Jenny Greenfield shares 10 top tips to help nurses set up and run effective cervical screening services
Read this article to learn more about:
- the current uptake of cervical screening
- how to encourage patients to attend cervical screening appointments
- how to reassure patients regarding the process involved.
Cervical screening is a method of preventing cancer by detecting and treating abnormalities of the cervix.1 During 2015–2016, 4.21 million women in England were invited to have a cervical screen compared with 4.31 million women during 2014–2015.2 As of 31 March 2016, 72.7% of eligible women (aged 25–64 years) were recorded as being screened adequately within the specified period—on 31 March 2015 this figure was 73.5% and on 31 March 2011 it was 75.7%.2
In the UK 3,224 women were diagnosed with cervical cancer in 2014.3 High-risk human papilloma virus (HPV) infection is estimated to be linked with 100% of cervical cancer cases in the UK.3 The introduction of the HPV vaccination programme in the UK for girls between the ages of 11–14 years is expected to prevent at least 7 out of 10 cancers of the cervix in those who have been vaccinated.4
It is thought that women between the ages of 35 and 64 years have a 60–80% lower risk of being diagnosed with cervical cancer in the 5 years following screen compared with women who haven't been screened—the benefits of screening benefits increase with age.5
So how can we try to encourage our ladies to attend appointments for cervical screening?
1 Appoint a cervical cytology lead for your practice
A cervical cytology lead, with protected time to oversee the practice cytology process, can cascade information to ensure good communication throughout the practice team.
2 Actively follow up non-responders and previous non-attenders
Phone or text non-responders and previous non-attenders 24 hours before their appointment to remind them to attend and give any reassurance required. There may be practical issues that have occurred and made it difficult for patients to attend appointments—for example, if clinic times are between 9.00–17.00. If possible offer early morning, weekend, or evening appointments. There may also be psychological barriers to the patient, such as embarrassment, fear of pain, or concern about what the test may find.6
3 Ensure the availability of suitably-trained staff
Before registered nurses routinely perform cervical screening examinations they must complete a recognized theoretical course and a period of supervised practical training.7 All training should be undertaken within a 9-month period before undertaking a final assessment—once training is complete, sample takers should continuously self evaluate competence in accordance with professional codes of conduct and perform one half-day training every 3 years.7 The competency framework Obtaining cervical cytology samples from women (CHS37), developed by Skills for Health, acknowledges that sample taking is not a standalone task and requires an appropriate level of clinical skill and experience.7,8
4 Provide appropriate information and support for different social and cultural groups
Depending on the demographic of your practice, try to provide leaflets in different languages. If appropriate and feasible provide occasional women-only sessions, and if necessary use an interpreter or bilingual support services at the appointment.
In a qualitative study a group of Asian women stated that there was general lack of understanding about cervical cancer by women within their ethnic group—particularly among those that had recently migrated and/or older women.9 In the same study, influenced by beliefs about sex outside of marriage, factors for not attending screening included a low perceived risk of cervical cancer and the feeling that a diagnosis may be considered shameful.9
Women with learning disabilities should be encouraged to attend for screening by tailoring invitations and appointments to their specific needs. Local learning disability teams can offer support, including assistance with consent, and may also be able to accompany women to their appointment. The Department of Health has produced an easy-to-read leaflet designed to help women with learning disabilities to better understand the benefits of cervical screening.10
Lesbian and bisexual women, and trans men who still have a cervix, should be encouraged to attend for their regular screens.
5 Allow sufficient protected time for the appointment
If it is possible allow a longer time for the patient's first appointment to address any fear of the procedure, to give information on any likely discomfort, and to explain what the result may mean—this approach may also be useful if the patient has had a previous negative experience. Before performing the procedure for the first time, and to dispel any fear show the equipment to the patient and explain how it is used.
Patient consent for a medical procedure is a legal requirement in the UK. Consent must be uncoerced and informed, and the benefits of any interventions must out-weigh any harmful effects. In the case of taking a cervical screening sample, consent is implied rather than being expressed. Attendance at the surgery for the procedure implies consent to the procedure, although a full explanation should still be given. The sample taker is responsible for this, and the language and terminology used is critical in helping to reassure the patient.11
6 Consider a 'buddy' system
Encourage patients to arrange an appointment in the same session as one of their friends or encourage two mums to come together for childcare purposes.
