Colorectal Cancer Screening – Importance and Strategies

The transformation of the United States healthcare system aims to advance and enhance the quality of healthcare delivery and patients’ health (Krist). Preventive care is a significant aspect of the transformation of healthcare. Cancer remains a top source of the number of deaths in the United States, although colorectal cancer (CRC) is a preventable disease. The prevention requires consistent utilization of screening methods as recommended (Spruce). Vast amount of research has continued to prove that CRC screening greatly reduces the occurrence of and death from CRC. There are a number of interventions for healthcare providers to use that help raise the rates that patients will adhere to screening, but ultimately health-promoting and preventive actions are a shared responsibility between both patient and healthcare provider. In order for the intended goal of raising CRC screening rates to occur, providers must not forget that patients need to be satisfied with their care, and that caring for and about the patient needs to be forefront (Spruce).  This paper will discuss utilization of colorectal cancer screening and strategies to increase screening adherence with a theoretical basis from the metaparadigm of nursing, Watson’s Theory of Human Caring, and Reigel’s Theory of Self-Care, and discuss aspects of colorectal cancer screening in relation complexity science.

Phenomenon of Interest

CRC screening interventions have targeted different subjects in attempts to raise screening rates including patients, healthcare systems, and healthcare providers (Garcia). Primary care providers should be targeted for implementation of interventions because they are in a unique position at the forefront to impact CRC screening rates. A majority of adult patients have primary care providers that they receive care from regularly, and primary care providers can use these many opportunities to recommend screening to all appropriate patients (Spruce). A recommendation of CRC screening from a healthcare provider is significantly influential in determining if a patient will comply with cancer screening. The process of CRC screening is extensive and involves developing a connection and rapport with the patient, educating the patient and opening discussions about the multiple screening options available to them, and supporting the patient’s decision (Spruce). Several patient-identified barriers to CRC screening exist such as anxiety, embarrassment, fear, and perception of pain, danger, or discomfort. The patient-provider relationship can help to dispel most barriers to screening with proper communication and education (Garcia). Ensuring that patients have options to choose from and encouraging participation in their own health care decisions has proven to raise CRC screening rates (Spruce).

Metaparadigm of Nursing

Fawcett (1984) identified the metaparadigm of nursing as the most global perspective of nursing that involves four central concepts of nursing as person, environment, health, and nursing. Person is defined as the one who receives nursing care, which often refers to the patient, but can refer to more than one person, including sociocultural factors such as family, friends, and community (Fawcett, 1984, 1996). The next part of the metaparadigm of nurse theory construction is health. Fawcett (1984) defines this as the patient’s degree of wellness or illness. Patients’ health refers to a large variety of aspects of the person’s wellbeing such as genetic factors, and also includes less obvious factors such as the patients’ intellectual, emotional, and spiritual wellness (Lusk). In regards to CRC screening, this aspect of the paradigm involves the use of preventive care to maintain a healthy state. Unfortunately, the underuse of preventive care is an issue leading to patients that are most in need of preventive care only going to a provider for sick visits, not for prevention (Krist, 2011). Patients that are seen in these visits perceive themselves to be possible in an ill state, reporting signs and symptoms of gastroenterology issues, often leading to providers to initiate CRC screening based off of symptoms (Garcia). Patients reporting to a provider at a healthcare facility is an example of the patient interacting with their environment, which is another aspect of the metaparadigm. The environment aspect of the metaparadigm refers to all internal and external surroundings, circumstances, and influences affecting the person, including the setting in which nursing occurs (Fawcett, 1984, 1996). Nursing is the fourth concept of the metaparadigm and is defined as nursing interventions done on behalf of or with the patient and the results by which positive changes in health status are affected. Nurse practitioners are in a critical position to reshape primary care to where it is focused on becoming patient-centered. Reformatting concepts of healthcare practice and introducing more patient-centered models of primary care delivery will allow for patients to receive the screening tests they need based on provider recommendation and individual patient choice (Spruce). Providing patient-centered care allows healthcare providers to respect and care about patient differences, morals, preferences, and needs while advocating disease prevention and promoting wellness (Lusk).

Grand Nursing Theory: Watson’s Theory of Human Caring

Nurse practitioners care for patients from numerous upbringings, cultures, and healthcare challenges. Primary prevention of disease and health promotion are great concepts for health practice, but nurse practitioners have been encouraged to keep nursing theory and research as a basis for their practice. The integration of Watson’s Theory of Human Caring into advanced practice provides an all-inclusive, humanistic view of the person which allows the practitioner to look at all aspects of the patient in need of care (Hagedorn).

