Defining Social ProblemsVivibelle
Cervical Cancer Screening in Adolescents: An Evidence-Based Internet Education Program for Practice Improvement Among Advanced Practice Nurses Kim Choma, DNP, WHNP-BC • Amy E. McKeever, PhD, CRNP, WHNP-BC
cervical cancer, cervical cancer
guidelines, female adolescents,
Web-based education, continuing
education unit (CEU),
ABSTRACT Background: The literature reports great variation in the knowledge levels and application of the recent changes of cervical cancer screening guidelines into clinical practice. Evidence-based screening guidelines for the prevention and early detection of cervical cancer offers healthcare providers the opportunity to improve practice patterns among female adolescents by decreas- ing psychological distress as well as reducing healthcare costs and morbidities associated with over-screening.
Purpose: The purpose of this pilot intervention study was to determine the effects of a Web- based continuing education unit (CEU) program on advanced practice nurses’ (APNs) knowledge of current cervical cancer screening evidence-based recommendations and their application in practice. This paper presents a process improvement project as an example of a way to disseminate updated evidence-based practice guidelines among busy healthcare providers.
Methods: This Web-based CEU program was developed, piloted, and evaluated specifically for APNs. The program addressed their knowledge level of cervical cancer and its relationship with high-risk human papillomavirus. It also addressed the new cervical cancer screening guidelines and the application of those guidelines into clinical practice.
Findings: Results of the study indicated that knowledge gaps exist among APNs about cervical cancer screening in adolescents. However, when provided with a CEU educational intervention, APNs’ knowledge levels increased and their self-reported clinical practice behaviors changed in accordance with the new cervical cancer screening guidelines.
Linking Evidence to Practice: Providing convenient and readily accessible up-to-date elec- tronic content that provides CEU enhances the adoption of clinical practice guidelines, thereby decreasing the potential of the morbidities associated with over-screening for cervical cancer in adolescents and young women.
BACKGROUND In 2009, the consensus guidelines for cervical cancer screen- ing unveiled a sagacious update that greatly impacted when to initiate screening for adolescent and young adult women. Based upon the large body of evidence surrounding the nat- ural history of human papillomavirus (HPV) and the minor burden of cervical cancer in this population, guidelines recom- mended delaying the onset of cervical cancer screening until age 21 years (American College of Obstetricians and Gyne- cologists [ACOG], 2009; Moscicki & Cox, 2010). Prior rec- ommendations (ACOG, 2003) encouraged screening 3 years after initiation of sexual intercourse, even if the young woman was less than 21 years of age, despite an “exceedingly rare” risk of cervical cancer development in young women. Studies
of healthcare providers in various specialties reported great variance among the participants surveyed about knowledge of cervical cancer and its screening guidelines as well as HPV infection and its risk of cervical pre-invasive and invasive ma- lignancy. Advances in research and information dissemination have mirrored technology’s rapid progression, leading to an abundance of scientific evidence that can overwhelm healthcare providers. In addition, reluctance to adopt clinical guidelines and barriers to their adoption and consistent implementation of evidence-based practice continue to be pervasive (McDonnell Norms Group, 2006; Melnyk, 2014). As a result, the applica- tion of consensus guidelines into clinical practice by health- care providers has varied, which has created inconsistencies in care for the adolescent and young adult female population
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(Montano, Kasprzyk, Carlin, & Freeman, 2005; Murphy, Schwarz, & Dyer, 2008). To address the need to increase adoption of clinical guidelines among busy and information- saturated healthcare professionals and to decrease the morbidi- ties associated with over-screening for cervical cancer in young women, this paper describes the development, implementa- tion, and evaluation of a pilot study that used a contemporary, Web-based design continuing education program (CEU) for advanced practice nurses (APNs).
