Be an agent for change for cervical screening

With efforts being made nationally to increase the uptake of cervical screening, this general practice nurse brings her own perspective on how to support people having this very personal procedure. GPN Jane Coomber discusses how should we be approaching this delicate area of the service that nurses provide in primary care, and shares how she uses her own experiences to help reassure patients. 

What can we do to make having a smear test/cervical screening as comfortable, informative and fuss free as possible – while giving our patient advice about the process that isn’t overwhelming but helps them to understand the programme?

There have been times since moving into general practice nursing in recent years that I’ve felt like an absolute beginner. But when we undertook the two days of cervical cytology training in my fundamentals GPN course, I did think “a-ha”, now here’s something I can totally relate to, as a patient and a nurse.

As an experienced nurse with a background of operating theatres and gynaecology care, I’d assisted with many gynae procedures and surgical interventions. I’ve seen when things escalate to cervical cancer, seen polyps and fibroids; the damage done by endometriosis; assisted with obstetric procedures, and understood the highs and lows of IVF, and live, and not live, births.

Then of course as a woman I’ve experienced the cervical screening procedure countless times myself – and other gynae procedures too – which to be honest were not always performed well or kindly by practice nurses, GPs or surgeons.

So, I felt very well equipped to support the people undergoing cervical screening, empathically, educationally and experientially.

This was one of the first skills I learned as a trainee GPN

This was one of the first skills I learned as a trainee GPN. I had to complete many smear tests in practice as part of my course, with and without my supervisor and assessor watching my technique and how I conducted the appointment; ensuring I entered the correct information and produced the documentation properly.

Since then, I’ve updated my training as required, and educationally, things have changed slightly in the three years since I first did the course, and the UK programme for recall and testing has altered with improvements in HPV detection and the uptake of vaccination.

Whatever our level of experience, smears don’t always go to plan. I’ve had a handful of inadequate tests, as many of us will have had, and it can be disheartening when you need to tell your patient that their test will need to be repeated. Having spoken to experts, trainers and lab techs, it’s not always our fault if a smear test we’ve taken needs to be repeated because it is deemed inadequate.

This is a gentle reminder to take your time; to not to feel rushed to find your os, or to ask for assistance if there’s a more experienced person available to help.

Personal experience can be helpful

I completed a short fundamentals course for my GPN training before I entered practice nursing proper, and I’ve gained confidence as time has gone on.

We will all have completed training, been signed off as competent for smear taking, and then be updated every three years once in practice. Being a chaperone to GPs, GP trainees and GPN students is also really helpful, because watching and teaching other people informs each other.

Drawing on personal experience is helpful as well. It does seem that many of us have had poor experiences of having this test ourselves as patients. This should help us to reflect on our own practice, as it has for me.

I tell them that I’ve had a couple of poor experiences too

If a patient is nervous, or if they’ve had poor experiences in the past that have put them off coming for their tests, and feel generally anxious about the procedure, I let them know I wouldn’t want this for my patient. I tell them that I’ve had a couple of poor experiences too.

Some younger women question if they really need to be screened at all. They might say they’ve had the HPV vaccination, not had many partners, or they trust their partner. I will then go into a more in-depth explanation about how the vaccine makes them a lower risk, but it’s still important to have the test to ensure the cells are unaffected if HPV has been present.

We really need to be tactful, share the evidence, and be gentle both physically and emotionally when addressing any concerns. There are leaflets available to support us with this when offering advice and explanations.

Some people have had a traumatic labour or birth, been the victim of sexual assault, or have undergone a form of FGM, making physical penetration of the vaginal cavity and inspection of the cervix difficult, due to the fear or discomfort. We may need several appointments with these patients or a referral to gynae teams to facilitate the testing. Reporting these findings is important, to protect the patient and any siblings or children in the family.

Supporting people who find a smear test distressing

A little chat can help to put your patient at ease, but gauge it carefully. Some patients have a sense of humour and gentle joking helps relax them; others want calm reassurance, scientific facts, and some like a bit of all of the above. If you have a chatty patient: let them talk; it is releasing their tension. If they’re very quiet, ask them some open questions and talk about things that are unrelated. Test things out, and use your best judgment.

If it’s their first test, do show them what the brush or broom and speculum look like. I also explain that I will use water-based lubricant for comfort, and will be slow and gentle, and they should try breathing slow, deeply, and to relax. I also tell them that they can insert the speculum in themselves if it feels more comfortable or safer to do that. I might tell them “It’s your body and you are in control, I’m just here to support you with getting the test taken”.

I will ask if there’s anything they want to know before we start the test, and if they’ve had a poor experience before I’ll offer extra reassurance. Despite thinking how rushed I might be on a busy day, I will make sure to use a kind calm tone of voice and I will explain that we can stop or slow down at any time if things feel too intense.

Once the test is taken I will be sure to be congratulatory, and explain how they’ll get their results and what that might be and not to worry. I will explain that if their test is positive for HPV, and that it may mean we need to see them in a year to check their cells and make sure they are clear for the virus. If they are asked to go to the colposcopy clinic for further testing or some treatment, I’ll encourage them to go, as it’s important to make sure they stay safe and well.

Help the patient to leave the experience on a positive note

I try to remember that, above all else, I may have carried out twenty smears that day, but when number 21 walks through the door to my clinic room it’s the first one, and the first one in three or five years for that person.

I want to be an agent for change – to support where I was not well supported, to inspire, to guide, to care, and if I can, to offer encouragement to other nurses.

I turned my bad experiences into something positive that has informed my practice

Look at your strengths as a GPN. How can you build on these? I turned my bad experiences into something positive that has informed my practice.

I never want any patient I see to go through negative experiences. I mostly receive smiles and “thank you” from patients, which makes my day because I know they will return next time their test is due, and I know I have done my job properly.

Jane Coomber is an RN, GPN working in SE London general practices

Diary of a General Practice Nurse is a regular series. Jane welcomes your feedback and responses. If you would like to comment on the above topic or want to write your own Diary article, please send this to the editor at [email protected]