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January 29, 2018

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Staying current on the basics

Having been a registered nurse for almost 10 years, I’ve been fortunate to have only been a patient for the happy occasions of welcoming my children into the world. During those visits at our local hospital, all with surgical births, I was thankful for the kindness, compassion, and understanding of the nursing staff as I asked many questions and stubbornly insisted on doing many of my own care activities. My first two deliveries, both daughters, are nearly a blur in my memory now. The care was excellent, evidence based, and respectful of my preferences and needs. My husband and I received patient centered discharge instructions that were personal and thorough. We felt confident leaving the hospital, and we truly gave all the credit to our amazing nurses.

Only the stay with my son sticks with me now as different than the first two. Like the deliveries before, we’d had a great OR experience, with excellent and evidence-based care. We’d kept our son in our room for the entirety of the stay, and were treated with respect and dignity. We had chosen to keep our son intact, to not circumcise, and had been supported in our choices. Our only hiccup occurred as we received our discharge instructions. “Be sure to pull back the foreskin completely to clean beneath it with every diaper change,” our well-meaning nurse said. My blank stare must have surprised her and she offered to demonstrate. My husband, a protective father, picked up his tiny boy.

“I’m a pediatric nurse,” I started cautiously, not wanting to offend this nurse who had taken such excellent care of me and my son, “and we can really harm him by pulling the skin back.” I went on to explain that in infants and young boys, the foreskin is fused to the penis like a fingernail is to a nailbed. The American Academy of Pediatrics offers a guide on intact care, and I pulled it up on my tablet to show her. “Wow, I was always taught to pull it back to clean,” she said, adding an apology. I told her not to be sorry, to just print a copy for me and put it somewhere that her colleagues could see it. It was an opportunity for us to share knowledge!

As we went on to take our son to his well appointments, I began to notice a trend. While we never had a provider be anything but respectful and supportive of our decision not to circumcise our son, we frequently were taught to retract the foreskin to clean him. Once, my husband, after reciting what had become something of a rehearsed “My son isn’t circumcised, and we don’t retract his foreskin. Please don’t manipulate it during your exam,” looked at me as a provider left the room. “I’m so glad you are a nurse. We’d be hurting him if you didn’t know better.” My heart hurt at his words. He was right, we were fortunate. I had worked in pediatrics most of my career, with my experience in a neonatal intensive care unit being how I had come to learn appropriate “intact care”. We had the health literacy to advocate for our son, and as an advanced practice nurse working on my DNP, I felt comfortable having conversations with our healthcare providers about best practices.

In talking with friends of ours who also made the decision to keep their sons intact, we found we were not alone. Many shared stories of how their sons had been forcibly retraced by well-meaning health providers during newborn hospitalizations or well visits. “What do they teach you?” they would say to me. “What do you mean?” I’d ask, feeling a little defensive of my profession. “You’re nurses, you’re supposed to know how the body works!” one frustrated friend vented. At the time, I didn’t have a good answer. Nearly two years later, I’m now a DNP and family nurse practitioner, practicing in pediatrics, and I wish I could have that conversation over again.

Receiving potentially harmful discharge instructions on that spring day was a reminder to me that even the simplest of our nursing interventions can have major implications for our patients and their families. I could have injured my son because I was taught how to care for him using outdated information. As nurses, we have incredible responsibility. Our patients trust us with their lives, and their children. As fewer American families circumcise their sons, nurses will need to be equipped with accurate information to care for these children safely and to educate their families. As practicing professionals, we’re charged with keeping up to date, even in the what we might think is the simplest of our interventions. We are teaching our students this knowledge of intact care, but overcoming traditions in practice is difficult. If you’re not sure you are up to date in your practice, check out this link: https://www.healthychildren.org/English/ages-stages/baby/bathing-skin-care/Pages/Care-for-an-Uncircumcised-Penis.aspx. Be sure you are teaching and practicing safely.

Kristen J. Munyan is an assistant professor in the school of nursing at Oakland University in Rochester, Michigan.

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