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.
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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.
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