Suggestions for Physicians and Primary Care Nurses

Printer-friendly version

As primary care providers, physicians and nurses are most likely to have the opportunity to build an ongoing professional relationship with patients. If you anticipate having a long-term professional relationship with a patient, you may consider incorporating a question about a history of abuse in taking the family history. Primary care practitioners are in an important role to coordinate the treatment plan for abuse survivors and help ease referrals. The following are ways to help survivors of abuse.

1. Practitioners in our study suggested an approach of "Universal precautions"
   • Routinely ask patients how you could help them feel more comfortable with the examination, procedure, or test, and if there is anything they think you should know before proceeding. Consider a possible abuse history if patients show signs of anxiety or tension. A "universal precautions" approach indicates an awareness of the prevalence of abuse, and sensitivity to any signals that may suggest an abuse history. It also demonstrates respect for the patient and offers them control and input into the test, examination, or procedure without necessarily needing to disclose their history.

      

2. Become more informed about childhood abuse
   • A patient's disclosure of past child abuse can be very intimidating for health care providers who may feel ill equipped to address the implications. Educate yourself about the long-term effects of abuse in ways appropriate to your scope of practice.
     
   • Be aware of possible effects of abuse over the course of a woman's life cycle (e.g., in relation to pregnancy); in relation to specific chronic conditions or health concerns.
   • Learn about strategies survivors have used for addressing particular fears they may have in a clinical setting.
   • Become knowledgeable about educational resources for women and caregivers that address the link between abuse experiences and health and how and where to find supportive health services.

    

3. Make your clinical setting more client-friendly
   • Most medical environments are intimidating rather than accommodating to patients. Provide a comfortable office environment for patients, particularly if they choose to disclose an abuse history.
   • Making small changes to the physical environment (e.g., cartoons, artwork, adjustable lighting, music, and informational posters on walls) can ensure a safe and welcoming environment to anxious clients.
   • Pamphlets or articles in waiting areas should describe what patients can expect from medical examinations. Materials that mention abuse and that it can be a part of a patient's history may also help.

    

4. Approaching patients
   • Use a gentle touch, it is less frightening.
   • Use relaxation techniques with women who have difficulty with certain examinations.
   • Be aware of cultural and/or other differences where women have disabilities, are immigrants or visible minorities from diverse cultural backgrounds, are aboriginal, have literacy challenges, or are lesbians.

    

5. Respect boundaries
   • Use curtains, ample cloth gowns appropriate for all sized women, knock or gently announce before entering the examining room, and discuss sensitive information only when women are sitting and dressed.
   • Ask patients beforehand if they would mind somebody in training being involved in the examination or procedure. Include a description of the sex and status of the person, and ask this question ahead of time without the person standing there, so patients are given the option, without having to say in front of somebody, "No I don't want you there."

    

6. Find ways to provide patients with a greater sense of control and comfort over procedures
   • Offer an initial appointment just to talk.
   • Involve the survivor in care and plan treatment together.
   • Provide a checklist that helps women identify which concerns they have about the health care encounter (e.g., discomfort with certain procedures, boundary issues and others).
   • Ask patients for ideas to make the examination or procedure more comfortable (e.g., specific signals to stop or have a time out)
   • Start with a straightforward procedure with patients who require a lot of time and are fearful. Also, suggest the patient come back another day.
7. Use interdisciplinary team meetings, hold case conferences, debrief with others, and share ideas and strategies for different ways of improving care for women survivors of abuse.
8. Help patients stay in the present and avoid dissociating
   • Use the patient's name.
   • Help them to stay connected by asking for example, "Are you able to hear me? Is this okay?"
   • Engage the patient in what is being done in each part of the examination, test or procedure (e.g., what you are doing and why), rather than in talk that distracts from what you are doing.
9. Integrate survivors' suggestions into your work situation

   The women interviewed with histories of CSA made suggestions for providing care to make things easier for them.

   • Having a support person with them
   • Being asked before any examination what might make it easier
   • Having examinations or procedures fully explained
   • More privacy in terms of gowns/drapes
   • Dimmer lights or brighter rooms
   • Being able to see a practitioner of a specified gender to perform certain procedures
   • Giving patients the option to stop or pause the procedure

    

10. Let the patient know that she can stop the procedure or exam at any time if she finds it too uncomfortable and that you will respect her wishes and limitations.

    Let patients choose to use clinic-issue drapes or keep on some of their clothing during an examination. Leaving their shirt and socks on under their gown is warmer and may make them feel less vulnerable.

    Allow the patient to see and handle a speculum and use the smallest speculum that allows adequate visualization.

    During prenatal visits when you listen to the fetal heartbeat, explain to patients how this will be done; e.g. "This is the gel and unfortunately it will feel cold..." etc.

    For a woman with unusual fear of surgery, work out a plan. This may involve offering to accompany her into the operating room and staying with her throughout the operation.

    Use examining tables that can be height adjusted for women with disabilities, and improved supports for legs during pelvic examinations.

    During pelvic examinations and other procedures where draping a sheet is used, arrange the sheet so that the patient can maintain eye contact throughout the procedure.

    Adjust the exam table to enable the patient to be partially sitting for the exam. This may help her feel more empowered and enables visual contact to be maintained.

    Allow ample time and flexibility for examinations by deferring Pap tests until the patient is ready or divide the examination into several office visits.

    Use clear, respectful language in examinations such as Pap smears, internal exams, STD checks, routine breast exams, and pelvic ultrasounds.