Nurse Intervention in Cervical Screening Programmes

Nurses deliver care to patients in an ever-changing
environment that revolves around changes in local and governmental policies as
well as technology and pharmaceutical advancement for effective practice,
(Ellis, 2016). According to Nursing and Midwifery Council (NMC) Code of Conduct
(2015), nurses assess patients’ needs and deliver timely, efficient and
effective patient care based on the best available evidence. Evidence Based
Practice is the integration of best research evidence with nursing practice and
patient needs and values to facilitate effective care, it also promotes
quality, safe and cost-effective treatment for patients, families, healthcare
providers and health care system, (Brown, 2014; Craig and Smyth 2012). This
assignment aims to explore an area in nursing, identifying gaps between theory
and practice. Using research and discussing strength of the literature and
overcoming related issues in the specified area.

The assignment will focus on barriers to cervical screening and nurses’ intervention to improve screening programmes. Cervical cancer screening can be detected early and treatment of precancerous cells and cervical cancer, (White et al., 2015) continues to exist. Cervical cancer starts from a pre-invasive stage known as cervical intraepithelial neoplasia (CIN) however, it can be detected through cervical screening, (Foran et al., 2015). Cervical cancer is the second most common cancer among women globally after breast cancer, (World Health Organization, 2016). According to the Department of Health (DH) (2012a) detecting cervical cancer at an early stage can prevent around 75% from developing. World Health Organization (WHO) (2015a) asserts that prevention and early detection of cervical cancer is cost –effective and a long-term strategy.  Hoppenot et al (2012) points out that screening can reduce incidence and death rates. Research shows cervical screening is associated with improved treatment for invasive cervical cancer, (Andrea et al., 2012). This highlights the importance of cervical screening programmes.

Cervical screening reduces the occurrence of cervical cancer and research shows it prevents approximately 4500 deaths annually in Britain, (Bryant, 2012). In England, there is an invitation for screening for women aged 25-64.  Women aged 25-49 should attend screening appointment every three years and women aged 50-64 every five years, (Health and Social Care Information, 2012).  However, the last fifteen years has seen a gradual increase in more women being left unscreened for  five years or above, from 16% in 1999 to 22% in 2013 (Health and Social Care Information Centre, 2013). Research shows differences in screening is among women who are younger, lower income earners, less educated or women from minority ethnic background and sexually abused women, (Waller et al., 2012; Cadman et al.,2012; Marlow et al., 2015; Albrow et al., 2014).

A comprehensive search of databases for literature review
namely, Medline, Science Direct, CINAHL, National Institute for Health and Care
Excellence (NICE) and Cochrane. An advance search strategy including ‘Cervical
Screening, Barriers to Cervical Screening, Early Detection Cervical Cancer and
Cervical Screening Adherence’. The search was refined to literature in the past
five years and incorporated international literatures from United Kingdom,
Australia, Sweden and Korea to give an insight of those barriers from a global
perspective.

Firstly, as regards discussion of non-attendance among
women from minority ethnic background. Marlow et al (2015) conducted both
qualitative and quantitative study titled ‘Understanding cervical screening
non-attendance among ethnic minority women in England’. The study investigated
and compared differences in attendance among 720 women from minority ethnic
background and White British women. For clarification purpose, ethnic minority
are black, Asian and minority ethnicity (BAME). The study found that BAME women
were less likely to attend cervical screening with 44-71% non-attenders
compared to 12% white British women. This highlights the need for more
intervention by nurses to improve practice. Reducing inequality in cancer
pathway particularly among minority ethnic groups is a policy priority (Dept.
of Health 2011).

Marlow et al (2015) found that women from ethnic minority
viewed that they were not sexually active so they did not have to do the test.
This is an important aspect for nurses to educate in order to improve practice
and to promote attendance with educational materials in various languages for
better interpretation. The study also found 65% women from minority ethnic background
believed they do not need to attend smear test in the absence of any symptoms
compared to 6% white British women. These barriers are primarily associated
with lower education and lower socio- economic status, (Fang and Baker, 2013).  It is surprising that women are still not
aware of cervical cancer screening when people should have received letters and
leaflets as part of the NHS programme, this highlights that women who have
never attended screening had not read any information, (Kobayashi, 2016).
Furthermore Benito et al. (2014) argued that nursing activities were mainly in
areas namely health education and promotion, clinical, research, training, and
program evaluation. Nurses’ intervention to educate thereby improving knowledge
and understanding of cervical cancer and the benefits of screening is
essential.

