Nurse, PhD student in Public Health, Institute of Public Health, Federal University of Bahia, Bahia, BrazilSamylla Maira Costa Siqueira
Nurse, PhD Student in Nursing by the Graduate Program in Nursing at the Federal University of Bahia, BrazilLiliane Silva Costa
Nurse, Specialist in Cardiology, BrazilLouise de Oliveira Lisboa Villa
Nurse, Master's Degree in Nursing by the Graduate Program in Nursing at the Federal University of Bahia, BrazilElane Nayara Batista dos Santos
Nursing Student, School Nursing at Federal University of Bahia, BrazilDayse Rosa
Nurse Master, Lecturer of Bahia Adventist College, BrazilMaria Carolina Ortiz Whitaker
Dra Nurse, Professor, School Nursing at Federal University of Bahia, BrazilClimene Laura Camargo
Dra Nurse, Professor, Deputy Coordinator of the Program of Graduate Studies in Nursing at Federal University of Bahia, Brazil
Submitted date: May 01, 2016; Accepted date: August 03, 2016; Published date: August 10, 2016
Introduction: Breast and cervical cancers show increasing prevalence among women in Brazil. In this context, the attributions of nurses of the Health Family Strategy are essential to prevent, control and detection of these tumors.
Objective: To identify the activities to prevent the cervical and breast cancers developed by nurses of Basic Health Units (BHU) and to describe their knowledge about the attributions of nurses in prevention and control of cervical and breast cancers to the light of Ministry of Health.
Method: This is a qualitative and exploratory approach. The study was conducted with 05 nurses of the Health Family Strategy in a city located in the Reconcavo of the state of Bahia. To collect data, we used a semi structured interview and were analyzed through Bardin content analysis technique.
Results: It was observed that the nurses of the Family Health Strategies, where the study was performed, develop some activities for the prevention and control of breast and cervical cancers, as recommended by the Ministry of Health, however it was noted weakness regarding the knowledge of these activities as recommendations.
Conclusion: The nurses develop some actions to prevent and control breast and cervical cancers according the guidelines of the Ministry of Health, although they do not recognize these activities as recommendations. Note also that the knowledge about the guidelines for prevention and control of these cancers is incipient. Therefore, it is important that nurses know their assignments, as well as what is recommended by the Ministry of Health, to combat the both cancers and make a significant contribution to the reduction of mortality about these cancers.
Nurse’s role; Breast neoplasms; Neoplasia of cervical
The prevalence of mortality from cancer has increased throughout the world every year. Among the various types, in the case of the female population, the most incidents are cancers of the breast and cervix, being in the first and second most affecting women in developing countries, respectively.1,2
In Brazil, where the female population represents 51,03% of the population, these cancers ranks first and third among the most incident in women.1 Therefore, the Ministry of Health instituted a range of political actions with the focus on women, seeking an early diagnosis and the reduction of mortality due breast and cervical cancers.3
In Brazil, in 2012, they were appointed 52,680 new cases of female breast cancer and 17,540 of cervical cancer.2 In the year 2015 were estimated 57,000 new cases for the first and 15 000 new cases for the second. Despite the developments to reduce morbidity and mortality caused by breast and cervix, through educational campaigns and actions for early diagnosis, it is observed an increasing prevalence, particularly breast cancer.¹
In this context, it’s necessary, in addition to intensify the actions in development, raise new strategies to reduce the incidence that is growing and the nurses who work in Health Family Strategies (HFS) have an important role with regard to the activities recommended by the Ministry of Health in the control and prevention of these cancers.3
So, these questions arose: Which activities are developed by nurses of primary care of Reconcavo of the state of Bahia in the prevention of cervical and breast cancers? Which is the knowledge of the nurses of primary care of Reconcavo of the state of Bahia about what is recommended by the Health Ministry in the prevention of cervical and breast cancers?
In order to answer the above questions, the objective is to identify the activities to prevent the cervical and breast cancers developed by nurses of Basic Health Units (BHU) and to describe their knowledge about the attributions of nurses in prevention and control of cervical and breast cancers to the light of Ministry of Health.