REVIEW OF LITERATURE Human Papillomavirus (HPV)—Incidence and Prevalence HPV is reported to be the most common sexually transmitted infection (STI) in the United States (Centers for Disease Con- trol [CDC], 2014; Weinstock, Berman, & Cates, 2004). Because it is not a reportable infection, the incidence and prevalence rates are based on estimates (Hager, 2009). Approximately 6 million new HPV infections occur each year, with nearly 20 million Americans infected (Ault, 2006). Female adolescents 20 years and younger (Widdice & Moscicki, 2008) are at the highest risk of HPV infection, with reported prevalence rates between 18.3% (Forhan et al., 2009) and 82% (Brown et al., 2005). As women age, the rate of HPV prevalence gradually decreases (Dunne et al., 2007). This may be related to an in- verse relationship with sexual activity and age; the younger populations’ higher level of sexual activity places them at in- creased risk for HPV infection (Saraiya, Martinez, Glaser, & Kulasingam, 2009).
Age as a Risk Factor Various factors can increase a female adolescent’s risk of ac- quiring HPV infection. The most common link for all women is sexual activity, even with one partner. Additionally, age is a distinct factor. HPV infection is most commonly seen in women 25 years and younger (Moscicki, 2005). When com- bined with biological and social cofactors, an adolescent’s risk of HPV acquisition is greatly increased. According to a longi- tudinal cohort study of adolescent women, Brown et al. (2005) found extremely high rates of HPV, with cumulative preva- lence among adolescent women at greater than 80%. In addi- tion, risky sexual behaviors often associated with adolescence (e.g., multiple partners, early age of sexual debut, lack of con- dom use), increases one’s risk of HPV acquisition along with the other STIs that are more prevalent in this population, such as gonorrhea and chlamydia. Indeed, coinfection with Herpes simplex virus or Chlamydia increases the risk of HPV infec- tion due to inflammation of the epithelial cells and breaks in the epithelial layer that allows a pathway for HPV introduction (Moscicki, 2005).
Differences in cell biology during various periods of a woman’s life have a great impact on increasing exposure to the HPV virus. During puberty, the cervical transformation zone (the area in which columnar cells meet squamous cells)
shifts outward onto the portio of the cervix. The columnar ep- ithelium gradually transforms into squamous epithelium, a physiologic process known as squamous metaplasia. It is this process of metaplastic cell formation that supports HPV repli- cation, due to the rapid transformation of the cells (Moscicki et al., 2012). In addition to this biological predisposition, female adolescents also may use oral contraceptives, which promote cervical eversion of the squamo-columnar junction, an area in which precursor and cancerous lesions from HPV infection arise. Finally, smoking also confers an increased risk of HPV persistence, especially among current (not former) smokers (Vaccarella et al., 2008; Xi et al., 2009).
Screening for Cervical Cancer—Female Adoles- cents Cervical cancer is no longer the dire threat it once posed Amer- ican women and those in countries with access to adequate reproductive services. During the early part of the 20th cen- tury, cervical cancer was the leading cause of cancer death among women in the United States. However, the advent of the Papanicolaou (Pap) test to screen for cervical cancer has decreased the death rate from invasive cervical cancer (ICC) by approximately 70% (ACS, 2013), despite the fact that the Pap test has never been subject to randomized controlled trials (National Cancer Institute [NCI], 2014).
When screened, female adolescents commonly manifest minimally abnormal results such as atypical cells of unde- termined significance (ASCUS), low-grade squamous intraep- ithelial lesions (LSIL), and histological findings of cervical intraepithelial lesions, grade one (CIN 1). These cytological or histological findings develop shortly after sexual debut (Moscicki & Cox, 2010). Results from a key study sponsored by the NCI, the ASCUS/LSIL Triage Study, demonstrated a 70% positive HPV infection rate among female adolescents with ASCUS cytologic findings, making HPV testing an un- necessary option for triage of minimally abnormal findings in female adolescents (Solomon, Schiffman, & Tarone, 2001). Of note, CIN 1 (pre-invasive cervical disease) is common in female adolescents, with rates seen in up to 50% of adolescent women (Moscicki et al., 2008; Solomon et al., 2001; Wright et al., 2005). However, even with these high rates of abnormalities, statistics indicate that female adolescents between the ages of 15 to 19 have an extremely low risk of developing ICC, with an in- cidence rate of .2 to 1.7 per 100,000 (Case et al., 2006; Watson et al., 2008) and 14 cases estimated annually among 2.7 mil- lion Pap smears conducted among this population (Bernard, Watson, Castle, & Saraiya, 2012).
