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Promoting dignity during cervical smears: a practical guide

Sarah Challinor explores the relevance of the concept of dignity during cervical smear consultations and makes practical suggestions for improving practice. Practice nurses have a crucial role in the screening process and must have an understanding of what dignity means to clients and how to maintain it

Sarah Challinor
BSc(Hons) Dip(HE) RN
Family Planning Nurse with Special Interest in General Practice and Women's Health

The value of cervical screening is undisputed; mortality has reduced significantly since the introduction of a formal screening programme.(1) Despite such benefits, screening is a cause of anxiety influenced by social and educational factors, and predominantly focused on fear of positive results and stigma related to misconceptions about promiscuity.(2,3)

Need for change
Strategies to reduce anxiety are commendable.  However, nurses should ensure that efforts are not concentrated on women displaying signs of anxiety. Furthermore there is evidence to suggest that nurses adopt standardised routines potentially resulting in task-oriented care.(4) Nurses could influence uptake of screening, which has seen a slight decrease particularly among young women over the past few years.(5) Improvement of patient experience could inform peer information-sharing, as discussion of the test can sway decision-making.(6)
A cervical smear test is an invasive procedure that requires women to willingly expose their genitals and adopt a recumbent position, which can cause feelings of vulnerability, embarrassment and disempowerment. Although it is possible that most women view the test as an accepted part of womanhood, dignity and communication remain important. It is proposed that by focusing on the broader concept of dignity, deleterious aspects can be minimised with less women feeling they are treated as tasks or disembodied objects.(7,8)

Theoretical perspectives
It is accepted that nurses must do all that is possible to promote dignity, which is defined as "being worthy of respect". However, a literature search identified that the relationship between dignity and cervical smears has not been explored.(9-11) Most studies identified anxiety following positive results, some touched upon dignity, but none defined how dignity could be promoted during screening.
Although there is much commentary about dignity, especially in gerontology and palliative care, there is little research exploring what the concept means to nurses and patients. A small study aimed to uncover perceptions of dignity and identified themes common to nurses and patients (see Table 1), which have parallels to those cited in the Essence of Care (see Table 2).(11,12) Another study identified themes important to maintenance of dignity, including being treated with respect, privacy, staff characteristics/resources and environment.(10)
In the absence of studies exploring the relationship between cervical smears and dignity, it is appropriate to consider the themes uncovered in the research and devise strategies that may promote dignity and meet Essence of Care benchmarks. The strategies are not intended as a "how to" guide for cervical smear taking, which are widely available in the nursing press. Additionally the concepts of ethnicity, sexuality and disability are not discussed, but require further consideration within clinical practice.

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[[nip38_table2_24]]

Organisation and environment
An evaluation of organisational and environmental factors is essential with failure to consider impact of such factors affecting consultation quality. It is not unknown for practices to offer "smear clinics", whereby smears are taken on certain days or at certain times of the day. Smaller practices may not have the resources to offer testing throughout the working week; however, such rigidity can pose considerable difficulties for women with childcare needs or commuters who require early morning or late afternoon appointments.
If a client finds making an appointment problematic, she may attend stressed or resentful or may not attend at all. Women need flexibility in choosing a time to suit themselves, which can promote feelings of control. If suitable appointment times are not available, women should be directed to services such as family planning clinics.
Appointment times should be long enough to prevent clients feeling rushed, which can compromise dignity; women may decide to use the consultation to open dialogue about sexual difficulties or contraception, and if there is insufficient free time to discuss matters some women may have unmet needs.(12) While many practices offer appointment times of 15 or 20 minutes, a longer consultation of 25-30 minutes would give women time to relax and perhaps find the courage to discuss difficult or sensitive problems. Employers are likely to resist such lengthy appointment times in view of the current general practice workload. However, nurses should negotiate using available evidence and with a clear argument as to how the clients and practice would benefit.
The physical environment can impact upon feelings of safety and privacy. esting should always be carried out in a private room, preferably with a lockable door (however, permission should always be sought prior to locking the door.) The couch area should have curtains or screens to allow the client to undress in private along with a chair or hook to hang clothes.
Delays or interruptions may prolong anxiety, and dignity may be lost if other priorities take over.(13) Once the client has been welcomed into the room, interruptions such as knocks at the door or ringing telephones, should, where possible, be ignored to enable the woman to feel that her needs are important.

