better? How can health care workers prevent this disparity from occurring? If they can’t on their own, what needs to happen?
I will answer these all together as they seem to be related. The speculative nature of the mechanism, to me, highlights that more research is needed to understand the precise dynamics behind the finding. Specifically:
- whether physician race serves as a proxy for differences in physician practice behavior,
- if so, which practices, and
- what actions can be taken by policy makers, administrators, and physicians to ensure that all newborns receive optimal care.
The work, in my mind, is a starting point. It identifies an issue that is a real problem and provides some paths forward. But a lot of work remains to understand the issue in its entirety.
More directly to your question, I also think the work underscores the need to continue the diversification of the medical workforce. Inasmuch as research suggests stereotyping and implicit bias contribute to racial disparities in health outcomes, I think the work also highlights the need for hospitals and other care organizations to invest in efforts to reduce such biases and explore their connection to institutional racism. But the effort doesn’t simply rest on the shoulders of hospital administrators. Reducing racial disparities in newborn mortality also requires raising awareness among physicians, nurses, and other health care actors about the prevalence of these disparities, furthering diversity initiatives, and revisiting the organizational routines in low performing hospitals in order to determine why these effects persist.
What is key is that we identify high performing physicians, teams, and acute care centers, identify what makes them higher performing, and then promulgate that information to lower performing locations.
What else should our readers know?
There is one thing I think bears specific note. One conclusion we have heard is that this means Black newborns should immediately be funneled to Black physicians. There are three critical flaws with this logic:
- The disproportionately white physician workforce makes this untenable because there are too few Black physicians to service the entire population (5% of practitioners vs 13% of the population). This would mean the market is functionally underserved as you highlight above.
- It avoids the foundational concern of resolving the disparities in care offered by white physicians. This would mean that even if improvements are made there is still the chance that a newborn would not receive sufficient care in an emergency situation.
- Physician performance varies widely among physicians of both races. There are tremendous physicians of both races, and there are underperforming physicians of both races too. So it isn’t really an effective selection criteria.
What we have is a situation where structural issues are causing babies to die. I don’t think any of the members of the coauthor team would claim this is a function of malice on the part of physicians. But if we are going to solve the problem, we first need to acknowledge that disparities of care exist. Once we do that, we can start to fix them.
Flight/Transport nurses travel throughout the country and even throughout the world. An issue in the field, though, is that not many minorities are choosing this line of work. So, how can we attract more minority nurses to flight nursing?
Bob Bacheler, MSN, CCRN, CFRN, Managing Director of Flying Angels, as well as a Board Member at Large for the Air & Surface Transport Nurses Association (ASTNA), brought this to our attention. He then took time to answer questions about why more minorities aren’t in this line of nursing world and how they can become involved if they want to pursue it.
About how many flight nurses are there in all? Do you know what percentage are minorities? Why do you think that there has been a historic underrepresentation of minority nurses in the transport nursing field? Why aren’t more BIPOC working in this field?
The shortage in minority nurses is not unique to transport/flight nursing. According to the 2017 National Nursing Workforce Survey, the nursing profession is comprised of a workforce which is predominantly female and Caucasian. Eighty-percent of all nurses identify as white, twenty percent of all nurses are BIPOC, and seven percent of the overall nursing workforce is male (2017 National Nursing Workforce Survey).
Of the overall nursing workforce, over 165,000 nurses are providing direct patient care in the transport environment (Board of Certification for Emergency Nursing (BCEN)). The flight nurse workforce trends higher in male nurses (18% in flight nursing compared to 7% overall), but lower in the percentage of BIPOC nurses (13% compared to 20% overall). Given the competitive nature getting into flight nursing, it’s beneficial for potential applicants to get their Bachelor’s or even Master’s degrees and certifications such as Critical Care Registered Nurse (CCRN), Certified Emergency Nurse (CEN), Trauma Certified Registered Nurse (TCRN), Transport Professional Advanced Trauma Course (TPATC) and/or Certified Pediatric Emergency Nurse (CPEN).