In addition, participants had deep-seated personal opinions
including fear and embarrassment. Ethnic minority women were more likely to be
fearful and preferred female health practitioner. To improve practice support
groups in the community may be a good avenue to discuss about screening. These
interventions should lay emphasis on the efficacy of cervical screening and
address concerns regarding shame and embarrassment. The main strength of this
study is information from a large population that makes it a relevant and reliable
study to improve cervical cancer screening programme.

A qualitative study conducted by Cadman et al (2012) titled
‘Barriers to cervical screening in women who have experienced sexual abuse; an
exploratory study.  Women from the age of
twenty and above who visit the Website of the National Association for People
Abused in Childhood (NAPAC), a United Kingdom Charity who provide support and
information for people from abusive background were invited to complete a
web-based survey of their opinions and experiences of cervical screening. This
survey included closed questions assessing social class, screening history and
past records of abuse. Participants indicated the type of abuse they had
experienced either physical, sexual, emotional, neglect, spiritual or any other
form of abuse. Study shows women who have a history of sexual abuse are at risk
of gynaecological problems and cervical neoplasia compared to women who have
not. Women who have been sexually abused are more likely to smoke, take drugs
and consume alcohol. The study revealed that a number of barriers impeded their
attendance and adherence to cervical screening including embarrassment, lack of
trust on meeting someone for the first time, gender of smear taker, pain,
tension, fear and anxiety. The findings indicated that some study participants
made remarks about the intrusive nature of the test. Some participants
mentioned they were not comfortable with interventions performed while on their
backs.  The argument suggest that women
who have history of sexual abuse may be fearful and anxious because of
triggering memories of the trauma so they may avoid such responses which is
true therefore this study is valid and reliable. In relation to evaluation and
analysis of the study, the findings also revealed that further training should
be provided to increase nurses’ knowledge and sensitivity.  NMC Code (2015) points out that health care
providers respect individual choices and deliver care without delay.  In an event of a sensitive discussion, nurses
are required to ask patient preference and should remain professional not
expressing any sign of shock. Fujimori et al. (2014) argues that to attain
effective communication, nurses should inquire patients’ preferences and
expectations at the start of the screening process. To improve this skill can
be taught in communications skills training which has proven to be an effective
approach. Nurses could show empathy by explicitly asking women about their
expectations of the screening encounter and whether they have any concerns.
This may help to surface issues that the nurse and patient could tackle together
to minimise anxiety and fear. For example, it could be to provide the option of
a female practitioner for the cervical screening appointment, maintain dignity
and sensitivity. Effective communication between nurses and patients is
essential. To achieve this, however, nurses must be sensitive to their specific
needs and demonstrate empathy. Having nurses who are adequately trained with
special knowledge of abuse is essential. There should be interventions such as
counselling and support activities as part of ways of ensuring that they attend
screening. This is particularly important at cervical screening appointments
for sexually abused patients to deliver safe and sensitive practice.

The Waller et al (2012) conducted a qualitative study
evaluating differences to barriers among women from different ages. The
study  interviewed practitioners working
in the screening programme and other related charities as well as women who
never attended screening focusing on their views on how age can influence non-
attendance and non-adherence in cervical screening. The study found that women
were classified into two distinct groups, which were those who wanted to go for
screening but did not attend which consisted younger women and others who had
decided not to attend were mainly older women. Wardle (2016) argues that
nurses’ intervention at improving uptake could be beneficial by considering
different approaches for various age groups to improve practice.

The findings of the following analysis identified barriers
that included many described in other studies namely fear of discomfort, pain,
embarrassment and lack of education. There is a reliable argument that
providing support with when, where and booking an appointment is effective.
Additionally one of the key themes emerging from the study is that older women
are more conscious about their bodies as they age. For example, one participant
discussed about changes in her self-image as she grew older and how it has
affected her self-esteem and how she feels reluctant to undergo invasive
procedures.  Nurses could encourage
action by  reassuring older women and  to remind them of the importance and benefits
of cervical screening. Sabatino et al (2012) argued that effective
communication improves cervical screening.

