Showing papers in "MCN: The American Journal of Maternal/Child Nursing in 2005"

Evidence for healing interventions with perinatal bereavement.

Abstract: The purpose of this article is to explore the concept of perinatal grief and evidence-based healing interventions for it. The loss of a pregnancy or death of an infant causes profound grief, yet society has long minimized or ignored this grief, which is among the most painful of bereavement experiences. Throughout the last century, research on grief and the special needs of bereaved parents has changed the context of professional intervention from protective to supportive. The central focus of bereavement interventions is to assist families in healing by helping them make meaning of their losses. The use of symbols, spirituality, and rituals has been shown to help bring meaning. Research has shown that memories are key to healing, and that gender, age, and relationships bring different grief expressions and experiences. While children's understanding of loss and grief differs with developmental age, they should also be given the opportunity to participate in grief rituals and practices. Professionals who care for bereaved parents have a unique opportunity to offer support by validating their grief, facilitating rituals, providing mementos, and letting the bereaved tell their stories. While no intervention can bring back their beloved children, appropriate intervention can promote healing.

Lack of preparedness: experiences of first-time mothers.

Abstract: Purpose To examine the experiences of first-time mothers following discharge from the hospital after vaginal delivery. Study design and method Qualitative, grounded theory. In-depth interviews were conducted with participants guided by open-ended semistructured questions. All interviews took place in the participants' homes within 4 weeks of delivery and were tape-recorded. Data collection and analysis occurred simultaneously. Open coding and selective coding were utilized to identify and refine concepts. Participants were primiparous, drawn from an urban location in the northeastern United States, English-speaking, and 18 to 35 years of age. Results Following the dramatic changes of pregnancy and delivery, the women in this study returned home feeling unprepared to care for themselves and their babies. Because of their lack of preparedness at a time of increased responsibility and vulnerability, they were overwhelmed. Exhausted, feeling unwell and isolated, they struggled to adapt to new role expectations. Propelled into information seeking by their lack of knowledge, they were further hampered by conflicting and fragmented advice. Family and friends were the primary sources for information for the majority of these new mothers, not healthcare professionals or services. Clinical implications Insight into the experiences of first-time mothers provides a framework for additional research and the development of programs and resources that will address their unique needs.

Nurses' knowledge, attitudes, and practices: regarding children's pain.

Abstract: Purpose To describe nurses' knowledge and attitudes about relieving children's pain, perceived barriers to optimal pain management, and analgesics administered by nurses in relation to levels of children's pain. Study design and methods Data were collected from 67 nurses and 132 children in their care. Outcomes were measured with The Nurses' Knowledge and Attitudes Survey Regarding Pain, the Nurses' Perceived Barriers to Optimal Pain Management for Children Survey, calculations of the ordered analgesia administered by the nurse, and the Oucher scale for intensity of children's pain. Results Most nurses demonstrated knowledge and positive attitudes about relieving children's pain but lacked knowledge about the incidence of respiratory depression and thought that children overreport their pain. Inadequate or insufficient physician medication orders for pain were identified by 99% of nurses as the greatest barrier to optimal pain management. The children's mean pain level was 1.63 (scale of 0 to 5). Of the 117 children who reported pain, 74% received analgesia. Nurses administered means of 37.9% of available morphine and 22.8% of available total analgesia. Clinical implications Nurses in practice need to become more aware of the adequacy of their analgesic administration, the value of children's self-report of pain, and the limitations of relying on children's behavioral manifestations to judge pain intensity. This study also demonstrates the importance of examining attitudes about children's pain relief and learning more about respiratory depression in children receiving opioids.

Feeding readiness in preterm infants: the relationship between preterm behavioral state and feeding readiness behaviors and efficiency during transition from gavage to oral feeding

