Health promotion has been defined as” the process of enabling people to increase control over their health and its detriments and thereby improve their health” (WHO 2005). Breast Health Promotion improves understanding and confidence among women. It can help to remove fear of breast cancer and it encourages early diagnosis (Breastcancer care 2008).Health promotion can be performed in various locations. The settings that have received special attention are the community, health care settings, schools and workplaces (Tilford et al 2001).
Breast cancer is a disease that affects almost 46,000 women and around 300 men in the United Kingdom every year. One in nine women in the U.K will develop breast cancer at some point in their lifetime (Cancer Research UK 2006).
The contents of this assignment will include the importance of health promotion, primary, secondary and tertiary levels in relation to breast cancer, legislation and barriers.
Breast cancer is a very frightening word and the detection of it harrowing therefore early detection in order to improve breast cancer outcomes and survival remains the cornerstone of breast cancer control (Anderson et al 2008).
Mortality from breast cancer is falling in all age groups and the reasons for this are not certain but early diagnosis through screening and improvements in treatment particularly greater use of adjuvant therapies (e.g. chemotheraphy or radiotherapy) undoubtedly contribute (Petro et al 2000). It is important that women have as much information about the benefits and the risks of potential treatments so that they are able to have an active role in their treatment plans. Treatment should be tailored to individual needs and circumstances (NICE 2009).
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There are several types of breast cancer which can develop in different parts of the breast and the most common form is ductal breast cancer which develops in the cells that line the breast ducts. Ductal breast cancer accounts for approximately 80% of all cases of breast cancer. (NICE 2002). Breast cancer can spread to different parts of the body such as the bones, lymph nodes and the liver. (NHS Choices 2010).
Primary interventions should be considered in the promotion of health in reducing some of the risks of getting breast cancer; these include maintaining a healthy diet (particularly one low in fat but high in fibre and vegetables). A key feature of the government’s prevention strategy to reduce early deaths from cancers and coronary heart disease is action to improve diet and nutrition with the introduction of eating 5 A DAY and CHANGE 4 LIFE. Evidence has shown that higher fruit and vegetable consumption can reduce the risk of breast cancer (DH 2000). Being active and undertaking some exercise also reduces the risk and women with higher levels of physical exercise have around 30% lower risk of developing breast cancer than those that are least active. The higher the level of physical activity the lower the risk (Dorn et al 2003). Drinking more than two units of alcohol per day over a number of years can also increase the risk (Macmillan 2008).
In order to help promote the government’s programmes, it is essential that the nurse has sound knowledge of these plans so that she can raise awareness of health benefits, offer advice and educate patients about all the strategies that they can do to help promote a healthier life.
It is very important to become familiar with how the breasts look and feel at different times of the month. The breast awareness 5-point code was introduced as a way of caring for your body and being able to notice any unusual changes in your breasts (Breast Cancer care 2007).The practice nurse will offer guidance to show patients how to examine their breasts or offer a leaflet which contains all the necessary information.
School nurses are also helping to promote breast health and breast cancer prevention to young girls across the nation in schools where they talk openly with girls about breast development and the complex health and emotional issues and problems that may occur. The health promotion enables the young girls to face the future with confidence and with knowledge of breast cancer. (Breast cancer 2008).
Breast screening is offered to all women between the ages of 50-70 years and they will receive an appointment by letter to attend for breast screening, however, if any unusual changes in the breast are noticed, it is essential that an appointment to see a G.P or the practice nurse is made, where a full examination of the breasts will be given. Reassurance and support will be given by the nurse or G.P and they will try to alleviate some embarrassment by maintaining privacy and dignity by locking the door and by pulling the curtains around (NMC 2008).If the nurse or G.P is uncertain about the problem, or they think that cancer may be present then a referral to a breast specialist for advice or treatment will be necessary.
All patients that are referred to a specialist with breast symptoms, even if breast cancer is not suspected should be seen within two weeks of the referral (DH 2007).
Diagnosis in the breast clinic at the hospital is made by a triple assessment (clinical assessment, mammography and/ or ultrasound imaging, core biopsy and/ or fine needle aspiration cytology (NICE 2009).
The breast cancer nurse will introduce herself and she will explain everything fully to the patient before gaining relevant historical information off them, the nurse will also ask the patient if they have any questions before asking the patient to put on a gown (ensuring dignity and privacy is maintained).The nurse must use sensitivity, empathy and understanding as this can often be emotionally upsetting and distressing for women. The nurse will ensure that prior consent is always gained off the patient (NMC 2008).
Screening is carried out by using either ultrasound scans of the breasts or by mammograms which are x-rays that use very low doses of radiation. In some cases women have both of these.