This is a descriptive research with a qualitative approach. The research was conducted in a city of the Reconcavo of the state of Bahia, located 110 km away from the state capital; its current population is 34,535,000 inhabitants.4 The study subjects were 05 nurses who develop activities of attention to health to prevent cervical and breast cancer at four basic health units from this city at least two years.
Data collection was carried out in October 2015 after Health District authorization of the region and approval of the Research Ethics Committee (CEP) with number of approval 1.244.432, being respected the Resolution 466/12.
Therefore, was applied a form to characterize the nurses participants and a semistructured interview with questions about the recommendations for prevention of cervical and breast cancer.
Interviews were conducted in a private room and recorded in MP4 portable voice recorder, having been transcribed in full by the researchers. To ensure the anonymity of the research subjects, participants were identified as E-1, E-2, and so on, according to interviews conducted order.
For the analysis of the data was used the technique of Bardin Content Analysis,5 and after grouping of units of analysis was possible to discuss from two categories, which are: “Prevention and control of cervical and breast cancer: activities developed by nurses of Health Family Strategies” and “Knowledge of nurses about prevention of cervical and breast cancers to the light of recommendations of Ministry of Health”.
The subjects were 4 females and 1 male sex, with average of 4,8 years of graduation, with work experiences about 3-5 years in primary care in relation to prevention of cervical and breast cancers.
The results raised described in the both categories below reflect the activities developed by nurses on their daily work to prevent the cervical and breast cancers and the knowledge of these professionals about the activities recommended by Ministry of Health to prevent and control of these diseases.
Prevention and control of cervical and breast cancers: actions taken by nurses of the family health strategy
Breast cancer is considered good prognosis when diagnosed and treated in early stage.6 With regard to cervical cancer, it is slowly progressive and can take years to reach the invasive stage, which provides good results on preventive actions in early diagnosis.7 Thus, it is possible to reduce the incidence, paying attention to the preventive and control as recommended by the Ministry of Health, specially actions.8
With a view to control the incidence of cervical and breast cancers, the nurse is a protagonist very active, since this professional develops actions beyond the collect of material for screening and diagnosing of these cancers.2,7-10
Based on this, for the nurse as part of the health team of the Health Family Strategies, skills have been established with regard to the prevention and control of breast and cervical cancers. In order to make sure to carry out the competence of the nurse activities for this purpose, it was examined if the professional developed the mentioned activities or not, and unanimously, the nurses reported to perform them.
As for the practices undertaken for the prevention and control of cancer in question, the nurses were asked what activities they developed, it could be seen by the speeches the emphasis on that refer to the practice of health education.
[...] Lectures, many lectures (E-1).
[...] To give lecture, educational reports through pamphlets, talk to women with active sex life, especially with the larger 40 years (E-2).
[...] Lectures, in waiting rooms, we work quite so, what is normal what is not normal, what are the symptoms, right? (E-3).
About health education, right? Through the waiting rooms, I also work on the calendar with holidays, as in the day fight against cervical and breast cancers. (E-4).
"We carried out the waiting room with clear and objective speech, talking about the control of breast cancer and cervical cancer." (E-5).
In the testimonies of the participants, it was also noted the statement on the completion of activities such as lectures in the waiting room.
Developed from the relationship between education and health, aiming at the possibility of changing habits in the individual and collective situations, taking into account the pre-existing knowledge, health education activities are seen as guiding principles of the actions of the nurse, it highlights to develop such practices in the context of prevention, health promotion and disease control, in view of stimulating self-care. On this, the study states that educational activities can provide new habits that impact on health, especially in with respect to self-care, with the fruitful environment of waiting room.10,11
The waiting room can set up a promising space for reception allowing dialogue, promoting the exchange of knowledge and especially a link with the population. Also, through this environment, the nurse can approach the user, understand him and establishing links. Of the various activities that can be developed in this space, it was cited the talks, widely used method, as an educational nursing intervention.11,12 The strategy has been commonly employed it aiming to prevent and control many diseases.12
Still, in the complaint about the activities developed by nurses interviewed, it could be identified the training of Community Health Agents (CHA).
