The Association of Catalan Nurses in Body Image Management and Aesthetic Dermatology (ACICDDI) holds its inaugural annual conference at the Official College of Nursing of Barcelona (COIB)

Post-surgical or post-treatment nursing care for patients having received procedures such as mastectomy, ostomy, chemotherapy or post-traumatic surgery involves ongoing nursing treatment including minor surgery as well as helping them deal with the practical and emotional issues associated with the permanent modifications made to their bodies. This area of nursing receives different degrees of attention and recognition in different regions and medical institutions. Here in Catalonia, the Association of Catalan Nurses in Body Image Management and Aesthetic Dermatology (ACICDDI) has been active for over a year, advocating for the recognition and formalization of these practices. On 27 March 2019 expert nurses, nursing students, and solutions providers from the private sector took part in the Association’s first annual conference, hosted by the Official College of Nursing of Barcelona (COIB).

Disseminating crucial information

The conference opened with an address from COIB President Albert Tort Sisó, who welcomed the creation of ACICDDI and was followed by an introduction by Núria Cuxart Ainaud, Dean of the College Advice of Nursing of Catalonia and COIB Programming Director, who outlined that the self-regulation by the sector of the disciplines concerned had been underway since November 2017 with the publication by the COIB of the document Professional Profile of the Nurse in the Area of Body Image Management, which she described as a good practices guide based on evidence. Cuxart Ainaud pointed out that few nurses practiced Body Image Management at present but that the discipline was poised to grow. Next, ACICDDI Founder and Director Núria Sáez Gómez expressed her gratitude to all in attendance and reiterated the importance of all work carried out to structure Body Image Management and Aesthetic Dermatology care and establish it as an official nursing specialty.
Núria Cuxart Ainaud and Albert Tort Sisó opened the conference, reasserting the support of the Official Colleges of Nursing of Catalonia and Barcelona for the work of ACICDDI

Where nurses come in

The first practicing expert to speak, Doctor Enrique Oltra Rodríguez, emphasized the paramount importance of body image from the patient’s perspective by considering that “We do not have a body, rather we are a body”. A nurse who specializes in minor surgery, Oltra Rodríguez earned his doctorate in 2013 and conducts research on how, where, and by whom minor surgery is best administered. In 2010 he received funding for a study and found that huge savings were achieved when minor surgery was handled by nurses or doctors in primary care centers rather than by doctors in hospitals, and that the highest patient satisfaction was achieved when the procedures were carried out by nurses. Yet modern society retains a skewed view of capacitation for minor surgery: even the Royal Academy of the Spanish Language (RAE) defined it inversely: “surgical procedures not usually practiced by the doctor”, with no mention of the nursing profession. Yet going back to the earliest form of civilization we can identify “paleo-nurses”, usually women, carrying out procedures including immobilizations and the dressing of wounds, while higher ranking patriarchs merely enacted rituals, leading to the feminization of nursing and the figure of the mystical “medicine man”. In the Middle Age, when efficient remedies competed with haphazard ones, nursing care continued to advance as new roles distinct from the physician emerged, such as the barber-bleeder and the midwife. The first records of quality standards for minor surgery were found in hospitals during the Renaissance, the first trace of nurses being officially charged with minor surgeries date back to late 19th century in the UK, and in the 1950s the Spanish government stipulated minor surgeries as the remit of nurses. Oltra Rodríguez believes that, while nurses today routinely carry out complex and successful procedures and these practices are officially approved, they still require definition and regulation. We should therefore ask which aspects of nursing belong in the domain of science. He sees two clear priorities: training, including ongoing and recurrent training, not just the initial training received for qualifications, and research.
Doctor Oltra Rodríguez: “Health concepts and practices are experiencing a vertiginous pace of evolution”
Isabel Pera Fàbregas, director of Legal Medicine and Professor at Vall d’Hebron University Hospital, as well as co-author of the COIB’s 2017 document Professional Profile of the Nurse in the Area of Body Image Management was also in attendance: “On the road to the acquisition of competencies, we have fought and we have acquired capacity. Now the time has come to exercise authority.”

Solutions providers exhibit their products

Following Doctor Oltra Rodríguez’ presentation and a first round of questions from the audience, attendees were invited to take a long coffee break and visit the stands of the various private companies in attendance, whose products included breast prostheses, negative pressure wound therapy devices, scarring aids, ostomy pouching systems, wigs, micropigmentation needles and pigments, and other products needed to restore patients’ body image following operations.
Breast prostheses: essential for routine life after a mastectomy and before the definite diagnosis that the intervention has been successful, often followed by reconstructive surgery
Wigs for hair loss resulting from chemotherapy or other interventions
The second session of the conference followed the products exhibition, with short presentations by the expert nurses in attendance, all members of the ACICDDI. The session was a roundtable format, moderated by Noemi Arasa Sole, an expert nurse in Body Image treatments who also serves as ACICDDI treasurer.
Noemi Arasa Sole, ACICDDI treasurer, moderated the roundtable in which active ACICDDI members and other experts participated along with the audience

