improving access to well woman screening utilizing an interprofessional approach icn inp/apn...

Improving Access to Improving Access to Well Woman Well Woman

Screening Utilizing Screening Utilizing an Interprofessional an Interprofessional

ApproachApproachICN INP/APN Conference 2006ICN INP/APN Conference 2006

Sandton, South AfricaSandton, South Africa

Kelly Power-Kean BN RN NP-PHC MHS(c)Kelly Power-Kean BN RN NP-PHC MHS(c)

ICN/APN Conference 2006

Newfoundland CanadaNewfoundland Canada


Well Woman ClinicsWell Woman Clinics

Two Rural Health CentresTwo Rural Health Centres Start date March 2004Start date March 2004 One clinic per month in both One clinic per month in both

locations locations 6-8 clients per clinic6-8 clients per clinic


How it all BeganHow it all Began

Need identified by CHN’s, NP and Need identified by CHN’s, NP and female clientsfemale clients

Higher rate of mortality by cervical Higher rate of mortality by cervical Ca in Newfoundland vs. Canadian Ca in Newfoundland vs. Canadian national statisticsnational statistics

Incidence of cervical Ca in Incidence of cervical Ca in Newfoundland has increased vs. Newfoundland has increased vs. national decrease national decrease


Mortality RateMortality Rate

CanNL PEINSNB QUONMN SK AL BC

0

0.5

1

1.5

2

2.5

3

3.5

4

Rate per 100,000

Estimated Mortality Rate of Cervical Cancer by Province 2005

Canadian Cancer Society/National Cancer Institute of Canada: Canadian Cancer Statistics 2005


Health Promotion Action Health Promotion Action PlanPlan

To increase the knowledge and awareness To increase the knowledge and awareness of Reproductive Health in the St. Mary’s of Reproductive Health in the St. Mary’s

Bay AreaBay Area


Literature ReviewLiterature ReviewWomen’s Perception of Women’s Perception of Barriers to ScreeningBarriers to Screening

Preferred female providersPreferred female providers Valued privacy (adequate Valued privacy (adequate

drapes/gowns)drapes/gowns) Treated in a caring/respectful mannerTreated in a caring/respectful manner Warm surfaces (speculum/stirrups)Warm surfaces (speculum/stirrups) Preferred flexible hoursPreferred flexible hours Identified a lack of counseling time Identified a lack of counseling time

( i.e. short rushed appointments)( i.e. short rushed appointments)


… … Barriers to ScreeningBarriers to Screening

Lack of understanding of need for Lack of understanding of need for screeningscreening

Adequate explanation of proceduresAdequate explanation of procedures Opportunistic screening/lack of screening Opportunistic screening/lack of screening

optionsoptions Women with bilateral T/L may have poor Women with bilateral T/L may have poor

screening compliancescreening compliance


Other ConsiderationsOther Considerations Reminders increased screening ratesReminders increased screening rates Physician recommendation was Physician recommendation was

significantly related to compliance significantly related to compliance with screeningwith screening

Need to target high risk populations Need to target high risk populations (elderly, economically disadvantaged, (elderly, economically disadvantaged, minority and rural women)minority and rural women)

Acquaintance with nursing staff has Acquaintance with nursing staff has been shown to improve attendance at been shown to improve attendance at cervical screening programscervical screening programs


What We Did…What We Did…

NetworkingNetworking Literature reviewLiterature review Developed Screening Developed Screening

GuideGuide Promotion and advertisingPromotion and advertising Decide on best locationsDecide on best locations Bookings and Bookings and

appointmentsappointments WaitlistWaitlist


Interprofessional TeamInterprofessional Team Clerical supportClerical support Community Health NursesCommunity Health Nurses Nurse PractitionerNurse Practitioner

By Referral:By Referral: PhysiciansPhysicians DieticianDietician GynecologistsGynecologists Mental Health ServicesMental Health Services Addiction ServicesAddiction Services

Other Partners:Other Partners: Health & Community Services Western (Cervical Health & Community Services Western (Cervical