Quite often, there are high rates of regression among ado- lescents with CIN 1 and CIN 2, with virtually no progression to ICC (Moscicki, 2005; Moscicki et al., 2012). Even with cervical cytology and pathology findings of CIN 2/3, rates of progres- sion (histological findings of pre-invasive cervical disease that may progress to invasive disease) to cervical cancer remain low in this population (Case et al., 2006; Mosicki & Cox, 2010).
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Figure 1. Cervical cancer progression model and optimized prevention strategy. Note. Adapted from “Cervical Cancer Progression Model,” Schiffman et al., 2011.
See Figure 1 for a model depicting HPV infection, precancer, and cancer incidence.
Economic Burdens of Cervical Cancer Over- Screening The financial and psychological burdens associated with ab- normal cervical cytology and HPV infections can be exces- sive, leading to increased healthcare costs (Insinga, Glass, & Rush, 2004). Approximately $2.25 to $4.6 billion dollars is di- rected toward the annual healthcare costs of screening, treating, and managing cervical cytological abnormalities in the United States (Fleurence, Dixon, Milanova, & Beusterien, 2007; Lipsy, 2008). Although these costs are phenomenally high, it is im- portant to note that only 10% of the expenditures are as a result of ICC treatment with more than 70% of total costs resulting from cervical cytological screening, follow-up and management of false-positive results, and incomplete or inconsistent cervical cytological follow-up (Lipsy, 2008). Given the inordinate costs of over-screening and the indirect costs of HPV-related disease (e.g., mildly abnormal cytology, genital warts), recommenda- tions have been developed by the ACOG, the Association for Colposcopy and Cervical Pathologists (ASCCP), and the Amer- ican Cancer Society (ACS) to refocus on age-appropriate peri- odic cervical cytologic screenings (Saslow et al., 2012). (See http://www.cdc.gov/cancer/cervical/pdf/guidelines.pdf for a summary chart of the guideline recommendations.) These guidelines reiterate the low risk of cervical cancer in young
women and encourage the application of the updated evidence- based guidelines into clinical practice.
Physiologic and Psychological Burdens of Over- Screening Precancerous CIN and early microinvasive cervical cancer are commonly treated with excisional cervical procedures to re- move abnormal tissue (e.g., cold-knife conization, loop electro- surgical excision procedure; Sadler et al., 2004; Wright et al., 2005). The literature has documented that multiple excisional or ablative procedures and excisional procedures that remove large sections of the cervix may be associated with pregnancy- related complications (Kyrgiou et al., 2006; Shanbhag, Clark, Timmaraju, Bhattacharya, & Cruickshank, 2009). These com- plications include: pre-term birth, low birth weight, and pre- term-premature rupture of membranes. To date, the evidence varies among studies, given that the research is retrospective and future research cannot involve prospective randomized controlled trials due to ethical concerns (Werner et al., 2010). In view of the fact that adolescents are at a higher risk of unplanned pregnancies (CDC, 2013), and a vast proportion of adolescents with CIN will experience CIN lesion regression, al- ternatives to cervical excision are advocated in this population (Fuchs, Weitzen, Wu, Phipps, & Boardman, 2007).