7 Make sure the procedure is performed correctly first time
Double check it is the right person, and that the right details are on the form and sample container. At every stage of the cervical screening process, good communication skills and sensitivity are essential. It is good practice to establish a welcoming, non-threatening environment and rapport to put the patient at ease. The sample taker should have sound empathetic listening skills and unconditional respect for the patient, allowing appropriate responses to any questions.
Ensure the room is sufficiently warm and that nobody will enter the room during the consultation.
All surgeries should have a chaperone policy in place and a chaperone must be offered. Throughout the procedure it is vital to maintain the patient's privacy and dignity, ensuring that patient confidentiality is upheld.
8 Dispel myths associated with cervical screening
Cervical screening is a test for detecting abnormal cells that could become cancerous if not treated properly—screening is performed to prevent cancer not to detect it.12
Women that have stopped having periods or that have undergone a hysterectomy where the cervix is still in place should continue to undergo screening.12 Women that have never been sexually active should also be screened—although the risk of developing cervical cancer is extremely low, it is still present.12
9 Ensure effective management of your patients in the NHS cervical screening programme
Ideally follow the steps below:
- use test results sent to the practice to set up a reminder for future recall dates
- check cervical screening status of all women aged 25 years and over at new patient checks
- patients who have formally withdrawn from the NHS cervical screening programme should be contacted every 5 years to see if they wish to change their minds
- electronic prior notification lists should be checked weekly—any ghost patients (registered with a GP after they have died or moved away from an area) and women no longer in the screening programme should be removed.
10 Encourage all staff to promote cervical screening
This may include participation in national awareness weeks: Cervical Cancer Prevention Week is held each January and Cervical Screening Awareness Week is held each June.
Jo's Cervical Cancer Trust has information for practice nurses and GPs, including electronic patient information slides that can be downloaded and free to order posters to use in surgery waiting rooms. Use your practice website to advertise the importance of screening.
- Public Health England. Cervical screening: programme overview. PHE, 2015. Available at: www.gov.uk/guidance/cervical-screening-programme-overview (accessed 16 January 2017).
- Health and Social Care Information Centre. Cervical screening programme—England, 2015–16. HSCIC, 2016. Available at: www.content.digital.nhs.uk/catalogue/PUB22414/nhs-cerv-scre-prog-eng-2015-16-rep.pdf
- Cancer Research UK. Cervical cancer statistics. CRUK. Available at: www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/cervical-cancer (accessed 16 January 2017)
- Cancer Research UK. HPV vaccines. CRUK, 2014. Available at: www.cancerresearchuk.org/about-cancer/cancers-in-general/cancer-questions/cervical-cancer-vaccine (accessed 16 January 2017)
- Cancer Research UK. Cervical cancer screening. CRUK, 2016. Available at: www.cancerresearchuk.org/about-cancer/type/cervical-cancer/about/cervical-cancer-screening (accessed 16 January 2017)
- Waller J, Bartoszek M, Marlow L, Wardle J. Barriers to cervical cancer screening attendance in England: a population-based survey. J Med Screen 2009; 16 (4): 199–204.
- Public Health England. NHS Cervical screening program—guidance for the training of cervical sample takers. PHE, 2016.Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/577158/NHS_Cervical_Screening_Progamme_-_guidance_for_cervical_sample_takers.pdf
- Skills for Health. Obtain cervical cytology samples from individuals (CHS37). Skills for Health, 2010. Available at: tools.skillsforhealth.org.uk/competence/show/html/id/1030/ (accessed 16 January 2017)
- Marlow L, Waller J, Wardle J. Barriers to cervical screening among ethnic minority women: a qualitative study. J Fam Plann Reprod Health Care 2015; 41 (4): 248–254.
- Public Health England. Cervical screening: an easy guide. PHE, 2013. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/433757/easy-guide-cervical-screening.pdf
- Royal College of Nursing. Cervical screening: RCN guidance for good practice. RCN, 2013. Available at: www.rcn.org.uk/__data/assets/pdf_file/0007/78730/003105.pdf
- Royal College of Nursing. Myth busting: cervical screening. RCN, 2015. Available at: www2.rcn.org.uk/development/nursing_communities/rcn_forums/womenshealth/news_stories/myth-busting-cervical-screening (accessed 16 January 2017).