UPDATE ARTICLES
Strategies for de-medicalizing the gynecological nursing appointment
Carla Marins SilvaI; Octavio Muniz da Costa VargensII
I Obstetric Nurse. Doctor of Nursing. Associate Professor, Faculdade de Enfermagem, Universidade do Estado do Rio de Janeiro. Researcher, Núcleo de Estudos e Pesquisas Enfermagem, Mulher, Saúde e Sociedade. Rio de Janeiro, Brazil. E-mail: carlamarinss@hotmail.com
II Obstetric Nurse. Doctor of Nursing. Professor, Faculdade de Enfermagem, Universidade do Estado do Rio de Janeiro. Leader, Núcleo de Estudos e Pesquisas Enfermagem, Mulher, Saúde e Sociedade. Rio de Janeiro, Brazil. E-mail: omcvargens@uol.com.br
ABSTRACT
Gynecological appointments are invasive towards women in a number of ways relating mainly to medicalized procedures, indiscriminate use of technology and excessive manipulation of women’s bodies. This article points to strategies and opportunities to de-medicalize the gynecological nursing appointment. In this context, nursing staff should give women clients an active role, be ready to consider all aspects of their lives and share with them any decision-making on subsequent manipulation of her body. The usual dynamics of the appointment should change towards a relationship of constant exchange between client and nursing staff. If practice is to be non-invasive on principle, things must be done differently, which requires bold changes to counter the medicalized attitude to care. These strategies seek to empower women and to respect their autonomy, independence and right to choose, and to acknowledge the value of their individual lives. Nursing based on a de-medicalized approach can contribute to establishing a humanized model of women’s care.
Keywords: women’s health; nursing; gynecology; gynecological appointment.
INTRODUCTION
The gynecological appointment is fundamentally important to the exercise of sexual and reproductive rights, besides preventing health disorders. However, as a setting for nursing care, the gynecological appointment is invasive of women in a number of manners connected with the set of medicalized practices involving indiscriminate use of technology. As a result, women patients are deprived of their autonomy and allow nursing staff to decide what type of conduct is appropriate, including excessive manipulation of their body, on the basis of a practice that is normative, prescriptive, hierarchized and performed from the outside in. Accordingly, during the appointment, women may not display their true health care requirements by, for instance, discussing their sexuality, fears, doubts or embarrassment, but rather are steered towards thinking only in terms of pathology-related complaints or signs and symptoms.
This situation has resulted from the dominance of the technocratic bio-medical model of care over the humanistic model. The former assigns more value to technicism and the supremacy of the institution over the individual. Nonetheless, this model, although current, is insufficient to meet all women’s needs and demands, especially at a gynecological appointment1.
The technocratic model assumes the separation between mind and body and regards the body as a machine, that is, it rests on the concept of separation. Note that, on this model women, are considered to be imperfect machines; as patients, they are treated as objects and health personnel are alienated from them; diagnosis and treatment are performed from the outside in; care is organized hierarchically and is standardized; authority and responsibility lie with the health care personnel and not the patient; science and technology are over-valued; interventions are aggressive and emphasize short-term results; death is considered a failure; and the system is profit-oriented and intolerant of other modalities of care2.
By contrast, the humanistic model rests on the connection between mind and body, and treats the body as an organism; the client is made the subject of the relationship; diagnosis and cure occur not just from the outside inwards, but also from within; the patient’s needs are balanced with those of the institution; decision making and responsibility are shared with the patient; science and technology are offset against more humanized care; the emphasis is on prevention; death is regarded as an acceptable possibility; care is motivated by empathy; and an open mind is maintained towards other modalities of care2.
In that context, de-medicalization is regarded as offering women other care options that coexist with the women’s right to choose and their autonomy, disallowing clinical-medical reasoning as the only possible alternative, but without excluding medical professionals or practices from care1.
In that light, the purpose of this article is to point to strategies and opportunities for de-medicalizing women’s nursing appointments. We believe this is important in that nursing based on de-medicalization can contribute to establishing a humanized model of women’s care.
THE PROCESS OF DE-MEDICALIZING WOMEN’S CARE
De-medicalization cannot be understood without first understanding the process of medicalization. This can be understood in three different ways. The first relates to society’s introduction of the capitalist mode of production, which set the focus on individual medical care3, instituting medical power and expertise4 and social control by transforming everyday problems into deviant or pathological occurrences, leading people into disharmony with their environment5.
Accordingly, the process of de-medicalization reveals this unseen power that invades women’s mental structures without their knowing, without their perceiving that they are reproducing a power structure that places them at a disadvantage in relation to men6.
One example of de-medicalization is the use of non-invasive technologies in nursing care. Care technologies are defined as all techniques, procedures and knowledge used by nurses in the process of caring for patients1.
Studies of care at childbirth discuss the concept of non-invasive care technologies, which are procedures whose practice rests on the following requirements: nurses should have no wish to be the subjects of the care process, the woman patient is the focus of care; nurses should not regard the process as merely biological, but entertain the possibility of other experiences arising under other cultural, social, environmental and mystical influences; nurses should believe that the process of caring (rather than controlling) admits the use of intuition, instead of rational practices, as signaling care procedures; and nurses should uphold the right to privacy and safety: any procedure that is invasive of the body should be performed only after authorization by the woman patient1.
In the context of the gynecological appointment, health personnel should give women a role as active agents, which includes considering all aspects of their lives (biological, psychological, social and cultural influences) and sharing decision making on subsequent body manipulation. An internal disposition to de-medicalize has to be developed as an attitude in favor of humanization in order for non-invasive care technologies to be applied. As a result, health care personnel should develop an anti-technocratic attitude and rid themselves of so-called truths imposed by scientific rationality, thus also freeing the subject of care from invasion by medicalization6,7.
