Factors of importance for developing a trustful patient-professional relationship when women undergo a pelvic examination

Abstract

We examined gynecological teaching women’s perception on what factors are important for developing a trustful patient-professional relationship when women undergo a pelvic examination. A qualitative research design was conducted with repeated focus group discussions. Our results show that healthcare professionals’ communications skills can strengthen a trustful patient-professional relationship. Treating women with dignity could make them feel less vulnerable and make the relationship trustworthy based on respect. Thus, having the ability to identify factors important for a trustful relationship may support healthcare professional’s ability to strengthen women’s health issues. A trustful relationship might also affect quality of care.

As part of a qualitative inquiry about the patient-professional relationships, the authors’ focuses in this study on which factors is of importance for developing a trustful relationship. The researchers (Juuso, Olsson, Skär, & Söderberg, 2013; Skär & Söderberg, 2018; Söderberg, Olsson, & Skär, 2012; Zotterman, Skär, Olsson, & Söderberg, 2016) have shown in their studies that the patient-professional relationship is central for patients to experience good care. Countless number of patient-professional relationships occurs in healthcare every day and some meeting are short and temporary while others are long-lasting and recurring. For women is a visit for a pelvic examination (PE) the most commonly performed procedure in gynecological care worldwide and is essential for women’s health. Reasons for performing a PE differ and could range from gynecological screening to a measure for diagnosis or differential diagnosis (Fiddes, Scott, Fletcher, & Glasier, 2003; Hilden, Sidenius, Langhoff-Roos, Wijma, & Schei, 2003). PEs are expected to be performed in a manner that makes the experience a positive one for the woman. Researchers (Jones, 1979; Olsson & Gullberg, 1991; Oscarsson & Benzein, 2002; Wendt, 2003) reveals that women undergoing a PE are very vulnerable, which in turn provokes negative feelings of embarrassment, anxiety, fear of illness, and pain. For women a PE entails undressing and exposure of intimate parts of the body because of which women experience discomfort and a lack of control. Women also experience anxiety, worries related to cleanliness and vaginal odor, and concerns about the gynecologist learning about their sexual habits. In addition to the psychological discomfort, women have to endure the physical unpleasantness of a cold instrument and the lack of gentleness during the PE (Grundström, Wallin, & Berterö, 2011; Hilden et al., 2003). Because women’s experience of a PE can determine willingness to participate in future examinations, gynecologists and midwifes are challenged with the task of making the experience a positive one by developing a trustful relationship (Grynberg et al., 2012; Siwe, Berterö, & Wijma, 2013; Yanikkerem, Özdemir, Bingol, Tatar, & Karadeniz, 2009).

To create a trustful relationship includes having enough time for communication and ensuring adequate opportunities for both the patient and the healthcare professional to ask each other questions (Zotterman et al., 2016). Healthcare professionals should have supportive, patient-oriented communication skills as lack of adequate information and communication between the patients and healthcare providers negatively affects patients’ experiences of the quality of care received (Skär & Söderberg, 2018). When patients do not understand the information being shared, they may find it difficult to participate in the decision-making (Petronio, Di Corcia, & Duggan, 2012), which in turn may affect the development of a trustful relationship (Zotterman et al., 2016).

Researchers (Wykurtz & Kelly, 2002) reveal that gynecological teaching women (GTW) may help facilitate the learning of communication skills among medical students. In the 1970s, a new program to facilitate the learning of PE was introduced as part of education for medical students, in which specially trained women or GTW, participated in the learning process. The GTW are specially trained to teach the PE procedure while allowing themselves to be examined by the medical students. They often work in pairs, with one acting as the patient and the other as an instructor for the medical student (Pickard, Baraitser, Rymer, & Piper, 2003). The program generated positive outcomes for skills learning by medical students and was incorporated into medical education in Sweden, 1983 at Linköping University, (Siwe, 2007; Wijma & Dahlgren, 1990) and at Umeå University in 2013 (Grankvist, Olofsson, & Isaksson, 2014).

The use of GTW as teachers in medical education has been well studied and is shown to improve medical students’ trained skills and help them perform better even after the completion of their obstetrics and gynecology internships (Hendrickx et al., 2009). In interviews, medical students have described this learning approach as effective, anxiety-reducing, and useful for strengthening their confidence in performing a PE (Grankvist et al., 2014). However, not many studies have explored how this learning process can support medical students in improving their skills to develop a trustful patient-professional relationship. Therefore, the authors’ aim of this study was to examine gynecological teaching women’s perception on what factors are important for developing a trustful patient-professional relationship when women undergo a pelvic examination.