This systematic review by Albrow et al (2014) found similar
findings with Waller et al (2012) further evaluated the influence of
intervention in cervical screening evidence uptake amongst women less than 35
years. The findings from the study increased validity and reliability from the
argument that younger women are less likely to attend cervical screening.
Ninety-two records were screened and four studies investigated. One of the
studies evaluated the use of invitation letters and reported no significant
increase compared to standard invitation. Three studies investigated the effect
of reminder letters. Study participants described how screening was yet another
demand on their time and often competed with work and childcare, which are of
higher priority. For others, they could not attend due to inconvenient
location, fear, discomfort and embarrassment, (Waller et al., 2012). There was
a widely view among 30 year old women as sickness was associated with old age
and felt they had no reason to attend screening (Blomberg, 2011). Analysis of
the findings  indicate an increase in the
number of women attending cervical screening after receiving reminder letters
compared to those that were not given, however the increase was relatively
small. For this reason, cervical screening programmes need to look beyond the
use of invitation and reminder letters among younger women and to develop other
interventions to overcome as many barriers. Another study reported no increase
amongst women aged 20-24, although in some places these women are below the age
threshold. However, the same study reported an increase among 25-29 (95%) and
30-34 that also reported (95%) increase. It could be argued that there is some
evidence to suggest that reminder letters had positive effects on adherence to
cervical screening programmes. The results also showed that telephone reminder
from a female nurse, which had 6.3% and 21.7% increase. The study also reported
2.4% increase after a physician reminder. In evaluation of how nurses can
improve practice among these, age group there is a need to remove practical
barriers and provide other incentive methods that includes mass media campaigns
and educational intervention. There are so many users of social media
especially within this age group and if used properly it will play a
significant role in creating awareness and educating patients (Merolli et al.,
2013). Concerning low perceived risk, this may relate to misperceptions of the
purpose of the screening programmes with patients focusing on detection rather
than prevention of cervical cancer. 
Again, patients should be empowered through social support in the community.  In addition, nurses can educate, giving
information regarding importance and benefits of cervical screening. Lastly,
the review of GP incentive such as nurses providing flexibility in appointment
times and out of clinic days will improve practice.

In conclusion, cervical cancer is preventable and
relatively easy to diagnose. Several barriers upon women’s decision to attend
cervical screening programme have been identified. Given this, there is a need
for how women view cervical cancer and make screening decision. This assignment
collates available evidence in order to investigate potential psychosocial
influences on women from different perspectives. It is essential that patients
adhere to nurses’ advice and educational interventions. In order to improve
cervical cancer patient experience, there is a need that nurses receive
adequate training and develop skills that can improve practice. One possible
strategy is being sensitive to the screening process as a result of its
intimate nature combined with effective communication. Nurses can play an
important role in treating patients with dignity, respect and showing empathy.
This can make a difference to all women most especially women who have
experienced sexual abuse. Another contributing factor is to respect patients’
choice; an example is providing preferred gender of the sample taker. This
could encourage more attendance and adherence to the cervical screening programme.

PART 2

Reflective practice is essential to nursing profession. My
search for the best evidence for cervical cancer screening interventions began
by doing literature search. Designing a research study is an advanced and
complex skill that requires clinical experience as well as analysing and
evaluating the research design. While doing my research I focused on the needs
of patients and effectiveness of nursing interventions. The result of my search
enabled me acquire knowledge and skills in patient care by extensive literature
search using electronic databases and advanced search with combined words.
Discovering how to refine my search using full text and finding up to date
evidence in the last five years.  My
skills have greatly improved using electronic databases. This was done in order
to obtain relevant up to date search. NMC (2015) requires nurses use up to date
evidence and competent to practice. Such insight in itself is relevant to
nursing competency and can help to improve patient care.  I read and understood articles relevant to
nursing practice, clinical expertise and understanding patient values. Reading
the research articles and reflecting on each one, identifying assumptions, key
concepts and methods and determined whether the conclusions were based on their
findings. Appraising the steps of the research process in order to critically
analyse and use it to inform practice. This developed my assessment skills and
I was able to identify valid and reliable studies. Reviews and ratings of the
evidence resulted in recommendations for practice. According to National
Institute of Nursing Research (NINR) 2013, nursing research is defined as
research that involves and develops nursing care in order to promote patient
healthcare. Nurses play an important role in the National Health Service (NHS)
they provide front line services, support patients and contribute to health
research. Furthermore, research generates knowledge for nurses and contribute
towards health care (Parahoo, 2014). I am more enlightened about the importance
of analysing and evaluating research studies, which helps nurses to acquire
more knowledge and be up to date with evidence thereby promoting patient care. It
is evident that evidence base practice will continue to have great impact on
the professional practice of nursing. Evidence based practice is important in
nursing because it improves patient outcomes, care is delivered more
effectively and efficiently and it minimises error, (Houser,  2016). I have acquired more knowledge, skills
during the duration of this evidence based practice assignment and recognised
my strengths, and areas that I needed to improve on.

REFERENCES

Albrow, R., Blomberg, K., Kitchener, H., Brabin, L.,
Patnick, J.and Tishelman, C. (2014) Interventions to improve cervical cancer
screening uptake amongst young women; A systematic review. Acta Oncologia,
Vol. 53, no. 4, pp.445-451.