A core biopsy may be used to take samples of cells from a lump or area of abnormality in the breast using a needle. This will be sent to the laboratory where it will be studied by a pathologist. The results of these tests can help determine if the lump contains cancerous cells. Local anaesthetic is used in biopsies and the breast may have some bruising or soreness afterwards. The nurse will be on hand to guide the patient through the experience and will offer advice in caring for the area afterwards and she will assist in making follow up appointments and further treatment plans. The nurse will also support the patient by trying to relieve anxieties, offering reassurances and by answering any concerns. Providing information by the nurse alongside all the support can empower the patient to retain or regain control over their lives (DH 2007).Lack of good, sensitive communication skills provokes poor patient care and it costs the NHS greatly in preventable loss of money, time and resources (DH 2000).
At tertiary level a number of treatments are available for early breast cancer. The patient will become part of a multidisciplinary team and the nurse specialist or consultant will discuss treatment plans with the patient ensuring that the patient is fully aware of what they are being told and that they understand. (Jefford 2002).
Breast surgery is often the first treatment for patients with breast cancer and this must be carried out by surgeons with a special interest and training in breast disease (BASO 2009).The nurse plays a vital role in the patient’s surgical experience and her role is to ensure that the patient is comfortable, pain free and that encouragement is give to promote independence by advising the patient on wound care, maintaining food and nutritional status, mobility, hygiene and the psychological effect that might be experienced.
Treatment given after surgery is known as adjuvant treatment and includes radiotherapy, chemotherapy, hormone therapy and targeted (biological) therapy. Understanding the fundamental principles of radiation therapy enables the oncology nurse to provide support both physically and psychologically by offering advice on nutritional needs, areas that may be affected by the treatment, side effects, practical problems such as money difficulties and transportation to the treatment centre. The oncology nurse will also provide strategies to ensure family members and friends are supported.
The delivery of chemotherapy is primarily the responsibility of the oncology nurse. The nurse must have sound knowledge of the pharmacology of the drugs used so that errors do not occur and that the patient is well informed of any possible side-effects. Patients can be very poorly because of the side-effects of chemotherapy so it essential that the oncology nurse gives the correct information to the patient and they should be informed and given guidance of who to contact if problems arise.
The use of any adjuvant therapy is frightening for most women but nurses can offer practical advice, emotional and physical support and direction throughout the patient’s journey The nurse will arrange follow-up appointments for any on-going treatments, and they will discuss with the patient where they would like the follow-up to be undertaken (NICE 2009).
As a healthcare professional, nurses are sometimes asked about a wide variety of complementary and alternative therapy as some 30% of women diagnosed with breast cancer visit a complementary therapist (Rees et al 2000). Nurses have a duty to be aware of the different types of therapies and in the aspect of health promotion they must be knowledgeable about safety issues, contra-indication and side effects before advising patients about alternative therapy. The nurse must always follow the NMC in working within ones own limits and using practice based evidence to support her actions (NMC 2008).
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Palliative care offers a support system to help patients live as actively as possible until death. The palliative care nurse will provide relief from pain and she will offer advice on how to deal with symptoms for example vomiting, diarrhoea and fatigue by explaining to the patient how to rest, positioning when resting, how to use relaxation techniques, they will educate the patient about diet and nutrition and how this can help maintain health and well being. If the patient has oral problems then the nurse can advise the patient on alternative foods such as calorie packed drinks. The palliative care nurse will use her knowledge, skills and caring compassion to guide the patient and their family to the end stage of life by communicating with them effectively, supporting emotionally and physically, planning outcomes with the patient as patient choice over place of death should be a priority (NICE 2004), promoting advice on equipment, wound care whilst always focusing on autonomy, justice and the spiritual needs of the patient.
The NHS Breast Screening programme (DH 1988) was first set up and the role of the breast care nurse is invaluable to the patient in providing support for patients by advising the best options in terms of treatment, emotional and psychological support. The nurses are there as a familiar face for the patient and they will continue to be available for the patient for on going advice throughout treatment. The breast care nurse will offer best advice on diet, health and mental well being and she will give guidance and offer literature on issues relating to the patients illness.
With the introduction of the NHS Cancer Plan (DH 2000), new funding for cancer services and cancer specialists became available. Nurses working in hospital and community settings help to detect cancer earlier by educating people about diet, health, exercise and raising public awareness by facilitating posters and leaflets around the health departments. Health clinics were set up where patients can attend for check ups, screening and other health related issues.
The cancer Reform Strategy (2007) enhances nurses by implementing training initiatives so that nursing staff can become better educated in cancer care, they can spread good practice, have a better understanding of inequalities, have more face to face communication with patients. Nurses are able to promote health awareness and disseminate information down to the people whose health and mental well being matter e.g. advising patients about smoking cessation and raising awareness about other lifestyle factors that contribute to cancer.