Methods

Design

A qualitative design was conducted: data were collected through repeated focus group discussions (FGDs), a method for capturing views and opinions of a particular issue (Polit & Beck, 2017). The data were then analyzed with thematic content analysis (Downe-Wamboldt, 1992).

Participants

A purposive sample of five women trained as GTW and engaged in medical students’ education in gynecology, participated in the study. The women had participated in an earlier study (Grankvist et al., 2014) about their experiences of acting as a GTW, during courses on obstetrics and gynecology at the medical school at Umeå University, Sweden. The inclusion criteria for educate as a GTW were normal weight (BMI <30) and a normal uterus as determined by bimanual palpation earlier by a gynecologist. The women had undergone a one-day training course that offered theoretical and practical guidance. The theoretical education focused on female reproductive physiology and anatomy, healthcare laws and regulations. The practical education involved performing a PE on one another while being supervised by the gynecologist (second author) at the Department of obstetrics and gynecology at the hospital. The women thereafter educated the medical students to perform a PE and afterwards participated in discussion meetings where the students and the women could reflect together about their experiences. During these meetings it emerged that the relationship between the patient and the gynecologist was crucial for how women experienced a PE. The gynecologist responsible for the program therefore asked the women if they wanted to participate in another interview study focusing on factors important for developing a trustful patient-professional relationship when women undergo a PE. All five women responded positively to take part in the study and their informed consent was obtained. The women were aged between 27 and 53 years (md 40.5 y); four had university educations, and one had a secondary education; four were married, and one was cohabiting. All but one of the women had given birth.

Ethical consideration

The study was performed in accordance with the recommendations of the Helsinki Declaration, and the Regional Ethical Review Board in Sweden (Um dnr 08-191Ö) approved the study. Before data collection, oral and written information about the nature of the study was shared with the participants. The GTW were informed of their right to withdraw participation at any time and were guaranteed confidentiality and anonymity in the presentation of the findings.

Data collection

The authors collected data through repeated FGDs at three times. The GTW worked together as one group in the medical education program, therefore was FGDs an appropriate method for data collection and the participant’s interaction contributed to increased data content richness (c.f., Polit & Beck, 2017). However, the number of participants were few (five women) but as the topic for the study was being emotionally charged and sensitive the data collection was carried out on three occasions (c.f., Coté-Arsenault & Morrison-Beedy, 1999). The first FGD focused on the meaning of a trustful relationship between a woman and the gynecologist. The second focused on the importance of a gynecologist’s communication skills for a trustful relationship, and finally the third, focused on the importance of an ethical conduct in healthcare.

At each FGD, the first author acted as a moderator by listening actively and guiding the discussion, while the last author acted as an observer, paying attention to non-verbal communication and providing a summary of each FGD. The authors used an interview guide to direct the focus of the study and the discussions of the GTW perceptions (Polit & Beck, 2017). During all FGDs the participants had the opportunity to develop their earlier discussions and the researchers to ask developing questions. The FGDs was completed every week during a three-week period and were carried out in a meeting room at the Department of obstetrics and gynecology at the hospital. The first FGD lasted 64 min, the second FGD lasted 76 min, and the third FGD lasted 47 min. The FGD lasted 187 min in total, were recorded digitally and transcribed verbatim.

Data analysis

The first and third author analyzed the transcribed FGDs with a thematic content analysis according Downe-Wamboldt (1992) to identify factors that are important for developing a trustful patient-professional relationship when women undergo a PE. We started the analysis, with reading each interview several times as open-mindedly as possible to gain a sense of the content. Meaning units that answered the study aim were then identified, condensed, and coded. A preliminary analytic structure was developed and sorted into themes, which formed the basis for an exploration of similarities and differences between the GTW views. The analysis was performed in several steps until no more themes could be identified. Finally, we identified three themes that captured the GTW perceptions, i.e. threads of meaning that appeared in the analysis. During the whole analysis, the authors occasionally went back to the original textual units and compared the results.

