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Pelvic examinations involve much more than good speculum technique. Researcher Dr Catherine Cook addressed the recent NZNO Women’s Health Section conference about what Māori women reported made a gynaecology exam into a positive experience they were willing to repeat. FIONA CASSIE reports.

A welcoming smile, a caring question about family and taking time to build a rapport – these all have little to do with speculum technique but were as important or more important to the women interviewed by Dr Catherine Cook about what made a gynaecological examination go well.

The Massey University School of Nursing researcher spoke to the recent NZNO Women’s Health Section about her recently published research looking at optimising cultural safety and comfort during gynaecological examinations.

She interviewed 10 women who identified as Māori as part of a larger study involving 16 female patients and 16 clinicians (including 10 doctors). The 10 women were aged 18–54 and between them had undergone160 speculum examinations.

Cook said the study built on her earlier doctoral research, which found that compliance is influenced strongly by the clinician’s actions and words. These include the clinician’s attention (or inattention) to power relations, rapport-building, attentiveness to the patient’s comfort (or discomfort), their technical skill and their gender.

Cultural competency requires nurses to reflect on the significance of their own cultural identity and its impact upon their nursing practice, says Cook. This includes nurses having an understanding of historical and social influence on health and not just a narrow awareness of rituals and practices. It also requires a  mindfulness of the power relations between clinician and patient and the ability to adapt care to meet diverse needs.

It’s the little things that count

Sometimes it is just getting the simple but very important things right – like the mihi or welcome that women receive when arriving at a clinic for a pelvic examination. Or as one interviewee told Cook:

How do clinics offer me a service that fits with me being Māori? Not every part of me is about being Māori but when I got there the receptionist was really busy but she looked up and she smiled… she had noticed me and I felt kind of really invited, I felt like I’d been welcomed. And then another woman who had brown skin who might not have been Māori, she turned around and she said, “Oh, kia ora, welcome,”... it felt like she was so happy to see me and from that moment my experience… became positive because suddenly yes, I was in the right place.”

Cook says whanaungatanga (a sense of belonging through relationships of shared experience) is also very important and women she spoke to who had longstanding, trusted relationships with their clinicians talked about feeling a sense of kinship with the clinic team. One interviewee put it this way:

I’ve been coming to this clinic for about 16 years... the staff are really friendly… and they can help with any needs of whatever’s happening ‘down there’….they’re soft people, because it’s all sensitive things that go on here... Mum having cancer – when I came in last week she [nurse] goes, “How is your Mum?” So like it’s not only what’s happening there [indicates pelvic area], she remembers so it’s like you’re valued, you’re not just another patient.”

Another skill emphasised was a clinician’s ability to listen, alongside their readiness to take the time to build a rapport and to explain and inform women about the examination and the timeframe for what could happen next. In addition, a willingness to take a collaborative approach to the examination, and any follow-up interventions, including a readiness to agree to go only as far as the patient was willling to go at that time, was also very important.

“For examinations to go well, women required clinicians to listen responsively, with a focus on the whole woman,” says Cook. “Listening was rendered extraordinary in that these experiences were uncommon and stood out to women.”

Much more than a privacy issue

Clinicians also need to be aware that examinations and sexual health talk are tapu during consultations, says Cook. For women to feel safe when normal bodily boundaries were broken, like having a pelvic examination, they emphasised that it was about more than just privacy. One woman put it this way:

“In terms of my own sense of self and my body, I’m very comfortable with my body... It’s not a privacy issue around privacy of the genital area but is around as a Māori needing a connection with the practitioner, with the receptionist, with all the people involved before I’m allowing people in my space.”

Pain is never welcomed as part of a pelvic examination but Cook says it is the clinician’s attention or inattention to the woman that can be more memorable and upsetting than any pain. Such a memory was shared by one interviewee:

“The procedure itself wasn’t painful but at one stage, she said, ‘You’re making it hard for me because you’re all tight.’ I thought, ‘Are we surprised by that!’ It was something like, “Relax, relax!’ [screeching]. She was really pissy [angry] with me. I said, ‘How do I do that?’ I’m quite kinaesthetic. I need things like, ‘Flex your toes’.”

Cook ended her conference presentation with some take-home messages based on a short Māori proverb: aahakoa he iti he pounamu(although it is small, it is a treasure).

“Although a speculum examination may seem like a small procedure, it is a treasure of an opportunity to engage with women in supporting them to value their health, and to demonstrate health professionals’ valuing of women,” says Cook.

“Although one health professional may wonder about the difference they can make, the data showed that when these women experienced culturally safe clinical practice, there was a ripple effect – they returned with their daughters, their relatives, their friends, and stayed connected with particular services and practitioners for years.”