Running Head: BREAST SELF-EXAMINATION

Nursing student perceptions and incidence of performing breast self-examinations related to educational level in a baccalaureate nursing program
Teresa Fulton
Erin Kane
Lisa Travers
Caitlin Van Brunt

Nursing of Department
The University of Scranton

Intro/Lit review:
Cancer is one of the most pervasive diseases in the world today. Breast cancer is the second most common cancer among women, second to skin cancer. According to the American Cancer Society (2008), it is estimated that 182, 460 women will be diagnosed with breast cancer in the year 2008. However, the incidence of breast cancer is decreasing which may be attributed to earlier detection and improved treatment (American Cancer Society [ACS].) Methods of detection include clinical breast examination, self breast examination and mammography. Breast self-examination (BSE) allows for a woman to be aware of the regular look and feel of her breasts using a systematic approach and to consequently detect any changes in breast tissue (Budden, 1999, p. 431.) Breast self-examination is a methodical palpation of breasts to detect signs of breast cancer or detect changes in breast tissue; figure ___ depicts the process of BSE (Lowdermilk, 2007, p. 93-94.) Breast self-examinations should be performed monthly, 1 week after menstruating, because breasts are non-tender and not swollen, or on the same day each month if a regular period is not applicable (Lowdermilk, 2007, p. 94.) Early detection can improve the likelihood of the diagnosis of breast cancer, as the frequency of breast exams will allow for a woman to detect a tumor in an early stage which is directly associated with a lower stage of cancer and a better outcome(American Cancer Society [ACS], 2008.) Although the effectiveness of breast self-exam to reduce mortality rates is an inconclusive and controversial issue, when performed correctly, it can help patients to detect breast cancer early. For example, the Kokta Piolet Project results support that BSE improved early detection and decreased mortality rates, however, the Russian studies have shown that there has been no evidence of BSE and mortality reduction rates (Dicle, 2007, p. 481.) Even still, the American Cancer Society (2008) still urges young women in their 20’s to seek out information about BSE (ACS, 2008.) Since, nursing students are future registered nurses at the forefront of BSE education, their knowledge of breast cancer and BSE is essential for patient education. If BSE is considered unimportant to the nursing curriculum or not properly taught to nursing students then educating the public about breast cancer and BSE will not be a priority among student nurses.
A research article about perceptions of breast cancer among college students reported that there was no significant difference between associate degree nursing students and baccalaureate degree non-nursing majors’ knowledge of breast cancer (Canales, Finnie, Powe, Underwood, 2005). The researchers surveyed sixty-seven female nursing students in an associate degree program and ninety-two female psychology or sociology majors in a baccalaureate program. The mean age for the nursing students was 26 and the mean age for the non-nursing students was 23. This study used a survey called the Breast Cancer Perceptions and Knowledge Survey. A 12 item subscale was adapted by changing the response format to yes (agree) or no (disagree) (Canales et al., 2005).” One a 0-12 scale, 1 point for each correct answer, the mean breast cancer knowledge score for nursing students was 7 and 8 for the non nursing students.
The common statements that were misperceptions about breast cancer that both groups got wrong included “Lumps in the breast that are cancer are usually painful,” 22% of nursing students agreed, 20% of non-nursing students agreed. “Changes found in the breast during BSE are usually cancer,” 15% of nursing students agreed and 8% of non-nursing students agreed. “One of the best ways to find cancer early is by BSE,” 100% of nursing students agreed and 99% of non-nursing students agreed. “Doctors and nurses are the only ones who could find a lump in the breast,” 97% of nursing students agreed and 99 % of non-nursing students agreed. All of the above statements the correct response should have been disagree. In the statement “A woman who eats foods high in fat and very few fruits and vegetables may be more likely to get breast cancer” the correct response is agree but only 45% of nursing students agreed and 37% of non-nursing students agreed. The researchers suggest that there is no universal standard of breast cancer education among nursing students which may contribute to many nurses’ lack of knowledge of breast cancer because “few nursing students reported obtaining information on common perceptions about cancer from their coursework (Canales, et al., 2005).” Additional research among BSN students may help evaluate the differences between AND and BSN students and grade level between programs. Misperceptions of breast cancer should be addressed to students, especially nursing students to empower their own health and to educate their patients.