Abstract: PURPOSE: The purpose of this secondary analysis was to assess whether alert behavioral states were associated with an increased number of feeding readiness behaviors (FRBs) and whether the number of FRBs were associated with subsequent feeding efficiency in healthy premature infants born between 29 to 35 weeks gestation. STUDY DESIGN AND METHODS: The data were collected as part of a larger study designed to compare the frequency of FRBs and feeding efficiency between control and experimental groups. Data from 21 stable premature infants were included in this secondary analysis. Infants were videotaped immediately prior to each of the first three oral feedings, from which infant behavioral state (IBS) and FRBs were assessed. Feeding efficiency was determined by calculating the ratio of feeding intake to feeding duration. RESULTS: IBS was not a significant predictor of the number of FRBs. The number of FRBs was predictive of feeding efficiency (p <.05). Group assignment was a marginally significant predictor of feeding efficiency (p < .10). Infant sex (p < .05), birthweight (p < .01), gestational age at birth (p <.01), and gestational age at entry (p < .05) were identified as significant predictors of the number of FRBs. Group assignment was marginally significant (p < .10). CLINICAL IMPLICATIONS: Feeding efficiency may be predicted by the increased number of FRBs immediately prior to feeding. An infant's attributes (sex, birth-weight, and gestational age) may relate to feeding efficiency and should be assessed when instituting oral feeding. Assessment of FRBs can be easily incorporated into routine clinical practice.

Neuroendocrine and immune relationships in postpartum fatigue.

Abstract: Purpose To explore relationships between fatigue, depression, stress, and infection in the postpartum. Study design and methods This was a cross-sectional, correlational design with a sample of 119 new mothers at 4 to 6 weeks postpartum. Mothers completed fatigue, mood, and stress instruments as well as maternal and infant infection checklists. Morning blood and hindmilk (in breastfeeders) samples were collected. ELISA was used to measure prolactin, cortisol, melatonin, and secretory IgA (sIgA). Correlations between psychosocial, health, and biologic variables were explored. Results Fatigue was correlated with symptoms of infection in both mothers and babies, with perceived stress and postpartum stress as well as with depression. Serum prolactin was inversely associated with depression. Milk sIgA was related to milk prolactin and inversely related to stress. Milk melatonin and prolactin were inversely related, and fatigue scores were correlated with melatonin and inversely with prolactin. Clinical implications The data suggest that fatigue, stress, depression, and infection are related in postpartum mothers and that these relationships extend to levels of serum hormones and milk factors. It is possible that a cycle is established that multiplies the effects of fatigue when mothers experience stress and that this cycle of stress and fatigue may lead to immune deficits and infectious illnesses.

Basal body temperature assessment: is it useful to couples seeking pregnancy?

Abstract: Advanced practice nurses (APNs) have an important role in the initial evaluation of both fertility and infertility and are frequently asked to discuss fertility issues with couples who desire a pregnancy. It is essential, therefore, that APNs understand the most current data regarding ovulation, optimal timing of intercourse in relation to ovulation, and time frames in which couples can expect to conceive. For many decades, basal body temperature (BBT) charting has been one of the methods discussed with couples to help them establish the presence of ovulatory cycles and to help them time intercourse. In view of the fact that now there are more accurate and prospective biologic markers available to predict and detect ovulation, it is relevant to ask whether BBT charting should be recommended. The purpose of this article, then, is to review the research basis for BBT to help APNs give the most current advice to couples seeking pregnancy.

Acculturation Level and Postpartum Depression in Hispanic Mothers

Abstract: Purpose Perinatal health outcomes for Hispanic women are associated with acculturation. The purpose of this study was to explore the relationship between acculturation levels and postpartum depressive symptomatology and diagnosed postpartum depression among Hispanic subgroups. Study design and methods The Postpartum Depression Screening Scale and the Short Acculturation Scale were used in the two phases of data collection. Phase 1 and 2 samples consisted of 377 and 150 Hispanic mothers, respectively. Puerto Rican mothers showed higher levels of acculturation than Mexican and other Hispanic women. A DSM-IV diagnostic interview (SCID) was used to establish a diagnosis of depression. Hierarchical regression analyses were used to study the unique relationships between ethnicity, depressive symptomatology, diagnosed depression, and acculturation. Results There was no consistent relationship between acculturation and postpartum depression. Significant predictors of elevated postpartum depressive symptoms in Hispanic mothers were Puerto Rican ethnicity and cesarean delivery. Single marital status was a significant risk factor for postpartum depression. A limitation of the study was use of language as the sole criterion measure for acculturation. Acculturation is a complex construct with problematic measurement that needs greater refinement to facilitate research in which it is used as a variable. Clinical implications Hispanic mothers are a heterogeneous group and should not be treated as a homogeneous group. Subgroups of Hispanic mothers may not have the same level of acculturation or the same level of postpartum depressive symptomatology.

