Student Nurse

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Cervical Screening

Introduction

This assignment will be written in first person as advocated by Fullbrook (2003) in order to show the thoughts, feelings and experiences of the author.

The purpose of this assignment is to consider the aims of the screening programme and examine the significance of the transformation zone. In addition it will reflect upon the communication skills used when interacting with women undergoing cervical screening. The Driscoll (1994) ‘What’ model of reflection will be utilised to facilitate this.

Screening programmes require certain elements to be successful namely the test should be highly sensitive and specific; cost effective; identify cases early to provide timely treatment and better outcomes; slow clinical progress to the end disease (Naidoo and Wills 2000, Sutherland 2001).

Screening Programme

Screening is defined by the UK National Screening Committee (2000) as when a set criterion of individuals who may not see themselves as at risk of or already developed a disease are offered a specific test which would identify those people more at risk.

Although cervical screening has been in operation in the UK since 1964 the structured NHS Cervical Screening Programme was only introduced in 1988 as a way of reducing the instance of cervical cancers (SIGN 2008, Padbury 2005).

In 1968 Wilson and Jungner (Andermann et al 2008, NHSCSP 2006) published a report, which identified the following 10 principles for screening: the disease should present an important health risk; an acceptable treatment should be available for patients with the disease; provisions should be available for diagnosis and treatment; there should be an identifiable early stage; there should be an appropriate test: the test should be acceptable to individuals; the natural progress from early stages to identifiable disease should be sufficiently well known and understood; there should be a set criteria of who to include in the programme; the programme should be cost effective; the programme should be an ongoing process.

In Scotland the programme starts at age 20 and women are called to have routine smears every 3 years until age 60 or more frequently if they have an abnormal smear (NHS Lothian 2004).

The ectocervix is made up of squamous epithelium and the endocervix is made of columnar epithelium with the junction of the two lying just inside the external os (NHSCSP 2006). At puberty and during pregnancy hormones cause the cervix to change shape allowing the columnar epithelium to advance outward onto the ectocervix and this becomes an area of ectopy (NHSCSP 2006). Over time these columnar cells transform into squamous cells and this metaplastic epithelium is known at the Transformation Zone (TZ) (NHSCSP 2006). Again due to hormonal changes at the menopause the cervix reduces and the squamocolumnar junction (SCJ) and cells of the TZ revert into the endocervix once again (Padbury 2005). Pre cancerous cell changes are most likely to occur in the TZ or the SCJ (Padbury 2005).

Reflection

The first part of the Driscoll (1994) model of reflection is ‘WHAT?’ which is a description of events and feelings.

At the outset of the cervical screening module I was concerned with my ability to pass speculums following a distressing interaction and passing of a speculum in the past. This preyed in my mind and I felt quite anxious about it and knew it was a barrier I was going to have to overcome. I had subsequently had the opportunity to pass speculums as a midwife nevertheless I still felt it was going to be a challenge. The first few attempts I did feel quite awkward and felt myself apologising to patients but with practice and the use of lubrication I began to feel more competent. However one supervisor did not think that lubrication should be used and I felt a bit unsure of myself.

I was aware that I had to ensure I collected cells from the transformation zone as this is where cell changes are most likely to occur. In post menopausal women I felt this could make gaining TZ cells more difficult as those cells migrate back inside the cervix.

One of my supervisors pointed out that I should place the brush in the solution immediately and swirl the brush around and push the bristles apart without delay, as I had been placing the brush in the solution and then removing the speculum in order to promote the woman’s dignity. But by talking to the patient and reassuring her I am able to promote her dignity whilst ensuring the cells will be preserved.

After establishing the patients understanding of the test I found it important to build up rapport and discover any concerns she has as this tended to make them feel more relaxed.

The Second part of the Driscoll (1994) model of reflection is ‘SO WHAT?’ which in analysis of the events.

Sutherland (2001) defines screening as the examination of a healthy person for a disease. Although this is not entirely true in the case of cervical screening as it aims to identify women who have changes in the cells before they would become an illness. The smear test is therefore not for the detection of cancer however it does prevent cancer through identifying women at high risk of developing invasive carcinoma and offering them early intervention (Padbury 2005, NHSCSP 2008). Cellular changes are called cervical intraepithelial neoplasia (CIN) and if left untreated may result in cancer (HNSCSP 2006).

The use of a small amount of water based lubrication is recommended by the NHS cervical screening programme (2006) and has been found not to interfere with results, so long as it does not cover the tip of the speculum (Gilson et al 2006, Griffith et al 2005, Aimes et al 2002, Harer Jr et al 2002). However in their study in 2006 Gilson et al found that it made little difference to comfort although they felt further research was required in this area.

The cervex brush must be inserted into the liquid based medium immediately to preserve the cells (NHSCSP 2006).

It is important for the smear taker not only to be knowledgeable skilled at taking smears but also have a good all round knowledge of the cervical screening programme as a whole to give a truly informed discussion to patients (Padbury 2005). It is important that the nurse conveys that a smear test is not a diagnostic test for cancer but for the detection of pre-cancerous cells and that a normal result indicates a low risk (Sutherland 2001). It is also essential to assess the individuals understanding of what the smear involves (RCN 2006)

The final section of the Driscoll (1994) model of reflection is ‘NOW WHAT?’ which is the action plan.

I must ensure that the women make an informed choice to have a smear by giving all the necessary information before, during and after the procedure and ensuring the patient has an understanding of the test, its purpose and the outcomes.

Given the evidence I will continue to use lubrication when passing speculums. And although it may not have any effect on comfort I will continue to promote autonomy and sharing of information as good explanations ease discomfort and embarrassment (Padbury 2005).

Conclusion

From being very nervous about passing speculums at the outset of the course I now feel confident taking smears and feel I have overcome my barriers. I have successfully taken smears supervised and unsupervised. Including giving through informed discussion the benefits and shortcomings of cervical screening.

I understand the importance of taking cells from the transformation zone and that in post menopausal women this is likely to be from the endocervix.

I will ensure that women are given the information needed to empower them to make an informed choice. I will endeavour to promote dignity in a comfortable environment during this intimate procedure.

Although I have not experienced any particular difficulties I am aware that at some point I may have a patient for whom taking a smear is very difficult and at that time I must acknowledge my limitations and hand her care over to a medical colleague.


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last updated 23/08/08

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