Screening Program)Screening Program) Community ChurchesCommunity Churches Canadian Cancer SocietyCanadian Cancer Society Biochemistry, cytology & microbiology labsBiochemistry, cytology & microbiology labs Newfoundland Breast Screening ProgramNewfoundland Breast Screening Program ClientsClients


What We Do…What We Do… 1 hour appointment1 hour appointment Complete a Complete a Well Woman Screening GuideWell Woman Screening Guide Physical Exam Physical Exam Health promotion integrated throughoutHealth promotion integrated throughout Health education on BSE/PapHealth education on BSE/Pap Pap smear, bimanual exam and CBEPap smear, bimanual exam and CBE Swabs, blood work and other Swabs, blood work and other

labs/diagnostic tests individualizedlabs/diagnostic tests individualized Provide literature Provide literature Referral and follow-up individualizedReferral and follow-up individualized All participants contacted regarding Pap All participants contacted regarding Pap

resultsresults


WELL WOMAN SCREENING WELL WOMAN SCREENING GUIDEGUIDE

DemographicsDemographics Menstrual/Reproductive Menstrual/Reproductive

HistoryHistory Risk Factors/Family HistoryRisk Factors/Family History Social/Personal HistorySocial/Personal History Past Medical/Surgical HistoryPast Medical/Surgical History MedicationMedication AllergiesAllergies Safety IssuesSafety Issues Health MaintenanceHealth Maintenance Physical ExaminationPhysical Examination Recommendations & Recommendations &

CommentsComments


Screening GuideScreening Guide Reports Attached

EASTERN HEALTH WELL WOMAN SCREENING GUIDE

Name: ________________ DOB: _______________ Date:___________________ MCP: _________________ Phone: ______________ Address:________________ Menstrual/Reproductive History: LMP: ________ Gravida: ______ Para: _______ Abortion/Miscarriage: __________ Dyspareunia: _______ Abnormal D/C: __________ Abnormal Bleeding: ___________ Current Symptoms: _____________________ Infections/STI’s: _______________ Cycle History: Length: ___________ Duration: ___________ _ Flow: _____________

Previous PAP Smear: No Yes Date: _________ Result: ____________ Previous Mammogram: No Yes Date: _________ Result: ____________ BSE: No Yes Contraceptive Use: __________ HRT/Estrogen Use:__________ Referral to Breast Screening Clinic: No Yes (1-800-414-3443) Risk Factors/Family History: Social/Personal History: Thyroid Disease No Yes Smoking: No Yes ______________ Hypertension No Yes Alcohol: No Yes ______________ Diabetes No Yes Other Drugs: No Yes______________ CVD No Yes Tetanus:__________ Influenza: ___________ Osteoporosis No Yes Pneumovax: ___________ Cervical Cancer No Yes Folic Acid (child bearing): No Yes Breast Cancer No Yes Calcium/Vit D Supplement: No Yes Colon Cancer No Yes (Age 19-50–1000 mg/day-400 IU, >50 1500 mg/day-800 IU)

Ovarian Cancer No Yes Other: ______________________ Past Medical History: Past Surgical History: ______________________________ ___________________________________ ______________________________ ___________________________________ ______________________________ ___________________________________ Current Medications: Allergies: ______________________________ ___________________________________ ______________________________ ___________________________________ ______________________________ ___________________________________ ______________________________ ______________________________ Safety Issues Discussed: Health Maintenance: Seat Belt Use No Yes Exercise: No Yes ATV/Helmet Use No Yes Type & Frequency ________________ Smoke Detector No Yes Diet: poor fair good Firearms No Yes Uses Canada’s Food Guide: No Yes Sun Exposure No Yes Dental Visit: ________________ Physical Examination: BP: ________ Pulse: _______ Weight: ________ Height: _______ BMI:___________ (>30 offer referral to dietician) Breasts: Left ________________________ Right ___________________ Pelvis: Cervix ______________________ Uterus __________________ Vulva _______________________ Vagina __________________ (L) Adnexae __________________ (R) Adnexae ______________ PAP Done: No Yes C&S Swab: No Yes Chlamydia: No Yes Blood Work/Tests Recommended: Stool OB (routine > 50) Lipid Profile (routine > 50) Bone Density (> 50 plus 1 major risk factor) Mammogram Other (specify) _____________________________ Comments/Referrals: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ CHN Signature: __________________________ Date: ___________________________ NP Signature: ____________________________ Date: ___________________________