Parenting preterm infants: a meta-synthesis.

Abstract: Purpose: To synthesize the findings of qualitative studies on parenting preterm infants and present a framework that will enable clinical nurses to provide better care. Study Design and Methods: A meta-ethnographic approach was used to synthesize the findings of 10 qualitative research studies that focused on parenting the preterm infant upon hospital discharge and on into the toddler years. Results: Five themes of parenting preterm infants emerged: adapting to risk, protecting fragility, preserving the family, compensating for the past, and cautiously affirming the future. Clinical Implications: Nurses provide expert care, anticipatory guidance, and education for NICU babies and families, but should also foster the inclusion of all family members in the NICU setting, provide opportunities for parental peer support, establish effective systems of continuity of care, and advocate for parents of preterms in policy-making arenas.

What has the literature taught us about culturally competent care of women and children.

Abstract: This article describes what is currently in the literature about culturally competent care for women and children. With the population of the United States growing increasingly diverse, there is a developing need for cultural competency among nurses and throughout healthcare organizations. Cultural competence includes both culture-specific and culture-generic knowledge, attitudes, and skills. While databased literature on cultural competency still requires further development, we do have evidence of positive outcomes of culturally competent care. The end result of the provision of culturally competent care by culturally competent nurses and healthcare organizations can be significant improvements in the health and well-being of women and children.

What are the responses & needs of mothers of infants diagnosed with congenital heart disease?

Abstract: This article addresses the needs of families of newborns with congenital heart disease (CHD). Approximately 40,000 infants are born with a congenital heart defect each year; a large percentage survive due to technological advances in treatment, resulting in an increasing number of families who have a child living with a chronic illness. While both parents are significantly affected by a diagnosis of CHD, much of the available literature discusses the experience of mothers. The mother's experiences after learning her child's diagnosis include grief, loss of her imagined healthy child, lack of knowledge of the disease, anger, and difficulty in caregiving, among other issues. Support and encouragement at the time of diagnosis and throughout each stage of the illness are essential. This article describes various strategies that nurses can use to assist these families through their difficult journey.

Effects of high-risk pregnancies on families

Abstract: Purpose To examine the psychosocial impact a high-risk pregnancy has on the family and to identify family strengths and how these strengths help families meet the challenges inherent in high-risk pregnancies. Study design and method A descriptive study using naturalistic inquiry was used to interview women who were currently pregnant and had differing high-risk obstetric health issues. Data collection for this study included semi-structured, one-on-one audiotaped interviews, observations, and a biographic profile completed by the participant. The audiotaped interviews were transcribed and data were examined, coded, clustered, and sorted into specific categories. Trustworthiness included member checks and audit trails. Results Three themes emerged from the data about psychosocial impact. Mixed Emotions described the women's perception of a high-risk pregnancy; Adjustment and Support was how the women described their family's experience with the high-risk pregnancy; and Informative Care arose from the women's explanation of care received. The most common family strength identified was the ability to manage stress and crisis, followed by commitment, appreciation and affection, a sense of spiritual well-being, and enjoyable time together. The least common strength identified was positive communication. Clinical implications A high-risk pregnancy not only affects women, but it also causes an alteration in family functioning. Nurses need to become familiar with family strengths and help families recognize their strengths when faced with significant life events.

Screening for infants' and toddlers' dietary quality through maternal diet.

Abstract: PURPOSE To investigate the relationship of mothers' dietary quality to that of their infants and toddlers in limited-income families at risk for poor health. STUDY DESIGN AND METHODS Secondary data analysis was conducted of dietary quality from 24-hour dietary recalls collected from 113 mother-infant/toddler pairs in limited-income families with a child at age 6 months and again at age 14 months. Dietary quality of mothers was evaluated on the basis of eating breakfast and having at least one serving of the five food groups from the Food Guide Pyramid. Diet quality of infants was determined by comparison to the Women, Infants, and Children feeding guidelines for their ages; the diet quality of the mother was then compared to that of her infant and, later, toddler. RESULTS Most mothers and their infants had poor diet quality at the first interview. By 14 months most mothers still had poor diet quality, but diet quality for the children improved such that only about one-half remained poor. Poor diet quality of mothers was useful to detect poor diet quality for her infant or toddler showing high concordance at both interviews. CLINICAL IMPLICATIONS A consistent marker for infants at risk for poor diet quality is having a mother who skipped breakfast and omitted fruits, vegetables, or dairy products. This could be a quick indicator to identify those at greatest risk for not following recommended guidelines in feeding their infants and toddlers.