Results

The analysis revealed the following three themes: Awareness of a woman’s vulnerability; Personalized communication strengthens a woman’s self-esteem; and Dignified treatment gives women a sense of ownership over their bodies. The themes are explained below with relevant excerpts from the FGDs.

Awareness of a woman’s vulnerability

The GTW discussed that an important factor for developing a trustful patient-professional relationship was that the healthcare professionals should recognize that a PE is a highly vulnerable experience for a woman. Healthcare professionals therefore need to be sensitive during the encounter to create a safe and comfortable situation. This can be achieved by asking the woman what feels good or uncomfortable, and who (the nurse, the midwife, the gynecologist, the assistant nurse) should be present during the PE. Some of the GTW added that during a PE, several healthcare professionals walk in and out in the examination room, which made the women uncomfortable. They expressed a preference for locking the room during a PE so as to decrease the woman’s vulnerability. Key excerpts from the FGD are listed below:

• To protect the woman, only the gynecologist should be present during the investigation.

• It’s not good that several other professionals could walk in and out of the examination room during the investigation.

• They (the healthcare professionals) have to take the woman’s dignity in account.

The GTW further pointed out that healthcare professionals must address a woman’s vulnerability by creating a trustworthy relationship. This should be based on a shared understanding between the professionals and the woman. They all, mentioned that women appreciate a gynecologist who is encouraging; however, personal comments about clothing and other personal aspects may be perceived as too private and offensive. Some seemed to suggest that private statements could negatively influence the creation of a trustworthy relationship if the women feel vulnerable.

• The physician can’t point out things like the woman has nice underwear or that she looks good, because it may influence the professional trustworthiness.

The GTW added further that an important factor for developing a trustful patient-professional relationship was to address women’s feelings of vulnerability. All the GTW mentioned that healthcare professionals should separate the examination room from the dressing room and from the gynecologist’s office. They explained that when the examination room is used for all these functions, the women tend to feel unsafe and find it uncomfortable to undress in the view of the healthcare professionals which in turn could affect the opportunities to develop a trustful relationship. Further, having all the functions in the same room may distract healthcare professionals from focusing on the women to handling administrative tasks. Some of the GTW explained that healthcare professionals need to be aware of their power as professionals and work toward strengthening the women in the role as a patient.

Personalized communication strengthens a woman’s self-esteem

The GTW discussed that communication was an important factor for developing a patient-professional relationship and that healthcare professionals have an obligation to strengthen a woman’s self-esteem through a personalized communication. Most of the GTW expressed that it was important for a woman to receive information according to her needs and that a personal and friendly approach was of great significance. Personalized communication was further described as a basis for a patient-professional relationship as it promoted feelings of comfort and facilitate a shared understanding. The GTW felt that an aspect of personalized communication was providing information to the woman before the start of a PE and explaining how the procedure would be performed. The following excerpts capture this sentiment expressed by three of the GTW:

-healthcare professionals need to see the woman as a person and communicate personally.

• Yes, and the information must be given before the examination so she knows what’s going to happen.

• Yes, because when the woman know what will happen, she could feel safe and strengthened.

The GTW discussed that healthcare professionals often took important PE steps for granted. For instance, women undergoing a PE sometimes feel both anxious and powerless before the procedure. This could be because the women and the gynecologists rarely engage in a mutual dialogue. Nearly all the GTW therefore stated that personalized communication should ensure that there was enough time for the woman to ask questions and that the information given by the gynecologist was tailored to the woman’s needs. Furthermore, the GTW asked for the information to be provided in a language that the woman could understand, including feedback and replies to the woman’s thoughts and questions. Some of the GTW also stated that healthcare professionals should be aware that women may be overwhelmed by the amount of information they receive, especially when they were under stress, such as, before or during the PE. Quotations from the FGD are provided below:

• It’s important that healthcare professionals talk in a language that the woman understands and that she feels comfortable to ask questions. She also needs feedback to be able to ask questions.

• Yes, and they (healthcare professionals) need to listen to her and discuss and inform about the gynecological examination in her terms.

• They (healthcare professionals) need to talk in a way she understands, then they (healthcare professionals) preserve the woman’s self-esteem.

