Reflection of Liquid Based Cytology - Case Study Example

Reflective Essay on Liquid Based Cytology Nurses are the backbone of any health care system. They play a major role not only in the assessment and treatment of the patients, but also in the promotion of sense of well-being of the patient through their caring feeling and sense of empathy. They work with patients suffering from different types of illness, diseases and undertake a diversity of roles and actions. Their roles demand professional knowledge and expert skills. Many a times, the situations handled by the nurses are complex and demand an understanding of the complexity of the situation which can be gained only through experience and reflection. Infact, every nurse-patient encounter is unique and many nursing problems have no fixed solutions. Reflection is a very important and core part of nursing training and education. The current trends and advancements in the profession of nursing have forced the profession to look for effective measure of effective practice, the most important of which is reflective activity. Advances in the 21st century are seeing many new developments in the field of healthcare forcing the nursing faculty to reinforce effective and appropriate education. This becomes of primary importance by virtue of the nature of the profession nursing is. As such, the primary goal of nursing is to provide quality health care to patients. High standards of competence can be maintained by the nurses through appropriate evaluation and examinations of ones own activities and performance, through clinical reflection. Reflection is the process by which a person evaluates and examines ones own thoughts and actions. Reflective practice is very essential for nursing clinical practice because it helps the nurse to understand, assess and learn through the experiences during clinical practice (Burns and Grove, 2005). In fact, reflection is a very important tool for development which challenges the practitioner to think in new ways, raise doubts about effective clinical practice and explore various new methods of solving problems encountered in day-to-day practice. “Reflection gives scope for better understanding of oneself so that existing strengths can be used to build-up for future actions "(Somerville and Keeling, 2006). In this essay, clinical reflection about handling a patient who is scheduled for liquid-based cytology will be discussed. Reflection using Gibbs model of reflection The frameworks make the process of reflection easy. There are many frameworks. Gibbs model is a reflective cycle which is a straight forward and recognized framework for reflection wherein it enables clear description of the situation of the patient, the analysis of feelings, evaluation of the experience, analysis to make sense of the experience, conclusion where other points are considered and reflection upon experience to examine what you would do if situation arose again. Description of the situation involves recollection of the condition of the patient, the signs and symptoms, and the initial evaluation parameters when the patient got admitted. Analysis of feelings involves evaluation of the feelings of the nurse towards the patient and also the feelings of the patient during the course of treatment. Evaluation of experience involves evaluation of the negative and positive actions of the nurse at that particular situation. Analysis involves evaluation of the impact of the actions of oneself on the condition of the patient, whether the actions cause improvement or deterioration of the condition of the patient. Description 40 year old Lucy (Name changed due to confidentiality reasons according to NMC code) was referred for cervical cancer screening. Lucy apparently had no health problems. She was mother of 3 children. She was accompanied by her husband. Lucy was apprehensive and nervous about the procedure. She had many doubts regarding the test. She asked me whether the test had any side effects, what were the benefits of the test, whether the test was fail safe and as to what would be the next step in case the results were abnormal. I sat down with Lucy and her husband and explained to them the need for testing. I told them that cervical cancer is associated with high mortality and morbidity and the best way to prevent it is by early identification through regular screening. I told Lucy that the test had minimal side effects like discomfort and bleeding. As far as fail safe is concerned, I told her that no screening results are 100 percent accurate; however, screening is the best screening method to detect cervical cancer in early stages. I provided Lucy with a comfortable and pleasant environment. She underwent the test. Feelings According to the National Health Service Cervical Screening Programme (NHSCSP) the cytology screening programme is recommended for women between 25-64 years of age. Opportunistic screening is recommended for those 20-24 year old (NHS, 2006). This is because of the trend of increasing sexual activity at an early age, that too with more than one partners, and poor sexual health. When Lucy expressed her doubts, especially about the fail safe of LBC, I was confused. However, I knew that this programme was initiated because it was the best method to prevent cervical cancer in women. Hence, I confidently told Lucy that screening is the best tool to identify cancer in early stages. Lucy also understood the importance of the test and underwent the procedure. Evaluation Whether LBC is a fail safe procedure is a much debated topic and many patients who come for LBC to us ask this question. The test is not 100 percent sensitive. However, it is the best screening procedure for cervical