[...] Training with our community workers, they pass the information and make the information multiply [...] (E-2).
Efforts with regard to training of personnel may be able to produce positive results when well planned. About that, in the case of CHAs in the context of prevention and control of breast and cervical cancer can be effective, because they theoretically know the reality of families, and it enables planning and assistance that will promote educational actions.13,14
Preventive exam was also one of the mentioned activities as can be seen in the statements of the respondents:
"[...] We perform a Pap smear test which is called preventive. Where we detect cell deformity CIN I, II, III "(E-2).
"[...] The realization of preventive [...]" (E-4).
"[...] We perform preventive collection once a week [...]." (E-5).
The Ministry of Health (MH) recommends screening for cervical cancer in sexually active women and who have the cervix through Pap smears, which can also be used as a means of prevention when by it are identified precursor diseases of this neoplasm. In addition, early diagnosis enables simpler and more effective therapies, thereby contributing to the reduction of the advanced stage of disease presentation.7-10
Other forms of prevention shape to the guidelines on sexually transmitted infections (STIs) and safer sexual practices.7
Other tasks cited by nurses were the clinical examination and referral.
[...] Also the examination of the breasts, so as to diagnose any changes, especially women over 40 years. (E-2).
[...] We also evaluated the breast ... and orient, to perform the self-examination monthly [...] (E-3).
[...] We orient women to do monthly self-examination of breasts and teach how to palpate the breast [...] (E-5).
[...] We send her on because in this case, here we cannot ask for mammography, we headed for the doctor, so that he can ask this woman to do (E-4).
The self-examination it is the practice of palpation of the breast itself, indicated by configure a painless, no-cost technique, besides being an effective means for early detection of breast cancer. However, examination of the breasts performed by the woman should not replace clinical examination effected by a health professional, especially the nurse qualified for this action,3 since there is evidence in a study on the inappropriate use of the technique when performed by women themselves.7 Perhaps the difficulty for the realization of self-examination is the requirement of a static and dynamic inspection, including palpation of the breast and axillary and supraclavicular lymph node chains.
The subsequent action after the examination in case of suspicion, is to refer the patient for diagnostic investigation in a reference service to perform mammography.1,3 Such action is very important for reducing morbidity and mortality caused by this kind of cancer.15
Knowledge of nurses about control and prevention of cervical and breast cancers in light of what is recommended by the Ministry of Health
In Brazil, the nursing exercise is regulated by Law No. 7,498, of June 25, 1986, in this are arranged the private activities of the nurse in its Article 11, which: planning, organization, coordination, implementation and evaluation of the assistance service nursing and prescription of nursing care and consultation.16
In nursing consultation, the nurse should provide an integral care, as recommended by Ministry of Health as described in the books of basic attention.3,15 They discourse on prevention, tracking and control of various diseases, including breast and cervical cancers. Thus, it is of paramount importance that the nurse is aware of the duties concerning the prevention and control of the reported cancers because it is assigned:
To attend the users in full; perform the nursing consultation and collection of cervical cancer screening; perform nursing consultation and clinical breast exam, according to age and clinical condition of the user; examine and evaluate patients with signs and symptoms related to cervical and breast cancers; order tests and evaluate the results; prescribe treatment for other diseases detected as STDs, according to clinical guidelines, protocols or technical standards established by the local manager and conduct referral to the reference services in diagnosis and/or treatment of breast and cervical; perform palliative care at units or at home, according to the user needs; evaluate periodically, and whenever there is complication, patients followed in Home Care 1 (AD1), and, if necessary, carry referral to inpatient units or multidisciplinary team of Home Care (EMAD); contribute, perform and participate in continuing education activities of all team members; and participate in the management of the inputs necessary for the proper functioning of the basic unit of health.3
To identify the knowledge of nurses on the above-mentioned tasks, recommended by the Health Ministry in control of breast and cervical cancers, we obtained the following answers:
[...] To Give the assurance to women's treatment, if they are detected with syphilis, or cancer even she will have within the unit monitoring the situation, as I have had several CIN I, CIN II patients, CIN III and we can follow this woman until healing (E-3).
