Response
Debate on articles in Contemporary Nurse
Susan Tregoning
School of Nursing and Midwifery, University of South Australia, SA
PP: 004 - 005
Article Text
In response to Chris Spencer's Soapbox: The politics of pap smears Vol 4(3), there are several points I wish to raise. I concur with the author's view that having pamphlets in various languages explaining the pap smear procedure will not in or of itself encourage women, for whom English is not their first language, to have a pap smear. Furthermore, I agree with the issue of nurse practitioner provider numbers as an issue of increasing importance. However, far more difficult and damaging elements to eradicate than cultural blindness or disputes over 'professional territory' in terms of increasing women's willingness to submit to 'well woman' screening, are the assumptions held by most women as to the purpose of the pap smear test and what an abnormal result might mean.
In my experience as a women's health nurse practitioner at the Adelaide Women's Community Health Centre, I found many women believed the pap smear test was to 'detect cancer' and an abnormal result meant a 'positive' result, that is positive for cancer and treatment would necessitate a hysterectomy at best. Given these assumptions, we must be cognisant of the inherent psychological 'cost' to the woman or 'Well woman' screening. In this case, the impact on her life when she is told she has a cervical abnormality requiring regular follow up, colposcopy and possible laser treatment. While we as nurse practitioners are aware of the subtle difference between pre-invasive CIN I, II, III and invasive cancer, women clients as a rule are not. Women are aware however, that much of the literature about cancer of the cervix suggests there is an increased risk of contracting the disease if they have had multiple partners and commenced (hetero) sexual activity at an early age because of the increased likelihood of being exposed to sexually transmitted diseases. Thus a diagnosis of a cervical abnormality also carries with it both the guilt and embarrassment of a sexually transmitted disease as well as the concerns that 'cancer' may be present and that they may die.
I am not suggesting screening for cervical abnormalities should be discouraged; in fact the detection of pre-cancerous lesions of the cervix is an ideal screening test allowing relatively easy intervention with a known good 'cure'. However, the psychological 'cost' to the woman who is not aware of this, cannot be ignored and it is on this aspect that we must focus our attention in our practice. Therefore, while agreeing with the proposed strategy put forward by this author as one possible solution to making the pap smear procedure more accessible to particular groups of women, I believe we must never underestimate the impact on a woman of an abnormal result and the fear of this may be a strong reason for her unwillingness to be screened. We therefore need to develop strategies in our practice to address these psychological issues as well as simply training more nurses.
Jan Thompson ELK RN DipAP Sci (Community Health) BN
Lecturer, School of Nursing, Flinders University of South Australia
In her article: Nursing as healing work Vol 4(3), Bev Taylor provides an eloquent and moving account of therapeutic nursing practices that are healing in nature. Through the power of the narrative, Bev Taylor places us at the 'heart' of what happens between nurses and patients and how healing work is enacted in service to patients. It is good to see the growing acceptance of the narrative in nursing research. Because of our oral tradition it is a style and method which provides ease of access to understanding complex practices.
In choosing to reveal and name therapeutic work as healing in nature, Bev Taylor contributes to an important dialogue about nursing practice. As pointed out by her in this article (and others such as Patricia Benner in her well-work on expert practice), the use of the therapeutic to describe the nature of nursing work is questionable. While its original use is consistent with nursing, the term therapeutic has become closely aligned with psychotherapy when it is applied to the nature of nurse-patient relationships. As such it conjures images of the distanced 'professional' who controls the level of interpersonal involvement in order to remain 'therapeutic'. Bev Taylor illustrates that healing work is not enacted though an aloof detached (and seemingly objective) stance, but rather an involved and enmeshed one. In using the concept of healing, she offers an alternative language that more closely captures the nature of nursing work.
The importance of healing work should be used to counter and resist movements such as ORCs and critical paths, which potentially threaten such work. While I would not advocate the quantification of such work through instruments to measure healing, we do need to be able to articulate that healing work produce positive patient outcomes, and that its absence is deleterious to patients' well being and recovery. We must be able to clearly demonstrate the difference that such healing work makes, in ways that are understandable to those who wish to treat health as a commodity and commercialise its delivery. If we are unable to do so, I fear healing will be relegated to the space of a 'warm fuzzy' notion that is impracticable in today's world.
The challenge now is to push the research agenda further so we can demonstrate that healing connections between nurses and patients positively affect patient outcomes, and that their absence of such creates unnecessary patient suffering. Perhaps it was not her intent, but in this article Bev Taylor has presented to us a challenge to demonstrate that healing work is not only legitimate but vital to effective health care.
Jane Stein-Parbury RN BSN Med
Associate Professor, Faculty of Nursing, University of Technology, Sydney
We wish to comment upon the value of the article written by Dr O'Brian, Ms Bradford and Professor Gibb entitled 'Nine steps to better nursing management of incontinence' Vol 4(3). The authors are firstly to be complimented on their choice of topic. Incontinence is one of the three major factors viz mental confusion, incontinence and immobility requiring admission to extended care settings and yet so often incontinence is a condition which is taken lightly, viewed apathetically or it is considered as inevitable and a nuisance factor to both elderly residents and staff who believe that little can be done. The development of the Nine Steps Assessment Model which appears to be an extension of the existing and well-known nursing process is another instrument enabling ward clinical nurses to have other options for the management of patients with continence problems. There is little doubt that this model expands the body of our nursing knowledge.
The Model has been developed based on the results of researching six patients in an extended care setting and the subsequent consultation with the practicing nurses via a survey. The feedback by the surveyed nurses was positive. Apparently, the next step of their action research is to involve more nurses to try the Model and not the outcome of the trials so as to establish the reliability and validity of the instrument. We are happy to give it a go and wish them every success. However, from our clinical experience and research funding, we are concerned about some of the constraining factors which have been hindering nurses' efforts in fighting this annoying clinical phenomenon. The factors such as the prevalent ageist attitude towards the elderly in our society, the passivism among some nurses and their lack of knowledge, skills and flexible strategy in the management of incontinence in an institution, and the lack of resources including human and facilities, vividly hamper the effort of health professionals (nurses in particular) to dramatically improve the dreadful situation. Implementing another model by not tackling these restrictions, may add to the nurses' scepticism about the purpose of this new practice which they may see as another academic activity. As some nurses pointed out in our previous research the 'It' (the continence program) is good in theory by not in practice.
Louis Wong RN BAppSc (Ad Nsg Ed) M Gerontology
Lecturer in Nursing, Victoria University of Technology
Diane Rees RN RMN Cert. Gerontology Nsg Cert. Nsg Home Management
Deputy Director of Nursing, Cranbourne Private Nursing Home
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