At home and abroad

One thing that became clear to attendees of the First ACICDDI Conference is that the specific cause of Body Image Management and Aesthetic Dermatology nursing is part of the broader effort to fully define and recognize the multiple competencies that exist within the nursing profession. Meritxell Planas Tura, a Family and Community Nurse working in Girona, offered insights on her Body Image Management experience in the UK working with ostomy patients. She pointed out areas in which the UK’s National Health Service (NHS) could be outperforming its Catalonian counterpart. For instance, she found the various dimensions of the UK healthcare system better interconnected through initiatives like multidisciplinary meetings attended by both private and public sector representatives from hospitals, primary care centers, community associations, and the pharmaceutical industry. Another example of the quality of the health service in the UK is the figure of the Community Nurse, also known as Health Visitor, who works directly with the community in homes, schools, or special care centers, typically providing pediatric or geriatric services or addressing the needs of the disabled. Mrs Planas also explained that nursing in the UK was more patient-centered, with nurses urged not to patronize patients but rather listen to and enquire about what they might have to say. Finally, she echoed Doctor Oltra’s advocacy of continuous training.
ACICDDI member Merixtell Planas Tura: “The challenge here in Catalonia is to connect the primary care center with the community”
Esther López Carcelle, a biochemist working as Associate Marketing Director at ConvaTec, a provider of ostomy solutions based in the UK, echoed Meritxell Planas’ presentation, in particular with regard to the patient-oriented approach of the NHS. She also argued that a stronger community instinct is at work in the UK, favoring home visits and the creation of support groups and other associations as well as associative networks. Health professionals receive a lot of training and support, there are magazines on every specialty, and information is easy to come by. Nurses derive patients to associations that provide support. In addition, the NHS is proactive and there is cooperation with solutions manufacturers. This translates into better services for the ostomy patient. By contrast, in Spain and Catalonia the associative network is far less developed, and some of the issues surrounding procedures such as ostomy remain taboo. She also warns against reliance on “Doctor Google,” which contains a lot of misinformation.
ConvaTec Associate Marketing Director Esther López Carcelle: “The ostomy patient is better off in the UK than here.”

The psychological dimension of ostomy

Cristina Navalón Pérez, an ostomy therapist, focused on the practical and psychological care provided by nurses specializing in pre- and post-ostomy body image management. She emphasized that the qualified nurse must be prepared to help the patient with anxiety before the operation, with getting used to his or her evacuation routines, and to cope with a changed body image. Clearly, one’s own perception of their body image is a complex construct determined by a number of pre-existing factors, including social and cultural pressure, the age and self-esteem of the patient. The nurse first does all she can to help the patient with pre-operation fears concerning test results, anesthesia, pain, and anxiety concerning life after the operation. She does this by thoroughly informing the patient, but she must also be particularly attentive to the particular situation at hand: the patient’s own response, any role that the family is likely to play or fail to play, and other subtle factors. She must do all she can to demystify the procedure and empower the patient to help himself or herself, to gain control and as much acceptance as possible of the situation. The ostomy therapist’s responsibilities are varied: she must provide privacy and confidentiality, recommend the optimal timing for the patient’s decision making when there is a margin, and detect and reinforce the patient’s strengths. She will coach the patient concerning diet and the factors that affect optimal irrigation. Past this practical phase she will return her attention to the psychological factors and talk openly with the patient about the process of the surgery and resulting bodily changes. This will involve helping to dissociate as much as possible feelings of self-worth from body image. It is also important to look for signs of how the patient is coping, to determine if the operation has resulted in social isolation, and also to help the patient identify actions to take to improve his or her image, accept the new challenges, and any resulting dependency on others. The patient must of course be given all the pertinent information concerning the use of devices, the maintenance of hygiene, how to detect complications and what to do or where to go in case they arise. The nurse tries to convert a defeatist attitude into a positive one and does all that is possible to potentiate the self-esteem of her patient.
ACICDDI member Cristina Navalón Pérez: “The loss of excremental function goes through same phases as mourning, and the patient needs accompanying”

Body Image Management and Aesthetic Dermatology for mastectomy and other cancer patients

Montserrat López Novella, a nurse with specific expertise in reconstructive micropigmentation for cancer patients in the private sector, commonly handles micropigmentation for areola and nipple reconstruction following breast implants as well for as for eyebrow and lip outline redefinition following the removal of facial tumors. Like Cristina Navalón before her, she described one of the most important skills of the Body Image Management Nurse as the intuition to perceive her patients’ needs as they face the pathology. She believes that an improved body image may help a patient feel better and as such becomes an inseparable aspect of the recovery process. She concluded by pointed out that the role of the micropigmentation specialist is not limited to scars resulting from cancer but also from a wide array of injuries including severe burns.
ACICDDI member Montserrat López Novella: “Feeling good about one’s own appearance is to feel better”
Eva González López concluded the presentations on a positive note. She explained that nurses in the Gijón are wanted to offer these services and so sought and obtained approval from plastic surgeons. The Spanish government then approved nipples and areola micropigmentation in 2017. Specialized units dedicated to micropigmentation restoration procedures now operate in public hospitals. She is happy with official support and client satisfaction, and stresses that the operations are low risk interventions, with no risk of losing breast implants.
Eva González López, Outpatient Procedures Nurse at the Gijón Red Cross Hospital, cited the positive response and support from plastic surgeons in her region and national health authorities

Milestones achieved and work ahead

The overall balance is positive, with the Body Image Management and Aesthetic Dermatology disciplines becoming increasingly common and receiving public acknowledgment and funding. However, advocacy and awareness campaigns continue to be needed as these specialties require full definition, accreditation, and regulation so that qualifications may be created and training offered. As the event drew to a close, ACICDDI Founder and Director and conference organizer Núria Sáez Gómez, responded to a question from the audience about the possibility of opening an independent nursing practice: “You are acting as a moderator yourself by raising this point, which may be the perfect open question to end our conference with. Unlike most other trades and despite what you have seen and heard today, nursing is unfortunately still not considered an independent profession. In attempting to open an independent nursing practice, you would be asked: ‘who is the doctor’?”
ACICDDI Founder and Director Núria Sáez Gómez, “Despite what we have seen and heard today, nursing is unfortunately still not considered an independent profession”

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