The Liverpool Care Pathway (LCP) is a framework which allows the caring team to plan care using specific goals, guideline-based interventions and a flow sheet that outlines an expected course of a patients care (Ellershaw 2002). The framework is patient focused so the nurse involved will document a plan of care required that includes comfort measures, anticipatory prescribing and discontinuation of inappropriate interventions. The nurse will work very closely with the patient and family and she will ensure that any religious, cultural or spiritual beliefs are adhered to.
The Gold Standards Framework (Thomas 2003) was developed and was aimed at primary care teams including nurses and palliative care nurses to help patients live well until the end of life. It helps the team to focus on promoting the needs of patients, families and carers. The nurse can help to plan “good” death with the patient and the nurse can offer practical and emotional support which will help to maintain the health of the patient and their loved ones. The nurse will offer advice on claiming benefit and financial support as this may have a detrimental impact on family members, carers and their health if they are worried that they cannot cope financially. The nurse can share knowledge with the multidisciplinary team which will help to maximise patient benefit. (GSF 2006).
Communication can be a barrier to effective health promotion especially if the individual cannot understand terminology used by the professional or English is not the first language. Effective communication is central to promoting high-quality care and barriers can be overcome by demonstrating active listening skills, talking to individuals in a manner that they can understand, showing supprt, maintaining realistic hope, taking time to talk to patients, being friendly, open and honest .Demonstrating good body language is also very important and this is one barrier that patients will detect very early on.
Many departments and clinical settings now employ interpreters, which is beneficial to the patient whose first language is not English. The use of interpreters improves the quality of care for the patient (Dreger et al 2002). Leaflets containing information are also available in different language for the patient to access.
Many individuals are unenlightened to their health needs and they may ignore preventative advice off health care professionals. This barrier can be overcome by educating people about health matters, by having health promotion posters, leaflets and information displayed in public places where people can access them without actually having to make an appointment to see a G.P or practice nurse (unless they want/need to).
Lifestyle is a barrier to health promotion. Many people face inequalities such as poor diet, poor health and financial difficulties’ The Department of Health’s healthy eating strategies such as 5 A Day and Change 4 Life have tried to change attitudes and raise awareness about the health benefits of eating fruit and vegetables by introducing it into schools, communication programmes e.g. 5 A Day logo, and ensuring that people can have adequate access to affordable, good quality fruit and vegetables within the local community. (DH 2003). Change4Life (DH 2009) can try to eradicate barriers by promoting healthy eating, having more exercise and living longer to young children with the added participation of other family members. The whole family can work together to initiate a healthy future.
Transportation difficulties present barriers for many people as they may find it difficult to access G.P surgeries, health centres or the hospital if they do not have the means to get there. Also if the person has mobility difficulties, attending appointments could prove to be a challenge for them. To encounter this problem health care trusts have provided walk in centres, one stop shops and mobile health units( e.g. for mammogram screening) within communities which are easily accessible , open later and at the weekend.
To conclude, it is evident from the information discussed in the assignment that early detection of breast cancer can significantly reduce mortality. The care and treatment of women (and men) with breast cancer has evolved greatly over the last few years and although there is no cure for metastatic breast cancer, evidence has shown that women are able to live longer withy the use of different treatments.
Breast screening is very important and evidence shows that the earlier breast cancer is diagnosed and treated, the better the chance of successful treatment.
The Governments campaigns such as Breast Awareness, 5 A DAY and ACTIVE 4 LIFE have enriched many people’s lives and by having more accessible clinics, walk in centres and mobile health units all contribute to a healthier, more active lifestyle.
Many of the clinics are now nurse led and this has proved to provide a warm, caring and informative environment for patients that attend.
Cancer provokes stress, anxiety, fear and anger in patients and nurses on the forefront can attempt to soften these fears by offering psychological and emotional support, guidance and empathy to patients. Caring for patients with breast cancer tests all aspects of holistic nursing care and by having all the necessary skills nurses can build a trusting, therapeutic relationship with the patient which will lessen some worries and anxieties for the patient. Communicating well, providing accurate information, listening and having time for the patient enhances the patient journey.
It is essential that autonomy is respected regardless of culture, spiritual or ethnicity differences and that what ever treatment the patient requires is undertaken with the utmost sincerity whilst upholding maximum dignity and privacy for the patient.
Lastly, end of life care is now firmly established as an important aspect of care delivery and it is an effective means of improving end-of-life care for all patients. The frameworks allow the patients to have a peaceful and meaningful end to their life.
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