The article “An application of the health belief model to the prediction of breast self-examination in a national sample of women with a family history of breast cancer” discusses the surveying of only women who have a history of breast cancer within their families. A questionnaire was completed in order for the researchers to use the health belief model (HBM), self-efficacy, behavioral intent and past behaviors in completing breast self-examinations (BSE). A nine month follow-up was then completed which showed that there was a strong support of the HBM self-efficacy aspect. The results were summarized and the results showed that “monthly BSE has been reported to be effective in detecting the early symptoms of breast cancer which in turn, greatly reduces mortality from breast cancer. However, despite the risk of breast cancer and the efficacy of monthly BSE many women do not perform BSE on a regular basis, even those with a family history of breast cancer. (Norman and Brain)
In a second study, the effectiveness of the peer education model in teaching BSE in late adolescent females attending Dokuz Eylul University was evaluated. The peer education model supports the notion that peers have the ability to influence other peers because they are in the same group, have social interaction with each other, consider themselves at equal status, and share similar identity, language, attitude and behaviors. The study suggests that women should start BSE in late adolescence, and due to an increase in identifying with peers and social interaction within this age group, the peer education model proves to be a valuable model in spreading the awareness of BSE among these young females and making them more apt to perform BSE on a monthly basis.
Fifteen volunteer students, averaging age 20, received training on how to perform BSE by a researcher and then were considered to be peer educators after earning a certain number of points of knowledge regarding “BSE knowledge and BSE implementation skills”, receiving practice skill education, and being observed by two observers. Each peer educator then taught 10 other peers how to perform BSE. Each student to be peer educated, surveys were implemented to understand the student’s knowledge of BSE and the incidence of performing BSE, prior to receiving education from a peer educator and after education was complete. Slides, posters, brochures, breast maquette and a CD were implemented to facilitate learning about BSE, and the peer educator taught BSE information using active teaching methods, and demonstrating BSE on a training model. Pre and Post tests were evaluated using the paired t-test, student t-test and the McNemar test.
Results found that only 2.66% of students performed BSE prior to peer education 66% of students performed BSE after receiving education. Education and peer support are essential to women performing monthly BSE. This proves the effectiveness of the peer education model. It further proves that educating nursing students about BSE is important and improves that chance of nursing students to teach peers, other university students, and ultimately the community, the importance of BSE, to improve the incidence of early detection.
Another study determined the attitudes and practices of 201 female nurses and 149 female physicians regarding BSE through the use of a questionnaire. The study used t-tests and chi-square tests to analyze the data. The study found that 72% of nurses and 68% of physicians perform BSE. A majority of the nurses and physicians not performing BSE stated, “I don’t take it seriously” (Cavdar, Akyolcu, Ozbas, Oztekin, Ayoglu, & Akyuz, 2007). The study did not specify which method of breast examination was used among participants. The fact remains that not all health care professionals are performing BSE, and are therefore less likely to include BSE training and education in their care planning. We must alter the education of future healthcare professionals in order to facilitate positive outcomes for patients.
In an earlier study, nursing students were polled on the incidence of performing breast self-examinations in relation to health beliefs, attitudes, and knowledge about BSE.
The sample consisted of women ages 40 years or younger who were students in the first year of an undergraduate preregistration nursing degree program in Australia. Data was collected using self-administered questionnaires given before and after one year of nursing school. Evidence showed that no significant differences were identified in the knowledge of BSE or the frequency of performance over the one year period. However, a positive association was found between the incidence of performing BSE and nursing experience. The incidence of performing BSE increased due to the education gained during the clinical experience, but not necessarily knowledge attained from a set structure in the nursing curriculum taught in the classroom (Budden, 1999). While conducting the literature review, this article was the only one found to reference a longitudinal study, over a period of 4 years, evaluating nursing students in a baccalaureate nursing program. This study concluded that there was a considerable increase in performing breast self-examination over time; however, this study was conducted in 1988. The lack of current information regarding the influence of breast self-examination in the nursing curriculum and subsequent performance of BSE in baccalaureate nursing students, further justifies the purpose of our study.