Preparation of client
Careful preparation is essential to ensure informed consent and provides an opportunity for health promotion and to dispel commonly held misconceptions about the test, and for the nurse and client to get to know one another better before the procedure. Many women lack understanding about the test and consider poor or insufficient explanations as negative aspects of the test. It is appropriate to ask the client what she believes the test is for and to clarify misunderstandings.(2) Care must be taken to avoid a patronising tone; being treated of low intelligence can cause feelings of disempowerment and thus compromise dignity.(14)
Discussion is important in promoting a sense of dignity: "One of the most important ways of conveying respect for patient dignity is through effective and sensitive communication."(15) Communication is not restricted to dialogue, but should encompass environment and recording of communication, for example, where possible, physical barriers such as desks should be moved to create a less formal atmosphere. Additionally, the client should be able to see what is being recorded in the notes, which can support a collaborative approach to care and may prevent anxieties about inappropriate recording when discussing sexual history.
A description of the procedure should be given in jargon-free language using pictorial aids where appropriate (eg, cervical smear diagram - see Resources), with leaflets offered to provide information at home; however, leaflets are not a substitute for adequate discussion. An evaluation of understanding should again take place using open questions such as "Is there anything else you would like to ask me?" or "Is there anything that doesn't make sense?" It is crucial, however, to allow clients free time in which to think and respond.

The procedure
Permission must be obtained before entering the curtained area to allow the client to feel in control of the start of the procedure and of her private space. To minimise exposure and reduce the time that dignity is compromised, the necessary equipment should be prepared prior to the consultation. Careful and compassionate preparation may have relaxed the client and allayed anxiety, but this may be in vain if the procedure has to be halted while a certain size of speculum is searched for.
Nurses have privileged access to private areas of the body, and although we are familiar with anatomical peculiarities women understandably feel self-conscious. Some women cheerfully expose themselves with the commonly heard refrain of "Once you have had children, you lose all dignity!" However, such statements should never influence the approach, and maintenance of a private, secure space must be assured.
Women should be advised that they can stop the procedure at any time and reminded that there is plenty of time to take the sample. The concept of feeling rushed is especially important here as it is at this point that women may feel most vulnerable. Consent to commence the procedure should again be gained before drawing back any modesty cover or inserting the speculum. It is not unknown for women to stop the procedure when the speculum is introduced due to flashbacks of sexual abuse - touch can trigger painful memories, and nurses must be prepared to face difficult and perhaps harrowing situations and have appropriate resources including rape and domestic violence support networks available (see Resources).(14,16)

Continuity of care
Clients should be advised how and when they will receive results; it is equally important that they are aware of available support following the end of the consultation, which demonstrates care and concern throughout the screening process. Informing a woman that she is welcome to return or telephone for a discussion of results could prevent anxiety and promote development of the relationship, indeed guidance makes the smeartaker responsible for communication of results and appropriate follow-up arrangements.(17)
Research demonstrates that nurse intervention following receipt of abnormal results can reduce anxiety. While it is unlikely that educational interventions will become widespread, the benefit of access to a familiar professional should not be underestimated.18 Professional experience confirms that some women like to return to discuss results, which provides time to explain the colposcopy procedure if indicated, and allows private space to express anxieties. Useful resources can support follow-up consultations, which in turn can promote dignity in enabling clients to feel in control of their healthcare and being acknowledged as a person.

Conclusion
In spite of employing the strategies mentioned and striving for patient-centred care, some women remark that the procedure is "undignified". It is possible that despite the best of intentions many women continue to feel that their dignity has been compromised, which may plausibly be due to negative body image affecting self-esteem rather than professional skills.(19)
Nurses need to be familiar with dignity as an essential concept in the screening process and use reflective skills in analysing their own practice in order to improve care. Auditing of smear quality is obligatory; it is logical to suggest that nurses should also audit the overall consultation.(17) The audit tool seen in Table 3 can be used to analyse practice with results informing learning needs. In addition, nurses must be up-to-date and aware of evidence-based guidelines to guard against the potential threats to dignity of outdated or unsafe clinical practice.