As a result, the ASCCP revised the consensus guidelines for management of adolescent and young adult women to include conservative medical management for 24 months post cervical
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cytology abnormality prior to considering any excisional procedures (Moscicki & Cox, 2010). Although adolescent and young adult women experience great physiological burden from HPV infection and its subsequent cervical disease, great psychological distress was noted to occur at time of and after diagnosis (Rubin & Tripas, 2010). Rubin and Tripas noted that feelings of uncertainty arose after receiving initial abnormal cervical cytologic findings, resulting in ineffective coping strategies, and poor body-image perception. In addition, Rubin and Tripas reported that anxiety and feelings of stigmatiza- tion were frequently manifested in women with a cervical cytological abnormality, especially if they were informed of the etiology of the HPV infection. Fleurence et al. (2007) conducted a systematic review of the psychological burden of HPV infection. Their results revealed that in addition to anxiety, women experienced anger, shame, and guilt; all of which was documented by the authors to negatively affect their sexual relationships (Fleurence et al., 2007).
Cervical Cancer Screening Guidelines for the Female Adolescent Synthesis of the information related to the natural history of HPV infection, cervical cancer incidence, and mortality in ado- lescents and young adult women has led to dramatic changes in Pap screening recommendations. In the past, guidance for screenings by national organizations was beset by significant differences, impacting their uptake among clinical practices of healthcare providers (Saraiya et al., 2007). The literature noted this great variance existed due to general knowledge gaps about HPV infection and cervical cancer, cervical cytologic screening recommendations, and hesitation among healthcare providers to accept revised and updated evidence-based guidelines as a part of standard practices (Irwin et al., 2006; Meissner, Tiro, Yabroff, Haggstrom, & Coughlin, 2010).
Healthcare providers need to consider paradigm shifts in the health prevention and screening foci of young women that result from evidence-based changes to include the delay of screening initiation to 21 years of age and periodic Pap screen- ing as an evolution of the understanding of the natural history of HPV and cervical cancer and its impact on adolescents. This can be accomplished by refocusing clinical practices to empha- size the needs more pertinent to young woman which include: STI screenings, reproductive health needs, lifestyle modifica- tions, and primary prevention and risk reduction education.
METHODS Purpose of the Program The impetuses for the program were derived from the evidence surrounding the burdens associated with over-screening young women at very low risk for ICC and a unique symposium, referred to as Practice Improvement in Cervical Screening and Management (PICSM) that helped set the stage for evidence-based practice changes (Moscicki & Cox, 2010).
PICSM was held in 2009 under the sponsorship of ASC and ASCCP that proffered this and other vital messages: Cervical cancer screenings should commence at the age of 21, regardless of sexual history. Prior to PICSM, recommendations called for Pap screenings in female adolescents to begin approximately 3 years after sexual debut (Smith, Cokkinides, Brooks, Saslow, & Brawley, 2010). PICSM provided an exceptional opportunity for key organizations to reach a consensus to increase guide- line uptake among clinicians who care for these young women and decrease unnecessary burdens (Smith et al., 2010).
As a result of the PICSM symposium, evolving recommen- dations for cervical cytology screenings (Meissner et al., 2010; Saslow et al., 2012), literature noting variance in HPV knowl- edge levels (Irwin et al., 2006) and inconsistent application of evidence-based practice guidelines in clinical practice among healthcare providers was reported (McDonnell Norms Group, 2006). Therefore an innovative, Web-based designed educa- tional Internet intervention was devised to evaluate the effect of a readily accessible program for APNs that included: HPV and cervical cancer screening in the adolescent population and the 2009 ACOG Cervical Cytology Screening (ACOG, 2009) guidelines in effect at the time the program was launched in 2010.