Major Risk Factors for Osteoporosis: age > 65 years vertebral compression fracture fragility fracture after age 40 family history of osteoporotic

fracture (esp. maternal hip fracture)

systemic glucocorticoid therapy of > 3 month duration

malabsorption syndrome primary hyperparathyroidism propensity to fall osteopenia apparent on x-ray hypogonadism early menopause (before age 45)

The CAGE Questionnaire I. Have you ever felt the need to CUT

DOWN on drinking? II. Have you ever felt ANNOYED by

criticism of drinking? III. Have you ever felt GUILTY about

drinking? IV. Have you ever taken a drink first thing

in the morning (EYE-OPENER) to steady your nerves or get rid of a hang over?

Two or more affirmative answers to the CAGE questionnaire suggest alcoholism. They indicate that you need to ask more questions about blackouts (loss of memory for event during drinking), seizures, accidents or injuries while drinking, job loss marital conflict or legal problems. Also ask specifically about drinking while driving or operating machinery.


Physical ExaminationPhysical Examination

Vitals signsVitals signs WeightWeight HeightHeight BMI (referral to dietitian BMI (referral to dietitian

if >40)if >40) Clinical Breast ExamClinical Breast Exam Pelvic ExamPelvic Exam PapPap Swabs for C & S and Swabs for C & S and

ChlamydiaChlamydia


Health PromotionHealth Promotion

Use screening guide Use screening guide Offer immunization updateOffer immunization update View video tape on breast self View video tape on breast self

examination (BSE) or Pap Smear examination (BSE) or Pap Smear ScreeningScreening

Demonstrate BSE on breast model and Demonstrate BSE on breast model and encourage practiceencourage practice

Counseling on various health issuesCounseling on various health issues


Blood Work/Tests Blood Work/Tests IndicatedIndicated

Stool OBStool OB Lipid ProfileLipid Profile Bone DensityBone Density Mammography Mammography OtherOther


Screening Guide Screening Guide SummarySummary

Record significant physical findingsRecord significant physical findings Record referrals made to: Record referrals made to:

family physicianfamily physician

specialist (e.g. OBGYN) specialist (e.g. OBGYN)

dietician dietician

mental health or addiction servicesmental health or addiction services Prescription renewal (i.e. contraception)Prescription renewal (i.e. contraception)

EvaluationEvaluation

An integral component of An integral component of any program.any program.


Telephone SurveyTelephone Survey

6 simple questions6 simple questions

Randomly selected clients Randomly selected clients

Survey conducted by BN student Survey conducted by BN student working with CHNworking with CHN

Completed within a 2 week periodCompleted within a 2 week period

40% of the total participants were 40% of the total participants were interviewedinterviewed


How did you learn about the How did you learn about the clinic?clinic?

0

2

4

6

8

10

12

14

CHN Church

Bulletin

Clinic Friend Telephone Nurse

Practitioner

Would you recommend Would you recommend the clinic to a friend? the clinic to a friend?

Why or why not?Why or why not?

Yes

100%

Were you satisfied with the Were you satisfied with the care you received at this care you received at this

clinic? clinic?

Why/Why not?Why/Why not?

Yes

100%


Would you come again? Would you come again?

Why/Why not?Why/Why not?

Yes

100%

Does this clinic meet your personal Does this clinic meet your personal health needs?health needs?

All responses were positive.All responses were positive.

Recommendations for improvement?Recommendations for improvement?To get message out to others.To get message out to others.


What did you like best/least What did you like best/least about the Women’s about the Women’s

Wellness Clinic?Wellness Clinic?Best: Best:

comfortable, for women comfortable, for women by women, professional, by women, professional, personal, convenient, personal, convenient, met needs, private, met needs, private, answered questions, not answered questions, not rushed.rushed.

Least:Least:

nothing identified by nothing identified by women surveyedwomen surveyed


ConclusionConclusion

Clinics improve access to breast and cervical Clinics improve access to breast and cervical screening and other health maintenance screening and other health maintenance opportunities to the women of our communities.opportunities to the women of our communities.