Parenting needs, goals, & strategies of adolescent mothers.

Abstract: The purpose was to identify and organize the perceived needs goals and strategies of teen mothers. Qualitative using a microethnographic design. Data collection strategies included focus groups and interviews in a naturalistic setting. The sample consisted of five unmarried 18-year-old mothers enrolled in an urban high school in a southern state. Data were analyzed using a clustering technique and a modified multistage method of content analysis. Teen mothers identified their needs as support and knowledge. Goals were happiness independence and career and strategies were a support group life skills education formal education and a job. A model was developed incorporating these themes. Nurses can use the findings of this study to develop support groups for adolescent mothers that offer peer support and education about teen and child needs are flexible and multidisciplinary are supportive and accepting have a comfortable physical environment and include the adolescents’ children and occasionally grandparents. (authors)

Family functioning and hope in children with juvenile rheumatoid arthritis.

Abstract: Purpose To examine the relationships among family functioning, hope, and quality of life in children with juvenile rheumatoid arthritis (JRA). Study design and method Sixty-eight children (8 to 12 years of age) with a diagnosis of JRA and one of their parents/guardians participated in this descriptive correlational study. Parents completed the Feetham Family Functioning Survey (FFFS), the Parent Report for Children Pediatric Quality of Life Inventory (PedsQL), and the Parent Report for Children PedsQL Rheumatology Module. The children completed the Children's Hope Scale (CHS), the Child Report for PedsQL, and the Child Report PedsQL Rheumatology Module. Data were analyzed using chi-square, t-tests, and correlation analyses. Results Family functioning and children's hope showed a negative correlation, indicating that a child's hope was lower when the parent reported greater dissatisfaction with family functioning. Hope was not related to parent or child ratings of the child's quality of life. Clinical implications In caring for children with JRA, nurses can assess the family's satisfaction with relationships to the broader community, subsystems, and individual members and seek ways to promote healthy family functioning. Nurses also can assess the level of hope in children with JRA and facilitate the development of hopefulness by helping children establish goals and develop strategies to meet them.

Tailoring Sti & Hiv Prevention Programs for Teens

Abstract: Successful HIV/sexually transmitted infection (STI) prevention programs are not “one size fits all.” To effectively meet the HIV/STI prevention needs of all adolescents, programs should be developmentally and gender specific, should integrate an understanding of racial/ethnic culture, and should be open to variations in sexual expression. Nurse researchers have demonstrated the importance of these differences in programs, and this article offers concrete suggestions for ways to apply this knowledge in community programs.

An intervention program for families with irritable infants.

Abstract: PURPOSE To describe and evaluate a home-based nursing intervention program, the REST routine, which incorporates the use of infant behavior assessment, pattern recognition, individualized infant schedules, specific management strategies, and parent education and support. STUDY DESIGN AND METHOD A two-site clinical trial was conducted on 164 healthy full-term infants with excessive unexplained irritability or colic. Infants between the ages of 2 to 6 weeks were randomized to routine care or a home-based intervention program (n = 121). A third group (n = 43) of infants too old at entry for randomization (mean age = 10.4 weeks) were entered into a posttest-only group. RESULTS Infants in the REST routine treatment group cried 1.3 hours per day on average following the intervention program as compared to the control group crying 3 hours per day (p = .02). Infant irritability was resolved (< 1 hour) in 62% of the treatment group while only in 29% of the control group at the time of the 8-week follow-up visit (p = .04). CLINICAL IMPLICATIONS Families in both the treatment and control groups reported benefiting from a nurse visiting in their home to inquire about their infant and their well-being. Options for individualizing the program for those most in need of intensive home visiting and other delivery modes for the intervention are areas for further investigation.

Are you often sad and depressed? Brief measures to identify women at risk for depression in pregnancy.