Program Overview A Web-based, CEU pilot program with narration was developed by the primary author to address the knowledge gaps and cur- rent debate of uptake of clinical guidelines among healthcare providers. The program, titled “Cervical Cancer Screening in Adolescents: A Review of the Evidence for Practice Improve- ment,” was launched on the New Jersey Forum of Nurses in Advanced Practice Website (under the umbrella of the New Jer- sey State Nurses Association [NJSNA]). All registered members of the forum were eligible to participate in the pilot program free of charge. The Web-based program was meant to appeal to APNs who may not wish to attend a conventional lecture or who would like to have electronic access to current clini- cal information that was accessible 24 hours a day during the program period.
Intervention The program was divided into three phases: a pretest (needs assessment), the Web-based educational CEU program, and a posttest CEU evaluation.
Step I: Needs assessment. An e-mail was sent to the New Jersey Forum of Nurses in Advance Practice electronic mailing list, inviting members to participate in an anonymous needs assessment via an online survey hosted by the NJSNA. The purpose was to determine interest and to obtain a baseline assessment of knowledge levels related to guidelines about HPV and cervical cancer screening among female adolescents. Twenty-five APNs participated. The findings revealed a schism between the guideline recommendations and actual clinical
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Figure 2. Demographics of advanced practice nurses.
practices. For example, 59% of the participants self-reported “they would initiate Pap screening in an 18-year-old woman who presents for her first gynecologic visit with a history of first sexual intercourse 3 years ago,” 66% would “perform a Pap test on a 19-year-old woman who presents with genital warts,” and 52% would “perform a Pap test on a pregnant ado- lescent who presents for her first visit prenatal care visit.” Of note, Pap smear screening was not indicated in all of these sce- narios, revealing a respondent knowledge deficit. The primary author utilized the results of the needs assessment to guide and develop the Web-based education program.
Step II: The educational intervention program. A storyboard was created from an outline of information based upon the APNs’ needs assessment results using a Microsoft Word doc- ument. Next, information from the storyboard was translated to a Microsoft PowerPoint presentation and further refined. Recording sessions were conducted with a media specialist for application of voice-over narration. Once completed, the Pow- erPoint and narration files were imported into Adobe Captivate 5 for Mac software (Adobe Systems, San Jose, CA, USA), where specific functions such as incorporating widgets to enhance the user’s experience were inserted. A widget was added to allow the user to enter an e-mail address and answers for the pretest and posttest, so this information could be collected for contact CEU hour documentation. Then, the project was posted on a Website where a heuristic evaluation was conducted by three APNs and two Internet technology experts. Feedback from the evaluators was used to refine the program, assess for bugs,
and to provide the primary author with constructive criticism. An application to the NJSNA Institute for Nursing was made and approved for 1.3 contact hours for the eLearning program. At that point, the eLearning program was then imported into a “Scorm Cloud” (Rustici Software, Franklin TN, USA, http://scorm.com/scorm-solved/scorm-cloud-features/). The Cloud, an eLearning management system, enabled tracking of participant data and participant’s use of the program (e.g., time spent working on program, grades, trends with users, etc.). This information was exported to an Excel spreadsheet, where it was prepared for data analysis using SPSS version 19.0 for Mac (IBM Corp., Armonk, NY, USA). A link for participants to access the program was also created, and posted on the NJSNA Website. In addition, an e-mail was sent inviting members of the New Jersey Forum of Nurses in Advanced Practice to participate in the free eLearning program. The program was made available for 5 weeks from December 2010 to January 2011. Although this endeavor was initially conceptualized as a local (state of New Jersey) project, it became a national one when it was posted (with permission) on an electronic mailing list for clinicians of Title X centers and data from those participants were included in the study.
Step III: Posttest and CEU evaluation. Three weeks after the CEU education program closed online, an e-mail invita- tion was sent to the participants inviting them to partake in a postprogram survey that was devised on www.surveymonkey. com. It included questions related to demographics, education,
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Figure 3. Mean evaluation scores of program and presenter.
and practice information. The survey was made available to the participants for 1 week.