Meet the needs of our female population through Meet the needs of our female population through interprofessional collaboration.interprofessional collaboration.

Increased screening leads to an increase incidence Increased screening leads to an increase incidence of cervical cancer but a decrease mortality rate.of cervical cancer but a decrease mortality rate.

Focus on timely and appropriate treatment.Focus on timely and appropriate treatment.

Need to assess cervical screening statistics to Need to assess cervical screening statistics to determine if they have increased since determine if they have increased since implementation of clinics.implementation of clinics.


References:References:Canadian cancer statistics (2005). Canadian cancer statistics (2005).

http://www.cancer.ca/ccs/internet/standard/0,3182,3172_14291__langId-en,00.hthttp://www.cancer.ca/ccs/internet/standard/0,3182,3172_14291__langId-en,00.htmlml

Castellano, P., Wenger, N. & Graves, W. (2001). Adherence to screening guidelines Castellano, P., Wenger, N. & Graves, W. (2001). Adherence to screening guidelines for breast and cervical cancer in postmenopausal women with coronary heart for breast and cervical cancer in postmenopausal women with coronary heart disease: An ancillary study of volunteers for HERS. disease: An ancillary study of volunteers for HERS. Journal of Women’s Health Journal of Women’s Health & Gender Based Medicine& Gender Based Medicine, 10(5): 451-461., 10(5): 451-461.

Clinical Practice Guidelines. http://www.cmaj.ca/misc/service/guidelines.shtmlClinical Practice Guidelines. http://www.cmaj.ca/misc/service/guidelines.shtmlCommunity accounts. Community accounts.

http://www.communityaccounts.ca/communityaccounts/onlinedata/default.htmlhttp://www.communityaccounts.ca/communityaccounts/onlinedata/default.htmlCoughlin, S. et al (2002). Cervical cancer screening in the workplace: Research, Coughlin, S. et al (2002). Cervical cancer screening in the workplace: Research,

review and evaluation. review and evaluation. AAOHN JournalAAOHN Journal, 50(1): 32-39., 50(1): 32-39.Fitch, M. I. et al (1998). Exploring the barriers to cervical screening in an urban Fitch, M. I. et al (1998). Exploring the barriers to cervical screening in an urban

Canadian setting. Canadian setting. Cancer NursingCancer Nursing, 21(6): 441-449., 21(6): 441-449.Newfoundland cancer treatment & research foundation. Newfoundland cancer treatment & research foundation. http://www.nctrf.nf.ca/http://www.nctrf.nf.ca/Rose, J. (2002). Cervical cancer screening in Newfoundland and Labrador: Status Rose, J. (2002). Cervical cancer screening in Newfoundland and Labrador: Status

Report 2002. (unpublished report).Report 2002. (unpublished report).Somkin, C.P. et al (1998). Reminder interventions increased women’s use of Somkin, C.P. et al (1998). Reminder interventions increased women’s use of

mammography and Pap smear screening. mammography and Pap smear screening. Evidence-Based NursingEvidence-Based Nursing, 1(2), 59., 1(2), 59.Spradley & Allender (1996). Spradley & Allender (1996). Community health nursing: Concepts and practice.Community health nursing: Concepts and practice. 4th 4th

Edition. Philadelphia, PA: Lippincott-Raven Publishers.Edition. Philadelphia, PA: Lippincott-Raven Publishers.Van Til, L., MacQuarrie, C. & Herbert, R. (2003). Understanding the barriers to Van Til, L., MacQuarrie, C. & Herbert, R. (2003). Understanding the barriers to

cervical screening among older women. cervical screening among older women. Qualitative Health ResearchQualitative Health Research, 13(8): , 13(8): 1116-1131.1116-1131.

Winkler, H. et al (1999). Compliance with Papanicolaou smear screening following Winkler, H. et al (1999). Compliance with Papanicolaou smear screening following tubal ligation in women with cervical caner. tubal ligation in women with cervical caner. Journal of Women’s HealthJournal of Women’s Health, 8(1): , 8(1): 103-107.103-107.

improving access to well woman screening utilizing an interprofessional approach icn inp/apn...

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