Share Your Story: What Have You Learned About Your Body from a Women's Health Nurse-Practitioner Or Other OB-GYN Clinician?
By Judy Norsigian — November 5, 2010
Our Bodies Ourselves recently received a wonderful picture of pre-teen girls watching one of their moms get a pelvic exam, complete with mirror and flashlight, along with a note about how the nurse-practitioner conducting the exam explained everything that was being done in simple, straightforward language.
As a way to underscore how much young women across the country are able to learn about their bodies through such critically important show-and-tell learning, we are inviting women to share with us (anonymously is fine) stories of how nurse-practitioners and other ob-gyn clinicians (including nurse-midwives, family physicians and obstetrician-gynecologists) have taken the time to teach them more about their bodies through use of speculums (some with flashlights built in!) and mirrors, participation in the “whiff” tests, and other approaches that directly engage women in the learning process.
In an era where the “yuck” factor is used to inappropriately encourage risky douching practices and use of scent-filled vaginal products that may be harmful to overall vaginal health, it is important to remember how valuable this kind of education during a clinical pelvic exam can be.
Moreover, clinicians who incorporate these recommended educational practices are helping to offset a conservative trend toward restricting information about women’s reproductive and sexual health. Access to books like “Our Bodies, Ourselves” is denied in some schools and libraries; self-knowledge is considered shameful or even dangerous.
Please share with us your stories as clinicians who provide such exams or as women who may have benefited from them. You can either add your story in the comments below, or email email@example.com. And feel free to share and re-post this call
We plan to post these anonymously on the Our Bodies Ourselves website so that young women will be encouraged to respond with a “Yes” the next time their ob-gyn clinician might offer them the option of seeing their own cervix or learning more about their vaginal secretions.
We would also welcome emails and letters from ob-gyn clinicians who might be able to cite articles in the medical literature that point to the benefits of this kind of education.
Thank you for taking part in this discussion!
Although we can’t point to direct evidence of the use of mirrors in women’s health exams, as women’s health nursing educators, we are commenting generally on the competencies and practice standards required of advanced practice nurses and specifically on best practices for the assessment and management of sexual and reproductive health problems.
First, patient education is at the core of all nursing practice as outlined in the American Nurses Association essential nursing practice documents —Scope and Standards of Nursing Practice .
Regardless of specialty, all nurses are expected to incorporate education within every plan of care to facilitate patient adherence to treatment regimens and promote disease prevention and self-care.
At the advanced practice nursing level, core competencies for all nurse practitioners (NPs) have established that every plan of care include teaching, coaching and education. These core competencies which provide the basis for all NP program education standards can be found here and here.
For example, the NP is expected to “impart knowledge and associated skills to patients … [and] the coaching function involves the skills of interpreting and individualizing therapies through activities of advocacy, modeling, and tutoring.”
In addition, the NP is to provide guidance and counseling which fosters the patient’s personal responsibility for health that includes “verifying physical exam findings with the patient.”
Specifically, patient education and assessment standards related to women’s health care build upon these core competencies. Curriculum and clinical training must also incorporate the attainment of these essential core competencies as required by accreditation agencies.
Two examples from standard WHNP Curriculum:
• Physical and pelvic exam standards include patient education during the course of the assessment process. Patients are taught how to examine their skin for abnormal changes such as moles; men are taught how to inspect their genitals for infection or hernia and women are taught breast self-exam and normal vulvovaginal anatomy and physiology. Mirrors are offered to patients for inspecting skin lesions on their backs or in areas of the body that are difficult to inspect directly. Obviously, a mirror can be very helpful in the inspection of the vagina. The operative word is “offered” as no woman is ever forced to use a mirror during the course of the physical or pelvic exam. Narrative examples are suggested to NP students for helping patients to become engaged in the physical assessment process such as, “some women like to be able to see the inside of the vagina or the cervix…we have a mirror if you would like to look.”
• The standard of care for the assessment of vaginal health includes taking a swab of vulva, vagina and the exocervix and examining the secretions using microscopy. Diagnosing various infections also includes assessment of amines in the vaginal secretions using potassium hydroxide commonly called the “whiff” test. The whiff test, if positive, produces a distinct ammonia odor and this information, like any other lab result is shared with the patient.