Sample Once institutional review board approval was obtained, the project was launched. A total of 78 participants completed the contact hour program. Sixty-one percent (n = 48) par- ticipated in both the contact hour program (Web-based educational program) and the postprogram survey. The survey used unique identifier codes for each user to ensure anonymity and was incorporated into the survey invitation link that was sent to each contact hour participant. A $10 coupon code to www.amazon.com was sent to users who completed the sur- vey. Of the participants surveyed, 93.7% were female and 6.3% were male; 70.8% were between the ages of 40 to 59 years. Among these respondents, 91.7% were white and 8.3% were nonwhite. The pie chart in Figure 2 depicts what type of cer- tification each program participant held (e.g., type of APN or area of certification).
Instrument The final tool used to survey the participants was developed by the primary author as a pilot survey and validated through heuristic evaluations, literature (Jain et al., 2006; Yabroff et al., 2009), and peer review. Five questions in total were used for the pretest and postprogram test to compare means among
different test times. Test scores were coded as follows: Correct = 1, Incorrect = 2. A total score of 5 was a perfect score. A total score of 10 indicated all incorrect answers. At the end of the program, participants were asked to evaluate the course objectives, the presenter (the primary author), the experience with the e-Learning technology, and overall experience with the program. The following rating scale was used in the program: A = excellent, B = good, C = fair, and D = poor. In SPSS, they were recoded as follows: 4 = excellent, 3 = good, 2 = fair, and 1 = poor.
RESULTS A paired-sample t test was computed to measure differences in means across pretest and postprogram scores among the 48 participants. The results indicated that mean postprogram scores (M = 6.02, SD = 1.20) were significantly lower than the mean pretest scores (M = 7.12, SD = 1.87), t(39) = 4.40, p < .00). This indicated that over time, APNs’ knowledge level increased from the pretest to posttest. Overall, partici- pants rated the objectives, presenter, and use of an effective eLearning method as good to excellent (see Figure 3).
An additional question was presented to the participants in the postprogram survey to determine if changes to practice patterns were made as a result of the program (Figure 4). Par- ticipant responses to this additional question indicated that, out of the 47 participants (one participant chose not to respond
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Figure 4. Program evaluation and application of clinical practice question.
to this question), only 51% responded with “none,” 38.5% felt the activity validated their current practices, and 84.6% chose response A, B, or C which affirmed that the program either improved or validated the participant’s clinical practice. See Figure 5 for bar chart of responses to the question.
DISCUSSION The differences in mean test scores across time indicated that participants increased their knowledge after learning the mate- rial. Specifically, pretest scores were significantly higher than posttest scores, indicating that the participants answered more questions incorrectly on the pretest than on the posttest scores were expected to drop after learning the material (recall m = 5 is a perfect score, whereas m = 10 is all answers are incorrect) once the user participated in the program. Postprogram mean test scores were significantly lower. Although the mean scores on the tests did show improvement among the participants and can be used as a measure of knowledge attainment regard- ing the information presented, they did not provide insight into the participants’ practice patterns postprogram comple- tion. The additional question presented to participants regard- ing whether changes in practice were made was affirmed by the majority of participants.
LIMITATIONS The goal of this project was to evaluate a contemporary and readily accessible Web-based educational CEU program on HPV infection and cervical cancer screening among
adolescents. The program was developed to address APNs’ knowledge gaps and application of new screening guidelines in clinical practice. Although the data support the attainment of these goals, the ability to generalize the findings to similar programs is limited, as the program’s sample size was small and the pilot survey did not undergo formal validity testing. Ad- ditional research is encouraged to validate the survey reflecting current literature for use on a larger scale, to determine if improved practice patterns are truly realized and the burdens associated with over-screening young women decrease.
CONCLUSIONS Cervical cancer is extremely uncommon in female adolescents, whereas infection with HPV is very common. Data exist to sup- port that HPV infection and CIN in adolescents rarely progress to ICC (Moscicki, 2005; Moscicki & Cox, 2010). As a re- sult, new evidence-based recommendations to change cervical cytology screening guidelines for women were developed to de- crease over-screening, decrease the physiologic and psycholog- ical burden due to HPV infection and cervical disease, decrease healthcare costs, and decrease excessive follow-up.