Watson (1990) states that caring is recognized as the central base to the nursing profession. According to Watson (1988), caring consists of ten Caritas – factors of care – that all create a structure for nursing science. The ten Caritas factors are: “humanistic-altruistic system of values, faith-hope, sensitivity to one’s self and to others, helping-trust relationship, expressing positive and negative feelings, creative problem solving, caring process, transpersonal teaching-learning, supportive, protective, and (or) corrective mental, physical, societal, and spiritual environment, human needs assistance and existential phenomenological-spiritual forces” (Watson, 1988). The first three factors shape the foundation for the science of caring, and the remaining factors stem from that foundation. Caritas Caring is defined as relationships with open communication that create a caring-healing environment (Watson & Foster, 2003). These relationships should be integrated with the guiding values of nursing that include upholding humanity, dignity, and fullness of self. The integration of and advancement of human caring as an initiative in nursing practice is a significant subject (Watson & Foster, 2003).

Watson’s Theory of Human Caring has several aspects that can be used for implications of practice with CRC screening. Colorectal cancer mortality and morbidity is a significant issue. Interventions as large as community-wide educational CRC screening programs embraces the Caritas through the transpersonal teaching and learning carative factor (Garcia). Interventions that are not as grand, such as individual provider and patient relationships to discuss CRC screening are just as powerful, if not more. Watson (1988) stresses the significance of having an equal partnership between nurse and patient rather than a relationship of imbalanced power. Shared decision making is applied and functional in the patient-provider relationship in the discussion of CRC screening strategies, in which the provider implements a caring attitude and respects the patient’s ultimate goals (Underhill). By sharing knowledge with the patient, the patient is able to assist in the decisions regarding their own care, and is the leader of their own plan (Lusk).  Patients gain autonomy with shared decision making, and this leads to patients finding sense and purpose in their own existence. This leads to an increase in their ability to have inner control and to problem-solve (Watson, 1988). The mistake that providers made in the past is presenting a single CRC screening option as the patient’s only choice as this is not the essence of truly caring for the patient (Spruce). Using Watson’s Theory of Caring, the focus should not be to only complete the task of getting the patient to adhere to a screening method, but on all aspects of the patient. This can include offering culturally sensitive interventions to increase knowledge of CRC to help improve screening uptake (Underhill). Providers should present appropriate evidence-based knowledge to the patient that is in their best interest. Most often, the evidence is in favor of a particular screening intervention. The patient should be allowed to make a decision, and this decision will be based on evaluation of the evidence presented but will also involve considering their principals and belief system. The helping-trust relationship between the nurse and the patient supports the patient’s decision, even if the decision is not in line with the provider’s suggestion and evidence (Lusk). The patient as a whole should be taken into consideration with CRC interventions to better ensure that the foundation of caring is forefront, and studies show that strategies that are patient-centered improve CRC screening behaviors (Underhill).

Middle Range Theory: Reigel’s Theory of Self-Care and Chronic Illness

Reigel, Jaarsma and Stromberg (2013) define self-care as a process of preserving a healthy state with practices that promote health and handle illness. Self-care can be implemented in a state of health and an ill state. Reigel et al. (2013) explains that when a person is sick but stable, they can still maintain health without necessarily having to transition into a different type of care that focuses on the illness. This is seen in cases when patients report to the healthcare provider with signs and symptoms that may be related to colon cancer, the perceived state of illness, and want to take actions such as CRC screening to try and regain the state of wellness or manage their state. Intended outcomes of selfcare include sustaining a healthy state, stabilization of illness, well-being, and quality of life (Reigel, Jaarsma & Stromberg, 2013). The three key concepts that help define self-care explained by Reigel et al. (2013) are self-maintenance, self-monitoring, self-management. Self-care maintenance is defined as actions done to improve well-being, maintain health, or to keep the stability of physical and emotional aspects of the patient. Self-care maintenance tends to be behaviors that reflect the recommendations of providers (Reigel et al, 2013). The behaviors of self-maintenance may be performed by patients after strong encouragement by others such as health care professionals or family members or the patient may choose to perform behaviors on their own to meet personal goals. Recommendations of CRC screening are sometimes initiated by a patient’s providers and family. Provider recommendation of CRC screening is critical to predicting the use of screening methods (O’Farrell). Nurses at all levels of practice regularly provide recommendations for preventive care to patients, and they are in optimal positions to do so because of increased contact with patients. This allows for enhanced CRC screening counseling, providing information that will increase knowledge regarding CRC screening guidelines (Bardach). Self-care maintenance is strongly enhanced when a patient reflects on the usefulness of the self-care behavior, is observant in performance of the behavior, and continues to evaluate the benefits and the effectiveness of the activities (Reigel). The purpose of education of CRC screening is for the patient to have knowledge of the benefits of screening and for the patient to continue with this avenue of self-care by adhering to continued screening as recommended by national guidelines (Bardach).  Adherence is a critical part of self-care maintenance. Health care providers collaborate with patients to discuss integrating into their daily life as many of the evidence based health-promotion behaviors as the patient can accept (Reigel). Adherence to CRC screening has been shown to be increased when providers utilized patient-centered care. These findings demonstrate the vitality of communication and a quality patient-provider in regard to screening behavior and have strong implications for clinical practice (Underhill).