[[nip38_table3_26]]

Although much in cervical screening requires precision, the perfect method for ensuring dignity does not exist; moreover it is clear that research is needed to illuminate what dignity means to women during cervical screening. However, by remaining aware of the importance of dignity to women throughout the consultation, much can be done to ensure transiency of negative aspects of the test, improve overall satisfaction of the experience and potentially shape future help-seeking behaviour.

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References

  1. Peto J, Gilham C, Fletcher O, Matthews FE. The cervical cancer epidemic that screening has prevented in the UK. Lancet 2004;364:249-56.
  2. McKie L. Women's views of the cervical smear test: implications for nursing practice - women who have had a smear test. J Adv Nurs 1993;18:1228-34.
  3. Balieff A. Cervical screening: patients' negative attitudes and experiences. Nurs Stand 2000;11:35-7.
  4. The Information Centre. Cervical screening programme England 2005-06. London: Office of National Statistics; 2006.
  5. Chew-Graham C, Mole E, Evans LJ, Rogers A. Informed consent? How do primary care professionals prepare women for cervical smears: a qualitative study. Patient Educ Couns 2006;61:381-8.
  6. Neilson A, Jones K. Women's lay knowledge of cervical cancer/cervical screening: accounting for non-attendance at cervical screening clinics. J Adv Nurs 1998;28:571-5.
  7. Bush J. "It's just part of being a woman": cervical screening, the body and femininity. Soc Sci Med 2000;50:429-44.
  8. Robinson G. Plastic specule: an aid to promoting attendance at cervical screening? Pract Nurse 2005;30:46-9.
  9. Haddock J. Towards clarification of the concept 'dignity'. J Adv Nurs 1996;24:924-31.
  10. Gallagher A, Seedhouse D. Dignity in care: the views of patients and relatives. Nurs Times 2002;98:38-40.
  11. Department of Health. The essence of care: patient-focused benchmarking for health care practitioners. London: DH; 2001.
  12. Walsh K, Kowanko I. Nurses' and patients' perceptions of dignity. Int J Nurs Pract 2002;8:143-51.
  13. Shotton L, Seedhouse D. Practical dignity in caring. Nurs Ethics 1998;5:246-55.
  14. Miers M. Gender issues and nursing practice. Basingstoke: Macmillan Press Ltd; 2000.
  15. Price B. Demonstrating respect for patient dignity. Nurs Stand 2004;19:45-51.
  16. Clifford D. The courage to listen. In: Wells D, editor. Caring for sexuality in health and illness. Edinburgh: Churchill Livingstone; 2000.
  17. Royal College of Nursing. Cervical screening. RCN guidance for good practice. London: RCN; 2006.
  18. Somerset M, Peters T. Intervening to reduce anxiety: do we know what works for women with mild dyskaryosis? J Adv Nurs 1998;28:563-70.
  19. Burnard J, Morrison L. Body image and physical appearance. Surgical Nurse 1990;3:4-8.

Resources
Association of Psychosexual Nursing
W: www.wanstead.park.btinternet.co.uk

British Society for Colposcopy and Cervical Cytology
W: www.bsccp.org.uk

Patient UK: cervical
smear diagram
W: www.patient.co.uk/showdoc/21692486

Refuge: domestic
violence helpline
W: www.refuge.org.uk

NHS Cervical Screening Programme
W: www.cancerscreening.nhs.uk/cervical

Rape Crisis: information of services in England and Wales
W: www.rapecrisis.org.uk
Relate: relationship and sex therapy
W: www.relate.org.uk

Skills for Health: Obtaining cervical cytology samples competence
W: www.skillsforhealth.org.uk/tools/viewcomp.php?id=4239

Women's Health Concern
W: www.womens-health-concern.org