Not Just Another “Annual Exam”
Rose Theroux
Nurse and Client Views of an Encounter
Well-woman check-ups, also known as annual examinations, offer advance practice nurses an opportunity to assess health and promote wellness of women across the lifespan. Although regarded as a “routine” office visit by some, the following story of an encounter at an annual exam demonstrates the importance of these visits. The experience here is viewed through both the nurse and patient perspective.
The Nurse’s View
It was the usual busy morning at a suburban, private practice women’s health office. There was a flurry of morning phone calls that needed to be answered. A visit with a patient for a problem took longer than anticipated, and I was running late for my next scheduled appointment, which is not an ideal situation. Although LT was an established patient in the practice, this was our first encounter. As I walked down the hall, I noted her pacing in the waiting room, and hurried to begin our visit.
Because of the limited time, I decided to briefly scan her chart, and proceed with her history. L.T. was a 36 year-old married woman who had come in for her annual exam. As I entered the room her anxiety was visible. As I began to inquire about her past history, she reported that she had no complaints, and was just here for a check-up. Part of this exchange occurred as she paced the room, talking while she began to undress. My initial impression was that she was either in a rush, was very anxious, or that she wanted this visit to be through as quickly as possible. I sensed something about her, but couldn’t quite explain why.
I proceeded to sit and talk further before starting with the physical exam. I decided to try to get to know more about her, and inquired about her current situation, and eventually asked if she worked outside of the home. This one question created an opening for her to speak. She quietly told me the story of why she did not work. Approximately three years ago, her 12 year-old daughter was killed in an auto accident. She and her daughter were both at the side of a road, assisting someone whose car had broken down. Suddenly a car veered off the road. She herself received extensive injuries, and woke from a three-week coma to discover the loss of her daughter. She was hospitalized for several months. The scars from that hospitalization, although healed, are still visible. The internal scars are not, and have taken much longer to heal. Since that time she has been in recovery from the loss. She described feeling “a hole in my heart that would never heal.” The loss of her daughter is felt each and every day. Although she had been to counseling in the past, she found that faith and religion had proved more helpful to her in her recovery process. As her story unfolded, time stood still, and a quiet calmness pervaded the room. I felt the beginning of tears come to my eyes. She paused.
I could have expressed my sympathy for her loss, or even possibly given advice, or simply decided to continue on with her physical exam, but I didn’t. I felt an immediate understanding of her situation of living trough trauma and loss. Her story had triggered memories of a similar past experience with one of my children over 10 years ago. Although a different situation, it involved trauma and loss. I thought about what would be appropriate at this point, and I decided to share my experience and my feelings with her because of the connection I felt. I related my personal story revealing that even many years later, I did not have an answer for “why?” My story was followed by more sharing about her past and current feelings, and the difficulties that she was having in healing from the loss. Although she entered the room as a stranger, a bond had developed quickly between us. Since my own past experience had enhanced my sensitivity to and understanding of trauma, I felt that her experiences might help her to develop a special empathy and ability to help others dealing with trauma and loss. I could visualize her in a role as a psychiatric nurse practitioner, and urged her to consider this possibility.
After the examination, we completed the visit with a hug. I felt that possibly this was simply a beginning to a relationship that would unfold over time. Upon reflection, I felt that this encounter had been one of the most positive, affirming experiences that I had ever had during a patient visit. Apparently, she had a similar experience. A week later I received a note which read, “I want to tell you how very moved and thankful I am that you were willing to open up to me and talk about your situation. Not just our discussion about trauma, but the open sharing was healing for me. Thank you very much.”
The Patient’s View
Last summer I felt emotionally able to see someone other than my OB/GYN MD, and chose to see the nurse practitioner. I waited quite a while in the waiting room, and being in no hurry, speculated on what might be keeping her. Was it an emergency? Was it because she spent time with people, listening to them? Finally the receptionist calls my name and I enter the examination room, don the appropriate garb, and wait. The nurse practitioner isn’t long and after introducing herself she asks, “So, do you work outside of the home?” I answer “No,” and while she is responding, I know in my gut that she will be able to hear my story.
I tell her that I have been a visiting nurse for many years, but in January of 1999 my daughter and I stopped to help someone whose car had slid off the icy road and crashed in the woods. On our way back to our own car, far from the other vehicle, and as pedestrians, we were hit by another vehicle sliding on ice. We were thrown to the base of a stone wall. I was in ICU for two weeks and then in rehab; my daughter was DOA at the ER.
She listens. She just stops what she is doing, and listens. I feel known now, heard, a recipient of her unspoken caring. Then she says that she, too, has known tragedy. I think that might be all she is going to say; she’s waiting to see how much I want to hear. I ask her to tell me about it, and she does. She had a very similar thing happen in her family, not exactly the same, but terrible and horrible for her. We are no longer Rose the nurse practitioner and Sue the patient; we are two women telling deep, painful, meaningful truth to each other.
Then Rose asks if I feel ready to return to work. I don’t yet, and I tell her that I have been trying to find something that interests me, because hardly anything does right now. The only thing I have felt any attraction to among the many letters that come my way as an RN begging me to work, are those encouraging me to try psychiatric nursing. I’ve never done it, but I know pain, and I am drawn there.