In summary, the best practice for any clinician is to include learning opportunities in every health care visit. To reduce the risk of sexually transmitted infections and promote sexual health requires sensitivity and skill on the part of the clinician and is often overlooked by many health care providers. A clinician who does incorporate these “best practices” of pelvic self-exam and education should be applauded for exemplary practice.
Diana Taylor RNP, PhD, FAAN
Professor Emerita, School of Nursing
(former Director, Women’s Health Nurse Practitioner Program)
University of California, San Francisco
Lynn Stringer, PhD, RNC, RDMS
Professor, School of Nursing, Women’s Health Nursing
University of Pennsylvania
Colleen Keenan PhD, FNP, WHNP
Professor, School of Nursing
Interim Director, NP Program
University of California, Los Angeles
The question has come up as to whether use of a mirror during pelvic exams is an acceptable and desired practice and whether teaching women about normal vaginal flora by encouraging patients to look into the microscope and understand the purpose of a wet mount is also part of standard practice.
First, let me say that I am unaware of a specific written standard of practice for this. However, the practice is encouraged to help women to better understand their bodies and to take the mystery out of health care. It is standard in my organization’s sessions on advanced pelvic skills to teach nurse practitioners how to incorporate use of a patient held mirror during the exam.
In my own practice as an NP, I routinely offered patients the opportunity to use a mirror during the exam. I also routinely involved patients to look through the microscope so that they could see what I was seeing on the wet mount.
Because I did not want to rely on my own experience, in addressing this issue, I polled our internal email list of key women’s health NP opinion leaders. The response I received indicates that use of the mirror is a common practice and that many, if not most, exam rooms are equipped with mirrors.
With regard to involving the patient with microscopy findings, this appeared to be limited by whether the microscope was in an exam room or in another patient area. Time constraints for the visit also appeared to limit this practice. Otherwise, it appears to be a practice that is utilized when appropriate. In general, it is considered a good teaching tool.
The practice of using a mirror and involving the patient in the microscopic evaluation of vaginal secretions rather than being a standard of practice, is an enhancement of practice that is focused on health teaching.
There is no question that for many women knowledge of what is normal is lacking. As a premier nurse practitioner organization focused on quality health care for women, this is a practice that we can endorse to better educate our patients to know more about normal as well as abnormal functioning.
Susan Wysocki, WHNP-BC
President and CEO, National Association of Nurse Practitioners in Women’s Health
it was a NP at Planned Parenthood in Michigan City In. that taught me what normal discharge was when I was 15 years old and also told me not to douche. She is the one that took the time to explain to me why douching and hygiene sprays were bad for my vaginal health. I have been thankful to her for years because while my friends were douching I had the knowledge to tell them why they should not. I still hear myself repeating advice given to me some 15+ years later as I talk to my daughters.
I write from the dual perspective of having had clinical training in obstetrics-gynecology and public health. Patient education is key for both domains as individuals can only improve self care, comply with medical regimens and advice if they understand their bodies and health. Health education is a central tool for improving health on a population level as well.
Standards for the conduct of pelvic examinations include patient education and it is considered best practice for any clinician is to include learning opportunities in every health care visit. Too many clinicians avoid this because of its time consuming and sensitive nature. A clinician who regularly incorporates these “best practices” of pelvic self-exam and education should be applauded for exemplary practice. The American college of Obstetrics-Gynecology strongly supports clinicians’ efforts to educate patients.
Ideally, every obstetric and gynecologic clinician should offer women educational opportunities to learn about their bodies and physiology. The physical examination and associated laboratory investigations offer some of these educational opportunities. The conduct of practice described here for nurse practitioners is in keeping with current standards of care.
Wendy Chavkin MD, MPH
Professor of Clinical Population and Family Health and Obstetrics-Gynecology, Heilbrunn Dept of Population and Family Health and Dept Obstetrics-Gynecology
Mailman School of Public Health and College of Physicians and Surgeons