Abstract: Purpose The purpose of this study was to test brief depression screening measures as an initial step to identify women at risk for depression in pregnancy. Study design and methods Psychometric theory and a prospective correlational research design with a convenience sample of 130 low-income women guided this study. Measurements included (a) single-item depression-screening measures, (b) a two-item depression screening measure, (c) the Brief Depression Screen (BDS), and (d) the Beck Depression Inventory-II (BDI-II), a standardized measure of self-reported depression that has been used widely in pregnancy. Results Depressive symptoms in pregnancy among these low-income women were 27% (35/128) as determined by a score of 16 or greater on the BDI-II. The two-item depression screening measure, "Are you often sad and depressed?" and "Have you had a loss of pleasurable activities?" had a sensitivity of 91% and a specificity of 52%, whereas the BDS measure had sensitivity of 53% and specificity of 80%. Clinical implications Asking the two-item screening questions could be an essential first step in determining which women should receive further evaluation and interventions aimed at treating depression during pregnancy.

Red alert: perinatal hemorrhage.

Abstract: The purpose of this article is to help nurses understand how to quickly and effectively manage the nursing care of patients with perinatal hemorrhage. The etiology, symptoms, medical management, and nursing care of the patient experiencing a perinatal hemorrhage are discussed. Hemorrhage during the antepartum, intrapartum, or postpartum period is a life-threatening emergency for the mother and/or fetus. Early antepartum hemorrhage (before 20 weeks gestation) can be related to abortion/miscarriage, ectopic pregnancy, or gestational trophoblastic disease; late antepartum hemorrhage (after 20 weeks gestation) may result from placental abruption and placenta previa. Intrapartum hemorrhage is most commonly due to placental abruption, or to uterine rupture, uterine inversion, invasive conditions of the placenta, or complications of Cesarean birth. Postpartum hemorrhage is defined as blood loss greater than 500 ml in a vaginal delivery or 1000 ml in a Cesarean birth; early postpartum hemorrhage occurs during the first 24 hours after delivery; late postpartum hemorrhage occurs after the first 24 hours after delivery. The most common cause of postpartum hemorrhage is uterine atony; however, lacerations, hematomas, and subinvolution of the uterus can also cause postpartum hemorrhage. Nurses who understand how to assess, plan, intervene, and evaluate outcomes for perinatal hemorrhage are in the position to prevent the major tragedies that can accompany hemorrhage in pregnancy and shortly afterward.

The context & clinical evidence for common nursing practices during labor.

Abstract: The purpose of this article is to review the context and current evidence for common nursing care practices during labor and birth. Although many nursing interventions during labor and birth are based on physician orders, there are a number of care processes that are mainly within the realm of nursing practice. In many cases, particularly in community hospitals, routine physician orders for intrapartum care provide wide latitude for nurses in how they ultimately carry out those orders. An important consideration of common nursing practices during labor is the context or practice model in which those practices occur. Nursing practice is not the same in all clinical environments. Intrapartum nursing practice consists of an assortment of different roles depending on the circumstances, hospital setting, and context in which it takes place. A variety of intrapartum nursing practice models have evolved as a result and in response to the range of sizes, locations, and provider practice styles found in hospitals providing obstetric services. A summary of intrapartum nursing models is presented. The evidence is reviewed for the three most common clinical practices for which nurses have primary responsibility in most settings and that comprise the majority of their time in caring for women during labor: (1) maternal-fetal assessment, (2) management of oxytocin infusions, and (3) second-stage care. Evidence exists for these nursing interventions that can be used to promote maternal-fetal well-being, minimize risk, and enhance patient safety.

Evidence for best practices in the neonatal period.

Abstract: The purpose of this article is to provide a review of current nursing research that supports best practices during the newborn period. The literature review of peer-reviewed research articles published between January 2000 and October 2004 was conducted via keyword searches using the databases of the Cochrane Library, CINAHL, and MEDLINE. Key words included neonatal nursing, newborn, neonate, premature infant, preterm infant, and low birthweight. Content analysis revealed the following primary categories of studies that provide solid evidence for nursing practice: developmentally focused nursing care, neonatal skin care, feeding, skin-to-skin care, and pain management. Neonatal nurse researchers have made many important contributions to the research literature. Future research should expand the findings to date on the effective use of pain scales, the outcomes of skin-to-skin care and infant massage as standard practice for all neonates, and the effectiveness of nursing interventions to support the developmental sequelae of prematurity. Neonatal nurses should become familiar with and implement those findings from nursing research that strongly support evidence-based nursing practice.