Becoming a Transport/Flight RN is only the beginning of the educational process. Obtaining certifications such as Certified Transport Registered Nurse (CRTN) or Certified Flight Registered Nurse (CFRN) requires considerable effort. Maintaining those certifications as well as usual requirements of most positions require continued education. According to BCEN, the average transport RN has 16 years of experience, with 78% holding a Bachelor’s degree or higher, which is far higher than the average RN population. Most of the applicants for Transport/Flight Nurses come from critical care nursing positions.
While the underrepresentation of BIPOC in flight nursing could possibly be attributed to a number of factors, a primary factor could be lack of access to the licensure requirements/higher education credentials necessary to obtain a flight nurse position. According to the American Association of Colleges of Nursing (AACN) report on 2018-2019 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing, nursing students from minority backgrounds represented only 34.2% of students in entry-level baccalaureate programs, 34.7% of master’s students, 33.0% of students in research-focused doctoral programs, and 34.6% of Doctor of Nursing Practice (DNP).
According to the 2018 AACN Healthy Work Environment National Workforce Survey Results, minority representation in critical care nursing has only increased slightly from 14% to 20% in the past 15 years. As identified earlier, critical care nursing is one of the primary career pathways to transport/flight nursing. Public policy interventions that would increase minority access to higher education could help to increase the number of minority nurses who enter the critical care nursing field, which would eventually increase the available pool of qualified applicants for transport positions.
Why are companies looking to hire BIPOC as transport nurses? What do they bring to the field?
As the percentage of BIPOC population increases nationally, companies realize that patients are often best served when the flight RN reflects the community they are serving.
Explain what a flight nurse does. Would someone need to get additional credentials to become a transport nurse?
Flight nurses are registered nurses that have specialty training to provide medical care as they transport patients in either rotor (helicopter) or fixed-wing (plane), or either by air ambulance or commercial aircraft. Flight nurses work with other trained medical professionals like paramedics and physicians. Helicopter RNs are often called upon to help transport critically ill or injured patients to trauma centers. Air Ambulance RNs are often transporting ICU level care patients long distances.
With Commercial Medical Transport, which is Flying Angels’ specialty, RNs are tasked with accompanying patients on commercial airlines transporting patients around the country and the world. These are people who need to be transported long distances, and while they do not need the ICU level of care provided by an Air Ambulance, they do require a nurse with significant experience and skill.
What are some of the benefits of working as a flying nurse? What are the challenges?
Each specialty—Rotor Wing, Air Ambulance, Ground Ambulance, and Commercial Medical Escort—have their own rewards. All have a higher degree of autonomy than nurses who work in hospitals. Rotor Wing nurses are saving lives every day, transporting critically ill patients from trauma scenes to hospitals. Air and Ground Ambulance RNs are practicing at the peak of their skills, in cramped quarters to make sure people are where they can get the best care. Commercial Medical Escort RNs are often reuniting families around the country and the world. In many cases, they are getting people home who would otherwise have no way of getting there. All share in the reward of doing good for their patients as well as sharing a high degree of job security.
Why do you think more minorities should look into this as a career choice?
All Transport/Flight RNs practice the peak of their skills and enjoy tremendous job satisfaction. Opportunities for Transport/Flight RNs are growing each year. Transport/Flight RNs enjoy an esprit de corps and a sense of community. They are also some of the highest-paid nurses working.
What would readers be most surprised about regarding being a flying nurse?
Being a Transport/Flight RN is often hard work, in cramped quarters, for long hours. The emotional toll can be draining. Adjusting to jet lag/time zone transferring can often prove to be difficult.
Is there anything else that is important for our readers to know?
Professional associations in transport/flight nursing promote the esprit de corps. These associations give you a place where you can connect with others and share best practices. Join a professional organization such as ASTNA, which has an employment job board, and attend conferences such as the Air Medical Transport Conference (AMTC).