cancer and has played a significant role in declining deaths related to cervical cancer (NHS, 2006). At this juncture it is worth discussing about cervical cancer so that the role of screening is further understood and emphasized. Cervical cancer is the second most common cancer among women worldwide. It is more common in developing countries (Tiffen and Mahon, 2006). It is however not as vicious as it sounds because, it is actually easily treatable when detected in early stages. Diagnosis is easy because it has a prolonged pre-cancerous state during which it sheds abnormal cells which can be collected by Pap smear. It originates from the squamocolumnar epithelium of the endocervix. About 90% of this cancer is squamous cell carcinoma. Only 10% is of other types –adenocarcinoma, adenosquamous carcinoma, small cell carcinoma and neuroendocrine carcinoma. The development of the cancer is preceded by precancerous lesion known as cervical dysplasia. Increased sexual activity, early age of onset of sexual life, promiscuity, lower socio-economic status, multiparity, smoking and history of genital warts are said to predispose and increase risk of cervical cancer (Garcia, 2006). The peak age of incidence is 40-50 years. The preinvasive stage of cervical cancer is termed cervical intraepithelial neoplasia (CIN) which can be further divided in to 3 stages based on Bethesda cervical cytology reporting system (Garcia, 2006). This test is done on pap smear. The first stage, CIN-1 is a phase where mild dysplasia occurs at the squamo-columnar junction of the endocervix. It is confined to the basal one third of the epithelium. It is also termed as low grade squamous intraepithelial lesion. CIN-2 comprises of moderate dysplasia. It is confined to the basal two third of the epithelium. CIN-3 is when there is severe dysplasia. The dysplasia may include the whole thickness of the epithelium. This stage may include carcinoma in situ. Both CIN-2 and CIN-3 are termed high grade squamous epithelial lesions because of their high chances of conversion to invasive cancer. The dysplastic changes seen are epithelial hyperplasia (acanthosis) and cytoplasmic vacuolization (koilocytosis). The stages of CIN can progress linearly over a period of time to develop in to invasive cancer. In some, invasive cancer may be detected without involving the initial stages. Once the cancer has entered invasive stage, it can have multiple growth patterns- exophytic, nodular, infiltrative and ulcerative. Of these exophytic type is the commonest. It usually arises from the exocervix. It can look polypoid or papillary. It can grow in to a bulky mass and can bleed excessively. On the other hand, the nodular variety arises from the endocervix and grows circumferentially in the stroma of the endocervix. There are basically 2 tests to screen for cervical cancer and they are Pap smear and LBC. LBC has several advantages. It simplifies the process of collection of the smear sample. It reduces inadequacy rate and also improves preservation of the cells. It allows transfer of all the cells that are collected into the vial. The process is quicker. Multiple slides can be produced in one collection setting, thus providing scope for further testing, for quality assurance or for teaching purposes. The residual material in the vil can be subjected to other tests like human papilloma virus assay. This test facilitates computer assisted screening, a future development. The screening process done thus is enhanced because of improvement and standardization of service (Dunleavey, 2009). LBC is a method of preparing sample from cervix for laboratory examination. The sample is collected in a method similar to Pap smear using a special device known as spatula. The spatula brooms and brushes the cells from the wombs neck thus, providing sample for testing. The cells get lodged in the head of the sample. Hence the head is broken off into a small vial made up of glass. This vial contains preservative fluid. In some centers, the head is washed into the preservative fluid. This method is different from Pap smear in which the sample is smeared directly into the microscope slide (NHS, 2010). The sample collected thus is sent to the laboratory. There it is spun and then treated to remove any material that is obscuring like pus and mucus. The remaining sample consisting of cells is taken and a thin layer is prepared over the slide. This is examined under the microscope by a cytologist (NHS, 2010). According to a large randomised trial, "compared with the conventional Papanicolaou (Pap) test, liquid-based cytology is not more sensitive or specific in detecting precancerous lesions or cervical cancer" (Nelson, 2009). According to the researchers, from the National Cancer Institute, "the choice comes down to cost-effectiveness issues related to laboratory productivity, slide adequacy, and ease of ancillary molecular testing, but not accuracy" (Nelson, 2009). Analysis Lucy was concerned if this method of screening did help other women in the past and what were the steps that would be taken in case the results were abnormal. I advised her LBC was useful only for screening and if the test was found abnormal, further tests would be done to confirm the diagnosis. Otherwise, repeat screening after 5 years would be recommended. Lucy was also concerned whether the test would help in obtaining adequate sample and if this was the right time for her to give sample. She was in the mid-cycle period. I advised her that LBC is a useful procedure that has benefited women in terms of reduction in inadequate rates, thus reducing uncertainty, anxiety and need for repeated testing. Prior to introduction of LBC, 9 percent of screening tests for