The GTW clarified further how inconvenient it could be for the woman to talk to the gynecologist while the PE was in progress. Some noticed that few women want to disturb the gynecologist by talking during the examination, and most found it uncomfortable to talk to someone they could not see when lying in the examination chair. Therefore, the GTW expected the healthcare professionals to know when to talk to the patient and chose an appropriate time for communication, either before or after the examination. This also included the gynecologist talking to other healthcare professionals over the women’s head and ignoring or dismissing the woman’s experiences during the conversation. All the GTW pointed out it was always important to include the woman in the conversation when she was present.

Dignified treatment gives women a sense of ownership over their bodies

The GTW described that they perceived the PE procedure as a situation in which the woman was absent except for her exposed private parts which in turn affected the possibilities to develop a trustful relationship. They explained that it was not possible to compare sexual organs with other parts of the body in other types of investigations or in other healthcare contexts. Some of the GTW added that this because of social norms and how the society’s views women today. Quotations from FGDs are provided below:

• A woman’s gender or sex organ is considered something that is special from the rest of the body in general.

• We cannot talk about the female sex, the woman’s body is a taboo.

• I think it’s the social heritage we all carry, therefore can’t we talk about it.

The GTW explained further that the female genitalia are a controversial topic, and undergoing a PE is a difficult prospect for women. Given the context, the GTW perceive that healthcare professionals should be responsible of respecting a woman’s integrity and not act sexually inappropriate. They discussed that sometimes healthcare professional’s failing to understand and meet the expectations and security of a woman. All the GTW agreed that if healthcare professionals treated a woman with dignity, by meeting her needs and expectations, it would give her a sense of ownership over her body and be an important factor for a trustful relationship. Quotations from FGDs are provided below:

• It is not just about the practical gynecological examination, instead it is about how healthcare professionals meet the woman and teach her about the female body.

• And teaching could first be done when healthcare professionals respect woman’s integrity and not just see the sex organ.

The GTW further explained that many women had little knowledge about their own body, but a dignified treatment could teach them more, and this process was more important than the PE itself. They also highlighted that the examination was a great opportunity for healthcare professionals to teach the woman about female anatomy as knowledge could help improve women’s health.

Discussion

The authors of this study suggest that the patient-professional relationship is central in a fundamental way to providing good care. Our results show that the PE procedure puts women in a vulnerable position and healthcare professionals needs knowledge and communication skills to develop a trustful relationship. Vulnerability is a fundamental aspect of health experiences and it is known that it affects patients’ integrity (Nichiata, Bertolozzi, Takahashi, & Fracolli, 2008; Sellman, 2005). Vulnerability may therefore have implications for the interactions and relationship development between the patient and the healthcare professional (Sellman, 2005). When the authors reflect on the results, the development of a trustful relationship based on a shared understanding could decrease women’s vulnerability and create a safe and comfortable examination situation, which in turn might increase women’s health. According to Ekman et al. (2011), a trustful relationship is an ethical aspect of quality care and a prerequisite for good and professional care. This is also consistent with the person-centered approach, which suggests that care should be based on trust and confirmation and an understanding of the patient’s experiences. Such care has been shown to have a significant impact on the patients’ and professionals’ relationships and the patients’ health and wellbeing outcomes (McCormack & McCane, 2010).

The GTW interviewed in this study expressed that the vulnerability of women undergoing PE could be mitigated by minimizing the exposure of woman’s body. The authors suggest that healthcare professionals need to be sensitive to the situation, act appropriate and communicate with dignity. This is in line with Bates, Carroll, and Potter (2011) who stated that a PE is an extremely vulnerably situation for the women and that healthcare professionals needs to consider the women’s integrity to preserving her self-esteem. When healthcare professionals understand how a PE procedure can make women feel vulnerable, they can contribute to making it a positive and trustful experience and thus help improve women’s health (Grundström et al., 2011). However, a PE could present a vulnerable situation for both the women and the professionals, this notion of mutual vulnerability is an important factor to acknowledge so that healthcare professionals can understand how to handle in sensitive caring situations (Gastmans, 2013). The most important principles of healthcare require that occupational practice and good care are conducted with respect for human rights, cultural values, and individual’s right to life, patient’s opportunity for participation in decision-making, and respect the patient’s dignity (Fry & Johnstone, 2008; International Council of Nurses, 2018). Healthcare professionals must therefore according to the authors interpretation, experiences of vulnerability by supporting patients to gradually develop and express their viewpoints. However, it is important to remember that sometimes, patients are ambivalent about treatment or examinations, especially when confronted with uncomfortable situations, such as a PE (Olsson & Gullberg, 1991).