Implications of Kangaroo Care for Growth and Development in Preterm Infants

Abstract: T comprehensive review article summarized 66 research studies published since 1985 on kangaroo care (KC) as a developmental intervention. The author searched nursing, medical, and child development research literature through PubMed. An extensive review of the literature focused on the following topics: the historical perspective of KC as a developmental intervention; the impact of KC on the central nervous system including temperature regulation, heart rate, respiratory rate, oxygenation, physiologic safety, and developmental needs of preterm infants; and the relationships between KC and parenting outcomes and infant growth parameters. While the majority of the studies reviewed were descriptive in nature (thereby limiting generalizability of results), several interesting findings were reported. The author concluded from the studies reviewed that KC is physiologically safe for premature infants and that the benefit of KC in terms of parent-infant attachment as well as infant growth and development is strongly substantiated. Specifically, body temperature of most premature infants older than 28 weeks is stable following KC, but nurses should watch for overwarming with a subsequent increase of apnea and decrease in weight gain in some infants. Additionally, most studies reported no heart rate changes following KC, but all concluded that careful monitoring during KC is still necessary. The same recommendations were given in relation to respiratory rates and oxygenation. While it makes sense that an intervention that promotes attachment and the development of self-regulation should enhance infant development, the studies are less conclusive as to the benefits of KC on weight gain. The author concluded that KC is safe and physiologically beneficial for monitored premature infants. Questions remain regarding first-time KC experience for parents that might cause increased stress, the effects of repeated KC on stabilization of vital signs, how control-group infants are positioned, and limited time of KC episodes. Further research must be conducted examining the physiologic benefits of KC; however, it may be concluded that as long as premature infants are monitored, KC is safe. Further benefits related to parental attachment as well as the development of self-regulation in premature infants is strongly supported. Comment by Judy Beal toward evidence-based PRACTICE

Screening for abuse during pregnancy: implementing a multisite program.

Abstract: Screening for abuse at every healthcare visit is a standard of practice promulgated by many healthcare professional organizations. The need for such screening is underscored by reports of homicide as a leading cause of maternal mortality during pregnancy and the first year of the baby's life in Massachusetts and Maryland, and by the calculation of the costs of intimate partner violence in the United States. This article discusses how we addressed problems that arose in implementing screening for abuse in 13 different sites as a part of a clinical nursing research project. Engaging in clinical nursing research necessitates close relationships with clinical agencies and their staff members. This often means establishing and maintaining relationships with all nurses caring for patients in each clinical unit serving as a study site. For research on abuse during pregnancy, our study team members were engaged in interactions with prenatal care providers at 13 different study sites. Central to the study was implementing use of a standardized abuse screening tool, the Abuse Assessment Screen, at each study site. This article also describes the lessons we learned in attempting to implement such a large scale change in clinical practice.

Medications in pregnancy and lactation.

Abstract: The issue of medication use during pregnancy is of concern because the physiology of pregnancy affects the pharmokinetics of medications used, and certain medications can reach the fetus and cause harm. Studying medication safety in pregnancy and lactation is challenging; thus, the U.S. Food and Drug Administration (FDA) categories of medication risk in pregnancy are limited, especially for the lactating mother. A better understanding of the role of physiologic changes in pregnancy, placental function, effects of medication on the fetus, and the mechanisms of drug transfer into breast milk can help nurses teach their patients both preconceptionally and during pregnancy and lactation. This article provides a review of current literature so nurses can become more aware of the basic principles involved in medication use for pregnant and lactating women.

Herb use in pregnancy: what nurses should know.

Abstract: During the last decade, there has been a dramatic rise in the availability and use of medicinal herbal preparations. Childbearing women are among those who are asking nurses about herbal use, and therefore nurses need to learn more about this topic. One of the most important points to understand is that in the United States herbs are classified as dietary supplements (not drugs), and manufacturers are therefore not required to provide proof of efficacy or safety before selling these substances. Few studies about effects of herbs have been conducted in the general population, and fewer still have been published about pregnancy use. Because the perinatal nurse has two patients to consider when caring for a pregnant woman, he or she has two equally important mandates: to help the mother without harming the fetus. This article provides an overview of key concepts underlying herbal use in general and also safety in pregnancy. Common herbs that can be safely be used in pregnancy are presented in detail to enable the nurse to better care for the pregnant woman who is considering herbal use.