Problem: Breast cancer is the second most common cancer among women. However, little is known about whether or not baccalaureate nursing programs of study include a curriculum that provides adequate knowledge about breast cancer and preventative measures, specifically breast self-examination. Few studies have addressed, specifically, the relationship between level of education of students in a baccalaureate nursing program and their knowledge about and frequency in performing breast self-examination.

Purpose: The purpose of this research study is to discover if a correlation exists between level of education of University of Scranton baccalaureate nursing students and their incidence of performing breast self-exams.

Question: Is there a correlation between level of education of baccalaureate nursing students and their incidence of performing breast self-exams?

Causal hypothesis: Persons who are more advanced in the enrollment of a four-year baccalaureate nursing program will have a greater incidence of completing a self breast-exam monthly then will persons less advanced in a four-year baccalaureate nursing program. The advancement of the Bachelor of Science in nursing (BSN) program is determined by year of enrollment in the program. We believe that the more classroom and clinical experience will result in a higher likelihood of BSE performance.

Framework: Social Learning Theory will be used as a conceptual framework for this study. This theory, created by Albert Bandura, supports that learning is facilitated by observing, maintaining, and mimicking behavior that is learned from other people. This theory may affect behavior by creating new behaviors, or increasing or decreasing the occurrence of specific behaviors. This theory can be directly applied to the incidence of performing BSE in baccalaureate program nursing students. If the nursing curriculum provides adequate knowledge about breast cancer and preventative measures, specifically breast self-examination to University of Scranton nursing students, this will be reflected by the incidence of BSE calculated among polled students.

Design: This study is a correlational cross sectional design. The study will be conducted to determine the affects of the current year in the baccalaureate nursing program in relation to the incidence of performing BSE. A total of four grades will be surveyed and evaluated. The independent variable includes the current year in which the student is enrolled in the baccalaureate nursing program and the dependent variable is the incidence in which students perform BSE.

Sample: This study sample only includes female nursing students ranging from 17-24 years of age enrolled at the University of Scranton participating in the baccalaureate nursing program. The sample excludes male students, and license practical nurses and registered nurses obtaining their bachelors of Science degree in nursing, and non-traditional students. These populations do not apply to the research in question. The four researchers, although they fit the criteria of this sample, will not be included in the study.

Method: Data will be collected via a close-ended survey. The survey will include three sections; demographics, attitudes and beliefs related to BSE, and frequency of performing BSE. Surveys will be completed during nursing classes of all grade levels in McGurrin Hall at the University of Scranton. The survey will take no more than ten minutes to complete. Directions at the top of the survey will explain the survey and inform the participant that they are free to decline participation. If the student chooses fill out the survey, consent will be rendered at time of completion. An administrator of the survey will be present while students quietly take the survey and will be available for questions.

Data Analysis: Data will be analyzed via the Pearson product-moment correlation coefficient, because it is widely used for the measurement of association between variables. This will provide information as to whether or not a relationship exists, and what type of relationship, among year of enrollment in the baccalaureate nursing program students at the University of Scranton and the frequency of performing BSE.

References
American Cancer Society. (2008). Overview: breast cancer. Retrieved September 18, 2008, from http://www.cancer.org/docroot/CRI/CRI_2_1x.asp?dt=5
Budden, L. (1999). Student nurses' breast self-examination health beliefs, attitudes, knowledge, and performance during the first year of a pre-registration. Career Nursing. 22, 430-437.
Cavdar,Y., Akyolcu, N., Ozbas, A., Oztekin, D., Ayoglu, T., & Akyuz, N. (2007). Determining female physicians’ and nurses’ practices and attitudes toward breast self-examination in Istanbul, Turkey. Oncology Nursing Forum, 34, 1218-1221.
Dicle, A., & Malak, A. (2007). Assessing the efficacy of a peer education model in teaching breast self-examination to university students. Asian Pacific Journal of Cancer Prevention. 8, 481-484.
Lowdermilk, D. L., & Perry, S.E. (2007). Maternity and women’s health care (9th ed.). St. Loius: Mosby Elsevier.
Powe, B.,Underwood, S., Canales, M., & Finnie, R. (2005). Perceptions about breast cancer among college students: Implications for nursing education. Journal of Nursing Education, 44, 257-265.