IMPLICATIONS FOR FUTURE RESEARCH Given the rapid and complex healthcare guidelines pertaining to cervical cancer screening, this project demonstrated how the use of Web-based education is valuable for busy clinicians to keep current with changing practice guidelines. As of May, 2014, the Food and Drug Administration (FDA) approved the
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HPV DNA test for women 25 years of age and older as a primary method of screening for cervical cancer. Because the HPV virus must be present for cervical cancer to develop, the FDA argues that conducting the HPV DNA test is enough to screen women for cervical malignancies, thus reducing rates of ICC. To date, women’s health organizations that make recommendations for clinical guidelines have not endorsed this as a primary screening alone in screening for cervical cancer. Because there has not been an official stand on how to interpret the FDA recommendations from the ACS, the ASCCP, and ACOG, most of the organizations are still debating on how to interpret and disseminate these findings. As a result great variation with the interpretation and application of these guidelines into clinical practice exists. Given that cervical cancer screening guidelines have changes several times, healthcare providers find it difficult to keep current with the rapidly evolving science in women’s health; the application and adaption of these new changes are challenging. Healthcare providers question these new recommendation: (a) What is the recommendation for interval of cervical cancer screening for women if HPV DNA is solely used? (b) When should HPV DNA screening begin? (c) What is the recommendation for follow-up management for women who do screen HPV positive? (d) What is the
recommendation for HPV DNA screening for a primary method for women who have received the HPV vaccine? and (e) What is the recommendation for high risk populations (immune suppressed women)? As this debate continues, efforts to educate healthcare providers on updated evidence on HPV’s history are necessary to address the incorporation of evolving practice guidelines into routine clinical practice.
Implications for clinicians include CEU programs using Web-based interventions as a medium to address rapid changes in the evidence-based practice. By disseminating evidence-based data via readily accessible Web-based pro- grams, reductions in the physiological harm, psychological distress, healthcare costs and morbidities associated with pre- mature or over-screening can be achieved, thereby improving the overall health of young women. WVN
LINKING EVIDENCE TO ACTION
� Evidence-based guidelines related to cervical can- cer screening are rapidly changing, thus continu- ing education for healthcare providers is necessary
58 Worldviews on Evidence-Based Nursing, 2015; 12:1, 51–60. C© 2014 Sigma Theta Tau International
to address the incorporation of evolving practice guidelines.
� Cervical cytology screening guidelines for women, particularly adolescent women, were revised to decrease over-screening, decrease the physiolog- ical and psychological burden of HPV infection and cervical disease, decrease healthcare costs, and decrease excessive follow-up; however, there is lack of consistency among healthcare providers in applying these guidelines in practice.
� Healthcare providers need to advocate for national guideline uptake in populations they serve and for application of clinical guidelines in peer and col- league clinical practices.
� Future research should include these key areas of investigation: Practitioners’ beliefs about new cervical cancer screening guidelines, and practi- tioner’s barriers to adaption of new cervical cancer screening guidelines, and interventions that en- hance adaption of new cervical cancer screening guidelines.
Kim Choma, Certified Registered Nurse Practitioner–Clinical Practice, and Clinical Lecturer, Rutgers University, College of Nursing, Summit, NJ; Amy E. McKeever, Assistant Professor, Villanova University, College of Nursing, Villanova, PA.
Address correspondence to Dr. Kim Choma, 2560 US Highway 22, East #226, Scotch Plains, NJ 07076; kim- [email protected]
Accepted 30 July 2014 Copyright C© 2014, Sigma Theta Tau International
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60 Worldviews on Evidence-Based Nursing, 2015; 12:1, 51–60. C© 2014 Sigma Theta Tau International
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