The GTW in this study highlighted the importance of personalized communication to strengthen a woman’s self-esteem in the PE situation. They stated that women and the healthcare professionals often do not engage in a mutual dialogue, which in turn affected women’s possibilities to develop a trustful relationship. Skuladottir and Halldorsdottir (2008) has shown that a personalized communication can strengthen a patient’s possibilities for participation in decision-making when there is room for a mutual dialogue. However, a personalized communication approach based on engaging conversations could help healthcare professionals learn more about their patients’ needs (Gastmans, 2013). Communication skills in practice require knowledge of ethical concepts, moral reasoning, critical thinking, and the ability to integrate several sources of information in the caring situation (International Council of Nurses, 2018). Self-esteem is also a key factor influencing health and wellbeing, and respecting a patient’s self-esteem can create a positive impression of the healthcare professional. Nåden and Eriksson (2004) explained that it is important for patients to feel understood, be listened to, and be seen as a human being. Ensuring these is linked to the healthcare professional’s responsibility and respect toward the patient. When patients are confirmed, important values are taken into accounts that preserve a trustful patient-professional relationship (McCormack & McCane, 2010).

The GTWs stated further, that a woman in a PE situation, may experience discomfort when she is to show her intimate parts of the body to someone else. This can lead to feelings of dignity violation and objectification as a female sex rather than being seen and respected as a human being. According to Milton (2008) dignity refers to the quality of being worthy, honored, or esteemed grounded in various definitions of human attributes or human rights. To experience dignity as a patient is fundamental important to every health process (Eriksson, 2006). In this study, the GTW articulated that being treated with dignity gives women undergoing a PE a sense of ownership over their bodies. They added that the PE is an intimate situation where women have to expose their private body parts, which could be embarrassing. According to Oscarsson, Benzein, and Wijma (2007) for women a PE is linked to feelings of embarrassment and that in turn might lead to feelings of lost dignity and integrity among women. To handle the situation, healthcare professionals could desexualize the situation and carry out the examination with respect for the women. For women a PE can also be seen as an opportunity to learn about their body, and the gynecologist can clear myths about the female body that are traditionally considered shameful, and thus empower women and give them a sense of control over their body (Sörensdotter & Siwe, 2016; Speer, 2005). This kind of a relationship provides a sense of meaning because healthcare professional can make difference for another person and motivating force is a shared feeling of trustfulness in the relationship (Chaw, 2013).

Limitation

A limitation of this study is the small sample size, but there are no fixed rules for sample size in qualitative research (c.f., Malterud, Siersma, & Guassora, 2016). Coté-Arsenault and Morrison-Beedy (1999) advocates smaller focus groups of about five participants when a topic is sensitive, as in this study. Repeated FGDs were therefore conducted according to the sensitivity of the phenomenon being studied and that the group of participants was based on dynamics, for accessing rich data (c.f., Coté-Arsenault & Morrison-Beedy, 1999). The participants and author’s possibilities to discuss topics and reflect over questions from previously FGD added rigor and credibility of the data, consistent with Janesick (2000) description of methodological considerations for qualitative studies. However, because this qualitative study involved a convenience sampling from a single institution which likely resulted in a non-representative sample thus limiting the generalizability of the findings. Nevertheless, this is not the goal of qualitative research and the results can be transferred to similar situations if they can be reformulated as the actual context (Polit & Beck, 2017).

Conclusion

Based on the results in this study, the authors conclude that healthcare professionals’ communications skills can strengthen a trustful patient-professional relationship when women undergo a PE. By respecting the women and treating them with dignity, healthcare professionals can reduce women’s feelings of vulnerability, and by teaching women about the female body, they can provide women with a sense of control and power over their own bodies. Healthcare professionals can also dispel myths that are traditionally considered shameful. The authors suggest that the results of this study can improve healthcare professional’s knowledge of what is important for a trustful patient-professional relationship and result in better quality of care for women undergo a PE and thereby result in increased health. The challenge for the future lies thereby in integrating gynecological teaching women’s and patient’s perceptions and experiences within both nursing and medical education, to develop the ability to create a trustful patient-professional relationship to make the relationship person-centered.

Acknowledgements

We would like to thank the gynaecological teaching women for their time to participate in this research.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.