[...] When it's exam I have to ask the community worker warn, to do active search. When it's something that I can deal with, and if you have related to the complaint, the screening test, so we just make a syndromic approach, as part of the protocol here in the city. And if it is not my responsibility I submit to the doctor and gynecologist (E-4).
The syndromic approach happens due to vaginal changes, and occurs by treatment after identification of signs and symptoms. That approach sets an important tool in the care process with regard to treatment and early diagnosis of cervical cancer.17-19
Also, the interviews addressed to health education through lectures, guidance and staff training, such activities are also recommended by the Ministry of Health.
Lecture, collection of preventive and active search [...] (E-1).
[...] It begins with the guidance from training with your own team, with awareness and information, until the contact with the patient, until the waiting room, to make educational lecture for the exam, so it begins with the contact on the unit until the residence of the patient (E-2).
[...] Campaign with women, guide lecturing, so one of the tasks that are key is to educate the woman that she must seek unity, she must have regular examinations (E-5).
The Ministry of Health provides health education as a relevant method to prevent and control cancer of the breast and uterine, because practices involving this activity, for example, lectures, guidance and staff training, can contribute to the improvement of the actions developed by professionals as well as in raising awareness with regard to change of patient habits.2,13,20-22 About such respects, integrative review study points to Nurses preference with regard to health education development, through guidance and educational activities.16,23
Other activities are also recommended by the Health Ministry are the cytological examination and clinical examination of breast, identified only in a discourse on this approach.
[...] What advocates the ministry of health that is prevention, specifically cancer of the breast and cervical cancer through the realization of Paps [...] (E-3).
Prevention of cervical cancer is one of the priority areas in primary care, and gynecological examination and the delivery of cytological results are responsibilities of the nurse as the health family strategy team component.9,10 Regarding the prevention of breast cancer it is recommended to screen, also performing the clinical examination.9
It was noted in speeches, that nurses have some knowledge of the activities recommended by the Ministry of Health for the prevention and control of breast and cervical cancers. However, it was observed that the respondents did not show in his speeches a deepening on these guidelines. Furthermore, they did not mentioned aspects, as an example, the participation of the management of the inputs necessary for the proper functioning of basic health unit and performing referral to inpatient units or EMAD.
Thus, it is essential that nurses develop their activities in line with what is proposed by the Ministry of Health, so that they can ensure the quality of care, prevention of cancers in discussion and early diagnosis with a view to healing.
Despite the health existing programs for control and prevention, the cervical and breast cancers still have a considerable existence in developing countries, particularly in Brazil. With that, it is essential that there is most investments in existent actions, as well as new approach are planned to minimize the incidence and prevalence these cancers. It is in this perspective that the nurse of primary care has fundamental role in prevention, screening and control of cervical and breast cancers.
As shown in this study, the nurses who develop actions in basic attention located in the Reconcavo of the state of Bahia make some attributions proposed by Ministry of Health in prevention and control of cancers that affect the women, which breast and cervical cancers. However, it must be observed that these activities should occur from screening through clinical examination of breast and Pap smears, but is important the implementation of actions that could promote the population awareness concerning the behavior change.
Despite the nurses don’t demonstrate intense knowledge about what is recommended by Ministry of Health for prevention and control of cervical and breast cancers, it is notorious in their accounts about the activities performed at work that some actions have already been developed, even though they do it without its being aware, what needs be reconsidered.
Thus, it is worth highlighting the importance of nurses knows about their attributions to prevent and control cervical and breast cancers and that they can optimize their contribution regarding the reduction of incidence and prevalence of these cancers.
All participants signed the Informed Consent and Informed, being informed about the objectives and relevance of the study and assured about the anonymity and confidentiality of responses. The study was approved by the Research Ethics Committee of the Federal University of Bahia School of Nursing, under opinion No. 1, 244, 432.
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