STRATEGIES FOR DE-MEDICALIZING THE GYNECOLOGICAL APPOINTMENT
In order to put de-medicalization into practice in the gynecological appointment, the habitual dynamics of the appointment has to be altered to show that it can be different and even pleasurable. The relationship between client and nurse should consist in a constant exchange in which the nurse reveals herself to the patient just as the patient reveals herself to the nurse. As mentioned above, practicing the principles of non-invasive care entails doing things differently, and daring to change away from the medicalized attitude to care.
Certain strategies based on the guiding principles of non-invasive care technologies can be used. These can be employed by nursing staff in their day-to-day care for women.
Physical and relational care practices are among the fundamental components of the appointment work process. The relationship between nursing staff and client should not be limited to performing technical procedures, because mechanist technique can distance the subject of care8.
In order to provide humanized gynecological care it is important to forge bonds. The relationship between the nurse and the subject of care should be understood from the outset as a form of intervention and/or treatment and not merely as an instrument for collecting the information necessary for a diagnosis9. Here, nursing staff can contribute to women patients’ satisfaction, to shared decision making in planning health actions, better treatment adhesion and improved quality of life. By behaving affectionately, looking them in the eye, calling them by name and touching them, and not leaving them alone, nursing staff encourage their women clients, demonstrate concern and impart reassurance7. Note that in order to build that bond nurses must be capable of identifying non-verbal cues given by gesture, gaze, smile and so on10. From this new perspective, nursing staff are challenged to change the way they approach patients and come to see the body as a being-in-the-world11. In that light, nurses come to regard the process as one of caring rather than controlling, and admit intuition as signaling care procedures that can be appropriately proposed and/or engaged in.
One example of a strategy that can help make appointments more welcoming to women is to eliminate the interview table. In that way, nurses eliminate not only a physical barrier, but also the symbolic barrier that this represents in the space where they communicate with women clients7. The institutions and environments where appointments take place have always favored the work of the health professionals, and have favored them ergonomically and technically to the detriment of providing an environment that is welcoming to clients. Therefore, such environments should be modified in order to break definitively with the technocratic model of care: the physical space and furniture should be tailored to meet the expectations of the clients, who are the real subjects of the care given there7.
Note that a gynecological appointment should create an environment that, although breaking with the traditional design to which both patient and nurse are accustomed, continues to respect women’s privacy and safety.
As part of that change, decision making can be shared, so that care is not based solely on professional expertise. Rather, nurses should consider the possibility of other kinds of knowledge and admit the possibility of cure and treatment deriving from ideas other than their own: they should give consideration to whatever originates from their women patients. That is to say, nurses should not see the process as solely biological. When enough information has been exchanged, then the next step can be taken, which is towards the care procedure proper, such as a pelvic examination and collection of material for cytology testing, a breast examination or a discussion of the woman’s main complaints.
Another example as regards empowering women is the breast self-examination. Although this examination may not actually form part of the particular woman’s life, for a long time it was considered a fundamental procedure in the breast cancer prevention program with a view to early diagnosis of possible lesions. At present, based on care from the standpoint of scientific rationality, the self-examination has ceased to be considered an essential activity for prioritizing use of mammography and other procedures that are more effective in achieving early diagnosis of breast cancer7-10,12. In the context of non-invasive care technologies, nurses should prioritize women’s knowledge of their own bodies as a fundamental condition for humanized care, and recognize breast self-examination as an important empowerment strategy. By incorporating this procedure, women are led to touch their own bodies and make a point of looking at themselves7. Note that this is not to deny advances in technology nor the importance of using them for early detection of breast cancer. However, concomitant use of self-examination is believed here to serve, among other things, as a path to encouraging women to seek professional care and more sophisticated diagnostic and treatment procedures more often.
One fundamental component in non-invasiveness is to wait for the right moment to undertake any manipulation of a woman’s body on the basis of an actively shared decision. When such manipulation is appropriately delayed and the decision to conduct such procedures is not imposed, body manipulation ceases to be invasive in nature. By acting in this way, nurses respect women’s privacy and security by only performing any invasive procedure once authorized by the woman client as the outcome of a shared decision.
The gynecological appointment involves a series of procedures that can cause dread, fear, discomfort and shame13.
One relevant example of a strategy for averting fear is to hand over the vaginal speculum to the woman: the gesture offers the woman the opportunity to learn, see and feel for herself. In this way, the instrument and its meanings come to form part of her lived experience. Remember that, in this way also, by transferring the focus of care to the client, the nurse ceases to be the subject of the care process.
This simple gesture is an important strategy for women to salvage their autonomy, become active agents in the care process, improve their self-esteem in socialization processes, reduce anxieties, shame and taboos, and manage to achieve a change in attitudes – besides making it possible to incorporate the non-invasive dimension into care. This way of proceeding to the examination enables women to learn about their own bodies and who they themselves are, and thus constitutes one way of empowering women7. What is important is for women to recognize that when they learn about their own bodies they are discovering the path towards a healthier life and a real awareness of their existence in the world14.
CONCLUSION
This article presented some strategies that can be employed by nurses in the process of de-medicalizing nursing care during gynecological appointments. It is an attitude that offers women patients opportunities to expand their self-knowledge, and helps to enable them to make their own demands and decisions.
These strategies are designed to empower women patients, to foster respect for their autonomy, independence, and right to choose and to restore recognition for the value of their individual life experience. In this way, nursing can contribute to establishing the humanistic model of care.
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Received: 27.03.2012
Approved: 25.11.2012