cancer needed repeat test. After introduction of LBC, the percentage of repeat tests has come down to 2.5 percent. The turnaround time is faster and thus the women are likely to get their results more quickly (NHS, 2010). The accuracy of LBC is not 100 percent, like any other screening technology. However, screening is the best defense against cervical cancer (NHS, 2010). Factors which contribute to inadequate smear test are unsuitable or insufficient material, inadequate fixation of the mear sample, inadequate spreading of the smear and presence of pus, blood and other exudates in the smear (Dunleavey, 2009). The optimum time for sample collection is mid-cycle. Whenever an abnormal smear has been reported, the next step is closer examination of cervix by colposcopy. Colposcopy may be defined as "examination of the cervix using a scope which allows visualisation and magnification of the cervix an the collection of biopsies" (Dunleavey, 2009). The aim of colposcopy is "to assess the nature, severity and extent of any abnormality detected in the cervical smear, and where appropriate to take specimens for cervical histology" (Dunleavey, 2009). Lucy wanted to know about the disadvantages of the test. LBC is associated with certain disadvantages too. It is more expensive than Pap smear, the conventional cytology. Reporting it requires skilled staff. Specialized approach is necessary for transfer of vials.In order to obtain a good sample for smear, sufficient number of metaplastic squamous cells and endocervical cells must be obtained from the transformation zone. To gain good smears, smear taking must not be done during menstruation, during presence of vaginal infection and also within 24 hours of vaginal pessaries and creams (Dunleavey, 2009). Analysis During my interaction with Lucy, I was happy that I could convince her that it was important for her to undergo LBC test. She trusted me because I was confident in solving her queries and I provided a comfortable atmosphere for her. According to the NMC, (cited in Somerville, and Keeling, 2004), nurses have a duty bested upon them to provide care that is to the best of their ability to the patients. In order to impart this duty, they need to have good knowledge, possess good skills and display appropriate behavior during their interaction with patients and their colleagues (Somerville, and Keeling, 2004). All this is possible through reflective practice wherein there is feedback on the impact of their actions on their patients, the families of the patients, their colleagues and ultimately on the organization. NHS (2006) recommends that every patient subjected to cervical screening must receive appropriate pretest care. She must be give appropriate verbal information using the language which the patient can understand. The patient must also be provided written information in the language she can understand. The nurse must respond to the needs and concerns of the patient on individual basis with preserved confidentiality, respect and dignity. Prior to testing, the practitioner must ensure that the patient is aware of the investigations that are being done, like swabs, cytology test, etc. the patient must also be informed as to why the test is being performed and also about the limitations of the test. NHS (2006) also recommends that a safe and comfortable environment must be provided when performing the test. The examination and consultation must be done with privacy and hygiene measures taken. The specimen vial label must be clear and patient information must be upto-date, clear and correct. The speculum size must be appropriate and passing and removing of this tool must cause least discomfort to the woman. the vulva, cervix and vagina must be visualized and any abnormal features noted. After the test, possible side effects like discomfort and mild bleeding must be advised. The patient must be informed when to collect the reports. She must also be informed about the range of results and the steps that will taken based on the reports. I acted as per the recommended guidelines. Conclusion Reflective practice is very essential in nursing profession. In this reflection, the understanding of LBC, its role in screening cancer, steps to be taken to perform the test, role of nurse in counseling the patient and addressing various concerns of the patient were dealt with. References Burns, N., and Grove, S. K.. (2005). The Practice of Nursing Research: Conduct, Critique and Utilisation, 3rd ed.. Philadelphia: W. B. Saunders Co. Dunleavey, R. (2009). Cervical cancer: A Guide for Nurses. London: Blackwell Publishing. Garcia, A.A., Hamid, M. & El-Khoueiry. A. (2006). Cervical Cancer. eMedicine from Web MD, Retrieved on 18th Feb, 2011 from http://www.emedicine.com/med/topic324.htm#section~introduction NHS. (2010). NHS Cervical Screening Programme. Retrieved on 18th Feb, 2011 from http://www.cancerscreening.nhs.uk/cervical/lbc.html NHS. (2006). Cervical Cytology Screening Guidelines. Retrieved on 18th Feb, 2011 from referrals.kch.nhs.uk/EasySiteWeb/getresource.axd?AssetID Nelson, R. (2009). Pap Tests and Liquid-Based Cytology Equivalent in Detecting Precancerous Lesions. Medscape family medicine. Retrieved on 18th Feb, 2011 from http://www.medscape.com/viewarticle/711469 Somerville, D. and Keeling, J. (2006). A practical approach to promote reflective practice within nursing. Nursingtimes.net, 100(12), p.42. Retrieved on 18th Feb, 2011 from http://www.nursingtimes.net/nursing-practice-clinical-research/a-practical-approach-to-promote-reflective-practice-within nursing/204502.article Tiffen, J., and Mahon, S.M. (2006). Cervical cancer: what should we tell women about screening? Clin J Oncol Nurs., 10(4), 527-31. Read More