Andrea, B., Andersson, T.M. and Lambert, P.C. (2012)
Screening and cervical cure; population based cohort study. British Medical
Journal, Vol. 1344, pp.900.

Bang, J.Y., Yadegarfar, G., Soljak, M. and Majeed, A.
(2012) Primary care factors associated with cervical screening coverage in
England. Journal of Public Health, Vol. 34, no. 4, pp. 532-538.

Brown, S.J. (2014) Evidence- based nursing. The research
practice connection. 3^rd ed., Sudbury MA; Jones & Barlett.

Bryant, E. (2012) the impact of policy and screening on
cervical cancer in England. British Journal of Nursing, Vol.4, pp. 6-10.

Cadman, L., Waller, J., Ashdown-Barr, L. and Szarewski, A.
(2012) Barriers to cervical screening in women who have experienced sexual
abuse; an exploratory study. British Medical Journals, Vol. 38, no. 4,
pp. 1-19.

Craig, J. and Smyth, R. (2012) the evidence based
practice manual for nurses. 3^rd ed., Edinburg Scotland; Church
Livingstone Elsevier Ltd.

Department of Health. (2012a) cervical screening. {Online} {Accessed on 12 September 2017} http;//www.tinyurl.com/7gvxef9

Ellis, P. (2016) Evidence – based Practice in Nursing. 3^rd
ed., London; Sage Publications.

Fang, D.M. and Baker, D.L. (2013) Barriers and facilitators
of cervical cancer screening among women of Hmong origin. Journal of Health
Care Poor Undeserved, Vol. 24, no. 2, pp. 540-555.

Ferlay, J., Soerjomataram, I., Ervik, M., Dikshit, R.,
Eser, S. and Mathers, C. (2013) Cancer incidence and Mortality Worldwide. IARC
Cancer Base NO.11 Lyon; International Agency for Research on Cancer.

Foran, C. and Brennan, A. (2015) Prevention and early
detection of cervical cancer in the UK. British Journal of Nursing, Vol.
24, no.10, pp.2.

Fujimori, M., Shirai, Y. and Asai, M. (2014) Effect of
communication skills training program for oncologist based on patients
preferences for communication when receiving bad news. Journal of Clinical
Oncology, Vol. 32, no.20, pp. 2172-3266.

Hope, K.A., Moss, E., Redman, C.and Sherman, S.M. (2017)
psychosocial influences upon older women’s decision to attend cervical
screening; a review of current evidence. Preventive Medicine, Vol. 101,
pp. 60-66.

Hoppenot, C., Stampler, K. and Dunton, C. (2012) cervical
cancer screening in high- and low resource countries; implications and new
developments. Obstetrician Gynaecology Survey, Vol. 67, no. 10, pp.
658-667.

Houser, J. (2016) Nursing Research; Reading, Using and
Creating Evidence. 4^th ed., Jones& Bartlett

Kobayashi, L.C., Waller, W.C. and Wardle, J. (2016) A lack
of information engagement among colorectal cancer screening non-attenders;
cross sectional study. British Medical Colorectal Public Health, Vol.
16, pp. 659.

Marlow, L.A., Wardle, J. and Waller, J. (2015)
Understanding cervical screening non-attendance among ethnic minority women in
England. British Journal of Cancer, Vol. 113, pp. 833-839.

Merolli, M., Gray, K. and Martin Sanchez, F. (2013) Health
outcomes and related effects of using social media in chronic disease
management; a literature review and analysis of affordances. Journal of
Biomedical Information.

Nursing and Midwifery Council. (2015) the Code;
Professional Standards of Practice and Behaviour for Nurses and Midwives.
NMC, London.

The Health and Social Care Information Centre annual report- 2012 to 2013 www.gov.uk/…/thehealth-and-social-care-information-centre-annual-report-an

Wardle, J., Wanger, C.N., Kralji-Hans, I., Halloran, S.P.,
Smith, S.G. and McGregor, L.M. (2016) Effects of evidence-based strategies to
reduce the socioeconomic gradient of uptake in the English NHS Bowel Cancer
Screening Programme (ASCEND) ;four cluster- randomised controlled trials.
Lancet, pp.751-759.

White, A., Thompson, T.D. and White, M.C. (2015) cancer
screening test- use- United States. MM WR Morb Mortal Weekly Rep, Vol.
66, pp. 201-206.

World Health Organisation (2015a) Cancer. {Online}
{Accessed on September 12 2017}