The second aspect of self-care as stated by Reigel et al. (2013) is self-care monitoring. Self-care monitoring is defined as a process of routine surveillance and observation of one’s body. Consistent and orderly monitoring creates the best outcomes (Reigel). Reigel et al. (2013) explains that monitoring one’s self, understanding the importance of it, and reporting abnormalities can allow for appropriate healthcare interventions to take place before a situation becomes detrimental. This facilitates the provider’s ability to give the best care (Reigel). This concept is critical to one aspect of the purpose of routine CRC screening.  Signs and symptoms that could be indicative of colon cancer signify a need for CRC screening, and this communication with the provider can facilitate the proper screening method to be implemented to potentially catch a situation before the devastating illness has developed (Bardach).

The third concept of self-care is self-care management. This is defined as involving an assessment of any changes in signs and symptoms – physical or emotional – to decide if an intervention is needed (Reigel). Reigel (2013) explains that decision making is one of the underlying concepts of self-care. Reigel () states that confusion, mistaken beliefs, and insufficient knowledge can all come into play and distort decision making, leading to inadequate self-care. This further indicates the importance of the relationship between patients and the providers (Reigel). Interventions that aim to educate and reduce barriers such as confusion are the most effective interventions targeting the patient for increasing participation rates in CRC screening (Garcia). Reigel () suggests that self-care is not always done by the patient alone. Most patients acknowledge the value of contributions from their environment or community and make use of the welcomed input-a process Reigel et al. (2013) describes as shared care.

Reigel et al. (2013) states that motivation is one of the outcomes of self-car. Patients can be motivated to perform self-care, and describes motivation as the power that influences people to achieve their objectives. The motivation can be intrinsic – driven by an internal desire – or extrinsic, referring to changing a behavior because it leads to a specific result that is anticipated (Reigel). Many patients have the extrinsic motivation to proceed with colorectal cancer screening with the hope that the outcome will be either remaining free from CRC or catching a potentially deadly disease early enough for the best prognosis (Atassi).

Complexity Science

Complexity science views systems as complex, having many parts that interact and are unpredictable, but can be adaptable. A complex adaptive system is a significant model of complexity science. Complex systems must be able to adapt, or else it will not survive (Florczak). Most systems involve layers of varied subsystems – microsystems -  that intermingle with each other (Florczak). A complex system can adapt its behavior overtime, and its parts respond to their environment by using adopted rule sets that motivate its behaviors (Plesk). This theory is used to explain an organization’s office systems improvements to implement clinical guidelines of CRC screening. Evidence has shown that CRC screening is on the rise due to adjustments and improvements in screening strategies (Atassi). Because the screening rates are still not where national guidelines are targeting, further adaptations and improvements are implemented to increase adherence to screening, such as including patients in the decision making, and using information technology for more accurate screening rate surveillance (Triantafillidis). This model is delivered by monitoring performance reports from EMR data, using special alerts embedded in the EMR that remind providers to initiate CRC screening as well as patient reminders, ensuring providers are culturally competent and implementing the concept of patient autonomy in decision making (Triantafillidis). According to the complexity science theory, providers in healthcare facilities that have a goal of increasing colon cancer screening will act accordingly with efforts to recommend CRC screening to patients.

Healthcare systems are moving toward adopting practices that focus of preventive care. Colorectal cancer is a disease that is preventable disease that remains a source of the most number of deaths in the United States. The prevention of colorectal cancer, as well as any preventable cancer, requires consistent use of recommended screening methods. Using simple strategies and adapting primary care practice to more patient-centered care will make a difference in the incidence and mortality from CRC. A holistic view of patients should be taken into consideration with CRC interventions to help ensure that caring remains a staple in healthcare. Nurse practitioners have a unique position that would allow for transforming primary care to where it is focused on becoming patient-centered.

References

Watson, J. (1988). Nursing, human science and human care. New York: National League for Nursing.