Now Rose surprises me and opens up something new. “Oh, psychiatric nursing. I teach psychiatric nurse practitioners.” I never said the word practitioner, but this feels right. She talks as she examines me, excited to tell me about this program. I have caught her non-verbal caring, and I am paying attention. My worldview is telling me “God is speaking to you through Rose, pay attention.” And then Rose says something that makes me feel safe, secure, not a feeling I have experienced much since the accident – she looks down into the emotional pit in which I am standing, reaches down with her hand, and tells me that if I am interested in the program “I’ll be your contact. Stay in touch and let me know how you are doing.”
Personal knowing has occurred. We have shared our stories, and something brand new has come of it. I am seriously considering going to grad school! I go home and check out the school website. Gulp. I’d have to take GREs. I call the school and speak with a very nice secretary in the nursing department, you know, just to check on what the lowest acceptable GRE scores would be. Then this secretary tells me that I don’t have to be a matriculated student to take a course. Many grad students start that way. “And by the way, registration is tomorrow.”
Later on in that semester, during one of my first classes, we discuss readings about personal knowing. I hold up my daughter’s picture, and share my experience of having been the recipient of caring, of having experienced that knowing that happens in a place where words just don’t exist, that knowing called personal knowing.
Commentary
Several nursing concepts come to mind in thinking about this nurse-patient encounter. The most important one could be described as “connection.” Both listening to the client’s story and the sharing of personal details from one’s own life experience–if relevant to the client’s situation– can be extremely beneficial to establishing an immediate connection. A model of health care relationships proposed by Thorne and Robinson (1988) advocates reciprocal trust, and the values of mutual learning and self-disclosure. A common theme of mutual exchange is found in many of the theories of caring.
Watson’s (1988) concept of transpersonal caring identifies a therapeutically reciprocal process. Mutual exchange is demonstrated by mutual self-disclosure, exchange of humor, and efforts to enlist client participation in decisions about their care. According to Marck (1990), therapeutic reciprocity is “a mutual, collaborative, instructive, and empowering exchange of feelings, thoughts, and behaviors between nurse and client for the purpose of enhancing the human outcomes of the relationship for all parties concerned” (p. 57). Marck (1990) viewed the exchange between nurse and client as facilitating positive growth for both nurse and client. This sharing of insights within the encounter is seen to guide the decision-making process to outcomes that are best for each individual. The knowledge acquired during the interaction assists the nurse to understand the perspective of the client. When using the client’s personal knowledge in planning care, mutual learning takes place. Marck (1990) viewed therapeutic reciprocity as empowering because of the nature of the mutual responsibility for the relationship by both nurse and client. “Neither the client or the nurse holds sole accountability for the outcome of the encounter” (p 52). Outcomes of this phenomenon are shared meanings between nurse and client, sharing of control and responsibility, and empowerment of both the nurse and client, helping them to cope more effectively with the situation.
Another concept related to the nurse-client interaction is mutuality. Mutuality and reciprocity in the nurse-client relationship have been considered to be important by nursing theorists. Qualitative studies have provided a description of the caring in the relationship, the processes, and role of the nurse. Kennedy et al. (2004) identified mutuality as the foundation of the client-midwife relationship. Within the relationship, both midwife and woman were regarded as equals. Personal disclosure by the midwife is described within the relationship with the woman. The concept of mutuality requires “being open to the woman and what she brings to the relationship, and at times entails personal disclosure” (p. 16). Many of the stories from woman and midwives revealed personal connection, a partnership, and sometimes a friendship.
Swanson (1991) developed a midrange theory of caring through three qualitative studies with women in perinatal settings. These studies sought to define caring and identify essential processes that characterize it. Five processes were identified. Knowing is striving to understand an event and the meaning attached from another’s point of view. Being with means emotionally present for the client. According to Swanson (1991), being there conveys “sharing feelings, whether joyful or painful. . . the message conveyed through being with is that the other’s experience matters to the one caring” (p. 221).
Summary
What occurred at this encounter reveals the importance of each and every interaction that we have with our clients. Although some may indeed be “routine,” without any warning important issues arise. These provide us with opportunities to provide clients with a caring experience within the relationship. These encounters can have a major impact on both our clients and ourselves.
References
Kennedy, H., Shannonh, M., Chuahorm, U., & Kravetz, K. (2004). The landscape of caring for women: A narrative study of midwifery practice. Journal of Midwifery & Women’s Health, 49 (1), 14-23.
Marck, P. (1990). Therapeutic reciprocity: A caring phenomenon. Advances in Nursing Science, 13 (1), 49-59.
Swanson, K.M. (1991). Empirical development of a middle range theory of caring. Nursing Research, 40, 161-166.
Rose Theroux is a certified women’s health nurse practitioner and associate professor in the Graduate School of Nursing. She teaches an elective women’s health course in the GSN. At the time the article was written, she was working as an NP in an OB/GYN private practice office in Massachusetts.
